Issue 2: April 2012

Volume 5 Issue 2 2012

Letter from the Editor - April 2012

Dear Colleagues,

The year is off to a wonderfully productive start for UroToday International Journal, and the inflow of interesting contributions is steadily increasing. We all look ahead to the upcoming 2012 AUA Annual Meeting in May with anticipation and excitement. Many of the topics generated from the meeting will inevitably fill our pages as the year progresses, and the changes and influences these presentations produce will be nothing less than inspirational and worthwhile for our readers.

There are also many new upcoming developments with the UIJ, and we look forward to growing and expanding with our current readership and the new bibliophiles and researchers we gather along the way.

In this issue, Abraham et al. demonstrate laparoscopic live donor nephrectomy experience in donors with multiple arteries and then compare the results with single artery donors on a case-matched basis, finding no significant difference in operative complications.

In an effort to promote transrectal sectional sonography as a more reliable method, Elwagdy et al. assess the effectiveness of TSS in the diagnosis and treatment of prostatic abscesses, eventually demonstrating successful transperineal needle aspiration in all cases.

Falahatkar et al. determine whether body mass index can influence the outcomes of percutaneous nephrolithotripsy in the prone and the supine position, demonstrating that both positions in obese and morbidly obese patients were safe and effective.

The first report of its kind, Kuykendall et al. evaluate a xenographic urethral replacement model utilizing porcine-derived, decellularized blood vessel matrices in rabbits. Their article suggests further investigation of a potentially off-the-shelf product for single-stage urethral reconstruction without stem cell technology.

Satâa et al. compare the clinicopathological characteristics and the prognosis of bladder transitional cell carcinoma according to age in young adults and the results this study yields, including tumor size and location, recurrence, and survival rates among the young.

Westermann et al. assess whether the concomitant use of a tension-free sling with minimally invasive sacrocolpopexy for the treatment of pelvic organ prolapse decreases postoperative stress urinary incontinence in women with and without preoperative symptoms of stress incontinence. They determine that a full or mini-sling significantly reduced postoperative symptoms.

Finally, in a review by Klaassen et al., resection of cancer metastasis to the brain is questioned, suggesting the indications for surgical resection in the nonemergent setting are less clear. Through their labor, they conclude that surgical therapy is reserved for patients with a good Karnofsky Performance Status, minimal-to-no systemic disease, solitary large lesions, and those with a life expectancy of more than 3 months.

We also present a series of case studies that include various topics, including Puigvert disease, pleomorphic sarcoma of the scrotum, and isolated renal hydatid cysts.

I hope the upcoming issue proves constructive and fruitful for our entire urologic community, no matter your purpose or focus, and thank you for your continued support as we forge ahead.

Kind regards,

Karl-Erik Andersson

Transrectal Sectional Sonography (TRSS) in the Diagnosis and Treatment of Prostatic Abscesses

ABSTRACT

Aim: The aim of this study was to assess the effectiveness of transrectal sectional sonography (TRSS) in the diagnosis and treatment of prostatic abscess.

Materials and Methods: Eighteen patients with prostatic abscess were the material of the present study. The criteria of abscess collection within the prostate gland and the periprostatic tissues were confirmed by TRSS, which guided the aspiration in all patients.

Results: Diagnosis and transperineal needle aspiration of prostatic abscesses were successful in all cases. After the second puncture procedure, recurrence was noted in 2 (11.1%) out of 18 patients, who were further subjected to transurethral unroofing under TRSS vision. The amount of pus drained ranged between 3.6 to 29.3 mL (mean 15.1 mL), compatible with the estimated volume by virtual organ computer-aided analysis (VOCAL) 3D measurements. The organism most frequently involved is escherichia coli. All patients received intravenous antibiotics (third generation cephalosporin) after the midstream urine analysis and further proper antibiotics, according to the aspirated pus culture and sensitivity.

Conclusions: Transrectal sectional sonography could be a more reliable method in the diagnosis of prostatic abscesses. It can provide precise needle guides into the best drainage location of the abscess cavity and justify transurethral unroofing if persistent recurrence is there.


