Issue 6: December 2010

UIJ Volume 3 Issue 6 2010

Letter from the Editor - December 2010

Dear Colleagues,

Welcome to the December 2010 issue of the UIJ. I am pleased to announce that all articles published in the UroToday International Journal are now indexed by SCOPUS and Excerpta Medica Database (Embase). Scopus is the largest abstract and citation database that contains both peer-reviewed research literature and Web sources. It has nearly 18,000 titles from more than 5,000 publishers. Embase contains over 23 million indexed biomedical records from more than 7,500 journals. These two major indexing sources provide readers with easy access to our articles and assure our authors of extensive coverage for their papers.

In this issue, Newman et al assesses the effects of darifenacin on the reduction in the number of incontinence episodes and diary days where no incontinence episodes are reported (termed "dry days") in a population of patients with incontinence and overactive bladder. The authors analyzed data from three-phase III fixed-dose, randomized, placebo-controlled studies (n = 1059). The results demonstrate that darifenacin treatment significantly reduces the number of incontinence episodes and increases the number of patients experiencing 3 or more consecutive dry days. Similar results were shown in the two-year, open label study, demonstrating significant improvement in health-related quality of life scores.

Halachmi et al examine renal cancer recurrence following nephron-sparing surgery in 229 patients. Significant predictors of oncological failure include: tumor size less than 4 cm, central tumor location, multifocal tumors, and male gender. Further, the findings include that warm ischemia time greater than 20 minutes is a significant predictor of recurrence. The oncological effectiveness of nephron-sparing surgery is compared to reported outcomes of radical nephrectomy.

Pandith et al evaluate the frequency and distribution of FGFR3 somatic mutations in bladder tumors. The authors examined DNA preparations from paired tumor and adjacent normal tissue specimens from 65 patients with transitional cell carcinoma (TCC). The authors identified Codon S417Y, a new mutation. The pattern and distribution of FGFR3 mutations were significantly associated with low-grade and low-stage tumors. The frequency of mutation decreased significantly with an increase in tumor invasiveness. The results indicate that FGFR3 mutations can be useful in distinguishing superficial from invasive bladder lesions.

Wang et al study 56 patients receiving renal transplant to evaluate the efficacy and safety of a preoperative high-dose (1.5 mg/kg) and postoperative short-term low-dose (0.5-1 mg/kg) prophylactic application of rabbit antihuman thymocyte immunoglobulin (ATG-R) plus immunosuppressive therapy. They compared the outcomes to a control group receiving only immunosuppressive therapy. ATG-R treatment resulted in a significantly lower incidence of delayed graft function and acute rejection within 6 months, without increasing the incidence of lung infection.

Abraham et al identified 745 men with a documented varicocele and severe oligospermia from a 10-year database review. The authors compare the outcomes of patients receiving laparoscopic correction with those receiving open varicocelectomy. The results demonstrate similar improvements in semen parameters and in the number of successful pregnancies. The authors conclude that laparoscopy appears to be an effective option for management of infertility due to a varicocele.

Tamer Aboushwareb provides a state-of-the-art review article on approaches to renal tissue engineering. The author describes the properties of stem cells and considerations of usefulness in regenerative medicine. He presents methods for identifying renal progenitor cells and their potential contributions for regeneration and renal repair. Finally, he describes disease-specific cellular therapies for renal dysfunction.

In this final issue of 2010, I thank the UIJ staff, reviewers, authors, and readers for your continued support. I extend my wishes to each of you that you may enjoy a healthy and productive 2011.


Karl-Erik Andersson

Risk Factors for Acute Urinary Retention in Patients With Benign Prostatic Hyperplasia From the Islamic Republic of Iran


INTRODUCTION: Acute urinary retention (AUR) is a serious complication in patients with benign prostatic hyperplasia (BPH). Some risk factors for AUR are known. However, it is important to study patients in different geographic locations because of cultural, dietary, medical, and lifestyle differences. The purpose of the present retrospective investigation was to compare patients with BPH and without AUR to patients with BPH and AUR from the Islamic Republic of Iran on a variety of possible risk factors.

METHODS: We reviewed files of 430 adult patients with BPH who were admitted for surgery from 2003 through 2008. The examined variables were: patient age, PSA, prostate volume, previous history of AUR, anesthesia, smoking, alcohol consumption, opium addiction, diabetes mellitus, hypertension, cardiovascular disease, and other comorbid diseases. There were 270 patients (66.2%) without a history of AUR and 138 patients (33.8%) with a history of AUR. Data for the 2 patient groups were compiled and compared using chi-square, Mann-Whitney, or Fisher exact tests. Logistic regression was calculated for the variables that resulted in significant group differences.

RESULTS: Mean (SD) patient age was 68 (9) years and 72 (9) years for patients without and with AUR, respectively (P < .003). Patients with AUR had a significantly larger mean prostate volume of 62.8 (23) mL, compared with 48 (21) mL for patients without AUR (P < .0001). Significantly more patients without AUR had low PSA levels (P < .001). However, the largest number of patients in both groups had a PSA over 4 ng/mL (44.8% of patients without AUR; 57.2% of patients with AUR). There was no significant group difference in the number of patients consuming alcohol or the number with opium addiction, hypertension, cardiovascular disease, or other underlying diseases (P > .05). Significantly more patients without AUR had diabetes mellitus (P < .001). Significantly more patients with AUR were smokers (P < .001).

CONCLUSIONS: Patient age, high prostate volume, high serum PSA, and smoking were the main risk factors for AUR. These outcomes were consistent with previous research with patients from other geographic locations.

