Urology

SIU Scholar: Dr. Fahed Abdullah Salem Baaboud

Fahed Abdullah Salem — 2011-11-09

The Société Internationale d’Urologie offers Training Scholarships for young doctors with basic surgical or urological qualifications. The SIU Scholarships involve training in a recognized Urological center of excellence located in the candidate’s geographical region. These SIU-accredited centers provide an excellent environment for learning and, in many instances, hands-on experience, so that candidates may acquire knowledge and skills that they will be able to transfer to their own setting of practice. In this series of short communications, SIU Scholars write about the impact that these training opportunities facilitated by the SIU had on their quality of care and career development. Information about applying for an SIU Scholarship is available at http://www.siu-urology.org/.

SIU Scholar: Dr. Ahmed Muhammed

Muhammed Ahmed — 2011-11-07

Prostatic Urethral Lift: Two-year Results After Treatment for Lower Urinary Tract Symptoms Secondary to Benign Prostatic Hyperplasia

2012-01-01

Objective: To evaluate the effectiveness of the prostatic urethral lift in relieving lower urinary tract symptoms (LUTS) secondary to benign prostatic hyperplasia. Methods: A total of 64 men, aged ≥55 years, with moderate to severe symptomatic benign prostatic hyperplasia were treated and followed up at 6 Australian institutions. The treatment consisted of transurethral delivery of small implants to secure the prostatic lobes in an open condition, thereby reducing obstruction of the urethral lumen. The effectiveness, including International Prostate Symptom Score, quality of life, benign prostatic hyperplasia Impact Index, and peak urethral flow rate were assessed at 2 weeks and 3, 6, 12, and 24 months. The effect of this treatment on erectile and ejaculatory function was assessed using the Sexual Health Inventory for Men and Male Sexual Health Questionnaire for Ejaculatory Dysfunction. Results: The prostatic urethral lift improved LUTS symptoms rapidly and durably. The International Prostate Symptom Score was reduced 42% at 2 weeks, 49% at 6 months, and 42% at 2 years in evaluable patients. The peak flow rate improved by ≥30% (2.4 mL/s) at all intervals compared with baseline. No compromise in sexual function was observed after this treatment. Conclusion: The present study demonstrated that LUTS and flow improvements without compromising sexual function. Although this was an early study with a small cohort, this therapy shows promise as a new option for patients with LUTS.

Evidence-based Medicine for Polypropylene Mesh Use Compared With Native Tissue Vaginal Prolapse Repair

Donald R. Ostergard — 2011-11-25

A review of the current medical literature for the use of polypropylene (PP) mesh for vaginally performed prolapse repair, including only those studies reporting prospective, randomized, controlled trials compared with native tissue repairs was undertaken. Five full manuscript publications and 4 studies still in abstract form were all consistent with PP mesh producing better anatomical results for cystocele repair, but when functional results in terms of the patient's quality of life are considered, no significant difference is found between PP mesh and native tissue repairs. PP mesh use results in better anatomical results in the short term but at a cost of repeated surgeries because of erosions and other complications. Patients do not recognize any added benefit from the use of these prostheses in their daily lives.

Editorial Comment

Gopal H. Badlani — 2012-01-01

With the release of the FDA statement, it has become fashionable to criticize the use of mesh. Rather than jumping on the bandwagon and focusing on selective information, we should look at the scientific basis for use of the mesh and evaluate the complications directly caused by mesh as opposed to the lumping device, surgical, and mesh-related issues in one group.

Reply

Donald R. Ostergard — 2012-01-01

Yes, let us give our female patients equal opportunity to avoid those mesh-related disasters that unequivocally totally alter a woman's whole being—vaginal contracture leading to severe dyspareunia or apareunia, pelvic pain for which there is no cure, or bowel and bladder injuries requiring multiple surgical procedures. The woman with these problems will never be the same. Total vaginal mesh adverse events are a severe public health issue.

Critical Appraisal of World Health Organization's New Reference Values for Human Semen Characteristics and Effect on Diagnosis and Treatment of Subfertile Men

2011-11-09

In 2010, the World Health Organization established new reference values for human semen characteristics that are markedly lower than those previously reported. Despite using controlled studies involving couples with a known time to pregnancy to establish the new limits, the reference studies are limited with regard to the population analyzed and the methods used for semen evaluation. The present review discusses concerns related to the new reference values for semen characteristics, including the effect on patient referral, diagnosis, and treatment of recognized conditions, such as varicocele, and on the indications for assisted reproductive technologies.

Life-threatening Hematuria Due to Recurrent Arterial-conduit Fistula

Satoshi Hori, Nikesh Thiruchelvam — 2011-10-14

A 74-year-old patient with an ileal conduit presented to the emergency department in July 2009 with a 6-month history of worsening painless intermittent hematuria. He had seen his general practitioner a few days before this presentation and was prescribed ciprofloxacin antibiotic for a presumed urinary tract infection, which helped to clear his hematuria temporarily.

Is Ultrasound Imaging Inferior to Computed Tomography or Magnetic Resonance Imaging in Evaluating Renal Mass Size?

Phillip Mucksavage, Parvati Ramchandani, S. Bruce Malkowicz, Thomas J. Guzzo — 2012-01-01

Objective: To evaluate whether ultrasonography was inferior in detecting the size of a renal mass preoperatively because of the increased attention on the harmful effects of ionizing radiation in medical imaging. Methods: A prospectively maintained database was reviewed of all patients who underwent renal ultrasonography before definitive therapy for the renal mass. Every patient who underwent ultrasound imaging also underwent computed tomography (CT) or magnetic resonance imaging (MRI), or both, before treatment. The size of the largest tumor identified per imaging modality was compared among the modalities using correlation and analysis of variance. Results: A total of 116 patients underwent ultrasound imaging before therapy. Of these patients, 80 also underwent MRI, 66 underwent CT, and 38 underwent all 3 modalities before treatment. The average pathologic tumor size for the entire cohort was 4.45 cm (range 1-13). The size differences between CT and MRI compared with ultrasound were small (<3.5%). Compared with MRI and CT, ultrasound was also well correlated (P < .001 and P < .001). In patients who underwent all 3 imaging modalities, no difference was found in the average tumor size (P = .896). Conclusion: Ultrasound imaging does not appear to be inferior to CT and MRI in the imaging of renal masses. This is useful in reducing the costs and levels of radiation exposure for the long-term follow-up of patients receiving active surveillance.

Editorial Comment

Maxwell V. Meng — 2012-01-01

The authors have attempted to address a very timely and clinically relevant question—whether ultrasonography is as good as either computed tomography (CT) or magnetic resonance imaging in determining the size of renal masses. The limitations and drawbacks of these cross-sectional techniques include the frequent need for intravenous contrast injection, dependence on adequate renal function to administer contrast, and generally greater costs compared with ultrasonography. In addition, significant concern has recently been raised regarding the radiation dose associated with abdominal CT and the increased risk of cancer development. Thus, the ability of ultrasonography to accurately assess the size of a mass within the kidney suggests that it might be able to substitute for CT and/or magnetic resonance imaging. This is particularly useful in patients pursuing active surveillance for small renal masses, which is increasingly recognized as a reasonable management strategy for select patients.

The Effect of Noise-cancelling Headphones or Music on Pain Perception and Anxiety in Men Undergoing Transrectal Prostate Biopsy

2012-01-01

Objective: To assess the effect of noise-cancelling headphones with or without music on patient pain and anxiety associated with routine, office-based transrectal ultrasound (TRUS)-guided prostate biopsy in a prospective randomized study. Methods: Patients scheduled for prostate biopsy as a result of elevated prostate-specific antigen and/or abnormal digital rectal examination were prospectively enrolled and randomized into a control, noise-cancelling headphones, or music-headphones group. Patients completed pain and anxiety questionnaires and had their physiological parameters assessed before and after the procedure and compared across groups. Results: Eighty-eight patients were enrolled. Pain scores increased from baseline across all study groups, with the lowest mean score in the music group. No appreciable change was noted in anxiety scores after the procedure between groups (P >.05). Although postbiopsy systolic blood pressure values remained comparable with baseline levels in all groups, postbiopsy diastolic blood pressure increased in the control and headphones groups (P = .062 and .088, respectively) but remained stable in the music group (P = .552) after biopsy, indicating lesser physiological response to anxiety and pain in this group. Conclusion: Music-induced attention shift during prostate biopsy may have a beneficial impact on procedural anxiety and pain perception, but no apparent effect was noted for use of headphones alone. Further studies are necessary to explore strategies to reduce perceived anxiety and pain in men undergoing prostate biopsy.

Prostate Sampling by 12-Core Biopsy: Comparison of the Biopsy Results With Tumor Location in Prostatectomy Specimens

2011-11-07

Objective: To analyze the diagnostic performance of individual prostate biopsy cores. The 12-core transrectal prostate biopsy scheme has emerged as a standard of care. However, quality of sampling may vary in different areas of the prostate included in this procedure. Material and Methods: Two-hundred fifty men underwent radical prostatectomy at our institution. All participants had a systematic 12-core transrectal prostate biopsy containing lateral and medial cores from each side of the apical, medial and basal thirds of the prostate. Biopsy results were matched with histologic maps of the prostatectomy specimens. Sensitivity, negative predictive value (NPV), and overall accuracy were calculated for each biopsy core location and compared between different groups of cores. In addition, patients in the upper quartile of prostate weight were compared with the rest of the cohort. Results: Sensitivity, NPV, and overall accuracy were significantly lower for apical cores. Average NPV and overall accuracy of basal and mid-lateral biopsies were inferior to those of medial biopsies on the same levels. However, sensitivity of these lateral cores was similar to that of the medial cores. Sensitivities of apical and mid cores were significantly lower in patients with larger prostates. Conclusion: Decreased accuracy in lateral mid- and basal cores results from higher frequencies of cancer in corresponding prostate areas, and therefore additional samples should be taken at these locations. In addition, diagnostic accuracy of apical cores may be improved through better targeting of the prostatic apex. This may be particularly important in patients with larger prostates.

