Grade Heterogeneity in High-Grade Urothelial Carcinomas: Does It Have an Impact on the Survival of Patients With Intermediate/High-Risk Nonmuscle-Invasive Bladder Cancer Who Received Adequate Adjuvant Bacillus Calmette-Guérin Therapy?

PURPOSE: We aimed to compare recurrence-free survival (RFS) and progression-free survival (PFS) of the patients with pure high-grade (HG) vs mixed-grade (MG) nonmuscle-invasive bladder cancer who received adequate bacillus Calmette-Guérin therapy. MATERIALS AND METHODS: We conducted a retrospective cohort analysis using data from an institutional database. The study included patients diagnosed with HG nonmuscle-invasive bladder cancer at the initial transurethral resection specimen between 2010 and 2020. The initial transurethral resection specimens of all patients were reevaluated by a dedicated uropathologist. The percentage of low-grade tumor areas accompanying HG areas was determined for each case. Time-to-event analysis was performed using the Kaplan-Meier method. RFS and PFS rates were compared between groups. RESULTS: Of the 203 patients enrolled in the study, 69 (34%) had MG tumors. Recurrence was observed in 41 out of 134 patients (30.6%) in the HG group and in 19 out of 69 patients (27.5%) in the MG group. The 36-month RFS rates were 69% (CI: 62-77) and 72% (CI: 62-83) for the HG-urothelial carcinoma (UC) and MG-UC groups, respectively. The RFS rates were similar between groups (log-rank, P = .58). Progression was observed in 22 out of 134 patients (16.4%) in the HG group and in 4 out of 69 patients (5.8%) in the MG group. The 36-month PFS rates were 84% (CI: 77-90) and 94% (CI: 89-100) for the HG-UC and MG-UC groups, respectively. The pure HG-UC group had a worse PFS than the MG-UC group (log-rank, P = .042). Multivariate analysis demonstrated that age and tumor grade were significant risk factors for the development of progression. CONCLUSIONS: The indication of MG-UC category separately from pure HG carcinomas in the pathology report seems to be an important issue that can guide patient management. In this way, both more accurate risk classification and more accurate patient counseling can be performed. More importantly, the treatment plan can be made more accurately. For more precise conclusions, our results should be supported by prospective studies with larger sample size.

Sexual dysfunction in women with interstitial cystitis/bladder pain syndrome: Do onabotulinum toxin-A injections improve sexual function?

INTRODUCTION: Interstitial cystitis/bladder pain syndrome (IC/BPS) has a negative impact on female sexual function. We aimed to evaluate the effect of intravesical botulinum toxin-A (BTX-A) injection on the improvement of sexual dysfunction and urinary symptoms using the multi-domain female sexual function Index (FSFI), interstitial cystitis symptom index (ICSI), and interstitial cystitis problem index (ICPI). MATERIAL AND METHOD: The data of the 23 patients (study group) who received intravesical BTX-A with the diagnosis of IC/BPS were reviewed. Twenty-three age-matched healthy, sexually active women were determined as the control group. Patients received 100 U BTX-A submucosally injections, including the trigone. One hundred units of BTX-A were diluted to 20 cc 0.9% saline, and 1 cc was then applied submucosally on 20 different points of the bladder wall (5 U/1 mL per site). The study group was asked to fill out FSFI, ICSI, and ICPI, as well as the visual analog scale (VAS) and bladder diary before and 3 months after the treatment. Patients in the control group completed the same questionnaires once. The pre- and post-treatment questionnaire scores were compared in the study group. The study group's data were also compared to the control group. RESULTS: Compared to the pretreatment period, the study group showed statistically significant improvement in the total FSFI score and each domain of the FSFI after BTX-A injection. The mean total FSFI score and three domains of FSFI (desire, lubrication, pain) reached to the score of the control group following BTX-A injection. Statistically significant improvements were also shown in scores of ICSI, ICPI, and VAS. (p < 0.05). CONCLUSION: IC/BPS is associated with a very high incidence of sexual dysfunction. Intravesical BTX-A injection may provide significant improvement in sexual dysfunction in women with IC/BPS.

Investigation of Atypical Cell Parameter in the Surveillance of Patients with NMIBC; Initial Outcomes of a Single Center Prospective Study.

