Basic Sciences, Miscellaneus : Urology

Development of glomerulations in younger women with interstitial cystitis.
Shear S, Mayer R
Urology. 2006 Aug;68(2):253-6.

OBJECTIVES: To evaluate the consistency of cystoscopic findings with hydrodistension in younger women with a clinical diagnosis of interstitial cystitis. METHODS: A retrospective chart review was conducted of patients aged younger than 26 years old at the time of initial cystoscopy and hydrodistension at a single institution. Data included approximate duration of symptoms, development of visible terminal hematuria, presence of ulcers, and semiquantitive evaluation of degree of glomerulations (negligible, moderate, diffuse), and bladder capacity under anesthesia. RESULTS: Eighteen women aged 15 to 25 years old (mean, 17.5 years) were identified. The mean duration of symptoms was 38 months, with an estimated mean age of onset of 16 years. No patient had Hunner's ulcers, and 13 had visible terminal hematuria with moderate-to-diffuse glomerulations. Ten women had repeat cystoscopies, and the mean time to repeat cystoscopy was 17 months. Three women underwent repeat cystoscopy and initially had a relatively normal bladder mucosa, with none or only rare glomerulations, but moderate-to-diffuse glomerulations were seen on the subsequent cystoscopy in addition to the development of terminal hematuria. One patient, conversely on subsequent cystoscopy, showed resolution of glomerulations. CONCLUSIONS: Interstitial cystitis symptoms can develop before an age where adult urologists or primary care physicians familiar with the diagnosis and treatment are usually involved with care. The cystoscopic appearance of the bladder wall after hydrodistension may not be constant over time, and the absence of initial findings of glomerulations or terminal hematuria does not preclude further development of these hallmarks of the disease on subsequent evaluation.

Urethral and vaginal infections, age of patients and state of the pelvic floor in the aetiology of the irritative symptoms of the lower urinary tract in women.
Vecchioli Scaldazza C, Morosetti C
Arch Esp Urol. 2006 Jun;59(5):554-60.

OBJECTIVES: The aim of this study was to evaluate the importance of a) urethral and/or vaginal infections caused by common germs or Mycoplasmas, Chlamydia, Candida; b) age of patients; c) pelvic floor disorders in the development of irritative urinary symptoms in women. METHODS: 77 consecutive abacteriuric symptomatic female patients were compared with 55 asymptomatic women. A detailed micturition history and a genitourinary physical examination were performed. Urine samples as well as vaginal and urethral swabs were taken for cultures. RESULTS: No statistical difference was found between the two groups regarding both urethral and/or vaginal infections and pelvic floor disorders. Whereas a significant statistical difference was found in the age of the patients. In the symptomatic group the women were older than in the asymptomatic group. CONCLUSIONS: The results of this study confirm that ageing is a very important cause in the development of the lower urinary tract symptoms in women.

Female urethral and bladder neck injury after rape: an appraisal of the surgical management.
Okeke LI, Aisuodionoe-Shadrach O, Ogbimi AI
Int Urogynecol J Pelvic Floor Dysfunct. 2006 Aug 10;.

The aim of this study was to discuss the surgical management of urethral and bladder neck injury after urethral coitus during rape. A 21-year-old lady presented with total urinary incontinence of 1-year duration after being raped. On examination, she had urethral laceration and a patulous urethra and bladder neck suggesting urethral coitus during the rape. Her introitus and vagina were however normal. She had repair of her urethral laceration and plication of her urethra and bladder neck via a vaginal approach. She regained her continence and voids without any residual urine. Urethral coitus is rare. Urethral coitus in the presence of a normal introitus and vagina is very rare. The urethral and bladder neck injury resulting from this can be satisfactorily corrected by urethral and bladder neck plication via a vaginal approach with the vaginal incisions positioned to forestall suture line apposition, which may lead to wound failure.

Severe eosinophilic cystitis in a woman with anorexia nervosa.
Philip J, Ali FS, Zakhour HD, Parr NJ
Int J Urol. 2006 Aug;13(8):1132-3.

Eosinophilic cystitis is a rare inflammatory disorder. It is considered to be self limiting necessitating only supportive therapy. Surgical intervention is unusual. We report here an association between eosinophilic cystitis and anorexia nervosa in an adult woman requiring radical surgery for progressive relentless disease. Estrogen deficiency associated with a possible allergic etiology could explain this association.

Urological survey: Trauma, and genital and urethral reconstruction.
Morey AF
J Urol. 2006 Sep;176(3):1030-2.

Urological survey: Infection and inflammation of the genitourinary tract.
Berger RE
J Urol. 2006 Sep;176(3):1017-8.

(99m)Technetium-mercaptoacetyltriglycine scintigraphy with full bladder in patients with severe bladder dysfunction.
Nagabhushan N, Syed R, Hoh IM, Syed I, Ell PJ, Shah PJ, Neild GH, Woodhouse CR, Bomanji JB
J Urol. 2006 Oct;176(4):1481-6.

PURPOSE: We evaluated (99m)technetium-mercaptoacetyltriglycine scintigraphy for detecting threshold bladder volume at which upper tract obstruction occurs in patients with bladder dysfunction. MATERIALS AND METHODS: A total of 24 patients 19 to 74 years old with severe bladder dysfunction who underwent (99m)technetium-mercaptoacetyltriglycine scintigraphy and videocystometrogram in a 4-year period were selected for retrospective study. (99m)Technetium-mercaptoacetyltriglycine scintigraphy was done with a full bladder with a mean instilled volume of more than 850 ml saline. In patients in whom an obstructed renal outflow pattern was observed saline was drained at a rate of 100 ml every 5 minutes while dynamic imaging was performed. If results were abnormal, the study was repeated with an empty bladder. Differential function, parenchymal transit time index and outflow efficiency were calculated. RESULTS: Of the 24 patients 15 had an obstructed outflow pattern with a full bladder, which was relieved at a bladder volume of less than 390 ml (median 300, range 250 to 600). Only 2 of these 15 patients had a normal vesical end filling pressure of less than 20 cm H(2)O. There was no obstruction in 9 patients, of whom 5 had increased vesical end filling pressures. Followup in patients who had normal tracer outflow on a full bladder showed no decrease in renal function, while a small decrease was seen in patients who had obstructed outflow on a full bladder. CONCLUSION: This novel, full bladder (99m)technetium-mercaptoacetyltriglycine scintigraphic technique provides the ability to detect bladder volumes at which obstructive outflow patterns develop in patients with severe bladder dysfunction.

Female urethral catheterization.
Urol Nurs. 2006 Aug;26(4):314.

July

Paternal Age and Spontaneous Abortion.
Kleinhaus K, Perrin M, Friedlander Y, Paltiel O, Malaspina D, Harlap S
Obstet Gynecol. 2006 Aug;108(2):369-377.

OBJECTIVE: To evaluate the influence of paternal age upon spontaneous abortion. METHODS: This case-control study of 13,865 women draws on data from women's antenatal or postpartum interviews in the Jerusalem Perinatal Study, a population-based cohort derived from 92,408 births in 1964-1976. Case women (n=1,506) reported spontaneous abortion in the pregnancy preceding the interview; they were compared with women reporting live births in their previous pregnancy (n=12,359). Logistic regression was used to adjust for maternal age, maternal diabetes, maternal smoking, history of spontaneous abortions before the index pregnancy, parity at interview, and interval between the index pregnancy and the interview. RESULTS: The adjusted odds ratio for spontaneous abortion was 0.59 (95% confidence interval 0.45-0.76, P< .0001) for pregnancies conceived from fathers aged younger than 25 years compared with those from fathers aged 25-29 years. For fathers age 40 years or older the odds ratio for spontaneous abortion was 1.6 (95% confidence interval 1.2-2.0, P=.0003) when compared with the same reference group. CONCLUSION: Increasing paternal age is significantly associated with spontaneous abortion, independent of maternal age and multiple other factors. LEVEL OF EVIDENCE: II-2.

