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.

Evaluation of a progressive treatment program for erectile dysfunction in patients with diabetes mellitus.

The aim was to evaluate the effectiveness of a progressive program, starting with simple methods and, when not effective, moving to more complex methods, to treat erectile dysfunction (ED) in patients with diabetes mellitus. A total of 284 diabetic patients with ED entered into a 6-phase program starting with sildenafil citrate (Viagra). Those with contraindications, side effects, or negative response (erection insufficient for vaginal penetration) were switched to the vacuum erection device (VED), and then progressively (for failures) to intracavernous injection (ICI), sildenafil citrate+ICI, ICI+VED, and penile prosthesis. Patients were followed for 2 y. Of the 284 patients 276 patients were eligible for sildenafil citrate and 147 (53.3%) responded positively, but 25 (9.1%) patients stopped it soon due to adverse effects. Of 162 patients (129 nonresponders, eight noneligible for the sildenafil and 25 patients who dropped out due to adverse effects), treated with VED, 114 (70.4%) responded well, however, only 19 (11.7%) patients agreed to continue its use. Of the remaining 143 patients (nonresponders, noneligible for the previously mentioned treatments and patients who dropped out due to adverse effects), 103/143 (72%) responded to ICI, 27/40 (67.5%) to sildenafil+ICI, and 9/13 (69.2%) to ICI+VED. Four patients received a penile implant. At the 2 y follow-up, 81 of 284 patients who entered the study (28.5%) were still responding to sildenafil, seven (2.5%) to VED, 113 (39.8%) to ICI, 24 (8.5%) to sildenafil+ICI, two (0.7%) to ICI+VED; 15 (5.3%) had a penile implant. In all 17 (6%) patients reported spontaneous erections, 11 (3.9%) stopped the treatment due to family reasons and 14 (4.9%) failed the treatment. In conclusion, the progressive treatment program for ED seems to be very effective for diabetic patients, yielded a complete response for short-term and 91.2% rate of success at the end of 2 y follow-up.

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.

Mycetoma of the renal pelvis caused by Fusarium species.

A preterm infant, with posterior urethral valves had a mycetoma of the renal pelvis caused by Fusarium species. Prolonged treatment with amphotericin B alone or with flucytosine failed. Combined surgical drainage and medical therapy resulted in full resolution.

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.

Evaluation of the relationship between semen parameters, pregnancy rate of wives of infertile men with varicocele, and gonadotropin-releasing hormone test before and after varicocelectomy.

OBJECTIVES: To determine whether the gonadotropin-releasing hormone (GnRH) test can serve as an indicator for the need and timing of surgery in infertile men with varicocele. METHODS: The GnRH test was performed in 121 infertile men with varicocele before surgical correction and 4 to 6, 9 to 12, and 16 to 18 months after. Levels of follicle-stimulating hormone (FSH) and luteinizing hormone (LH) were evaluated immediately before the test and 45 minutes after intravenous injection of 100 jig Relisorm L (a synthetic GnRH analogue). Eighteen fertile men with normal semen parameters served as control patients for defining the preoperative hormone levels. A more than twofold increase in FSH and a more than fivefold increase in LH was considered a positive result. Findings were correlated with semen parameters and rate of pregnancy in the patients' wives at 18 months postoperatively. RESULTS: Of the 121 patients, 89 (73.5%) had a positive GnRH test result, and 32 had a negative result. Semen parameters were improved postoperatively in 72 of the GnRH-positive patients (80.9%) and in only 6 of the GnRH-negative patients (1 8.7%). Corresponding pregnancy rates at 18 months in the two subgroups were 60 (67.4%) and 3 (9.3%), respectively. CONCLUSIONS: A positive preoperative GnRH test is a good predictor of improvement in semen parameters and pregnancy after varicocele surgery. We suggest that the GnRH test can serve as an additional indicator for varicocelectomy.

Progressive treatment of erectile dysfunction with intracorporeal injections of different combinations of vasoactive agents.

To account for severity of disease in patients with erectile dysfunction, we introduced a progressive treatment technique using four protocols of drug injections. The study group consisted of 452 men aged 26-85 gamma with erectile dysfunction. Protocol I. All patients began with a combination of papaverine and Regitine in doses adjusted to the estimated severity of dysfunction and to age, up to a maximum dose of 25 mg papaverine and 1.5 mg of Regitine. Protocol II. Patients who could not achieve sufficient rigidity on protocol I were switched to prostin VR, to a maximum of 25 mcg. Protocol III. Patients who failed protocol II received papaverine, Regitine and prostin VR. Protocol IV. Patients who failed protocol III received atropine sulfate (0.02-0.06 mg) in addition to papaverine, Regitine and prostin. Sufficient rigidity was achieved as follows: Protocol I=305 (67.4%) of the original cohort; Protocol II= 61 of the 147 failures with Protocol I (41.5%); Protocol III = 55 of the 86 failures with Protocol 11 (63.9%); Protocol IV = 20 of the remaining 31 patients (64.5%). Overall, sustained rigidity was achieved in 441 of the 452 patients (97.5%). Eleven patients (2.5%) failed all four protocols and were offered a penile prosthesis. Therefore, using our progressive method, by starting with the most available and inexpensive drugs, patients with erectile dysfunction can be given optimal treatment according to the severity of their disease. The success rate is high while costs are kept to a minimum.

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.

The activities of enzymes of purine metabolism in murine thymus dependent lymphocytes.

Measurement of the activities of purine metabolizing enzymes in murine T cell subpopulations showed that these activities differed markedly among T cells of different levels of functional maturity. The activities of adenosine deaminase and deoxyadenosine phosphorylation were highest in immature, PNA + thymocytes, while the activities of purine nucleoside phosphorylase, ecto-5'-nucleotidase and deoxyguanosine phosphorylation were highest in mature, splenic T cells. These enzymes' activities can be used as biochemical markers for T cell of different degree of maturation.

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.