Stesura Seveso Archivio Italiano di Urologia e Andrologia 2023; 95, 1 ORIGINAL PAPER and bladder dysfunction (1). The impact and pathophys- iology of diabetes on the urinary bladder could be multi- factorial including the osmolarity diuresis effect, metabol- ic perturbation, microvascular damage, and diabetic neu- ropathy, consequently resulting in detrusor smooth mus- cle and urinary bladder urothelial dysfunction (2). Historically, LUTS associated with DM were reported as a triad of symptoms; impaired bladder sensation, increased bladder capacity, and decreased detrusor contractility (3). However, more recently, DM was reported to cause a variety of LUTS, including detrusor overactivity (DO), impaired detrusor contractility and urethral dysfunction (4-6). These symptoms culminate in diabetic cystopathy and asymptomatic bacteriuria, which is reported to be between 25% and 90% in the literature (3). Despite the main focus of DM associated LUTS being referred to as diabetic cystopathy for many years, recent evidence has demonstrated the impact of diabetes on the lower urinary tract to be multifactorial (1, 2, 7). Furthermore, the pathogenesis of LUTS in diabetic patients is under-investigated, remaining elusive. Osmolarity diuresis effect, metabolic abnormalities, microvascular damage, and neuropathy of diabetes may result in dysfunctions of smooth muscle, urothelium, and neuronal components of the bladder (6, 8). Previous studies have reported several urodynamic findings in dia- betic patients (1, 8). However, there is a paucity in the lit- erature addressing the urodynamic changes concerning the duration of DM. Therefore, the study aimed to address the pattern of uro- dynamic findings in diabetic patients presenting with LUTS, comparing short and long-standing DM. PATIENTS AND METHODS Study design After obtaining ethical approval, a prospective study was conducted on patients who presented with LUTS symp- toms and had a concurrent diagnosis of type 2 DM between February 2016 and May 2018. All subjects signed informed consent to participate in the study. Patients with Purpose: To address the pattern of urody- namic findings in diabetic patients with lower urinary tract symptoms (LUTS), comparing short-standing and long-standing type 2 diabetes mellitus (T2DM). Methods: A prospective study was conducted on 50 patients pre- senting with LUTS and a concurrent diagnosis of T2DM, between February 2016 and May 2018. Patients were classified and evaluated according to the duration of diabetes into two groups: short-standing DM (< 15 years, n = 31), and long-stand- ing DM (≥ 15 years, n = 19) groups. The impact of LUTS and quality of life were assessed in female patients using ICIQ- FLUTS and male patients using ICIQ-MLUTS. Results: A total of 50 patients were included in the study. The mean duration of T2DM was 10 ± 0.7 years. The mean age was 56.3 ± 1.2 years, and the mean HbA1c was 7.5 ± 1.2%. Urodynamic evaluation detected significantly higher detrusor overactivity (DO) and increased bladder sensation with the short-standing DM group (35.5 vs. 15.8%, p = 0.01 and 32.3 vs. 5.3%, p = 0.01, respectively). Comparatively, weak, or absent detrusor contractility were more frequent in patients with long- standing DM (52% and 26% respectively p = 0.01). As expected, overflow incontinence and straining during voiding were signifi- cantly higher in the long-standing DM group (p = 0.04 and p = 0.03, respectively). Surprisingly, there was no significant corre- lation between patients presenting with urgency in their voiding diary (subjective) and urodynamic detection of DO (p = 0.07). Conclusions: There are different patterns in urodynamic charac- terizations of T2DM. Patients with short-standing DM present more commonly with storage symptoms and detrusor overactivi- ty on urodynamics. Contrastingly, patients with long-standing DM present more frequently with voiding symptoms and detru- sor underactivity on urodynamics. Thus, screening for an under- active bladder is advisable in patients with