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Comparison between TRUS and TP: The patient perspective

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Authors: S.Mustafa, W.Elabroni, A.McAdam,S. Elamin A.Thwaini

Urology Department, Belfast Health and Social Care Trust. United Kingdom

Accepted at the ANNUAL MEETING OF THE IRISH SOCIETY of UROLOGY (ISU)
Friday 23 and Saturday 24 September 2022

Introduction

Prostate cancer is the most common cancer in men with around 47,500 men in the UK diagnosed every year. Diagnostic approaches have evolved throughout the years, with a shift from transrectal (TRUS) biopsies to transperineal (TP) for various reasons. This study focuses on the patient experience of these procedures.

Method

We evaluated men who underwent prostatic biopsies between January 2019 and April 2020. 110 underwent local TP biopsy with a previous history of local TRUS biopsy. We used a modified validated patient-related outcome measure for our questionnaire for our cohort.

Results

The response rate was 78% (N=86). Overall, the majority of respondents (77%) prefer TP over TRUS biopsy. A large proportion, 86%, found TP to be a “minor- moderate procedure” with only 14% viewing it as a “major but tolerable under local anesthetic”. In terms of pain with TP biopsy, 22% of the respondents found the procedure to be completely painless, 43% experienced a little amount of pain, 29% found it to be somewhat painful, and 6% experienced a lot of pain during the procedure. 50% would not have a problem with undergoing a further TP biopsy in the future. Only 9% felt that it would be a major problem for them to undergo further procedures.

Conclusion

Our study demonstrates, that Transperineal Prostate biopsy appears to be preferable with patients having undergone both procedures; with the majority experiencing little or no pain with TP biopsies and a large proportion describing it as a “minor- moderate procedure” that they would not mind undergoing again if needed.

Stem Cell Therapy in Urethral Stricture Disease; a Concept

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Regenerative medicine is a relatively young field in the treatment of various conditions. Several novel applications of various types of stem cells have been tried and applied in various aspects of urology. Some published articles provide promising early results.
 
There are two main sources of stem cells. These are embryonic stem cells (ESCs) and adult-derived stem cells (ADSC). The latter has many sources including bone marrow stem cells (BMSCs), skeletal-muscle-derived stem cells (SkMSCs), adipose-tissue-derived stem cells (ADSCs), and arguably, amniotic-fluid-derived stem cells (AFSCs).
 
Stem cell use in urology:
 
BMSCs, SkMSCs, and AFSCs have been used for bladder augmentation and detrusor regeneration in animals. SkMSCs are the only stem cells to have been successfully tested in humans, for the treatment of stress urinary incontinence. ESCs, BMSCs, and SkMSCs have been shown to improve erectile function in animal models. Both ESCs and BMSCs can be differentiated into sperm and, remarkably, the ESC-derived sperms have generated offspring in mice.
 
Adipose-derived stem cells:
 
ADSC research is a relatively young field, and these cells are largely unstudied in urology. However, as a result of their high differentiation potential and ease of isolation, ADSCs represent an exciting resource for tissue engineering and regenerative medicine within and beyond urology.
 
Male urethral stricture disease:
 
This is one of the common urological conditions mainly affecting young men, and occasionally older men. The main causes are inflammatory from recurrent urethritis and urethral injury, whether from an accident or iatrogenic.
 
Until recently, the treatment of urethral stricture is mainly surgical, starting from endoscopic dilatation or urethrotomy, both have a high risk of recurrence, starting from 50% with increasing failure of cure in recurrent ones. Several attempts have been made to combat this problem. Many use intermittent dilatation, that though keeps the uretha patent, it induces more inflammatory reactions from repetitive trauma. The other way is major surgery, called urethroplasty, with a higher success rate but comes at a higher price of complications list (such as infection, bleeding, penile curvature, sexual dysfunction, and of course, recurrence of the stricture).
 
The main reason for the failure of urethral dilatations is the inflammatory reaction generated by the procedure, with resulting fibrosis.
 
This where stem cell therapy comes into place. Stem cells provide an alternative way of healing. Once deployed in the area of injury, they differentiate into the local functional cells (in this case the urothelium and possibly, in dense strictures, spongial tissue). This has the potential to prevent the usual inflammatory process that follows trauma, with potentially less scarring.

