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INTRODUCTION: We aimed to assess rates of depression in patients with bladder cancer undergoing radical cystectomy and identify its predictors. METHODS: Depressive symptoms in 42 consecutive patients were evaluated using the Beck's Depression Inventory (BDI) on the day prior to surgery, postoperative day (POD) 6, six weeks after surgery, and 12-18 months postoperatively. RESULTS: Fifteen patients (36%) presented with BDI scores =10 before the operation; this rate increased to 64% on POD 6 and 69% at six weeks post-surgery. Depression score rose from a preoperative median of seven to 11 on POD 6 (p=0.003) and to 15 at six weeks after surgery (p=0.001). Patients who arrived with a BDI score of <10 had a higher increase in the BDI at six weeks compared to patients with depressive symptoms prior to surgery (average increase of 9.8 vs. 0.8, p<0.01). Age, gender, type of diversion, and complications were not associated with depression at presentation or progression of depression. Patients who did not receive neoadjuvant chemotherapy tended to be at increased risk for depression progression (57.1% vs. 14.3%, p=0.093). Twenty-four patients completed a fourth questionnaire 12-18 months postoperatively. The median BDI score was eight; three patients with disease recurrence had a higher increase in the BDI score (average 12.7 vs. -5.2, p<0.01). CONCLUSIONS: Depression among patients facing cystectomy is high, and postoperative progression is substantial. Patients without depressive symptoms preoperatively are at increased risk of developing postoperative depression. After 12-18 months, the most influential risk factor for depression is recurrence. These findings highlight the need to consider interventions in selected patients. [ABSTRACT FROM AUTHOR]

Introduction The aim of the study is to review the continence and volitional voiding rate in a single center cohort of exstrophy–epispadias patients following Young-Dees-Leadbetter bladder neck reconstruction and to explore factors which predict continence. Materials and Methods Children who underwent Young-Dees-Leadbetter bladder neck reconstruction as a final stage of repair in a large single low-volume center in a small-population country between 1997 and 2019 were included. Demographic and clinical details were extracted from the patients' charts. The primary end point was continence and volitional voiding. Patients were categorized as incontinent, socially continent (daytime dry intervals > 3 hours, wet nights) and fully continent (daytime dry intervals > 3 hours, dry nights). Results The study cohort included 27 patients whose median age at reconstruction was 5 years, and median follow-up was 7.8 years (interquartile range [IQR] 6–11.2). The cohort included 24 classic exstrophy patients (89%, 17 males and 7 females) and 3 isolated complete epispadias patients (11%, 1 male and 2 females). Nine (33%) patients achieved full continence and social continence was achieved by nine (33%) patients, for an overall social continence rate of 67%. Preoperative bladder capacity of 110 mL or more was associated with achieving social continence (odds ratio = 6.4, p = 0.047). The overall volitional voiding rate was 67%. Conclusion Young-Dees-Leadbetter bladder neck reconstruction yielded rates of 33% for full continence and 67% for social continence and volitional voiding. These rates are comparable to those of large high-volume centers. A preoperative capacity of 110 mL or more was the sole predictor of social continence. [ABSTRACT FROM AUTHOR]

Introduction: The association between blood markers and testicular viability after testicular torsion (TT) is not well known. We evaluated the role of complete blood count markers and C-reactive protein (CRP) in predicting testicular viability after TT. Methods: Fifty men, ≥18 years of age, operated for TT between the years 2015–2020 were enrolled. Blood markers including neutrophil-, lymphocyte-, and platelet count, and CRP were obtained. Neutrophil-lymphocyte ratio (NLR) and platelet-lymphocyte ratio (PLR) were calculated. The study outcome was testicular salvage. Results: Median age was 23 years (interquartile range [IQR]: 21, 31). Median duration of torsion was 10 h (IQR: 6, 42). Sonographic texture of the testis was homogenous in 27 (56%) patients and heterogenous in 21 (44%). During scrotal exploration, 36 patients (72%) underwent orchiopexy and 14 (28%) underwent orchiectomy. Patients who underwent orchiopexy were younger (22 years vs. 31 years, p = 0.009), had a shorter duration of torsion (median 8 h vs. 48 h, p < 0.001), and a homogenous texture on scrotal ultrasound (76.5 vs. 7.1%, p < 0.001). Median NLR, PLR, and CRP were higher among patients who underwent orchiectomy; however, these differences did not reach statistical significance. Patients with heterogenous echotexture were significantly more likely to undergo orchiectomy (odds ratio = 42, 95% confidence interval: 7, 831, adjusted p value = 0.009). Conclusions: We found no association between blood-based biomarkers and testicular viability after TT; however, testicular echotexture significantly predicted outcome. [ABSTRACT FROM AUTHOR]

We aimed to validate a formula for improving the estimation of prostatic volume by abdominal ultrasound (AUS) prior to transurethral laser enucleation. A total of 293 patients treated for benign prostate hyperplasia (BPH) by laser enucleation from 2019–2022 were included. The preoperative AUS volume was adjusted by the formula 1.082 × Age + 0.523 × AUS − 53.845, which was based on specimens retrieved by suprapubic prostatectomy. The results were compared to the weight of the tissue removed by laser enucleation as determined by the intraclass correlation coefficient test (ICC). The potential impact of preoperative planning on operating time was calculated. The ICC between the adjusted volumes and the enucleated tissue weights was 0.86 (p < 0.001). The adjusted volume was more accurate than the AUS volume (weight-to-volume ratio of 0.84 vs. 0.7, p < 0.001) and even more precise for prostates weighing >80 g. The median operating time was 90 min. The adjusted volume estimation resulted in an overall shorter expected preoperative operating time by a median of 21 min (24%) and by a median of 40 min in prostates weighing >80 g. The adjustment formula accurately predicts prostate volume before laser enucleation procedures and may significantly improve preoperative planning, the matching of a surgeon's level of expertise, and the management of patients' expectations. [ABSTRACT FROM AUTHOR]

