An increasing number of men with healthy and normal penises want to enlarge their penis. Therefore, this review evaluated the mental health status of men who complained of a small penis and examined the state of nonsurgical and surgical treatments for male patients seeking penile enlargement, along with a risk assessment for each. Various medical, tractional, injectable, and surgical modalities have been investigated for penile augmentation. However, the development of new products and surgical techniques, such as Penuma, and tissue engineering may yield fewer complications, good operative effects, shorter operative times, and high patient satisfaction, bringing hope to patients interested in penile enlargement.

Background: Recent clinical trials have shown that inhibitors targeting programmed cell death protein 1 (PD-1) or its ligand (programmed cell death-ligand 1 [PD-L1]) provide significant efficacy and clinical benefit in the treatment of advanced or metastatic urothelial carcinoma (UC). This systematic review and meta-analysis aimed to compare the effectiveness and safety of PD-1/PD-L1 inhibitors in combination with chemotherapy or PD-1/PD-L1 inhibitor monotherapy versus platinum-based chemotherapy as a first-line treatment for advanced UC.

Materials and methods: From the beginning of the database construction to February 4, 2024, a combination of medical subject headings and free-text words was searched using the Population Intervention Comparison Outcome Study design framework. The PubMed, Cochrane Library, Embase, and Web of Science electronic databases were searched. Meta-analyses of progression-free survival, overall survival, objective response rate (ORR), complete remission rate, duration of remission, and grade ≥3 adverse events were performed.

Results: Four studies were included in the meta-analysis. The PD-1/PD-L1 inhibitors plus chemotherapy therapy is associated with significantly better ORR compared with chemotherapy. Unfortunately, there were no significant differences between PD-1/PD-L1 inhibitor monotherapy and chemotherapy in terms of ORR, duration of remission, or overall survival.

Conclusions: Our findings indicate that PD-1/PD-L1 inhibitors plus chemotherapy therapy provides more oncological advantages than standard chemotherapy and should be recommended as a first-line treatment for advanced or metastatic UC. Attention must also be paid to the adverse effects of the combination of PD-1/PD-L1 inhibitors and chemotherapy.

Objectives: Percutaneous nephropexy (PCN) has been demonstrated as a feasible method for treating nephroptosis. This study describes an improved technique for PCN that better addresses the issue of nephroptosis.

Materials and methods: We reviewed 4 patients who underwent the improved PCN procedure between January 2021 and January 2023. These patients were diagnosed with nephroptosis, with 1 case having both a narrow ureteropelvic junction and nephroptosis due to a kidney stone, and 3 cases having simple nephroptosis. Patient characteristics, perioperative data, and follow-up results were collected. Surgical success was determined by symptom relief (subjective success) and the absence of kidney descent by intravenous pyelography (objective success).

Results: Preoperative computed tomography urography showed that all patients had hydronephrosis, with severe hydronephrosis in 75% (3/4) and moderate hydronephrosis in 25% (1/4) of cases. The mean operative time was 63.8 minutes (range, 45-95 minutes), and the mean blood loss was 5 mL (range, 5-50 mL). The mean length of hospital stay was 4.5 days (range, 3-6 days). The mean time to removal of the nephrostomy tube was 2 months (range, 1-4 months). No serious complications (Clavien-Dindo grade ≥3) occurred during or after the procedure. The mean postoperative serum creatinine level was 54.75 μmol/L (range, 43-65 μmol/L). The mean follow-up time was 6.25 months (range, 4-8 months). The objective and subjective success rates were both 100%.

Conclusions: The improved PCN procedure that was used in this study is feasible and provides a good option for treating nephroptosis.

Introduction: The main goal of managing an obstructed megaureter (OMU) is to preserve the function of the affected kidney. To preserve the upper urinary tract, end cutaneous ureterostomy (ECU) seems to be a promising temporizing option. We aimed to evaluate our experience with ECU in patients with primary and secondary OMU and to demonstrate an efficacy of robot-assisted laparoscopic takedown ureterostomy and subsequent extravesical ureteric reimplantation.

