The headache of the post transurethral prostate surgery pyuria: Pursuit for evidence.

• Objective To prospectively assess early post-TUPS (transurethral prostate surgery) urinalysis changes and bacteriuria with its clinical relevance. • Methods Patients with BPO enrolled for TUPS were prospectively assessed. Patients were assessed at 2, 4, 8, 12, and 24-weeks postoperatively by DVAS (dysuria-visual-analogue-scale), IPSS-QOL, uroflow, and PVR. Routine urinalysis was performed before discharge and at all visits. MSUC (midstream urine culture) was performed before discharge, 4 and 12-weeks postoperatively. • Results At final analysis 152 patients were evaluable. Significant pyuria was reported in 52%, 96.1%, 94.1%, 71.7%, 78.9% and 52.5% in before discharge, 2-, 4-, 8-, 12-, and 24-weeks urinalysis postoperative respectively. The mean time to non-significant-pyuria (95%CI) was 19.1(17.5-20.7), 20.1(17.3-22.9), 15.8(12.8-18.8) and 14(10.3-17.8) weeks after prostate resection, vaporization, enucleation, and incision respectively, (P0.03). Regardless of the TUPS technique, half of the patients had significant pyuria at 24-weeks postoperative. MSUC was positive in 37/152(24.3%), 3/152(2%), 23/152(15.1%), and 5/152(3.3%) preoperatively, before discharge, 4 and 12-weeks postoperative respectively. Only positive preoperative urine leucocyte esterase independently predicted positive 4-weeks MSUC (OR3.8, 95%CI1.3-11.1, P0.013). No significant correlation was found between IPSS or DVAS and positive MSUC nor between IPSS and postoperative pyuria at different follow-up points (P>0.05). However, the degree of postoperative dysuria was significantly correlated with postoperative pyuria count by urinalysis at 2-Weeks (r0.69, P0.03), 8-Weeks (r0.26, P0.001) and 12-Weeks (r0.23, P0.004). • Conclusion There is a persistent but gradually declining pyuria and microhematuria following TUPS up to 6 months postoperative. An earlier resolution was noted following prostate incision and enucleation. While routine urine analyses screening in these months would be of no clear clinical value, a routine urine culture would be of a reasonable significance at 1 month post-operatively.

Could the bulbar urethral end location on the cystourethrogram predict the outcome after posterior urethroplasty for pelvic fracture urethral injury?

Objectives: To identify cystourethrogram (CUG) findings that independently predict the outcome of posterior urethroplasty (PU) following pelvic fracture urethral injury (PFUI). Methods: Findings of CUG included the location of the proximal end of the bulbar urethra in zones A (superficial) or B (deep) according to its relationship with the pubic arch. Others included the presence of pelvic arch fracture, bladder neck, and posterior urethral appearance. The primary outcome was the need for reintervention either endoscopically or by redo urethroplasty. Independent predictors were modeled using a logistic regression model and a nomogram was constructed and internally validated using 100-bootstrap resampling. Time-to-event analysis was performed to validate the results. Results: A total of 196 procedures in 158 patients were analyzed. The success rate was 83.7% with 32 (16.3%) procedures requiring direct vision internal urethrotomy, urethroplasty, or both in 13 (6.6%), 12 (6.1%), and 7 (3.6%) patients, respectively. On multivariate analysis, bulbar urethral end located at zone B (odds ratio [OR]: 3.1; 95% confidence interval [CI]: 1.1-8.5; p = 0.02), pubic arch fracture (OR: 3.9; 95%CI: 1.5-9.7; p = 0.003), and previous urethroplasty (OR: 4.2; 95% CI: 1.8-10.1; p = 0.001) were independent predictors. The same predictors were significant in the time-to-event analysis. The nomogram discrimination was 77.3% and 75% in the current data and after validation. Conclusions: The location of the proximal end of the bulbar urethra and redo urethroplasty could predict the need for reintervention after PU for PFUI. The nomogram could be used preoperatively for patient counseling and procedure planning.

Does immunohistochemical staining of P53, Ki 67 and cyclin A accurately predict Wilms tumor recurrence and survival?

