A Case of Fournier's Gangrene in a Patient With Malignant Priapism.

Fournier's gangrene is a rare and potentially life-threatening type of necrotizing fasciitis that affects the genital and perineal regions. Malignant priapism is a rare and serious medical condition characterized by persistent and painful erection of the penis that is not associated with sexual arousal or stimulation. We present a case of a 77-year-old man with concurrent Fournier's gangrene and malignant priapism. He first underwent surgical debridement to remove necrotic tissue and aspiration of blood from the corpora cavernosa. Then a palliative penectomy was performed. The patient succumbed to severe sepsis and died after 14 days of hospitalization.

Artificial Intelligence in Urologic Robotic Oncologic Surgery: A Narrative Review.

With the rapid increase in computer processing capacity over the past two decades, machine learning techniques have been applied in many sectors of daily life. Machine learning in therapeutic settings is also gaining popularity. We analysed current studies on machine learning in robotic urologic surgery. We searched PubMed/Medline and Google Scholar up to December 2023. Search terms included "urologic surgery", "artificial intelligence", "machine learning", "neural network", "automation", and "robotic surgery". Automatic preoperative imaging, intraoperative anatomy matching, and bleeding prediction has been a major focus. Early artificial intelligence (AI) therapeutic outcomes are promising. Robot-assisted surgery provides precise telemetry data and a cutting-edge viewing console to analyse and improve AI integration in surgery. Machine learning enhances surgical skill feedback, procedure effectiveness, surgical guidance, and postoperative prediction. Tension-sensors on robotic arms and augmented reality can improve surgery. This provides real-time organ motion monitoring, improving precision and accuracy. As datasets develop and electronic health records are used more and more, these technologies will become more effective and useful. AI in robotic surgery is intended to improve surgical training and experience. Both seek precision to improve surgical care. AI in ''master-slave'' robotic surgery offers the detailed, step-by-step examination of autonomous robotic treatments.

The use of indocyanine green in partial nephrectomy: a systematic review.

Introduction: The aim of this review was to assess the outcomes of partial nephrectomy using indocyanine green (ICG) regarding ischemia time, positive surgical margins (PSM), estimated blood loss (EBL) and estimated GFR reduction while also suggesting the optimal dosage scheme. Material and methods: A systematic review was performed using Medline (PubMed), ClinicalTrials.gov, and Cochrane Library (CENTRAL) databases, in concordance with the PRISMA statement. Studies in English regarding the use of indocyanine green in partial nephrectomy were reviewed. Reviews and meta-analyses, editorials, perspectives, and letters to the editors were excluded. Results: Individual ICG dose was 5 mg in most of the studies. The mean warm ischemia time (WIT) on each study ranged from 11.6 minutes to 27.2 minutes. The reported eGFR reduction ranged from 0% to 15.47%. Lowest mean EBL rate was 48.2 ml and the highest was 347 ml. Positive surgical margin rates were between 0.3% to 11%. Conclusions: Indocyanine green seems to be a useful tool in partial nephrectomy as it can assist surgeons in identifying tumor and its related vasculature. Thereby, warm ischemia time can be reduced and, in some cases, selective ischemia can be implemented leading to better renal functional preservation.

Ureteral stent related symptoms: A comparative study.

