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Howard J Korman,1 David Baunoch,2 Natalie Luke,2 Dakun Wang,3 Xihua Zhao,4 Michael Levin,1 David L Wenzler,1 Mohit Mathur5 1Comprehensive Urology Division, Michigan Healthcare Professionals, Royal Oak, MI, USA; 2Department of Research and Development, Pathnostics, Irvine, CA, USA; 3Department of Writing, Stat4Ward, Pittsburgh, PA, USA; 4Department of Statistical Analysis, Stat4Ward, Pittsburgh, PA, USA; 5Department of Medical Affairs, Pathnostics, Irvine, CA, USACorrespondence: Mohit Mathur, Pathnostics, 15545 Sand Canyon Suite 100, Irvine, CA, 92618, USA, Email mmathur@pathnostics.comPurpose: Complicated UTIs (cUTIs) cause significant morbidity and healthcare resource utilization and cost. Standard urine culture has limitations in detecting polymicrobial and non-E. coli infections, resulting in the under-diagnosis and under-treatment of cUTIs. In this study, patient-reported outcomes were compared between treated and untreated patients when an advanced diagnostic test combining multiplex-polymerase chain reaction (M-PCR) with a pooled antibiotic susceptibility method (P-AST) was incorporated into the patients’ clinical management.Methods: Patients who had symptoms typical of cUTI and positive M-PCR/P-AST test results were recruited from urology clinics. Symptom reduction and clinical cure rates were measured from day 0 through day 14 using the American English Acute Cystitis Symptom Score (ACSS) Questionnaire. Clinical cure was defined based on the sum of the scores of four US Food and Drug Administration (FDA) symptoms and the absence of visible blood in the urine.Results: Of 264 patients with suspected cUTI, 146 (55.4%) had exclusively non-E. coli infections (115 treated and 31 untreated) and 190 (72%) had polymicrobial infections (162 treated and 28 untreated). Treated patients exhibited greater symptom reduction compared to untreated ones on day 14 for those with exclusively non-E. coli organisms (3.18 vs 1.64, p = 0.006) and polymicrobial infections (3.52 vs 1.41, p = 0.002), respectively. A higher percentage of treated patients than of untreated patients achieved clinical cure for polymicrobial infections on day 14 (58.7% vs 36.4%, p = 0.049).Conclusion: Patients with cUTIs treated based on the M-PCR/P-AST diagnostic test had significantly improved symptom reduction and clinical cure rates compared to untreated patients among those with non-E. coli or polymicrobial infections.Keywords: urinary tract infection, complicated urinary tract infection, antibiotic, clinical outcome, diagnostic testing, polymerase chain reaction

Alexander Combes,1 Simon McQueen,2 Catalina Alejandra Palma,1 David Benz,2 Scott Leslie,1,3– 5 Paul Sved,1,5 John Boulas,1,5 Arthur Vasilaras,1,5 Chris Rogan,2,5 Ilias Drivas,2 David Robert Eisinger,1 Richard Waugh2 1Department of Urology, Royal Prince Alfred Hospital, Camperdown, NSW, 2050, Australia; 2Department of Radiology, Royal Prince Alfred Hospital, Camperdown, NSW, 2050, Australia; 3RPA Institute of Academic Surgery, Sydney, NSW, Australia; 4Faculty of Medicine, University of Sydney, Sydney, NSW, Australia; 5Department of Urology, Chris O’Brien Lifehouse, Sydney, NSW, AustraliaCorrespondence: Alexander Combes, Department of Urology, Royal Prince Alfred Hospital, 50 Missenden Road, Camperdown, NSW, 2050, Australia, Tel +612 9515 7773, Fax +612 9515 7774, Email combes_08@hotmail.comPurpose: Renal angiomyolipoma (AML) is the most common benign renal tumor. Whilst generally asymptomatic, they can cause life-threatening bleeding. Selective angioembolization (SAE) may be used to treat large symptomatic and asymptomatic AMLs. We aimed to evaluate the efficacy of SAE for symptomatic and asymptomatic renal AMLs and determine characteristics that predict spontaneous bleeding.Patients and Methods: Data were retrospectively collected from a prospectively maintained database from July 2011 to April 2022. Patients were included if AML was > 4cm and they underwent subsequent SAE. Follow-up imaging was analyzed to calculate mean reduction in AML size. Clinical notes were reviewed to analyze lesion characteristics including vascularity, fat content and presence of aneurysm as well as post-procedural complications.Results: 26 patients with 30 AMLs were identified. Interval of follow-up imaging ranged from 1 to 60 months. 25 AMLs were embolized electively with 5 emergency embolizations performed for bleeding. Mean reduction in AML volume was 41% at 3 months (p=0.013) and 63% at 12 months (p=0.007). All 5 bleeding AMLs had a rich vascularity with 60% also having either aneurysms or a low fat content. Complications included post-embolic syndrome (n=9), segmental renal parenchyma devascularization (n=3), acute bleeding requiring re-embolization (n=2), nephrectomy for ongoing bleeding (n=1) and delayed bleeding managed conservatively (n=1). No deterioration in renal function was observed.Conclusion: SAE is an effective procedure for managing symptomatic and asymptomatic renal AML, with minimal significant complications. AML vascularity, fat content and aneurysms may be useful characteristics to assess future risk of bleeding in patients with renal AML.Keywords: selective angioembolization, aneurysm, fat content, tuberosclerosis complex

Nicholas A Deebel,1 Kyle Scarberry,2 Collette A O’Connor,1 Rahul Dutta,1 Ethan Matz,1 Colleen A Hanlon,3 Ryan P Terlecki1 1Department of Urology, Atrium Health Wake Forest Baptist Medical Center, Winston-Salem, NC, USA; 2Department of Urology, University Hospitals Cleveland Medical Center, Cleveland, OH, USA; 3Department of Cancer Biology, Wake Forest University School of Medicine, Winston-Salem, NC, USACorrespondence: Ryan P Terlecki, Department of Urology, Atrium Health Wake Forest Baptist Medical Center, 1 Medical Center Blvd, Winston-Salem, NC, 27157, Tel +1 336 716 4131, Fax +1 336 716 9042, Email rterlecki@wakehealth.eduPurpose: Kratom (Mitragyna speciosa) exhibits μ-receptor agonism and is used as an opioid substitute. While opioids are known to inhibit sexual behavior, less is known regarding kratom. We conducted a pilot study to assess the subjective impact of kratom upon male sexual health including erectile and ejaculatory function.Patients and Methods: Twitter and Reddit (r/Kratom) were accessed to disseminate our survey featuring validated instruments (the International Index of Erectile Function, IIEF, and the premature ejaculation diagnostic tool, PEDT). Sexual health prior to and after 4 weeks of kratom use was assessed.Results: Most males surveyed (n = 165) were 18– 40 years old (84.9%), with 95.8% of respondents using it at least weekly and 82.4% using kratom for ≥ 1 year. Reasons for use included treating pain (39.4%), and mental health conditions (63.6%). Kratom was associated with a positive (37.7%) and negative (20.5%) impact on sexual health. Kratom subjectively increased time to ejaculation in 104 (66.6%) patients, perceived as positive by 62 (59.6%). Seventy-eight patients answered questions about premature ejaculation. The median (with interquartile range, IQR, following;) pre-kratom and kratom use scores were 13.0; 8.0 and 6.5; 5.0, respectively (p < 0.001). Ejaculation before 5 minutes improved after kratom (51.3% vs 12.8%) (p < 0.0001). Following kratom use, patients reported lack of frustration with ejaculation prior to desire (21.8% vs 61.5%) (p < 0.001). The erectile function domain of the IIEF was statistically significantly different however – clinically similar pre-kratom use (29.0; 5.75) versus 27.0; 6.75 during kratom use (p = 0.037).Conclusion: Clinicians treating male sexual health should be aware of kratom and its potential effect on ejaculatory and erectile function.Keywords: kratom, Mitragyna speciosa, premature ejaculation, analgesia, sexual function

Mahmoud Mustafa,1,2 Hamzeh Al Zabadi,3 Shaden Mansour,1 Aya Nabulsi1 1Department of Urology, An-Najah National University Hospital, An-Najah National University, Nablus, Palestine; 2Medicine Department, Faculty of Medicine and Health Sciences, An-Najah National University, Nablus, Palestine; 3Public Health Department, Faculty of Medicine and Health Sciences, An-Najah National University, Nablus, PalestineCorrespondence: Mahmoud Mustafa, Department of Urology, An-Najah National University Hospital, An-Najah National University, Nablus, Palestine, Email dr_mahmoud681@yahoo.com Hamzeh Al Zabadi, Public Health Department, Faculty of Medicine and Health Sciences, An-Najah National University, Nablus, Palestine, Email halzabadi@gmail.comBackground: In this study we aimed to assess and compare the rate of sem-irigid ureterorenoscope in the treatment of upper and lower ureter stones through pneumatic lithotripsy (PL).Materials and Methods: Ninety-two patients with a mean age±SD of 45± 15years who had had a surgical procedure performed by the same experienced surgeon between January 2013 and July 2015 were included in the study. The mean±SD stone size was 8.8± 2.6 mm. Forty-two of the patients (45.7%) had upper ureter stones and 50 (54.3%) had lower ureter stones in order to increase the success rate and avoid stone migration. The medical files of the patients were reviewed regarding age, sex, stone size, stone location, success rate, complications, and presence of hydronephrosis. Success was operationally defined as the complete fragmentation of stone to very small parts that could pass or complete extraction of the stone.Results: Eighty-four of the patients were stone free (91%). The success rates for patients with upper or lower ureteric stones were 93% and 90%, respectively (P=0.63). There were no complications during the operation. However, 4 patients (4.4%) had postoperative complications in terms of urinary tract infection or urosepsis. Those were accurately managed by the suitable medical treatment.Conclusion: Semi-rigid ureterorenoscopy by using PL was a safe and practical treatment option for managing the upper and lower ureter stones. Performing the tips and tricks of ureterorenoscopy by an experienced surgeon seems to enhance the success rate, especially in upper ureter stones.Keywords: pneumatic lithotripsy, Palestine, ureterorenoscopy, ureter stone, ureter

Ibrahim G Alghamdi Public Health Department, College of Applied Medical Sciences, University of Al-Baha, Al-Baha, Saudi ArabiaCorrespondence: Ibrahim G Alghamdi, University of AL-Baha, College of Applied Medical Sciences, Public Health Department, Prince Mohammad Bin Saud, Al-Baha, 65527, Saudi Arabia, Tel +966553777925, Email stat@hotmail.comObjective: This study examines the epidemiology related to testicular cancer (TC) in the administrative regions of Saudi Arabia by looking at not only the percentage/ frequency of diagnosed cases, but also the crude incidence rate, age-specific incidence rate, and age-standardized incidence rate stratified by the age group, diagnosis year, and regions.Methods: From 2004 to 2017, descriptive epidemiological research was carried out across all TC cases registered under the Saudi Cancer Registry (SCR). Descriptive statistics as well as the Kruskal–Wallis test, together with SPSS (version 20.0) were used to evaluate the data.Results: The SCR received 1114 reports of TC diagnoses between January 2004 and December 2017. TC was diagnosed most frequently in Saudi men aged 15– 44 years. In terms of Saudi men, Jouf, Tabuk, Hail, and the Northern region reported the highest age-specific incidence rate (ASIR) of TC at 1.1 per 100,000 men. Alternatively, Baha, Jazan, and Riyadh had the lowest overall ASIR of TC (0.1 and 0.3 per 100,000 men, respectively). The ASIR of TC exceeded its previous levels by twofold. The likelihood of TC was five times higher in Jouf, Tabuk, Hail, and Northern regions than in Baha and Jazan.Conclusion: In Saudi Arabia, the ASIRs of TC doubled between 2004 and 2017. TC was most frequently diagnosed in younger Saudi men. Jouf, Tabuk, Hail, and Northern regions of Saudi Arabia had the highest incidence of TC among Saudi men, whereas Baha, Jazan, and Riyadh had the lowest incidence.Keywords: cancer epidemiology, testicular cancer, Saudi Cancer Registry, oncology, incidence rate

Jing-Hua Yang,1 Zuohui Zhao,2 Wanting Niu,3 Han-Pil Choi,3 Kazem M Azadzoi4 1Department of Surgery, Boston University School of Medicine and Proteomics Laboratory, VA Boston Healthcare System, Boston, MA, USA; 2Department of Urology, Boston University School of Medicine, Boston, MA, USA; 3Research Department, VA Boston Healthcare System, Boston, MA, USA; 4Departments of Urology and Pathology, VA Boston Healthcare System and Boston University School of Medicine, Boston, MA, USACorrespondence: Kazem M Azadzoi, VA Boston Healthcare System, Building 1A, Room 317 (151), 150 South Huntington Avenue, Boston, MA, 02130, USA, Tel +1 857-364-5602, Email kazadzoi@bu.eduPurpose: Growing evidence suggests that ischemia provokes detrusor overactivity and degenerative responses in the bladder. Underlying mechanisms appear to involve modification of smooth muscle contractile rudiments by hypoxia, redox, cellular stress and cell survival signaling. Downstream pathways of cellular stress and stress response molecules eliciting bladder dysfunction in ischemia remain largely elusive. Our goal was to define the role of double stranded RNA (dsRNA), a stress response molecule provoked by redox, in ischemia mediated bladder dysfunction.Methods: A rat model of pelvic ischemia along with a cell culture hypoxia model were used to investigate the expression levels, functional consequences, structural aspects, and regulatory mechanisms of dsRNA in the bladder. Gene and protein expression were examined by reverse transcription polymerase chain reaction (RT-PCR), dot blot, and Western blotting, respectively. Tissue structure and function were assessed using histological staining and organ bath. Regulatory mechanisms were analyzed in cultured bladder smooth muscle cells.Results: The data presented here provide the first evidence of the formation of dsRNA in the overactive bladder. dsRNA is a cellular stress response molecule that sensitizes smooth muscle and regulates inflammatory and degenerative rejoinders. Our data suggest that the production of dsRNA in the bladder is provoked by ischemia. Formation of dsRNA appears to augment bladder smooth muscle contractions and provoke fibrotic and apoptotic responses. Downstream actions of dsRNA in the bladder may involve upregulation of dsRNA-activated protein kinase R (PKR) and caspase-3, the executioner of apoptosis.Conclusion: Activation of dsRNA/PKR pathway may play a role in sensitization of bladder smooth muscle cells to contractile stimuli, whereas dsRNA and caspase-3 crosstalk appear to modulate cellular stress and instigate degenerative responses in bladder ischemia. These observations suggest the role of dsRNA in bladder dysfunction and may open new perspectives to overcome overactive smooth muscle contractions and structural damage in the bladder.Keywords: bladder, ischemia, overactivity, dsRNA, contraction, degeneration