Objective: To evaluate whether p53, cyclin A and ki67 immunohistochemical (IHC) assay can be used as predictors for Wilms' tumor (WT) unfavorable outcomes. Methods: It is a non-concurrent cohort study including patients who underwent nephrectomy for WT from January 2000 to December 2015 in a tertiary referral center. Over a 5- year follow-up, unfavorable events, including relapse and cancer-specific mortality (CSM), were recorded. P53, cyclin A, and ki67 IHC assay were carried out for formalin-fixed paraffin-embedded WT samples. Results: After excluding those who did not meet the inclusion criteria, 75 patients were enrolled. Of the patients, 15/75 (20%) experienced WT relapse while 11/75 (14.6%) died of WT over five years. Unfavorable histology (UFH), including prominent blastemal components and anaplasia, was found in 15/75 (20%) children.Cyclin A immunopositivity was associated with high rates of relapse and CSM. P53 and ki67 positive IHC assay did not show any statistically significant association with unfavorable outcomes. Other risk factors e.g. advanced staging, UFH, extracapsular extension, tumor rupture, lymphadenopathy, and venous thrombosis were not associated with poor prognosis. However, the presence of residual tumors was accompanied by lower survival rates. Conclusion: Cyclin A IHC assay can be used as a predictor of WT recurrence and CSM. Further studies with prospective patterns and a larger sample size are needed.Abbreviations: WT: Wilms' tumor, UFH: unfavorable histology, IHC: immunohistochemical, PI: proliferation index, RFS: relapse-free survival, CSS: cancer-specific survival, FH: favorable histology, CSM: cancer-specific mortality, CDK: cyclin-dependent kinase.

Randomised trial of bipolar resection vs holmium laser enucleation vs Greenlight laser vapo-enucleation of the prostate for treatment of large benign prostate obstruction: 3-years outcomes.

OBJECTIVE: To compare transurethral resection in saline (TURIS), Greenlight laser vapo-enucleation of the prostate (GL.PVEP), and holmium laser enucleation of the prostate (HoLEP), for controlling lower urinary tract symptoms secondary to large benign prostatic hyperplasia (BPH) and to assess non-inferiority of 3-year re-treatment rates. PATIENTS AND METHODS: Eligible patients with BPH (prostate size 80-150 mL) were randomly assigned to one of the intervention groups. Non-inferiority of re-treatment rate was evaluated using a one-sided test at 5% level of significance. RESULTS: At the time of analysis, 60 GL.PVEP, 60 HoLEP and 62 TURIS procedures were included. Perioperative parameters were comparable between groups; however, the operative time was longer in GL.PVEP vs HoLEP and TURIS, at a mean (SD) of 92 (32) vs 73 (30) and 83 (28) min (P = 0.005); and was less effective with a mean (SD) removal of 1.2 (0.4) vs 1.7 (0.7) and 1.4 (0.6) g/min (P < 0.001), respectively. Perioperative complications and need for auxiliary procedures were similar in the three groups; however, there was a significantly higher rate of capsular perforation in TURIS group (five, 8%) compared to one (1.6%) in the GL.PVEP group and none in the HoLEP group (P = 0.01). There was a significantly longer hospital stay, catheter-time and higher rate of blood transfusion in the TURIS group. There was significant but comparable improvements in the International Prostate Symptom Score in three groups at different follow-up points. At 3 years, re-treatment for recurrent bladder outlet obstruction was required more after GL.PVEP and TURIS. More re-do surgeries for recurrent obstructing prostate adenoma was reported after GL.PVEP (four, 6.7%) and TURIS (six, 9.7%) than for HoLEP (none) (P = 0.04). CONCLUSION: The perioperative outcomes of GL.PVEP and HoLEP surpassed that of TURIS for the treatment of large prostates, but with a significantly prolonged operative time with GL.PVEP. The three techniques achieve good functional outcomes; however, 3-year re-treatment rates following TURIS and GL.PVEP were inferior to HoLEP.

A randomized trial comparing bipolar transurethral vaporization of the prostate with GreenLight laser (xps-180watt) photoselective vaporization of the prostate for treatment of small to moderate benign prostatic obstruction: outcomes after 2 years.

