Volume 3

UIJ Volume 3 2010

Lithiasis Inside a Blind-Ending Branch of a Bifid Ureter Causing Ureterohydronephrosis: A Case Report


A bifid blind-ending ureter is an extremely rare congenital anomaly of the upper urinary tract. Lithiasis inside the blind-ending branch has only been reported in a few cases. This unusual ureteric condition appears to be most common in female patients. A 53-year-old woman was admitted with right lumbar colic pain. A kidney-ureter-bladder X-ray revealed a spherical radiopaque shadow, projected on the right side of the sacrum in the region of the lower third of the right ureter. An intravenous pyelography showed a distal stone in the right ureter, with mild hydronephrosis and a hydroureter. Ureteroscopy and retrograde pyelography revealed a right blind-ending bifid ureter. The blind-ending branch, originating in the distal third of the ureter, contained a stone that caused obstruction of the normal branch. The stone was treated with endoscopic lithotripsy. At the 3-month follow-up evaluation, the patient was stone-free and asymptomtic. The clinical significance of this malformation is discussed in light of the current literature.

KEYWORDS: Blind-ending ureter; Bifid ureter; Abnormalities; Intravenous urography; Ureter; Calculus.

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

CITATION: Urotoday Int J. 2010 Jun;3(3). doi:10.3834/uij.1944-5784.2010.06.11

ABBREVIATIONS AND ACRONYMS: IVU, intravenous urography; RP, retrograde pyelography.



Commentary on Chronic Prostatitis/Chronic Pelvic Pain Syndrome: The Status Quo Is Not Good Enough (But It Can Be)


Prostatitis is the name given to a group of disorders that share surprisingly little in the way of etiology, symptoms, and treatment. Frequently, the diagnosis and management of these conditions is empiric, inadequate, ineffective, and contrary to the published literature of the past 10 years. In the present commentary, 23 "theses" are presented as a plea to physicians managing these patients to modify their ingrained approaches and incorporate simple evidence-based changes that can greatly improve outcomes and patient quality of life.

KEYWORDS: Prostatitis; Chronic pelvic pain syndrome

CORRESPONDENCE: Daniel Shoskes, MD, Glickman Urological and Kidney Institute, Cleveland Clinic, 9500 Euclid Ave, Desk Q10-1, Cleveland, Ohio, 44195, USA ().

CITATION: UroToday Int J. 2010 Jun;3(3). doi:10.3834/uij.1944-5784.2010.06.11

ABBREVIATIONS AND ACRONYMS: GU, genitourinary; LUTS, lower urinary tract symptoms; NIH, National Institutes of Health; PSA, prostate-specific antigen; UTI, urinary tract infection.



An Unusual Presentation of Renal Tuberculosis During Pregnancy


Reports from the World Health Organization estimate that nearly one third of the world's population is infected with Mycobacterium tuberculosis. The present case is a 33-year-old woman who was pregnant in the first trimester. She presented with mild fever and left flank pain and was treated for renal abscess. Postpartum investigations revealed renal tuberculosis (TB), necessitating medical treatment and open surgery drainage. The diagnosis of genitourinary TB is difficult because its symptoms are nonspecific, but early diagnosis is essential for successful management. Screening of TB should be considered for the following groups of pregnant women: (1) patients with symptoms suggestive of TB; (2) patients with HIV infection; (3) patients who were in close contact with infectious TB; and (4) patients who recently visited countries with high TB-prevalence. The authors report the case with a review of the literature.

KEYWORDS: Genitourinary tuberculosis; Pregnancy; Abscess.

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

CITATION: UroToday Int J. 2010 Jun;3(3). doi:10.3834/uij.1944-5784.2010.06.05

ABBREVIATIONS AND ACRONYMS: ESR, erythrocyte sedimentation rate; GUTB, genitourinary tuberculosis; M. tuberculosis, Mycobacterium tuberculosis; TB, tuberculosis; WHO, World Health Organization.



Cell-Based Approaches for Renal Tissue Regeneration


The kidneys serve a number of important roles that are required to maintain normal human physiologic function. Chronic kidney disease is a leading cause of mortality and morbidity, and a substantial number of these patients progress to end-stage renal disease. End-stage disease involves multiple organ systems and requires renal replacement therapy. Currently, the gold-standard treatment for this condition is renal transplantation, which can restore complete kidney function. However, renal transplantation is limited by the critical shortage of transplant organs and by complications that can result from chronic immunosuppressive therapy and graft failure. Recent advances in cell technologies have allowed for development of cell-based approaches for kidney tissue regeneration. Efforts are ongoing to identify reliable cell sources, develop ideal growth environments and innovative differentiation factors, and discover synthetic and naturally-derived materials for use as an ideal support structure for tissue regeneration. However, numerous challenges must be met in order to translate these techniques into clinically relevant therapies.

KEYWORDS: End-stage renal disease; Kidney; Renal tissue regeneration; Regenerative medicine; Tissue engineering; Cell-based therapy.

CORRESPONDENCE: James J. Yoo, MD, PhD, Wake Forest Institute for Regenerative Medicine, Wake Forest University Health Sciences, Medical Center Boulevard, Winston Salem, NC 27157, USA ().

