Current Urology

Elzanaty, Saad; Dohle, Gert

2012 Current Urology

doi: 10.1159/000343523pmid: 24917727

It is estimated that 3–6% of all vasectomised men request vasectomy reversal for different reasons. Microsurgical vasovasostomy is the gold standard technique of vasectomy reversal. However, the microsurgical technique is time-consuming and challenging to most urological surgeons. Therefore, alternative methods of vasal anastomosis have been studied including robotic-assisted vasovasostomy. This review discusses the feasibility and practice of robotic-assisted vasovasostomy. Based on the available studies robotic-assisted vasovasostomy is feasible. The reported rate of vasal patency associated with this new technique is similar to that of microsurgical vasovasostomy. There is no clear difference between the 2 approaches in terms of operating time. Robotic-assisted vasovasostomy does not appear to afford significant advantages in the era of vasectomy reversal.

Kawahara, Takashi; Sakata, Ryoko; Kawahara, Kimiko; Ito, Hiroki; Miyoshi, Yasuhide; Sano, Futoshi; Nakaigawa, Noboru; Uemura, Hiroji; Yao, Masahiro; Kubota, Yoshinobu; Makiyama, Kazuhide

2012 Current Urology

doi: 10.1159/000343524pmid: 24917728

Purpose: Nephron sparing surgery is an effective surgical option in patients with renal cell carcinoma. Laparoscopic partial nephrectomy involves clamping and unclamping techniques of the renal vasculature. This study compared the postoperative renal function of partial nephrectomy using an estimation of the glomerular filtration rate (eGFR) for a Japanese population in 3 procedures; open partial nephrectomy in cold ischemia (OPN), laparoscopic partial nephrectomy in warm ischemia (LPN), and microwave coagulation using laparoscopic partial nephrectomy without ischemia (MLPN). Materials and Methods: A total of 57 patients underwent partial nephrectomy in Yokohama City University Hospital from July 2002 to July 2008. 18 of these patients underwent OPN, 17 patients received MLPN, and 22 patients had LPN. The renal function evaluation included eGFR, as recommended by The Japanese Society of Nephrology. Results: There was no significant difference between the 3 groups in the reduction of eGFR. eGFR loss in the OPN group was significantly higher in patients that experienced over 20 minutes of ischemia time. eGFR loss in LPN group was significantly higher in patients that experienced over 30 minutes of ischemia time. Conclusion: This study showed that all 3 procedures for small renal tumor resection were safe and effective for preserving postoperative renal function.

Valentini, Françoise A.; Nelson, Pierre P.; Zimmern, Philippe E.

2012 Current Urology

doi: 10.1159/000343525pmid: 24917729

Objective: To compare a new index of voiding dysfunction (D) based purely on free uroflow vs. Abrams-Griffiths (A-G) number obtained from intubated flow, for classification of bladder outlet obstruction in men. Patients and Methods: Urodynamic tracings of 60 non-neurological patients (30 before transurethral resection of the prostate and of 30 men suspected of benign prostatic hyperplasia included in a medical therapy trial) were retrospectively analyzed. The Valentini-Besson-Nelson model was used to evaluate the value of the D index. A-G was obtained from intubated flows. Obstruction was defined as D > 32.5 cm H₂O (translation of A-G criterion). Results: D showed 82.05% sensitivity with 66.66% specificity; the positive predictive value was 82.05% and the negative predictive value 66.66% for the whole population, 83.3 vs. 80.9% sensitivity with 58.3 vs. 77.7% specificity for pre- transurethral resection of the prostate vs. medical therapy group. Conclusion: D index which can be obtained from a free uroflow appears as a valuable alternative to invasive urodynamic investigations when the diagnosis of bladder outlet obstruction needs to be more solidly established before a treatment decision or in men suspected of benign prostatic hyperplasia who elect for watchful waiting.

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

2012 Current Urology

doi: 10.1159/000343526pmid: 24917730

Background: The objective of this study was to determine factors associated with the postoperative development of chronic kidney disease (CKD) following partial nephrectomy. Patients and Methods: This study included 109 patients with normal renal function treated with partial nephrectomy for small renal tumors. Of these, 73 and 36 patients underwent open partial nephrectomy (OPN) and laparoscopic partial nephrectomy (LPN), respectively. Results: Among several parameters, there was a significant difference only in the ischemia time between the OPN and LPN groups. During the median observation period of 53.4 months, CKD, defined as estimated glomerular filtration rate (eGFR) less than 60 ml/min/1.73 m², developed in 29 (39.7%) and 14 (38.9%) patients in the OPN and LPN groups, respectively. Univariate analysis identified age at surgery, diabetes and preoperative eGFR as significant predictors of the postoperative development of CKD; however, only age at surgery and preoperative eGFR appeared to be independently related to CKD-free survival. In fact, there was a significant difference in the CKD-free survival between patients without any independent risk factor and those with at least one of these independent risk factors. Conclusions: Careful management following partial nephrectomy is necessary for elderly patients and/or those with impaired renal function, even mild, before surgery.

