Does Time Spent on Active Surveillance Adversely Affect the Pathological and Oncologic Outcomes in Patients Undergoing Delayed Radical Prostatectomy?

PURPOSE: Pathological and oncologic outcomes of delayed radical prostatectomy following prostate cancer active surveillance are not well established. We determined the pathological and oncologic outcomes of favorable risk, Grade Group 1, prostate cancer managed with active surveillance and progressing to radical prostatectomy for clinically significant prostate cancer (Grade Group 2 or greater). MATERIALS AND METHODS: Between 1992 and 2015, 170 men with favorable risk prostate cancer underwent delayed radical prostatectomy for clinically significant prostate cancer (ASRP) at the Princess Margaret Cancer Centre. Pathological and oncologic outcomes of the ASRP cohort were compared with a matched cohort treated with up-front radical prostatectomy (405) immediately before surgery. Biochemical recurrence-free survival, overall survival and cancer specific survival were compared. We examined the association between delayed radical prostatectomy and adverse pathology at radical prostatectomy and biochemical recurrence using logistic and Cox regression analyses, respectively. RESULTS: Median time spent on active surveillance before radical prostatectomy was 31.0 months. At radical prostatectomy pT3 (extraprostatic extension, seminal vesicle invasion), positive surgical margin and pN1 rates were comparable between the 2 cohorts. Median followup after radical prostatectomy was 5.6 years. The 5-year biochemical recurrence-free survival rate in the ASRP cohort and up-front radical prostatectomy cohort were 85.8% and 82.4%, respectively (p=0.38). Overall survival and cancer specific survival were comparable between the 2 groups. Delayed radical prostatectomy was not associated with adverse pathological outcomes and biochemical recurrence on regression analyses. CONCLUSIONS: Curative intent radical prostatectomy after a period of active surveillance results in excellent pathological and oncologic outcomes at 5 years. A period of active surveillance does not result in inferior outcomes compared to patients with similar risk characteristics undergoing up-front radical prostatectomy.

Role of steroid hormone receptors in formation and progression of bladder carcinoma: a case-control study.

PURPOSE: To compare the expression rate of sex steroid hormone receptors of estrogen (ER), progesterone (PR) and androgen (AR) in normal urothelium and urothelial bladder cancer (UBC) and to evaluate the possible associations of these receptors expression with cancer progression and patient's survival. MATERIALS AND METHODS: We evaluated the clinical data and tumor specimens of 120 patients with pathologically confirmed primary UBC with 132 normal healthy controls. Both patients and controls selected from list of subjects who have been referred to Sina Urology clinic, and had a minimum of one year follow-up duration. Data collected from medical cords. For evaluation of expression, immunohistochemistry was performed on paraffin-embedded tissue sections using a monoclonal antibody for androgen, estrogen and progesterone receptors. Presence of at least 10% positive cells defined as positive expression. RESULTS: None of the control subjects showed AR expression, while 22% of the patients were AR-positive. ER/PR expressions were observed in 4.2%/ and 2.5% of the cases and in 2.3% and 1.5% of the controls, respectively. A statistically significant correlation was found between AR expression and tumor stage and grade (P < .001). AR-positive patients showed a significantly poorer prognosis than AR-negative cases (log-rank test, P = .02, hazard ratio = 2.12; 95% confidence interval: 1.36-4.65). CONCLUSION: AR expression was significantly associated with higher grade and poorly differentiated tumors with unfavorable outcome. AR expression test might be useful as a diagnostic tool for determining the malignancy and outcome of UBC patients. 

Serum uric acid as a risk predictor for erectile dysfunction.