BACKGROUND: In urology, ureteral stents are used to treat obstructive diseases. Hematuria (54%), fever, discomfort, and lower urinary system symptoms are the predominant symptoms related to ureteral stent. AIM: This article links stent symptoms to double-j width and length, as well as patient's height, weight, and body mass index (BMI). Ureteric Stent Symptoms Questionnaire (USSQ) was used to measure ureteral stent symptoms at 1st and 4th week of stent in situ as well as the 4th week after pigtail removal. METHODS: A 200-patient prospective study, where patients were allocated into four groups following ureteral stent insertion depending on the stent characteristics. Those groups were: 4.8 Fr./26 cm (Group A), 4.8 Fr./28 cm (Group B), 6 Fr/26 cm (Group C), and 6 Fr/28 cm (Group D). RESULTS: Men comprised 53.5% of 200 patients. Participants had an average age of 49 ± 15.5 years, height of 175 ± 8.94 cm, and BMI of 23.8 ± 7.6 cm. The laboratory results were identical between groups. At the first and fourth week, groups had similar urine symptoms, pain severity, health status and occupational activities. The difference in pain location was statistically significant. Group A had 82.4% renal back pain in the first week, whereas Group B had 68.8%, Group C 31.3% and Group D 62.5 (p=0.04). At the fourth week, 64.7% of Group A patients reported kidney front pain, compared to 100% of Group B, 93.3% of Group C, and 100% of Group D (p=0.04). There was statistical significance in the sexual activity of the patients. 24.4% of Group C patients stopped sexual activity before stent installation, compared to 10.6%, 8.3%, and 6.4% of the other groups (p=0.03). A moderate percentage of patients had active sexual activity at week 4 (Group A: 7.8%, Group B: 5.8%, Group C: 8.2%, Group D: 4.1%), p=0.83. In multivariate analysis, urinary catheter group, age, weight, height, and BMI did not significantly affect urine index score (UIS), pain index score (PIS), general health (GH), quality of work (QW), and quality of sex (QS). CONCLUSIONS: Despite various attempts to establish the best ureteral stent, the effect of double-j stent physical features on stent-related symptoms remained unknown. No verdict is conceivable without adequate empirical data.

Robot-Assisted Urological Oncology Procedures, Outcomes, and Safety in Frail Patients: A Narrative Review of Available Studies.

In this study, we assess the impact of frailty on the success rate and risk of complications of robot-assisted urological procedures and introduce effective preoperative screening tools to evaluate frail patients' fitness to tolerate robot-assisted urological surgery. We performed a search of electronic databases for available studies, published up to August 2023, investigating the outcomes of robot-assisted urological oncology procedures and their safety in frail patients. Sixteen studies were ultimately selected, investigating the implications of frailty in robot-assisted radical cystectomy, robotassisted partial nephrectomy, and robot-assisted radical prostatectomy. All the studies used the Clavien-Dindo classification of complications with serious complications considered as Clavien-Dindo 3. Frail patients significantly benefit from robot-assisted urological procedures in comparison to open surgery, with lower rates of blood transfusion and a shorter length of stay. However, they also have a higher risk of postoperative complications than non-frail patients, as well as increased rates of conversion to open, total hospital costs, and in-hospital mortality after robot-assisted procedures. Robot-assisted urological procedures can improve the postoperative recovery of frail patients in comparison to open surgery. Reliable frailty indexes such as the Johns Hopkins indicator and simplified frailty index, as well as the Geriatric 8 screening tool, should be routinely used in the preoperative assessment of frail patients to optimize surgical decision-making.

The Management of a Case With Mucin-Producing Adenocarcinoma Originating From the Urachus.

Urachal cancer is a rare and aggressive type of cancer, frequently characterized by a lack of prominent symptoms. We herein report a case of a 50-year-old female with mucin-producing adenocarcinoma originating from the urachus who underwent partial cystectomy and the patient remains disease-free for 30 months after treatment.

Emerging Trends in AI and Radiomics for Bladder, Kidney, and Prostate Cancer: A Critical Review.

This comprehensive review critically examines the transformative impact of artificial intelligence (AI) and radiomics in the diagnosis, prognosis, and management of bladder, kidney, and prostate cancers. These cutting-edge technologies are revolutionizing the landscape of cancer care, enhancing both precision and personalization in medical treatments. Our review provides an in-depth analysis of the latest advancements in AI and radiomics, with a specific focus on their roles in urological oncology. We discuss how AI and radiomics have notably improved the accuracy of diagnosis and staging in bladder cancer, especially through advanced imaging techniques like multiparametric MRI (mpMRI) and CT scans. These tools are pivotal in assessing muscle invasiveness and pathological grades, critical elements in formulating treatment plans. In the realm of kidney cancer, AI and radiomics aid in distinguishing between renal cell carcinoma (RCC) subtypes and grades. The integration of radiogenomics offers a comprehensive view of disease biology, leading to tailored therapeutic approaches. Prostate cancer diagnosis and management have also seen substantial benefits from these technologies. AI-enhanced MRI has significantly improved tumor detection and localization, thereby aiding in more effective treatment planning. The review also addresses the challenges in integrating AI and radiomics into clinical practice, such as the need for standardization, ensuring data quality, and overcoming the "black box" nature of AI. We emphasize the importance of multicentric collaborations and extensive studies to enhance the applicability and generalizability of these technologies in diverse clinical settings. In conclusion, AI and radiomics represent a major paradigm shift in oncology, offering more precise, personalized, and patient-centric approaches to cancer care. While their potential to improve diagnostic accuracy, patient outcomes, and our understanding of cancer biology is profound, challenges in clinical integration and application persist. We advocate for continued research and development in AI and radiomics, underscoring the need to address existing limitations to fully leverage their capabilities in the field of oncology.

