Paratesticular rhabdomyosarcoma mimicking complicated epididymal cyst

Paratesticular rhabdomyosarcoma (RMS) is a rare nongerm cell intrascrotal malignant tumor in children and young adult/teens resulting from the mesenchymal tissues of the tunica vaginalis, epididymis, spermatic cord, and testis. RMS accounts for approximately 7% of all genitourinary tract RMSs and 12% of all pediatric scrotal neoplasms. Patients usually present with a painless unilateral scrotal mass. We report a 16-year-old boy with a paratesticular RMS mimicking epididymal cyst. To our knowledge, this is the first case reported in the literature presenting as an epididymal cyst.

Luminal Obstruction of Double J Stents Due to Encrustation Depends on Indwelling Time: A Pilot Study

Double J (DJ) stents serve as a therapeutic option to relieve obstruction. However, incrustation can be an important cause of dysfunction of these stents. We investigated the relationship between incrustation of DJ stents and indwelling time using a grading system for luminal occlusion. The medical records of 42 patients with urolithiasis related to DJ stent incrustation were retrospectively reviewed. All polyurethane DJ stents were examined for severity of incrustation with a grading system based on the occlusion of stent lumen. For the level of grades 3 groups of patients were compared: group 1 included 14 patients whose stents were removed a month after insertion; group 2 included 16 patients whose stents were removed 45 days after insertion; group 3 included 12 patients whose stents were removed 3 months after insertion. The incrustation of 42 DJ stents was graded from 1 to 3 depending on the occlusion of the DJ stent. Mean age of patients was 39.6±6.71 years and median indwelling time was 50 days. The groups were similar regarding age, sex, and side of DJ stent. In comparison, the grade of incrustation in group 3 was higher than the grades in group 1 and group 2 (p=0.001). Incrustation is one of the most important complications of DJ stents, and was related to indwelling time. Therefore, close follow-up and frequent DJ stent changes are very important in patients with urolithiasis.

Endoscopic Treatment of Renal Hydatid Cyst with Percutaneous Access through an All Seeing Needle

A 44-year-old woman, who had had left flank pain for the previous 3 months, was treated successfully for renal hydatid cyst disease by using an endoscopic technique with percutaneous access through an all seeing needle. Abdominal ultrasonography showed a Gharbi type III cyst in the lower pole of the left kidney. Computerised tomography of the abdomen revealed a bulky solid-cystic mass with calcified and well-defined wall and daughter cyst without contrast enhancement. The patient, who refused any renal operation, underwent a percutaneous intervention with access through an all seeing needle access. There were no intraoperative or early postoperative complications. To our knowledge, this is the first published report of this minimally invasive percutaneous access technique through an all seeing needle.

Nonischaemic priapism associated with selective serotonin-3 receptor antagonist

Priapism is a rare but severe urological emergency of erection of penis in the absence of physical and psychological sexual stimulation. Priapism is often idiopathic and is commonly associated with medications and underlying medical or traumatic causes. In this report, we present a case of a 70-year-old White Caucasian man who developed priapism after the administration of ondansetron, which is a selective serotonin type-3 (5-HT3) receptor antagonist. This case is unique, because, to date, there are only two presented cases in literature. The objective of this case report is to highlight the importance of recognising the possibility of priapism with ondansetron because this condition is not commonly seen in clinical practice to be associated with ondansetron and may go unrecognised. Also, potential pathophysiological mechanisms involved in the development of ondansetron-induced priapism are presented.

Relation between blood vitamin B12 levels with premature ejaculation: case-control study

The aim of this study was to investigate whether vitamin B12 levels are associated with premature ejaculation (PE). A total of 109 subjects (56 PE and 53 controls) were included in this study. PE was defined as self-reported intravaginal ejaculatory latency time (IELT) based on the Diagnostic and Statistical Manual of Mental Disorders IV criteria and those who had had an IELT of <2 min was considered as PE. All participants were evaluated using premature ejaculation diagnostic tool (PEDT), International Index of Erectile Function (IIEF) and Beck Depression Inventory (BDI). The vitamin 12 levels were measured in all subjects. The mean age between the PE and controls was comparable (p = .084). Mean IIEF and BDI scores between the two groups did not statistically differ. The mean IELT values in the PE group were significantly lower than in the control group (p < .0001). PE patients reported significantly lower vitamin B12 levels compared with the controls (213.14 vs. 265.89 ng ml^-1 ; p < .001). The ROC analysis showed a significant correlation between the diagnosis of PE and lower vitamin B12 levels. This study has demonstrated that lower vitamin B12 levels are associated with the presence of PE. This work also shows a strong correlation between vitamin B12 levels and the PEDT scores as well as the IELT values.

Chronic constipation: Facilitator factor for development of varicocele

AIM: To evaluate the possible relationship between varicocele and chronic constipation.

METHODS: Between April 2009 and May 2010, a total of 135 patients with varicocele or constipation and 120 healthy controls were evaluated. Patients were divided into two groups. In both groups detailed medical history was taken and all patients were examined physically by the same urologist and gastroenterologist. All of them were evaluated by color Doppler ultrasonography. All patients with constipation, except for the healthy controls of the second group, underwent a colonoscopy to identify the etiology of the constipation. In the first group, we determined the rate of chronic constipation in patients with varicocele and in the second group, the rate of varicocele in patients with chronic constipation. In both groups, the rate of the disease was compared with age-matched healthy controls. In the second group, the results of colonoscopies in the patients with chronic constipations were also evaluated.

