Volume 2

UIJ Volume 2 2009

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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A Case of Penile Trauma Caused by Magnets

ABSTRACT

The authors report a case of pediatric penile trauma that was caused by a magnet. No similar case has been recorded. The injury was self-inflicted, caused by 2 pieces of magnet placed on opposing sides of the penile shaft. This resulted in 2 circular scars extending to, but not through, Buck's fascia. An operative procedure to remove the 2 magnets was required. Long-term follow up showed no serious complications.

KEYWORDS: Penis; Penile trauma; Magnet

CORRESPONDENCE: Dr. Ahmed Al-Sameraaii, Department of Urology, The St. George Hospital, Gray Street, Kogarah 2217, NSW, Australia ().

CITATION: UroToday Int J 2009 Aug;2(4). doi:10.3834/uij.1944-5784.2009.08.10

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A Four-Gene Expression Signature for Prostate Cancer Cells Consisting of UAP1, PDLIM5, IMPDH2, and HSPD1

ABSTRACT

INTRODUCTION:The objective of the study was to develop a gene expression test that is highly associated with the presence of prostate cancer for use as an adjunct to the pathology examination of tissue.

METHODS: A gene expression database (U133A Affymetrix) was produced from 87 preparations of laser microdissected cells obtained from cancer (G3 and G4) and noncancer prostate tissues. The database was analyzed using univariate feature ranking and recursive feature elimination algorithms (support vector machine) to identify overexpressed genes that were associated with prostate cancer. RT-PCR assays were developed for the unique 4-gene set that was found to be reflective of prostate cancer. The gene expression data were used to construct a mathematical equation to classify tissues as cancer vs noncancer. The RT-PCR tests and the calculated gene expression score were validated in an independently collected set of formalin-fixed and fresh-frozen prostate tissues.

RESULTS: Analysis of the U133A gene expression database identified a group of 63 genes that were overexpressed in cancer and also gave an AUC (area under the curve) of > 0.84 for separating cancer vs noncancer. The gene discovery was validated with a database of 164 independently collected tissues reported in the Oncomine database. The 63 gene set was reduced to a subset of 4 complementary genes (UAP1, PDLIM5, IMPDH2, and HSPD1), using univariate feature ranking and recursive feature elimination (RFE) algorithms that gave an AUC = 0.94 for discrimination between cancer and noncancer prostate cells. Quantitative RT-PCR (reverse transcriptase polymerase chain reaction) assays were developed and validated. A mathematical formula based on the gene expression values of the 4 genes along with a housekeeping gene was developed for the classification of cancer vs noncancer tissues. In a blinded validation study of 71 independent prostate tissue samples that included both fresh prostate tissues and formalin fixed tissues, the 4-gene test gave a sensitivity of 90% with a specificity of 97% (the 95% confidence interval was 86% - 100%).

CONCLUSION: The 4-gene RT-PCR test can be used to detect Gleason grade 3 and grade 4 cancer cells in prostate tissue and may be useful as an adjunct test to the pathology examination of prostate tissue taken at biopsy or prostatectomy.

KEYWORDS: Prostate cancer detection; Support vector machine; Gene signature; UAP1, PDLIM5, IMPDH2, HSPD1, DNA microarray; RT-PCR assay

CORRESPONDENCE: Herbert A. Fritsche, PhD, Dept. Laboratory Medicine, MD Anderson Cancer Center, Houston, TX 77030 ().

CITATION: Urotoday Int J. 2009 Aug;2(4). doi:10.3834/uij.1944-5784.2009.08.06

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Seminal Improvement Following Microsurgical Subinguinal Varicocelectomy: Preoperative Sonographic Parameters of Success

ABSTRACT

INTRODUCTION: The aims of the study were to: (1) evaluate the use of color Doppler ultrasound to diagnose and grade varicocele, and (2) identify the ultrasonographic patient selection criteria for microsurgical subinguinal varicocelectomy that would result in the best seminal improvement.

