Volume 2

UIJ Volume 2 2009

Letter from the Editor - December 2009

Dear Colleagues,

As 2009 draws to a close, it provides an opportunity to reflect on what has transpired throughout urology in this past year. Has the UroToday International Journal delivered value through the publication to the readers? Have the goals of the journal been fulfilled? Our goals are to accelerate the timely and widespread dissemination of new urological research findings and, ultimately, to impact clinical outcomes. It has been a year of rapid growth for the journal. The response from the readership has been fantastic, and we have received an increasing number of high-quality manuscripts. We have been able to achieve the objectives for rapid publication, thanks to the excellent work of an increasing number of reviewers and timely response from the authors. The Journal issues throughout 2009 have been read by over 40,000 unique readers. A wide variety of relevant and interesting subjects have been covered, and this is continued in the present issue of the journal. A few of the articles are highlighted here.

In a retrospective study of 204 patients over 10 years, Dickstein et al assessed the risk of developing upper tract transitional cell carcinoma (TCC) after finding an abnormal upper tract cytology specimen without overt evidence of tumor. The authors developed an observation strategy for monitoring these patients for urothelial tumor development. They found that upper tract cytology has a poor sensitivity for tumors of the upper urinary tract. Patients with abnormal upper tract cytology were 3 times more likely than patients with normal cytology to develop TCC. They suggested that patients should be carefully monitored for at least 6 years.

Mohanty et al compared tamsulosin taken alone or in combination with tolterodine in a group of patients with lower urinary tract symptoms (LUTS) and detrusor overactivity. Physicians may hesitate to prescribe the combination of drugs because of the risk of acute urinary retention (AUR). The authors found no AUR and showed that patients with the combined drug treatment scored better on many laboratory tests and self ratings of satisfaction. Their findings confirmed several recent studies on the same subject.

Shelbaia et al reviewed the effect of early surgical repair of penile fractures (as opposed to a more conservative wait-and-see approach) in a retrospective study of 16 patients. The authors reported the overall healing of these injuries and the patient’s ability to regain erectile function. They found the surgery successful at 3 and 6-month follow-up. This issue also contains interesting case reports of patients with rare disorders. For example, Hutchings et al described a patient with cervical cancer that metastasized to the kidney. Other cases are related to treatment complications. Vasdev et al described a patient with inadvertent bowel injury following routine suprapubic catheter change. Sallami et al discussed the procedures and legal ramifications of textiloma, a complication that is rarely mentioned in the literature. Finally, although few surgeons will perform reanastomosis of an amputated penis, it is interesting to read the microsurgical procedures used by Wyczolkowski et al for one patient.

We occasionally like to provide review articles on topics of interest to our readers. In this issue, I joined with my colleagues to review noninvasive treatment options for patients with neurogenic detrusor overactivity (Andersson, Dmochowski, Wein). The use of oral antimuscarinic agents as a first-line approach is discussed, along with transdermal or intravesical administration of antimuscarinics, intravesical administration of other agents (including vanilloids and botulinum toxins A and B), and electrical stimulation. The efficacy and adverse events are described for these procedures, all of which allow surgery to be avoided where possible.

All of us at UIJ extend our wishes for a happy and peaceful new year. It has been exciting to experience the international cooperation that we have found with the readers, authors, and reviewers of the journal, and we look forward to continued collaborations. I join with the whole Editorial Team in thanking you for a wonderful year.

Kind regards,

K-E Andersson
Editor-In-Chief
UIJ

Early Management of the Fractured Penis: A Report of 16 Cases

ABSTRACT

INTRODUCTION: The purpose of this retrospective study was to review the effect of early surgical exploration and repair of penile fractures. The authors report the overall healing of these injuries and the patient's ability to regain erectile function.

METHODS: The participants were 16 patients with a fractured penile shaft following blunt trauma to the erect penis. Data were gathered over a period of 36 months. Retrograde urethrography was done in all cases. All patients were treated by early surgical repair within 24 hours of the injury.

RESULTS: Associated urethral injuries were found in 3 out of the 16 patients (18.75%). These patients had bleeding from the urethra at presentation. Seven patients had tears in the tunica albuginea only; the 9 remaining patients also had disruption of the corpus cavernosum. All tears involved the distal two-thirds of the penile shaft. The wounds healed successfully. All patients reported normal psychogenic, reflexogenic, and nocturnal erections with full sexual activity at 3-month and 6-month evaluations after surgery. Results of pharmacocavernosometric testing showed that all patients had rigid erections that occurred within 3-10 minutes and lasted for more than 30 minutes.

CONCLUSION: The authors recommend early surgical repair of penile fractures because of short hospitalization, successful healing, and early return to full sexual activity.