RESULTS: In the first group, mean age of the study and control groups were 22.9 ± 4.47 and 21.8 ± 7.21 years, respectively (P < 0.05). In the second group, mean age of the study and control groups were 52.8 ± 33.3 and 51.7 ± 54.3 years, respectively (P < 0.05). In the first group, chronic constipation was observed in 8 of the 69 patients with varicocele (11.6%) and 3 out of 60 in healthy controls (5%), respectively. In this regard, there was no statistical significance between varicocele patients and the healthy control (P = 0.37). In the second group, varicocele was observed in 16 of the 66 patients with chronic constipation (24.24%) and 12 out of 60 in healthy controls (20%) respectively. Similarly, there was no statistical significance between chronic constipation and healthy controls (P = 0.72). Internal/external hemorrhoids were detected in 4 of the 16 patients with chronic constipation and varicocele, in the second group. In the remaining 50 patients with chronic constipation 9 had internal/external hemorrhoids. In this regard, there was no statistical significance between chronic constipation and healthy controls (P = 0.80).

CONCLUSION: Chronic constipation may not be a major predictive factor for the development of varicocele, but it may be a facilitator factor for varicocele.

Finger assisted laparoscopic renal cyst excision: a simple technique

PURPOSE

Simple renal cysts are asymptomatic incidental findings; however, for a small subset of benign renal cysts, patients may present with pain, hematuria, recurrent infection, pyelocaliceal obstruction, or hypertension. Laparoscopic cyst ablation is an effective minimally invasive modality for the treatment of symptomatic benign renal cysts. We describe a simple laparoscopic cyst excision technique.

MATERIALS AND METHODS

Between June 2003 and May 2008, 28 patients underwent laparoscopic renal cyst excision via retroperitoneal approach. In our technique, retroperitoneum and Gerota's fascia were dissected with finger blindly before insertion of the trocars to the retroperitoneal space. Following finger dissection, 3 trocars were placed and the cyst walls were excised at the level of renal cyst and base of the cysts were cauterized with electrocautery scissors.

RESULTS

Mean patients' age was 59.3 years (range, 31 to 72 years). Mean operation duration time was 46 minutes (range, 27 to 102 minutes). Symptomatic and radiological success were achieved in 26 (92.8%) and 27 (96.4%) patients, respectively, with a median follow-up of 28 months (range, 6 to 56 months). No serious complications were encountered.

CONCLUSION

Laparoscopy is a versatile minimally invasive modality ideal for treating benign symptomatic renal cysts. According to our experience, we think that the finger assisted laparoscopic cyst excision is an easy and noninvasive procedure.

Adult posterior urethral valve: a case report

INTRODUCTION

Posterior urethral valve (PUV) is a congenital obstructive defect of the male urethra with an incidence of 1/8,000 to 1/25,000 live births. PUV is the most common cause of lower urinary tract obstruction in neonates. The diagnosis of PUV is usually made early, and PUV cases have rarely been detected in adults.

CASE PRESENTATION

Here we report the case of a 35 years old man presented with obstructive urinary symptoms. In spite of bladder neck rejection uroflowmetry pointed out infravesical obstruction with max. flow rate 9 ml/s and average flow rate 6 ml/s in uroflowmetry. During cystoscopy mild bladder trabeculation and resected bladder neck were seen. While the cystoscope was taken off, PUV were obtained.

CONCLUSION

Since PUV is a rare condition in adults and the diagnosis of PUVs is also difficult in these groups we must consider this situation during evaluation of adult patients with obstructive symptoms especially during cystourethroscopy.

Two-glove-finger-balloon dissection of retroperitoneal space for laparoscopic urology

BACKGROUND

We present our experience in retroperitoneal interventions with 2 catheter mounted glove fingers through 2 access points.

METHODS

Patients were placed in the lateral decubitus position, and the retroperitoneum was accessed by blunt dissection through a 10-mm transverse skin incision on the posterior axillary line. Another incision was performed through the anterior axillary line, and the surgeon inserted his finger to dissect the muscle layers in the retroperitoneum to develop an initial space to place the glove finger balloon, which was attached to a 14-F Nelaton catheter.

RESULTS

This technique was performed on 32 patients. The mean operation time was 57.4 +/- 26.7 minutes. A satisfactory retroperitoneal space for the operation was provided and both balloons inflated to 500 mL. No complications were observed.

CONCLUSION

Retroperitoneal laparoscopy using 2 balloons is a safe, cheap, effective minimally invasive procedure, and we believe that the technique described above both decreases both the operation time and cost.

ULTRASTRUCTURAL CHANGES ON SPERM AFTER EXTRACORPOREAL SHOCK WAVE LITHOTRIPSY IN PATIENTS WITH DISTAL URETERAL STONE

Theoretically, ESWL can cause several side effects on the male reproductive system. We determined here the long-term effects of ESWL on sperm with transmission electron microscopy (TEM) in patients with distal ureteral stone. Fifteen men with stones in the distal ureter applied to our clinic formed the group of study. The other 15 men with renal or upper ureter stones formed the group of control. The ESWL sessions, including maximum 19 kW energy level and 3000 shock waves, were performed with Siemens Lithostar (electromagnetic; Siemens Medical Systems, Erlangen, Germany) lithotriptor. We examined the semen samples from all patients on the day before and 90 days after ESWL. The semen samples were examined with transmission electron microscopy (TEM) to detect ultrastructural changes on the day before and 90 days after ESWL. All the statistical analyses were realized with SPSS 10.0 (SPSS Inc., Chicago, USA) statistical package program. When the control and study groups were compared for initial and day 90 sperm concentration and motility, a significant decrease was found in the study group. Although there was no important anomaly in the control group, we determined some damage on sperm structure in 5 patients (33.3%) who are in the study group 3 months after ESWL. It can reduce sperm concentration and motility permanently. It can also cause severe ultrastructural defects on sperm after a long term period in patients with lower ureteral stone. Therefore, we suggest other treatment modalities for young men with distal ureteral stones to prevent the development of male infertility.

