Management of Bladder Pain Syndrome (BPS): A Practical Guide

Bladder pain syndrome (BPS) is a prevalent and pervasive disease. The physical and psychological sequelae can be very burdensome for the patient, and the condition represents a real challenge for the clinician as well. With no simple pathognomonic test, finding harmony in navigating patient care can be demanding. Diagnosis and management rely upon a multidisciplinary and holistic approach. Treatment options include conservative measures and pharmacotherapies as well as bladder instillation therapies. Ultimately, surgery may be offered but only in cases of refractory disease. This article offers a pragmatic guide for clinicians managing this challenging disease.

Open Partial Nephrectomy with Zero Ischaemia Using a Supra 12th Rib Miniflank Incision: A Minimally Invasive Open Approach for Small Renal Masses

Introduction. To assess a minimally invasive open technique for partial nephrectomy with zero ischaemia time. Methods. A review was performed in a prospectively maintained database of a single surgeon series of all patients undergoing partial nephrectomy using a supra 12th rib miniflank incision with zero ischaemia. Data of seventy one patients who underwent a partial nephrectomy over an 82-month period were analyzed. Data analyzed included operative time, estimated blood loss, pre and postoperative renal function, complications, final pathological characteristics, and tumour size. Results. Seventy one partial nephrectomies were performed from February 2009 to October 2015. None were converted to radical nephrectomy. Mean operative time was 72 minutes (range 30–250), and mean estimated blood loss was 608 mls (range 100–2500) with one patient receiving blood transfusion. The mean pre and postoperative haemoglobin levels were 144 and 112 g/l. The mean pre and postoperative creatinine levels were 82 and 103 Umol/L. There were 8 Clavian–Dindo Grade 2 complications and 1 major complication (Clavian IIIa). Histology confirmed 24 benign lesions and 47 malignant lesions, 46 cT1a lesions, 24 cT1b lesions, and 1 cT2 lesion. Median follow-up was 38 months with no local recurrence or progression of disease with 5 patients having a positive margin (7%). Conclusion. Our results demonstrate that a supra 12th miniflank incision open partial nephrectomy with zero ischaemic time for SRMs has satisfactory outcomes with preservation of renal function. A minimally invasive open partial nephrectomy remains an important option for units that cannot offer patients a laparoscopic or a robotic procedure.

High-Intensity Focused Ultrasound (HIFU) Focal Therapy for Localized Prostate Cancer with MRI-US Fusion Platform

Objective. The study aimed at investigating the outcome of prostate HIFU focal therapy using the MRI-US fusion platform for treatment localization and delivery. Methods. It is a prospectively designed case series of HIFU focal therapy for localized prostate cancer. The inclusion criteria include clinical tumor stage ≤T2, visible index lesion on multiparametric MRI less than 20 mm in diameter, absence of Gleason 5 pattern on prostate biopsy, and PSA ≤ 20 ng/ml. HIFU focal therapy was performed in the conventional manner in the beginning 50% of the series, whereas the subsequent cases were performed with MRI-US fusion platform. The primary outcome was treatment failure rate which is defined by the need of salvage therapy. Secondary outcomes included tumor recurrence in follow-up biopsy, PSA change, perioperative complications, and postoperative functional outcomes. Results. Twenty patients underwent HIFU focal ablation. HIFU on an MRI-US fusion platform had a trend of a longer total operative time than the conventional counterpart (124.2 min vs. 107.1 min, p = 0.066 ). There was no difference in the mean ablation volume to lesion volume ratio between the two. The mean PSA percentage change from baseline to 6-month is more significant in the conventional group (63.3% vs. 44.6%, p = 0.035 ). No suspicious lesion was seen at 6-month mpMRI in all 20 patients. Two patients, one from each group, eventually underwent radical treatment because of the presence of clinically significant prostate cancer in the form of out-of-field recurrences during follow-up biopsy. No significant difference was observed before and after HIFU concerning uroflowmetry, SF-12 score, and EPIC-26 score. It was observed that energy used per volume was positively correlated with PSA density of the patient (r = 0.6364, p = 0.014 ). Conclusion. In conclusion, HIFU with conventional or MRI-US fusion platform provided similar oncological and functional outcomes.

Ultrasound Guided Percutaneous Nephrolithotomy in Mesh-Repaired Incisional Hernia

Objectives. To describe our technique of percutaneous nephrolithotomy (PNL) in patients with mesh-repaired flank incisional hernia. Polypropylene mesh which is used for fascia strengthening in hernia repair elicits intense inflammatory reaction and the consequent fibrosis alters the characteristics of abdominal wall. Thus, prior history of flank hernia repair with mesh may result in percutaneous nephrolithotomy failure. Materials and Methods. Demographic data, renal stones characteristics, and any complication during surgery and follow-up of patients who were treated by PNL during 2011 to 2020 and had mesh in their flank region were collected. Results. Percutaneous nephrolithotomy was performed without any problem in 8 patients with guide of ultrasonography. Conclusion. Based on our experience, ultrasound-guided PNL is feasible and hypothetically superior to fluoroscopy in such circumstances.