METHODS: Participants were 94 infertile patients undergoing microsurgical subinguinal varicocelectomy. All patients were evaluated with a case history, physical examination, semen analysis, hormonal assay, and color Doppler scrotal ultrasound. Postoperative improvement indexes in sperm concentration, sperm motility and normal sperm morphology were calculated. Improvement index > 0.5 was considered a good outcome. Statistical analysis was done to show the relationship between microsurgical varicocelectomy outcome and testicular vein diameter at the lower testicular pole and the degree of reflux measured by color Doppler ultrasound.

RESULTS: Seminal improvement indexes > 0.5 were found for sperm concentration, motility, and morphology in 61.3%, 29.9% and 19.3% of cases, respectively. Patients with testicular vein diameter ≥ 2.5 mm at the lower pole of the testis had a significantly higher seminal improvement index in sperm concentration, motility, and morphology than those with a testicular vein diameter < 2.5 mm (P = .001, .001, .003, respectively). Patients with reflux detected by color Doppler ultrasound at the lower pole of the testis had a significantly higher seminal improvement index in sperm concentration, motility, and morphology than patients with reflux only in the supratesticular venous channels (P = .02, .013, .042, respectively).

CONCLUSION: Color Doppler ultrasound is an important method for accurate diagnosis and grading of varicocele and for prediction of the outcome of varicocelectomy. Microsurgical subinguinal varicocelectomy is recommended for patients with testicular vein diameter ≥ 2.5 mm, regardless of the grade of reflux at the inferior pole of the testis.

KEYWORDS: Color Doppler ultrasound; Varicocele; Microsurgical varicocelectomy; Seminal improvement.

CORRESPONDENCE: Hashem Hafez, M.D., Department of Urology, Faculty of Medicine, Suez Canal University, Ring Road, Ismailia 41115, Egypt ()

CITATION: UroToday Int J 2009 Aug;2(4). doi:10.3834/uij.1944-5784.2009.08.04.

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Letter from the Editor - June 2009

Dear Colleagues,

This issue marks the one-year anniversary of the founding of UroToday International Journal. When the editorial team drafted our primary goal of “elevating access to relevant urology science to professionals around the world,” we had no idea that the journal would grow so quickly.

We are excited that our dream of becoming an international journal is being realized. Over the past year, we published articles from authors in 22 countries from 4 continents. These submissions reflect the world-wide distribution of our readership.

We could not achieve this success without the dedicated work of our reviewers, who continue to provide thorough and rapid feedback to our authors. We are grateful for their professional support. Because of their efforts, manuscripts received as recently as 7 weeks ago are appearing in this issue. We continue to strive for rapid turnaround of submissions so that we can share recent developments with our readers.

We have taken advantage of the fact that we are an electronic publication by adding other forms of media to the text of some articles. We hope to expand these multimedia educational tools and encourage authors to notify us if you have podcasts, video clips, Microsoft PowerPoint presentations, or audio commentary that may enhance your manuscript content. For examples, visit the audio recording of the basic science lecture in October, 2008 or the PowerPoint presentation accompanying the letter to the editor in April, 2009.

The current issue contains a wide variety of articles. Some highlights include: (1) a retrospective analysis on the effects of two dosage levels of darifenacin on 1053 patients with mild/moderate and severe urinary incontinence, written by Dr. Dmochowski and his colleagues; (2) a thorough discussion about different types of slings for correction of stress urinary incontinence, written by Dr. Farahat and his colleagues; (3) new surgical techniques for acute dilatation of the intramural ureter during ureteroscopy and for repair of distal and midpenile hypospadias, both provided by Dr. Gamal and his colleagues; (4) case reports on prostate leiomyosarcoma following radiation therapy to the prostate (Yee et al); an adenoid cystic variant of basal cell carcinoma following transurethral resection (Soloway et al); an appendicular vesical fistula (Labib and Mapulanga); a left-sided inferior vena cava in a patient with renal cell carcinoma of the right kidney (Katkoori et al); and surgical procedures to manage uterine prolapse associated with bladder exstrophy and to alleviate intractable groin pain following suburethral sling placement (Palma et al). Other articles on topics of interest to the practicing urologist and associated professionals are included.

