How to accelerate the upper urinary stone discharge after extracorporeal shockwave lithotripsy (ESWL) for < 15 mm upper urinary stones: a prospective multi-center randomized controlled trial about external physical vibration lithecbole (EPVL).

OBJECTIVE: To asset the efficacy and safety of EPVL plus ESWL compared with ESWL alone for the treatment of simple upper urinary stones (< 15 mm). MATERIALS AND METHODS: All patients with upper urinary stones (< 15 mm) were prospectively randomized into two groups. In treatment group, patients were assigned to immediate EPVL after ESWL, while in control group, ESWL alone was offered. All patients were reexamined at 1, 2, and 4 weeks after ESWL. Stone size, stone location, stone-free rate (SFR), and complication rate were compared. RESULTS: 56 males and 20 females in treatment group were compared to 52 male and 25 females in control group (p = 0.404). Median ages were 42.9 ± 1.5 years in treatment group and 42.7 ± 1.3 years in control group (p = 0.943). Median stone size was 10.0 ± 0.4 mm (3-15 mm) in treatment group and 10.4 ± 0.4 mm (4-15 mm) in control group (p = 0.622). The stone clearance rate in treatment and control group at 1 week after ESWL was 51.3% (39/76) and 45.4% (35/77) (p > 0.05), at 2 weeks was 81.6% (62/76) and 64.9% (50/77) (p < 0.05), and at 4 weeks was 90.8% (69/76) and 75.3% (58/77) (p < 0.05), respectively. CONCLUSIONS: EPVL is a noninvasive, effective, and safe adjunctive treatment which increases and accelerates upper urinary stones discharge after ESWL treatment.

Predicting survival in node-positive prostate cancer after open, laparoscopic or robotic radical prostatectomy: A competing risk analysis of a multi-institutional database.

OBJECTIVES: To investigate cancer-specific mortality and other-cause mortality in prostate cancer patients with nodal metastases. METHODS: The study included 411 patients treated with radical prostatectomy and pelvic lymph node dissection for prostate cancer with lymph node metastases at 10 tertiary care centers between 1995 and 2014. Kaplan-Meier analyses were used to assess cancer-specific mortality-free survival rates at 8 years' follow up in the overall population, and after stratifying patients according to clinical and pathological parameters. Uni- and multivariable competing risk Cox regression analyses were used to assess cancer-specific mortality and other-cause mortality. Finally, cumulative-incidence plots were generated for cancer-specific mortality and other-cause mortality after stratifying patients according to the number of positive lymph nodes and the median age at surgery, according to the competing risks method. RESULTS: Men with prostate-specific antigen ≤40 ng/mL and those with one to three positive lymph nodes showed higher cancer-specific mortality-free survival estimates as compared with their counterparts with prostate-specific antigen >40 ng/mL and >3 metastatic lymph nodes, respectively (all P < 0.001). At multivariable Cox regression analyses, preoperative prostate-specific antigen >40 ng/mL, >3 lymph node metastases and pathological Gleason score 8-10 were all independent predictors of cancer-specific mortality (all P-values ≤0.001). On competing risk analysis, when patients were stratified according to the number of positive lymph nodes (namely, ≤3 vs >3), the 8-year cancer-specific mortality rates were 27.4% versus 44.8% for patients aged <65 years, and 15.2% versus 52.6% for patients aged ≥65 years, respectively. CONCLUSIONS: Three positive lymph nodes represent the best prognostic cut-off in node-positive prostate cancer patients. In those individuals with >3 positive lymph nodes, the overall mortality rate is completely related to prostate cancer in young patients.

The impact of intravesical gemcitabine and 1/3 dose Bacillus Calmette-Guérin instillation therapy on the quality of life in patients with nonmuscle invasive bladder cancer: results of a prospective, randomized, phase II trial.

