Volume 4

UIJ Volume 4 2011

Laparoscopic Prostatectomy for Severely Symptomatic, Treatment-Refractory Chronic Prostatitis: Preliminary Observations from an Ongoing Phase II Clinical Trial


INTRODUCTION: We report outcomes 1 year after surgery for the first 6 consecutive patients enrolled in an ongoing, prospective, Phase II clinical trial of laparoscopic radical prostatectomy (LRP) as a treatment for severely symptomatic, treatment-refractory chronic prostatitis. The protocol is approved by the Western Institutional Review Board and listed on the searchable National Institutes of Health clinical trials Web site.

METHODS: Patients met prespecified eligibility criteria, were fully counseled before treatment, gave written informed consent, had surgery, and were regularly monitored after treatment. The primary outcome measure was symptom severity, which was measured prior to LRP and at 1, 3, 6, and 12 months after treatment using the Chronic Prostatitis Symptom Index (CPSI). The exact Wilcoxon signed rank test was used to compare pretreatment and 6-month posttreatment scores, with statistical significance at P < .05. Patients also described symptoms that were not included on the CPSI. Intraoperative and postoperative complications were recorded.

RESULTS: Average patient age was 48.5 years (range, 31-61 years). The pretrial median disease duration was 6.5 years (range 3-31 years). Aside from their prostatitis, all patients were generally healthy. All patients had failed numerous medical, surgical, and complementary treatments. LRP was uncomplicated. All patients reported resolution of their prostatitis. Median CPSI scores were 35 before surgery and 26, 15.5, 10, and 7.5 at 1, 3, 6, and 12 months after surgery, respectively. The 6-month CPSI scores were significantly lower than the preoperative scores (P = .03).

CONCLUSIONS: Preliminary data suggest that LRP may offer a previously unavailable level of relief for carefully selected patients with severely symptomatic, treatment-refractory chronic prostatitis. This potential needs to be further validated and more thoroughly characterized.

Arnon Krongrad,1 Shenghan Lai2

1 The Krongrad Institute, Aventura, FL, USA

2 Department of Pathology, Johns Hopkins School of Medicine, Baltimore, MD, USA

Submitted November 3, 2010 - Accepted for Publication February 23, 2011

KEYWORDS: Chronic prostatitis; Laparoscopic radical prostatectomy; Clinical trial.

CORRESPONDENCE: Arnon Krongrad, MD, The Krongrad Institute, 20900 NE 30th Ave, Suite 207, Aventura, FL 33180, USA ().

CITATION: Urotoday Int J. 2011 Apr;4(2):art30. doi:10.3834/uij.1944-5784.2011.04.12

ABBREVIATIONS AND ACRONYMS: CPPS, chronic pelvic pain syndrome; CPSI, Chronic Prostatitis Symptom Index; LRP, laparoscopic radical prostatectomy; NIH, National Institutes of Health.



Urethral and Bladder Changes and Stricture Recurrence Rates Following Internal Urethrotomy for Short Urethral Strictures


INTRODUCTION: We analyzed: (1) the effect of internal urethrotomy on objective and subjective measures of bladder function and bladder wall thickness, (2) the stricture recurrence rate, and (3) the effects of urethral and bladder changes on recurrent stricture formation.

METHODS: Between October 2008 and May 2009, 22 male patients with primary urethral strictures (14 membranous, 4 penile, 4 bulbous) were prospectively studied. Strictures were posttraumatic (68.2%), iatrogenic (27.3%), or idiopathic (4.5%). Urethral stricture was incised at the 12 o'clock position with a 21F internal urethrotome, which included a cold knife under direct monitoring. Patients were evaluated 6 and 12 months postoperatively. Statistical analyses included paired-sample t tests with a Bonferonni adjustment (significance at P < .004) and Pearson correlations.

RESULTS: The mean age of the patients was 59.1 (13.7) years. The length of stricture was 6.1 (1.7) mm. The stricture was most prevalent in the membranous urethra (63.6%). Significant improvements were detected in mean International Prostate Symptom Score and peak flow at 6-months and 12-months postoperatively, when compared with baseline (all with P < .001). Mean urethral width and the wall thickness of the empty bladder significantly decreased 6 and 12 months after surgery (all with P < .001). The mean bladder wall thickness of the filled bladder significantly decreased from baseline at 6 months (P < .001) but not at 12 months following surgery (P > .004). Stricture recurrence rates were 13.6% at 6 months and 27.3% at 12 months. All patients were instructed to perform intermittent self dilatation; at the postoperative 6-month and 12-month follow-up, 16 patients (72.7%) and 11 patients (50%), respectively, were using it. There was no significant correlation between stricture recurrence and wall thickness of the empty or filled bladder, bladder capacity, urethral stricture location, stricture length, or the length of the widest segment of the urethra.

Mustafa Aldemir, Evren Isık, Emrah Okulu, Kemal Ener, Önder Kayıgil

Department of 2nd Urology, Atatürk Teaching and Research Hospital, Ankara, Turkey

Submitted December 21, 2010 - Accepted for Publication January 26, 2011

CONCLUSIONS: Internal urethrotomy is a successful procedure with rapid effect for management of primary short-segment urethral strictures. Significant changes in the urethra and bladder occur after surgery. However, these changes do not appear to be correlated with stricture recurrence.

KEYWORDS: Urethral stricture; Internal urethrotomy; Urethral and Bladder Changes; Recurrence; Intermittent self-dilatation.

CORRESPONDENCE: Mustafa Aldemir, M.D., Aydinlikevler Mahallesi Arilik Sokak No: 5/5, P.O. Box 06130, Ankara, Turkey ().

CITATION: UroToday Int J. 2011 Apr;4(2):art27. doi:10.3834/uij.1944-5784.2011.04.09

ABBREVIATIONS AND ACRONYMS: EF, erectile function; ISD, intermittent self-dilatation; IU, internal urethrotomy; IPSS, International Prostate Symptom Score; Qmax, peak urine flow rate; RU, retrograde urethrography.