Patient tolerance during cystoscopy: a randomized study comparing lidocaine hydrochloride gel and dimethyl sulfoxide with lidocaine

PURPOSE

Cystoscopy is one of the most common examinations in urologic outpatient clinics. Various anesthetic approaches have been used to make cystoscopy more tolerable for patients. The aim of the present prospective randomized study was to evaluate the efficacy of lidocaine hydrochloride gel compared to dimethyl sulfoxide (DMSO) with lidocaine in rigid cystoscopy.

MATERIALS AND METHODS

Male patients requiring 17F rigid cystoscopy were eligible for inclusion in this study. A total of 140 patients were divided into two groups: group 1 (n=70) received approximately 11 mL of 2% lidocaine gel intraurethrally, while in group 2 (n=70) approximately 10 mL of 40% DMSO with an amount of lidocaine equal to that in the lidocaine gel was smeared around the scope and external urethral meatus. A penile clamp was placed for 15 minutes and 5 minutes in group 1 and group 2, respectively. Immediately after cystoscopic examination pain was scored on a 10-cm visual analog scale.

RESULTS

The mean pain scores after the procedure for group 1 and group 2 were 3.9+/-1.1 and 2.1+/-1.0, respectively. The pain scores were significantly lower for group 2 than for group 1 (P=0.015). No patients needed additional anesthetic agents or sedatives due to insufficient analgesia, and there were no serious side effects in either group.

CONCLUSIONS

Our study has shown that DMSO with lidocaine gel causes significantly less delivery discomfort in the male urethra than lidocaine hydrochloride gel. The advantages of DMSO with lidocaine are the mixture takes less time to act and had lower pain scores.

Evaluation of urinary inverted papillomas: a report of 13 cases and literature review

Inverted papilloma (IP) of the urothelium accounts for 2.2% of urothelial neoplasms. The aim of this study was to report the results of 13 patients with urinary IP, pointing out the clinical features, presentations, treatment options and outcomes. The mean age and mean follow-up periods of the patients were 60.23 +/- 3.25 (range, 44-81) years and 30 (range, 6-42) months, respectively. There was no coexistence of urothelial carcinoma with IP at presentation. Cystoscopy showed a solitary papillary tumor in the bladders of 11 patients and solid pedunculated tumors in the remaining two patients. The site of development was the bladder in 12 cases (92%) and ureter in one (8%) case. Transurethral bladder tumor resection was performed in 12 cases. For the case with IP in the ureter, nephroureterectomy was performed. Pathologic examination demonstrated that seven of the 13 cases were of the trabecular type and six were of the glandular type. Of the 13 cases, two (7%) had recurrence, at 1 year and 1 month and 1 year and 5 months from initial resection. The male to female ratio was 5.5:1. Initial symptoms included macroscopic hematuria in five cases, microscopic hematuria in four, and dysuria and microscopic hematuria in three; one case was asymptomatic. IPs of the urinary bladder are benign tumors that can be treated successfully by transurethral resection and fulguration of the tumor bed. In addition, these lesions must be followed up closely for recurrence and malignant transformation.

Comparison of ethanol and sodium tetradecyl sulfate in the sclerotherapy of renal cyst

BACKGROUND AND PURPOSE

Renal cysts are common in the adult population. Symptomatic cysts traditionally have been treated by percutaneous aspiration with injection of sclerosant agents. Our aim was to compare the efficacy and side effects of ethanol and sodium tetradecyl sulfate (STDS) as sclerosants for symptomatic simple renal cyst.

PATIENTS AND METHODS

Sixty-five patients with 68 symptomatic simple renal cysts were included in this study. An 8F pigtail catheter was inserted into the cyst under ultrasound guidance followed by aspiration of the cyst fluid. Either 95% ethanol (N = 34) or 3% STDS (N = 34), assigned randomly, was then instilled into the empty sac. Patients recorded any flank pain on a visual analog scale and were followed up by ultrasonography for 6 to 18 months.

RESULTS

There was complete ablation of 28 (82%) and 26 (76%) cysts, partial regression of 3 (9%) and 6 (18%) cysts, and failure of treatment in 3 (9%) and 2 (6%) cysts in the ethanol and STDS groups, respectively. There was no major complication in either group. The pain caused by the injection was significantly less for the group receiving STDS (pain score 2.1 +/- 1.1 v 3.8 +/- 1.2 for ethanol; P = 0.019).

CONCLUSIONS

Ethanol and STDS are simple, noninvasive, cost-effective, and well-tolerated sclerosants for the treatment of simple renal cysts. We prefer STDS as a first choice because it causes less pain.

Clinical Significance of Platelet Count in Patients with Renal Cell Carcinoma

INTRODUCTION

During the last decades numerous prognostic factors have been studied for predicting survival of renal cell carcinoma (RCC). Platelet count has previously been reported to correlate with prognosis in RCC. The aim of the this study was to evaluate the significance of thrombocytosis in determining prognosis in patients with localized RCC who underwent radical nephrectomy.

PATIENTS AND METHODS

The study included 118 consecutive patients. Patients were divided into a normal platelet count group (group 1) and a thrombocytosis group (group 2) according to the preoperative platelet count. Thrombocytosis was defined as a platelet count greater than 400,000/microl. The data about stage distribution, grade, tumor size, histological subtype, hemoglobin level, Body Mass Index (BMI), age, ECOG score, gender, and survival rate of tumors between these two groups were compared. Survival estimates were compared with the Kaplan-Meier method and multivariate analysis was performed using a Cox model.

