What is the effect of laser anatomical endoscopic enucleation of the prostate on the ejaculatory functions? A systematic review

INTRODUCTION

Laser anatomical endoscopic enucleation of the prostate (LAEEP) has emerged as a promising new approach in endoscopic surgery for BPH. LAEEP could still result in ejaculatory dysfunction.

AIM

This systematic review aimed to examine the impact of LAEEP on male ejaculatory functions.

METHODS

The review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement, and 15 records were included. Outcomes of interest included ejaculatory dysfunction (retrograde ejaculation, painful ejaculation, etc.) and validated questionnaire scores. The quality of studies included in the systematic review was determined using QUADAS scoring.

RESULTS

We retrieved data for 1877 men in 15 clinical studies investigating LAEEP surgery and reporting EjD rates. While only three of the obtained studies were on thulium fiber (ThuLEP), the rest were on holmium (HoLEP). The definition of "Ejaculatory Dysfunction" was not standardized, but in most works, it is referred to as retrograde ejaculation (RE). There were no data on the relationship between other LAEEP techniques and ejaculation functions. The authors compared the outcomes of used standard laser enucleation techniques with the modified techniques. The RE rate in LAEEP was 62.1 ± 25.1%, 71.3 ± 16.1% in standard techniques, and 27.2 ± 18.1% in ejaculation-preserving modified techniques (p < 0.001).

CONCLUSION

This review demonstrated that ejaculation-preserving techniques, i.e., modified techniques are superior to standard techniques. Studies have also shown that ejaculatory dysfunction rates gradually decrease with long-term follow-ups. Future well-designed studies could further investigate the ejaculation-preserving modification of LAEEP techniques and how they impact EjD rates and other sexual function outcomes.

How do endoscopic bladder tumor resection techniques affect pathology practice? EAU Section of Uro-Technology (ESUT) and Uropathology (ESUP) survey

PURPOSE

We aimed to examine how different endoscopic bladder tumor resection techniques affect pathologists' clinical practice patterns.

METHODS

An online survey including 28 questions clustered in four main sections was prepared by the ESUT ERBT Working Group and released to the pathologists working in the institutions of experts of the ESUT Board and the working groups and experts in the uropathology working group. A descriptive analysis was performed using the collected data.

RESULTS

Sixty-eight pathologists from 23 countries responded to the survey. 37.3% of the participants stated that they always report the T1 sub-staging. Of those who gave sub-staging, 61.3% used T1a, b. 85.2% think that en bloc samples provide spatial orientation faster than piecemeal samples, and 60% think en bloc samples are timesaving during an inspection. 55.7% stated that whether the tissue sample is en bloc or piecemeal is essential. 57.4% think en bloc sample reduces turnaround time and is cost-effective for 44.1%. A large number of pathologists find that the pathology examination of piecemeal samples has a longer learning curve.

CONCLUSION

The survey shows that pathologists think that they can diagnose faster, accurately, and cost-effectively with ERBT samples, but they do not often encounter them in practice. Moreover, en bloc samples may be a better choice in pathology resident training. Evidence from real-life observational pathology practice and clinical research can reveal the current situation more clearly and increase awareness on proper treatment in endoscopic management of bladder tumors.

A Delphi consensus to standardize the technique of anatomical endoscopic enucleation of prostate: a study by ESUT endoscopic enucleation of prostate study group

PURPOSE

Our objective was to establish a standardized technique for Anatomical Endoscopic Enucleation of Prostate (AEEP) utilizing a consensus statement to provide robust recommendations for urologists who are new to this procedure.

METHODS

The participants were electronically sent a questionnaire in three consecutive rounds. In the second and third rounds, the anonymous aggregate results of the previous round were presented. Experts' feedback and comments were then incorporated to refine existing questions or to explore more controversial topics in greater depth.

RESULTS

Forty-one urologists participated in the first round. In the second round, all Round 1 participants received a 22-question survey, resulting in a consensus on 21 items. In the third round, 76% (19/25) of the second-round respondents also participated, reaching a consensus on 22 additional items. The panelists consensually agreed on detaching the urethral sphincter at the beginning of the enucleation and not at the end of the enucleation. To prevent incontinence, it was recommended that the apical mucosa be preserved through various approaches between 11 and 1 o'clock while gently disrupting the lateral lobes in their apical part, avoiding an excess energy delivery approximation to the apical mucosa.

CONCLUSION

To optimize laser AEEP procedures, urologists must follow expert guidelines on equipment and surgical technique, including early apical release, using the 3-lobe technique for enucleation, preserving apical mucosa with appropriate approaches, gently disrupting lateral lobes at their apical regions, and avoiding excessive energy delivery near the apical mucosa. Following these recommendations can lead to improved outcomes and patient satisfaction.

Hydrogen peroxide signaling modulates neuronal differentiation via microglial polarization and Wnt/β-catenin pathway

OBJECTIVE

Reactive oxygen species (ROS) are generated within the cell and serve as second messengers in fundamental cellular processes under physiologic conditions. Although the deleterious effects of high-level ROS associated with oxidative stress are well established, it is unclear how the developing brain reacts to redox changes. Our aim is to investigate how redox alteration affects neurogenesis and the mechanism that underlies it.

MATERIALS AND METHODS

We investigated in vivo microglial polarization and neurogenesis in zebrafish after hydrogen peroxide (H2O2) incubation. To quantify intracellular H2O2 levels in vivo, a transgenic zebrafish line that expresses Hyper and termed Tg(actb2:hyper3)ka8 was used. Then, in vitro studies with N9 microglial cells, 3-dimensional neural stem cell (NSC)-microglia coculture, and conditioned medium experiments are carried out to comprehend the mechanism underlying the changes in neurogenesis upon redox modulation.

RESULTS

In zebrafish, exposure to H2O2 altered embryonic neurogenesis, induced M1 polarization in microglia, and triggered the Wnt/β-catenin pathway. N9 microglial cell culture experiments revealed that exposure to H2O2 resulted in M1 polarization in microglial cells, and this polarization was mediated by the Wnt/β-catenin pathway. Redox modulation of microglia interfered with NSC differentiation in coculture experiments. Neuronal differentiation was significantly higher in NSCs cocultured with H2O2-treated microglia when compared to control microglia. Wnt inhibition prevented the effects of H2O2-treated microglia on NSCs. No significant alterations were observed in conditioned medium experiments.

