Volume 3

UIJ Volume 3 2010

Malakoplakia of the Genitourinary Tract: A Report of 3 Cases


Malakoplakia is a rare chronic inflammatory disease, most commonly found in the urinary tract. It has been associated with chronic infections, malignancies, and immunocompromised states. The authors present 3 cases of malakoplakia of the genitourinary tract, seen in 3 female patients who sought medical attention due to pain or bleeding. The histopathological examination in all cases was compatible with malakoplakia and characterized by the presence of Michaelis-Gutmann bodies. All patients were effectively treated with surgical excision in combination with antibiotic therapy.

KEYWORDS: Malakoplakia; Michaelis-Gutmann bodies; Urethral tumor; Urethral diverticulum.

CORRESPONDENCE: Dr. Stavros Charalambous, Urological Department, Ippokratio General Hospital, 49 Konstantinoupoleos Street, Thessaloniki, 54642, Greece ().

CITATION: Urotoday Int J. 2010 Aug;3(4). doi:10.3834/uij.1944-5784.2010.08.12

ABBREVIATIONS AND ACRONYMS: E. coli, Escherichia coli; PAS, periodic acid-Schiff.



Efficacy and Safety of Tamsulosin With and Without Flavoxate in the Treatment of Symptomatic Benign Prostastic Hyperplasia: A Randomized, Single-Blind Study


INTRODUCTION: The purpose of the study was to evaluate the efficacy and safety of tamsulosin plus flavoxate with tamsulosin plus a placebo for the treatment of clinically proven lower urinary tract symptoms (LUTS) in patients with benign prostatic hyperplasia (BPH).

METHODS: The participants were 120 patients with BPH and LUTS who were randomized into 2 equal groups. Group 1 received tamsulosin modified release (0.4 mg) once daily and flavoxate (200 mg) 3 times daily; group 2 received tamsulosin modified release (0.4 mg) once daily and a placebo 3 times daily. All patients took the medications orally for 12 weeks. Patients were evaluated before and after treatment by the total International Prostate Symptoms Score (IPSS), the irritative symptoms, voiding symptoms, and quality of life (QoL) IPSS subscores, maximum urinary flow rate (Qmax), and postvoid residual (PVR) urine volume. Adverse events were also summarized. The t test was used for group comparisons in response to treatment.

RESULTS: All patients responded positively to treatment. The group taking tamsulosin plus flavoxate had significant improvement in the mean total IPSS (P < .001), irritative symptom subscore (P < .002), and QoL score (P < .002) when compared with the group taking tamsulosin plus placebo. There was no significant group difference in the mean voiding symptom subscore, Qmax, or PVR volume. Group differences in mean frequency and nocturia at the end of 12 weeks approached statistical significance (P = .05); patients taking tamsulosin plus flavoxate had fewer episodes. There was no significant group difference in urgency. One patient withdrew from each group due to complaints of impotence and ejaculatory dysfunction; all other adverse events were mild and transient.

CONCLUSION: Taking a combination of tamsulosin with flavoxate improved IPSS, irritating symptoms, and QoL significantly more than taking the alpha blocker alone. The combined drugs had good safety and can be considered as a therapeutic option for treatment of LUTS associated with BPH.

KEYWORDS: Tamsulosin; Flavoxate; Irritative symptoms; IPSS; LUTS

CORRESPONDENCE: Dr. Amitabh Dash, A-3, MIG Flats, Ground Floor, Prasad Nagar, New Delhi-110005, India ().

CITATION: UroToday Int J. 2010 Aug;3(4). doi:10.3834/uij.1944-5784.2010.08.09

ABBREVIATIONS AND ACRONYMS: BPH, benign prostatic hyperplasia; IPSS, International Prostate Symptom Score; LUTS, lower urinary tract symptoms; OAB, overactive bladder; PSA, prostate-specific antigen; PVR, postvoid residual; QoL, quality of life; Qmax, maximum urinary flow rate.



A Huge Renal Mass With Uncommon Pathology of Leiomyoma


Leiomyomas are benign mesenchymal tumors that arise from smooth muscle cells anywhere in the body. Renal leiomyoma is a rare condition. The authors report the case of a woman with a huge right-sided renal mass that was incidentally found.

KEYWORDS: Leiomyoma; Kidney; Benign tumor.

CORRESPONDENCE: Esat Korgali, MD, Cumhuriyet University Medical Faculty, Department of Urology, Kampus, Sivas, 58100, Turkey ().

CITATION: UroToday Int J. 2010 Aug;3(4). doi:10.3834/uij.1944-5784.2010.08.01

ABBREVIATIONS AND ACRONYMS: CT, computed tomography; USG, urine-specific gravity.



Condylomata Acuminata With Concomitant Squamous Cell Carcinoma of the Penis: A Rare Clinical Presentation


Condyloma acuminatum generally has been considered a benign growth with no malignant potential. The present patient presented with condylomata acuminate of the penis and concomitant invasive squamous cell carcinoma. Partial amputation of the penis along with cauterization of the warts was successfully undertaken.

KEYWORDS: Condylomata acuminata; Concomitant; Squamous cell carcinoma; Penis.

CORRESPONDENCE: Dr. Sachit Sharma, MD, MCh. Department of Urology, PGIMS, Rohtak (Haryana), 124001 India ().

