Dear Colleagues,

At the height of the summer, we hope you all have a chance to enjoy some time off and recharge your batteries! We at UroToday International Journal are not slowing down much at any time of the year but are proud to continue bringing our readership an interesting and educational mix of articles and case-reports in the field of urology and urologic oncology.

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In this issue, Pujari et al. analyzed the utility of tamsulosin in patients with pelvic floor urethral distraction injuries (PFUDD) undergoing voiding cystourethrograms to assess the posterior urethra for length of the distraction defect. They concluded that tamsulosin effectively relaxed the bladder neck and allowed the delineation of the posterior urethra in patients of PFUDD with a competent bladder neck. This prevented the patients from undergoing further invasive diagnostic techniques (bougiogram and antegrade cystourethroscopy).  

Sharma et al. prospectively evaluated the safety, feasibility, and efficacy of day care/ambulatory tubeless percutaneous nephrolithotomy. They conclude it is a feasible and effective option that can safely be offered to patients, providing uncomplicated surgery and favorable postoperative parameters.

A retrospective chart review was completed by Logan et al. to analyze their institutional renal cell carcinoma (RCC) database to determine how consistently aberrations in aspartate aminotransferase (AST), alanine aminotransferase (ALT), and alkaline phosphatase (ALP) values were present when metastatic RCC was present. They found that AST, ALT, and ALP are unreliable in suggesting the presence of metastatic RCC lesions in liver or bone, and underscore the importance of imaging.

Lodh et al. aimed to identify independent predictors of unsuccessful trial without catheter (TWOC) in men with acute urinary retention secondary to benign prostate hyperplasia. Their study suggested that age, intravesical prostatic protrusion, transition zone volume, transition zone index, and residual urine volume are significant risk factors for unsuccessful TWOC.

To reduce the OAB symptoms and to estimate safety and tolerability of non-invasive treatment, Kosilov et al. evaluated the use of combined antimuscarinics as the alternative to single agent treatment in elderly OAB patients. They found that the majority of elderly patients were treated successfully with combined high-dosage antimuscarinics. In addition, the quantity of side effects was comparable to that of normal-dosed antimuscarinics.

Pujari et al. performed a prospective study in an attempt to revise the serum PSA cut off level to suit the Asian population. The cut off level of serum PSA beyond which investigations are warranted in Asians is controversial at present and further multicenter trials involving a larger number of patients must be carried out to arrive at a consensus, since blindly following the current Western literature results in unnecessary interventions in this patient population.

A simple and safe technique of male urethral catheterization only requiring equipment readily available in every urology department is described by Gardi et al.

Finally, in a Letter to the Editor, McLean et al. discuss the parental attitudes toward fertility preservation in boys with cancer. Most parents of pediatric oncology patients are under-informed about fertility implications of cancer therapy, and most would want their son to undergo fertility preservation. Predictably, increased infertility risk and increased theoretical success rate both independently increase parents’ interest.

We also present a series of case studies that include various topics, including en-bloc kidney transplantation, isolated ano-vaginal fistula, renal pelvis squamous cell carcinoma, and giant leiomyoma of ureter.

It is our primary goal to publish original studies, and we encourage you to submit the results of clinical or basic science research in all areas of urology. I personally thank the authors and reviewers for their valuable contributions to this issue.

Warm Regards, 

Karl-Erik Andersson

ABSTRACT

Male urethral catheterization can be difficult and is still a familiar problem for urologists. A laborious male urethral catheterization is often consequent to the presence of a bulky prostate due to benign prostatic enlargement, a condition intimately related to aging with an increasing prevalence in elderly people. The task of passing a urethral catheter in this atypical condition often leads to repeated and unsuccessful attempts, which can cause the patient distress, and are often related to a wide range of complications, sometimes leading to medico-legal lawsuits.

We describe a simple and safe technique only requiring equipment readily available in every urology department. It facilitates the chances of an atraumatic and successful catheter insertion in men suffering from different pathologic or anatomic conditions when a primary attempt of simple transurethral catheterization fails.

The performance of the technique was tested in 76 patients who required bladder catheterization by a urologic consultant because of failed primary attempts. Difficulties were attributable to past transurethral resection of the prostate in 10 patients, past open radical retropubic prostatectomy in 7, and benign prostate enlargement in 59. Successful catheterization was obtained in 65 patients, 5 patients were otherwise catheterized by a rigid catheter, and 6 required a suprapubic catheter or flexible cystoscopy. Complications comprised self-limiting urethral bleeding in 12 patients, urinary tract infection in 4, and false passage in 2.

