Issue 3: June 2010

UIJ Volume 3 Issue 3 2010

Letter from the Editor - June 2010

Dear Colleagues,

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

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

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

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

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

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

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

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

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


Kind regards,

K-E Andersson

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


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

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

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

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

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



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


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

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

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

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

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

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

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

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



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


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

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

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

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

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

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

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

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



Isoenzyme Creatine Kinase Mi as a Possible Indicator of Spermatozoa Maturity


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

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

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

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

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

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

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

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



Double-Barreled Wet Ileostomy Following Pelvic Exenteration


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

KEYWORDS: Pelvic exenteration; Urinary diversion

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

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

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



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


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

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

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

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

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



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