Wunderlich syndrome, an unexpected urological complication in a patient with coronavirus disease 2019 (COVID-19): A case report.

We describe the first case of Wunderlich syndrome as a hemorrhagic complication in a patient with severe acute respiratory syndrome coronavirus 2 infection and acute respiratory distress syndrome. The possible underlying pathophysiological mechanisms have been extensively discussed. Emergency management included selective angioembolization of the upper polar arterial branches of the left kidney and discontinuation of thromboprophylaxis. The patient was discharged after 18 days. No other localizations or local recurrence of bleeding occurred during the hospitalization. Our report suggests a broad spectrum of clinical manifestations in patients with coronavirus disease 2019. As observed in our clinical case, in addition to thrombotic complications, bleeding is a significant cause of morbidity in coronavirus disease 2019 patients. Further studies should determine whether these urological bleeding sequelae are a direct manifestation of the infection or an indirect effect of thromboprophylaxis.

Boswellia resin extract and propolis derived polyphenols in patients with type III chronic prostatitis/chronic pelvic pain syndrome: An Italian prospective multicenter study.

Objective: To assess the efficacy and safety of a treatment regimen based on rectal administration of Boswellia resin extract and propolis derived polyphenols in patients with type IIIa and type IIIb chronic prostatitis and chronic pelvic pain syndrome (CP/CPPS). Methods: Patients with type IIIa and type IIIb CP/CPPS received one rectal suppository a day for 15 days per month for 3 consecutive months. Participants were evaluated with National Institutes of Health-Chronic Prostatitis Symptom Index (NIH-CPSI), the International Prostate Symptom Scores (IPSS), International Index of Erectile Function (IIEF), four-glass test, uroflowmetry, and prostate-specific antigen assessments at baseline and at Week 4, and Week 12. Primary endpoints were improvement in pain domain of NIH-CPSI and improvement of NIH-CPSI total score. Secondary outcomes included improvement of micturition and quality of life (QoL) domains of NIH-CPSI questionnaire. Results: A total of 61 males were enrolled. No adverse events were reported. Significant improvements from baseline to Day 30 were reported for NIH-CPSI total score (mean difference: -9.2; p<0.01), NIH-CPSI pain domain (mean difference: -5.5; p<0.01), NIH-CPSI micturition domain, NIH-CPSI QoL domain, and IPSS total score (mean difference: -5.6; p<0.01). No significant changes from baseline in terms of IIEF score or maximum flow rate were observed. At final follow-up (Day 90), further significant improvements in terms of NIH-CPSI total score (mean difference: -12.2; p<0.01), NIH-CPSI pain domain (mean difference: -6.6; p<0.01), NIH-CPSI micturition domain, NIH-CPSI QoL domain, and IPSS total score were reported. Conclusion: Rectal administration of Boswellia resin extract and propolis derived polyphenols is well tolerated and delivers a significant symptomatic improvement in most patients with type IIIa and type IIIb CP/CPPS.

Surgical management of urinary diversion and stomas in adults: multidisciplinary Italian panel guidelines.

INTRODUCTION: Urinary stomas represent a worldwide medical and social problem. Data from literature about stoma management are extensive, but inhomogeneous. No guidelines exist about this topic. Therefore, clear, and comprehensive clinical guidelines based on evidence-based data and best practice are needed. The aim of this article was to elaborate guidelines for practice management of urinary stomas in adults. EVIDENCE ACQUISITION: Experts guided review of the literature was performed in PubMed, National Guideline Clearing-house and other databases (updated March 31, 2018). The research included guidelines, systematic reviews, meta-analysis, randomized clinical trials, cohort studies and case reports. Five main topics were identified: "stoma preparation," "stoma creation," "stoma complications," "stoma care" and "stoma reversal." The systematic review was performed for each topic and studies were evaluated according to the GRADE system, AGREE II tool. Recommendations were elaborated in the form of statements with an established grade of recommendation for each statement. For low level of scientific evidence statements a consensus conference composed by expert members of the major Italian scientific societies in the field of stoma management and care was performed. EVIDENCE SYNTHESIS: After discussing, correcting, validating, or eliminating the statements by the experts, the final version of the guidelines with definitive recommendations was elaborated and prepared for publication. This manuscript is focused on statements about surgical management of urinary stomas. These guidelines include recommendations for adult patients only, articles published in English or Italian and with complete text available. CONCLUSIONS: These guidelines represent the first Italian guidelines about urinary stoma multidisciplinary management with the aim to assist urologists and stoma specialized nurses during the urinary stoma management and care.

