|
STONE
DISEASE
Effect of potassium citrate therapy on stone recurrence and residual
fragments after shockwave lithotripsy in lower caliceal calcium oxalate
urolithiasis: a randomized controlled trial
Soygur T, Akbay A, Kupeli S
Department of Urology, Faculty of Medicine, University of Ankara, Turkey
J Endourol. 2002; 16:149-52
- Background
and Purpose: To evaluate the efficacy of potassium citrate treatment
in preventing stone recurrences and residual fragments after shockwave
lithotripsy (SWL) for lower pole calcium oxalate urolithiasis.
- Patients
and Methods:
One hundred ten patients who underwent SWL because of lower caliceal
stones and who were stone free or who had residual stone 4 weeks later
were enrolled in the study. The average patient age was 41.7 years.
All patients had documented simple calcium oxalate lithiasis without
urinary tract infection and with normal renal morphology and function.
Four weeks after SWL, patients who were stone free (N = 56) and patients
who had residual stones (N = 34) were independently randomized into
two subgroups that were matched for sex, age, and urinary values of
citrate, calcium, and uric acid. One group was given oral potassium
citrate 60 mEq per day, and the other group served as controls.
- Results:
In patients who were stone free after SWL and receiving medical treatment,
the stone recurrence rate at 12 months was 0 whereas untreated patients
showed a 28.5% stone recurrence rate (P < 0.05). Similarly, in the
residual fragment group, the medically treated patients had a significantly
greater remission rate than the untreated patients (44.5 v 12.5%; P
< 0.05).
- Conclusion:
Potassium citrate therapy significantly alleviated calcium oxalate stone
activity after SWL for lower pole stones in patients who were stone
free. An important observation was the beneficial effect of medical
treatment on stone activity after SWL among patients with residual calculi.
- Editorial
Comment
A previous retrospective study by Fine and colleagues (1) demonstrated
the benefit of medical therapy in reducing the rate of stone recurrence
in both groups of patients, those rendered stone-free and those with
residual stone fragments after shock wave lithotripsy (SWL). The authors
of the current study evaluated specifically, in a prospective randomized
trial, the efficacy of potassium citrate therapy in reducing stone recurrence
or regrowth in patients undergoing SWL for lower calyceal stones. A
total of 90 patients, including 56 stone-free patients and 34 patients
with residual fragments, were randomized to receive either 60 mEq of
potassium citrate daily or no treatment, 4 weeks after undergoing SWL
for lower pole stones. After 12 months, all patients were evaluated
with plain abdominal radiographs and ultrasound. Among the stone-free
patients, no stone recurrences occurred in those treated with potassium
citrate, while 28.5% of control patients experienced recurrence. Among
the patients with residual fragments, 45.5% demonstrated clearance of
the fragments during follow-up, and the remaining 54.5% of patients
showed no stone growth or recurrence. In the control group, however,
only 12.5% of patients cleared their residual fragments, 25% of patients
showed no change in the size of the stones, and 62% demonstrated stone
growth.
This important study validates in a prospective trial the retrospective
findings of Fine and associates by demonstrating that medical therapy,
specifically potassium citrate, reduces the rate of stone recurrence
or stone growth in both group of patients rendered stone-free or left
with residual fragments after SWL. Of additional interest, potassium
citrate also apparently facilitated the discharge of residual lower
pole fragments in patients with residual stones. Consequently, adjuvant
medical therapy after SWL may actually improve stone free rates by encouraging
fragment clearance. If this is indeed the case, the administration of
potassium citrate immediately after, or even before, SWL may prove to
be efficacious. Interestingly, potassium citrate appeared to be effective
in a variety of metabolic backgrounds, although stratification of outcomes
by urinary biochemical abnormality was not performed. With further study,
short- or long-term potassium citrate treatment of patients undergoing
SWL may prove beneficial.
Reference
1. Fine JK, Pak CYC, Preminger GM: Effect of medical management and residual
fragments on recurrent stone formation following shock wave lithotripsy.
J Urol. 1995; 153:27-32.
Dr.
Margaret S. Pearle
Associate Professor of Urology
University of Texas Southwestern Med Ctr
Dallas, Texas, USA
Effect of low-carbohydrate high-protein diets on acid-base balance,
stone-forming propensity, and calcium metabolism
Reddy ST, Wang CY, Sakhaee K, Brinkley L, Pak CY
Department of Internal Medicine, Section of General Internal Medicine,
The University of Chicago, IL, USA
Am J Kidney Dis. 2002; 40:265-74
- Background:
Low-carbohydrate high-protein (LCHP) diets are used commonly for
weight reduction. This study explores the relationship between such
diets and acid-base balance, kidney-stone risk, and calcium and bone
metabolism.
- Methods:
Ten healthy subjects participated in a metabolic study. Subjects initially
consumed their usual non-weight-reducing diet, then a severely carbohydrate-restricted
induction diet for 2 weeks, followed by a moderately carbohydrate-restricted
maintenance diet for 4 weeks.
- Results:
Urine pH decreased from 6.09 (Usual) to 5.56 (Induction; P < 0.01)
to 5.67 (Maintenance; P < 0.05). Net acid excretion increased by
56 mEq/d (Induction; P < 0.001) and 51 mEq/d (Maintenance; P <
0.001) from a baseline of 61 mEq/d. Urinary citrate levels decreased
from 763 mg/d (3.98 mmol/d) to 449 mg/d (2.34 mmol/d; P < 0.01) to
581 mg/d (3.03 mmol/d; P < 0.05). Urinary saturation of undissociated
uric acid increased more than twofold. Urinary calcium levels increased
from 160 mg/d (3.99 mmol/d) to 258 mg/d (6.44 mmol/d; P < 0.001)
to 248 mg/d (6.19 mmol/d; P < 0.01). This increase in urinary calcium
levels was not compensated by a commensurate increase in fractional
intestinal calcium absorption. Therefore, estimated calcium balance
decreased by 130 mg/d (3.24 mmol/d; P < 0.001) and 90 mg/d (2.25
mmol/d; P < 0.05). Urinary deoxypyridinoline and N-telopeptide levels
trended upward, whereas serum osteocalcin concentrations decreased significantly
(P < 0.01).
- Conclusion:
Consumption of an LCHP diet for 6 weeks delivers a marked acid load
to the kidney, increases the risk for stone formation, decreases estimated
calcium balance, and may increase the risk for bone loss.
- Editorial
Comment
The popularity of low carbohydrate-high protein diets prompted the authors
to explore the potential effect of these diets on stone-forming risk
and calcium balance. They enrolled 10 healthy volunteers to participate
in a 3-phase trial mimicking the 2 phases of the Atkins’ diet,
including induction (2 weeks) and maintenance (4 weeks), preceded by
a baseline usual diet phase (2 weeks). During the last week of each
phase of study, the subjects consumed constant metabolic diets corresponding
to the appropriate phase of the Atkins’diet, at home for 3 days
and as in inpatient in the General Clinical Research Unit for the last
4 days. On the last 2 days of each phase, two 24-hour urine samples
were collected for stone risk factors, and blood was collected for serum
electrolytes, markers of bone turnover, PTH and vitamin D. Additionally,
fractional intestinal calcium absorption was measured. Urine pH decreased
significantly during the diet, from 6.09 to 5.56 to 5.67, and net acid
excretion increased by 56 mEq/d and 51 mEq/d from baseline during the
2 study phases, respectively. Accordingly, urinary citrate decreased
from 763 mg/d to 449 mg/d and to 581 mg/d during the 3 phases. Urinary
calcium increased significantly from 160 mg/d to 258 mg/d to 248 mg/d,
respectively, despite no change in fractional intestinal calcium absorption.
Consequently, estimated calcium balance decreased by 130 mg/d and 90
mg/d from baseline during the 2 study phases, respectively.
