Prognostic value of HPV DNA in Urothelial Carcinoma of the Bladder: A Preliminary Report of 2-Year Follow-up Results.

PURPOSE: The association between the human papillomavirus (HPV) and anogenital carcinomas is well established. However, despite its anatomic adjacency, the relationship between HPV and urothelial carcinoma of the bladder (UCB) is less clear. Recent meta-analysis and case-control studies demonstrated a significant relationship between the presence of HPV DNA and UCB. The aim of this clinical study was to compare the 2-year follow-up results of HPV-positive and HPV-negative UCB patients to evaluate the prognostic value of HPV DNA positivity in UCB. METHODS: The study included patients with stage pTa and pT1 UCB who underwent polymerase chain reaction (PCR) analysis of HPV DNA between January 1 and November 30, 2018. Based on their PCR results, 19 HPV-positive and 38 HPV-negative UCB patients who had regular follow-up in our clinic were evaluated in terms of tumor recurrence and disease progression over a 2-year follow-up period. RESULTS: There was no significant difference between the groups in terms of age, follow-up time, smoking, or tumor grade (P= .576, P= .368, P= .080, and P= .454). Tumor recurrence was observed at least once in 47.3% (n=9) of the 19 HPV-positive patients and 36.8% (n=14) of the 38 HPV-negative patients (P= .445). There was no difference in disease progression between the groups during follow-up. CONCLUSION: In our sample of UCB patients, the presence of HPV DNA was associated with a trend toward higher recurrence rate during the 2-year follow-up, though the difference was not statistically significant. No difference in disease progression was observed based on HPV DNA positivity.

Update on the Management of Urological Problems Following Kidney Transplantation.

Urological problems in kidney transplant recipients are not limited only to posttransplantation urological complications. These problems are a cause of significant patient mortality and morbidity that have wide-ranging effects on graft survival throughout the entire life of the graft. Ultimately, the transplant comprises a major portion of the urinary system; therefore, the transplant team should be prepared for foreseeable and unforeseeable urological problems in the short and long terms. These mainly include postoperative urological complications (urine leakage, ureteral stenosis, and vesicoureteral reflux), bladder outlet obstruction, and graft urolithiasis. In recent years, significant advances have been made in the management of urological complications, especially due to advances in endourologic interventions. The aim of this review is to summarize the management of urological problems after kidney transplantation in the context of the current literature.

New Approach to Microscopy of Gram-Stained Urethral Smear: The Kissing Slide Method.

BACKGROUND: The effectiveness of microscopy of Gram-stained smear (GSS) for the detection of male urethral infection is debatable, especially in cases with low inflammation and no visible urethral discharge. This clinical study compared GSS samples collected with the conventional swab method and our new technique, the kissing slide method, together with polymerase chain reaction results to demonstrate the effectiveness of this new method in men with acute urethritis. METHODS: The study included 64 men who presented to the urology outpatient clinic with complaints of acute urethritis between October 2019 and January 2020. Two GSS samples were collected from each patient, first using the kissing slide method (applying the slide directly to the urethral mucosa), followed by the conventional method. The results were compared with polymerase chain reaction findings. RESULTS: The patients' mean age was 37.4 ± 7.8 years, and 68.7% had no visible urethral discharge on physical examination. At a GSS threshold of ≥5 polymorphonuclear leukocytes/high-power field, sensitivity values were 60% (95% confidence interval [CI], 42.32%-75.41%) for the kissing slide method and 23.33% (95% CI, 11.79%-40.93%) for the conventional method. At a threshold of ≥2 polymorphonuclear leukocytes/high-power field, sensitivity values with the kissing slide and conventional methods were 80% (95% CI, 62.69%-90.5%) and 50% (95% CI, 33.15%-66.85%) in all patients, and 66.67% (95% CI, 41.71%-84.82%) and 20% (95% CI, 7.047%-45.19%) in cases without visible urethral discharge, respectively. CONCLUSION: The new kissing slide method is a noninvasive alternative method that may have better sensitivity than the conventional GSS sampling method in the diagnosis of male acute urethritis. Randomized studies are needed to verify these findings.

Is There any Association between Urothelial Carcinoma of the Bladder and Human Papillomavirus? A Case-Control Study.

