Urology - Articles in Press

Prospective Randomized Multicenter Study Comparing Prostate Cancer Detection Rates of End-fire and Side-fire Transrectal Ultrasound Probe Configuration - Corrected Proof

2012-05-11

Objective: To prospectively test the hypothesis that end-fire transrectal ultrasound prostate biopsy probes have greater cancer detection rates than side-fire probes. Retrospective studies have suggested that such probes might have greater cancer detection rates. Methods: The present prospective randomized multicenter trial aimed to compare the prostate cancer detection rates of the end-fire versus side-fire probe configuration during transrectal ultrasound-guided 12-core prostate biopsy. Patients were randomized according to age, prostate-specific antigen level and prostate volume. An interim analysis was planned after the inclusion of 300 patients. Results: At the interim analysis after the inclusion of 297 patients, no differences were found in the mean prostate-specific antigen level (P = .412), mean age (P = .519), mean prostate volume (P = .730), and positive digital rectal examination findings (P = .295). The prostate cancer detection rate did not differ between the end-fire and side-fire probe (34.3% vs 34.4%, P = .972). On multivariate analysis, suspicious digital rectal examination findings (relative risk 8.185, P < .001), prostate-specific antigen level (relative risk 1.051, P = .041), and prostate volume (relative risk 0.973, P < .001), but not probe configuration (relative risk 0.942, P = .831), were independent predictive factors for the detection of prostate cancer. The interim analysis committee suggested that, because no difference of 5 absolute percent was achieved after 300 patients, no additional recruitment was necessary. Therefore, the study was terminated early. Conclusion: The results of the present study have shown that the transrectal ultrasound probe configuration does not affect the prostate cancer detection rate during transrectal ultrasound-guided prostate biopsy.

Editorial Comment - Corrected Proof

J. Stephen Jones — 2012-05-11

Since the time we observed and then reported that PCa detection was significantly greater when biopsy had been performed using end-fire probes, we have emphasized in our courses and resident/fellow teaching that the side-fire probe tends to aim the biopsy needle tangentially, often missing cancer in the anterior prostate and “very apex.” To overcome this, when using the side-fire probe since that time, we intentionally torque the probe to ensure that these areas are included in the biopsy sample.

Urinary Metabolic Evaluation of Stone Formers—A Malaysian Perspective - Corrected Proof

Yet Hoi Hong, Norman Dublin, Azad Hassan Razack, Mustafa Ali Mohd, Ruby Husain — 2012-05-11

Objective: To investigate the urinary metabolic excretion pattern among local stone formers given the great differences in the intrinsic and extrinsic risk factors as well as the urinary metabolic excretions compared with other populations. Methods: Thirty urinary stone formers out of an initial 62 recruited provided a complete 24-hour urine sample for metabolic evaluation. Student's t-test and Pearson correlation test were used for the statistical analysis. Results: Urinary volume (1719 ± 712 vs 1215 ± 575, P < .05) and oxalate excretion (0.386 ± 0.111 vs 0.306 ± 0.104, P < .05) were significantly higher among stone formers than controls. Other commonly studied urinary parameters and urinary melamine did not differ significantly between the 2 groups. Similarly, the calcium/citrate ratio was unable to discriminate the stone formers from their controls. Hypocitraturia was the most prevalent urinary abnormality found in stone formers and low urinary citrate excretion was a general phenomenon in both stone formers and controls. Comparing within the stone formers cohort, the recurrent stone formers had a significantly higher urinary saturation and calcium excretion than their first-time stone former counterparts. Conclusion: Elevated urinary oxalate level was the most important urinary risk factor among the local stone formers. A low urinary citrate excretion appeared to be a general phenomenon among the studied cohorts.

Ischemic Postconditioning Inhibits the Renal Fibrosis Induced by Ischemia-reperfusion Injury in Rats - Corrected Proof

2012-05-11

Objective: To investigate whether ischemic postconditioning effects on the development of tubulointerstitial fibrosis follow acute renal ischemia-reperfusion. Methods: Rat models of warm renal I/R were established by clamping left pedicles for 45 minutes after right nephrectomy, both with and without treatment with ischemic postconditioning, and then reperfused for up to 12 weeks. Hematoxylin–eosin (H&E) and Masson's trichrome staining were used to assess renal fibrosis. The expression spot and protein levels of α-smooth muscle actin (α-SMA), transforming growth factor–β1 (TGF-β1), and phospho-Smad2 were also analyzed. Results: Our data showed that patchy inflammation and tubulointerstitial fibrosis were found 12 weeks later in rats subjected to I/R alone or with postconditioning. Tubulointerstitial fibrosis worsened further in rats subjected to 45-minute ischemia-reperfusion, accompanied by the increased expressions of α-SMA, TGF-β1, and phospho-Smad2 at the end of 12 weeks. In contrast, the above histologic changes and molecular expressions were significantly attenuated in rats of ischemic postconditioning group. Conclusion: The results indicated that 45-minute I/R injury may cause tubulointerstitial fibrosis in the long term, and ischemic postconditioning has beneficial effects on renal fibrosis. Its mechanisms may involve inhibition of the TGF-β1/phospho-Smad2 pathway to exert protective effects.

Scarless Pyeloplasty in the Pediatric Population - Corrected Proof

Paul H. Noh, Goutham Vemana — 2012-05-11

Objective: To assess the outcomes of a modified technique for pediatric laparoscopic pyeloplasty (LP) performed without instrument trocars. Methods: A retrospective cohort study for all LPs performed without instrument trocars was performed. Patient demographics, surgical technique, complications, and clinical outcomes were reviewed. All patients undergoing this procedure had a single trocar placed to insufflate and introduce the laparoscope. Skin punctures were used without trocars to introduce 3-mm instrumentation for LP. Results: Nine patients with 10 procedures were identified. Median age was 8 months old (range 3-190). Median weight was 8.3 kg (range 5.9-70.5). Median operative time was 229 minutes (range 145-387). All procedures were performed without additional trocars. There were no open conversions. Median hospital stay was 1 day (range 1-4). Median narcotic use was 0.1 mg/kg/d of intravenous morphine equivalent. There were no intraoperative complications. Median follow-up was 36 months (range 18-45). Follow-up renal ultrasound evaluation has demonstrated improved hydronephrosis in all patients. No reoperative pyeloplasty was performed. Subjective assessment of cosmesis has shown excellent outcome with almost imperceptible evidence of operative intervention. Conclusion: LP without instrument trocars can be safely and effectively performed without compromise of the surgical procedure, with minimal use of narcotics, and with a short hospital stay. Intermediate-term follow-up indicates encouraging results for achieving scarless surgery.

Automated Volumetric Assessment by Noncontrast Computed Tomography in the Surveillance of Nephrolithiasis - Corrected Proof

2012-05-11

Objective: To evaluate the use of automated volumetric assessment for stone surveillance and compare the results with manual linear measurement. Methods: We retrospectively reviewed patients seen in our stone clinic who had undergone 2 noncontrast computed tomography (NCCT) scans without stone intervention during the interval between scans. Thirty patients met our inclusion criteria and underwent longitudinal assessment for urolithiasis via NCCT (mean interval 583.2 days, range 122-2030). Fifty-two discrete calculi were analyzed. Three board certified radiologists measured maximal linear stone size in the axial plane using electronic calipers on soft tissue (ST) and bone windows (BWs). Automated stone volume was also obtained by each reader using a dedicated prototype software tool for stone evaluation. Results: Mean stone linear size and volume was 4.9 ± 2.8 mm (ST), 4.5 ± 2.6 mm (BW), and 116.2 ± 194.6 mm3 (window independent), respectively. Mean interobserver variability for linear size measurement was 16.4 ± 10.5% (ST) and 20.3 ± 13.8% (BW). Interobserver variability for volumetric measurement was 0%. Of the 52 persistent stones, the mean percent change in linear stone size between CT studies was 39.3 ± 46.7% (ST) and 42.9 ± 53.1% (BW) growth, compared with 171.4 ± 320.1% (window independent) growth for automated volume measurement over a mean of 583.2 days. However, discordant results for increased vs decreased interval size was seen between linear and volumetric assessment in 19/52 stones (36.5%). Conclusion: Automated volumetric measurement of renal calculi via NCCT is independent of specific reader and window settings. Volumetric assessment amplifies smaller linear changes over time, whereas as much as one third of cases show linear-volume measurement discordance. Volumetric assessment is therefore preferable, particularly for longitudinal surveillance of renal calculi.

