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51.  Reliability of pelvic floor muscle strength assessment in healthy continent women 
BMC Urology  2015;15:29.
The aim of this study was to compare pelvic floor muscle (PFM) strength using transvaginal digital palpation in healthy continent women in different age groups, and to compare the inter- and intra-rater reliability of examiners performing anterior and posterior vaginal assessments.
We prospectively studied 150 healthy multiparous women. They were distributed into four different groups, according to age range: G1 (n = 37), 30–40 years-old; G2 (n = 39), 41–50 years-old; G3 (n = 39), 51–60 years-old; and G4 (n = 35), older than 60 years-old. PFM strength was evaluated using transvaginal digital palpation in the anterior and posterior areas, by 3 different examiners, and graded using a 5-point Amaro’s scale.
There was no statistical difference among the different age ranges, for each grade of PFM strength. There was good intra-rater concordance between anterior and posterior PFM assessment, being 64.7%, 63.3%, and 66.7% for examiners A, B, and C, respectively. The intra-rater concordance level was good for each examiner. However, the inter-rater reliability for two examiners varied from moderate to good.
Age has no effect on PFM strength profiles, in multiparous continent women. There is good concordance between anterior and posterior vaginal PFM strength assessments, but only moderate to good inter-rater reliability of the measurements between two examiners.
PMCID: PMC4397693  PMID: 25888237
Gynecological examination; Parity; Pelvic floor; Urinary Incontinence; Reproducibility of results
52.  Association between self-perception period of lower urinary tract symptoms and International Prostate Symptom Score: a propensity score matching study 
BMC Urology  2015;15:30.
Most studies focusing on progression of BPH have been limited to the relationship between age and BPH progression, and only few studies have focused on the time duration to start treatment. This study aimed to investigate the association between self-perception period (S-PP) of lower urinary tract symptoms (LUTS) and International Prostate Symptom Score (IPSS).
This study used data from two large-population surveys: a community-based survey and a university hospital outpatient-based interview survey. Both surveys were conducted in male subjects aged 40 years or older who gave consent to the survey questionnaire and voluntarily expressed their intention to participate. Propensity score matching (PSM) was used to organize the population in both surveys into randomized groups to reduce selection bias. After excluding those who had missing values, 483 subjects were assigned to each group by PSM.
The S-PP of LUTS became significantly longer as the severity of LUTS increased. The S-PP was 4.15 years in the mild group, 4.36 years in the moderate group, and 6.23 years in the severe group. These differences were statistically significant. The correlation between S-PP of LUTS and IPSS was measured by partial correlation while controlling for age (correlation coefficient = 0.20, p <0.001). Multiple regression analysis after controlling for age revealed that one-year increase in the S-PP of LUTS significantly (p <0.001) increased IPSS by 0.322 points.
This study clarified the association between S-PP of LUTS and IPSS in a large-scale population. These findings suggest that, from the perspective of public health, S-PP is an important risk factor for LUTS progression.
PMCID: PMC4403909  PMID: 25886732
Lower urinary tract symptoms; Prostatic hyperplasia; Self-concept
53.  The ProCaSP study: quality of life outcomes of prostate cancer patients after radiotherapy or radical prostatectomy in a cohort study 
BMC Urology  2015;15:28.
This study describes and compares health-related quality of life (HRQOL) of prostate cancer patients who received either radical prostatectomy (nerve-sparing, nsRP, or non-nerve-sparing, nnsRP) or radiotherapy (external RT, brachytherapy, or both combined) for treatment of localised prostate cancer.
The prospective, multicenter cohort study included 529 patients. Questionnaires included the IIEF, QLQ-C30, and PORPUS-P. Data were collected before (baseline), three, six, twelve, and twenty-four months after treatment. Differences between groups’ baseline characteristics were assessed; changes over time were analysed with generalised estimating equations (GEE). Missing values were treated with multiple imputation. Further, scores at baseline and end of follow-up were compared to German reference data.
The typical time trend was a decrease of average HRQOL three months after treatment followed by (partial) recovery. RP patients experienced considerable impairment in sexual functioning. The covariate-adjusted GEE identified a significant - but not clinically relevant - treatment effect for diarrhoea (b = 7.0 for RT, p = 0.006) and PORPUS-P (b = 2.3 for nsRP, b = 2.2 for RT, p = 0.045) compared to the reference nnsRP. Most of the HRQOL scores were comparable to German norm values.
Findings from previous research were reproduced in a specific setting of a patient cohort in the German health care system. According to the principle of evidence-based medicine, this strengthens the messages regarding treatment in prostate cancer and its impacts on patients’ health-related quality of life. After adjustment for baseline HRQOL and other covariates, RT patients reported increased symptoms of diarrhoea, and nnsRP patients decreased prostate-specific HRQOL. RP patients experienced considerable impairment in sexual functioning. These differences should be taken into account by physicians when choosing the best therapy for a patient.
Electronic supplementary material
The online version of this article (doi:10.1186/s12894-015-0025-6) contains supplementary material, which is available to authorized users.
PMCID: PMC4404598  PMID: 25885890
Prostatic neoplasms; Radiotherapy; Prostatectomy; Quality of life; Cohort study
54.  Risk factors for biochemical recurrence after robotic assisted radical prostatectomy: a single surgeon experience 
BMC Urology  2015;15:27.
Radical prostatectomy is a standard surgical treatment of clinically localized prostate cancer. Margin status has been found to be an independent predictor of biochemical recurrence (BCR) after open radical prostatectomy in several large series but this is still controversy in Robotic Assisted Radical Prostatectomy (RARP) series. We therefore wanted to investigate the prognostic significance of positive surgical margin (PSM) and other pathological factors on BCR in patients treated with RARP by a single surgeon.
