The correlation between PI-RADS score and the detection of prostate cancer using MRI-ultrasound fusion-guided transperineal prostate biopsy: The first Philippine report

OBJECTIVE@#MRI-Ultrasound fusion guided targeted biopsy has revolutionized the diagnosis of prostatecancer through accurate identification, localization and characterization of prostatic lesions utilizingthe prostate imaging reporting and data system (PI-RADS) scoring system by multiparametric MRI(MPMRI). The fusion prostate biopsy system on the other hand, enables accurate targeting and easyaccess of the tumor. The study objective is to determine the detection rate of clinically-significantprostate cancer using fusion biopsy, and to establish the correlation between PI-RADS score andGleason's score.@*PATIENTS AND METHODS@#A retrospective cohort study was conducted to determine the correlation betweenPI-RADS score and the presence of prostate cancer using MRI-Ultrasound fusion guided transperinealprostate biopsy. This was carried out from June 2017 to July 2018 in a single institution. One hundredthirty five (135) men were included in this study. They presented with an elevated PSA, abnormalDRE or a previous negative prostate biopsy, but with a persistent rise in PSA. A total of 220 prostatelesions were identified. The following characteristics were measured: patient age; the size, location,the PI-RADS score of each lesion, the maximum PI-RADS score for select patients; and the Gleasonscore of discovered tumors.@*RESULTS@# Two hundred twenty PI-RADS 3, 4 and 5 lesions were detected in 135 patients by MPMRI.131 of the 220 lesions were scored as PI-RADS 3, 61 as PI-RADS 4 and 28 as PI-RADS 5. Theselesions were biopsied using the MRI-Ultrasound fusion guided transperineal prostate biopsy system.Thirty-three out of the 131 PI-RADS 3 lesions (25.2%), 44 out of the 61 PI-RADS 4 lesions (72.1%)and 24 out of the 28 PI-RADS 5 lesions (85.7%) respectively were positive for malignancy. Overall,there were 101 (45.9%) lesions classified as PI-RADS 3 to 5 that were positive for prostate carcinoma.Seventy four (74) of the 135 patients (54.8%) were diagnosed with prostate adenocarcinoma. Nineteenout of 65 patients with a maximum score of PI-RADS 3 (29.2%), 33 of 44 with a maximum of PI-RADS 4 (75%) and 22 of 26 with a maximum of PI-RADS 5 (84.6%) harbored malignancy. In termsof location, 45 of the 101 (44.6%) malignancies were in the peripheral sector, 31 (30.7%) in theanterior sector, and 25 (24.8%) in the central sector of the prostate. The mean Gleason grade of PI-RADS 3, 4 and 5 lesions were 6.61, 7.73, and 7.38, respectively. Using Spearman correlation, the rhocoefficient was 0.3153 (p-value =.00013) which denotes a significant positive relationship betweenGleason and PI-RADS score.@*CONCLUSION@#This is the first comprehensive Philippine study on Multiparametric MRI-Ultrasoundfusion-guided transperineal prostate biopsy. Present data validate the superiority of MPMRI in theidentification, localization and characterization of prostate cancers. The authors also verified thepositive correlation between PI-RADS score and Gleason score. Finally, they demonstrated theaccuracy of the MRI- ultrasound fusion-guided transperineal prostate biopsy system in targetingprostate lesions.

24-hour urinary citrate determination among Filipino urinary stone formers after potassium citrate therapy: A prospective, cohort study

OBJECTIVE@#Urolithiasis, a common problem in medicine, poses a significant burden with prevalenceof 1-15%. Potassium citrate therapy has become one of the cornerstones of medical stone managementwith hypocitraturia being the most common metabolic problem in stone formers. The authorsdetermined the effects of potassium citrate on urinary metabolic profiles and its impact on stoneburden among Filipino stone formers.@*PATIENTS AND METHODS@#This is a prospective, cohort study in patients seen at the UST Hospital between2016 and 2018. Twenty-four hour urine citrate levels, stone sizes and urine pH pre-therapy and post-therapy were analyzed.@*RESULTS@#Significant changes in urinary citrate, pH and stone sizes were noted as soon as 3 months afterthe onset of therapy. These changes included increase in urinary pH (6.1 to 6.7; p=0.001), increase inurinary citrate (109.1 to 253.4mg/day; p<0.001) and decrease in stone size (0.56 to 0.37cm; p=0.037).The changes in the urine citrate and the changes in the stone size were not correlated using the Pearsoncorrelation scatter plot.@*CONCLUSION@#Potassium citrate therapy provides a significant alkali and citraturic treatment among Filipino stone formers. However, there is no significant correlation between changes in stone size and changes in urine citrate level.

