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Male infertility is a common disease. Male infertility is also a core competency of urology training and clinical practice. In this white paper from the Society for the Study of Male Reproduction and the Society for Male Reproduction and Urology, we identify and define different physician productivity plans. We then describe the advantages and disadvantages of various physician productivity measurement systems for male infertility practices. We close with recommendations for measuring productivity that we hope urologists and administrators can use when creating productivity plans for male infertility practices.

A term infant with prenatally noted ambiguous genitalia and nonpalpable gonads presented with life-threatening hyponatremia, hypertension, acidosis, and anuric renal failure requiring peritoneal dialysis at age 3 months.Sequencing confirmed 46, XY Denys-Drash syndrome (DDS) due to heterozygous Wilms tumor-1 exon 8 mutation encoding p.His445Arg. Renal US identified bilateral multifocal renal masses at age 8 months. Bilateral retroperitoneal nephrectomies found bilateral nephroblastomatosis without Wilms' tumor avoiding chemotherapy, followed by bilateral laparoscopic orchiopexies. We suggest monthly screening of 46, XY DSD cases for DDS by evaluating for proteinuria and electrolyte disarray starting at diagnosis of DSD to prevent acute life-threatening renal failure presentation.

Objective To conduct a review of current literature to assess whether an association exists between Pentosan Polysulfate Sodium and the development of macular disease, as it is the only oral medication approved by the Food and Drug Administration for the management of interstitial cystitis. Materials and Methods A systematic review was conducted by the authors separately, with review methods established prior to the conduct of the review. Databases searched included PubMed, Ovid, Medline, EBSCO, and Google Scholar. A search was conducted for the terms “Pentosan Polysulfate Maculopathy,” “Pentosan Polysulfate Retinopathy,” and “Interstitial Cystitis Maculopathy.” All papers reporting on primary data were included. There were no study sponsors. Results A total of 14 papers reporting on primary data were identified. Most papers reported on the development of macular disease in the setting of chronic pentosan polysulfate sodium exposure. No randomized controlled trials have been performed to date and data was insufficient to perform a meta-analysis. Nevertheless, patients with interstitial cystitis were more likely to receive a diagnosis of maculopathy after several years of the medication use. Conclusion Although the nature of the published studies renders them prone to confounders, currently available data suggest an increased risk for developing maculopathy after years of pentosan polysulfate sodium use. In light of this, and the marginal effectiveness of the medication for the average individual, we suggest that education be provided as to the possible association and that regular ophthalmic evaluation be recommended for patients who are continued on chronic Pentosan Polysulfate Sodium.

OBJECTIVE To review the literature of 5 pediatric urology topics and conduct gender based and forecasting analyses of first and corresponding authors. METHODS A PubMed search was performed for hypospadias, hydronephrosis, vesicoureteral reflux, bladder and bowel dysfunction, and cryptorchidism over 3 decades from 1990 to 2019. The 50 most relevant “best match” papers from each decade were extracted by topic. Author gender, specialty, and advanced degrees, along with journal and publication variables were collected. Forecasting analyses were conducted through the Holt-Winters method. RESULTS Among 750 papers analyzed, 78% of corresponding and 70% of first authors were male. A significant upward trend was observed for female-authored publications in both first and corresponding positions over time (P CONCLUSION The majority of pediatric urology literature has been generated by male authors. A persistent, rising trend in female authorship across all examined pediatric urology topics was noted. These encouraging findings are projected to continue to increase in the future, suggesting a movement toward equal and fair gender representation in authorship in pediatric urology.

OBJECTIVE To review the robustness of hydronephrosis literature with the application of fragility index (FI) and fragility quotient (FQ) calculations. METHODS A literature review was conducted using Pubmed, Medline, and Ovid for “hydronephrosis” and associated terms and we included all studies with at least 2 groups being compared. FI was calculated by populating study results into a 2-by-2 contingency table and generating a P value using Fisher's exact test. Next, events were manually added to the group with the fewest events, while removing a nonevent from the same group and Fisher's exact test repeated until the P value was >.05. FQ was calculated by dividing FI by the total sample size. RESULTS The 130 included articles were published between 1986 and 2018 in 32 journals. Median citation count was 14 (0-252), 30% were RCTs and most papers originated in the United States (28%), Turkey(10%), and Canada(9%). Median FI was 2 (1-112), FQ was 0.023 (0.0010-0.55), and 60 papers (46%) had a FI of 1, indicating extremely fragile results. There was a significant difference in the FI between observational studies and RCTs (10 ± 17 vs 4 ± 5; P = .02); however, there was no difference in FQ (0.032 ± 0.030 vs 0.053 ± 0.080; P = .09) between them. CONCLUSION Nearly half of studies in hydronephrosis literature reporting significant results are extremely fragile, requiring addition of only a couple of events in 1 treatment arm to significantly modify the results. As such, objective reporting of robustness of results should include FI and FQ which may help diminish over-reliance on P values as the main indicator of clinical significance in comparative studies.