Prospectively collected data of 439 patients treated with RARP between October 2005 and June 2013 by a single surgeon at a single institution were analyzed. BCR was defined as follow-up PSA level > 0.2 ng/ml on two separate occasions or patients who had to undergo salvage therapy. Kaplan Meier curves and Log Rank test were used to compare the risk of BCR. Univariate and Multivariate Cox Regression analyses were performed to determine the prognostic impact of age, BMI, prostate weight, PSA prior to surgery, pathological T-stage, pathological Gleason sum, PSM and operative period.
In this study period, 34 out of 439 had BCR, giving an overall BCR rate of 7.7% for this cohort. Overall 2- and 3-year BCR-free survival rates were 93% and 88%, respectively. Patients with a PSM had a 2-year BCR free survival of 88% compared to 94% in those with negative margins (p < .0001). On the multivariate analysis, PSM as well as pathological Gleason sum > = 8, PSA, pathological stage and operative period were significantly associated with BCR.
In our case series of RARP performed by a single surgeon, PSM as well as pathological Gleason sum, PSA, pathological stage and early operative period for this surgeon were the independent predictors of BCR.
Electronic supplementary material
The online version of this article (doi:10.1186/s12894-015-0024-7) contains supplementary material, which is available to authorized users.
PMCID: PMC4391671  PMID: 25879548
Biochemical recurrence; Biochemical recurrence free survival; Cox regression analysis; Positive surgical margin; Robotic assisted radical prostatectomy
55.  Electrical stimulation of somatic afferent nerves in the foot increases bladder capacity in neurogenic bladder patients after sigmoid cystoplasty 
BMC Urology  2015;15:26.
A previous study showed that foot stimulation can delay the bladder filling sensation and increase bladder volume in healthy humans without OAB. The aim of this study was to determine whether or not electrical stimulation of somatic afferent nerves in the foot can increase bladder capacity in neurogenic bladder patients after sigmoid cystoplasty.
Eleven subjects underwent 30-min foot stimulation using skin surface electrodes connected to a bladder-pelvic stimulator. The electrodes were attached to the bottom of the foot. The subjects completed a 5-day voiding diary, during which time foot stimulation was applied on day 3. The stimulation parameter was a continuous, bi-polar square wave form with a pulse duration of 200 μs and a stimulation frequency of 5 Hz. The stimulation intensity was set by each subject at a maximal level without causing discomfort.
The volume per clean intermittent catheterization (CIC) was 279.4 ± 11.7 ml and 285.4 ± 11.8 ml on the 1st and 2nd days, respectively. On the 3rd day, the average volume per CIC increased to 361.1 ± 18.1 ml after stimulation (p <0.05). The average volume per CIC returned to 295.4 ± 13.4 ml and 275.1 ± 11.5 ml on the 4th and 5th days, respectively.
Foot stimulation can delay the bladder filling sensation and significantly increase bladder capacity in neurogenic bladder patients after sigmoid cystoplasty.
PMCID: PMC4393857  PMID: 25886827
Electrical stimulation; Foot; Bladder capacity; Neurogenic bladder; Detrusor overactivity
56.  Reimbursement cuts and changes in urologist use of androgen deprivation therapy for prostate cancer 
BMC Urology  2015;15:25.
We examined the impact of urologist academic affiliation on use of androgen deprivation therapy (ADT) for prostate cancer before and after major reimbursement cuts for ADT in hopes of better understanding the influence of financial incentives on its use. In particular, we hypothesized that if financial incentive was the predominant factor driving use, we should see a narrowing in the previously documented gap of ADT use between non-academic and academic urologists following the reimbursement cuts.
With the Surveillance, Epidemiology and End-Results (SEER)-Medicare linked database we examined use of ADT for potentially inappropriate indications (primary therapy of localized, lower risk tumors) among patients of 2214 urologists over the period 2000–2002 and 2004–2007, representing eras before and after reimbursement cuts. Multi-level logistic regression models were used to estimate the likelihood of ADT use adjusted for patient, tumor and urologist characteristics (academic affiliation, board certification, years in practice and patient panel size).
Overall, ADT use peaked in 2002 at 46.6% of patients, but dropped dramatically in 2005, with a slow continued decrease through 2007 to 31.1%. A similar pattern was evident within most strata of urologist characteristics, including academic affiliation. In the multilevel model, patients of non-academic urologists had a 30% higher odds of receiving ADT than those of academic urologists in both the eras before and after the reimbursement cuts.
A similar proportionate drop in use of ADT among both academic and non-academic urologists following reimbursement cuts suggests that factors other than financial incentives may have played a role.
PMCID: PMC4399221  PMID: 25885745
Androgen deprivation; Prostate cancer; Reimbursement
57.  Prospective evaluation of plasma levels of ANGPT2, TuM2PK, and VEGF in patients with renal cell carcinoma 
BMC Urology  2015;15:24.
To assess pathological correlations and temporal trends of Angiopoietin-2 (ANGPT2), vascular endothelial growth factor (VEGF) and M2 Pyruvate kinase (TuM2PK), markers of tumor vascular development and metabolism, in patients with renal cell carcinoma (RCC).
We prospectively collected plasma samples from 89 patients who underwent surgical/ablative therapy for RCC and 38 patients with benign disease (nephrolithiasis, hematuria without apparent neoplastic origin, or renal cysts). In RCC patients, marker levels were compared between at least 1 preoperative and 1 postoperative time point generally 3 weeks after surgery. Marker temporal trends were assessed using the Wilcoxon sign-rank test. Plasma VEGF, ANGPT2, and TuM2PK levels were determined by ELISA and tested for association with pathological variables.