Early investigational agents for the treatment of benign prostatic hyperplasia'.

INTRODUCTION: Benign prostatic hyperplasia (BPH), as a clinical entity that affects many people, has always been in the forefront of interest among researchers, pharmaceutical companies, and physicians. Patients with BPH exhibit a diverse range of symptoms, while current treatment options can occasionally cause adverse events. All the aforementioned have led to an increased demand for more effective treatment options. AREAS COVERED: This review summarizes the outcomes of new medications used in a pre-clinical and clinical setting for the management of male lower urinary tract symptoms (LUTS)/BPH and provides information about ongoing trials and future directions in the management of this condition. More specifically, sheds light upon drug categories, such as reductase­adrenoceptor antagonists, drugs interfering with the nitric oxide (NO)/cyclic guanosine monophosphate (GMP) signaling pathway, onabotulinumtoxinA, vitamin D3 (calcitriol) analogues, selective cannabinoid (CB) receptor agonists, talaporfin sodium, inhibitor of transforming growth factor beta 1 (TGF-ß1), drugs targeting the hormonal control of the prostate, phytotherapy, and many more. EXPERT OPINION: Clinical trials are being conducted on a number of new medications that may emerge as effective therapeutic alternatives in the coming years.

Ureteral stents: A brief narrative review of the different polymeric types, their characteristics, and their connection to stent-related symptoms.

Background: In routine urological practice, pigtails are frequently utilized to relieve blockage. Early signs of pigtail problems include pain, lower urinary tract symptoms, pain, hematuria (54%) and fever. Seventy percent of patients experience irritable voiding symptoms, and 80% of patients or even more report pain interfering with everyday activities. Methods: This article's goal is to evaluate the various polymeric stents that are currently on the market. In addition, a review of their fundamental bioqualities is conducted, and a connection between their physical attributes (length, size, and composition) and stent-related issues is looked into. For this review, extensive Medline, PubMed, and literature research from 1987 to January 2023 was conducted. Lower urinary tract complaints, ureteral stents, "pigtail," "materials," "characteristics," or "properties" were the search terms employed. Results: The reviews and publications that are now accessible linking certain materials to stent-related symptoms offer contradictory conclusions, and the majority of research do not specify the precise properties of the materials utilized. The results of the studies on the relationship between stents length and diameter and symptoms connected to stents are likewise inconclusive, despite the fact that there are several studies on this topic in the literature. Conclusion: Numerous studies imply a connection between the various types and properties of the utilized stents and stent-related complaints. However, the available data did not fully support this claim, necessitating additional research.

Surgical techniques to preserve continence after robot-assisted radical prostatectomy.

Radical prostatectomy significantly impacts the inherent anatomy of the male pelvis and the functional mechanisms of urinary continence. Incontinence has a considerable negative influence on the quality of life of patients, as well as their social and psychological wellbeing. Numerous surgical techniques have been demonstrated to support the preservation of continence during robot-assisted radical prostatectomy (RARP). In this in-depth analysis, we give a general summary of the surgical techniques used in RARP and their impact on incontinence rates.

Gangrenous Cystitis Secondary to a Spontaneous Hematoma of the Lesser Pelvis.

