Urology Journal

Purpose: In order to select the most appropriate donor and minimize psychological and physical complications in the kidney donors, it is of high importance to prepare the donor meticulously. The essential respective items are reviewed in this study.

Materials and Methods: The available published literature and papers presented in Medline from 1983 to 2003 were reviewed.

Results: One the sources of sources of kidney donation is the live donor which is mostly used in Iran. Similarly, due to long waiting lists of kidney recipients, live donor kidney transplantation have been increasingly used in developed countries. Consequently, several aspects of this issue have been considered and specific recommendations have been discussed; anatomy of the donor's kidney, age, ABO blood group, viral infections, weight, HLA type compatibility, psychological status, and diseases such as diabetes, ADPKD, and Alport syndrome should be evaluated in donation candidates.

Purpose: To report the first experience in laparoscopic adrenalectomy and to study its efficacy and safety in the treatment of different adrenal diseases.

Materials and Methods: From March 1997 to July 2001, 11 patients underwent laparoscopic adrenalectomy through transperitoneal approach, five of whom were males and 6 were females. Their mean age was 35.5 (range 28 to52) years. Lesion was located on the left side in 6 patients and on the right side in 5. All necessary evaluations were done preoperatively including CT scan, MRI, MIBG scan, and endocrine tests such as ACTH, cortisol, mineralocorticoid, 17-hydroxyprogesterone, and urinary VMA. Three (5, 10, and 12 mm) trocars were used in left laparoscopic adrenalectomy and three or four (12, 10, 5, and 5 mm) trocars were applied in right laparoscopic adrenalectomy. All the patients were followed up for three months with physical examination and paraclinical tests.

Results: Mean operative time (including anesthesia and surgery) was 205 ± 65.95 (range 130 to 310) minutes. No significant difference was seen between the operative time in the left side and the right side adrenalectomy (P = 0.5). Mean hospitalization was 5.54 ± 3.4 (range 3 to15) days. Mean size of mass was 5.45 ± 1.7 (range 2 to 8) cm. Blood transfusion was performed in 2 patients and open surgery was conducted for one because of extensive adhesions. No mortality was reported. During a 3-month follow-up, hormonal tests and blood pressure were normal for all the patients, with no medical treatment being required.

Conclusion: Our study demonstrated that transperitoneal laparoscopic adrenalectomy is an effective and safe approach in the treatment of adrenal masses with the least morbidity.

Purpose: To evaluate the safety and efficacy of transcutaneous ultrasound guided nephrolithotomy.

Materials and Methods: From December 1999 to December 2000, 12 patients with renal stone were selected for PCNL. Six patients had failed ESWL and the remainder had multiple and large stones in pelvis and lower calyx. Ultrasonography was used in 11 patients during the entrance to the system and dilatation of the tract. Entrance to the system was impossible in one case for which open surgery with dorsal lumbotomy was performed.

Results: The stone was removed by just one session of PCNL in 8 and the residual stone was less than 1 cm in the 3 other cases. Repeated PCNL from the same tract was performed in one case and ESWL was carried out in the other 2 cases. After three months, all of the 11 patients were stone free.

Conclusion: It seems that ultrasonography could replace fluoroscopy in patients with dilated collective urinary system and a single large stone in calyx or pelvis.

Purpose: To determine the accuracy of clinical staging methods of bladder cancer and TURBT results in estimating the pathologic stage of tumor.

Materials and Methods: Thirty two patients who had undergone radical cystectomy were studied in this retrospective survey. The results of bimanual examination, cystoscopy, TURBT pathology report and the tumor contour in CT scan, (size, infiltrative deepness, pelvic lymph nodes involvement and hydronephrosis) were recorded. The type of surgery and pathologic report of cystectomy sample were analyzed as well. Then the results of bimanual examination, tumor size, hydronephrosis and CT scan findings including tumor infiltrative deepness, pelvic lymph adenopathy and TURBT findings were compared to pathologic results of cystectomy sample.

