Volume 2

UIJ Volume 2 2009

Laparoscopic-Guided Percutaneous Nephrolithotomy in a Reoperated Pelvic Kidney

ABSTRACT

The stone-retaining pelvic ectopic kidney of a 46-year-old female was treated with laparoscopically assisted complete supine percutaneous transperitoneal nephrolithotomy. She had a past history of previous open surgery for a left kidney stone about 7 years ago, left transurethral ureterolithotripsy (TUL) about 5 years ago, and an unsuccessful left extracorporeal shock wave lithotripsy (ESWL) recently. Ultrasound and intravenous pyelogram (IVP) imaging showed multiple calculi in a left ectopic pelvic kidney overlying on the sacrum. The burden of stone was 5 cm. With the patient in the supine position under laparoscopic control, the bowels were dislodged with forceps until the kidney became visible. Under laparoscopic control, the nephrostomy track was created on the antegrade route using a one shot dilator. Percutaneous nephrolithotomy was carried out in the usual manner with a rigid 26F nephroscope. Stones were fragmented and removed. No complications occurred. The operating time was 105 minutes; the hospital stay was 4 days. On the basis of the authors' experience, PNL with guided laparoscopy in pelvic kidneys is safe even in reoperative patients.

KEYWORDS: Reoperated pelvic kidney; Complete supine percutaneous transperitoneal nephrolithotomy (PNL); Urolithiasis; Laparoscopic guided PNL; Ectopic kidney

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 Oct;2(5). doi:10.3834/uij.1944-5784.2009.10.06

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Mersilene Complication in Bladder Exstrophy Repair: Report of 3 Cases

ABSTRACT

Bladder exstrophy is one of the rare bladder anomalies. It needs complex surgical management. The main surgical procedures include bladder closure, epispadias repair, and pelvic stability with innominate bone osteotomy and symphysis pubis repair. Mersilene is a synthetic material that can be used for symphysis repair. The authors report Mersilene sinus formation and infection in 3 cases of bladder exstrophy. The cases were managed by Mersilene removal without any further effect on pelvic stability.

KEYWORDS: Bladder exstrophy; Pelvic stability; Mersilene complication

CORRESPONDENCE: Mai Banakhar, Urology Department, King Abdul Aziz University Hospital, PO Box 80215, Jeddah 21589, Kingdom of Saudi Arabia (KSA) ().

CITATION: UroToday Int J. 2009 Oct;2(5). doi:10.3834/uij.1944-5784.2009.10.01

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Post-Tubularized Incised Plate Urethroplasty Healing: An Experimental Randomized Study in 40 Dogs

ABSTRACT

INTRODUCTION: The mechanism of urethral healing after tubularized incised plate urethroplasty (TIP) is still debatable. The purpose of the present study was to report post-TIP healing in a randomized-study hypospadias dog model.

METHODS: The hypospadias model was created in 40 male mongrel dogs that were randomly allocated into group 1 and group 2 with 20 dogs in each, and 4 subgroups (1a and 1b; 2a and 2b) with 10 dogs in each. The urethral plate width was reduced to 10 mm and 6 mm in group 1 and group 2, respectively. The urethral plate (UP) was tattooed and bisected by midline longitudinal incision. The length of UP and urethral incision (UI) was 2 cm in subgroups 1a and 2a and 4 cm in subgroups 1b and 2b. Tubularization of UP was done over an 8 Fr feeding tube. After 4 weeks, the phallus was harvested and transverse sections were obtained from the area of UI. They were stained by hematoxylin and eosin (H&E), Masson's trichrome, and fibronectin stains and pathologically examined.

RESULTS: Four cases of proximal urethral fistulae were reported in group 2 (1 in subgroup 2a; 3 in subgroup 2b). Gross inspection exhibited intervening tissues at the site of UI. The size of the intervening tissues between the healing edges of the UI was 0.8 mm (SD = 0.1) in group 1 and 2.5 mm (SD = 0.2) in group 2. Light microscopy revealed creeping of normal-appearing squamous surface epithelium in all specimens. Increased collagen fiber deposition was recorded in group 2 when compared with group 1. Fibronectin was expressed in the subepithelial locations of the urethra in all studied animals. However, dense signals were reported in group 2 in comparison to group 1.

CONCLUSIONS: Healing after TIP occurs by secondary intention with creeping of the surface epithelium. Collagen deposition was increased in cases of UP ≤ 6 mm in width. Post-TIP complications may increase in cases of narrow UP, especially with the neourethra and UI > 2 cm in length.

KEYWORDS: Urethra; Hypospadias; Dog; Healing.

CORRESPONDENCE: Dr. Hisham Hammouda, Director of the Pediatric Urology Unit, Urology Department, Faculty of Medicine, Assiut University Hospital, 71111, Assiut, Egypt ().

CITATION: UroToday Int J. 2009 Oct;2(5). doi:10.3834/uij.1944-5784.2009.10.07

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Modified N-Shaped Ileal Neobladder After Radical Cystectomy

ABSTRACT

INTRODUCTION: The authors 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.