OBJECTIVE: To test the non-inferiority of bipolar transurethral vaporization of the prostate (TUVP) compared to GreenLight laser (GL) photoselective vaporization of the prostate (PVP) for reduction of benign prostatic hyperplasia-related lower urinary tract symptoms in a randomized trial. METHODS: Eligible patients with prostate volumes of 30-80 mL were randomly allocated to GL-PVP (n = 58) or bipolar TUVP (n = 61). Non-inferiority of symptom score (International Prostate Symptom Score [IPSS]) at 24 months was evaluated. All peri-operative variables were recorded and compared. Urinary (IPSS, maximum urinary flow rate and post-void residual urine volume) and sexual (International Index of Erectile Function-15) outcome measures were evaluated at 1, 4, 12 and 24 months. Need for retreatment and complications, change in PSA level and health resources-related costs of both procedures were recorded and compared. RESULTS: Baseline and peri-operative variables were similar in the two groups. At 1, 4, 12 and 24 months, 117, 116, 99 and 96 patients, respectively, were evaluable. Regarding urinary outcome measures, there was no significant difference between the groups. The mean ± sd IPSS at 1 and 2 years was 7.1 ± 3 and 7.9 ± 2.9 (P = 0.8), respectively, after GL-PVP and 6.3 ± 3.1 and 7.2 ± 2.8, respectively, after bipolar TUVP (P = 0.31). At 24 months, the mean difference in IPSS was 0.7 (95% confidence interval -0.6 to 2.3; P = 0.6). The median (range) postoperative PSA reduction was 64.7 (25-99)% and 65.9 (50-99)% (P = 0.006) after GL-PVP, and 32.1 (28.6-89.7)% and 39.3 (68.8-90.5)% (P = 0.005) after bipolar TUVP, at 1 and 2 years, respectively. After 2 years, retreatment for recurrent bladder outlet obstruction was reported in eight (13.8%) and 10 (16.4%) patients in the GL-PVP and bipolar TUVP groups, respectively (P = 0.8). The mean estimated cost per bipolar TUVP procedure was significantly lower than per GL-PVP procedure after 24 months (P = 0.01). CONCLUSIONS: In terms of symptom control, bipolar TUVP was not inferior to GL-PVP at 2 years. Durability of the outcome needs to be tracked. The greater cost of GL-PVP compared with bipolar TUVP is an important concern.

Renoprotective effect of local sildenafil administration in renal ischaemia-reperfusion injury: A randomised controlled canine study.

Objectives: To design a new canine model to assess the renoprotective effect of local sildenafil administration, as the renoprotective effect of systemic sildenafil administration in renal ischaemia-reperfusion (IR) injury in animal models has been shown but its local effects have not been established to date. Materials and methods: In all, 120 dogs were assigned to five groups: sham, oral control (OC) group (right nephrectomy + left renal ischaemia for 60 min), oral sildenafil (OS) group (oral sildenafil 1 mg/kg, 60 min before ischaemia), local control (LC) group (local renal perfusion with saline and heparin for 5 min) and local sildenafil (LS) group (perfusion with sildenafil 0.5 mg/kg). Renal functions, histopathological changes, expression of caspase-3, nuclear factor erythroid 2-related factor 2 (Nrf2), inflammatory cytokines (intracellular adhesion molecule 1, tumour necrosis factor α and interleukin 1ß) and endothelial nitric oxide synthase (eNOS) in renal tissues were assessed in all groups at 1, 3, 7 and 14 days. Results: There were significant improvements in renal functions and cortical and medullary damage scores in the sildenafil-treated groups compared to their control groups (P < 0.05). Also, the LS group showed significantly better improvement of renal functions and cortical and medullary damage scores than the OS group (P < 0.05). Moreover, sildenafil significantly decreased the expression of caspase-3 and inflammatory cytokines and increased the expression of Nrf2 and eNOS in renal tissue, which were statistically significant in the LS group. Conclusion: LS has a greater renoprotective effect against renal IR injury than systemic administration via anti-inflammatory, antioxidant and anti-apoptotic pathways. Abbreviations: BUN: blood urea nitrogen; Ct: cycle threshold; eNOS: endothelial nitric oxide synthase; GAPDH: glyceraldehyde 3-phosphate dehydrogenase; H&E: haematoxylin and eosin; IL-1ß: interleukin 1ß; NO: nitric oxide; Nrf2: nuclear factor erythroid 2-related factor 2; OC: oral control; OS: oral sildenafil; LC: local control; LS: local sildenafil.

Erectile dysfunction post-perineal anastomotic urethroplasty for traumatic urethral injuries: analysis of incidence and possibility of recovery.