INTRODUCTION: Serum uric acid (UA) is now beginning to be considered a risk predictor for cardiovascular diseases. However, little is known about the effect of hyperuricemia on the risk of developing other systemic vascular disorders, especially erectile dysfunction (ED). AIM: To evaluate whether serum UA is a predicting factor for ED while adjusting for other common risk factors. METHODS: Two hundred fifty-one patients aged 45.2 ± 10.1 years with newly diagnosed and documented ED and 252 age-matched participants without ED (aged 45.1 ± 8.4 years) were enrolled in this case-control study. Univariate and multivariate logistic regression analysis were performed to assess the effect of serum UA on ED; odds ratio (OR) and 95% confidence interval (CI) were calculated. Adjustments were made for potential confounding factors, including obesity, hypertension, diabetes, dyslipidemia, serum triglyceride, and smoking. MAIN OUTCOME MEASUREMENT: Serum UA concentration and the distribution of potential ED risk factors (age, smoking, lipid profile, hypertension, obesity, and diabetes mellitus) were evaluated. Serum UA levels were organized into tertiles. The five-item International Index of Erectile Function was used to evaluate the presence and the severity of ED. RESULTS: The mean serum UA levels in ED-positive and ED-negative groups were 6.12 ± 1.55 mg/dL and 4.97 ± 1.09 mg/dL, respectively (P < 0.001). On analysis of unadjusted variables, statistically significant differences were found for all variables, including serum UA, between ED-positive and ED-negative groups. After adjustment for major risk factors, a significant trend of increasing risk was found for serum UA concentration (OR 5.95, 95% CI 2.96-11.97; P < 0.001, comparing the highest with the lowest tertile). An increase of 1 mg/dL in serum UA level was associated with an approximately twofold increase in risk of ED (OR 2.07; 95% CI 1.63-2.64). CONCLUSIONS: Our findings reveal that serum UA can be considered a risk predictor for ED. Furthermore, hyperuricemia can be regarded as an independent risk factor in addition to the established ones.

Effect of PTEN Gene Mutations and Environmental Risk Factors on the Progression and Prognosis of Bladder Cancer.

BACKGROUND: Bladder cancer is the most frequent genitourinary malignancy in Iran. Environmental and genetic factors are the two factors linked with bladder cancer expansion. The aim of this study was to investigate the role of PTEN gene and environmental risk factors on the progression and prognosis of bladder cancer. METHODS: We evaluated 55 tumor specimens and 66 bladder mucosa samples of non-cancerous patients between 2011 and 2013. All samples were analyzed for PTEN mutations using PCR and direct DNA sequencing methods. Demographic data collected, were analyzed using SPSS version 19.0 software and a P value of < 0.05 was considered statistically significant. RESULTS: Of the 55 patients examined, tumor stage was T1, T2 (T2a, T2b) in 34 (61.8%) and 21 (38.2%) and tumor grade was high, low in 34 (61.8%) and 21 (38.2%), respectively. No mutations in the PTEN gene were found in patients with bladder cancer and control. Among the risk factors studied, only the occupation and history of urinary tract stones, were significantly associated with bladder cancer (P value<0.05). However, other risk factors did not show such a relationship. CONCLUSION: No mutation was found in PTEN gene of patients with bladder cancer. Therefore, mutations in this gene cannot predict the prognosis and progression of urothelial bladder cancer. On the other hand, significant rela-tionship was found between occupation and urinary stones with bladder cancer. This communication reflects the im-pact of these factors on the risk of bladder cancer.

Serum calcium concentration and prostate cancer risk: a multicenter study.

