Issue 6: December 2009

UIJ Volume 2 Issue 6 December 2009

Mucinous Adenocarcinoma of the Ileal Neobladder 20 Years After Cystectomy: The First Reported Case

ABSTRACT

The authors present the case of a 68-year-old male with mucinous adenocarcinoma of the ileal neobladder. The adenocarcinoma occurred 20 years after radical cystoprostatectomy for Stage pT2 transitional bladder cell cancer. An international literature search revealed 10 cases with a neoplasm in an ileocystoplasty, but this type of adenocarcinoma has not been reported previously. The present case supports the hypothesis that morphologic and molecular changes in an ileal neobladder may increase the risk of local malignancies. Patients with an ileal neobladder may develop glandular malignancy and should be closely followed.

KEYWORDS: Neoplasm; Bladder; Enterocystoplasty; Urinary diversion

CORRESPONDENCE: Dr. Satâa Sallami, Department of Urology, La Rabta Hospital-University, Tunis 1007, Tunisia ().

CITATION: Urotoday Int J. 2009 Dec;2(6). doi:10.3834/uij.1944-5784.2009.12.16

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Minimally Invasive Therapy for Neurogenic Detrusor Overactivity: A Review

ABSTRACT

Urinary incontinence secondary to neurogenic detrusor overactivity (NDO) is a common problem in patients with neurologic pathology. Patients with NDO are at increased risk for recurrent urinary tract infection and renal damage, especially due to high intravesical pressures. They may also experience urinary urgency, frequency, and incontinence, which are all factors that negatively affect quality of life. Oral antimuscarinic agents are considered first-line pharmacologic therapy, but their use may be limited by adverse effects and result in poor compliance and adherence. Surgical augmentation of the bladder is a rare final alternative when other attempts to restore continence have failed. However, there are other less invasive treatment options that are currently available or undergoing research. These options include transdermal or intravesical administration of antimuscarinics, intravesical administration of other agents (including vanilloids and botulinum toxins A and B), and electrical stimulation. The available alternatives have demonstrated varying degrees of efficacy and are all minimally invasive, allowing surgery to be avoided where possible. However, neither vanilloid nor botulinum toxin therapy is approved by the United States Food and Drug Administration for treatment of detrusor overactivity. Treatment should always begin with the most reversible forms of therapy and progress to more complex options.

KEYWORDS: Antimuscarinics; Botulinum toxin; Neurogenic detrusor overactivity; Neuromodulation

CORRESPONDENCE: Karl-Erik Andersson, MD, PhD, Wake Forest Institute for Regenerative Medicine, Wake Forest University School of Medicine, Medical Center Boulevard, Winston-Salem, NC 27157 ()

CITATION: UroToday Int J. 2009 Dec;2(6). doi:10.3834/uij.1944-5784.2009.12.10

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Transrectal Ultrasound-Guided Needle Aspiration of a Prostatic Abscess

ABSTRACT

Occurrence of prostatic abscess has become very rare since the advent of modern antibiotics. The authors report a case of a 51-year-old man with insulin-dependent diabetes mellitus and recurrent urinary tract infections who was diagnosed with prostatic abscess. He was treated successfully with transrectal ultrasound (TRUS) guided needle aspiration under local anesthetic. TRUS-guided drainage is a safe and effective therapeutic approach for the treatment of this disorder.

KEYWORDS: Prostatic abscess; Ultrasound guided needle aspiration

CORRESPONDENCE: Michael Nomikos MD, Consultant Urologist, Knossou Street 275, Heraklion, Crete, 71409, Greece ()

CITATION: UroToday Int J. 2009 Dec;2(6). doi:10.3834/uij.1944-5784.2009.12.11

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Successfully Performed Reanastomosis of a Completely Amputated Penis: Surgical Technique

ABSTRACT

Complete penile amputation is a rare condition that requires immediate and complex surgical treatment. There are few descriptions of successful operative techniques using microsurgical methods in the literature.

The authors present the rare case of 30-year-old man who amputated his penis at its base using an ax. Nine hours after the injury, the patient underwent microsurgical anastomosis of the arteries, veins, corpora cavernosa, and urethra. The authors describe the steps in their surgical procedure and provide illustrative figures. They also explain their perioperative and postoperative support therapy.

