Dear Colleagues,

It’s April again and we are welcomed by the rebirth of spring. With that comes potential, and we at UIJ know there are new ideas, innovations, and studies out there that authors are hoping to share. We encourage our current readers and authors to continue to spread the good word about UIJ, reminding potential submitters that submission, peer review, and publication are all free.

We would also like to welcome Anna Forsberg as the new editorial assistant on the UIJ. We are sure you will find her to be helpful as well as patient.  

In this issue, Pal et al. present a study performed to establish the efficacy of tacrolimus ointment as a mode of nonsurgical management of early balanitis xerotica obliterans. They show that the use of topical tacrolimus has promising results with good symptomatic relief and few side effects.

Singh et al. compare the clinical efficacy and tolerability of naftopidil versus tamsulosin in patients with lower urinary tract disorders due to benign prostatic hyperplasia. Tamsulosin acts via α1A/D-receptors and naftopidil mainly via α1D-receptors. Despite this difference, they find  that in the management of symptomatic BPH, naftopidil and tamsulosin appeared to be equally effective, safe, and well tolerated.

McCammon et al. performed a retrospective review of urodynamic findings in patients presenting to their institution with post-prostatectomy incontinence following either an open or robotic prostatectomy from 1985 through 2009. They found that following open compared to robotic prostatectomy, patients experienced elevated voiding pressures and decreased peak flows, presumably secondary to the increased incidence of anastomotic stenosis observed in those patients.

Daneshmand et al. attempt to evaluate the relationship and investigate the short-term effects of continent and non-continent diversions on patients with both normal renal function and pre-existing renal insufficiency. Their study suggests that mild pre-existing renal insufficiency may not be a contraindication to continent diversion.

A study by Wani et al. aimed to evaluate the incidence of von Hippel-Lindau (VHL) gene mutations among a group of Kashmiri patients diagnosed with renal cell tumors. They demonstrated that alteration in the VHL gene had been implicated in the pathogenesis of renal-cell sporadic cancer of the patients in their population.

The aim of a study by Swellam et al. was to evaluate the feasibility of tattooing of the bladder urothelium using different stains. Despite the side effects of the used materials, tattooing remains feasible. A wide range of dyes and pigments can be used, however, the type of material, dose titration, and long follow-up are needed to detect the most suitable material.

We also present a series of case studies on several topics, including disorders of sexual differentiation, a giant capsular leiomyoma of the kidney, and a large staghorn calculus.

As always, we are grateful to our continued readership for their loyalty, and I thank our editorial board for their dedication and commitment to quality with every article we publish. 

Warm regards, 

Karl-Erik Andersson

ABSTRACT

Objective: To evaluate the feasibility of tattooing of the bladder urothelium using different stains.

Methods: The study was performed on 20 healthy male and female dogs, which were divided into 4 groups according to the injected material. The first group (4 animals) was injected with hydrated iron (II) sulphate. The second group (4 animals) was injected with methylene blue added to hydrated iron (II) sulphate. The third group (8 animals) was injected with India ink, and the fourth group (4 animals) was injected with methylene blue. The procedure was performed under general anesthesia. The doses as well as the injection technique were standardized. Re-exploration with sacrifice of the dogs was performed after 40 days. The bladder was examined grossly for dye retention. Bladder, spleen, and liver specimens were sent for histopathological examination.

Results: Tattooing was performed successfully without any immediate reaction. Postoperative complications occurred in a single case in the form of vesicocutaneous fistula. At re-exploration, the dye was retained in both the first and second groups, and there was no difference in color intensity. Methylene blue increased the local inflammatory changes. The third and the fourth groups failed to retain the dye. Local reaction at the site of injection, as well as in the bladder, was present in all cases, being most severe in the third group. In cases of the first, second, and third groups the inflammatory reaction involved the liver with hepatic degeneration up to cirrhotic changes. Histopathological examination showed the presence of ferrous particles in the submucosa as well in the detrusor muscles. The presence of ferrous particles was also detected in the spleen.

Conclusion: In our study, tattooing the bladder urothelium was successful. Despite the side effects of the used materials, tattooing remains feasible; however, the type of material, dose titration, and long follow-up are needed to detect the most suitable material.