This study sought to further evaluate the possible effects of serum calcium level on prostate cancer (PC) risk, with considering the age, body mass index (BMI), and sex steroid hormones. Using data from a prospective multicenter study, serum calcium concentration, as well as thorough demographic and medical characteristics, were determined in 194 cases with newly diagnosed, clinicopathologically confirmed PC and 317 controls, without any malignant disease, admitted to the same network of hospitals. Serum total and ionized calcium levels were categorized into tertiles. Multivariate logistic regression model was used to estimate odds ratios (OR) and corresponding 95% confidence intervals (CI) after adjustment for major potential confounders, including age, BMI, smoking, alcohol, education, occupation, marital status, family history of PC, and sex hormones level. The mean serum calcium level (±SD) in case and control groups was 9.22 (±0.46) mg/dl and 9.48 (±0.51) mg/dl, respectively (P < 0.001). After adjustment for mentioned confounders, a significant trend of decreasing risk was found for serum total calcium concentration (OR = 0.27, 95% CI = 0.12-0.59, comparing the highest with the lowest tertile) and ionized calcium (OR = 0.25, 95% CI = 0.10-0.58). An increase of 1 mg/dl in serum calcium level was associated with a significant decrease in PC risk (OR = 0.52; 95% CI = 0.34-0.76). Our findings reveal the inverse association between serum total and ionized concentrations and PC risk, which supports the hypothesis that calcium may protect against PC. Furthermore, no evidence was found regarding age, BMI, and sex steroid hormones to modify the association between serum calcium and PC risk.

Image-guided biopsy of small renal masses in the era of ablative therapies.

OBJECTIVE: To further evaluate the accuracy, safety, and impact of image-guided renal biopsies on clinical decision making and management of the indeterminate small renal masses. METHODS: A total of 145 patients (males 99, females 46) with small renal masses suspicious for malignancy were evaluated during the study period. The patients' mean age was 67.2 (± 11.6) years. Computed tomography guided biopsies were carried out in all cases by an experienced interventional radiologist. An experienced genitourinary pathologist reviewed all pathological specimens. Patients' demographic characteristics, tumor histology and subsequent intervention, as well as periprocedural morbidities were recorded and analyzed. RESULTS: A total of 145 renal biopsy procedures were carried out. The small renal masses mean size was 2.4 ± 1.1 cm. Biopsy was diagnostic in 126 (86.9%) cases and non-diagnostic in 19 (13.1%) cases. Of diagnostic biopsies, 107 (84.9%) were malignant, 84.1% of which were primary renal cell carcinoma. Histological subtyping and grading of tumor was possible in 100% and 52.2% of renal cell carcinomas, respectively. The major renal cell carcinoma subtype was clear cell (63.3%) followed by papillary (24.4%) and chromophobe (8.8%). Repeat biopsy was carried out in nine of 19 non-diagnostic cases, and diagnosis was possible in 66.7%. Sensitivity of percutaneous renal biopsy was 91%, and its accuracy was 85.5%. Overall, patients' age, sex, tumor size, and location were not related to non-diagnostic biopsy results and/or tumor pathology. No cases of hemorrhage, seeding of biopsy tract, infection or mortalities were observed. CONCLUSIONS: Our findings showed that image-guided biopsy of indeterminate small renal masses is safe and can provide the correct diagnosis with a high degree of accuracy. Thus, this procedure can play an important role in establishing a histopathological diagnosis before treatment of enhancing small renal masses with ablative technologies. Furthermore, repeat biopsy can alter the clinical management of non-diagnostic biopsies.

Circulating sex hormones play no role in the association between sexual activity and the risk of prostate cancer.

INTRODUCTION: High sexual activity (SA) has been reported to reduce the risk of prostate cancer (PC). The role of sex hormones (SHs) in this regard remains controversial. AIMS: To determine the impact of SA and SHs on PC development. METHODS: In a multicentric hospital-based case-control study, 194 newly diagnosed PC patients along with 317 age-matched controls were studied. Sociodemographic and medical characteristics of participants were recorded. History of vasectomy and sexually transmitted infection (STI), marital status, age at first intercourse, premarital sex, and the current frequency of sexual intercourses per month (SPM) were evaluated. Total testosterone (TT), free testosterone (FT), estradiol (ES), sex hormone binding globulin, and albumin were also measured. Logistic regression model was used to identify independent risk factors for PC. MAIN OUTCOME MEASURES: (i) The association between SA, SHs, and the risk of PC; (ii) The correlation between SHs and SA; (iii) The interaction between SHs and SA and established risk factors for PC and erectile dysfunction in determining the risk of PC; and (iv) The correlation between SHs and SA in determining the risk of PC in different decades of life. RESULTS: Vasectomy, STI, and marital status did not differ significantly between two cohorts. Controls reported premarital sex more commonly than cases (P < 0.001). Cases had the first intercourse at older age (P = 0.03) and had less SPM (P < 0.001). TT, FT, and ES were higher in controls (P < 0.001). In multivariate analysis, TT, calculated FT, SPM >4, and age at time of marriage <24 were protective against PC. The protective effect of high SA and SHs increased as patients' age increased. CONCLUSIONS: High SA as well as TT and FT were protective against PC. Their protective role enhances by each decade of increasing age. The protective effect of high SA was independent from circulating levels of SHs.