CITATION: Urotoday Int J. 2010 Jun;3(3). doi:10.3834/uij.1944-5784.2010.06.22

ABBREVIATIONS AND ACRONYMS: 3-D, 3-dimensional; ESRD, end-stage renal disease; EPO, erythropoietin; hAFSC, human amniotic fluid-derived stem cells; MSC, mesenchymal stem cells; PEC, parietal epithelial cells; RT-PCR, reverse transcriptase polymerase chain reaction; Sca-1, stem cell antigen-1.



Efficacy and Safety of Tamsulosin-MR Versus Alfuzosin-SR for Treatment of Symptomatic Benign Prostatic Hyperplasia: A Randomized, Prospective Study


INTRODUCTION: Alpha-1 adrenoceptor antagonists are the mainstay for treatment of symptomatic benign prostatic hyperplasia (BPH). Tamsulosin and alfuzosin, the most commonly prescribed drugs, have good efficacy and safety. However, there is paucity of data comparing the modified release (MR) or sustained release (SR) formulas. The purpose of the present study was to compare the efficacy and safety of tamsulosin-MR 0.4 mg with alfuzosin-SR 10 mg in patients with symptomatic BPH.

METHODS: A total of 90 patients participated in the single-blind, parallel-trial design. Patients were randomly assigned to equal groups, receiving tamsulosin-MR (0.4 mg) or alfuzosin-SR (10 mg). Both were taken once daily for 12 weeks. The International Prostate Symptom Score (IPSS) and maximum urinary flow rate (Qmax) were determined before and at 6 weeks and 12 weeks after the initiation of therapy. The number of adverse events was recorded.

RESULTS: Patients in both groups had a significant mean change in both IPSS and Qmax at the end of 6 weeks and 12 weeks of therapy (P < .001). There was no significant group difference in mean IPSS or Qmax at 6 weeks. At 12 weeks, the group receiving tamsulosin had a significantly lower IPSS (P = .048) and a significantly higher Qmax (P = .045) than the group receiving alfuzosin. Adverse events were infrequent and not statistically different between groups. Dizziness and impotence were most common with tamsulosin; dizziness and fatigue were most common with alfuzosin.

CONCLUSION: Tamsulosin-MR was significantly more effective than alfuzosin-SR in improving IPSS score and Qmax at the end of 12 weeks of treatment, although the group differences in outcome measures were small.

KEYWORDS: Tamsulosin; Alfuzosin; BPH; IPSS; Qmax.

CORRESPONDENCE: Amitabh Dash, MD, A-3, MIG Flats, Prasad Nagar, Phase II, New Delhi, 110005, India ().

CITATION: UroToday Int J. 2010 Jun;3(3). doi:10.3834/uij.1944-5784.2010.06.19

ABBREVIATIONS AND ACRONYMS: BOO, bladder outlet obstruction; BPH, benign prostatic hyperplasia; IPSS, International Prostate Symptom Score; LUTS, lower urinary tract symptoms; MR, modified release; PVR, postvoid residual; Qmax, maximum urinary flow rate; SR, sustained release.



Hematuria During Pregnancy: An Unusual Presentation of Inverted Papilloma


Inverted papilloma (IP) of the urinary tract is an uncommon tumor that is usually regarded as benign. The exact cause of IP is presently unknown, although various theories have been postulated. It typically occurs during the fifth or sixth decade of life. Although IP has been reported in the pediatric age group, its occurrence in a young female during pregnancy has never been reported. The present case is a 24-year-old female who presented with gross hematuria in the 16th week of pregnancy. She had IP of the urinary bladder with extensive squamous metaplasia. Immunohistochemistry showed positivity with human papillomavirus strain 16. Transurethral resection of the bladder tumor was completed and there was no recurrence 16 months later. Squamous metaplasia has been defined as a diagnostic feature of IP, but its extensive presence during pregnancy raises questions about the influence of hormones on its development.

KEYWORDS: Inverted Papilloma; Pregnancy; Squamous metaplasia; Urinary bladder

CORRESPONDENCE: Dr. Punit Tiwari, Department of Urology, Institute of Post Graduate Medical Education and Research, SSKM Hospital, 242, AJC Bose Road, Kolkata, West Bengal, 700020, India ().

CITATION: Urotoday Int J. 2010 Jun;3(3). doi:10.3834/uij.1944-5784.2010.06.13

ABBREVIATIONS AND ACRONYMS: HPV, human papillomavirus; IP, inverted papilloma



Treatment of Lower Urinary Tract Symptoms in Children With Constipation Using Tegaserod Therapy


INTRODUCTION: Tegaserod, a selective 5-HT4 agonist, is a promotility agent used for the treatment of adults with irritable bowel syndrome with constipation and chronic idiopathic constipation. In children, constipation is commonly associated with lower urinary tract symptoms (LUTS). The purpose of the present retrospective investigation was to assess the effectiveness of tegaserod to treat children with refractory LUTS and either persistent constipation or persistent abdominal pain following resolution of constipation.