Tarek Abdallah Swellam, Ahmed S Zayed, Muhammed Ali, Ahmed Refaat, Muhammed Magdy El-Mahdi, Muhammed M Wishahy

Submitted January 23, 2012 - Accepted for Publication March 12, 2013

KEYWORDS: Bladder tattooing, urothelial marking, Indian ink, ferrous sulphate

CORRESPONDENCE: Tarek Abdallah Swellam, MD, PhD, Theodor Bilharz Research Institute, Giza, Imbaba, Egypt ()

CITATION: UroToday Int J. 2013 April;6(2):art 26. http://dx.doi.org/10.3834/uij.1944-5784.2013.04.13

ABSTRACT

We present an unusual case of chordee without hypospadias with a communicating, symptomatic epidermoid cyst. A 12-year-old boy presented with painful erections, especially early in the morning, over the last year and a watery discharge from swelling located near the meatus for 2 months. On examination, ventral chordee was present, the meatus was orthotopic, the prepuce was normal, and a ~0.5X0.5 cm swelling was present near the meatus on the ventral aspect with watery discharge. During operation, it was found that this swelling had communication with the urethra, and it was an epidermoid cyst on histopathologic examination.

Avinash Dutt Sharma, Malay Kumar Bera, Anup Kumar Kundu

Submitted January 30, 2012 - Accepted for Publication February 21, 2013

KEYWORDS: Chordee, hypospadias, congenital, preputial

CORRESPONDENCE: Avinash Dutt Sharma, M.S., Institute of Postgraduate Medical Education & Research, Kolkata, West Bengal, India ()

CITATION: UroToday Int J. 2013 April;6(2):art 24. http://dx.doi.org/10.3834/uij.1944-5784.2013.04.11

ABSTRACT

An ileovesical fistula is a rare complication of Crohn disease. It presents with recurrent abdominal pain, pneumaturia, fecaluria, recurrent urinary tract infection, and dysuria. A 13-year-old girl presented with an ileovesical fistula, which was diagnosed by clinical history, micturating cystourethrogram, and computed tomography (CT) cystography. Exploratory laparotomy, an excision of the fistulous tract, bladder repair, and ileostomy were performed. The histopathological examination of a resected, affected ileal segment showed the classical non-caseating granuloma, characteristic of Crohn disease. The restoration of bowel continuity was done later on. The patient is doing well after 3 years of follow-up.

Vishwajeet Singh, Dheeraj Kumar Gupta, Rahul Janak Sinha, Seema Mehrotra

Submitted February 2, 2012 - Accepted for Publication February 21, 2013

KEYWORDS: Ileovesical fistulae, pneumaturia, Crohn disease

CORRESPONDENCE: Vishwajeet Singh, MS, MCh (Urology), Chhatrapati Sahuji Maharaj Medical University (Formerly KGMC), Lucknow, Uttar Pradesh, India ()

CITATION: UroToday Int J. 2013 April;6(2):art 23. http://dx.doi.org/10.3834/uij.1944-5784.2013.04.10

ABSTRACT

Crossed renal ectopia is a rare congenital malformation and is the second most common fusion anomaly after a horseshoe kidney. Crossed ectopic kidneys are fused to their ipsilateral mate in 90% of cases. crossed fused renal ectopia is usually diagnosed when other disease states are being investigated. It rarely causes significant clinical problems. Treatment is only indicated for the complication of the anomaly rather than for the anomaly itself. 

Atul Kumar Khandelwal, Ahsan Ahmad, Vijoy Kumar, Rajesh Tiwari, Mahendra Singh, Khalid Mahmood

Submitted January 7, 2013 - Accepted for Publication January 24, 2013

KEYWORDS: Crossed-fused renal ectopia, staghorn, nephrolithiasis

CORRESPONDENCE: Atul Kumar Khandelwal, MBBS, MS, Indira Gandhi Institute of Medical Sciences, Flat No 2, New MDH, IGIMS Campus, IGIMS, Sheikhpura, Patna, Bihar 800014, India ()

CITATION: UroToday Int J. 2013 April;6(2):art 21. http://dx.doi.org/10.3834/uij.1944-5784.2013.04.08

ABSTRACT

A urinoma is a continued perinephric or peripelvic extravasation of urine leading to the formation of encapsulated retroperitoneal urine collection due to the disruption of the urinary collecting system. Non-obstetric urinomas are usually the result of trauma, a urologic procedure, infection, and nephrolithiasis. We report a case of perirenal urinomas that were detected during the postpartum period.

