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  • A meta-ethnography to understand the experience of living with urinary incontinence: ‘is it just part and parcel of life?’
    BMC Urol. (IF 1.583) Pub Date : 2020-01-16
    Francine Toye; Karen L. Barker

    Urinary incontinence (UI) is highly prevalent and affects the lives of many men and women. We aimed to conduct a qualitative evidence synthesis (QES) to explore the experience of living with UI and to develop a conceptual model that can help us to understand this experience, and the potential barriers to appropriate healthcare. We used the methods of meta-ethnography developed by Noblit and Hare and recently refined for larger studies. Meta-ethnography involves identifying concepts from the studies and abstracting these concepts into a line of argument. We searched for studies that explored the experience of adults with UI. We used the GRADE-CERQual framework to assess confidence in review findings. We screened 2307 titles, 429 abstracts, 107 full texts and included 41 studies (36 unique samples) in the synthesis. We organised the concepts into 26 conceptual categories, which we further abstracted into 6 themes: (1) Am I ill or is this normal? (2) It effects who I am and how I feel; (3) I feel stigmatised, ashamed and guilty; (4) talking can be difficult but it can help; (5) keeping incontinence under control; (6) have I got to the point that I need help? Our model conceptualises living with UI as navigating antagonists: Is UI normal or am I ill? Do I need help or am I managing? Do I keep UI to myself (and manage alone) or do I tell other people (and get the support that I need)? Do I use control strategies that focus on concealing (avoid risky situations, wear pads) versus, I use strategies that focus on improving the bodily function to improve continence. Our model highlights the experience of stigma, shame and guilt which exert a pull towards concealment. The culture of secrecy and profound sense of shame is barrier to seeking help. An environment which reduces the shame and stigma of UI may help people to switch the focus to strategies that will improve continence, rather than conceal incontinence.

  • Solitary fibrous tumor of the scrotum: a case report and review of the literature
    BMC Urol. (IF 1.583) Pub Date : 2019-12-30
    Tsung-Hsin Chang; Marcelo Chen; Chih-Chiao Lee

    Solitary fibrous tumor (SFT) is a rare soft tissue tumor originally reported in the pleura. Although it has been reported in various extra-pleural sites, the occurrence of SFT in the scrotum is extremely rare. Herein, we present a 48-year-old man who had scrotal SFT. There are very few reported cases of genitourinary SFTs, this is only the fifth report of SFT of the scrotum in the English medical literature. In this study, we report on a 48-year-old man who presented with a 5 × 8 cm scrotal mass between his testes. Physical examination revealed a 4.7 × 8.5 cm lobulated tumor mass located between his testicles. Surgical excision of the tumor with scrotal approach was done and pathology reported a SFT. The patient was alive without tumor recurrence or distant metastasis during ongoing follow-up for 9 months post-operatively.. Scrotal SFTs are very rare and only five cases have been reported in English literature to date. Treatment often involves surgical resection, and a definite diagnosis is made with the help of immunohistochemistry. The current general consensus for the management of SFTs is long-term follow-up after surgical excision of the tumor.

  • Robot-assisted laparoendoscopic single-site surgery for the simultaneous management of multiple urinary tract calculi: a case report and experience sharing
    BMC Urol. (IF 1.583) Pub Date : 2019-12-30
    Fan Zhang; Lisong Shan; Jiahui Yin; Luyang Liu; Pengchao Wang; Shengkun Sun; Xu Zhang; Hongzhao Li; Xin Ma; Gang Guo; Qiming Liu

    Urolithiasis is a clinically common benign disease in urology. Surgical treatments that are widely used in urolithiasis are percutaneous nephrolithotomy, rigid/flexible ureteroscopy, laparoscopic surgery, and endoscopic combined intrarenal surgery. The da Vinci surgical system is rarely used in the treatment of urolithiasis. In the current study, we report a case of multiple urinary tract calculi treated by robot-assisted laparoendoscopic single-site (RA-LESS) surgery. A 49-year-old male patient was admitted to our hospital and diagnosed with multiple urinary tract calculi. He previously underwent right ureterolithotomy, laparoscopic cholecystectomy, and extracorporeal shockwave lithotripsy. Computed tomography (CT) scan and three-dimensional reconstruction CT image showed that multiple calculi were located in the right kidney, right upper ureter, and bladder. The preoperative glomerular filtration rate (GFR) were 17.81 ml/min (right kidney) and 53.11 ml/min (left kidney). We utilized the da Vinci system docking with a single-site port to perform pyelolithotomy, ureterolithotomy, and cystolithotomy, simultaneously. The operative time was 135 min and estimated blood loss was 30 ml. The postoperative hospital stay was 5 days. Three months after surgery, the serum creatinine and urea nitrogen levels dropped to a normal range, and no residual fragments were found in the CT scan. The postoperative GFR were 26.33 ml/min (right kidney) and 55.25 ml/min (left kidney). RA-LESS surgery is a safe and effective surgical procedure in the treatment of multiple urinary tract calculi; however, further investigation is needed to validate its long-term therapeutic effect.

  • The resonance® metallic ureteral stent in the treatment of malignant ureteral obstruction: a prospective observational study
    BMC Urol. (IF 1.583) Pub Date : 2019-12-27
    Jun Miyazaki; Mizuki Onozawa; Satoshi Takahashi; Yuka Maekawa; Mitsuru Yasuda; Koichiro Wada; Yuji Maeda; Takuro Masaki; Akito Yamaguchi; Masahiko Suzuki; Yasuyuki Sakai; Tomokazu Kimura; Manabu Takai; Kensaku Seike; Takahiko Hashimoto; Shingo Yamamoto

    To study the outcomes and experiences of using metallic stents in treating patients with malignant ureteral obstruction (MUO), we examined the effects of metallic ureteral stenting using the Cook Resonance® stent in the treatment of MUO. All patients who had a Resonance metallic stent inserted between April 2015 and March 2018 at one of multiple facilities were prospectively observed with a 1-year follow-up. The primary outcome was the patency rate of the metallic ureteral stent. The secondary outcomes included the complications (e.g., infection and fever). Although stent insertion was attempted in 50 patients, the stent could not be inserted as a ureteral stent in three patients due to severe ureteral stricture, and one ureteral cancer patient was excluded from the analysis. The remaining 46 patients’ median age was 67 years (range 28–85 years) (16 males, 30 females). Twenty-four patients died during the study; their median survival time was 226 days. The median follow-up period for the censored patients was 355 days (range 16–372 days), and just seven patients were still alive without Resonance failure > 1 year later. The women’s IPSS scores tended to be lower than those of the men. Regarding the OABSS score, although the women’s total score tended to be low, the difference between the men’s and women’s scores was nonsignificant. The bacteria detected from urine culture after stent insertion were more gram-positive than gram-negative. Metallic ureteric stenting using the Resonance stent is safe and effective for treating MUO. Subjective symptoms were relatively less in the female patients.

  • Metachronous renal cell carcinoma with metastasis to the urinary bladder, and distant organs, 28 years after radical nephrectomy: a case report
    BMC Urol. (IF 1.583) Pub Date : 2019-12-27
    Mustufa Babar; Saad Hamdani; Corinne Liu; Jogarao Vedula; David S. Schnapp

    Metachronous renal cell carcinoma after radical nephrectomy is extremely rare. Renal cell carcinoma commonly metastasizes to distant organs. However, metastasis to the urinary bladder is very uncommon. Herein, we report a case of metachronous renal cell carcinoma with metastasis to the urinary bladder, left acetabulum, left rib, lungs, thyroid, right renal vein and inferior vena cava. The patient had undergone a left-sided radical nephrectomy 28 years ago. The pathological diagnosis of a fragment of the bladder tumor was consistent with Fuhrman grade 2 clear cell renal cell carcinoma. Although metachronous renal cell carcinoma after radical nephrectomy is rare, active surveillance should be still considered. Renal cell carcinoma has shown to unusually metastasize to the urinary bladder, a rarely reported organ of metastasis. Treatment options, such as immunotherapy, are available to patients with such metastasis and long-term survivorship can be achieved.

  • Robot-assisted laparoscopic antegrade versus open inguinal lymphadenectomy: a retrospective controlled study
    BMC Urol. (IF 1.583) Pub Date : 2019-12-23
    Hualiang Yu; Yongliang Lu; Yi Xiao; Jiaxiang Guo; Xiaotao Yin; Yu Yang; Hongwei Wang; Jiangping Gao

    To investigate the surgical methods and clinical results of robot-assisted laparoscopic antegrade inguinal lymphadenectomy. A retrospective study was performed on clinical data from 19 patients with penile cancer admitted from March 2013 to October 2017. Among them, nine patients underwent robot-assisted laparoscopic antegrade inguinal lymphadenectomy (robot-assisted group) and 10 patients underwent open inguinal lymphadenectomy (open group). In the robot-assisted group, preoperative preparation, patient position, robot placement, design of operating channel and establishment of operating space are described. Key surgical procedures and techniques are also summarized. In addition, the number of lymph nodes removed, postoperative complications and follow-up in both groups were statistically analyzed. For the 9 patients in the robot-assisted group, surgery was successfully accomplished at 17 sides without intraoperative conversion to open surgery. The surgery time for each side was 45~90 min using laparoscope with an average of 68.5 ± 13.69 min/side. The intraoperative blood loss was estimated to be < 10 ml/side, and the number of removed lymph nodes was not significantly different from that of the open group (12 ± 4.2/side vs.11 ± 5.8/side, P = 0.84). There were no postoperative complications such as skin necrosis, delayed wound healing and cellulitis in the robot-assisted group. Skin-related complications occurred in 9 (45%) of the 20 sides in the open group. During a median follow-up of 25 months in robot-assisted group and 52.5 mouths in open group, was not significantly different there were no statistical differences in recurrence-free survival between the groups (75% vs 60%, p = 0.536). Robot-assisted laparoscopic antegrade inguinal lymphadenectomy achieved the desired surgical outcomes with fewer intraoperative and postoperative complications. The robotic arms of the surgical system were placed between the lower limbs of each patient. There was no need to re-position the robotic arms during bilateral inguinal lymphadenectomy. This simplified the procedure and reduced the use of trocars. If necessary, pelvic lymphadenectomy could be performed simultaneously using the original trocar position.

  • Impact of case volume per year on flexible Ureteroscopy practice: an internet based survey
    BMC Urol. (IF 1.583) Pub Date : 2019-12-18
    Omar Alhunaidi; Abdulrahman A. Ahmad; Ahmed R. EL-Nahas; Bader Akroof; Ali Alamiri; Feras Al-Ajrawi; Abdullatif Al-Terki; Mohamed El-Shazly

    To report current worldwide variation in techniques and clinical practice of flexible ureteroscopy (FURS) among endourologists of different case volumes per year. Two invitations to complete an internet survey were emailed to Endourological Society members. Some of survey questions asked about indications of using FURS for renal and upper ureteral stones. Others were concerned with clinical practice of FURS (such as preoperative stenting, use of ureteral access sheath (UAS) and safety guidewire, technique of Laser lithotripsy and fragment retrieval, and post-FURS stenting. Responders were distributed into two groups; high-volume (> 100 cases/year) and low-volume surgeons (< 100 cases/year) and data were compared between both groups. Responses were received from 146 endourologists all over the world (62 high-volume and 84 low-volume). FURS for intrarenal stone > 20 mm was used by 61% of high-volume surgeons compared with 28.6% for low-volume (P < 0.001). Semirigid URS was used for upper ureteric stones in 68% among high-volume group and 82% in low-volume group (P = 0.044). UAS was used by 62% in low-volume group and 69% in high volume group (P = 0.516). Laser stone dusting was preferred by 63% in low-volume group versus 45% by high-volume (P = 0.031). More responders in low-volume group preferred to leave the stent for 6 weeks (P = 0.042). The use of FURS for treating upper tract calculi has expanded by high volume endourologists to include large renal stones > 20 mm. Low-volume surgeons prefer to use semi-rigid URS for treatment of upper ureteral stones, to apply Laser stone dusting and maintain ureteral stents for longer periods.

  • Quantitative proteomic characterization of human sperm cryopreservation: using data-independent acquisition mass spectrometry
    BMC Urol. (IF 1.583) Pub Date : 2019-12-16
    Longlong Fu; Qi An; Kaishu Zhang; Ying Liu; Yue Tong; Jianfeng Xu; Fang Zhou; Xiaowei Wang; Ying Guo; Wenhong Lu; Xiaowei Liang; Yiqun Gu

    Human sperm cryopreservation is a simple and effective approach for male fertility preservation. To identify potential proteomic changes in this process, data-independent acquisition (DIA), a technology with high quantitative accuracy and highly reproducible proteomics, was used to quantitatively characterize the proteomics of human sperm cryopreservation. A total of 174 significantly differential proteins were identified between fresh and cryoperservated sperm: 98 proteins decreased and 76 proteins increased in the cryopreservation group. Bioinformatic analysis revealed that metabolic pathways play an important role in cryopreservation, including: propanoate metabolism, glyoxylate and dicarboxylate metabolism, glycolysis/gluconeogenesis, and pyruvate metabolism. Four different proteins involved in glycolysis were identified by Western blotting: GPI, LDHB, ADH5, and PGAM1. Our work will provide valuable information for future investigations and pathological studies involving sperm cryopreservation.

  • Significant impact of three-dimensional volumetry of perinephric fat on the console time during robot-assisted partial nephrectomy
    BMC Urol. (IF 1.583) Pub Date : 2019-12-12
    Daisuke Motoyama; Yuto Matsushita; Hiromitsu Watanabe; Keita Tamura; Toshiki Ito; Takayuki Sugiyama; Atsushi Otsuka; Hideaki Miyake

    To assess the impact of volumetry of perinephric fat (PNF) on the perioperative outcomes of robot-assisted partial nephrectomy (RAPN). Between 2016 and 2019, a single surgeon performed RAPN for 128 patients with clinical T1a-b renal tumors at our institution, and the 70 most recent patients were included in this study to minimize the effects of surgical experience. PNF was defined as a fatty area around the kidney within the anatomical structures, including the lateroconal fascia, fusion fascia, psoas muscle, lumbar quadrate muscle and diaphragm, and its volume was calculated based on reconstructed three-dimensional computed tomography images using the SYNAPSE VINCENT system. In this series, the trifecta and MIC (margin, ischemia and complications) score system outcomes were achieved in 69 (98.6%) and 64 patients (91.4%), respectively. The median PNF volume in the 70 patients was 166.05 cm3, which was significantly correlated with both the body mass index (BMI) and Mayo adhesive probability (MAP) score (correlation coefficient = 0.68 and 0.74, respectively). There was no significant difference in the R.E.N.A.L. nephrometry score, PNF volume or console time during RAPN among 5 groups consisting of 14 consecutive patients. Of several factors examined, the console time was significantly affected by the sex, MAP score and PNF volume, and only the PNF volume was independently associated with the console time. Even if performed by an experienced robotic surgeon beyond the initial learning curve, the PNF volume may influence the console time during RAPN.