KEYWORDS: Penile fracture; Erectile function; Management; Prognosis

CORRESPONDENCE: Ahmed Mohamed Shelbaia, Borg El Atbaa, Faisal Street, Giza, Egypt (; ).

CITATION: UroToday Int J. 2009 Dec;2(6). doi:10.3834/uij.1944-5784.2009.12.14

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A Rare Case of Adenocarcinoma of the Urinary Bladder

ABSTRACT

Adenocarcinomas account for less than 2% of primary epithelial malignancies of the urinary bladder. The authors report a rare case of adenocarcinoma of the urinary bladder in a 65-year-old male patient who presented with frank hematuria. Extensive growth infiltration in paravesical fat planes was revealed by computed tomography imaging. The biopsy showed well-differentiated adenocarcinoma of the bladder with muscle involvement. The patient received bacille Calmette-Guérin (BCG) adjuvant therapy and later chemotherapy with poor response. Subsequently, he underwent total radical cystectomy with ileal conduit diversion. The aim of this report was to determine the anatomoclinical and therapeutic characteristics of this rare tumor.

KEYWORDS: Adenocarcinoma; Hematuria; Computed Tomography; Radical and Adjuvant BCG; Cystoprostectotomy

CORRESPONDENCE: Dr. Saleem M. Wani, Sher-I-Kashmir Institute of Medical Sciences, Department of Urology, Ward 4A, Srinagar, 190011, India ().

CITATION: Urotoday Int J. 2009 Dec;2(6). doi:110.3834/uij.1944-5784.2009.12.15

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Patient Response to Total Intravenous Sedation (TIVS) for Outpatient Ultrasound-Guided Prostate Biopsy

ABSTRACT

INTRODUCTION

Transrectal ultrasound (TRUS) guided biopsy is a common office urology procedure. Pain or discomfort associated with this procedure has been addressed with the use of periprostatic or intraprostatic infiltration and nerve block, local anesthesia, general anesthesia, suppository or oral analgesia, or lidocaine gel. The present study is an investigation of patient response to total intravenous sedation (TIVS) for TRUS-guided prostate biopsy. The authors describe the steps of the TIVS technique and critically examine the subsequent intraoperative and postoperative effects.

METHODS

Between December 2006 and April 2007, 100 patients underwent TRUS-guided prostate biopsy by a single surgeon (RK). TIVS sedation was achieved by intravenous administration of fentanyl (0.5-2 μg/kg), midazolam (0.03-0.05 mg/kg) and propofol (dosage titrated). Patients completed a modified Aldrete scoring system and modified postanesthetic discharge scoring system. The quality of the analgesia was assessed with a numerical pain rating scale. Patients were given a questionnaire to assess their perception of the pain and tolerability of the procedure.

RESULTS

The mean time between introduction of the probe and the end of the procedure was 10.5 minutes. Mean sedation time was 19 minutes and all patients were ready for discharge 70 minutes after the procedure. A total of 95 patients experienced a mild pain score of 1-3 out of 10 shortly after the procedure. The mean pain intensity score (95% Confidence Interval) was 1.36 (1.19-1.54), standard deviation = 0.865, median = 1. One patient developed intense nausea requiring IV antiemetic therapy. One patient developed urinary retention requiring urinary catheterization for a few days. There were no other complications related to the TIVS or TRUS procedure. Ninety-eight percent of the patients stated that they were not reluctant to have the biopsy repeated in the future if it was necessary.

CONCLUSIONS

TRUS-guided biopsy of the prostate can be accomplished with minimal pain by using TIVS. The authors believe that sedation should be considered and discussed with patients. TIVS provided sufficient analgesia and satisfactory hemodynamic stability. These effects facilitated recovery, allowing patients to be discharged less than 2 hours after the procedure.

KEYWORDS

Transrectal ultrasound; Biopsy of prostate; Procedural intravenous sedation (PIS); Total intravenous sedation (TIVS); Modified Aldrete scoring system, Modified postanesthetic discharge score

CORRESPONDENCE

Dr. Ahmed Al-Sameraaii, Department of Urology, The St. George Hospital, Gray Street, Kogarah 2217, NSW, Australia ( email address is being protected from spam bots, you need Javascript enabled to view it ).

CITATION

UroToday Int J. 2009 Dec;2(6). doi:10.3834/uij.1944-5784.2009.12.04

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Ureteroscopy During Pregnancy Using the Follow-the-Wire Technique

ABSTRACT

INTRODUCTION: The purpose of the study was to evaluate the use of ureteroscopy for the treatment for urolithiasis during pregnancy. The follow-the-wire technique was used.

