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Basic Sciences, Miscellaneus in Urology

Atypical presentations of emphysematous cystitis.
Chong SJ, Lim KB, Tan YM, Chow RK, Yip SK
Surgeon. 2005 Apr;3(2):109-12.

Emphysematous cystitis is an uncommon infection of the bladder with the formation of carbon dioxide either within the bladder or within its wall. It is commonly seen in women and those with poorly controlled diabetes mellitus, in association with some form of urinary stasis and obstruction. The clinical features are very varied and the outcome is often unpredictable. Radiography may reveal a radiolucent line around the bladder wall or gas within the bladder. Occasionally, computed tomography scans are required to help in the diagnosis due to their atypical presentation with acute abdominal pain. Herein, we report three patients with such a condition who were treated with favourable outcomes. Of the three patients, two had to undergo exploratory laparotomy due to their initial presentations with acute abdomens.

A prospective study of meat and meat mutagens and prostate cancer risk.
Cross AJ, Peters U, Kirsh VA, Andriole GL, Reding D, Hayes RB, Sinha R
Cancer Res. 2005 Dec 15;65(24):11779-84.

High-temperature cooked meat contains heterocyclic amines, including 2-amino-1-methyl-6-phenylimidazo[4,5-b]pyridine (PhIP), and polycyclic aromatic hydrocarbons, such as benzo(a)pyrene (BaP). In rodents, a high intake of PhIP induces prostate tumors. We prospectively investigated the association between meat and meat mutagens, specifically PhIP, and prostate cancer risk in the Prostate, Lung, Colorectal, and Ovarian Cancer Screening Trial. Diet was assessed using a 137-item food frequency questionnaire and a detailed meat-cooking questionnaire linked to a database for BaP and the heterocyclic amines 2-amino-3,8-dimethylimidazo[4,5-b]quinoxaline (MeIQx), 2-amino-3,4,8-trimethylimidazo[4,5-f]quinoxaline (DiMeIQx), and PhIP. During follow-up, we ascertained a total of 1,338 prostate cancer cases among 29,361 men; of these, 868 were incident cases (diagnosed after the first year of follow-up) and 520 were advanced cases (stage III or IV or a Gleason score of > or =7). Total, red, or white meat intake was not associated with prostate cancer risk. More than 10 g/d of very well done meat, compared with no consumption, was associated with a 1.4-fold increased risk of prostate cancer [95% confidence interval (95% CI), 1.05-1.92] and a 1.7-fold increased risk (95% CI, 1.19-2.40) of incident disease. Although there was no association with MeIQx and DiMeIQx, the highest quintile of PhIP was associated with a 1.2-fold increased risk of prostate cancer (95% CI, 1.01-1.48) and a 1.3-fold increased risk of incident disease (95% CI, 1.01-1.61). In conclusion, very well done meat was positively associated with prostate cancer risk. In addition, this study lends epidemiologic support to the animal studies, which have implicated PhIP as a prostate carcinogen.

Botox in urology.
Thwaini A, Shergill I, Radhakrishnan S, Chinegwundoh F, Thwaini H
Int Urogynecol J Pelvic Floor Dysfunct 2005 Nov 19;:1-5.

Lower urinary tract dysfunction is one of the challenging problems facing urologists and patients. Several treatment trials have been introduced in the literature, but none has proven to be as effective as being a gold standard treatment for such conditions. We reviewed the literature regarding the use of botulinum toxin (BTx) type A as a current treatment of lower urinary tract conditions described below. The toxin has been shown to be safe and effective in the treatment of conditions caused by increased muscle tonicity. Indications for the urological use of BTx and future applications are also considered.

Recurrent urinary tract infections.
Franco AV
Best Pract Res Clin Obstet Gynaecol 2005 Dec;19(6):861-73. Epub 2005 Nov 17.

Urinary tract infection (UTI) is one of the most common bacterial infections in women, and one in four of these women will develop a recurrence. Various risk factors predispose women of different age groups to recurrence. These factors include sexual intercourse, use of contraception, antimicrobials, oestrogen, genetics, and the distance of the urethra from the anus. Of the different pathogens, Escherichia coli is the organism most commonly isolated. A variety of treatment options has been proposed, including long-term or post-intercourse prophylaxis and patient-initiated therapy. Oestrogen and cranberry juice have also been used as prophylactic treatment adjuncts. At present, other therapeutic and preventive modalities are being investigated, including the development of vaccines to treat those most severely affected.

Urinary tract infection in women.
Sheffield JS, Cunningham FG
Obstet Gynecol 2005 Nov;106(5):1085-92.

Urinary tract bacterial infections are common in women. Moreover, they tend to recur throughout life and in the same relatively small group of women. In most cases, bladder and renal infections are asymptomatic and manifest by demonstrating coincidental bacteriuria. In some instances, however, especially with frequent sexual activity, pregnancy, stone disease, or diabetes, symptomatic cystitis or pyelonephritis develops and antimicrobial therapy is indicated. In most cases, cystitis is easily managed with minimal morbidity. When acute pyelonephritis develops in an otherwise healthy woman, however, consideration for ureteral obstruction is entertained. If her clinical response to proper therapy is not optimal, then imaging studies are indicated. Pregnancy is a common cause of obstructive uropathy, and severe renal infections are relatively common. Because they usually arise from preexisting covert bacteriuria, experts recommend screening and eradication of these silent infections as a routine prenatal practice.

Evaluation and medical management of benign prostatic hyperplasia.
Beckman TJ, Mynderse LA
Mayo Clin Proc 2005 Oct;80(10):1356-62.

Benign prostatic hyperplasia (BPH) is common among aging men. Untreated BPH may lead to complications including urinary tract infection, acute urinary retention, and obstructive nephropathy. Diagnosing BPH can be challenging because lower urinary tract symptoms are found in conditions other than BPH, and prostate size correlates poorly with symptoms of obstruction. Nonetheless, a careful medical history and physical examination, along with prudent use of diagnostic tests, can yield an accurate diagnosis. We review the evaluation of men with suspected BPH and indications for referral to a urologist for invasive therapy. We also review supporting evidence and treatment considerations for saw palmetto and the 2 major classes of prescription medications, alpha1-adrenergic antagonists and 5alpha-reductase inhibitors.

Holmium laser enucleation of the prostate: a size-independent new "gold standard".
Elzayat EA, Habib EI, Elhilali MM
Urology 2005 Nov;66(5 Suppl):108-13.

We report our experience with holmium laser enucleation of the prostate (HoLEP) for treatment of 552 patients with symptomatic benign prostatic hyperplasia (BPH) and their long-term outcome. Between March 1998 and January 2005, a retrospective review was conducted at our institution of 552 cases in which patients underwent HoLEP. Patient characteristics, indications for surgery, preoperative and postoperative International Prostate Symptom Score (I-PSS), peak flow rate (Qmax), postvoid residual urine, operative data, catheterization time, hospital stay, and immediate and long-term complications were recorded. The mean age of patients was 73.7 +/- 7.9 years, and the mean follow-up time was 36 months. The mean preoperative prostate size was 83.7 +/- 49.7 cm3 (range, 20 to 351 cm3), the mean enucleation time was 86 minutes (range, 15 to 255 minutes), and the mean enucleated tissue weight was 52.1 +/- 43.7 g (range, 5 to 340 g). The voiding parameters were significantly improved, with a 200% increase in Qmax, as well as a 75% improvement in I-PSS at 1 year postoperatively, which continued to improve during subsequent follow-up. A total of 11 patients required blood transfusion; 8 of them were on anticoagulant therapy. Irritative symptoms were noted in 9.4% and transient stress incontinence in 4.2% of patients. Bladder neck contracture and urethral stricture each developed in 1.3% of patients. We conclude that HoLEP is a safe and effective procedure for treatment of symptomatic BPH, regardless of prostate size, with low morbidity and short hospital stay. HoLEP appears to be the modern alternative to transurethral resection of the prostate and open prostatectomy, and it may be considered a size-independent new "gold standard."

Laparoscopic radical prostatectomy: conventional and robotic.
Menon M, Shrivastava A, Tewari A
Urology 2005 Nov;66(5 Suppl):101-4.

By 2015, prostate cancer will become the most commonly diagnosed cancer in men. Radical prostatectomy reduces disease-specific mortality in patients with localized prostate cancer; however, the invasiveness of surgery and its resultant side effects cause many men to seek other treatments. In 2000, laparoscopic radical prostatectomy emerged as a minimally invasive alternative to open surgery; it has been refined recently by the addition of robotic technology. To examine the outcomes of robotic radical prostatectomy and compare them with those from open and conventional laparoscopic radical prostatectomy, we prospectively collected baseline demographic data on all patients undergoing surgery for prostate cancer over a 4-year period at our center. Urinary function and sexual function were evaluated using standardized criteria as well as a questionnaire preoperatively and at 1, 3, 6, 12, and 18 months after their procedure. Operative and postoperative outcomes were compared using values for open radical prostatectomy as the reference standard. A total of 100 men underwent open radical prostatectomy with conventional laparoscopic radical prostatectomy (n = 50) and robotic radical prostatectomy (n = 500). The odds ratios for operative times, blood loss, postoperative pain, complications, and median times to urinary continence and resumption of sexual activity all were lower for robotic than for open or laparoscopic radical prostatectomy. It appears safe to conclude that conventional laparoscopic radical prostatectomy is a reasonable alternative to open radical prostatectomy in the surgical treatment of patients with clinically localized prostate cancer. The incorporation of robotics may result in even better surgical outcomes than conventional laparoscopy. However, the surgical robot is expensive; few centers have access to the technology and even fewer have expertise in the technique. For robotic radical prostatectomy to become the standard of care for the treatment of localized prostate cancer will require economies of cost, dissemination of surgical expertise, and data from randomized trials.

Radical prostatectomy: long-term cancer control and recovery of sexual and urinary function ("trifecta").
Bianco FJ Jr, Scardino PT, Eastham JA
Urology 2005 Nov;66(5 Suppl):83-94.

Radical prostatectomy (RP) disrupts the natural history of prostate cancer. However, it could be a significant source of long-term incontinence and potency morbidity. We studied the long-term cancer survival results and the probabilities of achieving ideal "trifecta" outcomes (cancer control, continence, and potency) after this surgical procedure. A total of 1746 intervention-naive patients with clinically localized newly diagnosed prostate cancer underwent RP with curative intent beginning in 1983. The mean follow-up time was 6 years (interquartile range, 3-9). The successive probabilities of achieving ideal trifecta outcomes for up to 24 months following RP versus experiencing biochemical recurrence were estimated using the cumulative incidence method. Additionally, long-term cancer control was assessed by preoperative and postoperative factors. Surgical excision controlled prostate cancer effectively in 1441 (83%) of the 1746 patients studied. At 5, 10, and 15 years, respectively, 82%, 77%, and 75% of patients were free from disease progression. Cancer-specific survival was 99%, 95% and 89%, respectively, at 5, 10, and 15 years. In men with disease progression, the 15-year probabilities of death from prostate cancer versus other causes were similar (32% and 33%, respectively). At 24 months, 60% of patients were potent, continent, and free of cancer, and 12% had experienced recurrence. Use of RP provided excellent long-term cancer control. At 15 years, only 11% of patients had died of prostate cancer. Cancer control was good even for patients with adverse prognostic features. The probability of death from cancer was similar to other causes after disease progression. By 2 years, 60% of men were continent, potent, and cancer free.