PURPOSE: To evaluate the incidence of erectile dysfunction (ED) and recoverability of erectile function (EF) after anastomotic urethroplasty for traumatic urethral injuries (TUIs) of different etiologies. METHODS: A retrospective review for patients' records underwent perineal anastomotic urethroplasty for TUIs from June 1998 to January 2014 was conducted. Those patients were contacted and evaluated using the International Index of erectile function questionnaire in sexually active men, and in unmarried men, the single-question self-report of ED was used. Patients with ED underwent penile color Doppler ultrasonography. RESULTS: Overall, 81 patients were included in the study. The incidences of ED following urethroplasty for TUIs were 72.3, 35.3 and 0% in cases due to pelvic fracture, straddle and iatrogenic injuries, respectively. None of the patients reported deterioration of EF after urethroplasty. Seven (13.5%) patients reported recovery of their EF within 2 years after trauma. The probability of recovery of EF after PFUI was 9% compared to 28.6 and 100% in patients with straddle and iatrogenic urethral injuries, respectively. Patients with type C pelvic fracture had no chance for EF recoverability. CONCLUSIONS: PFUIs have a probability of causing ED as much as 72% compared to 35 and 0% in men with straddle and iatrogenic urethral injuries, respectively. Anastomotic urethroplasty has no deleterious effect on EF. A tendency for higher recoverability of EF could be observed after iatrogenic urethral injuries followed by straddle injury then PFUIs. The probability of recovery decreased proportionally with severity of pelvic trauma.

Ejaculatory function after anastomotic urethroplasty for pelvic fracture urethral injuries.

PURPOSE: The effect of anastomotic urethroplasty for pelvic fracture urethral injuries (PFUIs) on ejaculatory profile is under-reported in the literature. There is controversy as regards the effect of bulbocavernous muscle splitting during surgery on ejaculatory function (EjF). We evaluated the effects of anastomotic urethroplasty on EjF using a validated questionnaire. METHODS: We retrospectively reviewed the computerized surgical records to identify patients who underwent anastomotic posterior urethroplasty for PFUIs from June 1998 to January 2014. Those patients were retrieved and evaluated for their EjF using the EjF component of the Male Sexual Health Questionnaire (MSHQ). RESULTS: Overall, 58 patients were included in the study with a mean age of 31.6 years. All patients except one have antegrade ejaculation, and according to the overall ejaculatory score, only 5 patients (8.6%) reported ejaculatory dysfunction and the remaining 53 (91.4%) had good or average EjF. Ten men (17.2%) reported decreased volume and force of ejaculate. Decreased pleasure during ejaculation was the commonest ejaculatory disorder (39.6%). The score of each of the seven ejaculatory questions among the study patients was in harmony to the previous study of anterior urethroplasty except that men in this study had higher ejaculatory frequency and latency. CONCLUSIONS: Nearly all men maintained antegrade ejaculation after posterior urethroplasty for PFUIs. The risk of urethral reconstruction and splitting the bulbocavernous muscle on ejaculation seems to be minimal.

GreenLight™ laser (XPS) photoselective vapo-enucleation versus holmium laser enucleation of the prostate for the treatment of symptomatic benign prostatic hyperplasia: a randomized controlled study.

PURPOSE: After the advent of the GreenLight XPS™ (180 W) 532 nm laser, photoselective vapo-enucleation of the prostate could compete with holmium laser enucleation of the prostate as a size independent procedure. We assessed whether photoselective vapo-enucleation of the prostate-XPS is not less effective than holmium laser enucleation of prostate for improvement of lower urinary tract symptoms secondary to benign prostatic hyperplasia. MATERIALS AND METHODS: A randomized controlled noninferiority trial comparing holmium laser enucleation of the prostate to photoselective vapo-enucleation of the prostate-XPS 180 W was conducted. I-PSS, flow rate, residual urine, prostate specific antigen and prostate volume changes as well as perioperative and late adverse events were compared. Noninferiority of I-PSS at 1 year was evaluated using a 1-sided test at 5% level of significance. The statistical significance of other comparators was assessed at the (2-sided) 5% level. RESULTS: Overall 50 and 53 patients were included in the holmium laser enucleation and photoselective vapo-enucleation of the prostate groups, respectively. Operative time, hospital stay and time to catheter removal were comparable between the groups. There was significant, comparable improvement in I-PSS and post-void residual urine volume at 1, 4 and 12 months. After 4 months prostate size reduction was significantly higher in the holmium laser enucleation of prostate group (74.3% vs 43.1%, p=0.001). At 12 months maximum urine flow rate was significantly higher in the holmium laser enucleation of prostate group (26.4 ±11.5 vs 18.4 ±7.5 ml per second, p=0.03). Re-intervention was needed in 2 and 3 cases in the holmium laser enucleation and photoselective vapo-enucleation of the prostate groups, respectively (p=1.0). Mean estimated cost per holmium laser enucleation of prostate procedure was significantly lower than per photoselective vapo-enucleation of the prostate procedure. CONCLUSIONS: Compared to holmium laser enucleation of prostate, GreenLight XPS laser photoselective vapo-enucleation of the prostate is safe, noninferior and effective in treatment of benign prostatic hyperplasia.

