News from GJU - Grand Journal of Urology

Current Approaches in Prostate Cancer Radiotherapy

Prostate cancer is one of the most common tumor in males. Radical prostatectomy, radiotherapy and watchful waiting are the main treatment options in localized disease. Radiotherapy together with hormonotherapy is accepted as the standard of care in patients with advanced stages. Surgery or radiotherapy has comparable local control and survival outcomes in localized disease. During recent years a significant reduction in the rate of serious side effects has been achieved due to the development of modern radiotherapy techniques.

Focal Ablation Therapies in Prostate Cancer

Focal ablation therapies in prostate cancer have been actively evaluated in the light of recent literature. 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. While waiting long-term oncological results, focal ablation therapies in prostate cancer are beinmg used increasingly.

A Cause of Recurrent Urinary Retention in Pregnancy; Retroverted Uterus

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.

A Rare Prostate Pathology: Mantle Cell Lymphoma

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.

Distant Metastases from a Small Renal Cell Carcinoma in a Renal Allograft Recipient with Prostate Carcinoma

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.

Inguinal Fistula by Suture Granuloma Post Microsurgical Varicocelectomy

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.

Management of Ureteral Stones During Covid-19 Outbreak

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 and Urological Cancers

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.