ISSN: 1735-1308

Vol. 6 No. 4 (2009)

REVIEW


The failure of prostate-directed treatment modalities to help all men or all symptoms has questioned the longstanding assumption that the prostate is at the root of all male urinary symptoms, and a correlation between urinary bladder function and prostate pathology has been recognized. Now, it is widely recognized that bladder dysfunction plays a role in some, if not most, of the benign prostatic hyperplasia-related symptoms and signs, and recent studies have suggested that pharmacotherapies that target the bladder, such as antimuscarinics, may improve storage urinary symptoms. Indeed, the current mainstays of overactive bladder syndrome pharmacotherapy are antimuscarinic agents with mixed actions, including musculotropic (calcium antagonistic) activity. Moreover, the combination therapy with alpha blocker and antimuscarinic agents is now suggested when bladder outlet obstruction related to benign prostatic hyperplasia coexists with overactive bladder symptoms. Combinational treatment, targeting to both decrease resistance to urine outflow through the prostatic urethra and increase bladder smooth muscle, may improve the bladder outlet surgery success rate, and perhaps it might reinforce the need to offer an additional trial without catheter in patients with benign prostatic hyperplasia who are likely to suffer from detrusor hypocontractivity. Currently, no clinical trial supporting the use of parasympathomimetic drugs in those with poor voiding and longstanding symptomatic benign prostatic hyperplasia exists in the literature; however, experimental studies present promising results.

SPECIAL FEATURE


ORIGINAL PAPER (ENDOUROLOGY AND STONE DISEASE)


Sterile Water Versus Isotonic Saline Solution as Irrigation Fluid in Percutaneous Nephrolithotomy

Seyed Mohammad Kazem Aghamir, Farshid Alizadeh, Alipasha Meysamie, Shadi Assefi Rad, Ladan Edrisi

Urology Journal, Vol. 6 No. 4 (2009), 17 December 2009 , Page 249-253
https://doi.org/10.22037/uj.v6i4.488

Introduction: We evaluated the safety of sterile water as an irrigation solution for percutaneous nephrolithotomy (PCNL).
Materials and Methods: Forty-four patients with kidney calculi were enrolled in this study and randomly divided into two groups for PCNL. Approaches to the calculi were through a single subcostal access with an Amplatz sheath, and either sterile water or isotonic saline solution was used as the irrigation fluid. Serum hemoglobin, haptoglobin, sodium, potassium, and creatinine were measured before and 12 hours after the procedure. The patients were evaluated for signs of transurethral resection of the prostate syndrome during the operation for 24 hours afterwards.
Results: The mean calculus size, irrigation volume, irrigation time, and age were not significantly different between the two groups. Hemolysis occurred in 10 and 9 patients in sterile water and saline groups, respectively. The mean change in haptoglobin level was -1.7 ± 59 mg/dL in the sterile water and 11 ± 55 mg/dL in the saline group. Also, the mean change in plasma sodium level was -2.2 ± 4.7 and -0.4 ± 3.8 in sterile water and saline groups, respectively. None of these values were significantly different between the two groups, nor were other laboratory values. None of the patients developed transurethral resection of the prostate syndrome or needed transfusion.
Conclusion: Sterile water is an inexpensive alternative to isotonic saline for irrigation during PCNL. We did not find any difference between the two irrigation solutions regarding the safety; however, this should be confirmed further, especially for larger calculi.

ORIGINAL PAPER (LAPAROSCOPIC AND ROBOTIC UROLOGY)


Laparoscopic Management of Adrenal Lesions Larger Than 5 cm in Diameter

Rajan Sharma, Arvind Ganpule, Muthu Veeramani, Ravindra B Sabnis, Mahesh Desai

Urology Journal, Vol. 6 No. 4 (2009), 17 December 2009 , Page 254-259
https://doi.org/10.22037/uj.v6i4.500

