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ORIGINAL ARTICLES
Virtual reality simulator face validity for topographic real situation of inflated abdomen
Tuncay Tas, Basri Çakiroglu, Esra Akdeniz, Ismet Aydin Hazar, Can Balci
April-June 2021, 33(2):35-39
DOI:10.4103/HUAJ.HUAJ_30_21  
Objective: The aim of this study is to investigate the face validity of LapSIM® (haptic feedback Xitact™ IHP, Mentice AB, Sweden) for the topographic real condition of the inflated abdomen in upper urinary tract laparoscopic interventions. Materials and Methods: The present study was conducted with 30 urologists with experience in transperitoneal laparoscopic renal surgery. Surgeons were divided into three groups: novices, intermediate experience, and experts. After performing the tasks, the participants were then asked to finish a five-item questionnaire regarding the face validity of the simulator. Participants answered questions with ratings from 1 (not realistic/useful) to 5 (very realistic/useful). Results: The mean age of the study group was 38.33 ± 5.45 (29–47) years. The mean years of experience of the doctors were 4.27 ± 1.89 (1–7) years. All the variables showed significant differences from the ideal value of 5. We also tested whether the medians differed from 3, and the restrained body posture of the surgeon, the monitor position, and the trocar position not show significance with one-sided P value of P = 0.825, P = 0.992, and P = 0.265, respectively. Conclusion: Although the LapSIM® virtual reality simulator provides face validity for the topographic real condition of the inflated abdomen, it should be improved.
  9,224 126 -
REVIEW ARTICLES
The online learning in medical education: A novel challenge in the era of COVID-19 pandemic
Fouad Ayoub, Mohamad Moussa, Athanasios G Papatsoris, Mohamad Abou Chakra, Nazih Bou Chahine, Youssef Fares
April-June 2020, 32(2):89-96
DOI:10.4103/HUAJ.HUAJ_9_20  
Online learning has a well-established role in medical education, and it is well accepted by students. Electronic learning (e-learning) strategy is aimed at improving the quality of medical education by providing students with equal access to quality learning resources. The main advantages of online learning are its flexibility and the capacity for learning to be self-paced. Online learning may be particularly useful for under- and post-graduate medical education. Virtual lectures can substitute conventional lectures in medical education in multiple fields. Online learning has several barriers including lack of time and poor technical skills of their providers, inadequate infrastructure, and the absence of development strategies of the universities. The current COVID-19 pandemic may represent a real challenge to medical education. Online learning techniques can be used to complete the curricula for medical schools during this crisis. This review presents a robust evidence base for e-learning in medical education. Further, it compares online and offline learning methods in medical education.
  4,571 353 2
ORIGINAL ARTICLES
Lessons learned from the POUT trial: Adjuvant chemotherapy does improve the outcomes of patients treated with radical nephroureterectomy for upper tract urothelial carcinoma
Achilles Ploumidis, Athanasios Pappas, Idir Ouzaid, Evanguelos Xylinas
April-June 2020, 32(2):73-74
DOI:10.4103/HUAJ.HUAJ_8_20  
Introduction: The management of patients with upper tract urothelial carcinoma (UTUC) is challenging, with radical nephroureterectomy (RNU) being the gold standard of treatment for high-risk disease. The role of chemotherapy is unclear. The POUT trial is a multicenter UK effort that addresses whether adjuvant chemotherapy improves disease-free survival (DFS) in patients with locally advanced and/or node-positive UTUC. Methods: The POUT trial enrolled 262 patients with UTUC (pT2-T4, N0-3, and M0) between 2012 and 2017. The patients were randomized (1:1) to four cycles of adjuvant gemcitabine–cisplatine (gemcitabine–carboplatin if GFR 30–49 ml/s) or surveillance following RNU. The patients were followed with cross-sectional imaging and cystoscopy every 6 months for the first 2 years and then annually for 5 years. The primary end point was DFS, whereas recurrence-free survival (RFS), overall survival (OS), toxicity, and quality of life (QoL) were the secondary end points. Results: The intent-to-treat analysis was conducted in 262 patients (131 chemotherapy and 131 surveillance). Among the patients treated with chemotherapy, 66% were offered gem-cis, while 68% completed successfully the four planned chemotherapy cycles. Approximately 50% of the patients undergoing chemotherapy developed Grade 3 or greater adverse events. A significant improvement in DFS (hazard ratio [HR]: 0.49 [confidence interval (CI): 0.31–0.76], P = 0.001) was observed at a median follow-up of 17.3 months. Considering the secondary end points, adjuvant chemotherapy was also associated with an improvement in RFS (HR: 0.49 [CI: 0.30–0.78], P = 0.02). Following adjustment for nodal involvement, the difference was more pronounced with a HR: 0.47 (CI: 0.30–0.74), P = 0.001. A difference in the OS curves favoring the adjuvant chemotherapy arm was noticed, but the difference remained nonsignificant due to short follow-up. Conclusions: The POUT trial provides exciting and convincing Level I evidence on the benefit associated with adjuvant chemotherapy administration in patients with locally invasive or node-positive UTUC.
