Urology

Letter From the Editor

2012-02-01

Beginning with the February issue, articles in the Images in Clinical Urology section will be published online only. This will allow more timely publication of these contributions and allow more room in the print edition for regular articles.

Tissue Engineering and Stem Cell Application of Urethroplasty: From Bench to Bedside

Qiang Fu, Yi-Lin Cao — 2011-10-19

Objective: To review the advances in the basic research and clinical application of tissue engineering and stem cell technology in urethral reconstruction. Urethral defects resulting from congenital malformations, trauma, inflammation, or cancer are a common urologic issue. Traditional urethral reconstruction is associated with various complications. Tissue engineering and stem cell technology hold novel therapeutic promise for urethral reconstruction. Methods: One of us searched the PubMed database (January 1999 to January 2011) using the English search terms “tissue engineering,” “stem cells,” “urethral reconstruction,” and “urethra.” A total of 86 reports were retrieved. After the repetitive and irrelevant reports were excluded, 40 were included in the final analysis. The review outlined and evaluated the advances in basic research and clinical application and the current status and prospects of tissue engineering and stem cell technology in urinary reconstruction. Results: Two therapeutic strategies are available for urethral reconstruction using tissue engineering: the acellular matrix bioscaffold model and the cell-seeded bioscaffold model. The acellular matrix bioscaffold model has been successfully used in the clinic and the cell-seeded bioscaffold model is making its transition from bench to bedside. Conclusion: Stem cells can provide the seed cells for urologic tissue engineering, but much basic research is still needed before their clinical use is possible.

We Need a Better Marker for Prostate Cancer. How About Renaming PSA?

Andrew J. Vickers, Hans Lilja — 2011-12-23

No doubt about it, we need something better than prostate-specific antigen (PSA). At least, that's what folks seem to be saying. Here's John Davis, urologist at MD Anderson: “we need a better marker of prostate cancer risk than PSA.” Or Ed Yong, head of health evidence and information at Cancer Research UK: “better ways of detecting aggressive prostate cancer” are needed. This view seems to shared by everyone in prostate cancer research, from the most well-known names (Gerry Andriole: “early detection of prostate cancer relies on finding more specific biomarkers”) to those whose work awaits wider recognition (Ekkehard Schütz: “We definitely need something better than PSA”).

A 37-Year-old Man With a History of Bladder Augmentation Presented With Gross Hematuria, Weight Loss and Flank Pain

Barbara Rubino, Ryan Dorin, Kaveh Naemi, Eila C. Skinner — 2011-10-17

The patient was a 37-year-old man with a history of severe bilateral vesicoureteral reflux who had undergone multiple bladder surgeries in Mexico throughout childhood, including colocystoplasty, followed by ileocystoplasty with ileal ureteral reimplantation. His kidneys ultimately failed, and he required dialysis. He was first seen at our hospital in 2006 for evaluation of recurrent pyelonephritis. He reported passing mucus in the urine and had stopped performing self-catheterization since beginning dialysis. He had febrile infections 2 or 3 times annually and was interested in kidney transplantation. He had no other significant medical history and no family history of genitourinary malignancy and denied past or current tobacco use.

High Classification of Chronic Heart Failure Increases Risk of Overactive Bladder Syndrome and Lower Urinary Tract Symptoms

2011-12-01

Objective: To assess the urologic symptoms among patients with chronic heart failure (CHF) and to explore whether a higher classification of CHF increases the risk associated with overactive bladder syndrome (OAB) and lower urinary tract symptoms. Methods: A total of 214 ambulatory patients with CHF (129 men and 85 women) and 378 age-matched subjects (222 men and 156 women) were enrolled in the present study. The urologic symptoms were evaluated using the Overactive Bladder Symptom Score (OABSS) and International Prostate Symptom Score (IPSS) from January to June 2010. Results: Compared with the controls, the patients with CHF had a significantly greater mean OABSS (4.6 ± 3.6 vs 3.4 ± 3.1, P < .001), total IPSS (8.3 ± 6.9 vs 6.9 ± 7.6, P = .021), and storage IPSS (4.8 ± 3.5 vs 3.7 ± 3.3, P < .001). Of the patients with CHF, 34.1% had moderate/severe OAB symptoms (OABSS ≥6), and 43.5% had moderate/severe lower urinary tract symptoms (IPSS ≥8). Compared with patients who had New York Heart Association (NYHA) class I CHF, the patients with NYHA class III CHF had a significantly greater OABSS and total, storage, and voiding IPSSs. Patients with NYHA class II CHF did not. A greater body mass index and stroke were significantly associated with the OABSS and storage IPSS, and pulmonary disease was significantly associated with the voiding IPSS. Conclusion: The patients with CHF had more storage urinary symptoms suggestive of OAB than did the age-matched controls. Among the patients with CHF, greater NYHA class heart function was significantly associated with OAB and lower urinary tract symptoms.

The Impact of Obesity on Urinary Tract Infection Risk

2011-11-30

Objective: To perform a study to describe the way in which an increasingly obese body mass index (BMI) is associated with urinary tract infection (UTI). The association between UTI and obesity is not well characterized. In fact, previous investigations of this subject have yielded conflicting findings. UTI is increasingly being recognized as a preventable complication, and UTI rates are used to measure quality of surgical care. Materials and Methods: We evaluated claims over a 5-year period (2002-2006) in a national private claims database to identify patients diagnosed with UTI or pyelonephritis by ICD-9 coding. Descriptive analyses were performed and odds ratios were calculated. Results: A total of 95,598 subjects were identified for evaluation. Gender distribution was 42.9% male and 57.1% female. In the overall study cohort, the diagnosis of a UTI or pyelonephritis occurred in 13% and 0.84%, respectively. Women were 4.2 times more likely to be diagnosed with a UTI (19.3% vs 4.6%), and 3.6 times more likely to be diagnosed with pyelonephritis (1.22% vs 0.34%), than were men. At all stratifications of obesity, the obese were significantly more likely to be diagnosed with a UTI or pyelonephritis than nonobese patients. Conclusion: Elevated BMI appears to be associated with an increased risk for UTI and pyelonephritis. Further study is needed to determine whether this association may be attributed to a cause-and-effect relationship. However, these results may serve to guide clinicians who treat obese patients, because it may be an additional benefit of weight loss.

Multidetector Computed Tomography Virtual Cystoscopy: An Effective Diagnostic Tool in Patients With Hematuria

2012-02-01

Objective: To evaluate the efficacy and the potential use of multidetector computed tomography virtual cystoscopy (MDCT-VC) in patients with gross hematuria. Methods: A total of 32 patients underwent MDCT-VC, cystoscopy, and a cytologic examination. The slice thickness of MDCT was 1 mm. Bladder distension was done with room air. The data were converted into 3-dimensional virtual reconstructive models. The data sets were reviewed independently by 2 experienced radiologists. Tumors confined to the mucosa, infiltrating the muscularis, and transmural tumors were distinguished. Results: VC showed a sensitivity and specificity of 100%. The radiologic accuracy regarding T stage correlated in 87.5%. MDCT-VC identified 21 bladder lesions suspicious for bladder cancer in 18 patients. The histologic results showed 22 patients with bladder lesions, 18 were diagnosed with transitional cell carcinoma of the bladder, 3 had bladder endometriosis, and 1 had an infiltrating colon cancer. Four patients had concomitant carcinoma in situ lesions, which were not seen completely with MDCT-VC. However, cytology was positive in those cases. Ten patients did not have any tumor signs on VC and the subsequent conventional cystoscopy did not bring any change to the initial tumor-free diagnosis of VC. Conclusion: MDCT-VC combined with urine cytology is a good alternative to conventional cystoscopy for patients with painless gross hematuria. It should be used as a decision-making aid to identify patients who will benefit from additional cystoscopic examination. Future developments should focus on the visibility of sessile and carcinoma in situ lesions.

Nephrolithiasis in Medullary Sponge Kidney: Evaluation of Clinical and Metabolic Features

2011-10-19

Objective: Medullary sponge kidney (MSK) is a disorder characterized by tubular dilation of renal collecting ducts and cystic dilation of medullary pyramids that has been associated with stone disease. The significance of nephrolithiasis and the mechanisms by which it occurs are incompletely understood. We describe clinical and metabolic features of nephrolithiasis in a cohort of patients with MSK. Methods: Records were reviewed of 56 patients, all with radiographic diagnosis of medullary sponge kidney and data collected pertaining to presentation, stone events and recurrences, stone composition, and metabolic profile to perform a descriptive study with median 3.7 years follow-up. Results: Nephrolithiasis was confirmed radiographically in 39/56 patients (69.6%). No patient without evidence of nephrolithiasis developed a stone event, whereas 13/39 (33%) of those with nephrolithiasis developed a recurrent stone event. Stones were composed of calcium oxalate monohydrate, calcium oxalate dihydrate, calcium phosphate apatite, and uric acid. Metabolic profile was obtained for 26 of 39 (67%) stone-forming patients demonstrating abnormalities in 22/26 (84.6%). These included hypercalciuria, 58% (15/26); low urine volume, 35% (9/26); hyperuricosuria, 27% (7/26); hypocitraturia, 19% (5/26); elevated urine sodium, 15% (4/26); and hyperoxaluria, 12% (3/26). Conclusion: Many patients with MSK have no evidence of nephrolithiasis. Among those who do, recurrence is common, and metabolic profile and composition are varied as in the general stone-forming population.

Omega-3 Fatty Acids Eicosapentaenoic Acid and Docosahexaenoic Acid in the Management of Hypercalciuric Stone Formers

2011-10-14

Objective: To investigate the use of fish oil in the dietary management of hypercalciuric stone formers. Prostaglandins have been linked to urinary calcium excretion, suggesting a role for omega-3 fatty acids in the treatment of hypercalciuric urolithiasis. Methods: We retrospectively studied a cohort of patients treated at our stone clinics from July 2007 to February 2009. Patients' urinary risk factors for stone disease were evaluated with pre- and post-intervention 24-hour urine collections. All patients received empiric dietary recommendations for intake of fluids, sodium, protein, and citric juices. All subjects with hypercalciuria (urinary calcium >250 mg/d for males or >200 mg/d for females) on at least two 24-hour urine collections were counseled to supplement their diet with fish oil (1200 mg/d). Results: Twenty-nine patients were followed for 9.86 ± 8.96 months. The mean age was 43.38 ± 13.78 years. Urinary calcium levels decreased in 52% of patients, with 24% converting to normocalciuria. The average urinary calcium (mg/d) decreased significantly from baseline (329.27 ± 96.23 to 247.47 ± 84.53, P <.0001). Urinary oxalate excretion decreased in 34% of patients. The average urinary oxalate (mg/d) decreased significantly from baseline (45.40 ± 9.90 to 32.9 ± 8.21, P = .0004). Urinary citrate (mg/d) increased in 62% of subjects from baseline (731.67 ± 279.09 to 940.22 ± 437.54, P = .0005). Calcium oxalate supersaturation decreased in 38% of the subjects significantly from baseline (9.73 ± 4.48 to 3.68 ± 1.76, P = .001). Conclusion: Omega-3 fatty acids combined with empiric dietary counseling results in a measurable decrease in urinary calcium and oxalate excretion and an increase in urinary citrate in hypercalciuric stone formers.

Simultaneous Antegrade/Retrograde Upper Urinary Tract Access: Bart's Modified Lateral Position for Complex Upper Tract Endourologic Pathologic Features

2011-10-14

Objective: To determine whether the Bart's modified lateral position is safe and effective for achieving simultaneous anterograde and retrograde access in complex upper urinary tract pathologic features. Methods: From November 2006 to September 2010, 45 procedures were performed, with the patients in the modified lateral position. The indication for these procedures was the presence of complex unilateral upper urinary tract pathologic features. The patients with muscular and/or skeletal abnormalities were excluded. All procedures were performed using simultaneous anterograde and retrograde access with the patient under general anesthesia. Results: The preoperative investigation protocol included assessment of the stone burden and location using enhanced abdominal computed tomography. The patients were routinely examined 6 weeks after the procedure with a combination of plain abdominal radiography and renal ultrasonography. For patients treated for conditions causing upper urinary tract obstruction (pelviureteral junction obstruction and/or ureteral strictures), a mercaptoacetyltriglycine renography was performed at 4, 12, and 24 months postoperatively. The mean patient age was 51.2 years (range 17-79). Stone clearance was achieved by a single combined procedure in 36 patients (80%). Successful recanalization was achieved in all patients with pelviureteral junction obstruction and ureteral strictures. In 4 patients (8.8%), persistent hematuria was noted, and 2 patients (4.4%) developed postoperative urinary sepsis and were treated conservatively. Conclusion: Modification to the lateral position compares equally with contemporary percutaneous nephrolithotomy series. It provides wide exposure of the flank, allowing the choice of multiple access sites, enhanced control, and a wide angle for handling of the antegrade instruments. Two surgeons can work simultaneously, addressing complex endourologic pathologic features in high-risk patients.