Purpose: Cystoscopy procedures can cause distress among patients. Patient perspectives on health services are essential inputs in decision-making. This study investigated the patient preferences in Spain regarding single-use cystoscopes (SUC) compared to reusable cystoscopes and their willingness to pay (WTP) for cystoscopy procedures.Patients and Methods: Between May and June 2021, an anonymous survey was distributed to Spanish patients who had previously undergone a cystoscopy. The survey included patient preference measures on reusable cystoscopes compared to SUCs and a discrete choice experiment. The survey was distributed through a human data science company (IQVIA), collected using an online survey tool (QuestionPro (R)), and analyzed using Stata/MP, StataCorp.Results: Of 300 respondents, 148 (49.33%) were female and 150 (50%) were male, and mainly between 18-49 years (247, 82.33%). Most (265, 88%) preferred to have their procedure performed with a SUC rather than a reusable cystoscope. Among these patients, 215 (80%) could imagine asking their doctor to use a SUC. A total of 231 (77%) respondents indicated an increased level of concern about the risk of exposure to contamination related to their cystoscopy following the COVID-19 pandemic. Patients would pay 62 EUR to have their initial consultation and cystoscopy procedure on the same day (p < 0.001), 59 EUR to reduce the environmental impact, and 57 EUR to reduce the risk of contamination (p < 0.001).Conclusion: Patients prefer to undergo cystoscopy using an SUC on the same day as their initial consultation. The increased contamination concerns due to the COVID-19 pandemic and WTP to reduce the risk of cystoscope contamination may explain patients' preferences for SUCs. The most important attributes related to their cystoscopy procedure are the ability to have their procedure performed on the same day as their initial consultation, the reduction of the environmental impact, and the reduction of the contamination risk.

Ana Neves,1 Luísa Viveiros,2 Veronica Venturelli,3 David A Isenberg4 1Internal Medicine Department, Centro Hospitalar Universitário de São João, Oporto, Portugal; 2Internal Medicine Department, Centro Hospitalar Universitário de Santo António, Oporto, Portugal; 3Rheumatology Unit, Department of Medical Sciences, Università degli Studi di Ferrara, Azienda Ospedaliero-Universitaria S. Anna, Cona, Italy; 4Centre for Rheumatology, Department of Medicine, University College London, London, UKCorrespondence: David A Isenberg, The Department of Rheumatology, Division of Medicine, University College London, Room 423 the Rayne Building, London, WC1E 6JF, UK, Email d.isenberg@ucl.ac.ukAbstract: Lupus nephritis (LN) is a frequent and serious complication of systemic lupus erythematosus (SLE), impairing patients’ quality of life and significantly increasing mortality. Despite optimizing the use of conventional immunosuppressants and other biological drugs, its management remains unsatisfactory. This is mainly due to the heterogeneity of SLE, but also to insufficiently effective treatment regimens and clinical trial limitations (strict criteria, low number of patients included, and side effects). Most clinical trials of new biological therapies have failed to meet their primary endpoints in both general SLE and LN, with only two biological drugs (belimumab and anifrolumab) being approved by the Food and Drug Administration (FDA) for the treatment of SLE. Recently, several Phase II randomized controlled trials have evaluated the efficacy and safety of new biologics in LN, and some of them have demonstrated an improvement in clinical and laboratory measures. Multi-target therapies are also being successfully developed and encourage a belief that there will be an improvement in LN outcomes.Keywords: biological therapies, systemic lupus erythematosus, lupus nephritis, trial

Megan Giles,1 Simon J Crabb1,2 1Department of Medical Oncology, University Hospital Southampton NHS Foundation Trust, Southampton, UK; 2School of Cancer Sciences, University of Southampton, Southampton, UKCorrespondence: Simon J Crabb, University of Southampton, Mailpoint 824, Centre for Cancer Immunology, Southampton General Hospital, Southampton, SO16 6YD, UK, Email S.J.Crabb@southampton.ac.ukAbstract: Muscle-invasive bladder cancer has poor prognosis. If organ confined, it is potentially curable; however, across all prognostic groups, approximately half of patients will relapse. For patients with advanced disease, the median overall survival remains under two years. Systemic treatment options are centered on the use of platinum-based combination chemotherapy, with the choice of cisplatin- or carboplatin-based regimens determined on the basis of criteria including performance status and renal function. PD-1/PD-L1 checkpoint-directed immunotherapy has been established for use in advanced disease with modest overall improvements in survival outcomes. Based on current data, optimal utilization appears to be a switch maintenance strategy on completion of chemotherapy. In the curative setting, cisplatin-based chemotherapy provides modest improvements in cure rates in those fit to receive it. Data on the use of adjuvant immunotherapy are currently contradictory, with disease-free survival demonstrated for adjuvant nivolumab, but not atezolizumab, and no overall survival benefit has yet been confirmed. The Nectin-4 directed antibody drug conjugate enfortumab vedotin is an established treatment option for patients previously treated with both chemotherapy and immunotherapy. The emerging therapeutic targets under evaluation include Trop-2 with sacituzumab govitecan, fibroblast growth factor receptors, HER2, and DNA repair deficiency in biomarker-selected patients. The development of properly validated predictive biomarkers has proven challenging for this disease and should be a central priority in the future development of treatment options. This review summarizes the available systemic treatment options in both palliative and curative disease settings, and highlights the available evidence and current limitations for making treatment recommendations.Keywords: bladder cancer, urothelial carcinoma, chemotherapy, immunotherapy, enfortumab vedotin

Benoît Vogt,1 Janine Dove-Rumé2 1Department of Urology, Polyclinique de Blois, La Chaussée Saint-Victor, France; 2English Department, François-Rabelais University, Tours, FranceCorrespondence: Benoît Vogt, Department of Urology, Polyclinique de Blois, 1 Rue Robert Debré, La Chaussée Saint-Victor, 41260, France, Tel +33 254906511, Fax +33 254906566, Email message@benoitvogt.frIntroduction: Ureteral stent obstruction hinders the management of malignant diseases. Adequate stent insertion through an obstructed ureter does not necessarily guarantee renal decompression and stent-related symptoms adversely affect patient comfort. There are two major problems associated with ureteral stents: obstruction and intolerance to the stents.Case Presentation: A 45-year-old woman was treated for cervical cancer with metastatic lymph nodes and ureteral obstruction with chemotherapy, radiotherapy, immunotherapy, and bilateral retrograde stenting. After recurrent stent obstruction, stent replacement was attempted more than 18 times over two years. In addition, stent-related symptoms adversely affected patient comfort. The patient was finally fitted with Superglide 8-French reinforced ureteral stents. Their replacement every six months was viewed by the patient as a relief compared to the all too frequent replacement of the previous stents. Moreover, the customized changes in the shape of Superglide stents improved patient comfort.Discussion: Recent publications tend to indicate that large-lumen ureteral stents are most likely to remain permeable over time. Various modifications of the bladder or endo-ureteral part of double-pigtail stents have been increasingly reported, with the aim of improving their tolerance while maintaining effective drainage.Conclusion: Adaptation of the internal lumen and shape of stents to the characteristics of the tumor and patient measurements appears to be important for increasing the drainage and tolerance of ureteral stents. The top priority for future ureteral stents suitable for malignant diseases should be to integrate these characteristics based on state-of-the-art data.Keywords: malignant ureteral obstruction, ureteral stent, renal failure, stent failure, stent-related symptoms

Naoki Wada, Noriyuki Abe, Kotona Miyauchi, Shogo Makino, Hidehiro Kakizaki Department of Renal and Urologic Surgery, Asahikawa Medical University, Asahikawa, JapanCorrespondence: Naoki Wada, Department of Renal and Urologic Surgery, Asahikawa Medical University, Asahikawa, Japan, Tel +81-166-65-2533, Email nwada@asahikawa-med.ac.jpPurpose: In this study, we investigated skeletal muscle loss and bladder dysfunction caused by high-fat/high-sucrose (HFS) diet.Methods: Twelve-week-old Sprague–Dawley (SD) female rats were fed on normal (Group N) or HFS (Group HFS) diet for 12 weeks. We conducted urodynamic investigation and pharmacologic in vitro. In addition, we measured gastrocnemius and tibialis muscle weight and protein concentration. The hypoxia-inducible factor (HIF)-1α and 8-hydroxy-2’-deoxyguanosine (8-OHdG) in the bladder were assayed.Results: The urodynamic investigations revealed the significantly shorter intercontraction intervals and lower maximal voiding pressure in Group HFS than in Group N. Furthermore, the absolute and relative weights of the gastrocnemius muscle were found to be significantly lower in Group HFS than in Group N. The protein concentration of the gastrocnemius muscle was also significantly lower in Group HFS than in Group N. The absolute and relative weights of the bladder were also significantly lower in Group HFS than in Group N. The contractile responses of the bladder strips to electrical field stimulation and carbachol were significantly lower in Group HFS than in Group N. The HIF1α and 8OHdG in the bladder muscle were significantly higher in Group HFS than in Group N. The HFS diet reduced bladder capacity and contractility along with the loss of the gastrocnemius muscle.Conclusion: HFS diet promotes bladder dysfunction similar to detrusor hyperreflexia with impaired contractility.Keywords: high-fat, high-sucrose, bladder dysfunction, rat, skeletal muscle

Laura Nino-Torres,1 Andrea Garcia-Lopez,2 Nasly Patino-Jaramillo,2 Fernando Giron-Luque,1 Alejandro Nino-Murcia1 1Department of Transplantation Surgery, Colombiana de Trasplantes, Bogotá, Colombia; 2Department of Transplantation Research, Colombiana de Trasplantes, Bogotá, ColombiaCorrespondence: Alejandro Nino-Murcia, Transplant Surgeon, Colombiana de Trasplantes, Av Carrera, 30 No. 47 A-74, Bogota, 111311, Colombia, Tel +57 3112499999, Email anino@colombianadetrasplantes.comBackground and Purpose: Kidney transplantation (KT) is the best therapy for chronic kidney disease (CKD). Major urologic complications (MUCs) are the second etiology associated to morbidity and graft loss following KT, after rejection episodes. The objective of this study was to estimate the incidence, risk factors and impact on graft survival associated to urological complications in KT patients.Patients and Methods: A retrospective cohort based on electronic patient files of kidney transplant recipients from Colombiana de Trasplantes was created for the period August 2008 to September 2019. Initiation of follow-up was defined as the date of transplantation up to 3 years post-transplantation. Incidence of ureteral stenosis, ureteral obstruction, and ureteral leak was measured. A logistic regression multivariate model was adjusted to determine the associated factors to MUCs (yes/no). Patient and graft survival time were analyzed using a Kaplan-Meier method.Results: A total of 1584 KT patients were included in the cohort. MUCs were present in 195 (12.6%) KT patients. We found that dialysis duration (OR: 1.004; p = 0.02) remained significant for the incidence of MUCs in KT patients of deceased donors. Probability of graft and patient survival at 3 years of follow-up was 90.5% and 85.5%, respectively. No significant difference was found on graft and patient survival in KT patients with or without MUCs.Conclusion: MUCs are frequent complications for KT. We did not observe significant differences in graft or patient survival according to the presence of MUCs. The identification of MUCs and risk factors may guide transplant teams for future surgical and clinical decisions.Keywords: major urologic complications, kidney transplantation, graft survival, patient survival

Severin Rodler,1 Alexander Buchner,1 Lennert Eismann,1 Gerald Bastian Schulz,1 Julian Marcon,1 Stephan Ledderose,2 Boris Schlenker,1 Christian G Stief,1 Alexander Karl,3 Jan-Friedrich Jokisch1 1Department of Urology, Klinikum der Universität München, Munich, Germany; 2Department of Pathology, Klinikum der Universität München, Munich, Germany; 3Department of Urology, Barmherzige Brüder Krankenhaus München, Munich, GermanyCorrespondence: Severin Rodler, Department of Urology, Klinikum der Universität München, Marchioninistr. 15, München, 81377, Germany, Tel +089 4400 73530, Fax +089 4400 76532, Email severin.rodler@med.uni-muenchen.dePurpose: Absence of tumor in the final histopathology after radical cystectomy (RC) is a rare but potentially favorable outcome. Therefore, we aimed to analyze outcomes and prognostic factors of patients with urothelial carcinoma (UC) undergoing RC and T0 in the final histology without neoadjuvant chemotherapy at a high-volume academic center.Patients and Methods: We retrospectively analyzed patients undergoing RC for pure UC between 2004 and 2020. Cancer-specific survival (CSS) and overall survival (OS) were calculated using Kaplan–Meier analysis and group comparison by Log rank test. Potential prognostic factors were analyzed using univariate Cox regression models.Results: A total of 1051 patients with UC underwent RC. 72 patients (6.7%) showed pT0 in the final histology. Across all T-stages, 5-year CSS was significantly different with 88% for pT0, 80% for pTa/pTis, 78% for pT1, 76% for pT2, 51% for pT3 and 27% for pT4 in our cohort (p=0.001). Neither instillation therapy (HR 0.31, 95% CI 0.07– 1.43), number of TURB prior RC (HR 1.47, 95% CI 0.25– 6.18), use of photodynamic diagnostics (PDD) (HR 0.64, 95% CI 0.14– 3.02), performing a second resection (HR 0.87, 95% CI 0.27– 2.86), muscle-invasive disease prior RC at any TURB (HR 0.7, 95% CI 0.2– 2.39) or muscle-invasive disease in the TURB prior RC (HR 1.0, 0.31– 3.29) were associated with CSS in univariate analysis.Conclusion: pT0 reveals a survival benefit in patients undergoing RC for UC and therefore presents a distinctive tumor entity. As clinical and cystoscopic characteristics do not improve patient stratification, further research is warranted to define risk groups in this specific tumor entity.Keywords: bladder cancer, radical cystectomy, pT0 status after cystectomy