Materials and methods: Retrospective analysis of patients that underwent ECU due to primary or secondary megaureter between 2003 and 2020. Nineteen patients (12 males, 7 females) with a mean age of 4.2 ± 3.5 months (mean ± standard deviation) underwent ECU of 27 renal units. Of those, 11 (57.9%) had primary OMU and 8 (42.1%) had secondary OMU. Undiversion was performed in 16 (84%) out of 19 patients (20 renal units out of 27 [74%]).

Results: In the vast majority of the cases, we have observed improvement in the hydronephrosis and renal function after ureterostomy. After reimplantation ultrasonography showed either stable or further improvement in hydronephrosis in 80% of patients. Robot-assisted laparoscopic patients had shorter admission period and indwelling catheter time after the surgery.

Conclusions: End cutaneous ureterostomy is a safe and effective temporary procedure for the treatment of progressive primary and secondary megaureters. Robot-assisted laparoscopic takedown of ureterostomy with subsequent reimplantation seems to be a good alternative for undiversion and subsequent reimplantation in these patients.

Renal cell carcinoma with inferior vena cava (IVC) tumor thrombus (RCC-IVCTT) has a high mortality rate, and surgery is the only promising treatment. Open surgery has been the gold standard treatment for several decades. However, with the development of minimally invasive surgical technologies, the advantages of robotic surgery have gradually emerged. The classic Mayo Clinic Classification system has certain limitations in guiding robotic surgery. Therefore, a new classification system that is compatible with robotic surgery is urgently needed. Advancements in robotic surgery must be systematically summarized and evaluated. Since Abaza's initial report on robotic surgery, the exploration of robotic radical nephrectomy (RRN) with IVC thrombectomy has resulted in numerous related techniques and approaches, including surgical positions and approaches, control of blood vessels, assisted exposure, step-by-step strategy, and preoperative and intraoperative auxiliary technology and equipment. Our team proposed a new tumor thrombus classification system termed the “301 Classification” based on RRN with venous thrombectomy, which matches each level of tumor thrombus with a distinct robotic surgical strategy. With advances in technology and accumulated experience, RRN with IVC thrombectomy holds promise as the preferred surgical option for RCC-IVCTT. Although “301 Classification” can provide objective advantages in robotic surgery, more cases are needed to be optimized for guiding surgery accurately. The overview provided in this paper aims to serve as a reference and inspiration for future research and clinical practice regarding RCC-IVCTT.

Background: Renal cell carcinoma (RCC) has traditionally been considered to be radioresistant. Response rates are believed to be improved by a high dose of stereotactic body radiotherapy (SBRT). A retrospective analysis was conducted of patients treated with SBRT for metastatic disease from RCC.

Material and methods: We reviewed records from 20 patients who underwent SBRT for a total of 30 RCC metastases from 2015 to 2020. Patients were included who had a confirmed primary RCC and radiographic evidence of metastasis, either synchronous or metachronous. The most common SBRT fractionation was 30 Gy in 3 fractions.

Results: Median age was 60 years (range, 40-77 years) and 60% were male. After a median follow-up of 18 months (range, 3-36 months), overall survival was estimated to be 85% and 70%, at 1 and 2 years, respectively, and local control at 2 years was 83.33%. Only 5 patients had documented progression of disease, all of whom received biologically effective dose inferior to 100 Gy, and no patients treated with a higher biologically effective dose had disease, which progressed. The most common acute toxicity was grade 1 fatigue (20%). No grade 3 or higher acute toxicity occurred.

Conclusions: Treatment with SBRT in patients with RCC metastases yielded a high local control rate, promising survival rate, and low toxicity.

Background: Small renal masses (SRMs) are defined as contrast-enhanced masses with a diameter of ≤4 cm, usually consistent with clinical stage T1a renal cell carcinoma (RCC). This study aimed to explore the histopathological features of a contemporary series of SRMs and investigate parameters that could predict their pathological nature, metastatic potential, and recurrence potential.

