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Purpose To summarize current knowledge on intracorporeal laser lithotripsy in flexible ureterorenoscopy (fURS), regarding basics of laser lithotripsy, technical aspects, stone clearance, lithotripsy strategies, laser technologies, endoscopes, and safety. Methods A scoping review approach was applied to search literature in PubMed, EMBASE, and Web of Science. Consensus was reached through discussions at the Consultation on Kidney Stones held in September 2019 in Copenhagen, Denmark. Results and conclusions Lasers are widely used for lithotripsy during fURS. The Holmium laser is still the predominant technology, and specific settings for dusting and fragmenting have evolved, which has expanded the role of fURS in stone management. Pulse modulation can increase stone ablation efficacy, possibly by minimizing stone retropulsion. Thulium fibre laser was recently introduced, and this technology may improve laser lithotripsy efficiency. Small fibres give better irrigation, accessibility, and efficiency. To achieve optimal results, laser settings should be adjusted for the individual stone. There is no consensus whether the fragmentation and basketing strategy is preferable to the dusting strategy for increasing stone-free rate. On the contrary, different stone scenarios call for different lithotripsy approaches. Furthermore, for large stone burdens, all laser settings and lithotripsy strategies must be applied to achieve optimal results. Technology for removing dust from the kidney should be in focus in future research and development. Safety concerns about fURS laser lithotripsy include high intrarenal pressures and temperatures, and measures to reduce both those aspects must be taken to avoid complications. Technology to control these parameters should be targeted in further studies.

Introduction Reducing tube voltage is an effective dose saving method in computed tomography (CT) assuming tube current is not concurrently increased. Recent innovations in scanner technology now enable CT tube voltage reduction to 70 kV thereby increasing opportunities for dose reduction in paediatric patients, but it is unclear if the increased image noise associated with 70 kV impacts on ability to visualise renal stones accurately. The purpose was to assess detectability of nephrolithiasis using a bespoke paediatric phantom and low kV, non‐contrast CT and to assess inter‐observer agreement. Methods Forty‐two renal stones of different size and chemical composition were inserted into porcine kidneys and positioned in a bespoke, water‐filled phantom mimicking a 9‐year‐old child weighing approximately 33kg. The phantom was scanned using 120 and 70 kV CT protocols, and the detectability of the stones was assessed by three radiologists. Absolute agreement and Fleiss’ kappa regarding detectability were assessed. Results The mean diameter of renal stones as measured physically was 4.24 mm ranging from 1 to 11 mm. Four stones were missed by at least one observer. One observer had a sensitivity of 93 and 95% at 70 and 120 kV, respectively, while the sensitivity for observers 2 and 3 was 98% at both kV levels. Specificity was 100% across readers and kV levels. Absolute agreement between the readers at 70 kV was 92% (kappa = 0.86) and 98% (kappa = 0.96) at 120 kV indicating a strong agreement at both kV levels. Conclusions The results suggest that lowering the kV does not affect the detection rate of renal stones and may be a useful dose reduction strategy for assessment of nephrolithiasis in children., Recent innovations in scanner technology enable CT tube voltage reduction to 70 kV thereby increasing opportunities for dose reduction in paediatric patients. In this study, the detection of renal stones was assessed using a bespoke phantom with renal stones inserted in porcine kidneys. The results suggest that lowering the kV does not affect the detection rate of renal stones and may be a useful dose reduction strategy for assessment of nephrolithiasis in children.

Purpose: PCNL requires a lithotrite to efficiently break stones, and some devices include active suction to remove the fragments. We set out to determine the efficacy and safety of the Swiss LithoClast® Trilogy, in a prospective European multicentre evaluation and compared it to published stone clearance rates for Trilogy based on surface area (68.9 mm 2/min) and using the 3D calculated stone volume (526.7 mm 3/min). Methods: Ten European centres participated in this prospective non-randomized study of Trilogy for PCNL. Objective measures of stone clearance rate, device malfunction, complications and stone-free rates were assessed. Each surgeon subjectively evaluated ergonomic and device effectiveness, on a 1–10 scale (10 = extremely ergonomic/effective) and compared to their usual lithotrite on a 1–10 scale (10 = extremely effective). Results: One hundred and fifty seven PCNLs using Trilogy were included (53% male, 47% female; mean age 55 years, range 13–84 years). Mean stone clearance rate was 65.55 mm 2/min or 945 mm 3/min based on calculated 3D volume. Stone-free rate on fluoroscopy screening at the end of the procedure was 83%. Feedback for suction effectiveness was 9.0 with 9.1 for combination and 9.0 for overall effectiveness compared to lithotrite used previously. Ergonomic score was 8.1, the least satisfactory element. Complications included 13 (8.2%) Clavien–Dindo Grade II and 2 (1.3%) Grade III. Probe breakage was seen in 9 (5.7%), none required using a different lithotrite. Conclusions: We have demonstrated that Trilogy is highly effective at stone removal. From a user perspective, the device was perceived by surgeons to be highly effective overall and compared to the most commonly used previous lithotrite, with an excellent safety profile.

BACKGROUND: Self-management approaches are widely used to improve chronic care. In this context, health care professionals call for efficient tools to engage patients in managing their illness. Mobile health (mHealth), defined by WHO as medical and public health practice supported by mobile devices, is demonstrated to enhance self-management and health-coaching as an engaging tool in supporting behaviour change. Nevertheless, it is unclear how health-coaching and mHealth can benefit from each other.OBJECTIVE: We conducted a scoping review to provide a literature-overview and identify any existing gaps in knowledge of mHealth in combination with health-coaching interventions for improving self-management in patients with chronic diseases.PATIENT INVOLVEMENT: No patients were involved in the review process.METHODS: The five-stage framework by Arksey and O'Malley was used. The review surveys; PubMed, CINAHL, Embase, Scopus, and PsycInfo. Two independent reviewers performed review selection and characterization.RESULTS: The review points at two approaches; (i) coaching used to support mHealth and (ii) mHealth as support for coaching. The findings suggest that patients prefer physical interactions to telecommunication. mHealth was primarily used to facilitate telecommunication and to monitor disease aspects.DISCUSSION: We found that mHealth and health-coaching interventions benefit from each other. The review report on a considerable unclarity in the coaching-methods and that the patients were more satisfied with physical interactions than mHealth. We suggest to prioritize human contact and to explore more personalized health technology.PRACTICAL VALUE: This scoping review can provide a framework for researchers and care providers to support discussion and introduction of new approaches and technology in self-management for patients with chronic diseases, thereby improving patients' quality of life.

Objective To investigate the anogenital distance in patients with and without testicular microlithiasis (TML). Methods A total of 101 patients underwent a conventional standard clinical B-mode scrotal ultrasonography and scrotal MRI. The patients were divided into two groups: patients with TML and non-TML. The latter served as control group. The anogenital distance was measured by a straight line from center of the anus to the posterior base of scrotum using MRI. Results In the TML group, mean AGD was 5.4 (± 1.07) cm (range 29–79 mm), and in non-TML 5.9 (± 1.03) cm (range 35–85 mm) (p = 0.04). Conclusion MRI is a useful tool to measure the AGD. It is easy to perform without any discomfort to patients. We found AGD to be lower in patients with TML.

This study aimed to evaluate the additional utility of an automated method of estimating volume for stones being treated with shockwave lithotripsy (SWL) using computed tomography (CT) images compared to manual measurement. Utility was assessed as the ability to accurately measure stone burden before and after SWL treatment, and whether stone volume is a better predictor of SWL outcome than stone diameter. 72 patients treated with SWL for a renal stone with available CT scans before and after treatment were included. Stone axes measurement and volume estimation using ellipsoid equations were compared to volume estimation using software using CT textural analysis (CTTA) of stone images. There was strong correlation (r > 0.8) between manual and CTTA estimated stone volume. CTTA measured stone volume showed the highest predictive value (r2 = 0.217) for successful SWL outcome on binary logistic regression analysis. Three cases that were originally classified as ‘stone-free with clinically insignificant residual fragments’ based on manual axis measurements actually had a larger stone volume based on CTTA estimation than the smallest fragments remaining for cases with an outcome of ‘not stone-free’. This study suggests objective measurement of total stone volume could improve estimation of stone burden before and after treatment. Current definitions of stone-free status based on manual measurements of residual fragment sizes are not accurate and may underestimate remaining stone burden after treatment. Future studies reporting on the efficacy of different stone treatments should consider using objective stone volume measurements based on CT image analysis as an outcome measure of stone-free state.

