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Tealab, Alaa A.; Ihab, Ibrahim; Maarouf, Arif M.; Mohamed, Mostafa; Said, Abd El Monaem; Fatma, Zaiton
2009 Current Urology
doi: 10.1159/000253378
Purpose: We evaluated the attenuation value of renal cal-culi on unenhanced axial computerized tomography (CT) as a predictor of calculus fragmentation by extracorporeal shock wave lithotripsy (ESWL). Patients and Methods: Fifty patients with renal calculi up to 20 mm were included in this prospective study. The calculus attenuation value was measured in Hounsfield units (HU) on unenhanced CT sections through the calculi. Patients were subsequently treated with ESWL. Results: Patients were grouped according to calculus attenuation value into 3 treatment groups, first those with stones less than 500 HU (20 patients), 2nd those with stones from 500 to 1,000 HU (14 patients) and 3rd those with stones greater than 1,000 HU (16 patients). Mean HU was calculated for each group. Of the 50 patients 41 (80%) underwent successful ESWL treatment. The stone clearance rate was 100% in group I (20 of 20 cases), 85.7% in group II (13 of 14), and 50% in group III (8 of 16). The clearance rate for stones with an attenuation value of greater than 1,000 HU was signifi-cantly lower than that for stones with a value of less than 1,000 HU (8 of 16 vs. 13 of 14 cases and 20 of 20 cases). Pa-tients in group III required a greater median number of shock waves for stone fragmentation than those in groups I and II. The mean attenuation value and number of shock waves required for calculus fragmentation correlated significantly. Conclusions: The CT attenuation value of renal calculi can help to differentiate stones that are likely to fragment easily on ESWL from those that would require a greater number of shock waves for fragmentation or may fail to fragment on ESWL.
Comploj, Evi; Becker, Tanja; Koen, Mark; Berger, Christoph; Riccabona, Marcus
2009 Current Urology
doi: 10.1159/000253379
Introduction: We evaluated the potential and outcome of preoperative percutaneous nephrostomy (PCN) in infants and children with severe hydronephrosis (Society for Fetal Urology grade IV) due to ureteropelvic junction obstruction. We focused on pre- and post-operative renal split function (RSF), histological findings of the renal pelvis and the reop-eration rate. Patients and Methods: The medical records of 249 patients (254 renal units) who underwent pyeloplasty for ureteropelvic junction obstruction between 1992 and 2009 were retrospectively reviewed. In 24 patients (group 1), PCN was performed before the pyeloplasty for various reasons. Renal split function was investigated using diuretic renogra-phy before PCN or pyeloplasty and 1 year after surgery. His-tological findings and reoperation rates were compared in patients with (group 1) and without (group 2) PCN. Results: Of the 254 renal units, 24 patients with a median age of 80 days (1 day to 11 years) received a PCN before pyeloplasty. The initial median RSF was 43% (4–58%) preoperatively and 45% (21–67%) 1 year postoperatively in group 1 and 47% (11–71%) preoperatively and 47% (0–74%) postoperatively in group 2. Histology revealed chronic inflammation of the renal pelvis in 60% of the PCN patients compared to 21% in group 2. The reoperation rate was 12.5% (3/24) in group 1 and 4% (9/230) in group 2. Conclusions: Preoperative PCN in severe hydronephrosis results in little or no improvement in RSF, causes a high percentage of chronic inflammation of the renal pelvis and increases the risk of reoperation.
Pigne, Alain; Valentini, Françoise A.; Nelson, Pierre P.
