Intravesical Mycetoma misdiagnosed as enterovesical fistula.

Fungus formation in the urinary tract mainly occurs in immunosuppressed patients, and is a rare and dangerous complication of candiduria that is commonly misdiagnosed. We report a case of intravesical mycetoma associated with hydronephrosis, initially diagnosed as enterovesical fistula. Cystoscopy revealed spongy material within the urinary bladder, and histopathological examination showed Mycetoma of Candida species. The urine culture showed Candida tropicalis. Endoscopic removal and antifungal therapy with fluconazole was initiated, and no complications occurred during follow-up.

Two Cases of Strictures after Percutaneous CT-Guided Radiofrequency Ablation for Renal Cell Carcinoma.

Percutaneous radiofrequency ablation is a safe and effective minimally invasive treatment option in selected patients with T1a tumors of the kidney with a low complication rate. We describe two cases that developed the rare but severe complication of thermal injury-induced strictures of the upper urinary tract and its consecutive management.

A cost analysis of stenting in uncomplicated semirigid ureteroscopic stone removal.

OBJECTIVE: To evaluate the outcome and the costs of stenting in uncomplicated semirigid ureteroscopic stone removal. MATERIALS AND METHODS: A decision tree model was created to evaluate the economic impact of routine stenting versus non-stenting strategies in uncomplicated ureteroscopy (URS). Probabilities of complications were extracted from twelve randomized controlled trials. Stone removal costs, costs for complication management, and total costs were calculated using Treeage Pro (TreeAge Pro Healthcare version 2015, Software, Inc, Williamstown Massachusetts, USA). RESULTS: Stone removal costs were higher in stented URS (€1512.25 vs. €1681.21, respectively). Complication management costs were higher in non-stented procedures. Both for complications treated conservatively (€189.43 vs. €109.67) and surgically (€49.26 vs. €24.83). When stone removal costs, costs for stent removal, and costs for complication management were considered, uncomplicated URS with stent placement yielded an overall cost per patient of €1889.15 compared to €1750.94 without stent placement. The incremental costs of stented URS were €138.25 per procedure. CONCLUSION: Semirigid URS with stent placement leads to higher direct procedural costs. Costs for managing URS-related complications are higher in non-stented procedures. Overall, a standard strategy of deferring routine stenting uncomplicated ureteroscopic stone removal is more cost efficient.

Impact of hours worked by a urologist prior to performing ureteroscopy on its safety and efficacy.

OBJECTIVE: The aim of this study was to evaluate the impact of hours worked by a urologist before performing ureteroscopy on its safety and efficacy. MATERIALS AND METHODS: Patients treated at a single institution from January 2010 to December 2013 were analyzed. The study assessed patient, stone and surgical parameters, stone-free rates and intraoperative complications performed in three work duration categories: less than 6 h, 6-12 h and more than 12 h of urologist's work. Statistical analyses included the chi-squared test, Kruskal-Wallis test, and univariate and multivariate logistic regression analyses. RESULTS: In total, 469 ureteroscopies were analyzed. Intraoperative complications differed non-significantly in the corresponding time categories: ureteral perforations (< 6 h 4.4%, 6-12 h 3.2%, > 12 h 7%, p = 0.46) and avulsions (all 0%). Rates for complete stone removal were 82% within the first 12 h vs 70.2% after 12 h (p = 0.03). Corresponding partial stone-free rates were 4.1% vs 3.5% (p = 0.83) and rates of unsuccessful ureteroscopy were 13.8% vs 26.3% (p = 0.01). In multivariate regression analysis, patients treated after 12 h of urologist's work had a 2.4 times higher risk of an unsuccessful ureteroscopy [odds ratio (OR) = 2.4, 95% confidence interval (CI) 1.2-4.7, p = 0.001] and lower chances of complete stone removal (OR = 0.46, 95% CI 0.24-0.89, p = 0.02). The odds of ureteral perforations were similar (p = 0.28). CONCLUSION: Work duration before ureteroscopy did not affect its safety. Stone-free rates decreased with increasing working time. Working time exceeding 12 h was identified as an independent risk factor for impaired stone-free rates.

Prospective, multi-institutional pain assessment of 150 women undergoing diagnostic cystoscopy.