METHODS: A chart review was conducted for all patients who had not responded to a bowel program (high fiber diet, increased fluid intake, stool softeners, senna laxatives) and were treated with tegaserod over a 2-year period. Inclusion criteria included LUTS and persistent constipation or persistent abdominal pain even though constipation appeared to be adequately controlled. Tegaserod dosing started at 2 mg twice daily and increased to a maximum of 6 mg twice daily until the patient had regular bowel movements and experienced no abdominal pain. The dose was reduced if patients exhibited signs of diarrhea or cramping. Senna laxative use was discontinued for all patients following tegaserod initiation. Treatment response was determined by presence of symptoms and measurement of postvoid residual (PVR) urine at baseline and final evaluation.

RESULTS: A total of 19 patients (11 girls, 8 boys) with a mean age of 9.3 years (range, 3-15 years) received tegaserod treatment. At baseline, 16 patients had an elevated PVR (mean = 91.2 mL) and 11 patients had a history of recurrent urinary tract infections. Tegaserod was well tolerated by all patients with no discontinuations; 2 patients had a dose reduction from 6 mg to 2 mg twice daily. All patients had resolution of abdominal pain. Urinary incontinence improved in all but 4 patients and there was complete resolution of urinary urgency, urinary frequency, and urinary tract infections. The average PVR volume of 14.2 mL after treatment was significantly reduced when compared with pretreatment levels (P = .0005).

CONCLUSION: The effects of tegaserod may be due to more than changes in stool volume in the colon, because there was a reduction in LUTS and improved emptying of the bladder.

KEYWORDS: Lower urinary tract symptoms; Constipation; Children; Tegaserod; Serotonin or 5-HT

CORRESPONDENCE: Israel Franco, MD, Section of Pediatric Urology, 150 White Plains Rd, Tarrytown, NY 10591, USA ().

CITATION: Urotoday Int J. 2010 Jun;3(3). doi:10.3834/uij.1944-5784.2010.06.17

ABBREVIATIONS AND ACRONYMS: CIC, chronic idiopathic constipation; IBS-C, irritable bowel syndrome with chronic constipation; LUTS, lower urinary tract symptoms; OAB, overactive bladder; PVR, postvoid residual; UTI, urinary tract infection.



Electrocardiographic Changes in Patients Undergoing Hemodialysis


INTRODUCTION: Patients with end-stage renal disease who are on long-term dialysis support have a very high mortality. Nearly half of deaths on dialysis are secondary to myocardial infarction, cardiac arrest, malignant arrhythmias, and other cardiac causes. The purpose of the present study was to compare electrocardiogram (ECG) disturbances before and after hemodialysis.

METHODS: The participants were 144 patients on dialysis who met specific inclusion criteria. Their mean (SD) age was 56.27 (14.2) years. A cross-sectional study was conducted between June and December, 2009. Twelve-lead ECGs were performed in identical conditions for all patients, 10 minutes before and 10 minutes after the midweek morning hemodialysis session. Duration and amplitude of P wave and QRS complex, and duration of QTc and QTd were calculated. ECGs were analyzed by a single observer who was blind to all patient information. The Kolmogorov Smirnov, Wilcoxon signed rank, and McNemar tests were used to compare the variables before and after hemodialysis.

RESULTS: The mean duration of the QRS complex and QTc were significantly higher after dialysis (P = .043 and P = .007, respectively). There were no significant differences in the mean P wave duration or mean QTd (P > .05). There was a significant increase in the mean P wave and QRS complex amplitudes after hemodialysis (P = .0001). There were no significant differences between the number of patients with normal and abnormal values before and after dialysis for the duration of QRS complex, P wave, QTc, or QTd, or the amplitude of the P wave and QRS.

CONCLUSION: In the present study, ECG changes before and after hemodialysis presented as a significant increase in duration and amplitude of QRS, amplitude of P wave, and duration of QTc. ECG changes, especially QT intervals, should be monitored in patients with a history of hemodialysis in order to decrease cardiac complications.

KEYWORDS: Electrocardiographic analysis; Hemodialysis.

CORRESPONDENCE: Gholamreza Mokhtari, 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.1944-5784.2010.06.03

ABBREVIATIONS AND ACRONYMS: ECG, electrocardiography/electrocardiogram; QRS-c, QRS complex; QTc, QT interval corrected for heart rate; QTD, QT dispersion.



Laparoscopic Nephrectomy in a Patient With Situs Inversus Totalis: First Reported Case


Situs inversus totalis is a rare congenital condition. It is characterized by left-right transposition of the internal viscera, including the great vessels, liver, and spleen. Previous reports of radical nephrectomy for suspicious renal masses in these patients have all been performed with an open surgical technique. The present case is the first known report of laparoscopic nephrectomy for treatment of solid renal mass in an individual with situs inversus. The surgery was performed safely following proper preparation and careful dissection of the altered anatomy.

KEYWORDS: Laparoscopic nephrectomy; Surgical technique; Situs inversus.

CORRESPONDENCE: Steven Brandes, MD, Washington University School of Medicine, Division of Urology, 4960 Children's Place, Campus Box 8242, St. Louis, MO 63110, USA ().

