The abstracts published in this supplement were selected by the Conference Committee and have not been peer reviewed. The Emirates Urological Society and Pan Arab Continence Society take responsibility for the content and scientific integrity of the abstracts.
Management of non-obstructive azoospermia with extracorporeal shock wave therapy and platelet-rich plasma
Maya Epifanova1
, Andrey Kostin
1,
Elena Gameeva
1,
Grigory Demyashkin
2,
Sergey Artemenko
1,
Alexander Epifanov
3
1Peoples Friendship University Of Russia (RUDN University), Moscow, Russian Federation, 2National Medical Research Radiological Centre, Moscow, Russian Federation, 3A.I. Yevdokimov Moscow State University of Medicine and Dentistry, Moscow, Russian Federation
Aims: The aim of our study is to determine and evaluate the effectiveness of platelet-rich plasma (PRP) and extracorporeal shock wave therapy (ESWT) in non-obstructive azoospermia.
Methods: Overall, 14 adult men with non-obstructive azoospermia were included. The diagnosis was confirmed by the testicular sperm extraction (TESE) before the treatment. However, 14 patients were divided into two groups. Group 1 had a normal baseline level of follicle-stimulating hormone (FSH) (n = 5), the mean age was 31 (28–43) years. Group 2 had a high level of FSH (n = 9), the mean age was 33 (28–40) years. All participants received two therapy sessions per week for 6 weeks. Session 1 included ESWT per testicle and ultrasound-guided PRP injections into the testicles and spermatic cords; finally, PRP was activated with ESWT. Session 2 included ESWT (Dornier Aries) per testicle. All men were evaluated at the beginning and at the end of the study (90 days after the last session) using hormonal profile, spermiogram, and scrotal ultrasound (median). In addition, a repeat TESE was performed on 180 days after the last session. The study was approved by Ethics Committee of the RUDN Medical Institute.
Results: FSH level in group 1 increased from 6.5 to 7.7 mIU/ml (p < 0.001), and FSH level in group 2 decreased from 15.7 to 14.8 mIU/ml (p < 0.001). Luteinizing hormone (LH) level in group 1 increased from 4.7 to 5.1 mIU/ml (p = 0.03). LH level in group 2 showed no changes – 7.8 mIU/ml. Testosterone level in group 1 decreased from 13.9 to 12.6 nmol/liter; testosterone level in group 2 increased from 12.8 to 16.0 nmol/liter. The majority of patients (n = 11) showed the positive dynamics. Only two men (14%) showed no changes. What is also important to note is that, in seven cases, we recorded more ‘advanced’ stages of spermatogenesis after the treatment (only spermatogonia was presented at baseline). One patient who was initially diagnosed with subtotal aplasia of male germ cells after therapy spermatozoa was found. However, 2 points (1–6) in group 1 according to modified Johnson scoring system (MJS) changed to 4 points (2–7). Whereas, 2 points (1–6) in group 2 according to MJS changed to 4 points (1–8). Meanwhile, 2 points (2–3) according to Leydig score changed to 4 points (3–5) in group 1. Also, 2 points (1–2) according to Leydig score changed to 5 points (1–5) in group 2. In group 1, spermatozoa were detected in one case; in group 2, spermatozoa were detected in four cases. In addition, combined treatment improved testicular blood flow and increased the value of the fibrous component. We recorded three (21.4%) pregnancies conceived by ART in group 2.
Conclusion: No serious adverse events or serious adverse reactions were observed in our cohort of patients. Therapy seems to be able to manage hormonal profile, increase testicular blood flow, promote to the restoration of the fibrous component of the blood-testicular barrier, and improve spermatogenesis.
The possibility of using extracorporeal shockwave therapy in the treatment of chronic prostatitis
Maya Epifanova1
, Andrey Kostin
1,
Elena Gameeva
1,
Badri Gvasalia
2,
Sergey Artemenko
1,
Vladimir Baranov
2,
Alexander Epifanov
3
1Peoples Friendship University Of Russia (RUDN University), Moscow, Russian Federation, 2Moscow State University of Food Production (MSUFP), Moscow, Russian Federation, 3A.I. Yevdokimov Moscow State University of Medicine and Dentistry, Moscow, Russian Federation
Introduction: The aim of this study was to evaluate the effectiveness of low-intensity extracorporeal shockwave therapy (LI-ESWT) in the treatment of chronic prostatitis (CP).
Methods: The study included 43 patients with CP. The patient’s mean age was 38 (27–65) years. The mean CP duration was 13.5 (3–24) months. However, 43 patients were divided into three groups based on transrectal ultrasound (TRUS) investigation. Group 1 had fibrotic changes in the prostate (n = 21). Group 2 had prostate calcifications (n = 5). Group 3 had fibrotic changes and calcifications in the prostate (n = 17). All patients received LI-ESWT (Dornier Aries) twice a week for 6 weeks. Each ESWT session comprised 2000–3500 pulses (0.05–0.062 mJ/mm2) and 8–6 Hz of frequency. The patients were examined on 0 and 60 days of the research using National Institutes of Health Chronic Prostatitis Symptom Index (NIH-CPSI), International Prostate Symptom Score (IPSS), TRUS of the prostate [mean (min&max)], the culture of seminal or prostate fluid, spermogram or prostate fluid analysis, and serum prostate-specific antigen (PSA; for men above 50 years of age).
Results: Patients aged above 50 years had a total PSA less than 4 ng/ml. Bacterial growth was found in 26 cases. They were additionally prescribed antibiotics according to antibiogram. NIH-CPSI decreased from 13.39 (1–34) to 5.54 (0–24) (p < 0.05), IPSS decreased from 11.39 (0–34) to 4.39 (0–29) (p < 0.05). Prostate volume decreased from 25.18 (12.2–58.8) to 22.78 (12–56.6) cm3 according to TRUS (p > 0.05). In group 1, in three patients, local fibrosis was completely resolved, and fibrotic changes decreased from 5.3 (0–13) to 3.24 (0–8.1) mm in 18 cases. In group 2, the number and the size of calcifications decreased from 6.92 (2–21) to 4 (0–20) mm (p > 0.05). In group 3, calcifications were completely resolved, the volume of fibrosis decreased from 6.8 (3.2–15) to 4.9 (1–17) mm (p < 0.05), and the calcification zone was replaced by fibrosis (17 mm) in one case. Bacterial growth was not found in 9 patients’ seminal/prostate fluid, and 16 patients had a decrease in the causative agent concentration on day 60.
Conclusion: The results suggest that LI-ESWT is an effective non-invasive medical treatment of CP.
The efficacy of tissue glue compared with suture approximation for wound approximation in pediatric circumcision: a meta-analysis of randomized controlled trials
Yufi Azmi
, Niwanda Yogiswara, Johan Renaldo
Urology Departement, Universitas Airlangga, Surabaya, Indonesia
Introduction: Tissue glue has been examined extensively for its effectiveness in pediatrics, and the findings are positive. The purpose of this research was to examine the effectiveness of tissue glue compared to absorbable suture for wound approximation in pediatric circumcision.
Methods: A systematic review and meta-analysis of the English literature (1997–2021) on children who had circumcision using tissue glue and absorbable suture was performed in line with the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) criteria. RevMan 5.4 was used to perform the meta-analysis. The mean differences for continuous and dichotomous data are determined using inverse variance, and the odds ratio was calculated using the Mantel–Haenszel technique.
Results: The inclusion criteria were met by six trials containing a total of 817 patients. According to the analysis, tissue glue significantly reduces pain severity [Standardized mean difference (SMD): −0.56; 95% CI (−0.80, −0.66); p < 0.00001], the duration of pain [MD: −0.56; 95% CI (−2.57, −2.08); p < 0.00001], and the duration of the operation [MD: −7.98; 95% CI (−12.35, −3.62); p = 0.0003] compared to absorbable suture. However, we found that there was no significant difference in the incidence of postoperative bleeding, infection, dehiscence, or overall complication when comparing absorbable suture to traditional suture.
Conclusion: Our systematic review and meta-analysis using the most recent data suggest that tissue glue usage might lower the operation time, and the intensity and duration of postoperative pain.
Outcomes of percutaneous nephrolithotomy: initial experiences of 100 cases
Mohammad Ibrahim Ali1
, Moatafiger Rahman
2,
Mohammad Faruk Hossain
3,
Nahid Kamal
4
1Urology Department, Mymensingh Medical College Hospital, Mymensingh, Bangladesh, 2Prime Medical College, Rangpur, Bangladesh, 3Shaheed Ziaur Rahman Medical College, Bogra, Bangladesh, 4Mymensingh Medical College, Mymensingh, Bangladesh
Objectives: Percutaneous nephrolithotomy (PCNL)has been practiced successfully in many centers in Bangladesh since 2000. The aim of the study was to describe the initial experience of first 100 cases by a single surgeon.
Methods: The study was carried out in Mymensingh Medical College Hospital from January 2020 to October 2021. A total of 100 PCNLs performed by the same surgeon were included in this study. Stone size was 10 mm to staghorn involving any calyx with or without pelvis. All patients were evaluated as per hospital protocol. The standard operative procedure was followed in every case. The radiological and sonographic evaluation was done 3 weeks after the operation to see stone clearance. Stone size > 4 mm was considered as residual stone.
Results: A total of 100 PCNLs were done in this period. Among them were 68 males and 32 females. The mean age was 37 ± 8.32(15–80) years. The stone size was 10 mm. The mean operation time was 75 ± 28.6 min. Blood transfusion is required in 12 cases. However, 10 cases required one unit transfusion, 1 case required two units, and 1 case needed three units of blood transfusion. Second-look PCNL was required in one case due to hard staghorn calculus with tract displacement and excessive bleeding which required three units of blood transfusion. The pelvicalyceal injury occurred in four cases, and lung or pleural injury was not diagnosed in any case. Colon injury occurred in one case which was managed by exploration and defunctioning loop ileostomy. A nephrostomy tube was placed in 38 cases, and a nephrostomy tubeless PCNL was done in 62 cases. The mean hospital stay was 2.25 ± 0.53 days. Postoperative urinary leakage wound infection occurred in 12 cases; among them, 1 case was due to Tuberculosis. Complete stone clearance occurred in 88 cases. Among 12 residual cases of residual stones, 5 cases were managed by extracorporeal shock wave lithotripsy (ESWL) and 3 cases required additional ureteroscopic stone removal, and in 4 cases, residual stone was located in calyx without any pelvicalyceal obstruction and advised for follow-up.
Conclusion: PCNL is a popular treatment option for any size renal stones located in any calyces. Although its high success rate, it has some complications.
First launch of 3D-printed high-fidelity hypospadias models, for hands-on training of standard hypospadias repairs
Abeer Aboalazayem1,2
, Muhammad Ba’Ath
3,
Mahmoud Marei
1,2
1Kasralainy School of Medicine, Cairo University, Cairo, Egypt, 2Cairo University Specialized Pediatric Hospital, Cairo, Egypt, 3American Hospital Dubai, Dubai, United Arab Emirates
Introduction: Simulated training in Pediatric Surgery/Urology is gaining significance due to the following reasons: (a) being a specialty of rare diseases affects individual surgeon’s exposure to index cases; (b) subspecialty areas are not universally accessible; and (c) Covid-19 affected elective surgery. Consequently, targeted training, via workshops and simulated models, is necessary. Hypospadias is the index case/operation in Pediatric Urology, requiring a spectrum of dissection and reconstruction skills. It is further challenging to revisit and redo, thus sound initial repair is crucial.
To date, there has been no successfully utilizable 3D-printed hypospadias model. We hereby present our experience with silicone 3D-printed high-fidelity hypospadias models.
Methods: Overall, 27 trainees from different countries, under the supervision of 15 instructors, completed the training exercise. They were all given a seminar to show the relevant anatomy and eight key steps of the exercise. Each trainee filled a structured assessment form for the quality of the exercise and resemblance to live surgery. Each exercise was evaluated by a trainer on-site, who supervised the activity and two independent assessors through photographs of the cardinal steps.
Results: In total, 11 (40.7%) trainees had 1–3 years of specialist training experience, 10 (37%) had 4–6 years, and 6 (22.2%) had beyond. Meanwhile, 2 (7.4%) trainees had no hypospadias experience, 16 (59.2%) assisted in procedures or performed steps, 5 (18.5%) performed whole procedures with guidance, and 4 (14.8%) without guidance. The trainees rated each step from unsatisfactory (1/5) to excellent (5/5) for each of the (1) degloving; (2) urethral marking; (3) incision; (4) tubularization; (5) glanuloplasty; (6) dartos layer preparation; (7) preputioplasty, and (8) skin closure. However, 20 (74%) trainees and 15 (100%) instructors judged the model to resemble the anomaly. Meanwhile, 17 (63%) trainees and 13 (86.6%) instructors rated needle penetrability of the material compared to human tissue ⩾ 3/5. In total, 16 (59%) trainees and 13 (86.6%) instructors rated suture holding ⩾ 3/5. Moreover, 11 (73.3%) and 13 (86.6%) instructors rated sutures’ evenness and edge cooptation ⩾ 3/5.
Conclusion: Majority of instructors found this 3D-model able to mediate transferring skills. Trainees reported adequate skill acquisition.
Management of cavernovenous leakage: a series of 133 patients with symptoms, hemodynamic work-up, and results of surgery
Eric Allaire1
, Helene Sussman
2,
Jean Floresco
2,
Pascal Hauet
2,
Ronald Virag
2
1Paris American Hospital, Paris, France, 2CETI, Paris, France
Introduction: Cavernovenous leakage (CVL) is a devastating although barely known disease, which is the first cause of major physical impairment in men below 25 years of age, and responsible for 50% of resistances to phosphodiesterase 5-inhibitors (PDE5-I) affecting 30–40% of users in this medication class. In this condition, too early blood drainage from corpora cavernosa prevents penile rigidity and penetration during sexual intercourses. The role of conservative surgery in this disease remains controversial.
Aim: The main aim of this study was to assess complications and results of combined open surgery and embolization for CVL
Methods: Between June 2016 and September 2021, 133 consecutive patients underwent surgery in our institution for CVL causing severe erectile dysfunction (ED) resistant to oral medical treatment. Procedures combined vein embolization and ligation with microsurgical techniques. We performed a pre- and postoperative clinical (Erection Hardness Scale: EHS), hemodynamic evaluation by duplex sonography in all patients. Before surgery, CVL network was visualized by computed tomography cavernography. Penile electromyography (EMG) was performed in case of diabetes or suspected other neurological condition. All patients were optimized for hormonal status. Data were prospectively recorded.
Results: Clinical signs suggesting CVL were ED since age lower than 25 years, loss of erection when changing position, and penile rigidity varying according to position. Main complications were minor pulmonary embolism in two patients, one after airline travel, one with Factor V Leiden heterozygote mutation, one infection and three hematomas requiring reoperation, and one decreased gland sensitivity lasting for more than 1 year. Mean preoperative pharmacologic EHS was 2.37 ± 0.64, mean pharmacologic postoperative EHS was 3.21 ± 0.60, p < 0.0001 (paired t-test). Mean EHS variation was 0.87 ± 0.74. After surgery, 81.5% of patients had a pharmacologic EHS equal or more than 3, allowing for intercourse with penetration. Three patients (2.2%) experienced lower postoperative EHS. Main cause of failure was leakage from the deep dorsal aspect of corpus cavernosa. In a 14-month follow-up, 83.2% patients had a clinical EHS equal or more than 3, allowing for sexual intercourse with penetration, one-third of them without any medication. Five patients had a penile implant after unsuccessful conservative surgery.