The technique is well tolerated and increases the likelihood of successful primary urethral catheterization in this set of patients; moreover, a hospital admission that is needed in case of placing a suprapubic catheter is not required.

Mario Gardi, Giulio Massimo Balta, Marcello Repele, Nicola Zanovello, Giovanni Betto, Simonetta Fracalanza, Wanni Battanello, Bruno Santoni, Silvia Secco, Andrea Agostini, Massimo Dal Bianco

Submitted June 1, 2013 - Accepted for Publication July 31, 2013

KEYWORDS: Difficult catheterization, bulky prostate, prostate enlargement, complication, malpractice

CORRESPONDENCE: Mario Gardi, MD, PhD, Urology Unit, Department of Surgery, Ospedale Sant’Antonio, Building G, Via Facciolati, 71, Padova, Italy ()

CITATION: UroToday Int J. 2013 August;6(4):art 53. http://dx.doi.org/10.3834/uij.1944-5784.2013.08.12

ABSTRACT

Leiomyoma of the ureter is a very rare benign tumor of mesenchymal origin, which may be very difficult to differentiate from malignant tumors before surgery. With the exception of the numerous fibrous polyps, only the occasional example of leiomyomas, neurofibromas, hemangioma, and fibrolipoma have been reported. To the best of our knowledge only 12 cases have been reported worldwide since 1955, with only 1 case of bilateral ureteric leiomyoma. The aim of this report is to highlight the rarity of this tumor and its impact on renal function.

Tanveer Iqbal Dar, Mohamad Sajid Bazaz, Nuzhat Tabasum, Mohammad Saleem Wani, Abdul Rouf Khawaja

Submitted March 21, 2013 - Accepted for Publication July 22, 2013

KEYWORDS: Ureteral tumors, leiomyoma, radical nephroureterectomy

CORRESPONDENCE: Dr. Tanveer Iqbal, Clinical Assistant, Department of Urology and Renal Transplant Surgery, Sir Ganga Ram Hospital, New Delhi, India, 110060 ()

CITATION: UroToday Int J. 2013 August;6(4):art 52. http://dx.doi.org/10.3834/uij.1944-5784.2013.08.11

 ABSTRACT

Cancer survival rates have increased dramatically in recent decades. Until better cancer therapies emerge, infertility will remain a common side effect of cancer therapy. Infertility therapies have likewise flourished in recent decades, but unfortunately the science of infertility has been relatively slow to infiltrate the oncology world. Parents of children with cancer are interested in preventing and/or preserving their children’s fertility. But do they know what their options are? Do they even know infertility is a risk? The answer to both, sadly, is often no. However, now that we know the majority of parents would agree to fertility preservation techniques, we may confidently proceed with appropriate clinical trials.

Thomas W. McLean, Hooman Sadri-Ardekani, Anthony Atala

Submitted June 16, 2013 - Accepted for Publication July 21, 2013

KEYWORDS: Cancer survival, fertility preservation, pediatric cancer

CORRESPONDENCE: Thomas W. McLean, Department of Pediatrics, division of Hematology/Oncology, Wake Forest University School of Medicine, Winston-Salem, North Carolina, USA ()

CITATION: UroToday Int J. 2013 August;6(4):art 50. http://dx.doi.org/10.3834/uij.1944-5784.2013.08.09

ABSTRACT

Introduction: This prospective study is an attempt to revise the serum prostate specific antigen (PSA) cutoff level to suit the Asian population.

Materials and Methods: A prospective study was carried out on 172 male patients who underwent transrectal ultrasound (TRUS) prostate biopsies. Only those patients with a serum PSA level within the range of 4 to 10 mg/mL were included in this study. The decision to perform the biopsy was undertaken only after further evaluation using free:total PSA ratio.

Results: Of the 172 patients, 9 (5.23%) patients had adenocarcinoma prostate with a Gleason's score ranging from 4 to 7. In total, 163 (94.7%) patients had benign pathology. Serum PSA ranged from 4.2 to 9.8 ng/mL.

