Issue 2: April 2011

Letter from the Editor - April 2011

Dear Colleagues,

This is the second issue of the UIJ being delivered on our new platform. One significant goal in this upgrade is supporting the continuous international readership growth. The UIJ is now read in over 190 countries and territories around the globe with an individual subscriber base of over 29,000 healthcare providers and researchers.

Also new in this month is the CME activity available exclusively from the UIJ, Frequently Asked Questions in the Management of Castrate-Resistant Prostate Cancer (CRPC), an expert panel interview. The faculty includes Pamela I. Ellsworth, MD, FACS, Program Chair, Associate Professor of Surgery Division of Urology The Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA. Christopher P. Evans, MD, FACS Professor and Chairman Department of Urology University of California, Davis School of Medicine, Sacramento, California, USA and Fred Saad, MD, FRCS Professor and Chairman of Urology Director of Urologic Oncology University of Montreal Endowed Chair in Prostate Cancer University of Montreal Faculty of Medicine Montreal, Canada.

In the current issue, Aggarwal et al. discuss the problems inherent in using a manual paper database system to monitor ureteric stent placement and removal. Their results showed that stent removal documentation was not completed in over one third of 379 stent procedures, and follow-up revealed that 22.4% of the stents exceeded the 6-month maximum indwelling time recommended by the stent manufacturers. The authors review literature showing similar findings from other centers and discuss the advantages of automated electronic follow-up systems.

Krongrad and Lai describe preliminary results of an ongoing clinical trial. Six patients with severely symptomatic chronic prostatitis were treated with a laparoscopic prostatectomy and followed for 1 year. The patients were selected from among those who had failed every previous medical, surgical, and complementary treatment. All patients reported resolution of their symptoms following surgery. This protocol is approved by the Western Institutional Review Board and the study is listed on the searchable National Institutes of Health clinical trials Web site. It may be considered controversial by some readers and the authors acknowledge that it requires further validation. However, their results indicate that this procedure may be an option for some carefully selected patients.

Finally, the case report by Laryngakis et al. provides insight into the cause of exercise-induced hematuria. The authors used cystoscopy to evaluate a 54-year-old marathon runner with painless gross hematuria. Results revealed multiple erythematous lesions of the bladder that were associated with a small filling defect of the left posterior bladder wall. They also found submucosal hemorrhages and a shaggy prostatic urethral mucosa. The authors recommend a complete work-up (cytology, cystoscopy, upper tract evaluation) for any patient with this disorder.



Karl-Erik Andersson


Renal Failure Secondary to Transurethral Resection of Bladder Tumors at the Ureteric Orifice: A Serious, Poorly Known Complication


We report a case of severe bilateral distal ureteral stenosis in a 76-year-old male. The stenosis was caused obstructive renal failure after transurethral resection of a periorificial bladder tumor and early postoperative bacillus Calmette-Guerin therapy instillation to prevent recurrence.

Sataa Sallami, Sami Ben Rhouma. Ali Horchani

Department of Urology, La Rabta Hospital-University, Tunis, Tunisia

Submitted November 5, 2010 - Accepted for Publication December 11, 2010

KEYWORDS: Ureter; Bladder neoplasms; Postoperative complications; Endoscopy.

CORRESPONDENCE: Dr. Sataa Sallami, Department of Urology, La Rabta Hospital-University, Tunis 1007, Tunisia ().

CITATION: UroToday Int J. 2011 Apr;4(2):art8. doi:10.3834/uij.1944-5784.2011.02.08

ABBREVIATIONS AND ACRONYMS: CT, computed tomography; TURBT, transurethral resection of bladder tumor.



Prognostic Value of the Anatomical Location of Upper Urinary Tract Urothelial Carcinoma


INTRODUCTION: The prognostic significance of pyelum versus ureteral urothelial carcinomas is controversial. The objective of the study was to evaluate the prognostic value of the anatomical location of transitional cell carcinoma (TCC) in the upper urinary tract.

