Post-traumatic renal arteriovenous malformation failed endovascular embolization.

Renal arteriovenous malformations (AVMs) are abnormal connections between the renal arteries and venous system. Arteriovenous fistulas account for 70%-80% of renal arteriovenous abnormalities, often resulting from iatrogenic injuries. While most renal AVMs are asymptomatic, hematuria is a common symptom caused by AVM rupture into the renal calyces. Angiography is the gold standard for diagnosis, but noninvasive imaging techniques like ultrasound, computed tomography, or magnetic resonance imaging are commonly used for initial evaluation. Most renal AVMs are managed conservatively. Symptomatic patients typically undergo endovascular embolization, the preferred treatment, while surgery is reserved for unstable patients or those with complex vascular anatomy. We present a case of a 32-year-old man with renal AVMs following a motor vehicle accident. The patient initially received unsuccessful endovascular embolization but achieved successful treatment through open fistula ligation. This case highlights the challenges in managing renal AVMs and the importance of considering alternative interventions when initial treatments prove ineffective.

Malignant testicular tumors in children: overview on 10 years of Saudi Cancer Registry.

BACKGROUND/OBJECTIVE: The aim of this study was to identify epidemiological and histopathological patterns of pediatric testicular tumor (TT) in Saudi population over 10 years. METHODS: Retrospective data extracted from the Saudi Cancer Registry for Saudi children diagnosed with TT from 2008 to 2017. The data collected included patient's factors as age, year of diagnosis, survival status, and tumor factors as basis of diagnosis, origin of the tumor, histopathological group and subtype, and tumor behavior, stage, and laterality. RESULTS: A total of 115 patients with a median age of 14 (IQR 1.5-17) were included. The primary tumor site was a normal descended testis in 98.3% (115). Yolk sac tumor was the most common 28.2% (33), followed by embryonal carcinoma in 27.4% (32) and mixed germ-cell tumors in 23.1% (27). Kaplan-Meier analysis revealed significant association between survival and the stage of the tumor (p = 0.002). However, there was a lack of significant association between survival and age groups, histopathological groups, and histopathological subtypes (p = 0.541, p = 0.609, and p = 0.733, respectively). The overall mortality rate of TT 5.2% with all deaths caused by non-seminomatous germ-cell tumor diagnosed with stage 3. CONCLUSIONS: The median age of the patients was 14 years. Yolk sac tumors were the most common while testicular choriocarcinomas were the least in incidence. No increase in the incidence of TT was seen and the mortality rate over the 10-year period was 5.2%. Shorter survival was associated with higher tumor stage.

Prostatic adenocarcinoma with transitional cell features among the Saudi Arabian population: a registry review.

Prostate cancer is the third leading cause of death from cancer among American men. Acinar adenocarcinoma is the most common form of prostate cancer; however, there are several nonacinar adenocarcinoma variants, such as transitional cell carcinoma of the prostate and ductal adenocarcinoma. Materials and Methods: A retrospective cohort study was conducted on all Saudi patients diagnosed with adenocarcinoma of the prostate with transitional cell features. The data was collected from the Saudi Cancer Registry, which collects tumor data from all private, military, and Health Ministry hospitals in Saudi Arabia through five regional offices. Results: Out of 3608 patients, only 16 (0.44%) had adenocarcinoma with transitional cell features. All the tumors under investigation were malignant and constituted. Only 6.2% of the tumors were well-differentiated, 43.8% were moderately differentiated, and 50.0% were poorly differentiated. Among the included patients, 56.3% of the patients (n=9) died. There were no significant factors associated with death among patients, including the demographic and tumor-related variables. Conclusion: To the authors' knowledge, this is the first study describing the prevalence of adenocarcinoma with transitional cell features and its characteristics in Saudi Arabia. The authors have demonstrated that this rare subtype may be more prevalent than what was originally believed. It is necessary for future studies to assess the effectiveness of various treatment modalities to combat it. Furthermore, identifying risk factors - if any - may be crucial in the prevention of its development among men worldwide.

