Urology

New treatment modalities with vaccine therapy in renal cell carcinoma Mehmet Giray Sönmez, Leyla Öztürk Sönmez Urology Annals 2019 11(2):119-125 The aim of implementing vaccine therapy is to activate immune response against malignant cells by overcoming the tolerance triggered by the tumor. These treatments are effective using the immune response against cancer. Not every type of cancer is suitable for vaccine therapies. For a vaccine therapy to be implemented, cancer should be immunogenic and contain tissue-specific proteins, should have a slow progression, and treatments should be feasible. For that reason, studies regarding urological cancers are mostly focused on the kidneys and the prostate. Vaccine therapies used in renal cell carcinoma (RCC) can be categorized under the following titles: autologous tumor cells, dendritic cells, genetically modified tumor cells, and protein/peptide. Although there are old studies on the implementation of vaccine therapies in RCC, researches have only been intensified recently. In addition to their effective potential for lengthening general survival, decreasing tumor burden and cancer development in long term, vaccine treatments are especially effective in metastatic RCC patients. We think that vaccine treatments would be applied more in near future since RCC are immunogenic. In this compilation, we will discuss vaccine therapies used in RCC, which urologists are not so familiar with, in the light of the up-to-date literature.

Guideline on writing a case report Basim Saleh Alsaywid, Nada Mansour Abdulhaq Urology Annals 2019 11(2):126-131 Research is an important competency that should be mastered by medical professionals. It provides an opportunity for physicians to develop numerous skills including communication, collaboration, time management, and teamwork. Case report, as a research design, describes important scientific observations that are encountered in a clinical setting to expand our knowledge base. Preparing a case report is far easier than conducting any other elaborative research design. Case report, with its main components, should be focused and delivers a clear message. In this article, the key components of a case report were described with the aim of providing guidance to novice authors to improve the quality of their reporting.

Lower urinary tract symptoms and feeling of incomplete emptying in Saudi Arabian men and its correlation with postvoid residual urine Reem Aldamanhori Urology Annals 2019 11(2):132-134 Purpose: This study was conducted to assess the clinical value of postvoid residual (PVR) urine measurement and associate it with the feeling of incomplete emptying in men with lower urinary tract symptoms. Methods: Two hundred men were surveyed in the King Fahd Hospital of the University. Patients who had previous urological surgery and patients who are currently on urology treatment were excluded. Information from the remaining 181 patients was analyzed. International Prostate Symptom Score (IPSS) sheets were filed, and then, the PVR was measured. Results: Data from IPSS sheets were evaluated: 45 patients (24.8%) were characterized as experiencing no symptoms (Score: 0 and 1), 87 (48%) as mild-to-moderate symptoms (Score: 2 and 3), and 49 (27%) as severe symptoms (Score: 4 and 5). The PVR measurement showed no statistical difference in all three categories (being 10, 13, and 12, respectively). Feeling of incomplete emptying despite little PVR was frequently observed. Conclusion: The study concluded that the feeling of incomplete emptying was poorly correlated with PVR urine volume measurement. This feeling was significantly associated with worsening of both voiding and storage symptoms.

Incidence of prostate cancer among patients with prostate-related urinary symptoms: A single institution series in 10 years Khalid M Alotaibi Urology Annals 2019 11(2):135-138 Purpose: The aim of the study is to correlate between the value of digital rectal examination (DRE), serum prostate-specific antigen (PSA), and transrectal ultrasound (TRUS) as predictors for diagnosing prostate cancer in patients with voiding symptoms. Materials and Methods: A total of 1610 male patients seen over a period of 10 years in a single institution had prostate-related voiding problems. Routine studies including DRE and serum PSA were done to all patients. TRUS and TRUS biopsy were performed for patients with suspected prostatic cancer based on abnormal DRE findings and/or serum PSA levels. Results: TRUS biopsy revealed prostate cancer in 206 out of 1610 patients with prostate-related voiding problems (13%), 40% had abnormal PSA and 28% had abnormal DRE. Combined abnormal PSA and DRE revealed cancer in 63% of patients. This percentage increased to 90% when TRUS was also abnormal, but dropped to 54% when TRUS was normal. Conclusions: DRE together with serum PSA and TRUS have the highest predictable values for diagnosis of prostate cancer among patients with voiding symptoms. In the absence of abnormal TRUS, PSA and DRE together are more predictable than either alone. Serum PSA alone is more predictable than DRE. Random prostate biopsies should be performed in the presence of high serum PSA, and/or abnormal findings by DRE in male patients with urinary symptoms suggestive of the prostate disease.