METHODS: We retrospectively analyzed data from 51 patients with upper urinary tract TCC (UTTCC) from a single institute. Patients were treated surgically between 1995 and 2007. Tumor location and other clinicopathological variables were evaluated regarding cancer recurrence and survival. Recurrence and cancer-specific survival probabilities following tumor resection were analyzed using the Kaplan-Meier method and log rank test. Univariate and multivariate analyses were performed using Cox proportional hazards regression model.

RESULTS: Mean patient age was 69.5 years (range, 25-87 years); median follow-up was 43.8 months (range, 37-142 months). TCCs were in the pyeleum or the calyx (n = 33), the ureter (n = 9), and in both locations (n = 9). There was no significant difference between the number of patients with transmural tumor growth (pT3-pT4) in the proximal ureter or pyelum (41%) when compared with distally located tumors (18.2 %) (P = .30). The majority of the patients (67%) had pT2 or pT3 primary tumors. None of the patients with Ta/cis, T1, or T2 primary tumors had nodal or distant metastatic disease, either initially or during follow-up. Median overall and disease-specific survivals were 37.9 months and 40.1 months, respectively. The repartition of tumor stage and grade was similar in the pyelum pelvis and the distal ureter (P = .06 and P = .46, respectively). The tumor location did not significantly affect the 3-year bladder recurrence rate (P = 0.83). The disease-specific survival rates were 88.2% for patients with tumors in both the pyelum and distal ureter locations. There was no significant impact of UTTCC location on 3-year survival.

CONCLUSION: Tumor location does not appear to be an independent prognostic factor for patients with UTTCC. Patients with pyelum or distal ureter TCC with the same tumor grade and stage had the same risk of bladder cancer recurrence and survival. We recommend the same surveillance protocol regardless of the tumor location.

Sataa Sallami,1 Sami Ben Rhouma,1 Karim Cherif,1 Nidhameddine Kchir,2 Ali Horchani1

1 Department of Urology, La Rabta Hospital-University, Tunis, Tunisia

2 Department of Pathology, La Rabta Hospital-University, Tunis, Tunisia

Submitted November 5, 2010 - Accepted for Publication December 6, 2010

KEYWORDS: Upper urinary tract; Transitional cell carcinoma; Prognosis; Recurrence; Survival rate.

CORRESPONDENCE: Dr. Satâa Sallami, Department of Urology, La Rabta Hospital-University, Tunis 1007, Tunisia ().

CITATION: UroToday Int J. 2011 Apr;4(2):art10. doi:10.3834/uij.1944-5784.2011.02.10

ABBREVIATIONS AND ACRONYMS: CT, computed tomography; TCC, transitional cell carcinoma; UTTCC, upper urinary tract transitional cell carcinoma.



Differential Diagnosis and Management of Megacalyces (Puigvert's Disease): A Case Report


Megacalyces is a rare congenital urinary anomaly consisting of nonobstructive dilated calyces. The renal pelvis and ureter have a normal caliber. We report an asymptomatic unilateral megacalyces in a 22-year-old woman. She had an increased number of dilated calyces on the right kidney and a cluster of small calculi over the lower pole. The largest stone in the lower calyx was 5 mm. The renal pelvis and ureter were normal and there was no evidence of obstruction. In the absence of functional symptoms and because of the small urinary stone size, we decided on surveillance. A follow-up examination 22 months later showed that the patient is still asymptomatic and the stone sizes are unchanged. We discuss literature related to the clinical features, differential diagnosis, and management of this condition.

Sataa Sallami, Adel Dahmani, Sami Ben Rhouma, Sabeur Rebii, Ali Horchani

Department of Urology, La Rabta Hospital-University, Tunis, Tunisia

Submitted November 10, 2010 - Accepted for Publication December 11, 2010

KEYWORDS: Malformation; Congenital; Renal abnormalities; Calyx; Megacalices.

