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Gabriel Molineros, Amichay Meirovitz, Marc Wygoda, Mohammad Zuaiter, Vladimir Yutkin, Mordechai Duvdevani, Guy Hidas, Ofer N Gofrit Department of Urology, Hadassah Hebrew University Hospital, Jerusalem, IsraelCorrespondence: Ofer N GofritDepartment of Urology, Hadassah Hebrew University Hospital, P.O. Box 12000, Jerusalem, 91120, IsraelTel +972 2-6776874Fax +972 2-6430929Email ogofrit@gmail.comPurpose: Patients treated by external beam radiotherapy (EBRT) for localized carcinoma of the prostate (CAP) often suffer from urinary obstruction. While most patients can be treated medically, some require transurethral prostatectomy (TURP) for alleviation of obstruction. The consequences of combing EBRT and TURP are controversial. The objective of this study was to evaluate the success and complication rates of TURP combined with EBRT.Patients and Methods: Between 2001 and 2017, 3501 patients underwent TURP. Sixty-six of them were treated with EBRT for CAP. Surgical complications according to the Clavien–Dindo (CD) scale and the need for secondary interventions were compared to 66 randomly selected patients operated on for benign prostatic hyperplasia (BPH).Results: Patients who underwent TURP for BPH were significantly older compared to the patients with CAP with an average of 76.4 (SD 4.3) vs 71 (SD 8.2) years, p< 0.0001. Substantial post-operative complications were rare in both groups with only a single case of CD grade 3 in each group. However, patients with CAP required significantly more secondary surgeries (21% vs 6%, p=0.02) and significantly more additional interventions (37.9% vs 13.6%, p=0.0025). There was no difference in complication rate, in the need for additional interventions or in the oncological outcome when comparing patients operated before or after EBRT.Conclusion: The complication rate of TURP done before or after EBRT is low and comparable to surgery for BPH. However, the rates of secondary surgeries and additional interventions in these patients are high (40%). TURP before or after EBRT provides similar results.Keywords: carcinoma of the prostate, external beam radiotherapy, transurethral prostatectomy

Urethral injuries occurring during pelvic trauma can cause a heavy morbidity and negative impact for the quality of life of a child.We present a case of a 7 years old boy with a complete posterior urethral disruption managed with a successful realignment by a unique modification of the “rendez vous” technique with the simultaneous performance of both antegrade flexible and a retrograde rigid cystoscopy.

Matan Mekayten, Vladimir Yutkin, Mordechai Duvdevani, Dov Pode, Guy Hidas, Ezekiel H Landau, Fadi Youssef, Ofer N Gofrit Department of Urology, Hadassah Hebrew University Medical Center, Jerusalem, Israel Background: Bladder recurrence after nephroureterectomy (NU) is common. However, there is no acceptable policy of adjuvant intravesical treatment after NU. Objective: To assess the rate of bladder recurrence following NU and to identify the high-risk subgroups that may become candidates for adjuvant intravesical therapy after NU. Patients and methods: Ninety-one patients (mean age 66.4 years) underwent NU. High-grade (HG) tumors were found in 63 patients and low-grade (LG) tumors in 28. Median follow-up was 72 months. The risk of bladder recurrence was assessed by uni- and multivariate analyses of patient and tumor characteristics. Results: Bladder recurrence developed in 38 patients (41.8%) after a median period of 11 months. Among these, 25 patients with HG upper tract urothelial carcinoma (39.7%) and 13 patients with LG upper tract urothelial carcinoma (46.4%) developed recurrence. HG bladder recurrence developed in 24 patients (63.2%) and LG recurrence developed in 14 patients (36.8%). Stages pTa, pT1, pT2, or higher bladder recurrence developed in 26 (68.4%), 7 (18.4%), and 4 patients (10.5%), respectively, and pure pTis developed in 1 patient. On uni- and multivariate analyses, the risk of bladder recurrence was independent of any clinicopathologic characteristics. Conclusion: High rate and short time interval of bladder recurrence after NU were found, with no specific subgroup of patients with increased risk. These findings support prescribing adjuvant intravesical therapy to all patients after NU. Keywords: urothelial upper tract tumors, bladder recurrence, nephroureterectomy

Ofer N Gofrit,1 Amos Shapiro,1 Ran Katz,1 Mordechai Duvdevani,1 Vladimir Yutkin,1 Ezekiel H Landau,1 Kevin C Zorn,2 Guy Hidas,1 Dov Pode1 1Department of Urology, Hadassah Hebrew University Hospital, Jerusalem, Israel; 2Department of Surgery, Section of Urology, Montreal, Canada Background: Partial cystectomy provides oncological results comparable with those of radical cystectomy in selected patients with invasive bladder cancer without the morbidity associated with radical cystectomy and urinary diversion. We describe a novel technique of partial cystectomy that allows accurate identification of tumor margins while minimizing damage to the rest of the bladder. Methods: During the study period, 30 patients underwent partial cystectomy for invasive high-grade cancer. In 19 patients, the traditional method of tumor identification was used, ie, identifying the tumor by palpation and cystotomy. In eleven patients, after mobilization of the bladder, flexible cystoscopy was done and the light of the cystoscope was pointed toward one edge of the planned resected ellipse around the tumor, thus avoiding cystotomy. Results: Patients who underwent partial cystectomy using the novel method were similar in all characteristics to patients operated on using the traditional technique except for tumor diameter which was significantly larger in patients operated on using the novel method (4.3±1.5 cm versus 3.11±1.18 cm, P=0.032). Complications were rare in both types of surgery. The 5-year local recurrence-free survival was marginally superior using the novel method (0.8 versus 0.426, P=0.088). Overall, disease-specific and disease-free survival rates were similar. Conclusion: The use of a flexible cystoscope during partial cystectomy is a simple, low-cost maneuver that assists in planning the bladder incision and minimizes injury to the remaining bladder by avoiding the midline cystotomy. Initial oncological results show a trend toward a lower rate of local recurrence compared with the standard method. Keywords: bladder cancer, partial cystectomy, cystoscopic-assisted partial cystectomy

The lamina propria (LP) of the urinary bladder lies between the urothelial mucosa and the muscularis propria. This complex stratum is composed of extracellular matrix, several cell types, and collagen types I and III fibers. LP invasion by urothelial carcinoma (progression from stage Ta to T1) is a determinant of bladder cancer advancement. We attempted to characterize collagen fiber arrangement in the LP. This could enrich our understanding of this important layer and potentially provide clues for sub-staging of the T1 bladder cancer. A total of 24 Masson trichrome-stained images of normal bladder, including 12,530 collagen fibers were quantitatively analyzed using the Dragonfly software. The LP was divided according to fiber orientation into superficial LP (SLP, 15% of the thickness) and the deep LP (DLP, 85% of the thickness). Collagen fiber geometry analysis demonstrated that the SLP fibers are more parallel to the urothelium with an average angle of 26 0 ±23 0 compared to 40 0 ±26 0 in the DLP (p=3.4X10 -144 ), more packed (average distance to the closest fiber of 0.61±0.67 compared to 0.66±0.77, p=0.0001), and their aspect ratio is considerably longer (average of 1.93±0.12 compared to 0.20±0.11, p=2.84x10 -8 ). No difference was found in fiber perimeter or Feret diameter. Thus, we conclude that bladder collagen fibers are arranged in two distinct layers: a dense-ordered SLP and a loose disorder DLP. This indicates that the physical barrier to cancer cell invasion probably lies in the SLP, immediately underneath the urothelium. Once this barrier is breached, the looser and disorganized DLP poses no remarkable obstacle. Thus, we believe that histology-based subdivisions of stage T1 are expected to fail in providing clinically meaningful prognostic information., (©The Author(s) 2024. Open Access. This article is licensed under a Creative Commons CC-BY International License.)

