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Varicocele and male infertility due to the formation of reactive oxygen species (ROS) Oxidative stress due to the varicocele leads to infertility due to the high proportion of harmful reactive oxygen species (ROS) causing the accumulations of sperm DNA fragmentation then to cellular and genetic instability in the testicles. The heat stress is as a result of the testicular temperature rising above its physiological level (36.6) degrees Celsius, especially when patients suffer from varicocele testis. The oxidative stress due to the aforementioned accumulation of the reactive oxygen species (ROS) in the testis induce sperm mitochondria dysfunction leading to a loss of the integrity and permeability of the sperm lipid membrane, as well as a disruption at the same time of the antioxidant enzymes and breach of the sperm nucleic acid (DNA), causing a significant deterioration of the antioxidant capacity in the seminal fluid by 40%, and ultimately to infertility. The incidence of men with Varicocele testis is 15%, this testicular disease causes infertility and erectile dysfunction by 20-30% and by 40% secondary hypogonadism. The cause of the development of varicocele testis is dilatation and sagging of the spermatic cord vein due to hereditary or acquired factors, it leads to increased hydrodynamic pressure on the testicles, oxidative stress with development of high level free radicals (reactive oxygen species (ROS)), accumulation of metabolic toxins on the testicles, inducing elevation of sperm DNA fragmentation with an imbalance in the growth and maturation of sperm, leading at the end to infertility. Oxidative stress is detected in semen of up to 40% of infertile men, and thus it is widely considered one of the main cellular mechanisms of ambiguous infertility. About 15% of couples do not achieve pregnancy within 1 year and seek medical treatment for infertility. One in eight couples encounter problems when attempting to conceive a first child (primary infertility) and one in six when attempting to conceive a subsequent child (secondary infertility) [1]. Male infertility factors are by 50% due to diseases either in the reproductive system, glandular or nervous system, and these three systems participate in the fertilization process, additionally to these 20-30% of male infertility could be caused by environmental pollution leading even so to the sperm DNA fragmentation because of the development of super oxidation and formation of reactive oxygen species of pollutant origin, whether it is in the air, water or food. It is worth knowing that oxidative stress has a detrimental impact in our cells and in the semen, especially when its ratio rises to more than 100,000 CPM per twenty million sperm per millimeter, because it is associated with the accumulation of DNA mutations, genomic instability, accelerated aging, and progression of pathological conditions like chronic inflammation and cancer development [2]. And since we cannot diagnose these changes in DNA through the traditional semen analysis, which depends on indicators of number, motility, vitality, and sperm abnormalities, as well as our inability to diagnose oxidative stress through that due to reactive oxygen species, other free radicals, and reactive nitrogen species (RNS), which are one of the most mysterious factors of infertility with high percentage of the free harmful and damaging reactive oxygen species (ROS). The diagnosis of the percentage of semen DNA fragmentation is the most successful in detecting the percentage of ambiguous infertility. The complementary clinical diagnostics should performed by touching the scrotum and its contents (testis and its venous vessels) and then through ultrasound with colour Doppler to confirm presence or absence of varicocele testis, and to assess the clinical stage as well to measure the size of the testicles, because these could be affected negatively to atrophy especially in the second and third stage, testicular atrophy occurs by 10-77% in patients with varicocele in the second and third stage. The other causes of infertility in general are acute inflammatory diseases of the urinary and reproductive system, especially of the prostate or epididymis. Male hormone deficiency syndrome indirectly leads to male infertility due to erectile dysfunction and decrease or loss of sexual desire. Obstruction or block of the spermatic vas deferens, anjaculation, or retrograde ejaculation are also male factors leading to infertility. Other risk factors that could lead to infertility are advanced age, obesity, smoking, and alcohol consumption. As for the modern treatment of this infertility, whether it is organic or unknown, it depends on the treatment of sperm DNA fragmentation, the oxidative stress, the acute and chronic inflammation of the prostate gland, and hormone replacement or