Salah Elwagdy, Mohamed A-Khalek, Abdalla El-Kheshen, Abdel Aziz Aun, Ahmed Eldaly, Amr Mostafa, Ehab Adel, Ashraf Enite

Date Received: January 04, 2012 Accepted on: February 10, 2012


KEYWORDS: Transrectal sectional sonography, prostatic abscess, diagnosis and treatment

CORRESPONDENCE: Salah Elwagdy, Azhar University, Cairo, Egypt ().

UroToday Int J. 2012 Apr;5(2):art 01. http://dx.doi.org/10.3834/uij.1944-5784.2012.04.09

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A Case-Matched Comparative Analysis of a Laparoscopic Donor Nephrectomy in Single and Multiple Renal Arteries

ABSTRACT

Introduction: Laparoscopic live donor nephrectomy (LLDN), in cases with multiple renal arteries, has not been universally practiced worldwide. This paper demonstrates LLDN experience in donors with multiple arteries and compares the results with single artery donors on a case-matched basis.

Methods: Of 553 LLDN surgeries performed between December 1999 and November 2009, 132 cases were performed for multiple renal arteries. One hundred cases were selected. Detailed demographic profiles, operative profiles, and renal function tests in the immediate postoperative period and up to 1 year post transplantation were recorded. A matched comparison was made with 100 cases of LLDN in single arteries.

Results: Ninety-two cases had double arteries, 7 had triple arteries, and 1 revealed quadruple arteries prior to vascular disconnection. One accidental creation of 5 arterial branches was encountered. Warm ischemia time (WIT), total ischemia time (TIT), operative duration, blood loss, analgesic need, and hospital stay were significantly different between 2 groups (p < 0.05). No significant difference was observed in operative complications, renal function at 5 days, time to normalization of creatinine, or creatinine at 1 month, 3 months, and 1 year. Two patients in multiple artery groups required dialysis in the first postoperative week.

Conclusions: LLDN is equally feasible in the scenario of multiple renal arteries.


George P Abraham, Krishanu Das, Krishnamohan Ramaswami, Datson P George, Jisha J Abraham, Thomas J Tachil, Oppukeril S Thampan

Date Received: September 11, 2011 Accepted on: October 14, 2011


KEYWORDS: Laparoscopy, donor nephrectomy

CORRESPONDENCE: Krishanu Das, MS, MRCS, MCh, FCPS, DNB, Senior Specialist in Urology, Lakeshore Hospital, Kochi, 682030, Kerala, India ().

CITATION: UroToday Int J. 2012 Apr;5(2):art 11. http://dx.doi.org/10.3834/uij.1944-5784.2012.04.11

ACRONYMS AND ABBREVIATIONS

ESRD: end stage renal disease

LLDN: laparoscopic live donor nephrectomy

USG: ultrasound

VCUG: voiding cystourethrogram 3D

CTA: three-dimensional spiral computed tomography angiogram

CTU: computed tomography urogram

MM: millimeter

GRT: Graft retrieval time (minutes)

WIT: Warm ischemia time (minutes)

GRT25, WIT25: GRT, WIT 25 cases, terminal and assisted approach

GRT75, WIT75: GRT, WIT 75 cases, total laparoscopic approach CIT: cold ischemia time (minutes)

TIT: total ischemia time (minutes) RI= resistive index

AT: acceleration time

BMI: body mass index (kg/m2)

BL: blood loss (milliliters)

HS: hospital stay (days)

OD: operation duration (minutes)

OT: time to tolerance of orals (hours)

A: analgesic need (grams of paracetamol)

CNT: serum creatinine normalisation time (days)

Cr5d, Cr1m, Cr3m, Cr6m, Cr1y: serum creatinine at fifth postoperative day, 1 month, 3 months, 6 months, and 1 year post-transplantation (mg/dl)

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Laparoscopic or Robotic Sacrocolpopexy with Tension-Free Sling to Prevent and Treat Symptomatic or Occult Stress Urinary Incontinence

ABSTRACT

Objective: This retrospective review was conducted to assess whether the concomitant use of a tension-free sling (TVT) with minimally invasive sacrocolpopexy for the treatment of pelvic organ prolapse decreases postoperative stress urinary incontinence (SUI) in women with and without preoperative symptoms of stress incontinence.

