Hematuria: Is it useful in predicting renal or ureteral stones in patient presenting to emergency department with flank pain?

Objectives: The objective of the study was to evaluate hematuria as a diagnostic test for renal and ureteral stones compared with a noncontrast-enhanced computed tomography (CT) scan (gold standard test) in emergency room patients with acute flank pain. Patients and Methods: In total, 604 patients treated in our emergency department from 2006 to 2011, with a history of flank pain and suspected urolithiasis were included in a retrospective review. All patients were evaluated with a noncontrast-enhanced CT scan and urine analysis. Using the noncontrast CT scan as the gold standard for the evaluation of the presence, number, size, and site (renal or ureteral [upper, middle, and lower]) of the stones, we calculated the sensitivity, specificity, and positive and negative predictive values of hematuria for diagnosing both renal and ureteral stones. Results: Urolithiasis was diagnosed in 388 patients (64%) and 216 patients (36%) had no stones on a noncontrast-enhanced CT scan. The sensitivity, specificity, positive predictive value, and negative predictive value for microhematuria were 77%, 33%, 67%, and 45%, respectively. Microhematuria was more common in patients with ureteral stones only (139 patients) and had a sensitivity of 85% compared to patients with renal stones only (32 patients), with a sensitivity of 55% (P < 0.001). There were no significant differences in the specificity or positive or negative predictive values. Conclusion: Although microhematuria is more sensitive to ureteral stones, the absence of microhematuria does not exclude the possibility of urolithiasis and a noncontrast-enhanced CT scan should be the gold standard diagnostic tool.

The Saudi urological association guidelines on urolithiasis.

Aims: The Saudi Urolithiasis Guidelines are a set of recommendations for diagnosing, evaluating, and treating urolithiasis in the Saudi population. These guidelines are based on the latest evidence and expert consensus to improve patient outcomes and optimize care delivery. They cover the various aspects of urolithiasis, including risk factors, diagnosis, medical and surgical treatments, and prevention strategies. By following these guidelines, health-care professionals can improve care quality for individuals with urolithiasis in Saudi Arabia. Panel: The Saudi Urolithiasis Guidelines Panel consists of urologists specialized in endourology with expertise in urolithiasis and consultation with a guideline methodologist. All panelists involved in this document have submitted statements disclosing any potential conflicts of interest. Methods: The Saudi Guidelines on Urolithiasis were developed by relying primarily on established international guidelines to adopt or adapt the most appropriate guidance for the Saudi context. When necessary, the panel modified the phrasing of recommendations from different sources to ensure consistency within the document. To address areas less well covered in existing guidelines, the panel conducted a directed literature search for high quality evidence published in English, including meta analyses, randomized controlled trials, and prospective nonrandomized comparative studies. The panel also searched for locally relevant studies containing information unique to the Saudi Arabian population. The recommendations are formulated with a direction and strength of recommendation based on GRADE terminology and interpretation while relying on existing summaries of evidence from the existing guidelines.

Emphysematous sloughed floating ball after prostate water vaporization Rezum: A case report.

BACKGROUND: Rezum™ water vapor therapy is a new minimally invasive endoscopic technology for the management and treatment of benign prostatic hyperplasia. CASE SUMMARY: A 63-year-old male presented to our department with severe dysuria, frequency, urgency, and interrupted stream 2 mo after receiving Rezum™ therapy. The symptoms were caused by a retained floating emphysematous necrotic sloughed tissue. We also discovered a persistent bacterial infection that was resistant to parenteral antimicrobial therapy. The treatment of the patient included surgical removal of the necrotic tissue. CONCLUSION: Despite the good safety profile and minimal adverse events related to Rezum™ therapy, major complications can still occur.

The Role of Phosphodiesterase Inhibitors in the Management of Cavernositis With Multifocal Abscesses: A Report of Case Series.

