Compression or obstruction: Prospective analysis of the function of the adjustable transobturator male system (ATOMS) based on pre- and postoperative urodynamic data

Introduction: This analysis, based on pre- and postoperative urodynamic data, is the first to elucidate the influence of the adjustable transobturator male system (ATOMS, A.M.I. GmbH, Feldkirch, Austria) on the lower urinary tract and disclose possible obstructive properties. Methods: A prospective study was performed in patients who had stress urinary incontinence and were scheduled for ATOMS implantation after radical prostatectomy. Apart from continence assessment (24-hour pad test, International Consultation on Incontinence Questionnaire-Urinary Incontinence Short Form [ICIQ-SF]), urodynamic testing was done with International Continence Society (ICS)-standardized pressure-flow analysis before and after ATOMS implantation/adjustment. The Wilcoxon signed-rank test was used for statistical analysis. Results: The analysis included 12 consecutive patients from two centers (mean 69 years) with a mean followup of 246 days. Median urine leakage dropped from 240 (72–1250) to 70 (0–700) g/24 hours postoperatively, with a pad reduction of 4 to 0.9 pads/day. Pressure-flow analysis revealed a significant change only in the bladder outlet obstruction index (BOOI). The bladder contractility index, intravesical pressure conditions, and uroflowmetry were not significantly affected. None of the patients showed de novo obstruction postoperatively in the ICS analysis. Conclusions: The ATOMS significantly increases the BOOI in conjunction with good continence results. However, no case reached pathological level according to the BOOI and thus there is no potential danger to the lower urinary tract or urethral integrity.

Images – Penile pain in the setting of end-stage renal disease: An unusual anatomic location for calciphylaxis

In this report, we present a case of penile calciphylaxis, an extremely rare and serious condition occurring in association with dysregulation of systemic calcium metabolism in the setting of chronic renal impairment. Calciphylaxis can occur at various body sites and is associated with diffuse vascular calcifications in small and medium-sized arteries of the involved tissues. Penile calciphylaxis has a grim prognosis. Calciphylaxis is an important etiologic differential diagnosis for penile necrosis and penile pain in patient’s being treated with dialysis for end-stage kidney disease. Diagnosis of penile calciphylaxis is possible via clinical and radiological evaluations. Medical management may alleviate symptoms; however surgical interventions may be necessary, and histological studies may allow for definitive classification.

Case – Renal artery pseudoaneurysm: A life-threatening occurrence following thulium laser lithotripsy

Introduction Renal artery pseudoaneurysm post-laser lithotripsy is a rare and potentially life-threatening complication. Traditionally, the most common modalities used for treatment of urinary tract stones were holmium laser lithotripsy and extracorporeal shockwave lithotripsy. However, thulium laser has recently gained momentum in the treatment of urinary tract stones with increasing use and availability in healthcare systems. We report a case of renal artery pseudoaneurysm post-thulium laser lithotripsy who presented in hemorrhagic shock after ureteral stent removal and was subsequently stabilized by endovascular embolization.

Management of adult tuberous sclerosis complex-related angiomyolipoma: A single-center experience

Introduction: Tuberous sclerosis complex (TSC) is a rare, multisystem, genetic disease. A significant cause of TSC-related morbidity is potential bleeding from renal angiomyolipoma (AML). To pre-emptively decrease AML bleeding, mTOR inhibitors can be used; however, thresholds for initiating and maintaining everolimus therapy remain uncertain. Recent literature suggests not triggering active treatment of AMLs based on size thresholds alone. We evaluated the appropriateness of initiating everolimus therapy in asymptomatic patients after considering AML size, rate of growth, and other factors. Methods: Diagnostic criteria developed by the 2012 International TSC Consensus Group and presence of AML were used as inclusion criteria. Medical and imaging reports of 20 TSC patients from a single center were reviewed. Results: Mean age was 40.55 (±16.27) and 11 patients were female. Eight asymptomatic patients at high risk for complications underwent everolimus therapy, of which seven (88%) demonstrated decreased AML size but multiple side effects were reported. Four high-risk asymptomatic patients did not undergo therapy due to side effect concerns, while four low-risk asymptomatic patients had stable AMLs under active surveillance. Four patients had reduced AMLs through local therapy. Conclusions: Everolimus treatment was effective for managing AML size in most high-risk asymptomatic patients with tolerable side effects. AML size can remain relatively stable for asymptomatic low-risk patients despite not receiving intervention(s). Patients with TSC-related AML can be safely managed with mTOR inhibitors like everolimus, with shared decision-making including factors such as bleeding risk, AML growth rate, and number and absolute size of AMLs.