Our heartfelt thanks go to the authors who have shared their work with us during the past year. We look forward to your future submissions as we continue to grow.

Kind regards,

K-E Andersson
Editor-In-Chief
UIJ

Peripheral Zone Sonographic Changes of the Prostate

ABSTRACT

INTRODUCTION: The aim of the investigation was to identify the diagnostic importance of peripheral zone sonographic findings in correlation with total prostatic specific antigen (tPSA) and pathological findings.

METHODS: Between January 2005 and January 2007, the transrectal biopsy records of 407 patients were reviewed for different prostatic indications. Echogenicity, calcific, and cystic changes of the peripheral zone were correlated with tPSA, total volume of the gland, digital rectal exam (DRE), and pathological findings.

RESULTS: The patients were divided into 3 groups (A, B, and C) according to tPSA: <4 ng="" ml="" n="159)," 4-10="" and="">10 ng/mL (n = 229), respectively. Heterogenicity was detected in 59.9% of cases and was higher when tPSA increased. Heterogenicity was found in the malignant biopsies of 78.7% of the patients (sensitivity = 78.78%; specificity = 44.6%). Calcific changes were found in 52% (n = 90) of group C (P < .05). Calcification was demonstrated in 41.4% (n=41) of malignant findings, but group comparisons were not statistically significant (sensitivity = 41.4%; specificity = 55.5%). Cystic changes were detected in 7.1% (n = 7) of malignant findings, but group comparisons were not statistically significant (sensitivity = 7.1%; specificity = 9.1%). However, 10.3% (n = 23) of patients with cystic peripheral zonal changes had high but not statistically significant PSA.

CONCLUSION: Heterogenicity of the peripheral zone is correlated with malignant pathology (positive predictor value = 31.9%) and high tPSA. Whenever a peripheral zone calcific change in prostatic sonography occurs, the urologist should suspect an increase of tPSA but without characteristic indicator of malignant anticipations (positive predictor value = 23.03%). Cystic changes in the peripheral zone are not specific findings and do not reflect any changes in tPSA or prostatic pathology.

KEYWORDS: Transrectal ultrasound; Echogenicity; Prostate calcification; Prostate cystic changes.

CORRESPONDENCE: El-Housseiny Ismail Ibrahiem (El- Zalouey) MD, Urology Department, Urology and Nephrology Center, Mansoura, Egypt. E-mail:

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Comparison of Ultrasonographic and Operative Findings in Undescended Testes

ABSTRACT

INTRODUCTION: A patient with a nonpalpable testis (NPT) is a diagnostic challenge. Use of ultrasonography (US) for the diagnosis of NPT is controversial. The purpose of the present study was to compare US with surgical findings.

METHODS: Between January 2000 and January 2007, 65 patients with a diagnosis of undescended testis (UDT) were evaluated. The 65 patients had 77 UDT. The patients had a physical examination that was followed by US and then surgery. All patients had a second physical examination in the operating room while under anesthesia

RESULTS: US localized 57 (74%) nonpalpable testes. Of these, 50 were in the inguinal region and 7 were in the abdomen. The sensitivity of US was 100% for the inguinal canal and 39% for intraabdominal viable testes.Enter text

CONCLUSION: All patients with presumed nonpalpable, undescended testes should be referred to a urologist for physical examination before receiving US. The authors recommend US as a first instrumental test for all patients with NPT. When US is negative, they advise laparoscopy.

