Current Urology

Arslan, Murat; Yuksel, Mehmet; Gunlusoy, Bulent; Degirmenci, Tansu; Kozacioglu, Zafer; Tatli, Engin; Ayder, Ali Rıza

2009 Current Urology

doi: 10.1159/000189684

Aims: The aim of this study is to evaluate the differences between the urodynamic patterns and findings of the subtypes of detrusor overactivity(DOA). Methods: An analysis of the urodynamic data of 82 patients who presented for evaluation of symptoms of urinary frequency, urgency and/or urge incontinence was done. The diagnosis of DOA is based on urodynamic findings considering the classification of DOA by EAU. Of the 82 patients, 50 had idiopathic DOA and 32 had neurogenic DOA. The specific data included the frequency and amplitude of uninhibited contractions, complience, cystometric capacity, reflex volume, presence of uninhibited contraction that cause incontinence determined in urodynamy, sex and age. Results: There were 50 patients(28 women, 22 men) with a mean age of 45.0 ± 8.8 (ranging 20 to 65) years in idiopathic DOA group and 32 patients (10 women, 22 men) with a mean age of 39.7 ± 7.4 (ranging 22 to 61) years in neurogenic DOA group. The most frequent symptoms were urgency, urge incontinence, nocturia. There were no differences between 2 groups in frequence values of uninhibited contractions (0.77), reflex volume (0.665), and age (0.297). On the other hand, there were main differences in each group in terms of sex (p = 0.028 ), uninhibited contractions that cause incontinence (p = 0.00 ), amplitude (p = 0.00 ), cystometric capacity (p = 0.003 ), complience (0.004). Conclusion: DOA is a frequent cause of incontinence with symptoms of frequency, urgency and urge incontinence. The urodynamic findings of DOA is important to identify the subtypes of DOA.

Sakai, Iori; Miyake, Hideaki; Muramaki, Mototsugu; Takenaka, Atsushi; Fujisawa, Masato

2009 Current Urology

doi: 10.1159/000189685

Background: The objective of this study was to retrospectively review oncological outcome following radical prostatectomy (RP) in patients with T1c prostate cancer. Patients and Methods: This study included 135 patients who were diagnosed as having T1c prostate cancer and subsequently underwent RP without any neoadjuvant therapies. In this series, biochemical recurrence (BR) was defined as a serum prostate specific antigen 0.2 ng/ml or greater on 2 consecutive measurements. Results: The pathological stage was pT2, pT3a and pT3b in 113, 18 and 4 patients, respectively, and a positive surgical margin was detected in 30; however, there was no patient with lymph node metastasis. During the mean observation period of 45.8 months, despite none of the patients dying of cancer progression, BR occurred in 17 patients, and the 5-year BR-free survival rate was 87.0%. Of several factors examined, BR was significantly associated with preoperative serum prostate specific antigen, pathological stage, seminal vesicle invasion and surgical margin status, among which only surgical margin status appeared to be an independent predictor of BR. Conclusions: Oncological outcome of RP as monotherapy for Japanese men with T1c prostate cancer would be favorable; however, RP alone may not be sufficient for cancer control in patients with a positive surgical margin.

Chen, Chi-Cheng; Chang, Chao-Hsiang; Wu, Hsi-Chin; Yeh, Chin-Chung; Chou, Eric Chieh-Long; Hsieh, Deng-Fu; Chen, Wen-Chi