Inconclusive Scrotal Ultrasound Reports: The Impact of a Second Scrotal Ultrasound


INTRODUCTION: The purpose of this retrospective study was to determine the accuracy of repeat sonographic tests for intrascrotal pathologies that were performed when the first ultrasound (US) report was inconclusive. We also examined the consistency of the first and final diagnoses and the effect on management procedures.

METHODS: In 2008, 3049 sonograms were performed for scrotal pathology. A total of 70 sonograms (2.3%) were inconclusive and a second US was requested; these became the database for the present study. We recorded the patient's age, presenting symptoms, time span between US sessions, grade of the US operator, US results, and final histopathological or clinical diagnosis. We also examined whether or not the follow-up US led to a change in management.

RESULTS: The mean age of patients was 46 years (range, 6-85 years) at the time of the original US. Indications for the second US were pain (n = 30), the presence of an indistinct swelling (n = 19), a discrete lump (n = 11), or a combination of these (n = 10). Overall, 66 patients (94.3%) had benign pathology; 4 patients were diagnosed with cancer following histopathology tests that were conducted because of abnormal tumor markers. In 22 patients (31%) there were appreciable differences between the first and subsequent diagnoses; in 48 patients (69%) there was no appreciable difference. For 45 patients (64.3%), the follow-up US did not alter the management plan; only 2 of these patients had a change from the initial diagnosis. However, 25 patients (35.7%) had an alteration in their management after the follow-up US; 20 of these patients had a different diagnosis following the repeated US. Of the 70 patients, 61 (87%) were managed conservatively; 9 patients received surgery.

CONCLUSIONS: A second scrotal US can be an effective diagnostic tool if a prior US is inconclusive, particularly if the condition is benign. Repeat US has minimal value in detecting malignant testicular pathologies.

Pejman Kheirandish, Sohayl Mukhtar, Rhana Zakri, Nitin Shrotri, Rajeshwar Krishnan

Department of Urology, Kent and Canterbury Hospital, Canterbury, Kent, United Kingdom

Submitted December 10, 2010 - Accepted for Publication January 26, 2011

KEYWORDS: Repeat scrotal ultrasound; Equivocal report.

CORRESPONDENCE: Mr Pejman Kheirandish, Department of Urology (Jasmin Ward), Newham University Hospital, Glen Road, Plaistow, London, E13 8SL, United Kingdom ().

CITATION: UroToday Int J. 2011 Apr;4(2):art26. doi:10.3834/uij.1944-5784.2011.04.08

ABBREVIATIONS AND ACRONYMS: CT, computed tomography; EKUHT, East Kent University Hospitals Trust; MRI, magnetic resonance image; US, ultrasound.



The Efficacy of a Manual Database System for Tracking Ureteric Stent Placement and Removal


INTRODUCTION: Manual paper database systems are commonly used to monitor JJ ureteric stent placement and removal. System failure can lead to patient morbidity and medicolegal implications. The objective of this study was to audit a stent database system at a large urology center in Western Sydney to determine the adequacy of the tracking procedure.

METHODS: From our single tertiary academic center, 316 patients underwent ureteric stent insertions in 2007. We conducted a retrospective analysis of the dates of stent insertion and removal (indwelling time). We noted if documentation of stent removal was clear (ie, in a surgical unit stent logbook, our urology office, or a consultant's records). If the stent removal date was unclear, clarification was sought from surgery records, inpatient manager software, patient files, records from other hospitals, or contact with the patient. Patients were divided into 5 stent follow-up categories and statistical analysis (using one way ANOVA and logistic regression) was used to make comparisons between groups. We used a stent indwelling time of 6 months as the maximum acceptable duration in situ.

RESULTS: A total of 379 stent procedures were conducted. The majority of patients had single, unilateral, denovo procedures due to stone disease. The majority of the removed stents had adequate documentation (n = 214; 56.5%). A total of 23 patients (6.1%) were deceased prior to stent removal. The remaining 142 (37.5%) of patients had no record of their stent removal in our database. Overall, 22.4% of all ureteric stents exceeded the 6-month maximum indwell time. These results were largely due to poor record keeping, loss or misplacement of endourological operation reports, or failure to notify the consultant who placed the sent if the patient was referred to other hospitals or consultants.

CONCLUSION: Based on the present and previous studies, the manual paper database system of ureteric stent follow-up is ineffective. We propose an electronic database recall system that alerts the attending urologist of an overdue stent and is readily accessible from within and outside the hospital.

Shagun Aggarwal,1 Howard M H Lau,1 Andrew J Brooks,1 Simon V Bariol,1 Malcolm Drummond,1 Manish I Patel,1,2 David Ende,1 Audrey C. Wang,1 Henry H Woo1,2,3

1 Department of Urology, Westmead Hospital, Westmead, Sydney, New South Wales, Australia

2 Sydney Medical School, Westmead Clinical School, University of Sydney, New South Wales, Australia

3 Sydney Medical School, Sydney Adventist Hospital Clinical School, University of Sydney, New South Wales, Australia

Submitted December 18, 2010 - Accepted for Publication January 13, 2011

KEYWORDS: Audit; Ureteric stents; Paper logbook database.

CORRESPONDENCE: A/Prof Henry Woo, P.O. Box 5017, Wahroonga, NSW, 2076, Australia ().

CITATION: Urotoday Int J. 2011 Apr;4(2):art23. doi:10.3834/uij.1944-5784.2011.04.05




Ischemic Distal Ureteric Obstruction Resulting From Transplant Renal Artery Stenosis: A Case Report


Ureteric stenosis is a known urological complication of kidney transplantation. We report a 40-year-old female patient who was treated for transplant renal artery stenosis (TRAS) with angioplasty and primary stenting. Five months later, she presented with renal dysfunction and moderate hydronephrosis on ultrasound. A tight stenosis of the distal ureter and the ureterovesical anastomosis was documented on an antegrade nephrostogram. It was balloon-dilated and stented, leading to improvement in renal function. This is the first known report that focuses on TRAS as a possible cause of distal ureteric ischemia resulting in stenosis.

