key: cord-0005261-twsy61oq
authors: nan
title: SIU 2015 Abstracts
date: 2015-09-21
journal: World J Urol
DOI: 10.1007/s00345-015-1684-3
sha: 54f7f652e2e9f0c01799ff760caaa75d43a0fdb0
doc_id: 5261
cord_uid: twsy61oq

nan

Introduction and Objective: Th e bladder is generally considered an organ for voiding and storage of urine, with the urothelium serving as an impermeable barrier. Recent discovery of aquaporins in the bladder urothelium in rodents and later on also in human challenges this notion of impermeability. Upregulation of aquaporins in response to dehydration or bladder outlet obstruction and downregulation following transitional cell carcinoma has been shown. Th is emphasize the need to better understand the function and distribution of aquaporins, as well as their role in bladder diseases. Th e present study aims at establishing basic knowledge about the expression of aquaporin 3 (AQP3) in the porcine bladder, related to gender and gestational age.

Th ree pregnant sows at 60, 80 or 100 days of gestation were sacrifi ced. Fetuses were removed and necropsied. Th e bladder was rapidly removed and whole wall tissue samples from the bladder dome was snap frozen in liquid nitrogen and stored at -800C. Genetic gender determination was performed and fetuses with uncertain gender determination were excluded. Aquaporin 3 mRNA expression was analyzed using QPCR and β-actin was used as the reference housekeeping gene. Results were compared using two-way ANOVA.

Results: A total of 41 samples were analyzed. Gestational age was either 60 (n=11), 80 (n=14) or 100 days (n=16). Aquaporin 3 was expressed in all samples. AQP3 mRNA expression was increased in the fetal porcine bladder with increasing gestational age (p<0.001). However, there was no signifi cant diff erence in AQP3 mRNA expression between genders (p=0.71).

Conclusion: Expression of AQP3 in fetal porcine bladder is demonstrated with increasing expression during gestation. To our knowledge aquaporins in the porcine bladder tissue have not previously been studied. Th is exciting new discovery contributes to the ongoing discussion on reviewing the dogma that the lower urinary tract has an impermeable barrier function.

Improved Contractility of the Long Term Bladder Outlet Obstruction Induced Bladder Underactivity Using Growth Factor Expressing Mesenchymal Stem Cells Introduction and Objective: As the underactive bladder is diffi cult to manage, a new method of increasing bladder contractility in patients with underactive bladder is desired. Mesenchymal stem cells (MSCs) can serve as vehicles for the gene, proliferate and differentiate into bladder smooth muscle cells to repopulate damaged bladder. Th e other is that the exogenous hepatocyte growth factor (HGF) gene can provide complementary functions as angiogenesis and inhibition of fi brosis. Th is study was performed to examine the recovery of the decreased bladder contractility in the long term bladder outlet obstruction (BOO) models of rats using transplantation of HGF expressing human MSCs (HGF-hMSCs) into the bladder wall.

Introduction and Objective: Suddenly dropping to low environmental temperature, cold stress exacerbates lower urinary tract symptoms (LUTS) such as urinary frequency and urgency. Th is study determined if transient receptor potential ankyrin 1 (TRPA1) channels could mediate the cold-stress induced detrusor overactivity in rats.

Materials and Methods: Twenty-four female 10-weeks Sprague Dawley (SD) rats were used. Th is 35th CONGRESS OF THE SOCIÉTÉ INTERNATIONALE D'UROLOGIE -SIU 2015 ABSTRACT BOOK study used HC030031 (TOCRIS Bioscience) as TRPA1 channel antagonist. Th ree days prior to cystometric investigations, polyethylene catheters were inserted into the bladder and abdominal cavity. Cystometric investigations of the unanesthetized rats were performed at room temperature (RT, 27±2°C) for 20 min. Following, the rats were intraperitoneally injected with vehicle, 1.0-(low dose), or 10.0-(high dose) mg/kg HC030031 (n=8, in each). Aft er 20 min, the treated rats were exposed to low temperature (LT, 4±2°C) for 20 min. During the cystometric investigations, the micturition parameters were recorded.

Introduction and Objective: Hypoxia-inducible factors (HIF1, HIF2 and HIF3) play a critical role in cellular and systemic responses to hypoxia by inducing a range of diverse genes involved in cell survival, they have also been implicated in development of renal cell carcinoma. We aimed to assess the eff ect of zinc and cobalt on hypoxia-inducible factor expression in immortalized human kidney cells.

1 to 5 cells in 1 mcl). ESR at the observed patient aft er the seventh transfusion decreased from initial 6 mm/ hour to 3 mm/hour. Aft er the fourth transfusion of mononuclear fraction of peripheral blood at the patient the increase in the content of the total testosterone that allowed to reduce a dose of 1% of dermal gel of testosterone from 1.6 ml per day to 0.5 ml per day was observed. Aft er the seventh transfusion of mononuclear fraction of peripheral blood because of normalization of production of testosterone the restored number of own Leydig's cells an androgen -replacement therapy was cancelled.

Introduction and Objective: Ketamine use as a recreational drug is on a rapid increase in young people. Many reports have shown that long-term ketamine abuse is liable to lead to lower urinary tract symptoms that resemble interstitial cystitis (IC). IC is a disease characterised by severe and chronic pelvic pain with frequency, urinary urgency, and nocturia in the absence of bacterial infection or other diseases. Th is study evaluated the therapeutic eff ect of human umbilical cord blood derived mesenchymal stem cells (UCB-MSCs) in a ketamine induced cystitis (KC) rat model.

For KC rat models 10-weekold, female Sprague-Dawley rats were used. Sham treatment (n=5) rats were assigned to the control group. Th e rats in the KC group (n=10) and KC+M-SCs group (n=9) were intravenously injected with ketamine at a dose of 25 mg/kg for 5 days a week over a duration of 2 weeks. Aft er one week, 1 x 106 UCB-MSCs were directly injected into the submucosal layer of the anterior wall and dome of the bladder in KC+MSCs group. Th e cystometric parameters and immunohistochemical results (Toluidine-Blue, Masson Trichrome, TUNEL staining) were measured at one week following the intervention.

Results: Most rats in the KC group exhibited irregular voiding frequency and decreased inter-contraction interval in comparison with the control group (118.8 ± 34.3 vs. 306 .5 ± 138.5 seconds, respectively; p< 0.05). Th e KC+MSCs group demonstrated improvement in most voiding parameters to normal levels within 1 week. A single injection of UCB-MSCs signifi cantly increased the inter-contraction interval (339.0 ± 131.2, p<0.05) ( Figure 1 ). In immunohistochemical analysis, the bladders in KC group were characterized by mast cell infi ltration in Toluidine-Blue staining, fibrosis in Masson Trichrome staining and apoptosis in TUNEL staining which were signifi cantly ameliorated in the bladders in the KC+MSCs group ( Figure 2 ). Conclusion: Th e injection of UCB-MSCs restored the damaged bladder and associated pathologies including mast cell infi ltration, fi brosis and apoptosis in the KC rat model. Stem cell therapy could be valuable treatment option for painful bladder conditions such as ketamine induced interstitial cystitis.

MP-01.12, Figure 1 .

Introduction and Objective: Currently no markers are available to predict intravesical Bacillus Calmette-Guerin (BCG) response. Among the various markers under study Survivin has good sensitivity in detecting bladder cancer cases and there has been very limited number of studies regarding Survivin as a prognostic marker and predictive marker. Prospective evaluation of urinary Survivin levels as a potential prognostic and predictive biomarker in non-muscle invasive bladder cancer cases on intravesical BCG therapy was planned in this study.

From august 2013 to august 2014 a total 30 intermediate and high risk group patients of NMIBC age ranging from 32 to70 yrs (mean 56) planned for intravesical BCG instillation were enrolled. Recurrence and progression score were calculated by using EORTC genitourinary scoring system and risk table. Patient's urinary samples were taken, pre and post [6 (T1), 12 (T2) and 24 weeks (T3)], intravesical BCG instillation. Urinary Survivin expression was studied by ELISA technique.

Results: Out of 30 patients, 25 (83.30 %) had complete remission at 6 months Th e mean Survivin levels in remission group (group I) was 0.41+/-0.49 which was signifi cantly less than those in recurrence group (group II) mean 1.92+/-0.19. Pre and Post BCG, there was a signifi cant decrease in the urinary Survivin levels in group I when compared to group II where there was a signifi cant rise in pre and post BCG urinary Survivin levels (P value<0.01).

Conclusion: Low pre BCG urinary Survivin level can be used as a useful predictive marker for achieving complete remission in NMIBC patients with on intravesical BCG immunotherapy. Also pre and post BCG urinary Survivin levels act as a useful prognostic marker and can be used as an adjunct to cystoscopy.

Introduction and Objective: Th e Natural Resistance-Associated Macrophage Protein 1 (NRAMP1) gene modulates macrophage activation in a myriad of infectious and autoimmune diseases. Its single nucleotide polymorphisms (SNPs) have been identifi ed to infl uence susceptibility to tuberculosis and response to BCG therapy in murine models. In this study, we evaluate the predictive role of NRAMP1 SNPs in the oncological outcomes of Asian patients receiving intravesical regimes of BCG for NMIBC.

A total of 139 NMIBC patients who underwent post-transurethral resection intravesical regimes of BCG (81mg or 27mg) or BCG (27mg) with interferon alfa from 1995 to 2013 and deemed intermediate to high risk by the European Organisation for Research and Treatment of Cancer risk tables, were prospectively recruited. From these patients and a group of 148 healthy controls, peripheral blood samples were stored and genomic DNA purifi ed. A total of 15 NRAMP1 SNPs were evaluated using high resolution melt analysis. Th e corresponding results were verifi ed by DNA sequence analysis. Kaplan-Meier and Cox regression methods were used to analyze the data.

Introduction and Objective: Microscopic hematuria can indicate presence of underlying urological conditions. AUA guidelines recommend evaluation algorithms for microscopic hematuria. Population-based studies have focused on risk pools such as heavy smokers and elderly men. We evaluated whether men interested in self-managing their lower urinary tract symptoms (LUTS) with an over-the-counter (OTC) product should be screened for microscopic hematuria to detect undiagnosed signifi cant conditions (including urothelial malignancy) causing hematuria.

Materials and Methods: Urine dipstick testing was conducted in men who preferred to self-manage LUTS using an OTC product. Urologic assessment was conducted by a urologist to determine conditions causing/contributing to the urinary symptoms for: men <45 years; and men ≥45 years who had traces of glucose, leukocyte, and/or blood in urine; or had an AUA Symptom Index score ≥20. Men experiencing complete urinary retention, dysuria, extreme thirst, gross hematuria, or urethral discharge ("Do Not Use" symptoms in this study) were also assessed. Men ≥45 years of age who did not meet any of these criteria did not undergo urologic assessment.

Introduction and Objective: Th is fi rst experience, pilot study, was aimed to evaluate the outcome of en-bloc bladder tumor resection using the plasma-button electrode in cases of papillary non-muscle invasive bladder tumors (NMIBT) from the perspectives of surgical safety and effi cacy, perioperative morbidity, histological assessment and short-term oncologic outcome.

A total of 55 patients previously diagnosed by abdominal ultrasound, contrast CT and fl exible cystoscopy with papillary bladder tumors over 1 cm in diameter were included in the trial. Th e exclusion criteria consisted in solid sessile tumors, lesions located in bladder neck area and tumors involving the ureteral orifi ce. En-bloc tumor resection using the plasma-button approach was applied in all enrolled cases. Th e tumor base was subsequently biopsied by standard single-wire loop resection and followed by plasma-button coagulation. Th e fi rst follow-up cystoscopy was completed at 3 months.

Results: All procedures were successfully performed leading to visually complete tumor ablation. Th e mean tumor diameter was 1.8 cm (range between 1 and 4 cm). No obturator nerve refl ex adverse events or cases of bladder wall perforation were encountered. No signifi cant postoperative hematuria and re-intervention requirements were encountered in this series. Th e mean catheterization period was 1.6 days (range 1 to 2.5 days) and the mean hospital stay was 2.1 days (range 1 to 3 days). Th e pathological analysis confi rmed the presence of detrusor muscle in the resected biopsy specimens for all enrolled patients, thus enabling for a reliable tumor staging to be established (all NMIBT histology diagnosed patients). A single case of other site residual lesion was found during the fi rst evaluation cystoscopy, while no orthotopic recurrences were described. To reduce the overdiagnosis and overtreatment of insignifi cant tumors there is an urgent need for a specifi c test to detect clinically signifi cant prostate cancer (PCa). Using gene expression profi ling specifi c PCa-biomarkers were identifi ed. Eight promising biomarkers were selected and the diagnostic accuracy was tested in urine of an intent-to-treat cohort. Th e aim of this study was to clinically validate the four-gene biomarker panel (HOXC6, DLX1, TDRD1 and HOXC4) using an independent prospective multicenter study cohort.

In two independent prospective, multicenter studies (cohort 1: n=490 en cohort 2: n=371) urine was collected aft er digital rectal examination (DRE) from men undergoing prostate biopsies based on an elevated serum PSA level (≥3.0 ng/ ml) and/or suspicious DRE. KLK3, HOXC4, HOXC6, TDRD1 and DLX1 mRNA levels were measured using RT-qPCR. Th e assay was validated according to MIQE criteria, hence the test is a standardized Laboratory Developed Test (LDT). Results from cohort 1 were used to develop models with (combinations of) the four genes based on the comparative CT method. Th e chosen model was validated in cohort 2, i.e. a fully independent validation cohort.

Results: PCa was identifi ed in 41% (202/490) and 47% (174/371) of men from the studies respectively. Th e model with the combination of HOXC6/DLX1 resulted in the highest average AUC (0.76) and specifi city (36%) at ≈90% sensitivity, based on cohort 1. Furthermore, HOXC6 and DLX1 were signifi cant in the logistic regression, in 96% and 94% respectively. Th is model was independently validated for the diagnosis of PCa with Gleason score ≥7 in prostate biopsies. Using ROC curve analysis HOXC6/DLX1 outperformed PCA3 in both cohorts (cohort 1 AUC=0.75 vs. 0.64; cohort 2 AUC=0.73 vs. 0.62). Adding serum PSA to the HOXC6/DLX1 model resulted in an AUC of 0.81 and 0.80, respectively.

Th is study showed the promising results of a new urine test for the early diagnosis of clini-cally signifi cant PCa using a model which combines HOXC6 with DLX1. Th ese results demonstrate that this model could be used to assess the risk of PCa with Gleason score ≥7 and therefore could reduce the amount of unnecessary prostate biopsies.

Introduction and Objective: Curcumin contains mul-Introduction and Objective: A family history of prostate cancer is a well-recognized high risk factor for this disease. Various models for an inherited risk for prostate cancer have been described, but to date traditional linkage and association studies have only identifi ed a small number of rare tumor suppressor genes and SNPs involved in prostate cancer risk and development.

We performed whole exome sequencing on multiple participants (n=5) with prostate cancer from 3 families with a signifi cant history of prostate cancer to potentially identify new prostate cancer susceptibility variants. Exome variants were fi ltered against a range of parameters with a subset of variants chosen for validation by Sanger sequencing and segregation analysis within their respective families. Each prostate cancer participant met the following criteria for inclusion if: (i) they had a verifi ed diagnosis of prostate cancer, (ii) there were multiple cases of prostate cancers in the family, iii) pathology, diagnostic and treatment notes were available, and (iv) they were classifi ed as BRCAX mutation status.

Results: Essential splice site, missense and stop lost variants were fi ltered against a recently published candidate gene list, leaving 19 shared truncating variants and 17 shared missense variants to be genotyped through all prostate aff ected (n=13) and unaff ected male participants (n=8). Th ree missense variants demonstrated complete segregation and one missense variant demonstrated partial segregation with the prostate cancers. Th ree truncating variants demonstrated complete segregation and three truncation mutations demonstrated partial segregation with prostate cancer. No segregating variants between the three families were shared.

Conclusion: Ten truncating or missense variants showed either complete or partial segregation in our three familial prostate cancer families. Of interest, we detected a CYP3A43 and PARP variant in our multicase prostate cancer families. Th ese two variants have previously been reported to occur in other familial associated prostate cancer families, thereby, potentially adding to the evidence that these two variants may have a role in the risk and development of prostate cancer. Another eight novel variants were detected that segregated with disease and warrants further investigation.

35th CONGRESS OF THE SOCIÉTÉ INTERNATIONALE D'UROLOGIE -SIU 2015 ABSTRACT BOOK were recorded. Patients with diabetes, hypertension or known cardiovascular disease were excluded.

Introduction and Objective: Traditional methods of Prostate Cancer diagnosis in males with an elevated or rising PSA have relied on Outpatient TRUS biopsy using local anaesthetic and taking between 6-18 biopsies. TRUS biopsy is painful, associated with rectal bleeding in 10%, UTI in 40% and Urosepsis in up to 5% of Patients. It is also has a poor sensitivity (<30%) low accuracy rates of <25% and a poor specifi city of <30%.

From 2010 we changed to Template Guided Prostatic Biopsy (TGPB) carried out transperineally under a general anaesthetic. To date we have carried out TGPB in 344 patients with a positive biopsy rate of 60% (accuracy of 81%; and Specifi city of 87%). Th e procedure is painless, UTIs occurred in 5%, no Sepsis and no rectal bleeding. Because of the large numbers of biopsies taken 15% of patients had transient retention. In patients who had a previous -ve TRUS biopsy 48% had a subsequent +ve TGBP and patients having TGBP on the fi rst occasion for an elevated PSA (2.5-10) 58% had a positive biopsy.

Results: With the advent of 3Tesla MRI and MRI fusion technology we have now progressed to MRI fusion biopsy using real time Ultrasound imaging and fusing the abnormal MRI image to perform the biopsy (BioJet Fusion, Global Prostate Solutions) . Th is allows for even greater accuracy of the biopsy without taking large numbers of samples. To date we have achieved a +ve biopsy rate of 75% with an accuracy of >90% (in 32 patients). To date there have been no cases of UTI, sepsis or retention.

To determine the suitability of circulating tumour cells (CTCs) as prognosticating indicator and biomarker for delivery of precision medicine.

Patients were recruited and screened (n=20) as a part of ADMET (Androgen Deprivation Th erapy and Adjuvant Metformin) trial. Five millilitres of whole blood was collected from patients for CTC enrichment, enumeration and propagation. Enrichment was performed using CD45 negative selection kit (RosetteSep™). CTCs were identifi ed using immunofl uorescence imaging with antibodies against prostate specifi c antigen, cytokeratin, CD45 and nucleus. Cells were propagated in customized stem cell solution with hypoxic conditions.

Results: At screening, 18 of 20 patients demonstrated circulating tumour cells with the mean number of 574 (range 1-1763, ±613) . In all of the enriched samples, cells could be propagated temporarily with the peak population being reached at 3.5 weeks. Cells were cultured in both 2D and 3D conditions and temporary organoids could be developed from 5 of 18 patients. Polymerase chain reaction and immunofl uorescence imaging at 4 weeks aft er culturing demonstrated characteristics consistent with prostate cancer cells.

Conclusions: Circulating tumour cell technology remains a viable option as a means of providing biomarker information and tumour activity indicator in delivering precision medicine. Firstly, enumeration can be used to help determine the response to a treatment. Secondly, temporary culture and progression into development of organoids may be used to allow for downstream analysis and therapeutic decision.

Transcriptionally-Targeted Retroviral Replicating Vectors: A Novel Strategy for Gene Therapy of Prostate Cancer

Introduction and Objective: While hematospermia is mainly associated with genitourinary infl ammatory disorders, there are very few studies for prostatitis associated hematospermia (PAH) via robust prostatitis evaluation methods. For this reason, we evaluated the incidence of PAH with systematic evaluation methods for prostatitis.

We evaluated 37 hematospermia patients from a single hospital over fi ve years. We classifi ed the patients into PAH versus he-matospermia without evidences of prostatitis (HWP) by using a NIH-CPSI (Chronic Prostatitis Symptom Index) questionnaire and expressed prostatic secretion studies.

35th CONGRESS OF THE SOCIÉTÉ INTERNATIONALE D'UROLOGIE -SIU 2015 ABSTRACT BOOK cant diff erence in patient's the quality of life impact (Table 2) .

Introduction and Objective: Chronic Prostatitis/ Chronic Pelvic Pain Syndrome is a chronic pain disease with high prevalence rates and substantial health care costs. Chronic prostatitis syndrome is a common urological condition that many clinicians fi nd diffi cult to diagnose and treat eff ectively. Th e signifi cance and diagnostic value of semen analysis in bacterial prostatitis has been extensively debated and remains controversial. Our objective was to investigate the diagnostic accuracy of semen and urine culture in the diagnosis and treatment outcome of bacterial prostatitis.

Th e present study is based on a retrospective analysis of a database of over 600 patients (age range 17-57 years) who met the consensus criteria for bacterial prostatitis, 75% of whom had dysuria, 35% perineal discomfort, 60% had obstructive luts, 37% infertility of unknown etiology, 10% erectile dysfunction and 25% recurrent infection of the partner. Segmented urine cultures and semen culture, were performed in all patients. Treatment were started as per the culture report and culture negative patients were treated empirically with quinolones group of antibiotics. Patients were followed-up for 1 year to rule out disease recurrence.

Results: Of the 600 patients, 425 had positive semen culture and 45 had positive urine culture; 130 had negative culture for both semen and urine. Of the positive cultures 75% of the bacteria was Gram-negative microorganisms (Escherichia coli was the commonest specimen isolated) and 25% had signifi cant positive cultures for Gram-positive microorganisms. Patients with positive semen culture had 100% response to antibiotics and full recovery was noted from the symptoms prospective aft er the full course of the antibiotic and recurrence of the disease were noted in 25% of the patient aft er 1year follow-up. Patients with urine positive cultures, 45% had response to antibiotic, but 75% recurrence were noted in 1 year. Patients with negative cultures, 10% had symptomatic relieve but all of them had recurrence in 1 year follow-up.

Conclusions: Th e diagnosis of chronic prostatitis is diffi cult due to the absence of typical clinical symptoms and specifi c ultrasonographic signs. Our data support the usefulness of semen analysis in the diagnostic work-up of prostatitis patients. Semen culture positive patient responded well to medications and recurrence rate was very minimal compared to urine positive and culture negative patients. In our clinical work-up, semenculture are considered the only tests necessary to diagnose bacterial prostatitis and also guide us through the treatment. (RC) has been shown to be a predictor of poor outcomes in patients with bladder cancer. Change in muscle volume during neoadjuvant chemotherapy (NAC) administration has not been well studied. Our objective was to assess for psoas muscle volume (PMV) change during the period of NAC therapy and to assess if such a change was a predictor of pathologic response or survival.

MP-05.03, Figure 1 .

Introduction and Objective: Alternative approach to the radical cystectomy for muscle-invasive bladder cancer is radical transurethral resection (TUR), followed by chemotherapy/ radiotherapy. Objectives: Primary end points of the study were OS (overall survival) and DSS (disease-specifi c survival). Secondary endpoint -OOS survival aft er salvage cystectomy.

Materials and Methods: Sixty eight patients with T2 bladder cancer were treated by 'complete' TUR fol-lowed by chemotherapy / radiotherapy. Th e follow-up ended in June 2014. All patients were subjected to "safety" resection. Patients who had no tumor (T0), or had non-muscle-invasive (T1) tumor were given the option of follow-up with cystoscopy and adjuvant therapy or immediate cystectomy. Mostly elder patients are candidates for bladder sparing. Th ose with invasive tumor on the safety resection were subjected to cystectomy-65 patients (control group). We used SPSS 17: xi-square and Kaplan-Meier for statistical processing.

Results: Five years overall survival (OS) in the bladder spared group was 53% (n-36), and 70 % of the cystectomy group (n-46) -p= 0.015. Th e disease specifi c survival (DSS) was 72% and 79% for the bladder spared and cystectomy group respectively (p=0.04). Th irty four percent (23 patients) with preserved bladder developed recurrent tumors. A repeated TUR was conducted. Fift een percent (4) of them were with invasive tumor and the action taken was cystectomy. Fift y percent (2) of the salvage cystectomy group and 70% of the immediate cystectomy group survived 5 years. Of the preserved bladder patients, 7 (10%) necessitated DJ stenting and 5 (7%) PNS. PNS in the cystectomy group were 2 (3%). Haematuria occurred in 12 patients with preserved bladder and in 4 of the cystectomy group. Th e statistical diff erence between both groups according to complications is p =0.001. Infl ammatory conditions were more common in the bladder sparing technique-4 orchiepididymitis, 1 urosepsis, 3 pyelonephritis, compared to 3 urosepsis and 3 pyelonephritis in the cystectomy group.

Conclusion: Bladder conservation and radical cystectomy for muscle-invasive bladder cancer appear comparable regarding the DSS until the 5th year. Cystectomy continues to be standard of care. Radical TUR is successful bladder-sparing strategy in selected patients with no residual tumor on reTUR and lower life expectancy.

Introduction and Objective: Bladder cancer occurs commonly in the elderly patients. In some circumstance, uremic patients developed bladder cancer. We considered patients who are aged more than 75 years old, end stage renal disease (ESRD) or poor performance status (Eastern Cooperative Oncology Group, ECOG >=2) as fragile patients for operation. We conducted this study to assess radical cystectomy (RC) outcomes and chemotherapy use including neoadjuvant and/or adjuvant chemotherapy in the fragile patients in routine practice.

All patients undergoing RC for bladder urothelial cancer in China Medical University Hospital from 2008 to 2014 were enrolled. Patients' basic characters, surgical and pathology reports and treatment records were retrospectively collected. Patients were stratifi ed into fragile and non-fragile group. Pearson's chi-square test and student t-test were used to assess parameters of these two groups.

Results: We identifi ed 93 patients. Th ere were 18 patients aged more than 75 years old, 11 patient are uremic status and 8 patients were performance ECOG:2. Total 32 patients were stratifi ed into fragile group. Th e sex and pathological staging were no diff erence in these two groups. Major perioperative complications defi ned as Clavien-Dino grade 3 or more were 31.5% in fragile group and only 4.9% in non-fragile group (P=0.009). Chemotherapy use rate was 53.1% and 75.4% in fragile and non-fragile groups (P=0.029). Th e 30-day morbidity rate of non-fragile and fragile group was 26.2% and 34.4%, respectively. Th e 90day morbidity was no signifi cant between these two groups (35.7% of non-fragile and 37.5% of fragile groups). In fragile group, 30-day mortality rate was 9.4% and 90-day mortality rate was 12.5%. Th ere was no 90-day mortality in non-fragile group. Half the patients died within 21 months in fragile patients and fi ft y percent of patients lived aft er 5 years in non-fragile patients.

Conclusions: Fragile patients received radical cystectomy had higher perioperative major complications rate and higher 90-day mortality rate. We off ered complications and morbidity rate in these patients who received radical cystectomy. In elderly, ESRD or ECOG>=2 patients, we need more cautious care to decrease complication and morbidity rate.

Introduction and Objective: Primary management of muscle invasive bladder cancer (MIBC) is cystectomy (cx). All traumas, including major surgery like cx, induce a stress response (SR), which plays an important role controlling the human immune system. A widely used parameter for systemic surgical SR is measurement of serum levels of C-reactive protein (CRP). Th is prospective study aims to compare the Introduction and Objective: Several prognostic models predicting survival of patients with metastatic urothelial carcinoma (UC) have been developed, however, of them, the fi rst model by Bajorin in 1999 is still the most representative and widely-used. Th e aim of this study was to validate three major prognostic models constructed based on phase 2 and 3 trials, by using a cohort of real-world patients.

We reviewed 200 patients with metastatic UC who received fi rst-line chemotherapy at our fi ve affi liate institutions between 2003 and 2011. Using this multi-institutional cohort, we validated the following models: the "Bajorin model", a model consisting of visceral metastasis and performance status (J Clin Oncol 1999; 17:3173) ; the "Apolo model", a nomogram including visceral metastasis, performance status, albumin and hemoglobin (J Natl Cancer Inst 2013; 105:499) ; and the "Galsky model", a nomogram including leukocyte count, number of sites of visceral metastases, site of primary tumor, performance status and lymph node metastasis (Cancer 2013; 119:3012) . Cox proportional hazards regression model was used for multivariate analysis. Harrell's c-index was calculated for each model. Conclusion: All models were demonstrated to have high external validities in real-world patients, and of them, the "Apolo model" achieved the highest c-index in the present population. Further studies with larger populations are needed for establishment of the next standard model.

The Impact of Female Gender on Bladder Cancer Specifi c Death Risk after Radical Cystectomy: A Meta-Analysis of 27912 Patients Liu S, Yang T, Na R, Jiang H, Ding Q

Introduction and Objective: Bladder cancer was one of the most commonly diagnosed cancers in the world. Up till now, there has been no study summarizing current studies on gender disparity and bladder cancer outcomes aft er radical cystectomy. To perform a fi rst meta-analysis on the association between female gender and cancer-specifi c death risk aft er radical cystectomy.

A comprehensive literature search of the MEDLINE and EMBASE databases was conducted for relevant studies published till November, 11th 2014 . Th e primary goal of our study was to investigate the impact of gender disparity on cancer-specifi c death risk aft er radical cystectomy in urothelial bladder carcinoma population. Th e meta-analysis was performed by estimating the odds ratios (OR) and confi dence intervals (CI) through a random eff ect approach.

Results: A total of 17 studies were included in the meta-analysis with a total population of 27912 patients. Th e baseline characteristics of the 17 studies were described in Table 1 . Female gender was associated with a worse survival (pooled OR: 1.20, 95% confi dence interval 1.09-1.32) compared with male gender aft er radical cystectomy. Signifi cant (Q=40.59, p=0.001) statistical between-study heterogeneity was present, with 60.6% of variance secondary to between-study diff erences (I2: 60.6%). Sub-group analysis found the correlation was signifi cant in North American, European studies (OR: 1.17, 95% CI 1.02-1.32 and OR: 1.34, 95% CI 1.19-1.51, respectively) and studies from larger size of samples (OR: 1.24, 95% CI 1.11-1.38). We also found studies adjusted for the key elements (T stage, N stage and grade) obtained positive correlation (OR: 1.21, 95% CI 1.09-1.35).

Introduction and Objective: Pathologic response after neoadjuvant chemotherapy for muscle invasive bladder cancer is used widely as a surrogate endpoint for overall survival. Controversy persists, however, whether the absence of residual cancer (pT0) or the presence of only non-muscle invasive residual cancer (pT1, pTis, pTa) is the optimal surrogate endpoint. We aimed to assess survival dependent on these pathologic responses in a large multicenter patient cohort.

We retrospectively reviewed records of patients with urothelial cancer who received neoadjuvant chemotherapy and underwent cystectomy at 19 contributing institutions from 2000-2013.

Patients with cT2-4aN0M0 and eventual pN0 disease were selected for this analysis. Estimated OS was compared between pT0 and pT1/pTa/pTis patients. A Multivariable Cox proportional hazards regression model for overall mortality was generated to evaluate hazard ratios (HRs) for variables of interest (age, gender, number of cycles and type of chemotherapy regimen, surgical margin, and pT0 vs. pT1/pTa/pTis). Conclusions: pT1/pTa/pTisN0 and pT0N0 stage on the fi nal cystectomy specimen are strong predictors of survival in patients receiving NAC and RC. We did not discern a statistically signifi cant diff erence in OS when comparing these two endpoints.

Signifi cance of Computer Materials and Methods: Fift y patients were included in our study, 39 of them presented with haematuria and a recent diagnosis of bladder carcinoma, and 11 patients with a history of previous transurethral resection of superfi cial bladder cancer in their follow up period. Th ey ranged in age 42 years to 75 years with a mean of 58.5; while male to female ratio was 5.25:1. Th e main steps to perform virtual cyctoscopy incorporate proper bladder distention with air aft er draining the residual urine through Foley's catheter and scanning the patient in both supine and prone positions. An excellent overview of the bladder masses was obtained in all cases and the results of virtual cyctoscopy and conventional one were comparable with excellent sensitivity rates of virtual cyctoscopy in detection, localization and morphology description of the bladder lesions at variable sizes.

Results: For detection of all lesions (n=62), virtual cyctoscopy alone showed sensitivity: 98.4%, specifi ty: 81.81% with two false positive and one false negative in comparison to conventional cyctoscopy which detected 61 lesion while in axial CT alone the sensitivity: 73.8%, specifi ty: 100% with 7 false negative fi ndings.

Conclusion: CT virtual cystoscopy is a promising technique for use in bladder tumor detection of lesions larger than 5 mm. Optimal evaluation requires adequate bladder distention with the patient in both supine and prone positions and interpretation of both transverse and virtual images. is an evolving technique aiming to improve upon the diagnostic sensitivity of prostate biopsy for the diagnosis and local staging of prostate cancer (PCa). Diff erences in interpretation, expertise and application of mpMRI may be responsible for the range of reported results. Th is retrospective study aims to evaluate the diagnostic accuracy of mpMRI in a cohort of patients from Melbourne, Australia, as compared to the gold standard of radical prostatectomy (RP).

Th is retrospective study was conducted in 2015 through the electronic patient records of a tertiary hospital and several private urology practices in Melbourne, Australia. Patients having undergone RP had their records assessed for the presence of a pre-operative MRI performed aft er 1st January 2013 which was then evaluated against the reference standard of a radical prostatectomy wholemount specimen. MRI sequences typically included T2 weighted imaging, diff usion weighted imaging and dynamic contrast enhancement at 3T. MRI reports were evaluated using the Prostate Imaging-Reporting and Data System (PI-RADS) system.

In our cohort the sensitivity and specifi city of mpMRI for prostate cancer (PCa) detection was found to be approximately 70-80% and 40-50% respectively. Th e area under the curve for determining local stage was approximately 0.5.

Conclusion: mpMRI may have a useful role as an adjunct for prostate cancer diagnosis and directing management toward improving patient outcomes. Staging information may be less reliable.

A Randomized Prospective Trial to Assess the Outcomes of MRI/TRUS-Guided Prostate Biopsy and Traditional 12-Core TRUS-Guided Prostate Biopsy Baco E 1 , Rud E 2 , Eri L 1 , Moen G 1 , Vlatkovic L 3 , Svindland A 3 , Eggesbø H 4 , Ukimura O 5 Introduction and Objective: Th e outcomes of magnetic resonance imaging (MRI) and 3-dimensional transrectal ultrasound (3D-TRUS)-image-fusion-guided prostate targeted biopsy (MRI-group) has not yet been compared with traditional 12-core TRUS-guided prostate biopsy (control-group) in a randomized control trial (RCT) . Th e aim of this study was to compare the prostate cancer (PCa) detection rates (CDRs) and histopathological outcomes in the two groups.

Th is prospective RCT included 175 prostate biopsy (PB) naïve patients with suspicion for PCa, where 85 were randomized to MRI-group and 89 to control-group from 09/2011 to 06/2013. In the MRI-group, two TB of MRI suspicious regions was followed by 12-core systematic random biopsy (RB). In the control-group, two TB towards palpable and/or TRUS-visible suspicious regions and 12-core systematic RB were performed. Clinically signifi cant Pca (CsPCa) on biopsy was defi ned as maximum cancer core length (MCCL) ≥5mm of Gleason score (GS) 6 or any MCCL of GS ≥7 according to START criteria. CDR of all PCa and CsPCa, and histopathological fi ndings were compared between the two groups.

Results: In the MRI-and control-group CDRs were 51/86 (59%) and 47/89 (53%), (p=0.573). CsPCa were detected in 37/86 (43%) in and 44/89 (49%) in control-group, (p=0.484). TB (median 2 cores/ patient) detected CsPCa in 32/38 (84%) in MRI-and 16/44 (36%) in control-group (p=0.012), respectively. Concordance of GS on biopsy and radical prostatectomy specimen was 16/22 (73%, k = 0.518) in MRI-and 14/25 (56%, k = 0.386) in the control-group (p<0.001).

Upgrading of GS biopsy vs. GS-RP specimen was 20% in MRI-group and 49% in control-group (p<0.001). Since the present study had a restricted cohort size, this may limit the generalizability of the results.

No signifi cant diff erence in CDRs was found between the two groups. PCa diagnosis can be achieved with few MRI/TRUS-fusion guided prostate biopsy. Gleason score on targeted biopsy was more accurate in the MRI-group.

Introduction and Objective: Infection is a complication of TRUS prostate biopsy, despite the use of antibiotic prophylaxis. Worryingly the rate of infectious complications following TRUS biopsy has been shown to be increasing. We aimed to determine the rate, severity, risk factors and microbiology resistance patterns associated with TRUS biopsy sepsis. As well the standard patterns of care surrounding TRUS prostate biopsy.

A retrospective case-control study was conducted. Using electronic coding all patients who presented to Cabrini Hospital with sepsis following a TRUS biopsy from 2009 to 2013 were identifi ed. Validated cases were matched to controls in a ratio of 1:3. Eligible controls were required to have undergone a TRUS biopsy at the same surgical institution as the case and in the closest period of time. Demographic, procedural and patient related data-points were recorded for all patients using hospital and urologist records. Univariate logistic regression models were constructed and used to determine risk factors associated with infection.

Results: Seventy-one cases developed sepsis following TRUS biopsy and were matched to 213 controls. Th e average rate of sepsis over the 5-year study period was 1.5%. A SOFA score ≥2 was identifi ed in 28% of cases. We found a high prevalence of antibiotic resistant E. coli, with 61% of blood culture isolates classifi ed as Multidrug resistant organisms. Eight diff erent prophylactic antibiotic regimens were identifi ed. Statistically signifi cant risk factors included previous antibiotic use and prior international travel within the six months prior to biopsy. Th e addition of a penicillin antibiotic to standard fl uoroquinolone antibiotic prophylaxis was protective.

Conclusions: TRUS biopsy is an elective procedure and as such needs to be associated with minimal morbidity. Th e patterns of care surrounding periprocedural variables for TRUS biopsies were non-uniform and diverse. A wide variety of diff erent prophylaxis regimens and bowel preparation routines were recorded. Patients with risk factors for sepsis may represent a better target population for intervention with alternative preventative strategies. Alternative preventative options include augmented prophylaxis, tailored prophylaxis or the TP biopsy approach either as a fi rst line biopsy modality or based on epidemiological risk factors.

PSA level) and pathological data was collected for all patients undergoing fi rst-time prostate biopsy with at least 7 months follow-up, at 32 MUSIC practices. From this overall cohort we identifi ed all patients whose pathology revealed multi-focal HGPIN and/or ASAP (pre-malignant pathology) . For this subgroup, we examined the frequency of repeat biopsy across MUSIC practices and cancer detection outcomes.

Introduction and Objective: Nowadays overtreatment is recognisable challenge in PCa management. Overdiagnosis is possible reason for further overtreat-ment. We hypothesised that repeated prostate biopsies could not only help to cure but also harm patients with PCa.

Consecutive 282 patients who underwent biopsy for suspicious PCa following at least one rebiopsy at single tertiary medical centre in 2004-2015 were included. Age, initial and subsequent PSA, DRV, histology and biopsy features were recorded along with characteristics of subsequently diagnosed PCa and chosen treatment approach. Descriptive statistical methods were used for further analysis.

Results: Basic characteristics were (mean±SD or frequency): age at initial biopsy (62.9±6.9 years), time between initial/fi nal biopsy (33.1±26.1 months), initial/ fi nal PSA (10.77±9.52 and 15.07±17.90 ng/ml), DRV (normal/suspicious 80.5%/19.5%), and number of initial/fi nal biopsy cores (8.1±1.8 and 10.0±2.7). Initial/ fi nal histology was BPH in 67 (23.8%)/44 (15.6%), infl ammation in 114 (40.4%)/85 (30.1%) and premalignant lesions in 101 (35.8%)/45 (16.0%) cases. Finally, 108 (38.3%) PCa were diagnosed (99 by biopsy, 9 by TURP) performing 712 biopsies aft er all. Mean number of biopsies per patient was 2.52 in total and 2.70 to reach cancer positive histology; TURP was performed in 61 (21.6%) patients. In 51 (51.6%) patients ≤2 biopsy cores were cancer positive and in 60 (60.6%) patients Gleason score was ≤ 6. Gleason score ≥ 8 was found in 18 (18.2%) cases. Treatment with curative intention was held in 39 cases (RRP 35, external radiotherapy 4), no treatment (AS/WW) in 6 and hormonal therapy in 237 patients. Fourteen patients with minimal low grade cancer (≤2 positive cores, Gleason score ≤ 6) underwent RRP (40% of all surgery cases).

Conclusion: Repeated biopsy is important approach in PCa diagnosis. However, based on our results we cannot exclude the risk of overdiagnosis and subsequent overtreatment with signifi cant impact on patients' quality of life, including radical surgery for low risk disease and early hormonal therapy in non-metastatic low-intermediate risk disease. Th e study is retrospective, but potential bias became the advantage, since we could exclude prospective "self-control" within treatment decision making process. (Siemens, Munich, Germany) and images were interpreted visually to evaluate uptake in biopsy districts of prostate gland. Th e lesions suspicious for PCa were submitted to additional targeted biopsies.

Introduction and Objective: Multiparametric MRI (mpMRI) and MRI/TRUS-fusion-guided biopsy (TB) are advocated to detect index lesions and signifi cant prostate cancer (PC) within the prostate more exactly than systematic biopsies (SB) . Th e aim of this study was to evaluate the detection accuracy of tumor foci by mp-MRI and TB on radical prostatectomy (RP) specimen.

We selected 120 consecutive patients who were treated with RP for localized PC diagnosed by TB and/or transperineal saturation SB. On mpMRI, all lesions were scored according to PIRADS. All lesions with PIRADS≥2 underwent TB. On RP specimen, index lesion was defi ned as highest Gleason score (GS) or highest tumor volume (TV). GS=3+3 and TV≥1.2ml or GS≥3+4 and TV≥0.7ml were considered signifi cant. We performed Spearmans correlation coeffi cient between mpMRI and RP specimen and Fisher's test between mpMRI, TB and SB. Introduction and Objective: Prostate biopsy is evolving to pre-biopsy multi-parametric MRI (MP-MRI), followed by systematic biopsy (SB) ± targeted biopsy (TB). MP-MRI combined with TRUS-guided TB may increase detection rates of prostate cancer (PCa), especially clinically signifi cant PCA (CSPCa). However, few studies compare the detection rate of SB versus TB in the same cohort of men, as recommended by the Standards of Reporting for MRI-Targeted biopsy studies (START) consensus panel. Th is study compares the diagnostic yield of SB and TB in a single cohort.

Th irty-three patients had a pre-biopsy MP-MRI that identifi ed a target lesion. Each patient then had a TRUS-guided SB and TB. Th e cognitive fusion technique was used to perform the TB.

Results: Among the 33 patients, mean age was 68 years; mean PSA was 9.4 ng/ml. Th e positivity rate for PCa was 64% (n=21) for both SB and TB. Th e positivity rate for CSPCa was 55% (n=18) for SB and 42% (n=14) for TB (p=0.46). SB underdiagnosed 2 cases (6%) of CSPCa that were detected through TB; TB underdiagnosed 5 cases (15%) of CSPCa (p=0.43) . Th e positivity rate for SB and TB combined was 61% (n=20) for CSPCa (p=0.35).

Conclusion: Detection rates for PCa using SB and TB were equal, but SB had a higher detection rate for CSPCa. Combining TB with SB increased the rate of detection for CSPCa by 6%. TB alone was 9% more Introduction and Objective: Active Surveillance (AS) has gained popularity with the intention of avoiding or postponing interventions in subjects with PCa of low biological potential. Unfortunately, several inclusion criteria have been proposed but many doubts still persist about their performance in predicting favorable disease. We aimed to assess the added value of biopsy factors, like maximum cancer length in a core (MCL), cumulative cancer length (CCL), cumulative length of positive cores (CLPC), and percentage of cancer involvement in positive cores (CIPC), to the PRIAS criteria in patients who underwent radical prostatectomy (RP) but eligible for active surveillance (AS).

From January 2002 to December 2007, 750 consecutive subjects underwent RP. We identifi ed 147 (19.05%) patients who were eligible for AS based on PRIAS criteria: clinical stage T1c or T2, PSA level of ≤10 ng/ml, Gleason score ≤6, PSA-D of <0.2 ng/ml2 and one or two positive biopsy cores. We calculated the diagnostic accuracy of biopsy factors in determining pathological confi rmed unfavorable disease. Decision curve analysis (DCA) were performed. explored, we examine the feasibility of monitoring low volume Gleason sum (GS) 3+4 disease compared to GS 3+3 disease.

Introduction and Objective: Th e selection of prostate cancer patients for active surveillance (AS) is based on the criteria for low risk according to protocols such as the National Comprehensive Cancer Network (NCCN) or European Association of Urology (EAU) guidelines. We aim to compare pathological upgrading and upstaging rates between prostate cancer patients who met the above guidelines but underwent radical prostatectomy. We also aim to refi ne the selection criteria for our local population.

A total of 317 men were treated with RP at our tertiary center from 2000 to 2013. Seventy-three patients met the NCCN criteria for active surveillance: cT1-T2a, prostate-specifi c antigen (PSA) less than 10ng/ml, and biopsy Gleason sum 2 to 6. Th irty-fi ve met the EAU guidelines, which had additional criteria of: 2 or less biopsy cores positive and 50% or less Ca detected per core.

Results: Of the 73 patients who met the NCCN criteria, 27 (40.0%) showed pathological upgrading (Gleason > 7) while 7 (9.6%) were upstaged (pT3). Upgrading and upstaging fi gures for the 35 patients meeting the EAU guidelines were 10 (28.6%) and 3 (8.6%) respectively. Analyzing the patients who met the NCCN criteria, those who had 25% or more of the number of biopsy cores positive for prostate cancer had a far greater upgrading rate of 70.6%, which was more than the 28.6% (P = 0.025) seen in the other patients. PSA density or percentage of individual core did not show any statistical diff erence in upgrading or upstaging.

Conclusion: A lower percentage of upgrading was seen in patients meeting the EAU. Upstaging fi gures were relatively the same. When counseling patients for active surveillance using the NCCN criteria for low risk, we should exercise strong caution in patients with 25% or more of the number of biopsy cores positive for prostate cancer.

Biochemical Recurrence Rates in Active Surveillance Candidates and the Role of Improving Gleason Grading Introduction and Objective: To evaluate prospectively the role of prostate-specifi c antigen (PSA) density to predict Gleason score upgrade in prostate cancer patients eligible for active surveillance (T1/T2, biopsy Gleason score ≤6 and PSA ≤10ng/ml and ≤2 positive biopsy cores).

Between January 2010 and November 2013, among the patients who underwent more than 10 core trans-rectal ultrasound guided biopsy, 60 patients eligible for active surveillance under-went radical prostatectomy. Using the modifi ed Gleason criteria, tumor grade of the surgical specimens was examined and compared to the biopsy results.

Results: A tumor upgrade was noticed in 24 (40.0%) patients. Extra-capsular disease and positive surgical margin was found in 6 (10.0%) and 8 (17.3%) patients, respectively. A statistical signifi cant correlation between the PSA density and postoperative upgrade was found (p=0.03); this is in contrast to the other studied parameters which failed to reach signifi cance, including PSA, prostate volume, number of biopsy cores and number of positive cores. Tumor upgrade was also highly associated with extra-capsular cancer extension (p=0.00). Th e estimated optimal cutoff value of PSA density was 0.13 ng/mL2, obtained by ROC analysis (area under the curve 0.66, p=0.02, 95% CI 0.53-0.78).

Conclusions: PSA density represents a strong predictor for Gleason score upgrade aft er radical prostatectomy in patients eligible for active surveillance. Since tumor upgrade increases the potential for postoperative pathological adverse fi ndings and prognosis, PSA density should be considered when treating and consulting patients eligible for active surveillance.

Surgical Outcomes of South Australian Patients Who Have Discontinued Active Surveillance Plagakis S 1 , O'Callaghan M 1,2,3 , Moretti K 2,4 , Foreman D 1, 5 Introduction and Objective: Active surveillance (AS) is a recognized management pathway for patients with low risk prostate cancer (PCa). Diff ering protocols exist to identify suitable patients and manage their follow up. Our study compares surgical pathology outcomes between patients who were initiated on, but discontinued, AS and underwent radical prostatectomy (RP) with patients who received surgery immediately at the time of diagnosis. We also explore predictors of AS discontinuation.

Our cohort comprised men diagnosed with PCa from the South Australian Prostate Cancer Clinical Outcomes Collaborative database between 2005-2012, aged 50-75 years, Gleason score ≤6 and PSA ≤10. Patients were stratifi ed into an immediate treatment group and an AS group. To assess if AS derivation rules aff ected outcomes, patients were sub-categorised according to enrolment criteria of University of Toronto, PRIAS and Royal Marsden protocols (with PSA and Gleason adjustment accordingly). All patients had a minimum of two years follow up. Chi squared, logistic regression and Cox proportional hazards modelling were used to compare outcomes between groups.

Results: Forty-three (17%) patients in the AS group underwent RP, compared with 260 in the immediate treatment group. Extra capsular extension and upgrading of histology at RP were more common in those managed by AS compared to those receiving im-mediate surgery. Th ese associations were supported by sensitivity analysis using PRIAS and Toronto criteria but not Royal Marsden selection criteria. AS trended to being associated with unfavourable surgical pathology in multi-variable analysis, but this was only statistically signifi cant for PRIAS ), p=0.02). In all patients managed by AS, sensitivity analysis suggested that the percentage of core positive at diagnosis is a signifi cant predictor of AS discontinuation in those meeting the University of Toronto selection criteria (HR 1.29 (1.10-1.51), p=0.001).

To determine if PRIAS has increased rates of active surveillance (AS) for patients with low-risk prostate cancer (PCa). Secondly, to determine whether urologists are operating on greater proportions of high-grade PCa as a result of increasing AS and what eff ect this has on surgical practice.

Prospective data was collected on patients from 2008-2013 (cohorts 2008-2010, 2011-2013) who underwent TRUS biopsy by a urologist in Geelong (n=537). Positive TRUS biopsies (n=288) in both the pre and post PRIAS cohorts were assessed to see if they met PRIAS eligibility and whether they received AS or active treatment (AT). AT patients were risk stratifi ed by Gleason Score and D' Amico Risk. Data on post-prostatectomy staging, margin status and nerve-sparing techniques were collected. Chi-squared test were used to calculate statistical signifi cance between cohorts.

Results: AS increased between cohorts (12%, 25%, P=0.006). Before PRIAS 29% (13/45) of patients eligible for AS by PRIAS criteria opted to undergo AS compared with 55% (17/31) aft er the introduction of PRIAS (P=<0.0001). Th e relative proportion of high-grade PCa (Gleason Score ≥ 8 and D' Amico High-Risk) undergoing AT increased from 5 to 12% (P=0.16) and 9 to 15% (P=0.27 

Introduction and Objective: Renal trauma is predominantly managed conservatively. Trauma nephrectomy is reserved for patients who fail conservative or alternative management options. Nephron sparing surgery is the cornerstone of renal preservation. Our objective was to review the management of renal trauma at three tertiary facilities in Queensland over a 10year period and compare these outcomes with current literature.

A retrospective analysis was performed to fi nd the total number of renal traumas presenting to the Princess Alexandra Hospital, Royal Brisbane and Women's Hospital and Gold Coast Hospital, in Queensland, Australia. Renal trauma patients were identifi ed using ICD-10 codes (S37.00-02) and operative databases. Patients requiring angioembolisation were obtained from radiological databases. We accessed the number of conservatively managed patients, trauma nephrectomies and angioembolisations for renal trauma.

Results: A total of 668 renal traumas were identifi ed from June 2002 to June 2012. Six hundred and sixteen injuries were managed conservatively. Th irty-three patients warranted acute exploration due to haemodynamic instability and resulted in nephrectomy in all cases. A trauma or general surgeon was the primary operator. Fift een patients underwent angioembolisation for blunt renal trauma and 4 patients for penetrating injuries. Two patients proceeded to delayed nephrectomy for ongoing bleeding and for a ureteric stricture requiring nephrectomy aft er failed auto transplantation. Th ese were performed by an urologist. Th ere were 2 further devascularised atrophic kidneys. Seventeen of 19 renal units were spared and 15 of 19 patients remained with functioning kidneys. All treated patients with angioembolisation were followed up with either MAG 3 renogram or CT triple phase and had functional kidneys at 2.5 years.

Conclusion: Renal trauma is managed conservatively in most cases, consistent with the current literature. Angioembolisation is an eff ective management option in selected patients with renal trauma. Th is may prevent the need for trauma nephrectomy. In our cohort, patients requiring a trauma nephrectomy had predominantly Grade IV and V injuries. General or trauma surgeons performed trauma nephrectomies in the acute setting of haemodynamic instability with rapid transfer to theatre. Delayed nephrectomies were performed primarily by urologists in this cohort.

Introduction and Objective: To review the contemporary management of traumatic extra-peritoneal bladder ruptures at an Australian level one trauma centre.

Patients presenting with bladder injuries from July 2001 through to June 2013 were identifi ed using the TraumaNET database. Th is was cross-linked with medical records and only patients with extra-peritoneal bladder rupture were included in the study. Clinico-pathological data were collected from the database, medical records and health information services coding data.

Results: Over the twelve-year study period, 41 multi-trauma patients sustained an extra-peritoneal bladder rupture. Of these patients, 95.1% had a concurrent pelvic fracture and 56.1% had co-existing intra-abdominal injury. A total of 23 patients underwent operative repair for the bladder rupture and 18 patients were managed conservatively with catheter drainage. Of the patients managed operatively, 83% of cases were done at the time of another general surgical or orthopaedic operation and only two cases were done as a stand-alone repair.

Conclusion: Extra-peritoneal bladder ruptures can be managed both conservatively and with operative repair. If operative repair is performed, it is usually done at the time of another operation for concomitant injury.

Management Outcomes of Major Renal Injuries following Blunt Trauma: Changing Concepts over Years Results: A total of 35/56 (62.5%) of group I, and 52/59 (88.1%) of group II were treated non-operatively. Diagnosis and grading in group I depended mainly on U/S, IVP and in some cases CT scan, while U/S and enhanced CT scan were mainly used for most of the group II cases. In the total cohort, grade III, IV and V renal injury were seen in 35 (30.4%), 48 (41.7%) and 32 (27.8%) patients respectively. Open exploration was followed in 21 (37.5%) and 7 (11.9%) patients of group I and II, with an overall exploration rate in 25/80 (31.3%) of grade IV and V injury. Th e incidence of nephrectomy have decreased from 8 cases (14.3%) in group I to 3 cases (5%) only in group II (2/3 kidneys were pathologic). Double-J stenting and percutaneous drainage of urinoma was done in 3 and 2 cases, and chest-tube drainage to one patient with traumatic urinothorax in the conservatively managed group.

Outcomes were excellent, however in the non-operatively managed (grade IV-V) cases, 4/55 (7.3%) normotensive patients had a non-functioning kidney within one year of follow up.

Conclusion: Non-surgical management of high grade blunt renal injury can be safely undertaken and also recommended unless the patient is haemodynamically unstable. Accurate grading is sometimes imprecise in multi-trauma patients, where instability is not always due to renal injury. Drainage of extravasation is necessary to reduce morbidity. Abdominal exploration does not mandate concomitant renal exploration, which is indicated in selected instances, otherwise it is an aggressive decision with a triple incidence nephrectomy rate.

Management of Grade IV Renal Trauma: A Revision of the AAST Renal Injury Grading Scale is Mandatory

Chiron P 1 , Hornez E 2,3 , Boddaert G 2 , Dusaud M 1 , Bayoud Y 1 , Molimard B 1 , Desfemmes F 1 , Durand X 1 Introduction and Objective: Th e AAST (American Association for the Surgery of Trauma) injury grading scale for renal trauma is currently the most important variable predicting the need for kidney repair or removal, for morbidity and mortality aft er blunt or penetrating injuries of the kidney. Th e 2011 revision included the renal pelvis, the uretero pelvic junction and the segmental vascular injuries as grade IV, limiting grade V to severe hilar injuries. However, this revision does not permit the identifi cation of the group of patients who will require surgery because of hemodynamic instability due to grade IV renal injuries. Th is study aims to propose an add-on for the grade IV of AAST renal injury scale, in order to improve the management of these patients.

We searched the following electronic databases: Medline and Scopus database. Searches were not restricted by date, language or publication status. Searches were last conducted in September 2014. Paediatric studies were excluded.

Results: Seventy-one articles were found, 57 were pertinent, including 6 directly related to the topic.

Th ree risk factors were identifi ed to be associated with surgery for hemodynamic instability: peri-renal hematoma >3.5cm, intravascular contrast extravasation, medial renal laceration. Presence of two or more of these criteria has been validated by 2 others studies to predict the need for intervention. Patients with >25% devascularized fragments also present a poor prognosis and should be treated more aggressively.

Conclusion: Th ese data should be incorporated into a future reassessment of the classifi cation, in order to better determine the need and time for surgery in grade IV renal traumas, generally leading to a nephrectomy.

Single Panurethral reconstruction can be a surgical challenge. Techniques include staged urethroplasty, augmented anastomosis with buccal mucosa graft (BMG) onlay via penile and/or transperineal, skin fl aps, or combinations of these. We report our experience of single stage modifi ed transperineal urethroplasty using a dorsal BMG in treatment of panurethral stricture.

Aft er obtaining IRB approval, we performed a retrospective review of our urethral stricture database and identifi ed patients having undergone single stage transperineal urethroplasty using dorsal BMG as treatment of pan-anterior urethral stricture. Patient characteristics, operative, and post-operative outcomes were studied. Failure was defi ned as a need to any intervention during the follow-up period.

Results: Th irteen patients underwent complete anterior urethra dorsal urethrotomy with dorsal BMG onlay between September 2011 and January 2015. Mean age was 47.9 years (SD: +/-8.4). Urethral stricture etiology was lichen sclerosis in 5 patients (38.5%), idiopathic in 5 (38.5%), hypospadias in 2 (15.4%) and infection in 1 (7.7%). Previous treatments of dilatation and DVIU were noted in 12 patients (92.3%) and previous urethroplasty in 2 (15.4%). Mean operative time was 258.7 minutes (SD: +/-68.5). Mean estimated blood loss was 280.8 cc (SD: +/-154.8). Th ere were no intraoperative complications. Early postoperative complications were buccal donor site bleed in 2 patients (15.4%) one treated with digital compression and other with hemostatic stitch, one patient (7.7%) presented a perineal abscess and secondary urethroperineal fi stula. Late complications was observed in 3 patients who had postoperatory dribbling (23%).

At mean follow up of 20.6 +/-14.6 months, 3 had recurrence (23.7%) requiring DVIU without new recurrence aft er a mean follow-up of 7.8 months (range 3-10) and one had meatal stenosis treated with dilatation (7.7%) without recurrence aft er 24.9 month of follow-up.

Conclusion: In this small cohort, reconstruction of panurethral strictures may be safely and eff ective-Introduction and Objective: We present a novel technique for reconstruction of bulbo-membranous urethral strictures aft er surgery for BPH with external sphincter sparing to preserve continence. Anatomical studies have shown that the rhabdosphincter is separated from the membranous urethra by a sheath of connective tissue. By meticulous dissection of this sheath we separated the muscle from the urethral wall preserving the sphincteric function.

Patients with bulbo-membranous strictures aft er TURP or open prostatectomy (OP) who failed dilation and/or internal urethrotomy were reconstructed with a bulbo-prostatic anastomosis with preservation of the fi bers of the external sphincter. Th e bulbo-membranous junction is approached dorsally, the inter-crural space is opened on the midline and the bulb is mobilized only from one side, without detachment from the perineal body. Th e bulbo-membranous junction and membranous urethra are exposed and secured with vessel loops. Th e membranous urethra sheath is opened circumferentially, carefully refl ecting the circular muscle fibers until exposure of the urethral wall. Gentle blunt proximal dissection allows separating the muscle away from the urethra up to the prostatic apex, where healthy urethra is found to perform the anastomosis.

Results: From January 2010 to March 2015 we operated 16 patients (9 aft er TURP and 7 aft er OP). All had membranous or bulbo-membranous strictures; bladder neck contractions were excluded. Mean age was 68 years (57 -81). Fourteen patients have been treated with either dilation and/or DVIU; seven were with a suprapubic tube. Mean length of stricture was 3 cm (1 -4.5) , mean time from surgery to reconstruction was 30 months (2 -153) and mean follow-up was 28 months (1 -63) . Two patients were not evaluable due to insuffi cient follow up. Of the remaining 14, twelve were completely dry or using one security pad (85.7% success). Th ere were two Clavien 1 complications (both scrotal hematomas) and no stricture recurrence.

Conclusion: Excision and bulbo-prostatic anastomosis with sphincter sparing for strictures aft er surgery for BPH is feasible and safe. Our technique allows preserving continence in most patients. To our knowledge this technique has not been described before. A larger series and reproduction in other centers will help to validate its therapeutic role.

Introduction and Objective: Panurethral strictures are complex and extensive strictures that involve the penile and bulbar urethra. Management of these patients is challenging. In the last two decades, oral mucosal graft s have gained widespread popularity as the most versatile substitute tissue for urethral reconstruction. Th e aim of this paper to present the shortterm outcome of our experience in the use of oral mucosal graft s in one-stage urethroplasty in patients with panurethral strictures.

Materials and Methods: Between April 2012 and October 2014, 32 men were evaluated and had one-stage oral mucosa urethroplasty for panurethral strictures.

Results: Th ere were 32 patients age range of 39-75 years with a mean of 53.16 years. Aetiological factors identifi ed were poorly treated urethritis 23 (71.9%), post-urethral catheterization 8 (25%) and lichen sclerosis 1 (3.1%). Th e commonest cause of catheter-associated panurethral strictures was part of intra-operative patient monitoring in 4 (50%), following spinal cord injury 2 (25%). Preliminary suprapubic cystostomy was done in 27 patients (84.4%). Graft length ranged from 4-20cm with a mean of 10.7cm. Oral mucosa donor sites were buccal in 17 (53.1%), labial 1 (3.1%), combined buccal and labial 12 (37.5%) and 1 (3.1%) for combined buccal/lingual and buccal/labial/penile skin fl ap respectively. Twenty eight patients (87.5%) had satisfactory voiding on removal of the urethral catheter and subsequent follow-up whereas 4 patients (12.5%) experienced diffi culty. Of these 4, one patient had bladder outlet obstruction due to benign prostatic hyperplasia which was the reason for previous repeated urethral catheterization that had resulted in the stricture. Oral mucosa donor site complications were present in 4 patients (12.5%) and consisted mainly pain and numbness in the mouth. Duration of follow-up ranged from 1-29 months and there was no mortality among the patients.

Conclusion: Panurethral strictures are common in our practice mainly resulting as complication of prolonged urethral catheterization. Urethral reconstruction by one-stage oral mucosa graft urethroplasty is feasible, has good outcome though it may be associated with minor donor site complications. Larger number of patients and longer-term follow-up are needed to assess durability of the procedure.

Missed and Delayed Ureteral Injuries in Hasan Sadikin Hospital, Bandung, Indonesia Introduction and Objective: To review our experience with delayed and missed traumatic ureteral injuries.

Materials and Methods: Genitourinary trauma database was retrospectively reviewed from 2012-2014. Variables such as time to diagnosis, imaging modalitites, location of missed or delay injuries, management, duration of operation, length of stay and complications were noted.

Introduction and Objective: Traumatic urethral stricture as the result of straddle injury or pelvic fracture urethral injury (PFUI) is associated with long term morbidity and reduce the quality of life. Most patients will end with long life urethral dilatation even aft er endoscopic treatment. Anastomotic urethroplasty at present is the answer of defi nitive treatment. General principles of urethroplasty are to defi ne healthy urethra above and below the site of surrounding fi brosis and to perform a spatulated end-to-end anastomosis. Prior to the year of 2013, most urethral stricture cases including traumatic anterior and posterior urethral stricture was managed mostly with direct vision internal urethrotomy (DVIU) in our institution. We present our experience with transperineal anastomotic urethroplasty. To our knowledge this is the fi rst Indonesian local centre report of the changing defi nitive treatment of traumatic urethral stricture in a series of patients.

We retrospectively reviewed traumatic urethral stricture due to straddle injury and PFUI that had been treated with urethral reconstructive surgery by transperineal anastomotic urethroplasty approach. Th e data cases from January -December 2013 were analyzed; which were the age of patients, location, length of gap, previous operations, and treatments. Th e clinical outcome was evaluated with urofl owmetry aft er 1, 3, 6, 9 and 12 months aft er the surgery.

Results: A total of 30 patients came with traumatic urethral stricture to Hasan Sadikin Hospital during 2013, which consist of 25 patients with PFUI and 5 patients with traumatic anterior urethral stricture due to straddle injury. Th e median age was 38.5 and 45.6 for PFUI and straddle injury, respectively. Twenty four percent of PFUI patients had distraction length >2 cm and 76% had distraction length <2 cm. Meanwhile, 80% of straddle injuries had stricture length <2 cm and 20% had distraction length >2 cm. In order to achieve tension free of anastomotic urethroplasty, 83% of PFUI patients underwent crural separation, 20% patients underwent inferior pubectomy and only one patient for supracrural re-routing. Sixteen percent of patient of PFUI are redo case urethroplasty. Success rate aft er transperineal anastomotic urethroplasty of PFUI cases was 87%, 75% for redo case PFUI and 100% for straddle injury cases. Mean Q max rates at 1, 3, 6, 9 and 12 months aft er catheter removal of PFUI patients was 19, 20, 21, 19 and 19 mL/s whereas for straddle injury patients was 19, 18, 15, 18 and 18.

Conclusions: In short term follow up, transperineal anastomotic urethroplasty achieved a signifi cant good result for traumatic urethral stricture treatment at our institution.

Recurrence after Urethroplasty in a Tertiary Care Centre in Sub-Saharan Africa: An Analysis of Preoperative Factors

Introduction and Objective: Urethral strictures disease remains very common in sub-Saharan Africa but despite this, there are no available reconstructive urology trainings / fellowships outside the formal urology residency programmes of the region. We reviewed the outcomes of urethroplasties at a tertiary urology centre in Nigeria, sub-Saharan Africa which typically off ers general urology service. Preoperative independent predictors of recurrence post-urethroplasty were determined.

Th e records of a total of 39 men who had urethroplasty for proven anterior urethral stricture disease between February 2012 and January 2014 were retrospectively analyzed. Age, Social status, Aetiology of strictures, Stricture location, length of strictures and type of urethroplasty were assessed. Appropriate inferential statistics were performed to determine independent predictors of stricture recurrence.

Results: Mean patient age was 48 years (range 25 to 90) and majority of the patients were of low income status 30 (76.9%). Iatrogenic strictures due to urethral instrumentations and catheterization 24 (61.5%) and Post infl ammatory strictures 12 (30.8%) were more common. Isolated penile and long segment peno-bulbar strictures accounted for over two-thirds of all patients 27 (69.2%). Mean stricture length was 5.2cm (range 2 to 16cm). Most patients had Quartey's urethroplasty 17 (43.6%), others had Buccal mucosal graft 10 (25.6%), orandi 6 (15.4%) and anastomotic bulbar urethroplasty 6 (15.4%). For a mean follow up of 10.8±12 months, the overall recurrence rate was 53.8% with mean time to recurrence of 10.3 months.

Of the evaluated preoperative factors (age, p=0.482; Social status, p=0.446; aetiology, p=0.296; stricture location, p=0.218; type of urethroplasty, p=0.057; stric-ture length, p=0.019), only stricture length (p=0.019) was a signifi cant predictor of recurrence. ROC analysis was done and stricture length >5cm signifi cantly predicted recurrence (AUC of 0.857, p=0.032).

Conclusion: Stricture length >5cm are a signifi cant cause of recurrence following urethroplasty in the setting of prevalent general urology practice in sub-Saharan Africa. Th e introduction of formal reconstructive urology fellowship or training may help improve skills and outcomes.

Introduction and Objective: Males with hypospadias are likely at increased risk for future urologic complications as adults. However, it is unclear how childhood surgery modifi es this risk. Th e purpose of this study is to describe the spectrum of adult presentations with hypospadias-related complications and examine the eff ect of childhood surgery on these complications.

A retrospective chart review over a 10 year period, from August 2004 -December 2014, demonstrated 93 adult patients who presented to an adult reconstructive urologist with urologic complications related to hypospadias. Patients were divided into two groups: those with no prior hypospadias surgery (Group 1, N=19) and those who underwent surgical correction as a child (Group 2, N=74). Charts were reviewed for age at presentation, initial complaints, history of repair, and surgical intervention required.

Results: Overall, the mean age at presentation was 34.6 years old. Meatal location was not statistically diff erent between Groups 1 and 2, respectively: glans (26.3% vs. 44.6%), subcoronal (1.6% vs. 29 .7%), coronal (10.5% vs. 1.4%), distal penile (15.8% vs. 9.5%), midshaft (10.5% vs. 5.4%), and penoscrotal (5.2% vs. 4.1%). Overall, LUTS (49.5%) was the most common presenting complaint, followed by spraying (23.7%), urethrocutaneous fi stula (18.3%), recurrent UTI's (15.1%), and chordee (14%). Comparison demonstrated Group 2 patients were more likely to present with LUTS (55.4% vs. 26.3%, p=0.04) and recurrent UTI's (18.9% vs. 0%, p=0.05). Contrastingly, Group 1 patients presented more commonly with cosmetic dissatisfaction (15.8% vs. 4.1%, p=0.04). Urethral stricture disease was demonstrated in more patients who had previous hypospadias repair, than those who had not (47.3% vs. 10.5% p=0.004). Of these, strictures were signifi cantly longer in the previous surgery group (5.5 cm vs. 3.0 cm, p=0.02). Surgical intervention was required in 31.6% of Group 1 and 56.8% of Group 2 (p=0.07).

Conclusion: Correction of hypospadias as a child likely increases the future risk of urethral stricture, recurrent UTI's, and subsequent LUTS, but improves patient satisfaction with cosmesis. Follow-up of hypospadias repair patients should extend into adulthood, as a signifi cant portion of adult presentations ultimately require surgical intervention.

Introduction and Objective: During male to female gender confi rming surgery with vaginoplasty, a space is created for the neovagina within the potential space between the prostate anteriorly, and Denonvillier's Fascia and Rectum posteriorly. Entry to this plane is challenging, and to date, the only surgical approaches to this space describe blunt and sharp dissection along the ventral surface of the urethra. Th e likely trauma to perirectal vasculature muscle-laden connective associated with this approach may account for the observed recto-vaginal fi stula rate associated with vaginoplasty. We describe an alternative, never before published approach using a male urethral sound upon the apex of the prostate to enter this plane with sharp dissection in a reliable and effi cient fashion.

We describe our surgical technique, wherein we use a male urethral sound during the dissection to help expose Denonvillier's Fascia over the apex of the prostate. We dissected a block of tissue containing prostate, Denonvillier's Fascia and rectum from human cadavers, to describe (using IHC) the location and relative abundance of blood vessels (Factor VIII Ab.), nerves (NF & S-100 Ab.), and connective tissue (H&E and Masson's Trichrome), to support the sharp surgical approach we describe over the traditional approach to this plane. We describe clinical outcomes and the recto-neovaginal fi stula rate utilizing this approach in our institutions.

Results: Immunohistochemistry results showed that the sharp dissection we describe is associated with incision through signifi cantly fewer blood vessels and sensory-motor nerves as compared to the traditional surgical approach. Use of the sharp dissection we describe resulted in, at our institutions, a signifi cant decrease in recto-neovaginal fi stula in the peri-operative period.

Conclusion: Th e surgical technique we describe for dissection of the plane between prostate and Denonvillier's Fascia during vaginoplasty is well supported by the anatomic studies we performed, and, is associated with lower morbidity. Th is surgical approach and technique is also likely useful for gaining access to this same plane for repair of recto-vesical and recto-urethral fi stulas. Introduction and Objective: Mitrofi noff procedure is commonly employed as bladder draining tool in patients who are unable to do clean intermittent self-catheterization through native urethera. It preserves renal function in small capacity and high pressure bladders and to improve quality of life. Here we want to share our single centre experience of patients undergoing Mitroffi noff procedure.

A retrospective study of 38 patients who underwent Mitrofi noff procedure from January 2009 till December 2014 with a median age of 23 (range =5 to 76). Twenty eight patients were males while 10 female. Indications for catheterizable stoma formation included neurogenic bladder in 22 patients, small bladder in 12, bladder tumor in 2, uretheral stricture in one and Interstitial Cystitis in one patient. Median follow-up was 1 month to 5 years. Stoma was made from appendix in 32 cases, from tapered ileum in 4 cases and from ureter in 2 cases. Stoma location was lower right quadrant in 30 cases, left lower quadrant in 4 cases and at umbilicus in 4 cases. Augmentation accompanied by Mitrofanoff was done in 22 patients while Mitrofanoff alone was done in 16 patients. Augmentation was done by using ileum in 20 patients and cecum in one and illeocecum in one patient. Data was entered from chart review and analyzed on SPSS.

Sixteen patients were analyzed in terms of complications and stoma revision.

Results: Post-operative complications included UTI in 10 (26.3%) patients, stones formed in 2 (5.26%), Fistula was seen in 1 (2.63%) patient (Augmentation Cystoplasty + Mitrofanoff ), Stoma Stenosis seen in 3 (7.89%), Stoma revision done in 2 (5.26%). One female (2.6%) patient had dribbling urine through urethera (incontinence), she underwent bladder neck closure. Metabolic complications were not seen based on Serum electrolytes follow-up records.

We concluded that aft er Mitrofanoff procedure renal function was preserved in most of the patients while no metabolic complications were seen in patients aft er undergoing Mitrofanoff +Bladder Augmentation. Stone risk was 5.26% which was not very high. Quality of patients was improved aft er Mitrofanoff procedure. Results: SESFM has higher porosity and larger pore size compared with BAM (P< 0.05). At 2 weeks, the presence of vesical calculus was evident in 7/10 rabbits. Histological analysis showed that SESFM and BAM promoted similar degree of urothelium regeneration (P>0.05), and SESFM promoted a higher degree of smooth muscle and vessel regeneration compared to BAM at each time point (P< 0.05 ). In addition, muscle strips supported by SESFM displayed higher contractile responses to carbachol, KCl, and phenylephrine compared with BAM. At 8 weeks, both matrices elicited similar mild acute and chronic infl ammatory reactions.

Conclusion: Our results demonstrated that SESFM has greater ability to promote bladder tissue regeneration with structural and functional properties compared to BAM, and with similar biocompatibility.

Introduction and Objective: Ureteral access sheaths (UAS) can aid ureteroscopy by facilitating multiple passes of the ureteroscope, maximizing irrigation drainage, and reducing intra-renal pressures. However insertion of the access sheath may induce ureteral ischemia, cause iatrogenic ureteric injury, and could ultimately lead to ureteric stricture. In this study, we aim to evaluate the stricture rate following ureteroscopy both with and without the use of UAS.

We performed a retrospective chart review of consecutive ureteroscopies performed at our center (a tertiary referral center for endourology) between April 2012 and April 2014 to treat ureteric and renal calculi. Th e primary outcome was the development of new hydronephrosis three months following successful ureteroscopy, not due to an obstructing stone. Patients without follow-up renal ultrasound (US) or CT scan 3 months post-ureteroscopy were excluded. Data on age, sex, size of the stone, location of the stone, stone density, stone-free rate (SFR), time of the procedure, pre-op stenting, postop stenting, use of the UAS, size of the UAS, length of the UAS, stone analysis, and imaging details were recorded. Baseline and outcome variables were compared with ANOVA and Chi-square analysis where appropriate using SPSS statistical soft ware.

Results: A total of 203 patients were eligible. A UAS was used in 121 (59.6%) patients; 103 (85.1%) for renal stones and 18 for proximal ureteric stones. Th ere was no signifi cant diff erence in baseline or demographic data. None of the patients developed new hydronephrosis or developed a ureteric stricture, and none required endoureterotomy.

Conclusions: UAS use during ureteroscopy for renal and ureteric stones is both safe and eff ective. Even with routine use of 11.5F and 14F UAS, ureteric stricture rates are very low (zero in this series), suggesting that signifi cant ureteric injury is rare with proper technique and case selection.

To evaluate the value of fl exible ureteroscopy for the treatment of the upper urinary tract calculi in children.

A total of 32 children, 17 males and 15 females, were identifi ed in this study. Th e median age was 6.9 years, range 8 months to 16 years. Among them, 18 patients had the upper ureteral calculi (15 with calculi in situ, 3 with middle/fi stal ureteral calculi shift ing to upper ureteral aft er rigid ureteroscopic lithotripsy) and 14 had renal calculi. Ipsilateral mild to moderate hydronephrosis was found in all of the cases. Four children had melamine-induced stones (3 with upper ureteral calculi and 1 with renal calculi). Th e calculi were found on left side in 17 cases, on right side in 11, and on both sides in 4 (upper ureteral calculi). Th e median stone size was 1.0 (range 0.6 to 1.5) cm. Retrograde fl exible ureteroscopy and anterograde fl exible ureteroscopy in mini-percutaneous nephrolithotomy was performed.

Results: Twenty eight cases were performed retrograde fl exible ureteroscopic procedure. One case was conversed to mini-percutaneous nephrolithotomy because the fl exible ureteroscope could not be inserted into the upper ureter. Th e fl exible ureteral access sheath was failed to insert into the upper ureter in 3 cases, and the fl exible ureteroscope was inserted into ureter directly. Th e successful rate of stone search was 100% in 31 cases. Th irty cases were successfully performed in one stage. Th e stones were successfully fragmented aft er two stages in two cases. Th e success rate of stone fragmentation was 90.6% with the holmium laser lithotripsy in one stage. Th ree anterograde fl exible ureteroscopy with mini-percutaneous nephrolithotomy were successfully performed, and the stones were successfully found and fragmented aft er a single holmium laser lithotripsy. Th e median operative time was 35 (range 20 to 70) mins. Th ere was no major perioperative complication. Th e patients were discharged from hospital aft er a median of 4.5 days (range 3 to 7). Double-J stent was removed aft er 2 to 4 weeks when no residual stones more than 2.0 mm in size were found. No recurred stones, no urethra stricture, no ureter stricture, no urinary incontinence and no vesicoureteral refl ux were found during the 2 to 72-months follow-up.

Conclusion: Flexible ureteroscopy is a safe and feasible method for the treatment of the upper urinary tract calculi in children. It is suitable for the stones in the pelvis and calyceal where the rigid ureteroscopy could not reach.

Introduction and Objective: Laparoscopic ureterolithotomy is an alternative to open ureterolithotomy for the primary treatment of large, impacted, proximal or mid ureteral stone. Transperitoneal and retroperitoneal approaches are the 2 basic techniques and each has its own advantages and disadvantages. Th e aim of this study is to compare retroperitoneal versus transperitoneal laparoscopic ureterolithotomy in eff ectivity, pain scale and early complications.

In this prospective comparison study from January 2013 to December 2014, 36 patients with proximal and mid ureteral stones underwent retroperitoneal laparoscopic ureterolithotomy or transperitoneal laparoscopic ureterolithotomy. Th e randomization occurred on consecutive sampling on a 1:1 basis. Groups 1 and 2 consisted of patients who underwent retroperitoneal laparoscopic ureterolithotomy and transperitoneal laparoscopic ureterolithotomy, respectively. Demographic and clinical variable, operative time, length of stay, ureteral suturing, pain scale according to visual analog scale (VAS) and early complications data were collected and analyzed. Statistical analysis was performed with SPSS® version 17.0 using student T-test and Mann-Whitney U tests with p value<0.05 considered statistically signifi cant.

Results: VAS on day 1 between the 2 groups was statistically signifi cant, and was higher in Group 2 (p<0.05). According to the Clavien-Dindo classification of surgical complication all the patients were in grade 1 classifi cation. Th e diff erences in operative time, length of stay, ureteral suturing, visual pain analog score on day 3, and early complications between the 2 groups were not statistically signifi cant.

Ionising radiation is commonly used in urological practice in the form of fl ouroscopy. To date there is a relative dearth of information regarding patient exposure during the urological procedures and the subsequent risk of development of a lethal malignancy due to the radiation exposure. Objectives: To determine the radiation exposure for a patient for the most commonly performed urological procedures and determine the lifetime additional risk of fatal cancer per procedure.

Data was collected prospectively in two institutions on endoscopic urological operations. Procedures were classifi ed as retro-graphic, semi-rigid ureteroscopic (URS) and fl exible ureterorenscopic (FURS). Data collected included procure type and diffi culty, dose are product [DAP (Gy*Cm2)]). Th e Eff ective dose (ED) as measured in millisievert was determined from the DAP by using the Monte Carlo calculation.

Results: A total of 395 consecutive operations from two institutions were assessed. Th e mean ED for all procedures in this study was 0.3948 mSev, IRQ (0.1184 -0.7583). Th e maximum ED was 5.938 mSev. Th e radiation exposure for all procedures was relatively small, for diagnostic retrographic procedures the median ED was 0.1121 mSev. For retrograde procedures that involved a stent insertion the median ED was 0.4389 mSev. Th e median ED for all ureteroscopic surgeries was 0.2957mSev, and the median ED for all FURS procedures is 0.4914.

Th e fi ndings of this study are reassuring. Endoscopic urological procedures appear to expose patients to relatively small radiation compared to other procedures requiring fl uoroscopy and a very low lifetime additional risk of fatal cancer per procedure.

Five During the follow no local recurrence was noted and two patients presented with distant metastasis. Th e actual 5-year overall and cancer specifi c survival was 91.8% and 98.2%, respectively. On multivariable cox regression analysis, ACCI was the only factor associated with increased risk of overall mortality (HR 1.51; 95% CI (1.10 -2.07)).

Conclusion: RPN achieves excellent long-term oncological outcomes. Age and comorbidities are associated with increased risk of overall mortality. To our knowledge, this is the fi rst series of long-term follow up aft er RPN reported to date.

Introduction and Objective: Partial nephrectomy provides equivalent oncologic and superior functional outcome compared with radical nephrectomy over the short and long term. With the development of laparoscopic techniques and increasing laparoscopic surgical experiences, laparoscopic partial nephrectomy (LPN) has become an acceptable alternative to radical nephrectomy for expert laparoscopic urologists to treat small renal mass. It was reported that using barbed suture can reduce warm ischemia time during LPN. We designed a single blind randomized controlled trial to fi nd whether the barbed suture can Materials and Methods: From July 2014 to March 2015, forty-six patients with RENAL score less than 10 were enrolled for this study. Patients were randomized into two groups: control and V-Loc group. All patients were evaluated before surgery including performance status, ASA score, liver and renal function, abdominal CT, lung function, and cardiac function etc. During the surgeries, standard 4 ports were placed. Aft er the renal artery was clamped by bulldog, tumor resection was performed using a cold scissor. Th en the inner layer deep vessels and collecting system, and outer layer were sutured with V-LocTM 180 respectively in V-Loc group. In control group, inner layer was sutured with 2-0 absorbable sutures, and the outer layer renal parenchyma was sutured with 0 absorbable sutures. Operative characteristics and complications were compared between groups.

Results: Laparoscopic partial nephrectomy was successfully completed in all forty-six patients without open conversion. Control and V-Loc groups were equivalent in demographic and tumor characteristics. No signifi cant diff erence was seen between control and V-Loc groups in operative time (137 vs. 132 min, P = 0.47), estimated blood loss (121 vs. 123, P = 0.33), warm ischemia time (23 vs. 21 min, P = 0.25), and complication rate (18% vs. 19.1%, P = 0.87).

Conclusion: LPN with V-Loc sutures for renorrhaphy is safe and feasible. However, using V-Loc suture for renorrhaphy doesn't show any superiority in patients with low and moderate complexity renal tumors in our randomized control trial.

Small Th e local recurrence free survival was signifi cantly better in the combined US/CT-guided group than in the US-guided group (p= 0.016). Recurrences were found in 2% with US/CT-group and in 20% in USgroup. Th e overall complication rate was similar (US/ CT 13% versus US 17%) in both groups. Th e mean percentage decrease in the estimated glomerular fi ltration rate (eGFR) aft er the treatment was 1.1±18.3% with US/CT, compared to 5.0±11.7% mean decrease in eGFR aft er treatment in the US-guided group (p= 0.27).

Conclusion: Th e use of combined US/CT-guidance when performing renal RFA resulted in superior primary and short term outcome compared to the use of US-guidance alone in patients treated at the same institution. Increased experience with RFA treatment probably also contributed to the results.

Introduction and Objective: To present our initial experience in 10 female patients undergoing transvaginal NOTES-assisted laparoscopic partial nephrectomy (PN).

Between August 2013 and January 2015, a prospective analysis of the initial ten patients who underwent transvaginal NOTES-assisted PN was entered into an institutional review board (IRB)-approved database. Th e procedure was performed using two umbilical trocars and one trocar through the vaginal wall. Th e main renal artery clamping, segmental renal artery clamping and unclamped PN were performed depending on the circumstances of the tumour. Some perioperative parameters including operative time, warm ischemic time, blood loss, and perioperative complications were recorded. Sexual function was assessed with the Female Sexual Function Index (FSFI) questionnaire before and aft er surgery. Th e cosmetic results were investigated by administering Patient Scar Assessment Questionnaire and Scoring System (PSAQ).

Results: Nine transvaginal NOTES-assisted PNs were completed successfully. One patient with a right anterior upper-pole tumor was converted to radical nephrectomy because of persistent bleeding from the parenchymal defect. Th e median (range) operating time was 120 (110-190) mins and the median (range) estimated blood loss was 140 (50-400) ml. Th e median (range) warm ischaemia time (WIT) was 25 (20-40) mins. Th e median (range) postoperative hospital stay was 5 (4-10) days. All surgical margins were negative. Eight patients completed the FSFI questionnaire, and analysis did not show diff erences in FSFI scores before and aft er surgery. Th e better cosmesis results were confi rmed by the PSAQ score.

Transvaginal NOTES-assisted PN is a safe and feasible surgical procedure in the treatment of small renal mass with excellent cosmesis results.

More prospective studies with long follow-up are needed to investigate the oncologic safety.

Introduction and Objective: To analyze the complications of urologic transvaginal natural orifi ce transluminal endoscopic surgery (TV-NOTES), and to explore eff ective measures for its prevention and management.