Introduction: Laparoscopic adrenalectomy remains a controversial procedure for large tumors. The incidence of adrenocortical carcinoma increases and technical difficulty of adrenalectomy increases as the size increases. We examined the outcome and complications of laparoscopic adrenalectomy for such lesions.
Materials and Methods: Twenty-nine patients underwent laparoscopic adrenalectomy, of whom 19 had tumors larger than 5 cm in diameter, having a median tumor size of 7.0 cm. They were compared with patients whose adrenal tumors were smaller than 5 cm.
Results: Patients with small tumors (< 5 cm) had a significantly shorter median operative time of 90 minutes as compared to 145 minutes in those with large tumors (> 5 cm). There was no significant difference in the median hemoglobin drop (1.05 g/dL versus 1.30 g/dL), time for starting oral intake (24 hours in both groups) or hospital stay (3.5 days versus 4.0 days) between patients with small and large tumors, respectively. There were no intra-operative complications except for 1 incidence of supraventricular tachycardia in a patient with a large pheochromocytoma. There were no major complications seen in any of the patients and no open conversions. Histopathology of large tumors revealed 16 benign tumors (8 pheochromocytomas, 4 adenomas, 2 ganglioneuromas, 1 pseudocyst, and 1 myelolipoma) and 3 malignancies, of which 1 was primary adrenocortical carcinoma and 2 were metastatic renal cell carcinoma.
Conclusion: In experienced hands, laparoscopic adrenalectomy is safe and feasible for large functioning adrenal tumors. Large adrenal tumors suspicious of harboring malignancy with no peri-adrenal involvement can be tackled laparoscopically.

ORIGINAL PAPER (KIDNEY TRANSPLANTATION)


Kidney Transplant Anastomosis: Internal or External Iliac Artery?

Wagner E Matheus, Leonardo Oliveira Reis, Ubirajara Ferreira, Marilda Mazzali, Fernandes Denardi, Victor A Leitao, Renato N Pedro, Nelson R Netto Jr

Urology Journal, Vol. 6 No. 4 (2009), 17 December 2009 , Page 260-266
https://doi.org/10.22037/uj.v6i4.501

Introduction: We compared the best technique for arterial anastomosis in kidney transplantation, end-to-side anastomosis to the external iliac artery or end-to-end anastomosis to the internal iliac artery.
Materials and Methods: A total of 38 patients with end-stage renal disease who received a kidney transplant from a deceased donor were randomized into two groups in order to undergo either end-to-end anastomosis to the internal iliac artery or end-to-side anastomosis to the external iliac artery. Length of arterial anastomosis, cold ischemia time, hospital stay, serum creatinine level, recovery of urinary output, and surgical and clinical complications during hospitalization were evaluated. After 3 years, in the patients with a functioning allograft, creatinine clearance measure, Doppler ultrasonographic study, survival, graft loss, and erectile function were compared between the two groups.
Results: Postoperative analyses showed similar recovery of urinary output (P = .39) and creatinine (P = .95) between the two groups. No differences in clinical (P = .55) and surgical (P = .80) complications or in hospital stay (P = .90) were noted. The 3-year follow-up demonstrated no differences in Doppler ultrasonography results, creatinine clearance (P = .80), patient survival (P = .22), and graft loss (P = .72). Erectile dysfunction was similar, being related only to pre-operative medical history and age.
Conclusion: Both techniques showed similar results in short- and long-term follow-ups. Larger prospective studies are warranted to clarify the risk of renal artery stenosis and development of erectile dysfunction.

ORIGINAL PAPER (ANDROLOGY)


Sildenafil or Vardenafil Nonresponders’ Erectile Response to Tadalafil

Berat Cem Ozgur, Faruk Gonenc, Ahmet H Yazicioglu

Urology Journal, Vol. 6 No. 4 (2009), 17 December 2009 , Page 267-271
https://doi.org/10.22037/uj.v6i4.502