  2,315 182 -
Our experience in the treatment of grade 4 renal injuries
Dimitrios Moschotzopoulos, Charalampos Fragkoulis, Georgios Theoxaris, Ioannis Glykas, Miltiadis Gravanis, Georgios Karydas, Georgios Stathouros, Georgios Papadopoulos, Konstantinos Ntoumas
April-June 2020, 32(2):80-83
DOI:10.4103/HUAJ.HUAJ_3_20  
Introduction: The aim of this study is to evaluate treatment modalities in patients with Grade 4 renal injury. Materials and Methods: In this retrospective study, we included a total of 64 patients who were diagnosed with Grade 4 renal injury at our trauma center hospital from 2015 to 2019. Patients who underwent immediate laparotomy due to concomitant injuries or penetrating wounds were excluded from the study. Hemodynamic instability was the absolute indication for nephrectomy as well as failure to respond to conservative treatment. Results: In our study, 10 patients (15.6%) underwent immediate nephrectomy due to hemodynamic instability. In 15 out of 54 remaining patients, arterial embolization was performed. Twelve patients presented with urinoma which required intervention. In this subgroup of patients, a double J stent was inserted in four of the patients and a nephrostomy tube was placed in the remaining eight patients for perinephric space drainage. Nephrectomy was performed in four of the patients in the urinoma group. From the patients treated totally conservative, two presented with perirenal abscess, but only one underwent computed tomography-guided abscess drainage. Conclusion: Patients with Grade 4 renal injuries may be treated conservatively or in a minimally invasive way, and immediate nephrectomy should be performed only in case of hemodynamic instability.
  2,259 177 -
Nephrometry scoring system selects candidates for radical nephrectomy versus nephron-sparing surgery for treatment of renal masses and predicts surgical and oncological outcome
Ahmed Mohamed Saafan, Hossam Abdelsamie Abdelmonem Mohamed, Magdy Fathallah Mansour, Mohamed Kotb Ahmed Tolba
April-June 2020, 32(2):75-79
DOI:10.4103/HUAJ.HUAJ_6_20  
Purpose: The study was designed to ensure the sensitivity of preoperative planning by applying radius, endophytic/exophytic, nearness to collecting system, anterior/posterior, and location to poles (RENAL) nephrometry scoring system on computed tomography films of patients having organ-confined solid and cystic renal tumors and to assess its correlation with the surgical technique by applying RENAL on the specimen intraoperative. Materials and Methods: Eighty-five patients with organ-confined solid and cystic renal masses underwent RENAL nephrometry system which was correlated with the surgical technique either radical or nephron-sparing surgery or the surgical and oncological outcome. Results: RENAL nephrometry scoring system shows high sensitivity with the type and outcome of surgery of resection of the renal tumors. Conclusion: RENAL nephrometry score system is an objective method to help in the decision of surgical approach to resect organ-confined solid and cystic renal tumors.
  2,263 169 -
Acupuncture as a treatment choice for persistent chronic bacterial prostatitis-related symptoms: A pilot study

July-September 2020, 32(3):109-112
DOI:10.4103/HUAJ.HUAJ_18_20  
Background and Aim: In several chronic bacterial prostatitis (CBP) cases, symptoms persist despite bacterial eradication. Since acupuncture has been shown to ameliorate the symptoms of chronic prostatitis/chronic pelvic pain syndrome, it may be an effective treatment option for clinically untreated CBP cases. In order to investigate the above hypothesis, we performed a pilot study. Methods: Patients with persistent CBP-related symptoms and confirmed bacterial eradication were randomly allocated to acupuncture or conventional medical treatment. Symptom burden was assessed at baseline, weeks 4 and 12. Eight patients received 30-min sessions of acupuncture twice weekly for 1 month (Group 1), ten patients received lornoxicam 8 mg orally once daily for 1 month (Group 2), eight patients received Serenoa repens (SR) 320 mg twice daily for 1 month (Group 3), and nine patients received pregabalin 25 mg twice daily for 1 month (Group 4). The primary outcome is the proportion of responders at week 4 with significant change from baseline in the National Institutes of Health Chronic Prostatitis Symptom Index (NIH-CPSI) total score and International Prostate Symptom Score (IPSS) at week 4. Secondary outcomes included ratings of clinical pain (visual analog scale) and quality of life at week 12. Results: At week 4, no statistically significant differences in the mean decrease of NIH-CPSI and IPSS total scores from baseline among groups were noted. After 12 weeks, none of the participants experienced complete resolution of pain. Differences in the mean pain and quality of life levels were statistically insignificant. Conclusion: Acupuncture is an effective treatment option for persistent CBP-related pain however is inferior to conventional medical treatment in reducing CBP-related lower urinary tract symptoms. For this reason, it may be offered in combination with medical therapy in patients with combined symptoms.