Francis A Jefferson, Brian J Linder Department of Urology, Mayo Clinic, Rochester, MN, USACorrespondence: Brian J Linder, Email Linder.Brian@mayo.eduAbstract: Hemorrhagic cystitis (HC) can be one of the most challenging clinical scenarios for urologists to manage. It most commonly occurs as a toxicity of pelvic radiation therapy or in patients treated with the oxazaphosphorine class of chemotherapy. Successful management of HC necessitates a stepwise approach with a thorough understanding of the various treatment options. Once ensuring hemodynamic stability, conservative management includes establishing bladder drainage, manual clot evacuation, and continuous bladder irrigation through a large-bore urethral catheter. If gross hematuria persists, operative cystoscopy with bladder clot evacuation is often required. There are multiple intravesical options for treating HC, including alum, aminocaproic acid, prostaglandins, silver nitrate, and formalin. Formalin is an intravesical option that has caustic effects on the bladder mucosa and is most often reserved as a last-line intravesical treatment. Non-intravesical management tools include hyperbaric oxygen therapy and oral pentosan polysulfate. If needed, nephrostomy tube placement or superselective angioembolization of the anterior division of the internal iliac artery can be performed. Finally, cystectomy with urinary diversion is a definitive, albeit invasive, treatment option for refractory HC. While there is no standardized algorithm, treatment modalities typically progress from less to more invasive. Clinical judgement and shared decision-making with the patient are required when choosing therapies for managing HC, as success rates are variable and some treatments may have significant or irreversible effects.Keywords: hemorrhagic cystitis, hematuria, cystectomy, formalin, bladder cancer, radiation

Meshari A Alzahrani,1 Muhammad Anwar Khan,2,3 Basel O Hakami,4 Abdulaziz Alahmadi,5 Mohammed Alzahrani,6 Faisal Alsaleh,6 Muath Almurayyi,7 Omar Safar,8 Mohammad Shakil Ahmad9 1Department of Urology, College of Medicine, Majmaah University, Al-Majmaah, Saudi Arabia; 2College of Medicine, King Saud bin Abdulaziz University for Health Sciences (KSAU-HS), Jeddah, Saudi Arabia; 3King Abdullah International Medical Research Centre (KAIMRC), Jeddah, Saudi Arabia; 4Department of Urologyṣ, King Faisal Medical City for Southern Region (KFMC), Abha, Saudi Arabia; 5College of Medicine, Taibah University, Madinah, Saudi Arabia; 6College of Medicine, King Saud University, Riyadh, Saudi Arabia; 7Urology Department, King Khaled University Medical City, Abha, Saudi Arabia; 8Urology Department, Armed Forces Hospital Southern Region, Khamis Mushayt, Saudi Arabia; 9Department of Family & Community Medicine, College of Medicine, Majmaah University, Al Majmaah, Saudi ArabiaCorrespondence: Meshari A Alzahrani, Department of Urology, College of Medicine, Majmaah University, Al-Majmaah, 11952, Saudi Arabia, Tel +966569990693, Fax +966164042500, Email ma.alzahrani@mu.edu.saBackground: Online medical education is critical for public health literacy and physician efficacy, but it must be trustworthy. Although it has the potential to be a useful resource for medical education, users must be able to identify reliable content.Objective: To assess the scientific quality of Arabic-language video content related to erectile dysfunction that is available on YouTube to learn what information our patients can handle online.Materials and Methods: A comprehensive search of the YouTube database was carried out to identify videos related to erectile dysfunction published in Arabic. The search was conducted using the following keywords: “Erectile dysfunction”, “Sexual dysfunction” and “Impotence”. Without a time, limit, the search was carried out until January 1, 2023. The quality assessment of the videos was done using the Kappa score.Results: The videos in our sample had up to one million views (average 2,627,485.6), and the kappa index was 0.86 (p < 0.001). Of these videos, 16% were considered scientific evidence-based (SEB), and 84% were considered not scientific evidence-based (NSEB) (p < 0.001). The NSEB group addressed details concerning natural remedies, the Psychosocial sphere, and lifestyle, whereas the SEB group tended to be more concerned with physiopathology, etiology, endothelial dysfunction, diagnosis, psychosocial treatment, oral treatment, injections, or prosthesis.Conclusion: On social media, misleading or incorrect information about erectile dysfunction is widely disseminated. This research may support urological and technical oversight and emphasizes guiding patients to the best men’s health options.Keywords: Arabic language, YouTube, erectile dysfunction, videos, internet, social media

Meshari A Alzahrani,1 Abdalah Almhmd,2 Muhammad A Khan,3,4 Feras Badriq,5 Budoor Salman,6 Zainab Y Aljaziri,7 Naif Alotaibi,8 Mohammad Alkhamees,1 Sulaiman Almutairi,1 Mohammad Shakil Ahmad,9 Sultan Alkhateeb10,11 1Department of Urology, College of Medicine, Majmaah University, Al-Majmaah, Saudi Arabia; 2College of Medicine, Majmaah University, Al-Majmaah, Saudi Arabia; 3College of Medicine, King Saud bin Abdulaziz University for Health Sciences (KSAU-HS), Jeddah, Saudi Arabia; 4King Abdullah International Medical Research Centre (KAIMRC), Jeddah, Saudi Arabia; 5Division of Urology, Department of Surgery, East Jeddah General Hospital, Ministry of Health, Jeddah, Saudi Arabia; 6Department of Urology, King Abdulaziz Medical City, Ministry of National Guard - Health Affairs, Jeddah, Saudi Arabia; 7Department of Family Medicine, Al Ahsa Health Cluster, Ministry of Health, Al Ahsa, Saudi Arabia; 8King Salman Bin Abdulaziz Hospital, Ministry of Health, Riyadh, Saudi Arabia; 9Department of Family & Community Medicine, College of Medicine, Majmaah University, Al Majmaah, Saudi Arabia; 10Department of Urology, King Faisal Specialist Hospital & Research Center, Riyadh, Saudi Arabia; 11College of Medicine, Alfaisal University, Riyadh, Saudi ArabiaCorrespondence: Meshari A Alzahrani, Department of Urology, College of Medicine, Majmaah University, Al-Majmaah, 11952, Saudi Arabia, Tel +966569990693, Fax +966164042500, Email ma.alzahrani@mu.edu.saBackground: There is limited research on whether women choose urology as a future career. Therefore, we aimed in this study to assess the influencing and challenging factors among female physicians in Saudi Arabia.Methods: We approached 552 female physicians, including 29 (5.2%) urologists and 523 (94.7%) non-urologists. A cross-sectional survey was carried out, which included five sections and 46 items to assess and compare the perspectives of (urologists and non-urologists regarding influencing factors to choose urology, challenges toward applying to urology, and challenges during and after urology residency. Statistical analysis was conducted using SPSS software. Responses were presented as frequencies and percentages, while associations were studied using the Chi-squared test/Fisher’s exact test. A p-value of ≤ 0.05 was considered significant.Results: Out of 552 female physicians, 466 completed the survey. The survey items compared urologists and non-urologists among female physicians. Among both cohorts, the most influencing factors in choosing urology were the diversity of practice and urological procedures (p =0.002, p< 0.001). There were no social barriers or challenges when applying for urology residency (p< 0.001). Overall, the majority of female urologists reported a high level of agreement that they have more time to work at the clinic (55.2%), they are satisfied as they are currently being urologists (75.8%), satisfied with their current lifestyle (72.6%). They would choose urology again as a future career (58.6%). Non-urologist female physicians 326 (74.6%) think they are more likely to have experienced gender discrimination than urologists 15 (51.7%) (p< 0.001). Female urologists were less likely to face social barriers when applying for urology residency than non-urologists (p< 0.001).Conclusion: As urologists, we must understand women’s struggles, such as gender discrimination, a lack of academic advancement, and a lack of mentorship. To foster women’s careers in urology, we must understand their unique needs, provide adequate mentorship, exterminate gender discrimination bias, and improve mentorship.Keywords: women, female, urology, training, residency, challenges, Saudi Arabia

Simone Ferretti,1,&ast; Chiara Mercinelli,2,&ast; Laura Marandino,2 Giulio Litterio,1 Michele Marchioni,1 Luigi Schips1 1Department of Medical, Oral and Biotechnological Sciences, G. d’Annunzio University of Chieti, Urology Unit, Chieti, Italy; 2Division of Experimental Oncology, Urological Research Institute, IRCCS San Raffaele Scientific Institute, Milan, Italy&ast;These authors contributed equally to this workCorrespondence: Michele Marchioni, Department of Medical, Oral and Biotechnological Sciences, G. d’Annunzio University of Chieti, Urology Unit, Chieti, Italy, Tel +393296544866, Fax +390871357756, Email mic.marchioni@gmail.comAbstract: The therapeutic landscape of metastatic hormone sensitive and metastatic castration-resistant prostate cancer (mCRPC) is rapidly changing. We reviewed the current treatment options for mCRPC, with insights on new available therapeutic strategies. Chemotherapy with docetaxel or cabazitaxel (for patients progressing on docetaxel), as well as treatment with androgen receptor axis targeted therapies, and Radium-223 are well-established treatment options for patients with mCRPC. The advent of theragnostic in prostate cancer established Lutetium-177 (177Lu)–PSMA-617 as a new standard of care for PSMA-positive mCRPC previously treated with ARAT and taxane-based chemotherapy. Olaparib, a poly-ADP-ribose polymerase (PARP) inhibitor, is approved for selected patients with mCRPC progressed on ARATs and in combination with abiraterone acetate as first-line treatment for mCRPC. Immunotherapy showed limited efficacy in unselected patients with mCRPC and novel immunotherapy strategies need to be explored. The search for biomarkers is a growing field of interest in mCRPC, and predictive biomarkers are needed to support the choice of treatment and the development of tailored strategies.Keywords: metastatic castration resistant prostate cancer, chemotherapy, androgen-receptors axis targeted therapies, PARP inhibitors, theragnostic, predictive biomarkers

Mehmet Yilmaz, Yusuf Sahin Department of Urology, University of Health Sciences Ba&gbreve;c&inodot;lar Training and Research Hospital, Istanbul, TurkeyCorrespondence: Mehmet Yilmaz, Email drmehmetyilmaz@yandex.comObjective: In this comparative study, we evaluated the results of flat prone and prone hip flexed percutaneous nephrolithotomy in terms of efficacy and safety to contribute to the optimal prone percutaneous nephrolithotomy position.Materials and Methods: Data of the patients who underwent percutaneous nephrolithotomy operations in a flat-prone or prone hip flexed positions due to renal pelvis and/or ≥ 2 Calix filling stones between January 2016 and January 2022 were collected retrospectively. Demographic data of the patient groups in different prone positions as well as clinical findings, stone characteristics and operative data were analyzed. The groups were also compared in terms of post-operative findings and complications.Results: The average age and CROES scores of patients included in the study were 47.15± 15.6 years and 221.76± 62.49, respectively. There was no statistically significant difference between the two groups in terms of patient demographic data, stone-free status and complication rates. Operation Room Time (ORT) (min) in flat prone PCNL group was shorter in average (100.57± 32.74 min vs 92.32± 28.75 min, p = 0.041) and duration with nephrostomy (days) and hospitalization (days) parameters were statistically significantly shorter in prone hip flexed PCNL (respectively, p < 0.001; p = 0.005).Conclusion: Flat-prone PCNL provides significantly shorter ORT. However, the time with nephrostomy and hospitalization with the prone hip flexed PCNL were shorter than flat-prone position. The findings will guide the optimal prone PCNL position.Keywords: flat prone position, hip flexed prone position, kidney stone, percutaneous nephrolithotomy