Results: Seven patients were females and 25 were males. Their mean age was 62 (range 36 to 80) years. Gross hematuria and irritative urinary symptoms were the most common complaints. The duration between symptom manifestation and patient’s referral was 5 days to 72 months (mean 12 months). Bimanual examination in estimating the extravesical involvement of tumor had a specificity of 82%, sensitivity of 46%, positive predictive value of 70% and negative predictive value of 63%. The size of tumor in determining extravesical involvement had a specificity of 41%, sensitivity of 93%, and positive predictive value of 58% and negative predictive value of 87%. Hydronephrosis was present in 15 patients of whom, 14 (93%) had bladder muscle involvement. CT scan specificity was 70%, and sensitivity was 46% regarding pelvic lymph adenopathy and perivesical fat involvement. In TURBT report no muscle sample was observed in 11 cases, so that the interpretations of results were impossible. The reported grade of tumor was lower than pathologic sample of cystectomy in 4 patients.

Conclusion: Clinical staging in invasive bladder cancers has not high accuracy regarding the involvement of bladder surrounding fats and pelvic adenopathies. A tumor sized more than 5 cm could be sensitive in estimating extravesical involvement. Positive predictive value of hydronephrosis is considerable regarding bladder muscle involvement. Tumor understaging by TURBT is happened in high percentage of patients with invasive bladder cancer.

Purpose: To evaluate the efficacy and safety of intravesical Bacillus Calmette-Gurein injection in the treatment of female patients with interstitial cystitis.

Materials and Methods: Thirty women meeting the National Institute of Arthritis, Diabetes, digestive and kidney diseases criteria for interstitial cystitis, were randomized in a double-blinded fashion in two groups each consisted of 15 patients to receive six, weekly instillation of 120 mg BCG vaccine of Iranian Institute of pastor or placebo. Periodic questionnaires on symptoms of interstitial cystitis, voiding diaries, bladder capacity at first desire to void, and maximum bladder capacity were obtained. Adverse events were closely monitored during the treatment and follow-up phases of the study. Subjective and objective baseline values were compared with the follow-up data.

Results: With a mean follow-up of 24 (range 6 to 33) months 11 out of 15 (73%) in BCG group, and 3 out of 15 (20%) in placebo group responded to the treatment (P < 0.002). Responders were defined the patients with more than 40% improvement in the symptoms of interstitial cystitis. The global improvement in symptoms and signs of interstitial cystitis was 62%. Adverse events were similar in both groups, mostly irritative in nature and no significant systemic event was noted. BCG did not worsen interstitial cystitis symptoms.

Conclusion: We concluded that intravesical BCG is safe, effective, available, and inexpensive with relatively durable results in the treatment of interstitial cystitis.

Purpose: To compare Buccal Mucosa Graft with Penile Skin Flap techniques in the management of anterior urethral diffuse strictures longer than 3 cm.

Materials and Methods: Thirty seven patients with a mean age of 28.5 (range 5 to 50) years had been treated by these two techniques using the ventral onlay patch from February 1997 to March 2002. Patients' follow-up included physical examination, history taking, retrograde urethrography, cystoscopy and uroflowmetry at the month six, at the end of the first and the second years, and then yearly if required.

Results: These techniques were applied for anterior urethral strictures (bulbar and penile) longer than 3 cm. Buccal mucosal graft (BMG) was used in 18 patients and penile skin flap (PSF) in 19. Mean follow-up was 27.5 (range 6 to 50) months. Mean age was 30.8 ± 11.8 years for BMG group and 27.8 ± 15.6 years for PSF group. Urethral stricture etiology, surgery history, and previous endoscopic surgery history were similar in both groups. The stricture site in BMG group was penile in 2 patients (11.1%), bulbar in 8 patients (44.4%), and penobulbar in 8 patients (44.4%). In PSF group the stricture site was penile in 11 patients (57.9%), bulbar in 5 patients (26.3%) and penobulbar in 3 patients (15.8%). Success rate in 6-month follow-up was 93.9% for BUG group and 83% for PSF. By performing dilatation and internal rethrotomy for mild strictures, the success rate with mean follow-up of 27.5 months was 13.8% for BMG group and 78.9% for PSF. Only one patient from BMG developed temporary impotence for about 12 months.