Introduction: Erectile dysfunction has usually been treated by a phosphodiesterase 5 inhibitor in men, especially in the past decade. Although sildenafil and vardenafil are widely used, there is a high percentage of people who do not respond to these drugs. This study was performed in order to evaluate the efficacy of the lastly presented phosphodiesterase 5 inhibitor, tadalafil, in nonresponder group of patients to sildenafil and vardenafil.
Materials and Methods: Forty married men with erectile dysfunction who had taken sildenafil or vardenafil at the maximum recommended doses and had not responded to the treatment were included. They were treated with tadalafil, 20 mg, at least 4 doses at different days. The effectiveness of the treatment was reviewed by different questionnaires, including the International Index of Erectile Function-5 (IIEF-5), Sexual Encounter Profile (SEP) questions 2 and 3, and the Global Assessment Question (GAQ), at the end of the 12th week.
Results: The IIEF-5 scores were 11.90 ± 4.78 and 12.67±6.70, before and after at least 4 doses of tadalafil, respectively (P = .30). The rate of positive responses to SEP2, SEP3, and GAQ questions were also insignificantly different after the treatment. During this period, flushing was seen in 10 and headache was seen in 5 patients.
Conclusion: The recommended maximum dose for tadalafil insignificantly improved the IIEF5, SEP2, SEP3, and GAQ scores in patients with erectile dysfunction who had not responded to sildenafil and vardenafil. The other treatment alternatives should be in mind after getting no response to the optimum doses and enough trials of sildenafil or vardenafil before trying a tadalafil regimen.

ORIGINAL PAPER (RECONSTRUCTIVE SURGERY)


Delayed Retropubic Urethroplasty of Completely Transected Urethra Associated With Pelvic Fracture in Girls

Jalil Hosseini,, Kamyar Tavakkoli Tabassi, Abdollah Razi

Urology Journal, Vol. 6 No. 4 (2009), 17 December 2009 , Page 272-275
https://doi.org/10.22037/uj.v6i4.503

Introduction: The objective of the present study was to evaluate the results and the complications of delayed retropubic urethroplasty of completely transected urethra associated with pelvic fracture in girls.
Materials and Methods: From 2002 to 2008, a total of 7 girls with complete urethral disruption after pelvic fracture were referred to our center and all of them underwent delayed retropubic urethroplasty with end-to-end anastomosis of the urethra.
Results: Seven female patients with a median age of 6 years old underwent delayed end-to-end anastomosis. The median time to surgery was 6 months from the trauma. Voiding was normal after catheter removal in all of the patients. The median follow-up was 36 months. Three patients had mild stress urinary incontinence after catheter removal.
Conclusion: There are some different strategies for management of complete urethral avulsion in females who have sustained pelvic fracture, including early realignment, bladder flaps, and end-to-end anastomosis. The strategy of delayed end-to-end anastomosis urethroplasty with retropubic approach is sound and produces acceptable results. The use of flexible cystoscope and omental flap is effective in achieving continence after urethroplasty in such cases.

The Use of Unaltered Appendix Transfer in Ileal Continent Reservoir: 10 Years Experience, A Novel Technical Modification

Nasser Simforoosh, Abbas Basiri, Seyed Amir Mohsen Ziaee, Farzaneh Sharifiaghdas, Ali Tabibi, Ahmad Javaherforooshzadeh, Reza Sarhangnejad, Emad-Adin Moudi, Farzad Tajali

Urology Journal, Vol. 6 No. 4 (2009), 17 December 2009 , Page 276-282
https://doi.org/10.22037/uj.v6i4.504

Introduction: We report a new modified technique of unaltered appendix transfer to ileal pouch and preserving ileocecal segment. This modification enables us to use ileum as the popular type of enteric segment instead of ileocecal segment while using appendix as a catheterizable stoma.
Materials and Methods: Forty-five patients (30 men) who needed reconstruction of the lower urinary tract were enrolled for using appendix as a catheterizable stoma. Reservoir was reconstructed using ileal segment. The appendix was circumcised from its base over its pedicle. The spatulated appendix tip was exteriorized as a catheterizable stoma to the skin, preferably umbilicus, and its base was implanted to the ileal pouch.
Results: Follow-up records of 38 of 45 patients were available. The median follow-up period was 29 months. The mean intermittent catheterization interval was 4.19 ± 1.6 hours. Urodynamic parameters were evaluated for 18 out of 38 patients. The median maximal pouch capacity determined as 380 mL. The median appendiceal closure pressure was 61 cm H2O. No pouch perforation occurred. Stomal stenosis occurred in 3 patients. They did not catheterize their appendiceal stoma because they restarted catheterization through the urethra.
Conclusion: This novel approach enabled us to use ileum as today's more popular type of bowel segment to reconstruct enteric pouch rather than using ileocecal segment, while using appendix as a catheterizable stoma. One of the unique advantages of this technique is that the postponement of clean intermittent catheterization will not result in pouch perforation since the urine will leak when the pouch becomes overfill.

