Vesical fungal bezoars on post-TURBT scar tissue causing obstruction and mimicking urothelial carcinoma.

Fungal bezoars (fungal balls) are rarely reported in the upper or lower urinary tract. They can be the cause of severe morbidities such as urinary tract obstruction, renal failure and fungaemia. Hereby, we present a rare case of a male patient who underwent transurethral resection of bladder tumour (TURBT), and during his postoperative period, he was diagnosed with bladder fungal bezoars adherent to his resection area. The fungal bezoars were covering an extended area of the right lateral bladder wall, including the right ureteric orifice and causing right urinary tract obstruction. Those findings were manifested only after a relooked cystoscopy and histological evaluation.We aim to present a rare example of fungal bezoars mimicking other pathologies in the urinary tract and review the current literature for similar documentation. We underline the necessity of follow-up examinations for urologists performing TURBT surgeries, including urinalysis, imaging modalities and cystoscopy.

Radiofrequency-assisted, laparoscopic, clampless partial nephrectomy in patients with low-complexity small renal tumors: A retrospective cohort study.

Background: This single-center, retrospective study was performed to investigate the safety and efficacy of radiofrequency-assisted (RF), laparoscopic partial nephrectomy (PN) with zero ischemia in patients with low-complexity small renal tumors. Materials and Methods: Patients with small renal masses (SRMs) who underwent laparoscopic, clampless laparoscopic partial nephrectomy - radiofrequency assisted (LPN-RFA) between January 2016 and June 2020 were studied. Demographics, clinical and pathological characteristics, recurrence-free survival, and overall survival were recorded. Results: Fifty-two SRMs were excised from corresponding patients using RFA-LPN. The median tumor size was 2.5 cm and all specimens involved low-complexity masses according to the renal nephrometry score. No conversions to radical nephrectomy were recorded. Postoperatively, there were one patient with fever, one with hematuria, and two with urinary leakage treated endoscopically. The majority of tumors (48/52, 86.2%) were clear-cell carcinomas. According to the glomerular filtration rate postoperatively and 12 months' posttreatment, adequate renal function was preserved in all patients. There were no positive surgical margins identified postoperatively and no recurrences during a median follow-up 24 months. All patients were alive at the last follow-up. Conclusions: This study suggests that RFA laparoscopic clampless PN represents an effective method for managing patients with low-complexity SRMs. It offers adequate intraoperative safety and excellent mid-term oncological control and functional preservation.

Combination of fusion guided multiparametric MRI-transrectal US with systematic biopsy of the prostate for the detection of clinically significant prostate cancer: A prospective single-center study.

PURPOSE: To investigate the diagnostic efficacy of fusion guided multiparametric MRI (mpMRI)-transrectal ultrasound (TRUS) biopsy versus systematic biopsy of the prostate in patients with suspicion of prostate cancer. METHODS: A total of 185 patients with PI-RADS 3 lesions or higher underwent fusion guided targeted and systematic prostate biopsy. Histology of samples was correlated with PI-RADS score and biopsy method for each patient. RESULTS: A total of 81/185 (43.8%) cases positive for cancer were detected; 23/81 (28.4%) cases with clinically insignificant prostate cancer-insPCa and 58/81 (71.6%) cases with clinically significant prostate cancer-csPCa. There was a statistically significant difference in the overall detection of adenocarcinomas between methods (p = .035, McNemar test). Moreover, there was a statistically significant difference in the detection of insPCa between the two methods (p = .004, McNemar test). Systematic biopsy detected 13 patients with insPCa more (14.4%) than the targeted biopsy method. However, there is no statistical difference in the detection rate of csPCa between the two methods (p = 1, McNemar test). When both techniques were combined more cases of csPCa were detected. CONCLUSION: The combined implementation of fusion-guided targeted mpMRI-TRUS and systematic biopsy of the prostate provides higher detection number of csPCa, compared to each method alone. The potential of fusion-guided mpMRI-TRUS biopsy of the prostate needs to be further assessed since each method has its limitations; therefore, systematic prostate biopsy still plays an important role in clinical practice.

The Impact of Enhanced Recovery after Surgery Protocol Implementation on Postoperative Pain Management in the Era of Opioid Crisis: The Postchemotherapy Open RPLND Experience.