Purpose: Advancements in endoscopy offer the possibility of inspection of intrarenal anatomy and pathology. The aim of the study was to evaluate renal papillary appearance in kidney stone formers and to correlate papillary findings with stone type and patient metabolic data. Materials and methods: A consecutive cohort of 46 kidney stone formers undergoing retrograde intrarenal surgery was enrolled. During surgery, renal papillae were characterized in the domains of ductal Plugging (DP), surface Pitting, Loss of papillary contour, and Amount of Randall’s plaque (RP, PPLA scoring). Stone material was analyzed using micro-CT and infrared spectroscopy, and blood and urine were collected for metabolic evaluation. Results: In all patients, renal papillae had changes in at least one of the domains of the PPLA score. Examining the total population, it was evident that patients with predominantly plugging (DP > 0) all had very low RP scores. There were no significant trends between mean PPLA scores and urinary analytes for the total group. Conclusion: Efforts to prevent renal stone formation have so far been insufficient in majority of patients. Digital endoscopy reveals that kidney stone formers have different and distinct papillary morphologies that seem to be linked to specific stone-forming pathways. Since renal papillary abnormalities may be easily identified during endoscopy, this may in the future prove to be an important method for tailoring prevention strategies in kidney stone patients.

BACKGROUND: Overtreatment is a well-known clinical challenge in local prostate cancer (PCa). Although risk assessment models have contributed to a better stratification of patients with local PCa, a tailored management is still in its infancy. Over the last few decades, microRNAs (miRNAs) have shown promising results as biomarkers in PCa. The aim of this study was to investigate circulating miRNAs after management of local PCa.METHODS: The relative expression of four miRNAs (miRNA-21, -93, -125b, and miRNA-221) was assessed in plasma from 149 newly diagnosed patients with local or locally advanced PCa. Real-time polymerase chain reaction was used for analysis. A baseline sample at time of diagnosis and a follow-up sample after 6 months were assessed. The patients were grouped in an interventional cohort (radical prostatectomy, curative intent radiotherapy, or androgen-deprivation therapy alone) and an observational cohort (watchful waiting or active surveillance).RESULTS: In the interventional cohort, levels of both miRNA-93 and miRNA-221 were significantly lower in the follow-up samples compared to baseline z = -2.738, P = 0.006, and z = -4.498, P CONCLUSIONS: The current results indicate a possible role of miRNA-93 and miRNA-221 in disease monitoring in localized and locally advanced PCa. Larger studies are warranted to assess the clinical impact of these biomarkers.

Purpose Ultrasonography is a useful tool to measure testicular volume. According to the European Society of Urogenital Radiology, the combination of testicular atrophy and testicular microlithiasis (TML) is a risk factor for testicular cancer. Testicular atrophy is defined as a volume of less than 12 ml. The aim of this study was to compare testicular volume in patients with TML to patients with normal testicular tissue. Materials and Methods From 2013 to 2015 we included a total of 91 adult patients with TML, and 91 adult patients with normal testicular tissue as a control group. All patients underwent scrotal B-mode ultrasound investigation including measurement of width, length and height in both testicles. Testicular volume was calculated using the formula π/6×length×height×width. Results The median age for patients with TML was 48 years (range: 19-94 years), and 48 years (range: 20–75 years) in patients with normal tissue. No statistically significant difference was found between total testicular volume (both testes) >30 ml in patients with TML compared to patients without (OR 0.77 (95% CI 0.43-1.38, p=0.37). However, patients with TML tended to have lower testicular volume compared to patients without TML, when investigating testicular volume below 12 ml. Conclusion Overall, no association was found between testicular volume and TML, but there was a trend indicating that severe atrophy is often seen in patients with TML compared to patients without TML. However, a significant difference was only found in testicular volume ≤8 ml.

Background Ultrasound elastography is increasingly available in clinical practice. Recent studies showed higher velocity stiffness in testicular tumors compared to normal testicles. Purpose To evaluate ultrasound elastography in combination with the apparent diffusion coefficient measurements in diffusion weighted (DW) magnetic resonance imaging (MRI) in testicles. DW can be a useful tool in evaluating testicular malignancies. However, the relationship between velocity stiffness and MRI diffusion is not well established. Material and Methods We prospectively included 132 patients with testicular microlithiasis (n = 53), or normal testicular tissue (n = 53), or suspected for testicular cancer (n = 26). All 132 patients underwent ultrasonography including shear wave elastography and MRI diffusion coefficient examination of the scrotum. Results No clinically relevant difference in velocity stiffness was found between normal and testicles with microlithiasis. There was a significant difference in stiffness between patients with testicular microlithiasis (0.78 m/s), normal testicular tissue (0.77 m/s), and patients with testicular cancer (1.95 m/s) ( P ≤ 0.001). Similarly, there was a statistically significant difference in MRI diffusion values between patients with testicular microlithiasis (0.978 × 10−3 mm2 s−1), normal testicular tissue (0.929 × 10−3 mm2 s−1), and testicular cancers (0.743 × 10−3 mm2 s−1) ( P Conclusion Patients with testicular microlithiasis had no malignant characteristics measured with shear wave elastography or MRI diffusion. MRI diffusion and elastography may be useful to preoperatively differentiate benign from malignant testicular lesions.

Introduction Short-term data on the effect of low-intensity extracorporeal shockwave therapy (Li-ESWT) on erectile dysfunction (ED) have been inconsistent. The suggested mechanisms of action of Li-ESWT on ED include stimulation of cell proliferation, tissue regeneration, and angiogenesis, which can be processes with a long generation time. Therefore, long-term data on the effect of Li-ESWT on ED are strongly warranted. Aim To assess the outcome at 6 and 12 months of linear Li-ESWT on ED from a previously published randomized, double-blinded, sham-controlled trial. Methods Subjects with ED (N = 126) who scored lower than 25 points in the erectile function domain of the International Index of Erectile Function (IIEF-EF) were eligible for the study. They were allocated to 1 of 2 groups: 5 weekly sessions of sham treatment (group A) or linear Li-ESWT (group B). After a 4-week break, the 2 groups received active treatment once a week for 5 weeks. At baseline and 6 and 12 months, subjects were evaluated by the IIEF-EF, the Erectile Hardness Scale (EHS), and the Sexual Quality of Life in Men. Main Outcome Measures The primary outcome measure was an increase of at least 5 points in the IIEF-EF (ΔIIEF-EF score). The secondary outcome measure was an increase in the EHS score to at least 3 in men with a score no higher than 2 at baseline. Data were analyzed by linear and logistic regressions. Results Linear regression of the ΔIIEF-EF score from baseline to 12 months included 95 patients (dropout rate = 25%). Adjusted for the IIEF-EF score at baseline, the difference between groups B and A was −1.30 (95% CI = −4.37 to 1.77, P = .4). The success rate based on the main outcome parameter (ΔIIEF-EF score ≥ 5) was 54% in group A vs 47% in group B (odds ratio = 0.67, P = .28). Improvement based on changes in the EHS score in groups A and B was 34% and 24%, respectively (odds ratio = 0.47, P = .82). Conclusion Exposure to 2 cycles of linear Li-ESWT for ED is not superior to 1 cycle at 6- and 12-month follow-ups.