induction therapy, this therapy could be given to the patients with diagnosed secondary hypogonadotropic hypogonadism. The therapy of this is the stimulating of the spermiogenesis with follicle-stimulating hormone (FSH), and human chorionic gonadotropin (HCG) as treatment for secondary or primary hypogonadism which is delays or stops development of puberty due to a congenital syndrome that causes dysfunction of the hypothalamus as a result of genetic mutations (Kallmann syndrome) or is characterized by the absence of gonadotropin-releasing hormone (GnRH) and the failure of the pituitary gland to produce the gonadotropins leading to delayed or interrupted puberty and sexual infantilism syndrome. Treatment of all cases depends mainly on hormone replacement therapy, which aims to stimulate the body of these patients to start the stages and signs of puberty and maintain normal levels of hormones. REFERENCES: [1]: Zegers-Hochschild, F., et al. The International Glossary on Infertility and Fertility Care, 2017. Fertil Steril, 2017.108: 393. [2]: Agarwal, A., et al. Male Oxidative Stress Infertility (MOSI): Proposed Terminology and Clinical Practice Guidelines for Management of Idiopathic Male Infertility. World J Men Health, 2019. 37: 296. Author Correspondence: Prof. Dr. Semir A. Salim. Al Samarrai Medical Director of Professor Al Samarrai Medical Center. Dubai Healthcare City, Al-Razi Building 64, Block D, 2nd Floor, Suite 2018 E-mail: semiralsamarrai@hotmail.com Tel: +97144233669

Human papillomavirus (HPV) is the most common sexually transmitted infection worldwide. In the United States, an estimated 14 million persons are newly infected each year [1]. Prevalence of any genital HPV is estimated at 42.5 percent among U.S. females aged 14-59 years [2]. Although most HPV infections are self-limited and cause no symptoms, persistent infections with human papillomavirus (HPV) can cause cervical and other cancers, including anal, oropharyngeal, penile, vaginal, and vulvar, as well as anogenital warts. HPV is estimated to be responsible for 40-50 percent of all invasive penile cancers and is associated with almost all cervical cancers. Cervical cancer is the second most common cancer and the fifth leading cause of death in women worldwide with nearly 4,000 dying from this disease in the U.S. each year. International Human Papillomavirus (HPV) Awareness Day falls on March 4th. The 2022 campaign theme is ” One less worry ” and focuses on three simple steps that should help in eliminating HPV – driven cancers via education (safer sex), vaccination, and early screening to detect the HPV infection. Ninety percent of genital warts are caused by HPV types 6 and 11. However, most HPV-associated cancers are caused by HPV types 16 and 18, including 15,000 cases of these cancers in females and 7,000 cases in males each year in the U.S [3]. For men, there is an overall annual increase in HPV – related cancers of 2.36 % per year, which is attributable in part to the numbers of HPV associated cancers among individuals infected with human immunodeficiency virus in high – income countries on account of the substantial incidence of anal cancer among men. Penile cancers are diagnosed more likely to be HPV – positive in recent years [4,5,6]. Penile cancer is one of the cancers that is increasing in incidence and the only such cancer that urologists manage in their clinical practice. Although rare in developed countries, as with any HPV – driven cancer, penile cancer is much more prevalent in the lowest – income countries (many of which are in sub – Saharan Africa and Latin America) [6,7]. Infections with HPV types 16, 18, 31, and 33 have been reported in high percentages of penile squamous cell carcinoma (SCC) cases, and in total it is estimated that one in two penile cancers globally is HPV-positive [7,8]. Oral HPV is associated with oropharyngeal carcinomas approximately 22.4 %, 4.4 % and 3.5 % of oral cavity, oropharynx and larynx cancers, respectively are attributed to HPV [9]. Systematic reviews have reported prevalence rates of oral HPV from 5.5-7.7 %, with HPV16 present in 1-1.4 % of patients. Risk factors for HPV infection include early age of first sexual intercourse, sexual promiscuity, higher frequency of sexual intercourse, smoking and poor immune function [10]. Overall, the prevalence of HPV in different sites seems to be higher in young, sexual – active adults compared to other population groups [10]. Stable sexual habits, circumcision and condom use are protective factors against HPV [11,12]. Added risk factors of oral HPV infection are alcohol consumption, poor oral hygiene and sexual behaviours (oral and vaginal) [10]. Positive HIV status, phimosis, and HPV status of the partner have also been associated with anogenital HPV status and decreased clearance in a number of studies [13]. HPV typically spreads by sustained direct