The impact of chemotherapy-naïve open radical cystectomy delay and perioperative transfusion on the recurrence-free survival: A perioperative parameters-based nomogram

Objective

To develop and internally validate a nomogram to predict recurrence-free survival (RFS) including the time to radical cystectomy (RC) and perioperative blood transfusion (PBT) as potential predictors.

Methods

Patients who underwent open RC and ileal conduit between January 1996 to December 2016 were split into developing (n=948) and validating (n=237) cohorts. The time to radical cystectomy (TTC) was defined as the interval between the onset of symptoms and RC. The regression coefficients of the independent predictors obtained by Cox regression were used to construct the nomogram. Discrimination, validation, and clinical usefulness in the validation cohort were assessed by the area under the curve, the calibration plot, and decision curve analysis.

Results

In the developing dataset, the 1-, 5-, and 10-year RFS were 83.0%, 47.2%, and 44.4%, respectively. On multivariate analysis, independent predictors were TTC (hazards ratio [HR] 1.07, 95% confidence interval [CI] 1.05-1.08, p<0.001), PBT (one unit: HR 1.40, 95% CI 1.03-1.90, p=0.03; two or more units: HR 1.72, 95% CI 1.29-2.29, p<0.001), bilateral hydronephrosis (HR 1.54, 95% CI 1.21-1.97, p<0.001), squamous cell carcinoma (HR 0.60, 95% CI 0.45-0.81, p=0.001), pT3-T4 (HR 1.77, 95% CI 1.41-2.22, p<0.001), lymph node status (HR 1.53, 95% CI 1.21-1.95, p<0.001), and lymphovascular invasion (HR 1.28, 95% CI 1.01-1.62, p=0.044). The areas under the curve in the validation dataset were 79.3%, 69.6%, and 76.2%, for 1-, 5-, and 10-year RFS, respectively. Calibration plots showed considerable correspondence between predicted and actual survival probabilities. The decision curve analysis revealed a better net benefit of the nomogram.

Conclusion

A nomogram with good discrimination, validation, and clinical utility was constructed utilizing TTC and PBT in addition to standard pathological criteria.

Effect of bulbospongiosus muscle injection with botulinum-A toxin for treatment of lifelong premature ejaculation; a randomized controlled trial

This study aimed at assessing a new line of treatment for lifelong premature ejaculation which is botulinum-A toxin injection into the bulbospongiosus muscle. Sixty patients with lifelong premature ejaculation were independently randomized into 2 groups; group I, 100 U botulinum-A toxin at 10 U/ml saline was injected with ultrasound guidance into the bulbospongiosus muscle and group II which was injected with similar volume of saline. The primary outcome was to compare both groups for changes in the Premature Ejaculation Profile (PEP), Intravaginal Ejaculatory Latency Time (IELT) and partner's satisfaction at 1, 3 and 6 months after intervention. The second outcome was to compare the adverse events in both groups. Fifty-seven patients completed the study. In group I, the mean PEP increased significantly at 1- (P = 0.02) and 3- months (P = 0.04) with insignificant increase at 6-month (P = 0.6) of follow-up. Also, no significant changes had been noted in IELT or partner's satisfaction scores throughout the study duration (P > 0.05). In group II, no significant changes had been noted in the PEP, IELT and partner's satisfaction scores throughout the study duration (P > 0.05). There were insignificant differences in the changes in the mean PEP (P = 0.7, 0.6 and 0.4), IELT (P = 0.6,0.6 and 0.5) and partner's satisfaction scores (P = 0.5,0.7 and 0.3) in comparison to the baseline values at 1-, 3- and 6- months, respectively between both groups. Adverse events were observed in only 3 patients (5.3%). In group I, mild erectile dysfunction and post micturition dribbling were reported in one patient each. Where in group II, one patient reported bleeding per urethra (P = 0.5). To conclude, injection of botulinum-A toxin into bulbospongiosus seems to be safe but failed to prove clinical efficacy for treatment of lifelong premature ejaculation when compared to placebo.

Bladder perforation as a complication of transurethral resection of bladder tumors: the predictors, management, and its impact in a series of 1570 at a tertiary urology institute

OBJECTIVES

To report the incidence, predictors, the impact of bladder perforation (BP), and our protocol of management in patients who underwent trans-urethral resection of bladder tumor (TURBT).

METHODS

This is a retrospective study, between 2006 and 2020, on patients who underwent TURBT for non-muscle-invasive bladder cancer (NMIBC). Bladder perforation was defined as any full thickness resection of the bladder wall. Bladder perforations were managed based on their severity and type. Small BP with no or mild symptoms were managed with prolongation of urethral catheters. Those with significant extraperitoneal extravasations were managed by insertion of a tube drain (TD). Abdominal exploration was done for extensive BP and all intraperitoneal extravasations.

RESULTS

Our study included 1,570 patients, the mean age was 58 ± 11 years and 86% were males. Bladder perforation was recorded in 10% (n = 158) of the patients. The perforation was extraperitoneal in 95%, and in 86%, the perforation was associated with no symptoms, mild symptoms, or mild fluid extravasation that required only prolongation of the urethral catheter. On the other hand, active intervention was required for the 21 remaining patients (14%) with TD being the most frequent management. History of previous TURBT (p = 0.001) and obturator jerk (p = 0.0001) were the only predictors for BP.

CONCLUSIONS

The overall incidence of bladder perforation is 10%; however, 86% required only prolongation of urethral catheter. Bladder perforation did not affect the probability for tumor recurrence, tumor progression nor radical cystectomy.

Voiding and renal function 10 years after radical cystectomy and orthotopic neobladder in women

OBJECTIVES

To assess long-term voiding and renal function (RF) changes after radical cystectomy (RC) and orthotopic neobladder (ONB) surgery in women without disease recurrence.

MATERIAL AND METHODS

Women who underwent RC and ONB reconstruction between 1995 and 2011 were included in this study. Patients who developed disease failure or were lost to follow-up were excluded. The study outcomes were long-term voiding function and the incidence and predictors of RF deterioration (defined as >20% decline of baseline). Analysis was performed using the log-rank test and Cox regression analysis.

