Journal of Clinical Urology

The holmium: yttrium-aluminum-garnet (Ho:YAG) laser, which has been the gold standard for lithotripsy, has evolved to high frequency systems with pulse modulation. However, there is now an alternative laser for lithotripsy - the thulium fiber laser (TFL).

While bench testing has shown superior fragmentation performance of the TFL compared to Ho:YAG, initial clinical results for ureteroscopy have not been as dramatic. We therefore analyze laboratory and clinical studies comparing these two laser platforms. Our goal is to offer insights into when and why to choose one laser over the other for ureteroscopy, along with strategies for optimal use.

In this narrative review we describe the characteristics of each laser and provide an overview of the in vitro studies comparing Ho:YAG and TFL for fragmentation, retropulsion and heat generation. We also review evidence from prospective comparative effectiveness clinical trials for ureteroscopy and lithotripsy. We provide our schema for when we use each laser for ureteroscopy, the rationale and our approach with laser settings.

Ho:YAG and TFL have distinct wavelengths, pulse duration, peak power, and water absorption parameters that make them suitable for different scenarios. The decision between which laser to choose rests upon individual preferences and confidence levels of use, with the ultimate priority for safe patient use.

Multiple nomograms have previously been described to predict recurrence, overall, and cancer-specific survival following radical cystectomy (RC) for urothelial carcinoma of the bladder (UCB).Our aim was to develop a nomogram for the preoperative prediction of lymph node (LN) metastasis in UCB.

We prospectively collected data from 483 patients which were used in construction of the statistical model. The variables considered as predictors in the model were demographic, histopathological and radiological factors.

The full model containing all 12 covariates produced an AIC (Akaike information criterion) value of 448.9. After model selection T-stage, grade, CIS (carcinoma in situ), pathology, LV (lymphovascular) invasion and CT (computed tomography) were included as the most parsimonious model while retaining predictive accuracy. Ta in 82 (17%), T1 in 214 (445) and T2 in 187 (38%) patients. This model had an AIC of 436.4, indicating a significant improvement in model fit after the removal of unimportant predictors. The C-indices were 0.821 and 0.808 for the reduced model and the full model, respectively, indicating greater discrimination ability for the reduced model.The nomogram further emphasises the effect of CT and LV invasion on the risk of LN positivity. Specifically, regardless of all other variables, a patient with a CT will have 100 points more than a patient without a CT, corresponding to a difference in risk of approximately 40%. The odds of LN positivity for patients with a CT are 7.45 times that of patients without a CT, regardless of all other covariates. LV invasion, pathology, CIS and T-stage are also statistically significant (p = 0.05).

This nomogram is a preoperative prediction tool that uses different preoperative variables with acceptable predictive accuracy for LN metastasis in patients with BC.

To determine if periodic triamcinolone injections into Hunner’s lesion in patients with bladder pain syndrome (BPS) reduces the need for opioids and other pain treatments.

This is a retrospective analysis of 28 patients receiving endoscopic injections of 0.5–1.0 cc of triamcinolone acetate into Hunner’s lesions between 2010 and 2018. Wilcoxon signed-rank test was used to compare pain regimens before and after injections.

Median age at first triamcinolone injection was 63 (IQR 54–73). Median number of injections/patient was 3 (IQR 2–5.5), at a mean of 8-month intervals (2–80). The median number of pain treatments prior to triamcinolone was 4 (0–13), and 25% of patients were using opioids. With one or more injections, 92.9% had improvement in pain symptoms. There was a significant decrease in number of pain treatments following triamcinolone injections (4.1 vs 0.8, p = 0.006). Fifty-seven percent managed with triamcinolone injections alone, with no other pain treatments. Of the seven patients using opioids, four discontinued opioids altogether.

Repeat triamcinolone injections into Hunner’s lesions are associated with a significant reduction in the number of pain treatments used for BPS, with an associated decrease in opioid use.