CITATION: UroToday Int J. 2010 Jun;3(3). doi:10.3834/uij.1944-5784.2010.06.16

ABBREVIATIONS AND ACRONYMS: COPD, chronic obstructive pulmonary disease; RCC, renal cell carcinoma.



Adult Wilms Tumor: Report of 2 Cases and Review of the Literature


Wilms tumor is rare in adulthood. The prognosis is poor when compared with children. Adults more frequently present with advanced disease stages, and chemotherapy has a moderate effect. The various protocols of chemotherapy and indications for surgery and radiotherapy are not yet precisely defined, mainly due to the rarity of the disease. The Society of Pediatric Oncology (SIOP) guidelines suggest that both pediatric and adult patients should have initial chemotherapy followed by surgery. However, the National Wilms Tumor Stage Group (NWTSG) recommends surgery followed by chemotherapy. The authors present 2 cases of adult nephroblastoma that were highly resistant to presurgical chemotherapy. Nephrectomy was not completed because of rapid disease progression. The poor response of these 2 patients indicates that the alternate NTWSG approach of initial surgery followed by systemic treatment might have better results for this population. The authors review related reports and discuss the diagnosis and management of adult Wilms tumor.

KEYWORDS: Adult Wilms tumor; Prognostic factors; Management.

CORRESPONDENCE: Samia Arifi, MD, Department of Medical Oncology, Hassan II University Hospital, Route Sidi Harazem, Fez, Morocco ().

CITATION: Urotoday Int J. 2010 Jun;3(3). doi:10.3834/uij.1944-5784.2010.06.04

ABBREVIATIONS AND ACRONYMS: AWT, adult Wilms tumor; CT, computed tomography; NWTSG, National Wilms Tumor Stage Group; OS, overall survival; PNET, primitive neuroendocrine tumors; PWT, pediatric Wilms tumor; SIOP, Society of Pediatric Oncology; VOD, venoocclusive disease.



A Rare Giant Urinary Bladder Stone: A Case Report


A vesical calculus weighing more than 100 g is categorized as a giant urinary bladder stone. Male preponderance for urinary bladder calculi is well known. A rare case of a giant bladder calculus weighing 565 g and occurring in a female patient is reported. The stone was removed by open cystolithotomy. Possible etiological factors are discussed, some of which are unique to this case.

KEYWORDS:Urinary bladder; Infection; Stone; Surgery

CORRESPONDENCE: Dr Rikki Singal, c/o Dr Kundan Lal Hospital, Ahmedgarh, Distt-Sangrur, 148021, Punjab, India ().

CITATION: Urotoday Int J. 2010 Jun;3(3). doi:10.3834/uij.1944-5784.2010.06.15

ABBREVIATIONS AND ACRONYMS: UTI, urinary tract infection.



Emphysematous Pyelitis Complicated by Renal Calculi: A Case Report


Emphysematous pyelitis (EP) is a rare infection of the urinary collecting system due to gas-forming bacteria. It is an uncommon form of acute pyelonephritis that has been reported sporadically in the literature. The present case of EP was complicated by renal calculi. The patient had surgery to remove the calculi 4 months after the initial diagnosis. During the 4-month interim between diagnosis and surgery, she had no antibiotic therapy. A presurgical CT showed the same stone burden with no evidence of abscess. There was a complete resolution of gas in the collecting system. At the 6-month follow-up evaluation, the patient was asymptomatic and the kidney remained stone-free.

KEYWORDS: Emphysematous pyelitis; Calculi; CT scan.

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

CITATION: UroToday Int J. 2010 Jun;3(3). doi:10.3834/uij.1944-5784.2010.06.10

ABBREVIATIONS AND ACRONYMS: CT, computed tomography; EP, emphysematous pyelitis; EPN, emphysematous pyelonephritis; KUB, kidney, ureter, bladder.



Sequential Chemoimmunotherapy Using Mitomycin Followed by Bacillus Calmette-Guerin (MCC + BCG) Versus Single-Agent Immunotherapy (BCG) for Recurrent Superficial Bladder Tumors


INTRODUCTION: The purpose of the present study was to compare the outcomes of patients receiving sequential chemoimmunotherapy using mitomycin (MMC) and bacillus Calmette-Guerin (BCG) with the outcomes of patients receiving BCG alone for the treatment of recurrent superficial bladder tumors.

METHODS: A total of 56 patients with recurrent Ta or T1 bladder tumors were enrolled in this prospective randomized study. Group 1 (n = 29 patients) received MMC instillation immediately after resection followed by weekly instillation for 4 weeks. Patients then received BCG monthly for 1 year. Group 2 (n = 27) received only BCG, instilled weekly for 6 weeks and then monthly for 1 year.

RESULTS: There was a significant treatment effect for both groups, as indicated by a reduction in mean recurrence rate and recurrence index (P = .001). However, the difference in recurrence rate and recurrence index distributions after treatment was significant in favor of group 1. The mean follow-up period was 24 months (range, 3-30 months). Recurrent tumors were found in 9 patients (31%) in group 1 and 16 patients (70%) in group 2 at the end of the follow-up period. Kaplan-Meier estimates were significantly different throughout the follow-up period. MMC followed by monthly BCG was significantly superior to BCG in the time to initial recurrence (log rank (P < .0024).

