Effect of COVID-19-related lockdown on functional urology practice and patient care in Gulf Cooperation Council region.

BACKGROUND: This survey was designed and conducted during the lockdown period to assess its effect on urology practice dealing with patients with voiding dysfunction and their care in the Gulf Cooperation Council (GCC) region. METHODS: An online survey was sent across to urologists managing patients with voiding dysfunction in countries of the GCC region through various social media platforms. All valid responses were tabulated and analyzed. RESULTS: A total of 202 responses were received. Higher proportion of urologists in private sector (98.2%) were treating patients in comparison to those in public or governmental hospitals (82.7%); (P = 0.007). Telemedicine was used by 72% of the respondents. Telephone calls were preferred With regard to perception of risk while examining patients, 65% of the respondents felt that their risk was equal to other specialties. Their preferred prevention strategy would be pre-operative screening. Financial impact affected only 10% claimed major catastrophic effect. There was a significant difference between private and public government urology services provided, with a higher proportion of patients seen, operations performed, fees charged for telemedicine, and financial effect in the private sector with P = 0.012, P = 0.037, P = 0.004, and P = 0.001, respectively. CONCLUSION: Our survey showed that majority of urologists in the GCC region were seeing patients during COVID-19 lockdown. Emergency services were prioritized. A large proportion of urologists had switched over to telephonic communication. Most of the responding urologists were uncertain about when and how to resume surgical procedures upon easing of the COVID-19-related restrictions.

Breaking the Ice of Erectile Dysfunction Taboo: A Focus on Clinician-Patient Communication.

Erectile dysfunction is a common yet complex problem facing men and their partners worldwide. It continues to be an under reported issue despites its high prevalence and negative impact as well as the availability of successful treatment. One of the main reasons for such a problem is the stigma surrounding it as a complaint and the deep-seated fear to discuss it. This paper aims to highlight the reasons behind the taboo and dilemma behind erectile dysfunction reporting and discusses means to overcome this stigma focusing on clinician-patient communication.

Association of endometriosis with interstitial cystitis in chronic pelvic pain syndrome: Short narrative on prevalence, diagnostic limitations, and clinical implications.

INTRODUCTION: Chronic pelvic pain (CPP) is a diagnostic and therapeutic challenge affecting women of all ages globally. The syndrome is not well understood, but the association of interstitial cystitis (IC) with endometriosis in causing CPP should not be overlooked in managing this cohort. Herein, we present a mini review of this association to evaluate the literature in determining the prevalence of endometriosis and IC concomitantly in patients with CPP, diagnostic limitations, and clinical implications. METHODS: A Medline search of the key words "evil twins' syndrome," "interstitial cystitis," "bladder pain syndrome," and "endometriosis" was conducted for full-text articles published in English over the past 20 years. The search yielded 40 articles, of which 21 were selected. Cross-referencing bibliographies of each publication yielded an additional 25 references. RESULTS: Both endometriosis and IC share a similar array of symptoms that are often exacerbated during the perimenstrual period. Multiple authors have reported the frequent coexistence of these two conditions. Over 80% of patients with CPP were found to have both conditions. The prevalence of endometriosis and IC coexistence was greater than that of each condition separately. CONCLUSIONS: It is crucial to look beyond the traditionally diagnosed endometriosis as the cause of CPP. This is true especially in patients whose previous treatment was ineffective. Simultaneous assessment for both conditions is essential to avoid the frequently delayed diagnosis and prevent unsuccessful medical and surgical therapies.

Salvage of a perfectly functioning sacral neuromodulation device (InterStim™) with asymptomatic tined lead wire skin exposure.

Sacral neuromodulation is a minimally invasive option to manage voiding dysfunction that is refractory to conservative measures and oral pharmacotherapy. The technique involves implantation of a sacral tined lead that is connected to a pulse generator to modulate the pelvic area. The procedure is carried out over two stages. Surgical explantation of the entire device with debridement of the infected tissue is recommended in instances of infection. Nevertheless, solid reports about management of device infections or skin erosions are lacking. Thus, I present a case of a tined lead wire skin exposure in a perfectly functioning device that was salvaged with surgical reposition without complications.

