Patterns of treatment of high-risk BCG-unresponsive non-muscle invasive bladder cancer (NMIBC) patients among Arab urologists

PURPOSE

To understand the treatment plans suggested for BCG-unresponsive non-muscle invasive disease (NMIBC) patients in the Arab countries and therapeutic decisions applied for BCG-naive patients during BCG shortage time.

METHODS

A 10-minute online survey was distributed through the Arab Association of Urology (AAU) office to urologists in the Arab countries who treat patients with NMIBC.

RESULTS

One hundred six urologists responded to the survey. The majority of urologists had treated, in the past 6 months, > 10 patients with NMIBC who were considered BCG-unresponsive (55% of respondents). Radical cystectomy (RC) was the most popular treatment option (recommended by 50%) for these patients. This was followed by intravesical chemotherapy (30%), repeat BCG therapy (12%), resection with ongoing surveillance (8%). Clinical trials and intravenous checkpoint inhibitors were never selected. The most preferred intravesical chemotherapy was by ranking: 60% gemcitabine, 19% mitomycin C, 8% docetaxel, 8% gemcitabine/docetaxel, 4% sequential gemcitabine/mitomycin C, and 1% valrubicin. The use of intravesical chemotherapy appears limited by Arab urologists due to concerns regarding clinical efficacy (fear of progression) and the lack of clear recommendations by urology societies. Given the BCG shortage, which may vary per Arab country, Arab urologists have adjusted by prioritizing BCG for T1 and carcinoma in situ (CIS) patients over Ta, adapting intravesical chemotherapy, and reducing the dose/strength of BCG administered. Most physicians report an eagerness to utilize novel therapies to address the BCG deficit, especially to try intravesical chemotherapy.

CONCLUSIONS

Even though Arab urologists are in the majority of cases selecting RC for BCG-unresponsive cases, one-third of them are most recently initiating intravesical chemotherapy as an alternative option. To further assist Arab urologists in the appropriate selection of BCG unresponsive high risk NMIBC patient treatments, enhanced education and pathway protocols are needed.

Effects of first year COVID-19 pandemic on urology practice in three major Arab Countries: Sub-Analysis of a survey by Arab association of urology research group

BACKGROUND AND OBJECTIVES

The World Health Organization (WHO) declared the coronavirus disease-19 (COVID-19) pandemic on March 11, 2020. The health care system faced tremendous challenges in providing ethical and high-quality care. The impact of COVID-19 on urological practices varied widely worldwide, including in Arab countries. This study aimed to compare the influence of the COVID-19 pandemic on urology practice in Egypt, the KSA, and the UAE during the first year of the pandemic.

METHODS

This sub-analysis assessed the demographics and COVID-19's effects on urological practice in terms of adjustments to hospital policy, including outpatient consultations, the management of elective and urgent surgical cases, and the continuation of education across the three countries. The availability of personal protective equipment (PPE) and urologists' emotional, physical, and verbal intimidation during COVID-19 were also compared.

RESULTS

Regarding the impact on hospital policy, consultations replaced by telemedicine were significantly higher in the KSA (36.15%), followed by the UAE (33.3%), then Egypt (10.4%) (P = 0.008). Elective cases requiring ICU admission were 65.1% in Egypt, 45.2% in the KSA, and 58.2% in the UAE and were performed only in high-risk patients. PPE was freely available in 20.8% of the Egyptian hospitals compared to 83.3% in the KSA and 81.8% in the UAE. Online courses were significantly higher in Egypt (70.8%), followed by the UAE (53%) and the KSA (41.7%) (P = 0.02). Emotional intimidation was higher than verbal intimidation, representing 80%, 75.9%, and 76% in the UAE, KSA, and Egypt, respectively.

CONCLUSION

This sub-analysis outlined significant hospital policy changes across the three Arab countries. Exposure to emotional, verbal, and physical intimidation was observed. The development of teleconsultations and online platforms for educational purposes was observed.

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.