On-clamp versus off-clamp partial nephrectomy: Propensity score-matched comparison of long-term functional outcomes.

OBJECTIVES: To compare long-term functional outcomes of off-clamp or on-clamp partial nephrectomy patients of two high-volume centers with cT1-2/N0 M0 renal tumors and baseline estimated glomerular filtration rate >60 mL/min. METHODS: A 3:1 propensity score-matched analysis was used to select two homogeneous cohorts to compare off-clamp versus on-clamp partial nephrectomy. Joinpoint regression analysis was used to compare the 2-8-year probabilities of estimated glomerular filtration rate modifications in both selected cohorts. The Kaplan-Meier method assessed the risk of developing a stage ≥3b chronic kidney disease during follow up. Multivariable analyses aimed to identify predictors of renal function deterioration. Perioperative complications and oncological outcomes were compared. RESULTS: Overall, 1073 patients were included (588 on-clamp and 485 off-clamp). After applying the propensity score-matched analysis, the two cohorts of 157 on-clamp and 472 off-clamp patients did not differ for all covariates, except for warm ischemia time and last estimated glomerular filtration rate. At joinpoint analysis, the off-clamp group showed higher probabilities of maintaining an unmodified estimated glomerular filtration rate (P = 0.02). The probability of developing a stage ≥3b chronic kidney disease was significantly higher (P < 0.001) in the on-clamp cohort. At multivariable analysis, estimated glomerular filtration rate at discharge and off-clamp approach were independent predictors of improved functional outcomes. Perioperative complications were comparable among the two cohorts (P = 0.67). There were not any statistically significant differences in terms of cancer-specific survival (P = 0.26) and overall survival (P = 0.18). CONCLUSIONS: Off-clamp partial nephrectomy seems to offer a higher probability of maintaining 100% estimated glomerular filtration rate after surgery. In our cohort, patients undergoing on-clamp partial nephrectomy presented a 7.3-fold increased risk of developing a severe chronic kidney disease during follow up.

Variations of Nighttime and Daytime Bladder Capacity in Patients with Nocturia: Implication for Diagnosis and Treatment.

PURPOSE: We subtyped patients with nocturia according to daily variations in urine production and bladder capacity. MATERIALS AND METHODS: Patients with 1 or more nocturia episodes per day were prospectively enrolled in this study. Post-void residual urine was collected and a 3-day frequency-volume chart was created. Nocturnal polyuria and bladder capacity were calculated for each patient. Reduced bladder capacity was defined as mean 24-hour bladder capacity less than 200 ml. Patients were categorized into 4 subgroups by the presence or absence of nocturnal polyuria and reduced bladder capacity. RESULTS: Of the 84 patients enrolled in study 50 (59.5%) had nocturnal polyuria and 50 (59.5%) had decreased bladder capacity. Patients with reduced bladder capacity and nocturnal polyuria had significantly greater mean and maximum bladder capacity at night than during the day (p = 0.002) and the highest number of nocturia episodes (3, IQR 2-3). Patients with normal bladder capacity but with nocturnal polyuria had significantly larger mean and maximum bladder capacity at night (p = 0.033 and 0.016, respectively). In patients with reduced bladder capacity and no nocturnal polyuria we observed no significant variation in bladder capacity during the day vs the night. On multivariable analysis the body mass index (OR 1.28 per unit, 95% CI 1.04-1.58, p = 0.019) and severe nocturia (OR 6.26, 95% CI 1.71-22.92, p = 0.006) were risk factors for nocturnal polyuria while only severe nocturia was a predictive factor for reduced bladder capacity (OR 3.77, 95% CI 1.20-11.83, p = 0.023). CONCLUSIONS: Patients with nocturnal polyuria have a different bladder capacity in the day and the night. Severe nocturia (3 or more episodes per night) predicts the presence of nocturnal polyuria and reduced bladder capacity. Our data suggest that in patients with severe nocturia those 2 conditions should be considered and managed.

