Société Internationale d’Urologie Journal

Objective: Transperineal prostate (TP) biopsy is the key diagnostic tool for evaluating prostate cancer and is feasible under local anaesthetic (LA) alone. However, concerns about its tolerability encourage use of a multimodal analgesia approach. Pre-emptive over-the-counter analgesia with LA may provide a simple and low-risk option. The objective of this study was to investigate the effects of over-the-counter analgesia on TP biopsies conducted under LA. Methods: This interventional single-centre study investigated 160 participants who undertook a TP biopsy under LA, with and without pre-emptive analgesia (1 g of paracetamol and 400 mg of ibuprofen). Pain tolerability was measured using a visual analogue scale (VAS) at three procedural points (probe insertion, LA infiltration, and biopsy); an overall average VAS score was subsequently calculated. The abstracted secondary variables include patient details (age, prostate size, and PSA level), biopsy details (number of cores and volume of LA used), and preferability for LA use in future TP biopsies. An inferential statistical analysis was performed using Wilcoxon’s Rank Sum non-parametric test, Pearson’s test of correlation, and Pearson’s Chi-squared test. Results: The groups were comparable in age, prostate size, and PSA level. Median VAS scores were consistently lower in the intervention cohort, but without statistical significance. A higher volume of LA was associated with lower overall VAS (p = 0.03). LA was strongly preferred over GA for hypothetical future TP biopsies in both cohorts. Conclusions: Pre-emptive analgesia does not significantly improve tolerability of TP biopsy under LA. Our study substantiates evidence that TP biopsy is generally well tolerated under LA and preferred over GA. Full article

Objectives: Large language models such as ChatGPT have been used to generate text in a conversational manner, and may be of use in providing patient information in a urological setting. This study evaluated the accuracy, presence of omissions, and preferability of traditional patient information to the large language models ChatGPT and Bing Chat. Methods: Eight common questions regarding urolithiasis and prostate cancer were selected from traditional patient information and posed to ChatGPT and Bing Chat. Responses from all sources were then evaluated by seven urologists in a blinded fashion for accuracy, omissions, and preferability. Results: We found that 96.43% of ratings of traditional patient information sources were rated accurate, compared to 94.6% for ChatGPT and Bing Chat; 7.1% of ratings of traditional patient information were rated as containing harmful omissions, compared to 10.71% for ChatGPT and 21.4% for Bing Chat; and 55.4% of rater first preferences were given to ChatGPT, compared to 35.7% for traditional patient information and 8.9% for Bing Chat. Conclusions: ChatGPT provided responses of a similar accuracy and preferability to traditional sources, highlighting its potential as a supplementary tool for urological patient information. However, concerns remain regarding omissions and complexity in model-generated responses. Full article

Aim: To assess the efficacy and safety of aspiration and sclerotherapy for the management of hydroceles in an ambulatory regional setting. Methods: A retrospective analysis was performed on all men who underwent aspiration and sclerotherapy for the management of symptomatic hydroceles at a single regional Australian centre from 1 January 2006 to 31 December 2023. All procedures were carried out in an ambulant setting under local anaesthetic and sodium tetradecyl sulphate (STD) as the sclerosing agent. Results: 291 men were included in the study with a median follow-up of 99 days. Resolution of hydrocele both clinically and symptomatically post initial aspiration and sclerotherapy was 58.8% (171/291). The average time to recurrence for men who failed initial management was 167 days (IQR 28–112 days). Following initial aspiration and sclerotherapy, 67.7% (63/93) of men with recurrence chose to have a repeat aspiration and sclerotherapy of these men, and 68.3% (43/63) had resolution of their hydroceles. Hence, after two aspiration and sclerotherapy interventions, 73.5% (214/291) of men had clinical and symptomatic resolution of their hydroceles. The median age of participants was 62.3 years (IQR 52.1–70.8). The median initial aspirated volume was 150 mL (IQR 100–250 mL), and the injected volume was 10 mL (IQR 8–10 mL). Notably, the median aspirated volume decreased for men with a recurrence to 100 mL (IQR 63.8–143.8 mL), and an injected volume of 0 ml (IQR 0–4.8 mL). The overall complication rate was 3.4% (10/291), of which all but one was managed conservatively. Conclusion: Aspiration and sclerotherapy with STD represent a minimally invasive, safe and effective treatment for hydroceles that can be utilized in the regional and ambulatory settings under local anaesthetic, potentially reducing wait times for interventions and improving patient flow for public hospital waitlists. Full article

