Post-voided residual urine ratio as a predictor of bladder outlet obstruction in men with lower urinary tract symptoms: development of a clinical nomogram.

PURPOSE: To confirm the correlation between post-void residual urine ratio (PVR-R) and BOO diagnosed by pressure-flow studies (PFS) in males with lower urinary tract symptoms (LUTS) and to develop a clinical nomogram. METHODS: A consecutive series of patients aged 45 years or older with non-neurogenic LUTS were prospectively enrolled. Patients underwent standard diagnostic assessment for BOO including International Prostatic Symptoms Score, uroflowmetry, urodynamic studies, suprapubic ultrasound of the prostate, and ultrasound measurements of the bladder wall thickness (BTW). PVR-R was defined as follows: PVR-R = (PVR/total Bladder Volume [BV]) × 100). Logistic regression analysis was used to investigate predictors of pathological bladder emptying (BOO) defined as Schafer > II. A nomogram to predict BOO based on the multivariable logistic regression model was then developed. RESULTS: Overall 335 patients were enrolled. Overall, 131/335 (40%) presented BOO on PFS. In a multivariable logistic age-adjusted regression model BWT (odds ratio [OR]: 2.21 per mm; 95% confidence interval [CI], 1.57-3.09; p = 0.001), PVR-R (OR: 1.02 per %; 95% CI, 1.01-1.03; p = 0.034) and prostate volume (OR: 0.97 per mL; 95% CI, 0.95-0.98; p = 0.001) were significant predictors for BOO. The model presented an accuracy of 0.82 and a clinical net benefit in the range of 10-90%. CONCLUSIONS: The present study confirms the important role of PVR-ratio in the prediction of BOO. For the first time, we present a clinical nomogram including PVR-ratio for the prediction of BOO.

Quality-of-Life Outcomes in Female Patients With Ileal Conduit or Orthotopic Neobladder Urinary Diversion: 6-Month Results of a Multicenter Prospective Study.

Radical cystectomy (RC) often affects patients' life as this surgery is a traumatic and invasive event for the patients, with drawbacks on their daily, social, working, and sex life. Such changes in the quality of life (QoL) of patients are commonly studied through retrospective clinical evaluations and rarely with longitudinal studies. To date, studies focusing on functional outcomes, sexual function, and health-related QoL for female patients are lacking. We evaluated 37 patients using EORTC QLQ-C30 (QLQ-30) and Short-Form 36 (SF-36) questionnaires, before and after surgery, at 3 and 6 months of follow-up. The mean values for the emotional functioning in QLQ-C30 as well as the mental health in SF-36 were significantly higher in the ONB group compared to the IC group at 3 months of follow-up. These differences were not significant at 6 months of follow-up. At 6 months of follow-up, the ONB group showed a higher mean score in the physical and role functioning than the IC group. Although there was a statistically significant age difference at baseline of the two groups, none of the results are correlated with age, as demonstrated by Spearman's analysis. The ONB seems to represent the most advantageous solution compared to the IC in terms of QOL at the 6-month follow-up.

Quality of Life in Female Patients Following Ileal Neobladder and Ileal Conduit: Where Are We?

Women undergoing a radical cystectomy (RC) followed by a urinary diversion (UD) for bladder cancer (BC), experience a substantial reduction in health-related quality of life (HRQOL). At present, studies comparing long-term QOL outcomes for different UD methods in female patients are lacking. We summarize the current state of the QoL assessment in female patients after an RC.

Corrigendum to endoscopic ultrasound-guided trans-duodenal biopsy of a renal mass: Case report and literature review [Urol Case Rep 31 (2020), 101203].

[This corrects the article DOI: 10.1016/j.eucr.2020.101203.].

Endoscopic ultrasound-guided trans-duodenal biopsy of a renal mass: Case report and literature review.

The importance of histologic characterization of renal masses is increasing in the management of small renal tumors and metastatic settings of renal cell carcinoma (RCC). Tissue sampling of renal lesions is generally achieved through a percutaneous approach yet endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) with cytological analysis could be more suitable in selected circumstances. We report a case of endoscopic ultrasound-guided fine-needle biopsy (EUS-FNB) of an anterior, mesorenal right kidney mass with a thrombus extending into the right atrium, unreachable via a percutaneous approach.