RESULTS

The study included 195 patients with a median (interquartile range) follow-up of 98 (53-151) months, of whom 95 had >10 years of follow-up. Daytime continence, night-time continence and chronic urine retention (CUR) were identified in 170 (87%), 134 (69%) and 52 patients (27%), respectively. Among patients with >10 years of follow-up, 82 (86%), 66 (70%) and 31 (33%) had daytime continence, night-time continence and CUR at the last follow-up visit, respectively. RF deterioration events occurred in 74 patients throughout the follow-up and chronic kidney disease (CKD) stage III-V developed in 80 patients. Patients' age (hazard ratio [HR] 1.41, 95% confidence interval [CI]1.06-1.89; P = 0.02) and serous-lined extramural tunnel diversion (HR 0.43, 95% CI 0.19-0.86; P = 0.02) were the independent predictors of RF deterioration. Among patients with >10 years of follow-up, RF deteriorated in 46 patients (49%) and CKD stage III-V developed in 40 (42%).

CONCLUSION

Women surviving more than 10 years after RC and ONB maintained acceptable continence status, apart from having a higher CUR rate, compared to those followed for <10 years. However, RF deterioration developed in nearly half of them.

Utility of Pre-Transplant Bladder Cycling for Patients With a Defunctionalized Bladder. A Randomized Controlled Trial

OBJECTIVE

To study the necessity of pre-transplant programmed bladder cycling (PBC) in patients with defunctionalized bladder (DB).

METHOD

This RCT included renal transplant (RT) candidates with DB. Eligible patients were assigned to 2 groups, group I underwent PBC before RT and group II underwent direct RT into the DB. The primary outcome was to assess the efficacy of PBC in improving post- RT bladder capacity. Secondly, to compare its impact on early urological complications and 3-month voiding function and 1-year graft function and survival. Graft function was evaluated using serum creatinine and eGFR using MDRD equation.

RESULTS

Groups I included 23 patients and group II included 20 patients. The mean ±SD of bladder capacity was 88.7±11.7mL and 90.6 ±9.8mL in both groups, respectively (P = .5). In group I, PBC increased bladder capacity to 194.7 ±21.2 mL (P < .001). Targeted bladder capacity was achieved in 19 (82.6 %) patients and 2 patients developed UTI. At 3-months, bladder capacity, compliance and bladder contractility index improved significantly in both groups with a significant reduction in maximum detrusor pressure with no significant difference between both groups (P = .3,0.4, 0.2 and 0.8, respectively). Urinary leakage occurred in one (4.3%) and 3 patients (15%) in group 1 and 2, respectively (P = .2). At 1-year, no statistically significant differences in the median (IQR) serum creatinine (P = .05) and eGFR (P = .07) between both groups were noted.

CONCLUSION

Pre-transplant PBC for DB-patients provided no clinical advantage concerning post-operative urological complication, urodynamic criteria and graft function and survival.

Azoospermia and Sperm Retrieval in Post-Pubertal Testicular Torsion; Benefits and limitations

OBJECTIVES

To assess the risk of azoospermia development and the value of sperm retrieval in post-pubertal testicular torsion (TT).

MATERIALS AND METHODS

This prospective study included patients with post-pubertal TT. Surgical exploration was urgently performed with either orchiopexy or orchiedectomy and contralateral orchiopexy. With the intention of cryopreservation, all cases underwent conventional testicular sperm extraction. Patients were followed-up after 1, 3, and 6 months with semen analysis and hormonal assay (FSH, LH and testosterone). Sperm retrieval rate (SRR), azoospermia rate and changes in hormonal profile were evaluated.

RESULTS

The study included 62 patients with a median (IQR) age of 19 (18-20.7) years and duration of testicular torsion of 32.5 (18.3-48) hours. Testicular salvage was successful in 20 (32.3%) while orchiedectomy was performed on 42 patients. The duration of torsion [OR, 95% CI = 0.75 (0.61-0.93), P = .008] was the independent predictor of testicular salvage. Successful SR was achieved in 58 patients (93.5%); (40 from the affected testis and 18 from the contralateral side). After 6 months, 21 patients (33.8%) developed azoospermia [19 (45.2%) in orchidectomy group and 2 (10%) in orchiopexy group, P = .006]. Abnormal contralateral testis was the independent predictor of azoospermia [OR, 95% CI = 92(8.4-101.5), P < .001]. Azoospermia patients showed a statistically significant increase in FSH and LH and decrease in testosterone level as compared to the non-azoospermia group (P < .001).

CONCLUSION

Azoospermia is not rare in post-pubertal TT patients; therefore, SR at time of intervention seems to be a good option for them to preserve their fertility potentials.

Could the bulbar urethral end location on the cystourethrogram predict the outcome after posterior urethroplasty for pelvic fracture urethral injury?

Objectives

To identify cystourethrogram (CUG) findings that independently predict the outcome of posterior urethroplasty (PU) following pelvic fracture urethral injury (PFUI).

Methods

Findings of CUG included the location of the proximal end of the bulbar urethra in zones A (superficial) or B (deep) according to its relationship with the pubic arch. Others included the presence of pelvic arch fracture, bladder neck, and posterior urethral appearance. The primary outcome was the need for reintervention either endoscopically or by redo urethroplasty. Independent predictors were modeled using a logistic regression model and a nomogram was constructed and internally validated using 100-bootstrap resampling. Time-to-event analysis was performed to validate the results.

Results

A total of 196 procedures in 158 patients were analyzed. The success rate was 83.7% with 32 (16.3%) procedures requiring direct vision internal urethrotomy, urethroplasty, or both in 13 (6.6%), 12 (6.1%), and 7 (3.6%) patients, respectively. On multivariate analysis, bulbar urethral end located at zone B (odds ratio [OR]: 3.1; 95% confidence interval [CI]: 1.1-8.5; p = 0.02), pubic arch fracture (OR: 3.9; 95%CI: 1.5-9.7; p = 0.003), and previous urethroplasty (OR: 4.2; 95% CI: 1.8-10.1; p = 0.001) were independent predictors. The same predictors were significant in the time-to-event analysis. The nomogram discrimination was 77.3% and 75% in the current data and after validation.

Conclusions

The location of the proximal end of the bulbar urethra and redo urethroplasty could predict the need for reintervention after PU for PFUI. The nomogram could be used preoperatively for patient counseling and procedure planning.