Conclusion: Open surgery combined to embolization for CVL is an efficient approach to CVL causing severe ED.
Prospective randomized comparison of efficacy of tamsulosin versus mirabegron for ureteric stent-related symptoms: validated questionnaire-based assessment
Manish Garg1,2
1NMC Speciality Hospital, Dubai, United Arab Emirates, 2IVY Hospital, Hoshiyarpur, India
Introduction: The aim of the study was to determine the efficacy of Mirabegron in comparison with Tamsulosin in relieving ureteral stent-related symptoms in a prospective randomized study.
Methods: In this study between January 2016 and February 2018, 104 patients (Mage = 35.5 years) with indwelling DJ stent after renal/ureteric stone removal procedures, such as Ureteroscopic Lithotripsy (URS) or Percutaneous Nephrolithotripsy (PCNL), were randomized into three groups: one group was given placebo, second group was given Tamsulosin 0.4 mg OD, and third group was given Mirabegron 50 mg OD until the stent was in situ for the average of 2 weeks. All the three groups were compared using Validated Ureteral Stent Symptom Questionnaire (USSQ) and Visual Pain Analogue Score (VAS) before stent removal as the primary end point of the study. Groups were evaluated related to different sub-domains of questionnaire. Statistical analysis was performed using one-way analysis of variance (ANOVA) with post hoc Tukey analysis in evaluating mean difference between specific pairs of groups with p < 0.05 considered statistically significant.
Results: Demographic profile, baseline characteristics, and stent indications were comparable in all the groups. All the domains of the USSQ had statistically significantly lower scores in both treatment groups, indicating efficacy of both the drugs in comparison to placebo. Urinary symptom score was significantly lower in Mirabegron group (17.31; range 3–31) as compared to Tamsulosin group (22.02; range 3–34) with a p-value of 0.036. Mean Body Pain score was lower in Tamsulosin group (9.35; range 3–18) as compared to Mirabegron group (11.8; range 4–21) with statistically significant difference (p = 0.009). Likewise, VAS score was non-statistically lower in Tamsulosin group (4.05; range 1–8) as compared to Mirabegron group (4.9; range 1–9) (p = 0.15). Remaining domains, including work performance, sex symptoms, and other symptoms, were comparable in both the treatment groups.
Conclusion: Mirabegron is more effective in relieving urinary symptoms while less effective in relieving body pain related to ureteric stent in comparison to Tamsulosin but comparable in other parameters, such as work performance, sexual, and other symptoms. Further multicentric large scale studies may be required to validate the results.
Lithotrite or laser in PCNL? An ex vivo assessment of stone phantom clearance rates: Trilogy™ versus Thulium fiber laser lithotripsy
Hammad Rauf1
, Charles O’Connor2, John O’Kelly1, Lorraine Scanlon1, Donnacha Hogan1, Derek Hennessey1
1Mercy University Hospital, Cork, Ireland, 2Mater Misercordiae University Hospital, Dublin, Ireland
Introduction: Lithotrites and high-power lasers are used for stone fragmentation in percutaneous nephrolithotomy (PCNL). This study aimed to evaluate and compare the efficiency of the newest lithotrite, the Trilogy to SuperPulsed Thulium fiber laser (TFL) ex vivo.
Methods: Kidney stone phantoms were made with BegoStone to produce calcium oxalate, calcium phosphate uric acid, and struvite stone phantoms. A 34 × 340 mm2 probe was used for the Trilogy, and a 500 µm laser fiber was used for the TFL. Stone clearance rates were then calculated. For each stone type, clearance rates were calculated for N = 3.
Results: For calcium oxalate stone phantoms, the clearance rate was 498.40 mm3/min for the Trilogy and 40.74 mm3/min for TFL. Calcium phosphate phantom clearance rate was 493.60 mm3/min for Trilogy and 39.65 mm3/min for TFL. Uric acid was cleared at a rate of 1267.61 mm3/min for Trilogy and 39.5 mm3/min for TFL. Struvite stone phantoms were also similar, 1299.64 versus 56.41 mm3/min. The Trilogy had statistically significantly faster stone clearance rates across all four stone types (p = 0.03). Use of the Trilogy results in complete fragment clearance, while the TFL left an extremely fine powder. In addition, a fluid temperature rise was noted. At a power of 10 W, the TFL caused a rise in temperature from 30°C to 43°C in 135 s (0.096/s). At a power of 20 W, the TFL resulted in the same temperature rise in 60 s (0.217/s).
Conclusion: The Trilogy lithotrite has statistically significantly faster stone clearance rates across all four stone types compared to TFL. Use of TFL was associated with a fluid temperature rise. Users of TFL need to be aware of this.
Transurethral laser ablation of non–muscle-invasive bladder cancer
Ayman Agag1
, Ahmed Ali
1,
Samer Jallad
2,
Mohamed Koura
2
1Frimley Park Hospital, UK, 2Wexham Park Hospital, UK
Introduction: Non–muscle-invasive bladder cancer (NMIBC) normally has a high recurrence rate. Treating these recurrences carries a risk of morbidity to those patients mainly due to the frequent resections under general anesthesia. Elderly patients with multiple morbidities are not usually fit for the conventional treatment under general anesthesia. Transurethral laser ablation (TULA) offers a technique using flexible cystoscopy for the treatment of bladder tumors under local anesthesia as an outpatient procedure. The used laser in TULA has the ability of simultaneous vaporization and coagulation offering a simple and safe method with minimal blood loss.
Methods: A total of 93 patients underwent TULA in the period from January 2021 to December 2021. Data were collected retrospectively from the electronic records – patients with recurrent low-risk NMIBC, elderly patients with comorbidities, patients on anticoagulants, and some selected cases with higher grades NMIBC or large tumors.
Results: The median age of the patients was 80 years. However, 49 patients (which is more than half of the number of the whole patients) were above the age of 80 years and 79 patients (85%) were above 70 years of age. Of these, 57% of the patients underwent tumor ablation only without the need for biopsies and 43% underwent tumor ablation plus biopsy. Biopsies were mainly taken when histology is clinically needed, where this might alter follow-up or treatment plans. However, 66% of the taken biopsies showed cancerous lesions and 34% were benign lesions. Meanwhile, 81% were low-grade pTa, 10% were high-grade pT1, and 9% were high-grade pTa. Patients usually undergo follow-up flexible cystoscopy ± biopsy in 3–6 months after the TULA session. However, 23% showed no recurrence in the flexible cystoscopy, 17% showed recurrent lesions, and 2% showed benign recurrences.
Conclusion: TULA avoids unnecessary or higher risk general anesthesia. It is well tolerated and has high patient satisfaction. TULA is making the treatment of (selected) bladder cancer cases quicker, safer, and easier. The recurrence rate is considered acceptable and comparable to the conventional methods. TULA lists free up a significant number of slots in the operating theater that could be used for other bladder cancer patients.
Endoscopic management of Upper Tract Urothelial Cancer (UTUC) – our experience of a feasible treatment strategic
M. Koura*, M. Ibrahim*, A. Desai**, J. Bhardwa*, H. Sharma*, J. Kalsi*
*Wexham Park Hospital, Frimley Health NHS Foundation Trust, UK, **Imperial College Healthcare NHS Trust, UK
Introduction: The gold standard treatment for organ-confined non-metastatic upper tract urothelial cancer (UTUC) is nephroureterectomy (NU); a major operation for which many elderly and comorbid individuals are not good candidates. Ureterorenoscopic laser ablation is an alternative treatment option for such patients. For select cases, endoscopic ablation of UTUC has been shown to yield comparable metastasis-free and cancer-specific survival rates to NU. We present analysis of all patients undergoing endoscopic ablation of their UTUC at our institute.
Methods: Data from the hospital’s electronic patient record system were analyzed for all patients being treated endoscopically with ureterorenoscopic holmium laser ablation of their UTUC at our institute. Patient and tumor-specific parameters were analyzed in addition to follow-up parameters, such as recurrence/progression of the urothelial cancer. Size of the UTUC was taken as maximum diameter of the filling defect measured on computerized tomographic (CT) scans.
Results: Over the last 4 years, 10 patients had their UTUC managed endoscopically at our institute. Mean age at the time of diagnosis was 84.9 (range 78–91) years, with an American Society of Anesthesiology (ASA) score of 3–4, that is, all patients were deemed to be a high anesthetic risk for major extirpative surgery. Mean serum creatinine and estimated glomerular filtration (eGFR) were 126 (range: 89–184) umol/liter and 45 (range: 31–59) ml/min/1.73 m2, respectively. One of the patients (10%) proceeded to NU after the first ureteroscopic ablative procedure. In total, 12 unilateral upper tract papillary tumors were found in 10 patients at diagnosis – 6 were renal pelvis and 6 were ureteric. Mean tumor size was 1.7 cm. Histological diagnosis was confirmed for all patients: five were G1 or 2 (low grade)pta, three were G2 (high grade)pta, and two were G3pta. Endoscopic clearance at the first ureterorenoscopic laser ablation procedure was achieved in six patients (60%). The median number of such procedures performed on each patient to date was 4 (range: 2–12) over a mean follow-up period of 25 (range: 15–36) months. Although the majority of patients had upper tract recurrences of superficial urothelial cancer on subsequent ureteroscopies, these were macroscopically cleared with laser ablation. There were no confirmed metastases on surveillance CT. Bladder recurrence of the urothelial cancer was found in 4 (40%) patients – all were found to be non–muscle invasive. There were two deaths during this follow-up period, neither were due to the urothelial cancer.
Conclusion: In carefully selected cases, endoscopic laser ablation of UTUC is an effective and important alternative treatment to NU. Analysis of our data supports the growing body of evidence that, in select cases, endoscopic ablation or nephron-sparing surgery can provide significant cancer-specific survival comparable to NU. Robust randomized comparative trials are necessary to further elucidate the relative efficacy of these different UTUC treatment strategies. In particular, these should be designed to assess the merits of broadening the indications and group of patients who are offered endoscopic management as first-line treatment.
Testicular mass: a rare presentation of Richter’s syndrome
Elsayed Desouky
, M. Koura, Jas Kalsi
Frimley Health NHS Trust, Slough, UK
Introduction: Richter’s syndrome is the transformation of indolent lymphoma into an aggressive form, most commonly diffuse large B cell lymphoma. Most patients are known to have chronic lymphocytic leukemia. Richter’s syndrome arises in the lymph nodes or bone marrow and rarely presents with extra nodal involvement.
Case presentation: A 72-year-old male patient presented with a painless right-sided scrotal swelling for few weeks. The patient had a history of G2Ta transitional cell carcinoma (TCC) of the bladder since 2016 and was on regular surveillance with cystoscopy and Mitomycin-C (MMC) intravesical treatment. Our patient had a history of stage A chronic lymphocytic leukemia (CLL) since 2015 and was under surveillance by hematology team. Scrotal examination revealed about 10 × 10 cm2 hard non-tender right-sided scrotal mass with normal left testicle. There was no peripheral lymphadenopathy or organomegaly.
Peripheral blood counts showed WBC = 17.5 × 109/liter with neutrophils of 4.39 × 109/liter and lymphocytes of 11.16 × 109/liter. Testicular tumor marker; normal levels. CT scan reported some borderline-enlarged left para-aortic and aorto-caval lymph nodes and unremarkable abdominal viscera. Right inguinal orchiectomy was performed. Histopathology reported that the entire right testicle was heavily infiltrated with sheets of medium-sized and large lymphoid tissue associated with frequent mitotic figures. Atypical lymphoid cells were positive for CD20, CD79a, BCL-2, BCL-6, CD10, and MUM 1. There was negative staining for CD23 and CD5 consistent with a high-grade Richter’s transformation to diffuse large B cell lymphoma of germinal center type, which was confirmed by expert’s second opinion. Hematology team planned the following treatment for the patient; to start on with R-CHOP (rituximab, cyclophosphamide, doxorubicin, vincristine and prednisolone). Second, as testicular lymphomas are associated with late lymphoma relapses in the central nervous system; proposed to give him methotrexate intrathecal. Finally, as testicular lymphomas tend to spread to the other testicle and after full counseling, our patient opted to go for contralateral orchiectomy rather than radiotherapy.
Discussion: Our patient presented with Richter’s syndrome at an extremely uncommon site, that is, testis. This is the fourth case reported in literature. Treatment needs multidisciplinary team approach: urologist, pathologist, and hematologist. Moreover, our case represents the longest follow-up reported so far with recurrence-free survival of more than 2 years now.
Forgotten antegrade stent: where are we and what can we do?
Elsayed Desouky
, David Maudgil, Simon Gill, M. Ali Omar
Frimley Health NHS Trust, Slough, UK
Introduction: We place many antegrade ureteric stents, often in an emergency situation. These temporary stents were not being tracked, risking delayed removal and complications of stent encrustation or fracture. This issue has been highlighted as a ‘never’ event, a source of litigation, and an important patient safety issue by Healthcare Safety Investigation Branch.
Methods: An initial RIS audit demonstrated that in 2019, 45 patients had antegrade stents placed, 67% as emergency admissions. Subsequently, 40% were exchanged retrogradely and 45% removed, with remainder extraanatomically stented or dying before follow-up. Mean time to planning removal was 13.1 days with range 1–73 days, and > 1 month in 16%. These findings were discussed at a joint uroradiology meeting and it was agreed that where possible stent removal was to be planned and booked before the antegrade stenting. On requesting a stent insertion, automatic request will bring the case to discussion in the uroradiology meeting. Radiology reports of stenting were to be emailed to Urologists, discussed at the next uroradiology meeting, and follow-up for removal confirmed at that meeting by Urology. In addition, a logbook was to be kept by IR, to ensure all cases were logged and were discussed.
Results: Reaudit showed that 23 patients had antegrade stents with improved time to removal request of 3.3 (range 5–16) days. The new system worked well with more robust process.
