Urology

SIU Scholarship: Dr. Anselm Okwudili Obi

Anselm Okwudili Obi — 2010-01-22

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/. I qualified as a Fellow of the West African College of Surgeons (Urology) in October 2001 and obtained the SIU Scholarship in June 2004. During this period, I knew I had limitations in several areas of Urology because of the limited facilities and scope of training in my country, Nigeria, and I yearned for an opportunity to improve myself.

Impact on Quality of Life of Urinary Incontinence and Overactive Bladder: A Systematic Literature Review

Simona Bartoli, Giovanni Aguzzi, Rosanna Tarricone — 2009-12-04

The paper provides a systematization of the scientific evidence on quality of life of patients affected by urinary incontinence (UI) and overactive bladder (OAB) through a systematic literature review. A single search strategy was performed through the databases and papers collected are reviewed by independent researchers finally, including 39 papers. A strong heterogeneity of studies emerged from the evidence. The multidimensionality of the consequences produced by UI and OAB increased the attention on the identification of the most affected dimension of life quality (i.e. physical, emotional) and on the attempt of predicting life quality impairment through specific variables.

Editorial Comment

Nabil K. Bissada, Ayman Mahdy — 2010-03-01

Overactive bladder (OAB) defined as “urinary urgency with or without urge incontinence, usually associated with frequency and nocturia” is a major health problem in the United States. One of 11 adults in the United States is estimated to suffer from OAB, with a total of 17 million adults being affected.

Reply

Simona Bartoli, Giovanni Aguzzi, Rosanna Tarricone — 2010-03-01

We highly appreciate the interest of the Urology journal in the field of quality of life (QoL) of people affected by UI and OAB. The topic has become of paramount importance during the last decades as it has highlighted the extra (and often hidden) burden imposed by diseases or treatments (ie, interventions, therapies) in addition to mortality and morbidity.

Reduction in the Risk of Prostate Cancer: Future Directions After the Prostate Cancer Prevention Trial

E. David Crawford, Gerald L. Andriole, Michael Marberger, Roger S. Rittmaster — 2009-12-25

The landmark Prostate Cancer Prevention Trial (PCPT) generated interest in the potential health benefits and cost of reducing prostate cancer risk—specifically, the potential role of 5α-reductase inhibitors. However, the PCPT raised several unanswered questions, including the cause and significance of the increased incidence of high-grade tumors associated with finasteride. In the present study, we review the PCPT findings and unanswered questions, next steps in this field, and ongoing prostate cancer prevention trials addressing these unanswered questions. Particular emphasis is placed on the design of the second large-scale trial of a 5α-reductase inhibitor, the REduction by DUtasteride of prostate Cancer Events (REDUCE) trial.

Editorial Comment

Ian M. Thompson — 2010-03-01

Prostatic adenocarcinoma is a major public health menace, taking the lives of almost 30 000 men annually in the United States. Generally, asymptomatic until metastatic, and at that point, median survival is 30-36 months, a statistic that has changed little since the advent of hormonal therapy. The advent of PSA screening provided an opportunity to identify early disease and more than half of men in the United States undergo screening annually; most men who are diagnosed with this disease undergo treatment. Initial results of two phase 3 screening studies provide a insight into this approach to disease control: in a United States study, no reduction in mortality was seen and in a European study, to prevent 1 prostate cancer death, 1410 men were screened and 48, treated. The people in the United States have moved beyond organized medicine. Men and their spouses read about the smallest case-control nutritional epidemiologic study and act, buying nutraceuticals, supplements, vitamins, and affecting diet changes, as well as expending resources and efforts in an attempt to reduce their risk of developing prostate cancer.

Why Can't Nomograms Be More Like Netflix?

Andrew J. Vickers, Paul Fearn, Peter T. Scardino, Mike W. Kattan — 2009-10-30

Nomograms have become ubiquitous in urology. As evidence, a simple PubMed search for “nomogram prostate” obtains over 450 hits; Web sites abound where patients can type in data and obtain predictions (including both http://www.nomogram.org and http://www.nomograms.org). Nomograms have been used as inclusion criteria for clinical trials; even patient medical records are now designed so that nomograms can be calculated automatically from a patient's data. For members of the public, however, the prediction model they are most likely to encounter is not a nomogram, but Netflix.

Top-down Approach for Evaluation of Urinary Tract Infection

Hsi-Yang Wu, Linda D. Shortliffe — 2009-10-30

Management of vesicoureteral reflux (VUR) involves as much controversy as management of prostate cancer. Imagine if there was an easily available serum or radiographic test that could definitively determine whether a man with prostate cancer would have any local spread of the disease, and whether it would ever cause any symptoms. Would not that test replace prostate-specific antigen (PSA) or any other marker as the gold standard for whether patients should be offered treatment? In VUR, we already have such a test: the dimercaptosuccinic acid (DMSA) scan. We can tell whether renal injury has occurred after a febrile urinary tract infection (UTI). The presence of VUR is only an imperfect marker (like PSA) for the real endpoint of renal parenchymal injury. The “top-down” approach gives us the ability to pick out those children who are at risk for renal injury, and to manage the remainder without performing a voiding cystourethrogram (VCUG). More importantly, it reminds us that our goalpost is not just successful correction of VUR, but decreasing the rate of renal injury regardless of whether VUR is present.

Post-transplantation Lymphoproliferative Disorder in the Renal Transplant Ureter

Mary K. Samplaski, Joshua Coleman, David Goldfarb — 2010-01-18

Dr. MKS: A 68-year-old Caucasian woman with a history of end-stage renal disease secondary to diabetic nephropathy underwent cadaveric renal transplantation in December 2008, using a standard criteria donor. The donor tested positive for cytomegalovirus (CMV) and Epstein Barr virus (EBV), and the recipient was negative for both. A stented Lich-Gregoir extravesical ureteroneocystostomy was used for ureteral reimplantation. Her immediate postoperative course was unremarkable. She received basiliximab induction and was maintained on an immunosuppressive regimen of tacrolimus, mycophenolate mofetil, and steroids. The serum creatinine nadir was 1.2 mg/dL. She received 3 months of prophylaxis for CMV with acyclovir 400 mg 3 times daily. Valacyclovir would have been the preferred antiviral medication; however, her insurance would not cover it, and acyclovir was believed to be an acceptable alternative. The ureteral stent was removed at 6 weeks postoperatively.

Lack of Pharmacodynamic Interaction of Silodosin, a Highly Selective α1a-Adrenoceptor Antagonist, With the Phosphodiesterase-5 Inhibitors Sildenafil and Tadalafil in Healthy Men

Scott A. MacDiarmid, Lawrence A. Hill, Weining Volinn, Gary Hoel — 2010-01-18

Objectives: To evaluate the orthostatic effects and safety of coadministration of silodosin with the phosphodiesterase-5 inhibitors sildenafil and tadalafil.Methods: In this placebo-controlled, open-label crossover study, 22 healthy men aged 45-78 years received 8 mg silodosin for 21 days. On days 7, 14, and 21, subjects also received a single dose of sildenafil 100 mg, tadalafil 20 mg, or placebo in random sequence. Orthostatic tests were performed before (baseline) and 1-12 hours after single-dose treatment. A positive orthostatic test was defined as decrease in systolic blood pressure (SBP) >30 mm Hg, decrease in diastolic blood pressure (DBP) >20 mm Hg, increase in heart rate (HR) >20 bpm, or presence of orthostatic symptoms. Treatment effects were compared by analysis of covariance.Results: In comparison with placebo, sildenafil or tadalafil caused small but statistically significant reductions in blood pressure; however, no statistically significant orthostatic changes in SBP, DBP, or HR (P >.05) were caused. Time-matched maximum mean difference (95% confidence interval) vs placebo in 1-minute orthostatic change was −2.3 (−6.8-2.2) mm Hg for SBP, −2.2 (−5.6-1.2) mm Hg for DBP, and 1.7 (−1.5-4.9) bpm for HR. The number of postdose positive orthostatic tests was similar for all treatments (sildenafil, 57; tadalafil, 59; placebo, 53). Adverse events (in 7 subjects) were mild (26) or moderate (2). No orthostatic symptoms occurred.Conclusions: Coadministration of silodosin and maximum therapeutic doses of sildenafil or tadalafil in healthy men caused no clinically important orthostatic changes in blood pressure or HR and no orthostatic symptoms.

Economic Costs of Overactive Bladder in the United States

2009-12-25

Objectives: To calculate, from a societal perspective, current direct (medical and nonmedical) and indirect costs of overactive bladder (OAB) in the United States and project them to future years. Existing cost assessments of OAB in the United States are incomplete and outdated.Methods: A prevalence-based model was developed incorporating age- and sex-specific OAB prevalence rates, usage data, and productivity data. On the basis of the information gathered from the recent 5 years of the medical literature, practice guidelines, Medicare and managed care fee schedules, and expert panel input, the annual per capita and total US costs were calculated for 2007. US census population forecasts were used to project the costs of OAB to 2015 and 2020.Results: In 2007, average annual per capita costs of OAB were $1925 ($1433 in direct medical, $66 in direct nonmedical, and $426 in indirect costs). Applying these costs to the 34 million people in the United States with OAB results in total national costs of $65.9 billion (billion = 1000 million), ($49.1 billion direct medical, $2.3 billion direct nonmedical, and $14.6 billion indirect). Average annual per capita costs in 2015 and 2020 would be $1944 and $1969 and total national costs would be $76.2 billion and $82.6 billion, respectively.Conclusions: These data suggest that the economic burden of OAB is about 5-fold higher than older, noncomprehensive estimates. These costs are higher than previously published data for the United States and Europe because this analysis relies on more current data, real world age- and sex-specific treatment patterns and costs, and includes a more complete set of cost components.

Editorial Comment

R. Duane Cespedes — 2010-03-01

There is little doubt that overactive bladder (OAB) is a substantial problem in terms of patient quality of life, personal economic hardship, and economic burden to society. Quantification of the extent of the problem has been the focus of many previously published articles—so why do we need one more? This data-heavy article (also see the on-line tables) expands tremendously on previous reports by using many more variables including age- and gender-specific parameters, a wider range of cost components, in-depth analysis of direct and indirect costs, and many more. The overall conclusion that the societal costs of OAB may be 5-fold higher than what was previously estimated is staggering. Although these new figures are clearly only a more accurate estimate with the same inherent data uncertainties that plague all these studies—the number of people affected, proportion of OAB “wet” vs “dry,” level of care rendered, medication use, treatment effectiveness, pads/management costs, etc., this study will be essential for anticipating future needs in medical care and funding.

Editorial Comment

Craig V. Comiter — 2010-03-01

The authors present an excellent study, based on the daunting task of calculating the economic burden of overactive bladder (OAB) in this country. However, it is imperative not to overestimate the costs of this important, albeit non–life-threatening disease state. Data from the NOBLE program revealed that only 25% of individuals with OAB and only 40% with incontinence actually visit a physician for this problem. This relative underutilization of resources may, in fact, help keep medical expenditures in check. In contrast, costs will likely increase if programs such as “direct-to-consumer” advertising raise awareness of this common condition, much as advertisements for phosphodiesterase type 5 inhibitors led to an increase in patient complaints regarding erectile dysfunction.

Reply

2010-03-01

We thank Drs. Cespedes and Comiter for their comments on our article and for pointing out important areas for consideration and future research, including differentiating OAB “wet” from “dry” patients in future economic and health-related quality of life (HRQOL) studies. As Dr. Comiter correctly notes, this article focuses on the economic costs of overactive bladder (OAB) in the United States, and it presents direct medical, direct nonmedical, and indirect (lost productivity) costs. Although the burden of OAB, as measured by clinical outcomes as well as psychosocial distress and diminution of HRQOL, is substantial, we focused on the economic costs of OAB because they represent financial impact of the clinical outcomes and opportunity costs to society—resources to be allocated elsewhere if not for OAB.