PURPOSE: Bacillus Calmette-Guérin and intravesical chemotherapy represent viable adjuvant options for intermediate risk nonmuscle invasive bladder cancer. Although bacillus Calmette-Guérin is perceived as less tolerable than intravesical chemotherapy, to our knowledge no comparative studies have addressed quality of life issues. We compared the quality of life of patients with nonmuscle invasive bladder cancer who received adjuvant intravesical gemcitabine or 1/3 dose bacillus Calmette-Guérin. MATERIALS AND METHODS: Our multicenter, prospective, randomized, phase II study included 120 patients with intermediate risk nonmuscle invasive bladder cancer. Of these patients 88 remained assessable at 1-year followup. Only 1 patient was withdrawn because of adverse events. Overall 61 patients received 2,000 mg/50 cc gemcitabine weekly for 6 weeks (maintenance monthly for 1 year) while 59 received 1/3 dose bacillus Calmette-Guérin Connaught weekly for 6 weeks (maintenance 3 weekly instillations at 3, 6 and 12 months). Quality of life was measured by the EORTC QLQ-C30 (European Organization for the Research and Treatment of Cancer Quality of Life Questionnaire Core 30 version 3.0) and QLQ-BLS24 (Quality of Life Superficial Bladder Cancer-Specific 24) questionnaires. Group differences were calculated using ANOVA (ANOVA/MANOVA). RESULTS: Treatment was well tolerated in both groups, although local and systemic side effects were more frequently reported in the bacillus Calmette-Guérin arm. Multivariate analyses showed no significant differences between the 2 groups in all quality of life dimensions. No significant changes over time in quality of life domains were detected for patients on bacillus Calmette-Guérin and gemcitabine except for physical functioning, which decreased significantly in both groups (p = 0.002). No significant differences were detected in terms of recurrence and progression between the 2 groups at 1-year followup. CONCLUSIONS: While a higher rate of side effects, albeit mild to moderate, was detected with 1/3 dose bacillus Calmette-Guérin compared to gemcitabine, our study failed to show significant differences between the 2 drugs in terms of quality of life.

Prognostic factors including Ki-67 and p53 in Bacillus Calmette-Guérin-treated non-muscle-invasive bladder cancer: a prospective study.

OBJECTIVES: To prospectively evaluate the prognostic utility of the traditional prognostic factors and molecular markers p53 and Ki-67 in a homogeneous series of patients with non-muscle-invasive bladder cancer (NMIBC) treated with Bacillus Calmette-Guérin (BCG). PATIENTS AND METHODS: 192 intermediate- and high-risk NMIBC cases were enrolled. The variables in study were age, stage, grade, focality, tumour size, presence of associated carcinoma in situ, recurrence rate before BCG, maintenance for BCG, Ki-67 and p53. The endpoints considered were recurrence-free survival, progression-free survival, cancer-specific survival (CSS) and overall survival (OS). RESULTS: T stage resulted in being associated with CSS, whereas age with OS. BCG maintenance was a significantly favourable independent predictor of OS, CSS, recurrence and progression. In univariate analysis, the labelling index of Ki-67 was significantly associated with OS, CSS and progression. Multivariate analysis, however, confirmed this association only for OS. On the contrary, the labelling index of p53 was a significant predictor of recurrence, both in uni- and multivariate analyses, but with a HR inferior to 1. CONCLUSIONS: Ki-67 was an independent predictor of survival. p53 overexpression showed a significant yet inverse correlation with recurrence, thus showing little clinical utility. Age, stage and maintenance were confirmed as independent predictors of BCG response.

Safety of Surgery in benign Prostatic Hyperplasia Patients on Antiplatelet or Anticoagulant Therapy: A Systematic Review and Meta-Analysis.