Objective To provide a comprehensive overview of genital anomalies encountered among adolescents, including late effects of problems addressed earlier in childhood. Materials and Methods The major congenital genital anomalies encountered in pediatric urology were identified. They include hypospadias, exstrophy-epispadias, cloacal malformations, disorders of sexual development, undescended testes, and some acquired penile anomalies seen in adolescence (priapism, adolescent varicocele). Recommendations of the International Consultation on Urological Diseases are provided on various aspects of these conditions, such as postpubertal cosmesis and function, fertility implications, and long-term nephrological considerations (when relevant). Results Specific recommendations for care, including strength of clinical recommendation, are provided in this paper. Whereas the basis of this paper is to discuss specific management recommendations as they relate to several heterogeneous conditions, general recommendations include patient-centered discussions regarding operative treatment be deferred until the patient is able to articulate goals and participate in shared decision-making and utilization of multidisciplinary teams for conditions where multiple organ systems may be involved. Conclusion Congenital abnormalities of the genitalia are common and widely heterogeneous. Late effects and concerns often emerge after puberty, and patients should be followed throughout their adult lives to address such concerns.

The paper provides a systematization of the scientific evidence on quality of life of patients affected by urinary incontinence (UI) and overactive bladder (OAB) through a systematic literature review. A single search strategy was performed through the databases and papers collected are reviewed by independent researchers finally, including 39 papers. A strong heterogeneity of studies emerged from the evidence. The multidimensionality of the consequences produced by UI and OAB increased the attention on the identification of the most affected dimension of life quality (i.e. physical, emotional) and on the attempt of predicting life quality impairment through specific variables.

Author(s): Lee, Austin W; Ramstein, Joris; Cohen, Andrew J; Agochukwu-Mmonu, Nnenaya; Patino, German; Breyer, Benjamin N | Abstract: ObjectiveTo examine the most cited literature in urethral reconstruction, review types of work published, and observe research trends.MethodsThe Web of Sciences Sci-Expanded Index was used to conduct a search for urethral reconstruction. References were assessed for relevance to urethral reconstruction by 2 independent reviewers and a final list of the top 100 articles ranked by citation count was obtained. For each article, citation count, publication date, corresponding author, origin institution, origin country, topic area, study design, level of evidence, and origin journal were collected.ResultsThe mean citation count per publication was 108 (median = 94.5; range = 69-366, SD = 43) with a total of 10,874 citations for all papers since 1970. The top 100 articles were published between 1973 and 2011, came from 19 different countries and 16 different journals. Nearly half were case series and most studies were Level III evidence or lower. The United States was the largest contributor to the top 100 with 56 publications, followed by Italy (14), England (12), and Egypt (7). "Outcomes of surgical treatment for urethral stricture disease" was the most prevalent topic area comprising 55 articles in the top 100, with most articles including descriptions or outcomes of novel surgical techniques.ConclusionIn this study, we discovered that the most cited literature in the field of urethral reconstruction is singularly focused and lacking in high levels of evidence. The top 100 cited articles originate primarily from the United States, focus on short-term outcomes after surgical treatment for urethral stricture disease, and are predominantly case series.

T recent American Urological Association centennial issue of the Journal of Urology was devoted to landmark papers that advanced urology. Two papers, dated 1972 and 1983, pertained to the implantation of the prostate with radioactive sources.1,2 One might therefore presume that prostate brachytherapy originated in the latter part of the 20th century. In actuality, radium therapy was used in the treatment of prostate cancer many decades earlier by several prominent urologists.3–6 The leading innovator was Benjamin Barringer, who performed hundreds of transperineal implantations beginning in 1915. X-rays were first identified in 1895, and, as the equipment was inexpensive and widely available, therapeutic x-irradiation was attempted within months of the discovery. Radioactivity was discovered the following year and radium, the first clinically useful radionuclide, in 1898. Radium, however, was scarce and prohibitively expensive. Glowing reports of its therapeutic value led, in 1913, to the founding of the National Radium Institute to develop a domestic source. Coincidentally, James Ewing took control of the Memorial Hospital in New York. As a consequence of his interest in radium therapy, the institution acquired a substantial stock of the substance and Ewing recruited several young surgeons to explore its utility in the treatment of cancer. Benjamin Stockwell Barringer (Fig. 1) was born in New York City in 1877, and was educated at Cornell Medical School (1902) and Europe. He joined the Memorial staff in 1915 and by October of that year had begun implanting bladder and prostate malignancies. Within 2 years, he had performed more than 20 of each. Other urologists of his era used radium to treat prostate cancer.3–7 Most (including Hugh Hampton Young) used an intracavitary (sources placed within a natural cavity) technique, arraying radium capsules along the anterior rectal wall, urethra, bladder neck, and perineum.6 Although the gland was surrounded by the radionuclide, the dose delivered to the prostate was limited by the tolerance of the intervening skin and mucosa. Barringer’s interstitial (sources implanted into the parenchyma) technique circumvented this limitation.

Objective To assess the success of robot-assisted holmium laser debridement of the pubic symphysis for osteomyelitis of the pubic symphysis with associated urosymphyseal fistula. Traditionally, excision of the fistulous tract and concomitant cystectomy with urinary diversion and pubic symphyseal debridement has been done using an open approach. This paper presents patients who were successfully managed with this approach. Methods and Materials Between January 2007 and January 2018, all patients who underwent pubic symphyseal debridement with or without cystectomy were identified. We reviewed patients who underwent planned robot-assisted cystectomy with holmium laser debridement for osteomyelitis of the pubic symphysis as a result of urinary fistula. Data on clinical presentation, perioperative outcomes, and recurrence of urinary tract fistula and symptoms were collected. Results Twelve patients underwent holmium laser debridement of the pubic symphysis during robot-assisted cystectomy for urinary fistula. Eleven patients had prior radiation treatments for prostate cancer with all having failed prior conservative management. Median operative time was 270 minutes with median length of stay of 5 days. At last follow-up, 11 (91.7%) of patients had complete resolution of their urinary fistula at median follow-up of 29 months. No patients developed osteonecrosis of the bone or complications from their urinary diversion at last follow-up. Conclusion Definitive surgical treatment with holmium laser debridement of the pubic symphysis with concomitant robot-assisted cystectomy and urinary diversion is a safe and durable approach to the complex problem of urinary fistula with pubic symphysis osteomyelitis.

