Retrograde intrarenal surgery as second-line therapy yields a lower success rate.

BACKGROUND AND PURPOSE: Retrograde intrarenal surgery (RIRS) is a recent addition to the treatment options for renal calculi. Therefore, the indications, as well as the predictors of success, are still being studied. Herein, we report a retrospective comparison of RIRS performed as the primary treatment and as second-line therapy, mostly after shockwave lithotripsy (SWL) failure. PATIENTS AND METHODS: Between October 2001 and August 2004, 93 patients underwent RIRS (11% of all ureteroscopies), all by the same surgeon. Patients were divided into two groups: group 1 (n = 42) consisted of patients undergoing RIRS as a first-line modality and group 2 (n = 51) of those having RIRS as secondline therapy. The indications for RIRS in group 1 were renal calculi with prior placement of a double-J stent (30%), renal + ureteral stone (25%), pushback of ureteral stone during ureteroscopy (22%), a radiolucent stone (8%), coagulopathy, and abnormal renal anatomy. In group 2, the patients were initially treated by SWL (92%) or percutaneous nephrolithotomy. The groups did not differ significantly in demographic characteristics, mean stone size (9.5 and 8.7 mm, respectively), or stone location (in both 60% in the lower pole). The variables analyzed were operating time, complications, length of hospitalization, and stone-free rate. RESULTS: The overall stone-free rate was 73%. However, the stone-free rate was significantly higher in group 1 than in group 2: 80% v 67%, respectively. A higher complication rate and longer hospitalization were noted in group 2, although the difference was not statistically significant. CONCLUSIONS: When RIRS is performed after failed SWL, it has a lower success rate and may be associated with a higher morbidity rate than if it is performed as first-line therapy. These results suggest that the success rate of RIRS may be influenced by the same negative factors that reduce SWL success. Therefore, if a patient fails SWL, careful consideration should be given to the best second-line therapy comparing RIRS with percutaneous stone removal.

Predictors of erectile function improvement in obstructive sleep apnea patients with long-term CPAP treatment.

The long-term effect of treatment with continuous positive airway pressure (CPAP) on erectile function was assessed in 60 patients with obstructive sleep apnea syndrome (OSAS). Severity of OSAS was evaluated by respiratory disturbance index (RDI) and minimal oxygen saturation (OxiMin). Severity of erectile dysfunction (ED) was assessed with the five question International Index of Erectile Function (IIEF-5) before and after CPAP treatment. Subjects were categorized into three groups on the basis of the change in IIEF-5 score: Group 1, no change (n=37); Group 2, improvement from 10+/-5.65 to 19.1+/-5.7, P<0.01 (n=12); Group 3, worsening from 19.9+/-4.7 to 9.5+/-7.8, P<0.01 (n=11). Group 2 had significantly higher RDI and lower OxiMin than the other groups, and was also more compliant and satisfied with CPAP. Change in IIEF-5 with CPAP treatment was negatively correlated (Pearson coefficient) with OxiMin (r=-0.374), and positively correlated with adherence to CPAP treatment (r=0.689). In conclusion, in selected patients, CPAP treatment for OSAS may by itself have a positive effect on erectile function by improving respiration during sleep. Predictors of erectile improvement include high RDI, low OxiMin, and CPAP compliance.

Quantitative SPECT of technetium-99m-DMSA uptake in the kidneys of normal children and in kidneys with vesicoureteral reflux: detection of unilateral kidney disease.

UNLABELLED: Quantitative SPECT was used to evaluate renal functional volume (cc), percent of injected dose/cc (%ID/cc) and renal uptake (%) in 11 children with unilateral vesicoureteral reflux grade 3 or greater, and in 19 normal control children without reflux. METHODS: Studies were performed 4-6 hr after intravenous injection of 0.750-2 mCi of 99mTc-DMSA. RESULTS: Control kidneys (n = 38) had a volume of 99.7 +/- 29.5 cc. The %ID/cc was 0.27 +/- 0.08, and the uptake in one kidney was 24.8% +/- 3.9%. Global renal uptake (right plus left) was 49.6% +/- 7.3%. Functional volume of the control kidneys showed an increase with age, and the %ID/cc showed a steeper decrease with age, resulting in a trend of the kidney uptake to decrease with age. Kidneys with reflux had a decreased kidney uptake of 15.7% +/- 29.5%, compared to age- and sex-matched controls (t = 4.7, p < 0.001). The contralateral kidneys without reflux had a significantly increased total uptake of 33.4% +/- 6.8% as compared to controls (t = 3.44, p < 0.01). Global uptake by the kidneys was 49.2% +/- 8.6% and was not statistically different from controls (t = 1.0, ns). CONCLUSION: Our results suggest that SPECT quantitation of 99mTc-DMSA uptake in each kidney separately could be used as a noninvasive method to assess impairment and compensation of the function of the individual kidney in children with vesicoureteral reflux.

Congenital bladder diverticula causing ureteral obstruction.