Background: The endocannabinoid system (ECS) plays a key physiological role in bladder function and it has been suggested as a potential target for relieving lower urinary tract symptoms (LUTSs). Whereas most studies indicate that activating the ECS has some beneficial effects on the bladder, some studies imply the opposite. In this study, we investigated the therapeutic potential of peripheral cannabinoid-1 receptor (CB 1 R) blockade in a mouse model for LUTSs. Materials and Methods: To this end, we used the cyclophosphamide (CYP; 300 mg/kg, intraperitoneal)-induced cystitis model of bladder dysfunction, in which 12-week-old, female C57BL/6 mice were treated with the peripherally restricted CB 1 R antagonist, JD5037 (3 mg/kg), or vehicle for three consecutive days. Bladder dysfunction was assessed using the noninvasive voiding spot assay (VSA) as well as the bladder-to-body weight (BW) ratio and gene and protein expression levels; ECS tone was assessed at the end of the study. Results: Peripheral CB 1 R blockade significantly ameliorated the severity of CYP-induced cystitis, manifested by reduced urination events measured in the VSA and an increased bladder-to-BW ratio. Moreover, JD5037 normalized CYP-mediated bladder ECS tone imbalance by affecting both the expression of CB 1 R and the endocannabinoid levels. These effects were associated with the ability of JD5037 to reduce CYP-induced inflammatory response, manifested by a reduction in levels of the proinflammatory cytokine, tumor necrosis factor alpha (TNFα), in the bladder and serum. Conclusions: Collectively, our results highlight the therapeutic relevance of peripheral CB 1 R blockade in ameliorating CYP-induced cystitis; they may further support the preclinical development and clinical use of peripherally restricted CB 1 R antagonism for treatment of LUTSs.

Objective: Urinary tract injury during cesarean delivery is a rare but severe complication. Due to the high prevalence of cesarean delivery, this injury may pose a high burden of morbidity. We reviewed the cases of lower urinary tract injuries identified during cesarean delivery in a tertiary medical center and identified diagnosis and treatment methods, as well as short and long-term outcomes, to establish a protocol of care for such cases., Methods: We included women with urinary tract injury during cesarean delivery between 2004 and 2018. The cases were identified according to ICD-9 codes, as well as free text in the medical report and discharge letter. Data were collected retrospectively. Telephone interviews were conducted to obtain additional data regarding long-term outcomes., Results: In14 years, a total of 17,794 cesarean deliveries were performed at our institution (17.5% of all deliveries), 14 cases of bladder injury, and 11 cases of ureteral injury were identified featuring an incidence of 0.08 and 0.06%, respectively. All bladder injuries were diagnosed and repaired intra-operatively. Six (55%) cases of ureteral injury were diagnosed in the post-operative period, and 3 of these patients required further surgery for definitive treatment. None of the patients suffered long-term adverse effects. Most bladder injuries occurred in women with previous cesarean delivery in the presence of abdominal adhesions. In contrast, most ureteral injuries occurred in women with emergency cesarean delivery during the second stage of labor, and were accompanied by an extension of the uterine incision. All women had normal kidney function in follow up and did not suffer from long term sequelae., Conclusion: Urinary tract injury is an uncommon complication of cesarean delivery. A high index of suspicion is recommended to avoid late diagnosis and complications. We propose a comprehensive protocol for the management of these injuries.

Introduction: We have recently validated a meatal Stenosis (MS) severity grading system that is based on physical examination., Objectives: The study objective was to examine the correlation between this grading system, patients' urinary symptoms, uroflowmetry and postvoid residual parameters., Study Design: Patients referred for our clinic for urinary and non-urinary complaints, were prospectively enrolled. Urinary symptoms questionnaire, uroflowmetry parameters and post-voiding residuals (PVR) were assessed, and photographs of the urethral meatus were taken for each patient. The photographs were graded blindly according to the previously validated grading system and correlated with urinary symptoms, uroflowmetry parameters and PVR., Results: Overall, 75 patients were assessed (20 grade 0, 23 grade 1 and 32 grade 2). When using grade 0 as a reference, the odds ratio (OR) for reporting narrow stream was 6.4 (95%CI 1.65-24.77) and 4 (95%CI 1.18-14.16) for grade 1 and 2 respectively. OR for prolonged urination was 6 (95% CI 1.47-24.89) for Grade 1 and 2; OR for upward stream deviation was10.08 (95%CI -2.43-41.82) for grade 1 and 15.12 (95%CI - 3.74-61.17) for grade 2. Uroflowmetry results showed lower Qmax from 16.8(SD ± 8.0) ml/sec in grade 0-9.6 ml/s on grade 1 and 2 (p < 0.001) (Figure 1). PVR was not statistically different in the three groups., Discussion: Our main findings were that meatal stenosis severity grade is associated with narrow stream as reported by parent, prolonged urination, and upward deviation of urinary stream, with increasing severity with worsening stenosis. MS grade was also associated with significant worsening of uroflow measures: a lower Qmax, Qmean and a longer time-to-Qmax. Post-void residual volume was not significantly different between the different severity grades. This study showed the clinical significance of the grading system. With subjective and objective measures. The implementation of this grading system in clinics, may aid in decision making regarding surgical intervention in the appropriate patients, and avoid unnecessary procedures., Conclusion: The Severity of MS seen on physical examination correlates well with obstructive symptoms and decrease of urine stream seen on uroflowmetry. These findings confirm the importance of the grading system in the evaluation of patients with MS and may be additional measure that assist in consulting parents on the indications to meatotomy., Competing Interests: Conflicts of interest The authors have no conflict of interest regarding this research., (Copyright © 2022 Journal of Pediatric Urology Company. Published by Elsevier Ltd. All rights reserved.)

Introduction: Preoperative test that can predict the salvageability of the torsed testis may add essential information to the surgeon managing testicular torsion (TT), this can assist with patients' and parents' expectations, particularly with nonviable testes. We aimed to examine if parenchymal echotexture changes in preoperative ultrasound can predict irreversible hemorrhagic necrosis., Materials and Methods: Preoperative ultrasound studies of 154 patients with TT were reviewed by 3 raters (2 radiologists and 1 urologist). The raters were asked to categorize the affected testicular parenchymal echotexture into one of the following categories: (1) normal (identical to the contra-lateral testis), (2) homogenous hypoechoic, or (3) focal heterogeneous echotexture. Testis non-viability was defined macroscopically during surgical exploration and correlated with the US results. Sensitivity, specificity, and positive and negative predicting values of the proposed diagnostic test were calculated. Cohen's kappa coefficient was used to determine inter-rater agreement., Results: A total of 54/154 patients had a nonviable testis. Mean of 59.5% cases was classified as category 1, 27.3% cases as category 2, and 13.2% cases as category 3. Testicular necrosis was 12%, 34%, and 92% in each category, respectively. Category 3 classified non-viability with a mean specificity of 99.3% and with a high inter-rater agreement level (Cohen's kappa coefficient of 0.830). Mean positive predictive value of 97% and mean negative predictive value of 74.3%. The mean sensitivity of this test however was low 39.7%., Conclusion: Ultrasound finding of focal parenchymal echotexture heterogeneous changes is highly specific although not sensitive, for nonviable testis. The presence of this finding reassures non-viability in over 99%., (© 2022. American Society of Emergency Radiology.)