METHODS: The participants were 26 pregnant women with persistent renal colic that did not respond to medications. Patients were seen between March 2002 and January 2009. The mean patient age was 24 years (range, 21-39 years). Three patients presented during the first trimester, 15 patients during the second trimester, and 8 patients during the last trimester. Ureteroscopy was performed using a 7.5-8 F semirigid ureteroscope. Cystoscopy was performed first and the ureteric orifice was identified. The guidewire was advanced through the ureteroscope into the ureteric orifice. The ureteroscope followed the guidewire until the site of obstruction was located. The guidewire was advanced under visualization, past the obstruction and to the kidney. The ureteroscope was removed and reintroduced. Lithoclast was used for stone disintegration and a Nitinol tipless dormia was used for stone extraction. A stent with string was placed.

RESULTS: The mean operative time was 26 minutes (range, 21-69 minutes). There was no difficulty in passing the proximal ureter, even in late pregnancy. Fluoroscopy was not required. Ureteral stones ranging from 6-9 mm in size were detected in 18 (69%) of the patients. Eleven patients had distal stones; 7 had proximal stones. Lithotripsy was performed for 16 patients; stones were directly extracted from 2 patients. There were no complications related to the procedures. Stents were left in place 5-7 days for patients with stones. For the 8 patients without stones, the surgeons left a silicone long-term double pigtail stent until after the delivery. Postoperative complications were mainly related to the stents and included dysuria or urgency (n = 2), hematuria related to movement (n = 2), and urinary tract infection (n = 1). All patients completed full-term pregnancies.

CONCLUSION: Ureteral obstruction during pregnancy can be safely managed by using the follow-the-wire ureteroscopy technique. It obviates need for ionizing radiation. In experienced hands, the technique is safe and reproducible.

KEYWORDS: Ureteroscopy; Pregnancy; Stones

CORRESPONDENCE: Ehab Rifat Tawfiek MD, Department of Urology, El Minia University Hospital, Elminia 16666, Egypt ().

CITATION: UroToday Int J. 2009 Dec;2(6). doi:10.3834/uij.1944-5784.2009.12.17

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A Rare and Serious Complication of Elective Suprapubic Catheter Change

ABSTRACT

Suprapubic catheter (SPC) insertion is a commonly performed elective or emergency procedure in urology. SPC change is a simple process that is typically completed in the primary care office in the United Kingdom. Urinary tract infection, hemorrhage, and injury to adjacent intraabdominal organs are potential complications. The authors present a case of inadvertent bowel injury following elective SPC change. They recommend techniques to prevent this complication.

KEYWORDS: Suprapubic catheter; Delayed bowel injury

CORRESPONDENCE: Nikhil Vasdev, Specialist Registrar, Department of Urology, Freeman Hospital, Newcastle upon Tyne, UK ().

CITATION: Urotoday Int J. 2009 Dec;2(6). doi:10.3834/uij.1944-5784.2009.12.06

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Efficacy and Safety of an Alpha-Blocker With and Without Anticholinergic Agent in the Management of Lower Urinary Tract Symptoms With Detrusor Overactivity

ABSTRACT

INTRODUCTION: The purpose of the present investigation was to compare the efficacy and safety of a fixed dose of uroselective alpha blocker (tamsulosin) taken alone or in combination with a pure anticholinergic agent (tolterodine) in a group of patients with urodynamically and clinically proven lower urinary tract symptoms (LUTS) and detrusor overactivity (DO).

METHODS: The participants were 75 men with LUTS and DO, randomly assigned to 2 groups. Group 1 (n = 37) received tamsulosin (0.4 mg) orally; group 2 (n = 38) received tamsulosin (0.4 mg) and tolterodine (4 mg) orally. All patients took the medications daily for 3 consecutive months. Patients were evaluated before and after treatment by the International Prostate Symptoms Score (IPSS), ultrasound of the kidney and urinary bladder (KUB), prostate specific antigen (PSA), and urodynamic pressure flow study. Patients were also questioned about their perception of treatment benefits and quality of life (QoL). Group comparisons in response to treatment were analyzed statistically.

RESULTS: Patients in group 2 had significantly better response to treatment than patients in group 1 for 5 of the 8 main urodynamic variables studied: (1) mean reduction in maximum detrusor pressure during micturition (P = .01), (2) mean reduction in maximum unstable detrusor contraction pressure/end filling pressure (P < .001), (3) mean increase in maximum cystometric bladder capacity (P = .007), (4) mean increase in volume at first unstable bladder contraction (P = .02), (5) mean increase in bladder compliance (P < .001). The groups were similar in their response to therapy for maximum flow rate, postvoid residual volume, and total IPSS. No acute urine retention (AUR) was reported in either group. Positive response to treatment was reported by 51.4% of patients in group 1 and 85.7% of patients in group 2. Group 2 also had significantly higher mean QoL scores (P = .02). Group 2 had a significantly greater reduction in the DO symptoms of frequency in 24 hours, urgency in 24 hours, and nocturia when compared with patients in group 1 (P = .02, P = .01, and P = .01, respectively). Patients taking tamsulosin and tolterodine had significantly more side effects of constipation, dry mouth, and dry eyes.

