Transurethral seminal vesiculoscopy acts as a therapeutic investigation for intractable hemospermia: Step-by-step illustrations and single-surgeon experience.

OBJECTIVE: To describe the methodology of transurethral seminal vesiculoscopy and the anatomy of the seminal tract, and to report a single-surgeon experience with this procedure. METHODS: A total of 38 consecutive patients with intractable macroscopic hemospermia were enrolled from January 2010 to July 2016. A 6/7.5-Fr semirigid ureteroscope was used to enter the seminal tract by one of these two approaches: through either a trans-ejaculatory duct opening or a trans-utricle fenestration. Patient characteristics and their preoperative and postoperative measurements were analyzed retrospectively. RESULTS: The success rate of transurethral seminal vesiculoscopy was 92.1%, whereas the approaching method in most patients was the trans-utricle fenestration (88.89%). A total of 34 (94.4%) transurethral seminal vesiculoscopy inspections ended with complete remission, even though nearly half of them (47.2%) only disclosed negative perioperative findings. The median period to complete remission was 4 weeks (interquartile range 4-6 weeks) after the procedure. Four patients had recurrent hemospermia, and the median time to recurrence was 21.5 (range 13-48.5) months. CONCLUSIONS: Transurethral seminal vesiculoscopy is a valuable diagnostic tool for intractable hemospermia, and also plays a therapeutic role by blocking the vicious cycle of stasis, calculi and seminal vesiculitis. More familiarity of the anatomy and enough practice would make the learning curve less steep.

Nephroscope-assisted single trocar peritoneal dialysis catheter insertion improves catheter survival compared with laparoscopic technique: Ten-year experience of a single-center.

BACKGROUND: An ideal technique for peritoneal dialysis (PD) catheter insertion should provide a long-term functioning catheter until permanent renal replacement therapy becomes available. We developed a technique using the nephroscope-assisted single-trocar approach in 2011. In this study, we report the outcomes, learning curve analysis and cost-effectiveness analysisof the nephroscopic approach compared with the traditional laparoscopic approach. METHOD: Between January 2005 and December 2020, we retrospectively reviewed 511 patients who received PD catheter insertions using the laparoscopic or nephroscopic approach. We compared the baseline characteristics of the patients, surgical outcomes, and complications of the two groups. We further analyzed the nephroscopic group to determine the cost-effectiveness analysis, learning curve and the complication frequency between the learning and mastery periods of the nephroscopic approach. RESULTS: A total of 208 patients underwent laparoscopic PD catheter insertion, whereas 303 patients received nephroscopic surgery. The median catheter survival in the nephroscopic group is significantly longer (43.1 vs. 60.5 months, p = 0.019). The incidence of peritonitis (29.3% vs.20.8%, p = 0.035) and exit site infection (12.5% vs. 6.6%, p = 0.019) were significantly lower in the nephroscopic group. The cost-effectiveness analysis showed a medical expense reduction of 16000 USD annually by using the nephroscopic technique. There was no difference in the frequency of surgical complications between the learning and mastery phases when examining the learning curve analysis for the nephroscopic technique. CONCLUSIONS: Compared with the traditional laparoscopic approach, the nephroscopic technique effectively prolonged catheter survival and reduces health care cost by reducing infectious complications. The low complication rate during the learning phase of surgery makes the procedure safe for patients and surgeons.

Role of Urological Botulinum Toxin-A Injection for Overactive Bladder and Voiding Dysfunction in Patients with Parkinson's Disease or Post-Stroke.

Botulinum toxin A (BoNT-A) paralyzes muscle by blocking acetylcholine release at the synaptic junction. BoNT-A has shown its therapeutic effects in neurological disorders such as Parkinson's disease (PD) and post-stroke spasticity. A high proportion of patients with PD and post-stroke develop neurogenic detrusor overactivity (nDO) and then develop urinary incontinence and overactive bladder (OAB) symptoms. This study aimed to disclose the safety and efficacy of BoNT-A injection in treating bladder and voiding dysfunction in PD and post-stroke patients by reviewing the current evidence. At present, intradetrusor injection of BoNT-A is a Food and Drug Administration (FDA)-approved third-line therapy for nDO and idiopathic OAB. Although intradetrusor injection of onaBoNT-A 200 U is already approved for nDO treatment, most researchers would like to manage PD and post-stroke patients by using onaBoNT-A 100 U intradetrusor injection to achieve long-term efficacy and reduce adverse effects. However, in contrast to its inclusion in the International Continence Society guidelines for PD treatment, the clinical use of BoNT-A for post-stroke patients is limited to experimental use due to the development of urinary retention in about one-fifth of patients. For treating urethral pseudodyssynergia, half of patients may respond to onaBoNT-A 100 U urethral injection. However, refinement is needed to reduce unwanted urinary incontinence.

