The role of oral antioxidants in the improvement of sperm parameters in infertile men.

PURPOSE: A variety of pathologic conditions may increase oxidative stress in semen resulting in structural modifications to spermozoa's plasma membrane that interfere with sperm motility, morphology, and count. Antioxidants are currently being marketed to treat male infertility. In semen, antioxidants may decrease oxidative stress and potentially improve sperm parameters. In this narrative, mini-review we evaluated the effectiveness of antioxidants in infertility. METHODS: This mini-review of the current literature has been carried out through searching of the PubMed and Google scholar databases. RESULTS AND CONCLUSIONS: The literature review suggests that there is evidence that oral antioxidants such as selenium, carnitine, zinc, coenzymeQ10, vitamins E and C, etc. alone or in combinations, improve sperm count, motility, morphology as well as pregnancy rates in infertile men with idiopathic oligoasthenospermia. Unfortunately, most of these studies are poorly designed, limited by sample size, varying in dosage, differing in primary end points, and most notably lacking live birth data. Importantly, large randomized, well-designed, placebo-controlled trials are needed.

Renal artery infarction in the SARS-Cov-2 era: A systematic review of case reports.

AIM: Renal artery infarction (RI) is the presence of blood clot in the main renal artery or its branches causing complete or partial obstruction of the blood supply. Its etiology is either related with disorders of the renal vasculature or with cardiovascular diseases. Recently, the SARSCoV- 2 virus is an emerging cause of thromboembolic events and the incidence of RI is anticipated to increase after the pandemic. METHODS: A systematic review based on COVID-19 associated RI was conducted. PROTOCOL: A systematic review of the Medline/Pubmed and Scopus databases was conducted in accordance to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (the PRISMA statement). Search strategy and information sources: A hand-search was performed using the terms "SARS-Cov-2" OR "COVID-19" AND "renal thrombosis" OR "renal infarction" OR "renal "thromboembolism". ELIGIBILITY CRITERIA: all types of publications (case reports, case series, letters to the editor, short communications) were evaluated for relevance. Inclusion criteria were: confirmed SARS-Cov-2 infection irrespectively of the age, diagnosis of RI during or after the onset of viral infection, and exclusion of other potential causes of thromboembolic event except of SARS-Cov-2. Patients with renal transplantation were also considered. Study criteria selection: after checking for relevance based on the title and the abstract, the full texts of the selected papers were retrieved and were further evaluated. Duplicated and irrelevant cases were excluded. Any disagreement was resolved by consensus with the involvement of a third reviewer. Quality of studies: The assessment of the quality case reports was based on four different domains: selection, ascertainment, casualty and reporting. Each paper was classified as "Good", "Moderate" and "Poor" for any of the four domains. Data extractions: Crucial data for the conduct of the study were extracted including: age, sex, time from SARS-Cov-2 infection till RI development, medical history, previous or current antithrombotic protection or treatment, laterality and degree of obstruction, other sites of thromboembolism, treatment for thromboembolism and SARS-Cov-2 and final outcome. DATA ANALYSIS: methods of descriptive statistics were implicated for analysis and presentation of the data. RESULTS: The systematic review retrieved 35 cases in 33 reports. In most cases, RI was diagnosed within a month from the SARSCov- 2 infection albeit 17 out of 35 patients were receiving or had recently received thromboprophylaxis. Right, left, bilateral and allograft obstruction was diagnosed in 7, 15, 8 and 5 patients respectively. 17 cases experienced additional extrarenal thromboembolism primarily in aorta, spleen, brain and lower limbs. Low molecular weight heparins (LMWH) (usually 60-80 mg enoxaparine bid) was the primary treatment, followed by combinations of unfractionated heparin and salicylic acid, apixaban and rivaraxaban, warfarin, acenocoumarol or clopidogrel. Kidney replacement therapy was offered to five patients while invasive therapies with thrombus aspiration or catheter directed thrombolysis were performed in two. Regarding the outcomes, five of the patients died. The total renal function was preserved in 17 cases and renal impairment with or without hemodialysis was recorded in 5 patients, two of them having lost their kidney allografts. LIMITATIONS: The majority of included studies are of moderate quality. The results and the conclusions are based on case-reports only and crucial data are dissimilarly presented or missing through the relevant publications. CONCLUSIONS: Thromboprophylaxis may not offer adequate protection against SARS-Cov-2 induced thrombosis. Most patients could be effectively treated with conservative measures, while in more severe cases aggressive treatment could be recommended. IMPLICATIONS OF KEY FINDINGS: Therapeutic doses of LMWH could be considered for protection against RI in SARS-Cov-2 cases. Interventional treatment could be offered in a minority of more severe cases after carful balancing the risks and benefits.