Effective Radiation Exposure in Evaluation and Follow-up of Patients With Urolithiasis

Nader M. Fahmy, Mohamed A. Elkoushy, Sero Andonian — 2011-09-21

Objective: To quantify the effective radiation dose associated with the evaluation and follow-up of patients with urolithiasis. Methods: Retrospective review was performed for consecutive patients presenting to a tertiary stone clinic with acute stone episodes between November 2007 and December 2008, and had at least 2 years of follow-up. Number and modality of imaging studies were collected. Effective radiation exposure (ERE) doses were calculated from the dose length product values reported with each computed tomography (CT) scan. Results: There were 72 males and 32 females with a mean age of 49 years (range 21-78). Patients underwent an average 1.8 (range 0-5) and 0.7 (range 0-2) plain radiographs, 0.82 (range 0-4) and 0.15 (range 0-2) CTs, 0.09 (range 0-1) and 0.03 (range 0-1) intravenous urograms, and 0.3 (range 0-1) and 0.6 (range 0-2) ultrasounds (US) during the first and second years, respectively (all P <.05). The average calculated ERE dose per CT scan was 23.16 mSv (range 4.94-72.77). The calculated mean ERE dose per patient significantly decreased from 29.29 mSv (range 1.7-77.27) in the first year to 8.04 mSv (range 1.4-24.72) in the second year (P <.01). This was because of significantly fewer CT scans and significantly more US imaging during the second year (P <.05). Although 18 (17.3%) patients exceeded 50 mSv during the first year, none exceeded this threshold during the second year. The mean ERE dose did not correlate with stone location, patient age, and sex. Conclusion: The calculated mean ERE dose significantly decreased during the second year of follow-up in patients with urolithiasis because of significantly higher use of US.

Biochemical Determinants of Severe Lithogenic Activity in Patients With Idiopathic Calcium Nephrolithiasis

2011-09-12

Objective: To analyze the biochemical alterations in plasma and the urine determinants of severe lithogenic activity in patients with idiopathic calcium nephrolithiasis. Methods: We performed a cross-sectional study of 120 patients divided into 2 groups: group 1, 60 patients without nephrolithiasis; and group 2, 60 patients with severe and/or recurrent calcium nephrolithiasis. In all patients, a study of renal function, calcium metabolism, and bone remodeling markers, and a study of the lithogenic factors were performed in urine after fasting and in 24-hour urine samples. Results: We observed greater values for phosphorus in group 1 than in group 2 (P = .03). Also, we found greater values for intact parathyroid hormone (P = .01), osteocalcin (P = .000), and β-crosslaps (P = .000) in group 2 than in group 1. In the 24-hour urine samples, significant differences were found between groups 1 and 2 in calciuria (11.7 vs 17.4 mg/dL; P = .000), citraturia (50.6 vs 33.5 mg/dL; P = .002), calcium/creatinine quotient (0.14 vs 0.20; P = .001), calcium/citrate quotient (0.05 vs 0.13; P = .04), and calcium/creatinine quotient after fasting (0.09 vs 0.16; P = .000). Conclusion: We consider the determinants of severe and/or recurrent calcium lithiasis to be hypercalciuria and hypocitraturia and a calcium/citrate quotient >0.06. As risk markers we can consider phosphatemia <2.9 mg/dL, phosphate/chlorine quotient >35, alkaline phosphatase >80 U/L, intact parathyroid hormone >60 pg/mL, osteocalcin >16 ng/mL, β-crosslaps >0.400 ng/mL, and β-crosslaps/osteocalcin quotient >0.028.

Prediction of Morbidity and Mortality After Percutaneous Nephrolithotomy By Using the Charlson Comorbidity Index

2011-08-18

Objectives: To determine whether the Charlson Comorbidity Index (CCI) predicts postoperative medical complications and death in patients treated with percutaneous nephrolithotomy (PCNL). Methods: A total of 1406 PCNL procedures were performed at 4-stone referral centers between September 2004 and March 2011 were reviewed in this multicenter study. Variables included patient and stone characteristics, preoperative comorbidities, intraoperative data, and postoperative complications, including mortality. Results: The present study included 868 (61.7%) men and 538 (38.3%) women. Mean patient age was 44.1 years (range 1-81). CCI score was calculated as “0” for 993 patients (70.6%, called group I), “1” for 316 patients (22.5%, called group II) and“≥2” for 97 patients (6.9%, called group III). The incidence of comorbidities increased with age (P = .001). The overall postoperative complication rate was 29.3%. Life-threatening medical complications developed in 2.9% of patients in group I, 7.6% of patients in group II, and 21.6% of patients in group III, (P = .001). There were 3 deaths for an overall 0.2% mortality rate. Perioperative bleeding requiring blood transfusion was observed in 9.5% of patients, and we found an increased risk of hemorrhage associated with CCI score (P = .049). High CCI score, patient age, hemorrhage, and operative time were significantly related to higher medical complication rates after PCNL. Conclusions: CCI is a quick, simple, and reproducible scoring system that accurately predicts the morbidity and mortality of PCNL.

The Impact of Pelvicaliceal Anatomy on the Success of Retrograde Intrarenal Surgery in Patients With Lower Pole Renal Stones

Berkan Resorlu, Ural Oguz, Eylem Burcu Resorlu, Derya Oztuna, Ali Unsal — 2011-08-18

Objectives: To evaluate the impact of pelvicaliceal anatomy on the success of retrograde intrarenal surgery (RIRS) for lower pole renal stones and determine which of these factors can be used to select patients who will benefit from RIRS. Methods: We evaluated 67 patients who underwent RIRS between 2009 and 2010 for isolated lower pole renal stones. The infundibular length (IL), infundibular width (IW), pelvicaliceal height (PCH), and infundibulopelvic angle (IPA) were measured by preoperative intravenous urogram. Success was defined as either complete clearance or clearance with insignificant residual fragments ≤3 mm in size at 2-months follow-up. Results: Mean IL was 26.7 ± 7.9 and 28.2 ± 5.3 mm, mean PCH was 20.7 ± 6.6 and 23.2 ± 4.9 mm in stone-free and non–stone-free patients, respectively. These were slightly larger in the non–stone-free group but not statistically significant (P = .140 and P = .072, respectively). Mean IW was 5.8 ± 3.5 and 5.6 ± 2.2 mm in stone-free and non–stone-free patients, respectively, which had no significant impact on the stone-free rate (P = .719). There were significant differences between the groups in terms of stone length (P = .001) and IPA (P = .003). The mean IPA was 49.37 ± 11.83 and 37.61 ± 13.22 mm in stone-free and non–stone-free patients, respectively. Conclusions: In addition to the influence of stone size, lower pole anatomy, especially IPA, has a significant impact on stone clearance for lower pole stones after RIRS.

Anatomical Variation Between the Prone, Supine, and Supine Oblique Positions on Computed Tomography: Implications for Percutaneous Nephrolithotomy Access

2011-08-05

Objective: To determine anatomical variations between the prone, supine, and supine oblique positions that are likely to affect percutaneous renal access. Material and Methods: Twenty patients underwent computed tomography urograms in the supine and prone positions. Twenty patients underwent supine oblique and prone scans. Mean nephrostomy tract length, maximum access angle, and anterior–posterior renal position were calculated. Results: Mean nephrostomy tract length was shorter in the prone position (82.6 mm right kidney, 85.4 mm left kidney) compared with the supine position (108.3 mm right kidney, P <.001; 103.7 mm left kidney, P <.001). Prone tract length was also shorter than supine oblique tract length (86.1 mm vs 96.5 mm; P = .048). Mean maximum access angle was significantly greater (P = .018 right kidney; P = .007 left kidney) in the prone position (right kidney 99.7°, left kidney 104.0°) compared with the supine position (right kidney 87.7°, left kidney 89.4°). The same was true for the prone compared with the supine oblique position (75.8° vs 58.7°; P = .004). No difference was noted in anterior–posterior renal position between the supine and prone positions (20.3 mm vs 26.7 mm; P = .094) or supine oblique and prone positions (22.8 mm vs 15.6 mm; P = .45). Conclusions: The prone position is associated with a significantly shorter nephrostomy tract length and more potential access sites, which may improve ease and safety of percutaneous renal access.

Metabolic Syndrome in Female Patients With Overactive Bladder

Hakkı Uzun, Orhan Ünal Zorba — 2011-10-19

Objective: To investigate the relevance of metabolic syndrome in the etiopathogenesis of overactive bladder in female patients. It has been shown that obesity has been associated with overactive bladder (OAB), and the metabolic syndrome and insulin resistance have been related to the annual growth rates of prostate and lower urinary tract symptoms. Methods: Female patients applying to our policlinics with OAB symptoms or other urologic complaints were enrolled in the study. The International Diabetes Federation criteria were used for the definition of the metabolic syndrome. The chi-square, Student t, and Mann-Whitney U tests and logistic regression analyses were used to compare differences in the variables. Results: The metabolic syndrome was diagnosed in 201 (64%) of 313 patients with OAB and 73 (35%) of 208 patients without OAB. The difference was statistically significant (P = .002). A larger waist circumference, greater body mass index, low high-density lipoprotein level, and incidence of hypertension were significantly greater statistically in the OAB group than in the controls. Conclusion: The metabolic syndrome correlates highly with OAB in female patients. The metabolic syndrome can be an etiologic pathway for the onset of symptoms.

Sling Location in Women With Recurrent Stress Urinary Incontinence Following Midurethral Sling

Alienor S. Gilchrist, Eric S. Rovner — 2011-10-19

Objective: Persistent or recurrent stress urinary incontinence (SUI) after a midurethral sling (MUS) may result from incorrect location of the sling relative to the midurethra. This study's objective was to evaluate the incidence of bladder neck (BN) or more proximal MUS in women undergoing reoperation for SUI after synthetic MUS. Material and Methods: A retrospective review was performed of patients referred and treated for isolated recurrent SUI after synthetic MUS (transobturator or retropubic approach). Patients undergoing sling excision for other indications (eg, outlet obstruction, urinary tract erosion) were excluded. Preoperative video urodynamic (VUDS) parameters were examined. Operative reports at re-exploration provided the anatomic location of the sling. Results: Fifteen women with SUI after MUS underwent VUDS and subsequent reoperation. The MUS was found proximal to or at the BN in 8 (53%) women and suburethral in 7 (47%). Women with BN or proximal sling location were equally likely to have an open (4/8 patients) or closed BN (4/8 patients) at rest on filling cystography. VUDS parameters, including the radiographic finding of an open BN preoperatively, were not predictive of BN or more proximal sling location intraoperatively. MUSs found at the BN or proximal were more likely to be retropubic slings (7/8 patients). Rates of concomitant anterior prolapse repair did not differ according to sling location. Conclusion: Recurrent SUI as a result of proximal MUS location cannot be predicted on preoperative VUDS parameters. Surgical exploration is the primary method for identifying this phenomenon as the etiology of failure in these patients.

