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

INTRODUCTION: The objective of this prospective randomized controlled study 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.

METHODS: Patients with symptomatic benign prostatic hyperplasia (BPH), aged 50 years or older, with estimated prostate volume (PV) ≤ 80 mL, maximum flow rate (Qmax) ≤ 15 mL/s, and an International Prostate Symptom Score (IPSS) ≥ 14 were included in the study. A total of 38 patients ranging in age from 52-78 years completed the study. Patients were randomly allocated to receive either TURP or TURPis in a 1:1 ratio. Primary endpoints were: (1) declines in serum sodium (Na+) and hemoglobin (Hb); (2) incidence of TUR syndrome; and (3) changes in IPSS, quality of life (QoL), and maximum flow rate (Qmax). Secondary endpoints included: (1) differences in procedure, irrigation, catheterization, and hospitalization times; (2) variations in blood transfusion, recatheterization, and clot retention rates; (3) changes in prostate specific antigen (PSA), prostate volume (PV), and postvoid residual urine (PVR); and (4) incidences of postoperative complications. Patients were followed for 6 months

RESULTS: The mean PV for the entire study population was 44.1 mL (SD = 2.0; range, 29-78 mL). There were no significant differences between groups on any of the baseline variables. Mean (standard deviation) declines in serum Na+ were 4.8 (1.1) and 0.9 (0.3) mmol/L for the patients receiving TURP and TURPis, respectively (P < .001). Mean declines in Hb were 1.5 (0.6) and 0.7 (0.4) g/dL for the patients receiving TURP and TURPis, respectively (P < .002). The patients receiving TURPis had significantly smaller declines for both of these variables. When compared with the patients receiving TURP, those receiving TURPis had significantly shorter mean times for the procedure (P < .03), irrigation (P < .001), catheterization (P < .02), and hospitalization (P < .02). The patients receiving TURPis had significantly fewer clot retentions (P < .05) than the patients receiving TURP. None of the patients in either group required blood transfusion or demonstrated TUR syndrome. One patient receiving TURP developed a bladder neck contracture; 1 patient receiving TURPis experienced urethral stricture. Efficacy outcomes (IPSS, QoL, Qmax, PSA, PV, and PVR) revealed that all changes from baseline were statistically significant in both groups (P < .05). However, none of the between-group comparisons reached statistical significance.

CONCLUSION: TURPis has the potential to be the new gold standard for BPH treatment. The present study demonstrated that over a 6-month period, TURPis has efficacy similar to TURP. TURPis has additional advantages of smaller declines in serum sodium and hemoglobin, reduced irrigation and catheterization times, shorter hospital stay, and elimination of TUR syndrome.

KEYWORDS: Benign prostatic hyperplasia; Bipolar; Bipolar transurethral resection; Prostate; Transurethral resection syndrome

CORRESPONDENCE: Dr. Taha Abo-Almagd Abdel-Meguid, PO Box 80215, Jeddah 21589, Saudi Arabia ().

CITATION: UroToday Int J. 2010 Feb;3(1). doi:10.3834/uij.1944-5784.2010.02.05

INTRODUCTION: Steinstrasse is a well-known complication following extracorporeal shock wave lithotripsy (ESWL). It has been identified in 5-10% of patients with large stone burdens (> 2 cm) and may necessitate surgical intervention if medical treatment fails. The objective of the present randomized, controlled study was to evaluate the efficacy of tamsulosin as a conservative management of steinstrasse.

METHODS: The participants were 88 patients with unilateral steinstrasse who were treated between January 2005 and December 2008. The patients were randomly allocated into 2 equal groups of 44 patients. There were no significant differences between groups for age, sex, stone location, stone length, or stone fragment size (P > .05). Patients in group 1 (study group) received a single daily morning dose of tamsulosin (0.4 mg) for a maximum of 4 weeks, in addition to pain-relieving therapy. Patients in group 2 (control group) received only the pain-relieving therapy. All patients were checked weekly with a plain x-ray of the urinary tract (PUT), urinary ultrasonography, urine analysis, and serum creatinine level. Pain episodes, day of spontaneous stone expulsion, total analgesic dosage, and drug side effects were recorded. The data were analyzed using chi-square.