Long-term results of standard procedures in urology: the ileal neobladder.
Hautmann RE, Volkmer BG, Schumacher MC, Gschwend JE, Studer UE
World J Urol. 2006 Aug;24(3):305-14. Epub 2006 Jul 8.

Over the past 20 years orthotopic urinary reconstruction with the techniques developed at Ulm and Bern has become a widely accepted form of urinary diversion. So far, both centers together have performed more than 1,300 orthotopic bladder substitutions with an overall rate of neobladder formation in 58% of all cystectomized patients. Today, the absolute contraindications for this procedure are urinary stress incontinence, damaged rhabdosphincter, severely impaired renal and liver function, severe intestinal diseases or an oncologic situation requiring urethrectomy. In patients treated for transitional cell carcinoma of the bladder, the rate of urethral recurrence in both centers was 1.5 and 5%, respectively, and the rate of upper urinary tract recurrence was 2-3%. Local tumor recurrence usually did not affect neobladder function. The rate of outlet obstruction by local recurrence was 2%, that of gross hematuria 1%, and of entero-reservoir fistulas 1-2%. Daytime continence at 12 months was 92%, while nighttime continence was lower around 80%. Transient or permanent urinary retention was seen in 11-12% of male patients. In both series, long-term upper urinary tract safety was good. The risk of stenoses of the uretero-intestinal anastomosis with consecutive loss of renal function decreased with the introduction of non-refluxing implantation techniques. The rate of long-term metabolic complications remains low when adequate substitution with sodium bicarbonate is guaranteed in patients with impaired renal function. Patient selection and meticulous postoperative follow-up contributed to achieve good long-term results after cystectomy and orthotopic ileal neobladder substitution of the two large series of patients from the Universities of Ulm and Bern.

Haematospermia - a systematic review.
Kumar P, Kapoor S, Nargund V
Ann R Coll Surg Engl. 2006 Jul;88(4):339-42.

Haematospermia (or haemospermia) is a distressing symptom in sexually active men. In most cases, it is caused by non-specific inflammation of the prostate and seminal vesicles. In a small percentage of men, however, it may be a manifestation of genito-urinary or systemic malignancy, in particular prostate cancer. The purpose of this review is to explain the causes and management of patients with haematospermia.

June

Metachronous metastasis to the penis from carcinoma of the rectum.
Appu S, Lawrentschuk N, Russell JM, Bright NF
Int J Urol. 2006 May;13(5):659-61.

Metastases to the penis are a rare event with most arising from pelvic organs, but occasionally the kidneys. Furthermore, very few cases exist where primary rectal carcinoma metastasising to the penis has been reported. We report on such a case and discuss the general management of penile metastases.

A case of leiomyosarcoma of the penis.
Nanri M, Kondo T, Okuda H, Tanabe K, Toma H
Int J Urol. 2006 May;13(5):655-8.

A case of leiomyosarcoma of the penis is reported. A 27-year-old-man presented to our department with a mass at the root of the penis. Biopsy of the tumor showed that the tumor was leiomyosarcoma. The tumor was clinically and pathologically categorized into the deep type. Despite total penectomy and adjuvant chemotherapy, the patient died from disseminated disease 14 months after surgery. This is the 45th case of penile leiomyosarcoma.

Repeat pelvic osteotomy in patients with failed closure of bladder exstrophy: applications and outcomes.
Nelson CP, King J, Sponseller PD, Gearhart JP
J Pediatr Surg. 2006 Jun;41(6):1109-12.

BACKGROUND/PURPOSE: In patients with failed primary or secondary closure of bladder exstrophy, repeat osteotomy is useful in facilitating reconstruction. The clinical consequences of repeated surgical disruption of the pelvic ring have not been carefully described, however. METHODS: We reviewed our experience with exstrophy patients who had undergone repeat pelvic osteotomy (RPO) and analyzed patient history, complications, and orthopedic outcomes. RESULTS: Fifty-six patients who underwent RPO were identified. All had previously failed at least one attempted bladder closure. The patients underwent RPO at a mean age of 23.2 months. The mean time from initial osteotomy to RPO was 20.5 months. Anterior innominate or combined iliac/innominate approaches comprised 80% of RPO procedures. Of the patients, 95% had a normal gait after RPO; all 3 patients with an abnormal gait had osteotomy site nonunion, which was treated with bone grafting. Five patients had local fixator pin site infections, which were managed with local care and oral antibiotics, and 1 patient had late osteomyelitis requiring incision and drainage. No patient had femoral or sciatic nerve palsy after RPO at our institution. CONCLUSIONS: Orthopedic complications after RPO are uncommon, and most patients have a normal gait postoperatively. Repeat pelvic osteotomy is useful in the complex reconstruction of failed exstrophy closures, and few cases fail reclosure when the reconstruction is combined with RPO.

Female urology: the changing realm of diagnosis and management.
Appell RA
J Urol. 2006 Aug;176(2):438

Trauma, and genital and urethral reconstruction.
Morey AF
J Urol. 2006 Jul;176(1):167-9.

25-year prostate cancer control and survival outcomes: a 40-year radical prostatectomy single institution series.
Porter CR, Kodama K, Gibbons RP, Correa R Jr, Chun FK, Perrotte P, Karakiewicz PI
J Urol. 2006 Aug;176(2):569-74.

PURPOSE: We report on 25-year cancer control and survival outcomes after radical prostatectomy in a single center series of patients treated during a 40-year period. MATERIALS AND METHODS: Between 1954 and 1994, 787 consecutive patients underwent radical prostatectomy at Virginia Mason Medical Center in Seattle, Washington. Kaplan-Meier 25-year probabilities of prostate cancer specific, overall, prostate specific antigen progression-free, local and distant progression-free survival were determined. Multivariate Cox regression models addressed prostate cancer specific mortality. RESULTS: Prostate cancer specific survival, overall survival, prostate specific antigen progression-free survival, local and distant progression-free survival ranged from 99.0% to 81.5%, 93.5% to 19.3%, 84.8% to 54.5%, 95.3% to 87.8% and 95.9% to 78.2%, respectively. In univariate analyses pathological stage, surgical margin status, pathological Gleason sum, delivery of hormonal therapy and radiotherapy represented statistically significant predictors of prostate cancer specific mortality (all p </=0.001). In multivariate analyses only Gleason sum (p = 0.03) and delivery of hormonal therapy (p <0.001) remained significant. CONCLUSIONS: This is one of the most mature radical prostatectomy series. It demonstrates that long-term biochemical cancer control outcomes after radical prostatectomy might be suboptimal. However, local and distant control outcomes are excellent, and cancer specific mortality is minimal even 25 years after surgery.

Long-term outcome following radical prostatectomy in men with clinical stage t3 prostate cancer.
Carver BS, Bianco FJ Jr, Scardino PT, Eastham JA
J Urol. 2006 Aug;176(2):564-8.

