Issue 1: February 2009

UIJ Volume 2 Issue 1 February 2009

Hypercontinence in Women after Orthotopic Neobladder Diversion

ABSTRACT

Introduction: There is a great debate about the cause of the higher incidence of hypercontinence in women undergoing orthotopic diversion after cystectomy in relation to men.

Methods: A total of 39 females with orthotopic diversion were studied: 21 from the Theodore Bilharz Research Institute (TBRI), and 18 from the University of South Florida at Tampa (USF). Nerve preservation was attempted in all cases. Cystectomy was done with a cut across the bladder neck in the TBRI cases, while the urethral cut in the USF cases was done across the proximal urethra.

Results: Hypercontinence was found in 38% (8 of 21) of TBRI patients and in 16% (3 of 18) of USF patients. Urodynamic evaluation was done in 10 of the TBRI cases, and it was comparable to other series regarding pouch capacity (mean = 500 ml), pouch pressure (mean = 17 cm H2O at capacity), maximum urethral pressure (mean = 67 cm H2O), and maximum urethral closure pressure (mean = 49.2 cm H2O).

Conclusion: The relaxation of the striated sphincter and the contraction of the longitudinal smooth muscle opens the way for micturition. The loss of this normal coordinated reflex leads to the presence of a urethra with a fixed tone that does not open with trials of evacuation. As men and women have an intact striated sphincter, the higher incidence of hypercontinence in females compared to males is due to the presence of the extra tone of the urethral smooth muscles. This study proves that the more urethral length left, the higher the incidence of hypercontinence because more smooth muscle tone is faced during micturition. Nerve preservation has no impact because the coordinated detrusor urethral smooth muscle action is lost.

Keywords: Women, Orthotopic diversion, Hypercontinence

Correspondence: Mohamed Ali A Ismail, Urology Department, Theodore Bilharz Research Institute, Giza, Egypt,

To Cite this Article: Ismail MAA, Wishahi MM, Elsherbeeny M, Sewallam TA, Lockhart J. Hypercontinence in Women after Orthotopic Neobladder Diversion. UIJ. In Press. doi:10.3834/uij.1944-5784.2008.12.05

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Azoospermic Patients: Mosaic Pattern in Testicular Sperm Extraction

ABSTRACT

Objective: To study the mosaic (focal) pattern of spermatogenesis in azoospermic patients.

Materials and Methods: We conducted a cross-sectional study between June 2003 and February 2007 that included 87 non-obstructed azoospermic patients who underwent testicular sperm extraction (TESE) mapping. The extraction of spermatozoa into a culture medium was compared with testicular histology results. Both histopathology and TESE results were reviewed independently and blindly. Positive mosaic (focal) spermatogenesis was considered in positive mapping or positive TESE with a negative histology.

Results: Mosaic pattern was identified in 26.44% (23 patients) of the study sample. There was no difference in mosaic distribution between testes. There was a mosaic pattern in 10 of the 22 (22.22%) right testes tested and in 13 of the 42 (30.95%) left testes (P = 0.071; CI = 0.10209-0.27669). Histopathological background showed a difference in mosaic distribution. Mosaic pattern was identified in association with maturation arrest in 12 (13.79%) patients, testicular atrophy in 3 (3.45%), atrophy and maturation arrest in 1 (1.14%), Sertoli cell in 3 (3.45%), hypospermatogenesis in 2 (2.3%), and mixed histopathology in 2 (3.45%), in which atrophy, maturation arrest, and hypospermatogenesis all were identified in the same histopathological sample (P = 0.055; CI = 0.050-0.059).

Conclusion: Mosaic pattern of spermatogenesis was found in 26.44% of men with non-obstructive azoospermia. Mosaic (focal) spermatogenesis is more often identified in the histological background of maturation arrest. The chance of sperm retrieval is improved by taking biopsies from multiple sites of the testes.