Low carbohydrate-high protein diets have enjoyed increasing popularity
in recent years, because of the effectiveness of the diet in weight
reduction. However, the stone-forming propensity of a high protein diet
has been well established in the literature based on the increased acid
load, which results in an increase in urinary calcium and uric acid
and a decrease in urinary citrate and pH. Likewise high protein consumption
has been associated with a negative calcium balance and bone loss. This
carefully executed study clearly demonstrates that a low carbohydrate
high protein diet confers a marked acid load that increases stone risk
and decreases calcium balance, potentially threatening bone health.
Clearly, further study with a long-term trial is necessary; however,
stone formers, and those with compromised bone mineral density, should
be cautioned before embarking on low-carbohydrate, high-protein weight
reduction plans. The authors additionally plan to investigate whether
alkali therapy can counter the negative effects of the acid load, potentially
reducing the risk of the diet.
Dr.
Margaret S. Pearle
Associate Professor of Urology
University of Texas Southwestern Med Ctr
Dallas, Texas, USA
ENDOUROLOGY & LAPAROSCOPY
Is lower
pole caliceal anatomy predictive of extracorporeal shock wave lithotripsy
success for primary lower pole kidney stones?
Sorensen CM, Chandhoke PS
From the Departments of Surgery (Urology) and Medicine (Renal Diseases),
University of Colorado Health Sciences Center, Denver, Colorado
J Urol. 2002; 168:2377-82
- Purpose:
The management of lower pole kidney stones is controversial. We examined
whether lower pole caliceal anatomy could predict the success of extracorporeal
shock wave lithotripsy of primary lower pole kidney stones 20 mm. or
less.
- Materials
and Methods:
From December 1997 to June 2001, 246 adults with a single, 20 mm. or
less radiopaque lower pole renal stone were treated with the Doli 50
lithotriptor (Dornier Medical Systems, Marietta, Georgia) while under
general anesthesia. Of the 246 patients 190 (77%) had excretory urography
available for review. Lower pole infundibular length and width, lower
pole infundibulopelvic angle and caliceal-pelvic height were measurable
on 161 (85%), 129 (68%), 128 (67%) and 163 (86%) excretory urograms,
respectively. Extracorporeal shock wave lithotripsy was considered a
failure if residual stone fragments remained after 1 month, or an auxiliary
procedure or re-treatment was required.
- Results:
The
overall stone-free rate was 78% (32 of 41) for stones 5 mm. or less,
73% (98 of 135) for stones 6 to 10 mm., 43% (22 of 51) for stones 11
to 15 mm. and 30% (7 of 19) for stones 16 to 20 mm. in maximum linear
dimension. The stone-free rates grouped according to stone surface area
were 76% (48 of 63 stones) for stone surface area 25 mm.2 or less, 69%
(97 of 141) for 26 to 100 mm.2 and 33% (14 of 42) for 101 to 400 mm.2.
Caliceal anatomy was not predictive of success even with stones grouped
as 10 or less or 11 to 20 mm. Grouping patients with favorable (lower
pole infundibulopelvic angle 70 degrees or greater, lower pole infundibular
length 30 mm. or less and lower pole infundibular width greater than
5 mm.) versus unfavorable (70 degrees or less, greater than 30 mm. and
5 mm. or less, respectively) anatomy was also not predictive of success.
- Conclusions:
On the Doli 50 machine stone size rather than caliceal anatomy is predictive
of treatment outcome. Initial treatment failures with this machine should
be managed by alternative endoscopic procedures if necessary rather
than by repeat shock wave lithotripsy.
- Editorial
Comment
The concept of lower pole anatomy impacting the results of shock wave
lithotripsy for lower pole renal calculi is hotly debated. Initially
proposed only on theoretical anatomical basis by Dr. Sampaio in 1992
(J Urol. 1992; 147:322-324), several initial clinical series suggested
that indeed a tighter infundibulopelvic angle of the lower pole (i.e.,
more dependent lower pole) is associated with poorer results. Subsequently,
however, there have been several articles (including this one) that
have challenged this association. It is notable that in the refuting
articles the percentage of patients with a lower pole infundibulopelvic
angle greater than 70–100 degrees, which is the range of upper
limit of “favorable” angles proposed by various authors, has
usually been far less than in the articles that did report an association
of infundibulopelvic angle and shock wave lithotripsy success. This
distinction, which may be due to differences in patient population,
or of the measurement techniques, likely accounts for much of the discrepancy.
That lower pole anatomy impacts the results of shock wave lithotripsy
makes intuitive sense, but there is no agreement on how to measure the
angle and whether or not other factors, such as infundibular length,
infundibular width, or calyceal-pelvic height, are important. Until
there is a clearer consensus in the literature, the exact impact of
lower pole anatomy will not be defined. While we are waiting for this,
I for one will continue to use a gross visual assessment of the caliceal
anatomy, without specific measurements, when advising patients about
treatment options for lower pole renal calculi.
Dr.
J. Stuart Wolf Jr.
Associate Professor of Urology
University of Michigan
Ann Arbor, Michigan, USA
Randomized prospective blinded study validating acquisition of ureteroscopy
skills using computer based virtual reality endourological simulator
Watterson JD, Beiko DT, Kuan JK, Denstedt JD
J Urol. 2002; 168:1928-32
- Purpose:
Surgical simulation has emerged in the last decade as a potential tool
for aiding acquisition of technical skills, including anesthesia protocols,
trauma management, cardiac catheterization and laparoscopy. We evaluate
and validate the use of a computer based ureteroscopy simulator (URO
Mentor, Simbionix Ltd., Lod, Israel) in the acquisition of basic ureteroscopic
skills.
- Materials
and Methods: We assessed 20 novice trainees for the ability to perform
basic ureteroscopic tasks on a computer based ureteroscopy simulator.
Participants were randomized to receive individualized mentored instruction
or no additional training, and subsequently underwent post-testing.
Pre-training and post-training improvement in performance was assessed
by objective simulator based measurements. Subjective overall performance
was rated using a validated endourological global rating scale by an
observer blinded to subject training status.
- Results:
Demographics and pre-test scores were similar between groups. Post-testing
revealed a significant effect of training on objective and subjective
measurements. Spearman rank correlation demonstrated a significant association
between objective simulator based measurements and the endourological
global rating scale.
- Conclusions:
Use of a computer based ureteroscopy simulator resulted in rapid acquisition
of ureteroscopic skills in trainees with no prior surgical training.
Results of this study demonstrate the use of a virtual reality ureteroscopy
simulator in endourological training. Correlation of simulator based
measurements with a previously validated endourological global rating
scale provides initial validation of the ureteroscopy simulator for
the assessment of ureteroscopic skills.
- Editorial
Comment
It has been fascinating to follow the development of surgical simulators
over the past few years. Initially very crude, these devices have steadily
improved. Technology that has any potential for consumer product development
tends to be introduced and refined in the consumer market before resources
are directed to the health care market. In this regard, the first surgical
simulators (in the 90s) looked like 70s computer arcade games, whereas
the current crop of simulators have closed the gap – such that
they might be compared to 3D graphics games for personal computers from
just a few years ago. Along with improvements in graphics, the utility
of the simulators in terms of situational elements have improved. This
study by Watterson and associates illustrates at the very least that
motor skills on the device can be improved with only a short training
period, and that such improvement can be measured with validated instruments.
This is an excellent first step, but there are many more important questions
to be addressed: Do skills on the simulator translate into skills in
the operating room? How long do benefits of the training last? How long
will it take for untrained students to catch up to the trained ones
with subsequent clinical experience? What are the trade-offs of time,
expense, and surgical risk that are made if surgical simulators are
used to replace or augment some portions of “apprenticeship”
surgical training? It seems very likely that surgical simulators will
play some role in training in the future, but many more issues need
to be worked out.
