Issue 5: October 2013

Letter from the Editor - October 2013

Dear Colleagues, 

We at UroToday International Journal hope all our current readers and authors have enjoyed a warm and nice early fall as we are fast approaching the Holiday season. In this issue of UIJ we are proud to announce the first ever article with videos included! The videos can be found on the homepage of UroToday,® the leading digital only, global urology website, where the first urology content dedicated Urology TUBE™ was recently launched. Urology TUBE™ is a rich media content distribution channel that offers a simplified interface providing easier access to video content channels.

The article by Nickles et al. present a technique for transvaginal removal of vesicular mesh erosion and the two accompanying videos demonstrate this technique in a step-by-step fashion in the Urology TUBE™ on urotoday.com

A review by Dr. Campeau shows thatsystemically administered cannabinoids may be able to become clinically useful for the control of lower urinary tract function. This review is a step towards understanding the potential in the development of novel cannabinoid drugs for the treatment of micturition disorders such as overactive bladder syndrome.

Newman and Strauss provide a synopsis of current practices and multimodal prevention strategies for catheter-associated urinary tract infections. These urinary catheter-related infections are associated with morbid events, such as delirium, and with longer lengths of stay and higher costs of medical care.

A retrospective review was completed by Dickstein et al. toevaluate the utility of computed tomography (CT) scanning in identifying patients with locally advanced bladder cancer.

An evaluation of the efficacy of alpha-adrenergic blockers with or without Deflazacort in the expulsion of a lower ureteric calculus ≤ 10 mm was performed by Phukan et al.

The ability to render patients tube and stent free after percutaneous nephrolithotomy (PNL) was studied by Al-Ba’adani et al. and they found that tubeless, stentless PNL decreases hospital stay, postoperative pain, and the need for analgesia, and subsequently lowered work abstinence.

Finally, Valentini et al. compared the geometric effect of the urethral catheter in regards to the effect of other mechanical parameters likely to influence the voiding phase during a urodynamic study. The geometric obstruction due to the catheter was almost negligible for non-obstructed individuals compared with the volume effect up to a 6 Fr catheter size.

We also present a series of case studies that include various topics, including the above mentioned study about Excision of Mesh Erosion, Crossed Renal Ectopia, Bladder Diverticulum, Colovesical Fistulae, Spontaneous Dissolution of a Double-J Ureteric Stent, Posterior Urethral Valve with a Bladder Stone, and Priapism as Unusual Sequalae of Malignant Melanoma.

We encourage our current readers and authors to continue to spread the word about UIJ, reminding potential submitters that submission, peer review, and publication are all free. I personally thank the authors and reviewers for their valuable contributions to this issue.

Warm Regards, 

Karl-Erik Andersson

 

Posterior Urethral Valve with a Bladder Stone: A Case Report

ABSTRACT

A posterior urethral (PU) valve and a bladder stone both may cause obstructive voiding symptoms. There are very few patients of a PU valve associated with bladder stones. We are presenting this case because of the rarity of its occurrence and for its unique way of management. 

Khalid Mahmood, Atul Kumar Khandelwal, Ahsan Ahmad, Mahendra Singh, Rajesh Tiwari, Vijoy Kumar

Indira Gandhi Institute of Medical Sciences, Patna, Bihar, India

Submitted September 12, 2013 - Accepted for Publication October 24, 2013

KEYWORDS: Posterior urethral valve, bladder, stone

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

CITATION: UroToday Int J. 2013 October;6(5):art 66. http://dx.doi.org/10.3834/uij.1944-5784.2013.10.13

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Preventing Catheter-Associated Urinary Tract Infections

 ABSTRACT

Catheter-associated urinary tract infections, a worldwide, leading hospital-acquired infection, have substantial impact on patient safety and antibiotic consumption. These urinary catheter-related infections are associated with morbid events, such as delirium, and with longer lengths of stay and higher costs of medical care. It has been estimated that 65 to 70% of CAUTIs may be preventable with recommended evidence-based practices. For this reason, the Centers for Medicare & Medicaid Services no longer reimburses acute care and rehabilitation hospitals for the cost associated with treating these infections, and has a national goal to reduce these infections by 25% in 2014. An expanding body of literature has demonstrated methods for ensuring the practices and processes for decreasing these infections. This article will provide a synopsis of current practices and multimodal prevention strategies for catheter-associated urinary tract infections.