long-standing T2DM. Key wORDS: Urodynamic study; Diabetes mellitus; LUTS; Urinary bladder; Urinary incontinence; Detrusor underactivity; Detrusor overactivity. Submitted 7 December 2022; Accepted 6 January 2023 INTRODUCTION Diabetes mellitus (DM) is a prevalent major health condi- tion associated with lower urinary tract symptoms (LUTS) Evaluation of urodynamic pattern in short and long-standing diabetic patients Haytham Elsakka 1*, Ahmed Ibrahim 2*, Abdulghani Khogeer 2, 3, Adel Elatreisy 4, Rawan Elabbady 2, Osama Shalkamy 4, Ayesha Khan 1, Iman Sadri 2, Ahmad AlShammari 2, Ahmad Khalifa 2, Serge Carrier 2, Melanie Aube-Peterkin 2 1 Urology Department, East Lancashire Hospitals NHS trust, Balckburn, Lancashire, UK; 2 Department of Surgery, Division of Urology, McGill University Health Center, Montreal QC, Canada; 3 Department of Surgery, Faculty of Medicine, Rabigh, King Abdulaziz University, Jeddah, Saudi Arabia; 4 Urology Department, Faculty of Medicine, Al-Azhar University, Cairo, Egypt. * Contributed equally as co-first author. DOI: 10.4081/aiua.2023.11072 Summary Archivio Italiano di Urologia e Andrologia 2023; 95, 1 H. Elsakka, A. Ibrahim, A. Khogeer, et al. previous pelvic surgery, coexisting neurologic disorders, or any other medical condition that interferes with bladder or sphincter function were excluded from the study. Patients were classified and evaluated according to the duration of diabetes into short-standing: > 15 years (group I), and long-standing: ≥ 15 years (group II). Subjects’ evaluation All patients were subjected to entire medical history. The impact of LUTS and quality of life was assessed in female patients utilizing ICIQ-FLUTS (International Consultation on Incontinence Modular Questionnaire on Female Lower Urinary Tract Symptoms) and in male patients using ICIQ-MLUTS (International Consultation on Incontinence Modular Questionnaire on Male Lower Urinary Tract Symptoms). These questionnaires provide rigorous validity and reliability, both of which are frequently used worldwide (9, 10). Patients underwent a clinical examination (including focused neurological examination), Furthermore, all patients underwent routine laboratory investigations, which included: urine analysis, urine culture and sensitivi- ty, HbA1c, fasting and postprandial blood sugar, and serum creatinine. imaging studies (KUB, abdominopelvic US), and urodynamic evaluation. The urodynamic machine used was the Ellipse-4 Andromeda (GmbH, Wallbergstraße 5. D-82024 Taufkirchen/Potzham - Germany). Statistical analysis Statistical analysis was carried out using SPSS software package version 28.0. Numerical values were presented as means and standard deviation (SD). Categorical values were presented as frequency and percentages. Comparison between different categorical variables was made using Fisher’s exact test. Additionally, a Student's t- test was used to compare the means of the continuous variables among different groups. Two-tailed P values less than 0.05 were considered statistically significant. RESULTS A total of 50 patients were included in the study: 40 women (80%) and 10 men (20%). The mean age was 56.28 ± 1.14 years (range 45 to 73 years), the mean HbA1c was 7.5 ± 1.2%, and the mean fasting blood sugar (FBS) was 199.88 ± 9.24 mg%. The mean duration of DM was 10 ± 0.77 years (Table 1). Clinical presentation Storage symptoms were the predominant class of LUTS reported by the participants. In particular, 88% described nocturia (44 subjects) followed by 86% noting daytime frequency (43 subjects), urgency 78% (39 subjects), urge incontinence 54% (27 subjects), and nocturnal enuresis 28% (14 subjects). Comparatively, voiding LUTS were reported less frequently: 40% complained of straining during voiding, 38% reported a weak urine stream and 34% of an interrupted stream. Overflow incontinence was the main complaint in 20% of the study cohort (Table 1). Voiding diary Charts were reported as the mean of variable per patient as follows: mean diurnal voids/day was 7.78 ± 0.45 and mean