Materials and Methods: From May 2010 to February 2015, a total of 245 cases underwent TV-NOTES in our institute. Intraoperative and postoperative complications were graded according to Satava and Clavien-Dindo grade classifi cations system. Th e major complications and their treatments were most importantly analyzed.

Results: Among the 245 TV-NOTES procedures, 5 case conversion to open surgery and one case conversion to suprapubic-assisted laparoendoscopic single-site surgery (SA-LESS). Th irty-one (12.65%) patients had intraoperative complications, the minor and major was 13 (5.3%) and 18 (7.35%), respectively. Th e intraoperative complications include 5 cases of pneumoderm, 4 cases of skin ecchymosis, 2 cases of pleural damage, 3 cases of liver injury, 1 case of adrenal central vein injury, 4 cases of spleen injury, 3 cases of inferior vena cava injury, 3 cases of renal veins injury, 1 case of right iliac vein injury, 1 case of bladder injury, 1 case of renal collecting system injury, 2 cases of colon injury, 1 case of rectum injury. Th e proportion of patients incurring minor and major postoperative complications undergoing TV-NOTES was 8.16% (n = 20) and 1.2% (n = 3), respectively. Th e postoperative complications include 1 case of adrenal crisis, 5 cases of incision infection, 10 cases of postoperative fever, 5 cases of postoperative bleeding, 1 case of the right external iliac artery thrombosis and 1 case of urinary leakage. No intraoperative and postoperative deaths occurred.

Conclusion: TV-NOTES operation is safe and feasible surgical technique in urology, and does not increase the incidence of complications. But there is a potential risk of major complications occurring, which should be paid more attention to prevent.

Introduction and Objective: Knotless barbed suture, a relatively innovative type of suture, can eliminate knot tying, speed the placement of the sutures, and create the possibility of improved scar cosmoses. Th e minimally invasive radical prostatectomy (MIRP), as one of the earliest surgeries that adopted this advanced technique, was reported about diverse eff ects on the patients and the surgeons. Our objective is to present the available evidence about the effi cacy and safety of barbed sutures in minimally invasive radical prostatectomy.

We searched PubMed, EM-BASE, and Cochrane Library for published studies and ClinicalTrials.gov for additional information to identify randomized controlled trials (RCTs) and cohort studies addressing the application of barbed and conventional sutures in MIRP (until Feb. 2015) . Quality assessment was performed according to Cochrane recommendations. Th e data were analyzed using Review Manager (Version 5.3), and sensitivity analysis was performed by sequentially omitting each study. hemi-pelvises, 80.0% had the periprostatic plexus (PPP) as the largest vein of the DVC. Th is was followed by the obturator vein (OV) (12.2%), which originates from the lateral part of the plexus and runs laterally. Next was the internal pudendal vein (IPV) (7.8%), which originates lateral to the posterior part and runs postero-laterally. In the RP group, the DVC bunching stump was an average of 11.8 mm from the origin of the cavernous vein. No complications occurred while performing examinations.

Conclusion: 3D-CT pelvic venography depicted the DVC and its related veins in all 110 cases. Venous systems making up the DVC diff ered among patients. In 80.0 %, the main venous system was the PPP, which can be controlled by conventional DVC ligation technique. However, in the remaining 20% of hemi-pelvises, the IPV and the OV were the main venous systems. Th ese will need wider ligation because of existing outside and to the back of pathways. We believe that a better understanding of DVC will lead to refi ned RP.

Introduction and Objective: Bladder pheochromocytoma and carcinoid tumors are rare neuroendocrine tumors of the bladder. Presenting a series of 3 cases of these rare bladder tumors which were managed laparoscopically.

Materials and Methods: Case 1 was a 51 years lady who presented with symptom of giddiness following micturition. Ultrasound revealed a 1.3 cm bladder mass at the bladder base. Twenty four hour urinary biochemical evaluation and MIBG scan did not reveal any abnormalities. Cystoscopy revealed a submucosal sessile mass above the trigone. On cystoscopic bladder distension a spike in blood pressure (180/100) was noticed which fell rapidly on emptying. Patient underwent laparoscopic partial cystectomy aft er 2 weeks of alpha blockade with phenoxybenzamine. Case 2 was a 33 years old gentleman who presented with episodes of severe headache following micturition. Despite 5 antihypertensives his blood pressures were not under control. Ultrasound revealed a 5 cm bladder mass in the left lateral wall encroaching close to the left ureteric orifi ce. Twenty four hour urinary biochemistry and MIBG scan was suggestive of bladder pheochromocytoma. Aft er 2 weeks of alpha blockade he underwent cystoscopy followed by laparoscopic partial cystectomy with left ureteric reimplantation. Case 3 was a 45 years old gentleman a hypertensive who underwent an attempted TURBT and subsequent hypertensive crisis and bleeding for a bladder mass in a peripheral hospital. He was stabilized and referred to our center for further management. Ultrasound revealed a 4 cm anterior wall mass. Twenty four hour urinary biochemistry and MIBG scan was suggestive of bladder pheochromocytoma. Aft er 2 weeks of alpha blockade he underwent laparoscopic partial cystectomy. MRI has shown to be accurate in diagnosing index tumours in prostate cancer. A variety of focal therapies has been explored in treating these lesions. Th is study aims to compare the detection rate, grade and location of non-index lesions found in radical prostatectomy specimens with their initial mpMRI.

A prospective database of all men undergoing mpMRI for suspicion of prostate cancer in our group practice was kept. Ethics approval was obtained from Epworth Healthcare. Of these men, all who had a 3-D summary diagram including PIRADS score for each mpMRI and who then underwent radical prostatectomy were assessed. Volumetric studies were performed for all prostatectomy specimens and compared to each corresponding mpMRI 3-D summary diagram. Analysis of non-index lesions was performed. Conclusion: A signifi cant amount of patients who underwent radical prostatectomy in treatment for prostate cancer were identifi ed to have non-index tumours in their volumetric analysis. In our cohort of patients, the majority of low grade disease was undiagnosed on mpMRI. However, a signifi cant amount of moderate grade non-index tumours were also missed on initial mpMRI. Th is questions the safety and appropriateness of focal therapy. Ongoing research is warranted and we will continue to report our prospective mp-MRI database as our experience with this modality grows.

Eligibility for Active Surveillance of Prostate Cancer and Functional Outcomes after Prostatectomy Shepherd A 1, 2 , O'Callaghan M 2, 3, 4 Introduction and Objective: We aimed to compare the outcomes following radical prostatectomy (RP) of active surveillance (AS) and non-AS candidates. We hypothesised that AS eligibility at diagnosis would be associated with favourable pathological, surgical and also functional outcomes.

Using a prospectively maintained database, all patients with a primary treatment of RP conducted prior to 2013 were identifi ed, including those who were initially eligible for AS. Men defi ned as eligible for AS were those: diagnosed between 50 and 75 years of age; with Gleason score ≤6; PSA ≤10; clinical stage ≤2a; and with percentage of positive cores ≤50%. We compared the histopathological and functional outcomes of the two groups.

Results: Of 2663 patients with a primary treatment of RP, 400 met the criteria for AS. Pre-operative tumour characteristics of the patients meeting criteria for AS were favourable compared with those ineligible (lower PSAs and less cancer in the biopsies; p<0.001). Functionally, the groups had similar pre-operative continence (95% vs. 98%) and potency rates (84% vs. 80%). Histologic characteristics of the prostate specimen in patients qualifying for AS were more favourable, with lower rates of positive surgical margins and extracapsular extension observed in this group (p<0.05). Following RP, at 6-, 12-and 24-month follow-up, there were no signifi cant diff erences in the proportion of men who were continent between AS and non-AS candidate groups (6 months: 96% vs. 93%; 12 months: 96% vs. 96%; 24 months: 83% vs. 94%; p>0.05). Similarly, no signifi cant diff erences between groups were observed in the proportion of men who were potent at 6-and 24-month follow-up (6 months: 52% vs. 43%; 24 months: 75% vs. 52%; p>0.05). Aft er 12-month follow-up, however, potency appeared to be higher for the AS candidates (71% vs. 52%; p=0.034). were assessed pre-implant as well as at 1, 3, and 6 months aft er seed implantation, and every 6 months thereaft er. We evaluated clinical factors, including prostate volume (PV), neoadjuvant combined androgen blockade (CAD), radiation dose to 90% of the prostate volume (D90), and to 30% of the urethral volume (UD30) to predict urinary disorders aft er brachytherapy using multivariate analysis.

Results: Th e mean pre-implant IPSS was 8.1, with the greatest mean score of 16.7 at 1 month aft er seed implantation. At 3, 6, 12, 24, 36 and 60 months, the mean IPSS had decreased to 16.6, 13.3, 9.8, 9.5, 8.5 and, 8.5 respectively. Th e mean pre-implant prostate volume (PV) was 27.1 g, followed by 20.8 g at 12 months and 19.5 g at 24 months aft er brachytherapy. In cases with PV more than 30 g, D90 more than 160 Gy, and UD30 more than 240 Gy, IPSS levels were signifi cantly high-er even 2 years aft er treatment. On multivariate analysis, D90 more than 160 Gy (p<0.0001) and UD30 more than 240 Gy (p=0.0226) were independent predictors for IPSS increases of more than 5 points at 2 years aft er brachytherapy. Only D90 was an independent predictor at 3 (p<0.0001) and 5 years (p=0.0002) aft er brachytherapy.

Introduction and Objective: Metformin has been shown to be protective in prostate cancer (PC). We aimed to assess the eff ects of metformin on PC outcomes in men treated with External Beam Radiotherapy (EBRT) and/or Androgen Deprivation Th erapy (ADT). We also aimed to investigate the eff ects of metformin on the above outcome measures in type 2 diabetic men with PC. Th e outcome measures of time to biochemical failure (BF), metastasis, PC specifi c mortality and overall mortality were analysed in men on metformin using a competing risk model and a Cox proportional regression model.

A total of 2055 eligible cases, of whom 116 were on metformin, were identifi ed with a median follow-up of 95.7 months. Th ere were no diff erences in age, initial PSA, Gleason scores, T stage, D' Amico risk or duration of ADT between men who were on metformin and those not on metformin. Treatment with metformin did not result in any apparent improvement in time to BF, time to metastases or overall survival but there was an increase of 1.5 fold in PC-specifi c deaths (p<0.05) in men on metformin and ADT when adjusted for cancer risk and co-morbidities. On a subgroup analysis of the 247 men with Type 2 diabetes, similar fi ndings were seen with metformin being associated with a 2.7 fold increase in PC-specifi c deaths (p <0.05). Th ese adverse eff ects were lost in men on metformin and statins.

Conclusions: Th e use of metformin did not improve time to metastases, time to BF or overall survival in men undergoing EBRT +/-ADT for PC with curative intent. However, in type 2 diabetic men on high doses of metformin there was an increased risk of PC-specifi c mortality. Further studies are needed to investigate these fi ndings. Th e objective of this study is to assess IRE eff ects in prostate tissue and to correlate IRE treatment planning with the 3D-histopathology of radical prostatectomy (RP) specimens that essential structures will be spared.

Sixteen patients, scheduled for RP, IRE procedures were performed 4 weeks before RP. Ablation was performed according to two protocols: focal or extended ablation. Th e electrode probes were inserted transperineally under ultrasound guidance. Th e locations of the electrodes were used as input for the plannings soft ware. Following RP, the specimens were processed into whole-mount sections, were histopathologically (PA) assessed and ablation zones were delineated. Th e volumes of tissue alteration were determined by adding the delineated areas. Th e planned and PA ablation volumes were compared using the Pearson correlation coeffi cient.

Results: Th e 3D volumes of the ablation zones follow the planned lesions volumes with a Pearson correlation index r=0.72 with a slope of 1.34 ( Figure 1 ). Th e focally planned ablations results in a volumetric smaller histopathological ablation zone than predicted whereas the extended ablations result in volumetric larger ablation. PA showed sharply demarcated fi brotic and necrotic areas with mild infl ammation. Th e urethra was aff ected by the IRE treatment in nine MP-09.08, Figure 1 . Correlation of Ablation Volumes T2-Weighted MRI and CEUS with H&E Pathology (PA) MP-09.09, Figure 1 . Scatterplot of Planned Ablation Zone Volumes Compared with Volumes in Histopathology patients were observed throughout the neurovascular bundle in thirteen prostates and extended beyond the prostatic capsule in twelve cases.

Conclusion: 1) IRE in prostates results in sharply demarcated lesions with fi brotic and necrotic features, but may damage essential structures as urethra, capsule and nerves. 2) Th e actual ablation zones on 3D-histopathology follow reasonably the planned ablation zones. 3) Focal ablation protocols lead to a smaller ablation zone than extended ablation protocols.

Therapeutic 

All patients treated at our institution with primary PCa T3-4, N0, M0 were included provided they did not present with a long history of ADT. Patients were stratifi ed into 3 groups according to their PSA Nadir occurring between 6-30 weeks following HIFU. Group A (n=96: Nadir <0.2 ng/ml), Group B (n=59: Nadir >0.21-2ng/ml ng/ml), Group C (n=29: Nadir >2 ng/ml). Th e primary endpoint of our analysis was the onset of any salvage therapy other than HIFU. Repeat HIFU can be performed without undue additional morbidity and is standardly not considered as salvage therapy but rather an adjuvant to the index HIFU. Multivariate analysis was performed to determine what predicts onset of salvage therapy.

Results: At inclusion: 91.5% of patients were T3 and 8.5% were T4. Outcomes are summarized in Table 1 .

Conclusion: Group A (Nadir <0.2) showed 77% salvage treatment free survival without ADT; Preoperative high Gleason, high initial PSA and "no TURP" were negative predictive factors for outcome; 25% of the patients had 2nd HIFU treatments in follow-up; In case of salvage therapy most patients opted for ADT. Metastasis-free survival of 93% at 5 and 87% at 10 years excludes TURP in PCa as potential metastasis-inducing factor. Combined "TURP and HIFU" showed its oncological effi cacy, postponing / avoiding classical salvage therapies (RAD/ADT) and their potential side eff ects.

Laparoscopic Radical Prostatectomy (LRP): Changing Trends in Practice

Introduction and Objective: We audited our LRP outcomes in order to evaluate outcomes and how our practice has evolved over the years. We evaluate pathological and margin status outcomes and determine whether there has been a shift towards treatment of higher risk disease and the impact of this practice on margin status.

A total of 339 patients underwent LRP performed by one surgeon at our institution from June 2004 to September 2014. We divided the cohort into early period from 2004-2008 (group 1, n=114) and 2009-2014 (group 2, n=225).

Results: Mean age was 64 yrs. Mean preoperative PSA (9.1) and Gleason score (GS, 6) did not diff er between groups. However, preoperative stage ≥T2c increased from 8 (7%) to 42 (19%) for groups 1 and 2 respectively. Postoperatively, diagnosis of GS ≥7 increased from 18 (16%) in group 1 to 118 (52%) in group 2. Similarly, 38% of group 2 was staged as pT3 compared to 24% of group 1. Th ere were more extracapsular extension in group 2 (31%) compared to group 1 (25%). Overall positive surgical margin (PSM) rate was 16% (group 1, 10% vs. group 2, 19%). When stratifi ed according to pathological stage, PSM was identifi ed in more men with pT3 (9%) compared to pT2 (7%). Th e commonest site of PSM was at the apex. Seminal vesicle invasion rate was similar (3%). Results: Mean operation time and length of hospital stay for RARP and LRP were 145.5±43.6 min and 118.1±39.1 min, and 6.4±0.9 days and 6.6±1.1 days, respectively (P = 0.003 and P = 0.721). Aft er 17 cases, the mean operation time for RARP was similar to LRP (less than 2 h). Positive surgical margins in localized cancer were seen in 11.1% and 8.9% of cases in RARP an LRP, respectively (P = 0.578). At postoperative 3 months, sexual intercourse was reported in 14% and 12%, and pad-free continence in 96% and 81% in patients with RARP and LRP, respectively (P = 0.796 and P = 0.012).

Conclusion: Previous large-volume experience of LRPs may shorten the learning curve for RARP in terms of oncological outcome. Additionally, previous experience with laparoscopy may improve the functional outcomes of RARP.

Introduction and Objective: Signifi cant prostate cancer is increasingly diagnosed in younger men. Th is patient group has high expectations regarding oncological and functional outcomes at robotic radical prostatectomy (RARP).

We reviewed a prospective database (1500 RARPs) at a single tertiary referral centre and obtained erectile dysfunction rates/treatment and continence pre-and post-operatively, positive margins, metastases and death. Median follow-up was 4 years. 

Male Sprague-Dawley rat aged 9 weeks were used. A total of 20 rats were divided into two groups. One group was used as a control and other group received intramuscular injections of testosterone propionate (3 mg/kg) plus 17β-estradiol (0.03 mg/kg) for 12 weeks to induce BPH. Th e prostate and genitourinary organ weights, histopathologic change and serum hormones were evaluated. We compared the eff ects of LDD175 (10 mg/kg) with tamsulosin (10 μg/kg) in intraurethral pressure responses induced by ES of the hypogastric nerves. We performed western blotting for alpha 1A and 1D receptor of adrenergic nerve.

Results: BPH-induced rats showed signifi cantly increased absolute prostate weight and prostatic index (prostate weight/body weight x 100), increased testosterone, free testosterone and estradiol levels in the serum. Histomorphology also showed that epithelial cell layers in the prostates of BPH-induced rats were larger than control groups. LDD175 and tamsulosin signifi cantly inhibited the intraurethral pressure elevation induced by ES of the hypogastric nerves. Alpha 1D and alpha 1A adrenergic receptors in BPH rat model were expressed more than control. LDD decreased expression of alpha 1D adrenergic receptor than control.

Conclusions: Th is study suggested that LDD175 could be an alternative medicine to treat BPH inducing lower urinary tract symptoms.

Does According to recent studies, atherosclerosis has a key role in the pathogenesis of BPH. Th erefore, we evaluate the correlation between prostate volume and intima-media thickness (IMT) of carotid artery in diabetic BPH.

From January 2010 to August 2014, 111 patients with DM were analyzed, retrospectively. Baseline characteristics and diabetic profi le were collected. Mean intima-media thicknesses (IMT) were collected using carotid doppler ultrasound. And prostate volume (PV) was measured by transrectal ultrasound. Two groups were analyzed using lineal regression analysis.

Results: Th e patients were classifi ed into Group 1 (n=67, 60.3%) and into Group 2 (n=44, 39.7%) based on the presence of BPH. Th ere were statistically signifi cant diff erences on BMI, waist circumference and HbA1c between the two groups (Table 1) . Th ere is a signifi cant correlations between IMT and PV and IMT and transition zone (Tz) (p=0.027, p=0.008, Figure 1 ). porting symptoms listed on the OTC label as reasons for not using the product; traces of glucose, leukocyte, and/or blood in their urine; or an AUA-SI score ≥20. Conclusion: PVP has demonstrated acceptable complication rates compared to traditional TURP in treating BPH in a cohort of men having a greater frequency of comorbidities and in those having to remain on oral anticoagulation. Th is makes PVP an attractive alternative to TURP in such men particularly if symptomatic relief and re-treatment rate in the longer term is demonstrated to be equivalent.

Prospective Study of High-Risk Patients Undergoing Photovaporisation of Prostate (PVP) without Cessation of Oral Anticoagulants Ow D 1 , Papa N 1 , Sengupta S 1,2 , Lawrentschuk N 1,2,3 , Bolton D 1 Introduction and Objective: GreenLight Laser photovaporisation of the prostate (PVP) is suggested to be safe to perform on high risk patients requiring surgical intervention in the management of Benign Prostatic Hyperplasia (BPH), where cessation of oral anticoagulation is not possible due to medical comorbidities. We prospectively evaluated the outcomes of patients who underwent PVP with ongoing oral anticoagulant therapy.

Materials and Methods: Between January 2011 and December 2013, 62 patients with ongoing oral anticoagulant therapy were treated with PVP. Types of oral anticoagulants were recorded and perioperative outcomes were collected. Th ese metrics included transfusion rate, duration of hospital stay and laser treatment variables. Ninety-day readmissions also were recorded as were complications of treatment.

Results: Sixty-two patients were treated by Greenlight laser PVP while taking oral anticoagulants. Out of this total, 27 patients (43.5%) were on warfarin while 26 (41.9%) had ongoing clopidogrel. Th e remaining 9 were either taking one or a combination of other (non-asprin) oral anticoagulants. Nine out of 62 (14.5%) patients required readmission post PVP, and all of these readmissions were for management of complications related to haematuria. Five of this group of 9 patients (18.5% of total cohort) had undergone PVP without cessation of warfarin, while 4 of 9 patients (15.4% of total cohort) had undergone treatment without cessation of clopidogrel. Th ree patients (4.8%) required blood transfusion.

Conclusions: Despite continuation of oral anticoagulants in these high risk patients, the readmission rate is low and transfusion rate is similar to what has previously been reported for conventional TURP in patients without anticoagulation. Greenlight laser PVP is a viable option for surgical management of BPH in patients for whom cessation of oral anticoagulant therapy is contraindicated.

Introduction and Objective: Cystinuria is a rare, chronic condition characterised by recurrent urolithiasis. Th e condition is due to a variety of genetic mutations in an amino acid transporter and accounts for between 0.5-2 percent of urinary tract stones. Cystine urolithiasis may be treated by preventative medical therapy or therapeutic urological intervention. It is the authors' experience that patients tend to shy away from long-term medical treatment, possibly due to a perceived lack of effi cacy or poorly tolerated side-eff ects. As with all chronic conditions, quality of life for cystinuric patients is expected to be diminished. Sub-optimal medical therapy and the need for repeated urological intervention is expected to have a further impact on quality of life. Th e authors seek to describe the natural history and quality of life in patients with cystine urolithiasis. Th is in turn allows further improvements to the standard-of-care off ered to such patients.

A cohort study was carried out involving participants recruited from a single surgeon's case mix. Participants suff ering from cystinuria and related urolithiasis were invited to complete a questionnaire involving demographic information, use of medical treatment, surgical interventions and the SF-36 quality of life survey. Attitudes towards the use of current and potential future medical treatments were also explored.

Results: Fourteen participants completed the survey. Th e SF-36 survey showed lower quality of life than the general public in 7 of 8 domains. Th e mean interventional rate in patients with cystinuria was 10.6 procedures per patient. Most patients reported previ-ous use of D-penicillamine and urinary alkalinisation medications, with most ceasing due to side-eff ects or lack of perceived effi cacy.

Conclusion: Cystinuria is associated with a high rate of surgical intervention and lower quality of life than the general public. Individuals with this condition report that medical management is either ineff ective or poorly tolerated. Th ere is a need for further improvements in medical management of cystinuria, to reduce the rate of operative intervention. Recommendations to guide clinical practice, based on patients' experience of cystinuria management can be made.

Dipstick Results: A total 600 patients were retrospectively reviewed for the pH results. Th e mean diff erence in pH between spot urine value and the 24-hr collection values was 0.52± 0.45 pH. Higher pH was associated with lower accuracy (p < 0.001). Th e accuracy of spot urine samples to predict 24-hour pH values of <5.5 was 68.9%, 68.2% for 5.5 to 6.5 and 35% for >6.5. Samples taken more than 75 days apart had only 49% the accuracy of more recent samples (p < 0.002). Th e overall accuracy is lower than 80% (p < 0.001). Infl uence of diurnal variation was not signifi cant (p = 0.588).

Conclusions: Spot urine pH by dipstick is not an accurate method for evaluation of the patients with urolithiasis. Patients with alkaline urine are more prone to error with reliance on spot urine pH.

Relationship is the fi rst lithotripter on the market with a unique design that allows for a dual focus system with the option of either a narrow or wide focal zone. Ex vivo data on the SLK-F2 lithotripter shows that the disintegration capacity and the renal vascular injury are independent of the focal diameter of the SW generator at the same peak positive pressure and disintegration power. Th e objective of this study is to compare the single-treatment success rates of narrow and wide focal zones for the shock wave lithotripsy of renal stones.

A total of 182 patients with previously untreated radio-opaque solitary stone located within the renal collecting system, measuring at least 5mm, were randomized to receive narrow or wide focus lithotripsy while maintaining a constant overall energy level. Patients were followed with KUB x-rays and renal ultrasound at 2 and 12 weeks post lithotripsy to assess stone area and stone free status. Urinary markers indicating the degree of renal cellular damage (Microalbulin and Beta 2 Microglobulin) were measured pre and post SWL, 24 hours post SWL and 7 days post-treatment. Primary outcome was success rate, defi ned as stone-free or adequate fragmentation (sand and asymptomatic fragments <=4mm) at 3 months post-treatment. MP-11.03, Figure 1 .

Introduction and Objective: Despite being uncommon, infantile kidney stone remains a major health problem due to its higher recurrence rate and morbidity. Th e parents usually notice that their infants have recurrent fever and failure to thrive of unknown origin. Th ose patients comprise a big challenge for the urologist in management. Th erefore, this study aimed to evaluate the outcome of shockwave lithotripsy (SWL) in management of renal stones in infants.

A retrospective analysis of prospectively collected data performed between January 2009 and December 2012 for infants underwent SWL for single radio-opaque renal stones ≤15 mm at a single stone center. SWL was performed with Dorneir S lithotripter with a maximum of 1500 shocks per session. A single session was indicated for each infant, but a second session was performed when satisfactory disintegration was not achieved. Follow-up based on urinalysis, urine culture and sensitivity, plain X-ray kidney ureter bladder (KUB) and abdominal ultrasonography (US) was carried out 2 weeks post SWL and monthly for 3 successive months. Multislice Computed tomography (MSCT) was performed 3-months post-SWL to confi rm the stone-free status.

Results: A total of 87 infants, less than 24 months of age were enrolled in this research. SWL success was defi ned as absence of any residual fragments on MSCT 3 months aft er the last session. Stone free rate was 93.1% aft er the fi rst SWL session and reached 100% aft er the second session. Rate of retreatment with second session of SWL was 6.9%. Urinary tract infection (UTI) was detected in 10.3%, transient renal obstruction with low grade fever in 4.6% of infants and no major complication had been recorded.

Conclusion: Th e new generation of SWL technology with a precise focal area seems to be safe and eff ective in management of kidney calculi in infants.

Stone 

Introduction and Objective: Th e incidence of abdominal discomfort is frequent during pregnancy, but renal colic is infrequent. One of the main causes of renal colic during pregnancy is urolithiasis. Managements of urolithiasis during pregnancy are hydration, antibiotics, ureteral stent insertion, percutaneous nephrostomy, and ureteroscopic stone removal. In this study, we assessed the reliability and stability of ureteral stent insertion to pregnant patients with renal colic. Results: Th e overall mean patient age (54 years), male to female ratio (1.8:1) and mean ASA score (2.0) did not vary signifi cantly between years. Admissions for elective renal stone procedures, adjusted for population, increased 45% over the study period. Th is growth was entirely in the last 5 years, corresponding with a 20-fold increase in the use of pyeloscopy (from 38 to 759 cases per year). From the fi rst to last year, there was a 6% reduction in ESWL (from 832 to 781 cases per year) and a 28% increase in PCNL (from 170 to 218 cases per year). Nephrolithotomy ranged from 11 to 20 cases per year. Th ere has been an increase in the proportion of associated ureteric stent insertions from 5% to 38%. Th e proportion of day-only admissions has decreased from 80% to 62%. Th e average government assigned cost per admission has increased 115%.

Conclusion: Victorian public hospitals have seen a rapid expansion in the use of pyeloscopy and laser for treatment of renal stones. Th is corresponds with a signifi cant increase in admissions for elective renal stone treatment, relatively fewer day-case admissions, higher treatment costs and more associated stent isertions.

Introduction and Objective: Th is retrospective study assessed the semirigid ureteroscopy approach coupled with ballistic or Ho:YAG laser lithotripsy for the treatment of proximal ureteral stones. 

Patients with a single lower calyceal stone with an evidence of a CT diameter between 1 and 2 cm were enrolled in this multicentric study. Exclusion criteria were the presence of coagulation impairments, age less than 18 or more than 75, presence of acute infection, presence of cardiovascular or pulmonary comorbidities. Patients were randomized into three groups: Group A: patients treated with SWL; Group B: patients treated with RIRS; Group C: patients treated with PCNL. Patients were controlled with abdomen X-ray and CT scan aft er 3 months. A negative X-ray or an asymptomatic patient with stone fragments less than 3 mm big and a negative urinary colture were the criteria to assess the stone-free status. A statistical analysis was carried out to assess patients' data, success and complications rates, re-treatment rate and need for auxiliary treatment. Radiotherapy is an eff ective and common treatment for the prostate cancer. However, there is still an historic deep rooted fear of its use due to the existence of late genitourinary toxicities such as the radiation cystitis. Nowadays these toxicities may pose less of a threat due to the use of newer radiotherapy techniques and the reduction of radiation doses applied to the tissues adjacent to the tumor. Th e objective of our study is to fi nd predictive factors and determine the cumulative incidence of overall and severe radiation cystitis. Conclusion: Radiation cystitis is a feared complication of the use of radiation therapy in prostate cancer which occurs infrequently, and the severe cases requiring hospitalization are very rare. Th e characteristics of the tumor, purpose of radiotherapy used or radiation dose applied do not seem to infl uence the incidence of radiation cystitis.

Introduction and Objective: Th e aim of the study was to assess prognostic factors of biochemical and radiological disease progression (DP) in subgroup of lymph node (LN) positive prostate cancer (PC) pts. 

Evaluation of Detection Rate of 68Ga-PSMA PET/CT for Biochemical Recurrence after Radical Prostatectomy Introduction and Objective: Prostate specifi c membrane antigen (PSMA) is overexpressed in more than 90% of all prostate cancers (PCa). Since the introduction of PET-imaging with 68Gallium-labelled PSMA, this method is regarded as a signifi cant step forward in the diagnosis for recurrent PCa.

From the 216 patients that were scanned for detection of recurrent PCa aft er radical prostatectomy between August and December 2014, 185 were evaluable for retrospective analysis. Patients underwent PET/CT aft er injection with the 68Ga-HBED-PSMA. Th e potential infl uence of PSA-level, primary Gleason Score (GSC) and PSA-doubling time (PSA-DT) on the detection rate were evaluated.

Results: A total of 129 (70%) patients had pathological fi ndings on the 68Ga-PSMA PET/CT, with an average PSA-level of 6.44 ng/mL (range 0.06-126 ng/ mL). Detection rates were 27%, 66%, 79% and 91% for PSA-levels <0.5, 0.5-1, >1-2.5 and >2.5 respectively. If recurrent PCa was detected, oligometastatic disease (5 metastasis or less) was most commonly seen (68%). Th e detection effi cacy was signifi cantly infl uenced (p<0.05) by higher GSC (59% and 80%, for GSC ≤7 and ≥8 respectively). For the 99 patients that were evaluated for the infl uence of PSA-DT on detection rate, no signifi cant diff erence was found (p=0.122) for PSA-DT <4 months and ≥4 months (detection rate 85% and 75% respectively).

Conclusion: 68Ga-PSMA PET/CT has a high detection rate compared to prior studies of conventional imaging modalities, especially in lower range PSA-levels. Further research is needed to determine to assess whether localization of small volume disease on 68Ga-PSMA PET/CT can improve diagnostic algorithms and outcomes in patients with recurrent PCa.

Introduction and Objective: To assess long-term results of salvage pelvic lymph node dissection (PLND) in prostate cancer (PC) patients (pts) with biochemical recurrence aft er primary local treatment and confi rmed solitary lymph node (LN) metastases. Results: A total of 9,356 abstracts were screened, 298 full-text papers were considered, and 26 articles were included (1 RCT, 8 comparative studies, and 17 case series). Th is abstract focuses on the comparative studies. Primary therapy was prostatectomy in 3, radiation therapy in 4, and 2 studies included both therapies. Diff erent defi nitions of recurrence were applied among mostly retrospective studies and the ADT strategy oft en not specifi ed. Factors associated with unfavorable outcomes (overall, PC-specifi c, or metastasis-free survival) included higher age, higher PSA nadir, higher Gleason score, higher PSA-DT, and early start of ADT at recurrence. Contradictory results were reported on the role of the length of ADT aft er EBRT, partly explained by a selection of high risk cases. Most patients with disease relapse aft er primary therapy seem not to benefi t from ADT while side eff ects are known to be harmful. Selected highrisk patients (short PSA doubling time, high Gleason score) however may have benefi t, and early start of ADT may be preferable in this group. An intermittent ADT strategy in this setting may be feasible. A RCT is indicated, although diffi cult to perform.

A personalized approach is warranted, taking disease characteristics, side eff ects, and quality of life into account. ADT may only be given in patients with PC recurrence who have high risk characteristics.

Introduction and Objective: Locally radio-recurrent prostate cancer (rr-PCa) can off er a chance of cure albeit with potential morbidities. Current salvage treatment options include radical surgery and minimally-invasive ablative modalities such as HIFU and cryosurgery (s-cryo). Current data suggests that s-cryo can achieve disease-free survival (DFS) rates up to 60% at 5 years. However, the majority of data is based on retrospective analysis with mid-term follow-up and there is still paucity of data on longterm outcomes. Th e aim of this study was to analyze morbidity and oncological outcomes, with median follow-up 10 years, of s-cryo on rr-PCa patients at an academic center. Figure 2 ). Adverse events were similar between the treatment arms. Figure 1 .

Th ese analyses demonstrates that, during the fi rst year of treatment, men treated with degarelix had a reduced risk of disease-related adverse events.

Th ere was also a lower risk of death, likely due to the higher incidence of CV events in LHRH agonist patients. Introduction and Objective: Androgen-deprivation therapy (ADT) appears to increase cardiovascular (CV) morbidity and mortality in men with prostate cancer, particularly in those with a history of CV disease (CVD). However, the risk is lower with the gonadotropin-releasing hormone (GnRH) antagonist, degarelix, compared with LHRH agonists. Here we evaluate regional diff erences in baseline CV status in men with prostate cancer treated with degarelix or LHRH agonists and their subsequent risk of CV events.

Th is was a pooled analysis of data from three phase 3 studies with a duration >6 months. Individual patient level data on baseline CV status and subsequent CV events over 1 year were summarized by geographic region (USA/Canada vs. Europe). CV event data were compared using cumulative incidence functions (with all-cause mortality as the competing risk) and Cox regression analyses. Canada had more severe disease and a higher CV risk (p<0.05) ( Table 1 ). In men with baseline CVD, cumulative incidence (95% CI) of a CV event was 9.4 (6.0-14.6) in USA/Canada vs. 3.6 (2.0-6.2) in Europe (p=0.007). At baseline, CV status was similar in the degarelix and LHRH agonist groups (Table 1) . However, in those with baseline CVD, degarelix was associated with a lower risk of subsequent CV events vs. LHRH agonists in both regions (hazard ratio [95% CI]: 0.42 [0.20-0.87]; p=0.02).

Conclusions: Men in the USA/Canada with prostate cancer and CVD and who were treated with ADT were more likely to experience a CV event than their counterparts in Europe. Th is likely refl ects the greater severity of baseline CVD and higher CV risk in these patients. Degarelix reduced the risk of CV events compared with LHRH agonists in both regions.

Introduction and Objective: Androgendeprivation therapy (ADT) decreases bone mineral density and may increase skeletal complications in metastatic prostate cancer. However, LHRH agonists and GnRH antagonists have diff erential eff ects on follicle-stimulating hormone (FSH), which regulates bone resorption. Th e current analysis compared the eff ect of LHRH agonists and the GnRH antagonist, degarelix, on serum alkaline phosphatase (SALP), a marker of bone turnover, and the incidence of skeletal adverse events (AEs). Conclusions: Degarelix suppressed S-ALP more quickly and for longer than LHRH agonists. It also reduced bone pain and was associated with a lower incidence of fractures. Collectively, these data indicate that degarelix provides better control of skeletal disease in men with metastatic prostate cancer, an eff ect that may be mediated by its diff erential eff ect on FSH.

Prognostic Introduction and Objective: Testosterone (T) regulates nitric oxide synthase and is necessary to achieve an optimum response to PDE5 inhibitors for erectile dysfunction. Recently, tadalafi l was found to be eff ective for treating lower urinary tract symptoms (LUTS) secondary to benign prostatic hyperplasia (BPH). We studied the relative importance of the T level in patients with LUTS and determined whether the T level predicts the response to tadalafi l 5 mg once daily for LUTS/BPH.

Aft er a 4-week washout period, 122 men older than 45 years without (n=62, T level ≥300 ng/dl) and with (n=60, T level <300 ng/dl) hypogonadism were given tadalafi l 5 mg once daily for 12 weeks. We assessed its impact and the severity of LUTS/BPH using the International Prostate Symptom Score (IPSS) and BPH Impact Index (BII) and IPSS quality-of-life (IPSS-QoL) subscores. Safety was assessed using treatment-emergent adverse events. Introduction and Objective: Diabetes has been reported as a major cause in patients who complain of erectile dysfunction and is frequent in the comorbidity of severe erectile dysfunction. Also, patients with diabetes are oft en poor response to treatment for erectile dysfunction. In such patients, according to the mirodenafi l (Mvix ) use of the ODF (oral decomposition fi lm) 50mg and 100mg was to compare the therapeutic eff ects of the treatment period.

Of the patients with erectile dysfunction were enrolled in a patient with diabetes. And the patients were classifi ed into two groups by randomized double blind controlled trial. Th e fi rst group was to take the mirodenafi l ODF 50mg once a daily and the second group was to take a 100mg at least twice one week, depending on the need to have sexual intercourse. International Index of Erectile Function-5(IIEF-5), International Prostate Symptom Score(IPSS) were examined for each time of initial visit, 4 weeks, 8 weeks, 12 weeks. Th e questionnaire items of two groups were analyzed at each time point.

Total of 39 patients were included in the study. Th e patients who were taking once a daily were 18 and the patients taking when needed were 16. Th ere was no signifi cant diff erence between age, IIEF-5 score, and IPSS of each groups on initial visit. IPSS score and quality of life score was lowered gradually all aspects in the two groups. IIEF-5 score was a tendency to increase in all categories. In comparing the two groups at 4 weeks, once a day group showed a signifi cantly higher score than the group taking when needed for the questionnaire of erection confi dence, erection times, IIEF-5 total score(p<0.05). Th ere was no diff erence between two groups at 8 weeks, 12 weeks. In addition, this study showed the similar therapeutic eff ect between the two groups at end point of continued treatment during the 12 weeks.

Conclusion: Aft er daily dose method 8 weeks, at least twice weekly dosing method and daily dose method is determined to exhibit the same eff ect. Th erefore, we think that it is possible to change the intermittent dosing from daily regimen aft er two months.

Introduction 

Introduction and Objective: Phosphodiesterase 5 inhibitors (PDE5i) are the established fi rst line therapy for most cases of erectile dysfunction(ED). It is estimated that 20-30% of ED patients may drop out and discontinue the usage of these drugs. Th is study aims to evaluate the patient perspective of discontinuation of on-demand Tadalafi l 20 mgm and switching to daily Tadalafi l 5mgm for ED.

Th e study comprises 72 men with median age 56 years suff ering from ED of average 1.6 years duration. Co-morbidities included: Hypertension (46%), Diabetes (38%), Dyslipidemia (32%) and Smoking (28%). Th e primary indication for usage of on-demand Tadalafi l 20 mgm was ED. All the patients had used 20mgm Tadalafi l on demand on more than 8 occasions over the last 3 months.

Results: Th irty-eight out of 72 men opted to discontinue on-demand 20mgm Tadalafi l and switch to daily dose 5mgm Tadalafi l. A detailed interview was conducted to identify the reasons for this switch over. Th e salient factors were: 1) Unsatisfactory clinical response to on-demand dose (42%), 2) Adverse eff ects with on-demand dose (22%), 3) Concomitant improvement in LUTS (44%), 4) Economic factors-daily dose therapy is cheaper than on-demand (14%), 5) Freedom of spontaneous sexual activity with daily dose (36%), 6) Patient perception of daily dose as a long-term cure for ED (26%), 7) Combination of above factors (78%). Overall 76% of patients planned to continue daily dose Tadalafi l 5 mgm.

Conclusion: Daily dose Tadalafi l 5mgm appears to be preferred by patients over on-demand 20 mgm Tadalafi l for ED treatment. and plateaued aft er two years. In 56% of men, IIEF-EF improved by 1 category, in 22% by 2 and in 6% by 3 categories. Five men remained within the same category despite slight improvements in score, 1 man's score dropped from 26 to 25 changing from "no ED" to "mild ED". Fift y six percent men achieved normal erectile function.

Conclusions: Improvements in erectile function were clinically meaningful and signifi cant during the fi rst 2 to 3 years of T therapy and sustained during the full treatment duration. Th ey were independent of obesity class. It may be necessary to continue T therapy for 2 to 3 years before an optimal response is achieved.

Hypogonadal Conclusion: All changes were clinically meaningful and sustained for the full observation period, despite the fact that patients' age increased by 7 years. T therapy seems to be highly eff ective in hypogonadal men with T2DM, improving both erectile function and glycemic control.

Needle-Free Delivery of Intracavernosal Injections: Proof of Concept Introduction and Objective: Intracavernosal injection is a well-established second line therapy for the treatment of erectile dysfunction (ED) and has shown very high success rates. Despite this, intracavernosal injection is not a therapy suited to all patients for a number of reasons including needle phobia (trypanophobia), pain, and anxiety with self-needling. Th e development of needle-free injectable devices has been heralded as a promising advance in the administration of certain vaccines and parenteral medications. Initial research into the use of these devices in the delivery of intracavernosal injections however showed inferiority to needle-tipped injectors in terms of efficacy and pain scores. Th e use of needle-free injection devices is not currently recognised for the administration of intracavernosal injections. It was the aim of our study to investigate the ability of contemporary needle-free injection devices to successfully deliver intracavernosal injections.

Two diff erent needle-free injection devices were used to inject 0.5mls of methylene-blue solution into the corporal bodies of a number of Australian brangus bullock penises; the Bioject®Ze-tajet™(spring-loaded fi ring system) and Biojector®2000 (pressurized CO2 fi ring system) were used. Both products are produced by Bioject Medical Technologies Inc., California, USA. All the available syringe depths were used for each device, and compared with the injection of the same volume of methylene-blue with an insulin syringe as a control. Following injection, a cross-section of the penis was taken, and the depth of penetration observed macroscopically.

Results: Despite the comparatively thicker and denser tunica albuginia of the bullock penis, the pressurized CO2 device successfully delivered the solution into the corporal body, through the tunica. None of the syringes from the spring-loaded device penetrated the tunica.

We have shown that contemporary needle-free injectable devices can in theory be used to administer intracavernosal injections successfully. Th e bullock penis model may not be the ideal model for the human penis but we are currently in the process of performing human cadaveric experiments with these devices. Needle-free injection devices may be very useful in the administration of intracavernosal injections in the future and extend the use of these therapies to a wider population of patients.

Penile Linear Shock Wave Therapy for Poor Responders to Prior Erectile Dysfunction Therapy (19), ICI with Alprostadil (4), VCD (2) and MUSE (1) . All these patients opted to discontinue these regimen due to unsatisfactory erectile improvement or side eff ects. Th ese patients were treated with LSWT by Renova device with four weekly outpatient sessions without any analgesia or preparation. LSWT was applied to four anatomical sites (right, left crura, and right, left corpus cavernosum) at 300 shocks per minute, total 5000 shocks per session. Patients were followed up at 1 and 3 months aft er the last session.

Results: At one month follow up statistically significant improvement in IIEF was recorded in 19 patients (73%) from mean score of 13.6 at baseline to 19.2.Th e improvement was maintained at 3 months .No side eff ect was noted. Overall 92% patients expressed satisfaction with LSWT irrespective of the clinical outcome.

Conclusion: LSWT appears to be a safe and eff ective noninvasive, offi ce based therapy in the management of diffi cult to treat poor responders to prior treatment of ED.

Introduction and Objective: Hypogonadism and sexual dysfunction are common clinical presentation in male liver transplant candidate. Th e aim of the study was to evaluate the eff ects of living donor liver transplantation (LDLT) on testosterone, sex hormone-binding globulin (SHBG), free androgen index (FAI) and erectile function in LDLT recipient. Introduction and Objective: Penile size has been a source of major concern and anxiety to the male population since several years. Diff erent methods for increasing penile size have been described in the literature, such as, pubopelvic liposuction, lipectomy, suspensory ligament dissection, Z-plasty, V-Yplasty and injections. Combining some of these techniques may be more eff ective to improve the length of the penis. In this study, patients were underwent the combination of Z-plasty and suprapubic lipectomy for increasing penile size.

Between 2004 and 2014, 29 patients who complained decreased penile size were underwent surgery. Z plasty and suprapubic lipectomy were performed to each patient. Informed consent was provided by all participants. Th e outcomes were assessed based on the preoperative and postoperative penile length in the fl accid state at maximal stretch and patient-partner satisfaction. Th e paired student t test was used for statistical analysis.

Results: Median age of the patients was 32.1 (20-72) years. Th e etiologies were congenital micropenis in 3 (10%), concealed penis in 16 (55%), previous penile surgery in 9 (30%) and epispadias in 1 (5%) patient. Mean preoperative and postoperative penile lengths were 8.1cm (6-11cm) and 10.9cm (7.3-14cm) respectively. Th e mean increase in stretched penile length was 2.8±0.6cm (minimum 1.3cm, maximum 4cm) (p<0.05). Th e patient and partner satisfaction rates were 82.7% (24/29) and 48.2% (14/29) respectively. Only one postoperative complication was detected.

Th is was a wound infection at suprapubic incision site.

Conclusions: Based on our results, the combining of the penoscrotal Z-plasty and suprapubic lipectomy is a safety, eff ective and satisfactory procedure for lengthening of the penis in selected cases.

Corporal Lengthening with Infl atable Penile Implants 79: 1310-5 (2012) ). Recently, we have developed a new technique that combines key aspects of these 2 approaches to create a minimally invasive, no-touch ("MINT") technique for penile prosthesis insertion. We theorized that the MINT technique would take advantage of the benefi ts that each of these established approaches off ered and therefore our aims were to assess feasibility, safety, post-operative hematoma and infection rate and percentage of patients cycling the prosthesis by 4 weeks.

Th e principles of the MINT technique involve a small infrapubic incision approach combined with a no-touch technique facilitated by using 2 standard surgical drapes (1 x clear non-adhesive drape and 1x Ioban® drape) and an Alexis® wound retractor. We present results for our fi rst 50 consecutive patients undergoing primary prosthesis implantation from May 2012 -July 2013 with at least 3 months follow-up. Patients having revision surgery, or with complex surgery necessitating >1 incision were excluded. Data was collected using a prospective database.

Results: Average age (±SD) was 59.8 (±11.3) years. Median follow-up was 11.7 months. Patients had one or more of the following etiologies for erectile dysfunction: vascular disease (n=22), post-radical prostatectomy (n=16), diabetes (n=8), Peyronies disease (n=8), venous leak (n=4) and priapism fi brosis (n=1). Seventy percent had used intracavernosal injections. Implant used: Coloplast Titan (n=47), American Medical Systems (LGX; n =2), (CX; n =1). Th e average (±SD) cylinder and rear tip extender length was 18.7 (±1.6) and 0.9 (±0.8) cms respectively. All operations were completed successfully and there were no peri-operative complications necessitating intervention or re-operation. Th ere were 2 post-operative hematomas (treated conservatively). Sixty-fi ve percent could cycle prosthesis by 4 weeks. Th ere were no post-operative infections.

Conclusion: Th e MINT technique for penile implant surgery is a safe and feasible procedure with a zero infection rate in our fi rst 50 patients.

Effi cacy and Safety of Botulinum Th e initial number of patients to be recruited were twenty-six, but actual patient enrolment was eleven (six control and fi ve botulinum toxin A). All of the patients had a history of vulvar pain for more than six months despite proper medical treatments. Patients were randomly assigned to two groups: control -saline injection, toxin -botulinum toxin A (Meditoxin® injection, Meditox, Inc., Korea). In both groups, areas of pain were mapped on the vestibule and injections were performed at fi ve sites to cover the entire painful area. Th e dosage of each injection was 1-2ml with a maximum cumulative total of 10ml. At baseline, two, four, and eight weeks aft er the injection, visual analogue scale (VAS) and SF-32 questionnaires were scored. Data was analyzed and p value was considered to be signifi cant at <0.05 according to the Mann-Whitney test.

Results: Th e mean age of patients was 43.2 (37-52) years old in the control group and 44.8 (26-56) years old in the toxin group. Aft er breaking of the blinding, two of the toxin group had 50IU of botulinum injection, and the others had 100IU injections. Two patients from the control group dropped out because of aggravated pain. Th eir VAS were 7 and 6 respectively at their drop-out point (baseline 3 and 4, respectively). At week eight, VAS was signifi cantly decreased in toxin group when compared with baseline (Table 1) . Th ere were no drug related adverse reactions. 

Introduction and Objective: Congenital anomalies of uro-genital system have increased globally as a consequence of higher maternal age at pregnancy and developments in assisted reproductive techniques in the last few decades. Aim of the study was to determine the incidence of apparent congenital uro-genital anomalies in North Indian newborns and factors associated with them.

A prospective study was conducted to collect data of all newborns delivered at our institute between September 2012 and August 2014. Th e predetermined format included newborn's birth weight and gestational age, maternal age, parity and infertility treatment if any. Newborns weighing less than 1000gm or born before 32 weeks of gestation were excluded from the study.

Results: Th ere were 20,432 deliveries with 10,952 males and 9480 females. A total of 799 apparent uro-genital congenital anomalies were recorded with an incidence of 39.1 per 1000 newborns. Th e most common anomaly was cryptorchidism found in 678 newborns, amongst others hypospadias was noted in 61, ambiguous genitalia in 34, congenital hernia/hydrocele in 20, exstrophy-epispadias complex in 5 and prune belly syndrome in 1newborn. Newborns weighing less than 2,500 grams had a higher proportion of anomalies (9.64%) in comparison to those weighing over 2,500 grams having 1.99% (p = 0.0001). Maternal age (>30yrs), parity (>2) and infertility treatment were recorded in 5.40%, 4.93 % and 9.80% respectively and all were independently associated with increased risk of uro-genital anomalies (p=0.0001).

Conclusions: Incidence of apparent congenital uro-genital anomalies was 3.91%. Infertility treatment, parity (>2) and maternal age (>30years) were independently associated with increased risk of congenital uro-genital anomalies.

Comparison Conclusions: Double-breasting spongioplasty is very good method to decrease complications in hypospadias repair, so it is recommended an as interposing tissue in TIPU. Advantages of the double breasting spongioplasty are that avoiding of suture line and adding two layers of spongiosum over neourethra decreases the chances of urethral fi stula and gives cylindrical shape to neo-urethra.

Use Stretched penile length (SPL) is the standard measurement used in reconstructive penile surgery (RPS), but is associated with high inter-rater variability, and is seldom reported. Furthermore, ruler-based measurements require that all measurements be made intraoperatively; post-hoc measurements are diffi cult to impossible. We used a novel smartphone application to assess the correlation of post-op digital-photo based length measurements to intra-operative ruler measurements.

35th CONGRESS OF THE SOCIÉTÉ INTERNATIONALE D'UROLOGIE -SIU 2015 ABSTRACT BOOK Materials and Methods: Intra-operative SPL was measured in a consecutive series of pediatric patients undergoing RPS who agreed to participate in this study. SPL was measured intra-operatively (SPL-IO), and a picture was taken, with the ruler and from a true lateral view, as proof. A second digital picture was taken at the same time, with a reference object (OBJ) (object whose dimensions are known and constant). Post-op, SPL was later measured using the MedMeasure! App for iPhone and iOS Android, using the picture with OBJ, by two diff erent surgeons blinded to intra-op measurements. Th e three diff erent measurements (Intra-op SPL (SPL-IO), and post-op using the App (SPL-S1 -SPL-S2) were then compared to assess overall correlation and correlation to ruler measurements using SPSS 20.0 statistical soft ware package.

Results: Twenty consecutive patients underwent surgery for hypospadias (n=15), buried penis (n=1), epispadias (n=3) and circumcision accident (n=1). Median age at surgery was 18 months [6-301]. Median penile SPL-IO was 3.8 cm [2.4 -8.9 ]. When ruler-based measurements (SPL-IO) and App-Photo based measurements were treated as independent measurements (Students t test), there was no statistical diff erence between any of the three groups (p 0.51-0.81). Even with SPL-IO measurements were treated as the gold standard, by Bland-Altman Limits of Agreement analysis, the correlation factor of SPL-IP to SPL-S1 & SPL-S2 was >99%.

Conclusions: When compared with intraoperative measurements, digital measurements using MedMeasure! are reliable and precise, provided that the picture is taken from a true anterior-posterior or lateral view. Because measurements are made based on captured images, a limitless number of length measurements (within the same plane as the reference object) can be made post-hoc. Use of digital photography and this smartphone app has the potential to aid in surgical planning, improve documentation, and, facilitate clinical research.

Aseel's Technique for Distal Penile and Coronal Hypospadius Repair (Simple, Easy with Less Complications)

Introduction and Objective: Th is technique is modification of the old operation of Arab that makes it very simple, easy to learn and even in cases of failure there will be no problem of redoing it or other operation because of the minimal tissue dissection.

Th is technique was applied in 43 patients. First a transverse ventral incision is done parallel to the circumcision incision and 1cm proximal to the urethral meatus, Figure ( 1) . Th en proximal and distal skin dissection is done, Figure  ( 2). A longitudinal incision across the urethra plate extending through the meatus is done, Figure ( 2) and closed transversely that leads to urethral advancement, Figure ( 3). Th en aided by 2 skin hooks the distal skin edge is pulled downwards to create a roof for the advanced urethra, Figure (4) followed by closure of the skin incision, no catheter or stent is left , Figure   ( 5). Th is is a 10-minute operation and the patient is discharged as a day case.

Results: Th irty-eight patients passed without complications and 5 had loss of the skin stitches either partial in 3 cases or complete in 2 cases that were repaired by reapplication of the stitches, no meatal stenosis or fi stula were reported.

Th is is a very easy technique that can be applied as an outpatient or day case, and done in 10 minutes, with no Catheter or stent per urethra left or complications such as urethral meatus stenosis or fi stula formation. Th e remained boys (261) underwent transinguinal laparoscopy during ipsilateral herniorrhaphy. All data were collected prospectively.

Results: Th e incidence of CPPV confi rmed by transinguinal laparoscopy was 27.5% (72/261). Th e width of hernia sac and mother's age at birth were signifi cant risk factors in the univariate analysis. However, in the multivariate analysis the width of hernia (>1cm) sac was only an independent risk factor for CPPV (odds ratio 2.335; p=0.03). Th e laterality, type of hernia, age, preterm, low birth weight, twin, blood type, father's and mother's age at birth, and the type of delivery were insignifi cant.

In this study the width of hernia sac was the independent risk factor for CPPV. Th is result suggests that the transinguinal laparoscopic examination is benefi cial for the detection of CPPV in boys with this risk factor. However, it should be considered in the clinical practice that the one-third of boys with CPPV has a narrowed width of hernia sac (<1cm).

Low Introduction and Objective: Traditionally bladder exstrophy complex is managed by staged repair, however now there is trend towards single stage repair. To achieve a satisfactory level of continence, secure abdominal wall closure and preservation of renal functions in patients with bladder exstrophy remains an elusive goal. Objective of the study was to assess continence and functional outcome of single stage repair pediatric and adults.

Materials and Methods: Th irteen patients, 11 boys and 2 girls with classic bladder exstrophy were treated from 2009 to 2013. Aft er proper evaluation patients under went complete primary repair of exstrophy repair (ureteric re-implantation, bladder closure with or without cystoplasty, iliac osteotomy, neck reconstruction and epispadias repair). Bladder and urethral plate was mobilized as single unit and bladder closure was done to create an adequate capacity bladder. Epispadias repair was done by separating the two corpora; tubularization of urethral plate and ventral transposition of neo-urethra to create an orthotopic neomeatus. Th en Bilateral anterior iliac osteotomies were performed and external fi xators were applied to approximate the pubic symphysis which helps in sphincteroplasty. Bladder neck was reconstructed using Young Dees technique and placed deep within the pelvis; sphincteroplasty was done followed by abdominal wall closure. Voiding cysto-urethrography was obtained at 3 months and at one year. Continence was defi ned as dry intervals of 3 hours or more. Patients were followed-up at 1, 3, 6, 12 months and annually.

Results: Age of patients varied from 5 days to 21 years (mean 11.2 years). Pre-operative symphyseal gap varied between 4 -8 cm and post operatively the average diastasis was 2.5 cm with the range of 2 cm to 4 cm. In a follow-up period was 6 months to 3 years, 10 patients had good results (2 girl and 8 boys) minor supra-pubic leak was present in 4 patients which was managed conservatively, all being able to hold urine for 3-4 hours with no leaking at night. Colo-cystoplasty was needed in 4 cases with small bladder plate. Overall Continence rate was 76.9% in single stage.

Two male incontinent patients were continent aft er second surgery.

Conclusions: Single stage complete bladder exstrophy repair is safe and viable option for both pediatric and adult cases. Augmentation enterocystoplasty is required in small bladder capacity cases. Anterior iliac osteotomy with approximation of pubic symphysis improves continence and allows tension free closure of abdominal wall and sphincter.

Long Wilms tumor (WT) represents approximately six to seven percent of all pediatric cancers and accounts for more than 95 percent of all tumors of the kidney in the pediatric age group. Recently some centers have explored the role of nephron sparing procedures in children with unilateral Wilms tumors because of the concern about late occurrence of renal dysfunction aft er unilateral nephrectomy. We assessed the long-term renal functional outcome aft er parenchymal-sparing procedure for non-syndromic unilateral Wilms tumor at our center.

We retrospectively reviewed the records of all children with unilateral Wilms tumor who had undergone nephron sparing surgery at our center. Patient's long-term renal function, tumor recurrence, and survival, were determined from a review of each patient's medical record.

Results: A total of eight patients underwent partial nephrectomy (PN) and the remaining three with polar tumors underwent hemi-nephrectomy (HN) following chemotherapy. Smaller tumor volumes were associated with not only preservation of renal function but also increase in eGFR during the follow-up period. Th e median preoperative eGFR was 106 ±10.78 and median eGFR at the last follow-up was 131.0 ±3.52.

In properly selected children with non-syndromic unilateral Wilms tumor, nephron sparing surgery provides excellent renal function preservation.

Introduction Introduction and Objective: Hyperbaric oxygen (HBO) therapy, which increases the amount of oxygen dissolved in the blood and that carried to tissues, is used in the treatment of several disorders. HBO therapy may be a useful adjunctive treatment in the management of some of challenging conditions encountered in pediatric urology practice. In this paper, we report our experience on the use of HBO therapy in children with urologic problems.

We reviewed our department's records to identify pediatric patients who received HBO therapy between 2011 and 2014. All patients were evaluated at the department of underwater and hyperbaric medicine and informed consent was obtained from the patient or his parents. Total number of HBO sessions was determined based on patient's clinical response to HBO therapy.

Results: Eleven patients received HBO therapy during the study period. All of them were male. Th e mean age was 8.63 ± 5.53 (1-17 years) . Indications of HBO therapy were necrosis aft er hypospadias and epispadias repair, penile glans necrosis, circumcision caused penile skin necrosis, sickle cell crisis induced priapism, and testicular torsion. Th e average number of HBO sessions was 6.72 ± 2.53 (4-11). Nine patients (81%) healed aft er HBO therapy, but 2 (19%) patients did not (Table 1) . . Th e essential parameters of Kegel exercise are duration of contraction and active relaxation, and, frequency of exercises. To date, exercise duration times could only be captured during in-clinic biofeedback. We hypothesized that a smartphone-based App that provides users biofeedback -and reports mean duration of contraction and relaxation, could help return to continence aft er RP. We designed/made a working prototype of such an App, and validated it.

Our novel App (iOS) was programmed to allow users to record the duration of Kegel active PFM contraction and relaxation. It also allows users to record urinary frequency, urgency, voiding, and leakage events, and number of pads used-on a daily basis. It contains a 12-Q Visual Analog Scale Questionnaire that queries satisfaction (urinary, sexual, erectile), pain control, depression, sleep quality, and quality of life. Data from the App can be "pushed" automatically by the User to a queryable custom database on a HIPAA-secure server (UCSF). We provided the App to 10 non-medical colleagues (5 women/5 men age 40-70) for evaluation. All completed 10 mock Kegel exercises using the App to measure contraction/relaxation duration, which were timed using a stopwatch. Measured times were compared to duration times recorded in our database for each User. A 10-point Likert Scale was used to query the following 3 items: 1) User reported ease of use; 2) Privacy related anxiety related to use of such an App to submit study data wirelessly; and 3) Perceived usefulness of the App to improve Kegel performance.

Results: Th e PFM contraction and relaxation times recorded by the App within the wireless database disagreed with stop-watch measured duration times by mean +/-<1 second for all 10 subjects. Mean Likert scores: 1. "Overall ease of use" score =9.4 (SD 0.5), "Privacy related anxiety" score = 9.1 (SD 0.7), and "usefulness"=9.8 (SD 0.3).

Conclusions: Our novel smartphone app appears to allow Users to accurately record key Kegel exercise parameters: duration and progress. Th e platform also allows collection of key patient data during daily life. A randomized controlled clinical study is warranted to further assess clinical utility, and, possible means to further enhance utility and research.

Safety and Effi cacy of Reduced Dose of Botulinum Toxin-A for Patients with Detrusor Overactivity

Place J, Vyas L, Watcyn-Jones T, Lupton B, Miah S, Darrad J, Kumar V

Introduction and Objective: Th is prospective study was carried out to look at the response of a lower dose of Botulinum Toxin-A for treatment of symptoms of OAB, its tolerability and side-eff ects.

Materials and Methods: Following due counselling and consenting, all newly diagnosed patients with confi rmed Detrusor Overactivity on UDS (n=49, with a mean age of 62.2 years (range=35-88)) were given 100 IU of trigone-sparing, intra-detrusor Botulinum Toxin-A. Of the total of 49 patients, 7 (14.2%) were males and 42 (85.8%) were females. Of this cohort, 57.1% stopped anticholinergic medications because of lack of benefi t. Th e rest (42.9%) could not tolerate the side eff ects. Th e procedure was performed in outpatient department using a fl exible cystoscope under local anaesthetic. Th ese patients fi lled up a pre-treatment ICIQ-SF for OAB as well as UI and follow-up scores at week 1, 6 and 16. Th e per-procedural pain score and follow-up urinary residual volumes were recorded.

Results: Two (4.1%) patients did not respond to the treatment at all. In the responders, average scores from the ICIQ-SF questionnaire fell from the pre-treatment level of 35.2 (21-40) to 13.92 (0-39) at week 1, 11.6 (0-25) at week 6 and 12.84 (0-22) at week 16 (p<0.001). Th e urgency incontinence scores fell from an average pre-treatment level of 17.2 (8-20) to 4.35 (0-18) at week 16 follow-up. Th e average daytime urinary frequency scores fell from 2.4 to 0.84 and nocturia scores fell from 3.13 to 2.1. Five patients went into urinary retention following intra-detrusor Botulinum Toxin-A injections. In the rest of the cohort, post void residuals remained largely unchanged with pre-procedure fi gure of 70.5 mls (0-224) to 74.8 mls (0-159) (p=NS). Average pain score was 3.75 (0-8) on a scale of 1 to 10. No symptomatic UTI was found in post procedural patients.

Conclusions: Th ese results albeit with a small number of cases, have suggested a signifi cant clinical response in over 95% patients with proven Detrusor Overactivity with a reduced dose of intra-detrusor Botulinum Toxin-A injections, thereby maintaining the clinical eff ectiveness of the drug and at the same time reducing the cost of delivery with possibly reduced incidence of urinary retention. Prior to the initiation of intravesical onabotulinumtoxinA treatment, all patients had an assessment of mid-stream urine for culture and sensitivity, renal tract ultrasound scan, subjective and objective assessments of symptoms (including ICIQ-UI and ICIQ-OAB questionnaires) and conventional urodynamic study. All patients had proven overactive bladder. OnabotulinumtoxinA effi cacy and durability was assessed by subjective and objective assessments of symptoms.

Results: Duration of effi cacy of onabotulinumtoxi-nA injections is well maintained in the IDOA group in comparison with NOAB group. Th ese trends are shown in Figure 1 . Four injections out of 55 administered in total to the IDOA group were unsuccessful (7.2%) and brought no relief of symptoms to the patient. Th ere were no unsuccessful treatments in the NDOA group (0/30 total injections administered). Results: From the general practitioner's records, none of the non-traceable patients were on botulinum toxin-A treatment elsewhere. Of the total number of traceable patients (n=28), 10 (36%) stayed on mirabegron alone. Of these 90% were satisfi ed (9/10). As a whole 32.1% (9/28) were satisfi ed and continued with Mirabegron only. One patient moved to combined Mirabegron with an anticholinergic. Of the 10 patients on Mirabegron ICIQ-SF scores fell from 13.36 (8-21) to 7.7 (0-20) at 18 months. Eighteen of 28 (64%) patients progressed requiring Botulinum Toxin A treatment. Side-eff ects included-palpitations (2), vomiting (1), rashes (1), lethargy (1) and yellow urine (1) .

Th is study showed that 36% of patient with refractory OAB symptoms awaiting fi rst or subsequent treatment with intra-detrusor Botulinum Toxin A injections will respond to Mirabegron and 80% of these responders (32.1% of total) are able to come off Botulinum Toxin A at 18 months, reducing the burden of the waiting list; with a cost reduction Mirabegron= £352 vs cost of Botulinum Toxin A= £525/year/patient. Th is is a small study but provides a medium-term option for patients on long waiting list for Botulinum Toxin A thereby helping to limit use of botulinum toxin-A for patients with detrusor Overactivity.

Introduction and Objective: Patients that fail to achieve symptom improvements with sacral neuromodulation (SNM) may benefi t from increased aff erent stimulation via tined lead placement at the pudendal nerve. We evaluated 2−year outcomes of chronic pudendal neuromodulation (CPN) in patients that had failed sacral neuromodulation (SNM).

Adults enrolled in our prospective observational neuromodulation study that had a pudendal lead placed were evaluated. Medical records were reviewed. Outcomes were measured at 3, 6, 12 and 24 months with Interstitial Cystitis Symptom/Problem Indices (ICSI−PI), Overactive Bladder Questionnaire (OABq) symptom severity (SS) and quality of life (QOL), voiding diaries, and Global Response Assessments (GRA 

Analysis of Voiding Dysfunction after Transobturator Tape Procedure for Stress Urinary Incontinence

Introduction and Objective: Voiding dysfunction is common complication of midurethral sling surgery (MUS) for stress urinary incontinence. However, the defi nition of post-MUS voiding dysfunction is inconsistent in the literature. Subjective feeling of slow stream, signifi cant postvoid residual (PVR), additional procedure for bladder emptying, or objective fl ow rates can be a yardstick of voiding dysfunction. In this study we retrospectively investigated the risk factors for post transobturator tape procedure (TOT) voiding dysfunction applying various defi nitions in one cohort.

Four hundred fi ft een patients were evaluated who underwent TOT. Preoperative urodynamic study were performed and urofl owmetry and international prostate symptom score questionnaire were investigated pre and post-operatively. Several postoperatively parameters representing voiding dysfunction were adopted for analysis. Acute urinary retention requiring catheterization (AUR), subjective feeling of voiding diffi culty during follow-up (VD), and signifi cant postoperative PVR greater than 100 mL or more than 50% of voided volume (PVR) were adopted for categorization of the defi nition of voiding dysfunction.

Results: Sixteen patients (3.9%) required catheterization, 45 (11.0%) experienced post-operative voiding diffi culty, 65 (17.7%) and 27 (7.4%) showed low fl ow rate and signifi cant PVR. In the AUR and VD category, concomitant co-operation and general anesthesia were signifi cant parameters, especially anteroposterior repair of vagina. Older and menopaused patients complained subjective voiding diffi culty. Th e patients in VD category showed lower fl ow rates and larger PVRs. Patients in PVR category had old age and low preoperative fl ow rates. Th e patients with VD tend to be prescribed alpha blocker during postoperative follow-up period. Th ere were no signifi cant urodynamic parameters attributing for various voiding dysfunction categories. With logistic regression analysis AUR, VD and PVR category had concomitant co-operation and preoperative retention history as risk factors.

Conclusion: Several factors including preoperative voiding symptoms and intraoperative parameters such as co-operation may aff ect postoperative voiding dysfunction. Th e diversity in clinical presentation underscores the importance of a high clinical suspicion with an appropriate diagnostic evaluation. Subjective and objective voiding dysfunction should be evaluated aft er midurethral sling operation.

Introduction and Objective: Some have hypothesized that patients with lower functional bladder capacity (FBC) experience less improvement in symptoms after staged neuromodulation procedures. Th erefore, we evaluated the impact of baseline FBC on generator implant rate and symptom changes.

Adults enrolled in our prospective observational neuromodulation study were evaluated. Functional bladder capacity (FBC) was defi ned as average volume per void on 3 day voiding diary. Data were collected from medical records, and validated Interstitial Cystitis Symptom/Problem Indices (ICSI−PI) and Overactive Bladder Questionnaire (OABq) symptom severity and health related quality of life (HRQOL) domains, and examined with descriptive statistics, Wilcoxon rank sum tests, logistic regression, and Spearman Correlation Coeffi cients.

Results: Of 242 patients (mean age 59.1 ± 16.8 years; 84% female), most had urinary urgency/frequency with or without urge incontinence (62%) and a sacral lead placed (81%); 19% had the lead placed at the pudendal nerve. Mean FBC at baseline was 156.5 ± 96.6 ml. Among the 242, 223 (92%) had ≥50% improvement in overall symptoms aft er lead placement with subsequent generator implant. Baseline FBC was similar between implanted/not implanted patients (p=0.25), however implanted patients had a median 20.7% increase in FBC aft er lead placement compared to explanted patients whose FBC decreased by median 2.7% (p=0.005). Logistic regression identifi ed a strong relationship between percent change in FBC aft er lead placement and generator implant (p=0.0058) but there was no relationship between baseline FBC (ml) and subsequent generator implant. At 3 months, a lower pre-implant FBC weakly predicted a greater improvement in OAB-q HRQOL from baseline (p=0.035; r = -0.23). FBC (ml) at baseline, or percent change in FBC aft er lead placement, had no relationship with achieving at least 50% improvement in ICSI−PI or OAB−q symptom severity scores at 3 months.

Conclusions: Lower baseline FBC should not be a contraindication to neuromodulation since there was no impact on outcomes. Improved FBC aft er lead placement may have contributed to overall improvements in symptoms leading to generator implant. Improvement in FBC was equal to or greater than that seen in medical treatment trials for OAB.

Introduction and Objective: To present our preliminary experience with the SARS (Sacral Anterior Root Stimulator) in spinal cord-injury patients with hyperactive bladder at our center.

Th e SARS is an implantable electronic device that allows patients with spinal cord injury to assume voluntary control of micturition, defecation and erectile function. It involves a S2-S4 dorsal (sensitive) rhizotomy and placement of electrodes around those roots, which are connected to a subcutaneous receiver antenna. By transcutaneous radiofrequency stimulation of that antenna the patient can selectively use 3 stimulation programs to activate the diff erent functions: program 1 for micturition, program 2 for defecation and program 3 for erection.

Results: Between January 2013 and November 2014 nine SARS implants (eight men and one woman) were performed in patients with spinal cord injury-related overactive bladder refractory to standard conservative treatment. Average age was 42 years and mean follow-up was 22 months (range 3-25). Bladder function: Eight of the nine patients exhibit an increase of the bladder capacity and use the device 4-5 times daily, voiding 250 -300 cc with ≤50cc residual urine. One of these 8 patients showed de-novo postoperative stress incontinence due to sphincter incompetence that was solved with placement of a suburethral sling. Th e ninth case had a poor compliance and low capacity bladder; despite SARS, he failed to increase capacity and persisted incontinent so aft er 15 months he underwent a continent urinary reservoir. Voiding objectives were therefore achieved in 8/9 patients (89% success). Defecation: All patients use the device once a day. Erectile Function: Of the eight male patients, seven achieved erection with SARS. However, this erection was not always reliable for intercourse; 4 patients associate sildenafi l and eventually 2 requested a penile prosthesis implantation. Complications: Th ere were no postoperative complications or failure of the internal components. One patient showed a transient S3 neurapraxia, which resolved spontaneously aft er 12 months.

Conclusion: In selected spinal cord injury patients, SARS is an excellent option for urinary and defecatory control, being also useful for erectile function in some of them.

How To determine the complication rate of Urolastic (vinyl dimethyl polydimethylsiloxane, PDMS), a bulking agent for female stress urinary incontinence.

Twenty-eight females with stress urinary incontinence were treated with PDMS. Th e group mainly consisted of secondary patients (n=25), with extensive comorbidity. Six patients had one previous surgical procedure for SUI; nine underwent two procedures and ten received three or more interventions. An amount of 3.2-4.4 ml of PDMS was injected at 3-4 positions paraurethrally at the midurethra. Procedures were performed on the outpatient department, with local anaesthesia. Th e Clavien Dindo score was determined aft er 6 months, to assess the severity of the complications encountered.

Results: Aft er six months, 29% (8/28) of the patients reported a 100% improvement, 14% (4/28) a 90-95% improvement and 14% (4/28) a 75-80% improvement, 11% (3/28) reported 50% improvement and 7% (2/28) was 20% improved. Six patients (21%) had no improvement aft er six months, four of which had also not shown initial improvement. In one patient the implants were removed during surgery, so no follow-up was available. Of twenty-eight patients treated, 43% (12/28) had no complications. In 57% (16/28) complications were seen, which were classifi ed following the Clavien Dindo-classifi cation. A score of I was appointed to 21% (6/28) of the patients. Reasons were: implant-exposure, minor pain, anti-emetics use or de novo retention. Th ree patients had a score of II, because of more severe complaints of pain or urge. Th ey were treated pharmacologically. In 25% (7/28) one or more implants were removed, mostly due to exposure, erosion or pain. Removal under local anaesthesia was performed in 14% (4/28) of the patients and this resulted in a IIIA-score. Th ree patients (11%) had a IIIB-score, which meant the implant(s) were removed under general anaesthesia.

In the fi rst twenty-eight diffi cult to treat patients receiving PDMS, in ten cases a Clavien Dindo grade II-IIIB is scored, mainly because of surgical removal of implants. In spite of the seemingly high complication rate, this remains a useful therapeutical option for female stress urinary incontinence.

Magnetic Stimulation for Stress Urinary Incontinence: A Randomized, Double-Blind, Sham-Controlled Trial Introduction and Objective: We conducted a multicenter, randomized, double-blind, sham-controlled trial to evaluate the effi cacy of magnetic stimulation (MS) for stress urinary incontinence (SUI).

A total of 120 SUI subjects were randomized 1:1 to active or sham MS for eight weeks (twice weekly). Th e primary criterion for response was a reduction of 5 points or more in the International Consultation on Incontinence Questionnaire for Urinary Incontinence-Short Form (ICIQ-UI SF). Th e secondary outcomes included objective (leakage of less than 1 gram on 1-hour pad test) and subjective cure (a 'never' response to 'How oft en do you leak urine?), incontinence diary, pelvic fl oor muscle strength, urofl owmetry, Patient Global Impression of Improvement (PGI-I) and International Consultation on Incontinence Questionnaire-Lower Urinary Tract Symptoms Quality of Life (ICIQ-LUTsqol).

Results: Using the primary criterion, 45 (75.0%) of 60 subjects were treatment responders in the active group compared to 13 (21.7%) of 60 subjects in the sham group (relative risk (RR) 3.46, 95% CI 2.09-5.72, p<0.001). Based on objective cure, 25 (41.7%) subjects in the active group were dry versus 4 (6.7%) subjects in the sham group (RR 6.25, 95% CI 2.32-16.87, p<0.001). Nineteen (31.7%) in the active group and 3 (5%) subjects in the sham group perceived themselves as dry (RR 6.33, 95% CI 1.98-20.28, p<0.001). Th e active group had greater reductions (p<0.05) in incontinence frequency than the sham group. Changes in pelvic fl oor muscle strength and urofl owmetry parameters were not statistically signifi cant between groups (p>0.05). Th irty-nine (65%) subjects in the active group reported signifi cant benefi ts (much/very much better) for PGI-I rating compared to 11 (18.3%) subjects in the sham group (p<0.001). All item scores in ICIQ-LUTSqol were not statistically diff erent (p>0.05) except 'eff ect on friends' , 'smell' , feeling of embarrassment' and 'overall impact' in the active group. Of all evaluable subjects, 3 (5.3%) of 57 subjects in the active group and 5 (8.6%) of 58 subjects in the sham group experienced adverse events (p=0.72). Conclusions: Modifi ed TVT Abbrevo is a simple, safe and eff ective procedure with comparable short-midterm cure rates to standard TVT Abbrevo. Th e modifi cations of avoiding the tunnelling device and groin exit helped to minimize the groin pain and analgesic requirements.

Evaluation of Standard Practice for Artifi cial Urinary Sphincter Implantation

Auckland DHB, Auckland, New Zealand; 2 UCD Medical Center, Sacramento, USA Introduction and Objective: Th e Artifi cial Urinary Sphincter (AUS) has been available since 1972 and over this time it has established itself as the gold standard in management of post prostatectomy incontinence. Th e successes, failures and diffi culties are well documented, however little is published regarding the standard implantation practice of the AUS. Our objective was to review the standard practice for implantation of the AUS within a group of high volume implanters.

Aft er obtaining institutional review board ethical approval a web-based questionnaire was designed using Survey Monkey soft ware. An email was sent to the current members of the Society of Genitourinary Reconstructive Surgeons (GURS) explaining the aims of the confi dential questionnaire with a web link to the aforementioned questionnaire. All results were collected via Survey Monkey and were then analyzed.

Results: One hundred and twenty GURS members were contacted by email, 70 members replied. Th is group averaged 18 AUS placements a year (range 5 to 53). Pre-operative assessment utilized routinely included pad weights in 32.1%, pad numbers in 84.9% and urodynamic studies in 55% of participants. Additionally 93% of participants surveyed would routinely perform a cystoscopy in the pre-operative assessment Ninety four percent of those surveyed used greater than one pre-operative antibiotic; most commonly gentamicin with either vancomycin or cefazolin. Th e antibiotic most commonly utilized alone was levofl oxacin. Post-operatively 87% continue antibiotics anywhere between 24 hours and 1 month, with 5% continuing intravenous antibiotics for a minimum of 5 days. Intra-operatively 74% have AUS componentry prepared on a separate set up stand. Th e single cuff AUS, size 4.0 and 4.5 cm cuff were the most commonly placed cuff s, with the 61 -70cm reservoirs. Radio-opaque contrast is used by 33% of participants in the AUS reservoir. Only 60% of participants would recommend a medical alert bracelet in the post-operative period, and 63% encourage pump traction.

Conclusion: Despite a uniform technique recommended for the implantation of the AUS by American Medical Systems in order to improve success and decrease complications, there is great heterogeneity in pre-operative assessment, surgical placement and post-operative management of the AUS in a cohort of high volume implanters. 

Patients presenting to a multi-disciplinary stone clinic were administered a survey. Th ey were asked to elect a treatment modality from shock wave lithotripsy (SWL), Ureteroscopy (URS) or Percutaneous Nephrolithotomy (PCNL) for a hypothetical 15mm kidney stone. Th e success rates (50% SWL, 75% URS and 95% PCNL), morbidity and the risks associated with each treatment options were explained. Patients were also to elect whether personal or doctors' decision of treatment is most preferred and the most important variable in deciding a choice of treatment modality.

Results: Of the 106 respondents with mean age 55.9±13.4, female/male ratio was 1:1 ( Figure 1 ). Majority of the subjects (57%) elected URS as their treatment choice (Table 1) . Previous experience with URS (P=0.002) and PCNL (P=0.044) impacted the choice of URS. Th e respondents were equally distributed in their primary concern being success rate (47%) versus risks (43%) associated with the procedure of choice (P=0.001). Age and gender has no infl uence on treatment choice (P=0.37 and P=0.22) and on whether the primary concern is success or risk (P=0.68 and P=0.67 respectively). Majority (86%) of the surveyed population would prefer the physician recommend the appropriate treatment.

Conclusion: Th ough patients prefer the physician to recommend the appropriate treatment for a medium-sized renal stone, it is important for the physician to consider the patient's priorities of minimizing risk versus maximizing success. As such, majority of patients selected ureteroscopy as a procedure with a balance of moderate risk and moderate success.

Solo Introduction and Objective: Sonography has been brought in percutaneous nephrolithotripsy (PCNL) as an adjunct to X-Ray to restrict radiation exposure. Th is study was designed to respond this question that "is sonography proper enough to supersede X-Ray in PCNL under spinal anesthesia?" Moreover, we investigated possible predictors of success. tract infection were excluded from study. Th e intraand post-operative surgical outcomes were evaluated.

Results: Th e mean age of the patients was 41.0 ± 12.4 years. Mean stone size was 3.9 ± 1.2 cm. Mean access and operative time were 12.1 ± 3.1 and 75 ± 12.2 minutes respectively. Superior calyx was selected for access in 47% of patients. Th e patients were categorized in following groups; history of more than one section previously open stone surgery (40%), horseshoe kidney (8%), major lumbosacral deformity (18%), failed standard PCNL (18%), children under 10 years old (10%), pregnancy (6%). Th e primary complete stone free rate was 68%, and aft er ancillary procedures (URS, SWL), raised to 84%. Th e mean hemoglobin drop was 2.1 ± 1.0 gr/dl. Transfusion needs in 6 patients. Signifi cant prolonged or delay hemorrhage was not shown in any cases. Pneumothorax was detected in one patient that managed with chest tube insertion. Visceral or solid abdominal organ injury was not occurred.

Conclusion: With some attention, the outcomes of ultrasonography-guided PCNL for challenging renal stones are comparable with standard fl uoroscopic approach, and in some situation, fl ank position contain benefi ts rather than standard prone position.

Study of Ten Cases of P.C.N.L in "Previously Operated Kidney Stone with Incisional Hernia" Conclusions: P.C.N.L in incision hernia patient is a safe procedure with excellent results. C.T. urogram is necessary tool for puncture.1st puncture in virgin fi eld (out of incisional hernia site) and avoiding colonic gas shadow on fl uoroscopy is key point. Bowel injury is the concern -which should be taken care during puncture.

Daycare PCNL: Now a Reality!

Introduction and Objective: PCNL as a therapy for renal stones is an established modality. Th e use of holmium laser has led to miniaturisation of instruments and sheaths and has thus made the procedure less morbid. A stage has come for the patient to now leave hospital on the same day of the procedure.

Materials and Methods: All cases were done under spinal anaesthesia and prone position. Aft er placing a retrograde ureteric catheter, PCS was accessed through the appropriate calyx, and a 15 French sheath with suction capability was used. Holmium laser was the energy used. Aft er fragmentation, clearance was achieved by a combination of suction and retrograde wash and confi rmed radiologically and visually. Clots were fl ushed out through the sheath which was then removed having retained the guide wire. Finger pressure on the puncture site achieved haemostasis. Th e guide wire and the retrograde catheter were fi nally removed. No urethral catheter was kept. A total tubeless procedure in the real sense. All patients were counselled about haematuria and pain.

Results: From January 2014 to March 2015, a total of 32 cases are included comprising 27 renal and 5 upper ureteric stones. Stone size ranged from 1.0 to 2.8 cms.

Age ranged from 22 to 68 yrs. Th e M/F ratio was 4:1.

Operative time ranged from 18 to 72 mins. Th ere was no signifi cant blood loss. All patients received 1 dose of a parenteral analgesic 2 hrs post procedure, were ambulant 6 hours postopt and were allowed oral liquids. 1 patient had leak at puncture site lasting for 24 hours .All had haematuria which cleared completely within 12 to 36 hours. All were off ered discharge on the same day without any major event. One patient had clot retention on the 5th po day requiring clot evacuation.

Conclusion: PCNL as a day care procedure has been achieved by the above described method. Patient acceptance is fair though most showed apprehension of going home the same day aft er a major procedure. Whether it can be accepted universally remains to be seen.

Initial Experience in UltraMiniPerc We have reviewed our initial experience of Ultra-MiniPerc-UMP in 100 patients.

Between June 2014 and March 2015, total 100 patients underwent Ultra-MiniPerc. Puncture and dilatation were done under fl uoroscopy in prone position. We used 11 and 13 Fr UMP Amplatz. Stones were fragmented by Holmium Laser and removed by whirlpool eff ect. Post-operative stone-free status was confi rmed by Ultrasonography and X-ray aft er 1 week.

Results: Mean patient age was 38 years (11 to 75 years) and male to female ratio was 1.2:1. In 15% the procedure was bilateral simultaneous and in 4% in solitary kidney. Stone locations were lower calyx (48%); upper calyx (5%), middle calyx (3%), renal pelvis (9%), upper ureter (11%) and rest were at multiple sites. Calyx punctures were lower (81%), upper (9%), middle (5%) and multiple in rest. Eight punctures were supracostal. Mean operative time from puncture to Amplatz removal was 32 minutes (range 20 to 75 minutes). Signifi cant bleeding (Hb drop more than 1.5 gm/dl) was in 5 %. All were managed conservatively without transfusion. DJ stents were kept in 16 patients. Nephrostomy-tube was not kept in any patient. Eleven percent of patients had minor complications like pleural eff usion (2%), UTI-fever (4%), and Mild hematuria (5%). All were managed conservatively. One patient required conversion to Miniperc-18 Fr track due to intraoperative poor vision. Mean hospital stay was 2 days (1-4 days). Th ree patients required readmission for fever or clot colic. Stone-free rate was 92%. Eight percent had small fragments that were treated by oral hydrotherapy. Two patients were treated by ESWL. 

Introduction and Objective: A prospective randomized controlled study was executed to compare minipercutaneous nephrolithotomy (miniperc) and retrograde intrarenal surgery (RIRS) in the management of renal stones larger than 10mm in a single session.

