Urology

Robotic Single-site Kidney Surgery: Evaluation of Second-generation Instruments in a Cadaver Model

2012-03-26

Objective: To evaluate the second generation of single-site instruments for robotic laparoendoscopic single-site surgery (R-LESS) for kidney procedures in a cadaver model. Methods: Three procedures, including 1 pyeloplasty, 1 partial nephrectomy, and 1 nephrectomy, were conducted in a female cadaver model. A da Vinci Si system (Intuitive Surgical, Sunnyvale, CA) and the second generation of single-site instruments, specifically designed for R-LESS, were used. Results: All the procedures were completed successfully without the addition of extra ports. Time to set up the port and instruments was 40 minutes. In the pyeloplasty, time to complete the anastomosis was 39 minutes. In the partial nephrectomy, simulated ischemia time was 21 minutes. In the nephrectomy, time to complete the resection was 13 minutes. No significant gas leak was noticed during the procedures. There were no injuries to intraabdominal organs or vessels. Conclusion: Robotic single-site renal surgery using a second generation of specifically designed instruments was feasible in a cadaver model, obviating many limitations of LESS. Lack of articulation at the tip of the instruments represents the main disadvantage of this novel instrumentation, especially in case of reconstructive procedures.

The Management of Bladder Lithiasis in the Modern Era of Endourology

2011-11-25

The recent evolution in the management of vesical lithiasis is a result of the major advancements of modern endourology. The ideal method for achieving stone clearance, however, remains an issue of debate and evidence-based recommendations are lacking. Contemporary literature focuses on management options, such as extracorporeal shockwave lithotripsy, transurethral, percutaneous and minimally-invasive surgery, as well as state-of-the-art energy sources. Issues of particular interest include the results of comparative studies, the management of lithiasis in the paediatric population and the recent challenge of the traditional dogma that dictated BPH surgery for the management of vesical lithiasis secondary to bladder outlet obstruction.

Capillary Hemangioma Masquerading as a Renal Artery Pseudoaneurysm

Evalynn Vasquez, Bernadette Aulivola, Maria Picken, John Milner — 2012-02-20

A 62-year-old woman with history of type 1 diabetes mellitus presented to the emergency department with intractable nausea and vomiting. On further evaluation, the patient was noted to have a history of a remote fall from standing caused by loss of balance. She was otherwise asymptomatic and had no genitourinary complaints. She was hemodynamically stable, and her physical examination was within normal limits. Her laboratory evaluation was normal, including a serum creatinine of 1.1 mg/dL and a normal urinalysis. A computed tomography (CT) scan was performed and showed a 1-cm hyperdense lesion identified in the area of the left renal hilum with decreased attenuation centrally (). Urological and vascular surgical consultations were obtained. A decision was made between both services to survey the lesion with a repeat CT scan at 6 months; this showed interval growth of the mass to 1.5 cm. An arteriogram was performed by vascular surgery to further delineate the lesion, which showed evidence of a patent superior renal artery and what was felt to be a thrombosed renal aneurysm vs pseudoaneurysm. A decision was made to continue to manage the patient conservatively with interval imaging. The lesion continued to grow on follow-up imaging over the next 18 months (). A decision was made to perform covered stent grafting of the left superior renal artery with the objective to exclude the presumed pseudoaneurysm and prevent further expansion. The procedure was performed by the vascular surgery service without complication. However, follow-up CT angiogram demonstrated further growth to 2.5 × 2.2 cm and continued perfusion of the lesion (). Because the mass continued to grow and etiology was unclear, surgical excision was advised.

Long-term Outcomes of Percutaneous Nephrolithotomy in Patients With Chronic Kidney Disease: A Single-center Experience

2012-02-06

Objective: To present our long-term follow-up data from patients with kidney stones and chronic kidney disease to identify the factors that could help predict the likelihood of long-term deterioration in renal function. Methods: From January 2002 to July 2010, we performed 1117 percutaneous nephrolithotomy (PNL) procedures in 1051 patients. We retrospectively analyzed 69 PNL procedures for 67 patients (47 men and 20 women) in whom the estimated glomerular filtration rate (eGFR) was <60 mL/min/1.73 m2. Two outcomes were measured. The percentage of change in the eGFR was measured comparing the preoperative and postoperative values. A 5% change in renal function was arbitrarily chosen to divide the population into 3 groups: group 1, an eGFR change of ≤5%; group 2, an eGFR increase of >5%; and group 3, an eGFR decrease of <5%. The second outcome measure was the presence of chronic kidney disease progressing in the first and consecutive years. Results: The mean patient age was 57 ± 14.1 years. The complication rate was 23.1% using the Clavien classification. The mean follow-up time was 45.7 ± 17.08 months. The mean eGFR before and after PNL was 37.9 ± 14.05 and 45.1 ± 16.8, respectively. Diabetes mellitus (odds ratio 15.82, P = .036) and urinary infection (odds ratio 10.6, P = .04) were predictive of renal function deterioration at 1 year on multivariate analysis. Conclusion: PNL in patients with chronic kidney disease is safe and results in renal function preservation for a 5-year period. Diabetes mellitus and urinary infection were independent predictive of renal function impairment. Therefore, patients with diabetes mellitus and urinary tract infection should be followed up carefully and informed about hazardous potential of those diseases.

Editorial Comment

Boris Gershman, Brian H. Eisner — 2012-02-06

This study presents a retrospective analysis of the changes in renal function after percutaneous nephrolithotomy (PCNL) performed at a large-volume facility in patients with pre-existing renal impairment. The authors observed a significant increase in Modification of Diet in Renal Disease-estimated glomerular filtration rate (GFR) for up to a 3-year period after surgery compared with the perioperative values. Perhaps the more important observation is the absence of renal deterioration after PCNL in patients with compromised renal function. The GFR appears to have remained stable for 1-5 years after surgery, even in this patient cohort with moderate-to-severe pre-existing chronic kidney disease (CKD) and risk factors for additional decline (eg, hypertension, recurrent infection). This is an important observation, because it suggests PCNL itself does not appear to increase the risk of renal deterioration in the intermediate term.

Factors Influencing Urologist Treatment Preference in Surgical Management of Stone Disease

M. Adam Childs, Laureano J. Rangel, James E. Lingeman, Amy E. Krambeck — 2012-01-13

Objective: To assess the surgeon factors influencing the surgical treatment decisions for symptomatic stone disease. The factors influencing the selection of shock wave lithotripsy (SWL), ureteroscopy, or percutaneous nephrolithotomy to treat symptomatic stone disease are not well studied. Methods: Electronic surveys were sent to urologists with American Medical Association membership. Information on training, practice, and ideal treatment of common stone scenarios was obtained and statistically analyzed. Results: In November 2009, 600 surveys were sent and 180 were completed. High-volume SWL practices (>100 cases annually) were more common in community practice (P < .01), and high-volume ureteroscopy and percutaneous nephrolithotomy practices were more common in academic practice (P = .03). Community practice was associated with SWL selection for proximal urolithiasis and upper pole nephrolithiasis (P < .005). An increasing time since urologic training was associated with SWL selection for proximal urolithiasis and upper pole nephrolithiasis (P < .01). Urologists reporting shock wave lithotriptor ownership were 3-4 times more likely to select SWL for urolithiasis or nephrolithiasis compared with urologists who did not own a lithotripter (P < .01). Routine concern for stent pain and rigid ureteroscope preference (vs flexible) were associated with SWL selection (P < .03). Conclusion: Surgeon factors significantly affected urolithiasis treatment selection. SWL was associated with community urology practice, increasing time since training, shock wave lithotriptor ownership, concern for stent pain, and ureteroscope preference.

Non-contrast Computed Tomography After Percutaneous Nephrolithotomy: Findings and Clinical Significance

2012-02-06

Objective: To describe the post-percutaneous nephrolithotomy (PNL) non–contrast-enhanced computed tomography (NCCT) findings and assessed their clinical significance. NCCT evaluates stone clearance after PNL and also reveals procedure-related changes. Methods: One hundred consecutive patients who underwent PNL were evaluated by NCCT one day post-procedure. Two radiologists analyzed the type and severity of the NCCT findings, which were then statistically analyzed in relation to the patient's clinical course. Results: The patients' mean age was 54 years (range 18–82) and the mean maximal stone diameter was 37 mm (range 15–70). The median operative time was 110 minutes for an immediate stone-free rate of 83%, changing to 94% (P = .073) after a second-look PNL in 11 patients. The post-PNL NCCT findings were hydronephrosis (70%), atelectasis (54%), ipsilateral pleural effusion (52%), paracolic gutter fluid (44%), perinephric hematoma (40%), perinephric fluid (32%), ureteronephrosis (31%), renal swelling (23%), contralateral pleural effusion (22%), residual fragments (RFs) (17%), subcapsular hematoma (10%), and flank hematoma (6%). Univariate analysis revealed a significant association with clinical variables for all NCCT findings except for atelectasis, ureteronephrosis, contralateral pleural effusion, RFs, and flank hematoma. In multivariate analysis, only perinephric fluid (P = .007) and ipsilateral pleural effusion (P = .034) were associated with longer hospitalization, and perinephric fluid with longer recovery (P = .004). The complication rate was 12%, but none were linked with the radiological findings. Conclusion: This work describes the post-PNL NCCT findings and their clinical significance. Perinephric fluid and ipsilateral pleural effusion were found to independently predict longer hospitalization and recovery time.

The Effect of Extralumenal Safety Wires on Ureteral Injury and Insertion Force of Ureteral Access Sheaths: Evaluation Using an Ex Vivo Porcine Model

2012-01-13

Objective: To evaluate the effect that a safety wire (SW) had on insertion force and direct ureteral trauma using ureteral access sheaths (UAS) in an ex vivo porcine model. Material and Methods: UASs were advance into 20 fresh ex vivo porcine kidney-ureters, either with or without SWs. The average and max force of insertion were recorded. Retrograde saline injection was used to identify the presence of lacerations. Results: For SW vs no SW, the mean insertion force (1.79 vs 0.67, P = .0003, respectively) and max insertion force (2.29 kg vs 1.00, P = .0007) was greater in the SW group. There were 9 lacerations, 6 of which were partial and 3 complete. Of the partial injuries, 2 were in the no SW group and 4 were in the SW group. Of the complete lacerations, 2 occurred in the no SW group and 1 in the SW group. However, there was no significant difference in the total number of lacerations (P = 1.00), the number of partial lacerations (P = .628), or the number of complete lacerations (P = 1.00) between the 2 groups. Conclusions: The use of an SW significantly increases the force required to insert a UAS; however, it does not appear to affect the force or the degree of ureteral injury.

Safety and Efficacy of Ultrasound-guided Percutaneous Nephrolithotomy for Treatment of Urinary Stone Disease in Children

2011-12-23

Objective: To present the feasibility and efficacy of ultrasound-guided percutaneous nephrolithotomy for the treatment of urinary stone disease in children. Methods: The medical records and files of 17 patients with renal stones (17 renal units) who were aged ≤16 years who had undergone ultrasound-guided percutaneous nephrolithotomy from 2008 to 2010 were retrospectively reviewed and analyzed. Ultrasonography was used for guidance in all patients in every step of the procedure. Fluoroscopy was used to aid in tract dilation in the initial cases of the series and to evaluate for stone clearance in all cases. The operative and postoperative findings were assessed. Results: The average age of the patients was 8.8 ± 2.86 years (range 5-15). The mean stone size was calculated as 337.4 ± 52.9 mm2 (range 260-446). The mean operative time was 67.9 ± 14.58 minutes (range 45-95). Fever, urine leakage, and bleeding requiring blood transfusion were observed in 3, 1, and 1 patient, respectively. The fluoroscopic screening time was limited to 17.76 ± 15.5 seconds (range 1-54). Neighboring organ injuries were not observed. The overall success rate improved from 82.35% to 100% with additional treatment modalities (shock wave lithotripsy in 2 and ureteroscopy in 1). Conclusion: Percutaneous nephrolithotomy can be safely performed with ultrasound guidance in children, providing the advantages of less radiation exposure, no adjacent organ injury, and similar success and complication rates compared with fluoroscopic guidance.