Design: Women who reported symptoms of SUI and chose to undergo minimally invasive sacrocolpopexy received a concomitant retropubic tension-free sling, and women who did not report symptoms of SUI and who chose to undergo sacrocolpopexy to treat prolapse received a prophylactic concomitant mini-sling. These patients were compared with those that did not have a sling procedure and chose to proceed with a step approach. They were evaluated 3 months and 1 year after surgery. The primary outcomes included measures of stress incontinence (symptoms, stress testing, or treatment) and urge symptoms. Complications with the additional procedures were also tabulated.

Setting: University hospital, single-surgeon cases

Patients: Of 236 women who underwent minimally invasive sacrocolpopexy, 157 were symptomatic with SUI and 75 were not symptomatic with SUI. They are compared with 100 patients who underwent a prolapse repair without incontinence repair in the 2 years prior to this study.

Interventions: One hundred and fifty-seven symptomatic patients underwent a concomitant retropubic sling and 75 asymptomatic patients received a mini-sling.

Measurements and Main Results: One year after surgery, 6.4% of the women in the TVT group and 7.2% of the mini-sling group met 1 or more of the criteria for stress incontinence (p = 0.38). There was no significant difference between the TVT and the mini-sling group in the frequency of urge incontinence (12.7% versus 13.4%, p = 0.44). After surgery, women in both groups were less likely to report bothersome symptoms of stress incontinence compared to those reported previously in the literature (24.5% versus 6.7%, p < 0.001). Major sling complications included cystotomy (8.1%), infection (UTI) (15%), and catheter use for 2 days (12.6%).

Conclusions: In women with or without stress incontinence who were undergoing minimally invasive sacrocolpopexy for prolapse, a full or mini-sling significantly reduced postoperative symptoms of SUI without increasing complications or other lower urinary tract symptoms.


Lauren B Westermann, Jessika Kissling, Neena Agarwala

Date Received: January 26, 2012 Accepted on: March 20, 2012


KEYWORDS: sacracolpopexy, prolapse, SUI, sling, prophylaxis

CORRESPONDENCE: Neena Agarwala, MD, MSc, The Reading Hospital and Medical Center, Reading, Pennsylvania, United States ().

CITATION: UroToday Int J. 2012 April;5(2):art 07. http://dx.doi.org/10.3834/uij.1944-5784.2012.04.13

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Outcomes of Prone and Complete Supine Percutaneous Nephrolithotripsy According to Body Mass Index

ABSTRACT

Introduction: To determine whether body mass index (BMI) can influence the outcomes of percutaneous nephrolithotripsy (PCNL) in the prone and the supine position or cannot.

Materials and Methods: We have reviewed the files of 110 patients who underwent the prone and the complete supine PCNL (csPCNL) between September 2007 and December 2008 in the 3 categories: BMI < 25, 25 > BMI < 30, and BMI > 30.

Results: The demographic data and surgical outcomes of the patients were evaluated. There was no statistically significant difference between groups, except the stone-free rate in the BMI < 25 group, which was higher in the prone position. Moreover, in groups with higher BMIs, the anesthesia time was increased. The overall stone-free rate was 78 and 73.3% in the prone and supine positions, respectively (p = 0.57). No statistically significant differences were found, except a higher incidence of fever in the prone approach and a significantly shorter anesthesia time in the complete supine position.

Conclusion: The outcomes of PCNL in both positions were not dependent on the patient‘s BMI. Also, the anesthesia time was prolonged in patients with a higher BMI. This study showed that the prone and the supine PCNL in obese and morbidly obese patients were safe and effective.


Siavash Falahatkar, Marzieh Akbarpour, Ahmad Enshaei, Samaneh Esmaeili, Amin Afsharimoghaddam

Date Received: January 10, 2012 Accepted on: February 14, 2012


KEYWORDS: Complete supine PCNL, prone PCNL, BMI, stone-free rate, fever, total ultrasonic guidance

CORRESPONDENCE:Siavash Falahatkar, Professor of Urology, Urology Research Center, Razi Hospital, Sardare Jangal Street, Rasht, Gilan Province, Iran ()

CITATION: UroToday Int J. 2012 Apr;5(2):art 12. http://dx.doi.org/10.3834/uij.1944-5784.2012.04.12

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Urological Cancer Metastasis to the Brain: When Should We Resect?

