This article reports the current evidence and expert opinions on patient-centered bladder management of neurogenic lower urinary tract dysfunction (NLUTD) among chronic spinal cord injured (SCI) patients in Taiwan. The main problems with SCI-NLUTD are failure to store, empty, or both. The management of SCI-NLUTD should be prioritized as follows: (a) preservation of renal function, (b) freedom from urinary tract infection, (c) efficient bladder emptying, (d) freedom from indwelling catheters, (e) patient agreement with management, and (f) avoidance of medication after proper management. The management of NLUTD in SCI patients must be based on urodynamic findings rather than neurologic evaluation inferences. It is important to identify high-risk patients to prevent renal functional deterioration in those with chronic SCI-NLUTD. Urodynamic studies should be performed on patients with SCI on a regular basis, and any urological complications should be adequately treated. When surgery is required, less invasive and reversible procedures should be considered first, and any unnecessary surgery in the lower urinary tract should be avoided. The most important aspect of treatment is to improve the quality of life in SCI patients with NLUTD. Annual active surveillance of bladder and renal function is required to avoid renal function deterioration and urological complications, particularly in high-risk SCI patients.

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Purpose: Collecting duct carcinoma of the kidney (CDC) is an aggressive subtype of renal cell carcinoma with a dismal prognosis. The available knowledge concerning optimal management is still unclear. We report the largest single-institutional experience in the management of CDC. Materials and Methods: All the cases of CDC which were diagnosed at our center following a radical or partial nephrectomy in the past 15 years were included. Treatment details, radiological features, and histological features were reviewed. Descriptive statistics were used to show the clinicopathological profile and management of these patients, and Kaplan–Meier overall survival (OS) estimate was calculated. Results: Eighteen patients who were diagnosed and underwent the primary intervention at our center were included. The median age of patients was 40 years, with a male-to-female ratio of 5:1. Typical histopathological features included high-grade nuclear features, stromal desmoplasia, and tubular architecture. Surgery was the primary modality of treatment. Five (28%) patients who had metastases received adjuvant therapy, three received interferon-alpha therapy, and two received adjuvant chemotherapy with gemcitabine and cisplatin. The median follow-up was 19 months (range: 3–46 months). Kaplan–Meier OS estimate was 68% at 1 year and 48% at 3 years. Conclusion: CDC of the kidney often presents at an advanced stage, and has a poor prognosis. Survival remains poor despite surgery and adjuvant therapy.

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Small renal masses (SRM) are defined as contrast-enhancing solid masses detected on diagnostic imaging, with a size of less than or equal to 4cm, corresponding to renal cell carcinoma stage T1a. These tumours are mainly benign, with an indolent nature and rare metastatic potential. Given the size and nature of these tumours, there has been a significant evolution and in management modalities of these tumours. These range from conventional radical approaches such as radical nephrectomy, partial nephrectomy, to more conservative approaches such as active surveillance, and some novel emerging management strategies such as various thermal ablation techniques. The treatment decision depends on patient factors such as age and co-morbidity, and tumour factor on radiological imaging, such as tumour size, location, growth rate and biopsy result. In this review, we aim to provide the latest updates on approaching SRM and various management modalities.

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Purpose: This study aimed to determine survival rate and clinical characteristics of testicular tumor patients with a history of scrotal violation. Materials and Methods: This study was a retrospective cohort; we reviewed medical records from 2017 to 2021 with testicular tumors who had a history of scrotal violation. We evaluate clinical characteristics and survival up to 5 years. We used the KaplanMeier survival analysis and log-rank test. Results: There are 27 patients with testicular tumor who had a history of scrotal violation. Based on histopathological findings, the most common type was seminoma testis. While based on TNMS staging of the testicular tumor, the most common presentation is T2; Nx; Mx; and S3. Furthermore, based on the prognostic group for testicular tumor we found 5 patients with stage IB, 15 patients with stage IS, 2 patients with stage II, and 5 patients with stage III. Clinical manifestations of scrotal violation were residual tumor found in scrotal region in 2 patients, inguinal and abdominal region in 3 patients. Using the Kaplan-Meier survival curve, the 5-year survival rate was 44% from Statistical test in log-rank test, a significant result is obtained. Conclusion: Survival rate of testicular tumors who had a history of scrotal violation were lower and influenced by ECOG Performance Status Scale. Prognosis of a scrotal breach in the late stage may have a higher mortality rate. In contrast, there was a significant difference in outcome if the scrotal violation had been known at the early stages.