Randomized comparison of 4.5/6 Fr versus 6/7.5 Fr ureteroscopes for laser lithotripsy of lower/middle ureteral calculi: towards optimization of efficacy and safety of semirigid ureteroscopy.

BACKGROUND AND PURPOSE: To compare 4.5/6 Fr versus 6/7.5 Fr semirigid ureteroscopes in terms of safety and efficacy in adult non-obese patients with middle or lower ureteric stones. MATERIALS AND METHODS: A total of 198 patients with middle/lower ureteric stone and a BMI ≤ 30 kg/m2 were recruited. Patients were randomized according to the size of ureteroscope into two groups: group 1 where a 4.5/6 Fr semi-rigid ureteroscope was used, and group 2 where a 6/7.5 Fr semi-rigid ureteroscope was used. Patient's demographic, stone characteristics, intraoperative and postoperative outcomes including stone-free rate (SFR) and complications were compared. RESULTS: Preoperative characteristics in terms of age, sex, BMI, and stone location, side, size, and HU were comparable between both groups (p values > 0.05). The overall SFR was significantly higher in group 1 (0.004). Balloon dilatation was not required in all patients of group-1 compared with 33% of group-2 (p = 0.0001). The JJ stent was required in 10% of group-1 compared with 30% of group-2 (p = 0.0004). Failure to reach the stone due to tight ureter occurred in 8% of group 2 (p = 0.003), respectively. Traxer's grade 1 ureteral injury occurred in 2% of group-1 versus 14% of group-2 (p = 0.001). Consequently, hematuria was significantly lower in group-1 (1% vs. 8%; p = 0.01), respectively. The hospital stay < 9 h was significantly higher in group 1 (p = 0.0001). CONCLUSIONS: The 4.5/6 Fr semi-rigid Ureteroscope was associated with significantly higher SFR and shorter hospital stay, with lower ureteral injury, fewer double-J stenting, and without the need for intraoperative balloon dilatation for the ureter.

Xanthogranulomatous inflammation of urachus: A case report.

The urachus is a midline tubular structure that extend between bladder dome and umbilicus which result from incomplete regression during normal development. Defective obliteration of the urachus is rare and can result in urachal abnormalities, most commonly malignant masses. Xanthogranulomatous urachal masses are rare forms of chronic inflammatory processes with only few reported cases. Differentiating malignant from benign urachal lesion is challenging due to lack of typical clinical and radiologic manifestations, coupled with limited diagnostic experience or awareness. We present an initial misdiagnosis of urachal carcinoma, which was revealed to be benign xanthogranulomatous inflammation of urachus on postoperative histopathological examination.

Bilateral same session renal stone surgery tolerance and complications.

INTRODUCTION: The prevalence rate of upper urinary tract calculi in Saudi Arabia is one of the highest globally. Bilateral renal stone management is an option but is still controversial. METHODOLOGY: The study was a retrospective study, including 31 patients with bilateral renal or ureteric stones who underwent bilateral same-session ureterorenoscopy (BSS-URS). The data collected included age, gender, body mass index (BMI), stone burden bilaterally, operative time bilaterally, hospital stay, stone location, type of anesthesia, stone history, renal anomaly as well as pre- and postoperative JJ stenting. In addition, data related to complications (ureteric injury, renal failure, urinary tract infection, pain requiring an emergency department visit within 1 week of the procedure), the stone-free rate (defined as £ 3 mm asymptomatic stone fragment identified with computed tomography Kidney, Ureter and Bladder 3 months after surgery was also collected. The data were collected from the electronic patient record system, entered in an Excel spreadsheet, and descriptive analysis was done. RESULTS: In total, 31 patients were included, with the majority (80.6%, n = 25) male. The mean age was 41.6 years, the mean BMI 28.7 ± 5.59, the mean operative time for each renal unit 46.53 ± 25.69 min, and the mean hospital stay 17.87 ± 8.43 h. The majority (96.7%, n = 30) received general anesthesia. Less than half (40.3%, n = 25) of the renal units had stones in multiple calyces and the majority (90.3%, n = 56) of the renal units were stone free at the 3-month follow-up. A small proportion (3.2%, n = 2) of the renal units were polycystic. Prestenting was documented in 40.3% (n = 25) of the renal units and the majority (95.2%, n = 59) were stented postoperatively. CONCLUSION: BSS-URS is a safe and a highly effective management option for bilateral renal stones.