Diane K. Newman,1 Robyn Strauss2

1Division of Urology, Penn Medicine, University of Pennsylvania; 2Department of Nursing, Hospital of the University of Pennsylvania

Philadelphia, Pennsylvania

Submitted September 26, 2013 - Accepted for Publication October 20, 2013


KEYWORDS: catheter associated urinary tract infections, indwelling urinary catheter, prevention, evidence-based guidelines, bladder bundle

CORRESPONDENCE: Diane K. Newman, Adjunct Associate Professor of Urology in Surgery, Research Investigator Senior, Perelman School of Medicine, University of Pennsylvania; Co-Director, Penn Center for Continence and Pelvic Health, Division of Urology, Penn Medicine, 34th and Civic Center Boulevard, Philadelphia, PA 19104 ()

CITATION: UroToday Int J. 2013 October;6(5):art 64. http://dx.doi.org/10.3834/uij.1944-5784.2013.10.11


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Cannabinoid System Contribution to Control Micturition

ABSTRACT

Cannabinoid compounds, such as those that can be extracted from the Cannabis sativa plant (marijuana), produce a very wide array of central and peripheral effects, some of which may be of importance for the control of lower urinary tract function. Thus, stimulation of cannabinoid receptors, located both in the central nervous system and in different components of the lower urinary tract, has been shown to affect both normal micturition and various disturbances of bladder function. It is clear that systemically administered cannabinoids may be able to become clinically useful; however, a much greater understanding of the mechanisms of cannabinoid receptors in the control of the human lower urinary tract is necessary to facilitate development of novel cannabinoid drugs for the treatment of micturition disorders such as overactive bladder syndrome.


Lysanne Campeau

Division of Urology, McGill University, Montreal, Quebec, Canada

Submitted September 1, 2013 - Accepted for Publication September 23, 2013


KEYWORDS: Cannabinoid, cannabinoid receptor, endocannabinoid, knockout mice, cystometry, bladder, urodynamics

CORRESPONDENCE: Lysanne Campeau, CM, MD, PhD, FRCSC, Assistant Professor, Division of Urology, Department of Surgery, Jewish General Hospital and Lady Davis Institute for Medical Research, McGill University, Montreal, Quebec, Canada

CITATION: UroToday Int J. 2013 October;6(5):art 59. http://dx.doi.org/10.3834/uij.1944-5784.2013.10.06

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Transvaginal Excision of Intravesical Mesh Erosion

ABSTRACT

Introduction and Objectives: Transvaginal mesh has been used in the management of a multitude of female urologic conditions; most commonly vaginal prolapse and stress urinary incontinence. However, in the event of a complication related to the use of such mesh, there is scant literature on its safe and efficacious removal. We present a technique for transvaginal removal of vesicular mesh erosion.

 

 

Excision of Intravesical Mesh Erosion

 

 

Transvaginal Removal of Intraurethral Mesh

Methods: The patient is placed in lithotomy position and cystoscopy is performed. Once bilateral ureteral catheters are in place, a Foley catheter is placed. Using a midline transvaginal approach, hydrodissection is performed. Allis clamps are used to grasp the vaginal epithelium, and vaginal flaps are developed. The sling is identified and the midline it is transected. A combination of sharp and blunt dissection is used to free the sling. The sling is dissected to the most lateral extent possible. Once the intravesical mesh is encountered, the entirety of the offending mesh is excised. Once the mesh has been removed, attention is then turned to the resultant cystotomy. The bladder is then closed in multiple layers. A urethral catheter is left indwelling postoperatively.

Results: The patient is discharged when ambulatory and tolerating a regular diet. A voiding cystourethrogram (VCUG) is obtained in 1 to 2 weeks and if urinary extravasation is not seen, the urethral catheter is removed.

