Issue 2: April 2009

UIJ Volume 2 Issue 2 April 2009

The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) Statement: Guidelines for Reporting Observational Studies


Much biomedical research is observational. The reporting of such research is often inadequate, which hampers the assessment of its strengths and weaknesses and of a study's generalisability. The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) Initiative developed recommendations on what should be included in an accurate and complete report of an observational study. We defined the scope of the recommendations to cover three main study designs: cohort, case-control, and cross-sectional studies. We convened a 2-day workshop in September 2004, with methodologists, researchers, and journal editors to draft a checklist of items. This list was subsequently revised during several meetings of the coordinating group and in e-mail discussions with the larger group of STROBE contributors, taking into account empirical evidence and methodological considerations. The workshop and the subsequent iterative process of consultation and revision resulted in a checklist of 22 items (the STROBE Statement) that relate to the title, abstract, introduction, methods, results, and discussion sections of articles. 18 items are common to all three study designs and four are specific for cohort, case-control, or cross-sectional studies. A detailed Explanation and Elaboration document is published separately and is freely available on the Web sites of PLoS Medicine, Annals of Internal Medicine, and Epidemiology. We hope that the STROBE Statement will contribute to improving the quality of reporting of observational studies.

Funding: The workshop was funded by the European Science Foundation (ESF). Additional funding was received from the Medical Research Council Health Services Research Collaboration and the National Health Services Research and Development Methodology Programme. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.

Competing Interests: The authors have declared that no competing interests exist.

Citation: von Elm Erik, Altman Douglas G, Egger Matthias, Pocock Stuart J, Gøtzsche Peter C, Vandenbroucke Jan P. The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) Statement: Guidelines for Reporting Observational Studies. UIJ. 2009 Feb;2(1). doi:10.1371/journal.pmed.0040296

Copyright: © 2007 von Elm et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. For details on further use, see the STROBE Web site ( In order to encourage dissemination of the STROBE Statement, this article will also be published and made freely available by Annals of Internal Medicine, BMJ, Bulletin of the World Health Organization, Epidemiology, The Lancet, and Preventive Medicine.

Abbreviations: CONSORT, Consolidated Standards of Reporting Trials; STREGA, STROBE Extension to Genetic Association Studies; STROBE, Strengthening the Reporting of Observational Studies in Epidemiology

* Address correspondence to .



The Value of Blood Tests Following Transurethral Resection of the Prostate


INTRODUCTION: Transurethral resection of the prostate (TURP) is an invasive procedure that can result in significant blood loss. Major national urological associations do not have specific recommendations regarding post-TURP blood testing, although this testing is performed routinely in many hospitals. The aim of the present study was to identify the need for routine blood testing post-TURP and to investigate the financial implications of performing such tests.

METHODS: The authors retrospectively studied pre and postoperative hemoglobin, sodium, potassium and creatinine values of 137 patients. The data collected included demographics, the value of blood tests pre and post TURP, transfusion rate and TUR syndrome rate.

RESULTS: Of the 137 patients, only 1 required blood transfusion in the postoperative period. Although 2 patients had low postoperative sodium, there was no TUR syndrome in any patient. There were no significant changes in the creatinine levels post TURP. The cost of postoperative blood tests in each patient was approximately £30 (US $45), which included all of the administrative costs for processing the tests.

CONCLUSIONS: Routine postoperative blood tests after TURP do not alter clinical management. The authors recommend selective blood testing based on clinical need.

