Prediction of surgical decision and postoperative renal function using RENAL nephrometry score for localized renal masses: A prospective study.

Purpose: The purpose of the study is to assess the value of RENAL nephrometry score (RNS) in predicting surgical decisions, complications, and decreases in kidney function in patients with localized renal tumors. Methods: Cases with solitary, solid, and enhancing renal masses were included, scheduled for nephron-sparing surgery (NSS), and assessed using routine laboratory and radiological data necessary for calculating the RENAL score. The primary endpoint was conversion to radical nephrectomy (RN), while the secondary endpoint was the prediction of a drop in renal function assessed by postoperative estimated glomerular filtration rate (eGFR) at the last follow-up visit compared with the preoperative values. The association between the scoring system and perioperative outcomes was evaluated. Results: In all, 84 cases were included, NSS was accomplished in 67 cases while conversion to RN was mandatory in 17 patients, median (interquartile range) RENAL score was 6.2 (4-10) for NSS and 9.7 (6-12) for RN (P < 0.001). Higher grades of complications were observed in the high-complexity subgroup. eGFR was 79.8 that dropped to 75.6 ml/min/1.73 m2 in the late value in patients who underwent NSS, while it was 82.9 that dropped to 58.3 ml/min/1.73 m2 in the late value in patients who converted into RN (P < 0.001). The percentage of drop in eGFR was significantly higher in the moderate and high-risk groups, which was positively correlated with the warm ischemia time. Regression analysis revealed that the continuous RENAL score was a more significant predictor of conversion to RN than tumor size alone. In the 67 NNS cases, the percentage decrease in eGFR was predicted using the continuous RENAL score. Conclusion: The RNS is a significant predictor of conversion to RN and can predict the percentage decrease in eGFR after NSS. Further investigations and follow-ups are necessary.

Clinical utility of vesical imaging-reporting and data system (VI-RADS) in non-muscle invasive bladder cancer (NMIBC) patients candidate for en-bloc transurethral resection: A prospective study.

OBJECTIVES: To assess accuracy of vesical imaging-reporting and data system (VI-RADS) 5-point score in detection of muscle invasive bladder cancer and avoiding second look transurethral resection of the tumors (TURBT). Additionally, to assess safety and efficacy of bipolar en-block transurethral urethral resection of bladder tumor. METHODS: Patients with bladder mass up to 5 cm were included in the study. VI-RADS 5-point score was done preoperative for all cases and postoperatively before second look TURBT. Patients were followed up for 12 months. RESULTS: In all, 80 cases were eligible for the study. Preoperative VI-RADS score at cutoff of 3 had sensitivity of 89.3 %, specificity 83.3 %, postive predective value (PPV) 92.6 %, negative predictive value (NPV) 76.9 %, accuracy of 87.5 %, while at cutoff 2 sensitivity was 82.1%, specificity 91.7%, PPV 95.8%, NPV 68.8%, accuracy of 85.0%. Operative time 28.8 ± 9.4 minutes, hemoglobin drop 0.3 ± 0.05 g/dl, catheterization time 2.8 ± 0.8 days, hospital stay 1.4 ± 0.4 days. No complications occurred. Recurrence in field of resection 3.75%. Detrusor muscle was available in 76 cases (95%). Postoperative VI-RADS score at cutoff of 3 had sensitivity of 78.6%, specificity 77.8%, PPV 84.6%, NPV 70.0%, accuracy of 78.3%. At cutoff 2 VI-RADS score sensitivity was 71.4%, specificity 77.8%, PPV 83.3%, NPV 63.6%, accuracy of 73.9%. CONCLUSION: VI-RADS 5-point score showed high sensitivity and specificity in preoperative discrimination of non-muscle invasive bladder cancer (NMIBC) from muscle invasive bladder cancer cases and in avoiding unnecessary second look TURBT. Bipolar en-block TURBT technique is both safe and efficacious in resecting NMIBC cases with low recurrence rate.