Major dietary factors and prostate cancer risk: a prospective multicenter case-control study.

The association between diet and prostate cancer (PC) risk, although suggestive, still remains largely elusive particularly in the Asian population. This study sought to further evaluate the possible effects of different dietary factors on risk of PC in Iran. Using data from a prospective hospital-based multicenter case-control study, dietary intakes of red meat, fat, garlic, and tomato/tomato products, as well as thorough demographic and medical characteristics, were determined in 194 cases with the newly diagnosed, clinicopathologically confirmed PC and 317 controls, without any malignant disease, admitted to the same network of hospitals. Odds ratios (ORs) and corresponding 95% confidence intervals (CIs) were obtained after adjustment for major potential confounders, including age, body mass index, smoking, alcohol, education, occupation, family history of PC, and total dietary calories. Comparing the highest with the lowest tertile, a significant trend of increasing risk with more frequent consumption was found for dietary fat (OR: 1.79, 95% CI: 1.71-4.51), whereas inverse association was observed for tomato/tomato products (OR: 0.33, 95% CI: 0.16-0.65). A nonsignificant increase in PC risk was revealed for dietary red meat (OR: 1.69, 95% CI: 0.93-3.06). For garlic consumption, a borderline reduction in risk was observed (OR: 0.58, 95% CI: 0.32-1.01; P = 0.05). In conclusion, our study supports the hypothesis that total fat may increase PC risk and tomatoes/tomato products and garlic may protect patients against PC.

High prevalence of chronic hepatitis B infection among injection drug users in Iran: the need to increase vaccination of adults at risk.

We measured the prevalence of HBV surface antigen (HBsAg) among male injection drug users (IDUs) in Detention, Tehran, Iran. A cross-sectional survey included 499 male IDUs arrested by police during a predetermined police sweep in Tehran (February, 2006). A questionnaire was filled out for each individual. Blood specimens were collected for HBsAg testing. Prevalence of HBsAg was 5.8% (95% CI 3.6-7.9). The majority of chronic HBV infections, 69.2%, were among adults age 25 to 34 years. The high prevalence of HBsAg highlights the need for special efforts to increase vaccination among adult populations at risk for HBV infection in order to reducing continuing transmission and stave off future high burden of disease.

Complications and outcomes following extracorporeal shock wave lithotripsy: a prospective study of 3,241 patients.

Extracorporeal shock wave lithotripsy (SWL) has become the least invasive treatment modality with high success rates for urinary calculi; however, its established efficacy has been associated with a number of side effects and complications. This study sought to further evaluate the incidence rate and management of the post-SWL complications and also the efficiency of procedure in a large scale of patients. During a 51-month period, 3,241 consecutive adult patients with the mean age of 38.1 years (range 15-75) and urinary calculi (>or=4 mm) underwent SWL at our referral center and were followed for 3 months prospectively. Overall, 3,614 stones [kidneys (83.5%), ureters (15.8%) and bladder (0.7%)] in 3,241 patients were treated requiring 7,245 SWL sessions. Stone-free state occurred in 71.5% calculi and success rate in 79.8% patients. The re-treatment was necessary in 37.2% patients. Auxiliary procedure and efficiency quotient were 5.6% and 0.50, respectively. SWL success rate decreased as the stone size increased (P < 0.0001). The stone-free rate was correlated with the location of the stone. During the study period, 4,075 complications occurred in our patients. Colicky pain (40%) was the most frequent symptom followed by gross hematuria (32%) and steinstrasse (24.2%). Symptomatic bacteriuria developed in 9.7% patients; Escherichia coli (30.4%) was the most causative organism. In conclusion, the complication rate following SWL was high in our study; however, the majority was mild and managed conservatively or with the minimal intervention. Moreover, the management of urinary calculi in adults using SWL was proved to be safe and efficient, particularly for ureteral stones <10 mm, renal pelvic stones <20 mm, and bladder stones <30 mm.