High- vs Low-power Holmium Laser Lithotripsy: A Prospective, Randomized Study in Patients Undergoing Multitract Minipercutaneous Nephrolithotomy

2011-10-17

Objective: To determine the efficacy and safety of high-power holmium: yttrium aluminum-garnet (Ho:YAG) laser lithotripsy for multitract modified minimally invasive percutaneous nephrolithotomy (MPCNL) in the treatment of patients with large staghorn renal calculi. Methods: A randomized, prospective study was conducted. Two-hundred seventy-three consecutive patients (291 renal units) with large staghorn renal calculi were randomized to undergo multitract MPCNL with 30-W low-power or 70-W high-power Ho:YAG laser lithotripsy. Both groups were compared in terms of perioperative findings and postoperative outcomes, including procedure time, stone-free rate, length of hospital stay, transfusion rates, renal function recovery, and other complications. Results: The average patient age was 49.2 years (range 22-73) and mean stone size was 5.54 ± 0.7 cm. The 2 groups had some comparable perioperative findings and outcome, including tracts required per operated renal unit (n), blood loss, postoperative fever, postoperative hospital stay, stone-free rate, and improvement of operated renal function. The operation time in the high-power group was significantly shorter than that in the low-power group (129.20 ± 17.2 vs 105.18 ± 14.2, P <.01). Conclusion: A combination of multitract MPCNL and high-power Ho:YAG laser lithotripsy can greatly decrease the operative time without increasing the intraoperative complications or delaying postoperative renal function recovery when compared with low-power Ho:YAG laser lithotripsy.

Shock Wave Lithotripsy and Diabetes Mellitus: A Population-based Cohort Study

2011-11-16

Objective: To determine if shock wave lithotripsy (SWL) is associated with diabetes mellitus (DM) in a community setting. The pancreas is vulnerable to injury at SWL as evidenced by case studies; thus, concern exists for the development of DM after SWL. Methods: The Rochester Epidemiologic Project was used to identify all Olmsted County, Minnesota residents diagnosed with urolithiasis from 1985 to 2008. New-onset DM was identified by diagnostic codes and treatment with SWL by surgical codes. Cox proportional hazards models were used to determine the risk of DM after SWL therapy. Results: A total of 5287 incident cases of stone formation without pre-existing DM and with ≥3 months of follow-up. After an average follow-up of 8.7 years, 423 patients (8%) were treated with SWL and new-onset DM had developed in 743 (12%). The diagnosis of DM followed SWL in 77 patients. However, no association was evident between SWL and the development of DM before (hazard ratio 0.98, 95% confidence interval 0.76-1.26) or after (hazard ratio 0.92, 95% confidence interval 0.71-1.18) SWL, controlling for age, sex, and obesity. Conclusion: In the present large, population-based cohort, the long-term risk of developing DM was not increased in persons who underwent SWL to treat their kidney stones.

Editorial Comment

Mitchell R. Humphreys — 2012-02-01

This is an important population-based study that attempts to further examine questions about shock wave lithotripsy (SWL)-associated injury. Presumably, this is the same group that reported in 2006 an increased risk of hypertension and diabetes mellitus (DM) in patients with 19 years of follow-up. Although this study showed a positive correlation between the number of shocks and treatment intensity with the subsequent risk of DM, it has been criticized for its methodology. Namely, that it was a retrospective study that relied on patient self-reporting for those who were treated with SWL (by survey) and chart review for a nonsurgically treated control population. Sato et al in 2008 followed up with their own study, also using the HM-3 lithotriptor, showing no increased risk of hypertension or DM an average of 17 years after SWL treatment between patients with renal stones and those with ureteral stones. Concerns about that study include the reduced number of shock waves applied (approximately 900 vs ≥2500 in other studies) and the possible overlap in energy patterns and focal zones of proximal ureteral compared with renal-treated stones. In a 6-year intermediate follow-up study using a mail-in survey of patients treated with a Medstone-STS electrohydaulic lithotripter also failed to show a correlation between SWL and the onset of DM. The authors used a matched National Health and Nutrition Examination Survey database as their control group. In another study by Krambeck et al of the outcomes of percutaneous nephrolithotomy compared with SWL and conservative management after 19 years, they did not demonstrate an increased risk of DM in the SWL group. As one might expect, the stone recurrence rate was significantly less in the percutaneous nephrolithotomy group than in the SWL group.

Reply

Amy E. Krambeck — 2012-02-01

We agree with the editorial views expressed. As outlined in the American Urologic Association White Paper “Current Perspectives on the Adverse Effects in Shock Wave Lithotripsy” (2009) (available from: http://www.auanet.org), shock wave lithotripsy is capable of producing acute injury in the animal model and in humans. The goal of our present study was to assess the long-term effect of such a treatment on the health of a well-defined population. Our results indicate that despite the potential acute risks associated with shock wave lithotripsy, there does not appear to be a long-term effect on hypertension in the community setting. Regardless of these promising long-term results, we strongly encourage physicians to use shock wave lithotripsy appropriately and to take measures to limit acute damage, as outlined by Dr. Humphreys in his editorial comment, including decreasing the shock wave rate, intensity, and number of shocks delivered. To date, no single treatment for urolithiasis has been proved safe and effective enough to use as a “one size fits all” approach. Thus, we must approach each patient individually and determine which surgical intervention is appropriate according to the stone size, location, and composition and concurrent medical comorbidities.

Silent Ureteral Stones: Impact on Kidney Function—Can Treatment of Silent Ureteral Stones Preserve Kidney Function?

2011-11-07

Objective: To report our experience with silent ureteral stones and expose their true influence on renal function. Methods: We analyzed 506 patients who had undergone ureterolithotripsy from January 2005 to May 2010. Silent ureteral stones were calculi found in the absence of any specific or subjective ureteral stone-related symptoms. Of the 506 patients, 27 (5.3%) met these criteria (global cohort). All patients were assessed postoperatively with dimercaptosuccinic acid scintigraphy (DMSA). A difference in relative kidney function of >10% was considered abnormal. Pre- and postoperative comparative DMSA analyses were electively obtained for 9 patients (kidney function cohort). A t test was used to assess the numeric variables, and the chi-square test or Fisher's exact test was used for categorical variables. Two-tailed P < .05 was considered statistically significant. Results: Stones were diagnosed by radiologic abdominal evaluation for nonurologic diseases in 40% and after previous nephrolithiasis treatment in 33%. The primary therapy was ureterolithotripsy in 88%. The mean follow-up time was 23 months. The overall ureteral stone-free rate after 1 and 2 procedures was 96% and 100%, respectively. In the global cohort, the mean pre- and postoperative serum creatinine levels were similar (P = .39), and the mean postoperative function on DMSA was 31%. In the kidney function cohort, no difference was found between the pre- and postoperative DMSA findings (22% ± 12.1% vs 20% ± 11.8%; P = .83) and serum creatinine (0.8 ± 0.13 mg/dL vs 1.0 ± 0.21 mg/dL; P = .45). Conclusion: Silent ureteral stones are associated with decreased kidney function present at the diagnosis. Hydronephrosis tends to diminish after stone removal, and kidney function remains unaltered.

Editorial Comment

Vincent G. Bird — 2012-02-01

Loss of renal function and possible long-term progression to end-stage renal disease is often a concern when addressing issues with upper urinary tract pathologies. This is of great importance in that loss of renal function, which may result in end-stage renal disease, is associated with significantly decreased quality of life, higher morbidity/mortality, and higher health care costs. This issue has received great attention in relation to renal preservation in the treatment of renal masses that are often found to be renal cell carcinoma. Concern is not limited to immediate procedure-related renal functional loss, but also with the resultant renal insufficiency, and what may then ensue for a patient in the future when new disease states and life-altering events manifest. Studies suggest that patients with urinary lithiasis are at a higher risk for development of chronic kidney disease. Further, among stone formers, cases of chronic kidney disease are more likely in those with a history of diabetes mellitus, hypertension, and urinary tract infection. Fortunately, there have been advances in imaging and treatment of urinary lithiasis. United States Renal Data System 2001-2005 results indicated that for patients starting dialysis during that time, 0.2% had kidney stones identified as the cause of end-stage renal disease. It remains unclear to what extent urinary stone disease may be a cofactor in patients where other primary causes were identified. Urinary lithiasis is a highly treatable condition in which timely intervention can very often successfully mitigate against negative consequences.

Reply

Giovanni Scala Marchini — 2012-02-01

Urinary stone prevalence is gradually increasing worldwide and asymptomatic stone disease can become a therapeutic challenge. Nephrolithiasis itself is not a life-threatening disease and severe cases are almost always related to symptoms. Conversely, our study proves silent stones to be potentially harmful to the kidney, translated as reduced ipsilateral renal function already at time of diagnosis. Although mainly retrospective, we could analyze in a prospective manner 9 patients of our cohort with comparative pre- and postoperative dimercaptosuccinic acid (DMSA) scan. Proper treatment with stone removal and adequate kidney drainage reduced hydronephrosis and stabilized renal function at DMSA, most likely preventing further renal damage. We agree there could be a selection bias because all of our patients were referred to a specialist and all had hydronephrosis. Also, our institution gives assistance to a particular low socioeconomic population and such individuals tend to underestimate the disease burden.

Modified Transurethral Incision for Primary Bladder Neck Obstruction in Women: A Method to Improve Voiding Function Without Urinary Incontinence

Xun-bo Jin, Hua-wei Qu, Hui Liu, Bo Li, Jin Wang, Yang-de Zhang — 2012-02-01

Objective: To describe the modified surgical technique and report the long-term outcomes of modified transurethral incision for the treatment of primary bladder neck obstruction in women. Methods: A total of 30 women were diagnosed with primary bladder neck obstruction from the videourodynamic study findings according to the Blaivas-Groutz nomogram for female bladder outlet obstruction. Patients with neurogenic, traumatic, anatomic, or iatrogenic causes of obstruction were excluded. The transurethral incision of the bladder neck was performed in all patients, with the modification of incising at 4 different sites on the bladder neck, at the 3-, 6-, 9-, and 12-o'clock positions. The urodynamic results and clinical improvement in voiding symptoms were assessed before surgery and 3, 48, and 60 months after treatment. Results: Follow-up data were available for 30 (100%), 28 (93%), and 25 (83%) of the 30 patients at 3, 48, and 60 months postoperatively, respectively. During the 5-year follow-up, the mean International Prostate Symptom Score decreased from 23.3 to 5.9. The mean quality of life scores decreased from 4.4 to 2.1. The mean peak urinary flow rate increased from 7.61 to 17.53 mL/s. The mean postvoid residual urine volume decreased from 185.11 to 28.75 mL. The mean voiding detrusor pressure decreased from 62.12 to 21.92 cm H2O. All 25 patients had improvement in both objective and subjective voiding functions 5 years after this modified treatment. Only 1 woman (3%) had mild stress incontinence postoperatively and was cured after the patient performed levator ani exercises. Conclusion: The modified transurethral bladder neck incision is effective in the long term in relieving voiding difficulties owing to primary bladder neck obstruction in women without urinary incontinence.

Monitoring Validated Quality of Life Outcomes After Prostatectomy: Initial Description of Novel Online Questionnaire

2011-12-01

Objectives: To describe a novel, low-cost, online health-related quality of life (HRQOL) survey that allows for automated follow-up and convenient access for patients in geographically diverse locations. Clinicians and investigators have been encouraged to use validated HRQOL instruments when reporting outcomes after radical prostatectomy. Methods: The institutional review board approved our protocol and the use of a secure web site (http://www.SurveyMonkey.com) to send patients a collection of validated postprostatectomy HRQOL instruments by electronic mail. To assess compliance with the electronic mail format, a pilot study of cross-sectional surveys was sent to patients who presented for follow-up after robotic-assisted laparoscopic prostatectomy. The response data were transmitted in secure fashion in compliance with the Health Insurance Portability and Accountability Act. Results: After providing written informed consent, 514 patients who presented for follow-up after robotic-assisted laparoscopic prostatectomy from March 2010 to February 2011 were sent the online survey. A total of 293 patients (57%) responded, with an average age of 60 years and a median interval from surgery of 12 months. Of the respondents, 75% completed the survey within 4 days of receiving the electronic mail, with a median completion time of 15 minutes. The total survey administration costs were limited to the web site's $200 annual fee-for-service. Conclusions: An online survey can be a low-cost, efficient, and confidential modality for assessing validated HRQOL outcomes in patients who undergo treatment of localized prostate cancer. This method could be especially useful for those who cannot return for follow-up because of geographic reasons.