Clinical Implications for the Early Treatment of Benign Prostatic Enlargement (BPE): a Systematic Review.

PURPOSE OF REVIEW: Therapeutic options for the management of lower urinary tract symptoms (LUTS) secondary to benign prostatic enlargement (BPE) have considerably increased in recent years. However, the ideal timing to initiate medical treatment of LUTS/BPE has not been fully established. The aim of this review was to systematically collect available evidence on the influence of early treatment on the natural history of LUTS/BPE patients. RECENT FINDINGS: A systematic literature search from January 1996 until April 2018 was performed by combining the following MESH terms: Lower Urinary Tract Symptoms, Benign Prostatic Enlargement, male, medical treatment, surgical treatment, early treatment/intervention, and early intervention/treatment. The Medline, PubMed, and Scopus databases were searched. Each article title and abstract was reviewed for relevance and appropriateness with regard to the topic of this review. In recent years, the medical armamentarium for the management of LUTS secondary to BPE has been extensively implemented, significantly improving treatment outcomes and markedly reducing the need for BPE surgery. Early intervention in patients at risk for disease progression may offer better clinical outcomes compared to a deferred approach. However, evidences supporting early treatment are scarce, and criteria to discriminate patients that could mostly benefit from immediate treatment remain poorly defined. Moreover, as a result of delayed surgery after prolonged medical treatment, patients undergoing surgical relief show larger prostates, older age, and comorbidities. Nevertheless, technological advancements in surgical techniques have largely counterweighed this critical scenario, and commonly, a non-pejorative trend has been reported in perioperative complications. The timeliest moment to start a medical treatment in LUTS/BPE patients is still undefined, and unexpectedly, peer-reviewed evidence remains scarce. Further studies are awaited to better discriminate patients who mostly benefit from early treatment of LUTS/BPE.

Patient centred care for the medical treatment of lower urinary tract symptoms in patients with benign prostatic obstruction: a key point to improve patients' care - a systematic review.

BACKGROUND: Even though evidence based medicine, guidelines and algorithms still represent the pillars of the management of chronic diseases (i.e: hypertension, diabetes mellitus), a patient centred approach has been recently proposed as a successful strategy, in particular to improve drug adherence. Aim of the present review is to evaluate the unmet needs in LUTS/BPH management and the possible impact of a patient centered approach in this setting. METHODS: A National Center for Biotechnology Information (NCBI) PubMed search for relevant articles published from January 2000 until December 2016 was performed by combining the following MESH terms: patients centred medicine, patient centered care, person centered care, patient centered outcomes, value based care, shared decision making, male, Lower Urinary Tract Symptoms, Benign Prostatic Hyperplasia, treatment. We followed the Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA). All studies reporting on patient centred approach, shared decision making and evidence-based medicine were included in the review. All original article, reviews, letters, congress abstracts, and editorials comments were included in the review. Studies reporting single case reports, experimental studies on animal models and studies not in English were not included in the review. RESULTS: Overall 751 abstracts were reviewed, out of them 87 full texts were analysed resulting in 36 papers included. The evidence summarised in this systematic review confirmed how a patient centred visit may improve patient's adherence to medication. Although a patient centred model has been rarely used in urology, management of Low Urinary Tract Symptoms (LUTS) and Benign Prostatic Obstruction (BPO) may represent the perfect ground to experiment and improve this approach. Notwithstanding all the innovations in LUTS/BPO medical treatment, the real life picture is far from ideal. CONCLUSIONS: Recent evidence shows a dramatical low drug adherence and satisfaction to medical treatment in LUTS/BPH patients. A patient centred approach may improve drug adherence and some unmet needs in this area, potentially reducing complications and costs. However further well designed studies are needed to confirm this data.

Moderate-to-high cardiovascular risk is associated with increased lower urinary tract storage symptoms in patients with benign prostatic enlargement.