Prostatic abscess: Objective assessment of the treatment approach in the absence of guidelines.

OBJECTIVE: To assess the outcome of the drainage procedure used for treating a prostatic abscess, and to propose a treatment algorithm to reduce the morbidity and the need for re-treatment. Patients and methods We retrospectively reviewed patients who were admitted and received an interventional treatment for a prostatic abscess. All baseline relevant variables were reviewed. Details of the intervention, laboratory data, duration of hospital stay, follow-up data and re-admissions were recorded. RESULTS: A prostatic abscess was diagnosed in 42 patients; 30 were treated by transurethral deroofing and 12 by transrectal needle aspiration. The median (range) size of the abscess was 4.5 (2-23) mL and 2.7 (1.5-7.1) mL in the deroofing and aspiration groups, respectively (P = 0.2). In half of the cases multiple abscesses were evident on imaging before the intervention. The median (range) hospital stay after deroofing and aspiration was 2 (1-11) and 1 (1-19) days, respectively (P = 0.04). Perioperative complications occurred only in the deroofing group, in which two patients developed septic shock requiring intensive care (Clavien 4) and one developed epididymo-orchitis (Clavien 2). There were two late complications in the deroofing group, in which one patient developed a urethral stricture that required endoscopic urethrotomy (Clavien 3a) and one developed a urethral diverticulum and urinary incontinence that required diverticulectomy and a bulbo-urethral sling procedure (Clavien 3b). A urethro-rectal fistula developed after aspiration in one patient. Re-treatment for the abscess was indicated in two (7%) patients in the deroofing group, which was treated by aspiration. CONCLUSION: Transrectal needle aspiration for a prostatic abscess, when done for properly selected cases, could minimise the morbidity of the drainage procedure.

Weekly intravesical bacillus Calmette-Guerin (BCG) alternating with epirubicin in Ta and T1 urothelial bladder cancer: An approach to decrease BCG toxicity.

CONTEXT: Bacillus Calmette-Guerin (BCG) therapy is the standard treatment for nonmuscle-invasive bladder cancer (NMIBC). However, its toxicity is a major concern. AIM: If we reduce the number of BCG doses by half and replace the second half with epirubicin, we may have a lower toxicity while maintaining the same efficacy of BCG. To test this hypothesis, we conducted this study as an update of our previous report. SETTING AND DESIGN: The study included 607 patients with Ta and T1 NMIBC between January 1994 and December 2008. MATERIALS AND METHODS: After transurethral resection of bladder tumor (TURBT), the patients received weekly doses of 120 mg BCG alternating with 50 mg epirubicin for six weeks (three weekly doses of each). Maintenance was given. Recurrence, progression rates, and toxicity were assessed. End points were progression, recurrence, and cancer-specific survival. RESULTS: A total of 532 patients were eligible for evaluation (mean age: 58 years; median follow-up: 45 months). Of these, 291 (55%) were free, 157 (29.5%) showed recurrence, and 84 (15.8%) showed muscle-invasive progression. Toxicity developed in 221 patients. These were mild in the majority (167), whereas 10 developed hematuria, 30 severe cystitis, and five systemic complications. The rate of permanent therapy discontinuation was 3.8%. STATISTICAL ANALYSIS USED: SPSS package version 16 and Kaplan-Meier curves were used to evaluate survival. CONCLUSIONS: Reducing the frequency of BCG instillations by half and replacing the second half with epirubicin results in a similar efficacy and a lower toxicity compared with historical cases receiving BCG alone. However, further trials are required to support these results.