Durability of the Next-generation Flexible Fiberoptic Ureteroscopes: A Randomized Prospective Multi-institutional Clinical Trial

2009-10-26

Objectives: To evaluate the durability of 4 next-generation flexible ureteroscopes in a randomized, multi-institutional, prospective study.Methods: Patients at 3 institutions were randomized to 1 of 4 flexible ureteroscopes: the Wolf Viper, Olympus URF-P5, Gyrus-ACMI DUR-8 Elite (DUR-8E), and Stryker FlexVision U-500. Each center used 1 scope from each manufacturer until it needed major repair (primary endpoint). Intraoperative data included total time of use, number of scope insertions through an access sheath, working time in the lower pole, number of insertions and total time for accessory instrumentation in the working channel, number of laser insertions through the working channel, and total laser energy used.Results: A total of 175 patients were randomized. The DUR-8E experienced early catastrophic failure (≤ 10 cases) at all 3 sites; however, this also occurred at 1 site each for the Stryker and Wolf scopes. The DUR-8E required major repair after the fewest average number of cases (5.3), the lowest average total time of usage (108 minutes), the fewest insertions through an access sheath (20.3), the shortest duration of laser firing (31.3 minutes), and the shortest instrument in the working channel time (224.7 minutes). As such, due to variation in durability within manufacturers, no differences could be demonstrated. Visibility ratings for the Wolf iper were significantly better than the DUR-8E (P = .034) and the Flexvision (P = .038).Conclusions: The Wolf Viper, Olympus URF-P5, and Stryker Flexvision U-500 flexible ureteroscopes seem comparable with regard to durability. However, larger prospective registry-based studies are needed to document significant differences between them.

Editorial Comment

Ben H. Chew — 2010-03-01

The authors present a relatively stringently standardized randomized trial evaluating 4 different fiberoptic ureteroscopes in real-life situations at 3 different centers. Although the ACMI DUR-8E was shown to be the most fragile of the scopes, with all 3 sites experiencing catastrophic failures during their first 10 uses, each of the sites also experienced this with the Wolf and Stryker scopes illustrating the variability in scope manufacturing. The average number of uses of the DUR-8E was 5.3 before a repair was required. This is contrasted by another study by Monga et al who found that the DUR-8E was the most durable among ureteroscopes tested and lasted over 14 uses before requiring repair.

Editorial Comment

James F. Borin — 2010-03-01

This article tells us very much as well as very little about the current state of fiberoptic flexible ureteroscopes. The authors compared 4 commonly used, “next-generation” ureteroscopes in a prospective trial involving 175 patients at 3 institutions. Access sheaths were used in almost all cases, and the ureteroscopes were removed from the study after they required a major repair as a result of severe deficits in vision or maneuverability. Of the 12 brand-new, direct from the manufacturer ureteroscopes, 5 needed repair after ≤10 cases. The DUR-8E fared poorly with early failure at all 3 institutions after an average of 5.3 cases. However, in prior studies, the DUR-8E was superior in durability to its competitors, lasting an average of 14 and 42 uses before repair (Refs. 5 and 7 in the article, respectively). In those prior studies, the ureteroscopes being compared with the DUR-8E were earlier generations of models evaluated in this article. Although their forebears failed after an average of 4 and 8 uses, the Wolf and Olympus ureteroscopes in this study lasted 17 and 18 cases, respectively. While definitive conclusions cannot be made, it would seem that the quality of most ureteroscopes is improving. The poor performance of the DUR-8E in this study is not commensurate with prior investigations, and the reasons for this are not entirely clear. However, no statistically significant differences in durability or performance can be concluded from this study. In fact, the only significant difference was subjective visibility ratings, favoring the Wolf Viper. Thus, the direct ureteroscope comparisons tell us very little about which ureteroscope might be superior.

Reply

Manoj Monga — 2010-03-01

We appreciate each of the constructive editorial comments and concur that critical evaluations of the performance and durability of digital flexible ureteroscopes under a variety of sterilization protocols are warranted as the next step in quality assurance and improvement. The lack of statistical differences in durability in this study, though powered in a similar fashion to previous studies, confirms the observation that the playing field has been leveled. Though an alternate mode of transportation would be appealing, for now the flexible ureteroscope takes us places where other surgical instrumentation cannot.

Assessment of Clinical Efficacy of Intranasal Desmopressin Spray and Diclofenac Sodium Suppository in Treatment of Renal Colic Versus Diclofenac Sodium Alone

2009-12-04

Objectives: To determine the effect of the combination of intranasal desmopressin spray and diclofenac sodium suppository on acute renal colic and compare it with diclofenac sodium suppository alone.Methods: A total of 150 patients aged 15-65 years referred to our hospital with acute renal colic were included in a double-blind controlled clinical trial study. Patients in group 1 received desmopressin, 40 μg intranasally plus diclofenac sodium suppository 100 mg, and patients in group 2 received diclofenac sodium suppository 100 mg plus a placebo spray consisting of normal saline 0.9%.Results: Significant differences were found in the pain scores at 15 and 30 minutes between the 2 groups (P < .05). Also, significant differences were found in the mean pain scores in the first 15 and first 30 minutes after treatment between the 2 groups (P < .05). Of the patients in group 1, 37.3% had no pain relief and required pethidine. However, this rate in group 2 was 69.3%. In 17 cases, we prescribed pethidine within 20 minutes after treatment, and these patients were excluded from our study.Conclusions: According to our results, intranasal desmopressin plus diclofenac sodium suppository caused prompt pain relief with significant decreases in pain scores after 15 and 30 minutes. We suggest that intranasal desmopressin spray is a useful supplemental therapy for renal colic in combination with nonsteroidal anti-inflammatory drugs, especially to reduce the use of opioids.

Changes in Gender Distribution of Urinary Stone Disease

Seth A. Strope, J. Stuart Wolf, Brent K. Hollenbeck — 2009-10-26

Objectives: To explore using population-based data the extent to which gender-specific rates of stone disease are changing. Historically, stone disease has been more common among men than women. However, differential changes in dietary intake patterns, fluid intake, and obesity in men and women may cause shifts in stone disease incidence and prevalence.Methods: The State Ambulatory Surgical Database and the State Inpatient Databases were queried for procedures related to renal colic or urolithiasis. Population-based rates of utilization were calculated for the years 1998-2004 by gender. Poisson regression models were fit to measure changes in utilization rates over time.Results: Of the 107 411 discharges for stone disease, 41 272 (38%) occurred in women. Service utilization increased in both men and women (86.6-105.5 and 42.5-64.4 per 100 000; P <.01 in both). However, the growth rate in women outpaced men (P <.01). Rates of outpatient (57.2-65.8 and 27.0-38.9 per 100 000; P <.01) and ambulatory surgery center utilization (6.4-17.7 and 2.9-9.3 per 100 000 men and women; P <.01) increased significantly in men and women, but inpatient utilization only increased in women (12.5-16.3 per 100 000; P <.01).Conclusions: Resource utilization for stone disease continues to increase. Most of this increase appears to be due to an increase in disease among women. Increasing obesity, dietary changes, or decreased fluid intake may be contributing to the rapid increase in stone disease treatments in women.

Intravesical Instillation of Hyaluronic Acid Prolonged the Effect of Bladder Hydrodistention in Patients With Severe Interstitial Cystitis

Yuan Shao, Zhou-Jun Shen, Wen-Bin Rui, Wen-Long Zhou — 2009-12-17

Objectives: To evaluate the efficacy of intravesical instillation of hyaluronic acid (HA) after hydrodistention for the treatment of patients with interstitial cystitis (IC) having small bladder capacity.Methods: A total of 47 patients with IC (aged 27-76 years) whose functional bladder capacity was less than 200 mL received bladder hydrodistention. Thereafter, 20 patients received intravesical instillation of 40 mg HA weekly in the first month and then monthly in the following 2 months. Sixteen patients received intravesical heparin instead and 11 patients received hydrodistention alone as the control. Mean voids per day, visual analog scale for pain, and functional bladder capacity were measured before hydrodistention and 3 and 6 months after hydrodistention in all 3 groups and 9 months after hydrodistention in HA and heparin groups.Results: Two patients in the HA group and 1 in the heparin group failed to complete the treatment. Three months after hydrodistention, there was no improvement in the control group. Six and 9 months after hydrodistention, rate of improvement was significantly higher in the HA group than in the heparin group (77.8% vs 33.3%, P < .05; 50% vs 20%, P < .05). At 9 months, heparin treatment did not show any improvement. Improvement in voids per day (−1.8 ± 2.5, P < .01), visual analog scale (−0.9 ± 1.1, P < .01), and bladder capacity (16 ± 18 mL, P < .01) was still significant in the HA group.Conclusions: Intravesical instillation of HA may obviously prolong the effect of bladder hydrodistention in patients with severe IC. Its effect was better than heparin.

Editorial Comment

Hanno M.D. Philip — 2010-03-01

This study by Shen and Shao from Shanghai suggests that 4 weekly intravesical instillations followed by 2 monthly intravesical instillations of 40 mg hyaluronic acid in 40 mL of normal saline can, when combined with initial hydrodistention of the bladder, result in significant improvement in pain, frequency, and functional bladder capacity extending over 6 months. The study is small and open-label, and does not include the 2 hyaluronic acid dropouts and 1 heparin/lidocaine dropout as failures, as would be consistent with an intent-to-treat study. Nevertheless, the findings are compelling and deserve follow-up in a larger, double-blind placebo-controlled trial that would ideally include a group without hydrodistention, but only cystoscopy.

Reply

Zhou-jun Shen — 2010-03-01

The treatment of interstitial cystitis/painful bladder syndrome (IC/PBS) is difficult, especially for patients with bladder capacity under anesthesia less than 200 mL. The effect of bladder hydrodistention is remarkable but diminishes within 2-3 months in most cases. Frequently repeated hydrodistention is inconvenient with high cost. Before 2003, we applied hydrodistention followed by intravesical instillation of heparin with lidocaine. We noticed that it might prolong the effect of hydrodistention, although many patients still required repeated hydrodistention after a few months of instillation.

Repeated Injections of Botulinum Toxin-A for Idiopathic Detrusor Overactivity

2009-12-25

Objectives: To report the efficacy and safety of repeated injections of botulinum toxin-A (BTX-A) in treating idiopathic detrusor overactivity refractory to anticholinergics. Furthermore, we describe whether dose alteration in patients with poor responses or voiding dysfunction after initial treatment can improve outcomes.Methods: A cohort of 34 patients who participated in a clinical trial was followed up and their progress reported. Twenty from this group had >1 BTX-A injection. Each patient received 200 U BTX-A initially, with subsequent injections between 100 and 300 U, administered by a trigone-sparing flexible cystoscopic technique. Efficacy was measured using voiding diaries and quality of life (QoL) assessed with Incontinence Impact Questionnaire-7 and Urogenital Distress Inventory-6 questionnaires. Urodynamic data were obtained for injections 1-3. All measurements were performed before and 3 months after injections.Results: Twenty patients received a repeat injection and of these 9 subsequently received a third and fourth injection. Significant improvements in overactive bladder syndrome symptoms and QoL were observed after each injection as compared with baseline. Maximum cystometric capacity and bladder compliance increased with decrease in the maximum detrusor pressure during filling cystometry. When comparing overactive bladder symptoms, QoL, and urodynamic parameters 3 months after the first and last injections, no significant differences were found. Nine patients had their BTX-A dose altered, with better outcomes in 5. The commonest reported problems were difficulty in emptying the bladder and urinary tract infection.Conclusions: BTX-A appears to be effective and safe after repeated administration in patients with idiopathic detrusor overactivity. Certain patients will benefit from dose optimization to improve efficacy or prevent voiding dysfunction.

Editorial Comment

Bertil F.M. Blok — 2010-03-01

Non-neurogenic detrusor overactivity or idiopathic detrusor overactivity (IDO) can pose significant challenges to the urologist. Despite multiple available modalities for conservative treatment, including antimuscarinics, biofeedback, and lifestyle changes, many patients are in need for additional, more or less, invasive treatment, like botulinum toxin A (BTX-A) injections or sacral neuromodulation.

Spontaneous Nephroduodenal Fistula in a 27-Year-old Woman

Steve Y. Chung, Robert B. Nadler — 2009-11-20

Spontaneous nephroduodenal fistula formation is a rare occurrence. An otherwise healthy young patient presented with worsening chronic right flank pain and fevers. Retrograde pyelogram and computed tomography studies eventually led to a diagnosis and successful management of a right nephroduodenal fistula.