Who is the average patient presenting with prostate cancer?
Greene KL, Cowan JE, Cooperberg MR, Meng MV, DuChane J, Carroll PR Investigators.
Urology 2005 Nov;66(5 Suppl):76-82.

Prostate cancer screening, diagnosis, and treatment have changed dramatically in the last 20 years. Patients with newly diagnosed prostate cancer have many treatment options available. We attempted to determine how patient demographics and quality of life (QOL) have changed, and we describe the average patient with newly diagnosed prostate cancer in the early 21st century. From the Cancer of the Prostate Strategic Urologic Research Endeavor (CaPSURE) we identified 3003 men with prostate cancer diagnosed between 1997 and 2003 for whom pretreatment demographic and QOL data were available. All patients completed both the University of California-Los Angeles Prostate Cancer Index (UCLA-PCI) and the Rand Medical Outcomes Study 36-Item Short-Form Health Survey (SF-36) as self-administered questionnaires at the time of diagnosis. We compared demographic variables (age at diagnosis, race/ethnicity, education, number of comorbidities, body mass index [BMI], and insurance type), treatment choice, and pretreatment QOL scores on the SF-36 and UCLA-PCI scales for the periods 1997 to 1999 or 2000 to 2003. Stratified analysis by risk category was performed for demographic and QOL data for the 2 periods. Race/ethnicity and insurance demographics were statistically different for the 2 periods. Low-risk patients also showed a statistically increased BMI in the 2000 to 2003 period. Risk category predicted performance on both inventories, with low-risk patients having better function than intermediate-risk patients and high-risk patients in the areas of urinary bother, bowel function and bother, and sexual function and bother, as well as in many general well-being and emotional health scales on the SF-36. We conclude that the "average" prostate cancer patient is white, 65 years of age, overweight, educated at a college level, and has 1 to 2 comorbidities. Patients report average or above-average pretreatment health-related QOL for all scales based on 2 validated instruments. In this cohort, more patients chose radical prostatectomy than any other form of treatment.

Advances in the treatment of carcinoma of the penis.
McDougal WS
Urology 2005 Nov;66(5 Suppl):114-7.

The aim of this article is to define the therapeutic advances in the treatment of penile cancer over the past 2 decades. A literature search was conducted for articles in which a major change in therapy was documented as beneficial. Case records were then reviewed in patients who underwent such procedures. Major advances have involved less disfiguring treatment of the primary lesion in selected cases and the recognition of improved survival by altering the timing of groin dissection for those at risk for metastatic disease.

Radical prostatectomy versus watchful waiting.
Marantz PR, Hall CB, Derby CA
N Engl J Med 2005 Sep 22;353(12):1298-300; author reply 1298-300.

Modified collagen fleece, a scaffold for transplantation of human bladder smooth muscle cells.
Danielsson C, Ruault S, Basset-Dardare A, Frey P
Biomaterials 2005 Sep 17;.

Several congenital and acquired diseases of the human genito-urinary tract may need, due to lack or destruction of functional tissues, mechanically stable biomaterials as cell carriers for the engineering of these tissues. When using collagen scaffolds, both their capacity to induce tissue regeneration and their biocompatibility are advantageous characteristics to render them apt for tissue engineering. The attachment of extracellular matrix or serum proteins to their surfaces does further improve these characteristics, mimicking a close to natural cell environment. In this study, equine collagen scaffolds (TissueFleece((R))) were modified by coating fetal bovine serum proteins, before human bladder smooth muscle cells were seeded. Cell growth was evaluated by WST-1 proliferation assay and improved when using modified collagen scaffolds. However, cell penetration assessed by histology showed similar results on modified and native scaffolds. These cell-scaffold constructs were further implanted in the dorsal subcutaneous space of athymic mice. In vivo studies showed the presence of the fluorescent-labeled transplanted smooth muscle cells until day 3 and thereafter angiogenesis was induced and infiltration of mouse fibroblasts and polymorphonuclear cells were observed. The latter had completely disappeared after 3 weeks.

Urinary tract injuries during pelvic surgery: incidence rates and predisposing factors.
Bai SW, Huh EH, Jung DJ, Park JH, Rha KH, Kim SK, Park KH
Int Urogynecol J Pelvic Floor Dysfunct 2005 Sep 30;:1-5.

OBJECTIVE: To review the cases of urinary tract injury following major pelvic surgery that were treated in our hospital over the last 12 years, in relation to possible predisposing factors and incidence rates of injury arising in various surgical procedures. MATERIALS AND METHODS: From 8,824 major gynecological operations performed in our department, 29 cases of intraoperative urinary tract injury were found. Thirty eight patients visited the urology department during the same period for the management of urogenital fistula following pelvic surgery. Parameters that were examined included type of urinary tract injury, indication for surgery, type of operation, coexisting pathological conditions, past history of pelvic surgery or pelvic irradiation, and the delay in the recognition and management of the urinary tract injury. RESULTS: The overall incidence of urinary tract injury in pelvic surgery was 0.33%. The incidence of urinary tract injury in radical hysterectomy was higher than that of total abdominal hysterectomy(0.76 vs 0.26%). Of the intraoperative urinary tract injuries, 48.4% coexisted pelvic pathologies. Of all the cases with urinary tract injury, the most common type of operation was total abdominal hysterectomy (n=45, 67.2%), and the most common indication was uterine myoma (n=25, 36.9%). The most common type of urinary tract injury was bladder injury, including bladder laceration and vesicovaginal fistula(n=57, 76.1%). The frequency of reoperation was found to be lower in patients with a shorter delay in the recognition of the injury (p<0.05). CONCLUSION: Possible predisposing factors for urinary tract injury are coexisting pelvic adhesion, distortion of normal pelvic configuration, previous irradiation history, previous operation history, and the extent of surgery. In high-risk patients, proper evaluation is needed to avoid urology complications before operation.

Female urethral diverticula.
Lee JW, Fynes MM
Best Pract Res Clin Obstet Gynaecol 2005 Sep 19;.

Urethral diverticula are frequently under-diagnosed. The pathogenesis of this condition is poorly understood, and these lesions represent a spectrum of disorders ranging from isolated suburethral cysts to herniation of the urethral lining into the vaginal mucosa. Women with this disorder frequently complain of a host of symptoms referable to the lower urinary and genital tracts. Accurate diagnosis is based on history and clinical evaluation. Perineal ultrasound and MRI are often helpful. Repeated courses of antibiotics and urethral dilatation often fail to resolve the problem, and definitive intervention usually requires surgical excision to provide relief. This chapter describes the current management of this condition, and it heralds a re-look at the patho-aetiology in view of recent MRI findings of symptomatic non-communicating microcystic lesions.

Lower Urinary Tract Symptoms: A Hermeneutic Phenomenological Study Into Men's Lived Experience.
Kaplan SA
J Urol 2005 Oct;174(4 Pt 1):1353-4.

Unusual female suburethral mass lesions.
Cocco AE, MacLennan GT
J Urol 2005 Sep;174(3):1106

Sexual Function-Preserving Cystectomy.
Tal R, Baniel J
Urology 2005 Jul 22;.

Prognostic factors in a recent series of patients treated with radical cystectomy for bladder cancer.
Novara G, Ficarra V, Alrabi N, Dalpiaz O, Martignoni G, Galfano A, Cavalleri S, Artibani W
Urol Int 2005;75(1):10-6.

OBJECTIVE: To identify the clinical and pathological prognostic factors in a homogeneous series of patients with bladder cancer who had undergone radical cystectomy in the late 1990s. MATERIALS AND METHODS: We retrospectively analyzed the clinical data of 156 patients who had undergone radical cystectomy and iliac-obturator lymphadenectomy for bladder carcinoma at our department between 1995 and 2001. RESULTS: The mean follow-up was 39.71 +/- 26.2 months. The 5-year overall and cancer-specific survival rates were 47.2 and 54.7%, respectively. Upper urinary tract obstruction (p = 0.03), clinical stage of both the primary tumor (p = 0.0001) and loco-regional lymph nodes (p = 0.04), pathological stage (2002 TNM) of the primary tumor (p < 0.0001), pathological loco-regional lymph node involvement (p < 0.0001), and vascular embolization (p = 0.005) were significant on univariate analysis. Pathological lymph node involvement (p = 0.001) and both pathological (p = 0.022) and clinical stages of the primary tumor (p = 0.002) turned out to be independent predictors of cancer-specific survival. CONCLUSION: Pathological lymph node involvement, clinical and pathological stage of the primary tumor were the cancer-specific, survival-independent, predictors in our series. Our multivariate analysis data identified pT3-4 and pN+ patients as those with the worst prognosis.

Polyorchidism: A case report and review of the literature.
Holland AJ
J Pediatr Surg 2005 Jul;40(7):1219.

A 15-year-old male was described with a right scrotal mass that had been present for several months. An ultrasound indicated a normal left testis and two testes on the right side. At operation, both testes communicated with a single vas and were supplied by the same testicular artery. The superior testis had an appendix and was therefore thought to represent the upper pole of the original testis. The two were preserved and sutured to create a single testis. The authors comment that polyorchidism remains rare, with 77 cases in the literature. Their patient reflected the most common variant: two testes with a common epididymis and vas deferens. This appears to arise from division of the genital ridge between the 4th and 6th weeks of embryological development. Up to 65% of supernumerary testes produce sperm. Traditional management has involved excision, but more recently no intervention has been advocated once malignancy has been excluded. The authors advocate fixation, based on the premise that this allows fixation, determination of the ability of a functional testis to contribute to spermatogenesis, biopsy, if necessary, and creation of a new, 'single testis' with additional cosmetic and psychological benefits.

Ambulatory surgery in urogynaecology.
Ghoshal S, Smith AR
Best Pract Res Clin Obstet Gynaecol 2005 Jul 27;.

Ambulatory surgery offers advantages to both patients and providers. It is imperative to ensure appropriate case selection, pre-operative counseling, a suitable environment, trained staff, adequate analgesia and post-operative care both in the hospital and the community. Many well-established urogynaecological procedures such as cystoscopy and vaginal repair may be performed in an ambulatory setting. Newer procedures such as injection of botulinum toxin or peri-urethral bulking agents and tension-free tapes for stress incontinence may also be performed in this way. To date, the literature is deficient in robust studies comparing outcomes and patient satisfaction between conventional and ambulatory surgical procedures, and randomized controlled trials are required.

Surgical procedures for urethral diverticula in women in the United States, 1979-1997.
Burrows LJ, Howden NL, Meyn L, Weber AM
Int Urogynecol J Pelvic Floor Dysfunct 2005 Mar-Apr;16(2):158-61. Epub 2004 Oct 22.

The objective of this study was to describe national rates of surgery for urethral diverticula in women. Data from the National Hospital Discharge Survey (NHDS), a federal database that samples inpatient hospitals in the United States, were analyzed from 1979 to 1997 for diagnosis and procedure codes using the ICD-9-CM classification system. The difference between the median age-adjusted rates from 1979 to 1988 and 1989 to 1997 were evaluated using the Mann-Whitney U test since the yearly rates fluctuated in a nonlinear fashion. Data from the National Statistics for Ambulatory Surgery (NSAS) database were analyzed from 1994 to 1996 in a similar fashion. The average age of women undergoing surgery for urethral diverticula increased from 41.6+/-15.1 years from 1979 to 1988 to 49.4+/-14.8 years from 1989 to 1997 (p=0.02). The average length of hospital stay decreased from 8.4+/-5.0 days in 1979 to 3.2+/-1.7 days in 1997 (p=0.007). Approximately 27,000 inpatient procedures were performed for the repair of urethral diverticula in the United States over a 19-year period, ranging from an estimated 500 to 3400 cases per year. The median age-adjusted rate of procedures decreased from 14.2 per 1 million women from 1979 to 1988 to 6.4 per 1 million women from 1989 to 1997 (p=0.009). Data from the NSAS indicated that an average of 6.7 surgeries per 1 million women per year were performed in the outpatient setting from 1994 to 1996. Age-adjusted rates of inpatient surgery for urethral diverticula were threefold higher for black compared to white women. Inpatient surgical repair of urethral diverticula is three times as high in black as compared to white women. These procedures are infrequent and rates appear to have decreased over time.

