Grand Journal of Urology
E-ISSN : 2757-7163

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Assoc. Prof. Ekrem GUNER
Dear colleagues, I am honored to share with you the first issue of 2023 (volume 3, issue 1) 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 visual scientific urology studies to academic platforms and to make significant contributions to the science of urology. Our journal has been abstracted/indexed in EBSCOhost, J-Gate, Index Copernicus International, EuroPub, SciLit, ResearchGate, ScienceGate and Google Scholar international databases. As of these achievements, the Grand Journal of Urology (GJU) has taken its place among the journals indexed by international databases. In this issue of our journal, there are many valuable articles under the subheadings of Urological Oncology, Neurourology, Urolithiasis and General Urology. 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 January 2023 Assoc. Prof. Ekrem GUNER, MD Editor-in-Chief
Ali Unsal, Serhat Cetin, Fazil Polat, et al.
Prostate cancer is the second most common cancer in men, and approximately 1.1 million new cases are diagnosed annually []. Prostate cancer in more than 90% of the patients is organconfined at the time of diagnosis []. Radical prostatectomy (RP) is the only definitive treatment alternative in localized disease, while it is performed as a part of multimodal therapy in locally advanced disease. In the 2020 EAU guidelines, there is a weak recommendation that none of the RP techniques (open, laparoscopic, robotic) is superior to each other in terms of functional and oncological results []. Over the years, thanks to the better definition of deep dorsal venous complex, puboprostatic ligaments, prostate shape and sphincter anatomy, RP techniques developed and contributed favorably to oncological and functional results [-]. In spite of the improvement in surgical techniques, urinary incontinence after RP remains an important complication that adversely affects patients" quality of life. In a meta-analysis including 51 articles, incontinence rates of patients who underwent RALP were evaluated. According to this meta-analysis, in the studies in which no pad use was accepted as full continence, the mean rate of incontinence at postoperative 12th months was shown as 16% (4-31%). In other studies which defined full continence as either no urine leakage or usage of security pads, this rate dropped to 9% (8-11%) []. Consequently, the preservation of urinary continence is an important target in patients undergoing RP. Anatomical and functional studies have shown that the length of the functional urethra is between 1.5-2.4 cm, and a significant part of it is located intraprostatically between the prostate apex and the colliculus seminalis [-]. In 2011, it was shown that the continence rate in patients who underwent open RP with the full functional-length urethral (FFLU) sphincter preservation technique defined by Schlomm et al. was significantly higher in the first week after catheter removal compared to patients who did not undergo this surgical technique. However, no significant difference was found between these two techniques in terms of continence rates at 12 months after catheter removal. Even if long-term continence results are comparable, earlyterm continence is an important desirable outcome for patients with incontinence anxiety. FFLU technique aims to preserve the functional urethral length in the patient by maintaining the integrity of the intraprostatic part of the urethra, including the colliculus seminalis []. The "collar technique" (CT) described by the Bianchi L et al. is the adaptation of the FFLU technique to RALP. Before the collar technique was described in the literature, we were performing the RALP procedure in our clinic by applying almost the same technique and planning to describe this technique. However, after this demonstrative new technical article published by Bianchi L et al., we have just aimed to compare our results with those of the standard technique [].
Dogukan Sokmen, Bedriye Koyuncu Sokmen
In developed countries, prostate cancer (PCa) is the most commonly diagnosed cancer in men and is the second-most common cancer overall. Recent epidemiologic studies have found a correlation between obesity and a rise in the incidence of various cancers. Obesity is linked to aggressiveness of PCa, a poor response to treatment, and a high risk of cancer- specific mortality [,]. Increased periprostatic fat tissue contributes to the development and progression of PCa which may be due to the disruption of adipokines (such as adiponectin, leptin, CCL7, etc.) secreted from enlarged periprostatic fat tissue [,]. Furthermore, increased periprostatic fat thickness (PPFT) is related to a higher stage or grade of PCa [,]. Magnetic resonance imaging (MRI) measures PPFT and visceral fat at multiple levels of the body. As a result, we believe that the measurement of PPFT with MRI could be a useful diagnostic tool for PCa. However, few studies have been conducted on the utility of PPFT in detecting PCa or clinically significant PCa (Gleason score 3+4 or higher). In this study, we aim to investigate the relationship between PPFT on MRI and GS.