Enlargement of Accessory Spleen After Splenectomy Can Mimic a Solitary Adrenal Tumor

Gregory S. Rosenblatt, Daniel J. Luthringer, Gerhard J. Fuchs — 2009-08-13

We report on a 72-year-old woman who had previously undergone splenectomy and subsequently presented with an incidental 5-cm adrenal mass. Laparoscopic adrenalectomy was performed, and the mass was identified to be an accessory spleen. Remaining accessory splenic tissue may undergo compensatory hypertrophy after splenectomy. When a biochemically inactive, well-marginated ovoid adrenal mass is identified in a postsplenectomy patient, consideration should be given to the presence of accessory spleen. In such cases, radionuclide imaging with technetium sulfur colloid may provide information that would confirm the presence of accessory normal tissue and would therefore support observation rather than surgical resection.

Nonpapillary Serous Cystadenoma of the Epididymis: Report of 2 Cases of a Rare Entity

M.J. Fernández-Aceñero, G. Renedo, J. Fortes, F. Manzarbeitia — 2009-11-25

Testicular and paratesticular tumors of the ovarian epithelial type have been well described in the published data. Since the seminal work by Young and Scully on 14 cases, several short series or isolated cases have been reported. All these tumors have been characterized by a benign indolent biological behavior, despite there also being cases of borderline and even malignant lesions of this type. Most reported cases have shown histopathologic features reminiscent of serous epithelial ovarian cystadenoma with papillary infoldings and nuclear stratification. In 2005, Pich and Galliano reported the first case of cystadenoma of the epididymis unassociated with any papillary growth, similar to some nonpapillary ovarian serous tumors. To the best of our knowledge, since this first report, only 2 cases of this so-called pure (nonpapillary) serous cystadenoma have been reported. After a thorough review of our articles, we have found 2 additional cases fulfilling the diagnostic criteria of this lesion, which we report in this study.

Prevalence of Testicular Size Discrepancy in Infertile Men With and Without Varicoceles

Sutchin R. Patel, Mark Sigman — 2009-12-07

Objectives: To compare the frequency of testicular size discrepancy between infertile men with and without varicoceles.Methods: The records of adult patients presenting for male infertility evaluations were examined. The testicular volumes and presence or absence of varicocele and varicocele grade were recorded. Testicular size discrepancy was defined as a testicular size difference of at least 4 mL.Results: Of the 3927 men presenting for male infertility evaluation, 3202 met the inclusion criteria of the study. A total of 705 patients (22%) had testicular size discrepancy and 1105 presented with a varicocele (34%). Testicular size discrepancy was found to be more common in patients with any varicocele than in patients with no varicocele (32% vs 17%; P <.001). In addition, testicular size discrepancy with a smaller left testicle was more common in patients with a left varicocele than in patients with no varicocele (30% vs 13%; P <.001). In patients with a left varicocele, testicular size discrepancy, if present, demonstrated a smaller testicle on the ipsilateral side 89% of the time and on the contralateral side 11% of the time. In contrast, with a right-sided varicocele, if testicular size discrepancy was present, the smaller testicle was located only on the left side.Conclusions: Testicular size discrepancy is approximately 2 times more common in infertile men with varicoceles than in men without varicoceles. Testicular size discrepancy with a smaller left testicle is more common than size discrepancy with a smaller right testicle, regardless of the side of the varicocele.

Editorial Comment

Michael A. Witt — 2010-03-01

This is an impressive retrospective study evaluating 3927 infertile men for the presence of testicular size discrepancy (TSD) defined as a difference in testicular volume (TV) of >4 mL, and a varicocele. A total of 3202 men met their inclusion criteria, of which 22% had TSD, 72% had no TSD with bilateral TVs > 19 mL, and 5% had no TSD with bilateral TVs < 19 mL. A total of 35% of patients had a varicocele, of which 32% had TSD compared with a TSD of 13% in men without a varicocele. If TSD was present, 84% had right and left TVs < 19 mL. If the varicocele was on the left, 89% had a smaller left testicle. If the varicocele was on the right, 100% had the smaller testicle on the left. The magnitude of TSD increased with the varicocele grade but did not correlate with patient age. The obvious conclusion from this study is that the presence of a varicocele increases the incidence and magnitude of TSD in both the right and left testicle. This confirms numerous studies that the presence of a varicocele can have an adverse effect on testicular histology. What I find interesting is that TSD exists without the presence of a varicocele and that the most commonly affected testicle is the left testicle even when the varicocele is on the right. These findings raise the question of what may cause TSD if a varicocele is not present and what is the mechanism by which a varicocele promotes this phenomenon. What this study cannot say is whether TSD has any effect on sperm production or fertility. Hopefully, the authors can provide such data in future publications.

Reply

Sutchin R. Patel, Mark Sigman — 2010-03-01

We agree with the reviewers that the results of our study lead us to question the etiology of testicular size discrepancy (TSD) in patients who do not have a varicocele or any other known condition that could affect testicular growth. Because all of these patients were being evaluated for infertility, it is not clear whether the TSD is even related to infertility. Future studies examining the prevalence of TSD in fertile men may help elucidate this issue. We do not have a clear explanation as to why all of our patients with a right varicocele had left TSD. Although evidence suggests unilateral varicoceles may have bilateral effects, this does not explain why hypotrophy is almost always on the left.

Robot-assisted Ureteroureterostomy in the Adult: Initial Clinical Series

David I. Lee, C. William Schwab, Andrew Harris — 2009-11-25

Objectives: To report what we believe is the first series of robot-assisted ureteroureterostomy (RAUU) in adults with greater than 24-month follow-up because ureteral stricture disease can be difficult to manage.Methods: During 2004-2006, a total of 3 patients were found to have complex ureteral pathology: 2 with refractory symptomatic ureteral strictures and 1 with a complete ureteral transection. After thorough discussion of all available treatment options, these patients agreed to undergo RAUU.Results: All patients had successful primary reanastomosis of the ureter robotically. Average operating room time was 136.6 minutes. Mean hospital stay was 3 days. All patients had ureteral stents placed during the operation. All patients at last follow-up were noted to be pain free with stable T½ on nuclear renal scan.Conclusions: RAUU is a potential treatment option for ureteral strictures in carefully selected patients. These cases may include failed endopyelotomy, refractory ureteral stricture, or cases of ureteral transection in which a ureteral reimplantation may be difficult. The robotic platform provides excellent reconstructive capabilities that may be difficult to obtain for surgeons who are not performing laparoscopic cases in high volume.

Port-site Hernias Occurring After the Use of Bladeless Radially Expanding Trocars

2009-10-26

Objectives: To compare and review the incidence of port-site hernias after use of bladeless radially dilating trocars after noticing a unique hernia entity developing in some patients. A review of the relevant published data is presented.Methods: We retrospectively identified patients who were diagnosed or treated for postoperative hernias at our institution between 2004 and 2007 using a departmental morbidity database. All patients had laparoscopic urologic surgery for malignant conditions using bladeless radially dilating trocars.Results: Of 1055 consecutive patients who underwent laparoscopic urologic oncology surgery between 2004 and 2007, a total of 7 patients (0.66%) were identified with trocar-site hernias. All hernias occurred using 12-mm bladeless radially dilating trocars without fascial closure. All hernias were confirmed by computed tomography of the abdomen and 6 by surgical findings. Of the 7 patients, 4 had an intrafascial incisional hernia; the small bowel herniated through a defect in the transversalis and internal oblique fasciae, but the external oblique fascia was intact. The intrafascial hernias were not evident on physical examination owing to an intact external oblique fascia.Conclusions: While rare, trocar-site herniation after use of bladeless radially dilating trocars is a potentially serious complication of laparoscopic surgery. A large proportion of these may be partial-wall or intrafascial hernias. It is important to increase awareness among laparoscopic surgeons of the possibility of intrafascial incisional hernias, as physical findings are subtle and early computed tomography diagnosis is necessary for timely surgical intervention.

Detection of Subclinical CO2 Embolism by Transesophageal Echocardiography During Laparoscopic Radical Prostatectomy

Jeong-Yeon Hong, Won Oak Kim, Hae Keum Kil — 2009-10-30

Objectives: To document incidences of subclinical embolism in laparoscopic radical prostatectomy with continuous monitoring using transesophageal echocardiography (TEE).Methods: A total of 43 patients scheduled for elective robotic-assisted laparoscopic radical prostatectomy under general anesthesia were enrolled in this study. A 4-chamber view of 5.0-MHz multiplane TEE was continuously monitored to detect any intracardiac bubbles as an embolism. An independent TEE specialist reviewed the tapes for interpretation, and emboli were classified as 1 of 5 stages. Cardiorespiratory instability during gas emboli entry was defined as an appearance of cardiac arrhythmias, sudden decrease in mean arterial blood pressure >20 mm Hg, or an episode of pulse oximetric saturation <90%.Results: Gas embolisms were observed in 7 of 41 (17.1%) patients during transection of the deep dorsal venous complex. Of them, 1, 3, 1, and 2 showed stage I, II, III, and IV, respectively. However, there were no signs of cardiorespiratory instability associated with emboli. The 95% confidence interval for gas embolism was 0.204%-0.138%. No correlation was observed between episodes of gas embolism and blood gas variables or end-tidal CO2 partial pressure.Conclusions: Subclinical gas embolisms occur in 17.1% of laparoscopic radical prostatectomies. We should consider that this procedure has a potential for serious gas embolism, especially with the increasing popularity of laparoscopic prostatectomy using robot-assisted techniques.

Retroperitoneoscopic Nephrectomy for Pyonephrotic Nonfunctioning Kidney

Ashok K. Hemal, Saurabh Mishra — 2009-08-13

Abstract: Objectives: To review the feasibility and outcome of retroperitoneoscopic nephrectomy (RPN) for pyonephrotic nonfunctioning kidneys.Methods: RPN for pyonephrotic nonfunctioning kidneys was used in 52 patients from July 2001 to May 2007. Percutaneous nephrostomy drainage was instituted in 46 patients because of sepsis before being referred to our institute. However, the remaining 6 patients underwent RPN without previous diversion. The mean patient age was 46.4 years (range 22-72). The etiology was stone disease in 29 patients, ureteropelvic junction obstruction in 18, and genitourinary tuberculosis in 5; 32 patients had diabetes mellitus as a comorbid condition.Results: RPN was performed successfully in 46 patients (88.5%); 6 patients required conversion to open surgery (1 emergently because of colonic injury and 5 electively because of nonprogression of the procedure). In 6 patients, subcapsular nephrectomy was required. The mean operating time was 110 minutes (range 90-180). The mean blood loss was 95 mL (range 80-300), and the mean analgesic requirement was 150 mg (range 50-400) of tramadol. Five patients had Clavien grade I, 7 had grade II, and 2 had grade IIIb complications. One patient required blood transfusion. The mean hospital stay was 3.6 days (range 2-8), and the mean return to normal activity was 14.2 days (range 11-21).Conclusions: RPN, although challenging, is safe, reliable, and successful for treatment of pyonephrotic nonfunctioning kidneys.

The Effects of Beta-blockers on Endothelial Nitric Oxide Synthase Immunoreactivity in the Rat Corpus Cavernosum

2009-12-04

Objectives: To explain the mechanism of the effects of β-blockers on endothelial dysfunction and release of nitric oxide from the endothelium.Methods: A total of 72 Sprague-Dawley rats were divided into 9 different groups as follows: group 1: control (n = 10), group 2: metoprolol (Beloc) 100 mg/kg/d (n = 7), group 3: carvedilol (Dilatrend) 50 mg/kg/d (n = 7), group 4: nebivolol (Vasoxen) 10 mg/kg/d (n = 6), group 5: estrogen receptor (ER) antagonist ICI 182.780 (Fluvestrant) 50 μg/g (n = 10), group 6: nebivolol+ER antagonist (n = 8), group 7: androgen receptor (AR) antagonist (flutamide) 20 mg/kg (n = 7), group 8: nebivolol+AR antagonist (n = 7), and group 9: DMSO (solvent for ER antagonist) (n = 10). All β-blockers were applied with gastric gavage after dilution with 5 mL of serum physiological; ER and AR were both applied intraperitoneally (i.p.) for 14 days. In the isolated rat cavernous tissues, endothelial nitric oxide synthase (eNOS) and ER and AR immunoreactivity were analyzed quantitatively. One-way analysis of variance and Tukey test were used for statistical analysis.Results: Although increased eNOS immunoreactivity was observed with nebivolol and nebivolol-flutamide in endothelial cells laying cavernous tissue, a lower score was observed after ICI-182.780 application, when compared with control cases. AR immunoreactivity in cavernosal endothelium was clearly higher with nebivolol. Higher H score and ER immunoreactivity were observed in the cavernous endothelium and smooth muscles in the nebivolol, carvedilol, and metoprolol groups when compared with control cases.Conclusions: We showed that eNOS activity was increased in the nebivolol and nebivolol-flutamide groups, whereas it was decreased in the ICI 182.780 group. We believe that an ER-dependent mechanism triggered by nebivolol played a role in nitric oxide formation.

