Advances in Urology The latest articles from Hindawi Publishing Corporation © 2015 , Hindawi Publishing Corporation . 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. Neoadjuvant Chemotherapy Use in Bladder Cancer: A Survey of Current Practice and Opinions Wed, 28 May 2014 13:23:08 +0000 Objectives. Level 1 evidence supports the use of neoadjuvant chemotherapy (NAC) to improve overall survival in muscle invasive bladder cancer; however utilization rates remain low. The aims of our study were to determine factors associated with NAC use, to more clearly define reasons for low utilization, and to determine the current rate of NAC use among urologic oncologists. Materials and Methods. Active members of the Society for Urologic Oncology were provided a 20-question survey. Descriptive statistical analysis was conducted for each question and univariate analysis was performed. Results. We achieved a response rate of 21%. Clinical T3/T4 disease was the most often selected reason for recommending NAC (87%). Concerns with recommending NAC were age and comorbidities (54%) followed by delay in surgery (35%). An association was identified between urologic oncologists who discussed NAC with >90% of their patients and medical oncologists “always” recommending NAC (). NAC utilization rate was between 30 and 57%. Conclusions. Amongst this highly specialized group of respondents, clinical T3-T4 disease was the most common reason for implementation of NAC. Respondents who frequently discussed NAC were more likely to report their medical oncologist always recommending NAC. Reported NAC use was higher in this surveyed group (30–57%) compared with recently published rates. N. G. Cowan, Y. Chen, T. M. Downs, B. H. Bochner, A. B. Apolo, M. P. Porter, J. C. La Rochelle, C. L. Amling, and T. M. Koppie Copyright © 2014 N. G. Cowan et al. All rights reserved. Trends in the Rates of Pediatric Pyeloplasty for Ureteropelvic Junction Obstruction over 19 Years: A PHIS Database Study Tue, 13 May 2014 12:53:55 +0000 Background. Over the past 20 years, the management of ureteropelvic junction obstruction (UPJ) has shifted. While many urologists note a decrease in the number of pyeloplasties performed over time, the nature of the change in practice has yet to be defined. In the current study, we utilize a national, multi-institutional database of children’s hospitals to evaluate trends in patients undergoing pyeloplasty as well as the rate of surgical reconstruction over the past 20 years. Material/Methods. We queried the Pediatric Health Information System (PHIS) database for all children undergoing primary pyeloplasty between 1992 and 2011. Clinical variables, including age at time of surgery, gender, length of stay (LOS), and geographic region, were determined. Age-adjusted rate of repair was also calculated per 100,000 PHIS inpatients. Results. 6,013 patients were included in the study, of which 71.6% were male and 64.2% were under the age of 24 months at time of surgery. Over the study period, the median age at time of surgery increased from 2–4 months to 12–14 months (). LOS decreased from a median of 5 days to 2 days (). The rate of surgery increased by 10.6 pyeloplasties per 100,000 PHIS inpatients from 1992 to 2011 (). The highest rate of pyeloplasty was in the northeast. The increase in pyeloplasties performed from 1992 to 1999 was specific to children aged greater than 24 months, while rates stayed the same in infants younger than 2 years during the same time period. In contrast, from 1999 to 2011, the rate of pyeloplasty decreased in patients less than 2 years of age, while the rate remained constant in patients over age 2. Conclusion. The rate of pyeloplasty increased in PHIS hospitals from 1992 to 2011. Trends are due to an increase in surgery in infants younger than 2 years from 1992 to 1999, followed by a progressive surgical rate decline, characterized by a shift towards patients older than 2 years of age. Ardavan Akhavan, Paul A. Merguerian, Cindy Larison, Adam B. Goldin, and Margarett Shnorhavorian Copyright © 2014 Ardavan Akhavan et al. All rights reserved. Incidental Prostate Cancer in Transurethral Resection of the Prostate Specimens in the Modern Era Tue, 29 Apr 2014 08:59:18 +0000 Objectives. To identify rates of incidentally detected prostate cancer in patients undergoing surgical management of benign prostatic hyperplasia (BPH). Materials and Methods. A retrospective review was performed on all transurethral resections of the prostate (TURP) regardless of technique from 2006 to 2011 at a single tertiary care institution. 