Effect of pelvic lymph node dissection and its extent on oncological outcomes in intermediate-risk prostate cancer patients: A multicenter study of the Turkish Uro-oncology Association.

BACKGROUND: Pelvic lymph node dissection (PLND) is the gold standard method for lymph node staging in prostate cancer. We aimed to evaluate the effect of PLND combined with radical prostatectomy (RP) on oncological outcomes in D'Amico intermediate-risk prostate cancer (IRPC) patients. METHODS: Patients with D'Amico IRPC were included in the study. In the overall cohort and subgroups (biopsy International Society of Urological Pathology [ISUP] grade group 2 and 3), patients were divided into two groups as PLND and no-PLND. More extensive PLND, defined as a number of removed nodes (NRN) ≥ 75th percentile. RESULTS: After exclusion, a total of 631 patients were included: 351 (55.6%) had PLND and 280 (44.4%) had no-PLND. The mean age was 63.1 ± 3.60 years. The median NRN was 8.0 (1.0-40.0). The mean follow-up period was 47.7 ± 37.5 months. The lymph node involvement (LNI) rate was 5.7% in the overall cohort, 3.9% in ISUP grade 2, and 10.8% in ISUP grade 3. Patients with PLND were associated with more aggressive clinicopathologic characteristics but no significant difference in biochemical recurrence-free survival (BCRFS) was found between patients with PLND and no-PLND (p = 0.642). In the subgroup analysis for ISUP grades 2 and 3, no significant difference in BCRFS outcomes was found in patients with PLND and No-PLND (p = 0.680 and p = 0.922). Also, PLND extent had no effect on BCRFS (p = 0.569). The multivariable Cox regression model adjusted for preoperative tumor characteristics revealed that prostate specific antigen (PSA) (HR: 1.18, 95% CI: 1.01-1.25; p = 0.048) was an independent predictor of biochemical recurrence (BCR). The optimum cut-off value for PSA, which can predict BCRFS, was assigned to be 7.81 ng/ml, with an AUC of 0.63 (95% CI: 0.571-0.688). The highest sensitivity and specificity were 0.667 and 0.549. CONCLUSION: Overall and cancer-specific survival analyzes were not evaluated because not enough events were observed. Neither PLND nor its extent improved BCRFS outcomes in IRPC. The LNI rate is low in patients with biopsy ISUP grade 2 and the BCR rate is low in those with PSA < 7.81 ng/dl so PLND can be omitted in these IRPC patients.

Adherence to guideline recommendations in the management of upper tract urothelial carcinoma: an analysis of the CROES-UTUC registry.

BACKGROUND: The European Association of Urology provides Clinical Practice Guideline on upper tract urothelial carcinoma (UTUC). Due to the rarity of UTUC, guidelines are necessary to help guide decision-making based on the highest quality of care evidence available. OBJECTIVES: To evaluate guideline adherence in the management of UTUC by assessing recommendations on diagnostics needed for risk classification and subsequent treatment selection; to assess predictors for the latter. PARTICIPANTS: Data from the Clinical Research Office of the Endo Urology Society UTUC-registry were included for analysis. STATISTICAL ANALYSIS: Overall compliance were evaluated by cross-tables, differences in risk groups characteristics and treatment selection were assessed by Chi-square tests, predictors for treatment selection by logistic regression analysis. RESULTS: Data from 2380 patients were included. Imaging by CT-scan had highest adherence (85%) but was low for other diagnostics (17.7-49.7%). Multivariable regression analysis showed higher odds of receiving radical nephroureterectomy in patients with large tumours (OR 5.45, 95% CI 3.77-7.87, p < 0.001), signs of invasion (OR 3.07,CI 2.11-4.46, p < 0.001), high tumour grade (OR 2.05, CI 1.38-3.05, p < 0.001) and multifocality (OR 1.76,CI 1.05-2.97, p =0.032). CONCLUSIONS: CT-imaging is the most used and most impactful decision tool for risk-stratification and treatment selection in UTUC. Due to the low compliance in most of the diagnostic recommendations, proper risk stratification is not possible in a significant group of patients raising the question whether current stratification is deemed applicable in daily practice. Established prognostic factors on survival guides decision-making regarding radical versus kidney-sparing surgery. Tumour size was the most influencing factor on treatment decision. CLINICAL TRIAL REGISTRATION: The study was registered at ClinicalTrials.gov (ClinicalTrials.gov NCT02281188; https://clinicaltrials.gov/ct2/show/NCT02281188 ).