Introduction: The integration of laser technology in urologic interventions, especially ureteral lithotripsy, has greatly advanced the field, with laser lithotripsy becoming the preferred method for treating ureteric stones via ureteroscopy. Recent advancements focus on enhancing power settings and reducing operating times, introducing high-power laser equipment capable of frequencies up to 120 Hz. However, concerns arise regarding thermal injuries to adjacent tissues due to increased energy delivery, potentially causing ureteric strictures. Objective: To explore temperature dynamics during ureteroscopic laser lithotripsy, considering factors like laser power settings and ureteroscope size, to optimize outcomes and mitigate risks for patients. Methods: A simulated in vitro model for ureteroscopic laser lithotripsy was designed with a holmium laser. Measurements of the temperature were recorded using a thermocouple placed at the laser tip at different sizes of ureteroscope (URS 6.0 Fr and URS 7.0 Fr), holmium laser (272 µm and 365 µm), various power settings (5 to 25 Hz; 0.2 to 3.0 J) and activation durations (3 to 30 s). Analysis of the variables associated with temperature change was performed. Results: All of the variables showed rising temperature trends as the laser activation time was prolonged, while ureteroscope size had no significant impact. Smaller laser fibers exhibited lower overall temperature profiles, around 34–35 °C. Notably, power settings significantly influenced temperature, with a substantial rise at 20 W (42.62 °C) and 30 W (40.02 °C). There was a significant rise in temperature as power (J × Hz) increased, where frequency carries a higher effect than energy at the same power setting. Conclusions: The recommendation includes exercising caution with higher power levels, shorter activation times, and preferably using small-caliber laser fibers to maintain lower temperatures. Full article

Background: Benign prostatic hyperplasia (BPH) is a frequent condition in ageing men. Surgery is recommended for severe BPH symptoms and BPH-related complications. TURP is the reference standard for BPH surgery, but carries a risk of bleeding, which can lead to significant perioperative morbidity and mortality. To reduce bleeding during TURP, antifibrinolytic agents like tranexamic acid (TXA) have been studied. We aim to review the current evidence regarding TXA use during transurethral BPH surgery. Objective: This review aims to assess the efficacy and safety of tranexamic acid in reducing bleeding during transurethral benign prostatic hyperplasia surgery. Methods: Major clinical research databases such as PubMed, Cochrane Central Register of Controlled Trials, EBSCO, Scopus, Google Scholar, and Web of Science were searched from 2012 to 2022 for randomised controlled trials (RCTs) comparing the use of TXA to placebo in transurethral BPH surgery using the PICOS format. We included RCTs without language restrictions that assessed intraoperative blood loss, transfusion rates, haemoglobin levels, length of hospital stay, postoperative thromboembolic events, and 30-day perioperative mortality as outcomes. The quality assessment of the included studies was performed using the Cochrane risk-of-bias tool, RoB 2, for randomised studies. Results: A total of six RCTs, which included 456 patients, were eventually included in the meta-analysis. The results showed that tranexamic acid is beneficial in reducing blood loss and minimising changes in haemoglobin levels during transurethral resection of the prostate. However, it does not lessen the need for blood transfusions or shorten the hospital stay. Conclusions: Tranexamic acid is useful in decreasing blood loss and reducing changes in haemoglobin in patients undergoing transurethral resection of the prostate. Its utility during BPH surgery in low-resource settings where the latest haemostatic enucleation techniques, such as holmium and GreenLight laser enucleation, may not be readily available needs further evaluation. Full article

Background: Across the world, many populations have limited access to urology care resulting in local general surgeons performing emergency urology procedures. This systematic review aims to evaluate the nature and outcomes of emergency urological surgeries performed by general surgeons. Methods: A systematic review was undertaken according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines with MEDLINE, Embase, Web of Science, and Google Scholar searched from inception to June 2024 for studies where general surgeons performed emergent urological surgery. We excluded studies on paediatric urology, acute scrotum, and Fournier’s gangrene. The Downs and Black checklist was used to assess risk of bias. Results: From 2093 initial results, six studies were included after screening. Two studies were from Australia, two from the United States of America, and one each from India and South Africa. For 977 emergency urological interventions, general surgeons (n = 486) and urologists (n = 491) each performed approximately half of the surgeries. Mortality rates for general surgeon-performed urology ranged from 0 to 8.0%. One study compared outcomes between the two surgical specialties, showing no significant difference for mortality or complication rates. No follow-up data was reported. The most performed procedures by general surgeons were traumatic bladder repair, ureteric stent insertion, and percutaneous nephrostomy. Conclusions: General surgeons perform a wide spectrum of emergency urological surgery when needed. Targeted training and utilisation of general surgeons could improve patient access to emergency urological surgery. Full article