Conclusion: Forgotten ureteric stents can have serious adverse effects and are an interspecialty problem. This was addressed and mitigated with teamwork and safe working systems developed between departments
Preventing catheter balloon inflation injury of the urethra: a prospective study using the Transurethral Catheterization Safety Valve in the United Kingdom and Ireland
Jenny Bo1
, Eabhann O’Connor2, Stefanie Croghan3, Olivia Baird4, John Fallon4, Peter Loughman4, Jibraam Esoof4, Robert Keenan2, James Ryan2, Rustom Manecksha5, Frank D’Arcy6, Subramanian Vaidyanathan7, Raghav Varma1, Helen Thursby1, Amber Matkowski1, Sami El Hadi1, Subhasis Giri4, Wasim Mahmalji1
1Department of Urology, Hereford County Hospital, Wye Valley NHS Trust, Hereford, UK, 2Department of Urology, Beaumont Hospital, Dublin, Republic of Ireland, 3Royal College of Surgeons, Dublin, Republic of Ireland, 4Department of Urology, University Hospital Limerick, Dooradoyle, Republic of Ireland, 5Department of Urology, Tallaght University Hospital, Dublin, Republic of Ireland, 6Department of Urology, Galway University Hospital, Galway, Republic of Ireland, 7Department of Urology, Southport and Formby District General Hospital, Southport, UK
Introduction: Catheter balloon injuries (CBI) of the urethra are potentially devastating and avoidable iatrogenic injuries that occur in just more than 1% of hospitalized male patients. The transurethral catheterization safety valve (TUCSV©) is a novel safety device designed to prevent CBIs. The safety device allows fluid in the catheter system to vent through a pressure relief valve if the catheter’s anchoring balloon is inflated in the urethra. This multi-institutional clinical study is a prospective analysis of the TUCSV’s ability to prevent urethral CBI over a 3-month study period.
Methods: Incidence of CBI was recorded in two Irish hospital groups and one English hospital over a 3-month period. The TUCSV was then introduced for 3 months in a variety of hospital settings in Ireland (April–July 2021) and England (August–October 2021). ‘Venting’ through the safety valve indicated prevention of urethral injury. CBIs referred to urology were recorded.
Results: In total, 729 urethral catheterizations were carried out using the TUCSV, with 16 (2.2%) episodes of TUCSV venting recorded. There were no urethral injuries in these patients. In the same period, 15 urethral CBIs were recorded where the TUCSV was not used. This suggests that the true incidence of CBI is 19% greater than documented cases.
Conclusion: Iatrogenic CBIs are a significant cause of patient morbidity. The TUCSV is a simple, effective, and innovative solution to this recurring problem; compatible with all commercially available catheters and applicable to all patient cohorts and catheterization settings.
Can surgical treatment for benign prostatic hyperplasia improve sexual function? A systematic review
Mahmood Vaziri1
, Julian Soans Soans
2,
Francesca Kum
3,
Wasim Mahmalji
1
1Department of Urology Hereford County, Hereford, UK, 2St. George’s Medical School, London, UK, 3Department of Urology, St George’s Hospital, London, London, UK
Introduction: Erectile dysfunction is an established, well-known risk of any operative management of benign prostatic hyperplasia (BPH). However, there are some cases reported in which surgical treatment has paradoxically improved erectile function. Here, we present a systematic review of the literature pertaining to the effect of surgery on erectile function, focusing on the reports of improvement in erectile function following surgery.
Methods: We searched PubMed, EMBASE, Web of Knowledge, and SCOPUS databases for the following key words: ( ‘sexual function’ OR ‘erectile function’) AND ‘improvement’ AND ‘benign prostatic hyperplasia’ AND ‘surgery’. We included English studies that specifically used a scoring system to report erectile function.
Results: Overall, 15 studies (total n = 2087) were reviewed which reported a significant improvement in any aspect of erectile function. Of these, 10 studies had a follow-up period of 12 months or more while 5 had a follow-up less than 12 months. Various surgical methods were included in the 15 studies; however, 5 reported transurethral resection of the prostate (TURP) outcomes specifically. However, 11 studies reported outcomes using the International Index of Erectile Function (IIEF). Overall a further 85 studies showed no significant change and 15 studies showed a significant reduction.
Conclusion: The majority of studies reported no change in erectile function following surgical intervention for BPH. There seems to be no obvious correlating factor between the studies reporting an improvement in erectile function. Further research is needed to guide us in how to consent our patients for erectile function outcomes for BPH surgery.
Prostate abscesses in patients with COVID-19 treated with genetically engineered biological drugs: IL-6 inhibitors
Damir Kantimerov
, Ruslan Trushkin, Nikolai Shcheglov, Oleg Shevtsov, Timur Isaev, Nikolai Morozov, Alexander Lubennikov
City Hospital #52, Moscow, Russian Federation
Introduction: Prostate abscess is a rare complication of acute bacterial prostatitis and accounts for 0.5–2.5% of patients with prostatitis. IL-6 is an immunoregulatory cytokine with multiple biological activities, one of which is urothelial immune defense against bacteria. Prostate abscess clinical presentation in patients with diabetes mellitus and immunodeficiency does not follow the standard criteria. We registered an increased number of prostate abscesses in patients with COVID-19 within a limited time.
Methods: Patients with drainable abscesses according to transrectal ultrasound and pelvic MRI underwent transperineal drainage of the prostate abscess (8 patients of 11). A safety drain was installed into the abscess cavity; trocar cystostomy and antibiotic therapy were performed.
Results: Within 6 months, 11 cases of prostate abscesses were detected; surgery was performed in 8 cases. However, 9 patients out of 11 had prostate abscesses in the peripheral zone. The average age was 72.8 (43–83) years. All patients received IL-6 inhibitors, followed by glucocorticoid therapy in eight cases. Leukopenia and no CRP elevations in the presence of fever were detected in eight patients. Procalcitonin test showed a bacterial infection only in 5 out of 11 patients. In all eight surgery cases, the aspirate was found in the culture with varying degrees of colonization: Klebsiella pneumonia 105 CFU (in seven patients), 107 CFU (in one patient). The average drainage time was 8 days. Two cases with minor abscesses were fatal.
Conclusion: Based on the 6-month clinical data, we can estimate an increase in the number of prostate abscesses in patients undergoing COVID-19 therapy and detected a change in their standard localization. The rising number of abscesses within 6 months may be considered as a concomitant risk factor, in particular, due to prolonged urethral catheter-associated bladder drainage, immunosuppressive therapy, and the shutdown of the main local regulatory mechanism of the body’s immune response to bacterial infection, mediated by IL-6.
Partial allograft nephrectomy within intrarenal reconstruction of urinary tract: a case report
Damir Kantimerov
, Ruslan Trushkin, Nikolai Shcheglov, Oleg Shevtsov, Timur Isaev, Nikolai Kolesnikov, Alexander Lubennikov
City Hospital #52, Moscow, Russian Federation
Introduction: Kidney transplantation has emerged as the gold standard for patients with chronic renal failure. Patients who have undergone renal transplantation are at twofold increased risk of developing malignancy compared with general population. Even if the incidence of renal cell carcinoma in allogenic kidney transplant is low (0.19–0.5%), it is a complicated clinical case for urologists. The current management of solid renal masses in allograft kidney transplant is the same as the management of the native kidney and includes partial nephrectomy, radical nephrectomy, percutaneous radiofrequency ablation, and percutaneous cryoablation.
Case presentation: We would like to introduce an interesting clinical case of a massive intra-sinus (10.3 × 8.3 cm2) tumor of the allograft kidney. An incidental allograft kidney tumor has been revealed in a young female patient (33 years of age). We performed partial nephrectomy and reconstructed the intrarenal part of the urinary tract. Postoperative period was unremarkable. On POD2, a CT-excretory urography was held. Drainages were removed on POD5. Creatinine level was 174 mcmol/liter before surgery and 130 mcmol/liter on the day of discharge. The patient was discharged after 10 days in hospital.
Discussion: Intrarenal reconstruction of intrarenal urinary tract can give a chance to save the kidney even if the tumor size is considerable and renal score points out a high complexity of partial nephrectomy. Moreover, it can also be performed in kidney transplant patients.
Opioid-free management of postoperative pain in minimal-invasive urology practice
Muhamad Abdullateef
, Mohamed elsaadany, Abdalla AlBloushi
Khorfakkan hospital/EHS, Khorfakkan, United Arab Emirates
Objective: The opioid epidemic due to postoperative over prescription in many countries, especially the United States, represents a challenge due to serious adverse events. We sought to present the outcome of implementing an opioid-free regimen in the postoperative care of minimal-invasive urology cases
Methods: We retrospectively examined all patients admitted to our urology unit and managed with an opioid-free regimen between January 2021 and May 2022. Demographic characteristics, type of urologic procedures, postoperative outcomes, and in-hospital and post discharge analgesic prescribed were extracted from electronic medical records. When there is no contraindication, paracetamol and diclofenac injections were used for pain management. Patients were monitored for pain every 6 h by Numeric Pain Intensity Scale (0 = no pain to 10 = severe pain). Our primary outcomes were patient response, including emergency department and unplanned outpatient clinic visits.
Results: A total of 49 patients were included in the study. Patient demographics were insignificant. Pethidine 50 mg injection was required in three patients as in-hospital analgesic representing 6%. All patients did not require an opioid prescription through 2 weeks post discharge. There were no postoperative complications in our cohort. The type of surgery and presence of ureteral stents had no statistical significance in relation to unplanned emergency visits with p-value 0.83 and 0.28, respectively. No patients who were discharged without a prescription called back to request one. Treatment was well tolerated, without evidence of nonsteroidal anti-inflammatory drug-related toxicity. Emergency visits for postoperative pain were documented in four patients. Outpatient clinic visits were as scheduled.
Conclusion: Opioid-free regimen for the management of postoperative pain in minor urology cases is applicable, safe, and effective and protected from the serious adverse events of opioids.
Arterioureteral fistula: a rare elusive cause of significant hematuria
Muhammad Waqar
, Suresh Jay Mathias
New Cross Hospital, Walsall, UK
Introduction: Arterioureteral fistula (AUF) is a direct communication between the ureter and an artery and is a rare cause of catastrophic, life-threatening hematuria. The true incidence of AUF is unknown, but there are increasing reports in the literature. Fistulation may occur between the ureter and any major or minor vessel.
Case presentation: We present an interesting and rare case of 73 years old lady who presented with intermittent large-volume hematuria. Diagnosis of right internal iliac – ureteral fistula was confirmed on Digital Subtraction Angiography of the renal tract. The fistula was successfully embolized using an endovascular approach.
Discussion: AUF is an exceedingly rare but life-threatening condition warranting emergent intervention. Prompt recognition and management of AUF in suspect patients presenting with gross hematuria are required for a successful outcome. AUF diagnosis is challenging but anyone presentation with brisk hematuria without any obvious cause should be investigated for it.
Evaluation of targeted versus systematic biopsy in transperineal prostatic biopsy
Abdelrahman Eltafahny
1,
Shady Salem
1,2,
Faisal Alhajeri1
, Yosef Alshamlan
1,
Abelrahman Almazedi
1,
Saad Aldousari
1,3
1Sabah Al-Ahmad Urology Center Kuwait, Salmia, Kuwait, 2Faculty of Medicine, Menofia University, Egypt, Egypt, 3Faculty of Medicine, Kuwait University, Kuwait
Introduction: MRI has an established role in the diagnosis of prostate cancer. High-quality MRI allows targeting the biopsy to the highest risk areas. The objective of this study was to evaluate the results of systematic versus targeted biopsy in patients undergoing transperineal (TP) biopsy.
Methods: This is a retrospective study analyzing data collected from prospectively designed database. After obtaining ethical committee approval and patients informed consent, we evaluated 51 patients who underwent TP biopsy for high prostate-specific antigen (PSA). Patients underwent 12–18 systematic biopsies plus 2–6 cognitive-targeted biopsies.
Results: We reviewed the targeted biopsy results of 51 consecutive cases. Mean age was 65.5 ± 7.2 years and prebiopsy PSA was 15.6 ± 30. Patients with Prostate Imaging Reporting and Data System (PI-RAD) scores 4 and 5 were 29 (56.86%), PI-RAD score 3 was 11 (21.6%), and PI-RAD scores 1 and 2 were 11 (21.6%). The targeted biopsy was positive in 24 (47%) cases, 3 (10.7%) out of them was Gleason Grade Score 1 (GGS1), GGS2 in 5 (20.8%), GGS3 in 10 (41.67%), GGS4 in 3 (12.5%), and GGS5 in 3 (12.5%). Comparing the results of targeted biopsy to systematic biopsy, targeted biopsy detected 3 (5.88%) patients with GGS2 or higher that would be otherwise missed with systematic biopsy. Targeted biopsy was benign in 7 (13.8%) patients where cancer was detected in systematic biopsy. Of them, 3 (5.9%) patients with GG1 and 4 (7.8%) with GG2 or higher.
Conclusion In our cohort, both systematic and targeted biopsies complement each other. The chance of missing a clinically significant cancer is higher when each technique used alone.
Transperineal biopsy as a new technique versus well-established transrectal biopsy for diagnosis of prostate cancer. A comparative study
Abdelrahman Eltafahny
1,
Shady Salem
1,2,
Yosef Alshamlan1
, Abelrahman Almazedi
1,
Saad Aldousari
1,3
1Sabah Al-Ahmad Urology Center, Kuwait, 2Faculty of Medicine, Menofia University, Egypt, 3Faculty of Medicine, Kuwait University, Kuwait
Introduction: Transrectal (TR) prostate biopsy has been the gold standard for prostate cancer diagnosis for years. With the emergence of transperineal (TP) prostatic biopsy, there is shift in practice across medical services to adopt TP biopsy as the primary method of prostatic biopsy.
Objective: The aim of the study was to compare cancer detection rates and complications in TP and TR biopsies.
Methods: This is a retrospective study using a prospectively designed database comparing consecutive 80 cases of TP biopsy to 80 cases of TR biopsy in single center.
Results: There were no statistically significant differences regarding demographic and prebiopsy prostate-specific antigen (PSA). Mean age for TP 65.8 ± 8.5 versus 65.1 ± 7.4 years TR group with a p-value of 0.633. Prebiopsy PSA was 14.2 ± 24.9 ng/dl in TP group versus 23.7 ± 71.3 ng/dl in the TR group with a p-value of 0.108. PI-RAD scores 4 and 5 lesions were found in 47 (58.9%) cases of TP biopsy versus 44 (60.3%) of TR group cases and p-value of 0.131. Cancer was detected in 49 (61.25%) patients in the TP group versus 45 (56.25%) in the TR group with no statistically significant difference and p-value of 0.665. Bleeding per rectum was absent in TP group and present in 14 (17.50 %) in TR group with p-value < 0.001. There were no statistically significant difference regarding the incidence of febrile urinary tract infection (UTI), hematuria, and hematospermia. In TP group, 0 (0%), 7 (8.75%), and 3 (3.75%) versus 2 (2.50%), 14 (17.50%), and 5 (6.25%) with p-values 0.497, 0.159, and 0.719, consecutively.
Conclusion: TP and TR biopsies have comparable cancer detection rate. TP biopsy has significantly lower rectal bleeding rate than TR biopsy. There is a trend toward lower febrile UTI in TP group; however, it did not reach statistical significance.
Microscopic Testicular Sperm Extraction for Azoospermia at a large tertiary referral center: male and female factors and outcomes
Mohamed Abu Yousif1, Marc Lucky1, Abigail Kwock1, Richard Jones1, Daphne Chong2, Andrew Baird1
1Royal Liverpool University Hospital, Liverpool, UK, 2Liverpool Women’s Hospital, Liverpool, UK
Introduction: Microscopic testicular sperm extraction (microTESE) remains the gold standard method in obtaining sperm in male non-obstructive azoospermia (NOA). Schlegel et al were the first to describe a novel microsurgical approach for sperm extraction. With this new novel surgical approach, it was possible to improve the selective extraction of larger seminiferous tubules with the aid of an operating microscope. The latest published European Association of Urology (EAU) guidelines on male infertility recommended the use of testicular sperm extraction (TESE) as the technique of choice in providing histological diagnosis and providing sperm in patients with NOA.