Gangrenous cystitis is considered a life-threatening but rather rare clinical entity due to the widespread use of antibiotics. We herein report a case of a 78-year-old female with gangrenous cystitis secondary to a spontaneous expanded hematoma of the lesser pelvis who underwent partial cystectomy followed by bilateral ureterostomies with no favorable outcome.

Radiation protection measures during endourological therapies.

Objective: The objective of this narrative review was to search the existing literature for studies reporting measures to minimize radiation use during endoscopic management of stone disease and present ways of reducing the exposure of both patients and operating room staff. Methods: A literature review in PubMed was performed to identify studies describing protocols or measures to reduce radiation received during endourological procedures from January 1970 to August 2022. Eligible studies were those that reported outcomes for ureteroscopy or percutaneous nephrolithotripsy regarding measures to minimize radiation doses used intraoperatively, performed either in real-life theatres or using phantoms. Both comparative and non-comparative studies were deemed eligible. Results: Protection can be achieved initially at the level of diagnosis and follow-up of patients, which should be done following an algorithm and choice of more conservative imaging methods. Certain protocols, which follow principles for minimized fluoroscopy use should be implemented and urologists as well as operating room staff should be continuously trained regarding radiation damage and protection measures. Wearing protective lead equipment remains a cornerstone for personnel protection, while configuration of the operating room and adjusting X-ray machine settings can also significantly reduce radiation energy. Conclusion: There are specific measures, which can be implemented to reduce radiation exposure. These include avoiding excessive use of computed tomography scans and X-rays during diagnosis and follow-up of urolithiasis patients. Intraoperative protocols with minimal fluoroscopy use can be employed. Staff training regarding dangers of radiation plays also a major role. Use and maintenance of protective equipment and setting up the operating room properly also serve towards this goal. Machine settings can be customized appropriately and finally continuously monitoring of exposure with dosimeters can be adopted.

Ureteral Stent-Related Symptoms and Pharmacotherapy: A Brief Narrative Review.

The purpose of this article is to review the effects of different types of pharmacotherapy on symptoms that affect the quality of a patient's life after stent insertion. A thorough Medline/PubMed nonsystematic review was conducted from 1987 to January 2023, using the terms: "pigtail" OR "ureteral stents" AND "lower urinary tracts symptoms" OR "LUTS" AND "pharmacotherapy" OR "drugs". Relevant studies conducted in humans and reported in English language were included. The available reviews and articles associating the use of drugs with stent-related symptoms (SRS) provide conflicting results. Most of them show a clear benefit of alpha blockers, particularly alfuzosin, on treating urinary SRS, and hence there is a strong recommendation for the use of alpha blockers for the treatment of SRS in the guidelines of the European Association of Urology. Anticholinergics and mirabegron have shown a significant benefit in dealing with irritative bladder symptoms. In contrast, the findings for combination therapies are contradictory, with some studies showing that combination therapy is no superior to monotherapy with regards to most of the subsets of the Ureteral Stent Symptom Questionnaire (USSQ), whereas others present a clear benefit of combination therapies, specifically silodosin and solifenacin, in treating stent-associated lower urinary tract symptoms (LUTS), in comparison with any other type of monotherapy or combination therapy. Many studies suggest that some categories of pharmacotherapy, such as alpha blockers, can alleviate SRS. However, there is conflicting evidence concerning most other types of medical treatment. Randomized trials with the largest number of patients are needed to investigate the effectiveness of novel approaches on SRS.

Complications After Radical Cystectomy: A Systematic Review and Meta-analysis of Randomized Controlled Trials with a Meta-regression Analysis.

CONTEXT: Radical cystectomy is considered a procedure of high complexity with a relative high complication rate. OBJECTIVE: To systematically summarize the literature regarding the complications of radical cystectomy and the factors that contribute to them. EVIDENCE ACQUISITION: We searched MEDLINE/PubMed, ClinicalTrials.gov, and Cochrane Library, according to the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines for randomized controlled trials (RCTs) on complications related to radical cystectomy. EVIDENCE SYNTHESIS: A total of 3766 studies were screened, and 44 studies were included in this systematic review and meta-analysis. Complications following radical cystectomy are quite common. The most common complications were gastrointestinal complications (20%), infectious complications (17%), and ileus (14%). The majority of complications occurring were Clavien I-II (45%). Specific measurable patient factors are related to certain complications and can be used to stratify risk and assist in preoperative counseling, while proper design of high-quality RCTs may better reflect real-life complication rates. CONCLUSIONS: In our study, RCTs with a low risk of bias had higher complication rates than studies with a high risk of bias, underlining the need for further improvement on complication reporting in order to refine surgical outcomes. PATIENT SUMMARY: Radical cystectomy is usually followed by high complication rates, which affect patients and are, in turn, strongly associated with patients' preoperative health status.