METHODS: Between April 2000 and April 2006, 42 patients (36 male, 6 female) with invasive bladder cancer were considered good candidates for orthotopic urinary diversion. All had radical cystectomy with bilateral pelvic lymphadenectomy and orthotopic bladder substitution by an ileal low pressure reservoir (N-shaped) with an afferent isoperistaltic tubular segment. Of the 42 patients, 36 (86%) had squamous cell carcinoma; 6 had transitional cell carcinoma. None of the patients had positive lymph nodes after pathologic examination of the specimen. Thirty-two males and 4 females were available for a median follow-up period of 24.8 months. Follow-up included clinical and radiographic studies to determine functional and oncological outcomes.

RESULTS: : Eleven patients (25%) had early complications during the period ≤ 3 months following surgery. Seven of these patients had complications such as wound infection, prolonged ileus, persistent urinary leakage, and deep venous thrombosis that were treated conservatively. One female patient developed a pouch-vaginal fistula that required repair. The remaining 3 patients had oncological failures, 1 of which was isolated urethral recurrence. Late complications occurred in 15 patients (37.5%). These included pouch stones, outflow obstruction, mucus retention, and adhesive bowel obstruction. Daytime and nighttime continence was achieved in 92% and 80% of the patients, respectively, and ureteroileal stricture was observed in 5%. The upper tracts remained unchanged or improved in 95% of the patients.

CONCLUSIONS: Ileal orthotopic bladder substitution (N- shaped) with an afferent ileal tubular segment offers good functional results with good preservation of the renal units. It is considered a safe and technically feasible surgical procedure.

KEYWORDS: N-pouch; Cystectomy; Orthotopic diversion

CORRESPONDENCE: Wael M Gamal, MD, Department of Urology, Sohag University, 31 el nasr Street, Sohag, Egypt ().

CITATION: Urotoday Int J. 2009 Oct;2(5). doi:10.3834/uij.1944-5784.2009.10.02

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Simplified Approach for Correction of Congenital Penile Curvature

ABSTRACT

INTRODUCTION: The purpose of the present study was to evaluate the long-term results of simplified tunica albuginea plication for correction of congenital penile curvature in adults.

METHODS: Twenty patients with congenital curvature of the penis had surgical correction. The mean age of the patients was 27 years (range, 16-48 years). Nineteen patients had a ventral penile curvature and 1 patient had a ventrolateral curvature. The mean angle of ventral bending was approximately 65° (range, 35°-90°). Detailed history was taken and physical examinations were conducted. Erection was induced by intracavernosal injection of 15 µg of prostaglandin E1 to assess all directions of penile curvature and to determine the angle of deviation. The course of the neurovascular bundles was determined without dissection. Type 2/0 polypropylene plicating sutures were taken through the full thickness of the tunica albuginea. Two to 3 pairs of longitudinal plication sutures placed in both sides of the neurovascular bundles avoided injury of circumflex veins. Plication stitches were made parallel to assure symmetrical adjustment of the curvature. Patients were discharged after 16-24 hours. Follow-up evaluations were done weekly for 8 weeks and annually thereafter. Patients were followed for 2-5 years.

RESULTS: Operative time was 60 to 100 minutes. Successful outcome was achieved in 19 (95%) of the patients. The penis became straight during full and rigid erections and the patients were satisfied with the penile cosmetic feature and sexual intercourse. No patient complained of significant shortening of the erect penis. Recurrence of curvature occurred in 1 patient due to excessive and rigid erections early postoperatively. Three patients complained of uncomfortable sensation due to palpable knots from the polypropylene sutures. One patient had corrective surgery due to coital discomfort caused by the knots. The stitches were removed under local anesthesia with no recurrence of the curvature.

CONCLUSION: The present technique of tunica albuginea plication is simple and not time consuming. It prevents the complications of dissection and mobilization of the neurovascular bundles. Slight shortening of the penis is a disadvantage of the technique. However, it does not interfere with sexual satisfaction.

KEYWORDS: Penile curvature; Congenital; Chordee; Tunica albuginea

CORRESPONDENCE: Dr. Tarek Salem, Rehab City, Modern Cairo, Group 94, Building 4, Flat 11, Cairo, Egypt ().

CITATION: UroToday Int J. 2009 Oct;2(5). doi:10.3834/uij.1944-5784.2009.10.03

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A Practical Approach to Diagnosis and Treatment of Interstitial Cystitis

ABSTRACT

Interstitial cystitis/painful bladder syndrome (IC/PBS) is characterized by pelvic pain, urinary urgency and frequency, and nocturia. The etiology of IC/PBS is unknown but likely multifactorial. It can be difficult to diagnose IC/PBS because of variable presentation. No definitive diagnostic tests and no established guidelines for the treatment of this condition exist. It is possible to distinguish IC/PBS from other similar conditions through careful history taking and physical examination. A variety of treatment options are available; multimodal therapy may offer patients the best outcomes.

