Soc. Int. Urol. J., Volume 5, Issue 1 (February 2024) – 13 articles

Introduction: Percutaneous nephrolithotomy (PCNL) is the standard procedure for treating large kidney stones, especially those measuring over 20 mm or staghorn stones. Accurate placement of the tract into the renal collecting system of interest is crucial. Objective: To compare the free-hand puncture technique with robotic-assisted puncture during fluoroscopy-guided PCNL on a phantom kidney model in terms of efficiency and safety. A self-assessment of confidence levels after each puncture was recorded. Study Design: This prospective single-center benchtop study was conducted at the University Malaya Medical Centre (UMMC). Four urological residents participated and performed phantom punctures using both the free-hand bull’s eye technique and the automated needle targeting system with X-ray (ANT-X). Each resident performed a total of 60 punctures on the renal phantom models, with 30 punctures using the free-hand technique and 30 punctures using the ANT-X robotic-assisted system. Results: A total of 240 needle insertions were conducted, with 120 in the ANT-X group and 120 in the free-hand group. The success rate of needle insertions was 100% in both groups. However, the study revealed that the ANT-X group required, on average, an additional 51 s for needle puncture compared to the free-hand group (p < 0.001). In terms of fluoroscopic exposure, the ANT-X group exhibited significantly lower radiation exposure compared to the free-hand group (p < 0.001). Sub-analysis showed that puncture time remained consistent regardless of the technique used, but fluoroscopic screening time decreased with increasing participant experience. The ANT-X group also resulted in significantly lower radiation exposure during initial sessions compared to the free-hand technique. Surgeons’ self-assessment of confidence levels indicated a high level of confidence in needle puncture. Conclusions: Our benchtop study comparing the efficacy and safety between free-hand and ANT-X phantom punctures revealed comparable results. The needle puncture technique facilitated by the ANT-X system showed promising results in terms of reducing fluoroscopic exposure, albeit at the cost of longer operative times. This technology holds promise for novice surgeons who are in the early stages of their learning curve and might be useful for experienced surgeons looking to reduce radiation exposure. Full article

Background: A number of assessment methods for the pelvic floor have been described. Male pelvic floor ultrasound is an accessible, noninvasive assessment tool. Objective: To evaluate current published literature on anatomical parameters on pre- and postoperative ultrasound imaging of the male pelvic floor and correlation with continence status following radical prostatectomy (RP). Methods: A comprehensive literature search was conducted using the PRISMA guidelines to identify publications up to November 2022. Exclusion criteria consisted of animal studies, non-English articles, case reports, reviews and abstracts or reports from conferences. A full-text review was performed on 12 papers using ultrasound to assess pelvic floor anatomy and correlation with continence status following RP. Results: A total of 18 anatomical parameters were evaluated using US. Membranous urethral length (MUL), striated urethral sphincter (SUS) morphology and activation were most commonly studied. Shorter pre- and postoperative MUL, decreased preoperative SUS thickness and vascularity, postoperative discontinuity of SUS muscle fibres and decreased SUS activation are associated with post-prostatectomy incontinence (PPI). There is a paucity of data comparing anatomical changes in men prior to and following RP. The benefits of transperineal ultrasound are that it is minimally invasive, accessible, provides dynamic imaging of all three striated muscle complexes simultaneously and includes a bony landmark to reference measures of pelvic floor muscle displacement. Conclusions: Ultrasound evaluation of the male pelvic floor is an evolving field as there is development in technology and understanding of pelvic floor anatomy. It is an accessible and dynamic imaging modality, which allows both morphological and functional assessment of pelvic floor anatomy and its role in PPI. MUL and SUS morphology and activation are associated with continence status following RP. Several other anatomical parameters that may predict PPI were identified. Current literature is limited by small, single-centre studies with heterogeneous cohorts and methodologies. Full article