  2,116 159 -
REVIEW ARTICLES
Use of carbohydrate antigen 19-9 in the management of bladder cancer
Muhammad Faisal Khan, Georgios Tsampoukas
April-June 2020, 32(2):84-88
DOI:10.4103/HUAJ.HUAJ_5_20  
Over the years, a distant effort has been made to find new prognostic biomarkers in the assessment of accurate response to treatment and detection of recurrences of bladder cancer. Among them, the carbohydrate-rich glycoprotein, Carbohydrate Antigen (CA) 19-9 has shown some usefulness as it is linked with the tumour aggressiveness and the prognosis of disease. Aim of this study is to review available evidence about the role of CA 19-9 in diagnosis, staging and prognosis of bladder cancer. After careful review of the related articles, a total of 16 useful and valued studies were found on the database. These studies evaluated relation of CA 19-9 to various different aspects of bladder cancer. These aspects include use of CA 19-9 as a tool for detection of bladder cancer, its role in the assessment of the prognosis at diagnosis and also looked at the significance of the CA 19-9 in the response to treatment of bladder cancer. These studies indicate that CA19-9 sensitivity and specificity was 71.6 and 91.6 in high-grade tumour and sensitivity of 74% and 83% in Ta and T1 tumours. Serum levels of > 29 U/ml are associated with shorter survival time and carried a 2.54 higher risk of death. High levels in metastatic disease are associated with increase response to chemotherapy. Although these results are encouraging, but due to the limited evidence, there can be no strong recommendation for use of the biomarker CA 19-9 and further studies are needed to establish a useful link.
  2,072 152 -
ORIGINAL ARTICLES
Intravesical botulinum toxin Type A injection therapy in neurological patients: A single center experience

July-September 2020, 32(3):103-108
DOI:10.4103/HUAJ.HUAJ_15_20  
Objectives: The objective of this study is to present real-life data on the efficacy and safety of the intravesical injection of the approved dose of 200U BOTOX in patients with drug-resistant incontinence of neurogenic etiology. Available literature is relatively limited. Materials and Methods: We analyzed routinely collected prospective data from the treatment of patients with neurogenic drug-resistant incontinence who attended an academic neurourology outpatient clinic. All patients received at least one intravesical injection of 200U BOTOX, following urodynamic confirmation of neurogenic detrusor overactivity while recording the presence of urinary tract infection (UTI). Patients were followedup at 6 and 24 weeks with urodynamic retests. This protocol was followed with each repeat treatment, while recording the relapse time of incontinence. Results: Forty-nine patients (28 males, 21 females, mean age 47.04 ± 14.16 years) were treated; 18 (36.7%) suffered from spinal cord injury, 12 (24.54%) from multiple sclerosis, and the rest from other neurological conditions. Fifteen received a 2nd Botox treatment, 10 a 3rd, 6 a 4th, and one a 5th and 6th session. Forty-two (85.7%) patients had urodynamically proven incontinence and in 14 (28.6%) an UTI was identified before the first treatment. Subjective cure of incontinence was recorded in 73.7% of patients after the first treatment. There was no correlation of gender, neurological diagnosis, or presence of UTI before the BOTOX treatment with the persistence of incontinence. The median relapse time after the first two treatments was 6 (interquartile range = 5) and 10.5 months, respectively (P = 0.31). Significant improvements were recorded urodynamically in maximum cystometric capacity after each treatment (P < 0.001) and in maximum detrusor pressure after the first session compared to baseline (P < 0.05, Bonferonni correction). The presence of UTI did not affect the incontinence relapse time or urodynamic changes after initial treatment. Conclusions: In the present cohort, intravesical administration of 200U BOTOX achieved complete cure of neurogenic drug-resistant incontinence in a significant proportion of patients with sustained clinical and urodynamic changes after each repeat injection.