Between June 2014 and February 2015, 70 patients presenting with renal stones >10mm were randomized to a miniperc or a RIRS group in a ratio of 1:1. Randomization was performed by a biostatistician and opened to the surgeon at the time of the patient's admission on the day before surgery. Patient and stone characteristics, perioperative outcomes, and complications were compared between the two groups. Th e primary end point was "Stonefree", which was defi ned as no residual stone or stones <2 mm on computed tomography within 3 months postoperatively.

Results: Th irty-fi ve patients (miniperc) and 33 (RIRS) were included in the fi nal analysis. Th ere were no statistically signifi cant diff erences in stone size (39.1 ± 30.7 versus 28.9 ± 17.5 mm, P=0.102) and stone number (4.71 ± 6.29 versus 2.54 ± 2.56, P=0.067) between the miniperc and RIRS groups. Laterality, mean Hounsfi eld units, stone location, presence of staghorn stone, and stone composition were similar between the both groups (P>0.05). Miniperc and RIRS had stone free rates of 85.7% and 97.0%, respectively (P=0.199). Operation time (76.1 ± 70.6 versus 99.6 ± 60.8 minutes, P=0.148), hemoglobin drop (0.69 ± 0.98 versus 0.38 ± 0.97 g/dL, P=0.323), and hospital stay (1.6 ± 1.1 versus 1.5 ± 0.9 days, P=0.728) were similar between the two groups. Pain visual analogue score at 1 hour postoperatively (4.2 ± 2.6 versus 5.7 ± 3.0, P=0.029) and analgesic requirement (31.4% versus 57.6%, P=0.050) were lower in the miniperc group. Two patients in the miniperc group and 1 in the RIRS group had minor pelvic or ureter perforation. One patient in each of both groups had hypertension and urinary tract infection.

Miniperc and RIRS are safe and feasible surgical options for managing renal stones larger than 10mm. RIRS had a little higher stone free rates, but more immediate postoperative pain and higher analgesic requirement compared with miniperc.

Colonic Perforation during Percutaneous Nephrolithotomy

Darabi Mahboub M, Aslzare M, Shakiba B

Introduction and Objective: Percutaneous nephrolithotomy (PCNL) is the treatment of choice for large, extracorporeal lithotripsy failure stones and those in the inferior calyx. Despite the development of new techniques and the increasing experience in recent decades, complications may still occur. Colonic perforation is one of the most dangerous and rare complications of PCNL, which may lead to peritonitis and sepsis. We present our 18-year experience on the diagnosis and management of colonic perforation during PCNL.

We retrospectively reviewed the data of 5260 PCNL procedures performed between May1995 and August 2013. Preoperative and operative factors, such as age, sex, history of previous ipsilateral stone intervention, stone side, stone location, site of skin puncture and punctured calyx, were reviewed in patients with colonic injury.

Results: Colonic perforation was found in 11 patients (5 males and 6 females) and the mean age was 40.4 ± 22.2 years (range: 4 to 71). All injuries were retroperitoneal. Th e left side was aff ected in 5 patients and the right side was injured in 6 cases. Conservative management was the treatment planned for all patients. It included withdrawal of the nephrostomy tube outside the kidney to the colon as a percutaneous colostomy, insertion of a double-J ureteral stent, intravenous broad-spectrum antibiotics, bowel rest and total parenteral nutrition. Under this conservative management, complete healing of the colon was achieved in all patients.

Early diagnosis and conservative management of colonic perforation can minimize patient morbidity and mortality and result in excellent healing of the fi stulous tract without any serious complications.

Colon Materials and Methods: During ten years, 6480 PNL procedures performed in our center. Extraperitoneal Colonic perforation complicated 11 procedures. All cases were managed without any tube in the colon. We took a retroperitoneal drain through PNL tract and a Double-J stent inserted in all cases. We reported the results of our 11 cases that managed without colostomy tube.

Results: Male to female ratio was 9/2. Th e diagnosis was established aft er nephrostomy tract dilation and nephroscope insertion before lithotripsy in two cases and in 9 other cases, at the end of nephrolithotomy during amplatz sheath removal. Conservative treatment was successful in all cases. Mean hospital stay was 5/7 days. Th ere wasn't any fever or other major complication.

Conclusions: It seems that management of retroperitoneal colonic perforation when diagnosed intraoperatively during Tubeless PNL without colostomy tube is safe and eff ective.

Does Intercostals Nerve Block and Peritubal Nerve Block with Bupivacaine Reduce Post-Operative Pain after Percutaneous Nephrolithomy?

Introduction and Objective: To fi nd the most eff ective post-operative analgesia method aft er percutaneous nephrolithotomy (PCNL).

In a prospective, 18-months duration study all patients undergoing PCNL (tubeless or with 24-F nephrostomy) were divided into 3 groups. Group 1 (PCNL in fi rst-6-months) had no intervention; Group 2 (PCNL between 7 and 12 months) received intercostal block (ICB) with 0.25% bupivacaine; Group 3 (PCNL in last 6-months of study) had peritubal track infi ltration (PTI) with 0.25% bupivacaine at end of procedure. Visual analog pain scores and rescue analgesia requirements at 3,6,12 and 24 hours in the 3 arms were compared.

Results: See Table 1 .

Conclusions: Peritubular tract infi ltration with bupivacaine established its superiority over both intercostal block and standard PCNL for post-operative analgesia and rescue analgesic requirements.

The Post-operative fever was defi ned as body temperature above 38.5 within hospital stay. Relationship between clinical factors and SIRS or post-operation fever was assessed using logistic regression analysis.

Results: A total of 110 male (67.1%) and 54 female (32.9%) were enrolled in our study (Table 1) . Forty-fi ve cases (27.4%) developed SIRS and fever was observed in 20 cases (12.2%). Shock was observed in 9 (5.5%) cases. In univariate analysis, stone size (p = 0.012) and urine WBC (p = 0.001) were found to be the predictors of SIRS. In multivariate logistic analysis, stone size (or=1.48, p=0.009) and urine WBC (or=1.00, p=0.007) were signifi cantly related to the development of SIRS (Table 2 ). In univariate analysis, post-operative fever was found to be associated with the location of stones (p=0.012), stone size (p=0.016), Urine WBC (p<0.001) and albumin (p=0.018). By multivariate logistic regression analysis, only stone size (or=1.62, p=0.024), urine WBC (or=1.00, p=0.002) and serum albumin (or=0.79, p=0.009) were associated with post-operative fever (Table 2) .

Conclusion: Patients with larger stone size and urinary tract infection before surgery might have higher risk of developing SIRS and fever, while a normal serum albumin was found to be the protective factors of fever development. 

Introduction and Objective: Perioperative hemorrhage owing to high vascularity in BPH is the fearsome complication of TURP that leads to clot retention, reoperation and oft en requiring blood transfusion. Finasteride, a type 2 5α-reductase inhibitor, by interacting with vascular endothelial growth factor (VEGF), reduces prostatic angiogenesis. Microvessel density (MVD) is a histological measurement of angiogenesis and thus a marker of bleeding. We aim to determine the eff ect of two weeks preoperative fi nasteride therapy in reducing prostate vascularity in terms of mean microvessel density (MVD) and expression of VEGF in prostate urothelium among patients of BPH by comparing with controls.

Trial has been conducted in Department of Urology at Shifa International Hospital Islamabad from Jan 2013 to Jan 2014. Total 80 patients of benign prostatic hyperplasia (BPH) planned for transurethral resection of prostate (TURP) having prostate sized of more than 40 grams on trans-abdominal ultrasonography were randomized into two groups each group having 40 patients. Th e Finasteride group (Group A) was prescribed oral 5mg of fi nasteride daily for 2 weeks before surgery. Th e control group (Group B) didn't receive any drug. Aft er 2 weeks, TURP was performed and prostate chips were sent for histopathological determination of MVD and expression of VEGF.

Results: Mean age 66.21±10.08 years, ranging from minimum of 48 years to 86 years. Th e mean prostate gland size was comparable in both groups (55±10.7 grams vs. 58.1±10.8 grams). Mean MVD in fi nasteride group was 20.25±10.3 whereas in control group mean MVD was 48.9 ±22.6. When compared the mean MVD in both group, the mean MVD was signifi cantly low in fi nasteride group as compared to control group with a P= <0.0001. Similarly mean expression of VEGF was 30% in fi nasteride group compared to 65% in control group. Th is expression of VEGF was also signifi cantly lower in fi nasteride group as compared to control group (p= 0.0017). Also mean MVD was clearly correlated with size of prostate gland and the correlation was found statistically signifi cant on Pearson correlation test (2-tailed) with p= 0.04.

Conclusion: Finasteride reduces microvessel density and hence prostate vascularity with only 2 week therapy and the mean MVD is clearly correlated with size of prostate.

Characteristics 5-Alpha Reductase Inhibitor Induced Prostate Volume Reductions

Yun J 1 , Yang H 2 , Kim D 2 , Jeon Y 2 , Lee C 2 Introduction and Objective: Benign prostatic hyperplasia develops in the transition zone of the prostate and 5α-reductase inhibitors (5-ARIs) reduce prostate volume. We investigated whether oral treatment with the 5-ARIs dutasteride and fi nasteride more significantly aff ected volume reduction in the transition zone or in the entire prostate.

Total prostate and transition zone volumes (TPV and TZV) were measured at baseline using a transrectal ultrasound (TRUS) and then at 1 yr aft er the commencement of dutasteride (0.5 mg) or fi nasteride (5.0 mg). Th e ratio of TPV to TZV was used to determine the transition zone index (TZI). Volume reduction (%) was calculated as the ratio of volume reduction to baseline prostate volume. Additionally, serum prostate specifi c antigen (PSA) concentrations were measured at baseline and then at 1 yr aft er the 5-ARI were commenced.

Results: All of the 43 patients (mean age, 68.5 yr ± 7.2; range, 53-82 yr) with clinical lower urinary tract symptoms suggestive of benign prostatic hyperplasia and who were 5-ARI naïve were prescribed dutasteride (0.5 mg, 74.4 %, 32/43) or fi nasteride (5.0 mg, 25.6 %, 11/43) for more than 1 yr (13.5 ± 4.2 mos). At baseline, the mean TPV, TZV, and TZI values were 58.0 ± 25.6 cm 3 , 30.8 ± 16.6 cm 3 , and 0.52 ± 0.13, respectively. At 1 yr aft er the commencement of the 5-ARI, the mean TPV, TZV, and TZI were 48.0 ± 23.5 cm 3 , 28.1 ± 19.0 cm 3 , and 0.55 ± 0.13, respectively. Th e TZI value is not signifi cantly diff erent at 1 yr compared with baseline (p > 0.05), while the TPV and TZV reductions are 22.7 ± 15.2 % and 27.2 ± 16.8 %, respectively; there is no signifi cant diff erence between the TPV and TZV volume reductions (p>0.05).

Conclusion: Th ese results show that prostate volume reduction induced by 5-ARIs occurs in the entire prostate universally, rather than in the transition zone specifi cally.

Russo G, Favilla V, Privitera S, Castelli T, Fragalà E, Cimino S, Morgia G

Introduction and Objective: Combination therapy with of 5-alpha reductase inhibitors (5-ARI) and alpha-blockers (AB) is the gold standard for the treatment of moderate-severe secondary to benign prostatic hyperplasia (BPH). Several clinical trials have already analyzed the overall impact of the medical treatment of LUTS/BPH on sexual sphere, but any one investigated the overall impact on erectile dysfunction (ED) and libido alterations (LA). Th e aim of this this systematic review and meta-analysis was to evaluate the impact of combination therapy on ED and LA from randomized clinical trial (RCT).

We performed a search of the Cochrane Central Register of Controlled Trials, PubMed, EMBASE, Cochrane Database of Systematic Review, and Web of Science, until December 2014. We conducted a meta-analysis to determine the impact of combination therapy (5ARI + AB) in determining the onset of ED or LA. A p value <0.10 was used to denote the presence of heterogeneity.

Of the 103 studies reviewed, only fi ve RCT were included, involving 6131 participants. Th e overall prevalence of erectile dysfunction was of 7.93%, 4.66% and 6.47% in patients treated with combination therapy, 5ARI and AB respectively. Th e overall prevalence of altered libido was of 3.69%, 3.37% and 2.37% in patients treated with combination therapy, 5ARI and AB respectively. Combination therapy 5ARI + AB was found to be associated with increased risk of ED (OR = 1.81; p <0.00001) and LA (OR = 1:58; p = 0.03) compared to monotherapy with AB. Th e combination therapy was found to increase the risk of ED (OR = 1.25; p = 0.04) compared to monotherapy with 5ARI, but not the risk of LA (OR = 1:03; p = 0.84).

Analyzing the individual monotherapies, therapy with alpha-blockers signifi cantly reduces the risk of ED (OR = 0.70; p <0.01) and LA (OR = 0.67; p = 0.01) compared to treatment with 5ARI.

Conclusions: Combination therapy 5ARI + AB is associated with a higher risk of ED. In addition, 5ARI monotherapy has the same risk of the combination of having LA. Th ese results could be taken into account during the counseling therapy in patients with LUTS/ BPH. 

Mladenov B, Mariyanovski V

Introduction and Objective: BPH bleeding is one of the common causes of gross hematuria in older men. 5-alpha reductase inhibitor (5ARI) treatment has been showed to reduce prostate tissue microvascularity and to prevent BPH-associated hematuria. Alpha-blockers are oft en prescribed, where their eff ect on hematuria is not well evaluated. Th e aim of this study was to investigate the impact and effi cacy of the current used drugs for BPH for treatment and prevention of BPH-caused hematuria.

A total of 119 men with median age of 69 were enrolled for a period of 2 years. All were presented with BPH-caused macrospopic hematuria, diagnosed according to an adopted investigation protocol. Detailed history was obtained, including usage of alpha-blockers and/or 5-ARI prior to the hematuria episode. Patients were released or immediately hospitalized and catheterized according to their status. All patients were followed up for 1 year for recurrent bleeding and were divided into 3 groups -with an alpha-blocker, 5-ARI, or without therapy.

In this study 82 patients were sent home and treated conservatively, other 37 with severe bleeding and/or clot retention necessitated catheterization and hospitalization. From 119 patients 22 (18%) were taking alpha-blockers, 9 (8%) 5-ARI, and 88 (74%) had no medications for the BPH prior to the hematuria. Patients were followed up for recurrent bleeding for 1 year in 3 medication groups. 39 were given alpha-blockers, 38 -5-ARI and 42 were released without medication for the BPH. Within 1 year BPH-bleeding occur respectively in 11, 5, and 14 cases. Th ere was a statistically signifi cant diff erence between the group with 5-ARI therapy and the group without therapy (p=0.001). No statistically signifi cant diff erence (p=0.075) was found between the groups with an alpha-blocker and without therapy. In all cases with medication the hematuria episodes were lighter according to blood loss and/or hospital stay (in days) than the initial one.

Conclusions: According to our study, BPH-associated hematuria can be eff ectively controlled and reduced with 5 ARI. Although as per our data alpha-blockers have a positive eff ect on the intensity of the recurrent hematuria, much more signifi cant results in treating and controlling BPH-bleeding are shown with 5-ARI.

Effi Overactive bladder syndrome (OAB) is a common condition with a negative impact on quality of life. Botulinum toxin is commonly used. Despite the favorable outcomes seen using Botulinum toxin A, the method of injection and side eff ects still need to be solved. Our aim is to use Botulinium toxin with simple method and check its safety and effi cacy.

A total of 82 patients with refractory OAB were included in this study. Inclusion criteria was refractory non neurogenic OAB not responding to conservative management for at least 3 months. Aft er written consent, Patients were randomly divided into two groups. Group A (45 patients) received Botulinium toxin A 100 unit intravesical instillation diluted in 50 cc normal saline, Group B (37 patients) received placebo in the form of 50 cc normal saline by the same method. Patients were evaluated initially by history, physical examination, overactive bladder symptom score (OABSS), quality of life symptom score (QOLSS), urine analysis, routine Laboratory investigations, KUB, Pelviabdominal ultrasound and urodynamics. Patients were followed up at one, and two month post instillation for effi cacy and safety by OABSs, QOL score, side eff ects and postvoid residual urine. Introduction and Objective: Th e authors evaluate the safety and effi cacy of the prostatic urethral lift when performed in conjunction with a second procedure.

In this retrospective study, 19 patients underwent the prostatic urethral lift between January 2014 and November 2014. Sixteen patients received the prostatic urethral lift as a single procedure and the mean patient age for this group was 65 years (range 39 to 86). In the remaining 3 patients, a second procedure was performed in conjunction with the prostatic urethral lift . Th ese 3 procedures were: Th ulium laser enucleation of the middle lobe, optical urethrotomy and bladder neck incision.

Results: In patients who were treated with the prostatic urethral lift as a single procedure the mean international prostate symptom score was 18.4 (range 14 to 26) and mean maximum urine fl ow rate was 10.9mLs-1 (range 5 to 19). Th e average prostate volume was 47cc (range 26 to 79) and mean quality of life rating was 3.9 points (range 3 to 5). At 6 months aft er the procedure, the mean international prostate symptom score improved by 7.2 points (40%), mean maximum urine fl ow rate by 5.6mLs-1 (51%) and mean quality of life rating by 1.9 (49%). Th e improvements achieved in the 3 combined procedures were greater than the patients who underwent the prostatic urethral lift as a single procedure. Th ere was one case (5%) of postoperative moderate pelvic pain which was managed conservatively with a nonsteroidal anti-infl ammatory drug. A urinary tract infection occurred in one case (5%) and resolved aft er treatment with an antibiotic. Th ere were no complications in the combined procedure cases. No patients reported any decline in erectile function, retrograde ejaculation or dysejaculation.

Conclusion: Th e prostatic urethral lift is a safe and eff ective treatment for lower urinary tract symptoms secondary to benign prostatic hyperplasia while preserving sexual function. In carefully selected patients, the performing the prostatic urethral lift in conjunction with a second procedure may achieve superior results with no major complications.

Evaluation . We sought to evaluate the effi cien-cy, safety and outcome parameters between Green-Light PVP and VIT.

Data of 955 XPS cases were retrospectively collected from 5 experienced surgeons at high volume GreenLight XPS centers. Preoperative, operative and post-operative parameters were collected and compared between groups. PVP was defi ned as pure vaporization only while VIT included techniques to incise into adenoma and allow tissue resection and removal.

Results: As summarized in Table 1 , men undergoing VIT (n=283) had larger prostate size, higher IPSS∕QOL and retention preoperatively than those undergoing PVP (n=672). While VIT allowed greater delivery of energy (4.9 vs. 3.5 kJ∕g), operative time was longer and had greater need for >2fi bres. Th ere were no diff erences in intra and post-operative adverse events. While no diff erences were observed in IPSS∕QOL at 6 months post-operatively, more favorable QMax and PVR were observed at 6months, along with greater PSA reduction, in the VIT group.

Preoperative Patient characteristics Introduction and Objective: To prospectively evaluate at two years, the quality of life (Qol) and satisfaction of subjects randomized to either GL-XPS or TURP for LUTS/BPO.

A total of 291 patients at 29 sites in 9 European countries who were candidates for surgical relief of BPO were randomised 1:1 to undergo GL-XPS or TURP. Subjects had IPSS scores >12 and prostate volumes <100mls. Multiple self-administered patient questionnaires were assessed from baseline to 2 years via: 1) A General health status EQ-5D-3L questionnaire (index score and visual scale); 2) Physical and mental health (SF-36 Physical Health and SF-36 Mental Health scores); 3) Erectile function and ejaculatory status (IIEF-5 questionnaire); 4) Urinary continence via OABq-SF symptoms, OABq-SF health and ICIQ-UI SF; 5) Overall satisfaction: willingness to undergo the procedure gain or 6) recommend to a friend. Table 1 and subject satisfaction at 2 years is shown in Figure 1 .

Conclusions: Th ere is a statistically similar improvement in Qol with GL-XPS and TURP at 2 years. Erectile function is not aff ected by GL-XPS or TURP and both result in a 70% risk of retrograde ejaculation at 2 years.

Functional 

Introduction and Objective: Technology for photoselective vaporisation of the prostate (PVP) has evolved in recent years. We report our early experience of PVP with the GreenLight™ 180-W XPS and assess our institutional learning curve for this technique.

We performed a retrospectively analysis of our fi rst 150 patients undergoing PVP using the GreenLight™ 180-W XPS over a twoyear period. Data was collected on demographics, prostate volume, length of stay, time to trial of void, and complications. Complications were graded according to the Clavien classifi cation system. Th e operative learning curve was analysed via various intra-operative lasering variables including the total delivered energy, total vapourisation time (VT), and vapourisation time/operation time (VT/OT). Th e study population was divided into three consecutive equal groups and the three groups were compared.

Results: Mean age was 68. Mean length of stay was 1.6 days. Mean prostate volume was 65cc. Twenty-fi ve percent were on some form of anticoagulation. Twenty-one percent were in-dwelling catheter-dependent preoperatively. Th e median duration to removal of in-dwelling catheter was 1 day. Seventy-six percent had a successful trial of void on Day 1. Th e overall complication rate was 15%, the vast majority of which were Clavien Grade I or II. Th ere were no statistically signifi cant diff erences between the groups in terms of age or prostate size. Over time, there was a statistically signifi cant decrease in OT and increase in VT/OT but no diff erences in complication rates, time to trial of void or length of stay as experience increased.

Conclusion: Greenlight laser PVP using the 180-W XPS is a safe and effi cient treatment option for benign prostatic hyperplasia, with minimal bleeding and low complication rates. Our data suggests that a learning curve exists for this procedure in terms of intra-operative lasering variables with no statistically signifi cant increase in post-operative complications or length of hospital stay during this period.

Tillou X, Le Gal S, Chahwan C, Oitchayomi A, Doerfl er A

Introduction and Objective: To compare results of PVP (Photoselective Vaporisation of the Prostate) in elderly patients to those observed in younger male patients taking into account the presence of an indwelling bladder catheter.

We performed a review of our prospectively maintained database between December 2012 and March 2015. A total of 123 patients were operated for LUTS related to HBP. Th ree groups were fi rst established to compare results of PVP in elderly male patients. We then analyzed the impact of an indwelling bladder catheter by comparing two groups of patients under and above 70 year-old.

Results: Th ere were no diff erences between groups for BMI, neurological disorder or hypertension history, aspirin treatment, IPSS, QoL and preoperative PVR (Post Void Residual). Patients above 75 years old had statistically more heart diseases (p=0.0001) and had more anticoagulant treatments (p=0.05). Prostate volume increased with aging (p=0.047), which resulted in an increased procedure time (p=0.05) and an increased amount of energy delivered (p=0.04). For postoperative outcomes, there were no diff erences between groups for bladder catheter removal time, IPSS, QoL, PVR, and surgical complications. Postoperative Qmax was statistically lower for patients above 75 years old (p=0.04) but with a decreased diff erence compared to preoperative measurements (p= 0.0001).

In the group without an indwelling catheter, postoperative catheter time was signifi cantly longer in patients over 70 years (p=0.016) with a greater PVR (p=0.03). Urofl owmetry and IPSS voiding were signifi cantly improved in both groups without diff erences. Th ere was no diff erence for early or late postoperative complications. For patients with an indwelling catheter, for all parameters studied, no statistically signifi cant diff erences were found except higher post-operative PVR in patients older than 70 year-old.

Conclusions: PVP is an effi cient and safe procedure in elderly male patients despite more heart diseases and anticoagulant treatments. With or without a previous indwelling bladder catheter, functional outcomes were identical whatever age. Introduction and Objective: Th e procedure of HoLEP has steep learning curve and more than 30 cases are needed for overcoming the curve. Th e objective of our study is for identifying the detailed steps in improving skills during learning curve.

Total 90 patients who underwent HoLEP in single center were included in the study. Th e operation was performed by 3 surgeons who were experienced TUR-P more than 200 cases. Patients were divided into 3 groups. Groups were initial 10 cases (Group 1), mid 10 cases (Group 2), and later 10 cases (Group 3) in each surgeons. Th e enucleation time, morcellation time, the amount of energy use, diff erential count of hemoglobin between pre-and post-operation, post-operative urofl owmetry parameter were compared between each group. Especially, enucleation time was divided into 2 diff erent steps, which was action time that was actual use of laser energy or dissecting prostate tissue using cystoscopy and identifi cation time was time for identifying anatomical structure without any procedure.

Results: Mean ages was 70.31 years old and mean BMI was 23.90kg/m2. Mean PSA was 5.89ng/ml and mean prostate volume was 68.97cc. Th ere were no signifi cant diff erences in baseline characteristics in preoperative data. Aft er 10 cases (Group 2), there was less use of laser energy, less time consuming for morcellation and identifi cation compared to Group 1. Identifi cation time was signifi cantly improved than Group 1 and more shortening feature as cases added but had no signifi cant diff erence. Aft er 20 cases (in groups 3), there was more signifi cant diff erence in all operative parameter. Especially morcellation time was signifi cantly improved aft er 20 cases. Th ere was no signifi cant diff erence in post-operative urofl owmetric parameters.

Conclusion: In initial experience, it seemed to be overcoming one step about identifying surgical anatomy in learning curve aft er 10 cases. Especially, 20 cases were optimal cases for overcoming learning curve for morcellation. Aft er 20 cases, we did not overcome the learning curve but all operative parameter was improved.

Transrectal Ultrasound as an Intraoperative Tool in the Identifi cation of the Plane of Dissection during HoLEP Procedure

Introduction and Objective: Holmium Laser Enuclation of the Prostate (HoLEP) has been named since 2013 as the potential gold standard of treatment for bladder outlet obstruction as a consequence of benign prostatic hiperplasia. One of the most important steps during procedure is to identify the plane of dissection between the adenoma and periferic zone. In this study we demonstrated the utility of transrectal ultrasound in the identifi cation of this surgical plane during Ho-LEP for novel surgeons.

Materials and Methods: Previews informed concerned, we preform transrectal ultrasound during HoLEP of 5 patients, using the 8880 proved of the 800 Flex Focus ultrasound system of BK medical, obtaining images of the prostate as a method to simplify the identifi cation of the surgical plane. We preformed HoLEP as a standard method with Storz endoscopic instruments using 26fr resectoscope with a Kunts element and with the 100 watts holium laser power suite from Lumenis,

We obtained images of the fi ve patients in real time with axial and sagital planes simultaneously, clearly helping the surgeon to identify the surgical dissection plane between the adenoma and the peripherical zone.

Conclusions: Transrectal ultrasound could be a useful tool during the training of novel surgeons in HoLEP technique.

Introduction and Objective: Th e Aristolochia family of herbaceous plants has been used worldwide for traditional medicinal purposes for more than two centuries. Th ese plants contain aristolochic acid (AA), a powerful nephrotoxin and human carcinogen, which, in susceptible individuals, causes chronic kidney disease and/or upper urinary tract urothelial carcinoma (UTUC). Bioactivation of AA yields a reactive intermediate that binds covalently with DNA to form aristolactam (AL)-DNA adducts. In the urothelium, these adducts give rise to a unique mutational signature. As there are several reports of renal dysfunction in Japan associated with the use of AA-containing Chinese herbs, we hypothesize that a fraction of UTUC cases in this country may result from past use of Aristolochia herbs.

Patients with histologically confi rmed UTUC who underwent nephroureterectomy in Kyushu University aft er August 2011 were eligible for this study. Informed consent was provided by each participant prior to surgery. Surgical specimens of tumor and renal cortex were snap-frozen following nephroureterectomy. DNA was isolated from renal cortex and analyzed for the presence of AL-DNA adducts using either mass spectrometry or a 32P-postlabelling method. DNA isolated from matched tumor samples was subjected to mutational analysis of the tumor suppressor gene TP53.

Results: Th irty three UTUC patients were enrolled in this study between August 2011 and March 2014, 22 males and 11 females, with a mean age of 73 years. AL-DNA adducts were detected in 2 of 33 renal cortex samples (6.1%) analyzed; adduct levels were 0.26 and 1.0 per 108 deoxynucelotides. Sequencing analysis of TP53 in tumor DNA revealed the absence of the unique mutational signature associated with AA.

Conclusion: AA exposure was confi rmed in two UTUC patients; however, in these two cases, the mutational profi le of TP53 in tumor DNA was not consistent with AA-induced carcinogenesis. Further accrual and analysis of UTUC cases are needed to estimate the prevalence of AA exposure in Japan, to evaluate the role of AA exposure to UTUC in this country, and to confi rm the public health implications of these fi ndings.

Preoperative Introduction and Objective: Our aims are to assess the association between upper urinary tract urothelial carcinoma (UUTUC) development and the polymorphisms in the Aurora kinase A (AURKA) Phe31Ile (rs2273535) and survivin rs1042489C>T genes.

A total of 186 patients with UUTUC and 187 hospital controls with bladder stones were recruited in this study. Clinical records, demographic data, and possible confounding factors were collected using a standardized questionnaire.

Genotyping was determined using a real-time polymerase chain reaction using Taqman probe.

Results: Signifi cantly more controls than patients with UUTUC drank alcohol and tea, but there were no diff erences in the frequencies of cigarette smokers and coff ee drinkers. AURKA Phe31Ile gene polymorphisms, but not survivin rs1042489C>T gene polymorphisms, were associated with UUTUC development (χ2 test and multivariate logistic regression) (χ2=3.88, P=0.048; crude OR=2.06, 95% CI=1.01-4.40; adjusted OR=2.67, 95% CI = 1.07-6.94). Stratifi cation analysis and multivariate logistic regression analysis showed that only the association between AURKA Phe31Ile gene polymorphisms and UUTUC development were diff erentiated between those with and without the habits of smoking, tea drinking, or coff ee drinking.

Conclusion: Our major fi ndings supported that AUR-KA Phe31Ile gene polymorphisms, but not survivin rs1042489C>T gene polymorphisms, increase genetic susceptibility to UUTUC.

Metastatic and has thereaft er stabilized around 50%. Th ere was a regional variation in the proportion of patients who underwent CN between 42% and 59%. Th e relative survival at fi ve years was 24% aft er CN compared to 4% in patients who did not undergo CN (p<0.05). Th e median age of the M1 patients who underwent CN was 66 years compared to 71 years in patients who did not undergo CN. Tumor recurrence, aft er initial treatment with curative intention in primary M0 patients, was 20% aft er fi ve years. Th e location of the metastases were: lung 56%, bone 21%, lymph nodes 21%, liver 16%, adrenal 7% and brain metastases in 5% of the patients. Th irteen percent of the patients suff ered local recurrence in the renal fossa aft er nephrectomy. Th e most common treatment for patients with a recurrence was oncological medical treatment (49%). Metastasectomy was performed in 17% of the patients with recurrence and in 63% of the patients the surgery had a curative intention.

Conclusions: Th e incidence of metastases in renal cell carcinoma in Sweden is decreasing and is lower than in historical materials. Th e patients with synchronous metastases who undergo CN have a signifi cantly better survival than patients who do not undergo CN, but constitute a highly selected group. Recurrence after initial treatment with curative intention is treated surgically in 17% and oncologically in 49%.

Immediate 

Introduction and Objective: Pretreatment characterization of renal masses (RM) remain suboptimal with overtreatment being a signifi cant concern. We examined the ability of preoperative clinical characteristics to predict histological features of RMs.

In the Global Renal Mass Study conducted by the Clinical Research Offi ce of Endourology Society (CROES), data were collected for consecutive patients with renal masses who underwent surgery for clinical stage I renal mass between 2010-2011. Based on surgical histology, tumors were categorized as benign, low aggressiveness cancer, and high aggressiveness cancer. We assessed the ability of clinical (patient gender, age, smoking history, BMI), laboratory (preoperative hemoglobin and C-reactive protein) and radiographic (tumor diameter, location, exophytic rate and enhancement) characteristics to discriminate between benign and cancer (low + high aggressiveness) and between highly aggressive tumors and others (benign + low aggressiveness cancer). Multivariate logistic regression was used to estimate the probability of the histological group by clinical and radiographic features in the entire cohort and a sub group of cT1a tumor. Th e performance of the models was consequently studied by calibration, Nagelkerke's R2, and discrimination (ROC area under the curve).

Results: Th e study cohort included 2224 patients with clinical stage I renal mass of which 1367 (61%) had cT1a mass. Benign lesions were found in 369 (16.6%), low aggressiveness tumors in 1156 (52%) and high aggressiveness tumors in 699 (31.4%). Male gender, smoking history, increased tumor size, and lower exophytic rate were associated with malignancy and high aggressiveness features (all p-values <0.05). Models developed based on these characteristics had the ability to discriminate benign from malignant (bootstrap corrected c-index of 0.64) and high aggressiveness tumors from benign and low aggressiveness tumors (bootstrap corrected c-index of 0.66). Similar results were achieved in the cT1a subgroup. Th e c-index of tumor diameter as a single predictor of malignancy and high aggressiveness tumors in the entire cohort was 0.6 and 0.63, respectively.

Conclusions: Although older age, male gender, smoking history, increased tumor diameter and reduced exophytic rate are associated with malignancy and high aggressiveness of renal mass, models incorporating these characteristics have modest discriminating power, slightly better than the predictive ability of tumor size alone in clinical Stage I tumors.

Could Surgery Be Prevented in the Management of Small Renal Masses?

Introduction and Objective: Th e diagnosis, characterization and management of small renal masses (SRMs) remains an important clinical issue. A proportion of SRMs may be benign or have low malignant potential. Th ese lesions could arguably be managed non-operatively. Strategies such as renal mass biopsy may be valuable in reducing the rate of unnecessary surgery. We evaluated a large contemporary surgical series of resected SRMs in a tertiary center with a very low biopsy rate to determine the number of procedures that could have been prevented for benign and low malignant potential lesions. Conclusion: SBRT is a safe and effi cacious modality and appears to be well-tolerated at the dose fractionation we have used, and its use correlates with improved survival in this cohort of patients with RCC.

CyberKnife can deliver complex treatment plans to multiple lesions while minimizing irradiation to the surrounding healthy tissue, thereby decreasing the risk of complications. CyberKnife has the potential to be an excellent treatment modality for renal cancer patients with renal cell carcinomas or patients with bilateral renal cell carcinoma who refuse surgery or are medically inoperable.

Introduction and Objective: Th e introduction of the robotic surgical systems has changed the way both surgeons and patients view urological surgical procedures. We tested the same theoretical and tangible benefi ts for partial nephrectomy with Tele-Lap Alf-X system. We review our technique of robot-assisted laparoscopic partial nephrectomy performed using a new robotic telesurgical device (ALF-X) on swine large white/Landrace model.

We set up an operating theatre to test ALF-X on partial nephrectomy procedure to be performed on swine large white/Landrace in total anesthesia. Th e console incorporates the following main components: an ergonomic seat, the laparoscopic teleoperation master (LTM) with haptic handles, a 3D-HD monitor, an eye-tracking system (ETS), a keyboard and a touchpad, and one foot pedal. Th e ETS is an infrared-based eye tracking system that detects which point the surgeon is looking at. Th ere was one surgeon placed at computer-console and one surgeon placed at the surgical table. A random decision on the kidney to be tested is performed before the operation. Once the trocars are placed and the kidney isolated a period of warm ischemia is due to perform the partial nephrectomy on the lower or upper pole (random choice). Th e haptic sensation can be used for palpation, pushing or pulling to estimate elasticity and consistency of tissues and controlling the tensility of the sutures when tying. Low-cost disposable or reusable instruments were used.

Results: To date, we performed 7 partial nephrectomy with Alf-X robot on swine large white/Landrace (pigs) models. Th ree robot's arms were used. Five partial nephrectomies were on the right kidney, while 2 were on the left one. Th e mean surgical time was 32.4 minutes (range 45-18 min). Th e mean warm ischemia time was 9.4 min (range 7.4-12 min). Th e mean blood loss was 48.6 ml (range 20-90 ml).

Conclusions: According to these experimental experiences on pig models, we may assume that robot-assisted laparoscopic partial nephrectomy, using Tele-Lap Alf-X system, is safe, feasible and reproducible procedure. Moreover it off ers a good perception when instruments touch each other avoiding collision between robotic arms. We believe that robot-assisted tele surgery approach could be reasonable an innovative contribution in the near future also in humans. It also off ers a reduction of costs per intervention.

Preoperative Chronic Kidney Disease To reduce the eff ects of selection bias and potential confounding factors, 600 patients in non-CKD group were selected by propensity score matching.

Results: Th e median age of all patients was 57.3 years (range, 20-94 years) and the median follow-up was 35.0 months (range, 1-154 months). Comparisons of the propensity score-matched cohorts showed that T and N stages were more advanced and the tumor size was larger in the CKD than in the non-CKD group (p < 0.05 each). Kaplan-Meier analyses showed that recurrence-free survival (RFS), cancer-specifi c survival (CSS), and overall survival (OS) were signifi cantly lower in the CKD group (p < 0.01 each). Multivariate regression analysis showed that preoperative CKD status was an independent predictor of CSS and OS in patients with RCC (p < 0.05 each).

Conclusion: Preoperative CKD may be associated with more aggressive features and poorer prognosis in patients with RCC. RCC patients with preoperative CKD should be followed up frequently and carefully aft er nephrectomy. .0014) were independent prognostic factors. Bone-modifying agents (zoledronic acid and denosumab) were not associated with OS. Th e median OS of patients receiving molecular-targeted therapy aft er diagnosis of bone metastasis was signifi cantly better than that of those who did not receive targeted therapy (16.0 vs. 9.0 months, p=0.0118).

Our study suggests that molecular-targeted therapy prolongs survival of RCC patients with bone metastasis. Th us, molecular-targeted therapy, nephrectomy and surgery for bone metastasis should be considered for these patients.

Introduction and Objective: Ureteric stenting for urinary tract obstruction secondary to malignancy may off er a survival benefi t and buy time for oncological management. Since the introduction of the ureteral stent symptom questionnaire (USSQ), studies have revealed that up to 80% of patients with ureteric stents for benign conditions experience stent related symptoms that interfere with daily activities and reduce quality of life. Our aim was to evaluate stent symptoms in patients with malignant obstruction and their impact on health related quality of life.

Patients with indwelling ureteric stents for malignant obstruction were identifi ed from the departmental stent register during a March to June 2014. Telephone interviews and face to face interviews at the time of stent change were conducted using the validated USSQ. Results were analysed according to the questionnaire scoring system.

Results: Twenty patients with a mean age of 73 years completed the USSQ. Of these patients 55-65% reported bothersome urinary symptoms that included storage symptoms, incontinence and haematuria. Fifty percent of patients experienced stent related pain in the fl ank (6/10), suprapubic (4/10) and groin area (4/10). Fift y percent of these patients required regular analgesia and 50-70% experienced pain interfered with activities and daily life. Seventy percent of patients experienced diffi culty in performing physical activities, with a negative impact on social life. One out of 20 patients reported sexual dysfunction. Eighty fi ve percent experienced urinary tract infection (UTI) with 25% having a UTI most or all of the time and 45% requiring admission to hospital. Mortality within one year of stent insertion was 30%.

Conclusion: Ureteric stents are associated with signifi cant debilitating symptoms and reduced quality of life in patients with malignant obstruction. Th is has signifi cant implications for management of cancer patients and patient counselling. Ureteric stenting can prevent death from malignant obstruction, but may result in prolonged suff ering due to stent symptoms without benefi t in overall survival.

Introduction and Objective: Management Pheochromocytoma Laparoscopic was initially controversial because of the possibility of adrenergic discharge with the generation of the pneumoperitoneum. Th e work of a proper medical preparation and anesthetic precise control obvious that circumstance and allows more precise surgery and a better image as it gives the laparoscopy to get with much less aggressive surgical removal. Our goal is to present the preparation and the key points in its approach.

We present 66-year-old male with recent diagnosis prostate cancer and high pressure treated with 2 drugs. Discovery of left adrenal mass of 5 cm. in CT and MRI and scintography with MIBG suggestive focus of pheochromocytoma in the adrenal gland. Twenty-four-hours urine: total Catecholamines: 164.5 ug/24 (14-110) adrenaline: 94.7 ug/24 hours (2d-23); Normetanephrines 2442 ug/24 (120-650), Metanephrines: 6631 ug/24 (50-350). Vanilvandelico 11.7 ug/24 (1-10). Preparing medical / anaesthetic consisted: entry 3 days before surgery and control alpha-blockers with Doxazosin every 12 hours. Treatment with beta-blockers with propranolol. Expansion of intravascular volume with intravenous fl uid therapy 12 hours before surgery. And control of blood glucose levels. Intraoperatively crisis were treated with Nitroprusiate.

Results: Aft er adrenalectomy laparoscopic left with a length of 110 minutes and adequate control pressure intraoperative the pathology diagnosis was of Pheochromocytoma. Postoperative attended without incident (Clavien I) and went out Hospital to the 48 hours.

Th e presence a Pheochromocytoma should not be a contraindication to laparoscopic approach of the adrenal gland in services experienced laparoscopic, and must be an exhaustive control of anesthetic, as well as a careful dissection of the gland trying to avoid excessive manipulation of the same.

Robotic Assisted "Davinci" Adrenalectomy

Al-Ansari A, Younes N, Al-Rumaihi K, Al-Jalham K, Gul T, Badawi A, Kamkoum H

Introduction and Objective: Adrenal mass could be challenging, especially when it is large in size or cystic, Adrenal had short and variable vasculature, in addition to functional adenoma, Adrenal surgery require minimal handling. Robotic assisted adrenalectomy (RA) had been proven to be safe and eff ective. Objectives: To describe robotic adrenalectomy (RA), to ensure a safe and eff ective removal of complex adrenal mass.

We reviewed the record of 10 consecutive patients who underwent RA performed by a single surgeon, between January 2012 and January 2015, fi ve were right and fi ve were left , 6 were solid and 4 were cystic, none were functional adenoma patients position and port placement were similar to renal surgery, aft er control of the renal vein the gland was dissected, small arteries were clipped and the gland were removed.

Results: Patients were 6 females and 5 males, age range between 23 to 66 years mean tumor size was 7.5 cm range (3.5-10 cm), mean hospital stay was 4 days, no perioperative complications, all masses were intact, one postoperative Addisonian crisis Pathology was benign 3 cyst, 2 adenoma, 2 ganglionuroma, 1 neuroendocine, 1 adrenal hyperplasia, 1 adrenocortical neoplasm of low malignant potential.

Conclusion: Robotic Adrenalectomy is safe and feasible in the management of complex adrenal mass.

Robotic Materials and Methods: Th e girl was in a good general health and came walking to our out-patients department. She was admitted and her investigations reviewed. She had a right renal mass with cavo-atrial extension with an isolated embolus in the pulmonary artery. She was planned for a complete excision under cardio-pulmonary bypass with deep hypothermic circulatory arrest. Under general anaesthesia, aft er establishing complete monitoring, she was opened by long midline laparotomy and mid-sternotomy. Mid-sternotomy extension was done up-front in-view of the pulmonary embolus. An incision was made in the posterior peritoneum medial to the inferior mesenteric vein. Th e right renal artery was dissected posterior to the left renal vein, ligated and divided. Suddenly her end tidal carbon-di-oxide fell. Th e video demonstrates the trans-esophageal echo-cardiography confi rming fragmentation of the cavo-atrial thrombus and its migration into the right ventricle and main pulmonary artery. Th e patient was immediately put on cardio-pulmonary bypass. Initially the venous return was low. She was rapidly cooled to 18 degrees centigrade and aorta cross clamped just above the diaphragm. Arterial infl ow was reduced to 1 litre per minute to main blood fl ow to the brain. Th e video demonstrates opening, clearing and repairing of the right atrium, right ventricle and main pulmonary artery in a step by step approach. Th e branches of the pulmonary artery were cleared with Fogarty's catheter. Right radical nephrectomy was completed and IVC cleared and repaired. Th e total circulatory arrest time was 32 minutes. She was slowly re-warmed and taken off cardio-pulmonary bypass.

Results: Her post-op recovery was uneventful. Th e fi nal histo-pathology report showed a primitive neuro-ectodermal tumor. She received adjuvant chemotherapy for 16 cycles and is well at 15 months of follow-up.

In an appropriate case pulmonary artery embolectomy along with excision of cavo-atrial tumor thrombus is acceptable in experienced centers. An up-front mid-sternotomy should be contemplated in patients where the risk of embolisation of tumor thrombus is high. 

A total of 29 consecutive patients who underwent a TURBTS were identifi ed from January 2010 to February 2015 by a single surgeon at our institution. We excluded 10 patients as they had a known history of bladder cancer that previously underwent treatment. Via rigid cystoscopy, tumors were resected en bloc using a polypectomy snare with electro-cautery and retrieved transurethrally. Following TURBTS, the base of the tumor was either biopsied and fulgurize or a formal TURBT was performed.

Results: Nineteen consecutive patients (Median age 70, range 43-97) underwent an initial TURBTS for the initial staging and management of bladder tumor. Median number of tumors found was 1 (range 1-8).

Median tumor size was 3cm (range 2cm-5cm). Median follow-up was 26 months (range 1-51months). Tumors sites were: 7 posterior wall, 2 trigone, 8 lateral wall, 2 anterior wall. Immediate aft er snaring of the tumor, 6 patients underwent biopsy and fulguration while 7 underwent a TURBT in the same operative setting. 1 patient from the TURBT group experienced an obturator refl ex. Muscle was visualized on 8 of 13 pathology specimens. 2 patients required subsequent redo procedure to obtain muscle for tissue diagnosis and staging. Recurrence occurred in 5 patients (median 6.5months, range 1.5-43 months).

Conclusion: TURBTS is a feasible technique for pedunculated bladder tumors. It provides a bloodless fi eld with maximal visibility for the surgeon and may be an adjunct in TURBT.

DiLEP-Diode Laser (980 nm 

Technical Aspects for Overcoming the HoLEP Learning Curve

Omori Y, Matsumoto S, Matsumoto S

Introduction and Objective: HoLEP is an excellent surgical procedure and alternative to TURP and open prostatectomy for bladder outlet obstruction due to benign prostatic hyperplasia. It has been widely accepted and performed, for its safety and eff ectiveness. However, it may not be considered an option for the majority of worldwide urologists, because of its steep learning curve. Our objective is to help beginners and operators who are interested in learning HoLEP to get familiarized with it, and feel confi dent about opting for this procedure.

In this video we demonstrate a case of HoLEP using 100 Watt holmium laser in a 74-year-old male with 65ml prostate. Th e operative fl ow is described as follow: 1) downward dissection of the left lobe and longitudinal incision; 2) downward dissection of the right lobe and longitudinal incision; 3) enucleation of the medium lobe; 4) lateral side dissection of the both lobes; 5) 12 o' clock incision and bladder neck ablation at between 2 and 10 o' clock 6) diagonal longitudinal incision of apical lobes; 7) enucleation of the both lobes; 8) hemostasis; 9) morcellation.

Results: In this video operative time was 55min (enucleation time: 30 min) and resected tissue weight was 38g. Our procedure has some modifi cations compared to the surgical technique from original procedure of Gilling, separating 3 lobes and dissecting in a retrograde fashion.

Conclusion: HoLEP is a safe and eff ective surgical procedure. We hope our procedure will become the reference for beginners and urologists who are wishing to master it, but are worried about methods and complications. And also we hope HoLEP will become the new gold standard for the treatment of benign prostatic hyperplasia. to obliterate the circular fi bers of bladder neck to the level of proximal urethra, carefully avoiding the external striated sphincter. Laser power is reduced to 40W to prior to vaporization of any pseudomembranous trigonitis, which is commonly found in PBNO or recurrent cystitis cases.

Results: Laser vaporization is successful in relieving voiding diffi culties. Th is procedure opens the bladder neck and allows for optimal post-operative urine fl ow. Th e patient had improvement in both objective and subjective voiding functions immediately aft er treatment. During 3-months follow-up urofl owmetry, the maximum fl ow rate increased from 6 to 17 mL/s. Th e postvoid residual urine decreased from 95mL to less than 20 mL.

Conclusion: Primary bladder neck obstruction in female can be eff ectively and safely treated with laser photoselective vaporization of the bladder neck.

Bilateral Retroperitoneal Laparoscopic Nephrectomy Using 3mm Instruments

Introduction and Objective: Laparoscopy has become the standard Nephrectomy approach. It has been shown that Th e Retroperitoneal approach is comparable to the Transperitoneal approach when it comes to safety and results, even more, it can present advantages in selected patients, as in patients with prior abdominal surgery. Th e use of 3mm instruments is gaining acceptance as a safe way to improve aesthetic results and minimize abdominal wall trauma while maintaining the principles of standard laparoscopy.

We present the case of a 61-year-old woman with a history of Radical Hysterectomy and radiotherapy, aft er which she presents: 1) Bilateral ureteral obstruction that produces terminal renal insuffi ciency, and, 2) Vesico-vaginal fi stula, refractory to conservative treatment. Th e decision is made to perform a Bilateral Retroperitoneal Laparoscopic Radical Nephrectomy as a defi nitive treatment of the vaginal fi stula and as preparation for the kidney transplant.

Results: Th e Right Nephrectomy is performed fi rst. Classic retroperitoneal technique is used, using 3mm trocars (with an 11mm trocar to create the retroperitoneal space). On the left side, a previously produced nephrostomy catheter tract is used to insert a 5mm trocar. No relevant intraoperatory complications were observed. Preoperative haemoglobin was 85 g/L and the postoperative was 88 g/L aft er transfusion of one bag of packed red blood cells. Th e only postoperative complication was the infection of the 5mm left side trocar tract (where the previous nephrostomy catheter was placed). Th e total hospital stay was 6 days. Th e pathological anatomy for both kidneys was: Chronic Pyelonephritis with extended interstitial fi brosis and tubular atrophy.

Conclusions: Retroperitoneal Laparoscopic Nephrectomy is an effi cient and safe approach, comparable to Transperitoneal Laparoscopic Nephrectomy, and even superior to this one in patients with previous abdominal surgery. Th e use of 3mm instruments (in this case in a combined fashion), allows performing the surgery in a safe way, with superior aesthetic results.

Pure Aft er complete mobilization of the renal artery three Hem-o-lok clips were applied and the artery was transected. Th e IVC was isolated upwards as far as possible, and intraoperative laparoscopic ultrasound was employed to identify the extent of the thrombus. Aft er the inferior vena cava IVC was blocked using tourniquet loops above and below the thrombus and the contralateral renal vein was blocked, the IVC was opened and the tumor thrombus was extracted entirely. Th e IVC was stitched with a running 4-0 polypropylene suture. Th e specimen was extracted in an endoscopic extraction bag through a Gibson incision.

Results: From February 2012 to June 2014, fi ve patients underwent pure conventional retroperitoneal laparoscopic nephrectomy and tumor thrombectomy. Th e mean patient age was 57 yr (43-71 yr). Th e mean operative time was 241 min (180-300 min), and the mean estimated blood loss was 290 ml (50-1000ml). Th e mean length of tumor thrombus was 5.5 cm (4-10 cm). With a mean follow-up of 11.5 mo (5-30 mo), one patient was identifi ed lung metastasis four months postoperatively. Introduction and Objective: Partial nephrectomy provides equivalent oncologic and superior functional outcome compared with radical nephrectomy over the short-and long-term. With the development of laparoscopic techniques and increasing laparoscopic surgical experiences, laparoscopic partial nephrectomy has become an acceptable alternative to radical nephrectomy for expert laparoscopic urologists to treat small renal mass. However, higher complexity tumors are associated with more resection of normal tissue, a longer warm ischemia time, and postoperative morbidity, especially entirely endophytic hilar tumor. In order to reduce normal tissue resected during laparoscopic partial nephrectomy for entirely endophytic hilar tumor, we develop a novel technique to deal with the higher complexity tumors.

Subject is a 43-year-old female with T1a clear cell carcinoma with a diameter of 2.6 cm. Th e tumor is entirely endophytic hilar tumor. RENAL nephrometry score is 10. She underwent laparoscopic partial nephrectomy in retroperitoneal approach. Standard 4 ports were placed. Th e surgeon opened Gerota's fascia and dissects along the renal capsule mobilizing the kidney from within Gerota's fascia. Th e resection line was marked using the laparoscopic ultrasound probe. Aft er the renal artery was clamped by bulldog, tumor enucleation was performed using a cold scissor. One incision above the tumor was made, and careful dissection was performed to approach the tumor. Th e tumor was completely mobilized outside its margin. Th en the inner layer renal parenchyma and collecting system was sutured with 2-0 absorbable sutures and the outer layer renal parenchyma was sutured with 0 absorbable suture.

Results: Th e procedure was successfully accomplished without open conversion and transfusion. Th e operative time was 120min, and the estimated blood loss was 50ml. Th e warm ischemia time was 30min. Histology revealed that the tumor was chromophobe renal cell carcinoma, and the surgical margin was negative.

Conclusion: Laparoscopic partial nephrectomy for entirely endophytic tumor is challenging. Tumor enucleation with one resection line can reserve more normal renal tissue during the procedure. More cases are needed to evaluate the effi ciency of the technique.

Introduction and Objective: Laparoscopic adrenalectomy by posterior approach carries high recovery and shorter operative time. Children with metastatic high risk neuroblastoma arising from the suprarenal gland should undergo local surgical excision of the primary tumor before further intensifi cation of chemotherapy and possible bone marrow transplantation. Herein, we report a video of left laparoscopic adrenalectomy showing the diff erent steps of the procedure.

35th CONGRESS OF THE SOCIÉTÉ INTERNATIONALE D'UROLOGIE -SIU 2015 ABSTRACT BOOK Materials and Methods: A 3.8-year-old boy with left metastatic suprarenal neuroblastoma, received chemotherapy according to high risk European protocol. Child positioned in prone position, fi rst trocar at the tip of the last rib by open introduction, two 5mm trocars one in costovertebral angle and the other is lateral. Balloon development of the space, gerota fascia opened, the upper pole of kidney identifi ed, mass dissected, suprarenal vein is clipped during dissection, extraction in bag.

Results: Oral feeding is begun aft er 6 hours, discharge from hospital in the second day postoperatively, rapid convalescence, rapid resumption of chemotherapy.

Conclusion: Laparoscopic adrenalectomy using posterior approach gives direct access to the adrenal gland, no peritoneal violation, rapid intestinal movement recovery, short hospital stay and rapid recovery. All advantages that might facilitate the early start of adjuvant chemotherapy in children with neuroblastoma, however, oncological outcome should be proven by long-term follow-up, larger number of patients, and good selection of small tumor facilitates surgical extirpation.

Introduction and Objective: Robotic multiplex partial nephrectomy (RMxPNx) is minimally invasive partial nephrectomy for three or more tumors in a single kidney. RMxPNx has been previously shown feasible with excellent preservation of renal function. We present our technique of off -clamp robotic transperitoneal multiplex partial nephrectomy in the treatment of multifocal and hereditary renal tumors.

A prospectively maintained database was retrospectively queried to identify all patients who underwent RMxPNx from 2007 to 2013. RMxPNx is defi ned a resection of 3 or more masses from a single kidney. Patients underwent RMxPNx when the largest tumor reached 3 cm in size. Tumors were excised using enucleation techniques. From the data of 54 eligible patients, a representative patient was identifi ed and surgical video was edited to demonstrate the important aspects of the surgical technique.

Results: Th e patient is a 20-year-old white male with Von Hippel Lindau diagnosed with bilateral multifocal renal tumors with several tumors >3cm in size. He underwent bilateral robotic multiplex partial nephrectomy separated by 6 weeks with no operative complications. Th irty fi ve tumors were excised from the right kidney. Fift y two lesions were then resected from the left kidney. His preoperative Creatinine was 0.88 and at 1 year postop from bilateral multiplex partial nephrectomies his Creatinine is 1.07.

In the hands of an experienced surgeon, off -clamp robotic transperitoneal multiplex partial nephrectomy is feasible, safe and eff ective in the treatment of multifocal and hereditary renal tumors.

Th is technique provides exceptional renal functional preservation and decreases technical diffi culty of reoperation.

Louie-Johnsun M

Introduction and Objective: Th e advantages of minimally invasive laparoscopic surgery are well documented. As there are few urological emergencies suitable for a laparoscopic approach, the increased use of robotic surgery for elective procedures that can be performed equally as well laparoscopically threatens the acquisition of skills that can be transferred from these elective procedures (e.g. laparoscopic radical prostatectomy, pyeloplasty and partial nephrectomy) to emergency cases. In emergency situations, a robotic approach may not be feasible or practical. We highlight this with three recent cases.

Materials and Methods/Results: A video presentation of three of our recent urological emergency cases managed successfully laparoscopically which includes: (1) A 17-year-old girl with neurogenic bladder presenting with urinary peritonitis aft er spontaneous rupture of an augmentation cystoplasty: Laparoscopic adhesolysis and repair of perforated augmented bladder.

(2) An 80-year-old woman with intraoperative mid ureteric injury during laparoscopic right hemicolectomy: Laparoscopic ureteroureterostomy and insertion of ureteric stent.

(3) A 40-year-old woman with ureterovaginal fi stula post laparoscopic hysterectomy: Laparoscopic ureteric reimplantation with psoas hitch and insertion of stent.

Conclusion: Despite the increasing use of robotic surgery in urology we encourage the continued training and dissemination of advanced laparoscopic skills in the elective setting to allow for the advantages of laparoscopy to be transferred to the less common urological emergency setting.

Robotic Ureteric catheter placement; 2) 4 port placement with patient in lateral position; 3) Bowel mobilization; 4) Localization of lower calyx by intra-operative ultra sound probe; 5) Lower segmental nephrectomy; 6) Anastomosis (ureterocalicostomy) with 3-0 V-lock sutures over a pre placed 5F ureteric catheter and drain placement; 7) changing of ureteric catheter to DJ-stent on 3rd day post-operatively.

Results: Th e procedure was completed successfully without any intra operative complications in all the cases. Mean operative time was 160±23 minutes and analgesic requirement of 192±40 milligram of tramadol. None of the patients required blood transfusion. Urethral catheter was removed on 5th and drain on 6th post-operative day and stent aft er 6 weeks. One patient had Clavien grade 1 (pyrexia) complication.

Conclusions: Robot-assisted laparoscopic ureterocalicostomy for secondary UPJO is safe and feasible in expert hands. Apart from the short recovery times, early mobilization, decreased analgesic requirements; robotic approach provides the added advantage of technical ease and precision of suturing.

Laparoscopic Dismembered Pyeloplasty for UPJO in Pelvic Ectopic Kidney

Apollo BGS Hospital, Mysore, India Introduction and Objective: Renal ectopia is a rare anomaly and may be associated with pelvic ureteric junction obstruction (PUJO). We report such a case with an ectopic pelvic kidney (L-type) with PUJO and its successful laparoscopic management. Th rough this report we emphasize the importance of adequate preoperative imaging and intraoperative details to avoid mishaps.

A 35-year-old male was admitted with complaints of right-side lower abdominal pain of a dull aching type lasting 6 months. Ultrasonography revealed Left pelvic Kidney. Th ese fi ndings were confi rmed with an intravenous pyelogram, which showed the Left kidney low lying in the pelvic region with features of Hydronephrosis and UPJO. CT angiography revealed no crossing vessel as the cause of PUJO.

Results: Th e patient was taken up for transperitoneal laparoscopic pyeloplasty under general anesthesia. Aft er creation of the pneumoperitoneum and with the ports in place, dissection was started and the dilated pelvis could be visualized through the peritoneal window. Th e peritoneum was incised and the dilated pelvis on the left side was reached. Aft er further dissection, the classic Anderson-Hynes dismembered laparoscopic pyeloplasty was done by using 4-0 Vicryl. Minimal excision of the redundant pelvis was required and because the kidney was not mobilized, nephropexy was not required. Care was taken to avoid injury to the right ureter, which was coursing in close proximity to the left renal pelvis. Preoperatively placed stent was retained and repositioned during the Pyeloplasty. Estimated blood loss during the procedure was around 50 mL, and the procedure was completed in 120 minutes without any intraoperative complications. Th e patient could tolerate oral feeding on the evening of the same day.

Conclusion: Th e UPJO in ectopic pelvic kidneys presents a large spectrum of presentation. Th e laparoscopic approach provides good surgical exposure, and operative times are compared to those of laparoscopic procedure in anatomically normal kidneys.

Laparoscopic We present laparoscopic radical cystectomy (LRC) and intracorporeal orthotopic ileal neobladder with two isoperistaltic aff erent limbs.

A 71-year-old male patient with recurrent urothelial bladder carcinoma. CT demonstrates bulky bladder tumor in right lateral wall. LRC and intracorporeal urinary diversion were performed. Six trocars were used in the procedure. Aft er LRC and extended pelvic lymph node dissection were accomplished, a 60cm ileal segment 15cm proximal to the ileocecum was harvested, of which a 10cm proximal ileal segment was moved to anastomose with the end of the harvested segment which was right isoperistaltic aff erent limb. Th en 40cm ileal segment was detubularisated leaving 10cm intact proximal ileum for left isoperistaltic aff erent limb. Th e harvested ileal segment was symmetrically folded with identical limb lengths. Th e posterior wall of the neobladder was sutured, and ileoureteral stents were delivered into the two isoperistaltic limbs and passed up the ureter and coiled into the renal pelvis, and one Foley catheter was delivered into the neobladder at the same time.

Bilateral ureteroileal anastomoses were performed in a continuous manner respectively. Th e anterior wall of the neobladder was closed and the posterior urethra was anastomosed with the neobladder.

We have performed 10 cases with this technique. All procedures were completed without open conversion. Th e mean operative time was 415min with a blood loss of 150ml. Th e construction time of the neobladder was 180min. Th e time to orally allow was postoperative day 5 in all. Th e mean hospital stay was 12d. Foley catheter and DJ stents were removed on postoperative day 21. No major complication was occurred.

Conclusion: Laparoscopic radical cystectomy and intracorporeal orthotopic ileal neobladder with two isoperistaltic limbs were a safe and feasible for experienced laparoscopic surgeons. However, more cases and long follow-up were required to evaluate the function of the novel neobladder.

All In this video, we wanted to share our robotics augmentation ileosistoplasty experience in 11-year-old male patient with a diagnosis of neurogenic bladder.

An 11-year-old male patient treated with clean intermittent catheterization and anti-cholinergic therapy for neurogenic bladder. Bladder capacity was detected 180cc, the irregularities in the bladder contour and left grade 1 VUR was detected in control video urodynamics. So we decided to implement robotic augmentation ileocystoplasty to the patients.

Results: Th e transperitoneal approach is performed by using veress needle to access the peritoneal cavity. Th e abdomen was insuffl ated using CO2 and trocars placed under direct vision (1 of camera port (12 mm), 3 of da Vinci ports (8 mm) was placed and 1 of 5 mm and 1 of 10 mm assistant ports were placed). A 30 cm segment of ileum with mesentery was incised with about 30 cm proximal from the ileocecal valve and this segment was suspended. Intestinal anastomosis was performed with 4-0 vicril and 4-0 monocril sutures and created a u-shaped ileal pouch. Th e bladder was released from the surrounding tissue. About 8 cm, longitudinal incision was made to the bladder. A single-J catheters were placed to the left ureter and bladder for the left ureteral catheter and cystostomy. Th e bowel prepared for bladder augmentation and it was sutured with 4.0 PDS with wate tight anastomosis. Operation was terminated by placing the drainage catheter.

Introduction and Objective: Although their numerous indications make Double-J stents frequently preferred in the armamentarium of the urological practice, serious complications can arise, if they are not used correctly. In endourological surgeries, due to type and stuff of material the breakage or fracture risk of the equipment is more. Th ere are various types of surgical procedures for the removal of the foreign bodies. Shock wave lithotomy (SWL) and ureteroscopy (URS) are the fi rst step in the removal encrusted ureteral stent. Th is report presents a case of successful forgotten ureteral stent removal by means of fl exible ureterorenoscope (FURS) and fl uoroscopic imaging.

A 32-year-old male patient was admitted to our clinic with the complaint of recurrent urinary tract infection. In his medical history he said that he had an open kidney stone surgery in 2013 and aft er 4 months D-J catheter removal had been performed. Aft er radiologic imaging it is determined that there are two D-J catheter pieces in the right kidney collecting system. FURS and removal of foreign body was performed successfully. Postoperative fi rst day patient discharged with no complication.

Results: Various materials and coatings have been developed to avoid ureteral stent complications such as encrustation and infections. Th e incidence of encrustation increases with the duration that the stent remains in place. Th ere are numerous types of removal techniques for foreign body removal, however FURS seems to be the better one with the minimal postoperative rates. Our technique was performed easily and in a short surgery time.

Conclusion: Flexible URS modifi ed with fl uoroscopy has particular advantages for treating encrusted ureteral stents. Th is procedure is least invasive and is thus considered to be most suitable surgery for encrusted ureteral stents or foreign body materials in the kidney. Results: We outline strategies to prevent diffi culties with urethro-ileal anastomosis during RARC IUCD neobladder formation. Furthermore we off er some key technical points that can be benefi cial in overcoming challenging urethro-ileal anastomosis.

Conclusions: Due to the technically complex nature of RARC ICUD neobladder formation, the awareness of potential pitfalls during each step of the process is essential. Issues and solutions discussed in this video provide a valuable resource for clinicians performing this procedure.

Robotic 

In this video we present a patient presenting with concomitant renal neoplasm and a large calculus in the renal pelvis that what was managed with robotic pyelolithotomy at the time of partial nephrectomy.

Results: Aft er exposure of kidney the ureter was identifi ed. Th e renal pelvis was exposed and pyelolithotomy was performed. Aft er this hilum was clamped and partial nephrectomy and renorrhaphy followed. Th e warm ischemia time was 21 minutes. Th e procedure was completed without any complications. Patient was discharged on the second postoperative day.

Conclusions: Although uncommon, the presence of concomitant stone and renal neoplasm can make the decision of optimal patient care more challenging. Using robotic platform simultaneous management of both conditions can be accomplished in appropriately selected cases.

Single Introduction and Objective: Female epispadias is a rare congenital anomaly and is classifi ed, into vestibular, subsymphyseal, and retro-symphyseal. Historically treatment consists of staged repairs with urethral and vulvar reconstruction in fi rst stage followed by bladder neck reconstruction at a later age. In addition, staged procedures require multiple sessions of surgery and anesthesia, and are associated with relatively higher morbidity. Recently single stage perineal urethroplasty has been used for epispadias repair.

Objective of the study is to evaluate the results of single-stage perineal urethroplasty with double breasting of the urethra and bladder neck and sphincteroplasty in female epispadias.

We treated 5 patients with severe female epispadias since 2007 to 2014. Age varied from 5 to 25 years (mean 10years). Perineal urethroplasty with double breasting, sphincteroplasty, and genitoplasty was done in cases. Th e urethral plate and bladder neck was mobilized from the surrounding tissue till bladder neck. A urethral mucosal strip of about 5 to 10 mm was denuded from the bladder neck to the end of urethral plate on one lateral edge, and tubularized over a 12F catheter. Urethroplasty was done with double breasting of the urethral muscle margins starting from inside the bladder neck downward to the neo-meatus with corporoplasty, sphincteroplasty, and genital reconstruction.

Results: All patients were satisfi ed and happy about cosmesis. Of the 5 patients, 4 were fully continent with a dry interval of 4 to 5 hours, one of them had occasional night wetting was put on anticholinergic.

One was partially continent with dry interval of 3 hours required anticholinergic.

Conclusions: Perineal urethroplasty with double breasting of urethra, from inside the bladder neck to the neomeatus, resulted in continence in most cases because it increased the urethral and bladder neck resistance, as well as bladder capacity, all were important factors in continence. We advocate this procedure as a fi rst choice in all patients with female epispadias, because it is simple, safe, and eff ective for continence.

Single We had partial penile disassembly to have the advantage of both technique. So objective of the study was to evaluate the functional and cosmetic outcome of single stage partial penile disassembly repair in isolated male epispadias.

A retrospective analysis of 43 cases of primary epispadias repair, performed during July 1998 to July 2013 at our institution. Patients were classifi ed on the basis of type of epispadias, urinary incontinence, presence/degree of chordee and penile rotation. Exstrophy Epispadias complex and secondary repair were excluded. Surgical technique: Penile de-gloving with mobilization of urethral plate from ventral to dorsal aspect with preservation of blood supply at both ends, distally up to the level of midglans and proximally up to pubic symphysis with division of penopubic ligament to lengthen the penis and position the urethra ventrally. Tubularization of urethral plate followed by spongioplasty, Corporoplasty with medial rotation of corporeal bodies (without any corporotomy) and glanuloplasty with meatoplasty to bring the meatus ventrally. Skin cover with rotation of ventral fl aps and z-plasty when required.

Results: Age of the patients varied from 6 months to 26 years with a mean of 9 years. Forty patients (93%) had excellent cosmetic outcome while three patients (7%) had minimal residual chordee/torque but didn't require any surgery in a follow-up to 2-10 years. All seven partially incontinent patients in the study group achieved continence aft er surgery. None of the patients developed complications like fi stula or stricture. All the 12 patients in the post pubertal group reported normal erections and successful ejaculations aft er the surgery. Post-operative follow-up ranged from 2-10 years with a mean of 4 years.

Conclusions: Th e technique incorporates all the benefi ts of Cantwell Ransley repair, needs less extensive dissection than total penile disassembly. Both functional and cosmetic results are good with low complication rate. Spongioplasty reconstructs near normal urethra and corporoplasty with spongioplasty also helps in prevention of urethral fi stula.

Introduction and Objective: To introduce a unique technique, single port laparoscopic assisted extraperitoneal closure of patent processus vaginalis using J shaped bended spinal needle.

Materials and Methods: A 2.7-mm 30-degree laparoscope was inserted through an umbilical incision. Th e scope could view both inguinal ring. J shaped bended 18G spinal needle was inserted just 5mm lateral to the internal inguinal ring. Th e needle was introduced to the extraperitoneal space over the vas deferens and spermatic vessels, injecting of saline for the preperitoneal hydrodilation. A 3-0 polyester suture was threaded through an 18G spinal needle. Same 3-0 polyester suture was threaded through a 20G spinal needle from the tip. Along the guidance of the suture and 18G needle, J shaped bended 20G spinal needle was reintroduced to extraperitoneal space. 20G spinal needle traveled through the upper margin of internal ring, 20G needle tip was pulled out of the initial 18G needle punctured opening. 3-0 polyester suture was pulled outside from the 20G needle tip and then 20G needle is also withdrawn. Aft er all these procedure, internal inguinal ring was completely encircled and tied extracorporeally. Th e knot was buried in the subcutaneous area within the punctured needle hole.

Results: Sixteen children underwent Laparoscopic Transcutaneous Extraperitoneal (LTE) repair of hydrocele by using J shaped bended spinal needle. All patients were discharged on the same day aft er surgery without any complication. During a mean follow-up period of 6 months (range 1-12mo), no recurrence has been observed except fi rst 2 cases.

Th is LTE technique is simple, fast, safe and cosmetic procedure for pediatric hydrocele.

Robot Assisted Laparoscopic Ureteral Reimplantation for Girl and Boy Patients: Differences and Similarities

Introduction and Objective: Nowadays robot assisted laparoscopic extravesical ureteral reimplantation is getting famous and in the literature is being an alternative for gold standard open surgery. In our clinic we have performed 8 RALUR procedures in our clinic for vesicoureteral refl ux and ureterovesical stricture and with this video-abstract we would like to share our experience on RALUR in girl and boy patients; diff erences and similarities of procedure.

We have performed 8 RAL-UR cases in our clinic between July 2014-April 2015 for pediatric and adult patients. Technique: All procedures have been performed under general anesthesia. Nasogastric tube and urethral catheter placed to all patients. For all procedures 4-port confi guration is used: two robotic 8 mm trocar, one 12 mm camera trocar and one 10 mm (including 5 mm cover) assistant trocar. Following docking robotic working arms of robot is placed. In all procedures one monopolar curved scissors, one needle holder and one Maryland bipolar forceps is used as the working arms. All procedures performed transperitoneally and extravesically.

In the working area of the procedure girls have more structures compared to boys. Uterus, Fallopian tubes and ovaries are the risky structures for girls while the vas deferens in boys. As seen in the video Fallopian tubes, uterus and vas deferens are extraperitoneal organs, but ovary is intraperitoneal organ. We create a peritoneal window to reach the retroperioneal space and to dissect the ureter. Dissecting the ureter we have been very careful not to harm vas deferens in boys and Fallopian tubes in girls. Protecting this structures we open one peritoneal window in boys and two windows in girls to fi nd and to work with the distal part of the ureter. Vessel tape is used to hang the ureters. Th e bladder is elevated with a 3-0 straight needle vicryl suture through the abdominal wall. Aft er that the ureter was clipped with a hemoloc clip and sutured with a 3-0 vicryl suture in watertight fashion (if necessary). Aft er suturing the distal ureter tailoring for the dilated distal rest ureter is performed (if necessary). Following detrusorotomy, mucosa is cut for the anastomosis (if necessary). Before the ureterovesical anastomosis 6 F nelaton or a DJ catheter was placed inside the ureter (if necessary). Ureterovesical anastomosis is made with a 4-0 monocryl suture (if necessary).

In the cases that ureter and mucosa are not cut, realignment suture is used. Detrusorraphy is performed by a 3-0 barbed suture. Following detrusorraphy we repaired the parietal peritoneum to close the peritoneal window one line and two lines in boys and girls, respectively.

Results: RALUR procedure has been used successfully in girls and boys by considering the anatomical differences. Bleeding was minimal in all patients. All patients discharged at the 2nd or 3rd postoperative days.

Conclusion: While using RALUR procedures in pediatric patients, surgeon must be aware of the anatomy. Mistakes during the procedure may damage the reproductive system components. Performing this procedure in children, compared in adult patients, there are diffi culties due to the small size of the abdominal cavity. With the appropriate trocar placement this problem can be solved.

Robot Assisted Laparoscopic Left Ureteral Reimplantation for Ureterovesical Stricture

Introduction and Objective: Extravesical robot-assisted laparoscopic ureteral reimplantation (RALUR) for vesicoureteral refl ux (VUR), ureterovesical strictures (UVS) and ureteral pathologies are alternative to the gold standard open repair in the literature. With this video presentation we want to share our initial experience with robot-assisted laparoscopic extravesical ureteral reimplantation using the ureteral advancement technique for a 5-year-old boy patient who is the youngest patient received this intervention in Turkey.

We have performed 8 RAL-UR procedure for adult and pediatric patients in our clinic. Th is patient explained in the video was a 5-yearold boy who has had recurrent infections due to this condition. When the patient applied to our clinic he had already grade 4 left ureterohydronephrosis. We performed left sided RALUR procedure for this patient. Technique: Th e DaVinci SI system was used via a transperitoneal approach. We used a 4 port confi guration for the procedure; one 12-mm trochar for optic, two 8-mm trochars for robotic working arms and one 10-mm trochar for assistance. Th e patient was placed in a modifi ed Trendelenburg (approximately 10°) position. Aft er docking the robotic arms, the ureter is identifi ed closed to the vas deferens. Th e ureter is dissected distal to the vas and tented up with a tape. Th e bladder is elevated with a 3-0 straight needle vicryl suture through the abdominal wall. A 4 cm detrusorotomy is performed". Aft er that left ureter was clipped with a hemoloc clip and sutured with a 3-0 vicryl suture in watertight fashion. Aft er suturing the distal ureter tailoring for the dilated distal rest ureter is performed. Before the ureterovesical anastomosis 6 F nelaton catheter is placed thorough urethra and bladder inside the left tailored ureter. Following this application nelaton catheter is binded to the urethral catheter. Ureterovesical anastomosis is made with a 4-0 monocryl suture. Detrusorraphy is performed by a 3-0 barbed suture. Following detrusorraphy we repaired the parietal peritoneum and fi nished the procedure. Foley catheter, nelaton catheter and drain are left at the end of the procedure.

Rectourethral fi stula is a morbid complication that can occur post trauma, radical prostatectomy, radiation, or pelvic surgery. Th e management of these cases can be challenging and might require multiple procedures to achieve cure. Th e use of omentum fl ap between the rectum and the urethra is recommended for its potential benefi ts in prevention of fi stula recurrence. We aim to illustrate the feasibility and safety of a new laparoscopic surgical technique for interposition of omentum in patients with complex pelvic fractures urethral injury (PFUI) and rectourethral fi stula (RUF).

We performed prospective case series of 3 patients with PFUI and RUF from September 2014 till October 2014. Th e initial approach is perineal with continued dissection until urethral transaction. Laparoscopic team mobilises omentum and enters retroperitoneum lateral to bladder. A TVT needle is passed from perineum hugging the posterior wall of pubic symphysis and enters peritoneal cavity. Th is tract is dilated and omentum transposed in to perineum. Th is omentum is used as interposition between urethral anastomosis and rectum. Th e clinical outcome was considered a failure when any instrumentation was needed or the recurrence of RUF.

35th CONGRESS OF THE SOCIÉTÉ INTERNATIONALE D'UROLOGIE -SIU 2015 ABSTRACT BOOK Results: Median age is 30 years (range 28-33). All 3 patients had complex PFUI with RUF. Th ey all had an attempt of perineal anastomotic urethroplasty with RUF repair that failed outside our center and were referred to us subsequently. All the patients had supra pubic catheters and 2 of the three patients were passing urine through the rectum and the urethral meatus. One of the patients had a loop colostomy that was closed during the fi rst failed surgery. No intra-operative or post-operative complications occurred. Patients were discharged home on post-operative day 3. All 3 patients had the urethral catheter removed aft er 6 weeks. Th ree-month follow-up shows no fi stula recurrence with good urine fl ow.

Conclusion: Using our new technique of laparoscopic omentoplasty for interposition of omentum in patients with RUF post PFUI is a viable and safe option. Th is allows us to perform a perineal surgery with the benefi t of omental interposition using a minimally invasive technique. Further studies with larger number of patients as well as longer follow-up would be needed.

Introduction and Objective: To test the hypothesis that a new surgical technique using elaborated perineal anastomotic urethroplasty combined with laparoscopic omentoplasty for patients with complex and prior failed pelvic fracture urethral defect repair was feasible, safe, and eff ective.

We performed a prospective, observational, stage 2a study to observe treatment outcomes of combined perineal and laparoscopic approach for Urethroplasty in patients with pelvic fracture urethral defect at a single center in Pune, India, between January 2012 and February 2013. Complex and redo patients with pelvic fracture urethral defect occurring aft er pelvic fracture urethral injury were included in the study. Anterior urethral strictures were excluded. Th e primary study outcome was the success rate of the surgical technique, and the secondary outcome was to evaluate feasibility and safety of the procedure. Th e clinical outcome was considered a failure when any postoperative instrumentation was needed.

Results: Fift een male patients with a median age of 19 years were included in the study. Seven patients were adolescents (12-18 years) and 8 patients (53.3%) were adults (19-49 years). Th e mean number of prior urethroplasties was 1.8 (range, 1-3). All patients underwent elaborated bulbomembranous anastomosis using a perineal approach with inferior pubectomy combined with laparoscopic mobilization of the omentum into the perineum to envelope the anastomosis and to fi ll the perineal dead space. Of 15 patients, 14 (93.3%) were successful and 1 (6.6%) failed. One adolescent boy 14 years old developed a recurrent stricture 2 months aft er the procedure and was managed using internal urethrotomy. Median follow-up was 18 months (range, 13-24months).

Conclusion: Combining a laparoscopic omentoplasty to a membranobulbar anastomosis for complex and redo pelvic fracture urethral injury is successful, feasible, safe, and with minimal additional morbidity to the patient. Th e technique has the advantage of a perineal incision and the ability to use the Omentum to support the anastomosis.

Dorsal Results: Buccal mucosal graft urethroplasty was done in all the patients with the graft being harvested from the buccal mucosa of the oral cavity. Postoperative evaluation was done with voiding cystourethrogram at the time of catheter removal during the 4th postoperative week. Mean peak urinary fl ow rate increased from 6.8 ml/sec to 30.8ml/sec with normal fl ow curve stabilised at 3 months to a mean of 24.4 ml/sec. Patients were followed at 3, 6, 9 and 12 months in the fi rst year and then 6 monthly thereaft er with urofl owmetry and ultrasonogram. Mean follow-up period is around 18 months. Two patients required urethral dilatation for recurrence of symptoms. None of the patients developed stress urinary incontinence during follow-up.

Conclusions: Female urethral stricture disease is under diagnosed and BMG urethroplasty is underutilised. Our study adds to the limited evidence base, that BMG urethroplasty can be done safely with good results in females.

A Introduction and Objective: Ureteral fi stula's treatment oft en includes long and complex surgical and endoscopic therapies and represent a challenge for the urologist oft en with disappointing results. UVENTA® stent placement could represent a new option of conservative treatment for ureteral fi stulas. Materials and Methods: UVENTA® self-expanding ureteral stent are able to restore urinary fl ow in ureteral stenosis and to facilitate the closure of ureteral fi stulas thanks to its triple layer structure made of two layers of metal mesh with interposed a PTFE membrane. UVENTA® stents are available in diff erent lengths and diameters, and allow the coaxial overlap of the ends of multiple stents, providing a lumen of large caliber able to ensure the proper urinary fl ow and the possibility of further endoscopic procedures. We show the case of 65-year-old man that in September 2014, undergone to pelvic surgery for an adenocarcinoma of the sigma in advanced stage. Th e postoperative period revealed a urinary leakage, dealt initially in conservative way by the general surgeon. Due to unsatisfactory results, the patient was then evaluated by the urologist and subjected to bilateral ascending pyelography highlighting the presence of a high fl ow left ureteral fi stula in pelvic tract; he case was managed immediately with Bilateral ureteral stenting prior to placement of a UVENTA® stent. Th e subsequent step was a retrograde pyelography through the left stent, used to identify the site of the ureteral fi stula. Aft er hydrophilic guidewire positioning and Mono-J stent removal, the delivery system of the UVENTA® stent is advanced coaxially to the guidewire under radiologia control. Once reached the desired position the stent is released from its delivery system whit pull-back technique playing a UVENTA® stent 9Fr x 20 cm allowing its simultaneous self-expansion. Th e next ureteroscopic control has shown the need to placement of an additional UVENTA® stent to complete fi stula's coverage. Following the insertion of a hydrophilic nitinol guidewire a new UVENTA® stent 9Fr x 12 cm has been positioned further in order that the ends of the two stent's overlap for a length of at least 3 cm.

Results: Intraoperative retrograde pyelography showed that the stent have eff ectively excluded the fi stula. Th e absence of contrast medium leakage was also documented by retrograde cystography performed after 7 days from stents positioning.

Conclusions: In our experience, the application of UVENTA® stent has proven to be an eff ective option in the conservative treatment of minimally invasive ureteral fi stulas.

Robotic 

We performed fi ve robotic ureteroplasties using a buccal mucosal onlay between September 2014 and March 2015. Th e graft was procured by our otolaryngology colleague (JCL). Th e graft onlay was performed using 5-0 PDS suture and stent was placed robotically. Stent was left in place for 4-6 weeks, and imaging repeated aft er removal.

Results: Table 1 describes each case and the outcomes observed. Th e three patients who have undergone stent removal and reimaging had complete success and resolution of obstruction. Th ere were 3 post-operative complications, and none were higher than Grade III (Table 1) . Table 2 shows the demographic and perioperative variables of the 5 patients undergoing this procedure.

Conclusion: Our technique of robotic buccal mucosal ureteroplasty is safe and eff ective. We believe this is a relatively simple technique which is easily replicated. Long-term data will be important to prove the validity of this procedure.

Primary Endoscopic Realignment of Rupture Urethra

Introduction and Objective: Pelvic fracture urethral injury (PFUI) is more common in India and subcontinent. Th ere is no consensus on the initial management of this injury. Th ere are two schools of thoughts in all cases of suspected or confi rmed urethral rupture: a) Initial supra-pubic catheterization (SPC) followed by urethral reconstruction of inevitable stricture; and b) Realignment of urethra. We demonstrate method of primary endoscopic realignment of rupture urethra and review the literature comparing these two procedures.

A 45/M-presented with retention of urine and bleeding per urethra. He had sustained pelvic trauma when he was crushed between a tank and a wall. Aft er initial resuscitation he had X ray pelvis, CT abdomen, RGU. He then underwent SPC under ultrasound guidance. On 17th day aft er SPC he underwent primary endoscopic realignment of the rupture urethra. We have shown a technique and reviewed the relevant literature emphasizing advantages of realignment.

Results: We used a two endoscopes technique one each from the SPC route and per-urethral route. Intra-operative contrast study was done to see extent of injury and also to see possible patency and continuity of the urethra. Additionally methylene blue study was also done. A PTFE guide wire (GW) was passed from below. At the fi rst site of the GW from above it was apparent that further manoeuvers such as "going for light" would not be required. Th e GW was carefully pulled in suprapubically. A silicon Foley catheter (14 F) was gently passed perurethrally over it. Th e position of catheter was confi rmed suprapubically. Patient had no major or minor complication. Catheter was placed in for 6 weeks and removed. Post catheter removal patient voided well. Th ese results correlated well with other studies in the literature.

Conclusion: 1) Technically not a challenging procedure. 2) Low risk and low complication rate. 3) One failure of procedure does not preclude further attempts. 4) Adequate experience and instrumentation are essential. 5) Level 3 evidence in favor of this approach over SPC alone and further urethroplasty.

Neourethra with Penile Skin Flap after Total Amputation of the Penis Kulkarni S, Joshi P, Batra V, Sharour W, Hunter C, Surana S, Kulkarni J

Introduction and Objective: Urethral carcinoma is a rare oncological entity. Th e standard treatment for invasive urethral squamous cell carcinoma is radical penectomy, prostatectomy, cystectomy and ileal conduit. In our technique, we describe a palliative surgery that avoids the ileal diversion and perineal urethrostomy through the use of dorsal penile skin tubularization. Th is video represents a detailed, step-by-step technique for retro auricular graft harvesting that we have found facilitates resident and general urologist teaching. Ears were prepped and draped. Th e grafted was areas were marked bilaterally. Diluted lidocaine with epinephrine was injected subcutaneously. Th e graft was harvested using sharp scissors. Donor site was closed in two layers with minimal aesthetic changes.

Conclusions: Our technique to harvest retroauricular graft is a simple and reproducible. It is useful in patients with lack of BMG. Th is step-by-step video could be a useful resource for residents and general urologist who wish to learn an alternative graft .

Hand 

Combined Antegrade and Retrograde Intraureteric Surgery in Re-implanted Ureter

Introduction and Objective: We review a case of re-implanted ureter complicated with stricture and stone impaction.

