Retrograde intrarenal surgery for lower pole stones utilizing stone displacement technique yields excellent results.

Objective: To evaluate the long-term stone-free rate (SFR) of retrograde intra-renal surgery (RIRS) in the treatment of lower pole renal calculi using only basket relocation and identify independent predictors of stone-free status. Methods: All consecutive patients undergoing RIRS lower pole renal calculi at a single high-volume tertiary center were analyzed retrospectively. Lower pole stones were relocated to the upper pole, where laser lithotripsy was performed. All patients were followed up in the clinic following the surgery and yearly thereafter. The stone-free status was assessed with a combination of an abdominal ultrasound and abdominal X-ray, or an abdominal non-contrast computed tomography if the stones were known to be radiolucent. Results: A total of 480 consecutive patients who underwent RIRS for treatment of lower pole renal calculi, between January 2012 and December 2018, were analyzed from a prospectively maintained database of 3000 ureteroscopies. With a median follow-up time of 18.6 months, the mean SFR was 94.8%. The procedures were unsuccessful in 26 (5.4%) patients due to unreachable stones. The median stone size of the unreachable stones was 12 mm (range 10-30 mm). Multivariable logistic regression analysis revealed two predictors of SFR for lower pole stones: a small cumulative stone burden (odds ratio [OR]: 0.903, 95% confidence interval [CI]: 0.867-0.941, p<0.0001) and preoperative ureteral stent insertion (OR: 0.515, 95% CI: 0.318-0.835, p=0.007). Conclusion: The long-term SFR of RIRS for the treatment of lower pole stones with basket displacement with appropriate patient selection is high.

Photoselective Vaporization of the Prostate in the Management of Lower Urinary Tract Symptoms in Prostate Cancer Patients on Active Surveillance.

OBJECTIVE: To demonstrate the safety and efficacy of photoselective vaporization of the prostate in alleviating refractory lower urinary tract symptoms in prostate cancer patients who are managed with active surveillance and to explore the association of this procedure with prostate specific antigen (PSA) levels and cancer progression rates. METHODS: Between 2008-2018, active surveillance patients who had refractory symptoms and needed surgery were studied. Perioperative functional variables were collected and analyzed. Disease progression was defined as an upgrade or upstage on surveillance biopsies or multiparametric prostate magnetic resonance imaging. Mean postop scores were estimated using locally-weighted methods. The risk of progression was reported using Kaplan-Meier's method. RESULTS: Seventy-one patients were included in the study. The median age was 68 years and the median surveillance time before surgery was 4 years. At 12 months, there were substantial improvements in the mean International Prostate Symptom Score (18-5.9), maximum flow rate (6.8-14 mL/s), postvoid residual (240-73mL), PSA (8.1-5.2 ng/mL), and prostate volume (85-57mL). At 30-days, only 2 patients with grade-III complications. Late consequences included tissue regrowth in 4 and urethral stricture (requiring a single dilation) in 3 patients. PSA levels decreased by 36% at 12 months postoperatively. With a median follow-up of 3.7 years, 7 men progressed and received radical treatment. At 3 years, the probability of remaining on surveillance was 93% (95% CI 87%- 100%). CONCLUSION: Photoselective vaporization of the prostate offers substantial relief of symptoms in active surveillance patients with refractory symptoms, without adverse effects on disease progression rates.

Management of voiding dysfunction associated with pelvic malignancies.