CONCLUSIONS

Our findings point to a robust interplay between microglia and neural progenitors influenced by the redox state. Intracellular H2O2 levels can interfere with neurogenesis by altering the phenotypic state of the microglia via the Wnt/β-catenin system.

International Alliance of Urolithiasis Guideline on Shockwave Lithotripsy

Different international associations have proposed their own guidelines on urolithiasis. However, the focus is primarily on an overview of the principles of urolithiasis management rather than step-by-step technical details for the procedure. The International Alliance of Urolithiasis (IAU) is releasing a series of guidelines on the management of urolithiasis. The current guideline on shockwave lithotripsy (SWL) is the third in the IAU guidelines series and provides a clinical framework for urologists and technicians performing SWL. A total of 49 recommendations are summarized and graded, covering the following aspects: indications and contraindications; preoperative patient evaluation; preoperative medication; prestenting; intraoperative analgesia or anesthesia; intraoperative position; stone localization and monitoring; machine and energy settings; intraoperative lithotripsy strategies; auxiliary therapy following SWL; evaluation of stone clearance; complications; and quality of life. The recommendations, tips, and tricks regarding SWL procedures summarized here provide important and necessary guidance for urologists along with technicians performing SWL. PATIENT SUMMARY: For kidney and urinary stones of less than 20 mm in size, shockwave lithotripsy (SWL) is an approach in which the stone is treated with shockwaves applied to the skin, without the need for surgery. Our recommendations on technical aspects of the procedure provide guidance for urologists and technicians performing SWL.

What Is the Ideal Treatment for 20-30 mm Kidney Stones? Comparative Outcomes of 1197 Patients

Background: The purpose of this study is to compare the efficacy and safety of extracorporeal shockwave lithotripsy (SWL), retrograde intrarenal surgery (RIRS), mini-percutaneous nephrolithotomy (mPNL), and standard-percutaneous nephrolithotomy (stPNL) for the treatment of 20-30 mm kidney stones. Methods: The records of 1197 patients (SWL = 149, RIRS = 205, mPNL = 525, and stPNL = 318) from 8 centers were reviewed retrospectively. Four procedures were compared for stone-free rates (SFRs), auxiliary treatment, and associated complications. Results: Initial SFRs were 43.6%, 54.6%, 86.7%, and 87.7% in SWL, RIRS, mPNL, and stPNL, respectively (P < .001), whereas the final SFRs were 71.8%, 80%, 90.5%, and 89.6% (P < .001). The rate of auxiliary treatment in the groups was 38.3%, 26.8%, 5%, and 4.4%, respectively (P < .001). The initial and final SFRs in the mPNL and stPNL groups were higher than those in SWL and RIRS groups (P < .001). The rate for auxiliary treatment was lower in the mPNL and stPNL groups (P < .001). The operation time was longer in the RIRS group (P = .005). According to the Clavien-Dindo classification, the complication rate in the SWL group was lower than that in the surgical approaches (P < .001); however, no statistical difference was detected between RIRS, mPNL, and stPNL groups. mPNL and stPNL had a higher success rate than RIRS or SWL for treating 20-30 mm kidney stones. Conclusion: In the treatment of 2-3 cm renal stones, RIRS and PNL were more effective than SWL to obtain a better SFR and less auxiliary treatment rate. Compared with RIRS, mPNL and stPNL provided a higher SFR with similar complication rates.

Could retrograde intrarenal surgery be a safe and effective alternative to mini-percutaneous nephrolithotomy ın the management of relatively large (20-30 mm) stones? A critical evaluation

PURPOSE

To compare the outcomes of mini-percutaneous nephrolithotomy (mPCNL) and retrograde intrarenal surgery (RIRS) in patients with renal stones sizing 2-3 cm.

METHODS

A total of 566 patients from 6 institutions who underwent mPCNL (n = 440) and RIRS (n = 126) procedures were enrolled in our study. The retrospective patient cohort was reviewed and compared. Binary logistic regression analysis was performed to determine factors predicting success in the RIRS group.

RESULTS

The stone-free rates were 91.1 and 77% for the mPCNL and RIRS groups, respectively (p < 0.001). The auxiliary procedure rates were 4.5 and 39.7% in the mPCNL and RIRS groups, respectively (p < 0.001). Mean values of hemoglobin decrease, fluoroscopy time, and hospitalization time were significantly higher in the mPCNL group (p < 0.001). While the Clavien grade 1-2 complication rates were 10.9 and 34.1% (p < 0.001) in two groups, these values were 2.7 and 1.6% (p = 0.539), respectively, for Clavien grade 3-4 complication rates. Although three patients in the mPCNL group received blood transfusions, none of the patients in the RIRS groups were transfused. The stone location and stone density parameters were found to be the independent predictive factors for RIRS success.

CONCLUSIONS

mPCNL provided a higher stone-free rate, less need for the auxiliary procedure, and lower complication rates compared to RIRS in patients with 2-3 cm stones. Blood loss, radiation exposure, and a hospital stay of mPCNL can be significantly reduced with the RIRS technique in selected patients.

Evaluation of the optimal duration for retrograde intrarenal stone surgery to prevent postoperative complications

OBJECTIVE

To evaluate retrograde intrarenal surgery (RIRS) outcomes and to determine the effect of operative time on complications of RIRS.

METHODS

Patients undergoing RIRS for renal stones were evaluated. These patients were divided into two groups according to the operation time (Group 1<60 minutes and Group 2>60 minutes). Peroperative outcomes such as fluoroscopy time, stone-free rates, complications and duration of hospitalization were compared.