The role of bladder wall thickness in the evaluation of detrusor underactivity: Development of a clinical nomogram.

AIMS: The aim of our study was to investigate noninvasive predictors for detrusor underactivity (DUA) in male patients with lower urinary tract symptoms (LUTS) and benign prostatic enlargement (BPE). METHODS: A consecutive series of patients aged 45 years or older with non-neurogenic LUTS were prospectively enrolled. Patients underwent standard diagnostic assessment including International Prostatic Symptoms Score, uroflowmetry, urodynamic studies (cystometry and pressure-flow studies), transrectal ultrasound of the prostate, and ultrasound measurements of the bladder wall thickness (BWT). Logistic regression analysis was used to investigate predictors of DUA, defined as a bladder contractility index < 100 mm H2 O. A nomogram was developed based on the multivariable logistic regression model. RESULTS: Overall 448 patients with a mean age of 66 ± 11 years were enrolled. In a multivariable logistic age-adjusted regression model BWT (odds ratio [OR]: 0.50 per mm; 95% confidence interval [CI], 0.30-0-66; P = .001) and Qmax (OR: 0.75 per mL/s; 95% CI, 0.70-0.81; P = .001) were significant predictors for DUA. The nomogram based on the model presented good discrimination (area under the curve [AUC]: 0.82), good calibration (Hosmer-Lemeshow test, P > .05) and a net benefit in the range of probabilities between 10% and 80%. CONCLUSIONS: According to our results, BWT and Qmax can noninvasively predict the presence of DUA in patients with LUTS and BPE. Although our study should be confirmed in a larger prospective cohort, we present the first available nomogram for the prediction of DUA in patients with LUTS.

Patient's Fear of Being Infected, Another Complication of COVID-19 Outbreak: A Lesson Learned from a Case of Life-Threatening Urolithiasis.

Background: Because of the fear of being infected with coronavirus disease 2019 (COVID-19), patients with nephrolithiasis, who choose to stay home, may suffer serious complications such as obstructive uropathy, deterioration of renal function, sepsis, and death. We present such a case that led to renal failure and necessitated emergent urologic intervention. Case Presentation: A 60-year-old Caucasian man presented with right flank pain, dizziness, and dyspnea at the emergency room. History was significant for a previous diagnosis of right renal pelvic stone that was scheduled for retrograde intrarenal surgery before the pandemic lockdown. Upon evaluation, he was found to have an elevated creatinine of 40.2 mg/dL, bilateral hydronephrosis, pericardial and pleural effusion. The patient underwent emergency hemodialysis, followed by preliminary bilateral percutaneous nephrostomy, and subsequently by ureteral stenting. He was discharged stable with the future plan for endoscopic stone management. Conclusions: In the midst of the COVID-19 pandemic, urologists should follow up all known kidney stone patients, regularly assess their condition, and prioritize those who need urgent care. Patient education and telemedicine are useful tools for this purpose and may help minimize the risk of complications during a community lockdown.

Efficacy and safety of Elevate® system on apical and anterior compartment prolapse repair with personal technique modification

ABSTRACT Aim: To evaluate the effectiveness and safety of Anterior Elevate® mesh kit system (AES) in woman with symptomatic stage 3 or 4 anterior and/or apical pelvic organ prolapse (POP). Materials and Methods: This retrospective, monocentric, single surgeon study enrolled between May 2010 and January 2013 fifty-six woman experiencing symptomatic anterior vaginal prolapse with or without apical descent (POP-Q stage 3 or 4). All women received a AES and 7 (12.5%) received a concomitant transvaginal hysterectomy. Primary endpoint was anatomic correction of prolapse; success was defined as POP-Q stage ≤ 1 or asymptomatic stage 2. Secondary endpoints were quality-of-life (QOL) results and patients' safety outcomes, which were assessed by 3 validated self-reporting questionnaires at baseline and annually: ICIQ-UI short form, ICIQ-VS and P-QOL. All patients completed 2-years and 28 women 3-years of follow-up. Surgical approach was modified in women with uterus, moving the two-propylene strips anteriorly around the cervix itself crossing one another, so the left will take place in the right side and the right on the opposite. This modification was made in order to better support the uterus. Results: Vaginal mesh exposure was present in 3 (5,3%) patients. Very good anatomical outcomes were seen, with one (1,8%) failure at 6-months, 4 (7,1%) at 1-year, 6 at 2-years (10,7%). Statistically significant improvements were seen in the ICIQ-VS and P-QOL questionnaires throughout follow-up. Conclusion: Our data suggest that AES is a minimally-invasive transvaginal procedure to repair anterior and apical POP, with good evidence related to mid-term safety and efficacy.