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Purpose: To evaluate the patient-reported outcomes of primary direct visual internal urethrotomy (DVIU) and nontransecting bulbar urethroplasty techniques (NTBU) for the short segment (<2 cm) nontraumatic bulbar urethral stricture using the modified urethral stricture surgery patient-reported outcome measures (USS PROMs). Materials and Methods: The USS PROM questionnaire used to evaluate lower urinary tract symptom (LUTS) was modified by adding a six-item International Index of Erectile Function and a four-item version of MSHQ-EjD to evaluate erectile and ejaculatory domains. All cases of short nontraumatic bulbar urethral stricture who underwent primary DVIU and NTBU who consented were asked to fill the modified PROM at initial evaluation, at 6 months, and at 1 year. Results: The LUTS score for NTBU at 12 months is significantly better (1.93 ± 2.13 vs. 8.76 ± 5.92, P = 0.000). The Peeling score of the NTBU is significantly better at 12 months (1.41 ± 0.68 vs. 2.67 ± 0.73, P = 0.000). The erectile function score at 12 months for NTBU is better than DVIU (24.37 ± 3.2 vs. 21.143 ± 2.86, P = 0.001). The Ejaculatory function score at 6 months and 12 months is significantly better for the NTBU. Receiver operating characteristic (ROC) AND Odd's Ratio analysis for analyzing patient satisfaction showed erectile function (area under ROC [AUROC] - 0.889, P < 0.001), ejaculatory function (AUROC - 0.957, P < 0.001) at 1 year and maximum flow rate of urine on uroflometry (Qmax) (AUROC - 0.928, P < 0.001) at 6 months and (AUROC - 1.000, P < 0.001) at 1 year. The overall satisfaction rates in patients undergoing NTBU is 96.5%. Conclusion: NTBU shows superior outcomes in almost all domains of USS-PROM with better overall satisfaction rates. Improvement of sexual function domain, followed by the LUTS domain was the best predictor of overall patient satisfaction and improvement in the quality of life at 1 year.

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Purpose: Sequential ureteral dilatation facilitates placement of ureteral access sheath during retrograde intrarenal surgery. The authors adopted some improvisations in conventional sequential ureteral dilatation methods to achieve improved ureteral accommodation and prefer to call the sequential ureteral dilatation performed with these improvisations as “Rule of five” (ROF) ureteral dilatation. The objective of the article was to describe the “ROF” ureteral dilatation technique and share the preliminary experience with the technique. Materials and Methods: “ROF” ureteral dilatation involves repetitive dilatation of ureter for five times by 10 Fr ureteral dilator, with each dilatation lasting for 5 s. The technique was used in patients who underwent retrograde intrarenal surgery for renal calculi and in whom 12 Fr ureteral dilator passage and 9.5/11.5 Fr ureteral access sheath placement was not possible by conventional sequential ureteral dilatation methods. Preliminary efficacy and safety outcomes were reported. Results: “ROF” ureteral dilatation was performed in 14 renal units. Ureteral access sheath placement was successful in 10 renal units (71.4%) and unsuccessful in 4 renal units (28.6%). Ureteral access sheath associated low-grade ureteral wall injury was noted in 2 renal units (14.3%). None had new onset hydroureteronephrosis in follow-up ultrasonography and all patients were asymptomatic in the follow-up period. Conclusion: “ROF” ureteral dilatation is an improvisation of conventional sequential ureteral dilatation. It facilitates successful and safe ureteral access sheath placement in a proportion of patients undergoing sequential ureteral dilatation.