Taqi F Toufeeq Khan, Mirza Anzar Baig

Division of Renal Transplant Surgery, Riyadh Military Hospital, Riyadh, Saudi Arabia

Submitted November 29, 2010 - Accepted for Publication December 20, 2010

KEYWORDS: Distal ureter; Ureteric stenosis; Transplant renal artery stenosis; Ischemia; Pathogenesis.

CORRESPONDENCE: CORRESPONDENCE: Dr. Taqi F Toufeeq Khan, PO Box 7897/624N, Riyadh Military Hospital, Riyadh 11159, Saudi Arabia ().

CITATION: Urotoday Int J. 2011 Apr;4(2):art21 doi:10.3834/uij.1944-5784.2011.04.03

ABBREVIATIONS AND ACRONYMS: ACR, acute cellular rejection; DGF, delayed graft function; TRAS, transplant renal artery stenosis.



Conservative Management of an Isolated Renal Vein Injury Following Blunt Abdominal Trauma: A Case Report


Renovascular injury following blunt abdominal trauma typically demands immediate attention and definitive repair. We report an isolated, partial-thickness rent in the left renal vein with a contained leak and perinephric hematoma in a 22-year old male following a motor vehicle accident. The injury was thoroughly evaluated and monitored. The patient had a drop in hematocrit on the first day following the injury that responded to blood replacement. Repeat imaging 48 hours after the injury confirmed spontaneous sealing of the venous rent and preservation of renovascular integrity. The case was successfully managed with conservative treatment.

George P Abraham,1 Krishanu Das,1 Thara Pratap,2 Krishnamohan Ramaswami,1 George P Datson,1 Jisha J Abraham,1 Thomas J Thachill,1 Oppukeril S Thampan1

1 Urology Department, Lakeshore Hospital, Kochi, Kerala, India

2 Radiology Department, Lakeshore Hospital, Kochi, Kerala, India

Submitted December 4, 2010 - Accepted for Publication January 6, 2011

KEYWORDS: Renal vein tear; CT scan; Conservative management

CORRESPONDENCE: Dr. Krishanu Das, Urology Department, Lakeshore Hospital, NH 47 Bye Pass Maradu Nettoor PO, Kochi, Kerala 682304 India ().

CITATION: Urotoday Int J. 2011 Apr;4(2):art22. doi:10.3834/uij.1944-5784.2011.04.04

ABBREVIATIONS AND ACRONYMS: CT, computed tomography.



Extravesical Antireflux Peritoneal Tunnel Technique for the Treatment of Dilated High-Grade Refluxing Ureters


INTRODUCTION: The purpose of the study was to assess the effectiveness of a new antireflux technique that uses a peritoneal flap as a tunnel for the treatment of high-grade refluxing ureters.

METHODS: This was a prospective, nonrandomized trial involving15 patients with grade 4 or grade 5 vesicoureteral reflux, seen between 1998 and 2004. Their mean age was 41 years (range, 27-58 years). Of the 15 patients, 13 had a past history of ureteroneocystostomy without an antireflux procedure for the treatment of bilharzial ureteral stricture; 2 patients had reflux secondary to neurogenic bladder. A peritoneal flap was used to create an extravesical ureteral tunnel as an antireflux procedure that does not interrupt the ureterovesical junction. The effective tension of the tunnel and its ability to prevent reflux were tested using intraoperative fluoroscopy. Patients were followed at 6 and 12 months with urine cultures, creatinine measurement, voiding cystourethrogram, and renal ultrasound.

RESULTS: Voiding cystourethrogram showed that 10 of 12 patients without reflux during the procedure remained free of reflux during follow-up; the remaining 2 patients developed grade 1 and grade 2 reflux. For 3 patients with low-grade reflux during surgery, 2 remained at the same grade and 1 progressed to high grade. There were no major changes in serum creatinine from baseline to follow-up. After surgery, the frequency and severity of urinary tract infections and pyuria were appreciably diminished. There was no evidence of ureteral obstruction.

CONCLUSIONS: The new technique was effective in preventing or downgrading reflux in this small number of patients. By creating an extravesical tunnel from a peritoneal flap, the technique avoids interrupting the ureterovesical junction in the dilated unhealthy ureter and fibrosed bladder wall. It could be applied to cases with a severely fibrosed ureter and bladder when other surgical techniques cannot be safely used.

Mahmoud Ezzat Ibrahim,1 Mohamed Mahmoud Ezzat,2 Wael Mahmoud Ezzat3 1 Department of Urosurgery, Ain Shams University, Cairo, Egypt 2 Department of General Surgery, Ain Shams University, Cairo, Egypt 3 Department of Neurology, Cairo University Hospital, Cairo, Egypt Submitted September 29, 2010 - Accepted for Publication November 30, 2010

KEYWORDS: Antireflux surgical procedure; Secondary refluxing ureters.

CORRESPONDENCE: Mahmoud Ezzat Ibrahim, 37 El Hassan Street, Mail Box 12411, Dokki, Giza, Egypt ().

CITATION: UroToday Int J. 2011 Apr;4(2):art37. doi:10.3834/uij.1944-5784.2011.04.19

ABBREVIATIONS AND ACRONYMS: UTI, urinary tract infection.



Y-V Glanuloplasty Modified Mathieu Technique with Versus Without a Urethral Stent in the Management of Distal Hypospadias


INTRODUCTION: Reported complication rates from the Y-V glanuloplasty modification to the Mathieu technique have varied and may be related, at least in part, to inconsistent use of the recommended stent. The purposes of the present investigation were to: (1) describe the intraoperative and postoperative complications associated with the Y-V glanuloplasty modification, and (2) compare results from patients receiving a stent with patients not receiving a stent.

METHODS: A total of 56 patients with distal hypospadias were included in this prospective study. Their mean age was 4.5 years (range, 3-8 years). All patients had a Y-V glanuloplasty modified Mathieu technique. They were randomly divided into 2 groups: group 1 (n = 30) had surgery without a urethral stent; group 2 (n = 26) had surgery with insertion of a 10 Fr urethral catheter (Nelaton draining catheter) down to the bladder. The stent was removed 5 days postoperatively. Follow-up evaluation occurred 5-7 days after surgery and then monthly for 12 months and every 3 months for 2 years. Complications were recorded at each visit and compared between groups.

