Journal of Clinical Urology

Training in holmium-laser enucleation of the prostate (HoLEP) is not ubiquitous in urological training programmes. We sought to investigate whether those who learn HoLEP at trainee (resident) level have similar outcomes to those who learn at consultant level.

Consecutive patients undergoing HoLEP by mentorship-trained consultant surgeons and a trainee surgeon were compared to a control group of cases performed by an experienced HoLEP surgeon. Specimen weight, length of stay (LOS), stress incontinence outcomes and complication rate data were collected retrospectively for 30 HoLEP cases by each surgeon. All patients underwent follow-up after 3–6 months. Data were then compared between groups to assess for any differences in outcomes.

Specimen weight and prostate volume were greater (p < 0.001) in the control group but were similar between learners. There was no difference between rates of stress urinary incontinence (p = 0.928), complications (p = 0.561) or LOS (p = 0.124) between groups.

Our data show comparable outcomes, regardless of the stage at which the surgeon trained in HoLEP. This demonstrates that learning as a trainee or a consultant is equally safe and effective, supporting the concept of HoLEP training starting from a more junior level.

This retrospective comparison study is level 4 evidence

One of the major pathophysiology linked to male infertility is oxidative stress. Due to its antioxidant properties, micronutrient supplementation has been shown to lower oxidative stress in critically ill patients. Recent meta-analysis revealed the significance of micronutrients, but no long-term fertility outcomes were reported in the study.

This study investigates the role of micronutrient supplementation in improving semen quality, hormonal parameters, and fertility outcomes in male with infertility.

Databases include PubMed, Cochrane, Scopus, ProQuest, and MEDLINE followed by citation searching until August 2024. The risk of bias was assessed using the Cochrane Risk-of-Bias Tool 2 (RoB2) and the ROBINS-I tool for intervention studies. Data synthesis was carried out using R Studio software.

A total of 35 studies were included for analysis. Semen volume was lower in patients receiving vitamin E (MD −0.27 mL, 95% CI −0.49, −0.04; p = 0.02). A combination consisting of L-carnitine, L-arginine, coenzyme Q10, and zinc was associated with higher sperm count (MD 9.44 mil, 95% CI 1.30, 17.59; p = 0.02). Folic acid was associated with higher sperm count (MD 4.27 mil, 95% CI 2.61, 5.93; p < 0.01). No significant difference was seen in sperm concentration, sperm vitality, proportion of sperm with normal morphology, sperm total motility, DNA fragmentation, hormonal parameters (i.e. Follicle-Stimulating Hormone (FSH), Luteinizing Hormone (LH), testosterone), and fertility outcomes between micronutrients and control groups.

Micronutrient supplementation using antioxidants (i.e. L-carnitine, L-arginine, coenzyme Q10), vitamins, and folic acid may improve sperm parameters in males with infertility.

Level 1 and 2

The global incidence of urolithiasis has doubled over the past four decades, potentially exacerbated by climate change. Fetuin-A (alpha-2-Heremans-Schmid glycoprotein) is a novel biomarker known for inhibiting calcification and is linked to chronic kidney disease and metabolic syndrome. This study aims to evaluate the association between fetuin-A levels and urolithiasis.

A systematic search of MEDLINE, ScienceDirect, ProQuest, EBSCO, Google Scholar, and Cochrane Library was conducted for case-control studies comparing fetuin-A levels in urolithiasis patients versus controls. Study quality was assessed using the JBI Critical Appraisal tool. Meta-analysis was performed with RevMan and JASP.

Seven case-control studies comprising 395 urolithiasis patients and 282 controls (total n = 677) were included. Urinary fetuin-A levels were significantly lower in urolithiasis patients (SMD = -2.24, 95% CI: -4.24 to -0.23, p = 0.029, I² = 98%). Six studies also reported a trend of reduced serum fetuin-A levels.

Fetuin-A may serve as a potential predictive biomarker for urolithiasis, particularly in recurrent cases. Significant urinary differences and serum trends warrant further research to clarify its diagnostic and prognostic value.