Androgenic-anabolic steroid abuse trend and management: A prospective, cross-sectional, questionnaire-based survey

Background and Aims

Androgenic-anabolic steroid (AAS) abuse is a global health concern, studies revealing an increasing trend of abuse and deleterious effects on reproductive health. Unfortunately, there is no consensus about management pathways due to the lack of specific guidelines.

Methods

A prospective study, multicentre, online survey, composed of 30 questions, was conducted to investigate the current trend of AAS abuse and the management followed by practitioners from different specialities dealing with this condition.

Results

A total of 151 respondents were included. The majority were general urologists (68.21%), andrologists (22.51%), and endocrinologists (9.28%). An increasing trend of AAS abuse was noticed by 90.73% of participants mostly in young age populations. Most of AAS abusers were presented with infertility (64.24%) and erectile dysfunction (59.60%), and their investigations showed abnormal semen analysis (77.48%), abnormal hormones (follicle-stimulating hormone, luteinizing hormone, testosterone, and estradiol) (94.70%), and reduction in testicular size (50.33%). Most of respondents expected: the need of long duration for spontaneous recovery (6-12 months), relapse of AAS abuse in one-third of patients, less knowledge about the adverse effects (39.74%), and risk of drug dependence (54.30%). Immediate treatment was the most offered plan of management (44.37%) followed by a waiting spontaneous recovery (32.45%), while the remaining would refer the patients to an either endocrinologist or andrologist. The treating physicians did not follow specific guidelines and most of participants (44.44%) reverted to their personal experience in the management.

Conclusions

Our study revealed an increasing trend of AAS abuse, deleterious effects of AAS use on reproductive health, and lack of consensuses among the treating physicians regarding the management of related adverse effects. Our study could be considered a call to the scientific bodies to have more studies, establish guidelines for management, and to have better awareness of this serious public health concern.

European Association of Urology Section of Urolithiasis and International Alliance of Urolithiasis Joint Consensus on Retrograde Intrarenal Surgery for the Management of Renal Stones

BACKGROUND

Retrograde intrarenal surgery (RIRS) has become the preferred treatment modality for nephrolithiasis. However, because of ongoing uncertainties regarding the optimal perioperative management, operative technique, and postoperative follow-up, as well as a lack of standardization for outcome reporting, consensus is needed to achieve more uniform clinical practice worldwide.

OBJECTIVE

To develop recommendations for RIRS on the basis of existing data and expert consensus.

DESIGN, SETTING, AND PARTICIPANTS

A protocol-driven, three-phase study was conducted by the European Association of Urology Section of Urolithiasis (EULIS) and the International Alliance of Urolithiasis (IAU). The process included: (1) a nonsystematic review of the literature to define domains for discussion; (2) a two-round modified Delphi survey involving experts in this field; and (3) an additional group meeting and third-round survey involving 64 senior representative members to formulate the final conclusions.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

The results from each previous round were returned to the participants for re-evaluation of their decisions during the next round. The agreement threshold was set at 70%.

RESULTS AND LIMITATIONS

The panel included 209 participants who developed 29 consensus statements on the following topics of interest: (1) perioperative infection management; (2) perioperative antithrombotic therapy; (3) fundamentals of the operative technique; and (4) standardized outcome reporting. Although this consensus can be considered as a useful reference for more clinically oriented daily practice, we also acknowledge that a higher level of evidence from further clinical trials is needed.

CONCLUSIONS

The consensus statements aim to guide and standardize clinical practice and research on RIRS and to recommend standardized outcome reporting.

PATIENT SUMMARY

An international consensus on the best practice for minimally invasive surgery for kidney stones was organized and developed by two international societies. It is anticipated that this consensus will provide further guidance to urologists and may help to improve clinical outcomes for patients.

How did the first year of the COVID-19 pandemic affect urology practice in Arab countries? A cross-sectional study by the Arab Association of Urology research group

Objective:

The aim of this study was to assess of the effect of coronavirus disease 2019 (COVID-19) pandemic on urology practice in the Arab world during the first year of the crisis.