RESULTS: A total of 13 patients (43%) in group 1 (without a stent) had complications that iacncluded dysuria (n = 10), edema of the glans that resolved after a few days (n = 2), and secondary bleeding due to severe infection and rupture of the flap that required reoperation (n = 1). A total of 7 patients (27%) in group 2 (with a stent) had complications. After removal of the stent, 4 patients had urgency and 3 patients had dysuria that disappeared after few days. None of the patients with a stent had infection or edema of the glans. At the end of the follow-up period, all patients in both groups were in good condition, with the neomeatus located at the tip of the glans. There were no long-term complications.

CONCLUSIONS: Y-V glanuloplasty modified Mathieu technique with meticulous subcuticular sutures has a high success rate and is suitable for distal hypospadias. Based on our results and those of previous studies, we do not recommend a catheterless technique.

Ahmed Shelbaia, Ali Hussein

Urology Department, Cairo University Hospital, Cairo, Egypt

Submitted December 26, 2010 - Accepted for Publication February 16, 2011

KEYWORDS: Y-V glanuloplasty; Modified Mathieu; Distal hypospadias; Urethral stenting; Subcuticular sutures.

CORRESPONDENCE: Dr.Ahmed Shelbaia, MD, Borg Elatbaa, Faisal Street, 5th Floor, Flat 5, Giza, Egypt ().

CITATION: UroToday Int J. 2011 Apr;4(2):art30. doi:10.3834/uij.1944-5784.2011.04.13

ABBREVIATIONS AND ACRONYMS: TIP, tubularized incised plate.



Apical Vaginal and Uterus Suspension to the Tendinous Arch of the Levator Ani and Uterosacral Ligaments by an Anchorage Device: A Proposed Method for Genital Prolapse Repair


INTRODUCTION: We developed a new surgical method using mesh to repair the prolapsed uterus or vaginal vault, called the TALA Suspension. The purposes of the study were to: (1) describe the surgical procedure, and (2) determine intraoperative and postoperative complications, (3) determine overall effectiveness for women with a vaginal vault or uterine prolapse.

METHODS: The retrospective study was conducted in 2010. The patients were 21 symptomatic females with apical (vaginal vault) prolapse (n = 9) or uterine prolapse (n = 12). The mean patient age was 57.8 years (range, 54-61 years). All patients were third degree on the Baden-Walker scale and fourth degree in Pelvic Organ Prolapse Quantification (POP-Q) staging. We anchored a polypropylene mesh (Dynamesh-PR; FEG Textiltechnik GmBH, Germany) to the tendinous arch of the levator ani (TALA) to repair apical prolapse and created a suspension to the origin of the uterosacral ligaments and the lateral vaginal fornix to repair uterine prolapse. Outcome measures were intraoperative and postoperative complications and overall patient status. Postoperative outcomes were recorded at 10 days, 1 month, and 6 months.

RESULTS: The mean total operative time was 35.4 minutes. The mean intraoperative blood loss was 140 mL. Five patients (23.8%) requested postoperative analgesic for 48 hours. The mean hospital stay was 2.1 days. The mean hemoglobin at dismissal was 11.2 g/L. All patients tolerated the procedure well. There were no neurologic or vascular complications or reports of obstructed defecation, urinary infection, or urinary retention. There was 1 case of dyspareunia in the vaginal apex. Based on the follow-up clinical evaluations and vaginal examinations by speculum, there was 100% surgical success. Six months after surgery, there was no evidence of recurrent prolapse.

CONCLUSIONS: This is a preliminary evaluation of a new surgical technique. Although the results are very positive, the number of cases was small and the follow-up was limited to 6 months. We recommend that this technique be performed by experienced surgeons who are capable of shifting from similar methods. Expanded trials with longer follow-up are needed to compare TALA Suspension to other prolapse repair techniques.

Jeremiah de Leon, Shuo Liu, Wan Yi Ng, Roy McGregor, Vincent Tse

Submitted January 19, 2011 - Accepted for Publication January 31, 2011

KEYWORDS: Female pelvic prolapse; Vaginal vault prolapse; Gynecological surgery; Pelvic floor disorders; Menopause; Anatomic defects

CORRESPONDENCE: Dr. Andrea Tinelli, Department of Obstetrics and Gynecology, Vito Fazzi Hospital, Piazza Muratore, 73100 Lecce, Italy ().

CITATION: UroToday Int J. 2011 Apr;4(2):art32. doi:10.3834/uij.1944-5784.2011.04.14

ABBREVIATIONS AND ACRONYMS: POP-Q, Pelvic Organ Prolapse Quantification; TALA, tendinous arch of the levator ani.



Letter from the Editor - February 2011

Dear Colleagues:

This, our first issue of 2011 is being published on the new UroToday International Journal on-line portal, which connects the global urology community to one of the most extensive urological collections freely available and always accessible on line. This proprietary platform creates an easy user interface, developed in consultation with UroToday readers, providing intuitive navigation and fast access to our on-line content.

In the current issue, Kollmeier and Bochner present results of a study that was conducted at Memorial Sloan-Kettering Cancer Center. They placed Visicoil linear fiducial markers (Core Oncology; Santa Barbara, CA, USA) into the bladder wall to counteract the effects of organ motion during radiation therapy for patients with bladder cancer. Their positive results indicate that such markers may help to improve the accuracy of radiation therapy.

Vijay et al investigated the effects of intraperitoneal or extraperitoneal carbon dioxide insufflation on 13 measures of cardiopulmonary and immunological response during urological laparoscopic surgery (N = 40). Although the mean intraoperative pO2 was significantly reduced from baseline, the results showed that CO2 insufflation had minimal effect on these otherwise-healthy patients.

Two of the current studies assess male infertility. Hussein et al compared the semen of 50 smokers with 50 nonsmokers and found that smoking had significant negative effects on some semen parameters, particularly sperm motility. Mohamed et al studied the impact of inguinal varicocele ligation on testicular volume, sperm parameters, and pregnancy rates before and after varicocelectomy in 50 infertile men. Three- and 6-months after varicocele ligation, ipsilateral mean sperm concentration and motility were significantly increased and mean testicular volume was significantly decreased. The partners of 24 patients (48%) were pregnant 6 months following surgery.

