Volume 3

UIJ Volume 3 2010

Gender Identity in a Female With Intersex Disorder of Sexual Development Due To Congenital Adrenal Hyperplasia: A Management Dilemma


Patients with an intersex disorder of sexual development (DSD) present the urologist with complex evaluation and management challenges. The patient's phenotype, psychosexual differentiation, and chromosomal sex assignment are all important considerations. The timing of gender assignment in the patient's development should be a multidisciplinary decision that includes the patient and family members. The authors present a rare case of a female with intersex DSD due to congenital adrenal hyperplasia of the simple-virilizing (non salt-losing) form. The patient's unique presentation and challenging management, including sex assignment, are described.

KEYWORDS: Female disorder of sexual development; Congenital adrenal hyperplasia; Intersex.

CORRESPONDENCE: Professor N. K. Mohanty, M.S., M.Ch, Additional DG and Head of Department, Vardhman Mahaveer Medical College and Safdarjung Hospital, C – II /124, Motibagh, New Delhi, India - 110021

CITATION: Urotoday Int J. 2010 Apr;3(2). doi:10.3834/uij.1944-5784.2010.04.06

ABBREVIATIONS AND ACRONYMS: CAH, congenital adrenal hyperplasia; DSD, disorder of sexual development; MRI, magnetic resonance image



Laparoscopic-Extended Pyelolithotomy With Concomitant Pyeloplasty: A Case Report



The authors provide the first known report of concomitant laparoscopic-extended pyelolithotomy with pyeloplasty. A 45-year-old male with symptomatic staghorn calculus secondary to pelviureteric junction obstruction underwent concomitant laparoscopic-extended pyelolithotomy and Fenger’s nondismembered pyeloplasty. The feasibility and limitations of the procedures are described. The authors concluded that despite its technical challenges, laparoscopic pyelolithotomy with pyeloplasty is a minimally invasive surgical option that provides the benefit of minimal morbidity with correction of the pelviureteric junction obstruction.

KEYWORDS: Staghorn Calculus; Pelviureteric junction obstruction; Pyeloplasty; Extended pyelolithotomy; Laparoscopy.

CORRESPONDENCE: Dr. Manickam Ramalingam, PSG Institute of Medical Sciences and Research, Peelamedu, Coimbatore – 641004, Tamilnadu, India ().

CITATION: Urotoday Int J. 2010 Apr;3(2). doi:10.3834/uij.1944-5784.2010.04.04

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



A Major Clinical Event Following Transperineal Prostate Biopsy: An Unexpected Duodenal Perforation


A 73-year-old Caucasian male underwent an ultrasound-guided transperineal prostate biopsy in an outpatient setting. Prostate cancer was suspected because of persistently rising prostate-specific antigen levels. The procedure was concluded early because the patient complained of extreme discomfort after the transrectal probe was inserted. After less than an hour, the patient described an acute abdominal pain that began suddenly after completion of the biopsy. Results of a computed tomography scan led to an emergency exploratory laparotomy. This procedure revealed a small duodenal perforation that was caused by a peptic ulcer and immediately repaired. The major clinical event of duodenal perforation following the execution of a transperineal prostate biopsy posed an immediate diagnostic challenge. The closely related timing of these 2 distinct and unlinked events represents the most unusual aspect of the case. It is a reminder that a concurrent disease always has to be considered and excluded despite the temporal closeness of reckoned occurrences.

KEYWORDS: Transperineal prostate biopsy; Peptic duodenal perforation; Complication

CORRESPONDENCE: Dr. Rafael Boscolo-Berto, Department of Oncological and Surgical Sciences, Urology Clinic, University of Padua, Via Giustiniani 2, 35100 Padua, Italy ().

CITATION: UroToday Int J. 2010 Apr;3(2). doi:10.3834/uij.1944-5784.2010.04.08



Giant Vesical Diverticulum Calculus: A Case Report


Vesical diverticula are herniations of the bladder mucosa and submucosa through the muscular wall of the bladder. A massive or giant vesical diverticulum calculus is a rare entity. It is usually secondary to bladder outlet obstruction. The patient typically presents with lower urinary tract symptoms, abdominal distension, or abdominal pain. The present case is a 75-year-old male with a giant vesical diverticulum calculus. The surgeons found 12 cm × 10 cm intradiverticular and 6 cm x 4 cm intravesical stones during laparotomy. They performed a diverticulectomy with stone extraction and primary closure. Six months postoperatively, the patient had no voiding dysfunction. The case is compared with 9 others reported in the literature.

KEYWORDS: Urinary bladder; Vesical diverticulum; Stone; Diverticulectomy.

