Ioannis Mykoniatis

Should we expand the indications for varicocele treatment

Current guidelines suggest that treatment of varicocele should be considered in patients with clinically palpable disease and abnormal semen parameters. However, the clinicians are often challenged with the decision whether to treat varicocele in patients with testicular pain or low testosterone levels. Moreover, varicocele is highly associated with DNA fragmentation due to the oxidative stress and it has been demonstrated that surgical repair of varicocele ameliorates oxidative stress markers and consequently the sperm DNA integrity. These new markers could have an adjunctive role to standard semen parameters especially when normal semen analysis is found in adult men with conventional methods. This review presents a contemporary overview of the rationale for varicocele treatment, as well as of the relationship between varicocele and other novel parameters such as DNA fragmentation index and reactive oxygen species. We will also discuss data from several recent series demonstrating that surgical treatment and especially microsurgical approach could resolve testicular pain, increase testosterone levels and fertility rate both in patients with non-obstructive azoospermia as well as in normozoospermia men. The correlation with progressive testicular failure will be also examined. We hope that this overview will provide clinicians with an evidence-based approach to managing these unanswered and conflicting topics.

Bladder cancer to patients younger than 30 years: a retrospective study and review of the literature

Objectives The aim of this report was to study the specific characteristics of bladder cancer in patients younger than 30 years. Materials and Methods Five patients with a mean age of 24 ± 2.83 years were included in the study. All patients had painless macroscopic hematuria as the first symptom. Three patients had pTa as a first diagnosis, one had pT1 and one pT2. All the patients had smoking as a risk factor and at least one additional possible risk factor. Results One patient with pTa had an aggressive course and after multiple recurrences was diagnosed with pT2 and refused to be submitted to radical cystectomy and died from the disease even though he received a multimodality treatment. The other two patients with the pTa diagnosis had no recurrence after the first TUR-BT and the patient with the pT1 diagnosis after one recurrence with a pTa histology is free of recurrence for the last 2 years. The patient diagnosed with pT2 was submitted to a radical cystectomy and an s-pouch diversion with a preservation of the genital system in order to have the ability of a future motherhood with the acceptance of course risks. Conclusions Young patients with bladder cancer is a difficult group of patients and show more reluctance to comply to the necessary strict follow-up of the repeated urinary cytology examinations, cystoscopies and CT pyelographies. Herein, we report a retrospective study of five patients younger than 30 years with bladder cancer.

Immunotherapy options for painful bladder syndrome: what’s the potential?

ABSTRACT Introduction: Painful bladder syndrome/interstitial cystitis (PBS/IC) is an enigmatic disease characterized by lack of evidence-based knowledge and an ongoing scientific debate regarding its definition, pathogenesis, diagnostic and treatment algorithm. An autoimmune theory for PBS/IC etiology has suggested immunotherapy as a potential treatment choice. Areas covered: In this review, the authors report existing and future immunotherapeutic options, potentially valuable to the management of PBS/IC while evidence for the immunological aspect of PBS/IC pathogenesis are also presented. Relevant data reported in human clinical studies but also in experimental studies using animal PBS/IC models have been reviewed. Expert opinion: Promising data has emerged lately regarding use of immunotherapy drugs for PBS/IC treatment. Specifically, human monoclonal antibodies inhibiting nerve growth factor and tumor necrosis factor-a have shown high efficacy in pain control for PBS/IC. Also, many other agents modulating immunopathways linked to PBS symptom etiology and leading to positive treatment effects have been reported lately mainly in experimental animal studies. Immunotherapy could potentially improve disease-related and patient-reported outcome; nevertheless, lack of consensus regarding PBS/IC diagnostic criteria, leading to high heterogeneity of patients enrolled in PBS/IC treatment studies, and low number of well-designed randomized clinical trials are limitations which must be addressed in the future.

Stem cell therapy in erectile dysfunction: science fiction or realistic treatment option?