PURPOSE: We evaluated patients at our institution who underwent radical prostatectomy for clinical stage T3 prostate cancer to determine their long-term clinical outcomes. MATERIALS AND METHODS: We reviewed our prospective surgical database and identified 176 men who underwent radical retropubic prostatectomy for clinical stage T3 prostate cancer from 1983 to 2003. Clinical and pathological data were reviewed and evaluated in a Cox proportional hazards model to determine preoperative predictors of biochemical recurrence. Clinical progression following biochemical recurrence was evaluated and clinical failure was defined as the development of clinical metastases or progression to hormone refractory prostate cancer. RESULTS: Of the 176 patients with cT3 prostate cancer 64 (36%) received neoadjuvant hormonal therapy. At a mean followup of 6.4 years 84 (48%) patients had disease recurrence with a median time to biochemical recurrence of 4.6 years. The actuarial 10-year probability of freedom from recurrence was 44%. On multivariate analysis biopsy Gleason score, pretreatment serum prostate specific antigen and year of surgery were independent predictors of biochemical recurrence. Neoadjuvant hormonal therapy was not a significant predictor of biochemical recurrence. Following biochemical recurrence clinical failure developed in 30 of 84 (36%) men with a median time of 11 years. Overall the 5, 10 and 15-year probabilities of death from prostate cancer were 6%, 15% and 24%, respectively. CONCLUSIONS: More than half (52%) of our patients remained free of disease recurrence following radical prostatectomy. In our series neoadjuvant hormonal therapy offered no advantage with respect to disease recurrence. Radical prostatectomy remains an integral component in the treatment of select patients with clinical stage T3 prostate cancer.

Penis conserving treatment for t1 and t2 penile carcinoma: clinical implications of a local recurrence.
Lont AP, Gallee MP, Meinhardt W, van Tinteren H, Horenblas S
J Urol. 2006 Aug;176(2):575-80.

PURPOSE: We evaluated our experience with primary tumor treatment for T1 and T2 penile squamous cell carcinoma and discussed the clinical implications of a local recurrence. MATERIALS AND METHODS: The primary tumor treatment and clinical course of 257 patients with T1 or T2 penile carcinoma were evaluated. Primary tumor treatment consisted of penis preservation in 157 and (partial) amputation in 100 patients. Median followup was 106 months (range 16 to 541). RESULTS: The 5-year local recurrence-free estimate after penis preservation was similar for T1 and T2 tumors (log rank test p = 0.1) and overall 63% (CI: 54%-72%) compared to 88% (CI: 81%-95%) for partial amputation (log rank test p = 0.0003). In case of a local recurrence after penis preserving treatment, local control could be achieved in 94% (51 of 54) of cases. Of patients with T1 tumors treated with penis preservation, regional recurrence developed in 33% (7 of 21) of patients with local recurrence compared to only 6% (3 of 47) of patients without local recurrences (Fisher's exact test p = 0.005). Of the patients with T2 tumors treated with penis preservation, regional recurrence developed in 27% (9 of 33) of patients with local recurrence compared to 27% (12 of 45) of patients without local recurrence (chi-square test p = 0.96). Of 10 patients with a local recurrence after partial amputation of the penis, 9 died of disease. CONCLUSIONS: The incidence of local recurrence increases with penis preservation but can be treated accurately in most cases. Local recurrences can signify lymphatic regional spread. A local recurrence after penile amputation carries a poor prognosis.

Fate of the leftover bladder after supravesical urinary diversion for benign disease.
Fazili T, Bhat TR, Masood S, Palmer JH, Mufti GR
J Urol. 2006 Aug;176(2):620-1.

PURPOSE: We studied the fate of the leftover bladder in patients who underwent supravesical urinary diversion without cystectomy for benign pathology. MATERIALS AND METHODS: This retrospective study was performed in 9 males and 15 females with a median age of 59 years in whom supravesical urinary diversion was performed for various benign conditions from 1996 to 2004. These conditions were incontinence, acontractile bladder, radiation and/or hemorrhagic cystitis, and neuropathic bladder. Median followup was 48 months. RESULTS: Of the patients 13 (54%) experienced problems with the retained bladder, 2 (8%) presented with urethral bleeding, which resolved by conservative means, and 11 (46%) had infective complications, which resolved with expectant treatment in 3 (12%). However, 8 patients (33%) had frank pyocystis and 3 (12%) were treated with the Spence procedure, which alleviated symptoms in only 1. Six patients (25%) required cystectomy. CONCLUSIONS: In patients undergoing supravesical urinary diversion for benign disease in whom the bladder remains in situ the risks of complications related to the defunctionalized bladder are more than 50% and 25% of patients subsequently need cystectomy. These patients should be offered primary cystectomy at urinary diversion.

May

Management of multicentric lesions of the lower genital tract.
Ait Menguellet S, Collinet P, Debarge VH, Nayama M, Vinatier D, Leroy JL
Eur J Obstet Gynecol Reprod Biol. 2006 May 17;.

OBJECTIVES: To report management and outcome of multicentric lesions of the lower genital tract. To define risk factors of recurrence. STUDY DESIGN: Retrospective review of multicentric dysplasias treated in our colposcopic clinic between 1996 and 2003. Multicentric dysplasias included CIN with VAIN and/or VIN. After primary treatment, follow-up was colposcopic, cytologic and virologic. RESULTS: Forty-four patients presented multicentric lesions out of 998 patients referred for CIN (4.4%). The average age was 36.8 years. Immunologic disorders were present in 20.4%. Ninety-one percent had cervicovaginal or cervicovulvar lesions, only 9% had three sites of genital dysplasia. 53.3% of lesions were concomitant. 79.5% of CIN were high grade, 62.5% of VAIN low grade and 62.5% of VIN high grade. Therapeutic modalities were as follows: conization for CIN (70.4%), CO2 laser for VAIN (33.3%) and surgery for VIN (41.7%). Forty patients were followed and had at least one post-treatment cytologic control; 55% of them had residual disease. Out of the 23 patients with at least two negative controls after treatment, 43.5% presented recurrence. Risk of recurrence was not statistically bound to such parameters as tabagism, immunologic disorder, high grade lesions, non-surgical treatment, and persistence of HPV infection after treatment. CONCLUSION: Multicentric dysplasias are associated with high rate of residual lesion and recurrence. Management of these lesions require long term follow-up.

Developmental exposure to estradiol and bisphenol a increases susceptibility to prostate carcinogenesis and epigenetically regulates phosphodiesterase type 4 variant 4.
Ho SM, Tang WY, Belmonte de Frausto J, Prins GS
Cancer Res. 2006 Jun 1;66(11):5624-32.

Early developmental perturbations have been linked to adult-onset prostate pathology, including excessive exposure to estrogenic compounds; however, the molecular basis for this imprinting event is not known. An important and controversial health concern is whether low-dose exposures to hormonally active environmental estrogens, such as bisphenol A, can promote human diseases, including prostate cancer. Here, we show that transient developmental exposure of rats to low, environmentally relevant doses of bisphenol A or estradiol increases prostate gland susceptibility to adult-onset precancerous lesions and hormonal carcinogenesis. We found permanent alterations in the DNA methylation patterns of multiple cell signaling genes, suggesting an epigenetic basis for estrogen imprinting. For phosphodiesterase type 4 variant 4 (PDE4D4), an enzyme responsible for cyclic AMP breakdown, a specific methylation cluster was identified in the 5'-flanking CpG island that was gradually hypermethylated with aging in normal prostates, resulting in loss of gene expression. Early and prolonged hypomethylation at this site following neonatal estradiol or bisphenol A exposure resulted in continued, elevated PDE4D4 expression. Cell line studies confirmed that site-specific methylation is involved in transcriptional silencing of the PDE4D4 gene and showed hypomethylation of this gene in prostate cancer cells. Importantly, the PDE4D4 alterations in the estrogen-exposed prostates were distinguishable before histopathologic changes of the gland, making PDE4D4 a candidate molecular marker for prostate cancer risk assessment as a result of endocrine disruptors. In total, these findings indicate that low-dose exposures to ubiquitous environmental estrogens affect the prostate epigenome during development and, in so doing, promote prostate disease with aging.