PURPOSE: The management strategies of anticoagulant (AC) or antiplatelet (AP) therapy in the preoperative period of benign prostatic hyperplasia (BPH) is still controversial. Therefore, a meta-analysis to systematically evaluate the surgical safety for BPH patients on AC or AP therapy was performed. MATERIALS AND METHODS: The protocol for the review is available on PROSPERO (CRD42018105800). A literature search was performed by using MEDLINE, Web of Science, PubMed, Cochrane library, and Embase. Summarized odds ratios (OR), mean difference (MD) and 95% confidence intervals (CI) were used to assess the difference in outcomes. RESULTS: We identified 13 trials with a total of 3767 patients. An intragroup significant difference was found in bleeding complications and blood transfusions when undergoing transurethral resection of the prostate (TURP). For laser surgery, the intragroup significant difference was found in the result of blood transfusion. Bridging therapy would not cause a higher risk of bleeding complications and blood transfusion during the perioperative period. Besides, no difference existed in operation time, catheterization time, hospitalization, and thromboembolic events. CONCLUSION: Patients with BPH on perioperative AC/AP therapy would have a risk of postoperative hemorrhage after TURP or laser treatments. To reduce the risk of hemorrhage, bridging therapy could be a good choice.

Comparison of Alpha-Blockers and Antimuscarinics in Improving Ureteral Stent-Related Symptoms: A Meta-Analysis.

PURPOSE: A meta-analysiswas conducted to compare alpha-blocker (AB) and antimuscarinic (AM) monotherapies in releasing US-related symptoms. METHODS: A comprehensive literature search was performed on online databases PubMed, Web of Science, Med-line, and Cochrane library. Ureteric Symptom Score Questionnaire (USSQ), International Prostate Symptom Score (IPSS), quality of life (QoL) and visual analogue pain scale (VAPS) were pooled and compared. RESULTS: Nine full-text articles met the inclusion criteria and have been included. The studies were conducted in 9 different centers between 2009 and 2016. All articles were RCT studies and a total of 654 patients were recorded totally, among which 323 were given alpha-blockers while others were given antimuscarinics. Although patients using alpha-blockers presented lower USSQ scores, no statistically significant difference was recorded in urinary symptom(SMD 0.5, 95 % CI -0.2 to 1.20, P = 0.159), pain(SMD 0.33, 95 % CI -0.26 to 0.92, P = 0.280),general health, work performance(SMD-0.34, 95 % CI -0.08 to 0.76, P = 0.115) and sexual performance (all p > 0.05) (SMD 0.12, 95 % CI -0.10 to 0.34, P = 0.280). Meanwhile IPSS (SMD -0.10, 95 % CI -0.32 to 0.11, P = 0.358), QoL(SMD-0.03, 95 % CI -0.23 to 0.18, P = 0.802) and VAPS(SMD 0.08, 95 % CI -0.15 to 0.31, P = 0.447) were similar between the two groups (all P > 0.05). CONCLUSION: The analysis suggests that AB showed a similar effect with AM. It is necessary to conduct a larger and more detailed cohort study and find the population that potentially might benefit most by AM.

The role of super-mini percutaneous nephrolithotomy (SMP) in the treatment of symptomatic lower pole renal stones (LPSs) after the failure of shockwave lithotripsy (SWL) or retrograde intrarenal surgery (RIRS).

To assess the safety and efficacy of super-mini percutaneous nephrolithotomy (SMP) in the treatment of symptomatic lower pole renal stones (LPSs) after the failure of shockwave lithotripsy (SWL) or retrograde intrarenal surgery (RIRS), we retrospectively evaluated 44 patients with symptomatic LPSs with previously failed SWL or RIRS and consequently underwent SMP from October 2014 to March 2016. The percutaneous renal access was performed 12-14F with C-arm fluoroscopy or ultrasonographic guidance. Stone disintegration was performed using either Holmium laser or pneumatic lithotripter. Perioperative parameters along with operations were assessed in detail. A total of 44 patients (mean age 49.1 ± 13.7 years) were included in the study. Stone size was 18.4 ± 6.0 mm (range 9-29), operative time was 63.9 ± 32.7 min (range 14-145) and hospital stay was 2.8 ± 1.2 days (range 1-5). The hemoglobin drop was 12.4 ± 8.8 g/L (range 0-31), and no patients required blood transfusion. Complete stone-free status was achieved in 40 (90.9%) patients. Clinically insignificant residual fragments were observed in three (6.8%) patients and only one (2.3%) patient had a 6 mm residual calculus. A total of three minor complications (urinary tract infection, hemorrhage resolved by hemostatics and renal colic requiring analgesics) were observed postoperatively. For symptomatic LPSs after the failure of SWL or RIRS, SMP is a safe and efficient auxiliary option and even might be an alternative to SWL or RIRS, while further considering the stone-free rates and stone-related events.