Comparison of the voiding pattern in toilet-trained Filipino children with urinary tract infection with and without vesicoureteral reflux: A prospective study

OBJECTIVES@#Vesicoureteral reflux (VUR) is a common abnormality of the urinary tract in children andremains a dilemma that is commonly seen by physicians. Unrecognized VUR associated with UTImay lead to long term effects on renal function and overall patient health. To date, there is no currentstudy on voiding patterns of children presenting as recurrent UTI with and without VUR. In thisstudy, the authors aim to determine if there is a difference in the voiding pattern of toilet trainedFilipino children with UTI between those with and without VUR and to see if there is associationbetween these parameters with the degree of VUR.@*MATERIALS AND METHODS@#The study employed a prospective research design. Population consisted ofpediatric patients seen in the clinic diagnosed as a case of UTI documented with positive urineculture. Voiding cystourethrogram was done to determine presence or absence of VUR. The procedurewas done by a single Urologist at a single institution. The patients were then subdivided into 2 groups,the first group consisted of patients with UTI with VUR and another group had those with UTI butwithout VUR. A subanalysis was done to determine association depending on the degree of reflux.Logistic regression analysis, chi-square test and ANOVA were used to determine if there was anystatistically significant difference between the two groups.@*RESULTS@#A total of 223 pediatric patients with ages ranging from 2 years to 17 years with mean age of9.5 years with documented urinary tract infection were noted. Among these, only 140 patientsunderwent VCUG hence included in the study. It consists of 57 male patients (40%) and 83 femalepatients (59%). Among these patients, 65 patients (46%) had vesicoureteral reflux and 75 patients(53%) had no vesicoureteral reflux. Each patient's voiding parameters such as bladder wall thickness,bladder capacity, postvoid residual, Qmax and voiding pattern were noted and compared betweengroups. A subanalysis was also done to determine any association of these parameters to the degree ofreflux.@*CONCLUSION@#In the present series, bladder capacity was the only parameter found to be statisticallydifferent between those with and those without VUR. Furthermore, this difference was only seenamong those with grades 3, 4 and 5 refluxes. Future study must be carried out to determine its clinicalsignificance. Physicians must be vigilant and must have a high index of suspicion in dealing withpatients with episodes of febrile UTI. To date, voiding cystourethrogram is still the gold standard todiagnose this disease entity.

Postoperative breakthrough infection and re-operation in patients with duplicated collecting systems: A comparative analysis of surgical outcomes

OBJECTIVE@#The purpose of surgical intervention for ureteral duplication is to decrease the risk ofinfections, preserve renal function and avoid bladder dysfunction. The objective of this study was todetermine if there is a difference in outcome between total reconstruction of the urinary tract, anupper tract approach, or a lower tract approach.@*MATERIALS AND METHODS@#The outcomes of partial nephrectomy, common sheath re- implantation, totalreconstruction and transurethral incision of ureterocele were pooled and compared against eachother. Primary outcome criteria included breakthrough infection, voiding dysfunction and need for asecond surgery. Procedural dependence of the primary outcomes for each surgery was analyzed usingChi square test. Odds ratio was then computed for each procedure with total reconstruction as thestandard. Logistic regression analysis of the odds ratio was done to determine statistical significance.@*RESULTS@#A total of 128 patients were included in the study. Breakthrough infection was seen in 18.8%of those who underwent partial nephrectomy, 23.8% of those who underwent re- implantation, 19.4%of those who underwent total reconstruction, and 46.4% of those patients who underwent TUI-U.Only 1 patient from the partial nephrectomy group and 1 patient from the total reconstruction groupexperienced voiding dysfunction. Of the 23 patients who underwent TUI-U, 5 (17.9%) needed asecondary procedure, while 3 from the partial nephrectomy, and none from the re-implantation andtotal reconstruction groups required re-operations. Analysis showed that breakthrough urinary tractinfection is dependent on the type of procedure. Using total reconstruction as the standard, the oddsratio for partial nephrectomy is 0.962, 1.302 for common sheath re-implantation and 3.611 for TUI-U. Logistic regression analysis showed statistical difference in the odds ratio of TUI-U and totalreconstruction.@*CONCLUSION@#Breakthrough infection is shown to be dependent on the procedure. TUI-U has a 3.6-foldhigher chance of breakthrough infection compared to total reconstruction, hence up to 18% of patientswho opt for TUI-U should be counseled regarding the need for a secondary operation. The odds ofbreakthrough infection in common sheath re-implantation and partial nephrectomy is not significantlydifferent from total reconstruction. No evidence was established regarding the dependence of re-operations and voiding dysfunction to the primary procedure.