Trospium chloride has been studied for use in pediatric patients with idiopathic or neurogenic detrusor overactivity. Bürst and Wolf provide a synopsis of studies that have been reported in the literature.

Finally, Wu et al describe their experience using laparoscopic surgery for a patient with paraganglioma. Open partial cystectomy is typically used to treat these uncommon neoplasms because there is multilayer involvement of the bladder wall and concern about intraoperative hypertensive crisis. The authors describe their treatment procedure and share the outcomes.

With this issue, we announce the 2011 Editorial Board. I offer my sincere thanks to the previous and current board members and to all of the reviewers who share their expertise and assist us in publishing this journal. We welcome your continued submission of manuscripts and look forward to a productive new year.

Karl-Erik Andersson

Uropathogens Causing Urinary Tract Infections in Females and Their Susceptibility to Antibiotics


INTRODUCTION: Understanding the uropathogens causing urinary tract infection (UTI) and their susceptibility to antibiotics is important to physicians who are choosing antibiotic therapy. The purpose of the study was to evaluate the uropathogens causing UTI and their antibiotic susceptibility in females residing in Saudi Arabia.

METHODS: The participants were 150 females with UTI that was proven by culture and sensitivity tests. Their mean age was 32 years (SD, 2.4; range, 6-55). There were 8 children and 142 adults. Of the adults, 92 patients were not pregnant and 50 were pregnant. All patients were treated with antimicrobials; the most common was fluoroquinolone for patients who were not pregnant and third-generation cephalosporin for patients who were pregnant. The distribution of uropathogens was compiled. Antimicrobial sensitivity testing was completed for each antibiotic administered.

RESULTS: The majority of UTIs occurred in the lower urinary tract for all patients. Escherichia coli was the most common pathogen, occurring in 52% of the patients who were pregnant and 53% of the patients who were not pregnant. Klebsiella was the second most commonly occurring pathogen, occurring in 15% and 16% of the patients who were not pregnant and pregnant, respectively. In females who were not pregnant, Pseudomonas and Staphylococcus aureus were also relatively common; in females who were pregnant, Staphylococcus epidermidis and nonhemolytic Streptococcus were more frequently found. The antibiotic susceptibility for E. coli ranged from 97% for fluoroquinolone to 48% for cefaclor; nitrofurantion was also high at 96%. Klebsiella had the highest response to gentamicin (80%).

CONCLUSION: E. coli was the most frequently isolated uropathogen in females with UTI, followed by other Gram-negative bacteria. There were some differences in the types of pathogens when compared with previous literature. These may be due to variations in geographic location, patient characteristics, or treatment methodology. Susceptibility rates are essential for determining the most sensitive antimicrobial for the causative organism.

Tarek A Salem,1 Mohamed H El-Azab2

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

Clinical Pathology Department, Faculty of Medicine, Ain Shams University, Cairo, Egypt

Submitted November 13, 2010 - Accepted for Publication December 17, 2010

KEYWORDS: Urinary Tract infection; Uropathogen; Antimicrobial.

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

CITATION: UroToday Int J. 2011 Feb;4(1):art15. doi:10.3834/uij.1944-5784.2011.02.15

ABBREVIATIONS AND ACRONYMS: AMC, amoxicillin-clavulanic acid; E. coli, Escherichia coli; IV, intravenous; TMX, trimethoprim-sulfamethoxazole; UTI, urinary tract infection.



Effect of Tobacco Smoking on Semen Quality in Men With Subfertility


INTRODUCTION: Smoking is considered a risk factor for male infertility, but studies have not shown a conclusive reduction in fertility associated with paternal smoking. The aim of the present study was to investigate the effects of smoking cigarette or shisha tobacco on semen parameters in men with subfertility.

METHODS: This was a prospective study of 100 patients with subfertility. There were 50 smokers with mean (SD) age of 37.1 (8.3) years and 50 nonsmokers with a mean age of 39.5 (9.0) years. The outcome measures were sperm abnormal forms (%), sperm count (M/mL), semen volume (mL), sperm motility (%), duration of infertility, and type, amount, and duration of smoking. Group differences (smoker vs nonsmoker and cigarette vs shisha) in semen volume and sperm parameters were analyzed with t tests. Pearson correlations were calculated to determine the association between smoking index and smoking duration and the semen parameters.

RESULTS: When compared with nonsmokers, the smokers had a significantly higher mean percentage of abnormal sperm forms (92.3 % vs 89.4%) (P < .01), a significantly lower mean sperm count (20.6 M/mL vs 44.9 M/mL), a significantly lower mean semen volume (2.01 mL vs 2.52 mL), and a significantly lower mean percentage of sperm motility (25.7 vs 37.9) (all with P < .01). There were no statistically significant differences in semen parameters between men smoking cigarettes or shisha. There were statistically significant negative correlations between smoking index and the percentage of sperm motility(r = -0.38; P = .006) and between smoking duration and the percentage of sperm motility(r = -0.32; P = .026). There was also a marginally significant positive correlation between smoking index and the percentage of abnormal sperm forms(r =0.28; P = .046). Correlations with other semen parameters were not significant.

CONCLUSION: Results showed significant deleterious effects of tobacco smoking on semen parameters. The correlation analysis placed special emphasis on the negative impact of smoking on sperm motility. Evidence from this and other studies seems sufficient to recommend that male smokers with subfertility should stop smoking to prevent detrimental effects on semen quality.

Alaa Hussein,1 Ayman AlGadaa,2 Mohamed ElFaras,1 Medhat ElFiky1

1 In Vitro Fertilization Center, King Fahd Specialized Hospital, Buridah, Kingdom of Saudi Arabia

2 Department of Surgery, Faculty of Medicine, Qassim University, Qassim Province, Kingdom of Saudi Arabia

Submitted November 10, 2010 - Accepted for Publication December 14, 2010

KEYWORDS: Smoking; Subfertily; Semen quality.