Omega-3 polyunsaturated fatty acids: a modified approach for chemo-prevention of bladder cancer in a rat model and molecular studies of antineoplastic mechanisms

OBJECTIVES

To test the chemo-preventative effects of omega-3 against bladder cancer (BC) induction in a rat model and its potential antineoplastic mechanisms.

MATERIAL AND METHODS

Ninety male Fisher rats were divided into three groups during a 22-week protocol: group 1 (control), group 2 (Placebo + N-butyl-N-4- hydroxybutyl nitrosamine (BBN) for induction of BC and group 3 received omega-3 (1200 mg/kg/day) + BBN. At the end, blood samples and bladder tissues were collected and checked for the presence of malignancy, markers of angiogenesis (VEGF relative gene expression), inflammation (IL-6), proliferation (KI-67 expressions), oxidative stress (serum MDA and serum SOD) and epigenetic control (miRNA-145 level).

RESULTS

At the end of the study, 60% and 86.6% rats survived in group 2 and 3 with significant weight loss among rats in group 2 when compared with other groups. In group 2, all rats developed visible bladder lesions of which five and 13 developed squamous cell carcinoma (SCC) and transitional cell carcinoma (TCC). In omega3-treated group, only one developed low grade SCC and one developed high grade non- invasive TCC. Bladders from omega-3-treated rats showed lower expression ofKI-67 (p < 0.05), VEGF (p < 0.001) and IL-6 (p < 0.001) and significant higher expression of mi-RNA (p < 0.001). Also, omega-3-treated group showed statistically significant lower MDA level (p < 0.001).

CONCLUSION

Omega-3 inhibits bladder tumor growth in the BBN-induced BC rat model, due to anti-inflammatory, antioxidant, anti-proliferative, and anti-angiogenic properties together with epigenetic control.

The effect of renal transplantation on female sexual function: An age-matched pair analysis

OBJECTIVES

To evaluate female sexual function (FSF) after renal transplantation (RT) and compare it to an age-matched normal females (control).

MATERIAL AND METHODS

The study included 100 sexually active RT women in child-bearing period. Sexual function was evaluated with Female Sexual Function Index (FSFI). We compared the mean scores of all domains of FSFI to an age-matched sexually active normal women. Also, we compared the current FSFI to the pre-transplant status in 54 married women before RT. Factors affecting the FSF after RT were assessed.

RESULTS

In comparison to control group, RT had statistically significant lower sexual desire (p <0.001) with no significant differences as regard arousal, lubrication, orgasm, satisfaction, pain and total FSFI score (P>0.05). Among RT, 83 % had normal sexual function and 83.7% of the control had normal sexual function (p=0.8). After RT, the FSFI score increased significantly from 20.7±5.4 to 27.8±3.1 (P<0.001) and 85.2% had normal sexual function compared to 22.2% before RT (P<0.001) with statistically significant improvement in all domains (p<0.001) except for pain score (p=0.8). Female circumcision was the only identified factor associated with FSD (P=0.02).

CONCLUSION

Successful RT significantly improves female sexual function of ESRD patients. The sexual function after RT is comparable to healthy control except for lower sexual desire.

Mirabegron for treatment of erectile dysfunction concomitant with lower urinary tract symptoms in patients with benign prostatic obstruction: A randomized controlled trial

OBJECTIVE

To assess the efficacy of mirabegron in the treatment of erectile dysfunction concomitant with lower urinary tract symptoms in benign prostatic obstruction patients.

METHODS

In this randomized controlled trial, 55 sexually active lower urinary tract symptoms/benign prostatic obstruction patients with concomitant erectile dysfunction were randomly allocated in two groups: the first received mirabegron 50 mg plus doxazosin 2 mg once daily (mirabegron group) and the second received tolterodine 4 mg plus doxazosin 2 mg (tolterodine group) for 12 weeks. The evaluation was based on the International Index of Erectile Function questionnaire, Erection Hardness Score questionnaire, International Prostate Symptom Score, quality of life, uroflowmetry and post-voiding residual. The therapeutic outcomes were assessed at 4 and 12 weeks compared with the baseline.

RESULTS

Only the mirabegron group achieved significant improvement in sexual functions after 4 and 12 weeks. By using ≥5 points difference from the baseline as a cut-off point of change, there was a significant difference in change of direction of the International Index of Erectile Function-15 total score in favor of the mirabegron group; after 12 weeks, the International Index of Erectile Function-15 total score decreased in 0%, was unchanged in 8.3% and improved in 91.7% in the mirabegron group compared with 8.7%, 65.2% and 26.1%, respectively, in the tolterodine group (P < 0.001). Regarding the urinary characteristics, both groups showed significant improvement in the International Prostate Symptom Score, quality of life, and post-voiding residual after 4 and 12 weeks, with no significant difference among them.

CONCLUSION

Mirabegron improves urinary characteristics and the associated sexual dysfunction in patients with lower urinary tract symptoms/benign prostatic obstruction.

Identification of Different miRNAs and Their Relevant miRNA Targeted Genes Involved in Sister Chromatid Cohesion and Segregation (SCCS)/chromatin Remodeling Pathway on T1G3 Urothelial Carcinoma (UC) Response to BCG Immunotherapy

BACKGROUND

Till now, no definite clinical or laboratory marker can predict the recurrence or progression of T1 G3 urothelial carcinoma (UC). Genetic aberrations of the chromatin remodeling genes and sister chromatid cohesion and segregation (SCCS) were identified in UC. Here we investigated the impact of novel miRNAs and their targeted expressed SCCS and chromatin remodeling genes on T1G3 UC response to Bacillus Calmette-Guérin (BCG) therapy.

METHODS

One hundred tissue samples were obtained from NMIBC patients. Gene expression and immunohistochemical assay of STAG2, ARID1A, NCOR1and UTX were assessed. MiRNA analysis for their targeting miRNAs (miR-21, miR-31, Let7a and miR-199a) was carried out. Assessed genes were compared between responders and no responders to BCG. Univariate and multivariate analysis of predictors of disease recurrence and progression were performed using cox regression analysis.