Keywords: TESE, Mosaic TESE, Azoospermic patients, Mosaic pattern of spermatogenesis in azoospermic patients, Mosaic pattern of spermatogenesis

Correspondence: Mai Ahmed Banakhar, King Abdul Aziz University Hospital, Surgical Department-Urology, P.O. Box 80215, Jeddah, 21589, Kingdom of Saudi Arabia (KSA),

To Cite this Article: Banakhar MA, Farsi HA, Jamil ST. Azoospermic Patients: Mosaic Pattern in Testicular Sperm Extraction. UIJ. In Press. doi:10.3834/uij.1944-5784.2008.12.08

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A Review of Pediatric Laparoscopic Pyeloplasty

No abstract available

To Cite this Article: Casale P. A Review of Pediatric Laparoscopic Pyeloplasty. UIJ. In Press. doi:10.3834/uij.1944-5784.2008.12.09

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Total Gangrene of the Penis due to Improper Application of a Condom Catheter

ABSTRACT

We describe an unusual case of penile gangrene in a patient suffering from urinary incontinence secondary to cerebrovascular accident. Gangrene developed due to continuous tourniquet effect on the penis caused by a condom catheter. Since gangrene of the penis is an irreversible process, this case highlights the importance of proper care and routine maintenance of condom catheters in preventing this complication.

Keywords: Penis, Gangrene, Condom catheter, Penectomy, Suprapubic cystostomy

Correspondence: Kusuma V. R. Murthy, Osmania General Hospital, Hyderabad, India,

To Cite this Article: Murthy KVR, Jayaram Reddy S, Panduranga Rao K, Jagadeshwar T, Srinivas S. Total Gangrene of the Penis Due to Improper Application of Condom Catheter. UIJ. In Press. doi:10.3834/uij.1939-4810.2008.12.03

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Extracorporeal Shock Wave Lithotripsy (ESWL) Versus Percutaneous Nephrolithotomy (PCNL) in the Eradication of Persistent Bacteriuria Associated with Infected Stones

ABSTRACT

Introduction: Infected stones function as a sanctuary for organisms that attenuate the effects of antibiotics. Therefore, to treat urinary tract infection associated with urinary calculi, complete extirpation of the stones is necessary.

Objective: We compared the incidence of persistent bacteriuria among patients with infected renal stones treated by (ESWL) and who received long-term antibiotics versus those who were treated by (PCNL) with the aim to completely eradicate all stone fragments.

Methods: We studied 73 patients with infected stones who presented with recurrent or persistent urinary tract infections (UTI). Urine culture was positive in all patients. We treated 35 patients by ESWL, of whom 23 had stones larger than 2 cm and were provided with fixed double-j stents for drainage and to prevent obstruction (stents were left in for no more than 6 weeks). The other 38 patients were operated upon by PCNL through single (29 patients) or multiple (9 patients) punctures or sessions.

Results: Of the 73 patients included in the study, 67 were available for follow-up (32 from the ESWL group, 35 from the PCNL group). Out of the 35 patients treated with PCNL, 32 (91.4%) were rendered stone-free, and only 2 of the 3 (5.7%) patients with residual stones showed evidence of persistent bacteriuria. Out of the 32 patients treated with ESWL, 16 (50%) were stone-free, and 13 of the 16 (40.6%) with residual stones showed evidence of persistent bacteriuria. A positive relation was found between residual stone fragments and persistent bacteriuria, as all patients in either group who were stone-free were also free of persistent infection. The study also showed that, in the ESWL group, the rate of eradication of stones and persistent infection was much better in cases with stones less than 2 cm (90.9% vs. 28.6%). The incidence of residual infected stone fragments was directly related to the degree of hydronephrosis.

Conclusion: PCNL is better than ESWL monotherapy in the eradication of persistent bacteriuria associated with infected stones, especially when associated with moderate and marked hydronephrosis, as it has a much better clearance rate of the residual infected stone fragments.

Keywords: Persistent bacteriuria, Stones, ESWL, PCNL

Correspondence: Mamdouh Roshdy, Urology Department, Theodor Bilharz Research Institute, Giza, Egypt,

To Cite this Article: Riad EM, Roshdy M, Ismail MAA, El-Leithy TR, Ghoubashy SE, Ganzoury HE, El Baz AG, Kamel AI. Extracorporeal Shock Wave Lithotripsy (ESWL) Versus Percutaneous Nephrolithotomy (PCNL) in the Eradication of Persistent Bacteriuria Associated with Infected Stones. UIJ. In Press. doi:10.3834/uij.1944-5784.2008.12.07

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Long-Term Efficacy of Tamsulosin in the Treatment of Lower Urinary Tract Symptoms Suggestive of Benign Prostatic Hyperplasia in Real-Life Practice

ABSTRACT

Background: α1-Adrenoceptor antagonists are recommended as the main pharmacological treatment for lower urinary tract symptoms suggestive of benign prostatic hyperplasia (BPH/LUTS). Short-term efficacy of tamsulosin has been verified in many randomized controlled trials. However, there is a relative paucity of long-term data on the maintenance of the efficacy of this drug.