Impact of COVID-19 on endourology surgical practice in Saudi Arabia: A national multicenter study.

OBJECTIVE: To identify the impact of COVID-19 on endourology surgical practice in Saudi Arabia. METHODS: A retrospective study of seven tertiary hospitals from January 2019 to April 2019, and from January 2020 to April 2020 was performed. Records of urology outpatient department (OPD) visits and endourology procedures in the first third of 2020 were analyzed and compared with those in the first third of 2019, as well as, during the full curfew time, i.e. April 2020 versus April 2019. RESULTS: Number of OPD visits in the first third of 2020 and 2019 were 19 499 and 26 594, respectively (p<0.001). Number of OPD visits in April 2020 was 1512, with a 78.6% decrease compared to that in April 2019, and among them 1373 (90.8%) were teleclinics. Number of elective procedures in the first third of 2020 has decreased by 34.3% (from 3025 to 1988) compared to that in the first third of 2019 (p<0.001). There were 120 elective procedures in April 2020, 84.1% lower than that in April 2019. Percutaneous nephrolithotomy, shockwave lithotripsy, and transurethral resection of prostate procedures declined by 94.2%, 98.5%, and 93.8%, respectively. Most procedures were performed as day surgery (85.0%). Number of emergency procedures in 2020 have fallen by 9.3% compared to 2019 (p=0.286). Urolithiasis was the commonest pathology (52.6%) presented to the emergency room (52.6%). CONCLUSION: During COVID-19 pandemic, urology services slashed by >75%, including OPD visits and elective endourology procedures. Most hospitals have changed their strategic preventive measures by increasing the rate of teleclinics and day surgeries.

Handedness switching as a presenting sign for pediatric low-grade gliomas: An insight into brain plasticity from a short case series.

PURPOSE: To describe clinical data, rehabilitation services, and outcomes of children with handedness switching as their presenting symptom before low-grade glioma (LGG) diagnosis. METHODS: A retrospective chart review was performed for five patients (four female and four white) with LGG and confirmed handedness switching before LGG diagnosis. RESULTS: All children were less than 8 years at diagnosis, and two patients were less than 3 years. All children were initially right-handed and experienced loss of motor function, ranging from weakness to paresis, in their dominant hand. The median time from switching handedness to diagnosis was 1 month (range: 0.75-60 months). Rehabilitation was offered for three patients, and motor function deficits in the initial dominant hand were resolved in two of the total cohort. At long-term follow-up, hand dominance returned to the initial hand in three patients. CONCLUSIONS: Handedness switching should be acknowledged as a potential sign of LGG in children, and early long-term rehabilitation services should be offered for these children.

Sloughing Prostatic Tissue, a Rare Complication Post Rezum Therapy: A Case Report.

Benign prostatic hyperplasia (BPH) is the most prevalent urological disease in men that leads to lower urinary tract symptoms (LUTS). The clinical presentation is, most likely, obstructive symptoms such as intermittency, hesitancy and poor stream, due to the obstructive nature of the pathology. BPH treatment approach varies. However, they can be divided into two main approaches which are non-surgical and surgical. Non-surgical methods usually started first, such as lifestyle modifications, watchful waiting, and medications. Hence, surgical intervention remains the mainstay of treatment to relieve clinical symptoms. Although transurethral resection of the prostate (TURP) is the gold standard, management is shifting towards minimally invasive surgeries such as Rezum due to its good outcome and fewer adverse effects. We present a case of prostatic tissue sloughing, a rare complication post Rezum system therapy in a 50-year-old male.