Approximately 20% of the distal spongy body and skin of the penis became necrotic beginning on the 6th postoperative day. On the 18th day, necrectomy of the penile skin flap was performed and the phallus was buried in the scrotum. Exteriorization of the penis that was partially covered by scrotal skin was completed 2 months after reanastomosis. The distal necrotic part of the urethra was reconstructed using buccal mucosa graft transplantation. A split-thickness skin graft from a lower limb was used to cover the rest of the phallus. The patient achieved return of physiologic micturition with no urethral structures. He also experienced incomplete erectile function.

KEYWORDS: Penile amputation; Penile replantation; Surgical techniques

CORRESPONDENCE: Marek Wyczółkowski MD, PhD, Department of Urology, Rydygier Memorial Hospital, Złotej Jesieni 1 Str., 31-826 Cracow, Poland ().

CITATION: Urotoday Int J. 2009 Dec;2(6). doi:10.3834/uij.1944-5784.2009.12.08

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Transurethral Electrovaporization of the Prostate as an Alternative to Transurethral Resection: A Five-Year Follow-up

ABSTRACT

INTRODUCTION: The aim of the present study was to compare the safety and efficacy of transurethral electrovaporization of the prostate (TUVP) with conventional transurethral resection of the prostate (TURP) in the treatment of patients with moderate to severe bladder outlet obstruction due to benign prostatic hyperplasia (BPH).

 

METHODS: Between December 2001 and November 2003, 131 patients presented to the author's institution with moderate to severe bladder outflow symptoms due to BPH. The patients were randomly assigned to undergo TURP (n = 67) or TUVP (n = 64). Patients receiving TURP had a significantly larger mean prostate size (P = .01) but were similar in all other evaluated characteristics. Using the hospital database, the author reports the available follow-up results after 1, 2, 3, and 5 years. The International Prostate Symptom Score (IPSS), uroflowmetry (Q-max), and postvoid residual volume (PVR) were used for evaluation. Operative time, catheterization time, hospital stay, and blood tests were also compared.

RESULTS: Of the 131 total patients, 51 patients receiving TURP and 50 patients receiving TUVP completed 5 years of follow-up; 21 patients died and the remaining 9 could not be contacted. No deaths were associated with either resection or vaporization of the prostate. Patients receiving TURP had a significantly longer mean postoperative catheterization time (P < .001) and mean hospitalization time (P < .001). Patients had significantly lower mean serum hemoglobin and hematocrit 1 hour following TURP (P < .001). There were no significant group differences for any other measures.

CONCLUSIONS: To the author's knowledge, the present study is the largest reported comparison of TURP and TUVP over a 5-year follow-up period. The low intraoperative and perioperative morbidity, rapid convalescence time, short hospital stay, and simplicity of the procedure make TUVP a potentially suitable, safe alternative to TURP in the therapeutic armamentarium for BPH. Because of its unique electrosurgical properties, higher risk patients can be treated successfully with this technique. The main disadvantage of TUVP appears to be the unavailability of prostate tissue needed for pathologic examination. Additionally, although TURP and TUVP were found to be comparable for prostate sizes < 60 g for patients in the present study, TURP may be advantageous for patients with larger prostates.

KEYWORDS: Transurethral electrovaporization of the prostate (TUVP); Transurethral resection of the prostate (TURP).

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.1944-5784.2009.12.12

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Direct Trocar Insertion Compared With Open Laparoscopy (Hasson Technique) in Patients Undergoing Urolaparoscopic Surgery

ABSTRACT

INTRODUCTION: The purpose of the study was to compare the ease of use, safety, and efficacy of direct trocar insertion (DTI) and open access (Hasson technique) in laparoscopic surgery. This is the first known report of DTI used in urolaparoscopy.

METHODS: The study was a retrospective evaluation of patients referred for laparoscopic procedures between December, 2005 and June, 2008. A total of 148 patients were studied; 62 patients (41.9%) received DTI and 86 patients (58.1%) received open laparoscopy. Patients were not randomly assigned to treatment groups. For the DTI, the abdominal wall was lifted and the trocar was pushed through the fascia and muscle layer. The surgeon felt when the trocar had pierced the peritoneum and entered the abdominal cavity. For the open technique, the peritoneal cavity was opened under direct vision and the trocar was inserted. The variables measured were access time, minor and major complications, visceral and vascular injury and bleeding, conversion to open surgery, length of hospitalization, failed entry, and abdominal pressure for creation of the pneumoperitoneum. Chi-square and t tests were used to compare categorical and continuous variables, respectively.