Aims: The aim of the study was to report on the outcomes and demographics of azoospermic couples undergoing microTESE in a large tertiary referral, regional center.
Methods: We carried out a retrospective analysis of patients undergoing microTESE in our tertiary referral center from March 2015 to August 2019. Retrospective analysis and evaluation of histopathology results, patient demographics, comorbidities, patient factors, and live birth outcomes was done. Data collection was done in liaison with the female fertility team at the Liverpool Women’s Hospital.
Results: In total, 102 microTESEs were performed in this timeframe. However, 30.3% of samples contained spermatozoa. The successful group had a mean age of 32.7 and a mean BMI of 26.8. There was a significant variation in the past medical history for patients who underwent microTESE. A large proportion of patients, that is, 13% had previous urological history and 12% had a previous history of asthma with no active medical treatment. The successful group had 15 live births (50%), while 20% had frozen their sperm. However, 93.3% achieved live birth from single-embryo transfer and currently have further surplus of unutilized embryos in cryostorage to create siblings in the future. Moreover, 20% had more than one live birth from a single microTESE. Sertoli cell-only syndrome (SCOS) was identified in 57.5% of cases making it the most common histology in azoospermic men. This was bilateral in 80% of cases (four cases only sampled unilaterally due to previous orchidectomies). The average Johnsen score was 3.1 (1–9). Of the SCOS group, six men went on to have successful sperm extraction (10%), this implied that they had areas of tubules not affected by SCOS and allowing spermatogenesis.
Conclusion: Men with previous urological conditions have an increased risk of azoospermia. SCOS was identified in 57.5% of cases making it the most common histopathological diagnosis in azoospermic men. Based on our cohort, microTESE offers potential sperm retrieval in azoospermic men with SCOS. Successful sperm extraction in patients was associated with 50% live births and appeared to be unaffected by presence of male/female factors. The number of live births could be higher as 20% had frozen their sperm. Concurrent female issues did not appear to effect successful outcome after microTESE, although numbers are small.
Can plasma fibrinogen and D-dimer be used as prognostic biomarkers in patients with non–muscle-invasive bladder cancer?
Sahil Singla,
Apul Goel
King George’s Medical University, India
Purpose: We aimed to evaluate the role of plasma fibrinogen and D-dimer as prognostic biomarkers in patients with non–muscle-invasive bladder cancer (NMIBC).
Methods: A prospective study that included 35 patients (30 males) with newly diagnosed NMIBC who underwent complete transurethral resection between September 2020 and December 2021. Patients with history of thromboembolic event or anticoagulant intake or active infection, patients with deranged hepatorenal functions, inflammatory bowel disease, refractory hypertension, or diagnosed with Covid-19 infection within 1 month before surgery or routine follow-up were excluded. Follow-up was done as per NCCN guidelines. Fibrinogen and D-dimer levels were measured within 7 days of surgery or follow-up and analyzed for recurrence-free survival (RFS) and progression-free survival (PFS). Cox regression analyses were adopted to assess the influence of these two parameters on RFS and PFS.
Results: The mean age was 53.9 years with a median follow-up of 9 months. The cut-off values of fibrinogen and D-dimer were 402.5 mg/dl and 0.55 µg/ml, respectively. Kaplan–Meier analysis demonstrated that high fibrinogen and D-dimer levels were significantly related to poor RFS (p < 0.001) and PFS (p < 0.001). On multivariate analysis, only fibrinogen and D-dimer retained their significance for RFS (p = 0.026 and 0.014, respectively) and PFS (p = 0.027 and 0.042, respectively) but not tumor size. High levels of fibrinogen and D-dimer were also present in patients who had recurrence or progression at follow-up visits compared to the rest of the patients.
Conclusion: High levels of fibrinogen and D-dimer may indicate worse prognosis in patients with NMIBC, suggesting that these two can be used as prognostic biomarkers.
Evaluating efficacy of internal urethrotomy followed by clean intermittent catheterization with and without clobetasol ointment in management of bulbar stricture urethra
Mukesh Kumar,
Apul Goel
, Diwakar Dalela
King George’s Medical University, India
Purpose: Compare the efficacy of self-urethral calibration (CIC) with and without clobetasol (0.05%) in stricture recurrence prevention after direct vision internal urethrotomy (DVIU).
Methods: All men who fulfilled the inclusion criteria and operated between December 2018 and December 2020 were evaluated. Inclusion criteria included bulbar stricture < 1.5 cm, no previous DVIU or urethroplasty, and 12-month follow-up. Group A were men who performed CIC using 0.05% clobetasol ointment while group B included men who did CIC without clobetasol. Men who reported at least 50% compliance with CIC protocol were included. Failure was defined as inability to pass 12-Fr catheter. Follow-up was done at 3, 6, and 12 months.
Results: There were 50 men in group A and 43 in group B. The two groups were similar regarding demographic data and stricture characteristics, such as length and etiology. By the end of 12 months, 12 men in each group had stopped CIC. The complications included painful CIC, bleeding during CIC, orchitis, and UTI and were similar in both groups. At the end of 12 months, stricture recurrence was noted in four and seven men in groups A and B, respectively. The mean duration of developing recurrence was 7.5 ± 1.23 months in group A and 5.1 ± 1.04 months in group B (p = 0.009).
Conclusion: Post-DVIU recurrence was lower in the group who performed CIC with 0.05% clobetasol ointment. Also, the recurrence was delayed in this group.
Bladder cancer in Saudi Arabia: a nationwide epidemiological and survival analysis
Mohammad Alghafees1
, Meshari Alqahtani
1,
Ziyad Musalli
1,
Ahmed Alasker
2
1College of Medicine, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia, 2Department of Urology, King Abdulaziz Medical City, Riyadh, Saudi Arabia
Introduction: Due to limited data, our understanding of the risk factors, prevalence, incidence rate, and age distribution of bladder cancer (BC) in Saudi Arabia is limited and insufficient. This study aimed to provide a nationwide descriptive epidemiology and a survival analysis for BC in Saudi Arabia.
Methods: This retrospective chart review included all patients diagnosed with a primary BC from January 1, 2008 to December 31, 2017. Frequency and percentage were used for the categorical variables, and a mean and standard deviation for the continuous variables. Chi-square test was used to test for an association between the categorical variables, and an ANOVA test was used to compare means of each group followed by a Tukey post hoc test to determine the exact differences between groups. The factors predicting survival were tested by a Kaplan–Meier analysis followed by a Cox proportional hazard regression analysis.
Results: In total, 3750 patients with BC were identified. The overall incidence of BC was 1.4 per 100,000 persons. According to the Kaplan–Meier survival analysis, significant difference in the distribution of survival was observed by age, gender, nationality, place of residency, tumor morphology, tumor grade, and extension. According to the Cox proportional hazard regression analysis, the predictors of a lower chance of survival were age, squamous cell carcinoma, grade III and IV bladder tumors, regional direct extension, regional: lymph node extension, combined regional lymph node, and direct extension, and distant metastasis. However, male gender and being widowed were standalone predictors of higher chances of survival.
Conclusion: This study provides further understanding of BC in a region with a high prevalence of risk factors. Highlighting these factors, specifically in Saudi Arabia, improves evidence-based practice in this region and may facilitate appropriate care to optimize outcomes.
The quality of TURBT surgery in Luton and Dunstable Hospital NHS trust according to international/ national standard guidelines, a descriptive study
Mohamed Hassan, Muhammad Salik, Anish Pushkaran, Barnby Barrass,
Aza Mohammed
Luton and Dunstable University Hospital, Luton, UK
Objective: The aim of the study was to improve the quality of transurethral resection of bladder tumor (TURBT) surgery; to evaluate the rate of detrusor muscle sampling at TURBT and the rate of single-instillation intravesical chemotherapy (SI-IVC) instillation within 24 h according to the national target and guidelines; and to describe the rate of documentation of resection completeness, tumor size, number, and location in the operative record according to the international/national standards.
Methods: A total of 25 patients had TURBT or reTURBT for non–muscle-invasive transitional cell carcinoma (TCC), in Luton and Dunstable Hospital between December 2020 and April 2021. The operations were done by urologist consultants and registrars; they all used their preferences in operative notes with no specific TURBT operative Performa notes. Data were retrieved from electronic patient records. This evidence forms the basis for the recommendations made in evidence-based guidelines, such as the European Association of Urology (EAU), the American Urological Association (AUA), and the National Institute for Health and Care Excellence (NICE).
Results: Patients above 16 years of age are involved in the study. Detrusor muscle resection rates – Our achievement was 80% of the patients and that meets the same percent in the international/national standard target of TURBT at 80%. However, 79% of the patients had SI-IVC given within 24 h compared to only 60% of patients in the international/national standard target. We documented the completeness of resection in 60% of the patients in the operative record compared to 90% of the patients that should have been filled according to the standard target. All three of tumor number, size, and location are documented in the operative record, we documented in 60% of the patient, and the standard target was at 90% of the patients.
Conclusion: Our TURBT surgery for non-invasive TOC met the EAU, AUA, and NICE standard target in two of the four criteria for assessment, in detrusor muscle resection rate, and in SI-IVC. We implement a special operative note Performa for TURBT to improve the quality of our TURBT surgery and to fulfill the complete standard international/national target.
Management of large renal stones with retrograde intrarenal lithotripsy monotherapy, a prospective descriptive study
Mohamed Hassan
, Aza Mohammed
Luton and Dunstable University Hospital, Luton, UK
Objective: The aim of the study was to evaluate the safety and efficiency of retrograde intrarenal lithotripsy with flexible ureteroscopy (FURS) and laser in the management of partial/complete staghorn renal stones as single modality.
Methods: A total of 13 patients with partial/complete staghorn renal stones who received FURS and Ho-YAG laser (Auriga XL, Boston Scientific) between April 2021 and February 2022 were included in this study. Data were retrieved from electronic patient records. Non-contrast CT scan was used to assess for residual stones and the need for further surgery in 4 weeks (unless it was decided already at the surgery). The study had been approved by the local hospital committee.
Results: The patients’ age ranged from 28 to 82 years. The female-to-male ratio was 8:5. The BMI range was 21–54.4 with the mean of 32.2. Pain was the initial presentation in 76.9% of patients. The mean stone density was 1050 HU. The group included both complete staghorn (23.1%) and partial staghorn (76.9%) as defined by the reporting radiologist. Patient choice was the dominant indication of FURS (53.8%) followed by high BMI and comorbidity in 23.1% for each. All patients had good function kidney on the ipsilateral side [as assessed by dimercaptosuccinic acid (DMSA) scan if needed]. We used the single-use Scope FURS (Zhuhai Pusen Medical Technology) in 53.9% and Standard Flex XC (Karl-Storz Tuttlingen, Germany) in 46.2% of the patients. No ureteric access sheath was used. We used 270-micron laser with the dusting setting. The operative time ranged from 100 to 210 min with the mean of 152.7 min. The hospital stay was mainly from 0 to 2 days with no postoperative complications reported. However, 61.5% of the patients (n = 8) required a single session FURS of whom 87.5% had partial staghorn stone. In this group, 57.1% (n = 5) had no residual stone and 28.6% (n = 3) had clinically insignificant residual stone from 1 to 3 mm. A further 41.7% (n = 5) of the patients had second-look FURS after 2–16 weeks of whom complete staghorn stone reported in 40% of the patients (n = 2), and 80% of all the patients who had second-session FURS (n = 4) were stone-free. Only one patient required third-session FURS for complete clearance (this patient had two sessions under urology trainee registrars and handed over to the consultant for the third session)
Conclusion: A limitation of this study is small sample size. Retrograde intrarenal lithotripsy is a safe and effective mode of surgical management of staghorn renal calculi and can be offered as an alternative to percutaneous nephrolithotomy (PCNL) especially in cases when PCNL is unlikely to be successful, such as high BMI. It is associated with less morbidity and shorter hospital stay but at the expense of needing more than one session.
Recreational use of Ketamine resulting to cystitis: a case report
Sourabh Karna1
, Sharad Chandra Prasad1, Eva Maharjan2
1Milton Keynes University Hospital NHS Foundation Trust, Milton Keynes, UK, 2St. Heliers Hospital, Sutton, Carshalton, UK
Introduction: Use of ketamine as a recreational drug is alarmingly increasing each day among young adults. Urological impact of long-term use of ketamine is still underdiagnosed by many doctors across the globe as they are unfamiliar of the disease. More than one-fifth of ketamine users develops urinary symptoms; however, the studies done in different parts of the globe show much higher percentage of Lower Urinary Tract Symptom (LUTS) (46% in Spain and 90% in Hong Kong)
Case presentation: A 24-year male presented with abdominal discomfort for 5 years with the history of urinary frequency, nocturia, and frank hematuria on and off associated with blood clots. No significant history of dysuria, fever, and burning sensation of urine was reported. Further history revealed that he used to sniff ketamine for 6 years. A CT urinary tract with contrast was arranged that revealed bilateral severe hydronephrosis, and moderate hydroureter down to the bladder wall is again seen with associated severe mural thickening along the ureteric walls, the renal pelves, the major calyces, and also in a small-volume bladder. A rigid cystoscopy was performed prior to this admission due to hematuria that revealed multifocal mixed tumor of size > 3 cm, not fixed with bladder, however was benign looking apart from the hyperemic bladder wall.
Discussion: Ketamine abuse can lead to severe cystitis with small-volume bladder and LUTS (storage symptoms mainly) resulting in deterioration in quality of life of a person. Complete abstinence of ketamine with proper psychosocial and behavioral counseling is regarded superior to medical and surgical therapy.
The importance of pre-transplant urologic evaluation in pediatric age group
Abdulmohsin Alfaddagh1, Osama Sarhan1,
Fouad Alkawai1,
Helmy Omar1
1Kfsh-d, Dammam, Saudi Arabia
Introduction: In children with end-stage renal disease (ESRD), renal transplantation is considered as the treatment of choice. Both urologic and non-urologic causes of ESRD in children were identified, and the congenital anomalies are the primary cause of ESRD. Children with and without lower urinary tract anomalies may suffer from voiding dysfunction post-renal transplant. There is still no consensus about the necessity of routine pre-transplant urologic consultation for all patients. We reviewed our pediatric renal transplant experience to determine if the routine pre-transplant urology evaluation is important or not.
Methods: We retrospectively evaluated all children who underwent renal transplantation at our institution between October 2008 and February 2020. We excluded patients who underwent renal transplantation at another hospitals and patients with missed pre-transplant information. All medical records were inspected to obtain baseline demographics, etiology of ESRD, type of transplant, operative details, pre- and post- transplant urology consultations, laboratory and radiological studies.
Results: A total of 149 children (92 males and 57 females) with a median age at transplant of 8 (range 2–18) years were included. Of those patients, 45 patients (30%) did not have any urology consultation pre-transplant while the remaining 104 (70%) did. Urologic evaluation included history (voiding–continence–UTIs), examination (abdominal–back–genitalia), and investigations [voiding cystourethrogram (VCUG)–flow rate and PVR + UDS). Out of those 45 patients who had never seen by urology before transplantation, 20 patients had a post-transplant consultation for reasons including febrile UTIs, retention, voiding dysfunction, and undescended testis.