RESULTS

Group 1 consisted of 264 patients and Group 2 consisted of 297 patients. SFR rates, duration of hospitalization, and postoperative urinary tract infection rates were similar in both groups. Fluoroscopy time was 7.8±7.3 (0-49) sec in group 1 and 13.1±9.8 (0-81) sec in group 2. Complications according to modified Clavien-Dindo classification system (MCDCS) were 13 and 32 patients (Grade 1), 31 and 63 patients (Grade 2), 1 and 1 patient (Grade 3) in group 1 and 2, respectively. There was statistical difference between the two groups in terms of duration of fluoroscopy time and the MCDCS. Although duration of hospitalization and UTI rates were higher in group 2, no statistical significance was observed among groups.

CONCLUSION

Limiting the operation time to 60 minutes in RIRS seems to be important in reducing postoperative complications.

A multicenter-based critical analysis of laser settings during intrarenal laser lithotripsy by the Turkish academy of urology prospective study group (ACUP study)

Objective: In this multicenter prospective study, we aimed to evaluate the use of holmium:yttrium–aluminum–garnet laser during retrograde intrarenal surgery for kidney stones and the relationship between laser-related parameters and procedure-related perioperative parameters.

Material and methods: The 769 patients whose laser setting parameters (fiber thickness, number of shots, frequency (max.), laser power (max.), and total energy) were completely registered were included in this study program. The intraoperative ureteral lesions were evaluated using postureteroscopic lesion scale (PULS) scores and the postoperative complications with the modified Clavien-Dindo classification system.

Results: The maximum levels of laser power and the frequency were used in the middle calyceal stones; the value of total energy consumed was found to be higher gain in cases with multiple stones (all parameters P < .05). There was a significant positive correlation among (mean number of shots [P < .001, r = 0.46], frequency [P = .009, r = 0.1], maximum power [P < .001, r = 0.11], total energy [P < .001, r = 0.25]), anesthesia time (P < .001, r = 0.42), surgery time (P < .001, r = 0.47), and stone size. The mean number of shots increased (P < .001, r = 0.25), and the frequency level decreased (P < .001, r = –0.17) significantly with increasing Hounsfield unit (HU) values. Again, the mean number of shots and maximum laser power increased in correlation with the increasing hospitalization time (P = .004, r = 0.09 and P = .02, r = 0.07, respectively). In addition, it was observed that higher laser subparameter values and thicker fibers were used in PULS grade 2.

Conclusion: As the stone size and HU values increased, laser-setting parameters were found to show significant variability. The increase in different parameters of the laser setting was found to be associated with longer anesthesia time, surgery time, and hospitalization period and increased risk of local trauma with PULS grade.

The creation of unilateral intermittent and unintermittent renal ischemia-reperfusion models in rats

Background and Aim:

This study aims to establish unilateral intermittent and unintermittent partial nephrectomy-like renal ischemia-reperfusion (I-R) model in rats and to compare the results with biochemical findings.

Material and Methods:

The study was conducted on 24 adult 8-week-old male Wistar-Albino rats, each weighing s200–250 g. The rats were divided into three groups. In the Sham group (n = 8), the kidney was surgically exposed and closed. We designed experimental I-R models in the second group (n = 8, a total of 30-min ischemia model in the manner of 3 intermittent sets 8 minutes clamping and 2 min unclamping) and in the third group (n = 8, one session of 30-min unintermittent ischemia). In postoperative day 1, the rats were sacrificed, and the effects of I-R models on the renal tissue were comparatively assessed by evaluating serum Neutrophil Gelatinase-Associated Lipocalin (NGAL), serum kidney injury molecule-1 (KIM-1), urinary NGAL, urinary KIM-1, and serum creatinine levels.

Results:

Urinary NGAL and KIM-1 levels were significantly higher in the continuous ischemia group when compared to those in the sham and intermittent ischemia groups (P < 0.05). In the intermittent ischemia group, urinary NGAL and urinary KIM-1 levels were significantly higher than those in the sham group (P < 0.05). Although the results of serum NGAL, serum KIM-1, and serum creatinine levels seemed to be in parallel to the results of urinary markers, no statistically significant difference was found.

Conclusion:

Renal injury was significantly less in the intermittent I-R model when compared to that in the unintermittent I-R model in our experimental rat study.

Determination of Face and Content Validity of Cadaveric Model for Holmium Anatomic Endoscopic Enucleation of the Prostate Training: An ESUT AEEP Group Study

Background

Bench and virtual reality nonbiological simulator models for anatomic endoscopic enucleation of the prostate (AEEP) surgery have been reported in the literature. These models are acceptable but have limited practical applications.

Objective

To validate a fresh-frozen human cadaver model for holmium AEEP training and assess its content validity.

Design, setting, and participants

Holmium AEEP operations on fresh-frozen cadavers performed by an experienced surgeon were recorded, and a video, including the main steps of the operation, was produced.

Outcome measurements and statistical analysis

The video and an accompanying questionnaire were subsequently distributed electronically to ESUT AEEP study group experts and associates (N = 32) for assessment of the AEEP training model. A ten-point Likert global rating scale was used to measure the content validity.

Results and limitations

A total of 26 answers were returned (81%). The experts agreed on the model’s suitability for AEEP training (mean Likert score: 8). According to the responses, “identifying anatomic structures and landmarks” was the most valuable aspect of the model in terms of AEEP training (median Likert score: 9). Conversely, the experts found the model’s ability, in terms of demonstrating laser and tissue reactions, to be weak (median Likert score: 6)

Conclusions

Based on the content validity assessment, the fresh-frozen cadaver-training model for laser AEEP seems to be a promising model for demonstrating and learning the correct prostate enucleation technique.

Patient summary

An increasing number of researchers have proposed that anatomic endoscopic enucleation of the prostate (AEEP) should replace transurethral resection of the prostate surgery and become the gold standard for treatment of bladder outlet obstruction due to benign prostatic hyperplasia. AEEP requires anatomic familiarity for enucleation, technical knowledge, and a solid training program before starting with the first cases. This is the first cadaver study to assess the content validity of a fresh-frozen human cadaver model for AEEP training.

Is 'Omega Sign' anatomical endoscopic enucleation of the prostate technique reproducible?