OBJECTIVES: Human papillomavirus (HPV) is a well-known oncogenic virus associated with anogenital carcinomas. Despite the anatomical proximity of the bladder and the anogenital region, the relationship between HPV and urothelial carcinoma of the bladder (UCB) is still a controversial issue. This study aimed to test the urethral swabs and first-void urine samples of patients with UCB for HPV-Deoxyribonucleic acid (DNA) using polymerase chain reaction (PCR) assay and to compare the results with a control group. MATERIALS AND METHODS: Sixty-nine patients who were diagnosed with UCB between January and December 2018 were included in this case-control study. Sixty-nine patients who visited the urology outpatient clinic for non-oncological reasons within the study period were designated as the control group. Urethral swab and first-void morning urine samples were collected from each patient. HPV-DNA presence was investigated using a PCR kit that can detect a total of 22 HPV genotypes, of which 18 are high-risk and 3 are low-risk genotypes. RESULTS: The mean age of the patients included in the study was 63.2 ± 12.6 years and the male to female ratio was 5.3. HPV-DNA was detected in 28.9% (20/69) of the patients in the case group and in 8.7% (6/69) of the patients in the control group. HPV-DNA positivity was significantly higher in the case group (OR 4.24; 95% CI 1.63-12.34). No statistically significant relationship was found between HPV-DNA positivity and tumor grade (p = 0.36). CONCLUSION: A statistically significant relationship exists between HPV infection and UCB, regardless of the tumor grade.

HPV infection in urology practice.

Human papillomavirus (HPV) is the most common pathogen of sexually transmitted disease worldwide. While HPV is responsible for low-grade benign lesions in the anogenital area such as condyloma acuminatum, it is also strongly associated with cervical, anal, vulvar/vaginal, and penile carcinomas. In addition to being an oncogenic virus, HPV causes a substantial socioeconomic burden due to the recurrence of benign lesions, the lack of a definitive treatment option that provides a complete cure, and the high cost of treatment. The global incidence of HPV infection is rising, especially among young and sexually active individuals; as a result, in recent years these infections have also become increasingly conspicuous in urology practice, both as incidental findings and primary complaints. The aim of this review is to evaluate the pathogenesis, diagnosis, and treatment modalities of HPV infections in light of the current literature from the urologist's perspective.

Classification of non-gonococcal urethritis: a review.

Non-gonococcal urethritis (NGU) is the most common disease of the genital tract in men. Recent studies have recommended avoiding the empiric antibiotic administrations that constitute the classical treatment approach in NGU and to aim toward treatment of causative pathogens. However, the classification of NGU agents remains controversial. In addition, the relevance of the commensalism of Mycoplasma hominis, Ureaplasma urealyticum, Ureaplasma parvum, and Gardnerella vaginalis, which are among the opportunistic pathogens found in the urethral flora, has yet to be determined. Furthermore, there are certain pathogens on which sufficient studies have not been conducted, although they are known to be NGU pathogens, and their statuses should be updated. In this review, the classification of NGU pathogens is summarized in the light of the current literature.

Microscopy of Gram-stained urethral smear in the diagnosis of urethritis: Which threshold value should be selected?

The aim of this study was to investigate the sensitivity of GSS in the diagnosis of urethritis in patients who present to the outpatient clinic with symptoms of urethritis. Sixty-three male patients who presented to our outpatient clinic with symptoms of urethritis between January and March 2018 were evaluated. Urethral smear samples obtained from patients were evaluated both by GSS examination and by Real-time Multiplex Polymerase Chain Reaction (rt-MPCR) assay. The sensitivity and specificity of GSS in detecting gonococcal urethritis (GU) and nongonococcal urethritis (NGU) were calculated for threshold values of ≥5 and ≥2 PMNL/HPF. The mean age was 33.2 ± 7.1 years. According to the rt-MPCR results, 14 patients had GU and 27 patients had NGU. A threshold value of ≥5 PMNL/HPF in the GSS demonstrated 92.9% sensitivity in the diagnosis of GU and 55.6% sensitivity in the diagnosis of NGU. A threshold value of ≥2 PMNL/HPF reached 100% sensitivity for GU and 92.6% sensitivity for NGU. A cut-off value of ≥5 PMNL/HPF in the GSS has low sensitivity in the diagnosis of NGU. On the other hand, a threshold value of ≥2 PMNL/HPF seems to have higher sensitivity in the diagnosis of both GU and NGU.

Ex vivo stone surgery in donor kidneys at renal transplantation.