AIM: Enhanced Recovery After Surgery (ERAS) protocols have been proven to optimize postoperative outcomes; however, misuse of opioid analgesics can still hinder postoperative recovery due to related side effects and potential complications. INTRODUCTION: To determine if the implementation of ERAS protocol in post-chemotherapy retroperitoneal lymph node dissection (PC-RPLND) patients could help with reducing postoperative pain and opioid use. METHODS: A case-control study of consecutive testicular cancer patients with indications for PCRLPND, who were offered Conventional Post-operative Management (CPM) or ERAS protocol. Outcomes of interest included Visual Analogue Scale (VAS)-assessed pain level at postoperative days 3, 7, and 30, and Morphine-Equivalent Doses (MEDs)/postoperative day. Intraoperative parameters and postoperative complications were recorded. Parametric and non-parametric tests were used for statistical analysis. RESULTS: In total, 100 opioid-naïve PC-RPLND patients were studied. CPM and ERAS groups (36 and 64 patients, respectively) had similar demographic and baseline clinical characteristics). ERAS group patients had significantly lower blood loss (p = 0.005), blood transfusion rate (p < 0.001), and duration of the procedure (p < 0.001). Post-operative complications were comparable between groups. Nausea and bowel disorders were numerically but not statistically more frequent in the CPM group. ERAS patients had shorter mean hospital stay (5.3 ± 1.4 vs. 7.4 ± 1.6 days, p < 0.001), lower daily MEDs (4.73 ± 2.63 vs. 7.04 ± 2.29, p < 0.001), and lower VAS scores on post-operative day 7 (3.89 ± 1.07 vs. 4.67 ± 1.17, p = 0.001). Post-operative pain was similar between groups on post-operative days 3 and 30. CONCLUSION: Systematic implementation of ERAS protocol after PC-RPLND improves pain management, optimizes patient recovery, and prevents over-prescription of opioid analgesics.

Greek validation of the user version of the Mobile Application Rating Scale (uMARS).

OBJECTIVE: The original user version of the Mobile Application Rating Scale (uMARS) is an English-language questionnaire that was designed to allow non-expert app users to assess the quality of health apps. We aimed to translate into the Greek language and validate the uMARS. METHODS: This was a qualitative prospective study. The World Health Organization translation process was followed and a readily available and free-of-charge app was used for the validation process. Internal consistency and reliability were tested twice within one month by 91 Greek medical students. RESULTS: The total uMARS score showed excellent internal consistency (Cronbach's alpha = 0.86). The internal consistencies of its subscales were also very high (engagement alpha = 0.71; functionality alpha = 0.71; aesthetics alpha = 0.67; information alpha = 0.63), with the notable exception of the satisfaction alpha, which was 0.61. The uMARS total score demonstrated almost perfect agreement levels in most of the subscales according to the rWG index from baseline to 1 month. CONCLUSIONS: The Greek uMARS is a reliable and valid tool for assessing the quality of mobile apps.

Clear-cell renal cell carcinoma single urinary bladder metastasis: a case report and review of the literature.

Renal cell carcinoma (RCC) is the most frequent solid lesion accounting for ~90% of all kidney malignancies. Clear-cell RCC (ccRCC) represents the most frequent subtype. Urinary bladder is a rare metastatic site either synchronous or metachronous. Hereby, we report the case of an 85-year-old male patient with a single urinary bladder metastasis due to ccRCC and we present a review of the literature.

The use of an artificial neural network in the evaluation of the extracorporeal shockwave lithotripsy as a treatment of choice for urinary lithiasis.

Objective: Artificial neural networks (ANNs) are widely applied in medicine, since they substantially increase the sensitivity and specificity of the diagnosis, classification, and the prognosis of a medical condition. In this study, we constructed an ANN to evaluate several parameters of extracorporeal shockwave lithotripsy (ESWL), such as the outcome and safety of the procedure. Methods: Patients with urinary lithiasis suitable for ESWL treatment were enrolled. An ANN was designed using MATLAB. Medical data were collected from all patients and 12 nodes were used as inputs. Conventional statistical analysis was also performed. Results: Finally, 716 patients were included in our study. Univariate analysis revealed that diabetes and hydronephrosis were positively correlated with ESWL complications. Regarding efficacy, univariate analysis revealed that stone location, stone size, the number and density of shockwaves delivered, and the presence of a stent in the ureter were independent factors of the ESWL outcome. This was further confirmed when adjusted for sex and age in a multivariate analysis. The performance of the ANN at the end of the training state reached 98.72%. The four basic ratios (sensitivity, specificity, positive predictive value, and negative predictive value) were calculated for both training and evaluation data sets. The performance of the ANN at the end of the evaluation state was 81.43%. Conclusion: Our ANN achieved high score in predicting the outcome and the side effects of the ESWL treatment for urinary stones.