skin – to – skin or mucosal contact, with vaginal, oral and anal sex being the most common transmission route [14]. In addition, HPV has been found on surfaces in medical settings and public environments raising the possibility of object – to – skin / mucosa transmission [15]. Further studies on non-sexual and non – penetrative sexual transmission are needed to understand the complexity of HPV transmission. HPV transmission may also be influenced by genotype, with a higher incidence of HPV51 and HPV52 and a high prevalence of HPV16 and HPV18 in the general and high – risk male population [14]. HPV presence is dependent on study setting. In men attending urological clinics HPV was detected in 6 % of urine samples [16]. A meta – analysis reported seminal HPV in 4.5-15.2 % of patients resulting in seminal HPV being associated with decreased male fertility [17]. A cross sectional study of 430 men presenting for fertility treatment detected HPV in 14.9 % of semen samples. The presence of HPV in semen was not associated with impaired semen quality [18]. However, another systematic review reported a possible association between HPV and altered semen parameters, and in women possible miscarriage or premature rupture of the membrane during pregnancy. The symptoms of HPV-infection may appear as warts on the female or male patient in equal ratio. The lesions may be large and grossly visible or may be discovered only after appropriate application of acetic acid and magnified scanning of the genitalia. In women, a screening study revealed a 2 % incidence of subclinical HPV infection in those with abnormal findings on Papanicolaou smear [19]. Any symptomatic or asymptomatic abnormal – appearing warts or lesions may be found to carry HPV infection in the external genitalia, and this can be discovered under magnification with genotype diagnosis through PCR-swabs from lesions or from condylomata warts [20]. In males, the HPV virus has been seen in warts when assessed with PCR-swabs for genotype diagnosis. Other studies have reported HPV type 16 in penile carcinoma along with types 31 and 35 [21]. The lesions may present in two basic morphologic forms. The classic wart known as condyloma acuminata presents as a verrucous papillary growth in the genital region that may range from 2 mm up to several centimeters in size. These warts may be found on the penis, perineum, or scrotum, or within the urethra. In women, the introitus, perineum, vagina, and urethra are common sites as is with the cervix. In patients who are immune suppressed, such as renal transplant recipients or patients on chemotherapy, lesions may attain enormous size and cover the entire perineum. The incidence of genital warts in children has increased

Generally, the Cancer develop when the cells begin to multiply randomly without control in the body affected by this cancer, and cancer cells may develop in any area of the body. Bladder, kidneys and testicles. There are different types of cancer that affect the body as the Cancer may start in the lung, breast, or colon, as well as in the blood, prostate, bladder, kidneys, and testicles. The International Agency for cancer research published that the incidence of cancer in the whole world unfortunately will increase and the reason attributed by this agency in terms of number, prevalence and deaths to social and economic development, the increasing population and the high rate of aging in the world and metabolic diseases as diabetes, obesity, high cholesterol and high blood pressure [1]. Prostate cancer is the second most common type of cancers, affecting about one in nine over the age of 50, now that there are more than 2.9 million men living in the US who have been diagnosed with prostatic cancer and the sixth leading cause of death from this cancer among Men in the world [2]. Prostate Cancer accounts for 1 in 5 men cancer diagnosis in men, with risk of progression to castrate resistance. The family history of the disease due to hereditary genetic mutations in the gene (HPCL) in the short arm of the Y chromosome, as well as other recently discovered genes such as (BRCA-2) and (BRCA-1) [3], these are well established risk factors for Prostate Cancer, and also environmental intoxication of the air, water and food contamination induce the free radical which responsible for the disruption of the genome repair system. One of the main risk factors is the wrong lifestyle caused by obesity. The obesity paradox is at the center of investigations regarding the role of human metabolism and body composition in prostate cancer outcomes. In some studies, obesity (BMI > OR = 30kg/㎡) increase the risk for high grade prostate cancer as well as recurrence after prostatectomy. The symptoms of the prostate cancer are related to storage pathological changes of the bladder causes urgency and to urethral obstruction causes weak urine flow. Multiple