BACKGROUND: The aim of this study was to prospectively assess women's pain during rigid and flexible diagnostic cystoscopy and afterwards during a one-week follow-up. METHODS: Prospective, multi-institutional trial analyzing numeric rating scales (NRS) of women undergoing diagnostic cystoscopy. Pain categories: no (0 points), mild (1-3), moderate (4-6) and severe pain (7-10). Assessing of pain before, during cystoscopy, and at day 1, 4 and 7 of follow-up. RESULTS: A total of 150 women undergoing rigid (N.=85) or flexible (N.=65) diagnostic cystoscopy were analyzed. Women undergoing flexible cystoscopy were more frequently pain-free (64.6% vs. 40%, P=0.003) and experienced mild pain less frequently (27.7% vs. 52.9% vs. P=0.002). No significant differences were noted among moderate (6.2% vs. 5.9%, P=0.95) and severe pain (1.5% vs. 1.2%, P=0.85). Patients undergoing their first (P=0.14) and repeat cystoscopy (P=0.08) had similar pain perception. In multivariate logistic regression analyses, women undergoing flexible cystoscopy had a 2.6 increased chance of being pain-free (OR=2.6, CI: 1.28-5.11, P=0.08) and their odds of experiencing mild pain were significantly lower (OR=0.34, CI: 0.17-0.71, P=0.004). The likelihood of experiencing moderate (OR=1.1, CI: 0.28- 4.4, P=0.83) or severe pain (OR=2.42, CI: 0.11-51.79, P=0.57) differed insignificantly. CONCLUSIONS: Rigid and flexible cystoscopies were well-tolerated by most women. However, flexible cystoscopy was associated with a higher likelihood of being pain-free and lower chances of experiencing mild pain. Patients' previous experience with cystoscopy did not influence pain perception.

Association between asymptomatic inflammatory prostatitis NIH category IV and prostatic calcification in patients with obstructive benign prostatic hyperplasia.

BACKGROUND: The aim of this study was to evaluate the incidence of prostatic calcification and prostatitis NIH category IV in patients with obstructive BPH. METHODS: Ninety-six patients with obstructive BPH who had undergone transurethral electroresection of the prostate gland were evaluated. In accordance with a preoperative transrectal ultrasound examination, patients were divided into one group with prostatic calcification (N.=31) and one without (N.=65). Prostatitis NIH category IV was classified according to the grading system by Irani. Correlations between the incidence of prostatic calcification, histological prostatitis, PSA, uric acid, cholesterol, triglycerides, CRP, IPSS, IIEF-25, and NIC-CPSI were analyzed. A stone analysis of prostatic calcification was performed using X-ray powder diffraction. RESULTS: Sixty-nine (71.9%) patients had NIH category IV prostatitis, accounting for 83.9% of those with prostatic calcification versus 66.1% of those without (P<0.04). Significant correlations were found between prostatic calcification and the severity of inflammation (P<0.02) as well as the NIH-CPSI subdomain of urinary symptoms (P<0.02). The only predictor for prostatic calcifications were elevated levels of uric acid. Such patients were 1.4times more likely of having calcifications in the prostate gland (OR=1.4, P<0.047). Stone analysis revealed the following: apatite in 41.7%, whewellite in 29.2%, weddellite and brushite in 8.7% each, whitlockite, apatite/whewellite and organic substances in 4.2%. CONCLUSIONS: On ultrasound examination, one third of patients who were treated with TURP for obstructive BPH had prostatic calcification. These were significantly more common in patients with NIH category IV prostatitis.

Prospective multi-institutional study analyzing pain perception of flexible and rigid cystoscopy in men.

OBJECTIVE: To evaluate pain perception in men undergoing flexible or rigid diagnostic cystoscopy. METHODS: This is a prospective multi-institutional analysis of men undergoing cystoscopy in 4 European departments of urology. Pain perception was assessed with an 11-point numeric rating scale. Pain categories were as follows: no (0 points), mild (1-3), moderate (4-6), and severe pain (7-10). Assessment of pain was before, during cystoscopy, and at days 1, 4, and 7 of follow-up. RESULTS: A total of 300 cystoscopies were analyzed (150 rigid and 150 flexible). Men undergoing flexible cystoscopy were more frequently free of pain (58.7% vs 24%; P <.0001). Mild pain (54% vs 30.7%; P <.0001) and moderate pain (18.7% vs 9.3%; P = .02) were more common with rigid devices. No significant differences were prevalent in severe pain perception (3.3% vs 1.3%; P = .25). Patients, who had previous experience with cystoscopy reported similar pain levels as patients naïve to cystoscopy, regardless if rigid (P = .92) or flexible (P = .26) devices were used. Pain decreased to the baseline during the 1-week follow-up after both, flexible and rigid cystoscopy. In multivariate regression analyses, rigid cystoscopy was an independent predictor for not being pain free (odds ratio [OR] = 0.15; confidence interval [CI] = 0.08-0.28; P <.0001), for experiencing mild pain (OR = 2.57; CI = 1.57-4.19; P <.0001), and for moderate pain (OR = 2.39; CI = 1.13-5.07; P = .02). Severe pain was seldom with both devices, and thus, no statistical difference was found. CONCLUSION: Flexible diagnostic cystoscopy caused less pain than rigid cystoscopy in men. Patient's previous experience with cystoscopy did not influence pain sensation. The type of cystoscope itself was identified as an independent risk factor of pain perception.

