Current Urology

Dadkhah, Farid; Safarinejad, Mohammad R.; Amini, Erfan; Lashay, Ali R.; Baghayee, Arash

2010 Current Urology

doi: 10.1159/000253399

Objectives: There have been several reports on different prostate cancer screening tests, which may improve the specificity in the early detection of prostate cancer. Cut-off values of these tests are mainly based on data from USA and Europe and may not be applicable to other races. We conducted this study to evaluate the utility of different screening tests for detecting prostate cancer in Iranian men. Patients and Methods: Between March 2007 and March 2008, 187 men with total prostate specific antigen (PSA) in the range of 2 to 20ng/ml and with no pretreatment of the prostate, underwent transrectal ultrasound guided prostatic biopsy for suspected prostate cancer. The diagnostic value of total PSA levels, the free to total PSA ratio (f/t PSA) and PSA density (PSAD) were compared using receiver operating characteristic curve analysis. Results: Prostate cancer was diagnosed in 101 (54.0%) of the 187 patients. There were significant differences between the groups in the age and all PSA related parameters. Areas under the curve of PSAD and f/t PSA were higher than that of total PSA indicating a better diagnostic accuracy. We also noted a significantly better performance for PSAD compared with f/t PSA in a subgroup of patients with total PSA between 2 and 10 ng/ml. Conclusion: PSAD was a better predictor of prostate cancer especially in men with PSA levels < 10 ng/ml.

Hadj-Moussaa, Miriam; Brownb, James A.

2010 Current Urology

doi: 10.1159/000253400

Background: The efficacy of certain challenging surgical procedures has been reported to correlate with surgeon volume. The aim of this study was to retrospectively evaluate a single surgeon’s experience with pubovaginal sling (PVS) and transobturator tape (TOT) suburethral slings to assess the impact of operative volume on therapeutic outcomes. Methods: A retrospective chart review of 10 patients who underwent PVS or TOT suburethral sling procedures between July 2001 and July 2008 was conducted. Patient age, type of urinary incontinence (UI), preoperative pelvic exam findings, type of surgery, operative time, estimated blood loss, postoperative continence, complications and adjuvant therapies were documented. Results: Ten women, mean age 52.5 years (range 35–67 years), underwent either a PVS (n = 7) or TOT (n = 3) to correct either stress urinary incontinence (SUI, n = 4) or mixed UI (n = 6). Operative reports were available for 8 patients. Concomitant repair of pelvic organ prolapse was performed in 3 patients. Mean operative times were 153 minutes (range 135–195 minutes) and 110 minutes (range 62–165 minutes) for the PVS and TOT, respectively. Mean estimated blood loss for PVS and TOT were 292 ml (100–600 ml) and 25 ml, respectively. No patient required transfusion. Two patients reported recurrent SUI at 5 and 18 months postoperatively. Research suggests that obesity, prior pelvic surgery, and pelvic organ prolapse are risk factors for unsuccessful UI procedures. All patients studied suffered from at least one of these conditions. Conclusions: Two patients continued to suffer from SUI, while the complications suffered by other patients were generally minor, treatable, and temporary. It appears that a low volume practice can produce acceptable operative time, cure and complication rates.

Gurbuz, Cenk; Polat, Haci; Yildirim, Asif; Canat, Lütfi; Bayram, Guner; Caskurlu, Turhan

2010 Current Urology

doi: 10.1159/000253401

Aim: To determine the role of fetuin-A, a glycoprotein which represents the alpha-2 band of protein electrophoresis and which prevents the precipitation of calcium both in the intravascular and extravascular areas, in the etiology of urolithiasis. Material and Method: Sixty-nine patients (55 patients with urolithiasis and 14 patients with a history of urolithiasis) and 44 control subjects (patients without urolithiasis) were included in the study. Fetuin-A concentrations were measured by the enzyme-linked immunosorbent assay method both in the serum and in 24-hour urine samples obtained from the patients and the control group. In addition, the other activators and inhibitors that may play a role in urolithiasis were measured biochemically. Results: There were no statistically significant differences in serum sodium, potassium, creatinine, calcium, magnesium, phosphorus, uric acid, albumin, and parathyroid hormone levels between the patients and the control group. Daily urine volume, magnesium, uric acid, potassium, sodium, calcium, phosphorus, citrate, oxalate and cystine levels measured in 24-hour urine collections were similar in both the patients and the control groups. The serum fetuin-A level was 0.5 g/l in the patients with urolithiasis, 0.45 g/l in the patients with a history of urolithiasis, and 0.51 g/l in the control group (p > 0.05). The urine fetuin-A levels were 8.71, 5.7 and 10.81 mg/d, respectively (p > 0.05). The data were not statistically significant between the 3 groups. Conclusion: There was no difference in between the serum and urine fetuin-A levels between the groups with and without urolithiasis. This result does not correlate with the results of another study which suggested a role for fetuin-A in the etiology of urolithiasis. This discrepancy needs to be elucidated with a larger population in further studies.

