BACKGROUND:Minimally invasive surgical techniques (MISTs) are becoming an increasingly popular outpatient treatment option for lower urinary tract symptoms. Although generally well-tolerated, MISTs may cause periprocedural discomfort. Virtual reality devices (VRDs) have been shown to reduce patient-reported pain during several procedures. This study aims to evaluate whether the use of VRD during MISTs could improve perioperative endovenous sedation needs of a VRD during MISTs in a case-control design. METHODS:We retrospectively analyzed patient data from MISTs performed between January 2024 and July 2025 at a single referral center (ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy). Procedures were conducted with or without a VRD (HypnoVR®, Strasbourg, France), based on patient preference and device availability. Patients were grouped into MISTs without VRD (group 1) and MISTs with VRD (group 2). Periprocedural data, endovenous sedation needs, Visual Analogue Scale (VAS) score for pain, use of additional painkiller drugs after the procedure, and complication rate have been addressed. RESULTS:Twenty-one procedures with VRD and 66 control procedures were analyzed. Groups were comparable in age, prostate volume, PSA, indwelling catheter presence, and type of MIST. Median (IQR) prostate volume was 41 (30-56) mL in group 1 and 36 (30-45) mL in group 2. MIST distribution was similar, though iTIND procedures were more frequent with VRD. Endovenous sedation rate was higher in group 1 (86.4 vs. 38.1%, p < 0.001). Median (IQR) VAS scores were 2 (1-2) in group 1 and 1.5 (1-2.75) in group 2. No VRD-related side effects or procedure interruptions occurred. CONCLUSION:This is the first study demonstrating the safety, feasibility, and tolerability of VRD use during MISTs. Although VRD did not significantly reduce pain scores, it markedly decreased endovenous sedation use, potentially facilitating faster recovery and discharge. VRD may be considered for patients undergoing MISTs where available.
Ketamine is a potent anaesthetic drug that has been used for decades. Ketamine abuse is an increasingly common problem, particularly among young people. Over one quarter of ketamine users will have at least one bothersome urological symptom, with heavier and longer use leading to potentially irreversible damage to the lower and upper urinary tract. Hence, this study carried out a narrative review focusing on ketamine-induced uropathy pathophysiology, clinical presentation, and treatment options. It was found that ketamine uropathy is an inflammatory condition affecting predominantly the bladder but also the upper urinary tracts. A hypersensitivity reaction to the drug has been proposed as the potential pathophysiological mechanism that causes inflammatory reaction, muscle hypertrophy, and non-reversible fibrosis in the advanced stages of the disease. Abstinence from ketamine use is the cornerstone of treatment at any stage of the disease, with effective pain management and psychological support being critical to reduce ketamine seeking behaviours. For mildly symptomatic patients, minimally invasive options such as bladder instillations and intravesical Botox injections can provide symptomatic relief. For more severe cases with refractory symptoms and upper urinary tract involvement, reconstructive urological operations might be necessary, including augmentation cystoplasty, cystectomy, or ureteric reconstruction. Ongoing surveillance of the upper tracts is recommended for both groups of patients. Ketamine induced uropathy is an increasingly prevalent condition, and ketamine abuse should always be inquired about in people with unexplained lower urinary tract symptoms. Adequate information of the public regarding ketamine abuse and early consultation with a urologist might prevent irreversible damage.