INTRODUCTION: Percutaneous nephrolithotomy (PNL) is the treatment of choice for larger and complex renal calculi. First step in performing PNL is to obtain access to the renal cavity using either fluoroscopy or ultrasound (US) guidance or a combination of both. Which guiding method to choose is controversial? A systematic review of the literature was performed comparing image guidance modalities for obtaining access in PNL. Evidence acquisition and synthesis: A PubMed, Scopus and Cochrane search for peer-reviewed studies was performed using the keywords "ultrasound" AND "fluoroscopy" AND "Percutaneous nephrolithotomy". Eligible articles were reviewed according to PRISMA criteria. Two hundred and forty records were identified using the keywords. Of these twelve studies were considered relevant.RESULTS: US guidance seems to be associated with a slightly lower complication rate, which may be related to fewer puncture attempts needed for obtaining access and to better peri-renal organ visualization. On the other hand, US-guidance alone needs the adjunct of fluoroscopy in a significant number of cases for achieving access. Stone free rate (SFR) was comparable between groups. Using US for renal access unequivocally reduces radiation exposure.CONCLUSION: Current evidence indicates that both fluoroscopy and US guidance may be successfully used for obtaining percutaneous renal access. Combining the image-guiding modalities - US and fluoroscopy - seems to increase outcome in PNL both with regard to success in achieving access and reducing complications. Furthermore, including US in the access strategy of PNL reduces radiation exposure to surgeon and staff as well as patients.

OBJECTIVE: Penile implants and injection of foreign materials have been described in texts like Kama Sutra for more than 1500 years, and are still being practiced around the world. The extent of this practice is unknown, and the documentation available today only scratches the surface. This study investigates and documents the complications after penile self-injections at the Mae Tao Clinic. To our knowledge, this study represents the largest series of patients representing complications to penile self-injections.STUDY DESIGN: Retrospective study.METHODS: We investigated data on 680 patients admitted with penile self-injections during a 5-year period. Data were studied for general patient data, symptoms, time of injection, and treatment.RESULTS: Age at admittance ranged from 17 to 68 with a mean age of 32 years. Time between injection and presentation was registered with a mean of 36.7 months, over half presented with complications within 1 year. Most frequent complications were penile pain (84%), swelling (82.5%), induration (42.9%), purulent secretion (21.8%), and ulceration (12.8%). Of the 680 patients, 507 (74.6%) underwent surgical treatment (503 excision and 4 circumcision), while 173 (25.4%) were treated conservatively.CONCLUSION: Our data suggest that penile self-injections with mineral oil are more prevalent in certain areas than previously acknowledged. In 5 years, more than 680 patients presented with complications to penile self-injections, of which 75% needed surgical intervention, mainly in the form of radical excision of the lesions followed by skin grafting. Preventive measures to this physically and psychologically devastating problem are highly warranted.

PURPOSE: The aim of this review was to provide current best evidence for evaluation, dietary, and medical management of patients with urolithiasis.METHODS: Literature addressing evaluation, dietary, and medical management of urolithiasis was searched. Papers were analyzed and rated according to level of evidence (LOE), whereupon a synthesis of the evidence was made. Grade of recommendation (GOR) was judged from individual clinical experience and knowledge of the evidence according to the Oxford Centre for Evidence-based Medicine.RESULTS: It is obvious that different stone diseases influence the life of stone-forming individuals very differently, and that evaluation and medical management should be personalized according to risk of recurrence, severity of stone disease, presence of associated medical conditions, and patient's motivation. With regard to evaluation, dietary and medical management of patients with urolithiasis evidence from the literature suggest that selective metabolic evaluation may lead to rational dietary and medical management. Statements based on LOE and GOR are provided to guide clinical practice.CONCLUSION: The provided evidence for evaluation of patients with urolithiasis aims at defining patients at high risk for recurrent/complicated stone disease. Based on this approach, evidence-based dietary and medical management regimes are suggested.

In the original publication of the article, we inadvertently left the author Kay Thomas of the submission

RATIONALE AND OBJECTIVES: To determine whether a single source computed tomography (CT) system utilizing fast kV switching and low dose settings can characterize (diameter and chemical composition) renal stones accurately when compared infrared spectroscopy.MATERIALS AND METHODS: The chemical composition of 15 renal stones was determined using Fourier transform infrared spectroscopy. The stones were inserted into a porcine kidney and placed within a water tank for CT scanning using both fast kV switching dual energy and standard protocols. Effective atomic number of each stone was measured using scanner software. Stone diameter measurements were repeated twice to determine intra-rater variation and compared to actual stone diameter as measured by micro CT.RESULTS: The chemical composition of three stones (one calcium phosphate and two carbonite apatite) could not be determined using the scanner software. The composition of 10/12 remaining stones was correctly identified using dual energy computed tomography (83% absolute agreement; k = 0.69). No statistical difference (p = 0.051) was noted in the mean stone diameter as measured by clinical CT and micro CT.CONCLUSION: Dual energy computed tomography using fast kV switching may potentially be developed as a low dose clinical tool for identifying and classifying renal stones in vivo supporting clinical decision-making.

Background: The rationale of the study was the predominant understanding that patient involvement in treatment-related decision-making is essential and that communication with cancer patients can affect their quality of life, satisfaction with care, and psychosocial and medical outcomes positively. Aim: This study explored how patients with advanced prostate cancer experience the communication with health professionals and their experiences of how and by whom treatment-related decisions were made. Methods: A phenomenological-hermeneutic research design was applied, and data were collected using qualitative interviews supplemented with participant observations in a urological outpatient clinic at a regional hospital in Denmark. Thirteen patients participated. Data were analysed using Ricoeur’s theory of interpretation. Findings: The patients experienced the course as being routine and that decisions related to treatment were made in advance. Three themes were identified: (1) Fast track diagnosing and treatment, (2) Off course I should have this treatment, and (3) They don't ask about existential issues. Conclusion: The study concluded that patients experienced communication primarily revolved around disease- and treatment-related issues and that it was characterised as efficient and straightforward, but insufficient. The patients experienced that the doctors made treatment-related decisions without involving them.

Introduction Previous studies have shown that focal low-energy extracorporeal shockwave therapy (Li-ESWT) can have a positive effect in men with erectile dysfunction (ED). Linear Li-ESWT (LLi-ESWT) for ED has not been previously assessed in a randomized trial. Aim To evaluate the treatment outcome of LLi-ESWT for ED. Methods Men with ED (n = 126) and a score lower than 25 points on the International Index of Erectile Function erectile function domain (IIEF-EF) were included. Subjects were allocated to receive LLi-ESWT once a week for 5 weeks or sham treatment once a week for 5 weeks. After a 4-week break, the two groups received active treatment once a week for 5 weeks. Subjects completed the IIEF, Erection Hardness Scale (EHS), Sexual Quality of Life–Men, and the Erectile Dysfunction Inventory of Treatment Satisfaction at baseline, after 9 weeks, and after 18 weeks. Main Outcome Measures The primary outcome measurement was an increase of at least five points on the IIEF-EF score. The secondary outcome measurement was an increased EHS score to at least 3 in men with a score no higher than 2 at baseline. Data were analyzed by linear and logistic regression. Results Mean IIEF-EF scores were 11.5 at baseline (95% CI = 9.8–13.2), 13.0 after five sessions (95% CI = 11.0–15.0), and 12.6 after 10 sessions (95% CI = 11.0–14.2) in the sham group and correspondingly 10.9 (95% CI = 9.1–12.7), 13.1 (95% CI = 9.3–13.4), and 11.8 (95% CI = 10.1–13.4) in the ESWT group. Success rates based on IIEF-EF score were 38.3% in the sham group and 37.9% in the ESWT group (odds ratio = 0.95, 95% CI = 0.45–2.02, P = .902). Success rates based on EHS score were 6.7% in the sham group and 3.5% in the ESWT group (odds ratio = 0.44, 95% CI = 0.08–2.61, P = .369). A limitation of this study is that device settings (number of shockwaves and penetration depth) were estimated based on an existing trial on focused ESWT. Conclusion No clinically relevant effect of LLi-ESWT on ED was found.