CONCLUSIONS: Patients receiving BCG single-agent immunotherapy and patients receiving sequential chemoimmunotherapy using MMC instillations followed by monthly BCG instillation both had significant treatment effects. However, the difference in recurrence rate and recurrence index distributions after treatment was significant in favor of the group receiving the sequential therapy.

KEYWORDS: Sequential chemoimmunotherapy; Bladder cancer; BCG; MMC.

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

CITATION: UroToday Int J. 2010 Jun;3(3). doi:10.3834/uij.1944-5784.2010.06.06

ABBREVIATIONS AND ACRONYMS: BCG, bacillus Calmette-Guerin; MMC, mitomycin; TUR, transurethral resection.



Comparison of Alfuzosin and Tamsulosin Once Daily for Treatment of Lower Urinary Tract Symptoms due to Benign Prostatic Hyperplasia: A Randomized, Prospective Study


INTRODUCTION: The purpose of the study was to evaluate the efficacy and safety of a once-daily dose of alfuzosin (10 mg) and tamsulosin (0.4 mg) in men from India with lower urinary tract symptoms (LUTS) due to benign prostate hyperplasia (BPH).

METHODS: In this prospective study, 100 patients with LUTS due to BPH attending general surgery and urology departments were evaluated between October 2008 and November 2009. Patients were randomly assigned to a group taking alfuzosin 10 mg or a group taking tamsulosin 0.4 mg once daily, both without dose titration. The outcome measures were uroflowmetry results (Qmax, average flow rate, total flow time, and maximum flow time), ultrasonography results (PVR volume and prostate size), Quality of Life (QOL) scores, and International Prostate Symptom Scores (IPSS). Adverse events were recorded. Data were analyzed using t and Fisher exact tests.

RESULTS: Both alfuzosin and tamsulosin improved LUTS. All comparisons of every outcome measure (baseline to 1 month, baseline to 3 months, and 1 month to 3 months) showed statistically significant, progressive change for both patient groups. There were no significant group differences for any outcome measure. Both alfuzosin and tamsulosin were well tolerated, with similar reports of dizziness (6%), headache (4%), and asthenia (4%). The only significant group difference was for abnormal ejaculation, which was only reported by 2 of the 50 patients (4%) taking tamsulosin.

CONCLUSION: Treatment with both alfuzosin and tamsulosin significantly improved all measures of uroflowmetry, ultrasonography, and quality of life. Both medications were well tolerated, but ejaculatory abnormalities were observed only in patients taking tamsulosin.

KEYWORDS: Alpha blocker; Alfuzosin; Tamsulosin; LUTS; BPH.

CORRESPONDENCE: Mahavir Singh Griwan, MD, Department of General Surgery, Pt. BD Sharma, Postgraduate Institute of Medical Sciences, 4/6 J, Medical Enclave, Rohtak, Haryana 91, India ().

CITATION: UroToday Int J. 2010 Jun;3(3). doi:10.3834/uij.1944-5784.2010.06.14

ABBREVIATIONS AND ACRONYMS: BPH, benign prostatic hyperplasia; IPSS, International Prostate Symptom Score; LUTS, lower urinary tract symptoms; PVR, postvoid residual; Qmax, maximum flow rate; QOL, quality of life.



Tumor Recurrence Following Nephron-Sparing Surgery for Renal Cancer: Rate, Patterns, and Predictors


INTRODUCTION: Tumor recurrence following nephron-sparing surgery (NSS) for renal carcinoma is a major concern. The aim of this retrospective study was to assess the rate, patterns, and predictors of tumor recurrence in patients following NSS for renal cancer.

METHODS: Between 1993 and 2008, 229 patients underwent NSS via flank incision for renal cell carcinoma. Patients without metastases at diagnosis (using CT and bone scan) were included in the outcome analysis. Categorical variables were compared with the Fisher-Irwin exact test. Kaplan-Meier was used to determine the probability of overall survival and probability of recurrence curves; significance was tested with the log-rank. The Cox hazard survival model was used to identify whether any of the demographic or clinical variables were predictive of the probability of recurrence.

RESULTS: During a mean (SD) follow-up time of 45 (34) months, tumor recurrence was observed in 13 patients (5.6%). Mean follow-up time for detection of oncological failure was 51 months. All patients with oncological failure were males, with a mean age of 61 years (median 58; range, 51-74 years). The average size of the enucleated lesion was 5 cm (range, 4-7 cm). Intraoperative frozen sections and postoperative pathological examination of the surgical margins were negative in all cases. Predictors of oncological failure included: warm ischemia time > 20 minutes (P = .012), tumor size ≥ 4 cm (P = .001), central tumor location (P = .015), multifocal tumors (P = .001), and male gender (P = .01). The probability of overall disease recurrence at 12 and 60 months was 1.8% and 4.0%, respectively. The overall cancer-specific survival rate was 93.8%. The 12-month and 60-month metastasis-free survival rates were 99.1% and 98.4%, respectively. Recurrence was due to surgeon-related and tumor-related patterns.