Can Sacral Neuromodulation Improve Minor Incontinence Symptoms in Doubly Incontinent Patients Successfully Treated for Major Incontinence Symptoms?

2011-11-18

Objective: To describe the effect of sacral nerve modulation (SNM) on less severe types of incontinence in patients who were successfully implanted for either urinary or fecal incontinence, and who presented with double incontinence. When conservative treatments fail, SNM is a first-line treatment for patients with urge urinary or fecal incontinence. Methods: All patients who received SNM between 2005 and 2010 at 5 hospitals and who still had the implant were included in our survey. All received a urinary and fecal change and quality of life questionnaire by mail to complete. Results: Of the 51 questionnaires sent out, 37 were returned, for a 72.5% response rate. The population was composed of 97.3% women, with a mean age of 56.8 years (SD 14). The main indication for SNM was urge urinary incontinence in 15 patients (40.5%) and fecal incontinence in 22 patients (59.5%). Eighteen patients (48.7%) had improvements in both urinary and fecal incontinence symptoms. The percentage increased to 53.3% (16/30) in the group of patients with urge urinary incontinence associated with fecal incontinence. Patients who reported an improvement in double incontinence symptoms complained more often of urge urinary incontinence than other patients (P = .04). Conclusions: Of the doubly incontinent patients who were successfully implanted for a predominant type of incontinence (ie, urinary or fecal incontinence), 48.7% had an improvement in the other type of incontinence. Patients with urge urinary incontinence associated with fecal incontinence were more likely to report an improvement in double incontinence than the other patients.

Increased Risk of Urinary Tract Calculi Among Patients With Diabetes Mellitus—A Population-based Cohort Study

2011-11-25

Objective: To investigate the inter-relationship among diabetes, urinary tract infection (UTI), and urinary tract calculi (UTC). Methods: This study used Taiwan's National Health Insurance claims data of ambulatory care visits and hospitalizations. A total of 12,257 newly diagnosed diabetes cases in 2000-2002 and 96,781 controls were followed to the end of 2007. The person-year approach with Poisson assumption was used to estimate the incidence density (ID) of UTC by diabetic status. Relative risk of UTC in relation to diabetes and UTI were estimated from Cox proportional hazard model with adjustment for sociodemographic variables and comorbidities. Results: Over nearly 8 years of follow-up, 8.9% of diabetes and 7.2% of control subjects sought ambulatory care or were hospitalized for UTC, representing the ID of 14.4 and 11.4 per 1000 person-years, respectively. The multivariate analysis indicated that UTC risk was independently associated with diabetes (hazard ratio 1.18, 95% CI 1.10-1.27) and UTI (HR 1.68, 95% CI 1.60-1.76). The hazard ratio of UTC in relation to diabetes in men and women without UTI was 1.24 and 1.26, respectively. Diabetes may further increase the rate of UTC in women with UTI, with an hazard ratio increased from 1.79-2.12. Such additive effect by diabetes in men with UTI was only marginal (HR 1.68 vs 1.67). Conclusion: This cohort study provides epidemiologic support for the causal association between diabetes and UTC, which is independent of UTI. In addition, female patients with UTI accompanied by diabetes tended to be associated with a greater rate of UTC.

Editorial Comment

Boris Gershman, Brian H. Eisner — 2012-01-01

Diabetes mellitus has been associated with an increased risk of kidney stone formation in a number of epidemiologic studies. With the exception of a study from Turkey, these data reflect the findings from a population of American adults, with presumably Western trends in diet and lifestyle. The present study not only provides additional evidence for the link between diabetes mellitus and kidney stone formation but also extends it to a large, Taiwanese cohort. It also reinforces the notion that nephrolithiasis is a reflection of systemic disease—an increased incidence of stone disease is seen in patients with diabetes mellitus, as well as other common systemic conditions, such as metabolic syndrome and hypertension. Urinary tract infection—an independent risk factor for stone disease—was also associated with stone formation in this study. The authors noted a synergistic effect between urinary tract infection and diabetes mellitus in the risk of stone formation for women but not for men. It remains to be seen whether this is a reflection of true physiologic differences by gender or is artifactual.

Reply

2012-01-01

Thank you for your comment on our report about the increased risk of urinary tract calculi (UTC) among patients with diabetes mellitus. In our study, we observed that diabetes mellitus had an additive effect on the rate of UTC in women with urinary tract infection (UTI). Evidence from previous studies suggests that previous UTI was associated with asymptomatic bacteriuria and asymptomatic bacteriuria occurs more frequently in diabetic women than in nondiabetic women. In addition, several studies have documented citrate depletion in urine when Escherichia coli was added in various concentrations. Asymptomatic bacteriuria can decrease the urine citrate concentration and further increases the rate of calcium-containing stone formation in female diabetic subjects.

Racial Differences in the Prevalence of Overactive Bladder in the United States From the Epidemiology of LUTS (EpiLUTS) Study

Karin S. Coyne, Mary Kay Margolis, Zoe S. Kopp, Steven A. Kaplan — 2011-11-07

Objectives: To estimate the prevalence of overactive bladder (OAB) in men and women in the United States (US) to determine whether there were racial differences. Methods: This was a secondary analysis of data from the EpiLUTS (Epidemiology of Lower Urinary Tract Symptoms) survey, an Internet-based cross-sectional, population-representative epidemiologic survey conducted in the US, UK, and Sweden. These analyses were limited to the data of men and women aged 40 and older from the US. The presence of OAB was defined as experiencing urinary urgency or urinary urgency incontinence. Case definitions of OAB symptoms were categorized as occurring at least “sometimes.” Prevalence rates of OAB were estimated by race. Logistic regression analyses were conducted for each gender to examine the role of race on OAB status, controlling for risk factors and comorbid conditions. Results: The response rate in the US was 59.6%. A total of 9237 men and 10,407 women self-identified their race and were included in the analytic sample. The prevalence of OAB at least “sometimes” ranged from 26% in Asian men to 33% in African American men. Similarly, the prevalence of OAB at least “sometimes” was lowest in Asian women (27%) and highest in African American women (46%). Race was predictive of OAB in men but not for women. Conclusions: The prevalence of OAB ranged from 26-33% across races for men and from 27-46% across races for women. African American and Hispanic race is predictive of OAB for men but not for women.

Diabetes Treatment and Progression of Benign Prostatic Hyperplasia in Community-dwelling Black and White Men

2011-11-23

Objective: To conduct a study to determine whether diabetes treatment is associated with benign prostatic hyperplasia (BPH)/lower urinary tract symptoms (LUTS) and progression in black and white men. Diabetes has been associated with BPH and LUTS in aging men. Methods: Using the Olmsted County Study of Urinary Symptoms and Health Status among Men and the Flint Men's Health Study, we examined how the use of medical therapy (eg, insulin regimens, oral hypoglycemics) related to changes in LUTS severity, maximal urinary flow rate measured by uroflowmetry, prostate volume determined by transrectal ultrasonography, and serum prostate-specific antigen concentrations. Results: Of the 2226 men participating in the Olmsted County Study of Urinary Symptoms and Health Status among Men and the Flint Men's Health Study, 186 men reported a history of diabetes, 76.9% of whom were treated with medical therapy. Overall, the men with diabetes had significantly greater odds of moderate/severe LUTS (age- and race-adjusted odds ratio 1.37, 95% confidence interval 1.00-1.87) compared with those without diabetes. However, among the diabetic men, those not taking medication had greater odds of moderate/severe LUTS than those taking medication. This association among men not taking medication was seen for 5 of the 7 individual symptoms. The prostate volume and prostate-specific antigen level were not significantly associated with diabetes treatment. No significant differences were observed for the annual change in BPH characteristics by diabetes treatment status. Conclusion: These findings suggest that the presence of diabetes and subsequent poor glycemic control might be less related to prostate growth and more to the dynamic components of lower urinary tract function. Additional evaluations of the associations between glycemic control and BPH progression are warranted.

An Unusual Case of Right Retrocaval Ureter Associated With Ipsilateral Ureterocele

2011-05-09

A 36-year-old man with right flank pain presented to our institution. Intravenous urography showed mild dilatation of the right pyelocaliceal system and large filling defect in the vesical lumen. Computed tomography revealed the right kidney to be smaller than the left, and with chronic pyelonephritis. The right ureter passed behind the inferior vena cava at the level of the pelvic-ureteral junction. The middle and lower ureter was dilated above a large ureterocele. Cystourethrography showed right vesicoureteral reflux. The patient underwent a resection of the ureterocele with reimplantation of the ureter. Follow-up at 3 months demonstrated resolution of the dilatation of the right ureter.

Pseudoaneurysm Kidney: A Rare Complication of Pseudopancreatic Cyst

Nitin Abrol, Amlesh Seth, Sanjay Sharma — 2011-04-19

Pseudocyst formation is a known complication of acute or chronic pancreatitis. Various complications can occur because of pseudocyst (eg, biliary obstruction, infection, rupture with fistula formation, and hemorrhage owing to pseudoaneurysm formation). Pseudoaneurysms due to a pancreatic pseudocyst have been described in relation to various visceral arteries. We report the first case of renal artery pseudoaneurysm owing to pancreatic pseudocyst.

Recurrent Giant Liposarcoma of the Spermatic Cord

Paola De Nardi, Massimiliano Bissolati, Marco Cristallo, Carlo Staudacher — 2011-04-13

A giant recurrent retroperitoneal liposarcoma of the spermatic cord was removed in a 40-year-old man. The tumor measured 50 cm and weighed 42 Kilograms. Radiotherapy and chemotherapy have little role in this neoplasm. Despite the huge dimension of the mass surgery was successfully undertaken without relapse at 12 months follow-up.

Vaginal Mass With Urinary Incontinence: A Rare Presentation

Navpreet K. Aulakh, Baldev S. Aulakh, Varun Mittal, Garima Daga — 2011-04-15

To our knowledge, there are only few published cases of benign renal AML presenting with tumor thrombus in females. We present a new case of this uncommon complication of a benign renal tumor.Epithelioid angiomyolipoma is a recently described rare variant of renal angiomyolipoma.It can occur in patients with or without tuberous sclerosis, and may potentially bemalignant. Benign renal angiomyolipoma (AML) rarely presents with evidence of extension into the renal vein, inferior vena cava (IVC) or atrium. We report a case of a benign renal AML with a tumor thrombus extending into the IVC in a 46-year-old female who presented with right-sided flank pain associated with a right sided abdominal mass. Right Radical nephrectomy with IVC tumor thrombectomy was done. Patient is totally asymptomatic. At 1 month after surgery, an abdominal ultrasound showed no evidence of thrombus within the IVC. CT scan of the abdomen at 3 months post-operatively showed no evidence of recurrence. Surgical treatment of angiomyolipoma with IVC thrombus is warranted in view of risk of malignancy and to prevent tumor embolus to the heart or lungs.