A 43-year-old gentleman was following the urology department at HMC. Between the year 1991 until 2014 he was managed by the same urology team for his multiple urological complaints. Diff erent open and endourological approaches were conducted.

At the year of 2013, this gentleman was complaining of colicky pain due to a 1 cm impacted stone in the left lower ureter, 4 sessions of ESWL failed to break it. IVU showed left ureteric stricture, cystoscopy with trial of ureteroscopy was unsuccessful because the left ureteric orifi ce couldn't be identifi ed, so left percutaneous nephrostomy access inserted and followed by antegrade fl exible ureteroscopy, small opening found at the lower part of mid ureter and opened widely by laser, then followed by antegrade double J stenting. Retrograde rigid ureteroscopy 7 french identifi ed the stone at mid ureter in a later session and fragmented by laser. A double J stent was reinserted and removed later with smooth recovery. Results: Management of stones, in the male urethra, is a challenge, more so in a reconstructed urethra. Th e dilemma always is whether it is worth incising an otherwise normal or reconstructed urethra, to extract a calculus, especially in this minimally invasive era. Th e point to note is the 'painting' technique used to powder the stone, rather than fragmenting the stone into large fragments, which are then diffi cult to remove. High frequency and low energy laser setting is the order of the day.

Conclusion: Laser lithotripsy using a high frequency low energy setting, is a good option for urethral calculi in a reconstructed urethra.

Retrograd Introduction and Objective: Uretery duplication is a most common congenital anomaly of upper urinary system. Th e incidence of it, in autopsy and intravenous pyelography (IVP) series, is 0.7% and 2-4% respectively. It is two-fold more frequent in women than men. Retrograde intrarenal surgery (RIRS) is a new technology in stone surgery with the fl exibility and most eff ective visualing. In patients who suff er from kidney or uretery with ureter duplication, RIRS become the best surgery choice with its advantages. In this case, we present a patient who have the symptoms of kidney stone and ureter duplication.

A 46-year-old male patient applied our clinic with the left fl ank pain. In his intravenous pyelography (IVP) and computerized tomography, it was clearly seen left ureter duplication of which both ureteropelvic junction and duplicated ureters obstructed by two kidney stones. Other laboratory tests were normal. RIRS surgery was performed the patient successfully. Postoperative fi rst day patient was discharged without any complication.

Results: Ureter duplication is a rare congenital anomaly of upper urinary system but the rarest thing is that the obstruction of both duplicated ureters with UPJ by kidney stones. In our case this kind of case successfully treated by RIRS. In this surgery a new technique of access sheet entering for RIRS was applied. To our knowledge it is the fi rst case in literature.

Surgical procedures in patients with urinary tract abnormalities are more diffi cult than the normal anatomy. Th e development of new technologies is changing approach to such cases. RIRS fi eld of use is gradually increasing in urologic practice. RIRS in is a preferable method in duplicated ureter with stone formation.

A 

Introduction and Objective: Nephron-sparing surgery is now the standard of management of small renal mass and is increasingly performed for larger and more challenging lesions. Th e aim of this study is to report our experience with robotic partial nephrectomy (RPN) and lapascopic partial nephrectomy (LPN) in 37 patient's surgical outcome (blood loss, WIT LOS renal function, complication). (2)) AML (RPN (6) LPN (8)), oncocytoma (RPN (2) LPN (0)) and simple cyst (LPN (1)). Th e positive surgical margin rate were both 0% in RPN and LPN group. Th e decline in glomerular fi ltration rate at the last available follow-up was similar in both groups. 

Laparoscopy Training at Home Guijarro A, Ascencios J, Morales S, Huertas J, Fernández B, Navarro F, Paniagua P

Introduction and Objective: Th e increasing use of laparoscopic surgery makes training fundamental to acquisition of the basics techniques of endourology. Unfortunately, laparoscopic fi eld requires high ability and a long learning curve so it's needed simulators to practice. Traditional pelvitrainers improve the laparoscopic skills of a trainee but don't simulate the real conditions of the human body. We present a homemade training surgical model that may help to achieve the skills needed and simulates the abdominal space. It is called Simulated Environment for Laparoscopic Training (SELT).

We have developed a laparoscopic training system based in a simulated environment. We modifi ed a dummy who represents a human trunk, this model it easy to fi nd in hardware stores. Th en, we performed several orifi ces in order to place traditional laparoscopic ports in pelvic surgery disposition and two additional for our camera. Inside the dummy we placed three screws and developed another hole for attaching a cork panel. Also, we used a wardrobe fl ashlight as lighting system. As optical system we have used a 9 inch tablet or a photographic camera linked to the TV. Finally, for reproducing a vesicourethral model we use two balloons in order to create an anastomosis between them. Final price for the SELT model, excluding optical system and disposables (we used discarded ports) was 20 euros, what is signifi cantly lower than the commercial pelvitrainers. Time needed for installing all the devices is about 60 minutes.

Results: Th e level of simulation is high, it is more realistic, being harder and diffi cult than "traditional" pelvitrainers. Th e degree of movements is limited by the real placement of the ports, distance until exercise is similar and we have to be able to work without Results: Nine patients underwent TMC left pyeloplasty. Th ere were 5 female and 4 male patients with age ranging from 21-28 years .Operating time ranged from 120-150 minutes with mean of 132 minutes. Per-operative blood loss was minimal ranging from 10-20 ml. Return of bowel movement was within 1-2 days. All patients were discharged within 2 days and drain removed with 2-3 days. Two patients were discharged on 2nd day but drain was removed on 3rd day in outdoor. Follow-up of 8 patients showed improvement in their pain status and IVU showed no re-stricture or stenosis. Our last patient is yet to come for the fi rst follow-up.

Conclusion: Tranmesocolic approach for left PUJ obstruction is feasible and seems to have low morbidity with shorter hospital stay. Comparison with Colon-refl ecting pyeloplasty and larger number of cases are needed for better statistical evaluation.

Transperitoneal Conclusion: Th e overall CDR (67%) for our cohort was comparable to results from MRI in-gantry biopsy.

In volumes >40 cm3, the CDR was 57% which was signifi cantly higher than that achieved by historical TRUS controls. Th is study reinforces the benefi t of fusion biopsy in prostates in all volumes, but this utility is further enhanced in large volume glands without the potential toxicity associated with increased number of biopsies.

Fusion MIM-Transperineal Fusion Biopsy Has the Greatest Impact in the Biopsy Naive Population Results: During the above mentioned period 246 patients underwent radical prostatectomy. In 99 (40.2%) cases ERP was preceded by mpMRI and PSM was detected in 16 of them (16.2%). In the majority of patients (11/16; 68.7%) with positive margins PCa was locally advanced or Gleason score was greater than 6. Th e margin was focal in 6 (37.5%) cases. Th e most frequent location of PSM was the prostate apex. It occurred in 10 patients (62.5%) and in 7 of them the right side was involved. In 9 (56.2%) patients PSM was detected in a location in which mpMRI did not reveal the presence of PCa. In 5 of them, cancer invaded periprostatic tissues. Macroscopic evaluation of the specimen performed directly aft er the ERP indicated the possibility of PSM presence only in 2 patients but in both cases histological evaluation of the prostate specimen revealed extensive PSM. the peri-prostate fat seen on MRI. Prostate volume was calculated using (height x width x length x π)/6. Peri-prostatic fat density was then calculated using peri-prostatic fat volume/ (Peri-prostatic fat volume + Prostate volume). Peri-prostatic fat ratio was calculated using (peri-prostatic fat volume / prostate volume). Intervention includes cryoablation, brachytherapy, prostatectomy, external beam radiation with or without androgen deprivation therapy.

Results: A higher periprostatic fat density is signifi cantly associated with a higher Gleason Score, p=0.026, odds ratio 32.0. A higher periprostatic fat ratio is also associated with a higher Gleason Score, p=0.004 odds ratio 3.25.Patients with a higher prostate fat density (p=0.003, odds ratio 91.95) and higher peri-prostatic fat ratio (p=0.004, odds ratio 2.87) was also more likely to undergo intervention for prostate cancer (Table 1 ). PSA has no correlation between periprostatic fat and periprostatic fat ratio.

A higher prostate fat density and fat ratio is signifi cantly associated with a higher Gleason Score and a higher likelihood of patient undergoing an intervention for prostate cancer. Peri-prostatic fat density and fat ratio may be an important risk factor in diagnosing patients higher grade prostate cancer.

Laparoscopic . Th e mean urinary pH among the diabetics was 5.61 ± 0.36 and among the non-diabetics was 6.87 ± 0.32, which was signifi cantly lower (p<0.000044).

Conclusions: Th ere is a strong association between type 2 diabetes and Uric acid stone formation. Th ere is also a strong association between diabetes mellitus, BMI, and also with lower urinary pH.

The Most patients 39 (80%) were discharged on good condition while one patient died post-operatively. Majority of patients 39 (80%) stayed in the ward more than 7 days post operation, the long-term post-operative outcome is yet to be assessed.

Conclusion: USD in our local setting seem to aff ect people of low social economic status whose daily activities in the fi elds, livestock keeping etc. mean survival; therefore longer stay in the hospital has a detrimental economic impact. Outdated diagnostic, treatment equipment and technology lead to prolonged hospital stay. Th ere is a need therefore for administrators and urologists in Tanzania to improve quality of management of USD by acquiring aff ordable equipment and technologies.

Percutaneous Nephrolithotomy in an Ambulatory Setting

Introduction and Objective: Percutaneous Nephrolithotomy (PCNL) is the gold standard for the surgical management of large renal stones. Various modifi cations have been done over a period of time to bring down the morbidity of this procedure. Ambulatory PCNL (A-PCNL) aims at short hospital stay which is less than 24 hours with faster recovery aft er PCNL. Th is study aimed at exploring the feasibility and safety of short stay ambulatory PCNL.

: Th e number of PCNL procedure done at our institute annually ranges between 750-900. Hence, carefully selected patients with single renal calculus, size<2cm, BMI <35kg/m2, favorable anatomy, no medical co-morbidities and moreover patients staying within a radius of 15km to the hospital with a supportive well informed family were given the option of A-PCNL. A total of 12 patients underwent A-PCNL from April 2014 to June 2014. All patients underwent totally tubeless PCNL with single puncture, Amplatz size <26F, minimal saline irrigation and puncture site infi ltration with 0.25% Bupivacaine. Postoperatively narcotic analgesics were given; catheter was removed in the post-operative ward and patient was discharged within 24 hrs. Patients were explained regarding the complications of the procedure and need for homecare management.

Results: Ten out of 12 patients had insignifi cant post-operative period. One patient returned aft er 48hrs with loin pain which was evaluated and managed with injectable NSAID. Another patient had hematuria which resolved aft er 72 hours with conservative management. Introduction and Objective: Chronic kidney disease (CKD) is associated with increased cardiovascular (CV) disease, independent of other risk factors. It is unclear whether anaemia develops in the setting of nephrectomy induced CKD, and whether it leads to an increased risk of CV morbidity. We assessed the impact nephrectomy has on renal function and evaluated our cohort for the presence of anaemia in relation to CKD stage and cardiac specifi c morbidity.

Pre-operative, post-operative, and yearly creatinine, Hb and Hct (up to 5 years) was collected from 91 nephrectomy patients between 2006 and 2009. Th e cohort was stratifi ed by cardiac risk factors and the prevalence of anaemia was stratifi ed by each CKD stage. We collected all-cause mortality and CV morbidity and mortality data. Statistical tests were two-sided. Where data was non-normally distributed median values and non-parametric tests were used.

Results: Th e eff ect of nephrectomy on renal function is immediate (pre-operative vs. post-operative Cr: p=0.00) but not progressive (post-operative vs. 5-year Cr: p=0.935). Elderly patients, patients with ≥2 risk factors, BMI≥30 or hypertension had signifi cantly higher post-operative Cr (p=0.00; p=0.003; p=0.046; p=0.041). Advanced age and mild CKD were important risk factors for CKD stage progression. Th e prevalence of anaemia increased as CKD stage increased.

At one year, the prevalence of anaemia was highest in CKD-4 patients (66.7%), compared to CKD-3 (28.6%) and CKD-2 (15.4%) patients. Fift een percent of patients experienced a new CV event; 62% of these patients were anaemic.

Conclusion: Nephrectomy leads to immediate renal function deterioration but with no progression over time. Th e clinical impact of nephrectomy is especially important in elderly patients and in patients with mild pre-operative renal impairment. Th e prevalence of anaemia is more common in patients who have a higher CKD stage aft er nephrectomy, and may be a key risk factor for CV morbidity in nephrectomy patients. We believe that it is important to be able to predict who will progress to clinically signifi cant CKD, in order to optimise comorbidities and aggressively treat complications of CKD, such as anaemia.

Renal Results: Urological complication were observed in 27.06% of all transplants. In an early phase we found that 1.76% of patients showed problems related to the ureterovesical suture (loosening of the suture or attaching the double-J stent in the suture). Suspicion of leakage with the formation of a urinoma was noted in 1.76% of cases. More frequent were the late urological complications: hydronephrosis was seen in 9.41% of cases. When further analyzing this group we discovered a distal ureteral stenosis in 3.53% of all transplants. Persistent hydronephrosis was resolved by reimplantation (3.53%), permanent nephrostomy (1.18%) or placement of a double-J stent (0.59%). A large group of late complications consisted of infectious pathology. Th us 8.82% suff ered from complicated urinary tract infections which slightly more than a quarter of this population presenting with hydronephrosis. Recurrent urinary tract infections without complications were found in 9.41% of transplanted patients.

Conclusion: Currently, the urological team mainly plays a role in the pre-and post-operative phase of renal transplantation. Given the signifi cant compli-cations associated with the ureterimplantation performed during kidney transplantation, we advocate a place for the urologist in the perioperative phase as well. Since the majority of the complications could be related to refl ux pathology, we propose a ureterimplantation with anti-refl ux mechanism. and October 2012, 46 patients were prospectively randomised into two groups. All patients presented with a simple renal cyst underwent ultrasonographic aspiration and injection of a sclerosing agent. In group 1, 25 patients had the cyst injected with EO, and in group 2, 21 were treated with AE. One injection was used in cysts of <200 mL and two injections were used in larger cysts. Complete and partial success were defi ned as complete cyst ablation or a >50% reduction in cyst volume with symptomatic relief, respectively. Patients were followed up using semi-annual ultrasonography and computed tomography for 2 years.

Results: Sclerotherapy was technically successful in all patients. Th ere was no signifi cant diff erence in cyst volume between the groups. Aft er 2 years of follow-up there was complete symptomatic relief in both groups, and the overall radiological success rate was 100% of both groups, at 79% complete and 21% partial in group 1, and 83% complete and 17% partial in group 2. Th e frequency of transient complications in the form of microscopic haematuria was 7% and 13%, and of low-grade fever was 4% and 10% in groups 1 and 2, respectively. A composite outcome parameter, known as "trifecta", has been recently proposed as measure of the surgical quality for partial nephrectomy (PN) procedures. We aim to validate the value of "trifecta" as a predictor of operated kidney functional preservation in a multi-institutional cohort of patients undergoing minimally invasive PN.

We retrospectively reviewed records of consecutive cases of minimally invasive (laparoscopic and robotic) PN performed for cT1 renal masses in 4 centres from USA and Europe from 2009 to 2013. Inclusion criteria consisted of availability of a renal scan obtained within two weeks prior to surgery and follow-up renal scan 3-6 months aft er the surgery. Trifecta was defi ned as a combination of negative surgical margin, zero perioperative complications and warm ischemia of less than 25 minutes. Th e primary endpoint of the study was to compare the degree of ipsilateral renal function preservation in relation to achievement of trifecta. Renal function preservation was defi ned as a proportion of post-operative to pre-operative split renal function assessed by MAG3 renal scan. A multivariable linear regression model was used to determine the independent value of several factors (surgical modality, Charlson comorbidity score, achievement of trifecta, R.E.N.A.L score) to predict ipsilateral split function preservation. Th e logic was that PNET is chemo-responsive and remaining are not.

Results: A total of 26 patients were identifi ed. Th e various histo-pathologies are shown in Table 1 . Group 1 had 20 and Group 2 had 6 patients. Mean age in Group 1 was 60.7 yrs (34-88 yrs) with 17 (85%) males and 3 (15%) females. Tumor was right-sided in 15 (75%) and left -sided in 5 (25%) cases. Th e mean tumor size was 9.55 (5-18) cm. Necrosis was noted in 4 (20%). Level of thrombus was level I in 1, level II in 10, level III in 4 and level IV in 5. Mean age in Group 2 was 25.8 yrs (14-35 yrs) with 3 (50%) males and 3 (50%) females. Tumor was right-sided in 5 (83.3%) and left -sided in 1 (16.6%) cases. Th e mean tumor size was 11.8 (7-16) cm. Necrosis was noted in 2 (33%). Level of thrombus was level I in 0, level II in 5, level III in 0 and level IV in 1. One of these was diagnosed pre-operatively by a biopsy and had received chemotherapy with partial tumor shrinkage. Remaining 5 received adjuvant chemotherapy. Of relevance is that the youngest patient in Group 1 was 34 years whereas the oldest patient in Group 2 was 35 years.

In patients with renal tumors and venous thrombus who are younger than 35 years, pre-operative biopsy should be contemplated. In patients with a diagnosis of PNET, neo-adjuvant chemotherapy can be studied. Introduction and Objective: Th e use of nephrectomy in emergency is increasingly rare due to the improved critical care urinary sepsis and development of radio-embolization. Few series have been reported on this subject. Th e aim of our study was to evaluate current indications, morbidity and mortality and results of nephrectomies performed in our hospital in emergency.

A single-center retrospective study was conducted from January 2007 to December 2013. Twenty patients were operated in emergency from total nephrectomy.

Results: Nine women and 11 men with a mean age 51.7 (46.6 to 85.2) were treated for 9 sepsis on emphysematous pyelonephritis or renal abscess, 4 trauma with haemorrhagic shock, 7 acute bleeding on renal tumours with haemorrhagic shock. One patient required critical care for multiple organ failure. Th e time between the initial care and surgery was 2.7 days (0.5-8). Ten patients were referred to the emergency room by their physician and 10 by a peripheral hospital. All these nephrectomies concerned native kidneys (14 left kidneys). Surgical approach was a lumbotomy for 14 patients and a median laparotomy for 6 patients. One patient died of multiple organ failure following urinary sepsis. One patient required dialysis following nephrectomy. Th e mean follow-up aft er surgery was 17.7 months (0.1 to 48.7).

Conclusion: Th e nephrectomy in emergency remains anecdotal. Uncontrolled urinary sepsis were the main indications. Th e identifi cation of populations at risk of progression to septic shock is essential for faster and reduced mortality in sepsis care.

Experiences of Adrenalectomy for the Incidentally Discovered Adrenal Masses 

Introduction and Objective: A diagnosis of urinary tract obstruction (UPJO) results in a functionally signifi cant impairment of the urinary transport from the renal pelvis to the ureter. Options for the surgical management of UPJO include ureteral stent placement, balloon dilation (antegrade, retrograde or cutting balloon), endopyelotomy, and open or laparoscopic pyeloplasty. However, in some cases, surgery is not eff ective, or too invasive for a particular patient. We herein report ten cases of treatment using bethanecol chloride. We retrospectively reviewed the record of 10 patients, 3 men and 7 women, aged 24 -84 years (mean 50.1) whose diagnosis was UPJO (7 cases of hydronephrosis on the left , 3 on the right). Th e chief complaints were back pain (5 cases) and urinary tract infection (3 cases). One patient had no complaint. All patients took 10mg of bethanecol chloride 3 times a day for two weeks. Aft er two weeks, kidney condition was evaluated using ultrasonography.

Results: Five cases of hydronephrosis decreased or disappeared. Five cases showed no improvement. Among the latter, one had pyelonephritis, two had received laparoscopic pyeloplasty (one of whom had a non-functioning kidney and a pyelonephritis), and another had a non-functioning kidney. 

Guzman Martinez-Valls P, Sanchez Rodriguez C, Doñate Iñiguez G, Maluff Torres A, Honrubia Vilchez B

Introduction and Objective: We present man 63-yearold, hypertensive, diagnosed incidentally of intrathoracic renal ectopia during a constitutional syndrome study. Intrathoracic renal ectopia is a very rare fi nd, with an incidence of less than 1 of every 10,000, which mainly aff ects left kidney since the liver protects the right diaphragm from pressure changes.

A literature review of incidence, source, clinic, diagnostic and treatment of this type of renal ectopia occurs and we present the case diagnosed in our service.

: Chest x-ray shows a mass back in mediastinum so it was decided to ask for Tomography Computer (CT) that shows a hernia left postero-lateral difragmatic with promotion to the thoracic cavity of upper pole and half of the left kidney. Since the patient is asymptomatic and the hernia is extrapleural does not need repairing surgical treatment. Annual checks will be.

Intrathoracic renal ectopia is a very uncommon, usually asymptomatic, fi nding oft en diagnosed incidentally and which does not usually require treatment.

Surgical (53), non-clamp zero ischemia (7). Th e average blood loss was 553ml (range 50ml -3200ml) and 8 patients (12%) required blood transfusion. Postoperatively 10 patients (15%) had surgical complications: severe haemorrhage requiring emergency completion nephrectomy (2), post-operative urinoma formation requiring ureteric stenting (7), pneumothorax requiring tube thoracostomy (1) . Early 30 day mortality occurred in one patient with pre-existing stage 5 chronic kidney disease who died of acute on chronic renal failure. Th e R.E.N.A.L. score of those with and without surgical complications was 7.1 and 8.1 respectively. Th e complication rate of low (score 4 -6), intermediate (score 7-9), and high (score 10-12) R.E.N.A.L. category was 11.8%, 20.8% and 50% respectively. Statistically, blood loss, transfusion rate and surgical complication rate were not signifi cantly associated with medical co-morbidity, R.E.N.A.L. score or mode of ischemia, although more complex mass apparently resulted in more surgical complications.

Our study suggested that partial nephrectomy is a safe operation with acceptable bleeding risk and low complication rate. Further larger scale study is needed to analyze the correlation of complications with renal mass complexity.

Introduction and Objective: Th e sound of running water has been eff ectively used for toilet training during the toddler period. However the eff ect of the sound of running water (SRW) on voiding function for adult male with lower urinary tract symptoms (LUTS) has not been evaluated yet. To determine the eff ect of the SRW on urination of male patients with LUTS, multiple voiding parameters of urofl owmetry with postvoid residual urine (PVR) were assessed according to the presence of the SRW played by mobile application.

A statistically pre-calculated numbers of 18 consecutive male patients with LUTS were prospectively enrolled between March and April 2014, excluding patients with hearing impairment, disability for movement, neurologic disease, urology deformity, and recent history of urinary tract infection or urethral stricture. Urofl owmetry with PVR measured by bladder scan were randomly performed once a week for two consecutive weeks with and without SRW in a completely sealed room away from exterior noise aft er pre-checking bladder volume scanned to be more than 150cc. Th e SRW was played with river water sound among relax melodies recorded in the smart-mobile application.

Results: Th e mean age of enrolled patients and their mean IPSS were 58.9 ± 7.7 years (range: 46-70) and 13.1 ± 5.9. All patients have not been prescribed any medications including alpha-blocker or anti-muscarinic agents in the last three months. A signifi cant increase in mean peak fl ow rate (PFR) with SRW was detected in comparison with PFR without SRW (15.7 ml/s vs. 12.3 ml/s, p = 0.0125). However, there were no diff erences in other urofl owmetric parameters including PVR. Materials and Methods: Over a two-year period, 214 men underwent lumbar spinal fusion by a single neurosurgeon. We excluded men with previous prostate or urethral surgery, a history of urinary retention, men taking alpha-blockers or fi ve alpha-reductase inhibitors, and men with prolonged hospital stay, leaving 148 men evaluable. All men left the operating room with a foley catheter in place and were given a void trial on the day of anticipated discharge. Twenty-three men were unable to void aft er eight hours and had their foley catheters replaced; they were discharged next day with an appointment for urologic follow-up. Th ese men were compared to successful voiders with respect to comorbid medical conditions, age, surgical placement of hardware, operative time, lumbar level, multiple level fusion, and surgical approach.

Results: Using multivariable analysis, successful postoperative voiders were compared with men who failed the initial voiding trial. Only insulin-dependent diabetes mellitus (p-value less than 0.01) and multiple lumbar level surgery (p-value less than 0.01) were predictive of initial postoperative failure of voiding trial.

Conclusion: Men scheduled to undergo lumbar fusion who have insulin-dependent diabetes or who will require multiple level intervention may benefi t from preoperative initiation of alpha blockade at the time of scheduling, as well as an inpatient postoperative urologic consultation.

Introduction and Objective: Heart rate variability (HRV) is a tool to measure autonomic nervous function, however there is no evidence that it is able to defi ne sympathetic hyperactivity in men with LUTS. We suppose that LUTS is diff erent between sympathetic hyperactive and hypoactive patients. Th erefore we measured their HRV, divided LUTS patients into two groups, sympathetic hyperactive group and sympathetic hypoactive group according to the LF/HF ratio, and then compared their clinical situations.

A total of 39 symptomatic LUTS patients (IPSS>8) and 48 healthy volunteers were enrolled. All subjects had no disease which can aff ect autonomic nervous system, such as diabetes, hypertension and so on. Electrocardiographic signals were obtained from subjects in resting state and calculated the HRV indices with spectral analyses. We divided LUTS patients into two groups by LF/HF ratio 1.8 which was mean value in healthy volunteer and compared the diff erence of clinical characteristics, IPSS, PSA and TRUS results. Th e parameters were compared by independent sample t-test using SPSS version 12.

Results: Th ere was no diff erence in age, serum PSA and volume of prostate. Th e comparative results of pa-rameters of HRV between groups (Mean ± Standard Error) are in the Table 1 .

Conclusions: As most investigators believe that LF and HF represent sympathetic and parasympathetic nervous system activity, respectively, our results may suggest that LUTS patients with relatively sympathetic hypoactivity suff er from nocturia more than those with sympathetic hyperactivity. We suggest that the imbalance of the autonomic nervous system activity may be a factor that evokes varieties of symptoms in men with LUTS.

Introduction and Objective: Women presenting with urogenital pain oft en have lower urinary tract symptoms (LUTS). Pelvic fl oor dysfunction and hypertonicity is thought to contribute to these symptoms. Physical therapy and myofascial release are eff ective for both conditions, suggesting a common underlying pathophysiology. We aim to investigate the association among pelvic fl oor tone, LUTS, and pelvic organ distress. Th ere was a tendency of lower hemoblobin decrease in 5ARI group, however, this results was not statistically signifi cant. Th ere were also no significant diff erences in improvement of IPSS, QoL and urodynamic fi ndings between the two groups.

Conclusion: Preoperative use of 5ARI does not compromise, but rather increase the effi ciency of surgery. Th e use of 5ARI is not a contraindication to Th ulium laser vapoenucleation.

Age-Specifi c Relationships between Lower Urinary Tract Symptoms and Late-Onset Hypogonadism Symptoms in the Japanese General Population Introduction and Objective: Aging is known to aff ect sexual, psychological and physiological functions including lower urinary tract symptoms (LUTS). Recent data suggested that severity of LUTS was associated with that of late-onset hypogonadism (LOH) in elderly men. However, information on the association in young adults is limited. In this study, we evaluated the relationship between LUTS and LOH symptoms in young and middle-aged adults. Results: Th e mean ages of the patient and control groups were 40.50±5.12 years and 38.17±2.12 years, respectively (p=0.09). Th e mean IFSF-total and all of the IFSF sub scales (except pain) in the patient group were signifi cantly lower than those of the control group. Th e mean UDI-6 score of the patients was signifi cantly higher than the controls (p=0.001). Th e mean IIQ-7 scores of the patients was higher than controls, however this increase was not statistically signifi cant (p=0.11). Introduction and Objective: SAV1 is one of the core components of Hippo pathway, and this pathway plays a role for cell proliferation, apoptosis and migration through regulation of Yes-associated protein 1 (YAP1). YAP1 is known as an oncogenic protein in many human cancers, but only a few studies demonstrated that YAP1 acts as an oncogene in renal cell carcinoma (RCC). In our previous study, we identifi ed SAV1 was downregulated in high grade clear cell renal cell carcinoma (ccRCC) cases compared with low grade ccRCC cases and re-expression of SAV1 inhibited RCC cell proliferation in vitro. To evaluate a role of SAV1 in vivo, we created a murine xenograft model of human RCC.

A total of 786-O cells with stable SAV1 re-expression (SAV1-1) and control cells (control) were subcutaneously injected into the fl anks of mice, respectively. Th ese two cell lines were also injected into subrenal capsule. Tumor size, histological appearance and proliferation rate were evaluated. Furthermore, transcriptome analysis was performed using a whole-genome microarray, in order to identify functional pathway by Ingenuity Pathway Analysis (IPA) soft ware. To explore whether the identifi ed pathway was involved in Hippo signaling pathway, western blotting was performed using antibodies against downstream proteins. In addition, the luciferase reporter assay was performed to explore whether the promoter activity is regulated by Hippo signaling.

Results: Tumors injected with SAV1-1 showed a decrease of tumor size and growth rate, compared with those of control. By immunohistochemical analysis, it was shown that re-expression of SAV1 caused YAP1 to localize in the cytoplasm. Pathway analysis revealed that TGFβ signaling was found to be inhibited in tumors with SAV1-1. In SAV1 re-expression cells, protein levels of TGFβ were lower than those in control cells. When YAP1 and TEAD were introduced, reporter activity of TGFβ promoter was increased. attached to a linear motion stage with a stepper motor. Shaft buckling was determined by measuring the peak force to compress a 12 cm section of the shaft a distance of 5 cm. Lubricity was measured by extracting each wire through simulated tissue at a constant speed, measuring average force over a 5 second period. Tip fl exibility was determined by isolating the distal 5 cm portion of each guidewire and measuring the peak force required to compress a distance 2.5 cm while securing the tip in a small hole in a wooden block. Perforation force was evaluated by stabilizing each wire in the dilator of a ureteral access sheath and measuring peak force required to perforate aluminum foil. UP.023, Table 3 .

Th e results showed that KH-204 protected TM3 cells against H2O2-induced oxdidative stress in a dose-dependent manner. It improved signifi cantly both the decline of semen parameters and decrease of testicular weight of androgen-defi cient rats at a dose of 400 mg/kg. Also it inhibited the activities of aromatase with and then increase the serum testosterone levels.

Conclusion: Th ese results suggested that the aromatase inhibitory activity of KH-204 may contribute to the improvement of serum testosterone levels in androgen-defi cient male rats.

Introduction and Objective: Although several theories have been suggested, the pathophysiology of interstitial cystitis/bladder pain syndrome (IC/BPS) is unclear. Disruption of the bladder epithelial barrier is an important pathophysiologic theory of IC/BPS, and uroplakin is known to have an important role in the bladder epithelial barrier. Th e change in expression of uroplakin subtypes in the bladder could be related to IC/BPS. We investigated the change in expression of uroplakin Ib and III in the bladders of patients with ulcerative IC/BPS.

Bladder tissue samples were obtained from patients with ulcerative IC/BPS who were treated with augmentation ileocystoplasty. Samples for the control were obtained from normal bladder tissue apart from the malignant lesions of 5 patients with bladder cancer who needed radical cystectomy. A voiding diary, the pain visual analogue scale (VAS), and the O'Leary-Sant interstitial cystitis symptom index (ICSI), and problem index (ICPI) were used to assess patients with IC/BPS before operation. Expressions of uroplakin Ib and III were compared between the ulcerative IC/BPS and control groups by immunofl uorescence staining and Western blotting.

Results: In total, 19 patients with IC/BPS (mean age 56.8 ± 11.6 years, 16 women and 3 men) were evaluated. Th e mean symptom duration was 4.2 ± 2.2 years. Preoperative voiding frequency, nocturia, and functional bladder capacity documented in the voiding diary were 21.1 ± 12.8, 5.9 ± 4.2, and 151.1 ± 62.7 mL (mean ± SD), respectively. Pain VAS score, ICSI, and ICPI were 8.4 ± 1.3, 17.7 ± 2.2, and 14.7 ± 1.8 (mean ± SD), respectively. Th e mean anesthetic bladder capacity was 518.8 ± 201.9 mL. Immunofl uorescence staining showed that uroplakin Ib and III were localized in the urothelium. In Western blot analysis, immunoreactive bands indicating expression of uroplakin III were signifi cantly increased in the IC/BPS group compared with the control group. However, uroplakin Ib expression was not diff erent between the IC/BPS and control groups. green fl uorescence protein cassette, and the infectivity of KSHV was assessed using fl ow cytometry. To investigate viral replication, the levels of expression of representative KSHV latent and lytic proteins were analyzed by immunofl uorescence assay. In addition, cell cycle and proliferation following KSHV infection was analyzed. Finally, cDNA microarray was performed to identify gene changes by infection of KSHV in BC.

Results: Four BC cell lines, except RT4, showed levels of infection similar to or higher than those of HU-VECs. Infectivity of KSHV in TCCSUP and HUVEC cells was similar, but T24, 5637, and HT-1376 cells showed signifi cantly higher infectivity than HUVEC. Our tested KSHV-infected BC cells were latently infected by KSHV. Interestingly, a subset of KSHV-infected BC cells showed higher BrdU incorporation and proliferation rate than non-infected cells. Furthermore, in soft agar colony formation assay, the numbers and sizes of colonies of KSHV-infected cells were signifi cantly greater and larger, respectively, than non-infected cells. cDNA microarray analysis showed that many proliferation and cancer development-related genes were simultaneously up-regulated in KSHV-infected cells. 

Introduction and Objective: Bladder cancer (BCa) is the second common genitourinary tumor, and especially muscle-invasive BCa (MIBC) is poor prognosis. Th erefore, it is important to clarify the mechanism of invasion in MIBC is useful for the strategy of appropriate treatment. Previously, we have showed HGF-MET signaling is correlated with invasion in BCa cells. Here, we investigate the eff ects of MET inhibitor, Cabozantinib (XL184), in BCa cells

To investigate the significance of MET upregulation in RT4, 5637, J82, T24, UM-UC-3 cells, we conducted Western blot analysis. Next, we examined eff ect of Cabozantinib on proliferation and invasion abilities using MTT and Matrigel invasion assays. Invasion assays were performed by the xCELLigence system. Moreover, to investigate biological function of HGF-MET signaling, we analyzed gene expression profi le and real time PCR of 5637 cells which cultivated with or without HGF stimulation. . Th e mechanical properties of scaff olds were measured to compare tensile strength between two types. For in vitro cell study, scaff olds were seeded with human fi broblast cell at 5 x 105 cells and were cultured for up to 2 weeks. Th e ability of these scaffolds to support fi broblast cell growth was also investigated in vitro.

Results: 3D strand-deposited scaff olds were characterized by SEM images and porosity measurement. SEM images showed the surface morphology of PCL scaff olds. Th e Young's modulus of 90°PCL was 20.7±4.8 MPa, and 45°PCL was 12.5±4.0 MPa, respectively. Human fi broblast cells covered well the surface of the scaff olds. Immunofl uorescent staining of α-ER-TR7on fi broblast cells/scaff olds confi rmed that the cells remained viable and proliferated throughout the time course of the culture.

Th is is a preliminary study to investigate the possibility of using 3D bioprinting technique for tissue engineered tunica albuginea.

Introduction and Objective: Aft er 35-40 years at people the decrease in a pool of pluripotent stem cells resulting in insuffi ciency of replenishment of cellular structure of cambial zones and, as a result, to incomplete replacement of the perishing old cells is observed. In reply surrounding epithelial and endothelial cells, and also the macrophages, attracted with death of old cells, stimulate cells division of growth zones by the cellular growth factors (Pechersky A.V. et al., 2008) .

To 11 patients aged from 52 till 76 years with a cancer of a kidney, bladder, prostate gland of a stage of T2-T4 the chemotherapy or target therapy was carried out. To 4 patients of 60 -82 years for restoration of regeneration it was carried out from 4 to 7 transfusions of mononuclear fraction of peripheral blood, same-gender and blood types with recipients.

Results: In 1 month aft er carrying out chemotherapy or target therapy aft er development of a leukopenia in 11 patients the level of the basic fi broblast growth factor (bFGF) increased on average by 1.74 times, at 4 patients from them the increase in level of the human vascular-endothelial growth factor (human VEGF-A) on average by 1.25 times was observed, the 3rd of them had an increase in the human epidermal growth factor (human EGF) on average by 1.13 times. In 3-6 months aft er the last transfusion of mononuclear fraction of peripheral blood the maintenance of hemopoietic cells predecessors of CD34+ in peripheral blood increased on average by 3.25 times (at 4 patients with 1 to 2-5 cells in 1 mcl). At 4 patients the level of the basic fi broblast growth factor (bFGF) decreased on average by 1.78 times, at 2 patients from them reduction of level of the human vascular-endothelial growth factor (human VEGF-A) on average by 1.48 times was observed, the 3rd of them had a reduction an human epidermal growth factor (human EGF) on average by 4.12 times. Decrease in levels of cellular growth factors naturally brought at all 4 patients in a buccal epithelium to decrease in an expression of p53 on average by 6.02 times, at the 3rd of them to decrease in an expression of bcl-2 on average by 60.0 times.

Excess stimulation of mitotic activity at people 40 years are more senior it is possible to lower to normal level by means of restoration of number of a pool of pluripotent stem cells by transfusion of mononuclear fraction of the peripheral blood from young donors of 18-23 years of one with the recipient blood types and a sex.

Mashhadi R To compare the expression rate of sex steroid hormone receptors of estrogen (ER), progesterone (PR) and androgen (AR) in normal urothelium and urothelial bladder cancer (UBC) and to evaluate the possible associations of these receptors expression with cancer progression and patient's survival.

We evaluated the clinical data and tumor specimens of 120 patients with patho-logically confi rmed primary UBC with 132 normal healthy controls. Both patients and controls selected from list of subjects who have been referred to Sina Urology clinic, and had a minimum of one year follow-up duration. Data collected from medical cords. For evaluation of expression, immunohistochemistry was performed on paraffi n-embedded tissue sections using a monoclonal antibody for androgen, estrogen and progesterone receptors. Presence of at least 10% positive cells defi ned as positive expression.

Results: None of the control subjects showed AR expression, while 22% of the patients were AR-positive. ER/PR expressions were observed in 4.2%/ and 2.5% of the cases and in 2.3% and 1.5% of the controls, respectively. A statistically signifi cant correlation was found between AR expression and tumor stage and grade (P < .001). AR-positive patients showed a signifi cantly poorer prognosis than AR-negative cases (log-rank test, P = .02, hazard ratio = 2.12; 95% confidence interval: 1.36-4.65).

Conclusion: AR expression was signifi cantly associated with higher grade and poorly diff erentiated tumors with unfavorable outcome. AR expression test might be useful as a diagnostic tool for determining the malignancy and outcome of UBC patients.

Park S, Park W, Yoon S

Introduction and Objective: Previous researchers consider interaction roles of AMPK and ROS as a regulator of cancer cell apoptosis and cancer invasiveness in hypoxia and oxidative stress. Th e aim of this study was to fi nd out the other aspect of invasion and cell death mechanisms as a new treatment option in urothelial cancer.

We performed western blot analysis to determine association between AMPK regulator (compound C, AICAR) and ROS scavenger (NAC and TEMPOL) as cytotoxic eff ectors. Using gelatin zymography to measure MMP-2, 9 activity, we evaluated the cancer invasion. Pathway activation analysis was also determined by western blot. Cell survival was investigated by MTT analysis.

Results: ROS scavenger like NAC and Tempol treated cells showed no change of expressions of phospho-AMPK. AICAR, compound C and tempol treated cells showed no change of MMP-2 and MMP-9 expressions. However, NAC treated cells showed decreased expressions of MMP-2 and MMP-9. AI-CAR and compound C treated cells with or without added NAC and tempol showed no change of mTOR and phospho-mTOR expressions. AICAR treated cells only showed decreased expression of phospho-P70S6K. Compound C and tempol treated cells did not showed statistically any change in cell counts. However, AICAR and NAC treated with or without added Compound C and tempol showed increased cell death signifi cantly.

Conclusions: Activator of AMPK and ROS scavenger like NAC decrease T24 invasion activity and increase T24 cell death. So, we demonstrate that the cytotoxic mechanism of bladder cancer remains to be further investigated.

Epigenetic Bladder cancer is still one of common human malignancies which some environmental agents play important role in the process of carcinogenesis, such as aromatic amines or chronic arsenism, and easy to be recurrent and progressive despite of therapy. It is continuing to search some novel genetic or epigenetic biomarkers and to investigate their signifi cance in bladder urothelial carcinoma. DOC-2/DAB2 (diff erentially expressed in ovarian carcinoma-2/disabled-2) interacting protein (DAB2IP), a novel family of Ras GTPase-activating protein family, is a potent tumor suppressor gene. Th e objectives of this study are to explore the prognostic values of DAB2IP expression and the possible regulatory mechanism in superfi cial bladder cancer.

With IRB consent and patient permit, eight human urothelial cancer cell lines and 64 superfi cial bladder cancer tissues were available for exploring DAB2IP expression using western blotting and immunohistochemical staining, respectively. Th e prognostic signifi cance of DAB2IP expression in term of recurrence and progression were analyzed with log-rank test. Aft er treated with demethylizing agents Trichostatin A (TSA) and 5-Aza 2' deoxycytidine (AZA) separately and together, 8 urothelial carcinoma cell lines were then tested with DAB2IP mRNA expression using quantitative RTPCR. Data mining was also done using published mRNA diff erential array (Dataset GSE 18423). 

Th irty patients with non-muscle invasive bladder cancer and 30 agematched healthy controls were included in the study. Peripheral blood samples were obtained from the patients before transurethral resection of bladder tumor (TURBT), twenty days aft er the operation (fi rst control) and at the end of intravesical immunotherapy (second control). VEGF-2, MMP-2, ES and TSP-1 were measured by enzyme-linked immunosorbent assay (ELISA). Th e mean marker levels of the patients and controls were statistically compared. Th e mean marker levels of the patients before TURBT, in the fi rst and second control were also compared.

Results: Th e mean age of the patients (6 females and 24 males) and controls (6 females and 24 males) were found to be 67.27±8.44 and 65.74±7.22, respectively (p=0.54). Although the mean VEGF and MMP levels in the patients before TURBT were signifi cantly higher than the controls (p<0.001 and p<0.05, respectively), there were no diff erences between the mean ES and TPS-1 levels (p=0.53 and p=0.67, respectively). Th e WEGF-2 and MMP-2 levels signifi cantly decreased aft er TURBT (p<0.001 and p<0.05, respectively). Th ese reductions continued aft er intravesical immunotherapy, but these diff erences between fi rst and second control were statistically insignifi cant.

Th is study showed that elevated angionenic factors in the patients with bladder cancer decreased aft er the treatment. We think that VEGF and MMP may be used for the follow-up and therapy of non-muscle invasive bladder cancer.

Prognostic Results: Nitrose oxide level and bFGF expression were signifi cally elevated in patients with urothelial carcinoma associated with chronic bladder infection, normal urothelium showed low levels of NO and low expression of bFGF.

Conclusion: Th e association of elevated levels of nitrose oxide and over-expression of bFGF indicated that the angiogenic peptide bFGF had been modulated by nitrose oxide. Th ese results would indicate an anti-angiogenisis target therapy in urothelial carcinoma associated with chronic bladder infection.

The Relationships between Increase of Serum Creatinine and Recurrence of Nonmuscle Invasive Bladder Cancer after Transurethral Resection of Bladder Tumor Introduction and Objective: While impaired renal function had a negative impact on the prognosis of invasive bladder cancer by infl uencing stage of tumor and selection of treatment modality, the relationships between the change of renal function and prognosis of non-muscle invasive bladder cancer (NMIBC) have not yet been studied. Preliminarily, we investigated the impact of increased serum creatinine and recurrence of NMIBC.

A total of 74 patients who underwent transurethral resection of bladder tumor (TURBT) with minimum follow-up of 40 months were divided into two groups based on with (n=41) or without recurrence (n=33). Th e changes of serum creatinine from the preoperative baseline to the time of recurrence were evaluated (Δ creatinine). For subjects without recurrence, serum creatinine was measured at 36 months aft er TURBT. Th e impact of variables including characteristics of host (age, sex, past medical history, BMI, and smoking history), tumor (location, size, and grade), and laboratory data on recurrence of NMIBC were then analyzed. 

Tsai Y 1 , Jou Y 2 , Tsai Y 1 , Liu B 3 , Lin H 4 , Wei C 3 , Chen S 5 , Tsai H 1 , Tzai T 1 Introduction and Objective: Bladder cancer is a common human malignancy and exhibits a life-long risk of disease recurrence and progression. It is continuing to search some simple, innovative biomarker to monitor the disease status in order to diminish the suff ering during cystoscopic follow-up. Th e metabolite of tryptophan aft er indoleamine 2,3-dioxygenase (IDO) digestion, 3-Hydroxyanthranilic acid (3-HAA) is conventionally thought to be a potential biomarker for bladder cancer occurrence. Th e aim to study is to investigate the diagnostic potential of an integrated a 3-HAA-based biosensor for urothelial carcinoma of the upper tract and urinary bladder.

Human urothelial cancer cell lines and human urothelial carcinoma tissues as well as adjacent benign tissues were available for exploring IDO expression, including western blotting and immunohistochemical staining. Patients who received urological surgery were enrolled for urine 3-HAA testing using an integrating biosensor for 3-HAA. Some of urine specimens were investigated with high performance liquid chromatography (HPLC) assay.

Results: From western blotting assays, eight human urothelial carcinoma cell lines exhibited more IDO expression than the immortalized cell SV-HUC. Both of urothelial carcinoma of urinary bladder and upper urinary tract exhibited more IDO immunoreactivity than those of the adjacent benign bladder, ureteral or cortical tissues (chi-square test, p=0.0073). Th ere is a moderate correlation for urine 3-HAA measurement based on between HPLC and the biosensor assays (r2=0.47, p=0.0033). Besides, the 3-HAA content within the cultured media of TCCSUP and BFTC905 measured with biosensors signifi cantly increased with incubation time (p <0.0001). Finally, Patients with urothelial carcinoma of bladder and upper tract have higher urine 3-HAA levels than those without recurrence or benign urological disease, such as BPH, or hernia (unpaired t-test, p=0.028), except for urolithiasis.

Conclusion: Th e integrated biosensor exhibited a modest accuracy in urine 3-HAA detection. Both of urothelial carcinoma of urinary bladder and upper tract exhibited higher IDO expression and its metabolite 3-HAA in urine. 

How a Cancer Spreads: Public Awareness of Genitourinary Cancer

Introduction and Objective: Patients' perceptions of disease can aff ect the diagnosis and treatment of the disease. It is diffi cult to give a defi nite answer to the questions; "Can genitourinary cancers be spread around during coitus or in public bathtub?". Doctors know that there is no evidence that cancers can be spread in this way, however many people don't know that. Th e objective of this study was to investigate the public awareness of genitourinary cancer.

One hundred and forty nine patients who have visited outpatient department of urology completed a self-administered questionnaire from June 2013 to July 2013. Th e questionnaires included epidemiologic information about age, gender, residential area, level of education and yearly income and the questions whether prostate cancer and bladder tumor could spread out during coitus or bathing. Returned responses to 11 questions were analyzed.

Results: A total of 149 of 160 (93%) patients completed the questionnaires. Mean age was 65 years, and 87 (58%) men and 62 (42%) women were included. Th e residential area were metropolitan in 117 (79%), urban in 18 (12%), and suburban in 13 (9%), respectively. Th e level of education were middle school graduates in 43 (29%), high school graduates in 54 (36%),

and college graduates in 52 (35%), respectively. Th e yearly incomes were under 30,000 dollars in 79 (53%), 30,000~50,000 in 54 (36%), and over 50,000 in 16 (11%), respectively. Seventeen (11%) and 7 (5%) patients answered that they thought that bladder tumor could spread during coitus and bathing, respectively. Likewise 18 (12%) and 3 (2%) patients answered that they believed that prostate cancer could spread during coitus and bathing, respectively. Moreover, young patients (<40 years) reported that they have the opinions that coitus spreads prostate cancer (25%) and bladder tumor (21%). Of college graduates, 17% and 15% reported that they thought coitus spreads prostate cancer and bladder tumor, respectively.

Conclusion: A signifi cant proportion of patients believed that prostate cancer and bladder tumor could spread during coitus. Furthermore, even young and highly educated people also tended to have this misbelief.

Protoporphyrin We evaluated the feasibility of photodynamic diagnosis of bladder cancer by spectrophotometric analysis of voided urine samples aft er extracorporeal treatment with 5-aminolevulinic acid (ALA). Further, we investigate the protein that plays a key role in increased accumulation of protoporphyrin IX in bladder cancer cells.

Sixty-one patients with bladder cancer, confi rmed histologically aft er the transurethral resection of a bladder tumor, were recruited as the bladder cancer group, and 50 outpatients without history of urothelial carcinoma were recruited as the control group. Half of the voided urine sample was incubated with ALA, and the rest was incubated without treatment. Intensity of the samples at the excitation wavelength of 405 nm was measured using a spectrophotometer. Th e diff erence between the intensity of the ALA-treated and ALA-untreated samples at 635 nm was calculated for photodynamic diagnosis of bladder cancer. Immunohistochemistry was used to estimate the expression of peptide transporter 1, hydroxymethylbilane synthase, ferrochelatase, ATP-binding cassette 2, and heme oxygenase-1 in samples from 75 patients who underwent transurethral resection of bladder tumors. Th e correlation between the expression of each protein in cells from resected bladder specimens and accumulated protoporphyrin IX in bladder cancer cells in voided urine was evaluated using Pearson's correlation analysis.

Results: Th e area under the curve was 0.84. Sensitivity and specifi city of the method were 82% and 80% respectively. Th e expression of peptide transporter 1 (p < 0.01, R = 0.39), heme oxygenase-1 (p < 0.01, R = 0.33), and ferrochelatase (p < 0.01, R = 0.75) was correlated with the accumulation of protoporphyrin IX in bladder cancer cells in voided urine.

We demonstrated that protoporphyrin IX levels in urinary cells treated with ALA could be quantitatively detected by spectrophotometer in patients with bladder cancer. Th e expression of ferrochelatase plays a key role in the accumulation of protoporphyrin IX in photodynamic diagnosis of bladder cancer.

Assessment of Visual Inspection as a Tool to Determine Pelvic Drain Fluid Type following Radical Cystectomy Crozier J, Papa N, Lawrentschuk N

Introduction and Objective: Following radical cystectomy, patients generally spend a period of days under observation on a urology ward. During that time, staff closely monitor pelvic drain output to assess for the possibility of a urine leak. We aim to investigate the ability of medical and nursing staff to correctly identify pelvic drain fl uid type using visual inspection alone.

Investigators collected a series of de-identifi ed images showing pelvic drain fl uid in patients post radical cystectomy. Th e fl uid type in each image was confi rmed by measuring creatinine level. Investigators then attended a Victorian public hospital urology meeting and a Victorian GP conference. Attendees were invited to participate in a study. Present staff included consultant urologists, urology registrars, urology residents, urology nurses, medical oncologists, radiation oncologists, general practitioners and medical students. Participants were then provided with a survey. Th ey were asked to indicate their level of experience working on a urology ward, the number of years since graduation from their primary medical or nursing degree. Participants were then shown the series of pelvic drain fl uid images on a project. Th ey were asked to correctly identifying the fl uid type in each image. Using the survey, participants had the option of choosing either urine or peritoneal fl uid.

Results: All groups poorly identifi ed fl uid type. No individual staff group was signifi cantly better at identifying fl uid type. Level of experience on a urology ward and years since graduation do not infl uence ability to determine fl uid type.

Conclusion: Visual inspection of pelvic drain fl uid is a poor determinant of fl uid type. 

Chang Y, Hsiao P, Chen G, Lee S, Huang C, Wu H, Yang C, Chang C

Introduction and Objective: Muscle invasive bladder urothelial cell carcinoma occasionally mixed with squamous diff erentiation. We conducted this study to investigate the incidence and treatment outcome of bladder urothelial cell carcinoma with squamous component.

We enrolled 93 patients muscle invasion bladder cancer who received radical cystectomy with bilateral pelvic lymph node dissection during 2008 to 2014. Patients' characteristics, chemotherapy record, and pathological report were retrospectively reviewed. Th e following endpoints were assessed: overall survival (OS) and recurrence-free survival (RFS). Response of neoadjuvant chemotherapy subgroup was also analyzed. All survival data were analyzed by the Kaplan-Meier method using a log-rank test and multivariate analysis was carried out using a Cox proportional hazards regression model. Results: It was very clear that more than one third of these cases coming from the south of Saudi Arabia (34.65%). Th e bilharzia infestation found in (25.07%) of the cases most of them are the southern patients. Th e T staging turn to be high in most of our cases (30.14% are T3B). Squamous cells carcinomas was also a striking feature of our result and found in (23.66%). Lymph node involvement found in one fourth of these cases (25.63%). A total of (26.76%) had local or lymph node recurrence and (28.17 %) got distant metastasis. Around 94% (337 cases) of our result showing that these cases having high grade and around 40% (292 cases) had a hydronephrosis upon presentation. Bladder cancer as a cause of death because of its advancement or recurrence account for (76.13%) of deaths happened in these cases. Th e survival of these cases severely aff ected by the fact that 110 cases (30.99%) could not know there survival status because they stop to show up in our institute for follow-up in spite the fact that there are some of them followed for more than 5 years.

Arabia showing that the bilharzia infestation is quit high especially in the south and the squamous cell cancer is not as low as we expected. Finding of hydronephrosis, lymph node involvement, high T and high recurrence in high percentage of our cases indicating that the bladder cancer aggressiveness behavior is not changing over 35 years.

Introduction and Objective: Th is is an observational retrospective study utilising long-term patient follow-up for 15 years (ys). To determine the survival and quality of life in women with age range 20-54 years, who had been treated for carcinoma of the bladder with radical cystectomy with preservation of genital organs.

Materials and Methods: Study included 13 women patients with invasive urothelial carcinoma of the bladder treated with genital sparring radical cystectomy during the period from 1995 to 2006. Th ey had orthotopic ileal neobladder. Follow-up included recurrence-free survival, metastases-free survival, overall survival, continence, and sexual function.

Results: Overall survival up to 10-15 ys was in 8/13 women (61.53%). Survivors up to15 ys were in 4/13 (30.77%). Survival from 5 to 9 ys was in 5/13 patients (38.46%). Tumours stage of T1 were 4/13 patients, T2 were 5/13 patients, and T3a were 3/13 patients. Tumour grade was G1 in 3/13, G2 in 9/13, and G3 in 1/13. Age range of 20-37 ys were 7 patients, range of 38-45 ys was 3 patients, range of 46-54 ys was 3 patients. Continence was good in10/13 patients; three patients 3/13 needed CIC. Sexual function tested by FSFI over<20-30 was (84.61%).

Conclusion: Th e study provide evidence of safety and effi cacy of radical cystectomy with sparing of genital organs in women aged 20 to 54 with low grade, low stage invasive urothelial carcinoma of the bladder. Oncological outcome for 5-15 years was good; continence and sexual function were very good. Th is procedure should be considered when surgical approach appears to be feasible.

Tan W, Sherer B, Nehra A, Deane L

Introduction and Objective: Radical cystectomy for bladder cancer has been the surgical gold standard for decades. Increasingly, experience with robotic assisted techniques has become more common in select centers. In the majority of instances, the urinary diversion has been performed extracorporeally and with the use of stents. Herein, we report our center's initial experience with robotic radical cystectomy and stentless totally intracorporeal urinary diversion.

A retrospective review of the medical records of all patients undergoing robotic cystectomy and intracorporeal diversion was conducted at RUMC from 2013-2014. Specifi cally, attention was focused on perioperative parameters.

Results: A total of 5 patients were identifi ed (Male=3, Female=2) in the sample. Four patients underwent intracorporeal ileal conduit reconstruction and one patient underwent totally intracorporeal ileal neobladder reconstruction. No patients received a pre op bowel preparation, post op PCA or epidural and all were allowed oral intake early. No patient received a transfusion for operative blood loss. One patient was readmitted for dehydration. See Table 1 for details.

Conclusion: Robotic assisted radical cystectomy with stentless intracorporeal diversion is safe and feasible. Eliminating bowel preparation, PCA and epidural, and incorporating early refeeding and ambulation may result in a shortened length of stay. A rigorous post-operative plan to optimize return of bowel function, permit rapid reintroduction of diet without restrictions and facilitate early ambulation is critical in improving outcomes for this patient population.

Computed UP.055, Table 1 .

and hypermethylation of these two gene promoters. In order to investigate clinical usefulness for noninvasive bladder cancer detection, we further analyzed the methylation status in urine samples of bladder cancer patients. Methylation of the tested genes in urine sediment DNA was detected in the majority of cases that were hypermethylated in tumor samples (93.7%) and the frequencies were 79.3% 70.8% and 96.3% for APC, RARβ and Survivin, respectively.

Our results indicate that methylation of APC, RARβ and Survivin gene promoters is a common fi nding in patients with bladder carcinoma. Th e ability to detect methylation not only in bladder tissue, but also in urine sediments, suggests that methylation markers are promising tools for noninvasive detection of bladder cancer.

Usefulness of the All cases were followed for over 1 year. Th e procedure is 1) point marking; 2) circular incision; 3) level incision; and 4) specimen retrieval using a needle electrode in accordance with the Ukai's method. We investigated pathological fi ndings (margin situation), operation time, complications and recurrence.

Results: It is possible to diagnose the precise pathological fi ndings by TURBO. We judged the width and depth ew in sequential section. Th ere were few complications during and aft er the operation. Operation time of TURBO (28-171 min) was longer than conventional TURBT. Urethral catheter holding period and hospitalization period aft er TURBO was the same as TURBT. TURBO is a relatively safe procedure even for beginners. Twenty cases had a recurrence in 50 cases. Eleven cases had a recurrence in under 1 year, but the same place recurrence was 4 cases. Th ere were few cases of same place recurrence in under 1 year among margin-negative cases. Th erefore we judged that ew-negative cases had no residual cancers.

Conclusion: TURBO is a safe and useful procedure that provides precise pathological fi ndings with minimal complications. Second TUR is not necessary for TURBO. TURBO has a possibility to be gold standard of the treatment for non-muscle invasive bladder cancer (NMIBC).

The Risks of Bladder-Preserving Bacillus Calmette-Guérin Therapy in High-Grade Non-Muscle-Invasive Bladder Cancer Continuous physical activity has many eff ects on human body. It doesn't only strengthen the skeleton or muscles; it also affects cardiovascular system, nervous system and etc.

In this research we wanted to fi gure out if continuous physical activity (CPA) eff ects the lower urinary tract symptoms in retired military offi cers or not.

Th is is a retrospective study. Retired offi cers attending to urology clinic for annual prostate control and not using any drugs for prostate were enrolled in this study. Aft er the patients' permission were taken for the study they were asked for CPA or not and their international prostate symptom scale (IPSS) answers were compared.

Results: Th ere were 22 patients in CPA group and 17 patients in non-CPA group. Th e mean age is 59 (45-71) in CPA group and 58.94 (47-71) in non-CPA group. Answers of questions in IPSS: Incomplete emptying (p=0.001), frequency (p=0.001), urgency (p=0.001), and straining (p=0.000) were detected statistically rare in CPA group (Table 1) . Although they were not statistically signifi cant, intermittency (p=0.1), weak stream (p=0.06) and nocturia (p=0.5) were rare in CPA group too (Table 1) .

In order to maintain a better lower urinary tract function, elderly men should continue their physical activity aft er retirement. Conclusions: Th e number of nocturia episodes was signifi cantly and linearly correlated with IPSS total score, voiding, storage, QoL and NIH-CPSI voiding scores. However, other risk factors, including BMI, body fat percentage, blood pressure, BUN, creatinine, lipid panel, CK, T3, free T4, prostate-specifi c antigen, serum testosterone levels, urine fl ow (assessed using urofl owmetry) and prostate size (assessed using transrectal ultrasound and digital rectal examinations) were not associated with the number of nocturia episodes, despite an a priori assumption that they all infl uence nocturia risk.

Risk Results: Symptom prevalence increased to 13.1%, and the mean International Prostate Symptom Score increased by 2.6 points during 3 years. Aft er adjusting for confounders, smoking history of ≥50 pack-years was an independent risk factor for symptom deterioration and storage sub-symptoms, compared with non-smokers (3.1 and 5.1 odds, respectively). Physical activity had a protective eff ect for voiding sub-symptoms. High daily protein intake exacerbated the storage symptoms. However, alcohol intake was not associated with symptom deterioration.

Conclusions: Th e symptom prevalence among elderly men living in a suburban area increased to 13.1%, and the International Prostate Symptom Score increased by 2.6 points during 3 years. Smoking history, physical activity, and protein intake were associated with symptom deterioration. However, there was no signifi cant association with alcohol intake and symptom deterioration.

Russo G, Castelli T, Urzì D, Privitera S, Fragalà E, Favilla V, Cimino S, Morgia G

Introduction and Objective: A signifi cant amount of epidemiological evidences have underlined an emerging link between MetS, benign prostatic enlargement (BPE) secondary to benign prostatic hyperplasia (BPH) and related lower urinary tract symptoms (LUTS). We aimed to assess the connections between lower urinary tract symptoms (LUTS) related to benign prostatic enlargement (BPE) and metabolic syndrome (MetS) with its components. 

Is Increased Prostatic Urethral Angle Related to Lower Urinary Symptoms in Male without Prostatic Obstruction?

Introduction and Objective: Th e prostatic urethra is a bent tube, and the clinical signifi cance of the prostatic urethral angle (PUA) was recently reported. We investigated the statistical signifi cance of an increased PUA on the International Prostate Symptom Score (IPSS), with LUTS/BPH.

A prospective analysis was made of 74 patients (64.50±7.95 years) with LUTS and/or BPH. Patient underwent an evaluation including the IPSS, PSA, transrectal ultrasonography, urofl owmetry, and measurement of post-void residual. PUA were measured by cystourethroscopy ( Figure 1 ). In order to minimize the eff ect of prostate, patients with prostatic obstruction under cystourethroscopy were excluded. Th e minimum PUA degree of symptoms change was constructed as a predictor of the eff ect of medication. All patients received tamsulosin 0.2mg during the fi rst 2 weeks and 0.4mg during the next 4 weeks.

Results: Th e PSA, prostate volume and PUA were 1.26±1.13ng/ml, 26.58±8.76ml and 26.32±6.77°, respectively. Th e area under the ROC curve was 0.542 at the 23 degrees with a sensitivity of 40.0% and a specifi city of 80.0%. Comparing a higher PUA (over 23 degree, Group A) with a lower PUA (under 23 degree, Group B), patient with a higher PUA had a longer LUTS period (p=0.026), an improvement of symptoms aft er medication (p=0.0374) and an increase of average fl ow rate (p=0.032). However, there was no signifi cant diff erence in age, PSA, post-voided volume between the two groups.

Conclusion: PUA showed signifi cantly correlated with the improvement of IPSS, the eff ect of medication, and urofl owmetry. Our fi ndings suggest that PUA under cystourethroscopy may be one method to assess the presence of LUTS in men and help in the treatment of individuals by better predicting their likely classifi cation from IPSS, urofl owmetry, and prostate volume. However, further studies are needed to explore the mechanisms and the eff ects of PUA under cystourethroscopy.

Introduction and Objective: Th e prevalence of lower urinary tract symptoms increased with age. It is known that irritable bladder symptoms such as urinary frequency, urgency, nocturia increased with age in many studies. Recently it was reported that vascular calcifi cation was one of the cause of lower urinary tract symptoms. We studied to evaluate the association between lower urinary tract symptoms of vascular calcifi cation in the abdominal CT using by Agar score.

Th e records were obtained from a retrospective database who underwent abdominal CT due abdominal pain, hematuria. Sex, age, height, weight, prostatic size, calcifi cation of aorta and internal iliac artery, amount of subcutaneous fat and visceral fat in the umbilicus level, International Prostate Symptom Score, overactive symptoms score and urofl owmetry were assessed. Calcifi cation of aorta was estimated from renal artery bifurcation to iliac artery bifurcation level. And internal iliac artery calcifi cation was calculated from bifurcation of iliac artery to bladder. We scanned each subject of 0.5cm interval on the CT scan. Th e calcifi cation of blood vessels was measured as Agar score using abdominal CT Aft er our explaining about each contents of NIH-CP-SI and IIEF-5, the paper was checked by volunteers in person, and then we collected it. Th e subjects were limited to 40-50s Korean male. We analyzed the collected questionnaires, and considered men who have perineal and/or ejaculatory pain or discomfort and a total NIH-CPSI pain score of ≥4 as having prostatitis-like symptoms, and categorized to four groups by IIEF-5 score, Mild (17-21), Mild-Moderate (12-16), Moderate (8-11), Severe (5-7).

Results: An average age of 1032 volunteers was 50 years old (42-59). Th e IIEF-5 category was divided to fi ve groups. Among total volunteers, 72 persons were chronic prostatitis like symptom patients (6.9%), and whose NIH-CPSI average of pain score, voiding score, quality of life score and total score were 7.6±3.1, 4.3±2.5, 5.8±2.3, and 17.8±6.7, respective-UP.064, Figure 1 . ly. Th ere were a little correlations among pain score, voiding score, Quality life score, but not signifi cant. An average of total IIEF-5 scores in chronic prostatitis like symptom patients was 14.0±6.8, it was signifi cantly lower than absent group. Th ere were all negative correlations of between IIEF-5 and Pain score (t=-6.199, r2= 0.036, p=0.000), voiding score (t=-0.157, r2 = 0.025, p=0.000), QOL score (t=-7.845, r2= 0.056, p=0.000), and total score (t=-9.366, r2 = 0.078, p=0.000).

Conclusion: Th e higher total NIH-CPSI score, especially pain score plays a larger role, adversely aff ects erectile function of chronic prostatitis like symptom patients in 40-50s Korean male.

A Antimuscarinic agent is the mainstay of treatment, but it have side eff ects such as dry mouth, constipation. Th ese eff ects resulted in cessation of medication in many cases. Th e authors therefore assessed the impact of side eff ects on health-related quality of life (HR-QoL) through an analysis of questionnaires.

Th is study was designed to investigate the patients' satisfaction by quality weight (utility weight) of health status as aff ected by the side eff ects of OAB medications in 4 tertiary hospitals in Korea. Patients who had OAB symptoms lasting longer than 3 months and side eff ects aft er any antimuscarinic treatment fi lled in the EQ-5D. Th e questionnaire and VAS score for two diff erent health statuses, presence or absence of side eff ects, were analyzed. Quality weight was calculated using the score of ED-5D health status.

Results: One hundred patients were enrolled. Th e most prevalent side eff ect was dry mouth (61%), followed by constipation (4%). Twenty-eight percent of the patients had dry mouth and constipation concurrently. Most of the patients with side eff ects tried to overcome these side eff ects (79%), but 10% desired a change in medication, and 6% stopped medication altogether. Fift y-fi ve patients replied that they consider side eff ects to be an important factor in deciding on the continuation of medication. Th e quality weight of EQ-5D without side eff ects was 0.863, while the quality weight with side eff ects was 0.666 (p=0.00000014). Th e VAS score was 79 in patient without side eff ects and 57 in those with side eff ects, supporting the results of quality weight assessment. Th e same trend was observed when stratifi ed according to age and sex. As for the overall distribution of ED-5D, the patients with side eff ects were less healthy in terms of daily life, pain/discomfort, and anxiety/depression. 

Introduction and Objective: Treatment of men with large prostates is challenging with greater risk of complication and retreatment. While photo-vaporization (PVP) has been well described for GreenLight 180W-XPS, vapor resection techniques have been described to help improve tissue resection, including vapour-incision techniques (VIT). We sought to evaluate the effi ciency, safety and outcome parameters between GreenLight PVP and VIT specifi cally for men with prostate volumes >80.

Among 955 XPS cases retrospectively collected from 5 experienced surgeons at high-volume GreenLight XPS centers, 271 had large prostates. Preoperative, operative and post-operative parameters were collected and compared between groups.

Results: As summarized in Table 1 , men undergoing VIT (n=100) had comparable preoperative parameters to those undergoing PVP (n=171). While VIT allowed greater delivery of energy (4.2vs3.2 kJ/g), operative time was longer and there was greater need for >2fi bres. Th ere were no diff erences in intra-and 90day post-operative adverse events. Both VIT and PVP demonstrated comparable marked improvements in IPSS/QOL at 6 months post-operatively. However, despite greater urinary retention and PVR preoperatively, men with VIT demonstrated signifi cantly lower post-operative PVR and greater QMax at 6 moths. No signifi cant diff erence in retreatment rates was noted between VIT and PVP follow-up.

Conclusions: Both GreenLight PVP and VIT techniques can be safely used to treat men with large prostates. Both techniques off er signifi cant and durable relief of symptom relief with comparable complication rates at 3 years. Longer follow-up is necessary to assess durability.

Open 

Within two years, one-hundred patients were prospectively randomized into two equal groups. All patients underwent TVP whereas RB was used in group-2. RB is a balloon fi xed to 3-way Foley catheter tip by blaster strip making it air tight. We placed it in the rectum opposing prostate and infl ate (pressure controlled) for 15 min. Hemoglobin (Hg) levels have been assessed pre-and postoperation. Blood transfusion, amount of saline for irrigation, catheter duration, hospital stay, and rectal complain were recorded. Follow-up was 1 and 3-mo, postoperatively.

Results: Enucleated adenoma weight was 102 gm in G-1 and 106 gm in G-2. Th ere is signifi cant diff erence between both group for Hg-loss within fi rst 24h post-operative and total Hg-loss 0.9 gm in G-1 and 0.2 gm in G-2 (p, 0.008) and 1.9 gm vs. 1 gm (p, 0.001) respectively. Also there is signifi cant diff erence between both group in relation to the saline/L for irrigation (11.4 vs. 2.5 L), catheter duration (5.7 vs. 4.3 day), and hospital stay (6.2 vs. 5.1 day), with favorable results to the RB group. Blood transfusion was 4 in G-1 and one in G-2. Th ere is no rectal complain.

Conclusion: RB infl ation post-TVP is simple and safe procedure without operative technique, reduces post-operative blood loss, blood transfusion incidence, saline for irrigation, and shortens the catheterization period and hospital stay, without rectal complication. Conclusion: Th ough this was not a head-to-head study and there were a number of dissimilarities in the study design, we demonstrated a non-inferiority of our study and a signifi cantly shorter median length of catheterization, time until stable health, and hospitalization relative to the Goliath Study.

Introduction and Objective: Th ulium Laser Enucleation of the prostate (Th uLEP) has been introduced as a minimally invasive treatment for benign prostatic obstruction (BPO). Th e aim of the study is to assess what are the intraoperative key points and possible complications of the morcellation procedure aft er Th uLEP. To assess whether this events have any eff ect on hospitalization length.

A cooperation between the University of Milan and Moscow was settled. Prospective study that analyzes events that prolonged the morcellation process aft er completing thullium laser enucleation procedure in a group of 337 consecutive patients was performed. Events related to the morcellation procedure were recorded. Patients' hospitalization length were evaluated aft er discharge only considering patients that were not re-admitted because of a surgical related issue. Statistical analysis was performed by the Student t and chi-square Test and logistic regression analysis. For all statistical comparisons signifi cance was considered at p<0.05.

Results: Mean age was 67.8 years. Five groups of reasons for prolonged morcellation were recorded. Bladder suction with wall damage, bleeding due to "ex vacuo" fast empting, suction problem, morcellation impairment and prolonged morcellation time due to enlarged prostate. Each group of issues was related to a signifi cant prolonged operative time (p<0.05). Th e Table 1 shows the key points rate and their correlation with a prolonged hospital stay. A statistical significance between the event and the prolonged hospital stay found only for Bladder suction.

Conclusions: Issues related to the morcellation procedure aft er Laser Enucleation of the Prostate (Th uLEP) causes prolonged hospitalization length only in the case of bladder suction. Other events, even if related to a slower operative time, do not mean a prolonged Hospitalization.

Suprapubic Cystostomy Makes TURP More Effective and Safer

Introduction and Objective: A recent survey found TURP the commonest performed procedure in BPH, despite the rising popularity of laser prostatectomy. Th e reasons for popularity in laser are ease of performance, lesser complications, and good results. It is the complications factor that makes it look attractive. Th e onus is therefore to make TURP safer. Th is is more applicable in India, where the cost of laser excludes 80-90% of patients. Numerous innovative procedures have been tried to make TURP safer. Continuous outfl ow has been described as innovation, the means to achieve it not described. Introduction and Objective: Prophylactic peri-vesical drain placement during suprapubic prostatectomy remains a widespread surgical practice. However the surgical technique of suprapubic prostatectomy has signifi cantly improved and as such the contemporary role of prophylactic surgical drains needs reevaluation. It has been traditionally assumed that prophylactic drains helps prevent fl uid collection (blood, serum, urine) which if not drained can lead to surgical wound complications. Th is paper investigates the incidence of surgical wound complications aft er a series of suprapubic prostatectomy done without placement of surgical drains but in the context of modifi cations to the surgical technique.

Prostatic Hyperplasia (BPH) were operated upon between 2009 and 2015 -all using a modifi ed suprapubic prostatectomy technique that includes meticulous dissection, hemostatic suturing that covers the main areas of anatomic distribution of the urethral arterial branches of the inferior vesical artery, non-placement of drains and suprapubic catheter, and also routine irrigation of the surgical wound with normal saline among other modifi cations. Pre-and post-operative blood hemoglobin levels, prostate specimen weights and presence of surgical wound complications if any were recorded. Th e main outcome measure was to determine the presence of early surgical wound complication defi ned as clinical evidence of hematoma/ seroma, infection, drainage or wound dehiscence.

Results: Th e mean age of the patients was 68.7 (range of 54 to 84 years). Th e mean prostate weight was 93.5gm-(range of 56 to 238gm). Th e mean hemoglobin diff erence was 1.13 mg/dl (range of 0.4mg/dl to 2.6mg/dl). On a minimum 30 days observation of the surgical wounds, there was only one case of superficial wound infection (0.9%) that healed with wound dressing. Th ere was no mortality and none of the patients received blood transfusion.

In the context of an improved surgical technique, suprapubic prostatectomy for BPH can be safely performed without the placement of prophylactic peri-vesical drain. Non-placement of prophylactic surgical drains in this series was not associated with increased wound complication rate.

Effects of Detrusor Underactivity Conclusions: According to detrusor activity, there were not diff erent in diff erences between preoperative or postoperative IPSS. Abnormal detrusor contractility (esp. DUA) cannot be a contraindication for TUR-P, and TURP should be a defi nite therapeutic option in abnormal detrusor activity.

Geavlete P, Dragutescu M, Multescu R, Georgescu D, Geavlete P

Introduction and Objective: Th is long-term retrospective study aimed to analyze the re-intervention necessities aft er bipolar plasma vaporization of the prostate (BPVP) in patients with medium sized benign prostatic hyperplasia (BPH).

Materials and Methods: Th ere were followed 328 patients who underwent BPVP for prostates sized between 30 and 80 ml. Th e re-intervention rates were analyzed during a follow-up period of at least 12 months.

Results: Additional interventions consisted of immediate reoperation for secondary hematuria, endoscopic re-intervention for urethral stricture or blad-der neck sclerosis and transurethral resection of the prostate (TURP) for residual BPH bulk. Endoscopic hemostasis during hospitalization was required in 2 cases (0.6%) and in discharged patients in other 2 cases (0.6%). During the follow-up period, 3 patients (0.9%) with bladder neck sclerosis underwent the plasma vaporization approach. Urethral stricture was diagnosed in 24 patients (7.3%), 21 of them receiving internal optical urethrotomy while urethroplasty was performed in 3 cases. Residual adenoma was present in 2 patients (0.6%), thus requiring and secondary TURP.

Conclusion: BPVP is a valuable endoscopic treatment alternative for medium size BPH cases with higher effi ciency and a satisfactory rate of reoperation.

Diode Laser 980nm for the Treatment of BPH: Long-Term Comparison of the Enucleation vs. Vaporization

Introduction and Objective: To report 5-years follow-up results of clinical trial comparing diode laser enucleation of the prostate (DiLEP) with diode laser vaporisation of the prostate (DLVAP).

A total of 151 consecutive patients were included in the prospective study who had received laser treatment for BPH. Patients were assigned to two groups based on the type of procedure: 106 to DiLEP group and 45 to DLVAP group. Patients with a history of neurogenic bladder dysfunction, chronic prostatitis or bladder cancer were excluded from evaluation. Standard follow-up examinations were performed in both study groups in predefi ned time points (in the perioperative period, at month 1 and month 3, and month 6, and then every year). Primary endpoints included: lower urinary tract symptoms (LUTS) as measured by the International Prostate Symptom Score (IPSS), urinary fl ow rates and post-void residual urinary volume. Complications were assessed. An additional endpoint was to review video records to precisely determine the timeframes for individual surgical procedures and to plot the learning curve.

Results: All the remaining 151 patients had undergone the 4-year follow-up assessment. Measurements were performed at 1, 3, 6, 12, 24, 36, 48 and 60 months. Th ere were no statistically signifi cant differences in baseline characteristics between the two groups. No signifi cant intraoperative and early postoperative bleeding was observed. Hospital stay aft er surgical intervention covered 1 day that was equal to average time of urethral catheter indwelling. Th e improvement rates, calculated based on the IPSS scores at 5 years aft er surgery, were 78.9% and 60.5% in the DiLEP and DLVAP group, respectively. Th e results indicate signifi cant decrease in severity of LUTS. Th e sustained treatment eff ect was in favor of DiLEP intervention group. Also treatment effi cacy was better in the DiLEP group compared to the DVLAP group, as regards the maximum urinary fl ow rate (Qmax). Th e diff erence was statistically signifi cant.

Conclusions: Diode laser enucleation and vaporisation of the prostate are low-risk minimally-invasive treatment option of treatment of patients with BPH. Both methods may be safely performed even in high risk and patients on ongoing oral anticoagulation. Treatment eff ects are better and more sustained with laser enucleation than with laser vaporization of the prostate. DiLEP is a true endourological alternative to TURP.

Changes in Urination According to the Sound of Running Water Using a Mobile Phone Application Introduction and Objective: Th e sound of running water (SRW) has been eff ectively used for toilet training during toddlerhood. However, the eff ect of SRW on voiding functions in adult males with lower urinary tract symptoms (LUTS) has not been evaluated.

To determine the eff ect of SRW on urination in male patients with LUTS, multiple voiding parameters of urofl owmetry with postvoid residual urine (PVR) were assessed according to the presence of SRW played by a mobile application.

Eighteen consecutive male patients with LUTS were prospectively enrolled between March and April 2014. Urofl owmetry with PVR measured by a bladder scan was randomly performed once weekly for two consecutive weeks with and without SRW in a completely sealed room aft er pre-checked bladder volume was scanned to be more than 150 cc. SRW was played with river water sounds amongst relaxed melodies from a smartphone mobile application.

Results: Th e mean age of enrolled patients and their mean International Prostate Symptom Score (IPSS) were 58.9 ± 7.7 years (range: 46-70) and 13.1 ± 5.9, respectively. All patients had not been prescribed any medications, including alpha-blockers or anti-muscarinic agents, in the last 3 months. Th ere was a signifi cant increase in mean peak fl ow rate (PFR) with SRW in comparison to without SRW (15.7 mL/s vs. 12.3 mL/s, respectively, p = 0.0125). However, there were no diff erences in other urofl owmetric parameters, including PVR.

Th e study showed that SRW from a mobile phone application may be helpful in facilitating voiding functions by increasing PFR in male LUTS patients.

Th is study aims to analyse how bladder outlet obstruction index (BOOI) and bladder contractility index (BCI) aff ect surgical outcome for BPH patients who were treated Homium Laser Enucleation of the Prostate (HoLEP).

We classifi ed the 166 patients, who were treated HoLEP and observed more than 6 months, into group I (BOOI≥40 and BCI≥100, n=45), group II (BOOI≥40 and BCI<100, n=24), group III (20<BOOI<40 and BCI≥100, n=18) and group IV (20<BOOI<40 and BCI<100, n=79) based on urodynamic study result. Patient's characteristics including volume of prostate, PSA, IPSS, maximum urinary fl ow rate and residual urine volume compared in each group. And we also compared IPSS, maximum urinary fl ow rate, residual urine volume before and 6 months aft er surgery.

Results: Th ere was no signifi cant diff erence comparing age, PSA, IPSS, maximum urinary fl ow rate and residual urine volume among each group. Th e prostate volume, ranked in ascending order of group, are as follows: 71.9±37.1ml, 61.5±21.9ml, 41.2±13.7ml and 40.9±14.9ml, it had signifi cantly disparity between group I and III (p=0.004), group I and IV (p=0.000), and group II and IV 9p=0.018). Using repeated measure ANOVA, we found that IPSS, maximum urinary fl ow rate and residual urine volume were signifi cantly improved within group in each group aft er surgery except IPSS storage subscore between group II and group III and residual urine volume. And the degree of improvement among each group was not diff erent (Table 1) . Th e incidence of AUR (6.5%) and BPH-related surgery (2.6%) were low in CT group. In comparison of baseline age, PSA, and PV according to switch of medical therapy, baseline PV was signifi cant diff erence in both groups, respectively (p=0.007, p=0.004).

Conclusion: Th ere was more MT than CT in initial treatment. However, there was more switch of medical treatment type in initial MT in real-world clinical practice over 10-year follow-up. Th e Incidence of BPH progression events was high in initial MT group. Th e initial use of CT is recommended in patients with LUTS and BPH.

Relationship between Bladder Wall Thickness and Lower Urinary board the Antarctic Research Vessel "Shirase" on their way home and approximately two months aft er returning to Japan. We analyzed the data of 12 members of the winter party who had responded to the questionnaires more than 3 times before departure and during their stays in Antarctica.

Results: Compared to before departure, the mean scores for all of the questionnaires decreased during their stays in Antarctica, from 3.42 to 2.31 points for IPSS, from 1.25 to 0.986 points for OABSS, and from 4.58 to 3.78 points for PSQI, but the mean volume voided per micturition increased from 213 to 233 ml. In regard to the amount of change in IPSS scores over the same period, a signifi cant diff erence was noted between 7 members with a pre-departure score ≥ 3 points and 5 members with a pre-departure score < 3 points (-2.22 vs. 0.448, p = 0.0416).

Th is study is the fi rst to report the urinary status of people in a polar environment investigated with questionnaires and voiding logs. We initiated this study under the assumption that one's urinary status would deteriorate in a polar environment, but our fi ndings indicated that urination and sleep tend to improve in Antarctica.

Management of Male LUTS: A Southeast Asia Regional Survey on Practice Patterns and Perspectives Results: Responses were obtained from 100 urologists from 54 centres with size ranging from 50 to 500 patients per week. Referral patterns diff er across the region -in Hong Kong, Singapore and Malaysia, patients prefer or are required to consult a general practitioner before seeking urologist care. Common investigations that respondents proposed included urofl owmetry ± post-void residual volume measurement (75%), PSA (63%), urinalysis (52%), voiding diary (45%), physical examination (38%) and TRUS-biopsy (33%). However, only urinalysis and symptom scores are essential investigations recommended consistently in major international guidelines. Whether urofl owmetry should become an essential investigation in SEA remains debatable. LUTS secondary to BPH/BPO (94%) and OAB (71%) were the two most common diagnoses for the case scenario, and correspondingly, alpha-blocker (97%) and antimuscarinics (55%) were the two predominant treatments suggested by respondents. Nocturnal polyuria is a common cause of nocturia especially amongst elderly, yet relatively few urologists (32%) considered this condition as a main diagnosis. Respondents felt that there was a paucity of large-scale epidemiology studies on LUTS in SEA, and on the natural history of the disease. More education on the proper evaluation and diagnosis of LUTS is needed for both GPs and urologists in the region.

Results from this SEA survey revealed variations in urologists' practice patterns and guideline recommendations, and pointed to the needs for further research and education in LUTS.

Female Urethral Prolapse:

Bhalla V 1 , Attri A 1 , Bhalla S 2 Introduction and Objective: Urethral prolapse means the protrusion of the distal urethra through the external urethral meatus. Female Urethral prolapse is a rare condition that has bimodal distribution aff ecting postmenopausal women and prepubertal girls. Female urethra has two layers of smooth muscles inner longitudinal layer and outer circular which remain adherent to each other by strong connective tissue. Separation of these two layers with episodic increase in intra-abdominal pressure leads to complete urethral prolapse. Birth trauma during prolonged vaginal delivery, perineal tears, debility, malnutrition and periurethral bulking agent injections have been implicated in postmenopausal group.

We present two postmenopausal female patients of urethral prolapse having similar clinical presentation aged 49 years and 52 years respectively. Th ey presented with symptoms of blood spotting of undergarments and voiding diffi culty with dysuria of acute onset. On physical examination a doughnut-shaped erythematous infl amed mass was seen protruding from external urethral opening. Th e evaluated parameters included POP-Q grade, international prostatic symptom score (IPSS), overactive bladder questionnaire (OAB-q), International consultation on incontinence questionnaires short form (ICIQ-SF), maximum fl ow rate (Q-max), and residual urine volume (RU). We evaluated them before and 1, 3, 5 year aft er surgery.

Results: POP-Q grade before surgery tended to be high in elderly group without signifi cance. Anatomical cure at 5 year aft er surgery (%) of non-elderly and elderly was 90 and 89%, respectively. A tendency to having poor scores was observed in elderly group concerning preoperative IPSS, ICIQ-SF and OABSS; however they did not attain signifi cance. Th ese three parameters improved in both groups aft er surgery; however, the percent improvement was signifi cantly poor in elderly group. Th e maximum fl ow rate before surgery was signifi cantly low in elderly group and was still low aft er surgery. Th e residual urine volume did not show signifi cant diff erence in each group before and aft er surgery. In the observation period of 5 year, de novo OAB and mesh extrusion were observed in elderly group with a signifi cant frequency.

Conclusions: Th ough the anatomical cure was not age specifi c, age apparently aff ected on the outcome of TVM especially in the percent improvement of LUTS.