Median age was comparable between groups. 83/89 (93%) of the cohort underwent surgical extirpation. 82% of the tumors were organ confined (T ≤2, N0). Only ANGPT2 exhibited significantly elevated preoperative levels in patients with RCC compared to benign disease (p = 0.046). Elevated preoperative levels of ANGPT2 and TuM2PK significantly correlated with increased tumor size and advanced grade (p < 0.05). Chromophobe RCC exhibited higher levels of ANGPT2 compared to other histologies (p < 0.05). A decline in marker level after surgery was not observed, likely due to the timing of the analyses.
Our results suggest that ANGPT2 is a marker of RCC. Additionally, ANGPT2 and TuM2PK significantly correlated with several adverse pathological features. Further studies are needed to determine clinical applicability.
PMCID: PMC4411704  PMID: 25885592
Biomarkers; Angiogenesis; Prospective; Renal cell carcinoma; Tumor metabolism
58.  A segregation index combining phenotypic (clinical characteristics) and genotypic (gene expression) biomarkers from a urine sample to triage out patients presenting with hematuria who have a low probability of urothelial carcinoma 
BMC Urology  2015;15:23.
Hematuria can be symptomatic of urothelial carcinoma (UC) and ruling out patients with benign causes during primary evaluation is challenging. Patients with hematuria undergoing urological work-ups place significant clinical and financial burdens on healthcare systems. Current clinical evaluation involves processes that individually lack the sensitivity for accurate determination of UC. Algorithms and nomograms combining genotypic and phenotypic variables have largely focused on cancer detection and failed to improve performance. This study aimed to develop and validate a model incorporating both genotypic and phenotypic variables with high sensitivity and a high negative predictive value (NPV) combined to triage out patients with hematuria who have a low probability of having UC and may not require urological work-up.
Expression of IGFBP5, HOXA13, MDK, CDK1 and CXCR2 genes in a voided urine sample (genotypic) and age, gender, frequency of macrohematuria and smoking history (phenotypic) data were collected from 587 patients with macrohematuria. Logistic regression was used to develop predictive models for UC. A combined genotypic-phenotypic model (G + P INDEX) was compared with genotypic (G INDEX) and phenotypic (P INDEX) models. Area under receiver operating characteristic curves (AUC) defined the performance of each INDEX: high sensitivity, NPV >0.97 and a high test-negative rate was considered optimal for triaging out patients. The robustness of the G + P INDEX was tested in 40 microhematuria patients without UC.
The G + P INDEX offered a bias-corrected AUC of 0.86 compared with 0.61 and 0.83, for the P and G INDEXs respectively. When the test-negative rate was 0.4, the G + P INDEX (sensitivity = 0.95; NPV = 0.98) offered improved performance compared with the G INDEX (sensitivity = 0.86; NPV = 0.96). 80% of patients with microhematuria who did not have UC were correctly triaged out using the G + P INDEX, therefore not requiring a full urological work-up.
The adoption of G + P INDEX enables a significant change in clinical utility. G + P INDEX can be used to segregate hematuria patients with a low probability of UC with a high degree of confidence in the primary evaluation. Triaging out low-probability patients early significantly reduces the need for expensive and invasive work-ups, thereby lowering diagnosis-related adverse events and costs.
PMCID: PMC4391477  PMID: 25888331
Macroscopic hematuria; Microscopic hematuria; Urine test; Urothelial carcinoma; Genotypic biomarkers; Gene expression; Phenotypic biomarkers; Triage; Clinical pathway; Urology
59.  Simultaneous retrograde intrarenal surgery for ipsilateral asymptomatic renal stones in patients with ureteroscopic symptomatic ureteral stone removal 
BMC Urology  2015;15:22.
Ipsilateral asymptomatic renal stone associated with symptomatic ureteral stone is not a rare event, and the recommended treatment policy was not declared clearly. This study was conducted to compare the outcomes of simultaneous retrograde intrarenal surgery (RIRS) and ureteroscopy to ureteroscopy alone for this clinical event.
415 patients with symptomatic ureteral stone and ipsilateral asymptomatic renal stones were reviewed to obtain two match groups, who were treating with simultaneous modality (group A, N = 72), or ureteroscopy alone (group B, N = 72). Matching criteria were ureteral and renal stone side, duration and location, the presence of pre-stented. Perioperative and postoperative characteristics were compared between the two groups.
Mean stone burdens were similar between group A and B. Mean operative duration for group A and B were 72.4 ± 21.3 and 36.4 ± 10.2 min, respectively (P < 0.001). Mean hospital duration was 6.4 ± 2.9 and 5.3 ± 2.1 days in group A and B, respectively (P = 0.521). Ureteral SFR was 100% in each group. Renal SFR for RIRS was 86.1%. Complication rates in group A were higher (22.2% vs 13.9%), but the differences were not statistically significant (P = 0.358). In group A, complications were significantly less in pre-stented patients (3/25 vs 5/11, P = 0.04). Auxiliary treatment rate was significant higher in group B (69.4% vs 5.6%, P < 0.001) during follow-up (mean >18 months).
Simultaneous RIRS for ipsilateral asymptomatic renal stones in patients with ureteroscopic symptomatic ureteral stone removal can be performed safely and effectively. It promises a high SFR with lower auxiliary treatment rate, and does not lengthen hospital duration and increase complications.
PMCID: PMC4391107  PMID: 25888137
Retrograde intrarenal surgery; Asymptomatic renal stone; Simultaneous treatment
60.  Penile metastasis of sigmoid colon carcinoma: a rare case report 
BMC Urology  2015;15:20.
Metastasis to penis usually arises from genitourinary organs, but in rare cases, metastasis comes from the sigmoid colon. Furthermore, very few cases of penile metastasis of primary sigmoid colon carcinoma have been reported.
