Prevalence of stress urinary incontinence and urge urinary incontinence in multiples sclerosis patients: a systematic review and meta-analysis.

Urinary incontinence (UI), encompassing stress urinary incontinence (SUI) and urge urinary incontinence (UUI), is a prevalent and debilitating condition in patients with multiple sclerosis (MS), profoundly impacting their quality of life. This systematic review and meta-analysis aimed to elucidate the worldwide prevalence rates of SUI and UUI among MS patients. This study was conducted by examining observational studies published between 2000 and 2023. An exhaustive literature search was conducted across databases such as PubMed, MEDLINE, Web of Science, Scopus, ProQuest, and Google Scholar. The Meta-prop method facilitated pooled prevalence estimation of UUI and SUI, while Egger tests assessed publication bias. In total, 27 studies with 15,052 participants were included in the meta-analysis. The findings revealed a high random effect pooled prevalence of UUI at 41.02% (95% Confidence Interval [CI]: 30.57-51.89; I2 = 99%, p < 0.001) and SUI at 25.67% (95% CI: 19.30-32.58%; I2 = 94.9%, P < 0.001). Additionally, the pooled prevalence of mixed urinary incontinence (MUI) was reported at 18.81% (95% CI: 7.55-33.48; I2:95.44%, p < 0.001). The high heterogeneity observed suggests variable prevalence across populations and highlights the intricate nature of UI in MS. These findings underscore the critical need for dedicated supportive, therapeutic, and rehabilitative interventions to manage this common complaint in MS patients effectively.

Emergency holmium laser enucleation of the prostate (HoLEP): a novel approach in the management of refractory hematuria for patients with benign prostatic hyperplasia (BPH): a single-institution experience.

INTRODUCTION: Refractory hematuria secondary to prostatic disease typically resolves with conservative management; however, this condition may require hospitalization with extensive measures to control life-threatening bleeding. The aim of this study was to report our experience using holmium laser enucleation of the prostate (HoLEP) as an emergency treatment in this clinical setting. METHODS: We conducted a retrospective review of all patients that presented to the emergency department with refractory hematuria of prostatic origin from October 2017 to September 2021, for whom hospitalization and conservative management failed to control bleeding. All emergency HoLEP procedures were performed by a single surgeon. Preoperative and intraoperative parameters, as well as perioperative outcomes, were collected and analyzed. Postoperative outcomes included duration of foley catheterization, length of postoperative hospital stay, and hospital readmissions. RESULTS: A total of 40 emergency HoLEP procedures were performed. Our cohort had a median prostate volume of 110.5 cc and a median resected weight of 81 g. Twenty-seven patients (67.5%) were on anticoagulant or antiplatelet medications on admission. The urethral catheter was removed within 1 day in 95% of patients with a successful trial of void (TOV). Moreover, 92.5% of patients were discharged home within 24 h of their procedure. Two patients (5%) experienced clot retention within one-week post-discharge with a 2.5% overall readmission rate. All postoperative parameters, including International Prostate Symptom Score (IPSS), quality of life (QoL), maximum flow rate (Qmax), and post-void residual volume (PVR), showed significant improvement at 1 year follow up. CONCLUSION: Our experience demonstrates that emergency HoLEP is an effective treatment option for patients with refractory hematuria of prostatic origin. Further studies are warranted to consolidate our results.

Transverse Lumbotomy for Open Partial/Radical Nephrectomy: How I Do It.

INTRODUCTION: Conventional open surgical techniques allow proper surgical management for renal malignancies but have their intrinsic drawbacks. The aim of this paper is to present our technique in minimal renal exposure while avoiding the intrinsic complications of conventional techniques. METHODS: We described our technique, which can be easily understood and replicated by urologists performing open kidney surgery. RESULTS: Ninety-five patients had this technique done safely over the last 4 years, and 3 patients had this exposure changed into intraperitoneal extended wound for very large upper pole tumours. The median operating time was 70 min. No single patient required intraoperative blood transfusion. Median warm ischemic time was 9 min. CONCLUSION: Transverse lumbotomy is a safe reproducible technique that allows proper kidney exposure through a relatively smaller wound and avoiding unnecessary auxiliary techniques as rib resection, pleural tear management, and intraperitoneal exposure.