KEYWORDS: TURP; Transurethral resection; Prostate; Blood transfusion; Hemoglobin; Creatinine; Benign prostatic hyperplasia

Correspondence: Mr. Abdul Hakeem, Senior House Officer, Department of Urology, Conquest Hospital, East Sussex Hospitals NHS Trust, St. Leonard's-On-Sea, East Sussex, England TN37 7RD. E-mail:



Successful Early Prostate Cancer Screening by Three-Dimensional Color Doppler Imaging-Transrectal Ultrasound: A Prospective Study


INTRODUCTION: Prostate-specific antigen (PSA) screening has been used successfully for the early detection of prostate cancer, but it does not localize the cancer area inside the prostatic gland. Conventional transrectal ultrasound imaging can be used for positioning of the biopsy needle. However, proper targeting is almost impossible when cancers are small. Therefore, overlooked cancer or over-biopsy is a permanent risk. Biplane color Doppler imaging (CDI), a technique that is currently emerging due to improvements in cancer detection, cannot be used to differentiate between different types of hypervascularized lesions such as prostatitis or cancer. Three dimensional (3D) CDI transrectal ultrasound (TRUS) was developed to solve many of these problems.

METHODS: In a prospective and histologically verified study, 418 patients with slightly elevated range of PSA-levels and/or hereditary risk for prostate cancer were screened by 3D CDI-TRUS. Patients were then classified into benign or malignant according to ultrasound criteria and afterwards biopsied.

RESULTS: 3D CDI-TRUS was used to diagnose these patients correctly, with a sensitivity of 0.82 and good specificity (0.91).

CONCLUSION: 3D CDI-TRUS may be used for prostate cancer screening while reducing unnecessary biopsies in men with elevated PSA levels.

KEYWORDS: Prostate cancer screening; Prostate cancer detection; Transrectal ultrasound; Three dimensional transrectal ultrasound; Prostate biopsy.

Correspondence: Walter Merkle, M.D. Dept. of Urology, German Diagnostic Clinic, Aukammallee 33, Wiesbaden, Hessen, Germany 65191. Email:



Spontaneous Bladder Rupture: A Diagnostic and Treatment Dilemma (Case Studes and Literature Review)


INTRODUCTION: Spontaneous bladder rupture (SBR) is uncommonly reported and often presents with non-specific clinical features. Therefore, SBR poses a diagnostic and management dilemma for the treating clinician. The authors present 3 cases of SBR with atypical presentation that were promptly diagnosed and successfully managed through conservative treatments.

METHODS: Three males presented to the authors’ emergency department. All 3 had features of urosepsis and difficulty voiding, 2 had lower abdominal cellulites, and 1 had uremia, abdominal distention, and tenderness. One patient had untreated urethral stricture negotiable with an 8Fr catheter, and the other 2 had paraplegia with a neurogenic bladder following spinal trauma. Ultrasound revealed a thick-walled diverticulated bladder with bilateral hydroureteroneprosis in all patients. A computed-tomography cystogram was performed because of a high index of suspicion for SBR.

RESULTS: The CT-cystogram showed bladder rupture in all 3 patients (intraperitoneal in 1 and extraperitoneal in 2). All were managed with parenteral antibiotics. Drainage of the urinary bladder and the collection was done through an incision in 2 patients and peritoneal drain in 1. Follow-up CT-cystogram in all patients revealed complete healing of bladder perforation and resolution of the collection. A cystometrogram of 1 patient revealed detrusor overactivity with poor contractility.

CONCLUSION: Physicians must keep a very high index of suspicion for SBR in the presence of diseased bladder associated with overdistension. The CT-cystogram is highly sensitive in diagnosing SBR. Conservative management by indwelling bladder catheter and drainage of extravasated collection is feasible in many cases of extraperitoneal bladder rupture. Conservative treatment may also be considered in carefully selected patients with intraperitoneal bladder rupture, especially if there is intent of temporarization. A follow-up functional assessment of the bladder is mandatory to prevent recurrence.

KEYWORDS: Bladder disease, Computed tomography, Neurogenic bladder, Urodynamics, Observation

Correspondence: Dr. Shrawan K Singh, Professor, Department of Urology, Level II, B Block, Advanced Urology Center, Nehru Hospital, Postgraduate Institute of Medical Education and Research, Chandigarh, India. PIN- 160012. Email: , .