Objective To evaluate the quality of web-based information on ablative therapies for prostate cancer. Methods The 2 most common search engines (Google and Bing) were queried for the following terms: “prostate cancer” + “HIFU” and “cryotherapy,” respectively. The top 50 websites for each were obtained. Websites were characterized and analyzed regarding their accuracy and completeness of information using criteria determined a priori. Academic papers were excluded. Results Of “HIFU” search results, 17% were advertisements, 13% and 29% were academic and private practice websites, respectively. Erroneous information on oncological efficacy was presented in 15% and 41% of academic and private practice websites, respectively. Criteria for treatment were mentioned in 31% and 66% of academic and private practice websites, respectively. Of “cryotherapy” search results, 18% were advertisements, 15% academic sites, and 11% private practices. Erroneous information was presented in 73% of both academic and private practice websites. Criteria for treatment were mentioned in 27% and 18% of these sites, respectively. Seventy eight percent and 75% of HIFU and cryotherapy sites, respectively, mentioned general side effects. Conclusion There is substantial inaccurate and incomplete information on the Internet regarding ablative treatments for prostate cancer from academic and private practice websites. Selection criteria are uncommonly discussed. More attention to accuracy of information is needed to ensure patients are not misled about the data behind these treatments.

OBJECTIVE To evaluate the association between SpaceOAR and radiation dosing, toxicity and quality-of-life vs no spacer across all radiotherapy modalities for prostate cancer. METHODS A systematic search of the Cochrane Central Register of Controlled Trials, MEDLINE, and Embase was performed from database inception through May 2020. Two reviewers independently screened titles/abstracts and full papers. Data extraction was performed, and quality assessed by 1 reviewer and checked by a second, using a third reviewer as required. The synthesis was narrative. RESULTS 19 studies (3,622 patients) were included (only 1 randomized controlled trial, in image-guided intensity-modulated radiotherapy (IG-IMRT), 18 comparatives non-randomized controlled trials in external-beam radiotherapy (EBRT), brachytherapy, and combinations thereof). No hypofractionation studies were found. Regardless of radiotherapy type, SpaceOAR significantly reduced rectal radiation dose (eg, V40 average difference -6.1% in high dose-rate brachytherapy plus IG-IMRT to -9.1% in IG-IMRT) and reduced gastrointestinal and genitourinary toxicities (eg, late gastrointestinal toxicity 1% vs 6% (P = .01), late genitourinary toxicity of 15% vs 32% (P < .001) in stereotactic body radiotherapy). Improvements were observed in most Expanded Prostate Cancer Index Composite quality-of-life domains (eg, bowel function score decrease at 3 and 6 months: Average change of zero vs -6.25 and -3.57 respectively in low dose-rate brachytherapy plus EBRT). CONCLUSION The randomized controlled trial in IG-IMRT demonstrated that SpaceOAR reduces rectal radiation dose and late gastrointestinal and genitourinary toxicities, with urinary, bowel, and sexual quality-of-life improvement. These advantages were verified in observational studies in various radiotherapy types. Further research is required in hypofractionation.

There is growing evidence suggesting cannabinoids may provide suitable alternatives to conventional treatments in an increasing number of clinical settings. This review evaluates how cannabinoids are used to treat certain benign urological pathologies and to clarify the clinical value of this data. This review includes 62 papers and was undertaken per PRISMA's guidelines, it evidences the therapeutic potential of cannabinoids in the management of specific benign urological diseases, most notably neurogenic bladder dysfunction (clinical studies), renal disease (animal studies), and interstitial cystitis (animal studies). However, whilst cannabinoids are increasingly used, they cannot be considered reliable alternatives to more recognised treatments.

Objective To validate the Martini staging system for postoperative rectourethral fistula (RUF) utilizing data from previous studies to determine whether it can accurately predict postoperative success rate. Methods A systematic search of peer-reviewed studies was conducted through January, 2020. The primary inclusion criteria for the studies were studies that evaluated outcomes based on the etiology of the fistula (ie, radiotherapy/ablation [RA] vs nonradiotherapy/ablation [NRA]). Martini RUF classification was utilized for the subgroup analysis. Results Out of 1948 papers, 7 studies with a total of 490 patients (251 in RA vs 239 NRA) were included in this study. Receiving RA increased the risk of permanent bowel diversion by 11.1 folds, eventual fistula recurrence by 9.1 folds, and post-op urinary incontinence (UI) by 2.6 folds. Similarly, compared to a Grade 0 fistula, a Grade I fistula increased the risk of permanent bowel diversion by 9.1 folds, fistula recurrence by 20 folds, and post-op UI by 2.7 folds. There were some valuable variables that were not captured by the Martini classification. Conclusion Overall, the Martini classification system is efficacious in stratifying post-op complications from RUF repair based on the grade and etiology; however, it is limited in application. There is an opportunity for the development of more comprehensive staging systems in this domain.