Editorial Comment

Matthew J. Resnick — 2012-02-01

In their novel work, the authors report a pilot study aimed at determining the feasibility of on-line assessment of functional outcomes after robotic assisted laparoscopic prostatectomy. The authors should be applauded for their low-cost, systems-based effort to improve longitudinal data collection after treatment of prostate cancer. In their study, the authors implemented a publicly available third-party on-line survey administration system to administer validated questionnaires to patients at a predefined interval. Of the 514 patients who agreed to participate in the study and provided a valid electronic mail address, 293 (57%) responded to the survey. Careful analysis of the baseline characteristics between the “responders” and “nonresponders” revealed a greater baseline prostate-specific antigen level among the “nonresponders.” Interestingly, no other differences were found in the socioeconomic, clinical, or pathologic features between the 2 groups.

Is Renal Biopsy a Better Predictor of the Outcome of Pyeloplasty in Adult Ureteropelvic Junction Obstruction?

Gajanan S. Bhat, Shivalingiah Maregowda, Sreenivas Jayaram, Sujata Siddappa — 2011-12-14

Objective: To prospectively evaluate per operative renal biopsy as a predictor of outcome of pyeloplasty in cases of unilateral pelviureteric junction obstruction in adults. Materials and Methods: We conducted a prospective study on 24 patients with unilateral UPJ obstruction undergoing pyeloplasty between November 2005 and August 2006 and followed them until December 2010. Intraoperative renal wedge biopsy was obtained in these patients and this was correlated with preoperative DRF on diuretic renogram. Outcome of pyeloplasty was assessed at 1 and 3 years by diuretic renograms and the renal biopsy as a predictive tool was compared with preoperative DRF. Results: Histology suggestive of obstructive damage to kidneys, such as significant glomerulosclerosis, widened Bowman's capsule, interstitial fibrosis, and tubular atrophy on renal biopsy was the highly significant predictor of poor outcome of pyeloplasty with a P value = .001 compared with preoperative DRF. Conclusion: Renal biopsy is better predictor of outcome of pyeloplasty compared with preoperative DRF in UPJ obstruction. In the presence of severe obstructive changes in renal biopsy, recoverability of renal function despite achievement of successful drainage is significantly decreased.

Adoption of Laparoscopic Radical Nephrectomy in the State of Washington

Jonathan D. Harper, E. Sophie Spencer, Michael P. Porter, John L. Gore — 2012-02-01

Objective: To examine state-wide trends in adoption of laparoscopic radical nephrectomy (LRN). Open radical nephrectomy and LRN confer equivalent long-term oncological outcomes, yet LRN usage has not increased analogous to diffusion of laparoscopy in other fields. Material and Methods: From the Washington State Comprehensive Hospital Abstract Reporting System, we identified patients who underwent ORN and LRN from 1998 to 2007. Number of LRNs was examined for each hospital state-wide. Length of stay outcomes were examined, and multivariate models were created to examine characteristics of LRN patients and of patients who received care at high-volume LRN hospitals (HiLap). Results: The proportion of nephrectomies performed laparoscopically increased 27%. In 1998, 7 hospitals (12%) performed ≥1 LRN compared with 36 hospitals (61%) in 2007. Four HiLap hospitals accounted for 61% of the increase in LRN from 1998-2002, and 36% of the increase overall. Women (OR 1.15, 95% CI 1.00-1.33) and healthier patients (OR 1.52, 95% CI 1.28-1.82 for patients with Charlson 0 vs ≥2) were more likely to undergo LRN. Mean length of stay for nephrectomies was shorter at HiLap hospitals (P = .04 for 1998-2002, P <.001 for 2003-2007). Conclusions: Uptake of LRN in Washington state parallels national trends; however, the proportion of LRN is lower than expected. A handful of hospitals account for the majority of the increase in LRN. The quality of nephrectomy care may be better at these centers. Barriers exist that prevent LRN adoption even after a trial case. Dissemination of the processes or personnel associated with use of LRN may increase the proportion of patients undergoing LRN.

Blood Transfusions in Radical Prostatectomy: A Contemporary Population-based Analysis

2012-02-01

Objective: To examine the homologous blood transfusion (HBT), autologous blood transfusion (ABT) and intraoperative blood conservation technique (IOBCT) rates and trends at open (ORP) and minimally invasive radical prostatectomy (MIRP). Methods: The Nationwide Inpatient Sample was queried. Multivariable logistic regression models focused on all three transfusion types. Covariables consisted of procedure specific annual hospital caseload (AHC), year of surgery, age, Charlson Comorbidity Index, and region. Results: Overall, 119,966 patients underwent radical prostatectomy between 1998 and 2007. The HBT, ABT, and IOBCT rates were 6.2%, 6.0%, and 1.2%, respectively. HBT rates ranged from 5.1-5.1% between 1998 and 2007 (P = .49) vs 9.4-2.7% (P < .001) for ABT vs 1.9-0.9% (P = .003) for IOBCT in the same time period, respectively. In multivariable analyses, ORP patients treated at intermediate (odds ratio [OR] 1.48, P = .003) and low (OR 2.73, P < .001) AHC institutions were more likely to receive an HBT than ORP patients treated at high AHC institutions. Conversely, MIRP patients treated at high (OR 0.46, P = .040), intermediate (OR 0.27, P = .001), and low (OR 0.59, P = .015) AHC institutions were less likely to receive an HBT than ORP patients treated at high AHC institutions. Conclusion: Our results indicate that the overall transfusion rate at radical prostatectomy decreased within the last decade because of a substantial decline in ABT use. Moreover, MIRP protects from HBT, even when performed at low AHC Centers.

Editorial Comment

Herbert Lepor — 2012-02-01

The present study is a comprehensive examination of transfusion rates after radical prostatectomy (RP) performed in the US between the years 1998 and 2007. Unlike other reported studies that have analyzed the SEER Medicare linked cohort, which is limited to RP performed in men >65 years of age (Ref 24, 25 in the manuscript), the present study uses the Nationwide Inpatient Sample (NIS) discharge records, which includes 119,966 RPs performed at hospitals within the US unrestricted to an age cohort. The lack of an age restriction in the present study is a major strength that makes the observations and conclusions more reflective of outcomes after RP in the US.

Reply

Jan Schmitges, Maxine Sun, Quoc-Dien Trinh, Pierre I. Karakiewicz — 2012-02-01

We read with great interest the comment, which pertained to our recent report. Since the advent of minimally invasive approach in radical prostatectomy (MIRP) in the context of patients diagnosed with prostate cancer, the comparisons between MIRP and open RP (ORP) are vast, among which is the subject of blood loss. In this regard, 2 principal observations were recorded within our study. First, the overall rates of homologous blood transfusion (HBT), autologous blood transfusion (ABT), and intraoperative blood conservation techniques were persistently lower for MIRP-treated patients compared with ORP, regardless of hospital caseload, even after the adjustment for all other available covariates. By contrast, in the last year of the study period (2007), among patients treated at hospitals with a high caseload of MIRP or ORP, HBT rates were virtually the same for the 2 procedures (3.0 vs 2.8%). As stated in the report, this finding suggests that an adequate HBT rate after an RP performed via the open approach may be expected, provided that skilled and trained personnel are available.

Association Between Obstructive Sleep Apnea and Urinary Calculi: A Population-based Case-control Study

Jiunn-Horng Kang, Joseph J. Keller, Yi-Kuang Chen, Herng-Ching Lin — 2011-10-14

Objective: To hypothesize an association between obstructive sleep apnea (OSA) and urinary calculi (UC) and assess the presence of such an association using a national population-based dataset. Elevated systemic proinflammatory pathways found in OSA patients may be linked to increased cardiovascular risk. Similar pathways have been identified in patients with UC. Materials and Methods: We identified 53,791 patients who had received a new diagnosis of UC between 2003 and 2008 from a dataset based on Taiwan's National Health Insurance program. We randomly selected 161,373 controls and then identified subjects with prior OSA in both groups. Odds ratios (ORs) for prior OSA in UC patients compared with controls were estimated in conditional logistic regression analyses by sex and by age group. Results: Prevalences of prior OSA were 1.2% in all subjects, 1.5% in patients with UC, and 1.1% in controls. After adjusting for patients' monthly income, geographic location, urbanization level, hypertension, diabetes, coronary heart disease and hyperlipidemia, and obesity, the OR for prior OSA in UC patients was 1.38 (95% CI 1.30-1.49) compared with controls. Prior OSA was associated with UC both in both males (OR 1.30, 95% CI 1.18-1.41) and females (OR 1.45, 95% CI 1.22-1.67). Notably, the adjusted OR was most pronounced in the youngest age group, <35 years (OR 2.57, 95% CI 1.97-3.34). Conclusions: We conclude that patients with UC had a higher prevalence of prior OSA. The OR for prior OSA was most pronounced in the youngest age group.

An Evaluation of the Effects of Long-term Cell Phone Use on the Testes Via Light and Electron Microscope Analysis

2011-12-23

Objective: To investigate whether the low-intensity electromagnetic waves transmitted by cell phones cause histopathological or ultrastructural changes in the testes of rats. Materials and Methods: Wistar-Kyoto male rats were placed into either a control group or a group that was exposed to an electromagnetic field (EMF). Two cell phones with Specific Absorbation Rate values of 1.58 were placed and left off in cages that housed 15 rats included in the control group, and four cell phones were placed and left on in cages that housed 30 rats included in the experimental group. After 3 months, weights, seminiferous tubule diameters, and spermatogenic cell conditions of all testes of the rats were evaluated. One half of each testis was examined also under an electron microscope. Results: No significant differences were observed between the testis weights, seminiferous tubule diameters, and histopathological evaluations between rats that had and had not been exposed to EMF. Electron microscope analysis revealed that the membrana propria thickness and the collagen fiber contents were increased and the capillary veins extended in the experimental group. Common vacuolization in the cytoplasm of the Sertoli cells, growth of electron-dense structures, and existence of large lipid droplets were noted as the remarkable findings of this study. Conclusion: Although the cells that had been exposed to long-term, low-dose EMF did not present any findings that were contrary to the control conditions, the changes observed during ultrastructural examination gave the impression that significant changes may occur if the study period were to be extended. Longer studies are needed to better understand the effects of EMFs on testis tissue.

Robot-assisted Laparoscopic Dismembered Pyeloplasty for Ureteropelvic Junction Obstruction: A Multi-institutional Experience

2011-12-14

Objective: To report a 6-year multi-institutional experience and outcomes with robot-assisted laparoscopic pyeloplasty (RLP) for the repair of ureteropelvic junction obstruction (UPJO). Patients and Methods: Between June 2002 and October 2008, 168 adult patients from 3 institutions underwent RLP for UPJO. A retrospective analysis of prospectively collected data were performed after institutional review board approval. Diagnosis was by intravenous urogram or computed tomography scan and diuretic renogram. All patients underwent RLP through a 4-port laparoscopic technique. Demographic, preoperative, operative, and postoperative endpoints for primary and secondary repair of UPJO were measured. Success was defined as a T½ of <20 minutes on diuretic renogram and symptom resolution. Pain resolution was assessed by subjective patient reports. Results: Of 168 patients, 147 (87.5%) had primary repairs and 21 (12.5%) had secondary repairs. Of the secondary repairs, 57% had a crossing vessel etiology. Mean operative time was 134.9 minutes, estimated blood loss was 49 mL, and length of stay was 1.5 days. Mean follow-up was 39 months. Overall, 97.6% of patients had a successful outcome, with a 6.6% overall complication rate. Conclusions: To our knowledge, this review represents the largest multi-institutional experience of RLP with intermediate-term follow-up. RLP is a safe, efficacious, and viable option for either primary or secondary repair of UPJO with reproducible outcomes, a high success rate, and a low incidence of complications.

Renal Function After Partial Nephrectomy: Effect of Warm Ischemia Relative to Quantity and Quality of Preserved Kidney

2012-02-01

Objective: To evaluate the effects of warm ischemia time (WIT) and quantity and quality of kidney preserved on renal functional recovery after partial nephrectomy (PN). The effect of WIT relative to these other parameters has recently been challenged. Methods: We identified 362 consecutive patients with a solitary kidney who had undergone PN using warm ischemia. Multivariate models with multiple imputations were used to evaluate the associations with acute renal failure and new-onset stage IV chronic kidney disease (CKD). Results: The median WIT was 21 minutes (range 4-55), the median percentage of kidney preserved was 80% (range 25%-98%), and the median preoperative glomerular filtration rate (GFR) was 61 mL/min/1.73 m2 (range 11-133). Postoperative acute renal failure occurred in 70 patients (19%). Of the 226 patients with a preoperative GFR >30 mL/min/1.73 m2, 38 (17%) developed new-onset stage IV CKD during follow-up. On multivariate analysis, the WIT (P = .021), percentage of kidney preserved (P = .009), and preoperative GFR (P < .001) were significantly associated with acute renal failure, and only the percentage of kidney preserved (P < .001) and preoperative GFR (P < .001) were significantly associated with new-onset stage IV CKD during follow-up. Using our previously published cutpoint of 25 minutes, a WIT of >25 minutes remained significantly associated with new-onset stage IV CKD in a multivariate analysis adjusting for the quantity and quality factors (hazard ratio 2.27, P = .049). Conclusion: Our results have validated that the quality and quantity of kidney are the most important determinants of renal function after PN. In addition, we have also demonstrated that the WIT remains an important modifiable feature associated with short- and long-term renal function. The precision of surgery, maximizing the amount of preserved, vascularized parenchyma, should be a focus of study for optimizing the PN procedure.