CONCLUSION: Results of the study confirm the safety and efficacy of combination therapy for patients with LUTS and DO.

KEYWORDS: Detrusor overactivity; Medical treatment

CORRESPONDENCE: Professor N.K. Mohanty, C – II /124, Motibagh, New Delhi, 110021 ().

CITATION: Urotoday Int J. 2009 Dec;2(6). doi:10.3834/uij.1944-5784.2009.12.02

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Mucinous Adenocarcinoma of the Ileal Neobladder 20 Years After Cystectomy: The First Reported Case

ABSTRACT

The authors present the case of a 68-year-old male with mucinous adenocarcinoma of the ileal neobladder. The adenocarcinoma occurred 20 years after radical cystoprostatectomy for Stage pT2 transitional bladder cell cancer. An international literature search revealed 10 cases with a neoplasm in an ileocystoplasty, but this type of adenocarcinoma has not been reported previously. The present case supports the hypothesis that morphologic and molecular changes in an ileal neobladder may increase the risk of local malignancies. Patients with an ileal neobladder may develop glandular malignancy and should be closely followed.

KEYWORDS: Neoplasm; Bladder; Enterocystoplasty; Urinary diversion

CORRESPONDENCE: Dr. Satâa Sallami, Department of Urology, La Rabta Hospital-University, Tunis 1007, Tunisia ().

CITATION: Urotoday Int J. 2009 Dec;2(6). doi:10.3834/uij.1944-5784.2009.12.16

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Minimally Invasive Therapy for Neurogenic Detrusor Overactivity: A Review

ABSTRACT

Urinary incontinence secondary to neurogenic detrusor overactivity (NDO) is a common problem in patients with neurologic pathology. Patients with NDO are at increased risk for recurrent urinary tract infection and renal damage, especially due to high intravesical pressures. They may also experience urinary urgency, frequency, and incontinence, which are all factors that negatively affect quality of life. Oral antimuscarinic agents are considered first-line pharmacologic therapy, but their use may be limited by adverse effects and result in poor compliance and adherence. Surgical augmentation of the bladder is a rare final alternative when other attempts to restore continence have failed. However, there are other less invasive treatment options that are currently available or undergoing research. These options include transdermal or intravesical administration of antimuscarinics, intravesical administration of other agents (including vanilloids and botulinum toxins A and B), and electrical stimulation. The available alternatives have demonstrated varying degrees of efficacy and are all minimally invasive, allowing surgery to be avoided where possible. However, neither vanilloid nor botulinum toxin therapy is approved by the United States Food and Drug Administration for treatment of detrusor overactivity. Treatment should always begin with the most reversible forms of therapy and progress to more complex options.

KEYWORDS: Antimuscarinics; Botulinum toxin; Neurogenic detrusor overactivity; Neuromodulation

CORRESPONDENCE: Karl-Erik Andersson, MD, PhD, Wake Forest Institute for Regenerative Medicine, Wake Forest University School of Medicine, Medical Center Boulevard, Winston-Salem, NC 27157 ()

CITATION: UroToday Int J. 2009 Dec;2(6). doi:10.3834/uij.1944-5784.2009.12.10

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Transrectal Ultrasound-Guided Needle Aspiration of a Prostatic Abscess

ABSTRACT

Occurrence of prostatic abscess has become very rare since the advent of modern antibiotics. The authors report a case of a 51-year-old man with insulin-dependent diabetes mellitus and recurrent urinary tract infections who was diagnosed with prostatic abscess. He was treated successfully with transrectal ultrasound (TRUS) guided needle aspiration under local anesthetic. TRUS-guided drainage is a safe and effective therapeutic approach for the treatment of this disorder.

KEYWORDS: Prostatic abscess; Ultrasound guided needle aspiration

CORRESPONDENCE: Michael Nomikos MD, Consultant Urologist, Knossou Street 275, Heraklion, Crete, 71409, Greece ()

CITATION: UroToday Int J. 2009 Dec;2(6). doi:10.3834/uij.1944-5784.2009.12.11

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Successfully Performed Reanastomosis of a Completely Amputated Penis: Surgical Technique

ABSTRACT

Complete penile amputation is a rare condition that requires immediate and complex surgical treatment. There are few descriptions of successful operative techniques using microsurgical methods in the literature.