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

CITATION: Urotoday Int J. 2010 Apr;3(2). doi:10.3834/uij.1944-5784.2010.04.13

ABBREVIATIONS AND ACRONYMS: IVU, intravenous urography; LUTS, lower urinary tract symptoms



Thermal Ablation of the Distal Ureteral Mucosa as an Elective Technique in Laparoscopic Nephroureterectomy for Renal Pelvic Carcinoma: Preliminary Results


INTRODUCTION: Although laparoscopic nephroureterectomy is an accepted procedure for treatment of urothelial carcinoma of the renal pelvis or middle and proximal ureter, the way to perform the distal ureterectomy next to the perimeatic bladder mucosa is controversial. The purpose of this study was to test the efficacy of a technique that is designed to destroy the ureteral mucosa and the bladder perimeatic mucosa through thermal ablation.

METHODS: A total of 27 patients with urothelial neoplasm were treated. The mean size of the tumors was 3.2 cm (range, 0.3-6 cm). Urinary cytology was positive and none of the tumors were classified as low-grade malignancy. All patients had thermal ablation of the distal ureter and perimeatic bladder mucosa with a Bugbee electrode through a cystoscope. The electrode was introduced 6 cm into the distal ureteral lumen and then extracted by a continuous rotating movement, with a 40 watt electrocoagulation power administered at the rate of 3 seconds per cm. The perimeatal mucosa was fulgurated with the same electrode, and the laparoscopic nephroureterectomy was performed.

RESULTS: There were no intraoperative complications. The mean follow-up period was 5.2 years (range, 3 months to 14 years). Three patients died from the progression of their disease. Of the remaining 24 patients, 9 had urothelial neoplasm recurrences in the bladder; none were in the ureteral trunnion or perimeatal mucosa. The other 15 patients were asymptomatic and disease-free at their final evaluation.

CONCLUSION: Thermal ablation of the distal ureteral mucosa simplifies the technique of laparoscopic nephroureterectomy for renal pelvic carcinoma and decreases the risk of cancer cell dissemination.

KEYWORDS: Ureteral laparoscopic detachment; Laparoscopic nephroureterectomy; Renal pelvic carcinoma.

CORRESPONDENCE: Prof. José Gabriel Valdivia-Uría, MD, Urbanización Santa Fe, calle 4a, no 13, Cuarte de Huerva 50410, Zaragoza, Spain ().

CITATION: UroToday Int J. 2010 Apr;3(2). doi:10.3834/uij.1944-5784.2010.04.12

ABBREVIATIONS AND ACRONYMS: TUR, transurethral resection



Renal Pedicle Vessel Control During Transperitoneal Laparoscopic Nephrectomy Using Hem-o-lok Clips With and Without LigaSure Sealing


INTRODUCTION: The technique used to control and divide the renal vessels during laparoscopic nephrectomy is critical to successful surgical outcomes. The aim of this study was to compare renal pedicle vessel control using (1) Hem-o-lok clips with a LigaSure vessel sealing system, and (2) Hem-o-lok clips without LigaSure.

METHODS: A total of 20 patients underwent unilateral transperitoneal laparoscopic nephrectomy between February 2007 and February 2008.  They were divided nonrandomly into 2 groups.  Group 1 (n = 10) underwent laparoscopic nephrectomy using Hem-o-lok clips and the Valleylab LigaSureâ„¢ vessel sealing system; group 2 (n = 10) underwent laparoscopic nephrectomy using Hem-o-lok clips without LigaSure.  Outcome variables were compared across groups using Mann-Whitney tests.

RESULTS: The mean operative time was significantly shorter for patients in group 1 (P < .0001).  Clip time was significantly shorter for patients in group 1 (P < .0001).  Transection time was significantly shorter for patients in group 2 (P < .0001).  There were no significant group differences in total pedicle dissection time (P > .05).  Subcutaneous emphysema and intraabdominal adherence were the only complications recorded, and there were no significant group differences in their occurrence.  There was no conversion to open surgery in either group. There was no significant group difference in mean length of hospitalization.

CONCLUSION: Results of the present study showed that using the LigaSure vessel sealing system for laparoscopic nephrectomy can decrease operative time. The shorter operative time is attributed to easier control of bleeding and a reduced number of instrument exchanges when using the LigaSure device.

KEYWORDS: LigaSure; Laparoscopic nephrectomy; Renal pedicle control; Hem-o-lok clip

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.1944-5784.2010.04.10



Is the Transitional Zone Biopsy Specimen Significant for Prostate Cancer Detection?


INTRODUCTION: Reports of prostate cancer (PCa) detected from biopsies obtained from the transitional zone (TZ) have become more common. However, TZ prostate biopsies have the potential to cause infectious complications, and questions remain about their value. The purpose of the study was to investigate the detection of PCa from biopsies taken from the TZ and peripheral zone (PZ), individually and in combination.

