PCNL in neurogenic bladder: A challenging population for both clinical management and analysis.

Objectives: To review the management of patients with neurogenic bladder undergoing percutaneous nephrolithotomy (PCNL) at our institution with the aim of assessing peri-operative morbidity. Subjects/patients and methods: We conducted a retrospective review of all neurogenic bladder patients who underwent PCNL at our hospital in the last decade with the aim of assessing peri-operative morbidity. Results: A total of 298 PCNL were performed during the study period of which 58 were in patients with a neurogenic bladder or urinary diversion, 33 of which were in SCI patients. Preoperative demographic and stone characteristics, intraoperative data and postoperative length of stay and complications are summarised in table form. Conclusion: PCNL remains an acceptably safe and efficacious treatment for upper tract stone disease in patients with neurogenic bladders and will continue to have a valuable role where SCI prevents alternative approaches such as ureteroscopy.

Progressing Towards Same-Day Discharges After Robotic-Assisted Radical Prostatectomy; Safe and Cost Effective to Discharge Without Routine Blood Tests.

Introduction: Changing population demographics and the recent SARS-CoV-2 pandemic have forever changed healthcare, with increasing demands on straining systems. The economic cost is yet to be fully realised, with growing concerns around the current system's ability to accommodate the ageing comorbid population. Consequently, a paradigm shift has taken place in healthcare systems, prioritizing cost accountability. In the absence of established guidelines or robust literature, the use of laboratory tests postoperatively is often guided solely by clinician preference. This study presents a retrospective analysis that investigates the utility and cost implications of routine postoperative investigation following robotic-assisted radical prostatectomies. The findings aim to emphasise the importance of evidence-based practices and cost-effective approaches in postoperative care. Materials/Methods: A retrospective analysis was performed on all robotic-assisted radical prostatectomies (RARP) identified from a single institution between 29th June 2017 to 28th June 2019. This interval was chosen in an attempt to avoid bias or confounding variables associated with the SRS-CoV-2 pandemic. A single clinician conducted a comprehensive medical record review using unit record numbers corresponding to identified procedural codes. Demographics and variables were recorded, including postoperative test results, hospital length of stay and 30-day readmission rates. Patients were assigned to either 'Routine Postoperative tests' (RPOT) or 'No Routine Postoperative tests' (No RPOT) and a comparative analysis was performed. Using the Australian National Pharmaceutical Benefits Scheme (PBS) pricing guide, total expenditure was calculated. Results: A total of 319 patients were included in the study with an average of 2.5 tests per patient within the first 24 hours. Routine postoperative tests had no bearing on outcomes, with comparable readmission rates between cohorts, and a significantly shorter length of stay in the "No routine postoperative tests" group when compared to the "Routine Postoperative Tests". A total of 1028 tests were performed within the first 48 hours following surgery with expenditure on routine testing totalling $20,516 based on the Australian PBS pricing schedule. Abnormal results were returned on 96% of patients. In the RPOT group, 18 out of the 20 common interventions occurred from 302 RARP. Among the patients in the RPOT group, eight individuals underwent blood transfusions. However, none of these patients met the hospital-specific criteria for transfusion, which require a hemoglobin level below 70 or symptomatic presentation with a hemoglobin level below 80. Conclusion: The data suggests routine postoperative laboratory has no bearing on re-admission rates, with patients experiencing significantly shorter hospital stays. Furthermore, our results indicate inefficient use of routine postoperative laboratory, with few clinical interventions, frequent abnormal results, and significant accumulative expenses.

Aquablation in men with benign prostate hyperplasia: A systematic review and meta-analysis.

Objective: The aim of the study is to investigate improvements in lower urinary tract symptoms in men with benign prostatic hyperplasia (BPH) treated with prostatic Aquablation. Materials and methods: We performed a literature search of clinical trials using the MEDLINE, Embase, and Cochrane Library databases and retrieved published works on Aquablation for the treatment of BPH up to August 2021. Unpublished works, case reports, conference proceedings, editorial comments, and letters were excluded. Risk of bias was assessed using the ROBINS-I tool. Raw means and mean differences were meta-analyzed to produce summary estimates for pre- versus post-International Prostate Symptom Scores, maximum flow rate, and male sexual health questionnaire value changes. An inverse-variance weighted random effects model was used. Results: Seven studies were included in this review (n = 551 patients) that evaluated various urological parameters. At 3 months, the International Prostate Symptom Scores raw mean difference from baseline was -16.475 (95% confidence interval [CI], -15.264 to -17.686; p < 0.001), with improvements sustained for 12 months. Similarly, maximum flow rate improved by +1.96 (95% CI, 10.015 to 11.878; p < 0.001) from pre to 3 months postoperatively. In addition, the male sexual health questionnaire change pooled effect size was -0.55 (95% CI, -1.621 to 0.531; p = 0.321) from preintervention to postintervention at 3 months. Meta-analyses of some outcomes showed large statistical heterogeneity or evidence of publication bias. Conclusions: Aquablation seems to improve lower urinary tract symptoms in men with BPH while providing relatively preserved sexual function. Further research is required to confirm these preliminary results.

