Giant Midline Prostatic Cyst: An Unusual Cause of Acute Urinary Retention.

Midline prostatic cysts are infrequent and mostly asymptomatic. We presented a striking case of a giant midline cyst and detailed its diagnosis, evolution, and treatment. From this case, we offered a comparison of congenital intraprostatic midline cysts, namely, Müller's cysts and utricle cysts. A 40-year-old male experienced recurrent urinary retention. A 10 × 11 mm2 cyst in the mid-prostatic region was diagnosed through transrectal ultrasound, leading to a transperineal puncture as a minimally invasive intervention. Seven years later, the cyst recurred, manifesting obstructive symptoms such as a weak urinary stream, frequent urination, and residual urine sensation. Laparoscopic surgery was then performed for the confirmed 98 × 13 mm2 cystic recurrence. The postoperative course was favourable with no complications. Symptoms were completely resolved, which was maintained over a three-year follow-up period. The therapeutic approach to midline cysts targets symptomatic cases or infertility, ranging from cyst puncture to transurethral endoscopic treatment. Recurrence after minimally invasive interventions is a challenge, with laparoscopic surgery as an alternative post-failed conservative approach. Although total cyst removal risks adjacent structure damage, marsupialisation improves the clinical outcomes. In summary, symptomatic midline prostatic cysts present challenges owing to recurrences after minimally invasive approaches. Enhanced laparoscopic techniques offer a solution, particularly in highly symptomatic cases requiring definitive treatment, as illustrated by this outstanding case report.

Feasibility of outpatient daycase local anaesthestic Rezum™ without sedation.

BACKGROUND: Rezum™ is a relatively new bladder outflow obstruction (BOO) procedure that uses thermal energy through water vapour to cause necrosis of prostatic tissue. The standard delivery of this treatment is in an operating theatre under a general or spinal anaesthetic, or under local anaesthetic with sedation that requires patient monitoring. METHODS: We propose an outpatient daycase method of delivering Rezum™ under local anaesthetic without sedation, using a prostatic local anaesthetic block and cold local anaesthetic gel instillation into the urethra. RESULTS: Preliminary results of our first thirteen patients demonstrate the feasibility of this new technique, with a mean pain score of 2.1 out of 10 on a visual analogue scale, a successful trial without catheter in all 13 patients (one patient voided successfully on second trial), a reduction in mean International Prostate Symptom Score (IPSS) from 20.6 to 5.4, and improvement in maximum flow from 8.8 ml/s to 14.4 ml/s. The complications were minor (Clavien-Dindo less than III) and included a UTI, minor bleeding not requiring admission, and retrograde ejaculation. CONCLUSIONS: We demonstrate that an outpatient local anaesthetic daycase service without sedation is feasible. This can be delivered in a clinic setting, reduce waiting times for BOO surgery, and increase availability of operating theatre for other general anaesthetic urological procedures.

Unveiling prostatic inflammation to optimize management of lower urinary tract symptoms: a discussion with experts.

Benign prostatic obstruction (BPO) and associated lower urinary tract symptoms (LUTS) are common conditions in men, which increase in frequency and severity with age, and have a significant impact on quality of life. Chronic prostatic inflammation is increasingly being recognized as a key component of BPO. This may lead to new targets for the management of BPO/LUTS. This podcast is based on presentations from a symposium titled 'Unveiling prostatic inflammation to optimize LUTS management' held at the European Association of Urology 2023 Congress. The presenters outline evidence of a role for prostatic inflammation in the development and progression of BPO/LUTS, approaches to the identification of biomarkers of inflammation, and the implications of prostatic inflammation for the optimal management of BPO/LUTS.

A Rare Case of Prostatic Malakoplakia Associated with Prostate Adenocarcinoma: A Case Report and Review of Literature.

Malakoplakia is a chronic granulomatous condition that has been rarely seen affecting the prostate. Isolated malakoplakia of the prostate occurring together with prostatic adenocarcinoma is rarer still with only 9 previously recorded cases. We present a case diagnosed through needle biopsy with prostatic adenocarcinoma and then on subsequent prostatectomy was diagnosed with extensive malakoplakia occurring with the carcinoma. Patient was noted to have a urinary tract infection (UTI) 2 weeks after needle biopsy and notably, 4 of the 9 previously reported cases also presented with UTI following their biopsies. The theory that prostatic malakoplakia may be a complication of the prostate needle biopsy is logically possible, but due to the paucity in cases, it is difficult to infer causality.

