High-grade prostate cancer demonstrates preferential growth in the cranio-caudal axis and provides discrimination of disease grade in an MRI parametric model.

OBJECTIVES: To determine if multiparametric MRI prostate cancer (PC) lesion dimensions in different axes could distinguish between PC, grade group (GG) >2, and GG >3 on targeted transperineal biopsy and create and validate a predictive model on a separate cohort. METHODS: The maximum transverse, anterio-posterior, and cranio-caudal lesion dimensions were assessed against the presence of any cancer, GG >2, and GG >3 on biopsy by binary logistic regression. The optimum multivariate models were evaluated on a separate cohort. RESULTS: One hundred and ninety-three lesions from 148 patients were evaluated. Increased lesion volume, Prostate Specific Antigen (PSA), Prostate Imaging Reporting and Data System score, and decreased Apparent Diffusion Coefficient (ADC) were associated with increased GG (P < .001). The ratio of cranio-caudal to anterior-posterior lesion dimension increased from 1.20 (95% CI, 1.14-1.25) for GG ≤ 3 to 1.43 (95% CI, 1.28-1.57) for GG > 3 (P = .0022). The cranio-caudal dimension of the lesion was the strongest predictor of GG >3 (P = .000, area under the receiver operator characteristic curve [AUC] = 0.81). The best multivariate models had an AUC of 0.84 for cancer, 0.88 for GG > 2, and 0.89 for GG > 3. These models were evaluated on a separate cohort of 40 patients with 61 lesions. They demonstrated an AUC, sensitivity, and specificity of 0.82, 82.3%, and 55.5%, respectively, for the detection of cancer. For GG > 2, the models achieved an AUC of 0.84, sensitivity of 91.7%, and specificity of 69.4%. Additionally, for GG > 3, the models showed an AUC of 0.92, sensitivity of 88.9%, and specificity of 98.1%. CONCLUSIONS: Cranio-caudal lesion dimension when used in conjunction with other parameters can create a model superior to the Prostate Imaging Reporting and Data Systems score in predicting cancer. ADVANCES IN KNOWLEDGE: Higher-grade PC has a propensity to grow in the cranio-caudal direction, and this could be factored into MRI-based predictive models of prostate biopsy grade.

Venous Thromboembolism (VTE) in Post-Prostatectomy Patients: Systematic Review and Meta-Analysis.

Radical prostatectomy (RP) is one of the recommended treatments to achieve oncological outcomes in localized prostate cancer. However, a radical prostatectomy is a major abdominopelvic surgery. Venous thromboembolism (VTE) is a well-known complication associated with surgical procedures, including RP. There is a lack of consensus regarding VTE prophylaxis in urological procedures. The aim of this systematic review and meta-analysis was to investigate different aspects of VTE in post-radical prostatectomy patients. A comprehensive literature search was performed, and relevant data were extracted. The primary aim was to perform a systematic review and meta-analysis (wherever possible) of VTE occurrence in post-RP patients in relation to surgical approach, pelvic lymph node dissection, and type of prophylaxis (mechanical or combined prophylaxis). The secondary aim was to investigate the incidence and other risk factors of VTE in post-RP patients. A total of 16 studies were included for quantitative analysis. Statistical methods for analysis included the DerSimonian-Laird random effects. We were able to conclude that the overall incidence of VTE in post-radical prostatectomy is 1% (95% CI) and minimally invasive procedures (MIS), including laparoscopic, as well as robotic procedures for radical prostatectomy and RP without pelvic lymph node dissection (PLND), are associated with less risk of developing VTE. Additional pharmacological prophylaxis to mechanical methods may not be necessary in all cases and should be considered in high-risk patients only.

Comparison of Outcomes of Active Surveillance in Intermediate-Risk Versus Low-Risk Localised Prostate Cancer Patients: A Systematic Review and Meta-Analysis.