Introduction: Extrusion of transvaginal mesh into the urethra is a rare but potentially serious complication. Our objective is to evaluate the efficacy and long‐term outcomes of women who underwent an endoscopic laser procedure to treat intraurethral mesh. Materials and Methods: A retrospective chart review identified women who underwent an endoscopic Holmium:YAG laser procedure to treat intraurethral mesh between September 2011‐October 2021. Information about the procedure, symptoms, and level of incontinence was gathered from the medical records. Primary outcomes were the need for further procedures, and the Urinary Distress Index‐6 score at last follow‐up. Results: We identified a total of 29 women; mesh sling procedure included tension‐free vaginal sling (19), transobturator sling (6), or other transvaginal mesh sling (4). Presentation of intraurethral mesh was a median of 6 (interquartile range [IQR]: 1–7) years after placement. After the endoscopic procedure, 18/29 (62%) women had no visible urinary mesh and complete resolution of their presenting symptoms. Retreatment was necessary in 3/29 women, and 6/29 (21%) reported new or worsening stress incontinence. The UDI‐6 was completed by all patients at a median of 3.7 (IQR: 2.0–5.8) years after their endoscopic procedure. The median score was 22 (IQR: 11–44), and 18/29 (62%) women had scores in the asymptomatic range. UDI‐6 scores were similar for the six women who had further mesh procedures and the ones who did not. Conclusions: Endoscopic laser treatment of an eroded transvaginal mesh sling is an acceptable treatment with minimal morbidity and satisfactory UDI‐6 scores after a median follow‐up of 3.7 years. [ABSTRACT FROM AUTHOR]

Introduction: Current guidelines don't support the use of pretreatment imaging in patients with favorable intermediate-risk prostate cancer. 68Ga-prostate-specific membrane antigen positron emission tomography/computed tomography (PSMA PET/CT) is more accurate than conventional imaging for preoperative staging. We aimed to evaluate whether pretreatment 68Ga-PSMA PET/CT is beneficial for identifying pathological lymph node involvement (LNI) and adverse pathology among patients with favorable intermediate-risk prostate cancer. Methods: We reviewed 88 patients with favorable intermediate-risk prostate cancer who underwent 68Ga-PSMA PET/CT prior to radical prostatectomy and lymph node dissection from 2016-2020. The primary endpoint was the presence of pathological LNI. Association between pretreatment characteristics and outcomes were evaluated. Results: Preoperative 68Ga-PSMA PET/CT showed suspicious uptake in lymph nodes in 4/88 patients (5%), hence, 20 patients would need to be scanned to identify a patient with a positive lymph node on imaging. Two patients had pathological LNI, only one of whom showed 68Ga-PSMA PET/CT uptake prior to surgery. The sensitivity, specificity, positive predictive value, and negative predictive values of 68Ga-PSMA PET/CT for identifying LNI were 50%, 97%, 25%, and 99%, respectively. After surgery, four patients had evidence of prostate-specific antigen (PSA) persistence. The rate of PSA persistence was higher among patients with LNI on preoperative 68Ga-PSMA PET/CT (2/4, 50% vs. 2/84, 2%, p=0.009). Conclusions: Preoperative imaging of favorable intermediate-risk prostate cancer patients using 68Ga-PSMA PET/CT showed a low yield for identifying patients at higher risk. Consistent with current guidelines, our findings do not support the routine use of PET/CT in this group of patients. Future prospective studies are needed to validate our findings. [ABSTRACT FROM AUTHOR]

Introduction: We aimed to analyze patterns of referral, yield, and clinical implications of noncontrast computed tomography (NCCT) in the acute evaluation of flank pain suspected as obstructive urolithiasis (OU) in a high-volume emergency department (ED). Methods: The study comprised 506 consecutive NCCTs performed in the ED over four months. Detection rates of OU, incidental, and alternative findings were calculated. Imaging signs suspicious for recent passage of stones were considered positive for OU, while renal stones without signs of obstruction were considered unrelated to the acute presentation. OU, other findings requiring hospitalization, and incidental findings warranting further workup were considered situations in which NCCTs were warranted. Results: NCCTs confirmed an OU diagnosis in 162 (32%) patients and non-clinically significant nephrolithiasis in 125 (25%). They revealed other findings in 108 (21%) patients, including 42 (8%) with clinically significant incidental findings and 26 (5%) with alternative diagnoses requiring hospitalization. NCCTs were entirely negative in 111 (22%) patients. Corroboration of these outcomes, together with overlapping of OU, incidental, and alternative significant findings in some patients resulted in an overall justified NCCT request rate of 44%. Conclusions: The yield of NCCT performed in acute presentations of flank pain suspected as OU is relatively low, and over one-half of the scans are unwarranted. The pattern of requesting NCCT in the ED needs refinement to avoid abuse that may lead to radiation overexposure, psychological burden, physical harm, and financial overload. [ABSTRACT FROM AUTHOR]

Background: Patients hospitalized due to gross hematuria frequently complete evaluation in the outpatient setting. The use of office flexible cystoscopy during hospitalization may lead to prompt diagnosis and treatment but can be limited due to low visualization and artifacts that can hamper diagnostic ability. Objective: The objective of this study was to assess flexible cystoscopy findings and yield performed in patients hospitalized due to gross hematuria. Methods: Medical records of patients who underwent flexible cystoscopy while hospitalized during September 2018–December 2019 were reviewed. Cystoscopic findings were categorized into (1) suspicious mass in the bladder or prostate, (2) nonsuspicious changes in the bladder, and (3) nondiagnostic exam. Descriptive statistics were used to report the clinical characteristics of the study cohort and the findings of cystoscopy. Univariate logistic regression analyses were used to identify predictors of malignant findings. Results: The study cohort consisted of 69 patients (median age of 76 years). Initial cystoscopy findings were suspicious for malignancy in 26/69 patients (38%), nonsuspicious for malignancy in 34/69 patients (49%), and nondiagnostic in 9/69 patients (13%). The median follow-up time was 9 months (range 4–14 months). Twenty patients (29%) were diagnosed with malignancy (sensitivity of 75% and specificity of 78%). The procedure led to either diagnosis or treatment of 39 patients (57%). However, in 30 patients (43%), the initial cystoscopy did not aid in the diagnosis, led to misdiagnoses, or required a follow-up cystoscopy. On univariate analyses, none of the precystoscopy variables were predictive of bladder malignancy. Conclusion: Flexible cystoscopy in the setting of acute hematuria requiring hospitalization did not lead to diagnosis or treatment in over 40% of cases. In this setting, consideration should be given to performing an upfront cystoscopy under anesthesia. [ABSTRACT FROM AUTHOR]