Not applicable

This study aimed to develop a behavioural modification programme for overactive bladder (OAB) facilitated by support staff and evaluate the effects on symptom improvement and patient satisfaction.

A standardised protocol for OAB education was developed, which support staff facilitated over 14 days. Pre- and post-education questionnaires, including the International Consultation on Incontinence Questionnaire Short Form (ICIQ-SF), Overactive Bladder Quality of Life Short Form (OAB-q SF), Perceived Stress Scale (PSS), and satisfaction scores, were administered.

Twenty-five out of 49 consecutive female patients completed the education programme with a median age of 73 years (range: 20–90). Compared to the baseline, the post-programme ICIQ-SF total score showed a significant decrease (p = 0.036), the OAB-q SF bother score decreased (p = 0.023), and the OAB-q SF health-related quality of life score increased (p = 0.030). PSS scores remained the same (p = 0.42). The median satisfaction score was ‘satisfied’, and symptom improvement was reported as ‘somewhat improved’.

This coaching programme, delivered by support staff, significantly improved patients’ OAB symptom severity and perceived quality of life. Patients were satisfied with the programme, even though perceived stressors remained the same. Personalised patient education is critical to patients’ satisfaction.

Level 3

This study aimed to determine whether postoperative cystography findings have predictive value for very early (1 day after catheter removal) functional outcomes following radical prostatectomy.

We retrospectively reviewed 221 patients who underwent robot-assisted radical prostatectomy (RARP) and open retropubic radical prostatectomy (ORRP) for prostate cancer at a single institution. Postoperative cystography was routinely performed 4 days after RARP and 7 days after ORRP. A ratio known as the bladder neck to pubic symphysis (BNPS) ratio was calculated. Very early continence rates were determined using a standardised pad test, and the associations between these variables were examined.

An increase in the BNPS ratio was associated with a significant decrease in the odds of being continent (p = 0.0003). Other variables, including bladder capacity, having undergone a nerve-sparing procedure, procedure type, and patient age, were not statistically significant. The model accurately classified 87.78% of cases.

These findings suggest that the BNPS ratio is an important factor in determining postoperative continence, with higher ratios significantly associated with an increased risk of incontinence. They may help in better stratifying patients and reducing the need for longer and more resource-intensive follow-up.

Level 3

Radical prostatectomy (RP) is an established treatment option for (d’Amico) high-risk prostate cancer (HRPC) as part of multimodal therapy. We aimed to find out the prostate cancer-specific survival (PCSS) and biochemical recurrence-free survival (BCRFS) after RP in HRPC patients.

We analysed retrospectively the pre-operative staging, histopathology, follow-up data and subsequent additional treatment of all patients who had RP from 2007 to 2017. The PCSS and BCRFS of HRPC were analysed using the Kaplan–Meier survival analysis curve.

A total of 497 patients had RP in the study period of which 217 were HRPC patients. Positive surgical margin, extracapsular extension, seminal vesicle involvement, lymph node involvement and International society of uro-pathology Gleason’s grade group (ISUP GGG) ⩾3 cancer were 34.1%, 52.9%, 15.2%, 5.5% and 47.5%, respectively. Median follow-up was 82.5 months (13–178 months). Fifteen patients (6.9%) had upfront adjuvant radiotherapy. Seventy-eight patients (35.9%) had biochemical recurrence (BCR) at median follow-up of 24 months (3–120 months). Salvage radiotherapy and hormone-only therapy were offered to 57 (73.0%) and 4 (5.1%) patients, respectively, whereas 17 patients (21.7%) were under observation. A total of 76 patients (35.0%) required multimodal therapy. At 10 years, PCSS and BCRFS were 92% and 55%, respectively. Both biopsy GGG (p = 0.003) and post-operative GGG (p = 0.002) as well as seminal vesical involvement (p < 0.001) were significantly associated with BCR.

RP in HRPC offers favourable long-term oncological outcome with acceptable peri-operative and delayed complications. Patients must be counselled about the requirement of multimodal therapy. Gleason’s score and seminal vesical (SV) involvement are strong predictors of BCR.