Pain and anxiety assessment during cystourethroscopy in males using voiding instruction: A prospective, randomized controlled study Debansu Sarkar, Kunal Kapoor, Dilip Kumar Pal Urology Annals 2019 11(2):139-142 Introduction: Office cystourethroscopy is one of the common and most frequent urological procedures. Pain and anxiety during the procedure might lead to noncompliance and incomplete cystoscopic examination. Negotiating cystoscope through external sphincter is the most painful and uncomfortable distressing part of cystoscopy. To overcome this, manual compression of irrigation bag during cystoscopy has been used and found to be helpful. Numerous other methods were also studied. Despite these, cystoscopy is still painful and causes anxiety in patients. External sphincter gets relaxed naturally during the act of micturition. Based on this principle, pain and anxiety were studied with voiding instruction during cystourethroscopy. Objective: To study the effect of voiding instruction on anxiety and pain during cystourethroscopy using the Hamilton Anxiety Rating Scale (HAM-A) and visual analogue scale (VAS), in a well-matched Eastern Indian male patient population in a prospective, randomized pattern. Methods: A total of 100 male patients were recruited from those who underwent cystourethroscopy examination in SSKM Hospital and were prospectively randomized into two groups: cystoscopy with or without voiding instruction. Pre- and postprocedure HAM-A score and postprocedure VAS score were recorded. Results: The mean postprocedural pain (VAS) score between voiding instructed and noninstructed groups reached statistical significance: 3.06 ± 1.98 (Range, 2–5) and 5.16 ± 2.86 (Range, 4–8), respectively (P < 0.001). Preprocedure HAM-A score was similar between both groups. Postprocedure median HAM-A score was statistically significantly lower (mean 17.86 ± 2.8 vs. 19.76 ± 3.12; P < 0.001) in voiding instructed group. Conclusion: Pain and anxiety level during cystourethroscopy examination in males can be significantly reduced when the patient is instructed to void during cystourethroscopy examination.

Effectiveness of bladder tumor antigen quantitative test in the diagnosis of bladder carcinoma in a schistosoma endemic area Abubakar Sadiq Muhammad, Ismaila Arzika Mungadi, Nnaemeka Ndodo Darlington, Garba Diffa Kalayi Urology Annals 2019 11(2):143-148 Introduction: Bladder carcinoma is the most common male cancer in our environment due to endemicity of schistosomiasis. Squamous-cell carcinoma is the most common histological type and patients present at an advanced stage. The objective of this study is to compare the sensitivity, specificity, and predictive values of the bladder tumor antigen quantitative test (BTA TRAK) and urine cytology in the diagnosis of bladder carcinoma in a schistosoma endemic area. Materials and Methods: This is a 12-month cross-sectional study of 88 patients, 52 of them with features of bladder carcinoma as study group, and 36 of them with hematuria from other urologic conditions, and benign urologic conditions and healthy volunteers as control group (CG). The mean ages of patients in the study and CGs were 47.17 ± 17.00 and 44.19 ± 18.89 years, respectively (P = 0.412). Bladder tumor antigen was assayed using enzyme-linked immunosorbent assay. Data were analyzed using SPSS version 20.0 for Windows. Results: The sensitivity of urine cytology and BTA TRAK in the study was 29.1% and 98.8%, respectively. The specificity of urine cytology and BTA TRAK was 95.5% and 13.6%, respectively (P = 0.05). The positive predictive values of urine cytology and BTA TRAK in the study were 96.2% and 81.7%, respectively. The negative predictive values were 25.0% and 75.0% for urine cytology and BTA TRAK, respectively. Conclusion: BTA TRAK is more sensitive but poorly specific as compared to that of the urine cytology for bladder cell carcinoma detection in a schistosoma endemic area.