793 men (ages 45–90) were identified by pathology specimen. Those with a known diagnosis of prostate cancer prior to TURP were excluded () from the analysis. Results. 760 patients had benign pathology; eleven (1.4%) patients were found to have prostate cancer. Grade of disease ranged from Gleason to Gleason . Nine patients had cT1a disease and two had cT1b disease. Seven patients were managed by active surveillance with no further events, one patient underwent radiation, and three patients underwent radical prostatectomy. Conclusions. Our series demonstrates that 1.4% of patients were found to have prostate cancer, of these 0.5% required treatment. Given the low incidental prostate cancer detection rate, the value of pathologic review of TURP specimens may be limited depending on the patient population. Brandon Otto, Christopher Barbieri, Richard Lee, Alexis E. Te, Steven A. Kaplan, Brian Robinson, and Bilal Chughtai Copyright © 2014 Brandon Otto et al. All rights reserved. Impact of Benign Prostatic Hyperplasia Pharmacological Treatment on Transrectal Prostate Biopsy Adverse Effects Mon, 28 Apr 2014 13:14:05 +0000 Background. Benign prostatic hyperplasia (BPH) pharmacological treatment may promote a decrease in prostate vascularization and bladder neck relaxation with theoretical improvement in prostate biopsy morbidity, though never explored in the literature. Methods. Among 242 consecutive unselected patients who underwent prostate biopsy, after excluding those with history of prostate biopsy/surgery or using medications not for BPH, we studied 190 patients. On the 15th day after procedure patients were questioned about symptoms lasting over a week and classified according to pharmacological BPH treatment. Results. Thirty-three patients (17%) were using alpha-blocker exclusively, five (3%) 5-alpha-reductase inhibitor exclusively, twelve (6%) patients used both medications, and 140 (74%) patients used none. There was no difference in regard to age among groups (). Postbiopsy adverse effects occurred as follows: hematuria 96 (50%), hematospermia 53 (28%), hematochezia 22 (12%), urethrorrhagia 19 (10%), fever 5 (3%), and pain 20 (10%). There was a significant negative correlation between postbiopsy hematuria and BPH pharmacological treatment with stronger correlation for combined use of 5-alpha-reductase inhibitor and alpha-blocker over 6 months (). Conclusion. BPH pharmacological treatment, mainly combined for at least 6 months seems to protect against prostate biopsy adverse effects. Future studies are necessary to confirm our novel results. Marina Zamuner, Ciro Eduardo Falcone, Arnaldo Amstalden Neto, Tomás Bernardo Costa Moretti, Luis Alberto Magna, Fernandes Denardi, and Leonardo Oliveira Reis Copyright © 2014 Marina Zamuner et al. All rights reserved. Pathologic Outcomes following Urethral Diverticulectomy in Women Thu, 17 Apr 2014 12:00:02 +0000 Purpose. Although most urethral diverticula in women are benign, there is a subset of patients who develop malignant changes. Limited studies report the pathologic findings associated with this relatively rare entity. We describe the clinicopathologic findings of women who underwent urethral diverticulectomy. Methods. A consecutive series of 29 women who underwent surgical resection of a urethral diverticulum were identified between 1992 and 2013. Clinical and radiographic data was collected by retrospective review of patient medical records. All pathological slides were rereviewed by a single urologic pathologist. Results. Of the 14 women with clinical data, 9 (64%) presented with urgency, 7 (50%) with urinary frequency, 3 (21%) with urinary incontinence, and 3 (21%) with dysuria. Mean diverticular size was 2.3 cm. Although one patient (3%) had invasive adenocarcinoma on final pathology, the remaining 28 cases (97%) demonstrated benign features. The most common findings were inflammation (55%) and nephrogenic adenoma (21%). Conclusions. Although most urethral diverticula in women are benign, there is a subset of patients