Advances in Urology The latest articles from Hindawi Publishing Corporation © 2015 , Hindawi Publishing Corporation . All rights reserved. Posterior Urethral Strictures Tue, 24 Nov 2015 13:17:10 +0000 Pelvic fracture urethral injuries are typically partial and more often complete disruptions of the most proximal bulbar and distal membranous urethra. Emergency management includes suprapubic tube placement. Subsequent primary realignment to place a urethral catheter remains a controversial topic, but what is not controversial is that when there is the development of a stricture (which is usually obliterative with a distraction defect) after suprapubic tube placement or urethral catheter removal, the standard of care is delayed urethral reconstruction with excision and primary anastomosis. This paper reviews the management of patients who suffer pelvic fracture urethral injuries and the techniques of preoperative urethral imaging and subsequent posterior urethroplasty. Joel Gelman and Eric S. Wisenbaugh Copyright © 2015 Joel Gelman and Eric S. Wisenbaugh. All rights reserved. Acridine Orange and Flow Cytometry: Which Is Better to Measure the Effect of Varicocele on Sperm DNA Integrity? Sun, 22 Nov 2015 06:42:10 +0000 We evaluated the effect of varicocelectomy on semen parameters and levels of sperm DNA damage in infertile men. A total of 75 infertile men with varicocele and 40 fertile men (controls) were included in this study. Semen analysis and sperm DNA damage expressed as the DNA fragmentation index using acridine orange staining and chromatin condensation test by flow cytometry were assessed before and 6 months after varicocelectomy. The patients were also followed up for 1 year for pregnancy outcome. Semen parameters were significantly lower in varicocele patients compared to controls (). Mean percentages of sperm DNA fragmentation and sperm DNA chromatin condensation in patients were significantly higher than those in controls (). After varicocelectomy, sperm DNA fragmentation improved significantly, whereas sperm chromatin condensation was not significantly changed. In 15 out of 75 varicocele patients, clinical pregnancy was diagnosed; those with positive pregnancy outcome had significant improvement in sperm count, progressive sperm motility, and sperm DNA fragmentation, but there was no significant difference in sperm DNA condensation compared to negative pregnancy outcome patients. We concluded from this study that acridine orange stain is more reliable method than flow cytometry in the evaluation of sperm DNA integrity after varicocelectomy. Essam-Elden M. Mohammed, Eman Mosad, Asmaa M. Zahran, Diaa A. Hameed, Emad A. Taha, and Mohamed A. Mohamed Copyright © 2015 Essam-Elden M. Mohammed et al. All rights reserved. The Use of Flaps and Grafts in the Treatment of Urethral Stricture Disease Thu, 19 Nov 2015 10:21:30 +0000 The use of various grafts and flaps plays a critical role in the successful surgical management of urethral stricture disease. A thorough comprehension of relevant anatomy and principles of tissue transfer techniques are essential to understanding the appropriate use of grafts or flaps to optimize outcomes. We briefly review these principles and discuss which technique may be best suited for a given anterior urethral stricture, depending on the location and length of the stricture, the presence or absence of an intact corpus spongiosum, and the availability of adequate and healthy penile skin. Eric S. Wisenbaugh and Joel Gelman Copyright © 2015 Eric S. Wisenbaugh and Joel Gelman. All rights reserved. A Review of the Literature on Primary Leiomyosarcoma of the Prostate Gland Thu, 12 Nov 2015 12:46:09 +0000 Primary leiomyosarcoma of the prostate (PLSOP) is rare, with less than 200 cases reported so far. PLSOPs present with lower urinary tract symptoms, haematuria, and perineal pain; may or may not be associated with a history of previous treatment for adenocarcinoma of prostate by means of radiotherapy and or hormonal treatment; may afflict children and adult male. Examination may reveal benign enlarged prostate and hard enlarged mass. PLSOPs may be diagnosed by histological examination findings of spindle-shaped carcinoma cells in prostate specimens. Immunohistochemical staining tends to be positive for vimentin, CD44, smooth muscle actin, and calponin, focally positive for desmin, and at times positive for keratin. They stain negatively for PSA, S-100, CD34, CD117, and cytokeratin. Cytogenetic study on primary leiomyosarcoma of the prostate gland may show clonal chromosomal rearrangement involving Chromosomes 2, 3, 9, 11, and 19. On the whole the prognosis is poor. Surgery with or without chemotherapy would appear to be the mainstay of treatment for PLSOPs that are operable, but generally there is no consensus opinion on the best therapeutic approach. Most cases of PLSOPs are diagnosed in an advanced stage of the disease. A global multicenter trial is required to find therapies that would improve the prognosis. Anthony Kodzo-Grey Venyo Copyright © 2015 Anthony Kodzo-Grey Venyo. All rights reserved. Flexible Ureteroscopy Can Be More Efficacious in the Treatment of Proximal Ureteral Stones in Select Patients Wed, 04 Nov 2015 07:15:23 +0000 Purpose. We aimed to compare and evaluate the outcomes and complications of two endoscopic treatment procedures, semirigid ureteroscopy (SR-URS) and flexible ureteroscopy (F-URS), in the treatment of proximal ureteral stones (PUS). Methods. SR-URS (group 1) was done on 68 patients whereas 64 patients underwent F-URS (group 2) for the treatment of PUS. Success rate was defined as the absence of stone fragments or presence of asymptomatic insignificant residual fragments < 2 mm. Outcomes and complications were recorded. Results. The differences were statistically not significant in