Sacrospinous Ligaments Anterior Apical Anchoring for Needle-guided Mesh is a Safe Option: A Cadaveric Study

Menahem Neuman, Jaromir Masata, Petr Hubka, Jacob Bornstein, Alois Martan — 2012-05-01

Objective: To evaluate the feasibility and safety of using the sacro-spinous ligament (SSL) as a fixation point for anterior-apical pelvic floor compartment mesh implants. The apical support achieved with the sacro-spinous ligament mesh fixation is considered adequate, as it provides a high and stronger anchoring point. Even though, meshes for anterior pelvic floor reconstruction are traditionally anchored to the arcus tendineous fascia pelvis (ATFP). The authors presumed that fixing the anterior mesh to the sacro-spinous ligament instead of the ATFP is both feasible and safe. The present study evaluated the anatomical aspects and relations of a modified tissue passage with sacro-spinous fixation of the anterior apical mesh arms. Methods: In 5 embalmed female cadavers and 1 fresh female cadaver, the apical arms of the anterior needle-guided mesh were placed through the SSLs rather than through the ATFP, using a transgluteal approach. The distances between the mesh arms and the ureters and uterine arteries were measured. Results: The minimal final distance between the mesh arms and the ureters or uterine arteries was 1.5 cm in the embalmed cadavers, but only 5 mm in the fresh cadaver. However, when analyzing the procedure carefully, it was noted that during dissection the ureters and arteries were pushed medially by the surgeon's finger, thus the operative procedure did not entail any real risk of injury to these structures. The introduced surgical needle caused no trauma to any adjacent cadaveric organs. Conclusions: Anterior pelvic floor meshes may be safely anchored to the SSL, thus potentially improving the apical support.

Effects of Intravesical Dexpanthenol Use on Lipid Peroxidation and Bladder Histology in a Chemical Cystitis Animal Model

2012-05-01

Objective: To demonstrate the effects of intravesical dexpanthenol use on bladder histology and lipid peroxidation in a chemical cystitis animal model. Methods: Thirty-five New Zealand rabbits were divided into 3 groups. Cystitis was conducted with transurethral intravesical hydrochloric acid instillation on the subjects in groups I and II. Then, Group I subjects were transurethrally administered intravesical dexpanthenol therapy twice a week, Group II subjects were given only intravesical isotonic NaCl instillation, and Group III subjects were administered intravesical isotonic NaCl instillation without conducting chemical cystitis to create the same stress. Treatment schemes of all groups were arranged in the same manner. After 6-week therapy, the rabbits were sacrificed and histopathologic investigations were carried out to demonstrate changes in the urinary bladder. Serum and tissue malondialdehyde (MDA) values were examined to investigate the effect of dexpanthenol on lipid peroxidation. Results: We observed that the basal membrane and mucosal integrity were maintained, inflammatory cells were suppressed, and MDA levels decreased in group I, which received dexpanthenol therapy. However, it was also observed that mucosal integrity was spoiled, numerous inflammatory cells were accumulated, and MDA levels were significantly increased in group II, which was administered isotonic NaCl. Conclusion: In light of our findings, intravesical dexpanthenol therapy could be a new therapeutic approach in the treatment of interstitial cystitis because of its low cost and acceptable side effects.

Understanding Criteria for Surveillance of Patients With a Small Renal Mass

2012-05-01

Objective: To better delineate which factors influence the decision to undergo active surveillance of small renal masses. Methods: We identified 204 consecutive patients at our institution with clinical Stage T1 renal masses from June 2009 through June 2010. A variety of demographic and clinical characteristics were measured. Based on our previous work, the “ideal” criteria for active surveillance included tumor size ≤4 cm, Charlson comorbidity index of ≥2, Eastern Cooperative Oncology Group (ECOG) performance status (PS) of ≥2, and estimated glomerular filtration rate <60 mL/min. We performed sensitivity analyses to identify the characteristics associated with choice of active surveillance and compared these with our “ideal” criteria. Results: Of the 204 patients, 73 (36%) and 131 (64%) underwent active surveillance and treatment, respectively. The patients undergoing active surveillance versus treatment differed with respect to distance from hospital >60 miles (P = .04), ECOG PS of ≥2 (P < .01), tumor size (P < .01), multifocality (P = .03), endophytic nature of lesion (P = .04), and whether the patient's surgeon generally used a robotic, laparoscopic, or open approach (P = .01). Neither the baseline estimated glomerular filtration rate (P = .91) nor the Charlson comorbidity index (P = .69) were significant factors. The combination of tumor size <3 cm, ECOG PS of ≥2, and an endophytic lesion were most predictive of active surveillance. Conclusion: Patient, tumor, and surgeon characteristics all influence the choice of active surveillance. From the sensitivity analyses, active surveillance was driven by a tumor size <3 cm, poor PS (ie, ECOG PS of ≥2), and an endophytic lesion.

Editorial Comment

Chad A. LaGrange — 2012-05-01

According to the most recent American Cancer Society Facts and Figures 2012, an estimated 64 770 cases of kidney cancer will be diagnosed in 2012, with 13 570 patients dying of kidney cancer. This recent publication has also indicated a decrease in death rates from kidney cancer by 0.6% annually in women and 0.4% annually in men from 2004 to 2008, the most recent period available. The increased incidence of kidney cancer is most likely due to asymptomatic incidental tumors found on cross-sectional imaging, which makes management and clinical decision-making all the more challenging for the urologist.

Complementary and Alternative Medicine Use, Patient-reported Outcomes, and Treatment Satisfaction Among Men With Localized Prostate Cancer

2012-05-01

Objective: To evaluate the association between complementary and alternative medicine (CAM) use, satisfaction with treatment, and patient-reported outcomes after treatment. Methods: The Prostate CAncer Therapy Selection Study prospectively surveyed patients newly diagnosed with localized prostate cancer about their treatment decision-making process and outcomes. The Prostate CAncer Therapy Selection Study recruited patients from 3 geographic areas through hospital-based urology clinics and community urology practices. Results: More than 700 patients completed the baseline and follow-up surveys. More than 50% of respondents reported using CAM; this decreased to 39% if prayer was excluded as a type of CAM. On multivariate analysis, factors related to communication with the treating physician, but not CAM use, were associated with treatment satisfaction. The likelihood of stability or improvement in urinary, bowel, and sexual function at 6 months was related to the choice of primary therapy but was unrelated to CAM use. Conclusion: In the present prospective observational study, CAM use was highly prevalent but unrelated to treatment satisfaction or changes in functional status. The effect of CAM on these endpoints remains to be established in comparative effectiveness studies.

Can We Avoid Percutaneous Nephrolithotomy in High-risk Elderly Patients Using the Charlson Comorbidity Index?

2011-12-23

Objective: To determine whether Charlson comorbidity index (CCI) predicts the postoperative complications after percutaneous nephrolithotomy (PCNL) and could be a plausible option to avoid surgery and its potential risks in elderly patients with significant comorbidites. Methods: The data from 283 elderly patients (age ≥60 years) who underwent PCNL in 4 large referral hospitals were reviewed in the present multicenter study. For each patient, we evaluated pre-existing comorbidities and calculated the CCI score. The patients were classified to 3 CCI score categories (0, 1, ≥2) and compared regarding the stone-free and complications rates. Results: The mean patient age was 64.7, 65.6, and 67.7 years in the 3 groups. The stone-free rate after primary PCNL was 85.7% in group 1, 86.1% in group 2, and 75.0% in group 3. These rates increased to 90.8%, 95.4%, and 83.9% after a second intervention (P = .049). The overall postoperative complication rate was 38.8%. The most common complication was hemorrhage necessitating blood transfusion in 34 patients (12%), and we found an increased risk of hemorrhage associated with the CCI score (P = .011). Life-threatening medical complications developed in 7.6% of the patients in group 1, 12% of the patients in group 2, and 28.6% of the patients in group 3 (P = .001). A multivariate logistic regression analysis showed that a high CCI score, bleeding, and operative time had significant influence on the postoperative medical complication in this population. Conclusion: Conservative management of asymptomatic large kidney stones appears to be a safe alternative to PCNL in elderly patients with significant comorbidites.

Relationship Between Mean Platelet Volume and Varicocele: A Preliminary Study

2012-03-01

Objective: To examine the relationship between the mean platelet volume (MPV) and varicocele to clarify the etiopathogenesis of varicocele. Methods: MPV levels were measured in 60 varicocele subjects (group I) and 57 healthy controls (group II) from 2009-2010. Ages were similar between the 2 groups. The diagnosis of varicocele was based on the findings from both physical examination and color Doppler ultrasound. Results: The average patient age at the time of examination was 28.12 ± 6.4 years in group I and 28.10 ± 5.8 in group II. MPV levels were statistically significantly higher in group I than in group II (P < .001). Positive correlations were found between MPV and varicocele grade as between MPV and diameter of left spermatic vein (P < .05). Conclusion: The increase in MPV is independent of the disease, and the increase in varicocele grade is associated with higher MPV in varicocele patients. On the basis of the importance of the vascular component in the pathophysiology of varicocele, we would suggest conducting more studies with platelets in varicocele patients.

Higher RENAL Nephrometry Score is Predictive of Longer Warm Ischemia Time and Collecting System Entry During Laparoscopic and Robotic-assisted Partial Nephrectomy

2012-05-01

Objective: To investigate the predictive value of the RENAL Nephrometry Score (RNS) on operative outcomes during both laparoscopic partial nephrectomy (LPN) and robotic-assisted partial nephrectomy (RPN). Methods: We reviewed 67 consecutive patients with suspicious renal lesions and available radiographic data who underwent LPN or RPN by a single surgeon. Data included operative type, body mass index (BMI), gender, age, and side of tumor. RNSs were recorded using either magnetic resonance imaging or computed tomography scans. Warm ischemia time (WIT), estimated blood loss (EBL), and collecting system entry (CSE) were the endpoints for the analyses. Results: Total RNS entered as a continuous or dichotomous variable (<7 or ≥7), R-score, and N-score were independent predictors of WIT on multivariable analyses (P <.001, P = .001, P = .026, and P <.01, respectively). The total RNS and N-score were predictive of CSE in univariate analysis (P <.001). Neither total RNS nor its individual components were predictive of EBL. Conclusion: Total RNS, as well as the N- and R-scores, can help predict both longer WIT and CSE during LPN and RPN. The RNS and its individual components may be useful in the preoperative planning and counseling of patients undergoing LPN or RPN.

Transperitoneal Laparoscopic Dismembered Pyeloplasty in Unusual Circumstances—Is the Outcome Comparable to That Achieved in Familiar Pathologies?