Erectile dysfunction severity as a risk predictor for coronary artery disease.

INTRODUCTION: Erectile dysfunction (ED) is now beginning to be considered as an early manifestation of a subclinical systemic vascular disorder and may be an index of subclinical coronary artery disease (CAD). AIM: To further evaluate whether ED is a predicting factor for CAD while adjusting for other common risk factors. METHODS: One hundred eighty-three patients with newly diagnosed and documented CAD and 134 participants without CAD were enrolled in this case-control study at our referral center. Univariate and multivariate logistic regression analysis were performed to assess the effect of classic risk factors and ED severity on CAD; calculating odds ratio (OR) and 95% confidence interval (CI). Adjustments were made for potential confounding factors including age, hypertension, diabetes, dyslipidemia, obesity, and smoking. MAIN OUTCOME MEASURES: The prevalence of ED and the distribution of CAD risk factors (age, smoking, lipid profile, hypertension, obesity, and diabetes mellitus) were evaluated. The 5-item International Index of Erectile Function was used to evaluate the presence and the severity of ED. RESULTS: The prevalence of ED in CAD-positive and CAD-negative groups was 88.5% and 64.2%, respectively (P < 0.05). A statistically significant difference was found for all risk factors (except total cholesterol and low-density lipoprotein levels), and also ED prevalence between studied groups. Adjusted OR for age, diabetes, hypertension, hypercholesterolemia, and smoking demonstrated a significant confounding effect. Our results also revealed a significant association between severe ED and CAD (OR: 2.22, 95% CI: 1.11-6.03; P < 0.05). CONCLUSION: This study suggests that ED could be considered as a surrogate marker which can predict the occurrence of CAD, and severe ED could be regarded as an independent risk predictor in addition to the established ones.

Anabolic-androgenic steroid effects on early morbid symptoms after open prostatectomy: a pilot study.

OBJECTIVES: Anabolic-androgenic steroids such as Nandrolone phenpropionate (NP) dramatically improve the tolerance to acute stress conditions, strength, and subsequently the quality of life in elderly men. We hypothesize that preoperative pulse-dose supraphysiological NP administration might improve the early morbid symptoms in older patients undergoing open prostatectomy. METHODS: From 2005 to 2006, 54 patients with a mean age of 70 years, diagnosed as benign prostatic hyperplasia and hospitalized for open prostatectomy were enrolled in the study. They were randomly selected to receive preoperative supraphysiological NP (100 mg, intramuscularly, pulse-dose) or sesame oil placebo, prospectively. Early postoperative morbid symptoms including subjective urinary symptoms (dysuria, bladder retention sensation), incision site pain and general satisfaction of their current urinary condition were assessed by a 6-point scale, self-administrated questionnaire at 24 and 48 h, postoperatively. The sex hormone binding globulin and the testosterone levels were also measured. RESULTS: The 24-h postoperative symptoms were significantly reduced in the NP group compared to the placebo (6.18 +/- 2.81 versus 9.77 +/- 2.15; P < 0.001). The postoperative symptoms were reported to have a decline in the 48 h following operation, though was calculated to be statistically insignificant (4.48 +/- 2.32 versus 5.55 +/- 1.84; P = 0.06). There was no complication attributed to NP therapy. CONCLUSIONS: The data supported the hypothesis that the preoperative anabolic steroid supplements (such as NP) could result in a better postoperative endurance in elderly men undergoing open prostatectomy. Further studies, longer and repeated pulse injections in a larger number of older men are mandatory to prove the claim.