Predictors of Immediate Postoperative Outcome of Single-tract Percutaneous Nephrolithotomy - Corrected Proof

2012-05-03

Objective: To evaluate the efficacy of single tract percutaneous nephrolithotomy (sPCNL) and investigate the preoperative predictive factors associated with stone clearance after sPCNL. Methods: A retrospective review of 351 cases of sPCNL performed at a single institution by 1 of 2 endourologists between January 2000 and March 2010 was performed. The primary outcome evaluated was stone-free rate (SFR) as assessed immediately after either an initial procedure or a second-look nephroscopy performed on postoperative day 2. Preoperative patient and stone factors, including age, sex, body mass index (BMI), preoperative hematocrit and creatinine, previous surgeries, comorbidities, renal anomalies, stone size, shape, location, and history of any previous treatment to the active stone burden were included in the univariate analysis. Significant or clinically relevant factors on univariate analysis were included in a logistic regression the multivariate analysis. Results: SFR after either an initial procedure or a second-look nephroscopy was 76%. On univariate analysis, rising preoperative creatinine, hypertension, increasing stone diameter, complete staghorn stone, presence of stones in the upper pole and absence of prior SWL were associated with lower SFR. Stone size, presence of stones in the upper pole, and prior SWL for the active burden were independent predictors of SFR on multivariate analysis. Conclusion: sPCNL is an efficient procedure to clear renal stones, especially when used in conjunction with routine second-look nephroscopy. Increasing stone size and upper pole stones are associated with lower rates of stone clearance, whereas SWL performed before percutaneous nephrolithotomy (PCNL) is associated with improved stone clearance. The role of SWL before PCNL warrants further prospective investigation.

Two Adolescent Girls With Keratinizing Squamous Metaplasia of the Bladder - Corrected Proof

2012-05-03

Squamous metaplasia is a proliferative lesion characterized by the replacement of the transitional epithelium with stratified squamous cells. In the urinary system, it is mostly seen in the bladder. It can be nonkeratinized or keratinized. We report the cases of 2 adolescent girls with keratinizing metaplasia, 1 of whom presented with difficulty with indwelling catheterization and 1 with final terminal hematuria. The predisposing factors were recurrent urinary tract infection and additional catheterization in 1 of the patients. The diagnosis was confirmed by histologic examination in both patients. We report on these cases to draw attention to this rare entity in children.

Inhibition of Fatty-acid Synthase Suppresses P-AKT and Induces Apoptosis in Bladder Cancer - Corrected Proof

Bo Jiang, En-Hui Li, You-Yi Lu, Qi Jiang, Di Cui, Yi-Feng Jing, Shu-Jie Xia — 2012-05-03

Objective: To investigate the role of fatty acid synthase (FASN) in bladder transitional cell carcinoma (BTCC). Methods: FASN expression was investigated in non–muscle-invasive BTCC tissue specimens by immunohistochemistry and BTCC cell lines by Western blot. After treatment with FASN-siRNA or FASN inhibitor cerulenin (Cer), the proliferation and apoptosis of BTCC cell lines 5637 and 253 J were determined by cell counting Kit-8 (CCK8) assay and flow cytometry respectively. The expression of p-AKT, cyclin D1 (CCND1), and apoptosis-related proteins were detected by Western blot. Results: High levels of FASN expression were observed in 59% (32/54) of non–muscle-invasive BTCC tissue specimens, and FASN expression was associated with histologic grade (P < .05) and recurrence (P < .05). FASN expression was high in 6 BTCC cell lines. FASN inhibitor Cer and FASN-siRNA produced the increased apoptosis and decreased proliferation of bladder cancer cells, and caused inactivity of AKT and downregulation of CCND1. Furthermore, treatment of BTCC cell lines with Cer resulted in apoptosis via the caspase-dependent pathway involving inactivation of antiapoptotic bcl-2 protein. Conclusion: Our data suggest that FASN plays an important role in BTCC development. Targeting FASN may be a new therapeutic strategy for BTCC.

Editorial Comment - Corrected Proof

Mohamed A. Elkoushy, Sero Andonian — 2012-05-03

The American Urological Association Guidelines recommend percutaneous nephrolithotomy (PCNL) as the standard of care for patients with staghorn or large renal stones because of the high stone-free rates (SFRs) with minimal morbidity. Before the advent of flexible fiberoptic instruments and Holmium laser lithotripters, it was not unusual for PCNL to require multiple access tracts directly on calyces containing stones to achieve stone-free status. Some authors even suggested performing auxiliary procedures, such as shock wave lithotripsy (SWL) as combination or “sandwich” therapy with PCNL to fragment stones that could not be reached using rigid instruments. However, SFRs were lower when SWL was not followed with PCNL to remove stone fragments. With the invention of flexible nephroscopes and ureteroscopes in addition to the availability of flexible miniaturized lithotripters, such as Holmium laser using 200- or 365-μm fibers, PCNL through a single incision and a single tract (sPCNL) becomes possible for large renal stones and even staghorns. In the above manuscript, the authors present a retrospective series of 351 patients who underwent sPCNL from 2000 to 2010. Although this method was first proposed by Wong and Leveillee, the authors should be commended for their meticulous collection of data over the 10-year period. In addition to limiting the incision to a single site (laparo-endoscopic single site [LESS), they also used a flexible ureteroscope through a natural orifice (urethra) during second-look nephroscopy to access calyces inaccessible using a flexible nephroscope; thus combining LESS with natural orifice transurethral endoscopic surgery (NOTES).

Status of High-risk Oncogenic Human Papillomavirus Subtypes Harbored in the Prepuce of Prepubertal Boys - Corrected Proof

Ayhan Verit, Fadile Yildiz Zeyrek, Cengiz Mordeniz, Halil Ciftci, Murat Savas — 2012-05-03

Objective: To evaluate whether the high-risk human papillomavirus (HPV) subtypes that are strongly related to cervical cancer are harbored in the prepuce of the circumcised tissue of prepubertal boys in the period just before active sexual life. Methods: The present study enrolled 30 healthy boys (age range 4-11 years, mean age 8.1 ± 1.6) who underwent a standard circumcision procedure, with hypospadias repair in 3 patients. All prepuceal samples were studied using real-time polymerase chain reaction and grouped according to HPV subtype prevalence as groups 1 (types 16 and 18), 2 (types 31, 33, 45, 52, and 58), and 3 (types 35, 39, 51, 56, 59, 66, and 68). Results: HPV DNA was reported in 25 (83.3%) of the 30 subjects. All samples showed a negative result for group 2. Although most of the positive findings were for group 3 (25 [83.3%] of 30), a positive result was reported for only 1 subject for group 1 (3.3%). Conclusion: The results of the present study have shown that the prepuce harbored the rarest HPV types, including types 35, 39, 51, 56, 59, 66, and 68 in preadolescence boys with a high rate (83%). These findings are in contrast to the common knowledge of HPV prevalence in adults that points to the dominance of HPV subtypes 16 and 18.

Coagulum Pyelolithotomy “Revisited” by Laparoscopy: Technique Modification - Corrected Proof

2012-05-03

Objective: Laparoscopic ureteropyeloplasty is a widely accepted treatment option for the obstructed ureteropelvic junction (UPJ). Although it is often a straightforward surgical procedure, there may be technical difficulties in the case of concomitant stone burden, with multiple calicial, small, mobile stones. The authors describe a modification to the classic coagulum pyelolitothomy, using a mixture based on commercially available fibrin sealant, first used in the laparoscopic era. Methods: During a laparoscopic transperitoneal dismembered ureteropyeloplasty complemented with coagulum pyelolithotomy, the following steps are suggested: (1) Exposure of the UPJ; (2) ureter clamping with a vessel loop 2 cm distal to the UPJ (to allow pelvis filling); (3) transabdominal puncture of the pelvis with an 18-G, 20-cm needle (under laparoscopic vision) and urine aspiration; (4) recording the volume of urine aspirated; (5) preparing an equal volume of fibrin sealant (to avoid overdistention of the pelvis); (6) injecting the sealer protein solution through that needle + 1 mL of methylene blue (color the coagulum and facilitate its identification in the removal procedure); (7) insertion of another needle to inject the thrombin solution; (8) wait 5 minutes to allow coagulum cast formation; (9) circumferential excision of the UPJ; (10) coagulum removal; (11) pelvis plastic reduction (if needed) and ureter spatulation; (12) double-J stent placement; and (13) tension-free anastomosis completion. Results: The procedure results in the extraction of a tenacious coagulum containing more stones than normally anticipated from the x-ray studies. Conclusions: This technique modification reduces the incidence of incomplete stone removal, when there are small, free stones lying in a large renal pelvis.