The authors present the rare case of 30-year-old man who amputated his penis at its base using an ax. Nine hours after the injury, the patient underwent microsurgical anastomosis of the arteries, veins, corpora cavernosa, and urethra. The authors describe the steps in their surgical procedure and provide illustrative figures. They also explain their perioperative and postoperative support therapy.

Approximately 20% of the distal spongy body and skin of the penis became necrotic beginning on the 6th postoperative day. On the 18th day, necrectomy of the penile skin flap was performed and the phallus was buried in the scrotum. Exteriorization of the penis that was partially covered by scrotal skin was completed 2 months after reanastomosis. The distal necrotic part of the urethra was reconstructed using buccal mucosa graft transplantation. A split-thickness skin graft from a lower limb was used to cover the rest of the phallus. The patient achieved return of physiologic micturition with no urethral structures. He also experienced incomplete erectile function.

KEYWORDS: Penile amputation; Penile replantation; Surgical techniques

CORRESPONDENCE: Marek Wyczółkowski MD, PhD, Department of Urology, Rydygier Memorial Hospital, Złotej Jesieni 1 Str., 31-826 Cracow, Poland ().

CITATION: Urotoday Int J. 2009 Dec;2(6). doi:10.3834/uij.1944-5784.2009.12.08

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Transurethral Electrovaporization of the Prostate as an Alternative to Transurethral Resection: A Five-Year Follow-up

ABSTRACT

INTRODUCTION: The aim of the present study was to compare the safety and efficacy of transurethral electrovaporization of the prostate (TUVP) with conventional transurethral resection of the prostate (TURP) in the treatment of patients with moderate to severe bladder outlet obstruction due to benign prostatic hyperplasia (BPH).

 

METHODS: Between December 2001 and November 2003, 131 patients presented to the author's institution with moderate to severe bladder outflow symptoms due to BPH. The patients were randomly assigned to undergo TURP (n = 67) or TUVP (n = 64). Patients receiving TURP had a significantly larger mean prostate size (P = .01) but were similar in all other evaluated characteristics. Using the hospital database, the author reports the available follow-up results after 1, 2, 3, and 5 years. The International Prostate Symptom Score (IPSS), uroflowmetry (Q-max), and postvoid residual volume (PVR) were used for evaluation. Operative time, catheterization time, hospital stay, and blood tests were also compared.

RESULTS: Of the 131 total patients, 51 patients receiving TURP and 50 patients receiving TUVP completed 5 years of follow-up; 21 patients died and the remaining 9 could not be contacted. No deaths were associated with either resection or vaporization of the prostate. Patients receiving TURP had a significantly longer mean postoperative catheterization time (P < .001) and mean hospitalization time (P < .001). Patients had significantly lower mean serum hemoglobin and hematocrit 1 hour following TURP (P < .001). There were no significant group differences for any other measures.

CONCLUSIONS: To the author's knowledge, the present study is the largest reported comparison of TURP and TUVP over a 5-year follow-up period. The low intraoperative and perioperative morbidity, rapid convalescence time, short hospital stay, and simplicity of the procedure make TUVP a potentially suitable, safe alternative to TURP in the therapeutic armamentarium for BPH. Because of its unique electrosurgical properties, higher risk patients can be treated successfully with this technique. The main disadvantage of TUVP appears to be the unavailability of prostate tissue needed for pathologic examination. Additionally, although TURP and TUVP were found to be comparable for prostate sizes < 60 g for patients in the present study, TURP may be advantageous for patients with larger prostates.

KEYWORDS: Transurethral electrovaporization of the prostate (TUVP); Transurethral resection of the prostate (TURP).

CORRESPONDENCE: Ehab Rifat Tawfiek MD, Department of Urology, El Minia University Hospital, Elminia 16666, Egypt ().

CITATION: UroToday Int J. 2009 Dec;2(6). doi:10.3834/uij.1944-5784.2009.12.12

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Direct Trocar Insertion Compared With Open Laparoscopy (Hasson Technique) in Patients Undergoing Urolaparoscopic Surgery

ABSTRACT

INTRODUCTION: The purpose of the study was to compare the ease of use, safety, and efficacy of direct trocar insertion (DTI) and open access (Hasson technique) in laparoscopic surgery. This is the first known report of DTI used in urolaparoscopy.

METHODS: The study was a retrospective evaluation of patients referred for laparoscopic procedures between December, 2005 and June, 2008. A total of 148 patients were studied; 62 patients (41.9%) received DTI and 86 patients (58.1%) received open laparoscopy. Patients were not randomly assigned to treatment groups. For the DTI, the abdominal wall was lifted and the trocar was pushed through the fascia and muscle layer. The surgeon felt when the trocar had pierced the peritoneum and entered the abdominal cavity. For the open technique, the peritoneal cavity was opened under direct vision and the trocar was inserted. The variables measured were access time, minor and major complications, visceral and vascular injury and bleeding, conversion to open surgery, length of hospitalization, failed entry, and abdominal pressure for creation of the pneumoperitoneum. Chi-square and t tests were used to compare categorical and continuous variables, respectively.