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To report on the experience of the management of lower urinary tract symptoms (LUTS) in men referred for prostate radiotherapy (RT) in a large tertiary referral centre.

Between February and November 2018, 156 men referred for radiotherapy were seen and assessed according to their LUTS history: International Prostate Symptom Score (IPSS), flow rate (FR) and post-void residual (PVR). Patients with LUTS were offered management options depending on severity including lifestyle advice, oral medication or surgery. A subset of patients (n = 102) were reassessed post-RT, and univariate and multivariate logistic regression was performed to predict symptoms improvement.

Prior to referral for RT and assessment at our dedicated LUTS clinic, 65% of men had a documented history of LUTS, 14% had completed an IPSS questionnaire and only 13% had a urinary FR; 17% (27/156) had prior treatment in the form of medication or surgery. In our assessment, 77/156 (49%) had mild, 66/156 (42%) moderate and 13/156 (8%) severe LUTS determined by IPSS. Out of 156, 71 (46%) had a quality-of-life score >3. Of the men, 81% were offered lifestyle advice, 47 patients were started on alpha blockers and 20 (12.8%) went onto Transurethral Resection of the Prostate prior to RT; 6 weeks following RT, 61 (50%) patients had higher IPSS scores. Patients who were started on alpha blockers (p = 0.022) or had TURP (p = 0.015) were less likely to have an increase in IPSS score on multivariate analysis.

Men undergoing RT for prostate cancer often have co-existing LUTS. Consideration and evaluation of their LUTS and offer of treatment either medication or surgery could improve urinary symptoms in men undergoing prostate radiotherapy in the short term. Longer term data are still needed to understand the full long-term impact on patient’s symptoms and quality of life. We recommend that patients have formal LUTS assessment pre-RT.

Not applicable.

To examine the urodynamic characteristics of men with mixed detrusor overactivity with detrusor underactivity (DODU) across the entire adult-age spectrum.

Data included all adult men who underwent urodynamics for refractory non-neurogenic lower tract symptoms between 2011 and 2019. DODU was defined as the concomitant presence of detrusor overactivity (DO) during storage with underactivity (bladder contractility index, BCI < 100) during voiding. Nonparametric tests with multiple hypothesis correction were used (SPSS 25.0).

DODU was noted in 199/1596 men (12.5%; median, 62 years). Men with DODU were older than men with detrusor underactivity (DU) or DO alone (median, 62, 48 and 56 years, respectively). DODU was commoner in older men but was noted across all age groups. As compared to men with isolated DU, men with DODU were more likely to be obstructed (38.7% versus 23.6%) and had better contractility (median BCI 81 versus 75). Peak detrusor contraction pressure during overactivity was lower in men with DODU than men with isolated DO.

DODU should not be regarded as an exclusively geriatric disease. Differences in urodynamic characteristics suggest that this condition might not just be the coincidental occurrence of DO and underactivity in the same individual.

III

To compare patient-reported outcome measures (PROMs) for patients with symptomatic renal stone disease treated by flexible ureterorenoscopy (fURS) and shockwave lithotripsy (SWL)

Historically, surgical outcomes are measured by surgeon-specific outcomes such as ‘stone-free rates’. More recently, there is increasing emphasis on PROMs to ascertain a patient’s perspective of their own surgical outcome. Despite this, the literature in reference to renal stone-specific PROMs following stone treatment remains limited.

Data were collected in a prospective multi-centre study. Patients undergoing fURS or SWL were asked to complete the validated Cambridge Renal Stone Patient Reported Outcome Measure (CReSP) on the day of initial treatment and at weeks 1, 6 and 12 post-operatively.

