The Impact of Sacral Neuromodulation on Sexual Dysfunction.

BACKGROUND/AIMS: Sacral neuromodulation (SNM) is a well-established treatment in several urinary and bowel dysfunctions, nevertheless its role on sexual dysfunction remains unclear. We evaluate the impact of SNM on sexual function and its association with age at SNM, functional diagnosis and post-void residual urine (PVR) before SNM. METHODS: Patients who had SNM were retrospectively analyzed. Sexual function was assessed before and after treatment with the International Index of Erectile Function (IIEF-5) for men and the Female Sexual Function Index (FSFI) for women. IIEF-5 and FSFI were also associated with age at SNM, functional diagnosis, and PVR. RESULTS: Fifteen females and 9 males, with a median age of 41 years (26-72 years), median follow-up 20.7 months (2-53 months) were enrolled. IIEF-5 improved in 4 patients (p = 0.06), and FSFI total score in 5 (p = 0.2). There was significant association between functional diagnosis and FSFI total score (p = 0.05), and FSFI specific domains of arousal (p = 0.03), lubrication (p = 0.04), and satisfaction (p = 0.03), with significant improvement showed in patients with detrusor overactivity with impaired contractility. CONCLUSION: Although gains observed in IIEF-5 and FSFI were modest, our preliminary results show that SNM may have favorable impact on sexual function.

Meta-Analysis of the Sensitivity of Decision Support Systems in Diagnosing Diabetic Retinopathy.

Diabetic Retinopathy (DR) is one of the most common microvascular complications presenting by patients diagnosticated with diabetic diseases. Uncontrolled hyperglycemia may manifest as visual impairment and blindness. The early detection of DR is essential to minimize the risk and consequence of visual diminishing. The standard gold diagnoses tool relies on different imaging modalities and requires a judgment of expert photographers, which are not available in most of the primary care centers or remote location. In that scenario, an automate or semiautomated DR screening systems can contribute to improving the accuracy of the diagnostic. Thus, we performed a Systematic Review and Meta-Analysis to evaluate the Decision Support Systems (DSS) in diagnosing DR. The overall Diagnostic Odds Ratio was 73.15 (95%CI: 37.54-142.50), sensitivity was 97.70 (95%CI: 97.50-97.90) and specificity was 90.30 (95%CI: 90.00-90.60). Our results corroborate with the concept of usefulness of DSSs in early diagnosis, screening and preliminary evaluation of suspicious images of DR.

Laparoscopic Training in Urology Residency Programs: A Systematic Review.

BACKGROUND/AIMS: Laparoscopy is a widespread surgical approach for many urological conditions. Achieving prof-ciency in laparoscopic surgery requires considerable effort due to the steep learning curve. Several residency programs include standardized laparoscopic training periods in their curricula. Our aim was to systematically analyze the evidence on the current status of training in laparoscopy in different residency programs in urology. METHODS: We performed a systematic review of PubMed/Medline and the Cochrane library, in February 2018, according to the Preferred Reporting Items for the Systematic Review and Meta-Analyses Statement. Identified reports were reviewed according to the previously defined inclusion criteria. Eight publications, comprising a total of 985 urology residents, were selected for inclusion in this analysis. RESULTS: There was a wide variation between training programs in terms of exposure to laparoscopy. Most residents considered that training in lap-aroscopy was inadequate during residency and had a low degree of confidence in independently performing laparo-scopic procedures by the end of the residency. Only North American residents reported high degrees of confidence in the possibility of performing laparoscopic procedures in the uture, whereas the remaining residents, namely from European countries, reported considerably lower degrees of confidence. CONCLUSION: There were considerable differences between national urology residency programs in terms of exposure to laparoscopy. Most residents would prefer higher exposure to laparoscopy throughout their residencies.

Nine-year survival after iterative metastasectomies for renal cell carcinoma.

We report the case of a 24-year-old male, diagnosed with an incidental T3a papillary renal cell carcinoma (RCC), treated with left laparoscopic radical nephrectomy. After 7 months, nodal recurrence was identified and retroperitoneal lymph node dissection (RPLND) was performed. Four months later, due to local recurrence, the patient underwent salvage RPLND, partial psoas resection and left adrenalectomy, and remained without recurrence during the following 15 months, after which treatment with sunitinib was started due to multiple metastases in pelvic lymph nodes, lungs, and bone. After 4 years of stable disease, progression at the quadratus lumborum and psoas muscles led to subsequent metastasectomy. No evidence of progression was identified for 2 years, after which, despite multimodal treatment (axitinib and radiotherapy to bone lesions), widespread disease progression led to patient death. This uncommon case of prolonged survival with metastatic RCC highlights the possible role of iterative metastasectomies in the management of advanced stage disease, as well as its potential to extend the survival substantially, even when progressive on tyrosine kinase inhibitors.

Low-intensity shock wave therapy for erectile dysfunction and the influence of disease duration.

