Urology - Articles in Press

Screening Ultrasound in Follow-up After Pediatric Pyeloplasty - Corrected Proof

Nicholas G. Cost, Juan C. Prieto, Duncan T. Wilcox — 2010-03-10

Objectives: To investigate whether an initial ultrasound (US) adequately identifies those patients who need further investigation and possibly intervention while decreasing instrumentation and radiation exposure. The recommended imaging after pediatric pyeloplasty has included intravenous pyelography, radionucleotide renography, and ultrasound US.Methods: We retrospectively reviewed pediatric open pyeloplasty cases performed between 1999 and 2007. Of 116 patients reviewed, 49 met the inclusion criteria of unilateral pyeloplasty with pre- and postoperative US and mercaptoacetyltriglycine (MAG-3). Hydronephrosis was judged by anterior posterior pelvic diameter and caliectasis. Change in renal function on MAG-3 was defined as increase or decrease in function >5%.Results: Of 49 patients, 42 (85.7%) showed improved or stable hydronephrosis postoperatively and 7 (14.3%) showed increased hydronephrosis. Forty-six (93.8%) patients had either improved or stable renal function. Of 42 patients with stable or improved hydronephrosis, 41 (97.6%) also had stable or improved function. Comparatively, of 7 patients with increasing hydronephrosis, 2 (28.6%) showed deteriorated renal function, P = .05.Conclusions: Postpediatric pyeloplasty imaging should aim to identify those who require further intervention. Our data demonstrate that at-risk patients can be identified with a sentinel US and selectively determine who needs further MAG-3 investigation. This should increase compliance while decreasing costs, instrumentation, and radiation exposure.

Protective Value of a Folkloric Medicinal Plant Extract Against Mortality and Hemorrhage in a Life-threatening Renal Trauma Model - Corrected Proof

2010-03-10

Objectives: To compare the efficacy of a folkloric medicinal plant extract (Ankaferd Blood Stopper [ABS]) with that of oxidized cellulose (Surgicel) in a life-threatening renal injury model. ABS is a mixture of 5 plants that has historically been used in Turkish traditional medicine. It has been approved by the Ministry of Health to manage external hemorrhage and dental surgery bleeding in Turkey.Methods: Twenty-two Wistar albino rats underwent partial nephrectomy after intravenous heparin anticoagulation (2000 U/kg). The cut surface received 1 of 3 therapies, namely no treatment, Surgicel (Johnson & Johnson, New Brunswick, NJ) or ABS (Trend Teknoloji İlaç AŞ, Istanbul, Turkey). Blood pressure was continually monitored. Survival time, total blood loss, and mean arterial pressure were recorded for 60 minute or until death. Rats that were alive (mean arterial pressure ≥20 mm Hg) at the end of 60 minutes were sacrificed with blood withdrawal with the help of catheters.Results: All animals that received no treatment died within 60 minutes of follow-up. One of 7 in the Surgicel group, and 5 of 7 animals in the ABS group, survived. Mean survival times for the Surgicel and ABS groups were 42.7 and 53.4 minutes, respectively. Rats in the ABS and Surgicel groups survived significantly longer than rats in the control group (P <.05). There were no significant differences between the ABS and the Surgicel groups in survival (P = .128).Conclusions: ABS is as effective as Surgicel in achieving hemostasis and lengthening survival time following partial nephrectomy in an experimental rat model.

Clinical Outcome in Metastatic Renal Cell Carcinoma Patients After Failure of Initial Vascular Endothelial Growth Factor-Targeted Therapy - Corrected Proof

2010-03-10

Objectives: To characterize and evaluate the efficacy of second-line therapy in patients who had progressed on initial anti-vascular endothelial growth factor (VEGF) therapy.Methods: Between 2005 and 2007, patients with mRCC who received second-line therapy after 1st-line VEGF-targeted therapy were identified across 7 cancer centers.Results: A total of 645 mRCC patients received first-line VEGF-targeted therapy, of which 216 patients received second-line VEGF-targeted therapy (sunitinib, n = 93; sorafenib, n = 80; bevacizumab, n = 11; axitinib, n = 8) or mammalian target of rapamycin (mTOR)-inhibiting agents (temsirolimus, n = 21; everolimus, n = 3). On multivariate analysis, a higher baseline Karnofsky performance status score before first-line therapy predicted which patients were more likely to receive second-line therapy (P <.0001). The median time to treatment failure of second-line therapy was 4.9 months for anti-VEGF therapy and 2.5 months for mTOR inhibitors (P = .014) (HR: 0.52, CI: 0.29-0.91 and HR: 0.495, CI: 0.27-0.9 after adjusting for Memorial Sloan-Kettering Cancer Center prognostic factors and histology, respectively). Overall survival from start of second-line therapy was not significantly different (14.2 vs 10.6 months respectively; P = .38).Conclusions: Baseline Karnofsky performance status is an independent predictor of receiving second-line targeted therapy. Patients who receive a second-line anti-VEGF drug appear to have a similar overall survival to those who receive a second-line anti-mTOR drug.

Holmium Laser Enucleation of the Prostate: Initial Report of the First 230 Egyptian Cases Performed in a Single Center - Corrected Proof

2010-03-10

Objectives: To report our experience with the first 230 cases of holmium laser enucleation of the prostate (HoLEP) performed in a single center.Methods: A total of 230 cases of HoLEP were performed between June 2007 and June 2008. Mean age of patients was 69.8 ± 10.3 years, and 21.3% of patients were either on anticoagulant or antiplatelet treatment. There was no limit for prostate size, with a mean prostate size of 86.5 ± 65.4 g (range: 20-350 g). Follow-up was performed regularly at 1, 3, 6, and 12 months, assessing the Qmax, PVR, and International Prostate Symptom Score.Results: Weight of prostate chips retrieved after morcellation was 78.6 ± 61.3 g (range: 10-350), with enucleation time 102.2 ± 55.4 minutes and morcellation time 19.3 ± 10.1 minutes, leading an estimated efficiency rate of 0.64 g/min. The rate of decrease in prostate volume and prostate-specific antigen was 90.8% and 82.5%, respectively. At 1 month, mean Qmax increased from 7.7 ± 2.3 to 25.8 ± 10.1 mL/s (P ≤.001), mean PVR decreased from 171.3 ± 126.3 to 41.6 ± 45.7 mL (P ≤.001), and mean international prostate symptom score improved from 17.3 ± 6.7 to 6.6 ± 3.4 (P ≤.001). These improvements were sustained throughout a 12-month follow-up period. Temporary irritative symptoms were evident in 34.6% and stress urinary incontinence in 9%, both of which were self-limited on medical treatment and Kegel exercises, respectively. Only 1 patient with pancytopenia required blood transfusion and there was no case for transurethral resection syndrome.Conclusions: HoLEP is a safe and an effective modern modality for the treatment of symptomatic BPH regardless of the gland size, with satisfactory clinical outcome.

Unclassified Renal Cell Carcinoma: Impact on Survival Following Nephrectomy - Corrected Proof

2010-03-10

Objectives: To evaluate the impact of the category of unclassified renal cell carcinoma (URCC) on survival following nephrectomy.Methods: Patients with clear cell RCC (ccRCC, n = 3048) and URCC (n = 38) were identified. Patients with URCC were matched 4:1 with ccRCC patients based on year of surgery, symptoms at presentation, tumor size, stage, regional lymph node involvement, metastases, grade, coagulative tumor necrosis, and sarcomatoid differentiation. Survival was estimated using the Kaplan–Meier method and compared between ccRCC and URCC patients using log-rank tests.Results: Patients with URCC were more likely to have regional lymph node involvement (P <.001), higher grade (P <.001), tumor necrosis (P <.001), and sarcomatoid differentiation (P <.001) as compared to patients with ccRCC. Overall survival was not significantly different between URCC and ccRCC patients in either the unmatched (P = .337) or matched (P = .345) cohorts. Cancer-specific survival was significantly worse for URCC patients compared with unmatched ccRCC patients (P = .020). However, this difference was not statistically significant when the URCC patients were compared with the matched cohort (P = .688). Distant metastases-free survival was somewhat worse for M0 URCC patients compared with unmatched M0 ccRCC patients (P = .063), but not in the matched cohort (P = .788).Conclusions: Although URCC is more likely to present with advanced clinicopathologic features compared with ccRCC, no statistically significant differences in outcome were noted after adjusting for these features in a matched analysis.

Better Short-term Outcomes With the U-Method Compared With the Hammock Technique for the Implantation of the TVT-SECUR Under Local Anesthesia - Corrected Proof

Louis-Olivier Gagnon, Le Mai Tu — 2010-03-10

Objectives: To observe the satisfaction of local anesthesia during the implantation of the tension-free vaginal tape (TVT)-SECUR (Gynecare, Ethicon, Somerville, NJ) for the treatment of stress urinary incontinence, using questionnaires completed by the patients, and to evaluate the short-term safety and efficacy of the sling.Methods: Forty-eight women were operated between January 2007 and October 2008. The implantation of the TVT-SECUR was done under local anesthesia by 1 surgeon. The “Hammock” technique was used in the first 23 patients and the “U-Method” in the last 25 patients.Results: Mean patient age was 61 years (range, 38-85). Visual analogue scale for pain immediately and 1 week after surgery showed a mean score of 19/100 and 29/100, respectively. Overall, 93% (43/46) of the patients would recommend this type of anesthesia. At 1 week, 2 months, and 6 months after surgery, the improvement in incontinence symptoms rate was 82% (18/22), 76% (16/21), and 69% (11/16) for the Hammock technique, compared with 75% (18/24), 92% (22/24), and 100% (22/22) for the U-Method. At 6 months, the difference was statistically significant (P = .0087). Postoperative complications included 6 partial tape exposures, all with the Hammock technique.Conclusions: Local anesthesia with light sedation represents an appropriate choice for the implantation of this new sling. The TVT-SECUR using the U-Method appears to be relatively safe, and the short-term efficacy rates seem to compare with traditional midurethral slings, with long-term efficacy still to be determined. This is the first report showing better outcomes of one technique over the other.

