Issue 5: October 2011

UIJ Volume 4 Issue 5 2011

Letter from the Editor - October 2011

Dear Colleagues,

Welcome to the October issue of UroToday International Journal. As the global economy continues its shift into uncharted territory burdened with challenges, it may appear that anxiety remains on the horizon. The truth is that although there are hurdles, there is always hope and eventual progress. We at UIJ remain at the forefront of progress, showcasing the most up-to-date advances in the field and sharing them with our ever-thriving community. Serving that community with a wealth of support is our newest editor, Jennifer Bennett, who works out of our offices in California. I know you will find her as helpful as she is friendly.

In this issue, an original study by Sallami brings up the very same socio-economic encounters expressed by many, detailing the current state of urology and urology training in Tunisia, its various limitations in education and equipment availability, and a lack of sub-specialty recognition prevalent in other countries. The author concludes with optimism, outlining ways to overcome these limitations while emphasizing review of economic and health care policies.

Khan and Baig review the successful results of ultrasound-guided lymphocele surgery following kidney transplantation. They stress meticulous surgical techniques where all lymphatics are carefully ligated, along with the reduction of known risk factors, in order to avoid recurrence.

Denewer et al. explore the minimally invasive techniques of hand-assisted cystectomy on forty patients with bladder carcinoma. The authors conclude that hand-assisted cystectomy combines the merits of open radical cystectomy with a decrease in blood loss, hospital stay, and complications. It also results in fewer treatment costs for the patient.

In an article by Soliman et al., the authors investigate obesity as an important risk factor for stress urinary incontinence in women. By comparing a group of 100 obese women with a control group of 100 normal-weight women, the authors discovered a significant difference in urinary bladder control in the two groups. They present a possible explanation of this relationship via ultrasound of the urethrovesical angle and bladder neck descent.

Daneshmand et al. express the importance of photodocumentation in bladder cancer surveillance based on fifteen patients who underwent flexible cystoscopy. During the fifteen-month surveillance period, photodocumentation proved a supportive and cost-effective tool for the observation and eventual biopsy of lesions in six patients.

We also present a series of case reports that provide various insights into multiple urologic complications, including giant bladder calculi and squamous cell carcinoma of multiple types.

As always, we offer free manuscript submission, peer review, and publication to our authors. Finally, without the continued loyalty of our authors and readers, UIJ would cease to be the success it is. Thank you for your continued support in all that we provide for the urology community. 



Karl-Erik Andersson


Challenges for a Resident in Urology in Tunisia in 2011


This article presents the actual state of urology and highlights some of the most significant challenges facing resident urological training in Tunisia. These include a specifically limited number of trained urologists, limited training capacity, limited availability of some modern equipment, and non-recognition of subspecialties related to urology. Brief suggestions to overcome these problems are made, and the need for a wholesome review of the economic and health care policies is emphasized.

Sallami Satáa

Submitted January 24, 2011 - Accepted for Publication July 3, 2011

KEYWORDS: Urology; Training; Residency; Education; Clinical competence; Motivation; Evaluation; Curriculum; Medical; Surgery; Endourology; Endoscopy; Laparoscopy

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

CITATION: UroToday Int J. 2011 Oct;4(5):art 59. doi:10.3834/uij.1944-5784.2011.10.01


Page Kidney - Rare but Correctable Cause of Hypertension


A case of Page kidney as a result of injury followed by hypertension is presented. An abdominal ultrasound revealed soft tissue mass suggestive of a hematoma, resulting in a nephrectomy during which there were dense adhesions on the posterior surface of the kidney due to a large sucapsular hematoma. This presentation aims to bring attention to Page kidney’s causes associated with hypertension and its correctable treatment.

Kapil Singla, Ashish K. Sharma, Sistla B. Viswaroop, Myilswamy Arul, Ganesh Gopalakrishnan, Sangam V Kandasamy

Submitted April 25, 2011 - Accepted for Publication May 19, 2011 

KEYWORDS: Page kidney; Subcapsular hematoma; Hypertension

CORRESPONDENCE: Kapil Singla, Department of Urology, Vedanayagam Hospital, 52 East Bashykaralu Road, Coimbatore 641002, Tamil Nadu, India ().