Metabolic Syndrome and Overactive Bladder Syndrome May Share Common Pathophysiologies.

Metabolic syndrome (MetS) is defined by a group of cardiovascular risk factors, including impaired glucose tolerance, central obesity, hypertension, and dyslipidemia. Overactive bladder (OAB) syndrome consists of symptoms such as urinary urgency, frequency, and nocturia with or without urge incontinence. The high prevalences of metabolic syndrome (MetS) and overactive bladder (OAB) worldwide affect quality of life and cause profound negative impacts on the social economy. Accumulated evidence suggests that MetS might contribute to the underlying mechanisms for developing OAB, and MetS-associated OAB could be a subtype of OAB. However, how could these two syndromes interact with each other? Based on results of animal studies and observations in epidemiological studies, we summarized the common pathophysiologies existing between MetS and OAB, including autonomic and peripheral neuropathies, chronic ischemia, proinflammatory status, dysregulation of nutrient-sensing pathways (e.g., insulin resistance at the bladder mucosa and excessive succinate intake), and the probable role of dysbiosis. Since the MetS-associated OAB is a subtype of OAB with distinctive pathophysiologies, the regular and non-specific medications, such as antimuscarinics, beta-3 agonist, and botulinum toxin injection, might lead to unsatisfying results. Understanding the pathophysiologies of MetS-associated OAB might benefit future studies exploring novel biomarkers for diagnosis and therapeutic targets on both MetS and OAB.

Intraoperative calculus or hemorrhage in transurethral seminal vesiculoscopy as a risk factor for recurrent hemospermia.

We have summarized our experience regarding transurethral seminal vesiculoscopy (TUSV) and analyzed both its recurrence status and the risk factors for recurrence. From January 2010 to December 2020, 48 patients with intractable hemospermia received successful TUSV at Taichung Invalids General Hospital. Upon analysis of the intraoperative findings, the five-year disease-free Survival rates (DFS) were 74.1% in the no calculus group compared to 37.1% in the calculus group with a significant difference (log-rank p = 0.015), 75.0% in the no hemorrhage or no blood clot group compared to 43.2% in the hemorrhage or blood clot group with significant difference (log-rank p = 0.032). Univariate analysis showed intraoperative calculus (p = 0.040; HR: 2.94, 95% CI: 1.05-8.21) to be significantly associated with recurrence (p < 0.05). Patients with intractable hemospermia who were diagnosed with stones or blood clots found during TUSV experienced a higher rate of hemospermia recurrence.

Bladder Management Strategies for Urological Complications in Patients with Chronic Spinal Cord Injury.

Neurogenic lower urinary tract dysfunction, common in patients with chronic spinal cord injury, inevitably results in urological complications. To address neurogenic lower urinary tract dysfunction after spinal cord injury, proper and adequate bladder management is important in spinal cord injury rehabilitation, with the goal and priorities of the protection of upper urinary tract function, maintaining continence, preserving lower urinary tract function, improvement of SCI patients' quality of life, achieving compatibility with patients' lifestyles, and decreasing urological complications. This concise review aims to help urologists address neurogenic lower urinary tract dysfunction by focusing on the risks of long-term urological complications and the effects of different bladder management strategies on these complications based on scientifically supported knowledge.

Associations between LncRNA MALAT1 Polymorphisms and Lymph Node Metastasis in Prostate Cancer.

Current evidence elucidates that long noncoding RNA metastasis-associated lung adenocarcinoma transcript 1 (MALAT1) could regulate genetic expression and play a crucial role in both the diagnosis and prognosis of prostate cancer. Single-nucleotide polymorphisms (SNPs) of MALAT1 could alter the oncogenesis in various cancers. However, the associations between MALAT1 SNPs and prostate cancer have barely been investigated to date. This study included 579 patients with prostate cancer who received robotic-assisted radical prostatectomy at Taichung Veterans General Hospital from 2012 to 2017. Three SNPs of MALAT1 were analyzed to identify the impacts of SNPs on the clinicopathologic features in Taiwanese prostate cancer. Our results show that patients with a polymorphic G allele at rs619586 had a significantly higher risk of being in an advanced Gleason grade group (AOR: 1.764; 95% CI: 1.011-3.077; p = 0.046). Moreover, individuals with at least one polymorphic A allele at MALAT1 rs1194338 in the PSA >10 ng/mL group were positively associated with node-positive prostate cancer. In conclusion, MALAT1 SNPs are significantly associated with the susceptibility to both advanced Gleason grade and nodal metastasis in prostate cancer. The presence of MALAT1 SNPs rs619586 and rs1194338 seems to enhance oncogenesis in prostate cancer.

Retzius-sparing Robotic-assisted Radical Prostatectomy Facilitates Early Continence Regardless of Neurovascular Bundle Sparing.