nocturnal voids/night was 3.78 ± 0.29; mean of urgency episodes/day was 4.54 ± 0.48, and mean of urge inconti- nence episodes/day was 2.17 ± 0.51. Finally, the mean voided volume/void was 268.47 ± 14.86 mL (Table 1). Urodynamic evaluation The free flowmetry of the cohort revealed that the mean voided volume was 235 ± 17.05 mL. The mean maximum flow rate was 15.21 ± 1.12 mL/s and the mean of post- void residual (PVR) urine was 114.94 ± 22.76 mL. Of note, 30% of participants had a PVR greater than 100 mL. Bladder sensation was normal in 54% (26 patients), increased in 22% (11 patients), reduced in 12% (6 patients) and absent in 14% (7 patients). The mean first sensation volume (FSV) was 159 ± 10.88 mL. The mean first desire volume (FDV) was 255.97 ± 11.36 mL, and the mean strong desire volume (SDV) was 334.68 ± 11.56 mL (Table 2). The mean value of bladder compliance was 81.70 ± 9.84 mL/cm H2O. The latter was normal in 88% (44 subjects), reduced in 10% (5 subjects), and increased in 2% (1 sub- ject). The mean maximum cystometric capacity (MCC) was 383.56 ± 15.7 mL of which, was valid for 74% of subjects. The MCC could not be assessed in 26% (13 subjects) due to either absent sensation, urine leakage, or reduced sen- sation (Table 2). Of the subjects whom the MCC was suc- cessfully calculated, 58% had a normal MCC; it was reduced in 14% and increased in 2% of the study cohort. Amongst the studied participants, 28% (14 subjects) had DO. The DO was phasic in 20% (10 subjects) and termi- Table 1. Patients demographics, clinical presentation, questionnaires evaluation and voiding diary profile. Variable Value Patients demographics: vMean age (SE, range), year 56.28 ± 1.14 (45 to 73) Male/female ratio, n (%) 10 (20%)/40 (80%) Mean duration of DM (SE, range), year 10 ± 0.77 (5 to 29) Mean FBS (SE, range), mg % 199.88 ± 9.24 (102 to 392) HbA1c 7.5 ± 1.2 Mean serum Creatinine (SE, range), mg % 1.09 ± .04 (0.5 to 1.5) Clinical presentation: Nocturia, n (%) 44 (88%) Daytime frequency, n (%) 43(86%) Urgency, n (%) 39 (78%) Urgency incontinence, n (%) 27 (54%) Nocturnal enuresis, n (%) 14 (28%) Weak stream, n (%) 19 (38%) Interrupted stream, n (%) 17 (34%) Straining during voiding, n (%) 20 (40%) Continuous drippling of urine, n (%) 10 (20%) Questionnaires evaluation: ICIQ-FLUTS 28.5 ± 7 ICIQ-MLUTS 30.3 ± 5.8 Voiding diary profile: Diurnal voids/day (SE, range) 7.78 + 0.45 (2 to 15) Nocturnal voids/night (SE, range) 3.78 + 0.29 (0 to 8) Urgency episodes/day (SE, range) 4.54 + 0.48 (0 to 14) Urgency incontinence episodes/day (SE, range) 2.17 + 0.51 (0 to 14) Voided volume/void (SE, range) 268.47 + 14.86 (90 to 500) Archivio Italiano di Urologia e Andrologia 2023; 95, 1 Urodynamics of diabetic patients nal in 8% (4 subjects) with regards to DO; the mean value of wave numbers was 3.64 ± 0.82 waves (range 1 to 12 waves), the mean duration was 45.85 ± 10.75 seconds (range 10 to 149 seconds), the mean amplitude was 41.4 ± 6.02 cm H2O, and the mean value of the first contrac- tion volume (FCV) was 141 ± 26.63. The detrusor con- tractility was normal in 60 % (30 subjects), weak in 26% (13 subjects), and absent in 14 % (7 subjects) (Table 2). With regards to the duration of DM, the cohort was classi- fied into group I (short-standing DM, < 15 years) included 31 patients (62%), and group II (long-standing DM, ≥ 15 years) included 19 patients (38%). The mean score of ICIQ-FLUTS was significantly lower in group I when com- pared with group II (24.67 ± 5.4 vs. 34.25 ± 4.9; p < 0.001). Likewise, the mean score of ICIQ-MLUTS was sig- nificantly lower for group I when compared with group II (28.7 ± 5.9 vs. 34 ± 2.3; p = 0.048) (Table 3). DO and increased bladder sensation were more common in patients with short-standing DM (35.5% vs. 15.8%, p = 0.01) and (32.3 vs. 5.3%, p = 0.01), respectively. In con- trast, weak or absent detrusor contractility was more fre- quent in patients with long-standing DM (52% and 26% respectively p = 0.01). As expected, overflow incontinence and straining during voiding were