age, gender, body mass index (BMI), and stone characteristics between groups. Mean ureteral stone size was 9.1 ± 0.4 mm and 8.9 ± 0.5 mm for groups 1 and 2. Mean operative time was 34.1 ± 1.5 min and 49.4 ± 2.3 min for groups 1 and 2 (). SFRs were 76.5% and 87.5% for groups 1 and 2 (). Two major complications (ureteral avulsion and ureteral rupture) occurred in group 1. Conclusion. F-URS is safer and less invasive than SR-URS in patients with PUS. There is no statistically significant difference in the efficacy of either technique. Nonetheless we recommend F-URS in the management of PUS as a first-line treatment option in select cases of proximal ureteral calculi. Erdal Alkan, Ali Sarıbacak, Ahmet Oguz Ozkanli, Mehmet Murad Basar, Oguz Acar, and Mevlana Derya Balbay Copyright © 2015 Erdal Alkan et al. All rights reserved. Can CT Virtual Cystoscopy Replace Conventional Cystoscopy in Early Detection of Bladder Cancer? Tue, 27 Oct 2015 09:41:13 +0000 Aim. To correlate findings of conventional cystoscopy with CT virtual cystoscopy (CTVC) in detecting bladder tumors and to evaluate accuracy of virtual cystoscopy in early detection of bladder cancer. Material and Method. From June 2013 to June 2014, 50 patients (46 males, four females) with history and investigations suggestive of urothelial cancer, with mean age 62.76 ± 10.45 years, underwent CTVC by a radiologist as per protocol and subsequently underwent conventional cystoscopy (CPE) the same day or the next day. One urologist and one radiologist, blinded to the findings of conventional cystoscopy, independently interpreted the images, and any discrepant readings were resolved with consensus. Result. CTVC detected 23 out of 25 patients with bladder tumor(s) correctly. Two patients were falsely detected as negative while two were falsely labeled as positive in CTVC. Virtual and conventional cystoscopy were comparable in detection of tumor growth in urinary bladder. The sensitivity, specificity, positive predictive value, and negative predictive value of virtual cystoscopy were 92% each. Conclusion. CTVC correlates closely with the findings of conventional cystoscopy. Bladder should be adequately distended and devoid of urine at the time of procedure. However, more studies are required to define the role of virtual cystoscopy in routine clinical practice. Sachin Abrol, Ankush Jairath, Sanika Ganpule, Arvind Ganpule, Shashikant Mishra, Ravindra Sabnis, and Mahesh Desai Copyright © 2015 Sachin Abrol et al. All rights reserved. Reduced Cardiovascular Capacity and Resting Metabolic Rate in Men with Prostate Cancer Undergoing Androgen Deprivation: A Comprehensive Cross-Sectional Investigation Mon, 26 Oct 2015 11:41:27 +0000 Objectives. To investigate if androgen deprivation therapy exposure is associated with additional risk factors for cardiovascular disease and metabolic treatment-related toxicities. Methods. One hundred and seven men (42–89 years) with prostate cancer undergoing androgen deprivation therapy completed a maximal graded objective exercise test to determine maximal oxygen uptake, assessments for resting metabolic rate, body composition, blood pressure and arterial stiffness, and blood biomarker analysis. A cross-sectional analysis was undertaken to investigate the potential impact of therapy exposure with participants stratified into two groups according to duration of androgen deprivation therapy (<3 months and ≥3 months). Results. Maximal oxygen uptake (26.1 ± 6.0 mL/kg/min versus 23.2 ± 5.8 mL/kg/min, ) and resting metabolic rate (1795 ± 256 kcal/d versus 1647 ± 236 kcal/d, ) were significantly higher in those with shorter exposure to androgen deprivation. There were no differences between groups for peripheral and central blood pressure, arterial stiffness, or metabolic profile. Conclusion. Three months or longer exposure to androgen deprivation therapy was associated with reduced cardiorespiratory capacity and resting metabolic rate, but not in a range of blood biomarkers. These findings suggest that prolonged exposure to androgen deprivation therapy is associated with negative alterations in cardiovascular outcomes. Trial registry is: ACTRN12609000200280. Bradley A. Wall, Daniel A. Galvão, Naeem Fatehee, Dennis R. Taaffe, Nigel Spry, David Joseph, and Robert U. Newton Copyright © 2015 Bradley A. Wall et al. All rights reserved. Surgical Repair of Bulbar Urethral Strictures: Advantages of Ventral, Dorsal, and Lateral Approaches and When to Choose Them Wed, 21 Oct 2015 14:27:11 +0000 Objectives. To review the available literature describing the three most common approaches for buccal mucosal graft (BMG) augmentation during reconstruction of bulbar urethral strictures. Due to its excellent histological properties, buccal mucosa graft is now routinely used in urethral reconstruction. The best approach for the placement of such a graft remains controversial. Methods. PubMed search was conducted for available English literature describing outcomes of bulbar urethroplasty augmentation techniques using dorsal, ventral, and lateral approaches. Prospective and retrospective studies as well as meta-analyses and latest systematic reviews were included. Results. Most of the studies reviewed are of retrospective nature and majority described dorsal or ventral approaches. Medium- and long-term outcomes of all three approaches were comparable ranging between 80 and 88%. Conclusion. Various techniques of BMG augmentation urethroplasty have been described for repairs of bulbar urethral strictures. In this review, we describe and compare the three most common “competing” approaches for bulbar urethroplasty with utilization of BMG. Krishnan Venkatesan, Stephen Blakely, and Dmitriy Nikolavsky Copyright © 2015 Krishnan Venkatesan et al. All rights reserved. Ureteral Dilatation with No Apparent Cause on Intravenous