Objective: To evaluate the long-term efficacy of tamsulosin for patients with BPH/LUTS in real-life clinical practice.

Methods: A total of 113 males with BPH/LUTS (mean age {SD} = 68.5 {8.8} years; mean prostate volume {SD} = 34.2 {15.7} ml) who were treated with tamsulosin (0.2 mg daily) for more than 3 months were retrospectively evaluated. The International Prostate Symptom Score (I-PSS), quality of life (QOL) score, average and maximum flow rate (Qave and Qmax), and postvoid residual urine volume (PVR) and percentage of residual urine (%PVR) were determined before (baseline) and after the initiation of treatment.

Results: Of these patients, 72 (64%) remained on tamsulosin (12 to 48 months of treatment) and 41 (36%) withdrew after a mean of 17.4 months on average. Reasons for withdrawal were: satisfied with the current condition in 1 patient (1%), lost to follow-up for unknown reasons in 18 (16%), detection of prostate cancer in 5 (4%), insufficient therapeutic response in 16 (14%; 1 patient stopped medication; 6 changed to other drugs; 9 underwent surgery), and adverse effects (headache) in 1 patient (1%). The mean total I-PSS, total I-PSS storage subscore, total I-PSS voiding subscore, post-micturition score, and QOL score were all significantly decreased with P values of < 0.0001 after 1 month and remained stable for up to 48 months of treatment. Qave and Qmax were significantly increased (P < 0.0001), and PVR and %PVR were significantly decreased (P = 0.0051 and P = 0.0001, respectively) after 3-month treatment. The means of these scores did not change significantly, but rather appeared to remain stable for 24 to 48 months.

Conclusion: Effects of tamsulosin on BPH/LUTS are immediate (within 1 month) and persist (for over 12 months). Tamsulosin is well tolerated for BPH/LUTS.

Keywords: Alpha-blocker, Benign prostatic hyperplasia, Lower urinary tract symptoms, Tamsulosin, Pharmacotherapy

Correspondence: Tomonori Yamanishi, Department of Urology, Dokkyo Medical University, 880 Kitakobayashi, Mibu, Tochigi, 321-0293, Japan,

To Cite this Article: Yamanishi T, Tatssumiya K, Furuya N, Masuda A, Kamai T, Sakakibara R, Uchiyama T, Yoshida KI. Long-Term Efficacy of Tamsulosin in the Treatment of Lower Urinary Tract Symptoms Suggestive of Benign Prostatic Hyperplasia in Real-Life Practice. UIJ. In Press. doi:10.3834/uij.1944-5784.2009.02.01

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A Cost Comparison of the Diagnostic Modalities Used in the Detection of Urothelial Carcinoma in Patients Undergoing Evaluation for Hematuria

ABSTRACT

Background: The incidence of bladder cancer was estimated at 61,420 in the United States in 2006, and the rate is increasing with the aging population. Studies have shown that 6% to 12% of hematuria evaluations yield diagnoses of urothelial carcinoma (UC) and upper tract tumors. This correlation translates into 500,000 to 1,000,000 hematuria evaluations per year in the United States, with a corresponding cost of $500 million to $1 billion annually. Because no studies have looked at the economic cost of hematuria evaluation, we reviewed our experience with the current recommended diagnostic approach and report the related medical costs associated with hematuria evaluation at our institution.

Methods: A retrospective review was performed on 744 consecutive patients who underwent evaluation for gross or microscopic hematuria. Of these patients, 373 patients underwent cystoscopy and CT urogram and had urine collected for nuclear matrix protein-22 (NMP-22) testing and cytology. The Medicare reimbursement rates as of January 1, 2006 were obtained for each of the above modalities. The McNemar test was used for pair-wise comparison of sensitivity and specificity.