Conclusion: The cutoff level of serum PSA beyond which investigations are warranted in Asians is controversial at present, and further multicentric trials involving a larger number of patients must be carried out to arrive at a consensus.

Nandan R. Pujari

Submitted March 21, 2013 - Accepted for Publication July 22, 2013

KEYWORDS: Prostate carcinoma, serum PSA, Asian population, adenocarcinoma

CORRESPONDENCE: Nandan R. Pujari, MS, DNB (Urology), MGM Medical College, Mumbai, Maharashtra, India ()

CITATION: UroToday Int J. 2013 August;6(4):art 51. http://dx.doi.org/10.3834/uij.1944-5784.2013.08.10

ABSTRACT

Keratinizing desquamative squamous metaplasia (KDSM) of the upper urinary tract is a rare condition. We present a case of a 45-year-old male smoker of more than 20 years presenting with a 1-month history of recurrent, intermittent left flank pain of moderate intensity associated with dysuria and nausea. In this case the differential diagnosis included renal cell carcinoma, tuberculosis of the kidney, and KDSM. However, the pathological findings showed squamous cell carcinoma arising in KDSM. Hence we report this rare association of a squamous cell carcinoma of the renal pelvis arising in KDSM.

Mohammed S. Al-Marhoon, P. A. M. Saparamadu, Krishna P. Venkiteswaran, Omar Shareef, Joseph Mathewkunju

Submitted June 7, 2013 - Accepted for Publication July 17, 2013

KEYWORDS: Squamous cell carcinoma, metaplasia, kidney

CORRESPONDENCE: Mohammed S. Al-Marhoon, PhD, MD, MRCSEd, BSc, Sultan Qaboos University, Al-Khould, Muscat, Oman ()

CITATION: UroToday Int J. 2013 August;6(4):art 49. http://dx.doi.org/10.3834/uij.1944-5784.2013.08.08

ABSTRACT

Isolated ano-vaginal fistulae without associated vesicovaginal fistulae following prolonged labor have not been reported. They present with fecal discharge per vaginum. A two-layered fistulae closure with interposition flap is the treatment of choice. Herein, we report such a rare entity that deserves mention.

Vishwajeet Singh, Dheeraj Kumar Gupta, Rahul Janak Sinha

Submitted May 15, 2013 - Accepted for Publication June 30, 2013

KEYWORDS: Ano-vaginal fistulae, vesicovaginal fistulae, obstetric delivery, interposition flap

CORRESPONDENCE: Vishwajeet Singh, M.S.,M.Ch (Urology), Chhatrapati Sahuji Maharaj Medical University (Formerly KGMC), Lucknow, Uttar Pradesh, India

CITATION: UroToday Int J. 2013 August;6(4):art 48. http://dx.doi.org/10.3834/uij.1944-5784.2013.08.07

ABSTRACT

Objectives: Numerous elderly patients with overactive bladder (OAB) demonstrate insufficient treatment results under antimuscarinic monotherapy with dose increase. To reduce the OAB symptoms and to estimate safety and tolerability of non-invasive treatment, we evaluated the use of combined antimuscarinics as the alternatives.

Methods: Eighty-one patients older than 65 years, both male and female, who earlier received (for 6 months or more before our study) double-dose antimuscarinic monotherapy (trospium), whose initial symptoms did not resolve (or the improvement was short lived), and who experienced mild or no side effects, were included in this study. The patients demonstrated urodynamic-proven overactive bladder with daily incontinence, increased intravesical pressure, and reduced bladder capacity. Taking into account the strength of the initial study treatment, they were distributed into 3 groups and treated with 2 antimuscarinics. The patients underwent urodynamic examination before enrollment in the sixth week and in the fourth month. During the whole treatment period, they kept special bladder diaries where they, among other issues, described side effects during treatment.

Results: Significant changes were noted at the 6-week follow-up in all 3 groups. The average number of daily incontinence events decreased from 6 to 2 events. The average maximum bladder capacity (177 to 356 mL) and reflex volume (149 to 284 mL) increased; detrusor compliance also improved (average, 16 to 37 mL/cm H₂O). Twenty-four patients reported side effects; 3 of them discontinued the successful treatment due to this reason. Seven other patients did not receive any noticeable improvement of detrusor dysfunction, although they did not report any side effects.