Hypoxia increases androgen receptor activity in prostate cancer cells.
Park SY, Kim YJ, Gao AC, Mohler JL, Onate SA, Hidalgo AA, Ip C, Park EM, Yoon SY, Park YM
Cancer Res. 2006 May 15;66(10):5121-9.

Recent studies show that prostate cancer cells are able to survive in a hypoxic tumor environment, and the extent of tumor hypoxia correlates with poor clinical outcome. Androgen deprivation, the most common form of prostate cancer therapy, was itself shown to induce a state of transient hypoxia at the microenvironmental level. Because androgen receptor (AR) signaling plays a critical role in prostate cancer, we investigated the effect of hypoxia in regulating AR function. We found that in LNCaP prostate cancer cells, AR binding to the androgen-responsive element (ARE), prostate-specific antigen accumulation, and ARE-reporter gene activity were increased after hypoxia treatment. Hypoxia-enhanced AR function was also observed when AR was exogenously introduced into AR-null DU145 cells. Confocal microscopy and chromatin immunoprecipitation assays showed that AR translocation to the nucleus and AR recruitment to the prostate-specific antigen promoter were facilitated after hypoxia treatment. The AR stimulatory effect seemed to be ligand-dependent because it was abrogated when cells were cultured in an androgen-depleted medium, but was restored with the addition of R1881, a synthetic androgen. The sensitivity of AR activation to R1881 was also increased after hypoxia treatment. Although concentrations of <1 nmol/L R1881 did not induce ARE reporter activity under normoxic conditions, exposure to hypoxia greatly potentiated the AR response to low levels of R1881. Collectively, our results provide compelling evidence that changes in hypoxia/reoxygenation stimulate AR trans-activation and sensitization. The AR-stimulatory effect of an unstable tissue oxygenation milieu of a tumor is likely to contribute to treatment resistance and the emergence of recurrent prostate cancer.

Self-management in lower urinary tract symptoms: the next major therapeutic revolution.
Yap TL, Brown CT, Emberton M
World J Urol. 2006 May 10;.

The standard treatments for men with lower urinary tract symptoms (LUTS) range from watchful waiting to medical and finally surgical intervention. However, the role of self-management interventions such as education and reassurance, lifestyle modification and behavioural changes has not been formally investigated, although they are widely advocated and utilised for LUTS. Self-management interventions are well established in other chronic diseases such as diabetes, arthritis and asthma. These interventions, if successfully organised within a structured program for LUTS, could improve patient outcomes as well as reduce the economic burden of LUTS treatment, by replacing or augmenting other treatments. Recent studies showing that long-term urodynamic and symptomatic deterioration of LUTS is minimal suggest that this is a safe and valid treatment option. This is supported by a recent pilot study of a LUTS self-management program which showed significant improvements in I-PSS and frequency-volume parameters. The results of a recently completed randomised controlled trial are awaited.

[Ionic solutions and possibilities of prevention of recurrent cystitis]
Benoit JM, Berges JL, Falcou M, Jeanjean P, Jourfier C
Prog Urol. 2006 Apr;16(2):163-7.

OBJECTIVE: In view of the importance of the phenomenon of adhesion of bacteria to urothelial cells in the pathogenesis of urinary tract infections, the authors investigated the possibility of decreasing this adhesion by means of a complex ionic solution: La Preste mineral water SUBJECTS AND METHOD: The in vitro adhesion of Escherichia coli P-fimbriae (Gal-Gal pili) to urothelial cells in women with recurrent cystitis was compared in neutral medium and in mineral water and the interaction of this same micro-organism with microparticles coated with Gal-Gal receptors was also studied in the same media. In vivo, urothelial cells of 13 women with a normal urological assessment, presenting recurrent cystitis and a high adhesion capacity, were tested three times a day in relation to the same micro-organism on the first and last day of their course of mineral water therapy RESULTS: In vitro, pretreatment of urothelial cells by mineral water induced decreased adhesion (p=0.001), while pretreatment of bacteria with the same mineral water had no effect. In vivo, adhesion was significantly (p=0.021) decreased 2 to 3 hours after ingestion of mineral water and a significant global reduction of adhesion (p=0.016) was observed between the first and last day of mineral water therapy. CONCLUSIONS: These data show a reduction of adhesion (type P) between Escherichia coli and urothelial cells in the presence of La Preste mineral water, due to an action on urothelial cells. These results indicate the probable role of sulphur and silica in this process, while modulation of adhesion by ions has only been demonstrated to date for calcium and magnesium.

The probiotic approach: an alternative treatment option in urology.
Clayman R
J Urol. 2006 Jun;175(6):2136.

The Standardization of Terminology of Lower Urinary Tract Function in Children and Adolescents: Report from the Standardisation Committee of the International Children's Continence Society.
Neveus T, von Gontard A, Hoebeke P, Hjalmas K, Bauer S, Bower W, Jorgensen TM, Rittig S, Walle JV, Yeung CK, Djurhuus JC
J Urol. 2006 Jul;176(1):314-324.

PURPOSE: We updated the terminology in the field of pediatric lower urinary tract function. MATERIALS AND METHODS: Discussions were held of the board of the International Children's Continence Society and an extensive reviewing process was done involving all members of the International Children's Continence Society as well as other experts in the field. RESULTS AND CONCLUSIONS: New definitions and a standardized terminology are provided, taking into account changes in the adult sphere and new research results.

Y-duplication of the male urethra: use of anterior anorectal wall for posterior urethral lengthening.
Sinha S, Sen S, Chacko J, Thomas G, Karl S, Mathai J
Pediatr Surg Int. 2006 Jun;22(6):529-31. Epub 2006 May 3.

We have approached two patients with Y-duplication of the male urethra by a new two-staged technique to provide better results. A strip of anterior anorectal wall in continuity with the posterior urethra was used for posterior urethral lengthening and a tubed pedicled prepucial flap was used to reconstruct the anterior urethra without using the native urethra. This was done under a covering colostomy. After a gap of 6 months to allow for healing of the anorectum and to ensure adequate functioning of the perineal neourethra, second stage reconstruction was done using buried scrotal tube for the mid urethra along with colostomy closure. On follow-up at 8 and 12 months, respectively, both children were well with no stricture or fistula. There was normal anal continence and no stenosis. This technique tackles the problem in Y-duplication of the male urethra of lengthening the posterior urethral channel, which is often difficult to bring to the anterior half of the perineum especially if the opening is high up in the anorectum (case 2).

Impact of autonomic nerve preservation and lateral node dissection on male urogenital function after total mesorectal excision for lower rectal cancer.
Kyo K, Sameshima S, Takahashi M, Furugori T, Sawada T
World J Surg. 2006 Jun;30(6):1014-9.