CITATION: Urotoday Int J. 2011 Oct;4(5):art54. doi:10.3834/uij.1944-5784.2011.10.10


The Role of Photodocumentation in Surveillance Cystoscopy for Bladder Cancer


PURPOSE: To determine if the combination of photodocumentation and electronic medical record keeping led to changes in the management of suspicious lesions in patients with bladder cancer undergoing surveillance cystoscopy.

METHODS: We reviewed the charts of all patients undergoing surveillance cystoscopy for bladder cancer during a 15-month period. We evaluated patients who had photodocumentation of bladder lesions in our electronic medical record (EPIC). Baseline demographics, surveillance data, and biopsy results were collected, and the outcome of photodocumentation was analyzed. A cost base analysis was performed using figures obtained from the billing department.

RESULTS: During the study period, 50 patients underwent flexible cystoscopy for bladder cancer surveillance at our institution. Fifteen were identified who met the study criteria. Using photodocumentation in EPIC, nine patients had well documented lesions that had no change during the surveillance period with negative urine cytology and therefore did not undergo biopsy. Six patients, however, did undergo biopsy based on a change in the appearance of the lesion. Biopsies demonstrated 3 benign lesions, 2 low-grade transitional cell carcinomas, and 1 muscle-invasive lesion. An economic base analysis demonstrated a cost reduction of 27% and 55% compared with office-based biopsy and transurethral resection of bladder tumor, respectively, by using photodocumentation.

CONCLUSIONS:  Photodocumentation of lesions during flexible cystoscopy is a useful tool in bladder cancer surveillance. It provides support for clinical decisions and is a cost effective way to monitor patients undergoing frequent interventions.

Eric S. Reid, Hooman Djaladat, Siamak Daneshmand

Submitted April 1, 2011 - Accepted for Publication June 16, 2011

KEYWORDS: Bladder neoplasm; Cystoscopy; Biopsy; Economic

CORRESPONDENCE: Siamak Daneshmand, M.D., Associate Professor of Urology, Norris Comprehensive Cancer Center, USC Institute of Urology, Los Angeles, CA 90033, USA ().

CITATION: Urotoday Int J. 2010 Oct;4(5):art 58. doi:10.3834/uij.1944-5784.2011.08.14



Spontaneous Rupture of Adrenal Myelolipoma


Adrenal myelolipoma is a benign tumor composed of adipose tissue and hematopoietic lesions. It is usually diagnosed incidentally in imaging tests such as computed tomogram (CT) or by patient symptoms such as retroperitoneal hemorrhage due to tumor rupture. We present a patient with retroperitoneal hemorrhage due to spontaneous rupture of a myelolipoma with enlargement of the mass and hemorrhage during the follow-up regimen of watchful waiting.

Minori Matsumoto, Katsumi Shigemura, Masato Fujisawa

Submitted March 22, 2011 - Accepted for Publication June 1, 2011

KEYWORDS: Rupture of Adrenal Myelolipoma; Enlargement of the mass and hemorrhage; Watchful waiting

CORRESPONDENCE: Katsumi Shigemura MD, PhD, Division of Urology, Department of Organs Therapeutics, Faculty of Medicine, Kobe University Graduate School of Medicine, 7-5-1 Kusunoki-Cho, Chuo-Ku, Kobe, Hyogo 650-0017, Japan ().

CITATION: UroToday Int J. 2011 Oct;4(5):art 55. doi:10.3834/uij.1944-5784.2011.08.11



Myeloid Sarcoma of the Bladder: Case Presentation and Review of the Literature


Myeloid sarcoma, an uncommon proliferative hematological entity associated with leukemia, can present in various extramedullary soft tissues in the body and its outcome is generally undesirable. Due to its rarity, the diagnosis can be challenging and commonly missed. A search through PubMed revealed only 8 cases in English literature. We would like to present a case of myeloid sarcoma in the bladder and briefly discuss this disease.