Does a retrograde pyelography prior to ureteroscopy influence stone-free rates and complication rates in ureteral calculi?

OBJECTIVES: To evaluate the impact of retrograde pyelography (RPG) in patients treated with ureteroscopy (URS) for ureteral calculi. METHODS: Retrospective analysis of patients treated with and without RPG prior to URS at a single institution from 2010 to 2013. Assessment of stone-free rates and intraoperative complications. RESULTS: Out of 469 URS, 211 (45%) were done with and 258 (55%) without RPG. Complete stone removal was achieved in 86.8% without RPG compared to 73% with RPG (p=0.0001). Partial stone removal rates were similar in both groups (p=0.77). Stone removal was not achieved in 9.3 vs. 22.7% (p=0.0001), with concordant findings in the distal (7.4 vs. 16.9%, p=0.007) and the proximal ureter (14.5 vs. 38.6%, p=0.002). Patients with RPG had a threefold higher chance of an unsuccessful URS (OR 3.05, 1.71-5.43, p<0.0001) and were less likely of having a complete stone removal (OR 0.37, 0.22-0.61, p<0.0001). Ureteral avulsions (0%) and ureteral perforation rates were similar (4.7 vs. 3.8%, p=0.65). CONCLUSIONS: Patients treated with an RPG prior to URS had significantly inferior stone-free rates. RPG was identified as an independent risk factor for inferior results. RPG neither facilitates nor diminishes complication rates during URS.

Update on the use of diode laser in the management of benign prostate obstruction in 2014.

AIM: To determine the status quo in respect of various diode lasers and present the techniques in use, their results and complications. We assess how these compare with transurethral resection of the prostate and other types of laser in randomized controlled trials (RCTs). When adequate RCTs were not available, case studies and reports were evaluated. MATERIALS AND METHODS: Laser for the treatment of benign prostatic hyperplasia (BPH) has aroused the interest and curiosity of urologists as well as patients. The patient associates the term laser with a successful and modern procedure. The journey that started with coagulative necrosis of prostatic adenoma based on neodymium: yttrium-aluminum-garnet (Nd:YAG) laser has culminated in endoscopic "enucleation" with holmium laser. Diode laser is being used in urology for about 10 years now. Various techniques have been employed to relieve bladder outlet obstruction due to BPH. RESULTS: The diode laser scenario is marked by a diversity of surgical techniques and wavelengths. We summarize the current published literature in respect of functional results and complications. CONCLUSION: More randomized controlled studies are needed to determine the position and the ideal technique of diode laser treatment for BPH.

Percutaneous radiofrequency ablation of renal tumors: a single-center experience.

PURPOSE: To evaluate the oncological outcomes, complications, and changes in renal function in patients treated with computed tomography-guided percutaneous radiofrequency ablation (RFA) for small renal tumors. MATERIALS AND METHODS: The charts of patients who underwent RFA from 2006 to 2011 at a single institution were reviewed. Oncological and functional outcomes were assessed. Statistical analyses were performed with IBM SPSS ver. 18.0 (IBM Co., Armonk, NY, USA). RESULTS: A total of 44 RFAs were done in 40 patients. Biopsy prior to RFA was performed in 79.6% of procedures. Of those, 68.6% had renal cell carcinoma (RCC). Mean tumor diameter was 26.2 mm. Grade I complications occurred in 25% of cases (n=11, pain or elevated temperature) and grade II complications in 2.3% (n=1, perirenal bleeding needing two units of blood transfusion). Serum creatinine slightly increased by 0.14 mg/dL at 2 years after RFA (p<0.004). Tumor recurrences were suspected in 8 of 43 cases during follow-up. In five patients, the suspected recurrence was a false-positive as shown by a negative biopsy result or lack of contrast enhancement on subsequent imaging. The verified recurrence rate was 7.7% in all tumors and 2.5% in RCC at a mean follow-up of 2 years. Tumor-free survival was 90% in all patients and 87.5% in those with RCC. Metastasis-free survival was 97.5% and cancer-specific survival was 100%. CONCLUSIONS: Percutaneous computed tomography-guided RFA shows promising results at intermediate follow-up. Suspected tumor recurrences are frequently false-positives findings. A longer follow-up is required to verify the durability of these results.