Tunica Vaginalis Free Graft Urethroplasty: Early Experience


INTRODUCTION: In the last few decades, many tissues have been used as substitution for long segment urethral strictures. The tissue of choice is still controversial, so new tissues and techniques are continuously being prescribed. The purpose of the present report was to describe the author’s experience with the use of tunica vaginalis (TV) free graft for substitution urethroplasty, along with midterm follow up.

METHODS: Between October 2005 and November 2008, a total of 20 patients had TV free graft urethroplasty in 2 institutions by the same surgeon [HA]. Patients were assessed preoperative by urethrography. In 8 cases, dorsal urethrotomy was done and the TV graft was placed dorsally and sutured with 3/0 polyglactin running sutures. In 12 cases, complete dissection of the stricture was done; both ends were spatulated, and the TV graft was placed using augmented anastomosis urethroplasty. Urethral stent fixed to a suprapubic catheter was left in situ for 2-4 weeks. The patients were assessed postoperatively by measuring the urine flow rate and by micturating cystourethrography. Follow up ranged from 2 to 38 months. Successful criteria were: patient satisfaction, urine flow rate above 15mL/s, patent urethrogram, and no need for dilation or any instrumentation during the follow-up period.

RESULTS: Out of 20 patients, 1 failed due to severe wound sepsis and the TV was redone successfully 6 months later. One had recurrent urethral stricture 3 months later, managed by optical urethrotomy. The remaining patients (18/20) were voiding well, with an average flow rate >16mL/s. Two developed superficial wound infection that did affect the urethra. None of the patients had any scrotal pain or discomfort in the follow-up period.

CONCLUSION: This early experience of using tunica vaginalis for substitution urethroplasty has shown encouraging results. The procedure is easy and convenient; donor tissue is obtained through the same incision as the one used for stricture repair. Tunica vaginalis urethroplasty should be considered as an additional option by reconstructive genitourinary surgeons.

KEYWORDS: Urethral stricture; Urethroplasty; Graft; Tunica vaginalis.

Correspondence: Hassan M Ashmawy, Consultant Urologist, Mpilo Central Hospital, Senior Lecturer, School of Medicine, National University of Science and Technology (NUST), P.O. Box 3682, Bulawayo, Zimbabwe. Email:



Renal Cell Carcinoma with Interseptal Metastasis


We report a single case of renal cell carcinoma (RCC) with renal vein, suprahepatic inferior vena cava, and right atrium thrombosis. The patient subsequently underwent radical nephrectomy and thrombectomy with intraoperative pulmonary artery exploration and tumor thrombectomy. During surveillance, the patient presented with an intracardiac interventricular septal disease recurrence 40 months after resection. The patient elected adjuvant therapy with oral sunitinib for the unresectable cardiac metastasis and was free from clinical progression for 8 months at last followup. This is the first known report in the literature of RCC with intraseptal cardiac metastatic recurrence.

Correspondence: Christopher Brede, B.S, University of Michigan, Department of Urology, 1500 East Medical Center Drive, Ann Arbor, MI 48109 United States. E-mail:



Complete Supine Percutaneous Nephrolithotripsy Comparison With the Prone Standard Technique: The Time for Change From Prone to Supine Position Has Come!

There is no abstract for this article.



Evaluation of Selective and Non-Selective Alpha-Andrenergic Blockers in the Treatment of Distal Ureteral Stones


Objective: To evaluate the efficacy of selective and non-selective alpha-adrenergic blockers in enhancing lower ureteral stone passage and shortening stone passage time in comparison to the standard medical treatment of only high fluid intake and analgesic and anti-inflammatory drugs before rushing into invasive intervention.

Patients and Methods: Our study consisted of 45 patients suffering from lower ureteral stones (not more than 10 mm in diameter) divided into 3 groups each consisting of 15 patients. The 3 groups were subjected to 3 different regimens of medical therapy for a maximum of 30 days.