Two boys with congenital periureteral bladder diverticula without vesicoureteral reflux but with severe hydronephrosis and ureteral obstruction are described. No bladder outflow obstruction was present. Urinary tract infection was the presenting symptom in both boys, and this is the most common presenting symptom of bladder diverticula. Diverticulectomy, ureteral tailoring, and reimplantation were performed. Three different mechanisms are proposed for the association of bladder diverticula and ureteral obstruction: compression of the extravesical ureter against the detrusor by the full, tense diverticulum, fibrosis resulting from peridiverticulitis, or primary hypomuscularity of the ureterovesical junction and distal ureter.

Seminoma of intra-abdominal testis in sixty-seven-year-old man.

A sixty-seven-year-old man found to have a seminoma of an undescended intra-abdominal testis is believed to be the oldest reported patient with this presentation. This case emphasizes the importance of careful palpation of the testis as part of the routine physical examination at any age. Testicular tumor or metastases should be included in the differential diagnosis of retroperitoneal mass.

Urinary ascites: complication of umbilical artery catheterization.

In the newborn, intraperitoneal extravasation of urine from a urachal laceration may follow an attempt at umbilical artery catheterization. Clinical results of this injury are neonatal ascites, anuria, and azotemia. Herein, we describe a case of iatrogenic bladder injury with successful management following late detection. The anatomy of the urachus and bladder in the newborn are reviewed as well as clues to the diagnosis of neonatal urinary ascites.

Type II ureteral triplication associated with ectopic ureter.

We report a case of type II ureteral triplication associated with ectopic ureter. The ureter, draining the upper renal segment, entered the vagina, and the other two ureters, draining the middle and lower renal segments, had joined and entered the bladder. The anatomic findings are compatible with those predicted by the Weigert-Meyer law. A thorough evaluation of such an anomaly is essential for effective management.

Correction of disproportion of corpora cavernosa as cause of chordee in hypospadias.

Correction of chordee is a basic step in hypospadias surgery. In some children with significant chordee, ventral deflection of the shaft will persist after all "chordee tissue" is excised from the surface of the corpora cavernosa. In the flaccid state, this persistent chordee may not be evident but is easily demonstrated with an artificial erection technique. The use of dorsal plication of the tunica albuginea to correct this deformity is emphasized.

Pelvic rhabdomyosarcoma: a review of the RPMI experience.

Between 1959 and 1983, 16 patients with pelvic rhabdomyosarcoma were treated at Roswell Park Memorial Institute (RPMI). A multidisciplinary approach was utilized consisting of surgery, radiotherapy (XRT), and combined chemotherapy which resulted in prolonged survivals of thirteen to one hundred forty-four months in 10 patients. This improved survival was observed despite the fact that 63 per cent of the patients (10/16) presented with advanced stages of the disease. Herein we present a retrospective study of these 16 patients.

Intracavernous injections for erectile dysfunction in patients with cardiovascular diseases and failure or contraindications for sildenafil citrate.

The aim of this study was to evaluate the effectiveness of a progressive program for the treatment of erectile dysfunction in patients with cardiovascular disease in whom sildenafil citrate (Viagra) was not an option. The study population included 106 patients selected from 267 with cardiovascular disease. The intracavernous injection program consisted of three protocols of increasingly complex combinations of vasoactive drugs, papaverine, phentolamine, prostaglandin E1 and atropine sulfate. Patients who failed the first protocol were switched to the second, and those who failed the second were switched to the third. A positive response was defined as an erection sufficient for vaginal penetration. A positive response was achieved on protocol I in 61 of the 106 patients (57.5%); protocol II in 32 of the remaining 45 patients (71.1%); and protocol III in seven of the remaining 13 patients (53.8%); the total success rate was 94.3%. These 100 patients were included in the 1-year follow-up, and 90 reported successful coitus at the end of that period: 79 patients (87.8%) with intracavernous injection and 11 (12.2%) without injection. The remaining 10 patients (10%) dropped out of the program, seven (7.0%) for health or marital reasons and three (3.0%) because of treatment failure. We conclude that a progressive program of intracavernous injections of vasoactive drugs may be a good alternative for the treatment of erectile dysfunction in patients with cardiovascular disease.

Polyneuropathy in impotence.

Three hundred and forty-one consecutive impotent patients were evaluated for the presence of polyneuropathy (PNP) by neurophysiological and psychophysical tools, including nerve conduction and quantitative sensory tests (thermal and vibratory). PNP was present in 38% of diabetics, and 10% of non diabetics. Overall, PNP was found in 19% of impotent patients. PNP is relatively common among impotent patients, and might play a causative role. Patients judged 'neurogenic' and those judged 'vasculogenic', based on nocturnal tumescence test (NPT) and vasoactive drug injection tests, had very similar rates of PNP (21 and 23%, respectively). Thus it is suggested that the vasoactive drug injection test does not serve in discriminating neurogenic from non-neurogenic impotence. NPT, however, faithfully discriminates psychogenic from organic impotence, as far as PNP is involved, since a very low percentage of patients with normal NPT had PNP.

Genitourinary trauma in children.

