Issue 4: August 2011

UIJ Volume 4 Issue 4 2011

Letter from the Editor - August 2011

Dear Colleagues,

The goal of UroToday International is to accelerate the timely and widespread dissemination of new urological research findings, and ultimately to impact clinical outcomes. This objective is most probably similar to all academic publishers, however most others survive by selling subscription use to libraries around the globe where according to a recent article in The Economist, Elsevier, the largest publisher of journals with nearly 2000 titles reported an operating profit margin of 36% while other media has experienced great declines. At the UIJ we offer manuscript submission, peer review and publication free for the authors providing the research and are now charging an annual subscription fee for use of the journal to offset the publications costs. All researchers, reviewers, and the editorial board provide their services for free. I want to express my sincere gratitude to our reviewers and editorial board members who contribute their time and resources to support the goal of free access to publishing, allowing results of important clinical or basic research findings to be provided to over 40,000 individual readers of this journal. We will continue on our journey to establish a new model for publishing that is privately supported to establish a way for all clinicians and scientists, irrespective of age or affiliation, the opportunity to have peer-review of their manuscripts and the power to have them published upon peer approval.

In this issue we have four original studies the first, by Anderson et al, was designed to determine the feasibility and effectiveness of medical hypnosis and cognitive behavioral therapy (CBT) for pain relief, improvement of psychological status, and quality of life in men with chronic prostatitis, (CP) also known as chronic pelvic pain syndrome (CPPS). The authors conclude the CBT and self-hypnosis training for patients with CP/CPPS was feasible, resulted in decreased symptoms, and provided patient self-directed methods to improve sense of control, ability to cope, and dissociation from pain symptoms.

Nederostek and colleagues present a subanalysis of stratification by risk group, race, prostate volume, and neoadjuvant hormone therapy for prostate cancer treated with current, third-generation cryotherapy. The authors conclude that the short-term results from this retrospective analysis justify the continuing use of cryosurgery for the management of localized prostate cancer.

Galal and Fath El-Bab studied the safety and efficacy of one stage ureteroscopy for the treatment of bilaterial ureteric stones. They conclude that the one-stage procedure was safe and effective and reduced anesthesia exposure and potentially provides cost savings.

Al-Sayyad and colleagues present an evaluation of biomarkers to differentiate upper from lower urinary tract infections in children younger than 2 years of age. The differentiation between the upper and lower UTI has important clinical implications in children where UTI is the most common bacterial infection. They conclude that some biomarkers used alone or in combination, help to differentiate between upper and lower UTI and may make more aggressive testing unnecessary in the future. Larger prospective studies will be necessary to confirm this finding.

Also in this issue is a mini report presenting a novel bridge technique designed for a skilled urologist, to simplify the learning curve for the laparoendoscopic single-site (LESS) surgery that includes an incisional LESS (iLESS) approach. The purpose of this report is to describe the method for establishing single-site access using the GelPort and standard instruments in a teaching hospital, as a learning tool toward LESS surgery.

There are also a series of case reports presented providing insights into less common situations that present in urology.

Thank you for your continued support in providing publication-worthy manuscripts - and to our reviewers and editorial board, a special recognition for your contributions in making timely decisions and recommendations. 



Karl-Erik Andersson


Feasibility Trial of Medical Hypnosis and Cognitive Behavioral Therapy for Men With Refractory Chronic Prostatitis/Chronic Pelvic Pain Syndrome


OBJECTIVE: To determine the feasibility and effectiveness of medical hypnosis and cognitive behavioral therapy (CBT) for relief of pain, improvement of psychological status, and quality of life in men with chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS).

METHODS: Men with refractory chronic pelvic pain who were symptomatic for >3 months were assessed for hypnotic susceptibility after medical, mental health, and social history were obtained. Psychological data from healthy men with no evidence of pain disorders or genitourinary symptoms were used as a comparator group. In 7 weekly sessions, the psychologist/hypnotherapist utilized CBT to challenge and balance negative cognitions associated with symptoms, performed guided imagery and hypnotic intervention, and provided patient training in self-hypnosis for symptom management. Changes in symptom indices, psychometrics, and compliance with home exercises using audiotapes of hypnosis sessions and CBT workbooks were assessed after 3 and 6 months.