METHODS: Retrospective data were collected from 482 men who underwent sextant PZ plus TZ biopsy (2 cores, 1 from each lobe) for suspected PCa. The data were analyzed for the relationships between the presence of PCa from TZ or PZ biopsies, prostate-specific antigen (PSA) levels, and Gleason scores (GSs).

RESULTS: PCa was detected on biopsy in 192 (39.8%) patients. PCa was detected only in the TZ for 10 patients (5.2%), only in the PZ for 69 patients (35.9%), and in both the TZ and PZ for 113 patients (58.9%). Obtaining a biopsy only from the TZ resulted in a significantly lower cancer detection rate than obtaining the biopsy only from the PZ or from the combined PZ and TZ (P < .05). High GSs (≥ 7) were found in 3 of 10 patients (30%) with PCa detected in the TZ, 29 of 69 patients (42%) with PCa detected in the PZ, and 90 of 113 patients (79.6%) with PCa detected in the combined TZ and PZ. Among the patients with PSA levels < 10 ng/mL, none of the 4 patients with PCa detected only in the TZ had GSs ≥ 7; however, 14 of 41 patients (34.1%) with PCa detected only in the PZ and 18 of 32 patients (56.3%) with PCa detected in the combined TZ and PZ had GSs ≥ 7. Patients with a biopsy only from the TZ had significantly fewer GSs ≥ 7 than patients with a biopsy only from the PZ or from the combined PZ and TZ in this PSA range(P < .05).

CONCLUSION: It may be possible to omit a prostate biopsy from the TZ for patients with serum PSA < 10 ng/mL.

KEYWORDS: Prostate biopsy; Transitional prostate zone; Gleason scores

CORRESPONDENCE: Katsumi Shigemura, MD, PhD, Division of Urology, Department of Organ Therapeutics, Faculty of Medicine, Kobe University Graduate School of Medicine, 7-5-1, Kusunoki-cho, Chuo-ku, Kobe, Japan 650-0017 ().

CITATION: UroToday Int J. 2010 Apr;3(2). doi:10.3834/uij.1944-5784.2010.04.05

ABBREVIATIONS AND ACRONYMS:GS, Gleason score; PBx, prostate biopsy; PCa, prostate cancer; PSA, prostate-specific antigen; PZ, peripheral zone; RP, radical prostatectomy; TRUS, transrectal ultrasound; TZ, transitional zone




Periurethral Injection of Self-Detachable Silicon Microballoons for Female Urinary Incontinence: Surgical Technique and Long-term Results


INTRODUCTION: Periurethral injections of absorbable and nonabsorbable materials have been proposed as treatment options for urinary incontinence due to intrinsic sphincter deficiency (ISD). Periurethral microballoon implantation has emerged more recently, but there are few reports regarding its efficacy and safety. The purpose of the present study was to describe the surgical technique and long-term follow-up results of periurethral microballoon implantation.

METHODS: A total of 11 female patients with urinary incontinence due to ISD were prospectively evaluated and treated with periurethral microballoon implantation. All patients were evaluated with a physical exam, urodynamic study, and 1-hour pad test both preoperatively and at follow-up assessments. The preoperative and final number of urine loss episodes, urodynamic assessment measures, and pad test results were compared statistically.

RESULTS: The mean operative time was 31 minutes (range, 20-47 minutes). The mean follow-up was 18 months (range, 9-60 months). Postoperatively, 3 patients (27.3%) were continent, 5 patients (45.4%) were improved, and 3 patients (27.3%) were incontinent. Both Valsalva leak point pressure and pad test weight values decreased significantly after surgery (P < .001). There were no significant presurgery and postsurgery differences for the number of urine loss episodes, detrusor pressure at maximum flow, maximum flow, maximum cystometric capacity, or postvoid residual volume (P > .05). Complications included de novo detrusor hyperactivity in 1 patient and microballoon extrusion in 5 patients (2 in the first year). Early extrusions appeared due to superficial injection of the balloon. Later extrusions may be attributed to the balloon's oval shape, because it offers no mechanical adherence to surrounding tissues.

CONCLUSION: Periurethral microballoon injection should not be used as an alternative treatment for female urinary incontinence because of a high number of extrusions and other reported complications.

KEYWORDS: Urinary incontinence; Treatment; Periurethral injection; Microballoon

CORRESPONDENCE: Ricardo Miyaoka, MD, Rua Durval Cardoso,172, Jardim Guarani, Campinas, Sao Paulo, Brazil ().

