Risk of tuberculosis in dialysis patients: association of tuberculin and 2,4-dinitrochlorobenzene reactivity with risk of tuberculosis.

BACKGROUND: Dialysis patients are at increased risk of tuberculosis (TB) and anergy due to attenuated cellular immunity. AIM: To define specific risks of TB in anergic and non-anergic dialysis patients. METHODS: A total of 272 dialysis patients were enrolled in this prospective study over a 36-month follow-up. Entering the study, participants had Mantoux and 2,4-dinitrochlorobenzene skin tests and their cell-mediated immunity (CMI)-index was estimated. Patients were classified as anergic (CMI-index

The relationship between the perineal length measurements and the urodynamic stress incontinence.

OBJECTIVE: The purpose of this study was to assess the relationship between the length of perineal body, the anal position index, the total fourchette-coccyx distance and the anal-coccyx length and female urodynamic stress urinary incontinence (USUI). PATIENTS AND METHODS: The study included 57 women with USUI (group A) and 45 women without USUI as control (group B). All patients underwent a urodynamic evaluation and measurement of the length of perineal body (PB) and the distance between the fourchette and the inferior margin of coccyx (FC). PB is the distance between the fourchette and the center of anal orifice. The ratio PB/FC is the anal position index. Subtracting the PB length from FC distance equals the anal-coccyx (AC) length. RESULTS: The student's t-test showed no significant statistical difference between any of the measured lengths in the two groups. Moreover, in the USUI group, ANOVA did not show any significant relationship between the urodynamic parameters and the measured lengths. Regarding to the investigated urodynamic parameters only the maximum urethral pressure (Pura max) presented a significant statistical difference between the two groups (P = 0.009). CONCLUSION: Theoretically, a differentiation of perineal distances probably brings to the surface a laxity of the pelvic floor, a factor predisposing to USUI. Furthermore, the anterior position of anus can be a cause of constipation which also contributes to USUI. However, our study did not reveal any relationship between the perineal length measurements and USUI. Further investigation with longer series of patients is needed to show if this simple, inexpensive and non-invasive test could be added in the armamentarium of the diagnostic and prognostic investigation of USUI. Regarding to the urodynamic parameters, our results emphasize the importance of the Pura max parameter in the urodynamic evaluation of USUI.

Prostatodynia or painful male urethral syndrome?

A prospective video-pressure-flow-EMG urodynamic evaluation in two groups of patients was undertaken to show possible differences in the prostatodynia versus nonprostatodynia group regarding their urodynamic characteristics. There was no statistically significant difference, and the main characteristic in both groups was the increased maximum urethral closure pressure (MUCP) recorded at the distal prostatic and membranous urethral segments. During voiding there was a distal urethral narrowing along with a proximal one seen in several patients and a synchronous decrease in urinary flow rate (peak and average flow) in the majority of patients. This functional urethral obstruction should be named "painful urethral syndrome" and not prostatodynia and may be only a step in a chain of events leading finally to chronic nonspecific prostatitis.

Female urethral syndrome: clinical and urodynamic perspectives.

Eighteen women with the urethral syndrome were studied urodynamically with synchronous video-pressure flow studies and electromyography of the external urethral sphincter (EUS). When compared with an age and sex matched control group, the most striking finding was a significantly higher than normal maximum urethral closure pressure. Abnormal and low urinary flow rates, instability of the intraurethral pressure at rest, incomplete funnelling of the bladder neck, and distal urethral narrowing during voiding constitute other typical urodynamic findings in the female urethral syndrome. Detrusor-striated sphincter dyssynergia or primary striated sphincter spasm was not observed. Even though striated EUS spasticity cannot be excluded as a cause of this syndrome in some patients, an autonomically mediated spasm of the smooth muscle sphincter seems plausible to explain both our urodynamic findings and a favorable response of 4 patients treated with alpha-blocking agents.

Rubinstein-Taybi syndrome.