WOS: 000398822400020, PubMed ID: 27492012, Ureterorenoscopy (URS) is a popular and growing option for management of ureteric and renal stones. The CROES URS Global Study was set up to assess the outcomes of URS in a large worldwide cohort of patients involving multiple centres. In this paper, we analysed the database for intra-operative and post-operative complications associated with ureterorenoscopy. The CROES database was established via collaboration between 114 centres in 32 countries worldwide, and information on both intra-operative and post-operative complications was collected electronically between January 2010 and October 2012. On analysis of a total of 11,885 patients, the overall complication and stone-free rates were found to be 7.4 and 85.6 %, respectively. The intra-operative and post-operative complication rates were 4.2 and 2.6 %, respectively, and in total 5 deaths were reported in the study period. Taking into account different world economies, there were no differences in the complication rates between the developing and developed nations or between different centres from different continents. Ureterorenoscopy is a safe and effective procedure for treatment of stones, the outcomes of which are broadly comparable in different parts of the world for similar patient and stone demographics., Boston ScientificBoston Scientific, The URS Global Study was supported by an unrestricted educational grant from Boston Scientific, who had no involvement in the design, collection, analysis, interpretation, or reporting of the data. Dr Nienke Wijnstok provided statistical support for this manuscript.

INTRODUCTION: We evaluated a new digital single-use flexible ureteroscope, LithoVue™ with respect to deflection, image quality and maneuverability.METHODS: A prospective cohort study was conducted in eight tertiary reference centers in Europe in December 2015 and January 2016. All consecutive patients included underwent flexible ureteroscopy and were 18 years or older. Deflection and image quality pre- and post-use and maneuverability were rated with a Likert scale.RESULTS: A total of 40 procedures were performed (five per institution). The indication for FURS was treatment of renal stones in 92.5 % of the cases. Before LithoVue™ usage, the median measured upward and downward deflections were both 270°. Image quality was rated as "very good" in 65 % of cases and "good" in 30 %. Maneuverability was "very good" in 77.5 % and "good" in 17.5 %. At the final evaluation, median upward and downward deflections were both 270°. Image quality was still "very good" in 65 % of cases and "good" in 30 % with no significant difference compared with preoperative data (p = 1). Maneuverability was "very good" in 72.5 % and "good" in 17.5 %, with no significant difference compared with preoperative data (p = 0.92). Two LithoVue™ broke during surgery (5 %): one occurring in extreme deflection with acute infundibulopelvic angle and spontaneous loss of vision for the second one.CONCLUSION: The LithoVue™ displayed good image quality, active deflection and maneuverability. Further evaluation of surgical outcomes and cost analysis will help to present the best utility of this single-use FURS in current practice.

Introduction: We present a retrospective 2-year follow-up cohort of 103 men with testicular microlithiasis (TML) and discuss patient compliance and the value of surveillance. Methods: A retrospective analysis of patients examined with scrotal ultrasonography (US) in the period from 2008 through 2010 was performed. A total of 103 men with TML were diagnosed and offered US follow-up every 6 months for 2 years. They were retrospectively analyzed regarding demographics and follow-up details, including the development of any kind of malignancy until March 2015, using the Danish Electronic Pathology Registry. Results: The prevalence of TML was 10.3%. Of the 103 men with TML, 23 (22.3%) had TML in the left testicle, 38 (36.9%) in the right (p=0.002), and 42 (40.8%) had bilateral TML. Patient compliance was low with 11.7% participating in all US follow-up examinations. 5 men presented risk factors (testicular atrophy (N=1) and previous testicular cancer (N=4)), but no cases of testicular malignancy were found in the follow-up period. Conclusion: The low patient compliance conflicts with the ESUR Scrotal Imaging Subcommittee guidelines that recommend scrotal US follow-up annually for TML until the age of 55 years. The fact that no cancers were found during follow-up using the pathology registry calls the value of follow-up into question.

Background The Bosniak classification was originally based on computed tomographic (CT) findings. Magnetic resonance (MR) and contrast-enhanced ultrasonography (CEUS) imaging may demonstrate findings that are not depicted at CT, and there may not always be a clear correlation between the findings at MR and CEUS imaging and those at CT. Purpose To compare diagnostic accuracy of MR, CEUS, and CT when categorizing complex renal cystic masses according to the Bosniak classification. Material and Methods From February 2011 to June 2012, 46 complex renal cysts were prospectively evaluated by three readers. Each mass was categorized according to the Bosniak classification and CT was chosen as gold standard. Kappa was calculated for diagnostic accuracy and data was compared with pathological results. Results CT images found 27 BII, six BIIF, seven BIII, and six BIV. Forty-three cysts could be characterized by CEUS, 79% were in agreement with CT (κ = 0.86). Five BII lesions were upgraded to BIIF and four lesions were categorized lower with CEUS. Forty-one lesions were examined with MR; 78% were in agreement with CT (κ = 0.91). Three BII lesions were upgraded to BIIF and six lesions were categorized one category lower. Pathologic correlation in six lesions revealed four malignant and two benign lesions. Conclusion CEUS and MR both up- and downgraded renal cysts compared to CT, and until these non-radiation modalities have been refined and adjusted, CT should remain the gold standard of the Bosniak classification.

PURPOSE: The objective was to evaluate high-level evidence studies of extracorporeal shock wave therapy (ESWT) for urological disorders.METHODS: We included randomized controlled trials reporting outcomes of ESWT in urology. Literature search on trials published in English using EMBASE, Medline and PubMed was carried out. The systematic review was performed according to PRISMA guidelines.RESULTS: We identified 10 trials on 3 urological indications. Two of 3 trials on Peyronie's disease (PD) involving 238 patients reported improvement in pain; however, no clinical significant changes in penile deviation and plaque size were observed. Four studies on erectile dysfunction (ED) including 337 participants were included. Using International Index of Erectile Function (IIEF-EF) and erectile hardness scale (EHS) data suggested a significant positive effect of ESWT in phosphodiesterase-5 inhibitor (PDE-5i) responders in 2 of 4 trials and 3 of 4 trials, respectively. Three studies on chronic pelvic pain (CPP) engaging 200 men reported positive changes in National Institutes of Health Chronic Prostatitis Symptom Index (NIH-CPSI). There was considerable heterogeneity between trials both with regard to treatment techniques and outcome measures, making it difficult to compare results.CONCLUSIONS: ESWT may resolve pain in PD patients, while evidence for reducing curvature and plaques size is poor. Effects of ESWT on IIEF in ED patients are inconsistent; however, data on EHS does imply that the treatment potentially may recover natural erection in PDE-5i responders. ESWT seems to be able to resolve pain in CPP patients in the short term. In all three disease entities, long-term outcome data are still warranted.

PURPOSE: To summarize knowledge on upper urinary tract carcinoma (UTUC) regarding diagnostic procedures, risk factors and prognostic markers.METHODS: A scoping review approach was applied to search literature in Pubmed, Web of Science, and Embase. Consensus was reached through discussions at Consultation on UTUC in Stockholm, September 2018.RESULTS: Tumor stage and grade are the most important prognostic factors. CT urography (CTU) including corticomedullary phase is the preferred imaging modality. A clear tumor on CTU in combination with high-grade UTUC in urine cytology identifies high-risk UTUC, and in some cases indirect staging can be obtained. Bladder urine cytology has limited sensitivity, and in most cases ureterorenoscopy (URS) with in situ samples for cytology and histopathology are mandatory for exact diagnosis. Image-enhancing techniques, Image S1 and narrow-band imaging, may improve tumor detection at URS. Direct confocal laser endomicroscopy may help to define grade during URS. There is strong correlation between stage and grade, accordingly correct grading is crucial. The correlation is more pronounced using the 1999 WHO than the 2004 classification: however, the 1999 system risks greater interobserver variability. Using both systems is advisable. A number of tissue-based molecular markers have been studied. None has proven ready for use in clinical practice.CONCLUSIONS: Correct grading and staging of UTUC are mandatory for adequate treatment decisions. Optimal diagnostic workup should include CTU with corticomedullary phase, URS with in situ cytology and biopsies. Both WHO classification systems (1999 and 2004) should be used to decrease risk of undergrading or overtreatment.