Case presentation
We described a case of a 53-year-old man with penile metastasis of sigmoid colon carcinoma along with a review of the literature. Physical examination revealed two subcutaneous nodules on the glans penis. Biopsy of the nodules showed that penile metastasis of sigmoid colon carcinoma.
Metastasis of sigmoid colon carcinoma to the penis is extremely rare, which presents an advanced form of sigmoid colon carcinoma, therefore survival is extremely shortened. Although treatment of penile metastasis is almost always palliative, it is important to recognize this unusual manifestation so that timely appropriate treatment can be initiated. Early recognition may enhance survival rate of these patients.
PMCID: PMC4371621  PMID: 25887957
Carcinoma; Penile metastasis; Sigmoid colon
61.  Factor V Leiden mutation triggering four major complications to standard dose cisplatin-chemotherapy for testicular seminoma: a case report 
BMC Urology  2015;15:21.
Major life-threatening complications secondary to cisplatin-based chemotherapy are rare in patients with testicular germ cell tumour (GCT). The incidence of complications increases with dosage of chemotherapy and with a variety of patient-related as well as disease-related conditions. We here report the first case of GCT experiencing as many as four major complications most of which can be explained by the conjunction of several predispositions.
Case presentation
A 48 year old patient with testicular seminoma and bulky retroperitoneal and mediastinal metastases underwent cisplatin based chemotherapy. During the third cycle of chemotherapy, he developed thrombosis of the central venous port device, subtotal splenic infarction, and Bleomycin induced pneumonitis (BIP). Three months after completion of therapy, he was struck by thalamic infarction. Genetic testing then revealed heterozygote mutation of Factor V Leiden (FVL). He received full-dose warfarin anticoagulation treatment and steroid treatment for BIP. 18 months thereafter, the patient is still disease-free, oncologically. Neurological symptoms have disappeared, but pulmonary dysfunction persists with a vital capacity of 50%.
The unique co-incidence of four major complications occurring in this patient were obviously triggered by the genetically determined predisposition of the patient to thrombotic events (FVL). Additionally, several patient-related and disease-related conditions contributed to the unique pattern of complications, i.e. (1) the slightly advanced age (48 years), (2) the prothrombotic condition caused by the disease of cancer, (3) the central venous port device, (4) retroperitoneal bulky metastasis, and (5) cisplatin chemotherapy. Whether or not FVL contributed to the pulmonary fibrosis as well, remains elusive. Practically, in the case of one major vascular complication during cisplatin chemotherapy at standard dose, genetic testing for hereditary thrombophilia should be considered. Thus, precautions for preventing further complications could be initiated.
PMCID: PMC4374368  PMID: 25887618
Seminoma; Cisplatin chemotherapy; Thrombosis; Thrombophilia; Factor V Leiden; Bleomycin induced pneumonitis
62.  Outcomes of experimental rat varicocele with and without microsurgery 
BMC Urology  2015;15:19.
Experimental rat varicocele was usually developed by the conventional technique but with varied success; and microsurgical rat varicocele model was an effective alternative. In this study we further analyzed differential outcome of experimental rat model with and without microsurgery.
One hundred and twenty male Sprague-Dawley rats were randomly assigned to two groups. In Group A, experimental rat varicocele model was developed with conventional technique. The left renal vein was partially ligated with concurrent ligation of communicating branches between the left spermatic vein and common iliac vein. In Group B, all the above procedures were finished with microsurgical manipulation under operating microscope. Before and after model development, the mean diameter of the left internal spermatic vein was compared; and at 8 weeks after initial surgery the mean sperm concentration and motility in both groups was analyzed.
The baseline mean diameter of the left internal spermatic vein in Group A and Group B was 0.14 ± 0.04 and 0.15 ± 0.03 mm, respectively (P =0.3157). In Group A 9 rats had severe complications resulting in model failure; while in Group B all rats had successful model except for one died of anesthetic accident (P = 0.008). At 8 weeks after initial surgery the mean left internal spermatic vein, sperm concentration and motility in both groups was 1.65 mm, 321.5×106/gm and 51.9%; and 1.65 mm, 318.9×106/gm and 53.5% respectively. There was nonsignificant difference of internal spermatic vein diameter, sperm concentration and motility between two groups.
Microsurgery makes developing experiment rat varicocele model easy. Compared with conventional technique, microsurgical rat varicocele model has higher success rate and less complication.
PMCID: PMC4391661  PMID: 25885464
Varicocele; Microsurgery; Rat
63.  A novel surgical management for male infertility secondary to midline prostatic cyst 
BMC Urology  2015;15:18.
To summary the procedure and experience of a novel surgical management for male infertility secondary to midline prostatic cyst (MPC).
From February 2012 to February 2014, 12 patients were diagnosed with PMC by semen analysis, seminal plasma biochemical analysis, transrectal ultrasonography (TRUS), and pelvic magnetic resonance imaging (MRI). All patients underwent the transurethral unroofing of MPC using resectoscope, the dilation of ejaculatory duct, and the irrigation of seminal vesicle using seminal vesiculoscope. All patients were followed up at least 3 months after operation.
Preoperative semen analyses of 12 patients showed oligoasthenozoospermia (5/12) or azoospermia (7/12), low semen volume (0–1.9 mL), and low pH level (5.5-7.0). Preoperative seminal plasma biochemical analyses showed reduced semen fructose. TURS and MRI revealed a cyst lesion located in the midline of prostatic. After 3 months follow up, the semen quality of 80% patients (4/5) with oligoasthenozoospermia improved obviously. The spermatozoa were present in the semen in 5 of 7 cases with azoospermia. In one patient, the spermatozoa occurred in the urine after ejaculation.
Surgical management using transurethral resectoscopy and seminal vesiculoscopy is effective, minimally invasive, and safe for male infertility secondary to MPC.