Autologous Materials and Methods: Ten women with sever and complicated stress urinary incontinence secondary to the bladder neck and urethral trauma or congenital epispadias (with or without extrophy) underwent transurethral injection of autologous muscle derived cells. A second injection was performed according to the assessment of patients, 6 months aft er the fi rst treatment session. All patients were followed at one week, 1, 6 and 12 months aft er injection by physical examination (cough stress tests), one hour pad test and IIQ-7 score. Multi-channel urodynamic study and maximal urethral closure profi lometry (MUCP) was performed before and 12 months aft er the last treatment session. Cough stress test, one hour pad test and urofl owmetry were repeated at 36 months aft er the last injection. In each visit the severity and incidence of complications was recorded.

Results: All patients completed the study and were followed for 36 months. Th ree patients were cured; four and three of patients were improved and failed to the treatment respectively. Th ere were no major adverse events related to the treatment.

Conclusions: According to our clinical results, in a limited number of female patients, muscle derived cell therapy is a minimally invasive and safe procedure in the treatment of patients with severe and complicated SUI. Th e cure rate is not high, though it may be considered as an option beside other treatment modality.

Are We evaluated the eff ect of patient position and bladder fi lling status on the Q-tip angle for urethral hypermobility.

We measured the Q-tip angle in the supine position and at a 45° angle in a reclining position in patients during bladder emptying and then repeated the measurements while fi lling the bladder, usually 200-300 mL. We defi ned urethral hypermobility as the urethral angle straining or coughing minus that at rest > 30°.

Results: All 63 female patients (mean age, 62 ± 11 years; range, 36-81) who complained of urinary incontinence were assessed using the Q-tip angle. Th e pelvic organ prolapse quantifi cation stages of all patients were ≤ stage 1. Mean Q-tip angle with an empty bladder was 14.1 ± 9.1° in the supine position and 16.4 ± 11.1° in the 45° reclining position (p = 0.001). Mean Q-tip angle during the fi lling bladder state was 15.4 ± 9.7° in the supine position and 15.9 ± 11.0° in the 45° reclining position (p = 0.771). Th e urethral hypermobility rate during the bladder emptying state was 11.1% (7/63) in the supine position and 19.1% (12/63) in the 45° reclining position. Th e relative positive ratio of the reclining to the supine position is 1.71. Th e urethral hypermobility rate during the bladder fi lling state was 15.0% (9/60) in the supine position and 15.3% (9/59) in the 45° reclining position. Th e positive rate was higher in the 45° reclining position during bladder emptying than that in the other position during bladder fi lling.

Conclusion: Th e outcome of the Q-tip angle measurement and the rate of urethral hypermobility changed in relation to patient position. Th e reclining position during bladder emptying increased the Q-tip angle, resulting in positive urethral hypermobility.

Rotational Th ere was no mortality from the surgical procedure, whereas pain and catheter blockage was main complication. All patients were followed at 2, 4, 24 and 48 weeks respectively. Our success rate was 100%.

Vesicovaginal fi stula is the most common urogenital fi stula. Obstructed labor and its complications are still the leading cause of its development, whereas iatrogenic fi stula is also up-coming warning for all health care professional.

The Effi cacy of Combination Therapy of Alpha Blocker with Anticholinergic in Adult Women with Overactive Bladder

Introduction and Objective: Overactive Bladder (OAB) is associated with symptoms including urgency, with or without urge incontinence, usually with frequency and nocturia. Anticholinergics are mainly used for the treatment of patients with OAB, especially women. Other than anticholinergics, alpha blockers have been shown in several clinical reports to be useful in treating detrusor overactivity caused by neurological diseases. Th e aim of the study is to evaluate the effi cacy of alpha blocker in combination with anticholinergics to treat women suff ering from OAB.

Th is prospective study enrolled 70 female patients with OAB. Patients have been randomised into two groups. Th e interventions for the 24-week treatment period included solifenacin daily for the group 1 and combination of both solifenacin and tamsulosin daily for the group 2. At baseline and 24 weeks aft er treatment, patients completed a 3-day bladder diary, International Prostate Symptom Score (IPSS), quality of life (QoL) index, Overactive Bladder Symptom Score (OABSS), maximum fl ow rate (Qmax) and postvoid residual urine volume (PVR).

Results: A total of 70 women were randomised and 54 completed this study (group 1; 29, group 2; 25). Statistically signifi cant improvements in terms of urgency and frequency were observed in both groups at 24 weeks aft er treatment as compared with baseline (p<0.03 and <0.02), while no inter-group diff erence was observed between the two groups. Although group 2 showed improvement of IPSS voiding subscore, QoL and Qmax than group 1 but not statistically signifi cant (p=0.15, p=0.15, p=0.07) . No signifi cant diff erence was observed in terms of toxic events between the two groups.

Conclusion: Th e combination of alpha blocker and anticholinergic for 24 weeks was noninferior to anticholinergic alone in effi cacy, and there was no evidence of benefi t of alpha blocker in treating female OAB. Further studies are needed to assess the role of combined therapy of alpha blocker and anticholinergic in the treatment of female OAB. Conclusion: Advancement of cystoscopy will continue undoubtedly. Th is report emphasizes the key people whom contributions will always be a corner stone in the fi eld of Urology.

"Gleason" in a Nutshell 

Unusual Urogenital Disorders

Introduction and Objective: To present some aspects of unusual urogenital disorders, congenital malformations, and syndromes, sometimes occurring in eminent personalities or having been described by famous scientists.

Th e review of historical sources and biographies of famous suff erers and the study of modern medical literature about all these rare urogenital diseases.

Results: Penile deformities such as hypospadias (the most known representative was Henry II of France 1519-1559, suff ering also from chordee) and the rare epispadias (respectively the most known was the Byzantine Emperor Heraclius, 575-641) were recorded by historians because of the infertility consequences or the bizarre urination habits (Heraclius needed protective measures to avoid getting wet). Historians also were attracted by spectacular and dramatic urological emergencies, such as Fournier gangrene, known by the case of the prominent suff erer Herod. Referring to famous researchers, François Gigot de La Peyronie (1678-1747), founder of the Royal Academy of Surgery of France, described the homonymous disorder (1743), consisting of penile deformity due to induration of the corpora cavernosa of the penis. Th e above disease, called also Induratio Penis Plastica (IPP) is one of the extraordinary urogenital problems together with the strongly psychologically and non-physically induced syndromes Koro (Genital Retraction Syndrome) and Castration Anxiety (the latter described by Freud). Belief that genitals have disappear and fear of damage or loss of the penis characterize them both. Much of the research has been done on the two above topics, although still relevant today.

Conclusions: Unusual urological disorders are broadly known when happening on famous personalities or when described by famous physicians or when attract the common opinion as extraordinary events (called Mirabilia by historians).

Koutsiaris E 1 , Drettas P 1 , Oikonomou A 2 , Poulakou-Rebelakou E 2 , Rempelakos A 3 Introduction and Objective: Th e loss of a testis represents a psychologically traumatic experience in males of any age. Testicular loss is commonly the result of torsion, trauma, infection or malignancy. Th e patients who experience orchiectomy request the implantation of an artifi cial testis for psychological or cosmetic reasons. Testicular prostheses are one of the most commonly implanted devices and we present the evolution of these devices.

Review of the medical literature regarding the history of testicular prostheses and the various materials that have been used during the decades.

Results: Th e fi rst testicular prosthesis was an alloy of molybdenium, cobalt and chromium and was used in 1941. During the 1950s, other materials were used such as plexiglass and polyethylene without much success. It was then suggested by the scientifi c community that the ideal testicular prosthesis should not produce any infl ammatory reaction and that should be also made by a proven non carcinogen material. It was also suggested that the material of the prosthesis should also resist mechanical press and take and hold the desired form. As a result, solid silicone rubber prostheses were introduced and used in the 1960s. Th e demand for more natural feeling implants lead to gel fi lled silicone devices appearing in 1972. In 1988, fi rmer silicone coated prosthesis became the "gold" standard. In the US in 1992, the Food and Drug Administration (FDA) halted the use of gel fi lled breast implants due to the risks of autoimmune disorders and the possibility of tumor development. As a consequence, in 1995 there was a voluntary withdrawal of silicone gel fi lled testicular prostheses and replacement with saline fi lled prostheses. Nowadays both silicone and saline fi lled testicular implants are used worldwide which are safe and eff ective.

Conclusions: Testicular prostheses reduce the psychological impact that results from loss or absence of a testicle and should be off ered to male patients of any age. 

Introduction and Objective: We investigated population-based management trends of urinary stone disease in the use of extracorporeal shock wave lithotripsy, ureteroscopy and percutaneous nephrolithotomy during the recent 5 years in a Korean population. 

We conducted this retrospective study by reviewing the medical records of patients diagnosed with acute ureteric colic in the emergency room and in the urology outpatient from January 2009 to December 2013. Nine hundred patients were diagnosed with ureteric stone and all of them underwent ultrasound as the primary imaging modality. Sensitivity, specifi city, positive and negative predictive value in determining the size, position of the stone in the ureter by Ultrasound has been documented.

Results: Out of 900 patients, there were 800 males (90 %) and 100 females (10%). Age range was 13-65 years.

Our study found that color Doppler ultrasound with twinkling sign, diagnosis was made with confi dence in 835 cases (92.7%). Sixty-fi ve patients who failed the ultrasound, the stones were confi rmed by helical CT, failure to detect the stone was mainly due to poor visualization (due to bowel gases and obesity) and smaller size of stone. Right side stones were seen in 338 (37.6%) patients while left side stones were seen in 562 (62.4%). Stones were detected bilaterally in 4 cases (0.4%). Th e range of stones size was 3-1.5mm. Th ere were 190 (21.1%), 77 (8.5%) and 633 (70.5%) upper, middle and lower ureteral stones.

Conclusion: Th ere is no doubt that Spiral CT is superior in the demonstrating of ureteral calculi. Th e present study emphasized that utilization of color Doppler ultrasound with twinkling in trained hands can provide an excellent alternative modality with high sensitivity and specifi city in diagnosis of acute ureteric colic and with confi dence can be used as fi rst imaging modality, hence we could avoid high cost, higher radiation dose and high workload.

Contemporary Imaging Practice Patterns following Ureteroscopy for Stone Disease

Cleveland Clinic, Cleveland, USA Introduction and Objective: Routine imaging following ureteroscopy for treatment of renal/ureteral calculi continues to be a topic of debate. However, with the increasing focus on healthcare costs and quality, judicious use of diagnostic imaging to optimize outcomes while minimizing resource utilization is a priority. We sought to identify post-ureteroscopy imaging practices amongst experienced urologists.

A REDcap questionnaire was sent to urologists in North America. Th e questionnaire surveyed demographic data, clinical volume, and imaging preferences post-ureteroscopy. Additionally, we surveyed the extent to which stone, anatomic, and procedure-related factors infl uenced these preferences. Th e likelihood of altering clinical practice and the desire for specifi c imaging guidelines were also assessed. Th e Interquartile range (IQR) was utilized as a measure of median consensus, with a lower IQR denoting increased agreement.

Results: Th ree hundred twenty two urologists completed the questionnaire. Th e mean number of years in practice was 18±10; 82% of respondents performed more than 5 ureteroscopic stone procedures monthly. Routine postoperative imaging was obtained by 48% of participants as follows: US (47%), KUB (17%), CT (4%), IVP (2%), and KUB + US (30%). Urologists who did not routinely image patients were more concerned about cost (55% vs. 25%, p= <0.0001), radiation exposure (69% vs. 44%, p= <0.0001), and diagnostic inaccuracy of US (57% vs. 44%, p= <0.02). Th ese urologists were also less likely to have completed an Endourology fellowship (7% vs. 23%, p= <0.0001). Th e most compelling predictors of obtaining postoperative imaging were post-op pain and fever (median 5, IQR 1), residual stones (median 5, IQR 1), ureteral perforation (median 5, IQR 2), and presence of a solitary kidney (median 4.5, IQR 2).

Conclusions: Currently, about 50% of urologists who regularly perform ureteroscopic stone procedures obtain post-op imaging. Imaging preferences were guided by the presence of residual fragments, ureteral perforation, solitary kidney, and postoperative pain or fever.

Introduction and Objective: CT scans expose patients to ionizing radiation which is associated with risks of secondary malignancy. We sought to evaluate the performance of reduced dose CT scans in patients evaluated for renal colic in the emergency room. 

UP.107, Figure 1 .

Introduction and Objective: Intraoperative exposure to ionizing radiation is a growing concern for the safety of both patient and OR staff . Eff orts to reduce the amount of radiation during ureteroscopic procedures oft en result in decreased image quality. LessRay™ is a device used to digitally enhance images obtained from a C-arm using a low-dose pulse setting allowing for reduction in radiation dose while maintaining image quality.

A randomized prospective trial of 23 patients was performed comparing ureteroscopic cases for unilateral obstructing ureteral stones using standard fl uoroscopy compared to LessRay™. Patient demographics, stone parameters, and operative characteristics were recorded in addition to total radiation dose, total fl uoroscopy time and images obtained ( (Table 2) . A statistically signifi cant reduction in radiation exposure to the surgeon was also noted (p = 0.03). Image quality was not compromised and no conversion from Less-Ray™ to standard fl uoroscopy was needed in any case.

A nearly threefold reduction in patient radiation exposure was achieved using the LessRay™ digital enhancement device compared to standard fl uoroscopy. Th is novel technology has not previously been used in urologic surgery and off ers a promising alternative to standard fl uoroscopy while ameliorating risks to both the patient and surgeon.

Bilateral Results: In the 10 cases of CN patients, 3 accepted retroperitoneal laparoscopic cyst unroofi ng, 5 accepted retroperitoneal laparoscopic partial nephrectomy, 1 patient with a preoperative diagnosis of cystic renal cell carcinoma, the maximum diameter of 8cm and located in the center of the kidney got retroperitoneal laparoscopic radical nephrectomy. One patient recurred 7 yrs later aft er retroperitoneal laparoscopic cyst unroofi ng, and underwent open partial nephrectomy at last. Six MESTK patients underwent retroperitoneal laparoscopic radical nephrectomy and 1 accepted retroperitoneal laparoscopic partial nephrectomy. Twelve cases were followed up for 6 months to 11 years, no recurrence.

Conclusion: CN and MESTK are rare benign tumors of the kidney. Preoperative misdiagnosis is high. Multi-cystic lesions with no mural nodules should take CN/MESTK into consideration, especially when the lesions convex to the pelvis, should be highly suspected for CN diagnosis, and to assess the possibility of partial nephrectomy. Cyst unroofi ng for CN has recurrence risk.

The Value of 3-T Multiparametric MRI for Detecting Prostate Cancer of T3 Stage Introduction and Objective: Th e objective of this study was to prospectively determine the value of 3-T multiparametric (mp) MRI with pelvic -phased array coil for prostate cancer of T3 stage.

December 2014, 114 patients underwent 3-T mpM-RI with pelvic -phased array coil, transrectal ultrasound-guided biopsy and radical prostatectomy for adenocarcinoma. MR images were evaluated by three experienced radiologists with regard to extracapsular extension and seminal vesicle involvement and compared with whole-mount histopathological sections as a gold standard. We estimated the sensitivity, specifi city, positive, and negative predictive value and overall accuracy of mpMRI for T3 disease. 

Introduction and Objective: Prostate cancer (PCa) imaging has undergone a revolution in the past fi ve years with the rise of multiparametric magnetic resonance imaging (MRI) for cancer detection and the evolution of positron emission tomography-computed tomography (PET-CT) for staging. Initially, choline PET-CT was considered the new standard for detecting metastatic disease where biochemical recurrence (BCR) occurs aft er primary treatment, but a newer agent based on prostate-specifi c membrane antigen (PSMA) has emerged. Despite the reported promising results with this novel imaging modality few reports correlating PSMA PET-CT with PCa histology have been documented.

We present the case of a fi t 76 year old gentleman, where PSMA PET-CT was used to accurately detect PCa pelvic lymph node (LN) metastasis in the setting of BCR following primary radiation treatment.

Results: Th e positive PSMA PET result was confi rmed with histological examination of the involved pelvic LNs following robotic-assisted laparoscopic pelvic LN dissection (PLND).

Larger studies are required to document accurately the role of PSMA PET-CT but it is likely it will usher in a new era of surgical and even radiation treatment of oligometastatic disease, aiming for cure or prolonged deferring of systemic treatment.

Introduction and Objective: Imaged guided radiotherapy has been shown to improve the outcome of pelvic radiotherapy, notably with prostate gold seed fi ducials. Lipiodol has been utilized for radiotherapy bladder fi ducials, but can be technically diffi cult to inject as discrete fi ducial markers, particularly in the post-prostatectomy setting. Th e objective is to investigate contrast agent/tissue glue mixtures as radiotherapy bladder fi ducials with respect to deliverability and visualisation for radiotherapy verifi cation.

Two radiopaque contrast agents, Lipiodol and Urograffi n were investigated. Th ese were mixed with a three tissue glues: Histoac-ryl™, Tisseel™ and Glubran™. To simulate the clinical procedure, the mixtures were injected ex-vivo into the submucosa of fl uid fi lled pigs' bladders using a cystoscope and Williams needle. Th e aim was to produce a small, medium and large fi ducial. Th e bladders were transferred to a pigs' pelvis to provide realistic tissue densities for radiotherapy imaging. Visualisation of the pelvis was performed in accordance with radiotherapy procedures. Th e initial imaging was done on a radiotherapy CT simulator. Radiotherapy verifi cation was performed by radiation therapists using widely accepted protocols including Cone Beam CT (CBCT) and kilovoltage (KV) & megavoltage (MV) 2D planar images.

Results: Delivery: Urograffi n glue mixtures were diffi cult to deliver as it polymerized rapidly in the catheter. Consequently it was only possible to produce a single fi ducial. Th e Lipiodol glue combinations were all deliverable. Visibility: Th e Urograffi n glue combinations were only able to produce a single fi ducial that was visible on CT and CBCT but were not visible with KV or MV verifi cation. All of the Lipiodol glue combinations produced multiple fi ducials that could be satisfactorily visualised on CT and CBCT. Lipiodol with either Hystoacryl or Glubran produced visible fi ducials on KV imaging, however the Lipiodol Tisseel combinations could not be seen. No combination produced suffi cient contrast with MV planar imaging. Introduction and Objective: Th e fl exible urethrocystoscopy is a procedure that is performed routinely in urology for monitoring bladder tumors and diagnosis in patients with lower urinary tract symptoms and hematuria. Th e aim of this study is to analyze whether the use or not of antibiotic prophylaxis is indicated in this outpatient procedure.

Prospective nonrandomized observational study in which 100 patients were divided into two groups: -Group 1: 48 patients with prophylaxis with ciprofl oxacin 500 mg 1 h before urethrocystoscopy; -Group 2: 52 patients without antibiotic prophylaxis. Prior to inclusion in the study absence of urinary tract infection is checked by urine culture obtained three days before the procedure. Indication of cystoscopy, cystoscopy results, presence of comorbidities, urine culture aft er 7 days, urinary symptoms over the next seven days were analyzed. Statistical analysis with SPSS 20.0 with signifi cance diff erences p≤0.05.

Results: Th e mean age of patients in Group 1 was 66.7 ± 12.4 years versus 65.6 ± 10.8 years in Group 2 (p=0.6). No diff erences in the percentage of men / women included among the groups. Fourteen percent of patients in Group 1 had bacteriuria compared with 12% in Group 2, no signifi cant diff erence. In the multivariate analysis, it appears that neither age, diabetes, smoking, lower urinary tract symptoms or immunosuppression were associated with the onset of bacteriuria between groups.

Conclusion: Th e use of ciprofl oxacin prophylaxis in fl exible cystoscopy is not indicated in our health area, because does not diminish the presence of urinary tract infection or bacteriuria.

Minimal Inhibitory Concentrations for a Novel Anti-Bacterial Peptide Eluting Urethral Catheter Introduction and Objective: Catheter associated urinary tract infection is a serious prevalent medical problem. Several strategies have been developed to suppress the seemingly inevitable ascent of foreign pathogens through the urethra. Th e primary strategy has been to coat the surface of the catheter with repellant agents, such as silver alloy hydrogels or anti-biotics. Anti-bacterial peptides, such as human beta defensing 3 (HBD-3) or cathelicidine are naturally produced peptides from the urothelium, acting to inhibit bacterial attachment and infi ltration as part of the innate immunity of the host. We have recently been able to engineer anti-bacterial peptide elution through gelatin coated catheters. Th is study investigates the effi cacy of this strategy in deterring common UTI pathogens.

Materials and Methods: E. coli and P. aeruginosa, bacteria commonly associated with UTI, were inoculated in tryptic soy broth, and then were aliquoted into each well of plates. Anti-bacterial peptides, either recombinant HBD-3 or cathelicidine, were diluted and added to each well at increasing concentrations, where microorganisms were exposed for 24 hours or for the indicated times following antimicrobial challenge and determination of the planktonic MICs. Bacteria were then enumerated by serial dilution plating. Time-kill studies were performed. Bactericidal activities of the antimicrobial agents were defi ned as a 3 log decrease in the cfu/mL over 24 hours relative to cell counts in the starting inoculum.

Results: Th e standard inoculant of E. coli and P. aeruginosa commonly required an MIC of 40μg/ml HBD-3, and 20μg/ml for cathelicidine. Time kill studies estimated bactericidal eff ect for HBD-3 on E. coli and P. aeruginosa both at 5 hours, while for cathelicidine it was 16 and 20 hours, respectively.

Conclusion: Th e current study demonstrates the efficacy and feasibility of a controlled release elution of anti-bacterial peptides, HBD-3 and cathelicidine, in inhibiting growth of common UTI pathogens.

The Conclusion: Co-infections of NG with CT appear less frequently. And mPCR method is rapid and accurate for identifi cation of STP. Th e mPCR should be conducted in advance prior to antibiotic treatment as well as it will be better to give suitable antibiotics rather than empirical combination antibiotics for NG with CT in patient with urethritis.

Introduction and Objective: Th e prevalence of multi-drug resistant extended-spectrum beta-lactamase-producing (ESBL) bacteria in normal gut fl ora in the Australian community is increasing. Current prophylactic antibiotic regimes for trans-rectal ultrasound (TRUS) prostate biopsies do not have activity against ESBL organisms leaving some men at risk of ESBL sepsis. Our objective is to determine the prevalence of ESBL in gut fl ora in Northern Tasmanian men and to identify risk factors for colonisation.

Patients were recruited into two groups. Group 1 were volunteers from the urology pre-operative clinic or the general community. Group 2 were men undergoing TRUS prostate biopsies. All patients were assessed via an enrolment questionnaire for the presence of known ESBL risk factors. Further procedural data were collected for those who had TRUS biopsies. All patients were assessed for ESBL via a faecal culture, prior to any antibiotic prophylaxis. Fisher's two-tailed test was used for comparative analysis. 

Patients with IC/PBS were assessed with the O'Leary-Sant interstitial cystitis index score and global response assessment questionnaire prior to commencing treatment. Assessment with these questionnaires was performed aft er 6 treatments (10 weeks) and again aft er 10 treatments (24 weeks). Assessment end points were pain, urgency, symptom score and problem score.

Results: Data was collected on 10 patients, 9 female and 1 male. Six patients had failed RIMSO-50 dimethyl sulphoxide (DMSO) 50% w/w treatment prior. At baseline the mean pain score was 6.6, urgency score 7.00, symptom score 13.5 and problem score 12.5. Aft er 24 weeks the mean pain score fell to 2.0, urgency score to 1.80, symptom score to 6.89 and problem score to 5.67. At 10 weeks the global response to treatment was 100%. Nocturia was the fi rst symptom to improve with urgency and pain following. No side eff ects were noted no was reported during instillation and all patients tolerated the treatments.

Conclusion: IC is a diffi cult disease to treat. It requires a multimodal approach. We found that intravesical chondroitin sulphate reduced pain, urgency and O'Leary-Sant symptom and problem scores in patients with IC/PBS. All patients tolerated the treatment and no side eff ects were reported. Introduction and Objective: Extended spectrum beta-lactamase (ESBL) producing Enterobacteriaceae are an increasing concern in an era of antibiotic resistance as they cause infections ranging from community acquired urinary tract infection (UTI) to life threatening sepsis. We retrospectively reviewed the incidence and antibiotic susceptibility profi le of all ESBL producing Enterobacteriaceae at a university hospital in the United Kingdom. Patient gender, age and catheter specimen were assessed as risk factors. Patient age, gender and specimen type were recorded in the database. Urine samples received from outside our institution (including community isolates) were excluded from the analysis. Urine was processed by calibrated loop sampling on to chromogenic clear media (Oxoid Ltd, Basingstoke, UK). A positive culture was defi ned as ≥ 105 CFU/mL except for samples from children and pregnant women where a cut-off value of >103 CFU/mL was used. Susceptibility testing was performed by BSAC (British Society of Antimicrobial Chemotherapy) disc diff usion testing and reported for ampicillin, co-amoxiclav, piperacillin-tazobactam, carbapenems (ertapenem, meropenem), nitrofurantoin, pivmecillinam, trimethoprim, cephalexin, fosfomycin, third generation cephalosporins (ceft riaxone, ceft azidime) quinolones (norfl oxacin or ciprofl oxacin), aminoglycosides (gentamicin, amikacin) and others. Cultures of more than two organisms (heavy mixed growth) were considered contamination and excluded. Other exclusion criteria included missing data such as gender, age or susceptibility results, age < 16 years old or an unusual specimen type such as an ileal conduit, nephrostomy, prostatic secretion, bag specimen or a suprapubic aspirate.

Results: Our initial database included 44,395 samples which was reduced to 37,538 samples from 28,604 unique patients aft er exclusion criteria were applied. Causative organisms were found to predominantly be E. Coli, Enterococcus, Klebsiella, Pseudomonas and Proteus species. Th e proportion of causative organisms was largely stable across the ten year period. Antibiotic resistance was demonstrated to have increased, particularly across fi rst line agents. Male gender and catheter use were associated with multi-resistance.

In the modern era of antibiotic resistance we demonstrate that antibiotic resistance in hospital urinary tract infections is increasing. Our results may be used to guide empirical treatment of hospital urinary tract infection.

Chronic Pyelonephritis Is a Risk Factor for Renal Dysfunction after Urinary Diversion in Bladder Cancer Uehara S 1,2 , Murao W 2 , Otsuki H 2 , Shimizu T 2 , Yoshioka T 1,2 , Fujio K 2 1 Okayama University, Okayama, Japan; 2 Abiko Toho Hospital, Abiko, Japan Introduction and Objective: Several reports showed that acute pyelonephritis is a risk factor for renal dysfunction in bladder cancer aft er urinary diversion, but the impact of chronic pyelonephritis fer renal dysfunction was unclear.

Materials and Methods: From 1990 to 2008, 140 patients underwent radical cystectomy in our institute. Among those patients, 68 who showed hydronephrosis (more than grade2) or did not have enough data were excluded in this retrospective study. Finally 72 patients were enrolled. Th e urinary diversions were divided into 4 types: ileal neobladder (IB), ileal conduit (IC), ureterocutaneostomy without stent (UC) and ureterocutaneostomy with stent (UCWS). Ureteral stents were indwelled because of the ureteral stenosis aft er ureterocutaneostomy. Because the cases of UCWS generally showed pyuria and bacteriuria, UCWS was determined as the chronic pyelonephritis model, and the estimated serum creatinine-based glomerular fi ltration rate (eGFR) was calculated and compared with other urinary diversion.

Results: Median follow-up period was 48.0 months (range 24-108 months) and median eGFR was 62.1ml/ min/1.73m2 before surgery and 54.8ml/min/1.73m2 at the last follow-up. Th e median decrease of eGFR during the period between pre-surgery and the last follow-up in IB, IC, UC and UCWS was 10.7, 6.1, 2.5 and 17.7ml/min/1.73m2 respectively. Renal function was signifi cantly impaired in UCWS cases than other urinay diversion.

Conclusion: Chronic pyelonephritis may be a risk factor for renal dysfunction aft er urinary diversion. To avoid the renal dysfunction, ureteral stents should not be indwelled permanently.

Comparison of Antibiotic Susceptibility of Escherichia coli between Community-acquired and Post-biopsy Acute Prostatitis Introduction and Objective: Th e etiology of acute prostatitis aft er transrectal-ultrasound-guided-prostate-biopsy (PBx-AP) seems to be diff erent from that of community-acquired acute prostatitis (CA-AP).

Recent studies suggested that PBx-AP should be considered a separate category of prostatitis, distinct from spontaneous acute prostatitis. Th us, we aimed to compare antibiotic susceptibility of Escherichia coli between CA-AP and PBx-AP.

Of 4,383 patients who underwent transrectal-ultrasound-guided-prostate-biopsy, a total of 34 patients had PBx-AP. In 22 among these, Escherichia coli was isolated on urine or blood culture. In 91 of the 209 patients with CA-AP, Escherichia coli was identifi ed on urine or blood culture test. Th us, a total of 113 patients with CA-AP (n = 91) or PBx-AP (n = 22) caused by Escherichia coli were included in this retrospective study. We compared demographic variables, data on clinical laboratory tests or transrectal ultrasound and antibiotic sensitivity data between the two types of prostatitis.

Results: In comparison to the CA-AP group, the PBx-AP group showed signifi cantly higher incidence of bacteremia and lower count of white blood cell. Th ere was no signifi cant diff erence between the two, regarding to other clinical or laboratory parameters including age, body mass index, serum PSA, prostate volume and percentage of patients with EBSL-positive Escherichia coli. Th e percentages of patients with quinolone-resistant Escherichia coli in the CA-AP and PBx-AP groups were 12.1% and 72.7%, respectively, while those with 2nd or 3rd cephalosporin-resistant Escherichia coli were 7.7% -9.3% and 18.2% -20.0%, respectively (Table 1 ). In both groups, the percentage of patients with amikacin-resistant Escherichia coli were 0.0%.

Our data suggest that a combination therapy of cephalosporin and amikacin can be recommended for treatment of PBx-AP while quinolone alone may be a feasible treatment option for CA-AP.

The Effectiveness of Prostatic Massage in Treating Chronic Prostatitis (CP)

Tanabalan C, Panah A, Kabir M, Masood J, Pati J, Nargund V

Introduction and Objective: We review the eff ectiveness of prostatic massage under general anaesthesia (GA) for persistent symptoms aft er failure of antibiotic therapy. Th e mainstay of treating CP is empirical antibacterial therapy with varying results. Prostatic massage has been used to treat CP with mixed results.

Retrospective study of patients that were seen in urology outpatient clinics from June 2010 to July 2014 with symptoms of chronic prostatitis. All patients had a full clinical evaluation and urinary samples were sent for culture/microscopy on their visit. Patients were treated initially with a course of 5-aminoquinolone and doxycycline in combination with lifestyle advice. If initial antibiotic therapy failed and no abnormal results detected in the work-up, a prostatic massage was off ered. Th is involved a rigid cystoscopy followed by a 5-minute prostatic massage under anaesthesia. Post-operatively patients received a further course of antibiotics. Patients were followed up aft er the procedure and were assessed for improvement in symptoms. A total of 64 patients (82%) commented on an improvement in some or all of their CP symptoms for a mean length of time of 11.9 (range 2.1 to 21.7 weeks). Mean PSA was 2.16 (range 0.266 to 58.8).

One bladder tumour and one urethral stricture were detected on cystoscopy with one prostate cancer following prostate biopsies. If voiding urinary symptoms present men were given an alpha-blocker, there was no signifi cant improvement in pain symptoms post-operatively between the two groups (p= 0.758). Th ere were no adverse eff ects from having the procedure with no complications noted.

Prostatic massage under GA is a safe and eff ective therapy in the treatment of refractory CP in select patients. Th e issues of long-term surveillance and assessment of response to treatment remains a challenge. Th ere seems little role for alpha-blockers, PSA testing and MRI prostate in the management of CP. Oral antibiotic therapy and lifestyle modifi cations should remain as a fi rst-line treatment option. Th e eff ect of stress, lifestyle and ethnicity has not been demonstrated in this study and further research will need to be undertaken.

Intravesical Hyaluronic Acid and Chondroitin Sulfate Therapy for Interstitial Cystitis and Painful Bladder Syndrome Shin B, Hwang E, Chung H, Kim S, Jung S, Kang T, Park K, Kwon D

Introduction and Objective: Damage to the urothelial glycosaminoglycan (GAG) barrier layer may underlie the pathogenesis of several chronic bladder pathologies, including interstitial cystitis/painful bladder syndrome (IC/PBS). Th is study evaluated the eff ect of intravesical hyaluronic acid (HA) in IC/PBS.

Twenty patients received intravesical HA 800 mg and chondroitin sulfate (CS) 1 g (IALURIL®) in 50 mL saline solutions once weekly for 4 weeks, once every 2 weeks for the next 1 month, then once every month for the next 4 months.

Results: A signifi cant improvement in urinary symptoms was evident on voiding diaries (number of voids and mean void volume; p=0.003 and 0.007, respectively). Th e Interstitial Cystitis Symptom Index and Interstitial Cystitis Problem Index resulted in a significant improvement in both scores (p=0.007 and 0.005, respectively). Th e storage symptom score (IPPS) decreased from 7.95 to 7.2 (p=0.012). Th e quality of life to urinary symptom reduced from 5.15 to 4.45 (p=0.002). Th ere was no statistical signifi cant change in the voiding symptom score of IPPS aft er IALURIL instillation (p=0.741).

Conclusions: Th is promising experience seems to offer an additional therapeutic option in patients with refractory IC/PBS.

Prevention of Surgical Site Infection: New Approach Alexander E 1,2 , Hulda T 1 , Edna D 1

Introduction and Objective: Until the middle of the 19th century, when Ignaz Semmelweis and Joseph Lister became the pioneers of infection control by introducing antiseptic surgery, most wounds became infected. In cases of deep or extensive infection this resulted in a mortality rate of 70-80%. Most surgical site infections (SSI) are superfi cial, but even so they contribute greatly to the morbidity and mortality associated with surgery. Th e aim of this study is to fi nd out rate of surgical site infection by single change of wound dressing.

Th e study is prospective in two hospitals (BA Regional Hospital, Tophill Hospital in Kumasi). Surgically clean cases are selected for operation. Wounds are not opened till the seventh day or when soaked. Window is left for wound inspection.

Results: Results are shown in Table 1 . Table 1 , 30 patients with diff erent surgical conditions were operated. Average post-surgery change of dressing was 7 days. SSI=1/30 (3.3%).

Single post-surgery change of dressing is eff ective SSI prevention method.

Effects of Semen Cuscutae on the Fertilization Ability in Varicocele-Induced Rat Introduction and Objective: Th ere is no specifi c medication to improve the sperm motility and count yet. Th is study aimed to evaluate the favorable eff ects of purifi ed fl avonoid, Semen Cuscutae extract (SCE) against oxidative stress injuries and other homeostatic imbalances in reproductive organs in adolescent rat with varicocele and to develop the new herbal medication to treat the male fertility.

Materials and Methods: Seventy-two rats were divided into 6 groups: control (CTR) + Hydroxypropyl-methyl cellulose (HPMC) (CTR + HPMC), CTR + 100 mg/kg SCE and CTR + 200 mg/kg SCE, varicocele (VC) + HPMC, VC +100 mg/kg SCE and VC + 200 mg/kg SCE. In CTR group, they were started with medication for 28 days from 4 weeks aft er environmental stabilization. For the VC groups, they were given medications for 28 days aft er 4 weeks of operation. Blood was collected before sacrifi ce for the testosterone test. Sperm motility, daily sperm production (DSP), sperm count, and sperm transit time were calculated. Th e seminiferous tubules were graded according to Johnsen scoring. Th e mRNA expression of glutathione peroxidase (GPX1) and .54 nmol/mg protein, respectively) than VC group (54.84 ± 12.76 U/mg protein and 37.7 ± 8.29 nmol/mg protein, respectively). Also, the testosterone, Johnsen score were signifi cantly increased in the dose of 200 mg/kg SCE group than other groups.

Th ese results suggest that purifi ed fl avonoid Semen Cuscutae extract could be an alternative medicine for the infertility patients by inhibition of oxidative stress by favorable mechanisms.

The Relationship between Pregnancy Rate and Semen Quality Improvement after Varicocelectomy Varicocele is the most common cause of male infertility and is generally correctable via surgery. In some reports, pregnancy rates were improved aft er varicocelectomy in male patients with poor semen quality. Th e aim of this study was to determine the relationship between semen improvement and pregnancy rate.

Patients who underwent microsurgical varicocelectomy from Jan. 2010 to Jun. 2012 were enrolled. All patients had history of infertility (>1 year) and confi rmed varicocele on physical examination. Th e abnormality of semen analysis results was based on 1997 WHO guidelines. Varicocelectomy was performed in patients with poor semen quality in a series of two semen analysis where the female partner was normal in spontaneous pregnancy, as evaluated gynecologically. Microsurgical varicocelectomy was performed by single surgeon. Follow-up semen analysis was performed 4 months aft er operation. Improvement in semen quality was defi ned as >20% improvement in total motile sperm compared with pre-operation semen analysis. Pregnancy rate, method of pregnancy, and time to pregnancy were investigated.

Results: A total of 98 male patients were included in this study, 69 (70.4%) in the improvement group (IG) and 29 (29.6%) in the non-improvement (NIG). Th e pregnancy rate was 81% (56/69) in the IG group and 76% (22/29) in the NIG group; there was no significant diff erence between groups. Pregnancy methods between the two groups were similar (Table 1) . 

Introduction and Objective: To review the learning curve, complications and outcomes of the fi rst 80 cases of microsurgical vasectomy reversal performed in a developing country.

Th e fi rst dedicated service in male infertility microsurgery in South Africa was established in 2012. Between January 2012 and December 2014, a total of 80 patients underwent microsurgical vasectomy reversal by a single surgeon (Amir D Zarrabi). Mean patient age was 45 years (range 29 to 66), mean age at vasectomy 33 years (range 19 to 56), mean number of children for the male partner 2.4 and mean age of the female partner 33 years (range 20 to 45). Th e mean time interval between vasectomy and reversal was 11.3 years (range 0.5 to 29.5). Five patients had previous failed vasectomy reversals and in 3 patients the indication for reversal was post-vasectomy pain syndrome. A total of 26% of patients travelled from other countries for their surgery.

Results: Mean surgical time per testicular unit was 80.2 minutes (range 37 to 115) and total operative time 157 minutes (range 95 to 200). Sperm motility (intra-operative light microscopy) was good in 23.5%, average in 8.4% and poor in 68.1%. Vasovasostomy was required in 45.8% of testicular units and vaso-epididymostomy in 42.2%. In 6 patients sperm was harvested at the time of reversal for cryopreservation. Complications occurred in 21% of patients and were managed conservatively in all but 3, who required an additional surgical procedure. For patients with adequate follow-up the overall surgical success rate was 81%. Mean post-operative sperm count was 73.3 million. Nine pregnancies and 3 live births have been recorded during the limited follow-up. Comparing the fi rst 40 cases with the last 40 cases revealed no signifi cant diff erences in surgical time, complications or patency rates. Th e mean post-operative sperm count was 10% higher for the last 40 cases.

Although microsurgical vasectomy reversal is technically demanding and requires specialized equipment and instruments, it can be successfully implemented in a developing country.

Infl uence of Unilateral Iatrogenic Torsin on Contralateral Testis in Rat, Prepubertal and Postpubertal

Introduction and Objective: Th e present study was conducted to investigate the infl uence of hemicastration and age at hemicastration on the subsequent contralateral testis.

Sixty-four Wistar-derived male rats divided randomly in 4 groups. Group 1 named immature intervention, group 2 immature control, group 3 mature intervention and group 4 mature control. In group 1, rats hemicastrated at 30 days of age (prepubertal). In group 2, sham surgery (midscrotal incision) was done at same age. In group 3, rats hemicastrated at 70 days of age (postpubertal) and in group 3 sham surgery was done at same age. Twenty days aft er fi rst surgery, in intervention groups contralateral orchiectomy was done and in control groups random orchiectomy (left or right) was done. Blood sampling for evaluation of serum testosterone was performed just before second surgery.

Results: Testis weight and the mean testicular weight per 100 g of body weight was greater in hemicastrated rats. Th ese parameters was greater in prepubertal group than postpubertal hemicastrated rats. Th ere was no appreciable diff erence in serum testosterone levels in 4 groups.

Our research demonstrated that hemicastration resulted in compensatory hypertrophy of the remaining testis and it decreased as the animals aged. Hemicastration does not lead to reduction in serum testosterone levels and remaining testis can retrieve a normal serum testosterone level.

Role of Antibiotic in the Treatment of Semen Hyperviscosity: A Single Institution Study

Introduction and Objective: Th e prevalence of semen hyperviscosity is estimated to be between 12-29% and can lead to male factor infertility both in vivo and in vitro. Semen is composed of fl uids secreted by the male accessory glands, which contain proteins essential to the coagulation and liquefaction of semen. Hypofunction of the prostate or seminal vesicles causes' abnormal viscosity of seminal fl uid. Hyperviscosity can impair normal sperm movement in the female reproductive tract, and can lead to decreased sperm count. Multiple factors have been predicated which result in the development of Semen hyperviscosity, of this infection is considered to be one of the main contributor. Aim of the study was to predict the eff ect of antibiotic in the treatment of hyperviscosity.

Th is is a single institution study, 80 patients (age range 21-41 years) were recruited who were diagnosed with semen hyperviscosity (failure to liquefy aft er 30 min). Medical, sexual, and family history were documented. All the patients semen were kept for culture and they all got levofl oxacin for 14 days and patient who had positive culture were changed to appropriate antibiotics. All the patients underwent repeat semen analysis aft er 3 weeks.

Results: Seventy seven percent patient had previous history of prostatitis, 12% patient had past history of Sexual transmitted diseases. Seventy fi ve percent patient are suff ering from infertility, of this 7% patient had a family history. Th irty seven percent patients had positive culture and of this only 10% patient had liquefaction post treatment. Culture negative patients, 40% patient had liquefaction post treatment.

Conclusions: Semen hyperviscosity is associated with infertility and exact cause is considered to be multifactorial, of this infection is considered to be the main factor. In our study we did found that most of the patients has infection but antibiotic treatment even for culture positive patients showed minimal eff ect. Treatment with antibiotic along to treat hyperviscosity cannot be considered curative since in our study the eff ect was only 30%. Further research is needed to better understand the contributors to semen hyperviscosity and the treatments that can be used for infertile males with hyperviscous semen.

Modifi ed Microsurgical Subinguinal Varicocelectomy: Bundle Ligation Technique Hong Y, Lee S, Choi K, Park D, Hong J

Introduction and Objective: Microsurgical varicocelectomy has become the gold standard because of low recurrence and postoperative complication rate.

During the procedure, ISVs should be carefully dissected, cut and suture-ligated one by one. However, it is not easy to divide all ISVs in a horizontal line, which can result in some uncertainty whether every single ISV was divided or the same vein was unnecessarily divided multiple times. Th erefore, we have developed a modifi ed technique, so called bundle ligation technique (BLT), to make the procedure more reliable and simpler.

A total of 89 cases of microsurgical subinguinal varicocelectomy performed from 2008 to 2013 were grouped as conventional varicocelectomy (CV, N=44, age: 20±7.4) and BLT (N=45, age: 21±6.7). Mean follow-up time was 12.2±5.9 months. BLT is a simpler procedure because ISVs are ligated as a whole, however, it is possible only aft er dissecting and securing the testicular artery fi rst. We compared operation time, resolution of palpable varicocele or pain, recurrence rate and complications.

Results: Mean operation time was 72.5±16.5 in CV group and 60.1±20.8 in BLT group (p=0.03). Resolution rates 3 months aft er surgery were 93.18% (CV) and 93.33% (BLT) in each group. Recurrence aft er surgery during the mean follow-up time was 7.31% (CV) and 4.76% (BLT). Th e aim of the study is to evaluate the eff ect of HBO on the level of sperm DNAF and on the content of reactive oxygen species (ROS) in semen.

Th e study included 90 men with idiopathic infertility, the level of sperm DNAF was above 15% and the content of ROS in the sperm was above 0.64 mV/sec. In the main group (n=60) 10 sessions of HBO were performed and in vitro fertilization (IVF) was carried out 3 months later. In the control group (n=30) IVF was performed without preceding HBO. Th e age of patients ranged from 25 to 37 years (median -30.5 years). Sperm DNAF was determined by TUNEL, the level of ROS in semen was studied by chemiluminescence. Th e assessment was made at the time of entry into the study and aft er 3 months (in the main group -3 months aft er HBO).

In the main group, average sperm DNAF aft er HBO decreased from 33.2±7.5% to 11.9±5.9% (p<0.05), the median level of ROS in semen decreased from 0.89 mV/sec to 0.39 mV/sec (p<0.05), whereas in the control group of patients these fi gures have remained almost at the same level -31.2±6.1% and 31.7±6.3% (p>0.05), 0.86 mV/sec and 0.88 mV/sec (p>0.05). Pregnancy resulting from IVF occurred in 63.3% (38/60) of the cases in the study group and in 36.7% (11/30) -in the control group (p<0.05).

Conclusion: HBO is an eff ective method to reduce the number of sperm with DNAF, which can potentially lead to an increased fertility in patients with idiopathic male infertility. To evaluate the natural history and growth kinetics between sporadic clear cell renal cell carcinoma (ccRCC) and ccRCC in von Hippel-Lindau disease (VHL).

We reviewed 60 patients with 61 sporadic ccRCCs and 15 patients with 30 VHL ccRCCs all confi rmed by delayed surgery aft er at least 12 months active surveillance. Th e growth rate was calculated. Th e growth kinetics between sporadic and VHL ccRCC were compared. Th e initial tumor diameter and pathological grade were reviewed, and their correlation with the growth rate were analyzed.

Results: Th e mean growth rate of sporadic ccRCC was 0.86 cm/yr (range, 0-4.74 cm/yr). Th e mean growth rate of VHL ccRCC was 0.49 cm/yr (range, 0.04-1.89 cm/yr). Th e growth rate of VHL ccRCC was lower than that of sporadic ccRCC (P=0.024). For VHL ccRCC, the initial tumor diameter aff ect the growth rate (r=0.804, P<0.001), while the pathological grade not (P=0.317). For sporadic ccRCC, the pathological grade aff ect the growth rate (P<0.001), while the initial tumor diameter not (r=-0.207, P=0.110).

Conclusion: Th e growth kinetics of VHL ccRCC is more indolent than that of sporadic ccRCC. For ccRCC with aggressive growth kinetics, its growth rate might correlates with the pathological grade, for those with slow growth kinetics, the growth rate might correlates with the initial tumor diameter.

Effects of TRPM7 Silencing on the Proliferation, Migration, and Invasiveness of Renal Cell Carcinoma (RCC) Cells proliferation, migration, and invasiveness of human RCC following TRPM7 knockdown.

We constructed siRNA sequences targeting the TRPM7 gene and then transfected them into RCC cells mediated by liposome. Th e potency of 100 nM TRPM7 siRNAs was detected TRPM7 mRNA measurement by RT-PCR. Th e eff ect of TRPM7 siRNA on cell viability was determined by WST-1 assay. Cell motility and invasiveness were evaluated by wound healing assays and a Matrigel migration and invasion assay. Transfected RCC cells were cultured in Eagle's minimum essential media supplemented with 10% fetal bovine serum. All measurements were done 24 hours aft er TRPM7 blocking.

Results: TRPM7 siRNA weakly inhibited the gene transcription of TRPM7. It was for nothing in the proliferation of human RCC cells. Compared with vehicle control, the migration and invasion of human RCC cells were suppressed signifi cantly by TRPM7 siRNA until aft er 48 hours. In addition, although protein levels of MMP-9 were not changed signifi cantly, we found that the protein levels of matrix metalloproteinase (MMP)-2 were diminished markedly by TRPM7 siRNA.

Th ese results suggest that TRPM7 may have a role in the RCC progression including migration and invasion through upregulation of MMP2.

Role of TNF-and CD44 in Resistance to Sunitinib Treatment in Clear Cell Renal Cell Carcinomas Introduction and Objective: Tumor necrosis factor-α (TNF-α) was originally reported as a cytokine to induce apoptotic cell death and cachexia. Recent studies have indicated that TNF-α also enhances tumor progression by inducing epithelial-mesenchymal transition (EMT). TNF-α is also known as a modulator of CD44 expression, which belongs to cancer stem cell marker in several cancers. In this study we clarifi ed the signifi cance of TNF-α as well as CD44 in clear cell renal cell carcinomas (ccRCCs).

Protein expression of TNF-α and CD44 was examined by immunohistochemistry in primary ccRCCs, untreated metastatic ccRCCs, and metastatic ccRCCs treated with sunitinib, and its association with the clinicopathological parameters and prognosis was analyzed. Involvement of TNF-α in EMT and induction of CD44 was analyzed by comparing expression of EMT-related genes and CD44, and migration and invasion in cultured ccRCC cell lines.

Results: TNF-α and CD44 were predominantly expressed in carcinoma cells of high-grade ccRCCs with positive correlations with primary tumor stage and distant metastasis. Th ere was a positive correlation between TNF-α and CD44 expression, and elevated expression of TNF-α and CD44 was a poor predictor of prognosis. TNF-α enhanced migration and invasion of ccRCC cells together with down-regulation of E-cadherin expression and up-regulation of matrix metalloproteinase 9 and CD44 expression. TNF-α also up-regulated the expression of TNF-α itself in ccRCC cells. Twenty-fi ve patients were treated with sunitinib for metastasis, and the patients with CD44-high tumors showed a shorter time to treatment failure compared to those with CD44-low tumors. Furthermore, residual carcinoma cells in the sunitinib-treated metastatic ccRCCs were strongly positive for CD44, and the CD44 expression was signifi cantly higher in tumors from the sunitinib-treated patients than in those from untreated ones.

Conclusions: TNF-α seemed to play an important role in progression of ccRCCs by inducing EMT, and suggested that TNF-α-induced CD44 might be involved in the resistance to sunitinib treatment. Although further experimental studies on the relations between CD44 expression and cancer stem cells in ccRCCs are needed, our data suggest that therapy targeting TNF-α and/or CD44 may provide a clue for improving the prognosis of patients with sunitinib-resistant ccRCC.

Introduction and Objective: Th e aim of this study was to investigate the relationship between the immunohistochemical expression of hypoxia-inducible factor-1α (HIF-1α) with histological parameters such as tumor size; presence of tumor necrosis and hemorrhage; nuclear grade and pathological stage in patients with Clear cell Renal Cell Carcinoma (ccRCC).

Specimens from 40 cases of RCC patients treated with radical prostatectomy were formalin-fi xed, paraffi n embedded, and stained with H&E. Additional sections from each case were stained for HIF-1α. HIF-1α immunohistochemical expression was estimated as negative (0), weak positive (+1), moderate positive (+2), and intense positive (+3). Th e statistical package "In Stat 3" was used for data processing.

Results: Immunohistochemical expression of HIF-1α in CRCC was signifi cantly higher than in normal kidney tissue at statistically signifi cant level (HIF-1α: X2-test = 8.76, P=0.012). A positive non-signifi cant correlation was found between HIF-1α and the tumor nuclear grade (r=0.181, P=0.262); between HIF-1α and presence of hemorrhage (r=0.08, P=0.589); whereas, a negative non-signifi cant correlation of a very weak scale was observed comparing HIF-1α and tumor size (r = -0.264, P=0.09); HIF-1α and pathological stage (r=-0.05, P=0.754), as well as HIF-1α and tumor necrosis (r=-0.164, P=0.309).

Conclusion: Our data showed heterogeneity in angiogenic activity, which might have an impact on biological behavior and anti-angiogenic, anti-VEGF therapy of ccRCC patients. Th is study suggests that there should be taken more than one tissue biomarkers into the consideration in predicting the biological behavior of ccRCC.

Introduction and Objective: Clear cell renal carcinoma (ccRCC) is the most frequent RCC subtype and is characterized by high mortality of 40%, due to late diagnosis and distant metastases found in 30% of RCC patients. Although the involvement of VHL (von Hippel-Lindau), HIF1A (hypoxia-inducible factor 1-alpha) and VEGF-A (vascular endothelial growth factor A) genes in development and progression of ccRCC is widely analyzed, our objective was to perform the common study of those factors in clinical samples of matched tumor-normal kidney biopsies of ccRCC cases.

Materials and Methods: VHL, HIF1A and VEGF-A mRNA levels in samples were assessed by quantitative polymerase chain reaction (qPCR); RNA was extracted from matched tumor-normal (T, C) kidney samples of 86 ccRCC patients (mean age 62.1 ± 11.2, median age 62); 41 ccRCC cases were characterized by local or distant metastasis; sunitinib was administrated to 30 patients. VHL, HIF1α and VEGF-A proteins were localized in matched tumor-kidney tissue of 6 patients with the use of immunohistochemistry (IHC). Molecular data was statistically calculated with clinical and follow-up data. 

Introduction and Objective: To identify tissue biomarker that are predictive of the therapeutic eff ect of sunitinib in treatment of metastatic clear cell renal cell carcinoma (mCRCC).

Our study included 39 patients with mCRCC; these were selected from 119 patients who received sunitinib in our hospital between the years 2005 -2012 according to inclusion criteria of the study. Patients were stratifi ed into two groups based on their response to sunitinib treatment; non-responders (progression), and responders (stable disease, regression). Th e eff ect of treatment was measured by comparing imaging studies performed before the initiation of treatment with those done between 3rd and 7th months of treatment. Histological samples of tumour tissue and healthy renal parenchyma, acquired during surgery of the primary tumour, were examined with immunohistochemistry to detect tissue biomarkers (mTOR, p53, VEGF, HIF1, HIF2, CAIX). Th e comparison between the two groups of patients was based on comparing the average levels of biomarker expression in both tumour tissue, as well as in healthy renal parenchyma. Results were evaluated using Student's T-test.

Results: When considering the results of the group of responders, statistically signifi cant diff erences in marker expression in tumour tissue versus healthy parenchyma were found for mTOR (4%/16.7%;p=0.01031), p53 (4%/12.7%;p=0.042019), VEGF (62.7%/45%;p=0.019836) and CAIX (45%/15.33%;p=0.001624). As for the group without response (non-responders), a statistically signifi cant diff erence was also evident in p53 a VEGF expression in tumour versus healthy tissue (3%/21.3%;p=0.02824 resp. 36.3%/12%;p=0.011921). In the responders, a further signifi cant diff erence was found in the frequency of high expression (more than 60%) between tumour tissue and healthy parenchyma in VEGF (65%/35%;p=0.026487) and CAIX (42%/8%;p=0.003328). CAIX shows high levels of expression in the tumour tissue, in both of the evaluated groups. When comparing the expression levels in the same type of tissue, between the group of responders and non-responders, no signifi cant diff erence in any biomarker was found.

Conclusion: A signifi cantly higher expression of VEGF in CRCC in comparison to healthy parenchyma, can predict a better response to sunitinib. On the other hand, the high expression of VEGF in healthy renal parenchyma can predict worse response to treatment.

The Impact of Preoperative Retrograde Pyelography before Radical Nephroureterectomy for Upper Urinary Tract Urothelial Carcinoma on Intravesical Tumor Recurrence Song P 1 , Ko Y 1 , Choi J 1 , Moon K 1 , Jung H 1 , Kim T 2 Introduction and Objective: Despite its diagnostic role in identifi cation of upper urinary tract urothelial carcinoma (UUT-UC), approach to ipsilateral ureteral potentially aggravates spread of tumor, as reported in preoperative ureteroscopy before nephroureterectomy. We thus assessed the impact of preoperative retrograde pyelography (RGP) on intravesical recurrence aft er radical nephroureterectomy for UUT-UC.

Of a total of 114 patients who underwent nephroureterectomy for UUT-UC from January 2000 to June 2012 in our institution, 72 patients who did not undergo preoperative ureteroscopy were selectively enrolled. Computed tomography and urine cytology as a basic diagnostic modality were performed in all subjects. Th e impact of preoperative RGP and the other variables (age, sex, operating time, clinicopathological factors, and hematological factors) on intravesical recurrence were analyzed by multivariate Cox regression model.

During a mean follow-up period of 61.2 months, 32 (44.4%) patients had intravesical recurrence aft er RNU, and 41 subjects (56.16%) underwent preoperative RGP. Th e mean duration from preoperative RGP to RNU was 14.2±19.4 days and mean interval of intravesical recurrence was 22.0±23.1 months. Multivariable analysis showed that RGP and pathologic stage over T2 were independent factors for intravesical tumor recurrence (p=0.012 and p=0.036, respectively, Table 1 ). Regarding the duration from preoperative RGP to RNU, no signifi cant diff erence was observed between the recurrence group and the non-recurrence group (p>0.05).

As with preoperative ureteroscopy, our data demonstrated that preoperative RGP is an independent factor associated with intravesical recurrence of UUT-UC aft er RNU.

Introduction and Objective: Axitinib which is tyrosine kinase inhibitor is standard 2nd-line treatment for metastatic renal cell carcinoma (mRCC). Th e neutrophil-to-lymphocyte ratio (NLR), an index of systemic infl ammation, is associated with outcome in several cancer types. To assess the relation of pretreatment NLR with progression-free survival (PFS) and overall survival (OS) of patients treated with axitinib.

Twenty-two patients with mRCC were treated with axitinib between October 2012 and January 2015. Patients were stratifi ed in two groups with NLR >3 (Group A: n=12) vs. <3 (Group B: n=10). PFS and OS were estimated using Kaplan-Meier method.

Results: Median OS and PFS were 11.8 and 8.3 months, respectively. Median OS was 8.0 and 21.2 months in Group A and Group B, respectively (p= 0.011). Median PFS was 5.6 and 15.4 months in Group A and Group B, respectively (p<0.001). Multivariate analysis showed that NLR >3 was an independent predictor of OS (HR .4.405; p=0.018).

In patients with mRCC treated with axitinib, pretreatment NLR might be an independent predictor for the outcome. Th e aim of this study was to evaluate whether preoperative neutrophil-to-lymphocyte ratio (NLR) predict the prognosis in patients with upper urinary tract urothelial carcinoma (UU-TUC).

A cohort of 147 patients diagnosed with UUTUC from 1994 to 2010 at Tokyo Metropolitan Tama Medical Center was enrolled in this retrospective study. Log-rank test and Cox proportional hazards regression models were used for univariate and multivariate analyses.

Results: On univariate analysis, pathologic T stage, grade, lymphovascular invasion, C-reactive protein (CRP) level, and NLR were signifi cantly associated with recurrence-free survival (RFS) and cancer-specifi c survival (CSS). Th e RFS rates for an NLR < 2.5 and for one ≥ 2.5 at 5 years were 80.9% and 27.8%, respectively. Th e CSS rates for an NLR < 2.5 and for one ≥ 2.5 at 5 years were 74.2% and 29.4%, respectively. Th e multivariate Cox proportional hazards regression models showed that the NLR could be an independent predictor for RFS and CSS. Based on the results of multivariate analysis, the scoring model was developed. RFS and CSS rates at 5 years were as follows: 0 risk factor, 97.0% and 97.0%, respectively; 1 risk factor, 91.3% and 91.3%, respectively; 2 risk factors, 56.1% and 37.8%, respectively; 3 risk factors, 25.8% and 23.4%, respectively; and 4 risk factors, 5.0% and 5.0%, respectively.

Conclusion: Th e preoperative NLR is an independent prognostic predictor. Th e model based on the NLR and pathologic factors can be useful in clinical practice.

Clinicopathological Outcome of Small Cell Carcinoma of Upper Urinary Tract: One Starting Point, Diverging Paths Lu K, Wang H, Lin V, Yu T

Introduction and Objective: Primary small cell carcinoma of upper urinary tract (UUT-SCC) is an extremely rare disease entity with distinct histological and biological behavior, representing less than 0.5% of urinary tract tumor. Th e rarity of these neoplasms poses a diagnostic and therapeutic challenge. Little is known about UUT-SCC and the current knowledge of this disease is based on case reports or small series. Our aim of study was to characterize the patients with UUT-SCC and to evaluate patient outcomes with the available treatment modalities.

Th is was a single-institute retrospective observational cohort study of patients with small cell carcinoma of upper urinary tract followed at E-Da Hospital, Kaohsiung City, Taiwan be-tween January 1, 2008 and October 1, 2014. Patient and tumor data were analyzed using descriptive statistical methods.

Results: Six patients with primary UUT-SCC were identifi ed, consisting of 2 arising from renal pelvis and 4 from upper ureter. Th e median age at diagnosis was 71 years with male-to-female ration of 2:4. Th e most common presenting symptoms were painless gross hematuria, followed by fl ank pain. Th e morphological appearance of the tumor cells and their immunohistochemical reactivity for neuroendocrine markers and cytokeratin helped establish the diagnosis. In 3 of 6 cases, SCC coexisted with urothelial carcinoma. Surgery was standard treatment given to all patients. Of all cases, 5 of 6 patients received chemotherapy, including one receiving neoadjuvant chemotherapy and 4 administering adjuvant chemotherapy. Overall median survival was 12 months.

Conclusion: Primary small cell carcinoma of the upper urinary tract is characterized by an aggressive clinical course with early metastatic spread and relatively short overall survival. Although high response rate to cytotoxic chemotherapy, its duration of response is limited and the prognosis remains dismal.

As there is no standard of care for patients with UUT-SCC, further eff orts should be directed at its early detection and made to develop more eff ective therapeutic approach for this high-risk lethal disease.

Prognostic Introduction and Objective: Th e aim of this study was to evaluate the impact of body mass index (BMI) on survival in patients with non-metastatic renal cell carcinoma (RCC) treated with radical or partial nephrectomy.

Between June 1994 and July 2012, 469 patients with RCC underwent radical or partial nephrectomy at two hospitals. Among these patients, 21 patients with lymph node or distant metastasis were excluded. Th us, the medical records of the remaining 448 patients (302 men and 146 women, mean age of 55.9 years) were retrospectively reviewed. Th e median follow-up duration was 44 months (range 4 to 215 months). Th e patients were classifi ed into 3 groups according to their BMI based on the Asia-Pacifi c criteria for obesity: normal (18.5 to <23 kg/m2), overweight (23 to <25 kg/m2), and obese (≥25 kg/ m2). Th e prognostic signifi cance of various clinicopathological variables including BMI was analyzed using univariate and multivariate analysis.

Results: Of the total 448 patients, 168 patients (37.5%) were categorized as normal, 112 (25.0%) as overweight, and 168 (37.5%) as obese. Forty-six patients (10.3%) developed local recurrence or distant metastasis and 20 patients (4.5%) died of disease during the follow-up period. In the univariate analysis, BMI, tumor size, T stage, Fuhrman's nuclear grade, coag-ulative tumor necrosis, and lymphovascular invasion were signifi cant predictors of recurrence-free survival. Also, BMI, tumor size, T stage, Fuhrman's nuclear grade, and lymphovascular invasion were signifi cant predictors of cancer-specifi c survival. In the multivariate analysis, BMI (p=0.010), tumor size (p=0.009), T stage (p<0.001), Fuhrman's nuclear grade (p=0.006), and lymphovascular invasion (p=0.001) were independent predictors of recurrence-free survival. Also, BMI (p=0.012), tumor size (p=0.004), T stage (p=0.028), and lymphovascular invasion (p=0.013) were independent predictors of cancer-specifi c survival.

Our results suggest that BMI is an independent prognostic factor for recurrence-free and cancer-specifi c survival in patients with non-metastatic RCC treated with radical or partial nephrectomy. Th ese fi ndings indicate that BMI could be an eff ective tool for predicting recurrence or survival in patients undergoing nephrectomy for non-metastatic RCC.

Phase I/II Study of Multipeptide-Based Cancer Vaccine IMA901 after Single-Dose Cyclophosphamide in Japanese Patients with Advanced Renal Cell Cancer

Hongo F 1 , Ueda T 1 , Nakamura T 1 , Naya Y 1 , Okihara K 1 , Tamada S 2 , Schoor O 3 , Singh-Jasuja H 3 , Nakatani T 2 , Miki T 1 Introduction and Objective: IMA901 is the fi rst therapeutic vaccine for renal cell cancer (RCC) consisting of multiple tumor-associated peptides (TUMAPs) confi rmed to be naturally presented in human cancer tissue. Objective was to assess the safety and tolerability of IMA901 vaccination.

In this phase I/II study in Japan, we treated a total of 10 Japanese patients with advanced RCC with human leukocyte antigen A (HLA-A)*02 + subjects in 2011-2012. Each of the vaccinations consisted of an i.d. injection of GM-CSF (75 μg) followed within 15-30 minutes by an i.d. injection of IMA901 (413 μg of each peptide). Th e vaccine therapy was a monotherapy, i.e. no other anti-tumor therapies were concomitantly administered during the study course. No treatment with either anti-cancer agents or immunosuppressants was allowed within 4 weeks before entering the trial. Patients were to receive 7 vaccinations in the fi rst 5 weeks of treatment (induction period) followed by 10 further vaccinations at 3 weeks intervals for up to 30 weeks (maintenance period). Th e primary endpoint was safety and tolerability. Th e secondary endpoints were PFS, OS, immunogenicity.

Results: No treatment-related serious adverse events (SAEs) or deaths were observed during the study period. At follow-up at 4 months, all cases were assessed for treatment response. Ten percent of patients had partial response (PR), 50% with stable disease (SD), 40% of patients had progressive disease (PD). Median PFS was 5.5 months and median OS was 17.5 months. Among all patients analyzed for T-cell response, fi ve showed vaccine-induced (VI) T-cell responses against at least one HLA class I-restricted TUMAP and two patients with responses to multiple TUMAPs. Interestingly, two of the immune responders were of HLA-A*0206 phenotype, a HLA suballele rarely occurring in Europe and US but common in Japan.

We evaluate the patients who underwent robot-assisted laparoscopic partial nephrectomy (RALPN), laparoscopic partial nephrectomy (LAPN), or open partial nephrectomy (OPN) in terms of perioperative outcomes.

All 95 patients with cT1a renal masses who underwent RALPN (n=10), LAPN (n=56), or OPN (n=29) between November 2005 and May 2014 at our institute were compared in terms of perioperative outcomes, including the mean operative time, ischemia time, estimated blood loss, change in the estimated glomerular fi ltration rate (eGFR), surgical margins, and complications. Intraoperative and early postoperative data were collected retrospectively. Conclusion: RALPN was signifi cantly associated with shorter ischemia time. Any methods of partial nephrectomy preserved renal function at three months postoperatively and showed good oncological outcomes.

Laparoscopic Nephrectomy: Does Patient Obesity Affect Outcome?

Introduction and Objective: Th e prevalence of obesity worldwide is increasing, up to 28% of men and 29% of women are now obese. Th ere are various means to assess obesity, waist circumference (WC) has emerged as a superior determinant of obesity and then body mass index (BMI). Th is study evaluates WC on the outcome of laparoscopic nephrectomy.

Data was obtained on 144 consecutive patients. A WC of >80 cm for women and >95 cm for men is considered obese. Data collected includes age, gender, ASA score, WC, anaesthetic duration, operative approach, surgery duration, blood loss, renal function, complication rate and duration of hospital stay.

Overall, 144 patients underwent laparoscopic nephrectomy, 86 were male and 58 female. Seventy three (50.7%) patients had WC above normal for their gender. Mean anaesthetic duration was longer in obese patients 208.1 minutes vs. 184.2 minutes, (p=0.0199). Operative duration in obese patients was also longer, 149.6 minutes vs. 134.9 minutes, (p=0.0856). Th ere was no diff erence between groups for conversion, number of ports, intra-operative complications, blood loss, or post-operative complications. However, obese patients had a longer in-patient stay; 10.6 days versus 6.3 days.

Conclusion: Laparoscopic nephrectomy is safe in obese patients. However, obese patients should be warned that their obesity may be associated with increased anaesthetic and surgical ties and prolonged recovery.

The Long-Term Oncologic Results of Radiofrequency Ablation for Small Renal Tumors Sung G 1 , Bae Y 2 , Kim S 1

Introduction and Objective: Th e aim of this study was to retrospectively evaluate the long-term oncologic results of radiofrequency ablation (RFA) of small renal masses (SRMs).

: Th e patients who had been followed over 5 years aft er percutaneous or laparoscopic RFA for small renal mass were included in this study. A total of 47 patients and 48 renal tumors were included. Th e follow-up study included physical examination, chest radiography, creatinine, and contrast-enhanced CT or MRI. Recurrence was defi ned as contrast enhancement aft er 3 months or lesion growth at subsequent imaging or viable cancer cells on follow-up biopsy.

Results: Th e mean tumor size was 2.3 cm and the mean follow-up period was 93.3 months. Technical success was achieved in 43/48 renal tumors (89.6%).

Repeated RFA was necessary in 5 tumors due to incomplete ablation. Th e overall complication (OC) occurred in 35.8% of which the low-grade complications accounted for 96.2% of OC. A relevant deterioration of renal function aft er RFA was very rare. Th e 5-year local recurrence-free survival rates, cancer-specific survival rates, and overall survival rates are 91%, 95.7%, and 89.3% respectively.

Conclusion: RFA is considered useful treatment for selected patients with SRMs and also for nephron-sparing. Our long-term follow-up results suggest excellent therapeutic outcome with RFA, while achieving eff ective local tumor control.

Introduction and Objective: Endoscopic approach of the terminal ureter was proposed as a complementary fi rst step in nephroureterectomy with perimetal cystectomy in order to obviate the low abdominal incision. We aimed to establish the value of a novel method of endoscopic distal ureteral management: pluck technique using bipolar plasma vaporization.

During the last 4 years, we performed nephroureterectomy involving plasma-button uretreal desinsertion by bipolar vaporization in 62 upper urinary tract transitional cell carcinoma (UUTTCC) cases (pTa -23 cases; pT1 -18 cases; pT2 -12 cases; pT3 -9 cases). Th e tumor was pyelocaliceal in 42 cases, ureteral in 16 cases and both ureteral and pyelocaliceal in 4 cases. Th e follow-up protocol included cystoscopy with urinary cytology, abdominal ultrasound and CT. Th e mean follow-up period was 18 months (range 3 to 42 months).

Results: All procedures were successfully completed. Th e mean duration of the endoscopic procedure was 12 minutes. In 2 cases, aft er the completion of the nephroureterectomy, endoscopic haemostasis of the desinsetion area and margins was necessary. Th e postoperative complications' rate was 4.8%: 3 cases of hematuria, one imposing endoscopic approach and another treated conservatively. During the follow-up period, 9 patients presented bladder recurrences, 1 had renal fossa tumor and 4 had secondary lymphnode invasion. Th e disease-specifi c mortality rate was 8%.

Conclusion: Th e endoscopic detachment of the terminal ureter using bipolar plasma vaporization as part of one-step nephroureterectomy is a safe and eff ective method. Mid-term evaluation demonstrated good oncologic outcomes.

35th CONGRESS OF THE SOCIÉTÉ INTERNATIONALE D'UROLOGIE -SIU 2015 ABSTRACT BOOK Introduction and Objective: We thought that combining open and laparoscopic surgery for partial nephrectomy would be less invasive than open method, easier and expend shorter time to clamp renal artery than pure laparoscopic approach. And combining approach would lead to introduce pure laparoscopic approach safely from open method.

We reviewed the records of patients with renal mass treated with partial nephrectomy from 2009 to 2014 at our hospital. A total of 125 patients underwent partial nephrectomy. Of these, 50 patients underwent pure laparoscopic procedures. Seventy-seven patients underwent combining method, and two patients of these with solitary kidney and one patient with chronic nephritis were excluded. We compared these two groups in terms of perioperative outcomes, including the mean operative time, ischemic time, change in the glomerulofi ltration rate (eGFR), and adverse events. Conclusion: Th is nonrandomized, comparative study suggests that pure laparoscopic approach had longer cold ischemic time but lower postoperative eGFR change. Complication rates were almost equivalent for both approaches. Th erefore, we might shift safely to pure laparoscopic approach through the combined approach in the way of partial nephrectomy.

Nephron Th irty-four (15.2%) had bilateral suspected malignant tumors and were used as material for this study. Twenty-fi ve were men and 9 were women.

Results: Eighteen patients (53%) had the same type of tumor in both kidneys. Ten of them had clear cell carcinoma and 4 had papillary renal cell cancer. Four patients had bilateral oncocytomas. In 12 patients (35%) the lesions diff ered between the kidneys (Table 1). In all patients only one kidney was operated on one occasion. In two patients treated with radical nephrectomy (RN) over 20 years ago for renal cancer the subtype of the fi rst tumor was unknown. Ten patients were treated with NSS -NSS, 12 with RN -NSS, 7 with NSS -RN, 4 with NSS -observation and 1 with NSS -radiofrequency ablation. Two of the patients had von Hippel-Lindaus disease and one had Birt-Hogg-Dubé syndrome.

Conclusion: Bilateral renal masses were found in 15% of the patients in a material of patients treated with NSS. Over 50% of them had the same type of tumor on both sides but 22% of these were benign. Th e combination of diff erent malignant and benign lesions occurred in 35%. Th ese fi ndings are strong arguments for tumor biopsy before surgery is decided.

Preoperative Oita Red Cross Hospital, Oita, Japan Introduction and Objective: Approximately 15% to 50% of patients who underwent total nephroureterectomy for upper urinary tract (UUT) urothelial carcinoma (UC) developed recurrence in the bladder during the follow-up period. Last year, we presented a risk factor for intravesical recurrence aft er laparoscopic radical nephroureterectomy (LRNU) in patients with UUT-UC in SIU congress. Th is time, we will report the result of analysis of a multi-center study.

A total of 126 patients with UUT-UC received LRNU between January 2002 and December 2013 in Oita University Hospital and 3 affi liated institutions that were enrolled in this study. Patients with concomitant bladder cancer or a history of bladder cancer were excluded from this study. Postoperative cystoscopy and urine cytology were performed every 3 months for 2 to 5 years, and postoperative intravesical recurrence was evaluated pathologically. Th e signifi cance of each variable was analyzed univariately by log-rank test. Multivariate analyses by Cox proportion hazards regression model was used to estimate simultaneous eff ects of multiple risk factors. Statistical signifi cance was defi ned as a P value of <0.05.

Results: Median follow-up aft er LRNU was 28 months (range 2-142). Of the patients, postoperative intravesical recurrences were shown in 48/126 (38%). Average time to fi rst intravesical recurrence was 7.01 months. In univariate analysis, there were two signifi cant risk factors of intravesical recurrences. One was for patients who did not receive postoperative adjuvant chemotherapy (P=0.018). Th e other was for patients with preoperative positive urine cytology indicating class IV and V (P=0.041). Multivarite analysis revealed that preoperative positive urine cytology indicating class IV and class V was a signifi cant risk factor for intravesical recurrence (HR2.23 95% CI 1.20 -4.15 P=0.011).

In this multi-center retrospective study, preoperative positive urine cytology was a significant risk factor for intravesical recurrence. Th erefore, adjuvant chemotherapy such as intravesical instillation therapy can be eff ective to prevent intravesical recurrence in patients with preoperative positive urine cytology.

Retroperitoneal Laparoscopic Nephron-Sparing Surgery for Complicated Renal Cysts Introduction and Objective: To evaluate the feasibility, effi cacy and safety of laparoscopic partial nephrectomy for complex renal cystic lesions.

A retrospective cohort study on clinical data of 27 patients with complex renal cystic lesions treated by laparoscopic partial nephrectomy from May 2008 to April 2011 in Peking University Th ird Hospital. According to the Bosniak classifi cation, 7 cases were lesions of grade IIF, 11 were grade III, and 9 were grade IV. Th e mean diameter of cystic lesions was (3.58±0.75) cm, and 4 lesions were larger than 4.0 cm.

Results: All procedures were performed through retroperitoneal approach and successful. Th e mean operative time was (123.1±16.8) min, ranged from 100 min to 160 min, and the mean renal warm ischemia time was (29.7±3.5) min, ranged from 25 min to 40 min. Blood loss in operations was from 50 mL to 110 mL, and the mean was (75.5±21.8) mL. Th e postoperative hospital stay was 4~6 days, and the mean was (5.11±0.85) day. Postoperative pathological results included 10 simple renal cysts (37.0%), 2 cases of adult cystic nephroma (7.4%), 1 mixed epithelial and stromal tumor (3.7%), 13 cases of renal cell carcinoma with cystic change (48.1%), and 1 multilocular cystic renal cell carcinoma (3.7%). Th e results showed 14.3% of cystic lesions of grade IIF, 45.5% of grade III and 88.9% of grade IV were malignant. In the follow-up ranged from 12 to 48 months (median 24 months), there was no case of recurrence.

Conclusion: Th e diff erentiation between benign and malignant renal cystic lesions before surgery remains diffi cult. According to the Bosniak classifi cation, radiological diagnostic fi ndings are standard but still limit to the accuracy to determine the dignity of pathological entity. Laparoscopic partial nephrectomy is feasible to treat complex renal cystic lesions, and is a safe and eff ective minimally invasive option.

Introduction and Objective: Th e aim of the study was to evaluate the value of metastasectomy in patients with metastatic renal cell carcinoma (mRCC) in the targeted therapy era.

We reviewed the medical records of 323 patients who presented with mRCC and received no systemic therapy before enrollment. Of them, 13 underwent complete metastasectomy followed by targeted therapy (complete metastasectomy group), 48 underwent partial metastasectomy followed by targeted therapy (partial metastasectomy group), and 262 treated with targeted therapy alone (non-metastasectomy group). We estimated progression-free and overall survival using Kaplan-Meier curves. A Cox proportional hazards regression model was used to estimate the prognostic signifi cance of metastasectomy.

Results: Clinicopathological variables did not diff er among the 3 groups except for history of nephrectomy, bone metastasis, number of metastatic sites, and time from diagnosis to treatment. Th e median progression-free survival was 17.1, 16.2, and 11.4 months in the complete, partial, and non-metastasectomy groups (P = 0.030). Karnofsky performance status (HR 3.21, P < 0.001), cell type (HR 1.84, P = 0.027), sarcomatoid or rhabdoid features (HR 2.21, P < 0.001), retroperitoneal lymphadenopathy (HR 1.86, P < 0.001), number of metastatic sites (HR 1.40, P = 0.030), lactate dehydrogenase (HR 1.75, P = 0.006), and time from diagnosis to treatment (HR 1.54, P = 0.009) were independent predictors of progression-free survival. Th e median overall survival was 70.9, 29.9, and 19.4 months in the complete, partial, and non-metastasectomy groups (P < 0.001). Complete metastasectomy (HR 0.3, P = 0.028) was an independent predictor of overall survival, along with age (HR 1.02, P = 0.005), Karnofsky performance status (HR 3.90, P < 0.001), sarcomatoid or rhabdoid features (HR 1.93, P = 0.001), bone metastasis (HR 1.67, P = 0.003), retroperitoneal lymphadenopathy (HR 1.82, P < 0.001), number of metastatic sites (HR 1.69, P = 0.001), hemoglobin (HR 1.47, P = 0.017), neutrophil (HR 1.78, P = 0.033), corrected calcium (HR 1.96, P = 0.022), and time from diagnosis to treatment (HR 1.68, P = 0.005).

Conclusion: Complete metastasectomy performed before targeted therapy signifi cantly increased overall survival in patients with mRCC. If surgically resectable, aggressive metastasectomy should be considered.

Guideline Results: Prominent international guidelines and strategies varied signifi cantly in relation to follow-up practice. Th e mode and frequency of radiological imaging was signifi cantly diff erent across the guidelines for low and intermediate risk disease.

Although there is currently no consensus within the literature regarding surveillance protocols, various guidelines and strategies have been developed using both patient and tumour characteristics. Th is information raises questions regarding the follow-up practice in Australia due to both the lack of guidelines and the fi nancial.

Introduction and Objective: Nephrectomy is the cornerstone therapy for renal cell carcinoma (RCC) and its continued refi nement through research may enhance patient outcomes. Medical registries are used domestically and internationally to aid research, assess trends and help guide future practice of many medical disciplines. Th ere is currently no national Australian nephrectomy registry. Th is review aimed to explore possible defi ciencies within the Australian RCC nephrectomy fi eld and through assessment of literature from established registries, determine if a National Nephrectomy Registry is appropriate and justifi ed to address these issues.

A PubMed search identifi ed records pertaining to RCC nephrectomy in Australia. A similar search identifi ed records relating to established nephrectomy registries internationally as well as other surgical registries of clinical importance.

Th ese records were reviewed to address the stated aims of this article.

Results: Australian RCC nephrectomy fi eld lacks population-based data: resulting key issues identifi ed 1) Diffi culty benchmarking individual and institutional outcomes; 2) Small sample sizes and reduced power of studies; 3) Assessment of regional and nationwide outcome trends: diffi cult to achieve and oft en done years in retrospect with no ongoing monitoring; 4) Care centralisation debate: can small volume centres provide comparable outcomes to high volume centres? 5) Best Practice Guidelines: patterns of adherence to existing protocols is uncertain; and 6) Limited platform for large scale prospective studies -restricting potential research. Review of established international registries demonstrated the registry model can eff ectively address issues comparable to those identifi ed in the Australian literature.

A centrally held, de-identifi ed national nephrectomy registry could provide a means of ad-dressing defi ciencies identifi ed in the Australian RCC nephrectomy fi eld. Th e model is supported by evidence from comparable international examples and will provide population-based data needed for studies at the institutional, regional and national level. Th e development of a confi dential and non-threatening escalation policy to be implemented should trends in the data emerge is a future possibility. Scope exists for possible integration with current or future registries/ databases to develop a more encompassing urological, cancer or surgical registry. Need remains for continued exploration of the feasibility and practicalities of initiating such a registry.

New Technologies of Identifi cation of Renal Artery in Retroperitoneal Laparoscopic Renal Surgery Hao Y, Xiao C, Liu Y, Ma L

Introduction and Objective: Th e objective of this study was to evaluate the feasibility of a new method to identify renal vessels during retroperitoneal laparoscopic nephrectomy.

A total of 90 patients underwent transperitoneal radical laparoscopic nephrectomies from January 2010 to August 2012. In the fi rst consecutive 30 patients (Group 1) we located renal artery with the standard technique; in the last consecutive 60 patients (Group 2) the medial arcuate ligament (MAL)-psoas muscle fat complex was used as an anatomic landmark to identify renal vessels. Comparative analysis was carried out between the two groups, including mean hilar exposure time, mean blood loss, duration of hospital stay, conversion rate and complication rate.

No diff erences were noted in gender, age, mean body mass index, tumor side and size of the lesions in the two groups (P>0.05). Mean hilar exposure times were 10.3 ± 3.1 minutes in Group 1 versus 6.1 ± 1.7 minutes in Group 2 (P<0.001). Mean blood loss was 153.3 ± 39.8 ml in Group 1 versus 110.8 ± 28.1 ml in Group 2 (P<0.001). No signifi cant diff erences were detected regarding duration of hospital stay, complication rate and conversion rate between the two groups (P >0.05). No complications and no recurrence of disease at CT evaluation were recorded neither in Group 1 nor in Group 2.

Conclusion: Radical laparoscopic nephrectomy in use of the MAL-psoas muscle fat complex as an anatomic landmark is technically feasible and safe. In conclusion, the MAL-psoas muscle fat complex can serve as an objective and belt-and-braces anatomic landmark for the identifi cation of the renal vessels in retroperitoneal laparoscopies.

Kalpinskiy A, Alekseev B, Kaprin A, Nyushko K, Vorobyev N, Vokach D

Introduction and Objective: Th e aim of our study is to evaluate the results of percutaneous radiofrequency ablation (RFA) of renal tumors in elderly patients with severe comorbidities and a high risk of surgical intervention. Th e aim of this study was to evaluate the expression of CD31 and microvessel density (MVD) in Clear cell renal cell carcinoma (ccRCC) as well as the relationship between MVD and possible prognostic markers like tumor size, degree of tumor necrosis and degree of tumor hemorrhage.

Expression of CD31 was detected in 40 patients with ccRCC and 20 cases with benign kidney tissue using immunohistochemical staining. Th e MVD was studied by Weidner's method.

Results: Th e expression of CD31 in the clear cell renal cell carcinoma (ccRCC) (109.5 (DS±76.5), varied from 5 to 292.) were signifi cantly higher than the expression of CD31 in the benign kidney tissue, as the control group, was 23.2 (DS±22.5) (U=699, P<0.0001). Th e MVD values marked by CD31 were negatively correlated with degree of tumor necrosis (r=-0.304, P=0.055), tumor size (r=-0.09, P=0.578), But no association was found between MVD values and degree of tumor hemorrhage (r=-0.01, P=0.93) in CRCC.

Our results show that MVD in CRCC were signifi cantly higher than MVD in the benign kidney tissue. Th ere was a negative non signifi cant correlation between the MVD and presence of tumor necrosis as well as between MVD and tumor size. On the other hand, there was no correlation between MVD and degree of tumor hemorrhage in ccRCC. Conclusion: Expression of HIF-1α and VEGF in CRCC was signifi cantly higher than in normal kidney tissue. Th e expression of HIF-1α and VEGF may be responsible for angiogenesis in ccRCC, however these angiogenic factors play an important role in the prognosis of ccRCC patients.

Transvaginal Hybrid NOTES Nephrectomy in a Low Resource Setting Firaza P, Lorenzo E, Bardelosa J, Reyes E, Patron N

Introduction and Objective: Hybrid NOTES decreases the invasiveness of conventional laparoscopic surgery and overcomes the limitation of pure NOTES especially in the absence of angulated instruments. Th e patients are 66, 69 and 32-year-old females with complaints of recurrent fl ank pain and urinary tract infection due to an obstructed non-functioning kidney.

Materials and Methods: Materials used include standard laparoscopic instrumentations and a 300 endoscope. Under general anesthesia the patient was placed in a lithotomy position with the aff ected side up at 45 degrees. Veress needle was initially inserted thru the umbilicus and was later replaced with a 10mm laparoscopic port with additional 5mm port also inserted at the aff ected lower quadrant site. Pa-tient was then positioned in a steep trendelenberg and 10mm port was inserted thru the posterior vaginal wall under direct vision from the abdominal cavity that was later used for the endoscope. Nephrectomy proceeded despite noted severe adhesions and the kidney was placed in the specimen retrieval bag. Th e vaginal port site was enlarged to 3cm for extraction of the specimen. Th e vaginal wound was repaired using running 2-0 absorbable sutures.