Body Mass Index Is Associated With Higher Lymph Node Counts During Retroperitoneal Lymph Node Dissection

2011-12-14

Objective: To determine whether body mass index (BMI) is associated with lymph node counts in patients treated with a primary retroperitoneal lymph node dissection (RPLND). Lymph node counts are a proposed measure of quality assurance for numerous malignancies. Investigation of patient factors associated with lymph node counts are lacking. Methods: Using the Memorial Sloan-Kettering Testis Cancer Database, we identified 255 patients treated with a primary RPLND for nonseminomatous germ cell tumors (NSGCT) from 1999–2008. The associations between BMI and node counts were evaluated using linear regression models in univariate and multivariable models adjusting for features reported to predict higher node counts (year of surgery, stage, and surgeon volume). Results: Median BMI (IQR) was 26.1 (23.4–28.7) and median (IQR) total node count was 38 (27–53). Median total node count for patients with a BMI <25, 25 to 29, and ≥30 was 35, 42, and 44 nodes, respectively. In a univariate analysis, higher BMI was significantly associated with higher total node counts (coefficient 0.7 nodes for each 1-U increase in BMI; P = .026). Features associated with higher node count on multivariate analysis included high-volume surgeon (P = .047), pathologic stage (P = .017), more recent year of surgery (P < .001), and higher BMI (P = .009). Conclusion: Our results suggest for the first time that BMI is independently associated with higher lymph node counts during a lymph node dissection. If confirmed by others, these results may be important when using lymph node counts as a surrogate for adequacy of a lymph node dissection.

Retroperitoneal Vascular Surgery for the Treatment of Giant Growing Teratoma Syndrome

2011-12-14

Objective: To evaluate whether an aggressive surgical policy, which included vascular surgery with standard retroperitoneal lymph node dissection (RPLND), would be justified for managing bulky retroperitoneal growing teratoma syndrome (GTS). Methods: Data were collected retrospectively from a series of 12 patients who, from 1992 to 2010, underwent radical RPLND for bulky GTS (retroperitoneal mass ≥10 cm in diameter). For complete resection, vascular procedures and nephrectomy were performed. Results: Median tumor diameter was 100 mm before and 140 mm (range 100-300) after chemotherapy. Two patients underwent iterative RPLND. In addition to RPLND, patients underwent aortic section with aortic anastomosis (n = 6), inferior vena cava resection (n = 3), both the latter and the former (n = 1), and aortic graft with left nephrectomy (n = 2). There were no operative deaths; 3 patients had complications (25%), but none were related to extended procedures. The median hospital stay was 15 days. Median follow up was 59 months (range 10–162). One patient died of metastatic cutaneous melanoma 112 months after RPLND, 10 patients survived and are disease-free, and one patient had a para-aortic recurrence. Conclusion: A 100% complete resection rate, long-term survival, no mortality, and acceptable morbidity were achieved when vascular surgery and left nephrectomy were combined with standard RPLND for bulky GTS.

Editorial Comment

Joel Sheinfeld — 2012-02-01

Completeness of resection of residual retroperitoneal disease is an independent prognostic variable of clinical outcome for patients with nonseminomatous germ cell tumors after chemotherapy. Data from both Memorial Sloan-Kettering Cancer Center and Indiana University have demonstrated an increased burden of therapy and decreased survival for patients who require reoperative retroperitoneal surgery. Donohue et al reported a survival rate of 55% for patients undergoing redo postchemotherapy-retroperitoneal lymph node dissection (PC-RPLND) compared with 84% for those who did not require reoperative RPLND, despite controlling for marker status, pathologic findings, and the need for salvage chemotherapy. Similarly, McKiernan et al reported the Memorial Sloan-Kettering Cancer Center experience and noted that the 5-year disease-specific survival rate for patients undergoing initial PC-RPLND was 90% compared with 56% for patients requiring redo-retroperitoneal surgery.

Reply

Mattia Stella, Michel Rivoire — 2012-02-01

Thank you for the comments on our report that give us an opportunity to further discuss the surgical treatment of growing teratoma syndrome. The risk of postoperative renal insufficiency after adjunctive nephrectomy and retroperitoneal lymph node dissection (RPLND) represents a major concern for patients treated by platinum-based chemotherapy. In our series, 2 patients underwent left nephrectomy; they did not experience platinum-related preoperative impairment of renal function, and they did not develop postoperative renal insufficiency. One patient of our series presented with preoperative renal failure; however, this patient did not belong to the subgroup who had received adjunctive left nephrectomy and renal failure was induced by urinary compression by the retroperitoneal tumor. This patient underwent preoperative endoscopic bilateral ureteral stenting and renal function normalized postoperatively.

Understanding the Role of Percutaneous Biopsy in the Management of Patients With a Small Renal Mass

2012-02-01

Objective: To evaluate patient and tumor characteristics associated with percutaneous renal mass biopsy (RMB) among patients with small renal masses (SRMs) and assessed the impact on clinical decision-making. Materials and Methods: For 204 consecutive patients presenting with a clinical stage T1 renal mass at our institution, we collected data regarding patient demographics, comorbidity, renal function, anatomic factors, and treatment plan. We then assessed the association between these characteristics and receipt of RMB, and between biopsy results and initial treatment decision. Results: Among 204 patients, 78 (38%) received RMB. Of the demographic and physiological parameters, only non-Caucasian race and family history of renal cell carcinoma were associated with biopsy (P < .05). In contrast, RMB was significantly associated with several anatomic factors, including larger tumor size, solitary kidney, juxta-hilar tumor location, greater body mass index (BMI), and high-complexity nephrometry score (P < .05). On multivariable analysis, only BMI >25 kg/m2, juxta-hilar location, and high-complexity nephrometry score remained significantly associated with RMB (P < .05). Biopsy was performed in a greater proportion of patients who ultimately underwent radical nephrectomy vs nephron-sparing surgery (NSS) (P = .04). Furthermore, RMB results directly impacted treatment, with active surveillance more frequent among patients with benign or favorable histology and surgical management more common among patients with more aggressive disease (P < .001). Conclusion: At our institution, one-third of patients presenting with a SRM undergo RMB, most commonly among patients with complicated anatomic and/or tumor considerations. Because these factors may limit the feasibility of NSS, biopsies are being used to guide decision-making aimed at minimizing total kidney loss.

Editorial Comment

Steven C. Campbell — 2012-02-01

This report considers the factors that predict the use of renal mass biopsy (RMB) for patients with clinical Stage T1 renal masses. The population consisted of 204 patients presenting at a single institution with a preference for RMB, and 38% underwent RMB as a part of their evaluation. The authors report that the strongest predictors of RMB were complicated anatomy according to the RENAL classification, juxtahilar location, or solitary kidney. As such, 1 of the main objectives of RMB in this series appeared to differentiate the operative approaches in cases with potentially challenging anatomy. Overall, RMB was performed more often in patients who ultimately underwent radical nephrectomy compared with those who underwent nephron-sparing surgery. In contrast, the number of patients treated with active surveillance was very similar in the group that underwent an RMB versus those who did not.

Reply

2012-02-01

We would like to thank Dr. Campbell for his insightful comments. As mentioned in his editorial comment, the management of small renal masses poses a challenging clinical dilemma. Despite aggressive surgical management, the rate of mortality from kidney cancer continues to rise, suggesting that the margin between appropriate and overtreatment remains narrow. In this regard, optimal care delivery will depend greatly on the thoughtful selection of treatment by each patient and treating urologist.

Changing Patterns (Age, Incidence, and Pathologic Types) of Schistosoma-associated Bladder Cancer in Egypt in the Past Decade

Hosni Khairy Salem, Soheir Mahfouz — 2011-11-23

Objective: To assess the patterns of schistosomiasis-associated bladder cancer in Egypt from 2001 to 2010 in a retrospective study. Bilharzial bladder carcinoma is the most common cancer, particularly in Egyptian men. Classically, carcinoma in a bilharzial bladder is most commonly of the squamous cell type. During the past decade, certain changes have occurred in the features in Schistosomiasis-associated carcinoma in Egypt with a decline in the frequency of squamous cell carcinoma and increase in the frequency of transitional cell carcinoma. Methods: This was a retrospective study of 1932 patients treated at Kasr Al Aini Hospital, Cairo University, from 2001 to 2010. Two groups were selected: group 1 included 1002 patients from 2001 to 2005 and group 2 included 930 patients from 2006 to 2010. Results: The mean patient age increased from 41 ± 11.2 years to 52 ± 8.6 years, and the male/female ratio changed from 5.6:1 to 4.2:1. The incidence of associated bilharziasis decreased from 80% to 50%. A significant increased occurred in transitional cell carcinoma from 20% to 66%, with a significant decrease in squamous cell carcinoma from 73% to 25%. No difference was observed in the tumor stage or grade or incidence of lymph node metastases between the 2 groups. Conclusion: The pattern of incidence of the various histologic types of bladder cancer have changed, with most cases now transitional cell carcinoma, in contrast to the findings in the earlier Egyptian series. Additional studies are encouraged to explain the factors explaining these changes.

Relative Efficacy of Perioperative Gemcitabine and Cisplatin Versus Methotrexate, Vinblastine, Adriamycin, and Cisplatin in the Management of Locally Advanced Urothelial Carcinoma of the Bladder

2011-12-23

Objective: To compare the outcomes of patients treated in the perioperative setting with methotrexate, vinblastine, adriamycin, and cisplatin (MVAC) versus gemcitabine and cisplatin (GC). Systemic cisplatin-based chemotherapy regimens are the mainstay of treatment for patients with advanced bladder cancer. GC has often been used interchangeably with MVAC in neoadjuvant or adjuvant settings for patients with locally advanced (cT2N0M0-cT4N2M0) bladder cancer without adequate evidence. Methods: A total of 114 patients treated with systemic chemotherapy for Stage T2-T4N0-N2M0 urothelial cell carcinoma of the bladder were included in the present study. The survival times were estimated and compared using the Kaplan-Meier method and log-rank test, respectively. Univariate and multivariate Cox proportional hazards models were used to determine the statistical significance. Results: Of the 114 patients included in the present study, 37 (32%) were treated with GC and 77 (68%) with MVAC. In the neoadjuvant group, no difference was found between the 2 chemotherapeutic regimens in terms of the pathologic complete response rate at either cystectomy or during cystoscopy (14 [31%] of 45 MVAC patients vs 4 [25%] of 16 GC patients; P = .645). On multivariate analysis, the choice of regimen was not an independent predictor of cancer-specific death (hazard ratio 1.3, 95% confidence interval 0.67-2.57; P = .421) or overall survival (hazard ratio 1.3, 95% confidence interval 0.76-2.24; P = .330). Conclusion: Despite the lack of data on the relative efficacy of GC versus MVAC in the neoadjuvant and adjuvant settings, these regimens have been used interchangeably. The present investigation did not find the choice of cisplatin-based regimen to be an independent predictor of survival. A trend was seen toward improved survival and a greater complete response rate in the MVAC group.

The Effects of Transrectal Radiofrequency Hyperthermia on Patients With Chronic Prostatitis and the Changes of MDA, NO, SOD, and Zn Levels in Pretreatment and Posttreatment

2011-11-18

Objective: To assess the effect of transrectal radiofrequency hyperthermia (TRFH) in 159 patients with chronic prostatitis (CP) and explore the changes of reactive oxygen species in CP patients pretreatment and posttreatment. Methods: Patients diagnosed with CP were randomized to 6 weeks of tamsulosin plus clarithromycin, TRFH, or TRFH with tamsulosin plus clarithromycin group. The primary outcome measure was evaluated by the National Institutes of Health Chronic Prostatitis Symptom Index. Malondiadehyde (MDA), superoxide dismutase (SOD), and nitrogen monoxide (NO) were measured by biochemical assay. Zinc (Zn) content was assayed by atomical spectrophotography. Results: All 105 patients in the TRFH or TRFH with tamsulosin plus clarithromycin group showed statistically significant improvement of pain, quality of life, and micturition domains compared with the tamsulosin plus clarithromycin group. Regardless of type IIIa or type IIIb CP, there was a significant improvement in the TRFH or TRFH with tamsulosin plus clarithromycin group compared with tamsulosin plus clarithromycin group (P <.05). Compared with pretreatment, MDA, NO, and Zn were decreased in type II and IIIa, whereas SOD was only increased significantly in type II (P <.05). Conclusion: Our study reveals TRFH as an effective therapy option for CP, especially type IIIa or type IIIb CP. The results of TRFH with tamsulosin plus clarithromycin group was superior to the TRFH group or the tamsulosin plus clarithromycin group alone. In comparison with pretreatment, differences in reactive oxygen species levels and Zn in CP patients suggest that these factors could be used as a biomarker to evaluate the symptoms of CP and the effects of treatment.