studies have reported a relation between clinical prostatitis and an increased risk of prostate cancer. The diagnostic evaluation includes medical history, symptom score questionnaires as the international prostate symptom score (IPSS), physical examination and digital-rectal examination and prostate size evaluation with transrectal ultrasound, urinalysis (dipstick or sediment) which must be included in the primary evaluation of any patient presenting with LUTS to identify conditions, such as urinary tract infections (UTI), microhaematuria and diabetes mellitus. Early diagnosis through PSA testing (normal level below 4 ng/ml) may reduce prostate cancer deaths [4]. PSA density (PSAD) below 0.15mg/ml/ml was considered as negative predictive factors for prostate cancer, so the right diagnosis of Prostate cancer increased by 94.1% to omit prostate biopsy [5]. Clinical examination is carried out using modern diagnostic methods, the most important of which is the examination of the prostate gland in its size and shape, as well as the bladder and urethra by ultrasound, as well as examination of the urodynamics of the urinary stream (Uroflowmetry). Radical prostatectomy that preserves the erectile nerves as well the robotic of them in this decade has encouraged more men to undergo this surgery. The Intuitive Surgical DaVinci XI Robot has been conducting FDA approval as minimally invasive surgery on humans for well over decade now. Positive surgical margins (PSMs) during robotic radical prostatectomy with the DaVinci XI are strong predictors of biochemical recurrence [6]. Cognitive guidance of multiparametric magnetic resonance imaging (mp MRI) during robot assisted radical prostatectomy may improve the preservation of neurovascular bundles and avoid positive surgical margins [7]. Prostate cancer annual screening is a primary life-saving measure for every man over the age of 40, and the secondary prevention is limited to Organic diet, daily exercise and proper weight. REFERENCES: (1): Esposito, K., et al. Effect of metabolic syndrome and its components on prostate cancer risk: meta-analysis. J Endocrinol Invest, 2013. 36: 132. (2): Mottet, N. et al. EAU-EANM-ESTRO-ESUR-SIOG Guidelines on Prostate Cancer 2020 update Part 1: Screening, Diagnosis, and Local Treatment with Curative Intent. Eur Urol, 2021. 79: 342. :(3) Randazzo. M.et al. A positive family history as a risk factor for prostate cancer in a population-based study with organised prostate-specific antigen screening: results of the Swiss European Randomised Study of Screening for Prostate Cancer (ERSPG Aarau BJU Int. 2016 117 576. (4): Stamey, T.A., et al. Prostate-specific antigen as a serum marker for adenocarcinoma of the prostate. N Engl J Med, 1987. 317:909. (5): Schmid, H.P., et al. Observations on the doubling time of prostate cancer. The use of serial prostate-specific antigen in patients with untreated disease as a measure of increasing cancer volume. Cancer, 1993 71:2031 (6): Dev Hs, Wilklund P, Patel V, et al. Surgical margin length and location affect recurrence rates after robotic prostatectomy. Urol oncol 2015;33, 109.e7-13. (7): McClure TD, Margolis DjA, Reiter RE, et al. Use of MR imaging to determine preservation of the neurovascular bundles at robotic-assisted laparoscopic prostatectomy. Radiology 2012;262:874-83. Author Correspondence: Prof. Dr. Semir A. Salim. Al Samarrai Medical Director of Professor Al Samarrai Medical Center. Dubai Healthcare City, Al-Razi Building 64, Block D, 2nd Floor, Suite 2018 E-mail: semiralsamarrai@hotmail.com Tel: +97144233669

The Benign prostatic enlargement is the most benign tumor that affects men in age beyond the age of forty, it is not dangerous for life, but its symptoms in the lower urinary tract hinder daily life. The cause of enlargement in aging is hormonal changes, and at the same time recent studies have shown that the increase in the body’s susceptibility and readiness to the genetic pathological mutations in these cells that lead first to benign enlargement and then cancer due to the high rate of environmental and food contamination. The obesity paradox is at the center of investigations regarding the role of human metabolism and body composition in prostate cancer outcomes. In some studies, obesity (BMI > OR = 25kg/㎡) increase the risk for high grade prostate cancer as well as recurrence after prostatectomy. Multiple studies have shown an association between clinical prostatitis and an increased risk of prostate cancer. BPH is likely a multifactorial process, the exact etiology of which is unknown, but requires testosterone. 