Purpose:\ud \ud To provide an overview of treatment modalities for management of upper tract urothelial carcinoma (UTUC).\ud Methods:\ud \ud In accordance with the standards for a scoping review, data presentation and discussion at the Consultation on UTUC in Stockholm, 6–7 September 2018, consensus was reached on the latest and most important treatment recommendations for UTUC. Using Pubmed, Web of Science, and Embase, publications were selected based on quality, clinical relevance, and level of evidence.\ud Results:\ud \ud Kidney-sparing surgery should be attempted for low-grade UTUC. Radical nephroureterectomy with bladder cuff excision is first option for high-grade disease. Post-operative bladder instillation of chemotherapy should be offered after RNU to reduce intravesical recurrence rate. Identification of tumor grade and stage is crucial when selecting treatment. Ureteroscopic management of low-grade and non-invasive UTUC achieves disease-free survival similar to that offered by radical nephroureterectomy but seems to be a risk factor for intravesical recurrence. Lymphadenectomy appears important for high-risk disease, although the therapeutic benefit needs further validation. There is little evidence supporting use of Bacillus Calmette–Guérin (BCG) and mitomycin C as monotherapy and adjuvant treatment in UTUC. A randomized clinical trial has indicated that platin-based chemotherapy for invasive UTUC improves disease-free survival, suggesting that adjuvant chemotherapy should be considered standard care for ≥ T2 N0–3M0 disease.\ud Conclusions:\ud \ud Risk stratification assessment is feasible and mandatory in UTUC. Identification of tumor grade and stage is essential for optimal treatment selection. Kidney-sparing surgery should be offered in low-risk disease, whereas radical nephroureterectomy and adjuvant chemotherapy should be considered in high-risk disease.

PURPOSE OF REVIEW: The pathophysiological mechanisms in kidney stone formation are insufficiently understood. In order to achieve a better understanding of the complexity of stone formation, studies evaluating anatomical variations in the renal papillae have been performed. This review intends to illuminate recent findings. Moreover, new techniques to improve the understanding and interpretation of crystallization mechanisms are reviewed.RECENT FINDINGS: Due to improvements of digital ureteroscopes, detailed endoscopic mapping of renal papillae is now possible. Connections between papillary morphology and histopathological changes in different subsets of stone formers have been documented. The formation of kidney stones seems to take place in relation to Randall's plaques, Ducts of Bellini or by free formation. Additionally, theories of kidney stone formation because of vascular injury or inflammatory events in the papillae have been suggested.SUMMARY: Novel techniques including improved digital endoscopic visualization, microcomputed tomography (CT), electron microscopy and energy dispersive compositional analyses of kidney stones seem essential in the search for effective and reliable methods to understand stone forming processes, which ultimately should result in effective measures for more personalized stone prevention strategies in the future.

OBJECTIVE: The aim of this study was to evaluate the incidence of ureteral lesions in retrograde intrarenal surgery (RIRS) with and without the use of a 10/12 Fr ureteral access sheath (UAS). A further objective was to search for preoperative factors that could influence the risk of ureteral damage.MATERIALS AND METHODS: Data were collected from a clinical database on 180 consecutive adult patients undergoing RIRS for kidney stones with or without a 10/12 Fr UAS. The primary outcome measure was ureteral lesions endoscopically identified at the end of surgery using the Post-Ureteroscopic Lesion Scale (PULS) classification system.RESULTS: The use of 10/12 Fr UASs resulted in less severe lesions than reported previously with larger diameter UASs. There was a higher risk of superficial lesions in the UAS group, with a calculated crude odds ratio (OR) of 1.84 [95% confidence interval (CI) 1.00-3.37]. When adjusting for age and gender, the OR was 1.68 (95% CI 0.90-3.13; p = 0.10) and thus was not significant. The only factor that remained significant was age (OR =1.02/year, 95% CI 1.00-1.04).CONCLUSION: There was a trend towards a higher risk of ureteral lesions in RIRS with a 10/12 Fr UAS compared with an endoscope alone, but when adjusting for age and gender the incidence of ureteral lesions was comparable between RIRS with and without the use of a 10/12 Fr UAS.

PURPOSE: To prospectively evaluate the new Flexor©Parallel™ Rapid Release™ (Cook(®), Bloomington, IN, USA) access sheath (UAS) which allows the use of a single wire to serve as both safety and working guide.MATERIALS AND METHODS: Between June and September 2014, adult patients from five European centers who underwent flexible ureteroscopy (fURS) for therapeutic and diagnostic purposes were included. The 12/14Fr Flexor©Parallel™ UAS was evaluated. Data were collected and examined by both univariate and multivariate analyses. The UAS material and usage characteristics were rated per case by the surgeons on a scale from very bad to very good.RESULTS: In total, 134 UASs were used in 67 male and 67 female patients. Fifty percent of ureters (67 patients) were pre-stented. Ninety percent of the procedures were therapeutic. The overall successful insertion rate was 94 %. Pre-stenting status was the only independent factor for a successful access sheath insertion: 98.5 % of the pre-stented patients had a successful UAS placement vs. 82 % of non-pre-stented (p = 0.001, C.I. 95 %: 1.2). Evaluation of the material and radiopacity was considered very good in over 90 % of cases. Release of the guidewire, hydrophilic coating, gliding of the endoscope and repeatability were considered very good in over 80 %. There were two (1.4 %) UAS malfunctions and one submucosal lesion reported.CONCLUSIONS: The use of the Flexor©Parallel™ Rapid Release™ (Cook(®), Bloomington, IN, USA) with usage of a single guidewire in a prospective multicentric scenario was clinically applicable in the majority of cases. Pre-stenting increased the chance of a successful insertion from 82 to 98.5 %.

Often when calcite is found as a component of urinary calculi, they are considered false calculi or artifacts. We present a case of true calcite urolithiasis. The stone material was removed percutaneously from a severely malnourished anorectic woman and analyzed by infrared spectroscopy (IRS). In addition, calcite urolithiasis was confirmed in several recurrent stone events by IRS. Laxative abuse with magnesium oxide was believed to be the underlying cause of stone formation, and ammonium chloride given as one weekly dose turned out to be effective for stone prevention.

Currently, indications for flexible ureterorenoscopy (fURS) are expanding, mainly due to technological advancements. Although data from clinical series definitely presents fURS as a safe procedure, serious complications including sepsis and ureteral lesions do occur. These complications seem to be a result of the unique elements of fURS, ureteral access and irrigation, pushing normal upper urinary tract physiology into pathophysiological processes, including intrarenal/pyelo-veneous backflow and ureteral contractions, potentially resulting in septic, haemorrhagic and ureteral lesional complications. Knowledge on normal upper urinary tract physiology are crucial for understanding how these harmful effects of fURS may be avoided or minimized. The pathophysiology of intrarenal pressure increases and ureteral access will be discussed as a basis for understanding preventive measures. Role of antibiotics, ureteral access sheaths, safty guidewires, pain medication, prestenting and pharmacologic modulation of pyeloureteral dynamics are reviewed from a pathophysiological perspective.

