Issue 3: June 2009

UIJ Volume 2 Issue 3 June 2009

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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Transcoccygeal Sacropexy Using a Mesh Repair for Resolution of High Grade Uterine Prolapse Associated with Bladder Exstrophy

ABSTRACT

Management of pelvic prolapse in women with bladder exstrophy is challenging. Anatomic changes involving the bony pelvis, connective tissue support, pelvic floor, and the length and axis of the vagina can result in technical difficulties. An abdominal approach and the use of mesh repair have been encouraged to deliver more durable results. The authors report on a case of high grade uterine prolapse successfully managed with a transcoccygeal approach and use of a polypropylene mesh.

KEYWORDS: Uterine prolapse; Bladder exstrophy; Nazca R Mesh; Transcoccygeal sacropexy

CORRESPONDENCE: Paulo Palma MD, State University of Campinas, Division of Urology, Rua Durval Cardoso, 172, Campinas, Sao Paulo, 13100-213, Brazil. ().

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Analysis of Bone Density Among Patients with Urolithiasis: The Role of Hypercalciuria in Bone Loss

ABSTRACT

INTRODUCTION: A kidney stone is a common urologic complaint. The association between hypercalciuria and bone mineral density (BMD) is well known. However, BMD reduction is also recognized among normocalciuric patients.

OBJECTIVE: Bone density in patients with stones was analyzed for the variables of age, sex, and stone configuration. Data were compared with a control group.

METHODS: Participants were 340 randomly chosen patients with upper urinary calcium stones. The control group included 340 healthy participants who were age and sex matched with the patient group. The quantitative variables included age, body mass index, T-score of bone densitometry in the lumbar vertebrae (L2-L4) and femoral neck, and the serum levels of uric acid, calcium, potassium, sodium, phosphor, alkaline phosphatase and parathyroid hormone. Furthermore, each patient’s 24-hour urine was studied for levels of creatinine, oxalate citrate, uric acid calcium, urea, and total volume.

RESULTS: The mean age of the patients was 43.22 years (SD =12.62); mean body mass index (BMI) was 27.44 kg/m2 (SD = 6.16). Lumbar vertebral bone densitometry bone mineral density (BMD) was normal in 144 patients (42.4%) and low normal in an additional 20 patients. One hundred forty patients (41.2%) had osteopenia and 56 (16.5%) were osteoporetic. Femoral neck BMD was normal in 188 patients (55.3%) and low normal in 28 patients. In comparison with the control group, lumbar and femoral BMD were significantly lower in patients with renal stones (P < .05). There were no significant differences among groups in quantitative variables, with the exception of serum uric acid level. There was a significant correlation between both lumbar T-score and femoral neck T-score with 24 hour urine uric acid. Lumbar T-scores increased in inverse relationship with age (P = .03).

CONCLUSION: The authors established that patients who form renal stones have a reduction in bone density. There was no significant difference in bone loss between hypercalciuric and normocalciuric patients, which indicates the existence of some interfering factors other than increased calcium loss. A low-calcium diet does not decrease stone formation, and it also leads to calcium imbalance and bone loss. Considering that the role of hypercalciuria in bone loss was not proven in this study and considering that a low-calcium diet has no proven role in renal stone prevention, the authors do not suggest low-calcium diets for renal stone formers.

KEYWORDS: Bone mineral density; Urolithiasis; Low-calcium diet; Hypercalciuria

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

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The Small Intestinal Submucosa (SIS) as a Suburethral Sling for Correction of Stress Urinary Incontinence: Preliminary Experience

ABSTRACT

INTRODUCTION: The purpose of the present investigation was to demonstrate the authors’ preliminary experience with the use of small intestine submucosa (SIS) as a suburethral sling in the treatment of stress urinary incontinence (SUI) in females.

METHODS: The participants were a carefully selected cohort of 17 women (mean age = 55 years; range, 44–63 years) with SUI based on clinical and urodynamic evidence. Patients with mixed incontinence, prior anti-incontinence, or transvaginal surgery were excluded. The SIS sling was placed as a midurethral sling via a transvaginal retropubic approach. Patients were followed up at 1 week and 3, 6, and 12 months after the procedure. Urodynamic evaluation was repeated at the last postoperative visit.