CORRESPONDENCE: Dr. Sataa Sallami, Department of Urology, La Rabta Hospital-University, Tunis 1007, Tunisia ().

CITATION: UroToday Int J. 2011 Apr;4(2):art13. doi:10.3834/uij.1944-5784.2011.02.13

ABBREVIATIONS AND ACRONYMS: CT, computed tomography; IVU, intravenous urography.



Urethral Leiomyoma in Females: Report of 3 Cases


Urethral leiomyomas are rare benign tumors arising from the smooth muscle of the urethra. We describe 3 female patients aged 40, 38, and 35 years, respectively. Each presented with a mass protruding from the urethral meatus. Other characteristics included urethral bleeding, dysuria, and dyspareunia. There were no reports of obstructive voiding. We explain the procedures needed for differential diagnosis. All patients underwent transvaginal excision of the mass and were free of recurrence at the 2- or 3-year follow-up. Related literature is reviewed.

Siddalingeshwar Ishwarappa Neeli, Sharanbasavesh B Alur, Suresh U Kadli, Pravin B Patne

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

KLES Dr. Prabhakar Kore Hospital and Medical Research Center, Belgaum, Karnatak, India

Submitted November 17, 2010 - Accepted for Publication January 19, 2011

KEYWORDS: Female urethra; Leiomyoma; Urethral tumor; Spindle cell neoplasm.

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. 2011 Apr;4(2):art24. doi:10.3834/uij.1944-5784.2011.04.06

ABBREVIATIONS AND ACRONYMS: CT, computed tomography; MRI, magnetic resonance image.



Runner’s Bladder: Exercise-Induced Hematuria With Lower Urinary Tract Pathology


Exercise-induced hematuria is an uncommon clinical entity experienced by long-distance runners and participants in other sports. The source and mechanism of bleeding have been debated. We explain the pathology in a 54-year-old male using cytoscopic evidence. The patient had multiple episodes of painless gross hematuria that occurred immediately after long-distance running. Cystoscopy performed 3 days after an episode revealed multiple erythematous lesions of the posterior bladder wall and prostatic urethra. There was shaggy prostatic urethral mucosa. After a 2-week period without long-distance running, repeat cystoscopy revealed nearly complete resolution of the bladder and prostatatic urethral lesions. Transurethral bladder and prostatic urethral biopsies identified no malignancy or dysplasia. This is one of the few known cases of exercise-induced gross hematuria with evidence of bladder and prostatic abnormalities on cystoscopy. A complete work-up for gross hematuria must be performed to avoid missing an underlying abnormality that presents incidentally or secondary to exertion.

Nicholas A Laryngakis,1 Scott R Caesar,1 Jeffrey S Berns,2 Alan J Wein1

1 Division of Urology, Department of Surgery, Hospital of the University of Pennsylvania, University of Pennsylvania School of Medicine, Philadelphia, PA, USA

2 Renal-Electrolyte and Hypertension Division, Department of Medicine, Hospital of the University of Pennsylvania, University of Pennsylvania School of Medicine, Philadelphia, PA, USA

Submitted November 16, 2010 - Accepted for Publication January, 6, 2011

KEYWORDS: Hematuria; Runner's bladder; Cystoscopy; Bladder injury; Urothelium; Cystitis cystica.

CORRESPONDENCE: Scott R. Caesar, M.D, Resident, Division of Urology, Department of Surgery, University of Pennsylvania Health System, 3400 Civic Center Blvd, 3rd Floor, West Pavilion, Rm 3-333W, Perelman Center for Advance Medicine, Philadelphia, PA 19104 USA ().

CITATION: UroToday Int J. 2011 Apr;4(2):art19. doi:10.3834/uij.1944-5784.2011.04.01

ABBREVIATIONS AND ACRONYMS: CT, computed tomography; FISH, fluorescence in situ hybridization.



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.