A Case of Methicillin-Sensitive Staphylococcus aureus (MSSA) Prostate Abscess, Osteomyelitis, and Myositis Associated with MSSA Bacteremia in a 60-Year-Old Patient Presenting with Back Pain.

BACKGROUND Staphylococcus aureus (SA) is a rare cause of prostatic abscess. Risk factors include genito-urinary instrumentalization and immunocompromised states. Because of the lack of guidelines on the diagnosis, management, and follow-up of SA prostate abscess, the diagnosis can sometimes be challenging. Our patient was a 60-year-old man who initially presented with lower back pain and was diagnosed with a methicillin-sensitive Staphylococcus aureus (MSSA) bacteremia, prostate abscess, osteomyelitis, and myositis. CASE REPORT A 60-year-old man presented with lower back pain. He had a past medical history of incompletely treated MSSA cervical osteomyelitis with epidural abscess, alcohol use disorder, intravenous drug use (IVDU), and poorly controlled diabetes mellitus (DM). He was afebrile and hemodynamically stable. Laboratory test results revealed leukocytosis and an elevated C reactive protein (CRP). Lumbar spine magnetic resonance imaging (MRI) showed vertebral osteomyelitis and right psoas myositis. Blood cultures isolated MSSA. The patient was treated with vancomycin and piperacillin-tazobactam. On day 5, our patient reported having fever, chills, flank pain, and dysuria. Computed tomography (CT) revealed a 4.0×4.9 cm prostatic abscess. CT-guided percutaneous abscess drainage was performed, and fluid culture revealed MSSA. Both antibiotics were discontinued and cefazolin was started following sensitivities. Post-drainage pelvic ultrasound (US) showed resolution of the abscess. CONCLUSIONS This case highlights the importance of a rapid diagnosis of SA prostate abscess in patients with documented risk factors and characteristic symptoms. Timely management with antibiotics and drainage as indicated are imperative to avoid further complications from the underlying bacteremia, including sepsis and metastatic infections.

Localization of external urethral orifice in coronary sulcus during urethroplasty in case of severe hypospadias accompanied by prostatic utricle cyst.

BACKGROUND: To explore whether opening the external urethral orifice in the coronal sulcus can reduce the incidence of epididymitis after operating on hypospadias with prostatic utricle cyst (PUC) connecting to the vas deferens. Group A consisted of 3 patients with severe hypospadias and PUC undergoing cystostomy, hypospadias correction and urethroplasty, along with the relocation of the external orifice of the urethra to the coronal sulcus. Group B consisted of 4 patients having initial hypospadias repaired with meatus in the orthotopic position in the glans, presenting with multiple epididymitis after hypospadias surgery and unsuccessful conservative treatment. MR confirmed that all the Group B patients had PUC connecting to the vas deferens. Group B patients underwent urethral dilatation along with urethral catheterization, cutting of the original corpus cavernosum that encapsulated the urethra, and extension of the position of the external urethral orifice to the coronal sulcus. RESULTS: In group A, 3 children underwent bladder fistula removal 2 weeks after the operation. The penis developed normally without any complications. Four children in group B underwent stent removal 12 weeks after operation, and one patient was still stenosed and dilated again. All patients in group B were followed without epididymitis recurrence. CONCLUSIONS: For patients with hypospadias complicating with a PUC, connecting to one side of the vas deferens, the positioning of the external urethral orifice in the coronary sulcus would be helpful to reduce the occurrence of epididymitis.

Prostatic cyst in a pediatric patient with autosomal dominant polycystic kidney disease.

Autosomal dominant polycystic kidney disease (ADPKD) is the most common inheritable form of renal cystic disease and is associated with cysts in other organs. Prostatic cysts are rare though and have not been reported in the paediatric population. Reported is the presence of a prostatic cyst that was incidentally noted on routine sonogram in a 15 year old with ADPKD.

Prostatic dystrophic calcification following salvage cryotherapy for prostate cancer - an under-reported entity?