RESULTS: Stone expulsion occurred in 32 of the 44 patients (72.7%) receiving tamsulosin and in 25 of the 44 patients (56.8%) in the control group. Patients receiving tamsulosin had a significantly higher stone expulsion rate (P = .017). There were no significant differences between groups for mean stone expulsion time or number of analgesics used. Twelve patients (27.3%) in the group receiving tamsulosin and 19 patients (43.3%) in the control group needed hospitalization; the group difference was statistically significant (P = .017).

CONCLUSION: When compared with no treatment, tamsulosin can significantly facilitate expulsion of retained ureteral stone fragments following ESWL with less need for hospitalization.

KEYWORDS: Tamsulosin; Steinstrasse; Extracorporeal shock wave lithotripsy (ESWL)

CORRESPONDENCE: Esam Eldin Salem, MD, Department of Urology, University Hospital, 22 Mubarak Street, Sohag, 67543, Egypt ().

CITATION: Urotoday Int J. 2010 Feb;3(1). doi:10.3834/uij.1944-5784.2010.02.09

Once prostate cancer reaches a castrate-resistant state with bone metastases, the typical next step in treatment is chemotherapy using agents of the taxoid family. In addition, in documented bony metastases, the biphosphonate zoledronic acid is used to prevent incidence of skeletal events. Zoledronic acid is also used to control bony pain and to increase bone mineral density. The patient in this case report had proven hormone-refractory, chemotherapy-naïve prostate cancer. This is the first documented instance of prostate-specific antigen (PSA) normalization and improvement on bone scan radionuclide imaging in a patient treated with zoledronic acid.

KEYWORDS: Castrate-resistant prostate cancer; Zoledronic acid; Metastasis; PSA

CORRESPONDENCE: Wassim Kassouf, MD, FRCS(C), Division of Urology, McGill University Health Center, 1650 Cedar Avenue, Rm L8-315, Montreal, Quebec H3G 1A4, Canada ().

CITATION: UroToday Int J. 2010 Feb;3(1). doi:10.3834/uij.1944-5784.2010.02.07

INTRODUCTION: The purposes of the present retrospective study were to (1) evaluate the outcomes of emergency urological interventions during gynecological operations, and (2) offer management guidelines for the practicing urologist.

METHODS: The authors evaluated the records of 20 female patients with urinary tract injuries that occurred during gynecological operations between May 2003 and May 2005. The mean patient age was 28 years (range, 20-40 years). The patients were evaluated preoperatively by routine investigations, intraoperatively by ureteric catheterization and/or cystoscopy and ureteric catheterization, and postoperatively by sonography every 3 months for 1 year and by intravenous urography 6 months after surgery.

RESULTS: Urologic injury occurred during cesarean section (n = 12) and hysterectomy (n = 8). Six patients had bladder injuries that were repaired intraoperatively, followed by urethral catheterization. Fourteen patients had distal ureteral injuries that were repaired by ureteric catheterization and/or ureterovesical neoimplantation. Catheters were removed after 1 week. Six months after surgery, all patients had an intact upper urinary tract with no back pressure changes. No reflux or ureteric stricture was observed 1 year after surgical intervention.

CONCLUSION: Iatrogenic injuries to the urinary tract may occur during gynecological surgery. The bladder and distal ureters are the most commonly involved organs. Ureteral catheterization via a cystoscope or directly through the orifices should be used to assess the intactness of the ureter. Key factors to obtaining optimal results are early recognition and immediate repair of the damage.