RESULTS: The mean length of hospitalization was 26.95 hours (SD = 7.78) for patients receiving DTI and 30.44 hours (SD = 13.98) for patients receiving open laparoscopy, but the difference was not statistically significant (P > .05). The mean access time for DTI was 91.75 seconds (SD = 79.77), which was significantly shorter than the mean access time of 263.97 seconds (SD = 119.28) for patients receiving open laparoscopy (P < .0001). The mean abdominal pressure for creation of the pneumoperitoneum with DTI was 16.17 mmHg (SD = 1.46), which was significantly higher than the mean abdominal pressure of 15 mmHg (SD = 0) with open laparoscopy (P < .0001). There were very few complications in either study group. Although 11 patients (17.74%) in the DTI group and 7 patients (8.14%) in the open laparoscopy group had previous open abdominal or groin surgery, the previous surgeries did not negatively impact the laparoscopic procedures (P = .01). There were no entry failures in either group.

CONCLUSION: DTI is faster and appears to be more efficacious for some aspects of surgery than the open laparoscopy technique, although the safety of the two techniques is equivalent. The authors suggest that direct trocar insertion can be used in urolaparoscopic surgeries. Future prospective studies with larger numbers of patients randomly assigned to treatment groups are needed to confirm the results.

KEYWORDS: Laparoscopic surgery; Direct trocar insertion; DTI; Laparoscopic access; Pneumoperitoneum; Emphysema; Urolaparoscopy; Endopth Xcel trocar

CORRESPONDENCE: Siavash Falahatkar M.D., Guilan University of Medical Sciences, Urology Research Center, Razi Hospital, Sardare Jangal Street, Rasht, Guilan 41448, Iran ( 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.1944-5784.2009.12.03.

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Spontaneous Rupture of the Upper Urinary Tract Caused by Ureteral Calculi: Effectiveness of Primary Ureteroscopic Treatment

ABSTRACT

INTRODUCTION: Spontaneous rupture (SR) of the urinary collecting system with perirenal and retroperitoneal extravasation of the urine is an unusual condition that is typically caused by ureteral-obstructing calculi. The authors present a retrospective study of 10 cases. They report evaluation, endoscopic management, and follow-up assessments.

METHODS: Between 1998 and 2008, 10 patients were admitted for SR of the urinary collecting system proximal to a lithiasic obstruction. There were 6 males and 4 females. The mean patient age was 51.5 years. At presentation, all patients had sudden severe flank pain. There were no other urinary symptoms. All patients had a physical examination, laboratory blood and urine analyses, and radiography, ultrasonography, intravenous urography (IVU), and/or computed tomography (CT). Ureteroscopy was performed. Ureteral stones were fragmented with a pneumatic lithotripter.

RESULTS: Ultrasonography and IVU or CT showed a perinephric collection due to urine extravasation that was compatible with rupture of the renal collecting system. SR was secondary to an obstructing calculus in all cases. Patients were managed successfully by primary endoscopic treatment of ureteroscopic lithotripsy and stenting. Follow-up was unremarkable.

CONCLUSION: SR of the urinary collecting system is a very rare pathological condition. It should be considered in cases of unusual renal colics. Ureteroscopic lithotripsy followed by double-J stenting of the ureter appears to be a quick, safe, and effective management approach.

KEYWORDS: Pelvis rupture; Ureteral rupture; Ureteral calculus; Computed tomography; Ureterel stent; Endoscopic lithotripsy

CORRESPONDENCE: Dr. Sallami Satâa, Department of Urology, La Rabta Hospital-University, Tunis 1007, Tunisia ().

CITATION: UroToday Int J. 2009 Dec;2(6). doi:10.3834/uij.1944-5784.2009.12.07

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Solitary Metastasis of Cervical Carcinoma to the Kidney: A Case Report and Review of the Literature

ABSTRACT

A 47-year-old female presented with a history of hematuria and right loin pain 18 months after receiving chemoradiotherapy for advanced cervical carcinoma. A CT scan demonstrated a grossly abnormal right kidney suggestive of either inflammatory or malignant change. A percutaneous biopsy under CT guidance demonstrated squamous cell carcinoma in keeping with metastatic cervical carcinoma. Metastasis of cervical carcinoma to the kidney is extremely rare, with only 8 previous cases reported in the literature.