Objective To investigate the effect of kidney function on stone composition and urinary mineral excretion in patients undergoing surgical intervention for nephrolithiasis. Methods Using our institutional kidney stone database, we performed a retrospective review of stone patients who underwent surgical intervention between 2004 and 2015. Patients’ demographic information, 24-hour urinary mineral excretion, and stone characteristics were reported. The patients’ estimated glomerular filtration rates (eGFR) were compared with their stone compositions and 24-hour urine mineral excretions. Results A statistically significant difference was noted between the groups, with uric acid stones being associated with lower eGFR and calcium phosphate stones associated with higher eGFR. No relationship could be demonstrated between eGFR and calcium oxalate or struvite stones. Patients with lower eGFR also demonstrated a statistically significant association with lower urinary pH as well as lower urinary excretion of calcium and citrate. Conclusion While various factors have been found to play significant roles in kidney stone formation and composition, our findings demonstrate a definite relationship between these and renal function. This paper highlights the fact that renal function evaluation should be considered an important component in the evaluation, counseling, and management of patients with nephrolithiasis.

A broader range of decisional tools should be investigated. This paper will update the decisional outcome data and assess the features of decisional tool. Literature search strictly followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guideline. Articles that cited Lin et al and Violette et al were searched. Features of decisional tools were analyzed using the International Patient Decision Aid Standards Instrument criteria. The scores of the 31 decisional tools ranged from 6 to 15, which did not correlate proportionally with the positive decisional outcomes. Personal importance appeared to be a significant component. Multidisciplinary clinics are superior in improving decisional outcomes as they promote more at shared decision making.

Objective To study the impact of genomic testing in shared decision making for men with clinically low-risk prostate cancer (PCa). Materials and Methods Patients with clinically low-risk PCa were enrolled in a prospective, multi-institutional study of a validated 17-gene tissue-based reverse transcription polymerase chain reaction assay (Genomic Prostate Score [GPS]). In this paper we report on outcomes in the first 297 patients enrolled in the study with valid 17-gene assay results and decision-change data. The primary end points were shared decision on initial management and persistence on active surveillance (AS) at 1 year post diagnosis. AS utilization and persistence were compared with similar end points in a group of patients who did not have genomic testing (baseline cohort). Secondary end points included perceived utility of the assay and patient decisional conflict before and after testing. Results One-year results were available on 258 patients. Shift between initial recommendation and shared decision occurred in 23% of patients. Utilization of AS was higher in the GPS-tested cohort than in the untested baseline cohort (62% vs 40%). The proportion of men who selected and persisted on AS at 1 year was 55% and 34% in the GPS and baseline cohorts, respectively. Physicians reported that GPS was useful in 90% of cases. Mean decisional conflict scores declined in patients after GPS testing. Conclusion Patients who received GPS testing were more likely to select and persist on AS for initial management compared with a matched baseline group. These data indicate that GPS help guide shared decisions in clinically low-risk PCa.

Objective To review a single institution's 15-year experience with urethral foreign bodies, including evaluation, clinical findings, and treatment. Materials and Methods In total, 27 patients comprising 35 episodes of inserted urethral foreign bodies were reviewed at Cook County Hospital between 2000 and 2015. Retrospective chart review was performed to describe the clinical presentation, rationale for insertion, management, recidivism, and sequelae. Results Median patient age was 26 (range 12-60). Twenty-six patients (97 %) were male, 1 was female (3%). Items inserted included pieces of plastic forks, spoons, metal screws and aluminum, pieces of cardboard or paper, staples, writing utensils such as pens and pencils, as well as coaxial cable and spray foam sealant. Reported reasons for insertion were self-stimulation, erectile enhancement, and attention seeking. Presenting symptoms included dysuria, gross hematuria, urinary retention, urinary tract infection, and penile discharge. The most common technique for removal was manual extraction with extrinsic pressure (n = 19, 54%). Other methods include endoscopic retrieval (n = 8, 23%), open cystotomy (n = 1, 3%), and voiding to expel the foreign body (n = 7, 20%). Postremoval complications included urinary tract infection (n = 7), sepsis (n = 4), urethral false passage (n = 5), laceration (n = 5), and stricture (n = 1). Conclusion We present the largest single-institutional series of urethral foreign bodies to date. Urethral foreign body insertion is a relatively rare occurrence and, commonly, is a recurrent behavior. Urethral trauma related to foreign body insertion is associated with significant risk of infection and urethral injury with long-term sequelae.