Evaluating pediatric spinal low-grade gliomas: a 30-year retrospective analysis.

PURPOSE: Most pediatric spinal tumors are low-grade gliomas (LGGs). Characterization of these tumors has been difficult given their heterogeneity and rare incidence. The objective was to characterize such tumors diagnosed at our institution. METHODS: Spinal tumors diagnosed in our pediatric patients between 1984 and 2014 were reviewed retrospectively. Demographics, presentation, pathology, imaging, management, and sequelae were examined. RESULTS: Forty patients had spinal LGG tumors, 24 (62%) of which were pilocytic astrocytomas. The most common initial presentations were pain (n = 15), partial extremity paralysis (n = 13), and ataxia (n = 11), with the diagnosis frequently delayed by months (median = 5.9 months, range 4 days-6.2 years). Twenty-nine patients had some tumor resection, and 8 required adjuvant therapy with chemotherapy (n = 4) or radiation (n = 4) post-resection. Ten other patients received only biopsy for histologic diagnosis, who were treated with chemotherapy (n = 4) or radiation (n = 5) post biopsy. Tumor progression was noted in 16 patients (2 after gross-total resection; 10, partial resection; and 4, biopsy). During the evaluation period, 3 patients died secondary to tumor progression. BRAF status could have shortened progression-free survival: patients with BRAFV600E mutations (n = 3) all experienced progression within 10 months. Long-term sequelae of the disease/treatment were mostly residual neurologic deficits (paresthesia, paralysis), chemotherapy-induced hearing loss, and scoliosis. CONCLUSIONS: Spinal LGG is a rare entity with significant long-term effects. Although surgery is the most common initial treatment option, more in-depth analysis of molecular biomarkers may improve stratification and prognostication.

Treatment burden and long-term health deficits of patients with low-grade gliomas or glioneuronal tumors diagnosed during the first year of life.

BACKGROUND: Low-grade gliomas (LGGs) and low-grade glioneuronal tumors (LGGNTs) diagnosed during the first year of life carry unique clinical characteristics and challenges in management. However, data on the treatment burden, outcomes, and morbidities are lacking. METHODS: A retrospective study of LGGs and LGGNTs diagnosed in patients younger than 12 months at St. Jude Children's Research Hospital (1986-2015) was conducted. RESULTS: For the 51 patients (including 31 males), the mean age at diagnosis was 6.47 months (range, 0.17-11.76 months), and the mean follow-up period was 11.8 years (range, 0.21-29.19 years). Tumor locations were hypothalamic/optic pathway (61%), hemispheric (12%), brainstem (12%), cerebellar (8%), and spinal (8%). There were 41 patients with histological diagnoses: 28 had World Health Organization grade 1 tumors, 6 had grade 2 tumors, and 7 had an LGG/LGGNT not definitively graded. Forty-one patients required an active intervention at diagnosis. Throughout their treatment course, 41 patients eventually underwent tumor-directed surgeries (median, 2 surgeries; range, 1-6), 39 received chemotherapy (median, 2 regimens; range, 1-13), and 21 received radiotherapy. Forty patients experienced disease progression (median, 2 progressions; range, 1-18). Ten patients died of progression (n = 5), malignant transformation (n = 2), a second cancer (n = 2), or a shunt infection (n = 1). The 10-year overall survival, progression-free survival, and radiation-free survival rates were 85% ± 5.3%, 16.9% ± 5.3%, and 51.2% ± 7.5%, respectively. Forty-nine patients experienced health deficits (eg, endocrinopathies, obesity, seizures, visual/hearing impairments, neurocognitive impairments, and cerebrovascular disease). Predictors of progression and toxicities were defined. CONCLUSIONS: Infantile LGG/LGGNT is a chronic, progressive disease universally associated with long-term morbidities and requires multidisciplinary intervention.