  2,027 169 -
CASE REPORTS
Traumatic testicular dislocation – A case report
Andreas P Christodoulides, Zafiro Kiriazi, Ziad Milad Ibrahim
April-June 2020, 32(2):99-102
DOI:10.4103/HUAJ.HUAJ_7_20  
We report a motorcyclist who presented with a case of empty scrotum and bilateral dislocated testes in the groin after a blunt scrotal injury. Ultrasound and computed tomography revealed viable testes. Manual reduction was performed with success under anesthesia following orchidopexy. The patient made an uneventful recovery.
  2,018 154 -
ORIGINAL ARTICLES
Improvement of health-related quality of life in patients with overactive bladder syndrome: A subanalysis of the prospective, noninterventional study BELIEVE in the Greek population
Apostolos Apostolidis, Garyfalia Petoumenou, Manto Tzanetakou
October-December 2020, 32(4):135-144
DOI:10.4103/HUAJ.HUAJ_17_21  
Objective: The BELIEVE study is a prospective, noninterventional study which was conducted in a real-world setting in Europe and assessed quality of life, treatment satisfaction, healthcare resource utilization, and persistence with treatment in patients with overactive bladder (OAB) syndrome prescribed mirabegron as part of routine clinical practice. We present the results of a subanalysis of the BELIEVE study in the Greek population. Materials and Methods: The primary endpoint was change from baseline in quality of life (QoL) based on the OAB-questionnaire (OAB-q), consisting of the Symptom Bother Scale and health-related QoL (HRQoL). Change from baseline in QoL based on the EQ-5D-5 L health survey, treatment patterns and persistence with treatment, as well as adverse events during the study were also assessed. The duration of the observation period was 12 months. Results: A total of 97 OAB patients from 10 sites in Greece participated in the substudy; 89 completed the OAB-q at baseline and at least at one follow-up visit (Full Analysis Set, mean age 62.7 ± 10.9 years, 86.5% female). At baseline, 73% of patients were “new,” 14.6% were “lapsed,” 9% switched treatment, and 3.4% were on combination treatment. The scores in the Symptom Bother Scale and HRQoL Scale improved significantly from baseline at 10–12 months (−32.4 ± 2.54 and 30.2 ± 2.49, respectively). The EQ-5D subscales confirmed that mirabegron led to an improvement in the HRQoL of patients. At 10–12 months, 72% of patients were continuing on mirabegron treatment for OAB, either as single treatment (60%) or as combination treatment (12%). Mirabegron was well-tolerated, as no serious drug-related adverse events (AEs) were observed, whereas only a small percentage (6.2%) of drug-related AEs resulted in treatment discontinuation. Conclusions: The Greek population subanalysis confirmed the European results of the BELIEVE study. Patients who received mirabegron in a real-world setting showed clinically meaningful improvements in HRQoL. Mirabegron demonstrated a high persistence rate (72% at 12 months), and good tolerability. The overall improvement in HRQoL, particularly in the population continuing to receive mirabegron at 10–12 months, and the low incidence of AEs may have contributed to the high persistence rate.
  1,805 270 -
Extracorporeal shock wave lithotripsy for bladder stones: Does it have any role in the modern endourology era?

July-September 2020, 32(3):113-116
DOI:10.4103/HUAJ.HUAJ_20_20  
Bladder lithiasis accounts for around 5% of all urinary tract stones diseases with typical symptoms dysuria, hematuria, urgency and intermittent urination. therapy, percutaneous procedures, and open surgical treatments have been replaced by transurethral lithotripsy. The aim of this study is to investigate the safety and efficacy of extracorporeal shock wave lithotripsy (ESWL) in the treatment of vesical lithiasis. A total of 47 patients underwent ESWL for bladder calculi, using the electromagnetic Dornier Lithotripter S. Stone and prostate size as well as postvoid urine residual was determined with sonography. The success of the procedure was determined in the absence of stone fragments after 4 weeks. The mean age of patients was 69.1 years (34–93 ± 11.43) with a median prostate size at 50.1 cm3 (0–85 ± 15.81) and an average postvoid residual at 131 ml (50–190 ± 32.82). The mean size of lithiasis was found 1.97 cm (1–4.5 ± 0.79) and the median number of impact waves 2704.34 (1800–3000 ± 293.37) with the average duration of session 20.63 min (15–25 ± 2.63). Only two patients received analgesic treatment and the mean pain visual analog scale score was 1.73 (0–4 ± 0.98). The stone-free rate was found at 76.5% (36/47) and no severe complications (Clavien–Dindo >2) were observed. ESWL is a safe and efficient alternative for the management of vesical lithiasis, especially for high-risk patients that are not candidates for a more invasive treatment.