The Effect of Diagnostic Ureterorenoscopy on Intravesical Recurrence in Patients Undergoing Nephroureterectomy for Primary Upper Tract Urinary Carcinoma.

OBJECTIVE: The objective of this study is to evaluate the effect of diagnostic ureterorenoscopy (URS) prior to radical nephroureterectomy (RNU) on intravesical recurrence (IVR), in patients with primary upper urinary tract urothelial carcinoma (UTUC). MATERIALS AND METHODS: Retrospective analysis of 354 patients, who underwent RNU for UTUC from 10 urology centers between 2005 and 2019, was performed. The primary endpoint was the occurrence of IVR after RNU. Patients were divided into URS prior to RNU (Group 1) and no URS prior to RNU (Group 2). Rates of IVR after RNU were compared, and a Cox proportional hazards model was used to evaluate potential predictors of IVR. RESULTS: After exclusion, a total of 194 patients were analyzed: Group 1 n = 95 (49.0%) and Group 2 n = 99 (51.0%). In Group 1, a tumor biopsy and histopathological confirmation during URS were performed in 58 (61.1%). The mean follow-up was 39.17 ± 39.3 (range 12-250) months. In 54 (27.8%) patients, IVR was recorded after RNU, and the median recurrence time within the bladder was 10.0 (3-144) months. IVR rate was 38.9% in Group 1 versus 17.2% in Group 2 (p = 0.001). In Group 1, IVR rate was 43.1% in those undergoing intraoperative biopsy versus 32.4% of patients without biopsy during diagnostic URS (p =0.29). Intravesical recurrence-free survival (IRFS) was longer in Group 2 compared to Group 1 (median IRFS was 111 vs. 60 months in Groups 2 and 1, respectively (p< 0.001)). Univariate analysis revealed that IRFS was significantly associated with URS prior to RNU (HR: 2.9, 95% CI 1.65-5.41; p < 0.001). In multivariate analysis, URS prior to RNU (HR: 3.5, 95% CI 1.74-7.16; p < 0.001) was found to be an independent prognostic factor for IRFS. CONCLUSION: Diagnostic URS was associated with the poor IRFS following RNU for primary UTUC. The decision for a diagnostic URS with or without tumor biopsy should be reserved for cases where this information might influence further treatment decisions.

Smartphone-based stent tracking application for prevention of forgotten ureteral double-J stents: a prospective study.

PURPOSE: Retained or forgotten ureteral stents (FUS) have a potential to cause significant morbidity as well as medico-legal issues and increased cost. We aimed to evaluate the efficacy and usefulness of smartphone-based Ureteral Stent Tracker (UST) application and compare the results with basic appointment card system to prevent FUS, prospectively. MATERIALS AND METHODS: A total of 90 patients who underwent ureteroscopic stone treatment procedure with indwelling DJ stents were equally distributed into two groups. In group-1, patients were followed using UST application. In group-2, only appointment cards were given to the patients. Two groups were compared in terms of stent overdue times and complete lost to follow up rates. RESULTS: Forty-four patients in group-1 and 43 patients in group-2 completed the study. Among patients, 22.7% in group-1 and 27.9% in group-2 did not return for the stent removal on the scheduled day. In group-1, these patients were identified using the UST and called for the stent removal on the same day. After 6 weeks of maximal waiting period, mean overdue times in group-1 and group-2 were 3.5 days and 20 days, respectively (p = 0.001) . In group-2, 3 patients (6.9%) were lost to follow up, while in group-1, it was none (p = 0.001). CONCLUSIONS: We found that the patients who were followed by the smartphone-based UST application has less overdue times and lost to follow up cases compared to the basic appointment card system. The UST application easily follows patients with indwelling ureteral stents and can identify patients when overdue.