Urography: Normal or Abnormal? A Pilot Study Wed, 21 Oct 2015 13:03:07 +0000 A pilot study was done in 18 adults to assess the significance of ureteral dilatation having no apparent cause seen on Intravenous Urography (IVU). A clinicoradiological evaluation was undertaken to evaluate the cause of ureteral dilatation, including laboratory investigations and sonography of the genitourinary tract. This was followed, if required, by CT Urography (using a modified technique). In 9 out of 18 cases, the cause of ureteral dilatation on laboratory investigations was urinary tract infection (6) and tuberculosis (3). In the remaining 9 cases, CTU identified the cause as extrinsic compression by a vessel (3), extrinsic vascular compression of the ureter along with ureteritis (2), extrinsic vascular impression on the right ureter and ureteritis in the left ureter (1), ureteral stricture (2), and ureteral calculus (1). Extrinsic vascular compression and strictures did not appear to be clinically significant in our study. Hence, ureteral dilatation without any apparent cause on intravenous urogram was found to be clinically significant in 12 out of 18 (66.6%) cases. We conclude that ureteral dilatation with no apparent cause on IVU may indicate urinary tract tuberculosis, urinary tract infection (E. coli), or a missed calculus. Thus, cases with a dilated ureter on IVU, having no obvious cause, should undergo a detailed clinicoradiological evaluation and CTU should be used judiciously. Vinita Rathi, Sachin Agrawal, Shuchi Bhatt, and Naveen Sharma Copyright © 2015 Vinita Rathi et al. All rights reserved. Outcomes of Direct Vision Internal Urethrotomy for Bulbar Urethral Strictures: Technique Modification with High Dose Triamcinolone Injection Wed, 21 Oct 2015 12:58:56 +0000 Objective. To evaluate the recurrence rate of bulbar urethral strictures managed with cold knife direct vision internal urethrotomy and high dose corticosteroid injection. Methods. 28 patients with bulbar urethral strictures underwent direct vision internal urethrotomy with high dose triamcinolone injection into the periurethral tissue and were followed up for recurrence. Results. Our cohort had a mean age of 60 years and average stricture length of 1.85 cm, and 71% underwent multiple previous urethral stricture procedures with an average of 5.7 procedures each. Our technique modification of high dose corticosteroid injection had a recurrence rate of 29% at a mean follow-up of 20 months with a low rate of urinary tract infections. In patients who failed treatment, mean time to stricture recurrence was 7 months. Patients who were successfully treated had significantly better International Prostate Symptom Scores at 6, 9, and 12 months. There was no significant difference in maximum flow velocity on Uroflowmetry at last follow-up but there was significant difference in length of follow-up (). Conclusions. High dose corticosteroid injection at the time of direct vision internal urethrotomy is a safe and effective procedure to delay anatomical and symptomatic recurrence of bulbar urethral strictures, particularly in those who are poor candidates for urethroplasty. Rishi Modh, Peter Y. Cai, Alyssa Sheffield, and Lawrence L. Yeung Copyright © 2015 Rishi Modh et al. All rights reserved. The Role of Interferon in the Management of BCG Refractory Nonmuscle Invasive Bladder Cancer Tue, 13 Oct 2015 06:59:31 +0000 Background. Thirty to forty percent of patients with high grade nonmuscle invasive bladder cancer (NMIBC) fail to respond to intravesical therapy with bacillus Calmette-Guerin (BCG). Interferon-α2B plus BCG has been shown to be effective in a subset of patients with NMIBC BCG refractory disease. Here we present a contemporary series on the effectiveness and safety of intravesical BCG plus interferon-α2B therapy in patients with BCG refractory NMIBC. Methods. From January of 2005 to April of 2014 we retrospectively found 44 patients who underwent induction with combination IFN/BCG for the management of BCG refractory NMIBC. A chart review was performed to assess initial pathological stage/grade, pathological stage/grade at the time of induction, time to IFN/BCG failure, pathological stage/grade at failure, postfailure therapy, and current disease state. Results. Of the 44 patients who met criteria for the analysis. High risk disease was found in 88.6% of patients at induction. The 12-month and 24-month recurrence-free survival were 38.6% and 18.2%, respectively. 25 (56.8%) ultimately had disease recurrence. Radical cystectomy was performed in 16 (36.4%) patients. Conclusion. Combination BCG plus interferon-α2B remains a reasonably safe alternative treatment for select patients with BCG refractory disease prior to proceeding to radical cystectomy. Andres F. Correa, Katherine Theisen, Matthew Ferroni, Jodi K. Maranchie, Ronald Hrebinko, Benjamin J. Davies, and Jeffrey R. Gingrich Copyright © 2015 Andres F. Correa et al. All rights reserved. Bipolar Transurethral Incision of Bladder Neck Stenoses with Mitomycin C Injection Thu, 08 Oct 2015 13:26:32 +0000 Introduction. To determine the efficacy of bipolar transurethral incision with mitomycin C (MMC) injection for the treatment of refractory bladder neck stenosis (BNS). Materials and Methods. Patients who underwent bipolar transurethral incision of BNS (TUIBNS) with MMC injection at our institution from 2013 to 2014 were retrospectively reviewed. A total of 2 mg of 40% mitomycin C solution was injected in four quadrants of the treated BNS. Treatment failure was defined as the need for subsequent intervention. Results. Thirteen patients underwent 17 bipolar TUIBNS with MMC injection. Twelve (92%) patients had failed a mean of 2.2 ± 1.1 prior endoscopic procedures. Median follow-up was 16.5 months (IQR: 14–18.4 months). Initial success was 62%; five (38%) patients had a recurrence with a median time to recurrence of 7.3 months. Four patients underwent a repeat procedure, 2 (50%) of which failed. Overall success was achieved in 77% (10/13) of patients after a mean of 1.3 ± 0.5 procedures. BNS recurrence was not significantly associated with history of pelvic radiation (33% versus 43%, ). There were no serious adverse events. Conclusions. Bipolar TUIBNS with MMC injection was comparable in efficacy to previously reported techniques and did not result in any serious adverse events. Timothy D. Lyon, Omar M. Ayyash, Matthew C. Ferroni, Kevin J. Rycyna, and Mang L. Chen Copyright © 2015 Timothy D. Lyon et al. All rights reserved. Treatment of Urethral Strictures from Irradiation and Other Nonsurgical Forms of Pelvic Cancer Treatment Thu, 01 Oct 2015 12:19:15 +0000 Radiation therapy (RT), external beam radiation therapy (EBRT), brachytherapy (BT), photon beam therapy (PBT), high intensity focused ultrasound (HIFU), and cryotherapy are noninvasive treatment options for pelvic malignancies and prostate cancer. Though effective in treating cancer, urethral stricture disease is an underrecognized and poorly reported sequela of these treatment modalities. Studies estimate the incidence of stricture from BT to be 1.8%, EBRT 1.7%, combined EBRT and BT 5.2%, and cryotherapy 2.5%. Radiation effects on the genitourinary system can manifest early or months to years after treatment with the onus being on the clinician to investigate and rule-out stricture disease as an underlying etiology for lower urinary tract symptoms. Obliterative endarteritis resulting in ischemia and fibrosis of the irradiated tissue complicates treatment strategies, which include urethral dilation, direct-vision internal urethrotomy (DVIU), urethral stents, and urethroplasty. Failure rates for dilation and DVIU are exceedingly high with several studies indicating that urethroplasty is the most definitive and durable treatment modality for patients with radiation-induced stricture disease. However, a detailed discussion should be offered regarding development or worsening of incontinence after treatment with urethroplasty. Further studies are required to assess the nature and treatment of cryotherapy and HIFU-induced strictures. Iyad Khourdaji, Jacob Parke, Avinash Chennamsetty, and Frank Burks Copyright © 2015 Iyad Khourdaji et al. All rights reserved. Visual Internal Urethrotomy for Adult Male Urethral Stricture Has Poor Long-Term Results Thu, 01 Oct 2015 12:18:48 +0000 Objective. To determine the long-term stricture-free rate after visual internal urethrotomy following initial and follow-up urethrotomies. Methods. The records of all male patients who underwent direct visual internal urethrotomy for urethral stricture disease in our hospital between July 2004 and May 2012 were reviewed. The Kaplan-Meier method was used to analyze stricture-free probability after the first, second, third, fourth, and fifth urethrotomies. Results. A total of 301 patients were included. The overall stricture-free rate at the 36-month follow-up was 8.3% with a median time to recurrence of 10 months (95% CI of 9.5 to 10.5, range: 2–36). The stricture-free rate after one urethrotomy was 12.1% with a median time to recurrence of eight months (95% CI of 7.1–8.9). After the second urethrotomy, the stricture-free rate was 7.9% with a median time to recurrence of 10 months (95% CI of 9.3 to 10.6). After the third to fifth procedures, the stricture-free rate was 0%. There was no significant difference in the stricture-free rate between single and multiple procedures. Conclusion. The long-term stricture-free rate of visual internal urethrotomy is modest even after a single procedure. Waleed Al Taweel and Raouf Seyam Copyright © 2015 Waleed Al Taweel and Raouf Seyam. All rights reserved. Anastomotic Repair versus Free Graft Urethroplasty for Bulbar Strictures: A Focus on the Impact on Sexual Function Thu, 01 Oct 2015 12:16:01 +0000 Objectives. To evaluate alterations in sexual function and genital sensitivity after anastomotic repair (AR) and free graft urethroplasty (FGU) for bulbar urethral strictures. Methods. Patients treated with AR () or FGU () were prospectively evaluated before, 6 weeks and 6 months after urethroplasty. Evaluation included International Prostate Symptom Score (IPSS), 5-Item International Index of Erectile Function (IIEF-5), Ejaculation/Orgasm Score (EOS), and 3 questions on genital sensitivity. Results. At 6 weeks, there was a significant decline of IIEF-5 for AR (−4.8; ), whereas there was no significant change for FGU (+0.9; ). After 6 months, differences with baseline were not significant overall and among subgroups. At 6 weeks, there was a significant decline in EOS for AR (−1.4; ). In the FGU group there was no significant change (+0.6; ). Overall and among subgroups, EOS normalized at 6 months. After 6 weeks and 6 months, respectively, 62.2 and 52% of patients reported alterations in penile sensitivity with no significant differences among subgroups. Conclusions. AR is associated with a transient decline in erectile and ejaculatory function. This was not observed with FGU. Bulbar AR and FGU are likely to alter genital sensitivity. Matthias Beysens, Enzo Palminteri, Willem Oosterlinck, Anne-Françoise Spinoit, Piet Hoebeke, Philippe François, Karel Decaestecker, and Nicolaas Lumen Copyright © 2015 Matthias Beysens et al. All rights reserved. Impact of Short-Stay Urethroplasty on Health-Related Quality of Life and Patient’s Perception of Timing of Discharge Thu, 01 Oct 2015 12:02:20 +0000 Objective. To evaluate health-related quality of life in patients after a short-stay or outpatient urethroplasty. Methods. Over a 2-year period a validated health-related quality-of-life questionnaire, EuroQol (EQ-5D), was administered to all patients