Objective: To investigate the prevalence of testicular microlithiasis and its association with sperm retrieval rates and histopathology in men with non‐obstructive azoospermia. Methods: A total of 120 men underwent scrotal ultrasonography prior to microsurgical testicular sperm extraction. Sperm retrieval rate, testicular histopathology, testicular size, reproductive hormones, karyotyping, Y chromosome microdeletion analyses, and presence of varicoceles and hydroceles were compared between men with and without testicular microlithiasis. Results: The total sperm retrieval rate was 40%. Ten men with normal spermatogenesis were excluded. The remaining 110 men with non‐obstructive azoospermia were analyzed and testicular microlithiasis was detected in 16 of them (14.5%). The sperm retrieval rate in that subgroup was only 6.2% (1/16) as opposed to 39.4% (37/94) in men with non‐obstructive azoospermia and no evidence of microlithiasis (P = 0.009). The mean right and left testicular diameters were significantly lower in the microlithiasis group (P = 0.04). On multivariate logistic regression analysis, the presence of mictolithiasis (odds ratio 7.4, 95% confidence interval 2.3, 12.2; P = 0.01) was the only independent predictor of unsuccessful sperm retrieval. The 15 patients with microlithiasis and without successful sperm extraction were diagnosed by histopathology as having Sertoli cells only. The 16th patient with successful sperm retrieval had a histopathology of mixed atrophy and was diagnosed with Klinefelter syndrome. Conclusion: The presence of testicular microlithiasis is associated with low sperm retrieval rates among our cohort of men with non‐obstructive azoospermia undergoing scrotal ultrasonography prior to microsurgical testicular sperm extraction. Larger, prospective studies should be conducted to confirm these findings. [ABSTRACT FROM AUTHOR]

The article presents a study on the outcomes of male patients with elevated postvoid residuals (PVR) and mild or no lower urinary tract symptoms who underwent transurethral prostatectomy (TURP). Topics discussed include the characterization of non-neurogenic chronic urinary retention, the methods used in the study, and improvement in PVRs after TURP in men with mild urinary symptoms and elevated PVRs.

Background: Data on who among the infertile male population may benefit from round spermatid injections (ROSI) are lacking. Objective: To determine the probability of finding round spermatids suitable for ROSI in men with non‐obstructive azoospermia (NOA) in whom no spermatozoa were retrieved at testicular sperm extraction. Materials and methods: Four‐hundred fifty‐seven consecutive men with azoospermia underwent testicular sperm extraction. Clinical examination included age, secondary sexual characteristics, testicular size, reproductive hormone estimation, karyotyping, and Y chromosome microdeletion analyses. Histologic examination was performed, and histologic classification was determined by the most advanced spermatogenetic cell identified in the combined histologic and cytologic examination. Results: Of the 457 azoospermic men, 342 were diagnosed with NOA, and 148 (148/342, 43%) had mixed atrophy on histopathology and retrievable spermatozoa. No spermatozoa were found in 194/342 men with NOA (57%). Histopathology diagnosed 145/194 (75%) of them with Sertoli cell only, 45/194 (23%) with spermatocyte maturation arrest, and 4/194 (2%) with spermatid maturation arrest. Conclusions: Histopathologically identified round spermatids without spermatozoa were rare in men with NOA. Only very few of them are likely to reap the benefits of ROSI, thus presenting the need to reconsider its actual clinical value. [ABSTRACT FROM AUTHOR]

Objective: Nephrostomy tubes (NTs) inserted in emergency settings by interventional radiologists are frequently unsuitable for subsequent percutaneous nephrolithotomy (PCNL). We report a novel method of adjusting these NTs to be used as PCNL tracts and avoid renal repuncture. Patients and Methods: A retrospective search of 981 consecutive PCNLs performed in our institution between 2002 and 2017 identified all patients with preoperatively inserted NTs. The NTs unsuitable for PCNL were adjusted by a novel approach in which a 5-mm incision was made at the ideal puncture location (IPL) as indicated under fluoroscopic guidance. The preinserted NT was removed after passing a guidewire into the kidney. A dissector clamp was introduced through the entry wound of the removed NTs to bluntly dissect a retroperitoneal tunnel and pull out the distal tip of guidewire through the IPL, while its proximal segment was maintained in the kidney. The newly positioned guidewire was used for PCNL tract preparation without repuncturing the kidney. Results: The NTs were located in the mid calix, lower calix, and renal pelvis in 6 (26%), 13 (57%), and 4 (17%) cases, respectively. The NT was suitable for PCNL in 5 (22%) cases, a new renal access was performed in 3 (13%), and the novel adjustment approach was used in 15 (65%), all successfully. The place of entry was moved an average of 6 cm (range 47) and the angle between the tract axis and the calix axis was reduced by 65° in average. The procedure was done uneventfully in an average of 4 minutes. Conclusions: The novel method of adjusting preoperatively inserted NTs for PCNL by repositioning their original entry location to the IPL offers the possibility of avoiding kidney repuncture. It is feasible, safe, and easy to implement, and it spares potential morbidity related to additional puncturing of the kidney. [ABSTRACT FROM AUTHOR]