ABSTRACT

Introduction: Although metastasis from urological malignancies to the brain occur late in the disease process and are typically associated with a poor prognosis, prolonged survival and excellent quality of life is achievable in a small, select population of patients. Surgical management has historically been utilized with large brain metastases, resulting in rapid increases in intracranial pressure and/or severe neurological deficits; however, the indications for surgical resection in the nonemergent setting are less clear.

Methods: The National Library of Medicine search engine PubMed was used to search for terms, including “brain metastasis, renal cell carcinoma,” “brain metastasis, bladder cancer,” “brain metastasis, prostate cancer,” and “brain metastasis, nonseminomatous testicular germ cell tumors.”

Results: Patients with renal cell carcinoma who typically have well circumscribed, firm radio and chemoresistant brain metastasis and patients with nonseminomatous testicular germ cell tumors who are generally younger with synchronous brain metastasis should be considered for aggressive surgical resection. Patients with brain metastasis from bladder or prostate cancer have a poor overall prognosis, and surgical resection is typically used only to improve quality of life, if not marginally extend survival.

Conclusion: Brain metastasis from urologic cancers are a late disease manifestation and surgical therapy is reserved for patients with a good Karnofsky Performance Status (> 70), minimal-to-no systemic disease, solitary large lesions (preferably > 3 cm), and those with a life expectancy of more than 3 months.


Zachary Klaassen, Faris Shweikeh, Ronald S Chamberlain

Date Received: January 26, 2012 Accepted on: February 22, 2012


KEYWORDS: brain metastasis, renal cell carcinoma, bladder cancer, prostate cancer, nonseminomatous testicular germ cell tumors

CORRESPONDENCE: Ronald S. Chamberlain, Chairman and Surgeon-in-Chief, MD, MPA, FACS, Saint Barnabas Medical Center, Livingston, New Jersey, 07039 United States ().

CITATION: UroToday Int J. 2012 Apr;5(2):art 10. http://dx.doi.org/10.3834/uij.1944-5784.2012.04.10

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Transitional Cell Carcinoma of the Bladder in Young Adults: Presentation, Natural History, and Outcome of 158 Cases

ABSTRACT

Background: The natural history of bladder transitional cell carcinoma (TCC) in young patients remains a matter of debate.

Purpose: To compare the clinicopathological characteristics and the prognosis of bladder TCC according to age in young adults.

Materials and Methods: From 1993 to 2006, 158 patients < 50 years with newly diagnosed bladder TCC were enrolled in this study. Patients were subdivided into 3 age groups: < 30 years (group I, n = 10), < 40 but > 30 years (group II, n = 37), and > 40 years (group III, n = 111). Data were analyzed with the Kaplan-Meier method to assess disease recurrence, progression, and survival.

Results: The study consisted of 140 males and 18 females. Eighty (50.6%) patients presented with pTa, 55 (34.8%) with pT1, and 23 (14.5%) with pT2-T3. The follow-up duration ranged from 36 to 158 months. The recurring tumors were stage Ta in 13 patients and stage T1 in 15. Five patients progressed to invasive cancer. The overall cancer-specific survival rate was 93%. The tumor size (p = 0.10), multiplicity (p = 0.71), tumor location (p = 0.60), T stage (p = 0.34), and tumor grade (p = 0.21) were similar in the 3 groups. The 5-year recurrence-free rates were 66.7, 77.4, and 81% (p = 0.76), respectively. The 5-year progression-free rates were 100, 96.8, and 95.8% (p = 0.74), respectively. The 5-year cancer-specific survival rates were similar in the 3 groups (p = 0.56).

Conclusion: Initial bladder TCC stage and natural history in young adults under 40 years old are similar to that in older patients.


Sallami Satâa, Adel Dahmani, Karim Cherif, Ines Chelly, Nidhameddine Kchir, Ali Horchani

Date Received: September 16, 2011 Accepted on: October 21, 2011


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

Citation: UroToday Int J. 2012 April;5(2):art 07. http://dx.doi.org/10.3834/uij.1944-5784.2012.04.07

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Spontaneous Ureteric Rupture: An Uncommon Emergency

ABSTRACT

Spontaneous ureteric rupture is an uncommon urologic emergency. Its presentation can vary, leading to clinical diagnostic challenges. We describe such a case, and its presentation is discussed briefly.