RESULTS

Thirty-two and 22 patients developed recurrence and progression to MIBC (BCG non-responders). BCG non-responders showed statistically significant higher expression of miR-21 and their targeted STAG2, miR-199a and NCOR1 gene (P < .001), and lower expression of miR-31, Let7a, ARID1A and UTX genes (P < .001). Higher miR-199a (P = .006) and lower miR-31 (P = .01), ARID1A (P = .008) and UTX (P = .03) were independent predictor of higher tumor recurrence. Recurrent disease (P = .003), higher expression of STAG2 (P = .01), NCOR1 (P = .01) and miR-21 (P = .03) genes and lower expression of miR-31 (P = .02), Let7a (P = .04) and ARID1A (P = .04) genes were the independent predictor of disease progression.

CONCLUSION

Upregulation of STAG2 and NCOR1 and down regulation of ARID1A and UTX genes and their targeting miRNAs were associated with UC non-response to BCG.

Predictive value of immunological markers after bacille Calmette-Guérin induction in bladder cancer

OBJECTIVES

To investigate the predictive value of different immunological markers on treatment outcomes after bacille Calmette-Guérin (BCG) induction in high-risk non-muscle-invasive bladder cancer (NMIBC).

PATIENTS AND METHODS

Patients who underwent transurethral resection of bladder tumour for NMIBC were assessed for study eligibility. Urine and blood samples were taken from patients at baseline (immediately before first dose of induction) and after induction (4 h after last [sixth] dose). Urine samples were evaluated for interleukin (IL)-2 and IL-10 by solid-phase enzyme-linked immunosorbent assay. Blood samples were evaluated for tumour necrosis factor α (TNF-α), cytotoxic T-lymphocyte antigen 4 (CTLA-4) and transcription factors (TFs) (GATA-binding protein 3 [GATA3], T-box expressed in T cells [T-bet], and forkhead box protein 3 [FoxP3]) using quantitative reverse transcriptase-polymerase chain reaction analysis. Change pattern and fold change of each evaluable marker was assessed in relation to different treatment outcomes (initial complete response [ICR]/recurrence/progression).

RESULTS

Between July 2013 and May 2019, 204 patients were included. Among evaluable markers, urinary IL-2 and serum TNF-α increased in all patients, serum CTLA-4 and FoxP3⁺ showed a predominant decreased pattern in 188 (92.2%) and 192 (94.1%) patients, respectively. An ICR was achieved in 186 (91.2%) patients. Serum TNF-α fold change and urinary IL-10 change pattern were significantly associated with an ICR (P = 0.001 and P = 0.03, respectively). At a median (range) follow-up of 37 (20-88) months, 104 (56%) patients developed recurrence. Urinary IL-10, serum CTLA-4, T-bet⁺ , FoxP3⁺ change patterns and GATA3⁺ /T-bet⁺ ratio were significantly associated with tumour recurrence (P = 0.001, P = 0.001, P = 0.02, P = 0.009 and P = 0.001, respectively). Tumour progression occurred in 34 (18.3%) patients. Urinary IL-10, serum CTLA-4, serum T-bet⁺ change patterns and GATA3⁺ /T-bet⁺ ratio were independent predictors of tumour progression (P = 0.001, P = 0.001, P = 0.02 and P = 0.001, respectively).

CONCLUSIONS

Urinary IL-10 and serum TNF-α can significantly predict ICR. Moreover, change pattern of urinary IL-10, serum CTLA-4, TFs (GATA3, T-bet and FoxP3) and GATA3⁺ /T-bet⁺ ratio after BCG induction can independently predict further BCG response. These markers could be implemented in clinical practice when management options are discussed or in systems with severe BCG shortage.

De novo chromophobe renal cell carcinoma in the graft three decades after renal transplantation in a patient with a history of three renal transplants

De novo renal allograft tumors were reported sporadically. Most of them were small, low-grade, and papillary renal cell carcinoma (RCC) type. A 46-year-old male presented with hematuria three decades after the first transplant. The patient had a history of three renal transplants. A tumor (12 cm × 13 cm) was diagnosed in the nonfunctioning first transplanted kidney. Radical nephrectomy of the graft harboring the tumor with preservation of the adjacent functioning graft was done and identified to be chromophobe RCC. After two-year follow-up, the patients had a perfect graft function with no evidence of oncological failure. We suggest that allograft tumor be considered in patient evaluation for hematuria. Regular follow-up imaging of transplanted kidney is mandatory even after graft failure for early detection of graft tumors.

5-Year Long-Term Outcome of Live-Donor Renal Transplant Recipients With Enterocystoplasty and Ureterocystoplasty: An Age- and Sex-Matched Pair Analysis

OBJECTIVE

To assess surgical complications, febrile UTI, graft function and 5-year graft survival after renal transplantation (RT) in patients with augmentation cytsoplasty (AC) and to compare them to RT patients with normal lower urinary tract.

MATERIALS AND METHODS

A case-control study of 34 RT patients with AC including 23 patients with enterocystoplasty (EC) and 11 patients with ureterocystoplasty (UC) was performed. The primary outcome was to determine the difference between both groups regarding postoperative surgical complications and febrile UTI episodes. Graft function was compared at 1, 3, and 5 years and 5-year graft survival was determined. The secondary outcome was to compare them to an age- and gender-matched control group (122 patients) with normal lower urinary tract.

RESULTS

There was no significant difference regarding surgical complications or rates of hospital readmission between AC groups. Seventeen (73.9%) and 5 (45.5%) patients developed 33 and 14 episodes of febrile UTI in EC and UC groups, respectively (P= .5). Control group had shown lower incidence surgical complications (P = .001) and febrile UTIs (P = .02) compared to AC groups. At 3 and 5 years, UC had higher median eGFR than EC (P = .08, 0.008, respectively). The 5-year graft survival was 32 (94.1%) with no statistically significant difference between EC (95.7%) and UC (90.9%) (P = .5) or between AC and control (85.2%, P = .3).

CONCLUSION

Although RT after AC was associated with higher surgical complications and UTI episodes, they had comparable 5-year graft survival to their control. When indicated, UC should be the preferred choice of AC whenever possible.