Construction of predictive models for recurrence and progression in >1000 patients with non-muscle-invasive bladder cancer (NMIBC) from a single centre.

OBJECTIVE: To construct predictive models based on the objectively calculated risks of progression and recurrence of non-muscle-invasive bladder cancer (NMIBC) in a large cohort of patients from a single centre. PATIENTS AND METHODS: Between October 1984 and March 2009 a cohort of 1019 patients (877 males; 142 females; median age 44 years) with histologically confirmed NMIBC was included in this study. Among these patients, 74% received bacillus Calmette-Guérin (BCG)-based therapy. Complete transurethral resection of bladder tumour of all visible tumours was carried out in all patients, and the stage and grade were determined. Univariate analysis and multivariate Cox regression were used to identify predictors of recurrence and progression. The studied predictors included age, sex, stage, grade, associated carcinoma in situ, tumour size, multiplicity, macroscopic appearance of the tumour, history of recurrence and type of adjuvant intravesical therapy. Multivariate logistic regression models were used to develop the 12- and 60-month recurrence and progression predictive models. The predictive accuracy of the models was assessed for discrimination as well as calibration. RESULTS: The median (range) follow-up was 44 (6-254) months. On multivariate analysis, stage, multiplicity, history of recurrence and adjuvant intravesical therapy were significantly associated with recurrence, whereas for progression only tumour grade and size were significant independent predictors. The constructed nomograms had a 64.9% and 69.4% chance of correctly distinguishing between two patients, one destined to have a recurrence and one not at 12 and 60 months, respectively. The constructed nomograms had a 70.2% and 73.5% chance of correctly distinguishing between two patients, one destined to progress and one not at 12 and 60 months, respectively. All predictive models were well calibrated. CONCLUSIONS: Based on multivariate analysis of the studied prognostic factors nomograms for predicting recurrence and progression in NMIBC were constructed. Most of the studied patients had received BCG-based therapy, making these models more closely applicable to contemporary practice than others. These predictive models have reasonable discriminative ability and are well calibrated, but require external validation before they can be applied to other populations.

DWI-MRI: single, informative, and noninvasive technique for prostate cancer diagnosis.

AIM: To evaluate diffusion weighted image-MRI (DWI) as a single diagnostic noninvasive MRI technique for prostate cancer (PCa) diagnosis. MATERIAL AND METHODS: A prospective study was conducted between July 2008 and July 2009. Candidates patients were equal or more than 40 years old, with suspicious digital rectal examination (more than clinical T2) or PSA >4 ng/mL. Informed consent was signed. DWI-MRI was performed at 1.5 T with a body coil combined with a spine coil in consecutive 100 cases. The histopathology of biopsies has been used as reference standard. Two examiners were evaluating MRI and TRUS, both of them were blinded regarding pathological findings. Accuracy, specificity, and sensitivity were statistically analyzed. RESULTS: Based on pathological diagnosis: group A (cancerous); 75 cases and group B (non-cancerous); 25 cases. Mean age was 65.3 and 62.8 years in groups A and B, respectively. Mean PSA was 30.7 and 9.2 ng/mL in groups A and B, respectively. Sensitivity of DWI was 58.3% while specificity was 83.8%. Accuracy of lesion detection was 52.4-77.8% (P < 0.05). Moreover, DWI at ADC value 1.2 × 10(-3) mL/sec could determine 82.4% of true positive cases (P < 0.05). ADC values were lower with Gleason score ≥ 7 (P < 0.05). CONCLUSION: DWI could represent a non invasive single diagnostic tool not only in detection and localization but also in prediction of Gleason score whenever DWI is used prior to invasive TRUS biopsy. Furthermore, targeted single biopsy could be planned after DWI to minimize patient morbidity by invasive techniques.

Survival after primary and deferred cystectomy for stage T1 transitional cell carcinoma of the bladder.