CITATION: UroToday Int J. 2010 Apr;3(2). doi:10.3834/uij.1944-5784.2010.04.11

ABBREVIATIONS AND ACRONYMS: ISI, intrinsic sphincter insufficiency; VLPP, Valsalva leak point pressure



Stress Urinary Incontinence Managed By Tension-Free Vaginal Tape: A Single Center Experience With 5-Year Follow-up


INTRODUCTION: Stress urinary incontinence (SUI) is a condition that affects quality of life. Approximately 50% of incontinent women have SUI. Although conservative management is the first line of treatment, it is expensive and of limited value. The aims of the present study were to evaluate the safety and efficacy of the tension-free vaginal tape (TVT) sling in management of SUI in Indian women and to report 5-year follow-up data.

METHODS: This prospective study was conducted between January 2003 and August 2004. It included 157 patients with genuine SUI, based on a strong clinical history, positive Bonney test, and urine leak on stress during urodynamic study and cysotoscopy. Mean age was 56.3 years; the mean number of births was 2.5. The patients underwent TVT sling procedure under spinal or caudal anesthesia. Periodic follow-up at monthly intervals for the first 6 postoperative months and every 3 months thereafter was done for next 5 years. Any TVT-related complications were recorded and managed accordingly. Objective and subjective measures of surgical success were recorded and analyzed statistically.

RESULTS: Mean operating time was 25 minutes (range, 20-30 minutes). The 157 patients were available for an average of 60 months (range, 58-72 months) of follow-up evaluations. Postoperative urinary tract infections occurred in 13 patients (8.2%). Perioperative complications requiring surgical correction occurred in 10 patients (6.3%) and included urinary retention (n = 5), bladder perforation (n = 3), and urethral perforation (n = 2). Objective cure was defined as the absence of urine leak during a cough test in the lithotomy or upright position. Objective cure, improvement, and failure were recorded in 134 (85.3%), 11 (7%), and 12 (7.6%) patients, respectively. Subjective cure was defined as no reported loss of urine with exercise, coughing, or weight lifting. Subjective cure, improvement, and failure were recorded in 137 (87.3%), 9 (5.7%), and 11 (7%) patients, respectively.

CONCLUSION: TVT is a minimally invasive procedure that is safe and efficacious in the long term for surgical management of genuine SUI. The procedure results in minimal perioperative complications.

KEYWORDS: Tension-free vaginal tape; Stress urinary incontinence; Urodynamics

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

CITATION: Urotoday Int J. 2010 Apr;3(2). doi:10.3834/uij.1944-5784.2010.04.02

ABBREVIATIONS AND ACRONYMS: ICCQ, International Consultation on Incontinence Questionnaire; SUI, stress urinary incontinence; TVT, tension-free vaginal tape; UTI, urinary tract infection; VLPP, Valsalva leak point pressure



Undetectable Prostate-Specific Antigen Level Following Prostate Brachytherapy: An Apples-to-Apples Comparison with Radical Prostatectomy


INTRODUCTION: Following radical prostatectomy for adenocarcinoma of the prostate, a long-term undetectable PSA level is associated with cure. Cure may also be defined by persistently low PSA levels after radiation, with the assumption that residual benign prostate tissue may produce low levels of PSA. There is no established PSA nadir following radiation therapy that has been universally associated with cure. The purpose of this study was to determine the frequency of undetectable PSA following prostate brachytherapy.

METHODS: A total of 163 patients were treated with radioactive iodine-125 seed implantation as definitive treatment, between 1996 and 2003. No patients received external radiation or hormone therapy. Posttreatment PSA levels were reviewed to ascertain the number of patients with PSA levels that were undetectable, ≤ 0.2, ≤ 0.3, and ≤ 0.5 ng/mL. PSA failure was based on the ASTRO consensus definition.

RESULTS: At a median follow-up of 85.2 months, 120 patients (73.6%) achieved and maintained an undetectable PSA level. Twenty-three patients (14%) experienced biochemical failure by the ASTRO definition; 80%, 83%, and 85% achieved and maintained PSA nadirs of ≤ 0.2, ≤ 0.3, and ≤ 0.5 ng/mL, respectively.

Comparing outcomes of patients treated with radical prostatectomy and radiation therapy for prostate cancer is difficult, due to different PSA patterns following treatment and varying definitions of success. The present study showed that an undetectable PSA level after brachytherapy is consistently associated with disease-free state, which reflects the durability of that biochemical status. It matches the most stringent definition of disease freedom following prostatectomy.

CONCLUSIONS: Comparing outcomes of patients treated with radical prostatectomy and radiation therapy for prostate cancer is difficult, due to different PSA patterns following treatment and varying definitions of success. The present study showed that an undetectable PSA level after brachytherapy is consistently associated with disease-free state, which reflects the durability of that biochemical status. It matches the most stringent definition of disease freedom following prostatectomy.