Percutaneous Nephrolithotomy Outcomes Based on S.T.O.N.E., GUY, CROES, and S-ReSC Scoring Systems: The First Prospective Study.

Objective: To evaluate predictive capability and clinical applicability of the current nephrolithometric scoring systems of S.T.O.N.E. score, Guy's scoring system (GSS), CROES (Clinical Research Office of the Endourological Society) nomogram, and S-ReSC (Seoul National University Renal Stone Complexity) score for percutaneous nephrolithotomy (PCNL) outcomes in the same cohort in a prospective study. Methods: Consecutive patients undergoing PCNL between 2015 and 2018 were included calculating the four scores in the same cohort. Stone-free status (SFS), complications, operative time (OT), estimated blood loss (EBL), fluoroscopy time, and length of hospital stay were investigated. Receiver operator characteristic (ROC) curves for predictive accuracy and regression analysis for predictors of SFS were performed. Results: In all, 162 PCNLs were accomplished and analyzed. Overall, SFS was 75.9% and complication rate was 30.9%. The mean acquisition time of scores was 52.9 ± 0.5 seconds for GSS, 05.1 ± 0.3 seconds for S.T.O.N.E. score, 224 ± 3.1 seconds for CROES, and 102.6 ± 3.5 seconds for S-ReSC score. SFS had the best association with CROES grade. Clavien grade was associated with S.T.O.N.E. score. Moreover, EBL and OT had best association with S-ReSC score. All scores had comparable predictive accuracy on ROC curves regarding SFS. Stone essence and tract length are not different in cases with residual stones. Number of involved calyces, single vs multiple stones and renal pelvic obstruction were significant predictors of SFS in regression analysis. Conclusion: The four scoring systems had comparable predictive accuracy for SFS. However, S.T.O.N.E. and S-ReSC scores were easily applicable and provided better association with EBL and OT compared with the GSS score. Number of involved calyces, stone multiplicity, and renal pelvic obstruction were significant predictors of SFS; hence, further studies are needed to invent a universally agreeable scoring system covering reported shortcomings in the currently used scores.

Two-stage repair of proximal hypospadias with moderate to severe chordee using inner preputial skin graft: prospective evaluation of functional and cosmetic outcomes.

OBJECTIVE: To critically evaluate inner preputial graft (IPG) used in staged proximal hypospadias with severe chordee regarding cosmetic and functional outcomes. PATIENTS AND METHODS: In this prospective study, patients with primary proximal hypospadias with moderate to severe chordee (> 30°) after penile degloving were considered candidates for staged repair between June 2011 to July 2017. After transection of the urethral plate (UP) and penile straightening, the bare shaft was covered with IPG. Tubularization of the graft was done as a second stage. Cosmetic and functional outcomes were assessed using HOSE score and uroflowmetry (UF). Additionally, factors influencing success were analyzed. RESULTS: In all, 38 consecutive cases were included. Native meatus was at proximal penile in 17, penoscrotal in 11, scrotal in 7, and perineal in 3 cases. Median age was 26 and 32 months at the first stage and the second stage, respectively. Preoperative testosterone was given for ten patients with a small penis and/or severe curvature. The mean follow-up was 18 ± 8.2, median 15 months. Grafts took well in all cases after the first stage except one. Cosmetic success achieved in 33 (86.8%). A total of ten complications occurred in six cases. Unplanned intervention was needed in 5/38 cases. Functionally, UF study revealed normal flow in 7/23 (30.4%), equivocal in 11/23(47.8%), and obstructed flow in 5/23(21.7%). CONCLUSION: Inner preputial graft use in proximal hypospadias with moderate to severe chordee seems to have a good technical outcome and functionally mimic the normal urethral function and could be considered an ideal option for substitution urethroplasty.

The impact of coexisting sperm DNA fragmentation and seminal oxidative stress on the outcome of varicocelectomy in infertile patients: A prospective controlled study.