Currently, there is no clear consensus regarding the role of active surveillance (AS) in the management of intermediate-risk prostate cancer (IRPC) patients. We aim to analyse data from the available literature on the outcomes of AS in the management of IRPC patients and compare them with low-risk prostate cancer (LRPC) patients. A comprehensive literature search was performed, and relevant data were extracted. Our primary outcome was treatment-free survival, and secondary outcomes were metastasis-free survival, cancer-specific survival, and overall survival. The DerSimonian-Laird random-effects method was used for the meta-analysis. Out of 712 studies identified following an initial search, 25 studies were included in the systematic review. We found that both IRPC and LRPC patients had nearly similar 5, 10, and 15 year treatment-free survival rate, 5 and 10 year metastasis-free survival rate, and 5 year overall survival rate. However, cancer-specific survival rates at 5, 10, and 15 years were significantly lower in IRPC compared to LRPC group. Furthermore, IRPC patients had significantly inferior long-term overall survival rate (10 and 15 year) and metastasis-free survival rate (15 year) compared to LRPC patients. Both the clinicians and the patients can consider this information during the informed decision-making process before choosing AS.

Are patients' fears of catching COVID-19 during an emergency hospital admission with an acute urological problem justified?-A UK epicentre experience.

BACKGROUND: To establish the risk of catching COVID-19 as urology emergency inpatient and assess patients' fears and attitudes towards seeking help. METHODS: A single-centre retrospective study of urological emergency admissions was conducted over a 10-week period in 2019 and compared to same period of 2020 pandemic. Also, a telephone survey was performed based on a COVID-19 fear questionnaire. RESULTS: In-hospital, infection rate was 0.82% during or within 28 days of discharge with no related mortality. The majority of patients were afraid to visit A&E during the pandemic with less being afraid to visit their GPs; 64% were reluctant to seek medical input by trying self-treatment; 56% admitted intentional delay to visit the hospital. Additionally, 56% considered risk of getting COVID-19 was higher rather than leaving their condition untreated. Interestingly, the vast majority (82%) stated that they would not change approach regarding hospital visits if the same situation occurred. CONCLUSIONS: The risk of contracting COVID 19 while a urology in patient in a COVID-19 epicentre was very low with no COVID-19-related mortality. Our data support that patients should be encouraged to attend rather than stay at home during future surges in the pandemic to prevent further non-COVID-19-related harm.

Active Surveillance-Is It Feasible for Intermediate-risk Localised Prostate Cancer?

BACKGROUND: Although active surveillance (AS) is a well-recognised treatment option for localised low-risk prostate cancer (LRPC), its role in the management of localised intermediate-risk prostate cancer (IRPC) is not clear yet and the available literature is slightly contradictory. OBJECTIVE: To compare the outcome of AS between LRPC and IRPC patients. DESIGN SETTING AND PARTICIPANTS: Between November 2002 and August 2019, 372 men with localised prostate cancer (PC) underwent AS in our hospital based on local departmental protocol. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: The primary outcome measures were overall survival, disease progression-free survival, treatment-free survival, and biochemical recurrence-free survival. Survival times in the low- and intermediate-risk groups were compared using Cox regression analysis. RESULTS AND LIMITATIONS: Out of 372 localised PC patients, 276 (74%) had LRPC and 96 (26%) IRPC. Overall, 86 (31.2%) low-risk and 25 (26%) intermediate-risk patients developed disease progression, and 86 (31.2%) low-risk and 22 (23%) intermediate-risk patients underwent active treatment. Among the treated patients, eight (2.9%) LRPC patients and one (1%) IRPC patient developed biochemical recurrence. In total, only one patient (from the low-risk group) had metastasis and 25 patients passed away (18 from the low-risk and seven from the intermediate-risk group). No death was recorded due to PC in the cohort. There was no difference in any of the survival outcomes between LRPC and IRPC patients in unadjusted analysis as well as when analysis was performed after adjusting the potentially confounding factors. Limitations include relatively short median follow-up time and failure to objectively define the criteria for the selection of IRPC patients suitable for AS. CONCLUSIONS: The option of AS could be considered for carefully selected and well-informed patients with IRPC provided close structured monitoring is maintained. PATIENT SUMMARY: In this report, we looked at various survival outcomes of active surveillance between low- and intermediate-risk prostate cancer patients in a large British population. There was no difference in any of the survival outcomes between the two groups. We concluded that carefully selected intermediate-risk prostate cancer patients could be offed the option of active surveillance.