We aimed to evaluate the learning curve of the surgically standardised 'Omega Sign' anatomical endoscopic enucleation (AEEP) of the prostate surgery technique for junior surgeons. This study is a retrospective comparison of cases that underwent AEEP by a mentor surgeon and three junior surgeons who have completed their learning curve. A video-based laser enucleation of the prostate assessment tool (LEAT) composed of 8 steps of the technique was used to assess a senior surgeon and junior surgeons' surgical compatibility and consistency. The surgeon who defined Omega Sign technique was determined as group 1, and cases by three junior surgeons were identified as group 2. The end points were to assess the reproducibility and repeatability and operative post-operative outcomes of the technique. 55 patients' videos were rated by five experienced endourologists. There was no significant difference in LEAT scores between the groups among all steps. The most symmetry was found in the 1st and 3rd steps. Inter-rater consistency was also high for each step, with no statistically significant difference between the evaluators. The standardised anatomical 'Omega Sign' technique is reproducible for the junior surgeons. The operative steps can be performed with high consistency, and the functional and perioperative outcomes are comparable with the senior surgeon.

Systemic inflammation in both open-angle and angle-closure glaucoma: role of platelet-to-lymphocyte ratio

AIM

To analyse the effect of systemic inflammatory status in patients with primary open-angle glaucoma (POAG) and primary angle-closure glaucoma (PACG) by calculating platelet-to-lymphocyte ratio (PLR) and neutrophil-to-lymphocyte ratio (NLR).

METHODS

This retrospective case-control study included 200 patients with POAG, 22 patients with PACG and 100 healthy subjects. The participants' white-blood-cell, lymphocyte, neutrophil, and platelet counts were recorded from previous blood assays. NLR and PLR were calculated manually. Results were compared among the groups.

RESULTS

Both the POAG and PACG groups had higher platelet counts and PLR values than the control group (p=0.001 and p=0.001; respectively). The difference in NLR between POAG, PACG and control groups was not statistically significant (p=0.076). The POAG group had higher NLR values than the control (p=0.035).

CONCLUSION

Both the POAG and the PACG groups exhibited higher platelet and PLR levels than the control. These results indicate a potential role of systemic inflammation in the pathogenesis of POAG and PACG (Tab. 4, Fig. 1, Ref. 35).

Impact of COVID-19 on Clinical and Academic Urological Practice: A Survey from European Association of Urology Section of Uro-technology

Background

The unexpected coronavirus disease 2019 (COVID-19) pandemic has spread worldwide rapidly, developing into a global health crisis. At the same time, it has seriously impacted the daily activities in all the fields of urology.

Objective

To better understand the impact of the COVID-19 pandemic on clinical, academic, and scientific activities as well as on the quality of life of urologists from the main centers in Europe.

Design setting and participants

We conducted a survey using a 37-item questionnaire. The survey included three main sections: clinical practice, academic/scientific activities, and personal/social quality of life.

Outcome measurements and statistical analysis

A descriptive analysis was performed using the collected data.

Results and limitations

A total of 107 representatives affiliated to different centers from 22 countries completed the survey. Clinical activities were affected in 54.2% of the centers, and 85.0% of the elective surgeries were cancelled. Of the urological departments, 64.5% were still performing minimally invasive surgery for malignant disease. In 33.6% of the hospitals, dedicated and specially equipped operating theaters for COVID-19-positive patients were not available. According to 72.9% of participants, COVID-19 had a substantial negative impact on academic activities, and 82.3% of the respondents agreed that their quality of life has been affected negatively by the pandemic. Finally, 92.5% of the participants believe that the pandemic will have a moderate to severe impact on the health system of their countries.

Conclusions

Data collected in this survey provide insight into changes brought about in clinical and academic settings amid COVID-19. Along with shortages such as bed occupancy and personal protective equipment, it highlights negative impacts on academic and scientific activities, including the personal and social life of urologists.

Patient summary

It is essential to understand the impact of the coronavirus disease 2019 (COVID-19) pandemic on clinical, academic, and scientific urological activities, as well as on related personal and social issues.

FRI0491 IS THERE A RELATIONSHIP BETWEEN VOGT-KOYANAGI-HARADA AND INFLAMMATORY RHEUMATOLOGICAL DISEASES

Background:

Vogt-Koyanagi-Harada Disease (VKHD) is a systemic autoimmune disease characterized by bilateral granulomatous panuveitis associated with systemic symptoms, including neurological, dermatological and audiovestibular systems. Due to its systemic nature, it may accompany with other autoimmune conditions. However, there is a considerably limited number of reports on the association of VKHD and rheumatologic diseases.

Objectives:

To investigate the relationship between VKHD and inflammatory rheumatological diseases.

Methods:

Patients who had bilateral granulomatous uveitis and fulfilled the 2001 revised diagnostic criteria for VKHD were included in our study. All patients were systematically reviewed in terms of the presence of any rheumatological manifestations including connective tissue diseases, spondyloarthritis (SpA), vasculitis, Behcet’s disease and sarcoidosis.

Results:

Demographic findings: There were fifteen patients in the study (86,7%,female), the mean age at diagnosis was 31,2 ± 11,1 years.

Comorbidities: Six patients (4 hashimoto thyroiditis, 2 diabetes mellitus) had comorbid diseases.

Rheumatological findings: Mechanical back pain in 4 patients, 1 patient had morning stiffness without any other SpA related features; 2 patients had inflammatory arthralgias in small joints, 4 patients had sicca symptoms, 1 patient had arthritis in knee joint, 3 patients had oral aphthae and 1 patient had photosensitivity.

Laboratory tests and autoantibodies: The acute phase reactants were within normal ranges. The mean CRP value at the time of diagnosis was 2,7 ± 3,2 mg/L and ESR was 14,4 ± 9,2 mm/h. Two (15,3%) out of 13 patients had high serum ACE levels. RF, anti-CCP and anti-dsDNA were negative in all patients. ANA was positive (>1/160 titers) in 4 patients (28,6%) and 3 patients had a titer above 1/320. Anti-ENA profile was positive in 2 patients with anti-SS-B and anti-histone components. MPO-ANCA was positive in one patient.