Results: Th ree cases of transvaginal hybrid NOTES nephrectomy were successfully completed. Th e median operative time was 310 minutes (range: 280-335). Th e mean estimated blood loss was 300 mL for the three cases. Median renal dimensions (cm) were as follows: craniocaudal 10.2 (range: 10.6-9), laterolateral 6.5 (range: 7-5.3), and anteroposterior 4.8 (range: 6.5-3.9). Th e patient resumed regular diet as early as day 1 post operatively. Drain was removed prior to discharge. Th e mean date of discharge was 3rd day post-operatively. Th ere were no noted surgical complications according to Clavien-Dindo grading system.

Conclusion: Hybrid NOTES transvaginal nephrectomy is a feasible and reproducible procedure in selected patients regardless of laterality for better cosmesis, reduced post-operative pain and early recovery. However, the view was challenging because it was from the pelvis. Th e left side procedure proved to be more diffi cult due to the gonadal vein obstructing the view, which is usually larger in young females.

Introduction and Objective: To summarize our clinical experiences of Laparoendoscopic Single-site Surgery (LESS) in Urology. Results: All procedure underwent successfully using Single Trocar X Cone (Storz) without any major complications. Early recovery with minimal scar is the Hallmark of LESS surgery. Duration of time (30-145 mns), Blood loss (5-40ml), mobilization (24-48 hrs), hospital stay (2-6days). No intraoperative complication without any conversion to other surgery (Multi port laparoscopic surgery) and uneventful post-operative period was the fi nal outcome. Introduction and Objective: Th e use of fl exible cystoscopy to study bladder is usually perform in urology departments using diff erent types of lubricant to reduce pain. Th e objective is to compare the use of lubricant gel with lidocaine versus lubricant gel without anesthetic in fl exible cystoscopy in terms of pain and tolerability.

Materials and Methods: Seventy two patients are divided in two groups in this observational not randomized study. Group 1: 38 patients with lidocaine gel 2% and Group 2: 34 patients with lubricant gel without anesthetic. Th e main variables analyzed are score in visual analogue scale (VAS) and score in Spanish pain questionnaire (SPQ). T-student test and Chi-square test are used to compare diff erences using SPSS program and signifi cant statistical diff erences is considered p≤0.05.

Results: Mean age of patients in Group 1 is 64.50 ± 12.39 years and 67.79 ± 10.87 years in Group 2 (p=0.23). Th e distribution according to sex was 29 men:9 women in Group 1 and 25 men:9 women in Group 2 (p=0.78). Th e main pain score in VAS was 2.21 ± 2.05 in Group 1 versus 1.59 ± 1.61 in Group 2 (p=0.16). In the SPQ, the current intensity value was 1.82 ± 0.86 in Group 1 versus 1.53 ± 0.74 in Group 2 (p=0.14), and the total intensity value was 1.92 ± 1.86 in Group 1 versus 1.03 ± 1.75 in Group 2 (p=0.04). Th e cost of gel with lidocaine is 1.25 euro and gel without anaesthetic 0.22 euro.

Conclusion: Th e use of lidocaine gel do not produce benefi t in the fl exible cystoscopy and expensive the procedure.

New Laparoscopic Surgery Using Water Filled Laparo-Endoscopic Surgery Systems Introduction and Objective: Urologist usual operated under water fi lled condition, such as transurethral surgery, percutaneous renal surgery. However, laparoscopic surgery was done under CO2. Water fi lled condition has several merits. Water pressure is suppressing venous bleeding and prevent from CO2 embolism in venous injury condition. To keep water temperature as same as body temperature was useful to avoid low body temperature. Simultaneous observation of ultrasound image from the surface of the body and laparoscopic view is possible during surgery. Th us we conduct to develop the water fi lled laparo-endoscopic surgery systems (WAFLES).

First problem is dispersion of blood aft er bleeding. It interrupts the laparoscopic view. We solved this problem to control the fl ow of irrigation, aff ording the continuous observation of bleeding point and it is easy to control the bleeding by vessel sealing system or coagulation. Second problem is managing fl oating organs such as intestine or nets. Th ese are disturbed the operating view and space. To keep the operating space, we use sheath and single port devices. However, obtaining wide view was still hard in the water because fl oating organs disturb the fi eld. To solve this problem, we use 3-D tracking navigation system.

Results: Using young male pig, we performed partial nephrectomy and radical cystectomy using this new system.

WAFLES is now developing. We will be present the update of this research soon.

Comparison of Safety, Effi cacy and Cosmetic Outcomes between Standard Laparoscopic Live Donor Nephrectomy and Mini-Laparoscopic Donor Nephrectomy: A Randomized Clinical Trial Introduction and Objective: Th is study was conducted to compare safety, effi cacy and cosmetic outcome between standard laparoscopic live donor nephrectomy (sLDN) and mini-laparoscopic donor nephrectomy (mLDN) in a randomized clinical trial.

From March 2012 to June 2013, 100 consecutive kidney donors were randomly assigned to two equal groups for laparoscopic donor nephrectomy.

From March 2012 to June 2013, 100 consecutive kidney donors were randomly assigned to two equal groups for laparoscopic donor nephrectomy.

mLDN: Six to eight centimeters Pfannenstiel incision was made slightly above pubis symphysis and 11 millimeters trocar was fi xed through exposed fascia using open technique. Five mm port was placed under direct vision at the umbilicus for camera insertion and two 3.5 mm ports were placed in subxiphoid and paraumbilical area.

sLDN: Ten mm port was placed at umbilicus using open access technique for camera insertion. Five mm trocar for grasping and 11 mm trocar for vascular clipping were placed at subxiphoid and paraumbilical areas under direct vision, respectively. Th e second 5 mm trocar was placed in suprapubic area.

Cosmetic appearance was assessed three months aft er surgery by using the modifi ed Patient Scar Assessment Questionnaire (PSAQ). Conclusion: Our experience in this study revealed that peri and postoperative fi ndings were comparable between sLDN and mLDN but mLDN has signifi cant better cosmetic appearance than standard laparoscopic approach.

Qiu M, Ma L, Lu J

Introduction and Objective: To report our experience and outcomes with retroperitoneal laparoscopic Anderson-Hynes dismembered pyeloplasty for the repair of ureteropelvic junction obstruction (UPJO).

We performed 47 retroperitoneal laparoscopic Anderson-Hynes dismembered pyeloplasty between June 2003 and December 2011. Ureter was found in the lower pole of the kidney psoas front, then ureteropelvic junction stenosis was dissociated. Ureter was cut at about 1 cm distal ureter beyond the part of stenosis, then stenosis was resected. Posterior wall was continuous sutured, and double J tube was antegrade placed. At last, anterior wall was continuous sutured. Patient characteristics and perioperative outcomes were analyzed. Perioperative parameters including operative time, estimated blood loss, postoperative length of hospital stay, and complication.

Results: Th e procedure was successfully accomplished in all patients, and no patient required conversion to open surgery. Th e mean operation time was 157.7min (80-317min), mean estimated blood loss was 69ml (10-400ml), mean postoperative length of hospital stay was 7.5d (4-28d), and mean time of keep drainage tube was 5.7d (1-26d) . Patients were followed up for 18 ~ 120 months (average 53.6 months). Eighteen cases were followed up in 5 years, and an-

Renal Cyst (12) other 11 patients were followed up for 5-10 years. Th e total remission rate was 86.2%.

Conclusion: Retroperitoneal laparoscopic dismembered pyeloplasty is a safe and effi cacious procedure for UPJO in a long time follow-up.

Positioning-Related Complications of Robot-Assisted Radical Prostatectomy (RARP) in a Steep Trendelenberg Position with Physique Fixation Appliance by the Negative Pressure Takeda H, Nakano Y, Narita H

Introduction and Objective: Because of recent advances in minimally invasive surgical techniques, robot-assisted radical prostatectomy (RARP) has become the primary treatment option in prostate cancer. RARP, however, necessitates patients to be placed in a steep Trendelenberg position, which presents multiple opportunities for complications relating to the positioning of the patient. Our study aims to study the prevalence and demographic predictors of these positioning complications.

We included patients who underwent RP from 2012 to 2015 using data extracted from our hospital database. All patients (n=103) had Trendelenberg position with Physique fi xation appliance by the negative pressure, HUG-U-VAC and Film dressings. Positioning complications (skin, eye, nerve, compartment syndrome/rhabdomyolysis) were identifi ed using patient-level diagnosis and procedural International Classifi cation of Disease, 9th edition, Clinical Modifi cation codes. We analyzed body pressure by portable interface pressure sensor.

Results: Positioning complications occurred in 1.2% of cases with shoulder complications contributing the most to this frequency. Rubefaction occurred in 4 cases, without bedsore. Having positioning complications not increased a patient's odds of having increased age, BMI, operation time, body pressure, insignifi cantly.

Conclusion: Th e steep Trendelenberg position used in RARP was not shown to be associated with patient positioning-related complications in this sample. Physique fi xation appliance by the negative pressure is safety and useful.

Evaluation of Nasogastric Tube (NGT) Suction for Evacuation of Large Bladder Blood Clot

Introduction and Objective: Blood clot formation in the urinary bladder can be caused by many etiologies such as postoperative bleeding, tumor bleeding, radiation cystitis and etc. Acute urinary retention may disclose and a large three way catheter with irrigation is placed conventionally to prevent further formation of blood clot and manually remove the blood clot. When this failed an endoscopic procedure takes place to con-trol the bleeding and to relief the bladder. Urologists may fi nd it diffi cult to remove a large, thick and bulky clot using Ellik evacuator. Here we introduce using nasogastric tube as an alternative to procure a safe and effi cient way to remove these bothersome clots. Aim: To introduce a novel method to successfully remove large, troublesome blood clots during cystoscopy.

We prospectively perform blood clot evacuation on 21 patients within 6 month (September 2014 -February 2015) in Hasan Sadikin Hospital. Th e patient, preoperatively have at least ½ of bladder volume with blood clot using ultrasonography. A 16 Fr NGT inserted into the bladder through the resectoscope sheath 24 Fr and connected to suction unit with a 300 mmhg negative pressure. A calibration of the NGT tip does not exceed more than 2 cm from the cystoscopy beak was made. Backward and forward movement was set in motion during the procedure to facilitate blood clot removal. Cystoscopy evaluation was performed in the end of the procedure to evaluate any complication. A total cystoscopy time, NGT suction time, and the volume of blood clot were documented.

Results: A total 21 patients was all successfully managed with this method without any complications such as bladder laceration/perforation. Th e mean age was 52 years old with male predominance. Most common etiologies of blood clots retention were postoperative bleeding (57 %). Th e average time for clot removal time was 20 (5 -70) minutes. Th e average volume of blood clots removed was 483 grams.

Conclusion: Evacuation using NGT suction is eff ective, safe and an effi cient way to remove of large bothersome clot.

Learning Curve Assessment of Robot-Assisted Radical Prostatectomy in the Oncological and Functional Outcomes Takeda H, Nakano Y, Narita H

Introduction and Objective: Th is study aims to compare the oncological, safety and functional outcomes between fi rst-step RARP and second-step RARP.

Th e study was conducted on a total of 100 patients having undergone robot-assisted radical prostatectomy from 2012 to 2015. Th e fi rst 50 patients (Group 1) were compared with the second 50 (Group 2) to evaluate the learning curve eff ects.

Results: Both groups were similar with respect to age, prostate-specifi c antigen level, body mass index, Gleason score, and distribution of the clinical stage. Th e operative time was 192 minutes for Group 1, and 172 minutes for Group 2 (P=0.01). Individual times of various stages of the procedure (dissection of the seminal vesicles, entering the extraperitoneal space and dissection of the endopelvic fascia, incision of the bladder neck, division of the prostatic pedicles and preservation of the neurovascular bundle, and urethrovesical anastomosis) decreased signifi cantly over time. Estimated blood loss was 241mL for Group 1, 189 mL for Group 2. Th e length of stay was 9.3 days for Group 1, 9.1 days for Group 2. Positive surgical margin rates were 31% for Group 1, 27% for Group 2. While one patient in Group 1 had biochemical recur-rence, no patient in Group 2 had biochemical recurrence. Continence rates at 12 months were 90.1%, and 92.5% in groups 1 and 2.

Conclusion: Surgical, oncologic, and functional outcomes of RARP improve with increasing experience. Outcomes similar to the published series by high-volume centers could be achieved aft er 80 to 120 RARP cases.

Possibility of 3D Modeling and Intraoperative Navigation during Procedures in the Retroperitoneal Space Introduction and Objective: Application of 3D modeling allows you to get more information about the spatial imaging of the disease. Intraoperative navigation in the retroperitoneal space is an innovative minimally invasive procedure, the surgeon improves orientation in retroperitoneal space. We present the method of intraoperative navigation based on virtual simulation during videoendoscopic partial nephrectomy for kidney's tumors.

Special computer program has been developed, that created three-dimensional image of operative space on the basis of preoperational tomographic data of a concrete patient. We used hardware-soft ware complex (HSC) for virtual modeling of the surgery zone. Th e complex consists of a PC, original soft ware and mechanical 3D digitizer. Th e HSC allowing to form virtual 3D model of a patient according to the results of tomography examination. Th e original method of matching the system of coordinates of a virtual model with the patient was off ered. Th e procedure was conducted under the conditions warm ischemia, aft er mobilization of the kidney, partial nephrectomy was performed by observing the image of 3D organ model agreed with the video image of the kidney tumor. Th e method was originally performed for the 12 patients with small renal tumors, who needed in surgical treatment, their average age was 42.5 (in the range from 36 to 54) years, men -5 (41.7%), women -7 (58.3%). Size of the tumors were 3.2 (2.0 -4.0) cm, they were located in the lower poles of the kidneys.

Average time of an operation performed with the use of the computerized choice of the surgical approach was 95.5 (80-155) minutes. Warm ischemia time was 20.5 (18 -28 min). Th ere were no complications during the operation and in the post-operative period. Th ere were no cases of positive surgical margins.

Conclusions: Usage of the introduced computer program allows the surgeon to determine compliance with the contours of the 3D models of the body shown in the video monitor. Th e technique provides additional possibilities for the surgeon in selecting borders in partial nephrectomy. Th is method is particularly perspective for teaching beginner surgeons, it can help them acquire skills in minimally invasive surgery.

Possible Impact of Continuous Drainage after Minimally Invasive Partial Nephrectomy

Introduction and Objective: Postoperative management of partial nephrectomy without drain placement is common, but the specifi c eff ects on patients are unclear. We investigated the impact of no drain placement aft er minimally invasive partial nephrectomy (MIPN).

We retrospectively studied 194 consecutive patients who underwent laparoscopic and robotic partial nephrectomy at a single academic center. Th e study group included 46 evaluable patients without drain placement. Th e quantity of postoperative fl uid collection in the perirenal space was calculated using computed tomography. Th e pre-and postoperative serum concentrations of total protein and albumin, in addition to neutrophils, lymphocytes, monocytes numbers and C-reactive protein (CRP) levels in the blood were compared.

Results: Drain was placed in 148 (76.3%) patients who underwent MIPN. Th e remaining 46 (23.7%) patients were not provided with drain placement. Although the average total quantity of fl uid discharged from the drain was 214 mL, the average fl uid remaining in the perirenal space was not signifi cantly diff erent with or without drain placement (20.3 mL vs. 16.8 mL, P=0.64). Decrease in serum total protein and albumin with drain placement was signifi cantly greater than without drain placement (total protein; 18.9% vs. 12.2% P<0.001 and albumin; 24.7% vs. 22% P=0.038).

No drain placement also caused markedly greater decreases in lymphocytes and monocytes than drain placement, while neutrophils and CRP were not different. A MIPN population was necessary by design, which may limit the ability to generalize these results.

Conclusion: Analysis of the quantity of fl uid collection showed little need for routine drain placement. No drain aft er MIPN prevents serum protein loss and might aff ect wound-healing immune responses.

Initial Experiences of Laparoscopic Radical Cystectomy Introduction and Objective: Simultaneous treatment of bilateral lesions is an interesting application of laparoscopy. Our goal was to present our experience with simultaneous bilateral laparoscopic pyeloplasty using three midline ports in two adult patients.

Two adult patients (one male and one female) underwent bilateral laparoscopic dismembered pyeloplasty in one session. One of the patients had horseshoe kidneys. A 12-mm trocar was placed through the umbilicus, and two 5-mm trocars were placed midline 10-12 cm superior and inferior to the umbilicus.

Results: Intra-and postoperative periods were uneventful. Operation time was 245 and 280 minutes in the fi rst and second patient, respectively. Obstruction was relieved in both patients bilaterally on a 6-month follow-up.

Conclusions: Simultaneous bilateral laparoscopic pyeloplasty using three midline ports is safe and feasible in adult patients with bilateral ureteropelvic junction obstruction.

Introduction and Objective: Radical cystectomy is considered to be the most eff ective treatment for patients with muscle-invasive bladder cancer. Most urinary diversions are performed extracorporeally because of complex procedure time consuming. However, with the development of minimally invasive radical cystectomy techniques, increasing attention has been focused on intracorporeal urinary diversions, including both ileal conduit and orthotopic neobladder. We reviewed cases of laparoscopic radical cystectomy with intracorporeal ileal conduit in our medical center.

Ten patients with bladder cancer who underwent laparoscopic radical cystectomy and intracorporeal ileal conduit were retrospectively reviewed. With the cystoprostatectomy and lymphadenectomy completed, a 15-20cm segment of ileum was identifi ed 15cm from the ileocecal junction. Division of the isolated segment of bowel and the mesentery was performed using the Endo-GIA stapler. Ileo-ileal continuity was reestablished by creating a generous side-to-side anastomosis with Endo-GIA stapler. Th e left ureter was passed to the right side of the abdomen. Aft er placement of single-J stent, the ureters were spatulated and the ureteroileal anastomis was performed with a running suture.

Results: laparoscopic radical cystectomy and intracorporeal ileal conduit were performed successfully in all ten patients from Jan 2014 to Dec 2014. Th e mean operating time was 330min (300 -450 min), and the mean ileal conduit construction time was 110min (95 -130min). Th e mean blood loss was 170 ml (60 -350 ml), and no patient received transfusion. Th e time to orally allow was postoperative day 5 (4-7). Th e mean hospital stay was 10d. No major complication occurred. Results: All the procedures were successfully completed without additional trocars except for one patient who was immediately converted to suprapubic-assisted laparoendoscopic single-site surgery (SA-LESS) nephrectomy for rectal injury during the placement of the Zou-Port. In our initial 3 cases, Tri-Port was used. In the subsequent 20 procedures, Zou-Port was used. Th ere were no other intraoperative complications occurred. Postoperative complications included a right external iliac artery thrombosis in one patient who underwent pure transvaginal NOTES simple nephrectomy. Th e mean operative time was 80 (range 60 to 90) mins and the mean estimated blood loss was 25 (range 20 to 50) ml for pure transvaginal NOTES renal cyst decortication. Th e mean operative time was 186 (range 160 to 280) mins and the mean estimated blood loss was 110 (range 160 to 280) ml for pure transvaginal NOTES nephrectomy. Th e mean visual analog scale (VAS) pain score was 3.1 (range 2-5) on postoperative day 1. Th e mean time for ambulation was 1.6 (range 1-2) d. Th e mean time for oral feeding was 2.2 (range 2~3) d. Th e mean postoperative hospitalization stay was 5.2 (range 3~8) d. During the 3 to 51-month follow-up period, all the patients were in good condition. Th e posterior colpotomy incision healed well. Th ere was no scar on the abdominal wall.

Th ere was no retrograde infection of pelvic and abdominal cavity, umbilical hernia, or uterine prolapse.

Conclusion: Th e application of Zou-Port in pure NOTES transvaginal eff ectively reduces the diffi culty of operation and avoids the abdominal and pelvic organ injury, which is worthy of clinical application.

lower ureter stricture. All the cases presented only one abdominal scar before surgery, including 13 cases with the history of caesarean section, 10 cases with the history of birth control surgery, 6 cases with the history of appendectomy, 3 cases with the history of inguinal hernia repair, 3 cases with the history of ureterolithotomy, one case with the history of bladder lithotomy, and 6 cases with the history of laparotomy surgery. Th e mean length of scar is 7.2 (1.5 to 18.5) cm. Under general anesthesia, the patients were positioned in lithotomy with aff ected side elevated at 70°. Two trocars (5mm or 10mm) were introduced into abdominal cavity from the incisions at the right and left medial margin of umbilicus. A 10-or 5-mm trocar was inserted into the abdominal cavity through the abdominal scar under the direct vision. Our technique for the transabdominal scar-assisted U-LESS is similar to that of standard laparoscopy, using conventional operating apparatus placed in the umbilical trocars, under direct vision achieved by a fl exible-tip 0° laparoscope placed through the trocar at the abdominal scar. Th e specimen was placed inside a homemade bag and removed under direct vision through an extended incision at the abdominal scar.

To explore the application of three-dimensional (3D) laparoscopic technique in hybrid transvaginal NOTES nephrectomy.

A total of 8 female patients underwent hybrid transvaginal NOTES nephrectomy using 3D laparoscopy system. Th ose included 4 cases of hydronephrosis, 3 cases of renal empyema, and 1 cases of renal atrophy. Th e median age was 39 (range 33 to 55) years, and body mass index was 23.7 (19.8~28.5) kg/m2. All patients were with unilateral disease and normal contralateral kidney. Th e perioperative data including operative time, estimated blood loss, and surgical outcome were analyzed.

Results: Th e procedures were successfully completed. Th e median operative time was 100 (85 to 150) mins. Th e median estimated blood loss was 120 (80 to 450) ml. Th e patients were recover ambulation on postoperative day 1 to 2, and tolerated diet on postoperative day 2 to 3. Th e patients were discharged on postoperative day 7 to 8. Th ere were no intraoperative or postoperative complications. During the 6-to 10-month follow-up period, all the patients were in good condition. Th e posterior colpotomy incision healed up well. Th ere were two hidden umbilicus scars. and p=0.961, respectively). Mean incision length was shorter (5.2 vs. 7.1 cm, p<0.001) and the scar satisfaction score was higher (8.6 vs. 7.7, p=0.001) in LDN with fl ank incision group. Th e postoperative pain scores were higher (p=0.025) in LDN with fl ank incision group but analgesic requirements were similar in both groups (p=0.565).

Conclusion: LDN with fl ank incision had cosmetic satisfaction and comparable graft function, although challenging to the surgeon with longer warm ischemia time and higher postoperative pain.

The Effect of Caudal Block on Postoperative Analgesia in Robotic Assisted Laparoscopic Prostatectomy: A Prospective Study in a National Referral Centre Introduction and Objective: Caudal block is widely used in paediatric surgery. It provides satisfactory postoperative pain relief in lower abdominal operations with minimal complications. Th is pilot study explores its eff ect on postoperative pain control and its safety in patients who underwent robotic assisted laparoscopic prostatectomy (RALP).

From 2013 to 2014, 40 consecutive patients were randomised into 2 groups of 20 patients. Th e intervention group received caudal block using ropivacaine immediately aft er operation, while the control group only received analgesia consisting of paracetamol, NSAIDs, and opioids. Both groups were assessed using verbalised pain scores in recovery room, and 6, 12, 24, 48, 72 hours aft er the operation. Additional analgesic requirements were recorded in the intervention group. Opioid-related adverse events and the time to passage of fl atus were also recorded. 

Introduction and Objective: Th e dorsal venous complex (DVC) ligation and vesicourethral anastomosis (VUA) are the most challenging parts during laparoscopic radical prostatectomy (LRP). Th is study will introduce a unique technique without any knots for the DVC ligation and VUA using the unidirectional single running self-retaining suture. Th is study is to examine the eff ectiveness of our knotless laparoscopic radical prostatectomy compared with the conventional technique.

Materials and Methods: From December 2013 to December 2014, 45 LRP were separated into 2 groups: Group 1 of 20 knotless LRP and Group 2 of 25 conventional single-knot LRP. During knotless LRP, the DVC is sutured using a 1-0 1/2 circle self-retaining suture with 3 bites at the same place, and the VUA is performed with a 23-cm 3-0 5/8 circle barbed self-retaining suture with one needle driver. Retroperitonoscopic pyeloplasty is a feasible approach in the management of Pelviureteric junction obstruction with a crossing vessel. Anterior transposition using the posterior approach demands a good experience. Herein, we present a case with complex vascular anatomy representing a real surgical challenge for a retroperitonoscopic approach.

In the period from 2006-2015, 21 cases with a crossing vessel were operated by a single surgeon using both transperitoneal and retroperitoneal approaches. We report here a 5 y old girl with left sided Pelviureteric junction obstruction presenting with recurrent loin pain. Lateral retroperitoneal laparoscopic approach was used with 3 trocars; 5mm optic trocar and two 3 mm working trocars. Th e Pelviureteric junction was tightly pushed anteriorly and close proximity to complex crossing vessels. Dissection from the crossing vessels was performed followed by anterior transposition of the Pelviureteric junction and a diffi cult anastomosis was performed with antegrade DJ insertion.

Smooth postoperative recovery, no leakage, DJ is removed aft er 1.5 month; follow-up Ultrasound revealed decompression of the pelvis with no recurrence of the symptoms during the follow-up period.

Conclusion: Retroperitonoscopic lateral approach is feasible for the management of Pelviureteric junction obstruction with crossing vessel even in the most diffi cult cases in well trained hands.

Robotic Assisted Laparoscopic Reimplantation for Iatrogenic Ureteral Injury

Franklin A, Jones C, Pokala N, Cummings J

Introduction and Objective: Ureteral injuries are a source of morbidity in pelvic surgery. Robotic approaches to these injuries have been proposed. We reviewed our experience with this approach to examine the outcomes in patients undergoing robotic assisted laparoscopic reimplantation (RALR) for iatrogenic ureteral injury. 

Oncological Outcomes of Robotic Prostatectomy in the Victorian Public Sector

Basto M 1,2 , Sathianathen N 3 , te Marvelde L 4 , Landau A 1,5 , Graves R 1,5 , Everaerts W 1,5 , Birch E 1 , Lawrentchuk N 1 , Goad J 1 , Moon D 1 , Murphy D 1, 2, 5, 6, 7 Introduction and Objective: Following the installation of the daVinci S at Peter MacCallum Cancer Centre in 2010, we aim to report medium-term oncological outcomes of patients undergoing robot-assisted radical prostatectomy (RARP) and to identify factors that act as predictors for biochemical recurrence (BCR) and oncological failure (OF).

A prospective cohort of 257 consecutive men who underwent RARP in a single Victorian public hospital were followed up for a median time of 12.6 and 12.9 months for BCR and OF respectively. OF was defi ned as BCR (PSA≥0.2ng/mL) or the start of adjuvant therapy. however, longer-term data is still required to better evaluate oncological success.

Functional Outcomes of Robotic Prostatectomy: The Victorian Public Sector Experience

Basto M 1,2 , Sathianathen N 3 , te Marvelde L 4 , Landau A 1,5 , Graves R 1,5 , Everaerts W 1,5 , Birch E 1 , Lawrentchuk N 1 , Goad J 1 , Moon D 1 , Declan Murphy D 1, 2, 5, 6, 7 Introduction and Objective: To report medium-term functional outcomes of men aft er undergoing robotic assisted radical prostatectomy (RARP). Furthermore, the impact of the procedure on quality of life will also be analysed.

A cohort of 258 consecutive men who underwent RARP in a single Victorian public institution was assessed post-operatively for continence and potency status. A 'Prostate Cancer Research Survey' that was distributed pre-operatively and at 3, 6, 12, 24 and 36 months post-RARP, in combination with hospital medical records were utilized to collect data. Th e following validated questionnaires were included in the survey: Expanded Prostate Cancer Index Composite for Clinical Practice (EPIC-CP), Sexual Health Inventory for Men (SHIM) and Prostate Cancer Related Quality of Life Scale (PCaR-QOLS). Th e latter primarily evaluated the impact of surgery on quality of life.

Results: Utilising hospital medical records, of the 178 (70%) men that had follow-up post-operatively, 79% (101/128) were fully continent at 12 months using a zero pad defi nition and 93% (119/128) were continent using a zero or security pad defi nition. Of those who completed the EPIC-CP questionnaire, preoperatively (n=113 responders), 95.6% and 98.2% were continent using a zero and security pad defi nition respectively. At 12-months (n=59 responders), 81.4% of patients were fully continent using zero pads per day and 94.9% of patients were continent using none or security pad per day. Regarding erectile function, SHIM scores were available for 106 men pre-RARP, of which 58% were considered to be potent. Of this subset of men, only 11%, 10% and 11% are considered post-operatively potent at 3, 6 and 12-months. None of the patients that were pre-operatively impotent regained their erectile function at 12 months. Sexual confi dence was the facet of life that was most impacted by RARP. Other quality of life subdomains showed no signifi cant diff erences aft er robotic prostatectomy.

Conclusion: Th ere has been satisfactory recovery of continence post-RARP, however, erectile dysfunction still remains an important adverse sequela of surgery.

Overall, robotic prostatectomy has been successfully implemented in the Victorian public sector with satis-Introduction and Objective: To compare patterns of care and perioperative outcomes of robotic prostatectomy to other surgical approaches, and create an economic model to assess the viability of robotic prostatectomy in the case-mix public health funding system.

We retrospectively reviewed all radical prostatectomies (RP) performed for localised prostate cancer in Victoria, Australia, between July 2010 and April 2013 from the Victorian Admitted Episode Dataset (VAED), a large administrative database that records all hospital inpatient episodes in Victoria, Australia's second most populous state. Patterns of care, length of hospital stay (LOS) and blood transfusion rates (BTR) were compared by surgical approach. We then created an economic model to evaluate the incremental cost of robotic assisted radical prostatectomy (RARP) over open radical prostatectomy (ORP) and laparoscopic radical prostatectomy (LRP) incorporating the cost off set from diff erences in length of hospital stay and blood transfusion rates. Th e economic model constructs estimates of the diagnosis related group (DRG) costs of ORP and LRP, adds the gross cost of the surgical robot (capital, consumables, maintenance and repairs), and manipulates these DRG costs to obtain a DRG cost per day which can be used to estimate the cost off set associated with RARP in comparison with ORP and LRP. Economic modelling was performed around a base-case scenario, assuming a 7-year robot lifespan and 124 robotic cases performed per fi nancial year, and one and twoway sensitivity analyses performed for the 4-arm da Vinci SHD, Si and Si dual surgical systems (Intuitive Surgical Ltd, Sunnyvale, CA, USA). Both situations present a challenge to the surgeon contemplating a radical prostatectomy for prostate cancer, due to surgical access and anomalous vascular and ureteric anatomy. Open radical prostatectomy has been reported in transplant recipients, but very little has been described using a robot-assisted laparoscopic approach.

A case series will be described, illustrating the challenges and techniques required to successfully perform transperitoneal robot-assisted radical prostatectomy in patients with a congenital pelvic kidney or renal transplant within the pelvis. Operations were performed using the Da-Vinci Surgical System.

We will describe a series of patients between 2007 and 2015 who underwent transperitoneal ro-bot-assisted radical prostatectomy, including patients with a congenital pelvic kidney and a redo renal transplant within the pelvis. Prostatectomy was performed using a partial nerve spare in all cases, and pelvic lymph node dissection was not performed. Th ere was a mean console time of 117 minutes with a mean estimated blood loss of 175 mL. Histopathology confi rmed Gleason sum 6-7 disease confi ned to the prostate with no extraprostatic extension or seminal vesicle invasion (pT2c), and surgical margins were free of tumour in all cases. Th e tumour volume ranged from 4.7 to 6.5 cubic centimetres. Th e PSA became undetectable postoperatively and remained undetectable without further therapy. Careful perioperative review of imaging and placement of ports under direct vision was essential in avoiding complications. 

Stay suture is applied at glans. Circumcision incision is applied leaving at least 5mm tissue of inner mucosal collar. Penile skin is denuded down to the penoscrotal junction. Minor degree of chordee is corrected by this procedure. A 6 Fr feeding tube in the urethra adds to identify the distal urethra which is just underneath the skin in these case, which removed at the end of procedure. Mucosa is defi cient ventrally and is replaced by a triangular patch of skin. Th is skin patch is excised and mucosal edges are approximated in the midline. Th is simple maneuver gives glans penis an upward tilt and meatus appears almost on the tip of glans. Redundant preputial skin is excised and mucocutaneous approximation is done with 6/0 PDS. No dressing is required.

We operated 18 cases of glanular hypospadias between December 2009 and January 2015. Mean age of children was 3.53±2.88 years. All cases were day cases. Th ere was no need for catheterization and dressing. We used temporary dressing for mild bleeding immediate post op in 4 cases only which were removed in recovery room. Th ere was no immediate post-operative complication like urinary retention, severe pain, fever or Urinary tract infection. Th ere was no complication of meatal stenosis in follow-up (2-12 month follow-up). Urine stream was good and cosmesis was satisfactory to parents.

We had low complications in our set up and success of glanular hypospadias by our technique was good in terms of good urine stream and cosmesis. Conclusions: Th e goal of modern hypospadias surgery is a functional neourethra that appears to be normally circumcised penis. Tubularized incised plate urethroplasty is a widely applicable technique for distal hypospadias repair. But our current series shows that modifi ed tubularized incised plate technique has low complication rate and excellent cosmetic results superior to tubularized incised plate urethroplasty for primary distal hypospadias repair. However, these results must be further evaluated by comparison study of large series.

The Impact (Catalona, 1988) was performed in 5 patients. Occult metastatic disease was found in two patients (3 groins) at the time of diagnosis and subsequently developed in 4 patients during follow-up. Th erefore, a total of 9 (36%) of the patients developed metastatic disease.

Conclusions: Current management protocols place moderately diff erentiated T1 penile SCC without vascular invasion in a low risk group for lymph node metastases. For this reason a primary option for these patients expectant approach is currently recommended. Our experience has shown that patients in this group are really at higher risk for metastatic disease, and we suggest early modifi ed groin dissection instead of expectant observation.

Introduction and Objective: Penile cancers are rare. In Ghana, they account for less than 2% of all genitourinary cancers. Data on penile cancers in Ghana is scanty. We report on 13 cases of penile cancers seen over the last 5 years at the Komfo Anokye Teaching Hospital (KATH). Th e aim of the study was to describe the clinicopathological presentation and the mode of treatment of penile cancers in our setting.

Th is was a retrospective study of histologically confi rmed cases of penile cancers seen at KATH from January 2009 to December 2014. Information gathered included age, the clinicopathological features and mode of treatment using a structured proforma.

Results: Th ere were 13 cases of histologically confi rmed penile cancers over the period. Th e age range was from 32 -91 years with a median age of 62 years. Eight were uncircumcised and 10 were married. In only one did the lesion not originate from the glans penis rather aff ecting the base and upper part of the left of hemi-scrotum. In 4 patients, the lesion was restricted to the glans penis, it had involved the distal penis in 3, midshaft in 2, proximal penile in 1 and base of penis in 2 one of whom had auto amputation. All were squamous cell carcinoma with majority being moderately well diff erentiated (80%). Seven had ulcerative lesions and 6 were caulifl ower-like. Majority were advanced (T4) involving the corpora (69%). Only one patient reported with a T1 lesion. Eleven patients (84.6%) had lymph node involvement and two had distant metastasis at presentation. Only one patient had a penile sparing surgery with 10 of them having partial penectomy at various levels with ure-throstomy at the stump ends. One had total penectomy with suprapubic urinary diversion whiles the one with auto amputation had radiotherapy as the primary treatment. Eleven of the patients had lymph node dissection. Four had adjuvant radiotherapy.

Conclusion: Most patients present with advanced disease making any hope of achieving a functional and cosmetically acceptable penis aft er treatment impossible. Further education is needed to ensure early detection and treatment.

How Does Partial Penectomy Due to Penile Cancer Affect the Sexual Life? Even though the high incidence of penile cancer in Brazil, the sexual life of its patients, as well as their partners, has never been evaluated before. Th e aim of this study is to evaluate erectile function in patients who underwent partial penectomy due to penile cancer, describe the socio-demographic and clinical data as well as to assess the patient's partners' sexual function.

We performed a prospective analysis in 40 patients between 2008 and 2014 at Pernambuco State Cancer Hospital in Brazil. Th e sample consisted of patients who were submitted to partial penectomy for the treatment of penile cancer. Control group included volunteer couples from the general population with similar socio-demographic features. Th e assessment of erectile function and female sexual dysfunction were evaluated with IIEF-5 and FSFI respectively.

Results: Th e prevalence of erectile dysfunction (ED) in the group of individuals subjected to partial penectomy was 62.5%, including severe ED in 25%, moderate ED in 10%, mild-to-moderate in 20%, mild ED in 7.5%, and no ED in 37.5% of the participants. Th e prevalence of ED in men of the control group was 26.3% and was typically characterized as mild ED (p < 0.001). Between partners of partial penectomy and control groups, 70% and 63% reported sexual dysfunction, respectively (p = 0.336). A comparative analysis of the risk factors for the ED showed that there were not diff erences between both groups (body mass index (BMI); tabagism; diabetes; hypertension; dyslipidemia and hypogonadism).

Conclusion: Th e actual incidence of erectile dysfunction in patients submitted to partial penectomy for penile cancer is 62.5%. Comparative analysis between patients who underwent partial penectomy and general population showed a higher dysfunction rate in addition to more severe ED. In despite of that, their partner's sexual function was similar between the analysed groups.

The 

Introduction and Objective: Androgens are essential for the development and growth of the genitalia. Th ey regulate the erectile physiology by multiple mechanisms. Several studies have examined associations among sex hormones' serum levels, erectile function and sex drive. We sought to identify a protocol for using testosterone in men with erectile dysfunction and late-onset hypogonadism (LOH).

During a 16-month period, men with erectile dysfunction who presented to the andrology clinic were selected. Th ey underwent a complete physical examination and fi lled out the International Index of Erectile Function-5 questionnaire. Serum luteinizing hormone (LH) and testosterone levels were evaluated. Patients received a single intramuscular injection of 250 mg testosterone. Th ereaft er, serum levels of LH and testosterone were measured 3 weeks later.

Results: Th e mean age was 53 years old. Aft er treating patients with testosterone, 45 (94%) showed improvement in LOH symptoms including libido, loss of energy, irritability and quality of life. Th e mean International Index of Erectile Function was 9 and 13.1, prior to and aft er treatment respectively. Mean serum testosterone levels before and aft er treatment were 4.2 and 4.1 ng ml_1 respectively (P = 0.849). Mean serum LH revealed a signifi cant decrease aft er the study (P = 0.004) (6.12 and 5.1 ng ml_1, before and aft er the study respectively).

Our fi ndings suggested that testosterone replacement therapy improves libido and LOH symptoms in individuals with almost normal or lower limit normal value of serum testosterone levels.

Does L-Carnitine Therapy Add Any Extra Benefi t to Standard Inguinal Varicocelectomy in Terms of Deoxyribonucleic Acid Damage or Sperm Quality Factor Indices: A Randomized Study

To evaluate if addition of L-carnitine therapy to standard varicocelectomy adds any extra benefi t in terms of improvement in semen parameters or deoxyribonucleic acid (DNA) damage.

One hundred patients enrolled in this study and were randomly divided into 2 groups (50 patients in each group). In Group 1, standard inguinal varicocelectomy and, in Group 2, standard inguinal varicocelectomy plus oral antioxidant therapy (oral L-carnitine, 250 mg 3 times a day) were performed for 6 months. For all patients, routine semen analysis and DNA damage test of spermatozoa (by 2 methods of terminal deoxynucleotidyl transferase dUTP nick end labeling and protamine damage assay) were performed at baseline and at 3 and 6 months postoperatively.

Results: In both groups, the improvement in semen analysis parameters and DNA damage was observed, but there was not any statistically signifi cant diff erence between the 2 groups in these parameters, although the slope of improvement in DNA damage was slightly better in Group 2 (that was not statistically signifi cant).

We observed that addition of 750 mg of L-carnitine orally daily to standard inguinal varicocelectomy does not add any extra benefi t in terms of improvement in semen analysis parameters or DNA damage.

Serum Uric Acid as a Risk Predictor for Erectile Dysfunction Introduction and Objective: Testicular torsion is one of the few urological emergencies that require prompt diagnosis and treatment, since its delay leads to testicular ischemia inevitably leads to testicular necrosis and atrophy. We aimed to determine the pattern of presentation and early outcome of patients with testicular torsion managed at KCMC.

Th is was a hospital based descriptive retrospective and prospective study involving 106 patients who were managed for testicular torsion between January 2006 and January 2015. Eighty three (78%) were at the age of 13 years with a mean 16.92 and a standard deviation of 6.01.

Results: Left side was more aff ected by 64.9%. Th irty two (29.7%) patients arrived at KCMC within six hours from the onset of symptoms. Scrotal pain was the main complaint. Seventy two (68%) patients were misdiagnosed at the peripheral health facilities and treated empirically with antibiotics. Ninety six point nine percent of those with more than 360 degrees of rotation and duration of arrival to KCMC beyond six hours were found with missed torsion compared to 52.4% of those with a degree of rotation less than 360 and less than six hours on arrival to KCMC (p-value 0.000). Orchiectomy of the aff ected testis and fi xation of the viable was the mostly adopted treatment option by 55.4%. Eighty four percent of our clients had fi rm and smooth testis at follow-up of three months with 16% having atrophic testis at three months in both groups (retrospective and prospective arms).

Conclusion: Testicular torsion aff ects more young adolescent males. All patients with testicular torsion presented with scrotal pain. Most patients arrived to KCMC hospital beyond six hours majority of them being treated empirically with antibiotics at the peripheral health facilities. Missed torsion is a common sequel to our Patients Outcome at three months is promising by having viable testis.

Ho:YAG Laser Ablation for Ulcerative Interstitial Cystitis

Tokyo Women's Medical University Aoyama Hospital, Tokyo, Japan Introduction and Objective: In cases of ulcerative interstitial cystitis are usually treated by TUR or by electrocautery, resulting in improvement of pain. Efficacy of electrocautery using laser remains unclear because of a very few number of case reports. We treated this time ulcers of interstitial cystitis by cautery using Ho:YAG laser to evaluate its effi cacy as well as safety.

Materials and Methods: Eight cases with Hunner's ulcers whose pains were hardly controlled aft er drug therapy and/or hydrodistention were treated with Ho:YAG laser. Patients were evaluated with interstitial cystitis symptom index (ICSI), interstitial cystitis problem index (ICPI), international prostate symptom score (IPSS), quality of life (QOL) index and a visual analog pain scale (VAS) at base line, one, three and six months post operatively. Statistical analysis was performed using the Paired t test, in which P<0.05 was considered statistically signifi cant.

Results: Patients were all females aged 56 to 84 years. Half of them were treated more than two times. Scores obtained by the questionnaire survey were improved aft er the laser therapy. Scores of ICSI, ICPI, IPSS, QOL index and VAS were statistically signifi cantly decreased at one and three months. Only VAS was statistically signifi cantly decreased at six months. Th ere was no severe complication associated by the therapy.

Conclusion: Ho:YAG laser therapy for ulcerative interstitial cystitis is effi cacious at least for three months. Also this treatment is safe for aged patients.

Introduction and Objective: Th e use of methylene blue (MB) to highlight anatomic structures in Urology is a well-established practice. A narrow urethral plate can be diffi cult to properly locate intraoperatively, particularly in panurethral strictures. Our objective is to assess the value of intraurethral injection of MB during urethroplasty.

Th ere is 5 cc of MB (10mg/ ml) diluted in 10 cc of normal saline. Th e MB is gently injected retrograde into the urethra. A penile clamp is applied for 5 minutes to increase the contact time of the MB with the urethra. Th e urethroplasty commenced and the urethra was opened. Th e impact of the MB on the anatomy of the urethra was by subjective assessment of a single surgeon (S.B.K.).

Results: A total of 492 consecutive cases were prospectively evaluated from 2010-2014. Precise staining of the narrow lumen was successfully observed in 464 (94%). In these 464 cases, the diseased urethral strictured portion of the urethra was subjectively stained blue with MB. Th e grossly normal appearing urothelium remained pink and did not take up signifi cant MB stain. In 28 (6%) cases minimal or no staining was observed. Extravasation in to the spongiosa was seen in 8 (2%) cases. In 22 (4%) cases there was dense staining distal to the narrow lumen. Th ere were no known allergic complications.

Conclusion: Normal urothelium does not appear to be stained by MB. MB readily stains diseased and strictured urotheilum. Intraurethral injection of MB is a useful tool in urethroplasty. It helps in delineation of stricture and identifying lumen. It guides us to the exact area of urethra to be augmented. It is a simple, non-costly and non-invasive tool. In our high volume tertiary referral unit, it is now standard to inject methylene blue in urethra immediately prior to urethroplasty.

Demography, Preoperative Imaging and Surgical Outcome in Penile Fracture Results: Condition was occurred in 73.8% of patients during an abnormal sex such as masturbation, aggressive sex and also taghaandan. All patients except one that refused intervention were treated surgically. Only four cases involved bilateral corporal injury. Two involved unilateral corporal injury with an associated urethral injury, and one involved bilateral corporal injury with an associated urethral injury that all were repaired primary. Urine analysis was performed for 69.2% of patients. Gross hematuria was seen in one and microscopic in two patients of urethral injury and did not see in others. Retrograde urethrogram were not taken of patients with urethral injuries. Diagnostic cavernosography or magnetic resonance imaging was not used in any of the patients. Cystoscopy was performed in case of gross hematuria with complete urethral transection. No complications occurred in the patients in early follow-up. We are interested in that report entire result of this study such as longterm surgical outcome at congress.

Conclusion: Based on Islam promotion for early and inexpensive marriage, avoiding from abnormal sex can signifi cantly decrease penile fracture. In addition, we recommended immediate surgical exploration and repair of tunica albuginea without any preoperative diagnostic imaging.

Introduction and Objective: Cowper's glands are two exocrine glands, which are located in the perineal pouch between the fascia layers of the urogenital diaphragm. Th ey excrete pre-ejaculate into the urethra to lubricate it and neutralize acid to enable sperm to pass through the urethra. Th e glands form two ducts that are 2.5 to 3 cm long. Although anatomic variations exist, the majority of ducts combine to make one confl uent passage that opens at the posterior part of the bulbar urethra. Cowper's gland collecting ducts dilatation is called syringocele, an uncommon and under-diagnosed anomaly in adults. In pediatric patients there are 1.5% and 2.3% found on autopsy studies.

We are presenting case of an adult 20-year-old male, whose symptoms were unrecognized by many physicians, even experienced urologists. Th e patient had diff erent treatments with antibiotics and other diff erent medications without success.

Results: Th e patient's chief complaint was dribbling aft er voiding few drops of urine when smiling, coughing, sneezing, crouching and any kind of eff ort. He received treatment as an outpatient by family physician and dermatologist. A bulging on the perineum was found by palpation, hard to elastic consistency, walnut size formation in the corpus spongiosum, easily movable from the perineal skin. Urethroscopy was performed and the fi nding in the bulbar urethra was a cystic formation, gray to white color with very thin blood vessels. It fi lled the lumen of the bulbar urethra, but with pressure very easily passed the urethra and verumontanum to the bladder. Voiding and retrograde urethrography showed fi lling defects in the bulbar urethra. Th is cystic formation was fi xed to the fl oor of the urethra. An incision and deroofi ng of the cystic wall by resection was done. Th e patient aft er this procedure was without dribbling aft er voiding. 

Introduction and Objective: Th e use of methylene blue (MB) to highlight anatomic structures in Urology is a well-established practice. Th ere are diff ering opinions regarding the management of short atraumatic bulbar strictures. Some favor augmentation with buccal mucosal graft (BMG) while others favor excision and primary anastamosis (EPA). Th e divergence of opinion is unifi ed toward EPA in the face of signifi cant spongiofi brosis. Our objective is to determine if MB can be used to assess the degree of spongiofi brosis in short atraumatic bulbar strictures.

We term the procedure methylene blue spongiography. Five cc of methylene blue (10mg/ml) is diluted in 10 cc of normal saline. Th e dissection for the urethroplasty continues until the bulbar urethra is exposed. Th e location of the stricture is identifi ed. Insulin needles are inserted in three locations. One needle is placed in the sponge proximal to the stricture. Another needle is placed in the sponge at level of stricture. Th e third needle is placed in the sponge distal to the stricture. Large atraumatic clamp is place at the most proximal extent of the bulb to limit the confounding blood fl ow from the bulbar artery. Methylene blue is gently injected via distal needle. Th e two remaining needles are then observed for MB effl ux. Presence of MB effl ux in needle proximal to stricture implies a defi ciency of signifi cant spongiofi brosis and urethral transection with EPA is not performed. Absence of effl ux of methylene blue in proximal needle implies signifi cant spongiofibrosis and EPA is performed.

We performed MB spongiosography in 22 short bulbar idiopathic strictures. Mean length of the stricture was 1.2 (range 1 to 1.5). In 18 (82%) cases methylene blue was seen across the stricture and transecting urethra was avoided. In 4 (18%) cases where no MB went across primary excision and anastomosis was performed. No patients had adverse reaction or complication of methylene blue.

Conclusions: Methylene blue spongiography can be performed to guide the method of urethroplasty performed. It is a simple, cost eff ective, and time effi cient method to further evaluate the degree of spongiofibrosis.

Effi . Th e Allium bulbar urethral stent is a fully covered, self-expandable, large caliber metal stent, specially designed for the treatment of bulbar urethral strictures. Th e indwelling time for the stents was planned to be 12 months. All men underwent an internal uretrotomy procedure followed by an endoscopic stent placement. Progressive decreasing of the urinary peak fl ow rate, recurrent urinary infection and stent migration were the early removal criteria. Th e success criteria aft er the stent removal were: no evidence of stricture on urethrogram or endoscopy, urinary peak fl ow greater than 15ml/sec and no recurrent urinary tract infection.

Results: Five stents were replaced since very early migration not more than one month period. None of the patients reported discomfort at the stent site. Five patients complained of mild urinary incontinence which was resolved aft er stent explantation. All stents were removed very easily without any complication 3 to16 months (mean 9.4 months) aft er implantation. Follow-up period was meanly 24 months (9 to 36) after stent explantation. Clinical success was achieved in 78 patients (78%).

Conclusion: Based on our results, temporary placement of Allium bulbar urethral stent, for management of the recurrent urethral strictures, is noninvasive, safe and eff ective procedure.

The Impact of Testicular Loss on the Psychopathology We also compared the results of long-term treatment group and short-term treatment group.

Th is study showed that 14 cases of long-term continuous administration of DOC consisting of 11 or more cycles among 51 patients of castration-resistant prostate cancer (CRPC) treated with DOC from October 2008 to September 2013 at our institution, retrospectively. Nineteen patients who had treated with DOC 10 or less cycles were defi ned as short-term dose group, and both groups were compared. DOC was administered every 3 to 4 weeks at 60 to 70 mg/m2, and was treated with prednisolone at 10 mg/day as a general.

Results: Th e median number of treatment cycles was 15 (range 11 to 27), and the median age of patients was 70 (range 60 to 80) years old. Th e median PSA levels at start of DOC based chemotherapy was 4.4 (range 2.2 to 171.7) ng/ml. Th irteen cases (93%) showed a decrease in PSA levels and 10 cases (71%) showed a decrease in PSA levels of 50% or more, the 1-year survival rate of long-term dose and short-term dose group were 100% and 16%. Adverse eff ects of grade 3 or lower consisted of leukocytopenia in 85% and thrombocytopenia in 28%, stomatitis and general fatigue in some cases, however, grade 4 or higher were not observed in long-term dose group. In multivariable analysis of parameters, long-term treatment was related to PSA levels at start of treatment and ALP levels. 

Pattern of Use of Androgen Deprivation Therapy in Prostate Cancer: An Italian Multicenter Cross-Sectional Analysis Introduction and Objective: Androgen deprivation therapy (ADT) for Prostate Cancer (PCa) is widely used with diff erent indications, however, some discrepancies exist between clinical practice and the recommendations of the international guidelines. Th e aim of this cross-sectional study was to evaluate patterns of use of ADT in patients with PCa in Italy. We also aimed to measure the adherence of ADT prescriptions to the recommendations of the EAU guidelines.

Materials and Methods: Th e CHOICE study was an Italian multicenter cross-sectional studying conducted from December 2010 to January 2012 on 1380 patients treated with ADT for PCa (fi rst prescription or renewal of therapy). Th e project involved 9 radiotherapy departments and 21 urology centers. Inclusion criteria were: age ≥18 years, previous diagnosis of PCa and current ADT. At baseline all the following information were included: Charlson Comorbidity Index (CCI), clinical stage, PSA level at the time of the diagnosis, total prostate volume and Gleason score; Gleason score and pathological stage from radical prostatectomy (RP) when available. We subdivided the cohort into three risk categories for each treatment group, based on D' Amico Classifi cation. Patients were categorized according to primary treatment into RP, radiotherapy (RT), RP + RT and ADT only. Radiotherapy comprised external beam therapy and brachytherapy. ADT included bilateral orchiectomy, GnRH agonists or anti-androgens. Th ree geographical areas were considered: northern, central and southern Italy. ADT change (ADT-C) was defi ned as any modifi cation of therapy between previous ADT and treatment prescribed aft er enrolment. 

The Prevalence and Outcomes of pT0 Disease after Neoadjuvant Hormonal Therapy plus Radical Prostatectomy in High-Risk Prostate Cancer Introduction and Objective: To identify the prevalence and clinical outcomes of pT0 disease following neoadjuvant hormonal therapy (NHT) and radical prostatectomy (RP) in high-risk prostate cancer.

We retrospectively included 111 patients who had received NHT and RP for the treatment of high-risk prostate cancer. We classifi ed the patients into two groups, the pT0 group and the non-pT0 group depending on whether a residual tumor was observed or not.

We identifi ed 6 cases (5.4%) with pT0 disease aft er reviewing all slides of the patients. Th ere was no recurrence of disease in the pT0 group during a median follow-up of 59 months. Among the 105 patients in the non-pT0 group, biochemical recurrence (BCR) developed in 60 patients (57.1%), with the median time to BCR being 14 months.

Conclusions: Among the 111 patients with high-risk prostate cancer, we found 6 cases that showed a pathologic complete response aft er NHT and no recurrence of disease during the follow-up, which means that the androgen-deprivation therapy could potentially eradicate high-risk prostate cancer. Th is is one of the largest studies demonstrating the prevalence of pT0 disease and its outcomes aft er NHT among patients with high-risk prostate cancer.

Introduction and Objective: In metastatic castration-resistant prostate cancer (mCRPC), data are limited regarding optimal combinatorial or sequential use of available treatments. P12-2 (STRIDE; NCT01981122) is an ongoing, randomized, open-label, phase 2 study evaluating concurrent vs. sequential administration of the androgen receptor inhibitor enzalutamide (enz) with the autologous cellular immunotherapy sipuleucel (sip-T).

Fift y-two patients (pts) with asymptomatic or minimally symptomatic mCRPC were randomized 1:1 to receive 3 sip-T infusions with enz starting 2 weeks before (n=25, concurrent arm A) or 10 weeks aft er (n=27, sequential arm B) sip-T initiation. Th e primary endpoint is peripheral T cell proliferation response to PA2024, the sip-T immunizing antigen. Secondary endpoints include interferon (IFN)-γ ELISPOT and humoral immune responses to PA2024 and prostatic acid phosphatase (PAP), product release parameters (total nucleated cell count, CD54+ cell counts, and antigen presenting cell activation [as measured by CD54 upregulation]), cytokine production, and adverse events (AEs). Results through week 26 are described.

Results: PA2024-specifi c T cell proliferative response was signifi cantly elevated at all post-baseline time points (p<0.001) and was sustained through week 26, including a >10-fold increase at week 20 in both arms. Th is PA2024-specifi c response was observed in nearly all pts, 95.8% in arm A vs. 92.6% in arm B. Both arms showed a signifi cant and sustained increase in humoral responses to PA2024 and PAP as well as IFN-γ ELISPOT response to PA2024. Sip-T product parameters were similar between arms. Cytokines indicative of immune activation (such as IFN-γ, interleukin-2, and tumor necrosis factor-α) were also elevated in both arms. AEs were observed in 88% (arm A) and 100% (arm B) of pts. Th e incidence of grade ≥3 AEs was similar between arms. Materials and Methods: TUR specimens without hormonal use (4 cases), specimens aft er three weeks of chlormadinone acetate (CMA) (9 cases), specimens aft er average six months of dutasteride (3 cases), and specimens two weeks aft er initial use of degarelix (3 cases) were studied using HE and immunohistochemical staining with prostate specifi c antigen (PSA), prostatic stem cell markers such as CD44, CD117, and Vimentin.

Results: Specimens treated with CMA showed acinar dilatation and atrophy of glandular cells. Specimens treated with dutasteride showed marked decrease of gland and increase of fi bromuscular tissue. Specimens treated with degarelix showed prominent decrease of gland and glandular cells. PSA was stained all of the prostatic glandular cells in all specimens. CD44 was stained at basal cells in normal prostatic tissue without hormones, however in hormone treated specimens, basal cells elongate and some glandular cells were also stained by CD44, especially in CMA treated specimens. CD117 was stained in many glandular cells without special patterns. Vimentin was stained in all mesenchymal interstitial cells and a part of basal cells, and not stained in glandular cells.

Conclusion: Elongation of basal cells and increased sensitivity to CD44 in glandular cells, especially treated with CMA, were thought to the result of EMT of prostatic glandular cells. Th ree weeks use of CMA might be a good model to observe EMT of prostatic cells among these three hormone models, presumably because six months use of dutasteride is long enough to alter the structure of prostatic tissue, and degarelix has strong apoptotic activity to prostate cells in a short period.

Aryl plays an important role in normal physiologic responses such as development, cell cycle regulation, and immune function in various tissues. Th e strong nuclear AhR expression was observed in the invasive phenotype and an elevated nuclear AhR expression was associated with a poor prognosis of human prostate. On the other hand, the AhR defi ciency results in a smaller volume and in increased susceptibility to prostate tumors in mouse model. In the present study, we investigated AhR expression and its role in the growth and invasiveness of human prostate cancer cells.

We checked AhR proteins expression in prostate cancer cell lines and in human prostate cancer specimens by immunoblotting and immunohistochemistry respectively. We used a small interfering RNA targeting AhR, constitutive active AhR expression vector, and AhR agonist and antagonist were used to moderate its expression and signaling to examine growth and invasion in prostate cancer cells. Introduction and Objective: Androgen deprivation therapy (ADT) has been increasingly used in patient with prostate cancer (PCa). It has been considered that ADT is associated with greater risk of incident cardiovascular disease (CVD). Th e one of the reason is that hyperlipidemia was caused by ADT may contribute to greater CVD risk. But the evidence remains inconclusive and sometimes contradictory. In our present study, we investigated an eff ect of ADT on arterial atherosclerotic changes assessed by cardio-ankle vascular index (CAVI) in PCa patients.

Th e present study was participated in 53 patients with prostate cancer before initiate ADT. We recorded and statistically analyzed the data of the patients before ADT and at 1 months, 3 months, and 6 months aft er ADT. And the patients' arterial atherosclerotic changes was evaluated by CAVI at baseline. 

Correlation between the Degree of Infl ammation and Gleason Score in Prostate Cancer Patients Alexandrescu E, Geavlete P, Georgescu D, Geavlete B

Introduction and Objective: Hypothesis regarding the involvement of infl ammatory processes in prostate cancer has been the subject of several recent studies. Chronic infl ammation generates the appearance of morphological changes of atrophic type, lesions located predominantly in the periphery of the gland, as well as prostate cancer (PCa). Th e aim of the study was to assess the possible infl uence of associated infl ammation on the Gleason score in PCa patients. Results: Th e Gleason score 5-6 was detected in 66 patients (50.76%), score 7-8 in 58 patients (44.62%) and score 9-10 in 6 patients (4.61%). Cases of aggressive disease (Gleason score 7 -10) were detected by prostate biopsy, while high-grade infl ammation has been mostly associated with PCa cases incidentally detected by TURP.

No signifi cant correlations were found between the presence and degree of histologically proved infl ammation and the Gleason score or the presence of PCa.

Identifi cation of N6-Methyladenosine Methylated mRNAs in Prostate Cancer Pang K 1,2 , Cumberbatch M 2,3 , Catto J 1,2

Introduction and Objective: RNA methylation is a common epigenetic event in oncogenesis, and the most common form is the methylation of N6-adenosine (m6A). Th e recent identifi cation of >12,000 m6A-methylated human mRNAs from >7000 human genes point towards novel epigenetic mechanisms. However, the distribution of m6A in the prostate transcriptome is unknown. We aimed to predict the mRNAs susceptible to m6A-methyation in primary prostate cancer (PCa) and castrate-resistant PCa (CRPC), and identify the functions of these mRNAs. Th e aim of this study was to assess the contribution of multiparametric MRI and PCA3 in pre-decision of initial biopsy in patients with serum PSA level 3-10 ng/ml and normal digital rectal examination.

Th e study is planned as prospective and single-centered. Patients whose serum PSA level 3-10 ng/ml with normal digital rectal examination scheduled for initial prostate biopsy were included in the study between February 2013 and March 2014. Each patient underwent multiparametric MRI (diff usion, spectroscopy, dynamic-contrast, T2) one week prior to biopsy. Th e lesion seen at least in two MRI was accepted as multiparametric MRI lesion. Twenty to thirty ml initial urine samples were taken aft er 3 minutes prostate massage for PCA3 examination before biopsy. PCA3 score over 35 was considered as signifi cant. Guided biopsies were taken according to lesions seen in multiparametric MRI. Patients with high PSA levels were separated into two groups as high PCA3 scores and normal PCA3 scores. Each group, then, was separated into two groups due to MRI results as lesion positive and negative. Tumor incidence and positive predictive values were calculated in patients with high PSA and PCA3 scores with positive multiparametric MRI lesion. Tumor incidence and negative predictive value were also calculated in patients with high PSA level but low PCA3 score with negative multiparametric MRI lesion. UP.248, Figure 1 . A biopsy-induced hemorrhage was defi ned as a case in which a subject complained of bleeding from the rectum and excretion of blood clots was confi rmed. We categorized signifi cant rectal bleeding into two grades for hemostasis management, including mild and severe. When the bleeding was classifi ed as mild, we inserted the gelatin sponge into the participants in either Group B or reinserted it into those participants in Group A. If the bleeding could not be stopped by this approach, we additionally used index fi nger pressure for ten minutes or more to promote hemostasis. In the severe cases, an endoscopic clipping was performed to control the bleeding because arterial bleeding was suspected. A blood test and a questionnaire survey, and pain related to biopsy was performed before and aft er biopsy. Th e diff erence in background factors between groups A and B was assessed. To identify the independent predictive factors for rectal bleeding for all participants, background factors, including insertion of a gelatin sponge into the rectum were analyzed by logistic regression analysis.

Results: Signifi cantly fewer patients in Group A required hemostasis aft er biopsy compared to Group B (3 (2.0%) vs. 11 (8.5%), P=0.029). Th e results of blood tests performed before and aft er biopsy and the results from the questionnaire did not diff er signifi cantly between the two groups. In multivariate analysis, only "insertion of a gelatin sponge into the rectum" emerged as a signifi cant predictor of hemostasis. 

Our results suggest that the tissue elastic modulus of prostate cancer may increase with an increase in the Gleason score and that the diff erence in the stiff ness between low-grade lesions and prostate hyperplasia may be slight. Th ese basic fi ndings will contribute to the development of quantitative elastography technique.

The Results: Th e median IPSS was 12, the mean PSA was 6.1 ng/ml; the mean size of prostate was 41.4cc. Of the total subjects, prostate cancer was detected in 707 (21.6%) patients. Among 8 subscores refl ecting specific LUTS, the nocturia was only symptom score predict the cancer detection. Th e detection rate of patient with nocturia more than 5 time a day was 60.2%, but the cancer detection rate of patient without nocturia was only 12.4%. At multivariate analysis adjusting infl uence of covariate of Age, PSA, prostate size and transitional zone size, frequency and nocturia scores were the two only factor predicting cancer detection. At the ROC curve analysis measuring the benefi t of the additional consideration of the severity of nocturia and frequency, the additional consideration induced 2.9% prediction accuracy elevation (From 0.834 to 0.863).

Conclusions: Men with frequency or nocturia have lesser chance of prostate cancer detection rate than the men without LUTS. However, the infl uence of these storage symptoms seems not strong enough to change current consensus of indication to biopsy the prostate.

Routine in the discontinuing group were 0%, 0%, -0.36%, -0.36% and -0.32%, respectively (P=0.5640). Th e median ΔeGFR at baseline, 1, 3, 6 and 12 months in the continuing group were 0%, 0%, -0.31%, -0.42% and -0.42%, respectively (P=0.6851). Th e continuing group decreased 6 months later. However, the renal function in the discontinuing group had a tendency to improve at 12 months aft er treatment insignifi cantly. Th ere was not statistical signifi cant diff erence in various factors between discontinuing group and continuing group.

Conclusions: It was possible that the recovery of testosterone was associated with the improvement of the renal function. It has been reported that the discontinuation of ADT recovered the level of testosterone. Namely, the discontinuation of ADT for prostate cancer might revive the renal function. Th erefore, it was suggested that intermittent ADT might recover the renal function.

Introduction and Objective: As more and more patients are getting diagnosed as Carcinoma of Prostate (CAP), we would like to look into how prostate cancers are presented at the early age of forties and how they were treated. As CAP is more popularised in the media, more and more people are asking GPs for PSA measurements. 

Introduction and Objective: Irreversible electroporation (IRE) is a novel ablative therapy for prostate cancer, with reported advantages of sparing surrounding essential structures. Th ese properties could potentially help to reduce or avoid side eff ects. Th e objective is to determine quality of life outcomes (QoL) and side-eff ects of IRE treatment.

Sixteen patients planned for radical prostatectomy (RP), were asked to participate in the study. All patients underwent an IRE treatment one month before RP, using a focal or extended ablation protocol. Th e safety was measured by the number of adverse events graded by the Common Terminology Criteria for Adverse Events (CTCAE). To determine QoL validated questionnaires (Expanded prostate cancer index composite (EPIC), the fi ve-item version of the International Index of Erectile Function (IIEF-5) and International Prostate Symptom Score (IPSS)) were used.

Results: Five developed a urinary retention (CTCAE grade 2) solved by an indwelling catheter or self-catheterisation. Two patients developed a urinary tract infection (CTCAE grade 2), one progressed to urosepsis (CTCAE grade 3), both resolved without sequelae. Mild haematuria (CTCAE grade 1) was noted in ten patients, spontaneously resolved within 27 days. Five patients experienced temporary incontinence with duration of 15-31 days, three suff ered from total incontinence and needed pads and pelvic fl oor training (CTCAE grade 2). Two patients reported mild hematospermia, lasting one and thirty days. IPSS showed no signifi cant diff erence between baseline (average of (avg) 11±8) and four weeks postoperatively (avg 12±7). IIEF showed no signifi cant diff erence between baseline (avg 17±7) and four weeks postoperatively (avg 17±8). EPIC outcomes, shown in Figure 1 , were not signifi cantly diff erent at baseline, one and four weeks aft er IRE, regardless of the used ablation protocol.

Conclusion: IRE treatment for prostate cancer is safe and shows only adverse events that lie within the range of what was expected and shows promising rates of genito-urinary functional preservation.

Introduction and Objective: MRI-guided transurethral ultrasound ablation (TULSA) is a novel minimally-invasive technology for treatment of prostate cancer aiming to provide local disease control with low morbidity. Th e ultrasound device generates conformal volume of thermal ablation, shaped precisely to the prostate using real-time MRI thermometry feedback control. Aim of this prospective, multi-national phase I study is to determine safety and feasibility of MRI-guided TULSA. Biochemical recurrence (BCR) was defi ned using Phoenix criteria (PSA NADIR + 2ng/dl) and positive biopsy in the treated area was considered recurrence. We compared the perioperative and oncologic outcomes following FC in patients with GS 6 vs. GS 7 (3+4) at initial TRUS biopsy. Th e complications were reported using the Clavien-Dindo classifi cation.

We found 82 patients with GS 6 and 21 with GS 7 (3+4). Clinical and operative characteristics were similar (Table 1) . Th e mean follow-up was 26.7 (±16.9) months. Th ere was no signifi cant diff erence noted between GS 6 vs. GS 7 in the biopsy recurrence (24% vs. 38%, p=0.3) and BCR rates. Th ere were 20 complications in 14 (13.5%) patients. All were low grade, except two patients who had III b complications (Table 2) .

Conclusion: Th e perioperative and oncologic outcomes of FC -Hemiablation for unilateral, organ confi ned PCa appears to similar between GS 6 and GS 7 (3+4) disease.

Pentafecta in the Evaluation of Surgical Results after Open Radical Prostatectomy

De La Rosa H, Rios S, Martinez N

Introduction and Objective: "Pentafecta" has been used to evaluate the oncological and functional results in patients with prostate cancer treated with minimal invasive radical surgical techniques. In this study we evaluate, with this quality tool, the outcomes in a group of patients undergoing open radical prostatectomy.

We analyzed retrospectively the database of surgeries performed at the Urology Department of the Military Hospital of Guadalajara and the clinical fi les of patients with localized prostate cancer treated with radical prostatectomy. We describe the patients' characteristics including the Charlson comorbidity index (CCI) and identify the parameters that conform pentafecta as well as the variables that can infl uence the oncological and functional results using the Fisher´s exact test.

Results: Fift y four patients were treated with radical prostatectomy between 2009 and 2014, fi nding in their fi les a minimum of 12 months of follow-up. Seven patients were discarded of the study because they undergo laparoscopic radical prostatectomy, and 4 more because missing information at their fi les. Th e average age was 64 (44-78) and the CCI average was 6.31 (0.9-11.5). Mean operative time was 257min (90-420) and intraoperative bleeding 650cc (100-2500). Th e presence of potency, continence, biochemical recurrence-free survival, negative surgical margins and no perioperative complications were 26%, 70%, 67%, 33% and 49% respectively. Seven (16%) patients achieved pentafecta, and 36 patients (84%) failed to achieve. Statistical analysis confi rmed the surgeon's experience as the only factor associated with achieving pentafecta.

Conclusions: Th e fi rst cause of failure to achieve pentafecta in our study group was impotence, second were positive surgical margins and third surgical complications mainly intraoperative bleeding. Pentafecta is a useful tool for objective assessment of oncological and functional outcomes of patients treated with open radical prostatectomy.

Plasma 

Introduction and Objective: Hepatocyte growth factor (HGF) is a well-known multifunctional growth factor, the amount of evidence has accumulated suggesting that the HGF/MET (HGF receptor) signaling axis is involved in cancer progression. Macrophage stimulating protein (MSP) is also known as a growth factor which activates not only macrophages but also cancer cells and osteoclasts through the activation of the specifi c Receptor d' origine nantais (RON). HGF and MSP are secreted as an inactive single-chain precursor (pro-HGF, pro-MSP), which lacks biological activity and, therefore, requires proteolytic activation for conversion to an active two-chain form by HGF activator (HGFA). Although, there have been reported a lot of study for HGF/MET signaling with castration-resistant (CR) PC and bone metastasis, the report for examination of plasma protein is rare. In addition, MSP/RON signaling axis is not well evaluated in PC. Here, we analyzed the associations between PC progression and plasma levels of HGF and a closely related molecule, MSP. Conclusion: Dehydroepiandrosterone (DHEA) concentrations in blood were examined by newly developed ultra-sensitive quantifying method, LC-MS/MS. We confi rmed that low serum DHEA levels in men with prostate were related to high Gleason score and advanced clinical stage. Th ese results suggest that serum DHEA level may be useful as a prognostic factor in men with prostate cancer.

Introduction and Objective: Androgen/androgen receptor (AR) signal is known as a powerful driver of prostate cancer (PCa) progression. Previously we reported the limitation of prostate-specifi c antigen (PSA), which is an AR-regulated protein, at diagnosis as a prognostic biomarker of PCa. Paradoxically PCa patients with low PSA < 3.5 ng/mL had a more advanced stage of cancer compared with those with PSA between 3.5 and 10 ng/mL. Although serum total testosterone (TT) has also been reported as a PCa prognostic biomarker, its usability is still controversial. We examine the potential and the character of TT as a biomarker, comparing to PSA.

Serum TT level of patients who underwent prostate biopsy at Kanazawa University Hospital between 2007 and 2013 were measured and PCa-specifi c survival (PCaSS), overall survival (OS), and the correlation between TNM stage and TT level were analyzed.

Results: Of total 379 biopsied patients, 255 were diagnosed with PCa. Median TT was 4.6 ng/mL (range: 1.4-11.7). When patients were divided into 5 groups according to their TT at diagnosis, patients with TT < 2 and ≥8 ng/mL had worse PCaSS than those with 2 ≤ TT <4, 4 ≤ TT < 6, and 6 ≤ TT < 8 ng/mL. OS in patients with TT 2 < and ≥ 8 ng/mL also was worse than that in other groups. Moreover, TT 2 < and ≥ 8 ng/mL showed worse PCaSS even in patients with advanced stage (T4 or N1 or M1). Higher TNM stage was observed in patients with TT 2 < and ≥ 8 ng/mL than those with 2 ≤ TT <8 ng/mL.

Low TT level has been reported as a predictive biomarker indicating worse outcomes in PCa patients. Th is study showed not only low but also high TT level may indicate poor prognosis. Th ese data are consistent with our previous studies showing low PSA (< 3.5 ng/mL) also might indicate poor prognosis as well as high PSA. Although poor prognosis of high TT and high PSA strongly depends on androgen/AR signal, poor prognosis of low TT and low PSA patients may be due to other signals than androgen/AR.

Usefulness of PSA as a Marker of Prostate Cancer in Men Treated with Dutasteride Takeda H, Nakano Y, Narita H

Introduction and Objective: To analyse whether the use of treatment-specifi c criteria for repeat biopsy maintains the usefulness of prostate-specifi c antigen (PSA) level for detecting prostate cancers.

Th is study was a retrospective investigation to assess the eff ects of dutasteride on PSA in asymptomatic men aft er negative 1st biopsy and on repeat prostate biopsy decision. Th e usefulness of PSA was evaluated using biopsy thresholds defi ned by three times consecutive rises and 0.4ng/ml up in PSA from nadir (the lowest PSA level achieved while in the study) in the dutasteride group. Prostate cancer pathological characteristics were compared.

Results: Of 115 men, 23 (dutasteride) underwent at least one prostate biopsy during the study and were included in the analysis. Mean follow-up (month) was 26.3, iPSA was 10.73 ng/ml, mean prostate volume(cc) was 38.15, PSAD was 0.28ng/ml/cc. Nine of 23 (39%) were detected prostate cancer, 11% (1/9) of Gleason 7 and 11% (1/9) of Gleason 8-10 cancers were detected in the dutasteride group. In the study, the incidence of Gleason 7 and Gleason 8-10 cancers generally increased with greater rises in PSA. Sensitivity of PSA kinetics with dutasteride was high as usual.

Conclusion: Using treatment-specifi c biopsy thresholds, the present study shows that the ability of PSA kinetics to detect prostate cancer is maintained with dutasteride in men with a previous negative biopsy. Biopsy decisions based on three times consecutive increased and 0.4ng/ml PSA measurement from nadir in the dutasteride group are useful, indicating the importance of confi rmation of PSA measurements. Our goal was to develop a fi t-for-purpose assay that could be performed on RNA from diagnostic needle biopsies, and provide improved risk stratifi cation in early-stage PCa.

To date, development and validation studies have included >1,500 patients from four academic centers. In these studies, archival tissues were assayed following prospectively designed protocols with pre-specifi ed methods and statistical analysis plans.

Results: Feasibility and development studies confi rmed gene expression and identifi ed genes whose expression was predictive of clinical recurrence, biochemical recurrence (BCR), prostate cancer death, and adverse pathology (AP) at surgery in the face of tumor heterogeneity and multifocality. Analytic validation studies showed that the assay provided robust, reproducible results over a wide range of RNA inputs, diff erent operators, instruments, and reagent lots. Th e fi rst clinical validation study established GPS as an independent predictor of AP in men with NCCN verylow to intermediate-risk PCa. Exploratory analyses showed that GPS is a robust predictor of AP despite inter-observer diff erences in pathologic grade and stage assessment. A second clinical validation study in a racially diverse population confi rmed the assay as a predictor of AP and validated the assay as a strong predictor of BCR (HR/20 GPS units=2.9; p<0.001). GPS was also signifi cantly associated with metastatic disease (HR/20 units=3.8; p=0.032). Other exploratory analyses showed that the assay can predict 1) likelihood of clinical recurrence aft er BCR, regardless of salvage therapy, and 2) tumor aggressiveness when assessed in adjacent normal-appearing tissue. All four gene groups contribute to the predictive value of the assay.

Conclusions: Th e development program for the assay addressed challenges of small sample size, tumor heterogeneity, multifocality, and biopsy under-sampling. Validation in two large contemporary cohorts of men with PCa in two prospectively designed studies provides level IB clinical evidence for GPS as a predictor of AP.

Clinical and Therapeutic Implications of Neuroendocrine Prostate Cancer: A Long Winding Road to Cure Lu K, Wang H, Lin V, Yu T

Introduction and Objective: Primary neuroendocrine cancer of prostate is an extremely rare variant of prostate cancer, comprising 0.5% to 2% of prostate malignancies. Th is entity encompasses various clinical contexts, ranging from the de novo small cell carcinoma (SCC) to a treatment-emergent transformed phenotype that arising from typical adenocarcinoma (Ad) of the prostate. Th e rarity of these neoplasms poses a diagnostic and therapeutic challenge. Little is known about neuroendocrine prostate cancer and the current knowledge of this disease is based on case reports or small series. Our purpose was to characterize the cases treated at a tertiary academic center and to evaluate patient outcomes with the available treatment modalities.

Th is was a single-institute retrospective observational cohort study of patients with neuroendocrine prostate cancer followed at E-Da Hospital, Kaohsiung City, Taiwan between January 1, 2008 and October 1, 2013. Patient and tumor data were analyzed using descriptive statistical methods.

Results: Among 826 prostate cancers, six patients were identifi ed with primary neuroendocrine prostate cancer, comprising 3 from de novo mixed variety (SCC and Ad) and 3 from transformed phenotype (pure SCC). Th e median age at diagnosis was 73.5 years. Th e most common presenting symptoms were obstructive symptoms (weak stream, incomplete empty and urine retention). Th e morphological appearance of the tumor cells and their immunohistochemical reactivity for neuroendocrine markers, and prostate specifi c antigen (PSA) helped establish the diagnosis. Overall median survival was 12 months from diagnosis of neuroendocrine prostate cancer/ prostate small cell carcinoma.

Conclusion: Primary neuroendocrine prostate cancer is characterized by an aggressive clinical course with relatively short lifespan. Although high response rate to cytotoxic chemotherapy, overall prognosis is poor. As there is no standard of care for patients with neuroendocrine prostate cancer, further eff orts should be directed at its early detection and made to develop more eff ective therapeutic strategy.

Association Th e mean duration for the side eff ect to occur was 11 months (range 6-18 months), the mean duration between the onset of side eff ect and beginning of HBO therapy was 12 months (range 5-18months). Th e patient with both hemorrhagic proctitis and cystitis completely recovered, and the remaining 5 patients had improvement of side-eff ects.

Conclusion: HBO therapy can be a choice of treatment for radiation induced side-eff ects.

A Treatment Trend of the Prostate Cancer in Japanese Provincial Hospital Introduction and Objective: Th e prostate cancer patients can choose various treatment options for cancer. However, the choice is limited by a diff erence in the scale and/or the location of each medical institution. We examined a treatment trend of the prostate cancer in our Japanese provincial hospital.

We evaluated 147 patients who had a diagnosis of prostate cancer between 2007 and 2013. Th ey were classifi ed four groups, 11 cases of the middle-aged generation (range -64 years old), 31 cases of the early advanced-aged generation (range 65-74), 74 cases of the middle advanced-aged generation (range 75-84) and 31 cases of the latter advanced-aged generation (range 85-). We sorted each groups using the D' Amico risk classifi cation system.

In the middle-aged generation, 8 patients, except for metastatic 3 cases, underwent radical prostatectomy or radiotherapy. In the early advanced-aged generation, 15 of 27 low-very high risk group patients (56%) chose radical prostatectomy or radiotherapy.

On the other hand, in the same generation, 6 of 10 intermediate risk group cases (60%) were treated with hormonal therapy. In the middle advanced-aged generation, only 12 of 65 low-very high risk group patients (18%) underwent radical prostatectomy or radiotherapy, which was fewer compared with the early advanced-aged generation. Th at means, they oft en chose hormonal therapy. In the latter advanced-aged generation, all patients, except for 3 cases, were treated with hormonal therapy. Th e 3 cases belong to the low-intermediate risk group, chose watchful waiting (PSA monitoring).

Introduction and Objective: Robot-assisted radical prostatectomy (RARP) has emerged as an excellent treatment option for men with localised prostate cancer. As with other surgical treatment options, urinary incontinence remains a signifi cant side eff ect of the procedure and has been associated with weak pelvic fl oor muscle (PFM) strength. We aimed to assess PFM strength preand post-RARP, its relevance to incontinence and relevant predictors of poor outcomes post-op.

We conducted a retrospective analysis of a prospectively collected database of 118 men undergoing RARP by 2 urologists over a 30-month period. Each man had a pelvic fl oor strength assessment pre-operatively and at 1 week and 4 weeks post-operatively. PFM strength was recorded as strong (grade 1), moderate (grade 2) or weak (grade 3). Continence rates were recorded at 4 weeks post-op, with continence defi ned as no requirement for pads or continence aids. Basic demographic data and histological data were also collected. Introduction and Objective: Urethral trauma is reported to occur in 0.3% of patients undergoing catheterisation but, in practice, seems to be more common than this. We have investigated its incidence retrospectively and prospectively and have evaluated a new approach to catheterisation to reduce the incidence of catheter-related trauma and its consequences, which has led to the development of a novel urethral catheterisation device (UCD) produced by Urethrotech™.

A total of 150 patients being catheterised for cardiac surgery were reviewed retrospectively and 74 studied prospectively to determine the incidence of urethral trauma due to urethral catheterisation. One hundred similar patients were then studied prospectively to trial a UCD to see if it reduced the incidence of trauma. (10) LAVH (9) Myomectomy (1) Lap. ovarian cyst excision (1) (4) Nephrectomy (1) Ileal ureter substitution (1) Ureterolithotomy (1) Angioembolization (1) URS c D-J stent (6) Ureteroneocystostomy (8) Ureteroureterostomy (7) 0.170

Hospitalization ( notes. None had documented consent and none had been counselled about potential complications. One hundred and forty-six were successfully catheterised. Four (2.7%) required a suprapubic catheter for traumatic and unsuccessful urethral catheterisation. No other adverse events were recorded. Seventy-four consecutive patients were studied prospectively aft er counselling and consenting. Th e incidence of urethral trauma was 7 out of 74 (9.5%). Five had urethral or perineal pain and urethral bleeding (6.8%) and 2 (2.7%) additionally required a suprapubic catheter.

Having developed a practice of passing a urethral catheter over a guide wire in patients undergoing reconstructive urethral surgery in our unit we subsequently trialled the Urethrotech™ UCD for routine urethral catheterisation. Th is UCD was used for catheterisation in 100 consecutive patients without complications.

We conclude that urethral catheterisation has a signifi cant risk of trauma -ten times the reported incidence -and to reduce that risk the catheter should be passed over a guide wire, as with the Ure-throtech™ UCD, as is the practice for passing catheters and similar tubes into other anatomical structures.

Th is should particularly apply in high risk patients, such as those being catheterised for cardiac surgery who are about to be heparinised, and in higher risk circumstances such as when catheterisation is being performed by junior medical or nursing staff .

Results: Mean age at the time of transplantation was 12.9 ± 3.6 years with male to female ratio of 1.9:1. Etiology of ESRD included renal parenchymal diseases (54%), 1o vesicoureteric refl ux (17%) and 2o vesicoureteric refl ux due to posterior urethral valve (14%), urolithiasis (8%) and neurogenic bladder (6%). Pre-transplant bilateral nephroureterectomies were performed in 14 patients, augmentation ileocystoplasty with Mitrofanoff conduit in 5 patients while posterior urethral valve fulguration in 5 patients. Mean serum creatinine post-transplantation was 0.6mg/dl and 0.8mg/dl at 1 week and 12 months respectively. Surgical complications occurred only in two patients; one developed lymphocele while other presented with febrile UTI due to ureteric refl ux in the early postoperative period and was managed by doing a new ureteral reimplantation. Th e mean graft and patient survival rates at one year were 97% and 100% respectively. One patient lost her graft at 3 months which was turned out case of hyperoxaluria. Acute rejection was seen in 6 (17%) patients. All of these were successfully reversed with pulse therapy. None of the patients developed cytomegalovirus (CMV) infections or lympho-proliferative disease. Symptomatic urinary tract infections aft er transplantation occurred in 12 (34%) patients including pyelonephritis in 3 (8.5%) patients. Two of these 3 patients with pyelonephritis had prior bladder augmentation. Ureteric stenosis is a well recognised major urological complication of renal transplantation. Following initial antegrade decompression, defi nitive treatment options include long-term ureteric stenting, endoscopic stricture dilatation/division or ureteric re-implantation. Th ere is minimal current data in the literature to help guide patient choice. We aimed to characterise the outcomes following management of ureteric stenosis at a large European regional transplant centre.

A retrospective cohort study was performed for all patients following renal transplantation who required treatment for ureteric stenosis between August 2008 and August 2013. Case identifi cation was via a prospectively maintained database on all renal transplant patients and International Classifi cation of Disease procedure codes.

Results: Of 629 renal transplants performed during the study time period, 21 patients developed ureteric stenosis requiring intervention (3.3%). Eleven patients underwent initial open ureteric re-implantation, 3 had endoscopic management and 7 had longterm ureteric stents. Mean length of time between elective stent changes was 4.2 months (range 1-12 months). One patient opted for open re-implantation aft er a period of stenting with a good outcome. One experienced graft failure due to non-compliance with immunosuppression, otherwise renal function was preserved. Of the 12 patients having open re-implantation only one experienced re-stenosis -managed with long-term ureteric stenting and 91.7% had satisfactory renal function at follow-up. Two patients received successful balloon dilatation and 1 patient had upper tract stenosis managed with pyeloureteroplasty. All 3 patients have experienced no decline in graft function since.