RESULTS: Sixteen men with median pain duration of 7 years and high symptomatic pain scores participated. All had moderate to high hypnotic ability. At 6 months after training, the median NIH-CPSI total score decreased 10.5 points (-7 to -27) relative to pretreatment in 57% of patients; McGill pain scores decreased a median of 6.5 points (-2 to -28). Both NIH-CPSI pain and quality of life domain scores significantly improved (P ≤ .02). Most (88%) patients reported continued self-hypnosis effective for symptomatic relief and improved coping.

CONCLUSION: CBT and self-hypnosis training for patients with CP/CPPS was feasible, resulted in decreased symptoms, and provided patient self-directed methods to improve sense of control, ability to cope, and dissociation from pain symptoms. Longer-term follow-up is required to determine the impact of these therapeutic approaches for selected men with this disorder.

KEYWORDS: Prostatitis; Chronic pelvic pain syndrome; Medical hypnosis; Cognitive behavioral therapy

CORRESPONDENCE: Rodney U Anderson, MD, FACS, Department of Urology, S287 Stanford University School of Medicine, Stanford, California 94305-5118, USA ().

CITATION: UroToday Int J. 2011 Aug;4(4):art46. doi:10.3834/uij.1944-5784.2011.08.02.

ABBREVIATIONS AND ACRONYMS: BSI, Brief Symptom Inventory; CAM, complementary and alternative medical; CBT, cognitive behavioral therapy; CNS, central nervous system; CP, chronic prostatitis; CPPS, chronic pelvic pain syndrome; CPSI, Chronic Prostatitis Symptom Index; DSM, Diagnostic and Statistical Manual; GRA, global response assessment; NIH, National Institutes of Health; PPSS, Pelvic Pain Symptom Scale


One-Stage Ureteroscopy for Bilateral Ureteric Stones: Outcomes From a Tertiary Referral Center


INTRODUCTION: The purpose of the study was to determine the safety and efficacy of one-stage ureteroscopy for treatment of bilateral ureteric stones.

METHODS: Retrospective data were obtained from the patient database in the Department of Urology at Minia University Hospital between March 2008 and November 2010. There were 34 patients (20 men and 14 women) with a mean age of 38.4 years (SD = 13.6; range,16-82 years). All patients underwent one-stage ureteroscopy for bilateral ureteric stones using an 8 Fr semirigid ureteroscope. A 0.038 inch floppy-tipped guidewire was passed through the selected ureteric orifice, advanced under direct vision, and monitored fluoroscopically. Balloon dilation of the intramural ureter was completed in most cases. Stone treatment was chosen according to its size and occurred by direct extraction or lithotripsy using the pneumatic lithoclast. Postoperatively, unilateral or bilateral ureteral stenting was done for 2 days to 6 weeks. Patients were followed for a minimum of 3 months.

RESULTS: Sixty four ureteroscopic procedures were successfully completed to treat 32 of the 34 patients. Mean stone size was 8.3 mm (range, 3-20 mm). The stones were radio-opaque in 28 patients and dense in 4 patients. A single stone was found in 30 patients (93.75%); 2 patients had multiple stones. Calculi were retrieved intact using baskets for 18 patients; lithotripsy was required for 14. The mean operative time was 85 minutes (range, 35-150 minutes). Intraoperatively, 25 of 32 patients (78.2%) were stone-free bilaterally and another 7 patients (21.8%) were stone-free unilaterally. Thirty patients (93.7%) were stone free 1-month after 1 endoscopic procedure; 2 patients were clear after 2 procedures. Early postoperative complications were rare and included fever in 4 patients; no long-term complications were observed.

CONCLUSION: One-stage ureteroscopy for bilateral ureteric stones is a safe and effective procedure that can achieve stone-free and complication rates that are comparable to those of unilateral ureteroscopy.

Ehab Mohamad Galal, Tarek Khalaf, Fath El-Bab

Submitted April 8, 2011 - Accepted for Publication April 28, 2011

KEYWORDS: One-stage ureteroscopy; Bilateral ureteric stones

CORRESPONDENCE: Ehab Mohamad Galal, MD, Urology Department, Minia University Hospital, Minia City, Egypt().