Microbiota, Prostatitis, and Fertility: Bacterial Diversity as a Possible Health Ally

Background. In health, microorganisms have been associated with the disease, although the current knowledge shows that the microbiota present in various anatomical sites is associated with multiple benefits. Objective. This study aimed to evaluate and compare the genitourinary microbiota of chronic prostatitis symptoms patients and fertile men. Materials and Methods. In this preliminary study, ten volunteers have included 5 volunteers with symptoms of chronic prostatitis (prostatitis group) and five fertile volunteers, asymptomatic for urogenital infections (control group) matched by age. Bacterial diversity analysis was performed using the 16S molecular marker to compare the microbiota present in urine and semen samples from chronic prostatitis symptoms and fertile volunteers. Seminal quality, nitric oxide levels, and seminal and serum concentration of proinflammatory cytokines were quantified. Results. Fertile men present a greater variety of operational taxonomical units-OTUs in semen (67.5%) and urine (17.6%) samples than chronic prostatitis symptoms men. Chronic prostatitis symptoms men presented a higher concentration of IL-12p70 in seminal plasma. No statistically significant differences were observed in conventional and functional seminal parameters. The species diversity in semen samples was similar in healthy men than prostatitis patients, inverted Simpson index median 5.3 (5.0–10.7) vs. 4.5 (2.1–7.8, p = 0.1508 ). Nevertheless, the microbiota present in the semen and urine samples of fertile men presents more OTUs. Less microbial diversity could be associated with chronic prostatitis symptoms. The presence of bacteria in the genitourinary tract is not always associated with the disease. Understanding the factors that affect the microbiota can implement lifestyle habits that prevent chronic prostatitis. Conclusion. Chronic prostatitis does not seem to affect male fertility; however, studies with a larger sample size are required. Our preliminary results strengthen the potential role; the greater bacterial diversity is a protective factor for chronic prostatitis.

Dual-Tracer Positron-Emission Tomography Using Prostate-Specific Membrane Antigen and Fluorodeoxyglucose for Staging of Prostate Cancer: A Systematic Review

PSMA PET is more accurate than conventional imaging (CT/bone scan) for staging of intermediate- or high-risk prostate cancer (PCa), but 5–10% of primary tumours have low PSMA ligand uptake. FDG PET has been used to further define disease extent in end-stage castrate-resistant PCa and may be beneficial earlier in the disease course for more accurate staging. The objective of this study was to review the available evidence for patients undergoing both FDG and PSMA PET for PCa staging at initial diagnosis and in recurrent disease. A systematic literature review was performed for studies with direct, intraindividual comparison of PSMA and FDG PET for staging of PCa. Assessment for radioligand therapy eligibility was not considered. Risk of bias was assessed. 543 citations were screened and assessed. 13 case reports, three retrospective studies, and one prospective study were included. FDG after PSMA PET improved the detection of metastases from 65% to 73% in high-risk early castration-resistant PCa with negative conventional imaging (M0). Positive FDG PET was found in 17% of men with negative PSMA PET for postprostatectomy biochemical recurrence. Gleason score ≥8 and higher PSA levels predicted FDG-avid metastases in BCR and primary staging. Variant histology (ductal and neuroendocrine) was common in case reports, resulting in PSMA-negative FDG-positive imaging for 3 patients. Dual-tracer PET for PCa may assist in characterising high-risk disease during primary staging and restaging. Further studies are required to determine the additive benefit of FDG PET and if the FDG-positive phenotype may indicate a poorer prognosis.

Evaluation of the Extent of Primary Buccal Mucosal Graft Contracture in Augmentation Urethroplasty for Stricture Urethra: A Prospective Observational Study at a Tertiary Healthcare Centre

Introduction. Buccal mucosal graft (BMG) urethroplasty is considered as gold standard in the treatment of urethral stricture disease. The successful outcome after BMG urethroplasty varies between 66 and 99%. One of the possible causes for failure is BMG contracture. Primary BMG contracture rate is poorly understood and unreported. The present study aimed to evaluate the extent of contracture of buccal mucosa immediately after harvesting. Materials and Methods. This was a prospective observational study conducted in the Department of Urology at our institute between January 2016 and December 2019. All patients with urethral stricture disease undergoing BMG urethroplasty for the first time were enrolled in the study after obtaining informed consent. Demographic and patient clinical profile was noted. Based on the intraoperative urethral stricture size, the preharvest graft was marked on the buccal mucosa and the size was calculated. Postharvest unstretched size of the graft was measured immediately after graft removal from the oral cavity. Alteration in BMG size was analysed using paired t-test. Results. Forty-four patients were included in the study. Mean age of the patient was 53.6 years. Mean stricture length was 7.45 cm (range 4–12 cm). Mean pre- and postharvest BMG size was 8.3 × 1.5 cm and 7.6 × 1.3 cm, respectively. There was a 8.4% decrease in length and 9.5% decrease in width of the buccal mucosal graft. Conclusion. Primary buccal mucosal graft contracture is around 8.4% in length and 9.5% in width. It would be better to mark wider than necessary while harvesting buccal mucosa so that tension-free anastomosis is performed.