A normal flow pattern in women does not exclude voiding pathology.
Pauwels E, De Wachter S, Wyndaele JJ
Int Urogynecol J Pelvic Floor Dysfunct 2005 Mar-Apr;16(2):104-8; discussion 108. Epub 2004 Sep 9.

It is a widespread assumption that normal micturition behaviour is reflected in a normal flow pattern. This would also mean that a normal flow curve would correspond with normal voiding and would even permit to exclude voiding difficulties. In our study we investigated the value of a normal flow pattern in four different groups: stress incontinent women, women with bladder overactivity, healthy middle-aged volunteers and healthy students. These women voided with a bell-shaped flow curve on pressure flow in 50, 65, 57 and 50%, respectively. Women who strained to void, a major component of dysfunctional voiding, managed to void a bell-shaped flow curve in 46, 60, 70 and 100%, respectively. Our study demonstrates that a "normal" bell-shaped flow curve does not exclude voiding dysfunction in women.

Leiomyoma of the female urethra: urodynamic changes after surgical intervention.
Goto K, Orisaka S, Kurokawa T, Miyazaki M, Kotsuji F
Int Urogynecol J Pelvic Floor Dysfunct 2005 Mar-Apr;16(2):162-4. Epub 2004 Sep 8.

Leiomyoma of the urethra is a relatively rare condition often presenting as an anterior vaginal wall mass or a mass that protrudes from the urethral meatus. We report on the urodynamic changes after vaginal surgery to remove a suburethral leiomyoma, which protruded from the vaginal orifice resulting in dysuria and dyspareunia. Urodynamic studies before the operation revealed a high detrusor pressure, low maximum flow rate with an elevated post-void residual urine on voluntary voiding, and high resting urethral resistance. Removal of the mass with proper reconstruction of paraurethral support restored normal detrusor pressure, maximum flow rate, and post-void residual, resulting in amelioration of her voiding difficulty and dyspareunia. The operative procedure did not affect leak point pressure and she is free from stress urinary incontinence.

Urinary control after the definitive reconstruction of cloacal anomaly.
Shimada K, Matsumoto F, Tohda A, Ainoya K
Int J Urol 2005 Jul;12(7):631-6.

Purpose : Urinary control after definitive repair of a cloacal anomaly is difficult to achieve. The present report aims to describe the clinical course of urinary control, and the need for the management of bladder dysfunction after reconstruction. Methods : The present consecutive series consisted of 11 girls who underwent definitive repair of cloacal anomalies over a period of 11 years. Eight patients were associated with hydrocolpos. Radiological examination included a plain X-ray radiograph of the lumbosacral spine and a voiding cystourethrography with or without a urodynamic study. Results : Reconstruction of the cloaca was performed on patients aged between 1 and 3 years using a posterior sagittal approach. Vaginal reconstruction was carried out 13 times in 11 patients using tubularized vaginal flap, distal rectal segment, perineal skin flap, or total urogenital sinus mobilization. Cystostomy or vesicostomy was carried out in four newborns/infants. Another seven patients could void spontaneously but incompletely with residual urine. Occult spinal dysraphism was found in five patients and hemisacrum in two patients. After definitive reconstruction, most patients acquired an adequate to normal bladder volume for 1-year-olds. Normal detrusor-sphincter function was seen in three patients. Detrusor areflexia was seen in two patients who underwent in utero vesico-amniotic shunt. Detrusor underactivity was observed in six patients. Bladder compliance was good in all patients except for one. No patients in the present series showed persistent urinary incontinence from the bladder neck or urethral dysfunction. Conclusion : It is postulated that wetting after definitive repair may be the result of overflow incontinence and poor bladder contractility rather than sphincter injury. The main clinical characteristic of bladder dysfunction was a failure to empty. We could not define the exact etiology, but iatrogenic injury from extensive dissection can lead to the higher risks of peripheral nerve damage. Accomplishment of definitive repair involves not only anatomical reconstruction, but also postoperative urinary control, including the initiation of clean intermittent catheterizations under repeated urodynamic evaluations.

The effect of fluid intake on urinary symptoms in women.
Swithinbank L, Hashim H, Abrams P
J Urol 2005 Jul;174(1):187-9.

PURPOSE: We determined the effect of caffeine restriction and fluid manipulation in the treatment of patients with urodynamic stress incontinence and detrusor overactivity. MATERIALS AND METHODS: This was a 4-week randomized, prospective, observational crossover study in 110 women with urodynamic stress incontinence (USI) or idiopathic detrusor overactivity (IDO) to determine the effect of caffeine restriction, and of increasing and decreasing fluid intake on urinary symptoms. Data were recorded in a urinary diary for the entire study period on urgency episodes, frequency, pad weight increase, wetting episodes and quality of life. RESULTS: A total of 69 women with a mean age of 54.8 years completed the study, including 39 with USI and 30 with IDO. In the IDO group decreasing fluid intake significantly decreased voiding frequency, urgency and wetting episodes with improved quality of life. In the USI group there was a significant decrease in wetting episodes when fluid intake was decreased. Changing from caffeine containing to decaffeinated drinks produced no improvement in symptoms. CONCLUSIONS: Conservative and life-style interventions are first line treatments in the management of incontinence and storage lower urinary tract symptoms. This study shows that a decrease in fluid intake improves some of these symptoms in patients with USI and IDO and, therefore, it should be considered when treating such patients.

Effectiveness of Oral Desmopressin Therapy in Posterior Urethral Valve Patients with Polyuria and Detection of Factors Affecting the Therapy.
Naghizadeh S, Kefi A, Dogan HS, Burgu B, Akdogan B, Tekgul S
Eur Urol 2005 Jul 2;.

OBJECTIVES: The present study aims to evaluate the effect of desmopressin treatment on urine output, density and glomerular filtration rate (GFR) in patients with posterior urethral valve (PUV) and the factors affecting the response to this treatment. METHODS: A total of 68 PUV patients who were followed-up after valve ablation were examined with the fluid intake, urine output and GFR. Sixteen patients who were polyuric (a urine output more than 30ml/kg/day) and had hypoosmolar urine (urinary density of 1015 or lower) included in the study. Blood chemistry and serum ADH level were studied. Following 5 days of observation, patients were given DDAVP perorally with a dosage of 0.4mg/day, two equal doses per day. After 7 days and after a 3 month period of treatment, voiding characteristics, day-time and night-time urine densities and also GFR have been re-evaluated. RESULTS: The mean age was 6.8 years (range 2 to 11 years). The mean age at valve ablation was 20.7 months (range 5 months to 6 years). The mean daily urine output during first week and at the third month of the treatment had decreased significantly (p=0.004 and p=0.006). There was increase in night-time and day-time urine density in 10 patients (62%) and in 13 patients (81%) respectively at the third month evaluation. Increments in urine density were statistically significant for the third month evaluation. Nine (56%) patients had ADH levels within normal (<7pcg/ml) levels and 7 patients had higher levels. There was no statistically significant difference between pretreatment and posttreatment micturation characteristics. However patients with voiding dysfunction responded better to DDAVP treatment. CONCLUSIONS: Desmopressin treatment improves polyuria in PUV patients. The responses are better particularly in PUV patients with significant bladder dysfunction. This supports the harmful role of polyuria on bladder dysfunction. The DDAVP treatment improves the day-time and night-time in PUV patients. Combination of DDAVP treatment with overnight catheterization may be a good alternative that needs to be evaluated by further prospective randomized studies.

A Double-Blind Placebo-Controlled Study Evaluating the Onset of Action of Doxazosin Gastrointestinal Therapeutic System in the Treatment of Benign Prostatic Hyperplasia.
Roehrborn CG, Prajsner A, Kirby R, Andersen M, Quinn S, Mallen S
Eur Urol 2005 Jul 1;.

OBJECTIVE: To determine the onset of improvement in benign prostatic hyperplasia symptoms in patients after treatment with doxazosin gastrointestinal therapeutic system (DOX GITS) versus placebo. METHODS: In this prospective, randomized, double-blind, placebo-controlled trial, baseline values, including International Prostate Symptom Score (IPSS) and maximum urine flow rate (Q(max)), were determined following a 2-week placebo run-in. Patients received DOX GITS 4mg/d (n=108) or placebo (n=105) for 14 days. IPSS was measured on Days 3, 7, and 14; Q(max) on Days 1, 3, 7, and 14; and the patients' perception of improvement was measured on Days 1 and 2 in the evening at home and in the office on Day 14. RESULTS: Significantly more patients treated with DOX GITS than placebo perceived improvement after Day 1 (60.6% vs. 41.9%) through Day 14 (84.3% vs. 64.1%). On Day 1, improvement in Q(max) with DOX GITS was not significantly different compared with placebo. On Day 3 of the trial (1) IPSS improvement was significantly greater with DOX GITS than with placebo; (2) proportion of patients with >/=30% improvement in IPSS was significantly greater with DOX GITS (49.5%) than placebo (28.4%) and remained so through Day 14; (3) improvement in Q(max) was significantly greater with DOX GITS (3.7mL/s) than placebo (1.9mL/s) and remained so through Day 14; (4) proportion of patients with >/=3mL/s increase in Q(max) was statistically greater with DOX GITS (54.4%) versus placebo (30.8%) and remained so through Day 14. CONCLUSIONS: DOX GITS significantly improved IPSS and Q(max) by Day 3 of treatment, and these changes were maintained through Day 14. More patients receiving DOX GITS than placebo perceived improvement in symptoms as early as Day 1.

Response to antibiotics of women with symptoms of urinary tract infection but negative dipstick urine test results: double blind randomised controlled trial.
Richards D, Toop L, Chambers S, Fletcher L
BMJ 2005 Jun 22;.

OBJECTIVE: To assess the effectiveness of antibiotic treatment of women with symptoms of urinary tract infection but negative urine dipstick testing. DESIGN: Prospective, double blind, randomised, placebo controlled trial. SETTING: Primary care, among a randomly selected group of general practitioners in Christchurch, New Zealand. PARTICIPANTS: 59 women aged 16-50 years presenting with a history of dysuria and frequency in whom a dipstick test of midstream urine was negative for both nitrites and leucocytes. Participants with complicated urinary tract infection were excluded. INTERVENTION: Trimethoprim 300 mg daily for three days or placebo. MAIN OUTCOME MEASURES: Self reported diary of symptoms for seven days, recording the presence or absence of individual symptoms each day, followed by a structured telephone questionnaire after seven days. The main clinical outcome was resolution of dysuria at three and seven days and median time to resolution. Secondary outcomes were resolution of other symptoms. RESULTS: The median time for resolution of dysuria was three days for trimethoprim compared with five days for placebo (P=0.002). At day 3, five (24%) of patients in the treatment group had ongoing dysuria compared with 20 (74%) in the placebo group (P=0.005). This difference persisted until day 7: two patients (10%) in the treatment group v 11 (41%) in the placebo group; P=0.02). The number needed to treat was 4. The median duration of constitutional symptoms (feverishness, shivers) was reduced by four days. CONCLUSIONS: Although a negative dipstick test for leucocytes and nitrites accurately predicted absence of infection when standard microbiological definitions were used (negative predictive value 92%), it did not predict response to antibiotic treatment. Three days' treatment with trimethoprim significantly reduced dysuria in women whose urine dipstick test was negative. These results support the practice of empirical antibiotic use guided by symptoms. Balancing the competing interests of symptom relief and the minimisation of antibiotic use remains a dilemma--further research is needed to determine clinical predictors of response to antibiotics.