RESULTS: The mean length of hospitalization was 26.95 hours (SD = 7.78) for patients receiving DTI and 30.44 hours (SD = 13.98) for patients receiving open laparoscopy, but the difference was not statistically significant (P > .05). The mean access time for DTI was 91.75 seconds (SD = 79.77), which was significantly shorter than the mean access time of 263.97 seconds (SD = 119.28) for patients receiving open laparoscopy (P < .0001). The mean abdominal pressure for creation of the pneumoperitoneum with DTI was 16.17 mmHg (SD = 1.46), which was significantly higher than the mean abdominal pressure of 15 mmHg (SD = 0) with open laparoscopy (P < .0001). There were very few complications in either study group. Although 11 patients (17.74%) in the DTI group and 7 patients (8.14%) in the open laparoscopy group had previous open abdominal or groin surgery, the previous surgeries did not negatively impact the laparoscopic procedures (P = .01). There were no entry failures in either group.

CONCLUSION: DTI is faster and appears to be more efficacious for some aspects of surgery than the open laparoscopy technique, although the safety of the two techniques is equivalent. The authors suggest that direct trocar insertion can be used in urolaparoscopic surgeries. Future prospective studies with larger numbers of patients randomly assigned to treatment groups are needed to confirm the results.

KEYWORDS: Laparoscopic surgery; Direct trocar insertion; DTI; Laparoscopic access; Pneumoperitoneum; Emphysema; Urolaparoscopy; Endopth Xcel trocar

CORRESPONDENCE: Siavash Falahatkar M.D., Guilan University of Medical Sciences, Urology Research Center, Razi Hospital, Sardare Jangal Street, Rasht, Guilan 41448, Iran ( email address is being protected from spam bots, you need Javascript enabled to view it).

CITATION: UroToday Int J. 2009 Dec;2(6). doi:10.3834/uij.1944-5784.2009.12.03.

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Spontaneous Rupture of the Upper Urinary Tract Caused by Ureteral Calculi: Effectiveness of Primary Ureteroscopic Treatment

ABSTRACT

INTRODUCTION: Spontaneous rupture (SR) of the urinary collecting system with perirenal and retroperitoneal extravasation of the urine is an unusual condition that is typically caused by ureteral-obstructing calculi. The authors present a retrospective study of 10 cases. They report evaluation, endoscopic management, and follow-up assessments.

METHODS: Between 1998 and 2008, 10 patients were admitted for SR of the urinary collecting system proximal to a lithiasic obstruction. There were 6 males and 4 females. The mean patient age was 51.5 years. At presentation, all patients had sudden severe flank pain. There were no other urinary symptoms. All patients had a physical examination, laboratory blood and urine analyses, and radiography, ultrasonography, intravenous urography (IVU), and/or computed tomography (CT). Ureteroscopy was performed. Ureteral stones were fragmented with a pneumatic lithotripter.

RESULTS: Ultrasonography and IVU or CT showed a perinephric collection due to urine extravasation that was compatible with rupture of the renal collecting system. SR was secondary to an obstructing calculus in all cases. Patients were managed successfully by primary endoscopic treatment of ureteroscopic lithotripsy and stenting. Follow-up was unremarkable.

CONCLUSION: SR of the urinary collecting system is a very rare pathological condition. It should be considered in cases of unusual renal colics. Ureteroscopic lithotripsy followed by double-J stenting of the ureter appears to be a quick, safe, and effective management approach.

KEYWORDS: Pelvis rupture; Ureteral rupture; Ureteral calculus; Computed tomography; Ureterel stent; Endoscopic lithotripsy

CORRESPONDENCE: Dr. Sallami Satâa, Department of Urology, La Rabta Hospital-University, Tunis 1007, Tunisia ().

CITATION: UroToday Int J. 2009 Dec;2(6). doi:10.3834/uij.1944-5784.2009.12.07

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Solitary Metastasis of Cervical Carcinoma to the Kidney: A Case Report and Review of the Literature

ABSTRACT

A 47-year-old female presented with a history of hematuria and right loin pain 18 months after receiving chemoradiotherapy for advanced cervical carcinoma. A CT scan demonstrated a grossly abnormal right kidney suggestive of either inflammatory or malignant change. A percutaneous biopsy under CT guidance demonstrated squamous cell carcinoma in keeping with metastatic cervical carcinoma. Metastasis of cervical carcinoma to the kidney is extremely rare, with only 8 previous cases reported in the literature.