Kiraç, Mustafa; Deniz, Nuri; Biri, Hasan

2012 Current Urology

doi: 10.1159/000343527pmid: 24917731

Introduction: The aim of this study was to evaluate the effect of microsurgical subinguinal varicocelectomy on semen parameters in azoospermic men with clinical varicocele and to determine the predictive parameters of postoperative improvement. Methods: Twenty-three men with non-obstructive complete azoospermia and varicocele underwent subinguinal open microsurgical varicocele repair. The outcome was assessed in terms of improvement in semen parameters after surgical repair for varicocelectomy. Results: Bilateral varicocelectomy was performed on 15 patients and unilateral (left) varicocelectomy was performed on 8 patients. In the post-operative period, of the 23 patients, 7 (30.4%) had motile sperm in the ejaculate. The mean sperm concentration of these patients was 1.34 ± 2.6 × 10⁶/ml and the mean total sperm motility was 37.5 ± 15.5%. Conclusion: Infertile men with non-obstructive azospermia can have improvement in semen analysis after subinguinal microsurgical repair of varicoceles. Motile sperm in ejaculate were detected after microsurgical varicocele repair.

DiBlasio, Christopher J.; Derweesh, Ithaar H.; Maddox, Michael M.; Mehrazin, Reza; Yu, Changhong; Malcolm, John B.; Aleman, Michael A.; Patterson, Anthony L.; Wake, Robert W.; Kattan, Michael W.

2012 Current Urology

doi: 10.1159/000343528pmid: 24917732

Objective: Transrectal ultrasound-guided biopsy (TRUSB) remains the mainstay for prostate cancer (CaP) diagnosis. Numerous variables have shown associations with development of CaP. We present a nomogram that predicts the probability of detecting CaP on TRUSB. Methods: After obtaining institutional review board approval, all patients undergoing primary TRUSB for CaP detection at a single center at our institution between 2/2000 and 9/2007 were reviewed. Patients undergoing repeat biopsies were excluded, and only the first biopsy was included in the analysis. Variables included age at biopsy, race, clinical stage, prostate specific antigen (PSA), number of cores removed, TRUS prostate volume (TRUSPV), body mass index, family history of CaP, and pathology results. S-PLUS 2000 statistical software was utilized with p < 0.05 considered significant. Cox proportional hazards regression models with restricted cubic splines were utilized to construct the nomogram. Validation utilized bootstrapping, and the concordance index was calculated based on these predictions. Results: A total of 1,542 consecutive patients underwent primary TRUSB with a median age of 64.2 years (range 34.9–89.2 years), PSA of 5.7 ng/ml (range 0.3–3,900 ng/ml), number of cores removed of 8.0 (range 1– 22) and TRUSPV of 36.4 cm³ (range 9.6–212.0 cm³). CaP was diagnosed in 561 (36.4%) patients. A nomogram was constructed incorporating age at biopsy, race, PSA, body mass index, clinical stage, TRUSPV, number of cores removed, and family history of CaP. The concordance index when validated internally was 0.802. Conclusions: We have developed and internally validated a model predicting cancer detection in men undergoing TRUSB in a contemporary series. This model may assist clinicians in risk-stratifying potential candidates for TRUSB, potentially avoiding unnecessary or low-probability TRUSB.

Vasdev, Nikhil; Kumar, Ashish; Veeratterapillay, Rajan; Thorpe, Andrew C.

2012 Current Urology

doi: 10.1159/000343529pmid: 24917733

Introduction: Hematuria secondary to benign prostatic hyperplasia (BPH) can occur due to a vascular primary gland itself or due to the vascular re-growth of the prostate following a transurethral resection of the prostate (TURP). We aim to evaluate the clinical presentation and management in patients within both these groups. Materials and Methods: We retrospectively archived the data of 166 men diagnosed with hematuria secondary to BPH from our hematuria clinic database from March 2003 and March 2006. The 166 patients were divided into 2 groups: Group I (n = 94) hematuria with no previous TURP; Group II (n = 72) hematuria with previous TURP. The clinical management in both groups included reassurance, commencement of a 5-alpha reductase inhibitor (finasteride) or a primary TURP in Group I or re-do TURP in Group II. Results: The median age was 73 years (range 45–94 years) for both groups. Outcomes combined for both groups included: reassurance alone in 26% (n = 43), finasteride in 51% (n = 84) and TURP in 12% (n = 19). Patients managed with reassurance alone or TURP had no further episodes of hematuria. At a mean follow-up was 18 months (range 7–22 months), 2 patients treated with finasteride re-bled but did require further intervention. A further 2 men elected to stop finasteride due to erectile dysfunction and gynecomastia respectively. Conclusion: BPH can present with hematuria. Following re-evaluation in a hematuria clinic, the lack of any subsequent cancer diagnosis in these patients suggests that repeat hematuria investigations should be carefully re-considered.

Masterson, J.; Avalos, E.; Santomauro, M.; Walters, R.; Marguet, C.; L’Esperance, J.; Drain, D.