Rubinstein-Taybi (broad thumb and big toe) syndrome, is characterized by mental and motor retardation and skeletal deformities of which broad thumb and large first toe are the most obvious. In addition, defects of the cardiovascular system and the urinary tract may be present. A case of Rubinstein-Taybi syndrome in a boy is presented.

Vesical diverticula: etiology, diagnosis, tumorigenesis, and treatment. Analysis of 74 cases.

A thirteen-year review of bladder diverticula was undertaken and 74 cases were identified. In 8 patients primary neoplasms arose in the diverticula, and their treatment included diverticulectomy or partial cystectomy with or without postoperative irradiation, irradiation only, and transurethral resection of the tumor combined with fulguration of the diverticular wall and postoperative bladder instillations with doxorubicin or thiotepa solutions. Early diagnosis with additional visualization of the interior of vesical diverticulum is mandatory, since carcinoma arising in it has a poor prognosis.

Penile duplication.

We report on a case of penile duplication in an eight-year-old boy. While diphallia was incomplete, there was a common root of the penis which divided into two shafts of different size, doubling in frontal plane. Only one urethra left the bladder along the lower and smaller penile shaft and ended with a hypospadiac meatus. After surgical plastic repair, the patient had a good functional and cosmetic result. In addition, this patient had a horseshoe kidney.

Gabapentin in the management of the recurrent, refractory, idiopathic priapism.

Recurrent idiopathic priapism is a difficult problem to treat and a true emergency for the physicians, and often even invasive therapeutic interventions fail. We recently managed three men with refractory idiopathic priapism with oral gabapentin. They responded to treatment within 48 h. Two men continue not to experience prolonged erections while treated with lower doses of gabapentin for 16 and 24 months, respectively. The third, after a successful treatment for 6 months, stopped gabapentin and priapism recurred. He responded to treatment again and continues to be free of episodes for 9 months. Gabapentin may be a safe alternative for the management of refractory idiopathic priapism.

Vardenafil (Levitra) for erectile dysfunction: a systematic review and meta-analysis of clinical trial reports.

Trials of the efficacy and safety of vardenafil in the treatment of male erectile dysfunction (ED) were meta-analysed. All available databases were searched (January 1, 2001-November 30, 2003). Trials were eligible if they included men with ED, compared vardenafil with placebo, were randomized, were at least of 12 weeks duration, and assessed clinically relevant outcomes. Two reviewers independently evaluated study quality and extracted data in a standardized fashion. Nine trials (6809 men) met the inclusion criteria. In results pooled from seven fixed-dose trials, vardenafil increases the Erectile Function domain of the International Index of Erectile Function questionnaire by 6.18 units (weighted mean difference (WMD)). Vardenafil also increases the percentage of erections firm enough to allow vaginal penetration (WMD: 26) and the percentage of sexual attempts that were successful per participant (WMD: 29.8). The percentage of men agreeing with the statement that 'the treatment they have been taking over the past 4 weeks improved their erections', is also in favour of vardenafil (relative risk (RR): 3). These efficacy variables appeared greater at higher doses, although there are no significant differences between 10 and 20 mg dose. The same results were extracted for the two flexible 'as needed' dosing trials. Discontinuations are greater at the vardenafil groups compared to placebo (RR: 2.25). Specific adverse events with vardenafil included flushing, dyspepsia, headache, and rhinitis. Vardenafil was not significantly associated with serious cardiovascular events or death. Vardenafil, in all treatment regimens, shows to possess superior efficacy to placebo in the treatment of patients with erectile dysfunction. More data is needed on patients' subgroups.

Erectile dysfunction in men with obstructive sleep apnea syndrome: a randomized study of the efficacy of sildenafil and continuous positive airway pressure.