who develop malignancy in association with the diverticulum. In this series, 97% of cases had a benign histology. These findings are important when counseling patients regarding treatment options. Melissa A. Laudano, Asha E. Jamzadeh, Claire Dunphy, Richard K. Lee, Brian D. Robinson, Renuka Tyagi, Steven A. Kaplan, Alexis E. Te, and Bilal Chughtai Copyright © 2014 Melissa A. Laudano et al. All rights reserved. Mechanisms Predisposing Penile Fracture and Long-Term Outcomes on Erectile and Voiding Functions Sun, 13 Apr 2014 00:00:00 +0000 Purpose. To determine the mechanisms predisposing penile fracture as well as the rate of long-term penile deformity and erectile and voiding functions. Methods. All fractures were repaired on an emergency basis via subcoronal incision and absorbable suture with simultaneous repair of eventual urethral lesion. Patients’ status before fracture and voiding and erectile functions at long term were assessed by periodic follow-up and phone call. Detailed history included cause, symptoms, and single-question self-report of erectile and voiding functions. Results. Among the 44 suspicious cases, 42 (95.4%) were confirmed, mean age was 34.5 years (range: 18–60), mean follow-up 59.3 months (range 9–155). Half presented the classical triad of audible crack, detumescence, and pain. Heterosexual intercourse was the most common cause (28 patients, 66.7%), followed by penile manipulation (6 patients, 14.3%), and homosexual intercourse (4 patients, 9.5%). “Woman on top” was the most common heterosexual position (, 50%), followed by “doggy style” (, 28.6%). Four patients (9.5%) maintained the cause unclear. Six (14.3%) patients had urethral injury and two (4.8%) had erectile dysfunction, treated by penile prosthesis and PDE-5i. No patient showed urethral fistula, voiding deterioration, penile nodule/curve or pain. Conclusions. “Woman on top” was the potentially riskiest sexual position (50%). Immediate surgical treatment warrants long-term very low morbidity. Leonardo O. Reis, Marcelo Cartapatti, Rafael Marmiroli, Eduardo Jeronimo de Oliveira Júnior, Ricardo Destro Saade, and Adriano Fregonesi Copyright © 2014 Leonardo O. Reis et al. All rights reserved. Overexpression of Aquaporin 1 in the Tunica Vaginalis May Contribute to Adult-Onset Primary Hydrocele Testis Tue, 08 Apr 2014 06:55:59 +0000 To investigate the cause of the adult-onset primary noncommunicating hydrocele testis, protein expressions of water channel aquaporins (AQPs) 1 and 3 in the tunica vaginalis were assessed. Frozen tunica vaginalis specimens from patients with adult-onset primary hydrocele testis and control male nonhydrocele patients were subjected to Western blot analysis for the detection of AQP1 and AQP3 proteins. Paraffin-embedded sections of tunica vaginalis specimens were histochemically stained with anti-AQP1 and anti-AQP3 antibodies as well as an anti-podoplanin antibody to stain lymphatic endothelia. Hydrocele fluid was subjected to biochemical analysis. AQP1 protein expression in the tunica vaginalis was significantly higher in patients with adult-onset hydrocele testis than in the controls. The AQP3 protein was not detected in the tunica vaginalis. Histochemically, AQP1 expression in the tunica vaginalis was localized in vascular endothelial and smooth muscle cells. The densities of AQP1-expressing capillaries and lymphatic vessels were similar between the tunica vaginalis of the controls and those of hydrocele patients. Sodium levels were higher in the hydrocele fluid than in the serum. In conclusion, overexpression of the AQP1 protein in individual capillary endothelial cells of the tunica vaginalis may contribute to the development of adult-onset primary noncommunicating hydrocele testis as another aquaporin-related disease. Mami Hattori, Akiko Tonooka, Masayoshi Zaitsu, Koji Mikami, Ayako Suzue-Yanagisawa, Toshimasa Uekusa, and Takumi Takeuchi Copyright © 2014 Mami Hattori et al. All rights reserved. Does an Association between the Idiopathic Left-Sided Varicocele and Eye Colour Exist? Mon, 07 Apr 2014 07:13:40 +0000 The possible interrelation between male reproductive disorders and iris pigmentation is poorly understood. We have found a link between eye colour and the existence of adolescent varicocele. Therefore, we aimed to extend our