KEYWORDS: Interstitial cystitis; Pelvic pain; Chronic pelvic pain; Painful bladder syndrome

CORRESPONDENCE: Robert Evans, MD, Alliance Urology Specialists, 509 North Elam Ave., Greensboro, NC 27403 ().

CITATION: UroToday Int J. 2009 Oct;2(5). doi:10.3834/uij.1944-5784.2009.10.11

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Medical Treatment for Small Stones in the Lower Ureter

ABSTRACT

INTRODUCTION: There are a variety of treatment options available for management of lower ureteral stones. Recent studies have shown the efficacy of some types of drug therapy. The present investigation was a prospective study with randomized patient groups. The purpose was to compare the efficacy of tamsulosin and nifedipine, two commonly prescribed drugs used in medical expulsive therapy for distal ureteric stones.

METHODS: A total of 171 patients with distal ureteral stones < 1 cm in diameter were randomly divided into 3 groups and given medications for a period of 30 days. Patients in all 3 groups received: (1) prophylactic ciprofloxacin (500 mg) 2 times/day for 1 week; (2) Rowatinex capsules (100 mg) 3 times/day until the stone was expelled; (3) EPIMAG magnesium citrate effervescent sachets (2.125 g) dissolved in water 3 times/day until the stone was expelled; (4) diclofenac sodium tablets (50 mg) 2 times/day for 1 week. In addition to the fixed medications described above, patients in group 1 (n = 58) were treated with tamsulosin (0.4 mg) 1 time/day for a maximum of 30 days; patients in group 2 (n = 57) took slow-release nifedipine (30 mg) 1 time/day for a maximum of 30 days. Patients in group 3 (n = 56) were not given tamsulosin or nifedipine. The variables measured were stone expulsion rate, time of expulsion, and number and severity of pain attacks. ANOVA and chi-square tests were used for statistical analysis.

RESULTS: There were no statistically significant differences between the 3 groups on characteristics of sex, age, stone size, or stone laterality. Results showed that 89.6% of the patients taking tamsulosin (group 1) expelled their stones within 30 days, compared with 66.6% of the patients taking nifedipine (group 2) and 57.1% of patients taking only analgesics (group 3). The difference between group 1 and the other groups was statistically significant. Patients taking tamsulosin expelled the stones in a significantly shorter amount of time than patients in the other 2 groups. They also had significantly fewer pain attacks and needed fewer analgesics. Patients taking nifedipine did not have any significant benefits over patients in the other 2 groups.

CONCLUSION: Medical expulsion therapy for lower ureteric stones is a successful procedure. Adding an α-1 adrenergic blocker such as tamsulosin to the treatment regimen is recommended before undertaking any more invasive intervention.

KEYWORDS: Ureter; Stones; Tamsulosin; Nifedipine

CORRESPONDENCE: Dr. Tarek Salem, Rehab City, Modern Cairo, Group 94, Building 4, Flat 11, Cairo, Egypt ().

CITATION: UroToday Int J. 2009 Oct;2(5). doi:10.3834/uij.1944-5784.2009.10.05

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Reoperative Hypospadias Repair Based on Urethral Plate Status

ABSTRACT

INTRODUCTION: The purpose of the study was to determine the suitable procedure for redo hypospadias repair based on the status of the urethral plate.

METHODS: Thirty-five patients with failed hypospadias repair were evaluated regarding the status of the urethral plate, the meatus, residual chordee, and the available surrounding tissues. The mean patient age was 5.8 years (range, 2-12 years). At presentation, 25 patients had the meatus at the distal shaft, 8 at the midshaft, and 2 had complete neourethral stricture. The urethral plate appeared healthy and wide in 30 patients and narrow in 3 patients. All patients had a straight penis with single previous repair. The initial procedure was unknown in 15 patients and was the tubularized incised plate (TIP) procedure in 20 patients. Thirty patients underwent reoperation with TIP procedure, 3 had a Mathieu technique, and 2 had onlay island flap. After repair, cosmetic and functional outcomes were evaluated.

RESULTS: Mean follow-up was 23.2 months (range, 12-36 months). Complete wound dehiscence occurred in 3 (8.6%) cases that had the TIP procedure; they are awaiting further repair. No fistulae occurred. Twenty-seven patients had a vertical slit meatus at the tip of the glans and 5 had a rounded meatus. Calibration was satisfactory in all cases using 8-10 Fr plastic catheters. Uroflowmetry was done in 15 (46.9%) patients and found to be within normal limits, with a Q mean of 9.53 mL/s (range, 5-16 mL/s).

CONCLUSIONS: Redo TIP urethroplasty is effective and safe when the urethral plate is healthy. When the urethral plate is narrow or the neourethra is stenosed, other alternatives should be considered for repair.

KEYWORDS: Hypospadias; Reoperation; Urethral plate

CORRESPONDENCE: Mohamed Mostafa Hussein, MD., Urology Department, Sohag Faculty of Medicine, Sohag University, Sohag, Egypt ().