The aim of this study was to compare the efficacy of sildenafil and continuous positive airway pressure (CPAP) in men with erectile dysfunction (ED) and obstructive sleep apnea syndrome (OSAS). In all, 30 men were randomly treated for 12 weeks either with sildenafil 100 mg before intercourse (15 men) or CPAP during night time sleep (15 men). Under sildenafil, 97/180 (53.9%) of attempted intercourses were successful compared to 33/138 (23.9%) under CPAP. The mean IIEF (erectile function domain score) was 12.9 and 9.3 after sildenafil and CPAP treatment, respectively (P=0.007), compared to 7.9 and 7 at baseline. In all, 53.3% of patients were satisfied with sildenafil and 20% with CPAP for ED treatment (P=0.058). Although sildenafil was superior to CPAP, comorbidities and OSAS per se possibly resulted in a lower effectiveness of sildenafil compared to that in the general population of ED men. While about half of the patients were not satisfied even with the more effective treatment, we conclude that a combination of the two therapeutic tools or a different therapeutic mode should be studied further.

A comparative, crossover study of the efficacy and safety of sildenafil and apomorphine in men with evidence of arteriogenic erectile dysfunction.

The aim of the study was to establish and compare the efficacy and safety of sildenafil and apomorphine in men with arteriogenic erectile dysfunction (ED). In all, 43 men with ED and postinjection max penile systolic velocity <25 cm/s in repeated Doppler ultrasonography were included. Of these, 24 men started on apomorphine 2 mg and 19 on sildenafil 50 mg, the doses titrated up to 3 and 100 mg according to effectiveness and tolerability. Safety was evaluated according to adverse events (AEs) and patient withdrawal. Efficacy was the percentage of attempts resulting in erections firm enough for intercourse, based on event log data. The incidence of AEs with apomorphine 3 mg was higher than with sildenafil 100 mg. Two men on apomorphine 3 mg discontinued treatment due to AEs. The overall success rate of sildenafil was 63.7% compared to 32.1% of apomorphine (Pearson chi(2), P<0.01). Of all men, 25 (58.1%) responded to sildenafil 50 mg without the need for dose increase, while only one responded to apomorphine 2 mg. The response to sildenafil 50 mg was age related (analysis of variance, p=0.04). Satisfaction was reported by 76.75 and 13.95% of patients for sildenafil and apomorphine, respectively, but 20.9% were not satisfied with any of the two drugs. In conclusion, this study provides clear evidence that sildenafil, even at 50 mg dose, is more effective than apomorphine 3 mg in men with arteriogenic ED. The fact that one out of five patients is not satisfied with the above-studied drugs shows that new oral agents need to be evaluated for the treatment of this disorder.

Assessment of encrustations on polyurethane ureteral stents.

PURPOSE: To determine the composition and the extent of crystalline (and other) encrustation on ureteral catheters inserted under sterile conditions in stone formers, in comparison with catheters of the same type inserted in nonstone formers for the same time but for different clinical reasons. MATERIALS AND METHODS: Forty consecutive self-retained polyurethane pigtail ureteral catheters removed by cystoscopy between November 2000 and February 2002 were studied, 30 from stone formers and 10 from patients without stone histories. The mean dwelling time was 55 days for the stone formers and 79 days for the other patients. The encrustations were collected and analyzed with Fourier-transform infrared spectroscopy, powder X-ray diffraction, or both. The stones from nine of the patients were also subjected to the same spectroscopic analysis. Representative sections of the catheters were investigated by scanning electron microscopy and energy-dispersive X-ray analysis. RESULTS: The most common encrustation in stone formers was calcium oxalate monohydrate. In patients without stones, deposits of organic compounds were found consistently. The mean mass of encrustation of stone formers was larger (71.05 mg) than that of patients without stones (1 mg). CONCLUSIONS: Calcium oxalate is the predominant type of encrustation on ureteral catheters in stone formers. Prevention of heavy encrustation should be directed to therapeutic measures concerning calcium oxalate lithiasis and development of new materials by the medical industry that are less prone to encrustation.

Coated v noncoated ureteral metal stents: an experimental model.