Conclusion: The routine pre-transplant urologic evaluation is important in pediatric renal transplantation. The value of this evaluation is to identify patients who are at risk of developing post-transplant urologic complications and to provide optimum management of urologic issues in a proper time.
Incidence and impact of post-transplant vesicoureteral reflux in pediatric age group: single-center experience
Abdulmohsin Alfaddagh, Osama Sarhan,
Fouad Alkawai
, Helmy Omar, Ahmad Alshammari
Kfsh-d, Dammam, Saudi Arabia
Objective: In pediatric renal transplantation, an antireflux ureteric reimplantation technique is usually carried out with the intention of preventing future urinary tract infections (UTIs). Nevertheless, vesicoureteral reflux (VUR) occurs up to 50% after pediatric renal transplantation and its impact on graft outcome is still debatable. The routine use of voiding cystourethrogram (VCUG) is not recommended for all patients post renal transplant and it is only done in certain situations. We reviewed our pediatric renal transplant experience to determine the incidence and the impact of post-transplant VUR in our pediatric patients and to know whether it can affect the graft function or not.
Methods: After obtaining the institutional review board approval, we retrospectively evaluated all children who underwent renal transplantation at our institution between October 2008 and February 2020. Pediatric renal transplant patients below the age of 18 years were included and we excluded patients who underwent renal transplantation at another hospitals and patients with missed follow-up data. All medical records were inspected to obtain baseline demographics, etiology of ESRD, age at transplant, type of transplant, operative details, postoperative complications, clinical laboratory, and radiological condition at last follow-up.
Results: A total of 149 children (92 males and 57 females) with a median age at transplant of 8 (range 2–18) years were included. Of those patients, 93 patients (62%) received a living donor transplant while the remaining 56 (38%) received a deceased donor kidney. A VCUG was carried out in 88 patients (59%) post transplant due to recurrent UTIs or persistent graft hydronephrosis, and VUR was evident in 46 patients. Post-renal transplant UTIs developed in 53 cases (35%) and there was no difference between cases with VUR and without VUR (p = 0.15). In all patients with a proved VUR, prophylactic antibiotics were initiated for 3–6 months. The majority of cases responded favorably to the antibioprophylaxis, while antireflux management was necessitated in 11 patients (9 deflux injections, 3 ureterovesical reimplantation). After a median follow-up period of 5 years, chronic kidney disease (CKD) developed in 31 cases (21%) and it was significantly associated with the presence of post-transplant VUR (p = 0.03).
Conclusion: There was a high incidence of post-transplant VUR in pediatric age group even though antireflux technique was used. Most of cases could be managed conservatively and only few cases needed surgical antireflux intervention. Association of VUR and poor graft function was evident in our cohort of patients.
Renal transplantation in children with abnormal lower urinary tract: single-center experience
Abdulmohsin Alfaddagh1,
Fouad Alkawai1
, Osama Sarhan1, Helmy Omar1
1Kfsh-d, Dammam, Saudi Arabia
Introduction: In pediatric renal transplantation, success depends on the creation of a functional low-pressure reservoir to store and eliminate urine without transmission of high pressure to the graft limiting the risk of urinary tract infections. Both urologic and non-urologic causes of end-stage renal disease (ESRD) in children were identified and the congenital anomalies are the primary cause of ESRD. Previous studies have shown that children with non-urologic causes of ESRD had better outcome than those with a urologic condition. This retrospective study reports the outcomes of renal transplantation for children with an abnormal lower urinary tract (LUT).
Methods: Between October 2008 and February 2020, 149 children (⩽18 years of age) received kidney transplants at our institution. We included 92 boys and 57 girls with a median age at transplant of 8 (range 2–18) years. We excluded patients who underwent renal transplantation in other hospitals and patients with missed follow-up data. Of those patients, 93 patients (62%) received a living donor transplant while the remaining 56 (38%) received a deceased donor kidney. All medical records were inspected to obtain baseline demographics, etiology of ESRD, age at transplant, type of transplant, presence or absence of abnormal LUT, operative details, postoperative complications, and graft function at last follow-up. Urologic evaluation included history (voiding–continence–UTIs), examination (abdominal–back–genitalia) and investigations (VCUG–Flow rate and PVR + UDS).
Results: Follow-up period ranged from 2 to 12 years (median = 5 years). Out of those 149 patients, 51 had LUT disorders including posterior urethral valves (PUVs) with valve bladder (n = 19), neuropathic bladders (n = 6), and small bladders due to pre-transplant anuria (n = 26). Those patients were managed with anticholinergics + clean intermittent catheterization (CIC) before and after renal transplantation. In five cases, bladder augmentation was carried out, while three patients were on vesicostomy at the time of transplantation. We compared the graft survival in this cohort of patients with a group of children with normal LUT who underwent renal transplant during the same period and the difference was significantly lower in those with abnormal LUT (p = 0.012).
Conclusion: The routine pre-transplant LUT evaluation is important in pediatric renal transplantation to provide optimum reservoir for future graft function. Despite proper management of children with LUT dysfunction, still the 5-year graft survival is lower than those with normal LUT. Those group of patients displays a high incidence of urologic and infectious complications.
Enhanced recovery after surgery following radical cystectomy: One size does not fit all patients!
Peter Fawzy1
, Joseph Zabell
2,
Yasser Osman
3,
Mohamed M. Hussein
1,
Christopher Weight
5,
Badrinath Konety
6
1Department of Urology-Aswan University, Aswan, Egypt, 2Department of Urology- University of Minnesota, Minneapolis, USA, 3Department of Urology-Mansoura Urology and Nephrology Center, Mansoura, Egypt, 4Department of Urology- Aswan University, Aswan, Egypt, 5Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, USA, 6Department of Urology, Rush Medical College, Chicago, USA
Aims: Enhanced recovery after surgery (ERAS) protocols are multimodal perioperative care protocols aiming to shorten recovery time. We reported the overall effect of ERAS protocol implementation in patients undergoing radical cystectomy and its impact on surgical outcomes and length of hospital stay (LOS) considering their comorbid conditions.
Methods: Retrospective cohort study involved 296 patients (146 non-ERAS patients versus 150 ERAS patients) undergoing radical cystectomy and urinary diversion from 2010 to 2018. Age-adjusted Charlson Comorbidity index (ACCI) score 8 was set as cut-off value between low-risk and high-risk patients. Primary outcome was the LOS. Secondary outcomes were time to bowel movements, tolerance of regular diet, the incidence of postoperative ileus, postoperative complications, and 30-day readmission rate
Results: A higher comorbidity burden was noticed in the ERAS group compared to non-ERAS patients (p = 0.046). Median (IQR) LOS for non-ERAS group 8 (4) and 8 (5) for ERAS group (p = 0.07). On multivariate analysis, ERAS protocol was not statistically associated with decreased LOS (p = 0.18); however, low ACCI was significantly associated with reduced LOS (p = 0.036). Low-risk patients managed by the ERAS protocol demonstrated a significantly shortened GIT recovery time (p = 0.001) and a reduction of LOS (p = 0.04) compared to the non-ERAS group. However, we did not find a significant reduction of LOS for a subset of patients with higher comorbidity when placed on the ERAS protocol (p = 0.79). There were no significant differences in postoperative complications or readmission rates between both groups.
Conclusion: In our cohort study, ERAS protocol implementation following radical cystectomy showed significant improvements in GIT recovery time; nevertheless, it did not result in a decrease in LOS or readmission rates. There is likely a subset of individuals with high levels of comorbidity who do not respond well to ERAS. Not all patients are ideal candidates for ERAS protocol implementation.
Prolonged operative time is a useful metric to predict postoperative complications and readmission rates in patients undergoing radical cystectomy
Peter Fawzy1
, Joseph Zabell
2,
Christopher Warlick
2,
Badrinath Konety
3
1Aswan University, Aswan, Egypt, 2University of Minnesota, Minneapolis, USA, 3Rush University, Chicago, USA
Aims: Radical cystectomy is a complex lengthy procedure associated with postoperative morbidity. Operative time is one of the important risk factors associated with postoperative complications. We assess the operative time in patients undergoing radical cystectomy and its impact on 90-day postoperative complications and readmission rates.
Methods: Retrospective cohort study including 296 patients undergoing radical cystectomy and urinary diversion from 2010 to 2018 in our institution. Operative time 369 min was set as a cut-off value between short and long operative time groups. Primary outcome was 90-day postoperative complication rates. Secondary outcomes were gastrointestinal recovery time, length of hospital stay (LOS), and 90-day readmission rates.
Results: The overall incidence of 90-day postoperative complications was 80.4% where 63.2% representing minor complications, and 36.8% representing major complications. GIT and infectious complications are the most common complications in our dataset (45.9%, 45.6%, respectively). On multivariable analysis, prolonged operative time was significantly associated with odds of high-grade complications [OR = 2.340, 95% CI (1.288, 4.250), p = 0.005] even with adjusted other variables. A higher incidence of major complications was identified in the long operative time group 69 (42.6%) compared to 40 (30.5%) in the short operative time group (p = 0.034). Although a shorter GIT recovery time was noticed in the short operative time group (p = 0.026), no differences were found in LOS between both groups. Prolonged operative time was associated with a higher 90-day readmission rate on univariate and multivariate analysis (p = 0.001, p < 0.0001, respectively).
Conclusion: Prolonged operative time (> 369 min) is associated with an increased risk of postoperative complications and readmission rates. Optimization of operative time could translate into better operative outcomes.
A pilot study of changing the conventional double-J stents by a new pigtail-suture stent: symptoms comparison
Mohamed Farah
, Raghav Varma, Mahmood Vazirian, Bashir Mohamed, Jenny Bo, Wasim Mahmalji
Hereford County Hospital–Wye Valley NHS Trust, Hereford, UK
Introduction: Double-J ureteric stents are commonly used in urological practice to relief ureteral obstructions. However, stent-related symptoms (SRS) remain a major issue with regard to the patients’ quality of life. More, recently, pigtail-suture stent (PSS) was developed to help with SRS where the distal portion of the stent is a 0.3 Fr suture that terminates in the bladder.
Aims: The aim of the study was to determine whether the new pigtail-suture JFil® stent can reduce stent-related symptoms compared to the conventional double-J Percuflex™ (Boston Scientific) stent.
Method: Our inclusion criteria were patients with pelvi-ureteric junction obstruction (PUJO) managed with long-term stents and above the age of 18 years. Patient with urinary stone or ureteric strictures was excluded. Four women with a median age of 64 ± 24 years, who have PUJO and underwent replacement of their long-term double-J Percuflex stents with pigtail-suture JFil stents were enrolled. All patients completed the ureteral stent symptoms questionnaire (USSQ), which explores the stent-related symptoms. The questionnaire was done prior to replacement (baseline) and Day 90 post replacement. The Student’s t-test was used to compare the means of each USSQ domain between the two stent types.
Results: The replacement of the DJS with the PSS significantly decreased the pain score (6.75 versus 22.25, p = 0.019). In addition, PSS improved the general health score (9.15 versus 19.75, p = 0.01). Mean score for urinary symptoms was better for PSS group, but the difference was not significant (25.75 versus 39.75, p = 0.065). No complications occurred with the PSS stents.
Conclusion: The PSS was associated with improved USSQ pain and general health scores, compared to the conventional DJS group. PSS seems to be a promising option to reduce ureteral SRS. We are planning to conduct a multi-center clinical study.
Recurrent Vesico-acetabular-cutaneous fistula: ‘ghost from Christmas past’
Feroz Amir Zafar1
, Sunny Goel2, Pankaj Wadhwa1, Rajesh Ahlawat
1
Medanta The Medicity Gurgaon India, Gurgaon, India, 2Epitome Kidney & Urology Institute, New Delhi, India
Introduction: Vesico-acetabular-cutaneous fistula is an extremely rare complication. We present a case with recurrence of fistula after 10 years following corrective surgery.
Case presentation: A 40-year-old policeman had a vehicle accident in June 2006. Initially managed for blunt abdominal trauma, fractured pelvis involving (L) acetabulum and pubic diastasis with posterior urethra disruption; he underwent exploratory laparotomy with placement of cystostomy. A primary perineal anastomotic urethroplasty was undertaken in August 2006, elsewhere. The patient failed to void and had recurrence of stricture. Re-evaluation in 2007 revealed post-traumatic neurogenic bladder-mixed lesion-UMN type with partial cauda-equina lesion with (L) foot drop, a stable fracture pelvis involving (L) acetabulum and pubic diastasis. He had a failed posterior anastomotic urethroplasty with left pseudo-diverticula bladder secondary to prior unrepaired extraperitoneal bladder injury with erectile dysfunction.
Cystogram revealed painful filling with (L) grade 2 reflux, smooth bladder with a pseudo-diverticula in left antero-lateral aspect, bladder neck competent. Retrograde urethrogram revealed complete block at proximal bulbar urethra. Initially treated with bladder relaxants which afforded pain/ strangury relief. Redo perineal progressive anastomotic posterior urethroplasty was performed in March 2007. He then underwent (L) Total hip replacement after 4 months, following which he was able to walk with support. He developed severe irritative LUTS; urodynamics confirmed detrusor hyper-reflexia and low compliant bladder and was treated with intradetrusor Botulinum toxin injection. He defaulted after 2nd Botox injection and presented with copious fluid drainage from (L) hip healed suture line in February 2009. High fluid creatinine & CT cystogram confirmed left vesico-acetabular-cutaneous fistula. Patch Ileal (clam) cystoplasty was performed in August 2009, and dense adhesions with near frozen pelvis were encountered, precluding fistula excision. He subsequently underwent redo (L) hip replacement after fistula site had healed and patient was performing CIC regularly. Penile vacuum device with PDE-5 inhibitors were used for treating ED.
He presented in December 2019 (10 years after cystoplasty) with recurrence of left vesico-acetabulo-cutaneous fistula, having stopped performing CIC regularly in the previous 4 months. MRI pelvis confirmed site of fistula at the previous site. A redo-cystoplasty with fistula excision and omental interposition was done in September 2020.
Discussion: This case highlights the challenges in lower urinary tract rehabilitation following complex pelvic injury. It reiterates the need to repair large extraperitoneal bladder injuries. It exemplifies the need to impress upon the patient the continued requirement of CIC in neurogenic bladders.
Role of retrograde intrarenal surgery in management of renal stones: single-center experience
Mohammed Ali Abdelghaffar
Menoufia University Hospital, Shibin-al-Kawm, Egypt
Objectives: The aim of the study was to assess the efficacy and safety of semi-rigid and flexible ureteroscopy for the management of renal stones by evaluating stone clearance rates and associated complications.
Methods: A retrospective study was undertaken of all Ureteroscopy cases between 2019 and 2021 performed at a single academic hospital. Ureteroscopic stone treatment was attempted in 77 patients. Stone size was defined as the largest linear diameter of the index stone. Semi-rigid Ureteroscopy (S-URS) was routinely performed in all patients. If the renal stones were accessible with the S-URS, they were then treated with holmium laser under direct vision. If the stones were not accessible, a flexible Ureteroscopy (F-URS) was performed. Patient demographics, intraoperative data, and postoperative outcomes were evaluated.