Dr.
J. Stuart Wolf Jr.
Associate Professor of Urology
University of Michigan
Ann Arbor, Michigan, USA
PATHOLOGY
Adenocarcinoma
of the prostate in young men: clinical and pathologic features
Chan TY, Sanderson HL, Epstein JI
The Johns Hopkins Hospital, Baltimore, MD
Mod Pathol. 2002; 15:157A
- Objectives:
To study 57 men £40 years of age with cancer on prostate needle
biopsy and when present in their radical prostatectomy (RP) specimens.
- Methods:
“Significant” tumors were defined as: RP tumor volume >0.5cc,
or Gleason score (GS) ³7, or non organ-confined disease. We defined
a favorable pre-operative prognostic group as: GS £6 in 1 core
with 10% of the core involved and a PSA £10 ng/mL; those with
GS £6 in £3 cores with £50% of the core involved and
a PSA £2 ng/mL.
- Results:
The mean age was 38 (20-40 years). 32.7% of patients had a family history
of prostate cancer, 32.7% presented with urinary symptoms and 34.6%
had cancer found on a routine physical exam. PSA averaged at 6.7 ng/mL
(range 0.6-66 ng/mL). Digital rectal examinations were abnormal in 37.3%.
The prostate needle biopsies showed 93.0% with GS <6, 3.5% with GS
=7, and 3.5% with GS ³8. 52.2% of biopsies had £10% of 1
core with cancer. 44.2% of men were in the better prognostic group.
Follow-up was available in 46 men, with 1 having radiation therapy.
RP in 45 men show 77.8% had GS <6, 13.4% had GS = 3+4, 4.4% had GS
= 4+3, 4.4% had GS = 8-9. 6.7% of men had positive margins, 17.7% extraprostatic
extension, and 4.4% seminal vesicle invasion and/or lymph node metastasis.
9.3% of tumors showed mucinous features, 4.6% foamy gland features,
23.3% atrophic and 11.6% pseudohyperplastic features. High grade PIN
(88.4%), inflammation (48.8%) and benign atrophy (60.5%) were seen in
association with tumor. Tumor volumes averaged 1.1cc (range 0.003 to
11.5cc) and 46.5% of tumors were >0.5cc. 48.9% were “significant”
tumors. There was no significant difference in specific tumor type,
association with PIN, inflammation or atrophy, and location of tumor
between patients with “significant” tumors and those with
“potentially insignificant” tumors. Although there was a trend
for family history of prostate cancer to be associated with “significant”
tumor, this was not statistically significant. All 13 men predicted
to have “insignificant” tumors were accurately predicted.
Of the 21 men predicted to have “significant” tumors, 18 (85.7%)
had “significant” tumors. Only 2 patients progressed in a
mean follow-up time of 42.1 months (range 1-180 months).
- Conclusions:
Unusual tumor patterns seen in young men are not different from those
reported in older men. In these young men, many with early cancer, the
vast majority of tumors were associated with high grade PIN. Although
about half the men had “significant” tumors on RP, the other
half may have been candidates for watchful waiting. Favorable biopsy
and PSA findings are predictive of “potentially insignificant”
tumors. Conservative management of these young men with the potential
of long-term tumor growth must be balanced by the greater impact of
potential morbidity from RP at a young age.
- Editorial
Comment
This is a rare series of men £40 years of age with cancer on prostate
needle biopsy. It corresponds to a period of 15 years of a reference
center (Johns Hopkins University). Analyzing the favorable pre-operative
prognostic group, we find the criteria much more restrictive than previously
described by Epstein, who is one of the authors of this paper. Gleason
score £6 in 1 core, with £10% of the core involved, and
a PSA £10ng/mL; or Gleason score £6 in £3 cores with
£50% of the core involved and a PSA £2ng/mL, are different
criteria than Gleason score £6 in £3 cores with £50%
of the core involved and a free/total PSA of 0.15 or greater, published
in 1998 by Epstein (Epstein JI et al.: Nonpalpable stage T1c prostate
cancer: prediction of insignificant disease using free/total prostate
specific antigen levels and needle biopsy findings, J Urol. 1998; 160:2407-11).
With these very restrictive criteria, all 13 men predicted to have “insignificant”
tumors were accurately predicted, and may have been candidates for watchful
waiting, considering the greater impact of potential morbidity from
radical prostatectomy at a young age. This study emphasizes the need
for an appropriate pathology report, in order to adequately analyze
favorable pre-operative prognostic groups. The pathology report must
be done on each of the cores, describing the presence of cancer, the
Gleason grading, and the percentage of cancer present on each involved
core. An example is as follows: Slide 1 (apical, left side) - normal
parenchyma; Slide 2 (apical, right side) - adenocarcinoma Gleason 3+4=7
involving 60% of the core, etc.
Dr.
Athanase Billis
Chair, Department of Pathology
State University of Campinas, Unicamp
Campinas, São Paulo, Brazil
Why linear extent, not percent, of cancer should be used to measure
cancer in needle biopsies
True LD, Wallner K
University of Washington, Seattle, WA
Mod Pathol. 2002; 15:184A
Dr.
Athanase Billis
Chair, Department of Pathology
State University of Campinas, Unicamp
Campinas, São Paulo, Brazil
IMAGING
Prostate:
high-frequency Doppler US imaging for cancer detection
Halpern EJ, Frauscher F, Strup SE, Nazarian LN, O’Kane P, Gomella
LG
Departments of Radiology and Urology, Jefferson Prostate Diagnostic Center,
Thomas Jefferson University, Philadelphia, PA, USA
Radiology 2002; 225:71-77
- Purpose:
To evaluate cancer detection with targeted biopsy of the prostate performed
on the basis of high-frequency Doppler ultrasonographic (US) imaging
findings versus cancer detection with a modified sextant biopsy approach
with laterally directed cores.
- Materials
and Methods:
Sixty-two patients were prospectively evaluated with gray-scale, color,
and power Doppler transrectal US performed with patients in the lithotomy
position. Gray-scale and Doppler findings within each sextant were rated
on a five-point scale. Up to four targeted biopsy specimens were obtained
from each patient on the basis of Doppler findings; this was followed
by a modified sextant biopsy. Conditional logistic regression analysis
was performed to compare the positive yields for targeted and sextant
biopsy specimens. Clustered receiver operating characteristic analysis
was performed to compare gray-scale, color, and power Doppler detection
of cancer at sextant biopsy sites.
- Results:
Cancer was detected in 18 (29%) of 62 patients, including 11 patients
in whom cancer was detected with both sextant and targeted biopsy, six
in whom cancer was detected only with sextant biopsy, and one in whom
cancer was detected only with targeted biopsy. The positive biopsy rate
for targeted biopsy (24 [13%] of 185 cores) was slightly higher than
that for sextant biopsy (36 [9.7%] of 372 cores; P = .1). The odds ratio
for cancer detection with targeted versus sextant cores was 1.8 (95%
CI: 0.9, 3.7). Receiver operating characteristic analysis demonstrated
that overall identification of positive sextant biopsy sites was close
to random chance for gray-scale (area under the curve, 0.53), color
Doppler (area under the curve, 0.50), and power Doppler (area under
the curve, 0.47) imaging.
- Conclusion:
Targeted
biopsy performed on the basis of high-frequency color or power Doppler
findings will miss a substantial number of cancers detected with sextant
biopsy.
- Editorial
Comment
Eighty-five percent of prostate cancers appear with variable degree
of increased flow when evaluated by color and power Doppler sonography.
For this reason, power Doppler has been used routinely as a complimentary
tool during transrectal US-guided biopsy of the prostate. Color Doppler
ultrasound is able to demonstrate 10-15% of cancers only by their hypervascularity,
since such lesions appear isoechoic in the normal peripheral zone on
gray-scale technique (1-3).