 Hypothesis:
 
Stem cells, once applied to the area of urethra dilatation/urethrotomy, in the same operative setting, might increase the chance of success of the operation, obviating the need for repetitive endoscopic dilatations and even urethroplasty.

Study proposal and methods:
 
A prospective randomized double blinded study is proposed, aiming at recruiting 40 participants;
 

  • Group I: n=20 who would receive the conventional urethral dilatation/optical urethrotomy. In addition, they would receive ADSC.
  • Group II: n=20 would receive the conventional urethral dilatation/optical urethrotomy.
     
    Procedure (Group I):
     
    Under general anaesthesia (whilst having the urethral dilatation). ADSC will be harvested by liposuction from the abdominal fat using micro-cannula and two tiny abdominal wall incisions. This fat would be then treated for mechanical extraction of the stem cells using purposely made nano blades. The process would take an extra half-an-hour to prepare. The resultant fluid containing stem cells would be then injected via the cystoscope into the area of the urethral dilatation/urethrotomy.

Post-operative care:
 
Both groups will have the same post-operative protocol; mainly having a urethral catheter, that will remain in situ from several hours up to 5 days depending on the density of the urethral stricture.
 
Follow up:
 
Anonymized and coded participants in both groups will have their first post-operative follow-up with an independent and “blinded” clinician, in two weeks, one month, three months, six months, and one year respectively. The follow-up will entail clinical assessment along with UroFlow rate measurement.
 
Results:
 
Once analyzed, the results will be written, presented at conferences, and will be published.
 

Summary:

The future of medicine ( and I dare to say that the possible demise of surgery!) lies in the development and application of stem cells to treat and possibly cure patients with various conditions.

However, as exciting as it seems, this application is quite novel, at least in many medical and surgical specialities, and it’s the application will have to be carried out within a reach, ethics, and Governance framework.

Once properly applied, the prospects are endless

Adult Derived Stem Cells with Low-Intensity Shock Wave for the Treatment of Male Erectile Dysfunction

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Treatment of Male Erectile Dysfunction

Regenerative medicine is a relatively young field in the treatment of various conditions. Several novel applications of various types of stem cells have been tried and applied in various aspects of urology. Some published articles provide promising early results.
 
There are two main sources of stem cells. These are embryonic stem cells (ESCs) and adult-derived stem cells (ADSC). The latter has many sources including bone marrow stem cells (BMSCs), skeletal-muscle-derived stem cells (SkMSCs), adipose-tissue-derived stem cells (ADSCs), and arguably, amniotic-fluid-derived stem cells (AFSCs).

Stem cell use in urology:

 
BMSCs, SkMSCs, and AFSCs have been used for bladder augmentation and detrusor regeneration in animals. SkMSCs are the only stem cells to have been successfully tested in humans, for the treatment of stress urinary incontinence. ESCs, BMSCs and SkMSCs have been shown to improve erectile function in animal models. Both ESCs and BMSCs can be differentiated into sperm and, remarkably, the ESC-derived sperms have generated offspring in mice.

Adipose-derived stem cells:


ADSC research is a relatively young field, and these cells are largely unstudied in urology. However, as a result of their high differentiation potential and ease of isolation, ADSCs represent an exciting resource for tissue engineering and regenerative medicine within and beyond urology.

ADSC’s need a target tissue to reach and excerpt their regenerative action. Signals are needed from the affected tissue to attract them.

Low-Intensity Shock Wave Therapy (Li-ESWT)

This relatively new modality of treatment is gaining acceptance with encouraging intermediate-term results, as proven with their approval as part of the urology guidelines.

Shock waves appear to induce micro trauma to the tether tissue hence, stimulate vascular flow and erectile function and one possible mechanism of action are through an endogenous stem cell-mediated regenerative effect. This micro trauma not only stimulates the local regenerative process, but the resultant signals act as a lighthouse for the ADSC’s to reach and synergistically enhance the local regenerative and repair process in the penile corpora.

Evidence:

Elliot Lander and Mark Berman reported a case series whereby 52 patients with Erectile Dysfunction received a concurrent combination of Li-ESWTand intracavernosal injection of autologous SVF (rich in MSCs and HSCs) from human lipoaspirate.