Ismail Evren, Yusuf Arikan, Deniz Noyan Ozlu, et al.
Testicular malignancy (TM) is the most common solid organ cancer in men aged 15-35 years and constitutes 1-1.5% of all male cancer cases []. Patient outcomes are very favorable with early diagnosis which increases the importance of diagnosis and treatment of testicular malignancies in their early-stages. The methods used in diagnosing TM are as follows: physical examination, imaging techniques, analysis of laboratory parameters, and tumor markers. In the literature, besides the studies showing the relationship between some hematological parameters with inflammation and tumorigenesis, the close relationship between the inflammatory response with tumorigenesis and invasion has also been demonstrated []. Inflammation plays a role in every step of carcinogenesis by various mechanisms []. Changes in the systemic inflammatory response can be evaluated using hematological parameters. Indeed, changes in C-reactive protein (CRP) levels, and the neutrophil-lymphocyte ratios (NLRs) are indicators of systemic inflammatory response in many malignancies []. The association of high NLR value with poor prognosis in some urological cancers has been shown in previous studies []. NLR is not only a marker of systemic inflammatory manifestations, but also a valuable predictor in many malignancies []. There is an increasing interest in easy-to-obtain hematological parameters, such as NLR to predict cancer prognosis and inflammatory conditions. NLR, LMR, PLR, and MPV can be used as prognostic predictive factors in many clinical conditions []. In the current study, we retrospectively examined these parameters that can be easily evaluated in clinical practice in patients diagnosed with TM in comparison with a control group of similar age that underwent varicocelectomy. Thus, we aimed to investigate the effects of these hematological parameters on the prognosis of TM.
Mehmet Sevim, Sibel Canbaz Kabay, Bekir Aras, et al.
Multiple sclerosis (MS) is a chronic young adult disease that shows its effect in the central nervous system (CNS) and manifests itself with attacks. It is an autoimmune and demyelinating disease. The disease mainly affects the brain and spinal cord, and is characterized by the accumulation of demyelinating plaques in the white and gray matter. In addition, atrophy and irreversible axonal degeneration can also be observed []. Demyelinated lesions and plaques eventually cause lower urinary tract dysfunction (LUTD) during the progressive course of the disease, depending on their localization in the CNS. LUTD may present in 5-10% of MS patients as the first symptom, but neuro-urological symptoms occur in 80% of patients 10 years later during the course of the disease. Depending on the location of the lesion, detrusor overactivity (DO), detrusor sphincter dyssynergia (DSD), or hypocontractility may occur during the course of the disease []. There are many medical and surgical treatment options for DO, but their therapeutic success is controversial. The firstline treatment of DO includes bladder training, pelvic floor muscle training, and anticholinergics. Since side effects of anticholinergic drugs which are among effective treatment options for DO such as dry mouth and constipation are common, only 20% of patients continue to take these drugs after 6 months [,]. Treatment options such as neuromodulation, intravesical botulinum toxin injection, bladder augmentation, detrusor myomectomy and urinary diversion are available for patients who discontinue the treatment due to its side effects, do not want to use drugs, or do not benefit from medical treatment. Percutaneous tibial nerve stimulation (PTNS) can be preferred as a safe and effective treatment option for the patients with DO symptoms who have not benefited from conservative and medical therapy or did not respond to treatment with at least two oral anticholinergic drugs [,-]. It has been reported that neuromodulation of the sacral nerve plexus (S2-4 roots) can be achieved by stimulating the posterior tibial nerve (PTN). The PTN contains