Management of Fournier's Gangrene in a COVID-19 Patient: Challenges and Dilemmas.

Fournier's gangrene is a urologic emergency manifested as an aggressive form of necrotizing fasciitis. Co-infection of Fournier's gangrene with COVID-19 might have catastrophic sequelae. We report a case of a 69-year-old male patient, unvaccinated against coronavirus, was obese, and with type 2 diabetes diagnosed with Fournier's gangrene. Apart from administration of piperacillin/tazobactam and clindamycin, the patient underwent surgical debridement four hours after his presentation. Postoperatively, the PCR test for COVID-19 was proved to be positive. The patients develop septic shock necessitating the delivery of dopamine, supplemental oxygen, and thromboprophylaxis. On the seventh postoperative day, left testicular ischemia was developed and ipsilateral orchiectomy was performed. After his full recovery from an in-hospital infection by Acinetobacter baumannii, the patient was transferred to the plastic surgery department. The prompt surgical debridement has likely counterbalanced the health risk originated from COVID-19 infection, contributing to the patient's full recovery. Testicular ischemia is a very rare condition in necrotizing fasciitis of the genital and perineal space and it could be attributed primarily to the thrombotic nature of coronavirus. Due to the assault of multiple organs and systems, a medical board consisting of urologists and other medical specialties substantially contributed to the favorable outcome.

Prognostic factors for the safety and efficacy of retrograde laser lithotripsy: Data from a contemporary series of 155 consecutive patients with single and multiple lithiasis of the urinary tract.

Treatment of large and multiple stones located in the ureter and/or the kidney may be challenging. The aim of the current study was to evaluate the results and complications of retrograde endoscopic lithotripsy for stones located in the urinary tract and to determine prognostic factors for treatment outcome. From April 2017 to March 2020, eligible patients for the active treatment of ureterolithiasis with or without concomitant nephrolithiasis <20 mm were enrolled in the study. The prognostic factors for the stone free rate (SFR) after the 1st and subsequent sessions and overall complications were assessed. Patients were divided into single or multiple lithiasis groups (groups A and B respectively). A comparison between these two groups was then conducted. Overall, 237 stones were detected in 155 patients, representing a mean burden of 1.53 stone per patient. The mean total stone size was 14.7 mm, the initial SFR was 80% and the final SFR (after a mean of 1.23 session per patient) was 94.2%. The rate of complications was 26.4%. Multivariative analysis revealed that preoperative stenting and total stone size were independent prognostic factors of initial SFR, while no independent factors were determined for final SFR. Age, total size and stones in the lower calyx were independent factors for complications. In group A and B, 114 and 41 cases with solitary and multiple stones were included, respectively. Excluding operation time (P=0.002), no significant differences were recorded in terms of initial (P=0.255) and final SFR (P=0.056), hospital stay (P=0.308), mean number of treatments (P=0.757) and the rate of complications (P=0.218) between the two groups. In conclusion, retrograde endoscopic management of multiple lithiasis has a favorable outcome irrespective of stone location. Older patients with higher burdens and stones in the lower calyx should be treated with caution.

Feasibility of a single session retrograde endoscopic laser lithotripsy of two large stones located in a bifid urinary tract. Presentation of a rare case.

A 76 year-old male presented with urosepsis and acute renal injury secondary to obstruction by a 13 mm stone located in the common segment of a bifid left ureter. A second 10 mm stone was detected in the mid calyx of the lower moiety of the kidney. Drainage of both moieties with two double-J stents was initially performed. Following recovery from urosepsis a retrograde endoscopic semirigid and flexible laser lithotripsy of the distal and proximal stone respectively was performed resulting in stone clearance. Although retrograde ureterolithotripsy has been presented in the past, to the best of the authors' knowledge, this is the first description of flexible retrograde intrarenal lithotripsy performed through a bifid ureter.

Clinical Outcome and Prognostic Factors of Sepsis, Septic Shock and Prolonged Hospitalization, of Patients Presented with Acute Obstructive Pyelonephritis.