RESULTS

The mean age of the patients was 61.4 years (range 30-78), and the mean follow-up period was 52.7 +/- 19.6 months (range 9-96). Thrombocytosis was present in 23 patients (19.49%). Fourteen (60.86%) of 23 patients with thrombocytosis died of disease progression. Patients with thrombocytosis had a worse prognosis than patients without thrombocytosis (p = 0.001). Thrombocytosis was noted in 8 (10.81%) of 74 patients with stage pT1-pT2 disease and in 15 (34.09%) of 44 patients with stage pT3-pT4 disease (p = 0.004). In univariate analysis, platelet count was correlated with T stage, hemoglobin level, lymph node positivity, ECOG score, and tumor size. Controlling for established prognostic indicators of pathologic stage, tumor size, platelet count, and lymph positivity using Cox's regression test, the difference in survival between the groups remained significant (p < 0.05).

CONCLUSION

The platelet count can be considered a useful prognostic factor in patients with RCC who undergo radical nephrectomy.

Large Vesicula Seminalis Cyst: A Very Rare Cause of Constipation and Male Infertility

We report a 35-year-old male patient with chronic constipation and infertility for 4 years. Spermiogram revealed severe oligospermia. An external mass compressing the rectum was found during rectal examination and flexible rectosigmoidoscopy. Abdominal computed tomography showed a presacral cystic mass which displaced the bladder anteriorly. The cyst was completely removed with open surgery. Histopathologic analysis revealed a cystic lesion covered with squamous epithelium including polymorphonuclear leukocytes, macrophages and sperm cells. After the operation, the patient's symptoms were relieved. We considered that the constipation was caused by external compression by the vesicula seminalis cyst. In cases of constipation with infertility, vesicula seminalis cyst should be kept in mind.

Comparing two local anesthesia techniques for extracorporeal shock wave lithotripsy

OBJECTIVES

To evaluate the efficacy of a eutectic mixture of local anesthetics (EMLA) cream compared with dimethyl sulfoxide (DMSO) with lidocaine during extracorporeal shock wave lithotripsy (ESWL) in a prospective randomized study.

METHODS

Of 167 patients, 85 received 10 g of EMLA cream (EMLA group) and 82 received 10 g of 40% DMSO (DMSO group) with an amount of lidocaine equal to that in the lidocaine gel, applied to the skin of the flank at the area of entry of the shock wave marked by the urologist. A second-generation lithotriptor Siemens Lithostar was used. The degree of pain was rated by the patients using a 10-point visual analog scale.

RESULTS

In 80 patients in the EMLA group (94%), the entire procedure was performed with no, minor, or tolerable pain after the application of EMLA cream (pain score 5.2 +/- 1.3). In 5 EMLA patients (6%), EWSL was interrupted because of intolerable pain. Of the 82 DMSO patients, 80 (98%) underwent the entire procedure with no, minor, or tolerable pain after the application of DMSO with lidocaine (pain score 3.7 +/- 1.1). In 2 DMSO patients (2%), EWSL was interrupted because of intolerable pain. The pain scores were significantly lower for the DMSO group than for the EMLA group (P = 0.011).

CONCLUSIONS

Our findings have indicated that the pain scores were significantly lower for the DMSO group than for the EMLA group. In addition to the local anesthetic effect of DMSO, diuretic, anti-inflammatory, muscle relaxant, and hydroxyl radical scavenger effects can be important for patients undergoing ESWL. These effects should be evaluated with new studies of patients undergoing ESWL.

Condylomata acuminata of external urethral meatus causing infravesical obstruction

Condyloma acuminata is one of the most common virally transmitted diseases. The most common sites for condyloma in males are the balanopreputial sulcus, frenulum and the glans' mucosa. Condylomata in the urethra is rarely seen occur and most often situated in the distal part of the urethra. A 24-year-male admitted to our clinic with complaint of papillary lesion at the urethral meatus and urinary retention. Physical examination revealed that multiple papillary lesions along the anterior urethra until 1 cm distance from the urethral meatus. Under the clinical diagnosis of condyloma acuminata, he was treated conservatively with radical local excision of the lesion and condyloma acuminatum was verified by histopathological examination. Four months after surgery, there has been no local or remote recurrence.

Unexpected, severe central nerve system toxicity of ofloxacine: report of two cases

Central nerve system toxicity of fluoroquinolones is well known but nearly always benign. Old age, concomittant central nerve system disease, drug interactions and/ or partial or total loss of renal function are the major risk factors. Although, in literature there is very limited number of severe central nerve system toxicity cases related to fluoroqinolones, prompt realization is vital as the only therapy is discontinuation of the drug. In this article, two cases of acute central nerve system toxicity of ofloxacin with an unexpected severity are described.

Ureteral membranous band causing ureteral obstruction after the ureterolithotomy

A 45-year-old male admitted to our clinic of symptoms with moderate left flank pain and intermittant macroscopic hematuria. During the last 6 months these complaints had worsened. He had history of open retroperitoneal ureterolithotomy 2 years previously for ureteral stone. He was investigated for calculi, infection and other urinary abnormalities. Although direct urinary system graphy was normal, excretory urography revealed left ureteric obstruction. On ureteroscopy membranous band like an ureteral valve causing ureteral obstruction was observed and removed with biopsy pens without resection.