Parecoxib Vs Paracetamol for Treatment of Acute Renal Colic Due to Ureteric Calculi: A Randomized Controlled Trial.

OBJECTIVE: To compare efficacy and safety of parecoxib and paracetamol for treatment of acute renal colic due to ureteric stones. MATERIALS AND METHODS: A randomized, double blinded, controlled trial included adult patients presented to emergency department with acute renal colic due to ureteric calculi between June 2019 and August 2020. Patients with hypersensitivity to either drug, peptic ulcer, coronary ischemia, peripheral vascular or cerebrovascular disease, hepatic impairment (Child-Pugh score >10) or chronic kidney disease stage 4 or 5 were excluded. Eligible patients were randomized to group 1 who received 1g intravenous Paracetamol infusion or group 2 who received 40mg intravenous Parecoxib infusion. Pain analogue score was evaluated before treatment and 30 minutes afterwards. The primary endpoint was the need for rescue analgesia for persistent pain. Safety was evaluated by the incidence of adverse events. RESULTS: The study included 203 patients (102 in group 1 and 101 in group 2). Pretreatment patients' data were comparable for both groups. The mean pain analogue score decrease from 7.6 to 3.8 in paracetamol group (P <.001) and from 7.8 to 3.4 in parecoxib group (P <.001). Rescue analgesia were needed in 36 patients (35.3%) in paracetamol group and 27 patients (26.7%) in parecoxib group (P = .187). Minor adverse events developed in 2 patients (2%) in paracetamol group and 3 patients (3%) in parecoxib group (P=0.683). CONCLUSION: Paracetamol and Parecoxib were effective for treatment for patient with acute renal colic. Both treatments showed comparable results in reduction of pain and need for rescue analgesia with minimal adverse events.

Development and validation of a score for emergency intervention in patients with acute renal colic secondary to ureteric stones.

Objectives: To develop and validate a scoring system to assess the need for emergency intervention (EI) in patients with uncomplicated acute renal colic (ARC) due to ureteric stones. Patients and methods: From May 2017 to April 2019, 382 adult patients presented to emergency department with ARC due to ureteral stones diagnosed by non-contrast computed tomography. Patients with solitary kidney, complications secondary to obstruction (intractable vomiting, fever or sepsis), bilateral ureteric stones, Stage ≥3 chronic kidney disease or those who underwent treatment of urolithiasis within the past 6 months were excluded. EI was performed in cases with persistent or recurrent pain despite analgesics. Multivariate analysis was performed for the first 200 patients to detect risk factors for EI. The score was developed from significant factors. Sensitivity and specificity of the ARC score were calculated using receiver operator characteristic (ROC) curve analysis. The data of last 182 patients were used for validation of the score. Results: In the first 200 patients, EI was needed in 119 patients (59.5%) and included ureteric stents in 92, ureteroscopy in 25 and percutaneous nephrostomy in two. Significant factors for EI were stone location (relative risk [RR] 3.34, P = 0.026), creatinine level (RR 1.04, P < 0.001), leucocyte count (RR 1.69, P < 0.001), and stone length (RR 1.85, P < 0.001). A score using these four variables was developed. The ARC score sensitivity was 86%, specificity was 80% and the area under the ROC curve was 0.902. Validation of the score showed strong correlation between ARC score and need for EI (r = 0.788, P < 0.001). Conclusions: The ARC score is a validated, highly sensitive and specific novel score to determine the need for EI in patients with uncomplicated ARC secondary to ureteric stones. Abbreviations: ARC: acute renal colic; AUC: area under the ROC curve; CDR: clinical decision rules; CKD: chronic kidney disease; ED: emergency department; EI: emergency intervention; MET: medical expulsive therapy; NCCT: non-contrast CT; PCNL, percutaneous nephrolithotomy; ROC: receiver operator characteristic; S.T.O.N.E.: stone size (S), tract length (T), obstruction (O), number of involved calyces (N), and essence or stone density (E); SWL: extracorporeal shockwave lithotripsy; URS: ureteroscopy; WBC: white blood cell.