This study was performed in order to evaluate the detection of prostate
cancer by targeted biopsy guided by the findings of high-frequency color
and power Doppler techniques compared to modified sextant biopsy scheme.
The authors concluded that targeted biopsy guided only by the findings
of color and power Doppler US will miss a substantial number of cancers.
Few points, however, should be considered regarding their results and
conclusions. First, we should not consider any focal area of increased
flow suspicious for cancer. Conversely, an area highly suspicious for
cancer is the one presenting a “chaotic” flow. “Chaotic”
flow is represented by a cluster of irregular and tortuous vessels.
The authors did not attempt to differentiate these patterns of hypervascularity.
Secondly, power Doppler, particularly when associated with intravenous
injection of echo-contrast, is useful as a complimentary tool for a
modified sextant biopsy scheme. After the administration of echo-contrast,
the sensitivity of power Doppler in detecting cancer increases from
38% to 85% (3). In our department, we perform a modified sextant biopsy
scheme (12 cores from the peripheral zone), plus 2 cores from any abnormal
finding in prostate texture, and plus 2 cores of any area with abnormal
flow. This protocol has been shown to be of value, particularly in patients
with large prostates (above 100 cm3). In conclusion, targeted biopsy
performed only on the basis of power Doppler US technique continues
to be insufficient to diagnose prostate cancer.
References
1. Lavoipierre AM, Snow RM, Frydenberg M, et al.: Prostate cancer: role
of Doppler imaging in TRUS. AJR 1998; 171:205-210.
2. Newman JS, Bree RL, Rubin JM: Prostate cancer: diagnosis with color
Doppler sonography with histologic correlation of each biopsy site. Radiology
1995; 195:86-90.
3. Bogers HA, Sedelaar JP, Beerlage HP, et al.: Contrast-enhanced 3-D
power Doppler angiography of the human prostate: correlation with biopsy
outcome. Urology 1999; 54:97-104.
Dr.
Adilson Prando
Department of Radiology
Vera Cruz Hospital
Campinas, São Paulo, Brazil
Renal angiomyolipoma: relationships between tumor size, aneurysm formation,
and rupture
Yamakado K, Tanaka N, Nakagawa T, Kobayashi S, Yanagawa M, Takeda K
Departments of Radiology and Urology, Mie University School of Medicine,
Tsu, Mie, Japan
Radiology 2002; 225:78-82
- Purpose:
To evaluate the relationships between tumor size, aneurysm formation,
and spontaneous rupture in renal angiomyolipomas.
- Materials
and Methods: Twenty-three
patients with renal angiomyolipoma were examined with angiography and
computed tomography (CT). The single largest lesion in each kidney was
evaluated. Tumor size was measured at CT, and aneurysm size was measured
at renal angiography. Tumor and aneurysm sizes were compared between
the group with ruptured angiomyolipoma and the group with unruptured
angiomyolipoma. Multiple regression analysis was performed to identify
factors affecting rupture.
- Results:
Twenty-nine kidneys with angiomyolipoma were identified. Eight angiomyolipomas
were hemorrhagic; the remaining 21 were not hemorrhagic. Tumor size
was larger than 4 cm and aneurysm size was 5mm or larger in all hemorrhagic
lesions. There were significant differences in mean tumor size (11.4
cm ± 5.5 [SD] vs. 5.0 cm ± 3.1, P < .02) and mean aneurysm
size (13.3 mm ± 6.2 vs. 2.4 mm ± 2.9, P < .02) between
the ruptured and unruptured tumor groups. When tumor size of 4 cm or
larger and aneurysm size of 5 mm or larger were used as predictors of
rupture, sensitivity and specificity, respectively, were 100% and 38%
with the former criterion and 100% and 86% with the latter criterion.
Multiple regression analysis indicated that aneurysm size was the most
important factor linked to rupture.
- Conclusion:
Aneurysm formation appears to be related to tumor size, and large aneurysms
confer a higher probability of rupture.
- Editorial
Comment
This study was conducted in a group of 23 patients with renal angiomyolipoma
(AML), in order to establish the correlation between tumor size, aneurysm
formation, and spontaneous rupture. Renal AML are benign neoplasms composed
of mature adipose tissue, thick-walled blood vessels, and smooth muscle,
in varying proportions. Spontaneous renal bleeding secondary to an AML
usually occurs when the tumor is larger than 4 cm (51%), although in
a recent review of our material, 3 (27%) of 11 hemorrhagic tumors measured
2.5 to 4.0cm in diameter (1). It is well known that the early phase
of selective angiography demonstrates aneurysms in the interlobar or
interlobular arteries in about 70 % of AMLs (2). These pseudoaneurysms
appear to be very difficult to detect when a non-hemorrhagic renal angiomyolipoma
is evaluated only by US, CT, or MRI. In a hemorrhagic renal AML, color-flow
Doppler sonography may demonstrate large pseudoaneurysm (= or >2cm
in diameter) within the lesion, and consequently is able to predict
if the hemorrhagic tumor is at risk of early recurrent bleeding (3).
As we know, the presence of a large aneurysm in renal AML has shown
to be cause of life threatening hemorrhage in few patients in the literature
(4). In this situation, heminephrectomy or therapeutic embolization
has been performed as therapeutic modalities .This fact emphasizes the
authors’ conclusion that aneurysm formation is probably related
to the size of the tumor, and that large pseudoaneurysms are related
to a higher probability of rupture.
References
1. Prando A: Renal angiomyolipomas: an imaging review and a radiologic
classification. Scientific Exhibit, RSNA, 2002.
2. Arima K, et al.: Renal angiomyolipoma: diagnosis and treatment. Hinyokika
Kiyo 1995; 41:737-43.
3. Lapeyre M, et al.: Color-flow Doppler sonography of pseudoaneurysms
in patients with bleeding renal angiomyolipoma. AJR, 2002; 179:145-7.
4. Adler J: Macro aneurysm in renal AML: two cases, with therapeutic embolization
in one patient. Urol Radiol, 1984; 6:201-3.
Dr.
Adilson Prando
Department of Radiology
Vera Cruz Hospital
Campinas, São Paulo, Brazil
INVESTIGATIVE
UROLOGY
Effects
of unilateral grade I testicular injury in rat
Srinivas M, Chandrasekharam VVSS, Degaonkar M, Gupta DK, Jha P, Jagannathan
NR, Das SN
Department of Pediatric Surgery, Department of Nuclear Magnetic Resonance,
Department of Reproductive Biology and Department of Biotechnology, All
India Institute of Medical Sciences, New Delhi, India
Urology 2002; 60:548-51
- Objectives:
The effect of unilateral blunt testicular trauma on subsequent testicular
function is still debated. None of the experimental studies had the
exact grading of testicular injury and evaluation of hormone status
and hence this study was designed.
- Methods:
Twenty male prepubertal (20 days old) Wistar rats were divided into
two groups: group 1 (n = 10) underwent sham surgery; group 2 (n = 10)
underwent blunt trauma to the right testis by a 5-g sterile weight dropped
three times on the testis from a height of 10 cm. T1-weighted and T2-weighted
magnetic resonance images were taken within 6 hours to confirm grade
I injury. At 60 days of age, blood samples were obtained from each rat
for follicle-stimulating hormone, luteinizing hormone, testosterone,
and estradiol levels, and both testes of each rat were harvested separately
for DNA flow cytometric analysis.
- Results:
Group 2 rats had significantly reduced (P <0.001) haploid cell populations
in both right and left testis compared with the corresponding testis
of the group 1 rats. Within group 2, the right testis was significantly
(P <0.001) more affected. Serum levels of testosterone were significantly
lower (P <0.05) and follicle-stimulating hormone (P <0.01) and
estradiol (P <0.05) levels were significantly higher in group 2 rats
than in group 1 rats. However, the luteinizing hormone levels were not
significantly different.