CONTEXT: The optimal time of cystectomy for nonmuscle invasive bladder cancer (NMIBC) is controversial. AIM: This study aims at comparing cancer-specific survival in primary versus deferred cystectomy for T1 bladder cancer. SETTINGS AND DESIGN: Between 1990 and 2004, a retrospective cohort of 204 patients was studied. MATERIALS AND METHODS: Primary cystectomy at the diagnosis of NMIBC was performed in 134 patients (group 1) and deferred cystectomy was done after failed conservative treatment in 70 (group 2) Both groups were compared regarding patient and tumor characteristics and cancer-specific survival. STATISTICAL ANALYSIS USED: Cancer-specific survival was calculated using the Kaplan-Meier method. RESULTS: Mean follow-up was 79 and 66 months, respectively, in the two groups. Tumor multiplicity was more frequent in group 2; otherwise, both groups were comparable in all characteristics. The definitive stage was T1 in all patients. Although the 3-year (84% in group 1 vs. 79% in group 2), 5-year (78% vs. 71%) and 10-year (69% vs. 64%) cancer-specific survival rates were lower in the deferred cystectomy group, the difference was not statistically significant. In group 2, survival was significantly lower in cases undergoing more than three transurethral resections of bladder tumors (TURBT) than in cases with fewer TURBTs. CONCLUSIONS: Cancer-specific survival is statistically comparable for primary and deferred cystectomy in T1 bladder cancer, although there is a non-significant difference in favor of primary cystectomy. In the deferred cystectomy group, the number of TURBTs beyond three is associated with lower survival. Conservative treatment should be adopted for most cases in this category.

Does the extent of lymphadenectomy in radical cystectomy for bladder cancer influence disease-free survival? A prospective single-center study.

BACKGROUND: Controversy exists regarding the optimal extent of lymphadenectomy and the number of lymph nodes to be retrieved at radical cystectomy (RC). OBJECTIVE: To compare the disease-free survival of patients with standard lymphadenectomy (endopelvic region composed of the internal, external iliac, and obturator groups of lymph nodes) versus extended lymphadenectomy (up to the level of origin of the inferior mesenteric artery) at RC in a prospective cohort of patients at a single, high-volume center. DESIGN, SETTING, AND PARTICIPANTS: Prospective data were collected from 400 consecutive patients treated with RC for bladder cancer by two high-volume surgeons at Mansoura Urology and Nephrology Center. Of the 400 patients, 200 (50%) received extended lymphadenectomy and the other 200 (50%) underwent standard lymphadenectomy at RC. The patients did not receive any neoadjuvant or adjuvant therapy. MEASUREMENTS: Patient characteristics and outcomes are evaluated. RESULTS AND LIMITATIONS: Median patient age for the entire group was 53.0 yr. Ninety-six patients (24.0%) had lymph node metastases. Median follow-up was 50.2 mo. Estimates of 5-yr disease-free survival in the extended lymphadenectomy group were 66.6% compared with 54.7% for patients with standard lymphadenectomy (p = 0.043). Extended lymphadenectomy was associated with better disease-free survival after adjusting for the effects of standard pathologic features (p = 0.02). When restricting the analyses to lymph node-positive patients, patients with extended lymphadenectomy had much better 5-yr disease-free survival compared with patients with standard lymphadenectomy (48.0% vs 28.2%; p = 0.029). The study was nonrandomized. CONCLUSIONS: Extended lymphadenectomy is associated with better disease-free survival for bladder cancer patients with endopelvic lymph node involvement and should be considered in these patients.

Urinary tract infection before and after mid-urethral slings: culture-proven diagnosis and analysis of risk factors.

OBJECTIVES: To study prevalence of UTI in women with SUI before and after mid-urethral slings based on culture-proven diagnosis. MATERIALS AND METHODS: Clean catch midstream urine samples were collected and sent for agar culture in 150 patients before and on follow-up after mid-urethral slings visit. Degree of agreement between culture-proved UTI and clinically suspected was assessed. In addition, risk factors for UTI were analyzed. RESULTS: Preoperative culture was positive in 9 (6%) patients, 7 of them were asymptomatic. UTI was primarily diagnosed in 39 (26%) patients suggested by symptoms. No bacterial growth was detected at first postoperative day. There were 6 out of 62 (9.7%) patients who had positive urine cultures at follow-up visits, all of them were symptomatic. Eleven (18%) patients were diagnosed as UTI, based on clinical suspicion. CONCLUSION: In contrast to UTI before surgery, asymptomatic UTI is unlikely to happen after mid-urethral sling.

Minimum 2-year follow-up of mid-urethral slings, effect on quality of life, incontinence impact and sexual function.