BACKGROUND:The prevalence of urinary stone disease (USD) is increasing among older patients. Data examining the association between patient age and clinical outcomes following surgical treatment for USD are limited. Our objective was to assess the safety profiles of ureteroscopy (URS), extracorporeal shock wave lithotripsy (ESWL), and percutaneous nephrolithotomy (PCNL) for USD by age in an older patient population. METHODS:We retrospectively identified all patients who underwent URS, ESWL, and PCNL for USD from 2010 to 2019 in the Veterans Health Administration. We fit multivariable logistic regression models to determine the association between age and post-procedure sepsis, hospital readmission, and all-cause mortality within 30 days of admission. RESULTS:We identified 50,519 procedures for USD, including 41,216 URS (81.6%), 5741 ESWL (11.4%), and 3562 PCNL (7.1%). Overall, increasing age was associated with post-operative sepsis (aOR per five-year increase 1.02; 95% CI: 1.00-1.05), hospital readmission (aOR = 1.02, 95% CI: 1.01-1.04), and all-cause mortality within 30 days (aOR = 1.19, 95% CI: 1.10-1.29). Among URS cases, increasing age was significantly associated with sepsis (aOR = 1.03, 95% CI: 1.00-1.05), hospital readmission (aOR = 1.03, 95% CI: 1.01-1.05), and all-cause mortality (aOR = 1.19, 95% CI: 1.09-1.30) within 30 days. We detected no association between increasing age and adverse outcomes following ESWL or PCNL. Limitations include a lack of data on the type of stone disease and analysis of predominantly older male veterans, potentially limiting generalizability. CONCLUSIONS:Following URS, age was independently associated with sepsis, hospital readmission, and all-cause mortality within 30 days of admission. This association was not found in patients who underwent ESWL or PCNL. Additional preoperative risk counseling and medical optimization may be beneficial in older patients undergoing URS.
OBJECTIVES:Lasers show promising application in partial nephrectomy due to their excellent hemostatic effect. This study aimed to evaluate the suction effect of the novel laser operating handle on the smoke generated by a 980-nm diode laser (DL) and a 532-nm potassium-titanyl-phosphate (KTP) green laser (GL) in laparoscopic partial nephrectomy (LPN) and to analyse the surgical smoke generated by the laser treatment. METHODS:Fresh porcine kidneys were purchased from a slaughterhouse. Electrocoagulation knife (EK), ultrasonic knife (UK), DL, and GL were utilised in LPN. The operation time and the composition and concentration of the surgical smoke were recorded. HE staining was performed to observe the degree of thermal damage. RESULTS:In terms of smoke generation, the 532-nm KTP laser results in the largest amount of smoke. The surgical field of DL-LPN was adequately improved with the aid of the instrument with the novel handle. The thickness of the coagulation layer, which ranged from thick to thin, was DL, GL, EK, and UK. The coagulation of EK, UK, DL, and GL was 0.35 ± 0.08 mm, 0.52 ± 0.08 mm, 4.16 ± 0.21 mm, and 1.55 ± 0.21 mm, respectively. For formaldehyde, total volatile organic compounds (TVOC), and carbon monoxide (CO), there was a marked reduction after the application of the aspirator. For the DL group, the Formaldehyde TVOC and CO were 4.95 ± 0.48 mg/m3 and 1.69 ± 0.46 mg/m3, 8.34 ± 0.72 mg/m3 and 1.11 ± 0.33 mg/m3, 124.14 ± 9.58 PPM and 23.71 ± 3.9 PPM, respectively. CONCLUSIONS:As shown in the present study, though a large amount of harmful smoke was generated during laser-assisted laparoscopic partial nephrectomy (LALPN), the novel laser handle can be sucked effectively and provides a clear surgical field. As to the harmful gases released, an effective protective mask is needed.
BACKGROUND:Testicular prosthesis implantation (TPI) is frequently performed as part of masculinizing genital gender-affirming surgery (GGAS), but complication and satisfaction data for assigned female at birth (AFAB) men remain limited. We report a single-centre experience assessing postoperative complications, explantation-free survival (EFS) and patient-reported satisfaction. METHODS:We conducted a retrospective cohort study including all patients who underwent unilateral or bilateral transmasculine TPI (TM-TPI) from May 2007 to April 2025. Primary outcomes were postoperative complications (e.g., surgical-site infection, contamination, hematoma, migration, pain, extrusion) and EFS rate. Satisfaction was measured at 12 months using the 13-item Transmasculine Testicular Prosthesis Satisfaction Index (TM-TPSI), a questionnaire tool developed for this cohort. RESULTS:Forty-four patients (mean age 40 ± 10 years) received solid silicone prostheses; median follow-up was 84.5 (IQR 65.3-95.0) months. Complications included superficial surgical-site infection in 8/44 (18%), one prosthesis contamination requiring removal, one extrusion requiring replacement, and one migration requiring repositioning (2%). Mean time to explant/reposition was 57.7 ± 61.5 months; the 5-year EFS rate was 97%. Of 41 respondents to the TM-TPSI, 84% were "mostly satisfied" or "more satisfied than unsatisfied"; the mean score was 46.0 ± 10.5. CONCLUSIONS:In this cohort, TM-TPI showed a low rate of surgical revisions and high patient-reported satisfaction over long-term follow-up. Multicentre studies and formal validation of the TM-TPSI are warranted to refine benchmarks and enable cross-cohort comparisons. TM-TPI is a procedure that needs to be further investigated with clear specificity for AFAB men.