- Conclusions:
Grade I unilateral blunt testicular trauma in prepubertal rats significantly
affected germ cell maturation in both ipsilateral and contralateral
testis and altered the sex hormone profile.
- Editorial
Comment
Unilateral testicular lesions have the potential to affect also the
contralateral testis function, probably due to immunologic damage following
rupture of the blood-testis barrier. Nevertheless, the effect of unilateral
blunt testicular trauma on subsequent testicular function is still poorly
known. In the present work, the authors evaluated the effects of grade
I testicular injury on germ cell status of the ipsilateral and contralateral
testis, as well as the sex hormone status, in Wistar rats. All 10 rats
in the experimental group had grade I trauma to the right testis that
was confirmed by T1-weighted and T2-weighted magnetic resonance imaging
(MRI). To our knowledge, this is the first study comparing the extent
of damage in the traumatized and contralateral testis within the same
experimental group, by using the sensitive techniques of MRI for confirming
grade I trauma, and DNA flow cytometry for detecting germ cell alterations
in the testis. The present results indicate significantly worse damage
to the traumatized testis compared to the contralateral testis after
unilateral blunt testicular trauma. Also, the study demonstrates that
even grade I unilateral blunt testicular trauma significantly affects
overall testicular function, by elevating FSH and estradiol levels,
and lowering testosterone levels when compared to controls. In summary,
the authors elegantly concluded that grade I unilateral blunt testicular
trauma in prepubertal rats significantly affects germ cell maturation
in both ipsilateral and contralateral testis and alters the sex hormonal
profile.
Dr.
Francisco J.B. Sampaio
Chairman, Urogenital Research Unit
State University of Rio de Janeiro
Rio de Janeiro, Brazil
Immunohistochemical localization of the retinoic acid receptors in human
prostate
Richter F, Joyce A, Fromowitz F, Wang S, Watson J, Watson R, Irwin Jr
RJ, Huang HFS
From the Department of Surgery, Division of Urology and Laboratory of
Medicine and Pathology, UMDNJ, New Jersey Medical School, Newark, New
Jersey, and VA Medical Center, East Orange, New Jersey
J Androl. 2002; 23:830-8
- Retinoic
acid receptors (RARs) are nuclear transcription factors that mediate
the effects of retinoids. Aberrant expression and regulation of RARs
have been linked to various malignancies, including steroid-related
breast and cervical cancers. Our previous results also suggest that
prostate cancer is associated with altered RAR signaling. To understand
the relationship between RAR signaling and prostate cancer, the current
study examined the cellular distribution of RAR-a, -b, and -g in human
prostate tissues exhibiting different pathologic conditions. In histologically
normal epithelium, both RAR-a and -g were present throughout the epithelium
with minimal nuclear accumulation. RAR-b was present only in basal epithelial
nuclei. On the contrary, RAR-a was significantly increased in the nuclei
of luminal epithelial cells, and both RAR-b and -g were increased in
basal and luminal epithelial nuclei in glands exhibiting benign prostatic
hyperplasia (BPH). RAR-a as also increased in luminal epithelial nuclei
in glands exhibiting prostatic intra-epithelial neoplasia (PIN). In
these glands, RAR-b was persisting in basal epithelial nuclei that were
also RAR-g positive. In low- and intermediate-grade cancerous glands,
RAR-a was also significantly increased in luminal epithelial nuclei,
and a strong RAR-g signal was seen in some cells. RAR-b was absent in
these glands. Both RAR-a and -g were also increased in high-grade cancer
cells. In conclusion, current results demonstrated changes in cellular
distribution of RAR-a and -g in human prostate tissues exhibiting different
pathologies. These results suggest links between altered RAR signaling
and deregulated cell growth and/or tumorigenic transformation of prostate
epithelial cells.
- Editorial
Comment
The authors examined the cellular distribution of retinoic acid receptors
(RAR) RAR-a, -b, and -g in normal (patients submitted to cystoprostatectomy
for bladder carcinoma) and pathologic (adenocarcinoma, prostatic intraepithelial
neoplasia, and benign prostatic hyperplasia) human prostate tissues,
with the purpose of comprehending the role of RAR signaling in human
prostate cancer biology. The results of the analysis performed demonstrated
differences in the cellular distribution of these receptors in prostatic
tissue exhibiting different pathophysiology. The findings emphasize
the importance of RAR signaling in prostate cell biology, and perhaps
in the genesis and progression of prostate cancer. Also, the distinct
distribution pattern of these receptors under different pathologic conditions
may qualify them as adjuvant markers for specific disease states.
Dr.
Francisco J.B. Sampaio
Chairman, Urogenital Research Unit
State University of Rio de Janeiro
Rio de Janeiro, Brazil
RECONSTRUCTIVE UROLOGY
Laser
welded vesicourethral anastomosis in an in vivo canine model: a pilot
study
Grummet JP, Costello AJ, Swanson DA, Stephens LC, Cromeens DM
Division of Urology, Department of Surgery, University of Melbourne, Melbourne,
Australia
J Urol. 2002; 168:281-4
- Purpose:
We evaluated laser welding as an alternative method of forming the vesicourethral
anastomosis.
- Materials
and Methods:
Eight dogs underwent open total prostatectomy, including 4 in which
the vesicourethral anastomosis was formed by 830 nm. diode laser welding
using a chromophore doped albumin solder and 3 or 4 support sutures.
The remaining 4 anastomoses were conventionally formed using 8 interrupted
sutures. Acute leakage was tested intraoperatively. The anastomosis
of 1 animal per group was assessed on postoperative days 3, 5, 7 and
14 by radiography before sacrifice. Each anastomotic specimen was then
tested for leak pressure and examined histologically.
- Results:
There were no leaks during intraoperative testing of laser welded or
sutured anastomoses. On radiography there were no leaks in the laser
welded group. In 1 control there was slight localized leakage. All anastomoses
achieved physiological leak pressures of 70 mm. Hg or greater with 3
of the 4 in the laser welded group recording supraphysiological pressures
of greater than 200 mm. Hg. While 3 of the 4 laser welded specimens
showed evidence of muscle necrosis, there were no other differences
in healing in the 2 groups.
- Conclusions:
These short-term results suggest that diode laser welded vesicourethral
anastomosis is feasible. This technique has the potential to simplify
anastomotic formation in laparoscopic radical prostatectomy, shortening
operative time. Diode laser welding in this small cohort created an
immediate and ongoing watertight anastomosis and, therefore, it may
also be an alternative in open radical prostatectomy cases. Further
study is needed to assess long-term effects on healing.
- Editorial
Comment
Laparoscopy has had more and more influence on urological surgery in
recent years. While retroperitoneal surgical procedures are now routinely
performed in many centers, laparoscopic surgery for urologic tumors
in the pelvis has not gained such a wide acceptance yet. This is particularly
true for laparoscopic cystectomy, mostly due to the fact that a subsequent
urinary diversion needs a lot of time consuming suturing.
In this paper the authors have again taken up laser welding as a possible
technique to create a surgical anastomosis, thereby reducing the amount
of necessary sutures. They chose vesicourethral anastomosis after radical
prostatectomy in a canine model. Laser welding was performed with a
diode laser, a liquid solder containing lyophilized bovine serum albumin
mixed with indocyanine green dye as a chromophore. With this technique
they were able to create a vesicourethral anastomosis which was watertight
at intraluminal pressures exceeding 200 mmHg after 7 days.
If laser welding can be applied for pelvic laparoscopic surgery, it
will not only further increase the number of laparoscopic radical prostatectomies,
due to the reduction of operating time and necessary training of newcomers
in the field of laparoscopy, but it may also make laparoscopic cystectomy
and urinary diversion an option for many more centers then just the
few which perform this type of surgery still rather infrequently. However,
several questions must still be solved. We don’t know how a solder
consisting of bovine serum albumine or any other non-autologous preparation
will react in the human setting. May this create a larger number of
strictures? Or may it even create immunologic reactions in some patients?