Materials and methods: Small renal masses were identified in 166 of 427 patients who underwent surgery for suspected RCC. The radical nephrectomy/partial nephrectomy ratio was 1:44, and autotransplantation was performed in a single case. Variables associated with metastatic recurrence of SRM were analyzed using χ² and logistic regression models.

Results: Renal cell carcinoma was confirmed in 86% (n = 143) of cases, whereas benign tumors were present in 14% (n = 23) of cases. Seventeen percent of the RCC cases were high-grade (Fuhrman G3-4). Among SRMs with a diameter of >2 cm, 71% were malignant. The mean ± standard deviation diameter of the removed SRMs was 28 ± 12 mm, significantly higher in the malignant SRMs group (31 ± 8 vs. 24 ± 9 mm) (p = 0.005). During follow-up, local recurrence was identified in 4 patients versus new distant metastasis in 11 patients. Metastatic lesions were detected in the lungs (1.8%), bone (1.2%), distant (1.9%) and regional lymph nodes (1.2%), liver (0.6%), and multiple organs (2.4%). Patients with malignant SRMs were significantly older than those with benign tumors (p = 0.036). The multivariate analysis identified tumor size, Fuhrman grade, stage, nodal and distant metastasis status, tumor localization, and treatment modality as characteristics significant for tumor recurrence.

Conclusions: The majority of treated neoplasms were malignant, but their incidence was low among SRMs with a diameter of <2 cm. Our results emphasized the importance of histopathological features and treatment modalities in predicting malignant recurrence.

Floseal Hemostatic Matrix is a topical hemostatic agent used across specialties and commonly applied to the renal bed during partial nephrectomy. Here we present the first adult case of Floseal allergy in the literature. A 62-year-old man underwent partial nephrectomy for a Bosniak type IV cyst. After unclamping the kidney, the patient declined precipitously, later determined due to an anaphylactic reaction to the Floseal placed on the renal bed. The patient had a prolonged anaphylactic reaction that required ionotropic support for over 24 h, possibly due to continued exposure. His tryptase level was elevated, and allergy testing revealed an allergy to the gelatin matrix component of the Floseal. Floseal anaphylaxis should be considered during episodes of cardiovascular collapse after drug administration. However, consideration should be given to removing it to prevent continued exposure and weighed against the risk of prolonged surgery in an anaphylactic patient.

Objectives: We explored the expression levels and clinical significance of human epidermal growth factor receptor 2 (HER2) in urothelial carcinoma (UC) tissues.

Materials and methods: Patient data were reviewed, and 111 paraffin specimens of UC obtained from the Department of Urology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, from 2020 to 2021 were collected. Immunohistochemistry was used to detect HER2 protein expression in all UC tumor tissues. The χ² and Fisher exact tests were used to analyze the relationship between HER2 protein expression and clinicopathological data (sex, age, histopathological diagnosis, invasiveness, histopathological grade, maximum tumor diameter, muscle invasion, regional lymph node metastasis, and clinical stage).

Results: In this study, 92 cases (82.88%) showed HER2 protein expression, and there was a statistically significant difference in the distribution of HER2 positivity (immunohistochemistry 2+ and 3+) according to the pathological grades of UC (p = 0.021). Human epidermal growth factor receptor 2 positivity was not associated with sex, age, histopathological diagnosis, invasiveness, maximum tumor diameter, muscle invasion, regional lymph node metastasis, or clinical stage (all p < 0.05).

Conclusions: Human epidermal growth factor receptor 2 protein is highly expressed in UC, and its expression may be closely related to the high pathological grade of UC.

Objective: This study aimed to perform an evaluation of changes in spermogram parameters after follicle-stimulating hormone (FSH) therapy in infertile males having oligo-asthenospermia at different levels of DNA fragmentation index (DFI).