KEYWORDS: Prostate cancer; Brachytherapy; Prostatectomy

CORRESPONDENCE: William L. Barrett, MD, Department of Radiation Oncology, University of Cincinnati College of Medicine, 234 Goodman Street ML 0757, Cincinnati, Ohio 45267-0757 USA ().

CITATION: Urotoday Int J. 2010 Apr;3(2). doi:10.3834/uij.1944-5784.2010.04.16

ABBREVIATIONS AND ACRONYMS: ASTRO, American Society for Therapeutic Radiology and Oncology; I-125, iodine-125; PSA, prostate-specific antigen.



Spontaneous Pyeloduodenal Fistula Complicating a Xanthogranulomatous Pyelonephritis: A Case Report


A 57-year-old female presented with recurrent episodes of right flank pain and fever for the past several years. No pathogens were detected in the urine culture. Intravenous pyelography and computed tomography revealed a poorly functioning right kidney with an upper pole cystic tumor. The right retrograde pyelography showed communication between the renal pelvis and the duodenum. A nephrectomy and fistula repair were performed. Histological examination revealed chronic pyelonephritis with xanthogranulomatous reaction and a cystic renal tumor. The patient remains well at 7-year follow-up.

KEYWORDS:Urodigestive fistulas; Urinary tract infection; Nephrectomy; xanthogranulomatous pyelonephritis

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

CITATION: UroToday Int J. 2010 Apr;3(2). doi:10.3834/uij.1944-5784.2010.04.09

ABBREVIATIONS AND ACRONYMS: CT, computed tomography; XPG, xanthogranulomatous pyelonephritis



Clinical Management of High-Flow Priapism and Penile Mondor's Disease Following Transrectal Prostate Biopsy


Transrectal ultrasound-guided biopsy is considered a safe procedure that can be performed in an outpatient setting. However, occasional major complications can occur. The present 53-year-old patient had a transrectal prostate biopsy because of persistently high prostate-specific antigen levels. The histologic examination reported the absence of cancer. Two weeks later, he presented with high-flow priapism and penile Mondor's disease that was characterized by penile superficial dorsal vein thrombosis. There was a palpable rope-like induration on the dorsal surface of the penile shaft. Diagnosis of the 2 concurrent disorders required complex radiological investigation that included magnetic resonance angiography, which is presented in detail in a companion paper. The present report contains a description of the conservative treatment simultaneously adopted for the posttraumatic priapism and the penile vein thrombosis. There was a progressive decrease in the induration, with a final complete resolution and preservation of full erections at 3 months.

KEYWORDS: Transrectal prostate biopsy; Penile Mondor's disease; Priapism; Complication

CORRESPONDENCE: Dr. Rafael Boscolo-Berto, Department of Oncological and Surgical Sciences, Urology Clinic, University of Padova, Via Giustiniani 2, 35100 Padova, Italy ().

CITATION: Urotoday Int J. 2010 Apr;3(2). doi:10.3834/uij.1944-5784.2010.04.14

ABBREVIATIONS AND ACRONYMS: MRA, magnetic resonance angiography; TRUS, transrectal ultrasound



Letter from the Editor - February 2010

Dear Colleagues,

It is a pleasure to welcome you to our first issue in 2010. The UIJ is consistently read by over 20,000 individual subscribers in 206 countries throughout the six continents of the globe. It is truly a unique scientific publication in that it is free for authors to submit manuscripts; it remains open access and resides on a custom platform, unlike any other journal that allows for searchable content within the entire database. It facilitates searchable content with topics, key words or any phrase and will rapidly provide a listing of all articles that include any of the above.

Several studies in the current issue are related to management of ureteral stones. Tawfiek stated that the ideal treatment procedures for large (> 1 cm) proximal ureteral stones have not been defined. Therefore, he divided 147 patients into a group treated with extracorporeal shockwave lithotripsy (ESWL) and a group treated with a semirigid ureteroscope and lithoclast. He found a statistically significant group difference at the 1-month evaluation, when 58% of the patients were stone free after ESWL and 92% were stone free after ureteroscopy. A study by Salem et al is about steinstrasse (stone street), an obstructive column of stone fragments retained in the ureteral lumen after ESWL. Spontaneous expulsion is reported in about 37% of cases; otherwise, ureteroscopy, percutaneous nephrolithotomy, or additional ESWL treatment is needed. The authors compared a group of 44 patients receiving tamsulosin (0.4 mg daily) for management of steinstrasse with a control group of equal size and similar characteristics. After 28 days, stone expulsion occurred in 72.7% of the patients receiving tamsulosin and 56.8% of the patients in the control group; the difference was statistically significant.