Serum selenium level and prostate cancer: a case-control study.

Selenium is a potential chemopreventive agent against prostate cancer. This study sought to evaluate and compare the serum selenium level in men with newly diagnosed prostate cancer and noncancerous patients. Between 2005 and 2006, this prospective case-control study was performed on patients referred to Sina and Imam University hospitals, Tehran, Iran; it included 62 men with clinicopathologically confirmed diagnosis of prostate cancer (case group) and 68 men with no detectable prostate cancer [normal digital rectal examination and prostate-specific antigen (PSA) level] or any other malignant disease (control group). The serum selenium level was assessed using Zeeman graphite furnace atomic absorption spectrometer (Varian Company, Australia). The mean serum selenium level in the case and control group was 66.3 +/- 17.7 microg/l and 77.5 +/- 22.5 microg/l, respectively (P = 0.002). Serum selenium was inversely associated with prostate cancer risk. After adjustment for age, body mass index (BMI), and smoking, the odds ratio was 0.16 and 95% confidence intervals were 0.06 to 0.47 (P trendq = 0.001) comparing the highest with the lowest tertile (> or = 89.3 microg/l). No correlation was observed between serum selenium level and age, BMI, or PSA level. In conclusion, serum selenium levels in prostate cancer cases were lower than in controls, which supports the hypothesis that selenium may protect against prostate cancer.

The risk factors of prostate cancer: a multicentric case-control study in Iran.

Prostate cancer (PC), in Iran, is the third most frequently diagnosed visceral cancer among men and the seventh most common underlying cause of cancer mortality. We evaluated the relation between speculated factors and PC risk using data from a multicentric case-control study conducted in Iran from 2005 to 2007 on 130 cases of incident, clinicopathologically confirmed PC, and 75 controls admitted to the same network of hospitals without any malignant disease. Odds ratios (OR) and corresponding 95% confidence intervals (CIs) were estimated using conditional logistic regression models. The risk of PC was increased with aging (OR: 5.35, 95% CI: 2.17-13.19; P<0.0001), and with the number of sexual intercourse >or=2 times/week (OR: 3.14, 95% CI: 1.2-8.2; P=0.02). One unit elevation in serum estradiol and testosterone concentration was related to increase (OR: 1.04, 95% CI: 1.01-1.06; P=0.006) and decrease (OR: 0.79; 95% CI: 0.64-0.96; P=0.02) of PC risk, respectively. Cases were less likely to have a history of diabetes (OR: 0.34, 95% CI: 0.12-0.98; P=0.04). Increasing in dietary consumption of lycopene and fat was associated with declined (OR: 0.45, 95% CI: 0.09-2.12) and increased (OR: 2.38, 95% CI: 0.29-19.4) PC development, respectively. Other factors including educational level, marriage status, dietary meat consumption, vasectomy and smoking have not been shown to affect PC risk in the Iranian population. Our study adds further information on the potential risk factors of PC and is the first epidemiologic report from Iran. However, justification of these results requires more well-designed studies with a larger number of participants.

Outcome of buccal mucosal graft urethroplasty for long and repeated stricture repair.