Erectile dysfunction (ED) has evolved from a quality-of-life concern to a recognized marker of systemic vascular disease and an early harbinger of cardiovascular events. The Princeton IV Consensus underscores that men presenting with erectile dysfunction should be presumed at increased cardiovascular risk until proven otherwise, advocating integrated risk stratification and lifestyle optimization. Beyond established risk scores, advances in omics, vascular imaging, and digital health promise precision tools for early detection and prevention. This review aims to examine erectile dysfunction as an early marker of cardiovascular disease and to summarize current and emerging approaches to cardiovascular risk stratification in men with ED.
BACKGROUND:Transurethral resection of the prostate (TURP) remains the standard surgical treatment for benign prostatic hyperplasia (BPH), whereas laser-based procedures have increasingly been adopted as alternatives because of their potential advantages in hemostasis and postoperative recovery. This study compared coagulation depth, perioperative outcomes, postoperative complications, and short-term functional outcomes between 450-nm blue laser vaporization of the prostate (BVP) and TURP. METHODS:This retrospective single-center study included 260 patients with BPH who underwent either TURP (n = 110) or BVP (n = 150). Coagulation depth was compared between the two procedures using an ex vivo porcine kidney specimen experiment. Baseline characteristics, perioperative variables, intraoperative and postoperative complications, and postoperative functional outcomes at 1, 3, and 6 months were analyzed. RESULTS:BVP produced a significantly shallower coagulation depth than TURP. Baseline demographic and clinical characteristics were generally comparable between the two groups, although BMI and baseline QoL differed slightly. Compared with TURP, BVP was associated with a shorter operative time, earlier catheter removal, and a shorter hospital stay. Intraoperative complications were uncommon in both groups, and several postoperative complications were numerically less frequent in the BVP group. Both procedures resulted in substantial postoperative improvement in Qmax, PVR, IPSS, and QoL. In adjusted repeated-measures mixed-effects analyses, BVP showed greater improvement in Qmax and IPSS across follow-up and greater PVR reduction at 3 and 6 months, whereas QoL improved over time without a significant overall group effect. CONCLUSIONS:Compared with TURP, 450-nm BVP was associated with a shallower coagulation depth, more favorable perioperative recovery, and comparable short-term functional outcomes in patients with BPH. These findings support BVP as a feasible and promising transurethral alternative for the surgical management of BPH. The reduced coagulation depth observed after BVP may also have implications for postoperative inflammatory recovery and warrants further investigation.
OBJECTIVES:Despite practice guidelines recommending hormonal testing for all cases of incidentally discovered adrenal adenomas (incidentalomas), only 30% of patients receive laboratory workup. This study sought to evaluate hormonal testing and adrenal surgery rates in incidentaloma patients seen by a specialist (endocrinologist, nephrologist, urologist, or general surgeon), compared to those not seen by a specialist. METHODS:We identified incidentaloma cases by querying the TriNetX Research Network for all adult patients with an unspecified adrenal mass occurring within 1 month following abdominal imaging. We compared those seen by a specialist against those not following an incidentaloma diagnosis. Primary outcomes were rates of hormonal testing and adrenal gland surgery. RESULTS:Of 132,217 incidentaloma patients, 1054 (0.7%) received a specialist consultation. Referral to a specialist was associated with increased hormonal testing (49.5% vs. 28.0%, p < 0.0001) and adrenal surgery (6.3% vs. 3.6%, p < 0.0001). Surgery rates were similar among those who received hormonal testing, regardless of specialist consultation (12.6% vs. 13.3%, p = 0.8445). Of all incidentaloma patients, 6765 (5.2%) proceeded to adrenal surgery. CONCLUSIONS:Patients receiving specialist services experienced more hormonal testing and treatment with surgery. Surgery rates did not differ among those undergoing any hormonal evaluation, regardless of specialist status, indicating that about 13% of incidentaloma patients will require adrenal surgery. Applying this rate suggests that nearly 14,000 incidentaloma patients in TriNetX did not receive surgery despite likely meeting criteria, a significant failure in treatment. Further, prospective studies are needed to investigate practice patterns and expose reasons for the lack of progression to evaluation or treatment.