Patients with obstructive uropathy frequently require haemodialysis prior to undergoing deobstructive surgical procedures. However, there are limited data on the necessity of preoperative dialysis and its impact on clinical outcomes. This study aims to evaluate the role of dialysis before deobstructive procedures and its influence on postoperative outcomes.

This retrospective observational study included all patients who underwent deobstruction procedures between January 2017 and September 2022 and had renal failure (serum creatinine > 4 mg/dL). A comparator group included patients undergoing deobstruction procedures with either serum creatinine > 3 times baseline, > 4 mg/dL, or anuric for more than 12 hours, but who did not require dialysis. The primary outcome assessed was renal recovery, and secondary outcomes included (1) incidence of acute left ventricular failure, (2) presence of hyperkalaemia (serum potassium > 6 mEq/L) and metabolic acidosis (serum bicarbonate < 18 mEq/L) postprocedure, (3) type of anaesthesia used (general, spinal, or local), (4) intraoperative bleeding > 500 mL or need for packed cell volume (PCV) transfusion within 1 week postprocedure, and (5) duration of hospitalisation following the procedure.

The need for dialysis prior to deobstruction procedures was primarily determined by the presence of chronic kidney disease, hyperkalaemia, and uremic symptoms. Patients who did not undergo dialysis had a higher risk of perioperative bleeding. Local anaesthesia was more commonly used in patients who required dialysis. Importantly, preoperative dialysis did not significantly influence renal recovery following the procedure.

Not applicable

To report our experience of transperineal needle biopsy of the prostate under transperineal ultrasound guidance in patients with no rectum.

Six patients with previous surgical removal of rectum were managed at our centre between December 2021 and July 2023. An initial magnetic resonance imaging (MRI) of the prostate was performed to identify target areas. Patients were placed in the lithotomy position. Local anaesthetic was injected into the skin and deep close to the prostate neurovascular bundle using transperineal ultrasound guidance. A transabdominal curvilinear ultrasound probe was used to locate the prostate. A Co-axial needle was used to pass the biopsy needle through the skin into the prostate to take multiple biopsies using a saturation Ginsburg protocol.

Prostate cancer was diagnosed in three of the six patients (50%). All patients had clinically significant prostate cancer, i.e. Grade group ≥ 2. The median recorded pain score was 1 (range 0–4). A total of 92 cores were taken from six patients included. Only five of them had no prostate tissue in it. No short-term complications were noted on a median follow-up of 17.6 months (7–28 months).

Prostate biopsy in patients with previous abdominoperineal resection of the rectum is feasible using a percutaneous ultrasound-guided freehand approach via the perineum with acceptable diagnostic yield. The procedure can be performed under local anaesthetic instead of other reported techniques which require a general anaesthetic.

Not applicable

Intra-detrusor botulinum toxin (IDBT) injection is a proven treatment for detrusor overactivity (DO) but carries a low risk of transient urinary retention. Despite this, hospitals invest in educating patients on clean intermittent self-catheterization (CISC). This study examines whether pre-IDBT CISC education is necessary.

In this retrospective cohort study, 67 patients underwent IDBT over 9 months. All received CISC education from a Clinical Nurse Specialist (CNS) and a follow-up phone consultation 2 weeks later. The primary outcome was new or increased CISC needs post-IDBT, with secondary outcomes assessing the cost of CISC education, and factors associated with CISC requirement.

The study included 67 patients, 9 (13.4%) developed a new or increased need for CISC following IDBT. Subgroup analysis of five patients with sustained CISC needs showed males and those with idiopathic detrusor overactivity (IDO) were at significantly higher risk. In addition, CISC naivety and lower IDBT doses strongly correlated with urinary retention in this subgroup. Educating patients on CISC required €3240.82 and 52 hours of CNS time.

Prioritising CISC education for these high-risk groups, particularly males with IDO, could effectively address up to 90% of patients developing sustained CISC needs, optimising resource allocation and reducing unnecessary costs.

This study is comprised of Level 2b evidence as per the Oxford Centre for Evidence-based Medicine Levels of Evidence (March 2009).