INTRODUCTION: Cavernositis is a rare acute infection of the corporal bodies of the penis. It might result in corporal cavernosal abscesses, fibrosis, and subsequently erectile dysfunction if the treatment is inadequate. Previous reports advocate penile aspiration when cavernosal abscesses were significantly present. AIM: We report 2 cases of cavernositis treated by the standard antimicrobial therapy in addition to the daily use of phosphodiesterase type 5 inhibitors (iPDE-5). METHODS: We include 2 patients who fulfill the criteria for the diagnosis of cavernositis. They were diagnosed clinically based on history and physical examination. Patient 1 had multifocal abscesses on initial penile contrast-enhanced magnetic resonance imaging (MRI). This patient showed rapid clinical improvement with the addition of phosphodiesterase inhibitor (PDEi) to the antimicrobial therapy without the need for surgical drainage of the abscesses. Patient 2 had persistent infection despite 3 weeks of oral second-generation cephalosporin (Cefuroxime). But he showed significant clinical improvement after being started on PDEi in conjunction with the current antimicrobial therapy. Follow-up after 3 months by clinical examination and penile magnetic resonance imaging in both patients showed normal erectile function with no scarring. CONCLUSION: PDEi have promising results on disease progression and outcomes. It synergizes the effect of antimicrobial therapy and can potentially reduce the residual corporal fibrosis and erectile dysfunction. However, large studies are required to validate and generalize this treatment approach. Bakhsh A, Daqqaq T, Alhasan A, et al. The Role of Phosphodiesterase Inhibitors in the Management of Cavernositis With Multifocal Abscesses: A Report of Case Series. Sex Med 2020;8:318-322.

Long-term urinary functional outcome of vesicourethral anastomosis with bidirectional poliglecaprone (Monocryl®) vs. barbed polyglyconate suture (V-LocTM 180) in robot-assisted radical prostatectomy.

INTRODUCTION: We aimed to evaluate urinary continence recovery following robot-assisted radical prostatectomy (RARP) using monofilament poliglecaprone (Monocryl®) suture vs. barbed suture (V-LocTM 180) during vesicourethral anastomosis (VUA). METHODS: In this prospective, observational cohort, data were collected on 322 consecutive patients. All patients underwent continuous, bidirectional, single-layer running anastomosis with either 3.0 monofilament suture (n=141) or 3.0 barbed suture (n=181). The primary outcome was continence recovery defined as time to 0 pad at one, three, six, 12, and 24 months following surgery. RESULTS: Continence rates were significantly better with monofilament VUA at all followup time points up to one year. Median time to continence was one month vs. five months in the monofilament group vs. barbed group, respectively (p<0.001). Continence rates in monofilament suture vs. barbed group at one, three, six, 12, and 24 months were 56% vs. 26% (p<0.001), 73% vs. 36.4% (p<0.001), 84.4% vs. 60.2% (p<0.001), 90.8% vs. 71.9% (p<0.001), and 93.5% vs.87.1% (p=0.1), respectively. Anastomosis time was shorter in the barbed group, with a median of 23 vs. 30 minutes (p<0.001). Patients anastomosed with Monocryl suture had smaller prostate weight (median 42.5 g vs. 50 g; p<0.001) and harbored less advanced disease (T2a-c 76.6 vs. 74%; p=0.01) relative to patients treated with V-Loc 180 suture. However, in a multivariate Cox logistic regression analyses, independent predictors of continence recovery were suture type (hazard ratio [HR] 53; 95% confidence interval [CI] 0.41-0.68; p=0.02] and prostate size (HR 0.99; 95% CI 0.98-0.99; p<0.001). CONCLUSIONS: Barbed VUA contributed to delayed continence recovery compared to monofilament poliglecaprone suture during the first year post-RARP. However, no statistically significant difference was recorded at two years post-RARP. These results warrant special attention, especially with the widespread use of barbed suture in recent years.

Perioperative predictors for post-prostatectomy urinary incontinence in prostate cancer patients following robotic-assisted radical prostatectomy: Long-term results of a Canadian prospective cohort.

