Prostate-specific Antigen Density as a Proxy for Predicting Prostate Cancer Severity: Is There Any Difference between Systematic and Targeted Biopsy?

Background: Prostate cancer screening with prostate-specific antigen (PSA) can result in unnecessary biopsies and overdiagnosis. Alternately, PSA density (PSAD) calculation may help support biopsy decisions; however, evidence of its usefulness is not concrete. Objective: To evaluate the predictive value of PSAD for clinically significant prostate cancer detection by systematic and MRI-targeted biopsies. Methods: This prospective study was conducted at two tertiary hospitals in Riyadh, Saudi Arabia, between December 2018 and November 2021. Patients suspected of prostate cancer were subjected to multi-parametric MRI, and for those with positive findings, systematic and targeted biopsies were performed. Clinically non-significant and significant prostate cancer cases were classified based on histopathology-defined ISUP grade or Gleason score. The PSAD was measured using the prostate volume determined by the MRI and categorized into ≤0.15, 0.16-0.20, and >0.20 ng/ml2 subgroups. Results: Systematic and targeted biopsies were carried out for 284 patients. The discriminant ability of PSAD is higher in MRI-targeted biopsy compared with systematic biopsy (AUC: 0.77 vs. 0.73). The highest sensitivity (97%) and specificity (87%) were detected at 0.07 ng/ml2 in targeted biopsy. More than half of the clinically significant cases were detected in the >0.2 ng/ml2 PSAD category (systematic: 52.4%; targeted: 51.1%). The CHAID methodology found that the probability of having clinically significant cancer (CSC) in patients with PSAD >0.15 ng/ml2 was more than threefold than that in patients with PSAD ≤0.15 ng/ml2 (64% vs. 20.2%). When considered by age, in PSAD ≤0.15 ng/ml2 subgroup, the percentage of CSC detection rate increased from 20.2% to 24.6% in patients aged ≥60 years. Conclusion: PSAD has good discriminant power for predicting clinically significant prostate cancer. A cutoff of 0.07 ng/ml2 should be adopted, but should be interpreted with caution and by considering other parameters such as age.

Transperineal versus transrectal multi-parametric magnetic resonance imaging fusion targeted prostate biopsy.

OBJECTIVES: To compare transperineal biopsies (TPBx) with transrectal ultrasound-guided biopsy (TRUSBx) in order to provide evidence, making clinicians able to select the appropriate biopsy approach under different conditions. METHODS: A comparative prospective study, conducted in King Khalid University Hospital (KKUH) and King Faisal Specialist Hospital and Research Centre (KFSH&RC), Riyadh, Kingdom of Saudi Arabia, between March 2019 and February 2020. All patients with raised prostate-specific antigen or atypical digital rectal examination findings were subjected to multi-parametric magnetic resonance imaging (MRI). Those with positive findings were referred to targeted fusion- guided biopsy either TPBx or TRUSBx, randomly. Complication rate, cancer detection rate, and procedure time were recorded. RESULTS: Transperineal biopsies and TRUSBx had an equivalent complication rate. However, both case detection rate and clinically significant cancer detection rate were significantly higher in TPBx versus TRUSBx (45.1% versus 29.1%, p=0.003; and 71.8% versus 43.7%, p=0.002; respectively). Transperineal biopsies was a longer procedure than TRUSBx (41.2±0.7 min versus 13±2.3 min, p=0.0001). CONCLUSION: No difference in complication rate was detected between the 2 procedures; however, TPBx was more effective for cancer detection in general and clinically significant cancer detection in particular.

Outcome of anastomotic posterior urethroplasty with various ancillary maneuvers for post-traumatic urethral injury. Does prior urethral manipulation affect the outcome of urethroplasty?

PURPOSE: We present our success rate and complications of delayed anastomotic urethroplasty (DAU) in patients with post-traumatic posterior urethral injury. MATERIALS AND METHODS: This was a retrospective study of patients aged ≥17 years that underwent DAU for post-traumatic posterior urethral injury during 2010-2014. Stricture length was measured by ascending and descending urethrogram. Success of procedure was considered when the patient was free of stricture-ralated obstruction and needed no further intervention. Primary group includes patients who underwent first time delayed urethroplasty while secondary group included patients who had some sort of urethral manipulation in local hospital. Results were analyzed using unpaired t-test, Chi-square test, binary logistic regression, Kaplan-Meier curves, and log-rank test. RESULTS: Of the 80 male patients, 73 (91.25%) patients underwent primary DAU while 7 (8.75%) patients had secondary DAU. Median age, stricture length, and follow-up were 27.0 ± 12.7, 1.6 ± 0.9, and 3.2 ± 0.9, respectively. Overall, success rate was 83.75% while success rate in primary group was 89.04% and secondary group was only 28.57% (P = 0.0059). Regarding ancillary maneuvers, urethral mobilization alone was done in 29 (36.25%) patients with success rate (72.41%), corporeal body separation in 36 (45%) patients with success rate (91.66%), inferior wedge pubectomy in 13 (16.25%) with success rate (84.61%), supracrural rerouting in 1 (1.25%) with success rate (100%), and abdominoperineal approach in 1 (1.25%) with success rate of 100% (P = 0.193). Patients who had prior urethral manipulation affect the outcome of definitive anastomotic urethroplasty. CONCLUSION: DAU has durable success rate with less morbidity. Ancillary elaborated maneuvers are frequently needed in patients with complex and elongated post-traumatic posterior urethral defect with successful outcome.