KEYWORDS: Undescended testes; Ultrasonography; Cryptorchidism; Operative Finding

CORRESPONDENCE: Dr. Ahmed Al-ahnoumi, PO Box 16913, Sana’a Yemen ().

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Urodynamic Evaluation of Patients With Chronic Pelvic Pain Syndrome

ABSTRACT

INTRODUCTION: The purpose of the investigation was to conduct urodynamic evaluation on patients with chronic pelvic pain syndrome (CPPS) and thus define a specific urodynamic profile that might add to the pathophysiology of the syndrome. This profile may also aid definitive treatment.

METHODS: Participants were 34 men with mean age 34.2 (SD = 8.5; range, 24-45 years). All patients presented with symptoms of chronic prostatitis (eg, dysuria, frequency of micturition, burning perineal sensation, lower abdominal discomfort and/or suprapubic pain). They were classified as having CPPS after excluding prostatic infection by standard bacteriological methods. The patients were then evaluated with urodynamic measures including free-flow rate, filling (water) cystometry, a pressure -flow study of micturition, and electromyography of the external urethral sphincter.

RESULTS: Of the 34 total patients, 22 (64.7%) had a low mean Qmax of 10.4 ± 1.6 mL/s (range, 4-14 mL/s); 25 (73.5%) had a first sensation of filling and 27 (79.4%) a first desire to void at low volumes (<150 and="" 250="" respectively="" nine="" patients="" 26="" 5="" 7="" obstructed="" 2="" unobstructed="" had="" idiopathic="" detrusor="" overactivity="" regarding="" pressure-flow="" measures="" 25="" 73="" an="" obstructive="" pattern="" of="" micturition="" as="" defined="" by="" a="" low="" qmax="" 9="" 1="" 44="" ml="" s="" high="" intravesical="" pressure="" at="" maximum="" flow="" 87="" 4="" cmh2o="" increased="" opening="" 76="" the="" emg="" external="" sphincter="" was="" normal="" in="" all="" p="">

CONCLUSION: A significant proportion of the patients with CPPS had a particular urodynamic pattern of functional infravesical obstruction and sensory bladder deficit.

KEYWORDS: Urodynamic; Chronic pelvic pain syndrome

CORRESPONDENCE: Hashem Hafez, M.D., Department of Urology, Faculty of Medicine, Suez Canal University, Ring Road, Ismailia 41105, Egypt ()

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Post Radiotherapy Leiomyosarcoma of the Prostate: Can Radiation Therapy Induce a Secondary Cancer? A Case Report

ABSTRACT

Sarcoma of the prostate is a rare neoplasm, accounting for less than 0.1% of prostate malignancies. There are only a few cases reported in the literature. The prognosis for this cancer is poor and the average survival is variable. The authors present a case report on a patient diagnosed with prostate sarcoma following initial diagnosis and treatment for adenocarcinoma of the prostate. What makes this case interesting is that the patient had a history of failed treatment for prostate adenocarcinoma that consisted of external beam therapy and palladium seed implants. Eight years later, the patient was diagnosed with leiomyosarcoma of the prostate. There may be a causal relationship between radiation therapy to the prostate and the development of the leiomyosarcoma.

KEYWORDS: Prostate cancer; Prostate leiomyosarcoma; Sarcoma; Radiation induced sarcoma; Prostate adenocarcinoma; Secondary prostate cancer; Secondary prostate leiomyosarcoma

CORRESPONDENCE: Ihor S. Sawczuk MD, John Theuer Cancer Center, Hackensack University Medical Center, 30 Prospect Avenue, Hackensack, NJ 07601, USA ().

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Left-Sided Inferior Vena Cava with Renal Carcinoma: A Case Report

ABSTRACT

The authors present a rare case of left-sided inferior vena cava (IVC) in a patient with renal cell carcinoma of the right kidney. The anomalous IVC poses significant challenge to the surgeon. Preoperative identification of this congenital anomaly prevents complications during the surgical procedure. In this patient, the suprarenal portion of the IVC is on the right side and the infrarenal portion is on the left side, with the cava taking a left to right turn at the level of the renal veins anterior to the aorta.