Conclusion: The majority of elderly patients, who previously demonstrated unsatisfactory results under dose-escalated monotherapy, were treated successfully with combined high-dosage antimuscarinics (87.6 %). The quantity of side effects was comparable to that of normal-dosed antimuscarinics.

Take-Home Message: The majority of elderly patients, who continued to suffer from symptoms of overactive bladder after dose-escalated antimuscarinic monotherapy, showed subjective and objective treatment success. The therapy used the combination of high-dosed antimuscarinics (87.6%). Obtained side effects were comparable to (did not exceed) the single-drug treatment.

Kirill Kosilov, Sergey Loparev, Marina Ivanovskaya, Lily Kosilova

Submitted April 16, 2013 - Accepted for Publication July 14, 2013

KEYWORDS: Overactive bladder, aging population, pharmacologic treatments, muscarinic antagonists, side effects, tolterodine, trospium, oxybutynin, solifenacin, combination antimuscarinics, urodynamic monitoring

CORRESPONDENCE: Kirill Kosilov, Far Eastern Federal University, Department of Neurourology-Urodynamics, Primorsky Regional Diagnostic Center, Vladivostok, Russian Federation ()

CITATION: UroToday Int J. 2013 August;6(4):art 47. http://dx.doi.org/10.3834/uij.1944-5784.2013.08.06

ABSTRACT

Introduction: Evaluation of patients with newly diagnosed renal cell carcinoma (RCC) often includes evaluating serum levels of aspartate aminotransferase (AST), alanine aminotransferase (ALT), and alkaline phosphatase (ALP). Traditional teaching is these laboratory values, if elevated, may indicate the presence of metastatic disease to the liver (AST and ALT) or bones (ALP). We analyzed our institutional RCC database to determine how consistently aberrations in these values were present when metastatic RCC was present.

Materials and Methods: A retrospective chart review was completed, identifying 315 patients diagnosed with RCC who had AST, ALT, and ALP values available for review. Overall rates of aberration, as well as rates of aberration in those patients presenting with metastatic RCC, were calculated.

Results: Of the 315 patients in the study cohort, 61 (19.4%) presented with an elevation in 1 or more of the laboratory values in question. Of these 61 patients, 58 (95%) presented with clinically localized disease. The remaining 3 patients (5%) presented with lung metastasis identified on imaging and had isolated elevations of ALP ranging from 130 IU/L to 278 IU/L; these 3 patients were of the 9 in the cohort who presented with lung metastasis. Five patients presented with metastatic lesions to the bone with no elevation of ALP present. Five patients presented with metastatic lesions to the liver, and none of these patients had any elevation of ALT or AST. However, 1 of these 5 patients did have minimal elevation in ALP, 130 IU/L, but also had a concomitant lung metastasis.

Conclusion: Elevation in ALP, while not seen in patients with bone metastasis in this cohort, was present in 33.3% of patients presenting with lung metastasis. Therefore, an identified aberration in ALP may be considered to direct closer pulmonary evaluation. Regarding AST and ALT, elevations of these laboratory values were not present in any patients with liver metastasis. These observations highlight that AST, ALT, and ALP are unreliable in suggesting the presence of metastatic RCC lesions in liver or bone, and underscore the importance of imaging.

Joshua E. Logan, David A. Staneck, Mary H. James, Jack W. Lambert, Robert W. Given, Raymond S. Lance, Michael D. Fabrizio, Stephen B. Riggs

Department of Urology, Eastern Virginia Medical School, Norfolk, Virginia, USA

Submitted April 18, 2013 - Accepted for Publication June 30, 2013

KEYWORDS: Renal cell carcinoma, metastases, laboratory values, AST, ALT, alkaline phosphatase

CORRESPONDENCE: Joshua E. Logan, MD, Fellow, Institute of Urologic Oncology, Department of Urology, David Geffen School of Medicine, University of California, Los Angeles, California, United States ()

CITATION: UroToday Int J. 2013 August;6(4):art 46. http://dx.doi.org/10.3834/uij.1944-5784.2013.08.05

ABSTRACT

We report a case of successful transplantation of en-bloc kidneys (EBK) from a 7-month-old male pediatric donor weighing 14.3 pounds into a 94.8-pound, 18-year-old female recipient. The cause of brain death in the infant was pseudomonas meningitis, and the donor and recipient received appropriate intravenous antibiotics. Both ureters were implanted separately and stented. The postoperative course was uneventful except for 2 episodes of acute cellular rejection. She remains well at more than 36 months post-transplantation, with a serum creatinine of 48 µmmol/L. We recommend en-bloc kidney transplantation into suitable adults if the pediatric donor weighs less than 33 pounds. 