Bladder neck contracture following transurethral resection of the prostate is a rare but feared complication. Treatment is often challenging with significant recurrence rates. In this report, we present a complicated case treated with a simple procedure. A 75-year-old male developed urinary retention due to bladder neck contracture after transurethral resection of the prostate. He was initially treated with several transurethral incisions, but the obstruction recurred few months after each incision. At urethroscopy, the bladder neck was completely obstructed. Using both retrograde and antegrade endoscopy, it was possible to place a through-and-through guidewire, after which the length of the stricture could be measured. Subsequently, the stricture was slightly dilated, and a double-cone thermo-expandable metal stent (Memokath 045) could be placed. The correct position was monitored with antegrade and retrograde endoscopy, securing the proximal cone expanded above the stricture and the distal cone above the sphincter. The patient was discharged the same day with spontaneous voiding and minimal residual urine. Twenty-one months after stent placement, the patient still had no complaints of his urination. Thus, the double-cone thermo-expandable metal stent, Memokath 045, may be a durable option for treatment of complicated bladder neck contracture after TURP for benign prostatic hyperplasia.

WOS: 000457123100013 PubMed ID: 30680241 Introduction We assessed the clinical performance of a new digital single-use flexible ureteroscope (UscopePU3022). Material and methods A prospective cohort study was carried out across 11 centers (July-Oct. 2017). The UscopePU3022 was assessed regarding ease of insertion; deflection, image quality, maneuverability and overall performance using either a visual analog* or Likert scale. Results A total of 56 procedures were performed in 11 centers (16 surgeons) with the indication being renal stones in 83%. The median score for ease of scope insertion was 10 (3-10). Intraoperative maneuverability was rated as 'good' in 38% and 'very good' in 52%. Visual quality was rated as 'poor or bad' in 18%, 'fair' in 37% and 'good very good' in 43%. Two scopes failed intraoperatively (4%). Preoperative and postoperative median upward and downward deflection was 270 degrees. Compared to standard flexible ureteroscopy (f-URS) maneuverability was rated as 'equivalent' in 30% and 'better' in 60%; visual quality was 'worse' in 38% and 'equivalent or better' in 62%; limb fatigue scores were 'better' in 86%; and overall performance was 'worse' in 55% and 'equivalent or better' in 45%. Conclusions UscopeTM3022 performed well with regards to maneuverability, deflection and limb fatigue and appears to be at least non-inferior to standard f-URS with regards to these parameters. Poor image quality is a concern for UscopePU3022 with it receiving a low overall performance rating when compared to standard f-URS. Despite this it scored highly when investigators were asked if they would use it in their practice if it was cost-effective to do so.

Objectives To compare elastography measurements in men with normal testicular tissue, testicular microlithiasis and testicular cancer. Methods A total of 248 consecutive patients were included. All men provided written informed consent. Testicular stiffness was assessed using shear wave elastography (SWE). Three SWE velocity measurements were assessed in each testicle. The patients were divided into three groups; men with normal testicular tissue (n=130), men with testicular microlithiasis (n=99) and men with testicular cancer (n=19). Results We found a higher mean velocity in the group of patients with testicular cancer (1.92 m/s (95% CI 1.82–2.03)) compared to both the group with normal tissue (0.76 m/s (95% CI: 0.75–0.78)) (p Conclusion The presence of testicular microlithiasis increased stiffness slightly, but within the range of variation in normal testicles. Increased stiffness may indicate testicular malignancy in testicular lesions. Ultrasound elastography could be a very useful tool when investigating scrotum.

BackgroundThere are limited studies about testicular microlithiasis (TML) and background information such as health, lifestyle, and socioeconomic status.PurposeTo assess the prevalence of TML in relation to socioeconomic status and ethnicity.Material and MethodsFrom a database of scrotal ultrasound examinations in a single institution, all men who underwent routine ultrasound examinations for a variety of symptoms from 1998 to 2015 were included. Skilled observers performed all examinations, and presence of any form of intra-testicular calcification, including TML, was recorded on the examination report and a representative image obtained and stored. A total of 1105 cases with TML were reviewed and random sample of 1105 controls from the same database was also reviewed. Demographics were recorded including ethnicity (white, black, and others) and socioeconomic groups (IMD Quintile).ResultsBlack men had increased prevalence of TML (odds ratio [OR] = 2.17, 95% confidence interval [CI] = 1.72–2.75) compared with white men. Among the 1105 TML cases, 423 (38.3%) were white, 273 (24.7%) black, 152 (13.8%) had other ethnicities, and 257 (23.2%) had no ethnicity recorded. In the control group of 1105 men without TML, 560 (50.7%) were white, 171 (15.5%) black, 111 (10.0%) had other specified ethnicities, and 263 (23.8%) had no ethnicity recorded. Men from the most deprived socioeconomic groups had higher prevalence of TML than men in the most affluent groups, with a trend in OR from the least deprived to the most deprived group.ConclusionPathogenesis and clinical relevance of TML is unknown but our results point towards possible ethnic and socioeconomic variation in the underlying causes of TML.

Objective: To examine the effect of ureteral access sheath (UAS) on the expression of the pro-inflammatory mediators cyclooxygenase-2 (COX-2) and tumor necrosis factor-α (TNF-α) in the ureteral wall. Material and Methods: In 22 pigs an UAS was inserted and removed after 2 minutes on one side and 2 hours on the contralateral side. Postoperatively ureters were excised in vivo, and tissue samples from the distal (2 minutes/2 hours) and proximal ureter (2 minutes/2 hours) were snap-frozen before quantitative polymerase chain reaction analysis of COX-2 and TNF-α. Five unmanipulated ureteral units from other pigs served as the control group. Results: Compared to controls COX-2 mRNA was significantly upregulated in all UAS treated ureteral groups. Similarly, TNF-α mRNA was upregulated in all groups except the 2-minute proximal ureteral group. Both COX-2 and TNF-α expression were significantly higher in the distal than in the proximal ureter in the UAS treated ureters. After UAS insertion for 2 minutes, expression levels in the distal ureter were increased 6.5- and 8-fold for COX-2 and TNF-α, respectively; and after 2 hours of UAS placement COX-2 and TNF-α mRNA expression levels were increased 9- and 9.5-fold, respectively. Conclusion: The pro-inflammatory mediators COX-2 and TNF-α were significantly upregulated in the ureteral wall by the influence of UAS. These findings may have implications for postoperative pain, drainage, and complications.

Background: Testicular microlithiasis and its clinical significance are not fully understood. Testicular microlithiasis and risk factors have been associated with testicular cancer. The role of testicular microlithiasis is investigated.Purpose: To investigate the association between testicular microlithiasis and socioeconomic and other pre-diagnostic factors.Material and Methods: All men who had a scrotal ultrasound examination at the Department of Radiology, Vejle Hospital, during 2001-2013 were included. They were categorized as patients with and without testicular microlithiasis and compared with pre-diagnostic data from a nationwide registry. A total of 2404 men (283 [11.8%] with testicular microlithiasis and 2121 [88.2%] without testicular microlithiasis) were included. The association between testicular microlithiasis and pre-diagnostic conditions was investigated with logistic regression.Results: Overall, we found no statistically significant differences in demographics, socioeconomic characteristics, or testicular diseases in men with and without testicular microlithiasis. Men with testicular microlithiasis had more often been treated for infertility (odds ratio [OR] 2.09, 95% confidence interval [CI] 0.84-5.24) and testicular torsion (OR 1.58, 95% CI 0.34-7.36) compared to men without testicular microlithiasis. We found no association between sexually transmitted diseases and testicular microlithiasis.Conclusion: Treatment for infertility and torsion was non-significantly associated with testicular microlithiasis and no other association was found. These data do not suggest early exposure is related to testicular microlithiasis.

e16507 Background: Metastatic castration resistant prostate cancer (mCRPC) is associated with high mortality. Monitoring of disease activity at this stage, with lack of validated prognostic models, is still a major clinical challenge. The role of microRNAs (miRNAs) has been widely investigated in prostate cancer with both diagnostic and prognostic potential. The aim of this study was to investigate the relationship between circulating miRNAs and treatment outcome in mCRPC patients. Methods: The relative expression of four miRNAs was investigated in plasma samples from 84 mCRPC patients; 40 patients were treated with docetaxel and 44 patients with abiraterone. Real-time polymerase chain reaction was used for analysis. Blood was sampled at baseline, before the second treatment cycle, and at radiological progression (RP). Associations to prognoses were analyzed using the Cox Regression analyses. Results: The plasma levels of all four miRNAs decreased significantly after treatment initiation in patients receiving docetaxel, and for miRNA-141 and miRNA-375 the level increased again at the time of RP. High baseline levels of miRNA-141 were significantly associated with a shorter time to RP in patients receiving both abiraterone, hazard ratio (HR) 3.18 (95% confidence interval (CI) 1.31-7.32), p < 0.01, and docetaxel HR 2.56 (95% CI 1.45-4.50), p < 0.01, and a shorter overall survival (OS), HR 3.20 (95% CI 1.25-9.37), p = 0.02, and HR 1.77 (95% CI 1.07-2.83), p = 0.02, respectively. Likewise, high baseline levels of miRNA-375 were also significantly associated with a shorter time to RP in both cohorts and OS in patients receiving docetaxel. Conclusions: Plasma levels of miRNA-141 and miRNA-375 were of prognostic importance in patients with mCRPC receiving both abiraterone and docetaxel and may be used in treatment monitoring irrespective of treatment modality.