Narrow Band Imaging Cystoscopy Improves the Detection of Non–muscle-invasive Bladder Cancer - Corrected Proof

2010-03-10

Objectives: To determine whether narrow band imaging (NBI) improves detection of non–muscle-invasive bladder cancer over white-light imaging (WLI) cystoscopy.Methods: We conducted a prospective, within-patient comparison on 103 consecutive procedures on 95 patients scheduled for (re-) transurethral resection of a bladder tumor (84) or bladder biopsies (19) in the Academic Medical Center, Amsterdam (September 2007-July 2009) and in the General Faculty Hospital, Prague (January 2009-July 2009). WLI and NBI cystoscopy were subsequently performed by different surgeons who independently indicated all tumors and suspect areas on a bladder diagram. The lesions identified were resected/biopsied and sent for histopathological examination. Number of patients with additional tumors detected by WLI and NBI were calculated; mean number of urothelial carcinomas (UCs) per patient, detection rates, and false-positive rates of both techniques were compared.Results: A total of 78 patients had a confirmed UC; there were 226 tumors in total. In 28 (35.9%) of these patients, a total of 39 additional tumors (17.3%) (26pTa, 6pT1, 1pT2, 6pTis) were detected by NBI, whereas 4 additional tumors (1.8%) (1pTa, 1pT1, 2pTis) within 3 patients (2.9%) were detected by WLI. The mean (SD, range) number of UCs per patient identified by NBI was 2.1 (2.6, 0-15), vs 1.7 (2.3, 0-15) by WLI (P <.001). The detection rate of NBI was 94.7% vs 79.2% for WLI (P <.001). The false-positive rate of NBI and WLI was 31.6% and 24.5%, respectively (P <.001).Conclusions: NBI cystoscopy improves the detection of primary and recurrent nonmuscle invasive bladder cancer over WLI. However, further validation of the technique with comparative studies is required.

Impact of Robotic Training on Surgical and Pathologic Outcomes During Robot-assisted Laparoscopic Radical Prostatectomy - Corrected Proof

2010-03-08

Objectives: To prospectively compare outcomes during robotic prostatectomy between surgeons with formal training in either robotic prostatectomy (RALP) or laparoscopic prostatectomy (LRP).Methods: A total of 286 robotic prostatectomies were performed by 12 urologists between August 2008 and March 2009 as part of a new robotic surgery program at one of the largest health maintenance organizations in the United States. Four surgeons had formal training in RALP and 8 had formal training in LRP. We prospectively compared surgical and pathologic outcomes between these 2 groups of surgeons.Results: The 4 RALP surgeons performed 121 RALPs and the 8 LRP surgeons performed 165 RALPs. Patient demographics were similar between groups. The robot-naive group had significantly more clinical stage T1c than the robot-trained group (87.9% vs 74.4%, P = .003). Prostatectomy parameters were similar between the 2 groups of surgeons in terms of prostate size, Gleason score, pathologic stage, and estimated blood loss. The robot-trained surgeons had significantly lower overall positive margin rates (24% vs 34.6%, P = .05) and lower margin rates in T3 tumors (38.5% vs 61.8%, P = .07), which were approximately statistically significant. There was no difference in margin rates in T2 tumors. The robot-trained surgeons had significantly lower apical margin rates (8.3% vs 21.2%, P = .003) and lateral margin rates (1.7% vs 7.3%, P = .05). The robot-trained surgeons had 10%-15% shorter procedure times. There was no difference in complication rates.Conclusions: Formal RALP training may be beneficial for surgical and pathologic outcomes of RALP compared with formal LRP training during the initial implementation of a new robotics program.

Racial Differences in Quality of Life Following Prostate Cancer Diagnosis - Corrected Proof

2010-03-08

Objectives: To evaluate the effects of race on QOL while adjusting for subjective stress and religiosity among African American and white prostate cancer patients. Although racial differences in quality of life (QOL) have been examined between African American and white prostate cancer patients, it is not known whether differences exist while adjusting for psychological and cultural factors. We predicted that African American men would report poorer emotional and physical functioning after adjusting for these factors and that greater subjective stress and lower levels of religiosity would be associated with poorer well-being.Methods: We conducted an observational study of QOL among 194 African American and white men who were recruited from February 2003 through March 2008.Results: Race had a significant effect on emotional functioning after adjusting for perceptions of stress and religiosity. Compared with white men, African American men (P = .03) reported significantly greater emotional well-being. Greater subjective stress was associated significantly with poorer emotional functioning (P = .0001) and physical well-being (P = .0001). There were no racial differences in physical functioning (P = .76).Conclusions: The results of this study highlight the importance of developing a better understanding of the context within which racial differences in QOL occur and translating this information into support programs for prostate cancer survivors.

Quantitative Loss of Heterozygosity Analysis for Urothelial Carcinoma Detection and Prognosis - Corrected Proof

2010-03-08

Objectives: To evaluate loss of heterozygosity (LOH) using microsatellite polymorphism analysis as a diagnostic and prognostic marker at the time of transurethral resection and as a follow-up marker preceding cystoscopic evidence of recurrence compared with cytology.Methods: A total of 127 urothelial carcinoma (UC) patients were included. Tumors were staged and graded according to the International Union Against Cancer–tumor, node, metastases system and to the 2004 World Health Organization classification. LOH urinalysis was performed using 8 markers and marker-specific LOH thresholds. Thirty control samples, obtained from healthy volunteers, were used to determine the positive cut-off for each marker.Results: LOH was significantly more sensitive than cytology in low-grade (64.8% vs 38.5%, P <.001) and low-stage UC (68.6% vs 45.5%, P <.001). The cumulative sensitivity of cytology and LOH reached 74.7% (P <.001) for low-grade and 80.2% (P <.001) for low-stage tumors. Both urinary LOH at TP53 and chromosome 9p markers were associated with an increased risk of recurrence (relative risk = 1.73 [1.30-2.31], P = .0002) and occurred more frequently in the initial urine samples of patients who later relapsed from primary tumors (36.4% vs 0.0%, P <.05 and 57.6% vs 15.8%, P = .0001). Among 32 relapse patients, LOH was positive alongside cystoscopy in 25 of 32 cases and tested positive before cystoscopy detected recurrence in a further 5 of 25 cases.Conclusions: UC diagnosis and monitoring would greatly benefit from supplementing conventional cytology with LOH urinalysis, using a panel of 8 microsatellite markers with specific threshold levels. Given the limitations of both cystoscopy and cytology, novel molecular markers are needed for detection and follow-up of UC.

Experimental Study for Electrovaporization of Renal Cell Carcinoma Using a New Shape Memory Alloy Probe - Corrected Proof

Yasuyuki Naitoh, Akihiro Kawauchi, Jintetsu Soh, Kazumi Kamoi, Tsunaharu Miki — 2010-03-08

Objectives: To develop a new shape memory alloy probe for percutaneous treatment of renal cell carcinoma (RCC) by electrovaporization, and investigate its efficacy and safety in experimental models.Methods: The shape memory alloy electrode can be manipulated to any shape at room temperature and regains its original shape at ≥65°C. By adding a high-frequency electric current to the probe, the electrodes quickly regain their original shape and vaporize tissues into a spherical defect. The performance of this probe was tested using agar, dog kidney, and rat RCC models. The treatment effect was evaluated by magnetic resonance imaging and histologic examination.Results: In the agar model, the electrovaporization inside the spherical electrode was successfully achieved in several seconds, with all power outputs tested. The area of ≥60°C extended about 5 mm beyond the periphery of the vaporized part and corresponded with the histologic findings on the dog kidney that an irreversible heat denaturation occurred to the same extent. The study on the RCC model also confirmed that about 5-mm extent of heat denaturation was seen in the muscular tissue adjacent to the tumor. In the study using the RCC model, some remaining tissues close to the tumor were observed after vaporization. However, dynamic magnetic resonance imaging demonstrated no enhancement in this area and no viable tumor cells were documented by histologic examination.Conclusions: This novel tissue ablation system has potential as a viable option for percutaneous treatment of renal tumors.

Implications of Serum Bone Turnover Markers in Prostate Cancer Patients With Bone Metastasis - Corrected Proof

2010-03-08

Objectives: To assess the diagnostic accuracy of serum bone turnover markers for detection of bone metastasis in patients with prostate cancer (PCa) and to assess the usefulness of these markers as predictors of mortality from PCa.Methods: Serum total alkaline phosphatase, bone-specific alkaline phosphatase, carboxy-terminal pyridinoline cross-linked telopeptide parts of type-I collagen (1CTP), tartrate-resistant acid phosphatase type 5 b, and prostate-specific antigen (PSA) levels were measured in 222 patients (58 with bone metastasis, 57 with T2M0 PCa, 55 with T3M0 PCa, and 52 without PCa). Multivariate stepwise logistic regression analysis was used to identify independent predictors of bone metastasis. Correlation of serum marker levels with bone metastasis was assessed using receiver operating characteristics analysis. Multivariate Cox proportional hazards analysis was used to predict cause-specific survival in PCa patients with bone metastasis.Results: Serum total alkaline phosphatase, bone-specific alkaline phosphatase, 1CTP, tartrate-resistant acid phosphatase type 5 b, and PSA levels were significantly elevated in patients with bone metastasis, and correlated significantly with the extent of disease on bone scintigraphy. Multivariate stepwise logistic regression analysis demonstrated that serum PSA and 1CTP were significant predictors of bone metastasis. Receiver operating characteristics analyses showed that serum 1CTP level was the most reliable predictor of bone metastasis (area under the curve = 0.85). Multivariate Cox proportional hazards analysis revealed that only serum 1CTP was an independent prognostic factor for PCa-related death.Conclusions: Serum 1CTP level was a more reliable marker than the others to detect bone metastatic spread and to predict survival probability in PCa patients with bone metastasis.