INTRODUCTION: We aimed to report the impact of perioperative factors that have not been well-studied on continence recovery following robotic-assisted radical prostatectomy (RARP). METHODS: We analyzed data of 322 men with localized prostate cancer who underwent RARP between October 2006 and May 2015 in a single Canadian centre. All patients were assessed at one, three, six, 12, and 24 months after surgery. We evaluated risk factors for post-prostatectomy urinary incontinence from a prospectively collected database in multivariate Cox regression analysis. The primary endpoint was continence, defined as 0 pad usage per day. RESULTS: 0-pad continence rates were 126/322 (39%), 187/321 (58%), 222/312 (71%), 238/294 (80%), and 233/257 (91%) at one, three, six, 12, and 24 months, respectively. Bladder neck preservation (hazard ratio [HR] 0.71; 95% confidence interval [CI] 0.5-0.99; p=0.04), and prostate size (HR 0.99; 95% CI 0.98-0.99; p=0.02) were independent predictors of continence recovery after RARP. Smoking at time of surgery predicted delayed continence recovery on multivariate analysis (HR 1.42; 95% CI 1.01-1.99; p=0.04). Neurovascular bundles preservation was associated with continence recovery after 24 months. No statistically significant correlation was found with other variables, such as age, body mass index, Charlson comorbidity index, preoperative oncological baseline parameters, presence of median lobe, or thermal energy use. CONCLUSIONS: Our results confirmed known predictors of postprostatectomy incontinence (PPI), namely bladder neck resection and large prostate volume. Noteworthy, cigarette smoking at the time of RARP was found to be a possible independent risk factor for PPI. This study is hypothesis-generating.

Prognostic utility of neutrophil-to-lymphocyte and platelets-to-lymphocyte ratio in predicting biochemical recurrence post robotic prostatectomy.

AIM: Utility of neutrophil-to-lymphocyte ratio (NLR) and platelet-to-lymphocyte ratio (PLR) in predicting biochemical recurrence (BCR) in patients with localized prostate cancer. MATERIALS & METHODS: Retrospective analysis of patients operated by robot-assisted radical prostatectomy. Variables included were: NLR, PLR pre-operative prostate specific antigen, pathological Gleason score, surgical margins status, extracapsular extension, seminal vesical invasion, and lymph node status. RESULTS: Out of 321 patients, no association between NLR or PLR and BCR was detected. Predictors of BCR were pathological Gleason score, extracapsular extension and positive surgical margins. On multivariate analysis, the Gleason Score, extracapsular extension and positive surgical margins remained the only predictors of BCR. CONCLUSION: Neither elevated NLR nor PLR predicted an increased risk of BCR.

Photoselective vaporization of the prostate with the 180-W XPS-Greenlight laser: Five-year experience of safety, efficiency, and functional outcomes.

INTRODUCTION: Transurethral resection of the prostate (TURP) is still considered the gold standard surgical treatment for symptomatic benign prostatic hyperplasia (BPH). However, photoselective vaporization of the prostate (PVP) has gained widespread global acceptance in national guidelines as a safe and effective alternative option. Nevertheless, further evidence is required to assess the durability of Greenlight PVP. Herein, we report our five years of PVP experience with the Greenlight 180W XPS laser system. METHODS: A retrospective analysis was conducted on a prospectively gathered database of 370 consecutively included patients who underwent PVP using Greenlight XPS-180 W laser system (Boston Scientific, Boston, MA, U.S.) performed by a single experienced laser surgeon between 2011 and 2016. Preoperative characteristics, intervention parameters, postoperative functional, uroflowmetry outcomes, and complications were collected. Outcomes are reported over a period of five years. RESULTS: Mean age was 68 years, with a mean prostate volume of 78.8 cc (95% confidence interval [CI] 70.9-78.7]). The mean followup was 59.4 months (55.4-63.5). Mean energy, operative time, and energy/cc were 270.2 kJ (255.2-285.2), 62.7 minutes (59.6-65.7), and 3.7 kJ/cc (3.6-3.9), respectively. Compared to preoperative values, International Prostate Symptom Score (IPSS), maximum flow rate (Qmax), and post-void residual (PVR) parameters were significantly improved and sustained over the five postoperative years. Of note, only 66 patients (out of 370) had a complete five-year followup. Prostate-specific antigen (PSA) reached nadir at one year, with a drop of 67% from the mean preoperative value of 6.2 ng/mL. Mean IPSS nadir was reached at three years, with a drop of 80.4% (-21.1 points). Similarly, mean quality of life (QoL) score dropped by 82.8% after three years (preoperative mean of 4.7). With respect to mean Qmax, there was an increase by 72.7% (+14.7 mL/s) at one year, reaching the value of 19.9 mL/s. Moreover, mean PVR was 32.8 mL at four years compared to 345 mL preoperatively. At five years followup, PSA, IPSS, QoL, and PVR dropped by 59.7% (3.7 ng/mL), 75.2% (19.7 points), 78.72% (3.7 points), and 84.4% (291.3 mL), respectively. Qmax increased by 12.9 mL/s. Clavien complication rates were low, with bladder neck stenosis observed in seven (1.6%) men. During the five-year followup, only four patients (1%) required BPH surgical re-intervention. CONCLUSIONS: This is the first long-term reporting of Greenlight XPS-180W laser system. In experienced hands, the observed outcomes appear to demonstrate that Greenlight XPS-180 W laser system is safe, efficacious, and durable for the treatment of bladder outlet obstruction (BOO) secondary to BPH.