after urethroplasty. Postoperatively patients were offered to be sent home immediately or to stay overnight. Within 24 hours after discharge they were assessed for mobility, self-care, usual activities, pain or discomfort, and anxiety and depression. An additional question assessing timing of discharge was added to the survey. Clinical and operative characteristics were examined. Results. Forty-eight patients after anterior urethroplasty completed the survey. Mean age and mean stricture length were 51.6 years (21–78) and 60 mm (5–200 mm), respectively. Most etiologies were idiopathic (50% n = 24), trauma (19%, n = 9), and iatrogenic (19%, n = 9). Forty-one patients (85%) stayed overnight, while 7 patients (15%) chose to be discharged the same day. Overall, ninety-six percent were discharged within 23 hours of surgery. In the short-stay and the outpatient cohorts, 90% and 86%, respectively, felt they were discharged on time. No patient reported a severe problem with postoperative pain or mobility. Conclusions. The majority of patients discharged soon after their procedure felt that discharge timing was appropriate and their health-related quality of life was only minimally affected. Henry Okafor and Dmitriy Nikolavsky Copyright © 2015 Henry Okafor and Dmitriy Nikolavsky. All rights reserved. High Intensity Focused Ultrasound versus Brachytherapy for the Treatment of Localized Prostate Cancer: A Matched-Pair Analysis Wed, 19 Aug 2015 09:49:18 +0000 Purpose. To evaluate postoperative morbidity and long term oncologic and functional outcomes of high intensity focused ultrasound (HIFU) compared to brachytherapy for the treatment of localized prostate cancer. Material and Methods. Patients treated by brachytherapy were matched 1 : 1 with patients who underwent HIFU. Differences in postoperative complications across the two groups were assessed using Wilcoxon’s rank-sum or test. Kaplan-Meier curves, log-rank tests, and Cox regression models were constructed to assess differences in survival rates between the two groups. Results. Brachytherapy was significantly associated with lower voiding LUTS and less frequent acute urinary retention (). Median oncologic follow-up was 83 months (13–123 months) in the HIFU cohort and 44 months (13–89 months) in the brachytherapy cohort. Median time to achieve PSA nadir was statistically shorter in the HIFU. Biochemical recurrence-free survival rate was significantly higher in the brachytherapy cohort compared to HIFU cohort (68.5% versus 53%, ). No statistically significant difference in metastasis-free, cancer specific, and overall survivals was observed between the two groups. Conclusion. HIFU and brachytherapy are safe with no significant difference in cancer specific survival on long term oncologic follow-up. Nonetheless, a randomized controlled trial is needed to confirm these results. Fouad Aoun, Ksenija Limani, Alexandre Peltier, Quentin Marcelis, Marc Zanaty, Alexandre Chamoun, Marc Vanden Bossche, Thierry Roumeguère, and Roland van Velthoven Copyright © 2015 Fouad Aoun et al. All rights reserved. Frequency of Electrolyte Derangement after Transurethral Resection of Prostate: Need for Postoperative Electrolyte Monitoring Mon, 18 May 2015 06:34:56 +0000 Objective. To determine the electrolyte derangement following transurethral resection of prostate (TURP). Methods. All patients undergoing TURP from June 2012 to April 2013 were included. Preoperative electrolytes were performed within a week of procedures. Monopolar TURP using 1.5% glycine was performed. Serum Na+ and K+ were assessed within 1 hour postoperatively and subsequently if clinically indicated. Results. The study included 280 patients. Sixty-six patients (23.6%) had electrolyte derangement after TURP. Patients with deranged electrolytes were older (mean age of 73.41 ± 4.08 yrs. versus 68.93 yrs. ± 10.34) and had a longer mean resection time (42.5 ± 20.04 min versus 28.34 ± 14.64 min). Mean weight of tissue resected (41.49 ± 34.46 g versus 15.33 ± 9.74 g) and volume of irrigant used (23.55 ± 15.20 L versus 12.81 ± 7.57 L) were also significantly higher in patients with deranged electrolytes (all ). On multivariate logistic regression analysis preoperative sodium level was found to be a significant predictor of postoperative electrolyte derangement (odds ratio 0.267, S.E. = 0.376, and value = 0.00). Conclusion. Electrolyte derangement occurs in older patients, with larger amount of tissue and longer time of resection and higher volume of irrigant, and in those with lower serum preoperative sodium levels. Wajahat Aziz and M. Hammad Ather Copyright © 2015 Wajahat Aziz and M. Hammad Ather. All rights reserved. The Natural History and Predictors for Intervention in Patients with Small Renal Mass Undergoing Active Surveillance Wed, 15 Apr 2015 13:10:42 +0000 Aim. To describe the natural history of small renal mass on active surveillance and identify parameters that could help in predicting the need for intervention in patients with small renal masses undergoing active surveillance. We also discuss the need for renal biopsy in the management of these patients. Methods. A retrospective analysis of 78 renal masses ≤4 cm diagnosed at our Urology Department at Bnai Zion Medical Center between September 2003 and March 2012. Results. Seventy patients with 78 small renal masses were analyzed. The mean age at diagnosis was 68 years (47–89). The mean follow-up period was 34 months (12–112). In 54 of 78 masses there was a growth of at least 2 mm between imaging on last available follow-up and diagnosis. Eight of the 54 (15%) masses which grew in size underwent a nephron-sparing surgery, of which two were oncocytomas and six were renal cell carcinoma. Growth rate and mass diameter on diagnosis were significantly greater in the group of patients who underwent a