Controlled Metabolic Diet Reduces Calcium Oxalate Supersaturation but Not Oxalate Excretion After Bariatric Surgery - Corrected Proof

2012-05-03

Objective: To identify the effect of a controlled metabolic diet on reducing urinary calcium oxalate (CaOx) supersaturation in subjects with hyperoxaluric nephrolithiasis after potentially malabsorptive forms of bariatric surgery. Methods: Subjects with a history of CaOx kidney stones and mild hyperoxaluria after bariatric surgery (n = 9) collected baseline 24-hour urine samples while consuming a free choice diet. They were then instructed to consume a controlled diet low in oxalate (70-80 mg/d), normal in calcium (1000 mg/d), and moderate in protein before 2 final 24-hour urine collections. Results: Overall, the urinary CaOx supersaturation decreased from 1.97 ± 0.49 delta Gibbs (DG) with the free choice diet to 1.13 ± 0.75 DG with the controlled diet (P < .01). This occurred in the absence of a significant change in urinary oxalate excretion (0.69 ± 0.29 mmol/d with the free choice diet compared with 0.66 ± 0.38 mmol/d with the controlled diet). Urinary volume, citrate, and pH all increased, although not significantly (P > .05), contributing to the significant CaOx supersaturation change. Conclusion: A controlled metabolic diet normal in calcium, moderate in protein, and reduced in oxalate can positively affect urinary CaOx supersaturation after bariatric surgery. However, this diet did not appear to decrease urinary oxalate excretion. Therefore, restriction of dietary oxalate alone might not be enough to reduce urinary oxalate excretion to normal levels in this group of patients with known enteric hyperoxaluria. Additional strategies could be necessary, such as the use of oral calcium supplements as oxalate binders and a lower fat diet.

Barriers to Fertility Preservation in Male Adolescents with Cancer: It's Time for a Multidisciplinary Approach that Includes Urologists - Corrected Proof

Leena Nahata, Laurie E. Cohen, Richard N. Yu — 2012-04-30

A cancer diagnosis can be devastating news for a child and his or her family. Fortunately, advances in the treatment of childhood cancers have resulted in 5-year survival rates close to 80%. Late effects of cancer treatment, such as infertility, have thus become an active area of research; a recent study found that male cancer survivors were only half as likely to sire a pregnancy as healthy males. Surgery, chemotherapy, and radiation exposure can all result in temporary or permanent damage to sperm production, and fertility may be compromised soon after treatment has begun. In addition to preserving reproductive capacity, sperm cryopreservation in young adults appears to have other benefits; for example, sperm banking has been reported to help young men endure the emotional battle against cancer. For all of these reasons, boys who are able to produce a semen sample are encouraged to bank sperm before starting oncological treatment.

Combined Laparoscopic and Percutaneous Management of Calcified Renal Hydatid Cyst—A Novel Nephroscope- and Lithotripter-assisted Technique - Corrected Proof

2012-04-30

Objective: To describe the novel technique of percutaneous nephroscope-assisted renal hydatid cyst evacuation and lithotripter-assisted division of the cyst wall for combined laparoscopic and percutaneous management. Methods: A calcified hydatid cyst of the kidney is a rare entity and needs special techniques for total laparoscopic management. A 45-year-old woman was treated successfully for a calcified renal hydatid cyst using the transperitoneal laparoscopic technique. A chlorhexidine gluconate and cetrimide mixture was used as the scolicidal solution to sterilize the cyst. The endocyst and daughter cysts were removed completely under vision, after placement of a single 26F nephroscope through a 10-mm port in the cyst, with grasper and lithotripter suction, using chlorhexidine-cetrimide mixture irrigation. Laparoscopic suction did not work well for the viscous contents. The calcified cyst wall did not yield to electrocautery or piecemeal fragmentation, until weakened by division and fragmentation using the pneumatic lithotripter. Partial cyst wall exicision/marsupialisation was complemented with omentoplasty. Results: No intraoperative or early postoperative complications occurred. The patient recovered well with little pain and was discharged early. This technique, in which the principles of percutaneous nephrolithotomy were applied for a special problem, is the first of its type. Conclusion: Calcified renal hydatid cyst evacuation using the novel nephroscope-assisted retrieval of contents and lithotripter-assisted division of the calcified wall is a safe and feasible technique for total minimally invasive management.

Urolithiasis With Penile Erection: A Rare Presentation - Corrected Proof

Bing Wu, Yue Xing — 2012-04-30

Urinary stones are rarely seen in the urethra and are usually encountered in men with urethral stricture or infection. We describe a unique case of giant impacted stones in a 20-year-old man with unreal penile erection.

Evaluation of Patient-reported Quality-of-life Outcomes After Renal Surgery - Corrected Proof

2012-04-30

Objective: To assess the feasibility of 2 patient-reported health-related quality of life (HRQOL) instruments, Convalescence and Recovery Evaluation (CARE), and SF-12, as tools for evaluating HRQOL outcome consequences after renal surgery, and to determine which domains of these HRQOL instruments are most sensitive to HRQOL outcome effects of renal surgery. Methods: Patients completed CARE and SF-12 preoperatively (baseline) and at 2, 4, 12, and 24 weeks after surgery. Clinical data, patient response rate, HRQOL changes over time, and likelihood of patient return to baseline HRQOL were evaluated. Results: Seventy-one patients were enrolled. Sixty patients completed the baseline and at least 1 follow-up set of questionnaires. The CARE pain, gastrointestinal (GI), and activity domain scores and the SF-12 physical composite score (PCS) were sensitive to changes in HRQOL (all P<.05), whereas other domain subscores of these instruments did not change from presurgical baseline to postsurgical follow-up. Postsurgical HRQOL effects detected by the CARE pain, GI, and activity domains, and SF-12 PCS were most evident at 2 weeks (all P<.001). The CARE composite score demonstrated that 74% and 50% of patients returned to within 90% of baseline 4 weeks after radical and partial nephrectomy, respectively. Conclusion: Evaluation of patient-reported HRQOL outcomes after renal surgery is feasible; our findings suggest that the activity, pain, and GI domains of CARE and PCS subscores of the SF-12 are sensitive measures of HRQOL outcome consequences of renal surgery and represent appropriate measures of either care quality or comparative effectiveness analyses of robotic, laparoscopic, and open renal surgery.

A Study on Voiding Pattern of Newborns with Hypoxic Ischemic Encephalopathy - Corrected Proof

Jian G. Wen, Li Yang, Lu Xing, Ya L. Wang, Chao N. Jin, Qian Zhang — 2012-04-26

Objective: To investigate the difference of voiding pattern between newborns with and those without hypoxic ischemic encephalopathy (HIE). Methods: Forty hospitalized newborns aged 4-21 days were included in this study. Twenty-one were preterm newborns with HIE, and the remaining 19 preterm newborns were without HIE. The voided volume, postvoid residual (PVR) volume, consciousness at voiding, voiding time, voiding frequency, and quantity of intake milk and liquid within 4 hours from 8 am–12 pm were recorded. The liquid intake was the same in both groups according to standard protocol. The diaper weight difference before and after voiding was defined as voided volume. The PVR volume was determined by ultrasound. The state of consciousness at voiding was monitored by electroencephalography. Results: Voided volume and rate of consciousness at voiding was significant lower in newborns with HIE compared with the control group ([10.8 ± 6.5 mL, 16.3 ±17.1%] vs [14.1 ± 7.1 mL, 57.1 ± 21.0%], P <.05, respectively), whereas PVR volume and voiding frequency were significant higher ([1.6 ± 1.0 mL, 4.0 ± 1.1 times] vs [1.2 ± 0.9 mL, 3.2 ± 0.9 times] per 4 hours, P <.05, respectively). Conclusions: The differences in voiding pattern supported the concept that the higher centers of the central nervous system were involved in the control of voiding. HIE had a significant effect on voiding pattern of preterm newborn.