Objective: To develop an efficient, clinical-grade, freezing protocol toward experimental clinical cryopreservation of testicular tissues in prepubertal boys suffering from cancer., Design: Experimental cryopreservation of testicular tissue., Setting: University Medical Center., Patients: Adult patients undergoing orchiectomy for various tumors and prepubertal boys scheduled for gonadotoxic treatment., Interventions: None., Main Outcome Measures: Histopathological analysis of tissue architecture, structural integrity, and cellular morphology was performed for control and frozen-thawed cryopreserved tissues.The number of seminiferous tubules per testicular section was calculated. The survival of spermatogonial stem cells (SSCs) and Sertoli cells of the control and frozen-thawed cryopreserved tissues was analyzed by immunofluorescence staining., Results: Uncontrolled Slow Freezing, Controlled slow freezing, and vitrification similarly preserved the integrity of the adult testicular tissues and the survival of SSCs and Sertoli cells. Controlled slow freezing of prepubertal testicular tissues effectively preserved their architecture, the number of tubules, SSCs, and Sertoli cells. In addition, we observed SSC loss after chemotherapy in prepubertal boys, reemphasizing the importance of fertility preservation before gonadotoxic treatment ., Conclusions: Future fertility restoration for male survivors of pediatric cancers depends on the development of an optimal prepubertal testicular tissue cryopreservation method. Our findings demonstrate the effectiveness of controlled slow freezing for cryopreservation of human prepubertal testicular tissues and may contribute to more effective banking of these tissues and potential fertility restoration., Clinical Trial Registration Number: NIH research clinical trials number: NCT02529826., (© 2021 The Authors.)

Inappropriate use of antibiotics is one of the leading causes of the increasing numbers of resistant bacteria strains, resulting in 700,000 deaths worldwide each year. Reducing unnecessary use of antibiotics and choosing the most effective antibiotics instead of broad-spectrum drugs will slow the arms race between germs and humans. Urinary tract infections (UTIs) are among the most common bacterial infections. Currently, accurate diagnosis of UTI requires approximately 48 h from the time of urine sample collection until antibiotic susceptibility test (AST) results. This work presents a rapid bacterial detection device that integrates a centrifuge, microscope, and incubator. Two disposable microfluidic chips were developed. The first chip was designed for bacteria concentration, detection, and medium exchange. A second multi-channel chip was developed for AST. This chip contains superhydrophobic and hydrophilic coatings to ensure liquid separation between the channels without the need for valves. The designed chips supported the detection of E. coli at a concentration as low as 5 × 10 3 cells/mL within 5 min and AST in under 2 h. AST was also successfully performed with Klebsiella pneumonia isolated from a human urine sample. In addition, machine-learning-based image recognition was shown to reduce the required time for AST and to provide results within 1 h for E. coli cells. Thus, the BactoSpin device can serve as an efficient and rapid platform for UTI diagnostics and AST.

Introduction: Neoadjuvant cisplatin-based chemotherapy prior radical cystectomy is the standard of care in patients with a muscle invasive bladder cancer. It is intended to treat micro-metastases. However, most patients do not develop metastases even without chemotherapy and are receiving this treatment in vain. In this study, we looked for pre-operative risk factors for developing metastases that can triage the patients that really need neoadjuvant therapy., Methods: From 1998 to 2018, 285 patients underwent radical cystectomy without neoadjuvant chemotherapy. During a median follow-up of 42.5 months, 99 patients (34%) developed recurrent disease after a median duration of 12 months. The study compared 10 different preoperative parameters of patients who developed or did not develop recurrence., Results: An increased risk of metastases was found in older patients (39.8% in older than 69 years vs. 33.3% in younger patients, p=0.045), in patients with a high Charlson Comorbidity index (46.2% in 5 and above vs. 28.2% when lower than 4, p=0.003), and in patients with large tumor diameter (p=0.01). No difference was found in the other variables examined including: gender, primary versus secondary tumor, tumor stage, presence of histological variant, hydronephrosis, carcinoma in situ (CIS) or sarcomatoid differentiation., Conclusions: Older age, comorbidity, and large tumor diameter predict the risk of recurrence after radical cystectomy. However, overlap between the groups precludes the use of these parameters for clinical decisions. Therefore, neoadjuvant chemotherapy treatment should currently be offered to all candidates for radical cystectomy. Hopefully, future molecular markers will be able to predict the risk of metastases.

The reported results of trimodal treatment (TMT) in muscle-invasive bladder cancer vary widely. We attempted to characterize the profile of ideal candidates for this approach. Between 2000 and 2019, 105 patients (median age 78 years) with T2-4aN0M0 bladder cancer were treated with TMT and analyzed retrospectively. Mean radiotherapy dose was 62 Gy (SD 8.4). Ten pretreatment prognostic parameters were evaluated including tumor diameter on pre-TURBT CT. Multivariate analyses was performed and combination of parameters was studied. After a median follow-up of 29 months, 53 patients (50.5%) developed recurrence and 70 patients (67.7%) died. Death was disease-specific in 46 patients (65.7%). Tumor diameter was the most significant prognostic parameter with p < 0.0001 for overall, disease-specific and recurrence-free survivals. For every 1 cm increase in tumor diameter, the risk of disease-specific mortality increased by 1.57. Age, cisplatin eligibility and the Charlson Comorbidity Index were significant predictors of overall survival but not of disease-specific or recurrence-free survival. Patients who were cisplatin-eligible with a tumor diameter ≤3 cm had a 5-year disease-specific survival rate of 79.2% as opposed to 33.9% in patients without one of these features (p < 0.001). When tumor diameter exceeded 5 cm (irrelevant of all other parameters), 5-year disease-specific survival rate was only 28.2%. Patient profiles can accurately predict response to TMT. In cisplatin-eligible patients with a tumor diameter ≤3 cm, TMT provides an excellent disease-specific survival rate. In patients with a tumor diameter >5 cm TMT renders unacceptably poor treatment outcomes., (© 2020 The Authors. Cancer Medicine published by John Wiley & Sons Ltd.)

Bladder trabeculation (BT) is commonly noted on cystogram images of patients with neurogenic bladder (NB). BT is associated with a hostile bladder often requiring prompt, more aggressive management. We aimed to define and validate a reliable grading system for BT severity. The proposed grading system will improve clinicians and radiologist's communication and serve as a foundation for future studies in the field of NB. The study was conducted in two phases: 1) Development of a grading system for BT and 2) testing of the proposed grading system for reliability and validity. Agreement between raters was assessed using Cohen's Kappa. Inter-rater reliability and intra-rater reliability was assessed using intra-class correlation coefficients (ICC) and Spearman's p (rho) correlation coefficient. The content of the grading system was assessed for face validity by senior pediatric urology and radiology experts. We observed inter-rater reliability with ICC of 0.998 (95%CI 0.996-0.999, p < 0.001), and a Cohen's Kappa ranging from 0.795 to 1.0, p < 0.001 and Spearman's p (rho) correlation coefficient ranging from 0.910 to 1.0, p < 0.001 between raters on the decided grades of BT. In conclusion, we established a defined grading system for BT severity that has substantial inter/intra-rater reliability and validity. This grading system could be useful for improving clinician and radiologist's communication about the status of a child's bladder wall and serve as a foundation for future studies assessing severity of NB., (Copyright © 2020 Journal of Pediatric Urology Company. Published by Elsevier Ltd. All rights reserved.)