mixed motorsensory fibers that originate from L5 through S3 in the spinal cord. It modulates the innervation to the bladder, urinary sphincter, and pelvic floor. The mechanism of PTNS in attenuating lower urinary tract symptoms (LUTS), however, is not yet fully understood [,,]. The effectiveness of PTNS for LUTS in overactive bladder (OAB) has been demonstrated in several studies []. It has been also reported that interruption of PTNS treatment may result in the reappearance of OAB symptoms []. Therefore, the introduction of maintenance therapy for PTNS is important for the treatment plan. Our study aims to reveal the changes in LUTS after 24 months of maintenance PTNS therapy in MS patients.
Mammadbaghir Aghasiyev, Cemil Kutsal
Bladder cancer is the second most common cancer of the genitourinary system. It ranks 7th in the male population worldwide and 11th in both genders. The average age at diagnosis is 65 years. By this age, 75% of bladder cancers are localized, while 25% of them metastasize to lymph nodes or distant organs []. Non-muscle invasive bladder cancer (NMIBC) consists of the majority of urothelial carcinomas, and it is the most expensive group receiving cancer treatment []. Cystoscopy is the gold standard diagnostic procedure used during diagnostic process and follow-up of these patients []. Urine cytology was expected to replace cystoscopy due to its low false-positive rates and high specificity, but it could not give the desired result due to its low sensitivity and its inability to recognize low-grade tumors [-]. Furthermore, NMIBCs are tumors with a high potential for progression and recurrence. Therefore, control and follow-up of the patients are essential. Various studies have been conducted on the factors affecting the recurrence and progression of bladder cancers []. However, any biomarker has not been used routinely in daily practice. An ideal tumor marker should be specific for the tumor being screened, should not yield positive results in other diseases or conditions, should demonstrate diagnostic sensitivity in the early stage of the disease and screening of small tumors, and should be able to identify all tumors in question. Since cystoscopy is the gold standard method for detecting bladder tumors the cystoscopic findings reported up to date in all studies have been evaluated and some sensitivity and specificity rates have been retrieved [,]. Considering that cystoscopy is practitionerdependent, using an additional diagnostic method and urologist"s prior knowledge about the NIMBC before application of the cystoscopy procedure may increase the detection rate of the tumor during cystoscopy []. As an actively used up-to-date parameter in the treatment and follow-up of many diseases, NLR suggestively predicts disease recurrence and progression in oncological patients []. Therefore, in this study, we aimed to investigate the predictive value of NLR in determining disease progression and recurrence in patients with NMIBC.
Kaan Karamik, Mehmet Kisaarslan
Bladder calculi occur most commonly as a result of either migration from the upper urinary tract or in the presence of predisposing conditions such as bladder outlet obstruction, neurogenic bladder dysfunction, intravesical foreign body, bladder augmentation, and urinary diversion []. Although stone formation around a foreign body in the bladder is common, the presence of a bladder stone around a foreign body with a bladder tumor is a very rare condition. We report the case of a patient who was admitted to our clinic with lower urinary tract symptoms (LUTS), recurrent urinary tract infection (UTI), and a hanging bladder stone formed around a nonabsorbable suture material and concurrent bladder tumor.
Seref Coser, Melih Balci, Serra Kayacetin, et al.
Although spontaneous retroperitoneal hematomas have a low incidence, the morbidity and mortality of the condition is high. Acute abdominal pain is a common presenting complaint in patients visiting the Emergency Department (ED). Spontaneous retroperitoneal hematoma is mostly of renal origin (rupture of parenchymal lesions such as angiomyolipomas, cysts and kidney carcinomas) []. Acute adrenal hemorrhage is rare but may have devastating outcomes. Main causes of acute adrenal bleedings are trauma and ruptured neoplasms. Adrenal myelolipoma is a benign tumor that contains mature fat cells and relatively young hematopoietic elements. Rarely, spontaneous rupture leading to retroperitoneal hemorrhage develops in some large lesions. Herein, we report a patient with a giant adrenal myelolipoma that presented with retroperitoneal hemorrhage and underwent emergency surgery.

