Issue 2: April 2010

UIJ Volume 3 Issue 2 2010

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.



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