KEYWORDS: Cervical carcinoma; Renal metastasis; Biopsy; Caval thombus

CORRESPONDENCE: Dr. David C. Hutchings, Department of Urology, Churchill Hospital, Oxford, OX3 7LJ, UK ().

CITATION: Urotoday Int J. 2009 Dec;2(6). doi:10.3834/uij.1944-5784.2009.12.05

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Outcome of Patients with Abnormal Upper Tract Cytology and Negative Initial Workup

ABSTRACT

INTRODUCTION: Patients with pathologically confirmed upper tract transitional cell carcinoma (TCC) currently undergo surveillance according to well described protocols. The literature offers little guidance for monitoring patients with abnormal upper tract cytology without prior upper tract TCC. The purpose of the present study was to assess the risk of upper tract TCC based on cytology and determine a reasonable observation strategy for this abnormal finding.

METHODS: The authors performed a 10-year retrospective cohort study of 204 patients (366 renal units) within the New England Veterans Administration Healthcare System. Upper tract cytology was collected: (1) as a consequence of lateralizing hematuria during cystoscopy in 2 patients; (2) following abnormal upper tract imaging in 27 patients; (3) from the bladder in the presence of a suspected bladder tumor and/or carcinoma in-situ (CIS) in 16 patients; (4) from the bladder despite a negative workup for lower tract tumor in 159 patients. Cytology results reported as negative or atypical were categorized as normal; suspicious or positive results were categorized as abnormal. Odds ratios (OR) were calculated and hazard curves plotted to determine risk and time span of tumor development among the cohorts.

RESULTS: Twenty-six renal units had upper tract TCC over a median follow up of 38 months. The OR for development of upper tract TCC with abnormal upper tract cytology was 3.27 and did not change with a previous history of lower tract disease. The accumulation rate differed with normal and abnormal upper tract cytology among those who developed upper tract TCC.

CONCLUSION: Upper tract cytology has a poor sensitivity for tumors of the upper urinary tract. Patients with abnormal upper tract cytology are 3 times more likely to develop TCC than patients with normal upper tract cytology and should be carefully monitored for at least 6 years. However, the exact method and frequency of monitoring remains undetermined.

KEYWORDS: Transitional cell carcinoma; Urothelial carcinoma; Cytology; Upper tract; Renal pelvis; Ureter

CORRESPONDENCE: Rian Dickstein, MD, Department of Urology, 720 Harrison Avenue, Suite 606, Boston, MA 02118 ()

CITATION: UroToday Int J. 2009 Dec;2(6). doi:10.3834/uij.1944-5784.2009.12.01

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Squamous Cell Carcinoma in the Meatus of a Distal Hypospadia

ABSTRACT

A 39-year-old male presented with a tumor in the urethral orifice. A papillary tumor (1 cm × 1 cm) was found at the meatus of a distal hypospadia. The patient underwent tumor resection without urethroplasty. The pathological diagnosis was squamous cell carcinoma. No recurrence or metastasis was found during 2 years of follow-up. Squamous cell carcinoma in the urethral orifice of hypospadias is extremely rare. To the authors’ knowledge, this is only the second case reported in the literature.

KEYWORDS: Urethral cancer; Squamous cell carcinoma; Meatus; Hypospadia

CORRESPONDENCE: Yoshiyuki Kojima MD, Department of Nephro-urology, Nagoya City University Graduate School of Medical Sciences, 1 Kawasumi, Mizuho-cho, Mizuho-ku, Nagoya 467-8601, Japan ().

CITATION: Urotoday Int J. 2009 Dec;2(6). doi:10.3834/uij.1944-5784.2009.12.13

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A Case of Textiloma Mimicking a Retroperitoneal Tumor

ABSTRACT

Foreign bodies left inside the patient following surgical procedures are infrequently reported in the literature. Incidence figures might be underestimated because of medico-legal implications. A 56-year-old male had a right ureterolithotomy for a lumbar ureteral stone. He was asymtomatic for 3 years before presenting with intermittent right flank pain. Imaging showed a tumor-like mass in the right lumbar region. Surgical exploration revealed a textiloma.

KEYWORDS: Urinary surgery; Retroperitoneal space; Postoperative complication; Foreign body; Textiloma.

CORRESPONDENCE: Dr. Sallami Satâa, Department of Urology, La Rabta Hospital-University, Tunis 1007, Tunisia ().