Visual Internal Urethrotomy for Adult Male Urethral Stricture Has Poor Long-Term Results.

Objective. To determine the long-term stricture-free rate after visual internal urethrotomy following initial and follow-up urethrotomies. Methods. The records of all male patients who underwent direct visual internal urethrotomy for urethral stricture disease in our hospital between July 2004 and May 2012 were reviewed. The Kaplan-Meier method was used to analyze stricture-free probability after the first, second, third, fourth, and fifth urethrotomies. Results. A total of 301 patients were included. The overall stricture-free rate at the 36-month follow-up was 8.3% with a median time to recurrence of 10 months (95% CI of 9.5 to 10.5, range: 2-36). The stricture-free rate after one urethrotomy was 12.1% with a median time to recurrence of eight months (95% CI of 7.1-8.9). After the second urethrotomy, the stricture-free rate was 7.9% with a median time to recurrence of 10 months (95% CI of 9.3 to 10.6). After the third to fifth procedures, the stricture-free rate was 0%. There was no significant difference in the stricture-free rate between single and multiple procedures. Conclusion. The long-term stricture-free rate of visual internal urethrotomy is modest even after a single procedure.

The effect of spinal cord-injury level on the outcome of neurogenic bladder treatment using OnabotulinumtoxinA.

AIM: The aim was to report the effectiveness and safety OnabotulinumtoxinA (Botox, Allergan, Inc., Irvine, CA, USA) intradetrusor injections in spinal cord-injured (SCI) patients with refractory neurogenic detrusor overactivity. And to assess the result based on SCI level. MATERIALS AND METHODS: We reviewed the chart of 103 patients with neurogenic bladder secondary to SCI at the rehab center who received OnabotulinumtoxinA in our Neurourology Department for treatment of lower urinary tract symptoms between January 2007 and December 2013. All patients had a clinical examination, urinalysis, and an urodynamic study at baseline and 3 months after treatment as well as a visual analogue scale (VAS; range scale: 0-10) and a bladder diary checked for 3 days. 300 IU of OnabotulinumtoxinA, detrusor muscle injections were performed in 30 sites under cystoscopic guidance. Outcome measures included frequency of urge urinary incontinence collected by bladder diaries; changes in urodynamic parameters such as maximum cystometric bladder capacity, reflex volume, maximum detrusor pressure; side-effects; antimuscarinic drug consumption and quality of life (QOL) measured with VAS. RESULTS: The study includes 32 female and 71 male with a mean patient age of 29 years (range: 18-56 year). The effect of Botox injection on bladder function was observed within 1-2 week after treatment. The urodynamic parameters were improved significantly after treatment compared with baseline values. There were significant reductions in the frequencies of incontinence episodes after treatment as seen in the voiding diary. A significant improvement in patient satisfaction was found after treatment which was expressed on the VAS assessment, with an improvement of the mean of 3 points. Patients with thoracic and lumbar injury have better result compare to cervical injury patients. The earliest recurrence of clinical symptoms was at 10 weeks. Overall, the mean duration of symptomatic improvement was 8 (2.5-21) months. CONCLUSION: Intradetrusor onabotulinumtoxinA injections are an effective and well-tolerated treatment for neurogenic overactive bladder that will increase patient satisfaction and improve QOL with persisted clinical efficacy for more than 8 months.

Isolated ureteric endometriosis presenting as a ureteric tumor.

A 32 year old lady presented with recurrent left flank pain for 4 weeks and chronic lower back pain. CT without contrast showed no stones and mild left hydronephrosis. CT of the spine suggested an inflammatory process at L5-S1 vertebra. The diagnosis was supported by a bone scan. Incidentally, the scan showed nonfunctioning left kidney. Diuretic renography confirmed poor perfusion and no excretion. A retrograde study showed narrowing of the ureter at the pelvic brim. Ureteroscopy showed a papillary mass in the lumen of the ureter from which multiple cold cup biopsies were taken. The pathology however was not conclusive. A robotic nephroureterectomy was carried out. Definitive pathology showed intrinsic endometriosis of the ureter. We conclude that endometriosis should be considered in the differential diagnosis of unexplained ureteric obstruction and ureteric lumen filling defects in young women.