Wesley J Smith, Maia E VanDyke, Nikit Venishetty, Brian T Langford, Bryce P Franzen, Allen F Morey Department of Urology, University of Texas Southwestern Medical Center, Dallas, TX, USACorrespondence: Allen F Morey, Department of Urology, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX, 75390-9110, USA, Tel +214-648-0202, Fax +214-648-8786, Email Allen.Morey@utsouthwestern.eduPurpose: Male stress urinary incontinence (SUI) has detrimental and long-lasting effects on patients. Management of this condition is an evolving field with multiple options for surgical treatment. We sought to review the pre-operative evaluation, intra-operative considerations, post-operative care, and future directions for treatment of male SUI.Methods: A literature review was performed using the PubMed platform to identify peer-reviewed, English-language articles published within the last 5 years pertaining to management of male stress urinary incontinence with an emphasis on devices currently on the market in the United States including the artificial urinary sphincter (AUS), male urethral slings, and the ProACTTM system. Patient selection criteria, success rates, and complications were compared between the studies.Results: Twenty articles were included in the final contemporary review. Pre-operative workup most commonly included demonstration of incontinence, PPD, and cystoscopy. Definition of success varied by study; the most common definition used was social continence (0– 1 pads per day). Reported rates of success were higher for the AUS than for male urethral slings (73– 93% vs 70– 90%, respectively). Complications for these procedures include urinary retention, erosions, infections, and device malfunction. Newer treatment options including adjustable balloon systems and adjustable slings show promise but lack long-term follow-up.Conclusion: Patient selection remains the primary consideration for surgical decision-making for management of male SUI. The AUS continues to be the gold standard for moderate-to-severe male SUI but comes with inherent risk of need for revision. Male slings may be a superior option for appropriately selected men with mild incontinence but are inferior to the AUS for moderate and severe incontinence. Ongoing research will shed light on long-term results for newer options such as the ProACT and REMEEX systems.Keywords: AdVance sling, AdVance XP sling, artificial urinary sphincter, male stress incontinence, male urethral sling, ProACT, REMEEX sling, Virtue sling

Prajit Khooblall, Raevti Bole, Scott D Lundy, Petar Bajic Cleveland Clinic, Center for Men’s Health, Glickman Urological and Kidney Institute, Cleveland, OH, USACorrespondence: Petar Bajic, Cleveland Clinic, Center for Men’s Health, Glickman Urological and Kidney Institute, 9500 Euclid Ave, Q10, Cleveland, OH, 44195, USA, Tel +1 216 379 6134, Fax +1 216 445 2267, Email bajicp@ccf.orgPurpose: In this narrative review we explore additional indications for which intralesional collagenase Clostridium histolyticum (CCH) injection therapy may be used, in addition to those utilized in the IMPRESS trials. The goal is to provide updated assessment of available intralesional therapies and justify whether to expand clinical indications based on advancements over the last decade.Results: Patients receiving CCH in the acute phase of PD have shown significant improvement in penile curvature - which may be even more significant than reported due to progressive curvature over the longitudinal course of injection therapy. Across studies, patients with ventral plaques achieved the greatest curvature improvement (~30°) compared to PD patients with dorsal or lateral plaques. Patients with curvature > 90° have been minimally documented. However, the concept of patients with higher degree of curvature achieving more significant degrees of improvement prevails across studies. Studies including PD patients with volume loss deformities or indentation(s) focus on curvature improvement and do not gauge improvement in these girth loss or indentation features specifically. PD patients with calcification may benefit from CCH, however, critical analysis of included study designs and results compared to placebo do not lend for strong support of CCH in PD at this time.Conclusion: Based on the most recent research, the use of CCH in the acute phase of PD and patients with ventral penile plaques may be effective and safe. The limited available research on the efficacy of CCH on calcified plaque(s) and curvature greater than 90° is promising, however, more research is needed to ensure safety and success in this patient cohort. Finally, the current literature continues to show the use of CCH is not effective in PD patients with volume loss, indentation, or hourglass deformity. When expanding the use of CCH to patients not originally included in the IMPRESS trials, providers must prioritize minimizing chances of potential injury to urethral tissue. Finally, further investigation is required to determine whether CCH has utility for curvature greater than 90° or calcified plaques, although the limited available literature is promising.Keywords: intralesional injection, Peyronie’s disease, collagenase, Clostridium histolyticum, penile curvature

Rayan Mohamed-Ahmed, Annika Taithongchai, Ana Sofia da Silva, Dudley Robinson, Linda Cardozo Department of Urogynaecology, King’s College Hospital, London, UKCorrespondence: Rayan Mohamed-Ahmed, Email r.mohamed-ahmed@nhs.netAbstract: Incontinence is defined by either ICS 2002 or IUGA/ICS 2010 as the involuntary loss of urine and includes urgency urinary incontinence (UUI), stress urinary incontinence (SUI) or mixed urinary incontinence (MUI). It has a high worldwide prevalence with an associated impact on quality of life. Despite existing management options for the management of urinary incontinence, patients continue to be troubled by symptoms or side effects of existing treatment. There is therefore a requirement for ongoing research into treatment options for the management of UUI and SUI, that are more effective and tolerable to patients. Advances in treatment of UUI include a more selective beta 3 agonist, Vibegron, which has less impact on cardiac function than Mirabegron. Hormonal treatment, including Ospemifene and Prasterone, may improve GSM and in turn symptoms of UUI. There are advances in the types of neuromodulators available, including those that are rechargeable at home and are MRI safe. Laser has shown promising initial results. There is developing interest in the microbiome, and how this may impact future treatment modalities. Advances in treatment of SUI include the use of mobile health applications to support delivery of pelvic floor muscle training. Litoxetine, a selective serotonin reuptake inhibitor, has shown promising results at phase III trials. Functional magnetic stimulation is being developed to improve contractility of pelvic floor muscles. We also discuss interventions that improve tissue elasticity and regeneration, such as platelet rich plasma, autologous stem cell transplantation, laser therapy and radiofrequency treatment, which show short term benefits.Keywords: overactive bladder, stress urinary incontinence, laser treatment

Milena Taskovska,1 Maja Frelih,2 Toma&zcaron; Smrkolj,1 Metka Volavšek2 1Chair of Surgery, Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia; 2Institute of Pathology, Faculty of Medicine, University of Ljubljana, Ljubljana, SloveniaCorrespondence: Metka Volavšek; Milena Taskovska, Email metka.volavsek@mf.uni-lj.si; milena.taskovska@kclj.siPurpose: Basal cell carcinoma of the prostate is rare. Usually, it is diagnosed in elderly men with nocturia, urgency, lower urinary tract obstruction and normal PSA.Case Presentation: We report on a case of a 56-years-old patient who presented at the emergency ward with weight loss, nausea and vomiting. The diagnostic evaluation showed acute renal failure due to a bladder tumor. After admission to the urology ward and subsequent contrast-enhanced CT urography and contrast-enhanced chest CT, a non-metastatic bladder tumor that infiltrated the right side of the bladder and seminal vesicles was found. High-grade muscle-invasive urothelial carcinoma was diagnosed from TURBT specimens, followed by radical cystoprostatectomy with pelvic lymphadenectomy and formation of ureterocutaneostomy sec. Bricker. The histopathological examination of the resection specimen surprisingly revealed the presence of prostatic basal cell carcinoma pT4N0M0 and not urothelial cancer. Due to renal failure, the patient required hemodialysis. The recommendation of the multidisciplinary oncological meeting was to follow up with the patient by the surgeon-urologist. On imaging six months after surgery, it was suspicious for recurrence. Patient was considered for adjuvant oncological treatment.Conclusion: Although rare, basal cell carcinoma of the prostate should be considered in patients with lower urinary tract symptoms, hematuria and normal PSA. Transurethral resection of bladder tumor is indicated in patients presenting with hematuria and bladder tumor. In evaluation of such cases rare histological types should be included in the differential diagnosis.Keywords: prostate cancer, basal cell carcinoma of the prostate, renal failure, bladder tumor, transurethral resection of bladder tumor, cystoprostatectomy

Thomas Hughes,1 Lazaros Tzelves,2 Bhaskar K Somani3 1Department of Urology, Warwick Hospital, Warwick, UK; 2Department of Urology, Sismanogleio Hospital, National and Kapodistrian University of Athens, Athens, Greece; 3Department of Urology, University Hospital Southampton, Southampton, UKCorrespondence: Bhaskar K Somani, University Hospital Southampton NHS Trust, Southampton, UK, Tel +44-2381206873, Email bhaskarsomani@yahoo.comAbstract: Cystinuria is a rare genetic condition that is responsible for cystine stones. Besides stone recurrence, patients with cystine stones have reduced health-related quality of life, increased rates of chronic kidney disease and hypertension. Although lifestyle measures, medical therapy and close follow up are essential to reduce and monitor cystine stone recurrences, surgical intervention is frequently needed for most cystinuria patients. Shock wave lithotripsy, ureteroscopy, percutaneous nephrolithotomy and active surveillance all have a role, and technological advances in endourology are vital in achieving a stone-free status and to prevent recurrences. The complexity of managing cystine stones necessitates a multidisciplinary team discussion, patient involvement and an individualised approach in a specialist centre for optimum management. Thulium fibre laser and virtual reality may have an increasing role in the future of cystine stone management.Keywords: kidney calculi, ureteroscopy, percutaneous nephrolithotomy, laser, cystine, recurrence

Joshua White,1 Ross Mason,2 Tarek Lawen,2 Jesse Spooner,2 Kauy VM Faria,3 Farah Rahman,1 Ranjith Ramasamy1 1Department of Urology, University of Miami Miller School of Medicine, Miami, FL, USA; 2Department of Urology, Dalhousie University, Halifax, NS, Canada; 3Department of Urology, Institute of Cancer of São Paulo, University of São Paulo School of Medicine, Sao Paulo, BrazilCorrespondence: Ranjith Ramasamy, University of Miami, Miller School of Medicine, 1120 NW 14th Street, 15th Floor, Miami, FL, 33136, USA, Tel +1 201 388-6644, Email ramasamy@miami.eduAbstract: Penile cancer is a rare malignancy, most commonly diagnosed in older men, associated with poor outcomes, dramatic decline in quality of life and sexual function. Squamous cell carcinoma is the most common histopathology of penile cancer, accounting for 95% of all cases. Localized, early-stage penile cancer can be effectively managed through penile-sparing techniques in many cases, though advanced stages of penile cancer carry a poor prognosis. Current innovative treatments are exploring the role of targeted therapy, HPV-directed therapy, immune checkpoint inhibitors and adoptive T-cell therapies in treatment and prevention of relapse of penile cancer. Clinical trials are investigating the potential of targeted therapies and immune checkpoint inhibitors in advanced penile cancer. This review examines the current management of penile cancer and highlights future directions in research and treatment.Keywords: penile cancer, inguinal lymph node dissection, immunotherapy, targeted therapy, HPV, adoptive T-cell therapy, sexual function

Takahira Kuno,1,2 Kenji Tamura,1,3 Nobutaka Shimizu,1 Hideo Fukuhara,1 Satoshi Fukata,1 Shingo Ashida,1 Takashi Karashima,1 Hirofumi Satake,3 Kohji Sawada,4 Ichiro Yamasaki,5 Fumito Komatsu,2 Hajime Kuroiwa,6 Motoaki Saito,7 Keiji Inoue1 1Department of Urology, Kochi Medical School, Kochi University, Nankoku, Japan; 2Department of Urology, Tosa Municipal Hospital, Tosa, Japan; 3Department of Urology, Chikamori Hospital, Kochi, Japan; 4Department of Urology, Kochi Prefectural Hata Kenmin Hospital, Sukumo, Japan; 5Department of Urology, Kubokawa Hospital, Takaoka-gun, Japan; 6Integrated Center for Advanced Medical Technologies (ICAM-Tech), Kochi Medical School, Nankoku, Japan; 7Department of Pharmacology, Kochi Medical School, Kochi University, Nankoku, JapanCorrespondence: Kenji Tamura, Email tamurak@kochi-u.ac.jpObjective: The treatment effects of vibegron have not previously been evaluated in a prospective, non-interventional observational study of elderly Japanese patients, particularly those ≥ 80 years old. In addition, no reports have referred to residual urine volume in switching cases. We therefore grouped patients by condition and investigated the treatment effects of vibegron on Overactive Bladder Symptom Score (OABSS), Overactive Bladder Questionnaire Short Form (OAB-q SF), and residual urine volume in each group.Methods: This multicenter, prospective, non-interventional, observational study consecutively enrolled OAB patients with total OABSS score ≥ 3 and OABSS question 3 score ≥ 2. Sixty-three patients from six centers were recruited. Vibegron 50 mg once daily was administered for 12 weeks as first-line monotherapy (first-line group), monotherapy switching from antimuscarinics or mirabegron due to failure of prior therapy (no washout period), or combination therapy with antimuscarinics (second-line group). OABSS, OAB-q SF, and residual urine volume were collected after 4 and 12 weeks. Adverse events were also recorded at each visit.Results: Of the 63 patients registered, 61 were eligible for analysis (first line, n=36; second line, n=25). The OABSS, excluding daytime frequency scores, and OAB-q SF scale showed significant improvement in all conditions. Switching from mirabegron to vibegron significantly reduced residual urine volume. No serious treatment-related adverse events were encountered.Conclusion: Vibegron 50 mg once daily significantly improved OABSS and OAB-q SF even in patients ≥ 80 years old. Notably, switching from mirabegron to vibegron resulted in significant improvements to residual urine volume.Keywords: selective β 3-adrenoreceptor agonist, overactive bladder, residual urine volume, vibegron, mirabegron