2009 Current Urology
doi: 10.1159/000253380
Aim: Our purpose was to compare at short follow-up the changes in the voiding phase induced by a sub-urethral tension-free vaginal tape (TVT) or TVT-obturator (TVT-O) for cure of stress urinary incontinence. Patients and Method: Twenty-two women underwent a TVT procedure and 22 a TVT-O procedure. Free uroflows were recorded before surgery and at 1-month follow-up. Results: Maximum flow rate decreased after surgery (p < 0.05); notable change of the shape of the flow curve (prolonged flow time, p < 0.017, or polyphasic curve) was observed (more frequently after TVTO). Modelling (VBN® micturition model) applied to uroflows, allows simulation of pathophysiological hypothesis to be analyzed, and to identify and quantify the mechanical effects of each tape on the urethra. Conclusion: Both tapes appear to induce a urethral compression in many patients. That compression is more frequent in the TVT group while its magnitude is higher in the TVT-O group. The reasons for this difference seem to be the position and the direction of the tape.
Nissenkorn, Israel; Lobik, Leonid
2009 Current Urology
doi: 10.1159/000253381
Objective: To determine whether replacement of indwelling catheters by intraurethral catheter (IUC) could significantly reduce catheter-induced urinaru tract infection (UTI), and improve men’s life quality. Methods: All patients were sur-gical risks with a catheter for 1–36 month’s due to prostatic obstruction. IUCs were inserted in an ambulatory setting, after local anesthesia of the urethra. Patients stayed in the clinic until they voided 2–3 times. Prophylactic antibiotic was given 48 h before stent insertion and continued for a week. Patients were followed for urinary symptoms and questioned about catheter interference with their life. Urine cultures were obtained after 10 days, a month, and every 3 months. Results: Fifty-seven IUCs replaced indwelling cath-eters in 50 men, from January 2007 to July 2008. Patient’s age ranged from 54 to 99 years. The follow-up period was 1–24 months. IUCs remained in place from 4 to16 months (mean 12.1 months). Six stents (10.5%) had to be removed earlier than intended because of stent displacement; stents were reinserted during 1–2 weeks. Bacteruria was found in 6 patients (12%), additional 2 men (4%) with acute UTI were hospitalized, and successfully treated with antibiotics. Pa-tients suffered dysuria, urgency, and urge incontinence for 4–8 days after stent insertion. Later on, patients were con-tinent, voided satisfactorily, and their life quality improved significantly. Conclusions: Insertion of IUCs instead of an indwelling catheter, did reduce UTI by 84%, and improved significantly patient’s quality of life. An indwelling catheter should be replaced by an IUC in men who are at high risk for surgery or anesthesia.
Grocela, Joseph A.; Buettner, Hannah
2009 Current Urology
doi: 10.1159/000253382
Purpose: Health care costs in the US continue to skyrocket at an approximate rate of 10% per year. However, with this burdensome economic pressure, significant potential sav-ings for society exist in the hormonal treatment for prostate cancer, which currently costs Medicare $315 million a year. Materials and Methods: The Centers for Medicare and Med-icaid Services database was searched for the number of treat-ments for prostate cancer with injection therapy (lutenizing hormone releasing hormone, LHRH agonist treatment) for the year 2006. The cost to Medicare ranged from $65 to $219 per month depending on reimbursement method calcula-tions, and the average treatment time for LHRH agonists was 7.5 years. The mean Medicare reimbursement for scrotal or-chiectomy was found to be $275. The price differential be-tween the total cost of LHRH treatment and scrotal orchiec-tomy was calculated to reduce costs by 50%. We coined and used the term ‘Worth to Society’ to describe an economic model for health care savings which aligns positive financial incentive to the physician while simultaneously realizing significant savings to Medicare. This is an alternative model to the relative value unit model, which has proven limited for containing health care costs for hormonal treatment of prostate cancer. Results and Conclusions: Using a ‘Worth to Society’ economic model, rather than the traditional relative value unit model, the surgeon’s reimbursement for Medicare for orchiectomy should be adjusted to $4,500 to realize an approximate 50% reduction in costs, for a total savings to Medicare of approximately $170 million per year.