Data were collected for 119 patients. Three were excluded as stone metric and demographic details were incomplete. Sixty underwent SWL and 56 underwent fURS. Median stone size was 7.52 mm. There were no significant differences in baseline PROM scores between the treatment groups. At 1 week, the PROM scores were significantly higher in the fURS group compared to SWL (27.40 ± 0.85^sd versus 22.51 ± 1.07^sd; p < 0.05). However, at 6 and 12 weeks, the PROM scores were significantly lower in the fURS group (18.51 ± 2.27^sd versus 23.67 ± 1.30^sd; p < 0.05) and (17.01 ± 2.29^sd versus 22.49 ± 1.49^sd; p < 0.05), respectively. By week 12, overall scores for anxiety and social factors were more favourable in the fURS cohort.

Our study suggests that fURS is associated with a short-lived increase in morbidity in comparison with SWL, which may be due to ureteric stenting in the majority of patients post-operatively. However, fURS patients appear to report significantly better PROM scores in the longer term. This appears to be associated with more favourable anxiety and social factor scoring over the treatment period.

Not applicable.

Artificial urinary sphincter (AUS) activation is usually deferred until 6 weeks following insertion. However, this timeframe for activation is based on traditional dogma. This study aims to assess the feasibility, efficacy and safety of earlier activation of AUS.

A prospective database was established on consecutive patients undergoing AUS implantation (AMS-800 Boston Scientific) from March 2019 to March 2022 by a single fellowship-trained urologist. Early activation was defined as <30 days from the date of implantation.

Twenty-one patients were included in the study with a median follow-up of 34 (range: 3–96) months. The most common indication for AUS insertion was post-prostatectomy stress urinary incontinence (n = 19, 90%). All 21 patients had their AUS successfully activated and used before 30 days, with a median of 14 (range: 9–28) days. Median (range) pre-operative continence pad numbers were 3 (2–6) and 0 (0–1) at 4 weeks post-operatively. Median (range) pad weight per day was 600 g (190–1310 g) pre-operatively and 6 g (0–6 g) at 4 weeks post-operatively. There were no adverse events associated with early activation.

To our knowledge, this is the first description of the early activation of the AMS-800 AUS device. Our preliminary experience indicates early activation is safe and acceptable for patients.

II

Inflatable penile prosthesis (IPP) surgery is an effective treatment for patients with erectile dysfunction (ED). The two most used surgical approaches are infrapubic (IP) and penoscrotal (PS). Concerns exist whether raised Body Mass Index (BMI) or poor glycaemic control negatively affect outcome. We conducted a retrospective review of 50 consecutive virgin IP IPP cases investigating the effect of BMI and glycaemic control on post-operative complications and implant utilisation.

Data collected included demographics, ED aetiology and risk factors, diabetic status, HbA1c and post-operative complications focusing on infection and re-operation. Telephone survey provided implant usage at 3, 6, 12 and 24 months post-operatively. All patients followed the same pre-, peri- and post-operative pathway, including antibiotic prophylaxis and implant preparation.

Complication rates of patients with BMI ⩾ 30 (2/20; 10%) and BMI < 30 (0/28, 0%) (p = 0.169) and of patients with poorly controlled diabetes mellitus (DM), HbA1c > 69 mmol/mol (0/6, 0%) versus HbA1c ⩽ 69 (2/21, 9.52%) (p = 1) were not significantly different. Two patients reported complications. Implant utilisation did not differ significantly between low or high BMI and HbA1c cohorts.

Our study shows pre-operative HbA1c and BMI do not significantly impact complication rates or implant utilisation in patients undergoing IP IPP insertion.

2b

Studies reporting increased risk of metastases in T3a disease are based on clinical staging (Digital rectal examination) in the pre-multiparametric–magnetic resonance imaging (MRI) (mp-MRI) era. The aim of our study was to assess the rate of positive bone scans in patients ascribed with T3a prostate cancer on a pre-biopsy mp-MRI.

We performed a multicentre, retrospective analysis of all patients with T3a prostate cancer staged by mp-MRI who had a bone scan between January 2017 and April 2020.