Endoscopic, open reconstruction and long-term stenting can all provide satisfactory outcomes for the majority of renal transplant patients aff ected by this problem. Medium-term graft function was well preserved. In recent years approximately half of patients have proceeded to open re-implantation. Surgical and clinical factors impact the choice of treatment. However, patient choice also plays a significant role. Th is study has provided up to date information to aid counselling patients. Further prospective study is warranted to assess what variables infl uence patient choice and cost effi ciency of open re-implantation versus long-term ureteric stenting.

The Angiogenic Mechanisms of Endothelial Progenitor Cells in Kidney Transplantation Patients

Introduction and Objective: Th e blood fl ow blocking during kidney transplantation oft en results in renal ischemic injury. In this process, endothelial cells and endothelial progenitor cells (EPCs) are activated to participate in angiogenesis. EPCs and endothelial cells participate in angiogenesis and tissue repair through diff erent signaling pathway. Prostaglandin E2 (PGE2) is a kind of metabolites of arachidonic acid, and is a mediator of infl ammation and ischemia. PGE2 took part in angiogenesis and EPCs diff erentiation according to our previous study. In this study we will demonstrate the angiogenic function of EPCs of kidney transplantation patients and reveal the molecular mechanisms of angiogenesis.

Materials and Methods: EPCs from peripheral blood aft er kidney transplantation were isolated by density-gradient centrifugation. FACS was used to identify the EPCs. Th e AA metabolites PGE2 in EPCs cultured medium was measured by liquid chromatography-tandem mass spectrometry (LC-MS/MS). Q-PCR and WB were used to detect the expression of endothelial markers in human umbilical vein endothelial cells (HUVECs) cultured with EPCs conditional medium. Tube formation assay was performed to elucidate the angiogenic ability of HUVECs.

Results: EPCs from kidney transplantation expressed c-kit and CD31 by FACS analysis. Multiple types of AA metabolites was detected in the conditional medium by LC-MS/MS and PGE2 was increased to more than 2-fold aft er kidney transplantation. HUVECs cultured with conditional medium highly expressed CD31 and VE-cadherin and also formed more tubes compared with control. HUVECs given PGE2 had the same biological characteristics like the conditional culture.

Conclusion: PGE2 paracrine of EPCs from kidney transplantation enhanced the capacity of angiogenesis in HUVECs.

Graft Survival, Proteinuria and Kidney Growth: Challenges between Pediatric and Adult Deceased Kidney Donation Basiri A 1,2,3 , Zare S 4 Introduction and Objective: Th e presence of widening discrepancy between supply and demand of donor and recipient in the fi eld of renal transplantation, has led us to compare the graft and patient survivals, post transplantation complications, rate and severity of proteinuria secondary to hyperfi ltration injury and the kidney growth of recipients who underwent transplantation from pediatric (Group 1) and adult deceased donors (Group 2).

Each groups contains 36 patients. Outcome measures included, patient and graft survivals, quality of graft function as assessed by serum creatinine (SCr) and estimated GFR (eGFR), surgical complications, Proteinuria that was detected by routine urinalysis and then confi rmed by a 24-h urine protein >250 mg, and kidney length that measured by early and following ultrasonography.

Results: Th e mean donor age in groups 1 and 2 were 8.5 (range 2.5 to 15 y/o) and 36 (15 to 65 y/o) respectively. Th e nine kidneys (25%) from pediatric donors (Group 1) were off ered en-block. Mean follow-up was 21 month (range 6 to 72). Th ere were no statistical differences in the incidence of DGF between two groups (21% versus 19%) (p=0.62). Group 1 had a slightly higher incidence of acute rejection than Group 2 (12 versus 8%), but the diff erence was not statistically signifi cant (p=0.57). One year's graft survival were similar between two groups (86% and 88%). Serum cre-atinine (SCr) and estimated GFR (eGFR) Th ere were no statistically diff erences between two groups (1.28 versus 1.31 mg/dl and 87 versus 88 cc/min respectively) (p=0.20). Th e incidences of surgical complications that required surgical intervention (urinary leakage, ureteral stenosis, lymphocele, vascular thrombosis) were similar in both groups (16 versus 14%) (p=0.42). Development of proteinuria was not diff erent between two groups (11% versus 9%) (p=0.12). Early kidney length within one week was signifi cantly lower in Group 1 than in Group 2 (75 ± 12 mm versus 112 ± 14 mm) (p<0.001), but the rate of increase of kidney length in Group 1 was signifi cantly greater than Group 2 (92 ± 15 mm versus 118 ± 16 mm) (p<0.001) under follow-up period.

Conclusion: Although in this study, median-term outcomes and complications of Single and en-block kidney transplantation from pediatric donors are acceptable and same as those from older donors. But assessment of functional and hemodynamic adaptation of small pediatric kidneys in adult recipients and subsequent hyperfi ltration eff ects requires the study with more cases and greater follow-up periods.

George A, Singh C, Devasia A

Introduction and Objective: Th e need for vascular access for hemodialysis (HD) increases with the increasing number of patients with end stage renal disease (ESRD) requiring HD, with increasing life span, and with more available facilities especially in developing countries. When the usual accesses (radiocephalic and brachiocephalic) have been utilised or failed, a PTFE graft is usually considered. We present here a 'bridging' option of a basilic vein transposition, as a doable, cost eff ective procedure before AV graft ing.

Patients with end stage renal disease were included. Th ey all either had poor cephalic veins at the wrist and cubital fossa, or had previously used and failed fi stulae. Anasthesia: Regional block (local anaesthetic). Technique: Th e basilic vein was exposed using three small incisions: 1cm above cubital fossa, mid arm (medial aspect), and upper arm (medial aspect up to axilla). Th e vein was completely freed off surrounding structures, tributaries tied, distal end ligated, patency ensured and vein delivered out of the uppermost incision. Using a tunneller, the vein was rerouted subcutaneously, anteriorly to reach the cubital fossa incision. Th e brachial artery was identifi ed and looped. Arteriovenous anastomosis was done using 7'O' prolene, continuous sutures. (Images in the poster).

Results: Out of a total of 230 venous access surgeries done during the study period, seven basilic vein transpositions were done. All had pre-operative Doppler evaluation to assess size and patency of veins. All fi stulae created were functional at the time of discharge. Th e fi stula is used for hemodialysis at 4-6 weeks, when the fi stula matures (arterialization of the vein implying good/suffi cient fl ow for dialysis). One patient needed exploration for a venous thrombus, 24 hours later, which was removed with a venotomy and 35th CONGRESS OF THE SOCIÉTÉ INTERNATIONALE D'UROLOGIE -SIU 2015 ABSTRACT BOOK using a Fogarty catheter. Subsequently with anticoagulation for 48 hours, the fi stula continued to function and is being used for access. Th e second patient had exploration on the 6th post-operative day for evacuating a subcutaneous hematoma. Th e fi stula is patent and will be used once it has matured. Five of the seven done were uneventful and are being used for hemodialysis access.

Conclusion: Basilic vein transposition, is the preferred option of vascular access over a PTFE graft , as it is cost eff ective, autologous and doable under regional anaesthesia.

Retrospective Results: A total of 160 renal transplants have been performed since 1996. Th e transplants were performed via an extraperitoneal approach with a modifi ed Lich-Gregoir ureteric anastamosis in most cases. JJ-stents were not routinely used. Th irty two urological complications were noted in 29 transplants (18%). Th ere were 20 boys and 9 girls with ages ranging from 2.5 to 18.4 yrs (mean 9.4). Th e most common complication was vesico-ureteric refl ux (VUR) occurring in 17 patients (59%). All those with VUR presented with recurrent urinary tract infections and bladder dysfunction was present in 41% (none were augmented). VUR was managed successfully with reimplant in six and submucosal injection of Defl ux in three; eight patients were managed conservatively. Post-operative urine leaks occurred in 6 patients (21%) and were managed with reimplant in two, uretero-ureterostomy in one, JJ-stent in one and conservatively in two. Ureteric stenoses presented in 6 patients (21%) with hydronephrosis and worsening renal function and were managed initially with either percutaneous nephrostomy or JJ-stent placement. Surgical management was performed in four patients (three reimplants and one uretero-ureterostomy); two patients were managed conservatively with transient JJ-stent placement. Th ree patients (10%) developed unexplained hydronephrosis -one with worsening renal function due to chronic rejection and two with stable renal function.

Loss of graft occurred in 3 patients (10%) as a direct result of their urological complication. Th ere were 3 deaths -two due to chronic rejection and one due to overwhelming sepsis immediately post uretero-ureterostomy for ureteric stenosis.

Conclusion: Urological complications following paediatric renal transplantation are common and can cause signifi cant morbidity and even mortality. VUR was the most frequently observed and, if presenting with recurrent UTIs, can be managed successfully with surgery. Other urological complications observed included urine leaks, ureteric stenoses and unexplained hydronephrosis.

Kidney Transplantation in Abnormal Bladder: Analysis of Outcome Kumar A, Gulia A, Chauhan U, Sharma A, Yadav R, Dassi V

Introduction and Objective: Kidney transplantation in abnormal bladder is a challenging situation and associated with poor outcome. We have analyzed outcome of our data of last 8 years.

Materials and Methods: From 2006 to 2014, 14 patients who had abnormal bladder had undergone kidney Tx. Average age at the time of transplant was 17 years. Average age at bladder reconstruction was 8 years. Four patients had neurogenic bladder who were practicing CIC, 3 using native urethra and one had appendix as a Mirofenof procedure. Two patients had bilateral nephrectomy for grade 5 VUR and their lower ureters were used for augmentation and other two had ileocystoplasty. Four patients of grade 5 VUR refl ux had subsequent transplant in the bladder. Four patients with PUV had bladder augmentation and Mitrofenof procedure due to poor compliance. One child with PUV had augmentation by stomach patch when he was 5 year old. One patient had cystectomy in the past and ileal conduit reconstruction where transplant ureter was implanted. All patients had very trabeculated and thick bladder during ureteric reimplantations. All patients had extravesical ureteroneocystostomy with stents. Urethral catheter was kept on average of 7 days.

No patients had any ureteric leak or stricture in postoperative period. All four patients with CIC through native urethra had recurrent UTI in the postoperative period and required long-term chemoprophylaxis. One patient who had ileocystoplasty before transplant, died due to sepsis just before his transplant. Incidence of UTI was 46% in this group. Six patients also had pyelonephritis, which was controlled by injectable antibiotic. Rejection rate was 22% in this group in fi rst 6 month which was higher than our normal bladder group. Average serum creatinine was 1.7 mg% at 3 months and 1.9 mg% at 1 year which was high than normal bladder population. Average follow-up is 2.8 years where serum creatine was 2.3 mg%. Mean hospital admission was 4.5 times.

Conclusion: Kidney transplant in abnormal bladder is a good option but long-term results are inferior. Recurrent UTI and pyelonephritis are still a troublesome problem. Various techniques and procedures are required to overcome these diffi cult situations.

Analysis of Results: Th e mean operative time, warm ischemia time and blood loos were 146 minutes, 5.2 minutes. 220 ml respectively. Th ere were 26 major complications including hemorrhage and injury to organs like bowel, spleen and pancreas. Fourteen of these patients required exploration to control bleeding or repair. Two patients were explored for adhesive obstruction. Th ere were 74 minor complications which were managed conservatively. One patient died in immediate postoperative period due to slippage of a single hemolock clip. All patients have adequate vascular and ureteric length. Th ere were 260 cases of multiple vessels. Th ere were two urinary fi stulae and one ureteric obstruction. Mild ATN was noticed in 36 patients. No graft was lost. Hospital stay was 4.26 days. Operative time has also come down to 110 from 150 minutes. Th e average cost of the laparoscopic donor nephrectomy is US$ 1000.

Conclusion: Lap donor nephrectomy is a safe and minimally invasive procedure. It is a cost eff ective procedures even for the developing country.

Prostate Carcinoma in Solid Organ Transplant Recipients Tillou X 1 , Guleryuz K 1 , Bouvier N 2 , Belin A 3 , Chiche L 4 , Bensadoun H 5 , Doerfl er A 1

Introduction and Objective: Improvements in immunosuppression and anti-infection drugs in solid organ transplantation have led to a signifi cant survival increase for patients and graft s. Prostate cancer (PC), being the most common tumor in men and given the increasing number of old male recipients, should show an increasing incidence in solid organ transplant recipients (SOTR). Th e aim of this study was to analyze retrospectively our Liver (LTR), Kidney (KTR) and Cardiac transplant recipients (CTR) treated for a PC.

Between January 1993 and December 2014, we found 43 PC in 1407 male SOTR (3%): 13 PC in LTR, 28 in KTR and 2 in CTR. A ge at diagnosis was 64.5±6.1 (51.7-77.6) years old and the interval from transplantation to diagnosis was 85.5±60.7 (9.1-241.5) months. Mean PSA level was 11.2±11.3 (0.5-53) ng/ml. Clinical stages were T1, T2 and T3 in respectively 25, 14 and 4 patients. Diagnosis was suspected during screening, because of prostatitis or bone pain in respectively 38, 1 and 1 patients. Th ree PC were discovered aft er prostate transurethral resection.

Results: Th irty-one patients (21 KTR and 10 LTR) with a localized disease underwent radical prostatectomy (RP). Histological fi ndings were 21 pT2c and 9 pT3 tumors, with 5 positive surgical margins. Gleason score (GS) was 5 in 1 case, 6 in 22 cases, 7 in 6 cases and 9 in 1 case. One patient with positive pelvic lymph nodes was given hormonotherapy. Another had a biochemical recurrence at 10 months and was treated with salvage radiotherapy. With a mean follow-up of 63.4±42.3 (0.6-199.1) months, two KTR died from KP, 3 and 11 years aft er Hormonotherapy and RP respectively.

Conclusions: Prevalence of PC in SOTR remains controversial, even though a signifi cant increase can be expected in the coming decades. It is therefore recommended to systematically screen male transplant recipients aft er 50 years of age because outcome is much better if PC is diagnosed and treated early. Radical prostatectomy is feasible in KTR as well as in LTR.

Conservative Introduction and Objective: Conservative surgery results in the transplanted population remain unknown because they are only presented in small series or case reports. Our objective was to study renal conservative surgery for kidney graft renal cell carcinomas (RCC) in a multicenter cohort. Nephron sparing surgery (NSS), radiofrequency ablation (RF) and cryoablation (CA) were studied. IIIb) . None of the patients treated by radiofrequency ablation or cryoablation had complications. Th e mean time of follow-up was 42.9 months (0.6-137). Fift y-nine (95.1%) patients had a functional kidney graft , without dialysis and no long-term complications. Specifi c survival was 100% at the last time of follow-up.

Conclusion: NSS has proven its effi ciency for treatment of small tumors of transplanted kidneys with good long-term functional and oncological outcomes, which prevent patients from returning to dialysis. Cryoablation and radiofrequency ablation seem to be alternative therapies that can be chosen with good results, in selected patients.

Ureteric Implantation into Introduction and Objective: Conventional technique recommends ureteric anastomosis to the bladder during kidney transplantation in patients with bladder augmentation. We report our experience of kidney transplantation in augmented bladders with the transplant ureter implanted into the bowel portion of the cystoplasty.

A total of 6 patients (Mean age, 28.2 years (Range 22-55 years), 2 Female, 5 Deceased donors) with augmented cystoplasty and subsequent kidney transplantation by a single surgeon between 2011 and 2014 was reviewed. Following standard arterial and venous anastomosis and reperfusion of the transplanted kidney, ureteric implantation involved continuous PDS 5/0 anastomosis between the spatulated ureter and full thickness bowel portion of the cystoplasty over a size 6Fr DJ stent. A second layer of bowel plication was performed around the anastomosis to prevent refl ux using interrupted 3/0 vicryl sutures. Chart review was performed to evaluate the short-term urological and kidney function outcomes.

Results: Th e cause of renal failure was bilateral vesicoureteric refl ux in 2 patients, posterior urethral valve with refl ux nephropathy in 2 patients, tuberculosis of the urinary tract with infl ammatory ureteric stricture in 1 patient, and lumbosacral agenesis with neurogenic bladder in 1 patient. Bladder reconstruction was performed at a median duration of 73 months (6-157 months) before transplantation. Gastrocystoplasty was performed in 2 patients, while the colon and/or ileum were used in the remaining patients. All reconstructed bladders except 1 had a Mitrofanoff created for clean intermittent self-catheter drainage aft er transplantation between 5 to 8 x / day. Aft er surgery, Th e dose fi nding study, toxicokinetics of human bone marrow-derived mesenchymal stem cells, and study deciding timing and number of cell injection were conducted in order.

Results: From the dose fi nding study, 1×106 was selected as dose per an injection of human bone marrow-derived mesenchymal stem cells. From the toxicokinetics of human bone marrow-derived mesenchymal stem cells, 14 days was selected as interval between repeat treatments. In the third study, the ratio of maximal intracavernous pressure to mean arterial pressure was signifi cantly lower in the control group than in the sham group (23.4% vs. 55.1%, P<0.001). Immediate single injection of human bone marrow-derived mesenchymal stem cells (39.8%, P=0.035) signifi cantly improved erectile function compared to that in the control group, whereas delayed single injection (38.1%, P=0.079) showed marginally signifi cant improvement. All histomorphometric changes were signifi cantly improved in the UP.319, Figure 1 .

immediate or delayed single injection groups than in the control group. Repeat treatments did not provide any incremental eff ect on recovery of erectile function and histomorphometric changes.

Conclusion: Intracavernous injection of 1×106 human bone marrow-derived mesenchymal stem cells results in recovery of penile erection along with histomorphometric changes in a rat model of cavernous nerve injury, even when treatment was delayed by 4 weeks following cavernous nerve injury. Any incremental eff ect aff orded by repeat treatments remains to be undefi ned.

Relationship between Metabolic Syndrome, Erectile Dysfunction and Hypogonadism

Abou Farha M, El-Abd S, El-Gharbawy M, Abou Farha O

Introduction and Objective: A strong association between erectile dysfunction (ED) and metabolic syndrome (MS) and hypogonadism was determined. Aim of the work: To investigate the relationship between (MS), (ED) and the incidence of hypogonadism. Th e correlation between hypogonadism and the metabolic risk factors was also determined.

A total of 227 patients with ED were included in the study, patients meet the criteria of MS were estimated. ED was classifi ed based on IIEF-5 domain score and the relation between severity of symptoms and the number of metabolic risk factors was determined. Th e incidence of hypogonadism in MS patients was determined and the correlation between hypogonadism and metabolic risk factors was identifi ed.

Introduction and Objective: Peyronie's Disease (PD) is a fi brotic disorder aff ecting the tunica albuginea of the corpora cavernosa. Erectile Dysfunction (ED) due to PD may be secondary to the penile deformity and the resultant changes in the hemodynamic parameters. Th e aim of this study is to defi ne Color Doppler Duplex Ultrasound (CDDU) characteristics in PD, with specifi c attention to describing the presence and etiology of ED in these patients. Introduction and Objective: Th e cause of Peyronie's disease (PD) is unknown. Th e most accepted causative theory is trauma to tunica albuginea. Because prevalence varies (0.4-9%), the potential for contributory cofactors have been proposed. We hypothesized that metabolic syndrome and other comorbidities may be found at higher rates in PD.

Retrospective chart review of 1833 patients presenting to a men's health clinic with a variety of complaints: erectile dysfunction (ED), premature ejaculation (PE), premarital checkup, small penis, decreased libido, lower urinary tract symptoms (LUTS) were screened for PD. Variables collected: presence/absence of diabetes mellitus (DM), hypertension(HTN), dyslipidemia (DL), body mass index (BMI), total testosterone (T), penile peak systolic velocity (PSV) and end diastolic volume (EDV), smoking, and glycosolated hemoglobin level (A1c) in patients with DM.

Results: A total of 1833 patients, with a mean age of 41 years (range 19-86) were analyzed. PD incidence ranged widely within individual clinics (7-51%, average 17%). Hypertension, BMI, T level, total number of comorbidities, low PSV, abnormal EDV, and mean A1c were not associated with the presence of PD.

35th CONGRESS OF THE SOCIÉTÉ INTERNATIONALE D'UROLOGIE -SIU 2015 ABSTRACT BOOK Diabetes was associated with PD (p=0.005) and DM patients had a 7% higher incidence. Patients with the highest A1c levels (>8.5) had an increased incidence of PD [OR 1.6 (p=0.025, CI 1.061-2.459)]. Increased age was correlated with PD (p=0.025); for each year of life, the likelihood increases by an OR of 1.019 (~2% per year) (p=0.001, CI 1.004-1.027). Dyslipidemia (p=0.006) and smoking (p=0.041) were associated with 5-7% lower incidences of PD.

Conclusion: Peyronies disease is found in about 17% of patients seen for other complaints. Diabetes, particularly poorly controlled diabetes, is associated with an increased incidence. Several other clinical factors appeared noncontributory. A decreased incidence of PD in smokers and patients with dyslipidemia is seen, but does not necessarily refl ect a protective role, but likely increased levels of erectile dysfunction in these groups--patients with inability to achieve erection are unlikely to complain of Peyronies' disease. Further research into the interaction of PD and DM are warranted.

Kim J, Park J, Chae J, Oh M, Park H, Kim J, Moon D

Introduction and Objective: Limited data are available concerning sexual behavior of Korean men. Th is study aimed to perform the national sex survey and to collect the basic data for establishment of the prevention strategies of sexually transmitted infections (STIs) and HIV/AIDS.

Th is is a national survey performed on a sample of 2,500 individuals (1,273 men and 1,227 women) aged 18-69 years old. Th e online surveys were carried out on a national scale in South Korea. Subjects were randomly selected from resident registration. A structured questionnaire was developed which elicited information concerning: demographic information, information on their sexual behavior, sexual identity, prostitution, experience of STIs, and experience of sex education.

Results: Th e majority of the subjects were either married or living with a partner. Mean number of sexual intercourse is 3.0±3.3 times a month. Mean sexual satisfaction score using visual analog scale is 63.2±24.6. Eighty-four percent had a fi xed sex partner; 13.1% (22.6% of men; 2.5% of women) had experience through a speed dating or prostitution; 0.9% of men and 1.1% of women were sexually attracted to the same gender only, 1.5% of men and 2.0% of women were sexually attracted to both gender; 1.8% of participants had the experience of the STIs. Only 10.4% of the respondents had received sex education in the past year.

We performed the National Sex Survey according to the nationwide distribution of population. It would be useful for establishment of the prevention strategies of STIs and HIV/AIDS. To control STIs and HIV/AIDS, powerful policies containing sex education and medical services will be needed.

The Introduction and Objective: Erectile function evaluated by International Index of Erectile Function-5 (IIEF-5) tends to decrease in aging, obesity and hypogonadism, but the importance of body composition is unclear. In the present study, we evaluated associations between IIEF-5, body composition and testosterone level (TT) in middle-aged men.

Design was a population-based cross-sectional study in middle-aged men. Between March and September 2013, 1910 police officers aged 40-59 years who had participated in a health examination were included. Total 1,845 men underwent a detailed clinical evaluation using the validated International Index of Erectile Function-5 (IIEF-5) questionnaires and body composition (measured by bioelectrical impedance analysis). Weight, body mass index (BMI), waist-hip ratio (WHR), and serum testosterone level were also established.

Results: Data from 1899 men were analyzed. Th e median age was 53.0 years, and median value of IIEF-5 score was 18. Th e IIEF-5 score was inversely associated with age, WHR, and body fat percentage (BFP) (r=-0.238; p<0.001, r=-0.106; p<0.001, r=-0.081; p=0.001, respectively), and positively associated with body muscle percentage (BMP) and body skeletal muscle percentage (BSP) (r=-0.080; p=0.001, r=-0.064; p=0.006, respectively). Testosterone level had no correlation with IIEF-5 score (p=0.147). Using logistic regression analyses, age, WHR, BFP, and BSP predict moderate to severe erectile dysfunction (ED) in univariate analysis. Age, WHR, and BFP were independent predictive factors for moderate to severe ED in multivariate analysis (p<0.001, OR 1.136, 95% CI 1.100-1.174; p=0.028, OR 0.876, 95% CI 0.778-0.986; p=0.024, OR 0.986, 95% CI 0.954-1.020, respectively).

Our data showed that erectile function in middle-aged men was closely associated with WHR and BFP than with testosterone level and body muscle percentage. However, WHR was identifi ed as a negative predictive factor for ED. Further studies for the unique form of obesity pattern in Korean men will be needed. In order to estimate the magnitude and outline the main components of adult male genital organs "dysmorphophobia" in Greece, we surveyed the beliefs of men about parameters potentially aff ecting their sexual performance and activity as they relate with self-perceptions regarding adequacy of their external genitalia image. Herein, we present preliminary results of this questionnaire based cross-sectional study.

A specially designed self-administered questionnaire, consisting of 15 demographic characteristics and 10 main outcome measure questions aiming at defi ning whether and how beliefs regarding men's sexual image adequacy aff ect their sexual confi dence and function (answers scored 0-5), was fi lled in by 70 males (aged 19-85) who consulted a single urology clinical setting, for symptoms unrelated to genital area pathology. Statistical analysis was performed using SPSS-22, p<0.05.

Results: Th e majority of subjects (86.4%) were highly satisfi ed of their sex organs image, while only one in seven (13.6%) reported moderate to low levels of satisfaction. Small penile size in the fl accid state was the most frequent (51.1%) complaint followed by small erect penis dimensions (20%). In one out of two men (49.3%), sex image inadequacy impression was based on self-assessment, in 27.5% on sexual partner comments and in only 5.8% on expert medical examination. Nine out of ten men (89.4%) considered external genitalia appearance the most signifi cant determinant of a man's sexual confi dence with 75.7% believing they strongly fulfi l this requirement, while most of them (71.3%) were highly satisfi ed with their whole body image. In only one in ten men (12.1%) the impression of the sexual partner regarding sex image aff ects signifi cantly his sexual performance. Most men (68.2%) argued against resorting to surgical techniques to improve their sex image, 6% considered this option imperative for their well-being, while one in four (25.8%) would consider surgery if a spectacular cosmetic result was guaranteed. Various statistically signifi cant correlations between demographic and main outcome measures variables were recorded.

Conclusions: Symptoms of genital organs dysmorphophobia, are expressed by one in seven men of the general population, in most cases complaints focus mainly at small penile size, while most frequently impression of inadequate sex image originates from self-assessment and negative sexual partner's comments. Th e majority of men consider genital image a strong determining factor for sexual performance, while very few experience sexual relationships difficulties due to feelings of genital inadequacy. Only a small minority of men would be strongly willing to undergo external genitalia surgery, which they consider imperative treatment for sexual image inadequacy.

Abou Farha M, El-Abd S, El-Gharbawy M, Abou Farha O

Introduction and Objective: Metabolic syndrome is a public health problem associated with increased incidence of erectile dysfunction (ED). Erectile dysfunction in patients with metabolic syndrome is diffi cult Introduction and Objective: Erectile dysfunction (ED) and lower urinary tract symptom/ benign prostatic hyperplasia (LUTS/BPH) has common pathophysiology. And phosphodiesterase type 5 inhibitor (PDE5-I) partially reverses the prostatic tissue contraction, and increases cyclic guanosine monophos- phate to show antiproliferative eff ects in the prostatic smooth muscle cells and consequently, voiding symptoms were suggested to be improved. However, there was no defi nite mechanism of the eff ectiveness of PDE5-I on LUTS/BPH. Some previous study has reported the hypothesis which is PDE5-I improve the blood fl ow rate of prostate and it may improve the LUTS. In present study, by transrectal ultrasonography (TRUS), evaluated the change of blood fl ow rate of prostate aft er PDE5-I administration.

Materials and Methods: Total 16 patients were included in this study. Among enrolled patients, 9 patients had once daily administrated mirodenafi l (MVIX®, SK chemical, Korea) 50mg for 1 week, other 9 patients had administrated placebo daily. Peak systolic velocity (PSV) and end diastolic velocity (EDV) were estimated by TRUS at before medication and a day aft er last administration.

Results: Baseline characteristics were no signifi cant diff erence between two groups. In mirodenafi l group showed 4.82 cm/sec increase of PSV and placebo group showed 0.29 cm/sec increase of PSV (p=0.029). Moreover, mirodenafi l group showed 0.38 cm/sec increase of EDV and placebo group showed 0.19 cm/sec decrease of EDV (p=0.543).

Once daily administration of mirodenafi l 50mg showed improvement of blood fl ow rate of prostate.

Factors Predicting Outcomes of Penile Rehabilitation with Udenafi l 50mg following Radical Prostatectomy Introduction and Objective: Udenafi l is a selective phosphodiesterase type 5 inhibitor (PDE5I) made available in recent years for the treatment of erectile dysfunction (ED). Penile rehabilitation using PDE5Is following radical prostatectomy (RP) has been advocated; however, there are no previous reports on the role of udenafi l for potency recovery aft er RP. Herein, we evaluated independent predictors of potency recovery in RP patients who underwent penile rehabilitation with udenafi l 50mg.

Between January 2011 and December 2013, a total of 305 patients underwent RP at a single institute. Among them, 143 men were enrolled in a penile rehabilitation program using udenafi l 50 mg every other day. Uni-and multivariable Cox regression analyses were used to determine independent predictive factors for potency recovery.

Results: Th e overall potency rate was 41.3% during the mean follow-up of 20.4 months. On the multivariate Cox analyses, preoperative International Index of Erectile Function (IIEF)-5 scores (hazard ratio [HR], 1.049; P = 0.040), alcohol consumption (HR, 2.043; P = 0.020), and Gleason biopsy score (HR, 0.368; P = 0.024) were independent preoperative predictors for potency recovery. Among post-RP variables, the use of robotic procedures (HR, 2.287; P = 0.030) and pathologic stage (HR, 0.506; P = 0.038) were significantly associated with potency recovery.

Conclusion: Th is study identifi ed predictive factors for the recovery of potency in patients undergoing penile rehabilitation with udenafi l following RP. Our results provide physicians with useful information for counseling RP patients and selecting optimal candidates for penile rehabilitation.

Introduction and Objective: Androgen replacement therapy (ART) effi cacy on late-onset hypogonadism (LOH) has been widely investigated in Western countries; however, it remains controversial whether ART can improve health and prolong active lifestyles. We prospectively assessed long-term ART eff ects on the physical and mental statuses of aging men with LOH in Japan.

Of 1637 volunteers eligible 334 patients > 40 years with LOH were randomly assigned to either the ART (n=169) or the control groups (n=165). ART was conducted with intramuscular injection of testosterone enanthate 250 mg each time every four weeks up to 12 times. Th e primary endpoint was health-related quality of life assessed by questionnaires. Secondary endpoints included glycemic control, lipid parameters, blood pressure, waist circumference, body mass index (BMI), body composition, muscular strength, bone mineral density (BMD), International Prostate Symptom Scores (IPSS), International Index of Erectile Function (IIEF)-5 scores, and serum prostate-specifi c antigen levels. Th e safety and tolerability of long-term ART were also examined in these populations.

Results: Fift y-two weeks aft er the initial treatment, ART signifi cantly aff ected the role physical subdomain of the Short Form-36 Health Survey (SF-36) scale (p = 0.032). ART was also associated with signifi cant decreases in waist circumstance (p = 0.002) and serum triglyceride (TG) (p = 0.013) and with signifi cant increases in whole-body and leg muscle mass volumes (p = 0.071 and 0.011, respectively), serum hemoglobin (p < 0.001), IPSS voiding subscore (p = 0.042), and the second question on IIEF-5 (p = 0.005). Th ere was no signifi cant deference between the groups in terms of BMI, BMD, isometric handgrip strength, serum fasting blood sugar and hemoglobin A1c, serum PSA, and the incidence of sever adverse events.

Conclusion: Long-term ART for patients with LOH have the benefi cial eff ects on Role Physical subdomain of the SF-36 scale, serum TG, waist circumstance, muscle mass volume, voiding subscore of IPSS, and the second question of IIEF-5. We hope our study will contribute to the future development of this area.

Introduction and Objective: Hyperoxaluria is characterised by a high urinary oxalate level. Super-saturation of urine with oxalate will lead to nucleation, aggregation and the formation of calcium oxalate crystals leading to renal calculi. Patients with hyperoxaluria are at increased risk of recurrent urolithiasis. Objectives: To analysis the interventions and outcomes of new patients with enteric and dietary hyperoxaluria referred to a metabolic stone clinic.

An analysis of patients with hyperoxaluria was performed. Data examined included; age, sex, metabolic abnormalities, malabsorptive syndromes, previous treatments, stone composition, medical and life style interventions. All patients had 2 or more 24hr collections of urine performed at median of 6 months apart. Twenty-four-month follow-up was performed to assess need of further stone treatment.

Results: A total of 37 patients were identifi ed for study. Twenty-fi ve were male, 12 were female. Th e median age is 50 years, IQR (22 -73). First median urinary oxalate level is 0.45 mM, IQR (0.3800 -0.5500). Patients that reduced their oxalate intake and increased their fl uid intake were signifi cantly less likely to need further long-term stone treatment. Th e ARR of increased urinary output and decreased urinary oxalate on the need for further stone surgery is 35th CONGRESS OF THE SOCIÉTÉ INTERNATIONALE D'UROLOGIE -SIU 2015 ABSTRACT BOOK 26.3%, CI (-1.534 -54.098) . Th e RRR for the need of stone surgery is 63.1%, CI (-43.8 -90.5) . Th e NNT to prevent one patient needed further stone treatment is 3.805, CI (1.848 --65.187) .

Conclusion: Hyperoxaluria is important cause of recurrent stone formation that requires management in a dedicated metabolic stone clinic. Compliance with fl uid, dietary and medical management is limited. In compliant patients, urine parameters and stone recurrence rates can be altered.

Clinical 

Using specifi c diagnosis codes from billing data, patients were identifi ed that met criteria for urosepsis secondary to an obstructive ureteral calculi. Data was analyzed in the following areas: demographics, admitting hospital of origin, duration of admission before transfer, need for higher level of care, need for invasive procedures, and length of hospital stay.

Results: Using the screening criteria 88 patients were identifi ed. Th e average age was 55; 71% were female versus 29% male. Patients transferred from an outside hospital made up 40% of the patients and overall hospital admission lasted 8.6 days. Of the patients transferred 31% went to the ICU for an average duration of 2.51 days. Of the transferred patients 29% needed vasopressor/ionotropic therapy, and 20% required intubation. Overall, over 90% needed urologic intervention; 57% had ureteral stent placement and 34% underwent nephrostomy tube placement. Patients admitted from the ED made up 60% of the patients and had an average admission of 6.74 days. Of these patients 30% went to the ICU for an average of 1.38 days. Only 11% and 15% needed vasopressor/ionotropic therapy and intubation respectively. Also, 77% had ureteral stent placement and only 6% had a nephrostomy tube placed.

Conclusion: Urospesis in the setting of an obstructive ureteral stone is a medical emergency that merits urgent relief of the obstruction. Once this condition is identifi ed, any facility without the resources for prompt intervention should transfer these patients immediately to a center with these capabilities. Th is is supported by our data, as transferred patients on average had a longer ICU and hospital stay, and needed more aggressive interventions.

Clinical Signifi cance of Ureteral Wall Thickness Adjacent to the Stone in Abdomen-Pelvis CT in the Patients Treated with Extracorporeal Shock Wave Lithotripsy Park M, Yeo J, Cho D

Introduction and Objective: Although, IVP was standard diagnostic tool for years, the use of abdomen-pelvis CT (APCT) without contrast, particularly in an acute setting, is becoming increasingly common. Th is study was planned to know the clinical signifi cance of ureteral wall thickness adjacent to the stone in APCT in the patients treated with extracorporeal shock wave lithotripsy (ESWL).

: Th e data of 174 patients who took AP-CT to diagnose ureter stone and were treated with ESWL was reviewed. Aft er maximum zoom of the AP-CT image showing the longest diameter of stone, the ureteral wall thickness adjacent to the stone was measured by same physician. Th e baseline characteristics of patients, the parameters related to ureter stone and effi cacy of ESWL were investigated. Th e correlation between ureteral wall thickness and those parameters was statistically analyzed. Th en, the patients were divided into two groups by the median value of ureteral wall thickness and the diff erence of those parameters between two groups was also investigated. Additionally, cut-off value of ureteral wall thickness contributing to the diff erence in the effi cacy of ESWL was determined.

In simple correlation analysis, BMI, stone length at KUB, stone diameter in CT, number of ESWL, and time to stone removal showed signifi cant positive correlation with ureteral wall thickness. Th e median value of ureteral wall thickness was 2.30mm and the patients were divided into two groups. In comparison of baseline characteristics between two groups, group II showed more incidence of pyuria than group I and stone burden at KUB and CT also showed statistical diff erence between two groups. In comparison of effi cacy of ESWL, group II showed more number of ESWL and longer time to stone removal than group I. Th e cut off value of ureteral wall thickness contributing to the diff erence in the effi cacy of ESWL was 2.095mm.

Conclusions: In addition to actual size of stone, ureteral wall thickness of CT also aff ects the treatment effi cacy of ESWL. Especially, the ureteral wall thickness greater than 2.095mm has an impact on the results of the ESWL.

The Introduction and Objective: Th e treatment of large volume bladder stones by current equipment continues to be a management problem in both developing and developed countries. AH-1 Stone Removal System (SRS) invented by us is primarily used to crush and retrieve bladder stones. Th is study evaluated the safety and effi ciency of transurethral cystolitholapaxy with SRS to treat the large volume bladder stone.

Materials and Methods: SRS, which was invented by Aihua Li in 2007, composed by endoscope, continuous-fl ow component, a jaw for stone handling and retrieving, lithotripsy tube, handle, inner sheath and outer sheath. A total of 126 patients with bladder stones were performed by transurethral cystolitholapaxy with SRS since 2008. Th ese patients were divided into four groups by the stone size. Fift y nine patients with stone size <2cm were in Group A, 40 patients with stone size from 2 to 2.9cm were in Group B, 16 patients with stone size from 3 to 3.9cm were in Group C, and 11 patients with stone size ≥4cm were in Group D and the largest stone was 6.4cm.

Results: Characteristics of patients and stone removal time in variable size were evaluated. To patients with single stone, stone size was 1.35±0.37cm and the operating time was 5.50±3.92min in Group A. Stone Introduction and Objective: ESWL has emerged as a primary modality of treatment for Solitary renal calculi in Modern era. Th e size of calculus is a major factor for consideration before subjecting a patient to ESWL procedure. Stone size less than two centimetre is considered ideal for ESWL. Other factors like obesity, position of calculus, renal infundibular anatomy and stone composition etc. also determine clearance rates. Given a choice patients in India still prefer one time clearance by PCNL than multiple ESWL sittings for similar sized calculus. Our study reiterates the benefi ts of ESWL in developing world with multivariate data supporting it. Th e objective of this study was to evaluate the feasibility and safety of minimally invasive percutaneous nephrolithotomy combined with fl exible ureteroscopy for upper urethral calculus aft er radical cystectomy urinary diversion.

A total of 6 patients underwent minimally invasive percutaneous nephrolithotomy combined with fl exible ureteroscopy from January 2013 to August 2014. Th ere were 4 cases that were diagnosed urinary stones aft er Bricker urinary diversion of radical cystectomy, 1 case of Studer orthotopic ileal neobladder, and 1 case of cutaneous ureterostomy. Th ere were 4 cases with left side calculi and 2 cases with right side ones, including renal calculus, ureteral calculus and ureterointestinal anastomotic calculus. Th e upper urethral calculi were identifi ed by urinary tract ultrasound and the multiplanar CT. All of 6 cases underwent minimally invasive percutaneous nephrolithotomy combined with fl exible ureteroscopy. Th e ureteral stent was indwelled for 4 weeks routinely. Th e kidney ureter and bladder X-Ray or a CT scan was examined 4 weeks aft er the procedure to evaluate the clinical outcomes. Any residual calculus larger than 4 mm was taken as signifi cant.

Results: Th e combined lithotripsy was carried out successfully in all the 6 cases. Th e mean operative time was (53±8.9) min. Th e nephrostomic catheter was removed 3 days aft er the surgery. Th e average blood loss was less than 50ml. No residual calculus was found during the 4 weeks' follow-up. Th e average follow-up was 11 months. One case had recurrent calculus 13 months aft er the fi rst procedure, which was successfully managed by the fl exible ureteroscopy again.

Minimally invasive percutaneous nephrolithotomy combined with fl exible ureteroscopy for upper urethral calculus secondary to urinary diversion aft er radical cystectomy is technically feasible Introduction and Objective: Th e main goal of any intervention for urolithiasis is complete stone removal in order to achieve a stone free status. Complete stone removal assures resolution of the immediate adverse outcomes of the stone disease, and prevents possible long-term complications such as pain, obstruction and stone growth. Percutaneous nephrolithotomy is an eff ective procedure which is being considered as the gold standard in the treatment of large/complex renal calculi. Reported stone free rates are up to 90%, probably refl ecting the level of experience, stone properties and equipment employed in the procedure. It is well established that higher incidence of residual fragments increases the complication rates and needs further interventions. Th e main reason for failure of complete radiolucent stone clearance is inability to visualize the residual stones either by nephroscope or by fl uoroscopy. Th e use of intraoperative Ultrasound for assessment of residual radiolucent stones during percutaneous nephrolithotomy, will help to increase stone free rate.

Materials and Methods: Between Sept. 2010 and Sept. 2014 intraoperative Ultrasound was used in 74 cases of large complex radiolucent renal stones.

Results: It showed stone free rate 100% in 68 patients, false negative in 4 patients (5%) and there was diffi cult scanning in 2 patients (3%).

Conclusions: Th e use of intraoperative Ultrasound for assessment of residual radiolucent stones during Percutaneous nephrolithotomy, it will help to increase stone free rate.

Intravenous Acetaminophen Decreases Sedation Requirements during Extracorporeal Shockwave Lithotripsy Conclusion: Th ere is benefi t in pre-operative administration of intravenous Acetaminophen in reducing the dose requirements of sedative analgesic for satisfactory pain control during the procedure of SWL under conscious sedation.

Introduction and Objective: While most of the bleeding associated with PCNL can be managed conservatively, few need angioembolisation. Th ere are diff erent technical methods of embolisation with risk of varying degree of parenchymal damage. We present case of ultrasonography guided embolisation.

Materials and Methods: Right Lower calyx PCNL was performed successfully in 17 year female with 21 mm renal stone in solitary kidney. She came back on 15th postoperative day with gross hematuria, with 7 cm by 5 cm clot in renal pelvis and 11 mm arterio-venous fi stula at PCNL puncture site. Patient was managed with IV higher antibiotics, strict bed rest, Blood transfusion and IV tranexamic acid. But her renal function deteriorated (creatinine-6.5 mg/dl). One haemodialysis was done and patient was explored by sub costal approach, with idea of removal of blood clots and suture ligation of AV fi stula. Renal pelvis was opened and clots were removed. During operation AV fi stula was located with Doppler USG and deep suture by 2-0 vicryl was attempted to close AV fi stula, but due to oedematous kidney suture closure was not possible. So under USG guidance 22 gauze lumber puncture needle was inserted into AV fi stula, its position was confi rmed by saline jet on real time USG and 1 cc Histoacryl tissue adhesive (monomeric n-butyl-2-cyanoacrylate) was injected into AV fi stula. Intraoperative embolisation of AV fi stula was confi rmed by colour Doppler.

Results: Renal functions became normal in 48 hours and patient was discharged on 5th postoperative day. Aft er 21 days IVP was done which demonstrated normally excreting whole kidney, showing successful superselective embolisation in solitary kidney.

Conclusions: USG guided procedure avoids the side eff ects of contrast media in case of acute renal failure. It avoids hazards of radiation and complications of angiographic catheterisation. Th e main importance of this procedure is preserving maximum renal tissue, especially in case of renal insuffi ciency and in solitary kidney. Th is procedure gives a new vision to do percutaneous USG guided embolisation by thin 22 gauze needle without need of angiography, IV contrast, radiation and minimum morbidity.

Ultrasound 

Th ree pregnant women in the 16th, 20th and 28th week of pregnancy presented with a symptomatic large renal stone in the fi rst and multiple renal stones in the second and third which were unresponsive to conventional medical therapy. Th ey required defi nitive stone treatment. Th e operations were done in Nov 2012, Jun 2014 and Feb 2015. Data was gathered prospectively. All steps of gaining access to the pyelocalyceal system including needle insertion, tract dilation, and Amplatz sheath placement were performed under ultrasonography guidance. Tract was dilated with single shot technique. Th e fi rst two procedures were performed in supine position and the third procedure was performed in lateral fl ank position.

Results: Two patients were stone-free postoperatively and one patient had only an asymptomatic 4 mm residual stone. Th ey were discharged on the 2nd postoperative day and had an uneventful postoperative course. No fever, bleeding or renal colic was noticed during postoperative hospitalization. Th e fi rst two patients delivered their fetuses at term without any abnormality reported by the examining pediatric specialist aft er their birth. Th e third patient was followed until 33 week of pregnancy without any obstetric complication.

Conclusion: Ultrasonography can be used as an imaging modality guiding all steps of obtaining percutaneous access in pregnant women. Supine or fl ank ultrasound guided percutaneous nephrolithotomy can be off ered to pregnant women in whom conservative measures fail to the patient's well-being.

Introduction and Objective: Acute ureteral obstruction in pregnancy may result in severe pain, hematuria and serious complications like upper urinary track infection with consecutive sepsis. Th e ureteral stenting has been usual in recent years. We evaluated the usefulness of ureteral stenting for ureteral obstruction with symptoms in pregnancy.

Fift y-three pregnant women participated in this study. Abdominal ultrasonography, serum creatinine levels, white blood cell (WBC) counts, urinalysis and urine culture were done in all patients. Of these 53 pregnant women, 18 women were treated by ureteral stenting because of not improving with conservative management (positioning, analgesia, antibiotics, etc.). Th ey were completely followed-up to removal of ureteral stent.

Results: Of these 53 pregnant women, 18 women who were treated by ureteral stenting, experienced signifi cant relief of pain at least for 2 days. In abdominal ultrasound, 16 patients (88%) had resolution of hydronephrosis. Twelve of 18 patients (66%) continued to have problems post-therapeutically irritative voiding symptoms with dysuria, urgency, frequency, and hematuria, but 11 patients experienced relief of symptoms for 10 days. A patient was taken remove of stent due to continuous complaint irritative voiding symptoms. Aft er delivery, 17 patients were taken IVP. Of 17 patients, 13 were normal fi nding with IVP. Four patients were diagnosed ureter stone (upper 2, mid 1, lower 1). Th ree patients were treated by extracoporeal shock-wave lithotripsy for the stone in upper and lower urinary tract. A patient was treated ureteroscopic lithotripsy.

Conclusions: Since the ureteral stents were usually placed without any major problems and well tolerated with only minor and short post-therapeutic discomfort. We concluded that the ureteral stenting was a simple, safe and eff ective method of internal upper tract drainage in case of symptomatic ureteral obstruction during pregnancy.

Safety Introduction and Objective: To evaluate objective and subjective outcomes of retrograde intrarenal surgery (RIRS) for the treatment of radiopaque 10 -20 mm renal calculi.

A retrospective analysis was performed for 34 patients who underwent RIRS to treat renal calculi sized with 10 -20 mm between April 2013 and December 2013. Operative and postoperative data were collected for each patient such as stone burden, stone location, number of sessions, and auxiliary procedures. Th e term of follow-up was one year at least. Surgery was usually performed under general anaesthesia. Flexible ureteroscopy with ureteral access sheath and holmium-YAG laser were employed. Patients were evaluated with simple radiography, abdominal ultrasonography, or CT without contrast. Surgery success was determined as stone free rate (SFR) at three months aft er last session. Re-treatment rates were also calculated.

Results: Mean age was 55.2 ± 13.6 years old. Th e highest-frequency location was pelvis (50%). Single stones were described in 74% of patients although multiple urolithiasis were detected in the 26%, mainly located in the lower calyceal. Average surgery time was 52.2 ± 17.7 min. Th e auxiliary procedure rate and the re-treatment rate were 2.9% and 8.8%, respectively. Th e overall SFR and SFR aft er a single session were 91.1% and 88.2%, respectively. Although no serious complications were noted in all of patients (above Clavien-Dindo Classifi cation level III), Clavien level I to II complications were identifi ed in two-patients (5.8%). All these patients were successfully treated conservatively.

Conclusion: Our fi nding suggest that RIRS represents a valuable treatment option of 10 -20 mm radiopaque renal calculi for selected patients. RIRS would be also a good therapeutic alternative to extracorporeal shock wave lithotripsy (ESWL) and percutaneous nephrolithotomy (PNL). RIRS should be considered as fi rst line treatment. Prospective analysis is required to be corroborated these fi ndings.

Ureteroscopic Lithotripsy for Extremely Old Patients Yoshioka T 1 , Uehara S 2 , Otsuki H 2 , Shimizu T 2 , Murao W 2 , Fujio K 2 , Kikuchi H 3 , Fujio K 1 , Wada K 1 , Araki M 1 , Ebara S 1 , Watanabe T 1 , Nasu Y 1 Introduction and Objective: One of the biggest problems in 21st century is an aging society. In 2013, the number of old people (≥65 years old) in Japan was 31,900,000. Th at is about 25% of all Japanese population. Japanese society is becoming not an "aging" society, but an "aged" society, and we have to prepare for this society. On the other hand, upper urinary stone is a common disease, and oft en occurs not only young people but also aged people. However, there are no standard treatments for aged patients of upper urinary stones, especially extremely old patients who are more than 85 years old. In this study, we investigate the safety and effi cacy of ureteroscopic lithotripsy of upper urinary calculi for these patients.

Between January 2012 and October 2014, 254 ureteroscopic lithotripsy (URS) underwent in Abiko Toho Hospital. Of these cases, 5 cases are for the extremely old patients (≥90 years old). We retrospectively reviewed gender, age, body mass index (BMI), American Society of Anesthesiology (ASA) physical score, stone size, reasons for operation (whether symptomatic or not), operative duration, and stone free rate (SFR) of all cases. All data were reviewed by one urologist, and ASA physical scores were evaluated by one anesthesiologist.

Results: All cases were bedridden female. Mean age was 91.75 (range 90 to 95), BMI was 19.4 kg/ m^2 (range 17.8 to 21.0), ASA physical score was 2.5 (range 2 to 3). 4 cases had preoperative complicated pyelonephritis, and 3 out of these 4 cases were indwelled preoperative unilateral ureteral catheters. Mean stone size was 6.68mm (range 4.4 to 9.6), and operative duration was 56.2 minutes (range 36 to 81). Postoperative complication was 1 pyelonephritis (Clavien grade 4), and SFR was 40% (2/5 cases). In all cases, postoperative unilateral ureteral catheters were indwelled, and were withdrawn 2 weeks later. Th ere have been no recurrent stones and/or pyelonephritis (median observation time: 10.5 months).

Conclusion: Although SFR was low, URS for extremely old patients can prevent recurrent complicated pyelonephritis even on infected stones. Th ere were 82.9% of patients who had a single urinary stone and 17.1% (n = 14) had 2 or more. One hundred and nine stones were treated. Sixty-three percent of stones were intrarenal. Th ere were 5 (6.5%) postoperative complications: two stage 2 Clavien classifi cation infections (prostatitis at day 13 and two pyelonephritis 48 hours aft er the procedure); three stage 3b complications (two renal colics requiring ureteral stenting 48 hours aft er discharge and 1 symptomatic perirenal urinoma 48 hours aft er discharge). Th ere was one intraoperative complication (1.9%): a ureteral wound with contrast leakage. Th e rate of transfer to conventional hospitalization was 2.2%. Stone size infl uenced the stone-free status and the need for more than one sessions (p <0.0001). Th ere was a signifi cant correlation between operative time and stone size above 10 mm (p=0.0002).

Conclusions: Flexible and rigid ureteroscopy are safe and effi cient procedures for upper urinary tract stones, and can easily be carried out in an outpatient Introduction and Objective: Renal stone disease is one of commonest urological disorders. Pakistan is located in stone belt region with high incidence of urolithiasis. Th ere have been innovations and improvement in stone treatment modalities. ESWL is one of them. Here we share experience of single centre in terms of stone free rate and effi cacy in adults.

A retrospective study in which we included adults (age above 18 years old) who underwent ESWL from January 2013 to December 2014. ESWL was done by standard technique. We used Modulith SL X lithotripter 4th generation Storz medical. Number of shocks per session 3500 for kidney and 4000 for Ureter. Energy level for kidney is set at 7 and for ureter at 9. Rate of shock wave delivery is 90 shocks/minute. We followed patients for 3 to 6 months aft er Last ESWL session done. Stone free status was defi ned as residual stone not more than 4 mm in size. We reviewed data charts of patients for diff erent variables mentioned in results.

Introduction and Objective: Yolk-sac tumor (YST) is formed almost 65% germ cell tumors of infant and children. YST is the most common type of testis tumors in prepubertal period, but adult pure YST is extremely rare. In this case we aim to share our surgical experience with an adult pure YST in the right testis.

A 47 year-old man was referred to our clinic from cardiovascular surgery department for right testicular mass which is detected during the evaluation of his deep vein thrombosis. Th e patient stated having a slowly progressive increase in size of his right gonad. Th ere is no history about testicular trauma or epididymoorchitis. Physical examination revealed a painful right testis which was uniformly increased in size and presented a smooth surface. USG showed a volumetric increase in the right testis. Mass size was detected as 9.5 x 10.5 x 10 cm, which was characterized by cystic components in heterogeneous echogenicity. Serum chemistry revealed a marked increase in AFP while β-hCG and LDH levels were within the normal limits.

Results: A right radical inguinal orchiectomy was performed. During the orchiectomy, because of the invasion to scrotum skin, scrotum skin was removed. Th e surgical specimen was rigid, its surface was smooth and necrotic areas were observed ( Figure  1 ). Pathologic examination revealed a pure YST with positive spermatic cord, tunica albugea, tunica vaginalis and scrotum skin invasion and in Light microscopy tumor cells with large hyperchromatic nuclei arranging concentrically around a small vessel were seen (Schiller-Duval or glomeruloid body).

Metastasis of lung adenocarcinoma to the testis is an extremely rare occurrence and very few cases have been reported to date. Th e authors aim to review the current literature in regard to incidence, clinical manifestation, sources of primary tumour and mechanism of metastasis, in addition to retrospective ten year review of testicular pathology at a single institution.

We report an unusual case of a 33-year-old non-smoking Australian gentleman who presented with a six month history of cough and dyspnoea. A physical examination, complete laboratory and radiological work up was performed. A palpable left testicular mass was identifi ed, CT scan revealed multiple bilateral lung nodules and mediastinal lymphadenopathy, however testicular tumour markers were negative. Th e patient underwent a radical left inguinal orchidectomy and endobronchial hilar lymph node biopsy with bronchial washings. Medical records and pathology results for patients undergoing radical orchidectomy over the past ten years at our institution were obtained and analysed.

Results: Histopathological examination of the left testis and lung biopsy revealed features of a moderately to poorly diff erentiated adenocarcinoma, with morphological and immunohistochemical appearances consistent with lung origin. Th e prognosis is extremely poor. A total of 130 patients underwent radical orchidectomy at our institution between January 2004 and February 2014. Th e mean patient age was 32 (18-66). Histopathology is summarised in Table 1 . Cur-UP.373, Figure 1 .

35th CONGRESS OF THE SOCIÉTÉ INTERNATIONALE D'UROLOGIE -SIU 2015 ABSTRACT BOOK rent literature review confi rms testicular metastases are rare and may be discovered incidentally at autopsy or following diagnostic orchidectomy. Autopsy series revealed testicular metastases in 0.02 to 2.5% of specimens. Th e most common primaries, excluding lymphoma and leukaemia, include prostate, melanoma, sarcoma, gastrointestinal tract, kidney and lung, with most testicular metastases being a fi nal manifestation of widespread tumours.

Conclusions: Testicular metastases from lung adenocarcinoma origin are scarcely encountered in clinical practice and may create a diagnostic dilemma by mimicking primary testicular neoplasms. Extensive pathologic evaluation and specifi c immunohistochemical staining is essential. In patients presenting with a testicular mass, the diff erential diagnosis must include metastatic carcinoma.

by 24.7 on average compared to only 8.6 by non-users (p=0.024). Many of these fi ndings were only present with recent VGE; heavy users from high school and middle school did not show similar trends (Table 1 ; Figure 1 ).

Conclusion: Th is study shows that subjects with heavy VGE perform better on the da Vinci Skills Simulator than subjects who report no VGE. Th e improvements seen with recent VGE are not apparent if stratifying for frequency of use during high school and middle school. Th ese fi ndings may have important implications for the future of surgical training.

'Virtual Urology Clinic': A Feasibility Study in a Busy UK Teaching Hospital

Introduction and Objective: Urology is an advancing surgical specialty with a parallel increase in demands from health service commissioners to meet national targets and patients' needs. Th is has been refl ected on the outpatient Urology service with a rising burden and delays in patients' outpatients' assessments. In our busy tertiary unit, we estimated a total of 1281 overdue outpatient appointment (by 6 months or more). Th us we designed this virtual clinic feasibility study aiming to: prioritise patients according to their clini- cal needs, enhance their care and decrease the burden by assigning patients to our novel computer based follow-up models.

We used the hospital information system to identify one Urologist overdue appointments (by 6 months or more). All included cases had thorough review of their medical notes, investigations and treatment before being stratifi ed according to their diagnosis then assigned one of 3 outcomes: Urology, Cancer nurse specialist (CNS) and GP follow-up.

Results: A total of 191 cases were reviewed in this virtual clinic over a period equivalent to 5 full working days. Even though they were all waiting to see one Urology cancer surgeon, only 27% had a primary diagnosis of cancer with the rest being diagnosed with a benign urological condition. Th e clinical investigator recommended for only 45% of all patients to have a Urology follow-up with 33% and 22% discharged to the GP and computer based follow-up respectively. All patients received a letter explaining the procedure of this clinic along with a tailored management plan.

Th ere was an evident gap between the dynamic changes in service provision with new available tools and our current practice. Th is virtual clinic allowed bridging this gap by categorising the Urological priorities and utilising existing resources such as our novel computer based follow-up models. Over the last year more than 1000 patients' visits have been registered on our computer based clinic which is potentially a cost eff ective model.

Patients' Perspectives of Accessibility Introduction and Objective: Patients undergoing major lower abdo/pelvic operations are oft en catheterised (IDC) at the start of the procedure to monitor urine output and decompress the bladder to avoid bladder injury. Early removal of urinary catheters aft er surgery has been associated with a decrease in urinary tract infections though increasing failure of trial of void (TOV), thus being discharged with IDC or prolonged admissions. Th e aim of this study is to determine the optimal time for TOV.

Th is is a retrospective study looking at Patients undergoing abdominal or pelvic procedures due to colorectal/pelvic pathology in the Townsville Base Hospital surgical unit from Jan 2008 -Dec 2012. Pre-procedure IDC and the deceased were excluded. Data was collected from the operating theatre database (ORMIS).

Results: Out of the 306 total, 142 were female while 164 male, 94 abdominal and 212 pelvic procedures. Sixteen male patients had documented prostatic history which include BPH, prostate cancer and prostatitis post radiation. Four were discharged with an IDC failing TOV. Fift y-seven percent of the patients had their catheters removed on day 2 post-op; 5.6% on day 1, 13% on day 3, 4.9% on day 4 and 11% >4 days. Th ree patients developed a Urinary Tract Infec-tion (UTI) (0.98%). Patients with good pre morbid function and female tend to pass their trial of void on day 1 post op for pelvic procedures. Th e majority of patients had comorbidities and failed TOV on day 1. Th ere was no signifi cant diff erence between day 1 and day 2 in UTI rates (increasing day 3 onwards).

Conclusions: IDC's should be removed in a timely manner to reduce complications, balanced with monitoring fl uid balance. We proposed that patients should have TOV on day 2, due to increased rates of failed TOV day 1 in patients with comorbidities and no diff erence in UTI rates between days 1 and 2. Th e limitation of this study is the lack of documentation of preoperative urinary function. To further this study, we can analyse the data to state diff erences between bladder dysfunction as well as TOV in groups with various comorbidities.

International Urology Journal Club on Twitter: A Growing Educational Forum Introduction and Objective: Urologists use urinary and thoracostomy drainage collection systems regularly. Pleural and urine fl uid pools at the bottom of dependent loops of both thoracostomy and urinary drainage tubing systems, respectively. We hypothesized that fl uid pooled in a dependent loop 1) diminishes the expected negative pressure-head delivered to the pleural space by a chest-tube, and 2) obstructs antegrade catheterized urine drainage. We created an ex-vivo thocacostomy tube model, and, performed two separate clinical trials to test our hypothesis.

A Pleur-Evac chest drainage system was connected to -20 cmH2O wall-suction. A digital pressure transducer was connected to the drainage tubing close to the insertion of connection to a chest-tube. Model: To simulate dependent loops observed in hospital patients, we created 21, 35, and 58cm-high dependent loops (distance between the bottom of loop and the highest-point en-route to the drainage box). Th e pressure close to the (blind-ending) chest-tube was measured as the drainage tube was fi lled in 5ml. increments. Fitted linear regression of pressure and loop-height was performed. Clinical trials #1. Pressure within the drainage tube was measured in six ICU patients with thoracostomy tubes in place following CABG surgery. Clinical trial #2: We performed early-morning hospital ICU bedside bladder-scan US on 20 patients with an indwelling urinary catheter and clear urine, to assess for un-drained residual urine.

Results: With an empty dependent loop, thoracostomy tube pressure equaled the suction pressure (-20cm H2O). Pooled of fl uid within the dependent loop diminished proximal negative pressure (p<0.0001) in a volume (i.e. loop-height) dependent fashion. Th e net range of proximal drainage tube pressure ranged from -20 to +35cmH2O. In ICU Patients, an identical relationship between loops and chest-tube pressure was observed. Bladder scan of catheterized ward patients revealed high urine residuals (mean 142 ml) with a dependent loop present, and ~zero residual when no loop present.

Conclusions: Th oracostomy-tube negative-pressure is steadily diminished as a dependent loop fi lls with fl uid. Th e resulting air-lock opposes antegrade drainage. Th e weight of the fl uid column accounts for positive thoracic pressures, and could account for why many patients fail water seal trials. Similarly, urinary tubing dependent-loops result in air-locks that prevent gravity dependent drainage. Th oracostomy and urinary drainage tubing should always be positioned without dependent loops.

Single incision mid-urethral sling (MiniarcTM) and tension-free vaginal tape (TVT) procedure in women with stress urinary incontinence (SUI) at 12 months.

A total 187 women with SUI were randomized to receive Miniarc and TVT. Th e primary outcomes were objective and subjective cure rates at a 12-month follow-up visit. Objective and subjective cure of SUI were defi ned as a negative cough stress test and absence of self-reported SUI symptoms. Cure rates of the two groups were compared at 12-month follow-up.

Results: A total of 158 (85%) of 187 women originally included in the study (MiniArc: 87, TVT: 71) were evaluated at 12-month follow-up. Th ere were no signifi cant diff erences found in demographic and clinical preoperative parameters. Objective cure rates for MiniArc and TVT groups were 90% and 94% while subjective cure rates were 84% and 89%. Th ere was no statistically signifi cant diff erence between groups (p>0.05).

Conclusions: Our 12-month randomized clinical trial showed that MiniArc single incision sling is not inferior to TVT procedure with respect to objective and subjective cures at 12-month follow-up.

Introduction and Objective: Male SUI is a debilitating and challenging problem to manage. Insertion of transobturator sling off ers less invasive treatment than AUS insertion. Published data demonstrate cure rates of 75% but are limited by short follow-up. Th e aim of our study was to report long-term outcomes for male transobturator slings for SUI with a mean 4 year (minimum 2 year) follow-up.

A single-centre retrospective audit of outcomes in 39 male patients who underwent transobturator sling insertion for SUI. Follow-up was conducted via telephone or in outpatient clinic. Incontinence was classifi ed as mild (≤2 pads/day), moderate (3-4 pads/day) or severe (≥5 pads/day). Classifications post-surgery were: cured -dry; improved -≤2 pads/day and ≥50% less pad use; failure -no change or worsened.

Results: In patients with mild/moderate incontinence, 20/31 patients (= 64.5%) were cured/improved with TOT. Success rates were poor in severely incontinent patients, regardless of radiotherapy history (25%; n=2). Of 22 'cured'/'improved' patients, 18 (81.8%) maintained that degree of continence for the duration of follow-up. One patient was lost to follow-up. Th ree patients reported a later decline in continence; 2 patients had had previous pelvic radiotherapy. One patient had progression of underlying prostate cancer.

Conclusion: Durable success rates of 64.5% are achievable in men with mild/moderate SUI who have not had pelvic radiotherapy. Pelvic radiotherapy may play a role in delayed failure of TOTs with 25% of patients with mild/moderate SUI who were initially cured/improved declining in the second or third year aft er surgery.

The Mesh Wallstent (UroLume) in the Treatment of Detrusor External Sphincter Dyssynergia in Men with Spinal Cord Injury

Dept. of Surgery, Div. of Urology, King Saud University Faculty of Medicine, Riyadh, Saudi Arabia Introduction and Objective: To evaluate the longterm effi cacy and safety of the UroLume stent for the treatment of detrusor sphincter dyssynergia (DSD) in spinal cord injured (SCI) patients.

Twenty-four spinal cord injured patients with neurogenic bladder and DSD associated with high detrusor pressures and incomplete emptying on pre-operative video-cystometrograms (VCMG) were retrospectively reviewed. Twenty-one patients had cervical level injury whilst 3 had a thoracic injury. Eleven patients were on clean intermittent catheterization (CIC) and 13 with indwelling Foley's catheter. All patients underwent Urolume stent insertion according to standardized protocol. Follow-up assessment included blood chemistry, ultrasound scan (upper tracts and residual urine) at one and three months aft er insertion, and a follow-up VCMG at six months. Residual urine volume, autonomic dysrefl exia, catheter need, and presence of bladder stones and hydronephrosis were compared before and aft er treatment. Post-operative patient and physician satisfaction, complications and re-obstruction rates were also analyzed. Paired t-test is used and p value <0.05 was taken as signifi cant.

Results: Th e twenty-four patients had a mean (range) follow-up of 4.1 (2.5-11) years. Th e mean age was 46

Introduction and Objective: At present, sacral neuromodulation (SNM) with InterStim® therapy is indicated for non obstructive urinary retention and overactive bladder, including urinary urge incontinence and signifi cant symptoms of urgency-frequency alone or in combination, in subjects who have failed or could not tolerate more conservative treatments and do not have any neurological disorder. Th ere are also reports of the use of InterStim® in the treatment of chronic pelvic pain and other conditions. We report our experience with the use of this device in patients with post-traumatic brain injury damage without anatomical anomalies and with severe urinary voiding dysfunction who had failed intensive medical and behavioral therapies.

Materials and Methods: From November 2013 to November 2014, 13 patients underwent InterStim® placement (9 male and 4 female). All had severe voiding dysfunction secondary to post-traumatic brain injury damage; ten of them had also defecatory disturbances (8 a chronic constipation and 2 fecal incontinence). Th e main goal was to evaluate the improvement of the urinary symptoms and the second goal the improvement of the intestinal symptoms. Success was defi ned as a ≥50% improvement in any of the two variables evaluated.

Results: With a mean follow-up of 10 months, 11/13 patients reported ≥50% improvement in their urinary voiding symptoms (85%), in these patients urinary frequency decreased from 17 to 6 episodes per day, mean voided volume increased from 159cc to 364cc, incontinence disappeared in 5 of 6 patients and urgency disappeared in all 11 patients. Of 10 patients with intestinal disturbances, 8 showed a signifi cant improvement (80%). One patient showed a Clavien III complication (seroma and partial dehiscence of the surgical wound managed with conservative surgical treatment).

Conclusion: SNM in post-traumatic brain injury patients is an eff ective and safe option for urinary and defecatory dysfunction when other conservative therapies have failed. To our knowledge the use of InterS-tim® in this scenario has not been reported previously. A larger series and a longer follow-up are needed to validate this indication.

Introduction and Objective: Th ere were some reports that in the patients who have stress incontinence (SUI) with detrusor underactivity, voiding symptoms aggravated aft er mid-urethral sling operation (MUS). We report our experiences of MUS cases on the patients who have SUI with detrusor underactivity. Conclusion: Urethral sphincter and bladder function worsen immediately aft er RARP and recover over time. Th e bladder storage function aft er RARP returns to almost the same level before RARP, the voiding function improves compared with the condition inserted into the rabbit bladder through the urethra and saline solution is infused using a disposable syringe into the bladder through the end cap. Conventional cystometry was performed and the intravesical pressure was measured by prototype intravesical pressure sensor at the same time. We also evaluated the biocompatibility of Ecofl ex® by checking changes in the levels of macrophages, macrophage migratory inhibitory factor, and infl ammatory cytokines in the bladder tissue and urine.

Cape Town, South Africa 35th CONGRESS OF THE SOCIÉTÉ INTERNATIONALE D'UROLOGIE -SIU 2015 ABSTRACT BOOK and urgency incontinence are signifi cantly detected LUTS in children with VUR

The 17-Gene Genomic Prostate Score Assay: Initial Commercial Experience of 4,000 Patients 35th CONGRESS OF THE SOCIÉTÉ INTERNATIONALE D'UROLOGIE -SIU 2015 ABSTRACT BOOK 35th CONGRESS OF THE SOCIÉTÉ INTERNATIONALE D'UROLOGIE -SIU 2015 ABSTRACT BOOK

Pelvic Strength Physiotherapy

Percutaneous Treatment of Bladder Stones in Children: 10-Year Experience; Is Blind Access Safe?

Extirpative Treatment of Upper Urinary Tract Urothelial Carcinoma: An 18-Year Comprehensive Review Paik L

Th e overall complication rate was 54%. No hydronephrosis were seen thought the follow-up period. Stricture rate was low, only one patient (4%) at one year, and none at 5 years had urethral stricture. 8 patients (33%) required re-stenting due to stent migration (7 patients, 29%), or stricture (1 patient, 4%), all of which happened during the fi rst year of surgery. 7 patients (29%) required alpha-blockers to control bladder neck dyssynergia post operatively. 2 stents (8%) were removed due to exacerbation of autonomic dysrefl exia symptoms (n =1); encrustation and stone formation (n =1). Overall, 88% of patients and 80% of physicians felt there was improvement in urination at 1 year. Conclusions: Th e treatment of detrusor sphincter dyssynergia in spinal cord injured patients with Urolome stent is safe and eff ective

Sacral Neuromodulation with InterStim® Therapy for Urinary Voiding Dysfunctions in Post-Traumatic Brain Injury Patients: A New Therapeutic Indication?

Hospital Pablo Tobon Uribe, Medellin, Colombia 35th CONGRESS OF THE SOCIÉTÉ INTERNATIONALE D'UROLOGIE -SIU 2015 ABSTRACT BOOK between pre-and post-operative Qmax

ABSTRACT BOOK before RARP; however, the urethral sphincter func

Male 6 (46.15%) 6 (60%) 0.68** 

Introduction and Objective: We evaluated the clinical eff ect of alternative fl utamide therapy for metastatic prostate cancer that relapsed aft er initial maximum androgen blockade (MAB), and investigated the relationship between the eff ectiveness of alternative fl utamide therapy and the eff ectiveness of initial MAB.

and December 2012, 87patients with metastatic prostate cancer that relapsed aft er initial surgical or medical castration along with bicalutamide for MAB were treated with fl utamide therapy (375 mg daily). Importantly, patients who had discontinued bicalutamide because of adverse events were excluded.Results: Of the 87 patients treated with alternative fl utamide therapy, prostate-specifi c antigen (PSA) levels decreased by >90% (Group A) in 18 patients (21%), by 50-90% (Group B) in 15 patients (17%), and by 0-50% (Group C) in 18 patients (21%), but increased by >0% in 36 patients (41%). Th e median duration of response was 22.5, 8.5, and 3.5 months for Groups A, B and C, respectively. Th e duration of response for 15 patients (17%) was more than 12 months. Aft er alternative fl utamide therapy, decreased PSA levels of >50% were achieved in 11 of 25 patients (44%) with MAB nadir PSA levels of <0.2 ng/ mL, in 14 of 37 patients (38%) with MAB nadir PSA levels of 0.2 to 4 ng/mL, and in 8 of 25 patients (32%) with MAB nadir PSA levels of >4 ng/mL. During the observation period there were no severe side eff ects.Conclusion: Approximately 60% of patients with metastatic prostate cancer who relapsed aft er MAB with bicalutamide achieved a decrease in their PSA level with no severe side eff ects. Th e nadir PSA level during MAB, however, was not a predictor for the eff ectiveness of alternative fl utamide therapy. Th us, alternative fl utamide therapy is a reasonable treatment option for metastatic castration resistant prostate cancer. Nevertheless, changing to another therapy should be considered in patients who achieve decreases in PSA levels of <50% with alternative fl utamide therapy, as the duration of response was relatively short in these patients.

Association of Renal Function and Androgen Deprivation Therapy with Prostate CancerMasuda H, Kanesaka M, Sugiura M, Hou K, Araki K, Kojima S, Naya Y

Introduction and Objective: We evaluated the change of renal function by androgen deprivation therapy (ADT) and examined the association of the occurrence of renal dysfunction and concomitant diseases.

Between January 2009 and April 2013, 106 patients who could measure estimated glomerular fi ltration rate (eGFR) at pretreatment, 1, 3 and 6 months were evaluated retrospectively. All of them were diagnosed prostate cancer by prostate biopsy pathologically and had taken ADT for at least 6 months. We assessed the renal function of 106 prostate cancer patients by using the eGFR and investigated the time-independent change rate of the eGFR (ΔeGFR) aft er ADT. Th e ΔeGFR was calculated by (post treatment eGFR-pretreatment eGFR)/pretreatment eGFR ×100). Univariate and multivariate logistic analyses were carried out to identify clinical covariates signifi cantly associated with the risk factors for renal dysfunction at 6 months later.Results: Th e incidence of the renal dysfunction at 6 months was 63% (67/106). Th e mean ΔeGFR at 1, 3, 6 months were -0.9%, -3.3% and -2.2%, respectively (P=0.0678). Th e incidence of the renal dysfunction at 6 months was signifi cantly associated with the renal dysfunction at 1 month (P<0.0001), at 3 months (P<0.0001), hypertension (P=0.0017) and dyslipidemia (P=0.0288). Th e renal dysfunction at pretreatment with ADT did not aff ect the renal function 6 months later (P=0.3577). Th e renal dysfunction at 1 months (odds ratio [OR] 7.05, P=0.0004), renal dysfunction at 3 months ([OR] 6.71, P=0.0001), hypertension ([OR] 3.49, P=0.0151) and hyperlipidemia ([OR] 5.85, P=0.0246) were independent predictors of the renal dysfunction at 6 months in the multivariate analysis.Conclusions: It was suggested that the renal dysfunction with ADT occurred relatively early. Th e earlier renal dysfunction may cause the renal dysfunction at 6 months later. So, when the treatment of ADT began, it was thought that an examination of periodical renal function was necessary. Th e present results suggested that it was necessary to control the blood pressure and lipid for receiving ADT with prostate cancer.

Immune (PC) and isolated lymph node metastases aft er curative therapy are usually treated with an anti-androgen therapy. Th e choline PET-CT is the method of choice in diagnostic of the recurrent PSA. Controver-sial in the latest debate is the oncological eff ectiveness of the local salvage therapy of isolated lymph node metastases. Th e aim of this study is to compare the oncologic outcome of the salvage lymphadenectomy (LA) alone versus the LA in combination with adjuvant radiotherapy (AR) and androgen deprivation therapy (ADT).Materials and Methods: Th erefore we randomized 86 patients with biochemical recurrence of a PC (PSA: ≥0,2ng/ml) aft er curative local therapy and detection of at least one lymph node metastasis. We applied two treatment arms. A (n=46): single LA; B (n=40): LA plus AR/ADT (bicalutamide) over 2 years. We determined the biochemical recurrence-free survival (BFS) and the time-to-treat (TtT) until complete androgen blockade. Conclusion: Compared for both treatment arms, the combination of LA plus ADT/AR is superior to LA alone. However, both methods are to be seen as individual decisions in highly selected patients. Th e oncological long-term eff ectiveness is questionable.

Stem Cell Transformation of Prostatic Cells after Hormonal Therapy 

We reviewed 16 consecutive patients who underwent transperineal MRI-TRUS fusion target biopsy followed by conventional transrectal systematic 12 core biopsy between July 2014 and Mar 2015 in our institution. In all patients, T2 low region was detected by prostate MRI image and target biopsy was conducted for region of interest (ROI) of the MRI image utilizing BioJet system. Baseline characteristics and pathological outcome were analyzed.Results: In analyzed cohort, mean age was 68.4±9.1 years, median initial PSA was 7.6 ng/mL (range, 4.2-18.6), median prostate volume (PV) was 33.2 mL (range, 17.5-92.2) , and median volume of ROI was 1.11 mL (range 0.16-2.41). Of 16 patients, prostate cancer was detected in 9 (56%) patients by target biopsy and 8 (50%) patients by systematic biopsy. Patients with positive biopsy was likely to be higher PSA than men with negative biopsy (P= 0.039). Median ROI/PV was not signifi cant between them (2.35 vs. 2.51: positive vs. negative, P=0.491). Cancer detection rates per core between target and systematic biopsy were 49.9 and 22.2 %, respectively (P=0.012).Regarding pathological results, mean Gleason score of target biopsy was 2.8 compared with 2.1 of systematic biopsy, although which is not statistically signifi cant (P=0.158).Conclusion: MRI-TRUS fusion target biopsy is gradually spreading in Japan, since its higher cancer detection rate compared with conventional systematic biopsy. In our institution, substantial detection ability of prostate cancer by MRI-TRUS fusion target biopsy was confi rmed, which encouraged future clinical trial for prostate focal therapy.

Multiparametric Introduction and Objective: Sepsis has always been a concern in the traditional transrectal ultrasound (TRUS) guided biopsy of the prostate. However, rates of sepsis following TRUS biopsy have shown to be increasing around the world in addition to the emergence of multiresistant organisms found in rec-tal fl ora. As a result, our practice of seven Urologists has switched to transperineal (TP) biopsy. We aim to determine the rate of hospital re-admission in our patients undergoing TP biopsy.

An ethics approved prospective database of all men undergoing TP biopsy at our practice has been kept including antibiotics used as well as re-admission for infection. Introduction and Objective: Robot-assisted radical prostatectomy (RARP) has become one of standard treatments for localized prostate cancer. However, a feasibility of RARP in elderly patients has not been clear yet. We performed a comparative analysis of peri-surgical / oncological outcomes for younger and elder patients underwent RARP.

We reviewed and compared our initial 280 consecutive patients who underwent RARP from 9/2012 to 3/2015 for peri-surgical outcomes, including surgical times, blood loss, complications, pathological fi ndings, continence recovery, and oncological outcomes stratifi ed by age less than 70 and over 70 years.Results: In our cohort, 173 men were age less than 70 and 107 men were ≥70. Preoperative parameters (age, PSA, Gleason score) were similar in both younger and elder groups. Operative time (mean: 167 vs. 171 minutes) and estimated blood loss were similar in both groups. One of elder patients (0.9%) needed transfusion. Peri/post-operative complications in both groups appeared to be minimal with no cases of intra-operative open conversion. One of younger patients needed a surgical settlement for port site herniation. Surgical positive margin rates in organ-confi ned (pT2) disease were also similar (7.6%, younger vs. 9.0%, elder). Continence at 3 months was 80% in elder patients as opposed to 87% in younger patients. Biochemical recurrences in short follow-up period (median 14 vs. 13 months) were observed 5.6% in elder patients as opposed 6.4% in younger patients.Conclusions: In our study, although urinary continence recovery in elderly patients might show a short delay, RARP in elderly patients was relatively safe and yielded good oncologic results. RARP is feasible eve in elderly patients.

Quality 

In the fi rst study, community-based urologists ordering at least 4 assays from 5/2013 to 1/2014 participated. Clinicopathologic data, the GPS and treatment were abstracted from medical records of GPS patients and a clinically similar baseline group. Th e proportion of men recommended and pursuing active surveillance (AS) before and aft er the availability of the GPS were computed. In the second prospective study, urologists at 3 centers (academic and community) recorded TR on pre-and post-GPS questionnaires, including changes in treatment intensity.Results: Fift een urologists completed the chart review study on 211 men (124 GPS; 87 baseline). Th e relative increase in TR for AS was 22%, (51% baseline, 61% GPS; absolute diff erence of 10%). GPS pts chose AS more than baseline pts (67% GPS; 43% baseline, absolute increase of 24%, relative increase of 56%). Of men recommended AS, 96% of GPS and 80% of baseline pts chose it. In 158 men in the prospective study, the relative increase in recommendation for AS was 24% and absolute TR increase for AS was also 10% (41% to 51%). 18% of TR changed post-GPS and TR modality and/or intensity occurred in 26% of men (25 decreased; 14 increased; 2 equivocal).Conclusions: Both studies, conducted with diff erent methodologies, demonstrate that use of GPS provides meaningful change in TR and decisions in men with newly diagnosed PCa and results in a net increase in recommendation and/or adoption of AS. In the chart review study, TR changes appear to underestimate changes in actual treatment received and more GPS patients than baseline patients were assigned to AS supporting the clinical utility of GPS in the initial assessment and management of men with low risk PCa.

Comparison We prospectively evaluated in patients with clinically localized prostate cancer, the possible association between HCE (≥5.0mmol/l) and aggressive prostate cancer.

Pre-operative serum cholesterol levels (CH), triglycerides (TR), were prospectively assessed in 767 men treated consecutively with radical prostatectomy from Feb. 2011 to Oct. 2014. Th e results were related to patient specifi c and clinico-pathologic data.Results: Patients with HCE (n=287) had a more aggressive grade Gleason score (GS) ≥7b, p<0.001)), a locally more advanced stage (≥pT3a, p<0.001), and lymph node metastasis (N+, p<0.001). HCE was also associated more frequent with a positive surgical resection margin (R1, p<0.001). In multivariate regression analysis HCE is associated with a high-risk PC (HR 13.26, 95% CI 8.23 to 21.37, p < 0.001) -adjusted for PSA, DRE, age and poor biopsy score (GS ≥8).Conclusion: Th e results indicate that HCA is associated with high-grade and metastatic disease in men diagnosed with clinically localized PC. Our fi ndings suggest that CH can be used as an additional predictive marker in therapy. Conclusion: Th e incidence of BS-positive tumours is low in men being staged for radical treatment except in high-risk disease. Pelvic/prostate mpMRI alone cannot be relied upon to exclude bone metastases in this group.

Hyperbaric Oxygen Therapy for Radiation Induced Side-Effects

Introduction and Objective: To evaluate the effi cacy of Hyperbaric Oxygen (HBO) Th erapy for prostate Conclusions: In our Japanese provincial hospital, the comparatively young patients chose a treatment according to treatment algorithm. However, according to aging, the patients tended to choose hormonal therapy regardless of algorithm. As for one of the reasons, it is thought as follows: Even if the patients chose operation or radiotherapy, it may be diffi cult to visit the institutions that have such a treatment because public transport does not develop in our prefecture.

Nurse-Led Telephone Follow-Up for Prostate Cancer SurveillanceTurner B, Tanabalan C, Nargund V, Pati J, Wells P

Introduction and Objective: We review the patients' experience of a nurse-led, telephone follow-up service for men with 'stable' prostate cancer, to measure satisfaction and quality. Th e telephone follow-up service is based on the premise that PSA measurement can be used as a surrogate for outpatient attendance. Telephone follow-up service serves to reduce the number of patients attending hospital appointments. Th is has led to increased clinic capacity and reduced waiting times, ensuring urgent care is available for patients who need it.

A nurse-led, protocol based telephone follow-up service was set up for patients deemed to have 'stable' disease. Questionnaires were sent to all patients. Survey was voluntary and anonymous. We addressed a variety of aspects of the service, including time, duration and content of the telephone appointments, patients' preference for type of follow-up (telephone vs. hospital follow-up) and overall satisfaction with the service.Results: Response rate of 73%. Reported high satisfaction with telephone follow-up (90% were either satisfi ed or very satisfi ed). Majority of patients found the length of the conversations to be 'just right' (93%) with a lesser majority expressing that the calls were always at times convenient to them (78%) and that they were always called when they were told they would be called (74%). Patients felt that the information given to them over the phone was always easy enough to understand (89%) and the majority felt that they always had the opportunity to ask questions during the conversations (81%). When asked whether they would prefer telephone follow-up or hospital follow-up, 79% of respondents reported that they would prefer telephone follow-up, citing convenience, time and privacy as the reasons for their preference. Twenty-one percent of patients would prefer hospital follow-up, reporting ease of understanding, not liking the telephone and preference for face to face contact.Conclusions: Telephone follow-up relieves pressure on the Outpatient Department, increases capacity, reduces waiting times and brings care closer to home. Patients perceive the service as a valuable addition to their care and report high levels of satisfaction with the service.

Prostate ' Th e target sample sizes of Australasian trials 'currently recruiting' ranged from 18 to 5000 men (median=380), the majority of trials investigating medical and radiation oncological interventions. Five of the trials 'currently recruiting' were recorded as single-centre studies in New South Wales, Victoria and Queensland. Of the remaining 11 trials, 82% (n=9) were recorded as international, industry sponsored, multi-centre studies with Australian and/ or New Zealand recruitment sites.Conclusion: Australasian prostate cancer clinical trial activity (though likely under-recognised in this study, due to trial registration limitations) represents a relatively small fraction of international eff ort. Continued investment will ensure that the talented and world-leading scientists and medical professionals across both nations can tackle the big challenges in prostate cancer through working collaboratively.

Assessment 

Modifi ed Laparoscopic Intravesical Nonrefl uxing Ureteral Reimplantation with Psoas Hitch Using a Submucosal Tunneling

Introduction and Objective: We aimed to study the safety and effi cacy of the cystoscopy-assisted nonrefl uxing ureteral reimplantation technique using sub-mucosal tunneling during laparoscopic ureteroneocystostomy (UNC) with a psoas hitch in patients with distal ureter stricture aft er gynecologic surgery.