The short-term effects of tolterodine on nocturnal incontinence after ileal orthotopic neobladder: a randomised crossover placebo-controlled study

OBJECTIVES

To assess the effect of tolterodine in the treatment of nocturnal urinary incontinence (NUI) after ileal orthotopic neobladder (ONB).

PATIENTS AND METHODS

This is a prospective randomised placebo-controlled crossover study (clinicaltrials.gov: NCT02877901). Patients with NUI after ONB were randomly allocated into two equal groups. Group T received 4 mg extended-release tolterodine at bed-time and Group P received placebo for 4 weeks followed by 2 weeks of washout, then crossed over to the alternate therapy for 4 weeks. Patients were assessed by the number of pads used per night (PPN) and with the Arabic version of the International Consultation on Incontinence Modular Questionnaire-Short Form (ICIQ-SF) at both phases of the study. The outcomes were the rate of NUI improvement and medication adverse events.

RESULTS

Out of 172 patients, 150 and 122 patients were evaluated at both phases of the study. The mean ICIQ-SF scores and PPN were significantly decreased in Group T compared to Group P in both study phases (P < 0.001). In Group T, 15 (10%) and 11 (9%) patients became dry after the first allocation and crossover, respectively. In Group T, 60 (77.9%) patients reported improvement vs four (5.5%) in Group P (P < 0.001) after the first allocation. Similarly, 46 (73%) and seven (11.9%) patients showed improvement in groups T and P after the crossover, respectively (P < 0.001). Dry mouth occurred in 31 (20.8%) patients.

CONCLUSIONS

Tolterodine seems to be a good choice for treatment of NUI after radical cystectomy and ONB. However, further studies are needed to delineate the long-term effects and the associated urodynamic characteristics.

Outcome of Live-Donor Renal Transplants With Incidentally Diagnosed Renal Angiomyolipoma in the Donor

INTRODUCTION

Accepting donors with renal lesion amenable for pre-transplant management with no suspected long-term harm seems to expand the live-donor pool. We aimed to assess the long-term outcome of live-donor renal transplantation with incidentally discovered renal angiomyolipoma (AML) during routine evaluation of donors.

PATIENTS AND METHODS

A retrospective evaluation of incidentally discovered AML, during live-related-donor evaluation, was performed. The tumor criteria were retrieved. In cases with exophytic tumor, a back-table, partial nephrectomy was done with frozen section to exclude malignancy. Endophytic lesions were kept in situ and transplanted. Both donor and recipient were followed up by periodic imaging.

RESULTS

Among 2925 cases, 6 AML with a median volume of 0.96 (range, 0.5-2) cm² were identified. The median recipients' age was 21 (range, 10-38) years and the median donors' age was 48 (range, 45-50). Two AML were exophytic and back-table partial nephrectomy was performed, while 4 were endophytic and kept in situ, and the kidney was transplanted. After a median follow-up of 82 (range, 25-150) months, 4 patients were alive with functioning grafts and 2 resumed hemodialysis 5 and 7 years after transplantation. There was no evidence of increase in the AML size or newly developed AML in the grafts. All donors were alive with normal renal function (mean ± standard deviation, serum creatinine was 0.9 ± 0.2 mg/dL) and none developed new AML in the remaining kidney.

CONCLUSION

Incidentally discovered AML during live-donor evaluation is not a contraindication of donation after proper counseling of the couples and regular, periodic follow-up.

Delivery of intravesical botulinum toxin A using low-energy shockwaves in the treatment of overactive bladder: A preliminary clinical study

Objective: To evaluate the efficacy and safety of botulinum toxin A (BoNT-A) instillation in the bladder under the effect of low-energy shockwaves (LESWs) for the treatment of refractory idiopathic overactive bladder (OAB). Patients and methods: A preliminary clinical study was conducted, including 15 patients with refractory OAB, between September 2016 and July 2017. Intravesical instillation of 100 IU of BoNT-A was done followed by LESWs (3000 shocks over 10 min) exposure to the supra-pubic area. Patients were followed-up by urine analysis, urine culture, post-void residual urine volume (PVR), and Overactive Bladder Symptom Score (OABSS) at 1, 2 and 3 months. Results: There were statistically significant improvements in all OABSS domains and the total score after 1 and 2 months of treatment (P < 0.05). Whereas, only the nocturia domain remained significantly improved after 3 months (P = 0.02). There was no significant increase in PVR throughout the study period (P > 0.05) and none of the patients required clean intermittent catheterisation. Two, two and three patients developed urinary tract infections after 1, 2 and 3 months, respectively. Conclusion: Intravesical instillation of BoNT-A and LESWs is safe and effective method for the treatment of refractory OAB with a durable response for 2 months. Abbreviations: BoNT-A: botulinum toxin A; CIC: clean intermittent catheterisation; DO: detrusor overactivity; LESWs: low-energy shockwaves; OAB: overactive bladder; OABSS: Overactive Bladder Symptom Score; Qmax: maximum urinary flow rate; QoL: quality of life; UUI: urgency urinary incontinence.

Renoprotective effect of local sildenafil administration in renal ischaemia-reperfusion injury: A randomised controlled canine study

Objectives: To design a new canine model to assess the renoprotective effect of local sildenafil administration, as the renoprotective effect of systemic sildenafil administration in renal ischaemia-reperfusion (IR) injury in animal models has been shown but its local effects have not been established to date. Materials and methods: In all, 120 dogs were assigned to five groups: sham, oral control (OC) group (right nephrectomy + left renal ischaemia for 60 min), oral sildenafil (OS) group (oral sildenafil 1 mg/kg, 60 min before ischaemia), local control (LC) group (local renal perfusion with saline and heparin for 5 min) and local sildenafil (LS) group (perfusion with sildenafil 0.5 mg/kg). Renal functions, histopathological changes, expression of caspase-3, nuclear factor erythroid 2-related factor 2 (Nrf2), inflammatory cytokines (intracellular adhesion molecule 1, tumour necrosis factor α and interleukin 1β) and endothelial nitric oxide synthase (eNOS) in renal tissues were assessed in all groups at 1, 3, 7 and 14 days. Results: There were significant improvements in renal functions and cortical and medullary damage scores in the sildenafil-treated groups compared to their control groups (P < 0.05). Also, the LS group showed significantly better improvement of renal functions and cortical and medullary damage scores than the OS group (P < 0.05). Moreover, sildenafil significantly decreased the expression of caspase-3 and inflammatory cytokines and increased the expression of Nrf2 and eNOS in renal tissue, which were statistically significant in the LS group. Conclusion: LS has a greater renoprotective effect against renal IR injury than systemic administration via anti-inflammatory, antioxidant and anti-apoptotic pathways. Abbreviations: BUN: blood urea nitrogen; Ct: cycle threshold; eNOS: endothelial nitric oxide synthase; GAPDH: glyceraldehyde 3-phosphate dehydrogenase; H&E: haematoxylin and eosin; IL-1β: interleukin 1β; NO: nitric oxide; Nrf2: nuclear factor erythroid 2-related factor 2; OC: oral control; OS: oral sildenafil; LC: local control; LS: local sildenafil.