A total of 586 patients were diagnosed with T3a prostate cancer on mp-MRI, with a median age of 71 years (range: 47–87). The median presenting PSA was 11 ng/mL (range: 1–537); 125 patients (21.3%) had a PSA ⩽ 20 and either grade group (GG) 1 or 2 in their prostate biopsy; none of these patients had bone metastases. Eighteen patients (3.1%) were found to have bone metastases: 11 patients had GG ⩾ 3 disease on biopsy and nodal disease, 6 had GG ⩾ 3 without evidence of nodal disease and 1 had a PSA of 103.

The use of bone scans in patients with T3a prostate cancer staged on mp-MRI but without other evidence of high-risk disease (GG ⩾ 3 and PSA > 20 ng/mL) appears to be unnecessary and could be safely avoided.

2b

The aim of this article is to present our experience of pedicled dorsal penile skin tube as neourethra after radical penectomy due to invasive primary male carcinoma of anterior urethra.

This is an observational descriptive study including seven men with primary urethral carcinoma who underwent radical penectomy between 2018 and 2021. Instead of urinary derivation with suprapubic catheter, perineal urethrostomy, or bladder orthotopic/heterotopic reconstruction, patients underwent reconstruction of the anterior urethra with a pedicled dorsal penile skin tube. In brief, before corpora amputation and radical urethrectomy, the dorsal penile skin is preserved to reconstruct the neourethra. The distal end of the skin is anastomosed with the proximal urethral stump (usually membranous urethra) to assure continuity of the urinary tract, without jeopardising urinary continence. Finally, the flap is tubularized with two layers of watertight running sutures.

Median age was 50 (35–70) years. Histology revealed squamous cell carcinoma in all patients. Almost 100% of patients presented locally advanced (pT3–4, G3) disease and received perioperative chemotherapy (MVAC). The median follow-up was 10 (5–24) months. Median operative time was 230 min (190–315). There were not severe (Clavien–Dindo III–IV) perioperative complications. All patients were able to void in standing position through the reconstructed neourethra. No patients reported post-operative incontinence. Two patients died after 8 and 11 months from surgery.

This new technique of using the dartos-based dorsal penile skin tube urethroplasty offers the possibility to void in standing position after radical penectomy with no need of urinary derivations.

Not applicable.

Intravesical Bacillus Calmette–Guérin (BCG) instillation is an established form of immunotherapy for intermediate and high-risk bladder cancers. Mandatory cystoscopic surveillance is commonly performed under general anaesthesia (GA) to facilitate biopsy or other procedures. However, it is resource-intensive with unclear clinical benefit.

We performed a two-cycle audit, before and after changing post-BCG surveillance policy, from GA cystoscopy to local anaesthetic flexible cystoscopy (LAFC) on trans urethral laser ablation (TULA) lists, where patients may undergo a tumour biopsy or laser ablation. In the first cycle, we audited 53 patients undergoing 114 post-BCG rigid cystoscopies from January 2018 to December 2019. In the second cycle, there were 56 patients undergoing 99 post-BCG LAFCs on TULA lists in 2020.

In the first audit cycle cohort, the mean patient age was 72.29 ± 8.98 years and 48 were men; malignant histology was identified only on five occasions (three grade progressions). Fourteen patients required overnight admission. In the second audit cycle cohort, the mean patient age was 70.44 ± 9.17 years and 47 were men. Four had a grade progression, while another a stage progression. Out of 99 LAFCs, 47 confirmed normal bladder appearance. A biopsy was taken during other 52 cystoscopies: 17 (33%) confirmed malignancy. Fifteen patients showed findings that were labelled as recurrence, but only two required a further GA procedure to deal with recurrence. One patient was admitted for post-procedure bleeding, which settled with irrigation.

Local anaesthetic TULA procedure is a safe and effective alternative for a GA rigid cystoscopy to survey bladders of patients on intravesical BCG therapy.

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