2009 Current Urology

doi: 10.1159/000189686

Objective: The study was performed to know if the possibility of tumor growth around a stone can be diagnosed immediately following the procedure of endourological surgery. Materials and Methods: A total of 423 percutaneous nephrostomy lithotripsies were performed on 408 patients. We performed routine mucosal biopsy close to the stone during percutaneous nephrostomy lithotripsy in 88 patients (61 men and 27 women, aged 56.1 ± 13.4 years) with staghorn stones which presented a suspicious mucosal lesion. Results: Acute or chronic inflammation accounts for 79 specimens, chronic tubulointerstitial nephritis occurred in 3 specimens and squamous dysplasia occurred in 2 specimens. Transitional cell carcinoma was diagnosed in 3 patients (two low grade and one high grade), and all underwent nephroureterectomy. One patient had squamous cell carcinoma and was treated by radical nephrectomy. Two patients died due to cancer metastases and tract invasion (squamous cell carcinoma and high-grade transitional cell carcinoma, survival 12 and 6 months). Conclusion: The rate of malignancy in patients with staghorn stone was 0.9% (4/408) and a positive biopsy rate of 4.5% (4/88) over suspicious mucosa. Although the rate of malignant tumor present in staghorn stone is rare, a few cancers still can be seen during operations that can not be found before the surgery.

Biers, Suzanne M.; Moon, Dan A.; Mostafid, Hugh

2009 Current Urology

doi: 10.1159/000189687

Background: To assess the effect of introducing a protocol for single dose of intravesical mitomycin-C (MMC) given in theatre immediately after transurethral resection of bladder tumor (TURBT) on the recurrence rate of non muscle-invasive bladder cancer. Patients and Methods: The recurrence rates of bladder cancer in patients undergoing TURBT only and following the introduction of a protocol for instillation of MMC in theatre after TURBT were calculated. Patients with muscle-invasive disease and those requiring further intravesical treatment were excluded from analysis. Results: In patients undergoing TURBT only, 55.9% had recurrence with a median follow-up of 20.4 months. Following the introduction of a protocol for instillation of MMC in theatre, 37.5% of patients had a recurrence with a median follow-up of 16 months. Recurrence rates were higher for T1, multifocal tumors and recurrent tumors. There were 2 minor complications following instillation of MMC in theatre. Conclusion: A single immediate instillation of MMC in theatre following TURBT is simple and safe. It reduces tumor recurrences and should be considered following TURBT. However, patients with multiple or T1 bladder tumors will still benefit from additional intravesical therapy.

Hidas, Guy; Welt, Michael; Sabo, Eduard; Mullerad, Michael; Moskovitz, Boaz; Nativ, Ofer

2009 Current Urology

doi: 10.1159/000189688

Aim: To evaluate the correlation of various nuclear morphometric variables with conventional staging categories in patients with urothelial cancer of the urinary bladder. Material and Method: Nuclear morphometry using interactive image analysis system was performed on hematoxylin and eosin stained slides of 39 patients with urothelial cancer of the bladder. Thirteen patients were classified as T_a, N₀, M₀, 5 as T₁, N₀, M₀, 13 patients had invasive disease (T ≥ 2, N₀, M₀), and 8 had pelvic lymph node involvement or distant metastases. Results: Univariate analysis demonstrated 19 out of 25 morphometric variables to show statistically significant difference between superficial disease (T_a, T₁) and invasive disease (T ≥ 2, N⁺). Standard deviation of heterogeneity, standard deviation of polygonal area and standard deviation of angle were found to be highly significant stage predictors on multivariate analysis (p < 0.0001). Receiver operating characteristics analysis based on this variables revealed that the best cut point of the discriminate score was –0.5 for distinguishing between superficial (T_a, T₁) and invasive disease (T ≥ 2, N⁺). The sensitivity of the test is 90.5% and the specificity is 88.9%. Only 2 variables demonstrate statistically significant difference between locally advanced and metastatic disease in univariate analysis, none of them were significant in the multivariate model. Conclusion: Nuclear morphometry enables objective and quantitative differentiation between superficial and invasive bladder cancer. Comparison between invasive (T ≥ 2) and nodal involvement (N⁺) and/or metastatic disease revealed no significant differences, suggesting that they might be biologically one entity.

Wiltz, Aimee L.; Reynolds, William Stuart; Jayram, Gautam; Fedunok, Paula A.; Bales, Gregory T.