Objective: To investigate prognostic factors of outcome of acute obstructive pyelonephritis (AOP). Materials and Methods: Patients with AOP were prospectively evaluated and logistic regression analysis was applied to identify factors associated with the duration of hospital stay and occurrence of sepsis and septic shock. Results: Based on CT scan findings, 62 patients were found to have AOP and subjected to emergency drainage. The main etiology of obstruction was lithiasis (70.9%). Double-J stent and percutaneous nephrostomy were introduced in 48 and 14 patients, respectively. Urosepsis and septic shock were diagnosed in 20 (32%) and 6 (9.7%) patients, respectively. None of the patients died of sepsis. In univariative analysis, older age, high neutrophils, increased serum creatinine, higher Charlson comorbidity index (CCI) score, any CCI score ≥1, diabetes mellitus (DM) longer operation time (OT), and multiresistant stains were risk factors of sepsis. Gender, type of drainage, laterality, white blood cell count, neutrophils rate >80%, C-reactive protein, and the presence of malignancy or lithiasis were not. Age, DM, and CCI score ≥1 were associated with prolonged hospitalization. None of the factors was associated with shock. In multivariative models, age (odds ratio [OR]: 1.09, 95% confidence interval [CI]: 1.02-1.16, p = 0.010), multiresistant strains (OR: 16.36, 95% CI: 1.97-135.71, p = 0.006), OT >20 minutes (OR: 1.03, 95% CI: 1.00-1.07, p = 0.048), and elevated creatinine (OR: 1.68, 95% CI: 1.001-2.84, p = 0.049) were independent prognostic factors of sepsis, and DM (OR: 30.8%, CI: 8.86%-52.8%, p = 0.007) was a prognostic factor of longer hospitalization. Conclusions: One-third of AOP patients will develop sepsis. Older age, elevated serum creatinine, longer OT presence of multiresistant strains, and DM are independent factors of worse outcome.

Malignant solitary fibrous tumor of urinary bladder: A rare clinical entity.

Solitary Fibrous Tumors (SFTs) are mesenchymal tumors occurring in several sites. Urinary bladder SFTs are quite rare. Eighteen cases are described in the literature and only two of them had malignant features. SFTs comprise a histologic spectrum of mesenchymal neoplasms that show fibroblastic differentiation. The signs and symptoms are non specific. Immunohistochemistry plays a pivotal role in the diagnosis, differentiating SFTs from other spindle cell mesenchymal tumors. Malignant criteria are considered the large size, increased mitotic activity, focal necrosis or hemorrhage, nuclear atypia, hypercellularity and infiltrative margins. Clinical and biological behavior of bladder SFTs is usually not aggressive but cannot be safely predicted based on the pathologic features. Complete surgical resection is the cornerstone of treatment. We present the third bladder SFT case with malignant features and a mini literature review.

How Effective Is Retrograde Semirigid and Flexible Ureteroscopic Lithotripsy for the Treatment of Large Ureteral Stones Equal of or Greater than 15 mm? Results from a Single Center.

PURPOSE: To present the results and complications of retrograde ureteroscopic lithotripsy for treatment of large ureteral stones. METHODS: Nineteen patients were treated for ureteral stones ≥15 mm detected in CT or plain KUB film. Endoscopy was performed with either a semirigid or flexible ureteroscope. Stone fragmentation was performed using a 30 W Holmium laser. RESULTS: The mean stone size was 20.7 mm (range 15-30). The mean duration of the operation was 82 min (45-140). Measures to prevent retropulsion of fragments into the kidney were not routinely applied. A subsequent RIRS during the same session was necessary in 2 cases. After a single procedure a stone free state was achieved in 15 cases (78.9%), while 4 others required a second session (ESWL or second ureterolithotripsy, 2 cases each). In only 1 patient, the stone-free state was not achieved after a 1.2 procedure per patient (overall success rate 94.7%). The mean duration of hospitalization was 1.9 days (range 1-5). Three patients experienced postoperative pyelonephritis and 2 others prolonged hematuria. CONCLUSION: Endoscopic lithotripsy is safe and effective in treating large ureteral stones. After a single endoscopic procedure, approximately 4 out of 5 patients are expected to become stone free. This rate increases to 95% with a second session of lithotripsy.

Is There a Role for Double J Stent Culture in Contemporary Urology?