CONCLUSIONS: NSS is an effective surgery with satisfactory long-term cancer control. Predictors of recurrence were consistent with previous literature except for warm ischemia time > 20 minutes (noted for the first time). Reasons for cancer relapse include seeding during surgery, residual disease, distant dissemination, and new tumor growth. Careful tumor handling and extensive perirenal fat resection are within the surgeon's control and may reduce failure rates.

KEYWORDS: Renal cell carcinoma; Nephron-sparing surgery; Cancer recurrence.

CORRESPONDENCE: CORRESPONDENCE: Sarel Halachmi MD, Department of Urology, Bnai Zion Medical Center, 47 Golomb St. 31048, Haifa, Israel ().

CITATION: Urotoday Int J. 2010 Jun;3(3). doi:10.3834/uij.1944-5784.2010.12.17

ABBREVIATIONS AND ACRONYMS: NSS, nephron-sparing surgery; RCC, renal cell carcinoma.



Letter from the Editor - April 2010

Dear Colleagues,

The UIJ has grown to be read in over 165 countries with an individual subscriber base of over 20,000 individuals. This growth has only been possible because of the work that the authors have done to produce the papers accepted through the fast-tracked peer-review process. The reviewers have also been dedicated to their roles in reviewing the manuscripts and offering their comments in a timely manner, consistent with the vision of the journal. I am pleased to introduce the selection of outstanding articles, one from each category from past publications that are being recognized as recipients of the first annual Editor's Awards for Excellence.

2008-2009 Editor's Award of Excellence: Basic Science Hammouda HM, Hassan YS, Abdelateef AM, Morsi MG, Ali MM, Abdelnaeim M. Post-Tubularized Incised Plate Urethroplasty Healing: An Experimental Randomized Study in 40 Dogs. UroToday Int J. 2009 Oct;2(5).

2008-2009 Editor's Award of Excellence: Clinical Trial Olshansky B, Spierings ELH, Brum J, Mongay L, Egermark M, Seifu Y.Validation of the Differential Cardiovascular Effects of the Antimuscarinic Agents Darifenacin and Tolterodine in a Randomized, Placebo-Controlled, 3-Way Crossover Study. UroToday Int J. 2009 Aug;2(4).

2008-2009 Editor's Award of Excellence: Original Study Dickstein RJ, Baker EH, Siroky MB. Outcome of Patients with Abnormal Upper Tract Cytology and Negative Initial Workup. UroToday Int J. 2009 Dec;2(6).

Gamal WM, Rashid A, Zaki M, Salem E, Mostafa M, Abuzeid A, Osman MM. Modified N-Shaped Ileal Neobladder After Radical Cystectomy.UroToday Int J. 2009 Oct;2(5).

2008-2009 Editor's Award of Excellence: Case Report Eldefrawy A, Katkoori D, De Los Santos R, Manoharan M, Soloway MS. Basal Cell Carcinoma of the Prostate: A Case Report and Review of the Literature. UroToday Int J. 2009 Jun;2(3).

Hutchings DC, Sammons EL, Patel NS, Sullivan ME. Solitary Metastasis of Cervical Carcinoma to the Kidney: A Case Report and Review of the Literature.UroToday Int J. 2009 Dec;2(6).

2008-2009 Editor's Award of Excellence: Topical Review Westerling D. Bladder Pain: Clinical Assessment and Treatment. UroToday Int J. 2009 Aug;2(4).

The authors will be honored along with the editorial board of the UIJ at a reception to be held in San Francisco, California, USA. The current issue offers a unique look at problems in defining treatment success following radical prostatectomy and radiation therapy for adenocarcinoma of the prostate. The authors Barrett and Hertzfeld treated patients with brachytherapy alone and found that 73.6% of their patients had an undetectable PSA level (< 0.1 ng/mL) that was consistently associated with a disease-free state at a median follow-up of 85.2 months, and 98% of patients with PSA ≤ 0.2 had subsequent nonrising PSA. When the results were compared with current literature, the authors concluded that brachytherapy appears to have success that is similar to prostatectomy.

Shigemura et al compared the results of prostate biopsies from the transitional zone only, peripheral zone only, and combined transitional and peripheral zones. They found that transitional zone biopsies resulted in significantly lower cancer detection rates, and concluded that biopsies from this zone may not be necessary for patients with serum PSA < 10 ng/mL.

Valdivia-Uria et al developed an alternative laparoscopic technique for distal ureterectomy used to treat ureteral and bladder perimeatic mucosa through thermal ablation, and they present promising long-term results.

Authors continue to contribute fantastic case studies that allow for all of us as readers to gain a perspective on select impacts of clinical practice and basic research. The 3 unique cases with genitourinary sarcoidosis as the initial presentation and no systemic manifestation, described by El-Zawahry et al, provide insight into an extremely rare disorder. The complex management issues involved with intersex disorders of sexual development are thoughtfully discussed in Kumar et al. Finally, studies involving basic science are always welcome. Lo et al described contractility of the detrusor muscle in the transverse and longitudinal directions in young rats.