Methods:

An Internet-based questionnaire was created and sent out via email to members of the Arab Association of Urology (AAU) using ‘Google Forms’. The survey assessed participants’ demographics in terms of age, gender, country of origin, type of practice and position. Impacts of COVID-19 on urological practice were assessed in terms of the changes in hospital policies regarding consultations, and elective and emergency surgical cases. Moreover, impacts of COVID-19 on urologists were assessed.

Results:

A total of 255 AAU members across 14 Arab countries (Emirates, Egypt, Saudi Arabia, Iraq, Jordan, Algeria, Kuwait, Yemen, Qatar, Lebanon, Libya, Oman, Sudan and Syria) completed the survey; 4% were female urologists. Consultations at outpatient clinics were closed or restricted to emergency cases or replaced by telemedicine in almost 15%, 40% and 25% of hospitals, respectively. Elective surgeries were stopped or reduced to under 25% of surgical capacity in >10% and about 25% of hospitals, respectively. Almost 90% (228) reported changes in the policy for emergency theatres. Nearly 65% of hospitals offered preoperative COVID-19 testing to patients and 50% of hospitals provided personal protective equipment (PPE) to their urologists. Of 99% (253) who reported a change in urological education, 95% relied on online webinars. About 56% of respondents had their own private practice, of whom 91% continued private practice during the crisis. About 38% of participants reported exposure to intimidation (75% emotional, 20% verbal and 5% physical).

Conclusion:

The COVID-19 pandemic resulted in major changes in hospitals’ policies regarding outpatient consultations, elective and emergency operative cases, and the shift to telemedicine. Arab urologists have been facing major challenges either in both the governmental or the private sectors, and some of them were exposed to emotional, verbal and even physical intimidation.

European Association of Urology Section of Urolithiasis and International Alliance of Urolithiasis Joint Consensus on Percutaneous Nephrolithotomy

CONTEXT

Although percutaneous nephrolithotomy (PCNL) has been performed for decades and has gone through many refinements, there are still concerns regarding its more widespread utilization because of the long learning curve and the potential risk of severe complications. Many technical details are not included in the guidelines because of their nature and research protocol.

OBJECTIVE

To achieve an expert consensus viewpoint on PCNL indications, preoperative patient preparation, surgical strategy, management and prevention of severe complications, postoperative management, and follow-up.

EVIDENCE ACQUISITION

An international panel of experts from the Urolithiasis Section of the European Association of Urology, International Alliance of Urolithiasis, and other urology associations was enrolled, and a prospectively conducted study, incorporating literature review, discussion on research gaps (RGs), and questionnaires and following data analysis, was performed to reach a consensus on PCNL.

EVIDENCE SYNTHESIS

The expert panel consisted of 36 specialists in PCNL from 20 countries all around the world. A consensus on PCNL was developed. The expert panel was not as large as expected, and the discussion on RGs did not bring in more supportive evidence in the present consensus.

CONCLUSIONS

Adequate preoperative preparation, especially elimination of urinary tract infection prior to PCNL, accurate puncture with guidance of fluoroscopy and/or ultrasonography or a combination, keeping a low intrarenal pressure, and shortening of operation time during PCNL are important technical requirements to ensure safety and efficiency in PCNL.

PATIENT SUMMARY

Percutaneous nephrolithotomy (PCNL) has been a well-established procedure for the management of upper urinary tract stones. However, according to an expert panel consensus, core technical aspects, as well as the urologist's experience, are critical to the safety and effectiveness of PCNL.

A prospective randomised controlled study comparing bipolar plasma vaporisation of the prostate to monopolar transurethral resection of the prostate

Objectives

To compare the safety and efficacy of bipolar transurethral plasma vaporisation (B-TUVP) as an alternative to the ‘gold standard’ monopolar transurethral resection of the prostate (M-TURP) for the treatment of benign prostatic hyperplasia (BPH) in a prospective randomised controlled study.