Bipolar Plasmakinetic Transurethral Resection of Prostate in 132 Consecutive Patients With Large Gland: Three-year Follow-up Results

Guangbin Zhu, Changying Xie, Xinghuan Wang, Xiuquan Tang — 2011-10-31

Objective: To assess the safety, efficacy, and medium-term durability of bipolar plasmakinetic transurethral resection of the prostate (PK-TURP) for the treatment of bladder outlet obstruction due to benign prostatic hyperplasia in a prospective study. Methods: From March 2007 to May 2008, 132 consecutive patients underwent PK-TURP at our institution. All patients were assessed perioperatively and followed up at 1, 3, 6, 12, 18, 24, and 36 months postoperatively. The parameters included the International Prostate Symptom Score, quality of life scores, maximal urinary flow rates, transrectal ultrasonography, postvoid residual urine volume, and serum prostate-specific antigen level. Results: The mean patient age was 64.55 ± 4.03 years. The prostate volume was 79.66 ± 12.36 g. The operative time was 78.83 ± 17.41 minutes, and the resected weight was 58.12 ± 7.29 g. The catheterization time was 69.00 ± 17.99 hours, and the hospital stay was 117.00 ± 17.99 hours. The decrease in hemoglobin and sodium was 1.55 ± 0.48 g/dL and 1.57 ± 0.38 mmol/L, respectively. A significant improvement occurred in the maximal urinary flow rate (22.34 ± 3.1 mL/s), International Prostate Symptom Score (2.90 ± 1.60), and quality of life (1.12 ± 0.60) at the 3-year follow-up compared with baseline (P < .001). Of the 132 patients, 6 (4.5%) required reoperation. Conclusion: PK-TURP represents an effective surgical intervention for the treatment of bladder outlet obstruction for large prostates. Furthermore, the functional results at 3 years demonstrated durability. Therefore, the PK-TURP technique could play an important role in the surgical treatment of patients with symptomatic benign prostatic hyperplasia with a large prostate gland.

Research of Correlation Between the Amount of Leukocyte in EPS and NIH-CPSI: Result From 1242 Men in Fangchenggang Area in Guangxi Province

2011-11-25

Objective: To investigate the correlation between the leukocyte in expressed prostatic secretion (EPS) and National Institutes of Health Chronic Prostatitis Symptom Index (NIH-CPSI) in a large Chinese male population. Materials and Methods: Data were collected from 1242 men who participated in the population-based Fangchenggang Area Male Health and Examination Survey (FAMHES), which was carried out in Guangxi, China from September 2009 to December 2009. The severity and symptoms of chronic prostatitis were accessed by the National Institutes of Health Chronic Prostatitis Symptom Index. Meanwhile, the leukocyte in EPS was counted. Demographic information, lifestyle characteristic, and medical history were also obtained through questionnaire. Results: There was no linear correlation between the leukocyte in EPS and NIH-CPSI scores in all subjects (n = 1242) (P >.05). Regardless of whether subjects had prostatitis-like symptoms (n = 107), there was no linear correlation between the leukocyte in EPS and NIH-CPSI scores (P >.05). After using chi-square tests linear-by-linear association, there were also no linear correlation between the leukocyte in EPS and NIH-CPSI scores (P >.05). Conclusion: The results of this study have demonstrated that either in all subjects or in the subjects with prostatitis-like symptoms, there was no linear correlation between the leukocyte in EPS and the severity symptom. So the amount of leukocyte in EPS was unsuitable to apply as the only index of diagnosis, evaluating and observing curative effect. The index should be taken into account for a variety of factors. The improvement of clinical symptom and quality of life were the key points.

Correlations Among Cardiovascular Risk Factors, Prostate Blood Flow, and Prostate Volume in Patients With Clinical Benign Prostatic Hyperplasia

I-Hung Chen, Yuh-Shyan Tsai, Yat-Ching Tong — 2011-12-01

Objective: To investigate the relationships among the cardiovascular risk factors, prostate blood flow, and prostate volume in patients with clinical benign prostatic hyperplasia (BPH). Methods: A total of 130 patients with the clinical diagnosis of BPH were recruited. The presence of 5 cardiovascular risk factors, including obesity, diabetes, hypertension, hyperlipidemia, and a history of cardiovascular events, was recorded. The urologic evaluation included digital rectal examination, serum prostate-specific antigen, International Prostate Symptom Score, and transrectal ultrasonography. Doppler spectrum analysis was performed with the patient in the right lateral decubitus position to measure the blood flow in the prostate capsular arteries, periurethral arteries, and neurovascular bundles. The correlations were analyzed between the resistive indexes of the prostatic branches and the cardiovascular risk factors, as well as the transrectal ultrasound findings. Results: The resistive indexes of the periurethral arteries and right neurovascular bundles showed positive correlations with the number of cardiovascular risk factors in the patients (r = .228, P = .01 and r = .225, P = .011, respectively). The periurethral artery resistive index also correlated positively with both prostate and transitional zone volumes, with the capsular artery correlating positively only with the latter. No significant correlations were noted between the resistive indexes and the International Prostate Symptom Score. Conclusion: Prostate vascular resistance in patients with BPH has positive correlations with cardiovascular risk factors and prostate size. These findings suggest that prostate hypoxia might play a role in the pathogenesis of BPH.

Delayed Primary Closure of Bladder Exstrophy: Immediate Postoperative Management Leading to Successful Outcomes

2011-12-20

Objective: To present the critical features of our postoperative plan for children undergoing delayed primary bladder closure because appropriate postoperative management is crucial to successful exstrophy repair. Methods: Using an institutionally approved database, patients with bladder exstrophy whose primary bladder closure was performed at least 1 month after birth were identified. All aspects of the postoperative management were reviewed. Results: A total of 20 patients (18 boys) were identified: 19 with classic bladder extrosphy and 1 with an exstrophy variant. The patients underwent closure at a mean age of 9.9 months. All patients underwent pelvic osteotomy and immobilization for an average of 34.8 days. Analgesia was administered by way of a tunneled epidural catheter in 90% of patients for an average of 18.8 days, and 12 patients (60%) required adjunct intravenous analgesia. Bilateral ureteral catheters and suprapubic tubes were used in all patients. Total parenteral nutrition was administered to 10 (83%) of 12 patients who underwent closure after 2000. All patients received preoperative antibiotics and 2 weeks of postoperative intravenous antibiotics that was followed by oral prophylaxis. The mean hospital stay was 6.3 weeks. With an average follow-up of 7.4 years, delayed closure was 100% successful. Conclusion: Successful delayed primary closure of bladder exstrophy requires a multidisciplinary approach. The keys to success include osteotomy, pelvic immobilization, analgesia, nutritional support, maximal bladder drainage, and infection prophylaxis.

Editorial Comment

Moneer K. Hanna — 2012-02-01

The authors reported the results of delayed primary closure for a select group of 20 children born with bladder exstrophy who had small inelastic or polypoidal bladders, with emphasis on their immediate postoperative management. Their multidisciplinary team included highly skilled pediatric urologists, pediatric orthopedic surgeons, and experienced nursing staff. Postoperatively, they treated the children parenteral nutrition, antibiotics, anticholinergics, and pain management. Successful closure was achieved in all 20 cases. These results make a compelling case for referral of difficult cases to centers of excellence. In a previous report in 2001 on 19 children, the authors achieved continence without the necessity for bladder augmentation or replacement in 47% of the cases (reference 6).

Reply

Nima Baradaran, Andrew Stec, John P. Gearhart, Ranjiv Mathews — 2012-02-01

The surgical management of the exstrophied bladder continues to evolve. Identifying the complexities associated with the management of infants with very small bladders that are deemed unsuitable for initial closure was the focus of this paper. At our institution, the focus of closure of the bladder and abdominal wall has always been directed toward achieving the best potential for voided continence. With this in mind, delaying closure to permit the bladder plate to increase in size has been a successful formula for our patients. Although there is potential for the bladder plate that is not well cared for to develop polyps and keratinization, with good parental education and ongoing follow-up, this has not been found to be a significant problem in our patient population. In our experience, immediate closure of the very small bladder template is at greater risk of potential failure and/or upper tract dilation.

Occult Megarectum—A Commonly Unrecognized Cause of Enuresis

Steve J. Hodges, Evelyn Y. Anthony — 2011-12-14

Objective: To determine whether occult megarectum remains a commonly unrecognized cause of enuresis and whether treating it will cure enuresis in most children. A landmark study proved constipation was a commonly unrecognized cause of enuresis in 1986 in which constipation was defined as abnormal rectal distension. However, modern recommendations have focused on signs of functional constipation, such as hard or rare stools. Methods: A retrospective review of 30 consecutive patients seen in our clinic with a chief complaint of nocturnal enuresis was performed, with an analysis of the results of their plain abdominal radiographs. The results of the studies were determined using a novel method termed the rectal/pelvic outlet ratio and Leech criteria. These results were compared with the reported constipation history according to the International Children's Continence Society guidelines, which recommends asking parents and children whether the child's bowel movements occur less often than every other day and whether the stool consistency is hard. Patients diagnosed with megarectum were treated with laxatives, with the goal of restoring normal rectal tone. Results: All patients demonstrated rectal distension according to the rectal/pelvic outlet ratio, and 80% were constipated according to the Leech criteria. Only 10% of the patient or families reported clinical symptoms of constipation. All the adolescent patients in our study and 80% of the younger patients were cured of enuresis with laxative therapy. Conclusion: Occult megarectum remains a commonly undiagnosed cause of nocturnal enuresis. Abdominal radiographs represent a simple, noninvasive method to diagnose megarectum and might improve the treatment of nocturnal enuresis.

Tubularized Incised Plate Repair for Penoscrotal Hypospadias: Role of Surgeon's Experience

Ashraf T. Hafez, Tamer Helmy — 2012-02-01

Objective: To give a retrospective analysis of factors affecting outcome of tubularized incised plate (TIP) repair for penoscrotal hypospadias. Methods: Data of all patients who underwent TIP repair for penoscrotal hypospadias by a single surgeon were retrieved. Follow-up was carried out every 3 months within the first year and annually thereafter. Repairs were divided into 2 groups: Group 1 included surgeries performed in the first 2 years after fellowship training, and group 2 included repairs performed afterward. Chi-square test was used for statistical analysis. Statistical significance was defined as P < .05. Results: Data for 90 patients were retrieved for july 2001 through march 2009: Group 1 included 20 patients and group 2 included 70. The neourethra was covered with spongioplasty in 25 and dartos flap in 65. The overall success rate was 86%. Group 2 patients showed a statistically significant higher success rate of 91% compared with only 65% for group 1. Use of dartos flap was associated with statistically significant higher success (92%) compared with coverage of the neourethra with spongioplasty (68%). In group 1, use of dartos flap was associated with statistically significant better success (82% vs 33%). In group 2 patients, use of dartos flap showed no statistically better success (94% vs 81%). Conclusions: TIP is a valid procedure for repair of penoscrotal hypospadias with chordee <30 degrees. The overall success (86%) is satisfactory. Surgeon's experience is the pillar for better success.