The objective of a randomized, controlled study by Abdel-Meguid was to compare transurethral resection of the prostate in saline (TURPis) using the TURis system with the standard monopolar TURP, to determine evidence of safety and efficacy. The results of the investigation in the context of current literature show that TURPis has the potential to become a preferred method for treatment of benign prostatic hyperplasia (BPH).

Although the focus of many articles in this journal is clinical, basic science research is always welcome. Geyer et al compared tissue distribution and brain penetration of the antimuscarinic drugs trospium chloride and oxybutynin in a mouse model. Additionally, the role of the drug efflux carrier P-glycoprotein for hepatobiliary and urinary excretion and the blood-brain barrier permeability of oxybutynin were evaluated by using knockout mice that were deficient in P-glycoprotein. The authors report that brain penetration of oxybutynin highly exceeded that of trospium chloride at an equal dosage. Implications for patients who are elderly or have disease conditions are discussed.

Finally, Merkle provides a timely review in response to the well known Selenium and Vitamin E Cancer Prevention Trial (SELECT) published in 2009. The SELECT Trial demonstrated that these supplements, alone or in combination, did not prevent prostate cancer in a population of relatively healthy men. Merkle discusses some possible limitations to the study and presents literature with contradictory evidence.

In this first issue of 2010, we introduce the Editorial Board for this year. We extend our gratitude to the retiring board members and our new board members, along with all of our reviewers, for their service. We look forward to the new research that our readers will share with us this year and welcome your submissions.

Kind regards,

K-E Andersson

Renal Brucelloma in a Herniated Kidney


Brucella is a common zoonotic infection worldwide that can target many organs. Nonetheless, genitourinary involvement is uncommon, with renal abscess formation being exceptionally rare. The authors present a rare case with extensive renal involvement in a patient previously undiagnosed with brucellosis. The patient's kidney herniated through the femoral canal into the thigh. The breadth of disease found on imaging is dramatic in comparison to the patient's mild presentation of chronic, nonspecific symptoms.

KEYWORDS: Brucellosis; Hydronephrosis; Renal abscess

CORRESPONDENCE: Siamak Daneshmand, MD. Section of Urologic Oncology, Oregon Health & Science University, 3303 SW Bond Ave, CH10U, Portland, OR 97239 USA ().

CITATION: UroToday Int J. 2010 Feb;3(1). doi:10.3834/uij.1944-5784.2010.02.11



Differences in the Brain Penetration of the Anticholinergic Drugs Trospium Chloride and Oxybutynin


INTRODUCTION: This study was performed to compare tissue distribution and brain penetration of the anticholinergic drugs trospium chloride and oxybutynin in a mouse model. Additionally, the role of the drug efflux carrier P-glycoprotein for hepatobiliary and urinary excretion and the blood-brain barrier permeability of oxybutynin were evaluated by using knockout mice that were deficient in P-glycoprotein.

METHODS: Radio-labeled trospium chloride and oxybutynin were administered orally (1 mg/kg) to wild-type and P-glycoprotein deficient knockout mice. Tissue distribution of the drugs was analyzed after 12 hours. Additionally, oxybutynin was applied intravenously to gall bladder cannulated mice of both types. Drug excretion into bile and urine was analyzed over 2 hours by catheterization.

RESULTS: Absolute drug concentrations in the brain were almost 200-fold higher for oxybutynin (~200 ng/g) compared with trospium chloride (~1 ng/g) when applied at an equal dosage of 1 mg/kg orally, whereas concentrations in the liver were only 15-fold different (~300 ng/g for oxybutynin and ~20 ng/g for trospium chloride). P-glycoprotein deficient knockout mice after oxybutynin application showed no significant differences in brain penetration or drug excretion into bile and urine when compared with wild-type mice.

CONCLUSION: Brain penetration of oxybutynin highly exceeds that of trospium chloride at an equal dosage (1 mg/kg, given orally). In contrast to trospium chloride, brain penetration of oxybutynin is not restricted by the drug efflux carrier P-glycoprotein because oxybutynin is not a P-glycoprotein substrate in vivo.

KEYWORDS: Trospium chloride; Oxybutynin; P-glycoprotein; Multidrug resistance gene 1 (mdr1); Blood-brain barrier; Transport

CORRESPONDENCE: Prof. Dr. Joachim Geyer, Institute of Pharmacology and Toxicology, Justus Liebig University of Giessen, Frankfurter Str. 107, 35392 Giessen, Germany ().