Siavash Falahatkar, Ali Hamidi Madani, Ahmad Enshaei, Ehsan Kazemnejad, Seyedeh Samaneh Ahmadi, Keivan Gholamjani Moghaddam, Aliakbar Allahkhah

Urology Research Center, Guilan University of Medical Science, Razi Hospital, Rasht, Islamic Republic of Iran

Submitted September 16, 2010 - Accepted for Publication October 29, 2010

KEYWORDS: Acute urinary retention; Benign prostatic hyperplasia; Prostate-specific antigen; Prostate volume; Risk factor.

CORRESPONDENCE: Ali Hamidi Madani MD, Assistant Professor of Urology, Urology Research Center, Guilan University of Medical Science, Razi Hospital, Sardar Jangal Street, Rasht, 41448, I.R.Iran ().

CITATION: UroToday Int J. 2010 Dec;3(6). doi:10.3834/uij.1944-5784.2010.12.15

ABBREVIATIONS AND ACRONYMS: AUR, acute urinary retention; BPH, benign prostatic hyperplasia; DM, diabetes mellitus; LUTS, lower urinary tract symptoms; MTOPS, medical therapy of prostatic symptoms; QoL, quality of life; PSA, prostate-specific antigen; TURP, transurethral resection of the prostate; TWOC, trial without catheter.



Vesicouterine Fistula Following Vaginal Birth After Cesarean in a Woman With Grand Multiparity: A Case Report and Review of the Literature


Vaginal birth after cesarean (VBAC) is rare in multiparous women in the developed world. A vesicouterine fistula (VUF) is a rare complication of VBAC. The present case is the first known report of a patient with grand multiparity who presented with a VUF after her fourth VBAC. A tentative diagnosis was made following her cystogram on postpartum day 1; the definitive diagnosis was reached with cystoscopy on postpartum day 4. Successful uterine-sparing repair of the fistula was obtained via laparotomy with fistula closure and an omental flap. A review of potential diagnostic and management methods is presented.

Sarah A Smith,1 Fatima Z Husain,2 Paul J Rusilko,2,3 Raymond A Bologna,2,3 J Kenneth Davis1,4

1 Department of Obstetrics and Gynecology, Akron General Medical Center, Akron, OH, USA

2 Department of Urology, Akron General Medical Center, Akron, OH, USA

3 Department of Urology,Northeastern Ohio Universities College of Medicine and Pharmacy, Rootstown, OH, USA

4 Department of Obstetrics and Gynecology, Northeastern Ohio Universities College of Medicine and Pharmacy, Rootstown, OH, USA

Submitted August 28, 2010 - Accepted for Publication October 14, 2010

KEYWORDS: Vesicouterine fistula; VBAC; Vaginal birth after cesarean

CORRESPONDENCE: Sarah A. Smith, DO, Department of Obstetrics and Gynecology, Akron General Medical Center, 224 W. Exchange Street, Suite 120, Akron, OH 44302, USA ().

CITATION: Urotoday Int J. 2010 Dec;3(6). doi:10.3834/uij.1944-5784.2010.12.06

ABBREVIATIONS AND ACRONYMS: CT, computed tomography; IVP, intravenous pyelogram; MRI, magnetic resonance imaging; VBAC, vaginal birth after cesarean section; VUF, vesicouterine fistula.



Prophylactic Use of Rabbit Antihuman Thymocyte Immunoglobulin in Renal Transplantation


INTRODUCTION: Patients receiving a renal transplant were studied to: (1) evaluate the efficacy and safety of a prophylactic application of rabbit antihuman thymocyte immunoglobulin (ATG-R) plus immunosuppressive therapy, and (2) compare the outcomes to those of a control group of patients receiving only immunosuppressive therapy.

METHODS: A total of 922 recipients receiving allograft renal transplantation in our hospital were enrolled between May 2003 and March 2009. Patients with inferior conditions in pregnancy history, blood transfusion history, repeated transplantation, panel reaction antibody, lymphocytotoxicity test, and human leukocyte antigen matching were assigned to the experimental group (n = 156). They received conventional immunosuppressive therapy plus a single-bolus preoperative high dose (1.5 mg/kg) and a short-term postoperative low dose (0.5-1 mg/kg) of ATG-R prophylactic treatment. A control group (n = 766) received only the immunosuppressive therapy. The incidence rates of delayed graft function (DGF), acute rejection (AR) within 6 months and lung infection within 6 months, and the 1-year patient and kidney survival rates of the patients in the experimental and control groups were compared.

RESULTS: The incidence of DGF was significantly lower in the experimental group than the control group (1.92% vs 8.49%; P < .01). The incidence of AR within 6 months was also lower in the experimental group (5.13% vs 10.97%; P < .05). There were no significant group differences in the incidence of lung infection within 6 months or 1-year patient and kidney survival rates. Survival rates for transplant recipients were 98.72% and 98.43% for the experimental group and control group, respectively.

CONCLUSION: A preoperative high dose and a postoperative short-term low dose of prophylactic ATG-R could markedly reduce the incidence of DGF and AR but not increase the incidence of lung infection in highly sensitive renal transplant recipients. This protocol may be an effective and feasible ATG immune-induction therapy.

Ke Wang, Lin Wang, De-kang Sun, Jun-jie Zhao, Chang-ping Men, Feng-chun Wan, Dong-fu Liu, Zhen-li Gao

Organ Transplantation Center, Yantai Yuhuangding Hospital, Yantai, China

Submitted August 29, 2010 - Accepted for Publication October 9, 2010

KEYWORDS: Renal transplantation; Rabbit antihuman thymocyte immunoglobulin; Prophylactic application.

CORRESPONDENCE: Dr. lin wang, Organ Transplantation Center, Yantai Yuhuangding Hospital, Yantai Yuhuangding East Road, Yantai, Shandong, 20264000, China ().