Another problem is still the unpredictable tissue damage created by
the laser-induced welding process, as well as individual differences
in the absorption characteristics and visual estimation of a completed
welding.
Nevertheless, welding seems to be a viable option for approximating
human tissues. It should be possible to solve the remaining questions
in the upcoming years, and thus make laser welding a possible technique
for laparoscopy, which might give minimal invasive surgery a new boost.
Dr.
Arnulf Stenzl
Professor and Chairman of Urology
Eberhard-Karls-University Tuebingen
Tuebingen, Germany
After cystectomy, is it justified to perform a bladder replacement
for patients with lymph node positive bladder cancer?
Lebret T, Herve J-M, Yonneau L, Milinie V, Barre P, Lugagne P-M, Butreau
M, Mignot L, Botto H
Department of Urology, Hopital Foch, Suresnes, France
Eur Urol. 2002; 42:344-349
- Purpose:
After cystectomy for bladder cancer, when pelvic lymph nodes are positive,
bladder replacement remains controversial. The aim of this study was
to evaluate the outcome of patients who underwent neobladder replacement
despite bladder cancer metastasis to the regional lymph nodes.
- Materials
and Methods: From
1981 to 1997, a total of 504 consecutive cystectomies for bladder cancer
were performed at our institution. For 150 patients, pelvic lymphadenectomy
were positive, nevertheless 71 patients underwent a neobladder replacement
(50 N1 and 21 N2). The distribution of patients by clinical stage, according
to the TNM 97 classification, was 4 T1, 14 T2, 32 T3 and 21 T4. No patient
showed signs of metastasis on diagnosis.
- Results:
Five-year disease specific survival rate of the entire group (71 patients)
was 46%. With a mean follow-up of 8.3 years (3.2-20 years), 25 patients
(35%) were alive and free of disease (72% with day continence), five
patients were alive with recurrence (three bone metastasis, one chest
metastasis and one with local recurrence), 41 patients died, (three
non-cystectomy related). Of the 46 patients who recurred, a total of
eight patients had local recurrence. For five patients, a severe dysfunction
of the plasty appeared: two needed definitive bladder drainage until
they died, one patient became totally incontinent, one patient needed
a conversion of the plasty to Bricker ileal conduit. For the remaining
patient the tumor involvement provoked recto-plasty-cutaneous fistula.
All these five patients died in the 6 months after the plasty dysfunction
appeared.
- Conclusions:
Although prognosis in bladder cancer metastasis to the regional lymph
nodes has been reported to be poor, this study demonstrates that after
cystectomy, it is justified to propose a neobladder replacement to well
selected patients. Local recurrence only occurred in 11% of patients
and there was no damage to enteroplasty function for nearly half of
the patients, and considering benefit to the quality of life, orthotopic
bladder substitution should be considered as the preferential diversion
in this patient population.
- Editorial
Comment
Orthotopic bladder substitution to the urethra after cystectomy is meanwhile
a standard procedure for both male and female patients. It offers the
best and most natural solution of any kind of urinary diversion available
today, if the surgical margins are negative. Initial concerns with regards
to local recurrence, especially the side of the urethrointestinal anastomosis,
proved to be insignificant compared to other forms of bladder substitution.
There is, however, an ongoing discussion whether positive lymph nodes
should be a contra-indication for orthotopic bladder substitution. As
the authors of this paper have shown, a sizeable number of patients
survive several years (46% of the patients survived at least 5 years
in the hands of these authors). Should they be spared a bladder substitution
to the urethra for the remaining years of their life, despite the positive
effects on their quality of life?
These authors, as well as others – e.g. Skinner et al from Los
Angeles, Hautmann et al or our own group from the previous institution
in Innsbruck – , have all shown a local recurrence rate around
10-12%, irrespective of the presence or the absence of microscopic lymph
node metastasis. Of all patients that did recur locally, half had an
undisturbed function of their continent reservoir for the remaining
time of their life. Those developing a voiding dysfunction did so in
the last 6 months of their life after they had a mean of 17 months life
with a normal functioning bladder substitution.
It seems therefore appropriate to conclude that continent urinary diversion
is a possible option, and it should be regarded as a first line method
of urinary diversion even in patients with microscopic lymph node metastasis
of bladder cancer. One may even further conclude that if there are no
macroscopic signs of lymph node involvement, why should you perform
any frozen sections of lymph nodes during surgery? We know that frozen
sections yield 20-25% false negative results and on the other hand they
might not change decision-making at the time of surgery.
Dr.
Arnulf Stenzl
Professor and Chairman of Urology
Eberhard-Karls-University Tuebingen
Tuebingen, Germany
UROLOGICAL
ONCOLOGY
Newly
diagnosed bladder cancer: the relationship of initial symptoms, degree
of microhematuria and tumor marker status
Boman H, Hedelin H, Jacobsson S, Holmäng S
From the Department of Surgery, Alingsas Lasarett, Department of Urology,
Kärnsjukhuset, Skövde, and Departments of Clinical Chemistry
and Transfusion Medicine and Urology, Sahlgrenska University Hospital,
Göteborg, Sweden
J Urol. 2002; 168:1955-9
- Purpose:
We recorded initial symptoms and evaluated the frequency and intensity
of hematuria in patients with newly diagnosed bladder cancer. We also
evaluated and compared the sensitivity of bladder wash cytology, NMP22
(Matritech, Newton, Massachusetts), BTA Stat (Bion Diagnostic Sciences,
Redmond, Washington) and UBC antigen (IDL Biotech, Sollentona, Sweden)
with hematuria dipsticks and flow cytometry for determining the size
of erythrocytes in urine.
- Materials
and Methods: Urine
samples were collected from 92 patients with newly diagnosed bladder
cancer, 64 with idiopathic microhematuria and 42 with nephritis. Urine
was analyzed for NMP22, BTA Stat, UBC and erythrocytes size using flow
cytometry. Bladder wash cytology was done at cystoscopy. Urine was analyzed
for microhematuria with hematuria dipsticks at home for 7 consecutive
days immediately before the operation and in the hospital on the day
of surgery.
- Results:
Sensitivity was 75% for NMP22, 78% for BTA Stat, 64% for UBC and 61%
for flow cytometry at 73% specificity. Cytology had 42% sensitivity
at 97% specificity. Tumor size, grade and stage had a statistically
significant influence on NMP22, BTA Stat, UBC and cytology. Of the patients
75% had microhematuria on the day of the operation and 75% had hematuria
at least 1 of 7 days when tested at home the last week before transurethral
bladder resection. The 70% of all patients with macroscopic hematuria
as the initial symptom did not seem to differ from those without the
condition in tumor size, grade, stage or tumor marker levels.
- Conclusions:
Flow cytometry was not well enough able to distinguish patients with
bladder cancer from controls. The sensitivity of all tested markers,
including hematuria dipsticks, was high for large and high grade, high
stage tumors. Further studies are needed to evaluate whether a marker
could be used to determine priority among patients referred due to microhematuria.
- Editorial
Comment
Non-invasive diagnosis of superficial bladder cancer is still an important
issue in urology. These authors recorded the initial symptoms of patients
with newly diagnosed bladder cancer, and compared different noninvasive
methods (cytology, NMP 22, BTA Stat, UBC-Antigen, hematuria dipsticks,
and flow cytometry) in 92 patients with bladder cancer and others with
nonmalignant disease. As with all other recent prospective trials incorporating
this diagnostic tool, cytology had a low sensitivity (42%), albeit,
at a high specificity (97%). The overall sensitivity of the other noninvasive
tests was unsatisfying 7%. The paper gives the detailed insight into
subgroups specificity, relationship of grade and stage to marker sensitivity,
and other interesting details. In conclusion, the results of this prospective
analysis would not convince the responsible urologist to abandon the
golden standard of cystoscopy if bladder cancer is suspected.