BACKGROUND: Salvage cryoablation (SCA) is an accepted treatment for radio-recurrent prostate cancer with well-established oncological and functional outcomes. Based on one of the longest reported prospective follow-ups in the literature (median 12 years) on 187 patients, this study reports what appears to be an under-appreciated finding in eight patients with dystrophic calcifications (DC) of the prostate following SCA, causing severe bladder outlet obstruction. MATERIALS AND METHODS: Between 1995 and 2004, 187 patients underwent SCA, with a median follow-up of 12 years. This database was reviewed for functional and oncological outcomes and DC were evaluated. RESULTS: Functional data was available in 85 patients, amongst whom eight patients were found to develop DC (9.4%) proven when the patients presented with urinary difficulties and attempted transurethral resection was undertaken for bladder outlet obstruction. Mean time for emergence of significant symptoms of bladder outlet obstruction was 8.6 years from SCA (standard deviation (SD) = 6 years). All eightpatients required permanent drainage (seven suprapubic catheters, one nephrostomy). All patients with DC experienced biochemical recurrence (BCR), compared to 57.1% of the patients with no DC (p = 0.01). CONCLUSION: DC following SCA appears to be an under-reported late adverse effect which may only become evident with long follow-up, and should be included in preoperative counselling.

Assessment of a clinical pathway for investigation of haematuria that reduces the need for cystoscopy.

AIM: To evaluate prospectively a clinical pathway for investigation of haematuria that involves an initial screening using a urinary biomarker of bladder cancer (Cxbladder Triage™ (CxbT)) in combination with either a renal ultrasound or a computed tomography imaging. Only test-positive patients are referred for specialist assessment and flexible cystoscopy. METHODS: The clinical outcomes of 884 patients with haematuria who presented to their general practitioner were reviewed. Outcome measurements included the findings of laboratory tests, imaging, cystoscopies, specialist assessment and histology. RESULTS: Forty-eight transitional cell carcinomas (TCC) and three small cell carcinomas were diagnosed in the study cohort. The clinical pathway missed a solitary, small, low-risk TCC. When combined, imaging and CxbT had a sensitivity of 98.1% and a negative predictive value of 99.9% to detect a bladder cancer. Follow-up for a median of 21 months showed no further new cases of bladder cancer had occurred in the patient cohort. Review of all new bladder cancers diagnosed in the 15 months following the study showed that none had been missed by haematuria assessment using the clinical pathway. CONCLUSIONS: The combination of CxbT and imaging reliably identifies patients with haematuria who can be managed safely in primary care without the need for a secondary care referral and a flexible cystoscopy.

Does Prostate Artery Embolization (PAE) Improve Voiding Symptoms, Storage Symptoms, or Both?

INTRODUCTION: Many studies have looked at global changes in the International Prostate Symptom Score (IPSS) following PAE; however, no studies have examined the breakdown between storage and voiding symptoms. We aimed to explore the extent to which PAE improves storage symptoms in relation to voiding symptoms. METHOD: This single-center, prospective cohort study recruited consecutive patients undergoing PAE from June 2012 to June 2016. The IPSS breakdown was recorded pre-PAE, at 3 months and 12 months post-PAE. Planned statistical analysis included the paired t test. RESULTS: A total of 43 patients were recruited (mean age 64.72 ± 6.27, prostate volume 88.65 ± 37.23 cm3, IPSS 23.02 ± 5.84, QoL 4.98 ± 1.01, PSA 4.2 ± 2.8). Storage symptoms were more frequently the most severe symptom (58.1%). Voiding score (13.35-5.39, p < 0.001) and storage score (9.67-5.08, p < 0.001) both improved; however, voiding improved to a greater extent (1.9 vs. 1.5 mean per question, p = 0.023). PAE was most consistent when improving storage symptoms ('Urgency' improved in 86% patients, 'Frequency' and 'Nocturia' 77%). CONCLUSION: Storage symptoms are a significant problem for patients with benign prostatic obstruction. PAE is an effective treatment for both storage and voiding symptoms. More research is needed to evaluate how this compares with surgical techniques.

Repetitive urinary tract infections and two prostatic masses: Prostatic soft tissue infection with Actinomyces neuii.

Actinomyces infection is a tissue destructive, low-grade infection that often resembles malignancy. We report the case of a 70-year-old male with repeated, culture-negative urinary tract infections while intermittently catheterized. At presentation, the patient reported a new episode of urinary tract infection with white discharge in his urine. Transrectal ultrasonography showed two lesions in the prostate, suspect for prostate cancer. However, biopsy did not show cancer, and anaerobic culture grew Actinomyces neuii. A 3-month antibiotic course of amoxicillin eventually cured the infection. This is a case of prostatic soft tissue infection with A. neuii. It is important to consider Actinomyces infection in patients with a non-malignant prostatic mass. Although ß-lactam antibiotics do not penetrate the prostate well, the Actinomyces infection was cured by prolonged amoxicillin treatment in this case. It is possible that the tissue damage enhanced the amoxicillin concentration in the infected prostate.