CITATION:UroToday Int J. 2011 Aug;4(4):art45. doi:10.3834/uij.1944-5784.2011.08.01

ABBREVIATIONS AND ACRONYMS: IVU, intravenous urogram; KUB, kidney, ureter, bladder


Trauma to a Horseshoe Kidney: Case Report and Review of the Literature


A horseshoe kidney (HSK) is the most common congenital renal fusion anomaly. It occurs in approximately 1 in 400 persons, with a 2:1 male:female incidence. Traumatic synchronous, multiorgan injury in the setting of anomalous anatomy adds to the complexity of surgical exposure and creates a formidable hemostatic challenge. We present a 30-year-old male with multiorgan injury secondary to blunt abdominal trauma sustained during a motor vehicle accident. We describe the preoperative evaluation that led to the identification of the HSK and other associated intra-abdominal injuries and the subsequent surgical procedure. Surgical management of blunt abdominal trauma to an HSK is difficult due to multiple variations in vascular anatomy and the location of this renal anomaly. Such anatomical variations can make reconstruction and preservation of the damaged kidney very challenging.

Prakash R Paragi, Pauline H Go, Zachary Klaassen, Mark Ingram

Submitted March 16, 2011 - Accepted for Publication May 11, 2011

KEYWORDS: Horseshoe kidney; Renal; Trauma

CORRESPONDENCE: Prakash R Paragi, MS, MD, Director of Minimally Invasive Surgery, Saint Barnabas Medical Center, 94 Old Short Hills Road, Livingston, NJ 07039 USA ().

CITATION: Urotoday Int J. 2011 Aug;4(4):art47. doi:10.3834/uij.1944-5784.2011.08.03

ABBREVIATIONS AND ACRONYMS: CT, computed tomography; FAST, Focused Assessment with Sonography in Trauma; HSK, horseshoe kidney; MVA, motor vehicle accident.


Evaluation of Biomarkers to Differentiate Upper From Lower Urinary Tract Infections in Children


INTRODUCTION: Distinguishing upper from lower urinary tract infections (UTI) has important clinical implications in children, especially in those younger than 2 years of age. The objective of this study was to test differences between upper and lower UTIs by using serum and urine biomarkers.

METHODS: Participants were 83 patients with UTI based on suggestive clinical symptoms and at least 1 positive urine culture. All had renal scintigraphy. Children with known concomitant diseases, any type of renal disorder, or a previous diagnosis of vesicoureteral reflux were excluded. Before the initiation of antibiotic treatment, blood was sampled for white blood cell (WBC) count, C-reactive protein (CRP), erythrocyte sedimentation rate (ESR), and procalcitonin (PCT). Urinary interleukin-6 (uIL-6) and macrophage migration inhibitory factor (MIF) were also measured. Data were analyzed using the Mann-Whitney or t test. Sensitivity and specificity were calculated for some variables in isolation and in combination.

RESULTS: There were 61 girls and 22 boys with mean (SD) age of 8.7 (3.4) months and 7.8 (4.5) months, respectively; 49 patients had acute pyelonephritis (APN) and 34 had lower UTI. The mean WBC counts were significantly higher in the group with APN than in the group with lower UTI (P < .01), as were CRP and ESR levels (P < .001). Significantly higher serum PCT, urinary IL-6, and MIF levels were detected in patients with APN when compared with patients with lower UTI (all with P < .001). For the prediction of APN, sensitivity and specificity levels were 95.9% and 88.2% for CRP, 87.8% and 91.2% for PCT, 71.4% and 94.1% for uIL-6, and 93.9% and 97.1% for urinary MIF. The sensitivity and specificity for CRP combined with other biomarkers were 93.9% and 91.2% (PCT with CRP), 95.9% and 91.2% (uMIF with CRP), and 85.7 % and 94.1% (uIL-6 with CRP), respectively.

CONCLUSION: Some biomarkers, used solely or in combination, help to differentiate between upper and lower UTI and may make more aggressive and invasive testing unnecessary in the future.

Ahmed J Al-Sayyad, Salah M EL-Morshedy, Ehab A abd Al Hamid, Nehad A Karam, A Basset A Imam, Rehab A Karam

Submitted April 10, 2011 - Accepted for Publication May 25, 2011

KEYWORDS: Urinary tract infection; Acute pyelonephritis; Biomarkers

CORRESPONDENCE: Ahmed Al-Sayyad MD, FRCSC, Assistant Professor and Consultant of Pediatric Urology, King Abdulaziz University, PO Box 1817 Jeddah 21441, Saudi Arabia ().