surgery. Conclusions. Small renal masses might eventually be managed by active surveillance without compromising survival or surgical approach. All masses that were eventually excised underwent a nephron-sparing surgery. None of the patients developed metastases. Zaher Bahouth, Sarel Halachmi, Gil Meyer, Ofir Avitan, Boaz Moskovitz, and Ofer Nativ Copyright © 2015 Zaher Bahouth et al. All rights reserved. Necrosis of the Ventral Penile Skin Flap: A Complication of Hypospadias Surgery in Children Wed, 01 Apr 2015 14:33:50 +0000 Objectives. To review cases of hypospadias that were repaired with TIPU method and consequently resulted in the necrosis of ventral penile skin flaps. Methods. Eighty-three patients with hypospadias underwent TIPU procedure by two surgeons. Neourethra in all patients was covered with dartos flap prepared from the preputium or penile shaft. In cases where ventral skin could not be covered primarily, closure was ensured by using preputial Ombredanne or Byars’ flaps to repair ventral defects. Results. The median age of patients was 4 years. Twenty-five (30.12%) patients that underwent hypospadias repair had urethral opening at the coronal level, 33 (39.75%) at the distal penis, 10 (12.04%) at the midpenis, and 15 (18.07%) at the proximal penis. The ventral skin defect could not be primarily covered in 10 patients with penile shaft hypospadias. Consequently, Byars’ method was used in 8 of these patients to cover the defect and the Ombredanne method was used in the remaining 2. Ventral skin flap necrosis developed in 5 patients (4 Byars and 1 Ombredanne). It was medically treated in 4 patients. Urethral fistula developed in the other patient whose necrosis was deeper. The mean hospital stay was 7 days for patients without necrosis, and 14 for those with necrosis. Conclusion. We are of the opinion that dartos flaps used in the TIPU method in order to cover neourethra and decrease the incidence of fistula development lead to necrosis in the Ombredanne or Byars’ flaps by causing low blood supply to the preputium and thus extend hospital stay. Ünal Bakal, Musa Abeş, and Mehmet Sarac Copyright © 2015 Ünal Bakal et al. All rights reserved. Measurement of the Physical Properties during Laparoscopic Surgery Performed on Pigs by Using Forceps with Pressure Sensors Tue, 17 Feb 2015 10:28:42 +0000 Objectives. Here we developed a unique training system, a patient specific virtual reality simulator, for laparoscopic renal surgery. To develop the simulator, it was important to first identify the physical properties of the organ. Methods. We recorded the force measured during laparoscopic surgery performed on pigs by using forceps with pressure sensors. Several sensors, including strain gauges, accelerometers, and a potentiometer, are attached to the forceps. Results. Throughout the experiment, we measured the reaction force in response to the forceps movement in real time. Conclusions. The experiment showed the possibility of digitizing these physical properties in humans as well. Hiroyuki Yamanaka, Kazuhide Makiyama, Kimito Osaka, Manabu Nagasaka, Masato Ogata, Takahiro Yamada, and Yoshinobu Kubota Copyright © 2015 Hiroyuki Yamanaka et al. All rights reserved. Predictors of Incisional Hernia after Robotic Assisted Radical Prostatectomy Mon, 02 Feb 2015 13:17:10 +0000 Introduction. To explore the long term incidence and predictors of incisional hernia in patients that had RARP. Methods. All patients who underwent RARP between 2003 and 2012 were mailed a survey reviewing hernia type, location, and repair. Results. Of 577 patients, 48 (8.3%) had a hernia at an incisional site (35 men had umbilical), diagnosed at (median) 1.2 years after RARP (mean follow-up of 5.05 years). No statistically significant differences were found in preoperative diabetes, smoking, pathological stage, age, intraoperative/postoperative complications, operative time, blood loss, BMI, and drain type between patients with and without incisional hernias. Incisional hernia patients had larger median prostate weight (45 versus 38 grams; ) and a higher proportion had prior laparoscopic cholecystectomy (12.5% (6/48) versus 4.6% (22/480); ). Overall, 4% (23/577) of patients underwent surgical repair of 24 incisional hernias, 22 umbilical and 2 other port site hernias. Conclusion. Incisional hernia is a known complication of RARP and may be associated with a larger prostate weight and history of prior laparoscopic cholecystectomy. There is concern about the underreporting of incisional hernia after RARP, as it is a complication often requiring surgical revision and is of significance for patient counseling before surgery. Avinash Chennamsetty, Jason Hafron, Luke Edwards, Scott Pew, Behdod Poushanchi, Jay Hollander, Kim A. Killinger, Mary P. Coffey, and Kenneth M. Peters Copyright © 2015 Avinash Chennamsetty et al. All rights reserved. Lower Urinary Tract Dysfunction in Pelvic Gynecologic Cancer: The Role of Urodynamics Sun, 23 Nov 2014 11:34:23 +0000 The exact incidence of lower urinary tract dysfunction is not known and its pathogenesis is not completely understood. Advances in urodynamic assessment and widespread availability of a standardized technique have facilitated its exploration prior to and subsequent to the surgical management of patients with gynecologic pelvic cancer. We performed a PubMed and Medline literature search using the following keywords: bladder dysfunction, urinary dysfunction, and urodynamics and all these terms in combination with radical hysterectomy in order to analyze the role of urodynamics in patients with pelvic gynecologic cancer in the preoperative as well as in the early and late postoperative settings. Fouad Aoun, Alexandre Peltier, and Roland van Velthoven Copyright © 2014 Fouad Aoun et al. All rights reserved. Efficacy of Optical Internal Urethrotomy