Blick, Chris; Patel, Nilay; Foley, Stephen J.

2010 Current Urology

doi: 10.1159/000253402

Introduction: A proportion of patients with ongoing stress urinary incontinence (SUI) following periurethral injections may wish to consider further intervention in the form of a tension-free obturator tape. This study aims to establish whether the presence of periurethral Zuidex alters the operative procedure or affects the success rate of subsequent tension-free tape surgery. Patients and Methods: In a study of 200 consecutive female patients suffering from SUI managed with the urethral bulking agent Zuidex we reported a 62% success rate. Twenty-two of 76 patients who continued to suffer from SUI following periurethral Zuidex opted for further surgical intervention in the form of a tension-free tape. The median age of the patients was 63 years and the time between Zuidex treatment and tension-free tape insertion ranged from 5 to 31 months (median 6.8 months). Results: The presence of the bulking agent did not alter surgical technique or increase the complexity of tape insertion. Twenty of 22 (91%) women were pad free after tension-free tape and 2 patients reported an increase in lower tract symptoms (cystoscopy normal). Conclusions: In our experience the success of transobturator tape surgery for stress incontinence is not adversely affected by the previous use of periurethral injections of Zuidex.

Okamura, Takehiko; Akita, Hidetoshi; Hashimoto, Yoshihiro; Tozawa, Keiichi; Hinotsu, Shiro; Akaza, Hideyuki; Kohri, Kenjiro

2010 Current Urology

doi: 10.1159/000253403

Objective: Bacillus Calmette-GuÉrin (BCG) is used as the gold standard for prevention of recurrence after transurethral resection of bladder tumor of non muscle invasive bladder cancer. However, in some cases the outcome is not optimal. In order to assess the possible impact of different variables on outcome, the present clinical evaluation of initially failed cases was performed. Patients and Methods: A total of 68 patients treated with BCG were evaluated. All suffered recurrence. Their original urothelial carcinomas were: G1/G2/G3 = 13/41/14, and Ta/T1 = 30/38. Thirteen high-risk T1G3 cases were included. Intravesical chemotherapy pretreatment was given to 10 cases. Results: The overall progression-free survival rates at 3, 5 and 10 years were 83.3, 80.9, and 72.0% respectively, with cancer-specific survival rates of 98.3, 89.0 and 89.0%. High-risk T1G3 patients were confirmed to have higher progression rates (p = 0.03, log-rank test). Total cystectomy was performed in 5 of 13 T1G3 patients, one died during the follow-up. Additional BCG treatments were performed for 8 patients, and all of them remain alive at the present time. Conclusions: These findings indicate that the response to BCG is definitely influenced by high-risk category, so that early selection of total cystectomy may improve the prognosis with T1G3 patients. However, it was also suggested that more than 1 course of BCG is a feasible option in some cases with a tendency for a worse outcome when pretreated with anti-cancer drugs.

Degirmenci, Tansu; Gunlusoy, Bulent; Arslan, Murat; Vardar, Enver; Kozacioglu, Zafer; Minareci, Suleyman; Ayder, Riza