significantly higher in the long-standing DM group (p = 0.04 and p = 0.03), respectively (Table 4). There was no significant correlation between patients presenting with urgency on voiding diary (subjective) and urodynamic detection of DO (p = 0.07). DISCUSSION Diabetic bladder dysfunction can present with a broad spectrum of LUTS (10). Clinically, LUTS in diabetic patients range from storage symptoms to voiding symp- toms. Common storage LUTS experienced by diabetic patients include nocturia, increased daytime frequency, urgency, and urge incontinence. On the other hand, fre- quently experienced voiding LUTS in diabetic patients encompass weak flow of urine, interrupted stream, strain- ing during voiding, and eventually urine retention or overflow incontinence. The pathology shows a diverse and progressive evolution from an overactive bladder to a Table 3. Comparison between the study groups regarding clinical presentation. LUTS evaluation Short-standing DM Long-standing DM P value N = 31 (%) N = 19 (%) Day time frequency 28 (90.3%) 15 (78.9%) 0.4 Nocturia 28 (90.3%) 16 (84.2) 0.66 Urgency 26 (83.9%) 13 (68.4%) 0.29 Urgency incontinence 18 (58.1%) 9 (47.4) 0.56 Nocturnal enuresis 5 (16.1%) 9 (47.4) 0.25 Weak stream 7 (22.6%) 12 (63.2) 0.07 Interrupted stream 6 (19.4%) 11 (57.9%) 0.12 Overflow incontinence 2 (6.5%) 8 (42.1%) 0.04 Straining during voiding 7 (22.6%) 13 (68.4%) 0.03 ICIQ-FLUTS 24.67 ± 5.4 34.25 ± 4.9 < 0.001 ICIQ-MLUTS 28.7 ± 5.9 34 ± 2.3 0.048 Table 4. Comparison between the study groups regarding urodynamic findings. Bladder sensation Short-standing DM Long-standing DM P value N (%) N=31 N=19 Normal 17 (54.8%) 9 (47.4%) 0.01 Increased 10 (32.3%) 1 (5.3%) Reduced 1 (3.2%) 5 (26.3%) Absent 3 (9.7%) 4 (21.4%) Bladder compliance 0.1 Normal 26 (83.8%) 9 (47.4%) Increased 2 (6.4%) 8 (42.1%) Reduced 3 (9.7%) 2 (10.5%) Maximum cystometric capacity 0.42 Normal 17 (54.8%) 12 (63.2 %) Increased 1 (3.2%) 0 Reduced 6 (19.4%) 1 (5.3%) Cannot be assessed 7 (22.6%) 6 (31.6) Parameters of detrusor overactivity 0.01 Phasic 9 (29%) 1 (5.3) Terminal 2 (6.5%) 2 (10.5%) With leak 6 (19.4%) 2 (10.5%) Without leak 5 (16.1%) 1 (5.3%) Detrusor contractility 0.01 Normal 26 (83.9%) 4 (21.1%) Weak 3 (9.7%) 10 (52.6%) Absent 2 (6.5%) 5 (26.3%) Flowmetry 0.12 Non obstructed 28 (90.3%) 14 (73.7%) Obstructed 1 (3.2%) 0 Could not be assessed 2 (6.5%) 5 (26.3%) Table 2. Urodynamic evaluation of the study’ cohort. 1. Free flowmetry: Mean voided volume (SE, range), mL 235 ± 17.05 mL. (12 to 468) Mean maximum flow rate (SE, range), mL/s 15.21 ± 1.12 mL/s. (1 to 40) Mean amount of post voiding residual urine (SE, range), mL 114.94 ± 22.76 mL. (0 to 500) 2. Filling cystometry: a. Bladder sensation: Absent bladder sensation, n (%) 7 (14%) Reduced, increased, normal bladder sensation, n (%) 6 (12%), 11(22%), 26(54%) Mean first sensation volume (FSV) (SE, range) mL 159 ± 10.88 (31 to 352) Mean first desire volume (FDV) (SE, range) mL 255.97 ± 11.36 (129 to 430) Mean strong desire volume (SDV) (SE, range) mL 334.68 ± 11.56 (206 to 474) b. Bladder compliance: Normal, reduced, increased bladder compliance, n (%) 35 (70%), 5 (10%), 10(20%) Mean value of bladder compliance (SE, range) mL/cm H2O 81.70 ± 9.84 (5.7 to 455) c. Maximum cystometric capacity: Normal, increased, reduced n (%) 29 (58%), 7(14%), 1(2%) Mean maximum cystometric capacity (SE, range) mL 383.56 ± 15.7 mL (225 to 657) d. Parameters of detrusor overactivity: Detrusor overactivity number (SE, range) 3.46 ± 0.82 (1 to 12) Detrusor overactivity duration (SE, range) 45.85 ± 10.75 (10 to 149) Detrusor overactivity amplitude (SE, range) 41.4 ± 6.02 (7.4 to 75) First contraction volume (SE, range) 141 ± 26.63 (31 to 347) e. Parameters of leakage with detrusor overactivity: Amount of leakage (SE, range) 125.62 ± 28.19 (30-258) First leakage volume (SE, range) 172.75 ± 32.78 (73-324) Leak detrusor pressure (SE, range) 56.34 ± 3.77 (43-75) f. Pressure flow study: Detrusor contractility: normal, weak, absent n (%) 30 (60%), 13 (26%), 7 (14%) g. Flow