Tkachenko А. I., Chetverikov S. G., Chaika A. M., Lysachenko V. V. Echinococcosis at urology. Pelvic parasitic cyst. Case report. Journal of Education, Health and Sport. 2019;9(3):296-300. eISNN 2391-8306. DOI http://dx.doi.org/10.5281/zenodo.2596630 http://ojs.ukw.edu.pl/index.php/johs/article/view/6707 The journal has had 7 points in Ministry of Science and Higher Education parametric evaluation. Part B item 1223 (26/01/2017). 1223 Journal of Education, Health and Sport eISSN 2391-8306 7 © The Authors 2019; This article is published with open access at Licensee Open Journal Systems of Kazimierz Wielki University in Bydgoszcz, Poland Open Access. This article is distributed under the terms of the Creative Commons Attribution Noncommercial License which permits any noncommercial use, distribution, and reproduction in any medium, provided the original author (s) and source are credited. This is an open access article licensed under the terms of the Creative Commons Attribution Non commercial license Share alike. (http://creativecommons.org/licenses/by-nc-sa/4.0/) which permits unrestricted, non commercial use, distribution and reproduction in any medium, provided the work is properly cited. The authors declare that there is no conflict of interests regarding the publication of this paper. Received: 20.02.2019. Revised: 28.02.2019. Accepted: 15.03.2019. ECHINOCOCCOSIS AT UROLOGY. PELVIC PARASITIC CYST. CASE REPORT А. I. Tkachenko, S. G. Chetverikov, A. M. Chaika, V. V. Lysachenko Reconstructive Center (University Clinic) of Odessa National Medical University, Odessa, Ukraine Abstract Introduction. Echinococcosis is a serious chronic parasitic disease. Early diagnostics and patients` treatment with echinococcal lesions is an up-to-date problem. Objective. The aim of the article is to present the clinical case of diagnostics and treatment of the patient with urological complications caused by parasitic echinococcal pelvic cyst. Clinical case. The article highlights the features of diagnostics and treatment of urological complications of pelvic echinococcal lesions. The patient was operated in volume: "Laparotomy. Resection of parasitic cyst of small pelvic cavity. Echinococcectomy of the liver, abdominal cavity, retroperitoneal space." The peculiarities of operation was highlighted. The postoperative period lasted without complications. Conclusions. The demonstrated clinical case points out the necessity of the dispanserisation, early diagnostics and special helminth treatment of the patients living in the endemic regions. It allows to prevent the appearance of the echonococcosis advanced cases that lead to the reoperations and frequent patients` disability. Keywords: echinococcosis, parasitic pelvic cyst, surgical treatment.

Objective To evaluate the histopathologic correlation of recently described subclassification of Bosniak category 3 cysts (3s and 3n). Materials and Methods A total of 106 patients who underwent partial/radical nephrectomy due to a complex renal cyst (≥Bosniak 3) were retrospectively reviewed. All the scans of the patients were reevaluated by 2 experienced uroradiologists. Bosniak 3 cysts were reclassified as 3n (nodularity on the cyst wall/septae) and 3s (septated cysts without nodularity) as described in a recently published paper. Group 1 consisted of patients with Bosniak 3s, Group 2 consisted of patients with Bosniak 3n, and Group 3 consisted of patients with Bosniak 4 cysts. Three groups were compared according to patients' characteristics, radiological findings, histopathologic results, and survival outcomes. Results There were 52 patients in Bosniak 3 group and 54 patients in Bosniak 4 group. Mean follow-up was 35.3 months. Among Bosniak 3 cysts, 37 lesions were classified in 3s and 15 were classified in 3n. Malignancy was higher in 3n group than 3s (86.7% vs 54.1%, P= .026). Lesion size was significantly lower for malignant cysts compared to benign ones in the patients with Bosniak 3 lesions (44.2 ± 27.5 vs 80 ± 55.9 P= .005). In the subgroups, malignant lesions were significantly smaller than benign lesions in 3s group similar to general Bosniak 3 group. Most of the Bosniak 3 lesions were organ confined and low grade. Conclusion The subclassification of Bosniak 3 cysts as 3s and 3n can help to differentiate highly suspicious malignant lesions from the relatively less suspicious ones.

Clinical results investigations of the Ukrainian uroflowmeter “Flow-KM” for a home urofloumetry monitoring of patients with lower urinary tract symptoms are presented in this paper. The apparatus has been developed A.E. Kvyatkovsky (2014). Thirty two patients with benign prostatic hyperplasia, prostate sclerosis, prostatitis, urethral stricture have been examined. The home urofloumetry monitoring eliminates the office stress impact during the uroflowmetry and allows to get the data as close as possible to real ones. The home monitoring is an evidence-based medicine diagnostic method of lower urinary tract urodynamics evaluation for several days and can detect hidden or circadian violations of urodynamics. Its application for the pharmacological tests conducting permits to evaluate the intensity and duration of drugs action. It helps to develop a drug therapy plan and to evaluate its effectiveness after treatment. The uroflowmeter “Flow-KM” is an accurate and reliable apparatus which permits urofloumetry monitoring.

Detrusor-external sphincter dyssynergia (DSD) is a debilitating problem in patients with spinal cord injury. DSD carries a high risk of complications, and even life expectancy can be affected. Management of this condition includes the use of antimuscarinic agents in combination with intermittent catheterization, indwelling urethral catheterization, suprapubic catheterization, and a variety of surgical options, depending on patient and physician preference. This paper will review the current literature and data on minimally invasive and endoscopic management of DSD.

The paper presents the results of the study of basic indicators of urological service for the adult population of Ukraine and the results of activities of the service during 2017 compared with the past. It is proved that the developed network, which has a high personnel potential, is stored in the country and works efficiently enough. However, there is a deterioration of health of population due to the accumulation of patients with the most common diseases ("kidney infection" chronic pyelonephritis, cystitis, urolithiasis, benign prostatic hyperplasia), increases cancer incidence (RC, prostate cancer) and prevalence of RC, RSM. Also increases the mortality level at all cancer diseases, and the reduction of indices in urolithiasis and benign prostatic hyperplasia is accompanied by high growth rates among men in the first and among the rural population with urolithiasis, benign prostatic hyperplasia, prostate cancer, malignancies of other organs and systems. Traceability of the regional variability of indicators related to the organization and the quality of provision of specialized assistance is of high socio-economic importance.