Eng Hong Goh, Akhavan Adel, Praveen Singam, Christopher Chee Kong Ho, Guan Hee Tan, Badrulhisham Bahadzor, Zulkifli Md Zainuddin, Fauzah Abdul Ghani, Noraidah Masir

Submitted April 12, 2011 - Accepted for Publication May 11, 2011

KEYWORDS: Myeloid sarcoma; Chloroma; Bladder

CORRESPONDENCE: Eng Hong Goh, Urology Unit, Department of Surgery, Universiti Kebangsaan Malaysia Medical Center, Jalan Yaacob Latif, Bandar Tun Razak, Kuala Lumpur 56000, Malaysia ().

CITATION: Urotoday Int J. 2011 Oct;4(5):art 48. doi:10.3834/uij.1944-5784.2011.08.13


Pheochromocytoma with the Renovascular Hyperreninemia Attendant on Renal Artery Stenosis


A 68-year-old female, diagnosed with essential hypertension, demonstrated a muscular depression caused by hypokalemia. Endocrinological data revealed elevated plasma rennin activity (PRA), plasma aldosterone concentration (PAC), and cathecholamine, and the computed tomography (CT) presented a 6 cm mass above the left kidney. I-metaiodobenzylguanidine (MIBG) scintigraphy showed an uptake in accord with the tumor and I-adosterol scintigraphy showed no abnormal accumulation. Magnetic resonance angiography (MRA) demonstrated left renal artery stenosis (RAS). Peak systolic velocity in the left renal artery measured by a duplex ultrasound was elevated. We considered that the left RAS accompanied by compression caused hyperreninemia. A tumor strongly adhered to the left renal artery and vein, so we performed a laparoscopic left nephroadrenalectomy. Two weeks after the operation, PRA, PAC, and cathecholamine were almost normalized. We present a rare case of pheochromocytoma with the renovascular hyperreninemia attendant on RAS diagnosed by MRA and a duplex ultrasound.

Fumitaka Shimizu, Kazuhiko Fujita, Takeshi Ieda, Kentaro Imaizumi, Taiki Mizuno, Kazuo Suzuki

Submitted March 21, 2011 - Accepted for Publication May 25, 2011

KEYWORDS: Pheochromocytoma; Renovascular hyperreninemia; Renal artery stenosis

CORRESPONDENCE: Fumitaka Shimizu, M.D., Department of Urology, Juntendo Shizuoka Hospital, 1129 Nagaoka, Izunokunishi, Shizuoka 410-2295, Japan ().

CITATION: UroToday Int J. 2011 Oct;4(5):art 56. doi:10.3834/uij.1944-5784.2011.08.12


Hand-Assisted Laparoscopic Radical Cystectomy and Orthotopic S-Shaped Ileal Neobladder: Functional and Oncologic Outcomes


Background & Objective: Open radical cystectomy is the standard procedure for the treatment of muscle-invasive bladder cancer. There has been a recent trend towards minimally invasive techniques aiming to decrease blood loss, hospital stay, and complications. Therefore, hand-assisted cystectomy (HAC) emerged as a rational choice, combining the merits of laparoscopic surgery with the feasibility of performing a continent urinary reservoir in a reasonable operative time and with reasonable treatment costs.

Patients & Methods: Forty patients with invasive bladder carcinoma were offered radical cystectomy with the HAC approach. Thirty-two men and 8 women underwent HAC. The mean age was 57.5 years. The mean operation time was 200 minutes for the extirpative part and 90 minutes for the reconstructive part of the procedure. Estimated blood loss was 450 ml. The mean hospitalization time was 17 days (range of 10 to 30). At a median follow-up of 2 years, no cases of port-site, incisional, or isolated pelvic recurrence was detected. The median DFS is 14.6 month (95%CI = 13.2-15.8).