Background: To evaluate the safety, efficacy, feasibility, stone-free rate, and complications of bilateral tubeless supine mini-percutaneous nephrolithotomy (M-PCNL) for bilateral multiple renal calculi with renal failure as a single-stage procedure. Materials and Methods: We conducted a retrospective study from January 2020 to March 2022 in adult patients with bilateral renal or proximal ureteric calculi with renal failure who were subjected to bilateral supine tubeless M-PCNL. Patients on regular hemodialysis before the procedure were excluded. Data regarding the demographic profile, stone characteristics on non-contrast computed tomography (NCCT), duration of surgery, complications, and auxiliary procedures were retrieved from clinical records. Residual stone fragments of≤4mm in NCCT were considered clinically insignificant. The Clinical Research Office of the Endourological Society validation ofClavien score for PCNL complications was used. Results: A total of twenty-seven patients with a mean age of 45.9years were included in this study. The mean size of stone diameter per renal unit was 2.4 ± 0.4 cm. The mean preoperative serum creatinine was 2.8 mg/dL. A total of 62 tracts and 27 sessions were required for complete treatment of all 54 renal units in the 27 successfully treated patients. The average operating time was 75 (52–122) min on both sides. Serum creatinine drop at onemonth postsurgery was statistically significant (p < 0.0001). Mean hospitalization time was 3.6 days [3–6 days]. The primary stone-free rate was 92.5%. Grade I, II, and IVA complications were recorded in three (11.1%), eight (29.6%), and two (7.4%) patients, respectively. Conclusion: Bilateral tubeless supine M-PCNL for bilateral renal calculi in selective patients with renal failure in a single session is a safe, feasible, and effective option which can be carried out without increased morbidity and can be attempted if the first-side M-PCNL has gone smoothly within a reasonable amount of time. Full article

Highlighting the restricted access to andrology medical devices in Arab Muslim countries, where unjust associations with sexual instruments lead to prohibitions, this commentary underscores the challenges in providing appropriate medical care for andrological conditions. Despite the crucial role of devices like penile extenders, vacuum devices, and vibrators in treating conditions such as Peyronie’s disease and erectile dysfunction, cultural and religious biases condemn them in certain regions. This lack of understanding deprives many patients of andrological treatments, limiting therapeutic options and equitable healthcare access. The commentary advocates for urology societies to raise awareness, engage policymakers, and use media to distinguish these devices from sex toys, emphasizing their medical nature for the benefit of patients. Full article

Background: Radical cystectomy is a complex procedure imposing significant post-operation complications. Objective: Explore the impact of peri-operative pRBC transfusion on mortality and overall morbidity in a matched cohort. Methods: The American College of Surgeons—National Surgical Quality Improvement Program’s (ACS-NSQIP) dataset was used to select patients who underwent RC in 2008–2019. Patients who witnessed pre-operative transfusion and emergency cases were excluded. Peri-operative pRBC transfusion was defined as an intra-operative or up to 24-h post-operative pRBC transfusion. We matched patients who underwent peri-operative pRBC transfusion to patients who did not receive transfusion. Length of stay, mortality, and overall morbidity were compared between the two matched cohorts. Results: The match cohort was matched on all pre-operative demographics and medical history variables and yielded 3578 matched patients. Patients who underwent peri-operative pRBC transfusion had a longer length of hospital stay (9.3 days) as compared to patients who did not undergo transfusion (8.13 days) (p < 0.001). Furthermore, patients who underwent transfusion also had higher odds of mortality (OR = 1.934) and overall morbidity (OR = 1.443) (p < 0.03). Specifically, patients who underwent transfusion had higher odds of organ space SSI, pneumonia, unplanned intubation, pulmonary embolism, failure to wean off of ventilator, renal insufficiency, urinary tract infections, stroke, myocardial infarction, cardiac arrest requiring CPR, deep vein thrombosis, and septic shock (p < 0.047). Conclusion: Peri-operative pRBC transfusion in RC was associated with longer hospital stays, significant morbidity, and mortality. For this reason, pre-operative patient optimization and possible alternatives to common pRBC practices should be considered in RC to circumvent complications. Full article

Objectives: It has been shown that concomitant autologous blood and dextranomer/hyaluronic acid (Deflux^®) injection, hydrodistension autologous blood injection technique (HABIT), had a better mound preservation and treatment success compared to the hydrodistension injection technique (HIT) in vesicoureteral reflux (VUR) correction. In this study, we aimed to show microscopically whether the concomitant injection of autologous blood decreases the leakage of Deflux^® particles. Methods: Children with VUR who underwent HIT or HABIT between March 2020 and January 2023 were enrolled. Following the completion of the procedure on each ureter, the bladder was irrigated for 3 to 5 min, and the retrieved sample of irrigation fluid was evaluated for dextranomer particle count as “immediate leakage”. A Foley catheter was placed, and a urine sample after 12 h was collected as “early leakage”. Results: A total of 86 children with a median age of 3.0 years (interquartile range = 4.6) were included. Overall, 66 patients underwent HABIT, and 20 children underwent HIT. Rupture was observed in five patients during the procedure, and re-injection was conducted successfully in these cases. Immediate, early, and total particle leakage in the first 12 h of the injection were significantly less in the HABIT group compared to the HIT group. In the regression analysis, only the injection technique (HIT/HABIT) and rupture were significantly associated with the total particle leakage in the first 12 h. Conclusions: Immediate injection of autologous blood into the mound following an endoscopic correction of VUR in children is associated with significantly less Deflux^® particle leakage from the injection site regardless of the VUR grade. We hypothesize that a concomitant blood injection into the Deflux^® mound will create a blood clot while the needle is kept in situ and help to stabilize the mound and decrease treatment failure by minimizing particle leakage from the injection site. Full article