Diapevtic is a sequential transition of diagnostic stages of the development of urology into effective instrumental and therapeutic intervention. Diapevtic operating aids in urology take leading positions in many diseases, including those with urolithiasis. To date, we have experience of more than 7,500 diagastrotic operations in the last 10 years. In our clinic, the complex “Modularis Uro Pro (Simens)” Germany, complete with endoscopes and consumables from Karl Storz Richard Wolf, is used to perform diagenetic interventions. Our accumulated experience has given us the opportunity to create and develop methodological recommendations for practitioners of Ukraine, taking into account the economic situation. The paper highlights possible complications and ways to eliminate them. Our experience allows us to evaluate diabetic treatments as the main method of treating urolithiasis, and to oppose remote therapies. We have worked out indications and contraindications for the management of anesthesia in diagentative interventions. The article outlines possible complications and ways to combat them. On the basis of our clinic formed elective courses for urologists on “urological diagnostics”. The course program is designed for a cycle of 78 hours, with the issuance of a certificate. For the successful and safe operation of urologists who solve the problems of modern interventions for urolithiasis, a gradual formation of “modular operating” ones is necessary, which allow removal of stones at any level of the urinary system by a non-invasive method. In our opinion, modern surgical intervention should be carried out with the help of combined ultrasound, X-ray and endoscopic guidance.

The cardiac chamber's involvement with neoplastic embolism has been rarely reported; it is mostly associated with gastric, breast, lung, liver, and prostate cancers, and usually affects the pulmonary arteries. This paper reports a case of a 31-year-old man with a malignant testicular germ cell tumor who presented with multiple episodes of pulmonary thromboembolism and died of sudden respiratory failure 1 year after the initial diagnosis. Death was attributed to massive pulmonary embolism and pulmonary infarction associated with a neoplastic thrombus that extended from the gonadal veins to pulmonary arteries. A postmortem computerized tomographic angiography and autopsy confirmed this finding.

Primary spindle cell sarcoma of prostate is an extremely rare malignancy and very few cases of it have been reported Ozturk and Sivrikoz, 2013; Hansel and Epstein, 2006. We searched the literature through MEDLINE database using PubMed and Scopus for the articles published between January 1988 and September 2016. Our search was limited to the following keywords: "spindle cell sarcoma," "prostate," and "surgical management." Most of the papers focused on histopathology of the tumor, and very few discussed surgical management. We present a case of localized primary spindle cell sarcoma of the prostate operated at our institute with the difficulties we faced and their management.

The present paper described a rare case of ureteral IgG4-related disease (IgG4-RD) that mimicked urothelial carcinoma. An otherwise healthy patient presented with computed tomography, ureteroscopic, and biopsy findings that were suspicious of urothelial carcinoma. The patient received a right nephroureterectomy. Histopathology showed ureteral IgG4-RD, without evidence of urothelial carcinoma. Accurate diagnosis of this rare entity should be based on clinical, biochemical, and histopathological findings.

To re-assess the Charlson Comorbidity Index (CCI) and the American Society of Anesthesiologists Physical Status Classification System (ASA grade) as predictive factors of complications after transurethral resection of prostate.This study retrospectively included and analyzed consecutive patients undergoing transurethral resection of the prostate at Peking University First Hospital between 1992 and 2013. A multivariate analysis was conducted to evaluate the connection of the ASA and CCI grades with the incidence of complications.This paper studied 2326 cases in total. The CCI and ASA grades were significantly correlated, with a Spearman ρ of 0.245 (P .001). No considerable differences among the patient cohorts with different CCI or ASA grades were observed in terms of day of catheter removal, surgical time, and prostate size. In addition, no considerable differences were observed in the different modified Clavien classification system scores of complications among patient cohorts with different grades of CCI.The majority of complications (86.9%) were of grades I, II, and III, whereas grade IV was less frequent (12.1%), and, after transurethral resection of the prostate, grade V was rare (1%). Males with an ASA grade ≥3 and higher CCI scores were more likely to demonstrate a higher incidence of morbidity than males with a lower grade. However, ASA grades and CCI scores were not independent predictors of complications because of the experience of the surgeon and progress in perioperative management and operative techniques. Therefore, for patients with more comorbidities and higher CCI scores or ASA grades, active surgical intervention is still suggested.

Objective To review established genetic causes of azoospermia, the most severe form of male infertility, and help clinicians, scientists, and infertile couples considering assisted reproductive technologies (ART) to understand the complexity of the disorder and to maximize the chances of having a healthy infant through proper counseling and treatment. Method An initial literature search was performed on PubMed using the key words “azoospermia” “oligospermia,” and “genetics.” The results were limited to the studies on humans and written in English, which were written within last 10 years. Although preliminary query results showed more than 900 articles, further queries using key words, such as “Y chromosome,” “monogenics,” “aneuploidy,” “mitochondrial DNA,” and “epigenetics,” along with “azoospermia,” narrowed the results to 30 papers, which were included in the present study. Results Genetic defects causing azoospermia were categorized into two large categories: chromosomal and nonchromosomal. Chromosomal defects were further categorized into (1) structural abnormalities, such as Y chromosome micro/macrodeletions, chromosomal inversions, and translocations; and (2) numerical abnormalities, also known as aneuploidy . Nonchromosomal defects included sperm mitochondrial genome defects and epigenetic alterations of genome. Conclusions As a result of advancements in ART, understanding the potential implications of genetic disorders for infertile couples is critical. Analysis of a potential genetic role in azoospermia holds promise to expand our knowledge to evaluate male infertility and to guide treatments.