Obstructive uropathy from a giant urinary bladder stone: a rare urological emergency.

A 53-year-old man presented with lower urinary tract symptoms and recurrent urinary tract infections since last 3 years without being investigated or treated properly. Examination revealed a hard mobile lump in the pelvis, and blood investigations showed raised serum creatinine of 2.9 mg/dL. Subsequent urgent ultrasound scan showed a large urinary bladder stone with bilateral hydroureteronephrosis, and X-ray kidney, ureter and bladder demonstrated a 9 cm×6 cm elliptical radio-opaque shadow in the pelvis. He underwent emergency admission followed by open cystolithotomy on the next day. He was discharged after 48 hours with a urethral catheter. After 2 weeks, his renal function recovered completely; repeat ultrasound scan revealed complete resolution of hydronephrosis. Urethral catheter was removed following a normal cystogram. Uroflowmetry after 6 weeks revealed underlying bladder outlet obstruction, and he was started on alpha blocker which improved his urinary flow.

Warfarin-induced Spontaneous Retroperitoneal Hemorrhage in a Patient With Metallic Mitral Valve-Dilemmas in Management.

We report a 70-year-old gentleman who attended the emergency department with a 1 day history of sudden onset right-sided flank pain. He was on warfarin due to metallic mitral valve. On presentation, he was hemodynamically stable, but his international normalized ratio was deranged at 4.7. An initial noncontrast computed tomography (CT) scan of abdomen showed a large right retroperitoneal hematoma and subsequent CT renal angiogram revealed evidence of active bleeding. There were dilemmas whether or not to reverse the effect of warfarin, proceed with angioembolization or explore the patient surgically. Here, we have addressed these issues.

Virtual consent for virtual patients: benefits of implementation in a peri- and post-COVID-19 era.

The COVID-19 pandemic has caused major disruptions to the healthcare system, including increased reliance on virtual services, particularly clinic appointments. This leads to difficulty in obtaining informed consent; the vast majority of patients now need to be consented on the day of the procedure. To reduce problems with this process, the practice of obtaining electronic consent may be the correct way forward.

Primary Urethral Tuberculosis With Urethrocutaneous Fistula in Association With Balanitis Xerotica Obliterans.

We present an unusual case of isolated urethral tuberculosis. The patient had a history of urethral strictures and persistent discharge from two peno-scrotal fistulas which was confirmed on urethrogram. He was treated with antitubercular treatment and a two stage urethroplasty.

Urethral Catheter Induced Huge Anterior Urethral Diverticulum.

We report a 22-year old gentleman who presented with postmicturition urinary dribbling for nearly 1 year along with urinary urgency and frequency. He had a history of brain tuberculosis 2 years back and was hospitalized for 4 months with a urethral catheter. Examination revealed a 3 cm cystic swelling in the penoscrotal junction. On pressing the sac, a gush of urine came out through the urethral meatus. A micturating cystourethrogram revealed a huge anterior urethral diverticulum. Cystoscopic assessment also confirmed the diagnosis and demonstrated transillumination. He subsequently underwent surgical excision of the diverticulum and is doing well on follow-up.

Spontaneous Ureterocutaneous Fistula Secondary to Obstructed Ureteric Stone.

We present a unique case of ureterocutaneous fistula secondary to an obstructed ureteric stone. A fistulagram confirmed a communication between right flank and the proximal ureter. Ureterocutanoues fistula in the absence of trauma, iatrogenic causes, granulomatous infection, or malignancy is highly unusual.

Short-term Alteration of Renal Function and Electrolytes after Percutaneous Nephrolithotomy.