PMCID: PMC4364565  PMID: 25888036
Male infertility; Midline prostatic cyst; Transurethral resectoscopy; Seminal vesiculoscopy
64.  Which anthropometric measurements including visceral fat, subcutaneous fat, body mass index, and waist circumference could predict the urinary stone composition most? 
BMC Urology  2015;15:17.
Although there is growing evidence of relationship between obesity and some specific stone compositions, results were inconsistent. Due to a greater relationship between metabolic syndrome and some specific stone type, obesity measured by body mass index (BMI) has limitation in determining relationship between obesity and stone compositions. The aim of this study was to determine the relationship among BMI, visceral fat, and stone compositions.
We retrospectively reviewed data of patients with urinary stone removed over a 5 year period (2011–2014). Data on patient age, gender, BMI, urinary pH, stone composition, fat volumes (including visceral fat, subcutaneous fat, total fat, waist circumference), and ratio for visceral to total fat using computed tomography based delineation were collected. To figure out the predicting factor while adjusting other confounding factors, discriminant analysis was used.
Among 262 cases, average age was 52.21 years. Average BMI and visceral fat were 25.03 cm2 and 124.75 cm2, respectively. By chi square test, there was significant (p < 0.001) difference in stone types according to sex. By ANOVA test, BMI, visceral fat, visceral to subcutaneous fat ratio, the percentage of visceral fat and total fat showed significant association with stone types. By discriminant analysis, visceral fat was proved to be a powerful factor to predict stone composition (structure matrix of visceral fat = −0.735) with 42.0% of predictive value.
Visceral fat adiposity strongly related with uric acid stone and has better predictive value than BMI or urinary pH to classify the types of stone.
PMCID: PMC4381452  PMID: 25887850
Urinary calculi; Obesity; Body mass index; Visceral fat; Computed tomography
65.  Controversies in the treatment of invasive urothelial carcinoma: a case report and review of the literature 
BMC Urology  2015;15:15.
More than 429,000 patients worldwide are diagnosed with bladder cancer each year and muscle-invasive bladder cancer has an especially poor outcome. The median age at diagnosis is over 70 years, and many patients also have a substantial number of age-associated impairments that need to be considered when planning therapeutic interventions.
Case presentation
Here, we report the case of a 63-year-old man with a cT3b urothelial carcinoma which was surgically removed. No neoadjuvant or adjuvant chemotherapy was administered. After 18 months a lung metastasis was confirmed and resected but no chemotherapy was given after surgery. Twelve months later, the patient relapsed and was treated with a combination of gemcitabine and cisplatin and after a decline in renal function the treatment was changed to a combination of carboplatin and gemcitabine which resulted in a partial response which lasted 8 months. Following this vinflunine was administered as a second line treatment.
Here we review the evidence available in the literature regarding the suitability of different treatment options for managing muscle-invasive bladder cancer at each step of the case presentation.
Bladder cancer treatment requires a multidisciplinary approach. Although, depending on the clinical characteristics of the patient, there are some controversial points in the management of this pathology we hope that the scientific data and the clinical trials reviewed in this case report, can help to guide physicians to make more rational decisions regarding the management of these patients.
PMCID: PMC4361131  PMID: 25887442
Muscle-invasive bladder cancer; Urothelial carcinoma; Neoadjuvant chemotherapy; Adjuvant chemotherapy; Unfit
66.  Testicular prostheses in patients with testicular cancer - acceptance rate and patient satisfaction 
BMC Urology  2015;15:16.
The loss of a testicle to cancer involves much emotional impact to young males. Little is known about the number of patients with testicular germ cell tumour (GCT) who would accept a testicular prosthesis. Also, knowledge about the satisfaction of implant recipients with the device is limited.
A retrospective chart analysis was performed on 475 consecutive GCT patients. Prior to orchiectomy, all patients were offered prosthesis insertion. Acceptance of implant was noted along with age, clinical stage, histology and year of surgery. 171 implant recipients were interviewed using an 18 item questionnaire to analyze satisfaction with the prosthesis. Statistical analysis involved calculating proportions and 95% confidence intervals. Multivariate analysis was performed to look for interrelations between the various items of satisfaction with the implant.
26.9% of the patients accepted a prosthesis. The acceptance rate was significantly higher in younger men. Over-all satisfaction with the implant was “very high” and “high” in 31.1% and 52.4%, respectively. 86% would decide again to have a prosthesis. Particular items of dis-satisfaction were: implant too firm (52.4%), shape inconvenient (15.4%), implant too small (23.8%), position too high (30.3%). Living with a permanent partner had no influence on patient ratings. Multivariate analysis disclosed numerous inter-relations between the particular items of satisfaction.
More than one quarter of GCT patients wish to have a testicular prosthesis. Over-all satisfaction with implants is high in more than 80% of patients. Thus, all patients undergoing surgery for GCT should be offered a testicular prosthesis. However, surgeons should be aware of specific items of dis-satisfaction, particularly shape, size and consistency of the implant and inconvenient high position of the implant within the scrotum. Appropriate preoperative counselling is paramount.
Electronic supplementary material
The online version of this article (doi:10.1186/s12894-015-0010-0) contains supplementary material, which is available to authorized users.
PMCID: PMC4363351  PMID: 25887552
Testicular cancer; Testicular prosthesis; Orchiectomy; Masculinity; Quality of life; Body appearance
67.  Correlation between psychological stress levels and the severity of overactive bladder symptoms 
BMC Urology  2015;15:14.
The relationship between psychological stress and interstitial cystitis/bladder pain syndrome (IC/BPS) has been well described. Even though there is some overlapping of symptoms between overactive bladder (OAB) and IC/BPS, there have been very few studies that specifically investigated the relationship between psychological stress and urinary symptoms in OAB patients who do not have pelvic pain. Here we examined the relationship between psychological stress levels and the severity of overactive bladder (OAB) symptoms.