Introduction: Urological cancers account for a significant portion of cancer diagnoses and mortality rates worldwide. The traditional treatment options of surgery and chemoradiation can have significant morbidity and become ineffective in refractory disease. The discovery of the CRISPR system has opened up new avenues for cancer research by targeting specific genes or mutations that play a role in cancer development and progression. In this review, we summarise the current state of research on CRISPR in urology and discuss its potential for improving the diagnosis and treatment of urological cancers. Methods: A comprehensive literature search was conducted on databases including PubMed, Embase, and Cochrane Library. The keywords included CRISPR and urology OR prostate OR renal OR bladder OR testicular cancer. Results: CRISPR has been used extensively in a preclinical setting to identify and target genes in prostate cancer, including AR, NANOG, ERβ, TP53, PTEN, and PD-1. Targeting PRRX2 and PTEN has also been shown to overcome enzalutamide and docetaxel resistance in vitro. In bladder cancer, CBP, p300, hTERT, lncRNA SNGH3, SMAD7e, and FOXA1 have been targeted, with HNRNPU knockout demonstrating tumour inhibition, increased apoptosis and enhanced cisplatin sensitivity both in vitro and in vivo. Renal cancer has seen CRISPR target VHL, TWIST1, PTEN, and CD70, with the first in-human clinical trial of Anti-CD70 CAR T cell therapy showing an excellent safety profile and durable oncological results. Lastly, testicular cancer modelling has utilised CRISPR to knockout FLNA, ASH2L, HMGB4, CD24, and VIRMA, with NAE1 found to be over-expressed in cisplatin-resistant germ cell colonies. Conclusions: CRISPR is a cutting-edge technology that has been used extensively in the pre-clinical setting to identify new genetic targets, enhance drug sensitivity, and inhibit cancer progression in animal models. Although CAR T cell therapy has shown promising results in RCC, CRISPR-based therapeutics are far from mainstream, with further studies needed across all urological malignancies. Full article

Objectives and Methods: Penile fractures are a urologic emergency involving the rupture of the tunica albuginea of the corpora cavernosum. Geography is known to impact fracture aetiology, and higher impact aetiology is thought to predispose patients to complex trauma. To review long-term urinary and sexual outcomes following fracture repair in Australia, a retrospective analysis of data from three metropolitan hospital services over 10 years was performed. Only patients with intraoperatively confirmed fractures were included. Patients were contacted by clinicians to complete a survey, which utilised validated questionnaires, including the International Index of Erectile Function-5 (IIEF-5) and the International Prostate Symptom Score (IPSS). Perioperative data were analysed against survey responses. Results: We identified 55 confirmed penile fractures. Twenty-one patients completed questionnaire follow-ups, comprising the study cohort. The median age at the time of the injury was 44.8 years (range: 25–65). The median time from injury to questionnaire completion was 4.0 years (range: 1–10). Furthermore, 95.5% (20) of the injuries occurred during sexual intercourse. The median IIEF-5 score was 23 (range: 5–25); the median IPSS score was 5 (range: 0–22). Seven patients (33.3%) sustained a bilateral cavernosal injury, and eight (38.1%) sustained a urethral injury. Upon conducting a Mann–Whitney U test, no significant relationships were found between bilateral cavernosal injury and IIEF-5 scores (p = 0.7377) or urethral injury and IPSS scores (p = 0.5338). Conclusions: The Australian aetiology of penile fractures appears consistent with that of other Western countries, with subsequent high rates of bilateral cavernosal and urethral injuries. The long-term erectile and urinary function outcomes observed are promising. A larger prospective study would further illuminate the relationship between injury factors and outcomes, revealing information not presented herein due to study limitations relating to the cohort size and follow-up rates. Full article