Long-term outcome of genital reconstruction of Middle Eastern women with congenital adrenal hyperplasia.

OBJECTIVES: There is a paucity of data on the long-term outcome of genital reconstruction of female children with congenital adrenal hyperplasia (CAH) as they become adult women. We report on the surgical outcome general condition and marriage status. MATERIALS AND METHODS: We reviewed the medical records of women 20 years or older with CAH who had genital reconstruction. We interviewed married patients utilizing the female sexual function index (FSFI-6) questionnaire and compared them to age-matched controls. RESULTS: We identified 43 women with CAH with a median age of 24.2 ± 3.9 years and a median follow-up of 23.4 ± 4.6 years. Salt wasting and the severity of virilization affected most patients, parents were commonly cousins, children were reared as boys for a protracted period and surgical reconstruction was usually complex. Only five women had married. Compared with single women, married women had significantly more frequent normal menses, emergency hospital admissions and number of repeated reconstructive surgery. There was no significant difference in FSFI score between patients and controls. Four women conceived and three gave birth to one healthy child. There was no significant difference in the number of children between patients and controls. CONCLUSIONS: CAH has a significant impact on adult women in our region. Most of the patients remain single. Few women get married and these are able to lead a nearly normal sexual life and give birth to healthy children.

Robotic uretero-ureterostomy of the retrocaval ureter without excision of the retrocaval segment.

Robotic reconstruction of the retrocaval ureter is gaining momentum as the method of choice for surgically treating this rare condition. Maintaining the retrocaval ureteric segment further facilitates the procedure. We report a case of a 23-year-old man who underwent intraperitoneal robotic resection anastomosis and repositioning of the retrocaval ureter. We also discuss the advantages of this technique.

Neurogenic bladder evaluation and management after spinal cord injury: Current practice among urologists working in Saudi Arabia.

AIM: The aim of this study is to determine the current trends in the management and surveillance of the NB population secondary to spinal cord injury (SCI) or myelomeningocele by certified urologist working in Saudi Arabia and to compare it to the current guidelines. MATERIALS AND METHODS: A cross-sectional study was conducted using a 12-points questionnaire distributed to urologists working in Saudi Arabia and registered at the Saudi medical association. The assessment and follow-up of upper and lower urinary tract function in neurogenic bladder patients, their optimal frequency and management of related infections were the topics of inquiry. RESULTS: Of the 272 urologists surveyed, 105 responded, yielding a response rate of 38%. Eighty-nine percent of respondents said that ultrasound was their diagnostic tool of choice for upper tract evaluation. Sixty-one percent of respondents said that they would follow their patients with a multichannel urodynamic study. Forty percent of urologists stated that they would treat asymptomatic bacteriuria. Clean intermittent catheterization (CIC) was the most common modality chosen for the management of neurogenic bladder in patients with emptying difficulties. CONCLUSION: This study confirms that most urologists in Saudi Arabia involved with neurogenic bladder management. However, more than one third of the urologists do not have urodynamic machine and only two of the reporting practitioners has a videourodynamic machine. The results emphasize the need for clear guidelines in this field of urology in Saudi Arabia. Highly specialized rehabilitation centers for neurogenic bladder secondary to SCI are required for optimal care and urologist teaching.

Computed tomography angiogram: accuracy in renal surgery.

OBJECTIVES: To determine the sensitivity and specificity of computed tomography angiogram (CTA) in detecting number and location of renal arteries and veins as well as crossing vessels causing uretero-pelvic junction obstruction (UPJO), and to determine if this can be used in decision-making algorithms for treatment of UPJO. METHODS: A prospective study was carried out in patients undergoing open, laparoscopic and robotic renal surgery from April 2005 until October 2006. All patients were imaged using CTA with 1.25 collimation of arterial and venous phases. Each multi-detector CTA was then read by one radiologist and his results were compared prospectively with the actual intra-operative findings. RESULTS: Overall, 118 patients were included. CTA had 93% sensitivity, 77% specificity and 90% overall accuracy for detecting a single renal artery, and 76% sensitivity, 92% specificity and 90% overall accuracy for detecting two or more renal arteries (Pearson chi(2) = 0.001). There was 95% sensitivity, 84% specificity and 85% overall accuracy for detecting the number of renal veins. CTA had 100% overall accuracy in detecting early dividing renal artery (defined as less than 1.5 cm branching from origin), and 83.3% sensitivity, specificity and overall accuracy in detecting crossing vessels at UPJ. The percentage of surgeons stating CTA to be helpful as pre-operative diagnostic tool was 85%. CONCLUSION: Computed tomography angiogram is simple, quick and can provide an accurate pre-operative renal vascular anatomy in terms of number and location of renal vessels, early dividing renal arteries and crossing vessels at UPJ.