Taqi F. Toufeeq Khan, Suhaib Kamal, Basem Koshaji, Faheem Akhtar

Submitted May 2, 2013 - Accepted for Publication June 16, 2013

KEYWORDS: 14.3-pound pediatric donor, bacterial meningitis, en-bloc kidneys, kidney transplantation, adult recipient

CORRESPONDENCE: Taqi F. Toufeeq Khan, Section of Kidney Transplantation, Department of Surgery, Riyadh Military Hospital, 11159 Riyadh, Kingdom of Saudi Arabia ()

CITATION: UroToday Int J. 2013 August;6(4):art 45. http://dx.doi.org/10.3834/uij.1944-5784.2013.08.04

ABSTRACT

Purpose: Tubeless percutaneous nephrolithotomy (PCNL) is a well-accepted procedure for uncomplicated renal calculi. We prospectively evaluated the safety, feasibility, and efficacy of day care/ambulatory PCNL (totally tubeless, discharge within 24 hours) for selected patients for which only few case series have been reported.

Materials and Methods: Total tubeless PCNL was planned in 40 easily accessible patients with uncomplicated renal calculi, with single infracostal punctures, normal intraoperative events, and acceptable postoperative parameters (visual analogue pain score, parenteral analgesic requirement, bleeding, urinary soakage, hemodynamic stability), allowing an early discharge within 24 hours. Parameters like pain score and analgesic requirement, any complications, and return date to normal work were evaluated at follow-up. Ultrasonography was performed after a week to document stone clearance.

Results: Mean patient age was 38.6 years (22 to 62), stone size was 21.4 mm (15.4 to 30), and operating time was 72 minutes (42 to 106) without blood transfusion. Regional anesthesia was used in 13 cases while general anesthesia was used in the rest of the patients. Average pain score after 6 hours of surgery was 2.3 (1.8 to 3.6) with vitals in the normal range, and hospital stay was 12.5 hours (5.5 to 23.5). Six patients were excluded due to peri- and postoperative events (2: multiple punctures, 1: hematuria, 1: urine leak, 2: pain). This data was taken with the intention to treat the analysis with a successful application of study protocol in 34 (85%) of preoperatively selected cases. Out of 34 patients that qualified for a complete study protocol, 11 were discharged on the same day of surgery while the rest were discharged the next morning. Postoperative USG confirmed no residual calculus, and all patients had uneventful recoveries. Three patients had minor complications (mild hematuria/urine leaks), which were managed conservatively.

Conclusion: Our experience with ambulatory PCNL in properly selected cases suggests it as a feasible and effective option that can safely be offered to patients, providing uncomplicated surgery and favorable postoperative parameters.

Adittya K. Sharma, M. Nagabhushan, G. N. Girish, A. J. Kamath, C. S. Ratkal, G. K. Venkatesh

Submitted May 20, 2013 - Accepted for Publication June 16, 2013

KEYWORDS: Percutaneous nephrolithotomy, nephrolithiasis, kidney calculi

CORRESPONDENCE: Adittya K. Sharma, MCh, Institute of Nephro-Urology, Victoria Hospital Campus, Bangalore, Karnataka, India (, )

CITATION: UroToday Int J. 2013 August;6(4):art 44. http://dx.doi.org/10.3834/uij.1944-5784.2013.08.03

ABSTRACT

Introduction: Acute urinary retention (AUR) is the most important event in the natural history of benign prostatic hyperplasia (BPH) that calls for urinary catheterization. Trial without catheter (TWOC) is an ambulatory care protocol, failure of which requires re-catheterization, a follow-up visit, subsequent evaluation, and surgical intervention. The aim of the study was to identify independent predictors of unsuccessful TWOC.