Patients in Group 1 were given the standard treatment of high fluid intake, phytotherapy, and analgesic and anti-inflammatory drugs. In addition to the standard treatment, patients in Group 2 were given the non-selective α1-adrenergic receptor blocker Terazosin (2 mg) once daily before bed for 4 days and then 5 mg once daily before bed. Patients in Group 3 were given the selective α1a-adrenergic receptor blocker Tamsulosin (0.4 mg) once daily in addition to the standard treatment.

All the patients were subjected to clinical assessment including history and examination. Laboratory investigations (complete urine analysis, urine culture and sensitivity if needed, serum creatinine) and imaging studies (plain X-ray, excretory urogram) were obtained for all patients.

Results: There was a higher combined incidence of stone passage in Groups 2 and 3 (73.4%) than in Group 1 (53.3%) and a more rapid combined stone passage (14.4 days vs. 18.25 days). Patients in Group 3 demonstrated a higher incidence of stone passage (80%) than patients in Group 2 (66.7%) and more rapid stone passage (9.58 days vs. 19.20 days).

Conclusion: The use of alpha adrenergic blockers is recommended in patients with uncomplicated lower ureteral stones. Selective α1a-adrenergic receptor blockers show better results because of their higher efficacy, minimum side effects, and excellent patient satisfaction. Further clinical research in this field is needed, and larger multicenter trials are awaited to formulate a standard regimen.

Keywords: Lower ureteral stones, Alpha blockers, Medical treatment

Correspondence: Ahmed Abdelbary, Urology Department, Bani Swef University Hospital, Bani Sweif, 11371, Egypt,

To Cite this Article: El-Batanouny A, Abdelbary A, Massoud A, Abdel-Mohsen M, Hegazy AR. Evaluation of Selective and Non-Selective Alpha-Andrenergic Blockers in the Treatment of Distal Ureteral Stones. UIJ. 2009 Apr;2(2). doi:10.3834/uij.1944-5784.2009.02.02



Splenogonadal Fusion: A Case Report


Splenogonadal fusion is a rare congenital anomaly in which there is fusion between the spleen and gonad, epididymis, or vas deferens. The abnormal splenic tissue may or may not be continuous with the orthotopic spleen. The diagnosis is most often made when an extratesticular scrotal mass is noted or a lesion is discovered during orchiopexy.

We reviewed the medical record of a 26-year-old male medical student with splenogonadal fusion diagnosed during surgical exploration for cryptorchidism.

Keywords: Splenogonadal, Cryptorchidism, Undescended testicle, Congenital anomalies

Correspondence: Stavros N. Charalambous, Ippokratio General Hospital, 49 Konstantinoupoleos Street, Thessaloniki, 54642, Greece,



A Randomized Controlled Study of Posterior Tibial Nerve Stimulation for Overactive Bladder

(No Abstract)


The aim of this study was to evaluate the safety and efficacy of electrical stimulation of the posterior tibial nerve (PTNS) in women with overactivity bladder symptoms (OAB) and to assess the impact on the quality of life (QoL) using the Overactivity Bladder Questionnaire (OABq-SF).



Efficacy and Tolerability of Add-On Trospium Chloride in Patients with Benign Prostate Syndrome and Overactive Bladder: A Noninterventional Trial Showing Use of Flexible Dosing


OBJECTIVE: This study was performed to elucidate efficacy and tolerability of an oral add-on therapy with trospium chloride in patients with benign prostate syndrome (BPS) without obstruction who showed International Prostate Symptom Score (IPSS) ≥ 8 and distinctive overactive bladder (OAB) symptoms under α-receptor blocker therapy.

RESEARCH DESIGN AND METHODS: This was a multicenter, open, non-interventional, prospective study performed in private urology practices. Only patients with OAB and BPS who were insufficiently treated with α-receptor blockers were eligible to participate. Patients received trospium chloride coated tablets* as oral add-on therapy. Dosing and duration of treatment were not predetermined; however, reference was made to the respective details in the product's package leaflet, and a minimal treatment period of 4 weeks was suggested.