More children die from trauma than from any single disease. In children who sustain multiple injuries, urinary tract trauma is second only to trauma to the central nervous system. Most pediatric trauma is associated with vehicular and pedestrian accidents. However, the increased participation in contact sports and awareness of sports medicine injuries have increased the relative frequency and detection of sports-related injuries as well. Also, the urologist is frequently involved with, and may be legally responsible for, evaluation of children in possible abusive situations. The authors emphasize genitourinary injuries unique to the pediatric age group and update controversies in the management of more complex urologic injuries.

Protein kinase C (PKC) isoenzymes immunohistochemistry in lymph node revealing solution-fixed, paraffin-embedded bladder tumors.

Protein kinase C (PKC) plays an important role in cellular differentiation and in the malignant process. In an earlier study, it was shown that the expression pattern of PKC isoenzymes is altered in some tumors compared to their corresponding normal tissue. In this study, we evaluated the pattern of PKC isoenzyme immunostaining in bladder transitional cell carcinoma (TCC) of different grades and stages and normal tissue. Twenty-seven TCC samples and six areas of normal bladder mucosa were stained with antibodies specific for the PKC isoenzymes: alpha, beta 1, beta 2, delta, and zeta. The sections were scored for intensity of staining, and the correlation with grade and stage of the tumors was computed. The PKC alpha and beta 2 immunostains were intense in normal urothelium and in all evaluated tumors. PKC beta 1 and delta stains were intense in normal and low-grade and -stage tumors and weak in high-grade and -stage tumors. The opposite trend was found for PKC zeta. PKC isoenzyme expression differs in invasive TCC compared to low-grade, low-stage TCC and normal urothelium. The value of these findings as a marker of tumor aggressiveness should be further assessed.

Familial varicocele.

Described are two families in each of which two young males had varicocele. HLA-A, B, C and D5R antigen studies were performed in one family but no genetic factors could be determined. In a review of several large series of patients with varicocele we found no mention of familial occurrence. Although the linkage between adolescent varicocele and spermatogenic dysfunction is still debatable, it is concluded from our experience that it is worthwhile examining other male members of families of affected adolescents or children but that expensive invasive studies are not warranted.

Involvement of internal genitalia in female patients undergoing radical cystectomy for bladder cancer: a clinicopathologic study of 37 cases.

Radical cystectomy for invasive bladder cancer in female patients implies anterior pelvic exenteration. The necessity for routine removal of all internal female genitalia has not, as yet, been investigated. The present study was conducted to investigate the involvement of internal genitalia in these patients. Cystectomy specimens from 37 consecutive female patients with bladder cancer were examined for internal genitalia and urethral involvement. Clinical data were retrospectively collected from hospital charts. Thirty-four patients were available for postoperative follow-up. Of the 37 cases, 30 were transitional cell carcinoma (TCC), 4 squamous cell carcinoma, 1 adenocarcinoma, and 2 undifferentiated carcinoma. Uterine involvement was observed in only 1 case: TCC, stage D1, grade IV. All patients had normal ovaries and a normal vagina regardless of tumor site or stage; however, late ovarian and vaginal recurrences developed in one patient, in whom one ovary had been preserved. Sixteen percent of the patients had urethral involvement. We conclude that synchronous or metachronous involvement of female internal genitalia in bladder cancer is uncommon. Preservation of ovaries and vagina in young patients undergoing radical cystectomy may be considered under strict criteria.

Predictive value of urinary cultures in assessment of microbial colonization of ureteral stents.

BACKGROUND AND PURPOSE: Bacterial colonization of indwelling ureteral stents may serve as a nidus for bacteriuria in operations where stents are manipulated. The predictive value of urine cultures in the assessment of stent colonization was examined in 65 patients with indwelling ureteral stents. PATIENTS AND METHODS: Prophylactic antibiotic treatment was administered prior to stent insertion. All patients were ambulatory at the time of investigation and were examined in the outpatient clinic. Urine cultures were taken prior to stent removal after 8 to 150 (mean 64) days. The stents were removed under aseptic conditions, and the proximal and distal ends were cut off and placed in a culture medium for evaluation. None of the patients was treated for urinary tract infection prior to stent removal. RESULTS: Bacteriuria was found in 15% of the patients. In 35 patients (54%), urine and stent cultures were sterile. In 20 patients (31%), the urine culture was sterile but the stent was colonized (Enterococcus 9, E. coli 5, Staphylococcus aureus 2, S. epidermidis 2, Candida 1, Citrobacter diversus 1). One patient had a sterile stent culture with bacteriuria. In 9 patients (13.5%), urine and stent cultures were identical (E. coli 4, Pseudomonas 4, Candida 1). The incidence of stent colonization did not correlate with stent dwelling time. The sensitivity of urine cultures for the detection of stent colonization was poor, being 31% only. In a specific patient with negative urine culture, the probability of stent colonization was 36%. CONCLUSION: A sterile urine culture does not rule out the stent itself being colonized. Therefore, patients with indwelling ureteral stents and a sterile urine culture may benefit from prophylactic antibiotic treatment prior to endourologic procedures. The prophylactic regimen must provide coverage for common gram-negative uropathogens as well as gram-positive bacteria, including enterococci.