Solitary Facial Cutaneous Metastasis as the Primary Presentation of a Small Renal Cell Carcinoma - Corrected Proof

Marc A. Bjurlin, Vishal Bhalani, Michael D. Jordan, Courtney M.P. Hollowell — 2010-03-08

Renal cell carcinoma (RCC) has been well described for its frequency to metastasize. Cutaneous facial lesions as the primary presentation of RCC is, however, extremely rare. We present clinical, radiographic, and histologic images of a 40-year-old man who presented with a cutaneous facial lesion that was diagnosed as metastatic RCC after excisional biopsy. A subsequent computed tomography demonstrated a small mass (3.5 × 2.6 cm) in the midpole of the right kidney. Partial nephrectomy with histologic analysis confirmed RCC, clear cell type.

The Value of C-Reactive Protein Determination in Patients With Renal Colic to Decide Urgent Urinary Diversion - Corrected Proof

2010-03-08

Objectives: To analyze whether C-reactive protein (CRP) predicts the need for urgent urinary diversion in patients with renal colic and urolithiasis. CRP may help in the differential diagnosis of complicated hydronephrosis.Methods: Prospective study done on 110 consecutive patients with renal colic secondary to upper urinary tract calculi admitted in the emergency room. Clinical and analytical data were collected. Criteria for emergency drainage had been established in advance, based on the risk of sepsis, renal failure, persistence of pain, and findings on computed tomography scan. CRP was blindly determined using immunoturbidimetric assay on the Integra 700 analyzer. Statistical analysis included Mann–Whitney test, Cox multivariate analysis, and receiver operating characteristic curves, to determine optimum cut-off points to decide drainage based on laboratory data.Results: Mean CRP value was 47.6 mg/L (CI, 31.4-63.8), 139.6 mg/L (CI, 13-183.1) in 29 patients treated with diversion and 14.67 mg/L (CI, 6.7-22.5) in the control group (P <.001). Age, sex, rate of patients with hypertension, history of cardiovascular disease, leukocyte total count, and serum creatinine differed between groups (P <.05). Regression analysis revealed CRP (P <.0001) and age (P = .0001) were predictive of urinary diversion. Receiver operating characteristic analysis revealed 68.4% area under the curve for creatinine, 68.8% for leukocytosis, and 86.8% for CRP. A cut-off point for CRP of 28 mg/L achieved optimum sensitivity (75.8%) and specificity (88.9%) for determining the decision for drainage.Conclusions: Determination of CRP in patients with renal colic due to urolithiasis provides an objective and useful parameter for deciding placement of urinary stent, which is even more valuable than leukocytosis or seric creatinine level.

Residual Prostate Tissue After Radical Prostatectomy: Acceptable Surgical Complication or Treatment Failure? - Corrected Proof

Hebert Alberto Vargas, Oguz Akin, Hedvig Hricak — 2010-03-08

Abstract: Positive surgical margins after radical prostatectomy are associated with an increased risk of cancer recurrence. Depending on the patient's clinical presentation and the amount of residual prostatic tissue, this could be described as a surgical complication or as treatment failure. Endorectal magnetic resonance (MR) imaging provides useful information regarding the presence and extent of benign and/or malignant residual prostate tissue. The clinical features and MR images from a 55-year-old man who underwent prostatectomy for prostate cancer and was found to have a considerable amount of residual prostatic tissue postoperatively on MR imaging are presented in the article.

Efficacy and Safety of Tolterodine Extended Release and Dutasteride in Male Overactive Bladder Patients With Prostates >30 Grams - Corrected Proof

Doreen E. Chung, Alexis E. Te, David R. Staskin, Steven A. Kaplan — 2010-03-08

Objectives: To assess safety and efficacy of 4 mg tolterodine extended release (TER) with 0.5 mg dutasteride (DUT) in men with persistent overactive bladder (OAB) symptoms and lower urinary tract symptoms (LUTS) unsuccessfully treated with DUT alone. TER is indicated for OAB and DUT is indicated for LUTS from benign prostatic hyperplasia.Methods: A total of 51 men treated with DUT for ≥6 months with persistent OAB symptoms enrolled in a 12-week, open-label study, and given TER (4 mg q.h.s.). Inclusion criteria were international prostate symptom score (IPSS) ≥12, IPSS quality-of-life item ≥3, significant bother, frequency (≥8 voids/24 h), and urgency (≥3 episodes/24 h). Visits occurred at 4, 8, and 12 weeks. Efficacy was assessed by changes in diary endpoints and IPSS (total, storage, and voiding). Safety was assessed by changes in postvoid residual, peak flow rate (Qmax.), adverse events, and retention.Results: Baseline prostate volume was 54.3 mL. TER significantly reduced frequency and urgency: 24-hour micturition frequency (−3.2, P <.02), OAB episodes (19.2%, P <.03), severe OAB episodes (71.4%, P <.05), and nighttime voiding (−0.9, P <.003). IPSS decreased with DUT (19.3-14.3) and decreased with addition of TER to 7.1 (P <.001). Storage symptoms decreased from 9.8 to 4.5 (P <.001). Dry mouth occurred in 4 (7.5%) subjects, constipation in 1 (2%), and decreased sexual function in 2 (3.9%) subjects. Postvoid residual increased by 4.2 mL, Qmax. decreased by 0.2 mL/s, and no patients went into retention.Conclusions: The combination TER and DUT was effective, safe, and well-tolerated in men with large prostates (≥30 mL) with persistent OAB symptoms and LUTS secondary to benign prostatic hyperplasia.

Insulin-like Growth Factor-1 Gene Delivery May Enhance the Proliferation of Human Corpus Cavernosal Smooth Muscle Cells - Corrected Proof

Minkyung Kim, Eu Chang Hwang, In-Kyu Park, Kwangsung Park — 2010-03-08

Objectives: To investigate the effects of IGF-1 gene transfer in human corpus cavernosal smooth muscle cells (HCCSMCs) ex vivo. Insulin-like growth factor-1 (IGF-1) promotes the proliferation of penile cavernous smooth muscle cells in the rats.Methods: A plasmid expressing human IGF-1 was constructed by subcloning hIGF-1 into pcDNA3.1 vector. HCCSMCs were harvested from 3 impotent patients and cultured in vitro. The cultured smooth muscle cells were identified by immunofluorescent staining. RNA was extracted from HCCSMCs, and the gene expression of IGF-1 was determined by reverse transcription-polymerase chain reaction. Cell growth was examined by use of a novel cell proliferation assay based on the bioreduction of the fluorescent dye Alamar blue. The subcloned product was transfected into HCCSMCs. Western blotting and immunoassay were performed 2 days after transfection to evaluate the transfection efficiency.Results: Endogenous IGF-1 mRNA expression was detected by reverse transcription-polymerase chain reaction analysis of total RNA extracted from cultured HCCSMCs. Increased proliferation of HCCSMCs in vitro was observed with exogenous treatment with IGF-1 (100 ng/mL) in a dose-dependent manner. Exogenous IGF-1 gene transfer to cultured HCCSMCs enhanced IGF-1 protein expression compared with the control, and the expression level peaked at 4 days after transfection and decreased slowly thereafter. Secretion of IGF-1 from transfected HCCSMCs induced cellular proliferation.Conclusions: IGF-1 gene transfer into HCCSMCs enhanced cellular proliferation, which was mediated by secretion of IGF-1. Our results suggest that IGF-1 gene therapy may be applied to corpus cavernosum regeneration.

Limitations to Ultrasound in the Detection and Measurement of Urinary Tract Calculi - Corrected Proof

A. Andrews Ray, Daniela Ghiculete, Kenneth T. Pace, R. John D.'A. Honey — 2010-03-08

Objectives: To evaluate differences in stone measurement using computed tomography (CT) and ultrasound (US). Axial unenhanced helical CT is thereference-standard imaging modality for the assessment of urinary tract calculi; however, US is also commonly used. Differences in stonemeasurement using these techniques are poorly described and contributors to measurement error remain unknown.Methods: All patients at our institution undergoing both abdominal CT and renal US less than 1 month apart since June 2004 were reviewed. Solitary renal calculi were identified on both CT and US in all cases.Results: We identified 71 calculi in 60 patients. Compared with CT, US overestimated stone size, an effect that was more pronounced with smaller calculi. The mean stone measurement on CT was 7.4 ± 4.4 mm and on US it was 9.2 ± 4.5 mm (P = .018). For stones ≤5 mm, US measurements were a mean of 1.9 ± 1.2 mm greater than CT (P <.001). US and CT measurements were discordant for 60% of stones ≤5 mm. Discordance was associated with US measurement of skin-to-stone distance (P = .018), but not body mass index (P = .189) or location within the urinary tract (P = .161). Review of the literature revealed that US has a pooled sensitivity and specificity of 45% and 94%, respectively, for the detection of ureteric calculi and 45% and 88%, respectively, for renal calculi.Conclusions: US overestimates stone size in urolithiasis, a finding that may have implications for stone management. Discordance in stone measurement varies with size and is greatest in stones ≤5 mm. US measurement of skin-stone-distance is an important determinant of error in US measurement of renal calculi.