HLA test: HLA-B27 was negative in all patients. HLA-B51 and B18 were positive in 2 patients.

Radiographic findings: One patient had heel enthesitis on X-ray, 4 patients had bilateral grade 1 and one patient had unilateral grade 2 sacroiliitis. None of them fulfilled the Modified New York criteria for radiographic sacroiliitis. Hand X-rays of all patients were normal. One patient had reticular density on chest X-ray.

Pathergy: The pathergy test was negative in all patients.

Capilleroscopy: Four patients had pathological capilleroscopy findings (3 patient tortuous loops, 1 patient tortuous loops and microhemorrhages).

Conclusion:

This study suggests that; 1) inflammatory arthralgias and sicca symptoms were the most common rheumatological findings, 2) the frequency of SpA related features were not increased in VKHD, 3) increased autoantibody frequency, particularly in high titers of ANA could be seen in VKHD possibly reflecting the autoimmune nature of the disease, 4) even though there were signs of rheumatic diseases, none of the patients were grouped into any rheumatologic diagnostic classification.

Demographic findings and rheumatological manifestations in VKHD patientsVKHD patients (n=15)Females,n (%)13 (86,7)Age,yrs (mean ± std)34,6 ± 12,6Age of diagnosis, yrs (mean±std)31,2 ± 11,1CRP baseline (mean±std)2,7 ± 3,2 mg/LESR baseline (mean±std)14,4 ± 9,2 mm/HHigh ACE levels,n(%)2/13 (15,3)RF positivity,n(%)0/14 (0)Anti-CCP positivity,n (%)0/6 (0)ANA positivity,n(%)4/14 (28,6)ANA pattern,(n)Homogeneous (2)Nuclear (1)Homogeneous speckled (1)Anti-dsDNA positivity,n(%)0/11 (0)Anti-ENA profile positivity,n(%)2/14 (14,2)ANCA positivity,n(%)1/12 (8,3)Pelvis X-Ray abnormality,n(%)Sacroiliitis (n)5/12 (41,7)Bilateral grade 1 (4)Unilateral grade 2 (1)Capilleroscopy abnormality,n(%)4/9 (44,5)Pathergy,n (%)0/12 (0)

Disclosure of Interests:

None declared

Current state of image-guided focal therapy for prostate cancer

PURPOSE

To review the current evidence regarding protocols and outcomes of image-guided focal therapy (FT) for prostate cancer (PCa).

METHODS

A literature search of the latest published studies assessing primary FT for PCa was carried out in Medline and Cochrane library databases followed by a critical review. FT modalities, follow-up strategies, and oncological and toxicity outcomes were summarized and discussed in this review.

RESULTS

Twenty-four studies with six different sources of energy met the inclusion criteria. A heterogeneity of patient selection, energy sources, treatment templates, and definitions of failure was found among the studies. While a third of patients may be found to have additional cancer burden over 3-5 years following FT, most patients will remain free of a radical procedure. The vast majority of patients maintain urinary continence and good erectile function after FT. Acute urinary retention is the most common complication, whilst severe complications remain rare.

CONCLUSION

An increasing number of prospective studies with longer follow-up have been recently published. Acceptable cancer control and low treatment toxicity after FT have been consistently reported. Follow-up imaging and routine biopsy must be encouraged post-FT. While there is no reliable PSA threshold to predict failure after FT, reporting post-FT positive biopsies and retreatment rates appear to be standard when assessing treatment efficacy.

How does the COVID-19 pandemic affect the preoperative evaluation and anesthesia applied for urinary stones? EULIS eCORE-IAU multicenter collaborative cohort study

Stone disease is a unique condition that requires appropriate management in a timely manner as it can result in both emergent conditions and long term effects on kidney functions. In this study it is aimed to identify the up-to-date practice patterns related to preoperative evaluation and anesthesia for stone disease interventions during COVID-19 pandemic. The data of 473 patients from 11 centers in 5 different countries underwent interventions for urinary stones during the Covid-19 pandemic was collected and analyzed retrospectively. Information on the type of the stone related conditions, management strategies, anesthesiologic evaluation, anesthesia methods, and any alterations related to COVID-19 pandemic was collected. During the preoperative anesthesia evaluation thorax CT was performed in 268 (56.7%) and PCR from nasopharyngeal swab was performed in 31 (6.6%) patients. General anesthesia was applied in 337 (71.2%) patients and alteration in the method of anesthesia was recorded in 45 (9.5%) patients. A cut-off value of 21 days was detected for the hospitals to adapt changes related to COVID-19. Rate of preoperative testing, emergency procedures, conservative approaches and topical/regional anesthesia increased after 21 days. The preoperative evaluation for management of urinary stone disease is significantly affected by COVID-19 pandemic. There is significant alteration in anesthesia methods and interventions. The optimal methods for preoperative evaluation are still unknown and there is discordance between different centers. It takes 21 days for hospitals and surgeons to adapt and develop new strategies for preoperative evaluation and management of stones.

Retrograde intrarenal surgery of renal stones: a critical multi-aspect evaluation of the outcomes by the Turkish Academy of Urology Prospective Study Group (ACUP Study)

AIMS

To outline and evaluate the incidence, management and follow-up of the residual fragments (RFs) following retrograde intrarenal surgery (RIRS) of renal stones by the Turkish Academy of Urology Prospective Study Group (ACUP Study).

METHODS

Following the ethical committee approval, 15 centers providing data regarding the incidence, management, and follow-up of RFs after RIRS were included and all relevant information was recorded into the same electronic database program ( https://acup.uroturk.org.tr/ ) created by Turkish Urology Academy for Residual Stone Study.

RESULTS

A total of 1112 cases underwent RIRS for renal calculi and RFs were observed in 276 cases (24.8%). Of all the parameters evaluated, our results demonstrated no statistically significant relation between preoperative DJ stenting and the presence of RFs (χ2 (1) = 158.418; p = 0.099). RFs were significantly higher in patients treated with UAS (82 patients, 29.3%) during the procedure compared to the cases who did not receive UAS (194 patients, 23.3%) (χ2 (1) = 3.999; p = 0.046). The mean period for a secondary intervention after RIRS was 28.39 (± 12.52) days. Regarding the procedures applied for RF removal, re-RIRS was the most commonly performed approach (56%).