Syah Mirsya Warli,1,2 Muhammad Haritsyah Warli,3 Fauriski Febrian Prapiska2 1Department of Urology, Faculty of Medicine Universitas Sumatera Utara – Universitas Sumatera Utara Hospital, Medan, North Sumatera, Indonesia; 2Department of Surgery Urology Division, Faculty of Medicine Universitas Sumatera Utara – Haji Adam Malik General Hospital, Medan, North Sumatera, Indonesia; 3Department of Urology, Faculty of Medicine Universitas Indonesia – Haji Adam Malik General Hospital, Medan, North Sumatera, IndonesiaCorrespondence: Syah Mirsya Warli, Tel +62 61-8364930, Email warli@usu.ac.idBackground: Prostate cancer is a highly prevalent urological carcinoma with an increasing incidence in Indonesia and all around the world. Early diagnosis can greatly affect treatment outcomes and increase life expectancy. Several biomarkers for detecting prostate cancer have been studied and showed great promise.Purpose: This study aims to analyze prostate cancer antigen 3 (PCA3) as well as transmembrane serine protease 2:ERG (TMPRSS2:ERG) for diagnosing and serving as urine biomarkers in predicting prostate cancer incidences.Methods: We conducted an analytical study to assess the utility of PCA3 and TMPRSS2:ERG for detecting prostate cancer. Thirty samples were included in this study to see the utilization of PCA3 and TMPRSS2:ERG as diagnostic biomarkers of prostate cancer. A urine sample was taken and the PCA3 test was performed using the PCA3 PROGENSA test, while the TMPRSS2:ERG was performed using the chemiluminescent DNA probe method with a hybridization protection test.Results: The average age of the subject was 61.07± 8.3 years. Based on calculations using the Mann–Whitney test, there was a significant relationship between prostate-Specific Antigen (PSA) overexpression (p< 0.001), TMPRSS2:ERG (p=0.001), and PCA3 (p=0.003) with prostate cancer incidence. The sensitivity of PCA3 and TMPRSS2:ERG in detecting prostate cancer was 76.9% and 92.3%, respectively. Hence, TMPRSS2:ERG and PCA3 can be used as biomarkers for the occurrence of prostate cancer. We also performed a Kruskal–Wallis test; however, there was no significant relationship between PSA (p=0.236), TMPRSS2:ERG (p=0.801), and PCA3 (p=0.091) with the Gleason score.Conclusion: There is a significant correlation between overexpression of PSA, TMPRSS2:ERG and PCA3 with the incidence of prostate cancer, and TMPRSS2:ERG and PCA3 can be used as biomarkers of prostate cancer.Keywords: prostate cancer, PSA, PCA3, TMPRSS2:ERG, urine biomarker

Lazaros Tzelves,1 Robert Michael Geraghty,2 Thomas Hughes,3 Patrick Juliebø-Jones,4 Bhaskar K Somani5 1Department of Urology, Sismanogleio Hospital, National and Kapodistrian University of Athens, Athens, Greece; 2Department of Urology, Freeman Hospital, Newcastle-Upon-Tyne, UK; 3Department of Urology, Warwick Hospital, Warwick, UK; 4Department of Urology, Haukeland University Hospital, Bergen, Norway; 5Department of Urology, University Hospital Southampton, Southampton, UKCorrespondence: Bhaskar K Somani, Department of Urology, University Hospital Southampton NHS Trust, 19 Tremona Road, Southampton, SO535DS, UK, Tel +44-2381206873, Email bhaskarsomani@yahoo.comAbstract: Urolithiasis is a common clinical condition, and surgical treatment is performed with different minimally invasive procedures, such as ureteroscopy, shockwave lithotripsy and percutaneous nephrolithotomy. Although the transition from open surgery to endourological procedures to treat this condition has been a paradigm shift, ongoing technological advancements have permitted further improvement of clinical outcomes with the development of modern equipment. Such innovations in kidney stone removal are new lasers, modern ureteroscopes, development of applications and training systems utilizing three-dimensional models, artificial intelligence and virtual reality, implementation of robotic systems, sheaths connected to vacuum devices and new types of lithotripters. Innovations in kidney stone removal have led to an exciting new era of endourological options for patients and clinicians alike.Keywords: kidney calculi, ureteroscopy, percutaneous nephrolithotomy, laser, artificial intelligence

Ramón Virasoro,1 Jessica M DeLong,1 Rafael E Estrella,2 Merycarla Pichardo,3 Ramón Rodriguez Lay,4 Gustavo Espino,5 Sean P Elliott6 1Urology of Virginia PLLC, Virginia Beach, VA, USA; 2Clinica Unión Medica, Santiago de los Caballeros, Dominican Republic; 3URUS, Santo Domingo, Dominican Republic; 4Cirujano Urologo Royal Center Panama City, Panama City, Panama; 5Centro Especializado San Fernando, Panama City, Panama; 6Department of Urology, University of Minnesota, Minneapolis, MN, USACorrespondence: Ramón Virasoro, Urology of Virginia PLLC, 225 Clearfield Ave, Virginia Beach, VA, 23462, USA, Tel +1 757-457-5100, Email viravira@yahoo.comIntroduction: Endoscopic management of male anterior urethral stricture disease is common; however, repeat treatment is associated with high recurrence rates. Here, we report the 3-year results of the ROBUST I trial, which evaluated the safety and efficacy of the Optilume® drug coated balloon (DCB) in men with recurrent urethral strictures.Methods: Adult men with recurrent bulbar urethral strictures ≤ 2 cm in length and 1– 4 prior endoscopic interventions were treated with the Optilume DCB. Functional success was defined as ≥ 50% reduction in International Prostate Symptom Score (IPSS) without need for retreatment. Other outcomes included quality of life, maximum flow rate, post-void residual urine volume, erectile function, and freedom from repeat intervention.Results: Of the 53 enrolled and treated men, 33 completed the 3-year visit, with 10 patients experiencing clinical failures at previous visits, giving a total of 43 subjects evaluable for the functional success endpoint. Functional success was achieved in 67% (29/43) and freedom from retreatment in 77% (33/43). Average IPSS improved from 25.2 at baseline to 5.5 at 3 years (p< 0.0001). Significant improvements were observed in quality of life, flow rate, and post-void residual urine volume. Erectile function was not affected by treatment. Device-related adverse events were mild or moderate in nature and resolved quickly after onset. There were no serious treatment-related adverse events.Conclusion: Symptomatic improvement after treatment with the Optilume DCB was maintained through 3 years in a population highly susceptible to recurrent urethral stricture disease. This minimally invasive therapy is safe with no negative impact on sexual function.Keywords: lower urinary tract symptoms, paclitaxel, urethral dilation, medical device, clinical trial

Iraklis C Mitsogiannis,1 Maria Mitsogianni,1 Vissarion Bakalis,2 Anna Tzortzi de Paz,3 Panagiotis J Vlachostergios,4,&ast; Vassilios Tzortzis3,&ast; 1Second Department of Urology, National and Kapodistrian University of Athens, Sismanoglio General Hospital, Athens, Greece; 2Department of Nursing, University of Thessaly, University Hospital of Larissa, Larissa, Greece; 3Department of Urology, University of Thessaly, Faculty of Medicine, University Hospital of Larissa, Larissa, Greece; 4Division of Hematology and Medical Oncology, Department of Medicine, Weill Cornell Medicine, New York, NY, USA&ast;These authors contributed equally to this workCorrespondence: Panagiotis J Vlachostergios, Division of Hematology and Medical Oncology, Department of Medicine, Weill Cornell Medicine, New York, NY, 10065, USA, Tel +1 646-962-2072, Email pjv9003@med.cornell.eduPurpose: Health-related quality of life (HRQoL) assessment has become an integral part of clinical research across different disciplines. However, the degree of incorporation of QoL standardized questionnaires in daily routine is variable. This survey study examined how HRQoL is perceived and utilized among urologists from the Hellenic Urological Association (HUA) in their daily practice.Methods: A nationwide survey of Greek urologists registered with the HUA was conducted. Participants were asked to complete a questionnaire sent via email. The survey questionnaire consisted of demographic data including sex, age, working position and working environment and 11 Likert-scale questions regarding perception and use of HRQoL in clinical practice.Results: A total of 1000 Greek urologists were contacted, of whom 400 (40%) responded. Participants were predominantly male (94.8%) with a mean age of 43.7 years and a mean working experience of 12.5 years. Most participants considered HRQoL assessment to be important in their clinical practice (95.3%) and valuable in both patient consultation (95.8%) and treatment follow-up (91.8%). Half of urologists (51%) agreed with the statement that there is limited time for HRQoL assessment in daily practice. Validated questionnaires were rated as useful by 75.5% of participants. Overall, only 26.7% of participants stated they have incorporated HRQoL questionnaires in their daily practice. A subgroup analysis of participants showed that experienced physicians (> 10 years) were less likely to utilize HRQoL (OR 0.38, p=0.008, 95% CI 0.19– 0.77) and experienced difficulty in distinguishing between HRQoL assessment and symptom-rating (OR 0.32, p< 0.001, 95% CI 0.17– 0.61). Lack of time for HRQoL assessment was a main concern for urologists in-training (OR 0.7, p< 0.001, 95% CI 0.57– 0.85).Conclusion: HRQoL assessment is well-perceived by Greek urologists, although it has yet to achieve a substantial degree of integration in their daily practice.Keywords: health-related quality of life assessment, urologic daily practice, survey, questionnaire

Zachary Werner,1 Ahmad Haffar,2 Emma Bacharach,1 Jennifer Knight-Davis,3 Ali Hajiran,1 Adam Luchey1 1Department of Urology, West Virginia University, Morgantown, WV, USA; 2School of Medicine, West Virginia University, Morgantown, WV, USA; 3Department of Surgery, West Virginia University, Morgantown, WV, USACorrespondence: Ahmad Haffar, School of Medicine, West Virginia University, Suite 6300 Health Sciences Center Morgantown, Morgantown, WV, 26505, USA, Tel +304 993-2237, Fax +304 293-2807, Email aihaffar@mix.wvu.eduObjective: Current urologic renal trauma guidelines favor conservative management. In 2012, we implemented an institution-wide renal trauma protocol to standardize management. This protocol details initiation of DVT (deep vein thrombosis) prophylaxis, cessation of bed rest, and frequency of laboratory studies. We hypothesized that low-grade injuries (grade I–III) could be managed without urologic consultation and that our chemical DVT prophylaxis regimen would not pose an increased risk of hemorrhage requiring transfusion.Methods: We performed a cross-sectional analysis of a prospectively maintained database containing all renal trauma at our institution from 2009 to 2019. We segregated injuries based on grade, presence of multi-organ trauma, and evaluated the presence and types of intervention, initiation of chemical DVT prophylaxis, and post-DVT prophylaxis hemorrhage requiring transfusion.Results: We identified 295 cases of renal trauma, of which 62 were isolated injuries. Forty-three of the isolated renal injuries were transferred from outside facilities, 70% of which were classified as low-grade injuries. There were 220 low-grade lacerations and 75 high-grade lacerations. No grade I or II lacerations required any interventions. Two (2.5%) grade III lacerations required IR embolization. Twenty-five (41%) grade IV lacerations required intervention, of which five were nephrectomy. Seven (54%) grade V lacerations required intervention, of which 5 were nephrectomies. Upon review of our protocol with early ambulation and DVT prophylaxis, there were no cases of isolated renal injury where initiation of either treatment resulted in delayed hemorrhage requiring transfusion or surgical intervention.Conclusion: Only 2/220 low-grade renal lacerations required intervention. Our data suggest that grade I and II renal lacerations can be managed safely without urologic consultation. Consultation is warranted for grade III injuries given the possibility of initial understaging. Furthermore, we believe our renal laceration protocol in our admittedly small, isolated sample has shown our DVT prophylaxis initiation to not pose increased risk.Keywords: renal, trauma, review, protocol, thromboembolic

Nicolas Fernandez,1 Julian Chavarriaga,2 Paola Ayala,3 Adriana Pedraza,4 John Bolivar,5 Juan Guillermo Prada,6 Juan Guillermo Cataño,6Herney Andres García-Perdomo,7 Juliana Villanueva,6 Daniela Varela,6 Ignacio Zarante3 1Division of Urology Seattle Children’s Hospital, University of Washington, Seattle, WA, USA; 2Division of Urology, Clínica Imbanaco - Quiron Salud, Cali, Colombia; 3Human Genetics Institute, Pontificia Universidad Javeriana, Bogota, Colombia; 4Division of Urology Clínica Desa, Cali, Colombia; 5Division of Urology, Department of Surgery, Hospital Universitario San Ignacio, Bogota, Colombia; 6Division of Urology, Hospital Universitario San Ignacio, Pontificia Universidad Javeriana, Bogota, Colombia; 7Division of Urology, Department of Surgery, Universidad del Valle, Cali, ColombiaCorrespondence: Nicolas Fernandez, Division of Urology, Seattle Children’s Hospital, University of Washington, 5801 Sand Point Way NE, Seattle, WA, 98105, USA, Tel +1 206 351 2618, Email nicolas.fernandez@seattlechildrens.orgPurpose: To identify micro-RNAs (miRNAs) expression profiles in peripheral blood plasma that could play a role as potential biomarkers in patients who progressed to castration-resistant prostate cancer (CRPC). Liquid biopsy analysis of miRNAs is a fast-developing field with a considerable likelihood to predict tumor progression and metastasis by targeting genes involved in oncogenesis.Patients and Methods: Differential expression analysis of miRNAs profile in CRPC patients was performed by creating small RNA libraries of circulating miRNAs using HiSeq2500 Illumina platform. A secondary analysis of aligned reads with miRNA identification and quantification was performed using miARmaSeq. Using the Bowtie algorithm, the selected variants were compared to reference nucleotide sequence GRCh38 and miRbase. Novel miRNA sequences were structurally analyzed using mirDeep2®.Results: A total of 16 patients with CRPC were included for analysis. Identified circulating miRNAs were hsa-miR-885-3p, hsa-miR-4467, hsa-miR-4686, hsa-miR-146a-3p, hsa-miR-6514-5p. Genes identified as regulated by these miRNAs were GPR56, BDNF, CTNND1, C17orf62, and DTNA.Conclusion: We explored the miRNA expression profile in patients with CRPC, identifying five miRNAs implicated in the regulation of genes involved in prostate cancer (PCa) oncogenesis and progression. We also found miRNA 855– 3p in peripheral blood for the first time, which has a critical role in tumor growth mechanisms and higher expression profile than in healthy individuals.Keywords: prostatic neoplasm, prostatic neoplasms, castration-resistant, microRNAs, biomarkers, genital neoplasms, male