Conclusion: BMG and PSF are considered as simple and proper techniques with good long term outcomes in the management of diffuse anterior urethral strictures. These 2 techniques could be applied in patients with history of several surgeries. The results of BMG were better than PSF, still, this difference was not statistically significant.

Purpose: To evaluate the results of plaque excision and dermal grafting in Peyronie’s disease.

Materials and Methods: Twenty seven patients were scheduled to undergo plaque excision and dermal grafting for Peyronie’s disease. Potency, bending of erected penis, and having painful erection were evaluated in patients before and after operation. To evaluate erectile dysfunction, we used International Index of Erectile Function (IIEF) by interviewing the patients and filling questionnaires by their partners. Doppler ultrasonography was used to determine the vascular competence of penis before and after operation in 15 patients.

Results: The disease was more prevalent between the ages of 40 and 60 years. Plaques were located as follows: dorsal in 18, right lateral in 6 and left lateral in 3. Mean plaque size was 11 (range 5 to 18) mm. After plaque excision and dermal grafting, penile deformity, erectile dysfunction, and painful erection had remained yet in 4 (15%) out of 27, 3 (16%) out of 19, and 3 (14%) out of 22, respectively. Doppler ultrasonographic study in 15 patients revealed improvement in peak systolic velocity (P < 0.01). In addition, a decrease in end diastolic velocity was noted also that was not significant statistically (P = 0.26). Resistive index did not improve after operation.

Conclusion: This procedure showed significant improvement in penile deformity (85% of cases), erectile dysfunction (84% of cases) and painful erection (86% of cases). We recommend plaque excision and dermal grafting as an effective procedure in treating Peyronie’s disease.

 

Purpose: To investigate the efficacy of “dermal patch graft†in surgical management of Peyronie’s.

Materials and Methods: eighteen of Peyronie’s disease cases, with a mean age of 49 and a history of penile curvature and painful erection were enrolled in this study. Diagnosis was made clinically by plaque palpation. All of them were in the chronic stage of disease with symptom duration of at least 6 months. We also evaluate their potency through Brief Sexual Function Inventory (BSFI) questionnaire before and after the operation, meanwhile the degree of penile curvature was measured with goniometry while artificial erection status was induced.

Results: Mean penile curvature, before and after the operation (58 and 5 degrees respectively), showed significant improvement (P < 0.001). The improvement of curvature was irrespective of the plaque size. All of our patients suffered from inability to intercourse due to significant penile curvature but after the procedure 11 of them (66.1%) could do so. Also the BSFI score improved significantly in this subgroup (P < 0.05). The remaining 7 cases (39%) already suffered from erectile dysfunction despite of operation; however, the penile curvature improved significantly in them. Six of this latter group had a plaque size greater than 4 cm² and BSFI score was not significantly improved.

Purpose: To evaluate the efficacy of modified Gil-Vernet anti-reflux surgery in the treatment of patients with primary vesicoureteral reflux in a prospective historical controlled trial.

Materials and Methods: A total of 30 patients with 46 refluxing units underwent this surgery since February 1998 until September 2002, with the mean follow-up period of 18 (range 6 to 43) months.

Results: Vesicoureteral reflux was resolved completely in 44 ureteral units (95.6%, P < 0001). In 2 refluxing units (4.3%) in spite of reflux improvement, hydroureter remained unchanged after the surgery. In respect to response rate, there was no significant difference between different grades, genders, age groups, and laterality of primary vesicoureteral reflux.

Conclusion: Our findings indicate that modified Gil-Vernet anti-reflux surgery which separately transfers each ureteral orifice to the tip of trigone with two fine absorbable suture on each side, is a completely successful procedure in the treatment of primary vesicoureteral reflux and produces a longer submucosal tunnel with a more suitable angel than classic Gil-Vernet procedure dose.

Purpose: Newly developed malignancies in kidney transplanted patients are one of the complications attributed to immunosuppression. Kaposi sarcoma is an unusual malignancy in general population, but may develop in kidney transplanted patients with highly varying prevalence. Our aim is to evaluate the prevalence, clinical manifestations, and outcome of Kaposi sacoma in kidney transplanted patients.