Background: Nephrolithiasis, or kidney stone disease, presents a significant global health burden, with global incidence rates and treatment practices varying widely. This study aims to discuss the epidemiology, risk factors, treatment modalities, and challenges for nephrolithiasis in the lower half of the World Bank rankings; that is, in low- and lower-middle-income countries. Methods: A comprehensive literature review was conducted using PubMed for each country on the list, focusing on studies published from January 2000 onwards and reporting data on prevalence, risk factors, treatment practices, and economic implications. Results: Nephrolithiasis represents a significant burden for healthcare systems, with noteworthy geographical variability in prevalence possibly dependent on socioeconomic status and gender. Risk factors include dietary habits, climate, pollution, and infectious diseases. Treatment practices in some regions still rely on open surgery due to limited access to advanced endourological techniques, while other regions demonstrate high proactivity in research. The burden is exacerbated by inadequate healthcare infrastructure and training. Conclusions: Addressing nephrolithiasis in challenging economic circumstances requires targeted interventions, including improved access to modern treatment methods, enhanced training for healthcare professionals, and better socioeconomic and environmental conditions. Future research should focus on region-specific strategies and the development of sustainable healthcare solutions. Full article

Kidney transplantation (KT) is a preferred treatment for end-stage renal disease (ESRD) because it offers better long-term survival and cost-effectiveness compared to dialysis. Significant global disparities persist in access to KT, particularly in low- and middle-income countries (LMICs). This study aims to assess the epidemiology and outcomes of KT in LMICs while examining the relationship between a country’s income level and its KT prevalence. A systematic review of the literature was conducted, with searches of PubMed, Scopus, and Web of Science from inception to 31 May 2024. Relevant articles reporting on the epidemiology and outcomes of KT or ESRD patients undergoing kidney replacement therapy (KRT) in LMICs were included. A total of 8054 articles were identified, with 972 articles selected for full-text screening after initial title and abstract review. Following full-text screening, 35 articles met the inclusion criteria. The data showed significant variation in KRT and KT prevalence across different geographical locations. Higher-income countries within LMICs tended to have higher KT prevalence rates. Barriers such as inadequate healthcare infrastructure, limited financial resources, and insufficient organ donation frameworks were identified as contributing factors to the low KT rates in these regions. The study highlights the disparities in KT access and prevalence in LMICs, underscoring the need for targeted interventions and international collaboration to address these gaps. Efforts to increase both living and deceased donor transplants, expand health system capacity, and incorporate KT in healthcare planning are needed to close this gap. Global partnerships spearheaded by organizations such as The Transplantation Society (TTS) and the International Society of Nephrology (ISN) are crucial for improving KT rates and outcomes in LMICs. Full article

Introduction: Urological conditions significantly impact global health, with increasing demand for urologists in both developed and developing countries. Disparities in access to surgical care between high-income countries (HICs) and low- and middle-income countries (LMICs) are evident. Despite advancements in urology, LMIC training programs often follow outdated curricula and traditional methods. Methodology: A comprehensive search strategy identified urology training programs in LMICs using the EduRank website, Google searches, and PubMed. Data were collected from the literature, official documents, and online resources, focusing on variables such as program duration, research requirements, and resident salaries. Results: The analysis revealed significant variability in program structures and requirements across LMICs. Residency training durations ranged from 4 to 6 years, with inconsistent research obligations and resident salaries averaging USD 12,857 annually, with a range from USD 5412 to USD 18,174. Fellowship opportunities were limited, with only a small number of programs achieving international accreditation. Conclusions: This study reveals disparities among urology training programs in LMICs, emphasizing the challenges faced by LMICs in providing comprehensive education. Outdated curricula, limited faculty, and insufficient resources contribute to the variability in training quality within LMICs. To bridge these gaps, there is a pressing need for standardized and locally tailored educational frameworks. Future research should focus on direct comparisons with programs in HICs to develop strategies that improve training opportunities and ensure equitable access to advanced urological education and care worldwide. Full article

Despite the considerable global burden of urologic malignancies, Low- and middle-income countries (LMICs) often encounter significant challenges in caring for patients with urologic malignancies. Several interrelated factors impact cancer care in LMICs, which face significant challenges that hinder effective diagnosis, treatment, and management of disease. Socioeconomic and healthcare infrastructure limitations are fundamental issues leading to the disparity observed in cancer care across the globe. This review aims to evaluate the challenges and disparities in access to comprehensive urologic care in LMICs, emphasizing the impact of such global disparities on incidence rates, timely diagnoses, and access to comprehensive care as it relates to prostate, kidney, and bladder cancers. Full article