CITATION:UroToday Int J. 2011 Aug;4(4):art49. doi:10.3834/uij.1944-5784.2011.08.05.

ABBREVIATIONS AND ACRONYMS: APN, acute pyelonephritis; CRP, C-reactive protein; DMSA, dimercaptosuccinic acid; ELISA, enzymelinked immunosorbent assay; ESR, erythrocyte sedimentation rate; IL-6, interleukin-6; MIF, migration inhibitory factor; PCT, procalcitonin; RPI, renal parenchymal involvement; UTI, urinary tract infection; WBC, white blood cell.


Prostate Cancer Treated With Cryotherapy: A Subanalysis of Stratification by Risk Group, Race, Prostate Volume, and Neoadjuvant Hormone Therapy


INTRODUCTION: Prostate cryoablation was developed with the intent of maximizing effectiveness while minimizing the morbidity of treating clinically localized prostate cancer. Our focus was to determine Kaplan-Meier (KM) biochemical recurrence-free survival (BRFS) estimates and how they might be affected by neoadjuvant hormone therapy, race, D’Amico risk group, and prostate volume.

METHODS: We retrospectively analyzed data from 190 patients receiving cryoablation for the primary treatment of T1 to T3 prostate cancer from 2003 to 2009. All patients underwent whole-gland prostate cryoablation by a single surgeon using the Cryocare CS System (HealthTronics; Austin, TX, USA). Patients received a prostate-specific antigen and digital rectal examination at 1, 3, 6, 9, 12, 18, 24, and 30 months after surgery. A PSA nadir of ≤ 0.1 ng/mL was used to define treatment success. KM BRFS curves were plotted overall and by subanalysis variable and compared using the log-rank test. Univariate Cox proportional hazard regression models were used to describe the effect of measured variables on risk of biochemical recurrence.

RESULTS: The mean follow-up was 27 months. A total of 153 patients (81%) reached the treatment goal of PSA nadir ≤ 0.1 ng/mL. Using a nadir + 2 ng/mL failure definition, BRFS rates were 94% and 85% for 1 year and 3 years, respectively. High D’Amico risk significantly predicted biochemical recurrence (hazard ratio [HR] = 3.65; P = .045). African American men had a nonsignificant trend toward increased risk (HR= 1.91; P = .12). BRFS did not differ when comparing men who did or did not receive hormone therapy (log-rank test: P = .57) or men with prostate size < 40 g vs ≥ 40 g (P = .72). The majority of complications were minor, with a rate of 12%.

CONCLUSIONS: Although neoadjuvant hormone therapy and prostate volume at the time of surgery were not statistically associated with BRFS, race approached significance and high D’Amico risk group was significant. Our short-term results justify the continuing use of cryosurgery for the management of localized prostate cancer.

KEYWORDS: Cryotherapy; Neoadjuvant Hormone Therapy; Prostate; Prostate Cancer; Prostate Cryoablation

CORRESPONDENCE: LCDR James C. Nederostek, MD, Department of Urology, Naval Medical Center Portsmouth, 620 John Paul Jones Circle, Portsmouth, VA 23708, USA ().

CITATION: Urotoday Int J. 2011 Aug;4(4):art48. doi:10.3834/uij.1944-5784.2011.08.04

ABBREVIATIONS AND ACRONYMS: ASTRO, American Society for Therapeutic Radiology and Oncology; BRFS, biochemical recurrence-free survival; CT, computed tomography; KM, Kaplan-Meier; PSA, prostate-specific antigen; RTOG, Radiation Therapy Oncology Group.


Incisional Laparoendoscopic Single-Site (iLESS) Nephrectomy Using the GelPort Device: A Training Bridge to LESS Surgery


INTRODUCTION: The laparoendoscopic single-site (LESS) technique has advantages over multi-site surgery that include better cosmesis, less incisional pain, and the ability to convert to standard multiport surgery, if needed. A steep learning curve makes the procedure prohibitive for trainees in many centers. To simplify this learning curve, we adopted a bridging technique that includes an incisional LESS (iLESS) approach using a GelPort device (Applied Medical Resources Corp; Rancho Santa Margarita, CA, USA). We describe the iLESS technique and report our initial experiences.