Functional and oncological outcomes of salvage external beam radiotherapy following robot-assisted radical prostatectomy in a Canadian cohort.

INTRODUCTION: We sought to determine the impact of salvage radio-therapy (SRT) on oncological and functional outcomes of patients with prostate cancer after biochemical recurrence (BCR) following robot-assisted radical prostatectomy (RARP). METHODS: Data of 70 patients with prostate cancer treated with SRT after developing BCR were retrospectively analyzed from a prospectively collected RARP database of 740 men. Oncological (prostate-specific antigen [PSA]) and functional (pads/day, International Prostate Symptom Score [IPSS], and Sexual Health Inventory for Men [SHIM]) outcomes were reported at six, 12, and 24 months after RT and adjusted for pre-SRT status. RESULTS: Men who underwent SRT had a mean age, PSA, and time from radical prostatectomy (RP) to RT of 61.8 years (60.1-63.6), 0.5 ng/ml (0.2-0.8), and 458 days (307-747), respectively. Freedom from biochemical failure (FFBF) post-SRT, defined as a PSA nadir <0.2 ng/mL, was observed in 89%, 93%, and 81%, at six, 12, and 24 months, respectively. Undetectable PSA was observed in 14%, 35%, and 40% at the same time points, respectively. There was no significant difference in urinary continence post-SRT (p=0.56). Rate of strict continence (0 pads/day) was 71% at 24 months compared to 78% pre-SRT. Mean IPSS at six, 12, and 24 months was 3.4, 3.6, and 3.6, respectively compared to pre-RT score of 3.3 (p=0.61). The mean SHIM score pre-SRT was comparable at all time points following treatment (p=0.86). CONCLUSIONS: In this unique Canadian experience, it appears that early SRT is highly effective for the treatment of BCR following RARP with little impact on urinary continence and potency outcomes.

The risk of urinary retention following robot-assisted radical prostatectomy and its impact on early continence outcomes.

INTRODUCTION: We aimed to evaluate the risk factors of acute urinary retention (AUR) following robot-assisted radical prostatectomy (RARP), as well as the relationship of AUR with early continence outcomes. METHODS: The records of 740 consecutive patients who underwent RARP by two experienced surgeons at our institution were retrospectively reviewed from a prospectively collected database. Multiple factors, including age, body mass index (BMI), international prostate symptom score (IPSS), prostate volume, presence of median lobe, nerve preservation status, anastomosis time, and catheter removal time (Day 4 vs. 7), were evaluated as risk factors for AUR using univariate and multivariate analysis. The relation between AUR and early return of continence (one and three months) post-RARP was also evaluated. RESULTS: The incidence of clinically significant vesico-urethral anastomotic (VUA) leak and AUR following catheter removal were 0.9% and 2.2% (17/740), respectively. In men who developed AUR, there was no significant relationship with regards to age, BMI, IPSS, prostatic volume, median lobe, nerve preservation, or anastomosis time; however, the incidence of AUR was significantly higher for men with catheter removal at Day 4 (4.5% [16/351]) vs. Day 7 (0.2% [1/389]) (p=0.004). Moreover, patients with early removal of the catheter (Day 4) who developed AUR had an earlier one-month return of 0-pad continence 87.5% (14/16) compared to patients without AUR 45.6% (153/335), with no significant difference at three months. CONCLUSIONS: While AUR is an uncommon complication of RARP, its incidence is much higher than VUA leakage. Further, it is often not well-discussed during patient counselling preoperatively. Moreover, earlier return of urinary continence was observed in patients experiencing AUR following RARP exclusively with catheter removal at Day 4. Future studies are warranted to validate the long-term impact of AUR on continence outcomes.

