Open Access Case Study

Complete Amputation of the Male External Genitalia: Case Report and Review of Management Challenges in Sub-Saharan Africa

Odezi Fidelis Otobo, Mba Okpan Ozinko, Friday Emeakpor Ogbetere

Asian Journal of Research and Reports in Urology, Page 1-5

Background: Amputation of the entire external genitalia is a rare surgical emergency. Spousal assault following misunderstanding, self-mutilation, and trauma are known aetiologies.  Complete amputation of the external genitalia for possible ritual purposes is scarcely reported in the medical literature.

Herein, we present a case of a 34-year-old security guard whose external genitalia was excised en-bloc and taken away by unknown persons for alleged ritual purposes. This case report lends credence to the occurrence of such uncommon injuries and to re-awaken interest in their prevention and medical management. The challenges of management in the sub-Saharan African setting are also discussed.

Open Access Original Research Article

Early Outcomes of the Reprocessing and Reuse of Disposable Flexible Ureteroscope for Renal Stone Management: A Single-Center Study in Nepal

Mahesh Bahadur Adhikari, Anil Kumar Sah, Bipin Maharjan, Jessica Kayastha, Samridha Malla

Asian Journal of Research and Reports in Urology, Page 6-13

Introduction: The use of disposable flexible ureteroscopy for the management of renal stone has become an established procedure since last few years however discarding the instrument after single use possess a financial burden to the patient in resource limited countries.   Therefore, it’s an attempt to assess the cost effectiveness and the safety profile of the procedure by reprocessing   and reusing the disposable flexible Ureteroscope.

Methods: It was a hospital-based prospective observational cross-sectional study. LithoVue, Single Use Flexible Ureteroscope from Boston Scientific device was used for the procedure. Operative time, level of intra-operative performance alteration and fluoroscopic guided stone clearance were assessed. Early postoperative complications, durability of each scope, postoperative ultrasonographic stone clearance were also assessed. The cause of immature scope damage was also identified.

Results: Thirty-eight   disposable flexible ureteroscope were used for 186 procedures of mean age of 42.67 ± 14.88 years. The mean size and average CT scan hardness of the stones were 14.65 ± 9.82mm and 1017 ± 340HU respectively. The number of disposable flexible ureteroscope and the patient ratio was found to be 1:5. The mean operative time was 44.26 ± 25.16 minutes. The immature damage of the scope was seen in 9 scopes. Five patients (2.76%) developed urinary tract infection. Sonography after 6 weeks following the procedure showed that 11 patients (6%) had Clinically Significant Residual Fragment (>5mm) whereas 32 patients (17%) had Clinically Insignificant Residual Fragment (< 5mm).

Conclusion: Reprocessing and reuse of disposable flexible ureteroscope is safe and cost-effective procedure with minimal probability of cross-infection and immature scope damage if reprocessing of the device is well supervised.

Open Access Original Research Article

Bone Metastasis of Urothelial Carcinoma

Modeste Mayele-Kenfuni, Mohamed Hamirifou, Nedjim Abdelkerim Saleh, Redaa Safwate, Deogracias Nzambimana, Amine Moataz, Mohamed Dakir, Adil Debbagh, Rachid Aboutaieb

Asian Journal of Research and Reports in Urology, Page 14-23

Background: Bone metastasis of urothelial carcinoma is the third most common metastasis after the lungs and liver. Bone complications adversely affect the quality of life. They are also associated with increased mortality. The objective of this study is to describe the epidemiological, clinical and prognostic aspects of bone metastasis  of urothelial carcinoma

Materials and Methods: This is a retrospective, monocentric study of 8 cases of bone metastases of urothelial carcinoma, collected from January 2018 to September 2020 at the Ibn Rochd University Hospital in Casablanca, Morocco. The analyzed data were collected on an exploitation sheet. Incomplete records were excluded from the study.

Results: The average age of our patients was 61.37 years. All the  patients  were male  and smokers. Pain was the main calling sign and was marked  in seven patients. Four patients had anemia and 50% of the patients had acute obstructive kidney disease.

CT scanning of the body  was requested to all the patients and confirmed bone metastasis in seven patients with predominantly osteolytic lesions. The treatment was palliative and consisted of chemotherapy, radiotherapy or combined therapy. Among them,three patients  died, two of them progressed to have  new lesions and three others had stabilized lesions.