2012-05-01

Objective: To compare the operative outcome, morbidity profile, and functional outcome after transperitoneal laparoscopic dismembered pyeloplasty for ureteropelvic junction obstruction in unusual circumstances (intrinsic pathology in anomalous kidneys or unusual extrinsic pathologies; group 1) to the outcome after this procedure in familiar pathologies (normally located kidneys with intrinsic dysfunctional segment or extrinsic compression due to a crossing vessel; group 2). Methods: The patients were evaluated in detail. All patients underwent transperitoneal laparoscopic dismembered pyeloplasty. The operative and postoperative parameters were recorded. Patients were followed up after the procedure on a 3-month protocol. Imaging was repeated at 1 year. No intervention during the follow-up period (ie, nephrostomy, ureteral stenting, or redo pyeloplasty) and improvement in the hydronephrosis grade and diuretic renogram parameters was interpreted as procedural success. The operative, postoperative, and follow-up parameters in the 2 groups were compared. Results: Group 1 included 17 patients with intrinsic pathologic features and renal anomalies with ureteropelvic junction obstruction due to unusual extrinsic pathology. All procedures were successfully completed with the laparoscopic approach. A significant difference was noted in the mean operative duration (group 1, 196.9 ± 10.3 minutes; group 2, 125.44 minutes, P = .00). The other operative and postoperative parameters were comparable. No significant operative or postoperative events were noted. A total of 14 patients (group 1) completed the 1-year follow-up protocol. The success rate was 92.9% (13 of 14) in group 1 and 97.9% (44 of 45) in group 2 (P = .42). Conclusion: The procedural duration for laparoscopic dismembered pyeloplasty in unusual circumstances is longer than in familiar pathologies. However, the morbidity profile and functional outcome in these 2 scenarios were comparable.

Perioperative Outcomes of Robotic-assisted Partial Nephrectomy in Elderly Patients: A Matched-cohort Study

2012-05-01

Objective: To compare elderly patients undergoing robotic assisted partial nephrectomy (RAPN) with a match cohort of younger patients. Investigating the benefits of minimally invasive RAPN including faster convalescence and decreased postoperative narcotic use make this an attractive option in patients with advanced age and numerous comorbidities. Methods: A retrospective review of 250 consecutive patients who underwent robotic-assisted partial nephrectomy (RAPN) for a solitary renal tumor from June 2006 to May 2010 at our institution was performed. Thirty-seven patients ≥70 years (G70) who underwent 38 robotic partial nephrectomy (RPN) procedures were identified. This group was matched with 38 patients <70 years (L70) who underwent 38 RPN procedures at our institution. Functional, perioperative, and oncological outcomes of RAPN in patients ≥70 years old were analyzed. Results: Overall, the median tumor size was 2.65 cm. Tumor characteristics, renal function, nephrometry score, and incidence of renal cancer in lesions were similar between the L70 and G70 groups. The two groups showed no differences in American Society of Anesthesiologists scores of 1-4 or Charlson comorbidity index score. Perioperative and postoperative outcomes showed no variation between L70 and G70 patients. Postoperative complications rate of 21% and 31.6% in the L70 and G70 groups, respectively, showed no difference (P < .48). There were 5 deaths, 3 of which occurred in the G70 group (8.1%) at a median of 22 months after surgery. Conclusion: RAPN for small renal masses offers a safe alternative for patients >70 years of age, with no increase in perioperative and postoperative morbidity and mortality. Age may not be predictive of perioperative complications.

Editorial Comment

Leslie Allan Deane — 2012-05-01

The authors report on a retrospective matched-cohort study of patients undergoing robotic assisted partial nephrectomy (RAPN) for renal masses deemed surgically resectable. They have sought to separate the groups into patients <70 years and those ≥70 years, the latter arbitrarily designated as “elderly.”

Reply

Shahab P. Hillyer, Riccardo Autorino, Jihad Kaouk — 2012-05-01

Demographic changes with an aging population have led to an increased emphasis on treatment choices for elderly patients with renal masses. Comorbidities, risk of metastasis, and quality of life are important components of the decision-making process with each patient. However, age should not be the sole justification to preferentially avoid surgical intervention.

Face, Content, and Construct Validation of the da Vinci Skills Simulator

2012-05-01

Objective: To report on assessments of face, content, and construct validity for the commercially available da Vinci Skills Simulator (dVSS). Methods: A total of 38 subjects participated in this prospective study. Participants were classified as novice (0 robotic cases performed), intermediate (1-74 robotic cases), or expert (≥75 robotic cases). Each subject completed 5 exercises. Using the metrics available in the simulator software, the performances of each group were compared to evaluate construct validation. Immediately after completion of the exercises, each subject completed a questionnaire to evaluate face and content validation. Results: The novice group consisted of 18 medical students and 1 resident. The intermediate group included 6 residents, 1 fellow, and 2 faculty urologist. The expert group consisted of 2 residents, 1 fellow, and 7 faculty surgeons. The mean number of robotic cases performed by the intermediate and expert groups was 29.2 and 233.4, respectively. An overall significant difference was observed in favor of the more experienced group in 4 skill sets. When intermediates and experts were combined into a single “experienced” group, they significantly outperformed novices in all 5 exercises. Intermediates and experts rated various elements of the simulators realism at an average of 4.1/5 and 4.3/5, respectively. All intermediate and expert participants rated the simulator's value as a training tool as 4/5 or 5/5. Conclusion: Our study supports the face, content, and construct validation attributed to the dVSS. These results indicate that the simulator may be most useful to novice surgeons seeking basic robot skills acquisition.

Functional Outcomes and Complications in Patients With Bladder Cancer Undergoing Robotic-assisted Radical Cystectomy With Extracorporeal Indiana Pouch Continent Cutaneous Urinary Diversion

2012-03-05

Objective: To evaluate the functional outcomes and complications for patients with bladder cancer undergoing robotic-assisted laparoscopic radical cystectomy with Indiana pouch continent cutaneous urinary diversion. Methods: From February 2004 to March 2010, 34 patients underwent robotic-assisted laparoscopic radical cystectomy with Indiana pouch continent cutaneous urinary diversion reconstruction. After surgery, the complications were identified, categorized, and graded using an established 5-grade modification of the original Clavien grading system, and continence was assessed. Descriptive statistics were used in evaluating the outcomes. Fischer's exact test was used in the comparison of early and late Clavien grade III complications. Results: Overall, 175 (123 early and 52 late) complications after surgery were reported in 32 (94%) of 34 patients. Within 90 days of surgery, 31 (91%) of 34 patients experienced ≥1 early complication. Of 34 patients, 15 (44%) reported ≥1 late complications (>90 days). Most (85% and 69%, respectively) early and late complications were graded as minor (grade II or less). Fewer patients with early complications required an additional intervention (grade III) compared with patients with late complications (14% vs 31%; P = .116). The most common complication in both intervals was infection, reported in 22% and 37% of patients with early and late complications, respectively. The continence data for 31 patients at a mean follow-up of 20.1 months (median 12.0) showed that all but 1 patient (97%) had daytime and nighttime continence. Conclusion: Patients undergoing robotic-assisted laparoscopic radical cystectomy with Indiana pouch continent cutaneous urinary diversion reconstruction have comparable complication rates and functional outcomes compared with patients in the open series.

Outcomes in Patients With Clinical Stage III NSGCT Who Achieve Complete Clinical Response to Chemotherapy at Extraretroperitoneal Disease Site

2012-03-26

Objective: To compare the survival outcomes of patients with advanced nonseminoma and extraretroperitoneal (ERP) disease observed for a clinical complete response (CCR) with those demonstrating a pathologic complete response (PCR). Methods: From 1989 to 2003, 237 patients with clinical Stage III nonseminoma underwent induction chemotherapy followed by retroperitoneal lymph node dissection. After chemotherapy, 107 demonstrated a CCR to treatment at the ERP disease site. Of the remaining 130 patients with radiographic evidence of residual ERP disease, 86 (66%) had fibrosis only on pathologic review (ie, PCR). The probability of progression-free and disease-specific survival was estimated using the Kaplan-Meier method. Cox proportional hazards regression analysis was used to determine the prognostic significance of risk factors for progression and survival. Results: The median follow-up was similar for both CCR and PCR patients (44.5 and 50.7 months, respectively). Overall, the 5-year probability of freedom from progression (93% vs 72%, respectively; P = .0005) and disease-specific survival (96% vs 87%, respectively; P = .08) rates were far better for men with a PCR. The predictors of disease progression included residual retroperitoneal nodal size after chemotherapy (P = .05), and resection of the residual disease at the ERP site was protective (P = .02). Conclusion: A CCR at the ERP disease site is associated with a greater likelihood of relapse compared with a PCR, underscoring the limitations of radiographic imaging after chemotherapy in detecting microscopic residual disease and need for rigorous monitoring of patients observed after a CCR. Furthermore, until more accurate clinical predictors of ERP histologic features are identified, we advocate for complete surgical resection of all sites of residual disease, when feasible.

Prognostic Value of Neutrophil-to-lymphocyte Ratio and Establishment of Novel Preoperative Risk Stratification Model in Bladder Cancer Patients Treated With Radical Cystectomy

2012-03-26

Objective: Preoperative prognostic factors in bladder cancer patients have not been fully established. This study was undertaken to investigate preoperative prognostic factors, including neutrophil-to-lymphocyte ratio (NLR), and to develop a novel prognostic factors–based risk stratification model for disease-specific survival (DSS) in bladder cancer patients treated with radical cystectomy (RC). Methods: We performed a retrospective analysis of 189 consecutive bladder cancer patients treated with RC at our institution. Prognostic value of the preoperative clinical and laboratory parameters were evaluated by univariate and multivariate Cox proportional hazard model analyses, and patients were stratified according to relative risks (RRs) for DSS. Results: One-, 3-, and 5-year DSS rates were 86.8%, 70.8%, and 61.7%, respectively. In univariate analysis, tumor size, clinical T stage, hydronephrosis, concomitance of carcinoma in situ, and some laboratory findings (hemoglobin [Hb] level, platelet count, C-reactive protein, neutrophil count, lymphocyte count, and NLR) were significantly associated with poor prognosis. In multivariate analysis, tumor size, hydronephrosis, Hb level, and NLR were independent factors for predicting poor prognosis. Patients were stratified into 3 risk groups: low (RR = 1.000-3.717), intermediate (RR = 4.149-9.315), and high (RR = 10.397-38.646). The differences among the groups were significant. Conclusions: NLR was an independent prognostic factor, as were tumor size, hydronephrosis, and Hb levels, and the combination of these factors can stratify DSS risks in bladder cancer patients treated with RC. This information may be useful for identifying patients who might be candidates for clinical trials of multimodal treatment strategies, including innovative neoadjuvant treatments.

Editorial Comment

Joshua Sleeper, Vitaly Margulis — 2012-03-26

Identifying characteristics for preoperative risk stratification has been a goal for all urological malignancies. In addition, a greater understanding of the complex interaction between the immune system and solid organ tumors has led to an attempt at incorporating measurable markers of the systemic inflammatory and immune responses into outcome prediction models. These authors investigated the value of the neutrophil-to-lymphocyte ratio (NLR) along with other factors in creating a preoperative prognostic model for patients with bladder cancer undergoing radical cystectomy. The NLR has been studied in other solid organ tumors, including renal cell carcinoma, with an increased ratio being associated with a worse prognosis. Other inflammatory markers, such as CRP have also been shown to correlate with poor outcomes, and this holds true in this article as well. The authors found that tumor size, presence of hydronephrosis, hemoglobin levels, and the NLR were independent predictors of disease-specific survival. Interestingly, clinical tumor stage was not a significant predictor of oncological outcome, and importance of lymphovascular invasion was not assessed. Using these variables, a prognostic model was created to predict disease-specific survival. Although these findings are intriguing, conclusions are limited because of the retrospective nature of the study, the small number of patients, and the lack of external validation. Further studies are needed to evaluate the use of incorporating such markers into clinical practice.