Initially SVF was harvested via liposuction and sent for preparation. Patients received Li-ESWT while awaiting the SVF preparation process. Then a tourniquet was applied to the base of the penis and 10 cc of SVF was injected into one side of the corpora cavernosa. The tourniquet was removed after 20 min.

Overall, 37 out of 52 patients (71%) reported an improvement in erectile function after combined SVF and Li-ESWT. None of the other fifteen patients reported worsening of their erectile function after treatment.

Future studies are needed in the form of placebo randomized trials to better establish the effects of stem cells combined with shock waves on Erectile Dysfunction.

Festive Seasons and their Effects on your Urinary System

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Christmas has just passed and we are still in the partying mode, preparing for the new year. It’s been tough couple of years with yet another wave, albeit less virulent, of COVID’s new disguise; Omicron.

We are on the verge of winning our war against it. It’s indeed worth the celebration. One has to be careful though with the effects of alcohol on our urinary system. The Celebration should not be at the expense of our health and the safety of people around us. Here are some facts about alcohol and its effects on our urinary system.

The effect of Alcohol on the kidneys:

Alcohol alters the filtration function of the kidneys adversely resulting in the reduction of its efficacy, thus rendering them less able to filter the blood.

Alcohol also affects the ability to regulate fluid and electrolytes in the body. It has a natural diuretic effect leading to frequent visits to the toilet after many drinks. This, however, leads to intracellular dehydration, resulting in loss of excess fluid and an Increase in electrolyte concentration in the body.

Regular heavy drinking has been found to double the risk of chronic kidney disease, which does not go away over time. Even a higher risk of kidney problems has been found for heavy drinkers who also smoke.

The Centers for Disease Control estimates that most American adults (two out of three) drink alcohol. Too often, some of these regular drinkers have more than five drinks at one time. In fact, about a quarter of drinkers reported they had done this on at least one day in the past year. “Binge” drinking is even worse. It has harmful effects on the kidney that can even lead to acute kidney failure. A sudden drop in kidney function is called acute kidney failure. This often goes away after a time, but it can occasionally lead to lasting kidney damage.

Added to that is the effect of chronic drinking on the increase in blood pressure resulting in different levels of kidney damage with protein loss in the urine.

Studies have demonstrated the effects of chronic alcohol intake on the cellular structure of the building brick of the kidney; The nephron. It’s been shown that the basement membrane of various aspects of the nephron develops an increase in its thickness, therefore hindering its ability to perform its filtration and concentration functions properly.

The effects of alcohol on the urinary bladder:

Alcohol has a double adverse effect on the urinary bladder: It has a strong diuretic affect leading to excessive frequency and urgency.

It will also lead to dehydration resulting in more concentrated urine, which causes burning of micturition by the concentrated urine.

It has been shown previously by various experiments when the bladder gets distended, the intravesical pressure increases to a peek after which (especially in situations not permitting paying visits to the toilet) the pressure drops down simply due to the thinning of the bladder muscle. This results and the reduction and pressure necessary to generate in order to empty the urinary bladder (law of Laplas).

Also, chronic alcohol intake leads to nerve damage resulting in “alcoholic cystopathy”. This would potentially lead to the current urinary retention.

In summary:

Drinking can be fun in certain cultures, let’s be honest. Excessive alcohol intake can lead to injury, accidents, serious embarrassment and long-term health problems. Even drinking small amounts of alcohol increases your cancer risk.

There are a few tips for those who would enjoy having a drink with their family and friends.

  • Eat before drinking to minimize the direct effect of alcohol on your body.
  • Drink plenty of water.
  • Don’t mix alcohol with sugary or energy drinks.
  • Avoid salty snacks – they will make you thirsty and likely to drink more.
  • Be in control of the number of drinks you take: Set yourself a drinks limit and stick to it. Avoid drinking in rounds (especially with friends who drink too much). Try to finish your drink before you start another, rather than topping up your glass.
  • Slow down when you drink: To keep safe, slow down your drinking to 1 drink per hour. You can do this by:
  • drinking non-alcoholic drinks as well as alcoholic drinks
  • drinking water to quench your thirst before you start drinking alcohol
  • opting for low-alcohol drinks. sipping rather than gulping

Wish you a Happy New Year

References:

Appearance and Performance-enhancing Drugs(APED)

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So you have been working hard in the gym trying to improve your appearance and performance. Things aren’t moving with the aspired speed. There are other ways to achieve your goal at a much shorter time and minimal side effects, correct?