  1,894 165 -
REVIEW ARTICLES
Acupuncture in the treatment of chronic prostatitis/chronic pelvic pain syndrome: A brief review

July-September 2020, 32(3):117-120
DOI:10.4103/HUAJ.HUAJ_17_20  
Introduction/Aim: Chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS) affects many adult men worldwide. It has been almost a decade since the introduction of acupuncture on CP/CPPS treatment. Since then, a number of studies have been performed. The aim of the study was to assess the effects and safety of the use of acupuncture for CP/CPPS. Materials and Methods: A systematic search was performed in electronic libraries for clinical trials, experimental studies, and systematic reviews on the topic using the terms: “chronic prostatitis,” “chronic pelvic pain syndrome,” “acupuncture” combined with the keywords: “treatment,” “efficacy,” and “safety,” in various combinations. In order to provide accurate conclusions, we evaluated only randomized studies focused on the effects and safety data of acupuncture in the treatment of CP/CPPS-related symptoms. Only trials performed in patients with confirmed CP/CPPS randomized with adequate methods and providing clear outcome reports were finally evaluated. Only full-text available papers written in the English language were considered. There was no restriction on publication date. Results: According to our research, 40 papers examining the role of the acupuncture in the treatment of CP/CPPS exist. Only 8 out of 40 fulfilled the above-mentioned criteria. Overall, evidence supports acupuncture as an effective treatment for CP/CPPS-induced symptoms, particularly in relieving pain. Regarding long-term responses without additional treatment, the examined studies provide inconsistent information. Moreover, evidence regarding urination problems is limited. Conclusion: Available data suggest that acupuncture treatment is able to decrease CP/CPPS related pain. Since it was associated with rare and slightly adverse events, it could be considered as a safe complementary therapeutic option for men with CP/CPPS.
  1,822 158 -
Nephrometry scores in renal cancer

July-September 2020, 32(3):121-127
DOI:10.4103/HUAJ.HUAJ_21_20  
Several independent tools and measurements can be used to assess the same endpoint. This is the case for renal tumors, for which different nephrometry scores (NSs) based on preoperative imaging are currently available. These systems provide objective information with regard to surgical complexity, risk of blood loss, ischemia time, and perioperative complications that can assist physicians in the decision-making process and in planning the most appropriate surgical approach. In this review article, the most widely used preoperative NSs are being mentioned; their parameters are analyzed and their usefulness and reliability in everyday clinical and surgical practice are being compared.
  1,804 125 -
CASE REPORTS
Case report: Polycystic horseshoe kidney incidentally detected in a male geriatric patient – Review of the literature
Sophia Voidila, Panagiotis Sideris
April-June 2020, 32(2):97-98
DOI:10.4103/HUAJ.HUAJ_4_20  
The case concerns a geriatric male patient who was hospitalized for gastrointestinal symptoms. Polycystic horseshoe kidney was incidentally detected during imaging. The spectrum of clinical manifestations is broad extending from asymptomatic patients (e.g., the presented case) to patients with acute deterioration demanding surgical treatment. Concomitant presence of renal polycystic disease and horseshoe anomaly is likely to bring closer the age of the presentation of renal failure, due to polycystic disease, and complicates the surgical technique for nephrectomy. Due to the rarity of the anomaly, there is lack of clinical experience, so is of clinical importance to report such cases.
  1,772 146 -
ORIGINAL ARTICLES
Upper-pole infra-costal access for supine percutaneous nephrolithotomy: Advantage or risk?
Stylianos Kontos, Niamh Smyth, Athanasios Papatsoris, Sarath Krishna Nalagatla
October-December 2020, 32(4):148-152
DOI:10.4103/HUAJ.HUAJ_11_20  
Objective: There are still disagreements in choosing a better approach to establish a percutaneous tract for percutaneous nephrolithotomy (PCNL), between supine and prone positions. The aim of this study is to investigate the safety, efficacy, and practicability of treating upper-pole renal stones, using an infra-costal puncture in both prone and supine positions. Materials and Methods: Fifteen patients underwent infra-costal puncture for the percutaneous treatment of upper-pole stones at our institution over a 3-year period. Seven patients underwent a prone procedure and six had a supine PCNL. All punctures were undertaken by two consultant urologists. Stone clearance was assessed with a plain X-ray kidney-ureter-bladder on postoperative day 1. We retrospectively analyzed our prospectively maintained database to assess stone clearance, complications, and length of stay of these patients. Results: The overall stone-free rate was 93.3% (all but one patient). One hundred percentage of the prone group were stone free following the procedure. Nearly 87.5% of the supine group had a complete clearance. Complications and length of stay were comparable for both groups. Almost 25% of the supine group and 14% of the prone group required transfusion. The postoperative pyrexia rates were similar for both groups. The overall complication rate was 26.7% (n = 4) – one case of sepsis and three patients required blood transfusion. There were no thoracic complications. Conclusions: Upper-pole renal stones can be safely and effectively treated percutaneously using direct upper-pole puncture via an infra-costal approach in supine position, as well as in prone position.