BACKGROUND: To assess the association between cardiovascular risk (CVR) and lower urinary tract symptoms (LUTS) in men with benign prostatic enlargement (BPE). METHODS: We enrolled a consecutive series of men with LUTS/BPE. International Prostate Symptom Score (IPSS), voiding (vIPSS) and storage (sIPSS) subscore and prostate volume were evaluated. We defined CVR according to the European Association of Cardiologist Guidelines, and metabolic syndrome (MetS) according to the Adult Treatment Panel III (ATP III). RESULTS: A total of 509 patients were enrolled. Median age was 66 years (IQR: 60-72), IPSS 9 (IQR: 5-15), vIPSS 5 (IQR: 2-9), sIPSS 4 (IQR: 2-7), Prostate volume was 54 cc (IQR: 40-73). Overall 309/509 (60.7%) patients had a moderate/high CVR and 128/509 presented MetS (25.1%). 297/509 (58.3%) men had an IPSS>7 and 282/509 (55.4%) a sIPSS>3. Men with moderate-to-severe CVR had higher IPSS (9; IQR: 4-14 vs. 10; IQR: 5-16; P=0.01), higher vIPSS (6; IQR: 2-9 vs. 4; IQR: 2-8; P=0.06) and higher sIPSS (4; IQR: 2-8 vs. 3; IQR: 1-6; P=0.005) when compared with no/low CVR patients. On multivariate analysis CVR was associated with an increased risk of IPSS>7 (OR=1.794; 95% CI: 1.111-2.888; P=0.01) and sIPSS>3 (OR=1.593; 95% CI: 1.101-2.555; P=0.04). CONCLUSIONS: A moderate/high CVR is associated with an increased risk of LUTS, particularly storage LUTS. Although the pathophysiology is yet to be understood, it can be assumed that an increased CVR may be associated with LUTS/BPE presence.

Castration-resistance prostate cancer: what is in the pipeline?

INTRODUCTION: To evaluate the available evidence on the standard diagnosis and management of men with metastatic castration resistant prostate cancer (mCRPC), and providing the timely update on new pharmacological treatments. EVIDENCE ACQUISITION: A systematic literature search from from January 2000 until March 2017 was performed by combining the following MESH terms: castrate resistant prostate cancer, abiraterone, enzalutamide, 223radium, sipuleucel-T, docetaxel, cabazitaxel, resistance mechanisms, resistance to androgen deprivation, androgen receptor (AR) mutations, amplifications, splice variants, and AR alterations. We followed the Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA). EVIDENCE SYNTHESIS: In the few last years the introduction of new treatment modalities as abiraterone or enzalutamide have significantly change our prospective in mCRPC management increasing patients survival and quality of life. The standard imaging modalities to define the presence of regional or distant metastasis or the different resistant mechanisms to the available treatments are still an issue of debate, however several studies are ongoing to define the standard of care and to reduce treatments' resistance. Data from ongoing phase III trials are awaited to introduce in clinical new effective treatments that can be used in patients resistant to abiraterone/enzalutamide or more probably in a different phase of the disease. CONCLUSIONS: Castration resistant prostate cancer is now the key issue in prostate cancer management and research. Our challenge in the near future will be to identify the right treatment or better the right combination and sequencing of treatments that should be used in patients with mCRPC or even with advanced prostate cancer.

Can Long-term LUTS/BPH Pharmacological Treatment Alter the Outcomes of Surgical Intervention?

PURPOSE OF REVIEW: We have reviewed the available evidence on the impact of long-term pharmacological treatment of lower urinary tract symptoms on the outcomes of benign prostatic hyperplasia surgery. EVIDENCE ACQUISITION: A systematic literature search from January 1990 to May 2017 was performed. Only references in the English language and peer-reviewed manuscripts were considered. RECENT FINDINGS: Over time, the ever-increasing use of long-term pharmaceutical treatments has considerably reduced the rate of BPH surgery in most countries. In addition, patients undergoing surgery are now generally older, more fragile and with larger prostates. Nevertheless, progress in the surgical field may have compensated for this critical picture and no pejorative trend has been recorded in peri- and post-operative complications and functional outcomes. The question whether long-term pharmacological treatment has altered the outcomes of surgical interventions of BPH remains with no clear answer. The call for randomized studies of long-term pharmacological vs surgical treatment of lower urinary tract symptoms due to BPH pharmacological treatment remains valid.