Does surgical delay for radical prostatectomy affect biochemical recurrence? A retrospective analysis from a Canadian cohort.

AIM: We sought to explore the impact of surgical wait time (SWT) to robot-assisted radical prostatectomy (RARP) on biochemical recurrence (BCR). METHOD: Retrospective review of a prospectively collected database between 2006 and 2015 was conducted on all RARP cases. SWT was defined as period from prostate biopsy to surgery. Primary outcome was the impact on BCR, which was defined as two consecutive PSA ≥ 0.2 ng/dl, or salvage external beam radiation therapy and/or salvage androgen deprivation therapy. Patients were stratified according to D'Amico risk categories. Univariable analysis (UVA) and multivariable analyses (MVA) with a Cox proportional hazards regression model were used to evaluate the effect of SWT and other predictive factors on BCR, in each D'Amico risk group and on the overall collective sample. RESULTS: Patients eligible for analysis were 619. Mean SWT was 153, 169, 150, and 125 days, for overall, low-, intermediate-, and high-risk patients, respectively. Multivariate analysis on the overall cohort did not show a significant relation between SWT and BCR. On subgroup analysis of D'Amico risk group, SWT was positively correlated to BCR for high-risk group (p = 0.001). On threshold analysis, cut-off was found to be 90 days. SWT did not significantly affect BCR on UVA and MVA in the low- and intermediate-risk groups. CONCLUSION: Increased delay to surgery could affect the BCR, as there was a positive association in high-risk group. Further studies with longer follow-up are necessary to assess the impact of wait time on BCR, cancer specific survival and overall survival.

Does surgical delay for radical prostatectomy affect patient pathological outcome? A retrospective analysis from a Canadian cohort.

INTRODUCTION: We sought to assess the impact of surgical wait time (SWT) to robot-assisted radical prostatectomy (RARP) on final pathological outcome. METHODS: A retrospective review of RARP patient records operated between 2006 and 2015 was conducted. SWT was defined as period from prostate biopsy to surgery. Primary outcome was the impact on postoperative Cancer of the Prostate Risk Assessment (CAPRA-S) score. Patients were stratified according to D'Amico risk categories. Univariate analysis (UVA) and multivariable (MVA) analysis with a generalized linear model was used to evaluate the effect of SWT and other predictive factors on pathological outcome in individual risk group and on the overall sample. RESULTS: A total of 835 patients were eligible for analysis. Mean SWT was significantly different between the three D'Amico groups, with mean SWT of 180.22 days (95% confidence interval [CI] 169.03; 191.41), 159.14 days (95% CI 152.38; 165.90), and 138.96 days (95% CI 124.60; 153.33) for low-, intermediate-, and high-risk groups, respectively (p<0.001). After stratification by D'Amico risk group, no significant association was observed between SWT and CAPRA-S score in the three risk categories on UVA and MVA. Predictors of higher CAPRA-S score in the multivariable model in the overall cohort were: older age (p=0.014), biopsy Gleason score (p<0.001), percentage of positive cores (p<0.001), and clinical stage (p<0.001). CONCLUSIONS: In the present study evaluating SWT for RARP in a Canadian socialized system, increased delay for surgery does not appear to impact the pathological outcome. Further studies are required to evaluate the impact of wait time on biochemical recurrence-free survival, cancer-specific survival, and overall survival.

Standardized 4-step technique of bladder neck dissection during robot-assisted radical prostatectomy.