Conclusion: Despite the use of mesh slings for stress urinary incontinence and pelvic organ prolapse, literature describing operative techniques to remove slings in the setting of urinary tract erosion is lacking. The described technique avoids significant manipulation of the urinary tract and further disruption of the periurethral and perivesical fascia while ensuring a watertight closure.


S. Walker Nickles, Lara MacLachlan, Eric Rovner

Medical University of South Carolina, Charleston, South Carolina, United States

Submitted September 27, 2013 - Accepted for Publication October 17, 2013


KEYWORDS: Mesh erosion, transvaginal surgery, mesh complication

CORRESPONDENCE: S. Walter Nickles, Medical University of South Carolina, Charleston, South Carolina, United States, ()

CITATION: UroToday Int J. 2013 October;6(5):art 63. http://dx.doi.org/10.3834/uij.1944-5784.2013.10.10

INTRODUCTION AND OBJECTIVES

Transvaginal mesh has been used in the management of a multitude of female urologic conditions; most commonly vaginal prolapse and stress urinary incontinence. However, in the event of a complication related to the use of such mesh, there is scant literature on its safe and efficacious removal. We present a technique for transvaginal removal of vesicular mesh erosion.

METHODS

The patient is placed in lithotomy position and cystoscopy is performed to identify the location of the mesh and to place ureteral catheters to aid in the identification of the ureters during the dissection of the offending mesh. Once bilateral ureteral catheters are in place, a Foley catheter is placed and gentle traction is placed on the catheter to aid in identification of the bladder neck by palpating the Foley balloon. Subsequently, using a midline transvaginal approach, hydrodissection is performed using injectable saline to infiltrate the length of the intended incision. Allis clamps are used to grasp the vaginal epithelium once incised, and vaginal flaps are developed in order to expose periurethral and perivesical fascia. Once the sling is identified in the midline it is transected, creating 2 arms. With traction on the edge of the transected sling, a combination of sharp and blunt dissection is used to free the sling from the medial to the lateral, working from known to unknown. The sling is dissected to the most lateral extent possible taking care to identify the location of the intravesical mesh. Once the intravesical mesh is encountered, the entirety of the offending mesh is excised, taking care to leave no eroded mesh in the bladder as a nidus for future infections or stones. Stay sutures can be placed upon encountering the intravesical portion of the mesh if there is concern the repair will be difficult to visualize. Once the mesh has been removed bilaterally at its most lateral aspect, attention is then turned to the resultant cystotomy. The bladder is then closed in multiple layers using delayed synthetic absorbable sutures, and stay sutures, if present, are removed. A urethral catheter is left indwelling postoperatively.

RESULTS

The patient is discharged when ambulatory and tolerating a regular diet. A voiding cystourethrogram (VCUG) is obtained in 1 to 2 weeks and if urinary extravasation is not seen, the urethral catheter is removed.

CONCLUSIONS

Despite the use of mesh slings for stress urinary incontinence and pelvic organ prolapse, literature describing operative techniques to remove slings in the setting of urinary tract erosion is lacking. The described technique avoids significant manipulation of the urinary tract and further disruption of the periurethral and perivesical fascia while ensuring a watertight closure.

 

Alpha-Adrenergic Blockers with or without Deflazacort for the Expulsion of a Lower Ureteric Calculus ≤ 10 mm: A Comparative Study

ABSTRACT

Introduction: A lower ureteric calculus is one of the most commonly encountered conditions in daily urological practice. There are various options for management of lower ureteric calculus, which includes watchful waiting, extracorporeal shock wave lithotripsy (ESWL), and ureteroscopic lithotripsy (URSL). The aim of our study was to evaluate the efficacy of following drugs in the expulsion of a lower ureteric calculus ≤ 10 mm. The drugs used are (1) tamsulosin, (2) naftopidil, (3) tamsulosin and deflazacort, and (4) naftopidil and deflazacort.