Reply

Tatsuo Gondo, Jun Nakashima — 2012-03-26

Preoperative outcome prediction, including risk stratification, has been a major concern for improving the current ability to predict outcomes in urological malignancies, including bladder cancer. However, preoperative prediction models of disease-specific survival (DSS) after radical cystectomy (RC) in patients with bladder cancer have not been completely established. One reason may be the limitation in clinical T staging accuracy. Despite recent developments in diagnostic imaging modalities and surgical skills in the staging diagnosis of bladder cancer, there is still a discrepancy between clinical T stage and pathologic T stage. We have reported that the pathologic T stage of RC specimens is an independent prognostic factor for DSS. However, the present study indicated that clinical T stage was not an independent prognostic factor through multivariate analysis, although clinical T stage was significantly associated with DSS through univariate analysis. Increasing evidence supports the involvement of systemic inflammation in cancer development and progression. Neutrophil-to-lymphocyte ratio (NLR)—a marker of systemic inflammatory response—is reportedly a useful parameter associated with poor outcome in certain cancers. In the present study, we indicated that the NLR as well as tumor size, presence of hydronephrosis, and hemoglobin level are significant predictive factors for DSS in bladder cancer patients. Through the use of these factors, we believe that the potential malignant aggressiveness of bladder cancer might be detected, which would not be recognized by conventional modalities and by transurethral resection of bladder tumor (TURBT). However, we did not evaluate the significance of lymphovascular invasion (LVI) in bladder cancer specimens by TURBT as suggested by Sleeper et al. LVI may also be a useful preoperative factor for predicting potential aggressiveness of bladder cancer as previously reported.

Clinical and Pathologic Factors of Prognostic Significance in Penile Squamous Cell Carcinoma in a North American Population

2012-03-05

Objective: To analyze, in a clinicopathologic correlation study, a small population of primarily white men with invasive squamous cell carcinoma of the penis for potential prognostic predictors. Penile squamous cell carcinoma is an uncommon cancer in North America. It has a wide spectrum of clinical behavior and an understudied pathogenesis. Methods: The data from 43 patients with invasive squamous cell carcinoma of the penis were studied retrospectively. Extensive chart reviews were conducted, glass slides were reviewed, and tissue microarrays were constructed for analysis of immunohistochemical stains p16INK4a, p53, and Ki-67. Univariate and multivariate logistic regression analyses were performed to elucidate any clinical or pathologic factors that would predict overall survival. Results: The mean age at diagnosis was 63 years. Most cases (63%) were invasive squamous cell carcinoma, not otherwise specified, and presented as pathologic stage T1 or T2 tumors. Of the 43 patients, 23% died of their disease; 53% of the cases stained for p16INK4a. Higher pathologic tumor stage and a lack of p16INK4a staining were independent predictors of worse overall survival (P = .014) and cancer-specific survival (P = .010). Conclusion: Our results have shown that 53% of the invasive penile squamous cell carcinoma cases in this population were associated with human papillomavirus, using p16INK4a as a surrogate marker of human papillomavirus infection. These patients had a statistically significant survival advantage, independent of other prognostic factors.

Role of Isotope Selection in Long-term Outcomes in Patients With Intermediate-risk Prostate Cancer Treated With a Combination of External Beam Radiotherapy and Low-dose-rate Interstitial Brachytherapy

2012-05-01

Objective: To examine the rates of long-term biochemical recurrence-free survival (BRFS) with respect to isotope in intermediate-risk prostate cancer treated with external beam radiotherapy (EBRT) and brachytherapy. Methods: A total of 242 consecutive patients with intermediate-risk prostate cancer were treated with iodine-125 (125I) or palladium-103 (103Pd) implants after EBRT (range 45.0-50.4 Gy) from 1996 to 2002. Of the 242 patients, 119 (49.2%) were treated with 125I and 123 (50.8%) with 103Pd. Multivariate Cox regression analysis was used to analyze BRFS, defined according to the Phoenix definition (prostate-specific antigen nadir plus 2 ng/mL) with respect to Gleason score, stage, pretreatment prostate-specific antigen level, and source selection. Late genitourinary/gastrointestinal toxicities were assessed using the Radiation Therapy Oncology Group/European Organization for Research and Treatment of Cancer scale. Results: At a median follow-up of 10 years, the BRFS rate was 77.3%. A statistically significant difference was found in the 10-year BRFS rate between the 125I- and 103Pd-treated groups (82.7% and 70.6%, respectively; P = .001). The addition of hormonal therapy did not improve the 10-year BRFS rate (77.6%) compared with RT alone (77.1%; P = .22). However, a statistically significant difference in the BRFS rate was found with the addition of hormonal therapy to 103Pd, improving the 10-year BRFS rate for (73.8%) compared with 103Pd alone (69.1%; P = .008). On multivariate analysis, isotope type (103Pd vs 125I), pretreatment prostate-specific antigen level >10 ng/mL, and greater tumor stage increased the risk of recurrence by 2.6-fold (P = .007), 5.9-fold (P < .0001), and 1.7-fold (P = .14), respectively. Conclusion: 125I renders a superior rate of BRFS compared with 103Pd when used with EBRT. Hormonal therapy does not provide additional benefit in patients with intermediate-risk prostate cancer treated with a combination of EBRT and brachytherapy, except for the addition of hormonal therapy to 103Pd.

Does Salvage Radiation Therapy Change the Biology of Recurrent Prostate Cancer Based on PSA Doubling Times? Results from the SEARCH Database

2012-03-26

Objective: To investigate whether salvage radiation therapy (SRT) may promote prostate cancer (PCa) transformation to more aggressive phenotypes. To accomplish that, we identified men who underwent SRT after radical prostatectomy for PCa and failed SRT. PSA doubling time (PSADT) was used as a surrogate endpoint for cancer aggressiveness. We compared PSADT calculated before start of SRT and after SRT failure. Methods: Of 287 men in the SEARCH database since 1988 who underwent SRT, we detected 78 with SRT failure defined as PSA ≥0.2 ng/mL above the post-SRT nadir. Of these, 39 had PSADT available before and after SRT, which was compared using Wilcoxon's paired test with men serving as their own controls. We tested predictors of PSADT change using multivariable logistic regression. Results: There were no differences in PSADT before and after SRT (10.2 vs 12.6 months; P = .46). However, in some individual cases, large changes were observed. Only seminal vesicle invasion showed a trend towards an association with a shorter post-SRT PSADT relative to the pre-SRT PSADT (P = .13). Conclusion: Overall, the PSADT after and before SRT were statistically identical, suggesting that after SRT failure, PCa does not emerge with more aggressive biological features. Further studies are needed to identify predictors and the clinical relevance of individual PSADT changes noted in our study.

National Trends in Surgical Therapy for Benign Prostatic Hyperplasia in the United States (2000-2008)

Bahaa S. Malaeb, Xinhua Yu, A. Marshall McBean, Sean P. Elliott — 2012-05-01

Objective: To report an update of the change in usage trends for different surgical treatments of benign prostatic hyperplasia (BPH) among the United States Medicare population data from 2000-2008. The rate of usage of thermotherapy and laser therapy in the surgical treatment of BPH has been changing over the past decade in conjunction with a steady decrease of transurethral resection of the prostate (TURP). Methods: Using the 100% Medicare carrier file for the years 2000-2008, we calculated counts and population-adjusted rates of BPH surgery. Rates of TURP, thermotherapy, and laser-using modalities were calculated and compared in relation to age, race, clinical setting, and reimbursement. Results: After years of a steady rise, the total rate of all BPH procedures peaked in 2005 at 1078/100,000 and then declined by 15.4% to 912/100,000 in 2008. TURP rates continued to decline from 670 in 2000 to 351/100,000 in 2008. Rates of microwave thermoablation peaked in 2006 at 266/100,000 and then declined 26% in 2008. Laser vaporization almost completely replaced laser coagulation and in 2008 was the most commonly performed procedure second to TURP, with the majority performed as outpatient procedures (70%) and an increasing percentage in the office (12%). Men between ages 70 and 75 had the highest rate of procedures. Reimbursement rates correlate using some but not all procedures. Racial disparities reported previously appear to have resolved. Conclusion: Surgical treatment of BPH continues to change rapidly. TURP continues to decline and laser vaporization is the fastest growing modality. There is a big shift toward outpatient/office procedures. Reimbursement rates do not appear to have a consistent effect on usage.

Editorial Comment

Henry H. Woo — 2012-05-01

This study of the rate of utilization of various surgical approaches to treat BPH pretty much confirms our individual impressions on what is happening in urological practice. Although a study of a Medicare population, particularly with the men being over 65 years of age, it reasonably matches the typical patient who will undergo a BPH surgical procedure in our own urological practices. Apart from the fact that the average of age of men requiring surgery will typically fall into this age group, we have also often managed to have our younger patients defer surgery into this age group by pharmacotherapy.

Reply

Sean P. Elliott — 2012-05-01

There are several aspects of BPH surgical trends that we are unable to detect with these data. We cannot differentiate monopolar from bipolar TURP nor can we separate holmium laser from GreenLight laser technology. Finally, we cannot detect the wattage used in the laser procedures.

Comparison of Harmful Gases Produced During GreenLight High-performance System Laser Prostatectomy and Transurethral Resection of the Prostate

Seung Chol Park, Sang Kyi Lee, Suk Hee Han, Yun Jo Chung, Jong Kwan Park — 2012-05-01

Objective: To compare the gases generated from GreenLight High-Performance System (HPS) laser prostatectomy with Urosol or normal saline solution and transurethral resection and vaporization of the prostate (TURVP) with Urosol. Methods: A total of 36 smoke samples were collected from a continuous irrigation suction system attached to a Tenax absorber during transurethral surgery of the prostate. The gases were qualitatively and quantitatively analyzed by gas chromatography-mass spectrometry equipped with a purge and trap sample injector. Results: The gas produced during TURVP contained propylene, allene, isobutylene, 1,3-butadiene, vinyl acetylene, mercaptomethane, ethyl acetylene, diacetylene, 1-pentene, ethanol, piperylene, propenylacetylene, 1,4-pentadiene, cyclopentadiene, acrylnitrile, and butyrolacton. The types and amount of gas produced during HPS laser prostatectomy were fewer and smaller than during TURVP. However, 1,3-butadiene, a well-known human carcinogen, was also generated by HPS laser prostatectomy. HPS laser prostatectomy with saline produced a greater amount and number of gases than HPS laser prostatectomy with Urosol. Conclusion: The surgical smoke produced from TURVP and HPS laser prostatectomy contains potentially harmful chemical compounds, although HPS laser prostatectomy produced less surgical smoke than TURVP. Urosol produced fewer types and a smaller amount of gas than normal saline during HPS laser prostatectomy.

Editorial Comment

Marco Carini, Andrea Minervini — 2012-05-01

The authors present a comparison of harmful gases produced during GreenLight HPS laser prostatectomy operating at 120 W and TURVP. Overall, their report is well written, and the method used is correct; however, one might criticize their study, because they chose to perform the 2 procedures (TURVP followed by HPS laser prostatectomy) in the same patient. Others would have chosen to create 2 distinct groups, 1 for TURVP and 1 for HPS laser prostatectomy.