CITATION: UroToday Int J. 2009 Oct;2(5). doi:10.3834/uij.1944-5784.2009.10.08

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Safety and Efficacy of Ofloxacin on Bacillus Calmette-Guerin Induced Toxicity in Patients with Superficial Bladder Cancer

ABSTRACT

INTRODUCTION: The purposes of the present prospective study were: (1) to investigate the role of a fluoroquinolone (ofloxacin) in reducing the side effects of bacillus Calmette-Guerin (BCG) therapy in patients with nonmuscle invasive bladder cancer; (2) to determine if ofloxacin had any influence on the antitumor efficacy of the BCG therapy.

METHODS: From December 2006 to December 2007, 100 consecutive patients were enrolled in the study. Patients were randomly assigned to group 1 (n = 50) to receive ofloxacin or group 2 (n = 50) to receive a placebo. The groups were similar in patient age, sex, tumor stage, and tumor grade. Patients were followed for 12 months. The efficiency of the BCG therapy was determined clinically using an adverse event scale index. The patients were also evaluated endoscopically.

RESULTS: During the study period, there were 267 adverse events occurring after more than 850 BCG instillations. A significant decrease of burning with micturition was noted in group 1 (n = 41) when compared with group 2 (n = 19) (P = .03). Ofloxacin did not significantly reduce the occurrence of any other mild, moderate, or severe adverse events. After a follow-up of 12 months, results showed that ofloxacin did not affect the efficacy of BCG therapy. There were no significant differences between the 2 groups in disease recurrence or progression rates.

CONCLUSION: Instituting antibiotic prophylaxis with ofloxacin after each BCG instillation appears to be an efficient and safe method of improving treatment tolerability for burning with micturition. Ofloxacin reduced this adverse event without serious consequences. By decreasing the burning symptoms, patients may be more inclined to continue the BCG treatment.

KEYWORDS: Bladder; Transitional cell carcinoma; BCG therapy; Adverse events;

CORRESPONDENCE: Yassine Nouira, 5 Rue Ibn Messaoud El Menzah 6 – 2091, Ariana, Tunisia ().

CITATION: Urotoday Int J. 2009 Oct;2(5). doi:10.3834/uij.1944-5784.2009.10.13

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Percutaneous Nephrolithotomy Versus Open Surgery for Patients with Renal Staghorn Stones

ABSTRACT

INTRODUCTION: In 2005, the American Urological Association Nephrolithiasis Clinical Guidelines Panel recommended percutaneous stone removal as first-line treatment for the management of staghorn calculi. New endourological techniques have led to treating staghorn calculi with more effective and less invasive methods. The aim of the present study was to compare the results of percutaneous nephrolithotomy (PCNL) with open surgery for staghorn stones.

METHODS: METHODS: There were 120 participants with staghorn stones; 72 patients (60%) had PCNL and 48 patients (40%) had open surgery. Variables of age, sex, group, intraoperative and postoperative complications, operation time, and duration of hospitalization were examined. Complications were compared and the probability of group differences reported.

RESULTS: Intraoperative complications occurred in 9 patients (18.8%) during PCNL and 10 patients (13.9%) during open surgery, but the group difference was not statistically significant (P = .611). The most common intraoperative complication for both groups was bleeding that required blood transfusion. Patients treated with PCNL had a significantly shorter mean hospital stay of 3.93 days when compared with a hospital stay of 5.08 days following open surgery (P = .003). Postoperative complications occurred in 2 patients (4.2%) following PCNL and 9 patients (12.5%) following open surgery, but the group difference was not statistically significant (P = .05). The stone-free rate was 81.9% after PCNL and 91.6% after open surgery, a difference that was not statistically significant (P = .84).

CONCLUSION: PCNL is a valuable treatment option for staghorn stones, with complication and stone-free rates comparable to open surgery. Moreover, PCNL resulted in a significantly shorter hospital stay. Therefore, the results of the present study concur with prior literature stating that PCNL should be considered the first stage in treatment for most patients with staghorn stones.

KEYWORDS: Percutaneous nephrolithotomy; Open surgery; Staghorn; PCNL; Stone Free Rate

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.1944-5784.2009.10.09

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Kidney Hemorrhage After Renal Biopsy Treated by Percutaneous Superselective Segmental Renal Artery Embolization

ABSTRACT

INTRODUCTION: Renal biopsy-related vascular injuries are frequent but usually unimportant. However, they can lead to dramatic situations of hemodynamic instability and even death. Transcatheter embolization is a minimally invasive technique used to treat some forms of arterial bleeding.

CASE PRESENTATION: A 33-year-old woman with acute renal insufficiency requiring hemodialysis received an ultrasound-guided renal biopsy of the right kidney. She developed a perirenal hematoma (12 cm diameter) with active bleeding from the lower pole. Superselective embolization was performed with a 2.7F catheter and microcoils 0.018 inches in diameter. Her hemodynamic status was stabilized and there was no further decrease in the hematocrit level. The renal parenchyma remained well perfused except for the embolized segment. Imaging during the follow-up period showed no significant damage. The patient was discharged with a residual hematoma.

CONCLUSION: Superselective embolization therapy for renal trauma provides an effective and minimally invasive means to stop active bleeding. Immediate clinical success with minimal renal parenchyma loss can be obtained.