  1,683 191 -
CASE REPORT
Partial orchiectomy: Experience of four cases in a secondary hospital of greece

July-September 2020, 32(3):132-134
DOI:10.4103/HUAJ.HUAJ_16_20  
Aim of the Study: The aim of this study is to review our collective experience with partial orchectomy due to testicular tumors in a secondary hospital of Greece. Materials and Methods: In total four young patients with relative indications for a partial orchectomy (single testis and/or tumors <2 cm in diameter, patient consent for a close follow-up, negative tumor markers) underwent partial orchiectomy in our institution. All operations were performed under clamping of the spermatic cord, and postoperative period was uneventful. Results: Pathology examination revealed one case of Sertoli cell only tumor, one patient with testicular cancer of mixed pathology (embryonal and teratoma), one case of organized hematoma, and one case with focal atypical inflammation. Patients underwent a close follow-up protocol. The patient with the mixed tumor was subjected to adjuvant chemotherapy with BEP (bleomycin, etoposide, cisplatin). The patient with atypical inflammation had a single testis due to a history of contralateral seminoma. During follow-up, he developed local tumor recurrence and underwent orchiectomy that revealed the presence of seminoma. The patient was set under testosterone replacement therapy. Conclusions: Partial orchiectomy represents a safe treatment option in the management of small testicular tumors. A benign pathology in up to 50% of cases should be expected. In case of both malignant and benign pathologies, a close follow-up is deemed necessary for the timely recognition of local recurrences in case of insufficient cancer eradication.
  1,639 137 -
ORIGINAL ARTICLES
Idiopathic urethritis in childhood: Presentation of five cases
Chrysie Koutsaftiki, Alexia Papatheodoropoulou, Diomidis Kozyrakis
October-December 2020, 32(4):145-147
DOI:10.4103/HUAJ.HUAJ_13_21  
Introduction: Idiopathic urethritis (IU) in childhood is a rare disease with very few cases reported so far. Methods: During the past 3 years, the medical records of young boys diagnosed with and treated for IU in our department were retrieved and analyzed. Herein, their clinical course is presented, and a brief review of the literature is performed. Results: Five young male patients (mean age: 8.2 years) presented to the pediatric office with blood spotting of the underwear or urethral discharge, with or without dysuria. All the patients were treated in an outpatient basis and the corresponding clinical courses after a mean follow-up was 15.8 months were favorable. Conclusions: IU is a rare disease with a generally benign clinical course. Treatment must be tailored to symptomatic relief with avoidance of antibiotics. An aggressive diagnostic workup should be reserved to those with persistent symptoms or frequent recurrences.
  1,579 172 -
REVIEW ARTICLES
Prostate cancer therapies and fertility: What do we really know?
Panagiotis Mourmouris, Lazaros Tzelves, Titos Deverakis, Lazaros Lazarou, Kimon Tsirkas, Anastasia Fotsali, Christiana Roidi, Ioannis Varkarakis
October-December 2020, 32(4):153-156
DOI:10.4103/HUAJ.HUAJ_9_21  
We reviewed the literature for articles in English in the Medline database from 1970 until today. The keywords used were “prostate cancer,” “fertility,” “radical prostatectomy,” “external beam radiotherapy,” “androgen deprivation therapy,” and “chemotherapy.” Only the studies with full paper were included in our review. The knowledge for this important issue is minimal and more minimal tends to be the consent of the patients. Prostate cancer does not seem to directly influence fertility, but all its therapies directly or indirectly seem to do so. In many of them, the impact may be reversible, but the mechanisms of this impact are still under consideration. Prostate cancer treatments, predominantly radiation, can cause long-term azoospermia; however, the data in the literature are sparse, mainly derived from small series, and based on these, no safe conclusions can be drawn.
  1,475 217 -
Optimizing anticancer therapy in newly diagnosed metastatic castration sensitive prostate cancer

July-September 2020, 32(3):128-131
DOI:10.4103/HUAJ.HUAJ_19_20  
Historically, androgen deprivation therapy has been the standard of care in the management of metastatic castration sensitive prostate cancer (mCSPC). However, during the past 5 years, numerous different treatment options have become available and have been set under investigation. The addition of docetaxel or abiraterone acetate has improved outcomes for patients with mCSPC and has become a new standard of care. New drugs targeting androgen receptor axis, local therapy including surgery, radiotherapy, and brachytherapy as well as metastatic-directed treatments have also demonstrated promising outcomes. In this work, the available data on all treatment modalities employed in mCSPC are being reviewed.
