Journal of Clinical Urology

Emergency ureteric stone treatment with lithotripsy is a key topic in Urology. This study describes the process of change in this unit to develop protocol-led quality care for patients with obstructing ureteric stones.

A retrospective series of 675 consecutive patients undergoing emergency ureteric stone lithotripsy. Treatment data, times from referral to treatment completion and outpatient follow-up by endourologist are analysed. Data are reviewed over a 4-year period while protocol-led care was introduced.

This study demonstrates significant improvement in timely patient management. In 2017, the median time from referral to post-treatment review was 147 days. With the introduction of the protocol-led booking system, the median time from referral to post-treatment review was reduced to 14 days. Improvements in evidence-based shock wave delivery and clinical coding are demonstrated.

This study demonstrates improvement in patient care through timely booking of lithotripsy treatment and follow-up. Barriers to improving care include IT support and changing established practice. Ongoing metrics for emergency ureteric lithotripsy should include the time taken from referral to post-treatment clinical review by an endourologist.

4

This study aims to assess whether the rate of readmissions after ureterorenoscopy (URS) is dependent on results of urine microscopy, culture and sensitivity (MC&S) or nitrite dipstick test performed before the procedure.

All patients attending for ureteroscopy for stone disease over 12 months were included and had urine dipstick performed immediately prior to the surgery with mid-stream urine (MSU) sample sent for culture. Asymptomatic bacteriuria (ABU) was not treated before ureteroscopy. All included patients received standard antibiotic prophylaxis. Readmissions within 30 days of the procedure were evaluated.

A total 120 ureteroscopies were included, of which 20% had ABU. Eight patients (6.67%) were readmitted due to all procedure-related complications; among them, five (4.17%) were readmitted with urinary tract infection (UTI). Readmission rates with UTIs were similar for patients with sterile urine and those who had untreated ABU. Of those patients who were readmitted with UTI, all had a negative nitrite result on preoperative urine dipstick specimens. Most patients (54.17%) who had ABU also had a negative urinary nitrite test.

Screening and routine treatment of ABU before ureteroscopy for urolithiasis may be unnecessary provided patients have standard antibiotic prophylaxis. Moreover, urine nitrite testing before ureteroscopy may not be a useful screening test for ABU before ureteroscopy.

2

To determine if a precise 5-point nerve-spare (NS) scoring system at the time of robot-assisted radical prostatectomy (RARP) correlates with post-operative erectile function recovery (EFR).

From 2014 to 2018, 277 patients underwent RARP by a single surgeon. NS quality was recorded as: grade 1, non-NS; grade 2, <50%; grade 3, 50%; grade 4, 75%; grade 5, ⩾95%. EFR rates were compared using Fisher’s exact test or Pearson’s chi-square test at 3–24 months, grouped based on the degree of NS: 1 = bilateral full NS (grade 5); 2 = bilateral NS with one good NS (⩾grade 4); 3 = unilateral good NS; 4 = incremental NS (grade 3); 5 = partial neurovascular bundle (NVB) resection (grade 2); 6 = complete NVB resection (grade 1).

At 24 months, EFR defined as Sexual Health Inventory for Men (SHIM) score ⩾17 was 75%, 55%, 41%, 23%, 12% and 0% for groups 1–6, respectively (p = 0.001). EFR defined as spontaneous erection sufficient for intercourse with or without PDE5i was 60%, 58%, 40%, 33%, 0% and 11% for groups 1–6, respectively (p < 0.001).

A precise anatomic NS scoring system at RARP allows good prognostication of EFR, which may inform patient counselling and erectile dysfunction management.

4

Bulking agents have been used for decades as an alternative treatment for patients with stress urinary incontinence who are not appropriate for surgery. Despite this their long-term complications are poorly documented and can be misdiagnosed. This paper presents a literature review and the results of a national survey of members of the Section of Female, Neurological and Urodynamic Urology (FNUU) of the British Association of Urological Surgeons (BAUS) identifying the common long-term complications of widely used bulking agents in clinical practice.

Following a comprehensive literature review an electronic survey was sent to members of the BAUS Section of FNUU. Data included hospital trust, use of urethral bulking agents (including type), the approximate number of procedures performed and whether any long-term complications had been observed and managed in their practice. Long-term complications were defined as those arising more than 12 months after treatment.