CITATION: UroToday Int J. 2010 Aug;3(4). doi:10.3834/uij.1944-5784.2010.08.02

ABBREVIATIONS AND ACRONYMS: HPV, human papilloma virus.



Management of Kidney Stones After Failure of Extracorporeal Shock Wave Lithotripsy


INTRODUCTION: The purpose of the study was to compare the outcome of flexible ureteroscopy (URS) and percutaneous nephrolitripsy (PCNL) following failure of extracorporeal shock wave lithotripsy (ESWL) for patients with renal stones.

METHODS: Participants were 66 adult patients with renal stones 8-20 mm in diameter. All patients had failed ESWL after a maximum of 2 sessions. Patients were assigned to treatment groups according to their choice. A total of 39 patients chose URS and 27 patients chose PCNL. Group differences in outcome measures were determined using Mann-Whitney and chi-square tests.

RESULTS: URS was technically successful in 31 cases; conversion to PCNL was done for the remaining 8 cases. The mean (standard deviation) operative time of 65 (15) minutes for the PCNL procedure was significantly shorter than the operative time of 115 (16) minutes for URS (P < .001). Conversely, the mean hospital stay of 1.19 (0.4) days and 1.09 (0.3) postoperative analgesic injections for the patients receiving URS were significantly shorter than the hospital stay of 5.28 (1.1) days and 3.2 (0.6) injections for the patients receiving PCNL (both P < .001). Revision of URS was needed in 4 cases; 2 of these patients became stone-free. One month postoperatively, the stone-free rate was 61% and 77% after URS and PCNL, respectively (P = .162). No patient in either group had significant complications.

CONCLUSIONS: Although the operative time was shorter for PCNL, URS is superior in terms of hospital stay and postoperative pain. Stone-free rates were not significantly different. These results help justify the preference of URS for treatment of kidney stones after failure of ESWL.

KEYWORDS: Kidney stones; Flexible URS; PCNL.

CORRESPONDENCE: Yehya Hassan ElShebiny MD, Division of Urology, Department of Surgery, Adan Hospital, Fahaheel, PO Box 46496, Kuwait City, 64015, Kuwait ().

CITATION: Urotoday Int J. 2010 Aug;3(4). doi:10.3834/uij.1944-5784.2010.08.13

ABBREVIATIONS AND ACRONYMS: ESWL, extracorporeal shock wave lithotripsy; PCNL, percutaneous nephrolithotomy; URS, ureteroscopy.



A Method for Teaching Junior Urologists How to Gain Access to the Pelvicalyceal System Under Fluoroscopy


INTRODUCTION: The purpose of the study was to determine the success of a teaching method for junior urologists who were learning to puncture a calyx for percutaneous nephrolithotripsy (PCNL) under fluoroscopic guidance.

METHODS: The participants were 4 junior urologists who had never performed a complete PCNL puncture on their own. There were 22 patients with kidney stones, ranging in age from 28-52 years. The procedure was conducted by 1 junior urologist while being guided verbally by the senior physician. A needle was placed on the skin where its trajectory hit the desired calyx in the 0o and 30o planes under fluoroscopy. The needle was advanced in successive 1 cm increments. Its position was checked after each step. Any deviation from the correct path in either plane was detected early and corrected, until the desired calyx was reached in both planes simultaneously. Success of the teaching technique was determined by how often the senior physician needed to intervene. Success of the surgery was determined by its outcome, including the need for needle reinsertion and presence of complications.

RESULTS: Each surgery was performed independently by the junior urologist, with no senior physician intervention aside from verbal guidance. Successful puncture of the desired calyx was achieved during the first trial in 17 patients (77%); the needle had to be reinserted 1 or more times to attain proper direction in 5 patients (23%). Complications were blood transfusion (n = 1) and prolonged urine leakage after postoperative removal of the nephrostomy tube (n = 2).

CONCLUSION: Step-by-step advancement of the needle is a simple, accurate way to gain access to pelvicalyceal system. Junior urologists are spared the frustration that they might have after repeated failure to gain access to the kidney with other techniques.

KEYWORDS: Step-by-step instruction; Pelvicalyceal system puncture; Fluoroscopy.

CORRESPONDENCE: Yehya Hassan Elshebiny MD, Division of Urology, Department of Surgery, Adan Hospital, Fahaheel, PO Box 46496, Kuwait, 64015, Kuwait ().

CITATION: UroToday Int J. 2010 Aug;3(4). doi:10.3834/uij.1944-5784.2010.08.04

ABBREVIATIONS AND ACRONYMS: PCNL, percutaneous nephrolithotripsy.



Prognostic Factors in Renal Cell Carcinoma With Vena Cava Extension


INTRODUCTION: The objectives were to: (1) analyze clinical and pathological features of renal cell carcinoma (RCC) with caval thrombosis in order to indentify independent prognostic factors, and (2) analyze perioperative morbidity and mortality.

METHODS: The authors retrospectively analyzed clinical and pathological data of 56 patients treated for RCC with caval thrombosis during a 20-year period. The surgical procedure was essentially unchanged. Independent variables were: TNM, creatinine value, age, histological extent, histological type, adjuvant treatment, and surgical technique; the dependent variable was overall survival. Contingency and logistic regression tables were used. Kaplan-Meier method, log-rank, and Cox models were used to analyze survival rates.