Simultaneous peritoneal and retroperitoneal splenosis mimics metastatic right adrenal mass

INTRODUCTION

Right retroperitoneal splenosis is rare with few reported cases. We report, here, the case of simultaneous peritoneal and retroperitoneal splenosis mimics metastatic right adrenal mass.

PRESENTATION OF CASE

A 28-year-old man who had previously undergone post traumatic splenectomy at childhood and subsequently presented with an large incidental non-functioning right adrenal mass with presence of extra-hepatic peritoneal focal lesion diagnosed as metastasis by magnetic resonance imaging (MRI). Adrenalectomy with metatstectomy was performed, and both masses were identified to be splenosis.

DISCUSSION

Adrenal incidentalomas (AIs) is defined as asymptomatic masses >1 cm. on cross-sectional imaging studies. AIs have significant malignant potential for masses > 6 cm. Splenosis are found most frequently in the left retroperitoneum in cases involving retroperitoneal splenosis. However, right retroperitoneal splenosis have been reported. Traditional imaging techniques cannot differentiate splenosis from malignancy.

CONCLUSION

Large right adrenal incidentalomas present with other abdominal, peritoneal masses could be splenosis in patient following post-traumatic splenectomy.

Contemporary Management of Renal Transplant Recipients With De Novo Urolithiasis: A Single Institution Experience and Review of the Literature

OBJECTIVES

We report on the long-term follow-up of managing allograft stones at a single tertiary referral institution and review the relevant literature.

MATERIALS AND METHODS

A retrospective analysis of renal allograft recipient charts was performed to identify patients who developed allograft lithiasis between 1974 and 2009. Patient and stone characteristics, diagnoses, treatments, and outcomes were described.

RESULTS

Sixteen patients developed 22 stones after a median follow-up of 170 months (range, 51-351 mo). The mean (standard deviation) and median diameter of the stones were 13.8 (8.5) mm and 11 mm. Among these, 3 stones were treated conservatively, 3 by shock-wave lithotripsy, and 7 by cystolitholapaxy. Seven patients underwent percutaneous treatment in the form of percutaneous nephrostomy tube fixation and spontaneous passage of stone (1 stone), shock-wave lithotripsy (1 stone), antegrade stenting (1 stone), and percutaneous nephrolithotomy (6 stones). All patients were stone free after treatment, except for 2 patients whose stones were stable and peripheral on long-term follow-up.

CONCLUSIONS

Allograft lithiasis requires a multimodal treatment tailored according to stone and graft characteristics. Protocols regarding spontaneous passage can be adopted if there is no harm to the graft and the patient is compliant. Careful attention to the anatomy during percutaneous nephrostomy tube placement is mandatory to avoid intestinal loop injury. A more attentive follow-up is required for early stone management.

Validation of the Arabic version of the Functional Assessment of Cancer Therapy-Bladder questionnaire in Egyptian patients with bladder cancer

Objectives

To validate the Arabic version of the Functional Assessment of Cancer Therapy-Bladder (FACT-Bl) questionnaire in Egyptian patients who underwent radical cystectomy (RC) and orthotopic neobladder (ONB) construction.

Patients, subjects and methods

The English version of the FACT-Bl was translated into the Arabic language using multi-step process by two urologist and two independent translators. The Arabic version was validated by inviting 90 patients who underwent RC and ONB and 72 normal individuals to complete the questionnaire. The reliability of the questionnaire was tested for internal consistency using the Cronbach’s α test. Inter-domain association was tested by Spearman’s correlation coefficient. The discrimination validity was measured by comparing the scores in RC patients and in normal individuals using the Mann–Whitney U-test and independent sample t-test.

Results

Internal consistency was high for all domains. There was high correlation between all domains. This high internal consistency and good correlation was maintained when assessment included patients with <7.5 and those with ≥7.5 years follow-up. Discrimination validation was confirmed by the statistically significant lower scores of all domains in the studied patients in comparison to the controls.

Conclusion

The Arabic version of the FACT-Bl is a reliable and validated instrument that can be used to evaluate health-related quality of life in patients after RC and ONB.

Acute kidney injury after percutaneous nephrolithotomy for stones in solitary kidneys

OBJECTIVES

The aim of this study was to report the incidence, severity, outcome and risk factors of acute kidney injury (AKI) following percutaneous nephrolithotomy (PNL) in solitary kidneys.

METHODS

The study included consecutive adult patients who underwent PNL for treatment of calculi in a solitary kidney between May 2012 and July 2015. Patients with congenital renal anomalies or with stages 4 and 5 chronic kidney disease (CKD) were excluded. Serum creatinine levels were measured the day before PNL, daily after PNL for 2-5 days and after 3 months. AKI was depicted according to changes in early postoperative serum creatinine levels and its severity was determined based on the Acute Kidney Injury Network (AKIN) classification. The outcome of AKI was evaluated after 3 months by changes in the stage of CKD. Univariate and multivariate statistical analyses were conducted to determine risk factors for developing AKI.

RESULTS

The study included 100 patients (62 males) with a mean ± SD age of 50 ± 11.7 years. Complications were reported for 27 patients. AKI developed in 25 patients; at the 3 month follow-up, 23 of them (92%) had completely recovered from AKI and two (8%) had developed stage 4 CKD. Independent risk factors for developing AKI were multiple PNL tracts and postoperative ureteric obstruction (relative risks were 14 and 22, respectively).