Atul Kumar Khandelwal, Mahendra Singh, Rajesh Tiwari, Vijoy Kumar, Shivani Khandelwal, Ahsan Ahmad

Submitted December 1, 2012 - Accepted for Publication February 12, 2013 

KEYWORDS: Urinoma, postpartum, perinephric

CORRESPONDENCE: Atul Kumar Khandelwal, MBBS, MS, Indira Gandhi Institute of Medical Sciences, Flat No 2, New MDH, IGIMS Campus, IGIMS, Sheikhpura, Patna, Bihar 800014, India ()

CITATION: UroToday Int J. 2013 April;6(2):art 22. http://dx.doi.org/10.3834/uij.1944-5784.2013.04.09

ABSTRACT

Introduction: Despite good supporting evidence, the dogma still exists that patients with renal insufficiency are not good candidates for continent diversions. In this paper, we attempt to evaluate this relationship and investigate the short-term effects of continent and noncontinent diversions on patients with both normal renal function and preexisting renal insufficiency.

Methods: From Sept 2004 to June 2009, 212 adult patients underwent radical cystectomy and intestinal urinary diversion by a single surgeon (SD). Forty-four were excluded secondary to inadequate follow-up (41) or other factors leading to renal compromise (3). Continent diversions were performed either with a Studer orthotopic ileal neobladder (ONB) or a catheterizable stoma with right colon pouch. Evaluation of renal function included pre- and postoperative serum creatinine, bicarbonate, and estimated glomerular filtration rate (eGFR) using the National Kidney Foundation (MDRD) equation. A multivariable linear regression model was used to assess the influence of different urinary diversions on the change in renal function.

Results: Median follow-up for the 168 patients was 18.7 months (3 to 60 months). Forty-four patients underwent ileal conduit and 124 underwent continent diversion (109 ONBs; 15 continent cutaneous diversions). The mean preoperative eGFR between the conduit and continent groups was 63.8 and 73.3, respectively (P < 0.001). The mean decrease in eGFR between the 2 groups was -4.1 and -10.3, respectively (P = 0.41). In patients with preexisting renal insufficiency, the mean change in eGFR was 1.7 and -0.49, respectively (P = 0.49).

Conclusions: The mean change in eGFR, creatinine, and bicarbonate levels following urinary diversion with either conduit or continent diversions were not statistically different in patients with normal or preexisting renal insufficiency at short-term follow-up. This data suggests that mild preexisting renal insufficiency may not be a contraindication to continent diversion. 

Brian Winters, Jie Cai, Siamak Daneshmand

Submitted January 21, 2013 - Accepted for Publication February 19, 2013

KEYWORDS: Ileal conduit, orthotopic neobladder, renal function, urinary diversion

CORRESPONDENCE: Siamak Daneshmand, MD, Institute of Urology, USC/Norris Comprehensive Cancer Center, 1441 Eastlake Ave, Suite 7416, Los Angeles, CA 90089, United States ()

CITATION: UroToday Int J. 2013 April;6(2):art 20. http://dx.doi.org/10.3834/uij.1944-5784.2013.04.07

ABSTRACT

Complete transection of the female urethra without associated pelvic fracture is a very rare presentation. We report a case of isolated rupture of the distal female urethra causing complete transection due to a bull horn injury for the first time in the literature. A 42-year-old woman presented to the Emergency Department immediately following a bull horn injury with complaints of severe bleeding via her vaginum and lower abdominal pain. A detailed examination revealed full laceration of the anterior vaginal wall with complete transection of the urethra 1 cm proximal to the external meatus with no signs of pelvic trauma on imaging. A primary repair was completed in layers with an excellent outcome, and there was no long-term morbidity during her 1-year follow-up. Female urethral injuries may be difficult to identify but early detection and primary repair provide the best chances of a cure. End-to-end repair is the gold standard for management in such cases.

Raman Tanwar, Santosh Kumar Singh, Devendra Singh Pawar

Submitted January 16, 2013 - Accepted for Publication January 30, 2013

KEYWORDS: Isolated urethral injury, female urethral injury, bull horn injury, complete urethral transection

CORRESPONDENCE: Raman Tanwar, MS, FMAS, Department of Urology, Pt BD Sharma PGIMS, Rohtak, 1013, Sector 15, Part 2, Gurgaon, Haryana, India ()

CITATION: UroToday Int J. 2013 April;6(2):art 19. http://dx.doi.org/10.3834/uij.1944-5784.2013.04.06

ABSTRACT

Introduction: Urodynamic findings in patients with post-prostatectomy incontinence (PPI) following either an open radial retropubic prostatectomy or a robotic-assisted laparoscopic prostatectomy are not well described.