KEYWORDS: Cesarean section; Ureter; Bladder injury; Cystoscopy; Ureteric catheterization; Ureterovesical reimplantation

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

CITATION: Urotoday Int J. 2010 Feb;3(1). doi:10.3834/uij.1944-5784.2010.02.04

INTRODUCTION: Despite evidence of increased cancer detection during repeat biopsy, no reports have addressed the likelihood of cancer detection after a negative repeat saturation biopsy or the risk factors that would warrant performing additional saturation biopsies. The investigators tested the hypothesis that a narrowly defined population with 2 biopsies showing no prostatic intraepithelial neoplasia (PIN) or atypia is effectively ruled out as having a risk of prostate cancer.

METHODS: The authors retrospectively evaluated 655 patients that had repeat saturation prostate biopsies from April 2002 to January 2009. Repeat saturation biopsy included patients who had 2 or more biopsies with at least the most recent being a saturation biopsy of 20 cores or more. Repeat biopsy was performed if prostate-specific antigen (PSA) rose significantly after the last biopsy. The variables analyzed were PSA, age, race, number of previous biopsies, number of cores taken, inflammation on pathology specimens, total prostate volume, and digital rectal exam (DRE) results.

RESULTS: Of the 655 patients with repeat saturation biopsies, 236 were truly negative, defined as no cancer, atypia, or PIN. In a mean follow-up of 33.2 months (range, 0-70) 70 of the 236 patients (30%) clinically required a repeat saturation biopsy. Of these, 10 (4.2%) developed prostate cancer. Most patients who were diagnosed with cancer had a PSA >10 ng/mL at the first saturation biopsy, as opposed to PSA <10 in="" the="" group="" that="" did="" not="" develop="" prostate="" cancer="" a="" multivariate="" analysis="" comparing="" patients="" developed="" with="" those="" remained="" free="" significant="" predictors="" of="" future="" were:="" higher="" number="" previous="" biopsies="" i="">P = .006), higher number of cores taken (P = .02), decreased total prostate volume (P = .03), and change in PSA (P = .0002). PSA at first saturation biopsy (P = .006) and PSA at final follow-up evaluation (P = .0001) were significantly different between patients with and without prostate cancer.

CONCLUSION: Patients with a history of negative saturation biopsy have around a 4% chance of being diagnosed with prostate cancer over a mean follow-up period of 33 months. Biopsy detection of prostate cancer in those men who had an additional biopsy because of elevated PSA or change in DRE resulted in a detection rate of 14%, which is clinically substantial. Patients with a rising PSA may warrant a lower threshold for subsequent repeat saturation biopsy. Saturation biopsy as repeat biopsy detects almost all significant cancers and may obviate the need for future biopsy in men who are carefully followed with clinical examinations.

KEYWORDS: Prostate biopsy; Saturation biopsy; Prostate-specific antigen (PSA)

CORRESPONDENCE: J. Stephen Jones, MD. Cleveland Clinic Glickman Urological Institute, Department of Urology, 9500 Euclid Ave, Cleveland, OH, 44195 USA ().

CITATION: UroToday Int J. 2010 Feb;3(1). doi:10.3834/uij.1944-5784.2010.02.10

Renal congenital, idiopathic, or acquired arteriovenous (AV) malformations are uncommon entities. Most symptomatic congenital renal AV malformations require active treatment. Arterial embolization is currently considered the treatment method of choice. The authors present a case of a 33-year-old male who presented with renal colic and macroscopic hematuria. Investigation showed renal AV malformation, which was successfully treated with selective embolization of the vessels using coils and glue.

KEYWORDS:Renal arteriovenous malformation; Selective embolization

CORRESPONDENCE: Ploutarchos Anezinis, Urologic Department of Venizeleion General Hospital, 40 Ermi Street, Heraclion, Crete, Greece P.C. 71409 ().

CITATION: UroToday Int J. 2010 Feb;3(1). doi:10.3834/uij.1944-5784.2010.02.02