  • A case report of endorectal displacement of a right ureteral stent following radiochemotherapy and Bevacizumab
    BMC Urol. (IF 1.583) Pub Date : 2019-12-09
    Alessio Tognarelli; Lorenzo Faggioni; Francesca Manassero; Angiolo Gadducci; Cesare Selli

    The angiogenesis inhibitor monoclonal antibody Bevacizumab is presently the standard treatment for numerous neoplasms but particular toxicities are emerging, such as hypertension, haemorrhage, thromboembolism, gastrointestinal perforation, fistulae, and delayed wound healing. The addition of Bevacizumab to radio and chemotherapy has improved the overall survival rate in patients with metastatic, persistent or recurrent cervical carcinoma. However an increased risk of enteric or urinary fistula formation has been documented, related to hypoxia which is induced by the inhibition of angiogenesis. Moreover, previous pelvic surgery, repeated ureteral stenting and radiation are additional risk factors. We describe the remarkable case of a right ureteral stent displacement inside the rectum lumen in a patient treated with Bevacizumab for pelvic recurrence of cervical cancer. The patient was referred to our Urology Department with urinary sepsis and bilateral hydronephrosis. Right ureteral stent substitution was planned; at cystoscopy the distal loop of the stent was not visualized inside the bladder. The presence of the distal loop of the right ureteral inside the rectum was clearly demonstrated with a CT scan. Since Bevacizumab is increasingly used in the treatment of gynaecological neoplasms and indwelling ureteral stents are often required to treat or prevent ureteral compressions, similar cases are likely to be diagnosed and this complication should be considered in the management of advanced pelvic cancers.

  • Comparison of Yang-Monti ileal ureter-bladder anastomosis versus Yang-Monti ileal ureter-ureteral anastomosis for the treatment of ureteral stenosis: a randomized controlled trial in a miniature pig model
    BMC Urol. (IF 1.583) Pub Date : 2019-12-10
    Wang Zhenxing; Sun Zhaolin; Yang Xiushu; Luo Guangheng; Tian Ye; Shen Lei; Su Zhiyong; Liu Hongming

    The aim of the present study was to establish an animal model of Yang-Monti ileal ureter-bladder anastomosis and Yang-Monti ileal ureter-ureteral anastomosis and compare the advantages and disadvantages of the two surgical methods. Fourteen 12-month-old male Chinese miniature pigs weighing 21 ± 1.38 kg were randomly divided into two groups. Group A (n = 7) underwent end-to-end anastomosis of the left Yang-Monti ileal ureter, left ileal ureter and left lower ureter; group B (n = 7) underwent anastomosis of the left Yang-Monti ileal ureter, left ileal ureter and bladder. In both groups, the contralateral kidney was removed at 1 week postoperatively. The incision length and operation time of the two groups were compared. Changes in serum creatinine and urea nitrogen were observed preoperatively, and at 2, 6 and 12 weeks postoperatively. Venous pyelography and cystography were performed at 12 weeks postoperatively to determine the ureteral patency and vesicoureteral reflux. At 12 months postoperatively, urinary culture was performed, and the diameter and histological changes of the intestinal ureter were assessed. Surgery was successfully completed in all 14 pigs. In group A, one pig died due to an anesthetic accident, and one pig died from a lung infection on postoperative day 4. In group B, one pig died from adhesive intestinal obstruction on postoperative day 7. The overall survival rate was 78.6%, and the 11 surviving pigs had no urinary or intestinal fistulae. Compared with group B, group A had a significantly longer surgical incision (30.86 ± 2.41 cm versus 26.71 ± 3.64 cm; p = 0.01) and shorter operation time (181.29 ± 15.10 min versus 157.71 ± 20.49 min; p = 0.02). The serum creatinine and urea nitrogen concentrations did not significantly differ between groups. All pigs had normal renal function pre- and postoperatively. There was no stenosis or obstruction on venous pyelography. The narrowest diameter of the ureter was significantly smaller in group B (5.90 ± 0.30 mm) than in group A (7.26 ± 1.06 mm; p = 0.01), but no contrast agent returned to the upper urinary tract in either group. Escherichia coli was detected on urine culture. In group A, one pig had obstruction of the ureteral ureter, while another had stenosis of the lower ureteral anastomosis. In group B, one pig had pelvic and intestinal ureteral dilatation; however, all anastomoses were patent. The ileal ureteral diameter was significantly larger in group A (9.40 ± 2.35 mm) than group B (6.62 ± 0.37 mm; p = 0.02). Two pigs in group A had separation of the transitional epithelium and columnar epithelial mucosa, with granulation tissue hyperplasia. The pigs with stenosis and obstruction had smooth fibrous tissue and smooth muscle of the anastomosis. In both groups, the two types of epithelial tissue were close together, and the intestinal villi were mildly atrophied and shortened. An animal model of Yang-Monti ileal ureter-bladder anastomosis was successfully established. Compared with Yang-Monti ileal ureter-ureteral anastomosis, Yang-Monti ileal ureter-bladder anastomosis is simpler, more reliable, and results in fewer complications.

  • Assessing somatization in urologic chronic pelvic pain syndrome
    BMC Urol. (IF 1.583) Pub Date : 2019-12-10
    C. S. North; B. A. Hong; H. H. Lai; D. H. Alpers

    This study examined the prevalence of somatization disorder in Urological Chronic Pelvic Pain Syndrome (UCPPS) and the utility of two self-report symptom screening tools for assessment of somatization in patients with UCPPS. The study sample included 65 patients with UCPPS who enrolled in the Multidisciplinary Approach to the Study of Chronic Pelvic Pain (MAPP) Study at Washington University. Patients completed the PolySymptomatic PolySyndromic Questionnaire (PSPS-Q) (n = 64) and the Patient Health Questionnaire-15 Somatic Symptom Severity Scale (PHQ-15) (n = 50). Review of patient medical records found that only 47% (n = 30) contained sufficient documentation to assess Perley-Guze criteria for somatization disorder. Few (only 6.5%) of the UCPPS sample met Perley-Guze criteria for definite somatization disorder. Perley-Guze somatization disorder was predicted by definite PSPS-Q somatization with at least 75% sensitivity and specificity. Perley-Guze somatization disorder was predicted by severe (> 15) PHQ-15 threshold that had > 90% sensitivity and specificity but was met by only 16% of patients. The moderate (> 10) PHQ-15 threshold had higher sensitivity (100%) but lower specificity (52%) and was met by 52% of the sample. The PHQ-15 is brief, but it measures symptoms constituting only one dimension of somatization. The PSPS-Q uniquely captures two conceptual dimensions inherent in the definition of somatization disorder, both number of symptoms and symptom distribution across multiple organ systems, with relevance for UCPPS as a syndrome that is not just a collection of urological symptoms but a broader syndrome with symptoms extending beyond the urological system.

  • Conservative treatment for urinary fistula following ileal conduit urinary diversion: a simple method
    BMC Urol. (IF 1.583) Pub Date : 2019-12-10
    Yun-lin Ye; Hai-tao Liang; Lei Tan; Xia Zheng; Dan Xiong; Kang-hua Xiao; Zi-ke Qin

    The presence of urinary fistula after ileal conduit urinary diversion is a challenging complication, and this study investigated the role of the intra-conduit negative pressure system (NPS) in the presence of urinary fistula following ileal conduit (IC) urinary diversion as a conservative treatment. Using the intra-conduit NPS, a minor drainage tube was placed within a silicon tube to suck urine from the conduit with consistent negative pressure. Patients with urinary fistula following IC from August 2012 to July 2017 were recorded, and the clinical characteristics and outcome were retrospectively analyzed. The intra-conduit NPS was used as a primarily conservative treatment for 13 patients who suffered from urinary fistula and presented with a large amount of abdominal/pelvic drainage without other significant morbidities. The median age was 60 years old (42–74 years), and 7patients were male. The median duration between the IC operation and the presence of urinary fistula was 15 days (2–28 days), and elevated creatinine levels were detected in the abdominal/pelvic drainage with a median level of 2114 μmol/L (636–388 μmol/L). A significant decrease in abdominal/pelvic drainage was identified in 12 patients. The median time that the NPS was used was 9 days (7–11 days). The other patient did not show any improvements after 2 days of observation and then underwent open surgery. With ureteral stenting, 2 abdominal drainage tubes and the intra-conduit NPS were placed during operation, no urine leakage was observed in the abdominal/pelvic field, and the patient was cured in 9 days. With a median follow-up of 22 months, no fistula recurrence or hydronephrosis was detected. The intra-conduit negative pressure system is a feasible and promising way to cure urinary fistula following ileal conduit urinary diversion. Because this procedure is a mini-invasive and simple approach, it might represent an alternative in selected patients.

  • Anterior gland focal cryoablation: proof-of-concept primary prostate cancer treatment in select men with localized anterior cancers detected by multi-parametric magnetic resonance imaging
    BMC Urol. (IF 1.583) Pub Date : 2019-12-05
    Christina Sze; Efrat Tsivian; Kae Jack Tay; Ariel A. Schulman; Leah G. Davis; Rajan T. Gupta; Thomas J. Polascik

    Due to their location away from the nerve bundles, anterior prostate cancers (APC) represent a rational target for image-guided cryoablation. This report describes the feasibility and short-term outcomes of anterior focal cryosurgery. A retrospective review between 2012 and 2016 of patients with clinically localized APC treated with anterior gland cryoablation was performed. Descriptive statistics were used to report: age, PSA, prostate volume, prostate cancer grade group (PGG), median time to follow-up, and changes in functional status measured with the International Prostate Symptom Score (IPSS) and the International Index of Erectile Function (IIEF-5) score. A total of 17 patients underwent anterior focal cryoablation with a median follow-up of 15 months. Median age and PSA at diagnosis were 67 years and 8.7 ng/mL. Pre-operative PGG1 was identified in 12 (71%) men and PGG2 in 5 (29%) men. Median (IQR) lesion volume was 2 mL(0.86, 3.1). Preoperative median IIEF-5 and IPSS scores were 19.5 and 5, and decreased to 19 and 4, post-operatively. All patients remained continent with no change in sexual function. All post-procedure targeted biopsies of the treated cancers were negative. Our pilot study demonstrates the feasibility of treating APCs with image-guided targeted focal cryoablation as a good balance between short-term oncologic control and near complete preservation of genitourinary function. Further follow-up is necessary to examine the potential benefits long-term.

  • Development of a high-precision bladder hyperthermic intracavitary chemotherapy device for bladder cancer and pharmacokinetic study
    BMC Urol. (IF 1.583) Pub Date : 2019-12-03
    Mingchen Ba; Shuzhong Cui; Hui Long; Yuanfeng Gong; Yinbing Wu; Kunpeng Lin; Yinuo Tu; Bahuo Zhang; Wanbo Wu

    Bladder hyperthermic intracavitary chemotherapy (HIVEC) has good effectiveness for bladder cancer, but conventional HIVEC systems lack precision and convenient application. To test the safety of a new HIVEC device (BR-TRG-II-type) in pigs and to perform a preliminary clinical trial in patients with bladder cancer. This device was tested on six pigs to optimize the temperature and time parameters. Then, 165 patients (HIVEC after transurethral resection (TUR), n = 128; or HIVEC, n = 37) treated between December 2006 and December 2016 were recruited. Mitomycin C (MMC) was the chemotherapeutic agent. A serum pharmacokinetic study was performed. The primary endpoints were tumor recurrence, disease-free survival (DFS), and cumulative incidence rate (CIR) during follow-up. The adverse effects were graded. The animal experiment showed that 45 °C for 1 h was optimal. HIVEC was successful, with the infusion tube temperature stably controlled at about 45 °C, and outlet tube temperature of about 43 °C in all patients, for three sessions. Serum MMC levels gradually increased during HIVEC and decreased thereafter. The mean DFS was 39 ± 3.21 months (ranging from 8 to 78 months), and the DFS rate was 89.1% during follow-up. No adverse events occurred. The use of the BR-TRG-II-type HIVEC device is feasible for the treatment of bladder cancer. Future clinical trials in patients with different stages of bladder cancer will further confirm the clinical usefulness of this device. chictr.org.cn: ChiCTR1900022099 (registered on Mar. 252,019). Retrospectively registered.

  • Second-line treatment strategy for urothelial cancer patients who progress or are unfit for cisplatin therapy: a network meta-analysis
    BMC Urol. (IF 1.583) Pub Date : 2019-12-02
    Huitao Wang; Jianhe Liu; Kewei Fang; Changxing Ke; Yongming Jiang; Guang Wang; Tongxin Yang; Tao Chen; Xin Shi

    Second-line treatment for urothelial carcinoma (UC) patients is used if progression or failure after platinum-based chemotherapy occurs or if patients are cisplatin-unfit. However, there is still no widely accepted treatment strategy. We aimed to analyze the effectiveness and safety of second-line treatment strategies for UC patients. The PubMed, Embase, and Cochrane databases were searched for randomized controlled trials (RCTs) that included UC patients who were cisplatin-ineligible or unfit up to April 19, 2019. The primary outcomes were progression-free survival (PFS), overall survival (OS), and objective response rate (ORR). Thirteen trials that assessed 3502 UC patients were included. This study divided the network comparisons into three parts. The first part contained studies comparing taxanes and other interventions; the second part assessed investigator’s choice chemotherapy (ICC)-related comparisons; and the third part assessed best support care (BSC). In the OS results of the first part, pembrolizumab (87.5%), ramucirumab plus docetaxel (74.6%), and atezolizumab (71.1%) had a relative advantage. Pembrolizumab also had advantages in ORR and severe adverse effect (SAE) results. Vinflunine and ramucirumab plus docetaxel had a relatively high surface under the cumulative ranking curve (SUCRA) rank by exploratory cluster analysis. This study concluded that atezolizumab and pembrolizumab are superior to other treatments, mainly in OS results, but no treatment confers a significant advantage in PFS. Pembrolizumab still has relative advantages in ORR and SAE results compared to ICC. Due to limitations, more studies are necessary to confirm the conclusions.