Conclusion: The presence of bone metastasis of urothelial carcinoma constitutes an unfavorable moment in the evolution of this cancer. These metastases are responsible for many complications that require multidisciplinary management.

Open Access Original Research Article

Study of Correlation between Intrarenal Pressure and Post-Operative Complications in Percutaneous Nephrolithotomy

Chitaranjan Shah, Arbind Kumar Shah, Prabodh Regmi, Robin Bahadur Basnet, Anil Shrestha, Parash Mani Shrestha

Asian Journal of Research and Reports in Urology, Page 24-31

Introduction: Even after constant advancement and miniaturization in percutaneous nephrolithotomy complications are evident. Stone burden, pre-operative microbiological status of urine, comorbidity, age, operative time, intra-operative level of sterility and antibiotic prophylaxis are commonly discussed risk factors for post-operative complications during percutaneous nephrolithotomy. Assessment of relationship between intra renal pelvic pressure and the complications was the aim of this study.

Materials and Methods: A prospective study was undertaken in patients undergoing percutaneous nephrolithotomy under fluoroscopic guidance during twelve months’ duration. The demographic characteristics, body mass index, stone characteristics (burden, density and number), rise in intrarenal pressure in relation to position of surgery, different energy sources used and size of tract, duration of operation and perioperative complications during percutaneous nephrolithotomy were recorded and the findings and outcome analyzed. 

Results: Out of 125 patients, intrarenal pelvic pressure was found to be raised >30 mmHg in 72.8% (91 cases). Forty-one patients (32.8%), developed fever, found to be significantly associated with raised intrarenal pelvic pressure >30 mmHg, (P = 0.01).   WBCs counts were significantly high among the raised intrarenal pelvic pressure group. Age of the patients, gender, body mass index and hospital stay were insignificant variables for development of fever in relation with rise in intrarenal pelvic pressure. Stone burden, prolonged duration of surgery, prone position of surgery and use of pneumatic lithotripsy were significant variables causing rise in intrarenal pelvic pressure.

Conclusion: Raised intrarenal pelvic pressure (> 30 mmHg) in association with increased stone burden, prolonged duration of surgery, prone position and pneumatic lithotripsy during percutaneous nephrolithotomy are significant risk factors for the development of post-operative complications mainly fever.

Open Access Original Research Article

An Analysis of Cases of Benign Prostatic Hyperplasia in a Tertiary Hospital in Eastern Nigeria: Incidence, Treatment, and Cost of Management

Chioma Nneoma Igwe, Unyime Israel Eshiet

Asian Journal of Research and Reports in Urology, Page 32-41

Background: Benign prostatic hyperplasia (BPH) is one of the most common conditions in aging men. Although BPH is not life threatening, the clinical manifestations such as lower urinary tract symptoms (LUTS) reduce patients’ quality of life. BPH is associated with high healthcare costs and is a burden on the patients’ families and society.

Objective: To assess the incidence, treatment pattern, and direct cost of management of BPH in a tertiary hospital, in Eastern Nigeria.

Methods: A retrospective descriptive assessment of case notes of patients diagnosed with BPH between September 2017 and August 2019. The treatment pattern was assessed for 12 months. Costs were calculated for BPH-related clinical procedures and medications.

Results: The incidence rate of BPH in this population is 6.7%. One-hundred and two case notes were retrieved and evaluated. About 50.4% of the patients visited the hospital between 2 to 4 times, with a mean visit of 4.4 times a year. Ninety-nine percent of the patients received pharmacological interventions, while the combination of alpha blockers and 5-alpha reductase inhibitors was the most frequently prescribed drug therapy for BPH. The total annual direct cost of managing BPH in this healthcare facility is about N4,966,080 (Nigerian Naira), an equivalent of $12,810 USD.

Conclusion: The combination of alpha blockers and 5-alpha reductase inhibitors was the most frequently prescribed drugs for BPH in this facility. Most patients made out-of-pocket payments hence, appropriate treatment options must be selected for each patient in other to prevent complications and reduce costs.