INTRODUCTION: To present the incidence of bacterial colonization on ureteral double J stents (DJS); isolate the uropathogens; define the rate of multi-resistant bacteria strains (MRBS) and present their clinical importance. MATERIALS AND METHODS: The whole body of 105 DJSs was examined for the presence of uropathogens. RESULTS: The main etiology for stent placement was lithiasis (57.1%). The most frequently cultured microorganisms were staphylococcus (28.6%). Forty-four stents hosted MRBS. 25 (23.8%), 10 (9.5%) and 8 (7.6%) of the patients were affected by malignancy, diabetes mellitus and chronic renal failure respectively. Apart from the female gender, none of the examined factors (age, duration of stenting and chronic diseases) was correlated with the colonization or the presence of MRBS. Eleven of the 61 stented patients (18%) who were operated upon developed a febrile urinary tract infections (UTI). In 7 of them the stent hosted MRBS (63.6%). After taking into consideration the sensitivity report, we altered our initial empirical antibacterial prophylaxis to targeted antibacterial treatment in the patients with MRBS with rapid remission of their infection and no urosepsis event. CONCLUSION: The knowledge of bacteriologic flora of DJS can be very helpful in an evidence-based prophylactic and therapeutic practice. Stent examination could be recommended in high-risk cases of developing UTI and sepsis after a urologic operation.

The Current Role of Osteoclast Inhibitors in Patients with Prostate Cancer.

PURPOSE: Prostate cancer (PCa) is one of the most frequently diagnosed malignancies worldwide. Hormonal deprivation therapy is a well-established treatment for locally advanced or metastatic diseases but exposes patients to the risk of osteoporosis and fragility fractures. Furthermore, the tropism of the PCa cells to osseous metastases increases the incidence of skeletal-related events (SREs). METHODS: A nonsystematic review of the international literature was performed in respect to the use of osteoclast inhibitors zoledronic acid (ZA) and denosumab (DEN) in PCa patients. RESULTS: DEN and ZA have proved their efficacy in preventing osteoporosis and bone mass loss in patients treated with hormonal therapy with no proven superiority of one agent over the other. However, the effectiveness in reducing fragility fractures has been proved only for DEN so far. In metastatic-free castrate-sensitive high-risk PCa patients, ZA has not shown any efficacy in preventing osseous metastasis, and evidence is lacking in favor or against the use of DEN. The use of osteoclasts inhibitors had no evident positive effect in overall and disease-specific survival in this group of patients. In advanced castrate-refractory malignancy, DEN has shown clinical superiority over ZA in preventing new SRE but not in overall survival. CONCLUSION: Superiority of DEN over ZA has been proved only in advanced castrate refractory disease in terms of preventing new SRE. In the rest of the cases, the selection of either agent should be based on the clinical condition of each patient and the cost of the treatment.

Do Calcium Supplements Predispose to Urolithiasis?

PURPOSE OF REVIEW: The purpose of this study was to investigate the role of calcium supplements, with or without vitamin D, in urinary stone formation in healthy population and in osteoporotic patients as well. Moreover, this review aims to clarify whether or not, and above which dose, they are associated with the risk of lithiasis. RECENT FINDINGS: A research in Medline, Embase, and Scopus databases up to September 2015 was conducted using the following keywords: calcium, supplements, vitamin D, complications, lithiasis, and urinary stone. All types of studies were taken into account (cohort studies, reviews, meta-analyses), and in case they fulfilled the inclusion criteria, they were included in our review. The analysis of the data showed that calcium supplements, probably in association with anti osteoporotic treatment, do not create a predisposition towards lithiasis formation among women suffering from osteoporosis, neither among non-osteoporotic older men. In healthy postmenopausal as well as younger women, the supplements might increase susceptibility to urinary stone formation in long-term basis. The consumption of calcium supplements with the meals could play a protective role in women and younger males. There is certain evidence that supplements containing citrate may be more beneficial over the rest of calcium supplements, particularly when consumed during the meal. Osteoporotic women and healthy men are not at risk of stone formation. On the contrary, healthy women should be aware of the potential risk of developing urinary lithiasis in long-term basis.

A Prospective Study of Bipolar Transurethral Resection of Prostate Comparing the Efficiency and Safety of the Method in Large and Small Adenomas.