Emergency vs elective ureteroscopy for a single ureteric stone.

OBJECTIVE: To compare emergency with elective ureteroscopy (URS) for the treatment of a single ureteric stone. PATIENTS AND METHODS: The files of adult patients with a single ureteric stone were retrospectively reviewed. Patients with fever or turbid urine on passage of the guidewire beside the stone underwent ureteric stenting or nephrostomy drainage. Patients who underwent URS were included and divided into two groups: the emergency (EM) Group, those who presented with persistent renal colic and underwent emergency URS within 24 h; and the elective (EL) Group, who underwent elective URS after ≥14 days of diagnosis. Patients with ureteric stents were excluded. The technique for URS was the same in both groups. Safety was defined as absence of complications. Efficacy was defined as the stone-free rate after a single URS session. RESULTS: From March 2015 to September 2018, 179 patients (107 in the EM Group and 72 in the EL Group) were included. There were significantly more hydronephrosis and smaller stones in the EM Group (P = 0.002 and P = 0.001, respectively). Laser disintegration was needed in more patients in the EL Group (83% vs 68%, P = 0.023). Post-URS ureteric stents were inserted in more patients in the EM Group (91% vs 72%, P = 0.001). Complications were comparable for both groups (4.2% for EL and 5.6% for EM, P = 0.665). Stone-free rates were also comparable (93% in the EL Group and 96% in the EM Group, P = 0.336). CONCLUSIONS: Emergency URS can be as safe and effective as elective URS for the treatment of a single ureteric stone if it is performed in patients without fever or turbid urine.Abbreviations: EL Group: elective group; EM Group: emergency group; KUB: plain abdominal radiograph of the kidneys, ureters and bladder; MET: medical expulsive therapy; NCCT: non-contrast CT; SFR: stone-free rate; SWL: shockwave lithotripsy; URS: ureteroscopy.

Infected penile prosthesis: literature review highlighting the status quo of prevention and management.

INTRODUCTION: Erectile dysfunction affects over 50% of men 70 years and above, and penile prosthesis (PP) is its third-line treatment. Complications of PPs include infection, however, no formal guidelines exist for its management. METHODS: We performed a literature search and reviewed 53 recent published literatures of experiences with management of PP infections, prevention, and treatment. RESULTS: Acute infection can present early with pain and discharge and detection of early signs is of utmost importance. MRI studies are more sensitive than CT studies to diagnose and plan surgical intervention. Introduction of antibiotic impregnated devices attributed to the reduction of infection rates with superiority proven for certain types; the no-touch technique had further reduced this rate. The Mulcahy salvage remains the most widely used surgical approach for treatment despite modifications and novel techniques described; conservative management of PP infections is recently reported with promising results. CONCLUSIONS: Despite absence of strict guidelines for the management of infected PPs, we reviewed and discussed numerous panel opinions and suggestions throughout literature. More research into the pathology, prevention, conservative management and advances in surgical treatment of this condition are called for to produce guidelines that unite the efforts to tackle these infections.

Dusting versus fragmentation for renal stones during flexible ureteroscopy.