OBJECTIVES: To study the relationship between sperm DNA fragmentation (SDF) and reactive oxygen species (ROS) levels in infertile patients with varicocele, and to examine the beneficial effect of varicocelectomy and elucidate predictors of improvement after repair. PATIENTS SUBJECTS AND METHODS: We prospectively studied 60 patients with varicocele and abnormal semen variables who attended the outpatient clinic complaining of infertility for ≥12 months. In all, 25 patients (41.7%) had bilateral varicoceles and 35 (58.3%) had left varicoceles. The DNA fragmentation index (DFI%, percentage of sperm with denatured nuclei), ROS and total non-enzymatic antioxidant capacity (TAC) were measured. Inguinal varicocelectomy was performed in all patients. At 3-6 months postoperatively, all measurements were repeated. A control group, comprised of 20 normozoospermic fertile men, was included. Regression analysis was used to examine predictors of improvement. RESULTS: The mean (SD) DFI% in the 60 infertile patients with varicocele was 29.9 (8.3) and 7.56 (2.84)% in the controls; ROS levels were 4.49 (0.9) in patients and 2.62 (0.8) photons/min in controls; and the TAC was 0.97 (0.4) in patients and 1.5 (0.5) mM in controls; with highly significant differences between the patients and controls. The DFI% showed a positive correlation with ROS levels, whilst the total motile sperm count (TMSC) had a significant negative correlation with DFI%, ROS levels and grade of varicocele, whilst there was significant positive correlation with TAC. The grade of varicocele and duration of infertility were related to the presence of higher levels of ROS and increased of DFI%. Postoperatively, improvement (measured as a >50% increase in TMSC) occurred in 40 of 55 (73%) patients available at follow-up, with a significant reduction in the mean (SD) DFI% from 29.49 (8.58) to 18.78 (7.23)%, ROS levels from 4.49 (0.88) to 3.27 (1.3) photons/min (both P < 0.001), and a significant increase in the mean (SD) TAC from 1.01 (0.44) to 2.05 (0.51) mM (P < 0.001). Responders had a shorter infertility duration and lower preoperative DFI% and ROS levels. Regression analysis showed that DFI% is a predictor of improvement after varicocelectomy. CONCLUSION: SDF was shown to have a negative impact on improvement after varicocelectomy. Hence, DFI% could be recommended as a prognostic test in infertile patients with varicocele to help decision-making as regards the necessity and the anticipated outcome of varicocelectomy in patients with infertility.

A Critical Analysis of Stented and Unstented Tubularized Incised Plate Urethroplasty Through a Prospective Randomized Study and Assessment of Factors Influencing the Functional and Cosmetic Outcomes.

OBJECTIVE: To compare, functionally and aesthetically, stented and unstented tubularized incised plate urethroplasty (TIPU). In addition, predictors of repair success were investigated. MATERIALS AND METHODS: One hundred ten children with distal hypospadias were included in this study. The length and width of the urethral plate (UP) and transverse glans diameter (TGD) were measured. Patients were randomized into two groups: stented and unstented TIPU. Postoperative assessment of pain was done using Face, Legs, Activity, Cry, Consolability (FLACC) scale, and cosmetic outcome was evaluated using hypospadias objective scoring evaluation. Uroflow was assessed at 6 months in toilet-trained boys. Complications were graded by the Clavien classification system. RESULTS: In 93 cases, Face, Legs, Activity, Cry, Consolability score, hospital stay, and dressing time were in favor of the unstented group, whereas hypospadias objective scoring evaluation score and uroflow parameters were comparable. TGD and UP width varied significantly between successful and failed cases. Cutoff values of 13.5 mm and 8.5 mm for TGD and UP width, respectively, are required for successful outcome. Acute urinary retention was 12.8% after unstented repair. Detrusor spasm was 47.8% after stented and 8.5% after unstented repair. In both groups, urethrocutaneous fistula of 5.4%, glanular dehiscence of 1.1%, and meatal stenosis of 5.4% were found in cases with small TGD and narrow UP. CONCLUSION: Unstented TIPU evades the associated drawbacks of the stent along with lower postoperative pain, hospital stay, and dressing time. Even without a postoperative stent, the complication rate in infants with distal hypospadias is low, and short-term functional and aesthetic outcomes were not compromised.

