Urology Journal
Volume:17 Issue: 5, Sep - Oct 2020

To review the current literature on the presence of COVID-19 virus in the urine of infected patients and to explore the clinical features that can predict the presence of COVID-19 in urine.

A systematic review of published literature between 30th December 2019 and 21st June 2020 was conducted on Pubmed, Google Scholar, Ovid, Scopus, and ISI web of science. Studies investigating urinary viral shedding of COVID-19 in infected patients were included. Two reviewers selected relative studies and performed quality assessment of individual studies. Meta-analysis was performed on the pooled case reports and cohort with a sample size of ≥ 9.

Thirty-nine studies were finally included in the systematic review; 12 case reports, 26 case series, and one cohort study. Urinary samples from 533 patients were investigated. Fourteen studies reported the presence of COVID-19 in the urinary samples from 24 patients. The crude overall rate of COVID-19 detection in urinary samples was 4.5%. Considering case series and cohorts with a sample size of ≥ 9, the estimated viral shedding frequency was 1.18 % (CI 95%: 0.14 – 2.87) in the meta-analysis. Urinary viral load in most reports were lower than rectal or oropharyngeal samples. In adult patients, urinary shedding of COVID-19 was commonly detected in patients with moderate to severe disease (16 adult patients with moderate or severe disease versus two adult patients with mild disease). In children, urinary viral shedding of COVID-19 was reported in 4 children who all suffered from mild disease. Urinary viral shedding of COVID-19 was detected from day 1 to day 52 after disease onset. The pathogenicity of virus isolated from urine has been demonstrated in cell culture media in one study while another study failed to reveal replication of isolated viral RNA in cell cultures. Urinary symptoms were not attributed to urinary viral shedding.

While COVID-19 is rarely detected in urine of infected individuals, infection transmission through urine still remains possible. In adult patients, infected urine is more likely in the presence of moderate or severe disease. Therefore, caution should be exerted when dealing with COVID-19 infected patients during medical in- terventions like endoscopy and urethral catheterization especially in symptomatic adult patients while in children caution should be exerted regardless of symptoms.

The safety and feasibility of percutaneous nephrolithotomy (PCNL) compared with retrograde intrarenal surgery (RIRS) are debated. This systematic evaluation was performed to obtain comprehensive evidence with regard to the treatment outcomes of PCNL compared with RIRS for management of renal stones in patients with solitary kidney.

A systematic search of Medline, Embase, Pubmed, Web of Science, CNKI, Scopus and the Cochrane Library was performed to identify studies that compared PCNL with RIRS for management of renal stones in patients with solitary kidney and published up to Aug 2019. Outcomes of interest included perioperative variables, complications, and stone-free rate (SFR).

Four studies assessing PCNL vs. RIRS for renal stones larger than 2cm were included for meta-analysis. Although patients underwent PCNL have higher initial SFR than RIRS (OR: 3.72, 95% CI:2.38 to 5.83; P < 0.001), patients underwent RIRS have less intraoperative blood loss (dropped Hb: WMD = 3.49 g/L, 95% CI:2.83 to 4.15; P < 0.001), lower blood transfusion rates (OR= 5.31, 95% CI:1.36 to 20.68; P = 0.02), and higher incidence rate of steinstrasse (OR:0.20, 95% CI:0.04 to 0.91; P = 0.04). All the other calculated results including operation time (WMD: -9.87 minute, 95% CI:-30.11 to 10.37; P = 0.34), final SFR (OR:1.65, 95% CI:0.80 to 3.42; P = 0.18) and overall complications (OR:1.22, 95% CI:0.78 to 1.93; P = 0.38) are similar between the two groups.

Our results indicate that PCNL has higher initial SFR than RIRS in the treatment of renal stones larger than 2cm in patients with a solitary kidney, the overall complications were similar in both groups. However, RIRS, with less blood loss and transfusion rate, may be an alternative in selected patients. But we need to pay more attention to the incidence rate of steinstrasse after RIRS.

Alpha-blockers have been proven as an effective method for increasing the stone expulsion rate of dis- tal ureteral stones. Limited studies have focused on doxazosin; its efficacy remained unclear. We performed this meta-analysis to investigate the efficacy and safety of doxazosin for patients diagnosed with distal ureteral stones less than 10mm.

