Management Patterns of Male Urethral Stricture Disease among Urologists: What Do the Guidelines Say? What Do Urologists Do?

BACKGROUND: The aim of the present study is to evaluate and analyze the daily clinical practice for male urethral stricture disease (MUSD) among urologists. METHODS: Considering the latest guidelines on urethral stricture disease, a survey was developed regarding the various treatment options and preferences in different sites of male urethral stricture disease. The survey was sent to urologists via e-mail and phone application. RESULTS: A total of 266 urologists completed the survey and were included in the final analysis. In regard to workplace, 62 (23.3%), 58 (21.8%), 71 (26.7%), and 75 (28.2%) respondents worked in university hospitals, training and research hospitals, state hospitals, and private practice hospitals, respectively. In regard to the diagnostic method used in male urethral strictures, 88.7% of the participants would choose uroflowmetry + postvoiding residual (UF + PVR), and 64.6% would choose retrograde urethrography (RUG). Direct vision internal urethrotomy (DVIU) was the most frequently chosen method in penile urethral strictures (PUS), being chosen by 72.9%. Direct vision anterior internal urethrotomy was the most common method for both ≤2 cm and >2 cm strictures, 63.1%, and 30.8%, respectively. The most preferred graft for augmentation urethroplasty was buccal mucosa (75.8%). Endoscopic incision/resection (transurethral resection (TUR)) is the most frequently applied treatment method for posterior urethral/vesicourethral anastomotic strictures (86.4%). CONCLUSIONS: The present study clearly shows that most urologists still prefer DVIU and urethral dilatation to urethroplasty in MUSD, which contradicts current guidelines. Urologists should be encouraged to perform urethroplasty and/or refer patients to experienced centres for recurrent MUSD.

Is endourological intervention a suitable treatment option in the management of iatrogenic thermal ureteral injury? A contemporary case series.

BACKGROUND: Iatrogenic ureteral injury (IUI) is relatively rare, however, can cause sepsis, kidney failure, and death. Most cases of IUI are not recognized until the patient presents with symptoms following pelvic surgery or radiotherapy. Recently, minimally invasive approaches have been used more frequently in the treatment of IUI. This study evaluates urological intervention success rates and long-term clinical outcomes according to the type of IUI following hysterectomy. METHODS: Twenty-seven patients who underwent surgery due to IUI in our clinic following hysterectomy were evaluated between January 2011 and April 2018. Patients were classified according to the time of diagnosis of IUI. The IUI cases diagnosed within the first 24 h following hysterectomy were designated as "immediate" IUI, while that diagnosed late period was considered 'delayed' IUI. The type of IUI was categorized as "cold transection" if it was due to surgical dissection or ligation without any thermal energy, and "thermal injury" if it was related to any energy-based surgical device. Patient information, laboratory and perioperative data, imaging studies, and complications were assessed retrospectively. RESULTS: All cases of delayed diagnosis IUI were secondary to laparoscopic hysterectomy (P = 0.041). Patients with thermal injury to the ureter were mostly diagnosed late (delayed) (P = 0.029). While 31% of the patients who underwent endourological intervention were diagnosed immediately, 69% of them were diagnosed as delayed. These rates were roughly reversed for open reconstructive surgery: 73% and 27% (P = 0.041), respectively. We detected eight ureteral complications in our patient cohort following the urological intervention. In all these failed cases, the cause of IUI was a thermal injury (P = 0.046) and the patients had received endourological treatment (P = 0.005). No complications were detected in patients who undergo open urological reconstructive surgery. While one of the patients who developed urological complications had an immediate diagnosis, seven were in the delayed group (P = 0.016). CONCLUSION: Endourological intervention is performed more frequently in delayed diagnosed IUI following hysterectomy, however, the treatment success rate is low if thermal damage has developed in the ureter. Surgical reconstruction is should be preferred in these thermal injury cases to avoid further ureter-related complications.

An evaluation of factors affecting pain during transrectal ultrasonographic prostate biopsy: a real-life scenario in a retrospective cohort study.

