Assoc. Prof. Ekrem GUNER, MD
Dear colleagues,
I am honored to share with you the second issue of 2024 (volume 4, issue 3) of the Grand Journal of Urology (Grand J Urol) with the
contributions of many respected researchers and authors.
Grand Journal of Urology (GJU) aims to carry written and visualscientific urology studies to academic platforms and to make significant
contributions to the science of urology. Our journal has been abstracted/indexed in Tubitak Ulakbim TR Index, EBSCOhost, J-Gate,
SciLit, ResearchGate and Google Scholar international databases. As of these achievements, the Grand Journal of Urology (GJU) has
taken its place among the journals indexed by national and international databases.
In this issue of our journal, there are many valuable articles under the subheadings of Functional Urology, General Urology, Urological
Oncology and Urolithiasis. I hope that these carefully prepared articles will make important contributions to valuable readers, researchers
and the urology literature.
On this occasion, I would like to express my heartfelt gratitude to our authors who have contributed to our journal with their articles, to
our reviewers who have meticulously evaluate the articles.
Respectfully yours
September 2024
Assoc. Prof. Ekrem GUNER, MD
Editor-in-Chief
Emrullah Söğütdelen, Ramazan Kurul, Adnan Gücük, et al.
Prostate cancer (PCa) is one of the most common diseases
among men []. Over one million transrectal ultrasoundguided
prostate biopsies (TRUS-Bx) which are among the gold
standard diagnostic procedures for PCa have been performed
annually []. Although TRUS-Bx is an invasive procedure, it
can be performed safely, even under outpatient conditions.
Patients often feel pain during the procedure, and such methods
as intrarectal application of local anesthetics and periprostatic
nerve blockade are implemented before TRUS-Bx to reduce
intraprocedural pain []. Despite the use of various methods of
anesthesia, approximately 16% of patients experience moderate
to severe pain during the procedure and 18% of them state that
they will not accept application of such a procedure again [].
The International Association for the Study of Pain (IASP)
defines pain as "an unpleasant sensory and emotional experience
associated with actual or potential tissue damage, or described
in terms of such damage" and notes that "pain is always a
subjective feeling" []. So, pain is a subjective unpleasant
experience and therefore has an emotional impact []. Pain
can only be assessed self-reportedly because it is the unique
cognitive process of previous pain experiences of an individual
concerning duration, and intensity of pain, social parameters,
emotional stress, and memory. The sensory components of pain
are felt when the impulses are trensferred to the lateral thalamus,
somatosensory cortex, and finally to posterior insular cortex [].
The pain threshold is defined as the minimal level of pain that an
individual can recognize. To induce painful stimuli, commonly,
four different types namely pressure, electrical, thermal, and
laser-induced pain assessment techniques are used. However,
pain scores can only be assessed subjectively, and individuals
rate the pain according to their own previous experiences [].
Local anesthesia whose effectiveness in reducing
intraprocedural pain has been shown in placebo-controlled
studies is commonly applied to the periprostatic region during
prostate biopsy [-]. However, despite perception of pain is
reduced after application of anesthesia, patients still feel pain
during biopsy []. Predicting patient's discomfort during the
procedure with anxiety, pain assessment before TRUS-Bx might
be useful in reducing the intraprocedural pain of the patient.
Thus, decreasing patient's discomfort can reduce the rate of
refusals for a repeat biopsy.
In this study, we investigated the relationship between
emotional status and pain assessments in patients scheduled for
TRUS-Bx and the pain they felt during the biopsy procedure.
Yusuf Arıkan, Mahmut Can Karabacak, Ömer Koraş, et al.