Patients diagnosed with OAB (n=51), IC/BPS (n=27), and age-matched healthy controls (n=30) participated in a case control study that inquired about their psychological stress levels using the perceived stress scale (PSS). PSS reported by the three patient groups were compared. Among OAB patients, their responses on the PSS was correlated to OAB symptoms using the following questionnaires: 1) international consultation on incontinence – urinary incontinence (ICIQ-UI), 2) international consultation on incontinence – overactive bladder (ICIQ-OAB), 3) OAB-q short form, 4) urogenital distress inventory (UDI-6), 5) incontinence impact questionnaire (IIQ-7), 6) urgency severity scale (USS), 7) numeric rating scales of urgency symptom, and 8) frequency symptom. Spearman’s correlation tests were performed to examine the relationship between psychological stress levels and the severity of OAB symptoms.
OAB patients reported psychological stress levels that were as high as IC/BPS patients (median 17.0 versus 18.0, p=0.818, Wilcoxon sum rank test), and significantly higher than healthy controls (17.0, versus 7.5, p=0.001). Among OAB patients, there was a positive correlation between perceived stress levels and urinary incontinence symptoms (ICIQ-UI, Spearman’s correlation coefficient=0.39, p=0.007), and impacts on quality of life (UDI-6, IIQ-7, OAB-q quality of life subscale; Spearman’s correlation coefficient=0.32, 0.31, 0.39, and p=0.028, 0.005, 0.029, respectively). No significant correlation was observed between perceived stress levels and urgency or frequency symptoms (ICIQ-OAB, USS, numeric ratings of urgency and frequency).
OAB patients reported psychological stress levels that were as high as IC/BPS patients, and significantly higher than healthy controls. There was a positive correlation between perceived stress levels and urinary incontinence symptoms, and its impacts on quality of life among OAB patients.
PMCID: PMC4357155  PMID: 25887525
Psychological stress; Overactive bladder; Urgency incontinence; Urinary urgency; Interstitial cystitis
68.  Prevalence of human papillomavirus in penile malignant tumors: viral genotyping and clinical aspects 
BMC Urology  2015;15(1):13.
The human papillomavirus (HPV) prevalence in males has been reported to be between 3.6% and 84%, depending specially on the socioeconomic status. HPV infection has been related as a risk factor for penile cancer. This is a rare tumor, and other risk factors include lack of personal hygiene and men who have not undergone circumcision. Penile cancer is less than 1% of cancers in men in the United States, however, is much more common in some parts of Asia, Africa, and South America, where it accounts for up to 10% of cancers in men. This study aimed to determine the prevalence of HPV-DNA in penile cancers in São Luís, Brazil and to correlate the virus presence to histopathological factors.
Tumor paraffin samples of 76 patients with penile carcinoma were tested in order to establish the prevalence and distribution of genotypic HPV using PCR/Nested and automated sequencing. To evaluate the association between HPV types and other clinical and morphological variables, a nonparametric ANOVA was performed using a Kruskal Wallis test, and statistical significance was determined to a value of p < 0.05.
The average age of patients at the time of diagnosis was 66 years ± 17.10. Regarding location, 65.79% of the tumors were located in the glans, and the most common types were vegetative (34.21%) and squamous (98.68%). Most of the lesions ranged in size from 2.1 to 5.0 cm, presenting Jackson I stage and Broders II degree. It was observed that 32 patients had at least one invaded and/or infiltrated structure. Lymph node involvement was observed in 19.76% of the patients, and 21.05% showed an inflammatory process. In the molecular evaluation, HPV infection was observed in 63.15% of the lesions, and the most common type was HPV 16.
From the statistical analysis, it can be verified that the variables were not associated with infection by the HPV virus. Although penile cancer can result from various risk factors that act in synergy, an HPV virus infection is important for the development of such neoplasm.
PMCID: PMC4349728  PMID: 25887354
Papillomavirus Infections; Penile Neoplasms; Association; Men’s health
69.  A discrepancy of penile hemodynamics during visual sexual stimulation observed by near-infrared spectroscopy 
BMC Urology  2015;15(1):11.
In this paper, we observed a discrepancy of penile hemodynamics dependent on location by using near infrared spectroscopy (NIRS) sensor, and showcase NIRS as a potentially suitable sensor in supplementing the diagnosis and treatment of erectile dysfunction.
To observe the effect that location has on penile hemodynamics, the NIRS sensor was placed on the top and the side of genital organ, and oxy- (HbO), deoxy-(RHb), and total (HbT) hemoglobin concentration changes were acquired. Our results from 6 healthy subjects show that hemodynamic changes vary depending on where the probe was placed. To observe a statistical difference between the signals, a Wilcoxon signed-rank test was performed.
The result shows a significant difference (p < 0.05) between concentration changes of RHb and HbT depending on the probes’ location. Moreover, the sensor placed on the top of the organ shows a rise of HbO and HbT concentration while RHb concentration decreased. However, hemodynamics from the side of the organ showed that RHb concentration increased along with HbO.
The outcomes demonstrates an ability of NIRS to be sensitive enough to detect the different hemodynamic changes in various locations of a healthy male genital organ during visual sexual stimulation. The results also show the importance of sensor location on the genital organ for the resulting hemodynamic changes. We can foresee our results as a way for clinicians to obtain more accurate hemodynamic measurements from the penis, and also show the likelihood for NIRS enhanced diagnosis tool of male erectile dysfunction over the current standards.