OBJECTIVE: To report our experience on the outcomes of ex vivo ureteroscopy and ex vivo pyelolithotomy carried out on the donor kidney before living donor renal transplantation. METHODS: Between 2009 and 2016, 13 stone-bearing donor kidneys underwent ex vivo bench surgery after donor nephrectomy. Of these, six patients underwent ex vivo ureteroscopy and seven patients underwent ex vivo pyelolithotomy. Data were analyzed for technical feasibility, intraoperative and postoperative complications, stone clearance, and stone recurrence. RESULTS: The mean stone burden was 9.1 mm (range 5-15 mm). Renal collecting system access and stone extraction were successfully achieved, and a stone-free status was accomplished with both techniques. The mean duration of ex vivo ureteroscopy was 12.5 min (range 9-20 min), and the mean duration of ex vivo pyelolithotomy was 3.1 min (range 1-8 min). One patient in the pyelolithotomy group developed urinary leakage and underwent surgical repair on the third postoperative day. The mean long-term follow-up duration was 49.6 months (range 14-101 months). None of the 13 patients included in the study suffered from stone recurrence. CONCLUSIONS: Our experience suggests that both ex vivo ureteroscopy and ex vivo pyelolithotomy procedures can safely and effectively be carried out in stone-bearing living donor kidneys, without compromising renal allograft function.

Outcomes of Conservative Management of Asymptomatic Live Donor Kidney Stones.

OBJECTIVE: To evaluate the long-term outcomes of asymptomatic stones ≤4 mm that are left in situ during renal transplantation (RT). MATERIALS AND METHODS: Between 2009 and 2017, 31 patients who received stone-bearing (≤4 mm) kidneys were analyzed. At their last follow-up, the patients were evaluated with computerized tomography (CT) imaging and the results were compared to the initial CT findings obtained during donor evaluation. RESULTS: The mean stone size was 2.9 mm (range 1-4.3). The mean follow-up period after RT was 43.1 months (range 12-97). According to the CT findings of the last follow-up, the stone had passed spontaneously in 26 patients (83.9%). Three patients (9.6%) with a stone size of 4 mm required surgical intervention because the stone became symptomatic within the first year after transplantation. In the remaining 2 patients (6.4%), the stone remained in situ, without a change in its size. In terms of spontaneous passage rate, there was no significant difference between lower and midupper pole stones (P = .948). De novo stone formation was observed in 2 patients (6.4%). CONCLUSION: Asymptomatic stones <4 mm that are detected on donor evaluation may safely be left in situ during RT. Regardless of their localization in the kidney, these stones have high spontaneous passage rates after RT, and the long-term recurrence rates are also considerably low.

The outcomes of transurethral incision/resection of the prostate (TUIP/TURP) performed early after renal transplantation.

OBJECTIVE: In the early period after renal transplantation, urinary retention stemming from bladder outlet obstruction (BOO) may directly affect graft success. The aim of this study was to evaluate the early and long-term outcomes of transurethral resection of the prostate (TURP) and transurethral incision of prostate (TUIP) procedures performed in the first month following RT due to BOO. MATERIAL AND METHODS: Between February 2009 and March 2016, 38 male patients underwent TURP/TUIP due to BOO within the first 30 days of renal transplantation. The urodynamic and renal function assessment results of all patients were collected during the pre-and postoperative periods. All patients were followed up for a minimum of 12 months for short and long-term complications. The results were evaluated retrospectively. RESULTS: The mean age of the patients who underwent operations was 59.2±12 years. The median duration of dialysis was 41 months (range 0-180). Before the operation the mean serum creatinine (sCr) level was 1.8±0.7 mg/dL, the mean total PSA level was 1.6±1.1 ng/mL. Of the voiding parameters, the mean Qmax and Qave were measured as 8.2±4.5 mL/sec and 4.6±2.5 mL/sec, respectively. The median post-micturition residual urine (PMR) was 105 mL (range 10-400). TURP/TUIP operations were performed at a median of 19 days (range 8-30) after renal transplantations. None of the patients experienced major complications. In the early postoperative period, 5 patients (13.1%) developed urinary tract infection. The mean decrease in sCr in the first month following TURP/TUIP was 1.4±0.4 mg/dL (p<0.001). The mean Qmax (22.4±11.1 mL/sec), and Qave (11.7±5.4 mL/sec) increased significantly (p<0.001), while the median PMR (15 mL, range 0-205) decreased significantly (p<0.001). The mean follow-up period after the procedure was 46.8±23.3 months. During the follow-up period, 3 (7.8%) patients suffered from urethral stricture and 2 (5.2%) patients from bladder neck obstruction. CONCLUSION: In the surgical treatment of urinary retention arising from BOO in the first month following renal transplantation, TURP/TUIP yield safe and successful results. In addition, regarding the short and long term outcomes, these procedures may be safely performed with low morbidity.