Sarcoidosis of the Ureter - Corrected Proof

2012-04-26

We report a rare case of sarcoidosis of the ureter in a 65-year-old Japanese man. Left nephroureterectomy and regional lymph node dissection were performed under the clinical diagnosis of transitional cell carcinoma of the left ureter with lymph node metastasis. Microscopically, noncaseous epithelioid granuloma with large Langerhans cells was noted in the ureter and dissected lymph nodes. Pulmonary lesions were not found on computed tomography. The final diagnosis was sarcoidosis of the ureter. Although sarcoidosis is rare in the genitourinary tract, it should be considered in the differential diagnosis of urologic conditions.

Effects of Concomitant Surgeries During Midurethral Slings (MUS) on Postoperative Complications, Voiding Dysfunction, Continence Outcomes, and Urodynamic Variables - Corrected Proof

2012-04-26

Objective: To determine whether concomitant surgeries affected outcomes in a randomized trial comparing retropubic midurethral sling (MUS) vs transobturator MUS. Methods: Subjects (n = 597) were stratified into 4 groups based on type of concomitant surgeries: group I had anterior/apical with or without posterior repairs (n = 79, 13%); group II had posterior repairs or perineorrhaphy only (n = 38, 6%); group III had nonprolapse procedures (n = 34, 6%); and group IV had no concomitant surgeries (n = 446, 75%). Complication rates, voiding dysfunction, objective and subjective surgical failure rates, and changes in urodynamic values (postop minus preop) were assessed and compared in these 4 groups. Results: There were no differences in complications, voiding dysfunction, and subjective failure outcomes between these 4 groups. Group I had lower odds ratio of objective surgical failure compared with group IV (OR 0.38, 95% CI 0.18-0.81, P = .05). The OR of failure of all patients undergoing concomitant surgeries (groups I-III) was lower than group IV (OR 0.57, 95% CI 0.35-0.95, P = .03). The change in Pdet@Qmax (from pressure-flow) was significantly higher in group III vs IV (P = .01). The change in Qmax. (from uroflowmetry) was significantly less in groups I and II vs group IV (P = .046 and .04, respectively). Conclusion: Concomitant surgeries did not increase complications. Subjects who underwent certain concomitant surgeries had lower failure rates than those undergoing slings only. These data support safety and efficacy of performing concomitant surgery at the time of MUS.

Coated Implants and “No Touch” Surgical Technique Decreases Risk of Infection in Inflatable Penile Prosthesis Implantation to 0.46% - Corrected Proof

J. Francois Eid, Steven K. Wilson, Mario Cleves, Emad A. Salem — 2012-04-23

Objective: To explore whether a “no touch” enhancement to the surgical technique of inflatable penile prosthesis (IPPs) implantaion will further decrease infection rates. Materials and Methods: A single surgeon performed 2347 IPPs between January 2002 and June 2011. Patients receiving each manufacturer's implants were stratified for age and diabetes. Since 2003, infection retardant–coated IPPs were implanted through the standardized penoscrotal approach. Since 2006, the “no touch” enhancement was added to the surgical procedure. Infection rates in the noncoated IPP, coated IPP with standard technique, and coated IPP implanted with “no touch” enhancement were calculated and subjected to statistical analysis. The two company's implants were scrutinized for their individual infection rates in each group. Results: Patients in all the groups were similar for age and diabetes. 132 noncoated implants had an infection rate of 5.3%. In the years 2003-2005, 704 coated devices had a statistically significant improvement in incidence of infection to 2%. In the years 2006-2010, the “no touch” technique enhanced the standard surgical procedure in 1511 patients. Only 7 infections were seen yielding an infection incidence of 0.46%. There was no difference in the two manufacturer's infection rates. Differentiation between virgin and revision operation displayed no bias in the infection rate. Conclusion: Infection-retardant coatings lower the risk of infection from 5.3% to 2%. The “no touch” enhancement to the surgical procedure further decreases the rate of infection to 0.46%. Neither manufacturer showed statistical superiority in survival from revision for infection.

Urethroplasty After Radiation Therapy for Prostate Cancer - Corrected Proof

2012-04-23

Objective: To report urethroplasty outcomes in men who developed urethral stricture after undergoing radiation therapy for prostate cancer. Methods: Our urethroplasty database was reviewed for cases of urethral stricture after radiation therapy for prostate cancer between June 2004 and May 2010. Patient demographics, prostate cancer therapy type, stricture length and location, and type of urethroplasty were obtained. All patients received clinical evaluation, including imaging studies post procedure. Treatment success was defined as no need for repeat surgical intervention. Results: Twenty-nine patients underwent urethroplasty for radiation-induced stricture. Previous radiation therapy included external beam radiotherapy (EBRT), radical prostatectomy (RP)/EBRT, EBRT/brachytherapy (BT) and BT alone in 11 (38%), 7 (24%), 7 (24%), and 4 (14%) patients, respectively. Mean age was 69 (±6.9) years. Mean stricture length was 2.6 (±1.6) cm. Anastomotic urethroplasty was performed in 76% patients, buccal mucosal graft in 17%, and perineal flap repair in 7%. Stricture was localized to bulbar urethra in 12 (41%), membranous in 12 (41%), vesicourethra in 3 (10%), and pan-urethral in 2 (7%) patients. Overall success rate was 90%. Median follow-up was 40 months (range 12-83). Time to recurrence ranged from 6-16 months. Conclusion: Multiple forms of urethroplasty appear to be viable options in treating radiation-induced urethral stricture. Future studies are needed to examine the durability of repairs.

Editorial Comment - Corrected Proof

Drogo K. Montague — 2012-04-23

Infection is the bane of penile prosthesis implantation surgery. To eliminate the infection, removal of all of the prosthetic material is necessary. Implantation of a second device at a later date is complicated not so much by placement of the pump or fluid reservoir as it is by cylinder implantation. Infection causes varying degrees of corporeal smooth muscle death, with subsequent fibrosis. This scarring makes the penis smaller and makes cylinder implantation difficult. In some cases, the fibrosis is so pronounced that removal of corporeal fibrotic material (corporeal excavation) is necessary.

Reply - Corrected Proof

J. Francois Eid — 2012-04-23

Diabetes was prevalent in our patient population, with 39% of noncoated implant patients, 37.9% of the standard technique patients, and 43% of the patients implanted with “no touch” having the disease. In our series, we had 28 infections total. Six patients (21%) had diabetes, 4 (14%) had erectile dysfunction (ED) after radical prostatectomy, 7 (25%) had hypertension as an associated condition, and 11 (39%) had other conditions. However, because the total number of infections was small, these figures lack statistical significance.

Editorial Comment - Corrected Proof

Joshua J. Meeks — 2012-04-23

The authors describe a large (29 patients) single-surgeon series of urethroplasty for radiation induced urethral strictures. With more prostate cancers detected every year, the rate of radiation-induced strictures will increase over time. First, the authors should be congratulated for achieving a high rate of success (90%). This rate is comparable with a previous multi-institutional series that reported a success rate >80% with reconstruction. There is now evidence that it is possible to reconstruct these very challenging surgical patients. With strictures occurring at an incidence of at least 2% of patients who receive radiotherapy, there must be more than the 59 patients treated in these series who are candidates for surgical reconstruction. As more urologists are trained in surgical reconstruction, more of these cases may be attempted with excellent outcomes. Second, the authors describe their surgical outcomes but do not address important quality-of-life outcomes, including patient satisfaction and erectile function. In a prior series, erectile dysfunction and incontinence rates approached 50% after reconstruction.