Efficacy and safety of tamsulosin oral-controlled absorption system, solifenacin, and combined therapy for the management of ureteric stent-related symptoms.

OBJECTIVES: To evaluate the efficacy of solifenacin, tamsulosin oral-controlled absorption system (OCAS), and the combination of both drugs on JJ stent-related symptoms using the validated Arabic version of the ureteric stent symptom questionnaire (USSQ). PATIENTS AND METHODS: In all, 260 patients who had undergone JJ stenting of the ureter for different endoscopic urological procedures were postoperatively randomly assigned into four equal groups. Patients in Group I received no treatment and served as the control group, Group II patients received tamsulosin OCAS 0.4 mg daily, Group III patients received solifenacin 5 mg daily, and Group IV patients received a combination of both drugs. Before stent removal, all patients completed the Arabic version of the USSQ. RESULTS: In all, 234 patients completed the study, comprised of 56 in Group I, 59 in Group II, 58 in Group III, and 61 in Group IV. Baseline characteristics and indications for JJ stenting were comparable in the four groups. There were highly significant differences in all items of the USSQ between the treatment groups and the controls, while Group II and III were comparable. The USSQ score was significantly lower in Group IV vs Groups II and III. Crossing of the distal curl of the stent to the midline had a significant positive correlation with the severity of the urinary symptoms, body pain, general health, and work performance in the medicated groups. CONCLUSIONS: Combined therapy with tamsulosin OCAS 0.4 mg daily and solifenacin 5 mg daily is a safe and well-tolerated management for stent-related symptoms. However, stent position remains a significant factor affecting response to medical therapy and patients' health-related quality of life.

Distal extension of the midline urethral-plate incision in the Snodgrass hypospadias repair: An objective assessment of the functional and cosmetic outcomes.

OBJECTIVES: To objectively assess the functional and cosmetic outcomes of a modified tubularised incised-plate (TIP) urethroplasty (Snodgrass) technique, with particular attention to the uroflowmetry study and Hypospadias Objective Scoring Evaluation (HOSE) score. PATIENTS AND METHODS: In a prospective case-series study, 43 consecutive patients with primary distal hypospadias were evaluated. The modified Snodgrass technique included an extension of the midline relaxing incision of the urethral plate from within the hypospadiac meatus to the very tip of the glans. The neourethra was tubularised starting at the neomeatus and proceeding proximally. The neourethra was covered with either a single or double dartos flap. In toilet-trained boys, at least 3 months after surgery, the flow pattern, maximum (Q max), and mean urinary flow rate (Q ave) were recorded, and the results plotted against a recently published flow-rate nomogram from normal children. The postvoid residual urine volume was measured using ultrasonography. The cosmetic outcome was assessed using the HOSE system. RESULTS: The native meatus was coronal in 11 (26%), subcoronal in 23 (53%) and distal penile in nine (21%) of the patients. The median (range) age was 4.2 (0.5-14) years. The neourethra was covered by a single dorsal dartos flap in 25 and a double dartos flap in 18 patients. At a median (range) follow-up of 6 (3-24) months, the uroflowmetry findings in 26 uncomplicated toilet-trained boys with a median (range) age of 5.2 (3.3-14) years showed an abnormal Q max below the fifth percentile in four (15%), with the Q ave above the fifth percentile in all. The flow pattern was bell-shaped in nine boys (35%), interrupted/intermittent in five (19%), slightly flattened in 10 (39%) and a plateau in two (8%). A vertical slit-like meatus located at the distal glans was created in 39 (91%) boys, and at the proximal glans in four (9%). The urinary stream was single and straight in 39 and angled in four patients. A straight erection was observed in 42 (98%) boys. Four patients had preoperative mild penile torsion of <45°, that was corrected by surgery. The mean (SD, range) HOSE score was 15.8 (0.6, 13-16). Two patients had a small, single subcoronal fistula. CONCLUSION: Extending the midline urethral plate-incision in the modified Snodgrass repair to the apical part of the glans can be done safely with a high rate of locating the neomeatus at the glans tip, with no resultant meatal stenosis. The functional and cosmetic results of the procedure are good, but long-term data and comparative studies are required to confirm these results.