Image Column

Does the Apical Dissection Technique Affect the Oncological and Functional Outcomes in Robot-assisted Laparoscopic Radical Prostatectomy? Collar Technique vs Standard Technique

In spite of the improvement in surgical techniques, urinary incontinence after RP remains an important complication that adversely affects patients’ quality of life. Anatomical and functional studies have shown that the length of the functional urethra is between 1.5-2.4 cm, and a significant part of it is located intraprostatically between the prostate apex and the colliculus seminalis []. 

An Extremely Rare Case: A "Hanging" Bladder Stone Concurrent with Bladder Cancer

Bladder stones constitute 5% of all urinary tract stones and males are more frequently affected []. Bladder stones are traditionally classified as primary, secondary, and migrant. Secondary stones occur as a result of predisposing conditions such as bladder outlet obstruction, neurogenic bladder dysfunction, foreign bodies, renal transplantation, bladder augmentation, and urinary diversion.

Correlation of Periprostatic Fat Thickness Measured on Multiparametric MRI with Prostate Cancer Aggressiveness

The periprostatic fat tissue is thought to be a metabolically active capsule-shaped organ. The relationship between periprostatic adipose tissue and the development and progression of PCa has attracted attention because of its potential role in the tumor microenvironment. The majority of studies showed a correlation between periprostatic fat tissue and the aggressiveness of PCa [].

A Rare Cause of Retroperitoneal Hemorrhage: Spontaneous Rupture of a Giant Adrenal Myelolipoma

Adrenal myelolipoma is a benign tumor containing hematopoietic and fat cells that are usually non-functional in hormonal evaluation. They are frequently detected incidentally and are the second most common cause of adrenal incidentalomas, preceded by adrenal adenomas (6-16%) []. They are usually diagnosed after the fifth decade of life.

Diphallus: A Rare Urological Anomaly- What to Do Next? Case Report and Literature Review

Diphallus, which is also known as diphallia, is a very rare congenital anomaly encountered nearly one in 5.5 million population. Since the first case was presented by Wecker in 1609, only 120 cases have been reported in the literature so far. Vast majority of cases with diphallus were accompanied by various congenital anomalies mainly genitourinary and anorectal malformations. Diphallus can be classified as glandular diphallus, bifid diphallus, and complete diphallia according to the anatomical structure involved.

Relationship Between SUVmax and ADC Values of Metastatic Lymph Nodes Detected by Ga-68 PSMA PET/MR in Prostate Cancer Patients

Prostate specific membrane antigen (PSMA) is a type 2 integral membrane protein which is shown to be overexpressed in prostate cancer cells []. Expression of PSMA increases with the grade of cellular dysplasia []. As the grade of prostate cancer increases PSMA expression also increases []. For imaging and therapeutic use, PSMA is radiolabeled with different radionuclides and to date Gallium-68 labeled PSMA (Ga-68 PSMA) is the most commonly used PSMA-targeted radiopharmaceutical for imaging.

Focal Ablation Therapies in Prostate Cancer

According to published data,focal ablation therapies appear to be well tolerated and have an acceptable side effect profile. Moreover, while clinical outcomes were not homogenous, short-term oncological results of some focal ablation therapies such as laser and irreversible electroporation (IRE) have been found as good as curative ones.