En bloc transurethral resection of bladder tumors: A review of current techniques

Introduction: Growing interest surrounds the concept of en bloc transurethral resection of bladder tumors (ERBT). Theoretical advantages include improved adherence to oncological principles and potential yield of superior pathological specimens. Multiple ERBT methods exist. This review summarizes the current evidence regarding application of differing techniques and technologies to ERBT. Methods: A systematic review of MEDLINE/EMBASE/Scopus databases was performed, using terms “en bloc,” “ERBT,” “bladder,” and “urinary bladder neoplasm.” Template-based data extraction included technique of ERBT, feasibility, tumor size, activation of obturator nerve reflex, operative complications, detrusor muscle sampling rate, and recurrence data. Results: Multiple approaches to ERBT have evolved, using a variety of energy sources. The feasibility of electrocautery, laser, combined waterjet/electrocautery, and polypectomy snare techniques have been confirmed in achieving ERBT. ERBT appears safe, with a low complication rate. The use of laser energy sources reduces the risk of activating the obturator nerve reflex during lateral wall resections. Otherwise, no energy source is unequivocally superior in achieving ERBT. The rate of detrusor muscle sampling is high with use of ERBT and appears superior to that achieved with conventional TURBT (cTURBT) in multiple comparative studies. A limited number of largely non-randomized trials assess bladder tumor recurrence; current evidence suggests this is similar between ERBT and cTURBT groups. Conclusions: En bloc resection of bladder tumors using a variety of technologies is feasible and safe, with a high detrusor muscle sampling rate. Further research is required to determine whether rates of residual disease or recurrence can be reduced with ERBT vs. cTURBT.

How the COVID-19 pandemic changed postoperative infections in urology wards: A retrospective cohort study from two urology departments

Introduction: We aimed to compare the rate of postoperative infection and drug-resistant organism (DRO) before and during the COVID-19 pandemic in urology departments. Methods: A retrospective cohort study was carried out. Data from all elective surgical procedures carried out in two urology departments between April and June 2018 and the homologous period in 2020 were collected. Main outcomes were the number of postoperative infections during the pandemic, and the number of DROs. Sample size was calculated based on a 50% relative reduction of infections during the pandemic. Variables were compared by Chi-squared test, and multivariable logistic regression was used to estimate predictors. Results: A total of 698 patients undergoing elective surgery were included. The postoperative infection rate during the pre-pandemic period was of 14.1% compared to 12.1% during the pandemic (p=0.494). DROs were lower during the pandemic (92.3% vs. 52.4%, p=0.002). The pandemic period was the main predictor for reduced multi-drug-resistant isolates, with an odds ratio of 0.10 (p=0.010, 95% confidence interval 0.016–0.57). Conclusions: Postoperative infection rates were not significantly reduced during the COVID-19 pandemic, despite the adoption of enhanced infection preventive measures. There was, however, a decrease in the rate of DROs during this period, suggesting a secondary benefit to enhanced infection prevention practices adopted during the COVID-19 era.