Reply

Jong Kwan Park — 2012-05-01

Surgical procedures make and release many toxic gases, including carcinogens. Surgical personnel might ignore the environmental risk factors, although these gases can threaten their health and even their life. Ascertaining how to best investigate the hazards of surgical procedures is crucial. Continuous inhalation of toxic gases for a prolonged period can cause severe disease in surgical personnel, especially operators and assistants.

Ileal Urinary Reservoir in Pediatric Population: Objective Assessment of Long-term Sequelae With Time-to-event Analysis

Ahmed M. Elshal, Ahmed Abdelhalim, Ashraf T. Hafez, Hassan Abol-Enein — 2012-05-01

Objective: To evaluate the long-term outcomes of an ileal urinary reservoir in children. Methods: This was a longitudinal study of pediatric patients who had undergone total ileal substitution of the bladder. Continence status was assessed, and all patients were evaluated for kidney function and biochemical profile. Standardized growth charts were used to assess linear growth. To assess bone mineral density, dual-emission x-ray absorptiometry scanning was performed. Clavien's scale was used to report and grade the long-term complications and their timing. We used a simple quality of life questionnaire to assess the effect of the procedure on the quality of life of the growing child. Results: A total of 17 patients were included; 3 with orthotopic and 14 with continent cutaneous reservoirs. After a mean follow-up of 87.3 months, all patients were voiding with clean intermittent catheterization, with a 94% final continence rate. Two patients (11.7%) had an estimated glomerular filtration rate of ≤45 mL/min/1.73 m2 at the last follow-up examination. However, no clinically manifest metabolic acidosis was detected. No anemia or neurologic deficit was detected, with a low-normal serum level of vitamin B12 in 2 patients (11.7%) and a low level in 1 patient (5.7%). One patient (5.7%) had chronic diarrhea. Low bone mineral density was found in 4 patients (22.8%), with 3 patients (17.1%) not exceeding the fifth percentile of height for age. High-grade complications (grade 3a-5) represented 64.5% of the complications, and the need for reintervention occurred late in the follow-up period. A high level of quality of life satisfaction was reported (88.5%). Conclusion: Ileal neobladder construction allows child to pass into adolescence dry with more confidence and self-esteem, with no external urine collection set. However, long-term follow-up is mandatory to maintain the positive outcome.

Diagnostic Value of Anteroposterior Diameter of Fetal Renal Pelvis During Second and Third Trimesters in Predicting Postnatal Surgery Among Korean Population: Useful Information for Antenatal Counseling

2012-03-05

Objective: To establish prognostic data regarding fetal hydronephrosis using the anteroposterior diameter (APD) and the need for interventional surgery in the Korean population. Methods: A total of 187 children with an APD of ≥4 mm on obstetric ultrasound scans at any gestational age were retrospectively reviewed. The affected renal units were divided into 2 groups: surgical and nonsurgical. The ultrasound findings were compared at 3 gestational ages: second trimester (15-26 weeks' gestation), early third trimester (27-33 weeks' gestation), and late third trimester (34-40 weeks' gestation). Results: The area under the receiver operating characteristic curve was 0.770, 0.828, and 0.812 at the second, early third, and late third trimesters, respectively. A 100% sensitivity for predicting postnatal surgery could be achieved at a cutoff APD of 5 mm during the second trimester, 8 mm during the early third trimester, and 10 mm during the late third trimester if scheduled antenatal ultrasound scans were performed. A cutoff APD of 11 mm during the second trimester was of diagnostic value in selecting children at risk of postnatal surgery with an odds ratio of 5.13 (95% confidence interval 1.62-16.25), with relatively high sensitivity and specificity. With a cutoff of 15 mm during the early third and late third trimesters, the odds ratio was 11.51 (95% confidence interval 5.05-26.23) and 6.94 (95% confidence interval 3.30-14.57), respectively. Conclusion: Compared with an APD of 10 mm, the most commonly used standard cutoff value in predicting postnatal hydronephrosis and its outcome, an APD cutoff of 5, 8, and 10 mm during the second, early third, and late third trimesters, respectively, is more specific in predicting the need for postnatal surgical intervention in the Korean population.

Does Child's Age Affect Interval to Stone-free Status After SWL? A Critical Analysis

2012-02-16

Objective: To evaluate the success rates and complications of extracorporeal shock wave lithotripsy (ESWL) in children with renal stones in an age-dependant manner. Methods: From 2006 to 2010, 164 children (male/female ratio 1:3) with renal calculi have been treated with ESWL (PiezoLith3000 lithotripter). The children were divided into 2 age groups: group 1, 0-6 years old (n = 133); and group 2, 7-15 years (n = 31). The patient- and treatment-related parameters were recorded for comparative evaluation. The success of ESWL in terms of the stone-free rates, additional procedures, and complications were comparatively evaluated. The data were analyzed statistically. Results: The mean age of groups 1 and 2 was 28 ± 18 months (range 4-71) and 119 ± 28 months (range 73-178), respectively. Although general anesthesia was used for all patients in group 1, 29% of the patients were treated under neuroleptic anesthesia in group 2. During the 3-month follow-up period, the complete stone-free rate was 94.7% (126 of 133), and treatment was unsuccessful in 7 patients (5.3%) in group 1. The corresponding data were 87% (27 of 31; P = .222) and 4 (13%; P = .089) in group 2. The stone-free rate after the first session was 67.6% (90 of 133) and 38.7% (12 of 31) in groups 1 and 2, respectively (P = .004). The mean number of ESWL sessions applied was 1.6 (range 1-5) and 2.9 (range 1-6) in groups 1 and group 2, respectively (P = .0001). No major complications were noted. Conclusion: Our results have demonstrated that ESWL is highly successful in the management of renal calculi in children. Compared the outcomes by age, the younger children become stone free more quickly than the older children with fewer ESWL sessions.

Para-meatus Skin Incision With Long Channel Technique for Midshaft Hypospadias Repair Without Penile Curvature

Cheng Su, Tianyou Yang, Zhichong Zhang, Yeqing Xu, Qifeng Liang — 2012-02-06

Objective: To report a new surgical technique for midshaft hypospadias repair without penile curvature. Methods: From September 2007 to October 2010, 21 patients, aged 13 months to 8.9 years, underwent single-stage hypospadias repair by 1 surgeon. The skin incision was created around the meatus, and a long channel beneath the urethral plate was created through the incision to the apex of the glans. The inner preputial flaps were tubularized into a neourethra, which was then transposed to the ventral channel through a ventrolateral tunnel beneath Buck's fascia. Most of the neourethra was covered by the intact soft tissue of the distal ventral penis. The proximal portion of the neourethra was covered by Buck's and dartos fascia around the skin incision, and the skin incision was closed longitudinally. The length of the urethral defect and channel and the postoperative complications were collected and analyzed. Results: A total of 21 patients underwent single-staged hypospadias repair. The average length of the channel was 30 mm (range 25-35). The average length of the neourethra was 35 mm (range 30 to 40). The mean operative time was 60 minutes (range 50-70). The mean hospital stay was 12 days (range 10-14). With an average follow-up of 20 months (range 6-37), no postoperative complication was detected. Conclusion: This technique provides excellent short-term results for midshaft hypospadias without penile curvature and is a safe and simple solution.

De Castro Technique Used to Create Neophallus: A Case of Aphallia

Katie H. Willihnganz-Lawson, Bahaa S. Malaeb, Aseem R. Shukla — 2011-11-30

We report on a rare case of aphallia in an X, Y-born male treated at our institution. The child underwent phalloplasty at 5 years of age using the De Castro phalloplasty technique and an abdominal skin flap. Although moderate distal necrosis was seen, the overall immediate and 12-month postoperative results were highly encouraging for our patient. Thus, this technique should be seen as a temporizing reconstructive option for patients with aphallia. Long-term follow-up is necessary to determine whether the neophallic size augments with axial growth and the need for additional intervention to facilitate onset of sexual activity.

Juvenile Granulosa Cell Tumor Arising From Intra-abdominal Testis in Newborn: Case Report and Review of the Literature

Nikolaos Partalis, Maria Tzardi, Sophia Barbagadakis, George Sakellaris — 2011-11-16

In the present case, the neonate presented with a left-sided abdominal mass and an empty left scrotum. Abdominal ultrasonography showed well-defined cystic formation, and laparotomy revealed a tumor arising from an intra-abdominal left testis. The carcinoembryonic antigen and neuron-specific enolase levels were within normal limits, and the serum β-human chorionic gonadotropin and α-fetoprotein levels were within age-related normal values. The findings from the immunochemistry tests confirmed the diagnosis.

Oligohydramnios Associated With Sonographically Normal Kidneys

2011-11-16

We report a male newborn presenting with sonographically normal kidneys, oligohydramnios during late pregnancy, and persisting anuric renal failure. Despite intensive treatment, the patient suffered from severe hypotension and died at the age of 4 weeks. At autopsy, kidneys were found to be normal; on histology, deranged renal structures, in particular proximal tubuli and vessels, were noted, leading to the diagnosis of renal tubular dysgenesis (RTD). The diagnosis was confirmed by 2 heterozygous nonsense mutations of the ACE gene. Because the recurrence rate of RTD is 25% for the autosomal recessive trait, knowledge and genetic diagnosis of the disease is important for the parents.

Reconstruction of Distal Urethral Strictures Confined to the Glans With Circular Buccal Mucosa Graft

2012-03-26

Objective: To report our results with 1-stage reconstruction in short distal urethral strictures using circular buccal mucosa graft (cBMG). Methods: The data of 19 patients (median age 41.8 years, range 25-58) operated between 2001 and 2010 were reviewed. Patients were evaluated with American Urological Association (AUA) symptom score, uroflowmetry, voiding cystourethrography (VCUG), and intraoperative urethroscopy. Stricture was limited to the glanular urethra (≤2 cm.) in all cases and 16 patients had lichen sclerosus. Strictured urethra was resected 0.5 cm proximal to the healthy urethra and a rectangular BMG with 4-cm length and 1.5- to 2.5-cm width (depending on the length of the defect) was rolled on a 24-Fr sound that calibrated the urethra. Proximal and distal edges of the cBMG were anastomosed circumferentially to the healthy mucosa and meatus, respectively. Foley catheter was removed within 10-14 days. Voiding symptoms, uroflowmetric parameters, and cosmesis were assessed at 1, 3, and 6 months, and yearly thereafter. Results: With a median follow-up of 38 months (range 12-96), 16 (84.2%) patients were cured. One patient developed early graft loss, and 2 patients developed stricture at proximal anastomotic site. Mean Qmax (mL/s) increased from 7.8 ± 5.4 preoperatively to 21.8 ± 9.2 postoperatively (P = .001), and mean AUA score decreased from 26.7 ± 3.9 preoperatively to 7.3 ± 3.8 postoperatively (P < .001). Conclusion: Our results suggest cBMG as a feasible alternative in 1-stage reconstruction of distal strictures confined to the glanular urethra because the glans penis has a good blood supply, providing an efficient circumferential graft take.