5-alpha reductase inhibitors use in prostatic disease and beyond.

5-alpha reductase inhibitors (5-ARIs) are commonly used and widely available, with benefits observed from their effect on androgen signalling. Their effect relies on the inhibition of the 5-alpha reductase enzyme which aids in the conversion of testosterone to dihydrotestosterone. 5-ARIs have increasing clinical relevance outside of benign prostatic hyperplasia (BPH). Such development requires clinicians to have an updated review to guide clinical practices. This review details the pharmacology and mechanisms of action for 5-ARIs and how this relates to multiple clinical indications. Of note, is the debunked association between finasteride and increased risk of high-grade prostate cancer. Furthermore, adverse effects of 5-ARI use are detailed in this review, with specific mentions to post-finasteride syndrome. In addition to overviews pertaining to BPH and prostate cancer, much attention has also been focused on severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2). The androgen axis may be associated with an increased virulence for SARS-CoV-2 in men, with some reporting a correlation between the severity of illness and androgenic alopecia. Since these observations, the role of antiandrogens, including 5-ARIs, has been explored further in SARS-CoV-2. Increasing understanding of pathological processes involving the androgen axis in which 5-ARIs work, has led to increasing clinical indications for 5-ARIs. Several novel off-label indications have been suggested including its potential role in the pathogenesis of SARS-CoV-2, but to date, these claims have not been substantiated. Previously held truths regarding the role of 5-ARIs and prostate carcinogenesis have been contested, inadvertently leading to the re-exploration of 5-ARIs utility in prostate cancer. With growing evidence into pathological processes involving the androgen axis, 5-ARIs are likely to become increasingly more used. This review serves as a timely update of 5 ARIs pharmacology, current indications and potential future directions.

High-flow post-traumatic priapism with delayed presentation.

Priapism is an urgent urological condition with varied aetiology that may be classified as low flow (ischaemic) or high flow (non-ischaemic). Diagnosis requires detailed clinical history and examination combined with appropriate investigations such as cavernosal blood gas sampling and penile Doppler ultrasound. In the case of high-flow priapism CT angiography can identify sources of abnormal arterial blood flow and cases may be managed conservatively, with surgery or through arterial embolisation. We detail a case of a young man presented 2 weeks after perineal trauma with high-flow priapism with an equivocal penile Doppler ultrasound. Cavernosal blood gas sampling was consistent with arterial blood and CT angiography was performed showing an arteriovenous fistula. The patient was then successfully managed with arterial embolisation resulting in detumescence and preserving sexual function.

Barriers in Managing Acute Ureteric Colic Clinical Review and Commentary.

With the global prevalence of urolithiasis increasing, the presentation of acute ureteric colic to emergency departments (ED) poses a significant burden on healthcare systems globally. Management strategies for ureteric colic encompass medical expulsion therapy and various interventional modalities aimed at urinary diversion or definitive stone management. By examining potential or established barriers to managing acute ureteric colic, we can minimise strain on healthcare providers while maintaining patient outcomes. This review aims to assess barriers to the management of acute ureteric colic through a comprehensive overview of the current literature. Acute ureteric colic barriers will be assessed throughout a patient's disease progression, borrowing a conceptual framework used to assess barriers in cancer care management. Barriers will be discussed in the context of patient-centred access to healthcare, clinical evaluation and diagnosis, and management. Numerous barriers to healthcare have been identified throughout the natural course of acute ureteric colic, both specific and non-specific. Patient-centred barriers typically arise during the initial onset of acute ureteric colic. Originating from patient awareness and access to healthcare, they include barriers founded on race inequalities, cultural beliefs, geographic location, transportation, and the concept of a universal standard of healthcare. Having accessed healthcare, barriers in the management of acute ureteric colic next occur during the clinical evaluation and diagnosis period. These are typically associated with clinical assessment or diagnostic imaging delays, including underutilisation of ultrasound, nurse-led pathways for faster clinical reviews, and general ED delays. The final period during acute ureteric colic management correlates to clinical management. The inherent unpredictable course of ureteral stones leads to poor prognostication and failed initial management modalities. Additionally, this period deals with periprocedural delays and preventative health. Barriers to the management of acute ureteric colic arise during a patient's journey through accessing healthcare. Reviewing barriers allow further research into areas requiring modification to expedite care and improve outcomes.

Critical shortage in BCG immunotherapy: How did we get here and where will it take us?

Intravesical Bacillus Calmette-Guérin vaccine, one of the most successful bio-therapies to date, has been the gold standard treatment for non-muscle invasive bladder cancer for 44 years. International shortages have necessitated rationing this life-saving medication with deleterious effects on the primary treatment of high-grade non-muscle invasive bladder cancer. Understanding the history of intravesical Bacillus Calmette-Guérin gives us insight into the current shortages and future perspectives for novel immunotherapy opportunities against this deadly disease.