The literature review revealed multiple case reports of complications secondary to bulking agent injection but no high-level evidence regarding frequency or severity. The survey revealed complications including granulomas, erosions, abscesses and misdiagnoses of urethral diverticula and calculi formation. 88% of urologists who responded to the survey had performed a urethral bulking agent injection and 51% of urologists had observed or treated a long-term complication, some many decades after injection.

Patients should be made aware of possible long-term complications of what appears to be a minimally invasive procedure in order for them to make an informed choice about treatment options.

Not applicable

Robotic radical prostatectomy (RARP) is a well-established treatment for localised prostate adenocarcinoma. The benefits of this minimally invasive technique include shortened operative time and improved patient recovery. However, the development of inguinal hernia (IH) before, during, and following RARP has been reported. The aim of this study is to evaluate the incidence, management, and recurrence of IHs in patients undergoing RARP for prostate cancer.

A literature search was conducted using the PubMed database from August 2007 to October 2020 using the keywords ‘robotic prostatectomy’ and ‘inguinal hernia’. Studies evaluating the incidence and recurrence of IH in patients undergoing RARP were identified and included. The initial search identified 77 articles. After excluding one duplicate, six case reports, three editorial comments, four articles not in English, eight review articles, and 14 studies that did not mention hernia incidence, 41 studies were included in our final literature review.

Concomitant IH repair (IHR) during RARP resulted in decreased symptomatic hernia recurrence during the follow-up period. When compared to patients who had not undergone hernia repair, the patients who underwent IHR during RARP did not experience greater complications in the postoperative period.

Patients that undergo an intraoperative IHR during RARP did not experience significant adverse postoperative complications. Although operative time can slightly increase compared to RARP alone, we recommend a thorough preoperative physical examination in all patients scheduled to undergo RARP to evaluate for IH in addition to a thorough discussion with the patient of the risks and benefits of intraoperative repair.

Not applicable

An 86-year-old male nursing home resident presented with increasing confusion and was initially treated for catheter-associated urinary tract infection. Computed tomography (CT) scan demonstrated complete inguinal bladder hernia with compression of the right vesico-ureteric junction leading to acute obstructive renal failure. Percutaneous nephrostomy was attempted but was not possible due to patient non-compliance. Patient improved with conservative management.

Bladder involvement in inguinal hernia is rare with most cases being identified at the time of hernia repair and there is a 17% risk of intra-operative bladder injury. Key risk factors include increasing age, male gender, lower urinary tract symptoms and previous hernia repair. Percutaneous nephrostomy followed by inguinal hernia repair is the treatment of choice for most patients. This case highlights that inguinal bladder hernia can lead to acute upper urinary tract obstruction even when the bladder is catheterised.

Level of evidence: IV

Due to the extensive use of indwelling stents and catheters in urology, bacterial colonization on these materials is a significant cause of infections in this group of patients. This study aims to investigate and compare the bacterial colonization in urine and in the three zones of the double J (DJ) stent.

Between August 2019 and May 2020, 67 patients (18–78 years old) who underwent DJ stenting were recruited in the study. Surgeries before stenting included transurethral lithotripsy (TUL), percutaneous nephrolithotomy (PCNL), or diagnostic ureteroscopy. Before stenting, sterile urine samples were collected, and urinary cultures were performed, and the same procedure was done after removal of the DJ stents. DJ stent cultures were also performed.

61 patients were analyzed. The mean age of all patients was 53 ± 16 years. The mean time of DJ installation in all patients was 27.6 ± 6.7 days (14–43 days). In these three parts of the DJ, 70.5%, 67.2%, and 72.1% of patients were without a colony, respectively. The microorganism distribution is approximately the same in the lower and upperparts, and Escherichia coli has the highest frequency (11.5%). The odds ratio (OR) of contamination was significantly lower in men than in women, but overweight and diabetes were not associated.

The severity and pattern of bacterial colonization are not significantly different in the proximal, distal, and middle parts of the DJ stent.