ObjectivesThe functions of the lower urinary tract (LUT) to store and periodically release urine are dependent on neural circuits in the brain and spinal cord. This paper reviews the central neural control of micturition and how disruption of this control can lead to bladder overactivity and incontinence. MethodsNeuroanatomic, electrophysiologic, and pharmacologic techniques have provided information about the neural circuitry and the neurotransmitters involved in the central nervous control of voiding. Experimental models of neural injury, including spinal cord transection, cerebral infarction, and localized brain lesions, have been studied to identify the mechanisms contributing to the neurogenic overactive bladder. Results.Normal storage of urine is dependent on 1) spinal reflex mechanisms that activate sympathetic and somatic pathways to the urethral outlet and 2) tonic inhibitory systems in the brain that suppress the parasympathetic excitatory outflow to the urinary bladder. Voiding is mediated by inhibition of sympatheticsomatic pathways and activation of a spinobulbospinal parasympathetic reflex pathway passing through a micturition center in the rostra1 pons. Damage to the brain can induce bladder overactivity by reducing suprapontine inhibition. Damage to axonal pathways in the spinal cord leads to the emergence of primitive spinal bladder reflexes triggered by C-fiber bladder afferent neurons. The C-fiber afferent neurotoxin capsaicin, administered intravesically, has been useful in treating certain types of neurogenic bladder overactivity. ConclusionsThe central nervous mechanisms controlling the LUT are organized in the brain and spinal cord as simple on-off switching circuits that are under voluntary control. Damage to central inhibitory pathways or sensitization of peripheral afferent terminals in the bladder can unmask primitive voiding reflexes that trigger bladder overactivity.

Chronic kidney disease (CKD) is common. According to several analyses of the National Health and Nutrition Examination Surveys (NHANES), as much as 13% of the non-institutionalized US adult population belongs to CKD stages 1 to 4. This includes 3.2% with stage 2 (GFR 60–89 mL/min/1.73m2) and 7.7% with stage 3 (GFR 30–59 ml/min/1.73 m2) (1). This high prevalence of renal impairment affects the analysis of blood biomarkers that are cleared by renal elimination. The low molecular mass of free PSA (fPSA) is compatible with clearance by glomerular filtration; this has been confirmed in several investigations. The half-life of fPSA after successful renal transplantation is 17 h, similar to that of creatinine (23 h) (2). Patients with terminal renal failure show significantly increased levels of fPSA and %fPSA (3,4). Percent fPSA was 39.5% in hemodialysis patients and 39.6% in patients on continuous ambulatory peritoneal dialysis, compared to 28.1% in controls (4). Among 101 patients with moderate renal failure with median GFR of 23 mL/min/1.73m2 (range 8–83 mL/min/1.73m2), Bruun et al showed a significantly higher level and percentage of fPSA, 0.45 μg/L and 47.2%, respectively, compared to controls, 0.29 μg/L and 29.9%, respectively (5). The strength of their study was the use of iohexol clearance, a gold standard for measurement of GFR. The current paper {URL-D-09-00510} takes another approach. The authors used a large group (n=3782) from NHANES, which is a well-established cohort with a representative population. The participation rate was high. The authors used estimated GFR (eGFR) from the 6-variable MDRD formula; this approach is less accurate than iohexol clearance but was the only possible way to define GFR in this large cohort. Among 382 men with eGFR 15–59 mL/min/1.73m2, fPSA and %fPSA were significantly elevated, and values were also higher in those with eGFR 60–89 mL/min/1.73m2. The strength of this study is the large sample size that ensures representative material. Both the current report, and a recently published study by Bruun et al, shows that fPSA and percent fPSA are importantly influenced by moderately impaired renal function in men with chronic kidney disease. Interestingly, both demonstrate that fPSA is also affected by slight renal impairment (GFR 60–89 mL/min/1.73m2). As noted above, slight and moderate renal impairment are highly prevalent in the general population, and they are even more frequent among elderly men. This means that a significant number of men may have reduced elimination of fPSA, which has implications for the use of %fPSA to discriminate prostate cancer from benign prostate hyperplasia. Use of the current clinical decision limits for percent fPSA could cause some men with decreased GFR and prostate cancer to be misdiagnosed as having benign disease. Therefore, one alternative could be to not use fPSA to diagnose prostate cancer in these patients. This new knowledge also does, however, create the possibility for strengthening %fPSA in the diagnosis of prostate cancer, especially for screening purposes. The present clinical decision limits were developed without this knowledge. Contingent of a proper accounting for the GFR, %fPSA may therefore have an even greater potential for differentiating prostate cancer from benign prostate hyperplasia.

Objectives Bladder cancer invokes the highest cost per patient from diagnosis to death and is the fifth most expensive cancer to treat overall, exceeding $3.4 billion annually. Current surveillance regimens require intense follow-up contributing to high cost and emotional burden. Bladder tumor markers hold the promise to reduce these costs, yet have not been widely adopted in oncological practice. We assessed the cost-effectiveness of bladder tumor markers in surveillance routines. Methods A MEDLINE search of all available literature concerning bladder tumor markers and cost-effectiveness was performed. We reviewed retrospective and prospective studies, reviews, opinion papers, decision analyses, and cost-effectiveness analyses. Results Bladder tumor markers exist in various stages of development and efficacy. Sensitivity and specificity values have been reported across a wide range, with tumor markers generally possessing a higher sensitivity and lower specificity than urine cytology. Several cost-effectiveness analyses have shown tumor markers significantly lower the cost of bladder cancer surveillance when using a modified regimen that lengthens intervals between cystoscopies. However, many of the studies rely on overconfident sensitivity and specificity estimates and do not incorporate data specific to recurrent bladder cancer. No comprehensive study incorporating utility analysis has been performed. Conclusions Bladder tumor markers cannot definitively replace cystoscopy in surveillance regimens given the current evidence. Recent reports suggest potential for tumor markers to control the financial and emotional cost of bladder cancer care and improve quality of life. Until prospective analyses incorporating quality of life outcomes are performed, wider adoption of bladder tumor markers will be hampered.