  1,522 123 -
Antioxidants and oligoasthenoteratozoospermia: A review of the literature
Christos Roidos, Stilianos Giannakopoulos
October-December 2020, 32(4):157-162
DOI:10.4103/HUAJ.HUAJ_22_21  
The present review examines whether and to which extent the antioxidant drugs have a role in the management of patients with oligoasthenoteratozoospermia (OAT). Subfertility and especially semen parameters disorders presented as OAT have been associated with increased oxidative stress and on this basis, several studies of antioxidants administration toward its treatment have been carried out. In the limits of this literature review and by using scientific publications search engines (PubMed, Medscape, Cochrane Library, Google Scholar), 285 related studies were found in total. Among them, the 34 more relevant to the investigated topic, with a complete statistical analysis, were isolated and included in the present review. It seems that there is a significant positive impact of antioxidants on semen parameters' improvement and childbearing. However, these studies are quite heterogeneous and more studies are required, for safe conclusions to be extracted. Administration of antioxidants to those men should be a matter of individualized approach.
  1,434 142 -
CASE REPORTS
A 36-year-old patient with acute urinary retention due to an anterior midline prostatic cyst: A case report and review of the literature
Dimitrios Deligiannis, Konstantinos Adamos, Angelos Tselos, Stamatios Mavrikos
October-December 2020, 32(4):163-166
DOI:10.4103/HUAJ.HUAJ_21_21  
During the years, there have been no more than a few reports (with ours being so far the sixth) of prostatic cysts prolapsing into the bladder and thus causing urinary obstruction. Most of those cystic formations are generally asymptomatic and are found during random controls. In our case, the cyst was located in the anterior midline of the prostate in a 36-years-old patient presenting at the E. R with severe suprapubic pain and urinary retention after 3 months of constantly deteriorating lower urinary tract symptoms. Transabdominal ultrasonography and magnetic resonance imaging revealed a projecting prostatic cyst that like a valve was blocking the bladder neck at 12 o'clock position. It was successfully removed by transurethral resection leaving the patient free of symptoms.
  1,191 135 2
REVIEW ARTICLES
Rare histolopathologic variants in bladder cancer
Eleftherios Tsiakoulas, Anastasios Zarkadas, Vasileios Tzortzis, Diomidis Kozyrakis
April-June 2021, 33(2):45-49
DOI:10.4103/HUAJ.HUAJ_41_21  
The heterogeneous spectrum of bladder cancer comprises the coexistence of conventional urothelial carcinoma (UC) with its variants as well as the non-urothelial carcinoma (including squamous and glandular tumors). Since the official classification of rare histologic subtypes, by the World Health Organization (WHO) in 2004, uropathologists and urologists are paying more attention to the role of these subtypes as potential prognostic markers. Most of these rare variants have been associated with increased risk of progression and poor prognosis. Therefore, patients diagnosed with some of the histologic subtypes, have been classified to “the very high risk group” of recurrence and progression, although it has not yet been clarified if this is due to advanced stages at presentation and underdiagnosis or due to the aggressiveness of each variant, as an independent factor. This review discusses the most common variants of bladder cancer (urothelial carcinoma with squamous and/or glandular differentiation, pure squamous carcinoma, pure adenocarcinoma, urachal carcinoma, nested pattern, microcystic, micropapillary, small cell carcinoma, plasmacytoid, sarcomatoid, and lymphoepithelial like carcinoma), outlining the recent advances regarding the diagnosis, differential diagnosis, treatment and clinical significance for each one. High index of suspicious is required by the uropathologists for detection of these variants and well-designed multi-institutional studies are necessary in order the specific treatment strategies for these patients to be established.