  • Determinants of treatment in patients with stage IV renal cell carcinoma
    BMC Urol. (IF 1.583) Pub Date : 2019-11-29
    Christopher S. Hollenbeak; Eric W. Schaefer; Justin Doan; Jay D. Raman

    Advances in systemic targeted therapies afford treatment opportunities in patients with metastatic renal cell carcinoma (RCC). Elderly patients with metastatic RCC present a subpopulation for consideration owing to competing causes of mortality and benefits seen with new therapeutic agents. We investigate treatment patterns for elderly patients with stage IV RCC and determine factors associated with not receiving treatment. The Surveillance Epidemiology and End Results (SEER) Medicare linked data set contained 949 stage IV RCC patients over age 65 diagnosed between 2007 and 2011. Treatment approach was modeled using multinomial logistic regression. Landmark analysis at 6 months accounted for early death as a potential explanation for no treatment. Of the 949 patients with stage IV RCC, 26.2% received surgery and 34.1% received systemic therapy within 6 months of diagnosis. Among our entire cohort, over half (51.2%) had no evidence of receiving surgery or systemic therapy. Among the 447 patients who survived at least 6 months, 26.6% did not receive treatment during this time. Older patients and those with a higher Charlson Comorbidity Index (CCI) had lower odds of being treated with surgery, systemic therapy, or both. Conversely, married patients had higher odds of receiving these therapies. These associations were largely sustained in the 6-month landmark analyses. Elderly patients with metastatic RCC present a unique subpopulation for consideration owing to competing causes of mortality. Many elderly patients with stage IV RCC did not receive surgery or systemic therapy up to 6 months from diagnosis. Several clinical and demographic factors were associated with this observation. Further investigation is needed to understand the rationale underlying the underutilization of systemic therapy in elderly patients.

  • Clinically significant Prostate Cancer diagnosed using a urinary molecular biomarker-based risk score: two case reports
    BMC Urol. (IF 1.583) Pub Date : 2019-11-29
    Pieter Minnee; Daphne Hessels; Jack A. Schalken; Wim Van Criekinge

    Identifying men for a repeat prostate biopsy is a conundrum to urologists. Risk calculators (RCs) such as the European Randomized Study of Screening for Prostate Cancer (ERSPC) RCs have been developed to predict the outcome of prostate biopsies and have been shown to improve diagnostic accuracy compared to PSA alone. However, it was recently shown that the outcome for high-grade prostate cancer (PCa) upon biopsy tended to be underestimated in men with previous negative biopsies using ERSPC RC model 4. For these men, an individualized approach combining the clinical information with the outcome of biomarker-related urine tests may help to make a more informed decision. Two men, aged 66 and 69 respectively when presented in the clinic, show the typical dilemma of urologist and patient for electing repeat prostate biopsy. Both men had normal DRE findings, did not have a family history of PCa, presented with serum PSA values between 3 and 10 ng/ml and the first biopsies were negative for disease. The ERSPC RC4 did not indicate a biopsy in these men. The urinary molecular biomarker-based test for HOXC6 and DLX1, combining biomarker-expression profiling with clinical risk factors, resulted in SelectMDx Risk scores for these men that were higher than the cut-off of the test. Based on this outcome, mpMRI was performed with an outcome of PI-RADS ≥4 in both men. Histopathological evaluation of TRUS-guided biopsies confirmed high-grade PCa. The urinary molecular biomarker-based risk score played a pivotal role in the diagnosis of clinically significant PCa whereas ERSPC RC4 outcome would not have indicated further diagnostic follow-up in these two cases. The timely diagnosis was shown to be crucial for the curative treatment by radical retropubic prostatectomy and the potential life-years gained for these two vital males.

  • The role of RENAL, PADUA, C-index, CSA nephrometry systems in predicting ipsilateral renal function after partial nephrectomy
    BMC Urol. (IF 1.583) Pub Date : 2019-08-05
    Yu-De Wang; Chi-Ping Huang; Chao-Hsiang Chang; Hsi-Chin Wu; Che-Rei Yang; Yu-Ping Wang; Po-Fan Hsieh

    Functional outcome is an important issue in nephron-sparing surgery. Various nephrometries have been developed to predict renal function preservation. The aim of this study was to examine the applicability of R.E.N.A.L., PADUA, C-index, and mathematical tumor contact surface area (CSA) in predicting ipsilateral renal function after partial nephrectomy using radio-isotope scans. We performed this retrospective study in patients who underwent partial nephrectomy between May 2013 and April 2017, and used abdominopelvic computerized tomography or magnetic resonance imaging to obtain R.E.N.A.L., C-index, and CSA. Renal function was measured by 99mTc mercaptoacetyltriglycine (MAG3). We evaluated correlations between nephrometries and perioperative parameters, and comparatively analyzed different nephrometries to determine the predictive ability in the percent change of effective renal plasma flow of the affected kidney. Three, two, and 35 patients received partial nephrectomy in open, laparoscopic, and robotic approaches, respectively. The median (IQR) tumor size was 3.13 (2.4) cm. The median (IQR) R.E.N.A.L., PADUA, C-index, and CSA scores were 7 (3), 8 (2), 2.01 (1.87), and 14.14 (19.25) cm2, respectively. Spearman correlation analysis showed that four nephrometries were correlated with each other. The strongest correlations were between CSA and C-index (coefficient: − 0.885, p < 0.001), followed by R.E.N.A.L. and PADUA (coefficient: 0.778, p < 0.001). Ischemia time was significantly correlated with R.EN.A.L. (coefficient: 0.35, p = 0.025), PADUA (coefficient: 0.42, p = 0.007), C-index (coefficient: − 0.45, p = 0.004), and CSA (coefficient: 0.41, p = 0.009). In multivariate analysis, PADUA significantly affected ischemia time (p = 0.04). The percent change in effective renal plasma flow (PCE) of the operated kidney was correlated with PADUA (coefficient: 0.48 p = 0.002), C-index (coefficient: − 0.74, p < 0.001), and CSA (coefficient: 0.75, p < 0.001). Only CSA and C-index independently affected PCE (both p < 0.05) in multivariate analysis. In ROC curve analysis, both C-index and CSA could predict 20% change in effective renal plasma flow (AUC: 0.91 vs 0.86, p = 0.2) of the affected kidney. We suggest using PADUA to evaluate surgical complexity and ischemia time. Regarding the accuracy of the prediction of post-operative ipsilateral renal function, both CSA and C-index outperformed R.E.N.A.L. and PADUA nephrometries.

  • Comparison of survival benefits of nephron-sparing intervention or active surveillance for patients with localized renal masses: a systematic review and meta-analysis
    BMC Urol. (IF 1.583) Pub Date : 2019-08-05
    Run-Qi Guo; Xiao-Guang Li

    Strong evidence comparing effectiveness between nephron-sparing intervention (NSI) and active surveillance (AS) is lacking. Thus, we aim to compare the outcomes of survival, including cancer-specific survival (CSS), overall survival (OS), and cardiovascular-specific survival (CVSS), in patients with renal masses who underwent NSI or AS. A systematic literature search of PubMed, Web of Science, and EMBASE was performed for citations published prior to September 2018 that described NSI, partial nephrectomy and thermal ablation included, and AS for patients with renal masses and a standard meta-analysis on survival outcomes was then conducted. The meta-analysis included seven studies containing 5809 patients. The results comparing NSI with AS were as follows: CSS (hazard ratio (HR) = 0.64, 95% confidence interval (CI): 0.46–0.89, P < 0.001), OS (HR = 0.46, 95%CI: 0.39–0.53, P < 0.001), and CVSS (HR = 0.37, 95%CI: 0.24–0.57, P < 0.001). This systematic review and meta-analysis indicates that NSI is associated with better OS, CSS and CVSS when compared with AS for patients with renal masses. Further better prospective cohort studies are needed to make definitive statements about these different treatment methods.

  • Dissection of the inferior mesenteric vein versus of the inferior mesenteric artery for the genitourinary function after laparoscopic approach of rectal cancer surgery: a randomized controlled trial
    BMC Urol. (IF 1.583) Pub Date : 2019-08-05
    Anna Pallisera-Lloveras; Paula Planelles-Soler; Naim Hannaoui; Laura Mora-López; Jesús Muñoz-Rodriguez; Sheila Serra-Pla; Arturo Dominguez-Garcia; Joan Prats-López; Salvador Navarro-Soto; Xavier Serra-Aracil

    Total Mesorectal Excision (TME) is the standard surgical technique for the treatment of rectal cancer. However, rates of sexual dysfunction ofup to 50% have been described after TME, and rates of urinary dysfunction of up to 30%. Although other factors are involved, the main cause of postoperative genitourinary dysfunction is intraoperative injury to the pelvic autonomic nerves. The risk is particularly high in the inferior mesenteric artery (IMA). The aim of this study is to compare pre- and post-TME sexual dysfunction, depending on the surgical approach usedin the inferior mesenteric vessels: either directly on the IMA, or from the inferior mesenteric vein (IMV) to the IMA. Prospective, randomized,controlled study of patients with rectal adenocarcinoma with neoadjuvant chemoradiotherapy, who will be randomly assigned to one of two groups depending on the surgical approach to the inferior mesenteric vessels. The main variable is pre- and postoperative sexual dysfunction; secondary variables are visualization and preservation of the pelvic autonomic nerves, pre- and postoperative urinary dysfunction, and pre- and postoperative quality of life. The sample will comprise 90 patients, 45 per group. The aim is to demonstrate that the dissection route from the IMV towards the IMA favors the preservation of the pelvic autonomic nerves and thus reducesrates of sexual dysfunction post-surgery. Ethical and Clinical Research Committee, Parc Taulí University Hospital: ID 017/315. ClinicalTrials.gov TAU-RECTALNERV-PRESERV-2018 (TRN: NCT03520088 ) (Date of registration 04/03/2018).

  • Prevalence and associated factors for dipstick microscopic hematuria in men
    BMC Urol. (IF 1.583) Pub Date : 2019-08-06
    Karim Courtemanche; Peter Chan; Wassim Kassouf

    Microscopic hematuria is a common incidental finding on routine urinalysis. Although there are no clear recommendations to perform routine urinalysis, some studies have shown that up to 50% of general practitioners continue to perform annual routine urinalysis regardless of age or risk factors. The aim of this study was to identify associated factors and prevalence of dipstick microscopic hematuria in the general male population presenting to an annual public men’s health fair. We conducted a retrospective analysis of prospectively collected data at an annual Men’s Health fair from 2008 to 2013. Patient reported health questionnaires, basic physical exam including digital rectal exam, basic bloodwork and dipstick urinalysis data was examined. A total of 979 patients were reviewed. Of these, 850 provided a urine sample and were included in the final analysis. Seventy-three (8.6%) patients had positive hematuria on urinalysis. Average age in both groups was 55 years. Presence of microscopic hematuria was correlated with presence of diabetes and proteinuria with odds-ratio of 2.8 (1.3–5.8) and 2.9 (1.7–5.0) respectively on multivariate analysis. There was no significant correlation identified with age, hypertension, coronary artery disease, body-mass index, smoking, prostate specific antigen (PSA) or International Prostate Symptom Score (IPSS). Limitation of this study is the lack of follow-up and knowledge of subsequent investigations of patients. Microscopic hematuria is a prevalent condition in the male population presenting to a health fair. The only factors associated with microscopic hematuria were diabetes and proteinuria. No association was found between hematuria and smoking, age, or lower urinary tract symptoms.

  • The impact of perivesical lymph node metastasis on clinical outcomes of bladder cancer patients undergoing radical cystectomy
    BMC Urol. (IF 1.583) Pub Date : 2019-08-16
    Meenal Sharma; Takuro Goto; Zhiming Yang; Hiroshi Miyamoto

    Perivesical lymph nodes (PVLNs) are occasionally isolated during grossing of cystectomy specimens. However, the prognostic implications of the involvement of PVLNs in bladder cancer patients, especially those with comparisons to pN0 disease, remain poorly understood. A retrospective review identified 115 radical cystectomy cases where PVLNs had been histologically assessed. These cases were then divided into 4 groups – Group 1 (n = 76): PVLN-negative/other pelvic lymph node (non-PVLN)-negative; Group 2 (n = 5): PVLN-positive/non-PVLN-negative; Group 3 (n = 17): PVLN-negative/non-PVLN-positive; and Group 4 (n = 17): PVLN-positive/non-PVLN-positive. pT stage at cystectomy was significantly higher in Group 3 (P = 0.013), Group 4 (P < 0.001), Groups 2 and 4 (P < 0.001), or Groups 2–4 (P < 0.001) than in Group 1. However, the number of positive PVLNs (mean: 1.8 vs. 2.1; P = 0.718) or the rate of extracapsular extension in the PVLNs (40% vs. 65%, P = 0.609) was not significantly different between Group 2 and Group 4. Kaplan-Meier analysis and log-rank test revealed significantly (P < 0.05) higher risks of disease progression (Group 3/Group 4), cancer-specific mortality (Group 2/Group 3/Group 4), and overall mortality (Group 4), compared with Group 1. Multivariate analysis further showed metastasis to both PVLN and non-PVLN (Group 4), PVLN (Groups 2 and 4), or PVLN and/or non-PVLN (Groups 2–4) as an independent prognosticator for cancer-specific mortality and overall survival. There were also insignificant (P = 0.096) and significant (P = 0.036) differences in cancer-specific survival and overall survival, respectively, between Group 3 versus Group 4, and the trend of the latter was confirmed by subset multivariate analysis (hazard ratio = 3.769; P = 0.099). Worse prognosis was observed in bladder cancer patients with isolated PVLN metastasis (vs. pN0 disease especially for cancer-specific survival), PVLN metastasis with or without non-PVLN metastasis (vs. pN0 disease), and concurrent PVLN and non-PVLN metastases (vs. PVLN-negative/non-PVLN-positive disease especially for overall survival). These findings indicate the importance of thorough histopathological assessment of PVLNs in radical cystectomy specimens.