PURPOSE: The purpose of the present study was to compare the standard metal stents with internally and externally coated metal stents in the pig model. MATERIALS AND METHODS: In nine female pigs weighing between 25 and 30 kg, the metal stents were randomly placed in either the right or left ureter, for a total of 18 stented ureters. Six ureters were stented with a Wallstent (Schneider, Zurich, Switzerland), six with a Passager stent (Boston Scientific, Natick, MA, USA), and six with a Corvita endoluminal graft (CEG) (Boston Scientific, Natick, MA, USA). Patency was examined by nephrostotomography 24 hours and 21 days after the initial procedure. RESULTS: Free flow of urine through the stents into the bladder was revealed in all ureters with the exemption of four cases where a Passager stent migrated into the bladder, jeopardizing ureteral patency. The Wallstent generated mild inflammation with metaplasia of the urothelium; the CEG a more pronounced inflammatory response in the adjacent ureter; and the Passager stent severe inflammatory reaction with necrosis of the urothelium. The sections of the Wallstents revealed the presence of a mild polypoid reaction adherent to the internal surface of the devices. The coated stents showed no tissue ingrowth through the lining material into the ureteral lumen, and thus, the urothelium was compressed beneath the prostheses. CONCLUSIONS: Our experimental results suggest that the standard Wallstent generates less inflammation of the surrounding tissues than coated stents. The coated stents have the advantage of minimal tissue ingrowth but have a tendency to migrate toward the bladder.

Metal stents for the management of atherosclerotic renovascular disease.

PURPOSE: We report on our experience with the use of metal stents for the treatment of atherosclerotic renovascular disease. PATIENTS AND METHODS: Since 1996, 62 patients (mean age 67 years) with ostial atherosclerotic renal artery stenosis were treated successfully by placement of metal stents. All patients presented with renovascular hypertension, and eight had additionally impaired renal function. In 12 patients, stents were placed bilaterally. In 54 patients, the introduction of stents was performed as the primary mode of treatment, and in the remaining 8 patients, the positioning of the endoprosthesis was deemed necessary because of recurrence of stenosis previously treated by renal percutaneous transluminal angioplasty (PTA). The patients were followed for a mean period of 18 months (range 9-48 months). RESULTS: Positioning of the endoprosthesis was successful in all patients. No major complications were reported. The 18-month patency rate was 77.4% (48 patients). Hypertension resolved in 39 patients and showed a trend to improvement in 15 patients. We observed no improvement of renal function in the eight patients who had impaired function prior to the procedure. CONCLUSION: Implantation of metal stents is a safe and effective method for the treatment of atherosclerotic renal artery stenosis and certainly presents an important alternative to renal PTA.

Percutaneous treatment of large symptomatic renal cysts.

PURPOSE: To evaluate the efficacy of alcohol in combination with tetracycline for the treatment of symptomatic renal cysts. PATIENTS AND METHODS: Twenty-four patients age 45 to 77 years (mean 66 years) with a large (5-13-cm; mean 7.5-cm) symptomatic renal cyst associated with flank pain were treated by aspiration under ultrasound guidance and injection of alcohol and tetracycline. Patients were followed with ultrasonography at 1, 6, and 12 months and once a year thereafter. RESULTS: The aspirated volume ranged from 65 to 1500 mL (mean 360.5 mL). Two patients experienced mild pain during alcohol injection, but the procedure was completed successfully. One patient reported severe pain after tetracycline injection. The tetracycline was immediately aspirated, and the procedure was then aborted. The remaining patients were relieved of their symptoms after treatment, and they remained symptom free during a mean follow-up of 20 months (range 7-36 months). CONCLUSIONS: The combination of alcohol and tetracycline is safe and effective and offers a very favorable minimally invasive therapeutic alternative for the treatment of symptomatic renal cysts.

Liposome-coated metal stents: an in vitro evaluation of controlled-release modality in the ureter.