Introduction: Meatal stenosis (MS) is a common finding in circumcised children. Indication for surgical correction is based on urinary symptoms such as strength and direction of urine stream as well as physical examination, including direction and caliber of the urinary stream. There is no objective grading of MS severity, and therefore indications for surgery and management protocols are vague., Objective: We aimed to formulate a standardized, validated, and reliable grading system for MS severity based on the physical examination finding., Study Design: Photographs of the urethral meatus were taken in patients scheduled for meatotomy due to MS, whereas patients without this condition served as control. The photographs were rated by three experienced fellowship trained pediatric urologists. The study was conducted in two phases: 1) development of a grading system by the expert panel and 2) testing of the proposed grading system for inter- and intra-rater reliability. To estimate the correlation between different rates, the intra-class correlation coefficient (ICC) was calculated., Results: Three grades were generated: Grade 0 (wide open meatus, visible mucosa), Grade 1 (minimal mucosa/fibrotic tissue visible), and Grade 2 (pinpoint meatus/no mucosa visible/large fibrotic layer). A panel of 51 raters (pediatric urologist, community urologist, pediatricians) participated in the survey evaluating the representative photos from 86 patients. Inter-rater reliability was high ICC = 0.99 (95% confidence interval [CI] of 0.983-0.996, P < 0.0001) Cronbach's alpha = 0.992. In total, 18 raters participated in the same survey two weeks later for intra-rater reliability. An identical grading was obtained in 83.3% of photographs (kappa = 0.455 [P < 0.05])., Conclusion: We propose a grading system that is a valid, reliable, and reproducible method to classify the severity of MS on physical exam. This grading system could improve the healthcare provider's and parent's communication and can be a building block for further research in this field. A further research should assess the correlation with clinical signs and symptoms., (Copyright © 2019 Journal of Pediatric Urology Company. Published by Elsevier Ltd. All rights reserved.)

Objective: To determine the importance of the duration of in-hospital management of patients with testicular torsion for testes survival. The time from onset of symptoms until surgery is a well-known factor determining testicular survival but there is no data regarding the contribution of in-hospital management duration to testicular survival. Unlike the time from onset of symptoms until seeking medical attention, the time from registration to the emergency department (ED) to the time of detorsion-"Door To Detorsion time" (DTD) is dependent on medical providers and should be minimized., Materials and Methods: Data was retrieved on all patients who underwent surgery for testicular torsion in 1994-2014 (N = 219). We used multivariable logistic regression analysis to examine independent association between DTD time or duration of symptoms to testicular survival., Results: Median DTD time was 135 minutes (range 23-546). Among patients with a viable testis, median DTD time was 107 minutes (range 35-381) compared to 160 minutes (range 23-546) among patients with a nonviable testis (P <.001). Logistic regression models showed that both DTD time (P = .04) and duration of symptoms (P <.001) are independent factors associated with testicular survival. Adjusted odds ratio was 1.0048 for a nonviable testis for every minute of delayed management in the ED (P = .04). Results suggest that every 10 minutes of delay in the ED increases the chance of having a nonviable testis in exploration by 4.8%., Conclusion: DTD is an independent factor predicting testicular survival. Institutional efforts should be made to decrease duration of DTD. DTD should be considered as a measure for quality of care., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Backgrounds/aims: Operation room (OR) time is of great value affecting surgical outcome, complications and the daily surgical program with financial implications., Methods: We retrospectively evaluated 570 consecutive patients submitted to ureteroscopy or ureterorenoscopy for the treatment of ureteral or renal stones. Demographic parameters, patient's stones characteristics, type of ureteroscope, surgeon experience and surgical theater characteristics were analyzed. OR time was calculated from the initiation of anesthesia to patient extubation. Multivariate analysis was conducted using a linear regression test with multiple parameters to identify predictors of OR time., Results: Eight factors were identified as significant. These include total stones volume, ureteroscope used, stone number, nurses experience, radio-opacity of the stone on kidney-ureter-bladder X-ray, main surgeon experience, operating room type, and having a nephrostomy tube prior to surgery., Conclusions: The surgical team experience and familiarity with endourological procedure, and the surgical room characteristics has a crucial impact on OR time and effectiveness., (Copyright © 2019 by S. Karger AG, Basel.)

Aims: To evaluate the development of benign prostatic hyperplasia (BPH) in patients with spinal cord injury (SCI) and to deduce the role of the nervous system in this process., Methods: Prostate volumes (PVs) of 65 men older than 30 years of age who sustained SCI were determined from CT scans. Correlations of PVs with SCI level, age, age during SCI and duration of paralysis were calculated., Results: Average patient's age during SCI was 37.7 (±19) years and during measurement of PV 54.8 (±15.3) years. PVs of patients with SCI were similar to expected age-adjusted volumes (29.7 ± 24 mL vs 29.9 ± 5.7 mL, P = 0.95). We dichotomized the cohort into two groups: High SCI (T5 and above) and low SCI (T6 and below) with almost identical: number of patients, age of SCI and duration of paralysis. Patients with lower injuries, had significantly smaller PVs when compared both to patients with higher injuries (19.4 ± 6.3 and 39.8 ± 30, P = 0.0006) and to age-adjusted normal PVs (19.4 ± 6.3 and 29.2 ± 5.8, P = 0.0005). Correlation of PV with age was found in patients higher injuries (R 2  = 0.26, p = 0.003) but not in patients with lower (R 2  = 0.08, P = 0.11). Moreover, patients with lower SCI had significantly smaller prostate even compared to expected PVs during SCI (18.7 ± 4.6 cc vs 27.8 ± 6.9 cc, P = 0.00006)., Conclusions: Low SCI stops and reverses age related increase in PV. This phenomenon does not occur in high SCIs. This suggests that continuous support of the nervous system is essential for sustaining BPH and raises the possibility of finding a non-hormonal pharmacological intervention for reversing BPH., (© 2018 Wiley Periodicals, Inc.)

Purpose: To compare percutaneous nephrolithotomy (PCNL) operations between patients with a preoperative nephrostomy tube and patients that the renal access was obtained at the time of the surgery., Materials and Methods: We retrospectively evaluated PCNL cases. Patients were divided into two groups. Group 1 - a non-nephrostomy tube (percutaneous nephrostomy, PCN) group and Group 2 - patients with a PCN placed before the procedure. All preoperatively placed PCN's were performed in emergency situations by interventional radiologists (IR). Complications were classified according to the Clavien-Dindo classification. We compared stone characteristics, operation time, complications, efficacy and PCN usability at surgery., Results: Five hundred twenty-seven patients who were submitted to PCNL for renal stones were included in the study. In 73 patients (13.9%) the PCNs were placed before the surgery. Patients and stone characteristics, mean operative time (p=0.830), complications (p=0.859) and stone-free rates (93.0%) were similar between the groups. There was a trend toward higher complication rates in Group 1, but the difference was not statistically significant. Only 21 (29.0%) of preoperatively placed PCNs were used during PCNL for establishing a tract. The reasons for not using PCN tract were: pelvic or infundibular insertion (30.0%) and suboptimal anatomic location (70.0%)., Conclusions: Preoperative emergency inserted PCNs by IR usage rates were low during PCNL. Its placement neither affects the incidence of complications nor affects the operation time and outcomes. As such, when emergency renal drainage is indicated, the need for a future definitive PCNL should not influence the decision about the modality of renal drainage., Competing Interests: CONFLICTS OF INTEREST: The authors have nothing to disclose.