Pelvic Floor Muscles and the External Urethral Sphincter Have Different Responses to Applied Bladder Pressure During Continence - Corrected Proof

Hai-Hong Jiang, Levilester B. Salcedo, Bo Song, Margot S. Damaser — 2010-03-08

Objectives: To determine the functional innervation of the pelvic floor muscles (PFM) and whether there is PFM activity during an external pressure increase to the bladder in female rats.Methods: Thirty-one female adult virgin Sprague–Dawley rats received an external increase in bladder pressure until urinary leakage was noted while bladder pressure was recorded (leak point pressure [LPP]) under urethane anesthesia. Six of the rats underwent repeat LPP testing after bilateral transection of the levator ani nerve. Another 6 rats underwent repeat LPP testing after bilateral transection of the pudendal nerve. Simultaneous recordings of PFM (pubo- and iliococcygeus muscles), electromyogram (EMG), and external urethral sphincter (EUS) EMG were recorded during cystometry and LPP testing.Results: Thirteen rats (42%) showed tonic PFM EMG activity during filling cystometry. Eighteen rats (58%) showed no tonic PFM EMG activity at baseline, but PFM EMG could be activated by pinching the perineal skin. This activity could be maintained unless voiding occurred. The external increase in bladder pressure caused significantly increased EUS EMG activity as demonstrated by increased amplitude and frequency. However, there was no such response in PFM EMG. LPP was not significantly different after levator ani nerve transection, but was significantly decreased after pudendal nerve transection.Conclusions: PFM activity was not increased during external pressure increases to the bladder in female rats. Experimental designs using rats should consider this result. The PFM, unlike the EUS, does not contribute to the bladder-to-urethra continence reflex. PFM strengthening may nonetheless facilitate urinary continence clinically by stabilizing the bladder neck.

Impact of Tadalafil Once Daily in Men With Erectile Dysfunction—Including a Report of the Partners' Evaluation - Corrected Proof

2010-03-08

Objectives: To evaluate the effect of tadalafil 5 mg taken once daily on efficacy (erection achievement and penetration) and overall sexual satisfaction in men with erectile dysfunction (ED) and their female partners.Methods: This retrospective analysis included data pooled from 2 multicenter, randomized, double-blind, placebo-controlled trials that included 505 couples (tadalafil, n = 373; placebo, n = 132) in which the men received tadalafil 5 mg once daily or placebo for 12 weeks. Individual Sexual Encounter Profile (SEP) diaries were completed independently by the male subject and his female partner after each sexual intercourse attempt. The mean per-subject/per-partner percentage of “yes” responses to SEP diary questions were assessed, as was agreement between subjects' and partners' responses.Results: Subjects and partners in the tadalafil-treated group reported significantly greater improvements in the man's ability to achieve some erection, vaginal penetration, and overall sexual satisfaction compared with the placebo-treated group (P < .001). For all intercourse attempts, the mean per-couple percentage of agreement for those in the tadalafil and placebo groups, respectively, was high for erection achievement (99.0% and 96.6%), vaginal penetration (98.6% and 97.4%), and overall satisfaction (84.3% and 82.8%).Conclusions: Tadalafil 5 mg taken once daily as treatment for ED improved overall satisfaction for men and their female partners. This analysis demonstrates the high concordance among couples in their responses to the man's treatment for ED.

Can Saturation Biopsy Predict Prostate Cancer Localization in Radical Prostatectomy Specimens: A Correlative Study and Implications for Focal Therapy - Corrected Proof

2010-03-08

Objectives: To determine whether saturation needle biopsy of the prostate (SBx) can accurately predict prostate cancer (PCA) location in radical prostatectomy (RP) specimens. The success of focal therapy for PCA relies on accurate mapping of cancer before the procedure.Methods: A total of 72 patients underwent SBx followed by RP for PCA. The biopsy protocol consisted of traditional sextant, plus additional ≥10 cores. A single pathologist mapped the tumor outline on RP, determined the number of PCA foci, their Gleason score (GS), and stage.Results: Patients' median age and preoperative serum prostate-specific antigen was 60 years and 5.6 ng/mL, respectively. SBx detected bilateral PCA in 33 and unilateral PCA in 39 men. All cases with bilateral PCA by SBx had bilateral tumor in RP. Only 4 of 39 patients with unilateral positive SBx had unilateral cancer in RP. Twelve potentially clinically significant PCA were missed by SBx in 11 of 35 patients: 2 were GS6 and 10 GS7; 11 were stage pT2 and 1 pT3. When patients with unilateral and bilateral positive SBx were compared with respect to prognostic parameters, biopsy GS (P = .004), number of biopsy cores involved (P <.0001), and highest percentage of core (P = .0005) involved by tumor were significantly higher for patients with bilateral positive biopsy.Conclusions: Most (90%) patients with unilateral PCA on SBx had bilateral cancer in RP; of those 31% had clinically significant undiagnosed PCA. A negative SBx does not confirm the absence of cancer in the corresponding side of the gland and cannot be used as single determinant when considering a patient for focal treatment.

Technetium-99m-L,L-Ethylenedicysteine Is More Effective Than Technetium-99m Diethylenetriamine Penta-acetic Acid for Excluding Obstruction in Patients With Pyelocalicinal Dilation - Corrected Proof

2010-03-08

Objective: To evaluate the utility of diuretic dynamic renal scintigraphy (DDRS) with technetium-99m-L,L-ethylenedicysteine (99mTc-EC) in patients with indeterminate or possible false-positive results for urinary obstruction by technetium-99m diethylenetriamine penta-acetic acid (99mTc-DTPA) DDRS.Methods: A total of 92 patients (63 male; mean age, 16.6 ± 21.25 years) were studied, with a total of 103 kidneys presenting indeterminate (20/103) or possible false-positive results for obstruction attributable to reduced renal function or severe kidney dilation (83/103) by 99mTc-DTPA DDRS (<60% of radiopharmaceutical excreted in 20 minutes—half-time clearance [T½] >15 minutes). Patients were reimaged after intravenous injection of 99mTc-EC, with dynamic images before and after furosemide administration using the same acquisition parameters applied in the previous 99mTc-DTPA study. Time interval between 99mTc-DTPA and 99mTc-EC renograms was 2-64 days. The percentage of excreted material 20 minutes after furosemide was calculated using both radiopharmaceuticals, and were statistically compared using the paired samples t test.Results: The excretion after furosemide injection was 25.3% ± 18.2% for 99mTc-DTPA and 41.2% ± 26.1% for 99mTc-EC, with a statistically significant difference between both radiopharmaceuticals (P 60%. A total of 10 of 83 kidneys (12.0%) with an obstructive pattern by 99mTc-DTPA study turned out to be indeterminate by 99mTc-EC DDRS. There was an agreement between 99mTc-EC and 99mTc-DTPA studies in 54 of 83 kidneys with obstructive (65.1%) and in 3 of 20 (15.0%) with indeterminate patterns.Conclusions: 99mTc-EC was more effective than 99mTc-DTPA for excluding obstruction, presenting less false-positive and indeterminate results. 99mTc-EC can substitute 99mTc-DTPA to evaluate patients with urinary tract dilation.

Last Resort in Devastated Bladder Outlet: Bladder Neck Closure and Continent Vesicostomy—Long-term Results and Comparison of Different Techniques - Corrected Proof

2010-03-08

Objectives: To compare surgical techniques and long-term outcomes in patients undergoing bladder neck closure (BNC) and continent vesicostomy for devastated bladder outlet.Methods: A total of 17 patients who underwent BNC, omental interposition, and continent vesicostomy between 1994 and 2008 were analyzed. Indication for surgery was recurrent anastomotic stricture combined with postradical prostatectomy incontinence (n = 10), postvulvectomy (n = 1), and neurogenic bladder dysfunction (n = 6). Diversion was performed in 8 patients with normal bladder capacity (>300 mL in adults) through a Mitrofanoff appendicovesicostomy (n = 4) or ileal intussusception valve (n = 4). Simultaneous ileocecal bladder augmentation was performed in 9 patients with primarily reduced bladder capacity, and either the in situ embedded appendix (n = 4) or an ileal intussusception valve (n = 5) served as the continent outlet. The stoma was placed in the lower abdomen using the “butterfly technique” (n = 8) or in the umbilicus (n = 9).Results: Medium follow-up was 68 months (range: 12-129). Primary BNC was successful in all patients and primary continence rate was 82%. Three patients (18%) suffered from continence failure, caused by reduced bladder capacity in 2 cases. The third patient presented with an iatrogenic destruction of his Mitrofanoff appendicovesicostomy. These patients were successfully reconstructed by ileocecal bladder augmentation with an ileal intussusception valve as the continent outlet. Four patients (23%) developed stomal stenosis (3/8 with an abdominal stoma and 1/9 with an umbilical stoma). Patients with simultaneous bladder augmentation had higher bladder capacity. No patients developed ureteral obstruction.Conclusions: This technique is an effective, last resort treatment for patients with nonreconstructible bladder outlet.

SIU Scholarship: Dr. Maurice Wambani - Corrected Proof

Maurice Wambani — 2010-02-26

The Société Internationale d'Urologie offers Training Scholarships for young doctors with basic surgical or urological qualifications. The SIU Scholarships involve training in a recognized Urological center of excellence located in the candidate's geographical region. These SIU-accredited centers provide an excellent environment for learning and, in many instances, hands-on experience, so that candidates may acquire knowledge and skills that they will be able to transfer to their own setting of practice. In this series of short communications, SIU Scholars write about the impact that these training opportunities facilitated by the SIU had on their quality of care and career development. Information about applying for an SIU Scholarship is available at http://www.siu-urology.org/.After obtaining the Master of Surgery degree at the University of Nairobi in 2002, I worked in the Department of Urology at Kenyatta Teaching Hospital in Nairobi. My aim was to get formal training to enable me to practice as a urologist in Kenya. I chose to go to the Mansoura Urology and Nephrology Center (UNC) in Egypt because I got a quick response to my application for training and it was affordable. I did not have a scholarship at that time, so I used my own savings. However, while I was at Mansoura, the Director of the UNC, Professor Hassan Abol-Enein, recommended me for the SIU scholarship, which came toward the end of my training, and I used it to purchase the parts of a used Olympus cystoscope and resectoscope.