The ex vivo and in vivo Characteristics of New DrillCutTM Prostate Morcellator after Holmium Laser Enucleation of the Prostate: A Pilot Study.

INTRODUCTION: The DrillCutTM morcellator is marketed for its fast and highly efficient removal of prostatic tissue and a higher level of patient safety. However, a paucity of publications has looked into its actual efficacy and safety. The aim of our study was to evaluate its ex vivo and in vivo efficiency and to compare its results with other devices presented in the literature. PATIENTS AND METHODS: We conducted a prospective pilot study on patients who underwent holmium laser enucleation of the prostate (HoLEP) from 2017 to 2018 using the Top-Down technique. Enucleated adenomas were morcellated using the DrillCutTM morcellator. We collected both preoperative and operative data. Operative data included the enucleated adenoma weight and operative time. Various morcellator parameters were collected including morcellation time and efficiency. We recorded the encountered complications and device malfunction. Ex vivo characteristics were evaluated in terms of morcellation speed and aspiration power. RESULTS: Sixty consecutive patients with a median age of 72.8 years were included. The enucleated adenoma was retrieved in 12.5 min (4-58). The median resected prostatic weight was 90 g (44-242). The DrillCutTM efficiency was calculated as 6.46 g/min (2.7-15). Only one patient had a simple bladder mucosal injury. Device malfunction was encountered in 4 patients (6.6%) due to blockage of the morcellator blades. The ex vivo aspiration speed was 52 s/L, while the morcellation power was 14 g/2 min. CONCLUSION: Our results showed that the DrillCut morcellator was effective and safe in managing our patients post-HoLEP. The DrillCutTM has better ex vivo morcellation power but modest aspiration speed in comparison to other morcellators.

Bladder-Adherent Primary Appendiceal Carcinoma Masquerading as a Carpeting Rectal Lesion Detected by a Fecal Immunochemical Test: A Case Report.

Introduction: Primary appendiceal carcinoma is rare and comprises up to 1% of all colorectal malignancies. Its invasion into adjacent organs, such as the bladder and rectum, especially as a presenting characteristic, is even less common. Case Presentation: A 75-year-old asymptomatic male tested positive on a screening fecal immunochemical test (FIT). Colonoscopy showed a rectosigmoid tumor and normal appendiceal orifice. Staging MRI surprisingly showed that the cancer was, in fact, of appendiceal origin, coursed posteriorly to invade the rectosigmoid and form adhesions with the urinary bladder. Staging CT did not show metastatic disease. Low anterior resection, en bloc appendectomy, and right hemicolectomy were performed along with cystectomy and ileal conduit. Hematoxylin and eosin stains showed appendiceal adenocarcinoma invading through the appendiceal wall into the rectal muscularis and submucosa. Features of neuroendocrine carcinoma were not identified on immunohistochemistry. This was a colonic type of adenocarcinoma of the appendix. Conclusion: This is a rare case of appendiceal carcinoma invading the rectum and presenting as a positive screening fecal immunochemical test in an asymptomatic individual. We effectively demonstrate the use of preoperative MRI to identify the appendiceal origin of the tumor, as well as to demonstrate the extent of tumor spread, which assisted with operative management and treatment planning.

Safety and clinical outcomes of GreenLight laser prostatectomy in octogenarians.