PMCID: PMC4341242  PMID: 25879202
NIRS; Hemodynamic; Erectile dysfunction; Penile erection
70.  Transurethral cystolitholapaxy with the AH-1 stone removal system for the treatment of bladder stones of variable size 
BMC Urology  2015;15(1):9.
The treatment of large volume bladder stones by current equipments continues to be a management problem in both developing and developed countries. AH-1 Stone Removal System (SRS) invented by us is primarily used to crush and retrieve bladder stones. This study evaluated the safety and efficiency of transurethral cystolitholapaxy with SRS for the treatment of bladder stones of variable size.
SRS, which was invented by Aihua Li in 2007, composed by endoscope, continuous-flow component, a jaw for stone handling and retrieving, lithotripsy tube, handle, inner sheath and outer sheath. 112 patients with bladder stones were performed by transurethral cystolitholapaxy with SRS since 2008. We compare the surgical outcome to bladder stones of variable size, and evaluate the surgical efficiency and safety.
Characteristics of patients and stone removal time in variable size were evaluated. To patients with single stone, stone size was 1.35 ± 0.37 cm and the operating time was 5.50 ± 3.92 min in Group A. Stone size was 2.38 ± 0.32 cm and the operating time was 11.90 ± 9.91 min in Group B. Stone size was 3.30 ± 0.29 cm and the operating time was 21.92 ± 9.44 min in Group C. Stone size was 4.69 ± 0.86 cm and the operating time was 49.29 ± 30.47 min in Group D. The difference was statistically significant between the four groups. Among them, 74 (66.07%) patients accompanied with benign prostatic hyperplasia (BPH) were treated by transurethral resection of the prostate (TURP) simultaneously. Compared between the four groups, the difference of the TURP time was not statistically significant, P >0.05. No significant complication was found in the surgical procedure.
Transurethral cystolitholapaxy with SRS appears to be increased rapidity of the procedure with decreased morbidity. It is a safe and efficient surgical management to bladder stones. This endoscopic surgery best fits the ethics principle of no injury; meanwhile, the accompanied BPH could be effectively treated by TURP simultaneously.
PMCID: PMC4343269  PMID: 25887148
Bladder stone; Transurethral cystolitholapaxy; Endoscopic surgery; AH-1 stone removal system
71.  Targeted salvage lymphadenectomy in patients treated with radical prostatectomy with biochemical recurrence: complete biochemical response without adjuvant therapy in patients with low volume lymph node recurrence over a long-term follow-up 
BMC Urology  2015;15(1):10.
Choline positron emission tomography/computed tomography (PET/CT) represents an option in restaging of prostate cancer patients with disease relapse after local treatment. The present study assess whether salvage resection of lymph node metastases detected on choline PET/CT imaging in prostate cancer patients with biochemical recurrence after radical prostatectomy can result in a long-term complete biochemical remission, without adjuvant therapy.
We analysed 13 patients with prostate specific antigen (PSA) recurrence (PSA median 1.64 ng/ml, range 0.5-9.55) after radical prostatectomy and suspicious lymph nodes (median 1; range 1–3) detected on [11C]choline and [18F]fluoroethylcholine PET/CT scans. An open salvage lymphadenectomy of positive lymph nodes in a PET/CT scan and nearby lymph nodes was carried out. We examined PSA outcome without adjuvant therapy; defined complete biochemical remission as PSA <0.01 ng/ml. Histological and PET/CT findings were compared.
Ten of 11 patients with histologically confirmed lymph node metastases showed a PSA response. Three of ten patients with single lymph node metastases had a complete biochemical remission (median follow-up 72 months, range 31.0-83). In five cases with single lymph node metastasis PSA decreased <0.02 ng/ml. Histologically confirmed 13 of 16 metastasis suspicious lymph nodes. No lymph node metastases were detected in two patients. All of the additionally removed 30 lymph nodes were correctly negative.
This is the first confirmation of a complete biochemical remission after PET/CT guided secondary resection of a single lymph node metastasis in prostate cancer patients with biochemical recurrence after radical prostatectomy, over the long-term (>6.5 years), without adjuvant therapy. In order to improve these promising results, longer-term studies with more patients are required.
PMCID: PMC4344760  PMID: 25881245
Prostate cancer; Choline positron emission tomography/computed tomography; Biochemical recurrence; Salvage lymphadenectomy; Lymph node metastases
72.  3D vs 2D laparoscopic radical prostatectomy in organ-confined prostate cancer: comparison of operative data and pentafecta rates: a single cohort study 
BMC Urology  2015;15(1):12.
Currently, men are younger at the time of diagnosis of prostate cancer and more interested in less invasive surgical approaches (traditional laparoscopy, 3D-laparoscopy, robotics). Outcomes of continence, erectile function, cancer cure, positive surgical margins and complication are well collected in the pentafecta rate. However, no comparative studies between 4th generation 3D-HD vision system laparoscopy and standard bi-dimensional laparoscopy have been reported. This study aimed to compare the operative, perioperative data and pentafecta rates between 2D and 3D laparoscopic radical prostatectomy (LRP) and to identify the actual role of 3D LRP in urology.
From October 2012 to July 2013, 86 patients with clinically localized prostate cancer [PCa: age ≤ 70 years, prostate-specific antigen (PSA) ≤ 10 ng/ml, biopsy Gleason score ≤ 7] underwent laparoscopic extraperitoneal radical prostatectomy (LERP) and were followed for approximately 14 months (range 12–25). Patients were selected for inclusion via hospital record data, and divided into two groups. Their patient records were then analyzed. Patients were randomized into two groups: the former 2D-LERP (43 pts) operated with the use of 2D-HD camera; the latter 3D-LERP (43 pts) operated with the use of a 3D-HD 4th generation view system. The operative and perioperative data and the pentafecta rates between 2D-LERP and 3D-LERP were compared.