Effect of Testicular Sperm Extraction Outcome on Sexual Function in Patients With Male Factor Infertility

Cem Akbal, Naşide Mangır, Hasan Hüseyin Tavukçu, Özay Özgür, Ferruh Şimşek — 2009-11-16

Objectives: To document the effects of the outcome of testicular sperm extraction (TESE) procedures on erectile function in patients with male factor infertility.Methods: A total of 66 nonobstructive azoospermic patients were divided into 2 groups: group I, with sperm-positive results and group II, with sperm-negative results. The patients were evaluated with the International Index of Erectile Function-5 (IIEF-5) and Hospital Anxiety-Depression Scale. Hormones were analyzed before and 6 months after the procedure. Each group was compared with the use of the paired t test, where P .05), respectively. The mean total testosterone level decreased from 7.83 ± 2 to 2.8 ± 2 ng/mL (P <.001). The Hospital Anxiety and Depression Scale revealed that patients who reported new onset ED also reported both depression and anxiety.Conclusions: Unsuccessful TESE procedures might have a negative effect on erectile function because of hormonal and psychological reasons. The andrologist should treat the ED of the patients and refer them to the psychiatrist for anxiety and depression assessment.

Editorial Comment

Tai Young Ahn — 2010-03-01

Although the authors did not show any pathologic findings of testis of nonobstuctive azoospermia patients, I guess that many of them might have Kleinfelter's syndrome whose total plasma testosterone levels are decreased in 50%-60% of the patients. Nevertheless, the mean baseline testosterone level 7.83 ng/mL in patients with unsuccessful sperm retrieval looks like to be much higher than that of nonobstructive azoospermia patients seen in the everyday practice.

Reply

Cem Akbal — 2010-03-01

Although the study by Komori et al reported no change in testosterone after TESE, Ramasamy et al demonstrated a significant decrease in serum testosterone—20%—at 3-6 months. Ramasamy et al also reported that the initial decrease was followed by a return to 95% of the pre-TESE testosterone levels at the end of 18 months.

Upregulation of GRP78 in Renal Cell Carcinoma and Its Significance

2009-07-17

Objectives: To investigate the expression of GRP78 in human renal cell carcinoma (RCC) and its significance.Methods: We studied RNA and tissue section of a tumor and adjacent nontumorous renal tissues obtained from radical nephrectomy specimens of 42 patients and RCC cell lines. We used reverse transcriptase-PCR and immunohistochemistry to detect the GRP78 mRNA and protein expression, respectively.Results: Reverse transcriptase-PCR revealed that GRP78 mRNA is positively expressed in RCC cell lines (786-0, OS-RC-2, and Caki-1); the GRP78 mRNA expression in the RCC and adjacent nontumorous renal tissues was 0.88 ± 0.34 and 0.44 ± 0.15, respectively (P < .001). The GRP78 protein was found in RCC cell lines. Immunohistochemistry results also showed that the level of GRP78 protein expression of RCC tissues was significantly higher than that of the adjacent nontumorous renal tissues (P < .001). The high levels of GRP78 mRNA and protein expression were related to the large tumor size and high clinical stage (P < .001) but not to sex, age, and cell differentiate (P > .05).Conclusions: To our knowledge, the present study is the first to report the upregulated expression of GRP78 and that it is possibly involved in pathogenesis of RCC.

The Relationship of Vascular Endothelial Growth Factor and Coagulation Factor (Fibrin and Fibrinogen) Expression in Clear Cell Renal Cell Carcinoma

2009-08-17

Objectives: To investigate the relationship between angiogenesis and coagulation markers in tumor tissues of primary renal cell carcinoma (RCC). Tumors stimulate angiogenesis and activate the coagulation cascade. The importance of the interplay between these pathways for RCC is unknown.Methods: In all, 69 clear cell RCC specimens were analyzed by immunohistochemical staining applied to tissue microarrays. The expression of vascular endothelial growth factor (VEGF), hypoxia-inducible factor-1α, fibrinogen and fibrin, and microvessel density were visually analyzed. Finally, staining patterns were related to clinical variables and survival.Results: The VEGF expression was detected in 100% of tumors, with 68% showing a high expression, whereas hypoxia-inducible factor-1α staining was low (only 26% had a moderate to high staining). Fibrinogen was expressed adjacent to the tumor cells in 26% of cases, whereas in 84% it was expressed around the blood vessels. In 30% of tumors, expression of fibrin was detected. High tumor VEGF expression correlated with high fibrin staining (P = .05). From a multivariate analysis, microvessel density (P = .033) and fibrinogen adjacent to tumor cells (P = .046) were independent factors related to VEGF expression.Conclusions: In this study, we found clinical evidence for the permeability activity of VEGF as reflected by extravascular fibrinogen expression adjacent to tumor cells in the extracellular matrix. In addition, VEGF and fibrin expression were associated, indicative for concomitant activation of the coagulation cascade and angiogenesis in RCC. Taken together, these data indicate that activation of angiogenesis and coagulation are related in RCC.

Primary Signet-ring Cell Carcinoma of the Urinary Bladder

Shusuke Akamatsu, Akira Takahashi, Masaaki Ito, Keiji Ogura — 2009-10-12

Objectives: To perform a comprehensive review and analysis of the clinical characteristics of primary signet-ring cell carcinoma of the bladder cases reported in Japan. Primary signet-ring cell carcinoma of the bladder is a rare condition. To date, the largest case series conducted for this condition includes only 11 cases.Methods: A search of published data was performed using the key words, “signet ring cell” and “urinary bladder.” The Ichusi, which is the largest medical database in Japan, and the PubMed databases were searched. All articles reported from Japanese institutions were reviewed, regardless of their language. Overall, we identified 131 titles reported between 1981 and 2008. Meeting abstracts were excluded, but the unpublished cases managed at our institution were included. In all, 54 cases were comprehensively reviewed and analyzed.Results: The median age at diagnosis was 61.2 years with male dominance (2:1). Among the selected cases, 46% had stage IV tumors. The overall survival rate at 2 years was 43%. However, none of the patients with stage IV disease at diagnosis were alive at 2 years. Multivariate analysis revealed that tumor stage and elevated carcinoembryonic antigen levels were significant prognostic factors. Of the 8 patients who were followed up for > 2 years and showed no evidence of recurrence, 7 were treated by either radical or partial cystectomy.Conclusions: Although the overall prognosis of this condition is poor, it is still dependent on the tumor stage at diagnosis. With early diagnosis and intervention, it may be possible to achieve long-term survival.

YouTube as Source of Prostate Cancer Information

2009-10-07

Objectives: Patients can search the Internet for prostate cancer information, and YouTube is a popular Web site that they may consult. We analyzed the prostate cancer videos on YouTube for information content and the presence of bias.Methods: YouTube was searched for videos about prostate-specific antigen (PSA) testing, radiotherapy, and surgery for prostate cancer. The included videos were in English and <10 minutes long. Two physician viewers watched each video and assigned a score for information content (excellent, fair, poor) and bias (for, against, neutral, or balanced). A third viewer arbitrated any discrepancies. The kappa statistic was used to measure interobserver variability, and Pearson's test was used to assess correlation.Results: A total of 14 PSA videos, 5 radiotherapy videos, and 32 surgery videos were analyzed. The PSA testing videos averaged 1480 ± 2196 views and 146 ± 174 s long and had an average viewer rating of 3.1 ± 2.1 (viewer rating scale 0-5). The surgery videos averaged 2044 ± 3740 views and 172 ± 122 s long and had an average viewer rating of scored 3 ± 2.2. The radiotherapy videos averaged 287 ± 255 views and 97 ± 45 s long and had a score of 1.8 ± 2.5. The information content was fair or poor for 73% of all videos. The bias for surgery, radiotherapy, or PSA testing was present in 69% of videos; 0% of videos were biased against treatment or PSA testing. The interobserver variability was well above than expected by chance alone.Conclusions: The results of our study have shown that although some videos are robust sources of information, given the preponderance of modest and unbalanced information among reviewed videos, YouTube is an inadequate source of prostate cancer information for patients.

The COMPARE Registry: Design and Baseline Patterns of Care for Men With Biochemical Failure After Definitive Treatment of Localized Prostate Cancer

2009-07-08

Objectives: To define current standards of care for patients with prostate-specific antigen (PSA) failure after initial definitive local treatment of prostate cancer using Comprehensive, Observational, Multicenter, Prostate Adenocarcinoma Registry (COMPARE). This article describes the design of the COMPARE Registry, together with patient characteristics and prostate cancer management at enrolment.Methods: The COMPARE Registry is a prospective, multicenter, observational study that collected data on patient characteristics, management practices, and outcomes of men presenting to their physician for the management of an increasing PSA level after definitive (surgical or radiotherapeutic) treatment of localized prostate cancer. Data collected by the physician and reported by the patient at the baseline (enrolment) visit are described.Results: Between February 2004 and March 2007, 1120 men were enrolled at 150 sites throughout the United States. The men had a median age of 73 years (range, 46-95 years), were predominantly white (77%), and had a median PSA level of 7.9 ng/mL (range, 0-710.8 ng/mL) at diagnosis. Observation (74%) was the most common initial management choice at registry enrolment, and androgen-deprivation therapy (22%) was the most common initial treatment choice.Conclusions: Data from the COMPARE Registry should provide a valuable source of prospectively collected information on the contemporary management of prostate cancer and patient outcomes after PSA failure.

Predictors of Symptomatic Lymphocele After Lymph Node Excision and Radical Prostatectomy

Angelo Naselli, Rossana Andreatta, Carlo Introini, Vincenzo Fontana, Paolo Puppo — 2009-05-25

Objectives: To identify the prognostic factors of symptomatic lymphocele.Methods: From January 2004, 359 patients underwent pelvic lymph node excision during radical prostatectomy at our center, of whom, 347 were followed up for ≥6 months.Results: At a median follow-up of 14.5 months (range 6-54), 44 patients had developed a lymphocele (12.6%). In 26 patients (7.4%), it was symptomatic and required treatment. On univariate analysis, lymphocele was associated with the extension of the lymph node dissection, the number of nodes retrieved, and the presence of nodal metastasis. Patient age, year of surgery, surgeon, anticoagulant or antiplatelet oral therapy before and after the period of low-molecular-weight heparin prophylaxis, American Society of Anesthesiologists score, use of neoadjuvant hormonal therapy, preoperative prostate-specific antigen value, Gleason score, and pathologic stage were not influential. After adjusting for covariates, logistic regression analysis revealed that only the number of nodes was significantly associated with the onset of a symptomatic lymphocele. The risk of lymphocele seemed to increase linearly with the number of nodes retrieved, and the incidence of positive nodes reached a plateau when >10-13 nodes were harvested.Conclusions: The benefit of more extensive nodal excision during radical prostatectomy should be weighed against the increased risk of lymphocele and its sequelae, including reintervention. In our series, no other factor, including previous anticoagulant or antiplatelet therapy, neoadjuvant hormonal therapy, and surgeon experience, influenced the incidence of symptomatic lymphocele.