Differences in Mast Cell Infiltration, E-cadherin, and Zonula Occludens-1 Expression Between Patients With Overactive Bladder and Interstitial Cystitis/Bladder Pain Syndrome - Corrected Proof

Hsin-Tzu Liu, Jia-Heng Shie, Sung-Ho Chen, Yu-Syuan Wang, Hann-Chorng Kuo — 2012-04-23

Objective: To investigate the difference of infiltration of mast cells and the distribution of protein involved in the urothelial barrier function between patients with overactive bladder syndrome (OAB) and interstitial cystitis/bladder pain syndrome (IC/BPS). Methods: Bladder wall biopsies were performed in 27 patients with OAB, 18 patients with IC/BPS, and 19 controls. The expression of junction protein E-cadherin, tight junction protein zonula occluden (ZO-1), and activated mast cells in the bladder wall were evaluated quantitatively using immunofluorescence staining. Results: The numbers of mast cells in the urothelium and suburothelium areas were low in the control group (mean ± standard error 1.77 ± 0.47). A highly significant increase in mast cell infiltration was observed in OAB (4.00 ± 0.55, P = .002) and IC/BPS specimens (4.64 ± 0.72, P = .000). ZO-1 expression was significantly decreased in IC/PBS (7.45 ± 0.99) compared with OAB (13.46 ± 1.32, P = .004) and control bladder samples (14.55 ± 2.08, P = .004). The E-cadherin expression was also significantly decreased in IC/BPS bladder samples (59.05 ± 9.48) compared with the controls (96.30 ± 9.15, P = .001). No significant difference was found in E-cadherin or ZO-1 levels between the OAB and control bladders (P = .170 and P = .763, respectively). Conclusion: Mast cell infiltration was found in both OAB and IC/BPS bladder wall, but E-cadherin and ZO-1 expression was only decreased in IC/BPS, suggesting the urothelial barrier function was not affected in the OAB bladder.

A Novel Approach in Eight Polyorchidism Cases: Vasoepidydimal or Epididymo-epididymal Approximation in Single Vas Deferens Duplicated Testis - Corrected Proof

2012-04-23

Objective: To discuss the classification systems and pose a rationale for a flexible approach. We also propose our surgical approach for vasoepididymal or epidymo-epididymal approximation. Polyorchidism is a rare congenital anomaly with about 200 cases reported. Methods: We present 8 cases of polyorchidism treated at our institute from 1992 to 2010. To our knowledge, this is the most numerous single-center experience. We performed vasoepididymal or epidymo-epididymal approximation to restore near-normal anatomy plus stabilization of the testicular and ductal system to facilitate possible future reconstructive surgery. Results: In the case of contralateral anorchia or an atrophic testis, a supernumerary testis can fairly replace the contralateral counterpart. The reproductive potential of the supernumerary testis must not be ignored. Also, the malignant potential of the supernumerary testis should not be overestimated. Conclusion: A careful pursuit of the vessel and vasal route during surgery for an undescended testis, judicious use of laparoscopy, and a lower threshold for diagnosis both on imaging studies and during surgery might result in a greater number of cases of polyorchidism in the daily practice of pediatric urology.

Short-term Patient-reported Quality of Life After Robot-assisted Radical Cystectomy Using the Convalescence and Recovery Evaluation - Corrected Proof

2012-04-23

Objective: To determine the short-term health status of patients after robot-assisted radical cystectomy using the Convalescence and Recovery Evaluation (CARE). Radical cystectomy and urinary diversion in patients with invasive bladder cancer can have a significant effect on patients' quality of life. Methods: A total of 91 patients completed the CARE preoperatively and postoperatively. The CARE scores were calculated from postoperative day 7 to 90. Outcome measures were calculated using the CARE difference index (CDI), defined as the difference between the baseline CARE and postoperative day 7 CARE scores. The primary outcome was the time taken to recover 90% of the CDI. Results: The mean age at robot-assisted radical cystectomy was 69 years (range 42-86). Of the 91 patients, 68 (74%) were men, 38 underwent extracorporeal urinary diversion, 52 underwent intracorporeal urinary diversion, and 1 underwent no diversion. A comparison of the preoperative and postoperative day 7 scores demonstrated a 48% decline in the total CARE score. The decline in specific CARE domains was 14%, 34%, 56%, and 66% against baseline for the cognition, pain, gastrointestinal, and activity domains, respectively. The mean time to recover 90% of the CDI for the total CARE score was 63 days. The mean time to recover 90% of the CDI for the pain, cognition, and activity domains was 33, 57, and 82 days, respectively. Patients did not recover 90% of the CDI for the gastrointestinal domain within the 90-day follow-up period. Conclusion: Patients who underwent robot-assisted radical cystectomy approached preoperative baseline levels within 90 days using the CARE in the total CARE, pain, cognition, and activity domains but not in the gastrointestinal domain.

Editorial Comment - Corrected Proof

Scott Gilbert — 2012-04-23

Interest in RARC has increased in recent years, and, as in other areas of urology in which robotics has taken hold, enthusiasm and early adoption have been largely based on the belief that robotics can improve the outcomes.

Reply - Corrected Proof

Andrew P. Stegemann, Khurshid A. Guru — 2012-04-23

We welcome the opportunity to publish our report in this issue of Urology and appreciate the editorial comments from Gilbert. In recent years, the volume and merit of QOL research on cystectomy and urinary diversion have increased. Validated instruments are now frequently used to measure QOL. A clear analysis of our QOL report shows that we do not assert that RARC “translates to better outcomes” compared with open radical cystectomy. Additional evaluation of peer-reviewed QOL studies of open radical cystectomy, not RARC, has established 2 primary conclusions. In a comprehensive literature review, Gerharz et al found that no level I evidence existed for QOL reporting. In a more recent report published in 2011, Shih and Porter concluded that the vast majority of QOL studies were retrospective and cross-sectional in nature. To the best of our knowledge, this is the first published study to evaluate immediate QOL in patients after RARC and 1 of the few prospective studies comparing both preoperative and postoperative QOL measures.

Left Kidney Cancer Grossly Extending into Left-sided Inferior Vena Cava of Duplicated Inferior Vena Cava - Corrected Proof

2012-04-23

The left radical nephrectomy with tumor thrombectomy in the presence of a duplicated inferior vena cava is of high surgical risk because the venous tumor thrombus renders the anomalous venous structures dilated and tortuous, making injury more likely. We present a case of a left kidney cancer grossly extending into the left side of a duplicated inferior vena cava. What is more important is to bring such an aberrant vascular anatomy with tumor thrombus to the attention of urologists with high-resolution pictorial illustrations.

Matched Comparison of Robotic-assisted and Open Radical Cystectomy - Corrected Proof

2012-04-18

Objective: To evaluate our initial robotic-assisted radical cystectomy (RARC) experience compared with a robust open radical cystectomy (ORC) series performed at a single institution using a matched-pair analysis. Although early results suggest that RARC is safe, with favorable perioperative and early oncologic outcomes, limited data exist comparing ORC and RARC. Methods: RARC and ORC patients were identified through a prospectively maintained institutional review board-approved bladder cancer database. RARC and ORC cases performed from September 2007 to November 2010 were matched 1:2 by age, sex, urinary diversion, and clinical stage. The perioperative, complication, and pathologic outcomes were compared. Results: A total of 50 RARC and 100 ORC cases were reviewed, with a median follow-up of 8 and 13.5 months, respectively. No differences in the demographic parameters were present between the 2 groups. RARC was associated with a significantly decreased median estimated blood loss (350 vs 475 mL) and 30-day transfusion rate (2% vs 24%) but with longer operative times (454.9 vs 349.1 minutes). No difference was found in the rate of 30-day minor or major Clavien complications, length of stay, or 30-day readmissions between groups. The 90-day mortality rate was 3% versus 0% for ORC and RARC, respectively. No difference in the final pathologic findings, number of lymph nodes removed, or margin status was identified. Conclusion: Early experience with RARC compared with a robust ORC experience demonstrated similar perioperative and pathologic outcomes. Continued experience with RARC has the potential to bring improved perioperative results.