Results: Through dividing the direct medical cost of each modality by the observed sensitivity, we determined the cost per diagnosis of NMP-22 ($39.82), cytology ($54.96), cystoscopy ($430.14), and CT urogram ($989.06). Cystoscopy was found to be more sensitive than CT scan, cytology, and NMP-22 in the diagnosis of UC (P < 0.05), and combining cystoscopy with other tests yielded no statistically significant improvements in sensitivity.

Conclusion: We showed that the workup of hematuria in terms of financial cost is not insignificant. In our specific patient series, cystoscopy proved to be the most effective modality at diagnosing UC, with 96% sensitivity and 97% specificity. Although imaging is an important part of the upper tract evaluation, the development and usage of better urinary markers may complement less expensive imaging modalities with less radiation exposure.

Keywords: Urothelial carcinoma, NMP-22, CT urogram, Cost comparison

Correspondence: Louis S. Liou, Boston University School of Medicine, Department of Pathology, 720 Harrison Avenue, Boston, MA 02118,

To Cite this Article: Berookhim BM, Sethi AS, Wen CC, Cui J, Liou LS. A Cost Comparison of the Diagnostic Modalities Used in the Detection of Urothelial Carcinoma in Patients Undergoing Evaluation for Hematuria. UIJ. In Press. doi:10.3834/uij.1939-4810.2008.12.01

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A Randomized Controlled Trial of Bacillus Calmette-Guerin and Botulinum Toxin-A for the Treatment of Refractory Interstitial Cystitis

ABSTRACT

Introduction: Interstitial cystitis (IC) primarily occurs in middle-aged women, with a female to male ratio of 9:1. Currently, IC therapy is inadequate with only 2 treatments approved by the Food and Drug Administration: oral pentosan polysulphate and dimethyl sulfoxide (DMSO) bladder instillation. Several researchers have evaluated the efficacy of intravesical bacillus Calmette-Guerin (BCG) instillation for the treatment of IC with promising results. On the other hand, botulinum toxin-A (BTX-A) has gained widespread acceptance for the treatment of bladder overactivity, detrusor-sphincter dyssenergia, and IC. The present work is designated to evaluate the use of intravesical BCG instillation versus intravesical injection of BTX-A in patients with IC.

Patients and Methods: We randomly divided 36 patients who met the National Institutes of Health-National Institute for Diabetes and Digestive and Kidney Diseases (NIDDK) criteria for IC and reported at least moderate pain and frequency for a minimum of 6 months into 2 groups (cases 1,3,5,etc vs. cases 2,4,6,etc). The first group (Group I) received the standard 6 weeks of intravesical BCG instillations. The other subjects (Group II) received an intravesical injection of 300 units of BTX-A. The patients were followed at routine intervals with questionnaires and voiding diaries. Adverse events were closely monitored in the treatment and follow-up phases of the study.

Results: During the follow-up period (23 weeks and 22 weeks, respectively), 11 of 16 (68.75%) patients in Group I and 14 of 16 (87.50%) patients in Group II continued to have an excellent response in all parameters measured. The global interstitial cystitis survey improved 71% in Group I and 92% in Group II; daily voids decreased 31% and 68%, nocturia improved 54% and 100%, pelvic pain decreased 81% and 96%, urgency decreased 71% and 100%, and dysuria decreased 82% and 92%, respectively. The patients in Group II showed a statistically significant improvement in all parameters compared to Group I.

Conclusion: Although the safety profile of BCG is acceptable, its response rate for treatment of intractable IC was poorer in relation to BTX-A. On the other hand, though BTX-A has not yet been approved by the FDA, clinical trials have proved intravesical injection of BTX-A to be a safe and effective therapy for treatment of intractable IC within a 22-week follow-up period.