The Effects of Testicular Cancer Treatment on Health-related Quality of Life

2009-12-07

Objectives: To prospectively describe the effects of adjuvant chemotherapy on health-related quality of life (HRQOL) among men with newly diagnosed non–seminoma germ cell tumors of the testis. Several characteristics of testicular cancer—young age at diagnosis, increasing incidence, and high survival rates—highlight the need for improved understanding of the variables influencing the survivorship experience.Methods: Participants (n = 116) were identified and recruited from the genitourinary services of 2 large medical centers—one in the United States and the other in the Netherlands. Baseline assessments were administered after diagnostic orchiectomy but before adjuvant treatment. Participants completed follow-up assessments after the completion of the chemotherapy regimen (or 3 months postdiagnosis for participants on surveillance regimens) and 12 months postdiagnosis. The 36-Item Short-Form Health Survey was used to measure HRQOL.Results: Findings indicated that men treated with chemotherapy reported significantly more bodily pain, poorer role physical functioning, poorer social functioning, poorer physical health, more fatigue compared with the men who did not receive chemotherapy at the post-treatment assessment. At the time of 12 month follow-up, HRQOL scores did not vary by treatment group, and scores were significantly higher than baseline HRQOL scores. No significant time by treatment group interactions were observed at the 12 month follow-up.Conclusions: Results from this study indicate that chemotherapy is associated with only a temporary decrease in HRQOL. Other HRQOL domains, including mental functioning, role emotional, and general health perceptions, were not associated with treatment type at any of the assessment times.

Does Oral Antiandrogen Use Before Leuteinizing Hormone-releasing Hormone Therapy in Patients With Metastatic Prostate Cancer Prevent Clinical Consequences of a Testosterone Flare?

2009-12-04

Objectives: To investigate whether oral antiandrogen therapy before initiation of leuteinizing hormone-releasing hormone (LHRH) agonists was associated with fewer clinical flares. LHRH agonists are associated with initial testosterone rises that may cause clinical disease flares in men with metastatic prostate cancer.Methods: We identified newly diagnosed metastatic prostate cancer patients treated in Veterans Affairs Hospitals from 2001-2004 with LHRH agonists with or without prior antiandrogen therapy. We assessed spinal cord compression, radiation therapy, fractures, bladder outlet obstruction, and narcotic prescriptions for pain within 30 days of starting LHRH therapy.Results: Of 1566 metastatic prostate cancer patients treated with LHRH agonists, 1245 (79.5%) patients received oral antiandrogens before initiating LHRH agonist treatment. Hispanic men, married patients, and those without prior cancer were treated less often with oral antiandrogens (all P ≤ .05). Complication rates did not differ by receipt of oral antiandrogens (all P ≥ .17). Spinal cord compression and pathologic fractures were extremely rare whether antiandrogens were used or not. In adjusted analysis, there was no decrease in odds of any event for treatment with an antiandrogen within 6 days (OR, 1.04, 95% CI, 0.78-1.40) or ≥ 7 days (OR, 0.95, 95% CI, 0.72-1.25) before LHRH agonist treatment.Conclusions: Antiandrogen therapy before LHRH agonists in metastatic prostate cancer was not associated with differences in fractures, spinal cord compression, bladder outlet obstruction, or narcotic prescriptions. Rates of spinal cord compression or fracture were < 1% in the first 30 days after beginning LHRH agonist therapy regardless of antiandrogen use.

Relationship Between Prostate-specific Antigen and Hematocrit: Does Hemodilution Lead to Lower PSA Concentrations in Men With a Higher Body Mass Index?

Kazuhiro Ohwaki, Fumiyasu Endo, Osamu Muraishi, Sonoe Hiramatsu, Eiji Yano — 2009-10-26

Objectives: To examine whether a lower hematocrit was associated with a lower prostate-specific antigen (PSA), when stratifying by body mass index (BMI) in healthy men. PSA test is widely used in screening for prostate cancer. Many studies have found that PSA levels inversely correlate with BMI. It remains unclear whether hemodilution causes this inverse relationship.Methods: We investigated 19 367 men who visited a hospital for a routine health checkup in 2007. We obtained information on age, BMI, PSA, hematocrit, and smoking status. BMI was categorized as < 18.5, 18.5-22.0, 22.0-25.0, 25.0-30.0, and ≥30.0 kg/m2.Results: In all subjects, older age and lower BMI were weakly correlated with a higher PSA (r = 0.20, P <.001 and r = −0.05, P <.001, respectively). A multiple regression model for predicting PSA was constructed using age, current smoking status, and hematocrit for each BMI category. After controlling for age and smoking, PSA increased significantly with increasing hematocrit in participants with BMIs of 18.5-30 kg/m2 (all P <.001). For example, in men with a BMI of 22-25 kg/m2, slight increases (1.4% increase; 95% confidence interval, 1.0%-1.9%) were observed in PSA with a 1-unit increase in hematocrit.Conclusions: In healthy men with a BMI of 18.5-30 kg/m2, a lower hematocrit was significantly associated with a lower PSA. Hemodilution may explain the lower PSA levels observed in men with a higher BMI, resulting in an inverse relationship between BMI and PSA.

Editorial Comment

Lionel L. Bañez, Stephen J. Freedland — 2010-03-01

It has been clearly established from multiple, very large cohorts around the world that obese men have lower PSA levels. Findings from the study by Ohwaki et al provide further evidence that these lower PSA levels result from obesity-related hemodilution. These findings, along with evidence that levels of other serum cancer markers (carcinoembryonic antigen and carbohydrate antigen 19-9 in men undergoing annual physical examination, and alkaline phosphatase in men with castrate-resistant prostate cancer) are lowered due to larger plasma volumes in men with increased body mass index (BMI), have sparked debates as to whether adjustments due to excess body weight are needed to properly interpret PSA results in men undergoing prostate cancer screening. Critics may question the significance of this phenomenon in clinical practice based on seemingly minimal effects of relative blood volume changes (represented by hematocrit levels in this study) on PSA levels.

Reply

Kazuhiro Ohwaki, Fumiyasu Endo — 2010-03-01

Many studies have observed that men with a higher BMI have lower PSA. Recently, some studies reported that hemodilution because of the increased plasma volume in obese men may be responsible for decreased PSA concentration. However, these studies were conducted using plasma volume estimated from height and weight. In the present study, we found that hematocrit, one of the indicators of plasma volume, was significantly associated with PSA concentration. As described in our article, this association was extremely weak. From a screening point of view, it is clinically less relevant for a Japanese population. However, as the editor suggested, hemodilution effect would be larger in more obese populations. This may result in leading to a delay in diagnosis, especially in obese men whose PSA levels are slightly lower than a cut-off level. It may be needed to re-evaluate the relationship between PSA levels and BMI using some indicator of plasma volume, such as hematocrit, in more obese populations.

Clinical Significance of IL-2, IL-10, and TNF-α in Prostatic Secretion of Patients With Chronic Prostatitis

Leye He, Yong Wang, Zhi Long, Chonghe Jiang — 2009-12-07

Objectives: To explore the clinical significance of interleukin-2 (IL-2), interleukin-10 (IL-10), and tumor necrosis factor alpha (TNF-α) in expressed prostatic secretions (EPS) of patients with different types of chronic prostatitis (CP).Methods: Fifty-seven CP patients and 12 healthy males (controls) were investigated. The CP patients were evaluated through routine examination of urine, EPS, 2 glasses urine culture, and the National Institutes of Health Chronic Prostatitis Symptom Index (NIH-CPSI) score and classified by the NIH prostatitis diagnostic criteria. The levels of cytokines TNF-α, IL-10, and IL-2 in the EPS were measured by two-antibody enzyme-linked immunosorbent assay.Results: CP patients fell into 3 groups: type II (n = 10), type IIIa (n = 26), and type IIIb (n = 21). EPS TNF-α and IL-10 levels were significantly higher in type II and type IIIa than in type IIIb and control groups. The levels of IL-2 were lower than control in all CP groups, but only type II was statistically different from the controls. In the CP patients, the level of TNF-α was positively related to the white blood cell counts (r = .77; P <.01), and the level of IL-10 was positively related to the NIH-CPSI scores (r = .55; P <.01).Conclusions: Determination of variety expression of TNF-α, IL-10, and IL-2 in the EPS of CP patients may provide a potential indicator for clinical diagnosis classification and an indicator to evaluate the effect of treatment of CP.

Preliminary Results of Prostate Vaporization in the Treatment of Benign Prostatic Hyperplasia by Using a 200-W High-intensity Diode Laser

2009-12-25

Objectives: To evaluate the efficacy and safety of a 200-W high-intensity diode laser in the treatment of benign prostatic hyperplasia.Methods: The prostate was vaporized by using a side-firing laser fiber (diode laser: power, 150-200 W; wavelength, 980 nm; Limmer, Germany). The following parameters were assessed at baseline, and after a follow-up period of 1- and 6 months: International Prostate Symptom Score, maximum uroflow rate, postvoid residual urine volume, and quality of life score. Prostate volume and prostate-specific antigen levels were assessed at baseline and 6 months postoperatively.Results: This study included 55 patients diagnosed with lower urinary tract symptoms secondary to BPH, who were treated between December 2007 and July 2008. The recatheterization rate was 10.9%. None of these patients required a blood transfusion or had transurethral resection syndrome. Statistically significant improvements (P < .001) were observed in the values of International Prostate Symptom Score, Qmax, postvoid residual urine volume, and quality of life score at 1- and 6 months of follow-up as compared with the respective baseline values. Transient urge incontinence was noted in 8 patients (8/55, 14.5%).Sloughing of necrotic tissues was observed on cystoscopy in 8 patients within several weeks or months after the operation. The retreatment rate (secondary transurethral resection of the prostate) was 7.3%.Conclusions: From our preliminary data, it was evident that diode laser prostatectomy can achieve excellent hemostasis, and provide immediate relief from obstructive voiding symptoms. However, the postoperative irritative symptoms and sloughing of necrotic tissues remained to be an important issue that needed to be resolved.

Stem Cells: A Review and Implications for Urology

Richard N. Yu, Carlos R. Estrada — 2009-12-07

Objective: The promise of stem cells is to provide a source of non-diseased material for the generation of patient-specific cells or tissue for replacement and reconstruction. This review will provide a broad perspective on stem cell research, from the sentinel discoveries to recent developments, and also discuss translational implications.Methods: We performed internet-based Pubmed database searches to identify recent articles and review papers pertaining to stem cell research and urologic applications.Results: Depending on their source, stem cells have a varied capacity to self-renew and divide and to differentiate into a desired phenotype. Pluripotent stem cells can potentially be differentiated into any cell type and multipotent stem cells are variably lineage restricted. In the urologic literature, stem cell derived smooth muscles have been produced and may be useful for tissue-engineered constructs.Conclusions: The future of reconstructive surgery will surely incorporate a number of these stem cell based technologies in revolutionary ways that may improve and extend lives. However, the ultimate utility and clinical applicability of the different types of stem cells will depend on a complex synthesis of further basic research, future clinical trials, and ethical and regulatory reconcilement.