We systematically searched Ovid MEDLINE®, Cochrane Library, EMBASE, and Pu- bMed for articles comparing doxazosin and conventional care or tamsulosin for distal ureteral stones through October 2019. The outcome measures were stone expulsive rate (SER), stone expulsive time (SET), pain episodes, analgesics consumption, and adverse events.

We included 12 studies involving 836 participants with distal ureteral stones less than 10mm in our review. The present meta-analysis showed doxazosin could significantly increase SER [RR=1.64,95%CI (1.32, 2.04), P < 0.00001], shorten SET [WMD=-3.97,95% CI (-5.68, -2.27), P < 0.00001] compared with conventional care. In the subgroup analyses, doxazosin showed no benefit in the children subgroup (<16 years old) [RR=1.63,95% CI (0.73,3.64), P = 0.23]. No statistically significant difference was observed regarding the effectiveness of doxazos- in and tamsulosin in SER, SET, and safety. Nine out of 286 participants reported doxazosin-related adverse events; most were mild to moderate.

This meta-analysis may suggest that doxazosin is a safe and effective MET for distal ureteral stones less than 10mm. It is not demonstrated to have any significant difference with tamsulosin in SER, SET, and safety. However, it showed no benefits for patients < 16 years old.

To review the safety and effectiveness of tubeless percutaneous nephrolithotomy (PCNL) with an exter- nalized ureteral catheter (EUC) compared with standard PCNL with nephrostomy tube and tubeless PCNL with double-J (DJ) stent following uncomplicated PCNL and the absence of residual stones.

Patients with kidney stones who underwent uncomplicated PCNL between January 2000 to December 2017 and had no residual stones were retrospectively evaluated. The 766 patients were divided into standard PCNL with nephrostomy tube (group 1; 350 patients), tubeless PCNL with DJ stent (group 2; 189 patients), and tubeless PCNL with EUC (group 3; 227 patients). Demographic characteristics, stone-related factors, perioperative and postoperative parameters were analyzed.

Demographic and stone-related characteristics were comparable. The differences in the mean operative time and complication rates were not significant. Postoperative hospitalization period was shorter in group 3 (3.19 ± 2.2 days) compared with group 1 (4.12 ± 2.4 days; p < .001) but not to that of group 2 (3.44 ± 2.8 days; p = .680). Postoperative pain score was lower in group 3 (3.24 ± 1.1) compared with both group 1 (6.36 ± 1.7; p < .001) and group 2 (4.85 ± 1.1; p < .001). Urine leakage complication was lower in group 3 (0.4%) compared with group 1 (2.9%, p = .038) but not to that of group 2 (0.5%; p = .897).

Tubeless PCNL is effective and safe for uncomplicated PCNL in the absence of residual stones. Tubeless PCNL with EUC is associated with decreased pain, hospitalization time, and urine leakage compared with standard PCNL. However, it is only associated with decreased pain when compared with tubeless PCNL with DJ stent.

To assess the cost-effectiveness of medical expulsive therapy (MET) versus observation for large distal ureteral stones in China and provide preliminary evidence for the determination of the course of MET by mathe- matical estimation.

With linear success rate assumptions, a decision tree was constructed by TreeAge Pro 2011 software. The stones passage rates after observation or receiving 0.4 mg daily tamsulosin were estimated according to a large randomized clinical trial (RCT). The costs of ureteroscopy, drugs and examinations were esti- mated according to related price from pharmacies or hospitals, or the guidance price published by the government. MET was also compared with observation by the sensitivity analysis. The effectiveness of MET or observation was presented by quality-adjusted life-day. Mathematical estimation of stone expulsion time was made by using a decision-analytic Markov model under the assumption that the daily stone expulsion probability is constant.

In China, the MET was associated with a $295.1 cost advantage over observation. The cost of ureterosco- py has to decrease to $77.8 to reach cost equivalence between observation and MET. Observation is cost-effective only if ureteroscopy is very cheap or the difference of stone expulsion rates is insignificant. The estimated expul- sion time was much longer than those reported in above mentioned RCT.