Editorial Comment - Corrected Proof

Harry W. Herr — 2012-04-18

The authors compared RARC and ORC in a 1:2 matched cohort study, claiming that RARC was associated with comparable morbidity and oncologic outcomes as with the conventional open approach. Although they used a standardized method for reporting complications, a direct comparison was constrained by only 150 patients in a nonrandomized study, and the small numbers precluded statistical comparisons. However, it is worth noting that within 30 days after RARC, the frequency of grade 3-5 complications, readmissions, reoperations, and interventional procedures was consistently greater than with ORC. Furthermore, complications >30 days continued to occur in more than one quarter of the patients in each group. The cancer outcomes appeared to be comparable; however, the follow-up period was too short to draw meaningful conclusions. The authors are to be congratulated for including patients undergoing standard neoadjuvant chemotherapy and by showing that RARC is safe in these patients.

Reply - Corrected Proof

Alon Z. Weizer — 2012-04-18

Randomized controlled trials (RCTs) use the random allocation of patients to determine the differences in efficacy between various treatment options on a particular endpoint. They continue to be the standard in aiding clinicians in choosing the most efficacious treatment of patients. However, in the absence of RCTs, observational data can provide valuable information to clinicians and patients regarding the potential advantages and disadvantages of different treatments. The limitations of observational data are well known. Observational studies can control for known potential confounders but cannot adjust for the unknown, and bias cannot be eliminated. There are a number of statistical techniques that can be used to adjust for confounding, including some techniques that take into consideration unknown effects. As such, these studies can provide valuable information to the clinician who recognizes these limitations.

Proteomic Study of Renal Uric Acid Stone - Corrected Proof

2012-04-18

Objectives: To analyze urinary uric acid stone matrix proteins (SMP) with mass spectrometry (MS) to evaluate the mechanisms of uric acid stone formation. SMP plays an important role in urinary stone formation. Several proteomic studies apply to calcium-containing stones have been reported; however no proteomic study for urinary uric acid stone has been reported. Methods: Pure kidney uric acid stones from 5 individuals were demineralized, and SMPs were isolated. The obtained proteins were analyzed with reverse-phase liquid chromatography–tandem MS. The acquired data were searched against a Swiss Prot human protein database using Matrix Science, Mascot. The identified proteins were submitted to the AmiGO Web site for gene ontology analysis. They were also sumitted to Metacore software and Kyoto Encyclopedia of Genes and Genomes website (KEGG) for pathway analysis. MS-determined protein expressions were verified by immunoblot. Results: MS analysis identified 242 proteins from 5 proteomic results and the number of the identified protein of each result ranged from 52 to 156. Metacore software analysis suggested that inflammation may play an important role for kidney uric acid stone formation. Endogenous metabolic pathways were also analyzed and submitted to KEGG Web site, which revealed that these proteins may participate in fat metabolism. Five identified proteins were selected for immunoblot validation, and 3 proteins were confirmed. Conclusions: Our results suggest that inflammatory process may play a role in kidney uric acid stone formation. Our endogenous metabolic pathway analysis data revealed that these proteins may participate in lipid metabolism. Whether this finding implies a relation between lipotoxicity and kidney uric acid stone former requires further investigation.

Effect of Partial Ureteral Obstruction and Bacterial Virulence on the Occurrence of Renal Scarring in a Mouse Model - Corrected Proof

2012-04-18

Objective: To evaluate the effect of the infection and the obstruction of urinary tract on renal parenchyma, we developed a model of ascending urinary infection in mice with partial unilateral obstructive uropathy. Methods: Six week-old CBA/J mice were operated on to perform a right partial ureteral obstruction and challenged transurethrally with Escherichia coli CFT073 (high virulent strain) or E. coli Mez (low virulent strain). Level of infection of urine and kidneys, score of inflammation and fibrosis of kidneys, and kidney weight ratio (KWR) in the short and long term were studied. Results: At short-term (72 hours) experimentation, partial ureteral obstruction does not influence the level of kidney infection in terms of bacterial count, and the score of inflammation regardless of whether a virulent or low virulent strain was used. At long-term (42 days) experimentation, E. coli Mez was eliminated from all mice kidneys, but CFT073 persisted in almost all; obstruction did not influence the level of kidney infection with CFT073 but a significant difference of KWR and the inflammation and fibrosis score between obstructed and unobstructed kidneys was found (P = .0078; P = .036, respectively). Although the E. coli Mez strain did not persist in renal parenchyma, severe damage of the renal parenchyma was observed. Conclusion: The proposed model is similar to the obstructive uropathy in children in which ureteral obstruction is present before the onset of infection. The association of obstruction and urinary infection impairs kidney growth and favors the occurrence of renal damage.

Second Multicenter, Randomized, Double-blind, Parallel-group Evaluation of Effectiveness and Safety of Intravesical Sodium Chondroitin Sulfate Compared With Inactive Vehicle Control in Subjects With Interstitial Cystitis/Bladder Pain Syndrome - Corrected Proof

J. Curtis Nickel, Philip Hanno, Keshava Kumar, Heather Thomas — 2012-04-18

Objective: To gain additional safety and effectiveness information regarding intravesical 2% chondroitin sulfate in subjects with interstitial cystitis/bladder pain syndrome (IC/BPS) in a controlled clinical trial. Methods: Women with IC/BPS were randomized to receive either 8 weekly bladder instillations of 20 mL of 2% chondroitin sulfate or 20 mL of inactive control solution. The primary effectiveness endpoint was the number of positive results using the Global Response Assessment at week 11 (4 weeks after the last instillation). The secondary effectiveness endpoint was a positive response to the Interstitial Cystitis Symptom Index (ICSI) at week 11. Additional effectiveness endpoints were changes from baseline at week 11 in the total ICSI score voiding diary, and visual analog scale for pain. Results: A total of 98 eligible women with a diagnosis of IC/BPS met the inclusion criteria and were the intention to treat population. Of the 98 women, 83% completed the study. More patients in the chondroitin sulfate group (38.0%) reported moderate or marked improvement (considered responders) compared with the inactive control group (31.3%) at the 11-week endpoint visit. Similarly, more subjects in the active treatment group were classified as ICSI and VAS pain responders and reported a greater decrease in ICSI and VAS pain scores than the control group. None of these differences were statistically significant. Conclusion: Intravesical chondroitin sulfate therapy for IC/BPS might result in minor improvements in IC/BPS-related symptom and pain. However, the magnitude of benefit in our small pilot study does not support its use as monotherapy for this condition. Better strategies for selecting patients with a bladder-specific clinical phenotype might improve the overall response to this type of intravesical therapy.

Editorial Comment - Corrected Proof

Mayank Mohan Agarwal — 2012-04-18

In the spectrum of BPS, IC is still a pathophysiologic enigma and its treatment empirical. Simplistically, it is considered to be result of a multifactorial cascade of events that culminate into an imbalance of the damage-repair process of the urothelium, leading to deficiency of the GAG layer and the resulting symptoms. Various oral and intravesical GAG analogs have been in clinical use, most notably pentosan polysulphate (oral), hyaluronic acid (intravesical), and heparin (intravesical). Of these, only pentosan polysulphate has been subject to comprehensive scrutiny through randomized placebo-controlled trials, the results of which have been published in peer-reviewed reports. Its efficacy has been reported to be moderate at best. In this regard, the authors must be complimented for conducting a very well-designed, double-blind, placebo-controlled trial on another GAG analog chondroitin sulphate and reaffirming the inefficacy of this medication. Therefore, despite the pathologic proof of GAG deficiency, none of the available GAG analogs have proved to have robust activity in controlling the symptoms.