Soft tissue infection after photoselective vaporization of the prostate: a life-threating complication.

Bladder outlet obstruction is a common aetiology of lower urinary tract symptoms in adult men and several treatment options are available. We report on a case of a 73-year-old man with a complicated soft tissue infection due to an urinoma after laser prostatectomy. He was treated by several surgical interventions and long-term antibiotic therapy.

Prostatic cyst in autosomal dominant polycystic kidney disease: unusual association.

Prostate cyst, as an extrarenal manifestation in patients with autosomal dominant polycystic kidney disease, although infrequent, nevertheless goes beyond tenuous concomitance and may rarely contribute to recurrent urinary tract infection or outflow obstruction and mostly remains asymptomatic. In this context, we report a case of incidentally detected, an asymptomatic prostatic cyst in a patient of autosomal dominant polycystic kidney disease.

The impact of surgical duration on complications after transurethral resection of the prostate: an analysis of NSQIP data.

BACKGROUND: Transurethral resection of the prostate is the most commonly performed procedure for the management of benign prostatic obstruction. However, little is known about the effect surgical duration has on complications. We assess the relationship between operative time and TURP complications using a modern national surgical registry. METHODS: We queried the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) from 2006 to 2016 for patients undergoing TURP. Patients were separated into five groups based on operative time: 0-30 min, 30.1-60 min, 60.1-90 min, 90.1-120 min, and greater than 120 min. Standard statistical analysis, including multivariate regression, was performed to determine factors associated with complications. RESULTS: 31,813 patients who underwent TURP were included. The overall complication rate was 9.0% and increased significantly with longer surgical duration (p < 0.001). Longer operative time was associated with a greater risk of postoperative sepsis or shock, transfusion, reoperation, and deep vein thrombus or pulmonary embolism. Longer surgical duration was associated with increased odds of any complication and, specifically, blood transfusion after controlling for age, race, comorbidities, American Society of Anesthesia (ASA) class, type of anesthesia administered, and trainee involvement. The adjusted risk of each of the above complications remained significantly increased for surgeries lasting longer than 120 min. CONCLUSIONS: As surgical duration increases, there is a significant increase in the rate of complications after TURP. These data demonstrate that this procedure is safest when performed in under 90 min.

Correlation of Ultrasonically Determined Bladder Wall Thickness and Prostatic Calcification With the Urinary, Psychosocial Dysfunction, Organ Specific, Infection and Neurological/Systemic Symptoms, and Tenderness Scoring System.

OBJECTIVE: To evaluate ultrasonically determined bladder wall thickness (BWT) and prostatic calcification presence, in men with chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS), and to correlate the findings with patient characteristics and the urinary, psychosocial dysfunction, organ specific, infection and neurological/systemic symptoms, and tenderness (UPOINT) classification system. MATERIAL AND METHODS: Between January 2008 and December 2017, data of 1294 patients diagnosed with chronic prostatitis, in a single urology clinic, meeting a number of selective inclusion/exclusion criteria, were retrospectively analyzed. Patients, compliant to fill out all requested questionnaires, between the ages of 21-65 years were included to the study. Exclusion criteria were noncompliance of filling out required questionnaires, acute and/or chronic bacterial prostatitis, history of genitourinary cancer, history of recent prostate surgery, and diagnosis of neurological diseases affecting the bladder. RESULTS: The median patient age and UPOINT subdomain was determined as 37 (IQR = 13, range 21-65) and 2 (IQR = 1, range 0-5), respectively. Median values for BWT, National Institute of Health-Chronic Prostatitis Symptom Index (NIH-CPSI), and International Index of Erectile Function were 3 (IQR = 1, range 2-6, 7), 4 (IQR = 6, range 1-23), and 25 (IQR = 10, range 1-30), respectively. The presence of calcification demonstrated a significant association with total NIH-CPSI score and BWT, whereas its relation with age and total UPOINT score was insignificant. However in contrast to calcification status, BWT ≥3.3 showed a strong and statistically significant relation to all the described measurements. CONCLUSION: Measurement of BWT can be used as an accessible and objective method for the diagnose of CP/CPPS according to UPOINT scoring system.

Transurethral ablation of a prostatic utricle cyst with the use of a holmium laser.

