Soc. Int. Urol. J., Volume 5, Issue 2 (April 2024) – 11 articles

Objectives: To determine if early (three months) and late (one year) post-operative continence is improved by performing a novel retropubic vascularised fascial sling (RoboSling) procedure concurrently with robot-assisted radical prostatectomy in men undergoing treatment for localised prostate cancer. To additionally assess surgical outcomes, quality of life and health economic outcomes in patients undergoing the novel RoboSling technique. Methods: This study aims to recruit 120 consecutive patients with clinically localised prostate cancer who have chosen to undergo robot-assisted radical prostatectomy in the Sydney Local Health District, Australia. A prospective assessment of early and late post-operative continence following robot-assisted radical prostatectomy with and without a RoboSling procedure will be performed in a two-group, 1:1, parallel, randomized controlled trial. Four surgeons will take part in the study, all of whom are beyond their learning curve. Patients will be blinded as to whether the RoboSling procedure is performed for them, as will be the research officers collecting the post-operative data on urinary function. Trial Registration: ACTRN12618002058257. Results: The trial is currently underway. Conclusions: The RoboSling technique is unique in that the sling is vascularised and has a broad surface area compared to previously described slings in the literature. If a clinically significant improvement in post-operative continence is established with the RoboSling, then, we can in turn expect improvements in quality of life for men undergoing this technique with radical prostatectomy. Full article

Background: Signet ring cell adenocarcinoma (SRCC) of the bladder is a rare and aggressive histological subtype of bladder cancer. Due to its infrequency, the understanding of its clinical behaviour, treatment strategies, and outcomes remains limited, being primarily derived from isolated case reports and series. Objective: To systematically review and analyse the available literature on SRCC of the bladder, emphasizing its clinical characteristics, diagnostic approaches, treatment modalities, and outcomes. Material and Methods: A comprehensive search was conducted across PubMed, Embase, and Medline following the PRISMA guidelines, including case reports, case series, observational studies, and clinical trials reporting on bladder SRCC. Results: We included 38 articles reporting on 77 patients, primarily males (79.2%), with a median age of 64 years. The most common presenting symptoms were haematuria (64.8%) and lower urinary tract symptoms (46.3%). All the diagnoses were based on histopathological examination of bladder tissue samples and immunohistochemistry. Mixed histological types of bladder cancer were found in 20.7% of cases, most commonly urothelial carcinoma (61.1%). The treatments varied, with 53.2% of patients undergoing radical cystectomy, 24.7% receiving radiotherapy, and 16.9% receiving chemotherapy. The five-year survival rates were 9.4%. Conclusion: Bladder SRCC presents aggressively, with varied treatment strategies; however, radical cystectomy appears to be the optimal means of surgical management for organ-confined disease. The overall survival rate is low, highlighting the need for further research to understand and manage this rare bladder cancer variant. All patients should undergo evaluation to exclude extravesical primaries. This systematic review contributes to a better understanding of this disease and may guide clinical management strategies. Full article

Objectives: Few studies have examined the role of prostate MRI in patients with suspicious digital rectal examination (DRE) and/or PSA > 10 ng/mL. In a cohort of non-screened patients with suspicious DRE, we investigated the rate of avoidable prostate biopsies and potentially missed clinically significant prostate cancer (csPCa) with negative MRI, and the concordance between targeted biopsy (TBx) and systematic biopsy (SBx) in detecting csPCa with positive MRI. Methods: We retrospectively examined 199 biopsy-naïve patients with suspicious DRE who underwent prostate MRI before transperineal biopsy. Prostate Imaging—Reporting and Data System (PI-RADS) v2.1 ≥ 3 category of the index lesion defined a positive MRI. Combined TBx/SBx and SBx alone were performed for positive and negative MRI, respectively. An International Society of Urogenital Pathology Grade Group ≥ 2 defined csPCa. We calculated the csPCa detection rate of TBx, SBx, and combined TBx/SBx. The Cohen kappa statistic was used to measure the concordance between TBx and SBx. Results: Ninety-one (45.7%) csPCa cases were detected. MRI was positive in 153 (76.9%) patients. In the 46 patients with negative MRI, SBx detected 5 (10.9%) csPCa cases. Prostate biopsy could, thus, be avoided in 41/199 (20.6%) patients at the cost of missing 5/91 (5.5%) csPCa cases. The concordance between TBx and SBx in detecting csPCa with positive mpMRI was substantial (k = 0.70). Specifically, 6/86 (6.9%) csPCa cases were detected with TBx, and 17/86 (19.7%) with SBx alone. Concordance was almost perfect (k = 0.82) in patients with PSA > 10 ng/mL. Only 4/38 (10.5%) csPCa cases were missed by TBx, and only 1 (2.6%) csPCa case was identified by TBx alone. Conclusions: MRI in patients with suspicious DRE could avoid roughly 21% of unnecessary biopsies at the cost of missing approximately 6% of csPCa cases. Moreover, MRI and TBx complemented SBx in detecting csPCa in the subgroup with PSA > 10 ng/mL. Full article