The Clinical Spectrum of the Presenting Signs and Symptoms of Anterior Urethral Stricture: Detailed Analysis of a Single Institutional Cohort

Keith Rourke, Jonathan Hickle — 2012-03-26

Objective: To accurately delineate the presentation of anterior urethral stricture in an economically developed patient cohort. It is widely assumed that patients with urethral stricture typically present with lower urinary tract symptoms (LUTS). There is a paucity of data examining this assumption. With no uniformly accepted clinical definition or measure of treatment success, a clear clinical description of urethral stricture is important. Methods: Retrospective detailed analysis was performed on 611 patients presenting with anterior urethral stricture from July 2004 to June 2010. Both the presenting complaint and associated signs and symptoms were classified according to one of 10 clinical categories. Results: The most common presenting complaint was LUTS typical of those found on the American Urological Association-Symptom Score (54.3%) and another 23.4% of patients presented initially with acute urinary retention (AUR). Symptoms other than LUTS or urinary retention accounted for 22.3% of presenting complaints. In addition, 22.9% of patients had genitourinary pain, 50.7% of patients required emergent urologic treatment, and 7.4% of patients presented with renal insufficiency or urethral abscess/necrotizing fasciitis directly related to urethral stricture. Conclusion: Although many patients with urethral stricture present initially with LUTS or AUR, almost one quarter of patients have a different presenting complaint. Defining successful treatment of anterior urethral stricture should include more than improvement in LUTS or absence of urinary retention. Urethral stricture is not just a “quality of life” condition because >50% of patients require emergent treatment and 7.4% have a life-threatening condition directly related to the stricture.

Unsuccessful Outcomes After Posterior Urethroplasty: Definition, Diagnosis, and Treatment

Mamdouh M. Koraitim — 2012-03-26

Objective: To establish some guidelines for the definition, diagnosis, and treatment of failed posterior urethroplasty. Methods: We identified 20 successive patients who required a secondary endoscopic or surgical procedure after anastomotic repair of a postpelvic fracture urethral injury from 1979 to 2010. Of the 20 patients, 18 had undergone perineal repair and 2 a perineo-abdominal procedure. Their medical records were reviewed with a focus on 6 postoperative items: symptoms, onset of unsuccessful result, urethral calibration, urethrocystography, urethroscopy, and treatment. Follow-up ranged from 1 to 25 years (mean 14). Results: Of the 20 patients, 11 (55%) presented shortly after removal of the urethral stent with failure to void (n = 9) or incontinence (n = 2), and 9 (45%) presented 1 month to 12 years after surgery with a weak stream. Early failures resulted from obstruction at the site of repair in 5 patients, retraction of the bulbar urethra in 3, wrong anastomosis to a false tract in 1, and an open bladder neck in 2. Correction was accomplished by salvage urethroplasty in 8 patients and bladder neck repair in 2. Late failures resulted from narrowing of the anastomosis and were corrected by direct visual internal urethrotomy in 7 patients and surgery in 2. Conclusion: Unsuccessful outcomes can be encountered shortly after removal of the urethral stent or delayed for several months or years after surgery. Early cases present by an inability to void or incontinence and usually require salvage urethroplasty or bladder neck repair. Late cases present by a weak urinary stream, are due to narrowing of the anastomosis, and are usually corrected by direct visual internal urethrotomy.

Editorial Comment

Bradley A. Erickson — 2012-03-26

There are few procedures in urology that are as consistently challenging and with as much at stake as a posterior urethroplasty. The urethral injuries are most commonly the result of extensive trauma, are extremely heterogeneous in presentation, and, if the repairs are not performed successfully, the patient can be relegated to a life with urinary diversion. Fortunately, these cases are relatively rare—but it is the rarity of the procedure that makes the analysis of outcomes and agreement on nomenclature difficult.

Reply

Mamdouh M. Koraitim — 2012-03-26

Developments in the field of posterior urethroplasty during the past 4 decades have greatly improved the outcome for patients with complex postpelvic fracture urethral injury, offering restoration of urethral continuity with urinary control and without the need for any additional urethral instrumentation in most cases. Thus, in the 21st century, and actually since the 1980s, permanent urinary diversion would not be accepted as an option for the treatment of these patients. In our experience, covering 35 years, we have not encountered a single patient who was relegated to a life with urinary diversion.

Safety and Efficacy of Periurethral Constrictor Implantation for the Treatment of Post–radical Prostatectomy Incontinence

2012-05-01

Objective: To assess safety and efficacy of the periurethral constrictor for the treatment of postprostatectomy urinary incontinence. Methods: Periurethral constrictor is a minimally invasive, low-cost (€2000) device based on an adjustable occlusive mechanism. From December 2004 to March 2010 the device was implanted in 66 patients with mild to severe incontinence (3 or more pads per day) through a 3- to 5-cm perineal incision. Median surgical time was 35 minutes (range 25-60). Discharge occurred on day 1 after removing the indwelling urethral catheter. Results: In 4 cases (6%), the device was removed because of infection/periurethral erosion. At 18 months, 62 patients were valuable; continence was recovered totally in 49 cases (79%), partially in 9 (15%) cases, and remained unchanged in 4 (6%). No one needed self-catheterization to empty the bladder. Conclusion: Periurethral constrictor improved continence in most of the patients. Nevertheless, a larger series and longer follow-up are needed to confirm safety and to test durability.

Editorial Comment

Brent K. Hollenbeck — 2012-05-01

Advances in surgical technique have greatly improved continence outcomes after radical prostatectomy. Unfortunately, severe and/or bothersome urinary incontinence does occur in some patients. In many cases, this can be unpredictable and a source of anxiety for patients contemplating prostate cancer surgery. Although other options have arisen to handle milder forms of postprostatectomy incontinence, artificial urethral sphincters have been a mainstay in the management of patients with the most severe symptoms.

Reply

2012-05-01

We truly appreciate your comments. We also believe that results assessment of the device implantation by means of validated questionnaires is needed. Achievement of continence is by itself the most simple and reliable way to define a “success,” but at the same time it risks being an excessively “mechanical” definition with respect to quality of life issues. Indeed, a score obtained from the assessment of urinary function allows for the correct definition of “success,” or not in patients who do not regain complete continence or who become perfectly dry but have an impaired quality of life because of urinary frequency or urgency. We also believe that experience from other surgeons is needed to reliably assess the pros and cons related to the procedure. To our knowledge, results of about 120 patients implanted with the periurethral constrictor have been published to date. However, this seems a small number. Finally, let us report only about an emerging problem, which is the onset of late incontinence (after a period of continence) or worsening preexisting incontinence in long-term survivors submitted to radical prostatectomy. They form a new category of patients, including some of the individuals described in our paper, that is gradually increasing. In general, the problem afflicts elderly people, who frequently carry many comorbidities and are poorly compliant in using the scrotal pump to begin to urinate. They probably would benefit greatly from the periurethral constrictor implantation because it is easy to be positioned, allowing a minimally invasive, fast surgery; it does not need a pump; and it is not expensive. We strongly believe this specific topic could be the object of future interesting studies.

Laparoscopically Assisted Vaginal Pull-through for High Urogenital Sinus: A New Surgical Technique

2012-03-26

Objective: To evaluate feasibility and outcome of a laparoscopically assisted vaginal pull through procedure for suprasphincteric high urogenital sinus malformation with hydrometrocolpos and normal external genitalia. Methods: A tension-free anastomosis of the vagina to the perineum was realized after laparoscopic mobilization of the vagina, separation from the bladder neck at the confluence and pull-through via an externally introduced expandable trocar, thereby avoiding perineal or perirectal dissection. Results: The approach resulted in good cosmetic and unimpaired functional outcome. Voiding cystourethrography showed normal lower urinary tract anatomy. No disturbances of bladder function could be detected 2 years after surgery. Conclusion: Laparoscopic assisted vaginal pull-through is a new approach for high UGS that significantly improved exposure of the uretro-vaginal junction, allowed extensive mobilization of the vagina and showed excellent cosmetic and functional result.

Selenium and Lycopene Attenuate Cisplatin-induced Testicular Toxicity Associated With Oxidative Stress in Wistar Rats

2012-05-01

Objective: To investigate the potential protective effects of selenium and lycopene, either alone or in combination, for cisplatin-induced oxidative stress and testicular dysfunction in male rats. Methods: A total of 50 adult male Wistar rats were divided into 5 groups of 10 animals each, as follows: control group (treated with placebo); cisplatin-alone group; cisplatin + lycopene group; cisplatin + selenium group; and cisplatin + selenium + lycopene group. The weights and dimensions of testes, epididymes, and accessory glands as well as sperm concentration, motility, and proportion of normal morphology were assessed. Testicular tissue malondialdehyde (MDA) and glutathione (GSH) levels, as well as superoxide dismutase (SOD), glutathione peroxidase (GSH-Px), and catalase (CAT) activities, and plasma testosterone were determined. Results: Cisplatin treatment caused significant reductions in weights and dimensions of testes, epididymes, and accessory glands, sperm concentration, motility, and proportion of normal morphology, enzymatic and nonenzymatic antioxidants, and plasma testosterone levels. There was significantly increased MDA. The co-administration of selenium and lycopene, either separately or in combination, significantly attenuated the harmful effects of cisplatin-induced lipid peroxidation, oxidative stress, loss of genital organ weight and dimensions, as well as function of reproductive organs collectively in the Wistar rat model. The combination of selenium and lycopene was more effective than supplementation of either agent alone in preventing cisplatin-induced testicular damage. Conclusion: Selenium and lycopene supplementation reduced cisplatin-induced testicular toxicity, improved testicular function and prevented cisplatin-related injury to the rat testes by suppression of oxidative stress.

Functional Role of Muscarinic Receptor Subtypes in Calcium Sensitization and Their Contribution to Rho-kinase and Protein Kinase C Pathways in Contraction of Human Detrusor Smooth Muscle

Nouval Shahab, Shunichi Kajioka, Narihito Seki, Seiji Naito — 2012-05-01

Objective: We investigated the role of muscarinic receptor subtypes in calcium sensitization and their contribution to rho-kinase (ROK) and protein kinase C (PKC) pathways in carbachol (CCh)-induced contraction of human detrusor smooth muscle (DSM). Materials and Methods: α-toxin-permeabilized human DSM strips were prepared and mounted horizontally to record isometric force. The roles of M2 and M3 muscarinic receptors in Ca2+ sensitization were studied using selective antagonists of M2 (AF-DX116) and M3 (4-DAMP) receptor subtypes. The effects of a selective inhibitor of ROK, Y-27632, and a selective inhibitor of PKC, bisindolylmaleimide I (GF-109203X), were also studied on contraction induced by 10 μM CCh with 100 μM guanosine triphosphate at a fixed 1 μM [Ca2+]i after preincubation with 1 μM AF-DX116 or 1 μM 4-DAMP. Results: Carbachol-induced Ca2+ sensitization was predominantly inhibited by 4-DAMP compared with AF-DX116. Four-DAMP equivalently inhibited the relaxation effect of 5 μM GF-109203X as well as that of 5 μM Y-27632 on CCh-induced Ca2+ sensitization. AF-DX116 reduced the relaxation effect of Y-27632 to a greater degree than GF-109203X. Conclusion: The results of the present study have demonstrated the predominant role of M3 receptor subtype in Ca2+ sensitization and the relative contribution to ROK and PKC pathways. Our study also shows that the ROK pathway is dominant compared with the PKC pathway after M2 receptor activation, which in turn is inferior, but not negligible, in producing Ca2+ sensitization.