Objectives: To compare stone dusting and spontaneous passage vs fragmentation and active fragment retrieval during flexible ureteroscopy (fURS) for renal calculi. Patients and methods: The study included patients who underwent fURS and holmium laser lithotripsy for renal calculi from January 2015 to March 2017. Dusting was done using low energy and high frequency (0.3-0.5 J and 15-20 Hz, respectively), and fragmentation was done with higher energy and lower frequency (1-1.2 J and 6-10 Hz, respectively) and then stone fragments were extracted using a basket. The stone-free rate (SFR) was evaluated after 2 months with non-contrast computed tomography. Operative time, complication rate, SFR, and the need for secondary procedures were compared. Results: The study included 107 consecutive patients, with a mean (SD) age of 49 (13) years. Dusting was performed in 51 patients and fragmentation in 56. The patients' demographics, laboratory tests, preoperative stents, stone and renal characteristics were comparable for both groups. Operative time was significantly shorter for dusting than fragmentation (76 vs 91 min, P = 0.009). Complication rates were comparable between the groups (7.8% for dusting and 8.9% for fragmentation, P = 0.840). The mean hospital stay was comparable for both groups (P = 0.686). The SFR was significantly better in fragmentation group (78.6%) compared with the dusting group (58.6%, P = 0.035). The need for a secondary procedure was 33.3% in the dusting group and 23.3% in fragmentation group (P = 0.244). Conclusions: During fURS for renal stones, the dusting technique had a significantly shorter operation time, whilst the fragmentation technique led to a significantly better SFR. Both techniques have comparable safety, hospital stay, and requirement for secondary procedures. Abbreviations: fURS: flexible ureteroscopy/ureteroscope; ICU: intensive care unit; KUB: plain abdominal radiograph of the kidney, ureter and bladder; NCCT: non-contrast CT; SFR: stone-free rate; SWL: shockwave lithotripsy; UAS: ureteric access sheath.

Right Testicular Infarction Secondary to Spontaneous Testicular Vein Thrombosis in a Child: Case Report and Literature Review.

OBJECTIVES: To describe a case of right testicular vein thrombosis in a child and to review the literature describing similar cases and their management. METHODS: An extensive literature review of the English language literature was conducted using the following databases: PubMed, ScienceDirect and Google Scholar. RESULTS: Six cases were reported previously and summarized in this article. CONCLUSION: A 14-year-old boy who suffered from spontaneous right testicular vein thrombosis was treated with right orchiectomy and oral anticoagulation. We also reviewed and summarized the previously described cases of pediatric testicular vein thrombosis.

Validation of the Arabic linguistic version of the 8-item overactive bladder questionnaire (OAB-V8).

INTRODUCTION AND HYPOTHESIS: This study aimed to translate and validate the 8-item overactive bladder questionnaire (OAB-V8). METHODS: Utilizing a multistep process, the English version of the OAB-V8 was translated into Arabic by three urologists and one independent translator. It was validated by asking 46 patients with overactive bladder and 58 healthy individuals to complete the questionnaire. Healthy individuals were involved in establishing the discrimination validity. The scores of both groups were compared using the Mann-Whitney test. The reliability of the Arabic version was evaluated utilizing Cronbach's alpha test for internal consistency. Spearman's correlation coefficient (r) was utilized to evaluate the domain structures and the inter-domain associations. RESULTS: Internal consistency was high (Cronbach's alpha = 0.923). There were good correlations among frequency, urgency, sudden urge to urinate, waking up at night to urinate and uncontrollable urge to urinate. There were weak or no correlations among urge, incontinence and nocturia. For discrimination validity, there were significant changes in all domain scores when comparing patients with ureteric stents and healthy individuals (P < 0.001). CONCLUSIONS: The Arabic version of the OAB-V8 proved to be a reliable and valid tool, which can be easily utilized to evaluate symptoms in Arabic patients. It is feasible in evaluating quality of life in relation to this disorder, as patients are able to demonstrate their symptoms accurately with the comfort of their first language, Arabic.

Does Psychological Disturbance Predict Explantation in Successful Pelvic Neuromodulation Treatment for Bladder Dysfunction? A Short Series.

INTRODUCTION: Sacral neuromodulation (SNM) is a safe and effective therapy for patients with lower urinary tract dysfunction (LUTD). It is used in patients who have exhausted conservative and first line therapeutic options. The selection of eligible candidates could predict a successful therapeutic outcome. Although many factors have been identified, psychological/psychiatric disturbances are neither well understood nor are routinely evaluated prior to implantation. CASE REPORTS: We report three cases where identified psychological/psychiatric disturbances post-implantation could have influenced explantation in an otherwise successful implantation of SNM device assessed both subjectively and objectively. The device had to be explanted in two of the three. One more patient has requested but has not-yet undergone explantation and is receiving treatment for severe depression. One of the explanted cases has successfully undergone re-implantation after successful treatment of her diagnosed psychological condition, while the other's request for re-implantation has not yet been fulfilled. CONCLUSIONS: Psychological/psychiatric disturbance have possibly affected the treatment outcome and explantation of SNM in our patients despite a high success in resolution of the urinary symptoms. Addressing such disturbances when determining patient eligibility for SNM therapy could reduce the explantation rate after a successful therapeutic response, and is an interesting point of interest for future research into predictors of successful SNM implantation and therapy.