BACKGROUND: Periprostatic infiltration anesthesia (PPIA) and intrarectal topical anesthesia (IRTA) are recommended methods to control pain in transrectal ultrasonographic prostate biopsy (TRUS-Bx). This study evaluates the factors affecting pain during TRUS-Bx, considering the pathologies involved in anorectal pain etiology and comparing the effectiveness of local anesthesia techniques in providing patient comfort. MATERIAL AND METHODS: We retrospectively evaluated 477 consecutive patients with TRUS-Bx for elevated Prostate Specific Antigen (PSA), abnormal rectal examination findings, or both. Patients were grouped as local anesthesia methods for pain control during TRUS-Bx. Both groups were compared in terms of age, body mass index, clinical T stage, PSA, prostate volume, number of biopsy cores, type of anesthesia, previous biopsy history, and presence of prostate cancer. We used a visual analog pain scale (VAS) to evaluate the patient's pain status; pre-procedure (VAS-0), during probe insertion (VAS-I), administration of anesthetic (VAS-A), and simultaneous with the biopsy procedure itself (VAS-Bx). For PPIA and IRTA, 4 ml lidocaine 20 mg/ml injection and 5 g 5% prilocaine-5% lidocaine cream was used, respectively. RESULTS: The PPIA was used 74.2% (n = 354) and IRTA was used for 25.8% (n = 123) patients. VAS-0, VAS-I, and VAS-A scores are similar between groups. VAS-Bx was significantly higher in the IRTA than in the PPIA (3.37 ± 0.18 vs. 2.36 ± 0.12 p > 0.001). Clinical T stage (OR: 0.59), number of biopsy cores (OR: 1.80), and type of anesthesia application (OR: 2.65) were independent variables on TRUS-Bx for pain. CONCLUSION: Three factors play roles as independent variables associated with the pain in TRUS-Bx; abnormal rectal examination findings, collection of more than twelve core samples during the biopsy, and the type of anesthesia used. Compared with PPIA, IRTA does not improve pain related to probe insertion, and using IRTA results in higher pain scores for biopsy-related pain. Thus, we recommend a PPIA to lower biopsy-related pain.

Nation-wide analysis of the impact of Covid-19 pandemic on daily urology practice in Turkey.

OBJECTIVE: To present a nation-wide analysis of the workload of urology departments in Turkey week-by-week during Covid-19 pandemic. METHODOLOGY: The centres participating in the study were divided into three groups as tertiary referral centres, state hospitals and private practice hospitals. The number of outpatients, inpatients, daily interventions and urological surgeries were recorded prospectively between 9-March-2020 and 31-May-2020. All these variables were recorded for the same time interval of 2019 as well. The weekly change of the workload of urology during pandemic period was evaluated, also the workload of urology and the distributions of certain urological surgeries were compared between the pandemic period and the same time interval of the year 2019. RESULTS: A total of 51 centres participated in the study. The number of outpatients, inpatients, urological surgeries and daily interventions were found to be dramatically decreased by the 3rd week of pandemics in state hospitals and tertiary referral centres; however, the daily urological practice were similar in private practice hospitals throughout the pandemic period. When the workload of urology in pandemic period and the same time interval of the year 2019 were compared, a huge decrease was observed in all variables during pandemic period. However, temporary measures like ureteral stenting, nephrostomy placement and percutaneous cystostomy have been found to increase during Covid-19 pandemic compared with normal life. CONCLUSIONS: Covid-19 pandemic significantly affected the routine daily urological practice likewise other subspecialties and priority was given to emergent and non-deferrable surgeries by urologists in concordance with published clinical guidelines.

Prognostic influence of 5 alpha reductase inhibitors in patients with localized prostate cancer under active surveillance.