Methods: The present study enrolled 83 patients with a first episode of AUR secondary to BPH. We have recorded details of various factors, including age, international prostate symptom score (IPSS), total prostate volume (TPV), transition zone volume (TZV), transition zone index (TZI), intravesical prostatic protrusion (IPP), and residual urine volume (RUV) drained following catheterization. Administration of 0.4 mg of tamsulosin once a day for 7 days was given to all following catheterization and TWOC performed on the eighth day. Our definition of unsuccessful trial was the inability to pass urine or post-void residual urine > 150 mL on ultrasound, with a maximum flow rate < 10 mL/sec. Statistical Package for the Social Sciences (SPSS) 16.0 was used for statistical analysis. Multivariate analysis was performed to identify independent predictors. Independent t-test and Fisher’s exact tests were used for other statistical analysis where a P value of < 0.05 was considered significant. Receiver operating characteristic curves (ROC) were constructed using cutoff values for independent predictors.

Results: TWOC was unsuccessful in 48 (57.83%) patients. Multivariate analyses revealed that age (odds ratio = 1.069; 95% CI = 1.002-1.140; P value = 0.042), TZV (odds ratio = 1.662; 95% CI = 1.035-2.670; P value = 0.035), TZI (odds ratio = 0.00; 95% CI = 0.00-0.150; P value = 0.032), and RUV (1.003, 1.000-1.007, 0.38) are independent predictors of a failed trial. The failure rates of the voiding trial based on grades I to III IPP were 2.08% (1 of 48 cases), 10.41% (5 of 48), and 18.75% (9 of 48).

Conclusion: Our data suggested that age, IPP, TZV, TZI, and RUV are significant risk factors for unsuccessful TWOC. Evaluation of a first episode of AUR secondary to BPH in respect to the previously mentioned factors may guide urologists during subsequent evaluation and treatment without giving a failed trial.

Bijit Lodh, Somarendra Khumukcham, Sandeep Gupta, Kaku Akoijam Singh, Rajendra Singh Sinam

Submitted May 4, 2013 - Accepted for Publication June 14, 2013

KEYWORDS: Acute urinary retention, benign prostatic hyperplasia, trial without catheter, intravesical prostatic protrusion, transition zone index

CORRESPONDENCE: Bijit Lodh, MS (General Surgery), MCh (Trainee in Urology), Regional Institute of Medical Sciences, Imphal, Manipur, India ()

CITATION: UroToday Int J. 2013 August;6(4):art 43. http://dx.doi.org/10.3834/uij.1944-5784.2013.08.02

ABSTRACT

Purpose: To analyze the utility of tamsulosin in patients with pelvic floor urethral distraction injuries (PFUDD) undergoing voiding cystourethrograms (VCUG) to assess the posterior urethra for length of the distraction defect.

Materials and Methods: A prospective randomized analysis of 107 patients with PFUDD who underwent VCUG from August 2007 to September 2011 at our tertiary referral center for urethral stricture. Patients were randomized into 2 groups. A dosage of 0.4 mg of tamsulosin, a potent selective alpha-blocker, was administered orally to patients in the study group (N = 53) undergoing VCUG in whom the posterior urethra was not delineated due to competency of the bladder neck. A repeat voiding film was taken 10 to 12 hours after administering tamsulosin. The control group (N = 54) did not receive tamsulosin. Instead, they underwent further diagnostic techniques (magnetic resonance imaging [MRI], bougiogram, and antegrade cystourethroscopy) to assess the distraction defect.

Results: Out of the 53 patients in the study group all 53 patients responded to oral tamsulosin. In the control group 32 patients required MRI, 20 patients required antegrade cystourethroscopy, and 2 patients required bougiograms.

Conclusion: Tamsulosin effectively relaxed the bladder neck and allowed the delineation of the posterior urethra in patients of PFUDD with a competent bladder neck. This prevented the patients from undergoing further invasive diagnostic techniques (bougiogram and antegrade cystourethroscopy). Further prospective studies with a larger number of patients with multicenter experience will be required to validate these results.

Nandan R. Pujari, Sanjay B. Kulkarni

Submitted March 21, 2013 - Accepted for Publication May 19, 2013

KEYWORDS: Tamsulosin, VCUG, distraction defect

CORRESPONDENCE: Nandan R. Pujari, MS, DNB (Department of Urology), MGM Medical College, Mumbai, Maharashtra, India ()

CITATION: UroToday Int J. 2013 August;6(4):art 42. http://dx.doi.org/10.3834/uij.1944-5784.2013.08.01