RESULTS: There were complications in 15 patients and 2 perioperative deaths. Overall mean (SD) survival rates were 32% (7%) and 24% (6%) at 3 and 5 years, respectively. Multivariate results showed that the significant prognostic indicators of survival were: the size of the tumor > 8 cm (P < .01), the presence of metastasis (P < .04), and lymph node invasion (P < .009). These were also regarded as the relevant variables, independent of patient survival.

CONCLUSION: The surgical approach for this disorder is challenging and not exempt of complications. Nodal involvement, tumor size, and distant metastases are the most important prognostic factors; thrombus extension has a clear impact on surgical planning and performance.

Jorge Rioja,1 Anibal Rincón Mayans,2 Juan Javier Zudaire Bergera,2 David Rosell Costa,2 Jose Enrique Robles García,2 Gregorio Rabago,3 Jose Maria Berian Polo2

1 Dept of Urology, AMC University Hospital, Amsterdam, The Netherlands

2 Department of Urology, Clínica Universitaria, University of Navarra, Pamplona, Spain

3 Department of Cardiovascular Surgery, Clínica Universitaria, University of Navarra, Pamplona, Spain

Submitted April 2, 2010 - Accepted for Publication July 13, 2010

KEYWORDS: Kidney cancer; Vena cava thrombus; Extracorporeal circulation, Prognostic factors; Multivariate analysis.

CORRESPONDENCE: Dr. Jorge Rioja, AMC University Hospital, Meibergdreef 9. 1105 AZ Amsterdam, The Netherlands ().

CITATION: UroToday Int J. 2010 Aug;3(4). doi:10.3834/uij.1944-5784.2010.08.18

ABBREVIATIONS AND ACRONYMS: ECC, extracorporeal circulation; IVC, inferior vena cava; RCC, renal cell carcinoma.



Isolated Renal Zygomycosis Caused by Syncephalastrum Species in an Immunocompetent Host: A Case Report


A 39-year-old male presented with left flank pain, intermittent high-grade fever, and passage of whitish flakes in the urine for the last 6 months. Urine culture was sterile. Fluffy whitish material, suggestive of fungal elements, was discovered during cystoscopy and ureteroscopy. On direct microscopy, this material showed fungal hyphae that were suggestive of Zygomycosis. The material was identified as Syncephalastrum species on Sabouraud dextrose agar (SDA) culture media. The patient was managed by endoscopic removal of the fungus and antifungal medication. He was doing well at the 1, 3, and 6-month follow-up evaluations. Renal Zygomycosis caused by Syncephalastrum species in an immunocompetent host is extremely rare and can be managed successfully by endoscopic removal and antifungal medication.

KEYWORDS: Renal Zygomycosis; Syncephalastrum species; Immunocompetent host.

CORRESPONDENCE: Suresh Kumar, MS, MCh, Resident, IPGMER & SSKM Hospital, 601, Doctor PG Hostel, 242, AJC Bose Road, Kolkata, West Bengal, 700020 India ().

CITATION:UroToday Int J. 2010 Aug;3(4). doi:10.3834/uij.1944-5784.2010.08.03

ABBREVIATIONS AND ACRONYMS: DTPA, diethylene-triamine-pentaacetic acid; RGP, retrograde pyelography.



Cystic Renal Leiomyosarcoma Treated With Partial Nephrectomy


Renal sarcoma is rare among all renal malignancies. The present report is a case of renal leiomyosarcoma in a 59-year-old woman. She had an asymptomatic cystic renal tumor that was incidentally found by abdominal computed tomography. The characteristics of the tumor mimicked cystic renal cell carcinoma. Partial nephrectomy was completed. The pathological diagnosis was low-grade leiomyosarcoma. The patient has remained well without recurrence for 44 months following the surgery.

KEYWORDS: Renal tumor; Sarcoma; Leiomyosarcoma; Cystic mass; Partial nephrectomy.

CORRESPONDENCE: Yuji Satoh, 5-1-1 Nabeshima, Saga 849-8501, Japan ().

CITATION: UroToday Int J. 2010 Aug;3(4). doi:10.3834/uij.1944-5784.2010.08.17

ABBREVIATIONS AND ACRONYMS: CT, computed tomography; NSS, nephron-sparing surgery.



Internal Spermatic and Peripheral Vein Plasma 5-Hydroxytryptamine Concentration Levels in Patients With Varicocele


INTRODUCTION: The purpose of the study was to compare the 5-hydroxytryptamine (5-HT) plasma levels of the internal spermatic vein and peripheral vein for patients with varicocele and infertility with a comparison group of fertile patients needing scrotal surgery for other reasons, and to examine the correlation between the 5-HT levels and semen parameters.

METHODS: Participants were 30 patients with varicocele and infertility and a comparison group of 30 fertile patients with inguinal hernia, hydrocele, or epididymal cyst. Their ages ranged from 24-35 years. Patients with varicocele received at least 2 semen analyses before surgery. Spermatic vein blood samples were taken intraoperatively and peripheral vein blood samples were taken preoperatively from all patients. Computer-assisted sperm analysis (CASA) was used for semen analysis; the enzyme linked immunosorbent assay (ELISA) method was used to measure blood plasma 5-HT levels. Analysis of variance and Spearman's rank correlation tests were used to analyze the data.