Conclusions: HAC is a rational procedure that can be used to perform radical surgery of invasive bladder carcinoma and orthotopic urinary diversion.

Adel Denewer, Fayez Shahato, Osama Hussein, Sameh Roshdy, Omar Farouk, Ashraf Khater, Mohammed Hegazy, Waleed ElNahhas, Mahmoud Mosbah, Mahmoud Adel

Submitted May 19, 2011 - Accepted for Publication July 25, 2011

KEYWORDS: Radical cystectomy; Ileal neobladder; Bladder carcinoma

CORRESPONDENCE: Adel Denewer, Surgical Oncology Center, Mansoura University, Egypt ().

CITATION: UroToday Int J. 2011 Oct;4(5):art 59. doi:10.3834/uij.1944-5784.2011.10.09


Post Kidney Transplant Lymphoceles: Meticulous Ligation of Lymphatics Reduces Incidence


Objective: To determine the impact of our surgical techinique with the incidence of lymphoceles in all patients who underwent renal transplantation, and identify other risk factors responsible for the development of lymphoceles.

Materials and Methods: The records of all patients who underwent kidney transplantation at the Riyadh Military Hospital from March 2007 to March 2011 were retrospectively reviewed to determine the incidence of lymphocele. Demographic characteristics, risk factors, and surgical technique were outlined. All transplants were performed by a single surgeon and his team.

Results: A total of 273 patients underwent kidney transplantation; only 1 recipient was diagnosed with a lymphocele on ultrasound 6 weeks after transplantation. This patient underwent ultrasound-guided aspiration with complete resolution without recurrence at a 1-year follow-up. Our surgical technique is based on (1) ligation of all paravascular hilar tissue in the allograft, (2) ligation and division of all lymphatic vessels when dissecting the recipient iliac artery and vein, (3) ligation and division of all lymphatics if iliac lymph nodes require removal, and (4) routine use of suction drains. The known risk factors are comparable with other studies and include an acute rejection (AR) rate of 6.6%, a body mass index (BMI) >30 to 24%, diabetes at 22%, retransplants at 15%, zero de novo sirolimus therapy, and 14.6% recipients on a steroid-free regimen.

Discussion: Post-renal transplant lymphoceles are not uncommon and can result in unnecessary morbidity. These patients can present with a palpable mass, renal impairment from obstruction of the ureter, lower limb edema from iliac vein thrombosis, and sepsis in case of infection. Diagnosis and follow-up with an ultrasound (US) is simple and efficient. The prevention of lymphoceles may be possible with meticulous surgical techniques where all lymphatics are carefully ligated. The reduction of known risk factors can also help reduce its incidence and morbidity. Treatment options include aspiration, sclerosant instillation, and surgery, but lymphoceles can recur and every effort must be made to reduce its incidence.

Conclusion: We feel that a meticulous surgical technique with ligation of all lymphatics, both during dissection of the recipient vessels and the donor allograft, along with appropriate suction drainage, was significant in reducing the incidence of lymphoceles following kidney transplantation in our recipients.

Taqi F Toufeeq Khan, Mirza Anzar Baig

Submitted June 11, 2011 - Accepted for Publication Aug 12, 2011

KEYWORDS: Post-renal transplant lymphocele; Meticulous surgical technique; Ligation of lymphatics; Risk factors; Incidence

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

CITATION: Urotoday Int J. 2011 Oct;4(5):art 64. doi:10.3834/uij.1944-5784.2011.10.07


Giant Bladder Calculus


We present a case of a 28-year-old male who presented with complaints of continous urinary incontinence and a lower abdominal lump over a few months. The X-ray KUB showed a large radio-opaque shadow occupying the entire urinary bladder, suggestive of a calculus. A suprapubic cystolithotomy was done. The calculus weighed 1064 grams and had a size of 13.2 cms x 10 cms x 9 cms. Giant bladder stones are an extreme rarity these days. This, we believe, is the largest bladder stone in terms of volume and weight reported in recent times.