  • Relationship between alterations of urinary microbiota and cultured negative lower urinary tract symptoms in female type 2 diabetes patients
    BMC Urol. (IF 1.583) Pub Date : 2019-08-22
    Jiawei Chen; Jie Zhao; Ying Cao; Guihao Zhang; Yang Chen; Jialei Zhong; Weina Huang; Jiarong Zeng; Peng Wu

    Lower urinary tract symptoms (LUTS) is the most common complication of diabetes. However, the underlying pathogenesis of cultured negative LUTS (cn-LUTS) in diabetic patients has not been well understood. Numerous evidence indicates that urinary dysbiosis is related to urologic disorders. We aim to study alterations of the urinary microbiota of cn-LUTS in type 2 diabetes (T2D) patients. Female T2D patients and controls were recruited and requested to finish the American Urological Association Symptom Index. Mid-stream urine was collected for culturing and extracting DNA. Microbial diversity and composition were analyzed by targeting to 16S rDNA. Linear discriminant analysis effect size (LEfSe) was carried out to identify significantly different bacteria. 32 female T2D patients and 26 controls were enrolled. No significant differences in alpha diversity were observed between patients and controls. However, statistically decreased richness (ACE index and Chao 1 index, 85.52(13.75, 204.84) vs. 129.82(63.89, 280.30) and 83.86(11.00, 210.77) vs. 125.19(62.00, 251.77), P = 0.005; Observed Species, 76(10, 175) vs. 98(54, 234), P = 0.011) and decreased species diversity (Shannon index, 1.37(0.04, 3.48) vs. 2.09(0.98, 3.43), P = 0.033; Simpson index, 0.46 (0.06, 0.99) vs. 0.23(0.07, 0.64), P = 0.029) were shown in moderate-to-severe LUTS group and high Hemoglobin A1c group, respectively. A significant difference of beta diversity was found between T2D patients and controls and T2D patients with different severity of cn-LUTS as well as the different level of Hemoglobin A1c. LEfSe revealed that 10 genera (e.g., Escherichia-Shigella and Klebsiella) were increased and 7 genera were decreasing in T2D patients, 3 genera (e.g., Escherichia-Shigella and Campylobacter) were increased and 16 genera (e.g., Prevotella) were reduced in moderate-to-severe LUTS group, 2 genera (Escherichia-Shigella and Lactobacillus) were over-represented and 10 genera (e.g., Prevotella) were under-represented in high Hemoglobin A1c group. Finally, Hemoglobin A1c was found positively correlated with the total score of the American Urological Association Symptom Index (r = 0.509, P = 0.003). Urinary dysbiosis may be related to cn-LUTS in female T2D patients. A better understanding of urinary microbiota in the development and progression of cn-LUTS in female T2D patients was necessary. The severity of cn-LUTS was correlated to hyperglycemia and chronic hyperglycemia might induce or promote cn-LUTS by influencing urinary microbiota.

  • Ureteric stent versus percutaneous nephrostomy for acute ureteral obstruction - clinical outcome and quality of life: a bi-center prospective study
    BMC Urol. (IF 1.583) Pub Date : 2019-08-28
    O. Shoshany; T. Erlich; S. Golan; N. Kleinmann; J. Baniel; B. Rosenzweig; A. Eisner; Y. Mor; J. Ramon; H. Winkler; D. Lifshitz

    To compare quality of life (QoL) indices between ureteral stent (DJS) and nephrostomy tube (PCN) inserted in the setting of acute ureteral obstruction. Prospective bi-centered study. Over the span of 2 years, 45 DJS and 30 PCN patients were recruited. Quality of life was assessed by 2 questionnaires, EuroQol EQ-5D and ‘Tube symptoms’ questionnaire, at 2 time points (at discharge after drainage and before definitive treatment). Patients’ demographics and pre-drainage data were similar. There were no clinically significant differences in patient’s recovery between the groups, including post procedural pain, defeverence, returning to baseline renal function, and septic shock complications. More DJS patients presented to the emergency room with complaints related to their procedure compared to PCN patients. At first, DJS patients complained more of urinary discomfort while PCN patients had worse symptoms relating to mobility and personal hygiene, with both groups achieving similar overall QoL score. At second time point, PCN patients’ symptoms ameliorated while symptoms in the DJS group remained similar, translating to higher overall QoL score in the PCN group. The two techniques had a distinct and significantly different impact on quality of life. Over time, PCN patients’ symptoms relieve and their QoL improve, while DJS patients’ symptoms persist. Specific tube related symptoms, and their dynamics over time, should be a major determinant in choosing the appropriate drainage method, especially when definitive treatment is not imminent.

  • Is it safe to use a ureteral access sheath in an unstented ureter?
    BMC Urol. (IF 1.583) Pub Date : 2019-08-29
    Asaf Shvero; Haim Herzberg; Dorit Zilberman; Yoram Mor; Harry Winkler; Nir Kleinmann

    The aim of this study was to examine ureteral stricture rate after the use of UAS in an unstented ureter and compare complications of smaller vs. larger-caliber UAS. We conducted a retrospective analysis of consecutive RIRS for renal stones, with the use of UAS in unstented ureters. We excluded cases with previous ureteroscopies, who carried ureteral stent or nephrostomy, had impacted stones, underwent radiation treatment, or had urinary tract malignancies. The primary outcome was formation of ureteral strictures diagnosed by hydronephrosis in ultrasound test and late secretion in dynamic renal scan. Secondary outcome was stone-free-rate (SFR) and complications. In addition, we compared safety and efficacy of smaller (9.5/11.5Fr) vs. larger-caliber (12/14Fr) UAS. The cohort included 165 patients with a median follow-up time of 115 days. There was no case of ureteral stricture formation after the use us UAS, despite using a larger-caliber UAS in nearly half the cases. Larger-caliber UAS was not associated with more complications compared to the smaller-caliber one (p = 0.780). SFR was non-significantly higher in the larger-caliber UAS group (p = 0.056), despite having a larger stone burden, and only stone number was associated with SFR (p = 0.003). These data suggest that the use of UAS during RIRS in an unstented ureter is safe and does not involve ureteral stricture formation after one procedure. Furthermore, the use of wider sheaths was not found to be associated with higher complications rate.

  • Penile metastasis from recurrent sarcoma in a teenager: a case report
    BMC Urol. (IF 1.583) Pub Date : 2019-09-02
    Chi-Fang Chen; Tzu-Ying Tang; Marcelo Chen; Li-Chen Chen

    Metastatic tumors of the penis are uncommon, and fewer than 500 cases have been reported since 1870. Most penile secondary tumors originate in organs of the genitourinary tract, followed by the gastrointestinal tract. Primary tumors of sarcoma origin are extremely rare. Herein, we present a teenager who had recurrent sarcoma of the right femur with penile metastasis. The 20-year-old male patient was diagnosed with sarcoma of the right femur when he was 16 days old. He was stable following combination chemotherapy with the VAC regimen (vincristine, adriamycin, and cyclophosphamide) and debulking surgery. In January 2018, five months ago, he presented with right leg pain and swelling, and a recurrent tumor was found. Following excision of the tumor showed recurrent sarcoma. However, 2 months after the operation, right thigh swelling with tenderness occurred. A firm nodule on the glans of the penis was also noted. Penile metastasis was suspected and a biopsy was performed. The final pathology report disclosed pleomorphic sarcoma with penile metastasis. Symptoms including priapism and inguinal lymph node enlargement progressed rapidly within 2 weeks. He also complained of voiding difficulty with urine retention. The patient died 35 days after admission due to pneumonia with septic shock. Penile metasitasis largely occurs from organs in the pelvis. To the best of our knowledge, this is the first case of a teenager with a secondary penile tumor, metastasizing from sarcoma of the bone. It presented as a palpable mass, and then progressed into priapism. The patient had a dismal prognosis and the symptoms progressed faster than his physicians anticipated.

  • Epidemic investigation of benign prostatic obstruction with coexisting overactive bladder in Shanghai Pudong New Area and its impact on the health-related quality of life
    BMC Urol. (IF 1.583) Pub Date : 2019-09-03
    Qing-Tong Yi; Min Gong; Chu-Hong Chen; Wei Hu; Ru-Jian Zhu

    We aimed to investigate the prevalence, relative risk factors, and the impact on the health-related quality of life (HRQoL) of benign prostatic obstruction (BPO) with coexisting overactive bladder (OAB) in men aged over 50 and living in Shanghai Pudong New Area. Using a multi-stage sampling and descriptive epidemiological method, 1632 men were selected from among the general population. Participants completed an evaluation of lower urinary tracts symptoms (LUTS), including international prostate symptom score (IPSS) and quality of life (QoL) questionnaires. Erectile function was assessed using the International Index of Erectile Function-5 (IIEF-5) questionnaire. In addition, the Overactive Bladder Symptom Score (OABSS) and King’s health questionnaire (KHQ) were used to assess the impact of BPO with coexisting OAB on the HRQoL. Maximum flow rate (Qmax), postvoid residual urine volume (PVR) and prostate-specific antigen (PSA) were also recorded. A total of 1476 men with complete data were analyzed. The overall prevalence of BPO with coexisting OAB was 39.6%. Age and prostate volume were associated risk factors for BPO with coexisting OAB. In addition, BPO with coexisting OAB negatively impacted the HRQoL, with increased IPSS, QoL, OABSS, and KHQ scores and decreased IIEF-5 scores compared to that in patients with BPO without OAB. Qmax, PVR and serum PSA did not predict whether the patients had a combined BPO + OAB or not. The prostate volume and age were associated risk factors for BPO with coexisting OAB. BPO is a progressive disease and may be one of the risk factors for OAB.

  • Follicular dendritic cell sarcoma (FDCS) of urinary bladder with coexisting urothelial carcinoma–a case report
    BMC Urol. (IF 1.583) Pub Date : 2019-09-05
    Jing Sun; Cheng Wang; Dandan Wang; Jiangtao Wu; Leiming Wang; Lan Zhao; Lianghong Teng

    Follicular dendritic cell sarcoma is a very rare bladder tumor with very few cases that have been reported in the English literature. We report an unusual case of follicular dendritic cell sarcoma that is coexistent with urothelial carcinoma (UC) in the urinary bladder of a 73-year-old man, who first presented with lower abdominal pain. Microscopic examination of the first transurethral resection of bladder tumor (TURBT) sample showed a neoplasm containing spindle or ovoid-shaped cells that were arranged in storiform, nested or swirling patterns. Abundant mitotic Figs. (30 mitoses/10 high-power fields) and apoptotic bodies were present. The tumor cells were positive for CD21 and vimentin, partly positive for CD23, D2–40 and CD35. After 6 weeks, the tumor recurred lately, which surprisingly contained a component of urothelial carcinoma. The first TURBT sample was then reviewed and a coexisting UC mixed with FDCS was identified by examining the deeper levels of the tumor blocks. This case is, to our knowledge, the first time to report the coexistence of FDCS and UC in the urinary bladder of an elderly patient. And these two tumors may share a similar molecular mechanism.

  • Predictive factors for response to salvage stereotactic body radiotherapy in oligorecurrent prostate cancer limited to lymph nodes: a single institution experience
    BMC Urol. (IF 1.583) Pub Date : 2019-09-09
    Christoph Oehler; Michel Zimmermann; Lukas Adam; Juergen Curschmann; Marcin Sumila; Räto T. Strebel; Richard Cathomas; Qiyu Li; Uwe Schneider; Daniel R. Zwahlen

    In patients presenting with limited nodal recurrence following radical prostatectomy (RP), stereotactic body radiotherapy (SBRT) results might improve with a better case selection. Single-institution retrospective analysis of patients presenting with 1–3 lymph node (LN) recurrences (N1 or M1a) on 18F-Choline PET/CT. Prior therapy included radical prostatectomy (RP) ± salvage radiotherapy (RT), in absence of any systemic therapy. Outcome parameters were biochemical response (BR), time to biochemical recurrence (TBR) and time interval between SBRT and androgen deprivation therapy start (TADT). Time to event endpoints was analysed using Kaplan-Meier method. Potential prognostic factors were examined using univariate proportional hazards regression for TADT and logistic regression for BR. The optimal cut-off point for LN size was calculated using the Contal and O’Quigley method. 25 patients fulfilling study criteria were treated with SBRT from January 2010 to January 2015 and retrospectively analysed. Median follow up was 18 months and median LN diameter 10.5 mm. SBRT was delivered to a median dose of 36 Gy in three fractions (range: 30–45 Gy). BR was reached in 52% of cases. Median TBR was 11.9 months and significantly longer in patients with larger LN (Hazard ratio [HR] = 0.87, P = 0.03). Using 14 mm as cut off for LN, median TBR was 10.8 months for patients with small LN (18 patients), and 21.2 months for patients with large LN (6 patients) (P unadjusted = 0.009; P adjusted = 0.099). ADT was started in 32% of patients after a median follow-up of 18 months. For PCa patients with 1–3 LN recurrence after RP (± salvage RT), SBRT might result in a better biochemical control when delivered to larger sized (≥ 14 mm) LN metastases. This study is hypothesis generating and results should be tested in a larger prospective trial.

  • Relationship between plasma Atherogenic index and final pathology of Bosniak III-IV renal masses: a retrospective, single-center study
    BMC Urol. (IF 1.583) Pub Date : 2019-09-13
    Emre Karabay; Nejdet Karsiyakali; Serdar Duvar; Cagatay Tosun; Ahmet Ruknettin Aslan; Omer Ergin Yucebas

    There is an increased incidence of renal cell carcinoma (RCC) in patients with metabolic syndrome who usually have high levels of serum triglyceride (TG) and low high-density lipoprotein-cholesterol (HDL-C). Plasma atherogenic index (PAI) is the logarithmic ratio of serum TG level to HDL-C and related to cardiovascular diseases. In this study, we aimed to determine the accuracy of PAI in determining renal malignancy in localized renal masses preoperatively. Totally 169 patients who were diagnosed with Bosniak III-IV lesions by imaging modalities and treated in our hospital with partial or radical nephrectomy were retrospectively analyzed using institutional renal cancer database between 2013 and 2018. Preoperative images were evaluated by two experienced radiologists. The patients were divided into two groups according to their postoperative pathological diagnosis as malignant or benign tumors. The PAI of each patient was calculated and the statistical significance of PAI in predicting malignancy for renal masses was analyzed using uni- and multivariable analyses. Of patients, 109 (64.5%) were males and 60 (35.5%) were females with a median age of 61 (33–84) years. Median tumor size was 6.5 (2–18) cm. Pathological diagnosis was malignant in 145 (85.8%) and benign in 24 (14.2%) patients. There was no statistically significant difference in serum TG levels between malignant and benign cases (p > 0.05). The HDL-C levels were significantly lower in malignant cases (p = 0.001). Median PAI value was 0.63 (0.34–1.58) and significantly higher in malignant cases (p = 0.003). The PAI cut-off value for malignancy was ≥0.34. The sensitivity was calculated as 88.2% and specificity as 45.8%, the positive predictive value as 90.8, negative predictive value as 39.3, and odds ratio as 6.37 (95% CI: 2.466–16.458). In multivariable analysis, gender, smoking status, and hypertension had no effect on malignancy, whereas PAI and HDL-C were independent risk factors (p = 0.003 and p = 0.003, respectively). The risk of malignancy was 5.019 times higher, when PAI was > 0.34 (95% CI: 1.744–14.445) in multivariable logistic regression analysis. The PAI can be used as a predictive tool in suspicion of malignant renal masses. In case of a benign pathology, PAI levels may be encouraging for surgeons for nephron-sparing surgery.