Obstructed, not obstructed, could not be assessed n (%) 1 (2%), 42 (84%), 7 (14%) Archivio Italiano di Urologia e Andrologia 2023; 95, 1 H. Elsakka, A. Ibrahim, A. Khogeer, et al. poor non-contractile bladder. Diabetic urinary symptoms manifest alongside the progression of diabetes. As such, we evaluated diabetic patients presenting with LUTS to specifically address the urodynamic pattern in such cohort over the course of the disease. Therefore, the study was conducted to characterize the specific urodynamic findings associated with the diabetic population in both short and long disease duration. As previously reported, in the early course of diabetes, the main pathological factor is related to polyuria, causing detrusor muscle remodeling, hypertrophy and overactivity. Over time, there is an accumulation of toxic metabolites and oxidative stress leading to a decline in detrusor smooth muscles contractility, and bladder urothelium and neuronal alteration. Collectively, this results in significant bladder sensation degradation and altered filling response (12). Several reports demonstrate both urodynamic DO and poor bladder contractility could be present. Among 182 diabetic patients with a mean follow-up period of 5 years, Kaplan et al. found that DO was the main urodynamic pattern (55%), while detrusor contractility was impaired among 23% of patients (13). Furthermore, Kebapci et al. found that decreased bladder sensation, weak bladder contractility, and increased blad- der capacity with PVR < 100 mL were the most promi- nent urodynamic findings in diabetic patients (14). In their cohort, the duration of diabetes was less than nine years, and HbA1c was less than 7%. Additionally, Yamaguchi et al. reported trends of increased residual urine in long-standing diabetic patients (duration > 10 years) despite not being statistically significant (15). Similarly, Malik et al. (16) conducted a prospective com- parative study on 288 non-diabetic and 96 diabetic women. They detected delayed first sensation, higher cys- tometric capacity, and reduced detrusor pressure at max- imum flow rate among the diabetic group. Those findings were more remarkable in long-standing DM (> 10 years). A significant relation between DM and a non-contractile bladder was not identified in their study. In contrast, in the present report, we included diabetic patients with a longer duration and reported weak detrusor contractility in 26% and 14%, respectively. Additionally, we detected a significant difference in detrusor contractility between long and short DM duration. 52% of patients had weak detrusor contractility and 26% had very weak detrusor contractility of long-standing T2DM, compared to 9% and 6 % in short-standing, respectively (p < 0.001). Furthermore, Shin et al. performed a retrospective review of a urodynamic study for 708 females who clinically pre- sented with stress urinary incontinence, comparing the diabetic and non-diabetic groups. They found that Qmax and bladder contractility index is significantly reduced among the diabetic group (17). The distinct finding of the present study recognises diabetes mellitus had a different impact on urinary bladder function; the pattern of dysfunction varies according to the duration of DM. Storage symptoms were more common amongst short-standing DM patients compared to long-standing T2DM patients. In particular, nocturia (90.3 vs. 84.2%), daytime frequency (90.3 vs. 78.9%), urgency (83.9 vs. 68.4%), and urge incontinence (58.1 vs. 47.4%). In con- trast, voiding symptoms were more frequent in long-stand- ing DM, namely weak stream (63.2 vs. 22.6%), interrupted stream (57.9 vs. 19.4%), overflow incontinence (42.1 vs. 6.5%), and straining during voiding (68.4 vs. 22.6%). Furthermore, the current study showed no significant cor- relation between urgency on voiding diary (subjective) and urodynamic detection of DO. We reported DO in 35.4% of patients who presented with storage LUTS. Such finding might reinforce the pathogenesis theory of diabetic LUTS as multifactorial (2). In such cohort, storage LUTS could be explained by the presence of glycosuria and osmolarity diuresis effect prior to detection of DO. Conversely, previ- ous studies reported significant urodynamic findings in patients with mild voiding LUTS, specifically in the late stages of diabetic LUTS (8, 18). They explain that with the insidious onset of diabetic LUTS, patients may overlook the symptoms. In addition, health care workers tend not to consider bladder dysfunction complications while screen- ing asymptomatic diabetic patients; they pay more atten- tion to neuropathy, nephropathy, and retinopathy (19). Hence diabetic patients are liable to be diagnosed during the late stages of diabetic cystopathy. Finally, the study is not without limitations. First, the MCC could not be assessed in 31% patients in the long- standing DM group due to absent bladder sensation. However, the filling was stopped after 600 mL to avoid post-procedural urine retention, which is considered high bladder capacity. Likewise, the MCC could not be assessed in 22% of the short-standing DM group primari- ly due to urine leakage. Therefore, the bladder filling was stopped earlier in those patients. Second, the relatively small sample size of the present study. Nevertheless, the present study is prospective with strict and explicit inclusion and exclusion criteria in an attempt to eliminate any confounding factors which might affect bladder function. Additionally, the voiding diary provided a subjective evaluation that could not reflect the objective bladder dysfunction in the urody- namic study. Thus, we believe it is crucial to create a newly validated screening test for patients with diabetic cytopathy. Further prospective studies are still advisable. CONCLUSIONS There are different patterns in the urodynamic character- ization of type 2 diabetic patients. Patients with short- standing DM often present with storage symptoms and detrusor overactivity on urodynamics. Comparatively, patients with long-standing DM present more frequently with voiding symptoms and detrusor underactivity on urodynamics. Screening for an underactive bladder is advisable in patients with a long-standing DM. REFERENCES 1. Bansal R, Agarwal MM, Modi M, et al. Urodynamic profile of dia- betic patients with lower urinary tract symptoms: association of dia- betic cystopathy with autonomic and peripheral neuropathy. Urology. 2011; 77:699-705. 2. Geerlings SE, Stolk RP, Camps MJ, et al. Diabetes Women Asymptomatic Bacteriuria Utrecht Study Group. Risk factors for symptomatic urinary tract infection in women with diabetes. Diabetes Care. 2000; 23:1737-41. Archivio Italiano di Urologia e Andrologia 2023; 95, 1 Urodynamics of diabetic patients 3. Lee WC, Wu HP, Tai TY, et al. Effects of diabetes on female void- ing behavior. J Urol. 2004; 17:989-92. 4. 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Correspondence Haytham Elsakka, MD haythamurology@gmail.com Ayesha Khan, MD Ayesha.khan@elht.nhs.uk Urology Department, East Lancashire Hospitals NHS trust, Balckburn, Lancashire (UK) Ahmed Ibrahim, MD, MSc (Corresponding Author) ahmed.eldemerdash@muhc.mcgill.ca eldemerdash90@gmail.com Clinical fellow at McGill University Health Centre 1001 Boulevard Décarie, Montreal, QC, Canada Abdulghani Khogeer, MD dr-abdulghani@hotmail.com Department of Surgery, Faculty of Medicine, Rabigh, King Abdulaziz University, Jeddah (Saudi Arabia) Adel Elatreisy, MD adel.elatreisy@azhar.edu.eg Osama Shalkamy, MD Dr_shalkamy@azhar.edu.eg Urology Department, Faculty of Medicine, Al-Azhar University, Cairo (Egypt) Rawan Elabbady, MD rawanelabbady93@hotmail.com Iman Sadri, MD iman.sadri@mail.mcgill.ca Ahmad AlShammari, MD dr.shammar@gmail.com Ahmad Khalifa, MD khalifa.urology@gmail.com Serge Carrier, MD serge.carrier@mcgill.ca Melanie Aube-Peterkin, MD Melanie.aube-peterkin@mcgill.ca Department of Surgery, Division of Urology, McGill University Health Center, Montreal QC (Canada) Conflict of interest: The authors declare no potential conflict of interest.