Endoscopic, Single-Session Management of Encrusted, Forgotten Ureteral Stents.

Background and Objectives: Remained or forgotten ureteral double-J stents may cause serious complications. Removing of an encrusted, forgotten stent can be challenging. We present our experience with heavily encrusted ureteral stents and discuss the endourologic treatment options as well as their effectivity. Materials and Methods: Eleven men and six women (mean 48.58 ± 14.48 years of age) with 18 encrusted forgotten stents (mean 16.4 ± 13.25 months of indwelling) were treated at our clinic. All patients underwent the operation after negative urine cultures were obtained. Their medical records were retrospectively reviewed and analyzed in terms of number of interventions required to remove the stent, operation time, complications, hospital stay and stone-free rate. Results: According to the Forgotten-Encrusted-Calcified (FECal) classification, the most common form of stent encrustation was grade III (64.7%) and 17.6% of the stents were fragmented. Four of 17 patients were initially treated with extracorporeal shock-wave lithotripsy. The patients required a mean of two endoscopic interventions for removing the encrusted stent and all stents were removed endoscopically in a single session. The mean operating time was 63.3 ± 41.8 minutes. Cystolithotripsy followed by ureteroscopy was the most common intervention (41.1%). Of the 17 patients, peroperative and postoperative complications were Clavien grade I in two, grade II in two and grade IIIb in one. The mean hospital stay was 1.3 ± 0.99 days. All patients were stone-free after a month of stent removal. Conclusions: The endourological removal of the encrusted forgotten stents in a single session is feasible and effective with a minimal morbidity. The treatment strategy should be to minimize the number of interventions.

The sufficiency of 6 core sextant prostate biopsy in patients with prostate specific antigen (PSA) values over 20 ng/mL.

OBJECTIVE: In this study, we aimed to investigate sufficiency of 6 core prostate biopsy in patients with PSA levels elevated above 20 ng/mL. MATERIALS AND METHODS: The medical record of the patients who received prostate biopsy at our institution between August 2011 to August 2016 who had serum total PSA values above 20 ng/mL, were reviewed retrospectively. In this study, we included 40 patients who received 6 core prostate biopsy and 40 patients who received 12 core prostate biopsy. A total number of 80 patients were enrolled in this study. Patients were divided into two groups, a 6 core biopsy group and a 12 core biopsy group. These groups are compared according to age, total PSA, prostate volume and final pathological diagnosis. RESULTS: Based on final pathological diagnosis, 2 patients (5%) had benign pathology and 38 patients (95%) had PCa in both group 1 and 2. The cancer detection rate in both groups was 95%. Although there were higher values of mean age, mean total PSA, and mean prostate volume in group 1, there was no statistically significantly difference at this variables in both groups. CONCLUSION: Although taking 6 core biopsies is not recently recommended, we proved that 6 core biopsy is adequate for patients with PSA values above 20 ng/mL.

Safety and efficacy of single-incision sling for female stress urinary incontinence: 3 years' results.

INTRODUCTION AND HYPOTHESIS: The purpose of this study was to investigate the success and complication rates of single-incision sling for treating stress urinary incontinence (SUI), with a 3-year follow-up. METHODS: This study comprised 173 female patients with SUI or mixed urinary incontinence (MUI) with dominant SUI who underwent minisling procedure. All patients had positive cough stress test preoperatively; they were followed up for 3 years after surgery (1, 3, 6, 12 months, and yearly). RESULTS: Total follow-up was 36 months, and mean age 51 years (44-77); 128 (74 %) patients presented SUI and 45 (26 %) MUI. Objective and subjective cure and failure rates were 83.8 % (145 cases), 6.4 % (11 cases), and 9.8 % (17 cases), respectively. There were no differences in cure rates between 1 and 3 years. Mean body mass index was 28.7 (26.1-35.2), and mean operating time 7.9 min. (6.5-11.9). There were no major intraoperative complications. Eleven patients (6.4 %) had de novo urge incontinence that resolved using anticholinergic drugs; no patient had urinary retention. Vaginal mesh extrusion was reported in nine (5.2 %) patients. CONCLUSIONS: The minisling system attained high success rates at 3 years' follow-up. The procedure was easy to learn and has lower complication rate.