CITATION: Urotoday Int J. 2010 Feb;3(1). doi:10.3834/uij.1944-5784.2010.02.12



Pure Laparoscopic Repair of Benign Colovesical Fistula Without Colectomy or Proximal Diversion: Report of 2 Cases


The authors report management of 2 patients with symptomatic colovesical fistula due to diverticular disease of the colon. Initial laparoscopy showed that there was: (1) no active inflammation, malignancy, or abscess; (2) a single fistulous communication without much adhesion; (3) a pliable colon; (4) no distal obstruction or other pathology in the large bowel; (5) a healthy omentum to interpose between the bowel and bladder. Therefore, conventional colectomy and proximal diversion were deferred. Laparoscopic excision of the fistula and closure of the bladder and colon were performed, with interposition of the omentum. To the authors’ knowledge, this is the first report of such a procedure. The 2 patients remained symptom-free after 5 years and 6 months, respectively. Pure laparoscopic repair of a colovesical fistula without colectomy or proximal diversion appears to be feasible, safe, and effective in select patients.

KEYWORDS: Colovesical fistula; Laparoscopy; Colonic divertulosis

CORRESPONDENCE: Dr. Manickam Ramalingam, Department of Urology, PSG Institute of Medical Sciences, Peelamedu, Coimbatore, Tamilnadu 641004, India ().

CITATION: Urotoday Int J. 2010 Feb;3(1). doi:10.3834/uij.1944-5784.2010.02.06



Evaluation of Prolene Mesh as a Transobturator Tape for Treatment of Female Stress Urinary Incontinence


INTRODUCTION: Slings are commonly used to treat female stress urinary incontinence (SUI). Various sling materials have been tried. The objective of this retrospective study was to determine the short-term efficacy, safety, and urodynamic effects of a suburethral sling made of polypropylene mesh and passed through the obturator foramen.

METHODS: The participants were 53 female patients with SUI; 16 (30%) had pure intrinsic sphincter deficiency (ISD) and 37 (70%) had mixed ISD and hypermobility. Preoperative evaluation consisted of history, voiding diary, examination, ascending cystography, urodynamic studies, and routine laboratory investigations. All patients were treated with a polypropylene mesh (Prolene; Ethicon Ltd, Bracknell, UK) suburethral sling. The Prolene mesh was cut into a tape measuring 30 x 1.5 cm and sterilized by autoclave. The mesh was placed at the midurethra and passed through the obturator foramen by Vicryl sutures, loaded on a curved needle that was specially designed to hold the suture. The needle was passed from the outside to the inside. The mesh was anchored to the subcutaneous tissue at the lateral edge of labia majora with Vicryl sutures. One month after surgery, patients had an interview, examination, urine analysis, and pelvic ultrasound to detect residual urine. Urodynamic evaluation was done 3 months postoperatively. Patients were then followed every 3 months through a voiding diary and examination. The mean follow-up period was 18 months.

RESULTS: All procedures were completed with no intraoperative complications, failures, or recurrences of SUI. At the 1-month follow-up, 3 patients (5%) had developed a small erosion of the anterior vaginal wall associated with lower abdominal pain, urgency, dysuria, and urinary tract infection. The patients were managed conservatively with antibiotics and local estrogen cream. At the 3-month follow-up, the erosion healed completely. Three patients (5%) complained of sensory urge incontinence both preoperatively and postoperatively. They were managed with anticholinergics.

CONCLUSION: Preliminary results showed that the suburethral transobturator Prolene mesh sling is a safe, efficient, reproducible, and low-cost technique for treatment of stress urinary incontinence. Complications exist but can be successfully managed.

KEYWORDS: Sling, Transobturator tape (TOT), Prolene, Stress urinary incontinence (SUI)

CORRESPONDENCE: Ahmed Abdelbary, MD, Department of Urology, Bani Swaif University, Bani Swaif, 11371, Egypt ().

CITATION: UroToday Int J. 2010 Feb;3(1). doi:10.3834/uij.1944-5784.2010.02.08



Comparison of Open vs Laparoscopic Nephrectomy: Outcomes and Complications


INTRODUCTION: Nephrectomy is indicated in patients with an irreversibly damaged kidney. The nephrectomy can be performed through open or laparoscopic procedure. Although there is evidence that laparoscopy is the preferred choice, additional evidence is indicated. The purpose of the present investigation was to compare the outcomes of nephrectomy through open and laparoscopic procedures.

METHODS: Between December 2006 and March 2009, 20 patients had laparoscopic nephrectomy and 20 patients had open nephrectomy. The mean patient age was 46.85 years in the group receiving open surgery and 48.15 years in the group receiving laparoscopy, with no significant group difference. Variables included operative time, length of hospitalization, and postoperative duration of nil per os (NPO) state. Complications such as hemorrhage, organ damage, infection, and reoperation were obtained from data in the patient’s medical records. The groups were compared using a t test and chi square.