'Minimum-incision' endoscopically assisted transvesical prostatectomy: Surgical technique and early outcomes.

OBJECTIVE: To describe the surgical technique and report the early outcomes of a 'minimum-incision' endoscopically assisted transvesical prostatectomy (MEATP) for managing benign prostatic obstruction secondary to a large (>80 g) prostate. PATIENTS AND METHODS: In a prospective feasibility trial, 60 men with large benign prostates underwent MEATP. The baseline and postoperative evaluation included the International Prostate Symptom Score (IPSS), a measurement of maximum urinary flow rate (Q max), and the postvoid residual (PVR) urine volume. The adenoma was enucleated digitally through a 3-cm suprapubic skin incision, and haemostasis was completed with endoscopic coagulation of the prostatic fossa. Perioperative complications were recorded and stratified according to the modified Clavien-Dindo score. RESULTS: The mean (SD, range) prostate weight estimated by ultrasonography was 102.9 (15.4, 80-160) g, the operative duration was 52 (8, 40-65) min, the haemoglobin loss was 2.1 (1, 0.4-5) g/dL, the catheterisation time was 5.2 (1.3, 4-9) days, and the hospital stay was 6.2 (1.4, 5-10) days. There were 21 complications recorded in 16 (27%) patients, and most (86%) were of grades 1 and 2. The most frequent complications were bleeding requiring a blood transfusion (8%), and prolonged drainage (5%). There was a significant improvement at 3 months after surgery in the IPSS (8.6 vs. 21.6, P < 0.001), Q max (19.5 vs. 7.7, P < 0.001), and PVR (15.8 vs. 83.9 mL, P < 0.001). CONCLUSION: MEATP is feasible, safe and effective. Comparative studies and long-term data are required to determine its role in the surgical treatment of large-volume BPH.

The influence of antisperm antibodies, intratesticular haemodynamics and the surgical approach to varicocelectomy on seminal variables.

OBJECTIVE: To evaluate the effect of antisperm antibodies (ASAs), hormonal levels, intratesticular haemodynamics and the surgical approach on the outcomes of varicocelectomy in infertile men, as assessed by seminal variables. PATIENTS AND METHODS: In a prospective case-series study, 82 infertile men with varicocele (35 left and 47 bilateral) were evaluated. The preoperative assessment included a physical examination, semen analysis, assessment of ASAs in seminal plasma, hormonal levels (follicle-stimulating hormone (FSH), luteinising hormone and testosterone), and scrotal colour Doppler ultrasonography (CDUS) to measure the peak systolic velocity (PSV), end diastolic velocity (EDV), resistive index (RI) and pulsatility index. Patients were scheduled for varicocelectomy, with high ligation (Palomo) used in 40 patients (18, 45%, with left and 22, 55%, with bilateral varicocele), or an inguinal approach (Ivanissivich) with loupe magnification used in 42 (17, 40%, with left and 25, 60%, with bilateral varicocele). The men were reassessed at ⩾3 months after surgery and according to the improvement in seminal variables (expressed as a ⩾50% increase in total motile sperm count, TMSC), patients were further categorised into 'improved' or 'unimproved'. Binary logistic regression analysis was used to investigate the predictors of improvement. RESULTS: Before surgery the ASAs were positive in 17 men (21%). There was no significant difference between the right and left sides in intratesticular haemodynamics. The TMSC was improved in 52 (63%) patients who had a significant improvement in the haemodynamic variables. Intratesticular haemodynamics, serum FSH and testosterone levels differed significantly between the improved and unimproved patients. Positivity for ASAs, the surgical approach and laterality of the varicocele were not significantly different, although the ASA-positive cases were characterised by a significant decrease in motility. Logistic regression analysis showed that the EDV, PSV, FSH, testosterone level and bilateral testicular volume (BTV) were significant predictors of improvement. CONCLUSION: Positivity for ASAs is not a predictor of the outcome after varicocelectomy but affects only the motile fraction in positive cases, despite the improvement in other seminal variables and testicular haemodynamics, and regardless of the surgical approach. The EDV, PSV, FSH, testosterone and BTV were significant predictors of a successful outcome.