Open Access Original Research Article

The Role of Urinary Cytology for Detection of Urothelial Cancer in Asymptomatic Hematuria Investigations

Daisaku Hirano, Hiroki Yoshioka, Yuki Irie, Maiko Yamada, Sumito Hamano, Yoshiaki Kusumi, Fuminori Sakurai, Sho Ohno, Kenichiro Kobayashi

Asian Journal of Research and Reports in Urology, Page 42-49

Objective: To determine the diagnostic accuracy of urinary cytology to diagnose urothelial cancer for patients with asymptomatic hematuria.

Patients and Methods: A retrospective cohort study was undertaken of asymptomatic hematuria patients referred from primary care to the Department of Urology in our institution.  All patients with asymptomatic hematuria received urinary cytology examination. Urinary cytology was classified according to the Paris System.  Patients with visible hematuria (VH) underwent to examine the kidney and bladder with filling using ultrasonography (KBFU), computed tomography urography (CTU) and flexible cystoscopy, while patients with non-visible hematuria (NVH) underwent initially KBFU, and in cases of having risk factors such as smoking history and exposed to chemical substances CTU and flexible cystoscopy were additionally performed. 

Results: The study included 790 patients with a median age of 69 years.  Of these patients 235 (29.7%) had VH and 555 (70.3%) were referred for NVH.  In the VH patients 61 (30.0%) and 5 (2.1%) were histologically diagnosed as bladder cancer and upper tract urothelial cancer (UTUC), while in the NVH patients 30 (5.1%) and 2 (0.4%) were histologically identified as bladder cancer and UTUC, respectively.  In the VH group the accuracy of urothelial cancer in the urinary cytology was: sensitivity 24.2% and specificity 100%, while in the NVH group sensitivity 31.2% and specificity 100%.  In histologically confirmed 98 patients with bladder cancer / UTUC the rate of sensitivity in the urinary cytology for even high-grade cancers had only 46.0%.  The rates of sensitivity in any type of hematuria and grade increased by approximately two times with adding atypical cytology results as positive.

Conclusion: Although urinary cytology is a convenient and noninvasive test with histologically high specificity for urothelial cancer, the rates of sensitivity of urinary cytology are inferior.  However, adding atypical cytology results as positive improves accuracy of detection of urothelial cancer and prevent from the missing diagnosis.  Nevertheless, urinary cytology has its place as an additive diagnostic tool to cystoscopy and imaging diagnosis for the investigations of asymptomatic hematuria.

Open Access Original Research Article

Perioperative Complications in Monopolar Transurethral Resection of Prostate: Single Center Retrospective Evaluation of 942 Cases

Sumeet Karna, Kinju Adhikari, Mahesh Bahadur Adhikari, Rajesh Batajoo, Binod Shrestha, Atul Kasaju, Jagdish Lal Baidya

Asian Journal of Research and Reports in Urology, Page 50-57

Aims: To describe the perioperative complications in monopolar transurethral resection of prostate (M-TURP) among the patients who underwent M-TURP for benigh prostate enlargement or palliative “channel” TURP in the hospital from the year 2010 to 2019.

Study Design: Retrospective single center study.

Place and Duration of Study: Department of Urology, B and B Hospital, Gwarko, Lalitpur, Nepal, between January 2010 and December 2019.

Methodology: Hospital based electronic records were retrieved for all M-TURP done during the above mentioned period. Variables considered were age, presenting symptoms, comorbidities, diagnosis, anesthesia type, operative duration, amount of prostatic tissue resected and any perioperative complication. Multinominal logistic regression model was used to calculate adjusted odds ratio of complications between different subgroups and P value < .05 was considered significant.

Results: The overall perioperative morbidity and mortality rate was 10.3% and 0.11% respectively. Most common complications were clot retention requiring bladder wash (3.29%), urinary tract infection (2.87%) and transurethral resection syndrome (1.06%). Incontinence, bladder injury and iatrogenic urethral injury occurred in 0.96%, 0.53% and 0.53% respectively. Single case of conversion to open surgery was recorded (0.11%). Average prostatic tissue resected was 35.4 ± 15.6 grams. Operative duration more than 90 minutes was significantly associated with complication with adjusted odds ratio 2.34 (95% CI 1.17-4.66, P value .02). Factors such as age, preoperative urinary retention, predominantly storage or voiding lower urinary tract symptoms, comorbidities, anti-platelet therapy, anesthesia, amount of prostate tissue resected did not show significant association.