MAIN OUTCOME MEASURES: Core symptoms of BPS, IPSS, overactive bladder symptoms, and Quality of Life (QoL) score were assessed at the beginning and end of the observation period. Adverse events and withdrawals, as well as the dosage regimens chosen, were documented at the end of the study. Furthermore, doctors and patients were requested to rate efficacy and tolerability of the treatment. All data were evaluated solely in an exploratory way.

*Trospium chloride coated tablets (Spasmex 30), Dr. R. Pfleger GmbH, D-96045 Bamberg, Germany

RESULTS: In total, 4104 cases fulfilled the predetermined criteria for the evaluation of efficacy; all 4382 cases were included in the safety analysis. After a mean (SD) treatment period of 40 (17.9) days with trospium chloride as add-on therapy, all core symptoms of BPS had improved: The mean daily micturition frequency was reduced from 11.8 (3.5) to 8.5 (2.5). The percentage of continent patients increased from 66.6% to 83.1%, and the proportion of patients requiring incontinence pads was almost halved from 19.9% to 11.7%. The median IPSS score was reduced from 18 to 12, and the QoL score improved from 4 to 2. Treatment tolerability was assessed as very good or good by 94.2% of the doctors. There were 121 (2.8%) early treatment withdrawals, and 35 (0.8%) patients experienced adverse events.

CONCLUSIONS: Patients with moderate to severe lower urinary tract symptoms due to BPS and OAB syndrome who were insufficiently treated with an α-receptor blocker may benefit from add-on therapy with trospium chloride, a compound generally well tolerated by the vast majority of the patients.

KEYWORDS: α-Receptor-blocker; Overactive bladder; Benign prostate syndrome; Trospium chloride

CORRESPONDENCE: Ulrich Schwantes, PhD, Head Medical Science/Clinical Research, Dr. R. Pfleger GmbH, D-96045 Bamberg.



Tubeless Percutaneous Nephrolithotomy


Objective: To evaluate the efficacy and safety of tubeless percutaneous nephrolithotomy (PCNL).

Patients and Methods: We studied 43 patients with kidney stones who underwent tubeless PCNL. All procedures were done in a 1-stage operation. Patients with ureteropelvic junction (UPJ) obstruction and a stone burden less than 2 cm were excluded from the study. Double puncture was performed in 6 patients, and each puncture was closed separately. The ureteric catheter was left indwelling for a period of 24 to 48 hours. This was compared to a control group of 45 patients who underwent standard PCNL.

Results: Of the 43 patients who underwent tubeless PCNL, 29 were males and 14 were females. Their age ranged from 17 to 45 years. Ureteric catheters were left in for 24 hours in 37 patients and for about 48 hours in 6 patients. The hospital stay ranged from 36 hours to 2 days. The mean (SD) hospital stay was 34.65 (5.37) hours. This was compared to the mean hospital stay of the control group 118.5 (45.15) (P = .000068). There was no bleeding from the nephrostomy site and no urine leakage in any of the patients. Some experienced mild hematuria but none required blood transfusion. There were no residual stones in any patients and mild pain in 5 cases who respond well to anti-inflammatory drugs.

Conclusion: Tubeless PCNL is suitable for any patient who can be rendered stone-free with a single procedure, as it decreases the hospital stay, recovery time and cost, and improves the quality of life.

Keywords: Tubeless percutaneous nephrolithotomy

Correspondence: Ahmed Shelbaia, Department of Urology, Cairo University, Borg El Atbaa, Faisal Street, Giza, Egypt,

To Cite this Article: Shelbaia A, Rahman SA, Hussein A. Tubeless Percutaneous Nephrolithotomy. UIJ. 2009 Apr;2(2). doi:10.3834/uij.1944-5784.2009.02.04