Neuropsychological outcomes of patients with low-grade glioma diagnosed during the first year of life.

PURPOSE: Low-grade gliomas (LGG) are a heterogeneous group of brain tumors, which are often assumed to have a benign course. Yet, children diagnosed and treated for LGG in infancy are at increased risk for neurodevelopmental disruption. We sought to investigate neuropsychological outcomes of infants diagnosed with LGG. METHODS: Between 1986 and 2013, 51 patients were diagnosed with LGG before 12 months of age and managed at St. Jude Children's Research Hospital. Twenty-five of the 51 patients received a cognitive assessment (68% male; 6.8 ± 3.3 months at diagnosis; 10.5 ± 4.8 years at latest assessment). Approximately half the patients received radiation therapy (n = 12; aged 4.0 ± 3.0 years at radiation therapy), with a median of 2 chemotherapy regimens (range = 0-5) and 1 tumor directed surgery (range = 0-5). RESULTS: The analyses revealed performance below age expectations on measures of IQ, memory, reading, mathematics, and fine motor functioning as well as parent-report of attention, executive, and adaptive functioning. Following correction for multiple comparisons, a greater number of chemotherapy regimens was associated with lower scores on measures of IQ and mathematics. More tumor directed surgeries and presence of visual field loss were associated with poorer dominant hand fine motor control. Radiation therapy exposure was not associated with decline in neuropsychological performance. CONCLUSIONS: Children diagnosed with LGG in infancy experience substantial neuropsychological deficits. Treatment factors, including number of chemotherapy regimens and tumor directed surgeries, may increase risk for neurodevelopmental disruption and need to be considered in treatment planning.

Tectal glioma as a distinct diagnostic entity: a comprehensive clinical, imaging, histologic and molecular analysis.

Tectal glioma (TG) is a rare low-grade tumor occurring predominantly in the pediatric population. There has been no detailed analysis of molecular alterations in TG. Risk factors associated with inferior outcome and long-term sequelae of TG have not been well-documented. We retrospectively studied TGs treated or referred for review at St. Jude Children's Research Hospital (SJCRH) between 1986 and 2013. Longitudinal clinical data were summarized, imaging and pathology specimen centrally reviewed, and tumor material analyzed with targeted molecular testing and genome-wide DNA methylation profiling. Forty-five patients with TG were included. Twenty-six (57.8%) were male. Median age at diagnosis was 9.9 years (range, 0.01-20.5). Median follow-up was 7.6 years (range, 0.5-17.0). The most common presenting symptoms were related to increased intracranial pressure. Of the 22 patients treated at SJCRH, 19 (86%) required cerebrospinal fluid diversion and seven (32%) underwent tumor-directed surgery. Five patients (23%) received radiation therapy and four (18%) systemic therapy. Ten-year overall and progression-free survival were 83.9 ± 10.4% and 48.7 ± 14.2%, respectively. Long-term morbidities included chronic headaches, visual symptoms and neurocognitive impairment. Lesion ≥3cm2, contrast enhancement and cystic changes at presentation were risk factors for progression. Among those with tumor tissue available, 83% showed growth patterns similar to pilocytic astrocytoma and 17% aligned best with diffuse astrocytoma. BRAF duplication (a marker of KIAA1549-BRAF fusion) and BRAF V600E mutation were detected in 25% and 7.7%, respectively. No case had histone H3 K27M mutation. DNA methylation profile of TG was distinct from other brain tumors. In summary, TG is an indolent, chronic disease with unique clinical and molecular profiles and associated with long term morbidities. Large size, contrast enhancement and cystic changes are risk factors for progression.

Profound hearing loss following surgery in pediatric patients with posterior fossa low-grade glioma.