RESULTS: The plasma free serotonin concentration of the internal spermatic vein was significantly higher than the concentration in the peripheral vein for patients with varicocele (P < .01), and significantly higher than the spermatic vein concentration of the comparison group (P < .01). In the comparison group, no statistically significant difference was found between the plasma free serotonin concentration of the spermatic and peripheral veins (P > .05). There were significant negative correlations between the plasma 5-HT levels of the internal spermatic vein and sperm density (Spearman r = -0.465, P = .0097) and sperm motility (Spearman r = -0.539, P = .0024) in the patients with varicocele.

CONCLUSIONS: Patients with varicocele have elevated free 5-HT plasma concentrations in the spermatic vein that may be a cause of fertility decline.

KEYWORDS: Varicocele; 5-hydroxytryptamine; Internal spermatic vein; Peripheral vein; Semen parameters .

CORRESPONDENCE: Salifou Issiaka TRAORE, MD, PhD. Wuhan University Zhongnan Hospital, Department of Urology, Wuchang East Lake Road No. 169, Wuhan City, P.O. Box 430071, China () or Professor Zheng Xin-min ().

CITATION: Urotoday Int J. 2010 Aug;3(4). doi:10.3834/uij.1944-5784.2010.08.11

ABBREVIATIONS AND ACRONYMS: 5-HT, 5-hydroxytryptamine; 5-HT2R, 5-hydroxytryptamine receptor type 2; CRF, corticotropin releasing factor; ISVD, internal spermatic vein diameter; OD, optical density; WHO, World Health Organization.



Can Modeled Analysis of Urodynamic Recordings Help to Demonstrate the Nervous Control of the Bladder and Urethra During Micturition?


INTRODUCTION: The purpose of the study was to build and test a mathematical model that allows new information about efferent neural activity for the bladder and sphincter to be extracted from urodynamic recordings during the micturition cycle.

METHODS: The main features of the VBN micturition model were reviewed. An extended VBN model that includes a more detailed model of nervous control was then described. The mean firing rate F(t) of efferent neurons was linked first to an effective calcium excitation E(t) in the muscle cells and then to the detrusor and urethral pressures. Finally, this model was used to retrospectively analyze urodynamic recordings of 166 male and female patients with various voiding characteristics.

RESULTS: The main result was the striking simplicity of the computed F(t) curves for both the detrusor and sphincter during the 3 phases of the micturition cycle (storage-continence, micturition, and return to continence). This result occurred in most of the micturitions: (1) normal with or without break of detrusor excitation, (2) abnormal with large residual volume, (3) abnormal with effect of a urethral catheter in situ. These curves F(t) were found as a sequence of constant values during the onset of flow and during the plateau phase, and then as a decreasing exponential during the return to continence phase. The transition between the 2 phases was always brisk, suggesting ON/OFF switching of reflexes.

CONCLUSION: The extended VBN model for analyzing urodynamic recordings facilitates comparison and discussion of successive micturitions from a given patient and is a valuable complement to animal studies and to functional imaging of the human brain.

Françoise A Valentini,1,2 Leonor Mazières,2 Pierre P Nelson2

1 Department of Physical Medicine and Rehabilitation, Charles Foix Hospital, Ivry-sur-Seine, France

2 Research Team #6 (Physiology and Pathophysiology of Motility in Humans), Pierre and Marie Curie University, Paris, France

Submitted April 15, 2010 - Accepted for Publication June 13, 2010

KEYWORDS: Mathematical modeling; Nervous control; Micturition; Urodynamics.

CORRESPONDENCE: Dr. Françoise A. Valentini, Department of Physical Medicine and Rehabilitation, Hôpital Charles Foix, 7, avenue de la République, 94200 – Ivry-sur-Seine, France (; ).

CITATION: Urotoday Int J. 2010 Aug;3(4). doi:10.3834/uij.1944-5784.2010.08.10

ABBREVIATIONS AND ACRONYMS: BPE, benign prostatic enlargement; D, index of voiding dysfunction (VBN parameter); DO, detrusor overactivity; E(t), « Effective calcium excitation »; F, firing rate; FF, free uroflow; G, Griffiths’ function; k, detrusor contractility (VBN parameter); LUT, LUTS, lower urinary tract, lower urinary tract symptom; NIDC, noninhibited detrusor contraction; N(t), « modulating factor » of pressure; pabd, pabd.eff, abdominal pressure, effective abdominal pressure; pcontractile, detrusor pressure due to contractile component; pdet, pdet.Qmax, detusor pressure, detrusor pressure at maximum flow rate; pelastic, detrusor pressure due to elastic component; PF, pressure-flow; prec, rectal presure; pves, bladder pressure; pucp, prostatic urethra counter pressure (VBN parameter); PVR, postvoid residual volume; Q, Qmax, flow rate, maximum flow rate; T, time constant; V, Vu, Vini, bladder volume, voided volume, initial bladder volume; VBN, Valentini, Besson, Nelson; W, ratio of active regulatory protein.