Effect of Varicocelectomy on Testicular Volume in Children and Adolescents: A Meta-analysis - Corrected Proof

2012-04-18

Objective: To evaluate the effect of surgical intervention on catch-up growth as determined by a decreased testicular volume discrepancy in children and adolescents with varicocele. Methods: A systematic search was performed using MEDLINE and the PubMed database and cross-referenced as of October 28, 2011 using the terms “varicocele,” “children,” “adolescent,” “surgery,” and “testicular volume.” All relevant studies were of the testicular volume discrepancy variance before and after surgical repair. The outcomes included the number of patients with initial testicular atrophy and those with catch-up growth after surgical repair. The database search, quality evaluation, and data extraction were independently performed by 2 reviewers. Results: Of 75 studies, 14 were included for analysis and involved 1475 patients. The combined analysis showed that the testicular volume discrepancy was significantly reduced after surgery in the ≥10% group (P < .00001) and ≥20% group (P < .00001), respectively. No difference was found between the 2 groups (P = .70). Taken together, the number of patient with testicular volume disproportion in all pediatric and adolescent varicocele patients significantly decreased after surgery (P < .00001). The average proportion of catch-up growth was 76.4% (range 52.6%-93.8%). Conclusion: The meta-analysis suggested clear advantages of surgical intervention on reducing testicular hypotrophy when the discrepancy is ≥10% in children and adolescents with varicocele. Additional prospective and controlled studies are warranted to elucidate the treatment of children and adolescents with varicocele.

Expression and Clinical Significance of Von Hippel-Lindau Downstream Genes: Jade-1 and β-Catenin Related to Renal Cell Carcinoma - Corrected Proof

2012-04-18

Objective: To investigate the expression of Jade-1 and β-catenin and their effect in the development of renal cell carcinoma (RCC). Methods: The expression of Jade-1 and β-catenin in 11 normal kidney tissue specimens (normal group) and 60 RCC specimens (RCC group) was determined using real-time polymerase chain reaction and immunohistochemistry. Also, their effect on early relapses of RCC was analyzed after 5 years of follow-up. Results: The expression of Jade-1 protein in the RCC group was significantly lower than that in the normal group (0.1655 vs 0.7438, P < .05), and the expression of β-catenin protein was significantly greater than that in the normal group (0.2756 vs 0.0855, P < .05). The expression of Jade-1 mRNA in the RCC group was 0.202 times that in the normal group, which were lower (P < .05). The expression of β-catenin mRNA was 1.014 times that in the normal group (P > .05). The expression of Jade-1 protein and β-catenin protein in poorly differentiated RCC specimens was significantly lower and higher than the expression in the well-differentiated RCC specimen (P < .05), respectively. Patients with negative Jade-1 expression and positive β-catenin expression were found to have shorter survival on univariate analysis (P < .05). Conclusion: RCC with a low expression of Jade-1 and high expression of β-catenin is associated with a poor outcome and decreased survival.

Complete Resolution of Tumoral Calcinosis After Renal Transplantation - Corrected Proof

Masahito Miyamoto, Yugo Shibagaki, Kenjiro Kimura — 2012-04-18

A 41-year-old male receiving hemodialysis for 10 years was referred to our hospital for multiple masses progressively growing in multiple joints and buttocks, which were diagnosed as giant tumoral calcinosis (TC) by radiographic findings. He had been hypercalcemic and hyperphosphatemic with high doses of vitamin D for chronic kidney disease-mineral and bone disorder. We then stopped vitamin D to manage the hypercalcemia and hyperphosphatemia; however, the TC did not regress after 1.5 years, thus the patient underwent renal transplantation. Subsequently, the TC gradually but almost completely disappeared over the next 1.5 years. A renal transplantation was thus found to be useful for the successful treatment of TC.

Urinary Diversion in Early Childhood: Indications and Outcomes in the Exstrophy Patients - Corrected Proof

2012-04-18

Objective: To evaluate indications and applicability of continent and incontinent urinary diversion (CUD and IUD, respectively) in early childhood in patients with classic bladder exstrophy (CBE). Methods: Using an institutionally approved exstrophy database, patients with CBE born after 1980 who underwent CUD or IUD by 2 surgeons within the first 5 years of life were identified. All aspects of their care and clinical outcomes were studied. Results: In the CUD group (n = 14), only 21% had successful primary closure. Indications were desire to be dry (7), persistent hydronephrosis (4), urinary tract infections (UTIs) (1), repeat CUD (1), and inaccessible proper follow-up (1). Three patients had neobladder creation, 10 had bladder augmentation with continent stomas, and 2 underwent ureterosigmoidostomy. Currently, all patients are dry with clean intermittent catheterization (CIC). In the IUD group (n = 5), only 1 had successful primary closure. In addition to small, noncontractile bladders, the indications for IUD were severe hydronephrosis (2), recurrent UTIs (2), and noncompliance with catheterization (1). Four patients were re-diverted to CUD after a mean of 9.4 years and 1 has colon conduit. All are socially dry via catheterization. There was no case of renal function loss or malignant transformation. Conclusions: The need for early diversion in CBE is primarily driven by upper tract changes after secondary closure and social factors. Urinary diversion can be safe in younger children with a favorable continence outcome.

Late Revelation of a Subphrenic Extralobar Pulmonary Sequestration as a Suprarenal Mass - Corrected Proof

Augustin Pirvu, Albéric de Lambert, Julie Gervasoni, Philippe Chaffanjon — 2012-04-18

Pulmonary sequestrations are some rare congenital anomalies. The incidence was estimated of 0.15% to 1.7%. They are characterized by a mass of non functioning pulmonary tissue that has no communication to the normal bronchial tree. The vascularisation is supplied by systemic arteries. They are classified further as intralobar and extralobar types. Extralobar sequestration, so-called accessory lung, is separated from the normal lung. We present a rare case of subphrenic extralobar pulmonary sequestration in a 57 years old patient. The lesion was initially presented as a non-typical suprarenal mass discovered on CT scan. The approach by laparatomy permitted the resection and the definitive diagnosis.

Performance Characteristics of Prostate-specific Antigen in Patients Undergoing Radical Prostatectomy - Corrected Proof

Jen-Jane Liu, Michelle Ferrari, Rosie Nolley, James D. Brooks, Joseph C. Presti — 2012-04-18

Objective: To assess the performance characteristics of prostate-specific antigen (PSA) for predicting the volume of total or high-grade cancer in men undergoing radical prostatectomy. It is known that the performance characteristics of PSA are improved for predicting the presence of high-grade prostate cancer. Methods: We identified 1459 patients from the Stanford Radical Prostatectomy Database with clinical Stage T1c (n = 783) and T2 (n = 676) disease who underwent surgery from 1988 to 2003 with detailed morphometric mapping. We generated receiver operating characteristic curves for PSA levels according to the total and high-grade (Gleason score 4 or 5) cancer volume and compared the areas under the curve (AUC) for the various total and high-grade cancer volumes. Results: For patients with Stage T1c disease, the AUC for the PSA ROC curve increased in a stepwise fashion as both the total cancer volume and the high-grade cancer volume increased. Significant differences between the AUCs for low and high volumes of total and high-grade disease were observed. For T2 disease, the AUCs for predicting high-grade cancer volume were generally greater than the corresponding AUCs for T1c disease, although no incremental increase was observed. Conclusion: In patients with Stage T1c disease, in whom the PSA level was the driving force for biopsy, the PSA performance improved in a stepwise fashion with greater total and high-grade cancer volumes as evidenced by improved ROC. Previous studies have shown that PSA performs better for detecting the presence of high-grade disease. We have shown that PSA performs better in predicting greater volumes of high-grade disease in radical prostatectomy specimens.

A Novel DNA/Peptide Combined Vaccine Induces PSCA-specific Cytotoxic T-lymphocyte Responses and Suppresses Tumor Growth in Experimental Prostate Cancer - Corrected Proof

Ke-qin Zhang, Fei Yang, Jin Ye, Man Jiang, Yong Liu, Feng-shuo Jin, Yu-zhang Wu — 2012-04-17

Objective: To develop a completely novel DNA peptide–combined vaccine and determine whether it can efficiently improve tumor-specific cytotoxic T lymphocyte (CTL) responses and inhibit tumor progression in experimental prostate cancer models. Methods: The DNA/peptide combined vaccine was prepared by the self-assembly of a cationic peptide ([K]18P9) containing 18 lysines and a CTL epitope peptide, prostate stem cell antigen (PSCA 14-22) (HLA-A2 restricted) with a recombinant plasmid encoding human full-length PSCA gene (pcDNA3.1(+)-PSCA) through electrostatic interactions. The formation of a DNA/peptide complex was examined by DNA retardation assay, DNase I protection assay, and transmission electron microscopy. The efficacy of vaccination using this complex was demonstrated in terms of the PSCA-specific CTL activity and antitumor immunity to PSCA+ tumors in a murine model. Results: This form of DNA/peptide complex could efficiently transfer the plasmid encoding full-length PSCA gene into mammalian cells and induced potent CTLs cytotoxicity against a human prostate carcinoma cell line established from the left supraclavicular lymph node metastasis from a 50-year-old man with prostate carcinoma in 1977. Expressing PSCA compared with pcDNA3.1(+)-PSCA, [K]18P9 peptide, or pcDNA3.1(+). Moreover, the vaccination of mice with this complex induced a potent antitumor immunity to prostate carcinomas in a xenograft tumor model in nude mice. Conclusion: This study suggests that a specific antitumor immune response can be induced by this DNA/peptide combined vaccine, which represents a new strategy for use in the immunotherapy of prostate cancer.