Kaori Yamashita,1,2 Yudai Ishiyama,1 Maki Yoshino,1 Hidekazu Tachibana,1 Daisuke Toki,1 Ryuichiro Konda,2 Tunenori Kondo1 1Department of Urology, Tokyo Women’s Medical University Medical Center East, Tokyo, Japan; 2Tomioka Clinic, Tokiwa Foundation, Fukushima, JapanCorrespondence: Kaori Yamashita,Department of Urology, Tokyo Women’s Medical University Medical Center East, 2-1-10, Nishi-ogu, Arakawa-ku, Tokyo, 116-8567, Japan, Tel +81 338101111, Fax +81 338940282, Email kmurology@yahoo.co.jpIntroduction: The aim of this study was to analyze urinalysis findings and urinary bacterial culture in hemodialysis-dependent end-stage renal disease patients. The research goal was to understand the proportion, risk factors, and the causative organisms of urinary tract infection in hemodialysis-dependent end-stage renal disease patients.Materials and Methods: Between May 2020 and June 2021, this study included 100 hemodialysis-dependent end-stage renal disease patients (50 male patients and 50 female patients). The urine underwent microscopic examination, pyuria was defined as ≥ 5 white blood cells per high-power field, and urinary bacterial cultures were conducted for patients with pyuria. Bacteriuria was defined as ≥ 104 colony-forming units/mL in men and ≥ 105 colony-forming units/mL in women. Daily urine output was investigated by oral listening. Postvoiding residual urine volume was measured.Results: Fifty-six percent of male patients and 30% of female patients had normosthenuria, 24% of male patients and 38% of female patients had pyuria, and 20% of male patients and 32% of female patients had a urinary tract infection. A comparison of normosthenuria and urinary tract infection revealed no statistically significant difference in age, time on dialysis, daily urine output, and postvoiding residual urine volume. The proportion of female patients among those with normosthenuria was 34.8%, whereas the proportion of female patients among those with UTI was 61.5%. Urinary bacterial cultures showed that the major causative organisms were Escherichia coli (45%; 18/40 cultures) and extended spectrum beta-lactamase-producing Escherichia coli (17.5%; 7/40 cultures).Conclusion: The incidence of urinary tract infection was higher in female patients than in male patients. The proportion of resistant bacteria as the causative organisms was high in hemodialysis-dependent end-stage renal disease patients. Urinary bacterial culture should be checked while patients are able to void urine.Keywords: bacteriuria, pyuria, renal dialysis, urinary tract infection, urine

Hana Abebe Gebreselassie, Binyam Gebremedihin Godu, Hiwote Girma Assefa, Maru Gama Erge St. Paul’s Hospital Millennium Medical College, Department of Surgery, Pediatrics Surgery Unit, Addis Ababa, EthiopiaCorrespondence: Hana Abebe Gebreselassie, St. Paul’s Hospital Millennium Medical College, Department of Surgery, Pediatrics Surgery Unit, Addis Ababa, Ethiopia, Tel +251 913 766 868, Email hanaabebe23@gmail.comBackground: Exstrophy variants are well described urologic anomalies. They are characterized by atypical anatomical and physical findings than those found in patients with classic bladder exstrophy and epispadias malformation. The combination of these anomalies with duplicated phallus is a rare occurrence. Here we present a neonate with a rare form of exstrophy variant associated with penile duplication.Case Summary: One day old male neonate who was born at term was admitted to our neonatal intensive care unit. He had lower abdominal wall defect and open bladder plate with no visible ureteric orifices. There were two completely separate phalluses with penopubic epispadias and urethral orifices draining urine. Both testes were descended. Abdominopelvic ultrasound showed normal upper urinary tract. He was prepared and operated with intra operative finding of complete bladder duplication in the sagittal plane and each bladder has its own ureter. The open bladder plate which had no connection with both ureters and urethras was excised. The pubic symphysis was approximated without osteotomy and abdominal wall was closed. He was immobilized with mummy wrap. He had uneventful post-operative course and was discharged on the 7th post-operative day. He was evaluated on the 3rd month post operatively and he was thriving well with no complications.Conclusion: The occurrence of a triplicated bladder along with diphallia is an exceptionally rare urologic anomaly. As a number of variations are possible in this spectrum, the management of neonates with this anomaly should be individualized.Keywords: bladder duplication, exstrophy variant, diphallia, duplicate exstrophy

Sohail Dhanji, Luke Wang, Franklin Liu, Margaret F Meagher, Ava Saidian, Ithaar H Derweesh Department of Urology, University of California San Diego School of Medicine, La Jolla, CA, USACorrespondence: Ithaar H Derweesh, Department of Urology, University of California San Diego School of Medicine, 3855 Health Sciences Drive, Mail Code: 0987, La Jolla, CA, 92037, USA, Tel +1 (858) 249-0900, Fax +1 (858) 822-6188, Email iderweesh@gmail.comPurpose: To review the current status of surgical and procedural treatments for renal cell carcinoma (RCC), focusing on oncological and functional outcomes, and the use of techniques for advanced disease over the last 10 years.Findings: Partial nephrectomy (PN) has become the reference standard for most T1 and T2 masses. In cT2 RCC, PN exhibits oncological equivalence and improved functional outcomes compared to radical nephrectomy (RN). Additionally, emerging data suggest that PN may be used to treat cT3a RCC. The robot-assisted platform is increasingly used to treat locally advanced RCC. Studies suggest safety and feasibility of robotic RN and robotic inferior vena cava tumor thrombectomy. Additionally, single-port robot-assisted laparoscopic approaches are comparable to multiport approaches in select patients. Long-term data show that cryoablation, radiofrequency ablation, and microwave ablation are equipotent in management of small renal masses. Emerging data suggest that microwave may effectively treat cT1b masses.Keywords: renal cell carcinoma, cryoablation, nephrectomy, microwave ablation, partial nephrectomy, radiofrequency ablation

Meshari A Alzahrani,1 Mishal M Alasmari,2 Moataz I Altokhais,3 Fawaz W Alkeraithe,4 Talal A Alghamdi,4 Abdulaziz S Aldaham,5 Alwaleed H Hakami,6 Saud Alomair,7 Basel O Hakami8 1Department of Urology, College of Medicine, Majmaah University, Al-Majmaah, Saudi Arabia; 2College of Medicine, King Khalid University, Abha, Saudi Arabia; 3Department of Urology, King Khalid University Hospital, Riyadh, Saudi Arabia; 4Department of Urology, King Fahad Medical City, Riyadh, Saudi Arabia; 5College of Medicine, Jouf University, Al Gurayat, Saudi Arabia; 6College of Medicine and Surgery, Jazan University, Jazan, Saudi Arabia; 7College of Medicine, Majmaah University, Al-Majmaah, Saudi Arabia; 8Department of Urology, King Faisal Medical City for Southern Region (KFMC), Abha, Saudi ArabiaCorrespondence: Meshari A Alzahrani, Department of Urology, College of Medicine, Majmaah University, Al-Majmaah, 11952, Saudi Arabia, Tel +966569990693, Fax +966164042500, Email ma.alzahrani@mu.edu.saAbstract: Testicular torsion is a serious urologic emergency that can present with unusual or atypical history and examination. Classical pain from testicular torsion is of sudden onset, significantly severe, and is accompanied by nausea and vomiting. However, in some patients, the initial scrotal pain appears to considerably subside within the next few hours. In others, testicular torsion tends to occur while sleeping, and many patients recount a history of being woken up from sleep by intense pain. Furthermore, some patients in this subset can resume normal activities and even sleep through the night with little or no discomfort, without a perceived need for pain medications. Other patients initially experience mild pain, which worsens over time. Consequently, these patients are less likely to be evaluated immediately. In view of these atypical cases, the question remains unanswered regarding sleep as a predisposing factor for testicular torsion. This narrative review focuses on exploring the association between sleep and testicular torsion.Keywords: testicular torsion, torsion of the spermatic cord, acute scrotum, sleep, sleeping, literature review

Alfredo Berrettini,1 Irene Paraboschi,1 Massimo Di Grazia,1 Michele Gnech,1 Guglielmo Mantica,2 Dario Guido Minoli,1 Erika Adalgisa De Marco,1 Gianantonio Manzoni,1 Marco Capece,3 Alessandro Palmieri,3 David Ralph,3 Vincenzo Mirone3 1Department of Pediatric Urology, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milano, Italy; 2Department of Urology, IRCCS Ospedale Policlinico San Martino, Genova, Italy; 3Department of Urology, Azienda Ospedaliera Universitaria “Federico II”, Napoli, ItalyCorrespondence: Irene Paraboschi, Department of Pediatric Urology, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Via Francesco Sforza 35, Milano, Italy, Tel +393313229495, Email irene.paraboschi01@gmail.comAbstract: We present the first case of a patient born with congenital fusiform megalourethra who underwent the successful placement of an inflatable penile prosthesis (IPP) and mesh phalloplasty due to primary erectile dysfunction (ED). After an extensive psychosexual assessment and a preoperative MRI scan, an IPP was successfully implanted. The procedure was carried out through a penoscrotal approach, which offered excellent exposure to the crura and the proximal ends of the corpora cavernosa. Following the incision and the dilatation of both corpora cavernosa, the penile cylinders were inserted and a mesh phalloplasty was performed, to replace the erectile tissues lacking in the distal corpora cavernosa. After reservoir and pump placement, the device was tested, and no mechanical issues were recorded. The postoperative course was uneventful, and, at the 2-year follow-up, the patient reported highly satisfactory results, with valid functional erections.Keywords: congenital fusiform megalourethra, inflatable penile prosthesis, phalloplasty, erectile dysfunction

Mohammed Alfozan Department of Surgery, College of Medicine, Prince Sattam bin Abdulaziz University, Alkharj, 11942, Saudi ArabiaCorrespondence: Mohammed Alfozan, Email dr.masf@gmail.comPurpose: The present study was conducted to analyze the effect of varicocelectomy on serum follicle-stimulating hormone (FSH) and testosterone. The interrelationship between seminal and hormonal variables is also investigated.Patients and Methods: A prospective cohort study was conducted on patients of the urology clinic from 2012 to 2017. The study was conducted in the Security Forces Hospital, in Riyadh, Saudi Arabia. Infertile patients who had already undergone the FSH examination and testosterone twice were included in the study. Statistical Package for Social Sciences (SPSS) version 21.0 was used to analyze the data.Results: A total of 186 patients were studied which reveals that the age group of 21– 30 years was higher than other age groups 80 (43%), micro varicocelectomy was performed in 138 (74%) of patients and 79 (47%) patients had one-year infertility. The study assessed the effect of varicocelectomy on sperm count and motility serum FSH, testosterone, luteinizing hormone (LH), and prolactin, and it was found that none of the variables showed significant association after varicocelectomy, except for luteinizing hormone (P-value = 0.014). Testosterone levels in patients who had FSH ≤ 10 were also evaluated and it was found that the level of testosterone was increased with a decreased level of FSH (P-value = 0.005).Conclusion: It was concluded from our results that after varicocelectomy, those patients who had FSH levels ≤ 10 were found to have increased testosterone levels. LH was also found to be significant; however, other hormones were not found to be significant. This may occur due to the reason that we have the majority of the participants in the age group 21– 30. Further prospective studies are needed to evaluate the association with ample sample size.Keywords: varicocelectomy, hormones, testosterone levels, Riyadh, Saudi Arabia

Ilan Gielchinsky,1,2 Naama Lev-Cohain3 1Research Branch, Meuhedet Health Services, Tel-Aviv, Israel; 2Department of Urology, Assaf Harofeh Medical Center, Tzrifin, Israel; 3Department of Radiology, Hadassah Medical Center, Jerusalem, IsraelCorrespondence: Ilan Gielchinsky, Research Branch, Meuhedet Health Services, Tel-Aviv, Israel, Medica Medical Center, Habarzel 28 street, Suit 203, Tel-Aviv, Israel, Tel +972-50-4048489, Email Gielchinsky@me.comIntroduction: Irreversible electroporation (IRE) technology for prostate cancer (PC) generates consecutive electrical pulses between pairs of electrodes which move through tumorous cells, irreversibly perforate their membranes and eventually lead to cell death, while avoiding tissue thermal effect. The technique is used for primary focal lesions as well as for focal salvage cases. This series reports short term oncological control, quality of life and safety results.Methods: Retrospective data were collected from 45 consecutive cases of primary (N=38) and salvage (N=7) PC patients treated with IRE. All patients had transperineal MRI/US fusion biopsy and PET-PSMA scan prior to treatment, to verify single lesion. Transperineal Nano-Knife IRE system was used in day-care theatre. Patients had 6 months mpMRI, blood PSA and 1 year confirmatory biopsy following procedure. Quality of life was recorded during the first year.Results: Median primary subgroup analysis (N=38): age 69 years, initial PSA 5.6 ng/dL, lesion size 0.8 mL and ISUP Group 2 (1– 3). Median salvage subgroup analysis (N=7): age 76 years, initial PSA 11.9 ng/dL, lesion size 2.0 mL and ISUP Group 4 (1– 5). Median catheter time 5 (3– 7) days. No Clavien–Dindo> 1 complications were reported nor re-admissions, incontinence, strictures or fistulas. 5% of patients were given PDE-5i drugs. Primary group PSA dropped by 39%, mpMRI clearance in 84%, out-field new lesion in 12%, in-field lesion in 4%. Biopsy at 1 year: 4 patients had out-field clinically significant PC, thus 3 had re-IRE and 1 had radiation therapy. Salvage subgroup MRI clearance was 60%, and 52% remained on active surveillance by 1 year.Conclusion: IRE treatment for focal PC is safe for primary and salvage cases, if done by a meticulously skilled and trained team, and under strict protocols. The short term oncological results are promising especially for primary lesions. Long term oncological results will be published over time.Keywords: prostate cancer, irreversible electroporation, focal therapy, Nano-Knife