PCaGuard: A Software Platform to Support Optimal Management of Prostate Cancer.

BACKGROUND AND OBJECTIVE: Prostate cancer (PCa) is a severe public health issue and the most common cancer worldwide in men. Early diagnosis can lead to early treatment and long-term survival. The addition of the multiparametric magnetic resonance imaging in combination with ultrasound (mpMRI-U/S fusion) biopsy to the existing diagnostic tools improved prostate cancer detection. Use of both tools gradually increases in every day urological practice. Furthermore, advances in the area of information technology and artificial intelligence have led to the development of software platforms able to support clinical diagnosis and decision-making using patient data from personalized medicine. METHODS: We investigated the current aspects of implementation, architecture, and design of a health care information system able to handle and store a large number of clinical examination data along with medical images, and produce a risk calculator in a seamless and secure manner complying with data security/accuracy and personal data protection directives and standards simultaneously. Furthermore, we took into account interoperability support and connectivity to legacy and other information management systems. The platform was implemented using open source, modern frameworks, and development tools. RESULTS: The application showed that software platforms supporting patient follow-up monitoring can be effective, productive, and of extreme value, while at the same time, aiding toward the betterment medicine clinical workflows. Furthermore, it removes access barriers and restrictions to specialized care, especially for rural areas, providing the exchange of medical images and patient data, among hospitals and physicians. CONCLUSION: This platform handles data to estimate the risk of prostate cancer detection using current state-of-the-art in eHealth systems and services while fusing emerging multidisciplinary and intersectoral approaches. This work offers the research community an open architecture framework that encourages the broader adoption of more robust and comprehensive systems in standard clinical practice.

Endothelin-1 indicates unfavorable prognosis in primary high-grade non-muscle-invasive urothelial bladder cancer.

OBJECTIVE: To conduct a prospective study of the potential prognostic role of endothelin-1 (ET-1) in a cohort of primary high-grade non-muscle-invasive urothelial bladder cancer patients, who were treated with adjuvant intravesical Bacillus Calmette-Guérin (BCG). MATERIAL AND METHODS: Patients with primary high-grade nonmuscle- invasive urothelial bladder cancer, who received postoperatively induction and maintenance BCG therapy, were prospectively included. Recurrence and progression were histologically proven. Immunohistochemical staining for ET-1 was assessed. Epidemiological, pathological and clinical parameters as well as the expression of ET-1 in tumor specimens were statistically analyzed for recurrence, progression, recurrence-free survival (RFS) and progression-free survival (PFS). RESULTS: ET-1 associates significantly with recurrence (p = 0.000), progression (p = 0.000), RFS (p = 0.000) and PFS (p = 0.000). The patient's age is also significant for recurrence (p = 0.003, OR = 1.273 95% CI: 1.086-1.492) and RFS (p = 0.013). CONCLUSIONS: ET-1 seems to deteriorate prognosis in patients suffering from primary high-grade non-muscle-invasive urothelial bladder cancer, who are treated with adjuvant BCG instillations. Furthermore, the patient's age associates with an increased likelihood for recurrence.

Renal Symptoms and Kidney Impairment Due to Dissecting Abdominal Aortic Aneurysm.

Renal artery stenosis leading to renal damage is not uncommon among patients with abdominal aortic aneurysm and has been identified in 20-38% of patients with aortic disease. In otherwise normal renal arteries, a thrombus at the origin of the artery may decrease the renal blood flow, leading to renal colic and kidney impairment. We report a rare case of a patient with renal symptoms associated with dissecting aortic aneurysm, with thrombus at the level of the origin of an otherwise normal right renal artery.