Methods: A prospective study was carried out in the Department of Urology from August 2012 to January 2013. A total of 150 patients were enrolled and were randomized into 5 equal groups of 30: A (control), B (naftopidil), C (tamsulosin), D (naftopidil and deflazacort), and E (tamsulosin and deflazacort). Complete hemograms; blood urea; serum creatinine; urine routine examination and culture and sensitivity; X-ray of the kidney, ureter, and bladder (KUB); and/or ultrasonography were done in all cases. Cases were followed up to 30 days or upon spontaneous passage of the calculus, whichever was earlier. X-ray KUB and/or ultrasonography were done to confirm the passage of the stone.

Results: The expulsion rate for a calculus ≤ 10 mm was statistically significant in all the groups in comparison to the control group. The mean days of expulsion and use of analgesics was also low in all the groups compared to control. Amongst all groups, the stone expulsion rate was highest, and episodes of pain and mean days of expulsion were lowest for the D group.

Conclusion: It is concluded that alpha-adrenergic blockers facilitate the expulsion of lower ureteric stones ≤ 10 mm and decreases the episodes of colic, which is further improved by the addition of deflazacort. Naftopidil plus deflazacort gives the best results in regards to stone expulsion rates, mean days of expulsion, and episodes of colic.


Mandeep Phukan, Debanga Sarma, Rajeev T. Puthenveetil, Sasanka K. Barua, Saumar J. Baruah

Department of Urology, Gauhati Medical College, Bhangagarh, Guwahati, Assam, India

Submitted August 28, 2013 - Accepted for Publication September 27, 2013


KEYWORDS: Lower ureteric calculus, medical expulsive therapy, alpha-adrenergic blocker

CORRESPONDENCE: Mandeep Phukan, Department of Urology, Gauhati Medical College, Bhangagarh, Guwahati, Assam, India 781032 ()

CITATION: UroToday Int J. 2013 October;6(5):art 62. http://dx.doi.org/10.3834/uij.1944-5784.2013.10.09

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Obstructive Effect of a Urethral Catheter During Voiding: Myth or Reality?

ABSTRACT

Introduction: Whether or not the presence of a urethral catheter can provoke an obstructive effect during voiding remains a controversial subject. Using the Valentini–Besson–Nelson (VBN) mathematical micturition model, the purpose of this study was to compare the geometric effect of the urethral catheter in regards to the effect of other mechanical parameters likely to influence the voiding phase during a urodynamic study.

Methods: The VBN mathematical micturition model was used to compute theoretical voidings. Starting from defined voiding conditions (Qmax) such as Vini = 300 mL, no catheter, normal detrusor contractility, and no urethral compression, we searched for relationships between changes in Qmax and the studied parameters: catheter diameter (Fr), detrusor contractility (k), and urethral compression (urac).

Results: A linearized approximation was obtained for both genders. The geometric obstruction due to the catheter was almost negligible for nonobstructed individuals compared with the volume effect up to a 6 Fr catheter size. Large decreases in Qmax resulted from impaired detrusor contractility or urethral compression. Higher effects resulted from concomitant decrease in detrusor contractility and urethral compression. Geometric effect of the catheter could lead to overestimation of bladder outlet obstruction in men.

Conclusion: A decrease in Qmax during voiding cystometrogram was found to be more often related to causes other than the catheter size, which, based on the VBN model, appeared to have a weak (almost negligible for nonobstructed individuals) effect, especially for small sizes (≤ 6 Fr).


Françoise A. Valentini,1,2 Pierre P. Nelson,1 Philippe E. Zimmern3

1ER6 – Université Pierre et Marie Curie, Paris, France; 2Service de Rééducation Neurologique, Hôpital Rothschild, Paris, France; 3The University of Texas, Southwestern Medical Center, Dallas, Texas, United States

Submitted July 5, 2013 - Accepted for Publication September 27, 2013


KEYWORDS: Catheter, flow rate, mathematical modeling, urodynamics

CORRESPONDENCE: Françoise A. Valentini, Service de Rééducation Neurologique, Hôpital Rothschild, 5, rue Santerre, 75012, Paris, France (, )

CITATION: UroToday Int J. 2013 October;6(5):art 60. http://dx.doi.org/10.3834/uij.1944-5784.2013.10.07

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Bladder Diverticulum with Stone and Transitional Cell Carcinoma: A Case Report

ABSTRACT

The incidence of bladder diverticulum is approximately 1.7% in children and 6% in adults. Dysplasia, leukoplakia, and squamous metaplasia and stone formation may develop in diverticulum and sometimes with malignant changes. The most common histological subtype of diverticulum tumors is transitional cell carcinoma (TCC). Herein we report 2 such cases of transitional cell carcinoma arising in diverticulum of the urinary bladder, one of which was associated with diverticular stones.