Does green tea consumption increase urinary oxalate excretion? Results of a prospective trial in healthy men.

OBJECTIVE: To investigate the impact of green tea on urinary oxalate excretion in healthy male volunteers. MATERIALS AND METHODS: The oxalate concentrations after different brewing times (2-60 min) of different qualities (2-8 g) of green tea were measured in in vitro experiment. In in vivo experiment, the effects on urine composition were assessed in 12 healthy men with an age of 24-29 years. Each subject was requested to collect two 24-h urine samples under normal dietary conditions. Green tea prepared from tea bags containing 2 g of tea leafs was consumed by the subjects for 7 consecutive days, and 24-h urine samples were collected and analyzed on days 6 and 7. After 3-week washout interval, all subjects consumed green tea containing 4 g of leaf tea for another 7 consecutive days. Two 24-h urine samples were collected on the last 2 days. Urine volume, pH, calcium, magnesium, sodium, phosphate, potassium, chloride, citrate, oxalate, urate and creatinine were measured. RESULTS: In the in vitro experiments, oxalate in solution increased with brewing time (p < 0.05) and tea quality (p < 0.05). In the in vivo experiment, 24-h urinary oxalate increased significantly (0.24 ± 0.09 mmol to 0.32 ± 0.13 mmol, p = 0.045) when tea was prepared from 2-g bags of green leaf tea. Consumption of green tea containing 4 g of leaf tea resulted in 24-h urinary oxalate increase (0.25 ± 0.25 mmol to 0.34 ± 0.22 mmol, p = 0.041). CONCLUSIONS: In vitro studies showed that there was a gradual increase in solution concentrations of oxalate that was associated with increased brewing time and increased quality of green tea. Studies in normal men showed that green tea consumption was associated with increased urinary exertion of oxalate.

Female primary bladder neck obstruction: role of videourodynamics and treatment options in a rare clinical entity.

INTRODUCTION: Primary female bladder neck obstruction is a rare clinical condition characterized by the absence/incomplete bladder neck opening during the voiding phase of micturition. METHODS: We present the cases of two women complaining dysuria, abdominal straining and sensation of incomplete bladder emptying. Videourodynamic evaluation was fundamental for a correct diagnosis. RESULTS: Videourodynamic evaluation showed a high detrusor pressure during emptying phase, partial use of abdominal strain, very low urine flow rate and significant postvoid residual; imaging showed a defect in the physiological funneling of the bladder neck, absent or incomplete. The first step therapy is represented by oral alpha-blockers and clean intermittent self-catheterization in case of high postvoid residual. Surgical operations, such as bladder neck incision and resection, represent the last option. CONCLUSIONS: In our experience, bladder neck obstruction is a rare condition in women and only a complete clinical evaluation associated with videourodynamic study can lead to an appropriate diagnosis and treatment.

Randomized Study of Ureteral Catheter vs Double-J Stent in Tubeless Minimally Invasive Percutaneous Nephrolithotomy Patients.