investigation on the relationship between the eye colour and varicocele in adult men. 231 andrology outpatients from Caucasian origin were included in the study. The presence of varicocele, sperm disturbances, and the iris pigment of the patients were investigated. Left-sided varicocele was found in 93 adults. In the group of light-eyed men the prevalence of varicocele was significantly lower than among the dark-eyed men (15% versus 59.5%, ). No associations were found between the eye colour and disturbances in semen parameters in males with varicocele () and in those without varicocele (). The present results in adult men suggest that the prevalence of varicocele could be associated with the iris pigment. A possible genetic linkage between the eye colour and the susceptibility to some disorders like varicocele could not be excluded. However, the iris pigmentation seems not to have a direct relationship with the sperm disturbances. Philip Kumanov, Ralitsa Robeva, and Analia Tomova Copyright © 2014 Philip Kumanov et al. All rights reserved. Structured Self-Rated Response to Iontophoresis with Verapamil and Dexamethasone in Peyronie’s Disease Thu, 03 Apr 2014 11:53:45 +0000 Introduction. New therapies evolve for the treatment of Peyronie's disease (PD) including the application of dexamethasone and verapamil using Electro Motive Drug Administration (EMDA). Patients and Methods. Patients with PD were routinely offered Potaba, Vitamin E, tamoxifen or colchicine for 6 to 18 months and for those with no improvement, 18 applications of dexamethasone and verapamil using EMDA occurred over a 6 week period. All 30 patients receiving EMDA therapy completed a questionnaire before and after treatment. The data was collected from December 2004 to November 2009 and analysed to evaluate the effectiveness of the treatment. Results. Median age of patients was 59 (range 39–71). Curvature was the most common presenting complaint (73.3%) followed by pain (23.3%), erectile dysfunction (13.3%), and lump (13.3%). 24/30 (80%) reported an improvement in symptoms after EMDA. 16 of the responders (66.7%) had a stable plaque for at least 6 months. The patients who complained of shortening of the penis () or lowered sexual desire () expressed subsequently significant response to treatment. There was statistically significant () improvement of penile deviation reported by responding men. Conclusion. A significant proportion of patients who received EMDA reported decreased curvature following iontophoresis. No serious adverse reactions developed. Abas Kokab, Kevan Wylie, Patricia Allen, Abhijeeth Shetty, and Debbie Davies-South Copyright © 2014 Abas Kokab et al. All rights reserved. The Role of Virtual Cystoscopy, after Multidetector Computed Tomography Imaging Reconstruction without the Use of Contrast Medium, in the Diagnosis and Evaluations of Bladder Tumors: Preliminary Study Wed, 02 Apr 2014 12:34:03 +0000 Introduction. Although conventional cystoscopy is considered to be the gold standard for diagnosis and follow-up of bladder tumors, it remains an invasive and costly procedure. With the advent of the multidetector CT (MDCT) scanners supported by specialized software virtual cystoscopy (VC) is possible. We assess the role of VC in diagnosing and evaluating bladder lesions. Materials and Methods. Between September 2010 and October 2011, 25 consecutive patients with cystoscopically confirmed bladder tumor underwent VC. The radiologists involved in this prospective study were blinded to the exact findings. After draining any residual urine with a catheter, the bladder was retrogradely insufflated with 200–600 cc of air. No intravenous or intravesical contrast was used. MDCT scan was performed in supine and prone positions and three-dimensional reconstruction of the urinary bladder was performed. Results. The examination was well tolerated by all patients with no complications. In total, 43 lesions were detected both with conventional cystoscopy and VC. Tumor size measured by CT ranged from 3 to 80 mm in diameter. The pathological report revealed noninvasive transitional cell carcinomas in all cases. Conclusion. VC has promising results in detecting exophytic bladder lesions. In the future it could be part of the diagnostic algorithm for bladder tumors. Kyriaki Kalokairinou, Achilles