Isolated Unilocular Renal Hydatid Cyst: A Rare Diagnostic Difficulty with Simple Cyst

Hydatid disease is endemic in many parts of the world. The location is mostly hepatic (75%) and pulmonary (15%), and only 10% of the cysts occur in the rest of the body. It may develop in almost any part of the body. Although hydatidosis can be present in all parts of the human body, urinary tract involvement develops in only 2-4% of all cases, and isolated renal cysts are extremely rare. There are no specific clinical symptoms or signs that will reliably confirm the diagnosis of renal echinococcosis. In addition, there is no laboratory finding that is pathognomonic for hydatid disease except for hydatiduria. Routine blood tests are generally normal except for eosinophilia which is found in only 50% of the cases. Radiological studies have a more important place in the preoperative diagnosis of renal hydatic disease. However, there is no specific sign on plain radiography or intravenous urography, and ultrasound or computed tomography cannot always show a hydatidosis as a specific lesion. From these reasons, sometimes it is difficult to differentiate between a unilocular hydatid cyst without mural calcification and a simple renal cyst. So, despite its rarity, hydatid disease should be included in the differential diagnosis of cystic lesions in solid organs or other anatomic sites, especially in endemic countries. We present herein a patient with isolated renal hydatid cyst mimicking a simple cyst treated successfully with complete excision.

Transitional cell carcinoma of the clitoris: direct implantation or metastasis

Transitional cell carcinoma (TCC) of the bladder is the seventh most frequent cancer of women. The possible mechanisms of local tumor recurrence are seeding and multicentricity. Distant metastases are most frequently as a result of vascular or lymphatic spread and to a lesser extent by seeding of the tumor cells with urine or transurethral instrumentation. We report a clitoral metastasis of a TCC of the bladder, which is a very unexpected and extremely rare site for metatstasis and discuss whether the possible mechanism is vascular spreading or direct seeding. To our knowledge this is the third case in the literature.

Comparison of Ileal Conduit and Transureteroureterostomy with Ureterocutaneostomy Urinary Diversion

INTRODUCTION

We compare the postoperative early and late complications of patients who had undergone ileal conduit (IC) urinary diversion and transureteroureterostomy (TUU) with ureterocutaneostomy (UC) urinary diversion during the same interval and by the same surgeons.

MATERIALS AND METHODS

Between 1992 and 2004, we performed TUU with UC urinary diversion in 27 men and 7 women (group I) and ileal conduit urinary diversion in 57 men and 10 women (group II). The mean age of the TUU with UC diversion and the ileal conduit patients was 57+/-11.2 (range 51-76) and 64+/-12.6 (range 54-76) years, and the mean follow-up was 37 (range 14-52) and 56 (range 14-72) months, respectively. The 6F or 8F stents were used routinely.

RESULTS

Of 34 TUU with UC cases 8 (23.52%) had early postoperative complications and 2 (5.88%) had early reoperation rates, whereas 11 (16.42%) of 67 ileal conduit cases had early postoperative complications and 4 (5.97%) had early reoperation. The mean hospital stay was 7 (range 5-25 day) and 11 (range 7-34 day) days for each group, respectively. Of the TUU and UC cases, 6 (17.64%) had late complications and 3 had (8.82%) late reoperation, whereas 14 conduit cases (20.89%) had late complications and 6 had (8.9%) late reoperation. Early postoperative complications were defined as those that occurred before hospital discharge or within 30 days from the date of surgery and late complications were defined as those occurring greater than 30 days from the date of surgery as previously described. In group I, the mean operative time was 170 min (range 120-325) compared with 260 min (range 170-473) in group II. The mean blood loss in group I was 474 ml (range 250-1,400) and 589 ml (range 300-1,700) in group II (p>0.05).

CONCLUSIONS

Our results suggest that patients undergoing a TUU and UC diversion have no additional risk of reoperation and the TUU with UC urinary diversion is a safe procedure with postoperative early and late complications.

Spontaneous ureteral stent fragmentation: a case report and review of the literature

Ureteral stents have been widely used for more than two decades with different indications. Due to the widespread usage of ureteral stents, the number of possible complications of ureteral stents has increased, including stent migration, encrustation, stone formation, and fragmentation. Among these complications, ureteral stent fragmentation is rare. Herein, we present a case of spontaneous ureteral stent fragmentation and review the relevant literature.

Case report: endoscopic treatment of isolated congenital urethroperineal fistula

Isolated congenital urethrocutaneous fistula is an extremely rare congenital anomaly. Management is sometimes complex and depends on the location. We report our endoscopic treatment in a man with a urethroperineal fistula.

Using two ipsilateral double j ureteral stents for extrinsic ureteral obstruction due to colon carcinoma

Although double J (DJ) ureteral stents are widely used in extrinsic ureteral obstruction, there are few studies using ipsilateral two DJ stents in the same ureter. We report using ipsilateral two ureteral DJ stents in the same ureter in a patient with extrinsic ureteral obstruction due to colon carcinoma.

Endoscopic treatment of multiple prostatic calculi causing urinary retention

Although prostatic calculi are relatively common, the etiology of these stones is not clear. We report a case with multiple prostatic calculi causing urinary obstruction and a concomitant bladder stone. We treated these stones endoscopically. We found a lot of different sized stones endoscopically, some protruding into the urethra, some filling different cavities on the prostate. So these cavities suggest prostatic calculi may occur related to intraprostatic reflux in the congenital or acquired diverticulum of the prostatic tissue. In addition, the stone composition of the bladder and prostatic stones was the same. All of these results show that the origin of bladder and prostatic stones can be the same. This case also supports a theory of intraprostatic reflux and urine stasis.