I am honored to present you with these open-access, peer-reviewed articles. We are grateful for your continued support.


Kind regards,

K-E Andersson

Differences in Transverse and Longitudinal Rat Detrusor Contractility Under K+ Channel Blockade


INTRODUCTION: Bladder contractility in the transverse direction is often overlooked, because longitudinal strips are the regular tissues of choice in most contractility studies. In the present study, the effects of K+ channel blockers on transverse and longitudinal rat detrusor contractility were compared.

METHODS: Detrusor strips in transverse and longitudinal directions were dissected from young adult rats. Isometric tension was monitored using a myograph. The effects of tetraethylammonium chloride (TEA), 4-aminopyridine (4-AP), glibenclamide (Glib), iberiotoxin (IbTX), charybdotoxin (ChTX), and apamin on carbachol (CCh)-induced contractions were examined.

RESULTS: No contractile differences were present between transverse and longitudinal strips following CCh stimulation. Equal sensitivity to 4-AP and IbTX was detected in transverse and longitudinal strips. Pretreatment with Glib or ChTX resulted in greater suppression of CCh contractions in longitudinal strips. Although apamin suppressed contractions in both transverse and longitudinal strips, CCh potency was lower in transverse strips only.

CONCLUSION: Functional heterogeneity of transverse and longitudinal detrusor contractility was revealed from selective K+ channel blockade. Longitudinal strips were more susceptible to ATP-sensitive and intermediate-conductance Ca2+-activated K+ channel blockades, whereas transverse strips were affected more by blockade of small-conductance Ca2+-activated K+ channels. The potential importance in evaluating multidirectional contractility in pharmacologic studies of detrusor smooth muscle is reinstated.

KEYWORDS: K+ channel; Rat detrusor; Contraction; Transverse; Longitudinal

CORRESPONDENCE: Willmann Liang, PhD, School of Biological Sciences, Nanyang Technological University, Singapore 637551 ().

CITATION: Urotoday Int J. 2010 Apr;3(2). doi:10.3834/uij.1944-5784.2010.04.07

ABBREVIATIONS AND ACRONYMS: 4-AP, 4-aminopyridine; BK, large conductance Ca2+-activated K+; CCh, carbachol; ChTX, charybdotoxin; CRC, concentration-response curve; Emax, maximal fitted response; Glib, glibenclamide; IbTX, iberiotoxin; IK, intermediate conductance Ca2+-activated K+; SK, small conductance Ca2+-activated K+; TEA, tetraethylammonium chloride



Recent Developments in Percutaneous Nephrolithotomy: Benefits of the Complete Supine Position


Percutaneous nephrolithotomy (PCNL) is usually performed in standard prone, semisupine, flank, or complete supine (csPCNL) position. Correct patient positioning is mandatory to facilitate the procedure and prevent complications. When compared with other positions, the csPCNL offers the potential advantages of less patient handling, the need to drape only once, less risk of colon injury, and the ability to perform simultaneous PCNL and ureteroscopic procedures. If PCNL is performed initially with spinal or regional anesthesia and general anesthesia is needed, the change is easier in this position. The supine position allows better access to the airway and may be less hazardous than other positions, especially for patients with compromised cardiopulmonary function, morbid obesity, or those who require a prolonged procedure. There is better drainage with the Amplatz sheath, and stone fragment evacuation is facilitated. The benefits of ultrasound-guided PCNL include no exposure to radiation for the patient or operating room staff, no need for dye materials, and no chance for injury to the surrounding tissues and organs. In ultrasound-guided PCNL, all of the tissues between the skin and kidney can be visualized directly. The present authors performed csPCNL with a subcostal upper-pole puncture and found that the kidney is situated lower than it is located in the prone position. As a result, access to the upper pole is feasible and associated with less complication. Overall, csPCNL is safe, effective, and suitable for most patients. Literature on csPCNL, imaging modalities, tract creation, tubless PCNL, and mini-PCNL is reviewed.

KEYWORDS: Percutaneous nephrolithotomy; Supine surgical position; Sonography; Imaging; Body mass index (BMI); Upper pole access

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

CITATION: UroToday Int J. 2010 Apr;3(2). doi:10.3834/uij.1944-5784.2010.04.03

ABBREVIATIONS AND ACRONYMS: BMI, body mass index; CT, computed tomography; csPCNL, complete supine percutaneous nephrolithotomy; ESWL, extracorporeal shock wave lithotripsy; NT, nephrostomy tube



Genitourinary Sarcoidosis: A Single Institution Experience and Review of the Literature


INTRODUCTION: Sarcoidosis is a multisystemic disorder characterized by granulomata in the diseased tissue. Genitourinary (GU) involvement is rare. The authors report 3 patients in whom GU sarcoidosis was the initial presentation without any systemic manifestation.

METHODS: The Medical University of South Carolina database of patients with sarcoidosis between the years 1986 and 2007 was reviewed to identify individuals with GU sarcoidosis. PubMed was searched for other reported cases.