2010 Current Urology

doi: 10.1159/000253404

Introduction: To evaluate the effect of gemcitabine-cisplatin as adjuvant chemotherapy in patients underwent radical cystectomy. Patients and Methods: A total of 25 patients with advanced bladder cancer with or without lymph node metastases (tumor stages pT2, pT3, pT4 and/or pN1, pN2) were evaluated between January 2001 and February 2006 for effectivity, toxic side-effects and overall survival. Patients received 4 cycles of a combination of gemcitabine 1,000 mg/ m² on days 1, 8, 15 and cisplatin 70 mg/m² on day 2, repeated every 4 weeks. Results: Median follow-up was 28.2 months. An average of 4.12 cycles of chemotherapy was administered. The median duration of survival for all the evaluable patients was 27.8 months. The overall survival was 86.4% at 1 year, 69.2% at 2 years and 54.5% at 3 years. Neutropenia and thrombocytopenia were clinically significant toxicities. Neutropenic fever was seen in 2 patients, and none died of sepsis. Conclusions: Better understanding of factors associated with postoperative outcomes associated with different types of chemotherapy in locally advanced bladder cancer is necessary. We conclude that gemcitabine-cisplatin regimen in adjuvant setting after cystectomy is feasible with a tolerable toxicity. But, randomized controlled trials will be required for the assessment of long-term benefit.

Nelson, Roscoe S.; Henderson, Sean J.

2010 Current Urology

doi: 10.1159/000253405

A new method is described using a nephrostomy balloon dilator to place a formal suprapubic tube. Primary large suprapubic tube placement has been a problematic procedure for urological surgeons compared to less invasive procedures placing smaller size (16 Fr or less) catheters suprapubically. Patients benefit from having a larger caliber catheter, which obstructs less frequently and can be changed in the office or by a home care provider. This new method uses a 10 mm diameter 15 cm nephrostomy balloon with controlled partial entry into the bladder over a guide wire to assist in adequate dilatation of an insertion pathway for primary placement of a councill tip catheter suprapubically. The procedure combines fluoroscopic and cystoscopic visualization to ensure maximal patient safety and decrease major risks. No complications from catheter placement using this technique were observed and patient follow-up visits were satisfactory. The method decreased time with the patient under anesthesia in the operating room and decreased patient postoperative recovery time. Assessment of this method used data from surgeries performed over the last 8 years evaluating both the procedure and follow-up patient visits. As we strive to achieve improved patient outcomes by novel surgical technique advancements, this new method appears to accomplish this objective and should be considered for conventional use.

Karadeniz, Tahir; Baran, Caner; Topsakal, Medih; Ozkaptan, Orkunt

2010 Current Urology

doi: 10.1159/000253406

Introduction: We investigated the efficacy of nephrostomy balloon catheter inflation in the access tract for the control of bleeding after percutaneous nephrolithotomy (PCNL). Materials and Methods: Sixty five patients who had undergone PCNL for kidney stones in our clinic between April 2006 and July 2008 were included in the study. Patients have been selected consecutively and randomized in 2 groups. In the first group which consisted of 33 patients (Group I), a 16 Ch nephrostomy tube has been left in the tract following PCNL. The second group consisted of 32 patients (Group II) and the nephrostomy balloon catheter was inflated at 10 atmosphere pressure at the end of the procedure and left in the tract for 24 h postoperatively. Preoperative and postoperative hemoglobin values at 24 h were compared statistically with regard to bleeding between both groups. Results: Average hemoglobin values at postoperative 24 h were 9.28 g/dl in the first and 10.65 g/dl in the second group. The difference between the 2 groups was statistically significant (p < 0.001). Conclusions: Inflation of nephrostomy balloon catheter in the access tract after PCNL is a safe and useful method for the control of bleeding.

Pushkar, Dmitry; Dyakov, Vladimir; Gumin, Leonid; Matsaev, Adam; Gvozdev, Mikhail; Sumerova, Natalia