Diagnosis and treatment in primary bladder small cell carcinoma: Literature review.

Small cell bladder carcinoma is a rare and frequently fatal disease. It can be distinguished from classical urothelial carcinoma microscopically and immunohistochemically. Small cell bladder carcinoma has histologically similar properties with other small cell carcinomas in other organs. It has a worse prognosis when compared to urothelial bladder cancer. Multimodal treatments are recommended although there is no widely accepted consensus regarding to the treatment algorithm because of its rarity. In this review, clinical properties and diagnosis of small cell bladder carcinoma, its histopathological and immunohistochemical properties and treatment modalities are examined.

Do cigarette and alcohol affect semen analysis?

OBJECTIVES: There are a number of studies about the effect of cigarette and alcohol on semen parameters in the literature. There is not a consensus on the relationship between use of cigarette and alchol and semen parameters in those studies. The number of studies in which cigarette and alcohol use are evaluated together is limited. This study was aimed to analyze the effect of cigarette and/or alcohol use on semen parameters. METHODS: In this prospective study, 762 patients who applied to an hospital urology polyclinic between January 2015 and March 2015 due to infertility, were questioned for alcohol and cigarette use in anamnesis. The remaining 356 patients were included in our study. Then, semen analysis of the patients was performed. The patients were divided into five groups according to cigarette use, into five groups according to alcohol use and into four groups according to cigarette and/or alcohol use. Significant differences were analyzed between the groups in terms of semen volume, semen concentration, total motility, forward motility and morphological (normality, head anomaly, neck anomaly, tail anomaly) values. RESULTS: According to cigarette use, only in group 4 (who use more than 20 package-years cigarette) semen volume was significantly lower than the control group (Mann-Whitney U, p = 0.009). There was no significant difference in any of the other parameters and groups compared with the control group (Mann-Whitney U, p > 0,05) CONCLUSION: According to our study, using more than 20 package-years cigarette decreases semen volume. The reason of this result might be the fact that the threshold value, from which the effect of cigarette and alcohol use on the semen parameters has to be determined.

Current approach for urinary system stone disease in pregnant women.

Urinary system stones can be classified according to size, location, X-ray characteristics, aetiology of formation, composition, and risk of recurrence. Especially urolithiasis during pregnancy is a diagnostic and therapeutic challenge. In most cases, it becomes symptomatic in the second or third trimester. Diagnostic options in pregnant women are limited due to the possible teratogenic, carcinogenic, and mutagenic risk of foetal radiation exposure. Clinical management of a pregnant urolithiasis patient is complex and demands close collaboration between patient, obstetrician and urologist. We would like to review current diagnosis and treatment modalities of stone disease of pregnant woman.

Renal cell carcinoma in patient with crossed fused renal ectopia.

Primary renal cell carcinomas have rarely been reported in patients with crossed fused renal ectopia. We presented a patient with right to left crossed fused kidney harbouring renal tumor. The most frequent tumor encountered in crossed fused renal ectopia is renal cell carcinoma. In this case, partial nephrectomy was performed which pave way to preservation of the uninvolved both renal units. Due to unpredictable anatomy, careful preoperative planning and meticulous delineation of renal vasculature is essential for preservation of the uninvolved renal units.

Accuracy of unenhanced computerized tomography interpretation by urologists in patients with acute flank pain.