PURPOSE: To analyse the changes in renal function and serum electrolytes in the early post-operative period ofpercutaneous nephrolithotomy (PCNL). MATERIALS AND METHODS: A total of 110 patients with normal renal function, who underwent PCNL in our institutewere evaluated prospectively. Haemoglobin percentage, packed cell volume, blood urea nitrogen, serum creatinineand serum electrolytes, namely sodium, potassium, chloride and ionized calcium were measured on the day beforesurgery and after 72 hours of the procedure. Renal function was assessed by Cockcroft-Gault formula and estimatedglomerular filtration rate was calculated by modification of diet in renal disease formula. RESULTS: Serum creatinine increased significantly from a mean value of 0.89 ± 0.199 mg/dL to 0.96 ± 0.252 mg/dL(P = 0.0002) and both creatinine clearance and estimated glomerular filtration rate experienced a significant fall -from a median value (interquartile ranges) of 82.99 (72.37 to 96.88) mL/min to 75.38 (63.89 to 94.05) mL/min incase of creatinine clearance (P = 0.0004) and from a mean value of 95.18 ± 19.87 mL/min/1.73 m2 to 89.30 ± 23.14mL/min/1.73 m2 in case of estimated glomerular filtration rate (P = 0.003). Furthermore, there were significantdrops in both haemoglobin percentage and packed cell volume. There were no significant alterations in serum electrolytes- sodium and potassium (mmol/L) [Median (IQR)] changed from a pre-operative figure of 137.5 (134.0 to140.0) and 3.85 (3.60 to 4.10) to a post-operative value of 138 (135.0 to 140.0) and 3.85 (3.50 to 4.10) respectively. CONCLUSION: Even though there is no significant variation in serum electrolytes, PCNL causes significant reductionin renal function in the early post-operative period.

Correction to: The clinical utility of prostate cancer heterogeneity using texture analysis of multiparametric MRI.

Unfortunately, in the original article one co-author's name is missing. The co-author name and affiliation is given as follows.

The clinical utility of prostate cancer heterogeneity using texture analysis of multiparametric MRI.

PURPOSE: To determine if multiparametric MRI (mpMRI) derived filtration-histogram based texture analysis (TA) can differentiate between different Gleason scores (GS) and the D'Amico risk in prostate cancer. METHODS: We retrospectively studied patients whose pre-operative 1.5T mpMRI had shown a visible tumour and who subsequently underwent radical prostatectomy (RP). Guided by tumour location from the histopathology report, we drew a region of interest around the dominant visible lesion on a single axial slice on the T2, Apparent Diffusion Coefficient (ADC) map and early arterial phase post-contrast T1 image. We then performed TA with a filtration-histogram software (TexRAD -Feedback Medical Ltd, Cambridge, UK). We correlated GS and D'Amico risk with texture using the Spearman's rank correlation test. RESULTS: We had 26 RP patients with an MR-visible tumour. Mean of positive pixels (MPP) on ADC showed a significant negative correlation with GS at coarse texture scales. MPP showed a significant negative correlation with GS without filtration and with medium filtration. MRI contrast texture without filtration showed a significant, negative correlation with D'Amico score. MR T2 texture showed a significant, negative correlation with the D'Amico risk, particularly at textures without filtration, medium texture scales and coarse texture scales. CONCLUSION: ADC map mpMRI TA correlated negatively with GS, and T2 and post-contrast images with the D'Amico risk score. These associations may allow for better assessment of disease prognosis and a non-invasive method of follow-up for patients on surveillance. Further, identifying clinically significant prostate cancer is essential to reduce harm from over-diagnosis and over-treatment.

Urinary incontinence following transurethral prostatectomy presenting as self inflicted penile gangrene.

An elderly diabetic man with a 67 g prostate developed a moderate degree of stress urinary incontinence along with urge urinary incontinence after transurethral resection of the prostate. Initially, he did not perform the recommended pelvic floor exercise and wrapped a rubber band around his penis to control the problem. He presented with late development of penile gangrene requiring partial amputation of his penis. The stress urinary incontinence subsided on subsequent follow-up. The patient is now doing well.

A study of molecular signals deregulating mismatch repair genes in prostate cancer compared to benign prostatic hyperplasia.