Ploumidis, Theodoros Kalogeropoulos, Lampros Vlachos, Kyriakos Stringaris, Ageliki Tavernaraki, Anastasios Thanos, Xenofon Papacharalampous, Vasilios Koutoulidis, Julien Letendre, Olivier Traxer, and Athanasios Gouliamos Copyright © 2014 Kyriaki Kalokairinou et al. All rights reserved. Extended Salvage Pelvic Lymph Node Dissection in Patients with Recurrent Prostate Cancer Wed, 12 Feb 2014 12:21:19 +0000 Background. Treatment of patients with a biochemical recurrence (BCR) of prostate cancer (PCa) is generally difficult and without valid treatment options. Since 2004 we have been developing therapeutic possibilities for these patients. Methods. We retrospectively analyzed a cohort of 41 patients with a BCR of PCa and a mean followup of months. Group 1 (): salvage radical prostatectomy (sRP) with SePLND (salvage extended pelvic lymph nodes dissection) (initial treatment: combined brachytherapy). Group 2 (): SePLND (initial treatment: radical prostatectomy (RP)). Group 3 (): SePLND (initial treatment: RP and adjuvant radiation therapy (RT)). We observed PSA, PSA-velocity, localization of LNs and LNs+, BCR-free period, and BR (biochemical response). Results. Group 1: 60% with BCR-freedom (mean 27.2 months). Group 2: 63.6% with BCR-freedom (mean 17.5 months). Group 3: 33.3% with BCR-freedom (mean 17.6 months). In total, BCR-freedom was observed in 23 of 41 patients (56.1%) after salvage surgery. 75.6% of all patients showed a BR. 765 LNs were removed and 14.8% of these were LN+. Conclusions. The BCR-free period and BR are comparable in all three groups. Sensibility to ADT can be reestablished and prolonged as a result of SePLND. Multicenter studies are needed for a reliable output. Daniar K. Osmonov, Alexey V. Aksenov, Annkathrin Boller, Almut Kalz, Diana Heimann, Isa Janssen, and Klaus-Peter Jünemann Copyright © 2014 Daniar K. Osmonov et al. All rights reserved. Factors Influencing the Duration of Urine Leakage following Percutaneous Nephrolithotomy Tue, 04 Feb 2014 11:37:18 +0000 Purpose. The duration of urine leakage following the removal of the nephrostomy tube after percutaneous nephrolithotomy (PCNL) shows significant variations depending on the techniques used. We aimed to assess the factors likely to influence the duration of urine leakage. Material and Methods. In total, 103 patients who underwent PCNL were reviewed retrospectively. DUL was evaluated regarding patient characteristics, thickness of the access line, presence of hydronephrosis, and residual stones. Results. DUL was significantly prolonged in accordance with a decrease in the thickness of parenchyma tissue (, ). DUL was prolonged as the degree of hydronephrosis (, ) and the number of patients with residual stones (, ) increased. Median DUL was significantly longer in patients with residual stones than those without residual stones (). In the receiving operating curve analysis, the optimum cut-off value of parenchymal thickness for hospitalization ≤12 h was 17.2 mm (sensitivity, 90.2%; specificity, 69.4%; ). Conclusions. We found that parenchymal thickness of the access line, hydronephrosis, and residual stones were the most influential factors determining DUL following PCNL, respectively. Ugur Uyeturk, Adnan Gucuk, Eray Kemahli, Emine Dagistan, Mevlut Yildiz, Burak Yilmaz, and Ahmet Metin Copyright © 2014 Ugur Uyeturk et al. All rights reserved. Postpercutaneous Nephrolithotomy Nephrostogram: Is It Mandatory? A Single Center Experience Mon, 03 Feb 2014 08:08:47 +0000 Aims and Objective. “Postpercutaneous nephrolithotomy nephrostogram” (PPNN) is routinely performed in most of the centers. No published series could be found in the literature without post percutaneous nephrolithotomy nephrostogram. Hence, the aim of our study is to highlight that post percutaneous nephrolithotomy nephrostogram is not mandatory and it only adds to cost and morbidity without adding any information in the management of such patients. Methods. It was a prospective study from 2005 to 2012, conducted in our institute. It included 119 patients of renal stones who underwent percutaneous nephrolithotomy performed under the guidance of a single surgeon. Postoperative nephrostogram was not done in any of the patients. Results. Complete stone clearance was achieved in 97.5% of patients and 2.5% of