OBJECTIVE: To demonstrate a safe and effective approach to the treatment of obstructing midline prostate utricle cyst with the use of a holmium laser. DESIGN: Video presentation. SETTING: University hospital. PATIENT(S): A 33-year-old man presented with chronic pelvic pain, pain with ejaculation, and infertility. Semen analysis demonstrated oligoasthenospermia with poor viability and computerized tomographic scan identified the presence of a midline 2-3-cm prostatic cyst with dilated seminal vesicles bilaterally. Transrectal ultrasound in the office confirmed the diagnosis of midline obstructing prostatic utricle cyst and estimated the distance from the urethra. INTERVENTION(S): Transurethral ablation of a midline prostate utricle cyst with the use of a holmium laser. MAIN OUTCOME MEASURE(S): Intraoperative technique highlighting the main steps for a transurethral ablation of a midline prostate utricle cyst with the use of a holmium laser. RESULT(S): This video highlights the technique for transurethral ablation of a midline prostate utricle cyst with the use of a holmium laser to unroof the cyst. Retrograde vesiculography was performed to confirm patency of the ejaculatory ducts. Outpatient surgery was tolerated well and the patient was discharged. After surgery at 4 weeks, his symptoms had abated and semen analysis revealed normozoospermia. CONCLUSION(S): We demonstrate safe and effective transurethral ablation of a midline prostate utricle cyst with the use of a holmium laser. Preoperative transrectal ultrasound or cross-sectional imaging can be useful for operative planning. When the orifices of the ejaculatory ducts can be identified, vesiculography can be performed to confirm patency of the ducts and seminal vesicles after relief of the obstructing cyst.

[Midline Cyst of the Prostate with Increased Urinary Frequency and Urgency : A Case Report].

A 40-year-old man presented to our institution with a few-month history of increased urinary frequency, urgency and voiding difficulty. He had severe lower urinary tract symptoms with an International Prostate Symptom Score of 28 and quality of life score of 6. The mean urinary frequency and voided volume was 20 times per day and 150 ml, respectively. Abdominal ultrasonography and pelvic magnetic resonance imaging revealed the prostate measuring 15 cm3 with a 3 cm midline cyst which compressed the posterior of the bladder wall. A subsequent examination indicated that his lower urinary tract symptoms could be attributed to the cystic mass which mainly affected his storage symptoms. The patient underwent transurethral unroofing of the prostate cyst. Immediately after the surgery, his storage symptoms were improved greatly. The voiding volume was increased to 250 ml, and the frequency of urination was decreased to 8 times. No recurrent symptoms were found for seven months after the surgery.

Prostatic cyst in general practice: A case report and literature review.

RATIONALE: Prostatic cyst is a rare disease of the prostate especially in general practice. As it is often asymptomatic, how to manage it is still unfamiliar with, general practitioners (GPs). PATIENT CONCERNS: The 24-year-old man presented with left back discomfort for 1 week without severe pain, dysuria, or fever. DIAGNOSES: Ultrasonography revealed the presence of a 14×14 mm cystic lesion. INTERVENTIONS: The patient was given the medicine and regular follow-up. OUTCOMES: Several days later, he recovered without lower back discomfort. LESSONS: Patients with prostatic cyst of small size and no symptom should be follow-up regularly. Although prostatic cyst of progressive symptoms, large size (2.5 cm or larger), or high serum prostate-specific antigen (PSA) should be timely referred to urological specialists.

Inguinal herniation of a mineralized paraprostatic cyst in a dog.

A firm mass was noted in the right inguinal subcutaneous region of an 11-year-old intact male Labrador retriever dog presented for right pelvic limb weakness. Pelvic radiographs showed 2 large ovoid structures with circumferential thin eggshell-like mineralization in the right external inguinal region. The structures were confirmed sonographically, and on magnetic resonance imaging as a large folded herniated mineralized paraprostatic cyst through a defect in the right inguinal wall. To the author's knowledge, this is the first published report of an inguinal herniated mineralized paraprostatic cyst.

Herniation inguinale d'un kyste paraprostatique minéralisé chez un chien. Une masse ferme a été observée dans la région sous-cutanée chez un Labrador retriever mâle intact âgé de 11 ans qui était présenté pour une faiblesse du membre pelvien droit et des radiographies pelviennes ont montré deux grosses structures ovoïdes avec une mince minéralisation circonférencielle semblable à une coquille d'oeuf dans la région inguinale droite. Les structures ont été confirmées par échographie et à l'imagerie par résonance magnétique comme un gros kyste paraprostatique replié minéralisé et hernié via un défaut de la paroi inguinale droite. À la connaissance de l'auteur, il s'agit du premier rapport publié d'un kyste paraprostatique minéralisé hernié inguinal.(Traduit par Isabelle Vallières).