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Purpose: This study aimed to review the functional urology guidelines, relate the level of evidence (LOE) of their recommendations and highlight the discrepancies between the LOE and grade of recommendation. Materials and Methods: The electronic search was conducted in May 2019 and updated in February 2021. Three researchers separately reviewed the extracted guidelines based on the Appraisal of Guidelines for Research and Evaluation II instrument. We extracted recommendations from each guideline and ranked them into three Grades of A, B, and C; and their evidence into four levels of I to IV. Results: Among the published functional urology guidelines, 18 guidelines were published between 2014 and 2020. Overall, 592 recommendations were abstracted. Of these, 121 recommendations were related to evaluation or diagnosis, and the others (n = 471) on the disease management. These recommendations were in the field of urinary incontinence (UI) (n = 216), overactive bladder (OAB) (n = 172), lower urinary tract symptoms (LUTS) (n = 126), and neurogenic bladder (NGB) (n = 78). Subgroup analysis showed that most of the recommendations in relation to UI were Grade A (n = 111; 51.4%), and one-third were Grade C (n = 83; 38.4%). The remaining 22 recommendations were Grade B (10.2%). In OAB, most of the recommendations were Grade B (n = 67, 39.0%), 55 of them were Grade A (32.0%) and the rest were Grade C (n = 50, 29.1%). Among UI guidelines, 51 (45.9%) Grade A recommendations were supported by LOE I evidence, and 39 (47.0%) Grade C recommendations were supported by LOE IV evidence. Across OAB guidelines, 43 (78.2%) Grade A recommendations were supported by LOE I evidence, and 20 (40.0%) Grade C recommendations were supported by LOE IV evidence. Across LUTS guidelines, 34 (61.8%) Grade A recommendations were supported by LOE I evidence, and 14 (23.3%) Grade C recommendations were supported by LOE IV evidence. Among NGB guidelines, 21 Grade A recommendations were supported by LOE I evidence, and 9 Grade C recommendations were supported by LOE IV evidence. Conclusion: Most of the recommendations in the field of functional urology are not based on the systematic review and meta-analysis of randomized controlled trials (RCTs) and high quality RCTs; which indicates that more attention is still needed in making decisions based on the certainty and grade of recommendations.

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Purpose: Metformin, an antidiabetic drug, has been proposed to play a possible protective role in cancer recurrence and patient mortality. However, the exact mechanism and efficacy of metformin in urothelial cancer, especially upper tract urothelial carcinoma (UTUC), remain unknown. In this study, we conducted a population-based analysis to investigate whether metformin could improve the survival rate of patients with UTUC. Materials and Methods: Males ≥40 years diagnosed with UTUC were included in this retrospective population-based longitudinal cohort study. Data were collected from the registry of the Taiwan National Health Insurance database for patients with UTUC and type 2 diabetes mellitus (T2DM). Patients who had received at least two prescriptions of metformin were included in the study cohort as ever-users, and patients who had never used metformin were included in the control cohort as never-users. The hazard ratios (HRs) were calculated using Cox regression for ever-users and never-users. Results: Among the 781 enrolled patients, 439 and 342 patients were included as ever-users and never-users, respectively. The median survival time was 3.95 years in the never-user cohort compared to 6.90 years in the ever-user cohort, which remained statistically significant in both univariate and multivariate analyses (HR = 0.63 and 0.72, P = 0.0001 and 0.011, respectively). Furthermore, subgroup analysis showed that continuous usage of metformin before and after the diagnosis of UTUC was associated with a better survival in patients with UTUC (adjusted HR = 0.72, 95% confidence interval: 0.55–0.93). Conclusion: This study shows a relationship between metformin usage and better survival outcome in patients with localized UTUC. The result may contribute a favorable anticancer role of metformin in localized UTUC and suggests that continuous metformin usage improves all-cause mortality in patients with localized UTUC and T2DM.

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