Wrong! Cutting corners always comes at a price. In addition to the bumpy ride and money spent on APED, you will get some results in improving your “appearance” but at the expense on your performance; both physically and mentally.

Normally cutting corners might get you back in track albeit it at a price. When it comes to using/absolute abusing APEDs, the price is higher, and recovery is significantly longer..

What are APEDs?

  • Anabolic-androgenic steroids. These are synthetic substances similar to the male sex hormone testosterone. They promote the growth of skeletal muscle (anabolic effects) and the development of male sexual characteristics (androgenic effects) in both males and females
  • Non-steroidal anabolics: include insulin, insulin-like growth hormone (IGF), and human growth hormone (HGH)—substances that are produced by the human body and are prescribed for legitimate medical uses but also sometimes misused for performance enhancement.

There are several misused APEDs, these include:

Oral Steroids
 • Anadrol (oxymetholone)
• Anavar (oxandrolone)
• Dianabol (methandienone )
• Winstrol (stanozolol)
• Restandol (testosterone undecanoate)
Injectable Steroids
 • Deca-Durabolin (nandrolone decanoate)
• Durabolin (nandrolone phenpropionate)
• Depo-Testosterone (testosterone cypionate)
• Agovirin (testosterone propionate)
• Retandrol (testosterone phenylpropionate)
• Equipoise (boldenone undecylenate)

Other Mia-used medications
 Many who practice using APED’s would be keen to try other medications that accentuate the function in terms of enhancing their body image. Some are thermogenics. These are compounds used to decrease body fat or to promote leanness versus muscle mass in endurance athletes.

Examples:

  • Xanthines: compounds that increase attention and wakefulness and suppress appetite. Examples are caffeine, the asthma drug theophylline, and theobromine—a substance found in chocolate, coffee, and tea.
  • Sympathomimetics: drugs that are similar in structure and action to epinephrine and norepinephrine—natural chemicals in the body that increase heart rate, constrict blood vessels, and raise blood pressure. An example is ephedrine, which is derived from the ephedra plant. Ephedrine/ephedra used to be included in dietary supplements that promoted weight loss, increased energy, and enhanced athletic performance. In 2004, the FDA banned the U.S. sale of dietary supplements containing ephedrine/ephedra due to various possible health risks including cardiovascular and nervous system effects.
  • Thyroid hormones: substances that regulate metabolism by altering the function of the thyroid. Cytomel is an example.

Cycling, stacking, pyramiding, and plateauing:

There are several traditionally used methods to inappropriately use these drugs; cycling involves taking multiple doses of steroids over a specific period of time, stopping for a period (so called “clearance”), and starting again.

Stacking means taking two or more different anabolic steroids, mixing oral and/or injectable types, and sometimes even taking compounds that are designed for veterinary use.

Pyramiding is taking APEDs for 6 to 12 weeks, tapering gradually rather than starting and finishing a cycle abruptly. At the beginning of a cycle, the person starts with low doses of the drugs being stacked and then slowly increases the doses. In the second half of the cycle, the doses are slowly decreased to zero. This is sometimes followed by a second cycle in which the person continues to train but without drugs. Steroid users believe that pyramiding allows the body time to adjust to the high doses, and the drug-free cycle allows the body’s hormonal system time to recuperate.

Plateauing is another medically unjustified hormonal manipulation whereby steroids are staggered, overlapped, or substituted with another type of steroid to avoid developing tolerance.

Side effects:

The use of anabolic steroids is associated with a wide spectrum of side effects, some of which are mild and others are severe or even life-threatening. Some are temporary and others are semi-permanent or permanent.

One review found 19 deaths in published case reports related to anabolic steroid use between 1990 and 2012.

APEDs effects on body:

Cardiovascular System

Inappropriate use of anabolic steroids could affect the cardiovascular system by raising the blood pressure and interfering with the cardiac function leading to heart failure and cardiac events, in addition to the development of the deranged lipid profile and increasing liability to Venus thrombosis and embolism.