Efficacy and safety of Elevate® system on apical and anterior compartment prolapse repair with personal technique modification.

AIM: To evaluate the effectiveness and safety of Anterior Elevate® mesh kit system (AES) in woman with symptomatic stage 3 or 4 anterior and/or apical pelvic organ prolapse (POP). MATERIALS AND METHODS: This retrospective, monocentric, single surgeon study enrolled between May 2010 and January 2013 fifty-six woman experiencing symptomatic anterior vaginal prolapse with or without apical descent (POP-Q stage 3 or 4). All women received a AES and 7 (12.5%) received a concomitant transvaginal hysterectomy. Primary endpoint was anatomic correction of prolapse; success was defined as POP-Q stage ≤ 1 or asymptomatic stage 2. Secondary endpoints were quality-of-life (QOL) results and patients' safety outcomes, which were assessed by 3 validated self-reporting questionnaires at baseline and annually: ICIQ-UI short form, ICIQ-VS and P-QOL. All patients completed 2-years and 28 women 3-years of follow-up. Surgical approach was modified in women with uterus, moving the two-propylene strips anteriorly around the cervix itself crossing one another, so the left will take place in the right side and the right on the opposite. This modification was made in order to better support the uterus. RESULTS: Vaginal mesh exposure was present in 3 (5,3%) patients. Very good anatomical outcomes were seen, with one (1,8%) failure at 6-months, 4 (7,1%) at 1-year, 6 at 2-years (10,7%). Statistically significant improvements were seen in the ICIQ-VS and P-QOL questionnaires throughout follow-up. CONCLUSION: Our data suggest that AES is a minimally-invasive transvaginal procedure to repair anterior and apical POP, with good evidence related to mid-term safety and efficacy.

Detrusor overactivity increases bladder wall thickness in male patients: A urodynamic multicenter cohort study.

AIMS: To evaluate the role of Bladder wall thickness (BWT) as a predictor of Detrusor overactivity (DO) in patients with Lower urinary tract symptoms (LUTS)/Benign prostatic enlargement without Bladder Outlet Obstruction. METHODS: From January 1996 to December 2000, each new patient, aged 45 years or older with LUTS, underwent standard diagnostic assessment, urodynamic studies (cystometry and pressure flow studies), and ultrasound measurements of the bladder wall thickness (BWT) in two centers. In order to exclude the possible effect of benign prostatic obstruction (BPO) on detrusor thickness, patients with a Schaefer class was ≥2 were excluded from the study. The area under the receiver operating characteristics curve (AUC) quantified the predictive accuracy (PA) of BWT for the diagnosis of DO. RESULTS: Overall 195 patients were enrolled. DO was observed in 98/195 patients (50%). The BWT presented an AUC of 0.70; 95% CI: 0.62-0.77 for the diagnosis of DO. At the best cut-off value of 3.85 mm sensitivity was 73%; specificity was 59%; positive predictive value (64%, PPV). Negative predictive value (69%, NPV). CONCLUSIONS: Our study firstly showed, how BWT in male patients may be a consequence of DO other than BPO. Our finding, if confirmed in further studies, could limit the accuracy of BWT in patients with DO and BPO.

An innovative approach to treating vaginal mesh exposure after abdominal sacral colpopexy: endoscopic resection of mesh and platelet-rich plasma; initial experience in three women.