KEYWORDS: Therapeutic embolization; Hemorrhage; Renal Biopsy

CORRESPONDENCE: Francisco Botelho, MD, Servico de Urologia - Hospital S. João, Alameda Prof. Hernani Monteiro; 4200-319 Porto, Portugal ().

CITATION: UroToday Int J. 2009 Oct;2(5). doi:10.3834/uij.1944-5784.2009.10.10

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Ideopathic Scrotal Calcinosis (ISC): Etiology and Treatment

ABSTRACT

INTRODUCTION: Idiopathic scrotal calcinosis (ISC) is a rare benign disorder characterized by multiple asymptomatic nodules. The nodules occur on the scrotal skin wall. The purposes of the present study were to: (1) determine whether or not there is a defect in calcium and phosphorous metabolism among patients with ISC; (2) study the effect of treatment with topical steroid and topical vitamin A on nodule recurrence.

METHODS: There were 18 patients with a mean age of 20 years (range, 18-55 years). Six of the patients reported that the nodules were asymptomatic; 12 reported symptoms of itching, heaviness in the scrotum, secondary infection in the lesions, and discharge. Evaluation included patient history, physical examination, and serum levels of calcium, phosphorous, and alkaline phosphatase. Lesions were excised. Patients in group 1 (n = 10) were treated with a long-term topical steroid for 2 weeks, followed by topical vitamin A for 6 months. Patients in group 2 (n = 8) received no topical treatment. Patients were reevaluated every 6 months for 3 years.

RESULTS: Serum levels were within the normal range for calcium (mean = 9.5 mg/dL; SD = 3.5) and phosphorous (mean = 3.2 mg/dL; SD = 0.7), but higher than normal for alkaline phosphatase (mean = 135 U/L; SD = 35). No nodule recurrence was observed in patients receiving the topical treatments. There were 4 reports of recurrence among patients receiving no topical treatments, occurring after 8, 13, 16, and 24 months.

CONCLUSION: The pathogenicity of ISC is not clear. It might be idiopathic, caused by dystrophic calcification, the result of inflammation of epidermal cysts or minor trauma, or due to degeneration and necrosis of dartos muscle. Diagnosis is solely confirmed by surgical excision and histopathologic examination. In the present study, the authors found no anomalies of calcium and phosphorous metabolism except an increase in alkaline phosphatase level. Recurrence was only seen among patients who did not receive topical treatment after surgical excision. Therefore, the authors suggest the use of local treatment of steroids and vitamin A to prevent probable recurrences. However, further studies are needed to reach a more definitive conclusion.

KEYWORDS: Idiopathic scrotal calcinosis; Calcium and phosphorous metabolism anomalies; Alkaline phosphatase

CORRESPONDENCE: Dr. Mahmood Molaei, Department of Urology, Ghaem Hospital, Mashhad University of Medical Sciences, Mashhad, Iran ().

CITATION: Urotoday Int J. 2009 Oct;2(5). doi:10.3834/uij.1944-5784.2009.10.04

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Letter from the Editor - August 2009

Dear Colleagues,


Progress in urology, like in any medical field, is dependent on a continuous accumulation of new knowledge. Every piece of new information, from brief case studies to large clinical trials, adds to our knowledge base and helps the profession grow. The editorial team of UroToday International Journal is grateful to the authors who shared their work in this issue and to the reviewers who ensured its scholarship.

Clinical trials of medications are among the most essential types of research, because they help to dictate treatment standards. Olshansky and his colleagues (Validation of the Differential Cardiovascular Effects of the Antimuscarinic Agents Darifenacin and Tolterodine in a Randomized, Placebo-Controlled, 3-Way Crossover Study) share the results of a well-designed investigation. They validated the results of a previous study showing that tolterodine caused an increase in heart rate (HR) and decrease in heart rate variability (HRV) in healthy older adults, whereas darifenacin did not. Both increased HR and decreased HRV have been associated with increased mortality rates in the general population, particularly in patients with cardiovascular morbidities. Because antimuscarinics are the recommended treatment of patients with the overactive bladder (OAB) syndrome, and these patients have a high prevalence of cardiovascular morbidity, a difference of 2-5 beats per minute in mean HR over 24 hours and a decrease in HRV may be of clinical importance. Physicians who prescribe antimuscarinics will be interested in these findings.

Review articles can provide useful updates on current clinical practice. Westerling’s review (Bladder Pain: Clinical Assessment and Treatment) provides thorough, practical information for any professional involved in the physiology, assessment, and pharmacological or nonpharmacological treatment of bladder pain. Patients with long-term bladder pain often have comorbidities and medications that can complicate management. They may benefit from a multi-disciplinary team approach. Westerling reminds us that quality of life may improve dramatically if these patients are seen by a pain specialist early in the treatment sequence, rather than waiting until the pain is out of control.