5a-reductase (5AR), with its two isoenzymes – type I and type II, converts testosterone to its active metabolite, dihydrotestosterone (DHT). DHT, which has a higher affinity for the androgen receptor and is considered the more potent androgenic steroid hormone, forms a complex that is then transported to the nucleus. The T/DHT-androgen receptor complex within the nucleus of the prostate cells initiates transcription of DNA and translation, with subsequent normal development, growth, and hyperplasia of the prostate. BPH develops due to an imbalance between growth and apoptosis (cellular death) in favour of growth, subsequently causing an increase in cellular mass [1,2]. Also Read:Ureaplasma acute and chronic infection of the bladder in women and prostate in men BPH is nearly ubiquitous in the aging male with increases starting at age 40-45 years, reaching 60% by age 60, and 80% by age 80. BPH can lead to benign prostatic enlargement (BPE), which can cause obstruction at the level of the bladder neck, termed benign prostatic obstruction (BPO). The prevalence of moderate-to-severe LUTS rose to nearly 50% by age 80, nearly 50% by age 80, with the development of acute urinary retention (AUR). Another study has estimated that 90% of men between 45 and 80 years of age suffer some type of LUTS [3,4,5]. The diagnostic evaluation includes medical history, symptom score questionnaires as the international prostate symptom score (IPSS), physical examination and digital-rectal examination and prostate size evaluation with transrectal ultrasound, urinalysis (dipstick or sediment) which must be included in the primary evaluation of any patient presenting with LUTS to identify conditions, such as urinary tract infections (UTI), microhaematuria and diabetes mellitus. Early diagnosis through PSA testing (normal level below 4 ng/ml) may reduce prostate cancer deaths (6). PSA density (PSAD) below 0.15mg/ml/ml was considered as negative predictive factors for prostate cancer, so the right diagnosis of Prostate cancer increased by 94.1% to omit prostate biopsy (7). Clinical examination is carried out using modern diagnostic methods, the most important of which is the examination of the prostate gland in its size and shape, as well as the bladder and urethra by ultrasound, as well as examination of the urodynamics of the urinary stream (Uroflowmetry). The most prevalent and generally first line approach is behavioural and lifestyle modifications followed by medical therapy, including alpha-adrenergic antagonists (alpha blockers), 5-alpha reductase inhibitors (5ARIS), and phosphodiesterase 5 selective inhibitors (PDE5S), anticholinergics, and beta-3 agonists which may be utilized alone, or in combination to take advantage of their different mechanisms of action. If these men with advanced age and those with advanced stages of this enlargement are not treated, then the gold standard for treating these stages is their eradication by the plasmapheresis of the two poles TUR-Prostate. REFERENCES: (1): Andriole G, Bruchovsky N, Chung Let al: Dihy- drotestosterone and the prostate: the scientific rationale for 5alpha-reductase inhibitors in the treatment of benign prostatic hyperplasia. J Urol 2004; 172: 1399. (2): Russell D and Wilson J: Steroid 5alpha- reductase: two genes/two enzymes. Annu Rev Biochem 1994; 63: 25. (3): Reynard J: Does anticholinergic medication have a role for men with lower urinary tract symptoms/benign prostatic hyperplesia either alone or in combination with other agents? Curr Opin Urol 2004; 14: 13. (4): McVary K: BPH: Epidemiology and Comorbidities. An J Manag Care 12 2006: (5 Suppl): S122. (5): Wei J. Calhoun E and Jacobsen S: Urologic diseases in America project: benign prostatic hyperplasia. J Uro! 2005; 173: 1256. (6): Stamey, T.A., et al. Prostate-specific antigen as a serum marker for adenocarcinoma of the prostate. N Engl J Med, 1987. 317:909. (7): Schmid, H.P., et al. Observations on the doubling time of prostate cancer. The use of serial prostate-specific antigen in patients with untreated disease as a measure of increasing cancer volume. Cancer, 1993 71:2031 Author Correspondence: Prof. Dr. Semir A. Salim Medical Director of Professor Al Samarrai Medical Center. Dubai Healthcare City, Al-Razi Building 64, Block D, 2nd Floor, Suite 2018 E-mail: semiralsamarrai@hotmail.com Tel: +97144233669

Ureaplasma acute and chronic infection of the bladder in women and prostate in men, Etiology, Diagnosis, Treatment and Prevention The bladder diseases in women, such as acute and chronic infections, urinary incontinence and pelvic pain syndrome and all urinary tract infections in men, especially acute and chronic prostate infections, lead to symptoms of the lower urinary tract, and this affects 15-60% of men over 40 years and 16-53% of women. The spreading and severity of these symptoms are closely related to advancing age, as well as many abnormal clinical and neurological pathological changes of the urinary bladder, urethra and prostate, these symptoms are not life-threatening, but they affect negatively the quality of daily life. The cumulative studies confirmed that these symptoms are also