Outcomes of duplex system ureteroceles in pediatric patients managed primarily with transurethral incision

@#Transurethral incision of ureterocele (TUI-U) is a simple, quick, less invasive, and less expensive,and an effective procedure for the management of ureteroceles. Several studies have already shownits utility for primary management of ureteroceles but it has also been associated with the need foradditional surgery. The authors reviewed charts of patients from their database to describe the outcomesof TUI-U done in ureteroceles associated with the upper pole moiety of a duplex system. They alsolooked into preoperative patient characteristics and post TUI-U outcomes that could influence theneed for subsequent surgeries.@*MATERIALS AND METHODS@#The authors identified patients from their duplex system database who presentedwith a ureterocele and underwent TUI-U. They reviewed the patient records of 25 patients who wereincluded in the study to determine the outcomes of TUI-U in duplex system ureteroceles. Chi squareand Mann Whitney U tests were used to determine whether preoperative patient features and postTUI-U outcomes were associated with secondary surgery.@*RESULTS@#Out of 65 patients who had duplex system ureteroceles, 25 patients (38.4%) underwent TUI-U at a mean age of 1.51 years old. TUI-U alone was successful in improving the prevalent signs andsymptoms of 15 patients (60%) in this group, while 10 patients (40%) had to undergo subsequentsurgical procedures. Breakthrough urinary tract infection (UTI) post TUI-U was the only patientfactor noted to be significantly associated with a secondary surgery for duplex system ureterocele(p=0.027).@*CONCLUSION@#TUI-U as primary treatment for duplex system ureteroceles is not yet widely accepteddue to reported rates of morbidities and need for secondary surgery. Present data however show thatTUI-U can be used as a primary procedure and even as a definitive procedure for this subset ofpatients with remarkable results in terms of symptoms resolution and improvement of upper tract profiles.

Voiding pattern of toilet-trained Filipino children with recurrent urinary tract infection and without urinary tract infection

OBJECTIVES@#The objectives of this study were to compare the voiding pattern of toilet-trained patientswith and without recurrent UTI, to describe the voiding pattern of toilet-trained patients withoutUTI aged 2 to 15 years old and to describe the voiding pattern of toilet trained patients with recurrentUTI aged 2 to 15 years old.@*MATERIALS AND METHODS@#A total of 80 toilet-trained Filipino children divided into two groups with 40each were included. R-UTI group consisted of patients aged 2 to 15 years old who presented withrecurrent UTI. The control (No-UTI) group consisted of children aged 2 to 15 years old without anyurinary symptoms and without history of urinary tract infection. Parents completed a 72-hour bladderchart at home. All participants answered Farhat's DVSS. Patients underwent uroflowmetry,uroflowmetry with EMG and post void residual assessment (PVR). Qmax, uroflowmetry pattern,bladder wall thickness and PVR were recorded and analyzed using independent t-test.@*RESULTS@#The mean age of subjects with UTI was 6.32 ± 2.77 years and those in the control group havea mean age 6.67 ± 2.77 years old. Of patients of R-UTI group the following were statisticallysignificant compared to No-UTI : Constipation (48% vs 15%), mean frequency of voiding volumesgreater than 125% of the estimated bladder capacity (EBC) at daytime (0.8 ± 0.22 vs 0.05 ± 1.20p=0.0002), frequency (45% vs 5%), mean average voided volume (126.54 ± 56.05 mL vs 84.34 ±34.26 mL p=0.0001), mean daytime average voided volume (121.33 ± 59.59 mL vs 87.90 ± 36.41mL p =0.0033), mean maximum voided volume (232.25 ± 113.99 mL vs 130.85 ± 49.99 mLp<0.0001), mean bladder thickness (3.83 ± 0.68 mm vs 3.38 ± 0.62 mm p = 0.0030), mean PVR(12.96 ± 10.54 mL vs 5.21 ± 5.68 mL p=0.0001). PVR was significant in 45% of cases compared to3% significant PVR (when 4-6 years old defined as >10ml or >10%of EBC, and if >7 years old >20mlor >15% of EBC). When mean PVR was computed as percentage of EBC, R-UTI group had astatistically higher percentage compared to the no-UTI group (6.27 ± 2.52 % vs 2.52 ± 2.75 %p=0.0001). Mean observed bladder capacity (OBC) was found to be more than the EBC in 35% ofcases in the R-UTI group compared to 12% of No-UTI group (p=0.018). Uroflow-EMG in the R-UTI group were, 85% synergic, 12% dyssynergic and 3% interrupted pattern. EMG in the No-UTIgroup were, 38% synergic, 55% dyssynergic, 2% delayed relaxation, 5% interrupted. The EMGpatterns were statistically significant between the groups (p<0.0001). Uroflow patterns werecomparable between the two groups (p=1.000).@*CONCLUSION@#Constipation was more frequent in the R-UTI group. R-UTI group had a higher meanfrequency of EBC > 125% during daytime, frequency, mean average voided volume, mean averagevoided volume during daytime, mean maximum voided volume, mean bladder thickness, mean PVRcompared to the without UTI group. Mean observed bladder capacity was observed to be greater thanthe EBC in the R-UTI group compared to the No-UTI group. R-UTI group was synergic compared toNo-UTI group which were dyssynergic.