In patients with early prostate cancer, is surgery better than watchful waiting?
Alibhai SM, Gogov S
CMAJ 2005 Jun 21;172(13):1682.

The effect of fluid intake on urinary symptoms in women.
Swithinbank L, Hashim H, Abrams P
J Urol 2005 Jul;174(1):187-9.

PURPOSE: We determined the effect of caffeine restriction and fluid manipulation in the treatment of patients with urodynamic stress incontinence and detrusor overactivity. MATERIALS AND METHODS: This was a 4-week randomized, prospective, observational crossover study in 110 women with urodynamic stress incontinence (USI) or idiopathic detrusor overactivity (IDO) to determine the effect of caffeine restriction, and of increasing and decreasing fluid intake on urinary symptoms. Data were recorded in a urinary diary for the entire study period on urgency episodes, frequency, pad weight increase, wetting episodes and quality of life. RESULTS: A total of 69 women with a mean age of 54.8 years completed the study, including 39 with USI and 30 with IDO. In the IDO group decreasing fluid intake significantly decreased voiding frequency, urgency and wetting episodes with improved quality of life. In the USI group there was a significant decrease in wetting episodes when fluid intake was decreased. Changing from caffeine containing to decaffeinated drinks produced no improvement in symptoms. CONCLUSIONS: Conservative and life-style interventions are first line treatments in the management of incontinence and storage lower urinary tract symptoms. This study shows that a decrease in fluid intake improves some of these symptoms in patients with USI and IDO and, therefore, it should be considered when treating such patients.

Results of urine cytology testing and cystoscopy in women with irritative voiding symptoms.
Sokol ER, Patel SR, Sung VW, Rardin CR, Weitzen S, Clemons JL, Myers DL.
Am J Obstet Gynecol 2005 May;192(5):1560-5.

OBJECTIVE: The purpose of this study was to assess rates of urinary cytologic abnormalities and cystoscopic outcomes in women with irritative voiding symptoms who were examined at a urogynecology clinic. STUDY DESIGN: All urinary cytology studies results that were sent between January 1, 2000, and July 31, 2003, for the evaluation of irritative voiding symptoms were reviewed. Data were then extracted from the charts of a subset of these patients to evaluate cystoscopic outcomes. Demographics, risk factors for urothelial cancer, laboratory results, and radiology imaging results were then analyzed and compared between patients with and without abnormal cytology and cystoscopic results. RESULTS: Of the 1783 total urinary cytology that were reviewed, 1661 test results were read as normal (93.2%); 112 test results (6.3%) were read as atypical, and 3 test results (0.2%) were read as unsatisfactory. Seven cytologic test results were categorized as suspicious or malignant, which accounts for only 0.4% of all cytologic test results that were sent. Of the 564 consecutive women whose cases were chosen for subanalysis, cytology was normal in 91.5% and atypical in 8.5% of cases. No cytology were suspicious or malignant. Cystoscopic findings were normal in 548 patients (97.2%). Only 1 patient (0.2%) received a diagnosis of transitional cell carcinoma. CONCLUSION: Urinary cytology and cystoscopy are low yield tests and should not be used routinely in the initial evaluation of women with irritative voiding symptoms.

The usefulness of urinary cytology testing in the evaluation of irritative voiding symptoms.
Sokol ER, Patel SR, Clemons JL, Sung VW, Rardin CR, Myers DL.
Am J Obstet Gynecol 2005 May;192(5):1554-9.

OBJECTIVE: The purpose of this study was to assess the clinical usefulness of urinary cytology testing for the evaluation of urothelial cancer in women with irritative voiding symptoms who were examined at a urogynecology service. STUDY DESIGN: Urinary cytology studies results that were obtained from January 1, 2000, to December 31, 2002, were cross-matched with the Rhode Island Department of Health Cancer Registry to identify those women who were diagnosed with urinary tract malignancies. The prevalence of urothelial cancer was determined, and the sensitivity, specificity, and positive and negative predictive values of urinary cytologic testing were calculated for 2 common classification strategies: (1) consideration of atypical cytologic test results to be normal and (2) consideration of atypical cytologic test results to be abnormal. RESULTS: Among 1516 cross-matched cytologic test results from 1324 patients, 5 urothelial cancers were identified. Two of the 5 malignancies were associated with positive cytology results. The prevalence of urothelial cancer was 0.38% (95% CI, 0.1%, 0.9%). When atypical cytology studies were classified as normal, the sensitivity of urinary cytology was 40% (95% CI, 7.2%, 83.0%); the specificity was 99.9% (95% CI, 99.5%, 100%); the positive predictive value was 66.7% (95% CI, 12.5%, 98.2%), and negative predictive value was 99.8% (95% CI, 99.2%, 100%). In contrast, when atypical cytology results were classified as abnormal, the sensitivity and negative predictive value remained the same, but the specificity declined to 93.6% (95% CI, 92.1%, 94.8%), and the positive predictive value decreased to 2.3% (95% CI, 0.4%, 8.8%). CONCLUSION: The low prevalence of urothelial cancers and low sensitivity of urinary cytology studies severely limit the usefulness of this test in the evaluation of women with irritative voiding symptoms.

Circumcision for the prevention of urinary tract infection in boys: A systematic review of randomized trials and observational studies.
Singh-Grewal D, Macdessi J, Craig J.
Arch Dis Child 2005 May 12;.

OBJECTIVE: Circumcision is the most frequently performed surgical procedure in boys. This systematic review summarises the existing data about the effect of circumcision on the risk of urinary tract infection in boys. DATA SOURCES: Randomised controlled trials and observational studies comparing the frequency of urinary tract infection in circumcised and uncircumcised boys were identified from the Cochrane Controlled Trials Register, MEDLINE, EMBASE, reference lists of retrieved articles and contact with known investigators. Review METHODS: Two of the authors independently assessed study quality using the guidelines provided by the MOOSE Statement for quality of observational studies. RESULTS: Data from 402,908 children was identified from twelve studies (one randomised controlled trial, four cohort studies and seven case control studies). A random effects model was used to estimate a summary odds ratio (OR) with 95% confidence intervals (CI). Circumcision was associated with a significantly reduced risk of urinary tract infection (OR 0.13; 95%CI, 0.08- 0.20; p<0.001) with the same odds ratio (0.13) for all three study designs. CONCLUSION: Circumcision substantially reduces the risk of urinary tract infection. Given a risk of UTI in normal boys of about 1%, the number-needed-to treat to prevent one urinary tract infection is 111. In boys with recurrent urinary tract infection or high-grade vesicoureteric reflux , the risk of urinary tract infection recurrence is 10% and 30% and the numbers needed-to-treat are 11 and 4 respectively. Haemorrhage and infection are the commonest complications of circumcision occurring at rate of about 2% and assuming equal utility of benefits and harms, net clinical benefit is only likely in boys at high risk of urinary tract infection.

Extramammary Paget's disease of penis and scrotum.
Yang WJ, Kim DS, Im YJ, Cho KS, Rha KH, Cho NH, Choi YD
Urology 2005 May;65(5):972-5.

OBJECTIVES: To make clear the uncertainty of the clinical outcome of extramammary Paget's disease (EMPD). Penile and scrotal involvement of EMPD is exceedingly rare, and only small series or case reports have been reported. METHODS: From 1995 to 2003, 36 patients with penile and scrotal EMPD were treated and followed up. Local wide excision was done in all patients with or without intraoperative frozen biopsy analysis. RESULTS: Of the 36 patients, 13 (36.1%) underwent intraoperative frozen biopsy analysis and only 1 patient (7.7%) had a positive surgical margin. However, 23 (63.9%) underwent local wide excision with excessive surgical margins of up to 1 to 2 cm only by gross examination, but 17 (73.9%) of them had positive surgical margins (P <0.01). Of the 17 patients with positive surgical margins, 8 developed local recurrence at a median of 8 months of follow-up (P <0.05). One patient who had invasion to the subcutaneous tissue died of metastatic EMPD and internal malignancy (renal cell carcinoma) at 17 months after the initial operation. No patient had underlying adnexal carcinoma. CONCLUSIONS: The results of our study indicate that local wide excision with intraoperative frozen biopsy analysis is essential to the complete treatment of EMPD.

Urogenital surgery of the 15th century in Anatolia.
Kendirci M, Kadioglu A, Boylu U, Miroglu C
J Urol 2005 Jun;173(6):1879-82.

PURPOSE: We examined the urological procedures of the 15th century covered in the surgery textbook, Cerrahiyyetu'l Haniyye. MATERIALS AND METHODS: Three copies of the surgery textbook, Cerrahiyyetu'l Haniyye (Sultan's Surgery), by Serefeddin Sabuncuoglu, who lived in Turkey between 1385 and 1470, were evaluated. The colorfully miniaturized and illustrated textbook, written 536 years ago, covers a number of surgical disciplines, including urology. We evaluated urological sections with regard to the type of procedures, definitions and approaches for certain diseases and surgical tools used for urological operations. RESULTS: The textbook reviews the surgical treatment of urological conditions such as varicocele, hydrocele, hermaphroditism, imperforated urinary meatus, meatal stenosis, hypospadias, penile and scrotal lesions, and circumcision techniques. It includes definitions of diseases, etiologies and surgical therapies, and describes surgical instruments. The author also illustrated surgical approaches and instruments. CONCLUSIONS: A treasure trove of surgical knowledge, Cerrahiyyetu'l Haniyye has enlightened urologists from the 15th century to the present day.

Melanoma of the penis, scrotum and male urethra: a 40-year single institution experience.
Sanchez-Ortiz R, Huang SF, Tamboli P, Prieto VG, Hester G, Pettaway CA.
J Urol 2005 Jun;173(6):1958-65.

PURPOSE: Genitourinary melanoma is rare and classically associated with a poor prognosis. We describe our experience with 10 patients with penile or urethral involvement. In addition, we present what is to our knowledge the largest reported series of melanoma of the scrotum (6 cases). MATERIALS AND METHODS: We reviewed the records of 16 men who presented consecutively to our institution with genitourinary melanoma between 1962 and 2000. Clinical and pathological characteristics were assessed, including Breslow thickness, primary surgical intervention and clinical course. RESULTS: Of 10 patients with penile or urethral melanoma 1997 American Joint Committee on Cancer melanoma pathological stage was T1 (depth less than 0.75 mm) in 4, T2 (0.75 to 1.5 mm) in 3 and T3 (1.51 to 4 mm) in 3. Only 1 of 4 patients with clinically palpable inguinal nodes had inguinal metastases at lymphadenectomy (BILND) and 3 who underwent prophylactic superficial BILND had negative findings. In 7 patients with T1-2N0M0 disease there were no local recurrences after wide local excision (WLE) or partial penectomy at a median followup of 35 months. Six of 7 men were rendered disease-free. One patient died of melanoma that developed at a second primary site. The 3 patients with T3 tumors who underwent partial (2) or radical (1) penectomy with or without BILND died of disease (2) or had progression (1). In all patients with penile melanoma the 5-year actuarial disease specific and recurrence-free survival rates were 80% and 60%, respectively, at a median followup of 39 months (range 20 to 210). Six patients with scrotal melanoma were treated with WLE without local recurrences. Three of the 6 patients had palpable inguinal nodes, of whom 2 died after chemotherapy for unresectable disease and 1 died of other causes 51 months after negative BILND. The 3 men with clinically negative groins who did not undergo prophylactic BILND had distant (1) or regional (2) metastases and died of disease. In patients with scrotal melanoma the 5-year actuarial disease specific and recurrence-free survival rates were 33.3% and 33.3%, respectively, at a median followup of 36 months. CONCLUSIONS: Partial penectomy or WLE provided effective local control for low stage penile or urethral melanomas and all scrotal lesions. Patients showing clinically positive, proven metastasis died despite appropriate surgical procedures and multi-agent chemotherapy. Prophylactic modified inguinal lymphadenectomy should be considered in select patients with penile, scrotal and anterior urethral melanoma.