Letter from the Editor - June 2010

Dear Colleagues,

This issue marks the beginning of the third year for UroToday International Journal, and anniversary issues always call for some reflection on how we are doing. Our primary goal was to elevate access to urology and uro-oncology science for professionals around the world. Since its inception, our readership has grown to over 21,000 individual subscribers and we have a large pool of reviewers from over 40 countries. Over the past 2 years, we have published articles with authors from 32 countries and have attracted subscribers from 206 countries and territories on 6 continents. We have been accepted into the EMCare (Elsevier) as well as EBESCOhost (research database service). We are now "old" enough to have applications currently being evaluated by the PubMed and PubMed Central (National Library of Medicine) and Scopus (Elsevier) database sources. We look forward to their responses. Our publication rate has grown from 6 articles in the first several issues to 22 in the present collection. We have also been able to continue our stated goal of rapid turnaround times from submission to publication. We could not achieve this success without the dedication of both our reviewers and authors.

The current issue contains a variety of articles, many of which are on current topics of high interest to the professional community. We are glad to announce several articles in basic science, because one of our goals is to increase our publication of basic science research. This type of research forms the foundation of any profession and we welcome your submissions.

Studies involving tissue engineering and regeneration are beginning to show promise for future application to patients with renal failure. Hopefully, these studies will one day solve the many problems associated with dialysis and renal transplantation. The topical review on cell-based approaches to renal tissue regeneration by Agcaoili et al provides an in-depth summary of related literature and a thoughtful discussion about the current limitations and future potential for this area of research.

Another basic science investigation, written by Uvelius and Kanje, is on the topic of plasticity of neurons following preganglionic and postganglionic pelvic injuries. Their results have immediate implications for patients needing a prostatectomy.

The current issue has two randomized, prospective investigations on the topic of alpha-blockers for the treatment of symptomatic benign prostatic hyperplasia (Griwan et al; Dash et al). The patients in both studies were from India. Because most previously reported studies involved patients from North American or European countries, it was interesting to note that dietary and lifestyle differences did not seem to alter the effects of the investigated drugs.

Another prospective, randomized, placebo-controlled, double-blind drug investigation was written by Asgari et al. They found significant, positive effects from the herbal drug Hypericum perforatum (St. John's wort) for the treatment of premature ejaculation.

Nomikos et al investigated the importance of the digital rectal examination (DRE) for prostate cancer detection in men with prostate-specific antigen (PSA) levels < 3 ng/mL and lower urinary tract symptoms. The authors compared literature on DRE for screening the general population with DRE in urological practice and emphasized the importance of keeping it standard in the specialist setting. Their concern is that many of the cancers detected by DRE alone are potentially curable but may have worse outcomes if the physician waits until PSA reaches an abnormal level.

Finally, this issue contains a number of interesting case reports. Two that are quite rare include a patient with renal tuberculosis during pregnancy (Benatta and Sallami) and a patient with situs inversus totalis (Shapiro et al).

We are pleased to host the 1st Annual UroToday International Journal reception following the AUA meeting in San Francisco honoring our authors, reviewers, and editors who have provided support by sharing their work and time. We look forward to future collaborations with professionals from around the world as we continue to grow.


Kind regards,

K-E Andersson

Sarcomatoid Urothelial Carcinoma of the Bladder With Axillary Lymph Nodal Mass: Case Report and Review of the Literature


A 55-year-old female presented with recurrent hematuria and urinary tract infections. Evaluations with computed tomography urogram, flexible cystoscopy, and urine cytology revealed an extensive bladder tumor with a vesicovaginal fistula. The TNM pathologic stage of the tumor was pT3a N0 M0. Histological evaluation showed that there were cohesive epithelioid malignant cells suggestive of urothelial carcinoma in few areas. However, most of the neoplasm consisted of singly dispersed cells with eccentric, abundant eosinophilic cytoplasm and bizarre, spindly nuclei characteristic of sarcomatoid urothelial carcinoma (SUC). The patient had anterior pelvic exenteration and adjuvant chemotherapy. No evidence of metastasis was found in preoperative or postoperative imaging. However, the patient presented with a rare axillary mass 3 months after surgery. Biopsy of the mass showed sarcomatous differentiation similar to the SUC primary tumor in the bladder. A CT scan of the chest and a whole body scan revealed lung, liver, abdominal, and mesenteric lymph node metastases. She died approximately 6 months after the initial diagnosis. The authors compare this case of axillary metastasis from sarcomatoid variant of urothelial cancer with other reports in the literature.

KEYWORDS: Sarcomatoid urothelial carcinoma; Axillary metastasis; Survival rate.

CORRESPONDENCE: Dr. Satya Allaparthi, Department of Surgery, University of Massachusetts Medical School, S4868, Division of Urology, 55 Lake Avenue North, Worcester 01655, MA ().

CITATION: UroToday Int J. 2010 Jun;3(3). doi:10.3834/uij.1944-5784.2010.06.01

ABBREVIATIONS AND ACRONYMS: CS, carcinosarcoma; CT, computed tomography; SUC, sarcomatoid urothelial carcinoma; TCC, transitional cell carcinoma; UC, urothelial carcinoma.