Results: The study included 30 (39%) male and 47 (61%) female patients. The mean patient age was 51 ± 13 years. The mean size of stone was 1.75 ± 0.9 while stone density was 1082 ± 322. The stone was located in the renal pelvis in 63 patients (81.8%), the upper calyx in 4 (5.2%) and middle calyx in 10 patients (13%). The stone clearance rates were in 58 of 77 patients (75.3%). The treatment failed in 19 patients (24.7%) due to the initial presence of the stone, or migration of large fragments to an inaccessible calyx. There were no intraoperative complications. Postoperative complications were found in 14 (18.2%) patients, 10 (13%) of them had fever and 4 (5.2%) had hematuria, all were treated conservatively.
Conclusion: Although it is well known that flexible ureteroscopy permits a detailed calyceal examination and therapeutic interventions, semi-rigid ureteroscopy is also often another sufficient means of reaching the renal pelvis and some calyces in selected patients.
Hypothermic lidocaine compared with normothermic lidocaine during cystoscopy as assessment for prostatic urethral lift–UroLift. A prospective single-blinded randomized study
Ananda Kumar Dhanasekaran
Sandwell and West Birmingham NHS Trust, Birmingham, UK
Introduction: Outpatient cystoscopy is a common procedure performed in urology practice. Rigid cystoscopy, however, even with the use of local anesthetic has been reported to cause mild-to-moderate pain in 76% of men. In our practice, minimally invasive treatment options for several disorders, such as the UroLift System (Teleflex, Pleasanton, CA, USA) or Rezu-m (Boston Scientific, Marlborough, MA, USA) for benign prostatic hyperplasia, have led to increasing numbers of procedures being performed as day surgeries under local anesthetic, but these involve rigid cystoscopes. Finding ways to improve the intraoperative experience of patients could increase the number of suitable patients opting to be treated this way. Lidocaine provides local anesthesia by preventing the transmembrane flow of sodium ions in nerve cells. Before taking effect, however, stimulation of nociceptors during administration can cause notable pain. This effect is reported to have been lessened by the addition of an alkalizing agent, such as sodium bicarbonate, or warming the gel to body temperature. Li et al investigated the use of alkalinized lidocaine gel for use during rigid cystoscopy. Patients who were administered lidocaine gel containing sodium bicarbonate reported substantially reduced visual analog scale (VAS) scores compared with those who received non-alkalinized lidocaine gel (mean 1.3 ± 0.9 versus 5.28 ± 1.99). However, this approach is not well assessed in men undergoing cystoscopy. Warming of lidocaine before injection also reduced intraprocedural pain, but the findings are not consistent, and whether the same effect is seen during intraurethral instillation is less clear. Flexible cystoscopy is generally well tolerated. Some studies suggest that anesthesia is unnecessary, although a meta-analysis of studies involving 411 men found that pain was likely to be reduced using lidocaine gel. Given the better tolerance of flexible cystoscopy, we used this approach to perform a proof-of-concept randomized study to investigate whether cooling of lidocaine gel alters pain levels during administration and cystoscopy procedures compared with room temperature lidocaine.
Methods: This was a single-center, randomized single-blind trial. Eligible patients were adult men (age > 18 years) scheduled to undergo flexible cystoscopy for the evaluation of LUTS or as a follow-up of previous bladder transitional cell carcinoma (TCC). Exclusion criteria were a previous prostatic urethral lift (PUL) procedure, the need to use rigid cystoscopy, and the need or patient preference to have the procedure under general anesthetic. All patients gave written informed consent before being enrolled in the study. Ethics approval was received from our trust clinical governance. The study was performed following the Declaration of Helsinki. We randomized 100 patients to receive either chilled in a fridge (4°C) or room temperature lidocaine gel. Randomization was done using computer-generated numbers. The masking of the participants was maintained by the team performing the procedure.
Patients attended the clinic on the day of cystoscopy 15 min before the schedule. They received the British Association of Urological Surgeons (BAUS) information leaflet on the procedure beforehand. We used Instillagel anesthetic antiseptic lubricant (CliniMed, Buckinghamshire, UK) in prefilled 11 ml disposable syringes containing 2% lidocaine gel. The syringes were kept and used at room temperature (20°C–22°C) or chilled in the fridge overnight before the procedure and administered at 4°C. Lidocaine was administered per-urethrally after appropriate counseling. We asked patients to rate pain on a 10-point visual analogue score (VAS) after the flexible cystoscopy procedure.
We calculated that we would need to enroll 100 patients into each group to achieve 80% power differentiation between pain outcomes. We used paired t-test to assess the difference in VAS scores between groups. We took p < 0.05 to indicate significance. Statistical analyses were performed with IBM SPSS Statistics, version 20.
Results: Of 123 screened, 100 patients were enrolled, 50 assigned to receive hypothermic lidocaine and 50 to receive normothermic lidocaine. The patients were well matched for age and indication for flexible cystoscopy. None of the patients required sedation. Patients in the hypothermic lidocaine arm tolerated the procedure better than those in the room temperature lidocaine group. Pain scores were generally lower with chilled than with room temperature lidocaine. The median VAS score with hypothermic lidocaine was 5 (range 2–7) and with normothermic lidocaine was 6 (range 3–8). The overall mean scores were 4.2 with hypothermic lidocaine versus 6.3 with normothermic lidocaine (p < 0.01).
Conclusion: Performing rigid cystoscopy under local anesthesia is challenging and requires substantial experience. However, the significant difference we found between the use of chilled and room temperature lidocaine before and during cystoscopy, we suggest that assessment should be extended to such procedures to increase the numbers of patients who may be treated in day surgery or ambulatory setting. It seems likely that adopting the approach has the potential to reduce discomfort in other common urological procedures, such as stent removal, laser treatment of bladder lesions, and the use of newer procedures to treat benign prostatic hyperplasia.
First safety report of Rigicon Infla10® inflatable penile prosthesis
Steven Wilson
, David Ralph, Raphael Carrion, Gabirel Antonini, Alejandro Caravajal, Paul Perito, Pedro Maria, Eric Chen, Mariano Rossello
Institute For Urologic Excellence, La Quinta, USA
Introduction: A new three-piece inflatable penile prosthesis (IPP) was introduced in 2019. The Rigicon Infla10 has been implanted in 26 centers by 103 physicians. Clinical investigation for FDA approval in United States will begin in late 2022. Data were obtained from the analysis of Patient Information Forms (PIFs) submitted to the manufacturer.
Methods: Overall, 319 patients implanted from January 6, 2019 to December 31, 2021 were followed to analyze device durability from revision/removal and rates of reoperation for infection, mechanical failure, or medical reason.
Results: Mean follow-up was 21.2 months with a range of 5–36 months. Mean age was 58.5 years. And 4.39% required removal or revision. Mechanical failure was 2.5%. There were no infections reported and only two (0.6%) medical problems (component out of place). One (0.3%) patient required revision for inadequate straightening of Peyronie’s disease. Three patients (0.9%) requested device removal for dissatisfaction. A total of 95.6% of Rigicon Infla10 was free from explant or revision 21 months from the original implant date. Kaplan–Meier analysis that revealed cumulative survival of the device at 12, 24, 36 months was 95.6%, 94.7%, and 93.7% until surgical invention.
Conclusion: While this is a retrospective study derived from volunteered PIFs, we believe the vast majority of the early Rigicon Infla10 IPP performed prior to January 2022 were included in the analysis. Early results show initial durability from reoperation equivalent to other contemporary devices.
Prognostic factors assessing response of androgen deprivation therapy in metastatic hormone-sensitive prostate cancer
Sumit Kabra
, Hemant Kumar Goel, Rajeev Sood, Umesh Sharma, Sumit Gahlawat, Anurag Singla
ABVIMS & Dr RML Hospital, New Delhi, India
Introduction: Androgen deprivation therapy (ADT) has been the mainstay of treatment in metastatic hormone-sensitive prostate cancer(mHSPC). However, the efficacy of ADT substantially varies, with most patients eventually progressing to metastatic castrate-resistant prostate cancer (mCRPC), within a few months or years. Thus, this study was carried out to assess factors to determine which patients are more likely to develop CRPC.
Methods: All newly diagnosed metastatic carcinoma prostate patients were included in the study. Baseline characteristics, including clinical, pathological, biochemical, and radiological parameters, were noted. All patients received ADT, either by medical or surgical castration and post-treatment parameters, including biochemical and radiological, were monitored and compared to predict the response to ADT. Response was assessed after 3 months, based on RECIST 1.1 criteria and serum prostate-specific antigen (PSA) levels.
Results: Overall, 43 patients were included in the study (Mage 68.42 ± 9.06 years). The mean decline in PSA at 3 months was 97.77% (range: 92.8–99.8%). According to RECIST 1.1 criteria, 14 patients showed partial response, 17 patients had stable disease while 12 patients showed progressive disease. On multivariate analysis, PSA declines at 3 months, prostate tumor volume(>1 cm3), Gleason Grade Group 4/5, T stage(T3/T4), and bone metastasis (EOD > 3) were found to be significantly associated with poor response to ADT.
Conclusion: PSA declines at 3 months, prostate tumor volume (>1 cm3), Gleason grade group > 3, T stage (T3/T4) and bone metastasis (EOD > 3) were found to be independent significant prognostic predictors of poor response to ADT.
Efficacy of low-power thulium laser enucleation of prostate larger than 80 g
Samer Morsy
, Islam Kamal, Alaa Meshref,
Ahmed Yehia
,
Mahmoud Abdel-Hakim
Kasr Alainy–Cairo University, Cairo, Egypt
Introduction: Thulium laser prostate enucleation (ThuLEP) has become a novel treatment option for bladder outlet obstruction (BOO). Most studies evaluated the safety and efficacy of high-power thulium enucleation using 120–200 W. We evaluated the use of low-power thulium (30 W) regarding efficacy and time needed to remove the adenoma at the level of the surgical capsule and postoperative urinary and sexual functions.
Methods: Patients with symptomatic benign prostatic hyperplasia (BPH) who failed medical treatment or developed BPH-related complications with prostate size larger than 80 ml and candidates for ThuLEP during the period from December 2019 to June 2021 were included. We used a 30-W Thulium laser with a 550 µm laser fiber and a 26 Fr continuous flow resectoscope. Data collected included prostate size, prostate-specific antigen (PSA), enucleation and morcellation time, postoperative International Prostate Symptom Score (IPSS), and IEFF-5 scores at 1 week, 1, 3, and 6 months.
Results: Overall, 37 patients underwent ThuLEP with a mean age of 68 ± 6 years. Refractory retention was the main indication for surgery in 21.6% of patients, hematuria in 8%, and failed medical treatment in 70%. The mean IPSS score of 3 was 25.6 ± 2.2. The mean prostate size was 111 ± 20 ml and the mean Q-max was 6.8 ± 2 ml/s. The mean enucleation time was 70 ± 10 min, and the mean morcellation time was 24 ± 6 min. The mean reduction in PSA level after 6 months was 3.4 ± 1.1 and the mean hemoglobin drop was 1.7 ± 0.6 mg/dl. The first follow-up visit was at 1 week with a mean IPSS 8.3 ± 1.9, mean Q-max improvement of 26 ± 4.6 ml/s. Our results showed significant improvement in postoperative urgency and UUI (p = 0.005) with no significant change in IIEF-5 score at 6-month follow-up compared to baseline.
Conclusion: Low-power ThuLEP is an efficient technique for prostate enucleation with less escharing effects and satisfactory urinary and sexual outcomes.
Review of surgical ambulatory receiving unit for management of renal colic in Manchester University NHS Foundation Trust
Mohammed El-Bahnasawi
Manchester University NHS Foundation Trust, Manchester, UK
Introduction: Renal colic referrals take up a major portion of a urology department’s resources and time in hot clinics. We aimed to assess the existing referral pathway in Wythenshawe hospital in Manchester by looking at the quality of suspected renal colic referrals to the Surgical Ambulatory Care Receiving Unit (SACRU) for a period of 2 months. We additionally investigated the compliance of Wythenshawe hospital with National Institute for Health and Care Excellence (NICE) Guidance in investigating and managing renal colic.
Method: There were 132 Urology referrals to SACRU from January 10, 2022 to March 10, 2022. We filtered out a total of 56 suspected renal colic referrals. We retrospectively identified from their electronic records the source of referral, urine dip result, and eGFR at time of referral, and timing of computed tomography-kidney ureter bladder (CT-KUB) from time of presentation. Ethical approval was not required.
Results: Out of 56 referrals for suspected renal colic from erectile dysfunction (ED), 36% did not have any renal or ureteric stones after CT-KUB in SACRU. However, 39% had stones below 5 mm and only 25% needed interventions. Meanwhile, 67% of suspected renal colic patients had their CT-KUB within 24 h of presentation, 6% waited as long as 6 days. Moreover, 21% of the referrals had no documented urine dip result and 23% had an eGFR of 60 or less at the time of referral to SACRU.
Conclusion: We are falling short of meeting NICE guidance of getting CT-KUBs done within 24 h one-third of the time and continue to make inappropriate or incomplete referrals. A new SACRU referral pathway for renal colic patients is needed.
Safety and outcome of retroperitoneal 3D-laparoscopic pyeloplasty in school children
Sherjeel Saulat
, Jahanzeb Sheikh, Awais Ayub, Mansoor Ejaz, Hamza Ashraf, Dur Amin, Umber Rasheed
Tabba Kidney Institute, Karachi, Karachi, Pakistan
Objective: The aim of the study is to evaluate the efficiency and efficacy of Laparoscopic Dismembered Pyeloplasty by Retroperitoneal method using a 3D imaging system in treating Ureteropelvic Junction Obstruction (UPJO) in pediatric patients.
Methods: All patients with the diagnosis of UPJ obstruction below the age of 12 years, who underwent retroperitoneal 3D-Laparoscopic Dismembered Pyeloplasty, were included in the study. Prospective data of patients treated from September 2020 to April 2021 were collected.
Results: This study included 30 patients in total out of which 24 were male and 6 were female. The mean age of patients was 8.4 ± 3.6 years. Complications were reported in 17 patients (56.6%) which were all limited to Clavien–Dindo grade 1, while no complication > grade 1 was witnessed. There was a peritoneal breach in three patients (10%). Visual analog scale (VAS) facial pain score on postoperative day-1 was graded as Mild in 24 patients (59.9%) while it was Moderate in only 4 patients (26.6%). After 3 months, there was complete resolution of symptoms in all patients. There was a significant reduction in hydronephrosis postoperatively when compared with preoperative imaging (p = 0.04). Mean preoperative APPD was 3.0 ± 0.94 mm while mean postoperative APPD was 2.1 ± 0.2 mm.
Conclusion: The Retroperitoneal Laparoscopic Dismembered Pyeloplasty is an attractive minimally invasive option in terms of patient comfort, hospital stay, postoperative pain, and recovery period with successful outcomes. A 3D imaging system in our experience helps to reduce technical difficulties and complications by providing better orientation of the surgical field.