Trends in the utilization of percutaneous and open nephrolithotomy in the treatment of renal calculi.

PURPOSE: To evaluate trends in the use of percutaneous nephrolithotomy (PCNL) and nephrolithotomy (NL) in patients with renal pelvis calculi. MATERIALS AND METHODS: An analysis of the 5% Medicare Public Use Files (years 2001, 2004, 2007, and 2010) was performed to assess changes in the use of PCNL and NL over a 10-year period. Patients were identified using the International Classification of Diseases-9 (cm) and Current Procedure Terminology codes. Statistical analyses, including the Fisher and chi-square tests and multivariate regression analyses, were performed using SAS 9.3 (SAS Institute Inc, Cary, NC) and SPSS v20 (IBM Corp., Armonk, NY). RESULTS: A total of 26,100 patients underwent either PCNL or NL. Use of PCNL and NL decreased from 3.1% to 2.5% in patients with a diagnosis of stones (P<0.0001). Women (odds ration [OR]=1.19, P=0.003) were more likely to undergo surgery. Patients aged ≥65 years were less likely to be treated (OR=0.65-0.71, P<0.05). Patients treated after 2004 were less likely to undergo surgery (OR=0.77-0.84, P<0.05). The use of PCNL exceeded NL at a stable 10:1 ratio. CONCLUSIONS: The use of PCNL and NL for treatment of patients with stone disease slightly decreased from 2001 to 2010, although the number of patients with renal calculi increased. The use of PCNL vs NL was unchanged during this period. Multiple inequalities existed in overall surgical treatment rates and were influenced by sociodemographic factors such as age and sex.

Psychological stress assessment of patients suffering from prostate cancer.

OBJECTIVE: The aim of this study was to assess the psychological distress of men with prostate cancer (PC) throughout the whole process from initial diagnosis to therapy and to evaluate patients' tolerance regarding treatment delay. MATERIAL AND METHODS: This prospective study, performed between July 2007 and March 2010, evaluated the psychological distress of 28 men who underwent prostate biopsy (PB), who were confronted with a cancer diagnosis and were about to undergo radical prostatectomy (RP). Three evaluation points were defined: E1, immediately before PB; E2, after definitive diagnosis and when RP was scheduled; and E3, on the day of admission for RP. RESULTS: Emotional distress was highest before PB, declining significantly until RP (p = 0.02). Symptoms of depression and anxiety were low at all evaluation points, with anxiety rising significantly after cancer diagnosis (p = 0.008). Concerns about postoperative erectile dysfunction and incontinence were registered at all evaluation points. Concerns about the effect on their partnership due to PC were low. The patient's tolerable waiting time for RP differed significantly from daily practice. CONCLUSIONS: Anxiety and depression as well as concerns about a negative effect on their partnership were shown to play a minor role in patients during the interval between PB and RP, while distress and concerns about erectile dysfunction and urinary incontinence were more prevalent. Support from the patient's medical and social environment and a sound partnership may have a protective effect on emotional status. Waiting time for surgery exceeded the patients' tolerated time-frames and may further contribute to the psychological distress of PC.

Long-term results of intravesical hyaluronan therapy in bladder pain syndrome/interstitial cystitis.

INTRODUCTION AND HYPOTHESIS: While the short-term efficacy of intravesical hyaluronan for bladder pain syndrome/interstitial cystitis (BPS/IC) has been demonstrated, no data exist on the long-term outcome of this therapy. METHODS: Seventy BPS/IC patients treated with intravesical hyaluronan therapy from 2001 to 2003 were asked to rate their present status of bladder symptoms on a visual analog scale. RESULTS: Forty-eight of 70 patients responded after a mean follow-up of 4.9 years. The average initial VAS score of 8.15 had been reduced to 2.71 after therapy and further to 2.14 5 years later. Fifty percent of patients (24/48) reported complete bladder symptom remission at 5 years follow-up without any additional therapy; 41.7% (20/48) with symptom recurrence was improved with hyaluronan maintenance therapy. No improvement was reported by four patients. CONCLUSIONS: Besides a high rate of acute symptom remission, intravesical hyaluronan also shows long-term efficacy in a considerable number of BPS/IC patients.

Effects of one-year treatment with isoflavone extract from red clover on prostate, liver function, sexual function, and quality of life in men with elevated PSA levels and negative prostate biopsy findings.