Methods: After IRB approval, we performed a retrospective review of urodynamic findings in patients presenting to our institution with PPI following either an open or robotic prostatectomy from 1985 through 2009.

Results: One hundred and twenty-six patients were identified for analysis (74 robotic, 52 open). Intrinsic sphincter deficiency was the cause of PPI in the majority of patients in both groups. Detrusor pressure at peak flow was significantly higher, and peak flow rate was significantly lower in patients who had undergone an open procedure. Anastomotic stenosis (AS) was also higher following an open procedure. Detrusor over- and underactivity were similar between the groups.

Conclusions: Following an open compared to a robotic prostatectomy, patients experienced elevated voiding pressures and decreased peak flows, presumably secondary to the increased incidence of AS observed in those patients.

Katherine Henderson, Jack Matthew Zuckerman, Kurt A McCammon

Submitted January 2, 2013 - Accepted for Publication February 14, 2013

KEYWORDS: Post-prostatectomy incontinence, stress incontinence, urodynamics, bladder neck contracture

CORRESPONDENCE: Dr. Kurt McCammon, Department of Urology, Eastern Virginia Medical School, 225 Clearfield Avenue, Virginia Beach, VA 23462, United States ()

CITATION: UroToday Int J. 2013 April;6(2):art 18. http://dx.doi.org/10.3834/uij.1944-5784.2013.04.05

ABSTRACT

Aim: To compare the clinical efficacy and tolerability of naftopidil versus tamsulosin in patients with LUTS due to BPH. Tamsulosin acts via α1A-receptor and naftopidil acts via α1D-receptor blocker. The latter is believed to be more efficacious with fewer side effects.

Settings and Design: A prospective, randomized, non-placebo clinical study.

Methods and Materials: 110 patients fulfilling our inclusion criteria were randomized (double-blinded) to receive naftopidil (50 mg) or tamsulosin (0.4 mg) once daily for 3 months after obtaining institutional ethical clearance and administering informed consent. The patients were followed for changes in International Prostate Symptom Score (IPSS), Sexual Function Inventory Score (SFIS), peak flow rate (PFR), average flow rate (AFR), post-void residue (PVR), episodes of acute urinary retention (AUR), and side effects, which were recorded and analyzed using appropriate statistical tools.

Statistical Analysis: Recorded data was analyzed using appropriate statistical tools including the unpaired Student t test, Tukey test, and the repeated measure ANOVA test.

Results: Naftopidil and tamsulosin both improved patient symptoms, uroflowmetry, and other parameters. Naftopidil appeared to have an earlier onset of action shown by significant change in values of IPSS (P = 0.003), PVR (0.041), storage subscore (SIPSS) (P = 0.011), and Qol (P = 0.017) at 2 weeks. A higher incidence of postural hypotension, headache, and drug failure were observed with tamsulosin (not statistically significant). SFIS was significantly lower in the tamsulosin group.

Conclusions: The management of symptomatic BPH, with either naftopidil or tamsulosin, appeared to be equally effective, safe, and well tolerated. Naftopidil appeared to have a faster onset of action with fewer side effects versus tamsulosin. All patients appeared to be equally compliant, and there was no treatment withdrawal due to observed side effects with either drug.

Iqbal Singh, Ankit Gupta, Vivek Agrawal, Mohit Joshi

Submitted January 2, 2013 - Accepted for Publication February 14, 2013

KEYWORDS: Tamsulosin, naftopidil, voiding dysfunction, LUTS

CORRESPONDENCE: Iqbal Singh, MCh (Urology), DNB (Genitourinary Surgery), MS, University College of Medical Sciences, the University of Delhi, New Delhi, India ()

CITATION: UroToday Int J. 2013 April;6(2):art 17. http://dx.doi.org/10.3834/uij.1944-5784.2013.04.04

ABSTRACT

Capsular leiomyoma of the kidney is a rare benign tumor. Usually they are very small tumors and do not produce symptoms. We report a case of a huge renal capsular leiomyoma in a pregnant woman, which led to premature delivery of the baby.