SIU Scholarship: Dr. Oranusi Chidi Kingsley - Corrected Proof

Oranusi Chidi Kingsley — 2010-02-26

The Société Internationale d'Urologie offers Training Scholarships for young doctors with basic surgical or urological qualifications. The SIU Scholarships involve training in a recognized Urological center of excellence located in the candidate's geographical region. These SIU-accredited centers provide an excellent environment for learning and, in many instances, hands-on experience, so that candidates may acquire knowledge and skills that they will be able to transfer to their own setting of practice. In this series of short communications, SIU Scholars write about the impact that these training opportunities facilitated by the SIU had on their quality of care and career development. Information about applying for an SIU Scholarship is available at http://www.siu-urology.org/.I wish to start by thanking the Société Internationale d'Urologie (SIU) for the opportunity they gave me through this training program to enrich my knowledge of Urology and patient care as a whole. I am very grateful to the SIU. I am also very grateful to Professor Hassan Abol-Enein, the director of the centre and chairman of the SIU scholarship programme for giving me the opportunity to come to his centre.

Prevalence of Erectile Dysfunction in HTLV-1–Infected Patients and Its Association With Overactive Bladder - Corrected Proof

2010-02-26

Objectives: To determine the prevalence of erectile dysfunction (ED) in human T-cell lymphotropic virus type I (HTLV-I)-infected patients, and its association with overactive bladder (OB).Methods: In a cross-sectional study, 111 male patients with positive serology for HTLV-I (by enzyme-linked immunosorbent assay and Western blot) were examined between October 2003 and December 2006. Exclusion criteria were age <18 and >80 years, other neurological diseases, penile prosthesis, neoplasm, and psychological and mental disease. Patients were evaluated by a urologist and neurologist. ED was determined by application of the abridged form of 5-item International Index of Erectile Function (IIEF-5). ED was defined as IIEF-5 ≤ 21. OB was determined by International Continence Society criteria. Using the Expanded Disability Status Scale (EDSS) to determine disautonomy status, a neurologist classified all patients as either asymptomatic carriers (EDSS = 0), “oligosymptomatic myelopathy” (EDSS > 0 e ≤ 2), or HTLV-1–associated myelopathy/tropical spastic paraparesis (HAM/TSP); (EDSS > 2). Diagnosis of HAM/TSP was performed according to World Health Organization recommendations.Results: Of the total of 111 patients, 6 were excluded and 105 were analyzed. The mean age was 48 ± 10.7 years. ED was observed in 55.2%. ED was documented in all patients who had HAM/TSP, in 79% of the group with EDSS > 0 and ≤2, and in 35.9% of HTLV-1–infected individuals with EDSS = 0. OB was detected in 93.75%, 33.3%, and 4.6%, respectively. Moreover, there was an association observed between ED and OB.Conclusions: ED is a frequent disease in HTLV-I-infected individuals, and the prevalence is directly correlated to the degree of neurological disability measured by EDSS. ED was strongly associated with OB symptoms.

Preliminary Study of Efficacy of Doxazosin as a Medical Expulsive Therapy of Distal Ureteric Stones in a Randomized Clinical Trial - Corrected Proof

Ali Akbar Zehri, M. Hammad Ather, Farhat Abbas, S. Raziuddin Biyabani — 2010-02-26

Objectives: To assess the clinical efficacy of doxazosin as the medical-expulsive therapy for distal ureterolithiasis.Methods: A total of 65 patients with a symptomatic 4-7 mm distal ureteral stone were included in the study. Patients were randomized to 1 of the 2 treatment groups. Group 1 (n = 32 patients) was the control group and received diclofenac sodium 50 mg for their pain and group 2 (n = 33 patients) received doxazosin (2 mg daily at the night) along with diclofenac sodium 50 mg. The treatment duration was until stone expulsion or 28 days, whichever come first. The primary endpoint of the study was the stone expulsion rate. The secondary endpoints included time to stone expulsion, use of analgesics, and number of emergency room visits, hospitalizations, and drug side effects. Statistical analyses were performed using chi-square test and Fisher exact test.Results: Both groups were comparable in terms of demographic, clinical, and stone-related parameters. Stone expulsion rate was significantly higher in the treatment group (38% for group 1 and 70% for group 2, P = .009) while the expulsion time was significantly lesser in group 2 patients (P = .005). During the treatment period, we observed significant differences between the 2 groups in the number of pain episodes and analgesic used (P = .0001). None of the patients in either groups reported adverse drug-related events.Conclusions: Doxazosin significantly improves stone expulsion and is associated with decreased colic frequency and use of analgesia. It is also well tolerated with no adverse drug-related events.

Assessment and Management of an Open Bladder Neck at Posterior Urethroplasty - Corrected Proof

Mamdouh M. Koraitim — 2010-02-26

Objectives: To determine the factors that may influence the risk of injury to the bladder neck in patients sustaining a pelvic fracture urethral injury and report our experience in the management of an open bladder neck at the time of delayed repair.Methods: We identified 21 patients with an open bladder neck on cystography before they underwent repair of a pelvic fracture urethral distraction defect. Of these patients, 12 were continent after urethroplasty and 9 received bladder neck reconstruction concomitant with or subsequent to urethroplasty. Bladder neck reconstruction was performed by Young-Dees-Leadbetter (5) or anterior bladder flap-tube (4) procedure.Results: Patients with an incompetent bladder neck were usually (67%) children ≤15 years old, had been most commonly (75%) managed initially by primary realignment, and all (100%) had fracture of ipsilateral ischiopubic rami. The preoperative cystogram showed a bladder neck opening of a rectangular shape, and suprapubic cystoscopy revealed a fixedly open bladder neck. Of the 9 patients who received a bladder neck reconstruction, 7 (78%) had a successful outcome and 2 (22%) had a treatment failure.Conclusions: It seems that the risk of injury to the bladder neck increases in children, in ipsilateral ischiopubic rami fracture and in cases managed initially by primary realignment. At posterior urethroplasty, the presence of an incompetent bladder neck is suspected by the finding of an open bladder neck of a rectangular shape on cystography and a fixedly open bladder neck on suprapubic cystoscopy. Reconstruction of the bladder neck by Young-Dees-Leadbetter procedure probably offers the best successful results.

Predictors of Surgical Outcome in Children With Vesicoureteral Reflux Associated With Paraureteral Diverticula - Corrected Proof

Ozgu Aydogdu, Berk Burgu, Tarkan Soygur — 2010-02-26

Objectives: To retrospectively evaluate success rates of different surgical approaches in the treatment of paraureteral (Hutch) diverticula (PUD) associated with vesicoureteral reflux (VUR) and also to define preoperative objective criteria to predict the surgical outcome.Methods: Records of 51 patients who underwent surgical treatment for PUD were reviewed. Intravesical ureteroneocystostomy (UNC), subureteral injection, and extravesical UNC were performed in 23, 28, and 10 renal units, respectively. Records of patients were evaluated with particular emphasis on predictors of treatment outcome. Mean follow-up was 22.1 months (range, 3-46). Statistical significance was set at P .05). The mean PUD index for patients who underwent endoscopic treatment was significantly lower (P <.05). In the endoscopic group, reflux was detected at the late-filling or voiding phase of voiding cystourethrography (P <.005). In patients, who were diagnosed with video urodynamics, reflux began at higher bladder pressures and volumes in the injection group (P <.005). UNC was more frequently used in patients with the orifice at the neck or dome (P <.005).Conclusions: For injection in the lower PUD index, onset of reflux at late-filling or voiding phase on voiding cystourethrography, higher pressure and volume on video urodynamics, and C position orifice are positive predictive parameters for success. Bilateral reflux with high PUD index and grade 5 VUR are associated with failure of intravesical reimplantation. Presence of grade 5 VUR and an early onset of reflux outstand as negative predictive factors for unilateral extravesical UNC.

Microanatomy of the Left and Right Spermatic Cords at Subinguinal Microsurgical Varicocelectomy: Comparative Study of Primary and Redo Repairs - Corrected Proof

Jamie L. Libman, Robert Segal, Abdulaziz Baazeem, Jason Boman, Armand Zini — 2010-02-25

Objectives: To examine and compare the left and right spermatic cord arterial and lymphatic anatomy identified at primary and redo microsurgical subinguinal varicocelectomy.Methods: We reviewed the operative reports of 335 consecutive microsurgical varicocelectomies performed by a single surgeon: 325 primary repairs and 10 reoperations. We recorded number of testicular arteries (internal and external spermatic) and lymphatic channels preserved at subinguinal microsurgical varicocelectomy, and evaluated the relationship between the right and left vascular anatomy at bilateral varicocelectomy.Results: A total of 235 left-sided and 90 bilateral primary repairs were performed. A mean (± standard deviation) number of 2.4 ± 1.0 arteries and 4.6 ± 1.5 lymphatics were identified during the left-sided repairs. For bilateral repairs, there were 2.4 ± 0.9 arteries and 4.4 ± 1.2 lymphatics on the left and 2.2 ± 0.9 arteries and 4.2 ± 1.3 lymphatics on the right with a significant correlation between the number of right and left internal spermatic arteries (r = 0.42). For the cohort of secondary (redo) varicocelectomies, we identified 2.3 ± 0.6 arteries and 4.8 ± 1.6 lymphatic channels (not significantly different from the primary varicocelectomy cohorts).Conclusions: The number of arteries and lymphatics preserved at microsurgical varicocelectomy is highly variable, but there is some similarity in the microanatomy of the right and left spermatic cords at the level of the external inguinal ring. The data also suggest that the number of arteries and lymphatic channels identified at a redo varicocelectomy is comparable to that observed during a primary varicocelectomy.