Patency Rates of Microsurgical Vasoepididymostomy for Patients With Idiopathic Obstructive Azoospermia: A Prospective Analysis of Factors Associated With Patency—Single-center Experience

2012-01-01

Objective: To evaluate the factors that might be associated with the patency rates of microsurgical vasoepididymostomy for idiopathic obstructive azoospermia. Methods: From January 2009 to July 2010, we evaluated the data from 73 men with obstructive azoospermia who had undergone longitudinal intussusception vasoepididymostomy. The mean age was 30.9 ± 4.9 years (range 22-48). The outcomes were analyzed by the pre- or intraoperative clinical findings: epididymal fullness, unilateral or bilateral procedure, site of anastomosis, and epididymal fluid findings. Results: The mean follow-up was 13.5 ± 5.3 months (range 4-22) for 53 patients (72.6%). The overall patency rate was 71.7% (n = 38). The patency rate was 87.2%, 80.7%, 78.8%, 100%, and 83.7% for epididymal fullness, bilateral surgery, corpus anastomosis, caudal anastomosis, and flowing fluid with motile sperm, respectively. The natural pregnancy rate was 33.3% at a mean of 9.9 ± 4.2 months of follow-up. Conclusion: Longitudinal intussusception vasopididymostomy can provide a good patency rate, with success associated with epididymal fullness, bilateral surgery, distal epididymal anastomosis, and flowing fluid with motile sperm.

Men Who Seek Infertility Care May Not Represent the General U.S. Population: Data From the National Survey of Family Growth

2011-11-25

Objective: To examine the National Survey of Family Growth to identify differences in the characteristics of men who did and did not seek infertility care to determine whether such men are representative of the U.S. population. Methods: We analyzed the data from the 2002 (cycle 6) National Survey of Family Growth. In-home interviews were conducted from March 2002 to February 2003. A total of 4928 men were surveyed, with underrepresented groups sampled at greater rates to provide an adequate sample size for meaningful statistical analyses. The use of infertility services was queried by a single question: “Have you been to a doctor to talk about ways to help have a baby together?” The demographic and socioeconomic variables, including age, marital status, number of children, race, religion, income, education, and insurance status were analyzed for the 2161 men surveyed who were aged 30-45 years. We performed bivariate and multivariate logistic regression analyses to determine the predictors of infertility service use. Results: Marital status and education level were strongly associated with infertility care seeking. In the adjusted analysis, married men were 9 times (odds ratio 9.3, 95% confidence interval 4.1-20.9) more likely to seek care than unmarried men, and men with a college degree and those with an advanced degree were 3 times (odds ratio 2.7, 95% confidence interval 1.4-5.0) and 5 times (odds ratio 4.7, 95% confidence interval 2.1-10.5) more likely to seek care, respectively. Conclusion: Men seeking infertility care in the United States tend to be married, older, and more educated than those not seeking care. Given these findings, some results of male infertility studies from cohorts of men from infertility referral centers might not apply to the U.S. population.

Risk Factors for Progressive Deterioration of Semen Quality in Patients With Varicocele

Shiou-Sheng Chen, Li-Kuei Chen — 2011-11-07

Objective: To assess the risk factors for progressive deterioration of semen quality (PDSQ) in adult patients with varicocele. Methods: A total of 32 men with left varicocele and impaired semen quality (group 1) and 30 age-matched patients with left varicocele and normal semen quality (group 2) were recruited for the present study. All the subjects received conservative treatment, and the parameters for evaluation every 12 months included semen quality, peak retrograde flow (PRF) and spontaneous venous reflux by color Doppler ultrasonography, body mass index, serum concentration of follicle-stimulating hormone, luteinizing hormone, prolactin, testosterone, testicular volume and discrepancy, grade of varicocele, and scrotal temperature. Results: The mean follow-up time was 63.2 months (range 60-66). The patients in group 1 had a significantly greater PRF, lower testicular volume, greater testicular volume discrepancy, lower testosterone level, higher scrotal temperature, and greater follicle-stimulating hormone level than those in group 2 at first. The semen quality deteriorated in 28 subjects (87.5%) in group 1, but in only 6 patients (20%) in group 2 during follow-up. Furthermore, the 6 subjects with PDSQ in group 2 had greater PRF and scrotal temperature than those without. Conclusion: The rate of PDSQ was significantly greater in the varicocele patients with an initially abnormal semen quality than in those with initially normal semen quality (87.5% vs 20%). Furthermore, the varicocele patients with initially normal semen quality who had greater PRF and scrotal temperature might have a greater risk of PDSQ.

Long-term Biochemical Recurrence Rates After Robot-assisted Radical Prostatectomy: Analysis of a Single-center Series of Patients With a Minimum Follow-up of 5 Years

2011-11-16

Objective: To address the long-term biochemical recurrence (BCR)-free survival rates of patients treated with robotic-assisted laparoscopic prostatectomy (RALP) with a minimum follow-up of 5 years. Materials and Methods: Prospectively collected data of 184 patients treated with RALP at a single institution were analyzed. Kaplan-Meier and life tables analyses targeted the rates of BCR according to pathologic parameters. Cox regression analyses addressed predictors of BCR. Results: Median follow-up was 67.5 months. One and 10 patients died of prostate cancer (PCa) and other causes, respectively. Mean time to BCR was 83.8 months. The 3-, 5-, and 7-year BCR-free survival rates were 94%, 86%, and 81%, respectively. These rates were 97%, 93%, and 85% for pT2 disease; 94%, 84%, and 84% for pT3a; and 69%, 43%, and 43% for pT3b (P <.001). The same figures were 97%, 90%, and 88% for Gleason sum 6 or lower; 90%, 86%, and 75% for Gleason sum 7; and 85%, 65%, and 65% for Gleason sum 8-10 (P = .01). At univariable analyses, prostate-specific antigen, pathologic Gleason score, and presence of extracapsular extension, seminal vesicle invasion, and adjuvant radiotherapy were significantly associated with BCR. At multivariable analysis, the presence of seminal vesicle invasion and the presence of Gleason sum 8-10 represented independent predictors of BCR (HR = 5.14; P = .004 and HR = 3.04; P = .04, respectively). Conclusion: We report the longest available follow-up in RALP patients. RALP represents an oncologically effective procedure. Our oncological results support the increasing diffusion of RALP for the treatment of organ-confined PCa.

Simultaneous Laparoendoscopic Single-site Radical Nephrectomy for Native Kidney and Open Nonischemic Partial Nephrectomy to Treat Concomitant Renal Cell Carcinomas in Native and Transplant Kidneys and to Preserve Allograft Function

Bashir R. Sankari, Shih-Chieh Jeff Chueh — 2011-11-07

Objective: To report a technique of minimally invasive radical nephrectomy for a native renal cell carcinoma (RCC) and nonischemic open partial nephrectomy for a transplant kidney RCC with only a laparoendoscopic single-site (LESS) incision. Concomitant RCCs in a native and transplant kidneys are very rare. Conventional surgical approach requires a long incision. Methods: A 50-year-old man 14 years after renal transplant was found incidentally to have concomitant RCCs in his native right kidney and transplant kidney. A right lower abdomen Gibson incision, along his transplant wound, was used initially for LESS right radical nephrectomy and lymphadenectomy, and that same wound was used for a nonischemic open partial nephrectomy in the transplant kidney. Results: The LESS right radical nephrectomy took 3.25 hours with estimated blood loss (EBL) of 80 mL and the partial nephrectomy for the transplant kidney took 3 hours with EBL of 220 mL. No transfusion was required. Pathologic examination revealed both tumors to be RCC, clear cell type, and 6.5 cm in the right native kidney and 2.8 cm in the transplant kidney. The final wound measured 9 cm. Postoperative recovery was uneventful with inpatient narcotic requirement of 37 mg morphine sulfate equivalent, and oral intake of food resumed in 2.5 days. His allograft function was well preserved with a serum creatinine unchanged (1.4 mg/dL) at discharge. Conclusion: In a patient with concomitant tumors in a native kidney and a transplant kidney, this unique approach provides exceptional benefits of minimally invasive tumor excision for both tumors, and good preservation of renal function.

On-demand Tramadol Hydrochloride Use in Premature Ejaculation Treatment

Mehmet Kaynar, Ozcan Kilic, Talat Yurdakul — 2011-11-16

Objectives: To determine the efficacy of tramadol in premature ejaculation (PE) treatment compared with placebo. Methods: A single-blind, placebo-controlled, crossover study was conducted with 60 lifelong (primary) patients with PE. The patients were randomized into 2 groups, each consisting of 30 patients, who took tramadol or placebo on demand. PE was defined as an intravaginal ejaculation latency time of ≤60 seconds in 90% of intercourse episodes. The efficacy of the drugs was assessed using the intravaginal ejaculation latency time, ability of ejaculation control, and sexual satisfaction scores after an 8-week treatment period. Results: All participants completed the study voluntarily. Two groups were similar in terms of the patient demographics. Increases in the intravaginal ejaculation latency time, ability of ejaculation control, and sexual satisfaction score between the placebo and tramadol groups were compared with the baseline values in both groups. At the end of study period, the tramadol group had significantly (P < .001) greater values for all 3 parameters compared with those in the placebo group. Conclusions: On-demand use of low-dose tramadol is effective for lifelong PE. Currently, selective seratonin reuptake inhibitors such as dapoxetine, are a more popular treatment option for PE. However, tramadol might be considered an alternative agent for primary PE treatment.