Bladder neck (BN) dissection is considered one of the most challenging steps during robot-assisted radical prostatectomy. Better understanding of the BN anatomy, coupled with a standardized approach may facilitate dissection while minimizing complications. We describe in this article the 4 anatomic spaces during standardized BN dissection, as well other technical maneuvers of managing difficult scenarios including treatment of a large median lobe or patients with previous transurethral resection of the prostate. The first step involves the proper identification of the BN followed by slow horizontal dissection of the first layer (the dorsal venous complex and perivesicle fat). The second step proceeds with reconfirming the location of the BN followed by midline dissection of the second anatomical layer (the anterior bladder muscle and mucosa) using the tip of the monopolar scissor until the catheter is identified. The deflated catheter is then grasped by the assistant to apply upward traction on the prostate from 2 directions along with downward traction on the posterior bladder wall by the tip of the suction instrument. This triangulation allows easier, and safer visual, layer by layer, dissection of the third BN layer (the posterior bladder mucosa and muscle wall). The forth step is next performed by blunt puncture of the fourth layer (the retrotrigonal fascia) aiming to enter into the previously dissected seminal vesical space. Finally, both vas deferens and seminal vesicles are pulled through the open BN and handed to the assistant for upper traction to initiate Denovillier's dissection and prostate pedicle/neurovascular bundle control.

Outcomes of a minimally invasive surgical approach to manage persistent high-grade vesicoureteric reflux post successful augmentation cystoplasty of patients with non-compliant bladder.

INTRODUCTION: Secondary vesicoureteric reflux (VUR) is a common problem associated with non-compliant bladders. Management of this disorder is debatable in literature. Many authors reported high resolution rate of VUR with augmentation cystoplasty (ACP) alone. Others showed significant residual VUR after ACP and recommend ureteric re-implantation (UR) at time of augmentation. OBJECTIVE: Studying efficacy of endoscopic correction of persistent high-grade VUR (ECVUR) post successful ACP. DESIGN: Patients with non-compliant bladders and high-grade VUR are enrolled in the program of our institute, where they are initially managed conservatively. Those not responding are managed endoscopically using intravesical botulinum toxin A and ECVUR. Patients who are not candidates or failed this approach undergo ACP without UR. A total of 82 patients with non-compliant bladder underwent ACP between 2001 and 2011. Of those, 24 patients had high-grade VUR with 44 refluxing units (RU), 20 bilateral and 4 unilateral. The mean age at intervention was 7.62 years with a mean follow-up of 5.6 years. Patients with persistent high-grade VUR and recurrent breakthrough febrile UTI despite antibiotic prophylaxis following ACP were identified and enrolled in our prospective trial of interval ECVUR. Statistical analyses was performed to identify predictors of high-grade VUR resolution after ACP and ECVUR. A p value <0.05 was considered statistically significant (Table 1). RESULTS: Of the 24 patients, 17 underwent ileocystoplasty and 7 underwent ureterocystoplasty. One of the patients that underwent ileocystoplasty found to have a blind ending RU that was excised. Of the 36 remaining RU, 21/36 (58.3%) showed complete resolution in the first follow-up cystogram, and 1 showed complete resolution after 1 year. Two patients, each with single RU, received repeat ACP because of poor compliance and/or inadequate bladder capacity post ureterocystoplasty and showed complete resolution of reflux post-operatively, which increased the resolution rate post ACP to 66.6% (24/36) (Table 2). Of the remaining 12 RU in 7 patients, 10 underwent trial of ECVUR. VUR resolved in 8 RU after the first trial and in another 2 after the second trial (Table 3). Parents of 1 patient with the remaining 2 RU preferred to continue with conservative management (Table 2). DISCUSSION: VUR in patients with non-compliant bladder is usually secondary to high detrusor pressure, low compliance and small capacity. Whereas some investigators showed high resolution rate of VUR post augmentation without UR, claiming that by successfully augmenting the bladder, compliance will increase, detrusor pressure will decrease, and as a result, VUR will spontaneously resolve. Others showed high incidence of persistent VUR (47-57%) and recommend UR at time of ACP. In our study, the incidence of spontaneous resolution was 66.6% (24/36). In cases where VUR persists, ECVUR was performed. With this approach, VUR resolution increased to 94% (34/36). This study is limited by the small number of patients, lack of randomization and lack of comparison group in which patients undergo ACP with UR. CONCLUSION: ACP without UR with interval endoscopic management seems to be an effective and adequate treatment for high pressure, non-compliant bladder as well as high-grade VUR when conservative management fails.