INTRODUCTION: Percutaneous nephrolithotomy (PNL) is usually performed worldwide with a rigid-only antegrade approach. Daily practice suggests that adding flexible nephroscopy and/or ureteroscopy to conventional rigid PNL might improve its efficacy and safety, but available evidence is weak. Appraisal of reliable outcomes of such PNL techniques would better guide intraoperative choices and optimize surgical results. Therefore our objective was to systematically review relevant literature comparing the outcomes of rigid-only PNL and combined flexible PNLs (adding flexible nephroscopy and/or flexible ureteroscopy) for the treatment of large and/or complex upper urinary tract calculi, with regard to efficacy and safety.EVIDENCE ACQUISITION: Ovid MedLine (R), PubMed, Scopus and Web of Science databases were searched in August 2016 to identify relevant studies. Article selection was performed according to the Preferred Reporting Items for Systematic Review and Meta-analysis criteria.EVIDENCE SYNTHESIS: Six articles reporting on 666 patients were included: two randomized controlled trials, two retrospective comparative studies and two case series > 50 patients (one prospective and one retrospective). A narrative synthesis of minor evidences was also prepared. The adjunct of flexible nephroscopy and/or ureteroscopy provided better stone-free rates (range 86.7-96.97%), through a single percutaneous access most of the times and in any position, reducing the need for second-look procedures. Safety of the combined flexible procedures was improved to a variable degree, with a consensual reduction of the mean hospital stay (range 5.1-7 days).CONCLUSIONS: The current evidence suggests that patients with large and/or complex urolithiasis might benefit from the adjunct of flexible nephroscopy and/or ureteroscopy to rigid PNL.

INTRODUCTION: In the last decade microRNAs (miRNAs) have been widely investigated in prostate cancer (PCa) and have shown to be promising biomarkers in diagnostic, prognostic and predictive settings. However, tumor heterogeneity may influence miRNA expression. The aims of this study were to assess the impact of tumor heterogeneity, as demonstrated by a panel of selected miRNAs in PCa, and to correlate miRNA expression with risk profile and patient outcome.MATERIAL AND METHODS: Prostatectomy specimens and matched, preoperative needle biopsies from a retrospective cohort of 49 patients, who underwent curatively intended surgery for localized PCa, were investigated with a panel of 6 miRNAs (miRNA-21, miRNA-34a, miRNA-125b, miRNA-126, miRNA-143, and miRNA-145) using tissue micro-array (TMA) and in situ hybridization (ISH). Inter- and intra-patient variation was assessed using intra-class correlation (ICC).RESULTS: Four miRNAs (miRNA-21, miRNA-34a, miRNA-125, and miRNA-126) were significantly upregulated in PCa compared to benign prostatic hyperplasia (BPH), and except for miRNA-21 these miRNAs documented a positive correlation between the expression level in PCa cores and their matched BPH cores, (r > 0.72). The ICC varied from 0.451 to 0.764, with miRNA-34a showing an intra-tumoral heterogeneity accounting for less than 50% of the total variation. Regarding clinicopathological outcomes, only miRNA-143 showed potential as a prognostic marker with a higher expression correlating with longer relapse-free survival (p = 0.016).CONCLUSION: The present study documents significant upregulation of the expression of miRNA-21, miRNA-34a, miRNA-125, and miRNA-126 in PCa compared to BPH and suggests a possible prognostic value associated with the expression of miRNA-143. The results, however, document intra-tumoral heterogeneity in the expression of various miRNAs calling for caution when using these tumor tissue biomarkers in prognostic and predictive settings.

PURPOSE: To correlate ureteral lesions visualized during ureteroscopy with histopathological findings.MATERIALS AND METHODS: Ureteral access sheaths (UAS) sized 13/15 Fr. were inserted bilaterally in 22 laboratory pigs. During retraction of the UAS with a semirigid ureteroscope inside, ureteral lesions were evaluated and registered using the Post-ureteroscopic lesion scale (PULS). Ureters were excised in vivo between the uretero-pelvic junction and the uretero-vesical junction. Embedded in paraffin, 4-µm thick sections were step sectioned at 250-300 µm intervals and haematoxylin and eosin (HE) stained. Histopathological scoring of ureteral wall lesions was subsequently performed according to PULS.RESULTS: In 72.1% of ureters, the highest histopathological score was at least 1 grade higher than the highest endoscopic PULS score. For 12 (27.9%) lesions, the difference was 2 scores higher, and for 1 (2.3%), it was 3 scores higher. The histopathological PULS grade was higher than the endoscopical PULS grade at all minimum, quartile, and maximum scores. There was a significant difference in the distribution of highest lesional scores between the endoscopic and histopathological PULS (p = 0.002). The calculated mean of the highest scores was 1.49 for endoscopic PULS and 2.51 for histopathological PULS (p < 0.0001).CONCLUSION: Histopathological evaluation of ureteral wall lesions after UAS placement revealed a significantly higher degree of severity than observed endoscopically. Thus, endoscopy underestimated the histopathological extent of the lesion in the majority of cases.

Summary Testicular microlithiasis (TML) is an incidental finding at ultrasonography of the scrotum. A link between testicular microlithiasis and testicular cancer has been suggested. However, the majority of studies are retrospective using ultrasonography with minor data on health status and life style characteristics. Our objective was to investigate if lifestyle and health are associated with TML. In 2014, we conducted a self‐administered questionnaire survey including 1538 men, who all due to testicular/scrotal symptoms had an ultrasound investigation of the scrotum during 2004–2013. The men were divided into men with TML and men without. The 23‐items questionnaire included items on age, height, weight, lifestyle (alcohol consumptions, smoking habits, workload, exercise and food), previous diseases in the testicles, pain and consumption of analgesics. The prevalence of TML was 12.8%. Overall, lifestyle factors did not vary between men with or without TML. However, men with TML did consume more crisp than men without. Development of TML was not associated to classic life style factors such as alcohol consumption, smoking habits, or mothers smoking during pregnancy. Also, age and height could not be linked to presence of TML. We did find, however, that men with TML experienced less physical activity and consumed more crisp than men without TML. Since ingestion of crisps has potential carcinogenic effect (acrylamide), this finding needs confirmation in a separate study.

Background Elastography of the testis can be used as a part of multiparametric examination of the scrotum. Purpose To determine the testicular stiffness using acoustic radiation force impulse imaging (ARFI) technique in men with testicular microlithiasis (TML). Material and Methods In 2013, 12 patients with diagnosed testicular microlithiasis in 2008 (mean age, 51 years; age range, 25–76 years) underwent a 5-year follow-up B-mode ultrasonography with three ARFI elastography measurements of each testis. We used a Siemens Acuson S3000 machine. Results No malignancy was found at the 5-year follow-up B-mode and elastography in 2013. However, we found an increase in TML; in the previous ultrasonography in 2008, eight men had bilateral TML, whereas in 2013, 10 men were diagnosed with bilateral TML. The mean elasticity of testicles with TML was 0.82 m/s (interquartile range [IQR], 0.72–0.88 m/s; range, 65–1.08 m/s). Conclusion Elastography velocity of testis with TML seems to be in the same velocity range as in men with normal testis tissue.