Is Left Ventricular Systolic Dysfunction a Risk Factor for Erectile Dysfunction? - Corrected Proof

2010-02-25

Objectives: To analyze erectile dysfunction (ED) in patients with left ventricular systolic dysfunction (LVSD).Methods: A consecutive series of men aged 50-65 years undergoing an echocardiography (EC) at the Danube hospital in Vienna was analyzed. All patients completed the International Index of Erectile Function-5 (IIEF-5). LVSD was defined by EC as an ejection fraction (EF) below 55%.Results: A total of 85 men (age, 58.5 years; standard deviation, 4.3) entered the analysis. Mean EF was 60.9% and mean IIEF-5 score 16.8. No ED (IIEF-5, 22-25) was present in 32 men (37.6%), mild ED (IIEF-5, 17-21) in 17 (20%), and 36 (42.4%) had moderate to severe ED (IIEF-5, 5-16). An EF below 55% was seen in 26 men (30.6%). Mean IIEF-5 in men with LVSD was 13.6 compared with 18.2 in those without LVSD (P = .005); the proportion of men with ED (IIEF-5 <22) was 76% in men with LVSD compared with 56.6% in those without LVSD (relative risk, 1.37; P = .05). In a logistic regression analysis adjusted for body mass index and age a declined IIEF-5 score was independently associated with a low EF (≤55%) (P = .02).Conclusions: Our data, generated via standardized assessment of LVSD (EC) and ED (IIEF-5) revealed a significant effect of chronic LVSD on erectile function in middle-aged men.

Extended Pelvic Lymph Node Dissection in Robotic-assisted Radical Prostatectomy: Surgical Technique and Initial Experience - Corrected Proof

2010-02-17

Objectives: To describe, and show in the accompanying video segments, a technique for extended pelvic lymph node dissection (ePLND) in robotic-assisted radical prostatectomy (RARP) and report our clinicopathologic and perioperative outcomes. The extent of pelvic lymphadenectomy during radical prostatectomy has not been standardized. However, evidence demonstrates that an ePLND yields a greater number of positive nodes.Methods: A total of 32 patients with clinically localized prostate cancer underwent RARP with ePLND by a single surgeon (J.C.) between January and August 2008. The template for the ePLND included the obturator, hypogastric, external iliac, and common iliac lymph nodes up to the bifurcation of the aorta. Systematic review and grading of adverse events were performed.Results: The median number of lymph nodes retrieved was 18 (interquartile range [IQR] 12-28). Four patients (12.5%) had lymph node metastases. Of the 4 patients with lymph node metastases, 1 patient (25%) had the involved lymph node exclusively in the common iliac region. Median operative time for the ePLND was 72 minutes (IQR 66-86). Median hospital length of stay was 2.0 days (IQR 2.0-2.8). Graded complications included 13 grade 1 events and 1 grade 2 event, with 1 grade 1 event being considered related to ePLND. No clinically presenting lymphoceles or thrombotic events were encountered.Conclusions: An ePLND during RARP is technically feasible and appears to have minimal morbidity. It produces a high lymph node yield and may result in improved pathologic staging.

SIU Scholarship: Dr. Noaman Mohammed Almashraki - Corrected Proof

Dr. Noaman Mohammed Almashraki — 2010-02-17

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

Health Disparities in Staging of SEER-Medicare Prostate Cancer Patients in the United States - Corrected Proof

2010-02-17

Objectives: To examine whether race or age disparities affected the odds of being staged among prostate cancer (PC) patients. Accurate staging is critical for determining treatment for PC.Methods: Multivariable logistic regression models examined race and age disparities with respect to the odds of being staged among PC patients using Surveillance, Epidemiology, and End Results-Medicare data. Similar analyses were performed to estimate the adjusted odds of being staged with distant metastatic vs in situ or local/regional disease.Results: The proportion of patients without staging ranged between 3% and 16% by age and between 6% and 8% by race. Adjusted results demonstrated statistically significant lower odds ratios (P <.05) for 70-74, 75-79, and 80+-year-olds of 0.76, 0.52, and 0.23, respectively, relative to PC patients aged 65-69. The odds of being staged for African Americans are 0.78 times that of non-Hispanic Whites (95% confidence interval = 0.72-0.86). The adjusted probability of distant metastatic disease at initial diagnosis is higher for African Americans (odds ratio = 1.61; 95% confidence interval = 1.47-1.76) and older men with odds ratios of 1.25, 1.85, and 4.33 for ages 70-74, 75-79, and 80+, respectively, compared with 65-69-year-olds (all P <.05).Conclusions: Even though the overall odds of being staged increased over time, race and age disparities persisted. When staging did occur, the probability of distant metastatic disease was high for African Americans, and there were increasing odds of metastatic disease for all men with advanced age.

Effects of Tadalafil on Lower Urinary Tract Symptoms Secondary to Benign Prostatic Hyperplasia in Men With or Without Erectile Dysfunction - Corrected Proof

2010-02-17

Objectives: To compare the safety and efficacy of the daily erectogenic therapy, tadalafil, on lower urinary tract symptoms secondary to benign prostatic hyperplasia (BPH-LUTS) in men with or without comorbid erectile dysfunction (ED).Methods: Following a 4-week placebo run-in period, men with moderate-to-severe BPH-LUTS were randomized to placebo or tadalafil 2.5, 5, 10, or 20 mg once daily for 12 weeks. International Prostate Symptom Scores (IPSS), IPSS quality of life, and BPH Impact Index were measured every 4 weeks. Safety was mainly assessed via spontaneous reports of adverse events. Data from men with (n = 716) or without (n = 340) ED at baseline were compared in posthoc analyses.Results: Men with ED were older and had more frequent hypertension, hyperlipidemia, coronary artery disease, and diabetes at baseline compared with men without ED. After 12 weeks, changes in IPSS in men with ED (least squares mean change from baseline, placebo: −2.4; tadalafil 2.5, 5, 10, 20 mg: −4.3, −4.8, −5.3, −5.6) and without ED (−2.4, −3.2, −5.3, −5.1, −4.5) were not significantly different (subgroup/interaction P values: .352/.644). Similar effects were observed for IPSS quality of life (with ED: −0.6, −0.9, −0.9, −1.0, −1.1; without ED: −0.6, −0.7, −0.9, −0.8, −0.8; 0.090/0.773) and BPH Impact Index (with ED: −0.7, −0.9, −1.3, −1.3, −1.4; without ED: −1.0, −0.7, −1.3, −1.3, −1.2; 0.753/0.852). Tadalafil was generally well tolerated, and men with or without ED had similar tolerability profiles.Conclusions: Changes in BPH-LUTS after 12 weeks of treatment with placebo or various doses of once daily tadalafil were similar in men with or without comorbid ED.

Effect of Sex Hormones on Crystal Formation in a Stone-forming Rat Model - Corrected Proof

2010-02-17

Objectives: To evaluate the contribution of sex hormones in urolithiasis using a stone-forming rat model. Gender differences because of sex hormones are thought to influence the incidence of urolithiasis.Methods: We divided rats into 7 groups, such as intact males, orchidectomized males, intact males subcutaneously implanted with testosterone, intact males subcutaneously implanted with estradiol, intact females, ovariectomized females, and intact females subcutaneously implanted with testosterone. At 10 weeks old, the rats were fed 0.5% ethylene glycol in drinking water and given 0.5 μg of 1,25-dihydroxy vitamin D3. Kidney crystal deposition and the degree of oxidative stress were examined in each group, and endogenous oxalate metabolism and antioxidant enzymes were compared among groups using real-time reverse transcription-polymerase chain reaction.Results: Extensive crystal deposition was observed in intact males and testosterone-administered males, whereas few crystals were found in intact females. Crystal deposition was inhibited in orchiectomized males and in those administered estradiol, whereas ovariectomized females and testosterone-administered females had slightly enhanced and very enhanced crystal deposition, respectively. Increases in urinary oxalate excretion paralleled renal crystal deposition, which were both enhanced by testosterone treatment through increased glycolate oxidase expression. Oxidative stress increased in groups with extensive crystal deposition compared with those without. Antioxidant enzyme expression was enhanced by estradiol.Conclusions: Testosterone was a promoter and estradiol an inhibitor of kidney crystal deposition, likely because of their effects on oxalate synthesis and oxidative stress.

Percutaneous Biopsy of Renal Cell Carcinoma Underestimates Nuclear Grade - Corrected Proof

Aaron J. Blumenfeld, Khurshid Guru, Gerhard J. Fuchs, Hyung L. Kim — 2010-02-17

Objectives: To assess the accuracy of renal biopsy for predicting the final nuclear grade and histologic subtype. Small renal masses can be safely observed in select patients who are poor surgical candidates. Renal biopsy may help identify patients who are candidates for observation.Methods: A total of 81 patients (29 female, 52 male) underwent percutaneous biopsy of their renal mass with ultrasound or computed tomography guidance. Percutaneous 18-gauge biopsy cores were obtained, and all patients subsequently underwent radical nephrectomy or partial nephrectomy. Preoperative biopsy results were compared with postoperative specimens.Results: The mean tumor size was 5.3 cm (range, 1-17). Overall, biopsy correctly identified 71 of 81 (88%) histologic subtypes. The preoperative biopsy correctly identified 62 of 64 (97%) clear cell renal carcinomas, 9 of 10 (90%) papillary carcinomas, 0 of 3 (0%) chromophobe carcinomas, and 1 of 2 (50%) oncocytomas. The final pathologies for 2 nondiagnostic biopsies were clear cell renal carcinoma and inflammatory pseudotumor. For 67 tumors, the pathologists assigned a nuclear grade for both the biopsy and the final specimen. The biopsy correctly identified 29 of 67 (43%) final nuclear grades. The biopsy underestimated the nuclear grade in 37 of 67 (55%) cases. In 7 of 67 (10%) cases, the biopsy nuclear grade increased by 2 when compared with the final grade. The biopsy rarely overestimated the nuclear grade; 1 case (1%) that was assigned a grade 2 on biopsy was assigned a grade 1 after nephrectomy.Conclusions: Core biopsies for renal masses underestimate nuclear grade in most cases; however, histologic subtype is more reliably assessed, particularly for clear cell renal tumors.