Aim: To assess the precision of preoperative ultrasonography (US)-determined prostate volume and to propose formulas for improving it. Methods: This retrospective study comprised 155 consecutive men who underwent open prostatectomy for benign prostatic hyperplasia (BPH) between 2013 and 2019. Preoperative prostate volume was estimated by either abdominal US (AUS) (n = 92) or transrectal US (TRUS) (n = 63), and was compared with the weight of surgically enucleated tissue at a conversion rate of 1 ml (US) = 1 g tissue. Statistical analysis was conducted and a novel formula for prostate volume was constructed. Results: The median prostate volumes by AUS and TRUS were 140 ml [interquartile ratio (IQR) 111–182] and 108 ml (IQR 93–120), respectively. Enucleated tissue weight was lower than the AUS assessment by a median difference of 50 g (IQR 28.7–75.7; p < 0.001), and lower than the TRUS assessment by a median difference of 27 g, IQR 10–43, p < 0.001). Using a cutoff of 80 ml, 30 (33%) AUS patients and 23 (36%) TRUS patients underwent unneeded open procedures. Mathematical calculations revealed two formulas that significantly adjusted for the actual weight: 1.082*Age + 0.523*AUS − 53.845 for AUS and 0.138*age + 2.22*prostate-specific antigen + 0.453*TRUS + 11.682 for TRUS (p < 0.001). These formulas increased the overall US prostate volume accuracy from 65% to 85%. Conclusion: Assessment of prostate volume by US is imprecise for decision-making of whether to perform open simple prostatectomy for BPH. Our novel formulas may enhance stratification of patients with prostatic enlargement to a more optimal surgical approach. Future studies in larger cohorts are needed to substantiate our results. [ABSTRACT FROM AUTHOR]

Introduction: To assess long-term outcomes of double internal stents (DIS) for the relief of external malignant ureteral obstruction (MUO). Materials and Methods: DIS (7F each; 12-month indwelling time) were inserted under general anesthesia in 62 consecutive patients (75 renal units) with MUO during 2007–2018. Surveillance was performed every 3 months, and stents were exchanged routinely every year. The need for permanent stent retrieval was considered stent failure. Maintenance of stent patency and disease-specific survival (DSS) were estimated (Kaplan–Meier). Risk factors were also assessed (univariate and multivariable Cox regression analyses). Results: The median follow-up was 27 months (interquartile range [IQR] 20–27). The most frequent tumors causing obstruction were colorectal and ovarian cancers. Six patients (10%) had stent failure caused by sepsis, creatinine elevation, or hematuria. The average time to failure was 15 months (range 1–27). A history of radiation and an estimated glomerular filtration rate (eGFR) ≤45 mL/(min/1.73 m2) were associated with stent failure (p = 0.038 and p = 0.001, respectively). Thirty-nine patients died with a median DSS of 21 months (IQR 8.6-not reached). Multivariate analysis identified eGFR ≤60 mL/(min/1.73 m2) (hazard ratio [HR] 2.1, 95% confidence interval [CI] 1.1–4.2, p = 0.02) and need for balloon dilation (HR 2.1, 95% CI 1.1–4.1, p = 0.02) as independent predictors for disease-related mortality. Twenty-six patients (42%) had stent-related complications, for example, irritative symptoms, hematuria, and infections, of whom only two failed. Conclusions: One-year indwelling DIS provide effective long-term relief of MUO and represent a simple and effective alternative to other methods of urinary diversion. They avoid the need for external tubes and contribute to improved patient satisfaction. [ABSTRACT FROM AUTHOR]

Objective: To evaluate the success rates of a simple posthypospadias urethrocutaneous fistula repair.Study Design: We evaluated children who underwent urethrocutaneous fistula closure by means of a simple standard technique in which the fistula tract was dissected to its base and resected and the urethral defect closed with a single layer of continuous sutures and covered with local subcutaneous tissue. No urethral stents or catheters were used, and the patients were discharged on the same day. Excluded were children who underwent fistula repair by a different technique, revision hypospadias repair for fistula, or concomitant meatoplasty for meatal stenosis. Study endpoints were fistula recurrence and the need for further penile surgery other than fistula repair.Results: Seventy-two children underwent 81 repairs. The mean follow-up was 7.9 years. Recurrence occurred in 17 cases (21%). Seven children (9%) underwent penile surgery other than fistula repair, including meatoplasty (n = 5) and re-do hypospadias repair for a diagnosis other than fistula recurrence (n = 2). There was no significant difference in recurrence rate between large and small fistulas, coronal or more proximal fistulas, or children w/wo prior fistula repairs.Conclusion: Standard fistula closure solely by adjacent tissues yielded success rates of 79% after long-term follow-up. This repair can be safely offered with the expectation of similar results for a variety of urethrocutaneous fistulas in children. [ABSTRACT FROM AUTHOR]

Introduction Assessment of urothelial bladder cancer during cystoscopy or transurethral resection of bladder tumour has a significant impact on the urologist's decision-making: treatment with simple outpatient fulguration, required depth of resection, and need of immediate post-surgical intravesical therapy. These choices depend heavily on the urologist's ability to accurately assess pre-biopsy tumour stage and grade. The aim of the study was to determine whether evaluation of photographs taken during transurethral resection of bladder tumour can reliably characterize a tumour's stage and grade. Methods Smartphone photographs of 50 urothelial bladder cancer cases were taken at the beginning of transurethral resection of bladder tumour and individually presented to seven senior urologists. All urologists were blinded to the final pathological report and to any other urological evaluation. Each one was asked to rate the tumour as low vs high grade and noninvasive Ta vs noninvasive T1 or muscle invasive. Results were compared with final pathology. Individual appraisal and the majority's opinion were evaluated. Results Urologists have correctly predicted tumour stage and grade in 63.5% of cases (222 of 350, average of 32 out of 50 accurate assessments). The final majority assessment was correct in 40 of 50 cases (80%). Sensitivity and specificity of the final results for the diagnosis of T1 or higher were 80% and 88.6%, respectively. Sensitivity and specificity for Ta low grade were 83.3% and 80%, respectively. Conclusions To the best of our knowledge, this is the first documented attempt to evaluate urologists' ability to assess urothelial bladder cancer stage and grade using endoscopic photographs. Urologists can usually identify stage and grade of urothelial bladder cancer but accuracy increases when multiple senior urologists examine the same photographs and achieve majority consensus. Presenting photographs of urothelial bladder cancer to a team of urologists may lead to an excellent decision regarding type and extent of surgical treatment and substantiate appropriate post-surgical management. [ABSTRACT FROM AUTHOR]