CORRESPONDENCE: Dr. Alaa Hussein, King Fahd Specialized Hospital, IVF Center, PO Box 2290, Buridah, Qassium Region, Kingdom of Saudi Arabia ().

CITATION: Urotoday Int J. 2011 Feb;4(1):art11. doi:10.3834/uij.1944-5784.2011.02.11

ABBREVIATIONS AND ACRONYMS: DNA, deoxyribonucleic acid; ROS, reactive oxygen species.



Efficacy and Safety of Trospium Chloride Use in Children With Idiopathic and Neurogenic Detrusor Overactivity: An Overview of Available Data


INTRODUCTION: There are limited data regarding treatment of idiopathic and neurogenic detrusor overactivity with anticholinergic drugs in children. Although oxybutynin and propiverine are authorized for use with children, treatment of this subgroup of patients is not officially approved for the newer anticholinergic drugs that have some advantages in tolerability. In particular, the quaternary drug trospium chloride (TC) has the benefit of not passing the blood-brain barrier (in contrast to the other anticholinergics, which are tertiary amines). The purpose of this article is to evaluate published data regarding the efficacy, safety, and dosage of TC in pediatric patients.

METHODS: Major computerized database indexes were analyzed for studies between 1960-2010 that involved treatment of children with TC and other anticholinergics. Key words used for searching were: trospium chloride, anticholinergic, oral application, incontinence, urgency, pollakiuria, and children. Variables compared across studies were the age of the patients, daily dose, duration of treatment, efficacy parameters, and safety aspects.

RESULTS: One randomized controlled trial with 58 participants and 3 uncontrolled studies with various inclusion criteria were identified in the literature. TC has been investigated in children aged between 3 and 14 years for a number of indications including bladder instability, neurogenic bladder dysfunction, and nocturnal enuresis. The reported studies ranged in length from 5 days to 12 weeks. In all studies, results showed improvement in symptoms for the majority of the patients. The occurrence of side-effects was low and none of the side-effects was severe.

CONCLUSIONS: A definite recommendation for the use of TC in children cannot be given due to insufficient data. Preliminary results indicate that its use may have potential advantages in children, but additional studies are needed.

Maria Bürst1, Anna Wolf2

1 Bereich Urologie, MVZ Klinikum Deggendorf GmbH, Deggendorf, AFG
2 Department of Medical Science/Clinical Research, Dr. R. Pfleger GmbH, Bamberg, DEU

Accepted December 23, 2010 - Published February 12, 2011

KEYWORDS: Trospium chloride; Children; Incontinence; Anticholinergic; Dosage.

CORRESPONDENCE: Anna Wolf, Dept. Medical Science/Clinical Research, Dr. R. Pfleger GmbH, 96045 Bamberg, Germany ().

CITATION: Urotoday Int J. 2011 Feb;4(1):art17. doi:10.3834/uij.1944-5784.2011.02.17




Hemodynamic, Respiratory, and Immunological Effects of Urological Laparoscopic Surgery: A Prospective Study


INTRODUCTION: Numerous physiological responses as a result of carbon dioxide (CO2) insufflation occur in almost every organ system. The present study investigated the impact of intraperitoneal or extraperitoneal CO2 insufflation on cardiopulmonary and immunological variables during urological laparoscopic surgery.

METHODS: From August 2007 to April 2009, we performed 40 laparoscopic urological surgeries (36 transperitoneal; 4 retroperitoneal) on otherwise healthy patients. There were 16 males and 24 females. Their mean age was 39 years. All patients underwent peripheral venous blood sampling preoperatively and 24 hours postoperatively. These were analyzed for C-reactive protein (CRP), white blood cell count, and differential leukocyte count. Arterial blood gas was sampled preoperatively and intraoperatively. Measurements were started when the patient was placed in the lateral decubitus position and continued at 2-minute regular intervals until the time of emergence. End-tidal CO2 (ETCO2) was measured every 15 minutes during the entire procedure. Outcome measures were surgery duration and mean pH level, partial pressure of oxygen (pO2), ETCO2, peak airway pressure (PAP), respiratory rate (RR), oxygen (O2) saturation, mean arterial pressure (MAP), heart rate (HR), systolic blood pressure (SBP), diastolic blood pressure (DBP), C-reactive protein (CRP), and leukocyte levels. Measures before and after CO2 insufflation were compared with paired t tests.

RESULTS: Mean operative time was 3.6 hours. The mean (SD) preoperative pO2 was 140.28 (25.61) mmHg, which was significantly higher than the mean intraoperative pO2 of 133.9 (24.43) mmHg (P < .05). There was no significant difference in the mean ETCO2 before and after insufflation. However, the mean change in ETCO2 at 15-minute intervals was significantly higher than the ETCO2 before insufflation. There were no significant changes in mean pH, O2 saturation, MAP, RR, ETCO2, PAP, HR, SBP, DBP, or RR. Inflammatory markers CRP and white blood cell count were statistically similar.

CONCLUSIONS: Physiological changes incurred as a result of CO2 insufflation have minimal adverse effects in healthy individuals undergoing urological laparoscopic surgery.

Mukesh Kumar Vijay, Preeti Vijay, Punit Tiwari, Suresh Kumar, Pramod Kumar Sharma, Amit Goel, Pratim Sengupta, Malay Kumar Bera

Department of Urology, Institute of Post Graduate Medical Education and Research, Seth Sukhlal Karnani Memorial Hospital, Kolkata, West Bengal, India

Submitted November 29, 2010 - Accepted for Publication December 19, 2010

KEYWORDS: Intra-abdominal pressure; Mean arterial pressure; Heart rate; pO2; End-tidal CO2.

CORRESPONDENCE: Mukesh Kumar Vijay, Department of Urology, Institute of Post Graduate Medical Education and Research, Seth Sukhlal Karnani Memorial Hospital, 682 A Newalipore O Block, Kolkata, West Bengal 700020, India ().