Materials and methods: Infertile men with oligo-asthenospermia, no underlying urogenital disease (such as varicocele), and medically fertile partners were enrolled over 1 year. Semen parameters, FSH, luteinizing hormone, and testosterone levels were determined; also, a Sperm DNA Fragmentation Assay Kit (Hamun Teb Pishro, Tehran, Iran) was used for determining sperm DFI at baseline. Participants were categorized into 3 groups based on DFI: DFI <15% (group 1), DFI of 15%-30% (group 2), and DFI >30% (group 3). All participants received subcutaneous recombinant FSH (150 mg every other day) for 6 months. Sperm specimens were tested 6 months after intervention (a single sperm control test).

Results: Sixty males whose average age was 28.4 years were enrolled. Only group 3 (poor fertility) exhibited a significant rise in sperm concentration (p = 0.001) and motility (p < 0.05) after FSH treatment. Group 1 (DFI <15%) and group 2 (DFI of 15%-30%) showed increased mean sperm concentration and motility postintervention, although these alterations were not significantly different. Follicle-stimulating hormone levels increased significantly in all 3 groups after FSH administration. Serum luteinizing hormone and testosterone levels were not significantly increased in any of the groups.

Conclusions: Follicle-stimulating hormone treatment improves sperm concentration and motility in men with oligo-asthenospermia, with significant improvements observed in men with DFI >30%. DNA fragmentation index can be a predictive indicator of response to FSH treatment in such patients.

Background: Suprapubic catheters (SPCs) are associated with a wide spectrum of undesirable symptoms and complications, ranging from skin overgranulation to septicemia. They can be effectively managed through various medical and healthcare interventions. We compared the impact of illustrated brochure healthcare education (IBHE) and verbal-only healthcare education (VOHE) on early postoperative complications of SPC in patients with low literacy levels.

Materials and methods: Eighty patients with low literacy levels who underwent SPC insertion were randomly allocated to receive either IBHE or VOHE between January 2019 and June 2020. Variables, including postoperative complications (within 30 days), were compared. This study was approved by our institutional review board (IRB number: 1780011/2019).

Results: The IBHE and VOHE groups included 40 patients each. The mean age ± standard deviation was 52.75 ± 16.46 and 53.25 ± 17.19 years, respectively. Acute urinary retention was the main presenting symptom (36 [90%] vs. 34 [85%]), and benign prostatic hyperplasia was the main underlying pathology (16 [40%] vs. 15 [37.5%]). The incidence of SPC obstruction (p = 0.000), urine leakage (p = 0.006), falling out (p = 0.003), suprapubic pain (p = 0.012), exit skin manifestations (p = 0.000), bleeding (p = 0.041), change (p = 0.003), and hematuria (p = 0.000) was significantly lower in IBHE than in VOHE. However, catheter-associated bladder discomfort (p = 0.247), bacteriuria (p = 0.154), and gross pyuria (p = 0.625) were not significantly different between the groups. The frequency of Clavien-Dindo grades was significantly higher in the VOHE group than in the IBHE group. Grade I (87.5% vs. 67.5%, p = 0.032) and grade IIIa (2.5% vs. 22.5%, p = 0.007) were significantly more frequent in the highest grade in IBHE and VOHE groups, respectively.

Conclusions: Illustrated brochure healthcare education appears to be a suitable and effective method for educating low-literacy patients undergoing SPC insertion. It significantly reduced the incidence and grade of early postoperative SPC complications compared with VOHE, except for catheter-associated bladder discomfort, bacteriuria, and gross pyuria.

Background: Laparoscopic transperitoneal donor nephrectomy (LTDN) is currently the standard procedure for renal donation from living donors. Only a handful of clinical studies have compared the outcomes of retroperitoneoscopic donor nephrectomy (RDN) and LTDN. More robust data and systematic comparative analyses of the outcomes and complications of these 2 techniques are needed. This study aimed to elucidate the noninferiority of RDN to LTDN.

Materials and methods: All live renal donors who underwent either RDN or LTDN at our institution during the period of January 2015 to March 2021 were considered subjects, excluding those who refused to participate in the study. This was a bidirectional cohort study. Demographic and clinical data were collected and analyzed using standard statistical methods. Statistical significance was set at p < 0.05.