and Intralesional Injection of Vatsala-Santosh PGI Tri-Inject (Triamcinolone, Mitomycin C, and Hyaluronidase) in the Treatment of Anterior Urethral Stricture Wed, 01 Oct 2014 09:58:01 +0000 Purpose. To study the efficacy of optical internal urethrotomy with intralesional injection of Vatsala-Santosh PGI tri-inject (triamcinolone, mitomycin C, and hyaluronidase) in the treatment of anterior urethral stricture. Material and Methods. A total of 103 patients with symptomatic anterior urethral stricture were evaluated on the basis of clinical history, physical examination, uroflowmetry, and retrograde urethrogram preoperatively. All patients were treated with optical internal urethrotomy followed by injection of tri-inject at the urethrotomy site. Tri-inject was prepared by diluting the combination of triamcinolone 40 mg, mitomycin C 2 mg, and hyaluronidase 3000 in 5–10 mL of saline according to length of stricture. An indwelling 18 Fr silicone catheter was left in place for a period of 7–21 days. All patients were followed up for 6–18 months postoperatively on the basis of history, uroflowmetry, and, if required, retrograde urethrogram and micturating urethrogram every 3 months. Results. The overall recurrence rate after first OIU is 19.4% (20 out of 103 patients), that is, a success rate of 80.6%. Overall recurrence rate after second procedure was 5.8% (6 out of 103 patients), that is, a success rate of 94.2%. Conclusion. Optical internal urethrotomy with intralesional injection of Vatsala-Santosh PGI tri-inject (triamcinolone, mitomycin C, and hyaluronidase) is a safe and effective minimally invasive therapeutic modality for short segment anterior urethral strictures. Santosh Kumar, Nitin Garg, Shrawan Kumar Singh, and Arup Kumar Mandal Copyright © 2014 Santosh Kumar et al. All rights reserved. Haematuria: An Imaging Guide Thu, 17 Jul 2014 00:00:00 +0000 This paper discusses the current status of imaging in the investigation of patients with haematuria. The physician must rationalize imaging so that serious causes such as malignancy are promptly diagnosed while at the same time not exposing patients to unnecessary investigations. There is currently no universal agreement about the optimal imaging work up of haematuria. The choice of modality to image the urinary tract will depend on individual patient factors such as age, the presence of risk factors for malignancy, renal function, a history of calculus disease and pregnancy, and other factors, such as local policy and practice, cost effectiveness and availability of resources. The role of all modalities, including conventional radiography, intravenous urography/excretory urography, ultrasonography, retrograde pyelography, multidetector computed tomography urography (MDCTU), and magnetic resonance urography, is discussed. This paper highlights the pivotal role of MDCTU in the imaging of the patient with haematuria and discusses issues specific to this modality including protocol design, imaging of the urothelium, and radiation dose. Examination protocols should be tailored to the patient while all the while optimizing radiation dose. Fiachra Moloney, Kevin P. Murphy, Maria Twomey, Owen J. O’Connor, and Michael M. Maher Copyright © 2014 Fiachra Moloney et al. All rights reserved. IL1RN and KRT13 Expression in Bladder Cancer: Association with Pathologic Characteristics and Smoking Status Tue, 08 Jul 2014 11:54:23 +0000 Purpose. To validate microarray data on cytokeratin 13 (KRT13) and interleukin-1 receptor antagonist (IL1RN) expression in urothelial carcinoma of the urinary bladder (UCB) and to correlate our findings with pathologic characteristics and tobacco smoking. Methods. UCB tissue samples () and control samples () were obtained from transurethral resection and radical cystectomy specimens. Immunohistochemical staining of KRT13 and IL1RN was performed and semiquantitative expression scores were assessed. Smoking status was evaluated using a standardized questionnaire. Expression scores were correlated with pathologic characteristics (tumor stage and grade) and with smoking status. Results. Loss of KRT13 and IL1RN expression was observed in UCB tissue samples when compared to controls (, ) in which KRT13 and IL1RN expression were high. IL1RN expression was significantly reduced in muscle-invasive tumors (). In tissue samples of current smokers, a significant downregulation of IL1RN was found when compared to never smokers (). Conclusion. Decreased expressions of KRT13 and IL1RN are common features of UCB and are associated with aggressive disease. Tobacco smoking may enhance the loss of IL1RN, indicating an overweight of proinflammatory mediators involved in UCB progression. Further validation of the influence of smoking on IL1RN expression is warranted. Thomas S. Worst, Verena Reiner, Ute Gabriel, Christel Weiß, Philipp Erben, Thomas Martini, and Christian Bolenz Copyright © 2014 Thomas S. Worst et al. All rights reserved. Effectiveness of Flexible Ureterorenoscopy and Laser Lithotripsy for Multiple Unilateral Intrarenal Stones Smaller Than 2 cm Thu, 12 Jun 2014 06:52:15 +0000 Purpose. To evaluate the safety and efficacy of RIRS for the treatment of multiple unilateral intrarenal stones smaller than 20 mm. Methods. Between March 2007 and April 2013, patients with multiple intrarenal stones smaller than 20 mm were treated with RIRS and evaluated retrospectively. Each patient was evaluated for stone number, stone burden (cumulative stone length), operative time, SFRs, and complications. Results. 