related to anxiety, depression and sleep disorders, but these symptoms can be caused as well from obstructive diseases by men and women at the level of the bladder neck and urethra Many men and women with lower urinary tract symptoms (LUTS) are not troubled enough by their symptoms to need drug treatment or surgical intervention. All men and women with LUTS should be formally assessed prior to any allocation of treatment in order to establish symptom severity and to differentiate between men or women with uncomplicated (the majority) and complicated LUTS. Watchful waiting is a viable option for many men and women with non – bothersome LUTS as few will progress to AUR in men and complications as well by women (e.g. renal insufficiency or stones), whilst others can remain stable for years. Most bacterial infections of the prostate in men and bladder in women are due to infection with the Bacterium Escherichia coli. The common factors that cause complex urinary tract infections, they are either due to a narrowing or obstructions in the upper or lower urinary tracts or as well due to vesicoureteral and renal reflux. The most bacteria infect the bladder, urethra, as well as the vagina in women are Escherichia coli and enterobacteriaceae. Usually, symptoms of acute bacterial cystitis appear suddenly, with difficulty in emptying the bladder, as well as pain and burning during urination. Irritative lower urinary tract symptoms such as urinary frequency, discomfort and dysuria are highly disruptive to quality of life. While such symptoms can be associated with urinary tract or sexually transmitted infections, by definition these diagnoses require a positive clinical culture. When such symptoms persist despite negative cultures or appropriate antibiotic treatment, some providers evaluate for the atypical organisms Ureaplasma and Mycoplasma.These 2 generations of the Mycoplasmataceae family include several species. Only M. genitalium is a documented pathogen, causing urethritis in men and cervicitis in women that can lead to endometritis, pelvic inflammatory disease and infertility [1,2]. U. urealyticum is variably associated with nongonococcal urethritis in men only, while U. parvum is highly prevalent in Woman. In asymptomatic women, the prevalence U. parvum ranges between 20% to 89%, respectively. Two prospective trials detected U. urealyticum and M. hominis in 30% to 62% of women with LUTS and demonstrated a significant improvement in symptoms after antibiotic treatment. Culture methods have primarily been abandoned for rapid polymerase chain reaction-based clinical testing (PCR), which performs better detecting all species. The European STI Guidelines Editorial Board concluded that routine testing and treatment of asymptomatic or symptomatic men and women for U. urealyticum, U. parvum and M. homini are not recommended. When queried as to their reasons for treatment, many providers state that some of their patients improve with antibiotic therapy targeting Mycoplasmataceae. Several scenarios may explain these findings. Antibiotics have anti-inflammatory properties that can relieve non-infectious symptoms. Symptoms may be self-limited and resolve regardless of antibiotic treatment. Also, the symptoms reported by these patients may be related to true infections that coexist with Mycoplasmataceae. Changes in the local genitourinary environment, such as increased pH and impaired epithelial integrity, can promote shifts in broader microbial communities [3]. M. hominis is commonly identified in women with bacterial vaginosis. When treated with metronidazole, M. hominis is often eliminated along with Gardnerella vaginalis. In addition, M. hominis is commonly found in association with Trichomonas vaginalis infection. Chlamydia trachomatis, which also causes urethritis and genitourinary pain, frequently coexists with Ureaplasma [3] and is treated by similar antibiotic regimens [4]. These findings suggest that Mycoplasmataceae may grow synergistically with or thrive in environments created by other GU pathogens, making them a bystander in other genitourinary infections. As a result, however, many patients and their partners undergo repeated treatment with extended antibiotic courses. Our current understanding of the risks of repeated and extended antibiotic treatment, however, requires a more targeted approach to antibiotic use. The most prevalent and generally first line approach treatment of the LUTS due to BPH, prostatitis in men, cystitis and overactive bladder OAB in women is behavioral and lifestyle modifications followed by medical therapy, including alpha-adrenergic antagonists (alpha blockers) in men and women, 5-alpha reductase inhibitors (5ARIS), phosphodiesterase 5 selective inhibitors (PDE58) for treatment of BPH and prostatitis in men and for OAB treatment in both additionally anticholinergics, and beta-3 agonists – which