Results: Our study included 89 subjects: 40 in the LTDN group and 49 in the RDN group. The RDN group had significantly shorter warm ischemia time (2.85 vs. 6.04 minutes), a lower fall in hemoglobin on postoperative day (POD)-1 (1.73 vs. 2.24 g/dL), lower estimated blood loss (601.93 vs. 797.27 mL), and lower pain on POD-1 (0.78 vs. 1.28). The improvement in recipient’s estimated glomerular filtration rate on POD-30 was significantly higher in the RDN group (79.98 vs. 63.73 mL/min/1.73 m²). There was a significantly higher fall in estimated glomerular filtration rate of donor after nephrectomy in RDN group on POD-30 (35.53 vs. 30.60 mL/min/1.73 m²). However, there were no significant differences in other parameters.

Conclusions: Our study, conducted in India, showed that the majority of RDN outcomes were better than those of LTDN. Hence, RDN is clearly non-inferior to the gold standard LTDN. A well-designed randomized controlled study is required to elucidate the statistical superiority of one approach over another.

Background: Renal protection is a frequent indication for urological surgery in pediatric patients; however, preoperative assessment is not routinely performed. We assessed the rates of preoperative renal function testing and stratified outcomes after major pediatric urological surgery. Pediatric urology patients, specifically high-risk patients undergoing genitourinary surgeries, are likely to have an underdiagnosis of renal dysfunction after surgery.

Materials and methods: Cases were identified from the 2012 to 2019 National Surgical Quality Improvement Program—Pediatric database. Patients who underwent major urological surgery on an inpatient basis were included in this study. Abnormal renal function was defined as a creatinine (Cr) level of ≥0.5 mg/dL (younger than 2 years) and a glomerular filtration rate of <90 mL/min (2 years or older). Glomerular filtration rate was calculated using the bedside Schwartz equation (2 years or older): estimated glomerular filtration rate = 0.413 × (height/Cr).

Results: A total of 17,315 patients were included, of whom 3792 (21.9%) had documented Cr values. Based on the defined criteria, abnormal renal function was found in 7.3% of infants (younger than 2 years), 6.3% of children (2-9 years), and 15.0% of adolescents (10-18 years). Patients with abnormal preoperative renal function values were significantly (p < 0.001) more likely to experience readmission (10.2% vs. 5.8%), reoperation (3.7% vs. 1.6%), surgical organ/space infection (0.9% vs. 0.4%), transfusion (1.5% vs. 0.6%), renal insufficiency (1.6% vs. 0.4%), or urinary tract infection (5.1% vs. 3.6%).

Conclusions: In this pediatric population, 21.9% of the patients had documented preoperative Cr values before major urological surgery. Patients with documented abnormal preoperative renal function tests experienced higher complication rates. These patients have higher rates of progressive renal insufficiency and acute renal failure than those with normal renal function. The introduction of a standardized and unbiased risk assessment tool has the potential to offer patients benefits by pinpointing individuals with a heightened risk of complications. Further investigation is necessary to enhance the precise categorization of at-risk patients.

This case study demonstrates a single-position supine approach for robotic retroperitoneal lymph node dissection (R-RPLDN) for the treatment of nonseminomatous germ cell tumors and residual masses after chemotherapy. We performed a bilateral R-RPLDN in a 33-year-old man with nonseminomatous germ cell tumors and residual postchemotherapy masses. For this approach, the patient was placed in a steep Trendelenburg position, and a 5-port transperitoneal technique was used, with the robot docked so that the arms were oriented cephalad. This approach allowed simultaneous access to both sides of the retroperitoneum, thereby eliminating the need for bilateral lymphadenectomy and patient repositioning. Bilateral R-RPLDN was performed using a single-position supine approach. This versatile approach offers a less invasive, more efficient, and safer solution for removing residual postchemotherapy testicular cancer masses.