Doxazosin Versus Tizanidine for Treatment of Dysfunctional Voiding in Children: A Prospective Randomized Open-labeled Trial

2011-12-23

Objective: To examine the efficacy and tolerability of tizanidine for the treatment of dysfunctional voiding in children compared with those of doxazosin. Methods: A total of 40 children with dysfunctional voiding were enrolled in a prospective, randomized, 2-parallel group, flexible-dose study. The evaluations were performed in accordance with the International Children's Continence Society guidelines. The children were followed up after 1 week and then monthly for 6 months for the clinical, urine culture, and urodynamic parameters. The degree of improvement was assessed using a satisfaction scale that ranged from 0 (no improvement at all) to 10 (total improvement). Results: A total of 40 patients with a mean ± SD age of 7 ± 2.6 years were enrolled. The clinical and urodynamic parameters were comparable between both groups. At the last follow-up visit, both groups had had similar improvement in the severity of symptoms, satisfaction scale, and noninvasive flowmetry parameters. In the doxazosin group, urge episodes was the only symptom that showed a significant reduction compared with the baseline values (P = .028). However, the incidence of nocturnal enuresis, urgency attacks, and daytime incontinence were significantly reduced compared with baseline in the tizanidine group (P = .003, P = .008, and P = .017, respectively). Adverse effects were recorded in 6 patients (15%). Epigasteric pain was reported in 2 children (10%) who received doxazosin. In the tizanidine group, a loss of appetite was noted in 2 children (10%), epigastric pain in 1 (5%), and headache in 1 (5%). Conclusion: Tizanidine could be a safe and effective treatment of children with dysfunctional voiding due to pelvic floor/skeletal sphincter dysfunction. More placebo-controlled trails with larger sample sizes are needed.

Bladder Leiomyoma in a 6-Year-old Boy

Hui Chen, Zhi Bin Niu, Yi Yang — 2011-08-05

The present report describes a 6-year-old boy with leiomyoma of the bladder and the imaging characteristics of the lesion, including images from ultrasonography, computed tomography, and the histopathologic examination. Leiomyoma of bladder is extremely rare in children. The present case, to our knowledge, represents the second reported case of bladder leiomyoma in pediatric patients since 1966. Although preoperative imaging can be useful to assess the disease extent, the final diagnosis depends on the histopathologic examination findings. Surgical excision is the ideal option to confirm the diagnosis and to treat the disorder. The prognosis is good after complete resection.

Retroperitoneal Lymphatic Malformation in Child With Horseshoe Kidney

Zhi Bin Niu — 2011-09-12

We describe a 12-year-old girl with a retroperitoneal lymphatic malformation (LM) and horseshoe kidney. The imaging characteristics of the lesions are reported. Retroperitoneal LM coexisting with horseshoe kidney is extremely rare. We hypothesized that they might share the similar etiologic factors. Imaging examinations are helpful in the definition of the 2 lesions and the relationship between them, but no characteristic findings are available to diagnose retroperitoneal LM before surgery. Surgical excision is ideal to treat LM, and the prognosis is good. Although asymptomatic horseshoe kidney need not be treated, it is important for patients to receive regular follow-up because of the propensity for various complications.

Benign Testicular Enlargement Due to Diffuse Interstitial Fibrosis Associated With Cryptorchid Testis in 11-Month-old Boy

Matthew E. Sterling, Marina A. Chekmareva, Joseph G. Barone — 2011-09-21

Benign testicular enlargement secondary to diffuse interstitial fibrosis is a rare clinical entity, especially in pediatric patients. To our knowledge, this is the first pediatric case reported of benign testicular enlargement due to interstitial fibrosis in a cryptorchid testis. We report a rare case of an 11-month-old boy with a cryptorchid testis found intraoperatively to have an asymmetrically enlarged testis secondary to diffuse, benign interstitial fibrosis of the testis. Additionally, we discuss previous case reports of testicular enlargement due to interstitial fibrosis, the potential etiology and the management.

Effect of Wound Closure on Buccal Mucosal Graft Harvest Site Morbidity: Results of a Randomized Prospective Trial

Keith Rourke, Shari McKinny, Blair St. Martin — 2011-11-25

Objective: To determine the effect of closure versus nonclosure of the buccal mucosal graft harvest site in men undergoing bulbar urethroplasty in a randomized prospective study. The optimal postoperative management of the buccal mucosal graft donor site remains unknown. Methods: A total of 50 consecutive patients were randomized to either donor site closure or leaving the donor site open. Postoperatively, questionnaires assessing pain, diet, salivation, perioral sensation, and mouth opening were completed daily for the first week and then monthly for 6 months. The primary endpoint was postoperative oral pain. The secondary endpoints were the interval to a regular diet, perioral numbness, changes in salivation, and interval to full mouth opening. Results: Of the 50 patients, 24 and 26 were randomized to the open and closed groups, respectively. The early postoperative pain scores demonstrated a trend favoring the nonclosure group until day 3 (4.1 vs 2.2; P = .07). At 6 months, no difference was found in the pain scores between the 2 groups (0.2 vs 0.3; P = .63). The return to a regular diet also favored the nonclosure group (70.8% vs 19.2% on day 1; P = .01) as did the return to full mouth opening (79.1% vs 15.3% on day 1; P = .001). Nonclosure resulted in less early perioral numbness (62.5% vs 92.3% on day 1; P = .008) and reduced the occurrence of bothersome numbness at 6 months (4.2% vs 23.2%; P = .05). Conclusion: The results of the present randomized prospective trial suggest that leaving the buccal mucosa graft harvest site open leads to lower reported early pain scores, an earlier return to a full diet, an earlier return to full mouth opening, and a decrease in bothersome perioral numbness at 6 months postoperatively.

Editorial Comment

Jeremy B. Myers, William O. Brant — 2012-02-01

The findings reported in the literature are disparate in regard to the morbidity associated with closure vs nonclosure of the buccal mucosal harvest site when buccal mucosa is used in urethroplasty. The types of problems that have been reported with buccal mucosal harvest are pain, salivary changes, difficulty with full opening of the mouth and peri-oral numbness. In the literature, these complications have been categorized into either short or long-term problems.

Reply

Keith Rourke — 2012-02-01

Although the randomized clinical trial represents the ideal method of definitively answering a clinical question, there is a relative paucity of these studies in the urological literature. The use of randomized trials in surgery has been debated, with opposing views focusing on the common limiting factors of time, cost, effort, and planning associated with performing a well-done prospective trial. It has also been argued that the subspecialty of reconstructive urology itself may not be amenable to randomized clinical trials because of variability in disease presentation, complex comorbid patient concerns, and the wide range of surgical techniques intrinsic to the “art” of reconstructive surgery. The literature has clearly demonstrated that retrospective, observational and nonrandomized studies contain excessive bias. Despite differing patient populations and surgical techniques among centers, many aspects of reconstructive urology are in fact amenable to meaningful randomized prospective study. It is these types of studies that can have a profound ability to change surgical practice in urology. Observational study designs remain a critical part of the urological literature, but without meaningful randomized studies it will be difficult to critically assess our surgical techniques. Many surgeons are very hesitant to change their clinical practice based on what is perceived to be “weak” or biased retrospective data. Ultimately, surgical progress will be delayed when inconclusive or inconsistent observational studies obscure accurate clinical outcomes. This current, randomized prospective study of donor site morbidity after buccal mucosal graft harvest has changed the pattern of surgical practice in our center. Before this study, the buccal mucosa donor site was routinely closed. We now leave the donor site open to diminish early postoperative morbidity and reduce the long-term risk of postoperative perioral numbness.

Risk Factors and Quality of Life for Post-prostatectomy Vesicourethral Anastomotic Stenoses

2011-12-23

Objective: To evaluate the difference in vesicourethral anastomotic stenosis (VUAS) rates after open radical retropubic prostatectomy (RRP) vs robot-assisted radical prostatectomy (RARP), and to analyze associated factors and effect on quality of life. Methods: From 2001 to 2009, a total of 1038 patients underwent RARP and 707 patients underwent open RRP. Perioperative factors and Expanded Prostate Cancer Index Composite (EPIC) quality of life scores were compared between patients who did and did not develop a VUAS. Independent significant predictors of VUAS development were identified using multivariable modeling. Results: The incidence of VUAS in open RRP cases was higher (53/707, 7.5%) than for RARP (22/1038, 2.1%) (P < .0001). Intervention consisted of dilation in 34 of 75 cases (45.3%), internal urethrotomy in 8 of 75 (10.7%), and multiple procedures in 30 of 75 (40%). Open technique (P < .0001, odds ratio [OR] = 3.0, 95% confidence interval [CI] = 1.8-5.2), prostate-specific antigen (PSA) recurrence (P = .02, OR = 2.2, 95% CI = 1.2-4.1), postoperative hematuria (P = .02, OR = 3.7, 95% CI = 1.2-11.3), urinary leak (P = .002, OR = 6.0, 95% CI = 1.9-19.2), and urinary retention (P = .004, OR = 3.5, 95% CI = 1.5-8.7) were significant independent predictors of VUAS development. EPIC incontinence scores were similar between VUAS and non-VUAS patients, whereas irritative voiding scores were worse initially with VUAS but became similar by 12 months. Conclusion: There is a higher rate of VUAS after open RRP vs RARP. Most cases of VUAS require endoscopic intervention. Predictors include open surgery, PSA recurrence, and postoperative hematuria, urinary leak, and retention. There is no diminution of quality of life scores at 12 months.

I-Stop TOMS Transobturator Male Sling, a Minimally Invasive Treatment for Post-prostatectomy Incontinence: Continence Improvement and Tolerability

2011-12-20

Objective: To prospectively evaluate the efficacy and tolerability of the I-STOP TOMS transobturator male sling in patients with post-prostatectomy stress urinary incontinence. Minimally invasive techniques, such as slings, are becoming the standard of care for mild to moderate post-prostatectomy incontinence. Methods: From March 2007 to June 2009, 122 patients with post-prostatectomy stress urinary incontinence were treated with the I-STOP TOMS sling and followed up for 1 year in the Phase IV HOMme INContinence trial. The preoperative and postoperative evaluation included daily pad use, pad test, questionnaires evaluating urinary function and bother (University of California, Los Angeles, Prostate Cancer Index – urinary function short form, and International Consultation on Incontinence Modular Questionnaire – urinary incontinence short form) and uroflowmetry, including the post-void residual urine volume. Patient satisfaction and perineal pain were also assessed. Results: A total of 103 patients were followed up for 12 months. The surgical procedure was considered easy to perform. The mean daily pad use decreased significantly from 2.4 to 0.6 at 12 months of follow-up; 87.0% of the patients reported improved continence (59.4% completely dry, 20.3% 1 pad/d, 7.3% >1 pad/d), and 13.0% reported no improvement. All quality-of-life scores (University of California, Los Angeles, Prostate Cancer Index – urinary function short form, and International Consultation on Incontinence Modular Questionnaire – urinary incontinence short form) improved significantly after sling implantation. Treatment satisfaction was >90%. The post-void residual urine volume did not increase substantially, and acute urinary retention did not occur. The perineal pain scores were very low at follow-up. Wound infection was seen in 2 patients at the 1-month follow-up visit. Conclusion: The I-STOP TOMS is a good treatment option for patients with post-prostatectomy stress urinary incontinence. With follow-up ≤12 months, most patients were continent or had improved continence. The intervention was well tolerated, with few infections.

Editorial Comment

Rajveer S. Purohit — 2012-02-01

This prospective study adds another technique to the growing armamentarium for the treatment of mild to moderate postprostatectomy stress incontinence. For severe incontinence, the artificial urinary sphincter remains the gold standard. The risk of erosion and relatively high reoperation rates, and the need for physical manipulation of a pump by elderly patients has increased the popularity of male slings in patients with less severe incontinence.

Reply

Philippe Grise — 2012-02-01

We agree with the comment on the growing number of male slings for the treatment of mild to moderate postprostatectomy incontinence. The I-STOP TOMS technique was first described in 2006 and results of the 2-arms initial device showed a good tolerance and a very low rate of urinary retention. The 4-arms I-STOP TOMS male sling is original. It was specially designed to adjust the tension of the sling precisely on the upper part and the lower part of the sling on the bulbar urethra. It is the only one, to our knowledge, to permit a 4-corner tension on the sling, thus avoiding a flap effect of slings maintained only in the middle part. The favorable benefit risk reported in this series is a critical point when an evaluation of a male sling is considered. Even if most of the complications in the literature are reported during the first year, a clearly needed; therefore, a study is currently ongoing to evaluate persistence of the reported good tolerance. Among the outcome measurements, we agree on the importance of the 24-hour pad test in selection of patients and to better appreciate incomplete results. However, the most relevant parameter regarding quality of life is complete continence, which is achieved in 60% of the patients in this prospective multicenter series.