CITATION: UroToday Int J. 2011 Feb;4(1):art18. doi:10.3834/uij.1944-5784.2011.02.18

ABBREVIATIONS AND ACRONYMS: CO2, carbon dioxide; CRP, C-reactive protein; DBP, diastolic blood pressure; ETCO2, end-tidal CO2; HR, heart rate; IAP, intraabdominal pressure; IL-6, interleukin-6; MAP, mean arterial pressure; O2, oxygen; PAP, peak airway pressure; pCO2, partial pressure of carbon dioxide; pO2, partial pressure of oxygen; RR, respiratory rate; SBP, systolic blood pressure.



Intravesical Fiducial Marker Placement to Facilitate Image-Guided Radiation Therapy for Patients With Muscle-Invasive Bladder Cancer


INTRODUCTION: Recent development of image-guided techniques facilitates the monitoring of organ motion during radiation therapy. The purposes of this study were to: (1) describe the technique of intravesical fiducial marker placement using Visicoil linear fiducial markers (Core Oncology; Santa Barbara, CA, USA) for treatment planning and delivery of radiation therapy for invasive bladder cancer, and (2) describe the feasibility of this program and initial results.

METHODS: Participants were 10 male patients with a mean age of 74 years (range, 58-87 years). They underwent placement of Visicoil fiducial markers into the bladder wall under endoscopic guidance for the purpose of facilitating treatment planning and delivery for external beam radiotherapy for bladder cancer. We assessed the feasibility of marker placement and stability of the marker using daily on-board imaging during a standard course of therapy. We assessed acute procedure-related complications and related toxicity using the National Cancer Institute Common Terminology Criteria for Adverse Events version 3.0.

RESULTS: All 10 patients had successful implantation of Visicoil fiducial markers without procedure-related acute complications. No patient developed acute toxicity related to the procedure or markers. All markers remained stable during radiation therapy using daily on-board imaging.

CONCLUSION: The use of Visicoil fiducial markers for the guidance of radiation therapy for bladder cancer is safe and feasible. The procedure is associated with minimal toxicity. The use of fiducial markers may enhance the accuracy and efficacy of radiotherapy for bladder cancer.

Marisa A Kollmeier, Bernard Bochner

Department of Radiation Oncology, Memorial Sloan-Kettering Cancer Center, New York USA.

Accepted December 23, 2010 - Published February 07, 2011

KEYWORDS: Bladder cancer; Fiducial markers; Image-guided radiotherapy; Radiation therapy.

CORRESPONDENCE: Marisa A. Kollmeier, M.D., Department of Radiation Oncology, Memorial Sloan-Kettering Cancer Center, 1275 York Avenue, New York, New York 10021 USA ().

CITATION: UroToday Int J. 2011 Feb;4(1):art16. doi:10.3834/uij.1944-5784.2011.02.16

ABBREVIATIONS AND ACRONYMS: 2-dimensional, 2D; CT, computed tomography; kV, kilovoltage; TUR, transurethral resection.



Laparoscopic Partial Cystectomy for Symptomatic Paraganglioma of the Urinary Bladder: A Case Report


Paragangliomas of the bladder are uncommon neuroendocrine neoplasms. Open partial cystectomy is usually performed because all layers of the bladder are involved. In this case, we used laparoscopic partial cystectomy to minimize surgical morbidity of the transabdominal approach. A 43-year-old female presented with symptomatic paraganglioma of the bladder. The patient was pretreated with alpha- and beta-adrenergic blockers before surgery. A 4-port technique was performed with the patient in the Trendelenburg lithotomy position. The bladder mass was excised with a rim of normal mucosa under both cystoscopic and laparoscopic vision. Total operative time was 170 minutes and blood loss was < 100 mL. The patient’s intraoperative blood pressure remained stable. The final histology showed a 6 cm paraganglioma with clear resection margins. Laparoscopic partial cystectomy is feasible for excising a symptomatic paraganglioma with adequate preoperative adrenergic blockage to prevent a hypertensive crisis during resection.

Fiona Mei Wen Wu,1 Shih Ling Kao,2 Thomas Paul Thamboo,3 Woo Chau Tsang,1 Chin Tiong Heng,1 Ho Yee Tiong1

1 Department of Urology, National University Hospital, Singapore

2 Department of Endocrinology, National University Hospital, Singapore

3 Department of Pathology, National University Hospital, Singapore

Submitted November 14, 2010 - Accepted for Publication December 17, 2010

KEYWORDS: Paraganglioma; Symptomatic; Laparoscopic partial cystectomy

CORRESPONDENCE: Dr Tiong Ho Yee, Consultant, Department of Urology, National University Health System, NUHS Tower Block Level 8, 1E Kent Ridge Road, Singapore 119228 ().

CITATION: Urotoday Int J. 2011 Feb;4(1):art3. doi:10.3834/uij.1944-5784.2011.02.03

ABBREVIATIONS AND ACRONYMS: CT, computed tomography; MIBG, metaiodobenzylguanidine scintigraphy.



Outcomes of the Urogenital Distress Inventory (UDI-6) for 20- to 50-Year-Old Females With Lower Urinary Tract Dysfunction in Qalubia Governorate, Egypt


INTRODUCTION: The 6-item Urogenital Distress Inventory (UDI-6) was recently validated on 68 women with lower urinary tract symptoms. The purpose of the present investigation was to use the UDI-6 to determine the types of lower urinary tract dysfunction across different age groups, as described by women from Qalubia Governorate, Egypt.

METHODS: The study group was recruited from females attending hospitals for urological consultation between February and August, 2009. There were 378 participants who were 20-50 years old. They had lower urinary tract symptoms for 3 months and a negative dipstick test. Each had a medical history, clinical evaluation, urine culture, and pelvic-abdominal ultrasound. All participants completed the Arabic version of the UDI-6. They were divided into 3 groups according to age: (1) 20-30 years (n = 144), (2) 31-40 years (n = 94), (3) 41-50 years (n = 140). Results were compared by age group using t tests; a Bonferroni adjustment was applied and significant differences were noted at P < .001.