OBJECTIVE: To investigate how well the Sysmex automated urine-analyzer's atypical-cell parameter can predict oncological outcomes when compared to cytology and pathology data in the follow-up of NMIBC patients. MATERIAL AND METHODS: We prospectively collected clinical data from 273 patients who underwent cystoscopic examination due to benign and malign reasons in our center between June 2020 and March 2021. Patients were divided into 2 groups. (Group-1: Patients with no previous diagnosis of bladder cancer(BC), Group-2: Patients with previously diagnosed NMIBC). The a typical-cell parameter was determined by studying the urine sample given by the patient for urinalysis. The atypical-cell parameter's sensitivity, specificity, negative predictive value (NPV), and positive predictive value (PPV) were assessed. RESULTS: A total of 76(41.1%) patients underwent diagnostic procedures (Group-1) and remaining 109(58.9%) patients were NMIBC patients (Group-2) who subjected to control cystoscopy on follow-up. BC was detected in 70 patients, 28 of whom were newly diagnosed (Group-1). Remaining 42 patients had recurrence during their follow-up (Group-2). Atypical cell values of 70 patients with BC were determined to be statistically significantly higher than those without malignancy. In Group-2, median atypical-cell values for those with no malignancy, those with low-grade BC reccurrence, and those with high-grade BC recurrence were 0.00(IQR:0.00-0.80), 0.25(IQR:0.10℃1.10) and 1.20(IQR:0.70-2.15), respectively (p<0.001). For a cut-off of 0.1 atypical cells/µL, sensitivity and specificity were measured as 83.33% and 53.73%, respectivel (AUC:0.727;p-value<0.001). CONCLUSION: Atypical-cell parameter of the Sysmex-UF-5000 automated urine-analyzer is a newly introduced research parameter. The results of this study are promising. Based on our results, we presume that the atypical-cell parameter may be used in surveillance of the NMIBC patients. Multi-center studies with larger patient populations are required to prove its efficacy.

What is the optimum lithotripsy method for high density stones during mini-PNL? Laser, ballistic or combination of both.

Percutaneous nephrolithotomy (PNL) is the primary treatment option for renal stones > 20 mm in diameter. Mini-PNL gained popularity with its minimally invasive nature. The aim of this study was to compare the efficiency of ballistic and laser lithotripsy with the combined use of both techniques. Data of 312 patients underwent mini-PNL for renal stones with Hounsfield Unit > 1000 was investigated retrospectively. We identified 104 patients underwent combined ballistic and laser lithotripsy. Propensity score technique was used to create the laser and ballistic lithotripsy groups. Groups were matched on stone size, stone density, and Guy's stone score. Primary end point of the study was to compare the stone free rate (SFR), complication rates, and duration of surgery. Mean age of the population was 49.4 ± 6.1, stone size was 24.6 ± 6.3 mm, and stone density was 1215 ± 89 HU. The groups were similar for age, stone size, stone density, and Guy's stone score. The SFR and the complication rates of the 3 groups were similar (p = 0.67). The duration of the surgery was shorter in the combined group (46.1 ± 6.3 min) compared to the laser lithotripsy (54.5 ± 6.6 min) and ballistic lithotripsy (57.2 ± 6.9 min) groups. Both laser and ballistic lithotripsy are effective methods for stone fragmentation during mini-PNL. Combined use of both methods has the potential to improve the fragmentation rates and diminish the operative times in case of high density stones.

Effects of onabotulinum toxin-A injection on sexual function in women with refractory interstitial cystitis/bladder pain syndrome: A prospective study.

OBJECTIVES: To determine the effect of intravesical onabotulinum toxin-A (BoNT-A) treatment on sexual functions in female patients with refractory interstitial cystitis/bladder pain syndrome (IC/BPS). METHODS: Female patients with IC/BPS refractory to previous treatments were included in the study between January 2020 and April 2022. Patients were treated with the trigone-sparing injection (Group 1) or trigone-included injection (Group 2) techniques. 100 Units of BoNT-A was applied submucosally on 20 different points. The patients were evaluated with visual analog scale (VAS), O'Leary-Sant Interstitial Cystitis Symptom Index (ICSI), Interstitial Cystitis Problem Index (ICPI), Female Sexual Function Index (FSFI) questionnaires, 3-day voiding diary, uroflowmetry, and post-voiding residual volume analysis in the preoperative period, as well as on the 30th and 90th days postoperatively. For the repeated measurements, analysis of variance was used to assess the time-dependent variation across groups. RESULTS: The baseline FSFI score of the patients was 15.96 ± 3.82. Following the treatment, the FSFI scores were 22.43 ± 4.93 and 24.41 ± 5.94 on the 30th and 90th days, respectively (p < .001). We observed statistically significant improvement in all FSFI subdomains (p < .05). Statistically significant improvements with treatment on ICSI, ICPI, and VAS scores were achieved (p < .05). Preoperative FSFI scores were similar in Group 1 and Group 2 (p = .147). While the preoperative FSFI scores were 17.00 ± 3.73 and 14.84 ± 3.72 for Group 1 and Group 2, respectively, the scores after the treatment were 22.85 ± 5.01 and 21.98 ± 5.01 on the 30th day, and 24.62 ± 6.06 and 24.19 ± 6.05 on the 90th day postoperatively. Significant improvement was observed in FSFI scores with treatment, and no difference was observed between the two groups in terms of treatment response (p = .706). CONCLUSIONS: Intravesical BoNT-A injection in the treatment of women with refractory IC/BPS improves sexual functions. It also significantly improves pain and symptom scores. Both trigone-sparing and trigone-including injections are similarly safe and effective.