Introduction: We set out to investigate whether general anesthesia with low ventilation (LV, respiratory rate ≤8/minute and tidal volume <500 mL) could reduce renal mobility and thereby facilitate improved retrograde intrarenal surgery (RIRS) compared with general anesthesia with standard ventilation (SV). Materials and Methods: All 60 consecutive patients who presented for RIRS in our department from September 1, 2017 to December 31, 2017 were prospectively randomized 1:1 into one group that was selected to receive SV and another that received LV. Significant factors influencing the study endpoints considered fragmentation rate (FR), removal rate (RR), processing rate (PR), and operating rate (OR), were statistically analyzed for the whole group as well as for comparison by level of surgeon expertise. Results: Univariate analysis revealed that LV was a significant factor in improving all endpoints. Some endpoints were also affected by the stone's volume, number, and density as well as the surgeon expertise. LV remained the single independent factor for FR, RR, and PR in the multivariate analysis. LV significantly improved all four of the fellows' endpoints (p < 0.05 for each) and positively influenced the expert's RR (p = 0.04), PR (p = 0.02) and OR (p = 0.04). The performance gap between the fellows and the experts narrowed under LV. The end-tidal CO2 was significantly higher in the LV group (50 vs 36 mm Hg; p < 0.0001), however, without any clinical significance. The overall stone-free rate (97%) and complication rate (5%) were not significantly different between the two groups. The patient's anesthesia-related safety was not affected by the mode of ventilation as evidenced by no need to convert from LV to SV during the procedures. Conclusions: LV during RIRS has a significant positive impact on the overall improvement of surgical performance and effectiveness. It does not negatively affect the patient's anesthesia-related safety and may contribute to considerably improving the performance of in-training endourologists. [ABSTRACT FROM AUTHOR]

Purpose: The ability of 5α-reductase inhibitors (5ARI) to reduce the risk of new onset bladder cancer (BC) has been studied with variable results. Our objective was to conduct a retrospective cohort population-based study to evaluate the association between 5ARI use, BC diagnosis, and BC mortality.Patients and Methods: We used routinely collected health care data from Ontario, Canada. Men ≥66 years of age with a prescription for a 5ARI were matched to non-5ARI users. Matching was done using a propensity score of selected covariates to make 96 different covariates comparable. We measured 5 additional baseline variables which may have impacted the risk of future BC diagnosis: prior cystoscopy, urine cytology, urinalysis, gross hematuria episodes, and transurethral resection of a bladder lesion. Only the first period of continuous usage of 5ARIs was considered. The prespecified at-risk period for outcomes started 1 year after initiating therapy and ended at the last date of 5ARI exposure + 1 year.Results: We identified 93,197 men who initiated 5ARI therapy (52% dutasteride, and 48% finasteride) between 2003 and 2013 and matched them 1:1 to men who did not start a 5ARI. The median at-risk period for the 5ARI group was 1.68 years (interquartile range 1.00, 4.27). With adjustment for the variables related to prior BC investigations there was no significant difference in BC diagnosis (hazard ratio [HR] 1.05, 95% confidence interval [CI] 0.82-1.32) during the period of 0 to <2 years of 5ARI use; however, after ≥2 years of 5ARI use, the risk of BC diagnosis was significantly lower among the 5ARI group (HR 0.82, 95% CI 0.79-0.94). In a similarly adjusted model, BC mortality was lower among 5ARI users, but no longer statistically significant (HR 0.82, 95% CI 0.65, 1.02). When stratified by type of 5ARI, finasteride significantly reduced the risk of BC diagnosis after ≥2 years of continuous use (HR 0.86, 95% CI 0.76, 0.96); however, dutasteride did not (HR 0.92, 95% CI 0.83, 1.03).Conclusions: In a large cohort of men, the use of a 5ARI was associated with a significantly decreased the risk of BC diagnosis after more than 2 years of continuous therapy. [ABSTRACT FROM AUTHOR]

Introduction: Concurrent systematic biopsies during image-guided targeted biopsies of the prostate were found to improve the detection rate of clinically significant prostate cancer (CSPC). However, these biopsies do not routinely include anterior or apical sampling. We aimed to evaluate the significance of anterior and apical samplings during combined biopsies.Methods: After obtaining institutional review board approval we identified 303 consecutive patients who underwent transperineal combined biopsies of the prostate between 2017-2020. Systematic biopsies were obtained from the peripheral zone, anterior zone, and apex. Study outcomes included CSPC and any cancer on anterior or apical biopsies. Logistic regression analyses were used to evaluate the association between pre-biopsy characteristics and study outcomes.Results: Median prostatic-specific-antigen value was 6.8 ng/dL. Most patients had stage T1c disease (77%). Overall, combined biopsies detected CSPC in 87 patients (29%). Any cancer and CSPC in the anterior zone were found in 54 (18%) and 19 (6%) patients, respectively. Any cancer and CSPC in the apex were found in 54 (18%) and 16 (5%) patients, respectively. Anterior/apical samplings upgraded the pathological result in 19 patients (6%). Logistic regression analyses demonstrated that PI-RADS 5 lesions predicted the presence of CSPC in both the anterior zone (OR = 8, 95%CI = 3-22, P <0.001) and apex (OR = 4, 95%CI = 1-10, P = 0.01).Conclusions: Avoiding anterior and apical samplings during prostate biopsy does not result in substantial under-diagnosis of significant cancer. However, these areas are easily accessible using the transperineal approach and should be sampled in selected patients, particularly those with PI-RADS 5 lesions. [ABSTRACT FROM AUTHOR]