2009 Current Urology

doi: 10.1159/000189689

Objective: The optimal management of vaginal mesh extrusion placed during incontinence and prolapse repairs has not been well defined. We reviewed our experience with these patients following aggressive surgical resection to assess treatment outcomes. Patients and Methods: Over a 3-year period, 27 patients were referred for the vaginal extrusion of mesh after surgery for stress urinary incontinence or pelvic organ prolapse. Presenting complaints included vaginal discharge, sensation of foreign body, pain syndrome, dyspareunia, or partner sensitivity during coitus. All patients ultimately required aggressive surgical mesh resection under anesthesia with circumferential mobilization of vaginal wall and primary closure. Patients were followed for recurrence of erosion and baseline symptoms. Results: The majority of patients (15/27, 56%) presented with vaginal discharge or bleeding as their primary complaint. Conservative management with topical estrogen cream and/or in-office trimming of mesh was attempted in 9/27 (33%) of patients and 8/27 (30%) had one or more previously attempted graft removals prior to presentation. At most recent follow-up (mean 7.2 months, range 0.5–32.5 months), all patients had complete resolution of symptoms related to mesh extrusion and no further recurrence of extrusion. Conclusions: Excellent out-comes following vaginal mesh extrusion can be achieved by complete resection of exposed mesh under anesthesia followed by primary closure. Consideration should be given to this aggressive approach immediately after mesh extrusion is diagnosed for motivated patients who desire a definitive solution.

Morita, Masaru; Matsuura, Takeshi

2009 Current Urology

doi: 10.1159/000189690

Background: We tried to resect and fulgurate all prostate tissues transurethrally together with prostate cancer (PCa) and to evaluate whether the transurethral procedure can be an effective treatment option for the radical treatment of PCa. Patients and Methods: We performed 193 radical transurethral resections of PCa on 152 patients with localized cancer (T1–2M0N0). Patients ranged from 55 to 91 years (mean ± SD: 73.0 ± 7.2, median: 74.0 years), and preoperative prostate specific antigen (PSA) levels were between 1.5 and 100.5 ng/ml (mean ± SD: 10.5 ± 12.3, median: 6.2 ng/ml). Results: Sixteen patients were lost to follow-up. The mean follow-up period of 136 patients included in the present study was 24.1 ± 10.8 months (median: 22.9, range: 6–8 months). PSA failure developed in 10 patients (7.4%). In the rest patients, PSA levels became stable as follows: PSA ≤ 0.01 ng/ml in 49 cases; ≤0.02 ng/ml in 16; ≤0.03 ng/ml in 10; ≤0.04 ng/ml in 7; ≤0.1 ng/ml in 16; ≤0.2 ng/ml in 15; ≤0.7 ng/ml in 13. The acturial biochemical non-recurrence rates for pT2a at 41 months and pT2b at 48 months were 0.95 and 0.92, respectively. There were no patients in whom water intoxication developed or who needed transfusions. Bladder neck contracture was the most frequent postoperative complication (41 cases, 28.9%), but it was easily treated by optical incision. Urinary incontinence was temporary, disappearing within 3 months. Erectile function was preserved postoperatively in 21 patients (67.7%) out of 31 evaluated patients. Conclusions: Radical transurethral resections of PCa, although somewhat difficult to acquire because of the resection skill, may be an effective treatment option for the radical treatment of PCa.

Petrut, Bogdan; Coman, Ioan; Nechita, Florin Vasile; Coman, Radu Tudor

2009 Current Urology

doi: 10.1159/000189691

Background: A good quality urethra-vesical anastomosis is the key for lowering the incidence of the urethral strictures. In the same time this anastomosis requires the most delicate and time consuming steps of the laparoscopic procedure. We designed and manufactured a device that allows performing the anastomosis starting from the urethra with separate stitches. Material and Method: The new technique inserts the suture needle through the urethra and allows the surgeon to perform extracorporeal knotting. The urethral anastomosis device was designed by the first author and we have a patent pending for it. We evaluated the characteristics of the vesico urethral anastomosis in 3 groups of 7 patients in which we performed it by the usual laparoscopic fashion (the first group 7 patients we used separate stitches, the second group 7 patients with continuous running sutures) and the third group using our urethral suturing device. We followed the parameters: duration of the anastomosis, number of stitches, urine leak time, and cooptation of mucosa rate. Result: The time of the anastomosis is decreased from 34 to 21 minutes by using the urethral suturing device. We were able to use more stitches when we used the urethral suturing device but the urine leak time was not significantly changed. The cooptation of mucosa was performed in all the stitches where we used the urethral suturing device. Conclusion: Using the urethral suturing device the difficulty of the urethral suturing during the vesico ureteral anastomosis is decreased. In this new manner we encountered a significant decreased anastomosis time. We postulate a lower incidence of the urethral strictures considering a better cooptation of the mucosa in the anastomosis using the urethral suturing device.