  • Patient-reported outcomes in randomised clinical trials of bladder cancer: an updated systematic review
    BMC Urol. (IF 1.583) Pub Date : 2019-09-14
    Mieke Van Hemelrijck; Francesco Sparano; Debra Josephs; Mirjam Sprangers; Francesco Cottone; Fabio Efficace

    Despite international recommendations of including patient-reported outcomes (PROs) in randomised clinical trials (RCTs), a 2014 review concluded that few RCTs of bladder cancer (BC) report PRO as an outcome. We therefore aimed to update the 2014 review to synthesise current evidence-based knowledge of PROs from RCTs in BC. A secondary objective was to examine whether quality of PRO reporting has improved over time and to provide evidence-based recommendations for future studies in this area. We conducted a systematic literature search using PubMed/Medline, from April 2014 until June 2018. We included the RCTs identified in the previous review as well as newly published RCTs. Studies were evaluated using a predefined electronic-data extraction form that included information on basic trial demographics, clinical and PRO characteristics and standards of PRO reporting based on recommendation from the International Society of Quality of Life Research. Since April 2014 only eight new RCTs for BC included PROs as a secondary outcome. In terms of methodology, only the proportion of RCTs documenting the extent of missing PRO data (75% vs 11.1%, p = 0.03) and the identification of PROs in trial protocols (50% vs 0%, p = 0.015) improved. Statistical approaches for dealing with missing data were not reported in most new studies (75%). Little improvement into the uptake and assessment of PRO as an outcome in RCTs for BC has been made during recent years. Given the increase in (immunotherapy) drug trials with a potential for severe adverse events, there is urgent need to adopt the recommendations and standards available for PRO use in bladder cancer RCTs.

  • Improvement in early urinary continence recovery after robotic-assisted radical prostatectomy based on postoperative pelvic anatomic features: a retrospective review
    BMC Urol. (IF 1.583) Pub Date : 2019-09-18
    Akihiro Nakane; Hiroki Kubota; Yusuke Noda; Tomoki Takeda; Yasuhiko Hirose; Atsushi Okada; Kentaro Mizuno; Noriyasu Kawai; Keiichi Tozawa; Yutaro Hayashi; Takahiro Yasui

    We investigated the impact of postoperative membranous urethral length and other anatomic characteristics of the pelvic floor shape as measured by magnetic resonance imaging on the improvement in continence following robotic-assisted radical prostatectomy. We retrospectively reviewed data from 73 patients who underwent postoperative prostate magnetic resonance imaging following robotic-assisted radical prostatectomy between 2013 and 2018. Patient demographics; pre-, peri-, and post-operative parameters; and pelvic anatomic features on magnetic resonance imaging were reviewed. Patients who used no urinary incontinence pads or pads for protection were considered to have achieved complete continence. Urinary continence was restored in 27.4, 53.4, 68.5, and 84.9% of patients at 1, 3, 6, and 12 months after robotic-assisted radical prostatectomy, respectively. When patients were divided into early and late continence groups based on urinary continence at 3 months after robotic-assisted radical prostatectomy, no significantly different clinical characteristics or surgical outcomes were found. However, the mean membranous urethral length (18.5 mm for the early continence group vs. 16.9 mm for the late continence group), levator muscle width (7.1 vs. 6.5 mm, respectively), and bladder neck width on the trigone side (7.2 mm vs. 5.4 mm, respectively) were significantly different between groups (all p < 0.05). Multivariate logistic regression analysis showed that membranous urethral length (odds ratio, 1.227; 95% confidence interval, 1.011–1.489; p = 0.038) and bladder neck width (odds ratio, 1.585; 95% confidence interval, 1.050–2.393; p = 0.028) were associated with the period of early urinary continence. Postoperative membranous urethral length and bladder neck width were significantly associated with early urinary continence recovery after robotic-assisted radical prostatectomy. It is highly recommended that surgeons focus on preserving the membranous urethral length and increasing the bladder neck width on the trigone side during surgery to achieve optimal continence outcomes after robotic-assisted radical prostatectomy.

  • Analysis of the association between paternity and reoperation for urethral obstruction in adult hypospadias patients who underwent two-stage repair in childhood
    BMC Urol. (IF 1.583) Pub Date : 2019-10-04
    Akihiro Kanematsu; Shiro Tanaka; Takahiko Hashimoto; Michio Nojima; Shingo Yamamoto

    The association between surgical outcome of hypospadias repair and long-term male reproductive function has not been documented. The purpose of this study was to clarify association between paternity in adult hypospadias patients and reoperation for urethral obstruction after two-stage repair during childhood. Ninety hypospadias patients who underwent the same kind of two-stage repair in our institute by a single surgeon, were initially treated at < 18 years old, and who were ≥ 18 years old during the survey were included in the study. Present physical, social, and life status were evaluated by a mailed self-entry questionnaire, and clinical background and surgical outcome data were evaluated by medical records. National survey data of the general population were used as external control. The paternity rate of the patient groups was evaluated by Kaplan-Meier curve analysis and log-rank tests. Twenty-six patients (28.9%) underwent 43 reoperations after completion of the initial repair. Twelve patients were reoperated for obstructive complication (Study group) and were compared with 14 patients who were reoperated only for non-obstructive causes and 64 patients who were not reoperated as Study control group (N = 78). The Study group patients showed sexual intercourse rate and marriage rate not statistically different in comparison with the Study control, although marriage rate at 32.5 years old were lower than the general population (p = 0.048, z-test). None of the Study group achieved paternity, which showed a significant difference to the Study control (p = 0.032, log-rank test). The difference was also statistically significant in the analysis among the 31 married patients (p = 0.012, log-rank test). Patients reoperated for obstructive complication documented worsened Quality of Life score in the International Prostate Symptom Score (2.3 ± 2.0 vs. 1.4 ± 1.2, p = 0.031, t-test) and ejaculation problems (66.7% vs. 17.4%, p = 0.003, chi-square test). History of reoperation for obstructive complication was associated with lower paternity rate in patients with hypospadias, presumably for multifactorial causes associated with marriage age and ejaculation problems. The present results may implicate importance of uncomplicated urethroplasty during childhood for achieving paternity, although it should be further tested in the future for larger groups of hypospadias patients.

  • Adherence and barriers to penile rehabilitation over 2 years following radical prostatectomy
    BMC Urol. (IF 1.583) Pub Date : 2019-10-07
    Jeffrey Albaugh; Brittany Adamic; Cecilia Chang; Nicholas Kirwen; Joshua Aizen

    A variety of penile rehabilitation (PR) therapies are available to improve post-prostatectomy erectile dysfunction (ED) with mixed results. It is uncertain how adherent men are to PR therapies. The aim of this study is to determine adherence to and identify barriers to PR treatment. A longitudinal cross-sectional approach was used in men who underwent radical prostatectomy over 2 years. Men were instructed to take a PDE5 inhibitor (PDE5i) three times per week, and if required, utilize a vacuum constriction device (VCD) daily. Outcomes were measured by multiple validated questionnaires. In addition, penile stretched length, side effects, compliance to PR regimen & barriers to participation were documented. Seventy-seven patients were enrolled, however only 49 completed evaluation at 3 or more timepoints and were included in analysis. This cohort was an average age of 58.1 years (±7.7), had robotic laparoscopic radical prostatectomy (91.7%), and had bilateral nerve sparing procedures (95.8%). Majority (62.5%) reported normal SHIM pre-operatively, however 79% used PDE5i. Erectile function as measured by IIEF and Erection Hardness Rating were negatively affected post-operatively, with gradual improvement in parameters throughout the 24 month follow up. Of the participants who had normal pre-op SHIM, only 23.1 and 28.6% regained baseline function at 1 and 2 years, respectively. Orgasm was significantly diminished immediately post-operatively, however, at the end of the study period only 37% of men reported diminished climax and no men reported absent orgasm. Adherence to penile rehabilitation therapies declined overtime. Men took oral PDE5i on average 2.3 times weekly at 12 and 24 months (p < 0.001). Men used the VCD 2.3–3.9 days a week, which declined overtime (p = 0.014). Improvement in erectile and orgasm parameters was observed over time, but most men did not return to baseline function. Despite comprehensive instructions and a frequent follow up schedule, PDE5i and VCD adherence was poor. High attrition rates were noted with only 55.8% of men remaining at 12 months and 45% of men completing 24 months. The most common barriers to PR adherence were cost, inconvenience and perceived ineffectiveness.

  • Comparison of gemcitabine and anthracycline antibiotics in prevention of superficial bladder cancer recurrence
    BMC Urol. (IF 1.583) Pub Date : 2019-10-15
    Tian-Wei Wang; Hui Yuan; Wen-Li Diao; Rong Yang; Xiao-Zhi Zhao; Hong-Qian Guo

    Because of the failure, shortage and related toxicities of Bacillus Calmette-Guérin (BCG), the other intravesical chemotherapy drugs are also widely used in clinical application. Gemcitabine and anthracycline antibiotics (epirubicin and pirarubicin) are widely used as first-line or salvage therapy, but which drug is better is less discussed. A total of 124 primary NMIBC patients administered intravesical therapy after transurethral resection of bladder tumor (TURBT) at Nanjing Drum Tower hospital from January 1996 to July 2018. After TURBT, all patients accepted standard intravesical chemotherapy. Recurrence was defined as the occurrence of a new tumor in the bladder. Progression was defined as confirmed tumor invading muscular layer. Treatment failure was defined as need for radical cystectomy (RC), systemic chemotherapy and radiation therapy. Of the 124 patients who underwent intravesical chemotherapy, 84 patients were given gemcitabine, 40 patients were given epirubicin or pirarubicin, with mean follow-up times (mean ± SD) of (34.8 ± 17.9) and (35.9 ± 22.1) months respectively. The clinical and pathological features of patients show no difference between two groups. Recurrence rate of patients given gemcitabine was 8.33% (7 out of 84), the recurrence rate was 45% (18 out of 40) for epirubicin or pirarubicin (P < 0.0001). The progression rates of gemcitabine, anthracycline antibiotics groups were 2.38% (2 out of 84) and 20% (8 out of 40), respectively (P < 0.001). The rate of treatment failure is 8.33% (7 out of 84) and 25% (10 out of 40), respectively (P = 0.012). Gemcitabine intravesical chemotherapy group was significantly related to a lower rate of recurrence (HR = 0.165, 95% CI 0.069–0.397, P = 0.000), progression (HR = 0.160, 95% CI 0.032–0.799, P = 0.026) and treatment failure (HR = 0.260, 95% CI 0.078–0.867, P = 0.028). In conclusion, gemcitabine intravesical chemotherapy group was significantly related to a lower rate of recurrence, progression and treatment failure. Gemcitabine could be considered as a choice for these patients who are not suitable for BCG.

  • Sustained density of neuroendocrine cells with aging precedes development of prostatic hyperplasia in spontaneously hypertensive rats
    BMC Urol. (IF 1.583) Pub Date : 2019-10-16
    Yuki Kyoda; Koji Ichihara; Kohei Hashimoto; Ko Kobayashi; Fumimasa Fukuta; Naoya Masumori

    Neuroendocrine (NE) cells may have an impact on the development and initial growth of benign prostatic hyperplasia (BPH) according to previous human studies. To explore the relationship of NE cells and BPH development, we compared the density of NE cells and also prostatic weight in spontaneously hypertensive rats (SHR), which develop by aging, and Wistar-Kyoto rats (WKY) as control. The total weights of the epithelium and stroma in the ventral lobes of 8-, 12, 16-, 28- and 56-week-old SHR and WKY were calculated using Image J software. NE cells in the ventral prostatic ducts (VPd) were quantified using immunohistochemical staining for serotonin. Although there was no significant difference in the estimated total weight of the epithelium and stroma in the ventral lobes adjusted by body weight (ES weight) between the two groups at 8, 12 and 16 weeks of age, ES weight was significantly greater in the SHR group than in the WKT group at 28 and 56 weeks. The density of NE cells in the VPd decreased with aging in the WKY group, whereas it was sustained until 16 weeks and then decreased with aging in the SHR group. The difference in the density between the two groups was most marked at 16 weeks of age. In the natural history of BPH, NE cells may play an important role in the initial development of BPH because sustained density of NE cells in the VPd precedes the development of prostatic hyperplasia.

    BMC Urol. (IF 1.583) Pub Date : 2019-10-16
    A. Rodríguez Antolín; L. Martínez-Piñeiro; M. E. Jiménez Romero; J. B. García Ramos; D. López Bellido; J. Muñoz del Toro; A. García García-Porrero; F. Gómez Veiga

    Fatigue is one of the most prevalent symptoms among cancer patients. Specifically, in metastatic castration-resistant prostate cancer (mCRPC) patients, fatigue is the most common adverse event associated with current treatments. The purpose of this study is to describe the prevalence of fatigue and its impact on quality of life (QoL) in patients with CRPC in routine clinical practice. This was a cross-sectional, multicentre study. Male chemo-naïve adults with high-risk non-metastatic (M0) CRPC and metastatic (M1) CRPC (mCRPC) were eligible. Fatigue was measured using the Brief Fatigue Inventory (BFI) and QoL was assessed using the Functional Assessment of Cancer Therapy questionnaire for patients with prostate cancer (FACT-P) and the FACT-General (FACT-G) questionnaire. Data were analysed using Mann-Whitney or Kruskal-Wallis tests (non-parametric distribution), a T-test or an ANOVA (parametric distribution) and the Fisher or chi-squared tests (categorical variables). A total of 235 eligible patients were included in the study (74 [31.5%] with M0; and 161 [68.5%] with M1). Fatigue was present in 74%, with 38.5% of patients reporting moderate-to-severe fatigue. Mean FACT-G and FACT-P overall scores were 77.6 ± 16.3 and 108.7 ± 21.4, respectively, with no differences between the CRPC M0 and CRPC M1 subgroups. Fatigue intensity was associated with decreased FACT-G/P scores, with no differences between groups. Among 151 mCRPC patients with available treatment data, those treated with abiraterone-prednisone ≥3 months showed a significant reduction in fatigue intensity (p = 0.043) and interference (p = 0.04) compared to those on traditional hormone therapy (HT). Patients on abiraterone-prednisone ≥3 months showed significantly better FACT-G/P scores than patients on HT (p = 0.046 and 0.018, respectively). Our data show a high prevalence and intensity of fatigue and its impact on QoL in chemo-naïve CRPC patients. There is an association between greater fatigue and less QoL, irrespective of the presence or absence of metastasis. Chemo-naïve mCRPC patients receiving more than 3 months of abiraterone acetate plus prednisone showed an improvement of fatigue and QoL when compared to those on traditional HT. Not applicable since it is not an interventional study.