OBJECTIVE: Low-intensity shock-wave treatment (LiSWT) is a therapy for erectile dysfunction (ED) with good results reported in the literature. The aim of this study was to evaluate the results of LiSWT on patients treated for ED and the influence of ED duration in treatment outcomes. MATERIAL AND METHODS: We performed an open-label single-arm prospective study of patients treated with LiSWT for ED. Patients were assessed with the IIEF-5 at baseline and at six weeks and three months after LiSWT, and with penile dynamic Doppler ultrasound before treatment and six weeks after. Patients were divided into two groups accordingly to ED evolution time: ≤ 24 months and > 24 months. RESULTS: Twenty-five patients were enrolled, 13 had ED ≤ 24 months and 12 > 24 months. Median baseline IIEF-5 was 14, at 6 weeks post LiSWT was 16 (p < 0.001) and at 3 months post LiSWT was 18 (p < 0.001). Mean baseline peak systolic velocity (PSV) was 29.3 ± 13.0 cm/s, after LiSWT was 35.9 ± 15.2 cm/s (p 0.001). Mean baseline end-diastolic velocity (EDV) was 2.6 ± 4.8 cm/s and after LiSWT was 1.3 ± 4.3 cm/s (p 0.015). No statistical significative difference was identified between the two groups. CONCLUSIONS: LiSWT is a safe, harmless and repeatable treatment tool for ED with good outcomes reported. Our results suggest that length of disease duration doesn´t negatively influences treatment results.

Bilateral synchronous testicular seminoma: A rare presentation of a rare disease.

OBJECTIVE: To present a case of a bilateral synchronous testicular seminoma in a young male clinical stage IIB. MATERIAL AND METHOD: A 37 years old man presented a bilateral testicular mass with elevated tumoral markers. Histology of frozen section revealed bilateral seminoma and bilateral radical orchiectomy was performed. RESULT: Enhanced chest and abdominopelvic staging CT scan revealed a lymphadenopathy of 30 mm within the inter-aortocava nodal chain (stage IIB). Patient received three cycles of BEP. Three months later 18F-FDG PET showed no evidence of hypermetabolic activity and serum tumoral markers were normal. CONCLUSION: Bilateral testicular germ cell tumors are a rare disease. Management of this tumors is controversial. Bilateral radical orchiectomy is the standard of care, nevertheless, in order to preserve fertility and androgen production, an organsparing surgery can be attempted in selected cases. Although prognosis is good, with overall survival rates similar to patients with unilateral disease, life-long close follow-up may be advocated due to relapse risk.

Incidental Detection of Occult Thyroid Carcinoma with 11C-Choline PET/CT for High Risk Prostate Cancer.

We report a case of a 65-year-old male patient with high-risk prostate cancer, re-staged with 11C-choline positron emission tomography/computed tomography (PET/CT) for prostate specific antigen recurrences 3 years after radical prostatectomy and adjuvant radiation therapy. In addition to 2 suspicious presacral lymph nodes which were resected and proven to be metastatic, PET/CT revealed a very high uptake in a calcified thyroid nodule. Evaluation with fine needle aspiration was suspicious for thyroid carcinoma and the patient underwent total thyroidectomy, confirming a non-metastatic encapsulated follicular variant of papillary thyroid carcinoma. To our knowledge, this is the first report of a thyroid cancer diagnosed with 11C-choline PET/CT for prostate cancer staging.

"Horrendoplasty" - A case of total perineal destruction by agricultural implement.

Although posterior urethral injury occurs almost always in association with pelvic fracture, it may result from severe trauma to the perineum with its associated potential lethality and severe morbidity. Early primary endoscopic realignment over a urethral catheter can be attempted, although an immediate suprapubic tube placement remains the standard of care. Definitive treatment consists of elective open posterior anastomotic urethroplasty through a perineal approach. The authors present a 53-year-old man who sustained total, massive perineal destruction resulting from work accident with an agricultural implement. Immediate suprapubic tube placement was performed followed by delayed elective transperineal anastomotic posterior urethroplasty. A major multidisciplinary approach was necessary in the management strategy, including orthopedic, general, plastic, vascular surgeries, and reconstructive urology teams. At a later stage, with the patient stabilized and recovered from major, life-threatening lesions dealt with by a multidisciplinary team, urethral reconstruction can be undertaken with ultimate good functional outcomes.

Hutch bladder diverticulum - unusual cause of adult obstructive uropathy.

OBJECTIVE: To present a case of a Hutch bladder diverticulum containing the ureteral opening. MATERIAL AND METHODS: An 83-year-old man presented a giant bladder diverticulum causing obstructive azotemia due to bilateral ureteral compression. Endoscopy revealed an unusual and potentially harmful anatomical alteration: the left ureteral orifice was inside in the diverticulum. Despite bladder emptying, the diverticulum remained full, causing bilateral ureteral compression. The patient underwent diverticulectomy with ureteroneocystostomy. RESULT: Post-operative follow-up showed renal and voiding functions restoration. CONCLUSION: Although clinical watching is a valid option in patients with Hutch diverticulum, reconstructive surgical approach, especially when complications are present, should be the standard of care.