PURPOSE: In vitro preparation of liposome-covered metal stents and loading of liposomal drug formulations that will slowly release the drug in the vicinity of the stent. MATERIALS AND METHODS: Polytetrafluoroethylene-coated stents were used. Large multilamellar (MLV) liposomes (phosphatidylcholine:cholesterol 1:1 mol/mol), empty or entrapping the corticosteroid anti-inflammatory drug, dexamethasone, were prepared by the thin-film hydration method and applied to pieces of stent using a simple and mild evaporation technique. Initially, a freeze-drying method for applying liposomes to stents was also evaluated, but it failed to produce stents that efficiently retain liposomal lipid when incubated in an aqueous environment. The presence of liposomes on the stent surface was confirmed by scanning electron microscopy. RESULTS: After analyzing the release of liposomal lipid (using a phospholipid assay) and liposomal drug (by a modified dexamethasone high-pressure liquid chromatography method) in an in vitro system developed to simulate in vivo conditions, it was found that 39.11+/-6.8% of the lipid and 50.84+/-5.48% of the drug was released from the stent pieces during 48 hours of incubation in the presence of artificial urine. The amount of dexamethasone released from stents during their application procedure was found to be negligible in an in vitro dry run. CONCLUSION: The use of stent-associated liposomal drug formulations as slow-release depots could be an efficient method of treating the untoward event of ureteral stent obstruction.

In vivo estimation of radiation dose in renal pelvis and parenchyma during renography.

A method is presented for the determination of the spatio-temporal distribution of the radionuclide in the kidney and estimation of the dose in the renal pelvis wall and parenchyma, during renograms, on the basis of real data. A protocol was formulated by means of which the processing of the frames acquired in the various stages of the renogram enables the determination of the mass of the renal pelvis and the parenchyma as well as the time distribution of radioactivity in these compartments. The proposed methodology was applied to 30 normal subjects and 35 patients with obstructive nephropathy, acute and chronic obstructive uropathy and hydronephrosis. Our results, when compared with the MIRD dose estimations for the entire kidney showed slight deviations in normals, whereas very significant deviations were observed in the cases with pathology. This is due to the fact that the mass of the 'source' and 'target' organs as well as the biodistribution of the radiopharmaceuticals are essential in dose determination and were completely different in our calculations from those used in the MIRD estimations. Comparing the absorbed dose in renal parenchyma and pelvis wall with that estimated in vivo for the kidney considered as a system of one compartment, we found large differences only in abnormal cases. Differences were also noted between the absorbed dose in the aforementioned renal compartments depending on the considered abnormal renal states.

Testicular torsion: can the testicle be saved one week later?

An unusual case of a 15-year-old male who presented with a characteristic clinical syndrome of testicular torsion one week prior to our observation, is reported. During our intervention the testicle was not removed but, on the contrary, restoration of a satisfactory testicular albugineal appearance was achieved.

Urodynamic indices change as a result of transrectal microwave thermotherapy (TMT) in benign prostatic hyperplasia (BPH).

Fifty-three patients with BPH have been evaluated and treated with TMT with a follow-up at 7 months. The prostate was heated transrectally to 42-43 degrees C and the treatment consisted of 5 to 6 sessions. The duration of each session was 60 minutes. The urodynamic parameters studied revealed an increase of the maximum flow rate and a decrease of the detrusor opening pressure as well as the detrusor pressure at maximum flow. A significant improvement in the amount of residual urine was seen in all patients. Based on the above, we propose TMT as a viable alternative to open surgical or transurethral removal of the prostate. Furthermore, TMT may serve as a preferred treatment option in patients with indwelling urethral catheters and highly increased surgical risk.

Pseudoneotesticle formation using indigenous scrotal structures.

We report on our experience with a new surgical procedure of forming a pseudoneotesticle from indigenous tissues obtained from the existing scrotal contents. This procedure has been performed in 32 patients with a diagnosis of hormone dependent cancer of the prostate as a therapeutic manoeuvre, and in 3 children who had diminution of their testicle down to a peanut size secondary to neglected testicular torsion on the ipsilateral side. The follow-up examination revealed a small decrease in the size of the pseudotesticles that remained stable in further evaluation. This new surgical technique is proposed as a viable alternative to the placement of various artificial scrotal prostheses.