OBJECTIVE: To prospectively analyze and compare the outcomes of using externalized ureteral catheter (EUC) vs Double-J ureteral stent (DJ) in tubeless minimally invasive percutaneous nephrolithotomy (MPCNL). PATIENTS AND METHODS: A total of 109 patients underwent tubeless MPCNL in our institute and have been enrolled into this study. Fifty-six and 53 patients had EUC and DJ positioning at the conclusion of the procedure, respectively. The two approaches have been compared for operative time, intraoperative blood loss, postoperative visual analogue pain scale (VAS) score, analgesic requirement, stent-related symptoms, hospital stay, degree of vesicoureteral reflux (VUR) on the operative side, and complications according to the modified Clavien system. RESULTS: There were no statistically significant differences between the two groups regarding the mean operative times, mean VAS scores, analgesic requirements, mean hemoglobin drop, mean hospital stay, and overall complication rate. However, compared with DJ group, EUC group presented fewer postoperative stent-related symptoms and less occurrence of severe VUR (p < 0.05). CONCLUSION: Positioning EUC in tubeless MPCNL is a safe alternative to DJ in patients with renal or upper ureteral calculi. EUC provides several benefits: obviated the need of a second endoscopic procedure, reduced stent-related discomfort, and lowered the occurrence of severe VUR.

Comparison of Effect of Minimally Invasive Percutaneous Nephrolithotomy on Split Renal Function: Single Tract vs Multiple Tracts.

OBJECTIVES: To observe serum creatinine (SCr) and treated side glomerular filtration rate (TGFR) variations in patients with upper urinary tract calculi after minimally invasive percutaneous nephrolithotomy (MPCNL). PATIENTS AND METHODS: A total of 178 patients underwent MPCNL in our institute and they were retrospectively evaluated between May 2014 and February 2016. SCr and TGFR variations were observed with renal scintigraphy using 99mTc-diethylene triamine pentaacetic acid (99mTc-DTPA) preoperatively and after at least 6 months of follow-up (FU). The patients were categorized into two groups according to the number of percutaneous access tracts: group I (single tract, n = 122) and group II (multiple tracts, n = 56). RESULTS: At a mean FU of 7.6 months, SCr dropped from 192.9 ± 151.9/L to 167.6 ± 113.9 µM (13.15% decrease, p = 0.008) and TGFR increased from 29.8 ± 21.2 mL/minute preoperatively to 32.7 ± 22.5 mL/minute postoperatively (9.79% increase, p = 0.022) in group I. Similarly, SCr dropped from 238.5 ± 130.1 to 215.8 ± 128.1µ (9.50% decrease, p = 0.013) and TGFR increased from 29.6 ± 21.4 mL/minute preoperatively to 32.9 ± 25.1 mL/minute postoperatively (11.17% increase, p = 0.014) in group II. No statistically significant difference between two groups according to SCr or TGFR variation was observed (p > 0.05). CONCLUSIONS: Stone clearance resulted in improvement of split kidney function after single tract or multiple tract MPCNL. Single tract or multiple tract MPCNL did not show statistically significant difference in split renal function postoperative recovery.

[Female incontinence surgery: state of the art]. / Chirurgia dell'incontinenza urinaria femminile: a che punto siamo?

Female urinary incontinence represents a medical and social problem with huge impact regarding both patient's quality of life and social costs. The diagnosis is important for therapeutic choice and should consider some factors: the degree of urethral mobility, urodynamics parameters, patient's will and expectations, information about surgical complications and risks. Nowadays suburethral sling evolution and bulking therapy for selected cases consent to perform miniinvasive surgery; the most relevant problem concerns the management of postoperative complications: in this sense autologous slings are used after urethrolisis. In most difficult cases, it is possible to consider artificial sphincter as the best option.

Two cases of retroperitoneal metastasis from a completely regressed burned-out testicular cancer.