According to the American Urological Association /
Endourological Society Guidelines, percutaneous nephrolithotomy
(PCNL) is recommended for patients with a stone burden greater
than 2 cm or staghorn stones in the pelvis []. PCNL which is
performed by puncturing the renal parenchyma, is more successful
in terms of stone removal compared to other endoscopic
procedures, but with an increased risk of complications. With the
technological developments on PCNL, it has been associated with
lower rates of postoperative complications, lesser pain, shorter
hospital stay and decreased hospital readmission (HR) rates
[,]. HRs and emergency room (ER) readmissions after hospital
discharge are considered as negative indicators of healthcare
quality and are associated with significant economic burden. For
these reasons, it is necessary to minimise the rate of HR and ER
referrals. [,]. In this study, we aimed to determine the patientand
procedure-related factors that increase the risk of HRs and ER
admissions after PCNL.
Abuzer Öztürk, İsmail Emre Ergin, Aydemir Asdemir, et al.
Prostate cancer is the most frequently diagnosed cancer
among men in 105 countries and is the second leading cause
of cancer-related deaths []. In patients with advanced prostate
cancer (PCa), androgen deprivation therapy (ADT) is the
standard treatment and currently the most frequently used drugs
in ADT are gonadotropin-releasing hormone agonists (GnRHs)
[]. After a median time of 18-24 months of ADT treatment,
castration- resistant prostate cancer (CRPC) will develop in
most patients [,]. In patients with metastatic CRPC (mCRPC),
median survival time is 16 months []. In most studies, various
prognostic factors have been identified indicating progression
to castration therapy, such as Gleason score (GS), the presence
of bone and visceral metastases, and performance status [,].
The prostate-specific antigen (PSA) is a useful tool in
diagnosing prostate cancer. Additionally, PSA levels are
evaluated periodically after completion of ADT for advanced
prostate cancer and used to estimate life expectancy based
on its serum levels. However, there is disagreement about the
prognostic significance of various PSA indices after hormone
therapy. Additionally, there are few studies on whether these
PSA indices accurately predict progression towards hormoneresistant
prostate cancer. ALP is one of the oldest known
tumor markers whose main sources are liver and bone. ALP
is a prognostic marker for overall survival (OS). In castrationresistant
metastatic prostate cancer patients, and its increased
levels correlate with the spread of metastatic bone disease.
Although there is not enough correlation between PSA and
ALP values in the evaluation of treatment responses, it is stated
that the evaluation of the treatment response with ALP is more
meaningful []. ALP is often used as a prognostic marker of
bone metastases. Although not certain, ALP is associated with
increased bone turnover, osteoblastic activity and osteoid
formation in the presence of bone metastasis. According to a
meta-analysis, high serum ALP levels in patients with hormonesensitive
prostate cancer were associated with increased overall
mortality and disease progression, but not with cancer-specific
mortality rates [].
Positron emission tomography/computed tomography (PET/
CT) is a hybrid imaging method that demonstrates molecular
processes of tissues as well as morphological imaging, providing
superior diagnostic performance. Prostate-specific membrane
antigen (PSMA) is a transmembrane protein primarily present
in all prostatic tissues and PSMA expression increases in
prostate cancer patients []. In recent years 68Ga PSMA PET/
CT has been the standard assessment method for prostate cancer
staging, evaluation of biochemical recurrence and treatment
response [].
In patients receiving ADT for advanced prostate cancer, PSA
levels increase 6 to 12 months before emengence of any clinical
indicators of disease progression [,]. The time to disease
progression is important for planning treatment. Indeed, when
the tumor burden is at a minimum level, the general health status
of the patients can tolerate alternative treatments. Therefore,
it is important to determine a suitable factor that can predict
progression to hormone-refractory prostate cancer (HRPC)
before the serum PSA value rises again. In this way, alternative
treatments can be applied at appropriate times. In this study, we investigated the relationship between PSA levels measured
before GnRH treatment in metastatic prostate cancer patients,
ALP levels, SUVmax values obtained by Ga-68 PSMA PET/
CT, and nadir PSA levels during follow-up and the time to the
development of castration- resistant PCa.