Dr.
Andreas Böhle
Professor and Vice-Director of Urology
Medical University of Luebeck
Luebeck, Germany
Intravesical bacillus Calmette-Guerin reduces the risk of progression
in patients with superficial bladder cancer: a meta-analysis of the published
results of randomized clinical trials
Sylvester RJ, Van Der Meijden APM, Lamm DL
From the European Organization for Research and Treatment of Cancer Data
Center, Brussels, Belgium, Jeroen Bosch Hospital’s-Hertogenbosch,
The Netherlands, and the Mayo Clinic, Scottsdale, Arizona
J Urol. 2002; 168:1964-70
- Purpose:
We determine if intravesical bacillus Calmette-Guerin (BCG) reduces
the risk of progression after transurethral resection to stage T2 disease
or higher in patients with superficial (stage Ta, T1 or carcinoma in
situ) bladder cancer.
- Materials
and Methods: A meta-analysis was performed of the published results
of randomized clinical trials comparing transurethral resection plus
intravesical BCG to either resection alone or resection plus another
treatment other than BCG.
- Results:
We identified 24 trials with progression information on 4,863 patients.
Based on a median followup of 2.5 years and a maximum of 15 years, 260
of 2,658 patients on BCG (9.8%) had progression compared to 304 of 2,205
patients in the control groups (13.8%), a reduction of 27% in the odds
of progression on BCG (OR 0.73, p = 0.001). The percent of patients
with progression was low (6.4% of 2,880 patients with papillary tumors
and 13.9% of 403 patients with carcinoma in situ, reflecting the short
followup and relatively low risk patients entered in many of the trials.
The size of the treatment effect was similar in patients with papillary
tumors and in those with carcinoma in situ. However, only patients receiving
maintenance BCG benefited. There was no statistically significant difference
in treatment effect for either overall survival or death due to bladder
cancer.
- Conclusions:
Intravesical
BCG significantly reduces the risk of progression after transurethral
resection in patients with superficial bladder cancer who receive maintenance
treatment. Thus, it is the agent of choice for patients with intermediate
and high risk papillary tumors and those with carcinoma in situ.
- Editorial
Comment
The efficacy of BCG against recurrences of superficial bladder cancer
is without question. However, it was widely disputed if BCG could act
against the progression of superficial bladder cancers. Up to now, only
one prospective trial could show clear results, whereas all others did
not show any significant advantage. The reason was the few cases in
each trial progressing to invasive or metastatic disease. This is where
the power of a well performed metaanalysis comes into its role. Combined
analysis of clinical trials comparing transurethral resection plus intravesical
BCG to either resection alone or resection plus another treatment than
BCG was performed and identified 25 trials with 4,863 patients. The
combined analysis of this metaanalysis shows a clear advantage of BCG
over other treatment, or over no treatment, on a high statistical level.
Interestingly, this held true for the overall analysis as well as for
the analysis by disease type (papillary, cis), and comparison to different
treatment (Mitomycin C, other chemo, other immuno). The effect of BCG-maintenance
was substantial. These results are highly important, and for the first
time show very clearly and indisputable that BCG favorably alters the
biologic course of superficial bladder cancer, even with regard to progression.
Dr.
Andreas Böhle
Professor and Vice-Director of Urology
Medical University of Luebeck
Luebeck, Germany
FEMALE UROLOGY
Sexual
function after using tension-free vaginal tape for the surgical treatment
of genuine stress incontinence
Maaita M, Bhaumik J, Davies, AE
BJU Int. 2002; 90:540-3
- Objective:
To determine whether the use of the tension free vaginal polypropylene
tape (TVT) procedure for the treatment of genuine stress incontinence
(GSI) affects sexual activity.
- Patients
and methods: Sixty-seven
women treated by insertion of a TVT between September 1998 and March
2001 for GSI were sent questionnaires 6-36 months after surgery to determine
any urinary symptoms, sexual activity, patient satisfaction and the
use of hormone-replacement therapy.
- Results:
The questionnaire was returned by 57 patients (87%); 43 (76%) reported
being sexually active and 14 (25%) were not. Of the former, 31 (72%)
reported no change in sexual function after surgery and only two reported
an improvement; six (14%) reported that sexual function was worse and
four did not reply to the questions. The patients reporting that sexual
function was worse cited loss of libido as the main reason. No patients
complained of dyspareunia.
- Conclusions:
There was no significant change in sexual function or activity after
the TVT procedure and patients can thus be reassured that this operation
will not affect their sex life.
- Editorial
Comment
The authors describe the impact on sexual function from the placement
of the tension-free vaginal polypropylene tape (TVT) for female urinary
stress incontinence. Through questionnaire interview with their patients,
the authors determined the change in sexual function after TVT surgery,
in addition to the causes of sexual inactivity, and the time required
to resume sexual activity.
This paper is very important for it addresses a topic that is only as
of late been receiving attention as a complication of uro-gynecological
surgery. It is notable that the authors found that the TVT surgery had
no pronounced impact on sexual activity. In addition, the authors found
that sexual inactivity was most often attributed to the lack of partner
and the loss of libido, and not to anatomic alterations; a finding often
found in the male population as well. Classically, the authors have
pointed out that vaginal surgery may be detrimental to sexual activity
because of anatomic changes, such as narrowing or scarring, as well
as operative failure. The authors did not find any anatomic alteration
post-operatively on either the 6 week or 6 month post-surgical examination.
Perhaps this can help explain the lack of discernable impact of the
TVT on sexual function.
The potential detrimental effect of gynecological surgery on sexual
function has been addressed before with other vaginal operations. These
have ranged from vulvectomy for carcinoma and well anti-incontinence
operations to reconstructive operations with the use of Martius flap
and vesicovaginal fistula repair (1-4). When compared to these operations,
perhaps the limited effect on sexual function can be attributed to the
limited dissection associated with the TVT. In past discussions on transvaginal
urethrolysis, issues regarding potential nerve damage with a suprameatal
technique have been debated (5).
The TVT is often offered to younger patients due to the attractiveness
of its limited invasiveness. Urologic surgeons may feel more comfortable
offering this operation [now] in view of the limited effect on sexual
function that this article reports. Further expansion of research in
this area may include an analysis of the partners’ view of post-operative
sexual function impact, as well the role of biothesiometry in those
patients with altered sexual function.
References
1. Elkins TE, DeLancey JO, McGuire EJ: The use of modified Martius graft
as an adjunctive technique in vesicovaginal and rectovaginal fistula repair.
Obstet Gynecol. 1990; 75:727-33.
2. Webster GD, Guranick ML, Amundsen CL: Use of the Martius labial fat
pad as an adjunct in the management of urinary fistulae and urethral obstruction
following anti-incontinence procedures. J Urol. 2000; 163:76 (Abst.).
3. Green MS, Naumann RW, Elliott M, Hall JB, Higgins RV, Grigsby JH. Sexual
dysfunction following vulvectomy. Gynecol Oncol. 2000; 77:73-77.
4. Petrou SP, Jones J, Parra RO: Martius flap harvest site: patient self-perception.
J Urol. 2002; 167:2098-9.
5. Petrou SP, Brown JA, Blaivas JG: Suprameatal transvaginal urethrolysis.
J Urol. 1999; 162: Letter to the Editor (Reply by Authors).
Dr.
Steven P. Petrou
Associate Professor of Urology
Mayo Medical School
Jacksonville, Florida, USA
Does post-voiding residual volume get less as mobility improves in a rehabilitation
ward for older adults?