OBJECTIVE: The incidence of prostate adenocarcinoma (PCa) is increased with the use of prostate-specific antigen (PSA). In the current study, we aimed to investigate the impact of 5- alpha- reductase inhibitors (5-ARI) on pathological progression in patients followed by active surveillance (AS). MATERIAL AND METHODS: Records of 69 patients with localized prostate cancer under AS (PSA ≤15 ng/mL, PSAD ≤0.20, ≤cT2c, Gleason sum ≤3+3, the number of cancer positive cores ≤3) were evaluated retrospectively. Patients were followed-up with quarterly PSA testing and semiannual digital rectal examination during the first 2 years, and semiannual PSA testing thereafter. Repeat biopsies were done annually and whenever indicated by clinical findings. Pathological progression was defined as increasing Gleason grade, number of cancer-positive cores, and/or increasing percentage of cancer in any core. RESULTS: Patients using (29/69: 42%) and not using (40/69: 58%) 5-ARI were followed for a median of 39 (IQR: 23-45) and 23.5 (IQR: 17-37.5) months, respectively. Pathological progression was observed in 32% (22/69) of the patients at a median of 25 (IQR: 18-39) months. Pathological progression was observed in 34.5% (10/29) and 30% (12/40) of the patients using and not using 5-ARI, respectively (Log-rank p=0.4151). Definitive treatment was done in 31% (9/29) and 47.5% (19/40) of the patients using and not using 5-ARI, respectively. Patients who did not use 5-ARI received definitive treatment earlier than 5-ARI users (Log-rank p=0.0342). On multivariate analysis, more than 2 cancer-positive cores (HR: 11.62) and age (HR: 0.94) were independently associated with pathological progression (p<0.05), rather than 5-ARI use (p=0.148). CONCLUSION: More than 2 cancer- positive cores at the initial biopsy was the strongest covariate associated with pathological progression; these patients should not be offered AS. There was no impact of 5-ARI use on pathological progression in AS.

Comparison between Retroperitoneal and Transperitoneal Approaches in the Laparoscopic Treatment of Bosniak Type I Renal Cysts: A Retrospective Study.

PURPOSE: We retrospectively compared laparoscopic transperitoneal and retroperitoneal approaches for the decor­tication of simple renal cysts with respect to safety, postoperative pain, and clinical results. MATERIALS AND METHODS: The study included 40 patients (28 males and 12 females) with symptomatic simple renal cysts and who underwent laparoscopic cyst decortication, and they were evaluated retrospectively. Patients' age, gender, disease-specific history, comorbid disease and family history, in general and urological and phys­ical examination findings were recorded. Patients prior to surgery were evaluated by urinalysis, serum creati­nine level, blood count, urinary tract ultrasonography, and unenhanced and contrast-enhanced abdominal com­puted tomography. Patients were informed about laparoscopic surgery and their written informed consent was taken. For those who preferred the laparoscopic approach, the placement of the cyst, history of prior surgery and obesity were evaluated. All patients filled out the visual analog scale (VAS) to evaluate postoperative pain. RESULTS: The mean age of the patients were 54.65 ± 5.26 years in the retroperitoneal group and 56.0 ± 4.66 years in the transperitoneal group. For all patients the indication for surgery included right or left flank pain. The mean operative time for the transperitoneal approach was 51.5 min., and that for the retroperitoneal approach was 44.75 min. This difference was statistically significant between the two groups (P < .05). According to VAS scale, the retroperitoneal scoring method was found to be lower than the transperitoneal scoring method. All patients were discharged on the first postoperative day, and the drains were taken out. None of the patients had complications. At the end of six months, no clinical and radiological recurrence was detected in any patient. CONCLUSION: We consider the retroperitoneal approach to be the first-choice because of its shorter operation time and particularly low level of postoperative pain.

Internal urethrotomy versus plasmakinetic energy for surgical treatment of urethral stricture.

PURPOSE: we aimed to compare the longterm outcome of surgical treatment of urethral stricture with the internal urethrotomy and plasmakinetic energy. MATERIAL AND METHODS: 60 patients, who have been operated due to urethral stricture were enrolled in our clinic. None of the patients had a medical history of urethral stricture. The urethral strictures were diagnosed by clinical history, uroflowmetry, ultrasonography and urethrography. The patients were divided two groups. Group 1 consisted of 30 patients treated with plasmakinetic urethrotomy and group 2 comprised 30 men treated with cold knife urethrotomy. RESULTS: There were no statistically significant differences between two groups in terms of patient age, maximum flow rate (Qmax) and quality of life score (Qol) value. A statistical difference between the two groups was observed when we compared the 3rd-month uroflowmetry results. Group 1 patients had a mean postoperative Qmax value of 16,1 ± 2,3 ml/s, whereas group 2 had a mean postoperative Qmax value of 15,1 ± 2,2 ml/s (p < 0.05). In the cold knife group, 3 of 11 (27,7%) recurrences appeared within the first 3 months, whereas in the plasmakinetic group zero recurrences appeared within the first 3 months in our study. The urethral stricture recurrence rate up to the 12 month period was statistically significant for group 1 (n = 7, 23%) compared with group 2 (n = 11, 37%) (p < 0.05). CONCLUSION: We believe that plasmakinetic surgery is better method than the cold knife technique for the treatment of urethral stricture.