Voiding dysfunction is common after surgical and radiation treatments in patients diagnosed with non-urological pelvic malignancies. Presentation might vary with lower urinary tract symptoms and/or overactive bladder, urinary retention, or incontinence. We reviewed the most recent literature with the aim of describing various types of urinary dysfunction that manifest after radical treatments for non-urological pelvic malignancies. Radical surgical or radiation treatment adversely affect other adjacent pelvic organ function, including viscera, pelvic musculature and the peripheral nervous system. This results in direct organ and indirect functional damage to the genitourinary tract. Multiple surgical and radiation modifications are available nowadays, allowing urologists to offer various treatments for better functional lower urinary tract outcomes. Diagnosing and understanding the type and severity of voiding dysfunction plays a key role in tailoring an appropriate treatment plan. The objective to better functional results relies on maintaining adequate bladder compliance and capacity while permitting volitional emptying, ideally through voiding. Management should routinely start with conservative measures, including pelvic floor muscle training with or without a combination of oral medication for urgency incontinence and clean intermittent catheterization for the management of urinary retention. Concomitant or isolated urinary incontinence can be further managed through multiple established surgical approaches. We attempted to address various treatment available for known lower urinary tract symptoms that might have been caused secondary to non-urological pelvic surgery or radiation. We discuss different diagnostic and treatment modalities individualized for patients with various entities, to help achieve optimal urinary function and improve quality of life.

Urinary Tract Infections After Urinary Diversion-Different Occurrence Patterns in Patients With Ileal Conduit and Orthotopic Neobladder.

OBJECTIVE: To compare the incidence rate of urinary tract infections (UTIs) and associated pathogens between patients with ileal conduit and patients with orthotopic neobladder urinary diversion. PATIENTS AND METHODS: The medical records of 179 patients treated with radical cystectomy between 2006 and 2011 were reviewed and data pertaining to postoperative UTI were collected. UTI incidence was reported at 3 months' intervals and compared by diversion type. Preoperative predictors of UTI were evaluated with Cox regression analyses. RESULTS: The study cohort included 130 patients with ileal conduit and 49 patients with orthotopic neobladder. Patients with a neobladder were younger (P <.001). Median follow-up was 38 months (IQR [interquartile range], 11-63). Median time from surgery to first infection was 1.5 months (IQR, 1-12.5) for patients with a neobladder and 11 months (IQR, 2.5-27) for patients with a conduit (P = .04). During the first 3 months after surgery, 29% of the patients with a neobladder and 8% of the patients with ileal conduit had a UTI episode (P = .001). Rates of UTI did not differ during subsequent follow-up. Diversion type was not associated with UTI on multivariable analysis. Escherichia coli was the most common pathogen in patients with a conduit (58%), and Klebsiella spp. in patients with a neobladder (29%). CONCLUSION: The risk of UTI is significantly higher in patients with a neobladder during the first 3 months after surgery and comparable to patients with ileal conduit during subsequent follow-up. These findings may facilitate preoperative counseling regarding the expected risk of UTI after urinary diversion.

Urinary tract infections in patients with orthotopic neobladder.

OBJECTIVE: Orthotopic neobladder urinary diversion is associated with a high rate of infectious complications, especially in the early postoperative period. The aim of the study was to assess the incidence, associated pathogens, and predictors of symptomatic urinary tract infection (UTI) in patients with an orthotopic neobladder. METHODS AND MATERIALS: The medical records of 79 patients treated with radical cystectomy and orthotopic neobladder urinary diversion at a tertiary medical center in 2004 to 2012 were reviewed for data pertaining to bacteriuria and symptomatic UTI after hospital discharge. Cumulative incidences of clinical events were assessed with the Kaplan-Meier method. Univariate and multivariate Cox regression models were used to identify clinical predictors of infection. RESULTS: A total of 69 men and 10 women were included in the study cohort. The estimated cumulative rates of symptomatic UTI were 34% at 3 months, 40% at 6 months, and 43% at 12 months. New events of symptomatic UTI occurred in 36% of the patients during the first 3 postoperative months, but only in 10% at 3 to 6 months and 8% at 6 to 12 months. Common pathogens were Pseudomonas aeruginosa (24%) and Escherichia coli (24%); 78% of bacterial pathogens were susceptible to amikacin. On multivariate analysis, there was no effect of age, gender, intermittent catheterization, bowel segment used for reconstruction, or perioperative chemotherapy on rates of UTI. CONCLUSIONS: Symptomatic UTI is a common complication after neobladder reconstruction, usually occurring within the first 3 months of surgery. P. aeruginosa infection is common. Inpatient empirical treatment with amikacin is recommended in this setting.