METHOD: The iLESS surgical technique is illustrated on a centrally-located 5 cm right renal mass in a 54-year-old female patient with a poorly functioning right kidney. A single-port supraumbilical nephrectomy was conducted using the GelPort device. The device was inserted through an 8 cm supraumbilical incision. Procedures are fully described and compared with the LESS technique.

RESULTS: The procedure was technically successful. The total operative duration was 2.2 hours, the estimated blood loss was 70 mL, and the hospital stay was 3 days. There were no complications during or after surgery. The total analgesia requirement was 30 mg of morphine. Visual analog pain scores were 7/10 and 2/10 at 1 and 2 days after surgery, respectively.

CONCLUSIONS: The iLESS nephrectomy is technically feasible using standard laparoscopic instruments. Selected patients should have a low body mass index and an anterior abdominal wall thickness of < 6 cm. We expect this procedure to help bridge the gap between standard laparoscopy and LESS, because the GelPort device simulates a modified type of laparoendoscopic single-site surgery. Rigid or flexible instruments are used selectively to provide a smooth learning curve.

Ahmed Al-Sameraaii, Edward Latif, Peter Aslan

Submitted March 20, 2011 - Accepted for Publication June 13, 2011

KEYWORDS: Incisional laparoendoscopic single site; iLESS; Supraumbilical; Single port; Laparoscopic surgery; Gelport

CORRESPONDENCE: Dr. Ahmed Al-Sameraaii, Department of Urology, Hurstville Private Hospital, 37 Gloucester Road, Hurstville, NSW 2220, Sydney, Australia ().

CITATION: UroToday Int J. 2011 Aug;4(4):art51. doi:10.3834/uij.1944-5784.2011.08.07.

ABBREVIATIONS AND ACRONYMS: GIA, gastrointestinal anastomosis; iLESS, incisional laparoendoscopic single-site; LESS, laparoendoscopic single-site.


A Novel Use for the Nitinol Stone Retrieval Basket: The Removal of a Catheter Tip from the External Iliac Artery


Nitinol retrieval basket is an instrument used by urologists to retrieve stones from the upper urinary tract. We report the innovative way of using an instrument purposely designed for endourology, by a urological surgeon in endovascular surgery. After an initial failed angioplasty, a 62-year-old man with peripheral vascular disease had a second right groin cross over catheterization angioplasty of the calcifi ed left iliac stenotic disease performed by a radiologist. This procedure was complicated by the fracture of the catheter tip in the external iliac. With no snares available at the time of the second angioplasty, a Urology Consultant successfully used a Zerotip 2.4 F Å~ 120 cm Nitinol Stone Retrieval Basket, avoiding an open laparotomy.

Costin Chintea, Ajantha Jayatunga, Alexander Wolinski, Henryk Krasnowski

Submitted April 16, 2011 - Accepted for Publication May 11, 2011

KEYWORDS: Stone retrieval basket; Urology; Endourology; Angioplasty

CORRESPONDENCE: Costin Chintea, 53 Stonehouse Lane, Quinton, Birmingham, West Midlands B32 3DU, United Kingdom ().

CITATION: Urotoday Int J. 2011 Aug;4(4):art4. doi:10.3834/uij.1944-5784.2011.08.08


Renal Angiomyolipoma complicated with spontaneous hemorrhage in a 22 years old female, a rare presentation


Renal angiomyolipoma (AML) rarely presents with hemorrhage. We report a case of a large-sized renal angiomyolipoma (12 X 7 X 6.5 cm) with intratumoral and subcapsular spontaneous hemorrhage in a 22-year-old female. The diagnosis was based on radiological features by CT scan and histopathological examination after removal of the tumor. The patient subsequently underwent right nephrectomy. Spontaneous hemorrhage from AML should be expected in large size tumors and fast decision for intervention is mandatory.

Hamdy AbdelMawla Aboutaleb, Mohammed Badr-Eldin

Submitted April 14, 2011 - Accepted for Publication May 19, 2011

KEYWORDS: Angiomyolipoma; Kidney; Hemorrhage

CORRESPONDENCE: Dr. Hamdy AbdelMawla Aboutaleb, Minoufiya University Hospital, Gamal Abdelnasser Street, P. O. Box 32511, Shebin Elkom, Minoufiya, Egypt ().

CITATION: UroToday Int J. 2011 Aug;4(4):art53. doi:10.3834/uij.1944-5784.2011.08.09.