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Acute urinary retention is one of the most common situations encountered in urological emergencies. It is more frequently seen in older men. Acute urinary retention in pregnant women is a rare condition but it may cause abortus, preterm labor and rarely uterine ischemia. It is very difficult to reveal the causes of acute urinary retention in pregnant women. One of them is acute urinary retention due to retroverted uterus which is observed in 11% of pregnant women.  In this case, we discussed a young pregnant patient who presented to our outpatient clinic.
Primary or secondary lymphoma of the prostate is a rare condition. Mantle cell lymphoma (MCL) represent 4-9% of all lymphomas. Prostate involvement with MCL is very rare, with only 11 reported cases up to now. Here we present a case with lower urinary tract symptoms and prostate-specific antigen (PSA) elevation diagnosed with MCL of the prostate. Prostate biopsy was performed in a 70-year-old patient due to increased PSA. After the pathology result was reported as prostatic MCL, imaging studies and sampling of additional pathological specimens were performed for staging.
Immunosuppressive therapy is related to the increasing frequency of malignancies after transplantation. A small percentage (4.6%) of malignancies seen in kidney transplant patients are renal cell carcinomas (RCC) which occur almost exclusively in native kidneys. The prognosis of RCC largely depends on the presence of metastasis. Metastatic disease is very rare in small renal masses. In this case report, we aimed to present our case of approximately 4 cm-mass of metastatic RCC in our kidney transplant patient.
Varicocele is dilatation and tortuosity of the vessels in the pampiniform plexus of spermatic cord and occurs in 11.7% of adult men. Varicocelectomy may lead to various complications such as hydrocele, testicular atrophy, haematoma, infection, damage of nerves and recurrence. A 22-year-old man presented after varicocelectomy with a rare postoperative complication of a fistula. The fistula tract was removed en bloc. The patient had a history of varicocelectomy, suggesting suture reaction. The fact that it is a rare complication of varicocelectomy makes our case interesting.
COVID-19 pandemic is the newest and most serious health threat worldwide. Medical and surgical priorities have been dramatically changed during this outbreak. Cancellation or postponement was fulfilled or considered for whole outpatient and some severe conditions to protect the facilities and resources for urgent healthcare. Most hospitals accepted individuals who have COVID-19 in affected countries. The COVID-19 pandemic has changed the patient admission process and healthcare strategies at numerous emergency departments across Turkey, and the possible effects of this alteration on people are still unclear. In upcoming periods, the healthcare workers, including urologists, possibly would be facing increasingly complex challenges, which could, in turn, make them develop various protection modalities to provide sufficient defense against this insult when dealing with the COVID-19 patients. 
 
Besides some modifications seen in the general medical approach, the treatment options applied in urinary stone cases have also significantly changed during the pandemic. Hence, the optimal anesthesia methods are still unknown. Under the current outbreak and COVID-19 pandemic scenario, hospitals should prioritized patients affected by lithiasis into low, intermediate, high risk, and emergency categories (according to the priority classification of the European Urology Guidelines Office Rapid Reaction Group Urolithiasis Guidelines Panel) to decide their delay and save resources, healthcare personnel, beds, and ventilators. However, patients with potentially serious septic complications need emergency interventions. The possibility of performing or restarting elective activity depends on local conditions, the availability of beds and ventilators, and the implementation of screening protocols in the context of the COVID-19 pandemic. Emergency intervention is inevitable if any alarming indication exists. Emergency cases tend to have a higher incidence of complications with the initiation of the COVID-19 outbreak when compared with before.
 
In a non-urgent urolithiasis condition, endo-urologists should make a rational treatment decision to prioritize the urolithiasis treatment. They should also compare the benefits and risks before the intervention. Because of the fear of being infected with COVID-19, patients with nephrolithiasis who stay at home instead of admitting to a medical center may suffer serious complications such as obstructive uropathy, deterioration of renal functions, sepsis, and even mortality. Although the number of emergency admissions related to stone disease cases has gradually decreased, some severe findings such as leukocytosis, higher creatinine levels, increased grade 3 and 4 hydronephroses, and complications tend to be seen more frequently when compared to the periods before the pandemics. Some endo-urologists prefer definitive stone treatment over temporary drainage to reduce the number of emergency room visits and hospital admissions, except if the infection is present or staged treatment is planned. Several clinical scenarios of non-emergency and non-urgent urinary stones are current; thus, endo-urologists should appropriately weigh patients' risk and surgery benefits to decide the proper intervention time. If the risks are more than the benefits to the patient, it would be better to postpone the surgery. A significant reduction in the global number of patients admitted to Emergency Department (ED) for urolithiasis was noted. Moreover, regarding the choice of treatment of hospitalized patients, a significant increase of stone removal procedures versus urinary drainage was reported in 2020. Renal colic should be managed with expulsive medical therapy and proper pain control with a close follow-up just in case it becomes an emergency. Indwelling JJ stent removal or exchange is a matter of debate: Some endo-urologists recommend removing, while the others recommend postponing it. 
 