RESULTS: The university database included 934 patients; 3 patients had GU sarcoidosis. All were African-American males, ranging in age from 27-48 years old. All initial laboratory results were normal. Case 1 presented with a painless left epididymal mass and no history of urinary tract infection. Scrotal ultrasound (US) revealed a hypoechoic left testicular lesion and an epididymal mass. Two months later, a repeat US showed bilateral testicular hypervascular epididymal masses. A left radical orchiectomy was performed. Pathology showed granulomatous orchitis. The patient later developed a large right epididymal mass and subcutaneous nodule. Angiotensin converting enzyme (ACE) and lactate dehydrogenase (LDH) were elevated, consistent with sarcoidosis, and CXR showed mediastinal lymphadenopathy. Case 2 presented with painless testicular lumps and no constitutional symptoms. Eventually, CXR showed bilateral hilar adenopathy. Endoscopic bronchial biopsy confirmed the diagnosis. He had atrophic testes with firm left posterior epididymis, and US showed multiple bilateral small hypoechoic lesions. The testicular mass did not respond to steroid therapy and excisional biopsy of the mass, which revealed granulomatous orchitis. Case 3 presented with prostatic nodules. Transrectal US and biopsy showed sarcoidosis. He subsequently developed hypogonadism and inguinal lymphadenopathy. Lymph node biopsy revealed noncaseating granuloma consistent with sarcoidosis. He also developed neurosarcoidosis and bilateral lymphadenopathy.

DISCUSSION: In the authors' institution, GU sarcoidosis was found only in 0.03% of all patients with sarcoidosis. GU involvement is now reported in 72 cases in the literature, but these are the first known cases with GU manifestation as the initial presentation of sarcoidosis. Sarcoidosis should be considered as a part of the workup and differential diagnosis in patients with GU granulomas.

KEYWORDS: Genitourinary sarcoidosis; Sarcoidosis; Testicular granuloma.

CORRESPONDENCE: Stephen J. Savage, MD, Medical University of South Carolina, 96 Jonathan Lucas St., PO Box 250620, CSB 644, Charleston, SC 29425 USA ().

CITATION: UroToday Int J. 2010 Apr;3(2). doi: 10.3834/uij.1944-5784.2010.04.01

ABBREVIATIONS AND ACRONYMS: ACE, angiotensin converting enzyme; AFP, alpha fetoprotein; GU, genitourinary; HCG, human chorionic gonadotropin; MUSC, Medical University Of South Carolina; US, ultrasound.



Real-time Penile Tumescence and Rigidity Monitoring: A Pilot Study in Healthy, Potent Men


INTRODUCTION: RigiScan™ penile monitoring can be used in the provocative (real-time) setting. However, normative data are limited. The goals of the present prospective study were to (1) generate preliminary data on the range of responses of real-time penile monitoring during audio-visual sexual stimuli (AVSS) in healthy, potent men, and (2) determine if there was an association between real-time erectile rigidity in response to AVSS and self-reported measures of erectile function.

METHODS: The participants were 25 potent men. Their ages ranged from 19-58 years. They were arbitrarily divided into younger (< 40 years) and older (≥ 40 years) groups for outcome measure comparisons. An International Index of Erectile Function (IIEF) erectile domain score was obtained. RigiScan™ monitoring was used to record erectile responses of penile tumescence and rigidity to AVSS. A qualified erectile event was defined as penile rigidity > 60% for 3 or more minutes.

RESULTS: The mean IIEF score for all participants was 29.3, with no significant difference between the younger or older groups (P = .95). Three men had no measureable erectile activity in response to the AVSS. For the remaining 22 men, measurable erectile activity ranged from 3-20.5 minutes. The mean time of measurable rigidity was 12.0 minutes and 11.9 minutes for the younger and older groups, respectively. Age and total erection time had a weak negative correlation (Pearson r = -.31). Ten participants (40%) achieved a qualified event of 60% rigidity. A total of 7 of the 15 participants in the younger group and 3 of the 10 participants in the older group had a qualified event. There was no significant difference in IIEF scores between participants with and without qualified events (P = .35).

CONCLUSION: Preliminary results indicate that real-time penile tumescence and rigidity monitoring in potent, healthy males during AVSS is highly variable and not necessarily corroborated by IIEF scores. This variability limits the utility of provocative mode RigiScan™ for determining potency for clinical purposes. A 60% rigidity criteria for a qualified event may underestimate potency. However, the RigiScan™ may still be effective for studies of erectile physiology.

KEYWORDS: Penis; Rigidity; Monitoring; Potent; Men

CORRESPONDENCE: Henry Gottsch, MD, University of Washington, Dept of Urology, 1959 NE Pacific St, BX 356510, Seattle, WA 98195-6510, USA ().

CITATION: UroToday Int J. 2010 Apr;3(2). doi:10.3834/uij.1944-5784.2010.04.15

ABBREVIATIONS AND ACRONYMS: AVSS, audio-visual sexual stimuli; IIEF, International Index of Erectile Function; NPTR, nocturnal penile tumescence and rigidity; VSS, visual sexual stimuli.



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