Impact of sympathetic dysfunction in the etiology of overactive bladder in women: A preliminary study.

AIMS: We investigated the effects of autonomic sympathetic dysfunction in the etiology of overactive bladder (OAB) in women, by assessing the sympathetic skin response (SSR). METHODS: In total, 40 women with OAB and 15 volunteers were enrolled. Group 1 (n = 20) consisted of patients who benefitted from oral anticholinergics, Group 2 (n = 20) consisted of patients who were refractory to oral anticholinergics, and the volunteers (n = 15) were the control group. All patients were asked to complete OAB-SF questionnaires. The absence of SSR was accepted as significant. Detailed physical examinations including neurological examinations were performed. All patients underwent SSR tests on the skin of the hands, feet, and genital area in our neurology department using electromyography, and SSR responses were recorded. Statistical significance was accepted at P < 0.05. RESULTS: The mean age was 47.2 ± 12.4 years. In total, 55 women were evaluated (20 in Group 1, 20 in Group 2, and 15 in the control group). Mean OAB scores were similar between groups 1 and 2, although urgency was significantly higher in Group 2 than 1. The absence of SSR was significantly higher in Group 2 than 1 (P = 0.01). Impaired SSR was observed more commonly in Group 2 than 1. All controls had normal SSRs. CONCLUSIONS: Regional dysfunction in the autonomic nervous system may be part of OAB's etiology. SSR may be a candidate test for determining early OAB, and may also be useful for predicting antimuscarinic-refractory patients.

Effect of doxazosin on expression of eNOS in rat kidney in the presence of partial bladder outlet obstruction.

BACKGROUND: The role of nitric oxide in the pathogenesis of renal injury has begun to be appreciated. We therefore designed this study to demonstrate the relationship between endothelial nitric oxide synthase (eNOS) expression and doxazosin in the kidneys of rats with surgically created partial bladder outlet obstruction (BOO), to further understand the role of doxazosin in the prevention of renal parenchymal damage by partial BOO. MATERIAL AND METHODS: A total of 35 adult female Wistar rats, mean weight 250 g, were randomly allocated to 3 experimental groups: group1, sham-operated (n=10); group 2, partial BOO group (n=14) and group 3, partial BOO group treated with doxazosin (n=11). Partial BOO in rats was surgically induced. Results were assessed by eNOS immunohistochemistry. RESULTS: eNOS staining in kidneys in group 1 (16.45 ± 1.63) was significantly higher than in group 2 (5.09 ± 0.61) (p<0.05). After 15 days of doxazosin treatment in addition to partial BOO (group 3), eNOS staining in the kidney (11.80 ± 1.63) was significantly higher than in group 2 (5.09 ± 0.61) (p<0.05). In samples taken after 15 days of doxazosin treatment in addition to partial BOO, eNOS staining in kidneys (11.80 ± 1.63) was lower than in the sham-operated group (16.45 ± 1.63), but the difference was not significant (p>0.05). CONCLUSION: These findings may provide insight into the beneficial and restorative effects of α(1)-adrenoceptor antagonists on eNOS expression in the kidney, when used to treat symptoms of benign prostate hyperplasia and hypertension.

Importance of TNF-related apoptosis-inducing ligand in pathogenesis of interstitial cystitis.

INTRODUCTION: Although interstitial cystitis is an inflammatory disease, its etiopathogenesis is not clearly understood. The objective of the present study is to investigate the distribution of TNF-related apoptosis-inducing ligand (TRAIL) and its receptors in bladder biopsy samples of patients diagnosed with interstitial cystitis and the role of TRAIL in the pathogenesis of interstitial cystitis. MATERIALS AND METHODS: TRAIL and its receptors were stained immunohistochemically in bladder biopsy samples of 27 patients diagnosed with interstitial cystitis, and the samples were evaluated independently by two pathologists and were scored in terms of expression intensity and distribution. RESULTS: An evaluation of the results of the statistical analysis showed that the TRAIL-R4 receptor was immunohistochemically stained with a higher score than TRAIL-R1, TRAIL-R2, TRAIL-R3 receptors and TRAIL, with a statistically significant difference (P < 0.05). CONCLUSION: These findings indicate that TRAIL-R4 is the predominant receptor in the interstitial cystitis inflammation.