2012 Current Urology

doi: 10.1159/000343530pmid: 24917734

Background: Men seeking a vasectomy should receive counseling prior to the procedure that includes discussion of later seeking a reversal. We sought to determine demographic factors that may predispose patients to possibly later seek a vasectomy reversal. Methods: All U.S. Military electronic health records were searched between 2000 and 2009 for either a vasectomy or vasovasostomy procedure code. Aggregate demographic information was collected and statistical analysis performed. Result: A total of 82,945 patients had a vasectomy of which 4,485 had a vasovasostomy resulting in a vasovasostomy-to-vasectomy rate of 5.04%. The average age at vasovasostomy was 34.9±5.0, with an average interval of 4.1±2.2 years. Men undergoing a vasectomy at a younger age were more likely to have a vasovasostomy. Various religions did have statistically significant differences. Within ethnic groups, only Native Americans [OR=1.39 (95% CI 1.198-1.614)] and Asians [OR=0.501 (95% CI 0.364-0.690)] had statistically significant differences when compared to Caucasians. Men with more children at the time of vasectomy were more likely to have a vasovasostomy. Conclusion: Younger men, Native Americans, and men with more children at vasectomy were more likely to undergo a vasovasostomy. The reason for these differences is unknown, but this information may assist during pre-vasectomy counseling.

Furukawa, Junya; Miyake, Hideaki; Sakai, Iori; Fujisawa, Masato

2012 Current Urology

doi: 10.1159/000343531pmid: 24917735

Background: The objective of this study was to assess the significance of the ureteroscopic biopsy grade for patients with upper tract urothelial carcinoma (UTUC). Patients and Methods: This study included 40 patients who were diagnosed with a single focus of UTUC by ureteroscopic biopsy and subsequently underwent nephroureterectomy. The significance of the biopsy grade as a predictive factor for pathological outcomes of nephroureterectomy was retrospectively analyzed. Results: Of these 40 patients, 19 (47.5%) and 21 (52.5%) were diagnosed with low and high grade UTUC, respectively. The ureteroscopic biopsy grade matched the pathological grade of surgically resected specimens in 35 of the 40 cases (87.5%), and there was a significant correlation between the biopsy and pathological grades (p < 0.001). Furthermore, the biopsy grade was also shown to be closely associated with the pathological stage (p < 0.001); that is, only 1 of the 19 patients (5.3%) with biopsy low grade UTUC were pathologically diagnosed as having muscle invasive disease, while 17 of the 21 patients (81.0%) with biopsy high grade UTUC appeared to show tumor invasion into muscle or deeper. Conclusions: The grade of UTUC on ureteroscopic biopsy could provide accurate diagnostic information on the final pathology of nephroureterectomy specimens.

Fallah, Fatemeh; Fallah, Mahdi; Sajadi Nia, Raheleh Sadat

2012 Current Urology

doi: 10.1159/000343532pmid: 24917736

Objective: The efficacy of intravesical thiotepa was evaluated compared with administration of Bacille Calmette-Guérin (BCG) in non-muscle invasive bladder cancer. Patients: In this multicenter, prospective, randomized study, eligible patients were those with proven non-muscle invasive bladder cancer. All patients were randomly allocated to Group A, receiving intravesical thiotepa (at a dose of 30 mg/30 ml) once weekly for 9 consecutive weeks and then monthly for 12 months or Group B, receiving intravesical Bacille Calmette-Guérin (Connaught strain, 80 mg/50 ml) over a 9-week induction course and each week for 3 weeks at 3, 6 and 12 months. Outcome measures were recurrence rate, time to first recurrence and progression rate. Treatment-related complications were also evaluated. Results: Seventy-two participants were enrolled, 36 for each group, 17 in Group A developed disease recurrence versus 25 of those in Group B (p < 0.05). There was no statistically significant difference in mean time to the first recurrence (Group A, 4.2 months; Group B, 4.1 months; p > 0.05). Seven of 17 (41%) patients in Group A and 16 of 25 (64%) patients in Group B had disease progression and underwent radical cystectomy (p < 0.05). Both intravesical administrations were generally well tolerated. Conclusion: Thiotepa is a promising intravesical agent for treatment of non-muscle invasive bladder cancer.

Yuksel, Mehmet B.; Gumus, Bilal; Özbek, Erdem; Nese, Nalan

2012 Current Urology

doi: 10.1159/000343533pmid: 24917737

Synchronous bilateral testicular germ cell tumors (TGCTs) are seen in exteremely rare cases. Although there is still no standard therapy for bilateral TGCTs, bilateral orchiectomy is recommended as the gold standard treatment. Nevertheless, it has some long-term problems, such as infertility and psychosocial difficulties, and thus some clinicians prefer to perform testis-sparing surgery in appropriate cases. We reviewed the first case of bilateral synchronous TGCT with concomittant bilateral diffuse intratubular germ cell neoplasia in a young single patient, who was treated by a left radical orchiectomy and right testis sparing-surgery with following local radiotherapy to the right residual testicular tissue with previous semen cryopreservation to maintain the ability to father children. We supposed that testis-sparing surgery can be a feasible therapeutic alternative to radical orchiectomy in patients with bilateral TGCTs in terms of improving the quality of life and continuing fertility and normal hormonal status with no medications. However, while the long-term effects are not yet known, this type of treatment should be perpormed in carefully selected cases with longlife expectancy.