Demographics of Bladder Injury and the Role of Cystography: A 7-Year Review of Trends in New South Wales, Australia


INTRODUCTION: Patients who sustain direct bladder trauma are at significant risk of bladder rupture. Contemporary literature supports conservative management for extraperitoneal (EP) bladder rupture using catheterized bladder drainage, and surgical repair with postoperative catheterization for intraperitoneal (IP) bladder rupture. A cystogram is standard practice for evaluating the integrity of the bladder prior to catheter removal, but indications and timing are not clearly defined. The aim of this retrospective study was to review the types of bladder injury and the results of cystography follow-up.

METHODS: A total of 15,046 patients were admitted to the authors' hospitals with traumatic injuries (including iatrogenic injuries) between January 2000 and March 2006. Patients with isolated, noncomplex bladder injuries were further evaluated for age, sex, cause of the injury, diagnostic methods used, type of management, follow-up results, and complications.

RESULTS: A total of 40 patients (0.03%) had isolated bladder injuries. The median age was 40.9 years. There were 24 males and 16 females. The bladder injuries were iatrogenic in 18 patients (45%), due to blunt trauma in 16 patients (40%), and due to penetrating gunshot wounds in 6 patients (15%). Of the 18 iatrogenic injuries, 12 were secondary to gynecological procedures; 14 of the 16 blunt trauma injuries were secondary to motor vehicle accidents. IP bladder ruptures were found in 24 patients (60%); EP bladder ruptures were found in 16 patients (40%). All patients underwent either surgical (70%) or conservative (30%) management and follow-up fluoroscopic cystography 7-21 days later. All cystograms were normal.

CONCLUSION: Iatrogenic and blunt injury represented the majority of bladder injuries. Follow-up cystograms were all normal and may not be required if catheter removal is planned after 14 days of drainage and the patient is asymptomatic. This recommendation applies to conservatively managed isolated EP and surgically repaired noncomplex IP bladder injuries only.

KEYWORDS: Cystography; Urinary bladder; Intraperitoneal and extraperitoneal injury; Iatrogenic.

CORRESPONDENCE: Dr. Ahmad Al-Sameraaii, Department of Urology, The St. George Hospital, Gray Street, Kogarah 2217, New South Wales, Australia ().

CITATION: Urotoday Int J. 2010 Jun;3(3). doi:10.3834/uij.1944-5784.2010.06.20

ABBREVIATIONS AND ACRONYMS: CT, computed tomography; IDC, indwelling disposable catheter; EP, extraperitoneal; IP, intraperitoneal



The Value of Digital Rectal Examination in Men With Lower Urinary Tract Symptoms and Prostate-Specific Antigen Less Than 3 ng/mL


INTRODUCTION: Controversy remains as to the value of digital rectal examination (DRE) for detecting prostate cancer in men presenting with lower urinary tract symptoms and low prostate-specific antigen (PSA) levels. The purposes of the present retrospective investigation were to: (1) evaluate the positive predictive value (PPV) of an abnormal DRE in patients with PSA < 3 ng/mL, (2) describe the stage and grade of the cancers detected, and (3) describe the treatment modalities used for patients at each clinical stage.

METHODS: A prospectively maintained prostate biopsy service database of consecutive men undergoing prostate biopsies from April 2004 to April 2006 was reviewed. Patients with PSA < 3 ng/mL and definitely abnormal DRE were divided into 3 groups according to PSA range. The relationship between abnormal DRE and positive prostate biopsy was determined. The International Prostate Symptom Score (IPSS), clinicopathologic features of prostate cancer, and the treatments used for each clinical stage were summarized.

RESULTS: From 1235 men who underwent prostate biopsies, 59 (4.6%) had PSA < 3 ng/mL and an abnormal DRE. Their mean age was 63.4 years. Fifteen of the 59 patients had true-positive DRE; 44 patients had false-positive DRE. The PPV of an abnormal DRE for detecting prostate cancer was 25.4%. The incidence of prostate cancer was 13.3%, 33%, and 53.3% in patients with abnormal DRE and PSA levels of 0.1-1.0 ng/mL, 1.1-2.0 ng/mL, and 2.1-2.9 ng/mL, respectively. Patients with significant LUTS (IPSS > 19) were likely to have false-positive DREs (P = .019). Patients with mild LUTS (IPSS < 7) and abnormal DREs tended to have positive prostate biopsies (P = .030). Modalities used to treat the 15 patients with cancer included active monitoring, brachytherapy, and external beam radiotherapy in 3 (20%), 5 (33.3%) and 4 (26.6%) patients, respectively. Hormonal deprivation was used for 1 patient; radical prostatectomy was used for 2 patients.

CONCLUSIONS: DRE has a significant role in detecting prostate cancer in men presenting with PSA < 3 ng/mL. The higher the PSA, the greater the possibility of detecting prostate cancer in this selective cohort.

KEYWORDS: Digital rectal examination; Low PSA; Prostate cancer diagnosis

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

CITATION: Urotoday Int J. 2010 Jun;3(3). doi:10.3834/uij.1944-5784.2010.06.07

ABBREVIATIONS AND ACRONYMS: DRE, digital rectal examination; GP, general practitioner; IPSS, International Prostate Symptom Score; LUTS, lower urinary tract symptoms; PPV, positive predictive value; TRUS, transrectal ultrasound.