The Clinical Impact of Hexanic Extract of Serenoa repens in Men with Prostatic Inflammation: A Post Hoc Analysis of a Randomized Biopsy Study.

A randomized biopsy study showed that hexanic Serenoa repens (HESr) treatment resulted in prostatic inflammation reduction. This post-hoc analysis evaluated the clinical impact of HESr and investigated correlations between baseline parameters and treatment response. Patients were randomized to receive HESr 320mg/day for six months or no therapy. Assessment included International Prostate Symptoms Score (IPSS), prostate volume (PV), and maximum flow rate (Qmax). Baseline characteristics were recorded, including body mass index (BMI) and metabolic syndrome (MetS) components. In patients under α1-adrenoceptor antagonists (α1-blockers), the addition of HESr resulted in statistically significant IPSS improvement after 6 months (p = 0.006). IPSS remained stable in patients under a1-blockers only (p = 0.346). Patients treated only with HESr reported a significant IPSS amelioration (p = 0.001). In the control group of naïve patients, no significant IPSS change was detected (p = 0.298). Baseline PV showed fair correlation (r = -0.20) with inflammation reduction in the HESr patients. BMI (r = 0.40), diabetes mellitus (r = 0.40), and PV (r = 0.23) showed fair correlation with Qmax increase but without reaching statistical significance. MetS (p = 0.06) was an influent biomarker for Qmax improvement. Treatment with HESr (as monotherapy or add-on therapy to a-blockers) may improve urinary symptoms in terms of IPSS in patients with prostatic inflammation.

Cefixime versus prulifloxacin as a prophylactic treatment for prostate biopsy: a randomized study.

INTRODUCTION: Urinary tract infections may be a severe complication after prostate biopsy. The aim of our study is to investigate the efficacy of cefixime versus prulifloxacin, as a prophylactic treatment in the era of fluoroquinolone resistance. MATERIAL AND METHODS: In this prospective randomized trial, patients were allocated into two groups. In Group A, patients received cefixime 400 mg p.o./day, while in Group B, prulifoxacin 600 mg p.o./day, both for three days, starting the day before procedure. Eligible for the study were men with a high prostate-specific antigen (PSA) and/or a positive rectal examination. Exclusion criteria were allergy to cefixime or fluoroquinolones, low glomerular filtration rate and drug-resistance to these antibiotics. Patients were followed-up for seven days. RESULTS: Finally, 120 patients were divided into 2 groups of 60 patients with a mean age of 68.6 years. A total of 16 (13.3%) men had already undergone another biopsy in the past, while 18 (15%) had received prulifloxacin and 8 (6.67%) cefixime, at least once in the last three months. During follow-up, hospital admission due to a severe urinary tract infection (UTI) was required in 2 of 60 (1.3%) and 1 of 60 (1.67%) patients from Group B and A respectively. The bacterial specimens detected in those urine cultures were resistant to prulifloxacin or cefixime. Among the remaining 117 patients (97.5%), nobody presented with a UTI. CONCLUSIONS: Prophylactic cefixime could be suggested as effective in preventing severe UTIs after prostate biopsy in the era of high bacterial resistance to fluoroquinolones.

Lower urinary tract symptoms and bladder cancer in children: The hidden scenario.

Bladder cancer is extremely rare in children. We report a case series of two children with transitional cell bladder cancer who presented with lower urinary tract symptoms. Pathology revealed a low risk for recurrence and progression tumor. In such a case, early diagnosis is crucial and surgical treatment is usually the only treatment needed.

Current and emerging mechanical minimally invasive therapies for benign prostatic obstruction.

Transurethral resection of the prostate (TURP) is considered the 'gold standard' for the surgical management of lower urinary tract symptoms (LUTS) due to benign prostatic obstruction (BPO). However, during recent years TURP has been challenged by several minimally invasive therapies (MITs). The reasons for the development of these MITs are the need for anesthesia and the rather unchanged morbidity of TURP, including ejaculation disorders. Mechanical MITs may represent an attractive option for treating LUTS/BPO by using mechanical forces to maintain urethral patency without cutting, ablating, heating or removing prostatic tissue. The present paper provides an update on currently available mechanical devices for the treatment of LUTS/BPO including the prostatic urethral lift (PUL), the temporary implantable nitinol device, and new intraprostatic implants. It analyzes the evidence for their safety, tolerability, and efficacy in clinical practice and aims to define those subpopulations of patients who will benefit from these MITs. It is obvious that there is a wide variation in the degree of mature of the available mechanical MITs. Time and high-quality long-term studies will decide which of these therapies will be accepted by patients and urologists. At the moment, PUL is claiming its position in the armamentarium of BPO treatment.