Urinary stone in infants; should vitamin D prophylaxis be stopped?

BACKGROUND: This study investigated the effect of the discontinuation of vitamin D supplementation on kidney stone formation in children under 2 years of age. METHODS: This study involved a retrospective analysis of two patient groups. The first group comprised postoperative patients who were stone-free, while the second group consisted of asymptomatic patients with kidney stones. The patients who discontinued vitamin D supplementation and those who continued were compared in terms of stone formation and stone size progression. The data collected included patient characteristics, stone size measurements, and laboratory results. RESULTS: The findings showed that the discontinuation of vitamin D supplementation was not associated with kidney stone formation or the progression of stone size in either group. For patients who were stone-free on ultrasonography 1 month after the operation, according to the 12-month ultrasonography evaluation, in the group that discontinued vitamin D, 42 (78%) patients had no stones, 6 (11%) patients had stones larger than 3 mm, and 6 (11%) patients had microlithiasis. However, in the group that continued vitamin D, 49 (72%) patients were stone-free, 10 (15%) patients had stones larger than 3 mm, and 9 (13%) patients had microlithiasis. There was no difference between the groups in terms of stone status at 12 months (p = 0.76). For patients with asymptomatic kidney stones, the initial stone sizes were similar between the groups (p = 0.74). During the 6th month of ultrasound, the changes in stone size were 1.76 ± 1.81 mm and 1.79 ± 1.75 mm for the two groups, respectively (p = 0.9). During the 12-month ultrasound measurement, the changes in stone size were 1.98 ± 2.93 mm and 2.60 ± 2.48 mm for the two groups, respectively (p = 0.09). CONCLUSIONS: We believe that more research is needed to make definitive recommendations regarding vitamin D prophylaxis in infants with kidney stones. Although the first objective of our study is not conclusively proven with the current findings, we recommend continued vitamin D prophylaxis in infants with urolithiasis.

The impact of audiovisual information on parental anxiety levels prior to hypospadias surgery: A prospective single center cohort study.

BACKGROUND: Most parents have anxiety before a pediatric surgical procedure. Parental anxiety may impair the parents' ability to cope with new or stressful situations while their children are undergoing surgery. By effectively improving the education of parents regarding the diagnosis, treatment, and potential complications of hypospadias and surgical repair, it might be feasible to reduce their anxiety during this process. OBJECTIVE: To determine whether structured audiovisual information would reduce parents' anxiety levels compared to classic verbal information. MATERIAL AND METHODS: The diagnosis was made and, treatment options were explained, and State-Trait Anxiety Inventory Form - State Anxiety (STAI-I) forms were filled out by parents at the first consultation. In the second consultation, parents were divided into structured audio-visual-information (Group-1) and classic verbal information (Group-2) groups. Following these consultations, all parents in both groups filled out STAI-I again. Parents filled out the forms for the last time on the postoperative-14th-day and the results were compared. RESULTS: A total of 124 (51.2%) parents were informed with structured-audiovisual-informational material and 118 parents (48.8%) were informed with classic verbal information. First STAI-I scores were 57.65 ± 5.17 and 56.91 ± 5.28 for Group-1 and Group-2, respectively, and there was no difference between the groups (p = 0.709). The STAI-I scores after the second consultation were 44.82 ± 5.65 and 49.42 ± 2.81 for Group-1 and Group-2, respectively. Parental anxiety decreased in both groups following the second consultation. Notably, a statistically significant superiority was found between the groups in favor of Group-1 (p = 0.001). DISCUSSION: Parents whose children will undergo hypospadias surgery experience significant anxiety. We observed that informing patients adequately and in appropriate language using a suitable method was associated with less anxiety. Preoperative parental anxiety is influenced by several variables, including parent age, parent gender, child age, lack of knowledge, and concerns over complications or pain. Although we are unable to alter the factors of child age and parent gender, we can impact parents' concerns regarding postoperative pain and anesthesia by enhancing their comprehension of the procedure via providing them of sufficient and accurate information. CONCLUSION: Providing parents with structured audio-visual information about the preoperative and postoperative period before hypospadias surgery is associated with lower parental anxiety levels. Supplying structured audiovisual information regarding the preoperative and postoperative periods can help parents have an improved comprehension of the procedure and minimize their anxiety.