INTRODUCTION: We evaluated the impact of age on perioperative morbidity and clinical outcomes in patients undergoing GreenLight laser prostatectomy for benign prostatic hyperplasia (BPH). METHODS: We conducted a retrospective study of prospectively collected data from individuals who underwent GreenLight laser prostatectomy from May 2018 to July 2022. Patient demographics and outcome measures were recorded, including indications for the procedure and American Society of Anesthesiology (ASA) scores. All patients had postoperative followup visits at one, three, six, and 12 months. Our evaluation included the International Prostate Symptom Score (IPSS ), quality of life (QoL) assessment, maximum urinary flow rate (Qmax), postvoid residual volume (PVR), and catheter-free status. RESULTS: One-hundred-sixty-eight males who underwent GreenLight laser prostatectomy were included. The non-octogenarian group consisted of 111 patients and the octogenarian group comprised 57 individuals. Based on ASA scores, most octogenarians were deemed high-risk (ASA III: 91.2%), while over half of non-octogenarians were lower-risk (ASA II: 53.2%) (p<0.001). Intraoperative parameters, including operative time, vaporization time, lasing time, and energy did not differ significantly between groups. There was no difference in the proportion of intraoperative complications between non-octogenarians and octogenarians (0.9% vs. 3.5%). Postoperative complications were not statistically significant between the two groups (p=0.608). There was also no observed difference in the proportion of patients requiring readmission (p=0.226) or retreatment (p=1.0). CONCLUSIONS: GreenLight laser prostatectomy is a safe and effective treatment for BPH regardless of age. It provides similar surgical and functional outcomes as younger men while maintaining the QoL of octogenarians.

Efficacy of GreenLight laser prostatectomy in urinary retention.

INTRODUCTION: The objective of our study was to evaluate the efficacy and durability of GreenLight laser prostatectomy for the management of acute urinary retention (AUR) and chronic urinary retention (CUR) and to determine outcomes compared to patients without preoperative urinary retention (UR). METHODS: We conducted a retrospective study of prospectively collected data from individuals who underwent GreenLight laser prostatectomy at our institution from May 2018 to July 2022. Patient demographics and outcome measures were recorded, including indications for the procedure, median urinary volume drained, or median postvoid residual urine volume (PVR) before catheterization or GreenLight laser prostatectomy. CUR was defined as PVR >300 mL in males able to void and initial catheter drainage >1000 mL in males unable to void in the absence of pain. All patients had postoperative followup visits at one, three, six, and 12 months. Our evaluation included the International Prostate Symptom Score (IPSS), quality-of-life (QoL) assessment, maximum urinary flow rate (Qmax), PVR, and catheter-free status. RESULTS: One hundred sixty-eight males who underwent GreenLight laser prostatectomy were included in our study. The UR group consisted of 88 patients (50 AUR and 38 CUR), and the lower urinary tract symptoms (LUTS) group was comprised of 80 individuals. There were no statistically significant differences between the AUR and CUR subgroups regarding demographics. The UR group had a significantly higher age and a significantly higher postoperative catheterization time compared to the LUTS cohort. The CUR subgroup had a significantly higher PVR at one, three, and six months compared to the AUR subgroup, although other outcome measures were similar between the two cohorts. During three- and six-month followup visits, the UR group had a significantly higher PVR than the LUTS cohort. At 12 months postoperative, the LUTS group had a higher catheter-free rate than the UR group (p=0.001). The successful first trial of void (TOV) rate for the UR and LUTS groups were 83% and 80%, respectively. At 12-month followup, the catheter-free rate for the UR and LUTS cohorts was 87.5% and 100%, respectively. CONCLUSIONS: GreenLight laser prostatectomy is an effective and durable treatment for UR, with a high catheter-free rate and comparable outcomes when performed to manage LUTS.

Timing of Urinary Catheter Removal After Urethroplasty: A Systematic Review.

OBJECTIVE: To synthesize existing evidence to evaluate the outcomes of different urinary catheter removal timing (early vs late) after urethroplasty. METHODS: We performed a comprehensive search of PubMed, Embase, the Cochrane Library, and Web of Science from inception to August 7, 2022. Articles were initially screened by title, abstract, and subsequently by a full paper review before being included in the final analysis. All comparative studies that assessed the association between urethral catheterization duration and frequency of extravasation and recurrence rate in patients who underwent urethroplasty were included in the analysis. Exclusion criteria were case reports, case series, letters to editors, and non-English studies. The risk of bias was assessed using the Newcastle-Ottawa Scale. RESULTS: Of the 439 relevant records in the literature databases, 5 studies involving 634 patients were included. In all 5 studies, the extravasation rate was not significantly different between the early and late catheter removal groups. Among the 3 studies that reported recurrence rates, the recurrence rate was low, with no statistically significant difference between the early and late catheter removal groups. Wound and urinary tract infections were among the most common complications, with a higher rate in patients with late catheter removal. CONCLUSION: Early catheter removal following urethroplasty does not increase the rate of extravasation or recurrence during long-term follow-up. The existing evidence can serve as the foundation for additional research with a larger sample size.