Ectopic Insertion of a Single Ureter into the Bladder Adjacent to the Contralateral Ureter

We report a 30-year-old female with a single ectopic ureter that opens into the bladder adjacent to the right ureter.

Endoscopic seminal vesicle stone removal

Seminal vesicle stones are extremely rare, and few cases have been reported. Treatment requires removal of the stone, generally through an open vesiculectomy. A 31-year-old man presented with perineal pain, painful ejaculation, and infertility of several years' duration. Multiple stones in the seminal vesicle duct system were diagnosed by radiologic examination. We treated the patient by seminal vesicle endoscopic stone removal, thereby obviating organ loss. The composition of the stones was whewellite. To our knowledge, this approach has not been previously reported, and our result may be encouraging for treatment of such pathologic conditions of the seminal vesicles.

Prospective, randomized comparison of transperitoneal versus retroperitoneal laparoscopic adrenalectomy

PURPOSE

We report a prospective, randomized comparison of transperitoneal laparoscopic adrenalectomy (TLA) vs retroperitoneal laparoscopic adrenalectomy (RLA) for adrenal lesions with long-term followup.

MATERIALS AND METHODS

Between December 1997 and November 1999, 57 consecutive eligible patients with surgical adrenal disease were prospectively randomized to undergo TLA (25) or RLA (32). Study exclusion criteria were patient age greater than 80 years, body mass index greater than 40, bilateral adrenalectomy and significant prior abdominal surgery in the quadrant of interest. Mean followup was 5.96 years in the 2 groups.

RESULTS

The groups were matched in regard to patient age (p = 0.84), body mass index (p = 0.43), American Society of Anesthesiologists class (p = 0.81) and laterality (p = 0.12). Median adrenal mass size was 2.7 cm (range 1 to 9) in the TLA group and 2.6 cm (range 0.5 to 6) in the RLA group (p = 0.83). TLA was comparable to RLA in terms of operative time (130 vs 126.5 minutes, p = 0.64), estimated blood loss (p = 0.92), specimen weight (p = 0.81), analgesic requirements (p = 0.25), hospital stay (p = 0.56) and the complication rate (p = 0.58). One case per group was electively converted to open surgery. Pathology data on the intact extracted specimens were similar between the groups. Averaged convalescence was 4.7 weeks in the TLA group and 2.3 weeks in the RLA group (p = 0.02). During a mean followup of 6 years 2 patients in the TLA group had a late complication (port site hernia). Mortality occurred in 5 patients, including 1 with TLA and 4 with RLA, during the 6-year followup.

CONCLUSIONS

For most benign adrenal lesions requiring surgery laparoscopic adrenalectomy can be performed safely and effectively by the transperitoneal or the retroperitoneal approach.

Water jet assisted laparoscopic partial nephrectomy without hilar clamping in the calf model

PURPOSE

Hemostasis represents a primary challenge during laparoscopic partial nephrectomy (LPN). We typically clamp the renal artery/vein en bloc and perform LPN expeditiously under warm ischemia conditions. We evaluated Helix Hydro-jet assisted LPN without renal hilar vascular control in the survival calf model.

MATERIALS AND METHODS

Staged bilateral LPN using the Hydro-jet was performed without renal hilar vessel control in 10 survival calves (20 kidneys). Parenchymal hydrodissection was performed with a high velocity, ultracoherent saline stream at 450 psi through a small nozzle with integrated suction at the tip. The denuded intrarenal parenchymal blood vessels were precisely coagulated with a BIClamp bipolar instrument and transected. Followup involved biochemical, radiological and histopathological evaluation at designated sacrifice intervals of 1 and 2 weeks, and 1, 2 and 3 months, respectively.

RESULTS

All LPNs were completed successfully without open conversion. Of 20 LPNs 18 (90%) were performed without hilar clamping. Pelvicaliceal suture repair was necessary in 5 of 10 chronic kidneys (50%). Mean Hydro-jet(R) partial nephrectomy time was 63 minutes (range 13 to 150), mean estimated blood loss was 174 cc (range 20 to 750) and mean volume of normal saline used for hydro-dissection was 260 cc (mean 50 to 1,250). No animal had a urinary leak. Histological sections from the acute specimen revealed a thin (1 mm) layer of adherent coagulum at the amputation site with minimal thermal artifact. At 2 weeks a layer of adherent fibro-inflammatory pseudomembrane with giant cell reaction was seen.

CONCLUSIONS

In this more stringent and robust survival calf model Hydro-jet assisted LPN can be performed without hilar vessel control, thus, completely avoiding warm ischemia. This approach has the potential to decrease the level of technical difficulty inherent in LPN.

Impact of intraoperative heparin on laparoscopic donor nephrectomy

PURPOSE

At many centers systemic heparinization is performed during laparoscopic donor nephrectomy because of concerns regarding graft thrombosis. However, no consensus exists in this regard. We evaluated the impact of intraoperative heparin on donor and recipient outcomes.

MATERIALS AND METHODS

Between September 2000 and February 2003, 79 consecutive patients underwent laparoscopic live donor left nephrectomy at our institution. They were sequentially divided into 2 groups, that is group 1-the initial 40 patients who intraoperatively received 5,000 IU heparin intravenously and group 2-subsequent patients who did not receive heparin. The 2 groups were well matched demographically. Data were compared using the paired 2-tailed t test.