CONCLUSIONS

Despite the reported safe and successful outcomes, the incidence of RFs is higher, after the RIRS procedure particularly in cases with relatively larger calculi. Such cases need to be followed in a close manner and although a second flexible ureteroscopy is the treatment of choice for fragment removal in the majority of these patients, shock wave lithotripsy and percutaneous nephrolithotomy may also be preferred in selected cases.

Intense fluoro-2-deoxyglucose uptake in high-grade prostatic adenocarcinoma with negligible prostate-specific membrane antigen expression

While ⁶⁸Gallium prostate-specific membrane antigen positron emission tomography/computed tomography (⁶⁸Ga-PSMA) has demonstrated increasing utility in the evaluation of prostatic carcinoma, it is essential to be aware of false-negative findings. Further subtype analyses of prostate cancer will be helpful in the understanding of the underlying reasons. We herein present a high-grade prostate adenocarcinoma, with metastatic lesions showing high ¹⁸F-labeled fluoro-2-deoxyglucose uptake instead of 68Ga-PSMA.

Can ablation win against partial nephrectomy and become first line therapy in cT1a renal tumours?

PURPOSE OF REVIEW

Currently, small renal masses account for the largest proportion of renal tumour and small renal cell carcinomas (RCC). Although partial nephrectomy, whenever possible, is recognized as the gold standard for treatment, thermal ablation has gained increasing attention as optional treatment in a population sector harbouring small renal masses/small RCCs. The purpose of this review is to update comparative outcomes between these two options of treatment.

RECENT FINDINGS

Recent observational case-control and population-based cohorts applying propensity score or inverse probability treatment weighted methodology adjusting for baseline patient and tumour characteristics, compare outcomes between partial nephrectomy and thermal ablation (both cryotherapy and radiofrequency), radical nephrectomy and thermal ablation and between thermal ablation and nonsurgical management. Most of them focus on T1aRCC.

SUMMARY

Comparative outcomes' evidence is limited to population-based or institutional series adjusted for baseline differences and systematic reviews. With exception of special clinical situations, thermal ablation provides similar estimated 5-year cancer and overall survival with a clear benefit in postoperative outcomes when compared to partial nephrectomy in cT1a older patients. The trade-off is more evident when thermal ablation is compared to radical nephrectomy. The advantages in terms of adverse events persist up to 1 year after treatment. Benefits are less apparent in solitary kidneys and when synchronous bilateral approaches are performed.

A prospective randomized comparison of micropercutaneous nephrolithotomy (Microperc) and retrograde intrarenal surgery (RIRS) for the management of lower pole kidney stones

OBJECTIVE

To make a comparison between the safety and efficacy of micropercutaneous nephrolithotomy (microperc) and retrograde intrarenal surgery (RIRS) for the management of lower pole kidney stones up to 15 mm.

PATIENTS AND METHODS

60 patients presenting with solitary lower pole kidney stones up to 15 mm were included in the study between March 2013 and December 2015. Patients were randomized into Microperc or RIRS groups with computer-generated numbers.

RESULTS

The mean stone size was 10.6 (5-15) and 11.5 (7-15) mm for Microperc and RIRS groups, respectively (P = 0.213). In the Microperc group, the scopy time was 158.5 s, while in the RIRS group, the scopy time was 26.6 s (P = 0.001). The hospitalization period in the Microperc group was 542 h, while it was 19 h in the RIRS group (P = 0.001). No statistical differences were observed during the operating time, pre-operative-post-operative hemoglobin (Hb), serum creatinine, and estimated glomerular filtration speed (e-GFR) values and stone-free rates. No intraoperative complications were observed in either of the groups, while post-operative complications were observed in six patients in Microperc Group and five patients belonging to the RIRS Group (P = 0.922).

CONCLUSIONS

Both Microperc and RIRS are safe and effective alternatives, and have similar stone clearance and complication rates for the management of lower pole kidney stones up to 15 mm in diameter. However, prolonged hospital stay and scopy times are the main disadvantages of Microperc and further research is needed to evaluate the renal tubular damages caused by both of these methods.

Evaluation of mental foramen location in the 10-70 years age range using cone-beam computed tomography

INTRODUCTION

Mental foramen (MF) locations were determined according to gender and age in terms of the vertical distance from the surrounding anatomical structures and the vertical and horizontal size of the MF.

MATERIALS AND METHODS

One hundred-seven male and 103 female patients in the age group between 10 and 70 years were included in our retrospective study and were examined using cone-beam computed tomography (CBCT). The right and the left MF locations were determined from panoramic and cross-sectional images. On the cross-sectional CBCT images, the distance of the MF upper limit from the alveolar crest edge, the distance of the MF lower limit from the lower edge of the mandible, and vertical size of the MF were measured.

RESULTS

MF location differed in males and females (P < 0.001); it was generally located at the first and second premolar in females, and at the level of the second premolar in males. However, the MF location was not different on the right and left sides (P = 0.436). The distance of the MF from the surrounding anatomic structures were found to be lower in females than in males in all measurements (P < 0.001). The horizontal size of the MF was found to be less on the left side (P < 0.001).

CONCLUSIONS

Knowing both the position and the distance of the MF from the surrounding anatomical structures is not only useful information for surgery, but will also help avoid complications such as paresthesia.

Measuring the resistance of different substructure materials by sticking them to dentine with two different resin cements in vitro

INTRODUCTION

The resistance of three different substructure materials - metal (Cr-Co), zirconium (Zr), and ceramics (IPS Empress II) - was measured by sticking them to dentine with two different resin cements, a dual-cure resin cement (Panavia F 2.0 Light) and a self-adhesive resin cement (BisCem).