  • Supernumerary kidneys: a clinical and radiological analysis of nine cases
    BMC Urol. (IF 1.583) Pub Date : 2019-10-17
    Peter Rehder; Rafael Rehwald; Julia M. Böhm; Astrid E. Grams; Alexander Loizides; Marco Pedrini; Jannik Stühmeier; Bernhard Glodny

    A supernumerary kidney (SK) is an additional kidney with its own capsule and blood supply that is not fused with the ipsilateral kidney (IK). Because individual case reports indicate a high morbidity rate, the aim of this retrospective study was a detailed analysis of this rare anatomical variant. Our systematic imaging-based search for SKs, conducted in the period from 2000 and to 2017, yielded 9 cases in total (5 men, 4 women; mean age: 51.8 ± 22.8 years). The SKs were observed on the right in six and on the left side in three cases. In six subjects (66%) they were located caudal and in three cases (33%) cranial to the ipsilateral kidney. Calculi were found in three (33%) of the renal collecting systems. Five (56%) of the SKs had hydronephrosis grade IV and one SK had recurrent pyelonephritis (11%). Two of the ureters opened into the ipsilateral seminal vesicle (22%). Two (22%) SKs were functional but atrophic. Clinically relevant findings were made in 33% of the IKs: atrophy (n = 2), calculi (n = 1), and reflux with recurrent pyelonephritis (n = 1); another 33% had anatomical anomalies without functional impairment. The correct diagnosis of a SK is possible using CT imaging in all subjects. The prevalence of SK based on CT imaging can be estimated to be 1:26750. CT is the method of choice for visualizing SKs. The correct diagnosis is crucial in preventing dispensable surgical procedures and for providing optimal patient treatment and outcome.

  • Pathological upgrading in prostate cancer treated with surgery in the United Kingdom: trends and risk factors from the British Association of Urological Surgeons Radical Prostatectomy Registry
    BMC Urol. (IF 1.583) Pub Date : 2019-10-17
    Nicholas Bullock; Andrew Simpkin; Sarah Fowler; Murali Varma; Howard Kynaston; Krishna Narahari

    Accurate grading at the time of diagnosis if fundamental to risk stratification and treatment decision making in patients with prostate cancer. Whilst previous studies have demonstrated significant pathological upgrading and downgrading following radical prostatectomy (RP), these were based on historical cohorts and do not reflect contemporary patient selection and management practices. The aim of this national, multicentre observational study was to characterise contemporary rates and risk factors for pathological upgrading after RP in the United Kingdom (UK). All RP entries on the British Association of Urological Surgeons (BAUS) Radical Prostatectomy Registry database of prospectively entered cases undertaken between January 2011 and December 2016 were extracted. Those patients with full preoperative PSA, clinical stage, needle biopsy and subsequent RP pathological grade information were included. Upgrade was defined as any increase in Gleason grade from initial needle biopsy to pathological assessment of the entire surgical specimen. Statistical analysis and multivariate logistic regression were undertaken using R version 3.5 (R Foundation for Statistical Computing, Vienna, Austria). A total of 17,598 patients met full inclusion criteria. Absolute concordance between initial biopsy and pathological grade was 58.9% (n = 10,364), whilst upgrade and downgrade rates were 25.5% (n = 4489) and 15.6% (n = 2745) respectively. Upgrade rate was highest in those with D’Amico low risk compared with intermediate and high-risk disease (55.7% versus 19.1 and 24.3% respectively, P < 0.001). Although rates varied between year of surgery and geographical regions, these differences were not significant after adjusting for other preoperative diagnostic variables using multivariate logistic regression. Pathological upgrading after RP in the UK is lower than expected when compared with other large contemporary series, despite operating on a generally higher risk patient cohort. As new diagnostic techniques that may reduce rates of pathological upgrading become more widely utilised, this study provides an important benchmark against which to measure future performance.

  • Electrical conductivity-based contrast imaging for characterizing prostatic tissues: in vivo animal feasibility study
    BMC Urol. (IF 1.583) Pub Date : 2019-10-21
    Yong Soo Cho; Young Hoe Hur; Hyun Ju Seon; Jin Woong Kim; Hyung Joong Kim

    Electrical conductivity-based magnetic resonance (MR) imaging may provide unique information on tissue condition because its contrast originates from the concentration and mobility of ions in the cellular space. We imaged the conductivity of normal canine prostate in vivo and evaluated tissue contrast in terms of both the conductivity distribution and anatomical significance. Five healthy laboratory beagles were used. After clipping the pelvis hair, we attached electrodes and placed each dog inside the bore of an MRI scanner. During MR scanning, we injected imaging currents into two mutually orthogonal directions between two pairs of electrodes. A multi spin echo pulse sequence was used to obtain the MR magnitude and magnetic flux density images. The projected current density algorithm was used to reconstruct the conductivity image. Conductivity images showed unique contrast depending on the prostatic tissues. From the conductivity distribution, conductivity was highest in the center area and lower in the order of the middle and outer areas of prostatic tissues. The middle and outer areas were, respectively, 11.2 and 25.5% lower than the center area. Considering anatomical significance, conductivity was highest in the central zone and lower in the order of the transitional and peripheral zones in all prostates. The transitional and peripheral zones were, respectively, 7.5 and 17.8% lower than the central zone. Current conductivity-based MR imaging can differentiate prostatic tissues without using any contrast media or additional MR scans. The electrical conductivity images with unique contrast to tissue condition can provide a prior information on tissues in situ to be used for human imaging.

  • Robotic stereotactic ablative radiotherapy for renal cell carcinoma in patients with impaired renal function
    BMC Urol. (IF 1.583) Pub Date : 2019-10-21
    C. Senger; A. Conti; A. Kluge; D. Pasemann; M. Kufeld; G. Acker; M. Lukas; A. Grün; G. Kalinauskaite; V. Budach; J. Waiser; C. Stromberger

    Robotic stereotactic ablative radiotherapy (SABR) is currently under investigation as a noninvasive treatment option for patients with renal cell carcinoma (RCC). For radiation therapy of RCC, tumor motion and the need for high ablative doses while preserving the remaining renal parenchyma is a challenge. We aimed to analyze the safety and efficacy of robotic radiosurgery in RCC in a specific difficult subgroup of patients with impaired renal function. We retrospectively identified all patients with RCC, treated with robotic SABR and motion compensation in our institution between 2012 and 2017. Either single fraction SABR of 24 or 25 Gy or 3 fractions of 12 Gy prescribed to the 70% isodose line was applied. Local control, overall survival, radiation side effects were evaluated together with renal function and tumor motion. We analyzed data of 13 lesions treated in 10 patients with clear cell RCC and a mean age of 70.5 ± 13.6 years (range: 48–87). Prior to SABR, 8 patients underwent previous complete and/or partial nephrectomy, 7 patients presented with chronic kidney disease ≥ stage 3. The median of minimum, mean and maximum planning target volume doses were 23.2, 29.5 and 35.0 Gy for single fraction and 24.4, 42.5 and 51.4 Gy for the three fractions regime. Persistent local control by robotic SABR was achieved in 9 out of 10 patients (92.3% of all lesions) within a median follow-up period of 27 month (range: 15–54). One patient underwent nephrectomy due to progressive disease and sufficient renal function of the contralateral kidney. Renal function remained stable with a mean estimated glomerular filtration rate (eGFR) of 51.3 ± 19.7 ml/min at baseline and 51.6 ± 25.8 ml/min at follow-up. The largest respiratory-induced tumor motion was seen in superior-inferior direction, compensated by the CyberKnife with mean targeting errors of maximal 2.2 mm. Robotic SABR is technically feasible for the treatment of RCC in preexisting kidney disease with good local tumor control at about 2 years follow-up. Robotic SABR with motion tracking offers a valid treatment option for patients, who are at increased risk for progression to end-stage renal disease due to partial nephrectomy or ablative techniques.

  • Safety and efficacy of Holmium laser enucleation of the prostate (HoLEP) in patients with previous transperineal biopsy (TPB): outcomes from a dual-centre case-control study
    BMC Urol. (IF 1.583) Pub Date : 2019-10-22
    Chris Bell; Sacha L. Moore; Amarit Gill; Obinna Obi-Njoku; Stephen F. Hughes; Asad Saleemi; Gidon Ellis; Farooq Khan; Iqbal S. Shergill

    We investigated the surgical feasibility, safety and effectiveness of 50 W (low power) Holmium Laser enucleation of the prostate (HoLEP) in patients who have undergone previous template biopsy of the prostate (TPB). Data encompassing pre-operative baseline characteristics, intra-operative measures and post-operative outcomes was collected for 109 patients undergoing HoLEP across two UK centres. Patients were stratified into two groups; group 1 (n = 24) had undergone previous TPB were compared with ‘controls’ (no previous TPB) in group 2 (n = 85). The primary outcome was successful HoLEP. There were no statistically significant differences in either key baseline characteristics or mass of prostate enucleated between groups 1 and 2. There was no statistically significant difference in enucleation or morcellation times parameters between the two groups other than enucleation efficiency in favour of group 1 (p = 0.024). Functional outcomes improved, without any statistically significant difference, in both groups. In patients with a previous TPB, HoLEP is surgically feasible, safe and effective. TPB should not be considered a contraindication to HoLEP. Our work provides a strong foundation for further research in this area.

  • Which is the best treatment of pediatric upper urinary tract stones among extracorporeal shockwave lithotripsy, percutaneous nephrolithotomy and retrograde intrarenal surgery: a systematic review
    BMC Urol. (IF 1.583) Pub Date : 2019-10-23
    Qing He; Kaiwen Xiao; Yuntian Chen; Banghua Liao; Hong Li; Kunjie Wang

    Although the indications of minimally invasive treatments for pediatric urolithiasis are similar to those in adults, it is still crucial to make the right treatment decision due to the special considerations of children. This review aims to evaluate the efficacy and safety of extracorporeal shockwave lithotripsy (SWL), percutaneous nephrolithotomy (PCNL), and retrograde intrarenal surgery (RIRS) in the management of pediatric upper urinary tract stones. EMBASE, PubMed, and the Cochrane Library were searched from their first available date to March 2018. The studies that meet the inclusive criteria were included. The efficacy and safety of the treatments were assessed by means of meta-analysis of the stone free rate (SFR), complication rate, effectiveness quotient (EQ) and secondary outcome indicators. A total of 13 comparative studies were identified for data analysis. PCNL presented a significantly higher SFR compared with SWL. Similarly, the single-session SFR of RIRS was significantly higher than SWL. However, no significant difference was found between RIRS and SWL in the overall SFR. There was no significant difference between PCNL and RIRS in the SFR. Furthermore, no significant differences in complication rates were found among the three therapies. Compared with the other two treatments, PCNL had a longer operative time, fluoroscopy time and hospital stay. SWL had a shorter hospital stay, higher retreatment rate and auxiliary rate in comparison with the other two treatments. The present data also showed that PCNL presented a higher EQ than the other two treatments, and RIRS had a lower efficiency than SWL and PCNL. In the subgroup analysis of pediatric patients with stone ≤20 mm, the comparative results were similar to those described above, except for the higher complication rate of PCNL than SWL. Although SWL as an outpatient procedure provides shorter hospital stay and reduces operative time, it has a lower SFR and higher retreatment rate than the other two treatments. PCNL exhibits a higher SFR and EQ than SWL; nevertheless, it has a longer operative time and fluoroscopy time than the other two procedures. RIRS offers a similar SFR as PCNL but a lower efficiency than PCNL.

  • A phosphodiesterase 5 inhibitor, tadalafil, suppresses stromal predominance and inflammation in a rat model of nonbacterial prostatitis
    BMC Urol. (IF 1.583) Pub Date : 2019-10-23
    Mikio Sugimoto; Xia Zhang; Nobufumi Ueda; Hiroyuki Tsunemori; Rikiya Taoka; Yusi Hayashida; Hiromi Hirama; Yasuyuki Miyauchi; Yuki Matsuoka; Hirohito Naito; Yu Osaki; Yosiyuki Kekehi

    Chronic inflammation is thought to be a major causative factor for the development of benign prostatic hyperplasia (BPH) and lower urinary tract symptoms (LUTS). Tadalafil, a phosphodiesterase type 5 inhibitor (PDE5-I), which has been used for the treatment of BPH-LUTS in daily practice, is known to act at several urinary organs. In this study, focused on the prostate, we examined the effect of tadalafil on the pathological changes and inflammatory factors in a rat nonbacterial prostatitis (NBP) model. Forty ten-month-old male Wistar rats were divided into nonbacterial prostatitis (NBP), NBP with tadalafil treatment (NBP-tadalafil), control, and control treated with tadalafil (control-tadalafil) groups (n = 10 per group). The NBP and NBP-tadalafil groups were castrated and then received daily subcutaneous 17β-estradiol for 30 days. The control-tadalafil and NBP-tadalafil groups were administered daily oral tadalafil for 30 days. All rats were then sacrificed and pathological changes and inflammatory factors were assessed in the prostatic tissues. In the NBP group, the stroma-to-epithelium (S/E) ratio in the ventral prostate was significantly higher than in the control group (P < 0.001). In the NBP-tadalafil group, the S/E ratio was significantly lower than in the NBP group (P < 0.001). The macrophage levels and the extent of T-cell infiltration in the NBP-tadalafil group were significantly lower than in the NBP group (P < 0.005; P < 0.001, respectively). Compared with the NBP group, tissue concentrations of inflammatory cytokines, such as tumor necrosis factor-α, interleukin-8, and interleukin-1β, were significantly downregulated in the NBP-tadalafil group (P < 0.01; P < 0.05; P < 0.005, respectively). Tadalafil suppressed stromal predominance and showed anti-inflammatory effects in a rat NBP model in association with downregulation of inflammatory cytokines.