Sanjay Kolte, Chandrashekhar Mahakalkar, Rucha Jajoo

Submitted April 7, 2011 - Accepted for Publication July 3, 2011

KEYWORDS: Bladder calculus; Giant stone

CORRESPONDENCE: Sanjay Kolte, Datta Meghe Institute of Medical Sciences, Sawangi (Meghe), Wardha 442004, Maharashtra, India ()

CITATION: UroToday Int J. 2011 Oct;4(5):art 61. doi:10.3834/uij.1944-5784.2011.10.03


The Link Between Female Obesity and Urinary Stress Incontinence


Background: Stress urinary incontinence (SUI) has an observed prevalence of between 4 and 35%. Aging, obesity, and smoking have consistent causal relationships with the condition.

Objective: To elucidate the relationship between obesity and urinary incontinence in women and a possible explanation of this relationship by ultrasound of the urethrovesical angle and bladder neck descent.

Material and Methods: This prospective, comparative study was conducted in Tanta University Hospital from January 2006 to July 2010, and it included 100 obese women compared to 100 normal-weight control women regarding symptoms of SUI, ultrasonographic examination of the bladder neck, and bladder neck descent during straining for the detection of SUI.

Results: In the obese group, 70% of patients had symptoms of SUI, whereas in the normal-weight group, 17% of patients had symptoms of SUI, denoting a significant increase among the obese. Ultrasonographic examination revealed that in obese women, the urethrovesical angle is nearly at a right angle with an empty urinary bladder at rest and becomes obtuse at straining; but when the bladder was full, this angle became obtuse at rest and during straining. In normal-weight women, the urethrovesical angle was acute at rest and nearly at a right angle at straining while the bladder was empty, and it became a right angle with a full bladder at rest and slightly obtuse at straining with a full urinary bladder. In obese women, the average bladder neck descent during straining was 10 ±3.5 mm compared with a mean of 3±1.2 mm in the normal weight group, with a significant difference between the 2 groups.

Conclusion: Female obesity is an important risk factor for the occurrence of SUI.

HH Eltatawy, TM Elhawary, MG Soliman, MR Taha

Submitted May 27, 2011 - Accepted for Publication July 25, 2011

KEYWORDS: Obesity; Female stress incontinence

CORRESPONDENCE: M. G. Soliman, Lecturer of Urology, Urology Department, Faculty of Medicine, Tanta University, Tanta, Egypt ().

CITATION: UroToday Int J. 2011 Oct;4(5):art 63. doi:10.3834/uij.1944-5784.2011.10.05


Von Hippel-Lindau Disease - A Case Report and Review of Literature


Von Hippel-Lindau disease is a dominantly inherited familial cancer syndrome with variable expression. Here we are reporting a case of von Hippel-Lindau disease in a family.

Vedamurthy Pogula Reddy, Dandu Venkata Satya Rambabu, Surya Prakash Vaddi, Subramanian S

Submitted May 1, 2011 - Accepted for Publication July 3, 2011

KEYWORDS: Von Hippel-Lindau disease; Familial renal cancer

CORRESPONDENCE: Vedamurthy Pogula Reddy, Department of Urology and Renal Transplantation, Narayana Medical College and Hospital, Nellore, Andhra Pradesh, India 524002 ().

CITATION: UroToday Int J. 2011 Oct;4(5):art 64. doi:10.3834/uij.1944-5784.2011.10.06

ABBREVIATIONS AND ACRONYMS: RCC, renal cell carcinoma; VHL, von Hippel-Lindau; VEGF, vascular endothelial growth factor; HIF, hypoxia induced factor; PDGF, platelet derived growth factor


Squamous Cell Carcinoma of the Urinary Bladder Associated with a Big Bladder Stone in a 55-Year-Old Female: A Case Report