Editorial Comment

Anthony Atala — 2010-03-01

The authors presented an excellent overview of the stem cell field and its potential applications. The discovery of pluripotent stem cells, which are cells that can potentially become any tissue in the body and form teratomas, only dates back to 1981 with the discovery of mouse embryonic stem cells, and to 1998, with the description of human embryonic stem cells. Over the last decade, many alternate stem cell sources have been described. These recent advances, such as the creation of induced pluripotent stem cells from skin, or the more urologic-related spermatogonial cells isolated from the same patient, make it possible to obtain cells that will not be rejected when implanted into a patient. These cells have similar pluripotent ability as human embryonic stem cells, but they also have some of the same clinical limitations, the most relevant being that the cells tend to form tumors, such as teratomas and teratocarcinomas. Thus, the clinical use of pluripotent stem cells has stalled. As of this writing, only one human embryonic stem cell line has been given FDA clearance for a limited 10-patient experience. In comparison, adult multipotent stem cells, such as those derived from the bone marrow, can form cells from all of the embryonic germ layers that give rise to most tissues in the body, and they have been used in tens of thousands of patients in hundreds of clinical trials. Bone marrow stem cell use, especially for ectoderm and endoderm derivatives, is limited clinically because of the difficulties encountered in expanding these cells in large quantities. Other types of stem cells, such as those derived from amniotic fluid and placenta, do grow readily, doubling in number every 36 hours in a manner similar to human embryonic stem cells. However, they do not form tumors, because these cells are slightly more advanced in terms of their differentiation. Other cells with limited potential, such as hematopoietic cells or mesenchymal cells from fat, are further lineage restricted. Mesenchymal cells, for example, are restricted to differentiation into mostly fat, bone, and cartilage. Finally, organ-specific progenitor cells, such as urothelial cells are fairly unidirectional. A urothelial progenitor cell can only become a urothelial cell. What does all this mean clinically? There are many stem cell types and they all have their strengths and weaknesses. The cell choice for a therapy will largely depend on the indications and the patient's needs. Our preference is to first use organ-specific progenitor cells. They are autologous, will not reject, and they do not need to be manipulated to become another cell type. If the organ is not available for cell retrieval, like in an anephric patient, one can use other multipotent stem cells from the same patient which can be directed to become the desired cell type. For primary cells, such as liver, nerve, or pancreas, that still cannot be grown outside the body in large quantities, autologous stem cells are preferred, as one is able to avoid rejection. Furthermore, it is preferable not to use pluripotent stem cell populations that have the potential for tumor formation. If autologous stem cells such as those from the bone marrow or placenta cannot be used, then heterologous stem cells may be a viable choice. Physicians and scientists will play a major role in deciding what is best for specific treatments. The stem cell field is evolving rapidly. Today's preferences may be tomorrow's historical footnotes. Nonetheless, regardless of the cell technology used, patient safety remains the paramount goal.

Reply

Carlos R. Estrada — 2010-03-01

The stem cell field is indeed a rapidly evolving one, and as was written so succinctly in the accompanying editorial comment, we have myriad choices and possibilities. The degree of “stemness,” or the ability of a stem cell to become differentiated cells or tissue types, varies widely between the most plastic or pluripotent, the embryonic stem cell, and the most restricted or unipotent, the organ-specific progenitor cell. Although we agree that embryonic stem cells by definition form teratomas when implanted in vivo, they do so if implanted in their undifferentiated state. For many applications, the hope is that these powerful cells can be terminally differentiated before clinical use or can be “guided” to appropriate differentiation by in vivo signals. Admittedly, much work still needs to be done, and the recent change in the US political climate promises to further accelerate the already blinding pace of embryonic stem cell research and discovery. The previous federally mandated limitations on embryonic stem cell research had deeply stifled critically needed work, which partly may explain why the clinical use of pluripotent stem cells has “stalled.” In addition to their potential clinical use, embryonic stem cells provide an incredible in vitro model to study developmental biology, and relatedly hold promise in the treatment of single-gene–related diseases. This is not to say that we should bet everything on 1 horse. As was commented, exciting and promising work is ongoing, involving other pluripotent stem cells, namely the induced pluripotent stem cell and amniotic fluid-derived stem cells. Both of these hold much promise of their embryonic counterpart, but are devoid of the ethical and moral questions that will always surround the use of embryonic stem cells. Also like their embryonic stem cell counterpart, whether either of these cell types aberrantly differentiates into tumors in long-term clinical applications is unknown. Clearly, much work is still required in the arena of all pluripotent stem cells.

Comparison of Local Anesthetic Effects of Tramadol With Prilocaine During Circumcision Procedure

2009-10-26

Objectives: To compare the local anesthetic effects of tramadol hydrochloride with prilocaine for circumcision procedure.Methods: This study included 40 patients with American Surgical Association-I scores. Patients were randomly allocated to receive either 5% tramadol (2 mg/kg) plus adrenaline (0.0125/mL) (group 1, n = 20) or 2% prilocaine plus adrenaline (0.0125/mL) (group 2, n = 20). The degree of burning sensation and pain at the injection site were documented. Sensory block was assessed 1 minute after injection and the patients were asked to grade touch and pinprick sensation. Five minutes after drug administration, incision was performed and intensity of pain, felt by the patient was evaluated on a 4-point scale (0-3). Pain at the injection site and local skin reactions were also recorded.Results: Mean ages were 9.7 and 10.3 years for groups 1 and 2, respectively. Mean duration of surgery was 19.6 minutes. In control visit, 2 of 20 (10%) in group 1 and 10 of 20 (50%) children in group 2 reported extra need for oral ibuprofen (P .05). Total postoperative ibuprofen consumptions were 10 and 50 mg for groups 1 and 2, respectively (P <.05).Conclusions: A combination of tramadol 5% plus adrenaline can provide a safe and effective local anesthesia during circumcision procedure and postoperative period in children.

Editorial Comment

Christopher S. Cooper — 2010-03-01

The authors performed a well-designed, randomized, double-blinded study demonstrating decreased postoperative need for analgesia in 8- to 12-year-old boys after circumcision under local anesthesia with 5% tramadol (2 mg/kg) plus epinephrine, compared with those receiving prilocaine (1.5 mg/kg) plus epinephrine. The authors noted that a higher percentage of patients in the tramadol group required additional injections (45% vs 30%) for analgesia during the procedure. Although this difference did not reach statistical significance, the study is limited by the relatively small number of only 20 patients in each group. I would like to see the authors continue this study with a larger number of patients, so as to feel comfortable accepting that the immediate analgesic effect with tramadol is equivalent to prilocaine. Although the reduced postoperative analgesic requirement demonstrated is clinically relevant, I suspect most boys and men would consider the immediate intraoperative analgesic effect even more clinically relevant. Apart from this concern, the authors are to be congratulated for a well-designed study aimed at improving a commonly performed procedure. It is through efforts like these—efforts that examine and test the different variables involved in otherwise routine procedures—that our daily practice is advanced.

Reply

Eksal Kargi, Bulent Erol — 2010-03-01

Tramadol is an exceptional compound, which is produced as a racemic mixture composed of 2 isomers with a different spectrum of activity. It activates both opioid and nonopioid systems, which are mainly involved in the inhibition of pain. The effect of the nonopioid component of tramadol is mediated through α2-agonistic and serotoninergic cascades in the central nervous system by inhibiting the reuptake of norepinephrine and 5-hydroxytryptamine, respectively, and possibly by displacing stored 5-hydroxytryptamine from nerve endings. Recent studies have disclosed the local anesthetic action of tramadol. Altunkaya et al compared the local anesthetic efficacy of 5% tramadol with that of 2% prilocaine injected intradermally in the excision of the lesions of size < 1 cm. They obtained a local anesthetic effect with tramadol comparable to that of prilocaine for small lesions. In a double-blinded study by Kargi et al, 5% tramadol and epinephrine has local anesthetic effects similar to those of lidocaine and epinephrine when used in tendon repairs.

Biodegradable Mini Plate and Screw: A Secure Method for Internal Fixation of Symphysis Pubis in Animal Model of Pubic Diastasis

2009-12-04

Objectives: To investigate short-term results of symphysis pubis reapproximation in a simulated animal model of pubic diastasis using biodegradable plate and screw, in comparison with animals with no fixation, in terms of inflammatory reaction, histologic changes, and three-dimensional pelvic bone CT (3D-CT) scan.Methods: Fifteen male goats were divided in 3 groups and underwent midline pubic symphysiotomy. In GI (n = 6), the pubes were brought together with sutures through the bone and fixed by placing a biodegradable plate and screws. In GII (n = 3), symphysis was brought together by inserting sutures. Animals' pubes received no fixation in GIII (n = 6). Three-dimensional CT scan was performed, after 3 months in GII, and at the third and sixth months in GI and GIII. Furthermore, tissue-implant interface was examined for tissue reaction and implant degradation.Results: Pelvic bone 3D-CT scan in the biodegradable group revealed characteristic differences in pubic diastasis, iliac wing angle, and inter-triradiate distance compared with GII and GIII. Decreases of 21.8 ± 0.7 mm, 7.28 ± 0.4 mm, and 7.43 ± 1.5° were observed in pubic diastasis, inter-triradiate distance, and iliac wing angle, respectively, in biodegradable group in comparison with GIII in the sixth month. Neither clinical nor histologic evidence of inflammation due to insertion of biodegradable system was reported.Conclusions: Pubic bone adaptation with biodegradable plate and screws is a safe and reliable procedure for secure anterior pubic fixation in bladder exstrophy. Easy intraoperative handling, no long-term traction, biocompatibility, and no disturbance in skeletal growth are important prerequisites for introduction of this method of pubic approximation into clinical practice.

Editorial Comment

John P. Gearhart — 2010-03-01

This is a novel method of bringing the pubic bones into apposition without the use of a metal plate. However, it suffers from 2 issues that must be addressed, which the authors have explained in their discussion. First, the pubis diastasis on average is 4 cm in the newborn with exstrophy, but can be > 6 cm in those with a large template (just the ones that you really want to work) and not simply separation of the pubis as in the model. Second, regardless of whatever material is used to bring the bones into apposition and whether or not osteotomy is used with or without fixation, they all separate with time. Thus, although this short-term animal study is novel, it does not address why there is undergrowth of the pelvis in exstrophy and why they all regain their diastasis to some degree regardless of the materials used to join the pelvis. Thus, once our basic science studies find the reason for such a shortage of bone in the anterior pelvis, possibly stimulation of the bony pelvis with growth factors in utero would be advantageous. With this stimulation if the bony pelvis grew more in utero, the diastasis would be narrowed and a fixation system such as this one would allow firm anterior apposition without the need for pelvic osteotomy.

Editorial Comment

Richard Grady — 2010-03-01

The pubic reapproximation that occurs at the end of a primary closure for exstrophy is the Achilles heel of the operation. This is true regardless of the technique used. The authors examine the use of a biodegradable plate to secure the pubic symphyses. This adds another layer of security to the closure and the biodegradable nature of the plate reduces the risk of later erosion and eliminates the need to remove it later. The results from this large animal study look promising. However, because no reproducible animal model for exstrophy exists, the successful use of a biodegradable plate in children who are undergoing exstrophy repair may be an entirely different affair. The mechanical forces on the plate will certainly be different than in the goat model used here.

Editorial Comment

Paul D. Sponseller — 2010-03-01

Correction of the pelvic diastasis in exstrophy helps minimize the tension on the closure and restore the integrity of the pelvic floor. This is done via pelvic approximation with or without osteotomy. The diastasis repair is typically held with suture or metal. This article attempts to solve problems of long immobilization and late effects of implants. The authors create a model of exstrophy by resecting a segment of the pubis in immature goats. By 3 months after surgery, the controls had a 21-mm diastasis, whereas the repaired group had only 4 mm.

Reply

Abdol-Mohammad Kajbafzadeh, Azadeh Elmi — 2010-03-01

We have applied this method of approximation and internal fixation in pubic diastases as a biocompatible alternative to current metal fixation system with amenable imaging and tissue responses. This adds a layer of security to the pubic closure along with other current surgical armamentarium of bladder exstrophy. The key point was obtaining a persistent bony pelvis relationship restoration without inflammatory reaction and disturbance in bony growth. A reliable model was mandatory for this purpose. A major source of information concerning bladder exstrophy has come by the induction of an artificial exstrophy complex in animal models, or using naturally occurring classic bladder exstrophy in the animal population. Both techniques have considerable limitations for conducting a study to introduce new methods for anterior pelvic ring approximation; the high mortality in inducting the congenital anomaly in animals, and rarity of this birth defect, respectively. Additionally, such models are more useful in the assessment of embryologic development of exstrophy and proposing a possible role of mechanobiological stimulation of the bony pelvis in utero. In this regard, we used the symphysiotomy model. Considering the ongoing outward forces, on the separated pelvis, generated due to the quadric position of the animals, this model seems to be an acceptable representative of pubic diastasis in patients with bladder exstrophy. However, the rectangular shape of the pubis in goat may contribute to better fixation than human beings; our primary clinical results of biodegradable pubic fixation hold great promise.