  1,088 121 -
ORIGINAL ARTICLES
The impact of age and education level in the linguistic validation of the Acute Cystitis Symptom Score (ACSS) questionnaire
Konstantinos Stamatiou, Evangelia Samara, Jakhongir F Alidjanov, Kurt G Naber, Adrian Pilatz, Florian M Wagenlehner
January-March 2021, 33(1):1-4
DOI:10.4103/HUAJ.HUAJ_19_21  
Introduction/Purpose: The Acute Cystitis Symptom Score (ACSS) was developed as a simple and self-reporting questionnaire for diagnosing and monitoring acute uncomplicated cystitis in female patients. It consists of 18 questions placed in four subcategories: (1) typical symptoms, (2) differential diagnosis, (3) quality of life and (4) coexisting gynecological conditions. It has been translated into many languages. The purpose of this work is the linguistic evaluation of ACSS in the Greek language. Materials and Methods: The translation of ACSS into Greek was carried out in accordance with international standards and guidelines. The process consisted of 4 stages: in the 1st and 2nd stage a translation was made into the target language (Greek) from the original (Russian, English) by native speakers, while reverse translation and re-evaluation was made by experts whose mother tongue language is the target language. In stage 3, a cognitive assessment was performed by female subjects with and without a history of uncomplicated urinary tract infection. At this stage, based on the degree of understanding, the final draft was chosen between the two drafts of different origins (Russian or English). In stage 4: the final clinical evaluation was performed by female subjects with acute episode of uncomplicated cystitis (Arm 1 - Patients) and female subjects undergoing treatment for any other diseases (Arm 2 - Control). The Memorandum of Understanding between the Greek Study Group of ACSS and the copyright holders of ACSS was made on 17 November 2019 while it has been approved by the Ethics Committee of the Hospital. The diagnosis of acute uncomplicated cystitis was made based on the history and results of laboratory findings. Results: The two pre-final versions in Greek were randomly applied to 15 healthy women aged between 89 and 22 years. The mean age of the final sample was 23.84 years. The level of education differed between a doctorate and a primary school diploma with most participants graduating from universities (8/30) and high school (8/30). According to the answers, 20 women would prefer the English standard translation, compared to 10 women, who preferred the Russian translation. The 2: 1 ratio was similar whether the participants had higher education or not. No significant difference was observed in the mean age of the participants who chose one or the other version. Conclusion: The process of translating and adapting a study instrument such as a questionnaire for a different ethnic group is a difficult task since it requires to adapt it in a culturally relevant and comprehensible form despite peculiarities of the target language. Considering these difficulties, we were able to develop a linguistically validated Greek version of the ACSS, which now can be used for clinical and research purposes in a multidisciplinary fashion.
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CASE REPORTS
Mucinous adenocarcinoma of the prostate found incidentally in adenomectomy specimen complicated with vesicocutaneous fistulae
Spinos Theodoros, Lardas Michail, Kotoulas Grigorios, Thanos Anastasios, Kyriazis Iason
April-June 2021, 33(2):53-55
DOI:10.4103/HUAJ.HUAJ_34_21  
Primary mucinous tumors of the prostate gland are rare, including mucinous adenocarcinoma, prostatic adenocarcinoma with mucinous features, and mucinous adenocarcinoma of the prostatic urethra. In this report, we present a case of a locally advanced mucinous variant of prostatic ductal adenocarcinoma, found incidentally during pathology examination of an adenomectomy specimen, after bladder outlet obstruction surgery. Recent large studies indicated that mucinous adenocarcinoma of the prostate, treated by radical prostatectomy, is not more aggressive than ordinary nonmucinous prostatic adenocarcinoma. In our case, the rapid deterioration of our patient, the return of tumor in its initial size soon after surgery, in addition to its distal metastatic spread should be attributed not only to the mucinous variant of prostatic adenocarcinoma but also to the advanced stage during initial diagnosis and the noncompliance of the patient with the suggested treatment after surgery, omitting radiotherapy, and hormonal maneuvers.
  954 93 -
Conservative management of hemodynamically stable patient with grade V renal trauma: Case presentation and review of the literature
Charalampos Fragkoulis, Ioannis Glykas, Dimitrios Moschotzopoulos, Odysseas Aristas, Georgios Papadopoulos, Georgios Stathouros, Konstantinos Ntoumas
October-December 2020, 32(4):167-169
DOI:10.4103/HUAJ.HUAJ_26_21  
Renal trauma is a major health problem involving mostly young patients. It is estimated that renal trauma is diagnosed in almost 5% of all trauma patients. Patients diagnosed with Grade V renal trauma require surgical intervention and usually nephrectomy. The aim of this study is to present a case of Grade V renal trauma in a hemodynamically stable patient treated conservatively in our department. A 24-year-old male was admitted to the urology department due to Grade V left renal trauma after a motor accident. The patient presented with hematuria and was hemodynamically stable. A conservative approach was performed with close monitoring of hemodynamic status. Two red blood cells units was transfused. The patient remained hemodynamically stable and renal hematoma reduced in size in follow-up computed tomography. The patient was discharged in excellent clinical status after 17 days of hospitalization. Although Grade V renal trauma involving vascular injury requires immediate surgical intervention, in selected patients diagnosed with shattered kidney, a conservative approach may be successful provided that the patient remains hemodynamically stable and under close monitoring. Hemodynamic instability is an absolute indication for surgical exploration and possible nephrectomy.
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