Muto, Giovanni; Castelli, Emanuele; Rosso, Rodolfo; D’Urso, Leonardo; Giacobbe, Alessandro; Migliari, Roberto
2009 Current Urology
doi: 10.1159/000253383
Aim: To evaluate the use of cyanoacrylic glue to fix the kidney in laparoscopic nephropexy for symptomatic nephroptosis. Patients and Methods: From 1998 to 2006 we performed nephropexy in 10 women with symptomatic nephroptosis. In all patients we performed transperitoneal laparoscopic nephropexy using cyanoacrylic glue to fix the kidney. Preoperatively all patients were investigated by clinical exami-nation, urography (intravenous pyelogram, IVP) and split renal scintigram in supine and upright positions. After a minimum follow-up of 30 months, all patients were evalu-ated for symptoms, were asked about their satisfaction and underwent IVP and renal scintigraphy. Results: The mean operative time was 53 minutes. No intra- or post-operative complication occurred. The mean hospital stay was 4.5 days. After a mean follow-up of 88 months, improvement in symp-toms was reported in all cases, with complete and significant relief in 9 (90%) and 1 (10%) case respectively. Postoperative IVP and renal scintigraphy in supine and upright positions showed the resolution of renal ptosis and the normal distri-bution of split renal function in both positions. Conclusions: Our series seems to demonstrate that cyanoacrylic glue may be a safe and efficient agent to fix the kidney in laparoscopic nephropexy.
2009 Current Urology
doi: 10.1159/000253384
Objective: To create a modified Mitrofanoff continent stoma with minimal incidence of stoma stenosis and incontinence. Materials and Methods: A new modified surgical technique was used to construct a catheterizable channel based on the Mitrofanoff principle at King Abdulaziz University Hospital in Jeddah. Twelve boys, 2 girls, and 1 adult were included in the study. The children’s ages varied between 6 and 13 years (mean 9 years) with different underlying etiologies, while the adult patient was 36 years old after several failed ure-throplasties. The ileal segment was isolated with its segmental blood supply, the channel constructed over 8, 10 or 12F catheters, and the selected ileal segment tapered over the catheter except for its distal part which was left tubularized, and a nipple technique was used to create the stoma. Twelve patients underwent simultaneous ileocystoplasty and 1 patient bladder neck closure. Results: Postoperative complications unrelated to stoma occurred in 5 patients including wound infection in 2 patients, metabolic acidosis with hy-perkalemia in 1 patient, vesicocutaneous fistula in 1 patient, and intestinal obstruction in 1 patient. Bladder emptying was easy to perform in 11 patients while 4 patients required recatheterization of the channel for an additional 14 days. Conclusion: Our modified surgical technique for construc-tion of a catheterizable stoma based on the Mitrofanoff principle was successful in creating a continent easy catheteriz-able non-stenotic stoma.
Singh, Pratap B.; Bansal, Harbans; Sharma, Girish K.; Pandey, Ashwani K.; Swain, Samir; Trivedi, Sameer; Dwivedi, Udai S.
2009 Current Urology
doi: 10.1159/000253385
Objective: Main concern in the patients undergoing orthotopic neobledder construction following radical cystectomy has been urinary incontinence and need of clean self in-termittent catheterization. Our objective is to assess conti-nence rate associated with technique of retrograde radical cystectomy and ileal neobladder with ileal neourethra as compared to the standard antegrade technique. Methods: We retrospectively analysed the results of 130 patients who underwent radical cystectomy and ileal neobladder in our department during last 19 years. First 32 patients underwent classical antegrade cystectomy and ileal neobladder construction as described by Hautmann et al. Last 98 patients underwent retrograde radical cystectomy followed by ileal neobladder with ileal neourethra construction. Results: Continence rates were much better in the patients undergoing retrograde radical cystectomy and ileal neobladder with neourethra formation without any added morbidity. Our immediate daytime continence rates improved from 81 to 94% and nocturnal rates from 53 to 91%. Most of our patients are having adequate neobladder capacity and functional urethral length. Conclusions: Retrograde method of radical cystectomy preserves the rhabdosphincter with preservation of good length of urethra. Ileal neourethra further increase urethral length. Spherical shape of neobladder leads to complete emptying of bladder without need of clean self intermittent catheterization.