RESULTS

The 2 donor groups were comparable in regard to mean blood loss (139 vs 179 cc, p = 0.59), intraoperative urine output (1.6 vs 1.6 l, p = 0.74), warm ischemia time (4 vs 4.2 minutes, p = 0.52), operative time (3.5 vs 3.5 hours, p = 0.97), and cold ischemia time (75 vs 82 minutes, p = 0.38). Complications occurred in 1 patient in group 1 (rhabdomyolysis induced acute renal failure) and in 2 in group 2 (chylous ascites and lumbar vein injury, respectively). No graft was lost due to vascular thrombosis in either group. Recipient immediate, early and delayed (6-month) graft function was comparable between the 2 groups. Acute rejection occurred in 5 recipients in group 1 and 1 in group 2. There was 1 recipient death per group at delayed followup.

CONCLUSIONS

Routine use of heparin during laparoscopic donor nephrectomy is not necessary. Because of its potential for causing intraoperative or early postoperative hemorrhage, we no longer routinely administer intraoperative heparin during laparoscopic donor nephrectomy at our institution.

Influence of estradiol pretreatment on antimuscarinic action of oxybutynin in rat detrusor muscle

OBJECTIVES

To investigate the antimuscarinic effect of oxybutynin in the rat detrusor muscle after estrogen pretreatment because, to our knowledge, no study has been done on the interaction of estrogen with antimuscarinic drugs. Estrogen has been shown to affect muscarinic receptors in the detrusor muscle of animals. In addition, oxybutynin has been shown to block muscarinic receptors in the bladder.

METHODS

Estradiol benzoate (150 microg/kg) or saline was given subcutaneously to virgin female Wistar albino rats (n = 6, each group) for 10 consecutive days. On the 11th day, isolated detrusor muscle strips were taken, and acetylcholine (ACh)-induced contractions were evaluated in the absence or presence of oxybutynin (10 and 100 nM).

RESULTS

ACh induced concentration-dependent contractions in the detrusor muscle. In the estradiol-pretreated group, the maximum of the ACh-induced contractions was diminished compared with that in the control group (P < 0.05). Oxybutynin (10 and 100 nM) inhibited ACh-induced contractions competitively (pK(B) 8.85). In the estradiol-pretreated group, the concentration-response curve to ACh was shifted further to the right in the presence of oxybutynin (100 nM).

CONCLUSIONS

We have demonstrated for the first time that oxybutynin further inhibits ACh-induced and muscarinic receptor-mediated contractions in rat detrusor muscle after pretreatment with estrogen.

Transrectal ultrasound-guided transperineal and transrectal management of seminal vesicle abscesses

OBJECTIVE

The treatment of seminal vesicle abscesses (SVA) by transrectal ultrasound-guided transrectal and transperineal approaches were evaluated in this study.

MATERIALS AND METHODS

Six SVA cases were diagnosed among 2350 patients admitted to our ultrasound unit with prostate and seminal vesicle symptoms during the last 6 years. Four out of six cases had bilateral, and two had unilateral SVA. Transperineal puncture and aspiration was done in four patients with bilateral abscesses and transrectal approach was preferred in two patients with unilateral abscesses.

RESULTS

For both approaches, the aspiration was successfully done without any complication. The mean durations of intervention were 64 and 13 min, and the durations of hospitalization were 2 and 3 days for the transperineal and transrectal approaches, respectively.

CONCLUSION

Transrectal ultrasound examination allows simultaneous evaluation of the gland and the guidance for a needle puncture and aspiration. Furthermore, rapid pain relief, regression of other symptoms, minimally invasive technique and shorter hospitalization seem to be important features as compared with conservative and surgical treatment modalities.

Relationship between extracorporeal shock wave lithotripsy and semen parameters in patients with lower ureteral stones

The objective of this study was to investigate whether extracorporeal shock wave lithotripsy can affect semen parameters in patients with distal ureteral stones. We concluded that extracorporeal shock wave lithotripsy could reduce sperm concentration and motility permanently in men with lower ureteral stones.

Laparoscopic nephron-sparing surgery for two or more ipsilateral renal tumors

OBJECTIVES

To review our experience with laparoscopic nephron-sparing surgery in the management of two or more synchronous, ipsilateral renal masses. Minimally invasive nephron-sparing procedures are increasingly used for the treatment of select patients with a single, small renal tumor.

METHODS

Since 1998, we have performed laparoscopic nephron-sparing surgery in 288 consecutive patients, including laparoscopic partial nephrectomy (n = 200) and renal cryotherapy (n = 88). Of these, 13 patients (4.5%) were treated for synchronous ipsilateral renal masses.

RESULTS

A total of 27 renal tumors were treated in 13 patients. The patients were divided into four groups on the basis of the treatment. Group 1 (n = 3) underwent en-bloc laparoscopic partial nephrectomy encompassing both tumors; group 2 (n = 2) underwent individual laparoscopic partial nephrectomy of discrete masses during the same procedure; group 3 (n = 2) had one mass treated with partial nephrectomy and the other mass treated with cryotherapy; and group 4 (n = 6) had all tumors treated with cryotherapy. All cases were completed successfully without conversion to open surgery or laparoscopic nephrectomy. The mean overall operative time was 4.3 hours, and the mean blood loss was 169 mL. No intraoperative complications occurred. Three patients had postoperative complications, none requiring re-exploration. One patient in group 4 developed de novo tumors in the treated kidney, located distant from the cryoablated sites.

CONCLUSIONS

Laparoscopic partial nephrectomy is an emerging, efficacious laparoscopic treatment option for select patients. Laparoscopic cryotherapy is a useful alternative or adjunct to partial nephrectomy. The judicious combination of these complementary techniques further extends the scope of minimally invasive nephron-sparing surgery.