Patients and methods

In all, 82 patients indicated for prostatectomy were assigned to two groups, group I (40 patients) underwent B-TUVP and group II (42 patients) underwent M-TURP. The safety of both techniques was evaluated by reporting perioperative changes in serum Na⁺, serum K⁺, haematocrit (packed cell volume), and any perioperative complications. For the efficacy assessment, patients were evaluated subjectively by comparing the improvement in International Prostate Symptom Score and objectively by measuring the maximum urinary flow rate (Q_max) and post-void residual urine volume (PVR) before and after the procedures.

Results

In group II, there was a significant perioperative drop in serum Na⁺ (from 137.5 to 129.4 mmol/L) and haematocrit (from 42.9% to 38.2%) (both P < 0.001). Moreover, one patient in group II had TUR syndrome. The remote postoperative complication rate was (15%) in group I and comprised of stress urinary incontinence (5%), bladder outlet obstruction (5%), and residual adenoma (5%). In group II, the remote postoperative complication rate was (4.8%), as two patients developed urethral stricture. There were statistically significant improvements in micturition variables postoperatively in both arms, but the magnitude of improvement was statistically more significant in group II.

Conclusion

B-TUPV seems to be safer than M-TURP; however, the lack of a tissue specimen and the relatively high retreatment rate are major disadvantages of the B-TUVP technique. Moreover, M-TURP appears to be more effective than B-TUPV and its safety can be improved by careful case selection and adequate haemostasis.

Stepwise evolution of pandrug-resistance in Klebsiella pneumoniae

Carbapenem resistant Enterobacteriaceae (CRE) pose an urgent risk to global human health. CRE that are non-susceptible to all commercially available antibiotics threaten to return us to the pre-antibiotic era. Using Single Molecule Real Time (SMRT) sequencing we determined the complete genome of a pandrug-resistant Klebsiella pneumoniae isolate, representing the first complete genome sequence of CRE resistant to all commercially available antibiotics. The precise location of acquired antibiotic resistance elements, including mobile elements carrying genes for the OXA-181 carbapenemase, were defined. Intriguingly, we identified three chromosomal copies of an ISEcp1-bla(OXA-181) mobile element, one of which has disrupted the mgrB regulatory gene, accounting for resistance to colistin. Our findings provide the first description of pandrug-resistant CRE at the genomic level, and reveal the critical role of mobile resistance elements in accelerating the emergence of resistance to other last resort antibiotics.

Role of posterior tibial nerve stimulation in the treatment of refractory monosymptomatic nocturnal enuresis: a pilot study

PURPOSE

We evaluated the early clinical and urodynamic results of posterior tibial nerve stimulation in patients with refractory monosymptomatic nocturnal enuresis.

MATERIALS AND METHODS

We randomly assigned 28 patients with refractory monosymptomatic nocturnal enuresis to 2 equal groups. Group 1 received a weekly session of posterior tibial nerve stimulation for 12 weeks and group 2 was the placebo group. Evaluation was performed in each group at baseline and after posterior tibial nerve stimulation to compare clinical and urodynamic findings. Another clinical assessment was done 3 months after the first followup.

RESULTS

The 2 groups were comparable in baseline clinical and urodynamic data. Overall, 13 patients (46.4%) had detrusor overactivity and 14 (50%) had decreased bladder capacity. After treatment 11 group 1 patients (78.6%) had a partial or full response to posterior tibial nerve stimulation but only 2 (14.3%) in group 2 had a partial response (p = 0.002). Also, the average number of wet nights in group 1 was significantly lower than at baseline (p = 0.002). All urodynamic parameters significantly improved in group 1. In contrast, the number of wet nights and urodynamic parameters did not change significantly in group 2. At 3-month followup the number of patients with a partial or full response in group 1 had decreased from 11 (78.6%) to 6 (42.9%). No change was evident in group 2.

CONCLUSIONS

Posterior tibial nerve stimulation can be a viable treatment option in some patients with refractory monosymptomatic nocturnal enuresis. However, deterioration in some responders with time suggests the need for maintenance protocols.