Fabio Turco,1,&ast; Lavinia Di Prima,1,&ast; Chiara Pisano,1 Stefano Poletto,1 Marco De Filippis,1 Veronica Crespi,1 Giovanni Farinea,1 Massimiliano Cani,1 Mariangela Calabrese,1 Isabella Saporita,1 Rosario Francesco Di Stefano,1 Marcello Tucci,2 Consuelo Buttigliero1 1Department of Oncology, University of Turin, at Division of Medical Oncology, San Luigi Gonzaga Hospital, Turin, Italy; 2Department of Medical Oncology, Cardinal Massaia Hospital, Asti, Italy&ast;These authors contributed equally to this workCorrespondence: Marcello Tucci, Department of Medical Oncology, Cardinal Massaia Hospital, Corso Dante Alighieri 202, Asti, 14100, Italy, Tel +393286754734, Email marcello.tucci@gmail.comAbstract: Prostate cancer (PC) is a hormone-sensitive tumor. Androgen deprivation therapy (ADT) is the cornerstone of systemic therapy for patients with intermediate or high-risk localized, recurrent, and metastatic prostate cancer. Although generally well tolerated, ADT can lead to short- and long-term adverse events that can worsen the quality of life of patients with PC. In the last decade, the introduction of novel generation androgen receptor pathway inhibitors (ARPI) has resulted in an improvement in the prognosis of patients with metastatic PC when used in combination with ADT. The use of ARPI in increasingly early stages of the disease determines a longer exposure of patients to these treatments. Although ARPIs are normally well-tolerated drugs, they generally cause an increase in toxicity compared to ADT alone, being able to worsen some adverse events already induced by ADT or leading to the development of specific side effects. Although there are no specific treatments for all the adverse events induced by hormonal therapies, it is essential to know the possible toxicities induced by the different treatments and to start procedures to prevent and/or recognize and consequently treat them early in order to not compromise the quality of life of the patients with PC. The aim of this review is to describe the adverse events induced by hormonal therapies. We will first describe the side effects induced by both ADT and ARPI and then the specific adverse events of the different ARPIs. Furthermore, we will try to highlight the possible therapeutic options to prevent or mitigate the toxicity induced by hormone therapies in order to improve the quality of life of the patients with PC.Keywords: prostate cancer, androgen deprivation therapy, androgen pathway inhibitors, management of adverse events

Martin Lund,1,&ast; Ditte Valsgaard Vammen,2,&ast; Milad Hanna,3 Søren Høyer,4 Lars Lund1,2,5 1Department of Urology, Odense University Hospital, Odense, Denmark; 2Department of Urology, Viborg Hospital, Viborg, Denmark; 3Department of Urology, Imperial College National Health Service Trust, London, UK; 4Department of Pathology, Aarhus University Hospital, Aarhus, Denmark; 5Clinical Institute, University of Southern Denmark, Odense, Denmark&ast;These authors contributed equally to this workCorrespondence: Lars Lund, Department of Urology, Odense University Hospital, Sdr. Boulevard 29, Odense, DK-5000, Denmark, Tel +45 5140 8982, Fax +45 6541 1726, Email Lars.Lund@rsyd.dkObjective: Low-energy extracorporeal shockwave therapy (LE-ESWT) has been shown to induce organ repair and neo-vascularization. The ability of LE-ESWT to improve erectile function in rodents as measured by improvements in intracavernosal pressure is well-established in various pathological situations. The underlying molecular mechanism are unclear and likely vary between different disorders, making rational drug design for synergetic effects with LE-ESWT difficult, without further research. In this placebo-controlled study, we aim to establish whether LE-ESWT can activate neovascularization biomarkers in diabetic tissues.Material and Methods: Forty Wistar rats, aged 8 weeks, were randomly divided into 4 groups: 8 untreated controls, 12 controls that underwent LE-ESWT treatment, 8 controls with induced diabetes mellitus (DM) and 12 with DM underwent LE-ESWT treatment. DM was induced by streptozotocin. LE-ESWT treatment was performed with a Duolith SD1 machine (Storz), with a total amount of energy of 6.4 J per treatment. The rats received a total of three LE-ESWT treatments with 2-week intervals between treatments.Results: Diabetic rats had significantly elevated blood glucose concentrations compared to control rats (P < 0.001) and experienced significant weight loss compared to controls (P < 0.001). Diabetic rats had elevated creatinine and urea and lower albumin (P < 0.001). Histologic analysis of penile tissue showed significant levels of vascular endothelial growth factor (VEGF) and fibroblast growth factor (FGF) expression in the LE-ESWT groups compared to controls (P< 0.01).Conclusion: LE-ESWT induces neo-angiogenesis as expressed by VEGF and FGF in erectile tissue in normal and diabetic rats.Keywords: erectile dysfunction, diabetes mellitus, extracorporeal shockwave therapy

Mendy Hatibie Oley,1– 3 Maximillian Christian Oley,3– 5 Ari Astram Adhiatma Iskandar,6,7 Christof Toreh,6,7 Marcella Tirsa Tulong,3 Muhammad Faruk8 1Plastic Reconstructive and Aesthetic Surgery Division, Department of Surgery, Faculty of Medicine, Sam Ratulangi University, Manado, Indonesia; 2Plastic Reconstructive and Aesthetic Surgery Division, Department of Surgery, R. D. Kandou Hospital, Manado, Indonesia; 3Hyperbaric Centre Siloam Hospital, Manado, Indonesia; 4Division of Neurosurgery, Department of Surgery, Faculty of Medicine, Sam Ratulangi University, Manado, Indonesia; 5Division of Neurosurgery, Department of Surgery, R. D. Kandou Hospital, Manado, Indonesia; 6Division of Urology, Department of Surgery, Faculty of Medicine, Sam Ratulangi University, Manado, Indonesia; 7Division of Urology, Department of Surgery, R. D. Kandou Hospital, Manado, Indonesia; 8Department of Surgery, Faculty of Medicine, Hasanuddin University, Makassar, IndonesiaCorrespondence: Mendy Hatibie OleyPlastic Reconstructive and Aesthetic Surgery Division, Department of Surgery, Faculty of Medicine, Sam Ratulangi University, Jalan Raya Tanawangko No. 56, Malalayang Satu Barat, Malalayang, Manado, North Sulawesi, 95162, IndonesiaFax +62 431-863786Email mendy.hatibie@unsrat.ac.idIntroduction: Hyperbaric oxygen therapy (HBOT) has been applied to urological wound healing because it reduces inflammation, facilitates angiogenesis through endothelial proliferation, stimulates fibroblast, lymphocyte, and macrophage activity, and exerts bactericidal effects. Thus, we present a case series of reconstructive urology wounds treated adjunctively with HBOT.Case Report: Here, we present the cases of eight patients with urology wounds who underwent different forms of surgical reconstruction. Three patients received penile shaft silicone fluid injection with repeated infection, successful excision of a siliconoma mass, and defect closure with a full-thickness skin graft. One patient had hypospadias and multiple post-closure fistulae. Two patients had bilateral keystone flaps (post total penectomy, orchidectomy, perineotomy, and penile tumors) closed with a split-thickness skin graft (STSG). Two patients had Fournier’s gangrene in their genital area, for which the wound was debrided and then closed with a STSG. All patients received HBOT after surgery with satisfying results.Conclusion: HBOT promotes wound healing and improves graft integration in patients undergoing urological reconstructive surgery.Keywords: hyperbaric oxygen therapy, tissue reconstruction, would healing, adjunctive treatment, urology

Robert Shapiro,1,2 Alec Sunyecz,3 Stanley Zaslau,1,2 Manuel C Vallejo,1,4 Tyler Trump,2 Omar Dueñas-Garcia1 1Department of Obstetrics and Gynecology, West Virginia University School of Medicine, Morgantown, WV, 26506, USA; 2Department of Urology, West Virginia University School of Medicine, Morgantown, WV, 26506, USA; 3West Virginia University School of Medicine, Morgantown, WV, 26506, USA; 4Department of Anesthesiology, West Virginia University School of Medicine, Morgantown, WV, 26506, USACorrespondence: Robert ShapiroHealth Science Center North, West Virginia University, PO Box 9001A, Morgantown, WV, 26506, USATel +1 304-293-5631Fax +1 304-293-5160Email rshapiro@hsc.wvu.eduBackground: In this study, we aim to compare outcomes after cystotomy repair between standard sutures (910 polyglactin, poliglecaprone) versus barbed (V-LocTM 90) suture. As a secondary outcome, we analyzed factors for suture preference between the two groups.Methods: A retrospective chart review was undertaken for surgeries complicated by cystotomy, identified by ICD-9/10 codes from 2016 to 2019 at West Virginia University (WVU) Hospital. Comparisons were made between cystotomy repair using barbed suture versus standard braided suture. Injuries were categorized by procedure, surgical route, type of suture used in repair, and subsequent complications related to repair. Primary endpoints were examined by Pearson’s Chi-square test and interval data by t-test. A p < 0.05 was significant.Results: Sixty-eight patients were identified with iatrogenic cystotomy at WVU. Barbed suture was used for cystotomy repair in 11/68 (16.2%) patients. No significant difference was seen in postoperative outcomes between patients repaired with barbed suture versus standard braided suture. Barbed suture was significantly more likely to be used for cystotomy repair in minimally invasive surgery (p = 0.001). It was most often utilized in a robotic approach 7/11 (63.6%) followed by laparoscopic 3/11 (27.3%). Body mass index (BMI) was significantly higher in patients receiving a barbed suture repair (p = 0.005).Conclusion: Barbed suture may be comparable to standard braided suture for cystotomy repair. Barbed suture may offer a practical alternative to facilitate cystotomy repair in minimally invasive surgery, especially in patients with a high BMI.Keywords: barbed suture, cystotomy, minimally invasive surgery, obesity

Susan Gong,1 Lakshay Khosla,1 Fred Gong,1 Nikhil Kasarla,1 Karel Everaert,2 Jeffrey Weiss,1 Abdo Kabarriti1 1Department of Urology, State University of New York Downstate Health Sciences University, Brooklyn, NY, USA; 2Department of Uro-Gynecology, Ghent University Hospital, Ghent, BelgiumCorrespondence: Susan GongDepartment of Urology, State University of New York Downstate Health Sciences University, 450 Clarkson Ave., Brooklyn, NY, 11203, USATel +1 845-891-6642Email Susan.Gong@downstate.eduPurpose: Current literature has suggested a relationship between nocturnal enuresis (NE) in childhood and the development of nocturia later in life as both disorders have similar underlying etiologies, comorbidities, and treatments. The objective was to synthesize the available evidence on the association between childhood NE and later presentation of nocturia.Methods: PubMed, CINAHL, Scopus, and Google Scholar were searched for peer-reviewed studies published between January 1980 and April 2021. Case–control and cohort studies that reported on childhood NE and current nocturia were included. The PRISMA protocol was followed (PROSPERO ID: CRD42021256255). A random-effects model was applied to calculate the pooled odds ratio (OR) and 95% confidence interval (CI). Risk of bias was assessed using the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) criteria and with a funnel plot.Results: Of the 278 articles identified, 8 studies met inclusion criteria. The 6 case–control and 2 prospective cohort studies resulted in a total sample size of 26,070 participants. In a random-effect pooled analysis, childhood NE was significantly associated with the development of nocturia (OR: 1.75, 95% CI: 1.11– 2.40). Significant heterogeneity (I2 = 92.7%, p < 0.01) was identified among the included studies, which was reflected in an asymmetrical funnel plot. NE and nocturia have similar underlying etiologies of hormonal abnormalities, sleep disorders, physiological disorders, and psychological disorders.Conclusion: The history of childhood NE is significantly associated with nocturia later in life. The data in this meta-analysis support this transition and identify potential similarities between the two disorders. The sparse number of articles relevant to this topic is a strong indicator of the need for more work on this transition from childhood to maturity. More studies are warranted to further explore the association between NE and nocturia.Keywords: LUTS, pediatric urology, incontinence, nocturnal polyuria

Lukas Rath, Friedrich Jokisch, Gerald Bastian Schulz, Alexander Kretschmer, Alexander Buchner, Christian G Stief, Philipp Weinhold Department of Urology, Ludwig-Maximilians-University, Munich, GermanyCorrespondence: Philipp WeinholdDepartment of Urology, Ludwig-Maximilians-University, Marchioninistrasse 15, Munich, 81377, GermanyTel +4989-4400-73528Fax +49894400-78735Email philipp.weinhold@med.uni-muenchen.dePurpose: There are only a few case reports and case series that investigated combined laparoscopic or robotic surgery for simultaneous prostate and kidney cancer. In this study, we want to close a gap in existing research to assess the feasibility and oncological outcome of combined open prostatectomy and kidney surgery.Methods: We retrospectively analyzed patients who underwent a combined open prostatectomy and either a partial or complete nephrectomy from 2013 to 2020. Descriptive statistics were used to assess perioperative parameters and the 12-month functional and oncological outcomes after combined surgery.Results: We identified 10 patients undergoing combined open surgery. Partial nephrectomy was performed in 4, radical nephrectomy in 6 patients. For prostate cancer, histopathological analysis showed a tumor stage ≥ pT2c in all 10 patients. For renal tumors, histopathological analysis showed clear cell renal cell carcinoma in 8 patients and oncocytoma in 2 patients. Operating time was 177 ± 36 minutes. Two perioperative complications (Clavien 2a and 3) were observed. Three months postoperatively, the International Index of Erectile Function (IIEF-5) score was 5.6 ± 5.9, the ICIQ-SF score was 7.3 ± 5.6 and were using 1.9 ± 2.2 pads per day. This improved after 12 months postoperatively, as patients had an IIEF-5 score of 6.33 ± 6.5, an ICIQ-SF score of 4.4 ± 5.7 and were using pads 0.9 ± 1.7 per day.Conclusion: In this study, we showed that open surgery is a safe and valid approach for combined prostatectomy and renal surgery with acceptable complications and oncological outcomes. The combined open approach could be a good alternative to combined laparoscopic/robotic surgery in this field, especially to treat patients with advanced renal tumors or previous abdominal surgery or radiation.Keywords: retropubic prostatectomy, kidney surgery, simultaneous prostate and kidney cancer, combined surgery