The August issue contains many other articles of interest, including: (1) the very timely topic of a gene expression test for prostate cancer, written by Guyon and colleagues; (2) the continuous bladder irrigation model developed by Norman and Connor that shows urethral outflow with and without the addition of suprapubic inflow, using suprapubic catheters of different size combinations; and (3) the use of bacillus Calmette-Guerin therapy with cauterization of 10 mm of the tumor margin in patients with bladder cancer−a management protocol that showed promising results for Falahatkar and colleagues. Finally, Al-Sameraaii and Bowkett remind us of dangers to our children that may reside in the most unlikely places, including their toys.

Kind regards,

K-E Andersson
Editor-In-Chief
UIJ

Efficacy of Bacillus Calmette-Guerin (BCG) Therapy and Cauterization of the Tumor Versus BCG Therapy Without Cauterization for Superficial Bladder Cancer

ABSTRACT

INTRODUCTION: Bladder cancer recurrence occurs in 30-80% of cases after resection depending upon the grade, stage and number of tumors. The rate of recurrence for superficial bladder cancer is 70%. Cauterization is known to destroy malignant cells. Therefore, the authors studied the efficacy and tumor recurrence rate of bacillus Calmette-Guerin (BCG) therapy with cauterization of 10 mm of the tumor margin versus BCG therapy without cauterization.

METHODS: The authors reviewed files of 60 patients, including 30 patients with cauterization (group 1) and 30 patients without cauterization (group 2). Patients were referred from March 2006 to June 2008 with primary stage Ta, T1, and T2a, grade G1 to G3 transitional cell carcinoma (TCC) of the bladder. All patients were treated by transurethral resection of the tumor (TUR-BT). The 2 groups did not differ significantly in age and sex or in tumor grade, location, and size. Grade, stage, location and size of tumors with recurrence were compared.

RESULTS: There were no significant differences between the two groups in stage, location, and size of tumors. Tumors returned in 25 of the 60 patients (9 from group 1; 16 from group 2). The group difference in recurrence rate was not statistically significant (P = .06). The mean time of tumor recurrence was 21 months and 13 months in groups 1 and 2, respectively. Group 1 had a significant delay in tumor recurrence when compared with group 2 (P = .01). Most of the tumors that recurred were from patients with grade 1 and grade 2 tumors (5 patients in group 1; 15 in group 2). Four out of 5 patients with grade 3 tumors in group 1 and the only patient with a grade 3 tumor in group 2 had recurrence. The recurrence rate for low-grade tumors in group 1 was significantly less than in group 2 (P = .02).

CONCLUSIONS: Cauterization of the tumor margins combined with BCG therapy appears to be useful for reducing recurrence in patients with grade 1 and grade 2 bladder tumors. Cauterization also resulted in a longer period of time before recurrence.

KEYWORDS: Bladder tumor; Cauterization; BCG therapy, Bladder cancer recurrence

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 Aug;2(4). doi:10.3834/uij.1944-5784.2009.08.01

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New Prognostic Factors in Fournier’s Gangrene: A 10-Year Experience

ABSTRACT

INTRODUCTION:Fournier's gangrene is a rapidly progressing infection of the male genitalia, including the anal and perianal region and usually extending to the abdominal wall. The objective of the present investigation was to study the epidemiologic and clinical reports of patients with Fournier’s gangrene in order to evaluate the prognostic factors of the disease.

METHODS: The patients were referred to Ghaem hospital from 1998-2008. Their files were reviewed for: (1) laboratory parameters of urea, creatinine (Cr), hematocrit (Hct), white blood cell (WBC), albumin (Alb), sodium (Na), Calcium (Ca), and potassium (K); (2) probable risk factors (eg, diabetes); (3) ulcer microbiology; and (4) the extent of the gangrene.

RESULTS: There were 71 patients with a mean age of 60.9 years (SD = 17.02). The time between onset of symptoms and referral to a health care unit was 6.7 days (SD = 5.25). The source of infection was the skin in 25 patients (35%), urogenital in 34 patients (48%), and rectal in 12 patients (17%). The anorectal source was responsible for 11 out of 16 deaths. Diabetes was a predisposing factor in 39.4%.

The patients were divided in 2 groups: the survival group (n = 55) and the mortality group (n = 16). The survival group had a significantly higher socioeconomic status, shorter mean time between the onset of the illness and referral to a health clinic, lower percentage of gangrene involvement, fewer required debridements, and higher mean Alb and Ca and lower mean urea laboratory values (P < .05). There were no other significant between-group differences for the remaining variables.

CONCLUSION: The authors compared the data in the present study with data from the Laor Fournier's Gangrene Severity Index. None of the conventional indices (temperature, heart rate, respiratory rate, Hct, Cr, WBC, Na, K) were found to be significantly different when the mortality and survival group were compared in the present study. The authors recommend new prognostic criteria for Fournier’s gangrene: (1) time between onset of the symptoms and referral to the hospital; (2) source of infection; (3) extent of the gangrene; (4) laboratory results of Alb, urea, and Ca; and (5) the number of required debridements.

KEYWORDS: Fournier's gangrene; Laor Fournier's gangrene severity index; Prognosis; Risk factors

CORRESPONDENCE: Mahmood Molaei, M.D., Department of Urology, Ghaem Hospital, Mashhad University of Medical Sciences, Mashhad, Iran ().

