Antegrade ejaculation preservation in surgical treatment for benign prostatic hyperplasia: quest for balance between voiding and sexual function.

PURPOSE OF REVIEW: Surgical treatment of benign prostatic hyperplasia (BPH) carries a significant risk of ejaculation dysfunction. Preservation of antegrade ejaculation while providing effective, well tolerated, and durable treatment of BPH is a paramount component of physical and sexual well being for significant number of men. We reviewed available literature with an aim of providing status on antegrade ejaculation preserving BPH surgical therapies. RECENT FINDINGS: Minimally invasive surgical therapies for BPH have been developed over the last decade, with significant marketing emphasis on their potential for preservation of antegrade ejaculation. However, the question about durability of relief of bladder outlet obstruction remains. Parallel to this technological development, the understanding of anatomical structures involved in ejaculation have resulted in technical modifications of well established surgical treatments modalities like transurethral resection of prostate, endoscopic enucleation of prostate and simple prostatectomy, thereby providing safe and durable relief of bladder outlet obstruction secondary to BPH with a satisfactory preservation of antegrade ejaculation. SUMMARY: Preservation of antegrade ejaculation is an important goal for significant number of men needing BPH surgery. Novel minimally invasive surgical technologies have been developed for this purpose; but understanding of the anatomical structures essential for antegrade ejaculation have allowed technical modification of existing surgical techniques with excellent preservation of antegrade ejaculation.

Long-term evaluation of outcomes and costs of urolithiasis re-interventions after ureteroscopy, extracorporeal shockwave lithotripsy and percutaneous nephrolithotomy based on German health insurance claims data.

PURPOSE: Comparisons of ureteroscopy (URS), extracorporeal shockwave lithotripsy (SWL) and percutaneous nephrolithotomy (PCNL) for urolithiasis considering long-term follow-up are rare. We aimed to analyze re-intervention rates, costs and sick leave days of URS, SWL and PCNL patients within 7 years. METHODS: This retrospective cohort study was based on German health insurance claims data. We included 54,609 urolithiasis patients incidentally treated in 2008-2010. We investigated time to re-intervention, number of sick leave days and healthcare costs. We applied negative binomial, extended Cox regression and gamma models. RESULTS: 54% were incidentally treated with URS, 40% with SWL and 6% with PCNL. 15% of URS, 26% of SWL and 23% of PCNL patients were re-treated within 7 years. Time to re-intervention was significantly lower for PCNL (955 days) and SWL (937 days) than URS (1078 days) patients. Costs for incident treatment were significantly higher for PCNL (2760€) and lower for SWL (1342€) than URS (1334€) patients. Yet, total costs including re-interventions were significantly higher for PCNL (5783€) and SWL (3240€) than URS (2979€) patients. Total number of sick leave days was increased for PCNL (13.0 days) and SWL (10.1 days) compared to URS (6.8 days) patients. CONCLUSION: This study describes outcomes after use of different intervention options for urolithiasis. URS patients showed longest time free of re-interventions and lowest number of sick leave days. Although SWL patients initially had lower costs, URS patients had lower costs in the long run. PCNL patients showed high costs and sick leave days.

Outcomes and costs of ureteroscopy, extracorporeal shockwave lithotripsy, and percutaneous nephrolithotomy for the treatment of urolithiasis: an analysis based on health insurance claims data in Germany.

PURPOSE: Comparisons of ureteroscopy (URS), extracorporeal shockwave lithotripsy (SWL), and percutaneous nephrolithotomy (PCNL) for urolithiasis considering long-term health and economic outcomes based on claims data are rare. Our aim was to analyze URS, SWL, and PCNL regarding complications within 30 days, re-intervention, healthcare costs, and sick leave days within 12 months, and to investigate inpatient and outpatient SWL treatment as the latter was introduced in Germany in 2011. METHODS: This retrospective cohort study based on German health insurance claims data included 164,203 urolithiasis cases in 2008-2016. We investigated the number of complications within 30 days, as well as time to re-intervention, number of sick leave days and hospital and ambulatory health care costs within a 12-month follow-up period. We applied negative binomial, Cox proportional hazard, gamma and two-part models and adjusted for patient variables. RESULTS: Compared to URS cases, SWL and PCNL had fewer 30-day complications, time to re-intervention within 12 months was decreased for SWL and PCNL, SWL and PCNL were correlated with a higher number of sick leave days, and SWL and particularly PCNL were associated with higher costs. SWL outpatients had fewer complications, re-interventions and lower costs than inpatients. This study was limited by the available information in claims data. CONCLUSION: URS cases showed benefits in terms of fewer re-interventions, fewer sick leave days, and lower healthcare costs. Only regarding complications, SWL was superior. This emphasizes URS as the most frequent treatment choice. Furthermore, SWL outpatients showed less costs, fewer complications, and re-interventions than inpatients.