Introduction: Postoperative surveillance protocols after nephrectomy for kidney cancer include periodic computed tomography (CT) scans of the chest and abdomen. A single study exposes the patient to 21 mSv (equivalent to 7-year exposure to natural background radiation). The objective of this study was to evaluate the hypothesis that an abbreviated CT protocol restricted to the chest and upper abdomen (i.e., to the level of the intervertebral disk L3-L4) is sufficient for routine postnephrectomy follow-up as it detects most tumor recurrence with lower radiation exposure., Methods: We identified 493 patients treated with radical or partial nephrectomy for localized kidney cancer and followed with periodic CT scans of the chest and abdomen for prolonged periods. The frequency and location of cancer recurrence were documented. The ratio of infield recurrence for the complete chest, and abdomen and for the abbreviated protocol was recorded. The decrease in radiation exposure was calculated., Results: At a median follow up of 96 months, 82 patients (16.6%) developed recurrence. The frequent sites of recurrence were the lungs (53), the bones (9), and local recurrence (22). Complete chest and abdominal CT identified 78 of the recurrences (95%) and the abbreviated protocol identifying all but one of these (94%). The abbreviated protocol exposed the patient to 48% (standard deviation 4.3%) less radiation compared to the full protocol., Conclusions: Using an abbreviated CT protocol that includes the chest and upper abdomen for surveillance after surgery of localized kidney cancer decreases radiation exposure by half with only a minor decrease in the sensitivity of the examination., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Introduction: A "Negative" ureteroscopy (URS) is defined as a URS in which no stone is found during the procedure. It may occur when the stone has already been passed spontaneously or when it is located outside the collecting system. The aim of the study was to outline risk factors for Negative-URS., Materials and Methods: We retrospectively analyzed the possible risk factors for Negative-URS from a database of 341 URS cases. In every case where presumptive ureteral stone was not found, a formal nephroscopy as well as a whole collecting system revision was completed. The Negative-URS group was compared with the non-Negative-URS group, in terms of patient and stone characteristics., Results: The database of 341 URS cases included 448 different stone instances, of which 17 (3.8%) were negative and 431 (96.2%) were therapeutic. There was no statistical significant difference between the two groups concerning age, body mass index, stone location in the ureter, stone laterality, and whether the patient was prestented. The stepwise multiple logistic regression revealed three important risk factors, namely CT stone surface area (p < 0.0001), radiopacity of the stone at kidney, ureter, and bladder radiograph (KUB; p = 0.0004), and gender (p = 0.0011) with an area under the curve of 0.91. Women were found to have more possibilities to have a negative procedure by four- to sevenfold than men depending on the model. A nonradio-opaque stone at KUB is more likely to be correlated with a Negative-URS by 9.5- to 11-fold more than a radiopaque stone at KUB. For each increase of 1 U in CT stone surface area, there is an increase of 10%-12% to be non-negative., Conclusions: Female gender, a nonradio-opaque stone at KUB, and a smaller stone surface were statistically significantly different in the Negative-URS population.

Objectives: To report our experience with the active surveillance policy in patients with recurrent low-risk bladder tumors., Methods: The files of 52 patients who underwent active surveillance instead of immediate surgical resection were reviewed. Different variables concerning tumor growth rate were evaluated., Results: A total of 75 surveillance periods were documented in 52 patients (mean age 75.6 years S.D. 10.45 years, 37 males and 14 females), Mean surveillance period length was 16.5 months (S.D. 16.1). All tumors resected after surveillance were found in stage Ta and in low-grade except one tumor which was high-grade; 70 active surveillance periods ended with tumor resection, and 5 patients were still under surveillance when the research ended; 27 surveillance periods (37.7%) ended because of the growth of additional tumors. Active surveillance therefore spared 27 surgeries. The rate of tumor growth during surveillance depended on the tumor's largest diameter at the beginning of surveillance. If initial tumor diameter was smaller than 5 mm (68 cases), the median tumor growth rate was 1.12 mm3/month (IRQ: 0-6.55). If the initial tumor diameter was ≥5 mm (7 cases), the median tumor growth rate was 137.14 mm3/month (IRQ: 2.21-1787.5, p < 0.05)., Conclusions: Small, recurrent papillary bladder tumors pose minimal risk to the patient. An active surveillance policy, without immediate resection of the tumor is safe, can spare surgeries and can be considered in patients presenting with small papillary recurrence.

Background and Purpose: Temporary drainage of the upper urinary tract after ureterorenoscopy for the treatment of urinary stones is almost a routine in endourologic practice. In these cases, a Double-J stent (DJS) is left for 7 or more days. In borderline cases, a ureteral catheter attached to the urethral catheter may be left for 24-48 hours. In some situations, tubeless approach is possible. The purpose of this study was to evaluate the necessity and immediate postoperative implications of upper tract drainage by comparing complications and symptoms at the immediate postoperative period in these three groups of patients., Materials and Methods: A database of 516 consecutive patients who underwent ureterorenoscopy for ureteral and/or renal stones between October 2014 and September 2016 was retrospectively evaluated. The cohort was divided according to postoperative drainage type of the upper urinary tract. The data consisted of demographic parameters, stone location, number and burden, severity of preoperative obstruction, and postoperative complications. Symptoms at the immediate postoperative period, assessed by visual analog scale (VAS) score, frequency, and type of analgesics used, were evaluated and compared. Categorical dependent variables were evaluated using chi-square or Spearman's correlation tests, whereas continuous dependent variables were analyzed using Pearson correlation analysis., Results: There were 196 (38%) tubeless, 214 (41%) UC, and 106 (21%) DJS cases. Patients who were drained with DJS at the end of the procedure were significantly with higher stone volume (p < 0.005), higher stone density (p < 0.005), and with more severe preoperative obstruction (p < 0.005). Postoperative complications (infection, stone-street, and acute renal failure), mean VAS score, or analgesics used were not different in the three subgroups., Conclusions: A tubeless approach is safe in properly selected cases. There is no difference in postoperative course compared with drained groups. Tubeless procedures may facilitate an outpatient approach for treatment of upper urinary tract stones.

Objective: To evaluate the homogeneity of the 'low-risk' bladder cancer group in an attempt to optimise follow-up protocols., Patients and Methods: Between June 1998 and December 2008, 211 patients (mean [sd] age of 66.7 [12.8] years) underwent transurethral resection of low-risk bladder cancer. Postoperative follow-up included cystoscopy at 3 and 12 months after surgery, then annually for a total of 5 years, and then annual ultrasonography indefinitely., Results: After a median follow-up of 10 years, 65 patients (30.7%) developed tumour recurrence and three (1.4%) stage progressions. In all, 84 patients (40%) had tumours of ≤1 cm; these patients were significantly younger than patients with 1.1-3 cm tumours (64.6 vs 68.3 years, P = 0.03). Their 5-year recurrence-free survival rate was significantly higher (92% vs 70% in patients with larger tumours, P < 0.001). The median time to recurrence was 5.7 years in patients with smaller tumours and 3.6 years in patients with larger tumours (P = 0.03). Only 43.7% of the recurrences in patients with small tumours occurred within 5 years, compared to 75.5% in patients with larger tumours., Conclusions: Patients with low-risk bladder cancer make an inhomogeneous group. They can be stratified according to tumour size. Patients with tumours of ≤1 cm are younger, have lower risk of tumour recurrence, and most of their recurrences arise beyond the recommended 5-year surveillance period. It seems that these patients can be classified separately to a 'very-low-risk' group. Follow-up in these cases can be based on prolonged non-invasive evaluations., (© 2017 The Authors BJU International © 2017 BJU International Published by John Wiley & Sons Ltd.)