INTRODUCTION: Urogenital dysfunction is a well recognized complication of rectal cancer surgery. The aim of this study was to assess the impact of autonomic nerve preservation (ANP) and lateral node dissection (LND) on male urogenital function after total mesorectal excision for lower rectal cancer. METHODS: We studied, using a questionnaire, preoperative and current urogenital function in 47 male patients who underwent total mesorectal excision with the ANP technique for lower rectal cancer. Patients with and without LND were analyzed separately. RESULTS: A total of 37 patients (78.7%) (22 patients without LND, 15 with LND) returned the questionnaire. Among the 15 patients with LND, 2 underwent unilateral ANP. One patient without LND had urinary dysfunction preoperatively, and among the other 21 patients only 2 (9.5%) reported minor urinary complications postoperatively. After LND, 5 patients (33%) reported minor complications; there were no severe complications. Among patients who were sexually active prior to the operation, 90% and 70% of patients without LND and 50% and 10% of those with LND maintained sexual activity and ejaculation, respectively. However, 50% of patients who underwent low anterior resection or Hartmann resection without LND and all patients with abdominoperineal resection or LND reported reduced overall sexual satisfaction. CONCLUSIONS: The ANP technique offers the great advantage of maintaining urogenital function after rectal cancer surgery. After LND, although the ANP technique minimized urinary dysfunction, sexual function, particularly ejaculation, was often damaged. Careful follow-up is important even after ANP to improve postoperative sexual satisfaction.

April

Is Pelvic Lymph Node Dissection Necessary in Patients with a Serum PSA<10ng/ml Undergoing Radical Prostatectomy for Prostate Cancer?
Schumacher MC, Burkhard FC, Thalmann GN, Fleischmann A, Studer UE
Eur Urol. 2006 Feb 28;.

OBJECTIVE: Controversy persists concerning the role of pelvic lymph node dissection (PLND) in patients with preoperative PSA values <10ng/ml undergoing treatment for prostate cancer with a curative intent. The aim of this study was to determine the incidence of lymph node metastasis in this subgroup of patients. METHODS: Patients with clinically localized prostate cancer and a serum PSA<10ng/ml, without neoadjuvant hormonal or radiotherapy, with negative staging examinations who underwent radical retropubic prostatectomy with bilateral extended PLND and with >/=10 lymph nodes detected by the pathologist in the surgical specimen, were included in the study. RESULTS: A total of 231 patients with a median serum PSA of 6.7ng/ml (range 0.4-9.98) and a median age of 62 years (range 44-76) were evaluated. A median of 20 (range 10-72) nodes were removed per patient. Positive nodes were found in 26 of 231 patients (11%), the majority of which (81%) had a Gleason score >/=7 in the surgical specimen. Of the patients with a Gleason score >/=7 in the prostatectomy specimen 25% had positive nodes, whereas only 3% with a Gleason score </=6 were node positive. CONCLUSIONS: The incidence of positive nodes in patients with clinically localized prostate cancer, a serum PSA<10ng/ml and a Gleason score >/=7 in the prostatectomy specimen was 25% after extended PLND. It seems that in this patient group extended PLND, including removal of nodes along the internal iliac vessels, is warranted.

Giant Lithiasis in a Female Urethral Diverticulum.
Gallo AG, Sepulveda JP, Montes MS
Eur Urol. 2006 Mar 13;.

The formation of gallstones in a urethral diverticulum is a rare clinical entity and is usually seen in males. The case of a 50 years old woman is presented, who consults for hard vaginal mass and dispareunia associated with repeated urinary infections, with radiological images and an interesting photoendoscopic vision of the upper dome of the gallstone. The diverticulum was approached via vaginal way and the local extraction was successful.

Y-duplication of the male urethra: use of anterior anorectal wall for posterior urethral lengthening.
Sinha S, Sen S, Chacko J, Thomas G, Karl S, Mathai J
Pediatr Surg Int. 2006 May 3;.

We have approached two patients with Y-duplication of the male urethra by a new two-staged technique to provide better results. A strip of anterior anorectal wall in continuity with the posterior urethra was used for posterior urethral lengthening and a tubed pedicled prepucial flap was used to reconstruct the anterior urethra without using the native urethra. This was done under a covering colostomy. After a gap of 6 months to allow for healing of the anorectum and to ensure adequate functioning of the perineal neourethra, second stage reconstruction was done using buried scrotal tube for the mid urethra along with colostomy closure. On follow-up at 8 and 12 months, respectively, both children were well with no stricture or fistula. There was normal anal continence and no stenosis. This technique tackles the problem in Y-duplication of the male urethra of lengthening the posterior urethral channel, which is often difficult to bring to the anterior half of the perineum especially if the opening is high up in the anorectum (case 2).

Does age matter in the selection of treatment for men with early-stage prostate cancer?
Konski A, Eisenberg D, Horwitz E, Hanlon A, Pollack A, Hanks G
Cancer. 2006 May 8;.

BACKGROUND: The specific aim of the current study was to compare freedom from biochemical failure, distant metastases-free survival, and overall survival in men age </=55 years, men ages 60 to 69 years, and men age >/=70 years presenting with localized prostate cancer. METHODS: A matched pair analysis compared patients age </=55 years (Group 1) who were treated with 3-dimension conformal radiation without androgen deprivation to men age >/=60 years and <70 years (Group 2), and men age >/=70 years (Group 3) who were treated at the Fox Chase Cancer Center between November 1989 and October 2001. The groups were matched for disease stage (T1/T2b vs. T2C/T3), Gleason grade (2-6 vs. 7-10), radiation dose (<70 Gray [Gy] vs. >/=70-76 Gy vs. >/=76 Gy), and pretreatment prostate-specific antigen (PSA) level. Estimates of outcome were accomplished using Kaplan-Meier methodology and compared by age group using the log-rank test. RESULTS: Eighty-four men were identified according to the selection criteria. No statistically significant difference was found in the 5-year overall survival rates for Group 1, Group 2, and Group 3 (94%, 95%, and 87%, respectively) or the 5-year rate of freedom from biochemical failure in Group 1, Group 2, and Group 3 (82%, 76%, and 70%, respectively), or freedom from distant metastases (96%, 97%, and 98%, respectively). CONCLUSIONS: Men age </=55 years who present with localized prostate cancer do not appear to have a worse prognosis. External beam radiation therapy appears to be a viable treatment alternative and should be offered to men age </=55 years who present with organ-confined prostate cancer.

Quality of life in long-term survivors of bladder cancer.
Allareddy V, Kennedy J, West MM, Konety BR
Cancer. 2006 Apr 28;.

BACKGROUND: The quality of life (QOL) of long-term survivors of bladder cancer in a population-based registry was assessed. METHODS: The Functional Assessment of Cancer Therapy (FACT-BL) instrument was used to evaluate QOL in a population-based sample of bladder cancer patients. QOL scores were compared between those undergoing radical cystectomy (RC) or those with an intact bladder (BI) and between continent and conduit urinary diversion groups. The influence of current age and time since diagnosis of cancer on QOL were also examined. Multivariate regression analyses were performed to examine the influence of age, time since diagnosis, current condition, treatment, stage of cancer, and comorbid conditions on QOL. RESULTS: A total of 259 patients participated in the study who had undergone RC (n = 82) or other therapy (BI) (n = 177). There were no differences in general QOL scores between RC and BI groups and between the 2 urinary diversion groups, but patients undergoing RC had worse sexual function scores. QOL scores for BI patients tended to decrease with increasing age (P = .01). Presence of comorbid conditions lowered QOL (P<.05). CONCLUSIONS: General QOL does not vary among long-term bladder cancer survivors regardless of treatment, but sexual functioning can be adversely affected in those undergoing cystectomy. Long-term QOL declines even in those with intact bladders, particularly in those with comorbidities. Cancer 2006. (c) 2006 American Cancer Society.