CONCLUSIONS

The incidence of AKI was 25% after PNL for a solitary kidney. The likelihood of renal function recovery was 92%. Multiple PNL tracts and postoperative ureteric obstruction were risk factors for developing AKI.

Health related quality of life after radical cystectomy in women: orthotopic neobladder versus ileal loop conduit and impact of incontinence

BACKGROUND

Enough data about health related quality of life (HRQOL) after radical cystectomy (RC) and urinary diversion (UD) in women is still lacking. The objectives are to evaluate HRQOL in women after RC and orthotopic neobladder (ONB) versus ileal loop conduit (IC) and to assess the impact of urinary continence.

METHODS

The study included 145 women who underwent RC and came for routine follow-up. HRQOL was assessed by two questionnaires (EORTC-QLQ-C30and FACT-Bl). ONB group was stratified to: totally continent, with nocturnal incontinence (NI) and patients in chronic urinary retention (CUR) and maintained on CIC. The orthotopic group (as a whole and its 3 subgroups) was compared to IC.

RESULTS

ONB group included 22 continent women, 35 with NI and 27 in CUR and on CIC. There were no statistically significant differences between ONB and IC groups in all domains of the two questionnaires. However, continent women showed statistically significant better most of EORTC-QLQ-C30 scales and emotional well-being, functional well-being, bladder cancer subscale and FACT-Bl total Score (P˂0.05) than IC group. Similarly, women in CUR showed statistically significant better global health and physical functioning EORTC-QLQ-C30 scores (P values=0.0001, 0.01) and all domains of FACT-Bl. On the other hand, women with NI showed statistically significant lower values in all domains of the EORTC-QLQ-C30 and FACT-Bl than IC group.

CONCLUSIONS

In women, HRQOL is better after ONB than IC as long as continence status is preserved. If incontinence is expected, IC may be a better option for UD.

Inflammatory pseudotumor of the urinary bladder: A case series among more than 2,000 urinary bladder tumor cases

"Inflammatory pseudotumor" (IPT) has infrequently been reported in the medical journals. A retrospective analysis was conducted among more than 2,000 bladder tumor cases from January 1999 to December 2012 looking for patients with IPT in the final diagnosis. Six patients were found with median tumor size of 3.5 cm (range: 3-8 cm); computed tomography and/or magnetic resonance imaging was used to diagnose the tumor. All patients had complete resection of the tumors. On a median follow-up of 6 years (range: 2-10 years), no recurrences for IPT have been observed in all patients. We concluded that IPT is a rare disease of the urinary bladder and should be regarded with a high degree of suspicion. Although an extensive workup may be needed for definite diagnosis, it is worth to avoid unnecessary chemoradiotherapy or radical surgeries.

After urgent drainage of an obstructed kidney by internal ureteric stenting; is ureteroscopic stone extraction always needed?

OBJECTIVES

To assess the probability of spontaneous stone passage and its predictors after drainage of obstructed kidney by JJ stent, as insertion of an internal ureteric stent is often used for renal drainage in cases of calcular ureteric obstruction.

PATIENTS AND METHODS

Between January 2011 and June 2013, patients for whom emergent drainage by ureteric stents were identified. The patients' demographics, presentation, and stone characteristics were reviewed. The primary endpoint for this study was stone-free status at the time of stent removal, where all patients underwent non-contrast spiral computed tomography (NCCT) before stent removal. Ureteroscopic stone extraction was performed for CT detectable ureteric stones at the time of stent removal. Potential factors affecting the need for ureteroscopic stone extraction at the time of stent removal were assessed using univariate and multivariate statistical analyses.

RESULTS

Emergent ureteric stents were undertaken in 196 patients (112 males, 84 females) with a mean (SD) age of 53.7 (16.2) years, for renal obstruction drainage. At the time of stent removal, 83 patients (42.3%) were stone free; with the remaining 113 patients (57.7%) undergoing ureteroscopic stone extraction. On multivariate analysis, stone width [odds ratio (OR) 15.849, 95% confidence interval (CI) 2.83; P = 0.002) and radio-opaque stones (OR 12.035, 95% CI 4.65; P < 0.001) were independent predictors of the need for ureteroscopic stone extraction at the time of stent removal.

CONCLUSION

Spontaneous ureteric stone passage is possible after emergent drainage of an obstructed kidney by ureteric stenting. Stone opacity, larger stone width, and positive preoperative urine culture are associated with a greater probability of requiring ureteroscopic stone extraction after emergent drainage by ureteric stenting.

Studying the Morbidity and Renal Function Outcome of Missed Internal Ureteral Stents: A Matched Pair Analysis

PURPOSE

To investigate the effect of missed internal ureteral stents (IUS) on renal function and to describe different modalities of management and associated morbidity.

PATIENTS AND METHODS

A retrospective study included patients with missed IUS (>1 year). The complications of missed IUS were categorized according to the forgotten, encrusted, calcified (FECal) grading system. The estimated glomerular filtration rate (eGFR) was calculated using the Modification of Diet in Renal Disease (MDRD) equation at time of initial stent placement and time of stent removal. An age- and sex-matched group of patients who had IUS and had available follow-up for the same duration of the study group were used as a control.

RESULTS

A total of 46 missed IUS in 46 patients were included. Complicated stents were reported in 34 (73.9%) patients. FECal grade 1 was reported in 16 (57.2%) patients followed by grade 2 and 4 in 5 (17.8%) patients each. Retrograde removal, visual cystolitholapaxy, ureteroscopy with laser disintegration of encrustations and combined retrograde and antegrade approach have been used in 21, 5, 10, and 9 patients, respectively. In the missed IUS group, the mean±standard deviation (SD) eGFR has declined from 65.5±26.3 mL/min/1.73m(2) to 54.3±30 mL/min/1.73m(2) (P=0.001). While in the control group, the mean±SD eGFR has increased from 57.5±30 mL/min/1.73 m(2) to 66.7±27 mL/min/1.73 m(2) (P=0.001).

CONCLUSIONS

Missed IUS were associated with significant complications that necessitated more invasive intervention. In addition, IUS had a negative impact on renal function at time of removal.