Due to the high cost of ureteroscopy, MET showed a cost advantage over observation in treating distal ureteral stones in China. The daily stone passage rate was inconstant. More studies are needed to find the appropriate duration of MET.

To explore the clinical efficacy of ureteroscopic occluder and stone retrieval basket combined with hol- mium laser in the treatment of upper ureteral calculi.

This retrospective study included 103 patients treated with ureteroscopic holmium laser lithotripsy for upper ureteral stones. Patients were divided into two groups based on the device applied during lithotripsy: group 1 for the occluders (52 cases), and group 2 for the stone retrieval baskets (51 cases). The stone upward migration rate, stone-free rate, and complication rate during or after surgery were compared.

The operation time was 45 ± 7 min in the occluder group and 43 ± 5 min in the basket group (P = .111). There was no significant difference between the stone retropulsion rate (13% vs. 16%, P = .787). The successful one-time stone-free rate was 92% vs. 94% (P = .999) respectively. Furthermore, there was no significant difference in the hospitalization time (P = .581) and postoperative complication rate (P = .715) between 2 groups.

The treatment of upper ureteral calculi with ureteroscopic occluder and stone retrieval basket com- bined with holmium laser lithotripsy can both effectively prevent intraoperative stone retropulsion, improve the success rate of one-time lithotrips. The occluder was more cost-effective than the stone retrieval basket, yet it was a more desired choice for over dilated ureters.

To investigate the safety and efficacy of Minimally Invasive Percutaneous Nephrolithotomy (MPCNL) combined with vacuum-assisted access sheath in the treatment of obstructive calculous pyonephrosis.

Seventy-six patients with obstructive calculous pyonephrosis, who were planned to re- ceive MPCNL, were randomly divided into two groups. Group A was treated with Amplatz sheath combined with Cyberwand double probe ultrasound lithotripsy, and group B was treated with Vacuum-assisted Access Sheath (VAAS, ClearPetra, Well lead Medical) combined with holmium laser lithotripsy. The primary outcome was the operation success rate. Other perioperative, and postoperative data such as operation time, stone free rate and com- plications were compared between groups.

Single 20F access sheath was established in all cases. All patients underwent one-stage procedure. Com- pared with group A, group B had a higher initial stone-free rate (84.2% vs 63.1%, P = .037). The operation time of group B was 56.3 ± 19.83 min, significantly shorter than that of group A at 70.4 ± 14.83 min. The complication rate of B group was 15.8%, which was lower than that of group A (P = .035 ). Five patients (15.8 %) of group B had a postoperative fever (>38.5 ºC) (Clavien grade 2) that required additional antibiotics compared with 8 patients (21.1 %) of group A (P = .361). There was no blood transfusion in group A, and one case in group B required transfusion.

One-stage MPCNL combined with Vacuum-assisted Access Sheath and holmium laser lithotripsy is a simple, safe, effective, and ergonomically practical method for selected patients with obstructive calculous pyonephrosis.

Several studies have compared the short-term outcomes of extraperitoneal robot-assisted laparoscopic radical prostatectomy (EP-RALP) and transperitoneal RALP (TP-RALP). The study was designed to evaluate the long-term outcomes of the two methods.

A prospective, non-randomized study was conceived. The demographics and operative outcomes of patients with prostate cancer undergoing RALP from September 2016 to January 2017 at our center were included.

A total of eighty-six patients were enrolled. Thirty-seven patients underwent EP-RALP, and forty-nine patients received TP-RALP. No significant difference was observed in age, body mass index, pathological T stage, pathological N stage, M stage, 2014 International Society of Urological Pathology group, comorbidities or Amer- ican Society of Anesthesiologists score. A lower preoperative prostate-specific antigen (PSA) was detected in the EP-RALP group. No significant differences were observed in overall operation time, robotic console time, surgical margin status, postoperative hospitalization time, drop of hemoglobin and complications, except that patients with EP-RALP had a shorter time to first exsufflation after surgery than those with TP-RALP (41.35 vs. 51.80 h, P < .001). Postoperative PSA until 12 months was deemed comparable in both groups. Complete continence until 12 months after surgery was desirable but not significantly different between two groups (75.0% in EP- RALP vs. 86.7%. in TP-RALP, P = .179).