Isolated Hemangioma Causing Gross Painless Hematuria in an Adolescent Male - Corrected Proof

Jeremy B. Wiygul, Lane Palmer — 2010-02-17

Hematuria in children is usually a benign entity, with hypercalciuria being the usual etiology; however, rarer causes also exist, including genitourinary hemangioma. Hemangioma is a benign tumor, which has a tendency to regress spontaneously by the second year of life. Involvement of the urinary tract is rare, and in patients with bladder involvement, an accompanying syndrome such as Sturge-Weber is usually found. However, there are reports of isolated bladder hemangioma in the pediatric population causing isolated gross hematuria. We report a case of bladder hemangioma causing gross painless hematuria in an otherwise healthy 14-year-old boy.

Single Institutional Experience with Nephron-sparing Surgery for Pathologic Stage T3bNxM0 Renal Cell Carcinoma Confined to the Renal Vein - Corrected Proof

2010-02-17

Objective: To assess our institution's experience with the management of pathologic stage T3bNxM0 renal cell carcinoma with tumor thrombus confined to the renal vein treated with nephron-sparing surgery (NSS).Methods: Of the 492 patients who have undergone NSS at Columbia University from 1998 to 2009, 8 patients were found to have stage T3bNxM0 renal cell carcinoma (RCC) on final pathology. Records were reviewed for indication for NSS, imaging studies, perioperative management, surgical details, pathology, and both functional and disease-specific outcomes. Postoperative renal function was estimated by most recent glomerular filtration rate using Modification of Diet in Renal Disease formula. Recurrence of RCC was monitored using serial axial imaging.Results: The 8 patients were presumed to be clinical stage T1aN0M0 RCC before surgery; however, tumor thrombus was identified in the renal vein intraoperatively and on final pathology in 4, and 4 cases, respectively, corresponding to stage T3bNxM0 RCC by current American Joint Committee on Cancer–Tumor-Necrosis-Metastasis 2002 criteria. After a median follow-up of 19.8 months, the patients experienced a mean decrease in estimated glomerular filtration rate of 27.1%. One patient developed new-onset renal failure, defined as an estimated glomerular filtration rate below 30 mL/min/1.73 m2. Clean surgical margins were obtained in 7 patients. Carcinoma was identified at the parenchymal margin in 1 patient. No patients have evidence of recurrence of RCC by serial axial imaging.Conclusions: NSS does not seem to have had a negative impact on a small series of patients with pathologic stage T3bNxM0 RCC limited to the renal vein and may be a feasible option when the clinical situation indicates a need for preservation of renal function.

Relationship Between Bone Mineral Density and Androgen-deprivation Therapy in Japanese Prostate Cancer Patients - Corrected Proof

2010-02-17

Objectives: To examine Japanese patients who had received androgen-deprivation therapy (ADT) for longer periods, as it is known that ADT of patients with prostate cancer reduces their bone mineral density (BMD). However, our previous cross-sectional study revealed that short-term ADT (average, 23.5 months) does not significantly increase the prevalence of osteoporosis in Japanese patients.Methods: The subjects consisted of 201 native Japanese patients with prostate cancer. They comprised 113 ADT-treated and 88 hormone-naive patients. Lumbar spine, total hip, and femoral neck BMDs were measured by dual-energy x-ray absorptiometry and expressed in standard deviation units relative to the scores of young adult men (T-score) or age-matched men (Z-score). Serum levels of bone metabolism markers were also measured.Results: The ADT-treated patients had significantly lower BMD values, T-scores, and even Z-scores than the hormone-naive patients (P <.001). For patients who were hormone-naive, ADT-treated for less than 2 years, and ADT-treated for more than 2 years, the osteoporosis prevalence was 4.5% (4/88), 12.1% (4/33), and 10.8% (4/37), respectively. The ADT-treated patients had significantly higher serum amino-terminal telopeptide levels than the hormone-naive patients (P = .014), but significantly lower serum carboxy-terminal telopeptide of type-I collagen levels than the ADT-treated patients with bone metastasis (P <.001).Conclusions: Our cross-sectional study confirmed that both ADT-treated and hormone-naive Japanese patients with prostate cancer have low rates of osteoporosis. These findings are different from those of studies in western countries. Genetic and hormonal or other environmental factors may result in population differences in the characteristics of prostate cancer and BMD.

An Epidemiologic Study of Voiding and Bowel Habits in Korean Children: A Nationwide Multicenter Study - Corrected Proof

2010-02-17

Objectives: To evaluate the prevalence of abnormal voiding and bowel habits in healthy children, and to identify possible relationships between personal and familial factors and voiding and/or bowel habits.Methods: A randomly selected cross-sectional study was conducted in 19 240 children (5-13 years old) nationwide in the Republic of Korea. Parents were asked to complete questionnaires, which included items about nocturnal enuresis, daytime dysfunctional voiding symptoms (DVSs), and abnormal bowel habits (ABHs). Rates and associated factors were investigated.Results: The overall rates of DVS, ABH, and of both were 46.4%, 31.3%, and 18.4%, respectively, and nocturnal enuresis was reported in 919 (5.6%). Daytime dysfunctional voiding symptoms were as follows: increased voiding frequency in 419 (2.5%), decreased voiding frequency in 720 (4.4%), urgency in 2740 (16.6%), daytime incontinence in 1854 (11.2%), urge incontinence in 2775 (16.8%), and holding maneuvers or postponed voiding in 3888 (23.5%). ABHs were as follows: constipation by frequency in 1103 (6.7%), constipation by the Bristol scale in 1941 (11.8%), fecal incontinence in 1293 (7.8%), and difficult or painful defecation in 2609 (15.8%). Delayed stool control, history of urinary tract infection, and a double-income family were positively associated with DVS or ABH or both. Furthermore, fathers with a low level of education and a low income were found to be associated with higher risk of ABH or DVS or both.Conclusions: Delayed stool control, a history of urinary tract infection, a low paternal level of education, a double-income family, and a lower family income had a negative effect on voiding or bowel habits in children.

SIU Scholarship: Dr. Yousuf M. Alhallaq - Corrected Proof

Yousuf M. Alhallaq — 2010-02-15

The Société Internationale d'Urologie offers Training Scholarships for young doctors with basic surgical or urological qualifications. The SIU Scholarships involve training in a recognized Urological center of excellence located in the candidate's geographical region. These SIU-accredited centers provide an excellent environment for learning and, in many instances, hands-on experience, so that candidates may acquire knowledge and skills that they will be able to transfer to their own setting of practice. In this series of short communications, SIU Scholars write about the impact that these training opportunites faciliated by the SIU had on their quality of care and career development. Information about applying for an SIU Scholarship is available at http://www.siu-urology.org/.My SIU scholarship, from June to December 2006 at the Al-Mansoura Urology and Nephrology center in Egypt was very fruitful, scientifically as well as socially. The grant from SIU represented a great opportunity, and I enthusiastically looked forward to updating my scientific knowledge, improving my surgical skills to meet international standards, and overcoming the lack of contact with centers around the world, which was a result of the long-standing sanctions against Iraq.

SIU Scholarship: Dr. Anthony M. Kariuki - Corrected Proof

Anthony M. Kariuki — 2010-02-15

The Société Internationale d'Urologie offers Training Scholarships for young doctors with basic surgical or urological qualifications. The SIU Scholarships involve training in a recognized Urological center of excellence located in the candidate's geographical region. These SIU-accredited centers provide an excellent environment for learning and, in many instances, hands-on experience, so that candidates may acquire knowledge and skills that they will be able to transfer to their own setting of practice. In this series of short communications, SIU Scholars write about the impact that these training opportunities faciliated by the SIU had on their quality of care and career development. Information about applying for an SIU Scholarship is available at http://www.siu-urology.org/.Surgical services in Kenya have been expanding in the last decade. Since the late 90s to date there has been intensive and sustained training of general surgeons with a view to having a surgeon in every district hospital (there are over 50 such hospitals). This goal has so far been achieved.

Value of Transrectal Ultrasonography in Female Traumatic Urethral Injuries - Corrected Proof

Tao Ying, Qin Li, Chunjuan Shao, Zhaoling Zhu, Liang Feng, Bing Hu — 2010-02-15

Objectives: To estimate the value of transrectal ultrasonography (TRUS) in traumatic urethral injuries of various types in females.Methods: A total of 30 female patients with symptoms of urethral injuries after trauma underwent TRUS between January 2005 and July 2008. Of them, 28 patients with operative indications undertook operation; the other 2 received conservative management and then a follow-up ultrasonography. All outcomes were used to validate the results of TRUS.Results: Urethral injuries were clearly observed in 30 cases with TRUS. The continuity of urethral wall, unblocking of urethral lumen, and homogeneous echo of surrounding structures had been changed. Urethral injuries varied in types, including urethrovaginal fistula, urethral stricture, urethral rupture, and urethral hematoma. It was common to find several injury patterns simultaneously in 1 patient. The outcomes in 28 cases with operative indications were consistent with results of surgery. The other 2 cases were diagnosed as urethral hematoma by TRUS which disappeared in a follow-up sonography after 3 months' conservative management.Conclusions: TRUS is a reliable technique to exhibit abnormalities in injured urethra associated with trauma in female.