Manifestation of Spontaneous Rupture of the Urinary Bladder in Pregnancy: A Systematic Review of the Literature.

Spontaneous rupture of the urinary bladder (SRUB) during pregnancy is a potentially fatal event that necessitates immediate surgery. The aim of this systematic review is to determine the symptoms, causes, associated factors, and prognosis of SRUB in pregnancy. We searched the literature from inception until December 2022 using the Cochrane Central Register, PubMed, EMBASE, ProQuest, Scopus, and Google Scholar. Articles not in English and those unrelated to the topic were excluded. The JBI Critical Appraisal Checklist for case reports was employed for the risk of bias assessment. The search strategy yielded 312 citations; 29 full-text articles were evaluated for eligibility after screening. Five case reports were included in this review. The age range of the cases was 27-39 years. Four cases were in their second trimester of pregnancy, and one was in her third. Two cases had undergone previous cesarean sections, and one had an appendectomy and salpingectomy due to an ectopic pregnancy. One case reported a history of alcohol and drug abuse. The most common symptoms were abdominal pain, abdominal distension, oliguria, voiding difficulty, hematuria, fever, and vomiting. The diagnosis of SRUB was primarily made via emergency laparotomy due to the patients' critical conditions. Beyond its diagnostic role, laparotomy was also the treatment method in all cases. Tear repair, antibiotic therapy, and urinary catheterization were all integral parts of the treatment. Four cases resulted in an uneventful pregnancy and a healthy, full-term baby. In one case, a hysterectomy was performed due to a combined uterus and bladder rupture. SRUB often presents with non-specific symptoms, leading to a delayed diagnosis. A high index of suspicion is essential when a pregnant woman exhibits urinary symptoms and severe abdominal pain, especially in those with a history of previous surgery. Early detection and treatment of SRUB are critical for an uneventful recovery.

Top-down holmium laser enucleation of the prostate (HoLEP) versus traditional HoLEP for the treatment of benign prostatic hyperplasia (BPH): 1-year outcomes of a randomized controlled trial.

BACKGROUND: The top-down holmium laser enucleation of the prostate (HoLEP) technique recently emerged as a safe and effective modification of traditional HoLEP. In our randomized controlled trial, we compared intraoperative and postoperative outcomes of traditional and top-down HoLEP for the treatment of benign prostatic hyperplasia (BPH) in patients with a prostate size ≥80 g. METHODS: One-hundred patients with BPH and a prostate volume ≥80 cc participated in this prospective randomized controlled trial. Outcome measures were collected and compared, including IPSS, QoL, flow rate, PVR, IIEF-15, PSA, and TRUS prostate volume changes. Perioperative complications were also recorded. All patients were followed up at 1, 3, 6, and 12 months. RESULTS: There were no significant differences in preoperative baseline characteristics between the two surgical groups. The median prostate volume for the traditional and top-down HoLEP groups was 107 and 102 cc, respectively. The operative parameters and postoperative outcomes were comparable for both cohorts. The median enucleation time for traditional HoLEP was 60 min, which was not significantly longer than that of top-down HoLEP (52 min) (p = 0.07). At 3 months follow-up, there was no statistically significant difference in transient stress urinary incontinence (SUI) in the traditional HoLEP (4.1%) versus the top-down HoLEP group (2.2%), (p = 0.61). There were no significant differences in functional and sexual outcomes between the two groups at 12 months. CONCLUSIONS: The HoLEP procedure significantly improves patients' urinary functional outcomes and has comparable postoperative outcomes regardless of the technique utilized.

Endophytic to total tumour volume ratio: An added variable to patients with T1b/T2 renal tumours undergoing partial nephrectomy.