BACKGROUND:Onabotulinum toxin-A (BoNT/A) intradetrusor injection is an established, effective, and safe treatment for overactive bladder (OAB) refractory to anticholinergics. Although primary non-response to BoNT/A is infrequent, it remains clinically relevant. We investigated whether baseline clinical, demographic, or urodynamic characteristics could predict non-responders prior to treatment. METHODS:A Retrospective analysis of 65 consecutive refractory idiopathic OAB (I-OAB) male and female patients treated with 100 U BoNT/A at Jewish General Hospital between 2005 and 2015 was conducted. Response defined as >30% increase in maximum cystometric bladder capacity (MCBC) at 12 weeks, confirmed clinically and through urodynamic studies (UDS). Non-response was verified by lack of improvement after the second intradetrusor injection. RESULTS:A total of 13 men and 52 women with a mean age of 70 years (range 21 to 94) were studied. At 12 weeks, 63% (41/65) of patients demonstrated a significant response in both symptoms and UDS (p < 0.05), while 37% (24/65) were non-responders. Non-responders exhibited significantly higher baseline first desire to void volume (FDV) and postvoid residual urine (PVR) (p < 0.05), with a trend toward greater bladder compliance (18.8 ± 15.1 vs. 13.3 ± 9.4 cmH2O, p = 0.09). Multivariate logistic regression identified no independent predictors of response. CONCLUSIONS:Elevated baseline FDV and PVR are associated with poor response to 100 U BoNT/A in refractory I-OAB patients.
OBJECTIVES:Complex cystic renal lesions pose a significant diagnostic challenge in the preoperative assessment of malignancy. Although percutaneous renal mass biopsy is well established for solid tumours diagnosis, its role in cystic lesions remains controversial. This systematic review aims to evaluate the diagnostic performance, safety, and clinical impact of percutaneous sampling-fine-needle aspiration (FNA) and core needle biopsy (CNB)-in Bosniak III-IV renal cysts. METHODS:A systematic review and meta-analysis were conducted in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines [International Prospective Register of Systematic Reviews (PROSPERO) ID CRD420251124563]. PubMed/MEDLINE (Medical Literature Analysis and Retrieval System Online), Embase, Cochrane Central Register of Controlled Trials (CENTRAL), Scopus, and Web of Science were searched (1980-May 2025). Eligible studies included adult patients with Bosniak III-IV cysts undergoing FNA or CNB. Pooled diagnostic estimates were calculated using a bivariate random-effects model. RESULTS:Seven studies, including 954 patients, met the inclusion criteria. Three studies evaluated FNA, yielding a pooled sensitivity of 59% [95% Confidence Interval (CI): 14-93], specificity of 84% (95% CI: 62-94), and an overall diagnostic performance of 0.84 [Area under the curve (AUC)]. Sensitivity estimates varied widely, whereas specificity was consistently high. Four studies assessed CNB, reporting diagnostic yields between 75% and 81%. Cystic morphology was identified as the strongest independent predictor of non-diagnostic sampling, with odds ratios (OR) up to 13.9. No major complications or cases of tumour seeding were reported across the included studies. Reporting of minor complications was limited and heterogeneous, precluding a pooled analysis. CONCLUSIONS:Percutaneous sampling of Bosniak III-IV cystic renal masses is feasible but diagnostically challenging. FNA provides limited value due to high rates of non-diagnostic and false-negative results. CNB achieves higher accuracy, particularly when a solid component is present, and may be considered within a multidisciplinary setting when histological confirmation is likely to influence treatment decisions.