The association of statin subgroups with lower urinary tract symptoms following a prostate biopsy

Introduction: This was a secondary analysis aiming to assess whether hydrophilic or hydrophobic statins have a differential effect on urinary retention (UR) and lower urinary tract symptoms (LUTS) in men following a prostate biopsy (PB), who were at risk for prostate cancer development. Methods: This was a population-based cohort study with data incorporated from the Institute for Clinical and Evaluative Sciences database to identify all Ontarian men aged 66 and above with a history of a single negative PB between 1994 and 2016, with no drug prescription history of any of several putative chemopreventative medications (statins, proton pump inhibitors, five-alpha-reductase inhibitors, and alpha-blockers). Multivariable Cox regression models with time-dependent covariates were used to assess the association of hydrophilic and hydrophobic statins with UR and LUTS within 30 days of a PB. All models were adjusted for other known putative chemopreventive medications, age, rurality, pharmacologically treated diabetes, comorbidity score, and study inclusion year. Results: Overall, 21 512 men were included, with a median followup time of 9.4 years (interquartile range [IQR] 5.4–13.4 years). Hydrophobic and hydrophilic statins were initiated by 30.7% and 19.6% of men, respectively, after the first negative PB. UR and LUTS were experienced by 2.2% and 10% of men, respectively. Cox models demonstrated hydrophilic statins were associated with a lower risk of UR (hazard ratio [HR] 0.56, 95% confidence interval [CI] 0.38–0.83, p=0.0038) and LUTS (HR 0.86, 95% CI 0.76–0.98, p=0.022), while no such association was shown for hydrophobic statins. Conclusions: Initiation of hydrophilic statins in men older than 66 appears to be inversely associated with the risk of UR and LUTS within 30 days of a PB.

Associations between body mass index and bladder cancer survival: Is the obesity paradox short-lived?

Introduction: We investigated the associations of pre-surgical body mass index (BMI) with bladder cancer outcomes in patients treated with radical cystectomy. Methods: We retrospectively analyzed data from 488 bladder cancer patients treated with radical cystectomy between 1994 and 2007 and followed up until 2016. Cox regression with step function (time-segment analysis) was conducted for overall survival because the proportional hazard assumption was violated. Results: Of 488 bladder cancer patients, 155 (31.8%) were normal weight, 186 (38.1%) were overweight, and 147 (30.1%) were obese. During the median followup of 59.5 months, 363 (74.4%) patients died, including 197 (40.4%) from bladder cancer. In adjusted Cox regression analyses, BMI was not significantly associated with bladder cancer-specific survival for overweight (hazard ratio [HR] 0.79, 95% confidence interval [CI] 0.57–1.10, p=0.16) or obese (HR 0.76, 95% CI 0.52–1.09, p=0.13) patients. In the Cox regression with step function for overall survival, the time interaction was significant overall (p=0.020) and specifically for overweight patients (p=0.006). In the time-segment model, the HR for overweight during the first 63 months was 0.66 (95% CI 0.49–0.90, p=0.008), whereas it was 1.41 (95% CI 0.89–2.23, p=0.14) after 63 months. Although not statistically significant, a similar pattern was observed for obese patients. Conclusions: Our findings suggest that overweight and obese bladder cancer patients had better outcomes within the first five years after radical cystectomy; however, there were no differences in longer-term survival. These data suggest that the obesity paradox in bladder cancer patients treated with radical cystectomy may be short-lived.

Techniques – Mini incision and plication (MIP) cure hydrocele: A minimally invasive surgical variation

Idiopathic hydroceles are the commonest cause of chronic benign scrotal swelling, affecting 1% of adult men. Larger idiopathic hydroceles can become symptomatic and affect quality of life. The popular Jaboulay technique described in 1902 is curative and remains the standard for most surgeons. However, it is associated with significant morbidity and has a reported recurrence rate of 5%. Various minimally invasive approaches have been described with fewer reported complications but are of limited efficacy and unacceptable recurrence rates requiring multiple treatments. In this single-surgeon case series of 92 men, we present the mini incision and plication (MIP) cure hydrocele technique for the treatment of idiopathic hydrocele. This minimally invasive open surgical variant achieves the desired eversion and plication with minimal hydrocele manipulation, providing excellent results independent of hydrocele size, with fewer complications and a recurrence rate of <1%.