Tanveer Iqbal Dar, Abdul Rouf Khawaja, Mohd Sajid Bazaz, Farzana Bashir, Ajay Kumar Sharma

Submitted January 15, 2013 - Accepted for Publication February 4, 2013

KEYWORDS: Leiomyoma, kidney, pregnancy

CORRESPONDENCE: Dr. Tanveer Iqbal Dar, Senior Resident, Sir Ganga Ram Hospital, New Delhi, Delhi, India 1900 60 ()

CITATION: UroToday Int J. 2013 April;6(2):art 16. http://dx.doi.org/10.3834/uij.1944-5784.2013.04.03

ABSTRACT

Introduction: The primary aim of this study was to evaluate the incidence of von Hippel-Lindau (VHL) gene mutations among a group of Kashmiri patients diagnosed with renal cell tumors. Correlation of these mutations was explored with clinical pathological status of the illness.

Methods: PCR-SCCP and DNA sequencing evaluated the DNA samples of both the tumor and adjacent normal tissue for the occurrence of VHL gene mutations. In addition, blood samples were used from all the cases to rule out any germ-line mutation.

Results: Mutations of the VHL gene identified in renal-cell cancer (RCC) patients were 52.5% (21 of 40), including 9 missense, 10 frame shift, and 2 non-sense mutations. Of the mutations, 52.38% were detected in exon 1, 38.1% in exon 2, and 9.52% in exon 3. Nineteen out of 23 (82.6%) cases of the clear-cell type and 2 out of 2 (100%) of angiomyolipomas of RCC were positive for VHL gene mutation. No correlation was found between tumor grade and/or stage and the presence of VHL mutation.

Conclusions: In conclusion, sporadic RCC shows mutations in the VHL gene, which mainly appear in the clear-cell subtype in our patients. Thus alteration in the VHL gene has been implicated in the pathogenesis of renal-cell sporadic cancer of the patients in our population.

Aashaq Hussain Bhat, Arshad Ahmad Pandith, Zafar Amin Shah, Saleem Wani

Submitted January 23, 2013 - Accepted for Publication February 5, 2013

KEYWORDS: Renal cell carcinoma, PCR, sporadic, angiomyolipoma

CORRESPONDENCE: Dr. Mohammad Saleem Wani, Department of Urology, Sher-I-Kashmir Institute of Medical Sciences, Soura, Srinagar, Kashmir ()

CITATION: UroToday Int J. 2013 April;6(2):art 15. http://dx.doi.org/10.3834/uij.1944-5784.2013.04.02

ABSTRACT

Background: Balanitis xerotica obliterans (BXO) is a well-known chronic disease affecting male genitalia. There are several treatment options available for this. This study was performed to establish the efficacy of tacrolimus ointment as a mode of nonsurgical management of early BXO changes.

Introduction: BXO is a chronic, lymphocyte-mediated skin disease causing glandular urethral stricture of unknown origin. Exact incidence of the disease is obscure; there are several surgical and nonsurgical treatment options available. Among the nonsurgical management, the use of tacrolimus (immunomodulator) ointment is being considered.

Methodology: This study was performed at our institution among the patients attending the outpatient department with typical clinical features of BXO during the year 2011. Thirty cases were studied.

Results and Discussion: The majority (63.33%) of cases presented during the third to sixth decade of life. Symptomatic relief occurred in 16 cases (53.33%) treated with tacrolimus ointment. There are several modes of nonsurgical management, including steroid ointment usage, carbon dioxide laser therapy, topical tacrolimus application, etc. Among these therapies, the use of topical tacrolimus has promising results with better symptomatic relief and fewer side effects, as seen in our study.

Anowar Ali Mallick, Tapas Kumar Majhi, Supriya Basu, Dilip Kumar Pal

Submitted November 24, 2012 - Accepted for Publication February 4, 2013

KEYWORDS: Balanitis xerotica obliterans (BXO), topical, tacrolimus, treatment

CORRESPONDENCE: Dilip Kumar Pal, MS, MCh, Vinayak Garden, Flat No. A/3D 41B, Simla Road, Kolkata, India 700006 ()

CITATION: UroToday Int J. 2013 April;6(2):art 14. http://dx.doi.org/10.3834/uij.1944-5784.2013.04.01