Cardoso, Andre; Correia, Tiago; Soares, Ricardo; Cerqueira, Manuel; Almeida, Mantintto; Prisco, Rui

2009 Current Urology

doi: 10.1159/000189692

Circumcaval ureter is a rare anomaly resulting from embryologic maldevelopment of the inferior vena cava. It may be managed conservatively if there is minimal dilation, no infection or stones, and the patient is asymptomatic. Otherwise, the treatment is surgical and consists of dismembered pyeloplasty or ureteral section with mobilization of the ureter to a position anterior to the inferior vena cava and a watertight anastomosis. The authors report a case of circumcaval ureter incidentally discovered when investigating a renal pelvis urothelial tumor. The radical nephroureterectomy procedure had to be modified in order to avoid manipulation of the great vessels and traction on the ureter. This case report illustrates how this rare anatomic anomaly may change the surgical approach of an unrelated disease.

Adam, Ahmed; Ebrahim, Zaeem I.; Engelbrecht, Matthys J.; Van Heerden, Izak J.; Moshokoa, Evelyn M.

2009 Current Urology

doi: 10.1159/000189693

The Mayer-Rokitansky-Küster-Hauser syndrome is a rare entity characterized by congenital aplasia of the vagina and uterus in the presence of normal ovarian function, in conjunction with a 46 XX karyotype. This condition is mostly signalled by primary amenorrhoea around the time of puberty. We report on its diagnosis in a 4-year-old child presenting with urinary incontinence. Also of interest in our index patient is the presence of a pure urogenital sinus anomaly. This extremely rare association has not been previously diagnosed in childhood.

de Oliveira, Mário J. Alves; Mendes, Miguel Gomes Oliveira; Ribeiro, Jorge Cabral; dos Santos, Américo Ribeiro

2009 Current Urology

doi: 10.1159/000189694

Renal sinus hemangiomas are extremely rare and little is known about these benign mesenchymal tumors. We report a case of a suspected complex renal cyst. Ultrasonography, computed tomography and magnetic resonance were unable to rule out malignancy. The patient underwent nephrectomy, and histology revealed a renal sinus hemangioma without relation to parenchyma. Based on this case we discuss this infrequent pathology.

Kadner, Gregor; Richter, Manfred; Juenk, Andreas; Romer, Helmut; Jurczok, Andreas

2009 Current Urology

doi: 10.1159/000189695

Background: Ureteral endometriosis presents a rare manifestation of endometriosis with approximately only 1% occurrence. Here we present an example of its strong pleomorphism with flank pain, obstruction and a large polypoid intravesical lesion originating from the distal ureter. Case: A 50-year-old woman was admitted with symptoms of acute flank pain, fever and signs of acute pyelonephritis. The patient was diagnosed as unilateral hydronephrosis of unknown origin and cytoscopy revealed an intravesical polypoid lesion with its origin from the distal ureter. Ureteroscopic resection of the polypoid tumor was performed and conservative management with ureteral stenting and hormone therapy for 6 months followed but failed. CT scan revealed ureteral fibrosis secondary to endometriosis. Consequently, ureterocystoneostomy was performed and complete relief of symptoms was accomplished. The post-operative excretory urography at 1 month showed no obstruction. No further episodes of pyelonephritis and flank pain have occurred during a 4 month follow-up. Conclusion: It appears that ureteral endometriosis is a highly pleomorphic disease capable of forming long tumor-like polypoid lesions. Surgical therapy in combination with hormone ablation remains the current therapy of choice for the treatment of ureteral endometriosis.