The treatment of choice of penile paraffinoma (PP) is surgical resection. Penile soft tissue coverage in a combined Urology/Plastic Surgery procedure, is often needed.Objective: To describe the surgical techniques, aesthetics and functional outcomes, and to provide a practical algorithm for the surgical management of symptomatic PP.Methods: We retrospectively recruited PP patients treated with surgical resection, from 2004 to 2020, in the Reina Sofia Hospital of Murcia (Spain) and Sourasky Medical Center (Israel). Procedural and postoperative erectile function, according to the short version of the International Index of Erectile Function (IIEF-5) data were collected.Results: Eight patients underwent surgery. The mean age was 30 years. The mean time between substance injection and surgery was 6 years. The most frequently injected material was liquid paraffin (50%), followed by Vaseline. Extensive skin involvement was present in all patients with liquid paraffin, requiring 2-stage surgery or skin graft. PP surgical treatment was successfully achieved in an Urology/Plastic Surgery joined effort. Postoperative erectile function was preserved in all cases.Conclusion: PP can pose a surgical challenge. A combined surgical approach with urology and plastics allows for functional and aesthetic preservation. The extent of PP and the viability of shaft skin preservation should guide surgical approach. [ABSTRACT FROM AUTHOR]

Aim Methods Results Conclusions The value of post‐operative pelvic drain placement after robot‐assisted radical prostatectomy (RARP) for the purpose of diagnosing post‐operative complications is undetermined. The aim of this study was to assess the yield of pelvic drain outputs in predicting post‐operative early‐onset urinary leaks from a vesicourethral anastomosis.We conducted a retrospective analysis of 204 consecutive patients who underwent RARP in our institution between 2018 and 2022. The daily outputs of the drain and the urinary catheter were measured, and patients with early‐onset anastomotic urinary leak were compared with those who were free of any leak. The association between post‐operative drain output and the presence of urinary leak was investigated by regression analyses.Post‐operative early‐onset leak was present in six patients (3.4%) whose baseline characteristics were not different from those of patients with no leak. The median pelvic drain output on post‐operative day 1 (D‐POD1) was 80 mL (interquartile range [IQR] 51–150 mL) and 122 mL (IQR 62–200 mL) on D‐POD2. The median D‐POD1 of patients with a leak was significantly higher than those without one (250 mL vs 80 mL, respectively; P < .001). The threshold to predict an anastomotic urinary leak was 227 mL on D‐POD1 (area under the curve 0.88; P < .001), and an association between D‐POD1 >227 mL and the presence of urinary leak (odds ratio 35; P < .001) was found.Pelvic drain output on POD1 can predict early‐onset urinary leak. Given the relatively low rate of this complication via a robotic approach, however, we consider that, unless otherwise indicated, the routine placement of a pelvic drain may be safely avoided. [ABSTRACT FROM AUTHOR]

Introduction: Data on the accuracy of 68Ga-PSMA positron emission tomography/computed tomography (PET/CT) in patients with intermediate/high-risk prostate cancer are being accumulated. Its role in assessing the extent of local disease has not been fully elaborated.Aim: To determine the performance characteristics of 68Ga-PSMA PET/CT in identifying local disease extension in patients with intermediate/high risk prostate cancer.Methods: 68Ga-PSMA PET/CT studies of 61 consecutive patients with intermediate/high-risk prostate cancer who underwent radical prostatectomy were reviewed by nuclear medicine specialists. Tumor location, extraprostatic extension (EPE), seminal vesicle invasion (SVI), and lymph nodes involvement (LNI) were compared to pathological findings. The incremental value of 68Ga-PSMA PET/CT to established nomograms was determined.Results: Two patients without pathologic uptake of 68Ga-PSMA were excluded. Seventeen patients were diagnosed with EPE (29%), 12(20%) had SVI and 3(5%) LNI. The concordance between tumor location and 68Ga-PSMA PET/CT findings was 48%, and EPE was not indicated by PET in any of the patients. The sensitivity, specificity, positive, and negative predictive value for SVI were 58%, 96%, 78%, 90%, respectively (area under the receiver operating characteristic curve = 0.77) and for LNI 67%, 98%, 67%, 98%, respectively (area under the receiver operating characteristic curve = 0.82). Incorporating imaging findings into the MSKCC-SVI nomogram enhanced the diagnostic accuracy from 0.84 to 0.95 (Integrated Discrimination Increment 0.24, P = 0.004).Conclusion: In patients with intermediate/high-risk prostate cancer, 68Ga-PSMA PET/CT provides information regarding intraprostatic tumor location, SVI and LNI but has no role in assessment for EPE. This information might be useful for pretreatment counseling, decision-making and possibly preoperative planning. [ABSTRACT FROM AUTHOR]

Objective: To evaluate whether meatal stenosis treated concomitantly with urethral fistula repair alters the results of fistula closure.Methods: A retrospective cohort study, included were all children who underwent local fistula closure following hypospadias repair between 2006 and 2017. Patients who underwent reoperative urethroplasty were excluded. Data were extracted from electronic records, and missing data were supplied by telephone interviews. Characteristics of patients and fistulas were compared between children who underwent fistula closure only and those who underwent meatoplasty for meatal stenosis during the same surgery. The primary endpoint was fistula recurrence.Results: In total, 106 local repairs of urethrocutaneous fistulas were performed during the study period, and 25 of them included concomitant meatoplasty for meatal stenosis. There was no difference in terms of location, size, and number of fistulas or the number of recurrent fistulas between the 81 patients who underwent fistula closure only and the 25 who underwent concomitant meatoplasty. The fistula recurrence rate was 17 per 81 (21%) for the fistula only group and 5 per 25 (20%) for the fistula and meatoplasty group after a median follow-up of 7 and 8 years, respectively. Meatoplasty was required in a subsequent procedure in 5 of 81 in the former group vs 3 of 25 patients in the latter group.Conclusion: The presence and repair of meatal stenosis does not alter the recurrence rate of urethrocutaneous fistulas repaired concomitantly following hypospadias repair. [ABSTRACT FROM AUTHOR]