KEYWORDS: Cervical carcinoma; Renal metastasis; Biopsy; Caval thombus

CORRESPONDENCE: Dr. David C. Hutchings, Department of Urology, Churchill Hospital, Oxford, OX3 7LJ, UK ().

CITATION: Urotoday Int J. 2009 Dec;2(6). doi:10.3834/uij.1944-5784.2009.12.05

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Outcome of Patients with Abnormal Upper Tract Cytology and Negative Initial Workup

ABSTRACT

INTRODUCTION: Patients with pathologically confirmed upper tract transitional cell carcinoma (TCC) currently undergo surveillance according to well described protocols. The literature offers little guidance for monitoring patients with abnormal upper tract cytology without prior upper tract TCC. The purpose of the present study was to assess the risk of upper tract TCC based on cytology and determine a reasonable observation strategy for this abnormal finding.

METHODS: The authors performed a 10-year retrospective cohort study of 204 patients (366 renal units) within the New England Veterans Administration Healthcare System. Upper tract cytology was collected: (1) as a consequence of lateralizing hematuria during cystoscopy in 2 patients; (2) following abnormal upper tract imaging in 27 patients; (3) from the bladder in the presence of a suspected bladder tumor and/or carcinoma in-situ (CIS) in 16 patients; (4) from the bladder despite a negative workup for lower tract tumor in 159 patients. Cytology results reported as negative or atypical were categorized as normal; suspicious or positive results were categorized as abnormal. Odds ratios (OR) were calculated and hazard curves plotted to determine risk and time span of tumor development among the cohorts.

RESULTS: Twenty-six renal units had upper tract TCC over a median follow up of 38 months. The OR for development of upper tract TCC with abnormal upper tract cytology was 3.27 and did not change with a previous history of lower tract disease. The accumulation rate differed with normal and abnormal upper tract cytology among those who developed upper tract TCC.

CONCLUSION: Upper tract cytology has a poor sensitivity for tumors of the upper urinary tract. Patients with abnormal upper tract cytology are 3 times more likely to develop TCC than patients with normal upper tract cytology and should be carefully monitored for at least 6 years. However, the exact method and frequency of monitoring remains undetermined.

KEYWORDS: Transitional cell carcinoma; Urothelial carcinoma; Cytology; Upper tract; Renal pelvis; Ureter

CORRESPONDENCE: Rian Dickstein, MD, Department of Urology, 720 Harrison Avenue, Suite 606, Boston, MA 02118 ()

CITATION: UroToday Int J. 2009 Dec;2(6). doi:10.3834/uij.1944-5784.2009.12.01

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Squamous Cell Carcinoma in the Meatus of a Distal Hypospadia

ABSTRACT

A 39-year-old male presented with a tumor in the urethral orifice. A papillary tumor (1 cm × 1 cm) was found at the meatus of a distal hypospadia. The patient underwent tumor resection without urethroplasty. The pathological diagnosis was squamous cell carcinoma. No recurrence or metastasis was found during 2 years of follow-up. Squamous cell carcinoma in the urethral orifice of hypospadias is extremely rare. To the authors’ knowledge, this is only the second case reported in the literature.

KEYWORDS: Urethral cancer; Squamous cell carcinoma; Meatus; Hypospadia

CORRESPONDENCE: Yoshiyuki Kojima MD, Department of Nephro-urology, Nagoya City University Graduate School of Medical Sciences, 1 Kawasumi, Mizuho-cho, Mizuho-ku, Nagoya 467-8601, Japan ().

CITATION: Urotoday Int J. 2009 Dec;2(6). doi:10.3834/uij.1944-5784.2009.12.13

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A Case of Textiloma Mimicking a Retroperitoneal Tumor

ABSTRACT

Foreign bodies left inside the patient following surgical procedures are infrequently reported in the literature. Incidence figures might be underestimated because of medico-legal implications. A 56-year-old male had a right ureterolithotomy for a lumbar ureteral stone. He was asymtomatic for 3 years before presenting with intermittent right flank pain. Imaging showed a tumor-like mass in the right lumbar region. Surgical exploration revealed a textiloma.

KEYWORDS: Urinary surgery; Retroperitoneal space; Postoperative complication; Foreign body; Textiloma.

CORRESPONDENCE: Dr. Sallami Satâa, Department of Urology, La Rabta Hospital-University, Tunis 1007, Tunisia ().

CITATION: UroToday Int J. 2009 Dec;2(6). doi:10.3834/uij.1944-5784.2009.12.09

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