RESULTS: No adverse inflammatory reactions to the implanted sling or evidence of sling erosion or extrusion were noted in any patients throughout the follow-up period. No major complications were reported; however, minor complications were reported in 3 patients (17.6%). One year after the procedure, 14 patients (82.3%) were completely dry and 2 patients reported occasional episodes of leakage on more than usual daily exercise. The procedure failed to cure SUI in 1 patient, and 1 patient had persistent de novo urinary urgency requiring anticholinergic medication.

CONCLUSION: The preliminary results strongly support the feasibility of the use of SIS as a suburethral sling for treatment of SUI. However, long-term follow up is needed to confirm the durability of these encouraging initial observations.

KEYWORDS: Stress urinary incontinence; Suburethral slings; Small intestine submucosa (SIS).

CORRESPONDENCE: Yasser Farahat, Ph.D., Urology Department, Faculty of Medicine, Tanta University, 11 Ebn Elaas Str., Tanta, Ghr 31111, Egypt. Email:

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Tubularized Incised-Plate (TIP) Repair Augmented by Spongioplasty for Distal and Midpenile Hypospadias

ABSTRACT

INTRODUCTION:The objective of the study was to evaluate the cosmetic and functional results of tubularized incised-plate (TIP) repair of distal and midpenile hypospadias, using the hemicorpora spongiosa as an additional cover in the Y to I maneuver.

METHODS: From February 2004 to February 2007, 50 patients with distal (n=30) and midpenile (n=20) hypospadias had surgical repair. The mean age of the patients was 4.2 years (range, 2-6 years). All patients received primary TIP repair with bilateral dissection of the hemicorpora spongiosa to cover the neourethra (spongioplasty).

RESULTS: The mean follow-up period was 12.6 months (range, 10-17 months). Of the 50 cases, 48 patients (96%) had successful outcome with regard to a straight urine stream, vertically slit meatus, and acceptable cosmetic appearance. Two patients with midpenile hypospadias developed a small fistula at the site of the native meatus. Both patients had successful fistula closure through a secondary repair 3 months later.

CONCLUSION: Spongioplasty is a reliable and important adjunct for covering the neourethra in TIP hypospadias repair. This surgical technique results in a low rate of fistula formation.

KEYWORDS: Hypospadius; Spongioplasty; Urethra

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

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The Effect of Voiding Position on Uroflowmetry Findings and Postvoiding Residual Urine in Patients with Benign Prostatic Hyperplasia

ABSTRACT

INTRODUCTION: The purpose of the present study was to determine whether sitting or standing positions had an effect on voiding in patients with bladder outflow obstruction due to benign prostatic hyperplasia.

METHODS: The authors studied 100 male patients over the age of 45 years with benign prostatic hyperplasia. All underwent uroflowmetry and prevoiding and postvoiding estimation of the residual urine in standing and sitting positions. Patient group 1 had uroflowmetry maximum flow rate (Qmax) ≤ 10 mL/sec.; Group 2 had Qmax 10-15 mL/s. All parameters of uroflowmetry (eg, Qmax, average flow rate, time to maximum flow, and postvoiding residual) were compared for both groups in both positions.

RESULTS: Comparison of all parameters of uroflowmetry and postvoiding residual showed statistically significant differences in favor of sitting more than standing. This result was found for all patients and all variables except one: there was no statistically significant difference in the time to maximum flow in sitting and standing positions for patients in group 2.

CONCLUSION: Voiding in the sitting position in patients with benign prostatic hyperplasia is preferred due to a decrease in obstructive parameters shown by uroflowmetry and postvoiding residual urine volume. As a result, fewer complications such as UTI and bladder stone formation are expected.

KEYWORDS: Voiding Position; Uroflowmetry; Benign prostatic hyperplasia

CORRESPONDENCE: Dr. Mohamed Ali, Department of Urology, Faculty of Medicine, Suez Canal University, Ring Road, Ismailia 41115, Egypt ().

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