CITATION: Urotoday Int J. 2009 Aug;2(4). doi:10.3834/uij.1944-5784.2009.08.02

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Validation of the Differential Cardiovascular Effects of the Antimuscarinic Agents Darifenacin and Tolterodine in a Randomized, Placebo-Controlled, 3-Way Crossover Study

ABSTRACT 

INTRODUCTION:Previous studies have demonstrated that antimuscarinics used for the treatment of overactive bladder (OAB), such as tolterodine and darifenacin, exert differential effects on heart rate (HR) and HR variability (HRV). OAB is a chronic symptomatic condition of high prevalence in older patients with cardiovascular (CV) comorbidities. Physicians prescribing these medications should take into consideration their specific effects on the parasympathetic control of the heart.

OBJECTIVE: The primary objective was to detect if there was a difference between tolterodine and darifenacin in change from baseline in mean HR over 24 hours during once-daily administration of these compounds in healthy participants. The protocol was designed to confirm results from a previous study.

METHODS:This was a 3-way crossover, placebo-controlled, double-blind study in healthy participants of similar age to OAB patients (≥ 50 years). Participants were randomized to one of 6 possible treatment sequences and consecutively received once-daily tolterodine 4 mg, darifenacin 15 mg, and matched placebo for at least 7 days in separate treatment periods. Electrocardiogram monitoring (Holter) for 24 hours was used to assess changes in mean HR and HRV between treatment arms

RESULTS: Tolterodine but not darifenacin significantly increased mean HR over 24 hours compared with darifenacin (2.24 beats per minute [bpm], P = .0004) and placebo (1.84 bpm, P = .0037). In contrast, darifenacin did not significantly alter HR compared with placebo (–0.40, P = .5219). Overall, HRV over 24 hours decreased with tolterodine but not with darifenacin or placebo.

CONCLUSION: Tolterodine increased HR and reduced HRV compared with darifenacin and placebo in healthy participants aged ≥ 50 years. Because increased HR and decreased HRV are associated with increased CV risk and patients with OAB often have CV comorbidities, careful selection of antimuscarinic treatment for OAB patients may be warranted.

KEYWORDS: Antimuscarinic; Cardiovascular effects; M3 selectivity

CORRESPONDENCE: Brian Olshansky, MD, Professor of Medicine, University of Iowa Hospitals, 4426a JCP, 200 Hawkins Drive, Iowa City, Iowa 52242, USA ().

CITATION: Urotoday Int J. 2009 Aug;2(4). doi:10.3834/uij.1944-5784.2009.08.07

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Neuropathic Symptoms After Surgery Using Transobturator Tape for Stress Incontinence

ABSTRACT

A 40-year-old female patient with frequency of micturition and stress incontinence had surgery using transobturator tape (TOT). The surgical procedure was uncomplicated but the patient developed symptoms of groin pain, loss of sensations in the legs, and inability to stand or bear weight 48 hours postoperatively. Neurological assessment did not reveal any motor loss, although reduced sensations in the right thigh persisted for a few days. Pelvic collection, mesh infection, and exposure were excluded. Physiotherapy and analgesia were administered and her symptoms diminished. No residual symptoms were present at 4 and 8-week follow-up evaluations.

KEYWORDS: Transobturator; Groin pain; Neuropathy; Obturator nerve damage

CORRESPONDENCE: Dr. Asma Farrukh MRCOG, Derby Hospitals, Department of Obstetrics and Gynaecology, Uttoxeter Road, Derby, DE223NE, United Kingdom ().

CITATION: Urotoday Int J. 2009 Aug;2(4). doi:10.3834/uij.1944-5784.2009.08.05

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Does the Addition of Extra Inflow From a Suprapubic Catheter Improve Continuous Bladder Irrigation Through a 3-Way Transurethral Catheter?

ABSTRACT

INTRODUCTION: Continuous bladder irrigation (CBI) is often used to help manage hematuria and might be optimized by adding suprapubic inflow to increase urethral outflow. The objective of the present investigation was to develop an experimental model that would reliably measure urethral outflow through a 3-way transurethral catheter (UC) with and without the addition of suprapubic inflow using a variety of suprapubic catheters (SC) of different size combinations (Bard).

METHODS: A 1 L intravenous bag (Hospira Inc; Lake Forest, IL) was modified by inserting a 3-way UC into its outflow spigot and a 2-way SC into the front of the bag. The urethral outflows for each size of UC were measured in various combinations of 18F, 20F, 22F, and 24F 3-way UC with and without added inflows from 12F, 14F, and 16F 2-way SC. Water was used as the irrigant for both the urethral and suprapubic catheters and was drained by gravity from 3 L bags from a height of 140 cm. Urethral outflow was measured with a Dantec Urodyn 1000 uroflowmeter. Each run was done 5 times using outflows of at least 150 cc over at least 75 seconds. Means were compared by paired t test.