Potent Cytotoxic Effect of a Novel Nuclear Factor-κB Inhibitor Dehydroxymethylepoxyquinomicin on Human BladderCancerCellsProducingVariousCytokines - Corrected Proof

2010-02-15

Objectives: To explore the potential therapeutic effects of the nuclear factor-κB (NF-κB) inhibitor dehydroxymethylepoxyquinomicin (DHMEQ). KU-19-19 cells, originally derived from a patient with invasive bladder cancer who exhibited marked leukocytosis, produce multiple cytokines. This model of clinically advanced bladder cancer, in which NF-κB is constitutively activated, was used in this study.Methods: Expression of p65 protein in fractionated KU-19-19 cells was determined by Western blotting analysis. DNA-binding activity of NF-κB was detected by electrophoretic mobility shift assay. The cytotoxic effects and induction of apoptosis by DHMEQ were analyzed, and cytokines in the supernatant of KU-19-19 cells cultured with or without DHMEQ were measured by enzyme-linked immunosorbent assay (ELISA). Athymic nude mice bearing KU-19-19 subcutaneous tumors were subjected to intraperitoneal administration of 2 mg/kg/d DHMEQ for 3 weeks. Tumor growth was monitored and microvessel density, vascular endothelial growth factor expression, and the apoptotic index of tumors were evaluated by tissue immunohistochemistry.Results: NF-κB was constitutively activated in KU-19-19 cells. DHMEQ reversibly inhibited the DNA-binding activity of NF-κB by blocking its nuclear translocation. Both cell viability and production of cytokines were significantly and dose-dependently suppressed by DHMEQ, and significant apoptosis was also induced. In in vivo studies, the mean tumor volume in mice treated with DHMEQ was significantly smaller than in controls. Immunohistochemical analysis of tumors revealed marked reduction in microvessel density, vascular endothelial growth factor expression, and induction of apoptosis.Conclusions: Blockade of NF-κB function by DHMEQ may be a useful new molecular targeting treatment for highly aggressive bladder cancer.

Enterococcus faecalis Cellulitis/Fasciitis After Hypospadias Surgery - Corrected Proof

Regina D. Norris, Ahmad Z. Mohamed, Judith M. Martin, Steven G. Docimo — 2010-02-15

We describe a case of Enterococcus faecalis–associated cellulitis/fasciitis after hypospadias surgery.

Reduction in Patient-reported Acute Morbidity in Prostate Cancer Patients Treated With 81-Gy Intensity-modulated Radiotherapy Using Reduced Planning Target Volume Margins and Electromagnetic Tracking: Assessing the Impact of Margin Reduction Study - Corrected Proof

2010-02-15

Objective: To investigate whether patient-reported quality of life after high-dose external beam intensity-modulated radiotherapy for prostate cancer can be improved by decreasing planning target volume margins while using real-time tumor tracking.Methods: Study patients underwent radiotherapy with nominal 3-mm margins and electromagnetic real-time tracking. Morbidity was assessed before and at the end of radiotherapy using Expanded Prostate Cancer Index Composite (EPIC) questionnaires. Changes in scores were compared between the Assessing Impact of Margin Reduction (AIM) study cohort and the comparator Prostate Cancer Outcomes and Satisfaction with Treatment Quality Assessment (PROST-QA) cohort, treated with conventional margins.Results: The 64 patients in the prospective AIM study had generally less favorable clinical characteristics than the 153 comparator patients. Study patients had similar or slightly poorer pretreatment EPIC scores than comparator patients in bowel, urinary, and sexual domains. AIM patients receiving radiotherapy had less bowel morbidity than the comparator group as measured by changes in mean bowel and/or rectal domain EPIC scores from pretreatment to 2 months after start of treatment (−1.5 vs −16.0, P = .001). Using a change in EPIC score >0.5 baseline standard deviation as the measure of clinical relevance, AIM study patients experienced meaningful decline in only 1 health-related quality of life domain (urinary) whereas decline in 3 health-related quality of life domains (urinary, sexual, and bowel/rectal) was observed in the PROST-QA comparator cohort.Conclusions: Prostate cancer patients treated with reduced margins and tumor tracking had less radiotherapy-related morbidity than their counterparts treated with conventional margins. Highly contoured intensity-modulated radiotherapy shows promise as a successful strategy for reducing morbidity in prostate cancer treatment.

Complications of the AdVance Transobturator Male Sling in the Treatment of Male Stress Urinary Incontinence - Corrected Proof

2010-02-15

Objective: To evaluate prospectively the complication rate of the retrourethral transobturator sling (AdVance sling) for the functional treatment of male stress urinary incontinence (SUI).Methods: In 230 patients with SUI due to nonintrinsic sphincter deficiency (without direct sphincter lesion) after radical prostatectomy (n = 213), radical cystoprostatectomy with ileal neobladder (n = 2) and transurethral resection of the prostate (n = 15) a retrourethral transobturator sling was implanted. Patients were followed up for a median of 17 months (range, 4-42 months) with regard to intraoperative, early postoperative, and midterm postoperative complications.Results: Overall complication rate of the AdVance sling was 23.9%. Despite one accidental sling misplacement, no intraoperative complication occurred. Forty-nine patients (21.3%) experienced urinary retention postsurgery. Two slings were explanted (0.9%), 1 due to initial wrong placement and the other due to a symphysitis, attributed to a Guillain-Barré syndrome and not to a sling infection. One sling was transected (0.4%) due to slippage of the sling with obstruction of the urethra. Further complications were local wound infection (0.4%), urinary infection with fever (0.4%), and persistent moderate perineal pain (0.4%). There was no correlation between postoperative acute urinary retention and age at sling implantation, time of incontinence before sling implantation, preoperative daily pad use, or prior invasive incontinence treatment, respectively.Conclusions: The retrourethral transobturator AdVance sling is a safe treatment option for male nonintrinsic sphincter deficiency SUI, with the main postoperative complication being transient acute urinary retention. Severe intra- and postoperative complications are rare and sling explantation rate is very low.

Differential Roles of M2 and M3 Muscarinic Receptor Subtypes in Modulation of Bladder Afferent Activity in Rats - Corrected Proof

2010-02-15

Objectives: To investigate the effects of various muscarinic acetylcholine receptor (mAChR) antagonists, including selective M2 and M3 mAChR antagonists, on bladder overactivity. It has been proposed that the urothelium modulates the activity of bladder afferent pathways. However, the differential roles of mAChR subtypes in local bladder afferent activation remain unclear.Methods: Cystometry was performed in urethane-anesthetized female rats. We examined the effects of intravesical administration of antimuscarinic agents (nonselective mAChR antagonists: atropine sulfate, tolterodine tartrate, and propiverine hydrochloride; M2-selective antagonists: dimethindene maleate and methoctramine hemihydrate; M3-selective antagonists: darifenacin hydrobromide and 4-DAMP) on bladder overactivity induced by oxotremorine-M (oxo-M; nonselective mAChR agonist).Results: Intravesical administration of oxo-M (200 μM) elicited bladder overactivity as evidenced by decreased intercontraction interval, bladder capacity, and pressure threshold. These effects were blocked by intravesical administration of nonselective or M2-selective antagonists (30-60 μM), whereas M3-selective antagonists (150 μM) did not suppress the overactivity. When instilled intravesically by itself, none of the antimuscarinic agents (nonselective, M2-selective or M3-selective antagonists) affected any cystometric parameters.Conclusions: The M2 mAChR subtype plays an important role in the local cholinergic modulation of bladder afferent activity that contributes to bladder overactivity in normal rats. Therefore, it is expected that antimuscarinic agents that have antagonistic activity against M2 mAChR can be more beneficial for the treatment of patients with overactive bladder if enhanced acetylcholine mechanisms are involved in pathogenesis of overactive bladder.

Laparoscopic Pyeloplasty: Comparison Between Retroperitoneoscopic and Transperitoneal Approach - Corrected Proof

2010-02-15

Objective: To compare both approaches of laparoscopic pyeloplasty, transperitoneal vs retroperitoneoscopy.Methods: A total of 65 procedures were performed in 62 patients, 36 females and 26 males. Laparoscopic pyeloplasty with Anderson Hynes technique was performed transperitoneal in 34 cases and retroperitoneal in 31 cases. Parameters studied were the operative duration, the rate of conversion to open approach, transposition of crossing vessel, complications and reintervention, results, and the duration of hospitalization. Then, overall success rate for both approaches was evaluated in the presence or absence of crossing vessels, and if transposition of crossing vessel was performed vs without.Results: The overall success rate for both procedures was 85% (87% for the retroperitoneal vs 82% for the transperitoneal approach). The mean operative duration was 231.69 ± 59.97 and 194.76 ± 25.37 minutes for the retroperitoneal and transperitoneal approaches, respectively (P = .029). The rate of conversion was 19.35% (6 of 31) and 2.9% (1 of 34) for the retroperitoneal and transperitoneal approaches, respectively (P = .047). No significant statistical difference was noted between both techniques related to the age of patient, the hospital stay, and intraoperative and postoperative complications. Transposition of crossing vessel had no effect on the results (81.25% with transposition and 80% if not, P = .93).Conclusions: Retroperitoneoscopic approach is associated with longer operative time and more conversion rate than transperitoneoscopy. However, the overall outcomes of laparoscopic transperitoneal pyeloplasty vs retroperitoneoscopic were comparable.