Salvage of grafts with vascular thrombosis during live donor renal allotransplantation: a critical analysis of successful outcome

OBJECTIVES

To report a high-volume institution experience with salvage techniques for vascular accidents during live donor renal allotransplantation.

METHODS

Between March 1976 and January 2011, 2208 recipients underwent live donor renal allotransplantation. A retrospective review of recipients with vascular accidents - renal artery thrombosis and renal vein thrombosis - was carried out. Salvage procedures were recorded and their outcomes were assessed.

RESULTS

A total of 23 (1%) vascular accidents occurred, including renal artery thrombosis and renal vein thrombosis in 19 (0.8%) and four (0.18%) recipients, respectively. All renal artery thrombosis patients were treated by open revascularization and the graft was salvaged in 12 patients (63%). Two renal vein thrombosis events were resolved by percutaneous catheter-directed thrombolytic therapy. Of the other two allografts, one was salvaged by thrombectomy and revascularization, and the other was lost. On univariable analysis, older recipients (P = 0.003), pretransplant hypertension (P =  0.001), more human leukocyte antigen mismatches (≥3; P = 0.036), shorter ischemia time (≤45 min; P = 0.004) and longer time to diagnosis (>3.5 days; P = 0.013) were significantly associated with non-salvage of the graft after vascular accidents. Nevertheless, none of these variables were significant on the multivariable analysis. Over a median follow up of 35 months, the median (range) serum creatinine was 2 mg/dL (range 0.8-8.8 mg/dL), and 11 (79%) recipients were living with functioning grafts.

CONCLUSIONS

Despite the devastating complications, vascular accidents are salvageable and revascularization is crucial for graft salvage. Angiographic percutaneous techniques are viable alternatives for renal vein thrombosis.

Health-related quality of life after radical cystectomy and neobladder reconstruction in women: impact of voiding and continence status

OBJECTIVES

To assess health-related quality of life, and the impact of night-time incontinence and chronic urinary retention on health-related quality of life in women with bladder cancer after radical cystectomy and orthotopic neobladder.

METHODS

The study included 74 women who underwent radical cystectomy and orthotopic neobladder, and completed 1 year of follow up. Health-related quality of life was evaluated using the questionnaires of the European Organization for Research and Treatment of Cancer-Quality of Life Questionnaire and the Functional Assessment of Cancer Therapy bladder cancer-specific form. Health-related quality of life was compared with an age-matched control group. The impact of night-time incontinence and chronic urinary retention on health-related quality of life was assessed.

RESULTS

The study group included 18 completely continent patients with spontaneous voiding, 29 with night-time incontinence and 27 with chronic urinary retention. The study group was statistically significantly lower in all domains of health-related quality of life than the control group. In all domains of the European Organization for Research and Treatment of Cancer-Quality of Life Questionnaire and Functional Assessment of Cancer Therapy bladder cancer-specific form, completely continent women were comparable with those with chronic urinary retention. Women with night-time incontinence had a significantly worse health-related quality of life than completely continent women, shown by the mean global health score (P = 0.038), social functioning score (P = 0.012), pain European Organization for Research and Treatment of Cancer-Quality of Life Questionnaire score (P = 0.04), and functional well-being Functional Assessment of Cancer Therapy bladder cancer-specific form (P = 0.049) score.

CONCLUSIONS

After radical cystectomy and orthotopic neobladder in women, health-related quality of life is lower than that of the normal population. Night-time incontinence has a negative impact on social life and most domains of health-related quality of life. Thus, night-time incontinence has a higher social impact than chronic urinary retention.

Prepubertal testicular tumours: Should testicular-sparing surgery be considered? A single-institution experience and review of the literature

OBJECTIVES

To review our 10-year experience with uncommon testicular tumours in children (prepubertal testicular and paratesticular), to review previous reports, and to determine the appropriate management of these rare tumours, specifically the role of testicular-sparing surgery.

PATIENTS AND METHODS

We retrospectively reviewed all cases of testicular tumours managed at our institution between 1999 and 2009. Boys aged <16 years were included in the study. The patients' characteristics, presentation, the diagnostic tools, tumour markers, mode of treatment, pathological findings and outcome were assessed. We reviewed previous reports that addressed testicular and paratesticular tumours in prepubertal boys, using a Medline/PubMed search.

RESULTS

From 80 patients, 13 boys (median age 8.7 years) presented with testicular tumours (16%) and were included in the study. Two boys presented with precocious puberty and one with gynaecomastia. The level of α-fetoprotein was high in three boys, and the human chorionic gonadotrophin level was elevated in one, and both markers were high in one. Testicular-sparing surgery was performed in three boys. Six of the 13 tumours were malignant and seven were benign. None of the patients developed a recurrence or testicular atrophy after testicular-sparing surgery. From the review of previous reports we devised an evidence-based algorithm for managing prepubertal testicular tumours.

CONCLUSIONS

Paediatric testicular tumours are rare but they require an inguinal approach for either orchidectomy or testicular-sparing surgery; we recommend the latter option as long as frozen sections are analysed and a safety margin is maintained.

Angle of convergence of posterior crown preparations made by predoctoral dental students

The aim of this study was to determine angle of convergence (AC) of posterior crown preparations made by predoctoral dental students at the University of Toronto. Ninety-one dies of students' crown preparations were digitally scanned with an in-Eos-Blue scanner (Sirona). Created images were virtually sliced at three similar locations of mesiodistal and buccolingual planes. Virtual protractor was used to determine AC of each section. Means and SDs were calculated, and data were statistically analyzed with ANOVA and student's t-test for operator's gender, experience, and tooth type. There were no significant differences among the groups except for AC of preparations grouped by tooth type (p<0.0001). The greatest mean mesiodistal AC was 26.4° found with mandibular molars, while the smallest was 16° found with maxillary premolars. ANOVA revealed significant difference in mean mesiodistal AC among groups (p<0.01). Also, greatest mean buccolingual AC was 25° found with mandibular molars, while the smallest was 20.8° found with maxillary premolars. ANOVA did not reveal significant difference in mean buccolingual AC among groups (p>0.05). Overall mean AC values were greater than ideal range of 2-5°; however, they were within ranges published for dentists/prosthodontists. Gender and experience had no significant effect on AC, but tooth type significantly affected AC.