Eng Hong Goh, Omar Syed, Boon Wei Teoh, Kah Ann Git

Date Received: September 11, 2011 Accepted on: November 07, 2011


KEYWORDS: Spontaneous, ureter, rupture, perforation

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

CITATION: UroToday Int J. 2012 Apr;5(2):art 3. http://dx.doi.org/10.3834/uij.1944-5784.2012.04.03

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Isolated Renal Hydatid Cyst: A Report of 2 Cases

ABSTRACT

Human echinococcosis remains a complex problem that affects several organs. Primary involvement of the kidney without the involvement of the liver and lungs is very rare. The treatment of a renal hydatid cyst usually requires intervention ranging from minimally invasive percutaneous aspiration techniques to laparoscopic and open techniques. Herein, we describe 2 cases of isolated renal hydatid cysts treated successfully by cyst excision, with open techniques without content spillage. They were treated with 400 mg of albendazole for 2 months. The patients showed no evidence of recurrence within their 2-year follow-up.


Vijayabhaskar Reddy Gouru, Surya Prakash Vaddi, Vedamurthy Pogula Reddy, Chandra Mohan Godala, Ajit Vikram, Sreedhar D, Punit M, Venkata Krishna

Date Received: July 27, 2011 Accepted on: November 13, 2012


KEYWORDS: Hydatid disease, kidney, isolated renal hydatid

CORRESPONDENCE: Vedamurthy Pogula Reddy, Narayana Medical College, Nellore, Andhra Pradesh, India ().

CITATION: UroToday Int J. 2012 Apr;5(2):art 06. http://dx.doi.org/10.3834/uij.1944-5784.2012.04.06

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Pelvic Lipomatosis: A Rare Case with a Good Surgical Outcome

ABSTRACT

Pelvic lipomatosis is defined as a condition characterized by the diffuse proliferation of normal mature fatty tissue in the perirectal and perivesical region. We report a case of a 40-year-old, obese male who presented with marked lower urinary tract symptoms. Imaging studies and blood tests revealed bilateral hydroureteronephrosis and right non-excretory kidney with deranged renal function. Diagnosis of the pelvic lipomatosis was established on the basis of clinical and radiological findings. The patient was successfully managed by simple cystectomy and ileal conduit. After 6 years of follow-up, the patient is doing well with normal renal parameters.


Sanjay Kumar Gupta, Mahendra Singh, Vijoy Kumar, Rajesh Tiwari, Sanjay K Suman, Atul Khandelwal, Vinod Priyadarshi

Date Received: December 03, 2011 Accepted on: January 04, 2012


KEYWORDS: Pelvic lipomatosis, pear shaped bladder, simple cystectomy, cystitis glandularis

CORRESPONDENCE: Sanjay Kumar Gupta, Department of Urology, Indira Gandhi Institute of Medical Sciences, Patna, Bihar, India ().

CITATION: UroToday Int J. 2012 Apr;5(2):art 4. http://dx.doi.org/10.3834/uij.1944-5784.2012.04.04

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High-Grade Pleomorphic Sarcoma of the Scrotum: A Rare Clinical Entity

ABSTRACT

A majority of the malignant extratesticular tumors arise from the spermatic cord. Sarcomas are the most common malignant tumor, with rhabdomyosarcoma being common in children while liposarcoma is common in adults. However, pleomorphic sarcoma, leiomyosarcoma, mesothelioma, and lymphoma also occur in the scrotum. High-grade pleomorphic sarcoma is a rarely reported tumor of the scrotum.


Atul Khandelwal, Sanjay Kumar Gupta, Mahendra Singh, Vijoy Kumar, Rajesh Tiwari, Anju Singh

Date Received: October 21, 2011 Accepted on: January 04, 2012


KEYWORDS: Paratesticular, sarcoma, scrotal, malignant

CORRESPONDENCE: Atul Khandelwal, MBBS, MS, Indira Gandhi Institute of Medical Sciences, Patna, Bihar, India ().