Clinical Outcomes of Nonoperative Management in Emphysematous Urinary Tract Infections - Corrected Proof

2012-04-17

Objective: To investigate the clinical outcomes of nonoperative management of emphysematous urinary tract infections (EUTIs). Methods: We retrospectively reviewed 28 consecutive cases of EUTI over a 5-year period, all of which were treated with urinary drainage and medical management without surgical intervention. EUTIs were classified as either emphysematous pyelonephritis (EP) or emphysematous cystitis (EC). Clinical, diagnostic, and therapeutic data were analyzed. Results: Of the 28 patients evaluated, 13 had EP and 15 had EC, all of which were diagnosed by computed tomography. Of EP patients, the mean age was 54 years with a median serum creatinine (sCr) of 1.8 mg/dL (estimated glomerular filtration rate [eGFR] 38 mL/min/1.73 m2). Obstructive uropathy was present in 69%, and 100% received antibiotics and percutaneous drainage without mortality. Median follow-up was 10 months without any subsequent nephrectomy and median sCr decreased to 1.1 mg/dL (P = .04) and eGFR increased to 63.5 mL/min/1.73 m2 (P = .06). Of EC patients, the mean age was 60 years with a median sCr of 1.3 mg/dL (eGFR 55 mL/min/1.73 m2). All were managed with antibiotics and catheter drainage with a single mortality (7%). Median follow-up was 2 months and median sCr decreased to 1.2 mg/dL (P = .83) and eGFR increased to 46 mL/min/1.73 m2 (P = .68). The most common causative pathogen was Escherichia coli for both EP (54%) and EC (53%). Conclusion: Early detection, medical management, and urinary drainage of EUTI can result in a favorable prognosis. This strategy results in low levels of mortality without the need for surgical intervention and can preserve renal function.

Surgical Outcome of Different Types of Primary Hypospadias Repair During Three Decades in a Single Center - Corrected Proof

2012-04-16

Objective: To evaluate the surgical outcome of different techniques of primary hypospadias repair in a single department. Methods: We retrospectively evaluated the medical files of all patients who had undergone primary hypospadias repair at our department during the past 3 decades (1978-2009). Results: A total of 820 patients were divided into 3 groups. The first group of 309 patients (37.7%) had glanular hypospadias, the second group of 398 patients (48.5%) had distal hypospadias, and the third group of 113 patients (13.8%) had proximal hypospadias. Of these 820 patients, 67 (8.2%) required corpoplasty to straighten the penis. In the first group, 67 (21.7%) children underwent meatal advancement or meatoplasty, 211 (68.3%) underwent meatal advancement and glanduloplasty, 8 (2.6%) underwent tubularized incised plate hypospadias repair, and 23 (7.4%) underwent Mathieu flap hypospadias repair. In the second group, 196 (49.2%) underwent Mathieu hypospadias repair, 38 (9.5%) underwent tubularized incised plate repair, 142 (35.7%) underwent meatal advancement and glanduloplasty, and 22 (5.5%) underwent onlay-type hypospadias repair. In the third group, 28 (24.8%) underwent 2-stage hypospadias repair, 85 (75.2%) underwent single-stage surgery (including 68 [60.2%] onlay and 11 [9.7%] tubularized island flap), and 6 (5.3%) underwent tubularized incised plate hypospadias repair. Immediate complications developed in 46 (14.9%) in the first, 123 (30.9%) in the second, and 66 (58.4%) in the third group; 38 (4.6%) required additional surgery during or after adolescence. Conclusion: Our data have shown that despite the numerous techniques used for hypospadias surgery, the incidence of complications is still high in patients who undergo hypospadias repair.

Editorial Comment - Corrected Proof

Julian Wan — 2012-04-16

Hypospadias repair, along with the management of vesicoureteral reflux, are arguably the 2 leading problems that helped to define modern pediatric urology. John Duckett coined the term “hypospadiology” to encourage those who performed hypospadias repair to view the complex topic as one deserving of serious dedicated study. For many urologists, it meant the development of new procedures such as the meatal advancement and glanduloplasty, transverse island flap, or tubularized incised plate (TIP or Snodgrass). However, it should also encompass an understanding of how these methods have been adapted and their limitations. Surgical solutions are not fixed but reflect the level of medical knowledge of their era. Improvements in the understanding of the underlying problem, anatomy, technique, and materials have led to advances in nearly all types of operations. Fashion also is a factor; some operations become quite in vogue for a number of years and then fade away as a new style emerges or if a major advancement in knowledge makes them obsolete.

Reply - Corrected Proof

Boris Chertin — 2012-04-16

We would like to thank the reviewer for the valuable comments. We do agree that the surgical techniques in the “hypospadiology” field have undergone a major evolution. Our report reflects this evolution. During the past 3 decades, many techniques were applied in our patients, along with the changes in the hypospadias surgery around the world. However, the surgical outcome is still not optimal. Even in the distal shaft hypospadias repair, the complications ratio can reach 30% and can be greater in the proximal localization of the hypospadias meatus. It seems that one of the solutions to the high incidence of complications after hypospadias surgery is the creation of a prospective database of all patients who undergo hypospadias surgery in a single service, as it was suggested recently by Snodgrass, to judge the surgical results in real time rather than retrospectively. We do agree with the reviewer that a serious drawback of our report, just as with many others, is the lack of long-term follow-up. We have presented data on the long-term follow-up after adolescence for only 70 patients. Because we do not have data from the remaining patients, we can speculate that they did well and decided to cease follow-up because they did not have any problems after surgery during short-term observation. Of course, these data should be verified during prospective studies. The questions regarding the long-term efficacy in terms of sexual and voiding function should be addressed in future studies.

Survey on Benign Prostatic Hyperplasia Distribution and Treatment Patterns for Men With Lower Urinary Tract Symptoms Visiting Urologists at General Hospitals in Korea: A Prospective, Noncontrolled, Observational Cohort Study - Corrected Proof

2012-04-16

Objective: To survey cases of benign prostatic hyperplasia (BPH) among patients visiting urologists with lower urinary tract symptoms (LUTS) at general hospitals in Korea and to investigate treatment outcomes in current clinical practice. Methods: This was a multicenter, prospective study conducted in 18 urology centers in Korea. The symptoms of BPH were observed via the International Prostate Symptoms Score (IPSS), transrectal ultrasonography, uroflometry, prostate, specific, antigen, PSA) and postvoid residual volume at the baseline, 1 week, 4 weeks, 12 weeks, 24 weeks, and 52 weeks after initial evaluation. The patients were divided into three groups according to age (group I: 50-59; group II: 60-69; group III: 70 years or older). Results: Of the 1054 screened men, 966 were enrolled and 917 were diagnosed with BPH. Total IPSS and storage subscores were significantly higher in group III than in group II or I. By month 12, significant improvements on total IPSS and voiding subscores were demonstrated in group I over groups II and III (P = .02. 03, respectively). The incidence of dual combination therapy was significantly higher in the patients whose prostate volume was ≥30 mL and whose PSA was ≥1.5. Conclusion: At the initial visit, patients with LUTS/BPH, especially those who were relatively young, visited urologic centers because of to voidingsymptoms rather than storage symptoms. In contrast, elderly men who visited the urologic centers complained not only of voiding symptoms but also storage symptoms. However, at 12 months' follow up, all of the age groups showed improvement in both storage and voiding symptoms.