  • Ureteroenteric strictures: a single center experience comparing Bricker versus Wallace ureteroileal anastomosis in patients after urinary diversion for bladder cancer
    BMC Urol. (IF 1.583) Pub Date : 2019-10-24
    Frank Christoph; Franziska Herrmann; Peter Werthemann; Thomas Janik; Martin Schostak; Christian Klopf; Steffen Weikert

    To evaluate the outcome and complication rate in a single institution experience using the two most commonly used techniques of ureteroenteric anastomosis, the Bricker and Wallace anastomosis. A total of 137 patients underwent ileal conduit for bladder cancer. Ureters were anastomosed by two experienced surgeons, one performing a Bricker and the other, a Wallace anastomosis. Stricture was identified during clinical follow-up. Seventy-five patients underwent a Bricker anastomotic, and 65 received a Wallace anastomosis. The average age was 70 in both groups, males were predominant (66% Bricker, 70% Wallace). Follow up period was 36.5 months in Bricker group and 17 months in Wallace group. In both groups, the body mass index (BMI) was similar (26.1 kg/m2 Bricker and 26.4 kg/m2 Wallace). We observed that the stricture rate after performing the Bricker anastomosis technique was 25.3% (19/75) as compared to 7.7% (5/65) after Wallace anastomosis technique, which was statistically significant (p = 0.001). In the Bricker group, patients with strictures had higher BMI (28.3 vs. 25.7 kg/m2, p = 0.05). On average it took 8.5 months in the Bricker group and three months in the Wallace group (p = 0.6) to develop stricture. The stricture rate was significantly higher when Bricker technique was applied. Although the BMI was not different in both groups, patients with a higher BMI were more likely to develop stricture. We believe that the approach of the separate and refluxing technique of Bricker anastomosis especially in obese patients poses a higher risk for anastomotic stricture formation.

  • Comparisons of cancer detection rate and complications between transrectal and transperineal prostate biopsy approaches - a single center preliminary study
    BMC Urol. (IF 1.583) Pub Date : 2019-10-28
    Guan-Lin Huang; Chih-Hsiung Kang; Wei-Ching Lee; Po-Hui Chiang

    Prostate biopsy remains the gold standard approach to verify prostate cancer diagnosis. Transrectal (TR) biopsy is a regular modality, while transperineal (TP) biopsy is an alternative for the patients who display persistently high levels of prostate-specific antigen (PSA) and thus have to undergo repeat biopsy. This study aimed to compare the cancer detection rates between TR and TP approaches and assess the post-bioptic complications of the two procedures. Besides, the feasibility of performing TP biopsies under local anesthesia was also evaluated. A total of 238 outpatient visits meeting the criteria for prostate cancer biopsy were enrolled for this study. They were divided into two groups: the TP group (n = 130) consists of patients destined to undergo local anesthetic TP biopsy; and the TR group (n = 108) contained those who received TR biopsy as comparison. Age, PSA level, digital rectal exam (DRE) finding, prostate volume, and biopsy core number were used as the parameters of the multivariable analyses. The comparable items included cancer detection rate, complication rate, admission rate and visual analog scale (VAS) score. The cancer detection rates between TP and TR groups were quite comparable (45% v.s. 49%) (p = 0.492). However, the TP group, as compared to the TR group, had significantly lower incidence of infection-related complications (except epididymitis and prostatitis) that commonly occur after biopsies. None of the patients in the TP group were hospitalized due to the post-bioptic complications, whereas there was still a minor portion of those in the TR group (7.4%) requiring hospitalization after biopsy. Medians (25–75% quartiles) of visual analog scale (VAS) were 3 [3, 4] and 4 [3–5] respectively for the TP and TR procedures under local anesthesia, but no statistical significance existed between them (p = 0.085). Patients receiving TP biopsy are less likely to manifest infection-related complications. Therefore, TP biopsy is a more feasible local anesthetic approach for prostate cancer detection if there are concerns for infectious complications and/or the risk of general anesthesia.

  • Laparoscopic adrenalectomy - is it safe in hands of residents in training?
    BMC Urol. (IF 1.583) Pub Date : 2019-10-28
    Jadwiga Dworak; Michał Wysocki; Anna Rzepa; Michał Natkaniec; Michał Pędziwiatr; Andrzej Budzyński; Piotr Major

    Laparoscopic adrenalectomy (LA) has become the “gold standard” for treating most adrenal tumors in the past decade. However, it is still considered a relatively complicated procedure requiring experience from surgeon. The aim of the study was to evaluate the safety of laparoscopic adrenalectomy performed by residents who are undergoing training in general surgery. A prospectively collected database containing all 300 transperitoneal laparoscopic adrenalectomies performed in II Department of General Surgery JU MC, Krakow between January 2013 and March 2018 was retrospectively reviewed. Patients were divided into two groups; patients operated on by residents (group 1, 54 operations) and by attending general surgeons (group 2, 246 operations). We compared the course of the operation and patient hospitalization in these two groups. If the operation was completed by a different person than the one who started the procedure, we refer to this as “operator conversion”. We found no differences in demographic factors or comorbidities between the two groups. The mean operative time was similar in the residents’ and the specialists’ groups (p = 0.5761). Median blood loss did not differ between the groups (p = 0.4325). The overall ratio of intraoperative adverse events was similar in both groups (p = 0.8643). The difference in the ratio of perioperative complications between the groups was not statistically significant (p = 0.6442). The average mean hospital stay after surgery was 2 days for both groups. We identified 25 cases (8.33%) of operator conversion; the difference in operator conversions between two groups was not statistically significant (p = 0.1741). Laparoscopic transperitoneal adrenalectomy performed by a supervised resident is a safe procedure. The course of the operation and patient hospitalization did not differ importantly when comparing procedures performed by residents and attending surgeons. Liberal use of operator conversions from resident to attending surgeon and from a surgeon to a senior surgeon provides reasonable safety and prevents complications. In high-volume centers performing minimally invasive techniques, closed supervision allows residents to safely perform LA.

  • CoQ10 ameliorates monosodium glutamate-induced alteration in detrusor activity and responsiveness in rats via anti-inflammatory, anti-oxidant and channel inhibiting mechanisms
    BMC Urol. (IF 1.583) Pub Date : 2019-10-28
    Dalia F. El Agamy; Yahya M. Naguib

    Competent detrusor muscles with coordinated contraction and relaxation are crucial for normal urinary bladder storage and emptying functions. Hence, detrusor instability, and subsequently bladder overactivity, may lead to undesirable outcomes including incontinence. Multiple mechanisms may underlie the pathogenesis of detrusor overactivity including inflammation and oxidative stress. Herein, we tested the possibility that CoQ10 may have a potential therapeutic role in detrusor overactivity. Forty adult male Wistar albino rats weighing 100-150 g were used in the present study. Rats were divided (10/group) into control (receiving vehicles), monosodium glutamate (MSG)-treated (receiving 5 mg/kg MSG daily for 15 consecutive days), MSG + OO-treated (receiving concomitantly 5 mg/kg MSG and olive oil for 15 consecutive days), MSG + CoQ10-treated (receiving concomitantly 5 mg/kg MSG and 100 mg/kg CoQ10 daily for 15 consecutive days) groups. MSG resulted in significant increase in bladder weight and sensitised the bladder smooth muscles to acetylcholine. MSG has also resulted in significant increase in bladder TNF-α, IL-6, malondialdehyde, nerve growth factor and connexion 43, with significant decrease in the antioxidant enzymes superoxide dismutase and catalase. Olive oil had no effect on MSG induced alterations of different parameters. Treatment with CoQ10 has resulted in a significant restoration of all the altered parameters. Taken together, our results suggest that CoQ10 antagonizes the deleterious effects of MSG on detrusor activity. We propose that CoQ10 could be a therapeutic strategy targeting urinary bladder dysfunction.

  • Staged male genital reconstruction with a local flap and free oral graft: a case report and literature review
    BMC Urol. (IF 1.583) Pub Date : 2019-10-29
    Da-chao Zheng; Min-kai Xie; Shi-bo Fu; Jian-hua Guo; Wen-ji Li; Hai-jun Yao; Zhong Wang

    Male genital skin loss is a common disease in urology. However, male genital skin loss accompanying a penile urethra defect is rarely reported. Herein, we describe a novel surgical technique using a composite local flap and oral mucosal graft to reconstruct the penis, which may provide a new solution for patients with similar conditions. A 36-year-old male with a penile urethra defect and a large area of genital skin loss required urethral reconstruction. The meatus had descended to the penoscrotal junction. This procedure was divided into three stages. The first stage of the surgery involved burying the nude penile shaft beneath the skin of the left anteromedial thigh for coverage of the skin defect. The second stage consisted of releasing the penis and expanding the size of the urethral plate for further urethroplasty. The third stage consisted of reconstruction of the anterior urethra 6 months later. Postoperatively, the patient reported satisfactory voiding. The maximal flow rate (MFR) was 22.2 ml/s with no postvoiding residual urine at the 24-month follow-up visit. No edema, infection, hemorrhage, or cicatricial retraction were observed. The patient’s erectile function was satisfactory, and his international index of erectile function-5 score (IIEF-5 score) was 23 at the 24-month follow-up visit. Additionally, the presence of nocturnal penile tumescence demonstrated that he had normal erectile function. This procedure is an effective surgical option for men with complete foreskin and penile urethra defects. It could also be extended as a treatment strategy when composite local or pedicle transposition flaps and free grafts are needed for specific patients.

  • Dysuria due to benign prostatic hyperplasia of the median lobe with ketamine-associated uropathy in a young male
    BMC Urol. (IF 1.583) Pub Date : 2019-10-30
    Zhangcheng Liao; Zhao Wang; Zhongyuan Jin; Zhengyan Tang

    Benign prostatic hyperplasia (BPH) rarely occurs in children or young males. In this case report, a 29-year-old male patient diagnosed with BPH coexisting with ketamine-associated uropathy was reported to investigate the possible relationship between BPH and ketamine-associated uropathy as well as therapeutic strategies. A 29-year-old male patient with a 3-year history of ketamine inhalation, complaining of dysuria with frequency and urgency, was admitted. Hydronephrosis, hydroureters, uneven bladder wall thickening and a tumour located in the outlet of the bladder were detected with computed tomography (CT). The patient agreed to cystoscopy under general anaesthesia. A spherical tumour with a diameter of approximately 2 cm was found to originate from the median lobe of the prostate and follicular lesions were diffusely distributed on the right bladder wall. The tumour and follicular lesions in the bladder were resected successfully, and pathology demonstrated BPH and chronic inflammation of the mucous membranes separately. The patient quit ketamine completely during the one-year follow-up. Dysuria was relieved completely and no tumour or follicular neoplasm recurrence was found. Inflammation in the urothelium, as a direct or indirect consequence of ketamine, may contribute to the development of BPH. Both surgical interventions to remove obstruction and ketamine cessation are necessary approaches.

  • Bilateral adrenal hemorrhage after hip arthroplasty: an initially misdiagnosed case
    BMC Urol. (IF 1.583) Pub Date : 2019-11-04
    Lei Wang; Xiao-fei Wang; Ying-chao Qin; Jia Chen; Cun-hai Shang; Guo-feng Sun; Ning-chen Li

    Bilateral adrenal hemorrhage (BAH) is a rare but potentially catastrophic condition. Its clinical manifestation is often non-specific and sometimes difficult to be diagnosed in time. A 57-year-old woman, who presented with severe fatigue, nausea and vomiting after left hip arthroplasty due to her femoral neck fracture in a local hospital, was transferred to our medical center. Laboratory results revealed significant hyponatremia, low serum cortisol and elevated serum ACTH. Computed tomography (CT) showed a bilateral adrenal mass, measured 3.6 × 2.7 cm on the left and 3.4 × 2.3 cm on the right. Further magnetic resonance imaging (MRI) confirmed the diagnosis of BAH. The patient was prescribed with oral prednisolone acetate, 5 mg, tid, and her condition improved gradually. Nine months after, the patient was in good condition with 5 mg prednisolone acetate per day. CT revealed a clearly shrunken adrenal mass compared with 9 months ago. This case illustrates the difficulty in making the diagnosis of BAH with atypical presentation. Such cases necessitate greater alertness on the part of the clinician and require rapid diagnosis and prompt glucocorticoid replacement for better clinical outcomes.

  • Surface-projection-based transperineal cognitive fusion targeted biopsy of the prostate: an original technique with a good cancer detection rate
    BMC Urol. (IF 1.583) Pub Date : 2019-11-04
    Lei Wang; Xiaofei Wang; Wenfeng Zhao; Zichen Zhao; Zhihu Li; Shengmin Fei; He Zhu; Xiang Ji; Bing Yang; Ningchen Li; Yanqun Na

    To report a new standardized cognitive fusion technique on transperineal targeted biopsy (TB) of prostate, and to evaluate its efficacy for cancer detection combined with systematic biopsy (SB) . We present a retrospective review of consecutive patients undergoing multiparametric magnetic resonance (mpMRI) imaging of the prostate with subsequent transperineal prostate biopsy from January 2016 to December 2018. A free-hand 12-core SB was performed for each patient. PI-RADS 3–5 lesions were further targeted for biopsy with our TB technique. Firstly, a central point of suspicious lesion (B′) was registered cognitively on a transverse section of transrectal ultrasound (TRUS). Then, biopsy gun punctured vertically through a fixed pioneer site (A) on skin of perineum, and deep into the TRUS section to get A’. Next, targeted site (B), the surface-projection of B′, would be determined on skin of perineum by A and distance from B′ to A’. Finally, puncture through B to reach B′. Pathological findings of SB and TB were analyzed. A total of 126 patients underwent transperineal prostate biopsy (47 SB only, 79 SB + TB). The age of the patients was 68.7 ± 9.2 years. The median preoperative PSA value was 11.8 ng/mL. Preoperative prostate volume was 60.5 ± 50.0 mL. The numbers of patients with PI-RADS scores of 1 through 5 were 4, 43, 27, 21 and 31, respectively. The overall detection rate of cancer was 61/126 (48.4%), and it was significantly higher in the combination cohort (56/79, 70.9%) compared with the SB only cohort (5/47, 10.6%, p<0.001). When focused on the combination cohort, TB detected a similar overall rate of PCa (53/79, 67.1% vs 52/79, 65.8%; p = 0.87) compared with SB. The clinically significant PCa (csPC) detection rate was 52/79 (65.8%), while for TB and SB the csPC/PC rate was 51/53 (96.2%) and 48/52 (92.3%), respectively(p = 0.44). TB demonstrated a better sampling performance (positive rate for each core) compared with SB (51.0% vs 31.3%, p < 0.001). Surface-projection-based transperineal cognitive fusion targeted biopsy of the prostate has a good efficacy in detecting PCa.