A major source of complications in vaginoplasty results from injury to the rectum during dissection of the neovaginal cavity. The SpaceOAR™ System is a rectal hydrogel spacer mostly used as a safety technique during prostate cancer treatment.

This was a feasibility study performed in a single cadaveric perineum.Methods: Prior to standard cavity dissection, SpaceOAR was injected transperineally into the Denonvilliers’ fascia under guidance of transrectal ultrasound. Dissection of the neovaginal cavity with spacer gel was qualitatively assessed to be significantly easier, allowing for a blunt and quick approach.

A satisfactory vaginal length was achieved rapidly and safely.

We show that transgender vaginoplasty using this adaptation of SpaceOAR is technically feasible in the cadaveric model and may reduce the incidence of rectal injury or rectovaginal fistula during neovaginal cavity creation. Future experimental endeavours should focus on the reproducibility of this approach and characterise the degree of rectal protection provided.

Not applicable

To date, the number of prostate cancer ranked first among newly diagnosed malignant tumors in men from multiple countries. Localized prostate cancer could be controlled by curative therapy. However, for patients with metastatic prostate cancer (mPC), the prognosis is poor. As among first-line treatments of systemic therapies for mPC, docetaxel and androgen receptor (AR)-targeted therapies have been widely used. However, mPC patients inevitably developed resistance to the current therapy. More importantly, there is a cross-resistance between docetaxel-based chemotherapy and AR-targeting therapy during the treatment process, which could impair the overall survival benefits without proper administration.

Therefore, it is urgent to elucidate the mechanism of cross-resistance and explore the optimal sequential strategy.

Here, in this review, we systematically reviewed and summarised the updated literature on clinical evidence and mechanistic research of treatment resistance in mPC.

Emerging evidence indicated that AR splice variants, AR overexpression or mutations, AR nuclear translocation, as well as AR signaling reactivation collectively contributed to the cross-resistance. With the current understanding of cross-resistance, multiple solutions are promising for improving the benefits, including refining the sequencing of available therapies for mPC, in combination with potential targeted inhibitors or immune checkpoint inhibitors. Further studies are needed to explore the combination of emerging strategies and eventually control the progression of prostate cancer.

This review defined the mutual and unique resistant mechanism of these treatments, which might help to focus and accelerate therapeutic research that may ultimately improve clinical outcomes for patients with prostate cancer.

Not applicable

To evaluate current first-line treatment strategies in advanced or metastatic renal cell carcinoma (RCC), and to review other promising treatments under investigations.

We reviewed all relevant pivotal first-line systemic therapy trials, and studies investigating the role of cytoreductive nephrectomy, metastectomy, and ablative radiotherapy in advanced or metastatic RCC.

In total we identified 21 relevant studies, investigating both systemic and non-systemic therapies, including treatments under investigations.

Metastatic RCC (mRCC) is a highly heterogeneous disease that is notoriously difficult to treat, however, the discovery of novel targeted therapies over the past decade have revolutionised its management. The International mRCC Database Consortium (IMDC) is a prognostic model that is commonly used in both clinical trials and routine clinical care to risk-stratify patients with mRCC, which has helped with therapy selection for mRCC patients over the past decade. However, with an improved understanding of tumour biology and genetics, this has prompted a shift from cytokine therapy to receptor tyrosine kinase inhibitors, and now to Immune Checkpoint Inhibitors (ICIs). Recent promising results from clinical studies with ICI combination treatments have transformed the treatment landscape for the management of intermediate- and poor- risk clear cell RCC, however, further research is still needed for favourable-risk, and non-clear cell patients.

Not applicable

To deliver a case report showing that robotic pyeloplasty in a patient with a horseshoe kidney is not only successful but also potentially superior to laparoscopic surgery. To the best of our knowledge, this is the first case report of its kind in the United Kingdom.

PubMed was used to do a literature search. We have excluded papers that were written in foreign languages, or were paediatric case studies.