Is early benign prostatic hyperplasia (BPH) treatment worthwhile?

BACKGROUND: The medical armamentaria for the treatment of lower urinary tract symptoms (LUTS) secondary to benign prostatic hyperplasia (BPH) have been extensively implemented over the past decade. Nevertheless, the timeliest moment for a possible treatment has not been fully established. EVIDENCE ACQUISITION: A systematic literature search in January 1996 until June 2016 was performed to answer the following question: in men with LUTS due to BPH, does early treatment result in better outcome? An ad hoc Population/patient Intervention/indicator Comparator/control Outcome (PICO) was developed.The Medline, PubMed and Scopus databases were searched. Each article title and abstract were reviewed for relevance and appropriateness with regard to the topic of this review. EVIDENCE SYNTHESIS: Overtime, the introduction of novel medications and the implementation of surgical techniques have significantly improved the treatment outcomes and markedly reduced the rate of BPH surgery. Early treatments in patients at risk of disease progression may result in better clinical outcomes than a delayed approach. However, the evidence to support early intervention remains weak and criteria to identify the patient phenotype that could best benefit from immediate treatment remain ill-defined.On the contrary, the patients who ultimately undergo surgery following prolonged pharmacological treatment present with larger prostates, older age and comorbidities. At the same time, the technological progress has partly compensated this critical scenario, and commonly, a nonpejorative trend has been recorded in perioperative complications. CONCLUSIONS: The ideal moment to begin a treatment in LUTS/BPH patients is still uncertain, and surprisingly, rare good quality studies are available on this topic.

Metabolic Syndrome Does Not Increase the Risk of Ejaculatory Dysfunction in Patients With Lower Urinary Tract Symptoms and Benign Prostatic Enlargement: An Italian Single-center Cohort Study.

OBJECTIVE: To evaluate the relationship between metabolic syndrome (MetS) and ejaculatory dysfunction (EjD) in patients with lower urinary tract symptoms and benign prostatic enlargement. MATERIALS AND METHODS: From 2012 to 2016, a consecutive series of men with lower urinary tract symptoms and benign prostatic enlargement who were attending our prostate clinic were evaluated using the International Prostate Symptom Score (IPSS) and were subsequently enrolled into a prospective database. All patients were assessed using the short form of the International Index of Erectile Function (IIEF-SF) and the Male Sexual Health Questionnaire ejaculatory dysfunction short form (MSHQ-EjD-SF) that evaluates the ability to ejaculate, the ejaculation force, the ejaculation volume, and subjective bother associated with EjD. MetS was defined according to the Adult Treatment Panel III criteria. RESULTS: A total of 220 patients were enrolled; 48 of 220 patients (22%) presented a MetS. Mean age was 70 ± 8 years, mean IPSS was 8.3 ± 6.2, mean IIEF score was 17.3 ± 7.9, and mean MSHQ-EjD-SF was 9.9 ± 4.7. Overall, 109 of 220 patients (50%) were affected by a moderate or severe EjD. On multivariate analysis, age (odds ratio [OR]: 1.058, 95% confidence interval [CI]: 1.016-1.123; P = .007), IIEF score (OR: 0.899, 95% CI: 0.856-0.943; P = .000), and IPSS (OR: 1.065, 95% CI: 1.011-1.123; P = .018) were found to be predictors of EjD. In our series MetS was not found to be predictive of EjD. CONCLUSION: In our single-center study, MetS has no influence on the EjD evaluated with the MSHQ-EjD-SF.

Clinical significance of intravesical prostatic protrusion in the management of benign prostatic enlargement: a systematic review and critical analysis of current evidence.