Bengisu Tüfekçi, Emel Sönmezer, Ömer Bayrak, et al.
Current hypotheses suggest that overactive bladder (OAB)
develops as a result of disabled inhibitory mechanisms due to
sensitized afferent nerves leading to contractions similar to
primitive voiding reflexes. Another hypothesis suggests that the
intercellular connections between detrusor myocytes increase and
the spontaneous stimulation of these cells results in OAB
[]. Despite the fact that none of these hypotheses completely
explains the pathophysiology of OAB syndrome, some writers have
proposed that sensory hypersensitivity may play a role in OAB
[,]. According to a study, up to 40% of the OAB-afflicted
women who took part associated the urge brought on by the
symptoms with pain, pressure, or discomfort rather than
the fear of incontinence, a symptom that significantly reduced
patients with OAB syndrome's quality of life and led to
admission to medical facilities [-].
Central sensitization has been suggested to be the
underlying cause of chronic pain syndromes [,]. Central
sensitization is a state of increased neuronal hyperexcitability in
response to peripheral stimuli. Primary hyperalgesia,
secondary hyperalgesia, reflected pain, and allodynia are
observed in cases where the supraspinal and spinal levels are
responsible []. Patients with central sensitization experience
pain perception changes and decreased pain threshold, which
leads to psychosocial effects and deterioration in the quality of life
[,].
Although pain is not considered a feature of OAB,
the mechanisms underlying pain perception and afferent
hypersensitivity are thought to contribute to the clinical
manifestations of OAB []. Given that central sensitization is one
of the pathophysiological processes driving OAB, it
should be kept in mind that these individuals may suffer
symptoms similar to those of chronic pain syndromes [].
Studies on the issue showed that compared to healthy women,
women with OAB experienced much more pain from bladder
symptoms [,]. However, there is no study that compared
patients with OAB to healthy controls to examine changes in
general pain perception and pain threshold.
The aim of our study was to examine the differences between pain
characteristics and quality of life in women with OAB and healthy
controls.
Jorge Abril Piedra, Patricio Garcia Marchiñena, Tomas Carminatti, et al.
Renal cell carcinoma (RCC) can present with venous
thrombus in approximately 6% of cases, and invasion of the
renal vein, and extension up to the atrium may be seen in 44%,
and 1-4 % of these cases, respectively []. Mayo clinic thrombus
classification is the most frequently used staging system to decide
on feasibility of surgical treatment. Since various treatment
methods have been used for level III tumors, Ciancio et al.
divided these tumors into 4 sublevels, so as to assess therapeutic
challenges and surgical feasibility in the management of these
tumors []. Multidisciplinary management is required from both
clinical and surgical perspectives, and the surgical intervention
is the first option in these patients [].
Systemic treatment should be considered as a first-line
alternative if a metastatic or unresectable RCC is present [].
We have described 2 cases and reviewed the available literature
up to February 2024.
Aravind TK, Sandeep Kumar, Anju Bansal
As rarely encountered neoplasms, extra-uterine leiomyomas
of urethral origin were first reported in 1894 by Buttner et al. []
They most commonly manifest themselves as perineal masses.
Apart from the rarely recognized characteristics of the disease,
unique properties such as its characteristic growth pattern and
excellent prognosis following surgical excision make it an
entity of clinical relevance with good curative possibilities.
In addition, the diagnostic difficulties owing to a long list of
possible differential diagnoses and specific complications that
accompany surgical management make urethral leiomyomas
an interesting entity to report with the aim to recognize this
pathology, and learn its characteristic features [].