REAL-TIME TRANSRECTAL ULTRASONOGRAPHY DURING LAPAROSCOPIC RADICAL PROSTATECTOMY

PURPOSE

We describe the technical aspects of real-time transrectal ultrasound (TRUS) monitoring and guidance during laparoscopic radical prostatectomy (LRP). Furthermore, we describe the TRUS visualized anatomy of periprostatic structures during LRP.

MATERIALS AND METHODS

In 25 consecutive patients undergoing transperitoneal LRP, baseline preoperative, real-time intraoperative and immediate postoperative TRUS evaluations were performed. To define periprostatic anatomy precisely TRUS measurements were obtained with specific reference to the neurovascular bundle (NVB), prostate apex, membranous urethra, bladder neck, rectal wall and any cancer nodule. Conventional gray scale, power Doppler, harmonic imaging and 3-dimensional ultrasound functions were used.

RESULTS

Real-time TRUS navigation facilitated 3 technical aspects of LRP. 1) It identified the correct plane between the posterior bladder neck and prostate base, allowing quick laparoscopic identification of the vasa and seminal vesicles. 2) It identified the occasional, difficult to see distal protrusion of the prostate apex posterior to the membranous urethra, thus enhancing apical dissection with negative margins. 3) It provided visualization of any hypoechoic nodule abutting the prostate capsule, alerting the laparoscopic surgeon to perform wide dissection at that location. TRUS measured various anatomical parameters including i) the mean distance +/-SD between the NVB and the lateral edge of the prostate a) at apex (1.9 +/- 0.9 mm), b) base (2.5 +/- 0.8 mm) and c) tip of seminal vesicle (4.0 +/- 1.6 mm), ii) the dimensions of the NVB a) before (4.5 x 3.9 mm), b) after (4.2 x 3.6 mm) nerve sparing LRP and c) after nonnerve sparing LRP (0.9 x 0.9 mm), iii) arterial blood flow resistive index within NVB a) before (0.83 +/- 0.04), b) after (0.84 +/- 0.03) nerve sparing LRP and c) after nonnerve sparing LRP (0), iv) and the length of membranous urethra a) before (12.2 +/- 1.1 mm) and b) after (11.7 +/- 1.0 mm) surgery. Focal distortion of the prostate surface by an exophytic nodule was visualized on TRUS in 3 patients, necessitating ipsilateral nerve resection at LRP and contributing to negative surgical margins.

CONCLUSIONS

This initial experience suggests that real-time intraoperative TRUS guidance may enhance anatomical performance of LRP. This improved understanding of periprostatic anatomy has the potential to improve functional and oncological outcomes. Such corroboration is awaited.

Priapism in a patient receiving long-term chlorpromazine therapy. A case report

Priapism is an uncommon urologic emergency with a variety of known etiologies including the use of psychotropic medications. We report a priapism case who has taken chlorpromazine for 3 years.

Increased vasoconstrictor reactivity and decreased endothelial function in high grade varicocele; functional and morphological study

The pathophysiology of human varicocele is not fully understood. We investigated vasoconstrictor reactivity, endothelial function and morphological changes in different grades of varicocele to clarify the pathophysiology. Contractile responses to phenylephrine, norepinephrine, serotonin and histamine were determined in isolated human varicose spermatic veins using the organ bath technique. Endothelial function was tested with acetylcholine-induced relaxation after phenylephrine-induced precontraction in the absence and presence of nitric oxide synthase inhibitor, L-NAME, and cyclooxygenase inhibitor, indomethacin. The cyclic guanosine monophosphate (cGMP) level was measured in the spermatic vein and peripheral plasma. Morphological changes were evaluated with light microscopy. Phenylephrine, norepinephrine, serotonin and histamine induced concentration-dependent contractions. The maximum contractions for all of these agents except norepinephrine were significantly higher in grade III than grade I and II (P<0.05). The sensitivity to phenylephrine was significantly higher in grades II and III than in grade I (P<0.05). In the presence of L-NAME and indomethacin, the difference from respective control phenylephrine-induced contractions was higher in grade I and II than grade III. Acetylcholine did not induce stable relaxation but the level of cGMP, which is responsible for the vasorelaxant effect of NO, in veins was lower in grades II and III than grade I (P<0.05). Vessel wall thickness increased in grade II and dilatation developed in grade III when compared to grade I (P<0.05). Our findings suggest that endothelium produces less vasorelaxant which results in the more enhanced effects of vasoconstrictor substances in grade III, indicating that endothelial dysfunction develops at high grades of varicocele.

Giant seminal vesicle stones. Report of two cases

Seminal vesicle stones are rare conditions and only a few cases have been reported in the literature. Here we present 2 cases with single and multiple seminal vesicle calculi.

Extracorporeal shock wave lithotripsy treatment in paraplegic patients with bladder stones

BACKGROUND

Spinal cord injury patients are at increased risk of developing urolithiasis and many will require treatment, most commonly with extracorporeal shock wave lithotripsy (ESWL).

METHODS

We examined 20 consecutive spinal cord injury patients (all male) undergoing ESWL for the treatment of bladder stones between April 1992 and May 2000. The mean number of shock waves administered in these 20 patients was 3600 and the shock power was 19 kW/s. All patients were treated without anesthesia. After ESWL, the bladder was irrigated with povidone iodine solution and stone fragments were evacuated through a 22F endoscopic sheath.

RESULTS

All patients became stone-free after ESWL. Stone fragments were observed in the urethra of 3 patients, which were removed by urethroscopy. No major complication was observed; however, 5 patients had minor hematuria (which subsided within 24 h) and subfebrile fever (37.2-37.5 degrees C).

CONCLUSION

ESWL and transurethral bladder irrigation is a safe, effective and simple modality for the treatment of bladder stones in spinal cord injury patients.