CITATION: UroToday Int J. 2010 Dec;3(6). doi:10.3834/uij.1944-5784.2010.12.04

ABBREVIATIONS AND ACRONYMS: AR, acute rejection; ATG-R, rabbit antihuman thymocyte immunoglobulin; DGF, delayed graft function; HLA, human leukocyte antigen; PRA, panel reaction antibody; WBC, white blood cell count.
Drug abbreviations: AZa, azathioprine; CsA, cyclosporine A; FK-506, tacrolimus; MMF, mycophenolate mofetil; MP, methylprednisolone; MZR, mizoribine; Pred, prednisone.



Right Renal Vein Augmentation in Deceased Donor Kidney Transplantation: Importance of the Contiguous Inferior Vena Cava


INTRODUCTION: The short, thin-walled right renal vein (RRV) makes anastomosis and hilar hemostasis challenging in deceased donor kidney transplantation. The right renal artery is twice the length of the vein. The purposes of the present retrospective study were to: (1) describe a surgical technique that uses the contiguous inferior vena cava (IVC) segment to lengthen the right renal vein, and (2) report the surgical outcomes.

METHODS: A total of 44 right deceased-donor kidneys were transplanted into 44 recipients between March 2005 and February 2010. Recipient ages ranged from 19-68 years (28 females; 16 males). We used the contiguous IVC to augment short renal veins in the right kidney allografts. This resulted in a horizontal extension of the RRV, with outflow through the orifice of the left renal vein (LRV). Augmented right renal veins were anastomosed end-to-side to the external iliac vein, and the right renal arteries with aortic patches were anastomosed end-to-side to the external iliac artery in all recipients except 1. Surgical outcomes were assessed.

RESULTS: Among the 44 kidney recipients, 39 were first transplants and 5 were second transplants. The kidneys were placed on the right side (n = 38), left side (n = 5), and into the peritoneum (n = 1). The mean RRV augmentation time was 32 minutes (range, 24-49 minutes); completion of back-table dissection added another 40 minutes. The cold ischemia times ranged from 3 hours 50 minutes to 19 hours. The rewarming times ranged from 34-44 minutes. Immediate graft function was noted in 37 kidneys; 3 patients required dialysis for delayed graft function; 4 patients had slow graft function but did not require dialysis. In a follow-up period ranging from 8 months to 5 years, no graft was lost from vascular complications following the augmentation of the RRV. All 44 venous anastomoses were safe and easy, and kinking of the renal artery was avoided because the reconstructed vein matched the length of the artery.

CONCLUSION: Augmentation of the short RRV utilizing the contiguous IVC is a safe, simple, and reliable procedure that avoids graft loss from vascular complications in deceased donor renal transplantation.

Taqi F Toufeeq Khan,1 Mirza Anzar Baig,1 Rafat Zahid,1 Dujanah Mousa2

1 Division of Kidney Transplant Surgery, Riyadh Military Hospital, Riyadh, Kingdom of Saudi Arabia

2 Division of Transplant Nephrology, Riyadh Military Hospital, Riyadh, Kingdom of Saudi Arabia

Submitted September 13, 2010 - Accepted for Publication October 19, 2010

KEYWORDS: Deceased donor right kidney; Short renal vein; Contiguous caval segment; Back-table augmentation.

CORRESPONDENCE: Dr. Taqi F Toufeeq Khan, Division of Kidney Transplant Surgery, PO Box 7897/624N, Riyadh Military Hospital,Riyadh, 11159, Kingdom of Saudi Arabia ().

CITATION: Urotoday Int J. 2010 Dec;3(6). doi:110.3834/uij.1944-5784.2010.12.08

ABBREVIATIONS AND ACRONYMS: IVC, inferior vena cava; LRV, left renal vein; RRV, right renal vein.



Laparoscopic Extraperitoneal Cystolithotomy (Single-Incision Laparoscopic Surgery): A Sutureless, Tubeless Technique


Three bladder calculi were removed from an 73-year-old adult male by laparoscopic extraperitoneal cystolithotomy (single-incision laparoscopic surgery), a sutureless and tubeless procedure. Surgery was performed without difficulty. No problems of stone fragmentation, prostatic bleeding, or sepsis were encountered. The entire procedure lasted only a few minutes, thereby minimizing the patient's time under anesthesia. Laparoscopic extraperitoneal cystolithotomy is safe and easy to learn. It should be part of all urologists armamentarium against bladder calculi. Similar procedures have been reported in children for removal of calculi after bladder augmentation.

Richard D Levin

Urodocs, PA, Aventura, Florida, USA

Submitted October 25, 2010 - Accepted for Publication November 7, 2010

KEYWORDS: Laparoscopic; Extraperitoneal; Cystolithotomy; Sutureless; Tubeless.

CORRESPONDENCE: Richard D. Levin, MD, Urodocs PA, 210-17 NE 34th place, Spinnaker Bay at the Waterways, Aventura, Fl 33180, USA ().

CITATION: Urotoday Int J. 2010 Dec;3(6). doi:10.3834/uij.1944-5784.2009.08.16

ABBREVIATIONS AND ACRONYMS: LUTS, lower urinary tract symptoms; SILS, single-incision laparoscopic surgery; TURP, transurethral resection of the prostate.



Managing Patients With ‘Wet’ Overactive Bladder: Results of Pooled Studies Show Efficacy of Darifenacin as Measured by ‘Dry Days’


INTRODUCTION: Incontinence is a bothersome symptom in patients with overactive bladder (OAB) and a main symptom for help-seeking behavior. Our analysis of three phase III studies aimed to assess the effect of darifenacin on the number of Dry Days and incontinence episodes (IEs) in participants with OAB with incontinence.