INTRODUCTION AND HYPOTHESIS: Polypropylene mesh exposure is uncommon after abdominal sacral colpopexy (ASC), but in case of symptomatic vaginal mesh exposure, surgery is needed. When treating it, care must be taken to completely remove the exposed mesh (EM), saving as much vaginal tissue as possible to avoid a subsequent shortened and narrowed vagina. In this video, we present a minimally invasive technique for treating EM after ASC using endoscopic mesh resection and autologous platelet-rich plasma (PRP) technology. METHODS: Three women were referred to our outpatient clinic for vaginal vault mesh exposure after laparoscopic ASC with concomitant hysterectomy. All women underwent endoscopic bipolar PlasmaKinetic resection (BPR) of EM, and PRP gel was delivered in the surgical site to cover the gap left by the resection. RESULTS: Mean operative time was 39.6 min. Surgery was uneventful in all cases. All women recovered sexual function, and nobody experienced relapsed pelvic organ prolapse at 1-year follow-up. CONCLUSIONS: Our preliminary results show that BPR and PRP are safe, effective, and feasible for treating vaginal mesh exposure with conservation of anatomy and sexual function.

Serum 25(OH)D seasonality in urologic patients from central Italy.

Hypovitaminosis D is increasingly recognized as a cofactor in several diseases. In addition to bone homeostasis, vitamin D status influences immune system, muscle activity and cell differentiation in different tissues. Vitamin D is produced in the skin upon exposure to UVB rays, and sufficient levels of serum 25(OH)D are dependent mostly on adequate sun exposure, and then on specific physiologic variables, including skin type, age and Body Mass Index (BMI). In contrast with common belief, epidemiologic data are demonstrating that hypovitaminosis D must be a clinical concern not only in northern Countries. In our study, we investigated vitamin D status in a male population enrolled in a urology clinic of central Italy. In addition, we evaluated the correlation between vitamin D status and UVB irradiance measured in our region. The two principal pathologies in the 95 enrolled patients (mean age 66years) were benign prostate hypertrophy and prostate carcinoma. >50% of patients had serum 25(OH)D values in the deficient range (<20ng/mL), and only 16% of cases had serum vitamin D concentration higher than 30ng/mL (optimal range). The seasonal stratification of vitamin D concentrations revealed an evident trend with the minimum mean value recorded in April and a maximum mean value obtained in September. UVB irradiance measured by pyranometer in our region (Abruzzo, central Italy) revealed a large difference during the year, with winter months characterized by an UV irradiance about tenfold lower than summer months. Then we applied a mathematical model in order to evaluate the expected vitamin D production according to the standard erythemal dose measured in the different seasons. In winter months, the low available UVB radiation and the small exposed skin area resulted not sufficient to obtain the recommended serum doses of vitamin D. Although in summer months UVB irradiance was largely in excess to produce vitamin D in the skin, serum vitamin D resulted sufficient in September only in those patients who declared an outdoor time of at least 3h per day in the previous summer. In conclusion, hypovitaminosis D is largely represented in elderly persons in our region. Seasonal fluctuation in serum 25(OH)D was explained by a reduced availability of UVB in winter and by insufficient solar exposure in summer. The relatively high outdoor time that emerged to be correlated with sufficient serum 25(OH)D in autumn warrants further studies to individuate potential risk co-variables for hypovitaminosis D in elderly men.

Transobturator surgery in presence of corona mortis: a study in 13 women.

PURPOSE: Severe and life-threatening bleeding has been reported in the literature after retropubic mid-urethral slings procedure, due to corona mortis damage. The aim of this study is to evaluate safety of transobturator passage of the tape in stress-urinary incontinence (SUI) correction and anchoring the mesh in pelvic-organ prolapse (POP) repair in the presence of corona mortis. MATERIALS AND METHODS: Thirteen women with a pre-operatory contrast-enhanced abdominal multidetector computed tomography were prospectively enrolled in the study between January 2009 and December 2014. Eight women underwent a Monarc® and one a Spark® Sling System procedures for SUI correction, and three an Elevate® Anterior and Apical prolapse system and one a Perigee procedure to repair anterior/apical POP. All procedures were performed by a single experienced pelvic surgeon. RESULTS: Surgery was uneventful in all cases. No major bleeding was seen during surgery. No pelvic hematoma was identified 24 hours after the procedure. All women were discharged 1 day after surgery. CONCLUSIONS: Transobturator surgery seems to be a safe way in the presence of the corona mortis. However, further studies are needed to confirm these preliminary findings.

Leptin contributes to long-term stabilization of HIF-1α in cancer cells subjected to oxygen limiting conditions.