Role of M2 and M3 Muscarinic Acetylcholine Receptor Subtypes in Activation of Bladder Afferent Pathways in Spinal Cord Injured Rats

2012-03-05

Objective: To evaluate the role of M2 and M3 muscarinic acetylcholine receptor (mAChR) subtypes in the activation of bladder afferent pathways in rats with chronic spinal cord injury (SCI). Methods: Adult female Sprague-Dawley rats were spinalized at the T9 level. Continuous cystometry was performed under awake conditions 2 or 4 weeks after SCI. The effects of intravesical administration of an mAChR agonist (oxotremorine-methiodide), a nonselective antagonist (atropine), an M2-selective antagonist (methoctramine), and an M3-selective antagonist (darifenacin) were examined. After cystometry, the bladder was removed and separated into the mucosa and detrusor, and the M2 and M3 mAChR mRNA expression in the mucosa was determined using real-time quantitative polymerase chain reaction. Results: At 2 and 4 weeks after SCI, intravesical administration of a nonselective mAChR agonist (25 μM oxotremorine-methiodide) increased the area under the curve of nonvoiding contractions, although the intercontraction interval of voiding contractions and maximal voiding pressure did not change. This effect was blocked by atropine and methoctramine (10 μM) but not by darifenacin (50 μM). However, mAChR antagonists alone (10-50 μM) had no effect on cystometric parameters. M2 mAChR mRNA expression was increased in the mucosa of SCI rats compared with that in normal rats. Conclusion: Our results suggest that the M2 mAChR subtype plays an important role in bladder afferent activation that enhances detrusor overactivity in SCI rats. However, because mAChR antagonists alone did not affect any cystometric parameters, the muscarinic mechanism controlling bladder afferent activity might not be involved in the emergence of detrusor overactivity in SCI.

Vascular Endothelial Growth Factor, Carbonic Anhydrase 9, and Angiogenin as Urinary Biomarkers for Bladder Cancer Detection

2012-03-05

Objective: To investigate whether elevated urinary levels of vascular endothelial growth factor (VEGF), carbonic anhydrase 9 (CA9), and angiogenin are associated with bladder cancer (BCa). Methods: This was a case-control study in which voided urine samples from 127 patients (63 control subjects and 64 patients with BCa) were analyzed. The urinary concentrations of VEGF, CA9, angiogenin, and bladder tumor antigen (BTA) were assessed using enzyme-linked immunosorbent assays. We used the area under the curve of receiver operating characteristic curves to determine the ability of VEGF, CA9, and angiogenin to detect BCa in voided urine samples. Data were also compared with the findings from a commercial enzyme-linked immunosorbent assay-based BCa detection assay (BTA-Trak). The sensitivity, specificity, and positive and negative predictive values were calculated. Results: The urinary concentrations of VEGF, CA9, angiogenin, and BTA were significantly elevated in those with BCa. VEGF was the most accurate urinary biomarker (area under the curve 0.886, 95% confidence interval 0.8301-0.9418). Furthermore, multivariate regression analysis highlighted VEGF (odds ratio 5.90, 95% confidence interval 2.60-13.40, P < .0001) as an independent variable. The sensitivity and specificity for VEGF (83% sensitivity and 87% specificity) outperformed those for BTA (80% sensitivity and 84% specificity). Conclusion: VEGF could be a valuable addition to voided urine sample analysis for the detection of BCa. Larger, prospective studies are needed to determine the clinical utility of urinary VEGF and angiogenin as biomarkers in the noninvasive evaluation of patients with BCa.

Live Surgical Demonstrations: An Old, but Increasingly Controversial Practice

Brian Duty, Zhamshid Okhunov, Justin Friedlander, Zeph Okeke, Arthur Smith — 2012-02-27

Objective: To survey a group of leading academic urologists from North America and abroad about their opinions regarding the educational value, safety, and ethics of live surgical demonstrations. Materials and Methods: An anonymous survey pertaining to live clinical demonstrations was sent to all active members of the American Association of Genitourinary Surgeons (AAGUS). Results: Ninety (50%) members completed the survey. Most respondents had performed at least one live surgical demonstration (93.2% at away institution, 81.5% at home institution). Overall anxiety level as a visiting professor was rated as moderate, high, and very high by 29.8%, 25.0%, and 17.9% of respondents, respectively. Anxiety while performing demonstrations at one's home institution was reported as moderate, high, and very high by 28.2%, 9.9%, and 8.5% of respondents, respectively. Excessive conversation in the operating room was cited as a major distraction by 41.3% of respondents. Concern over the appropriateness of selected cases was reported often (43.9%) and always (13.4%) of the time. Only 28.2% of AAGUS members would let a visiting faculty member operate on them or a family member. Most (70.9%) respondents felt live surgical demonstrations are morally ethical, but only 30.1% stated they should continue indefinitely in their present form. Conclusion: No studies have been published within the urological literature about live operative demonstrations. Results from the present survey support concerns within the cardiothoracic and endoscopy literature about the continued use of live operative demonstrations. A formal review culminating in the development of an explicit policy statement by urologists should be undertaken.

Characterization of Urine-derived Cells From Upper Urinary Tract in Patients With Bladder Cancer

2012-03-01

Objective: To investigate whether cells isolated from the upper urinary tract (UTCs) possess stem cell characteristics and could be an alternative cell source for patients with bladder cancer. Current tissue engineering approaches for urologic tissue regeneration require invasive tissue biopsies to obtain autologous cells, and these procedures are associated with potential complications, such as donor site morbidity. Recently, cells isolated from voided urine (VUCs) have been proposed as an alternative cell source for urologic tissue engineering. However, VUCs should not be used in patients with bladder cancer, because the voided urine sample could contain malignant cells. Methods: Urine samples were collected from the upper urinary tract of 4 male patients with bladder cancer using a ureteral catheter. The samples were centrifuged and the pellets plated for primary culture. The cells were analyzed for colony-forming unit, proliferation rate, cytogenetics, stem cell characterization, and tumorigenicity. The results were compared with those of VUCs collected from 3 healthy men. Results: The UTCs were able to form colonies, had a greater proliferation rate than the VUCs, and had a normal karyotype without any chromosomal aberrations. The UTCs possessed stem cell characteristics (expression of CD44+, CD73+, CD90+, CD105+, SSEA4+) and expressed several markers for urothelial, smooth muscle, and endothelial cell lineages. The UTCs did not form teratoma when implanted into the subcapsular space of a mouse kidney. Conclusion: The UTCs possessed stem cell characteristics and can potentially be an alternative cell source for urologic tissue regeneration in patients with bladder cancer.

Hydroxyfasudil Ameliorates Bladder Dysfunction in Male Spontaneously Hypertensive Rats

Seiya Inoue, Motoaki Saito, Atsushi Takenaka — 2012-02-27

Objective: To investigate the effect of hydroxyfasudil, a nonselective Rho-kinase inhibitor, on hypertension-related bladder dysfunction in spontaneously hypertensive rats (SHRs), as there is an increasing evidence that the Rho-associated protein kinase (ROCK) system plays an important role in bladder contraction. Methods: Twelve-week-old male SHRs were treated with hydroxyfasudil (1 mg/kg i.p.) once a day for 6 weeks. Wistar rats and SHRs without treatment with hydroxyfasudil were used as controls. Six weeks after the hydroxyfasudil treatment, voiding functions were evaluated by metabolic cages and cystometric studies under urethane anesthesia (1.0 g/kg i.p.). Bladder blood flow (BBF) was estimated by the hydrogen clearance method. The bladder tissue levels of nerve growth factor (NGF) and ROCK activity were evaluated by the ELISA method. Results: The SHR showed significant increases in micturition frequency and decreases in single-voided volume in metabolic cages, and significantly increases in micturition frequency and intercontractile interval in cystometric studies. Furthermore, the SHR showed significant increases in the BBF and bladder NGF concentration compared with the Wistar rats. These alterations in the SHR were significantly ameliorated after treatment with hydroxyfasudil, with small changes in blood pressure. However, the maximum detrusor pressures during voiding and the ROCK activities in the experimental bladders were similar in all rats examined. Conclusion: Our data indicate that this dose of hydroxyfasudil was effective on the BBF, whereas it had no significant effect on micturition pressure. These findings suggest that hydroxyfasudil could ameliorate hypertension-related bladder dysfunction in the SHR via improvement of the BBF (248 words).

Papillary Renal Cell Carcinoma Is Associated With PTEN Hamartoma Tumor Syndrome

Jessica L. Mester, Ming Zhou, Nichole Prescott, Charis Eng — 2012-03-01

Objective: To formally study the prevalence and histologic classification of renal cell carcinoma (RCC) in a series of patients with PTEN hamartoma tumor syndrome (PHTS). Methods: We evaluated prevalence of RCC within a prospectively-accrued series of 219 patients found to have pathogenic germline PTEN mutations. Clinical data including pathology reports were requested for all participants. Slides and tumor blocks were requested for central pathology re-review and immunohistochemistry (IHC) analysis. Results: Nine patients were identified with RCC. Based on Surveillance Epidemiology and End Results (SEER) data 0.28 RCC cases were expected for the group, giving an overall age-adjusted Standardized Incidence Ratio (SIR) of 31.7 (95% CI 15.4-58.1, P < 0.001) with a higher sex-adjusted SIR for females (46.7 vs 21.6 for males). Reported histology of each mutation positive patient's RCC was variable. However, on central pathology re-review of eight patients, six examined lesions were determined to be of papillary subhistology (pRCC), with the other two patients' tumors consistent with the initial report of chromophobe RCC (chRCC). IHC demonstrated complete loss of PTEN protein in all PTEN mutation positive patients' pRCCs and patchy positivity in one chRCC. Conclusion: PHTS is a hereditary syndrome newly associated with pRCC, and PTEN IHC may be a helpful screening tool to identify pRCC patients with PHTS. Physicians caring for PHTS patients should note the >31-fold increased risk for RCC and have a low threshold for investigating possible RCC in patients with relevant complaints. Renal ultrasound is not sensitive for detecting pRCC and so PHTS patients should have alternate renal imaging (CT or MRI).

Unusual Presentation of Bilateral Ureteroceles With Ureterolithiasis in a Patient After Robotic Prostatectomy

Toby Lees, Naveen Kella — 2012-05-01

We present a unique case of incidentally discovered symptomatic, stone-laden ureteroceles after robotic prostatectomy at a high-volume institution. The 2-month postoperative timeline to presentation and laser unroofing management strategy for bilateral ureteroceles after robotic prostatectomy are described.

Upper Ureteric Obstruction Secondary to Entrapment Between Twin Segments of Inferior Vena Cava—An Unusual Occurrence

2012-05-01

A retrocaval ureter is a rare congenital cause of upper ureteric obstruction that results from entrapment of the upper ureter by the inferior vena cava (IVC) as it courses posterior to the cava. We report an interesting scenario of upper ureteric obstruction secondary to entrapment between twin segments of IVC.

Bladder Metastasis From Maxillary Sinus Undifferentiated Carcinoma: A Rare Case

François-Xavier Nouhaud, Sophie Le Gal — 2012-03-26

We report the rare case of a 72-year-old woman with maxillary sinus undifferentiated carcinoma with metachronous metastasis localized to the bladder. Bladder metastases and maxillary sinus carcinoma are rare tumors. The bladder is not 1 of the usual sites of distant extension for parasinus tumors. To our knowledge, no data have been reported regarding bladder metastasis originating from a maxillary sinus carcinoma.

Cystographic Images of Youssef Syndrome: Flower on Top of the Bladder

Apul Goel, Sangeeta Goel, Bhupendra P. Singh, Satya N. Sankhwar — 2012-03-26

Vesicouterine fistula after obstructed labor is very rare. Hysterosalpingography is the investigation of choice. Cystography primarily does not demonstrate the fistula because the intrauterine pressures are higher than the vesical pressure. A 38-year-old woman presented to us with vecisovaginal fistula and vesicouterine fistula that had developed 13 years earlier after obstructed labor and vaginal delivery of a stillborn neonate. She was found to have normal renal function, but she had developed small capacity bladder and the cystogram performed with Foley catheter showed contrast spilling into the uterus. She was managed by continent urinary diversion.