Prostate cancer is one of the leading causes of mortality among aging males. There is an unmet requirement of clinically useful biomarkers for early detection of prostate cancer to reduce the liabilities of overtreatment and accompanying morbidity. The present population-based study investigates the factors disrupting expression of multiple functionally related genes of DNA mismatch repair pathway in prostate cancer patients to identify molecular attributes distinguishing adenocarcinoma from benign hyperplasia of prostate. Gene expression was compared between tissue samples from prostate cancer and benign prostatic hyperplasia using real-time-PCR, western blot and immunohistochemistry. Assessment of genotypes of seven single-nucleotide-polymorphisms of three MMR genes was conducted using PCR-coupled RFLP and sequencing. Promoter methylation was interrogated by methylation-specific-PCR and bisulfite-sequencing. Interaction between microRNAs and MMR genes was verified by 3'UTR-based dual luciferase assays. Concurrent reduction of three MMR genes namely hMLH1, hMSH6 and hMSH2 (34-85%, P<0.05) was observed in prostate cancer tissues. hMSH6 polymorphism rs1800932(Pro92Pro) conferred a borderline protection in cancer patients (OR = 0.33, 95% CI = 0.15-0.75). Relative transcript level of hMLH1 was inversely related (r = -0.59, P<0.05) with methylation quotient of its promoter which showed a significantly higher methylation density (P = 0.008, Z = -2.649) in cancer patients. hsa-miR-155, hsa-miR-141 and hsa-miR-21 gene expressions were significantly elevated (66-85%, P<0.05) in tumor specimens and negatively correlated (r = -0.602 to -0.527, P<0.05) with that of MMR genes. hsa-miR-155 & hsa-miR-141 and hsa-miR-155 & hsa-miR-21 were demonstrated to bind to their putative seed sequences in hMLH1 and hMSH6 3'UTRs respectively. Relatively higher expression of DNA methyl-transferases (DNMT1 and DNMT3b) and HIF-1α genes (34-50%, P<0.05) were also detected in tumor tissues. This study provides statistical evidence that MMR deficiency is correlated with hypermethylation of hMLH1 promoter and upregulation of hsa-miR-155, hsa-miR-141 and hsa-miR-21 in prostate cancer. This comparative study reflects that microRNA expression level, particularly hsa-miR-155, exhibits predictive signature of prostate adenocarcinoma.

Evaluation of stone-free rate using Guy's Stone Score and assessment of complications using modified Clavien grading system for percutaneous nephro-lithotomy.

To prospectively evaluate the ability of Guy's Stone Score (GSS) in predicting stone clearance rate and complication rate (by modified Clavien grade) for renal stones treated by percutaneous nephrolithotomy (PNL). From January 2013 to June 2014, a total of 142 patients undergoing PNL were evaluated prospectively. Patients with co-morbidities like hypertension, diabetes, renal failure were excluded from the study. All patients were classified according to GSS based on the findings of pre-operative intravenous urography (IVU) and per-operative retrograde pyelography (RGP). All PNL procedures were done by standard technique in prone position and success was defined as no residual stone visible on X-ray KUB done on the third postoperative day. Complications were classified according to modified Clavien grading system. The initial stone clearance rate was 71.1% and overall final stone clearance rate was 90.14%. The complication rate according to Clavien grading system was 40.1%. The final stone clearance rates were 93.9, 85.71, 90.47, and 77.77% in GSS I, II, III, and IV, respectively (p<0.001, <0.05, <0.05 and >0.05, respectively). The Clavien complication rates were 23, 61, 52, and 77.7% in GSS I, II, III, and IV, respectively (p<0.001). The GSS is a simple and easily reproducible system to preoperatively predict stone-free rate and perioperative complication rate. It helps in better patient counseling preoperatively.

Parameatal Cyst : A report of Two Cases and Review of Literature.

Cyst formation in the parameatal area is a relatively rare entity and not many cases have been reported in the literature. Two such cases are reported here. First patient was a 46 year old sexually active male who developed a spherical, cystic swelling of 1 cm in size on right lip of external urethral meatus. The second case was a 4 year old boy who presented with asymptomatic recurrent left parameatal swelling. In both the cases, cysts were completely excised and defects were sutured. Histologically, the cyst walls were lined by tall squamous and columnar epithelium. Good cosmetic results were obtained in these two cases without any recurrence at 2 two months follow up.