Outcome predictive values of the Society of Fetal Urology (SFU) Grading System and Urinary Tract Dilation (UTD) Classification in patients with high-grade ureteropelvic junction obstruction-like prenatal hydronephrosis

Objectives@#This study aimed to determine the surgical predictive value of both SFU and UTD classifications in a specific subset of patients presenting with high-grade (SFU 3 and 4; UTD P2 and P3) UPJO-like hydronephrosis on prenatal ultrasound. Furthermore, this study also aimed to determine the likelihood of spontaneous resolution of high grade UPJO-like hydronphrosis based on both grading systems. @*Methods@#Patients who presented with high-grade hydronephrosis on prenatal ultrasound based on the SFU grading system (Grades 3 and 4) were included in this study. The prenatal renal ultrasounds of these patients were reclassified by a single interpreter according to the UTD classification. Logistic regression was used to test the predictive value of SFU and UTD; ROC curves were plotted accordingly. Kaplan-Meier curves were used to model time to operation and mean time to operation was computed with a 95% confidence interval. Breslow Test was used to determine significant differences in survival curves across the different SFU grades and UTD classifications.@*Results@#Of the 163 patients in the database who presented with prenatal hydronephrosis, 25 patients presented with high-grade UPJO-like hydronephrosis (50 renal units). Logistic regression revealed that the SFU grading system was able to explain only 18.7% of the variance of the occurrence of pyeloplasty, thus, was a poor predictor of the occurrence of surgery. In contrast, logistic regression of the UTD classification was able to explain 47.3% of the occurrence of pyeloplasy with an accuracy of 86% making it a good predictor of surgical intervention. Both SFU and UTD classifications were poor predictors of spontaneous resolution. Mean time to pyeloplasty from the time of diagnosis was 2.98 years (95% CI: 2.45-3.53) Kaplan-Meier curve analysis for the time of pyeloplasty for the SFU grading system revealed no significant difference in the time to operation among the different SFU grades (p=0.110) while for the UTD classification, there was a significant difference in time to pyeloplasty across the different UTD classes with the higher classes correlating to a shorter time to pyeloplasty. (p<0.05) @*Conclusion@#The UTD classification system is a good predictor of surgery in patients presenting with high-grade UPJO-like hydronephrosis on prenatal ultrasound with a predictive accuracy of 86%. High-grade hydronephrosis based on the UTD classification equates to a shorter time to surgical intervention from the time of diagnosis necessitating closer follow-up of these patients.

The utility of ureteral jet angle sonography as initial screening tool for assessing vesico-ureteral reflux in the Philippines: A prospective, cross-sectional trial