Objectives: Our objective was to assess the rate of complications and gastrointestinal adverse effects of rectal spacer insertion for salvage post prostatectomy radiation therapy. Methods: A retrospective observational study was performed. Between September 2018 and March 2022, 64 post-radical prostatectomy patients who were planned for salvage radiation therapy received a rectal spacer. The selected patients were those who had nerve-sparing prostatectomy with intrafascial or interfascial dissections (where Denonvillier’s fascia is retained). Radiation dose to the rectal wall and gastrointestinal symptoms were assessed. Symptoms were graded using the National Cancer Center Institute Common Terminology Criteria for Adverse Events v4.0 grading scheme. A total of 39 patients had pre-spacer planning computer tomography (CT) scans, and the rectal dose before and after the spacer insertion was calculated. Comparisons were made using the Student’s t-test, with a p-value < 0.05 representing statistical significance. Finally, clinicians were surveyed to rate the ease of the procedure using a 5-point Likert scale of 1 to 5 (1: very difficult, 2: difficult, 3: moderate, 4: easy, 5: very easy). Results: A total of 64 patients successfully underwent rectal spacer insertion. The mean age was 64.4 years (standard deviation: 5.7 years). After a median of 14 months’ (range 6 to 35) follow up, acute grade 1 and above gastrointestinal (GI) toxicities were seen in 28% of patients (grade 2 in 1.5%), and late grade 1 and above GI toxicities were seen in 12% of patients (grade 2 in 1.5%). Amongst the 39 patients with pre-spacer planning CT images, the volume of the rectum receiving 60%, 70%, 80%, 90%, and 100% of the prescribed radiation dose was reduced by 25.9%, 34.2%, 35.4%, 43.7%, and 61.7%, respectively. All dose reductions were statistically significant. The procedure was rated as “easy” or “very easy” to perform in 56% of cases. Conclusions: The insertion of a rectal spacer in selected patients undergoing PPRT is feasible and safe and significantly improves rectal wall radiation dosimetry in salvage post prostatectomy radiation therapy. It was accomplished in >95% of patients, increasing vesico-rectal separation from ‘immediate vicinity’ to 11 mm without any post-operative complications in experienced hands. In addition, it achieved significant reduction in rectal radiation doses, leading to low rates of acute and late grade 2 toxicity. Full article

Urinary tract infections (UTIs) are highly prevalent and have significant implications for patients. As internet-based health information becomes more relied upon, ChatGPT has emerged as a potential source of healthcare advice. In this study, ChatGPT-3.5 was subjected to 16 patient-like UTI queries, with its responses evaluated by a panel of urologists. ChatGPT can address general UTI questions and exhibits some reasoning capacity in specific contexts. Nevertheless, it lacks source verification, occasionally overlooks vital information, and struggles with contextual clinical advice. ChatGPT holds promise as a supplementary tool in the urologist’s toolkit, demanding further refinement and validation for optimal integration. Full article

Metallic prostate stapling (e.g., UroLift) is a minimally invasive treatment option for men with bladder outlet obstruction from benign prostatic hyperplasia (BPH). While it provides rapid relief and preserves sexual function, unexpected interactions with other medical devices can compromise surgical procedures. In this letter, we highlight five cases where stapled metallic implants resulted in damage to bipolar energy device during transurethral resection of the prostate (TURP) and stimulation of obturator nerve. Laser may also reflect off metallic prostate implants which can result in laser equipment malfunction. Monopolar TURP should be considered in patients with existing metallic prostate implants who need further transurethral surgery for obstructive BPH to prevent bipolar instrument damage and obturator kick. Full article

Electronic cigarette use is rising globally. Although it may represent a potential smoking cessation tool, amidst misinformation and social media promotion, there is a growing concern regarding the health risks associated with its usage. These risks include adverse effects on the genitourinary system. This commentary investigates the genitourinary effects of approved smoking cessation tools versus electronic cigarettes, urging urologists to prioritize established methods over electronic cigarettes due to their potential for multisystem toxicity and uncertain long-term health implications. Further research is warranted to evaluate comprehensively the genitourinary effects of these interventions. Full article

There are many causes of ST-elevation on electrocardiogram (ECG). ECG changes in the setting of intra-abdominal pathology is a rare and under characterised and includes the “spiked helmet sign”. We report a rare case of the “spiked helmet sign” that presented with ST-elevation in the precordial leads due to post-operative ileus. Full article

Objectives: Proximal and distal bulbar urethral strictures (BUS) have different disease characteristics and require different treatment strategies despite being regarded as a single condition. To clarify the differences, we analyzed our database by distinguishing the two types of BUS. Methods: We retrospectively reviewed the data of 196 patients with BUS who underwent urethroplasty at the National Defense Medical College (Japan) between August 2004 and March 2022. We divided patients into proximal (group 1) or distal (group 2) groups based on the stricture segment and compared patient background and surgical techniques for each group. We assessed whether the stricture segment was an independent predictive factor for substitution urethroplasty selection using multivariate logistic regression analysis. The recurrence rates were calculated and compared using the Kaplan–Meier method and log-rank test, respectively. Results: Patients in group 1 had a less frequent non-obliterated lumen (73% vs. 94%, p = 0.020) and significantly shorter strictures (10 mm vs. 23 mm, p < 0.001) more frequently caused by external traumas (47% vs. 26%, p = 0.010) than those in group 2. Logistic regression analysis revealed that the stricture segment (distal) (p < 0.001), stricture length (≥20 mm) (p < 0.001), ≥2 prior transurethral procedures (p = 0.030), and a non-obliterated lumen (p = 0.020) were independent predictive factors for substitution urethroplasty. However, the recurrence rate (p = 0.18) did not significantly differ between the two groups. Conclusions: Proximal and distal BUS have substantially different anatomical characteristics and etiologies and require different reconstructive techniques. Full article