INTRODUCTION: Filling cystometry and pressure flow studies (PFS) are the most widespread used invasive urodynamic techniques in the assessment of male LUTS. However, these techniques are time- and cost-intensive. Intravesical prostatic protrusion (IPP) has been proposed as non-invasive method used to diagnose bladder outlet obstruction (BOO) in men with male lower urinary tract symptoms (LUTS). The purpose of the present review is to analyze the diagnostic and therapeutic relevance of IPP. EVIDENCE ACQUISITION: A comprehensive systematic MEDLINE search was performed for English language reports published before June 2016 using the term "intravesical prostatic protrusion." EVIDENCE SYNTHESIS: We identified 28 eligible original articles. Determination of IPP seems as useful method to predict BOO. The area under the curve of IPP for the prediction of BOO was found to range from 0.708 (95% CI: 0.615-0.791) to 0.858 (95% CI: 0.809-0.908). IPP seems to have a predictive role in a successful trial without catheter following acute urinary retention. The percentage of successful TWOC in patients with IPP>10 mm was reported at 13% and 18%, respectively, compared to a approximately 80% chance of successful trial in patients with IPP<10 mm. The impact of IPP on postoperative outcomes following surgery for benign prostatic enlargement seems controversial. The heterogeneity of the current studies, the potential intra-observer variability and the potential learning curve need to be taken into account. CONCLUSIONS: Analysis of IPP may be regarded as potential non-invasive alternative to standard PFS in the assessment of BOO. Patients with IPP>10 mm should be counseled regarding the high chance of need for surgical treatment following acute urinary retention.

Non-invasive ultrasound measurements in male patients with LUTS and benign prostatic obstruction: implication for diagnosis and treatment.

BACKGROUND: To evaluate the role of the ultrasound assessments of the bladder/detrusor wall thickness (BWT/DWT) and the ultrasound estimated bladder weight (UEBW) in lower urinary tract symptoms diagnosis and treatment. EVIDENCE ACQUISITION: A systematic literature search from January 1995 until February 2016 was performed on PubMed using the following terms: "bladder weight", "bladder wall thickness", "detrusor wall thickness", "LUTS", "bladder outlet obstruction" (BOO), "benign prostatic obstruction". Additional references were obtained from the reference list of full-text manuscripts. Abstracts presented at the annual congresses of the European Association of Urology, American Urology Association and the International Continence Society were also included. EVIDENCE SYNTHESIS: BWT and DWT are accurate predictors of BOO. Despite several differences in the technique assessment, population characteristics and study design, the BWT/DWT accuracy for BOO was close to 90%. Furthermore, the ultrasound evaluation of bladder/detrusor thickness correlates positively with symptoms score and the main clinical parameters in BPH patients. Lastly, BWT and DWT have proved to be optimal predictor of response to medical/surgical treatment of lower urinary tract symptoms/benign prostatic obstruction (LUTS/BPO). However, the lack of standardization among the available studies marks these methods promising but still experimental and further studies are needed to clarify the standard methodology. CONCLUSIONS: The ultrasound evaluation of bladder/detrusor thickness appears to be simple, highly accurate and non-invasive technique to predict BOO and to evaluate the clinical outcomes after medical/surgical treatments for LUTS/BPH. The implementation of these techniques and their standardization will probably better define their role in the diagnostic algorithms of patients with LUTS and possibly reduce the number of unnecessary pressure flow-studies.

Basic methods for the assessment of health-related quality of life in uro-oncological patients.

BACKGROUND: The evaluation of patients' expectations and quality of life in uro-oncology is considered an important outcome of treatment efficacy and satisfaction. Aim of this systematic review was to evaluate the most frequently adopted tools in uro-oncology to assess Health Related Quality of Life (HRQoL). EVIDENCE ACQUISITION: A systematic literature search until October 2015 was performed on MEDLINE, Cochrane Library, PubMed combining the following terms: "quality of life," "health-related quality of life," "kidney cancer," "bladder cancer," "prostate cancer." Additional references were obtained from the reference list of full-text manuscripts. Data were synthesized using meta-analytic methods conformed to the PRISMA statement. EVIDENCE SYNTHESIS: HRQoL is a fundamental step in evaluating treatment outcome in patients with urological cancers. HRQoL is mostly measured through several questionnaires, which are generally categorized in generic questionnaires, exploring the patient's well-being en bloc; specific questionnaires, assessing each single domain of health status; and uro-oncological specific questionnaires, mainly characterized by a modular approach. Although different questionnaires have been proposed and validated, the standard method to be adopted in urology is far from the solution and further studies should investigate the strength and weakness of the different questionnaires. CONCLUSIONS: HRQoL questionnaires should become a standard method to evaluate medical/surgical outcomes in uro-oncology. Their implementation may significantly improve patients' satisfaction and help physicians in the decision-making process and possibly reduce health care costs.