RESULTS: The most common symptoms of lower urinary tract dysfunction were stress urinary incontinence and lower abdominal or genital pain. Stress urinary incontinence was present in 182 (48.1%) of the 378 patients. It occurred in 4.8% of patients age 20-30 years, 8.1% of patients age 31-40 years, and 17.2% of patients age 41-50 years. Urge incontinence was present in 84 patients (22.2%). The presence of mild and moderate stress incontinence and mild urge incontinence increased significantly in patients who were 41-50 years old (all with P < .001). Micturition difficulty and micturition frequency occurred in < 7% of patients. Lower abdominal or genital pain was described by 204 patients (53.9%). Micturition difficulty, micturition frequency, and lower abdominal or genital pain did not have significantly different distributions across age.

CONCLUSION: The most common symptoms of lower urinary tract dysfunction were stress urinary incontinence and lower abdominal or genital pain. The presence of mild and moderate stress incontinence and mild urge incontinence increased significantly in patients who were 41-50 years old. These patterns are similar to those reported by authors from other countries.

Osama Abdelwahab, Ashraf Mohamed, Tarek Mohamed, Mohamed Abdelzaher

Urology Department, Benha Faculty of Medicine, Benha University, Benha, Egypt

Accepted November 17, 2010 - Published February 07, 2011

KEYWORDS: Stress urinary incontinence; Voiding dysfunction; Lower urinary tract symptoms.

CORRESPONDENCE: Osama Abdelwahab, Professor of Urology, Benha Faculty of Medicine, Benha University, 1st Gameel Street-Makkah Tower, Benha, Egypt ().

CITATION: UroToday Int J. 2011 Feb;4(1):art6. doi:10.3834/uij.1944-5784.2011.02.06

ABBREVIATIONS AND ACRONYMS: LUTS, lower urinary tract symptoms; UDI, Urogenital Distress Inventory; UI, urinary incontinence.



Dysfunctional Voiding as a Presenting Feature of Marfan Syndrome: A Rare Case


Dysfunctional voiding is incontinence resulting from voiding-phase dysfunction. It has been associated with various disorders, but there are only 2 known reports of dysfunctional voiding as a presenting feature of Marfan syndrome in the literature. The present case is a 16-year-old boy with dysfunctional voiding who was diagnosed as having failure to void due to sphincter dyssynergy associated with an unsafe bladder, left-sided vesicoureteric reflux, and emerging Marfan syndrome. Diagnosis of Marfan syndrome was based on the number and type of his clinical features. Because of the prohibitive cost of regular botulinum toxin injections to the sphincter in India, the patient's dysfunctional elimination was managed with clean intermittent self-catheterization, anticholinergics, and stool softeners. Follow-up included monitoring the thorax for any signs of increasing aorta size. It is important to predict dysfunctional elimination in children born with any syndrome that has generalized hypermobility of the joints.

Gajanan Bhat, Girish Nelivigi, Maregowda Shivalingiah, Chandrashekhar Ratkal

Department of Urology, Institute of Nephrourology, Karnataka, India

Received November 09, 2010 - Accepted for Publication December 17, 2010

KEYWORDS: Marfan syndrome; Ghent criteria; Dysfunctional voiding.

CORRESPONDENCE: Dr. Gajanan S. Bhat, Resident in Urology, Institute of Nephrourology, Victoria Hospital Campus, Fort Bangalore - 560 002, Karnataka, India ().

CITATION: Urotoday Int J. 2011 Feb;4(1)art14. doi:10.3834/uij.1944-5784.2011.02.14

ABBREVIATIONS AND ACRONYMS: CIC, clean intermittent catheterization; CISC, clean intermittent self-catheterization; DSD, detrusor sphincter dyssynergia.



Occult Ileovesical Fistula in a Patient Presenting With Squamous Cell Carcinoma of the Bladder: An Unsual Intraoperative Diagnosis


Enterovesical fistulae are commonly caused by pathology related to the gastrointestinal tract such as colonic malignancy and inflammatory bowel disease. On rare occasions, an ileovesical fistula can develop due to a primary bladder neoplasm. Alternatively, a fistula may cause chronic bladder inflammation that leads to the development of squamous cell carcinoma. We report an unusual way of diagnosing an occult ileovesical fistula in a 61-year-old male. The patient presented with hematuria and urinary tract infection and histologically proven squamous cell carcinoma of the urinary bladder. Bladder irrigation-like fluid bypassing the endotracheal tube during transurethral resection of the bladder tumor was highly suspicious of an ileovesical fistula. A postoperative computed tomography scan confirmed the diagnosis. This is the first known case in the literature to report this type of intraoperative diagnosis of an ileovesical fistula.

Costin Chintea, Yuko Smith, Aniruddha Chakravarti

Department of Urology, Dudley Group of Hospitals NHS Trust, Russells Hall Hospital, Dudley, West Midlands, United Kingdom

Submitted November 7, 2010 - Accepted for Publication December 11, 2010

KEYWORDS: Ileovesical fistula; Bladder; Squamous cell carcinoma; Enterovesical fistula.

CORRESPONDENCE: Dr. Costin Chintea, Department of Urology, Dudley Group of Hospitals NHS Trust, Russells Hall Hospital, Dudley, West Midlands, United Kingdom, DY1 2HQ ().

CITATION: Urotoday Int J. 2011 Feb;4(1): art9. doi:10.3834/uij.1944-5784.2011.02.09




Spontaneous Bladder Perforation Due to Tuberculosis

(no abstract)

Christopher CK Ho

Department of Surgery, Universiti Kebangsaan Malaysia Medical Centre, Kuala Lumpur, Malaysia

Submitted December 6, 2010 - Accepted for Publication December 20, 2010

KEYWORDS: Spontaneous bladder perforation; Tuberculosis; Management.

CORRESPONDENCE: Dr. Christopher C.K. Ho, Department of Surgery, Universiti Kebangsaan Malaysia Medical Centre, Jalan Yaacob Latif, Bandar Tun Razak, 56000 Cheras, Kuala Lumpur, Malaysia ().

CITATION: Urotoday Int J. 2011 Feb;4(1):art12. doi:10.3834/uij.1944-5784.2011.02.12



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