METHODS: Pooled data from three randomized, placebo-controlled, fixed-dose studies (n=1059) were analyzed. Participants with OAB received 12 weeks' treatment with once daily darifenacin 7.5 mg (n=337) or 15 mg (n=334) or placebo (n=388). The number of participants achieving ≥ 3 consecutive Dry Days was the primary analysis endpoint. Health-related quality of life (HRQoL) was assessed using the King's Health Questionnaire (KHQ).

RESULTS: Significantly more participants taking daridenacin at week 12 achieved ≥ 3 consecutive Dry Days versus placebo (52.6% versus 39.8%, respectively; P ≤ .001). Significant improvements were observed in participants with mild (< 14 IEs/week) and moderate/severe (≥ 14 IEs/week) OAB with incontinence. Participants with ≥ 3 consecutive Dry Days had statistically significantly greater improvements in IEs, IEs resulting in a change of pads/clothing, micturitions/day, episodes of urgency and KHQ scores, compared with those who did not achieve ≥ 3 consecutive Dry Days. Darifenacin was well tolerated.

CONCLUSIONS: Darifenacin treatment significantly increased the number of participants achieving ≥ 3 consecutive Dry Days and significantly reduced the number of IEs. Similar improvements were observed with long-term treatment and were associated with significant improvements in HRQoL. These findings indicate that darifenacin is an effective treatment for participants with 'wet' OAB.

Diane Newman,1 William S Aronstein,2 Yodit Seifu,3 Andrea Larson-Peters,4 Lidia Mongay3

1 Division of Urology, University of Pennsylvania, Philadelphia, PA, USA

2 CTI Clinical Trial and Consulting Services, Cincinnati, OH, USA

3 Novartis Pharmaceuticals Corporation, East Hanover, NJ, USA,

4 Procter & Gamble, Cincinnati, OH, USA

Submitted August 2, 2010 - Accepted for Publication October 27, 2010

KEYWORDS: Antimuscarinic agents; Darifenacin; Overactive bladder; Urinary incontinence.

CORRESPONDENCE: Diane Newman, Co-Director, Penn Center for Continence and Pelvic Health, Director, Clinical Trials, Division of Urology, University of Pennsylvania Medical Center, 9 Penn Tower, 34th & Civic Center Blvd, Philadelphia, Pennsylvania 19104, USA ().

CITATION: UroToday Int J. 2010 Dec;3(6). doi:10.3834/uij.1944-5784.2010.12.11

ABBREVIATIONS AND ACRONYMS: AE, adverse event; IE, incontinence episode; HRQoL, health-related quality of life; KHQ, King's Health Questionnaire; LOCF, last-observation-carried-forward;OAB, overactive bladder.



Primary Retroperitoneal Extraovarian Granulosa Cell Tumor: A Case Report


A primary extragonadal granulosa cell tumor (GCT) is very rare. It is believed to arise from the ectopic gonadal tissue along the embryonal route of the genital ridge. We encountered one such tumor in a 45-year-old female who presented with a large intraabdominal mass. She had an abdominal hysterectomy with unilateral salpingo-oophorectomy 10 years previously for dysfunctional uterine bleeding. She underwent exploratory laparotomy and excision of the mass. The histologic features failed to differentiate between a carcinoid and granulosa cell tumor. Immunohistochemistry showed that the neoplastic cells expressed calretinin, smooth muscle actin, melan-A, inhibin-alpha, and progesterone receptors and were negative for desmin, CD10, cytokeratin, epithelial membrane antigen, synaptophysin, or chromogranin-A. An English literature search revealed only 4 similar cases, primarily arising from the retroperitoneum. Immunohistochemistry helps to differentiate GCTs from other tumors.

Siddalingeshwar Ishwarappa Neeli,1 Prakash R Malur2

1 Department of Urology, KLE University, J. N. Medical College, Belgaum, India

Department of Pathology, KLE University, J. N. Medical College, Belgaum, India

Submitted October 7, 2010 - Accepted for Publication October 27, 2010

KEYWORDS: Extraovarian; Retroperitoneal; Granulosa cell tumor; Calretinin; Melan-A; Inhibin.

CORRESPONDENCE: Dr. Siddalingeshwar Neeli, Associate Professor & Consultant Urologist, Department of Urology, KLE University's J. N. Medical College and KLES Dr. Prabhakar Kore Hospital and Medical Research Center, Belgaum-590010, India ().

CITATION: UroToday Int J. 2010 Dec;3(6). doi:10.3834/uij.1944-5784.2010.12.14

ABBREVIATIONS AND ACRONYMS: EMA, epithelial membrane antigen; GCT, granulosa cell tumor; PgR, progesterone receptors; SMA, smooth muscle actin.



Correction of a 180 Degree (Upside Down) Penile Torsion in a 55-Year-Old Patient with Severe Erectile Dysfunction


In the present case report, we describe a new technique for penile torsion correction that may be used in select patients. A 55-year-old male presented to our facility with a long history of erectile dysfunction. He had counterclockwise 180° (half-circle) penile torsion and severe arteriogenic erectile dysfunction. During surgery, the decision was made to do a circumcision incision with degloving of the penis. We took down all skin and subcutaneous adhesions. This procedure resulted in partial correction of the torsion. Then, bilateral corporotomies were done with corporeal dilation and placement of 9.5 mm diameter, 18 cm long Genesis devices (Mentor Corp; Santa Barbara, CA, USA). This led to full correction of the torsion. We closed the wound with a drain inside. He had an uneventful postoperative period and was doing well 6 months after surgery.

Mohamed A Ismail, Mohamed Amin

Department of Urology-Andrology, Elaj Medical Group, Jeddah, Kingdom of Saudi Arabia

Submitted September 10, 2010 - Accepted for Publication October 10, 2010

KEYWORDS: Penile torsion; Erectile dysfunction; Prosthesis.