Bipolar technology offers a new perspective in the treatment of BPH. Purpose. To present our experience with the TURis system (Olympus, Tokyo, Japan). Materials and Methods. From February 2011 till December 2013 in a prospective study, 93 patients were treated for BPH. They were evaluated with IPSS, QoL, uroflow (Q max), and residual urine (RU), preoperatively as well as 6 and 9 months postoperatively. Based on the prostate volume, the patients were divided into two groups: group A (n = 48) with prostates ≥ 75 cc and group B (n = 45) with smaller prostate glands. All patients underwent bipolar TURP or/and plasma vaporization. Results. The postoperative improvement for IPSS, QoL, Q max, and RU was statistically significant. The operation time was longer in group A in comparison with group B (P < 0.001). The former group also had higher infection and stricture formation rates; however, there was no statistical difference between the two groups. Conclusions. Treatment with the TURis constitutes an effective technique and can be offered to large prostates with results equivalent to those in small ones. Regarding safety, large adenomas treated with TURis are not at a higher risk for urethral stricture but their odds to develop urogenital infections are relatively higher compared to the smaller adenomas.

Is V-Y plasty necessary for penile lengthening? Girth enhancement and increased length solely through circumcision: description of a novel technique.

Our objective is to describe a novel ligamentolysis approach using a subcoronal incision technique and to determine its safety and efficacy. During the last 7 years, 82 consecutive patients had penile augmentation surgery. Ligamentolysis, through a lower abdominal incision (V-Y plasty) in the first 35 males, was performed (Group A), followed by circumcision ligamentolysis in the next 47 males (Group B). The operation time, complications, and the preoperative and postoperative values of penile length and girth along with the self-esteem and relations questionnaire score as well as satisfaction score was calculated before and after the surgery, and a comparison was conducted between the groups. The mean age at presentation was 32 years (range: 18-56 years). Seventy-nine patients suffered from penile dysmorphophobia, and three patients had micropenises (length <7.5 cm). The mean surgical times were 150.7 and 125.2 min for Groups A and B, respectively (P=0.005). Postoperatively, four Group A patients and three Group B patients (11% versus 6%, respectively) experienced penile retraction (P=0.453). Hypertrophic scars were observed in 18 men (51%) in the former [corrected] group. In the circumcision group, no major wound complications were recorded. The length and girth improvements between the groups were similar. In terms of satisfaction and SEAR improvement, the resulting difference for both variables favored the circumcision group (P=0.007 and <0.001, respectively). With strict selection criteria, the circumcision ligamentolysis procedure compared to the V-Y plasty demonstrated improved results in terms of safety, operation time, retraction rate and cosmetic appearance without any compromise in the gained penile size.

Inverted papilloma of the ureter: study of a rare case with emphasis on clinicopathologic implications.

A 62-year old male patient presented complaining of intermittent macroscopic hematuria. The ultrasonographic investigation revealed a hydronephrosis of remarkable degree with indiscrete renal parenchyma. The abdominal computed tomography scan identified a ureteral lesion with proximal dilatation, hydronephrosis and a functionless ipsilateral renal unit. The retrograde urography showed a 4-cm lesion with multiple filling defects and a smooth contour. The endoscopic examination showed an exophytic lesion, highly suspicious for malignancy. Urine cytology revealed atypia. Right nephroureterectomy was performed and the pathology revealed a ureteral inverted papilloma (UIP). Polymerase chain reaction examination for the presence of human papilloma virus, using GP5+/6+ consensus primers, was negative. The presence UIP should be considered in patients with urotheleal lesions in the ureter when the diagnostic workup for malignancy is inconclusive. The clinical course of the disease seems to be favorable.

Lymphoepithelioma-like bladder cancer: clinicopathologic study of six cases.

Herein, we report on our experience with six patients (0.3%) diagnosed with lymphoepithelioma-like bladder carcinoma (LELBC) over the past 15 years at our department. The mean age of the patients with LELBC was 73 years (range 69-80 years). All patients had at least pT2 disease. The primary treatment was transurethral resection of the bladder tumor, radical cystectomy (RC), and radiotherapy (RT) in one, two, and three patients, respectively. After a mean follow-up of 31 months (range 13-72 months), three patients are still alive. The predominant subtype was diagnosed in four patients, three of whom are alive at the time of writing, compared with the two patients in whom the focal subtype was diagnosed, both of whom are dead. Two of the living patients were treated with a bladder-preservation strategy. Our experiences suggest that RC may not be necessary in muscle invasive disease and that RT and chemotherapy may be reliable treatment options. The pathology report may be useful in selecting patients suitable for bladder-preservation treatment.

Small cell carcinoma of the urinary tract: a case report.

Neuroendocrine small cell carcinoma of the urinary tract is rarely encountered and very few cases have been reported in the literature. Herein we describe a case of small cell malignancy located contemporarily in the ureter and the bladder.