Materials and Methods: Five hundred and eighty cases (330 male, 250 female) with a mean age of 38.2 were followed for 36 months (range 9 months to 10 years), visiting every two months. History taking and physical examination with emphasis on skin and mucosa were taken. Biopsy of suspicious sin, mucosal, and visceral lesions assigned by other paraclinical methods was performed. Except 7 cases which were HLA identical to donors, all patients were managed with cyclosporine, Azathioprine and Prednisolone.

Results: Fourteen patients (2.2%) developed Kaposi sarcoma (biopsy documented which constituted 60% of all post-transplantation malignancies. They were 11 males and 3 females with a mean age of 41 years. Sarcoma developed 8 to 31 months after transplantation with an average of 18 months. Of these patients, 13 had skin involvement that one of them had pulmonary involvement too. Another patient had only abdominal involvement. Azathioprine was discontinued all patients, and cyclosporine was reduced in skin affected patients. In patients with visceral involvement cyclosporine was discontinued and then chemotherapy was initiated. All 3 patients with visceral involvement didn't respond to chemotherapy and expired after 6 months. Of 11 patients with skin involvement, one had complete and 2 had incomplete remission of whom, one expired due to acute rejection. Renal function in 8 patients was acceptable, but 2 had impaired renal function, yet didn't need dialysis.

Conclusion: Prevalence of Kaposi sarcoma in our patients is more than western countries. Visceral involvement is uncommon. But has poor prognosis. Reducing immunosuppression with discontinuation of azathioprine and significant reducing cyclosporine dosage can cease skin evolvement, with preserving renal function in most of the patients.

Purpose: To study the effects of Tamsulosine (Flowmax) as a specific ?-blocker in patients with prostate weighted less than 40 g and lacked median lobe and to compare them to patients with prostate weighted more than 40 g with median lobe.

Materials and Methods: Forty outpatients with BPH were referred to clinic and intentionally enrolled in this study. Patients were divided into 2 groups of 20 patients. Tamsulosine was daily administered for all of them for 6 weeks. Routine tests were performed for all patients, all of which were normal. The probability of prostate cancer was ruled out. The size of prostate and type of hypertrophy were determined by one radiologist via DRE, suprapubic ultrasonography and TRUS-P. Patients were divided into A and B groups according to the size of prostate and the lack of median lobe or its presence. Prostate size was less than 40 mg in group A and all patients lacked median lobe; whereas, prostate size was more than 40 mg (between 40-60 mg) in group B and patients had some median lobe.

Results: An increase of 30% in base line Q Max and a decrease of 25% in base line IPSS was seen in 16 patients (80%) of group A, while these were observed only 9 patients (45%) of group B.

Conclusion: Determination of prostate size and the type of hypertrophy seems to be essential before any Tamsulosine administration. The weight of prostate is determined by protoscan.

Purpose: To perform an epidemiologic study of urogenital injuries in traumatic patients who were referred to three traumatic centers in Tehran during one year.

Materials and Methods: This study included a part of data of National Trauma Registries, which was performed within one year. Questionnaires were completed by trained staff in three different geographical regions of Tehran: Shohada-e-Tajrish hospital (north of Tehran), Sina hospital (south of Tehran), and Shaheed Faiazbakhsh (west of Tehran).

Results: Two hundred and eighty four (5%) out of 57367 patients who were referred to the above mentioned centers had genitourinary trauma, of whom, 145(42%) were hospitalized. Males with a frequency of 92% (258 patients) were the most injured group. Patients mean age was 25 ± 14 years, mostly between 20 and 29 years (33.6%) followed by 10-19 years age group with a frequency of 25.6%. Non-penetrating trauma with a frequency of 96% was the most common type and accident was the most mechanism of trauma. One hundred and one patients out of the studied population had associated injuries. The most frequent injuries were occurred in extremities (40%) and the less in head and neck (7%). There were 22 (21.7%) intra-abdominal organ injuries. Sixty nine percent of patients developed mild injury (ISS < 7), 20% developed severe injury and (ISS > 12), and 4.2% of patients died. The most common injured organ was kidney (3.3%) and the least one was ureter, as no ureteral injury was reported.