Anthropometric characteristics and relationship with non-muscle invasive bladder cancer in Greece: A case-control study.

BACKGROUND: Risk factors like smoking, radiation, chronic infections and exposure to occupational chemicals are strongly associated with occurrence of bladder cancer. Association between increased body weight and bladder cancer has been controversial. The aim of this case-control study is to evaluate association of anthropometric characteristics on bladder cancer incidence in Greek population. METHODS: This case-control study was conducted at a tertiary hospital in Greece with cases being patients with bladder cancer diagnosed within the last 2 years and controls patients admitted to hospital for reason other than cancer and not related to common risk factors related to bladder cancer. Anthropometric characteristics like weight, height, body mass index, waist and hip circumference were measured. Analyses was done with R (Vienna, Austria). RESULTS: Comparison between groups showed that patients with bladder cancer had higher weight, BMI and waist circumference compared to controls. However, multivariate, binomial logistic regression showed that only age (OR 1.03, 95% CI: 1-1.05, p = 0.02), no use of smoke (OR 0.12, 95% CI: 0.07-0.23, p < 0.001) and occupation related to bladder cancer (OR 7.45, 95% CI: 2.53-27.93, p < 0.001) significantly predicted the incidence of bladder cancer. CONCLUSIONS: Bladder cancer incidence is strongly linked with specific risk factors such as smoking, occupation with exposure to chemicals and smoke, increasing age, radiation and chronic infections. Several studies have shown a weak association between anthropometric characteristics and bladder cancer, although most studies in European populations did not confirm these findings. Similarly in our case-control study in a Greek population, we found potential relationship between increased weight/BMI and waist circumference with bladder cancer, but the association disappeared in multivariate analysis.

Diagnosis and management of intradiverticular bladder tumours: A pooled analysis of 498 cases.

OBJECTIVE: Intradiverticular bladder tumors (IDBT) are uncommon clinical entities. We reviewed the literature for clinical presentation, diagnosis and therapeutic options to establish recommendations for diagnostic and therapeutic management. METHODS: Bibliographic research was performed using PubMed from database inception until October 15, 2022. A pooled analysis was performed of 498 patients with IDBT presented in the literature. The evaluation included patient sex, age, diagnostic methods, symptoms, localization of the tumor, tumor staging, tumor histopathology, treatment, and the presence of recurrence. To express results, descriptive statistics were used appropriately. RESULTS: The mean age at diagnosis was 64.81 years (range 49 days to 84 years). The ratio between men and women was ≈ 24:1, suggesting a male predominance (85% male, 3.6% female). The most common presenting symptom was gross hematuria (60.88%). Most of the patients had cystoscopy (56.85%) and intravenous or computed tomography urography (52.01%). Regarding tumor staging, most of the patients were diagnosed with pT1 tumors. For the histopathology of IDBT, 87.95% of the specimens were transitional cell carcinomas and in 10.84% there were concomitant CIS. Regarding the treatment, radical cystectomy was chosen in 34.34%, partial cystectomy in 26.66%, diverticulectomy in 15.95% and transurethral resection of bladder tumour (TURBT) in 16.36% of the patients. CONCLUSIONS: Most common diagnostic tool for IDBT seems to be cystoscopy followed by computerized tomography urogram. Due to the absence of muscle layer in the diverticulum and the highgrade histology of most of them at diagnosis, cystectomy is the first therapeutic choice. However, for patients that are not considered appropriate candidates or for those presenting with lowgrade and low volume tumors, TURBT is a good option.