173 intrarenal stones in 48 patients were included. Mean age, mean number of stones per patient, mean stone burden, and mean operative time were years (23–63), (2–18),  mm (12–45), and minutes (30–130), respectively. The overall SFR was 91.7%. SFRs for patients with a stone burden less and greater than 20 mm were 100% (23/23) and 84% (21/25), respectively (, ). Complications occurred in six (12.5%–6/48) patients, including urinary tract infection or high-grade fever >38.5°C in three cases, prolonged hematuria in two cases, and ureteral perforation in one case, all of whom were treated conservatively. No major complications occurred. Conclusions. RIRS is an effective treatment option in patients with multiple unilateral intrarenal stones especially when the total stone burden is less than 20 mm. Erdal Alkan, Oguz Ozkanli, Egemen Avci, Mirac Turan, M. Murad Başar, Oguz Acar, and M. Derya Balbay Copyright © 2014 Erdal Alkan et al. All rights reserved. Pelvic Muscle Rehabilitation: A Standardized Protocol for Pelvic Floor Dysfunction Wed, 11 Jun 2014 11:21:24 +0000 Introduction. Pelvic floor dysfunction syndromes present with voiding, sexual, and anorectal disturbances, which may be associated with one another, resulting in complex presentation. Thus, an integrated diagnosis and management approach may be required. Pelvic muscle rehabilitation (PMR) is a noninvasive modality involving cognitive reeducation, modification, and retraining of the pelvic floor and associated musculature. We describe our standardized PMR protocol for the management of pelvic floor dysfunction syndromes. Pelvic Muscle Rehabilitation Program. The diagnostic assessment includes electromyography and manometry analyzed in 4 phases: (1) initial baseline phase; (2) rapid contraction phase; (3) tonic contraction and endurance phase; and (4) late baseline phase. This evaluation is performed at the onset of every session. PMR management consists of 6 possible therapeutic modalities, employed depending on the diagnostic evaluation: (1) down-training; (2) accessory muscle isolation; (3) discrimination training; (4) muscle strengthening; (5) endurance training; and (6) electrical stimulation. Eight to ten sessions are performed at one-week intervals with integration of home exercises and lifestyle modifications. Conclusions. The PMR protocol offers a standardized approach to diagnose and manage pelvic floor dysfunction syndromes with potential advantages over traditional biofeedback, involving additional interventions and a continuous pelvic floor assessment with management modifications over the clinical course. Rodrigo Pedraza, Javier Nieto, Sergio Ibarra, and Eric M. Haas Copyright © 2014 Rodrigo Pedraza et al. All rights reserved. Transpubic Urethroplasty: A Single Center Experience Mon, 09 Jun 2014 08:49:52 +0000 Objective. To evaluate the long-term results of transpubic urethroplasty for pelvic fracture urethral distraction defects. Patients and Methods. Sixteen patients who had undergone transpubic urethroplasty for posttraumatic complex posterior urethral disruptions between 2007 and 2013 were analyzed retrospectively and prospectively. Patients were followed up for a mean (range) of 24 (6–60) months by history, urinary flow rate estimate, retrograde urethrography, and voiding cystourethrography. Results. The mean age of the patients was 30.4 years. The estimated radiographic stricture length before surgery was 4.3 cm. Transpubic urethroplasty was successful in 14 out of 16 patients. Postoperative complications were recurrent stricture (12.5%), urethrocutaneous fistula (12.5%), incontinence (31.25%), impotence (25%), and wound infection (18.75%). Failed repairs were successfully managed endoscopically in one patient and by perineal anastomotic repair in the other, giving a final success rate of 100%. Five out of 16 patients were incontinent of which 3 of them resolved and 2 had permanent incontinence. Impotence was seen in 4 out of 16 patients. There were no reported complications of pubectomy in any of our patients. Conclusions. Though considered obsolete now, transpubic urethroplasty for complex posterior urethral disruptions is still a viable alternative with excellent results and minimal morbidity. Raj Kumar Mathur, Niraj Shriram Tiwari, and Sudharshan A. Odiya Copyright © 2014 Raj Kumar Mathur et al. All rights reserved. US Pilot Study of Lumbar to Sacral Nerve Rerouting to Restore Voiding and Bowel Function in Spina Bifida: 3-Year Experience Mon, 02 Jun 2014 11:56:37 +0000 Objective. To report our experience with creating a skin-central nervous system-bladder reflex arc with intradural lumbar to sacral motor root microanastomosis to restore bladder/bowel function in spina bifida patients. Methods. Urinary/bowel changes from baseline to three years were evaluated with questionnaires, voiding diaries, urodynamics (UDS), and renal function studies. Treatment response was defined as CIC once/day with stable renal function, voiding efficiency > 50%, and no worsening of motor function. Results. Of 13 subjects (9 female, median age 8 years), 3 voided small amounts at baseline, one voided 200 cc (voiding efficiency 32%), 4/13 reported normal bowels, and 2/13 were continent of stool. Postoperatively, all had transient lower extremity weakness; one developed permanent foot drop. Over three years, renal function remained stable and mean maximum cystometric capacity (MCC) increased (). In the 10 that returned at 3 years, 7 were treatment responders and 9 had discontinued antimuscarinics, but most still leaked urine. Only 2/8 with baseline neurogenic detrusor overactivity (NDO) still had NDO, all 3 with compliance <10 mL/cm H2O had normalized, 7/10 considered their bowels normal, 5/10 were continent of stool, and 8/10 would undergo the procedure again. Conclusion. Lumbar to sacral nerve rerouting can improve elimination in spina bifida patients. This trial is registered with NCT00378664. Kenneth M. Peters, Holly Gilmer, Kevin Feber, Benjamin J. Girdler, William Nantau, Gary Trock, Kim A. Killinger, and Judith A. Boura Copyright © 2014 Kenneth M. Peters et al. All rights reserved.