A 55-year-old-female Egyptian presented to us with severe dysuria. Laboratory investigations showed high serum creatinine of 3.4 mg/dl. A urinalysis revealed pyuria and hematuria. Liver enzymes were very high due to viral hepatitis and the daily usage of NSAIDs. A KUB showed a large, lamellated, radio-opaque shadow in the pelvis. A non-contrast CT revealed a contracted bladder with diffuse thickening of the bladder wall, and a single, large urinary bladder stone 5 x 6 cm, bilateral marked hydronephrosis, and hepatomegaly. A VCUG showed left reflux grade IV. A cystoscopy confirmed the presence of the stone with multiple biopsies from the erythematous bladder wall. A histopathology showed invasive squamous cell carcinoma. A right percutaneous nephrostomy was inserted with a urethral catheter. There was conservative management for liver disease till the liver functions returned to normal. A radical cystectomy and ileal conduit urinary diversion was performed successfully. The association between a large, neglected bladder stone and SCC should be considered.

Hamdy AbdelMawla Aboutaleb, Atef Badawy, Ahmed Gamal-eldin, Mohammed Badr-eldin

Submitted April 14, 2011 - Accepted for Publication June 13, 2011

KEYWORDS: Bladder stone; Squamous cell carcinoma

CORRESPONDENCE: Hamdy AbdelMawla Aboutaleb, Department of Urology, Minoufiya University Hospital, Shebin Elkom, Minoufiya, Egypt ()

CITATION: UroToday Int J. 2011 Oct;4(5):art 67. doi:10.3834/uij.1944-5784.2011.10.08

ABBREVIATIONS AND ACRONYMS: SCC, squamous cell carcinoma; CT, computerized tomography; KUB, kidney ureter bladder X-ray; VCUG, voiding cystourography; NSAIDs, Nonsteroidal anti-inflammatory drugs


Intravesical Explosion During TURP: A Rare Complication of a Common Procedure – What We Should Know


A case of bladder rupture due to intravesical explosion during transurethral resection of prostate (TURP) is presented. Exploratory laparotomy done on clinical suspicion revealed a large inverted “V” shaped bladder tear that was sutured in 2 layers. An incidence of intravesical explosion during TURP is extremely rare. It occurs due to a mixture of explosive gases produced during TURP, with the air introduced into the bladder while activating the electrosurgical instrument. The presentation aims to bring attention to this rare complication once again with a literature review and emphasis on the necessary precautions needed to prevent it.

Rahul Kapoor, Hemant R. Pathak

Submitted April 8, 2011 - Accepted for Publication June 1, 2011

KEYWORDS: Transurethral resection of the prostate; Intravesical explosion; Bladder rupture

CORRESPONDENCE: Rahul Kapoor, Department of Urology, Apollo BSR Hospital, Junwani Road, Bhilai 242002, Chhattisgarh, India ().

CITATION: Urotoday Int J. 2011 Oct;4(5):art 60. doi:10.3834/uij.1944-5784.2011.10.02


Squamous Cell Carcinoma of Renal Pelvis with Fungal Infection in a Non-Functioning Kidney - A Rare Entity


Squamous cell carcinoma of the urinary tract is a very rare tumor associated with chronic renal calculi and infection. This tumor is highly aggressive and often detected at an advanced stage with a poor outcome. We hereby describe a case report of a 56-year-old male who presented with hydronephrosis and hydroureter in a non-functioning left kidney with ureteric calculi. Histopathology of the nephrectomy specimen revealed unexpected squamous cell carcinoma with chronic pyelonephritis. The pus culture came out positive for fungus—Geotrichum.

Hamdy AbdelMawla Aboutaleb, Atef Badawy, Ahmed Gamal-eldin, Mohammed Badr-eldin

Submitted April 14, 2011 - Accepted for Publication June 13, 2011

KEYWORDS: Non-functioning kidney; Fungal infection-Geotrichum; Squamous cell carcinoma

CORRESPONDENCE: Anubha Singh Yadav, Department of Urology, Pt. BDS PGIMS, University of Health Sciences, Rohtak ().

CITATION: UroToday Int J. 2011 Oct;4(5):art 62. doi:10.3834/uij.1944-5784.2011.10.04