Investigation of the reasons for withdrawal from long-term treatment with mirabegron of treatment-naïve Japanese female patients with overactive bladder in the real-world clinical setting Yoshinori Tanaka, Yasushi Tanuma, Naoya Masumori, Hirofumi Ohnishi Urology Annals 2019 11(2):149-154 Purpose: The persistence of treatment with mirabegron and the reasons for withdrawal from the treatment among treatment-naïve Japanese female patients with overactive bladder (OAB) were prospectively investigated for 3 years in the real-world clinical setting. Materials and Methods: A total of 62 treatment-native Japanese female patients clinically diagnosed with OAB were treated with mirabegron and prospectively followed for 3 years. The persistence rate was estimated using the Kaplan-Meier method. If mirabegron had to be terminated or a patient did not come to the hospital to receive a prescription, the reasons for withdrawal from treatment were determined. Results: The 6-month, 1-year, 2-year, and 3-year persistence rates were 51.6%, 38.7%, 32.3%, and 25.8%, respectively. The most frequent reasons for withdrawal from treatment with mirabegron were symptom resolution (38.7%), deterioration of comorbidity unrelated to OAB (12.9%), lack of efficacy (8.1%), and adverse events (4.8%). Conclusions: The persistence rate of treatment with mirabegron among treatment-naïve Japanese female patients with OAB is low for 3 years in the real-world clinical setting. Many patients discontinue the treatment for various reasons, the most frequent of which is symptom resolution. These findings provide important considerations for clinicians whose patients are continuing medication for OAB.

Evaluation of response in patients of metastatic castration resistant prostate cancer undergoing systemic radiotherapy with lutetium177-prostate-specific membrane antigen: A comparison between response evaluation criteria in solid tumors, positron-emission tomography response criteria in solid tumors, European organization for research and treatment of cancer, and MDA criteria assessed by gallium 68-prostate-specific membrane antigen positron-emission tomography-computed tomography Manoj Gupta, Partha Sarathi Choudhury, Sudhir Rawal, Harish Chandra Goel, Shriram Avinash Rao Urology Annals 2019 11(2):155-162 Introduction: We evaluated various morphological and molecular response criteria in metastatic castration-resistant prostate cancer (PCa) patient undergoing peptide receptor radioligand therapy (PRLT) with Lutetium177-prostate-specific membrane antigen (PSMA) by using Gallium 68-PSMA positron-emission tomography-computed tomography (Ga68-PSMA PET-CT). Methods: A total of 46 pre- and 8–12 weeks' post-PRLT Ga68-PSMA PET-CT studies were reanalyzed (23 comparisons). Prostate-specific antigen drop of ≥50% and ≥25% increase was considered as partial response (PR) and progressive disease (PD), respectively, for biochemical response (BR) while change in-between was considered as stable disease (SD). Response evaluation criteria in solid tumors 1.1 (RECIST 1.1) and MD Anderson (MDA) criteria for morphological response while PET response criteria in solid tumors 1.0 (PERCIST 1.0) and European organization for research and treatment of cancer (EORTC) criteria for molecular response were used. Kappa coefficient was derived to see the level of agreement. Results: The proportion of PD, PR, and SD by BR and RECIST criteria was 9 (39.13%), 3 (13.04%), and 11 (47.83%) and 5 (21.74%), 2 (8.70%), and 16 (69.57%), respectively. The proportion of PD, PR, and SD was same by PERCIST and EORTC criteria and which were 8 (34.78%), 5 (21.74%), and 10 (43.48%). The proportion of PD, PR, and SD by MDA criteria was 1 (4.35%), 1 (4.35%), and 21 (91.30%), respectively. Poor agreement between BR and both morphological criteria while a statistically significant agreement with both molecular criteria seen. Conclusion: We concluded that molecular criteria performed better than morphological criteria in response assessment by Ga68-PSMA PET-CT in metastatic castration resistant PCa patients undergoing PRLT.