PURPOSE: The aim was to compare the findings of non-contrast computerized tomography (NCCT) evaluated by urology specialists with the findings of experienced radiologists, who are accepted as a standard reference for patients who present with acute flank pain. MATERIALS AND METHODS: Five hundred patients evaluated with NCCT were included in the study. The NCCT images of these patients were evaluated by both radiologists and urology specialists in terms of the presence of calculus, size of calculus, the location of calculus, the presence of hydronephrosis, and pathologies other than calculus, and the results were compared. RESULTS: The evaluations of urology specialists and standard reference radiology specialists are consistent with each other in terms of the presence of calculus (kappa [κ]: 0.904), categorical stone size (κ: 0.81), the location of calculus (κ: 0.88), and hydronephrosis (κ: 0.94). However, the evaluations of urology specialists in detecting pathologies other than calculus, which may cause acute flank pain or accompany renal colic, were found to be inadequate (κ: 0.37). The false-negative rate of detecting pathologies outside of the urinary system by the urology specialists is calculated as 0.86. CONCLUSION: Although the urology specialists can evaluate the findings related to calculus sufficiently with NCCT, they may not discover pathologies outside of the urinary system.

Different presentation types of primary Brucella epididimo-orchitis.

Brucellosis is a zoonotic disease that involved genitourinary system in 2-20% and most commonly cause single sided epididymo-orchitis. In our country Brucella is an endemic disease and causes serious and different diagnosis of acute scrotum and epididymo-orchitis. In this paper six cases of epididymo-orchitis cases which were resistant to classical treatment were discussed according to clinical and laboratory findings. We describe different types of presentation of Brucella epididymo-orchitis with diagnosis and treatment modalities.

The relationship between serum hormone levels (follicle-stimulating hormone, luteinizing hormone, total testosterone) and semen parameters.

OBJECTIVE: The aim of this study was to investigate the effect of serum gonadotropin and total testosterone levels on semen parameters. MATERIALS AND METHODS: Three hundred and eighty-two patients that applied to a male infertility polyclinic were included in our study. Serum gonadotropin and total testosterone levels and semen parameters of the patients were analyzed during the first visit to the clinic. The reference FSH value was 1.5-12.4 mIU/mL, that of LH was 1.7-8.6 mIU/mL and the reference value for total testosterone was 249-836 ng/dL. RESULTS: While there was no statistically significant difference between the patients with low gonadotropin levels and the controls regarding any of the semen parameters (p > 0.05), there was a strong statistically significant difference between the patients with high gonadotropin levels and the controls regarding sperm concentration (p = 0.000), total motility (p = 0.000), progressive motility (p = 0.000), and morphology (p = 0.000). There was a strong statistically significant difference between the patients with low testosterone levels and the controls regarding total motility (p = 0.012) and progressive motility (p = 0.010), and a weak statistically significant difference in morphology (p = 0.042). There was no statistically significant difference in semen volume or sperm concentration (p > 0.05). There was no statistically significant difference in any of the semen parameters between the patients with high testosterone levels and the controls (p > 0.05). CONCLUSIONS: Our findings especially regarding LH and T levels are not in agreement with previous reports. In this regard, there is a need for larger-scale and randomized trials to resolve this discrepancy.

A rare complication after renal transplantation: Forgotten stent.

In renal transplantation surgery, double J stents (DJS) are often used to reduce complications, protect the anastomosis between ureter and bladder, provide drainage in ureteral obstructions and enhance healing if there is an ureter injury. Urinary tract infections, hematuria and irritative voiding symptoms are the early complications of DJS. Migration, fragmentation, encrustation and rarely sepsis are among the late complications of DJS. In this report we describe a renal transplantation case whose DJS stent was forgotten because the patient did not attend the regular follow-up and noticed 5 years after surgery.

Clinical and bacteriological efficacy of amikacin in the treatment of lower urinary tract infection caused by extended-spectrum beta-lactamase-producing Escherichia coli or Klebsiella pneumoniae.