patients needed two to three sessions of ESWL later on. None of the patients needed second look percutaneous nephrolithotomy or nephrostogram. Conclusion. Postpercutaneous nephrolithotomy nephrostogram increases chances of infection, inconvenience, contrast related complications, and cost, with no added advantage over plain X-ray KUB, and it should not be done as a routine investigation prior to the removal of PCN tube in patients with complete stone clearance. Abdul Rouf Khawaja, Tanveer Iqbal Dar, Ajay Kumar Sharma, Farzana Bashir, Vipin Kumar Tyagi, and Mohammad Sajid Bazaz Copyright © 2014 Abdul Rouf Khawaja et al. All rights reserved. Defining the Pros and Cons of Open, Conventional Laparoscopy, and Robot-Assisted Pyeloplasty in a Developing Nation Sun, 02 Feb 2014 13:35:13 +0000 Introduction. Congenital pelviureteric junction obstruction (PUJO) is one of the most common causes of hydronephrosis. Historically, open dismembered pyeloplasty has been considered the gold standard intervention for correcting PUJO. The aim of this study was to compare the surgical and functional outcomes of three different approaches, namely, open, conventional laparoscopy, and robotic pyeloplasty. Material and Methods. 60 patients underwent minimally invasive pyeloplasty (30 conventional laparoscopies and 30 robotics) for congenital PUJO at a tertiary health center in India. Demographic, perioperative, and postoperative data were prospectively collected and analyzed. The data of these patients were retrospectively compared with another cohort of 30 patients who had undergone open pyeloplasty. Results. There was significant difference in operative time, time to drain removal, hospital stay, pain score, and complications rate between open and minimally invasive pyeloplasty (). SFI was considerably lesser in robotic as compared to conventional laparoscopy. The success rate in OP, CLP, and RP was 93.33, 96.67, and 96.67%. Conclusion. Robotic pyeloplasty is safe, effective, and feasible. It is associated with significantly lesser operative time, lesser blood loss, less pain, shorter hospital stay, and fewer complications. It is also associated with considerably lesser surgeon fatigue as compared to conventional laparoscopy pyeloplasty. Mrinal Pahwa, Archna R. Pahwa, Mohit Girotra, Rtika Ryfka Abrahm, Sachin Kathuria, and Ajay Sharma Copyright © 2014 Mrinal Pahwa et al. All rights reserved. Is Metabolic Syndrome Truly a Risk Factor for Male Lower Urinary Tract Symptoms or Just an Epiphenomenon? Thu, 23 Jan 2014 16:20:04 +0000 To define whether the association of male lower urinary tract symptoms (LUTS) and metabolic syndrome (MS) is real or simply an epiphenomenon, 490 male adults (mean age 58 ± 9 years) underwent International Prostate Symptom Score (IPSS), physical and prostate digital examinations, blood analysis, and urinary tract transabdominal ultrasound with prostate volume measurement. Mild, moderate, and severe LUTS were found in 350 (71.4%), 116 (23.7%), and 24 (4.9%) patients, respectively. MS was present in 198 (40.4%) patients, representing 37.4% (131 of 350) of those with mild LUTS, 46.5% (54 of 116) of those with moderate, and 54.1% (13 of 24) of those with severe. The odds ratio of MS having moderate or severe LUTS was 2.1. MS was more common in older age, higher body mass index, and larger prostate size. Moderate and severe LUTS were more frequent in older age, lower levels of high density cholesterol, and higher blood pressure. Older age and body mass index had significant relative risk for lower urinary tract symptoms and only age remained independent factor for LUTS on multivariate analysis. Our results suggest that the association of male LUTS, prostate volume, and MS might be coincidental and related to older age. Marina Zamuner, Walker Wendell Laranja, João Carlos Cardoso Alonso, Fabiano A. Simões, Ronald F. Rejowski, and Leonardo O. Reis Copyright © 2014 Marina Zamuner et al. All rights reserved. The Relationship between ALA16VAL Single Gene Polymorphism and Renal Cell Carcinoma Thu, 23 Jan 2014 08:05:08 +0000 Objectives. The aim of this study was to investigate the association of RCC and Ala16Val polymorphism in Turkish patients with RCC. Materials and Methods. A total of 41 patients with RCC who underwent radical or partial nephrectomy in