In most COVID-19 infected patients with urolithiasis, extracorporeal shock wave lithotripsy (ESWL) should be kept in mind as a treatment option for the patient who doesn't require active stone removal. While patient and health care worker interaction kept minimum, it also represents the least morbid treatment and can generally be performed without a ureteric stent. Physicians can also prefer medical expulsive therapy (MET) as a treatment option for patients with distal ureteral stone, which shows highly effectiveness against distal 5-10 mm urinary stones. If a patient requires an active surgical approach, persistent obstruction, renal failure, and refractory pain can be safely and effectively treated by endoscopic ureteral stone treatment.
 
During the COVID-19 pandemic, there has been a significant reduction of emergency admissions for urolithiasis. Patients admitted to ED had more complications, more frequently need hospitalization, and early stone removal was preferred over urinary drainage only in clinical management. All urologists should be aware that they could face an increased number of admissions for urolithiasis and manage more complicated cases in the following months. Delaying urolithiasis surgery and increasing waiting lists will have consequences and will require considerable additional effort. Teleconsultation may help guide these patients, reduce visits and unnecessary exposure.
 
Coronavirus disease-2019 (COVID-19) is a global epidemic that has affected the whole world. COVID-19 has caused the postponement of elective operations, especially urological cancer surgeries, by affecting hospitals, patients, urologists, auxiliary health personnel, and resources at different rates in many countries and still continues with the current fluctuation. Delayed can-cer diagnosis and management during the pandemic will cause an increase in the incidence of untreated cancer patients in the coming months and we will face greater problems than the effects of COVID-19. If we list the urinary system cancers, they are adrenal, kidney, upper urinary system urothelial cancer, bladder, prostate, penis, and testicular cancer.
 
Adrenal gland cancers, especially adrenocortical cancer, have an aggressive course and require early surgery. Surgery for T1 kidney cancers may be delayed until sufficient resources are available. Early surgery should be planned if patients with T2 kidney cancer have unfavorable pre-operative prognostic factors, otherwise, it may be delayed. Higher stage kidney cancers should be considered for early surgery. An early multidisciplinary approach is recommended for metastatic kidney cancers. Early surgery should be performed especially in patients with the high-risk class of upper urinary tract urothelial carcinoma. Muscle-invasive bladder cancer is susceptible to high progression. Radical cystectomy, including neoadjuvant chemotherapy, should not exceed 12 weeks. If radical cystectomy cannot be performed, radiotherapy in combi-nation with chemotherapy should be considered for eligible patients. Patients with non-muscle invasive bladder cancer should be appropriately counseled based on their risk stratification. Intravesical treatments can be continued in accordance with urology guidelines. Short-term delays in this patient group do not carry a high risk of poor prognosis. Prostate cancer screening, imag-ing, and biopsies may generally be suspended. Active monitoring in low-risk prostate cancer should be done as in normal practice. Treatment can be safely delayed in low and intermediate-risk patients. Although surgery may be delayed in high-risk prostate cancer, neoadjuvant hormonal therapy and radiotherapy may need to be considered with little evidence. Initiation of long-term androgen deprivation therapy (ADT) together with external beam radiotherapy (EBRT) in high-risk and very high-risk prostate cancer may be preferred as a suitable alternative. Testicular cancer should be treated in a timely manner with surgery or chemotherapy as indicated. Penile cancer can have worse sexual, functional, and oncological consequences with prolonged surgical delay. In penile cancer, negative results were observed in 3-month delays before inguinal lymphadenectomy.
 
COVID-19 has dramatically changed the management of urological cancers and raises concern in urological cancer management with its ongoing high case numbers. Telemedicine-online interviews and meetings that increase the patient's awareness about the disease and discuss complicated patients should be encouraged. In order to minimize the risk in all urological cancer groups, correct planning and, if possible, early surgical treatment should be carried out by considering previous guidelines and data on the management of urology cancer patients in the cur-rent COVID-19 pandemic period.