Stem cell therapy has become a subject of great interest to researchers worldwide. One of the medical conditions being studied for possible treatment with the use of stem cells is erectile dysfunction, and particularly organic and post-radical prostatectomy erectile dysfunction. However, is stem cell therapy a viable treatment option for erectile dysfunction? The current body of literature provides a wide array of clinical trials performed on animal models simulating different types of human erectile dysfunction. Unfortunately, only a handful of studies have been performed on human patients and almost all of them were phase 1 studies limited by the small sample size. This review aims to summarize the available evidence on the use of stem cell therapy for the treatment of erectile dysfunction and also to provide an overview of upcoming and ongoing clinical trials in this field.

Non-visible asymptomatic haematuria: a review of the guidelines from the urologist’s perspective

ABSTRACT Introduction: Non-visible hematuria, also referred to as ‘microscopic hematuria’ or ‘dipstick positive hematuria’ is a common reason for urology referrals with prevalence rates that range from 13% to 20%. The main concern for investigating non-visible hematuria, especially in the absence of lower urinary tract symptoms, is its potential relation to urinary tract malignancy, which however does not exceed 5%. The pathway of investigation of non-visible hematuria is impeded by the lack of clarity over definitions, diagnosis and specialist referral criteria. Towards that goal guidelines have been introduced by different societies. In this review we aim to discuss differences in current guideline regarding the investigation, management and follow up of non-visible hematuria. Areas covered: Guidelines, recommendations, algorithms and original articles on hematuria published in the English literature were retrieved using the following PubMed search terms ‘microscopic hematuria’, ‘dipstick hematuria’, ‘non-visible hematuria’ and ‘guidelines’. Expert commentary: Available guidelines for investigation of microscopic hematuria actually differ both in the extent and the intensity of the proposed imaging and invasive tests. There is evidence that guidelines are not adhered to and this reflects the necessity for introducing selection criteria and maybe variable levels of investigation for microscopic hematuria depending on the individual patient.

Single lower calyceal percutaneous tract combined with flexible nephroscopy: A valuable treatment paradigm for staghorn stones

INTRODUCTION We evaluated the efficacy and safety of single lower calyceal tract combined with flexible nephroscopy for the management of staghorn renal stones by percutaneous nephrolithotomy. METHODS The medical records of patients who underwent percutaneous nephrolithotomy for the management of staghorn stones were analyzed. We included patients aged >18 years, while patients with incomplete data and renal anatomical anomalies were excluded from the study. Stone-free rate, postoperative complications, procedure duration, fluoroscopy time, and length of hospitalization were recorded. Postoperative outcomes were evaluated by non-contrast computed tomography scan 4-6 weeks after the operation. Stone-free status was defined as the absence of residual stones >4 mm. RESULTS The study cohort consisted of 103 consecutive patients. Stone-free rate was 65.0%. No complications were observed in 69.9% of the cases; most postoperative complications were Grade 1 (13.6%) and 2 (10.7%). Five patients (4.9%) suffered a Grade 3a complication and another patient (1.0%) suffered a Grade 3b complication. CONCLUSIONS Percutaneous nephrolithotomy through a single lower calyceal tract combined with flexible nephroscopy can be a valuable treatment option for the treatment of staghorn calculi, providing efficacy and safety. Nevertheless, the present study is limited by both its retrospective nature and being conducted at a single centre and, thus, proper prospective studies with head-on comparisons are needed to prove or disprove the advantages and disadvantages of either approach.

Giant scrotal fibrolipoma

Fibrolipoma, an infrequent histological subtype of lipoma, is considered a benign mesenchymal neoplasm. Fibrolipoma of the scrotum is an even more rare entity. We report a case of a 55-year-old male complaining for a slow-growing, painless mass in his left hemis-crotum. Imaging with ultrasonography and magnetic resonance imaging was inconclusive regarding the nature of the tumor and the tumor was excised, sparing the testis. The surgical specimen was a well-defined, yellowish white, solid, and firm mass, measuring 19.5×7×5 cm. There was no cytological atypia or mitosis and no lipoblasts recognized. On immunohistochemistry, MDM2 and CDK4 were not expressed. The histopathology report was fibrolipoma of the scrotum. To the best of our knowledge, this is only the fourth case of fibrolipoma originating from the scrotal components, spermatic cord or testis that has been reported in the English literature.