Urinary tract infections among adolescents.
Berger RE
J Urol. 2006 May;175(5):1905.

March

Current antibiotic therapy for isolated urinary tract infections in women.
Kallen AJ, Welch HG, Sirovich BE
Arch Intern Med. 2006 Mar 27;166(6):635-9.

BACKGROUND: Sulfa antibiotics, such as a combination product of trimethoprim and sulfamethoxazole, have traditionally been the drugs of choice for urinary tract infections (UTIs) and remained the most common treatment as recently as a decade ago. However, increasing sulfa resistance among Escherichia coli may have led to changes in prescribing practices. METHODS: We used the 2000-2002 National Ambulatory Medical Care Survey and National Hospital Ambulatory Medical Care Survey to obtain nationally representative data on antibiotics prescribed for women with isolated outpatient UTIs following visits to physicians' offices, hospital clinics, and emergency departments (n = 2638). Logistic regression was used to determine predictors of quinolone use. RESULTS: Quinolones were more commonly prescribed than sulfa antibiotics in each year evaluated. In the most recent year of data, quinolones were prescribed in 48% and sulfas in 33% of UTI visits (P<.04). Quinolones were significantly more likely to be prescribed to older patients and in visits occurring in the Northeast; however, no difference in quinolone prescribing was seen when evaluating insurance status, setting, race, ethnicity, health care provider type, and year. Approximately one third of the quinolones used were broader-spectrum agents. CONCLUSIONS: Quinolones have surpassed sulfas as the most common class of antibiotic prescribed for isolated outpatient UTI in women. Few significant predictors of quinolone use exist, suggesting that the increase is not confined to a certain subset of patients. This pervasive growth in quinolone use raises concerns about increases in resistance to this important class of antibiotics.

The surgical risk of suprapubic catheter insertion and long-term sequelae.
Ahluwalia RS, Johal N, Kouriefs C, Kooiman G, Montgomery BS, Plail RO
Ann R Coll Surg Engl. 2006 Mar;88(2):210-3.

INTRODUCTION: Suprapubic catheter (SPC) insertion is a common urological procedure, which is often referred to as safe and simple even in inexperienced hands. There is, however, very little published evidence on the safety of this procedure. Our study aimed to provide evidence on the associated morbidity and mortality and provide guidance for practising clinicians.PATIENTS AND METHODS: A total of 219 patients who underwent SPC insertion under cystoscopic guidance at two urology institutions between 1994 and 2002 were identified and their case notes reviewed.RESULTS: The intra-operative complication rate was 10% and the 30-day complications rate was 19%. Mortality rate was 1.8%. Long-term complications included recurrent UTIs (21%), catheter blockage (25%) resulting in multiple accident and emergency attendance (43%). Despite this, the satisfaction rate was high (72%) and most patients (89%) prefer the SPC over the urethral catheter.CONCLUSIONS: SPC bladder drainage results in a high patient satisfaction rate. Patients and clinicians should be aware of the potential complications associated with SPC insertion.

Mucosal Host Responses to Bacteriuria in Colonic and Ileal Neobladders.
Wullt B, Bergsten G, Carstensen J, Gustafsson E, Gebratsedik N, Holst E, Mansson W
Eur Urol. 2006 Feb 24;.

OBJECTIVE: To study the local host response in patients with colonic and ileal neobladders, with or without bacteriuria. METHODS: Twenty-three patients with colonic neobladders and 19 with ileal neobladders were included. Eleven radical prostatectomy patients and seven healthy male volunteers were used as controls. Six urine samples were obtained from all patients and controls over a six-month period. The samples were cultured semiquantitatively, and the number of neutrophils and concentrations of the inflammatory mediators interleukin 6 and 8 (IL-6, IL-8) in the urine were determined. RESULTS: The prostatectomy patients and healthy volunteers had sterile urine, and concentrations of IL-6 and IL-8 were below the detection limit. Most (>70%) of the urine samples from patients with colonic and ileal neobladders showed anaerobic or aerobic bacterial growth, and uropathogens were identified in about 45% of the samples. The local host response was minimal or undetectable in the sterile urine samples. However, the host response was markedly induced by uropathogenic strains in the urine, but not by urinary carriage of nonpathogenic or anaerobic strains. IL-8, but not IL-6, was increased in colonic neobladders, which corresponds to the mucosal host responses in patients with intact lower urinary tracts and asymptomatic bacteriuria. In ileal neobladders, the IL-8 responses were higher, and levels of IL-6 were significantly increased. CONCLUSION: Neobladders exhibit a significant local host response to colonization with bacterial uropathogens. This reaction is more pronounced and includes IL-6 activation in ileal neobladders than in colonic neobladders.

Robotic Radical Prostatectomy with the "Veil of Aphrodite" Technique: Histologic Evidence of Enhanced Nerve Sparing.
Savera AT, Kaul S, Badani K, Stark AT, Shah NL, Menon M
Eur Urol. 2006 Mar 9;.

OBJECTIVE: We have recently described a modification (Veil of Aphrodite) designed to preserve the lateral prostatic fascia (LPF) during robotic prostatectomy. Here, we histologically compare the Veil of Aphrodite technique (VT) and standard nerve-sparing technique (ST). METHODS: Thirty-six consecutive prostatectomies performed by a single surgeon were processed by the whole-mount method. The right and left anterolateral (AL) zones of each prostate were independently evaluated for LPF, plane of excision, capsular incision/margin status, margin clearance, and quantitative analysis of periprostatic nerve bundles using S100 immunostain. RESULTS: There were 42 AL zones with ST and 30 with VT. In all 42 ST zones, the plane of excision was outside the prostate and a rim of LPF was present. The mean margin clearance was 1.4mm (0.6-2.8mm) and the mean nerve bundle count was 10 (3-19). Capsular incision and margin status were negative in all 42. For VT, 24 of 30 zones lacked LPF and the plane of excision ran just by the prostatic edge. The mean margin clearance was 0.3mm (0-1.7mm) and the mean nerve bundle count was two (0-11). Two VT AL zones revealed capsular incision; the margin was negative for tumour in all 30. Differences in the margin clearances and nerve bundle counts between ST and VT were statistically significant (p<0.0001). CONCLUSIONS: The LPF contains nerve bundles that run along the surface of the AL zones. The VT is a safe procedure that effectively preserves the LPF and appears to provide enhanced nerve sparing as compared to the ST.

Positive Surgical Margins in Robotic-Assisted Radical Prostatectomy: Impact of Learning Curve on Oncologic Outcomes.
Atug F, Castle EP, Srivastav SK, Burgess SV, Thomas R, Davis R
Eur Urol. 2006 Mar 10;.