CITATION: UroToday Int J. 2009 Dec;2(6). doi:10.3834/uij.1944-5784.2009.12.09

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Letter from the Editor - October 2009

Dear Colleagues,

UroToday International Journal offers open access with the objective to accelerate the timely and widespread dissemination of new urological relevant research findings and, ultimately, to have a more immediate impact on clinical practice than traditional publishing methods. The editorial team is pleased to publish both clinical and basic research, in addition to review articles, case studies, and other articles representing clinical practice. This combination of clinical and basic research is reflected in the present issue.

The article by Hammouda et al in (Post-Tubularized Incised Plate Urethroplasty Healing: An Experimental Randomized Study in 40 Dogs) is an example of research in a dog model. The authors studied the mechanism of urethral healing after tubularized incised plate urethroplasty and describe some aspects of wound development following hypospadia repair. A clinical study on the same theme is found in the article by Hussein (Reoperative Hypospadias Repair According to Urethral Plate Status). He found the tubularized incised plate urethroplasty to be effective and safe when the urethral plate is healthy.

The topical review article in this issue, written by Evans et al, discusses the diagnosis and treatment of interstitial cystitis. The authors describe the etiology of the disorder, diagnostic tests, and pharmacologic and nonpharmacologic treatments presented in the literature to date.

In this issue, the focus on clinical practice includes an article by Salem (Medical Treatment for Small Stones in the Lower Ureter) comparing the efficacy of the α-adrenergic blocker tamsulosin and the calcium channel blocker nifedipine, two commonly prescribed drugs used in medical expulsive therapy for distal ureteric stones. Patients taking tamsulosin experienced significant benefits. Another study by Salem et al provides longitudinal results of a surgical approach for correction of penile curvature, including a tabled review of comparable literature. Falahatkar et al authored 3 articles in this issue. Perhaps the timeliest was a study comparing the use of stents with no stents after uncomplicated ureteroscopic lithotripsy for small (< 10 mm) middle and distal ureteral stones. Their results helped to build support for elimination of indwelling stents in these circumstances.

Readers will undoubtedly find several other articles of interest in this issue. Gamal et al report on the feasibility and outcomes of the N-shaped pouch with an afferent tubular isoperistaltic segment as a new technique for creating a capacious, low pressure bladder substitute following radical cystectomy; Ahmadnia et al discuss pathophysiology and treatment of the rare disorder, idiopathic scrotal calcinosis, and Fitouri et al report the safety and efficacy of ofloxacin on BCG-induced toxicity in patients with superficial bladder cancer. Finally, Banakhar and Mosli, and Botelho et al present interesting and relevant case reports.

We thank the authors for their submissions and the reviewers for providing timely responses in the peer review process for publication. We look forward to hearing your views on the articles that are presented here in post-publication discourse and we look forward to your future submissions.

Kind regards,

K-E Andersson
Editor-In-Chief
UIJ

Is Ureteral Stenting Necessary After Uncomplicated Ureteroscopy Lithotripsy for Small Middle and Distal Ureteral Stones?

ABSTRACT

INTRODUCTION: Previous studies have suggested that routine stenting can be avoided following ureteroscopy. A prospective investigation was performed to determine the outcome of stent or no-stent placement after uncomplicated ureteroscopic lithotripsy for small (< 10 mm) middle and distal ureteral stones.

METHODS: Fifty six patients meeting inclusion criteria underwent uncomplicated ureteroscopic intracorporeal lithotripsy using a pneumatic device. No patient required ureteral dilation. Patients were randomly assigned to nonstented (n = 28) and stented (n = 28) treatment groups. The stent was removed after 2 days. Patients were followed for 2 weeks postoperatively.

RESULTS: There were no significant between-group differences in patient age, sex, stone size, or stone location. There were no significant between-group differences in mean operation time and postoperative pain. The group receiving the stent had a significantly longer mean hospital stay (2.14 days vs 1.25 days) (P < .0001). The stone-free rate was exactly the same at 96.4% for each group; the procedure was not successful for 1 patient in each group. There were no significant between-group differences in flank pain, fever, and hematuria. However, dysuria was significantly more common in the group receiving a stent (P = .002).

CONCLUSIONS: Patients who did not receive a stent after ureteroscopic intracorporeal lithotripsy had the same success rates as those who received a stent, while needing a shorter hospital stay and having less dysuria. These findings suggest that ureteral stent placement following uncomplicated ureteroscopy may be avoided, thereby reducing patient morbidity and surgical costs.

KEYWORDS: Ureteral stone; Ureteroscopy; Ureteral stent

CORRESPONDENCE: Siavash Falahatkar M.D., Guilan University of Medical Sciences, Urology Research Center, Razi Hospital, Sardare Jangal Street, Rasht, Guilan 41448, Iran ().

CITATION: Urotoday Int J. 2009 Oct;2(5). doi:10.3834/uij.1944-5784.2009.10.12

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