Detrusor overactivity increases bladder wall thickness in male patients: A urodynamic multicenter cohort study.

AIMS: To evaluate the role of Bladder wall thickness (BWT) as a predictor of Detrusor overactivity (DO) in patients with Lower urinary tract symptoms (LUTS)/Benign prostatic enlargement without Bladder Outlet Obstruction. METHODS: From January 1996 to December 2000, each new patient, aged 45 years or older with LUTS, underwent standard diagnostic assessment, urodynamic studies (cystometry and pressure flow studies), and ultrasound measurements of the bladder wall thickness (BWT) in two centers. In order to exclude the possible effect of benign prostatic obstruction (BPO) on detrusor thickness, patients with a Schaefer class was ≥2 were excluded from the study. The area under the receiver operating characteristics curve (AUC) quantified the predictive accuracy (PA) of BWT for the diagnosis of DO. RESULTS: Overall 195 patients were enrolled. DO was observed in 98/195 patients (50%). The BWT presented an AUC of 0.70; 95% CI: 0.62-0.77 for the diagnosis of DO. At the best cut-off value of 3.85 mm sensitivity was 73%; specificity was 59%; positive predictive value (64%, PPV). Negative predictive value (69%, NPV). CONCLUSIONS: Our study firstly showed, how BWT in male patients may be a consequence of DO other than BPO. Our finding, if confirmed in further studies, could limit the accuracy of BWT in patients with DO and BPO.

The influence of the medical treatment of LUTS on benign prostatic hyperplasia surgery: do we operate too late?

INTRODUCTION: The aim of this article is to systematically collect the available evidence on the influence of lower urinary tract symptoms (LUTS) medical treatment on benign prostatic hyperplasia (BPH) surgery. EVIDENCE ACQUISITION: A systematic literature search January 1990 until June 2016 was performed by combining the following MeSH terms: "lower urinary tract symptoms", "benign prostatic hyperplasia", "male", "medical treatment", "surgical treatment", "deferred/postponed treatment/intervention", "early intervention/treatment". Each article title and abstract was reviewed for relevance and appropriateness with regards to the topic of this review. EVIDENCE SYNTHESIS: The pharmacological treatment of LUTS is undoubtedly a successful story in the field of urology. Over the last two decades, the introduction of novel pharmaceutical agents has dramatically reduced the rate of BPH surgery interventions all over the world. Thus, nowadays, patients who undergo surgery are generally older, with more severe comorbidities and with larger prostates, theoretically requiring more challenging interventions. Nevertheless, the recent advances in surgical techniques and instruments have counterbalanced this unfavorable scenario and, overall, a non-pejorative trend has been observed in peri-/postoperative complications. On the other hand, evidence from the "pre-pharmacological-treatment era" suggested that immediate BPH surgery might be the best option for patients at risk of severe BPH progression. Still, no clear-cut, shared criteria have yet been established to effectively identify these patients. CONCLUSIONS: Several questions remain unanswered regarding the role of medical treatment in BPH, and good-quality studies available on this topic are surprisingly rare. The evidence presented in this review supports the need for prospective comparative studies evaluating long-term LUTS/BPH pharmacological treatment versus an early surgical intervention, particularly using the emerging laser technologies.

Inflammatory mediators in the development and progression of benign prostatic hyperplasia.

Benign prostatic hyperplasia (BPH) is the most common urological disease in elderly men. Epidemiological data suggest a causal link between this condition and prostatic inflammation. The prostate is an immune-competent organ characterized by the presence of a complex immune system. Several stimuli, including infectious agents, urinary reflux, metabolic syndrome, the ageing process, and autoimmune response, have been described as triggers for the dysregulation of the prostatic immune system via different molecular pathways involving the development of inflammatory infiltrates. From a pathophysiological standpoint, subsequent tissue damage and chronic tissue healing could result in the development of BPH nodules.