our clinic and 50 healthy volunteers living in the same geographic area were included in this study. DNA samples from serum of RCC patients and controls were genotyped for MnSOD polymorphism analysis. Genotype ratios and allele frequencies were compared between two groups and odd ratios with 95% confidence intervals were calculated statistically. A value of <0.05 was considered statistically significant. Results. There was a significant difference in the MnSOD genotype distributions between the RCC patients and the controls in terms of Ala/Ala+Ala/Val and Val/Val genotypes (). The Ala/Ala+Ala/Val genotypes were found significantly suspicious for RCC with an OR of 2.64 (95% CI = 1.06–6.69, ). In addition, Ala allele was found significantly suspicious for RCC with an OR of 2.26 (95% CI = 1.24–4.12, ). Conclusion. Our study indicated that MnSOD Ala16Val polymorphism may be one of the many genetic factors for renal cancer susceptibility in Turkish patients. Dogan Atilgan, Bekir S. Parlaktas, Nihat Uluocak, Engin Kolukcu, Fikret Erdemir, Huseyin Ozyurt, and Unal Erkorkmaz Copyright © 2014 Dogan Atilgan et al. All rights reserved. Surgical Approaches to Supradiaphragmatic Segment of IVC and Right Atrium through Abdominal Cavity during Intravenous Tumor Thrombus Removal Wed, 22 Jan 2014 11:25:19 +0000 Objective. The purpose of this study was to investigate safety and feasibility of some surgical approaches to the supradiaphragmatic inferior vena cava (IVC) and the right atrium through the diaphragm from the abdominal cavity. Materials and Methods. The material of the anatomical study included 35 fresh cadavers. Several options of surgical access to the supradiaphragmatic IVC were successively performed. Feasibility and risk level of each of the approaches were evaluated with the use of a special scale. Results. The isolation of the supradiaphragmatic IVC and cavoatrial junction was most easily performed via T-shaped or circular diaphragmotomy (grade “easy” was registered in 74.3% and 80% of patients, resp., compared to 31.4% for transverse diaphragmotomy and 40% for isolation of the IVC in the pericardial cavity). The risk analysis has demonstrated the highest safety level for T-shaped diaphragmotomy (grade “safe” was registered in 60% of cases). The intervention via transverse diaphragmotomy, circular diaphragmotomy, and IVC isolation in the pericardial cavity was graded as “risky” in 80%, 62.9%, and 82.9% of cases, respectively. Conclusions. In our opinion, T-shaped diaphragmotomy is the most safe and easy-to-perform access for mobilization of the supradiaphragmatic IVC through the abdominal cavity. Dmytro Shchukin, Vladimir Lesovoy, Igor Garagatiy, Gennadiy Khareba, and Redouane Hsaine Copyright © 2014 Dmytro Shchukin et al. All rights reserved. Nested Variant of Urothelial Carcinoma Wed, 22 Jan 2014 09:06:04 +0000 Background. Nested variant of urothelial carcinoma was added to the WHO’s classification in 2004. Aims. To review the literature on nested variant of urothelial carcinoma. Results. About 200 cases of the tumour have been reported so far and it has the ensuing morphological features: large numbers of small confluent irregular nests of bland-appearing, closely packed, haphazardly arranged, and poorly defined urothelial cells infiltrating the lamina propria and the muscularis propria. The tumour has a bland histomorphologic appearance, has an aggressive biological behaviour, and has at times been misdiagnosed as a benign lesion which had led to a significant delay in the establishment of the correct diagnosis and contributing to the advanced stage of the disease. Immunohistochemically, the tumour shares some characteristic features with high-risk conventional urothelial carcinomas such as high proliferation index and loss of p27 expression. However, p53, bcl-2, or EGF-r immunoreactivity is not frequently seen. The tumour must be differentiated from a number of proliferative lesions of the urothelium. Conclusions. Correct and early diagnosis of this tumour is essential to provide early curative treatment to avoid diagnosis at an advanced stage. A multicentre trial is required to identify treatment options that would improve the outcome of this tumour. Anthony Kodzo-Grey Venyo Copyright © 2014 Anthony Kodzo-Grey Venyo. All rights reserved.