2010 Current Urology

doi: 10.1159/000253407

Background: Recurrent lower urinary tract infection (UTI) is often associated with sexual intercourse. Usually these patients are young females. Repeated courses of antibiotic therapy help some, but not helpful to all patients. Distal urethra vaginal ectopy seems to play an important role in accumulating microorganisms, resulting in recurrent UTI. The repositioning of the distal part of the urethra may potentially minimize microbial contamination in this area. Objective: The purpose of this study is to share the results of minimal invasive procedures, such as distal urethral transposition, in the treatment of female patients with symptomatic UTI associated with sexual intercourse. Patients: A total of 328 woman (mean age 25.9 years) with recurrent symptomatic lower UTI associated with sexual intercourse and repeated unsuccessful conventional treatment were found to have intravaginal urethral displacements during vaginal examinations. Two hundred and seventy-one patients underwent distal urethral transposition (group I) – a procedure depicted on a DVD provided with this article. Fifty-seven patients (mean age 25.9 years) with the same histories, anatomical findings, and symptoms and signs of lower UTI, receiving conventional treatment, served as controls (group II). The mean follow-up time of the 271 patients from group I was 52.5 months (48 – 57 months). Surgical Procedure: The operation makes it possible to withdraw the meatus from the area concerned. Measurements: All patients were initially diagnosed and treated for chronic cystitis and urethritis for at least 6 months without success. During vaginal examinations, special emphasis was given to the position of the distal urethra. A plastic penile imitator was introduced vaginally to evaluate urethral movements simulating intercourse. All patients were required to avoid sexual intercourse postoperatively for 1 month and were treated with standard antibiotic therapy for a mean time of 3 weeks. Results and Limitations: Patients from group I were evaluated after 3 months, showing no postoperative complications. Examinations of 204 (75.3%) patients from group I 1 year later showed no symptoms or signs of UTI. Sixty-seven (24.7%) patients required further antimicrobial prophylaxis after the procedure because of the longer preoperative duration of their symptoms. Nineteen patients (7.0%) showed poor results. One hundred and eighty-three patients were available for additional examinations after 3 and 5 years, (mean 4.4 years) revealing stable results with no lower UTI for these patients. Group II patients were followed-up for 1 year. Fortysix (80.7%) of them were found to have recurrent symptoms with poor response to the therapy, and had to undergo repeated treatment. Conclusions: Young female patient suffering from recurrent lower UTI should be evaluated with a specific emphasis on possible intravaginal urethral displacement during sexual intercourse. Conventional treatment can be long and often unsuccessful for the majority of patients. Distal urethral transposition is feasible, replicable, and can be used for these patients, leading to good and stable results in 93% of cases.

Lewis Jr., Bertram A.; Lachance, Gilles; Terry, Max

2010 Current Urology

doi: 10.1159/000253408

Recurrence of bladder cancer in the urethra represents a rare, but potentially morbid event. For advanced cases, a urethrectomy involving a wide excision may be quite disfiguring with little oncology yield. In particular, if there is lymph node involvement, then little curative benefit may be obtained from surgery. We report urethral recurrence treated via radiation and chemotherapy yielding rapid regression of the tumor and significant palliation.

Nunez-Nateras, Rafael; Ko, Edmund Y.; Andrews, Jack R.; Humphreys, Mitchell R.; Castle, Erik P.; Andrews, Paul E.

2010 Current Urology

doi: 10.1159/000253409

Xanthogranulomatous pyelonephritis (XGP) is a chronic severe granulomatous reaction that results in diffuse renal destruction. XGP is usually a result of nephrolithiasis, causing obstructive uropathy and infection. Misdiagnosis is common and the delay in the diagnosis can lead to a renal insufficiency, renal loss and death. We described a patient who underwent laparoscopic nephrectomy for a nephrobronchial fistula secondary to a non-treated XGP. This case illustrated the importance of early recognition of patients with XGP and encourage for high index of suspicion for early diagnosis to prevent the morbidity and mortality associated with XGP.

Miller, J.; Ost, L.; Kay, P.; Collette, D.

2010 Current Urology

doi: 10.1159/000253410

We present one of the few reported cases of primary perivascular epithelioid cell tumors (PEComa) of the bladder. PEComas are a group of rare mesenchymal neoplasms with a distinct cell type, the perivascular epithelioid cell, which has no known normal tissue equivalent. A 26-year-old woman was diagnosed with a ureterovaginal fistula 4 d after an abdominal hysterectomy. Retrograde pyelogram demonstrated an approximately 1-cm defect in the right ureter. Computed tomography scan and magnetic resonance angiography demonstrated a large mass in the right pelvis drained by multiple enlarged venous structures. The patient underwent arterioembolization of the mass followed by a partial cystectomy, psoas-hitch and right ureteral reimplantation. Histopathologic analysis was consistent with a PEComa. PEComas are rare and have uncertain malignant potential. Treatment is primary excision and the use of immunotherapy has been described.

Hadj-Moussa, Miriam; Boyd, Buffi; Brown, James A.

2010 Current Urology

doi: 10.1159/000253412

The degree of intimal injury induced at the site of arterial occluding clamp placement is proportional to the force exerted by the clamp. We report a case of renal artery thrombosis following partial nephrectomy with shodded Bulldog clamps, and suggest that shodding may counterintuitively increase arterial occlusion pressure and the subsequent risk for intimal wall injury and arterial thrombosis.