The new gold standard in Laparoscopic imaging: 3D versus 4K laparoscopic nephrectomy, a single-centered prospective study
Sherjeel Saulat
, Syed Saeed uddin Qadri, Jahanzeb Sheikh, Dur Amin, Numan Kiani, Anil Kumar
Tabba Kidney Institute, Karachi, Karachi, Pakistan
Objective: The aim of the study is to evaluate the outcomes (i.e. hemoglobin fall, post-procedure complications, operative time, IPD stay, etc.) of 3D and 4K laparoscopic nephrectomy.
Methods: Patients aged 15–85 years, with a plan of nephrectomy, were divided into two groups randomly. All patients included in the study were diagnosed to have symptomatic nonfunctioning kidneys on the basis of both renal scintigraphy and computed tomography-kidney ureter bladder (CT-KUB). After group stratification, patients underwent Laparoscopic nephrectomy, clarity of image, procedure easiness, and outcomes recorded along with operative time. The surgeon’s effort was also determined via a predesigned Performa of Task load index by NASA. The NASA Task Load Index is a properly designed multi-dimensional scale that provides ratings on six subscales required by the performer to finish the task; the mentioned subscales are as follows: Mental Demands, Physical Demands, Temporal Demands, Own Performance, Effort, and Frustration. The average of the abovementioned subscales is counted and described, as the overall stress and workload of the surgeon performing the surgery.
Results: The mean age of patients in the 3D and 4K groups was 39.6 ± 16.4 and 45.0 ± 16.1 (p = 0.31) with a range of 48 and 47 years, respectively. While comparing both the groups (3D and 4K), we observed that the 3D group had a significantly shorter mean total operative time 172.1 ± 36.9 versus 272.5 ± 14.1, respectively (p < 0.005). Concerning the individual operative times for tasks 1, 2, and 3, the mean operative time for task 1, that is, from camera entry to the identification of pedicle was 51.87 ± 34.8 and 58.7 ± 15.8 min (p = 0.52), for task 2, that is, time taken to secure the pedicle was 53.1 ± 21.1 and 101 ± 30.9 min (p < 0.005), and for task 3, that is, time taken for mobilizing the kidney was 67.18 ± 18.3 and 112.5 ± 37 min (p = 0.005) for 3D and 4K groups, respectively. Though, the mean operative time for task 1 was shorter in 3D group but was statistically insignificant. Though, the drop was lesser in 3D than in the 4K group but was statistically insignificant (p = 0.7). Mean hospital stay was 2.5 ± 0.6 for 3D group and 2.7 ± 0.9 for 4K group. It too was statistically insignificant with a p-value of 0.8.
Conclusion: We conclude that despite being the latest technology advancement with a greater zooming capability, the 4K imaging system could not prove any superiority over the 3D imaging system, in terms of operative time and hospital stay when used for laparoscopic nephrectomy. 3D laparoscopic imaging systems when compared to 4K technology, in addition to enhancing depth perception and reducing hospital stay also significantly reduce the overall operative time and laparoscopic nephrectomy. Further high-quality studies comparing the outcomes of not only 3D and 4K imaging systems but also 2D and 4K technologies in a variety of surgical procedures, especially complex ones, need to be executed to better determine their efficacy. These studies should also compare the differences in outcomes of 3D/4K and 2D/4K surgical procedures when performed by surgeons having different levels of expertise.
Miniaturization is the future of PCNL: effects of different sizes of Amplatz sheaths on outcomes of Tubeless Miniaturized PCNL in the treatment of large renal calculi
Sherjeel Saulat
, Jahanzeb Sheikh, Syed Saeed Uddin Qadri, Dur Amin, Awais Ayub, Mansoor Ejaz
Tabba Kidney Institute, Karachi, Karachi, Pakistan
Objective: The aim of the study was to assess and compare the efficacy of different sizes of miniaturized amplatz sheaths used in tubeless mini-percutaneous nephrolithotomy (PCNL) for the treatment of renal calculi of > 2 cm on postoperative outcomes, safety, and patient comfort.
Methods: It is a prospective, comparative study, including three groups A, B, and C, comprising different amplatz sheath sizes of 14, 18, and 22 Fr, respectively, used during mini-PCNL. All patients presented with renal calculi were evaluated for eligibility and randomly allotted with the help of computerized randomization software in three groups. After careful counseling from the primary investigator, the patients were requested to sign the consent form. On successful enrollment, PCNL was performed with pre-defined amplatz sheaths and the patient was shifted to ward for postoperative care. Pre-procedure, intraoperative, and post-procedure details were documented and analyzed.
Results: A total of 62 patients were enrolled in the study and randomly divided into three groups allocated by the programmed software. There were 20 patients in group A, 21 patients in group B and 21 patients in group C. Overall stone clearance rate was comparable among all groups and it was 95% in group A, 90.5% in group B, and 85.7% in group C (p = 0.6). Overall complication rate was 14.5% in total but significantly higher for group C (p = 0.04). Smaller sheaths resulted in a decreased need for blood transfusion (p = 0.43), less Hb drop (p = 0.07), decreased need for postoperative opioid analgesia (p = 0.07), and less VAS pain scores (p = 0.03), and less duration of hospital stay (p = 0.17). Larger size sheaths, however, had superiority in terms of shorter operating durations (p = 0.03).
Conclusion: The use of smaller amplatz sheaths is better in terms of stone clearance rate, complications rate, and postoperative recovery as compared to their larger counterparts but at the cost of longer operating durations.
All that glitter is not gold: computed tomography-kidney ureter bladder is not necessary for a safe percutaneous nephrolithotomy
Sherjeel Saulat
, Jahanzeb Sheikh, Syed saeed uddin Qadri, Dur Amin, Hamza Ashraf, Mansoor Ejaz
Tabba Kidney Institute, Karachi, Karachi, Pakistan
Introduction: Diagnosis of renal stones is tricky, and appropriate diagnosis requires exact location and size identification of renal stones along with the degree of obstruction and hydronephrosis. This study aimed to compare the difference between ultrasound (USG) and computed tomography-kidney ureter bladder (CT-KUB) groups for stone clearance, diagnostic accuracy, laboratory parameters, and complications.
Methods: This is a cross-sectional, comparative effectiveness trial; patients (n = 100) with suspected renal stones were randomly assigned with a 1:1 ratio to two different imaging groups, group A (n = 50) participants had ultrasonography, and group B (n = 50) patients had CT as a diagnostic imaging modality. The complications and operative differences were compared with the help of Student’s t-test and chi-square tests, a p-value of 0.05 was considered statistically significant.
Results: The mean age of the patients was 37.3 ± 17 and 45.8 ± 14.7 years in group A and group B, respectively. The study found no difference (0.3 and 0.1) between preoperative stone size measurements of the renal unit by ultrasound and CT [(2.4 ± 0.9 and 2.7 ± 1.8 cm (right) and 1.8 ± 1.0 and 1.9 ± 0.7 cm (left)]. The sensitivity and specificity of USG for renal stone diagnosis was 84.8%, while CT indicated 86% accuracy, X-Ray KUB was used for radiopaque stones only and showed 78.6% sensitivity and specificity.
Conclusion: The preoperative stone sizes indicated in ultrasonography and CT were similar in intraoperative, retrograde pyelogram (RPG) measurements, which referred to the accuracy of stone size prediction. Simple X-ray and ultrasonography are cost-effective, and easily available in hospitals, with minimal radiation exposure.
Elgamasy technique: transobturator vaginal wall sling for the treatment of female stress urinary incontinence
Abdelnaser Elgamasy
Tanta University, Tanta, Egypt
Introduction: There are multiple surgical options for treatment of stress urinary incontinence (SUI) but midurethral slings are the most effective and durable form of treatment. Herein, a novel technique using in situ tissue for the treatment is presented. The objective of this study was to evaluate efficacy and safety of transobturator vaginal wall sling as a treatment for female SUI.
Methods: We evaluated the outcomes of 20 consecutive females who underwent transobturator vaginal wall sling (either in situ island or as graft) for SUI. One prolene suture was sutured at each side of the sling and fixed around the midurerhra in the similar way of transobturator tape. Concomitant cystocele and rectocele were repaired in the usual way. Patients were followed in the outpatient clinic after 1 week, 2 weeks,1 month, and 3 months postoperatively. Outcomes were measured subjective by the International Consultation on Incontinence Questionnaire Female Lower Urinary Tract Symptoms (ICIQ-FLUTS) score comparing preoperative and postoperative scores and objective by cough stress test and Q-Max.
Results: The mean age of patients was 42.3 ± 10.6 (31–62) years, 14 patients (70%) were premenopausal and 6 patients (30 %) were postmenopausal. The mean BMI was 31.5 ± 7.1 kg/m². The technique was performed and the patient was discharged the next day after surgery. Mean operative time was 57 min ± 20. Follow-up for patients was carried out at 1 week, 2 weeks,1 month, and 3 months postoperatively. All patients showed significant improvement in all domains: frequency, voiding, and incontinence, and in quality of life related to frequency, voiding, and incontinence. Overall, 19 patients (95 %) showed negative cough stress test 3 months postoperatively and none of them suffered from severe (Clavien III–V) complications or required reoperation to release the sling. There was no significant change between pre- and postoperative Q-Max. Only one patient (5%) was considered failure with the persistence of incontinence.
Conclusion: Elgamasy technique (Transobturator vaginal wall sling placement) appeared safe, effective, and cheap with excellent short-term outcomes. However, long-term follow-up is needed.
Predicting tumor behavior in Renal Cell Carcinoma using signature of molecular biomarkers (PRL3 phosphatase, CAV2, LAMA4, and GRP78)
Manoj Kumar, Nidhi Gupta, Seema Kaushal, Alpana Sharma
All India Institute of Medical Sciences, AIIMS, Delhi, India, Delhi, India
Background and Objectives: Among the urological malignancies, renal cell carcinoma (RCC) is the most lethal. Clear cell is the commonest subtype of RCC. One-fourth of the patients present with locally advanced or metastatic RCC and recurrence is seen in about one-third of the patients after surgery. The use of biomarker signature when measured in combination has high predictive value in predicting the tumor behavior in RCC. The objective of this study is to examine the expression of signature of molecular markers (PRL3 phosphatase, CAV2, LAMA4, and GRP78) mRNA and protein expression in tissue of RCC patients by comparison between malignant and normal parenchyma, serum level of molecular markers of RCC patients in comparison of serum level with controls and to correlate these levels with stage and grade of RCC.
Methods: A prospective study of 60 patients who underwent nephrectomy for renal tumor between May 2017 and March 2019. Tumor and adjacent non-malignant renal parenchyma of the same patient were collected. Each sample specimen was divided into two parts; one part is for mRNA expression using reverse transcriptase (RT)-PCR and the other part is for immunohistochemistry (IHC) analysis. Protein expression was done using western blot. Peripheral blood (5 ml) of the patients and age- and gender-matched controls were taken and allowed to clot for 2 h at room temperature. Serum levels was measured using a commercially available ELISA Kit.
Results: The molecular expression (both mRNA and protein) of PRL3 phosphatase, CAV2, LAMA4, and GRP78 were investigated in tumor tissue and adjacent non-tumor tissue in RCC patients by Q-PCR and western blotting, respectively. The molecular expression of all the molecules was significantly higher (p < 0.05) in tumor tissue as compared to adjacent non-tumor tissue.
Moreover, circulatory levels of PRL3 phosphatase, CAV2, LAMA4, and GRP78 were also determined in serum samples of RCC patients and controls and it has been observed to have significant elevation of all the molecules in circulation of RCC patients in comparison to controls.
Conclusion: There was a positive correlation between the circulatory and tissue levels of PRL3 phosphatase, CAV2, LAMA4, and GRP78 which suggests the potential tumor markers for RCC. The molecular signature could help in risk stratification of RCC in future after validation in a large patient cohort.
The rule of Rezum in the management of refractory urinary retention due to benign prostatic hyperplasia
Ibrahim Khalil
, Majd AlKabbani, Khalid Abdulhadi, Khalid Al-Rumahi
Hamad Medical Corporation, Doha, Qatar
Introduction: The most common cause of urinary retention in men is benign prostatic hyperplasia (BPH). Transurethral resection of the prostate (TURP) remains the gold standard surgical treatment. However, more minimally invasive treatments have been introduced due to the morbidity and mortality associated with TURP, such as vaporizing the prostate using Rezum System.
Methods: All patients with urinary retention who underwent Rezum procedure in Qatar from June 2020 until December 2022 participated in the study. Preoperative evaluation of the patient characteristics and prostatic parameters were collected. The primary outcome was the rate of a successful trial of voiding without a catheter. Secondary outcomes were improvement in International Prostate Symptom Score (IPSS) score, medication discontinuation, and complications.
Results: The study included nine patients with a mean age of 74.8 + 9.1 years. The comorbidities were diabetes in five patients (55%), hypertension in five patients (55%), coronary artery disease CAD in three patients (33%), and chronic kidney disease (CKD) in one patient. All patients used alpha-blocker or combination therapy. The pre-Rezum prostate volume was 96 cc [42-220], the mean baseline prostate-specific antigen (PSA) was 11 µg/liter, and the mean baseline IPSS score was 20. Successful trial of voiding rate was 100%, mean Q-max was 10 ml/s at 1 month, and 11.25 ml/s at 3 months post-procedure. The post-void residual volume (PVR) at 3 months was 27 ml. None of the nine patients had a decrease in the ejaculate volume. No major complications were recorded at 1 and 3 months of follow-up. The IPSS score improved post-Rezum to a mean of 13.25 at 1 month and 11.4 at 3 months. Six (66%) patients discontinued their medications.
Conclusion: Rezum is an effective modality to treat comorbid patients with urinary retention due to BPH without significant morbidity or complications.
Permanent cutaneous vesicostomy: a pragmatic approach to safely manage lower urinary tract dysfunction in pediatric palliative care patients with neuropathic bladder
Ibrahim Khalil1
, Ahmed Al Saeedi1, Joao Luiz Pippi Salle2, Santiago Vallasciani2
1Department of Urology, Hamad Medical Corporation, Doha, Qatar, 2Pediatric Urology Division, Department of Surgery, Sidra Medical and Research Center, Doha, Qatar
Introduction: Bladder dysfunction, characterized mainly by chronic retention, leads to progressive hydronephrosis, loss of renal function, recurrent urinary tract infections (UTIs), and stone formation, which are difficult to manage in pediatric patients with neuropathic bladder admitted to palliative care facilities. Vesicostomy is a simple, reversible, and well-tolerated surgery with few complications, with a proposed protective effect on the upper tract, improved renal function, and less febrile UTI. Herein, we describe our experience with the use of permanent cutaneous vesicostomy for this complex population.