Acute kidney injury in COVID-19: are kidneys the target or just collateral damage? A comprehensive assessment of viral RNA and AKI rate in patients with COVID-19.

PURPOSE OF REVIEW: To investigate the possible effects of severe acute respiratory syndrome-related coronavirus 2 (SARS-CoV-2) on kidney function and assess the rate of viral ribonucleic acid (RNA) shedding/detection in urine. RECENT FINDINGS: Most of the research on the topic suggests that for the moment our ability to estimate whether SARS-CoV-2 is a direct causative agent in acute kidney injury (AKI) or whether it has a cytokine storm effect is limited. During our prospective assessment of 333 patients with COronaVIrus Disease 2019 (COVID-19) it was found that frequency of AKI of 9.6% (32 cases). Despite previous data suggestive of the ability to detect SARS-CoV-2 in urine, we were unable to identify any traces of messenger ribonucleic acid (mRNA) in our group. Both COVID-19 severity (odds ratio, OR = 23.09, confidence interval, CI 7.89-67.57, P < 0.001) and chronic kidney disease (CKD) history (OR = 7.17, CI 2.09-24.47, P = 0.002) were associated with the AKI rate. SUMMARY: AKI is a relatively frequent condition for patients with COVID-19 and is normally correlated with the severity of the disease and the patient's history of CKD. The available data fail to address whether SARS-CoV-2 mRNA is present in urine, whereas our prospective trial data suggest that mRNA is undetectable in urine irrespective of the severity of the disease.

Ureteroscopy is more cost effective than shock wave lithotripsy for stone treatment: systematic review and meta-analysis.

INTRODUCTION: A rising incidence of kidney stone disease has led to an increase in ureteroscopy (URS) and shock wave lithotripsy (SWL). Our aim was to compare the cost of URS and SWL for treatment of stones. METHODS: A systematic review and meta-analysis based on Cochrane and PRISMA standards was conducted for all studies reporting on comparative cost of treatment between URS and SWL. The cost calculation was based on factual data presented in the individual studies as reported by the authors. English language articles from January 2001 to December 2017 using Medline, PubMed, EMBASE, CINAHL, Cochrane library and Google Scholar were selected. Our study was registered with PROSPERO (International prospective register of systematic reviews)-registration number CRD 42017080350. RESULTS: A total of 12 studies involving 2012 patients (SWL-1243, URS-769) were included after initial identification and screening of 725 studies with further assessment of 27 papers. The mean stone size was 10 and 11 mm for SWL and URS, respectively, with stone location in the proximal ureter (n = 8 studies), distal ureter (n = 1), all locations in the ureter (n = 1) and in the kidney (n = 2). Stone free rates (84 vs. 60%) were favourable for URS compared to SWL (p < 0.001). Complication rates (23 vs. 30%) were non-significantly in favor of SWL (p = 0.11) whereas re-treatment rates (11 vs. 27%) were non-significantly in favor of URS (p = 0.29). Mean overall cost was significantly lower for URS ($2801) compared to SWL ($3627) (p = 0.03). The included studies had high risk of bias overall. On sub-analysis, URS was significantly cost-effective for both stones < 10 and ≥ 10 mm and for proximal ureteric stones. CONCLUSION: There is limited evidence to suggest that URS is less expensive than SWL. However, due to lack of standardization, studies seem to be contradictory and further randomized studies are needed to address this issue.