Simultaneous uroflowmetry and urinalysis with single specimen - A prospective evaluation of automatic urine strip analyzer of ORUBA INALYS: Uroflowmetry-urinalysis combined device.

Objective: To evaluate the consistency of the urinalysis results performed with the ORUBA INALYS device, (Oruba, Ankara, Turkey) which can perform urinalysis and uroflowmetry simultaneously, with the analysis results performed with the SYSMEX UC3500 automated urine chemistry analyzer (Sysmex, Kobe, Japan). Material and methods: In this prospective study, urinalysis of 50 male patients with lower urinary tract symptoms were evaluated. The parameters of glucose, pH, urobilinogen, bilirubin and ketone, leukocyte, protein, and blood were measured with ORUBA INALYS, and the same urine specimens collected from ORUBA INALYS by a special setup were sent to the laboratory for urinalysis with Sysmex UC-3500 to assess the concordance of the results between two devices. Results: Urinalysis results in ORUBA INALYS device in terms of glucose, pH, urobilinogen, bilirubin, and ketone parameters were shown to achieve 100% agreement within ±1 category with SYSMEX UC3500 whereas these values were slightly decreased to 88%, 96%, and 98% for leukocyte, protein, and blood, respectively. Among the calculable weighted kappa values for the test parameters, the highest value was found for glucose and followed by blood, pH, leukocyte, and specific gravity respectively. Conclusion: Significant consistency of the urinalysis results obtained from ORUBA INALYS with those obtained from device SYSMEX UC3500 shows the reliability of the urinalysis performed with ORUBA INALYS. ORUBA INALYS could minimize costs and workload, provide time save and reduce plastic waste.

Predicting ESWL success by determination of Hounsfield unit on non-contrast CT is clinically irrelevant in children.

The necessity of determining stone density by non-contrast computerized tomography (NCCT) before extracorporeal shock wave lithotripsy (ESWL) is a controversial topic due to the radiation exposure. We aimed to investigate whether stone density is helpful in predicting the success of ESWL in pediatric patients or not. In this retrospective study, database of a single center was used to identify 232 children aged between 2 and 16 years. Patients with abnormal renal anatomy, distal obstruction, a known cystine stone disease, a previous history of an intervention regarding stone, and an insufficient follow-up period (< 3 months) were excluded from the study. A total of 209 patients were included in the study (94 with NCCT, 115 without NCCT). Groups were compared in terms of stone size, stone location, and stone-free rate at 3 months after a single ESWL session. The mean age was 6.17 ± 3.27 years and 120 (57.4%) of the patients were male and 89 (42.6%) were female. Mean stone size was 11.7 mm in NCCT group and 12.3 mm in non-NCCT group (p 0.128). The complete stone clearance rate in NCCT and non-NCCT group at 3 months after ESWL was 57.4% (54/94) and 54.7% (63/115), respectively, and there was no statistically significant difference (p 0.316). In conclusion, unnecessary NCCT use should be avoided before ESWL considering the similar success rates after ESWL and the risk of exposure to radiation.

Does Switching Bacillus Calmette-Guerin Strains During Maintenance Therapy Affect the Outcome in Non-Muscle Invasive Bladder Cancer?