A Report of an Iatrogenic Bladder Rupture in a Normal Healthy Child During Voiding Cystourethrography

Rose Khavari, Aaron P. Bayne, David R. Roth — 2009-08-31

Iatrogenic and spontaneous bladder disruption in healthy children during a voiding cystourethrography is very uncommon. We present a case of iatrogenic extraperitoneal bladder rupture in a healthy normal child during the filling phase of a voiding cystourethrography performed by a pediatric radiologist, using routine gravity technique. This injury completely healed after 48 hours of catheter drainage with observation and was confirmed with a normal voiding cystourethrogram. The patient's underlying disease, age, proper catheter placement, and appropriate speed and volume of the contrast instilled are important factors to prevent this very uncommon event in this very common radiologic test.

Cystic Dysplasia of the Rete Testis: A Case of Spontaneous Regression and Review of Published Reports

Ram Jeyaratnam, Daniela Bakalinova — 2009-08-05

Cystic dysplasia of the rete testis (CDT) is a rare benign testicular tumor. We present the second case of spontaneous regression in a 9-year-old boy and summarize the findings of 48 cases in published reports. The most common presentation is scrotal and/or testicular swelling. Common associated renal tract anomalies include ipsilateral renal agenesis and multicystic dysplastic kidney. In 13% of patients, no associated renal anomalies were observed. Orchidectomy was performed in 65% of patients (n = 31) and testicular-sparing surgery, that is, enucleation in 15% (n = 8). In 5 of these 8 patients, recurrence was noted. In a further 12% of patients (n = 5), cystic dysplasia of the rete testis was treated with surveillance. At present, there is no clear consensus on treatment. The conservative approach of “watch and wait” may be supported by this case of spontaneous regression.

Transpubic Urethroplasty Revisited: Total, Superior, or Inferior Pubectomy?

Mamdouh M. Koraitim — 2009-12-04

Objectives: To describe research base pertaining to transpubic urethral surgery and present our experience with this approach to repair pelvic fracture urethral defects.Methods: A total of 64 patients, 5-40 years old, underwent repair of a pelvic fracture urethral defect via the partial transpubic approach between 1979 and 2008. The length of urethral gap varied from 2.5 to 8 cm (mean, 4.2 cm). A wedge-shaped piece of bone was subperiosteally resected from the medial portions of the pubic bones by an osteotome. The mobilized bulbar urethra was passed up through the subpubic tunnel or rerouted around the left penile crus to be anastomosed to the prostatic apex inside the pelvis. The site of anastomosis was wrapped by an omental pedicle. Follow-up ranged from 1 to 24 years.Results: The results were successful in 63 (98.4%) patients. None of the patients experienced abnormal gait or pelvic girdle pain. Apart from 2 patients who developed stone bladder 6 and 14 years after surgery, no postoperative complications were encountered. Impotence as a direct result of transpubic surgery occurred in 2 patients.Conclusions: Partial transpubic approach provides an excellent exposure that greatly facilitates the creation of an undervision tension-free and scar-free bulboprostatic urethral anastomosis. It is the only way to go for complex cases associated with intra-abdominal pathologic conditions. For a long-gap posterior urethral distraction defect the excellent results of both the partial transpubic and elaborated perineal procedures compete rather than contradict each other for the best welfare of the patient.

A Randomized Prospective Trial of Primary Versus AlloDerm Closure of Buccal Mucosal Graft Harvest Site for Substitution Urethroplasty

Joseph E. Jamal, Daniel S. Kellner, John A. Fracchia, Noel A. Armenakas — 2009-12-04

Objectives: To present a prospective, randomized trial comparing primary and AlloDerm closure of the oral harvest site. The use of buccal mucosa grafts for substitution urethroplasty is an established and durable technique. The optimal management of the buccal mucosa grafts harvest site for the intraoral defect has yet to be determined.Methods: Between February 2003 and September 2006, a total of 20 men undergoing buccal mucosal urethroplasty were randomly assigned to either primary (n = 10) or AlloDerm closure (n = 10) of the oral harvest site. All patients were clinically examined postoperatively and each completed a 10-point analog pain score and descriptive questionnaire postoperatively, at 3 weeks, and at 3, 6, and 12 months.Results: A 100% of patients completed the study at 12 months follow-up. Oral pain dissipated acutely after 3 weeks. No significant differences in either neurosensory or mouth tightness symptoms were noted, except increased incidence of cheek swelling at 3 weeks in the AlloDerm group.Conclusions: AlloDerm proved to be an effective means of closing the harvest site, but offered no significant advantages when compared with primary closure. AlloDerm closure was associated with increased morbidity in mouth tightness symptoms, cheek swelling, and discomfort while chewing food; only increased incidence of cheek swelling at 3 weeks was found to be significant. Despite its excellent molecular properties and nonimmunogenic nature, the role of AlloDerm graft use in closing the buccal mucosal harvest site appears to be an unnecessary step. Primary closure was extremely well tolerated in both short- and long-term follow-up, with minimal sequelae at 12 months.

Modified Suprapubic Prostatectomy Without Irrigation Is Safe

Chukwudi O. Okorie, Martin Salia, Ping Liu, Louis L. Pisters — 2009-11-16

Objectives: To determine whether postoperative bladder irrigation can be safely eliminated in the context of a modification to surgical technique. Post-operative irrigation is routinely used following suprapubic prostatectomy for benign prostatic hyperplasia (BPH).Methods: Single center retrospective study of 82 patients who underwent suprapubic prostatectomy for BPH comparing complications in those treated with irrigation to patients treated with surgical modification and no irrigation. These consecutive patients were divided into 2 groups: group 1 consisted of 43 patients who underwent suprapubic prostatectomy before June 2006 with post operative bladder irrigation and standard method of surgical hemostasis. Group 2 consisted of 39 patients who underwent suprapubic prostatectomy after June 2006 with no post operative irrigation and a modified bladder neck repair performed with the intent of improving hemostasis. The modified bladder neck repair is described.Results: Patient characteristics and prostate specimen weights are comparable in both groups. Clot retention was more common in the group 1 patients (11 patients in group 1 vs 2 patients in group 2, P = .01), and 2 patients with disruption of the anterior bladder wall closure were in group 1.Conclusions: Suprapubic prostatectomy can be safely performed without the use of postoperative irrigation. The elimination of postoperative irrigation significantly reduces the economic burden on patients in our locality.

Editorial Comment

Peter J. Gilling — 2010-03-01

A technique that enables suprapubic prostatectomy to be consistently performed without the need for postoperative irrigation is a worthy goal. Although this procedure comprises only 4.6% of inpatient BPH procedures done in the United States (2000 data), it remains an important technique in many other countries (18% of cases in a recent Japanese series) and particularly in the developing world. The fact that only 1 (1.2%) patient overall in the current series received a blood transfusion is commendable and is considerably less than the 12.7% seen in a very large contemporary series however, the availability of blood products and the criteria for their administration were not stated. Transfusion rates as high as 36% and as low as 2.3% have been reported in the past. The fact that so many technical modifications have been proposed over the years and the large variation in reported rates of transfusion is testimony to the uncertain nature of hemostasis with open simple prostatectomy.

Reply

Chukwudi O. Okorie, Martin Salia, Ping Liu, Louis L. Pisters — 2010-03-01

Suprapubic prostatectomy is the tested and most widely accepted option of surgery for men with large-volume benign prostate hyperplasia (BPH) and against which newer alternatives need to be compared. The morbidity and mortality associated with open suprapubic prostatectomy has generally decreased over the years, yet morbid events are still commonly reportedly. Significant and often excessive hemorrhage is the most immediate and serious problem of suprapubic prostatectomy. With regard to surgical technique, our study suggests that tapering the bladder neck to index finger size and oversewing of the mucosal edge may be important for hemostasis. Ensuring adequate hemostatic control lowers morbidity and reduces the need for blood transfusion. Blood transfusion in general is highly undesirable in our environment that is presently burdened with high rates of HIV infection. Our treatment center has a blood bank, though supply can occasionally be erratic. The only patient who had blood transfusion in our study is an 82-year-old man who had clot retention and is presently in the control group of patients managed with standard postoperative irrigation. This patient needed transfusion for symptomatic anemia. It is encouraging to know that no patient needed blood transfusion in the group of patients who were managed with our new surgical modification.

Renal Masses Herniating Into the Hilum: Technical Considerations of the “Ball-valve Phenomenon” During Nephron-sparing Surgery

Brett Lebed, Shraddha D. Jani, Alexander Kutikov, Kevan Iffrig, Robert G. Uzzo — 2009-10-26

Objectives: To describe our technique to recognize and resect renal tumors “ball-valving” into the sinus. Partial nephrectomy (PN) offers a functional advantage over radical nephrectomy for many cases of localized renal cell carcinoma. However, PN is underutilized particularly in anatomically challenging cases. Often unrecognized is the tendency for central renal tumors to herniate into the renal sinus.Methods: From our prospective kidney cancer database, we identified 36 patients who underwent open, laparoscopic, or robotic PN for solitary localized renal cell carcinoma herniating into the renal sinus.Results: Axial and reformatted radiographs were reviewed for all renal hilar lesions. Intraoperative techniques include hilar dissection, establishment of a sinus plane allowing tumor and parenchymal retraction, reduction of the tumor out of the sinus, resection, and repair. Mean preoperative lesion size was 3.8 cm. Indications for PN included 15 of 36 (42%) absolute, 13 of 36 (36%) relative, and 2 of 36 (6%) reoperative PN. No procedure was converted to radical nephrectomy. Of the 36 PN, 5 (14%) were performed using a minimally invasive approach and no minimally invasive surgery procedures were converted to open. No patient required renal replacement.Conclusions: Recognition of the tendency for hilar masses to herniate or “ball-valve” into the renal sinus is essential for effective PN of central tumors. By using our technique, we have demonstrated success in nephron-sparing surgery with minimal intraoperative complications and favorable postoperative outcomes in patients with central tumors herniating into the renal sinus.

Editorial Comment

Paul Russo — 2010-03-01

Accumulating evidence regarding the best surgical management of small renal masses clearly favors partial nephrectomy for the following 3 major reasons: (1) Oncologic equivalence with radical nephrectomy for T1 tumors is 7 cm or less, (2) A high percentage (a maximum of 45%) of small renal tumors are either benign (oncocytoma, metanephric adenoma, fat poor angiomyolipoma), of low grade, or of low metastatic potential (papillary type 1, chromophobe), (3) Radical nephrectomy has been associated with an increased likelihood of developing chronic kidney disease (CKD), cardiovascular morbidity, and worse overall survival; yet, despite this information, partial nephrectomy remains grossly underutilized for T1a (< 4 cm) tumors in the United States (< 20%) and its widespread application (> 90%) restricted to referral centers with large surgical volumes and an academic commitment to renal preservation.

Reply

Alexander Kutikov, Robert Uzzo — 2010-03-01

Although partial nephrectomy is an established standard for the treatment of localized RCC, it remains largely underutilized. In a recent review of the NCDB, researchers noted that only 27% of > 92 000 patients with clinical T1 disease underwent nephron-sparing approaches in 2005. Moreover, the lure of laparoscopy and its more routine use in radical nephrectomy at times “justifies” overutilization of nephron-wasting techniques despite the recognized implications on GFR and of chronic kidney disease.

A Novel Technique to Prevent Postradical Retropubic Prostatectomy Inguinal Hernia: The Processus Vaginalis Transection Method

2009-11-25

Objectives: To present a novel technique to prevent inguinal hernias after radical retropubic prostatectomy (RRP). The incidence of inguinal hernia after RRP has been reported to occur in the range 12%-21%. Indirect hernias are more common than direct hernias after RRP.Methods: A total of 569 Japanese patients with prostate cancer underwent antegrade RRP between January 2001 and February 2007. Since February 2006, 138 patients underwent procedures for concurrent inguinal hernia prevention at the time of RRP. For hernia prevention, the processus vaginalis was ligated close to the peritoneal cavity and transected. The remaining 431 patients who underwent the same RRP procedures without hernia prevention were considered control group. The incidence rates of postoperative inguinal hernia in the 2 groups were statistically compared.Results: An inguinal hernia developed postoperatively in 105 (24%) of the 431 control patients during follow-up of median 42 months. Hernia-free survival rates were 87%, 81%, and 77%, for 1-, 2-, and 3-year, respectively. By contrast, 2 of the 138 patients (1.4%) who underwent hernia prevention developed an inguinal hernia during follow-up of median 24 months. Hernia-free survival rates were both 99% for 1- and 2-year (P <.0001). The hernia prevention procedure added approximately 10 minutes to the surgery time. There were no significant complications associated with the hernia prevention procedure.Conclusions: Our results suggest that this prophylactic measure is safe and effective to prevent post-RRP inguinal hernias. However, a longer follow-up period is needed to confirm the results.