The long-term outcomes of EP-RALP were analogous to those of TP-RALP. Therefore, EP-RALP is an alternative approach for patients with localized prostate cancer

To determine disease-related predictors for the occurrence of prostate specific antigen (PSA) failure in Iranian prostate cancer patients who underwent radical prostatectomy.

In this cohort study, we enrolled eligible patients with prostate cancer who underwent radical prostatec- tomy at our center between 2001 and 2018. The primary endpoint was the incidence of postoperative biochemical failure, defined as two consecutive PSA levels ≥ 0.2 ng/dl. Patients with TNM stage ≥ III, Gleason score ≥ 8, or baseline PSA above our calculated cut-off level were considered as high risk. Kaplan–Meier survival method and Cox proportional hazards regression analysis were used for determining the biochemical relapse-free survival and its predictors.

Data of 959 patients (age = 61.2 ± 6.4 years) were analyzed with a median follow up of 36 months (range 6 months to 18 years). A total of 97 patients (10.1%) developed biochemical failure at the time of analysis who had a significantly older age and longer follow-up duration (P = 0.024 and P < 0.001, respectively). Preoperative PSA level of 8.85 mg/dl could predict the occurrence of biochemical failure with a sensitivity of 83.2% and specificity of 39.2% (Area under the curve = 0.601, 95% CI: 0.541-0.662; P = 0.001). In the multivariate analysis, higher pre- operative PSA, Gleason score ≥ 8, and high-risk TNM stage were independent predictors for biochemical relapse (P = 0.029, P = 0.001, and P = 0.008, respectively).

Preoperative PSA, Gleason score, and TNM stage were independent predictors for biochemical fail- ure following radical prostatectomy in prostate cancer patients. We also determined a lower cut-point for PSA that could predict biochemical failure.

Role of pulmonary metastasectomy of renal cell carcinoma (RCC) is significant considering its contri- bution to survival rates. The aim of this study is to present the prognostic factors affecting the surgical outcomes and long-term survival.

Forty-eight patients who had undergone pulmonary metastasectomy of RCC between 2000 and 2018 were analyzed in terms of gender, age, subtypes and pathological T stages of RCC, side and size of pulmonary metastases, disease-free interval (DFI) and type of lung resections in order to reveal the prognostic factors from the stand point of selecting suitable patients for lung metastasectomy.

Overall survival was 56.2 ±21.7 months. Survival time was less than 3 years for 7 (14.6%), between 3 and 5 years for 11 (22.9%) and more than 5 years for 30 (62.5%) patients. Young age, female gender, unilateral pulmonary lesions, longer DFI, lung metastases limited in number and volume were statistically significant for better survival rates (P <.05) whereas subtypes and pathological stage of the primary tumor or the type of pulmo- nary metastasectomy did not act on the outcomes (P >.05).

The most distinctive factor affecting the surgical outcomes is the complete resection of lung metas- tases rather than the extent of the surgery. This study clearly states that patients aged under 50 years with unilat- eral lung metastases counting less than 3 and measuring smaller than 4 cm3 , and also DFI lasting longer than 32 months benefit from pulmonary metastasectomy of RCC.

Germ cell tumors (GCTs) are rare and highly curable malignancies. However, salvage treatments for relapsed or refractory disease are needed in approximately 20-60% of the patients. As salvage therapy, autologous stem cell transplantation (ASCT) administered after high-dose chemotherapy (HDCT) may be a feasible option as well as standard dose chemotherapy (SDCT). This study aimed to evaluate the efficacy and toxicity of ASCT in salvage therapy of GCTs retrospectively.

Male patients older than 18 years of age who underwent ASCT due to a relapsed/refrac- tory GCT were included in the study.

The median age of 18 patients included in the study was 28 (19-46). The majority of patients (n:16, 88.8%) had non-seminomatous GCT histology. All of the patients had relapsed or refractory GCTs and received bleomycin, etoposide, cisplatin (BEP) combination therapy previously. Half of the patients were in the poor risk group. ASCT was administered as a second-line therapy in 14 (77.7%) patients and third-line therapy in four (22.2%) patients. There is no ASCT-related exitus. Febrile neutropenia (FN) developed in almost all patients. Complete response (CR) was obtained in 7 (38.8%) patients, partial response (PR) in four (22.2%) patients after ASCT. The 2-year progression free survival (PFS) was 44.4% and the median PFS was 8.7 (2.7-12.6) months. Median overall survival was 22.7 (3.9-41.7) months and 3 years OS was 50.0%.