Sankar Prasad Hazra, Vinod Priyadarshi, Nipun Awasthi, Debashish Chakrabarty, Dilip Kumar Pal

Institute of Post Graduate Medical Education and Training, Kolkata, West Bengal, India

Submitted May 28, 2013 - Accepted for Publication September 5, 2013


KEYWORDS: Bladder diverticulum, stone, transitional cell carcinoma

CORRESPONDENCE: Vinod Priyadarshi, MBBS, MS, Institute of Post Graduate Medical Education and Training, Kolkata, West Bengal, India

CITATION: UroToday Int J. 2013 October;6(5):art 58. http://dx.doi.org/10.3834/uij.1944-5784.2013.10.05

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Tubeless, Stentless Percutaneous Nephrolithotomy: An Initial Study

ABSTRACT

Objective: To study the ability of rendering our patients tube and stent free after percutaneous nephrolithotomy (PNL).

Patients and Methods: Between February 2011 and March 2012, 38 patients (40 units) with 20 to 60 mm (mean: 31.17) renal stones underwent tubeless stentless PNL. The sample consisted of 28 males and 10 females, and their ages ranged between 17 and 65 years (mean: 33.7). Twenty-two cases were in the right kidney while 18 were in the left, and the stones were bilateral in 2. Most of the stones were in the renal pelvis and lower calyx and removed through the lower calyx subcostal with a single puncture. After ensuring that the patient was almost stone free, no nephrostomy was left and the ureteric catheter was removed within 30 minutes.

Results: Operative time ranged between 15 and 80 mins (mean: 42.34) and no blood transfusion was needed. The mean reduction in hemoglobin level was 1.52 gm (range: 0.3 to 4.8) and the hospital stay ranged between 12 to 36 hours (mean: 17.7). The success rate was 100% while the stone free rate was 95%. Analgesia was needed in 20% of cases. There were no intraoperative complications while postoperative complications occurred in 3 patients (9.7%) in the form of leakage, perirenal collection, and secondary hemorrhage.

Conclusion: Tubeless, stentless PNL is safe with acceptable complications, provided patients are stone free with no or minimal extravasations, have acceptable bleeding, and there is a single puncture. It decreases hospital stay, postoperative pain, and the need for analgesia, and subsequently lowered work abstinence. A further study with a larger sample is needed.


Tawfik H. Al- Ba’adani, Qaid Al-Ghashami, Shihab Al Germozi, Salah Ahmed, Shoukry Al Flahi, Ibrahim Al-Nadhari, Gamil Al Alimi, Walid Al Asbahi, Khalid Telha, Ibrahim El-Nono

Urology Department, Urology and Nephrology Center, Thawra Hospital, Sana'a University, Sana'a, Yemen

Submitted May 16, 2013 - Accepted for Publication September 13, 2013


KEYWORDS: Stentless, tubeless, PNL

CORRESPONDENCE: Tawfik H. Al- Ba’adani, Urology Department, Urology and Nephrology Center, Thawra Hospital, Sana'a University, Sana'a, Yemen ()

CITATION: UroToday Int J. 2013 October;6(5):art 57. http://dx.doi.org/10.3834/uij.1944-5784.2013.10.04

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Spontaneous Dissolution Mid-Shaft of a Double-J Ureteric Stent

ABSTRACT

A vanishing shaft of a double-J uretric stent is a rare complication of a “forgotten” ureteric stent. A retained “forgotten” ureteric stent is not only disastrous for the patient but also comes with severe medicolegal implications for the treating urologist. Herein we report such a case with its subsequent management.