Coccidioidomycosis of the male genital tract.
Sohail MR, Andrews PE, Blair JE.
J Urol 2005 Jun;173(6):1978-82.

PURPOSE: Symptomatic genital tract infection is a rare manifestation of disseminated coccidioidomycosis. We characterized the clinical presentation, diagnosis, management and outcome in male patients with genitourinary coccidioidomycosis. MATERIALS AND METHODS: We reviewed all cases of genital tract coccidioidomycosis involving testes, epididymis or prostate at our institution between 1990 and 2000, and searched the medical literature for all reports since the first reported case in 1943. RESULTS: A total of 30 male patients with a median age of 58 years who had coccidioidomycosis of the genital tract were identified, including 6 at our institution. Four patients (13%) had a simultaneous pulmonary infection and 63% (19) had a remote history of primary pulmonary coccidioidomycosis. The most commonly involved genital tract sites were the epididymis in 18 cases, prostate in 14 and testes in 6. Patients with prostatitis presented with urinary obstruction, prostatic enlargement, tenderness and palpable nodules. Most patients with epididymal infection presented with scrotal swelling, tenderness and induration. All 30 patients (100%) had histopathological evidence of granulomatous inflammation with fungal spherules. Urine fungal cultures were positive in 19 cases (63%). A total of 12 patients received combined medical and surgical treatment, and 18 underwent surgical excision only. Most immunocompetent patients with isolated genital coccidioidomycosis did well with surgical resection alone. Six deaths occurred in patients with multifocal, extragenital, disseminated disease. CONCLUSIONS: Male genitourinary coccidioidomycosis is rare but it should be considered in the differential diagnosis of patients with exposure to the endemic area who present with prostatitis or epididymitis.

Contemporary issues and management of bladder cancer.
Resnick MI
Urol Clin North Am 2005 May;32(2):xi.

Prostate botulinum A toxin injection--an alternative treatment for benign prostatic obstruction in poor surgical candidates.
Kuo HC
Urology 2005 Apr;65(4):670-4.

OBJECTIVES: To evaluate, in a prospective study, the effectiveness of prostate injection of botulinum A toxin in patients who were poor surgical candidates. Patients with benign prostatic hyperplasia (BPH) are usually successfully treated with medical treatment or transurethral resection. However, some patients with chronic urinary retention or a large postvoid residual urine volume due to BPH are poor surgical candidates or are patients in whom medical treatment has failed. METHODS: Ten patients with BPH and urinary retention or a large postvoid residual urine volume received 200 U botulinum A toxin injection into the transition zone of the prostate. The clinical results and urodynamic parameters at baseline and after treatment were compared. RESULTS: All patients had an improvement in spontaneous voiding after treatment. Of them, 8 had an excellent result (80%) and 2 had an improved result. Both voiding pressure and postvoid residual volume were significantly decreased after treatment. The total prostate volume was significantly reduced, and the maximal flow rate was significantly increased after treatment. The maximal effects of botulinum A toxin appeared at about 1 week and were maintained at 3 and 6 months after treatment. At 6 to 12 months (mean 9) of follow-up, no patient had had recurrence of urinary retention and the voiding condition in all patients remained at the post-treatment status. No adverse effect was noted. CONCLUSIONS: Prostate injection of botulinum A toxin is an effective alternative treatment with minimal adverse effects for patients with benign prostatic obstruction who are poor surgical candidates or in whom medical treatment has failed.

Effect of age and grade on surgery for patients with varicocele.
Ishikawa T, Fujisawa M
Urology 2005 Apr;65(4):768-72.

OBJECTIVES: To assess the seminal characteristics, hormonal levels, and pathologic findings in patients of various age groups with varicocele before and after ligation to establish the presence of an aging effect in patients with varicocele on those characteristics. METHODS: The records were retrospectively evaluated for 70 infertile patients with azoospermia or oligospermia who underwent microsurgical left inguinal varicocele ligation. The mean +/- SD patient age was 33.9 +/- 5.5 years. Left varicocele was detected in 70 patients. We divided our patients into three groups according to age: group 1, 20 to 29 years old (n = 17); group 2, 30 to 39 years old (n = 41); and group 3, older than 40 years (n = 12). RESULTS: Before ligation, no significant differences were seen among the three groups in luteinizing hormonal level, prolactin level, estradiol level, right testicular volume, semen volume, and sperm concentration and sperm motility. Significant differences were seen in the follicle-stimulating hormonal level, testosterone level, and left testicular volume. After ligation, even in group 3, the sperm concentration and motility increased from 6.38 +/- 5.47 to 13.07 +/- 9.05 million/mL (P = 0.042) and from 28.42% +/- 23.22% to 39.92% +/- 22.06%, respectively. No significantly greater degree of improvement in semen characteristics was observed between grade II and grade III after varicocele ligation. CONCLUSIONS: The results of our study have shown that age is not a significant predictive factor of improvement in semen characteristics before ligation. It is reasonable to perform ligation to improve the semen characteristics in patients older than 40 years old.

Fluorocholine PET/CT in Patients with Prostate Cancer: Initial Experience.
Schmid DT, John H, Zweifel R, Cservenyak T, Westera G, Goerres GW, von Schulthess GK, Hany TF
Radiology 2005 May;235(2):623-8.

Institutional review board approval and written informed consent were obtained. Patients with newly diagnosed prostate cancer and patients suspected of having recurrent prostate cancer were prospectively evaluated with fluorine 18 fluorocholine (FCH) combined in-line positron emission tomography (PET) and computed tomography (CT). In 19 patients (mean age, 67 years +/- 8; range, 57-85 years), standardized uptake values of FCH in 17 different tissues were determined by using volumes of interest. In nine patients evaluated at initial staging, histologic findings of the resected prostate were compared to FCH uptake. Only small variations of physiologic tracer accumulation were measured in all organs but the kidneys. Differentiation of benign hyperplasia from cancerous prostate lesions was not possible with FCH PET/CT. However, in patients with recurrent prostate cancer, FCH PET/CT is a promising imaging modality for detecting local recurrence and lymph node metastases. (c) RSNA, 2005.

Urethral adenocarcinoma mimicking urethral caruncle.
Cimentepe E, Bayrak O, Unsal A, Koc A, Ataoglu O, Balbay MD
Int Urogynecol J Pelvic Floor Dysfunct 2005 Apr 15;.

Urethral caruncles are considered as benign tumors. They need to be treated surgically; specimens should carefully be evaluated for the presence of any malignancy. We are presenting a 57-year-old female patient with a urethral lesion that looks like caruncle, but histopathologic examination of the excised lesion was reported as urethral adenocarcinoma.

Intussusception of the bladder neck does not promote early restoration to urinary continence after non-nerve-sparing radical retropubi c prostatectomy.
Sakai I, Harada K, Hara I, Eto H, Miyake H
Int J Urol 2005 Mar;12(3):275-9.

Background: The objectives of the present study were to investigate whether buttressing sutures, which prevent the bladder neck from pulling open as the bladder fills, can promote earlier recovery from urinary incontinence after radical retropubic prostatectomy (RRP) and to identify possible risk factors associated with urinary incontinence after RRP. Methods: The present study included 72 patients who underwent non-nerve-sparing RRP without neoadjuvant therapy between January and December 2003. Among these 72 patients, intussusception of the bladder neck was performed in 24 who consented to this procedure. In the present series, continence was defined as the absence of any need to use sanitary pads or diapers. Continence was evaluated by a patient interview 1, 3 and 6 months after RRP. Results: There were no significant differences in clinicopathological characteristics between patients with and without intussusception of the bladder neck. The percentage of continent patients 1, 3 and 6 months after RRP was 34.7%, 63.9% and 95.8%, respectively, and there were no significant differences in continence between the two groups at any time point. Among several factors examined, only bladder neck preservation was an independent predictor of recovery from urinary incontinence 1 and 3 months after RRP. Conclusions: These findings suggest that it would be important to preserve the bladder neck for early return to continence after non-nerve-sparing RRP; however, intussusception of the bladder neck may not offer significant improvement in earlier return of urinary control.

Eosinophilic cystitis and its management.
Teegavarapu PS, Sahai A, Chandra A, Dasgupta P, Khan MS
Int J Clin Pract 2005 Mar;59(3):356-60.

Eosinophilic cystitis (EC) is a rare clinicopathological condition characterized by transmural inflammation of the bladder predominantly with eosinophils, associated with fibrosis with or without muscle necrosis. The cause of EC remains unclear, although it has been associated with various aetiological factors, such as allergy, bladder tumour, bladder trauma, parasitic infections and chemotherapeutic agents. EC is, probably, caused by the antigen-antibody reaction. This leads to the production of various immunoglobulins, which, in turn, cause the activation of eosinophils and initiates the inflammatory process. The most common symptom complex consists of frequency, haematuria, dysuria and suprapubic pain. Cystoscopy and biopsy are the gold standard for diagnosis. Additional laboratory evidence supporting the diagnosis includes proteinuria, microscopic haematuria and peripheral eosinophilia, the last one occurring in few patients. There is no curative treatment for this condition. Current treatment modalities include transurethral resection of the bladder lesion along with non-specific medical therapy, such as non-steroidal anti-inflammatory agents or steroids. Because the lesion tends to recur in spite of the above therapy, long-term follow-up is mandatory.

Treatment options for paraphimosis.
Little B, White M
Int J Clin Pract 2005 May;59(5):591-3.

Paraphimosis is a frequently presented complaint in the emergency department. This review outlines the treatment options available for resolving this condition: manual reduction methods, osmotic methods, puncture and aspiration methods and treatments using sharp incision. The technique of penile block local anaesthesia is described. A technique sequence for treatment is suggested.

Enlarging the scope of managing benign prostatic hyperplasia: addressing sexual function and quality of life.
Martin DJ, Mulhall JP
Int J Clin Pract 2005 May;59(5):579-90.

Benign prostatic hyperplasia is a common genitourinary disorder that increases in incidence with age. Symptoms of this condition include a weak urinary stream, hesitancy, intermittency and sensations of incomplete emptying, as well as frequency, urgency, urge incontinence and nocturia. These symptoms can be ameliorated successfully by a variety of medical treatments - such as alpha(1)-adrenergic blockade and 5-alpha-reductase inhibition - and surgical therapies - including transurethral resection of the prostate and less-invasive procedures. However, many of the treatments are known to result in sexual dysfunction, which can have a negative impact on the patient's quality of life. This must be considered when the physician seeks to determine the appropriate treatment for an individual patient. Current reports suggest that alpha(1)-adrenergic blockade is most likely to improve lower urinary tract symptoms while resulting in the fewest sexual side-effects; 5-alpha-reductase inhibitors appear to be particularly appropriate in men with large prostates. Among surgical therapies, transurethral resection of the prostate remains the gold standard, but is associated with a high incidence of sexual side-effects, especially retrograde ejaculation. Transurethral incision of the prostate, which is an endoscopic procedure, may be as effective as transurethral resection, but results in fewer side-effects. Minimally invasive procedures, including laser ablation or resection of the prostate, transurethral microwave thermotherapy and transurethral needle ablation, are rapidly evolving technologies that have demonstrated promising results, at least in the short term.