CORRESPONDENCE: Mohamed Ali Ismail, MD, Elaj Medical Group, Department of Urology-Andrology, Altahleya St., Jeddah By Jeddah Mall, PO Box 51141, Jeddah 21453, Mekka, Kingdom of Saudi Arabia ().

CITATION: UroToday Int J. 2010 Dec;3(6). doi:10.3834/uij.1944-5784.2010.12.03

ABBREVIATIONS AND ACRONYMS: ED, erectile dysfunction.



Merits and Demerits of Laparoscopic Lymphatic-Sparing Testicular Vein Ligation: Conclusions From a 10-Year Database Review


INTRODUCTION: This retrospective study was designed to: (1) assess the perioperative and postoperative outcomes of patients following laparoscopic correction of varicocele; (2) compare the outcomes with a group of patients receiving open varicocelectomy; (3) describe predictors of surgical success following the laparoscopic procedure.

METHODS: Data were gathered between January 1998 and December 2008. Male partners of couples seeking care for infertility were evaluated. Those with a documented varicocele and semen analysis suggestive of severe oligospermia constituted the study cohort. A total of 245 patients underwent bilateral laparoscopic testicular vein ligation with a standard approach; 500 patients underwent open varicocelectomy. Patients were evaluated for semen profile and fertility every 3 months for 1 year and at 3 years postsurgery. Perioperative data, complications, semen parameters, fertility rates, and varicocele recurrence rates were compared for each surgical approach.

RESULTS: All patients receiving laparoscopic testicular vein ligation had a bilateral procedure. The mean operative time for patients receiving laparoscopy was 20 minutes (SD, 1.3; range, 15-25 minutes). The mean (SD) analgesic requirement was 1.6 (0.1) grams of paracetamol. The mean duration of the hospital stay was 13 hours (SD, 0.8; range 8-16 hours). When compared with open varicocelectomy, laparoscopy resulted in significantly less analgesic, shorter mean duration of surgery, and shorter mean hospital stay (all with P < .05). There were no statistically significant differences in the number of postoperative wound infections or hydroceles. Similarly, there were no significant differences in improvement of semen parameters, number of successful pregnancies, or number of recurrent varicoceles. One year following laparoscopic surgery, there was ≥ 50% improvement in sperm count in 182 males (74.3%), ≥ 30% increase in sperm motility in 219 males (89.4%), and ≥ 15% increase in normal sperm morphology in 190 males (77.6%). A total of 161 female partners (65.7%) reported a positive pregnancy test within 1 year of laparoscopic correction. Three patients had recurrent varicocele with secondary infertility that was corrected via an open approach.

CONCLUSION: Laparoscopic lymphatic-sparing testicular vein ligation is an effective option for management of infertility attributed to varicoceles. The short-term and long-term fertility outcomes are comparable to open approaches.

George P Abraham,1 Krishanu Das,1 George P Datson,2 Ramaswami Krishnamohan,2 Jisha J Abraham,1 Thomas Thachill,1Oppukkeril S Thampan2

1 Department of Urology, Lakeshore Hospital, Kochi, India

2 Department of Urology, PVS Memorial Hospital, Kochi, India

Submitted August 10, 2010 - Accepted for Publication September 30, 2010

KEYWORDS: Laparoscopy; Oligospermia; Varicocele.

CORRESPONDENCE: Dr. Krishanu Das, Department of Urology, Lakeshore Hospital, NH 47 By-pass Maradu Nettoor PO, Kochi, Kerala, 6823040, India ().

CITATION: Urotoday Int J. 2010 Dec;3(6). doi:doi:10.3834/uij.1944-5784.2010.12.01



Remote Access for Teaching and Reporting Urodynamics: Use of Smartphones


INTRODUCTION: The field of telemedicine has expanded over the past few decades. Remote operation of various devices enables physicians to provide off-site assistance in different areas of medicine. The purpose of the present report was test the use of hand-held smartphones for remote-access urodynamic telementoring.

METHODS: Telementoring was performed using the Teleurodynamics software program ( The program was downloaded and installed at the testing site. Simultaneous use of voice over internet protocol (VoIP) software through smartphones allowed: (1) visualization of the tests for individuals at all settings, and (2) dialogues between the person performing the test, observers, and patients. Mentors participated during the test or helped interpret stored data. Password-protected access provided patient privacy. Urodynamic tests were performed between January, 2008 and August, 2010. The tests were conducted by residents at one center and by a technician at a second center. A recording of the procedure is available from the author on request.

RESULTS: The authors remotely monitored over 1000 urodynamic studies, using 50 different examiners in various locations. They were able to analyze the urodynamic tests and reports in the same way as when the examiner was in situ, because all participants were using the same software programs. Occasional loss of the signal was eliminated by using an optional portable 3G connection.

CONCLUSION: Telementoring urodynamic examinations by using computers and smartphones facilitates teaching and consultation. The technology adds very little cost to equipment and operating procedures. Hand-held smartphones can make the procedure available to a large number of users.

Salvador Vilar Correia Lima,1,2 Fabio de Oliveira Vilar,1,2 Eugenio Soares Lustosa,1 Carlos Antonio de Souza,1 Evandilson Guenes C de Barros,1 Sharlles Gois Cavalcanti1

1 Department of Urology/Surgery, Federal University of Pernambuco, Recife, Brazil

2 Centro Urológico de Pernambuco, Recife, Brazil

Submitted August 24, 2010 - Accepted for Publication October 7, 2010

KEYWORDS: Urodynamics; Telementoring; Cystometry.

CORRESPONDENCE: Salvador Vilar Correia Lima, MD, Department of Urology/Surgery, Federal University of Pernambuco, Av. Parnamirim, 95, Recife, Pernambuco, 52060, Brazil ().