Extending Anatomic Barriers to Right Laparoscopic Live Donor Nephrectomy

2011-12-14

Objective: To analyze the effects of a right-sided-complex laparoscopic live donor nephrectomy, defined as bifurcation of the right renal artery behind the inferior vena cava. Right-sided laparoscopic live donor nephrectomy is now a widely accepted procedure when complex anatomy is encountered on the left. Technical Considerations: The present retrospective case note review involved 59 of 303 laparoscopic live donor nephrectomy procedures performed in a single center from January 2001 to April 2010 (group 1, simple, n = 48; and group 2, complex, n = 11). The effect of a donor right procedure on warm ischemia, graft function, and donor/recipient complications was analyzed. Results: No difference in donor or recipient age or first and second warm ischemic times was found between the 2 groups. No difference was found in the estimated glomerular filtration rate or serum creatinine at 1 week and 3 and 6 months [estimated glomerular filtration rate (6/12), 49 ± 15 vs 60 ± 9 mL/min, P = .087; and serum creatinine (6 months), 159 ± 116 vs 120 ± 25 μmol/L; P = .356]. No cases of delayed graft function were reported, and none of the grafts developed vascular thrombosis. The cumulative estimated glomerular filtration rate at 6/12 was 51 ± 15 mL/min and the serum creatinine was 153 ± 108 μmol/L. Two patients (4%) required conversion to open surgery in group 1, and the cumulative conversion rate was 3.3%. In the complex group with retrocaval dissection, 8 kidneys were retrieved with a single artery and 3 had multiple vessels (2 with 2 vessels and 1 with 3 vessels; anastomotic time 26 ± 6 minutes). Conclusion: Complex vasculature in a right-sided donation should not be considered a contraindication, because the kidneys procured had excellent function compared with those with single vasculature with no increase in the conversion or vascular thrombosis rate. In addition, the described techniques permit improved arterial length and, importantly, organs procured with a single artery.

A Muscle-sparing Modified Gibson Incision for Hand-assisted Retroperitoneoscopic Nephroureterectomy and Bladder Cuff Excision—An Approach Through a Window Behind the Rectus Abdominis Muscle

Wen-Horng Yang, Chien-Hui Ou — 2011-12-23

Objective: To report our technique using a modified muscle-sparing Gibson incision for hand-assisted retroperitoneoscopic nephroureterectomy (HARN) and open bladder cuff excision. Materials and Methods: Thirty-four patients with upper tract transitional cell carcinoma received HARN and open bladder cuff excision using the modified muscle-sparing Gibson incision—an approach through a window behind the rectus abdominis muscle with the patient in a supine position with the legs extended and abducted at 45-60° with the surgeon standing between the legs of the patient. The window behind the rectus muscle was identified with ease. HARN and open bladder cuff excision were performed uneventfully using this incision. Mean estimated blood loss was 119 mL. Mean operation time was 139 minutes. Morphine was required for pain relief for 1-3 days (mean 16.5 mg). Mean time to oral intake was 1.5 days and to ambulation was 2.1 days. No lower abdominal bulge was found during a 15.4-month follow-up. Conclusion: This modified muscle-sparing Gibson incision for retroperitoneal hand-assisted laparoscopic nephrectomy has the benefit of easier retroperitoneal approach of the Gibson incision. Iliohypogastric nerves can be spared under direct vision. By merely retracting and not incising or splitting the rectus abdominis muscle, this incision may decrease wound-related morbidity. This window could be an important portal for hand-assisted laparoscopic surgeries.

Prevention of Wrong Site Surgery During Upper Tract Endoscopy

2012-02-01

Objective: To evaluate the use of radiopaque stickers during endoscopic surgical cases to prevent wrong side surgery. Methods: We used radiopaque markers before planned endoscopic surgery to ensure correct side surgery. These markers are labeled “R” and “L” and are identifiable during fluoroscopy. Results: These markers were a valuable tool to prevent wrong side endoscopic upper tract procedures. They were also well-accepted by patients at their preoperative surgical verification process. Conclusion: Radiopaque stickers can assist in the prevention of wrong side surgery during upper tract endoscopic procedures.

Modified Surgical Technique for the Management of Renal Cell Carcinoma With Level I or II Tumor Thrombus

2012-02-01

Objective: To describe a modified open surgical technique for the resection of renal cell carcinoma with level I or II tumor thrombus. Method: In our modified technique, the renal artery is ligated early and the tumor thrombus is secured ahead of kidney mobilization by either milking into the renal vein or with extirpation from the inferior vena cava. We retrospectively studied patients who were managed with this technique. Results: Between September 2006 and June 2010, 20 patients with a median age of 65 years underwent surgery for renal cell carcinoma with level I (n = 15) or II (n = 5) tumor thrombus using the modified technique. Median blood loss was 275 mL with 75% of patients requiring at least 1 transfused unit of blood. No case was complicated by an intraoperative tumor embolism. Following surgery, patients stayed a median of 5 days in the hospital and none experienced a perioperative complication. Conclusion: The described surgical technique allows for the safe and effective resection of renal cell carcinoma with level I or II tumor thrombus. This technique enables vascular control of the inferior vena cava with a minimal risk of tumor embolization.

Editorial Comment

Siamak Daneshmand — 2012-02-01

This is an interesting modification of the surgical technique for resection of renal cell carcinoma with level I or II tumor thrombus, wherein the thrombus is managed and removed before kidney mobilization. This comes from a group with extensive experience in this area and provides another surgical perspective on this technically demanding surgical scenario.

Reply

2012-02-01

Intraoperative tumor embolization is a rare complication of radical nephrectomy with tumor thrombectomy of the inferior vena cava. Although rare, this complication does frequently result in the devastating outcome of intraoperative death. Shuch et al reviewed their surgical experience treating 282 patients with renal cell carcinoma and venous invasion. Of these patients, 85 had level I or II tumor thrombus, 3 (3.5%) of which were complicated by intraoperative tumor embolization. All 3 embolic events occurred during kidney mobilization, with 2 (66.7%) resulting in intraoperative death. In that same report, Shuch et al reviewed the combined data of previously reported series of tumor thrombectomy (n = 803). Among those cases complicated by a tumor embolism, 75% resulted in death.

Characterization of Hydrogen Sulfide and Its Synthases, Cystathionine β-Synthase and Cystathionine γ-Lyase, in Human Prostatic Tissue and Cells

Hui Guo, Jun-Wei Gai, Ying Wang, Hong-Fang Jin, Jun-Bao Du, Jie Jin — 2012-02-01

Objective: To investigate hydrogen sulfide and its synthases, cystathionine β-synthase (CBS) and cystathionine γ-lyase (CSE), in human prostatic tissue and cells. Methods: CBS and CSE in human prostatic tissue and cells were located using immunostaining. Western blot and a sulfur-sensitive electrode were used to evaluate the expression levels and catalytic activity of CBS and CSE. We analyzed the association between dihydrotestosterone-added or hormone-reduced medium-induced CBS/CSE protein levels with androgen receptor levels in prostate cancer lines. All experiments were repeated ≥3 times. Results: Endogenous hydrogen sulfide and its synthases existed in various areas of human prostatic tissue and cells. Cell activity and CBS/CSE protein levels were greatest in the androgen-dependent prostate cancer cell LNCaP among all cells and downregulated by dihydrotestosterone. Conclusion: Hydrogen sulfide and its synthases in human prostatic tissue and cells were modulated by dihydrotestosterone, which could suggest a potential therapy for prostatic disease.

Efficacy of Neuroselective and Site-specific Nociceptive Stimuli of Rat Bladder

Yasuhiro Yamada, Osamu Ukimura, Guiming Liu, Tsuneharu Miki, Firouz Daneshgari — 2011-12-01

Objective: To evaluate the organ specificity of sine wave electrical stimulation of the bladder through assessment of the expression of Fos-immunoreactive (IR) cells in rat spinal cord regions. Methods: A total of 37 female Sprague-Dawley rats were divided into 8 groups: sham stimulation; 5, 250, and 2000 Hz stimulation with 1.5- or 2.0-mA intensity; and a group instilled with capsaicin in the bladder. Using a recently developed bladder sensory threshold device, sine wave electrical stimulation was applied for 90 minutes to the rat bladder. The spinal cord was harvested after the rats were killed. The Fos-IR cells in the spinal regions of the medial dorsal horn, lateral dorsal horn, dorsal commissure, and sacral parasympathetic nucleus were measured. The distributions of the Fos-IR neurons were compared. Results: The maximal expression of Fos-IR cells, induced by 250- and 5-Hz stimulation of the bladder, was found at L6 of the spinal cord and was significantly greater than that in the control group (P < .01). Stimulation with 2000 Hz did not induce any Fos-IR cells. Fos-IR neurons were predominantly seen in the sacral parasympathetic nucleus region in response to 250-Hz stimulation and in the dorsal commissure region in response to 5-Hz stimulation. The number of positive neurons was similar to the number caused by capsaicin instillation. Conclusion: Frequency-specific sine wave electrical stimulation of the rat bladder induced the expression of Fos-IR cells in a neuroselective manner. The bladder sensory threshold device could be used for exploration of the pathophysiology of diseases with disturbances of the afferent pathway of the bladder.

Intravesical Chondroitin Sulfate Inhibits Recruitment of Inflammatory Cells in an Acute Acid Damage “Leaky Bladder” Model of Cystitis

2011-12-01

Objective: To investigate whether a physiologic effect of “glycosaminoglycan (GAG) replenishment therapy” altered recruitment of inflammatory cells in an acute bladder damage model. Replacement of the GAG layer with intravesically administered GAGs is an effective therapy for interstitial cystitis in at least some patients. Intravesically administered chondroitin sulfate was previously shown to bind to and restore the impermeability of surface-damaged (“leaky”) urothelium to small ions. Methods: Rat bladders were damaged with 10 mM HCl. Negative control bladders were treated with phosphate-buffered saline. On the following day, the animal bladders were treated with 20 mg/mL chondroitin sulfate in phosphate-buffered saline, and the negative and positive controls were treated with phosphate-buffered saline alone. At 2 and 4 days after treatment with chondroitin sulfate, the rats were killed, and sections of their bladders were analyzed using toluidine blue staining for mast cell immunohistochemical labeling using antibodies against CD45 for lymphocytes and myeloperoxidase for neutrophils. Results: Chondroitin sulfate treatment reduced the recruitment, in a statistically significant manner, of inflammatory cells, including neutrophils and mast cells to the suburothelial space but did not alter recruitment of CD45-positive lymphocytes. Conclusion: For the first time, we have demonstrated that intravesical GAG replenishment therapy also produces a physiologic effect of decreasing recruitment of inflammatory cells in an acute model of the damaged bladder. These findings support the use of intravesically administered GAG for bladder disorders that result from a loss of impermeability, including interstitial, radiation, and chemical cystitis, and possibly others as well.

Are Multiple Cryoprobes Additive or Synergistic in Renal Cryotherapy?

2011-12-21

Objective: To investigate the relationship between multiple cryoprobes was investigated to determine whether they work in an additive or synergistic fashion in an in vivo animal model because 1.47 mm (17-gauge) cryoprobes have been introduced to the armamentarium for renal cryotherapy. Methods: Laparoscopic-guided percutaneous cryoablation was performed in both renal poles of 3 pigs using 3 IceRod cryoprobes. These 12 cryolesions were compared with 12 cryolesions using a single IceRod cryoprobe. Each cycle consisted of two 10-minute freeze cycles separated by a 5-minute thaw. The iceball volume was measured using intraoperative ultrasonography. The kidneys were harvested, and cryolesion surface area was calculated. The lesions were fixed and excised to obtain a volume measurement. Statistical analysis was used to compare the single probe results multiplied by 3 to the multiple probe group for iceball volume, cryolesion surface area, and cryolesion volume. Results: The iceball volume for the first freeze cycle for the single cryoprobe multiplied by 3 was 8.55 cm3 compared with 9.79 cm3 for the multiple cryoprobe group (P = .44) and 10.01 cm3 versus 16.58 cm3 for the second freeze (P = .03). The cryolesion volume for the single cryoprobe multiplied by 3 was 11.29 cm3 versus 14.75 cm3 for the multiple cyroprobe group (P = .06). The gross cryolesion surface area for the single cryoprobe multiplied by 3 was 13.14 cm2 versus 13.89 cm2 for the multiple probe group (P = .52). Conclusion: The cryolesion created by 3 simultaneously activated 1.47-mm probes appears to be larger than that of an additive effect. The lesions were significantly larger as measured by ultrasonography and nearly so (P = .06) as measured by the gross cryolesion volume.