Clinical Outcomes of Intracavernosal Injection in Postprostatectomy Patients: A Single-center Experience

2011-11-07

Objective: To evaluate the clinical outcomes of intracavernosal injection (ICI) use in an undifferentiated group of men with erectile dysfunction at various stages after radical prostatectomy. Methods: Retrospective charts, mailed questionnaires, and a telephone survey of patients after radical prostatectomy prescribed ICI by a single urologist from January 2006 to January 2008. The patient demographics and prostate cancer profiles, current ICI use patterns, adverse outcome, and clinical efficacy were collected. Results: A total of 117 patients completed the questionnaire. The mean age was 65 ± 6.2 years, and the patients had undergone radical prostatectomy 4.1 ± 2.7 years earlier. Most patients had hypertension (38%) and dyslipidemia (26%); 51% of the patients actively used ICI, with a median of 3 attempts monthly. Sixty-eight percent of all patients were sexually active (98% of ICI users vs 36% of ICI nonusers, P < .001). In the sexually active patients, ICI was associated with significantly greater International Index of Erectile Function scores (20.8 ± 4.1 vs 16.0 ± 6.9, P = .008). ICI was most frequently discontinued because of patient-perceived ineffectiveness (48%), pain (21%), and prolonged erections (11%). Twenty-eight percent of patients had erections lasting longer than they had wished at some point in their treatment, with 10% incidence of priapism. Conclusion: ICI use among patients after prostatectomy can be highly effective but has a significant attrition rate (49%). The identification of reasons for discontinued use can aid healthcare providers to support patients in the early period after adoption of ICI and to direct their counseling more effectively.

Clinical Impact of Residual Extraretroperitoneal Masses in Patients With Advanced Nonseminomatous Germ Cell Testicular Cancer

2012-01-01

Objective: Integration of platinum-based chemotherapy and surgical resection of residual masses is essential in the management of advanced nonseminomatous germ cell tumors (NSGCT). We reviewed our institutional experience in patients undergoing resection of extraretroperitoneal (ERP) residual masses after chemotherapy to assess its impact on cancer progression and survival. Methods: Between 1989 and 2003, 532 patients with advanced NSGCT underwent postchemotherapy retroperitoneal lymph node dissection (PC-RPLND) with a median follow-up of 41 months. Survival probabilities were estimated by the Kaplan–Meier method. Cox proportional hazards regression analysis was used to determine the prognostic significance of risk factors for progression and survival. Results: Of 532 patients, 402 (76%) underwent PC-RPLND alone, and 130 (24%) underwent resection of ERP residual disease concurrently or in a staged fashion within 6 weeks. Concordance between retroperitoneal (RP) and ERP sites of disease was 83% in the presence of fibrosis, 42% for teratoma, and 47% for viable NSGCT. Overall, 34% of patients undergoing resection of ERP residual disease had either teratoma or viable disease on final pathology. Five-year probability of freedom from progression was 74% (95% CI 65%, 82%) and disease-specific survival was 84% (95% CI 75%, 89%). On multivariable analysis the histologic findings at the ERP site were significant predictors of disease progression, independent of the RP findings. Conclusion: Our data suggest that teratoma or viable NSGCT is present in approximately one-third of patients undergoing resection of residual ERP disease. The presence of residual ERP teratoma and viable NSGCT predicts for cancer progression independent of RP histology.

Effect of Warm Ischemia on Renal Function During Partial Nephrectomy: Assessment With New 99mTc-Mercaptoacetyltriglycine Scintigraphy Parameter

2011-11-09

Objective: A decrease in renal function after partial nephrectomy caused by ischemic damage or nephron loss cannot be distinguished by conventional methods. We quantified renal function using a new 99mTc-mercaptoacetyltriglycine (99mTc-MAG3) renal scintigraphy parameter. Material and Methods: We included 32 patients with a normally functioning contralateral kidney who received open partial nephrectomy with average warm ischemic time of 26.0 (range 14–46) min in this study. Effective renal plasma flow (ERPF) was calculated from 99mTc-MAG3 renal scintigraphy before and at 1 week and 6 months after surgery. We also analyzed regional 99mTc-MAG3 uptake in the surgically nonaffected parts. Results: One week after surgery, average ERPF in the operated kidney decreased to 66.4% from baseline (from 177.8 to 116.9 mL/min/1.73 m2) and regional 99mTc-MAG3 uptake decreased to 83.4%. A stronger correlation was found between ischemic time and the decrease in regional 99mTc-MAG3 uptake (P < .001) compared with ERPF (P = .029). The decrease in regional 99mTc-MAG3 uptake remained at 6 months in the group with ischemic time ≥25 minutes, whereas it recovered when ischemic time was <25 minutes. Conclusion: This new parameter quantified ischemic renal damage better than the conventional split functional evaluation. When warm ischemic time was ≥25 minutes, irreversible diffuse damage was seen in surgically preserved nephrons.

Editorial Comment

Matthew N. Simmons — 2012-01-01

In this report, Funahashi et al used technetium-99m mercaptoacetyltriglycine (99mTc-MAG3) renograms to measure the changes in function after partial nephrectomy. The study is unique in that it measured tracer uptake in the regions of interest of the operated kidney unaffected by tumor excision to allow direct study of the ischemic effects. The effective renal plasma flow (ERPF) at 1 week after partial nephrectomy in the whole kidney and the regions of interest was 66% and 83%, respectively. This discrepancy suggested that ischemic injury and other factors, such as volume loss additively contributed to the functional decrease at 1 week. The ischemic duration correlated with the ERPF at 1 week. Typically, the peak creatinine level occurs 1-2 days after partial nephrectomy; thus, these data suggest that ERPF is altered well into the recovery phase. Another interesting observation was an increase in ERPF in the contralateral kidney in some patients. It is uncertain whether this was real or an artifact; however, if real, it would suggest the possibility that adult kidneys have a functional reserve. At 6 weeks, the ERPF levels of the patients with a warm ischemia time of ≤25 minutes had recovered to the preoperative ERPF levels, but those of the patients with a warm ischemia time of >25 minutes remained depressed. Their conclusion was that an ischemia time >25 minutes resulted in irreversible diffuse damage.

Smoking Knowledge Assessment and Cessation Trends in Patients With Bladder Cancer Presenting to a Tertiary Referral Center

2011-10-26

Objective: To determine the knowledge level of patients with bladder cancer (BC) regarding smoking risks. We also sought to determine the role of their urologists in initiating smoking cessation at the diagnosis. Smoking is the leading risk factor for BC in industrialized nations. However, little information is available regarding patients' knowledge of the risks of smoking and the role of their urologists in initiating smoking cessation at diagnosis. Methods: A smoking knowledge and cessation questionnaire was administered to 71 patients referred to the Johns Hopkins Hospital for BC from April 2008 to June 2009. The questionnaire captured data on demographics, BC history, smoking status and history, risk factor knowledge, and cessation patterns. Results: The mean age of the cohort was 65.1 years (range 42-86) and 72% were men. At the referral, all 71 patients (100%) knew smoking was a risk factor for lung cancer compared with 61 (86%) who knew it was for BC. Only 36 patients (51%) knew smoking was the leading risk factor for BC. Of the 17 patients (24%) who were smokers at their BC diagnosis, 12 (71%) were counseled by their referring urologist to quit smoking; however, the significant majority (76%) was not offered any specific intervention. Conclusion: The association between smoking and BC was not as well known as that of lung cancer in our cohort of patients. Most current smokers were advised to stop smoking by their primary urologist; however, few were offered any intervention to aid in cessation. Urologists should assume a more active role both in educating patients regarding smoking's link to BC and in initiating smoking cessation.

Editorial Comment

Joy Knopf, Edward Messing — 2012-01-01

The causative relationship between cigarette smoking and bladder cancer, although well known to urologists and oncologists, may be unrecognized by urology patients. Even in this study's relatively well-educated, young, and motivated patients seeking care at a tertiary referral center, 15% were unaware of the connection between smoking and bladder cancer, and more than one half of current smokers continued to smoke despite being informed of this association.

Patient Resources Available to Bladder Cancer Patients: A Pilot Study of Healthcare Providers

2011-10-12

Objective: To survey thought leaders attending an annual bladder cancer conference about resources available to survivors at, primarily, large academic centers treating a high volume of patients. Bladder cancer is a disease with high treatment burden. Support groups and survivorship programs are effective at managing physical and psychosocial impairments experienced by patients. The Institute of Medicine recommends increased resources for cancer survivorship, but no description of current resources exists for bladder cancer patients. Methods: Preceding the 4th annual Bladder Cancer Think Tank meeting in August 2009, we carried out an Internet-based survey of registrants that queried respondents about institutional resources and support systems devoted to bladder cancer survivors. Data were collected using SurveyMonkey.com, and descriptive statistics were computed. Results: A total of 43 eligible respondents included urologists (77%), medical oncologists (16%), and other physicians or health professionals (7%). Physician respondents represented 22 academic centers and 2 private groups. Although 63% of respondent institutions had a National Cancer Institute designation, only 33% had an active bladder cancer support group. Survivorship clinics were available in 29% of institutions, and peer support networks, community resources for education, and patient navigation were available in 58%, 13%, and 25% of respondent institutions, respectively. Conclusions: Resources for bladder cancer survivors vary widely and are lacking at several academic centers with high-volume bladder cancer populations. Bladder cancer providers are often unaware of available institutional resources for patients. Urologists need to advocate for additional survivor resources and partner with other disciplines to provide appropriate care.

Gleason Pattern 5 is Frequently Underdiagnosed on Prostate Needle-core Biopsy

Turki O. Al-Hussain, Michael S. Nagar, Jonathan I. Epstein — 2011-10-31

Objective: To assess underdiagnosing Gleason pattern 5 on needle biopsy and discuss the potential consequences for patient management. Material and Methods: We retrieved 300 consecutive prostate biopsy cases from the consultation files at The Johns Hopkins Hospital (JHH) from 2009-2010 in which we identified Gleason pattern 5. All of these cases were diagnosed by one of the authors and all were sent in as a final diagnosis for which the outside pathologist was not requesting consultation because of difficulty with the diagnosis. The Gleason grades assigned to these cases at our institution were compared with the grade rendered by the submitting pathologists from the outside institution. Results: In 146 (48.7%) of the cases, Gleason pattern 5 was not identified by the outside pathologists. Of the 146 cases, the outside Gleason score was ≤7 in 61 (20.3%) and 4 + 4 = 8 in 85 (28.4%). Even when the tumor was diagnosed at JHH as Gleason score 5 + 5 = 10, only 26 (41.3%) were diagnosed as the same by the outside pathologists; Gleason score 9 was graded in 27 (42.8%). Conclusion: Considering the important prognostic and therapeutic implication of misdiagnosing Gleason pattern 5, efforts should be made by the pathology community to acknowledge this as a problem and improve on individual pathologists' accuracy by diverse medical education programs. In addition, urologists should not hesitate in sending biopsies with high-grade prostate cancer for expert genitourinary pathology second opinions.