CITATION: UroToday Int J. 2010 Oct;3(5). doi:10.3834/uij.1944-5784.2010.12.02

ACRONYMS AND ABBREVIATIONS: 3G, third generation; VoIP, voice over internet protocol.



Nonpharmacological Treatment Using Transcutaneous Electrical Nerve Stimulation for Children With Benign Joint Hypermobility Syndrome and Overactive Bladder


INTRODUCTION: Joint hypermobility is a condition in which there is extreme mobility of the joints, often leading to manifest symptoms. Overactive bladder (OAB) is a commonly associated problem. The purpose of the present study was to evaluate the use of transcutaneous electrical nerve stimulation (TENS) as a sole treatment for children with OAB associated with benign joint hypermobility syndrome (BJMS).

METHODS: A total of 26 children with OAB and without voiding dysfunction or constipation participated in the study. Their ages ranged from 5-14 years. All patients were evaluated by uroflowmetry to exclude patients with high flow rate, ultrasound of the urinary tract to exclude organic causes and high postvoid residual urine, and urine analysis and culture to exclude infection. None of the patients were taking anticholinergics during the investigation. All patients were treated by TENS, using 2 superficial 4 cm electrodes that were placed on each side of sacral segment 3. Sessions lasted for 20 minutes and were conducted every other day, to a maximum of 20 sessions. Sessions were terminated if the physician and parent agreed that the child had attained complete success. All parents (or patients) completed a voiding diary before treatment and for 1 month after the last session. Improvement was assessed on an analog scale. Chi-square was used to test the hypotheses that response rates were the same in each category with regard to patient age and sex.

RESULTS: The total number of sessions ranged from 12-20. Out of 26 patients, 19 (73%) complained of urge incontinence following treatment (13 girls; 6 boys). Of these 19 patients, 15 had associated nocturnal enuresis (11 girls; 4 boys). None of the 7 patients without urge incontinence had enuresis. Eleven patients (42.36%) had complete clinical improvement, 6 (23%) had excellent improvement, 3 (11.54%) had mild improvement, and 6 (23%) had no change. There were no significant differences in the degree of improvement regarding the patient's sex or age (P > .05).

CONCLUSION: Transcutaneous electrical nerve stimulation shows promise as an alternative to pharmacological treatment for OAB symptoms in children with BJHS.

Tarek Salem,1 Hashim Hafez,1 Manal Ali2

1 Urology Department, Faculty of Medicine, Suez Canal University, Egypt

2 Rheumatology and Rehabilitation Department, Faculty of Medicine, Ain Shams University, Egypt

Submitted September 30, 2010 - Accepted for Publication October 23, 2010

KEYWORDS: Benign joint hypermobility syndrome; Transcutaneous electrical nerve stimulation; Overactive bladder.

CORRESPONDENCE: : Dr. Tarek Salem, Department of Urology, Suez Canal University, Faculty of Medicine, Ismailia 31911, Egypt ().

CITATION: Urotoday Int J. 2010 Dec;3(6). doi:10.3834/uij.1944-5784.2010.12.10

ABBREVIATIONS AND ACRONYMS: BJHS, benign joint hypermobility syndrome; GJH, general joint hypermobility; LUTD, lower urinary tract dysfunction; OAB, overactive bladder; PVR, postvoid residual; S3, sacral segment 3; TENS, transcutaneous electrical nerve stimulation; UI, urge incontinence; UTI, urinary tract infection.



Cell Approaches in Renal Tissue Engineering


Renal regenerative therapy is an exceedingly complex endeavor due to the multiple functions of the kidney. There is a shortage of donor kidneys and more patients are now progressing to end-stage renal disease, so a significant clinical application from this research is urgently needed. Renal regenerative therapy has great potential for clinical impact in the future through the use of methods described here. Many approaches are currently being researched, but this review focuses on investigations using cellular therapies. The properties of embryonic stem cells, induced pluripotent stem cells (reprogramming), and adult stem cells are compared for their usefulness in regenerative medicine. Methods for identifying the renal progenitor cells that are responsible for generating tubules and glomeruli are discussed, along with the potential contributions of these cells for regeneration and endogenous renal repair. Finally, targeting a single function of the kidney has led to disease-specific cellular therapies for renal dysfunction. Contributions of these therapies to the understanding of stem cells are highlighted. Many methods, techniques, and approaches of regenerative medicine using cells, scaffolds, or a combination of both are being utilized in a variety of projects for kidney regeneration. Therefore, it is not out of the question that we could have a regenerative solution for renal failure in the near future.

Tamer Aboushwareb

Wake Forest Institute for Regenerative Medicine, Wake Forest University School of Medicine, Winston-Salem, NC, USA

Submitted November 23, 2010 - Accepted for Publication November 24, 2010

KEYWORDS: Kidney; Regenerative medicine; Tissue engineering; Cell therapy; Renal progenitor cells; Metanephros.

CORRESPONDENCE: Tamer Aboushwareb, MD, PhD, Wake Forest Institute for Regenerative Medicine and Urology Department, Wake Forest University School of Medicine, Medical Center Boulevard, Winston-Salem, NC 27157 USA ().

CITATION: Urotoday Int J. 2010 Dec;3(6). doi:10.3834/uij.1944-5784.2010.12.18

ABBREVIATIONS AND ACRONYMS: AFPS, amniotic-fluid and placental-derived stem; EPO, erythropoietin; ES, embryonic stem; hES, human embryonic stem; iPS, induced pluripotent state; PEC, parietal epithelial cells.