Hormonal System

Abnormal use of steroids leads to disturbance in the hormonal function including testicular atrophy decreased quality and quantity of sperm production degrees libido especially after withdrawal symptoms in addition to sexual dysfunction.

Females with anabolic steroids miss-use will potentially have an adverse effect of these APEDs on the hair leading to frontal boldness, in addition to deepening of the voice. With continued administration of steroids, some of these effects become irreversible. It is commonly believed that anabolic steroids will produce irreversible enlargement of the clitoris in females.

Liver damage

Chronic use of APEDs is associated with impaired liver function, hepatic cysts, and in rare cases, malignancy

Musculoskeletal System

Unjustified use of anabolic steroids in adolescence might potentially lead to premature closure of the growth plates for the bones leading to short stature. In addition, excessive use of anabolic steroids needs to change in stiffening, which might lead to a tendon injury.

Skin

Acne, unsightly and uncomfortably oil skin. Yellowish discoloration in advanced cases of liver damage

Behavioral changes

An experienced andrologist would be able to spot APED users from a distance. There’s a clear agitation and aggression in extreme cases. In addition, anabolic steroid abusers would suffer from anxiety lack of sleep and depression.

Although testosterone replacement in cases of deficiency has a proven fact on improving the cognitive function in the construction ability, younger people using anabolic steroids excessively might suffer from cognitive dysfunction Maile lots of attention span and concentration ability.

How to treat an existing case of a PED miss-use:

This is naturally and multidisciplinary team Approach. This includes the following:

  • Endocrine treatment to restore the answer genic function for those with withdrawal symptoms
  • Antidepressants for those who do not respond to Endocrine replacement therapy
  • Psychological assessment and support for those who are suffering from body dysmorphia.

In summary:

Are the use of appearance and performance-enhancing drugs as an increasing phenomenon at an alarming rate with serious potentially permanent consequences affecting young Adolescence and adults. There needs to be white education about their potential side effects and in case of medical needs for these medications this should take place under strict supervision. Those who are interested in enhancing their appearance and performance should concentrate on the physiological increase by Healthy diet and exercise.

Otherwise, cutting corners by unjustified usage of these medications would possibly give short term results and definitely give long-term consequences

Reference: drugabuse



Chronic Prostatitis

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Background

Chronic prostatitis is a condition with a persistent inflammation of the prostate gland. This is rather a very common condition affecting man that’s all ages. It is presumed that at least one of two men will have at least one attack prostatitis during their lifetime.

Types of prostatitis

There are several types of chronic prostatitis ranging between those caused by a bacterial invasion and the more coming others being caused by chronic inflammatory process of unknown origin. This is traditionally called chronic abacterial prostatitis. Other forms of put the tightest could give the same symptoms without an inflammatory reaction and they are typically called prostatodynia or type III prostatitis. The last form is being only histologically diagnosed without any symptoms.

Chronic prostatitis Symptoms

There’s a reason behind naming chronic prostatitis as chronic pelvic pain syndrome. This is usually due to the vague presentation and different manifestations in different men. This could be ranging in the form of penile tip pain or scrotal discomfort. Others could present with chronic low back pain and pain during ejaculation. This could be well associated with storage lower urinary tract symptoms.

Chronic prostatitis Management

Thankfully this condition is not sinister however due to its vague symptoms and chronicity, curing it remains a challenge

The management starts from lifestyle modifications and adopting a healthy lifestyle, including sexual health, and avoiding irritating food and extreme temperature changes.

The medical management and has a wide spectrum of treatment options including empirical antibiotic courses, according to the European Association of Urology guidelines. These were historically from the family of quinolones. However, that has now changed into Fosfomycin. In addition, there are other medical treatments, which are mainly for symptom symptom control those are in the form of alpha-blockers and nonsteroidal anti-inflammatory agents in addition to amitriptyline small doses.

For resistant cases, peri-prosthetic injection of local anesthetic and / or steroids can be tried with promising intermediate term outcomes.

Other interventional procedures the experimental have some limited success mail in the form of shockwave therapy and microwave therapy.

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