Lower Urinary Tract Symptoms Have Negative Associations With Glomerular Filtration Rate Irrespective of Prostate Volume in Korean Men

2011-10-03

Objective: To understand the relationship between lower urinary tract symptoms (LUTS) and renal function by prostate volume (PV) in Korean men. LUTS can be related to early renal dysfunction, irrespective of bladder outlet obstructive lesions, few studies have been conducted. Methods: We conducted a cross-sectional survey of 3713 men, aged ≥40 years, who received routine comprehensive health evaluations, including transrectal ultrasonography and the International Prostate Symptom Score questionnaire. We used the estimated glomerular filtration rate (GFR) for the assessment of renal function and the IPSS for LUTS severity. We compared LUTS and GFR using multivariate regression analysis after adjusting for age and/or PV. Results: An increasing severity of LUTS, especially voiding LUTS, was associated with a decreasing GFR in the older age group (≥55 years). In a stratified analysis by PV of 30 cm3, voiding LUTS showed a negative association with GFR, irrespective of the PV (P for trend < .01 and P for trend < .02), but total LUTS did so only in the small PV group. Conclusion: In men without known urinary tract disease, LUTS and renal function had a negative association, especially in older men with a normal PV. Although the underlying mechanism is uncertain, physicians who treat patients with moderate or severe LUTS should monitor renal function, even in patients with a normal PV.

Effect of Sexually Transmitted Infections, Lifetime Sexual Partner Count, and Recreational Drug Use on Lower Urinary Tract Symptoms in Men Who Have Sex With Men

2011-10-03

Objective: To investigate the relationship of lower urinary tract symptoms (LUTS) to urinary tract infection, prostatitis, sexually transmitted infection, lifetime sexual partner count, and recreational drug use in a population of men who have sex with men. LUTS in men are a source of considerable morbidity, distress, and medical expense. Methods: We conducted a cross-sectional, Internet-based survey of urinary quality-of-life outcomes in men who have sex with men. The main outcome was the International Prostate Symptom Score (IPSS), classified as none/mild (IPSS 0-7), moderate/severe (IPSS 8-35), or severe (IPSS 20-35). The participants were also asked whether they ever sought medical attention for urinary problems. Results: The survey web site was accessed by 2783 men, of whom 2348 (84.3%) completed the questionnaire. The median age was 39 years (range 18-81). Age, depression, human immunodeficiency virus infection, gonorrhea, syphilis, prostatitis, and prescription drug abuse were all associated with LUTS. Men who sought medical attention for LUTS were more likely to report older age, diabetes, depression, gonorrhea, urinary tract infection history, and prostatitis. Conclusion: Specific infectious conditions of the urinary tract and depressive symptoms are independent predictors of LUTS in men who have sex with men. Although LUTS are often multifactorial, a common unifying explanation for our finding could be the effects of local and systemic inflammation on the lower urinary tract.

Are Metabolic Syndrome and Its Components Associated With Lower Urinary Tract Symptoms? Results From a Chinese Male Population Survey

2011-09-16

Objective: To investigate the association between severity of lower urinary tract symptoms (LUTS) and metabolic syndrome (MetS) and its components in a large male population in China. Methods: Data were collected from 3103 men attending the Fangchenggang Area Male Healthy and Examination Survey (FAMHES) from September 2009 to December 2009. LUTS were assessed by the International Prostate Symptom Score (IPSS) and MetS were defined using a modification of the Adult Treatment Panel III guidelines. Blood samples were drawn to determine serum lipids and glucose levels. Comprehensive information on demographic characteristics and medication was also collected through questionnaires. The association between LUTS and MetS was presented as odds ratios and 95% confidence intervals estimated using a logistic regression model. Results: The presence of MetS was not associated with the severity of LUTS (multivariate OR = 0.97, 95% CI = 0.67-1.39), but its subcategories of moderate or severe storage symptoms were inversely related to MetS (multivariate OR = 0.64, 95% CI = 0.44-0.91). Aging was observed to be a major risk factor for LUTS, such that men 60 years or older experienced 2-fold the odds of moderate or severe LUTS (OR = 2.79, 95% CI = 1.82-4.29) when compared with men 40 years or less). Component of MetS, such as systolic blood pressure, has increased odds for moderate or severe postmicturition symptoms but with no statistically significant results in multivariate analysis (multivariate OR = 1.22, 95% CI = 0.93-1. 60). Conclusions: Our data suggest that the MetS is not associated with LUTS. However, for subcategory symptoms, decreased odds of MetS was observed in moderate or severe voiding storage symptoms.

Effect of the Ratio of Resected Tissue in Comparison With the Prostate Transitional Zone Volume on Voiding Function Improvement After Transurethral Resection of Prostate

Hyoung Keun Park, Sung Hyun Paick, Yong Soo Lho, Kyung Kyu Jun, Hyeong Gon Kim — 2011-10-19

Objective: Few studies exist correlating the extent of tissue resected with symptom improvement after transurethral resection of prostate (TURP). This study evaluated the effect of the ratio of resected tissue in comparison with the transitional zone volume (TZV) on improvement of voiding symptoms and flow rate. Methods: A total of 263 patients who underwent TURP from January 2001 to June 2008 were included in this retrospective study. TURP efficacy was assessed at 6 months using International Prostate Symptom Score (IPSS) and uroflowmetry. Patients were then stratified into 2 subgroups according to resection ratio (volume of resected tissue/TZV); individuals with resection ratio <50% (group A) and ≥50% (group B). The 2 groups were compared with regard to prostate volume, TZV, preoperative and postoperative IPSS, quality of life (QoL), peak flow rate (Qmax), and postvoid residual (PVR). Similar analyses were performed according to prostate volume (small [<40 g] vs large [≥40 g]). Results: Of these individuals, 85 (32.3%) met the criteria for group A, and 178 (67.7%) for group B. There were no statistically significant differences in age, prostate volume, TZV, preoperative IPSS, QoL score, Qmax, and PVR. After TURP, there was no significant difference of IPSS, QoL score, Qmax, and PVR between the 2 groups. After stratification according to prostate size, the differences in clinical variables were not significant according to resection ratio. Conclusion: Resection ratio had no effect on post-TURP clinical improvement. These results suggest that complete prostate adenoma resection may not be essential.

Congenital Renal Anomalies in Patients With Classic Bladder Exstrophy

Andrew A. Stec, Nima Baradaran, John P. Gearhart — 2011-11-07

Objective: To determine the proportion and type of renal anomalies that occur in children born with classic bladder exstrophy. Material and Methods: All patients in a database of 1044 patients with the bladder exstrophy-epispadias-cloacal exstrophy complex were reviewed. Those with classic bladder exstrophy had their complete medical records reviewed and children with radiographic evidence of congenital renal anomalies were identified and characterized. Results: A total of 674 patients were identified with classic bladder exstrophy, of whom 462 had renal ultrasounds at the authors' institution. In this population, 13/462 (2.8%) had concomitant renal anomalies. The most common malformation was a duplicated collecting system in 6 patients. Hypoplastic or absent kidneys were present in 3 patients, pelvic kidney in 2, ureteropelvic junction obstruction in 1, and multicystic dysplastic kidney in 1 patient. Conclusion: Isolated renal anomalies occur at a rate of 2.8% in children born with classic bladder exstrophy. Although uncommon in this rare birth defect, anatomic understanding of the entire genitourinary system is critical for operative planning and long-term follow-up of patients with bladder exstrophy.

Hemiscrotal Agenesis: New Variation in a Rare Anomaly

Andrew S. Flum, Antonio H. Chaviano, William E. Kaplan — 2011-08-05

Scrotal agenesis is a rarely encountered developmental anomaly of the scrotum, with only 6 cases of complete agenesis reported in published studies. We report, to our knowledge, the first case of hemiscrotal agenesis. The specific embryologic basis of scrotal agenesis is unknown but is likely multifactorial, involving localized androgen insensitivity, localized 5α-reductase deficiency, and/or failure of labioscrotal fold formation.

Intrahepatic Paratesticular Cyst: Unique Presentation of Vestigial Remnants of Wolffian Duct

Silvia Ceccanti, Ermelinda Mele, Gabriele Masselli, Sandro Bosco, Denis A. Cozzi — 2011-07-08

To report on a case of a progressively enlarging intrahepatic cyst in a 1-year-old boy who also presented with bilateral undescended testes. At surgery, the lesion emerged from the anterior surface of the liver but was unexpectedly found to arise from the epididymis of the right testis, which was located intra-abdominally. The histologic findings were consistent with a paratesticular cyst of vestigial remnants derived from the Wolffian duct. Such an unusual event has not been previously reported among the possible location of a paratesticular cyst, nor has it been described in the differential diagnosis of cystic lesions of the liver.

Inflammatory Myofibroblastic Tumor of the Bladder in a 3-Year-old Boy

2011-07-08

Inflammatory myofibroblastic tumor (IMT) is a rare neoplasm with unknown malignant potential that has been described in most organ systems. We present the case of a 3-year-old boy who was referred with lower urinary tract symptoms and macroscopic hematuria. An IMT was suspected after clinical, radiological, and surgical work-up, and the diagnosis was confirmed after a partial cystectomy was performed. A bladder-preserving approach is the treatment of choice, but close clinical follow-up is recommended because of the unknown biological behavior of these tumors.

Scrotoschisis: An Extremely Rare Congenital Uropathy

Lisieux E. Jesus, Samuel Dekermacher, Jorge Abikair Filho, L.J. Rocha — 2011-07-08

Scrotoschisis, the congenital extrusion of the testis through the scrotal wall, is very rare. We describe a new case and review the pertinent published data. A male neonate presented with left scrotoschisis that was repaired successfully with a Denis-Browne trans-scrotal orchiopexy, with antibiotic coverage. The testes were intrascrotal and symmetric after 2 years of follow-up. Most cases of scrotoschisis are unilateral and affect normal males. The immediate prognosis is good, but long-term results are not available. The etiology of the disease is unknown, but it might be related to spontaneous healed fetal intestinal perforations with meconium peritonitis.