Safendra Siregar, Bambang Sasongko Noegroho, Ricky Adriansjah, Akhmad Mustafa, Ananta Bonar Department of Urology, Faculty of Medicine, Universitas Padjadjaran, Hasan Sadikin General Hospital, Bandung, IndonesiaCorrespondence: Safendra SiregarDepartment of Urology, Faculty of Medicine Universitas Padjadjaran, General Hospital Hasan Sadikin Bandung, Jl. Makmur No. 16, Bandung, IndonesiaTel +62811227180Email safendra.sir@yahoo.co.idIntroduction: Varicocele is the predominant cause of male infertility. Reactive oxygen species was found in varicocele which induce the lipid peroxidation process in the plasma membrane of spermatozoa and may cause damage to spermatozoa in semen and seminiferous tubules, disrupting spermatogenesis. Human adipose derived stem cells (hADSC) can suppress oxidative stress in some oxidative injury model. This study investigate the effect of intratesticular hADSC injection on malondialdehyde (MDA) level and spermatogenesis process by histopathological examination in the varicocele rat model.Methods: This is an experimental study. A total sampling of 9 male Wistar rats were divided into three groups. Group I consist of 1 Wistar rats without any treatment or model (sham group), group II consist of 4 Wistar rats with varicocele model without hADSC therapy (control group), and group III consist of 4 Wistar rats with varicocele model and were given injections of 1.0× 106 hADSC cells intratesticularly 30 days after model was made (therapy group). Testicular tissue was harvested for evaluation.Results: In all varicocele model rats (group II and III), the result of MDA level in therapy group (2.53 mol/liter) was significantly lower than the MDA level in control group (4.43 mol/liter) (p = 0.01). On histopathological examination, the average Johnson’s Score in the therapy and control group was 9.77 and 9.18, respectively. The analysis showed Johnson’s score in the intervention group was significantly higher (p = 0.018).Conclusion: Intratesticular injection of hADSC can help reduce MDA levels and improve spermatogenesis process, which is damaged by varicoceles.Keywords: human adipose-derived stem cell, varicocele, spermatogenesis, infertility, malondialdehyde, MDA

Joshua White,1 Marco-Jose Rivero,1 Arslan I Mohamed,2 Jamie Thomas,3 Akhil Muthigi,1 Farah Rahman,1 Jesse Ory,4 Francis Petrella,5 Ranjith Ramasamy1 1Urology, University of Miami Miller School of Medicine, Miami, FL, USA; 2Undergraduate Medical Education, City University of New York, New York, NY, USA; 3Undergraduate Medical Education, Nova Southeastern University Kiran Patel College of Osteopathic Medicine, Fort Lauderdale, FL, USA; 4Urology, Dalhousie University, Halifax, Nova Scotia, Canada; 5Urology, McGill University, Montreal, Quebec, CanadaCorrespondence: Joshua White; Ranjith Ramasamy, Email jwhit784@gmail.com; Ramasamy@miami.eduAbstract: The 2022 global monkeypox (MPX) outbreak is the largest in history to occur outside of endemic African regions. Disease spread during this outbreak has been primarily through human-to-human transmission, with sexual contact being of particular concern. Clinical presentations have commonly featured genital, perianal, and oral lesions associated with sexual activity among men who have sex with men (MSM), who compose the vast majority of MPX cases. This review discusses the epidemiology, clinical features, and evaluation of MPX with regards to men’s sexual health. Comparisons were made between MPX and its relative from the Orthopoxvirus genus, smallpox, in order to make informed inferences on the potential effects of MPX on men’s sexual health. This review also discusses the role of men’s health specialists and urologists in addressing the current outbreak.Keywords: monkeypox, infertility, sexual health, transmission, men’s health

Guglielmo Mantica,1,2 Wesley Verla,3 Andrea Cocci,4 Miko&lstrok;aj Frankiewicz,5 Jan Adamowicz,6 Felix Campos-Juanatey,7 Clemens M Rosenbaum,8 Marjan Waterloos,9 Luis A Kluth,10 Malte W Vetterlein11 On behalf of the Trauma and Reconstructive Urology Working Party of the European Association of Urology Young Academic Urologists1IRCCS Ospedale Policlinico San Martino, Genova, Italy; 2Department of Surgical and Diagnostic Integrated Sciences (DISC), University of Genova, Genova, Italy; 3Department of Urology, Ghent University Hospital, Ghent, Belgium; 4Department of Urology and Andrology, Careggi Hospital, University of Florence, Florence, Italy; 5Department of Urology, Medical University of Gda&nacute;sk, Gda&nacute;sk, Poland; 6Department of Regenerative Medicine, Collegium Medicum, Nicolaus Copernicus University, Bydgoszcz, Poland; 7Andrology and Reconstructive Urology Unit, Marques de Valdecilla University Hospital, IDIVAL, Santander, Spain; 8Department of Urology, Asklepios Hospital Barmbek, Hamburg, Germany; 9Department of Urology, Division of Reconstructive Urology, Ghent University Hospital, Ghent, Belgium; 10Department of Urology, University Medical Center Frankfurt, Frankfurt/Main, Germany; 11Department of Urology, University Medical Center Hamburg-Eppendorf, Hamburg, GermanyCorrespondence: Guglielmo Mantica, IRCCS San Martino Hospital, University of Genova, Largo Rosanna Benzi 10, Genova, 16132, Italy, Tel +390105555964, Email guglielmo.mantica@gmail.comAbstract: Urethral stricture disease is a very heterogeneous condition where different urethral segments can be involved as a result of diverse etiologies which come with variable prognosis. The surgical management of urethral strictures, and in particular urethroplasties can result in very diverse outcomes on many levels and, currently, there is absolutely no consensus about what should and what should not be considered a “success” after urethral surgery. In the wake of well-established quality criteria in urologic oncology, such as tri- or pentafecta outcomes, and given the lack of agreement on meaningful outcomes after urethral surgery, we aim to introduce our study protocol as the first step of a multistep research endeavor to reach consensus on comprehensive urethroplasty outcomes within a novel conceptual framework: the “stricture-fecta criteria”. The development of stricture-fecta will be based on a Delphi consensus involving some of worldwide most influencing reconstructive urologists.Keywords: urethral stricture, urethral stenosis, urethrotomy, urethroplasty, pentafecta

Safendra Siregar, Aidil Rahman Novesar, Akhmad Mustafa Urology Department, Hasan Sadikin Academic Medical Center Universitas Padjadjaran, Bandung, IndonesiaCorrespondence: Safendra Siregar, Urology Department, Hasan Sadikin Academic Medical Center Universitas Padjadjaran, Bandung, Indonesia, Email Safendra_sir@yahoo.co.idIntroduction: Erectile dysfunction is a health problem that arises from various conditions and causes an impaired quality of life with a significant health burden. Regenerative and stem cell therapies are some of the potential treatments for erectile dysfunction. This study aimed to review the available information in the literature regarding the use of stem cells in the treatment of erectile dysfunction.Methods: This study is a systematic review conducted based on the PubMed, Google Scholar, Cochrane, and DOAJ databases. Literature searching was conducted in English and included articles from 2000 to 2020.Results: The result was a total of 318 articles. Following the elimination process, 9 articles remained in the final analysis. The analyzed studies included 164 patients with erectile dysfunction with various medical conditions. Several stem cell types have been used for treating erectile dysfunction, including mesenchymal stem cell, placental matrix-derived stem cell, mesenchymal stem cell-derived exosome, adipose-derived stem cell, bone marrow-derived mononuclear stem cell, and umbilical cord blood stem cell. Generally, stem cell therapy showed a good efficacy and safety profile, although not enough studies on the protocol, dosage, and mechanism of action.Conclusion: Stem cell therapy has a good therapeutic potential in erectile dysfunction, the available data from the literature could be the base of usage of stem cells in the treatment of erectile dysfunction although need more research for broader usage.Keywords: erectile dysfunction, stem cells, regenerative medicine, systematic review

Guglielmo Mantica,1 Francesco Chierigo,1,2 Farzana Cassim,3 Francesca Ambrosini,1,2 Stefano Tappero,1,2 Rafaela Malinaric,1,2 Stefano Parodi,1,2 Andrea Benelli,4 Federico Dotta,4 Marco Ennas,4 Martina Beverini,1,2 Chiara Vaccaro,5 Salvatore Smelzo,6 Giovanni Guano,1,2 Federico Mariano,1,2 Calogero Paola,1,2 Giorgia Granelli,1,2 Virginia Varca,5 Carlo Introini,4 Salvatore Dioguardi,7 Alchiede Simonato,7 Andrea Gregori,8 Franco Gaboardi,6 Carlo Terrone,1,2 André Van der Merwe3 1IRCCS Ospedale Policlinico San Martino, U.O. Urologia, Genova, Italy; 2Department of Surgical and Diagnostic Integrated Sciences (DISC), University of Genova, Genova, Italy; 3Department of Urology, Tygerberg Academic Hospital, Stellenbosch University, Cape Town, South Africa; 4Department of Urology, Galliera Hospital, Genoa, Italy; 5Department of Urology, ASST Rhodense, G. Salvini Hospital, Milan, Italy; 6Department of Urology, San Raffaele Turro Hospital, Milan, Italy; 7Department of Surgical, Oncological, and Oral Sciences, Section of Urology, University of Palermo, Palermo, Italy; 8Urology Unit, Ospedale Sacco, Milan, ItalyCorrespondence: Guglielmo Mantica, IRCCS Ospedale Policlinico San Martino, Largo Rosanna Benzi, 10, Genoa, 16132, Italy, Tel +390105552815, Email guglielmo.mantica@gmail.comPurpose: To evaluate the prostate cancer (PCa) detection rate in men with chronic use of Aspirin and to compare it with the detection rate of non-users.Patients and Methods: Prospectively maintained database regarding patients undergoing prostate biopsy over the last 10 years in five institutions. Patients were divided into two groups according to their exposure to Aspirin. We relied on multivariable linear and logistic regression models to test whether Aspirin administration was associated with lower PSA values at prostate biopsy, higher PCa diagnosis, and higher Gleason Grade Grouping (GGG) at biopsy.Results: Were identified 1059 patients, of whom 803 (76%) did not take Aspirin vs 256 (24%) were taking it. In multivariable log-linear regression analysis, Aspirin administration was associated with lower PSA levels (OR 0.83, 95% CI 0.71– 0.97, p = 0.01), after controlling for age, prostate volume, smoking history, associated inflammation at prostate biopsy, presence of PCa at biopsy, and GGG. In multivariable logistic regression analysis, Aspirin administration was not found to be a predictor of PCa at prostate biopsy (OR 1.40, 95% CI 0.82– 2.40, p = 0.21) after controlling for age, PSA, smoking history, prostate volume, findings at digital rectal examination and the number of biopsy cores. In patients with PCa at prostate biopsy (n = 516), Aspirin administration was found to predict higher GGG (OR 2.24, 95% CI 1.01– 4.87, p = 0.04).Conclusion: Aspirin administration was found to be a predictor of more aggressive GGG. These findings suggest that a lower PSA threshold should be considered in patients taking Aspirin, as, despite low PSA levels, they might harbour aggressive PCa.Keywords: prostate-specific antigen, aspirin, inflammation, prostate cancer, prostate biopsy

Naim Yarak, Skander Zouari, Omar Karray, Walid Sleiman, Alaa Abdelwahab, Stéphane Bart, Maher Abdessater Urology Department, Centre Hospitalier Régional René DUBOS, Pontoise, 95300, FranceCorrespondence: Maher Abdessater, Email maher.abdessater@gmail.comObjective: To describe our new endoscopic approach in treating iatrogenic ureteral stenosis using the “cut-to-The-light” technique.Methods: Case of a 54 year-old female patient who underwent a right percutaneous nephrolithotomy to treat a staghorn calculus with two subsequent complimentary ureteroscopies complicated by a severe proximal ureteral obstruction. An antegrade flexible uretereroscope and a retrograde rigid ureteroscope were used to locate the stenosis. With the aid of a 365-μm Ho: YAG laser fiber (settings 0.4 J, 12 Hz), we managed to successfully create a small incision in the stenotic lesion, the rigid ureterscopy light was clearly seen by the antegrade flexible ureteroscope and a through-and-through guidewire was then placed, securing the ureter. Ureteral dilatation was then performed followed by a full thickness incision of the ureteral stenosis. A single 8Fr, 28 cm double J ureteral stent was finally placed after stone fragmentation.Results: The operating time was 200 mins. No blood loss. No fever or signs of UTI were seen shortly after the operation. The Foley catheter was successfully removed at day one post-op. The hospital stay was short of only 2 days.Conclusion: The “cut-to-the-light” technique is a new application in the arsenal of ureteral stricture treatment that has been scarcely described in the literature before. The use of this method seems to offer excellent outcomes thus demonstrating the importance of this minimally invasive technique as an alternative to conventional invasive methods used. We believe that studies with larger samples and longer follow up are needed in order to fully determine the benefits of this method and to assess and reveal its suitable application and its drawbacks.Keywords: ureteral stenosis, ureteroscopy, “cut-to-the-light” technique, laser endoureterotomy