Management of Severe Bleeding Following Partial Nephrectomy With Selective Renal Artery Embolization: A Case Report


We describe the immediate and short-term effects of selective transcatheter embolization of the renal artery used to treat severe bleeding that followed nephron-sparing surgery. The patient was a 27-year-old male with renal cell carcinoma that was associated with von Hippel Lindau syndrome. Partial nephrectomy was performed to remove a tumor mass. On the 7th postoperative day, the patient demonstrated macrohematuria, strong flank pain, a significant drop in hemoglobin level, and an increase in creatinine level. CT scan indicated the presence of hemorrhagic blots in the left renal pelvis and left ureter and disorganization of the caliceal group on the upper pole. Selective embolization was performed. Three months later, creatinine level measurements (1.4 mg/dL) showed relatively good function of the remaining kidney. A MAG3 nephrogram revealed a 65-35 split function. The immediate radiologic and clinical success of selective transcatheter embolization in this complication of partial nephrectomy is discussed.

Stavros N Charalambous, Aristidis Karelis, Asterios Fotas, Ioannis Vouros, Athanasios Papathanasiou, Vasilios Rompis

Urological Department, Ippokratio General Hospital, Thessaloniki, Greece

Submitted July 3, 2010 - Accepted for Publication October 23, 2010

KEYWORDS: Partial nephrectomy; Embolization; Renal artery bleeding; von Hippel-Lindau syndrome.

CORRESPONDENCE: Stavros Charalambous MD, PhD, FEBU, Consultant Urologist, Urological Department, Ippokratio General Hospital, 49 Kostantinoupoleos str., 54642 Thessaloniki, Greece ().

CITATION: UroToday Int J. 2010 Dec;3(6). doi:10.3834/uij.1944-5784.2010.12.09

ABBREVIATIONS AND ACRONYMS: CT, computed tomography; PN, partial nephrectomy; VHL, von Hippel-Lindau.



Comparison of Videocystourethrography and Ambulatory Urodynamic Monitoring in Identifying the Causes of Overactive Bladder Symptoms


INTRODUCTION: The purposes of the present study were to: (1) compare the findings from videocystourethrography (VCU) with those from ambulatory urodynamic monitoring (AUM) to determine their level of agreement in identifying the causes of overactive bladder (OAB) symptoms; (2) examine changes in the diagnoses that were made following the first test (VCU) after the patient had the second test (AUM).

METHODS: This was a retrospective analysis of our AUM database during 2007 and 2008. The inclusion criteria were: (1) female patients over the age of 18 years with OAB symptoms; (2) complete documentation of all OAB symptoms; (3) results from both VCU and AUM. Patients were referred for AUM because the findings following VCU did not explain the presenting symptoms. The frequency and type of OAB symptoms and the results from the tests were recorded and compared.

RESULTS: A total of 100 women fulfilled the inclusion criteria. The mean age was 56 years (range, 19-87 years). The cause of the OAB symptoms was defined in 55% of the patients following VCU and 64% of the patients following AUM. Detrusor overactivity (DO) was not identified for any patients following VCU; it was found in 32 patients following AUM. Urgency with or without urge urinary incontinence was the symptom most frequently associated with DO. Of the 100 patients, 45 women had normal results from the VCU. Nine of these women also had normal results following AUM. For the remaining 36 women, the results from AUM identified abnormalities that could explain their symptoms. The most common findings were DO (58%) and urodynamic stress incontinence (16%).

CONCLUSION: Results from VCU for patients with symptoms of OAB should be interpreted with caution. AUM appears to be a more discerning tool in identifying DO. Clinicians should interpret urodynamic results in conjunction with clinical symptoms, particularly if a continence surgery is contemplated. AUM is particularly recommended for complex cases.

Ismaiel A Mahfouz, Angie Rantell, Linda Cardozo, Dudley Robinson, Sushma Srikrishna

Department of Urogynaecology, Kings College Hospital, London, United Kingdom

Submitted September 22, 2010 - Accepted for Publication October 27, 2010

KEYWORDS: Overactive bladder; Detrusor overactivity; Urodynamics; Ambulatory urodynamic monitoring.

CORRESPONDENCE: Ismaiel Mahfouz, MSc, MRCOG, Obstetrics and Gynaecology, North Hampshire Hospital, Basingstoke, RG24 9NA, United Kingdom ().

CITATION: UroToday Int J. 2010 Dec;3(6). doi:10.3834/uij.1944-5784.2010.12.13

ABBREVIATIONS AND ACRONYMS: AUM, ambulatory urodynamic monitoring; DO, detrusor overactivity; ICS, International Continence Society; LUTS, lower urinary tract symptoms; OAB, overactive bladder; UDS, urodynamic study; USI, urodynamic stress incontinence; UUI, urge urinary incontinence; VCU, videocystourethrography; VD, voiding dysfunction.



A New Access for Implantation of a Malleable Penile Prosthesis During Perineal Radical Prostatectomy


The present 67-year-old male had clinically localized prostate cancer and needed a perineal radical prostatectomy. He also needed prosthesis implantation for severe erectile dysfunction. We describe a new perineal access for implantation of a malleable penile prosthesis during the prostatectomy surgery that does not require a second incision. The prostatectomy technique was not altered. Prosthesis implantation began after removal of the prostate and before performing the vesicourethral anastomosis. The procedure is described. Dilatation of the cavernous bodies and prosthesis implantation were performed without technical problems. Transoperative bleeding was similar to that observed for prosthesis implantation through a penile access. No shortening of the urethral stump was observed and vesicourethral anastomosis was performed without difficulty. Surgical time was 40 minutes. Use of the same access for the 2 procedures is easy and has low morbidity. This approach should be considered by other surgeons for patients with prostate cancer and severe erectile dysfunction.