Vascularized Dartos Flap in Conjunction with Tubularized Incised Plate Urethroplasty: Single versus Double Flaps for Management of Distal Hypospadias.

OBJECTIVE: To compare the results of Snodgrass repair with single versus double vascularized dartos pedicle flap for neouretheral coverage. PATIENTS AND METHODS: Fifty-eight pediatric patients with mean age 41.5 ± 21 months (range 9-96 months) underwent primary hypospadias repair, 39 uncircumcised and 19 circumcised, classified into 2 groups according to coverage of the neourethra. Single layer coverage (Group I) was performed in 28 (48.3%) while double layers coverage (Group II) was done in 30 (51.7%) cases. RESULTS: After mean follow-up 8.6 ± 5.4 months (range 3-24 months), good cosmetic results with vertical slit like meatus at the tip of conical shaped glans were obtained in 53 cases (91.4%). Totally 5 cases occurred postoperative complications, of which 4 cases in Group I [2 (7.1%) with urethrocutaneous fistula, 1 (3.6%) with meatal stenosis and 1 (3.6%) with skin necrosis], 1 case in Group II [glanular dehiscence (3.3%)]. No fistula was observed in Group II. CONCLUSION: The Snodgrass tubularized incised-plate repair in conjunction with double layer coverage of the neourethra could be considered the procedure of choice for distal hypospadias with low complications rate especially urethrocutaneous fistula.

Combined intracavernous vasoactive drugs and sildenafil citrate in treatment of severe erectile dysfunction not responding to on-demand monotherapy.

OBJECTIVE: To investigate the effect of chronic use of sildenafil and intracavernous injection (ICI) with trimix in men not responding to on-demand monotherapy with sildenafil or ICI with prostaglandin-E1 (PGE1). PATIENTS AND METHODS: The study included 40 patients with erectile dysfunction (ED), with a mean (SD) age of 50.7 (11.3) years and unresponsive to on-demand sildenafil or ICI with PGE1 as monotherapy. They were assessed using the Sexual Health in Men (SHIM)-5 score for ED severity, penile colour Doppler ultrasonography (CDUS) for peak systolic velocity (PSV), end-diastolic velocity (EDV) and resistance index (RI) with an ICI test using 0.25 mL of trimix of papaverine, PGE1 and phentolamine. Testosterone, prolactin and cholesterol levels were assessed. Patients received 25 mg sildenafil daily for 8 weeks, combined with twice weekly ICI with 0.25 mL of trimix. After treatment, the Erection Hardness Score (EHS), penile CDUS with ICI and ED Inventory of Treatment Satisfaction were assessed. RESULTS: The mean (SD) SHIM-5 score before treatment was 8.3 (0.5) in 15 of the 40 men and 6.3 (0.4) in 25. Penile haemodynamics were normal in five (13%), showed arterial insufficiency in five (13%), venous occlusive disease in 26 (65%) and mixed vascular in four (10%). There was an improved SHIM-5 score in 28 (70%) patients, as shown by their haemodynamic values, duration of erection and EHS with therapy, and 66% satisfaction with treatment. Adverse effects (penile pain, headache, facial flushing, dyspepsia, nasal congestion, dizziness) were reported in 17 patients (43%). CONCLUSION: Chronic use of trimix plus daily low-dose sildenafil improved penile haemodynamics in these patients with ED not responding to on-demand phosphodiesterase-5 inhibitors or ICI with PGE1 monotherapy.