Intravesical resiniferatoxin for the treatment of interstitial cystitis: a randomized, double-blind, placebo controlled trial.
Payne CK, Mosbaugh PG, Forrest JB, Evans RJ, Whitmore KE, Antoci JP, Perez-Marrero R, Jacoby K, Diokno AC, O'Reilly KJ, Griebling TL, Vasavada SP, Yu AS, Frumkin LR Cystitis).

J Urol 2005 May;173(5):1590-4.
PURPOSE: Interstitial cystitis is a painful bladder condition of unknown etiology and poorly understood pathophysiology. Current therapies have met with limited success. Vanilloid receptor agonists such as resiniferatoxin (RTX) desensitize C-fibers that transmit pain; it is hypothesized that such drugs will be effective in the treatment of interstitial cystitis and painful bladder syndrome by decreasing the pain that leads to urinary frequency and urgency. MATERIALS AND METHODS: A randomized, double-blind, placebo controlled study was conducted in 163 patients with interstitial cystitis. Participants were randomly assigned to receive a single intravesical dose of 50 ml of either RTX 0.01 microM, 0.05 microM, 0.10 microM, or placebo. Safety and efficacy was evaluated over 12 weeks. The primary efficacy endpoint was the Global Response Assessment, a 7-point scale rating overall change in symptoms of interstitial cystitis after 4 weeks. Secondary efficacy endpoints included reduction in pain, urgency, frequency, nocturia, average void volume, and the O'Leary-Sant Symptom and Problem Indexes. RESULTS: RTX did not improve overall symptoms, pain, urgency, frequency, nocturia, or average void volume during 12 weeks followup. RTX resulted in a dose-dependent increase in the incidence of instillation pain, but was otherwise generally well tolerated. CONCLUSIONS: In the largest prospective, randomized clinical trial reported to date with intravesical vanilloid therapy, single administration of RTX at doses of 0.01 microM to 0.10 microM was not effective in patients with interstitial cystitis.

Surgical procedures for urethral diverticula in women in the United States, 1979-1997.
Burrows LJ, Howden NL, Meyn L, Weber AM
Int Urogynecol J Pelvic Floor Dysfunct 2005 Mar-Apr;16(2):158-61. Epub 2004 Oct 22.

The objective of this study was to describe national rates of surgery for urethral diverticula in women. Data from the National Hospital Discharge Survey (NHDS), a federal database that samples inpatient hospitals in the United States, were analyzed from 1979 to 1997 for diagnosis and procedure codes using the ICD-9-CM classification system. The difference between the median age-adjusted rates from 1979 to 1988 and 1989 to 1997 were evaluated using the Mann-Whitney U test since the yearly rates fluctuated in a nonlinear fashion. Data from the National Statistics for Ambulatory Surgery (NSAS) database were analyzed from 1994 to 1996 in a similar fashion. The average age of women undergoing surgery for urethral diverticula increased from 41.6+/-15.1 years from 1979 to 1988 to 49.4+/-14.8 years from 1989 to 1997 (p=0.02). The average length of hospital stay decreased from 8.4+/-5.0 days in 1979 to 3.2+/-1.7 days in 1997 (p=0.007). Approximately 27,000 inpatient procedures were performed for the repair of urethral diverticula in the United States over a 19-year period, ranging from an estimated 500 to 3400 cases per year. The median age-adjusted rate of procedures decreased from 14.2 per 1 million women from 1979 to 1988 to 6.4 per 1 million women from 1989 to 1997 (p=0.009). Data from the NSAS indicated that an average of 6.7 surgeries per 1 million women per year were performed in the outpatient setting from 1994 to 1996. Age-adjusted rates of inpatient surgery for urethral diverticula were threefold higher for black compared to white women. Inpatient surgical repair of urethral diverticula is three times as high in black as compared to white women. These procedures are infrequent and rates appear to have decreased over time.

Re: Urinary conduit formation using a retubularized bowel from continent urinary diversion or intestinal augmentations: II. Does it have a role in patients with interstitial cystitis?
van Ophoven A
J Urol 2005 Apr;173(4):1435.

Skill Assessment of Urological Laparoscopic Surgeons: Can Criterion Levels of Surgical Performance Be Determined Using the Pelvic Box Trainer?
Katz R, Hoznek A, Salomon L, Antiphon P, de la Taille A, Abbou CC
Eur Urol 2005 Apr;47(4):482-487. Epub 2005 Jan 1.

OBJECTIVES: To correlate between surgeons' experience in urological laparoscopy and their performance of a set of laparoscopic tasks performed on a box trainer in the laparoscopic laboratory. METHODS: 44 urologists participated in this study. A self-administrated questionnaire enquired about their experience in laparoscopy and they were divided to 4 categories: no experience, minimal experience, basic and advanced laparoscopists. Tests consisted of 4 tasks: passage of a ligature, intracorporeal knotting, intracorporeal suturing, and cutting a carton circle out of a square. All tests were supervised and time was recorded for each of the tasks. Histograms were plotted showing the mean time for performance of each task in each experience group. The Kruskal-Wallis analysis of variance was used to assess statistical significance. RESULTS: Seven participants had no previous experience in laparoscopy and 14 had minimal experience. 15 had basic experience and 8 were advanced laparoscopists. No difference in performance was found between the no experience and minimal experience group and they were united and defined as beginners. A significant difference in performance was noted between the beginners, basic and advanced groups, especially when comparing beginners to advanced. Criterion level values of surgical performance drawn from this data were highly discriminative with sensitivity of 71-85% and specificity of 74.2%-88%. CONCLUSIONS: We were able to differentiate between various levels of laparoscopic skills among the participating urologists. Values drawn from such studies could be the basis of criterion level values for technical laparoscopic performance during training programs and before granting laparoscopic privileges to urologists.

[Leriche technique for the treatment of La Peyronie's disease]
Khouaja K, Delmas V, Boccon-Gibod L
Prog Urol 2004 Sep;14(4):586-9; discussion 588-9.

OBJECTIVE: The treatment of La Peyronie's disease comprises medical treatment during the inflammatory acute phase and surgical treatment at the stage of stabilization of the lesions. This technical report describes the Leriche technique for the treatment of the stable phase of La Peyronie's disease. OPERATIVE TECHNIQUE: Patients are operated on an outpatient basis under local anaesthesia, after localization of the plaque by intraoperative ultrasound of the penis with erection induced by physiological saline. A percutaneous tear of the plaque is performed with an 18 gauge needle. MATERIALS AND METHODS: Ten patients with a mean age of 58 years (range: 32-82 years) were operated for La Peyronie's disease between January 2002 and January 2004. They all presented with painless penile curvature on erection, but severe discomfort or impossibility of sexual intercourse. The patients were reviewed at 1 and to 3 months. The results were assessed in terms of the degree of penile straightening and resumption of sexual activity. RESULTS: Three patients obtained complete cure. Two patients gained sufficient penile straightening to allow sexual intercourse and recovery was insufficient to allow sexual intercourse for 3 patients, but the result was improved after a second or even a third attempt. The last 2 patients were classified as treatment failures and were treated by penile prosthesis in one case and by the Nesbit technique in the other case. The results observed at 1 month persisted at 3 months. CONCLUSION: The Leriche technique for the treatment of La Peyronie's disease is a simple, minimally invasive technique with satisfactory results. It does not compromise a subsequent procedure and does not present any short-term or long-term complications.

Nephrolithiasis and nephrocalcinosis in rats with small bowel resection.
O'connor RC, Worcester EM, Evan AP, Meehan S, Kuznetsov D, Laven B, Sommer AJ, Bledsoe SB, Parks JH, Coe FL, Grynpas M, Gerber GS
Urol Res 2005 Apr 7;.

Intestinal resection (IR) may lead to hyperoxaluria and nephrolithiasis. A rat model of IR was developed, in which kidney stones form. We describe the urine chemistries and histopathologic features. Rats underwent resection of 40-45 cm of distal ileum (n=16) or sham resection (SR) (n=8), and were then fed a 1% Na oxalate, 0.02% Ca diet. After 1 week on the diet, 24 h urine samples were obtained for stone chemistries. At 4-7 months after surgery, kidneys were examined grossly and by light microscopy. The extent and location of crystallization was assessed by polarized light. Histochemistry and infrared spectroscopy were used to determine crystal composition. IR rats had higher urine oxalate excretion (P<0.01) and concentration (P<0.001) than SR rats, and lower urine citrate excretion; only IR rats formed kidney stones (12/15 surviving rats). Tissue calcification was found only in kidneys from IR rats, located in the cortex (83% of kidneys), medulla (73%) and papillary tip (47%). Crystals, composed of CaOx, apatite, and calcium carbonate, filled collecting duct lumens, and were associated with tubular obstruction, and interstitial inflammation. Crystals in the papillary interstitium incited inflammation with tubular destruction and development of progressive papillary erosion. This new rat model of nephrolithiasis and nephrocalcinosis resembles the pattern of urinary abnormalities and tissue calcification that may be seen in humans with small bowel resection. The model allows further studies of the mechanisms of renal crystal formation, and possible therapeutic interventions.

Laparoscopic retropubic simple prostatectomy.
Sotelo R, Spaliviero M, Garcia-Segui A, Hasan W, Novoa J, Desai MM, Kaouk JH, Gill IS
J Urol 2005 Mar;173(3):757-60.

PURPOSE: Open retropubic simple prostatectomy is occasionally performed for symptomatic, large volume benign prostatic hyperplasia. We describe the technique of laparoscopic simple retropubic prostatectomy. MATERIALS AND METHODS: Since August 2001 at our 2 institutions laparoscopic simple retropubic prostatectomy has been performed in 17 patients with symptomatic significant prostatomegaly on transrectal ultrasonography (60 gm or greater, mean 93). Essential aspects of our 5 port technique are transverse cystotomy just proximal to the prostatovesical junction, subcapsular plane development, prostatic adenomectomy, prostatic fossa trigonization and prostatic capsule suture repair. Demographic, perioperative and outcome data were recorded. RESULTS: Mean operative time was 156 minutes (range 85 to 380), blood loss was 516 ml (range 100 to 2,500), hospital stay was 48 hours (range 15 to 110), and Foley catheter duration was 6.3 days (range 3 to 7). Mean specimen weight on pathological examination was 72 gm (range 32 to 120). Five patients (29%) required blood transfusion. Complications occurred in 3 patients (19%), that is intraoperative hemorrhage, catheter clot obstruction and duodenal ulcer bleeding in 1 each. All patients reported complete continence during a followup period of 1 month to 2 years. Considerable improvement from baseline was noted in American Urological Association score (preoperative vs postoperative 24.5 vs 9.9) and the maximum urine flow rate (preoperative vs postoperative 7 vs 22.8 cc per minute). CONCLUSIONS: Laparoscopic simple retropubic prostatectomy for large benign prostate hyperplasia is feasible. Our initial experience is presented.