BACKGROUND/AIM: Retzius-sparing robotic-assisted radical prostatectomy (RARP) has had better results in early continence rate and comparable oncological safety compared to the retropubic approach. However, the role the neurovascular bundle (NVB) sparing plays in the rate of early continence after catheter removal remains unclear. In this study, we sought to compare the early continence rate between Retzius-sparing RARP and the retropubic approach RARP to assess whether NVB sparing affects the continence rate in patients with prostate cancer. PATIENTS AND METHODS: This was a retrospective case series of 133 patients who underwent RARP from 2004 to 2017. 92 patients underwent retropubic RARP and 41 patents underwent Retzius-sparing RARP. All procedures were performed by a single surgical team in a single institution. Baseline patient characteristics were recorded and analyzed. Continence results and oncological outcomes were compared between the two groups. Continence outcome of Retzius-sparing RARP with NVB sparing was also analyzed. RESULTS: No differences in age, prostate size, pathology T stage, PSA, and NVB sparing were found between the two groups. The oncological results including surgical margin and biochemical recurrence rate at one year showed no difference between the two groups. With respect to immediate continence results, the Retzius-sparing group showed a better continence result compared to the retropubic approach (75.6% vs. 26.1 %, respectively, p<0.001) after catheter removal. However, there was no difference between the two groups after 6 months. Furthermore, no significant difference in immediate continence result was found in the Retzius-sparing group between patients with NVB sparing (75 %) and those without (75 % vs. 78%, respectively, p=1.00). CONCLUSION: Retzius-sparing RARP may provide a better immediate continent result compared to retropubic RARP. In Retzius-sparing RARP, NVB sparing did not enhance immediate continence after the operation.

Impact of H19 Polymorphisms on Prostate Cancer Clinicopathologic Characteristics.

Active surveillance is the preferred strategy for very low risk, low risk, and some favorable intermediate risk of prostate cancer. However, the current risk stratifications with initial prostate-specific antigen (iPSA) levels and Gleason scores at biopsy can underestimate the true oncologic threat. More precise predictors are required to avoid the overtreatment of prostate cancer. H19 single-nucleotide polymorphisms (SNPs) have been found to play crucial roles in numerous malignancies, but not yet in prostate cancer. This study assessed the clinicopathologic effects of H19 SNPs on prostate cancer to identify potential active surveillance candidates. A total of 579 patients with prostate cancer who underwent robot-assisted radical prostatectomy between 2012 and 2017 were recruited. The patients were grouped by iPSA levels, and five H19 SNPs were evaluated. Our results show that patients with an iPSA level of ≤7 ng/mL had increased an likelihood of having Gleason score and group grade upgrades after radical prostatectomy compared with patients with an iPSA level of >7 ng/mL. Moreover, patients with loci polymorphisms in either rs3024270 or rs3741219 had a significantly higher risk of perineural invasion (rs3024270: Odds ratio (OR) 2.76, 95% confidence interval (CI) 1.30-5.87, p = 0.01; rs3741219: OR 2.30, 95% CI 1.17-4.54, p = 0.018). In conclusion, our results suggested that H19 SNPs play a role in the perineural invasion of prostate cancer.

Retzius-sparing Robotic-assisted Radical Prostatectomy Associated with Less Bladder Neck Descent and Better Early Continence Outcome.

BACKGROUND/AIM: We attempted to evaluate the association of early continence outcome of Retzius-sparing robotic assisted radical prostatectomy (RARP) and bladder neck descent with postoperative cystography. PATIENTS AND METHODS: From November 2014 to December 2015, 30 patients with prostate cancer who received Retzius-sparing LRP/ RARP were compared to 30 patients that received retropubic approach RARP with propensity score matching analysis. Cystogram was used to evaluate the bladder neck descent using the bladder neck to pubic symphysis (BNPS) ratio and the continence state was evaluated. RESULTS: A total 60 patients were included 30 of which had received Retzius-sparing and 30 the retropubic approach, using propensity score matching analysis. There was no difference in age, prostate size, pathology T stage and PSA among groups. BNPS ratio is significantly low in the Retzius-sparing group (0.25±0.10 vs. 0.46±0.14, p=0.000). Early continence was improved in the Retzius-sparing group and early continence within the first week was 73.3% compared to 26.7% (p=0.000), but no difference was seen at one year (100.0% vs. 93.30%, p=0.150). The independent risk factors affecting post-operative continence were age and approach. The association between less bladder neck descent as BNP ratio and continence was also confirmed (HR=0.048, 95%CI=0.005-0.420, p=0.006). CONCLUSION: With the advantage of more normal pelvic anatomy preserved in Retzius-sparing RARP, it was associated with less bladder neck descent and better early continence outcome. Age was also an independent risk factor for postoperative continence.

Comparison of cancer detection between 18- and 12-core prostate biopsy in Asian patients with prostate-specific antigen levels of 4-20 ng/mL.