Background: Benign prostatic hyperplasia (BPH) is the leading cause of lower urinary tract symptoms (LUTSs) in men, with a histological prevalence that increases significantly with age. While extensive research on BPH has been conducted in high-income countries (HICs), limited information exists regarding its burden in low- and middle-income countries (LMICs), especially in Sub-Saharan Africa (SSA). Understanding the prevalence, impact on quality of life, and management practices in these regions is crucial for developing effective healthcare policies and improving patient outcomes. Objectives: This scoping review aims to collate the existing literature on the burden of BPH in LMICs, focusing on prevalence rates, quality-of-life impact, and management practices. The goal is to provide a comprehensive overview that informs healthcare strategies in resource-constrained settings. Methods: A scoping review methodology was employed, following the framework proposed by Arksey and O’Malley. The review encompassed five stages: identifying the research question, identifying relevant studies, study selection, charting the data, and collating, summarizing, and reporting the results. A comprehensive search of electronic databases, including Google Scholar, PubMed, Scopus, and Embase, was conducted using specific search terms related to BPH and LMICs. The inclusion criteria were studies conducted in LMICs (limited to SSA); reporting on the prevalence, impact, or management of BPH; and published in English. Results: The review included studies that reported the wide-ranging prevalence rates of BPH in LMICs, highlighting significant regional variations. The impact of BPH on quality of life was profound, with many men experiencing significant bother and reduced daily functioning due to LUTSs. The management practices in these regions often differed from those in HICs, with limited access to pharmacological treatments and surgical interventions. The economic burden of BPH in LMICs was also notable, with many patients facing financial barriers to accessing effective care. Conclusions: BPH poses a significant health and economic burden in LMICs, particularly in SSA. The prevalence of the condition is high, and its impact on quality of life is substantial. There is an urgent need for improved diagnostic and management strategies tailored to the resources available in these settings. Policymakers should consider integrating BPH management into broader healthcare initiatives to enhance patient outcomes and reduce the overall burden of the disease. Full article

All 189 World Bank member countries are classified by their capita gross national income into one of four income groups. In this review, we aim to explore the economic burden and management of urologic oncology conditions in low- and middle-income countries (LMICs), emphasizing disparities and challenges in treatment access. The current World Bank classification system highlights economic stratification, showing significant health outcome disparities, particularly in urologic oncology conditions including kidney, bladder, and prostate cancer. First, this review focuses on the management of advanced prostate cancer in Asian LMICs, revealing higher mortality-to-incidence ratios and a greater prevalence of metastatic disease compared to high-income countries (HICs). The prohibitive costs of novel hormonal therapies (NHTs) like abiraterone and enzalutamide limit their use and exacerbate outcome disparities. Second, we review Wilms tumor treatment with chemotherapy in African countries, noting significant price variations for adapted and non-adapted regimens across different economic settings. The cost of chemotherapy agents, particularly dactinomycin, acts as a primary driver of treatment expenses, underscoring the economic challenges in providing high-quality care. Lastly, bladder cancer treatment costs in Brazil and Middle Eastern countries are examined, highlighting how detrimental the economic burden of intravesical therapies, like mitomycin C and Bacillus Calmette–Guérin (BCG), is on treatment accessibility. Overall, this literature review emphasizes the financial strain on healthcare systems and patients, particularly in regions facing economic instability and drug shortages, and underscores the need for international cooperation and effective resource allocation to address the economic barriers to urologic care in LMICs, aiming to improve health outcomes and ensure equitable access to advanced treatments. Full article

We performed a literature review to identify articles regarding the state of urological cancers in low-to-middle-income countries (LMICs). The challenges that LMICs face are multifactorial and can include poor health education, inadequate screening, as well as limited access to treatment options and trained urologists. Many of the gold standard treatments in high-income countries (HICs) are scarce in LMICs due to their poor socioeconomic status, leading to an advanced stage of disease at diagnosis and, ultimately, a higher mortality rate. These standards of care are vital components of oncological disease management; however, the current and sparse literature available from LMICs indicates that there are many obstacles delaying early diagnosis and management options in LMICs. In the era of evolving medical diagnosis and treatments, sufficient data must be gathered and understood in order to provide appropriate diagnostic and treatment options to curtail rising mortality rates and, therefore, help to alleviate the burden in LMICs. Full article