INTRODUCTION: Partial nephrectomy is the standard of care to patients with small renal masses. It is still encouraged to larger tumours whenever feasible. The aim of this study is to look for the endophytic to total tumour volume ratio as an added variable to study the complexity of partial nephrectomy to patients with T1b/ T2 renal tumours. METHODS: Retrospective data collection of patients that had partial nephrectomy for T1b/T2 renal tumours by a single surgeon was done. Radiological re-assessment for the CT images to measure the endophytic to total tumour volume ratio was done. RESULTS: The mean age of the patients was 63 years. The study included 25 males and 11 females. All cases were managed by open surgery using retroperitoneal transverse lateral lumbotomy and warm ischemia was used in all patients. The mean tumour volume was 74 cc, the mean endophytic tumour volume was 29 cc. The mean percentage of endophytic to total tumour volume was 42%. CONCLUSIONS: Partial nephrectomy is safe for most of the patients with good performance status, having large renal masses. More complex surgery can be predicted in patients with endophytic to total tumour volume greater than 42%.

Same-day trial of void and discharge following standard vs. MOSESTM holmium laser enucleation of the prostate: A single-center experience.

INTRODUCTION: We aimed to compare perioperative and postoperative outcomes and to assess the safety and feasibility of same-day trial of void (TOV) in patients who underwent standard holmium laser enucleation of the prostate (HoLEP) vs. MOSESTM HoLEP (MoLEP). METHODS: We conducted a retrospective review of prospectively collected data of patients that underwent HoLEP (100 W) or MoLEP (120 W) with same-day catheter removal three hours postoperatively at our institution from August 2018 to September 2021. Patient demographics, intraoperative parameters, and postoperative outcomes were analyzed. Data were compared as means with standard deviation and medians with interquartile range (IQR) or numbers and percentages. Continuous and categorical variables were assessed using the Mann-Whitney U test and Chi-squared test, respectively. Predictors of shorter enucleation time and failed same-day TOV were investigated. RESULTS: Of the 90 patients included, 28 underwent HoLEP while 62 had MoLEP. There was no significant difference between the groups in terms of the successful TOV (23 [82%] vs. 58 [93.5%], p=0.1) and readmission rate (3 [10.7%] vs. 1 [1.6%], p=0.08); however, the MoLEP group had a significantly shorter mean enucleation time (p<0.001), mean hemostasis time (p<0.001), mean morcellation time (p=0.003), and lower mean energy used (p<0.001). On the logistic regression model, MoLEP (odds ratio [OR] 0.03, 95% confidence interval [CI] 0.007-0.19, p<0.001), lower preoperative prostate-specific antigen (PSA) test (OR 1.25, 95% CI 1.01-1.55, p=0.03), and smaller prostate size (OR 1.06, 95% CI 1.02-1.09, p<0.001) were independent predictors of shorter enucleation time. History of preoperative retention was the only significant factor associated with a failed same-day TOV (p=0.04). There was no difference in intraoperative or postoperative complication rates or postoperative functional outcomes between the two technologies. CONCLUSIONS: Same-day TOV and discharge are feasible following standard HoLEP and MoLEP, with comparable outcomes; however, the use of MOSESTM technology offered better enucleation efficiency with excellent hemostatic potential. Preoperative retention was the only predictor of failed same-day TOV.

Holmium Laser Xpeeda Vaporization vs GreenLight XPS Vaporization of the Prostate for Benign Prostatic Obstruction: 1-Year Results from a Randomized Controlled Clinical Study.

Introduction and Objective: To compare the safety and efficacy of Holmium Laser Xpeeda Vaporization and GreenLight XPS Vaporization of the prostate in patients with prostate size ≤80 g. Methods: Ninety-two men with benign prostatic hyperplasia (BPH) and prostate size ≤80 g scheduled for laser prostatectomy were included in this prospective randomized trial. Outcome measures were collected and compared, including International Prostate Symptom Score (IPSS), quality of life (QoL), flow rate, postvoid residual urine volume (PVR), International Index of Erectile Dysfunction (IIEF)-15, prostate-specific antigen (PSA), transrectal ultrasound prostate volume, and catheterization time. Perioperative complications were also recorded. Patients were offered a trial of void (TOV) 3 hours after their procedures. All patients were followed-up at 1, 3, 6, and 12 months. Results: There were no significant differences in preoperative baseline data between the two surgical groups. Operative parameters and postoperative outcomes were comparable. Effective same-day TOV was noted in 73.1% and 72.7% of the Xpeeda and GreenLight XPS patients, respectively (p = 0.98). All patients were discharged home within 24 hours of their surgeries. The laser energy and postoperative complications were significantly lower in the Xpeeda group (p = 0.002 and p = 0.026, respectively). At 3 months, the PSA levels significantly dropped in both groups (p = 0.002 and p < 0.001). There were no significant differences in functional and sexual outcomes between the two groups at 12 months. Conclusions: Holmium Laser Xpeeda Vaporization and GreenLight XPS Vaporization are safe and effective in the treatment of BPH. Same-day discharge with early TOV is a feasible option. Clinical Trials.gov Identifier: NCT04386941.