We reviewed six female patients who underwent gynecological surgeries. All patients showed persistent postoperative distal ureter stricture or obstruction. Th ese patients underwent laparoscopic nonrefl uxing UNC with a psoas hitch using a submucosal tunneling technique combined with cystoscopy at our institute.Results: Th ey had corrective surgery at an average of 13.3 weeks aft er ureteral injury. Th e short-term success was confi rmed either by voiding cystourethrography (VCU) or by diuretic isotope renal scan (MAG-3) conducted 3 months aft er the operation. None of the patients showed evidence of postoperative stricture at the reimplanted site and refl ux on either MAG-3 renal scan or VCU. None of the patients showed major or minor complications during follow-up.

It is safe and feasible to perform the laparoscopic nonrefl uxing UNC with a psoas hitch using a submucosal tunneling technique combined with cystoscopy for ureteral stricture. Upper ureteral injuries were more frequent in the urological surgery group than in the non-urological surgery group (50% vs. 9.5%). Complications or serious injuries were more frequent in the urological surgery group. Th ere were no signifi cant diff erences in the mean durations of hospitalization and indwelling times between the groups.

Conclusion: Th e occurrence of a ureteral injury during urological surgery is an infrequent but serious complication may occur. Urologists should pay attention to the potential for ureteral injury, especially during a ureteroscopic ureterolithotomy for the treatment of an upper ureter stone.

Reducing the Risks of Trauma Due to Urethral Catheterisation Mundy A, Yim I, Tamini A, Roberts N

Conclusion: Isolated ureteric trauma can be managed successfully using minimally invasive endoscopic and radiological approach. A PCN initially helps in minimizing extravasation and ureteral wall edema subsequently facilitating stent placement.

Medium-and Long- University of Sydney, Sydney, Australia Introduction and Objective: Urethral stricture is a common urological presentation for obstructive lower urinary tract symptoms. Th e treatment of choice for a durable outcome is usually substitution urethroplasty using buccal mucosal graft . Graft failure is not uncommonly encountered. We present the mediumand long-term outcomes of ventral buccal mucosal graft urethroplasty using spongio fl ap technique.

A retrospective review of a single surgeons experience was reviewed for a period of 17 years. Data was collected from medical records, surgeon's notes and operation reports. Inclusion criteria included reconstruction of anterior urethral stricture using BM graft positioned ventrally and graft support using spongio fl ap technique. Patients who were lost to follow-up were excluded from analysis. Graft patency was defi ned as having a lumen greater than 17 Fr. Th is was assessed via cystoscopic examinations at 3, 9 and 18 months intervals post procedure.Results: A total of 296 male patients identifi ed with age ranging from 15 to 79 years and mean age of 46 years. Average length of BM graft used was 4.4cm. Total of 271(92%) achieved long-term successful outcome. Of these 262 (88.5%) patients had successful outcomes with no further interventions, and 9 (3.5%) required gentle urethral dilatation at fi rst cystoscopy and subsequently achieved long-term patency. Sixteen (5.5%) of this cohort formed recurrent stricture at initial cystoscopy, and 9 (3.5%) of patients formed urethral stricture formed delayed stricture, despite the initial cystoscopic examination and urethral dilatation.Conclusion: Ventral Buccal Mucosal Graft Urethroplasty using spongio fl ap technique has very good short-term and long-term graft patency outcomes.

Outcome of Paediatric Kidney Transplantation: Single Center Experience Nawaz G, Jamil I, Athar Khawaja M, Muhammad S, Shohab D, Ur Rehman A, Ali Khan I, Khan A, Hussain I, Akhter S

Introduction and Objective: Renal transplantation is the treatment of choice for children with end-stage renal disease (ESRD) because in addition to making them off dialysis it also improves growth and development of the child. About 15-25% of children have a lower urinary tract dysfunction due to congenital or acquired genitourinary anomaly as the etiology of ESRD and they need a diversion or augmentation procedure prior to transplantation. We aim to deter-mine the outcome of paediatric renal transplant at 1 year in term of graft survival and complications.

We retrospectively reviewed the record of 35 consecutive children underwent living related renal transplant between Jan 2002 to Jan 2014. All were primary renal transplants and had living related renal donors. Patient characteristics, causes of ESRD and pre transplant surgical procedure were recorded. Patients with lower tract abnormalities as cause of renal failure underwent reconstructive procedure prior to transplant. Induction immunosuppression consisted of triple therapy with antithymocytic globulin (ATG), prednisone and mycophenolate mofetil (MMF). Cyclosporine was introduced when creatinine came down to >50% of normal. All patients were treated as CMV positive with either acyclovir or ganciclovir and received daily dose of trimethoprim-sulfamethoxazole as prophylaxis for pneumocystis carnii pneumonia aft er transplantation. Post transplant surgical and medical complication, graft and patient survival were recorded.Conclusion: Ureteric implantation into the bowel portion of augmented bladders appears safe in this population of patients with previously reported increased risk of ureteric complications and urinary tract infections aft er transplantation.

Transition of Cavernous Function after Radical Prostatectomy Materials and Methods: Study subjects were 33 ED patients with a history of RP (median age: 67). Intervals between RP and examination diff ered among patients (range: 1 to 92 months). We also performed Doppler penile ultrasound examination using intracavernous injection of 20 micrograms of prostaglandin E1. We adopted an infusion rate of less than 20 ml/min at 90 mmHg of intracavernous pressure as the normal cavernous function limit for DICC.Results: Arterial velocity in ultrasonic examinations showed a tendency to decrease. Cavernous function aft er RP clearly diff erentiated according to phospho-diesterase 5 inhibitors (PDE5Is) response ( Figure 1 ). In the PDE5Is responder patient group (7 cases), the rate of normal cavernous function was 0% at 1 month, 4 months, and 6 months, but the rate increased to 50% at 9 months, and 100% at 12 months. A diff erent transition was seen in the PDE5Is non-responder patient group (26 cases). In this group, the rate of normal cavernous function was also 0% at 1 month. However, from here, the rate increased to 67% at 6 months, and then aft er this point, it decreased to 17% at 12 months. 

Sixteen 12-week-old Sprague-Dawley rats were induced Diabetes by a onetime intraperitoneal injection of streptozocin (50 mg/ kg). One week later, the diabetic rats were randomly divided into 4 groups including a normal control, DM control and two UU treated group (100, and 500 mg/kg/d). Th e latter 8 rats were fed UU by intragastric administration for 8 weeks. Aft er 8 weeks, penile hemodynamic function was evaluated by measuring the intracavernosal pressure aft er electrostimulating cavernous nerve. We measured nitric oxide (NO) and cyclic guanosine monophosphate (cGMP) activity. Endothelial nitric oxide synthase (eNOS) and neuronal NOS (nNOS) protein expression was determined by Western blot. Masson's trichrome staining was also assessed.Results: Serum glucose level in DM +UU group was signifi cant lower than in that of the DM control groups. Maximum intracavernosal pressure in DM control rats decreased signifi cantly compared to normal control rats and increased signifi cantly compared to untreated DM rats aft er UU supplementation. DM + UU500 group had signifi cantly increased NO and cGMP level compared with the DM control group. Decreased activity and expression eNOS and nNOS were found in the DM groups compare with normal control group. Decreased eNOS and nNOS in diabetic rats were improved by UU administration. Decreased the cavernous smooth muscle to collagen ratio was improved in DM + UU groups in the Masson's trichrome staining.Conclusions: UU eff ectively ameliorated erectile function in a streptozocin induced diabetic rat model of erectile dysfunction.

You D 1 , Jung S 1 , Jang M 2 , Kim B 1 , Lee C 1 , Song G 1 , Choi K 3 , Shin H 3 , Suh N 4 , Kim Y 3 , Ahn T 1 , Kim C 1 the etiology and management of erectile dysfunction (ED) in patients with metabolic syndrome (MS).

Eighty-six patients suff ering from erectile dysfunction and metabolic syndrome were included in the study, patients were classifi ed based on IIEF-5 domain into three groups: Mild ED (n= 21), Moderate ED (n=46) and Severe ED (n=19). Th ese patients were treated using upgraded regimen protocol (changing of the life style for 3 months, on demand use of PDE-5 inhibitors for 4 months, chronic dosing with long acting PDE-5 inhibitors for 4 months and combination therapy of PDE-5 inhibitors and intracavernosal injection for 4 months) re-evaluation of the patients was done at the end of each stage by (IIEF-EF, Waist circumference and Laboratory Investigations).Results: Aft er 3 months of lifestyle modifi cation there was increase in the IIEF-EF but this change was not signifi cant the overall improvement was (30%), Aft er on demand PDE-5 inhibitors for 4 months(76.4%) of patients with mild ED were improved, (60%) with moderate ED and (46.1%) with severe ED were improved. Non-improved patients in each group aft er on demand PDE-5 inhibitors received PDE-5 inhibitors chronic dosing for another 4 months then re-evaluated (55.5%) of patients with mild ED were improved, (38.8%) with moderate ED and (28.5%) with severe ED were improved, Combination therapy in the form of tadalafi l 10 mg daily and PGE1 10μg on demand were off ered to patient whom reported failure of PDE-5 inhibitors chronic dosing Patients with mild symptoms reported the maximum improvement (50%), patients with moderate symptoms reported fair improvement (18.2%); however patient with severe symptoms reported no improvement at all.Conclusion: PDE5 inhibitors should be considered as the fi rst line phamaco-therapy in treatment of ED in metabolic syndrome patients. Non-responders to PDE5 inhibitors may have a benefi t from daily dosing of long acting PDE-5 inhibitors. Combination therapy of PDE-5 inhibitors chronic dosing associated with intracavernosal injection of PGE1 may play a role as a salvage therapy aft er failure of monotherapy. Following this upgraded regimen case with MS and ED can have overall successful results in 78.7%.

Comorbidity of Premature Ejaculation and Erectile Dysfunction: Are They Inseparable in Chinese Adult Men?Tang Y, Yang J, Jiang X

Introduction and Objective: Premature ejaculation (PE) and erectile dysfunction (ED) are usually regarded as a symbol of incompetence. But in China for the inconsistent defi nitions of PE, some of them cannot correctly distinguish PE from ED. Th erefore, to fi nd out the real relationship between PE and ED, a detailed investigation was implemented. were enrolled. All the subjects were evaluated by the face-to-face questionnaires of Premature Ejaculation Diagnostic Tool (PEDT) and the International Index of Erectile Function (IIEF-5). A professional urologist was invited to measure their lengths of penis and volumes of testes. All the data were analyzed by SPSS version 13.0 soft ware.Results: A total of 1782 men aged from 18 to 70 years (30.99 ± 6.60) were categorized into lifelong PE (LPE) (244 men), acquired premature ejaculation (APE) (440 men), variable PE (VPE) (727 men) and subjective PE (SPE) (371 men), respectively. Th ere was no signifi cant diff erence among the four PE subtypes except for the IELTs and the IIEF-5. Th e self-estimated IELT of SPE was signifi cant longer than that of other subtypes, and the similar case could be seen in IIEF-5. Th e highest percentage was found in APE (55.68%) for chronic prostatitis (CP) and in LPE (96.72%) for ED.Conclusion: VPE was the most common subtype, next APE, thirdly SPE and the least one is LPE. Consistent with the previous reports, we found that the incidence of CP in APE was the highest among all the four subtypes of PE, and CP was a signifi cant risk factor of APE but not for other subtypes. Th ere has always been controversial about the relationship between PE and ED. Th e results from our multinomial logistic regression analysis showed that ED was not only associated with PE, but also could be regarded as a risk factor of PE. Introduction and Objective: Depression oft en overlapped with late-onset hypogonadism (LOH) syndrome. Clinically, many LOH patients who have depressive symptom were treated with testosterone replacement therapy (TRT). However, treatment efficacy of TRT for these patients is unclear. In this study, we aimed to identify characteristics of LOH patients on TRT who had medical history of ongoing mental health treatment for depression syndrome.

We reviewed 190 consecutive patients who visited men's health clinic and underwent TRT in our institution during June 2007 and December 2012. Prior to TRT, patients received a physical examination and full hormonal evaluation including free testosterone (fT), lutenzing hormone (LH), and follicle-stimulating hormone (FSH). Th e Aging Males' Symptoms (AMS) score was also evaluated. TRT was conducted by 125mg monthly testosterone injection. Effi cacy of TRT was noted when diff erential of AMS score between pre-and post-treatment was more than 10 points.

In the entire cohort of 190 patients, the mean age was 56.6 ±10.6 years and pre-TRT AMS score was 49.5±13.7. Pre-TRT fT, LH, and FSH were 6.5 ± 2.1 ng/mL, 6.3 ± 5.9mIU/mL, and 11.9 ± 14.7mIU/mL, respectively. Of total 190 patients, 68 cases (35.8%) had diagnosis of depression by psychiatrist and ongoing mental health treatment. Patients with positive medical history of mental health treatment were found to be younger (53.8 vs. 58.1 years, P = 0.007), higher pre-TRT AMS score (56.8 vs. 44.9, P < 0.001), lower LH (5.1 vs. 7.0%, P = 0.022), and lower FSH (9.4 vs. 13.4%, P = 0.006) compared to patients with negative medical history of mental health treatment. Effi cacy of TRT was greater in men who have mental treatment history (66.7 vs. 38.2%, P = 0.002) based on AMS improvements. While, there were no signifi cant diff erence in fT (6.75 vs. 6.40 ng/mL, P = 0.328), TRT duration (498 vs. 557 days, P = 0.571), and TRT discontinuation rate (80.9 vs. 73.8%, P = 0.269) between two groups.Conclusion: Even though, LOH patients who had diagnosis of depression and underwent medical treatment such as antidepressant, TRT can be feasible approach for those patients. Majority of those LOH patients underwent mental health treatment at the same moment with TRT, which may not harm treatment effi cacy of TRT.

The Effect on Blood Flow Rate of Prostate in Daily Administration of Mirodenafi l 50mg for Benign Prostatic Hyperplasia Patients: Randomized Paroxetine is the most eff ective SSRIs. In few studies, tramadol has been used to treat PE. Considering the high incidence of PE in men and lack of consensus on its treatment, we decided to compare the therapeutic eff ects of tramadol, paroxetine and placebo in the treatment of primary PE.

In this randomized, double-blind, placebo-controlled clinical trial, 150 patients were randomly divided into 3 groups. One group was treated with tramadol 50 mg, the other group took paroxetine 20 mg and the third group was treated with placebo. Before starting treatment and aft er 12 weeks, patients were asked to measure their average intravaginal ejaculation latency time (IELT) and fi ll the PEP (Premature Ejaculation Profi le) questionnaire. Aft er collecting the data, they were recorded in SPSS version 19 and were analyzed.Results: Patients in the 3 groups in baseline characteristics, including mean age, IELT and PEP were similar at the beginning of the study and there was no clinically signifi cant diff erence in the 3 groups (P>0.05). A total of 126 patients completed the study period. At the end of the 12th week, the mean IELT and average of PEP scores increased in all 3 groups. Th ese changes in tramadol group were signifi cantly higher than the paroxetine and placebo groups (P<0.0001). Th ere were no signifi cant diff erences in terms of side eff ects between the 3 groups.

Th e results showed that despite an increase in mean IELT and PEP scores in all 3 groups, the rate of improvement in tramadol group was considerably more than the other groups. Th us, Tramadol may be considered as an appropriate alternative therapeutic for long-life PE.

The Effi cacy and Safety of Tadalafi l 5mg Once Daily for the Treatment of Erectile Dysfunction Related to the Vascular Causes after Robot-Assisted Radical Prostatectomy: 2-Year Follow-upDong-A University Hospital, Busan, South Korea; 2 Jeil Hospital, Ulsan, South Korea Introduction and Objective: To evaluate the effi cacy and safety of tadalafi l 5 mg once daily use in the treatment of erectile dysfunction (ED) based on the vascular cause aft er robot-assisted radical prostatectomy (RARP).

Th e study retrospectively evaluated 92 patients who underwent RARP and had a penile rehabilitation by tadalafi l 5mg once daily use at our medical center. Th e patients were surveyed based on the abridged fi ve-item version of the International Index of Erectile Function (IIEF-5) Questionnaire, which was self-administered before the surgery, and at 6 months, 1 year and 2 years aft er the surgery. Th e 92 patients were classifi ed into the tadalafi l group (n=47) and the non-tadalafi l group (n=45). Each group was then classifi ed depending on the nerve-sparing (NS) procedure: bilateral NS and unilateral NS. Additionally, patients who underwent a penile color-duplex U/S study to evaluate the cause of erectile dysfunction were also analysed.Results: At 6 months, 1 year, and 2 years, the total IIEF score of the tadalafi l group and that of the non-tadalafi l group were 10.0±3.4 vs. 7.0±4.0, 13.2±5.6 vs. 7.7±4.8, and 13.8±4.7 vs. 8.1±4.2, respectively. Statistically signifi cant improvements (P<0.05) were observed in the tadalafi l group for all 5 domains of IIEF-5 score, while in the non-tadalafi l group there was no signifi cant improvement in any of the domains at 1 and 2 years. Fift y three patients had a penile color-duplex U/S study. Arteriogenic and venogenic ED was seen in 31 patients (58.5%) and 7 patients (13.2%). Fift een patients (28.3%) showed unremarkable fi ndings. Venogenic ED patients had little response compared to arteriogeinc ED patients by tadalafi l 5mg once daily use (0% vs. 22.5%). Th e overall side eff ects were hot fl ushing in 8.5%, headache in 4.3%, and dizziness in 2.1%.

In ED patients aft er NS RALP, a once daily dosage of tadalafi l 5 mg was well tolerated and signifi cantly improved EF compared with the non-tadalafi l group until two years. But in the venogenic ED patients, response to a once daily dosage of tadalafi l 5 mg was relatively limited compared to the arteriogenic ED patients.

Effects of Long-Term Androgen Replacement Therapy on the Physical and Mental Statuses of Aging Males with Late-Onset Hypogonadism (EARTH): A Randomized Phase 3 Trial in Japan Introduction and Objective: To determine the role of stone density and skin-to-stone distance (SSD) by non-contrast computed tomography of the kidneys, ureters and bladder (CT-KUB) in predicting the success of extracorporeal shock wave lithotripsy (ESWL).

We evaluated 267 patients who received ESWL for renal and upper ureteric calculi measuring 5-20mm, over a 50 month period. Mean stone density in Hounsfi eld units (HU) and mean SSD in millimeters (mm) was determined on pre-treatment CT-KUB at the CT workstation. ESWL was successful if post-treatment residual stone fragments were ≤ 3 mm.Results: E5WL success was observed in 63.5% of the patients. Mean stone densities were 513 ± 163 and 795 ± 101 HU in E5WL successful and failure groups, respectively; this was statistically signifi cant (p < 0.001, student's t-test). Mean SSD were 11.2 ± 1.8 and 12.4 ± 2.2cm in ESWL successful and failure groups, respectively, this was not statistically signifi cant.Conclusions: Th is study shows that stone density can help in predicting the out-come of ESWL. We propose that stone densities <500 HU are highly likely to result in successful ESWL. Conversely, stone densities >800 HU are less likely to do 50. Th is should be accounted for when considering ESWL.

Assessment 

Th is prospective study was conducted upon 20 children with mean age 4.47 ± 2.17 years. Patients underwent retrograde intrarenal surgery (RIRS) under general anesthesia as monotherapy. Th e procedure was initially started by the semi-rigid ureteroscope (Storz 7.5 F) and holmium laser and was completed by the fl exible ureterorenoscope (fl ex X2) for other parts of the stone which were not accessible by the semi-rigid ureteroscope. Ureteral access sheath was not used and only hydrodilation was performed. Patients were evaluated preoperatively by ultrasound and plain X-ray of the abdomen and pelvis. Pre-intervention sterilization of urine was performed in all patients using culture guided antibiotics. Follow-up lasted for 3 months.Results: Stone-free rate aft er a single session treatment was 80% and 95% aft er second session. Mean operative time was 52.0 ± 16.50 minutes. Th e mean fl uoroscopy exposure time was 16.0 ± 6.20 seconds. Mean hospital stay was 1.25 ± 0.64 days. All patients had JJ stent inserted. No major complications (Clavien III-V) occurred. None of the children received blood transfusion. Th ree patients needed a second session of RIRS, 1 patient required a PNL session.Conclusions: Retrograde intra renal surgery using combined semi-rigid and fl exible ureteroscope off ers eff ective and safe option for treatment of medium sized renal stones children with comparable results to Shock Wave Lithotripsy (SWL) and Percutaneous Nephrolithotomy (PNL). Introduction and Objective: Calcium stones are associated with osteoporosis and manifested mainly by elevated fasting urinary calcium/creatinine ratio. Th e objective of this study is to demonstrate the presence of abnormal metabolism of calcium and calciuria in women with osteoporotic fracture with no previous-ly known renal lithiasis compared to women without osteoporosis and without renal lithiasis.

Eighty-seven women were included in the study and divided into two groups: Group 1: 55 postmenopausal women with osteoporotic fracture and without renal lithiasis; Group 2: 32 postmenopausal women without osteoporosis and without history of renal lithiasis. Th e following parameters of phospho-calcium metabolism were analyzed: calciuria 24 h, oxaluria 24 h, uricosuria 24 h and citraturia 24 h. Th e presence of hypercalciuria, hyperoxaluria, hyperuricosuria and hypocitraturia was compared between the two groups. Statistical signifi cance was determined as p≤0.05. Results: Th e mean age was 70.1 ± 13.8 years in Group 1 and 56.7 ± 6.4 years in Group 2 (p = 0.0001). Women in Group 1 had higher levels of serum alkaline phosphatise (p<0.05) and fasting urinary calcium/ creatinine ratio (p<0.05) than women in Group 2. Th e percentage of women with hypercalciuria in Group 1 (40%) was higher compared to women in Group 2 (18.8%) and statistically signifi cant (p = 0.04). Th ere were no statistically signifi cant diff erences in the percentage of hyperoxaluria, hyperuricosuria and hypocitraturia between the two groups. Th is paper has the limitations of cross sectional study in a unique center and with a low number of patients. Dept. of Urology, Ulster Hospital, Dundonald, UK Introduction and Objective: Bladder stones are more common found in children from developing countries. Open Cystolithotomy or transurethral cystolithalopaxy are the traditional treatment but a percutaneous approach has been advocated. We present our experience with percutaneous cystolithotomy in children with bladder stones without any ultrasonic or fl uoroscopic guidance.

From April 2001 to October 2011, a total of 147 children (135 boys and 12 girls) with a mean (range) age of 4.07 (1-12.5) years underwent percutaneous cystolithotripsy (PCCL). Th e mean (range) stone diameter was 2.74 (0.8-5) cm. One hundred thirty-eight children (94%) had a solitary stone while nine (6%) had more than one stone. Th e main component of the stones were calcium oxalate in 70 patients (48.6%).Results: All children were stone-free aft er one PCCL; no recurrent stones developed. Th e mean (range) PCCL procedure time was 29.6 (12 to 48) min and intraoperative blood loss was scant. Perioperative complications were few. Th e mean (range) hospital stay was1.2 (1-3) days.Conclusions: Blind access PCCL (without any ultrasonic or fl uoroscopic guidance) is a facile and safe approach for removing stones in the pediatric bladder stones. Advantages include the lack of ionizing radiation, no need for opacifi cation by iodine contrast media and low relative cost. We recommend this minimally invasive technique for management of large bladder stones (larger than 1cm) in children. To our knowledge, this is the largest single center series re-ported on percutaneous cystolithotripsy of endemic bladder stones in children.

Retrograde Intrarenal Surgery (RIRS) in an Unusual Kidney (21), Polycystic kidney (10)]; who underwent RIRS for stone management was evaluated. Stone size was less than 20mm in all the cases. Bleeding being the commonest complication, Hemoglobin drop was measured to fi nd out the blood loss. All patients were assessed by X-ray and USG on the fi rst postoperative day and 1 month follow-up. Th e other parameter of focus was Operative time, Hospital Stay, Stone free rate and the auxiliary procedure. Th e auxiliary procedure was divided as (Staged, follow-up (1month) or other-PCNL/SWL) so that stone free was the main target for the patients. Conclusion: Urolithiasis occurs in an abnormal kidney, indeed challenging, but RIRS can also be performed successfully. Proper handling of Instrument can increase the longevity of the instrument for cost eff ectiveness. Although complete stone clearance cannot be achieved, but meritorious achievement is less morbidity, early recovery, minimal bleeding with less complication. Th us, RIRS can be performed effi ciently, effi caciously and successfully in an unusual kidney with prior exposure of RIRS.

Value of Intraoperative Ultrasound in Decreasing of the Risk of Residual Radiolucent Stone Post-PCNL Al Shareef J, Aboelmagd M

Introduction and Objective: Hemorrhage is the most concerning complication aft er tubeless percutaneous nephrolithotomy (PCNL). We compressed the access tract of the kidney with oxidized regenerated cellulose (Surgicele) aft er PCNL to facilitate homeostasis for tubeless PCNL.

Since April 2013 to September 2014, 162 PCNL was performed at our hospital. All patients received one stage procedure with metal dilator. Aft er the end of stone extraction, the access tract was cauterized and an 8 F Foley catheter was inserted to the renal pelvis through the working sheath then infl ated and gently retracted. Th e working sheath was withdrawn to the renal capsule and the access tract of the renal parenchyma was packed with Surgicele and compressed with small sized dilators through the working sheath for 5 minutes. A bloodless tract usually could be obtained in nearly every patient and all patients underwent tubeless modifi cation. Th e results of these patients were analyzed with retrospective chart review.Results: Th e age of these 162 patients ranged from 26 to 82 (mean 56.1) years old. Th e average stone size was 3.7 (0.9-10.5) cm and the average operation time was 80.1 (30-200) minutes. Th e target stones had been removed in all patients and the overall stone free rate was 69.1%. Th e postoperative blood transfusion rate was 3.1% with no patient underwent angiographic intervention or other management for severe hemorrhage. Postoperative fever was noted in 14.2 % patients and sepsis was noted in 1.2% patients. Th is study was designed to evaluate the adverse eff ects of SWL on the metal devices for spine fi xation and the hemoclips for hemostasis.

A total of 7 cases who underwent SWL for treatment of upper ureteral and renal stones were investigated. Th eir ages were from 56~71years (mean 63.4±5.8838). Male patient was one and female patients were 6. Th e Piezolith 3000 (Wolf, Germany) was used as the lithotripter. Th e metal devices were hemoclips for cholecystectomy in one, and pedicle screw in fi ve patients and bone cement (polymethylmethacrylate) in one patient for spinal fi xation through L1 to S1. Th e locations of the stones were the kidneys in 3 and the upper ureter in 4 patients and their sizes were from 0.6cm to 1.2cm (mean, 0.95±0.2572) . Th e numbers of the SWL were 2.0~17.0 times (Median, 2) . Th e distances between the stones and metal devices were 3.0~5.5cm (Mean, 4.5±0.9962). Th ey were followed-up for 0.0~15.0 months (5.4±6.5219). Th e complications were investigated in terms of pain, fever, damage of the devices (change of morphology and location in simple X-ray fi lm and their function).

No patient showed fever and pain in sites of the devices requiring medication, injection or other management during or aft er SWL. One patient was admitted for acute colick fl ank pain with tenderness in costovertebral angle caused by acute ureteral obstruction by a crumbled small piece of the stone. Th ere was no complication concerning with the eff ect of the SWL on metal devices.

Even though SWL is one of the safe treatment modality in various clinical fi elds, it can't be said that SWL is always safe without complication. However, it can be said that it would be safe when it being done following the instruction.

A Prospective Study to Identify Risk Factors of Pleural Injury during Percutaneous Nephrolithotomy 

A total of 332 patients with renal/upper ureteric stones, undergoing PCNL between January 2013 and June 2014 were evaluated for pleural injury. An erect chest x-ray antero-posterior view on inspiration was done within 6-hours of PCNL. Th e patients were divided into Groups A and B depending on whether they developed or did not develop pleural injury. Patient-, stone-, renal-and procedure-related factors were compared between the two groups. Patients with any known disease of lungs or pleura, patients undergoing simultaneous bilateral PCNL, relook nephroscopy, concomitant other procedures such as endo-pyelotomy or retrograde ureterorenoscopy were excluded from study. Tract dilatation up to 28-F was done using Alken metal dilators and an Amplatz sheath was placed into system. Nephroscopy was done with rigid nephroscope and stones were fragmented with pneumatic lithoclast.Results: Pleural complications occurred in 10 patients (3%). Out of 332 patients, 141 had supra-costal puncture and 6 (4.2%) developed pleural injury; 191 patients had infra-costal puncture and pleural injury occurred in 4 (2% On multivariate analysis, only low BMI and mean age <27-years was associated with higher risk of pleural injury. Th e limitation is the small number of patients (as pleural injury is not common a very large number is needed to show signifi cance).Conclusions: Higher incidence of pleural injury was noted in patients with low BMI and younger age. Large multicenter study can provide a true picture.

Flexible and Rigid Ureteroscopy in Th e success rate was defi ned as radiopacities less than 2 mm on plain fi lm at one month follow-up aft er the fl exible ureteronoscopic procedure. Our tips included: Tip 1, moving technique, refers to move the lower pole stones to the upper pole or middle pole depending on the convenient site for fragmenting the stones with the Escape basket. If the stones were large or the lower pole orifi ce is narrow, we fragmented the stones into two or more pieces, trapped and moved the stones into the convenient pole. Tip 2, Holding technique, refers to hold the stones in the renal pelvis and insert a laser fi ber through the Escape to fragment the stones. Tip 3, sheath technique, refers to extract the large stones and pull the stones to the sheath distal side, the stone was too large to pull out, a laser fi ber was inserted though the Escape, fragmented the stones. All the videos were recorded.Results: Overall success rate was 95.1%. Th e success rate in the renal pelvis stone, upper pole, middle pole and lower pole was 100%, 97.3%, 93.3%, 93.1% respectively. Th e operating time was 113.6 minutes on the average. Th ree patients had fever over 38°C aft er the procedures. No urosepsis occurred.Conclusion: Our tips are feasible in the treatment of kidney stones with fl exible ureteronoscopy. Satisfactory success rate, shortening operating time, less fl exible ureteronoscopy consuming and less complication were obtained in the procedures of fl exible ureteronoscopy with Escape.

Ureteroscopic Introduction and Objective: Patients with underlying diseases, especially in old-aged, the urinary tract obstruction with the ureter stone would progress to the severe condition like renal failure or sepsis. Prompt urinary diversion like percutaneous nephrostomy or removal of the stone via ureteroscope is necessary for these patients. However, most of them have poor general conditions to endure regional or general an-esthesia. So, we tried to implement the ureteroscopic removal of stone (URS) without anesthesia for the patients with ureter stone who were in septic conditions or severe urinary tract infections (UTI).

Fift een patients (2 males and 13 females) included this study and all of them had serious problems like sepsis, heart problems or lung problems which were diffi cult to endure anesthesia. Most of them were inserted pre-operative percutaneous nephrostomy catheter (PCN) due to impending septic shock. All of the stones were impacted in the ureter and URS were successfully performed with painkiller like pethidine 25mg IV. Success rate of stone removal, pain perception during operation using a visual analog pain scale were done. Results: Th e mean age of the patients was 71.8 (±10.84). Th e position of the stones was as follows; 6 upper ureter, 1 mid-ureter and 8 lower ureter stones. And there was no patient that had to stop the operation because of intolerable pain. Th e mean of VAS (visual analogue pain scale) was 3.2(±0.86). Overall success rate was 100%. However, 20% of cases were unable to fi nd the impacted calculi but stone debris and blood clots. Th e general condition of the patients except one was improved quickly aft er operation and discharged aft er 5.4 (±5.75) days.Conclusion: Most obstructive uropathy due to calculi was in serious conditions to need immediate procedures and URS were safely and successfully performed under intravenous analgesics. In some of female patients, URS is well-tolerated even without analgesics. Prompt URS procedure with intravenous analgesics can recover these conditions with minimal morbidity.

Geavlete P, Georgescu D, Multescu R, Geavlete B

Introduction and Objective: Percutaneous nephrolithotomy (PCNL) is nowadays a widely practiced procedure. Despite the good stone-free rates, it still has a specifi c morbidity. Our goal was to describe the complications of this method on a signifi cant series of patients.

Between January 2001 and January 2015, 3248 patients (age between 18 and 82 years) underwent PCNL (3546 procedures). We used 24F rigid nephroscopes and 15F fl exible ones (214 procedures). Th e mean follow-up period was 92 months (range 2 to 148 months).Results: Intraoperative incidents were encountered during 122 procedures (3.4%): losing the percutaneous traject (63 cases), poor visibility due to bleeding and imposing the termination of the procedure (41 cases) and descendant stone fragments' migration imposing antegrade ureteroscopic removal (26 cases). Th e overall complications' rate was 18% (638 cases): signifi cant bleeding requiring blood transfusions (83 cases), emobolisation (7 cases) nephrectomy (4 cases) or open surgical hemostasis (3 cases), sepsis (7 cases), fever (121 cases), pyelocaliceal perforations (38 cases), hemoperitoneum (1 case), persistent lumbar uri-nary fi stulae requiring retrograde JJ ureteral stenting (371 cases) and extra-renal stone fragments migration (3 cases). However, the majority of these complications were minor. Th e mortality rate related to PCNL procedures was 0%.Conclusion: According to our experience, PCNL is a safe and eff ective technique. Most of the intraoperative incidents or complications are minor and easy to solve. However, an adequate training is imperative in order to reduce the associated morbidity.

Is Spinal Anesthesia Adequate for Percutaneous Nephrolithotomy?

Introduction and Objective: To evaluate the adequacy of spinal anesthesia in terms of patient and surgeon satisfaction and convenience during percutaneous nephrolithotomy.

Patients who were candidates for percutaneous nephrolithotomy and operated by two endourology fellows during July -September 2014 were enrolled. Spinal anesthesia was performed using an injection of 0.25 mg/kg bupivacaine 0.5% in the intrathecal space; no opium (fentanyl) agent was used. All procedures were performed with the patient in the prone position. Access was achieved by fl uoroscopic guidance, and the tract was dilated using a single-stage technique. Anestheisa duration was defi ned from injection of anesthetic medication to fi xation of nephrostomy tube. Operation duration was defi ned from start of cystoscopy to fi xation of nephrostomy tube. Patient pain and satisfaction during operation and surgeon satisfaction was measured by an ordinal likert-type scale and collected by an examiner blinded to the study objectives.Results: A total of 50 patients (mean±SD age, 48.1±12.2 years; 29 male) were enrolled during the study period. Th e mean±SD of anesthesia and operation duration were 83.4±21.5 and 52.7±23.0 minutes respectively. Severe pain causing signifi cant discomfort to the patient and surgeon was observed in 6 patients (12%). In three patients the operation was prematurely terminated because of excessive pain and/ or agitation of the patient. Mild-moderate pain was observed in eight patients (16%). Vomiting and headache was observed in another two patients. 

The African 300: Our Experience of Stenting Ureters in Outpatients without Screening or GA

Introduction and Objective: To review 301 ureteric catheters/DJ stents placed under local anaesthetic, with antibiotic coverage, without the use of screening, at Groote Schuur Hospital (GSH) over the last 8 years.

A prospectively collected database exists from July 2007 until present. All patients signed informed consent and received pre-procedural oral antibiotics. A post-procedural abdominal KUB radiograph was obtained to ensure correct placement. Demographic data and variables (stent/catheter, indication, side, success/failure -including reasons for failure) were collected. Patients were asked to subjectively rate the level of pain at the end of the procedure.Th e data has been collected and tabulated into an Ex-cel® worksheet.Results: A total of 301 procedures (average 37.6 per year) were performed with age range from 14 to 94 years (average: 47.8 years). Th e average time taken was 15 minutes (median: 10 minutes). Th e shortest procedure recorded was 3 minutes, and longest was 60 minutes (with a failure). Th e failure rate totals 14.3% and further inspection shows that 9.3% of failures were with bilateral stents, 46.5% Right sided and 41.9% Left sided. Stated diff erently, 19% (4/21) of bilateral stents failed, 16.1% (20/124) of Right sided stents failed, and 12.2% (18/148) Left sided stents failed. Th ere was a success rate of 85.7% with stenting under local anaesthetic. Th e average subjective pain score was 3.9, which is tolerable. Sivalingam et al (2013, Urology 81: 498-502) showed the average cost for stenting under general anaesthetic was almost 4 times more expensive than under local. Th eir local group had a failure rate of 8.7%, which was lower than our 14.3%, but we had a larger group (300 in 8 years vs. 46 in 4 years).Conclusion: Flexible cystoscopy and stenting under local anaesthetic without screening is useful and feasible, with minimal morbidity, discomfort and failures. It can be practiced as a cost eff ective, offi ce-based procedure and is suitable for the third world environment. 

Introduction and Objective: Urolithiasis is an ancient disease with global distribution and is an important health problem all over the world. Th ere are diff erent results for stone clearance rate in diff erent renal and ureteric locations aft er ESWL. Here we share our experience of the comparison of stone free rates and complications in diff erent renal locations.

A retrospective study in which we included adults (age above 18 years old) who underwent ESWL from January 2013 to December 2014. ESWL was done by standard technique. We used Modulith SL X lithotripter 4th generation Storz medical. We followed patients for 3 to 6 months aft er Last ESWL session done. Stone free status was defi ned as residual stone not more than 4 mm in size. We reviewed data charts of patients for diff erent variables mentioned in results. Introduction and Objective: Tubeless percutaneous nephrolithotomy (PCNL) for staghorn calculi has been reported to be safe and eff ective in select patients. Although outpatient PCNL has been recently been shown to be safe and eff ective in a series of 50 patients, it requires further study before urologists embrace same day discharge following PCNL. Th e objective of this study is to report our early experience in treating staghorn calculi with PCNL on a completely outpatient basis, assessing its safety and effi cacy.

A review of all outpatient tubeless PCNL cases between March 2007 and May 2014 at two Canadian centres was performed, including collection of preoperative, intraoperative and postoperative data. Strict preoperative, intraoperative and postoperative criteria were used in the selection of candidates for outpatient PCNL: no intraoperative complications including signifi cant bleeding or collecting system perforation; postoperative hemodynamic stability; adequate pain control; reliable patient with supportive family.Results: Fift y patients underwent ambulatory PCNL during the study period. Staghorn calculi were treated in 9 patients including 2 cases of bilateral staghorn calculi, resulting in a total of 11 staghorn renal units treated by ambulatory PCNL. All 9 patients were discharged home uneventfully 2-6 hours postoperatively. Th ere were no major postoperative complications, emergency room visits, hospital readmissions or deaths. Th e stone-free rate was 64%, with 7 of the 11 renal units being stone-free at follow-up.Conclusion: Th is small series represents the largest series of ambulatory PCNL for staghorn calculi to date. In very carefully selected patients, PCNL for staghorn calculi on a completely outpatient basis appears safe and may be feasible. Further research on ambulatory PCNL for staghorn calculi is required prior to widespread adoption by urologists. Introduction and Objective: Th e most diffi cult aspect of percutaneous nephrolithotomy (PCNL) is frequently the renal puncture. Most are performed under fl uoroscopic control. Parallax, the assessment of the displacement of an object when viewed along two lines of sight, is the concept which allows the surgeon to gauge the 3D relationship of the needle to the kidney from a 2D fl uoroscopic image. Whilst most urologists appreciate successful access correlates with both kidney and stone images moving in unison on rotation of the C Arm (or "reverse parallax"), confusion oft en arises with unsuccessful attempts in relating how to amend the puncture with the radiological fi ndings.

We create a model to describe visual observation of parallax. By way of a short video we outline how it can be implemented seamlessly into routine PCNL.Results: Visualization of the theory followed by its application in theatre clearly demonstrates a failsafe technique to allow operators to reliably detect when their puncture needle is deep or superfi cial to the stone.Conclusions: Parallax, as an adjunct to routine fl uoroscopy during PCNL, allows the operating urologist to rapidly gauge depth of needle in relation to the collecting system in diffi cult access scenarios. Familiarity with this technique is important to minimize radiation exposure, ensure satisfactory access to the collecting system and improve operating times.

The Signifi cance of Non-Enhanced Compute Tomography for Renal Colic Has Been Overestimated in Absence of Pyuria Kim T 1 , Ahn S 2 , Kang J 3 , Kim J 1 , Myung S 1 , Moon Y 1 , Kim K 1 , Chang I 1 1

Introduction and Objective: Th e study was undertaken to compare clinical utility in patients undergoing non-enhanced computed tomography (NECT) and intravenous urography (IVU) in patient with classic symptoms of renal colic without evidence of urine infection and to determine the clinical importance.

Th is was a retrospective observational analysis of all adult patients between 2005 and 2013. All NECT and IVU were reviewed and categorized as the cause of symptoms. Non-urolithiasis cause were further categorized as "acutely important", "follow-up recommended", and "other unimportant cause". Full record review blinding to imaging fi nding was underwent including demographics, diagnosis, and management. We compared stone characteristics on imaging study, and demographic, exact diagnosis, and management methods between NECT and IVU groups.Results: A total of 2,218 patients were available inclusion criteria and 1525 (68.8%) patients were underwent IVU and 693 patients were NECT. Th e incidence of NECT was 1.25% at 2005, but 94.9% at 2013. NECT group was older (45.5±15.0 vs. 42.4±13.7 years old, p<0.01), less hematuria in urine analysis (87.2 vs. 90.2%, p<0.05) and more admit (18.6 vs. 12.0%, p<0.01) than IVU group. Urinary stones were detected 1413 (63.7%) patients. NECT group showed higher proportion of renal stone, mid ureteral stone and multiple stones (20.9 vs. 13.8%, p<0.001, 5.5 vs. 2.7%, p<0.01, 14.6 vs. 6.5%, p<0.001, respectively), and smaller stone (3.62±3.23 vs. 4.15±2.36 mm, p<0.001), and more radiolucent stone (25.7 vs. 13.2%, p<0.001) comparing to IVU group. Th e incidence of urolithiasis more than 4mm were no diff erence between NECT and IVU groups (20.5 vs. 20.0%, p=0.79 on radiologic fi nding, and 20.2 vs. 20.5%, p=0.87 on full chart record). Moreover, the incidence of "acutely important" among non-urolithiasis cause was similar between NECT and IVU groups on full record review (1.3 vs. 0.9%, p=0.14) . Th e incidence of the active management including surgery and extracorporal shock wave therapy (ESWL) were not diff erence between NECT and IVU group (35.4 vs. 39.9%, p=0.67).Conclusions: NECT is a rapid and accurate diagnosis test for suspected renal colic, and nowadays almost renal colic patients in our hospital underwent NECT in ED. However, it did not show better advantage for the detection of clinically signifi cant urolithiasis and acutely signifi cant cause of renal colic in patient with renal colic and absence of pyuria. 

From January 2007 to July 2014 we reviewed the scrotal ultrasound images of all patients diagnosed with Leydig cell Tumor and treated with conservative surgery (group A). We considered only patients that were fi rst diagnosed at one of the participating centers. We create a random homogenous control group of patients (group B), in term of age and presentation, diff erent from the group A just for the defi nitive malignant histology. All the images were collected and we analyzed ultrasound features of the lesions classifi ed in terms of length, US lesion homogeneity, shape, presence of hypervascularization. Th e collected data were analysed by an online regression (Student's t-test, chi-square test, and logistic regression analysis).Results: Th irty fi ve patients with Leydig cell tumor underwent conservative surgery at our centers. A random group B of 35 patients was also considered. Pa-tient mean age was 35.11 years (range 28 to 45) for the fi rst group and 33.89 years for the second one (range 22 to 41). Patients presented either with a palpable testicular nodule (12 patients group A, 34.28% -29 patients 82.86% group B) or a nodule diagnosed by ultrasound (23 patients group A, 65.72% -6 patients 17.14% group B). Mean ultrasound size was 0.96 cm and 1.57 cm for the two groups respectively (range 0.25 to 1.8 cm and 0.8 to 3 cm). Both groups had hypervascularization of the lesions with no signifi cant diff erences. Patients presenting with LCT (group A) had an homogenous ultrasound intralesional aspect and the shape is defi ned with an elliptic or spheroid mold while patients from group B had dis-homogenous intralesional aspect and non-defi ned margins (p>0.05).Conclusion: Although most focal lesions will be malignant and require an orchiectomy, recognition of the benign entity may be challenging. In a small lesion mainly not palpable the presence of a well-defi ned shape with an homogenous intralesional ultrasound aspect do correlate with a LCT.

Adult Testicular Pure Yolk-Sac Tumor 

The Association of Torsion with Testicular Cancer: A Retrospective Study

Introduction and Objective: Testicular torsion is a medical emergency that usually requires surgical exploration of scrotum to allow reperfusion of the aff ected testis. Nonetheless, such surgeries can be frequently resulted in orchiectomy due to tissue ischemia and necrosis. However, testicular malignancy has been anecdotally reported with the association of torsion in the surgical specimens and the literature remains scant on the association of torsion with testicular tumors. Th is retrospective study was set to explore the association of torsion with testicular cancer in cases of testicular torsion undergoing orchiectomy during scrotal exploration.

A chart review was performed for patients who admitted to our clinic and had a diagnosis of testicular torsion between January 2003 and February 2015. Data of patients' characteristics, the laterality of the torsion, time and type of intervention and pathological examination were recorded. Results: Overall, 32 patients with a diagnosis of testicular torsion were identifi ed. Th e mean age was 21.1 years (ranges from 7 to 39 years). All the patients had unilateral intravaginal testicular torsion aff ecting the left side in 17 cases (53.1%) and on the right side in 15 cases (46.8%). Manual detorsion was successful in 6 patients (18.7%) all of whom underwent bilateral testicular fi xation surgery within 24 hours via scrotal incision. Twenty-six (81.2%) patients underwent emergency surgery with a testicular detorsion and fi xation surgery in 6 (18.7%) cases (bilaterally in 5 and right-sided in 1) and orchiectomy in 20 (62.5%) cases (8 in right side and 12 in left side). Th e type of incision was scrotal in 6 cases, inguinal in 10 cases and unspecifi ed in 4 surgeries. Pathological examination of specimens revealed ischemia and necrosis in 18 cases, while 2 patients underwent testicular removal via inguinal incision had malignancy including seminoma and malign mixed germ cell tumor.Conclusion: Our retrospective study, as the largest case series in the current literature, showed the association of intravaginal torsion with testicular cancer to be 6.4%. Further high-level evidences are needed to establish the optimal incision type in testicular torsion cases with surgical exploration to avoid scrotal violation resulted from suboptimal approaches.

Wong L 1,2 , Dickson B 2 , Catton C 2 , Yap S 2,3 , Alkasab T 2 , Van der Kwast T 2 , Hamilton R 2 , Jewett M 2 1 St Vincent 's Hospital, Melbourne, Australia; 2 Princess Margaret Hospital, Toronto, Canada; 3 University of California Davis, Davis, USA Introduction and Objective: Paratesticular sarcoma (PTS) is an uncommon disease and the literature is mostly confi ned to small case series with short follow-up. Herein we present an update on our institution's experience in the management of patients with PTS.

Fift y-one men with PTS at Princess Margaret Cancer Center, between 1990 and 2012 were identifi ed from retrospective chart review. Important relevant clinical pathological variables were collected with study endpoints being local recurrence, metastasis and overall survival. Univariate analysis of variables associated with survival end points was performed with Cox proportional hazards regression.Results: Median follow-up of our cohort was 11.0 years (IQR 4.3-18.2) with a median overall survival of 13.9 years. At presentation 92.2% (n=47) of men had localized disease. Interval completion hemiscrotectomy (performed aft er initial unplanned diagnostic surgery) was done in 25 men, in which 25% (n=5) had residual disease present. Local recurrence (LR) occurred in 12 patients (23.5%). Median time from diagnosis to LR was 15months. Univariate analysis showed presence of positive margins at diagnostic surgery (HR 4.81, p=0 .047) and upfront/ completion hemiscrotectomy (HR 0.21, p=0 .02) to be signifi cant variables. At last follow-up, 7/12 men (58.3%) with LR were alive and disease free, 4 developed metastatic disease with 3 PTS-related mortalities, and 1 deceased of other cancer type. Metastasis was present in 13 men (25.5%), with median time to metastasis 18mo, and median to from metastasis to death 11.4mo. At last follow-up, 21.6% (n=11) of the patients were deceased with 7 cases attributable to PTS. On univariate analysis, there were no significant variables for metastatic disease, and age (HR 1.04, CI 1.00-1.08, p=0.02) and non-localized disease at presentation (HR 5.17, p=0 .02) were signifi cant for overall survival.Conclusion: In our cohort of PTS patients with median 11 years follow-up, aggressive treatment of local recurrence (23.5%) resulted in good disease free survival for 7 of 12 men. Completion hemiscrotectomy, particularly for positive margin disease, may decrease local recurrence.

A Rare Case of Testicular Metastasis from Primary Lung Adenocarcinoma: Case Report and Ten-Year Review of Testicular Pathology at a Single Institution Demkiw S 1 , Jackett L 2 , Goad J 1 , Wong L 1

Introduction and Objective: Health care websites provide a valuable resource of health information to online consumers, especially patients. Offi cial surgical and medical society websites should be a reliable fi rst point of contact. Th e primary aim of this study was to quantitatively assess medical and surgical society websites for content and highlight the essential features required for a high-quality, user-friendly society website.

Twenty specialty association websites from each of the regions, Australia, UK, Canada, Europe, and the USA were selected for a total of 100 websites. Medical and surgical specialities were consistent across each region. Each website was systematically and critically analysed for content and usability.Results: Th e average points scored per website was 3.2 out of 10. Of the total (N=100) websites, 12 scored at least 7 out of 10 points and 2 scored 9 out of 10. As well, 35% (35.0/100) of the websites had an infor-mation tab for patients on their respective homepages while 38% (38.0/100) had download access to patient information. A minority of the websites included different forms of multimedia such as pictures and diagrams (24.0/100, 24%) and videos (18.0/100, 18%).

We found that most society websites did not meet an adequate standard for delivery of information. Half of the websites were not patient accessible, with the primary focus being for health professionals. As well, most required logins for information access. Specialty health care societies should create patient-friendly websites that would be benefi cial to all online consumers.

Application Materials and Methods: Students were selected by sampling in PBL group (n =56) and PBL-EBM group (n =51), and the two groups received clinical teaching of urology by PBL and PBL-EBM model respectively. At the end of the study, each student received objective and subjective evaluation.Results: Th ere was no signifi cant diff erence in results of the baseline on evidence-based medicine between two groups (P>0.05), but the percentage of high-recommended-level research evidence obtained by the students in the PBL-EBM group was signifi cantly higher than that in PBL group (P<0.05). And questionnaire showed more students in PBL-EBM group believed that this teaching model improved their ability of comprehensive analysis and application of medical evidence, and developed their skills in solving problem and obtaining information on various subjects (P<0.05).Conclusions: Th e model of problem-based learning combined with evidence-based medicine is feasible and eff ective in clinical teaching of urology and optimize the outcomes from PBL education. By the PBL-EBM model teaching, students improve the ability to advantage in managing evidence from medical studies, analyzing and solving problem, obtaining and applying medical information.

Incidence (DVT) or pulmonary embolism (PE), is recognized as one of the most serious complications of surgery. In urologic surgery, this has not been well reported thus the objective of this study is to access the risk factors for the development of VTE among patients undergoing major pelvic surgery for prostate and bladder cancer in an Australian tertiary referral center.

Consecutive patients undergoing major pelvic uro-oncologic surgery, namely radical cystectomy and radical prostatectomy over a fi ve-year period (2009-2013) were identifi ed. Patient variables, types of surgery, types of thromboprophylaxis (pharmacological and/or mechanical) used in this patient cohort were collected for analyses as predictive factors.Results: An overall incidence of VTE was 1.8%. Patients undergoing radical cystectomy were more likely to suff er a VTE event compared to patients having radical prostatectomy. In this cohort, the risk factors for VTE include, prolonged operative time of greater than 4 hours, lymph node dissection (LND) and patients requiring blood transfusions.Conclusion: Patient undergoing major pelvic uro-oncologic surgery have a 2% risk of developing VTE. Risk factors identifi ed in this study should be used to guide the use of early and prolonged thromboprophylaxis.

Optimal Trial of Void after IDC Insertion for Pelvic Surgery Th am C 1 , Ho P 2 Introduction and Objective: In 2012, we pioneered the fi rst international twitter-based journal club (#urojc) to discuss urology articles on a monthly basis with diverse global participation. Since that time, this model of an international twitter-based journal club has been adopted by several other medical specialties including general surgery, respiratory medicine and nephrology. Th e objective of this study is to examine the development of the urology journal club into an innovative and thriving forum for exchange of ideas, information and opinions since its conception two years ago.

Monthly twitter analyses such as number of users, tweets and impressions for the journal club were obtained via a third-party service called Symplur using the hashtag #urojc. Qualitative analysis was also performed of each individual tweet to assess for relevance to the discussion. Comparisons were made between data from the fi rst and second year of operation of the journal club, including the number and geographic location of participants, as well as the quantity and quality of tweets.Results: See Table 1 for summary statistics. Th e total number of unique users of #urojc almost doubled from year one to year two. Th e mean number of total participants increased by seven per month, and mean number of total countries represented increased by three per month. While the number of tweets per month also increased from year one to year two, the proportion of content-relevant tweets remained stably high at approximately 60%. Meanwhile, there was a greater degree of participation from authors of the study being discussed over time.

Journal Club continues to draw robust participation from a global audience, and serves as a benchmark for twitter-based journal clubs in other specialties. Th e majority of tweets are relevant to the content of the article, providing a novel forum to discuss new research fi ndings with a global audience.

Prognostic Impact of Perinephric Fat Stranding on Computed Tomography in Ureteral Urothelial Carcinoma 

Introduction and Objective: Ureteral urothelial carcinoma causes gradual ureteral obstruction. Perinephric fat stranding is defi ned as linear areas of soft tissue attenuation in the perinephric space, which can result from any acute process or injury to the kidney. We analyzed the prognostic impact of perinephric fat standing as well as secondary signs of upper urinary obstruction on the oncologic outcomes of patients with ureteral urothleial carcinoma.

A total of 86 patients who were evaluated by abdominal-pelvic computed tomography (CT) preoperatively and were diagnosed with ureteral urothelial carcinoma aft er nephroureterectomy conducted between January 2001 and December 2010 were enrolled in this retrospective study. We analyzed the association between oncologic outcomes and clinical-pathologic fi ndings, including secondary signs of upper urinary obstruction on preoperative CT such as hydronephrosis grade, perinephric fat stranding, renal enlargement, kidney density diff erence, renal cortical thinning, periureteral fat stranding.Results: Preoperatively 46 patients (53.5%) had perinephric fat stranding on preoperative CT. Multivariate analysis showed that perinephric fat stranding, higher pT stage (≥ T3), lymph node involvement of cancer, and positive surgical margin were independent prognostic factors of cancer-specifi c survival (p = 0.030, p = 0.007, p < 0.001 and p = 0.029, respec-tively). And perinephric fat stranding, higher pT stage (≥ T3), lymphovascular invasion, and lymph node involvement of cancer were identifi ed as independent prognostic factors of recurrence-free survival in ureteral urothelial carcinoma (p = 0.018, p = 0.021, p = 0.010 and p = 0.001, respectively).Conclusion: Perinephric fat stranding on preoperative CT in ureteral urothelial carcinoma was found to be an independent prognostic factor of disease recurrence and cancer-specifi c mortality. Our fi ndings indicate that immediate radical surgery and adjuvant therapy should be considered in patients with perinephric fat stranding preoperatively.

Lower Increased urinary tract malignancy in end-stage renal disease (ESRD) has been reported. However, little is known in chronic kidney disease (CKD). Th is study is designed to explore the association between CKD and upper urinary tract urothelial carcinoma (UUT-UC).

Health Insurance Database, we included CKD patients between January 2000 and December 2011. Th e non-CKD controls were selected with the ratio 4:1 and frequency matched with gender, age group and index date. Chi-square test and t-test were used to inspect sociodemographic information and comorbidities. Logistic regression analysis was used to calculate hazard ratio (HR) and 95% confi dence interval (CI). 

A 74 year-old man with a strong family history of various cancers presented with haematuria and was subsequently found to have a mass in the right pelviureteric junction suggestive of urothelial carcinoma. Work-up confi rmed the diagnosis without evidence of metastatic disease and the patient went on to have an open transperitoneal nephroureterectomy. Laparoscopic approach was initially attempted but abandoned due to dense adhesions thought secondary to previous open bowel resection for colorectal cancer. A fl ank incision was used; there were no specifi c operative complications and the specimen was easily retrieved without manipulation or rupture. Post-operative recovery was unremarkable and histological analysis of the tumour revealed a non-invasive high-grade papillary urothelial carcinoma at the right pelviureteric junction with clear resection margins. Approximately 9 months post-operatively the patient re-presented with a rapidly enlarging mass at the fl ank incision. Imaging demonstrated a circumscribed hypodense mass within the muscle layers at the site of the scar and biopsy revealed poorly diff erentiated carcinoma. Surgery to excise the mass was subsequently performed and immunohistochemical analysis revealed a lack of staining for MSH6.Results: Abdominal wall metastasis following open nephroureterectomy for upper tract urothelial carcinoma is rare, with only one case reported previously. Given patient's previous history of colorectal cancer, strong family history and immunohistochemical fi ndings are highly suggestive of Lynch syndrome. Incisional site tumour recurrence following surgery for urological malignancy is a very rare complication, with only a handful of case reports existing, mostly relating to port-site metastasis following laparoscopic surgery. Wound recurrence following open surgery is an extremely uncommon but recognised event, more frequent in certain gynaecological and general surgical malignancies. LS involves inherited defects in the DNA mismatch repair system, resulting in predisposition to a number of malignancies.

Urologists should consider the possibility of Lynch Syndrome in any patient with de-novo upper tract urothelial carcinoma, and strongly recommend genetic testing where patients meet the Amsterdam II criteria or are diagnosed under the age of 60.

Prognostic ) developed recurrent bladder cancer within 2 years aft er nephroureterectomy, and the median interval between surgery and intravesical recurrence was 15.5 months (range 6 to 48 months). Multifocal tumors, native aristolochic acid nephropathy and distal ureter invasion were determined as risk factors for intravesical recurrence by univariate analysis. However, by multivariate analyses, multifocality (hazard ratio = 2.603, 95% CI = 1.529 -8.906, P = 0.019) and native aristolochic acid nephropathy (hazard ratio = 2.179, 95% CI = 1.085 -8.093, P = 0.038) were identifi ed as independent predictors for the development of recurrent bladder cancer aft er surgery for UUT-UC in renal transplant recipients.Conclusions: Th e incidence of intravesical recurrence aft er laparoscopic nephroureterectomy for UUT-UC in renal transplant recipients is high, and most subsequent bladder cancers recur within 2 years aft er surgery. Tumor multifocality and native aristolochic acid nephropathy are signifi cant independent risk factors in developing initial intravesical recurrence aft er laparoscopic surgery for primary upper urinary tract urothelial carcinoma aft er renal transplantation.Introduction and Objective: Transient urinary incontinence may occur in up to 44% of patients aft er holmium laser enucleation of the prostate (HoLEP). However, there are few published data concerning the factors associated with de novo urinary incontinence (UI). Th e aim of this study was to investigate the associated factors of de novo UI aft er HoLEP.

Our study included 141 patients who underwent HoLEP. Enrolled patients were divided into two groups according to the presence of UI. Independent t test was used to compare between two groups. Logistic regression was performed to analyze a correlation between de novo UI and other factors such as age, prostate volume, retrieved tissue weight, operative time, and the fi rst post-void residual (PVR) urine volume immediately aft er removing postoperative urethral catheter. Urethral catheter was removed aft er bladder instillation with a 200 ml normal saline via urethral catheter, and PVR urine volume was estimated immediately aft er the fi rst postoperative self-voiding. All defi nitions of UI corresponded to recommendations of the International Continence Society.Results: Aft er HoLEP, 44 patients (31.2%) had de novo UI, most of which resolved within 1-6 months; 34 had stress UI, 6 had urgency UI, and 4 had mixed UI. Age and PVR urine volume were signifi cantly higher in UI group than non-UI group (75.09 ± 6.82 vs. 72.01 ± 8.04 years; P = 0.029, 81.88 ± 67.13 vs. 30.15 ± 23.56 ml, P < 0.001). In a logistic linear regression analysis, only PVR urine volume was an independent predictor of de novo UI aft er HoLEP. Th e most optimal cut-off value of PVR urine volume for predicting de novo UI was defi ned as 39.5 ml in the receiver operating characteristics curve analysis (sensitivity, 75.0%; specifi city, 74.2%; AUC, 0.815; P < 0.001).Conclusion: About one-third of patients might undergo de novo UI following HoLEP, and most of them might have been resolved within 1-6 months. High PVR urine volume aft er removal of postoperative urethral catheter is associated with de novo UI aft er HoLEP, and could be used a practical tool to predict postoperative de novo UI.

Concomitant Transurethral and Introduction and Objective: Stress urinary incontinence is a common medical problem among women. Th e urethral closure complex and/or the support mechanisms are responsible for incontinence in the majority of patients. Several surgical procedures with diff erent degrees of invasiveness and outcomes have been reported to treat the problem. Although many are reasonably eff ective, a general trend towards study of natural and biocompatible tissues is emerging over popular synthetic materials. Here we report our experience with injection of autologous adipose-derived stem cells to the periurethral region as a new method of stress urinary incontinence treatment.

Ten women with symptoms of stress urinary incontinence were treated by injections of autologous adipose-derived stem cells into the periurethral region via transurethral and transvaginal approach under urethroscopic observation. Th is report presents the short-term outcome of the patients. Th e outcome measured by pad test results, ICIQ-SF scores and Qmax.Results: Th e mean age of the participants was 45.8 ± 8.7 years. Urinary incontinence signifi cantly decreased through the fi rst two, 6 and 24 weeks aft er the injection therapy. Th e diff erence was signifi cant in pad test results (p<0.001) and ICIQ-SF scores (p<0.001), especially comparing results between 2 and 6 weeks and among 6 and 24 weeks, but not for 2 and 6 weeks compared to each other. Surprisingly, Qmax showed improvement aft er the study period (means 32.6 vs. 35.7; P=0.002).

Th is study showed that injection of the autologous adipose-derived stem cells to periurethral region is a safe, yet shot-term eff ective treatment option for stress urinary incontinence. Further studies with longer follow-up are needed to confi rm its longterm effi cacy.

SPARC Sling System for Treatment of Female Stress and Mixed Urinary Incontinence in the Elderly Sung L, Noh C, Chung J, Yoo J

Introduction and Objective: Th e aim of this study was to investigate the safety and effi cacy of the suprapubic arch (SPARC) sling procedure for the management of urinary incontinence in elderly versus younger women.

A total of 299 women underwent the SPARC procedure for female urinary incontinence. Of these patients, 258 were classifi ed younger women (SUI, 214. MUI, 44) and 41 (SUI, 32. MUI, 9) were elderly (more than 65 year). Th e preoperative evaluations included a complete medical history, a female bladder questionnaires, urogynecological examination and urodynamic test with valsalva leak point pressure (VLPP). Th e main outcome measures were perioperative morbidity, postoperative SUI, persistent or de novo urge incontinence, postoperative complication and voiding dysfunction. Th e objective and subjective success rate were evaluated by visual analogue score and global patient impression questionnaire at 1, 3, 6 months. Th e mean follow-up period was 36±14 mo (range, 12-90 mo).Results: Th e incidence of SPARC related morbidity was similar in both groups. For the operation outcome results, in younger group (258 patients) there were 232 cases of cure (89.9%), 20 cases of improvement (7.8%), and 6 cases of fail (2.3%) and in elderly group (41 patients) there were 36 cases of cure (87.8%), 4 cases of improvement (9.8%), a case of fail (2.4%) (p>0.05). Th e operation satisfaction rate of patients was 93.7% in the younger group and 90.2% in the elderly group (p>0.05). A total of 279 patients (93.3%) would like to recommend the SPARC procedure to others. Th e objective success rate and operation satisfaction rate of the younger group did not diff er from elderly group. No severe intraoperative or postoperative complications occurred in both groups.Conclusions: Th e SPARC procedure is eff ective and off ers a satisfactory cure rate without signifi cant morbidity in elderly women.

Validity Introduction and Objective: Urinary incontinence secondary to surgery or trauma is a debilitating condition for the patient, and for the urologist a diffi cult situation to manage. Because of the complexity of reconstructive surgical techniques and the cost of the prosthetic devices used, there is a need for a simple procedure. Aims: We here in report our experience in managing urinary incontinence secondary to sphincteric incompetence in 7 patients using a modifi ed bulbar urethral sling procedure over a period of 5 years. Results: All patients were continent postoperatively, with only mild stress leakage in the erect posture in two patients, during a mean follow-up of 30.5 months (range 3-58 months) and required one or some time two pads per day to remain continent during the daytime. One patient required clean intermittent catheterization for a short period postoperatively.

Conclusions: Th e male bulbourethral sling procedure using a polypropilene mesh is economical and safe but further experience is needed to establish this procedure as an alternative for the treatment of male urinary incontinence.

Investigation of a Teikyo University, Tokyo, Japan; 2 Juntendou University, Tokyo, Japan Introduction and Objective: Th is study compares the safety and benefi ts of administering anticholinergic agent propiverine hydrochloride in combination with adrenergic alpha-1 receptor antagonist silodosin (SP group) as therapy for patients diagnosed with benign prostatic hyperplasia with overactive bladder, as opposed to administering silodosin alone (S group).

Th is study included 41 male patients aged 50 or above who had an International Prostate Symptom Score (I-PSS) of 8 or more, an overactive bladder, a QOL index of 2 or greater, an overactive bladder syndrome score (OABSS) of 3 or more along with an OABSS urgency score of 2 or greater, and a maximum urinary fl ow rate of <15ml/s. At random, 19 patients were assigned to the SP group, and 22 to the S group. Th e SP group was administered 8 mg/day of silodosin along with 20mg/day of propiverine hydrochloride and the S group 8mg/day of silodosin only, for 12 weeks respectively. I-PSS, QOL index, OABSS urofl owmetry results, and residual urine were evaluated prior to therapy and 4, 8, and 12 weeks post-therapy.Results: Th ere were no statistically signifi cant diff erences in patient background between the two groups. Statistically signifi cant improvements were seen in I-PSS total score, QOL index, and OABSS 4 weeks post-therapy, but there were no statistically signifi cant diff erences between the two groups. Both groups refl ected statistically signifi cant improvements in I-PSS storage symptom scores and voiding symptom scores, but there were no diff erences between the two groups. Analyzing by prostate volume, among those with lower prostate volume (average 23.6 ± 6.4mm3), the SP group showed a statistically signifi cant improvement in I-PSS total score and OABSS as compared to the S "monotherapy" group. No serious side eff ects were shown in either group.Conclusion: Among benign prostatic hyperplasia patients with overactive bladder, those treated with silodosin alone showed statistically signifi cant improvements in both storage and voiding symptoms, as did those additionally treated with propiverine hydrochloride. Results were even more benefi cial when both silodosin and propiverine hydrochloride treatment were used for patients with lower prostate volumes.

The Effi cacy and Safety of Fesoterodine in Vulnerable Elderly Patients with Overactive Bladder Takeda H, Nakano Y, Narita H

Introduction and Objective: We evaluated the efficacy and safety of fesoterodine in medically complex vulnerable elderly patients with overactive bladder.

In this 12-week, patients were community dwelling men and women 65 years old or older. Patients with OAB had scores of less 3 or more on the VES-13 by NCCN (Vulnerable Elders Survey). We evaluated the changes of each parameter before and 4 to 12 weeks aft er the administration of fesoterodine 4 mg per day. Th e overactive bladder symptoms score (OABSS), IPSS were used as a subjective questionnaire for overactive bladder symptoms. We compare between vulnerable elderly group and no-vulnerable elderly groups. Statistical comparisons before and aft er the administration were made using the Wilcoxon signed-rank test. To examine the relation between OABSS and IPSS, Spearman's testing was used for correlations between independent variables and P<0.05 was considered statistically significant. Safety evaluations included self-reported symptoms and post-void residual volume.Results: A total of 47 patients were enrolled (mean age71.8 years, 53.4% age 75 years or greater). Th e vulnerable elderly patients had high rates of comorbidities, polypharmacy and functional impairment. At week 12 both group had insignifi cantly greater improvements in OABSS (p=0.34) and IPSS (p=0.18). Adverse eff ects were generally similar.Conclusions: Fesoterodine improved overactive bladder symptoms not only in no-vulnerable elderly patients, but also in vulnerable elderly patients.

The Effectiveness and Tolerability of Fesoterodine 8mg in "Real World" Outpatient Clinical Settings 

The Benefi cial Effect of a Combination of Solifenacin and Mirabegron on OAB Patients Persu C, Paraianu B, Nita G, Geavlete P

Introduction and Objective: Th e development of a new drug class intended for the treatment of OAB patients opened a new and promising era for our patients. Th e current study aims to evaluate the eff ects of a combination therapy using an antimuscarinic and mirabegron.

We designed a prospective study including OAB patients with or without wet episodes. Treatment was started with two months of solifenacin 10 mg, then mirabegron 25 mg was added for the next two months. Th e patients were evaluated using a bladder diary for three consecutive days at the end of each treatment period. We compared the total number of voidings, the number of urgency episodes and the number of urge incontinence episodes. Th e statistical analysis included only the patients who fi nished the whole four month period. 

A total of Fourteen Female Sprague-Dawley® rats weighing 175-200g were used, which were randomly divided into two groups. Both the experimental group and the control group, fourteen rats were inserted intrathecal catheter in the spinal L6-S1 segment. Seven days later, all rats were catheterized through the bladder dome for saline-fi lling cystometry. In experimental group, seven rats were given intrathecal diff erent concentration ketanserin (0.01-0.1mg/kg) Dose-response curves for ketanserin were followed by DOI (0.1mg/kg) test.In control group, seven rats were given intrathecal normal saline. All rats were intravascularly perfused with 4% paraformaldehyde aft er the completion of the urodynamic recordings. Th e L6-S1 Spinal cord were removed and pathological sections and immunohistochemical staining were made. Meanwhile, we observed and recorded the distribution of 5-HT2A receptors in the spinal motor neuron. Results: Th irty-four patients were included in the study. Twenty-four of them completed the follow-up. Twenty-one were female and 13 were male with an average age of 9.48 years (5-31 years). Detrusor sphincter dyssynegia was the most common abnormal urodynamic fi ndings in these patients. Th ere was an improvement in bladder capacity, detrusor and sphincter action following de-tethering surgery.Conclusion: Urodynamics should be considered as a part of preoperative evaluation in all patients with primary tethered cord syndrome to decide the urological aspect of management.

Urinary Bladder Reinnervation with Creation of a "Somato-Autonomic" Refl ex Pathway in Rabbits -S1) and detrusor muscle (recipient, S1-S2) were located. Aft er their resection, intradural anastomosis of donor root to the recipient distal root stub was performed. Th ose roots whose stimulation elicited the largest response were always selected. Aft er 8-16 months (mean 12 months), the artifi cial refl ex arc's function was examined (to date in 11 rabbits). Under general anaesthesia, skin segments L5-S1 were peripherally stimulated and then the spinal root above the anastomosis was stimulated. Detrusor response was measured using an EMG strip electrode and intravesical pressure (Pves) monitoring and sphincter response using an EMG needle electrode. A root sample from under the anastomosis was resected for histology.Results: Electromyography confi rmed detrusor response to peripheral skin stimulation in 7 (64%) animals and sphincter response in 8 (73%). Five (45%) animals displayed elevated intravesical pressure (Pves) up to 15 cm H2O. Root stimulation induced detrusor and sphincter EMG response in 7 (64%) and 9 (82%) rabbits, respectively, and 4 (36%) animals displayed increased Pves up to 24 cm H2O. Micturition was not induced in any animals. With confi rmed detrusor contraction (EMG, elevated Pves), external sphincter activity was never inhibited. Somatic-to-autonomic anastomosis creation was histologically confi rmed in all samples. Hind limb paresis occurred in 2 (18%) animals and spinal lesion in 3 (27%).Conclusion: Lumbar-to-sacral-nerve rerouting is a technically manageable method with donor root fibres verifi ably joining recipient roots. Only in a limited percentage of cases, however, can the method achieve positive functional results, i.e. demonstrable detrusor contractions and elevated intravesical pressure. Physiological micturition without detrusorsphincter dyssynergia as described in the literature did not occur in our experiment.

Development In this study, we evaluate the effi cacy of the prototype intravesical pressure sensor integrated into a catheter-like tube and in the rabbit and biocompatibility of Ecofl ex® as a packing materials in the rats.

Th e catheter type wireless pressure sensor is manufactured by direct inserting the prototype sensor into the port split from the feeding tube between the sensor and the port so the tube could hold the bladder pressure. Th e tip of the tube is Results: Th e measured resonance frequencies and the pressure data converted from those signals were compared to the reference pressure data obtained from a conventional cystometry. Th e scale factor of the sensor to correlate the prototype sensor resonance frequencies to the reference pressure data is -2.1 kPa/ MHz (=-0.476 MHz/kPa), comparable to the result of its in-vitro measurement, a pressure responsivity of -0.418 MHz/kPa. Increased macrophage activity and MIF in the bladder were revealed in the early phase aft er implantation of Ecofl ex®. However, decreased macrophage activity and MIF in the bladder were observed in the later aft er implantation. Furthermore, decreased infl ammatory cytokines were also observed at that time.

In this study, we demonstrated the feasibility of the catheter type which is non-invasive method and easy to apply to patients in actual examination. Further investigation to overcome the limitation of the prototype intravesical pressure sensor is necessary for the application to the real life practice. In addition, Ecofl ex is biocompatible materials for the implanted medical devices in the bladder. Introduction and Objective: Urethral pressure profi le (UPP) is a primary method for evaluating urethral continence function in human beings. However, UPP recording in female rat, a widely used animal model, has been challenging because of the animal's small body size. Th is study reports a novel method for recording UPP in female rats.

Seventeen anesthetized female rats were studied. Leak-point pressure (LPP) data of 14 rats were included; the other 3 rats were excluded due to animal die or abnormal urogenital organ. UPP curves were recorded using a modifi ed method of water-perfusion catheter system, with the lateral hole facing 3-, 6-, 9-, 12-o' clock positions respectively in a randomized sequence. LPP, functional urethral length (FUL), and maximum urethral close pressure (MUCP) were the analysis parameters. In the era of aging society, an easy-to-use screening tool for voiding dysfunction refl ecting to activity of daily life is much-needed. Bladder diary (frequency volume chart) is gold standard to check urine storage status, but diffi cult for elderly to measure and record all the time. Urofl owmetry is useful to check voiding status, but limited to clinics or hospitals. We developed a portable device, p-Urofl owdiary®, which records every urine fl ow with bladder diary at home. We elucidate the feasibility and the usefulness of this device.

Materials and Methods: p-Urofl owdiary® records voiding time and date, length of voiding, voided volume, fl ow rate and self-evaluation of every urination for a couple of days with gravimetric determination method. Th e device consists of a disposable urine cup, a load cell and the circuit board on which microcomputer, clock, acceleration sensor, audio guidance, Bluetooth and SD card mounted. Self-evaluation of every urination is recorded by pushing one of the four buttons on the body-side, which represent "very good", "good", "bad" and "very bad". Th e Data in SD card are analyzed using the dedicated soft ware. Accuracy of the measurement has been approved in a comparative study of the device and an existing urofl owmeter. Th e infl uences of hand shaking are canceled by acceleration sensor and are smoothed by the soft ware.Results: Th e feasibility study were done under the approval of IRB of Nara Medical University. First semester study in 230 healthy volunteers focused on user-friendliness. Th e results were almost acceptable except for female volunteers, especially in elderly. Th e urine volume and peak fl ow rate as well as self-evaluation were linearly related in volunteers who measured multiple sessions. A clinical trial in patients with voiding dysfunction is in operation in seven institutions, and summarized data will be reported.Conclusion: p-Urofl owdiary® is light and small and easy-to-use at home even in elderly. Although its practical usefulness as voiding diary have been proved, the usefulness as urofl owmetry and self-evaluation of every urination is not clarifi ed yet. However, p-Urofl owdiary® seems to be a useful tool for screening of voiding dysfunction as well as assessment of therapeutic performance. To determine the continence position and the contributory factors in the female canine urethra.

Materials and Methods: By using 12 adult female dogs, we determined the continence function of each 5 mm intervals of the urethra when we excluded these segments by progressively inserting a 12Fr catheter and recording the abdominal leak-point pressure (ALPP). Th e urethral pressure profi le (UPP) and ALPP were determined before and 1min aft er occlusion of the abdominal aorta. Each urethra specimen was split into 16 segments averagely and the histological components were determined. Th e relationship between the histological components and the urodynamic parameters were analyzed.Results: Th e striated muscle confi ned to the distal 1/3 urethra. Th e anatomic structure of the proximal 2/3 urethra was found to be quite homogenous, which surrounded by circular smooth muscle. Th e connective tissue constituted with abundant collagen fi bers and vascular plexus was most voluminous in the distal 1/3 urethra, and relatively richer near the bladder neck. UPP had 2 pressure zones: high pressure zone corresponding to the distal 1/3 urethra and low pressure zone corresponding to the proximal 2/3 urethra. ALPP decreased sharply when exclusion progressed over the distal 1/3 urethra. ALPP and MUCP decreased about 24% and 40% aft er occlusion of aorta, respectively. Th e distribution of the urethral pressure or pressure change is in accordance with the location of the striated muscle sphincter; there is no linear correlation with any other particular tissue component in the diff erent urethral segments.Conclusion: Th e strongest continence function locates at the distal 1/3 urethra with striated muscle layer; the remaining 2/3 proximal urethra lacking striated muscle has only weak continence function. Striated muscle is the predominant contributory factor to continence and the other components like vascular sinusoids, smooth muscle, collagen fi bers are minor contributory factors.

Urodynamics in Children: A 10-Year Experience Persu C, Mirciulescu V, Geavlete P

Introduction and Objective: Urodynamics, in the modern defi nition of the term, developed rapidly from a state of the art gadget into an extremely useful tool in the armamentarium of the modern practitioner, who is no longer accepting the clinical exam as the mainstay of the diagnosis, but requires more and more in-depth data from paraclinical investigations.Our study aims to review the particular aspects of the urodynamic examination in children.

We retrospectively reviewed the data from our archive in patients aged less than 16 years old, examined in our department in the last 10 years. For analysis purposes, patients were divided into two groups, less than 10 years old and more than 10 years old, considering that compliance during the examination improves greatly with age. A total of 43 children were evaluated, 21 in the fi rst group and 22 in the second. We noticed changes in the procedure over time, due to the lack of standardization.Results: Th e main conditions behind the urinary symptoms were spina bifi da, myelomeningocele, cerebral palsy, spinal cord injury, frontal dementia. Children with chronic conditions showed a signifi cantly better compliance during the examination, providing "cleaner" traces and shorter examination times. In 5 cases (11%), the results of the exam were considered unreliable. In the fi rst group, sensations are recorded in only 4 cases (19%), the other traces are marked as pain or crying. In the second group, the sensations are reported by 20 children (91%). In six cases (15%), more than one examination was available, and the intra-individual variability was higher than in adult patients.

Urodynamics in children is a challenging, yet useful investigation, which requires both a state-of-the-art equipment and dedicated and highly professional staff . Th e main question when thinking about urodynamic testing in children is not whether it can be done, but if it is really needed for the management of the patient, keeping in mind not only the benefi ts but also the potential harm that it can do.

The Underactive Bladder Syndrome: A Single Center Experience Persu C, Geavlete P

Introduction and Objective: Detrusor underactivity (UAB syndrome) is defi ned as a contraction of reduced strength or duration, leading to obstructive symptoms of the lower urinary tract. Our study aims to review our clinical experience with such cases.

We reviewed the electronic fi les of the patients diagnosed with UAB aft er urodynamics in the past 5 years. Our review focused on the referral diagnosis and other associated conditions, as well as on the symptoms reported by the patient during history taking or the examination itself. We tried to correlate symptoms with the parameters obtained during urodynamics. Th e initial treatment offered was also recorded.Results: A total of 67 patients (41 males, 36 females) were analyzed. Th e most common referral diagnosis was bladder outlet obstruction (40 pts -60%), followed by OAB syndrome (20 pts -30%) and other conditions (7 pts -10%). Most patients reported signifi cant dysuria (57 pts -85%), sensation of incomplete voiding (40 pts -60%) and the need for straining in order to void (30pts -45%). Other reported symptoms include recurrent UTIs (24 pts -36%), urgency (20 pts -30%), frequency (20 pts -30%) and urinary incontinence (10 pts -15%). Th e initial treatment consisted of self-catheterization (33 pts -49%), α blockers (20 pts -30%), suprapubic cystostomy (6 pts -9%), double voiding (6 pts -9%) and neurostimulation (2 pts -3%).Conclusion: Th e most common causes for UAB include neurogenic conditions and obstructive symptoms associated with aging. Th ere are no specifi c symptoms to support this diagnosis but some might suggest it stronger than others. Urodynamic evaluation is mandatory to assess the parameters of this condition.

Underactive Bladder: Clinical Features, Urodynamic Parameters, and TreatmentHoag N, Gani J

Introduction and Objective: Underactive bladder is a complex clinical condition that remains poorly defi ned in the available literature. We aim to determine its prevalence among those with voiding dysfunction, presenting symptoms, risk factors, urodynamic fi ndings, and treatment undertaken.

A retrospective chart review was conducted on consecutive urodynamic studies performed for voiding dysfunction between 2012 and 2014, to identify patients with detrusor underactivity. Underactive bladder was defi ned as bladder contractility index less than 100. Charts and urodynamic tracing were examined for patient demographics, suspected risk factors, presenting symptoms, urodynamic parameters, and treatment undertaken.Results: Th e prevalence of Underactive bladder in this series was 23% (79/343). Average age was 59.2 (range 19-90). Women represented 68.4% (54/79) of patients. Th e most common reported symptoms were: urinary urgency (63.3%), weak stream (61.0%), straining (57.0%), nocturia (48.1%), and urinary frequency (46.8%). Prior pelvic surgery and prior back surgery was noted in 40.5% and 19.0%, respectively. Most common management was intermittent self-catheterization at 54.4%, followed by observation/conservative treatment at 25.3%, and sacral neuromodulation at 12.7%.Conclusion: Underactive bladder is common, yet precise diagnosis and treatment remains nebulous. Th ere exists signifi cant overlap in symptoms compared to other bladder disorders, and urodynamic evaluation is useful in determining those patients with impaired detrusor contractility. Th is will help prevent mismanagement of these patients with surgery or medical therapy that may worsen their condition. Th ere remains much work to be done to better understand this condition, and establish optimal management for patients.

What Is the Relationship between the Size of a Patient's Medical Notes and Their Fitness?Birring A, Jelski J, Burns-Cox N

Introduction and Objective: Assessment of patients' co-morbidities is necessary when considering treatment options. Comorbidity tools exist but aren't always used outside of studies. Clinicians may infer a patient's fi tness from the size of their notes. Th is is particularly apparent in multidisciplinary meetings when the patient, and sometimes the referring clinician, is absent. We aim to establish if any correlation exists between the thickness and weight of medical notes and patient comorbidity.

Th ickness and weight of medical notes was measured for 100 consecutive patients admitted to a urology/surgical ward. Comorbidity was assessed using the Charlston Comorbidity Index (CCI).Results: Mean (and range): age 63 (19-93) years; thickness 4.2 (0.3-36.4) cm; weight 1770 (157-16874) g; CCI 1.6 (0-8). Male to female ratio 1:1. Pearson's correlation (r) between thickness and CCI was 0.27 (p=0.01). Th e correlation between weight and CCI was 0.25 (p=0.01). Regression analysis showed, an 8.5cm increase in thickness gives in a 1-point increase in CCI (p=0.01); and a 5000g increase in weight gives a 1-point increase in CCI (p=0.01).Conclusion: Th ere is a statistically signifi cant relationship between the thickness and weight of a patient's notes and their CCI (p=0.01), but the strength of this relationship is extremely weak (r=0.25 and 0.27). On average, an 8.5cm or 5kg diff erence in size has only a 1-point diff erence in CCI. Th is change may reduce the 10-year survival of a patient by as little as 5%. Size of notes is a highly misleading indicator of fi tness. Patients should have a formal comorbidity assessment before deciding treatment options.Did you know? SIU Academy...

The endorsed event programme allows approved webcasts from high-quality meetings around the world to be presented and shared on the portal.Off ers a wide range of content eligible for selflearning CME credits Non-accredited content is eligible for self-learning credits. Contact your national accreditation body to fi nd out how.

Navigate the portal to its full potential by using the top and bottom panels. This allows you to narrow down your search by selecting the type of content, topic, sub-topics and labels to fi nd exactly what you are looking for.

what's trendingThe What's Trending page gives you an overview of featured content and the most recent material at a glance.

The "Rate & Comment" feature allows you to share your feedback on every piece of material available on the portal.

Share exciting new content with colleagues through Facebook and Twitter at the click of a button.www.siu-urology.orgRegister today! SIU Academy reaches over 43,000 users.Are you ONE OF them?SIU members span over 100 countries and represent the full spectrum of clinicians and investigators from all the urological subspecialties, including established academic and non-academic urologists, as well as physicians undergoing full-time training in urology.SIU membership gives you an equal voice in this influential organization. We believe that each member can contribute the knowledge and experience needed to forge valuable links between urologists, and between developed and developing nations. By working together, our members carry on the tradition of creating positive change in a changing world. As a new member, you will be a partner in the one urological association dedicated to creating sustainable educational projects and providing and improving urological resources worldwide.Members are able to vote for SIU leadership, organize SIU-endorsed educational activities, become involved in the congress scientific programme, as well as contribute to various SIU Academy programmes. We strive to make each member feel valued, respected, and supported.The SIU network, both virtual and live, is an unparalleled pool of global contacts. SIU brings urologists together.