Primary High-Grade Non-Muscle-Invasive Bladder Cancer: High NFκB Expression in Tumor Specimens Distinguishes Patients Who are at Risk for Disease Progression.

To investigate the potential prognostic role of NFκB expression in primary high-grade non-muscle-invasive bladder cancer. Patients with primary high-grade non-muscle-invasive bladder cancer who received induction and maintenance BCG therapy were retrospectively included. Recurrence and progression were histologically proven. Intensity and extent of immunochemistry were assessed. The final evaluation of the NFκB staining was done by combining intensity and extent as ΄΄product΄΄ and expressing it as ΄΄low NFκΒ expression΄΄ or ΄΄high NFκB expression΄΄. Epidemiological, pathological, clinical parameters and NFκB expression were statistically analyzed for recurrence (REC), progression (PR), recurrence-free survival (RFS) and progression-free survival (PFS). NFκB is significantly associated with disease progression (p < 0,001 in univariate analysis and p = 0,001, Odds Ratio = 14,484, 95% Confidence Interval = 3187-65,821 in multivariate analysis), but not with recurrence. The median value of NFκB expression as ΄΄product΄΄ is significantly higher for the patients with progression in comparison to patients with recurrence only (p = 0,003) and patients without recurrence or progression (p = 0,001). Patients' age is significantly associated (p = 0,001 in univariate analysis and p = 0,003, Odds Ratio = 1273, 95% Confidence Interval = 1086-1492 in multivariate analysis) with disease recurrence. High NFκB expression in primary high-grade non-muscle-invasive bladder cancer, treated with postoperative intravesical BCG immunotherapy, could represent an unfavorable prognostic factor.

The effect of hexanic extract of Serenoa repens on prostatic inflammation: results from a randomized biopsy study.

PURPOSE: To evaluate the effect of hexanic extract of Serenoa repens (HESr) on prostatic inflammation in patients with diagnosed prostatic inflammation. METHODS: Patients with prostatic inflammation histologically confirmed by TRUS prostatic biopsy were randomized either to receive HESr (320 mg/day) or no treatment. A second biopsy was performed 6 months later according to standard clinical practice. Inflammation was assessed by the Irani's score and immunohistochemical staining using the CD3, CD4 and CD8 (for T-leucocytes), CD20 (for B-leucocytes) and CD163 (for macrophages) antibodies. RESULTS: Overall 97 patients were eligible for analysis. In the HESr group the mean inflammation grading and aggressiveness grading score significantly decreased from 1.55 and 1.55 at baseline to 0.79 (p = 0.001) and 0.87 (p = 0.001) at the second biopsy, respectively. In the control group the mean inflammation grading score was 1.44 at first biopsy and 1.23 at the second biopsy. The mean aggressiveness gradings core was 1.09 and 0.89, respectively. No statistical significance was found (p = 0.09 and p = 0.74).The mean decrease in all inflammation scores was statistically higher in the HESr patients compared to controls. The immunohistochemical staining showed a significant change in the expression of the analyzed antibodies for the HESr patients compared to the first biopsy. In the nontreatment group, no significant difference was found at the second biopsy. The change in expression of each antibody in the HESr group was statistical significant compared to control. CONCLUSIONS: HESr seems to reduce prostatic inflammation in terms of histological and immunohistochemical parameters in this specific patients population.

Primitive neuroectodermal tumor transformation of testicular teratoma.

Malignant transformation of teratoma develops in a small subset of testis cancer patients. Primitive neuroectodermal tumor represents a highly malignant component of testicular germ cell tumors. It is a rare clinical entity which is characterized by a high risk of disease progression and death. Surgical resection plus chemotherapy appears to be the therapy of choice.

Self-Healing pH- and Enzyme Stimuli-Responsive Hydrogels for Targeted Delivery of Gemcitabine To Treat Pancreatic Cancer.