BACKGROUND: Hearing loss may occur in patients with posterior fossa low-grade glioma who undergo surgery. METHODS: We retrospectively reviewed 217 patients with posterior fossa low-grade glioma, including 115 for whom results of hearing tests performed after surgery and before chemotherapy or radiation therapy were available. We explored the association of UHL with age at diagnosis, sex, race, tumor location, extent of resection, posterior fossa syndrome, ventriculoperitoneal shunt placement, and histology. RESULTS: Of the 115 patients, 15 (13.0%: 11 male, 6 black, 8 white, 1 multiracial; median age 7 years [range, 1.3-17.2 years]) had profound UHL after surgery alone or before receiving ototoxic therapy. Median age at tumor diagnosis was 6.8 years (range, 0.7-14.1 years), and median age at surgery was 6.8 years (range, 0.7-14.1 years). Patients with UHL had pathology characteristic of pilocytic astrocytoma (n = 10), ganglioglioma (n = 4), or low-grade astrocytoma (n = 1). Of these 15 patients, 4 underwent biopsy, 1 underwent gross total resection, 1 underwent near-total resection, and 9 underwent subtotal resection. UHL was more frequent in black patients than in white patients (OR 7.3, P = .007) and less frequent in patients who underwent gross total resection or near-total resection than in those who underwent subtotal resection (OR 0.11, P = .02). CONCLUSIONS: Children undergoing surgery for posterior fossa low-grade glioma are at risk for UHL, which may be related to race or extent of resection. These patients should receive postoperative audiologic testing, as earlier intervention may improve outcomes.

Mortality in children with low-grade glioma or glioneuronal tumors: A single-institution study.

BACKGROUND: While pediatric low-grade glioma/glioneuronal tumors (LGG/LGGNTs) are considered slow-growing, indolent tumors with excellent long-term prognosis, mortality due to the disease is not unknown. Few studies have addressed the cause of death in this population. METHODS: Retrospective review of clinicopathologic and radiologic data for children 21 years or younger with LGG/LGGNT who died at St. Jude Children's Research Hospital between April 1985 and June 2015. Our primary objective was to determine the causes and timing of mortality in affected children. RESULTS: For the 87 eligible patients, median age at diagnosis was 7.7 years (range, 0.21-21 years), median age at death was 14.26 years (range, 0.58-32 years), and median time to death from diagnosis was 4.02 years (range, 0.21-24 years). Midbrain/thalamus was the most common tumor location (n = 34), followed by suprasellar/hypothalamic (n = 18) and cerebrocortical (n = 13). Astrocytoma not otherwise specified (n = 24), pilocytic astrocytoma (n = 23), and fibrillary astrocytoma (n = 11) were the predominant histologic diagnoses. Causes of death included progressive primary disease (PD) (n = 43), progression of PD with histological features of a high-grade glioma at progression or at autopsy (PD-HGG) (n = 15), second cancer (n = 3), suicide (n = 4), and vehicular accident (n = 3). Among the 15 patients with PD-HGG, 12 received radiation therapy before histologic confirmation of progression. CONCLUSIONS: PD and PD-HGG contributed to 66% of the mortality in our patient cohort. Early psychological intervention should be included as part of the multidisciplinary management approach of children with LGG/LGGNT to reduce the risk of suicide in vulnerable subjects.

The prevalence of urinary tract infection, or urosepsis following transrectal ultrasound-guided prostate biopsy in a subset of the Saudi population and patterns of susceptibility to flouroquinolones.