Keywords: Interstitial cystitis (IC), Bacillus Calmette-Guerin (BCG), Botulinum toxin (BTX-A)

Correspondence: Yasser A. Farahat, Urology Department, Tanta University Hospital, Tanta, Egypt,

To Cite this Article: El-Bahnasy AE, Farahat YA, El-Bendary M, Taha MR, El-Damhogy M, Mourad S. A Randomized Controlled Trial of Bacillus Calmette-Guerin and Botulinum Toxin-A for the Treatment of Refractory Interstitial Cystitis. UIJ. In Press. doi:10.3834/uij.1944-5784.2008.12.06

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Urethroplasty with Lingual Mucosal Graft for Management of Long and Recurrent Strictures of the Anterior Urethra

ABSTRACT

Background: Currently, there is renewed controversy over which tissues and techniques are optimal for urethral replacement. Because surgical treatment of urethral stricture diseases is an evolving process, new technical refinements are continuously being suggested.

Objectives: To evaluate the efficacy and mid-term results of using lingual mucosal grafts (LMG) in management of long and recurrent strictures of the anterior urethra.

Patients and Methods: The study included 18 patients with long recurrent strictures of the anterior urethra. The recurrence arose in 14 patients after several visual internal urethrotomies, after hypospadias repair in 2, and after buccal mucosal graft (BMG) urethroplasty in 2. The strictures varied in length from 3 to 9 cm. Dorsal onlay of the LMGs was used in 12 patients, while ventral onlay was used in 6 patients. Follow-up lasted from 3 to 24 months. Postoperatively, all patients were followed by urethrography, uroflowmetry, and urethroscopy. Successful reconstruction criteria were a peak flow rate greater than 15 ml/sec and no need for postoperative dilatation.

Results: Out of 18 cases, 15 were successful (83.3%). Of the 3 failures, 1 patient had an urethrocutaneous fistula, and 2 patients developed recurrence in the stricture 3 months after urethroplasty.

Conclusion: The technique of substitution urethroplasty using lingual mucosal grafts has been shown to be easy, safe, and reproducible with good surgical and functional outcomes. The success rate is comparable to other techniques of substitution urethroplasty, especially BMGs, but with fewer donor site complications. Our mid-term results are satisfactory, but larger comparative studies with longer duration of follow-up are needed to confirm the durability of these results.

Keywords: LMG, BMG, Urethroplasty

Correspondence: Maged M Ragab, Urology Department, Tanta University Hospital, Tanta, Egypt,

To Cite this Article: Ragab MM, Elgamal S, Farhat Y, Saber W, Hawas M, Elsharaby M. Urethroplasty with Lingual Mucosal Graft for Management of Long and Recurrent Strictures of the Anterior Urethra. UIJ. In Press. doi:10.3834/uij.1939-4810.2008.12.02

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Bilateral Native Nephrectomy: Before or After Renal Transplantation?

ABSTRACT

Objectives: We hypothesized that patients undergoing bilateral native nephrectomy have a better perioperative course and earlier recovery when renal transplantation is performed before nephrectomy rather than afterwards, since the anuric state is avoided.

Methods: Of 9 patients undergoing bilateral nephrectomy between November 2000 and December 2005, 5 had nephrectomy before renal transplant and 4 had nephrectomy after transplant. Hospital course and complications within 3 months of each operation were compared.

Results: Patients who underwent bilateral nephrectomy prior to transplantation spent more days in the hospital overall (mean = 25 days) than did patients who received their transplant before nephrectomy (mean = 14 days). Serum creatinine levels over the course of both operations were greater for the group maintained on dialysis, but both groups had similar values at the time of discharge from the second procedure and at 1-year follow-up. Major and minor complications were more frequent in those who underwent nephrectomy before transplant.

Conclusion: The order of operations for patients undergoing both bilateral nephrectomy and renal transplantation impacts perioperative course, especially in the first 3 months after the operations are completed. Bilateral native nephrectomy before renal transplantation is associated with a greater risk of complications and longer overall duration of hospitalization.

Keywords: Transplantation, Nephrectomy, Laparoscopy, Postoperative complications

Correspondence: J. Stuart Wolf Jr., Department of Urology, University of Michigan Health System, 1500 East Medical Center Drive, TC 3875, Ann Arbor, MI, 48109,

To Cite this Article: Kaplan JR, Sung RS, Wolf JS. Bilateral Native Nephrectomy: Before or After Renal Transplantation?. UIJ. In Press doi:10.3834/uij.1939-4810.2008.12.04

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