Leptin, a cytokine produced by the adipose tissue in response to food intake, is a key player in the regulation of energy balance and body weight control. Physiological action of leptin in modulating the metabolic adaptation of different peripheral tissues supports the hypothesis that it could also exert a direct effect on cancer cells. In vitro, treatment with leptin up-regulated HIF-1α and stimulated adhesion and invasion of prostate cancer cells cultured in hypoxia. Leptin action was effective in both low and high glycolytic cancer cell lines, and determined the up-regulation of lactate exporter MCT4 and its associated protein CD147. HIF-1α stabilization was oligomycin-independent and was associated with an important modulation of mitochondrial homeostasis. In fact, leptin treatment produced mitochondrial biogenesis, stabilization of mitochondrial membrane potential and increased uncoupled respiration through the up-regulation of UCP2. Furthermore, leptin counteracted the downmodulation of SIRT1 induced by hypoxia, and persistent high levels of SIRT1 were directly involved in HIF-1α stabilization. Leptin can sustain cancer progression in hypoxic environment and when mitochondrial respiration is impaired. Leptin signaling axis, including the new proposed intermediate SIRT1, could represent a new diagnostic and therapeutic target in prostate cancer.

Use of transvaginal ultrasound in females with primary bladder neck obstruction. A preliminary study.

INTRODUCTION AND AIM: The video-urodynamics study is the principal exam to establish a possible primary bladder neck obstruction (PBNO) condition. While trans-rectal ultrasonography plays an important role in the evaluation of the low urinary tract symptoms (LUTS) and the severity of bladder outlet obstruction (BOO) in men, the use of the transvaginal ultrasound (TVUS) in women with symptoms suggesting BOO remains unclear. We tried to check the utility of the TVUS in women with PBNO condition. MATERIAL AND METHODS: We selected female patients which presented BOO without pelvic organ prolapse (POP). According to the data of the video-urodynamic exam we selected the patients with the suspicion of PBNO. A TVUS in basal and during micturition was performed before and after surgery. RESULTS: TVUS showed a closed bladder neck bladder in basal condition and during micturition similarly to the fluoroscopic image during video-urodynamics. The mean distance from bladder neck to the vaginal mucosa resulted 1.3 cm in this patients. CONCLUSIONS: TVUS results worthy in the evaluation of patients with PBNO before and after surgery.

Low-Dose Intravaginal Estriol and Pelvic Floor Rehabilitation in Post-Menopausal Stress Urinary Incontinence.

INTRODUCTION: Pelvic floor muscle training (PFMT) and electrical stimulation (ES) are conservative models of therapy for treating female stress urinary incontinence (SUI). The presence of estradiol receptors in the lower urinary tract advances the case for estradiol therapy in SUI. The aim of our study was to investigate the effects of the combination of pelvic floor rehabilitation and intravaginal estriol (IE) on SUI treatment in postmenopausal women. MATERIAL AND METHODS: Sixty-two women with SUI were randomized to PFMT, ES and biofeedback (Group 1) or the same treatment plus 1 mg IE (Group 2) for 6 months. Patients were evaluated with medical history, pelvic examination, urodynamics, 24-hour pad test. Urinary incontinence was evaluated using the International Consultation on Incontinence questionnaire on urinary incontinence short form and quality of life using the Incontinence Impact Questionnaire-Short Form. RESULTS: Two patients were lost at follow-up and one discontinued the study. Mean urine leakage at the 24-hour pad test dropped from 42.3 ± 20.2 g/die to 31.5 ± 14.2 g/die in Group 1 and from 48.3 ± 19.8 g/die to 22.3 ± 10.1 g/die in Group 2. Symptoms scores and incontinence status were statistically significant better in Group 2 when compared to Group 1. CONCLUSION: IE added to PFMT, ES and BF is a safe and efficacious first-line therapy in postmenopausal women with SUI.

Modulating the inflammatory response to provide the best environment for healing in the pelvic organ prolapse (POP) repair. A preliminary study using coated medical devices.