In conclusion, ASCT was found to be an effective and safe treatment option in salvage therapy of GCT patients in our study.

Open surgical reimplantation of ureters is a highly successful procedure, with reported correction rates of 95 to 99 percent regardless of the severity of vesicoureteral reflux (VUR). Leadbetter-Politano ureteroneocysto- stomy is one of the most preffered technique for open ureteroneocystostomy. The authors report the modified Poli- tano-Leadbetter technique with extravesical mobilization and transection of the ureter at the level of ureterovesical junction and intravesical reimplantation.

Fifty-seven children with unilateral VUR, underwent modified Leadbetter-Politano ureteral reimplantation with extravesical mobilization and transection of the ureter at the level of ureterovesical junction and intravesical reimplantation. Indications for open reimplantation were, persistence of VUR after en- doscopic correction, breakthrough urinary infections, complications due to antibiotics, progressive renal scarring, and parental preference. Operations were done by two full-time pediatric surgeons. Operation time and hospital stay of the patients, reflux persistency, voiding dysfunction and complications were recorded.

No ipsilateral VUR was detected postoperatively. While mean operation time was 78.42 min (±7.36 min; range, 70-86 min) Mean duration of the hospital stay is 82.31 h (±9.48 h; range, 71-94 h) for classic Leadbet- ter-Politano procedure, mean operation time was 56.54 min (±8.24 min; range, 52-67 min) and mean duration of the hospital stay is 62.31 h (±8.35 h; range, 50-63 h) for modified technique. Postoperative gross hematuria was not seen in any patients. No voiding dysfunction and no late complications was encountered.

Modified Leadbetter-Politano technique is a good option to treat VUR with success rate up to 100% without any major complicatons such as viscus perforation and ureteral obstruction. It is a rather simple technique that require less operative time.

To evaluate the association between inflammation in prostatic tissue/serum sample and BPH-LUTS Patients and

The prostatic tissue and serum sample were collected from 183 patients who underwent transurethral plasmakinetic resection of the prostate (TUPKRP). The association between inflammation detected on prostatic tissues/ serum sample and LUTS related parameters, including International Prostate Symptom Score (IPSS) and peak flow rate (Qmax) were analyzed with SPSS version 13.0, and P-value < 0.05 was chosen as the criterion for statistical significance.

There was a positive association between prostate tissue inflammation and LUTS. The differences of IPSS, VSS and SSS were seen with the increase in grade of prostate tissue inflammation (P < .001; .001; =.014, respectively). Qmax and IPSS 12months after surgery were better in no inflammation group (P = .016; .031). Logistic regression analysis revealed a statistically significant association between the NEUT% NLR and prostate tissue inflammation (P = .010; .004), but ROC curve showed the NEUT%, NEUT, and NLR area under the curve (.526; .452; .513, respectively) were calculated as < 0.600. Patients with Qmax over 7.12 had more WBC count in peripheral blood (7.56 ± 1.77 VS 6.37±1.86, P = .026). The NLR was significantly higher in the group of IPSS over 20 and AUR presence (P = .018; .017). The NEUT%, LYMPH%, LYMPH, and NLR showed a statistical significance in different obstruction classification (P = .047; .046; .028; .014, respectively).

There was a correlation between chronic Inflammation and LUTS related to BPH. The patient with- out inflammation could acquire more sustained and steady relief than those with inflammation in LUTS related to BPH after TUPKRP.