Introduction: Most men diagnosed with very-low and low-risk prostate cancer are candidates for active surveillance; however, there is still a misclassification risk. We examined whether PI-RADS category 4 or 5 combined with ISUP 1 on prostate biopsy predicts upgrading and/or adverse pathology at radical prostatectomy., Materials and Methods: A total of 127 patients had ISUP 1 cancer on biopsy after multiparametric MRI (mpMRI) and then underwent radical prostatectomy. We then evaluated them for ISUP upgrading and/or adverse pathology on radical prostatectomy., Results: Eight-nine patients (70%) were diagnosed with PI-RADS 4 or 5 lesions. ISUP upgrading was significantly higher among patients with PI-RADS 4-5 lesions (84%) compared to patients with equivocal or non-suspicious mpMRI findings (26%, p < 0.001). Both PI-RADS 4-5 lesions (OR 24.3, 95% CI 7.3, 80.5, p < 0.001) and stage T2 on DRE (OR 5.9, 95% CI 1.2, 29.4, p = 0.03) were independent predictors of upgrading on multivariate logistic regression analysis. Men with PI-RADS 4-5 lesions also had significantly more extra-prostatic extension (51% vs. 3%, p < 0.001) and positive surgical margins (16% vs. 3%. p = 0.03). The only independent predictor of adverse pathology was PI-RADS 4-5 (OR 21.7, 95% CI 4.8, 99, p < 0.001)., Conclusion: PI-RADS 4 or 5 lesions on mpMRI were strong independent predictors of upgrading and adverse pathology. Incorporating mpMRI findings when selecting patients for active surveillance must be further evaluated in future studies.

Background: Preoperative identification of the bowel on imaging is essential in planning renal access during percutaneous nephrolithotomy (PCNL) and avoiding colonic injury. We aimed this study to assess which noncontrast computed tomography (NCCT) window setting provides the optimal colonic identification for PCNL preoperative planning. Methods: Ten urologic surgeons (four seniors, six residents) reviewed 22 images of NCCT scans in both abdomen and lung window settings in a randomized blinded order. Colonic area delineation in each image was performed using a dedicated, commercially available area calculator software. A comparison of the marked colonic area between the abdomen and lung window settings was performed. Results: Overall, the mean marked colonic area was greater in the lung window compared with the abdomen window (8.82 cm 2 vs 7.4 cm 2 , respectively, p < 0.001). Switching the CT window from abdomen to lung increased the identified colonic area in 50 cases (50%). Intraclass correlation showed good agreement between the senior readers and among all readers (0.92 and 0.87, respectively). Similar measurements of the colonic area in both abdomen and lung windows were observed in 26/44 (60%) of the seniors cases and in 7/66 (10%) of the resident cases ( p = 0.002). Conclusion: Lung window solely or in combination with abdomen window appears to provide the most accurate colonic identification for preoperative planning of PCNL access and potentially reduce the risk of colonic injury. This pattern is more evident among young urologists, and we propose to introduce it as a standard sequence in PCNL preplanning.

Aim: This study aims to assess the accuracy of computed tomography (CT) in detecting recurrent laryngeal tumors after failed chemoradiation therapy (CRT)., Background: Local recurrence of laryngeal tumors following CRT has been reported in approximately 25%, yet it is often difficult to detect., Methods: Ten patients with laryngeal cancer who failed CRT and subsequently underwent salvage total laryngectomy were included. The laryngeal subsites involved in the tumor were identified based on postoperative pathology. The corresponding preoperative CT scans were selected for review by seven experts (head-and-neck surgeons or radiologists) who scored the extent of tumor spread on each scan on a 5-point scale, from no tumor detected to clearly visible tumor., Results: The rates of high tumor detectability (scores 4-5) varied according to laryngeal subsite, from 75% in the glottic region, to 45% in the subglottic region, and to 19% in the supraglottic region (P=0.01). The detectability rates were higher on scans performed 2 years or more after CRT., Conclusion: The CT evaluation of laryngeal cancer after CRT has limited value, particularly in the epiglottis and subglottis., (Copyright© Bentham Science Publishers; For any queries, please email at epub@benthamscience.net.)

Introduction: Current guidelines do not support the use of pretreatment imaging in patients with favorable intermediate-risk prostate cancer. 68 Ga-prostate-specific membrane antigen positron emission tomography/computed tomography (PSMA PET/CT) is more accurate than conventional imaging for preoperative staging. We aimed to evaluate whether pretreatment 68 Ga-PSMA PET/CT is beneficial for identifying pathological lymph node involvement (LNI) and adverse pathology among patients with favorable intermediate-risk prostate cancer., Methods: We reviewed 88 patients with favorable intermediate-risk prostate cancer who underwent 68 Ga-PSMA PET/CT prior to radical prostatectomy and lymph node dissection from 2016-2020. The primary endpoint was the presence of pathological LNI. Association between pretreatment characteristics and outcomes were evaluated., Results: Preoperative 68 Ga-PSMA PET/CT showed suspicious uptake in lymph nodes in 4/88 patients (5%), hence, 20 patients would need to be scanned to identify a patient with a positive lymph node on imaging. Two patients had pathological LNI, only one of whom showed 68 Ga-PSMA PET/CT uptake prior to surgery. The sensitivity, specificity, positive predictive value, and negative predictive values of 68 Ga-PSMA PET/CT for identifying LNI were 50%, 97%, 25%, and 99%, respectively. After surgery, four patients had evidence of prostate-specific antigen (PSA) persistence. The rate of PSA persistence was higher among patients with LNI on preoperative 68 Ga-PSMA PET/CT (2/4, 50% vs. 2/84, 2%, p=0.009)., Conclusions: Preoperative imaging of favorable intermediate-risk prostate cancer patients using 68 Ga-PSMA PET/CT showed a low yield for identifying patients at higher risk. Consistent with current guidelines, our findings do not support the routine use of PET/CT in this group of patients. Future prospective studies are needed to validate our findings.