Cytoreductive nephrectomy for synchronous metastatic renal cell carcinoma. Is there enough evidence?

OBJECTIVE: To assess the role of Cytoreductive Nephrectomy for synchronous metastatic Renal Cell Carcinoma patients in the Systemic Therapy era and beyond regarding the Overall Survival, the optimal sequence between Systemic Therapy and Cytoreductive Nephrectomy and prognostic factors. METHODS: The systematic review was conducted in accordance with the PRISMA guidelines. Bibliographic search was performed in Medline (PubMed), ClinicalTrials.gov, and Cochrane Library-Cochrane Central Register of Controlled Trials (CENTRAL). Studies included were those indexed from 2005 in an attempt to limit those conducted in the cytokine era. Risk of bias assessment was performed by two authors (K.S and T.L) using the Cochrane Collaborative Risk of Bias tool for randomized trials, the Cochrane Risk Of Bias In Non-randomized Studies of Interventions (ROBINS-I) tool for nonrandomized studies. RESULTS: Cytoreductive nephrectomy was associated with improved overall survival in all but one of the observational studies. While in all of these studies the unvariable analysis showed improved overall survival in favor of the cytoreductive nephrectomy group in some studies the subgroup analysis showed no benefit. Regarding the optimal sequence, deferred cytoreductive nephrectomy demonstrated better results in more studies than upfront cytoreductive nephrectomy but a advantage was not clearly certain. In the analysis of possible prognostic factors for overall survival with cytoreductive nephrectomy, most common prognostic factors found were age (in 8 studies), tumor histology (in 7 studies), number of metastasis (in 6 studies), and T stage. CONCLUSIONS: Cytoreductive nephrectomy can still play an important role in wisely selected patients, although the role of cytoreductive nephrectomy in the new immunotherapy era needs to be defined.

Frailty and benign prostatic hyperplasia: The thrilling underlying impact.

BACKGROUND: World population is aging. The number of individuals aged over 65 are expected to be 71 million only in the US. 43% of this population will be men. Benign prostatic hyperplasia (BPH), defined as the benign neoplasm of the prostate gland affects 8% of men by their forties, but 90% of men over 90 years old. Lower urinary tract symptoms (LUTS) can be caused by an enlarged prostate, and it seems to be associated more with older and frailer individuals. METHODS: The purpose of this study is to review the potential interplay between frailty syndrome and benign prostatic hyperplasia. A thorough MEDLINE/PubMed non-systematic literature review was conducted from 1990 to March of 2022. The terms used for the search were "frailty and benign prostatic hyperplasia" and "low muscle mass and benign prostatic hyperplasia". RESULTS: It seems that, frailty poses a negative impact on the prognosis of patients with BPH, as it is associated with increased incidence of LUTS. In addition, frailty seems to be a strong predictor concerning surgical procedure failure and mortality following invasive procedures for BPH. Prostatic stent placement on the other hand appears to be the ideal solution for frail patients. CONCLUSIONS: BPH has a strong association with frailty and increasing age.

Sarcopenia in Urinary Bladder Cancer: Definition, Prevalence and Prognostic Value in Survival.

Sarcopenia, defined as the systemic loss of muscle function and mass, is commonly seen in advanced oncologic states, usually in conjunction with cancer cachexia. Bladder cancer represents one of the most common neoplasms worldwide and affects mainly the elderly who are already frail. The purpose of this study is to review the potential association between sarcopenia and bladder cancer in patients receiving different types of treatments. A thorough MEDLINE/PubMed non-systematic literature review was conducted from 1990 to January 2022, using the following search terms: "sarcopenia and bladder cancer" and "low muscle mass and bladder cancer". Sarcopenia probably poses a negative impact on the prognosis of patients at any stage of bladder cancer, as it is linked with overall worse survival, cancer specific survival and progression-free survival in those treated, with either radical cystectomy or chemotherapy. In addition, sarcopenia seems to be a strong predictor concerning complications and a negative prognostic factor following chemotherapy and surgery for bladder cancer. On the other hand, it seems that sarcopenic patients who receive radiotherapy or immunotherapy are not so severely affected.