CITATION: UroToday Int J. 2012 Apr;5(2):art 5. http://dx.doi.org/10.3834/uij.1944-5784.2012.04.05

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A Rare Presentation of Penopubic Testis in an Infant

ABSTRACT

An ectopic testis is defined as one that has emerged from the external ring but fails to reach the scrotum. There are, in general, 5 sites of ectopic testis. A rare case of penopubic ectopic testis is reported here. A 6-month-old infant presented with penopubic ectopic testis. An orchidopexy was performed. During the operation, a gubernacular attachment was not found on the testis. Although Lockwood’s 5 tails of gubernaculum form a commonly quoted mechanism of ectopic testis, our case could not fit in this mechanism since the gubernaculum was absent. A break in the gubernaculum during testicular descent, as suggested by Sonneland, leaving the testis radar-less after its exit from the superficial ring, may be an explanation for ectopic location in our case.


Nitinkumar Bhajandas Borkar, Nitin Pant, Satish Kumar Aggarwal

Date Received: November 26, 2011 Accepted on: January 06, 2012


KEYWORDS: Ectopic, penopubic, testis

CORRESPONDENCE: Nitinkumar Bhajandas Borkar, MCh, Department of Pediatric Surgery, Jawaharlal Nehru Medical College, Sawangi, Wardha, Maharashtra, India ().

CITATION: UroToday Int J. 2012 Apr;5(2):art 92. http://dx.doi.org/10.3834/uij.1944-5784.2012.04.02

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Megacalycosis or Puigvert Disease, a Rare Congenital Calyceal Anomaly: A Report of 3 Cases

ABSTRACT

Megacalycosis is most likely congenital. It is primarily a disease of the renal calyces, which is usually diagnosed because of its complications, such as calculi or infections in the urinary tract. It has also been diagnosed prenatally. In the absence of complications, the disease is discovered accidentally in the course of urologic examination undertaken for a different reason. This article reports 3 cases of megacalycosis presenting to us with varying symptoms. Awareness of the possible existence of megacalycosis in patients suffering from infections and calculi in the urinary tract contributes to and facilitates the choice of appropriate treatment.


Bikash Bawri, Rajeev T Puthenveetil, Saumar J Baruah, Sassanka K Barua, Puskal K Bagchi

Date Received: November 23, 2011 Accepted on: December 22, 2011


KEYWORDS: Megacalycosis, hydronephrosis, nonobstructive

CORRESPONDENCE: Bikash Bawri, RK Singh Apartment, House No 54, Ashram Road, Kasturba Nagar, Ulubari, Guwahati-781007, Assam, India ().

CITATION: UroToday Int J. 2012 Apr;5(2):art 01. http://dx.doi.org/10.3834/uij.1944-5784.2012.04.01

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Decellularized Porcine-Derived Blood Vessel Matrix Graft for Urethral Replacement in a Rabbit Model

ABSTRACT

Objective: To evaluate a xenographic urethral replacement model utilizing porcine-derived, decellularized blood vessel matrices in rabbits.

Materials and Methods: In 17 male rabbits, a 1 cm tubular segment of porcine, acellular blood vessel matrix replaced a 1 cm urethral defect without a postoperative catheter. The animals were sacrificed at varying intervals (1, 3, and 6 months) and assessed for graft patency and integration properties.

Results: All but 1 animal survived. One animal died of unknown etiology 1 month after surgery. In all 17 rabbits, the urethra was patent, without evidence of stricture formation as confirmed by gross inspection and passage of a 10 Fr catheter at the time of euthanasia/tissue harvest. At 1 month, histological examination revealed epithelialization, host-cell infiltration, angiogenesis, and migration of the smooth muscle. The smooth muscle bundles were more organized by 6 months. No significant fibrosis or stricture was observed in the anastomotic area.

Conclusion: This successful experiment would support efforts for further investigation of a potentially off-the-shelf product using acellular blood vessel matrices for single-stage urethral reconstruction without requiring stem cell technology. To our knowledge, this is the first report of a xenograft blood vessel matrix for urethral substitution.


Sam Kuykendall, Gilad A Amiel, Erin T Bird

Date Received: November 22, 2011 Accepted on: February 02, 2012


KEYWORDS: Urethra, graft, repair, urethroplasty, biomaterial

CORRESPONDENCE: Sam Kuykendall, MD, Scott and White, Texas A&M Health Science Center, Temple, Texas, United States ().

CITATION: UroToday Int J. 2012 Apr;5(2):art 8. http://dx.doi.org/10.3834/uij.1944-5784.2012.04.08

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