Horseshoe kidneys are the commonest congenital abnormality of the renal and are often associated with pelvic-ureteric junction obstruction (PUJO) – in the order of 30%. Minimally invasive surgery is the gold standard for management of PUJO. With the advancement of the Da Vinci robot, this case report presents a patient undergoing pyeloplasty in a horseshoe kidney with PUJO on the left side, using a robotic technique. We performed a robotic pyeloplasty on a 32-year-old woman, with a horseshoe kidney. We felt this is a case worth discussion, giving the alteration in the surgical technique in conjunction with the anatomical abnormalities, and the lack of similar reported cases in the literature. We propose that in some cases, the robotic operative technique is superior to standard laparoscopic technique. Although there is an increased cost when using the Da Vinci robot, this may be offset by the 3D visualisation, enhanced dexterity, tremor filtering and movement scaling, increased range of motion, as well as the reduction of operative time, hospital stay, blood loss, complications, and indeed patient satisfaction. In addition to the benefits of robotic surgery itself, we demonstrate that robotic surgery in this particular case was preferable to other techniques, given the anatomical exclusivity of a horseshoe kidney.

We propose that in some cases, the robotic operative technique is superior to other minimal access techniques in urological surgery.

Level of Evidence: 4

Onco-microsurgical testicular sperm extraction (Onco-microTESE) allows the microsurgical extraction of testicular sperm from the unaffected regions of the tumour-bearing testis at the time of radical orchidectomy. We report the case of a 36-year-old hypogonadotropic male with a testicular tumour and non-obstructive azoospermia.

A left radical orchidectomy was performed with simultaneous onco-microTESE. Although some sperm were found during the procedure, these were unsuitable for cryopreservation due to abnormal morphology. Given his low testosterone level (4.1 nmol/L), contralateral surgical sperm retrieval at the same sitting was not performed. Histology of the affected testicle demonstrated a classical seminoma and ‘Sertoli cell only’ appearance. He was subsequently started on clomiphene citrate.

After 9 months of clomiphene citrate, repeat semen analysis showed a total of 2.8 million sperm (1 million/mL), with 80% motility. Four vials of semen were cryopreserved, and this ejaculated sperm was used for in vitro-fertilisation (IVF) with intracytoplasmic sperm injection (ICSI). All six harvested eggs were fertilised. By day 5, there were two top grade blastocysts available, one of which was transferred and another frozen. After 9 months, the couple welcomed the birth of a healthy male infant.

To our knowledge, this case is the first to demonstrate the benefit of clomiphene citrate in a patient with testis cancer resulting in a reversal of azoospermia and a subsequent live birth with assisted conception.

Not applicable

To report on the outcomes and demographics of azoospermic couples undergoing microscopic testicular sperm extraction (micro-TESE) in a large tertiary referral centre.

A retrospective study of patients undergoing micro-TESE in a tertiary referral centre from March 2015 to August 2019 was undertaken. Histopathology, patient demographics, comorbidities, patient factors and live birth outcomes were evaluated.

A total of 102 micro-TESEs were performed with a sperm retrieval rate (SRR) of 30.3%. The successful group had a mean age of 32.7 years and a mean body mass index (BMI) of 26.8 kg/m². Female partners in the successful group had a mean age of 32.2 years. Twenty percent of female partners had infertility factors, 86.7% had no previous pregnancy and 13.3% had a previous miscarriage. The successful group had 15 live births (50%), while 20% had frozen their sperm. 93.3% achieved live birth from single embryo transfer and currently have unutilised embryos in cryostorage to possibly create siblings in the future. Twenty percent had more than one live birth from a single micro-TESE. Sertoli cell-only syndrome (SCOS) was identified in 57.5% of all cases. This was bilateral in 80% of these cases (four cases only sampled unilaterally due to previous orchidectomies). Of the SCOS group, six men went on to have successful sperm extraction (10%). The presence of previous urologic history/surgery increased the risk of azoospermia by 13%.

Men with previous urological conditions have an increased risk of azoospermia. SCOS was identified in 57.5% of cases making it the most common histopathological diagnosis in azoospermic men. Based on our cohort, micro-TESE offers potential sperm retrieval in azoospermic men with SCOS. Successful sperm extraction in patients was associated with 50% live births and appeared to be unaffected by the presence of male/female factors. The number of live births could be higher as 20% had frozen their sperm. Concurrent female issues did not appear to affect successful outcome after micro-TESE, although numbers are small.

Not applicable