may be utilized alone, or in combination to take advantage of their different mechanisms of action. As for the treatment of the aforementioned infections, it is based on effective antibiotic treatment against the bacteria diagnosed by PCR or urine culture. In recent years, high efficacy drug therapy for overactive bladder, urge incontinence has witnessed great development. The European society of urology has strongly recommended to reduce of the detrusor over activity, as the use of beta 3 adrenoreceptor (β3 –AR) agonist (mirabegron), or antimuscrinics (solifenacin), apha blockers, and botulinum toxin A (Botox A) as intra vesical treatment. These all to suppress neurotransmitter present in the membrane and bladder muscle, and the patient will be cured of this disease with the help of our God. Antibiotics, particularly extended courses, carry substantial risk. Such collateral damage is well documented: increased rates of recurrent infections, antibiotic resistance, antibiotic-associated diarrhea etc, Clostridium difficile colitis, allergic reactions. Normal GU commensals are thought to be critical for maintaining bladder physiology; antibiotic therapy

Prostate cancer is the second most common cancer among American men, affecting about one in nine over the age of 50, now that there are more than 2.9 million men living in the US who have been diagnosed with prostatic cancer [1]. The reason is the growth of the global population on earth, advanced age, and a family history of the disease due to hereditary genetic mutations in the gene (HPCL) in the short arm of the Y chromosome, as well as other recently discovered genes such as (BRCA-2) and (BRCA-1), these are well established risk factors for Prostate Cancer [2]. Prostate cancer is confirmed as the lifestyle that depends on excessive red meat intake and obesity, as well the metabolic syndrome and its componants [3]. Early diagnosis of the prostate-specific antigen may reduce prostate cancer deaths. Praise be to God, diagnosis of cancer earlier than before in its first & second stages, due to the development of diagnostic methods for this disease compared to the past decades, the most important diagnostic tools are the physical examinations of the prostate, as well as the PSA blood investigation and the density of PSA as a prognostic factor, additionally the prostate examination by ultrasound as well as MRI are important and necessary. The Intuitive Surgical DaVinci XI Robot has been conducting FDA approval as minimally invasive surgery on humans for well over decade now. Positive surgical margins (PSMs) during robotic radical prostatectomy with the DaVinci XI are strong predictors of biochemical recurrence [4]. Cognitive guidance of multiparametric magnetic resonance imaging (mp MRI) during robot assisted radical prostatectomy may improve the preservation of neurovascular bundles and avoid positive surgical margins [5]. An intraoperative frozen section analysis is the most commonly used technique for real –time assessment of surgical margins during prostatectomy. Intraoperative frozen section can be directed to the index lesion detected by mp MRI since larger volume index lesions are responsible for the vast majority of positive surgical margins [5]. The biochemical recurrence   or metastasis of this cancer can be diagnosed through investigation of the prostate-specific antigen (PSA) in the blood, which decreases after radical prostatectomy to below 0.002 ng/ml, if this PSA rises after a period of time after the radical removal of this cancer to more than 0.002 ng/ml, this indicates the emergence or spread of metastatic cancer, If the elevated PSA is confirmed above the aforementioned, then special diagnostic procedures must be performed to start either the total androgen deprivation hormone therapy or chemotherapy if it proves spread in the bones or other organs in the body of these patients. REFERENCESES: [1]: Mottet, N. et al. EAU-EANM-ESTRO-ESUR-SIOG Guidelines on Prostate Cancer 2020 update Part 1: Screening, Diagnosis, and Local Treatment with Curative Intent. Eur Urol, 2021. 79: 342. [2]: Randazzo. M.et al. A positive family history as a risk factor for prostate cancer in a population-based study with organised prostate-specific antigen screening: results of the Swiss European Randomised Study of Screening for Prostate Cancer (ERSPG Aarau BJU Int. 2016 117 576. [3]: Esposito, K., et al. Effect of metabolic syndrome and its components on prostate cancer risk: meta-analysis. J Endocrinol Invest, 2013. 36: 132. [4]: Dev Hs, Wilklund P, Patel V, et al. Surgical margin length and location affect recurrence rates after robotic prostatectomy. Urol oncol 2015;33, 109.e7-13. [5]: McClure TD, Margolis DjA, Reiter RE, et al. Use of MR imaging to determine preservation of the neurovascular bundles at robotic-assisted laparoscopic prostatectomy. Radiology 2012;262:874-83.