Myoblasts Differentiated From Adipose-derived Stem Cells to Treat Stress Urinary Incontinence

Qiang Fu, Xiao-Fei Song, Guo-Long Liao, Chen-Liang Deng, Lei Cui — 2009-12-07

Objectives: To investigate the application of adipose-derived stem cell (ADSC) technology in the treatment of stress incontinence.Methods: The vaginal balloon dilatation method was used to establish an animal model of stress incontinence (in 20 female Sprague–Dawley rats), which was further examined by urodynamics and histology. Endogenous rat ADSCs were collected and induced into myoblasts with 5-Aza induction technology in vitro. The identity of myoblasts was confirmed through immunofluorescence labeling with desmin and myosin. Induced cells were injected into the posterior urethral muscularis in the bladder neck of animals with stress incontinence. The effects were examined after 1 and 3 months by urodynamics and histology. Untreated ADSCs were also implanted as a method of control.Results: Both maximal bladder capacity and leak point pressure significantly increased after 1 and 3 months postimplantation, compared with the control (P <.05). Increased thickness of inferior muscularis in urethral mucosa and a greater number of large longitudinal muscle bundles were observed. Increased numbers of myoblasts appeared under the mucosa, as demonstrated by the immunochemistry analysis of α-smooth actin.Conclusions: ADSCs have the ability of differentiating into multiple lineages, including myoblasts. This ability to induce myoblasts can be used to treat stress incontinence, with the advantages of minimal invasion and faster recovery.

Telomere DNA Content in Prostate Biopsies Predicts Early Rise in Prostate-specific Antigen After Radical Prostatectomy for Prostate Cancer

2009-07-16

Objective: To determine whether measurement of telomere DNA content (TC) in prostate biopsy tissue predicts prostrate-specific antigen (PSA) recurrence in men after undergoing radical prostatectomy for prostate cancer.Methods: Slot blot titration assay was used to quantitate TC in archived diagnostic prostate needle biopsy specimens for subjects (n = 103) diagnosed with prostate cancer and who subsequently underwent radical prostatectomy between 1993 and 1997. TC was compared to the clinical outcome measure; PSA recurrence, defined as an increase in PSA ≥ 0.2 ng/mL on 2 or more consecutive measurements post-prostatectomy, was observed retrospectively, for a mean follow-up period of 114 months (range, 1-165).Results: In the cohort, 46 subjects had a PSA recurrence. In a univariate Cox proportional hazards model, low TC (<0.3 of standard) demonstrated a significant risk for PSA recurrence (HR = 1.94; 95% CI: 1.02-3.69, P = .04). In a subset analysis of men with biopsy Gleason sum ≤ 6 (n = 63; 25 recurrences), a univariate Cox proportional hazards model demonstrated that low TC had a greater risk of PSA recurrence (HR = 4.53; 95% CI: 2.00-10.2, P < .01). In a multivariate Cox proportional hazards model, low TC was also significantly associated with PSA recurrence in this subset after controlling for preoperative PSA levels (HR = 6.62; 95% CI: 2.69-16.3, P < .01).Conclusions: Low TC measured in prostate biopsy tissue predicts early likelihood of post-prostatectomy PSA recurrence in a retrospective analysis, and in men with biopsy Gleason sum ≤ 6 disease it is also independent of preoperative PSA level.

The Effects of Sacral Acupuncture on Acetic Acid-induced Bladder Irritation in Conscious Rats

Kokoro Hino, Hisashi Honjo, Masahiro Nakao, Hiroshi Kitakoji — 2009-07-09

Objectives: To investigate the effects of sacral acupuncture on acetic acid–induced bladder irritation using cystometry in conscious rats, with particular focus on effects on afferent fibers of the bladder.Methods: A total of 40 female Sprague-Dawley rats weighing 200-270 g were used. The animals were divided into 5 groups: (1) rats with bladder overactivity induced by acetic acid, without sacral acupuncture stimulation (irritated bladder group); (2) rats treated with sacral acupuncture stimulation after induction of bladder overactivity by acetic acid (acupuncture stimulation group); (3) rats treated with sacral acupuncture stimulation after capsaicin desensitization (capsaicin-desensitized group); (4) rats treated with atropine (atropine injection group); and (5) rats treated with sacral acupuncture stimulation after nonacetic acid infusion (nonirritated bladder group). Cystometry was carried out without anesthesia, and the following variables were measured in all animals: intercontraction interval (ICI), basal pressure, threshold pressure, and micturition pressure.Results: In the acupuncture stimulation group, sacral acupuncture stimulation resulted in a 140.1 ± 5.9% increase in ICI after acetic acid–induced irritation to an interval similar to baseline (P = .072). A significant difference in the percent of ICI increase was observed between the acupuncture stimulation and irritated bladder groups (P < .01). In the capsaicin-desensitized groups and acupuncture stimulation groups, no significant differences in ICI occurred, before and after acupuncture.Conclusions: Sacral acupuncture could contribute to improve acetic acid–induced bladder irritation through inhibition of capsaicin-sensitive C-fiber activation.

Capsaicin Mediates Cell Death in Bladder Cancer T24 Cells Through Reactive Oxygen Species Production and Mitochondrial Depolarization

2009-07-09

Objectives: To investigate the effects of capsaicin (CAP) on proliferation of bladder cancer T24 cells in vitro as well as on xenografts in nude mice in vivo.Methods: T24 cells were assessed for cell viability and apoptosis by 3-(4, 5-dimethylthiazol-2-yl)-3, 5-diphenyltetrazolium bromide assay and flow cytometry analysis after incubation with different concentrations of CAP. To uncover the mechanism by which CAP affected the viability of T24 cells, intracellular production of reactive oxygen species (ROS) and mitochondrial membrane potential were assessed. To study the in vivo effects of CAP, T24 cells were grown as xenografts in nude mice and CAP (5 mg/kg by wt) was subcutaneously injected into nude mice with bladder tumors.Results: CAP decreased the viability of T24 cells in a dose-dependent manner without marked apoptosis. CAP induced ROS production and mitochondrial membrane depolarization, thereby inducing cell death, not apoptosis, in T24 cells at a concentration of 100 μm or higher. Furthermore, these effects of CAP could be reversed by capsazepine, the antagonist of transient receptor potential vanilloid type 1 channel. In vivo experiment showed that CAP significantly slowed the growth of T24 bladder cancer xenografts as measured by size (661.80 ± 62.03 vs 567.02 ± 43.94 mm3; P <.01).Conclusions: CAP mediates cell death in T24 cells through calcium entry-dependent ROS production and mitochondrial depolarization, and it may have a role in the management of bladder cancer.

Gene Expression Profiling and Pathway Analysis of Superficial Bladder Cancer in Rats

2009-08-03

Objectives: To reveal the gene expression profile and pathways involved in host-tumor interactions in a rat orthotopic syngeneic bladder cancer model.Methods: Rat bladder cancer cells (AY-27 cell line) were inoculated intravesically into female Fischer rats. The bladders were analyzed at 7, 14, and 28 days by histologic examination and at 14 days with Affymetrix GeneChip with a newly developed bioinformatics program for the Kyoto Encyclopedia of Genes and Genomes (KEGG).Results: The cancer had developed into Stage Ta and carcinoma in situ (Tis) after 7 days, Stage T1 after 14 days, and Stage T3 after 28 days in the bladder. At 14 days, >4000 genes were found to be differentially expressed and 20 KEGG pathways were actively involved in the bladder. The molecular pathway for (human) bladder cancer development was activated, and, at the same time, pathways in connection with the host immune responses were altered, including antigen processing and presentation, the T-cell receptor signaling pathway, natural killer cell-mediated cytotoxicity, the Toll-like receptor signaling pathway, and the B-cell receptor signaling pathway. Moreover, the cell adhesion molecules associated with the immune system were upregulated, but those associated with the neural system were downregulated.Conclusions: The bladder cancer developed aggressively despite active host immune responses. Conceivably, the cancer immunoediting process is associated with the progression of bladder cancer in this model.

Douglas M. Dewire — 2009-12-17

This well-written and informative update details breaking news and controversies in reproductive medicine. Leading authorities in the fields of reproductive endocrinology, embryology, andrology, reproductive biology, and urology are among the contributors. The authors' vision is to “provide an ongoing appraisal of current knowledge, and to foster communication and collaboration among all those working to help couples resolve their infertility (Preface, vii).” Toward accomplishment of this goal, the book is written by reproductive endocrinologists and urologists bearing male infertility squarely in mind.

Re: Branney et al.: Choosing Health, Choosing Treatment: Patient Choice After Diagnosis of Localized Prostate Cancer (Urology 2009;74:968–971)

Ceri Evans, Rhys Dawe, Andrew Carson-Stevens — 2010-03-01

We read with interest the article “Choosing Health, Choosing Treatment: Patient Choice After Diagnosis of Localized Prostate Cancer.” This raises many important issues, but three resonate within the modern day climate of health reform and focus on quality of care and service delivery. First, an aging population means that an increase in prostate cancer incidence is inevitable. Second, patient choice continues to climb up the healthcare policy agenda on both sides of the Atlantic. Third, prostate cancer treatment options could perhaps be considered as extremes: ranging from no treatment to major therapy with many side effects. As a consequence, such issues deem it important that patients are correctly informed of all treatment options before they are commenced.

Reply by the Authors

Peter Branney, Chris Hiley — 2010-03-01

Mr. Carson makes several important and pithy points with which we agree. However, there is 1 overarching point that we read into his response to our article “Choosing Health, Choosing Treatment: Patient Choice After Diagnosis of Localized Prostate Cancer,” that how health services are to support patients in making choices is still to be decided and is therefore an important point of discussion. To continue this discussion, we want to follow-up Carson's comment about the role of nurses in supporting patient choice and his suggestion about including clinical epidemiologists in multidisciplinary teams (MDTs).

Re: Hajj et al. Prevalence of Renal Cell Carcinoma in Patients with Autosomal Dominant Polycystic Kidney Disease and Chronic Renal Failure (Urology 2010;74:631-634)

Stuart M. Flechner — 2010-03-01

Patients with end-stage renal disease (ESRD) have abnormal kidneys that exhibit a greater propensity to form renal tumors. This creates an additional burden for ESRD patients, namely, the need to screen and follow them up as a high-risk group for kidney cancer. Simply removing all these kidneys during diagnosis of ESRD would solve this dilemma, but it is neither practical nor in the best interest of these patients. Retained native kidneys have definitive metabolic advantage. If producing urine, they can help remove harmful electrolytes such as potassium and prevent acidemia. Intrinsic renal erythropoietin and vitamin D3 also have beneficial physiological effects. The authors highlight the increased incidence of renal cancer in kidneys with adult polycystic kidney disease (ADPKD) by reporting their experience over a 20-year interval. They retrospectively analyzed the surgically removed ADPKD kidneys during this interval, and found 11 cancers among 89 kidneys. In 5 cases, a solid renal mass was the primary indication for nephrectomy. Although this number is several times that expected in the general population, one should remember that this group was selected from kidneys that were enlarging and causing symptoms. Nevertheless, all these tumors were pT1a, Fuhrman grade 1 to 2, with a mean diameter of 1.8 cm. The likelihood that these tumors would be lethal, or cause significant morbidity in the life of the ESRD patient is speculative. Therefore, noninvasive screening of ADPKD patients seems warranted, but caution should be used when considering nephrectomy for this indication alone.

Erratum

2010-03-01

The Letter to the Editor “Re: Sarma et al.: Risk Factors for Urinary Incontinence Among Women With Type 1 Diabetes: Findings From the Epidemiology of Diabetes Interventions and Complications Study (Urology 2009;73:1203-1209)” was printed with the authors listed in incorrect order. The correct order of the authors' names is F. Araco, R. Alvaro, G. Gravante, R. Sorge, G. Venturini, and E. Piccione.