Mario Paranhos, Enrico Andrade, Luiz Carlos Neves de Oliveira, Marcos Dall`Oglio, Alberto Antunes, Joaquim A Claro, Miguel Srougi

Division of Urology, University of São Paulo Medical School, São Paulo, Brazil

Submitted September 10, 2010 - Accepted for Publication October 9, 2010

KEYWORDS: Erectile dysfunction; Penile prosthesis; Prostatic cancer; Radical perineal

CORRESPONDENCE: Dr. Mario Paranhos, Rua Mapuá¡, 16 – Chá¡cara Inglesa, CEP-04647-030, São Paulo, Brazil ().

CITATION: Urotoday Int J. 2010 Dec;3(6). doi:10.3834/uij.1944-5784.2010.12.05



Malignant Mesothelioma of the Tunica Vaginalis Testis: A Rare, Enigmatic Tumor


Malignant mesothelioma of the tunica vaginalis is a rare urologic tumor with fewer than 100 cases reported in the literature. Patients can present at any age with nonspecific symptoms. A typical sonographic appearance of paratesticular papillary excrescence or nodularity typically leads to a preoperative diagnosis of hydrocele or testicular tumor. Following diagnostic intraoperative frozen sample analysis, radical orchiectomy is recommended. Recent advances in Doppler sonography allow hypovascularity or hypervascularity of paratesticular nodules to be identified. These characteristics are suspicious for malignant mesothelioma, which potentially assists in preoperative diagnosis. The current case depicts a 37-year-old male with a 1-week history of subtle testicular enlargement. He was diagnosed with malignant mesothelioma of the tunica vaginalis following scrotal excisional biopsy. Literature is discussed relative to patient demographics, diagnostic and management issues, prognosis, and follow-up guidelines.

Zachary Klaassen,1 Bernard J Lehrhoff2

1 Department of Surgery, Saint Barnabas Medical Center, Livingston, New Jersey, USA

2 Department of Surgery, Saint Michael’s Medical Center, Newark, New Jersey, USA

Submitted August 12, 2010 - Accepted for Publication October 27, 2010

KEYWORDS: Asbestos; Doppler sonography; Mesothelioma; Radical orchiectomy; Tunica vaginalis.

CORRESPONDENCE: Zachary Klaassen, MD, Department of Surgery, Saint Barnabas Medical Center, 94 Old Short Hills Road, Livingston, New Jersey 07039, USA ().

CITATION: Urotoday Int J. 2010 Dec;3(6). doi:10.3834/uij.1944-5784.2010.12.12

ABBREVIATIONS AND ACRONYMS: CT, computed tomography; EMA, epithelial membrane antigen.



FGFR3 Germline Mutations Identified in Skeletal Dysplasia Significantly Cause Low-Grade and Low-Stage Bladder Cancer by Somatic Mutations


INTRODUCTION: Germline mutations identified in the FGFR3 gene cause skeletal disorders. The same point mutations have been reported to cause bladder carcinomas, but more research is needed into the various signal pathways of this gene. The purpose of the present study was to analyze the frequency and distribution of FGFR3 somatic mutations in bladder tumors and to determine their relationship with different clinicopathological characteristics for patients with urinary bladder cancer.

METHODS: This prospective study was conducted in Kashmir, India between 2008 and 2010. The paired tumor and adjacent normal tissue specimens of 65 consecutive patients with transitional cell carcinoma of the bladder were examined. The median patient age was 61 years (range, 38-80 years); the male:female ratio was 5:1. The DNA preparations were evaluated for the occurrence of FGFR3 gene mutations by PCR-SCCP and DNA sequencing. Blood was also collected from all patients to rule out any germline mutation. Chi-square was used to compare the FGFR3 gene mutation with the clinicopathological characteristics.

RESULTS: Somatic point mutations of the FGFR3 gene aggregated to 21 of the 65 patients (32.30%). All mutations except 1 had been previously identified in various skeletal dysplasias. Codon S417Y mutation has not been previously identified in any disease and is reported for the first time. The pattern and distribution of FGFR3 mutations were significantly associated with low-grade and low-stage tumors (P < .05). The frequency of mutation decreased significantly with an increase in the depth of tumor invasion (P < .05).

CONCLUSION: Our findings reveal that FGFR3 mutations characterize a subgroup of superficial bladder tumors with low grade and low stage. The high incidence of FGFR3 mutations can be an effective prognostic and predictive factor in distinguishing superficial from invasive bladder tumors.

Arshad A Pandith,1 Zaffar A Shah,1 Nighat P Khan,2 Mohammad S Wani,3 Adfar Yousuf,2 Roohi Rasool,1 Dil Afroze,1 Mushtaq A Siddiqi1

1 Department of Immunology and Molecular Medicine, Sher-I-Kashmir Institute of Medical Sciences, Srinagar, Kashmir, India

2 Department of Biochemistry, Sher-I-Kashmir Institute of Medical Sciences, Srinagar, Kashmir, India

3 Department of Urology, Sher-I-Kashmir Institute of Medical Sciences, Srinagar, Kashmir, India

Submitted October 1, 2010 - Accepted for Publication October 14, 2010

KEYWORDS: Bladder carcinomas; Transitional cell carcinoma; Polymerase chain reaction.

CORRESPONDENCE: Mushtaq A. Siddiqi, Professor & Chairman, Department of Immunology and Molecular Medicine, Sher-I-Kashmir Institute of Medical Sciences, Soura, Srinagar, Kashmir, 190011, India ().

CITATION: UroToday Int J. 2010 Dec;3(6). doi:10.3834/uij.1944-5784.2010.12.07

ABBREVIATIONS AND ACRONYMS: DNA, deoxyribonucleic acid; FGFR3, fibroblast growth factor receptor 3; PCR, polymerase chain reaction; SSCP, single-strand conformation polymorphism; UCC, urothelial cell carcinoma.