BACKGROUND: Although prostate biopsy is an accepted option for cancer detection, there is little data regarding the clinical outcome of 18-core transrectal ultrasound (TRUS)-guided biopsy. This retrospective study compared cancer detection rates and biopsy complications between 12- and 18-core TRUS biopsy in Asian patients with prostate-specific antigen (PSA) levels between 4.0 and 20.0 ng/mL. METHODS: In total, 1120 consecutive patients with PSA levels between 4.0 and 20.0 ng/mL were divided into the 12-core (552 patients) and 18-core TRUS biopsy (568 patients) groups. The clinical outcomes of the 12- and 18-core TRUS-biopsy groups were compared. Clinical outcomes were evaluated by comparing the prostate cancer detection rates and post-biopsy complication rates. RESULTS: There were no significant group differences in the PSA levels, but the mean age was significantly older in the 12-core biopsy group than in the 18-core biopsy group (mean age, 67.0 vs. 64.0 years, respectively; p = 0.001). The abnormal digital rectal examination rate was higher in the 12-core biopsy group than in the 18-core biopsy group (39.9% vs. 24.5%, respectively; p < 0.001). The prostate cancer detection rate was significantly higher in the 18-core group than in the 12-core group [adjusted odds ratio: 2.75, 95% confidence interval = 2.04-3.01; p < 0.001], especially in patients with age ≥ 50 years, PSA < 10 and cancer clinical stage cT1. (p < 0.001). Moreover, in patients with prostate volumes >30 mL or PSA densities <0.2, the prostate cancer detection rate was significantly higher in the 18-core group than in the 12-core group. There were no differences in the complication rates (e.g., urinary retention, hematuria, urinary tract infection, and urosepsis). CONCLUSION: In Asian patients with serum PSA levels between 4.0 and 20.0 ng/mL, 18-core biopsy was associated with superior clinical outcomes to those of 12-core biopsy for detecting prostate cancer.

A Modified Application of Peritoneal Dialysis Catheter Implantation: A Revolution from the Laparoscope- to the Nephroscope-Assisted Surgery.

INTRODUCTION: A laparoscope provides many advantages when establishing abdominal access for peritoneal dialysis (PD), particularly with direct observation and correction of the catheter's position. However, laparoscopic placement requires specialized equipment and usually requires using more than one working port, which may increase the potential for complications, including dialysis leakage. We modified the surgical technique by using a nephroscope, rather than a laparoscope. This study aimed to illustrate this modified technique step by step and compare the postoperative outcomes. MATERIALS AND METHODS: This study was based on a retrospective chart review of 397 consecutive patients who underwent either laparoscope- or nephroscope-assisted PD catheter insertion between September 2005 and December 2016 in our institute, as performed by a single surgeon. Data were collected and analyzed to compare the characteristics of the patients, including age and gender, along with surgical outcomes and complications between the two groups. RESULTS: Two-hundred fourteen patients underwent laparoscopy implantation, whereas 183 patients received the nephroscope-assisted method. More patients had previously undergone abdominal surgery in the nephroscopy group (29% vs 18.7%, p = 0.035) than those in the laparoscopy group. There was no significant difference in the 1-year catheter survival (82.5% vs 79.4%, p = 0.734) rate between the two groups. A total of five patients experienced dialysis leakage within the laparoscopy group, whereas none had dialysis leakage in the nephroscopy group. CONCLUSIONS: The surgical times were significantly shorter in the nephroscopy group. Although comparison of the complication rate between the two groups revealed no statistical significance, there were trends that showed there were less early surgical complications in the nephroscopy group.

Assessments of Neoadjuvant Hormone Therapy Followed by Robotic-Assisted Radical Prostatectomy for Intermediate- and High-Risk Prostate Cancer.

BACKGROUND/AIM: It is still unclear whether neoadjuvant hormone therapy (NHT) followed by radical prostatectomy is the best treatment option for advanced prostate cancer. This study aimed to evaluate the benefits of NHT followed by robotic-assisted laparoscopic radical prostatectomy (RaLP) in locally advanced prostate cancer. PATIENTS AND METHODS: This study included 48 patients that had received NHT prior to RaLP by a single surgeon. The control group was selected using computerized 1:1 ratio matching. General characteristics, peri-operative parameters, and oncologic outcomes were analyzed retrospectively. RESULTS: Significantly shorter operative time, lesser blood loss and lower positive surgical margins were reported in the NHT group. The median period to biochemical recurrence (BCR) was shorter (3 months vs. 5 months, p=0.0145) and the overall BCR rate was lower (54.17% vs. 87.5%, p=0.0243). CONCLUSION: NHT followed by RaLP may provide clinicopathological benefits, especially in patients with pre-operative PSA values between 10-20 and above 50. Further prospective studies are needed to assess the impacts of NHT.