Kevan English
A 22-year-old woman presented to the emergency
department with a 2-hour history of abdominal/flank pain. She
was involved in a motor vehicle collision where she was the
driver. Airbags were deployed, but her seat belt compliance
was unknown at the time of injury. Her medical history was
mysterious and unattainable due to her altered mental status. On
general appearance, the patient appeared intoxicated. Physical
examination was only significant for abdominal tenderness to
palpation. Vital signs revealed hypotension (97/64 mmHg). All
other values, such as pulse, temperature, oxygen saturation,
and respiration, were within normal limits. Laboratory values
on admission revealed elevated transaminases (AST 117/ ALT
86), and urinalysis showed hematuria (RBCs >182/HPF). All
other values were within the normal range. A FAST (focused
assessment with sonography in trauma) ultrasound was
subsequently done, which revealed free fluid collection within
the abdomen.
A multidisciplinary team, including urological surgery, was
consulted. A subsequent computed tomography (CT) scan of
the abdomen and pelvis showed intraperitoneal extravasation of
contrast, consistent with dome rupture (Figure 1). Exploratory
laparotomy was performed after and revealed a rupture across
the bladder dome (Figure 2). The bladder was surgically
repaired (3-0 Vicryl), and a Foley catheter was placed for
twelve days. On follow-up, a cystogram was performed, which
confirmed bladder healing, and the catheter was removed.
The postoperative course was uncomplicated, and the patient
completely recovered after two months.
Figure 1. A computed tomography scan of the pelvis
showing extravasation of contrast, which is consistent
with an intraperitoneal bladder rupture. A: coronal view;
B: sagittal view
Figure 2.
Laparoscopic
view of the
abdomen
demonstrating
free bloodstained
fluid in
the pelvic cavity
and rupture
across the dome
of the bladder
Bladder rupture is a rare condition due to the protection of the
bladder by the sturdy pelvic bones []. Today, bladder injuries
remain relatively uncommon, accounting for only up to 10%
of abdominal trauma [-]. Although motor vehicle collision is
the most common cause of injury, intragenic causes, including
surgical and endoscopic procedures, have also been identified [,]. Bladder rupture can be divided into intraperitoneal or
extraperitoneal rupture []. Extraperitoneal injuries are the most
common among the two, accounting for approximately 80% of
cases, with a general association of pelvic fracture with damage
to the bladder trigone, neck, or wall []. Extraperitoneal injuries
are commonly treated conservatively (with catheter drainage via
foley or suprapubic tube) []. Most bladder ruptures, regardless
of the classification, typically manifest with symptoms of
pelvic pain with difficulty voiding and gross hematuria [-].
Intraperitoneal injuries, on the other hand, account for 15%
of bladder injuries []. This typically occurs when there is a
compressive force against a full bladder, which ruptures the
weakest portion (dome) as presented in this patient [,]. A
FAST ultrasound may be positive as urine accumulates in the
abdominal cavity [,]. Treatment includes surgical repair,
which has demonstrated high success rates [-].
Recent practical guidelines regarding intraperitoneal bladder
injuries suggest surgical repair due to a more considerable risk for
lacerations with poor wound healing, electrolyte derangement,
and peritonitis [-]. According to the American Urological
Association (AUA) guidelines, extraperitoneal injuries should
be managed conservatively [-].
Acknowledgements: I would like to sincerely thank Dr.
Matthew Meece (Department of General Surgery, University
of Miami Leonard M. Miller School of Medicine/Jackson
Memorial Hospital, Miami, FL, USA) for his assistance in
interpretation of the images.
Ethics Committee Approval: Not applicable, as this is an
anonymous clinical image.
Informed Consent: The patient in this study provided written
informed consent prior to participation.
Publication: The results of the study were not published in full
or in part in form of abstracts.
Peer-review: Externally peer-reviewed.
Authorship Contributions: Any contribution was not made
by any individual not listed as an author. Concept – K.E.;
Design – K.E.; Supervision – K.E.; Resources – K.E.; Materials
– K.E.; Data Collection and/or Processing – K.E.; Analysis
and/or Interpretation – K.E.; Literature Search – K.E.; Writing
Manuscript – K.E.; Critical Review – K.E.
Financial Disclosure: This article received no specific grant or
support from any public or private agencies.