Introduction: Kidney cancer accounts for approximately 2-3 % of all types of cancers. Renal tumors prevalence and especially the prevalence of small renal tumors, is on the rise. About half of the tumors currently diagnosed are smaller than 4 cm. Minimally invasive methods of radiofrequency ablation technology were recently developed for the treatment of small renal tumors and are characterized by reducing the surgical and anesthetic risk. The ablation is performed with a percutaneous approach guided by ultrasound, CT or MRI. We reviewed the results of this treatment., Methods: A total of 75 patients with a mean age of 69.5 years (27 - 90) were treated using RF during the period 2007-2014. The average tumor diameter was 28.4 mm (11-58 mm); 40 tumors were exophytic and 30 were central. Monitoring protocol after treatment included imaging after 1, 3, 6, 12 months subsequent to treatment and later annually; median follow-up time was 21 months (1 - 97)., Results: Evidence of tumor recurrence was observed in 9 patients (11.4%); 8 were treated successfully by another RF session. Cases in which recurrence was observed were characterized by a tumor larger than 30 mm (5/9) and adjacent to renal cysts (3/9); 5 of the lesions were central (endophytic) (P=0.5). One patient died due to metastatic RCC and a metastatic disease developed in two additional patients who died of other causes., Conclusions: It is possible to destroy most of the small renal tumors by RF ablation. When the tumor size is up to 30 mm, a 94% long-term cure may be reached. In the event of renewed growth of the tumor, the treatment can be repeated with good results. In light of short-term experience, it is recommended to limit this treatment to older patients, with a short life expectancy or when anesthetic risks prohibit surgery.

Purpose: We evaluated the ability of a bladder pressure/volume diary to identify patients at risk for increased intravesical pressures., Materials and Methods: Patients dependent on clean intermittent catheterization used ruler based manometry to measure intravesical pressures before leakage or scheduled drainage at home. We prospectively collected clinical, urodynamic and bladder pressure/volume diary data in patients with spina bifida who were optimized on anticholinergic therapy and clean intermittent catheterization. Measurements were taken with patients in the supine position with relaxed abdominal muscles. We defined increased pressure as detrusor pressure greater than 30 cm water as measured by urodynamics. ROCs were plotted to correlate bladder pressure/volume diary variables with abnormal intravesical pressures, and the most sensitive variable in determining abnormal intravesical pressures was sought as the end point., Results: A total of 30 patients with a mean age of 10 years (range 1 to 20) were included. Home pressures measured at maximal clean intermittent catheterization volume and mean bladder pressure/volume diary pressures were most reliable in predicting urodynamic pressures greater than 30 cm water (AUC 0.93 and 0.87, respectively). Home pressures measured at maximal clean intermittent catheterization volumes less than 20 cm water were associated with normal bladder pressures (less than 30 cm water) on urodynamics, with a sensitivity of 100% and a specificity of 80%., Conclusions: Home manometry less than 20 cm water provides a reliable measurement of safe pressures. A bladder pressure/volume diary is feasible and can aid in monitoring pressures at home without the additional cost and morbidity of urodynamics. A bladder pressure/volume diary may be a useful tool to help identify patients who would benefit from urodynamic testing., (Copyright © 2017 American Urological Association Education and Research, Inc. Published by Elsevier Inc. All rights reserved.)

Purpose: Transurethral surgery has been traditionally done using the nonelectrolyte, isotonic 1.5% glycine solution as irrigation fluid. The emergence of modern technologies, which can be applied with electrolyte solutions, such as bipolar resection and LASER evaporation, as well as the worry of transurethral resection (TUR) syndrome have driven urologists away from glycine toward the use of physiologic solution. Differences in the transparencies of these fluids have not been studied., Materials and Methods: The ability to resolve two bars at 1 mm apart using a 30° cystoscope lens immersed in different solutions was studied. Physiologic solution, distilled water (DW), and 1.5% glycine solutions containing increasing concentrations of blood, from 0.5% to 2%, were tested. Solutions containing 2% blood were inspected with magnification and microscopy., Results: One-millimeter resolution was reached in as much as 2% blood in 1.5% glycine solution and as much as 1% blood in DW, but in none of the blood-saline solutions. Magnified and microscopic views of 2% blood solutions showed an even distribution of red blood cells (RBCs) in physiologic solution, clumps of RBCs in 1.5% glycine, and an almost complete hemolysis in DW., Conclusions: Glycine solution increases the transparency compared to physiologic solution or DW owing to the clumping of RBCs. When the risk of TUR syndrome is low, as in resection of bladder tumors or small prostates, we propose that 1.5% glycine solution should be preferred over saline, owing to its improved visibility.

Objectives: To evaluate the prognosis of patients who underwent surgery for invasive bladder cancer and to search for prognostic factors., Methods: The files of all the patients who underwent radical or partial cystectomy for invasive bladder cancer between 1992 and 2014 were reviewed. The effect of various prognostic factors was evaluated by uni- and multivariate analyses., Results: A total of 160 patients were included in the study and were followed for a median period of 25.5 months after surgery. The overall 2 years and 5 years survival rates were 70% and 61.2% respectively. The disease-free 2 years and 5 years survival rates were 64.4% and 61.9% respectively. The overall 2 years and 5 years survival rates of patients with disease limited to the bladder (≥T2N0) were 88.2% and 82.4% and of patients with disease extending beyond the bladder (≤T3N0) 56.5% and 45.7% respectively. Factors that were found to be significantly associated with overall survival were: TNM stage, co-morbidity (Charlson 6-11) and the tumor's diameter. No association was found between: disease presentation, smoking habits, positive cytology, the tumor being primary or secondary, variant histology, the presence of endophytic growth pattern, the presence of CIS, hydronephrosis, positive lymph nodes on pre-operative imaging, surgery type (radical or partial cystectomy) and adjuvant chemotherapy., Conclusions: The survival rates of the locally treated patients match the reported rates in the literature. Tumors' T stage were found to be the strongest prognostic factor. Tumors' diameter was found to be an independent prognostic factor. This is reported here for the first time in the literature.

Objective: To assess interobserver reliability and reproducibility of the Clinical Research Office of the Endourological Society (CROES) nephrolithometric nomogram., Patients and Methods: Preoperative data and postoperative outcomes of 100 consecutive patients who underwent percutaneous nephrolithotomy were obtained. Patients' data were reviewed separately by 4 independent urologists of different academic level: an experienced attending endourologist, a graduated fellow, a young fellow, and a resident. Each rater adjusted a CROES score in all 100 patients. Interobserver reliability was analyzed by assessing intraclass correlation (ICC) and kappa coefficient among and between all different raters., Results: Assessment of interobserver reliability showed good or excellent agreement among all raters. Moderate agreement was only found between the raters for the "presence of staghorn" score. ICCs among all raters expressed excellent levels for each independent CROES parameter and reached great statistical significance. The highest correlation was noticed for "stone burden" in contrast to "presence of staghorn" parameter that showed the lowest. ICC for the final CROES score revealed good to excellent agreement among all raters and all pairs of raters., Conclusion: CROES nephrolithometry is a reproducible nomogram. Reproducible results were obtained within a single institution by multiple reviewers of varying experience within a short period of time after undergoing standardized training., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Background: Strong evidence suggests that in order to prevent irreversible testicular damage surgical correction (orchidopexy) for undescended testis (UDT) should be performed before the age of 1 year., Objectives: To evaluate whether orchidopexy is delayed in our medical system, and if so, to explore the pattern of referral for orchidopexy as a possible contributing factor in such delays., Methods: We conducted a retrospective chart review of all children who underwent orchidopexy for UDT between 2003 and 2013 in our institution. We collected data on the age at surgery and the child's health insurance plan. We also surveyed pediatricians from around the country regarding their pattern of UDT patient referral to a pediatric urologist or surgeon for surgical correction., Results: A total of 813 children underwent orchidopexy in our institute during the study period. The median age at surgery was 1.49 years (range 0.5-13). Only 11% of the children underwent surgery under the age of 1 year, and 53% between the ages of 1 and 2 years. These findings were consistent throughout the years, with no difference between the four health insurance plans. Sixty-three pediatricians who participated in the survey reported that they referred children to surgery at a median age of 1 year (range 0.5-3 years)., Conclusions: Our results demonstrate delayed orchidopexy in our medical system. There is a need to improve awareness for early specialist consultation in order to facilitate earlier surgery and better care.