Increased Cell Apoptosis of Urothelium Mediated by Inflammation in Interstitial Cystitis/Painful Bladder Syndrome

Jia-Heng Shie, Hsin-Tzu Liu, Hann-Chorng Kuo — 2012-02-01

Objective: To investigate whether bladder inflammation could directly modulate the signaling pathway of increased urothelial cell apoptosis in interstitial cystitis/painful bladder syndrome (IC/PBS). Chronic inflammation and impaired urothelial homeostasis are possible pathogenesis of IC/PBS. Methods: A total of 29 patients with IC/PBS and 5 control patients were enrolled in the present study. Double stain, protein array analysis, and Western blotting were performed to analyze the alterations of caspase 3, Bad, Bax, phospho-p53, phospho-p38α, and tumor necrosis factor-α (TNF-α) in bladder mucosa specimens from patients with IC/PBS and control patients. The intensities of the proteins in the arrays and Western blots were quantified using ImageJ processing. Inflammatory molecule-treated urothelial cells were analyzed using terminal deoxynucleotidyl transferase-mediated deoxyuridine triphosphate nick end labeling staining and Western blotting for the level of molecules involved in apoptosis. Results: Phospho-p38 and terminal deoxynucleotidyl transferase-mediated deoxyuridine triphosphate nick end labeling double staining indicated that inflammatory and apoptotic events coexisted in the IC/PBS bladder. Protein-antibody array analysis showed that several inflammatory molecules were increased in the IC/PBS samples. We also found that the levels of pro-apoptotic proteins, including phospho-p53 (Ser 15), Bad, Bax, and cleaved caspase-3 were significantly increased in the IC/PBS bladders. These results were confirmed by immunoblotting and suggested that the tissue damage and abnormal urothelium in the IC/PBS bladder might be regulated concurrently by inflammatory signals, such as p38 mitogen-activated protein kinase and TNF-α. The in vitro analysis also showed that the apoptotic process could be induced by TNF-α treatment and anisomycin stimulation in normal urothelial cells. Conclusion: Apoptosis of urothelial cells in patients with IC/PBS could result from upregulation of inflammatory signals, including p38 mitogen-activated protein kinase and TNF-α.

Urethral Steinstrasse With Urethrocutaneous Fistula

Santosh Kumar, Sumit Sharma, Raguram Ganesamoni, Shrawan K. Singh — 2011-05-09

A middle-age man presented with acute urinary retention and a history of passage of urine and stones through a fistula at the root of the penis of 7 years' duration. Computed tomography of the soft tissue penis revealed multiple calculi in the urethra. After an initial suprapubic cystostomy, he underwent Johanson's Stage I urethroplasty with excision of the fistulous tract and retrieval of the urethral stones. Intraoperatively, dense stricture of the distal penile urethra was found, with complete obliteration in places. A urethral stricture, if not promptly managed, can lead to devastating complications necessitating complex surgical management.

Female Covered Urethral Duplication With Urogenital Sinus

2011-05-23

We report a covered urethral duplication in a girl presenting prenatally with an enlarged fluid-filled vulvar cyst, genital duplication, and urogenital sinus revealed by fetal magnetic resonance imaging (MRI) and serial ultrasounds. Physical examination revealed an enlarged vulvar mass covering the clitoris, a single orifice, and normally sited anus. Congenital adrenal hyperplasia was ruled out at birth. MRI in addition showed an accessory duct between the sinus and the urine-filled vulvar pouch with a bifid clitoris. A total urogenital sinus mobilization with resection of the accessory urethra and vulvoplasty was performed with uneventful follow-up.

Renal Cell Carcinoma With Inferior Vena Cava Tumor Thrombus and Metastatic Caval Wall Invasion

Jeffrey C. Loh-Doyle, Mukul B. Patil, Siamak Daneshmand — 2011-07-04

We present a case of renal cell carcinoma with inferior vena caval tumor thrombus and metastatic involvement of the distal inferior vena cava.

Clinical Stage T1 Micropapillary Urothelial Carcinoma Presenting With Metastasis to the Pancreas

2011-07-04

Micropapillary carcinoma of the bladder is an extremely aggressive variant of urothelial carcinoma. Radical cystectomy is the standard treatment for all patients, including those with nonmuscle-invasive disease. We present a patient diagnosed with clinical Stage T1 micropapillary carcinoma of the bladder who was found to have a 2-cm metastasis to the head of the pancreas. To our knowledge, this case represents the first report of a solitary metastatic urothelial carcinoma to the pancreas.

Dramatic Reduction in Tumor Burden With Neoadjuvant Sunitinib Prior to Bilateral Nephron-sparing Surgery

Michael A. Gorin, Obi Ekwenna, Mark S. Soloway, Gaetano Ciancio — 2011-06-15

Neoadjuvant sunitinib has recently been described for the management of renal cell carcinoma. We present the pre and posttreatment images of a 49-year-old male with bilateral biopsy-proven clear cell renal cell carcinoma who underwent treatment with sunitinib prior to nephron-sparing surgery. After four four-week cycles of daily 50 mg sunitinib, the patient demonstrated a dramatic reduction in tumor burden allowing for successful bilateral partial nephrectomy.

Colocalycostomy for Repair of Ureterojejunal Fistula

Liyan Zhuang, Brian D. Duty, Michael J. Conlin, Siamak Daneshmand — 2011-06-27

Calycostomy is a procedure used for an inaccessible renal pelvis during pyeloplasty. We report the first case of using an anterior calycostomy to repair a ureterojejeunal fistula in a transverse colon conduit in which the ureter and pelvis were not accessible because of intense fibrosis.

Pelvic Angiomyolipoma

Tristan M. Nicholson, Granville L. Lloyd, Guan Wu — 2011-06-30

Angiomyolipoma is a rare benign tumor most commonly found in the kidney and, infrequently, extrarenally. We report a case of pelvic angiomyolipoma in a male patient without stigmata of tuberous sclerosis. The patient presented with right retroperitoneal bleeding and was found to have bilateral renal angiomyolipomas as well as a pelvic mass with similar appearance as the other lesions. He underwent urgent embolization of the large right angiomyolipoma and subsequent robot-assisted left laparoscopic partial nephrectomy with simultaneous resection of the pelvic mass, which was well-tolerated. Pathology confirmed what is, to our knowledge, the only reported case of pelvic angiomyolipoma.

Giant Seminal Vesicle Cyst Causing Ipsilateral Hydronephrosis With Contralateral Renal Agenesis

Ahmed El-Assmy, Mohamed E. Abou-El-Ghar — 2011-07-15

Seminal vesicles cyst (SVC) associated with ipsilateral renal agenesis is a rare condition. Until now, contralateral renal agenesis has been found together with SVC in only 3 cases. We report the first case in the literature where contralateral renal agenesis was seen together with giant SVC, causing ipsilateral ureteral obstruction with rising of serum creatinine.

Adrenocortical Carcinoma Masquerading as a Benign Adenoma on Computed Tomography Washout Study

2011-08-02

An incidental adrenal mass is a common finding on cross-sectional imaging, with most of these lesions being benign adenomas. Indications for adrenalectomy turn on the likelihood that a mass is malignant or whether it exhibits metabolic activity. Modern imaging is considered highly accurate in differentiating adrenal adenomas from other adrenal pathology. We present a case of a 5-cm adrenal lesion with computed tomography washout characteristics consistent with a benign adenoma, which proved upon resection to be an adrenocortical carcinoma.

Invasive Fungal Bezoar Requiring Partial Cystectomy

2011-11-25

A 67-year-old man developed dysuria and position-dependent obstructive voiding symptoms after undergoing holmium laser ablation of the prostate (HOLAP) for benign prostatic hypertrophy. A large fungal (candidal) ball adherent to the bladder wall was removed by loop excision, but the bezoar recurred in 2 weeks despite systemic fluconazole and intravesical amphotericin B. A second attempt at endoscopic removal with ultrasonic lithotripsy, endoscopic graspers, and fulguration was also unsuccessful. The patient underwent open partial cystectomy to remove his invasive fungal bezoar. Convalescence was unremarkable. Urinalysis, culture, and follow-up cystoscopy after partial cystectomy demonstrated successful definitive treatment of the fungal ball.

Squamous Cell Carcinoma of the Enlarged Prostatic Utricle in an Adult

Cuijian Zhang, Xuesong Li, Zhisong He, Yunxiang Xiao, Shuqing Li, Liqun Zhou — 2011-08-05

A 39-year-old man with gross terminal hematuria and urethral discharge for 5 months was found to have a partial cystic and partial solid mass above the normal site of prostate, which was confirmed by magnetic resonance imaging (MRI) and transrectal ultrasonagraphy. A radical resection of the tumor was performed, and classical squamous cell carcinoma was confirmed by pathologic assay.

Dermoid Cyst of the Testis With Neural Tissue in an Adult

Alison K. Ramsay, Murat Gurun, Daniel M. Berney, Robert Nairn — 2011-08-16

Abstract: Although some authors question the validity of the diagnosis of dermoid cyst of the testis, it does seem to be identical to tumors seen in the ovary and is distinct from a mature teratoma of the testis. Previous cases have described variants of the “classical” dermoid cyst, including noncutaneous teratomatous elements: bone, cartilage, respiratory epithelium, intestinal mucosa. We describe a unique case demonstrating a testicular dermoid cyst containing mature neural tissue, which has previously not been described in an adult. It has been suggested that these tumors are persistent prepubertal teratomas that are known to behave in a benign manner.

Bilateral Primary Adrenal Lymphoma Accompanying Hypertension

Quan Wang, Xueyuan Cao, Jing Jiang, Tao Wang, Mei-Shan Jin — 2011-08-22

Primary adrenal lymphoma (PAL) accompanied by hypertension is extremely rare. We present a case of PAL with hypertension, whom was treated with bilateral adrenalectomy and a combination of the modified Appleby operation and chemotherapy. Computed tomography and biopsy is helpful to aid diagnosis.

Re: Breyer et al.: Use of Google Insights for Search to Track Seasonal and Geographic Kidney Stone Incidence in the United States (Urology 2011;78:267-271)

Roni Zeiger, Matthew H. Mohebbi — 2012-02-01

We read with great interest your article “Use of Google Insights for Search to Track Seasonal and Geographic Kidney Stone Incidence in the United States” by Breyer et al. They noted that when they entered the query “kidney stones” into Google Insights for Search, the curve showing the popularity of this Google query over time has approximately the same shape as the curve for hospital admissions for kidney stones. Similarly, the geographic distribution of Google searches for “kidney stones” is similar to that of hospital admissions for this condition.

Reply by the Authors

Benjamin N. Breyer, Michael L. Eisenberg — 2012-02-01

We greatly appreciate the interest in our manuscript. Our findings, teamed with our previous research, and an outstanding report by the group from Tucson, Arizona, all demonstrate that Internet search volume can track kidney stone incidence. The authors of the letter are mistaken when they assert that we selected search terms by guessing. Terms associated with kidney stones were selected and analyzed based on clinical experience and knowledge.

Re: Graft Reconstruction of Inferior Vena Cava for Renal Cell Carcinoma Stage pT3b or Greater (Urology 2011;78:838-843)

Rajinikanth Ayyathurai, Obi Ekwenna, Gaetano Ciancio — 2012-02-01

The authors report their surgical experience of graft reconstruction of the inferior vena cava (IVC) after resection of renal cell carcinoma (RCC) with tumor thrombus. They also reported their experience of patch grafting (n = 11) and IVC interposition (n = 6) of the IVC during RCC tumor thrombus surgery.

Re: Samplaski et al.: Inclusion of Erectile Domain to UPOINT Phenotype Does Not Improve Correlation With Symptom Severity in Men With Chronic Prostatitis/Chronic Pelvic Pain Syndrome (Urology 2011;78:653-658)

Vittorio Magri, Florian M.E. Wagenlehner, Gianpaolo Perletti — 2012-02-01

Samplaski et al have recently reported the results of a retrospective study including 100 patients affected by chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS). From their findings, the authors questioned some of the conclusions of a study performed by our research group of a cohort of European patients, aimed at testing the novel urinary, psychosocial, organ specific, infection, neurologic/systemic, tenderness of skeletal muscles (UPOINT) phenotyping system for CP/CPPS.

Reply by the Authors

Daniel A. Shoskes, Mary K. Samplaski, Jianbo Li — 2012-02-01

Thank you for the opportunity to respond to the letter from Dr. Magri and colleagues. We believe a careful read of our article, particularly the Methods and Discussion, will actually address the concerns raised. First, the authors say that we “question some of the conclusions of a study performed by our research group on a cohort of European patients.” We did not question the veracity of their findings and acknowledged that there were differences in methodology and patient characteristics that could account for a different outcome in our North American patient cohort. We addressed in our paper the rationale for focusing only on erectile dysfunction, and the complete answer to the authors' question 2 can be found at length in the final paragraph of our discussion.

Retraction Notice

2012-02-01

This article has been retracted at the request of the authors. They believe that the article contains findings that may be unreliable. As the authors re-reviewed the data points presented in the article, they identified differences between some of the plate reader values and those that were reported in the article. For some of the duplicates run, one of the values was indeed from the plate reader data, whereas the source of the counterpart value is not easily apparent. Therefore, because the authors could not replicate some of the counterpoint values, they cannot state if the data points represent the actual data generated in the experiments described. Furthermore, the duplicate values may not have been handled in the manner described within the Materials and Methods section of the paper and the values were not blanked. Taken together, the inconsistencies in validating the data collection and recordation warrant retraction of the article. The authors sincerely apologize for any inconvenience this might cause.

Aims and Scope

2012-02-01

Editorial Board

2012-02-01