Isoenzyme Creatine Kinase Mi as a Possible Indicator of Spermatozoa Maturity


INTRODUCTION: The assessment of creatine kinase (CK) in human sperm cells is an unbiased indicator of sperm maturity and fertilization potential. Elevated CK values are associated with an increased number of functional abnormalities and increased cytoplasmic residues. The CK-Mi isoenzyme in human sperm is of mitochondrial origin. Increased spermatozoal CK activity is associated with high CK cell levels. The objective of the present study was to compare the biochemical marker CK with morphological changes of the head, neck, and tail. The authors also investigated the assessment of CK activity in human sperm to obtain an objective biochemical marker of sperm maturity and fertilization potential.

METHODS: The activity of CK was assessed for seminal plasma-deprived spermatozoa in 126 men. The participants were divided into 2 groups. Patients in group 1 (n = 64) had reduced spermatozoa count. They were subdivided into: group 1a (n = 28) patients with moderate oligospermic characteristics (spermatozoa count 5.1 - 20 x 106/mL), and group 1b (n = 36) patients with severe oligospermic characteristics (spermatozoa count < 5 x 106/mL). Group 2 (n = 62) was a comparison group of patients with normospermic characteristics (spermatozoa count > 20 x 106/mL; motility > 0.30). Semen analysis was performed according to World Health Organization guidelines. The CK-Mi isoenzyme was separated from CK-B using DEAE Sephadex™ A-50 columns, and agarose gel electrophoresis was used for separating the CK-Mi isoenzyme. The total CK activity was assessed with a spectrophotometer.

RESULTS: CK was significantly higher in the group with severe oligospermia (mean [SD] = 1.9 [2.2] UI/108 sperm cells) than in the group with normospermia (0.097 [0.026] UI/108 sperm cells) (P < .01). The group with oligospermia had a significantly lower CK-Mi/CK ratio (0.16 [0.10]) than the group with normospermia (0.36 [0.12]) (P = < .01).

DISCUSSION: The concentration of CK and synthesis of CK-Mi isoforms reflect normal spermatogenesis and can be used for predicting human sperm maturity and fertilization potential. CK appears to be a sensitive indicator of spermatozoa quality and maturity for men with male-factor infertility.

KEYWORDS: Oligospermia; Normospermia; Creatine kinase; Isoenzyme CK-Mi

CORRESPONDENCE: Professor Sava Micic, MD, PhD, Institute of Urology and Nephrology, Resavska 51, Belgrade 11000, Serbia ().

CITATION: UroToday Int J. 2010 Jun;3(3). doi:10.3834/uij.1944-5784.2010.06.08

ABBREVIATIONS AND ACRONYMS: CK, creatine kinase; CK-Mi, CK of mitochondrial origin.



Double-Barreled Wet Ileostomy Following Pelvic Exenteration


A 30-year female with history of ulcerative colitis and partial colectomy presented with rectal bleeding and fecal and urinary incontinence. She had active colitis with granulation tissue, crypt abscess formation, extensive regenerative changes, and lymphoid aggregate formation. She also had a contracted bladder and vesicovaginal fistula. She underwent total proctocolectomy and cystectomy. Simultaneous urinary and fecal diversion was achieved with a double-barreled wet ileostomy (DBWI). The anterior pelvic exenteration was technically challenging secondary to prior surgery, but no major complications were encountered. This is the second known reported case following development of the DBWI technique in 2005. The case shows that DBWI can be safely performed after total colectomy and pelvic exenteration, with no serious complications or morbidity in the first 19 months. This technique may be particularly advantageous for patients with fistulous intestinal tracts.

KEYWORDS: Pelvic exenteration; Urinary diversion

CORRESPONDENCE: Sertac Yazici, MD, Hacettepe University School of Medicine, Department of Urology, Sihhiye, Ankara 06100, Turkey ().

CITATION: Urotoday Int J. 2010 Jun;3(3). doi:10.3834/uij.1944-5784.2010.06.02

ABBREVIATIONS AND ACRONYMS: DBWI, double-barreled wet ileostomy; UC, ulcerative colitis.



Persistent Mullerian Duct Syndrome and Hernia Uteri Inguinalis in a Male With Normal Fertility


Nonregression of Mullerian ducts in individuals who are phenotypically male with an XY genotype is a rare occurrence. This condition usually presents as unilateral or bilateral undescended or partially descended testes. Additionally, it is often associated with inguinal swellings. These swellings are caused by an undescended testis and may be bilateral, or they may present as unilateral if both testes are in the same inguinal region (transverse testicular ectopia). Inguinal swellings may also result from embryological remnants of the Mullerian duct. Most males with this disorder have azoospermia. The present report is a very rare case of a 28-year-old male who presented with unilateral inguinal swelling on the left side. Exploration of the inguinal canal on suspicion of an inguinal hernia revealed a hypoplastic uterus, single nodular ovary, and coiled Fallopian tube with an easily discernable fimbrial end. Histology confirmed hernia uteri inguinalis. No testicular tissue could be located in the inguinal canal. The right testis had a normal volume and was descended completely in the scrotum. Quite uniquely, this individual possessed a normal stature, sperm count, and fertility. These characteristics are very rarely documented in association with persistent Mullerian duct systems in men.

KEYWORDS: Azoospermia; Hernia uteri inguinalis; Mullerian duct; Transverse testicular ectopia.