Caliceal-cutaneous Fistula After Kidney Transplantation

2012-03-05

Urinary fistula is a one of the most common complications after kidney transplantation. Conservative treatment with stent and Foley catheter drainage may be tried, however in some cases more invasive approach is needed. Caliceal fistula is a rare condition and the diagnosis may be missed. Here we present an interesting case of caliceal-cutaneous fistula diagnosed by computed tomography after living kidney transplantation. After failure of conservative management, the patient was successfully treated with partial nephrectomy.

Hepatic Splenosis Diagnosed After Inappropriate Metastatic Evaluation in Patient With Low-risk Prostate Cancer

Hanhan Li, Devon Snow-Lisy, Eric A. Klein — 2011-11-25

A man interested in active surveillance of low-risk prostate cancer sought a second opinion after having undergone an inappropriate metastatic evaluation that demonstrated multiple enhancing liver masses. Because of his history of splenectomy for trauma, hepatic splenosis was suspected. Despite reassurance, the patient desired biopsy of the masses to confirm splenosis. The imaging features and pathophysiology of hepatic splenosis are presented. Owing to the low rates of metastatic disease, the current guidelines do not recommend diagnostic imaging for low-risk prostate cancer. The present case illustrates the dangers of the current widespread practice of inappropriate diagnostic imaging of patients with low-risk prostate cancer.

Metastatic Prostate Carcinoma Mimicking Primary Anal Cancer

Valerie Kremer, Arye Kremer, Kiyanda Baldwin, Sandeep Sirsi, Amer Rafiaa — 2011-11-16

A 71-year-old man with a history of castration-refractory prostate cancer was initially treated with hormonal therapy. He responded with a decreasing prostate-specific antigen level and improved symptoms. Chemotherapy was initiated later, after an increasing prostate-specific antigen level and findings of distant metastases. Nine months after his initial diagnosis, he presented with a large multinodular perianal mass that was suspicious for primary anal cancer. Biopsy revealed poorly differentiated metastatic prostate carcinoma. The patient died 2 months after the initial presentation with perianal skin metastasis.

Metastatic Renal Cell Carcinoma to the Phalanx

Douglas F. Beach, Robert Somer — 2011-11-23

A 79-year-old man presented with a history of clear cell carcinoma of the right kidney, Fuhrman grade 2, 12 years after nephrectomy, and a history of low-risk prostate adenocarcinoma 11 years after brachytherapy. One year before presentation, the renal cell carcinoma had metastasized to his axial skeleton, and temsirolimus was started. Approximately 1 year later, he presented with a new, painful, lytic lesion in a rare site, his middle phalanx, which was biopsy proven to be clear cell carcinoma.

Re: Isen et al.: Experience With the Diagnosis and Management of Symptomatic Ureteric Stones During Pregnancy (Urology 2012;79:508-512)

2012-05-01

Symptomatic ureteric stones during pregnancy pose a diagnostic and therapeutic challenge for the managing physician. Diagnostic signs may be obscured because of normal physiological and anatomic changes during pregnancy. The treatment of symptomatic ureteric stones during pregnancy is also controversial. In the study by Isen et al, the diagnosis and treatment of symptomatic ureteric stones was discussed. However, other concerns should be added to the published data, which will serve as a guide for evaluation of these patients with symptomatic ureteric stones.

Reply by the Authors

2012-05-01

Thank you for the comments on our report about the experience with the diagnosis and management of symptomatic ureteric stones during pregnancy. Symptomatic ureteric stones in pregnancy are often a diagnostic and therapeutic challenge. At present, ultrasonography (US) is the preferred first-line imaging modality in pregnancy, being noninvasive and free of ionizing radiation. However, it is operator-dependent and sensitivity ranges from 34% to 95.2%. Similarly, we used US in our study, and the ureteric stones were diagnosed in approximately 70% of the patients. US did not adequately resolve the diagnostic dilemma in approximately 30% patients at the time of initial assessment. For the patients, additional Doppler sonographic features of obstruction, including resistance index (RI), inter-renal difference in RI (ΔRI), asymmetric absence of the ureteric jet, or hydronephrosis inconsistent with only physiologic changes of pregnancy may also be used for resolving the diagnostic dilemma. They may enhance the accuracy of US as a diagnostic test for ureteric stones in pregnancy. However, all of the features indicate the grade of obstruction are operator dependent, and do not actually show the stones. Furthermore, Doppler US findings in asymptomatic pregnant women may simulate the appearance of high-grade ureteral obstruction because of diminished smooth muscle tone in the ureter and extrinsic ureteral compression by the gravid uterus. Approximately 15% of asymptomatic pregnant women have been reported to have absent unilateral jets. Doppler US is somewhat time-consuming and requires hydration, which permits better detection of ureteral jets by increasing the difference in specific gravity between the incoming urine and urine in the bladder. This may not be well tolerated by all pregnant patients. Although some authors recommend that these Doppler sonographic features should be included in diagnosis of symptomatic ureteric stones during pregnancy, at present, routine usage of this feature for resolving this dilemma is limited and controversial.

Re: Moore et al.: Treatment of Vesicoureteral Reflux in Adults by Endoscopic Injection (Urology 2011;77:1284-1287)

Sunil P. Shenoy, Prashanth K. Marla, M.B. Hanumanthappa — 2012-05-01

We congratulate the authors on the excellent study. The results suggest that the STING procedure or its hydrodistention implantation (HIT) modification, being patient friendly, simple to perform and comparably effective, may be the treatment of choice for adult primary vesicoureteral reflux (VUR). We wish to offer our comments on the study.

Reply by the Authors

Katherine Moore, Stéphane Bolduc — 2012-05-01

We acknowledge the comments of our readers and take this opportunity to clarify some points regarding our original paper. We agree that all patients should ideally have both a pre- and postoperative DMSA scan to document scarring. However, in our population, only 15% of patients showed renal scars on preoperative imaging after recurrent pyelonephritis, thus making the odds of new ones extremely low, especially without other infection. Furthermore, we assert that renal scarring after pyelonephritis is a rare event in adults as compared to the pediatric population. Early treatment was shown to be effective in preserving nephron integrity. In our study, we did not consider observation to be an alternative option because of the recurring pattern of pyelonephritis; most patients had already failed conservative management, ie, observation, antibiotic prophylaxis, or treatment of dysfunctional voiding. We argue that the control of infective events alone had a great impact on the patients who needed admission. Loss of productivity with major impact on daily activities for several days was documented for a large number of patients.

Re: Göktas et al.: SWL in Lower Calyceal Calculi: Evaluation of the Treatment Results in Children and Adults? (Urology 2011;78:1402-1406)

Swarnendu Mandal, Apul Goel, Jai Prakash — 2012-05-01

Goktas et al compared the results of extracorporeal shockwave lithotripsy (ESWL) for inferior pole calculi between children and adults. They found 86% stone-free rates in children compared with 31.5% in adults and therefore recommended ESWL as the preferred initial treatment of lower pole calculi of 1-2.5 cm in children. They postulate that the good results are a result of lower loss of energy through the small body volume of a child; shorter, more elastic, and distensible ureter in children; and greater ability to clear stone fragments than in adults.

Reply by the Authors

2012-05-01

Regarding the easy and practical disintegration of the stones in pediatric cases, all discussed parameters that lead to an effective disintegration of the calculi are all hypothetical. No reliable study data could be found in the literature that either evaluated or compared these factors in adults. Each of these factors (mentioned in our study as well as mentioned by the author here) may have a certain role in the easy disintegration of the stones and we agree with the author that the shorter duration of the disease in pediatric cases could lead to an effective disintegration of the stones in the lower pole.

Re: Twardowski et al.: Phase II Study of Aflibercept (VEGF-Trap) in Patients With Recurrent or Metastatic Urothelial Cancer: A California Cancer Consortium Trial (Urology 2010;76:923-926)

Przemyslaw Twardowski — 2012-05-01

It recently came to my attention that I have not acknowledged the key contributor to the manuscript “Phase II Study of Aflibercept (VEGF-Trap) in Patients with Recurrent or Metastatic Urothelial Cancer: a California Cancer Consortium Trial.”

Re: Liao et al.: Serum C-reactive Protein Levels are Associated With Residual Urgency Symptoms in Patients With Benign Prostatic Hyperplasia After Medical Treatment. (Urology 2011;78:1373-1379)

Swarnendu Mandal, Sachin B. Patil, Apul Goel — 2012-05-01

We congratulate the authors for this innovative article where they have documented elevated serum C-reactive protein (CRP) levels in men with the residual symptom of urgency after receiving medical therapy for benign prostatic hyperplasia. The authors hypothesize that chronic inflammation (probably in the prostate) may have a role in residual urgency. CRP is excreted in the urine and its level has also been measured in other body fluids. Can chronic inflammation of the urinary tract lead to high levels of CRP in the urine? If so, then we feel that urinary CRP rather than serum CRP would have been more useful.

Reply by the Authors

Chun-Hou Liao, Hann-Chorng Kuo — 2012-05-01

Although male lower urinary tract symptoms (LUTS) had traditionally been attributed to benign prostatic hyperplasia, bladder dysfunction and comorbidities have also been considered possible causes of LUTS. We have reported that serum C-reactive protein (CRP) levels are greater in patients with overactive bladder (OAB) and interstitial cystitis. A recent population-based study also showed a consistent association of increased serum CRP levels with OAB in both men and women. The elevated serum CRP level in male LUTS might reflect not only chronic inflammation in the prostate, but also chronic inflammation in the urinary bladder.

Re: Rourke et al.: Effect of Wound Closure on Buccal Mucosal Graft Harvest Site Morbidity: Results of a Randomized Prospective Trial (Urology 2012;79:443-447)

Swarnendu Mandal, Vishwajeet Singh, Satyanarayan Sankhwar — 2012-05-01

We congratulate the authors on conducting a randomized prospective trial that suggests that leaving the buccal mucosa graft harvest site open (compared with closure of the donor site) leads to lower early pain scores, an earlier return to a full diet, an earlier return to full mouth opening, and a decrease in bothersome perioral numbness postoperatively. Their results are similar to our published data (nonrandomized).

Re: Binbay et al.: Does Pelvicaliceal System Anatomy Affect Success of Percutaneous Nephrolithotomy? (Urology 2011;78:737-738)

Apul Goel, Swarnendu Mandal, Arvind Kumar — 2012-05-01

We read with great interest this article on the risk factors for residual stones after percutaneous nephrolithomy (PCNL). The authors have looked into the variables of pelvicaliceal system (PCS) anatomy to predict success or failure of the procedure. The authors reported that only 2 parameters predicted the success rate: staghorn type of stone and the PCS surface area. In our opinion, these are confounding variables because they address the same parameter. As the stone size increases, there is always a simultaneous increase in the size of the PCS. In fact, there were 58.7% patients with staghorn type of stone in patients with PCNL failure (where the PCS surface area was also found to be large) compared with only 21.1% of patients in the group with PCNL success. In our opinion, the larger surface of the PCS is not an independent risk factor for the failure of PCNL. The authors have reasoned that the lower success rate in larger systems is caused by: (1) Difficulty in reaching stones located in other calices through a single access point; (2) short size of equipment, especially in the obese; (3) need for multiple punctures; (4) ineffectiveness of a flexible nephroscope, especially for long infundibular lengths; and (5) stone migration into inaccessible calices during fragmentation.

Aims and Scope

2012-05-01

Editorial Board

2012-05-01