Hemant Kumar Goel, Dilip Kumar Pal, Nipun Awasthi, Anupkumar Kundu, Shwetank Mishra, Vinod Priyadarshi, Praveen Pandey

M. S., I. P. G. M. E. & R. and S. S. K. M. Hospital, Kolkata, West Bengal, India

Submitted March 3, 2013 - Accepted for Publication September 5, 2013


KEYWORDS: DJ stent, forgotten

CORRESPONDENCE: Hemant Kumar Goel, M. S., I. P. G. M. E. & R. and S. S. K. M. Hospital, Kolkata, West Bengal, India ()

CITATION: UroToday Int J. 2013 October;6(5):art 56. http://dx.doi.org/10.3834/uij.1944-5784.2013.10.03

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Accuracy of Computed Tomography for Identifying Locally Advanced Disease in Patients with Muscle-Invasive Bladder Cancer


ABSTRACT

Introduction: To retrospectively evaluate the utility of computed tomography (CT) scanning in identifying patients with locally advanced bladder cancer.

Methods: We performed an Institutional Review Board-approved review of 858 patients that underwent radical cystectomy (RC) from 2000 to 2008 at our institution. We selected patients with muscle-invasive bladder cancer (MIBC) who underwent up-front RC without neoadjuvant chemotherapy and who were assessed by preoperative CT scan. We limited this analysis to 48 CT scans obtained prior to transurethral resection. All CT scans were blinded and retrospectively re-read by a dedicated genitourinary radiologist (CSN) to identify tumor location, the presence of wall thickening, and evidence of extravesical disease (stranding or nodularity) or lymph node metastases. These radiologic findings were compared with pathologic findings.

Results: Pretransurethral resection CT scans were able to accurately identify tumor location in 66.7% of patients (sensitivity = 88.9%, specificity = 33.3%) while lymph node assessment was accurate in 58.3% (sensitivity = 75%, specificity = 62.5%). However, only 16.7% of patients with pathologic T3b disease were actually identified on CT as having radiologic evidence of extravesical disease. Specific radiologic signs suggestive of local disease extension, such as wall thickening, stranding, and nodularity correlated poorly with true pathologic T3b disease.

Conclusion: CT scanning has limits in its ability to accurately identify extravesical disease and lymph node spread in patients with MIBC. Investigations into additional or alternative means of clinical staging for bladder cancer patients are incredibly crucial.


Rian J. Dickstein, Chaan S. Ng, Colin P. Dinney, Ashish M. Kamat,

Departments of Urology and Radiology, the University of Texas, M. D. Anderson Cancer Center, Houston, Texas, United States

Submitted May 29, 2013 - Accepted for Publication August 14, 2013


KEYWORDS: Urinary bladder neoplasms, X-ray computed tomography, neoplasm staging

CORRESPONDENCE: Ashish M. Kamat, Department of Urology, Unit 1373, the University of Texas, M. D. Anderson Cancer Center, 1515 Holcombe Boulevard, Houston, Texas 77030, United States ()

CITATION: UroToday Int J. 2013 October;6(5):art 55. http://dx.doi.org/10.3834/uij.1944-5784.2013.10.02

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A Large Calculus in Crossed Renal Ectopia without Fusion: A Case Report


ABSTRACT

Crossed renal ectopia is a congenital malformation that occurs either in fused or non-fused form. Only 10% are of the non-fused variety. Most cases remain undiagnosed because they remain asymptomatic. We report a case of crossed left-to-right renal ectopia with stones and successful management.


Atul Kumar Khandelwal, Ahsan Ahmad, Mahendra Singh, Vijoy Kumar, Rajesh Tiwari, Shivani Khandelwal

Indira Gandhi Institute of Medical Sciences, Patna, Bihar, India

Submitted June 1, 2013 - Accepted for Publication July 31, 2013


KEYWORDS: Crossed ectopia, kidney without fusion, calculus

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

CITATION: UroToday Int J. 2013 October;6(5):art 54. http://dx.doi.org/10.3834/uij.1944-5784.2013.10.01

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