Urinary tract infections (UTIs) caused by extended-spectrum beta-lactamase (ESBL)-producing bacteria have become a growing problem limiting therapeutic options. The aim of this study was to investigate the clinical and microbiological efficacy of amikacin treatment in adult patients with lower UTIs due to ESBL-producing Escherichia coli (Ec) or Klebsiella pneumonia (Kp). We conducted a retrospective study of 36 outpatients aged >18 years with dysuria or problems with frequency or urgency in passing urine; pyuria and a positive urine culture (10(5) cfu/ml) for ESBL producing Ec or Kp which is also resistant to nitrofurantoin, fosfomycin, quinolones and trimethoprim/sulfamethoxazole, between January 2013 and February 2014. Patients received intramuscular amikacin 15 mg/kg/day for 10 days. Clinical success was defined as disappearance of symptoms. Bacteriological success was defined as sterile control urine cultures. 58.3% of patients were female. Age range was 18-89 years. All of the patients had at least one complicating factor. 77.8% of the isolates were E. coli. Clinical success rate was 97.2%. Overall bacteriological success rates were 91.7% on the 3 day of treatment, 97.1% at the end of the treatment and 94.1% on the 7-10 days after treatment. After 28-32 days following the treatment, reinfection was found in 12% whereas relapse was not determined. Nephrotoxicity was developed in one patient. The clinicians should keep in mind that amikacin treatment is an efficient and safe alternative treatment option before the carbapenem treatment especially in patients with lower UTIs caused by ESBL-producing Ec or Kp that are resistant to all oral antibiotics.

Post-renal acute renal failure due to a huge bladder stone.

A 63-year old male was referred to our emergency unit due to acute renal failure. The level of serum renal function tests levels, blood urea nitrogen (BUN)/creatinine, were 63 mmol/L/848 µmol/L. CT (Computarised Tomography) scan showed a huge bladder stone (5 cm x 6 cm x 5 cm) with increased bladder wall thickness. Post-renal acute renal failure due to bilateral ureterohydronephrosis was diagnosed. The huge bladder stone was considered to be the cause of ureterohydronephrosis and renal failure. The patient was catheterised and received haemodialysis immediately. He received haemodialysis four times during ten days of hospitalization and the level of serum renal function tests levels (BUN/ creatinine) decreased 18 mmol/L/123 µmol/L. After improvement of renal function, we performed cystoscopy that demonstrated normal prostatic urethra and bladder neck and bilaterally normal ureteral orifices. Bladder wall was roughly trabeculated and Bladder outlet was completely obstructed by a huge bladder stone. After cystoscopy open, cystolithotomy was performed to remove calcium phosphate and magnesium ammonium phosphate stone weighing 200 g removed. Four days after operation the patient was discharged uneventfully and urethral catheter was removed on the seventh day. Post-renal acute renal failure due to large bladder stones is rare in literature. According to the our knowledge; early diagnosis of the stone avoid growth to large size and prevent renal failure.

Rare type of bladder cancer: malign fibrous histiocytoma.

Malignant fibrous histocytoma (MFH) is the most common soft tissue sarcoma in adults. Urinary tract is a very rare location for MFH. Involvement of the bladder is more common in males and at the 6th decade of life. A case of MFH of the bladder with poor prognosis is presented. Prognostic factors for MFH are tumor grade, amount of invasion, age, tumor size, and histological type. Survival rate is very low and 3-year disease specific survival is approximately 40%.

To evaluate the etiology of erectile dysfunction: What should we know currently?

Erectile dysfunction (ED) is the inability to develop normal erection or an hardening problem at various extent that causes inability to maintain the erection for the sufficient time required for a complete sexual activity. It can be the result of neurologic, psychogenic, vascular, urogenital and hormonal abnormalities. It is reported that it affects 52-67% of men between 40 and 70 years old. Numerous theories and opinions are issued in the literature in order to explain the hemodynamic changea that occur during erection and detumescence. Especially the effects of chronic diseases and psychogenic factors on the pathophysiology of erectile dysfunction are common matters of discussion in recent years. In this review, we will evaluate the current developments in the literature about the etiology of erectile dysfunction.

A case with primary signet ring cell adenocarcinoma of the prostate and review of the literature.

Primary signet cell carcinoma of the prostate is a rare histological variant of prostate malignancies. It is commonly originated from the stomach, colon, pancreas, and less commonly in the bladder. Prognosis of the classical type is worse than the adenocarcinoma of the prostate. Primary signet cell adenocarcinoma is diagnosed by eliminating the adenocarcinomas of other organs such as gastrointestinal tract organs. In this case report, we present a case with primary signet cell adenocarcinoma of the prostate who received docetaxel chemotherapy because of short prostate specific antigen doubling time.