Randomized Controlled Trial of Laparoscopic versus Open Radical Cystectomy in a Laparoscopic Naïve Center

Background. Laparoscopic radical cystectomy is a challenging surgical procedure; however, it has been largely abandoned in favor of the more intuitive robotic-assisted cystectomy. Due to the prohibitive cost of robotic surgery, the adoption of laparoscopic cystectomy is of relevance in low-resource institutes. Methodology. This is a randomized controlled trial comparing laparoscopic radical cystectomy (LRC) to open radical cystectomy (ORC) at a single institute. Each group included thirty patients. The trial was designed to compare both approaches regarding operative time, blood loss, transfusion requirements, length of hospital stay, time to oral intake, requirement of opioid analgesia, and complications. Results. LRC was associated with less hospital stay (9.8 vs. 13.8 days, P = 0.001 ), less time to oral solid intake (6 vs. 8.6 days, P = 0.031 ), and lower opioid requirements (23.3% vs. 53.3%, P = 0.033 ). There was a trend towards lower blood loss and transfusion requirements, but this did not reach statistical significance. Overall complication rates were comparable. Conclusion. Laparoscopic radical cystectomy was associated with comparable postoperative outcomes when compared to ORC in the first laparoscopic cystectomy experience in our center. Benefitting from the assistance of an experienced laparoscopic surgeon is recommended to shorten the learning curve.

Penile Hemodynamic Response to Phosphodiesterase Type V Inhibitors after Cavernosal Sparing Inflatable Penile Prosthesis Implantation: A Prospective Randomized Open-Blinded End-Point (PROBE) Study

Forceful corporal dilatation amidst penile prosthesis implantation may injure cavernosal arteries compromising penile vasculature. In this study, we aimed to compare the conventional and cavernosal sparing techniques regarding cavernosal artery preservation. Overall, 33 patients underwent inflatable penile prosthesis implantation with Coloplast Titan Touch® three-piece inflatable penile implants. 16 patients had conventional implantations with serial vigorous dilatations, while 17 patients were implanted with the cavernosal sparing technique, consisting of a single minimal corporal dilatation after an intraoperative intracavernosal injection (ICI) of Alprostadil. Postoperatively, a penile duplex Doppler ultrasound study was performed. Whenever a cavernosal artery was spared and thus successfully probed, its hemodynamics were studied before and after an oral administration of a phosphodiesterase type 5 inhibitor (PDE5i). A cavernosal artery was successfully probed in 16/17 (94%) of patients in the cavernosal sparing group compared to 5/16 (31%) of patients in the conventional group with a significant statistical difference ( P = 0.001 ). This demonstrated that the cavernosal sparing technique was superior to the conventional approach in preserving the cavernosal artery (odds ratio 35.2, 95% IC 3.5–344.2; P = 0.0022 ). Whenever a cavernosal artery could be probed, its hemodynamic responsiveness was also preserved. This trial is registered with NCT03733860.

Understanding the Impact of Urinary Incontinence in Persons with Dementia: Development of an Interdisciplinary Service Model

Introduction. Prevalence of urinary symptoms such as incontinence (UI) in patients with dementia is estimated to exceed 50%. The resultant psychological and socio-economic burden can be substantial. Our aim was to develop a dedicated urology service within a cognitive impairment clinic in order to treat and better understand the bothersome urinary symptoms suffered by persons with dementia. Methods. Patients attending this clinic were invited to be assessed and interviewed by urologist, together with their family and/or carer. In addition, formal history, examination and relevant investigations, themes of importance such as quality of life, and select question items were drawn from validated questionnaires. Multidisciplinary team (MDT) meeting was carried out on the same day. Outcomes of the first 75 patients with UI and dementia have been reported. Results. Average age was 70 years (range 58–98). Majority of persons had a diagnosis of Alzheimer’s disease (n = 43, 57%). Average score for how much urine leakage interferes with everyday life was 7.7/10 (range 2–10). 58.7% (n = 44) revealed some degree of sleep disturbance due to UI. 83% (n = 62) stated daily activities were limited due to UI. Two-thirds of persons with dementia (n = 50) stated their bladder problem makes them feel anxious. 88% (n = 67) felt the topic was socially embarrassing. All carers stated that the person’s continence issues affect the care they provide. Less than one-third of carers (30.7%, n = 23) were aware of or had been in contact with any bladder and bowel community service. More than half of the carers (n = 46, 65%) were concerned incontinence may be a principal reason for future nursing home admission. Conclusion. UI can be distressing for persons with dementia. Care partners were concerned about loss of independence and early nursing home admission. Awareness of bladder and bowel services should be increased.