PurposeTo perform a systematic literature review to assess whether the occurrence of testicular microlithiasis (TML) in conjunction with other risk factors is associated with testicular cancer.MethodsA systematic literature search was performed of original articles in English published 1998 to 2015. Relevant studies were selected by reading the title and abstract by two of the authors. Studies were included if TML was diagnosed by ultrasonography and a risk condition was reported. Studies were only eligible if the particular risk condition was reported in more than one article.ResultsIn total, 282 abstracts in were identified. Based on title and abstract the eligibility was assessed and 31 studies were included. Five conditions in relation to TML and testicular cancer emerged: Down syndrome, McCune–Albright syndrome, cryptorchidism, infertility and familial disposition of testicular cancer.ConclusionData support the conclusion that TML is not an independent risk factor for testicular cancer but associated with testicular cancer through other conditions. In male infertility, TML appears to be related to an increased risk of testicular cancer possibly as part of a testicular dysgenesis syndrome. PURPOSE: To perform a systematic literature review to assess whether the occurrence of testicular microlithiasis (TML) in conjunction with other risk factors is associated with testicular cancer.METHODS: A systematic literature search was performed of original articles in English published 1998 to 2015. Relevant studies were selected by reading the title and abstract by two of the authors. Studies were included if TML was diagnosed by ultrasonography and a risk condition was reported. Studies were only eligible if the particular risk condition was reported in more than one article.RESULTS: In total, 282 abstracts in were identified. Based on title and abstract the eligibility was assessed and 31 studies were included. Five conditions in relation to TML and testicular cancer emerged: Down syndrome, McCune-Albright syndrome, cryptorchidism, infertility and familial disposition of testicular cancer.CONCLUSION: Data support the conclusion that TML is not an independent risk factor for testicular cancer but associated with testicular cancer through other conditions. In male infertility, TML appears to be related to an increased risk of testicular cancer possibly as part of a testicular dysgenesis syndrome.

Prostate cancer is the most common cancer among men in the western world. Clinical practice is continuously challenged by the pitfalls of the available diagnostic tools. microRNAs may represent promising biomarkers in many types of human cancers, including prostate cancer. The aim of this study was to investigate microRNA expression in tumour tissue and matched plasma in a cohort of patients with primary metastatic prostate cancer. The relative expression of 12 microRNAs was assessed in diagnostic needle biopsies from the prostate and matched plasma samples in two prospective cohorts (screening cohorts) comprising 21 patients with metastatic prostate cancer and 25 control patients. An independent validation cohort of plasma samples was collected prospectively from 149 newly diagnosed patients with local/locally advanced prostate cancer. Analyses were performed using real-time polymerase chain reaction. miRNA-93 showed a significant negative correlation between expression in tumour tissue and plasma in patients with metastatic prostate cancer. Furthermore, the plasma level of miRNA-93 significantly decreased after treatment in patients with local/locally advanced prostate cancer compared to baseline plasma level. The expression of six microRNAs (let-7b, miRNA-34a, -125b, -143, -145 and -221) was downregulated, and three microRNAs (miRNA-21, -25 and miRNA-93) were upregulated in tumour tissue compared to benign prostate tissue. In plasma, six microRNAs were upregulated (miRNA-21, -125b, -126, -141, -143 and -375), while let-7b was downregulated in patients with metastatic prostate cancer compared to the control cohort. In the metastatic prostate cancer cohort, the expression of four microRNAs (miRNA-125b, -126, -143 and -221), and miRNA-141 in tissue was associated with Gleason score and prostate-specific antigen, respectively. The expression of miRNA-93 in tumour tissue was correlated with matched plasma levels and showed a significant decrease in plasma level after intervention in local prostate cancer. Differential expression between tumour and benign prostate was detected for several microRNAs in both tissue and plasma.

Objective. High intraluminal pressure during ureterorenoscopy (URS) increases risk of infectious and haemorrhagic complications. Intrarenal pressure may be reduced by the use of ureteral access sheaths (UASs), which on the other hand may cause ureteral damage. We have previously shown that the β-agonist isoproterenol (ISO), when administered topically in the irrigation fluid, is able to inhibit ureteral muscle tone and lower intrarenal pressure during URS. The aim of this study was to examine the effect of ISO on the success rate of UAS insertion in a porcine model. Materials and Methods. 22 pigs in which a UAS could not initially be placed were randomized to endoluminal irrigation with either ISO (0.1 μg/mL) or saline before a new insertion trial. Subsequently, it was registered whether the UAS could be passed without resistance. During extraction of the sheath, any ureteral lesions were characterized ureteroscopically using the PULS classification system. Surgeons were blinded to randomization. Results. In the ISO group, the observed effect of irrigation was 63% successful UAS insertions, compared to 27% in the saline group. No serious lesions ( Conclusions. Endoluminal irrigation with ISO may facilitate UAS insertion and potentially decrease UAS related ureteral lesions.

Joint analysis of pain intensity and opioid consumption is encouraged in trials of postoperative pain. However, previous approaches have not appropriately addressed the complexity of their interrelation in time. In this study, we applied a non-linear mixed effects model to simultaneously study pain intensity and opioid consumption in a 4-h postoperative period for 44 patients undergoing percutaneous kidney stone surgery. Analysis was based on 748 Numerical Rating Scale (NRS) scores of pain intensity and 51 observed morphine and oxycodone dosing events. A joint model was developed to describe the recurrent pattern of four key phases determining the development of pain intensity and opioid consumption in time; (A) Distribution of pain intensity scores which followed a truncated Poisson distribution with time-dependent mean score ranging from 0.93 to 2.45; (B) Probability of transition to threshold pain levels (NRS ≥ 3) which was strongly dependent on previous pain levels ranging from 2.8-15.2% after NRS of 0-2; (C) Probability of requesting opioid when allowed (NRS ≥ 3) which was strongly correlated with the number of previous doses, ranging from 89.8% for requesting the first dose to 26.1% after three previous doses; (D) Reduction in pain scores after opioid dosing which was significantly related to the pain intensity at time of opioid request (P

PURPOSE OF REVIEW: Indications for ureterorenoscopy are expanding without hard scientific evidence to support its efficacy. Therefore, it is extremely important to focus on potential harmful effects of the procedure itself. This review explores how physiology of the upper urinary tract reacts to ureterorenoscopy, potentially translating into harmful effects, and how such pathophysiological processes may be minimized.RECENT FINDINGS: Complications to ureterorenoscopy and postoperative pain seem to be related to intrarenal pressure and/or access. Mean intrarenal pressures in the range of 60-100 mmHg during ureterorenoscopy without access sheaths have been measured, thus by far exceeding the threshold for intrarenal backflow, potentially resulting in septic complications. Intrarenal pressure may be reduced by use of ureteral access sheaths, which, however, may cause ureteral damage due to the limited size of the ureter and strain-induced ureteral contractions (peristalsis). Different receptor types modulate this peristaltic activity. β-receptor agonists have been investigated in animal and human trials for the purpose of relaxing the ureter. In randomized, placebo-controlled trials in pigs and humans, usage of the β-receptor agonist isoproterenol in the irrigation fluid has shown a potential for reducing both intrarenal pressure and ureteral tone during ureterorenoscopy.SUMMARY: Upper urinary tract physiology has unique features that may be pushed into pathophysiological processes by the unique elements of ureterorenoscopy: access and irrigation. Pharmacological ureteral relaxation during ureterorenoscopy deserves further attention with regard to reducing complications and postoperative pain.