To analyze the predictive factors causing ischemic priapism following penile doppler ultrasonography (PDU) with intracavernosal papaverine injection

Medical records of 467 patients who underwent PDU examination following intracav- ernosal papaverine injection for erectile dysfunction (ED) between 2009 and 2017 were retrospectively reviewed. Patients with hematological disease anamnesis, patients taking phosphodiesterase-5 inhibitor, patients with intra- cavernosal injection therapy anamnesis, and patients who underwent PDU with other intracavernosal vasodilator drugs other than papaverine were excluded from the study. The remaining 268 patients were divided into two groups as priapism (38 patients) and non-priapism (230 patients). The groups were compared in terms of demo- graphic data, American Society of Anesthesiologists (ASA) score, comorbidities, international index of erectile dysfunction (IIEF) score, and PDU results. The significant parameters were analyzed with binary logistic regres- sion analysis. The receiver operating analysis was used to obtain cut-off, sensitivity, and specificity values for the independent predictive factors.

The age, ASA score, diabetes mellitus, IIEF score, duration of ED, peak arterial, and peak end diastolic venous flow values in the 20th minute were significantly different in the two groups (p < 0.001). Binary logistic regression analysis found age, duration of erectile dysfunction, IIEF score, peak arterial flow, and venous flow rate in the 20th minute were predictive variables for the occurrence of priapism.

Young patients, patients with good IIEF score, patients with ED for a short time, and patients with normal peak arterial and venous flows are more prone to developing post-papaverine ischemic priapism.

The present study was designed to compare the efficacy of alfuzosin therapy as an alpha-blocker in met- abolic syndrome (MetS) and non-MetS patients with moderate lower urinary tract symptoms (LUTS).

This prospective-observational study included male patients with obstructive voiding and had a moderate LUTS according to International Prostate Symptom Score (IPSS). Patients were divided into two groups: MetS and Non-MetS. Following the measurement of uroflowmetric parameters (maximum flow rate [Qmax], post-void residual volume [PVR], urine volume) and the determination of IPSS scores, the patients were initiated on alfuzosin 10 mg once daily for a period of 12 weeks. At the end of the therapy, treatment outcomes were determined based on uroflowmetric parameters and IPSS scores.

301 patients were included in the study (MetS: 160, non-MetS: 141). Pre-treatment uroflowmetric meas- urements and IPSS scores were similar in both groups. After the therapy, the median Qmax level increased from 12.80 (10.62-14.82) ml/s to 14.55 (12.00-16.60) ml/s in the MetS group and from 12.60 (8.60-14.60) ml/s to 15.70 (13.20-17.20) ml/s in the non-MetS group (p < 0.001 for both). Similar statistically significant changes were valid for PVR and IPSS. Post-treatment Qmax, PVR values and IPSS scores were higher in the non-MetS patients com- pared to MetS patients.

Although the non-MetS patients had greater benefit from the alfuzosin therapy compared to the MetS patients, alfuzosin is an effective alpha-blocker in the treatment of MetS patients with moderate LUTS. Based on these findings, it is tempting to consider that MetS might be a negative factor for benign prostate hyperplasia treatment.

Laparoscopic pyelolithotomy has recently been introduced for renal stones. However, the use of this technique is limited in patients with a history of extensive abdominal surgeries. We present a case of right side staghorn renal stone with history of abdominal open cystectomy who underwent laparoscopic pyelolithotomy with an uneventful outcome

Traditionally, the standard treatment of bladder-prostate rhabdomyosarcoma (BP-RMS) is total cystoprostatec- tomy and urinary diversion. However, current multimodal treatment approaches emphasize the importance of bladder-sparing surgery. In this case series, we aimed to indicate the results of the laparoscopic bladder-sparing approach of two pediatric patients with BP-RMS. They were admitted to the emergency department due to acute urinary retention (AUR). The tumors located in the prostate causing AUR were detected by Magnetic resonance imaging (MRI) and the pathological diagnosis was confirmed by biopsy. The patients were managed in a prosper- ous manner by implementing laparoscopic surgery with the cause of detection of a significant decrease in the size as well as the enhancement pattern of the tumors following neoadjuvant chemotherapy. No urinary incontinence, tumor recurrence or metastasis was observed at 36 and 28 months follow-up in case 1 and case 2, respectively. Laparoscopic bladder-sparing approaches may have an advantage in patients with BP-RMS to decrease morbidity and mortality related to radical surgery. To our knowledge, these are the first cases of laparoscopic bladder-sparing approach in the treatment of pediatric prostate-derived embryonal RMS (PDERMS).