"Paper and pencil" sexual inventories are widely used by the pharmaceutical industry for categorizing the severity of erectile dysfunction (ED) and for efficacy end points of drug therapy. The International Index of Erectile Function (IIEF) evaluates several domains of male sexual behavior: erection, orgasm, desire, and satisfaction. We compared the subjective IIEF score for erectile function with the severity and etiology of ED as determined by pharmacologic testing with prostaglandin E1 (PGE1) and color duplex Doppler ultrasound testing (penile blood flow study [PBFS]).Five questions from the IIEF that require the patient to quantify his erectile performance were compared with PBFS data. Examiners were unaware of IIEF scores during testing. PBFSs were performed after PGE1 injection, privacy, and self-stimulation; dosing was 6 microg (50 to 59 years) or 10 microg (60 years or older). PBFS diagnoses were arterial insufficiency (AI) for peak systolic velocity (PSV) less than 25 cm/s; cavernous venous occlusive disease (CVOD) for PSV greater than 35 cm/s and resistive index (RI) less than 0.9; and mixed vascular erectile dysfunction for a PSV from 25 to 35 cm/s and RI less than 0.9. A normal vascular diagnosis required a PSV greater than 35 cm/s and an RI of 0.9 or greater. Visual ratings of the erectile responses without Doppler assessment (inadequate, adequate, or excellent) were also compared with the IIEF and Viagra Study Group criteria (Q3+4).Eighty-nine patients underwent the complete evaluation. Eight patients (9%) were found to be normal vascularly (mean PSV 40.9 cm/s, mean RI 0.99). Thirty-four patients (38%) had AI (mean PSV 17.5, mean RI 0.74), 33 patients (37%) had mixed vascular ED (mean PSV 29.1, mean RI 0.80), and 14 patients (16%) had CVOD (mean PSV 45.9, mean RI 0.73). The mean IIEF score for the normal responders was 13.3; patients with AI, mixed vascular ED, and CVOD had mean IIEF scores of 6.9, 8.5, and 8.1, respectively. IIEF and Q3+4 values differed significantly between the normal and abnormal groups (P0.05 and P0.025, respectively), but no statistically significant differences in IIEF or Q3+4 scores were noted among the subgroups of abnormal responders. Analysis of the visual ratings of erections demonstrated that IIEF scores were significantly different between inadequate and excellent responders (P0.05).IIEF scores did not statistically differentiate among the specific etiologies of ED as determined by evidence-based testing with PBFS. Furthermore, patients with normal results after testing with PGE1 (10 microg or less) had surprisingly low self-ratings of erectile performance (13 of 25 points). For the primary caregiver, the IIEF may help in the taking of the male sexual history, but for the specialist, sexual inventory scores will not distinguish among the various etiologies of vascular ED and do not predict the results of pharmacologic testing.

The aim of this paper is to describe a simple, fast, and effective method for repair of difficult vesicovaginal fistulae by means of a free bladder mucosal graft. Six patients with high, large, multiple, or recurrent vesicovaginal fistulae were treated using a free bladder mucosal graft. Three patients underwent "early" repair (less than 3 months from time of injury) and 3 "late" repair (more than 6 months from time of injury). Via a suprapubic cystotomy, the mucosa of the fistulous tract was debrided without any attempt to excise the tract or close the bladder or vaginal defects. A free bladder mucosal graft was harvested from an unaffected portion of the bladder and placed over the fistulous tract, and mucosal approximation was made using interrupted 5-0 chromic stay sutures. The donor urothelial defect was allowed to re-epithelialize. A Foley catheter, suprapubic tube, and vaginal packing were left in place. Five patients noted an immediate result, with no evidence of leakage, and the suprapubic tube was removed by week 3. One patient required prolonged catheter drainage, and the tube was successfully removed by week 6. This patient had undergone irradiation. All patients remain dry at follow-up, which ranges from 2 to 6 years. We describe a simple and effective method for transabdominal vesicovaginal fistula repair, involving minimal mobilization, decreased dissection, and no need for rotational or interposition flaps, obviating the need to open the peritoneum. A free bladder mucosal graft can be used regardless of the individual anatomy or proximity to the ureteral orifices, because it can easily be tailored. This technique represents an important repair of difficult, recurrent, or multiple vesicovaginal fistulae.

Superficial transitional cell carcinoma of the urinary bladder usually can be well handled by transurethral resection or by fulguration. Because of the high rate of recurrence of these tumors, their multifocal presentation, and the progression in some patients to invasive and metastatic disease, urologists have long sought a therapeutic modality that would be effective with low toxicity. The intravesical instillation of chemotherapeutic agents was first introduced in 1948 by Semple' when he used Podophyllin. The purpose of this paper will be to update the reader .on intravesical agents being used both as therapy to ablate superficial bladder cancer remaining in the bladder after surgery, and as prophylaxis to prolong the disease-free status of these patients whose bladders have been rendered tumor free.