ORIGINAL PAPER (CELLULAR AND MOLECULAR UROLOGY)


Special Characteristics of Culturing Mature Human Bladder Smooth Muscle Cells on Human Amniotic Membrane as a Suitable Matrix

Farzaneh Sharifiaghdas, Reza Moghadasali, Hossein Baharvand, Seyed Mohammadmehdi Hosseini-Moghaddam, Nastaran Mahmoudnejad

Urology Journal, Vol. 6 No. 4 (2009), 17 December 2009 , Page 283-288
https://doi.org/10.22037/uj.v6i4.505

Introduction: Our aim was to evaluate the natural behavior, growth pattern, morphology, and specific features of human bladder smooth muscle cells (HBSMCs) on two different matrixes, including human amniotic membrane (HAM) and collagen.
Materials and Methods: The HBSMCs were obtained from 6 children with primary vesicoureteral reflux undergoing open antireflux surgery, and they were isolated from the anterior wall of the bladder. The specimens were cultured on a tissue culture plate of bovine dermal collagen serving as control and on decellularized HAM. Histological, transmission electron microscopy, and immunocytochemical examinations were done, thereafter.
Results: On HAM, very few HBSMCs slowly migrated from explant tissue on the 7th day of culture. All the cells were placed at the same direction, and in some parts, formed multilayer. After 35 to 40 days, the confluency rate was 75% and the cells were orderly arranged. On collagen, cell migration from explant culture took place as rapidly as the 3rd to 4th day of culturing. On days 30 to 40, the confluency rate was 100%. Immunocytochemical staining was positive for anti-actin and antidesmin antibodies. On transmission electron microscopy, cell organelles of HBSMCs exhibited the same features of the natural smooth muscle cells. They were tightly attached to each other and the underlying layer basement membrane.
Conclusion: A well-designed growth pattern of HBSMCs on HAM with abundant cell-to-cell adhesions encourages us to use it as a competent tissue for reconstruction of relatively damaged or diseased bladders. Undoubtedly, further clinical studies should be performed to replicate our results.

Inductive Role of Collagen Type IV During Nephrogenesis in Mice

Mehdi Jalali, Mohammad Reza Nikravesh, Abbas Ali Moeen, Mohammad Hassan Karimfar, Shahin Saidinejat, Shabnam Mohammadi, Houshang Rafighdoost

Urology Journal, Vol. 6 No. 4 (2009), 17 December 2009 , Page 289-294
https://doi.org/10.22037/uj.v6i4.506

Introduction: During nephrogenesis, transition of mesenchyme to the epithelium of tubules and glomeruli occurs via the interaction of ureteral bud and metanephric mesenchyme. The distribution pattern of collagen type IV suggests that a regulated balance of activities is required to facilitate migration of the ureteral bud branches into the mesenchyme and to control early extracellular matrix changes during tubulogenesis. We used a specific antibody for tracing collagen type IV basement membrane during renal tubules morphogenesis.
Materials and Methods: Twenty female Balb/C mice were divided randomly into 10 groups and were kept until finding vaginal plug was as an indicator of day zero of pregnancy. Twelve pregnant mice were sacrified by cervical dislocation in one of gestational days 13 to 18 and their fetuses were fixed, serially sectioned, and underwent immunohistochemical study for tracing of collagen type IV in basement membrane of glomeruli. The same processes were used for kidneys preparation on postnatal days 5, 10, 15, and 20 in newborns of 2 mothers for each day.
Results: Collagen type IV showed weak reaction on day 14 of gestation in tubular basement membrane. The amount of collagen increased continuously until the following days of fetal life and of the first 5 postnatal days in basement membrane. After this period, collagen type IV reaction was not showed significant change in newborns.
Conclusion: These results indicate that developmental changes in various nephron segments from most immature stages to most differentiated structures are dependent on the collagen type IV expression.

POINT OF TECHNIQUE


CASE REPORT


UROLOGY FOR PEOPLE