OBJECTIVE: To compare the patients who have received 1 type of BCG strain during maintenance therapy with patients treated with multiple BCG strains. MATERIAL AND METHODS: We reviewed 279 patients treated with BCG between January 2012 and May 2019, retrospectively. The primary endpoints of the study were recurrence-free survival (RFS) and progression-free survival (PFS) rates among patients receiving same BCG strain (Group-1) and multiple BCG strains (Group-2). Matching analysis was performed to balance the groups. The Kaplan-Meier method was used for estimating RFS and PFS. The difference between the 2 groups in terms of adverse effects was evaluated using the chi-square test. RESULTS: A total of 225 (80.6 %) patients were treated with single BCG strain, and 54 (19.4 %) were treated with multiple BCG strains. Overall, recurrence and progression was observed in 86 (30.8%) and 38 (13.6%) patients, respectively. There was no significant difference between the 2 groups in terms of recurrence-free survival and progression-free survival on both without matching and with propensity score match analysis (log rank; P=.760 and P=.559, P=.533 and P=0509 for non-match and matched analysis respectively). Most of the patients in both groups experienced BCG therapy related side effects, but there was no statistically significant difference between groups (P=.235/.833). CONCLUSIONS: Switching the BCG strain because of unavailability of the induction strain does not decrease the effectiveness of the treatment. When it is not possible to reach the starting BCG strain, treatment can be safely continued with any available strain.

Effect of Active Aspiration and Sheath Location on Intrapelvic Pressure During Miniaturized Percutaneous Nephrolithotomy.

OBJECTIVE: To evaluate the effects of location of the tip of percutaneous sheath and nephroscope in the collecting system together with active aspiration on the Intrapelvic pressure measurements (IPP) during miniaturized percutaneous nephrolithotomy (miniPNL). MATERIALS AND METHODS: The data of 20 patients underwent miniPNL in supine position was collected prospectively. IPP measurements were done with an 8 Fr urodynamic pressure measurement catheter in 4 different settings with respect to location of tip of sheath and nephroscope. All 4 settings were repeated with active aspiration. Totally measurements were done and compared in 8 different settings for 90 seconds in each patient. RESULTS: Highest mean IPP measurements were recorded in setting II (35.3 ± 11.8 cm H2O) where the sheath was located in the calyx and the tip of the nephroscope was in the renal pelvis. When active aspiration was applied, the mean pressure measurements were significantly lower than the counterpart settings without aspiration (all P values <.0001). When the active aspiration was applied, intrarenal pressure measurements did not exceed 40 cm H2O in any settings in any of the patients. CONCLUSION: Location of the tip of the sheath and the nephroscope has significant effect on IPP measurements. Active aspiration significantly lowers the IPP and keeps it <40 cm H2O. Endourologists should be aware of possible alterations in IPP during miniPNL and active aspiration should be kept in mind as an effective solution to decrease the risk of complications related to high IPP.

Effect of continuous antibiotic prophylaxis in children with postoperative JJ stents: A prospective randomized study.

OBJECTIVE: We aimed to investigate the effectiveness of continuous antibiotic prophylaxis (CAP) in patients with JJ stent and tried to identify the group that could specifically benefit from CAP by a prospective randomized study. METHODS: A prospective, randomized, controlled, non-blind, non-placebo study was performed in a single center.A total of 105 patients who underwent surgery with JJ stent (PNL, URS, pyeloplasty, UNC) were randomized into two groups. 53 patients in Group A received CAP and 52 patients in Group B were controlled without CAP, during the presence of a JJ stent. Patients with external stents, nephrostomy tubes, indwelling long-term urethral catheters were excluded. History of preoperative use of CAP and lower urinary tract symptoms were noted. Trimethoprim/sulfamethoxazole (TMP/SMX) was used as the initial choice of antibiotic however if there was a history of antibiotic resistance in previous urinary cultures, Nitrofurantoin was administrated. Urinary cultures were obtained before surgery and before stent extraction. JJ stents were sent to culture. Symptomatic febrile urinary tract infections with positive urine cultures (105 CFU on a clean catch or 103with urethral catheterization) were compared between groups. DISCUSSION: Our study has some limitations; the study is the single-center, we did not follow-up of patients in terms of scar, there were low number of uncircumcised patients, multiple types of surgical procedures were performed. JJ stent is a frequently used instrument in children. Unfortunately, any randomized prospective on antibiotics administration while using a JJ stent is not available in the current literature. We hope our research will contribute to the existing literature and cause a significant change in clinical practice. RESULTS: The mean age among all patients was 4.8 ± 3.9 years. The mean length of time jj stents stayed inside was 16.34 ± 6.45 days in group A and 15.29 ± 7.71 days in group B. The incidence of febrile urinary tract infections with CAP was significantly reduced (3.8% vs. 19% (p 0.015)). Multivariate regression analysis revealed that a positive history for preop febrile urinary tract infections and/or LUTS has a significantly higher association with the incidence of febrile urinary tract infecitons. CONCLUSIONS: CAP in the presence of JJ stents reduced the incidence of febrile urinary tract infections in a short period, especially in children with the previous history of febrile urinary tract infections and lower urinary tract symptoms.