INTRODUCTION: Primary extragonadal germ cell tumors (EGCT) are rare and it is still a matter of debate if they have to be considered as primary extragonadal issues or metastases from a primary testicular neoplasm. We describe two cases of the so-called burned-out seminoma, a primary testicular germ-cell tumor that spontaneously regressed after demonstration of retroperitoneal metastases. CASES PRESENTATION: Two patients (35 and 50 years old, respectively) presented with CT findings of retroperitoneal masses. In both cases physical examination of the testis was not suspicious, and only scrotal ultrasound (SUS) showed parenchymal alterations such as scarring, calcifications and nodular lesions. Left orchiectomy and chemotherapy were then performed in both cases. Currently, they are both free of disease. CONCLUSIONS: Although primary germ cell tumors may be of retroperitoneal origin, the likelihood of metastasis from a testicular primary origin should always be carefully considered in order to avoid misdiagnosis and to apply the best treatment schedule for the patients. Therefore, a testicular ultrasonography is mandatory in patients presenting CT findings of retroperitoneal adenopathy, even if patients are completely asymptomatic and their physical examination appears normal.

Innovations in the endoscopic management of bladder cancer: is the era of white light cystoscopy over.

Bladder cancer is the most common tumor of the urinary tract, with a worldwide incidence of 8.6 x 100000 in men and 2.6 x 100000 in women (1). The majority of patients (75-85%) present as non-muscle invasive bladder cancer (NMIBC); within this category the most represented stage is Ta (70%), followed by T1 (20%) and, less frequently, carcinoma in situ (CIS) (10%) (2). The diagnosis of NMIBC and, more generally, of bladder cancer, depends on urine cytology and endoscopic examination with histological evaluation of the resected tissue. Clearly, an optimal cystoscopy with accurate transurethral resection (TUR) is of great importance in order to improve the detection rate and to reduce the probability of recurrence and progression. Today the cystoscopy is routinely performed with the white light technique (WLC), the same of about 80 years ago (3). Several studies have demonstrated that an initial TUR with WLC can miss small papillary lesions and, particularly, flat lesions such as CIS. Moreover, recurrence rates of non-muscle invasive bladder cancer (NMIBC) are directly related to the possibility of achieving a complete resection: residual cancer is present in a large percentage of re-TUR, showing a not so good performance of resection with this method. For these reasons new methodologies have been investigated in order to improve the sensitivity and specificity of WLC, such as photodynamic diagnosis (PDD), narrow band imaging (NBI), optical coherence tomography (OCT) and CT virtual cystoscopy. Some of them have been well established and supported by consistent literature while others are still to be viewed as experimental. The purpose of this review is to investigate the state of the art of these new techniques.

A rare case of primary mantle cell lymphoma of the prostate: clinical aspects and open problems.

A case of primary prostate involvement by mantle-cell lymphoma diagnosed at the time of transvesical adenomectomy is reported. Diagnostic difficulties and clinical outcome are also presented. The possibility of prostate involvement by malignant lymphomas, albeit rare, should be considered in any case of histological evidence of dense prostate lymphoid infiltrate in patients with lower urinary tract obstruction, and should be highly suspected in patients with prior history of systemic lymphoma. Immunohistochemical analysis is essential for a correct diagnosis. Both urologists and pathologists should be aware of the existence of such a rare clinical condition.

Laparoscopic management of sacral neurinoma causing hydronephrosis.

We report the case of a sacral neurinoma, which presented with mild hydronephrosis, due to compression of the right ureter, in a 71-yr old woman admitted to our hospital with recurrent urinary tract infections. CT and MRI detected a 4 x 4 cm mass pressing on the right ureter at the sacral level, in continuity with the second sacral foramen. Given this finding, the mass was thought to be of presumable neurogenic origin. In order to both reach a conclusive diagnosis and relieve the compression of the ureter, a laparoscopic resection of the mass was performed. Surgery was successful and the pathologic examination revealed a sacral Antoni A neurinoma. Neurinomas, also called Schwannomas, are uncommon benign nerve sheath tumors arising from Schwann cells. Their diagnosis can be extremely difficult due to their aspecific symptoms and the lack of pathognomonic characteristics on imaging exams. Therefore, histopathologic evaluation is essential in establishing the diagnosis. Surgical resection seems to be the best approach, both for diagnostic and therapeutic purposes.