Effects of fluid absorption following percutaneous nephrolithotomy: Changes in blood cell indices and electrolytes Dipti Saxena, Divyangna Sapra, Atul Dixit, Saurabh Chipde, Santosh Agarwal Urology Annals 2019 11(2):163-167 Background and Aims: Effects of fluid absorption on hematological profile in the immediate postoperative period in patients undergoing percutaneous nephrolithotomy (PCNL) have not been given due importance. Considering the limited number of studies available, we conducted this study to evaluate the changes in hemodynamics, complete blood count (CBC), and electrolytes in patients undergoing PCNL using normal saline for irrigation in the prone position. Furthermore, we evaluated the common factors known to affect the absorption. Materials and Methods: Forty American Society of Anesthesiologist Class I or II patients aged 18–65 years were recruited who underwent PCNL under general anesthesia. Heart rate, blood pressure (BP), CBC, and serum electrolytes were recorded preoperatively and just before extubation and compared using the Student's t-test. Correlation of these changes with height and total volume of irrigating fluid, total time of irrigation, duration of operation, and total intravenous fluids administered intraoperatively were performed using the Pearson's correlation coefficient. Results: There was a statistically significant fall in mean hemoglobin (12.5 g/dL to 11.5 g/dL), packed cell volume (38.6%–35.6%), platelet count (2.9 × 105 cells/μL to 2.5 × 105 cells/μL), and sodium ion concentration (Na+) (138.9 meq/L to 137.7 meq/L) in the immediate postoperative period as compared to that of the preoperative values. Rest of the blood indices and electrolytes did not show any significant change. There was a significant rise in postoperative heart rate and BP. Postoperative systolic BP showed a significant positive correlation with the total volume of irrigating fluid. No significant correlation was observed with height and total time of irrigation. Conclusion: This study reveals that there is a significant fall in hemoglobin and Na+ during PCNL in the immediate postoperative period. Only, total volume of irrigating fluid and total duration of surgery had a significant correlation with blood cell indices.

Practice patterns in ordering a voiding cystourethrogram for pediatric patients among different specialties in a Middle Eastern Tertiary care center Mohammad Hout, Bilal Aoun, Lamya Ann Atweh, Ali Merhe, Yaser El-Hout Urology Annals 2019 11(2):168-170 Introduction: Voiding cystourethrogram (VCUG) is a very popular test performed to evaluate genitourinary tract anomalies. Nevertheless, this test can be overused and can lead to unnecessary patient discomfort, radiation exposure, and cost. We sought to study the practice patterns in ordering a VCUG in a Middle Eastern tertiary care center. Methods: Over a period of 3 years, a retrospective analysis of all VCUG images done for pediatric patients in a single center was made. Further clinical details were extracted from the electronic health records. The specialty of an ordering physician and the reported indication for the procedure were noted. Indications for VCUG were recorded based on the AAP 2011 guidelines, NICE guidelines 2007, and ACR 2011 guidelines. Based on these criteria, patients were analyzed. Results: A total of 92 VCUGs were evaluated. Of all VCUGs done, pediatricians ordered the most VCUGs (50/92), followed by pediatric infectious disease (16/92), pediatric nephrology (9/92), pediatric urology (7/92), adult urology (5/92), pediatric surgery (3/92), obstetrician-gynecologist (1/92), and emergency medicine (1/92). Properly indicated VCUGs were 50% by general pediatrics, 55% by pediatric infectious disease, 45% by pediatric nephrology, 40% by adult urology, 33% by pediatric surgery, and 100% by pediatric urology. Conclusion: VCUG is utilized differently by different specialties. In some centers, adult specialties may order a pediatric VCUG. General pediatricians order VCUG the most with a tendency for misuse in up to 50%. Pediatric urology is not the most ordering specialty of VCUG; however, it utilizes it most appropriately. The noted practice patterns may be improved with awareness of the indications and limitations of the study and with proper referral.