INTRODUCTION AND HYPOTHESIS: In this study, the impact of mid-urethral slings (MUS) on incontinence-related distress, quality of life and sexual function is assessed at a minimum 2 years. METHODS: Patients received either a pubovaginal sling (PVS) or a tension-free vaginal tape (TVT). The Arabic translation of urogenital distress inventory (UDI)-6, incontinence impact questionnaire (IIQ)-7, and short form Female Sexual Function Index (FSFI) were administered at baseline and 24 months. RESULTS: Sixty three women with a mean age of 47.8 years were included in this study. A median follow-up was done after 54 ± 21.9 months. Thirty nine women had PVS while 24 had TVT. Cure was defined as a significant decrease in UDI-6 and a negative stress test at 200 ml, which was found to be 93.65% and 95.2%, respectively. Overall, UDI-6 decreased from a mean preoperative value of 68.1 ± 16.9 to 27.6 ± 18.3 (p < 0.0001). IIQ-7 decreased from 70 ± 19 to 24 ± 20.8(p < 0.0001). The difference between pre- and postoperative values was insignificant. CONCLUSION: An MUS gives a cure rate of over 93% at a median follow-up of 54 months. A significant decline in UDI-6 and IIQ-7 is evident after surgery. Sexual function, as measured by the FSFI, was not significantly affected.

TOT for treatment of stress urinary incontinence: how should we assess its equivalence with TVT?

INTRODUCTION AND HYPOTHESIS: Synthetic mid-urethral slings are currently considered the treatment of choice for stress urinary incontinence (SUI). In this study, two types of slings are compared: TVT vs. TOT. METHODS: In a prospective randomized study, 40 patients underwent either TVT (19 patients) or TOT (21 patients). Stress-specific and overall success was evaluated. Perioperative complications were classified according to Clavien's classification. RESULTS: Mean duration of follow-up was 20 months. At last follow-up, stress-specific success rate was 94.6% in TVT vs. 81% in TOT. No significant difference was detected in terms of post-void residual urine, symptom score, and filling and voiding parameters. Thigh pain represented the main complication in the TOT group. CONCLUSIONS: Both TVT and TOT are effective procedures for treatment of SUI. When compared to each other, TOT seems to be inferior to TVT in terms of efficacy, causing less serious complications.

Validation of Epstein criteria of insignificant prostate cancer in Middle East patients.

BACKGROUND: Since introduction of Contemporary Epstein criteria, it has been studied and validated in many countries and nations. However, they were not validated in Middle East patients up till now. AIM OF THE WORK: To validate the Contemporary Epstein criteria in Middle East patients. MATERIALS AND METHODS: On past 8 years, 70 cases underwent radical prostatectomy for T1c prostate cancer. Contemporary Epstein criteria were applied retrospectively on prostatic biopsies. Among our patients, 35 cases met the criteria for clinically insignificant prostate cancer. Pathological revision of the prostatic biopsies, definitive prostatectomy specimens and re-staging were done by single pathologist. Assessment of recurrence rate was done. Up and down grading of the Gleason scoring was studied. RESULTS: The preoperative data and biopsy results using the Contemporary Epstein criteria were fulfilled on 35 cases. On definitive pathology; 16 cases (45.7%) had Gleason score >6, while 8.6% of cases are non-organ confined (2 cases and 1 case with extra- capsular and Seminal vesicles infiltrations, respectively). Both lobes were involved in 20 cases. Moreover, 40% (14 cases) showed upgrading of the score. Lymphatic permeation could be recognized in four cases. Mean follow-up time 88.1 months, 8.6% cases develop metastasis. CONCLUSION: Whenever Epstein criteria are applied in Middle East patients, the decision of active surveillance based for clinically insignificant prostate cancer (who met the Epstein criteria) will miss nearly 46% of unfavorable prostate cancer. As well as a risk of later metastasis could be in 8.6% of them.

Ureteric injury after lumbosacral discectomy: a case report and review of the literature.

Herein, a case of ureteric injury was inflected during lumbo-sacral laminectomy is reported to be added to the previously published 15 cases. Ureteric injury is a rare complication that may be encountered during lumbar disc surgery. We traced 15 cases that were published in literatures allover the past years with different management techniques. To the best of our knowledge, we report the first case that was treated by ileal ureteric replacement. Special attention should be paid regarding ureteric injury during surgery. Despite rare incidence of such injury with laminectomy, there were some reportable complications. So, surgeons should be aware of prediction, early diagnosis, and possible management alternatives for such injuries to safe patients from unsuspected handicapping.