Issue 6: December 2009

UIJ Volume 2 Issue 6 December 2009

Letter from the Editor - December 2009

Dear Colleagues,

As 2009 draws to a close, it provides an opportunity to reflect on what has transpired throughout urology in this past year. Has the UroToday International Journal delivered value through the publication to the readers? Have the goals of the journal been fulfilled? Our goals are to accelerate the timely and widespread dissemination of new urological research findings and, ultimately, to impact clinical outcomes. It has been a year of rapid growth for the journal. The response from the readership has been fantastic, and we have received an increasing number of high-quality manuscripts. We have been able to achieve the objectives for rapid publication, thanks to the excellent work of an increasing number of reviewers and timely response from the authors. The Journal issues throughout 2009 have been read by over 40,000 unique readers. A wide variety of relevant and interesting subjects have been covered, and this is continued in the present issue of the journal. A few of the articles are highlighted here.

In a retrospective study of 204 patients over 10 years, Dickstein et al assessed the risk of developing upper tract transitional cell carcinoma (TCC) after finding an abnormal upper tract cytology specimen without overt evidence of tumor. The authors developed an observation strategy for monitoring these patients for urothelial tumor development. They found that upper tract cytology has a poor sensitivity for tumors of the upper urinary tract. Patients with abnormal upper tract cytology were 3 times more likely than patients with normal cytology to develop TCC. They suggested that patients should be carefully monitored for at least 6 years.

Mohanty et al compared tamsulosin taken alone or in combination with tolterodine in a group of patients with lower urinary tract symptoms (LUTS) and detrusor overactivity. Physicians may hesitate to prescribe the combination of drugs because of the risk of acute urinary retention (AUR). The authors found no AUR and showed that patients with the combined drug treatment scored better on many laboratory tests and self ratings of satisfaction. Their findings confirmed several recent studies on the same subject.

Shelbaia et al reviewed the effect of early surgical repair of penile fractures (as opposed to a more conservative wait-and-see approach) in a retrospective study of 16 patients. The authors reported the overall healing of these injuries and the patient’s ability to regain erectile function. They found the surgery successful at 3 and 6-month follow-up. This issue also contains interesting case reports of patients with rare disorders. For example, Hutchings et al described a patient with cervical cancer that metastasized to the kidney. Other cases are related to treatment complications. Vasdev et al described a patient with inadvertent bowel injury following routine suprapubic catheter change. Sallami et al discussed the procedures and legal ramifications of textiloma, a complication that is rarely mentioned in the literature. Finally, although few surgeons will perform reanastomosis of an amputated penis, it is interesting to read the microsurgical procedures used by Wyczolkowski et al for one patient.

We occasionally like to provide review articles on topics of interest to our readers. In this issue, I joined with my colleagues to review noninvasive treatment options for patients with neurogenic detrusor overactivity (Andersson, Dmochowski, Wein). The use of oral antimuscarinic agents as a first-line approach is discussed, along with transdermal or intravesical administration of antimuscarinics, intravesical administration of other agents (including vanilloids and botulinum toxins A and B), and electrical stimulation. The efficacy and adverse events are described for these procedures, all of which allow surgery to be avoided where possible.

All of us at UIJ extend our wishes for a happy and peaceful new year. It has been exciting to experience the international cooperation that we have found with the readers, authors, and reviewers of the journal, and we look forward to continued collaborations. I join with the whole Editorial Team in thanking you for a wonderful year.

Kind regards,

K-E Andersson

Early Management of the Fractured Penis: A Report of 16 Cases


INTRODUCTION: The purpose of this retrospective study was to review the effect of early surgical exploration and repair of penile fractures. The authors report the overall healing of these injuries and the patient's ability to regain erectile function.

METHODS: The participants were 16 patients with a fractured penile shaft following blunt trauma to the erect penis. Data were gathered over a period of 36 months. Retrograde urethrography was done in all cases. All patients were treated by early surgical repair within 24 hours of the injury.

RESULTS: Associated urethral injuries were found in 3 out of the 16 patients (18.75%). These patients had bleeding from the urethra at presentation. Seven patients had tears in the tunica albuginea only; the 9 remaining patients also had disruption of the corpus cavernosum. All tears involved the distal two-thirds of the penile shaft. The wounds healed successfully. All patients reported normal psychogenic, reflexogenic, and nocturnal erections with full sexual activity at 3-month and 6-month evaluations after surgery. Results of pharmacocavernosometric testing showed that all patients had rigid erections that occurred within 3-10 minutes and lasted for more than 30 minutes.

CONCLUSION: The authors recommend early surgical repair of penile fractures because of short hospitalization, successful healing, and early return to full sexual activity.

KEYWORDS: Penile fracture; Erectile function; Management; Prognosis

CORRESPONDENCE: Ahmed Mohamed Shelbaia, Borg El Atbaa, Faisal Street, Giza, Egypt (; ).