Background/aim: The COVID-19 pandemic highlighted the need to develop tools prioritizing high risk patients for urgent evaluation. Our objective was to determine whether Glasgow Prognostic Score (GPS), an inflammation-based score, can predict higher grade and stage urothelial bladder cancer in patients with gross hematuria who need urgent evaluation., Patients and Methods: We analyzed a database of 129 consecutive patients presenting with gross hematuria. GPS was calculated using pretreatment C-reactive protein (CRP) and albumin levels. Patients with bacteriuria or other known malignancies were excluded. The relationship between GPS and final diagnosis was analyzed with multivariate logistic regression., Results: A total of 101 patients were included in the study and 24 patients were identified without any pathology and 77 with a bladder tumor. Pathology demonstrated 21 with muscle invasive, 18 with high grade non-muscle invasive, and 38 with low grade superficial bladder cancer. Twenty-six of 39 (67%) patients with high grade tumors had a GPS of 1 or 2 compared to only 8 out of 62 (13%) patients with either low grade or negative findings (p<0.0001). Ten of 21 (48%) patients with muscle invasive disease had a GPS of 2 compared to 1 out of 18 (6%) with high grade non muscle invasive tumors (p=0.04). On multivariate analysis, GPS was a strong independent predictor of high grade and stage bladder cancer., Conclusion: GPS may serve as a highly accessible predictor of high grade, high stage, and large urothelial bladder tumors at the time of initial evaluation and can help identify patients who need urgent evaluation., (Copyright © 2022 International Institute of Anticancer Research (Dr. George J. Delinasios), All rights reserved.)

Purpose: Revision surgery for the removal of excess foreskin after circumcision is a common procedure. The decision regret scale (DRS) is a validated questionnaire which assesses regret after medical decision making. The aim was to evaluate parental regret by means of the DRS and querying about factors associated with regret about deciding to revise their child's circumcision., Patients and Methods: Included were all pediatric patients who underwent revision of neonatal circumcision in a single center between 2010 and 2016. Excluded were children who underwent revision for reasons other than excess foreskin, those who underwent additional surgical procedures during the same anesthetic session, and those who had undergone previous penile surgery other than circumcision. Response to the DRS questionnaire was by a telephone call with the patient's parent. Regret was classified as none (a score of 0), mild (1-25), or moderate-to-strong (26-100). Surgical and baseline demographic data were obtained from the departmental database and compared between the no regret and regret groups., Results: Of the 115 revisions of circumcisions performed during the study period, 52 fulfilled the inclusion criteria, and the parents of 40 (77%) completed the DRS questionnaire. Regret was reported by 11/40 [28%: nine as mild (23%) and two as moderate-to-strong (5%)]. The average age of the child in the regret group was 17 months compared to 18 months in the no regret group ( p = 0.27). The median weight percentile was 43% in both groups. Surgical variables, including anesthesia type (caudal vs. no block, p = 0.65), suture type (polyglactin vs. poliglecaprone, p = 0.29), operation time (28 vs. 25 min, p = 0.59), and anesthesia time (55 vs. 54 min, p = 0.57) were not significantly different between the groups., Conclusions: Regret for deciding upon revision surgery for removal of excess foreskin post-circumcision was reported by 27.5% of parents of children who underwent revision. No clinical, surgical, or demographic characteristics predicted parental decisional regret., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2022 Bar-Yaakov, Mano, Ekstein, Savin, Dekalo, Ben-Chaim and Bar-Yosef.)

Introduction: To assess the outcome of same-session bilateral tubeless percutaneous nephrolithotomy (BPCNL) in supine and prone positions and to compare them to unilateral tubeless PCNL (UPCNL)., Materials and Methods: Consecutive PCNL patients treated at two institutions between 2006-2016 were analyzed. Tubeless BPCNL was performed when indicated., Results: Fifty-eight patients underwent BPCNLs [30 supine (SBPCNL) and 28 prone (PBPCNL)], while 1395 patients underwent UPCNLs. Demographics and baseline data were similar for all groups (p > 0.05). SBPCNL had a longer operating time (124 +/- 38 minutes versus 105 +/- 36 minutes; p = 0.49) and a significantly longer hospital stay (3.6 +/- 1.9 versus 2.4 +/- 1.3 days, respectively; p = 0.019) in comparison to PBPCNL. Seven planned BPCNLs were converted to UPCNL, resulting in a BPCNL success rate of 58/65 (89%). When compared to UPCNL, BPCNL patients had a significantly increased postoperative creatinine level (0.74 +/- 0.3 versus -0.04 +/- 0.8 g/dL; p = 0.07E-7), a decreased postoperative hemoglobin level (2 +/- 1.1 versus 1.4 +/- 1.7 mg/dL; p = 0.026), a higher blood transfusion rate (9% versus 2%; p = 0.023), and a longer hospital stay (3 +/- 1.7 versus 1.6 +/- 1.7 days; p = 0.001E-4). Stone-free and overall complication rates were similar for both groups., Conclusion: BPCNL can be routinely offered to patients with a bilateral indication. BPCNL is associated with higher blood transfusion rates and longer hospital stays, but it may spare patients from repeat anesthesia and hospitalization. SBPCNL takes longer to perform than PBCNL, but without clinical ramifications.

Objective: MRI of the prostate improves diagnostic accuracy of prostate cancer. Different fusion approaches with transrectal ultrasound images are employed. To determine detection rate of prostate cancer in men undergoing transperineal MRIbased cognitive fusion biopsy., Materials and Methods: One hundred and sixty-four consecutive men underwent a multiple-core prostate transperineal biopsy. Univariable and multivariable logistic regression analyses were used to address the relationship between clinical parameters and prostate cancer detection rate., Results: One hundred and fourteen patients underwent mpMRI prior to the transperineal biopsy, 52 (45%) were diagnosed with prostate cancer, of them, 36 had Gleason score ≥7 (69%). Among these 114 patients, 82 had suspicious lesions on MRI, and 43 of them were diagnosed with cancer (52%). On multivariate analysis, the most significant independent predictive factors were PSA density (P<0.001) and suspicious MRI lesion (P=0.006). Men with a PSA density of more than 0.22 and a suspicious lesion on MRI had a detection rate of 78%. Detection rate among 50 patients with no MRI study prior to this biopsy was 26%., Conclusions: This study showed that among a group of mostly multi-biopsied patients, the presence of mpMRI lesions and high PSA density values helped to detect clinically significant prostate cancer using cognitive MRI/TRUS fusion biopsies., (Copyright® by the International Brazilian Journal of Urology.)