History of infantile BCG immunization did not predict lamina propria invasion and/or high-grade in patients with non-muscle invasive bladder cancer.

OBJECTIVE: To evaluate the utility of infantile BCG vaccination history in predicting stage and grade of tumours in non-muscle invasive bladder cancer (NMIBC). MATERIALS AND METHODS: We retrospectively analyzed data from patients from a single center who were diagnosed with new NMIBC and underwent transurethral resection of bladder tumour (TURBT) between 2017 and 2022. We assessed BCG immunization status with various demographics and comorbidities, as well as tumour recurrence, progression, stage, and grade. RESULTS: A total of 188 patients met the inclusion criteria for our study. The mean age of patients at the time of diagnosis was significantly lower in those that had been immunized with BCG (71 ± 9) than those who had not (77 ± 10) (p < 0.0001). History of BCG immunization did not correlate with sex, history of diabetes mellitus (DM), prior history of intravesical BCG treatment, and tumour recurrence, progression, stage, and grade. CONCLUSIONS: History of infantile BCG vaccination did not correlate with the depth of invasion and/or the grade in patients with non-muscle invasive bladder cancer. Patients that received infantile BCG vaccination were significantly younger at the time of diagnosis of NMIBC.

Thulium Fiber Laser vs Pulse-Modulated Holmium MOSES Laser in Flexible Ureteroscopy for the Management of Kidney Stones: A Single-Center Retrospective Analysis.

Introduction and Objective: The study's primary objective was to compare the laser efficiency and clinical outcomes of two widely used systems, the holmium MOSES laser and the thulium fiber laser (TFL), in managing kidney stones. The secondary outcomes were to evaluate the impact of stone composition on laser efficacy. Methods: We conducted a retrospective review of patients who underwent flexible ureteroscopy (f-URS) for solitary renal calculi between December 2020 and August 2022 at our institution and had a 3-month postoperative CT scan. Patient demographics and stone parameters were recorded, including stone site, size, volume, and density. Intraoperative data were collected and analyzed, including total operative time, ureteroscopy time, lasing time, technique, total energy delivered, and stone composition. All patients underwent a CT scan at 3 months follow-up. We recorded the presence of residual stones and the percentage of stone volume reduction. Ablation efficiency was calculated by dividing the energy utilized (J) by the stone volume (mm3). The ablation speed was calculated by dividing the stone volume (mm3) by the lasing time (seconds). Patients with a stone size <4 mm were deemed stone-free. Results: The MOSES and TFL groups comprised 62 and 49 patients, respectively. There were no significant differences between groups for baseline patient demographics or stone characteristics. The two modalities had comparable total energy, laser time, efficacy, and ablation speeds. No differences were detected in stone-free rates or complications between both groups. When dealing with calcium phosphate stones, we observed that the lasing time was significantly shorter with MOSES than TFL (7.95 vs 10.85 minutes, respectively [p = 0.01]). Conclusions: MOSES and TFL laser systems had comparable efficacy for lithotripsy of renal calculi during f-URS; however, calcium phosphate stones had a longer lasing time with TFL. REB Number: 100210.

Successful Surgical Management of Locally Advanced Renal Cell Carcinoma Invading Spleen and Pancreas.