Pilot Study of the Vesicocutaneous Continent Catheterizable Stoma (Mitrofanoff) in Adults—High Complication Rates

Lauren Eisenberg, Jeremy Johnson, Richard Santucci — 2011-11-09

Objective: To report our experience with an adult vesicocutaneous Mitrofanoff, an alternative to standard appendiceal or ileal Mitrofanoff. Material and Methods: Retrospective chart review was performed on 3 patients who underwent a vesicocutaneous Mitrofanoff by a single surgeon. Data were collected on etiology, complications, and number of procedures to correct the complication. Results: Indications for the procedure included neurogenic bladder and urinary retention. Mean follow-up time was 485 days with mean time to first complication of 24 days. One-hundred percent of patients saw stenosis and dehiscence of their wounds. All 3 patients required subsequent surgery. Sixty-six percent required reoperation to the standard Mitrofanoff with a mean time to this procedure of 222 days. The mean number of procedures was 4 (range 2-6). Conclusion: Continent catheterizable stomas have been a continuous challenge for adults who have had multiple abdominal surgeries, making a typical appendix, ureter, or small bowel Mitrofanoff difficult. We looked at our experience with a cutaneous Mitrofanoff (an extraperitoneal procedure often done in pediatrics but never before in adults) as an alternative but found complication rates of 100%. These included stenosis and dehiscence eventually requiring reoperation, with some even requiring conversion to an ileal or appendiceal Mitrofanoff. Although there are high complication rates in the standard Mitrofanoff, we conclude that a vesicocutaneous Mitrofanoff is not an effective alternative.

A More “Conventional” Way to Perform Percutaneous Endopyeloplasty: A Feasibility Study

2011-11-07

Objective: Percutaneous endopyeloplasty is a horizontal suturing of the endopyelotomy incision via a unique percutaneous tract. We present a feasibility study of our technique of percutaneous endopyeloplasty using a conventional suture with a laparoscopic needle holder via the nephroscope. Materials and Methods: A longitudinal endopyelotomy incision is performed through a 24-Fr working sheath placed via an upper calyx. Then an initial suture is placed, approximating the endopyelotomy incision distal and proximal apex, using a conventional absorbable 13-mm needle suture with a lengthened 3.5-mm pediatric laparoscopic needle holder, via the nephroscope. If possible, an additional 2 sutures are eventually placed, 1 on either side of the initial midline suture. Results: Percutaneous endopyeloplasty, using a conventional suture with a pediatric laparoscopic needle holder via a nephroscope, is technically possible, reproducible, and effective, and was performed in 10 consecutive patients. The tissue approximation provides a fast, full thickness ureteral healing. Endopyelotomy horizontal suturing leads to a wider caliber reconstruction of the ureteropelvic junction. Conclusion: Percutaneous endopyeloplasty is a promising technique. Our procedure for endopyeloplasty is technically feasible and effective, with little need for highly specialized equipment. However, further technical experience and longer follow-up in a larger group of patients are necessary for more development of this technique.

Editorial Comment

Mahesh Desai, Arvind P. Ganpule — 2012-01-01

The gold standard treatment for primary ureteropelvic junction obstruction (UPJO) is a pyeloplasty; the approach can be open, laparoscopic, or robotic and could be a matter of surgeon preference. The authors need to be congratulated for describing a conventional and novel approach for performing endopyeloplasty with a 3.5-mm pediatric laparoscopic needle-holder.

Reply

2012-01-01

We genuinely appreciate the comments of Desai et al regarding our feasibility study describing a more “conventional” way to perform percutaneous endopyeloplasty. This technique was performed without any patient selection. Thus, we think that in dependent position ureteropelvic junction (UPJ), the 2 endopyelotomy incision apexes are wide apart, thus endopyeloplasty is best suited for short UPJ obstruction. However, in high inserted UPJ, a longer endopyelotomy can be performed until reaching the more dependent renal pelvic part. Mostly in this case, the 2 tissue edges are adjacent, so endopyeloplasty is easier.

Use of Patient-specific MRI-based Prostate Mold for Validation of Multiparametric MRI in Localization of Prostate Cancer

2012-01-01

Objective: To demonstrate the use of a patient-specific magnetic resonance imaging (MRI)-based prostate mold to generate histologic sections that directly correlate to axial MRI slices in a patient with anteriorly located prostate cancer. Anteriorly located prostate cancer has traditionally been difficult to detect on digital rectal examination and transrectal ultrasound-guided biopsy. Multiparametric MRI has potential as a valuable tool for the diagnosis and focal treatment of prostate cancer. A significant difficulty to date has been accurate correlation between the magnetic resonance images and histopathologic specimens. Methods: A patient-specific mold from a preoperative T2-weighted MRI scan was created to hold and shape the prostate specimen. Slots for slicing were positioned at 6-mm increments coplanar to the axial MRI slices. After surgical excision, the specimen was inked to maintain the orientation and fixed in formalin. The seminal vesicles were excised, and the prostate was oriented in the mold such that the color-coding matched the anatomic labels on the mold. The specimen was sliced with a single blade and the resultant 6-mm tissue blocks were used for histologic analysis. Results: Preoperative multiparametric MRI revealed a lesion in the right anterior transition zone that was positive on T2-weighed MRI, apparent diffusion coefficient maps of diffusion-weighted MRI, magnetic resonance spectroscopy, and dynamic contrast-enhanced MRI. The histologic sections obtained using the mold demonstrated a similar Gleason score 6 (3 + 3) lesion in the right anterior transition zone, correlating with the MRI findings. Conclusion: The use of patient-specific prostate molds to register the MRI findings with the histopathologic specimen in prostate cancer could offer several benefits compared with current specimen processing techniques. This technique might further validate MRI as an accurate tool for prostate cancer localization and staging.

Up-regulation of Plakophilin-2 and Down-regulation of Plakophilin-3 are Correlated With Invasiveness in Bladder Cancer

2011-11-25

Objective: To examine plakophilin proteins (Pkp) and 3 expression levels in bladder cancer, in particular their levels during cellular growth and invasion. Pkp is associated with the binding of cadherin to intermediate filaments of the cytoskeleton. Methods: The relative mRNA and protein expression levels of Pkp2 and 3 in bladder cancer cell lines were determined using quantitative real-time polymerase chain reaction and Western blot analyses. The cellular localization of Pkp2 and 3 proteins in bladder cancer cells was also assayed using immunohistochemistry. The proliferation and invasive activities of bladder cancer cells were evaluated using cell growth and in vitro cell invasion assays, and were compared with those of bladder cancer cells treated with Pkp2 and 3 small interfering RNAs. Results: Pkp2 mRNA and protein levels were elevated, and those of Pkp3 were reduced, in bladder cancer cells that are known to exhibit increased proliferation and invasive activity. Pkp2/3 protein expression was predominantly observed in the cytoplasm of invasive bladder cancer cells and tissues. Pkp2 knockdown inhibited, and Pkp3 knockdown enhanced, invasion of bladder cancer cells, but these knockdowns did not alter cell proliferation. Conclusion: We conclude that high Pkp2, and low Pkp3, expression is associated with bladder cancer cell invasion and that neither Pkp2 nor Pkp3 is associated with cell proliferation. We further hypothesize that accumulation of Pkp2 and 3 in the cell cytoplasm, rather than their recruitment to the cell membrane, is related to an increased ability of the tumor to invade and metastasize.

Utility of Urothelial mRNA Markers in Blood for Staging and Monitoring Bladder Cancer

2011-11-07

Objective: To test the efficiency of 6 mRNA bladder markers in staging urothelial cell carcinoma (UCC) and monitoring UCC dissemination from blood samples. Methods: From 2002 to 2009, 347 blood samples were collected from 150 patients with UCC and 29 healthy controls. Sequential blood sampling was performed in patients undergoing cystectomy at surgery and 6, 12, 18, and 24 months postoperatively. The median follow-up was 33 months. The presence of KRT20, FXYD3, C10orf116, UPK2, AGR2, and KRT19 markers in blood was evaluated in all patients and controls by measuring the gene expression using preamplified cDNA and reverse transcriptase quantitative polymerase chain reaction. Gene expression data were correlated with the tumor risk, follow-up, and outcomes data. Results: Expression of C10orf116 and KRT19 genes differed between patients and controls (P < .001). KRT20, C10orf116, and AGR2 differentiated between low- and high-risk nonmuscle-invasive bladder cancer (P = .001, P = .011, and P = .001, respectively). FXYD3 differentiated between patients with high-risk nonmuscle-invasive bladder cancer and those with muscle-invasive bladder cancer (P = .009). In contrast, the 6 markers showed no differences in gene expression between metastatic and patients without metastases who had not undergone cystectomy (P = NS). None of the markers were significantly increased in the metastatic patients at 6, 12, 18, or 24 months after surgery. Conclusion: The gene expression of bladder-specific mRNA markers in blood was different among the various tumor risk groups of patients with UCC. However, this gene expression analysis is not suitable for predicting metastases or monitoring UCC hematogenous dissemination in patients who have undergone cystectomy.

Interactions Between Cholinergic and Prostaglandin Signaling Elements in the Urothelium: Role for Muscarinic Type 2 Receptors

C.J. Nile, J.I. Gillespie — 2011-11-07

Objective: To characterize the interactions between the cholinergic and prostaglandin signaling systems within the urothelium-lamina propria of the guinea pig and elucidate the role of muscarinic receptors in these interactions. Methods: The urothelium-lamina propria was isolated from guinea pig bladders, cut into strips (5 × 10 mm), and maintained in vitro. The tissue was either stretched or left unstretched but exposed to 2′(3′)-O-(4-benzoylbenzoyl)adenosine-5′-triphosphate tri(triethylammonium) salt, arecaidine, and prostaglandin E2 (PGE2). Acetylcholine and PGE2 release was measured using a GeneBLAzer M3 CHO-K1-bla cell reporter assay and an enzyme immunoassay, respectively. The role of the muscarinic type 2 and 3 (M2 and M3, respectively) receptors and nitric oxide in mediating PGE2 release was determined in the presence of the muscarinic antagonists 11-[(2-[(diethylamino)methyl]-1-piperidinyl)acetyl]-5,11-dihydro-6H-pyrido[2,3b][1,4] benzodiazepin-6-one and darafenicin and a nitric oxide donor (NONOate). Results: Acetylcholine release was detected in response to stretch and in the unstretched preparations exposed to PGE2 or the adenosine triphosphate analog 2′(3′)-O-(4-benzoylbenzoyl)adenosine-5′-triphosphate tri(triethylammonium) salt. The cholinergic agonist arecaidine induced a concentration-dependent production of PGE2 (half-maximal concentration 75 nM). The arecaidine stimulation of PGE2 production was inhibited in a dose-dependent manner by the antagonist AFDX-116 (M2 > M3; half-maximal inhibition 110 nM) but not darifenacin (M3 >> M2). Finally, in the presence of the nitric oxide donor, NONOate, arecaidine-stimulated PGE2 production was inhibited. Conclusion: These observations demonstrate that complex signal interactions occur within the urothelium involving acetylcholine, adenosine triphosphate, nitric oxide, and PGE2. In addition, the data have demonstrated a role for muscarinic M2 receptors and nitric oxide in the cholinergic regulation of PGE2 production in the bladder wall.