Purpose: To our knowledge the effect of testicular torsion on the pregnancy rate is unknown. In this study we focused on the pregnancy rate, which is the ultimate index of fertility status., Materials and Methods: We reviewed the records of 273 patients who presented to our emergency room with testicular torsion between 1994 and 2014. Study inclusion criteria included being in a relationship with the intent to conceive for at least 1 year, age greater than 25 years and a normal contralateral testis. Patients with primary infertility, those who were unwilling to participate or unreachable and those with a history of undescended testis and/or varicocele were excluded from analysis. Patients were contacted by telephone and interviewed according to a standardized questionnaire. Pregnancy rates in the orchiopexy and orchiectomy groups were compared to each other and to the accepted pregnancy rate in the literature., Results: A total of 63 patients met study inclusion criteria, including 41 and 22 in the orchiopexy and orchiectomy groups, respectively. The pregnancy rate in the orchiopexy and orchiectomy groups was 90.2% and 90.9%, respectively (p = 1.0). The accepted pregnancy rate in the general population is 82% to 92%. Mean ± SD time to pregnancy in the orchiopexy and orchiectomy groups was 6.6 ± 5.50 and 7.2 ± 5.4 months, respectively (p = 0.27)., Conclusions: Several studies suggest decreased fertility potential in patients with a history of testicular torsion. However, in the current study in couples in which the male had a history of testicular torsion the pregnancy rate and the interval to pregnancy were within the accepted range of the general population., (Copyright © 2016 American Urological Association Education and Research, Inc. Published by Elsevier Inc. All rights reserved.)

Introduction: Adequate penile length in males with bladder exstrophy or epispadias is a major challenge. Kelly previously described a surgical technique of a single stage reconstruction for patients with exstrophy or epispadias that potentially achieves significant penile lengthening by completely detaching the insertion of the corpora cavernosa from the ischiopubic rami. However, because of the possibility of damage to the pudendal neurovascular supply that may lead to partial or complete penile loss, this technique has not gained popularity. The aim of this study is to describe the surgical anatomic relationship of the pudendal neurovascular bundle (NVB) to the ischiopubic rami and to determine a safer approach to dissection during the Kelly procedure., Methods: We performed meticulous dissection in three formalin-fixed and one fresh adult male cadavers to demonstrate the anatomical relationships between the pudendal neurovascular supply of the penis and the cavernosal insertion to the ischiopubic ramus., Results and Discussion: We demonstrated the relationships and distance between the NVB and the area of separation between the crus and the ischiopubic ramus at the level of the periosteum. The insertion of the crus to the ischiopubic ramus is inferior lateral, whereas the NVB lies at a superior medial position. This anatomical relationship is best visualized when the dissection is carried out starting from the distal portion of the NVB and proceeding proximally. This area of the periosteum is avascular and the NVB can be preserved safely as long as the dissection is conducted at that subperiosteal level. Based on this cadaver dissection study, we suppose that detaching the corporal cavernosa from the pubic bones at the subperiosteal level allows for a safe distance to be maintained from the pudendal nerve at all times. We believe that if a surgeon performs the dissection inferiorly and laterally, the corpora cavernosa can be safely detached from the ischiopubic ramus and injury to the pudendal vessels and nerve can be avoided. However, it must be noted that there are limitations to applying the results from this study of normal, adult cadavers to the anatomy of children and adolescents with exstrophy or epispadias, who form the largest proportion of patients who are candidates for this procedure., Conclusion: This anatomical study demonstrates the relationship between the pudendal NVB, the crus, and the ischiopubic ramus. We demonstrated how the separation of the crus from the ischiopubic periosteum might be performed more safely., (Copyright © 2016 Journal of Pediatric Urology Company. Published by Elsevier Ltd. All rights reserved.)

Background: High-grade urothelial carcinomas (UCs) often show foci of variant differentiation. There is limited information in the literature about the response of these variant urothelial tumors to immunotherapy with bacillus Calmette-Guerin (BCG). We compared the response, to treatment with BCG, of UC containing glandular, squamous, nested, and micropapillary types of differentiation to response of conventional non-muscle invasive high-grade UC., Methods: A total of 100 patients were diagnosed with variant histology urothelial cancer between June 1995 and December 2013. Forty-one patients with Ta or T1, confirmed by second look biopsies, received immunotherapy with BCG. Fourteen patients in this group were diagnosed with micropapillary differentiation, 13 patients with squamous differentiation, 9 patients with glandular differentiation, and 7 patients with nested variants. The control group included 140 patients with conventional high-grade UC. Both groups have been treated and followed similarly., Findings: Patients with variant tumors had similar clinical features to patients with conventional disease, including age, male to female ratio, stage, the presence of Tis, and median follow-up. Patients with variant tumors had a significantly worse prognosis compared to patients with conventional high-grade UC, including 5-year recurrence-free survival (63.5 Vs. 71.5%, p = 0.05), 5-year progression (≥T2)-free survival (60 Vs. 82.5%, p = 0.002), 5-year disease-specific survival (73 Vs. 92.5%, p = 0.0004), and overall survival (66 Vs. 89.5%, 0.05)., Interpretation: A patient with variant bladder cancer treated with intravesical immunotherapy has a 27% chance of dying from this disease within 5 years compared to 7.5% chance for a patient with conventional high-grade UC.

Objective: To develop a reliable and valid questionnaire to monitor neurogenic bowel symptoms in children., Patients: Thirty-four children aged 6-18 with neurogenic bowel and their caregivers. Eighteen control patients., Methods: An expert panel generated a domain of observables and formative/reflective content. Response options were scaled following Likert-type items. Key informant interviews revised the measures. A final questionnaire was given to patients twice to calculate intra-rater reliability using Cohen's Kappa Coefficient (k) and paired t-test. Blinded interviews were conducted after physical examination and health assessment and questionnaires completed by a nurse to determine construct validity and inter-rater reliability using k and Spearman's rank-order correlation. Control patients completed the questionnaire once, their results were used to determine discriminate validity and a receiver operating characteristic (ROC) curve., Results: Intra-rater reliability showed 85% of the questionnaires having k >0.6. Paired t-test results of t(33) = 1.997, P = 0.054, d = 0.53, confirmed there was not a significant difference between the scores of the two completed questionnaires. Inter-rater reliability showed 97% of the questionnaires having k >0.6 between the nurse and the patient/caregiver responses. Scores had a strong positive correlation at rs (32) = 0.943, P < 0.0005. Mean score with neurogenic bowel was 15.18(STD ±  5.77) and control group 4.68(STD ± 2.98). ROC analysis showed an area under the curve of 0.9. A score of 8.5 correlated with presence of neurogenic bowel with sensitivity of 94% and specificity of 87%., Conclusion: The questionnaire shows positive reliability and validity when used for pediatric neurogenic bowel patients. The questionnaire differentiates between normal and neurogenic patients. Larger studies are necessary to conduct further validation., (© 2014 Wiley Periodicals, Inc.)