Over the last two decades, the treatment of metastatic RCC has changed significantly, and the role of surgery is being debated. A 50-year-old man presented with pain in his left loin. An ultrasound, followed by a CT scan, revealed a 17.5 cm left renal mass invading the left suprarenal gland, spleen, and pancreatic tail. Radical nephrectomy through chevron incision under epidural block with general anesthesia was performed. The entire mass was removed en bloc. The estimated blood loss was 300 mL, and no blood transfusions were performed. The operation took approximately 2 h. Histological examination revealed clear cell renal carcinoma with extension into the spleen, pancreatic tail, and diaphragmatic fibers with negative resection margin. The patient discharged after a 3-day uneventful hospital stay. Aggressive surgical removal of a locally invasive renal cell carcinoma is feasible and should be considered in patients with good performance status and no or minimal distant metastases.

Radical cystectomy for clinical T4b urothelial carcinoma: An Ontario, single-center experience.

INTRODUCTION: Guidelines surrounding the management of T4b muscle-invasive bladder cancer (MIBC) with radical cystectomy (RC) are limited and lack clarity. Our objective was to analyze our single-center experience to provide additional insight into the role of RC. METHODS: We performed a retrospective data analysis using clinical, radiological, and pathological information for all patients managed by RC for cT4b MIBC at the Thunder Bay Regional Health Sciences Centre (July 2015 to July 2020). Patients that had MIBC as their first diagnosis were termed the de novo group and patients that were initially diagnosed as having non-MIBC were termed the progressive group. RESULTS: Nineteen consecutive patients (16 males and three females), with a median age of 68 years, managed by two urologists over the last five years, met study criteria. Eleven (58%) of the patients had de novo MIBC while eight (42%) presented with progressive disease. All patients had dysuria as a presenting symptom. Only one (5%) patient received neoadjuvant chemotherapy. There were low rates of perioperative transfusion (11%), bowel resections (5%), postoperative transfusions (0%), ileus (32%), urine leak (16%), and wound dehiscence (5%). Fourteen patients (74%) had positive lymph nodes. All patients had adjuvant chemotherapy. The one-year recurrence rate in these patients was 53%, with 32% of recurrence being distant metastasis. The one-year survival rate was 95%. CONCLUSIONS: Patients in the de novo and progressive arms of our cohort had similar rates of surgical complications and disease recurrence. We found operative morbidity and disease control to be reasonable, suggesting RC can be considered more often in the management of T4b MIBC patients.

Aristolochic acid: What urologists should know.

To the Editor, Aristolochic acid is one of major causes for upper tract urothelial carcinoma, especially in younger population. While it is mentioned as a cause in guidelines, little is actually known about the toxin by urologists. We are aiming in our letter to provide some direct and clear information to ourselves that would help us to know more about that toxin and how it can adversely affect our patients [...].

Radical cystectomy for bladder urothelial carcinoma with aggressive variant histology.

PURPOSE: The aim of this study is to report our experience in managing bladder cancer in patients with variant pathology. METHODS: Retrospective data collection for all patients managed by radical cystectomy over the last 3 years for a variant pathol-ogy was completed. We specifically included micropapillary and nested variants. RESULTS: Ten patients were identified, with eight having micropapillary carcinoma (MPC) and two having nested vari-ants. Nine patients were male. The median age was 75. The two patients with nested variant were 56 and 62 years old, respec-tively, whereas all patients with MPC were over the age of 70. Upon cystectomy of all micropapillary cases, three patients (37.5%) had positive lymph node invasion and the final patholo-gy was T2 (two patients), T3 (two patients), and T4 (four patients). Barring a grade III complication Clavien-Dindo classi-fication due to wound dehiscence that necessitated secondary surgical closure, there were no specific perioperative complica-tions. Given the urethral invasion, cystourethrectomy was per-formed on the female patient. Within a median 13-month fol-low-up, three patients developed local recurrence, including two urethral and one new lateral pelvic mass. CONCLUSIONS: Considering the muscle invasive nature of micropapillary and nested bladder cancer, aggressive surgical management should not be postponed. Moreover, due to notable prevalence of concurrent and/or recurrent urethral involvement, initial urethrectomy or early and frequent postoperative ure-throscopy should be provided. Patients with variant histology bladder cancer may benefit from early radical cystectomy when compared to bladder sparing protocols and prostate sparing cystectomy treatment options.