A novel, multifunctional hydrogel that exhibits a unique set of properties for the effective treatment of pancreatic cancer (PC) is presented. The material is composed of a pentablock terpolypeptide of the type PLys- b-(PHIS- co-PBLG)-PLys- b-(PHIS- co-PBLG)- b-PLys, which is a noncytotoxic polypeptide. It can be implanted via the least invasive route and selectively delivers gemcitabine to efficiently treat PC. Simply mixing the novel terpolypeptide with an aqueous solution of gemcitabine within a syringe results in the facile formation of a hydrogel that has the ability to become liquid under the shear rate of the plunger. Upon injection in the vicinity of cancer tissue, it immediately reforms into a hydrogel due to the unique combination of its macromolecular architecture and secondary structure. Because of its pH responsiveness, the hydrogel only melts close to PC; thus, the drug can be delivered directionally toward the cancerous rather than healthy tissues in a targeted, controlled, and sustained manner. The efficacy of the hydrogel was tested in vivo on human to mouse xenografts using the drug gemcitabine. It was found that the efficacy of the hydrogel loaded with only 40% of the drug delivered in one dose was equal to or slightly better than the peritumoral injection of 100% of the free drug delivered in two doses, the typical chemotherapy used in clinics so far. This result suggests that the hydrogel can direct the delivery of the encapsulated drug effectively in the tumor tissue. Enzymes lead to its biodegradation, avoiding removal by resection of the polypeptidic carrier after cargo delivery. The unique properties of the hydrogel formed can be predetermined through its molecular characteristics, rendering it a promising modular material for many biological applications.

Is There a Role for Double J Stent Culture in Contemporary Urology?

INTRODUCTION: To present the incidence of bacterial colonization on ureteral double J stents (DJS); isolate the uropathogens; define the rate of multi-resistant bacteria strains (MRBS) and present their clinical importance. MATERIALS AND METHODS: The whole body of 105 DJSs was examined for the presence of uropathogens. RESULTS: The main etiology for stent placement was lithiasis (57.1%). The most frequently cultured microorganisms were staphylococcus (28.6%). Forty-four stents hosted MRBS. 25 (23.8%), 10 (9.5%) and 8 (7.6%) of the patients were affected by malignancy, diabetes mellitus and chronic renal failure respectively. Apart from the female gender, none of the examined factors (age, duration of stenting and chronic diseases) was correlated with the colonization or the presence of MRBS. Eleven of the 61 stented patients (18%) who were operated upon developed a febrile urinary tract infections (UTI). In 7 of them the stent hosted MRBS (63.6%). After taking into consideration the sensitivity report, we altered our initial empirical antibacterial prophylaxis to targeted antibacterial treatment in the patients with MRBS with rapid remission of their infection and no urosepsis event. CONCLUSION: The knowledge of bacteriologic flora of DJS can be very helpful in an evidence-based prophylactic and therapeutic practice. Stent examination could be recommended in high-risk cases of developing UTI and sepsis after a urologic operation.

Do Calcium Supplements Predispose to Urolithiasis?

PURPOSE OF REVIEW: The purpose of this study was to investigate the role of calcium supplements, with or without vitamin D, in urinary stone formation in healthy population and in osteoporotic patients as well. Moreover, this review aims to clarify whether or not, and above which dose, they are associated with the risk of lithiasis. RECENT FINDINGS: A research in Medline, Embase, and Scopus databases up to September 2015 was conducted using the following keywords: calcium, supplements, vitamin D, complications, lithiasis, and urinary stone. All types of studies were taken into account (cohort studies, reviews, meta-analyses), and in case they fulfilled the inclusion criteria, they were included in our review. The analysis of the data showed that calcium supplements, probably in association with anti osteoporotic treatment, do not create a predisposition towards lithiasis formation among women suffering from osteoporosis, neither among non-osteoporotic older men. In healthy postmenopausal as well as younger women, the supplements might increase susceptibility to urinary stone formation in long-term basis. The consumption of calcium supplements with the meals could play a protective role in women and younger males. There is certain evidence that supplements containing citrate may be more beneficial over the rest of calcium supplements, particularly when consumed during the meal. Osteoporotic women and healthy men are not at risk of stone formation. On the contrary, healthy women should be aware of the potential risk of developing urinary lithiasis in long-term basis.