The overall pentafecta rates at 3 months were 47.4% and 49.6% in the 2D- and 3D-LERP group respectively. The pentafecta rate at 12 months was 62.7% and 67% for each group respectively. 4th generation 3D-HD vision system provides advantages over standard bi-dimensional view with regard to intraoperative steps. Our data suggest a trend of improvement in intraoperative blood loss and postoperative recovery of continence with the respect of the oncological safety.
Use of the 3D technology by a single surgeon significantly enhances the possibility of achieving better intraoperative results and pentafecta in all patients undergoing LERP. Potency was the most difficult outcome to reach after surgery, and it was the main factor leading to pentafecta failure. Nevertheless, further studies are necessary to better comprehend the role of 3D-LERP in modern urology.
PMCID: PMC4349673  PMID: 25887253
Laparoscopic radical prostatectomy; Pentafecta; 3D laparoscopy; Prostatectomy
73.  Urinary ATP as an indicator of infection and inflammation of the urinary tract in patients with lower urinary tract symptoms 
BMC Urology  2015;15(1):7.
Adenosine-5′-triphosphate (ATP) is a neurotransmitter and inflammatory cytokine implicated in the pathophysiology of lower urinary tract disease. ATP additionally reflects microbial biomass thus has potential as a surrogate marker of urinary tract infection (UTI). The optimum clinical sampling method for ATP urinalysis has not been established. We tested the potential of urinary ATP in the assessment of lower urinary tract symptoms, infection and inflammation, and validated sampling methods for clinical practice.
A prospective, blinded, cross-sectional observational study of adult patients presenting with lower urinary tract symptoms (LUTS) and asymptomatic controls, was conducted between October 2009 and October 2012. Urinary ATP was assayed by a luciferin-luciferase method, pyuria counted by microscopy of fresh unspun urine and symptoms assessed using validated questionnaires. The sample collection, storage and processing methods were also validated.
75 controls and 340 patients with LUTS were grouped as without pyuria (n = 100), pyuria 1-9 wbc μl-1 (n = 120) and pyuria ≥10 wbc μl-1 (n = 120). Urinary ATP was higher in association with female gender, voiding symptoms, pyuria greater than 10 wbc μl-1 and negative MSU culture. ROC curve analysis showed no evidence of diagnostic test potential. The urinary ATP signal decayed with storage at 23°C but was prevented by immediate freezing at ≤ -20°C, without boric acid preservative and without the need to centrifuge urine prior to freezing.
Urinary ATP may have a role as a research tool but is unconvincing as a surrogate, clinical diagnostic marker.
PMCID: PMC4351839  PMID: 25886951
Lower urinary tract symptoms (LUTS); Adenosine-5′-triphosphate (ATP); Urinary tract infection (UTI)
74.  Urethral orifice hyaluronic acid injections: a novel animal model of bladder outlet obstruction 
BMC Urology  2015;15:8.
We produced a novel model of bladder outlet obstruction (BOO) by periurethral injection of hyaluronic acid and compared the cystometric features, postoperative complications, and histopathological changes of that model with that of traditional open surgery.
Forty female Sprague-Dawley rats were divided into three groups. Fifteen rats were subcutaneously injected with 0.2 ml hyaluronic acid at 5, 7, and 12 o’clock around the urethral orifice. Another fifteen rats underwent traditional open partial proximal urethral obstruction surgery, and 10 normal rats used as controls. After 4 weeks, filling cystometry, postoperative complications, and histopathological features were evaluated in each group. Three rats were also observed for 12 weeks after hyaluronic acid injection to evaluate the long-term effect.
Hyaluronic acid periurethral injection caused increased maximum cystometric capacity, maximum bladder pressure, micturition interval, and post-void residual urine volume compared with control (p < 0.01). The injection group had significantly shorter operative time, less incidence of incision infection and bladder stone formation compared with the surgery group (p < 0.01). Hematoxylin and eosin (HE) staining showed suburothelial and interstitial hyperemia edema and smooth muscle hypertrophy in both injection and surgery bladders; these were not observed in the control group. Bladder weight and thickness of smooth muscle in the injection and surgery groups were significantly greater than those in the control group (p < 0.01). Urethral epithelial hyperplasia and lamina propria inflammation were observed in the surgery group but not in the injection or control groups. Rats periurethrally injected hyaluronic acid were stable the compound was not fully absorbed in any rat after 12 weeks.
Hyaluronic acid periurethral injection generates a simple, effective, and persistent animal model of BOO with lower complications, compared with traditional surgery.
PMCID: PMC4364086  PMID: 25887057
Bladder outlet obstruction; Animal model; Hyaluronic acid
75.  Spleen injury following left extracorporeal shockwave lithotripsy (ESWL) 
BMC Urology  2015;15:4.
A splenic rupture associated with extracorporeal shockwave lithotripsy (ESWL) is exceedingly rare. We report a case of stage 3 splenic laceration, hemoperitoneum and subsequent splenic rupture following an ESWL for a left mid polar renal calculus.
Case presentation
During the ESWL, although the patient’s pain was controlled the gentleman was very nervous and had to be repositioned eight individual times.
Approximately 6 hours after the ESWL, the patient phoned the urologist complaining of severe left flank pain unlike any previous episode of renal colic. A computerized tomography (CT) scan demonstrated a stage 3 splenic injury with hemoperitoneum. The patient decompensated and an emergent splenectomy was then performed and the patient experienced an uneventful recovery.
Splenic injury likely results from unintentional movement during the sound wave administration for the stone fragmentation procedure. Utilizing noise cancelling headphones during ESWL may preclude the potential pitfalls of patient nervousness.
PMCID: PMC4429660  PMID: 25972225
Splenic injury; Splenectomy; ESWL

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