BACKGROUND:Beckwith-Wiedemann syndrome (BWS) is a congenital overgrowth disorder that may be associated with renal abnormalities, although benign renal manifestations presenting in adulthood are less well characterized. CASE DESCRIPTION:We report the case of a 20-year-old woman with genetically confirmed BWS who was diagnosed with medullary sponge kidney (MSK) during adulthood after imaging evaluation for suspected renal abnormalities. Contrast-enhanced computed tomography and intravenous urography demonstrated characteristic medullary collecting duct dilatation with nephrocalcinosis, consistent with MSK, associated with hypercalciuria and hypocitraturia. Medical management with thiazide diuretics and potassium citrate achieved metabolic control and stable imaging findings. CONCLUSION:This case highlights the importance of considering MSK in patients with BWS and underscores the role of appropriate imaging and metabolic evaluation for accurate diagnosis and long-term management.
BACKGROUND:The incidence rate of prostate adenocarcinoma in the United States was 112 per 100,000 in 2019. Men aged 65 to 74 years had a higher incidence rate (638 per 100,000), and 70% of the cases were detected locally (confined to the primary site) per the United States Cancer Statistics. While rare, prostate adenocarcinoma metastasis to the penis has variable presentation and potentially atypical histology that may require immunohistochemical, biomarker, and genetic analysis for confident diagnosis. CASE DESCRIPTION:We present a 56-year-old patient with advanced prostate cancer post-chemoradiation and androgen deprivation therapy with an uncommon site of metastasis to the penis. The clinical presentation and progression of the disease led to surgical removal and frozen section analysis. Initial pathologic assessment proved equivocal in the distinction between metastatic prostatic carcinoma versus primary penile squamous cell carcinoma. Diagnostic difficulty due to ambiguous histomorphological features was attributed to the loss of intrinsic prostatic protein markers in metastatic post-treatment cases. Immunohistochemistry and detailed biomarker analysis eventually aided diagnosis. CONCLUSIONS:This report illustrates some of the gross and microscopic histological ambiguity that can obfuscate immediate diagnostic certainty of origin of rapidly growing cutaneous penile lesion in the context of existing prostate cancer, while elaborating on immunohistochemical and genetic markers that can increase otherwise elusive diagnostic certainty. Early patient education and intervention represent sites of potential improvement in management of similar cases.
BACKGROUND:Recurrent prostate surgery may pose additional challenges for achieving an efficient and anatomically precise enucleation. This research investigates how prior transurethral resection of prostate (TURP) affects the perioperative course, functional outcomes, and technical difficulty of Holmium Laser Enucleation of the Prostate (HoLEP) when performed as a primary procedure versus as a salvage treatment. METHODS:In this retrospective study, 174 patients who underwent HoLEP between August 2023 and April 2025 were analyzed. Group 1 included 137 patients undergoing primary HoLEP, and group 2 included 37 patients undergoing HoLEP for TURP recurrence. Outcomes assessed included enucleation weight, enucleation and morcellation time and efficiency, blood transfusion, catheter removal, and three-month postoperative International Prostate Symptom Score (IPSS), quality of life (QoL), incontinence, and urethral stricture rates. RESULTS:Mean age was comparable between groups (group 1: 67.84 ± 8.67 vs. group 2: 67.24 ± 8.66 years; p = 0.840). Preoperative prostate volume and enucleation weight were higher in group 2 (81.24 vs. 67.34 mL, p = 0.012; enucleation weight, p = 0.037), while enucleation and morcellation times and efficiencies were similar. At three months, IPSS (8.31 vs. 7.19), QoL (1.56 vs. 1.58), incontinence, and urethral stricture rates did not differ significantly. CONCLUSION:With meticulous surgical planning, HoLEP represents a safe and effective salvage procedure following TURP, maintaining functional outcomes comparable to primary intervention.