MATERIALS AND METHODS

In an in vitro study, 72 central upper front teeth were selected with no decay or apparent breakage and with complete development, removed for periodontal reasons. Labial and incisal surfaces of all teeth were prepared. Molds were obtained to prepare metal (Co-Cr), Zr, and ceramic (IPS Empress II) blocks for use in the study. The compressive strengths of the obtained material infrastructures were examined after thermal cycle processing by performing cementation to the teeth with two different cements. The data obtained were analyzed statistically. The Mann-Whitney U-test was used for comparisons of the groups with two options, and Kruskal-Wallis variance analysis was used to compare more than two groups. P<0.05 were considered statistically significant.

RESULTS

While the highest result between samples was 117.86 ± 47.94 N in the dual-cure (Panavia)-ceramic group, the lowest value was observed at 6.53 ± 3.12 N in the self-adhesive (BisCem)-metal group. There was a significant difference between dual-cure (Panavia) and self-adhesive (BisCem) groups.

CONCLUSION

In this study, we measured the bond strength; our most durable resistance groups were found to be, in order, Panavia-ceramics >Panavia-metal >Panavia-Zr >self-adhesive-ceramics >self-adhesive-Zr >and self-adhesive-metal.

Comparison of absorbed irrigation fluid volumes during retrograde intrarenal surgery and percutaneous nephrolithotomy for the treatment of kidney stones larger than 2 cm

Purpose

Irrigation-induced increase in intrarenal pressure is of concern because it may cause infection due to increased pyelovenous and pyelolymphatic absorption. This study is the first to compare prospectively the absorbed fluid volumes during percutaneous nephrolithotomy (PCNL) and retrograde intrarenal surgery (RIRS) for stones larger than 2 cm.

Materials and methods

General anesthesia was applied to all patients. Isotonic solution containing 1 % ethanol was used as irrigation fluid. Venous blood ethanol concentration was first measured with the start of irrigation and thereafter every 15 min until the patients left the recovery room. Absorbed fluid volumes were measured using the blood ethanol concentrations. Duration of irrigation, irrigated fluid volume, stone size and grade of hydronephrosis were also recorded.

Results

A total of 60 patients were included the study. Fluid absorption occurred in all patients. Minimum and maximum ranges of fluid absorption were 20–573 mL for RIRS and 13–364 mL for PCNL. The increase in fluid absorbed volume was observed as a result of the given amount of irrigating fluid used in the PCNL group. Also prolongation of operation led to a significant increase in absorption in the PCNL group. Increase in body mass index, stone size, and hydronephrosis did not affect fluid absorption significantly in either of the two operation techniques in correlation analyzes.

Conclusion

Both RIRS and PCNL are conducted under high pressure and can be accompanied potential complications such as SIRS. The fluid absorption confirmed in our study should be taken into consideration during RIRS and PCNL.

Laparoscopic temporary clipping of uterine and ovarian arteries for the treatment of interstitial ectopic pregnancy

PURPOSE OF INVESTIGATION

To assess the effect of laparoscopic temporary clipping of uterine and ovarian arteries for the treatment of interstitial ectopic pregnancy.

MATERIALS AND METHODS

A 29-year-old woman with vaginal bleeding and pelvic pain was admitted to the current clinic. She had secondary amenorrhea for nine weeks. Transvaginal ultrasonography revealed normal empty uterus and right interstitial ectopic pregnancy with viable embryo. Laparoscopic temporary clipping of uterine and ovarian arteries, interstitial pregnancy resection, and primary myometrial suturing was performed.

RESULTS

Following dissection Latzko pararectal space for the visualization of both uterine arteries, four vascular clips were placed (two to uterine arteries, two to infundibulopelvic ligaments). Excision of interstitial pregnancy and primary myometrial suturing was performed with minimal blood loss. The patient was discharged from the hospital after one day without any remarkable complications.

CONCLUSIONS

To the best of the authors' knowledge, this is the first case of interstitial pregnancy that was successfully treated by temporary laparoscopic clipping of uterine and ovarian vessels prior to interstitial ectopic pregnancy resection.

Intraoperative Evaluation of Ureteral Access Sheath-Related Injuries Using Post-Ureteroscopic Lesion Scale

OBJECTIVE

In the present study, intraoperative ureteral injuries inflicted during retrograde intrarenal surgery (RIRS) with ureteral access sheath (UAS) use were evaluated using the Post- Ureteroscopic Lesion Scale (PULS).

MATERIALS AND METHODS

Patients in whom a UAS was used during RIRS and for whom ureter images were video recorded during the procedure were included in the study. PULS grading was performed after UAS removal, and video sequences of all patients were viewed by a junior resident, a senior resident, and four experienced urologists and assessed according to the PULS. Ureteral lesions in distal, middle, proximal, and multiple locations were evaluated and compared according to the PULS scale. The inter-rater reliability of PULS grading among various urologists was also evaluated.

RESULTS

The evaluation comprised 101 patients. In 77 patients, 9.5/11.5 French UAS devices were used, and in 24 patients, 12/14 French UAS devices were used. The stone-free rate, clinical insignificant residual fragments, and final stone-free rate were 41.6%, 53.5%, and 98%, respectively. In 58.4% of the patients, no lesions were present according to PULS grading. No lesions of Grade 3 and above were found; however, there were lesions of Grade 1 and 2 in 38.6% and 2.9% of the patients, respectively. Injuries were found in the proximal ureter only and distal ureter only in 45.23% and 40.47% of the patients, respectively. Multiple injuries occurred in 5.94% of the patients (in 3.96% in the proximal and distal ureter, in 0.99% in the mid- and distal ureter, and in 0,99% in the proximal, mid-, and distal ureter). In the grading performed according to the PULS classification, there was a high accuracy among the residents and specialists.

CONCLUSIONS

The assessment of UAS-induced injuries using standardized intraoperative methods will help to evaluate the procedure more objectively and will guide the postoperative follow-up of patients.