Targeted prostate biopsies using magnetic resonance imaging (MRI) have gained prominence for early detection. We compared cognitive fusion biopsy, the most practical of these biopsy methods, with systematic prostate biopsy performed under transrectal ultrasonography (TRUS).

Between August 2021 and August 2022, 81 patients who had never undergone prostate biopsy or surgery, with total prostate-specific antigen (PSA) levels between 4 and 20 ng/mL, and had lesions scoring 3 or above on the Prostate Imaging Reporting and Data System (PIRADS) on multiparametric MRI (Mp-MRI), were included in the study. Of these patients, 39 underwent standard TRUS-guided systematic prostate biopsy, while 42 underwent cognitive fusion biopsy (systematic + targeted).

The ages, PSA levels, and prostate volumes of the patients included in the study were compared, and no significant differences were found between the groups. The prostate cancer detection rate was 41% in the systematic biopsy group and 52.4% in the cognitive fusion biopsy group, but this difference was not statistically significant (p = 0.306). The detection rate of clinically significant prostate cancer was 25% in the systematic biopsy group and 63.6% in the cognitive fusion biopsy group, with this difference being statistically significant (p = 0.019). In the cognitive fusion biopsy group, 36.4% of patients with malignant biopsy results had no tumour at the targeted site, while 63.6% had tumours detected at the targeted site (p = 0.286).

Cognitive fusion biopsy was found to be superior to standard TRUS-guided systematic prostate biopsy in diagnosing clinically significant prostate cancer. However, there was no difference between the two biopsy techniques in overall prostate cancer detection.

Not applicable

A standardised specific investigation protocol for the investigation of visible haematuria (VH) remains a debate. Our department was highlighted as a high user of computer tomography urogram (CTU) screening for VH in our region. A departmental audit identified 73% of VH referrals received a CTU between May and October 2018. A 4-year follow-up review of this cohort revealed no increase in missed cancers. Therefore, a selective approach for CTU screening was subsequently adopted based on patient risk factors of age, smoking status and persistent unexplained VH. We present a post-intervention study, performed to identify the impact of the selective approach on cancer detection rates.

Retrospective case-note review of all 2-week-wait referrals for VH from December 2022–June 2023. Data collection included the investigations utilised and the incidence of cancer detection.

In total, 360 patients (257 men, 103 women; median age 75 years, 45% smokers) underwent investigation for VH. 46% received a CTU compared to 73% pre-intervention. Cancer detection rates post-selective investigation remained consistent (18% bladder cancer, 1.4% renal cancer, 1.1% upper tract urothelial cancer) with pre-intervention rates and comparable to the literature.

A selective approach to investigation with CTU in patients with VH appears safe and effective with no reduction in cancer detection rates.

2c

To determine whether ureteral stent placement versus ureteral rest for pre-operative management of ureteropelvic junction obstruction (UPJO) prior to robotic pyeloplasty affects peri-operative or post-operative outcomes.

Patients undergoing robotic pyeloplasty for symptomatic UPJO at a single academic centre from 2009 to 2021 were retrospectively reviewed. Patients were grouped based on placement of ureteral stent for UPJO prior to robotic pyeloplasty. Patient demographics and characteristics were gathered. Univariate, multivariate, and Kaplan–Meier analyses were performed.

192 patients were analysed. There were no differences in pre-operative demographics or characteristics between groups. There were significant differences in operative time (227 vs 210 minutes, p < 0.0001) and frequency of ureteral fibrosis requiring ureterolysis (13.6% vs 8.8%, p = 0.0025) between groups. There was no significant difference (p = 0.1342) in pyeloplasty success when stratified by pre-operative ureteral stent placement.

Robotic pyeloplasty for UPJO can be performed safely and with similar outcomes following pre-operative ureteral stent placement compared to percutaneous nephrostomy tube (PCN) or no stent. Patients should not be limited to the traditional practice of PCN placement for management of UPJO prior to pyeloplasty when a stent or nephrostomy is required before pyeloplasty.

Cohort study.