OBJECTIVE: The presence of positive surgical margins following radical prostatectomy is a known risk factor for disease recurrence and may lead to adjuvant treatment. Our goal was to assess the incidence of positive surgical margins in our series of robotic-assisted radical prostatectomy (RARP) and its relationship to our learning curve. METHODS: Between February 2003 and August 2005, 140 patients underwent RARP by the same surgical team at our institution. The records of our first 100 consecutive RARPs were retrospectively reviewed. The patients were divided into three groups based on the time of surgery: group I included the first 33 cases; group II included the second 33 cases; and group III comprised the last 34 cases. We compared the incidence and location of positive surgical margins among the groups. Additional variables evaluated included the patient's prostate-specific antigen (PSA) level, preoperative/postoperative Gleason score, clinical/pathologic stage, and pathologic tumour volume. RESULTS: The positive margin rates were 45.4%, 21.2%, and 11.7% for groups I, II, and III, respectively. The difference in positive margin rates in the three groups was statistically significant (p=0.0053). Positive margin rates declined specifically at the apex and bladder neck when comparing the first 33 patients to the last 34 patients. Patient demographics and preoperative staging variables were comparable among all three groups, with no statistically significant differences among them. CONCLUSIONS: This study illustrates that experience gained with time led to a decrease in the incidence of positive surgical margins. We do not feel that a selection bias affected our results because clinical and pathologic staging was evenly distributed within the three study groups. A steady reduction in positive surgical margin rates demonstrates a learning curve, of approximately 30 patients, associated with RARP, and suggests that oncologic outcome is affected by the experience of the robotic surgeon.

Soluble Fas-A promising novel urinary marker for the detection of recurrent superficial bladder cancer.
Svatek RS, Herman MP, Lotan Y, Casella R, Hsieh JT, Sagalowsky AI, Shariat SF
Cancer. 2006 Apr 15;106(8):1701-7.

BACKGROUND: The objective of this study was to test the hypothesis that elevated urinary levels of soluble Fas (sFas) would aid in the surveillance of patients with a past history of nonmuscle-invasive transitional cell carcinoma (TCC) of the urinary bladder. METHODS: sFas levels were determined in cell lysates and supernatants from 2 human bladder cancer cell lines (T24 and TCC-SUP) and in voided urine from 188 consecutive patients who were at risk for TCC recurrence, 31 patients who had noncancerous urologic conditions, and 10 healthy individuals. The authors also obtained barbotage cytology and voided nuclear matrix protein 22 (NMP22) levels. sFas was analyzed continuously and categorically on the basis of its quintile distribution. RESULTS: sFas was present in cell lysates and conditioned media from both cell lines. sFas levels were found to be higher in the TCC group (n = 122 patients) compared with the control group (P < .001). Higher levels of sFas were associated with positive cytology assay results (P < .001), higher NMP22 levels (P < .001), NMP22 levels > 10 U/mL (P < .001), and tumor stage >/=T1 (P < .001). The areas under the receiver operating characteristics (ROC) curves of sFas and NMP22 for bladder cancer detection were 0.757 (95% confidence interval, 0.694-0.819) and 0.704 (95% confidence interval, 0.637-0.772), respectively. In the > 75% sensitivity region of the ROC curves, sFas was consistently more specific than NMP22. In multivariate analyses, sFas, NMP22, and cytology all were found to be associated with the presence of bladder cancer (P values </= .009), but only sFas and cytology were associated with tumor stage >/= T1 (P values </= .026). CONCLUSIONS: sFas was produced and released by bladder TCC cells. Urine sFas was an independent predictor of bladder cancer recurrence and invasiveness in patients who had a past history of nonmuscle invasive bladder TCC, and it outperformed NMP22. Cancer 2006. (c) 2006 American Cancer Society.

Bladder Management for Patients with Myelodysplasia.
Carr MC
Surg Clin North Am. 2006 Apr;86(2):515-523.

Urethral adenocarcinoma mimicking urethral caruncle.
Cimentepe E, Bayrak O, Unsal A, Koc A, Ataoglu O, Balbay MD
Int Urogynecol J Pelvic Floor Dysfunct. 2006 Jan;17(1):96-8. Epub 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.

Two extremes of the megalourethra spectrum.
Vaghefi H, Simmons MN, Hsia MH, Ross JH
Urology. 2006 Mar;67(3):614-6.
The 2 cases of megalourethra presented in this report illustrate the variability in the severity of congenital malformations associated with this condition. Surgical repair of a scaphoid-type megalourethra is discussed. Also, a digital video of megalourethra in a degloved penis is presented that uniquely illustrates the functional anatomy of this condition.

The M2 muscarinic receptor mediates in vitro bladder contractions from patients with neurogenic bladder dysfunction.
Wein AJ
J Urol. 2004 Dec;172(6 Pt 1):2498-9.

Phosphodiesterase-linked inhibition of nonmicturition activity in the isolated bladder.
Wein AJ
J Urol. 2004 Dec;172(6 Pt 1):2496-7.

Lower urinary tract dysfunction in ambulatory patients with incomplete spinal cord injury.
Patki P, Woodhouse J, Hamid R, Shah J, Craggs M
J Urol. 2006 May;175(5):1784-7.

PURPOSE: We evaluated urinary tract dysfunction in individuals with spinal injury who remained able to ambulate. We observed changes with time in urological management. MATERIALS AND METHODS: All patients attending outpatient clinics with traumatic, incomplete (American Spinal Injury Association grades D and E) spinal cord injury during a 2-year period were identified. All patients had their hospital notes reviewed retrospectively and salient urological data extracted. RESULTS: A total of 43 men and 21 women were identified during this period. Mean age was 46 years (range 18 to 70). Mean followup was 7 years (range 1 to 18). At the time of inpatient discharge 40 of the 64 patients (62.5%) could void spontaneously, 20 required CSIC and 4 had a suprapubic catheter. In 19 of these 40 patients (47.5%) who had been initially assessed as having a bladder that was safe to void spontaneously the condition deteriorated, such that CSIC was required. Conversely 5 of 20 patients (25%) who initially required CSIC improved, such that it became redundant. At last followup 68.7% of the patients had abnormal urodynamics and 24 of the 64 (37.5%) required a change in urological management despite no appreciably detectable neurological change. CONCLUSIONS: Despite relatively near total neurological recovery patients with incomplete SCI have neuropathic bladder unless proved otherwise. Salient deterioration in bladder dysfunction is not uncommon. Regular urological monitoring and appropriate treatment changes are required in the long term.

February

Bladder Management for Patients with Myelodysplasia.
Carr MC
Surg Clin North Am. 2006 Apr;86(2):515-523.

Two extremes of the megalourethra spectrum.
Vaghefi H, Simmons MN, Hsia MH, Ross JH
Urology. 2006 Mar;67(3):614-6.

The 2 cases of megalourethra presented in this report illustrate the variability in the severity of congenital malformations associated with this condition. Surgical repair of a scaphoid-type megalourethra is discussed. Also, a digital video of megalourethra in a degloved penis is presented that uniquely illustrates the functional anatomy of this condition.

The M2 muscarinic receptor mediates in vitro bladder contractions from patients with neurogenic bladder dysfunction.
Wein AJ
J Urol. 2004 Dec;172(6 Pt 1):2498-9.

Sonographic Quantitative Evaluation of Scrotal Veins in Healthy Subjects: Normative Values and Implications for the Diagnosis of Varicocele.
Cina A, Minnetti M, Pirronti T, Vittoria Spampinato M, Canade A, Oliva G, Ribatti D, Bonomo L
Eur Urol. 2006 Mar 10;.

OBJECTIVES: To define the normative values of scrotal vein diameters, investigate the eventual presence and characteristics of scrotal reflux in healthy subjects, and describe its implication for the diagnosis of scrotal varicocele. METHODS: Color-Doppler ultrasonography was performed on a population of 145 healthy, symptomless subjects, with clinical examinations and semen analyses within normal limits. RESULTS: The upper limit of the scrotal veins diameter (3.7-3.8mm) exceeds values presently employed for a diagnosis of varicocele. Furthermore, a high percentage of healthy subjects (53%) were found to have reflux in the scrotal veins, currently considered one of the criteria for diagnosing varicocele, especially in its subclinical form. CONCLUSIONS: To reduce the risk of misinterpretations between the various specialists involved in Color-Doppler ultrasonography and urologists, quantitative data of the scrotal veins (i.e., maximum diameter and the presence, velocity, and duration of reflux) should be described in reports of sonographic examinations performed for scrotal varicocele.