Conclusions: Monopolar TURP has acceptable morbidity and mortality rates which can be further minimized by limiting the duration of surgery to 90 minutes.

Open Access Original Research Article

Endourology Techniques in Children: Experience of a Nord Africain Center

M. Boughdir, S. Bellila, A. Daib, Y. Hellal, S. Nechi, M. A. Sbai

Asian Journal of Research and Reports in Urology, Page 75-83

Introduction: Bladder endoscopy in children has been improving over the last few years because of the miniaturization of the instruments. It seems to be now the method of choice for the diagnosis and the management of many pediatric diseases with low morbidity and excellent results.

The aim of our study was to discuss the role of cystoscopy in pediatric surgery and to overview its future prospects.

Methods: Between January 1st, 2019 to December 31, 2019, patients who underwent a cystoscopy were reviewed retrospectively. This monocentric study has been conducted by the department of Pediatric Surgery in Habib Thameur Hospital., Tunisia.

Results: 39 males and 27 females were included in our study.  The average age was three years. The different etiologies were: the vesico-ureteral reflux in 29 patients; pelvi-ureteric junction obstruction in 22 patients, ureterocele in 4 patients, posterior urethral valves in 2 patients, megaureter in 2 patients, and others in 7 patients. The endoscopy was performed for a therapeutic purpose in 60 cases and for a diagnostic one in 6 cases.

The endoscopy made it possible to diagnose a bladder tumor and to perform a biopsy, to investigate hematuria or a gender ambiguity, or to exclude. the diagnosis of urethral valves.

The urethrocystoscopy was performed for the injection of Deflux®, the treatment of posterior urethral valves, and ureteroceles. It was also used for placing or removing JJ stents.

Conclusion: Many instrumental innovations have expanded the indications for bladder endoscopy in children. The field of robotics is also knowing as a big expansion with a high precision of work and great results but the high cost of these technics remains a big challenge in our country.

Open Access Review Article

Efficacy of Mirabegron Compared with Tolterodine, Placebo, and Different Doses of Mirabegron on OAB Patient Evaluated in 4 Weeks Period: A Meta-Analysis

Christian Nurtanto Putra, Kevin Ivandi, Kadek Adit Wiryadana, Pande Made Wisnu Tirtayasa, Gede Wirya Kusuma Duarsa

Asian Journal of Research and Reports in Urology, Page 58-74

Introduction: Mirabegron is one of the therapeutic options in overactive bladder where its efficacy and safety are better than antimuscarinics in several existing studies. Tolerability, treatment duration, and cost are often the deciding points for patient adherence and compliance in taking treatments. Many patients and doctors expect fast and visible results with relatively short treatments duration. This meta-analysis study describes and compares the efficacy of mirabegron compared with antimuscarinic, placebo or different doses of mirabegron over 4 weeks’ treatment range.

Methods: A literature search was performed using the Cochrane Library, Pubmed, and 5 other journal database. The literature reviewed included randomized and nonrandomized prospective and clinical trial studies. Mean difference (MD) was used to assess micturition frequency, incontinence episode, mean volume voided, nocturia episodes, urgency episodes, urgency incontinence episodes, and level of urgency of patients recorded within 4 weeks treatment duration. We used the Cochrane Collaboration’s Review Manager 5.4.1 software for statistical analysis

Results: Six publications that met eligibility criteria was included in this study. Meta-analysis of extractable data showed that Mirabegron was found significantly more efficacious than placebo for majority of efficacy endpoints recorded within 4 weeks’ treatment duration. In contrast, the comparison of mirabegron with tolterodine 4 mg showed no significant difference in outcome across all seven assessment criteria. On the other hand, mirabegron was also found to be more efficacious when administered in higher doses compared to lower doses at the majority efficacy endpoint

Conclusion: Withtin 4-week treatment duration, Mirabegron can provide significant results compared to placebo. However, the results are still not much different from tolterodine. Higher doses of mirabegron also provide a better result when compared with lower doses. The lowest dose with statistically significant results compared to placebo was obtained from mirabegron 25 mg.