AIM: We studied the inflammatory response in Phosphorylcholine (PC)-coated and uncoated meshes after 4 weeks of implantation in the subcutaneous tissue of the hypogastric region in six patients. MATERIAL AND METHODS: Six patients underwent POP surgery using two different types of mesh. In three of them a PC-coated mesh was implanted and an uncoated one was implanted in the last three. A small part of the mesh has previously been cut with a standard size decided by the authors and was subsequently implanted in the same time of the pop repair in the subcutaneous fascia of the hypogastric region. After 4 weeks the small part of the mesh was explanted and tissue growth in the fishnet-like mesh was analyzed. RESULTS: A typical foreign body response formed around the uncoated meshes. On the other hand there was a lack in the inflammatory response around the PC-coated mesh identifying less histiocytes, less giant cells and a thinner fibrous capsule formation. DISCUSSION: PC polymers have demonstrated excellent biocompatibility and hemocompatibility. The adsorption of protein onto materials' surface and the trauma involved in surgery necessary for device implantation determines an inflammatory response. The ability of the PC coating to reduce the extent of nonspecific proteins, modulates the specific environment around the implant. CONCLUSION: This preliminary study showed that modulating the inflammatory response we attempt to provide the best environment for healing.

Tumor-stroma metabolic relationship based on lactate shuttle can sustain prostate cancer progression.

BACKGROUND: Cancer cell adopts peculiar metabolic strategies aimed to sustain the continuous proliferation in an environment characterized by relevant fluctuations in oxygen and nutrient levels. Monocarboxylate transporters MCT1 and MCT4 can drive such adaptation permitting the transport across plasma membrane of different monocarboxylic acids involved in energy metabolism. METHODS: Role of MCTs in tumor-stroma metabolic relationship was investigated in vitro and in vivo using transformed prostate epithelial cells, carcinoma cell lines and normal fibroblasts. Moreover prostate tissues from carcinoma and benign hypertrophy cases were analyzed for individuating clinical-pathological implications of MCT1 and MCT4 expression. RESULTS: Transformed prostate epithelial (TPE) and prostate cancer (PCa) cells express both MCT1 and MCT4 and demonstrated variable dependence on aerobic glycolysis for maintaining their proliferative rate. In glucose-restriction the presence of L-lactate determined, after 24 h of treatment, in PCa cells the up-regulation of MCT1 and of cytochrome c oxidase subunit I (COX1), and reduced the activation of AMP-activated protein kinase respect to untreated cells. The blockade of MCT1 function, performed by si RNA silencing, determined an appreciable antiproliferative effect when L-lactate was utilized as energetic fuel. Accordingly L-lactate released by high glycolytic human diploid fibroblasts WI-38 sustained survival and growth of TPE and PCa cells in low glucose culture medium. In parallel, the treatment with conditioned medium from PCa cells was sufficient to induce glycolytic metabolism in WI-38 cells, with upregulation of HIF-1a and MCT4. Co-injection of PCa cells with high glycolytic WI-38 fibroblasts determined an impressive increase in tumor growth rate in a xenograft model that was abrogated by MCT1 silencing in PCa cells. The possible interplay based on L-lactate shuttle between tumor and stroma was confirmed also in human PCa tissue where we observed a positive correlation between stromal MCT4 and tumor MCT1 expression. CONCLUSIONS: Our data demonstrated that PCa progression may benefit of MCT1 expression in tumor cells and of MCT4 in tumor-associated stromal cells. Therefore, MCTs may result promising therapeutic targets in different phases of neoplastic transformation according to a strategy aimed to contrast the energy metabolic adaptation of PCa cells to stressful environments.

[An unusual case of massive funicular lipoma]. / Un inusuale caso di voluminoso lipoma funicolare.

Intrascrotal lipomas are benign diseases that originate from adipose tissue inside the scrotal sac or constituting the scrotal wall itself. Paratesticular spermatic cord lipomas are a rare type of intrascrotal lipomas. A 78 years old patient in good health comes to our attention for massive tense-elastic swelling of left hemiscrotum appeared about 3 years ago and slowly increasing. Ultrasound evaluation of the intrascrotal mass showed inhomogeneous images mainly hyperechoic, not infiltrating the ipsilateral testis and scrotal wall. The ultrasonography found a lipomatous lesion with benign characteristics and a surgical excision has been performed. The lipomatous mass removed presented a size equal to 25 cm x 14 cm x 11 cm and a weight of about 490 gr. The microscopic examination of the tissue showed only the presence of mature adipocytes in the absence of cellular atypia, of other cellular types and of vascular abnormalities.