Nocturia: state of the art and critical analysis of current assessment and treatment strategies.

This editorial of the topic issue of the World Journal of Urology provides a state of the art on nocturia which includes descriptions of the terminology, epidemiology, health-related quality of life, medical and financial consequences, pathophysiology, assessment tools and treatment strategies of nocturia. This summary also includes a flowchart on the pathophysiology of nocturia with illustration of the various causes of reduced bladder capacity, increased fluid intake or increased diuresis; a flowchart with the key findings of frequency-volume charts to determine the underlying pathophysiology; and a flowchart on the treatment of the various causes of nocturia. The editorial critically discusses current assessment and treatment strategies in patients with lower urinary tract symptoms suggestive of benign prostatic hyperplasia (LUTS/BPH) and nocturia. The outcome of nocturia remains hidden in drug trials of patients with LUTS/BPH because nocturia-specific measures were not included. The authors recommend using frequency-volume charts, measurement of the hours of undisturbed sleep, and nocturia-specific quality of life questionnaires (e.g., ICIQ-N or N-Qol) in all future studies in patients with LUTS/BPH and nocturia.

Objective assessment of working tool impact on irrigation flow and visibility in flexible ureterorenoscopes.

BACKGROUND AND PURPOSE: Impaired irrigation causes reduced visibility in flexible ureteroscopy. The aim of this ex-vivo study was to investigate the impact of working tools on light transmission in a medium as an objective measurement of visibility in flexible ureteroscopes. MATERIALS AND METHODS: Five ureteroscopes (Viper, Cobra, FlexX(2), URF-P5, DUR-8 Elite) were evaluated. The endoscopes were placed into a dark chamber with a photo diode, measuring light transmission. Light transmission was measured in a clear liquid and a 2% ink solution to simulate impaired vision. The time needed to restore light transmission by clear irrigation inflow was measured. Measurements were carried out five times, with empty and loaded ureteroscopes (1.7F, 2.2F basket, 273 µm laser fiber). RESULTS: The time needed to restore light transmission as a measurement of visibility depends on tool size and the length of the working channel. The presented setup provides more sensitive results than the measurement of the irrigation flow rate. With empty working channels, the fastest restoration of light transmission (increase by 1000 units) was achieved with the Cobra dual channel device (25 s), followed by single channel DUR-8 (28 s), Viper (38.5), and Flex X(2) (40 s). The ureteroscope with the longest working channel (URF-P5) needed the longest irrigation time to restore light transmission (66.5 s). These results become even more obvious with the use of different working tools. CONCLUSION: Measurement of light transmission is a sensitive tool to evaluate irrigation performance. Double irrigation is superior to single irrigation in terms of light transmission.

"Homemade" TUR-simulator for less than $40 U.S.? The "Tupper" experience.

INTRODUCTION: Transurethral surgery is important in daily urologic life. In training residents it is important to develop resection skills. We introduce a homemade simulator to improve capabilities for the training of transurethral procedures. MATERIALS AND METHODS: Material consists of 7 cm of a 30F garden hose, a suprapubic tube, a Tupperware box (Frankfurt, Germany), three catheter plugs, and silicone gel. Cost of materials is below $40 U.S. Transurethral procedures such as mono- and bipolar resection and RevoLix laser vaporesection were carried out. Different meat types were tested to develop a close to real resection feeling. Further, flexible cystoscopy was trained with the simulator. Multiple markings were placed inside the box. These markings had to be identified by flexible cystoscopy. The time to completion of this task was recorded. RESULTS: Transurethral resection and flexible cystoscopy is feasible. Pork and beef lead to a realistic feeling compared with transurethral resection. For laser surgery, pork and chicken seem to be most realistic. Further, confidence in flexible cystoscopy could be obtained. During the flexible cystoscopy task, an average time reduction of 50.96% could be achieved. CONCLUSION: This cheap and simple resection simulator allows easy training of lower urinary tract procedures. It helps young urologists to acquire basic endourologic skills. It may be beneficial for residents in the process of learning lower urinary tract surgery. Further, new techniques can be trained and may lead to a decreased risk for the patients.