RESULTS: Mean operative time for open surgery was 176.25 min; mean operative time for laparoscopy was 188.8 min. There was no significant difference in mean operative time between the groups (P = .571). Mean length of hospitalization was significantly longer for patients receiving open surgery than for patients receiving laparoscopy (4.9 days versus 3.45 days, respectively) (P = .004). There were no significant group differences in mean postoperative duration of NPO state for patients receiving open and laparoscopic surgeries (24.6 hours and 28.25 hours, respectively) (P = .542). Operative complications occurred in 6 patients in the open group and in 5 patients in laparoscopic group. There was no significant group difference in complication rates (P = .376).

CONCLUSIONS: The overall outcomes of the two procedures were similar. Laparoscopic nephrectomy, which is a minimal invasive procedure, is a recommended alternative for open surgery.

KEYWORDS: Nephrectomy; Laparoscopic nephrectomy; Open nephrectomy; Radical nephrectomy

CORRESPONDENCE: Ahmad Enshaei MD, Guilan University of Medical Sceinces, Urology Research Center, Razi Hospital, Sardare Jangal Street, Rasht, Iran ().

CITATION: Urotoday Int J. 2010 Feb;3(1). doi:10.3834/uij.1944-5784.2010.02.01



Prophylaxis and Treatment of Prostate Cancers by Nutrition Supplements: A Clinician's View of Facts and Hope After the SELECT Study


The well-known Selenium and Vitamin E Cancer Prevention Trial (SELECT) published in 2009 seems to show that prevention of prostate cancer by nutrition supplements is ineffective. Many opposing studies have found that various vitamins, minerals, and other over-the-counter (OTC) drugs show measurable effects in prostate cancer prevention and treatment. One purpose of the present review is to discuss some possible causes for the negative results in the SELECT study. For example, it is possible that unknown intake of vitamin C influenced their results, because vitamin C alters the effect of selenium. A second purpose of this review is to present evidence from other literature that an effective prophylaxis of prostate carcinoma is possible. Protective evidence from the literature is shown for selenium, lycopene, lignane, vitamin D, and vitamin E; vitamin C and vitamin B are not protective. Supplement combinations are preferable to single agents. Other substances with preliminary data are discussed. In conclusion, there is substantial evidence in the literature that daily use of protective supplements can be beneficial, and that these benefits should not be dismissed based on a single study that did not control all of the baseline variables.

KEYWORDS: Prostate cancer; Vitamin D; Vitamin E; Selenium; Lignane; Lycopine; Nutrition supplementation

CORRESPONDENCE: Walter Merkle, MD, Department of Urology, German Diagnostic Clinic, Aukammallee 33, Wiesbaden, 65191, Germany ().

CITATION: UroToday Int J. 2010 Feb;3(1). doi:10.3834/uij.1944-5784.2010.02.13



Treatment of Large Proximal Ureteral Stones: Extracorporeal Shock Wave Lithotripsy Versus Semirigid Ureteroscope with Lithoclast

See notice of redundant publication at the end of this article.



INTRODUCTION: The purpose of the study was to assess the safety and efficacy of extracorporeal shockwave lithotripsy (ESWL) versus a semirigid ureteroscope with a lithoclast for treatment of large proximal ureteral stones.

METHODS: The participants were 147 patients with large (> 1 cm) upper ureteral stones. ESWL and ureteroscopy were performed for 71 and 76 patients, respectively. The mean stone sizes and standard deviations (SD) were 1.34 cm (SD = 0.03) for the patients receiving ESWL and 1.51 cm (SD = 0.04) for the patients receiving ureteroscopy. There were no significant group differences in stone size (P = .604). ESWL was performed under intravenous sedation with a Siemens modularis litho vario lithotripter. Ureteroscopy was performed under spinal anesthesia with a 7.5 Fr semirigid ureteroscope and lithoclast.

RESULTS: At the 1-month evaluation, 41 out of 71 patients (58%) were stone free after the initial ESWL and 70 out of 76 patients (92%) were stone free after ureteroscopy. The group difference in the stone-free rate was statistically significant (P = .003). The stones were accessible in 72 of the 76 patients (95%) having ureterscopy. Stone fragments were available for analysis from 23 patients receiving ESWL and 70 patients receiving ureteroscopy. The majority of stones in both groups were composed of calcium oxalate dihydrate (COD). No major complications were encountered in either group.

CONCLUSIONS: The present study demonstrates that ureteroscopy with a lithoclast can be considered an acceptable treatment modality for large proximal ureteral calculi. It can be used as an initial treatment for large proximal ureteral stones.

KEYWORDS: Ureteroscopy; Extracorporeal shock wave lithotripsy (ESWL); Proximal ureter; Lithoclast

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

CITATION: Urotoday Int J. 2010 Feb;3(1). doi:10.3834/uij.1944-5784.2010.02.03



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