Saccharomyces boulardii CNCM I-745 reduces the duration of diarrhoea, length of emergency care and hospital stay in children with acute diarrhoea

Evidence from the literature has shown that Saccharomyces boulardii provides a clinically significant benefit in the treatment of acute infectious diarrhoea in children. In this multicentre, randomised, prospective, controlled, single blind clinical trial performed in children with acute watery diarrhoea, we aimed to evaluate the impact of S. boulardii CNCM I-745 in hospitalised children, in children requiring emergency care unit (ECU) stay and in outpatient settings. The primary endpoint was the duration of diarrhoea (in hours). Secondary outcome measures were duration of hospitalisation and diarrhoea at the 3rd day of intervention. In the whole study group (363 children), the duration of diarrhoea was approximately 24 h shorter in the S. boulardii group (75.4±33.1 vs 99.8±32.5 h, P<0.001). The effect of S. boulardii (diarrhoea-free children) was observed starting at 48 h. After 72 h, only 27.3% of the children receiving probiotic still had watery diarrhoea, in contrast to 48.5% in the control group (P<0.001). The duration of diarrhoea was significantly reduced in the probiotic group in hospital, ECU and outpatient settings (P<0.001, P<0.01 and P<0.001, respectively). The percentage of diarrhoea-free children was significantly larger after 48 and 72 h in all settings. The mean length of hospital stay was shorter with more than 36 h difference in the S. boulardii group (4.60±1.72 vs 6.12±1.71 days, P<0.001). The mean length of ECU stay was shorter with more than 19 h difference in the probiotic group (1.20±0.4 vs 2.0±0.3 days, P<0.001). No adverse effects related to the probiotic were noted. Because treatment can shorten the duration of diarrhoea and reduce the length of ECU and hospital stay, there is likely a social and economic benefit of S. boulardii CNCM I-745 in adjunction to oral rehydration solution in acute infectious gastroenteritis in children.

Contemporary Management of Medium-Sized (10-20 mm) Renal Stones: A Retrospective Multicenter Observational Study

PURPOSE

To evaluate contemporary management approaches to medium-sized (10-20 mm) renal stones.

PATIENTS AND METHODS

A total of 935 patients treated for medium-sized renal stones (10-20 mm) between July 2012 and March 2014 were included in the study program. Contemporary minimally invasive approaches applied in the management of such stones were evaluated and compared.

RESULTS

The cohort consisted of 561 male (60%) and 374 female (40%) patients. Of the 935 patients with medium-sized renal calculi, 535 (57.2%) were treated with shockwave lithotripsy (SWL), 201 (21.4%) with retrograde intrarenal surgery (RIRS), 110 (11.7%) with minimally invasive percutaneous nephrolithotomy (miniperc), and the remaining 89 (11.7%) patients with micropercutaneous nephrolithotomy (microperc). In the SWL group, stones were located mostly in the pelvis (51%), while in the miniperc and microperc groups, they were located mainly in the lower pole (46%, 53%, respectively). Stone-free rates after a single session were 77.2%, 86.1%, 88.8%, and 83.6% in the SWL, RIRS, microperc, and miniperc groups, respectively. Although no serious complications (above Clavien level III) were noted in any of the groups evaluated, Clavien I to II complications were common in the miniperc group.

CONCLUSION

Although SWL is the preferred treatment option for patients with medium-sized (10-20 mm) renal stones, endourologic methods also have been found to have a significant role. Relatively lower complication rates along with higher stone-free status observed with the RIRS technique compared with percutaneous approaches have made this method a valuable option in the management of such stones in recent years.

Macular injury resulting from a high-powered tank laser telemetry device

A high-powered laser is an essential part of a modern military rangefinder; however, this paper presents three cases with macular injury resulting from a high-powered tank laser telemetry device. All injuries occurred when another user deliberately pointed the telemetry target unit at the patient's eyes. The devastating effect of this high-powered laser resulted in a permanent foveal scar in the second patient and a macular hole formation in the third patient. This report emphasises that education plays a primary role in preventing accidental laser injuries. Using general guidelines and safety regulations will prevent accidental macular injuries.

Amniotic fluid lamellar body count as a novel biochemical marker for timing elective caesarean delivery

The aim of this study is to evaluate the performance of amniotic fluid lamellar body count (LBC) on the timing of elective caesarean delivery (CS) at ≥ 39 weeks. After allocating the study group (group I, transient tachypnoea of newborn (TTN), n = 14), an age-matched control group (group II, no TTN, n = 79) was selected for amniotic fluid LBC analysis. The median amniotic fluid LBC levels in group I were significantly lower than in the control group. Furthermore, the median values of mean lamellar body volume, median lamellar body distribution width and lamellar bodycrit in group I were also significantly lower than in group II. The best amniotic fluid LBC value to predict TTN was 40.15 × 10(3)/μl, with 82.3% sensitivity and 64.3% specificity. The favourable sensitivity and specificity values to predict the TTN for amniotic fluid LBC may suggest using it as an elective caesarean delivery-time scheduling marker.

Protective effects of growth hormone on bacterial translocation and intestinal damage in rats with partial intestinal obstruction

OBJECTIVE

One of the reasons of bacterial translocation (BT) is the complete or partial intestinal obstructions (PIO) of the gastrointestinal system. In this study, we aimed to investigate the effects of recombinant human Growth Hormone (rhGH) on BT in rats with partial intestinal obstruction (PIO).

MATERIAL AND METHODS

The rats were randomly divided into the 4 groups: Group I: Sham-operated (SO) (n = 12), Group II control PIO (n = 12), Group III: PIO with rhGH treatment for 5 days (n = 12), Group IV: PIO with rhGH treatment 5 days before PIO and 5 days after PIO (a total of 10 days) (n = 12). In the groups III and IV, the effects of 5 and 10 days administered rhGH were examined.

RESULTS

The level of serum and of intestinal fluid IgA was significantly higher in the Group IV compared to the Group I, Group II and Group III. In the Group IV, the number of small intestinal goblet and colonic goblet cells, and the lengths of intestinal mucosal villi and crypt depths were statistically significantly higher than in Groups II and III. The rate of bacterial translocation was higher in the Group II: 100 % in MLNs, 41.6 % in blood culture and 50.8 % in the liver cultures, it was significantly higher compared to the other groups (p < 0.01).

CONCLUSIONS

The study results demonstrated that administration of rhGH to the rats with PIO for at least 10 days decreased bacterial translocation (Fig. 3, Ref. 25).