@#<p style="text-align: justify;"><strong>INTRODUCTION:</strong> One of the common risk factors in urinary tract infection is vesico-ureteral reflux. According to some studies, it is seen in 30%-50% of children and 40%-50% present with febrile urinary tract infection. The presence of moderate to severe reflux is an important risk factor in terms of acute pyelonephritis and reflux nepropathy. Investigation of children with urinary tract infection has undergone change so as to detect those who will benefit from diagnosis and treatment at the same time avoid over investigation.<br /><strong>OBJECTIVE:</strong> The present study aimed to determine the role of ureteral jet angle (UJA) in detecting vesicoureteral reflux (VUR) as compared to the gold standard of voiding cystourethrography (VCUG).<br /><strong>METHODS:</strong> A total number of 152 kidneys from 76 patients (37 female and 39 males) ages from 2 months up to 11 years old were included in this study. These patients presented with recurrent urinary tract infection as confirmed via routine urinalysis and/or urine culture and sensitivity and assessed to have vesico-ureteral reflux disease as confirmed by voiding cystourethrogram (VCUG). They were included regardless of the grade of reflux (grade I-V). Patients with urinary tract infection but negative VCUG were also included. Excluded from the study were parents with no consent, patients with neurogenic bladder disorder as cause of recurrent urinary tract infection, patients who had postoperative correction of vesico-ureteral reflux prior to ureteral jet angle sonography, patients currently taking medication for urinary tract infection and patients currently symptomatic for recurrent urinary tract infection i.e. fever,chills,dysuria. All of the participants underwent kidney, urinary bladder ultrasound with ureteral jet angle sonography and all data were collected.<br /><strong>RESULTS:</strong> Out of 152 kidneys, vesicoureteral reflux was seen in 91 of them (60%). Low grade reflux defined as grade I or grade II reflux was present in 32 kidneys (21%) and high grade reflux defined as grade III-V reflux was seen in 59 kidneys (39%). In both right and left kidneys, no significant difference was observed in bladder volume and expected bladder capacity (EBC) by VUR status. On the other hand, there was a significant difference observed in volume to reach reflux by VUR status of both right and left kidneys. No significant difference was observed in UJA volume, EBC, EBC% and UJA degrees by VUR status in the right kidneys. On the other hand, UJA volume, EBC and EBC% was significantly different by VUR status in the left kidneys. All AUCs were less than 0.7 even if EBC was considered. Therefore, UJA may have poor ability to classify patients correctly according to their VUR status.<br /><strong>CONCLUSION:</strong> Doppler flow ultrasound measurement of ureteral jet angle may be a simple and real non invasive test in children of any age but it only showed poor correlation compared to voiding cystourethrography in detecting vesicoureteral reflux. The ureteral jet angle sonography may not be a good initial diagnostic test in assessing vesicoureteral reflux due to its low sensitivity and specificity in detecting the said disease.</p>

In-vitro cultivation of urothelial cells for genito-urinary tract reconstructive surgery: an experimental study

An in-vitro system for the cultivation of urothelial cells has been developed. Urothelial cells were isolated from 30 tissue samples obtained from the urinary bladders of six adult New Zealand rabbits that underwent partial cystectomy. The cells from 15 samples were grown in M-199 culture media and that from the remaining 15 samples were grown over human placental membranes measuring 3 x 4 x 0.1 centimeter (cm) contained in the same media. Confluent cell monolayers covering the entire base of the plastic multiwells and the entire amniotic membranes were produced within 7 days respectively in all cases. Subsequent subcultures likewise achieved the same confluency within another 7 days. Morphological analysis of all cultures by inverted phase contrast microscopy revealed cells of epithelioid nature. Cells from the media were likewise concentrated by centrifugation and smeared over glass slides, heat-dried and fixed with absolute ethanol. The smears underwent Giemsa staining and were examined under light microscopy and confirmed the presence of urothelial cells. The cultured urothelial graft developed from this study is a potentially useful material for future in-vivo researches involving genito-urinary tract reconstructive surgeries.

Local prototype self-retaining ureteral stent designed from a polyvinyl tube: an animal study

The self-retaining ureteral stent has evolved to be an invaluable tool in the urologists armamentarium. Its high cost and occasional unavailability led to the innovative idea of designing a local prototype. The Fr 5 feeding tube (polyvinyl chloride) was fashioned into a self-retaining stent by utilizing the inherent property of this thermoplastic. Eight male dogs were divided into 2 groups: one group was stented for three weeks, while the other for six weeks. The prototype stents were placed at the right while silicone stents at the left ureters. Ureteral tissue reactions and tensile strengths of these stents were evaluated. Results showed that tissue reactions were more prominent on those stented with the prototype stents. However, the difference was not statistically significant.

Locating the chordee in hypospadias

Ten patients with hypospadias were included in this study. The type of hypospadias and the degree of penile bowing were described. The location and the extent of the fibrotic tissue representing the chordee were defined in relation to the corpus spongiosum, the hypospadic meatus, and the urethral plate. A common finding among all ten patients was that the location of the fibrosis extended from the area proximal to the meatus to the proximal edge of the glans penis. Splaying of the fibrotic tissue resulting in its fan-shaped formation, as classically described in most textbooks, was not noted. The relationship of the fibrotic tissue to the corpus spongiosum, to the urethral meatus, and to the urethral plate was found to be inconsistent.