KEYWORDS: Left Inferior vena cava; Nephrectomy; Renal cell carcinoma

CORRESPONDENCE: M. Manoharan, M.D. Associate Professor, Department of Urology, University of Miami Miller School of Medicine, P.O. Box 016960 (M814), Miami, Fl 33101, USA ().

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Artisanal Transobturator Sling Removal for Intractable Groin Pain

ABSTRACT

INTRODUCTION: The transobturator approach was first described by Delorme in 2001. It has become the preferred approach for suburethral sling placement in many centers due to its efficacy and low morbidity. Nevertheless, complications have been associated with it.

METHODS: The authors describe management of a female subject with intractable groin pain after the insertion of an artisanal transobturator sling. The right side of the sling was removed.

RESULTS: The patient described significant but incomplete pain improvement at the time of hospital discharge. After one week, she had no pain but moderate stress urinary incontinence recurred.

CONCLUSION: The present case illustrates that a partial removal is not indicated for complete treatment. Time-related intractable groin pain may completely subside after sling tape removal. However, possible recurrence of urinary incontinence following intervention must be reinforced during patient counseling.

KEYWORDS: Synthetic slings; Transobturator; Groin pain

CORRESPONDENCE: Paulo Palma, MD, PhD, Division of Urology, Department of Surgery, Rua Jose Pugliesi Filho 265, Campinas, Sao Paulo, Brazil 13085-415 ()

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Ureteroscopy With Two Guide Wires: A New Technique

ABSTRACT

INTRODUCTION: The purpose of the investigation was to evaluate the use of the two-wire technique for acute dilatation of the intramural ureter for ureteroscopy.

METHODS: Between April 2003 and April 2007, 400 consecutive ureteroscopic procedures were performed. There were 55 patients (40 male, 15 female) with a mean age of 28 years (range, 20-45 years). Patients had acute dilatation of the intramural ureter by the two-wire technique.

RESULTS: The mean operation time was 34 minutes (range, 20–70 minutes). All patients underwent successful ureteroscopy with a semirigid ureteroscope using the two-wire technique. Perforation or intramural false passage of the ureter did not occur. Patients were discharged from the hospital within 6–12 hours. The mean follow-up was 9.7 months (range, 6–18 months). Ultrasonography, intravenous urogram, and voiding cystourethrography were obtained at 3 and 6 months. Ultrasonography was done every 3 months until the end of the follow-up period. Follow-up imaging showed no distal-ureteral stricture or vesicoureteral reflux.

CONCLUSION: Acute dilatation of the intramural ureter by the two-wire technique is cost effective, easy, and time saving with no associated complications

KEYWORDS: Ureteroscopy; Ureteral dilatation; Two-wire technique

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

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Efficacy of Darifenacin in Patients with Varying Baseline Symptom Severity

ABSTRACT

INTRODUCTION:The severity of overactive bladder (OAB) symptoms such as incontinence episodes (IEs), urgency episodes, and micturition frequency varies between patients. It is therefore of interest to determine if patients respond differently to OAB antimuscarinic therapy according to symptom severity.

The objective of the present study was to evaluate data on symptom reduction and time of onset of action for patients in a pooled analysis of three phase III darifenacin studies. These data were analyzed in relation to darifenacin dose received and OAB symptom severity at baseline, as defined by IE frequency at randomization.

METHODS: The investigation was a retrospective analysis of pooled data from three 12-week, fixed-dose, double-blind studies involving 1053 adults (19-88 years old) who received darifenacin 7.5 mg or 15 mg once daily and matched patients who received placebos. Patients with mild/moderate OAB (defined as < 21 IEs/week at baseline) or severe OAB (≥ 21 IEs/week) were analyzed at 2, 6, and 12 weeks or the end of the study. Measurements included the absolute and percentage change from baseline in IEs/week, urgency episodes/day, micturitions/day, and mean volume/void.