CITATION: UroToday Int J. 2009 Dec;2(6). doi:10.3834/uij.1944-5784.2009.12.14



A Rare Case of Adenocarcinoma of the Urinary Bladder


Adenocarcinomas account for less than 2% of primary epithelial malignancies of the urinary bladder. The authors report a rare case of adenocarcinoma of the urinary bladder in a 65-year-old male patient who presented with frank hematuria. Extensive growth infiltration in paravesical fat planes was revealed by computed tomography imaging. The biopsy showed well-differentiated adenocarcinoma of the bladder with muscle involvement. The patient received bacille Calmette-Guérin (BCG) adjuvant therapy and later chemotherapy with poor response. Subsequently, he underwent total radical cystectomy with ileal conduit diversion. The aim of this report was to determine the anatomoclinical and therapeutic characteristics of this rare tumor.

KEYWORDS: Adenocarcinoma; Hematuria; Computed Tomography; Radical and Adjuvant BCG; Cystoprostectotomy

CORRESPONDENCE: Dr. Saleem M. Wani, Sher-I-Kashmir Institute of Medical Sciences, Department of Urology, Ward 4A, Srinagar, 190011, India ().

CITATION: Urotoday Int J. 2009 Dec;2(6). doi:110.3834/uij.1944-5784.2009.12.15



Patient Response to Total Intravenous Sedation (TIVS) for Outpatient Ultrasound-Guided Prostate Biopsy


INTRODUCTION: Transrectal ultrasound (TRUS) guided biopsy is a common office urology procedure. Pain or discomfort associated with this procedure has been addressed with the use of periprostatic or intraprostatic infiltration and nerve block, local anesthesia, general anesthesia, suppository or oral analgesia, or lidocaine gel. The present study is an investigation of patient response to total intravenous sedation (TIVS) for TRUS-guided prostate biopsy. The authors describe the steps of the TIVS technique and critically examine the subsequent intraoperative and postoperative effects.

METHODS: Between December 2006 and April 2007, 100 patients underwent TRUS-guided prostate biopsy by a single surgeon (RK). TIVS sedation was achieved by intravenous administration of fentanyl (0.5-2 μg/kg), midazolam (0.03-0.05 mg/kg) and propofol (dosage titrated). Patients completed a modified Aldrete scoring system and modified postanesthetic discharge scoring system. The quality of the analgesia was assessed with a numerical pain rating scale. Patients were given a questionnaire to assess their perception of the pain and tolerability of the procedure.

RESULTS: The mean time between introduction of the probe and the end of the procedure was 10.5 minutes. Mean sedation time was 19 minutes and all patients were ready for discharge 70 minutes after the procedure. A total of 95 patients experienced a mild pain score of 1-3 out of 10 shortly after the procedure. The mean pain intensity score (95% Confidence Interval) was 1.36 (1.19-1.54), standard deviation = 0.865, median = 1. One patient developed intense nausea requiring IV antiemetic therapy. One patient developed urinary retention requiring urinary catheterization for a few days. There were no other complications related to the TIVS or TRUS procedure. Ninety-eight percent of the patients stated that they were not reluctant to have the biopsy repeated in the future if it was necessary.

CONCLUSIONS: TRUS-guided biopsy of the prostate can be accomplished with minimal pain by using TIVS. The authors believe that sedation should be considered and discussed with patients. TIVS provided sufficient analgesia and satisfactory hemodynamic stability. These effects facilitated recovery, allowing patients to be discharged less than 2 hours after the procedure.

KEYWORDS: Transrectal ultrasound; Biopsy of prostate; Procedural intravenous sedation (PIS); Total intravenous sedation (TIVS); Modified Aldrete scoring system, Modified postanesthetic discharge score

CORRESPONDENCE: Dr. Ahmed Al-Sameraaii, Department of Urology, The St. George Hospital, Gray Street, Kogarah 2217, NSW, Australia ( email address is being protected from spam bots, you need Javascript enabled to view it ).

CITATION: UroToday Int J. 2009 Dec;2(6). doi:10.3834/uij.1944-5784.2009.12.04



Ureteroscopy During Pregnancy Using the Follow-the-Wire Technique


INTRODUCTION: The purpose of the study was to evaluate the use of ureteroscopy for the treatment for urolithiasis during pregnancy. The follow-the-wire technique was used.

METHODS: The participants were 26 pregnant women with persistent renal colic that did not respond to medications. Patients were seen between March 2002 and January 2009. The mean patient age was 24 years (range, 21-39 years). Three patients presented during the first trimester, 15 patients during the second trimester, and 8 patients during the last trimester. Ureteroscopy was performed using a 7.5-8 F semirigid ureteroscope. Cystoscopy was performed first and the ureteric orifice was identified. The guidewire was advanced through the ureteroscope into the ureteric orifice. The ureteroscope followed the guidewire until the site of obstruction was located. The guidewire was advanced under visualization, past the obstruction and to the kidney. The ureteroscope was removed and reintroduced. Lithoclast was used for stone disintegration and a Nitinol tipless dormia was used for stone extraction. A stent with string was placed.