OBJECTIVES: To study the prevalence of urinary tract infections (UTI), or sepsis secondary to trans-rectal ultrasound-guided (TRUS) biopsy of the prostate, the pathogens involved, and patterns of antibiotic resistance in a cohort of patients. METHODS: This is a descriptive study of a consecutive cohort of patients who underwent elective TRUS biopsy at King Abdulaziz Medical City, Riyadh, Saudi Arabia between January 2012 and December 2014. All patients who underwent the TRUS guided prostate biopsy were prescribed the standard prophylactic antibiotics. Variables included were patients' demographics, type of antibiotic prophylaxis, results of biopsy, the rate of UTI, and urosepsis with the type of pathogen(s) involved and its/their antimicrobial sensitivity.  RESULTS: Simple descriptive statistics were used in a total of 139 consecutive patients. Urosepsis requiring hospital admission was encountered in 7 (5%) patients and uncomplicated UTI was observed in 4 (2.8%). The most common pathogens were Escherichia coli (90.1%) and Klebsiella pneumoniae (9.1%). Resistance to the routinely used prophylaxis (ciprofloxacin) was observed in 10 of these patients (90.9%). CONCLUSION: This showed an increase in the rate of infectious complications after TRUS prostate biopsy. Ciprofloxacin resistance was found in 90.9% of patients with no sepsis.

Clinical characteristics and genetic subtypes of Fanconi anemia in Saudi patients.

We reviewed our institutional experience from 2011 to 2015 on new cases of Fanconi anemia (FA). Ten unrelated cases were diagnosed during this period. Four patients with severe aplastic anemia (SAA) had c.2392C > T (p.Arg798*) BRIP1/FANCJ mutation. Another child with SAA had novel c.1475T > C (p.Leu492Pro) FANCC mutation. One individual with SAA and acute myeloid leukemia had c.637_643del (p.Tyr213Lysfs*6) FANCG mutation. Three patients presented with early onset of cancer, two had BRCA2 mutation c.7007G > A (p.Arg2336His) and one had a novel c.3425del (p.Leu1142Tyrfs*21) PALB2 mutation. Another infant with c.3425del PALB2 mutation had clonal aberration with partial trisomy of the long arm of chromosome 17. Mutations in FA downstream pathway genes are more frequent in our series than expected. Our preliminary observation will be confirmed in a large multi-institutional study.

Efficacy of sacral neuromodulation in treatment of bladder pain syndrome: long-term follow-up.

AIMS: This study was sought to evaluate the efficacy and durability of sacral neuromodulation in the treatment of bladder pain syndrome (BPS) patients. METHODS: A retrospective chart review was performed of patients who had unilateral sacral nerve stimulator (InterStim®) for refractory BPS between June 2002 and December 2004. Patients were qualified for permanent implantation by showing ≥ 50% improvement in their bladder pain and voiding symptoms 1-week post-percutaneous nerve evaluation (PNE). Voiding diary was completed at pre-implantation, 1 year, and on the last visit. Urinary distress inventory short form was completed pre-implantation and on the last visit. Bladder pain was evaluated by visual analogue scale. Primary outcome was improvement in bladder pain. Differences among groups were compared by one-way ANOVA and t-test. Statistical significance was set at P ≤ 0.05. RESULTS: Twenty-one female patients diagnosed with BPS had PNE; 11 patients (52%) showed ≥ 50% improvement in their bladder pain and voiding symptoms and they consider candidates for permanent implantation (Table I), while 10 patients (48%) failed to show 50% improvement in their voiding symptoms or bladder pain (Table II). In those 11 patients who underwent permanent implantation, the average patient's age was 44.3 ± 8.9 years; average time since diagnosis was 3 ± 0.8 years; the average follow- up was 71.5 ± 9.3 months (Table III). There was significant improvement in the bladder pain and voiding parameters at 1-year follow-up, which was maintained at 5-year follow-up. There was continuous improvement in urgency (1.2 ± 0.68) at 1-year follow-up, and (0.98 ± 0.72) at the last visit. Average voided volume was also continuously improved from 242 ± 62.7 ml at 1-year follow-up to 276 ± 64.7 ml on the last visit. CONCLUSION: Sacral neuromodulation as part of multimodal treatment provides an effective long-term treatment option for sub-group of refractory BPS.