RESULTS: There was a statistically significant improvement in OAB symptoms at week 12 or the last visit for patients with mild/moderate OAB taking darifenacin 7.5 mg and 15 mg, when compared with patients taking the placebo. There was also a statistically significant improvement in OAB symptoms at week 12 for patients with severe OAB taking darifenacin 15 mg, when compared with patients taking the placebo. Patients taking darifenacin 15 mg had statistically significant improvements in as few as 2 weeks for all OAB symptoms measured when compared with patients taking the placebo, regardless of baseline severity.

CONCLUSION: Both darifenacin 7.5 mg and 15 mg effectively relieved OAB symptoms, with statistically significant reductions in symptoms seen in as few as 2 weeks. For patients with mild/moderate OAB, 7.5 mg was sufficient to achieve a statistically significant effect; for patients with severe OAB, 15 mg was the most effective dose. These findings highlight the importance of dose titration according to individual patient needs.

KEYWORDS: Antimuscarinic; Darifenacin; Detrusor overactivity; Symptom severity; OAB

CORRESPONDENCE: Roger R Dmochowski, Vanderbilt University School of Medicine, Department of Urology, A1302, Medical Center North, Nashville, TN 37232, USA ().

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Commentary on New Developments in Sling Procedures for Treatment of Female Stress Urinary Incontinence

ABSTRACT

Despite its long-standing history, surgical treatment of female stress urinary incontinence is still a developing medical field. Better understanding of its physiopathology has allowed the creation of novel approaches. Slings have become the mainstay of treatment. The authors provide a brief overview of the development and progress of sling techniques throughout the years.

KEYWORDS: Urinary stress incontinence; Sling; Transobturator tape; Synthetic slings; Mini slings

CORRESPONDENCE: Ricardo Miyaoka, M.D., State University of Campinas, Department of Urology, Rua Durval Cardoso, 172, Campinas, Sao Paulo, 13100-213, Brazil. Email:

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Basal Cell Carcinoma of the Prostate: A Case Report and Review of the Literature

ABSTRACT

We report a case of an adenoid cystic variant of basal cell carcinoma (BCC) of the prostate in a patient diagnosed following transurethral resection (TURP). A single focus of adenoid cystic carcinoma (ACC) was found. One year later the patient had an episode of hematuria, for which a second TURP was performed; the specimen showed diffuse ACC. The patient then underwent a total prostatectomy (TP). There was no remaining tumor. The patient has been followed for 6 years with no recurrence.

KEYWORDS: Adenoid cystic carcinoma; Basal cell carcinoma; Immunohistopathology; Prostate

CORRESPONDENCE: Mark S. Soloway, MD, Professor and Chairman, Department of Urology, University of Miami, Miller School of Medicine, P.O. Box 016960, Miami, FL 33101, USA. ()

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Appendicovesical Fistula: A Case Report

ABSTRACT

The author reports a case of a young boy with appendicular vesical fistula. He presented to the University Teaching Hospital, Lusaka, Zambia with urinary retention. He was also passing stool in the urine. Appendicular vesical fistula is one of the intestinal vesical fistulas. It is a very rare condition. The most common form is vesical colonic fistula, which is caused by diverticulosis (50-60%), colonic cancer (20-25%), or Crohn's disease (10%). Appendicular cancer, especially carcinoid tumor, is another underlying cause. Appendicular vesicle fistula is a rare but well known complication of appendicitis. The most common presentation is pneumaturia, fecaluria, and recurrent or chronic urinary tract infections.

KEYWORDS: Appendix; Urinary bladder; Fistula

CORRESPONDENCE: Mohamed Awny Labib, University Teaching Hospital, Nationalist Road, PO Box 33982, Lusaka, 10101, Zambia ()

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