Introduction: It has been well recognized that simulators are effective tools to teach and evaluate technical skills in laparoscopic surgery. Endoscopic injection for the correction of vesicourteral reflux has a definite learning curve. Surgeon experience has also been demonstrated to have an important role in the outcome of the procedure. Simulated training allows for practice in a realistic setting without the inherent risk of harm to the patient. This stress free environment allows the trainee to focus on the acquisition of surgical skills without worry about surgical outcome., Objective: The aim was to validate a porcine bladder simulator curriculum for training and assessment of the surgical skills for the endoscopic correction of vesicoureteral reflux., Study Design: We developed a porcine bladder-based dextranomer/hyaluronic acid (Dx/HA) injection simulator consisting of a dissected ex vivo porcine bladder in a polystyrene box with the distal ureters and urethra secured (Figure). We performed content validation by five experienced pediatric urologists. We then organized a simulator curriculum, which included lecture, demonstration, and a 2-h hands-on training on the simulator. Content, discriminant, and concurrent validation of the simulator curriculum were carried out using 11 urology trainees at different levels of expertise. All the trainees were evaluated for each step of the procedure of both their first and last performances on the simulator., Results: Overall, the model demonstrated good content validity by all experts (mean questionnaire score 92%). The simulator curriculum demonstrated a significant improvement in the performance of the trainees between their first and last evaluations (56-92%; p = 0.008). Specific parts of the procedure that showed significant improvement (p < 0.05) were identification of the ureteral orifice, ureteral orifice hydrodistention, first and second injection, and location, size, and depth of the mound after injection., Discussion: The Dx/HA endoscopic injection simulator is an effective training tool to improve the performance of the surgeon carrying out the procedure. This teaching tool may be used to help improve the performance of the surgeon carrying out the procedure. This teaching curriculum may shorten the early learning curve historically associated with the procedure and provide a greater understanding of the technical components of successful endoscopic vesicoureteral reflux correction. Additionally, the implementation of this simulator within the developed curriculum can improve the performance of training urologists in all steps of the challenging technique of Dx/HA needle injection confirming concurrent validity. The next step in evaluation of this surgical skill-training curriculum would be to determine if the improvement in skill performance observed during training translates to improved performance in the clinical realm, or predictive validity., Limitations: Some small differences exist between the porcine model and human ureteral orifices. In the porcine model the ureteral orifices are located medially and distally in the bladder neck, which make injection more challenging. Participants suggested that after practicing with the simulator endoscopic injection to a human ureteral orifice would be easier., Conclusion: The simulator curriculum was able to improve the performance of the surgeon carrying out the procedure during subsequent simulations., (Copyright © 2015 Journal of Pediatric Urology Company. Published by Elsevier Ltd. All rights reserved.)

Objective . To evaluate and compare the efficacy and safety of retrograde versus antegrade ureteroscopic lithotripsy for the treatment of large proximal ureteral stones. Patients and Methods . We retrospectively analyzed the medical records of patients with proximal ureteral stones >15 mm, treated in our institution from January 2011 to January 2016. Intraoperative parameters, postoperative outcomes, and complications were recorded and compared between the two techniques. Results . Our analysis included 57 patients. Thirty-four patients (59.6%) underwent retrograde and 23 patients (40.4%) underwent antegrade ureteroscopy. There was no significant difference in patients' demographics and stone characteristics between the groups. Stone-free rate was significantly higher ( p = 0.033) in the antegrade group (100%) compared to retrograde one (82.4%). Fluoroscopy time, procedure duration, and length of hospitalization were significantly ( p < 0.001) lower in retrograde approach. On the other hand, the need for postoperative stenting was significantly lower in the antegrade group ( p < 0.001). No difference was found between the groups ( p = 0.745) regarding postoperative complications. Conclusions . Antegrade ureteroscopy is an efficient and safe option for the management of large proximal ureteral stones. It may achieve high stone-free rates compared to retrograde ureteroscopy with the drawback of longer operative time, fluoroscopy time, and length of hospitalization.

Purpose: We constructed a risk prediction instrument stratifying patients with primary vesicoureteral reflux into groups according to their 2-year probability of breakthrough urinary tract infection., Materials and Methods: Demographic and clinical information was retrospectively collected in children diagnosed with primary vesicoureteral reflux and followed for 2 years. Bivariate and binary logistic regression analyses were performed to identify factors associated with breakthrough urinary tract infection. The final regression model was used to compute an estimation of the 2-year probability of breakthrough urinary tract infection for each subject. Accuracy of the binary classifier for breakthrough urinary tract infection was evaluated using receiver operator curve analysis. Three distinct risk groups were identified. The model was then validated in a prospective cohort., Results: A total of 252 bivariate analyses showed that high grade (IV or V) vesicoureteral reflux (OR 9.4, 95% CI 3.8-23.5, p <0.001), presentation after urinary tract infection (OR 5.3, 95% CI 1.1-24.7, p = 0.034) and female gender (OR 2.6, 95% CI 0.097-7.11, p <0.054) were important risk factors for breakthrough urinary tract infection. Subgroup analysis revealed bladder and bowel dysfunction was a significant risk factor more pronounced in low grade (I to III) vesicoureteral reflux (OR 2.8, p = 0.018). The estimation model was applied for prospective validation, which demonstrated predicted vs actual 2-year breakthrough urinary tract infection rates of 19% vs 21%. Stratifying the patients into 3 risk groups based on parameters in the risk model showed 2-year risk for breakthrough urinary tract infection was 8.6%, 26.0% and 62.5% in the low, intermediate and high risk groups, respectively., Conclusions: This proposed risk stratification and probability model allows prediction of 2-year risk of patient breakthrough urinary tract infection to better inform parents of possible outcomes and treatment strategies., (Copyright © 2015 American Urological Association Education and Research, Inc. Published by Elsevier Inc. All rights reserved.)

Surveillance studies of enhancing renal masses report on a mean tumor growth rate of about 0.3 cm/year. In most of these studies however, only small tumors in elderly patients were followed. In the current report, we attempt to evaluate the growth rate of "clinically significant" renal carcinomas defined as tumors that were treated immediately upon diagnosis. 46 patients (mean age 64 years SD 11 years) were treated for renal carcinoma. All had a cross-sectional imaging studies performed 6-60 months prior to diagnosis of kidney cancer demonstrating no tumor. Tumor growth rate was calculated by dividing tumor's largest diameter by the time interval between the normal kidney imaging and diagnosis of renal cancer. Mean tumor diameter was 4.5 cm (SD 2.4 cm). Mean time period from the normal imaging to diagnosis of renal cancer was 33.6 months (SD 18 months). According to the proposed model, the average growth rate of "clinically significant" renal carcinomas was 2.13 cm/year (SD 1.45, range 0.2-6.5 cm/year). Tumor growth rate correlated inversely with patient's age (p = 0.007). Patient gender or Fuhrman's grade did not correlate however. The growth rate of "clinically significant" renal cancer appears to be higher than the rate reported in surveillance trials. Renal tumors tend to grow faster in young patients. As such, variable growth rate should be taken into account when considering active surveillance in young patients and when designing trials for evaluation of anti-cancer agents.