Weatherall M
Neurourol Urodyn. 2002; 21:132-5
- Impaired
bladder emptying is common in frail older adults. This study tests the
hypothesis that more complete bladder emptying is associated with better
mobility in a rehabilitation ward for older adults. Consecutive admission
to a rehabilitation ward for older adults were considered for inclusion
in the study in the week after admission to the ward. Exclusion criteria
were cognitive impairment such that consent could not be obtained, non-English
speaking, or presence of an indwelling urinary catheter. A post-voiding
residual (PVR) bladder volume and Rivermead Mobility Index (RMI) were
completed for subjects who gave consent, on a weekly basis until discharge.
The BladderScan BVI 3000 Diagnostic Ultrasound, instrument was used.
Statistical analysis was by a general linear mixed model. In the study
period, 114 people were admitted and 57 approached for consent. Twenty-four
people gave consent. Fifty percent of participants had a least one PVR
greater than 100mL. One person was found to be in urinary retention,
with a PVR of greater than 700mL, and was excluded from further analysis.
The PVR increased by 1.2mL (95% CI – 4.6 to 7) for each unit improvement
in the RMI. This study suggests that PVR does not decline with improvement
in mobility in older adults receiving inpatient rehabilitation.
Editorial Comment
The author reviews the effect of mobility on post-void residual bladder
volume measurement. This study is completed by assessing serial post-void
residual measurements as the same time as the Rivermead Mobility Index
(RMI) determination. The patients investigated had a weekly bladder
scan – with the first scan being within one week of admission –,
and this was performed until the patient was discharged from the rehabilitation
ward. All scans were performed within half an hour after voiding, and
all scans were performed in the supine position. The RMI was completed
by patient interview and observation of the ability to stand unsupported
for 10 seconds.
This study is valuable, for it found that there was no substantial relationship
between mobility and residual. The report is well written, and the discussion
section does an excellent job of self-analysis and critique. An insightful
commentary is made about the natural tendency to associate poor mobility
with poor bladder emptying and incontinence in frail, older adults.
It was surprising to find that there was no correlation between increasing
mobility and diminishing post void residual. The study author does point
out that due to exclusionary factors in patients agreeing to participate
in this study, only 20% of the admissions to the rehabilitation ward
were included. In addition, as pointed out by the author, the exclusion
criteria of poor mentation and presence of a urethral catheter on admission
may have led to a significant selection bias. Of note, the author did
point out that a substantial portion of participants had a least one
post void residual >100cc.
During this current era, when it appears that the average patient age
is increasing, it is an important fact that perhaps increasing mobility
does not diminish post void residual and voiding efficiency. This observation
may help guide us to perhaps not be as dismissive of an elevated residual
in an elderly female as be secondary to immobility, and spur us to look
for other addressable problems of this elevated residual, such as detrusor
failure or anatomic causation. It is hopeful that the author in the
future will look at the association of mobility and catheter dependent
urinary retention in the elderly female population residing in the rehabilitation
ward.
Dr.
Steven P. Petrou
Associate Professor of Urology
Mayo Medical School
Jacksonville, Florida, USA
PEDIATRIC
UROLOGY
Ultrasonography
is unnecessary in evaluating boys with a nonpalpable testis
Elder JS
Division of Pediatric Urology, Rainbow Babies and Children’s Hospital,
Department of Urology, Case Western Reserve University School of Medicine,
Cleveland, Ohio, USA
Pediatrics 2002; 110:748-51
- Objective:
An
inguinal sonogram often is obtained in boys with a nonpalpable testis
to “localize” the testis, i.e., determine whether the testis
is present. The results of ultrasonography in boys with a nonpalpable
testis were analyzed.
- Methods:
The
records of boys who were referred to a pediatric urology center with
a diagnosis of nonpalpable testis and who had undergone inguinal sonography
were reviewed. The results of sonography were compared with findings
in the office as well as surgical findings.
- Results:
A total of 62 boys who were referred with a diagnosis of a nonpalpable
testis and who had undergone a sonogram were reviewed. The sonogram
was ordered by the primary care physician in 51 boys (82%) and by a
general urologist in 11 cases (18%). The testis was identified by sonography
in 12 (18%) of 66 cases, and all were localized to the inguinal canal.
Physical examination by a pediatric urologist showed that 6 were in
the scrotum and 6 were in the inguinal canal or perineum. Of the 54
testes that were not localized by the sonogram, 33 (61%) were palpable
and 21 (39%) were nonpalpable. Of the truly nonpalpable testes, laparoscopy
and abdominal/inguinal exploration identified the testis as abdominal
in 10 cases and atrophic secondary to spermatic cord torsion in 11 cases.
- Conclusion:
Sonography
is unnecessary in boys with a nonpalpable testis, because it rarely
if ever localizes a true nonpalpable testis, and it does not alter the
surgical approach in these patients.
- Editorial
Comment
This is a long-awaited confirmation of the information that most pediatric
urologists already know. Ultrasound is a non-invasive technology and
is often used to find testes that are difficult to palpate. On the other
hand, the information it provides is unreliable. Indeed, it is less
accurate than a physical examination by an experienced examiner. Furthermore,
the physical examination is much better at determining whether a testis
is “retractile.” In an era were health care costs are rising,
ultrasound to determine testicular position is almost never warranted.
Interestingly, many insurance companies discourage referrals to specialists
using the justification that they are expensive and unnecessary, but
this paper shows that for this condition, a referral to a specialist
results in not only better care, but also in cost savings.
Dr.
Barry A. Kogan
Chief and Professor of Urology and Pediatrics
Albany Medical College
Albany, New York, USA
A ventral
rotational skin flap to improve cosmesis and avoid chordee recurrence
in epispadias repair
Pippi Salle JL, Jednak R, Capolicchio JP, Franca IM, Labbie A, Gosalbez
R
Divisions of Paediatric Urology, Montreal Children’s Hospital-McGill
University Health Center, Montreal, Canada, and Miami Children’s
Hospital, Miami, USA, and Department of Paediatric Surgery, Hospital Fernando
Fonseca, Amadora, Portugal
BJU Int. 2002; 90:918-23
- Objective:
To describe a technical modification that facilitates dorsal skin closure,
improves cosmesis and eliminates chordee recurrence secondary to contracture
of the dorsal penile skin in the repair of epispadias.
- Patients
and Methods: Eleven
patients with penopubic epispadias (mean age 1.8 years) had the epispadias
repaired using a modified ventral penile skin flap. Four patients had
isolated epispadias and seven had had a previous primary closure of
bladder exstrophy. Nine patients underwent the Cantwell-Ransley technique,
leaving the meatus in a glanular position. Two patients were repaired
using the penile disassembly technique of Mitchell and Bagli, because
they had a short urethral plate. A ventral island skin flap was fashioned,
starting at the base of the penis. Dissection was carried ventrally
into the scrotum to allow for adequate dorsal flap transposition. The
flap was rotated laterally to shift the suture line from the midline
and to cover the dorsal aspect of the penis with untouched penile shaft
skin. Redundant ventral foreskin was discarded.
- Results:
All patients had an uneventful course after surgery. Dorsal penile skin
was viable in every case and no patient developed recurrence of chordee
or an urethrocutaneous fistula. The cosmetic result was excellent in
all patients.
- Conclusions:
Dorsal skin closure using lateral rotation of ventral penile skin flap
improves cosmesis after epispadias repair and eliminates the recurrence
of chordee secondary to midline dorsal scarring.
- Editorial
Comment
This ingenious technical modification can be added to most types of
epispadias surgery. Dorsal skin coverage is almost always a problem
in these cases, and there is often a separation of the penis and scrotum
as well. This modification helps on both accounts. The authors should
be congratulated on a nice improvement in the technique of epispadias
repair.
Dr.
Barry A. Kogan
Chief and Professor of Urology and Pediatrics
Albany Medical College
Albany, New York, USA
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