Methods: After IRB approval (IRB#1592907) from Sidra medical and research center research committee, we studied the results of permanent cutaneous vesicostomy (CV) retrospectively in patients admitted to a palliative facility with lower urinary tract dysfunction (LUTD) not responding to initial management of antibiotics and clean intermittent catheterization in terms of hydronephrosis, stone formation, and rate of UTI in the period between 2015 and 2019. Children with chronic and life-limiting diseases necessitating admission to pediatric long-term care units as step down from high dependency units before to allow for continuity of care and provide palliative care when indicated were included. The study population do share common characteristics such as multisystem involvement, polypharmacy, Gross Motor Function Classification System (GMFCS) levels of 4 or 5, frequent and prolonged hospital admissions, and need for optimal coordination of care.
Results: Overall, 18 patients included in the study presented signs and symptoms of LUTD with one or more of the following: UTI 18 patients (100%), stones in 5 patients (27%), or progressive hydroureteronephrosis in 3 patients (16%). Of the 18 patients, 9 (50%) developed complicated LUTD and underwent CV. Follow-up for a mean of 11.3 months showed improvement of hydronephrosis in all patients (100%). The UTI rate was reduced in eight out of nine patients; five patients had complete resolution with no further interventions, and three required intermittent bladder irrigation through vesicostomy. Urinary bladder stone did not recure after CV. Revision of the vesicostomy was required in two cases (11%) at 12 and 24 months postoperatively due to stoma stenosis.
Conclusion: CV is a simple and effective procedure for managing complicated LUTD in complex institutionalized palliative patients with neurogenic bladder. Besides effective urinary decompression, it provides alternative access for bladder washouts whenever necessary to manage recurrent UTIs.
Evaluation of risk factors and baseline characteristics of recurrent renal stone patients in Saudi Arabia
Ali Abdel Raheem1, Mohammed Alshehri2, Hind Alsaeed3, Malath Alrowili3, Faisal Alhoshan4, Ayman Hagras5
1Urology Department, King Saud Medical City, Riyadh, Saudi Arabia, 2Urology Department, King Abdullah ben Abdulaziz University Hospital, Princess Nourah Bint Abdulrahman University, Riyadh, Saudi Arabia, 3Princess Nourah Bint Abdulrahman University, Riyadh, Saudi Arabia, 4Prince Sultan Military Hospital, Taif, Saudi Arabia, 5Division Of Urology, Surgery Department, Sharura Armed Forces Hospital, Sharourh, Saudi Arabia
Introduction: We investigated the demographic data among Saudi Arabian renal stone patients, and the risk factors of renal stone recurrence after successful primary treatment.
Methods: A prospective observational study was conducted from March 2020 to March 2021. A non-validated self-administered questionnaire was disseminated among patients with a history of renal stone treatment. The primary endpoint of the study was to assess the baseline and demographic characteristics of stone formation among Saudi Arabian patients. While, the secondary endpoint was to evaluate the predictors of renal stone recurrence after successful primary treatment.
Results: A total of 1260 participants (820 males and 440 females) with history of renal stone treatment completed the online questionnaire and were included in our study. Primary treatments were percutaneous nephrolithotomy (PCNL), retrograde intrarenal surgery (RIRS), extracorporeal shock wave lithotripsy (ESWL), surgery, and medical treatment in 22.5%, 34.7%, 26.5%, 10.3%, and 6%, respectively. Among the participants, 383 (30.4%) had recurrent renal stone and 877 (69.6%) did not develop recurrence after primary stone treatment. After treatment, 970 (77%) and 1011 (80.2%) of patients did not have either stone chemical analysis or metabolic work-up, respectively. Multivariate logistic regression analysis revealed that male patients [OR: 1.686; 95% CI (1.216, 2.337)], hypertension [OR: 2.342; 95% CI (1.439, 3.812)], primary hyperparathyroidism [OR: 2.806; 95% CI (1.510, 5.215)], low fluid intake [OR: 28.398; 95% CI (18.158, 44.403)], and high daily protein intake [OR: 10.058; 95% CI (6.400, 15.807)] were predictors of renal stone recurrence.
Conclusion: Male gender, hypertension, primary hyperparathyroidism, low fluid intake, and high daily protein intake increase the risk of renal stone recurrence among Saudi Arabian patients.
Initial 10-year experience in the treatment of non–muscle-invasive bladder cancer with radiofrequency-induced thermo-chemotherapy effect using Mitomycin-C
Ahmed Mohamed
, Moustafa Elsawy, Mark Yao
1,
Sister Angela Eliott
1,
Sanjeev Madaan
1
Dartford and Gravesham NHS Trust, Dartford, UK
Introduction: Radiofrequency-induced thermo-chemotherapy effect (RITE) using Mitomycin-C (MMC) is a second-line treatment option for patients with high-risk non–muscle-invasive bladder cancer (NMIBC) after failed or inappropriate response to intravesical immunotherapy (BCG).
Methods: At the point of care, prospectively obtained patient data were retrieved from the database.
The induction regime was weekly for 6 weeks (excluding CIS, which was 8 weeks). Maintenance treatment was seven doses (1 every 6 weeks), then five doses (1 every 8 weeks). Cystoscopy was performed every 3 months for 2 years, and a CT intravenous urogram was performed annually.
Results: Overall, 76 patients received treatment between November 2011 and December 2021. Median age was 77 years, 62 were males and 14 were females. However, 43.4% (n = 33) of the patients were internal and 56.5% (n = 43) were referred from other centers. Indications for treatment were BCG failure in 82% (n = 62), BCG intolerance in 8% (n = 6), BCG shortage in 4% (n = 3), BCG contraindication in 4% (n = 3), previous TB in 1% (n = 1), and BCG resistance in 1% (n = 1). Overall, 790 doses were given; on average, 10.8 doses per patient. However, 30.2% (23) patients stopped treatment early; most commonly due to progression (n = 9), pain (n = 6), stricture (n = 5), incontinence (n = 4), and dysuria (n = 4). The follow-up duration was 0–72 months (median 18 months). Recurrence during follow-up was 34.2% (n = 26) (median recurrence time 18 months).
Conclusion: Based on our experience, RITE-MMC provides an alternate modality for the treatment of NMIBC, particularly in patients who are BCG-refractory or resistant. Our first statistics revealed a good response rate.
Comparison of mini versus maxi PCNL performed in a district general hospital
Ahmed Mohamed
, Neophytos Petrides, Danielle Whiting, Seshadri Sriprasad, Faqar Anjum
Dartford and Gravesham NHS Trust, Dartford, UK
Introduction: Percutaneous nephrolithotomy (PCNL) is an established procedure in the management of large renal and upper ureteric calculi. It is more commonly performed using a 24 + Fr sheath. Mini-PCNL has gained popularity recently as a less invasive procedure to manage larger renal calculi. In this abstract, we are comparing the outcomes of mini (16.5 Fr) and maxi (24–30 Fr) PCNL with a urologist performing the access puncture, in the supine position.
Methods: Data were collected from the electronic databases of a district general hospital retrospectively over 6 years. All PCNLs performed by a single surgeon were included in the analysis.
Results: We report our outcomes including length of stay, stone clearance, and complications rates, for 194 consecutive PCNLs performed between 2015 and 2021 by a single surgeon. Mini-PCNL was performed in 72 patients and larger access was used in 122 patients. Stone size varied from 1.6 cm to complete staghorn. Mini-PCNL was used for smaller stones on average and the overall comparison is shown in Table 1. When comparing 2–4 cm stones (32 mini versus 59 maxi), complete stone clearance was 28/32 (87.5%) for mini and 50/59 (84.7%) for maxi. Complication rates were four grade 2 for mini compared to eight grade 2 and seven grade 3 for maxi.
Conclusion: In our experience, mini-PCNL with a urologist gaining access is an excellent procedure that allows for safe management of most upper urinary tract calculi (excluding complete staghorn calculi). It has at least equal stone clearance rates to larger puncture calibers with lower complication rates.
State of the art and accessibility of laparoscopic surgery in urology in Douala Cameroon
Axel Stéphane Nwaha Makon
University of Yaounde, Cameroon
Introduction: Laparoscopic surgery is a minimal-invasive surgical approach, which involves performing an operation without a large parietal opening, unlike laparotomy. Still in full development in Africa, it is not practiced frequently in urology. In this study, we evaluate the accessibility of laparoscopic surgery in urology in Douala Cameroon, a low-income country.
Methods: This was a multi-center descriptive cross-sectional study in the city of Douala over a period of 65 months, from January 2016 to May 2021. It included complete record files of patients who had undergone urology laparoscopy and patients admitted and managed by laparoscopic surgery for urological pathology. We excluded incomplete recorded files and patients who withdrew their consent.
Results: We selected 26 patients and 160 recorded files of patients operated on by laparoscopic surgery in urology. The hospital prevalence was 8.1% with a predominance; the male/female sex ratio was 5.4. The mean age was 44.6 ± 17.5 years. Subjects above 55 years of age were the most represented. Varicocele surgery for infertility was the most common laparoscopic procedure in urology with 37.6%. Dissection-clipping of the spermatic cord vessels in case of varicocele with 29.6% was the most performed procedure. Among the laparoscopic approaches, the one most used was the transperitoneal approach in 92.5% of cases (172 cases). The main intraoperative complication was found to be a vascular lesion (4 cases). One case of indicated conversion due to intraoperative bleeding was recorded during testicular lowering. Surgical procedures lasted on average of 1.5 ± 0.5 h, with extremes ranging 0.3–3.1 h. The postoperative complication rate was 8.1%, dominated by postoperative infection at 2.7%. The average hospital stay was 2.3 ± 1.4 days. More than half of the operated cases resumed their activities within 2 weeks. The cost of the operations varied between 200,000 XAF (USD$325) and 2,500,000 XAF (UD$4000) depending on the hospital structures.
Conclusion: Laparoscopic surgery is poorly practiced in urology in our environment due to a multifactorial association including skills, technical facilities, and the cost of care. Despite multiple indications, its practice and accessibility remain limited. We recommend funding the field of urological laparoscopy to promote its development.
Complications of circumcision in three hospitals in Douala: epidemiological, clinical, and therapeutic profile
Axel Stéphane Nwaha Makon
University of Yaounde, Cameroon
Objective: The aim of the study was to describe the epidemiological, clinical, and therapeutic aspects of the complications of circumcision in three hospitals in the city of Douala.
Methodology: This was a descriptive cross-sectional study lasting 4 months (January–April 2021) with retrospective recruitment over 10 years (January 1, 2011 to 31 December, 2020) in the Surgery Departments of the Douala General Hospital, the Catholic Hospital, Notre Dame de l’Amour of Douala and the Urology Department of Laquintinie Hospital of Douala. During this study period, all records of complications of circumcision that met the inclusion criteria were included. A pre-designed questionnaire was used for data collection.
Results: We screened 102 patient files, of which 96 presented a single complication while 6 patients had more than one complication. The average age was 6.51 ± 5.74 years with extremes ranging from 1 month to 29 years. The age group most represented was that of 0–5 years. The time elapsed before the consultation was 1.86 years with extremes from 30 min to 16 years. The main reason for consultation was leakage of urine through urethral fistula (26.47%) followed by dysuria (24.51%). We found that 23.5% patients were circumcised outside the hospital. Paramedical personals were responsible for the majority complications (66.7%). The most common complication was urethral fistula 27.5%, followed by stenosis of the urethral meatus 24.5%. The study showed that 16.66% of patients required emergency treatment, among 29.50% hemostatic suture and 12.60% pressure dressing, etc. A total of 95 patients received surgical treatment. The clinical course was satisfactory in 96.1% of cases and 3.9% had a reserved opinion.
Conclusion: Circumcision which is known as the most practiced surgical act must be performed by informed and trained staff to avoid the occurrence of complications.
Cryoablation for small renal masses: cohort study in Qatar
Majd Alkabbani
, Ibrahim Adnan, Nagy Younis, Khalid Al-Rumaihi
Hamad Medical Corporation, Qatar
Introduction: The incidence of small renal masses has increased in recent years, likely due to increased incidental detection. Percutaneous renal cryoablation has gained growing acceptance for the management of small renal masses in selected comorbid patients. We present here the Qatari experience with cryoablation.
Methods: All patients who underwent percutaneous cryoablation in Qatar from 2016 to 2022 have been included in a retrospective cohort analysis. The nephrometry score and histopathology of renal biopsies were recorded. Primary outcome was the oncological control, while secondary outcomes were complications and renal impairment post cryoablation.
Results: The study included 37 patients who underwent percutaneous cryoablation with mean age of 57 + 4.6 years. In 33 cases, the renal mass was less than 4 cm, while in 4 cases, the mass exceeded that size. The majority of cases (62.2%) had a nephrometry score of 6, and none of the cases scored more than 10. Most of the cases had one or more medical comorbidity warranting them as high risk for surgical intervention. Percutaneous biopsy was performed in 19 cases (51.3%) and showed clear cell carcinoma in 16 out of the 19 cases (84.2%), oncocytoma in 2 cases (10.5%), and papillary renal cell carcinoma in 1 case. Oncological control was defined as progression and local recurrence. Progression and metastasis were not recorded in any of the cases; however, four cases developed local recurrence. The renal masses in all four cases of local recurrence were more than 4 cm in size. Chronic renal impairment post ablation was recorded in 8.1% of the cases. Other complications included fever in two cases, hematuria that was treated conservatively in two patients, and vomiting was encountered in two cases due to bowel proximity.
Conclusion: Percutaneous cryoablation can be an optimal option for comorbid patients under high risk of surgical intervention with small renal masses less than 4 cm.
Successful implantation of InterStim Micro in a pediatric patient with neurogenic bladder; a case report of the first case in the world
Abdulmalik Alkhamees1
, Wadha Alqahtani
2,
Fouad Alkawai
2,
Ali Alabbad
2,
Riyad Almousa
2
1King Fahd Hospital of the University, Imam Abdulrahman Bin Faisal University, Dammam, Saudi Arabia, 2King Fahad Specialist Hospital, Dammam, Saudi Arabia
Introduction: Spina bifida refers to a condition of incomplete neural tube closure during the early development of the central nervous system. The majority of the patients with lipomyelomeningocele (LMMC) are affected by neurogenic bladder (NB). Sacral neuromodulation (SNM) is not FDA approved for the treatment of children with or without NB yet. However, it has been used as off-label for NB patients in the last two decades. The objective of this case report is to highlight the successful treatment of a 10-year-old girl with NB due to LMMC using the InterStim Micro System.
Case presentation: The patient underwent LMMC repair at the age of 7 years. Her primary symptom was mixed urinary and fecal incontinence. The patient had voiding lower urinary tract symptoms, and she was voiding by straining with overflow incontinence. She also complained of chronic constipation, in which she used laxatives to help her symptoms. A bladder diary was obtained, the patient was doing clean intermittent catheterization (CIC) every four to six times per day, associated with leakage in 90–100% of voids. Based on the failure of conservative therapy, she underwent two stages of SNM implantation. InterStim Micro system was used due to the patient’s condition and the need for MRI in the future. After 2 weeks of the procedure, her bladder diary showed dramatic improvement of her symptoms. She voided freely four to six times a day. She had no urine leak, and her bowel habit improved on a daily basis.
Discussion: Our experience demonstrates a complete resolution of NB symptoms caused by LMMC using the new InterStim Micro system, which is a promising alternative to treat NB in pediatric age group as it is safe, minimally invasive, small in size, rechargeable, and MRI compatible.