Safety of Sacral Nerve Stimulation in Pregnancy: A Literature Review.

OBJECTIVES: Sacral nerve stimulation (SNS) is an FDA approved intervention for a spectrum of conditions. Women of childbearing age and those who are pregnant constitute a fair number of sufferers of overactive bladder symptoms and nonobstructive urinary retention; however, hypothesized effects of SNS on the fetus, mother, and the device limit its use in such a group of patients. We present a literature review to support possible safety of SNS in pregnancy. MATERIALS AND METHODS: We reviewed a number of animal studies on effects of neuromodulation on myometrial activity and fetal abnormalities, and several case reports and series describing continued SNS as well as other related modes of neuromodulation during gestation and reported effects on the mother, fetus, and device. RESULTS: Studies on female mammals showed neurostimulation of myometrial tissue aided in embryo transfer and increased latency, evidence against inducing preterm labor, and follow-up of pregnant rats showed no effects on mothers or offspring. Reviewed cases adopted interrupted and uninterrupted courses of SNS until delivery. There were almost no pregnancy complications; infants were healthy at birth, delivered electively by Caesarean section close to term. One follow-up of 2 infants reported some health issues, though SNS was not concluded as a cause. Device replacement after delivery was occasionally performed for different reasons. CONCLUSION: No negative effects of SNS on fetus, mother or device were significantly reported in literature. Further studies expanding on data in the literature could place SNS therapy during pregnancy on the way for declaration as a safe practice.

Pharmacological treatment of pure stress urinary incontinence: a narrative review.

INTRODUCTION AND HYPOTHESIS: Treatment escalation from conservative directly to surgical in the management of pure stress urinary incontinence (SUI) reveals a gap for effective pharmacological treatments. The introduction of a drug therapy would fill this gap and widen the treatment options. Nevertheless, various pharmaceutical agents have been used off-label and are being investigated and becoming more widely available. In this review, we examined the latest published data regarding pharmacotherapy used in the treatment of SUI. METHODS: We performed a literature review to evaluate the relevant studies pertaining to any pharmacotherapy used in the management of SUI, examining the English language literature. RESULTS: Currently, no drug exists that is approved by the food and drug administration for the management of SUI. A few oral pharmacological agents are occasionally used off-label. Lack of proven efficacy and high incidence of bothersome side effects of these agents limit their use. Duloxetine, a serotonin norepinephrine reuptake inhibitor, represents a major therapeutic advance for the treatment of SUI based on findings from a number of controlled clinical trials. CONCLUSIONS: Several pharmacological agents have been used off-label and investigated for safety and efficacy, but none has demonstrated sufficient effectiveness to receive widespread verification for its use in the treatment of SUI.

Intradetrusor injection of botulinum toxin for the management of refractory overactive bladder syndrome: an update.

Overactive bladder (OAB) is a common syndrome that has a negative impact on daily activities and quality of life. The first-line treatment to manage this condition includes behavioral modifications, physical treatment, and oral pharmacotherapy with antimuscarinics. Botulinum toxin has emerged as an alternative and second-line treatment option for patients with OAB who are refractory to first-line treatment modalities when injected into the detrusor muscle. Although its application in the management of OAB remains off label, studies have shown its efficacy both subjectively and objectively. It is considered as a minimally invasive and reversible alternative. Adequate dosage of the toxin, number of injection sites, and reinjection rates are yet to be determined. This review attempts to provide an update on the current position of botulinum toxin in managing refractory OAB addressing contemporary data on the mechanism of action, technique, safety, complications, and clinical results.