OBJECTIVES: To evaluate the efficacy of one-stage buccal mucosal tubed graft in long and repeated urethroplasty. METHODS: Thirty-four patients with long and repeated strictures of the urethra underwent buccal mucosal urethroplasty from 2000 to 2003. For all patients, one-stage buccal mucosal tubed graft urethroplasty was performed by releasing and extracting the fibrous tissue around the stricture, harvesting buccal mucosa from the inner cheek, tubing the graft, and interposing it in the defect. The urethral catheter was removed 3 weeks postoperatively. Suprapubic drainage was in place until urethral patency was confirmed by antegrade cystourethrography. The patients were followed up with clinical history and symptom reporting, urinalysis and culture, periodic uroflowmetry, ultrasonography, and cystourethrography at 1, 3, and 6 months and yearly thereafter. The urinary flow rates before and after surgery, postvoid residual urine volumes, restricture rates, and incidence of incontinence, erectile dysfunction, fistula, and diverticulum were assessed. RESULTS: The procedure was technically successful in all patients. The mean operative time was 150 minutes. During 28 months (range 12 to 39) of follow-up, the success rate was 76.5%. Restricture occurred in 5 patients during the first year postoperatively. Urethrocutaneous fistula, erectile dysfunction, and diverticulum occurred in 2, 1, and 1 patient, respectively. The mean urinary flow rate and postvoid residual urine volume improved significantly. Patient satisfaction was good. CONCLUSIONS: Buccal mucosal grafts are tough, resilient, easy to harvest, and leave no scar. They appear to be an optimal substitute for anterior and posterior long urethral strictures in repeated urethroplasty.

Posttransplant infectious complications: a prospective study on 142 kidney allograft recipients.

INTRODUCTION: We evaluated the posttransplant complications resulting from infections and their association with graft function, immunosuppressive drugs, and mortality. MATERIALS AND METHODS: A total of 142 kidney allograft recipients were followed for 1 year after transplantation. The patients' status was assessed during regular visits, and data including clinical characteristics, infections, serum creatinine level, acute rejection episodes, immunosuppressive regimen, graft function, and mortality were recorded and analyzed. RESULTS: Infections occurred in 77 patients (54%). The lower urinary (42%) and respiratory (6.3%) tracts were the most common sites of infection. The most frequent causative organisms were Klebsiella in 34 (24%) and cytomegalovirus in 25 patients (18%). Wound infection occurred in 7 patients (5%). The mortality rate was 7.7% and infection-related death was seen in 5 patients (3.5%) who developed sepsis. Graft loss was seen in 16 patients (11%), of whom 2 developed cytomegalovirus infection, 2 experienced urinary tract infection, and 5 developed sepsis and died. Mycobacterial and hepatitis C infections were noticeably rare (0.7% and 2.8%, respectively). CONCLUSION: This study showed that infections are important causes of morbidity and mortality during the posttransplant period. We recommend that serologic tests be performed before and after transplantation to recognize and meticulously follow those who are at risk. In our study, high-risk patients were those with elevated serum creatinine levels who received high doses of immunosuppressive drugs. As the urinary tract is the most common site of infection, early removal of urethral catheter is recommended to reduce the risk of infection.

Buccal mucosal graft in repeat urethroplasty.

INTRODUCTION: Our aim was to evaluate the efficacy of a tubed buccal mucosal graft in repeat urethroplasty for patients with urethral stricture and failed previous operations. MATERIALS AND METHODS: Ten patients (aged 12 to 47 years) with urethral stricture were entered into the study. All had a history of failed previous urethroplasties, and 5 had failed internal urethrotomies, too. Repeat urethroplasties were performed by excising the fibrous tissue around the stricture; buccal mucosa was then harvested from the inner cheek, made into graft tubing, and interposed into the defect. The patients were followed at 1, 6, and 12 months. RESULTS: The procedure was technically successful in all the patients. The mean operative time was 150 minutes. The stricture sites were in the posterior urethra in 8 and the anterior urethra in 2 patients. The mean urethral defect length was 4.9 cm. The primary etiology was pelvic fracture in 7 patients. Strictures recurred postoperatively in 3 patients, all of whom had a urethral defect longer than 5 cm, and 2 of whom had more than 1 previous failed urethroplasties (compared with 1 out of 7 in the successful cases). Urinary flow rate increased significantly (from 0 to 10.4 +/- 7.33 mL/s) postoperatively (P = .018). Longer strictures produced significantly poorer graft urethroplasty outcomes (P = .001). CONCLUSION: Urethroplasty with buccal mucosal grafts is tough, resilient, easy to harvest, and leaves no scar. It appears to be an optimal substitute for anterior and posterior urethral strictures longer than 3 cm.