A Chinese Herbal Formula, Shuganyiyang Capsule, Improves Erectile Function in Male Rats by Modulating Nos-CGMP Mediators

Ji Wang, Qi Wang, Baoxing Liu, Donghuan Li, Zhuojun Yuan, Huimin Zhang — 2011-11-09

Objective: To evaluate the effects of the Chinese herbal formula Shuganyiyang (SGYY) capsule on arteriogenic erectile dysfunction (ED) in a rat model and to investigate the underlying molecular mechanism. Methods: Forty male Sprague-Dawley rats were subjected to bilateral ligation of the internal iliac artery and then divided into 4 groups (n = 10 per group). They were treated daily with either sildenafil (10.5 mg/kg), or SGYY at 1 of 2 dosages (1 g/kg and 0.5 g/kg) for 30 days. Erectile function was evaluated using cavernous nerve electrical stimulation after treatment, and the cavernous tissue specimens of all animals were harvested for gene and protein examination using real-time reverse transcriptase polymerase chain reaction, Western blot analysis, and cyclic guanosine monophosphate (cGMP) measurement. Results: The ratio of the maximal intracavernous pressure to the mean arterial pressure was significantly higher in the SGYY (1 g/kg and 0.5 g/kg) rats than that in the models (P <.01). The gene and protein expression of 3 subtypes of nitric oxide synthase (NOS)—neuropathic (nNOS), inducible (iNOS), and endothelial (eNOS)—and cGMP concentrations in cavernous tissue in SGYY-treated rats were significantly higher than in the models. However, phosphodiesterase type 5 (PDE5) expression in the SGYY rats was lower than those in models (P <.01 or P <.05). Conclusion: SGYY significantly improves the maximal intracavernous pressure in arteriogenic ED in a rat model. The underlying mechanism of action of SGYY involves increasing the expression of some main factors in the NOS-cGMP pathway and reducing the expression of PDE5.

Re: Kim et al.: Influence of Prostatic Calculi on Lower Urinary Tract Symptoms in Middle-aged Men (Urology 2011;78:447-449)

Christopher C.K. Ho, Srijit Das — 2012-01-01

We read with much interest the published report “Influence of Prostatic Calculi on Lower Urinary Tract Symptoms in Middle-Aged Men” by Kim et al. The authors meticulously discuss the relationship of prostatic calculi with lower urinary tract symptoms. The authors concluded that large prostatic calculi are a significant associated factor of moderate lower urinary tract symptoms with a 1.784-fold increase in risk compared with no and small calculi. We wish to discuss some important facts related to the topic.

Reply

Won Jae Yang, Seung Whan Doo, Yun Seob Song, Woong Bin Kim — 2012-01-01

Thank you for your important comments. Reanalysis of our study revealed the storage symptoms were more affected by the size of prostatic calculi as you stated in your hypothesis. The mean International Prostate Symptom Score (IPSS) of storage symptoms in the large calculi group was 4.0 ± 2.7, which was significantly higher than 2.8 ± 2.2 in the no calculi and small calculi groups (P <.001). The mean IPSS of voiding symptoms was also significantly different between 2 groups (5.8 ± 4.7 in large calculi vs 5.0 ± 4.0 in no calculi and small calculi, P = .043). We assume that this finding may be contributed more by the age factor than by the size of calculi, because the average age of patients in the large calculi group was 50.9 years, which was significantly older than the average 49.3 years in the no calculi and small calculi groups (P <.001). Prostate volume was not significantly different between the 2 groups although large calculi group tends to have larger prostates (25.3 ± 6.9 vs 24.4 ± 7.1, P = .10).

Aims and Scope

2012-01-01

Editorial Board

2012-01-01

Urology

SIU Scholar: Dr. Fahed Abdullah Salem Baaboud

SIU Scholar: Dr. Ahmed Muhammed

Prostatic Urethral Lift: Two-year Results After Treatment for Lower Urinary Tract Symptoms Secondary to Benign Prostatic Hyperplasia

Evidence-based Medicine for Polypropylene Mesh Use Compared With Native Tissue Vaginal Prolapse Repair

Editorial Comment

Reply

Critical Appraisal of World Health Organization's New Reference Values for Human Semen Characteristics and Effect on Diagnosis and Treatment of Subfertile Men

Life-threatening Hematuria Due to Recurrent Arterial-conduit Fistula

Is Ultrasound Imaging Inferior to Computed Tomography or Magnetic Resonance Imaging in Evaluating Renal Mass Size?

Editorial Comment

The Effect of Noise-cancelling Headphones or Music on Pain Perception and Anxiety in Men Undergoing Transrectal Prostate Biopsy

Prostate Sampling by 12-Core Biopsy: Comparison of the Biopsy Results With Tumor Location in Prostatectomy Specimens

Effective Radiation Exposure in Evaluation and Follow-up of Patients With Urolithiasis

Biochemical Determinants of Severe Lithogenic Activity in Patients With Idiopathic Calcium Nephrolithiasis

Prediction of Morbidity and Mortality After Percutaneous Nephrolithotomy By Using the Charlson Comorbidity Index

The Impact of Pelvicaliceal Anatomy on the Success of Retrograde Intrarenal Surgery in Patients With Lower Pole Renal Stones

Anatomical Variation Between the Prone, Supine, and Supine Oblique Positions on Computed Tomography: Implications for Percutaneous Nephrolithotomy Access

Metabolic Syndrome in Female Patients With Overactive Bladder

Sling Location in Women With Recurrent Stress Urinary Incontinence Following Midurethral Sling

Can Sacral Neuromodulation Improve Minor Incontinence Symptoms in Doubly Incontinent Patients Successfully Treated for Major Incontinence Symptoms?

Increased Risk of Urinary Tract Calculi Among Patients With Diabetes Mellitus—A Population-based Cohort Study

Editorial Comment

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Racial Differences in the Prevalence of Overactive Bladder in the United States From the Epidemiology of LUTS (EpiLUTS) Study

Diabetes Treatment and Progression of Benign Prostatic Hyperplasia in Community-dwelling Black and White Men

An Unusual Case of Right Retrocaval Ureter Associated With Ipsilateral Ureterocele

Pseudoaneurysm Kidney: A Rare Complication of Pseudopancreatic Cyst

Recurrent Giant Liposarcoma of the Spermatic Cord

Vaginal Mass With Urinary Incontinence: A Rare Presentation

Patency Rates of Microsurgical Vasoepididymostomy for Patients With Idiopathic Obstructive Azoospermia: A Prospective Analysis of Factors Associated With Patency—Single-center Experience

Men Who Seek Infertility Care May Not Represent the General U.S. Population: Data From the National Survey of Family Growth

Risk Factors for Progressive Deterioration of Semen Quality in Patients With Varicocele

Long-term Biochemical Recurrence Rates After Robot-assisted Radical Prostatectomy: Analysis of a Single-center Series of Patients With a Minimum Follow-up of 5 Years

Simultaneous Laparoendoscopic Single-site Radical Nephrectomy for Native Kidney and Open Nonischemic Partial Nephrectomy to Treat Concomitant Renal Cell Carcinomas in Native and Transplant Kidneys and to Preserve Allograft Function

On-demand Tramadol Hydrochloride Use in Premature Ejaculation Treatment

Clinical Outcomes of Intracavernosal Injection in Postprostatectomy Patients: A Single-center Experience

Clinical Impact of Residual Extraretroperitoneal Masses in Patients With Advanced Nonseminomatous Germ Cell Testicular Cancer

Effect of Warm Ischemia on Renal Function During Partial Nephrectomy: Assessment With New 99mTc-Mercaptoacetyltriglycine Scintigraphy Parameter

Editorial Comment

Smoking Knowledge Assessment and Cessation Trends in Patients With Bladder Cancer Presenting to a Tertiary Referral Center

Editorial Comment

Patient Resources Available to Bladder Cancer Patients: A Pilot Study of Healthcare Providers

Gleason Pattern 5 is Frequently Underdiagnosed on Prostate Needle-core Biopsy

Lower Urinary Tract Symptoms Have Negative Associations With Glomerular Filtration Rate Irrespective of Prostate Volume in Korean Men

Effect of Sexually Transmitted Infections, Lifetime Sexual Partner Count, and Recreational Drug Use on Lower Urinary Tract Symptoms in Men Who Have Sex With Men

Are Metabolic Syndrome and Its Components Associated With Lower Urinary Tract Symptoms? Results From a Chinese Male Population Survey

Effect of the Ratio of Resected Tissue in Comparison With the Prostate Transitional Zone Volume on Voiding Function Improvement After Transurethral Resection of Prostate

Congenital Renal Anomalies in Patients With Classic Bladder Exstrophy

Hemiscrotal Agenesis: New Variation in a Rare Anomaly

Intrahepatic Paratesticular Cyst: Unique Presentation of Vestigial Remnants of Wolffian Duct

Inflammatory Myofibroblastic Tumor of the Bladder in a 3-Year-old Boy

Scrotoschisis: An Extremely Rare Congenital Uropathy

Pilot Study of the Vesicocutaneous Continent Catheterizable Stoma (Mitrofanoff) in Adults—High Complication Rates

A More “Conventional” Way to Perform Percutaneous Endopyeloplasty: A Feasibility Study

Editorial Comment

Reply

Use of Patient-specific MRI-based Prostate Mold for Validation of Multiparametric MRI in Localization of Prostate Cancer

Up-regulation of Plakophilin-2 and Down-regulation of Plakophilin-3 are Correlated With Invasiveness in Bladder Cancer

Utility of Urothelial mRNA Markers in Blood for Staging and Monitoring Bladder Cancer

Interactions Between Cholinergic and Prostaglandin Signaling Elements in the Urothelium: Role for Muscarinic Type 2 Receptors

A Chinese Herbal Formula, Shuganyiyang Capsule, Improves Erectile Function in Male Rats by Modulating Nos-CGMP Mediators

Re: Kim et al.: Influence of Prostatic Calculi on Lower Urinary Tract Symptoms in Middle-aged Men (Urology 2011;78:447-449)

Reply

Aims and Scope

Editorial Board

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