RESULTS: The mean operative time was 26 minutes (range, 21-69 minutes). There was no difficulty in passing the proximal ureter, even in late pregnancy. Fluoroscopy was not required. Ureteral stones ranging from 6-9 mm in size were detected in 18 (69%) of the patients. Eleven patients had distal stones; 7 had proximal stones. Lithotripsy was performed for 16 patients; stones were directly extracted from 2 patients. There were no complications related to the procedures. Stents were left in place 5-7 days for patients with stones. For the 8 patients without stones, the surgeons left a silicone long-term double pigtail stent until after the delivery. Postoperative complications were mainly related to the stents and included dysuria or urgency (n = 2), hematuria related to movement (n = 2), and urinary tract infection (n = 1). All patients completed full-term pregnancies.

CONCLUSION: Ureteral obstruction during pregnancy can be safely managed by using the follow-the-wire ureteroscopy technique. It obviates need for ionizing radiation. In experienced hands, the technique is safe and reproducible.

KEYWORDS: Ureteroscopy; Pregnancy; Stones

CORRESPONDENCE: Ehab Rifat Tawfiek MD, Department of Urology, El Minia University Hospital, Elminia 16666, Egypt ().

CITATION: UroToday Int J. 2009 Dec;2(6). doi:10.3834/uij.1944-5784.2009.12.17



A Rare and Serious Complication of Elective Suprapubic Catheter Change


Suprapubic catheter (SPC) insertion is a commonly performed elective or emergency procedure in urology. SPC change is a simple process that is typically completed in the primary care office in the United Kingdom. Urinary tract infection, hemorrhage, and injury to adjacent intraabdominal organs are potential complications. The authors present a case of inadvertent bowel injury following elective SPC change. They recommend techniques to prevent this complication.

KEYWORDS: Suprapubic catheter; Delayed bowel injury

CORRESPONDENCE: Nikhil Vasdev, Specialist Registrar, Department of Urology, Freeman Hospital, Newcastle upon Tyne, UK ().

CITATION: Urotoday Int J. 2009 Dec;2(6). doi:10.3834/uij.1944-5784.2009.12.06



Efficacy and Safety of an Alpha-Blocker With and Without Anticholinergic Agent in the Management of Lower Urinary Tract Symptoms With Detrusor Overactivity


INTRODUCTION: The purpose of the present investigation was to compare the efficacy and safety of a fixed dose of uroselective alpha blocker (tamsulosin) taken alone or in combination with a pure anticholinergic agent (tolterodine) in a group of patients with urodynamically and clinically proven lower urinary tract symptoms (LUTS) and detrusor overactivity (DO).

METHODS: The participants were 75 men with LUTS and DO, randomly assigned to 2 groups. Group 1 (n = 37) received tamsulosin (0.4 mg) orally; group 2 (n = 38) received tamsulosin (0.4 mg) and tolterodine (4 mg) orally. All patients took the medications daily for 3 consecutive months. Patients were evaluated before and after treatment by the International Prostate Symptoms Score (IPSS), ultrasound of the kidney and urinary bladder (KUB), prostate specific antigen (PSA), and urodynamic pressure flow study. Patients were also questioned about their perception of treatment benefits and quality of life (QoL). Group comparisons in response to treatment were analyzed statistically.

RESULTS: Patients in group 2 had significantly better response to treatment than patients in group 1 for 5 of the 8 main urodynamic variables studied: (1) mean reduction in maximum detrusor pressure during micturition (P = .01), (2) mean reduction in maximum unstable detrusor contraction pressure/end filling pressure (P < .001), (3) mean increase in maximum cystometric bladder capacity (P = .007), (4) mean increase in volume at first unstable bladder contraction (P = .02), (5) mean increase in bladder compliance (P < .001). The groups were similar in their response to therapy for maximum flow rate, postvoid residual volume, and total IPSS. No acute urine retention (AUR) was reported in either group. Positive response to treatment was reported by 51.4% of patients in group 1 and 85.7% of patients in group 2. Group 2 also had significantly higher mean QoL scores (P = .02). Group 2 had a significantly greater reduction in the DO symptoms of frequency in 24 hours, urgency in 24 hours, and nocturia when compared with patients in group 1 (P = .02, P = .01, and P = .01, respectively). Patients taking tamsulosin and tolterodine had significantly more side effects of constipation, dry mouth, and dry eyes.

CONCLUSION: Results of the study confirm the safety and efficacy of combination therapy for patients with LUTS and DO.

KEYWORDS: Detrusor overactivity; Medical treatment

CORRESPONDENCE: Professor N.K. Mohanty, C – II /124, Motibagh, New Delhi, 110021 ().

CITATION: Urotoday Int J. 2009 Dec;2(6). doi:10.3834/uij.1944-5784.2009.12.02



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