RESULTS: Three-way 18F, 20F, and 22F UC showed no significant or minimal improvement in outflows by adding 12F, 14F, or 16F suprapubic inflows. None of these 3-way catheters were able to handle the extra inflow from a 16F suprapubic catheter and the "bladder" became overly distended (OD). Three-way 24F UC showed maximal improvement in outflow when combined with 14F or 16F suprapubic inflows; OD was not a problem.

CONCLUSION: Additional inflow from a 14F or 16F SC will maximally increase urethral outflow by at least 3.6 cc/second only when combined with a 24F 3-way UC.

KEYWORDS: Continuous bladder irrigation; Transurethral catheter; Suprapubic catheter; Three-way catheter; Hematuria.

CORRESPONDENCE: Dr. Richard W Norman, Suite 620, 5991 Spring Garden Road, Halifax, Nova Scotia, B3H 1Y6, CANADA ()

CITATION: UroToday Int J 2009 Aug;2(4). doi:10.3834/uij.1944-5784.2009.08.09

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Bladder Pain: Clinical Assessment and Treatment

ABSTRACT

INTRODUCTION: Bladder pain may arise due to infection, inflammation, trauma, cancer, or unknown reasons. Bladder pain may be acute, long term and/or associated with other symptoms and syndromes. The treatment of bladder pain must consider both the pain and the function of the bladder.

METHODS: The definition, physiology, assessment, pharmacological treatment, and nonpharmacological treatment of bladder pain are reviewed and discussed. Three cases of complex bladder pain are presented.

RESULTS: Bladder pain is a symptom, not a disease. There is no single therapy that is helpful for all patients. Multimodal pain therapy that is tailored to the patient's present situation, genetics, ongoing treatment, and previous treatment(s) may reduce pain and improve quality of life.

CONCLUSION: Multidisciplinary evaluation and referral to a pain specialist should be considered for patients with complicated bladder pain with or without associated long-term pain problems. Patients with complex bladder pain may benefit from a consultation and second opinion from a pain specialist early in the course of the workup and not as a last measure when everything else has failed. Multidisciplinary pain teams with pain specialists should be part of the network available for clinicians who provide care for patients with complex pain problems.

KEYWORDS: Bladder pain; Assessment of pain; TENS; Pharmacology; Analgesia

CORRESPONDENCE: Dagmar Westerling, M.D. Ph.D., Acute Pain Unit, Department of Anesthesiology, Wake Forest University School of Medicine, Medical Center Boulevard, Winston Salem NC, 27157, USA ().

CITATION: UroToday Int J 2009 Aug;2(4). doi:10.3834/uij.1944-5784.2009.08.03

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Pilot Study on the Comparative Assessment of Maximum Bladder Capacity for the Diagnosis of Interstitial Cystitis: NaCl 0.9% Versus 0.2M KCl

ABSTRACT

INTRODUCTION: A deficiency in the glycosaminoglycan (GAG) layer alters bladder urothelial permeability, mainly to potassium ions, in patients with interstitial cystistis (IC). The potassium sensitivity test (PST) causes bladder discomfort after instillation of a 0.2 molar potassium chloride solution (0.2 M KCl). The objective of the present study was to assess maximum bladder capacity (Cmax) using a 0.2 M KCl solution compared with 0.9% sodium chloride (NaCl) in patients with IC, in order to achieve diagnosis.

METHODS: The authors studied 17 female patients diagnosed with IC, based on criteria from the National Institute of Diabetes and Digestive and Kidney Diseases. Patients completed the Pelvic Pain and Urgency/Frequency (PUF) questionnaire. Cystometry was performed first with a 0.9% NaCl solution, followed by 0.2M KCl soon after. The desire to void and Cmax were measured in both cystometries. After undergoing tests with each solution, the patients evaluated pain and urgency by using a visual numeric scale.

RESULTS: All patients presented a larger decrease in Cmax when using KCl, compared with NaCl. The median Cmax decrease was 32.8% (range, 7.69% - 57.8%). A decrease in Cmax > 30% was observed in 9 patients; the remaining 8 patients had a decrease < 30%. All patients reported greater discomfort with the use of 0.2M KCl solution. The visual numeric scale score for pain revealed a mean value of 2.41 for the NaCl solution and 4.52 for KCl, with 5 representing maximum pain. The average PUF score was 23.76 (range, 18-33). When the PUF score was compared between patients with a decrease in Cmax > 30% and < 30%, no statistically significant difference was found.

CONCLUSION: PST is a well-tolerated alternative when evaluating both the increased sensitivity to potassium and the diagnosis of IC, considering the reduction in Cmax. The PUF score has no direct correlation with the PST positivity.

KEYWORDS: Interstitial cystitis; Potassium sensitivity test; Cystometry; Urinary urgency; Nocturia; Painful bladder syndrome

CORRESPONDENCE: Arlon Breno da Silveira, Rua Amélia, 610. Recife/PE. CEP – 52011-050 Brazil ().

CITATION: Urotoday Int J. 2009 Aug;2(4). doi:10.3834/uij.1944-5784.2009.08.08

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