Massanyi, Eric Z.; Allison, Randy G.; Clarke, Raymond E.; Spear, Kevin A.
2009 Current Urology
doi: 10.1159/000253387
Primitive neuroectodermal tumor (PNET) may arise within the testicle in one of two forms: a pure primary malignancy of the testis or a lesion arising from a teratomatous lesion. Primary PNETs occur in several locations including the testicle; however, there are few reports of PNETs arising from testicular teratomas. We present a case of a 39-year-old male who presented with painless bilateral scrotal enlargement, hepatomegaly, and lower extremity edema. Computerized tomography demonstrated multiple liver masses and para-aortic lymph node enlargement. Ultrasonography revealed bilateral scrotal enlargement. The patient underwent a left orchiectomy with histologic and immunohistochemical evaluation. Histology revealed a highly cellular, mitotically active, necrotic tumor consistent with a PNET arising within a malignant teratoma. The tumor was highly aggressive, and the patient expired shortly after orchiectomy. This rare case is presented along with an updated literature search on Ewing/PNET and teratomatous PNET.
DaJusta, Daniel G.; Mueller, Thomas J.; Ioffreda, Richard; Deen, Malik; Barone, Joseph A.
2009 Current Urology
doi: 10.1159/000253392
Background: Churg-Strauss is a rare form of vasculitis characterized by pulmonary and small-vessel necrotizing vasculitis, vascular and/or extravascular granulomas, eosinophilia and tissue infiltration by eosinophils. Investigations: We Report a case of a patient with known history of this type of vasculitis who presented with severe right testicular pain. Scrotal sonogram evaluation revealed an associated hypoechoic lesion on his right testicle. Tumor markers (alpha-fetoprotein and β human chorionic gonadotropin) were within normal limits. Diagnosis: Differential diagnosis considered were tumor, hematoma and possible vasculitis involvement of the testis. Management: Secondary to persistent pain the patient elected to have surgery. Right orchiectomy was performed and final pathological evaluation of the lesion was consistent with infarct secondary to patient known vasculitis. Patient did well after surgery and is currently on steroid therapy for his underlying condition. Vasculitis involvement of the testis is rare and sonogram imaging does not differentiate well between a tumor and an infarct secondary to the vasculitis. In patient with negative tumor markers unless symptoms dictate otherwise a conservative approach can be taken and surgery avoid. This is the first case ever reported of Churg-Strauss syndrome involving the testicle.
2009 Current Urology
doi: 10.1159/000253397
Bladder infections and their sequelae of stone formation, catheter blockage and pyelonephritis are common problems in patients with spinal cord injury and indwelling Foley catheters. The infections contribute to skin breakdown, debilitation and frequent hospitalizations. The use of recent improvements in catheter design, and a recognition of the importance of biofilm formation on indwelling catheters, have made possible a bladder management program which nearly eliminates these problems. This case report presents a patient with chronic bladder infection, encrustation, stone formation, catheter blockage, bladder distention, debilitation and autonomic dysreflexia despite the use of accepted interventions. The catheter was changed to a silicone, silver-coated Foley, a suprapubic insertion site was created, and the catheter was changed weekly. This program resulted in dramatic improvement in all bladder and associated problems and in general health, enabling him to resume the pursuit of his career goals.
Charles, Thomas; Roy, Catherine; Lang, Hervé; Jacqmin, Didier; Hansmann, Yves
2009 Current Urology
doi: 10.1159/000253398
A 46-year-old healthy man presented to the emergency room with an abscess of corpus cavernosum. The patient was successfully treated by a surgical drainage and antibiotics. The two causes which are discussed are the trauma due to fellatio or hematogenous spread of a periodontal abscess because of bacteria of the oral commensal flora (Streptoccoccus constellatus and Peptostreptococcus) founded in the abscess. Ten months later, the patient had an erectile dysfunction as sequel.