Treatment of urethral syndrome: a prospective randomized study with Nd:YAG laser.
Costantini E, Zucchi A, Del Zingaro M, Mearini L
Urol Int. 2006;76(2):134-8.

INTRODUCTION: The urethral syndrome is characterized by irritative disturbances, the urgency-frequency syndrome and/or pain associated with negative urine cultures. Areas of metaplasic tissue in the trigonal-bladder neck region (trigonitis) are sometimes present. We performed a comparative randomized study to assess the efficacy of side- or end-firing neodymium (Nd):YAG laser surgery in destroying metaplasia and relieving symptoms. MATERIALS AND METHODS: Between January 1997 and December 2003, 62 consecutive women with the urethral syndrome and squamous metaplasia of the bladder neck-trigone, who were refractory to drugs, were randomly assigned to treatment with end-firing (group A) or side-firing (group B) Nd:YAG laser. Three, 6 and 12 months after surgery all patients underwent a clinical urological examination and cystoscopy. Surgery was considered successful when patients reported they were satisfied with the outcome or stated on the UDI-6 questionnaire that symptoms were reduced by at least 75%. RESULTS: Group A end-firing laser: patients rapidly improved (2-3 weeks) but symptoms worsened within 3 months. At 6-12 months, symptoms had improved in 19% of the 31 patients and remained unchanged or worsened in 81%. Group B side-firing laser: irritative disturbances worsened in the 7-10 days after therapy but markedly improved within 2-3 months. Symptoms significantly improved in 68% of the 28 patients and remained unchanged or worsened in 32%. Results were significantly better after side-firing laser (p < 0.001) and a trend towards improvements emerged as the joule levels rose. At 3 months, cystoscopy and biopsy showed squamous metaplasia was no longer present in patients whose symptoms had improved. Whitish areas were still present in the bladder neck-trigone in patients whose symptoms had remained unchanged or worsened. These patients were retreated. CONCLUSIONS: In the treatment of the urethral syndrome the few reports on attempts to restore a normal urothelium by means of diathermocoagulation and cryotherapy have been encouraging. Side-firing laser, which produces necrotic coagulation followed by reconstitution of normal functional epithelium, was significantly more successful than end-firing and was associated with a 78% success rate. These results are encouraging in patients who are usually refractory to medical therapy.

The tongue as an alternative donor site for graft urethroplasty: a pilot study.
Simonato A, Gregori A, Lissiani A, Galli S, Ottaviani F, Rossi R, Zappone A, Carmignani G
J Urol. 2006 Feb;175(2):589-92.

PURPOSE: Urethroplasty with a buccal mucosal graft provides excellent clinical results but it may also cause oral complications in some cases. The mucosa covering the lateral and under surface of the tongue is identical in structure with that lining the rest of the oral cavity. We evaluated LMGs for urethroplasty. MATERIALS AND METHODS: From January 2001 to September 2004, 8 men 34 to 65 years old (mean age 46.1) with urethral strictures 1.5 to 4.5 cm long were selected for 1-stage dorsal onlay urethroplasty. The site of the harvest graft was the lateral mucosal lining of the tongue. Postoperatively all patients were followed with urethrography, uroflowmetry, cystourethrography and flexible urethroscopy after 3 and 12 months. Successful reconstruction criteria were peak flow rate greater than 15 ml per second and no need for postoperative urethral dilation. RESULTS: Median followup was 18 months (mean 22.1, range 3 to 47). Seven cases were successful. One patient had a partial urethral stricture. In successful cases cystourethrography revealed no significant graft contractures or sacculations and at flexible urethroscopy LMG was almost indistinguishable from native urethra. There were no pain, esthetic or functional complications at the donor site. CONCLUSIONS: Harvesting the LMG is feasible and easy to perform. Compared with the buccal mucosal graft the LMG seems to be associated with less postoperative pain and a minor risk of donor site complications. These preliminary functional and esthetic data are satisfactory.

Prostatic Infarction Involving the Urinary Sphincter, an Association with Pyoderma Gangrenosum.
van de Riet JE, Benton EC, McNeill SA
Eur Urol. 2006 Jan 13;.

A 70-year-old man presented with haematuria and restrictive urinary symptoms 7 years after a transurethral prostatectomy (TURP). Onset of symptoms coincided with development of a large skin ulcer on his back. A diagnosis of pyoderma gangrenosum was made based on clinical signs and histopathology. On repeated cystoscopy the urethral sphincter was obliterated by necrotic tissue, suspicious for malignancy. Histopathology revealed only necrotic tissue consistent with infarction of the prostate and sphincter. This clinical presentation with infarction of the prostate and sphincter, concurrent with development of skin ulcers, was consistent with pyoderma gangrenosum affecting the prostatic urothelium and sphincter. Previous prostatic surgery may have predisposed our patient to development of pyoderma gangrenosum in the area of the prostate.

Chemoprevention of human prostate cancer by oral administration of green tea catechins in volunteers with high-grade prostate intraepithelial neoplasia: a preliminary report from a one-year proof-of-principle study.
Bettuzzi S, Brausi M, Rizzi F, Castagnetti G, Peracchia G, Corti A
Cancer Res. 2006 Jan 15;66(2):1234-40.

Green tea catechins (GTCs) proved to be effective in inhibiting cancer growth in several experimental models. Recent studies showed that 30% of men with high-grade prostate intraepithelial neoplasia (HG-PIN) would develop prostate cancer (CaP) within 1 year after repeated biopsy. This prompted us to do a proof-of-principle clinical trial to assess the safety and efficacy of GTCs for the chemoprevention of CaP in HG-PIN volunteers. The purity and content of GTCs preparations were assessed by high-performance liquid chromatography [(-)-epigallocathechin, 5.5%; (-)-epicatechin, 12.24%; (-)-epigallocatechin-3-gallate, 51.88%; (-)-epicatechin-3-gallate, 6.12%; total GTCs, 75.7%; caffeine, <1%]. Sixty volunteers with HG-PIN, who were made aware of the study details, agreed to sign an informed consent form and were enrolled in this double-blind, placebo-controlled study. Daily treatment consisted of three GTCs capsules, 200 mg each (total 600 mg/d). After 1 year, only one tumor was diagnosed among the 30 GTCs-treated men (incidence, approximately 3%), whereas nine cancers were found among the 30 placebo-treated men (incidence, 30%). Total prostate-specific antigen did not change significantly between the two arms, but GTCs-treated men showed values constantly lower with respect to placebo-treated ones. International Prostate Symptom Score and quality of life scores of GTCs-treated men with coexistent benign prostate hyperplasia improved, reaching statistical significance in the case of International Prostate Symptom Scores. No significant side effects or adverse effects were documented. To our knowledge, this is the first study showing that GTCs are safe and very effective for treating premalignant lesions before CaP develops. As a secondary observation, administration of GTCs also reduced lower urinary tract symptoms, suggesting that these compounds might also be of help for treating the symptoms of benign prostate hyperplasia.

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Pelvic Floor Digest 2006

Basic Sciences, Miscellaneus : Urology

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