  • Clinical and morphological effects of hyperbaric oxygen therapy in patients with interstitial cystitis associated with fibromyalgia
    BMC Urol. (IF 1.583) Pub Date : 2019-11-05
    Gerardo Bosco; Edoardo Ostardo; Alex Rizzato; Giacomo Garetto; Matteo Paganini; Giorgio Melloni; Giampiero Giron; Lodovico Pietrosanti; Ivo Martinelli; Enrico Camporesi

    Interstitial Cystitis (IC) is a debilitating disorder of the bladder, with a multifactorial and poorly understood origin dealing with microcirculation repeated damages. Also Fibromyalgia (FM) is a persistent disorder whose etiology is not completely explained, and its theorized alteration of pain processing can compromise the quality of life. Both these conditions have a high incidence of conventional therapeutic failure, but recent literature suggests a significant beneficial response to Hyperbaric Oxygen Therapy (HBOT). With this study, this study we evaluated the effects of HBOT on quality of life, symptoms, urodynamic parameters, and cystoscopic examination of patients suffering from both IC and FM. We structured an observational clinical trial design with repeated measures (questionnaires, urodynamic test, and cystoscopy) conducted before and 6 months after a therapeutic protocol with hyperbaric oxygen for the treatment of patients suffering from both IC and FM. Patients were exposed to breathing 100% oxygen at 2 atm absolute (ATA) in a multiplace pressure chamber for 90 min using an oro-nasal mask. Patients undertook a cycle of 20 sessions for 5 days per week, and a second cycle of 20 sessions after 1 week of suspension. Twelve patients completed the protocol. Changes after HBOT were not significant, except for hydrodistension tolerance (mean pre-treatment: 409.2 ml; mean post-treatment: 489.2 ml; p < 0.05). A regression of petechiae and Hunner’s ulcers was also noted 6 months after the completion of HBOT. Our study showed no improvement of symptoms, quality of life, and urodynamic parameters, except for hydrodistension, and a slight improvement in cystoscopic pattern. However, to date, we could not demonstrate the significance of overall results to justify the use of HBOT alone in patients with IC and FM. This observation suggests that additional studies are needed to better understand if HBOT could treat this subset of patients. NCT03693001 ; October 2, 2018. Retrospectively registered.

  • Effects of biofeedback-based sleep improvement program on urinary symptoms and sleep patterns of elderly Korean women with overactive bladder syndrome
    BMC Urol. (IF 1.583) Pub Date : 2019-11-08
    Jooyeon Park; Choal Hee Park; Sang-Eun Jun; Eun-Ju Lee; Seung Wan Kang; Nahyun Kim

    The prevalence of overactive bladder syndrome (OAB) increases with age. Sleep disturbances in elderly individuals with OAB is a common problem. The purpose of this study was to examine the effects of a biofeedback-based sleep improvement (BBSI) program on urinary symptoms and sleep patterns in elderly Korean women with OAB. A non-equivalent control group pre−/post-test design was used. Elderly women with OAB were assigned to an intervention group (n = 20) or a control group (n = 18). The BBSI program was implemented in the intervention group for 12 weeks, while two educational sessions of general sleep hygiene and lifestyle modification were provided to the control group. Using SPSS 23.0, the data were analyzed by descriptive analysis using the chi-square test, Fisher’s exact test, Mann-Whitney test, and Wilcoxon test. After the 12-week BBSI program, significant improvements were found in the intervention group’s the square root of the mean squared differences of successive R-R intervals (p = 0.025), low frequency/high frequency ratio (p = 0.006), and epinephrine (p = 0.039). We also observed a significant difference in urinary symptoms, sleep efficiency, wake after sleep onset, number of awakenings, and number of awakenings within 3 h after sleep onset (p < 0.001, p = 0.004, p = 0.001, p = 0.001, and p = 0.048, respectively). However, no significant changes were found in these variables in the control group. The BBSI program effectively improved urinary symptoms and sleep patterns of elderly Korean women with OAB. Further longitudinal research is required to investigate the sustainability and effects of the BBSI program. KCT0003882. Date of registration: 02/05/2019. Retrospectively registered.

  • Cost comparison between open radical cystectomy, laparoscopic radical cystectomy, and robot-assisted radical cystectomy for patients with bladder cancer: a systematic review of segmental costs
    BMC Urol. (IF 1.583) Pub Date : 2019-11-08
    Yasuhiro Morii; Takahiro Osawa; Teppei Suzuki; Nobuo Shinohara; Toru Harabayashi; Tomoki Ishikawa; Takumi Tanikawa; Hiroko Yamashina; Katsuhiko Ogasawara

    Robot-assisted radical cystectomy is becoming a common treatment for bladder carcinoma. However, in comparison with open radical cystectomy, its cost-effectiveness has not been confirmed. Although few published reviews have compared total costs between the two surgical procedures, no study has compared segmental costs and explained their impact on total costs. A systematic review was conducted based on studies on the segmental costs of open, laparoscopic, and robot-assisted radical cystectomy using PubMed, Web of Science, and Cochrane Library databases to provide insight into cost-effective management methods for radical cystectomy. The segmental costs included operating, robot-related, complication, and length of stay costs. A sensitivity analysis was conducted to determine the impact of the annual number of cases on the per-case robot-related costs. We identified two studies that compared open and laparoscopic surgeries and nine that compared open and robotic surgeries. Open radical cystectomy costs were higher than those of robotic surgeries in two retrospective single-institution studies, while robot-assisted radical cystectomy costs were higher in 1 retrospective single-institution study, 1 randomized controlled trial, and 4 large database studies. Operating costs were higher for robotic surgery, and accounted for 63.1–70.5% of the total robotic surgery cost. Sensitivity analysis revealed that robot-related costs were not a large proportion of total surgery costs in institutions with a large number of cases but accounted for a large proportion of total costs in centers with a small number of cases. The results show that robot-assisted radical cystectomy is more expensive than open radical cystectomy. The most effective methods to decrease costs associated with robotic surgery include a decrease in operating time and an increase in the number of cases. Further research is required on the cost-effectiveness of surgeries, including quality measures such as quality of life and quality-adjusted life years.

  • The distribution of Preputial vessels in different severity of rat congenital hypospadias model: imaging study using micro-computerized tomography
    BMC Urol. (IF 1.583) Pub Date : 2019-11-08
    Defu Lin; Pei Liu; Guannan Wang; Weiping Zhang; Ning Sun

    Micro-computerized tomography (micro-CT) is considered as an innovative non-invasive and high-resolution imaging technology. The current research aims to reconstruct the distribution of preputial vessels in different severity of rat congenital hypospadias model by micro-CT, and to provide an anatomic basis for the selection of preputial vessel pedicle flaps in surgery. Pregnant rats were exposed to finasteride from gestational day 12 to 17. Depending on the position of the urethral meatus, the pups were divided into normal, mild hypospadias and severe hypospadias groups. Six months after birth, the preputial blood vessels were observed in vascular perfusion with Microfil (a silicone-based polymer) and scanned by micro-CT. CTvox and NRecon were utilized to reconstruct 3-dimentional (3D) images. A pathological analysis of the specimen was taken in order to determine the position of Microfil. The normal group and the mild hypospadias group had similar preputial image characteristics. At the junction of the inner and outer prepuce, the deep layer vessels of the superficial fascia were transversely distributed and formed a vascular ring-like structure. Among the severe hypospadias group, five had sufficient blood circulation while six had insufficient blood circulation. In sufficient blood circulation type, the ring-like vessels were found at the junction of the inner and outer prepuce similar to that of the normal and mild hypospadias group. However, only a small amount of capillary supply to this area in the insufficient type. The junction of the inner and outer prepuce with abundant blood circulation was suitable to be a vascular pedicle flap. The tubularized preputial island flaps were consistent with the ring-like vessels area, and the original blood supply was retained to the greatest extent.

  • Surgical approaches for treatment of ureteropelvic junction obstruction – a systematic review and network meta-analysis
    BMC Urol. (IF 1.583) Pub Date : 2019-11-11
    Annemarie Uhlig; Johannes Uhlig; Lutz Trojan; Marc Hinterthaner; Alexander von Hammerstein-Equord; Arne Strauss

    Multiple surgical treatment options are available for the treatment of ureteropelvic junction obstruction (UPJO). The aim of this study is to compare the most frequently used technics in a comprehensive network approach. A systematic literature search of the EMBASE, MEDLINE and COCHRANE libraries was conducted in January 2018. Publications were included that evaluated at least two of the following surgical techniques: open pyeloplasty (OP), endopyelotomy (EP), laparoscopic (LP) and robot assisted pyeloplasty (RP). Main outcomes were operative success, complications, urinary leakage, re-operation, transfusion rate, operating time, and length of stay. Network meta-analyses with random effects models simultaneously assessed effectiveness of all surgical techniques. A total of 26 studies including 3143 patients were analyzed. Compared with RP, EP and LP showed lower operative success rates (EP: OR = 0.09, 95%CI:0.05–0.19; p < 0.001; LP: OR = 0.51, 95%CI:0.31–0.84; p = 0.008). Compared with OP, LP and RP had lower risk for complications (LP: OR = 0.62; 95%CI:0.41–0.95; p = 0.027; RP: OR = 0.41; 95%CI:0.22–0.79; p = 0.007). Compared with RP, no significant differences were detected for urinary leakage or re-operation, transfusion rates. Compared with EP, RP yielded longer operating time (mean = 102.87 min, 95%CI:41.79 min–163.95 min, p = < 0.001). Further significant differences in operating times were detected when comparing LP to EP (mean = 115.13 min, 95%CI:65.63 min–164.63 min, p = < 0.001) and OP to EP (mean = 91.96 min, 95%CI:32.33 min–151.58 min, p = 0.003). Multiple surgical techniques are available for treatment of UPJO. RP has the highest rates of operative success and as well as LP lower complication rates than OP. Although surgical outcomes are worse for EP, its operating time is shorter than OP, RP, and LP. Surgeons should consider these findings when selecting the optimal treatment method for individual patients.

  • Retzius-sparing robot-assisted laparoscopic radical prostatectomy: functional and early oncologic results in aggressive and locally advanced prostate cancer
    BMC Urol. (IF 1.583) Pub Date : 2019-11-12
    Joanne Nyaboe Nyarangi-Dix; Magdalena Görtz; Georgi Gradinarov; Luisa Hofer; Viktoria Schütz; Claudia Gasch; Jan Philipp Radtke; Markus Hohenfellner

    Retzius-sparing robot-assisted laparoscopic radical prostatectomy (rsRARP) allows entire prostatectomy procedure via the pouch of Douglas. In low- and intermediate-risk prostate cancer (PCa) there is level 1 evidence that the Retzius-sparing approach impacts early continence recovery. Since specific data on aggressive and locally advanced cancer is lacking and avoiding rsRARP is presently suggested, we investigated urinary and sexual recovery, perioperative complications and early oncologic outcomes after rsRARP in this particular cohort. Prospectively collected data of 50 consecutive men (median age 66 years) with high-risk PCa who underwent rsRARP in a single institution was analysed retrospectively. The follow-up for all patients was 12 months after surgery. 3 vs. 12 months after surgery, 82% vs. 98% of men used no pad or one safety pad and 50% vs. 72% used no pad. 89% of patients did not observe a decline of continence if postoperative radiotherapy was carried out. Considering the 17 preoperatively potent patients who underwent bi- or unilateral nerve-sparing surgery, 41% reported their first sexual intercourse within 1 year after rsRARP. 84% of patients had ≥pT3a disease and 42% positive surgical margins. A lymphadenectomy was done in 94% of patients with a median lymph node removal of 15 and lymph node metastasis in 13%. 34% underwent adjuvant radiotherapy and 22% adjuvant androgen deprivation therapy (ADT). 1-year recurrence-free survival was 96%, including 25% of patients on adjuvant or salvage ADT. RsRARP in high-risk PCa is feasible and results in excellent continence rates, even after postoperative radiotherapy. The potency rates are promising but need further clarification in larger cohorts. Reliable oncologic outcomes require longterm follow-up and are awaited.

  • Langerhans cells in hypospadias: an analysis of Langerin (CD207) and HLA-DR on epidermal sheets and full thickness skin sections
    BMC Urol. (IF 1.583) Pub Date : 2019-11-12
    Bernhard Haid; Daniela Reider; Felix Nägele; Anne-Françoise Spinoit; Elisabeth Pechriggl; Nikolaus Romani; Helga Fritsch; Josef Oswald

    Hypospadias are among the most common genital malformations. Langerhans Cells (LCs) play a pivotal role in HIV and HPV infection. The migration of LC precursors to skin coincides with the embryonic period of hypospadias development and genetic alterations leading to the formation of hypospadias impact the development of ectodermally derived tissues. We hypothesized that this might be associated with a difference in frequency or morphology of epidermal and dermal LCs in hypospadias patients. A total of 43 patients from two centers were prospectively included into this study after parental consent and ethics approval. Epidermal and dermal sheets were prepared from skin samples of 26 patients with hypospadias, 13 patients without penile malformations and 4 patients with penile malformations other than hypospadias. Immunofluorescence staining of sheets was performed with anti-HLA-DR-FITC and anti-CD207/Langerin-A594 antibodies. Skin sections from 11 patients without penile malformation and 11 patients with hypospadias were stained for Langerin. Frequencies as well as morphology and distribution of epidermal and dermal LCs on sheets and sections were microscopically evaluated. Cell counts were compared by unpaired t-tests. There was no difference in frequency of epidermal LCs, Neither on sheets (873 ± 61 vs. 940 ± 84LCs/mm2, p = 0.522) nor on sections (32 ± 3 vs. 30 ± 2LCs/mm2, p = 0.697). Likewise, the frequency of dermal LCs (5,9 ± 0,9 vs. 7.5 ± 1.3LCs/mm2, p = 0.329) was comparable between patients with hypospadias and without penile malformation. No differences became apparent in subgroup analyses, comparing distal to proximal hypospadias (p = 0.949), younger and older boys (p = 0.818) or considering topical dihydrotestosterone treatment prior to surgery (p = 0.08). The morphology of the LCs was not different comparing hypospadias patients with boys without penile malformations. LCs are present in similar frequencies and with a comparable morphology and distribution in patients with hypospadias as compared to children without penile malformations. This suggests that patients with hypospadias are not different from patients with normal penile development considering this particular compartment of their skin immunity.

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