Cadaveric anatomy of pelvic fracture urethral distraction injury: most injuries are distal to the external urinary sphincter.
Mouraviev VB, Santucci RA
J Urol 2005 Mar;173(3):869-72.

PURPOSE: The anatomy of posterior urethral distraction injuries is controversial. We present a cadaver study of posterior urethral distraction injuries. To our knowledge this is the first study that establishes that the most common location is distal to the external urinary sphincter. MATERIALS AND METHODS: We performed an autopsy review of 10 male patients with posterior urethral distraction injuries. RESULTS: Urethral disruption occurred distal to the external urinary sphincter in 7 of 10 patients. It appeared to occur when the anterior pelvic ring and urogenital diaphragm complex were displaced caudal and rostrally, tearing the urogenital diaphragm off of the urethra. The average inner mucosal defect +/- SD was 3.5 +/- 0.5 cm, while the defect between the outer urethral layer (tunica of the spongiosum) was 2.0 +/- 0.2 cm due to mucosal retraction. Simple and complex injuries could be observed, according to the clinical classification proposed by Turner-Warwick in 1989. Simple injuries had less significant dislocation of the symphysis, general maintenance of urethral continuity and slightly shorter mucosal distraction (3.3 cm). Complex disruptions had significant symphyseal dislocation, complete disassociation of the urethral ends (often with interposition of other tissues) and a slightly longer mucosal distraction (3.8 cm). CONCLUSIONS: Posterior urethral distraction injuries appear to most commonly occur distal to the urogenital diaphragm, contrary to classic teaching. These injuries are on average between 3 and 4 cm, and they are more significant dorsal than ventral. They appear to occur as simple or complex injuries, mirroring the clinical findings seen in clinically simple and complex urethral strictures.

The treatment of posterior urethral disruption associated with pelvic fractures: comparative experience of early realignment versus delayed urethroplasty.
Mouraviev VB, Coburn M, Santucci RA
J Urol 2005 Mar;173(3):873-6.

PURPOSE: Urological treatment of the patient with severe mechanical trauma and urethral disruption remains controversial. Debate continues regarding the advisability of early realignment vs delayed open urethroplasty. We analyzed our experience with 96 patients to determine the long-term results of the 2 approaches. MATERIALS AND METHODS: We retrospectively reviewed the records of 191 men with posterior urethral disruption after severe blunt pelvic injury between 1984 and 2001, of whom 96 survived. Data on 57 patients who underwent early realignment were compared to those on 39 treated with delayed urethroplasty with an average 8.8-year followup (range 1 to 22). All patients were evaluated postoperatively for incontinence, impotence and urethral strictures. RESULTS: The majority of patients had severe concomitant organ injuries (78%) and severe pelvic fractures (76%). The overall mortality rate was 51%. Diagnosis of urethral rupture was based on clinical findings and retrograde urethrography. Strictures developed in 49% of the early realignment group and in 100% of the suprapubic tube group. Impotence (33.6%) and incontinence (17.7%) were less frequent in the early realignment group than in the delayed reconstruction group (42.1% and 24.9%, respectively). Patients with delayed reconstruction underwent an average of 3.1 procedures compared with an average of 1.6 in the early realignment group. CONCLUSIONS: Early realignment may provide better outcomes than delayed open urethroplasty after posterior urethral disruption. Increased complications are not seen and, although it can be inconvenient in the massively injured patient, it appears to be a worthwhile maneuver.

Testicular descent and cryptorchidism: The state of the art in 2004.
Hutson JM, Hasthorpe S
J Pediatr Surg 2005 Feb;40(2):297-302.

Abstract The understanding of testicular descent has changed much in the 20 years since the authors' laboratory began studying the mechanism. The process is now known to occur in 2 steps with different anatomy and hormonal regulation but with many still unresolved controversies. Recent advances include the recognition of acquired cryptorchidism of critical early postnatal germ cell development and the recommendation for surgery at 6 months of age. The authors still await long-term outcome studies.

Bladder stone formation after sigmoidocolocystoplasty: Statistical analysis of risk factors.
Zhang H, Yamataka A, Koga H, Kobayashi H, Lane GJ, Miyano T
J Pediatr Surg 2005 Feb;40(2):407-11.

Abstract Purpose Bladder stone formation (BSF) after sigmoidocolocystoplasty (SCP) is a major source of morbidity. The authors identify risk factors and analyze them statistically. Methods Medical records of 106 patients who had SCP at our institute were reviewed to examine the incidence of post-SCP BSF, the stone removal method and length of follow-up. The primary underlying pathological conditions were myelomeningocele in 103 patients and other conditions in 3. Risk factors for BSF were statistically assessed by comparing cases with and without BSF. Results Bladder stone formation occurred in 20 (18.9%) of 106 patients (BSF group). The remaining 86 did not have stones (NBSF group). Mean age at SCP was 11.7 years in the BSF group and 10.2 years in the NBSF group. Mean follow-up was 12.0 years in the BSF group and 11.0 years in the NBSF group. BSF developed after a mean of 30.3 +/- 25.6 months after SCP. Twenty-two stone removal procedures were performed in the BSF group and spontaneous evacuation occurred in 4 instances. Once stone free, BSF recurred in 4 patients. Although differences between the 2 groups with respect to sex, age at SCP, follow-up period, bladder capacity, bladder compliance, incidence of gram-negative bacteriuria, incidence of gram-positive coccus bacteriuria, electrolytes, frequency of urinary catheterization, post-SCP incidence of vesicoureteric reflux, and incidence of ureteric reimplantation were not statistically significant, differences in the incidence of spontaneous micturition, bladder neck tightening procedures, or gram-positive bacillus bacteriuria, or frequency of bladder irrigation were all statistically significant ( P < .05 in all, Fisher's Exact test). Conclusions The authors are the first to statistically analyze a wide range of varying risk factors for BSF. BSF would appear to be common after SCP.

Urinary tract infections: new insights into a common problem.
Kucheria R, Dasgupta P, Sacks SH, Khan MS, Sheerin NS
Postgrad Med J 2005 Feb;81(952):83-6.

This review discusses recent advances in the understanding of how the common pathogen, uropathogenic Escherichia coli, interacts with the host to lead to infection.

The vicious cycling: bicycling related urogenital disorders.
Leibovitch I, Mor Y
Eur Urol 2005 Mar;47(3):277-87. Epub 2004 Dec 30.

PURPOSE: Bicycle riding is one of the most popular means of transportation, recreation, fitness and sports among millions of people of all ages who ride on road and off road, using a variety of bicycle types. It is also a readily available form of aerobic non-impact exercise with established cardiovascular beneficial effects. Bicycles are also a common source of significant injuries. This review focuses upon the specific bicycling related overuse injuries affecting the genitourinary tract. MATERIALS AND METHODS: MEDLINE search of the literature on bicycling and genitourinary disorders was performed using multiple subject headings and additional keywords. The search yielded overall 62 pertinent articles. We focused primarily on the most prevalent related disorders such as pudendal nerve entrapment, erectile dysfunction and infertility. The potential effect of bicycling on serum PSA level was also discussed in depth in view of its recognized clinical importance. Infrequent disorders, which were reported sporadically, were still addressed, despite their rarity, for the comprehensiveness of this review. RESULTS: The reported incidence of bicycling related urogenital symptoms varies considerably. The most common bicycling associated urogenital problems are nerve entrapment syndromes presenting as genitalia numbness, which is reported in 50-91% of the cyclists, followed by erectile dysfunction reported in 13-24%. Other less common symptoms include priapism, penile thrombosis, infertility, hematuria, torsion of spermatic cord, prostatitis, perineal nodular induration and elevated serum PSA, which are reported only sporadically. CONCLUSIONS: Urologists should be aware that bicycling is a potential and not an infrequent cause of a variety of urological and andrological disorders caused by overuse injuries affecting the genitourinary system.

Cross-sectional survey of long-term quality of life after radical perineal prostatectomy.
Yang BK, Crisci A, Young MD, Silverstein AD, Peterson BL, Dahm P
Urology 2005 Jan;65(1):120-5.

OBJECTIVES: To evaluate the late health-related quality of life (HRQOL) after radical perineal prostatectomy (RPP) and identify the predictors of outcome. METHODS: We performed a cross-sectional study of 266 consecutive patients who underwent RPP for clinically localized prostate cancer between July 1998 and December 2000. Of the 236 patients successfully contacted, 187 (79.2%) returned a validated patient self-assessment questionnaire, the Expanded Prostate Cancer Index Composite, a mean of 42.1 months (range 29 to 64) months after surgery. The median HRQOL scores were calculated in four disease-specific domains: urinary, bowel, sexual, and hormonal. Preoperative baseline information from a separate group of 144 consecutive RPP candidates from January 2002 to May 2003 was used for comparison. Univariate and multivariate logistic regression analyses were used to identify predictors of more favorable long-term HRQOL outcomes. RESULTS: No statistically significant differences were found in any of the domain-specific summary scores between the study and reference groups, except in the sexual domain (median score 19.2 versus 56.4; P = 0.001). The number of medical comorbidities was a statistically significant predictor of HRQOL summary scores in all domains (P <0.05). In addition, the urinary summary score was statistically significantly associated with income (P = 0.03), sexual summary with the use of erectile aids (P = 0.003), bowel summary with secondary radiotherapy (P = 0.001) and income (P = 0.002), and hormonal summary with androgen ablation (P = 0.004). CONCLUSIONS: The results of this study have shown that the long-term HRQOL of RPP patients in the urinary, bowel, and hormonal domains is favorable. HRQOL outcomes depend on a spectrum of factors, including the presence of comorbid disease, socioeconomic status, and secondary cancer treatments. Future studies should seek to address the efficacy of preserving the sexual domain HRQOL in patients undergoing bilateral nerve-sparing RPP.

Effects of Local Estrogen Therapy on Recurrent Urinary Tract Infections in Young Females under Oral Contraceptives.
Pinggera GM, Feuchtner G, Frauscher F, Rehder P, Strasser H, Bartsch G, Herwig R
Eur Urol 2005 Feb;47(2):243-9.

BACKGROUND: Previous studies have demonstrated the efficacy of local application of estrogen in treating postmenopausal women with recurrent urinary tract infections (RUTI) and urinary incontinence. Younger women under oral contraceptives (OC) can suffer from similar symptoms. The aim of this pilot study was to evaluate the effectiveness of local estrogens on RUTI and the impact of local hormonal supplementation on bladder neck vascularization. METHODS: 30 women (mean age 22.7 years) with a longstanding history of RUTI were included. Pre-treatment investigation included complete clinical history, urinalysis, urine culture and cystoscopy. All subjects completed a questionnaire about onset and duration of disease and quality of life before and after treatment. Local (vaginal) estrogen therapy consisted of 1mg estriol (E3) 7 times a week for two weeks and twice a week for two additional weeks. Sonographic examination of bladder vascularization was performed before and after treatment using transperineal color Doppler ultrasound (6MHz, Acuson Sequoia 512, Mountain View, CA, USA) with a filled bladder. After angle correction, peak systolic blood flow velocity (PSBFV) and end diastolic blood flow velocity (EDBFV) were measured in 2 bladder arteries; and the Resistive Index (RI) was calculated. Flow velocity in each vessel was measured at least four times and the mean value determined. RESULTS: All patients completed the therapy course without severe side effects. Patients had a mean history of RUTI over 2.3 years; the mean period under OC was 3.2 years. In the follow-up period of 11 months after treatment, 24/30 patients reported no symptoms of cystitis and used no additional medication. Normal bladder epithelium in control cystoscopy after E(3) therapy was seen in all patients with trigonal metaplasia and vulnerable, highly vascularized urothelium at the initial investigation. RI decreased from 0.945 to 0.705 after treatment (p<0.001), concomitantly the mean EDBFV increased highly significantly from 0.82cm/sec to 4.45cm/sec after estrogen treatment (p<0.001). INTERPRETATION: In a majority of young patients under OC and a longstanding history of RUTI, a considerable infection-free period was achieved after local application of estrogen. Decreased RI and increased EDBFV indicate vasodilatation and less peripheral vascular resistance. Responsiveness to local E(3) may correspond to improved cystoscopic findings as a consequence of increased bladder perfusion.