CORRESPONDENCE: Dr. Niladri Kumar Mahato, Associate Professor, Department of Anatomy, Sri Aurobindo Institute Of Medical Sciences (SAIMS), Indore-Ujjain Highway, Bhawrasala, Indore, Madhya Pradesh, 452 010 India ().

CITATION: UroToday Int J. 2010 Jun;3(3). doi:10.3834/uij.1944-5784.2010.06.09

ABBREVIATIONS AND ACRONYMS: DMP, dysgenetic male pseudohermaphroditism; DSD, disorder of sexual development; MGD, mixed gonadal dysgenesis; MIF, Mullerian inhibiting factor; PMDS, persistent Mullerian duct syndrome.



Glial Cell Activation in Pelvic Ganglia After Preganglionic But Not Postganglionic Lesions


INTRODUCTION: Pelvic surgery can result in injuries to the parasympathetic innervation of the pelvic organs. Such injuries can involve both preganglionic and postganglionic lesions. The purpose of the present study was to describe activation of the pelvic ganglion cells by the transcription factors ATF3 and p-c-Jun after preganglionic or postganglionic lesions in the rat.

METHODS: ATF3, p-c-Jun, and ED1 were monitored in rat pelvic ganglia 4 days after preganglionic and postganglionic lesions using immunocytochemistry.

RESULTS: Control ganglia exhibited weak nuclear staining for p-c-Jun but not ATF3. Postganglionic lesions induced ATF3 and p-c-Jun in neuronal nuclei. In contrast, preganglionic lesions induced ATF3 and p-c-Jun mainly in the nuclei of satellite cells and Schwann cells, although some neuronal nuclei were intensely p-c-Jun positive. No neurons expressing ATF3 were found. Staining by ED1 showed an increased number of macrophages in the ganglia after preganglionic lesions.

CONCLUSION: The authors hypothesize that the induction of nuclear ATF3 and p-c-Jun in Schwann cells and satellite cells is induced by degeneration, and that the expression of p-c-Jun and ATF3 in neuronal nuclei reflects activation of sprouting mechanisms.

KEYWORDS: Pelvic ganglion; p-c-Jun; ATF3; Denervation; Decentralization

CORRESPONDENCE: Bengt Uvelius, MD, Department of Urology, Skane University Hospital, SE-20502 Malmo, Sweden ().

CITATION: UroToday Int J. 2010 Jun;3(3). doi:10.3834/uij.1944-5784.2010.06.18

ABBREVIATIONS AND ACRONYMS: NO, nitric oxide; PBS, phosphate-buffered saline; TH, tyrosine hydroxylase; VIP, vasoactive intestinal peptide.



Safety and Efficacy of the Herbal Drug Hypericum Perforatum for the Treatment of Premature Ejaculation


INTRODUCTION: Premature ejaculation (PE) is one of the most prevalent forms of male sexual dysfunction. The benefits of Hypericum perforatum for treatment of PE are unknown, although it is hypothesized that its effect on depression and neurotransmitter activity may be beneficial. The authors assessed the efficacy and safety of H. perforatum for the treatment of PE.

METHODS: A prospective, double-blind, randomized, placebo-controlled design was used. Participants were 50 married men with PE. They were 18-50 years old and were evaluated between January 2007 and December 2008. Patients were randomly assigned to one of 2 equal groups. Group 1 received 3 daily tablets of hypericum extract (150 mg per tablet). Each tablet contained 160μg of hypericin. Group 2 received a placebo. All participants recorded intravaginal ejaculation latency time (IELT) and completed the International Index of Erectile Function (IIEF-5) questionnaire before and after treatment. Side effects were self-reported using a questionnaire. Results were compared using chi-square and paired t tests.

RESULTS: Forty-two patients completed the study. Hypericum extract was discontinued due to anejaculation (n = 2) and erectile dysfunction (n = 1); 5 patients taking the placebo were lost to follow-up. There was a significant group difference in mean IELT (P < .001); IELT increased from 1.17 minutes to 5.8 minutes in the group taking hypericum extract. Patients taking hypericum extract also had significantly higher IIEF-5 ratings for the measures of intercourse satisfaction and overall satisfaction (P < .001). There were no significant group differences in mean IIEF-5 ratings of orgasmic function, erectile function, or sexual desire. Mild adverse events of headache, constipation, and photosensitivity were seen in 6 patients (27%) taking hypericum extract.

CONCLUSION: H. perforatum (St. John's wort) may be an effective and safe treatment for PE, possibly because of its effect on neurotransmitters such as serotonin.

KEYWORDS: Hypericum perforatum; Premature ejaculation; IELT; IIEF-5; Drug therapy.

CORRESPONDENCE: Siavash Falahatkar, MD, Urology Research Center, Guilan University of Medical Sciences, Razi Hospital, Sardare Jangal Street, Rasht, Guilan 41448, Iran ().

CITATION: UroToday Int J. 2010 Jun;3(3). doi:10.3834/uij.1944-5784.2010.06.21

ABBREVIATIONS AND ACRONYMS: 5HT, 5-hydroxytryptamine; IELT, intravaginal ejaculation latency time; IIEF-5, International Index of Erectile Function; PE, premature ejaculation; SJW, St. John's wort; SSRI, selective serotonin reuptake inhibitors.



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