OBJECTIVES: To asses the effect of an isoflavonoid extract from red clover on the prostate, liver function, quality of life, and sexual function in men with an initial elevated prostate-specific antigen (PSA) level and negative prostate biopsy findings during a 1-year treatment period. METHODS: A total of 20 men (mean age 65 years) were treated with a daily 60-mg dose of an isoflavone extract for 1 year. Liver function, sexual hormone levels (total testosterone, estrogen, luteotropic hormone, follicle-stimulating hormone, and dehydroepiandrosterone sulfate), transrectal ultrasonography volumetry of the prostate, PSA level, International Prostate Symptom Score, and International Index of Erectile Function score were recorded at the beginning of the study and every 3 months for 1 year. RESULTS: The average PSA level was 10.16 ng/mL at baseline versus 7.15 ng/mL after 12 months, for a statistically significant reduction of 33% (P <0.019). The mean prostate volume had decreased slightly from 49.3 cm3 to 44.3 cm3 after 12 months (P <0.097). The sexual hormone levels did not change throughout the study. We registered a significant increase in all three liver transaminases after 3 months (P <0.001). The International Prostate Symptom Score showed a mean value of 7.9 at baseline and 6.68 after 12 months (P <0.421). Sexual function was not influenced by the treatment. CONCLUSIONS: Daily oral administration of 60 mg of an isoflavone extract was well tolerated and caused no side effects. The significant increase in liver transaminases and the significant decrease in total PSA levels by >30% indicates that patients, general practitioners, and urologists should be informed about these potential effects of red clover extracts and possibly other phytoestrogens, on liver transaminases and elevated total PSA levels.

Hyaluronan treatment of interstitial cystitis/painful bladder syndrome.

The aim of this study is to evaluate the efficacy of intravesical hyaluronan therapy in interstitial cystitis/painful bladder syndrome (IC/PBS). One hundred twenty-six patients with IC/PBS and an average disease duration of 6.1 years were treated with weekly instillations of a 50-cm3 phosphate-buffered saline solution containing 40 mg sodium hyaluronate. To be eligible for hyaluronan treatment, a positive modified potassium test was requested as a sign of a urine-tissue barrier disorder. Data were obtained by a visual analogue scale (VAS) questionnaire rating from 0 to 10 that asked for global bladder symptoms before and after therapy. Additional questions evaluated the therapeutic impact on quality of life. A positive and durable impact of hyaluronan therapy on IC/PBS symptoms was observed--103 (85%) of the patients reported symptom improvement (> or =2 VAS units). The mean initial VAS score of 8.5 decreased to 3.5 after therapy (p < 0.0001). Out of 121 patients, 67 (55%) remained with no or minimal bladder symptoms after therapy (VAS 0-2). The majority (101, 84%) reported significant improvement of their quality of life. Intravesical therapy had to be initiated again with good success in 43 patients (34.5%) as symptoms recurred after discontinuation of treatment, while the rest stayed free of symptoms for up to 5 years. In general, hyaluronan therapy was well tolerated and, with the exception of mild irritative symptoms, no adverse reactions were reported for a total of 1,521 instillations. Timely hyaluronan instillation therapy may lead to complete symptom remission or even cure in part of the IC/PBS patients, while some responders need continuous intravesical therapy. The present results suggest that selection of patients for hyaluronan therapy by potassium testing improves the outcome of intravesical therapy with a response rate of >80%.

Comparative assessment of maximal bladder capacity, 0.9% NaCl versus 0.2 M Kcl, for the diagnosis of interstitial cystitis: a prospective controlled study.

PURPOSE: Increased urothelial permeability has been proposed as a cause of interstitial cystitis (IC). The potassium sensitivity test assesses bladder discomfort after instillation of 0.4 M KCl for identification of increased urothelial permeability. Since exposure to 0.4 M KCl may be extremely painful for patients with IC we investigated a less traumatic alternative. MATERIALS AND METHODS: The study comprised 38 controls and 40 patients with IC. In all subjects cystometry was performed with 0.9% NaCl followed by 0.2 M KCl, and filling volume at first urge and maximum bladder capacity (Cmax) were assessed for both solutions. RESULTS: Controls did not show a significant change in Cmax. KCl decreased Cmax in 37 of 40 (92%) patients with IC with a mean decrease of 30%. The examination was painless in all controls and in 33 of 40 (82%) patients with IC, and was moderately painful in 7. CONCLUSIONS: For demonstration of increased potassium sensitivity and diagnosis of IC, comparative assessment of Cmax is a well tolerated alternative to the 0.4 M potassium sensitivity test. Statistical evaluation of these results suggests that a decrease in Cmax greater than 30% is indicative of IC.