Convenience voids: an important new factor in urinary frequency volume chart analysis.
Darling R, Neilson D
J Urol 2005 Feb;173(2):487-9.

PURPOSE: We assessed the impact of convenience voids (CVs) on urinary frequency volume chart (FVC) analysis. MATERIALS AND METHODS: A total of 53 healthy volunteers completed a FVC for 1 week, highlighting as CVs samples when there was no sensation of bladder fullness, but rather a social reason to pass urine instead. RESULTS: Of the volunteers 72% had at least 1 CV during the week. Removing the CVs from analysis resulted in an increase of 17 ml in average mean individual voided volume from 308 to 325 ml (p <0.001). The average mean interval between voids increased by 11 minutes from 4 hours 34 minutes to 4 hours 45 minutes (p <0.001). CONCLUSIONS: Convenience voids have a small but significant effect on parameters analyzed on FVCs. They should be considered for inclusion in the FVCs used in research when changes in voided volume are being investigated.

The safety of telephone management of presumed cystitis in women.
Schaeffer AJ
J Urol 2005 Feb;173(2):468.

Physician adherence to recommendations for duration of empiric antibiotic treatment for uncomplicated urinary tract infection in women: a national drug utilization analysis.
Schaeffer AJ
J Urol 2005 Feb;173(2):467.

The natural course of uncomplicated lower urinary tract infection in women illustrated by a randomized placebo controlled study.
Schaeffer AJ
J Urol 2005 Feb;173(2):467-8.

Altered inducible nitric oxide synthase expression and nitric oxide production in the bladder of cats with feline interstitial cystitis.
Birder LA, Wolf-Johnston A, Buffington CA, Roppolo JR, de Groat WC, Kanai AJ
J Urol 2005 Feb;173(2):625-9.

PURPOSE: Alterations in nitric oxide (NO) levels have been demonstrated in some humans with interstitial cystitis (IC) as well as in chemically induced animal models of cystitis. Thus, in the current study we investigated whether inducible NO synthase (iNOS) mediated NO production is altered in the bladder of cats with a naturally occurring model of IC termed feline IC (FIC). MATERIALS AND METHODS: We examined iNOS expression using Western immunoblotting and baseline NO production using an NO microsensor from smooth muscle and mucosal bladder strips in 9 healthy cats and 6 diagnosed with FIC. RESULTS: There was a significant increase in baseline NO production in cats with FIC compared with that in healthy cats in smooth muscle and mucosal strips. This production was not ablated in the absence of extracellular Ca (100 microM egtazic acid) or following incubation with the calmodulin antagonist trifluoroperazine (20 microM), indicating iNOS mediated Ca independent NO production. Release was significantly decreased following incubation with the NOS antagonist L-NAME (N-nitro-L-arginine methyl ester) (100 microM). Furthermore, immunoblotting revealed a trend toward increased iNOS expression in smooth muscle and mucosal strips from FIC cats but not from healthy cats. CONCLUSIONS: In light of previous findings that the barrier property of the urothelial surface is disrupted in FIC and iNOS mediated increase in NO alters barrier function in other types of epithelium our findings suggest that iNOS dependent NO production may have a role in epithelial barrier dysfunction in FIC.

Inhibitory effect of intravesically applied botulinum toxin A in chronic bladder inflammation.
Vemulakonda VM, Somogyi GT, Kiss S, Salas NA, Boone TB, Smith CP
J Urol 2005 Feb;173(2):621-4.

PURPOSE: We evaluated a putative inhibitory effect of intravesical botulinum toxin A (BTX-A) on afferent pathways in conditions of chronic bladder inflammation. MATERIALS AND METHODS: Female Sprague-Dawley rats were divided into 4 groups, namely group 1-saline treated, group 2-BTX-A treated, group 3-cyclophosphamide (CYP) treated and group 4-BTX-A and CYP treated. At the beginning of the treatment period all animals received intravesical protamine sulfate (1%), followed by intravesical BTX-A or saline. Subsequently CYP or saline was injected intraperitoneally every 3 days for 10 days. The rats then underwent cystometrogram evaluation prior to spinal cord harvest. Sections from the L6 and S1 spinal cord segments were examined for the total number of Fos immunoreactive cells. RESULTS: Comparisons of the L6 and S1 sections showed a significant difference among groups (p <0.05). CYP treated animals had a significant increase in L6 and S1 (78% and 107%, respectively) c-fos expression compared with saline controls (p <0.001). Comparison of the CYP and BTX-A/CYP groups showed a significant decrease in L6 and S1 in c-fos expression (50% and 52%, respectively) in the BTX-A/CYP treated group (p <0.001). No significant difference was present between the saline and BTX-A alone groups. Cystometrogram studies revealed that the nonvoiding intercontractile interval increased by more than 10-fold in BTX-A/CYP treated animals compared with CYP treated rats (p <0.01). CONCLUSIONS: In a CYP model of chronic bladder inflammation intravesical BTX-A significantly inhibits the afferent neural response without impairing efferent bladder function.

Botulinum toxin: a new dimension in the treatment of lower urinary tract dysfunction.
Sahai A, Khan MS, Fowler C, Dasgupta P
Urology 2005 Jan;65(1):211.

Do atherosclerosis and chronic bladder ischemia really play a role in detrusor dysfunction of old age?
Shenfeld OZ, Meir KS, Yutkin V, Gofrit ON, Landau EH, Pode D
Urology 2005 Jan;65(1):181-4.

OBJECTIVES: To determine whether atherosclerosis-induced chronic pelvic ischemia plays a role in the pathogenesis of aging bladder dysfunction. METHODS: Old (70 weeks of age), apolipoprotein E gene knockout (APOEKO) mice, known to develop atherosclerosis spontaneously were used. A group of 70-week-old C57B mice were used as controls. The mice were killed and bladder smooth muscle strips obtained for in vitro contractile force determinations. The maximal contractions in response to 110 mM KCl, 10(-5) M bethanechol, and resting muscle tone were compared. The abdominal aortas and iliac arteries were harvested from the mice, and computerized image analysis was used to determine the percentage of surface area of atherosclerosis in each mouse. RESULTS: Although the APOEKO mice had massive atherosclerosis of the abdominal aortas and iliac arteries (lesion surface area +/- SEM 15.93% +/- 3.02%, n = 4), the control mice (n = 5) had no atherosclerosis at all. No statistically significant difference was found in detrusor function (KCl 0.48 +/- 0.11 versus 0.49 +/- 0.05, bethanechol 0.11 +/- 0.02 versus 0.13 +/- 0.04, tone 0.063 +/- 0.019 versus 0.07 +/- 0.004, respectively) between the APOEKO mice (n = 6) and the control mice (n = 6). CONCLUSIONS: Pelvic atherosclerosis caused no statistically significant changes in bladder smooth muscle contractile responses to bethanechol, KCl, or resting tone. The difference between these and previously reported results may have been a result of the more gradual onset of atherosclerosis in our model, which better mimics pelvic organ ischemia in the elderly.

Pelvic floor reconstruction before orthotopic bladder replacement after radical cystectomy for bladder cancer.
Puppo P, Introini C, Calvi P, Naselli A
Urology 2005 Jan;65(1):174.

Female incontinence and pelvic organ prolapse have been defined as contraindications to orthotopic bladder substitution. A 75-old-year woman with slight stress incontinence, Stage III cystocele, and vaginal vault prolapse after subtotal hysterectomy underwent radical cystectomy for Stage T2 bladder cancer. After radical cystectomy, pelvic floor integrity was restored by colposacropexy with a rectangular polypropylene mesh and an ileal reservoir to urethra was constructed. After 1 year of follow-up, she had complete daytime continence and only needed to wear a pad during the night. Her postvoid residual urine volume was constantly less than 100 mL.

Post-micturitional hypotension in patients with multiple system atrophy.
Uchiyama T, Sakakibara R, Asahina M, Yamanishi T, Hattori T
J Neurol Neurosurg Psychiatry 2005 Feb;76(2):186-90.

BACKGROUND: Patients with multiple system atrophy (MSA) occasionally have episodes of syncope or pre-syncope after micturition. OBJECTIVE: To clarify the mechanism of these episodes by investigating the haemodynamic changes associated with micturition. METHODS: 25 patients with probable MSA and 16 age matched normal controls were studied. Continuous records of blood pressure and heart rate were made during water cystometry, along with the Valsalva manoeuvre, head up tilt testing, measurement of plasma noradrenaline, and calculation of coefficient of variance of RR intervals. RESULTS: Compared with normal controls, MSA patients had a lower baseline blood pressure, smaller blood pressure and heart rate increases during bladder filling, and an abnormal fall in blood pressure for a longer duration after voiding, resulting in significantly lower blood pressure than at baseline (mean systolic blood pressure reduction -15.2 mm Hg), and hypotension compared with control blood pressure (-29.0 mm Hg). The blood pressure fall was greater in patients with micturition syncope/pre-syncope than in those without. It was also greater in patients with abdominal straining resulting from difficulty in voiding. Other cardiovascular indices did not correlate with the fall in blood pressure. CONCLUSIONS: Hypotension after voiding in MSA patients may result from generalised autonomic dysfunction and abnormal abdominal straining, resulting in micturition syncope.

Management of urinary tract infections in female general practice patients.
Hummers-Pradier E, Ohse AM, Koch M, Heizmann WR, Kochen MM
Fam Pract 2005 Feb;22(1):71-7. Epub 2005 Jan 07.

BACKGROUND: Though guidelines for the management of urinary tract infections (UTI) exist in several European countries, little is known about GPs' adherence, and the appropriateness of their management with regard to antibiotic resistance. OBJECTIVES: To describe German GPs' management of female patients with symptoms of UTI, to assess the diagnostic accuracy of dipsticks in a German general practice setting, to develop diagnostic prediction rules for culture-confirmed UTI, and to compare the adequacy of empirical treatment strategies and GPs' actual prescriptions. METHODS: In 36 (of 118 invited) teaching general practices, urine cultures and resistance testing were performed during 4 months on all symptomatic patients. GPs completed a questionnaire on each patients' symptoms, risk factors and treatment. Adequacy of different treatment approaches was calculated based on culture results. RESULTS: 445 adult women (76% of all patients) were included, with a median age of 53 years. Complicating factors were present in 27%. Urine culture revealed UTI in 77%. GPs' diagnostic accuracy, using both dipsticks and clinical impressions, was low. A positive nitrite test, dysuria and older age were the only predictive factors of culture-confirmed UTI, however the negative predictive value of dipsticks is low (35%). Empirical treatment of all symptomatic patients with either nitrofurantoin or fluoroquinolones would result in a higher rate of appropriate therapies than the individualized approach chosen by the GPs. CONCLUSION: Most patients with urinary symptoms were not treated according to current guidelines, and GPs' diagnostic and therapeutic accuracy was low. Empirical treatment of all symptomatic patients is probably the most effective policy, but implies unnecessary antibiotic prescriptions.