Role of spinning top urethra in dysfunctional voiding.

OBJECTIVE: The role of spinning top urethra (STU) in children with dysfunctional voiding was evaluated retrospectively. MATERIAL AND METHODS: From 1995 to 2002, the records of 154 children with dysfunctional voiding were reviewed retrospectively. Of the children 110 (71%) were girls and 44 (29%) were boys (mean age 8 years, range 4-14). All children were neurologically normal and no exhibited physical signs of occult spinal dysraphism. Patients were divided into two groups according to their width of proximal urethra: group I had STU and the group II had normal urethral width. The groups were compared with each other for gender, voiding symptoms, urinary tract infection (UTI), vesicoureteral reflux (VUR) and urodynamic observations. RESULTS: There were 84 children (mean age 8.3 +/- 2.2 years, range 4-14) in group I and 70 (mean age 8.0 +/- 2.1 years, range 4-14) in group II; no significant age difference was found between the two groups (p = 0.4674). Group I consisted of 66 (71%) girls and 18 (29%) boys and group II 44 (63%) girls and 26 (37%) boys. STU was observed more in girls than boys in group I (p = 0.0316). UTI was observed in 57 patients (68%) in group I and 34 (49%) in group II (p = 0.0154). Mean duration of symptoms was 42 +/- 24 months (range 6-118) and 39 +/- 23 (range 3-120) months in groups I and II, respectively (p = 0.6302). Postvoid residual urine (PVR) more than 10% of expected bladder capacity was detected in 15 patients (18%) in group I and seven (10%) in group II. No association was found between the meaningful PVR and STU (p = 0.1653). The presence of detrusor overactivity during filling was observed in 54 patients (64%) in group I and 42 (60%) in group II (p = 0.4676). Diminished bladder compliance (< 10 ml/cmH(2)O) was detected in 34 patients (40%) in group I and 17 (24%) in group II (p = 0.0335). The mean voiding pressure was measured as 56 +/- 29 cmH(2)O in group I, which was significantly higher than in group II (49 +/- 25 cmH(2)O) (p = 0.0373). The mean flow rate during the emptying phase of urodynamics was 16 +/- 8 and 15 +/- 6 ml/s in groups I and II, respectively (not significant, p = 0.2686). VUR was detected in 16 patients (19%) in group I and two (3%) in group II (p = 0.0018). CONCLUSIONS: STU was related to recurrent UTIs, VUR, poor bladder compliance and more serious functional urinary obstruction. Furthermore, STU may be a consequence of a neurogenic maturation defect in detrusor-sphincter coordination resembling that of urofacial syndrome, because development of this situation was found to be independent of the duration of symptoms.

Midline dorsal plication to repair recurrent chordee at reoperation for hypospadias surgery complication.

PURPOSE: Midline dorsal plication is an efficient and safe surgical technique to correct chordee. We investigated the efficacy of midline dorsal plication for recurrent chordee in complicated hypospadias reoperations. MATERIALS AND METHODS: We retrospectively evaluated the charts of 25 boys who underwent reoperation between 1999 and 2004 due to complications of primary hypospadias repair other than meatal stenosis. A total of 15 cases were initially managed elsewhere for primary repair or complications. The etiology of recurrent chordee was defined at surgical correction. When recurrent chordee was noted a midline dorsal plication was performed. RESULTS: Of 25 patients 10 had previously undergone chordee repair. Nine of these patients were observed to have recurrent chordee and 1 had de novo chordee. A total of 10 patients had recurrent or delayed onset chordee. Mean patient age at primary repair was 6.28 years (range 1 to 33). Mean age at last operation for chordee was 15.9 years (range 4 to 66). Mean interval to recurrent chordee was 6 years (range 1 to 16), excluding a 66-year-old blind patient who did not know when recurrent chordee developed. Five patients had chordee recur before puberty at a mean interval of 2.6 years. Mean reoperation rate was 2.4 for recurrent chordee cases and 2.6 for chordee-free cases. Mean followup after midline dorsal plication for recurrent chordee repair was 22 months (range 8 to 56), while mean followup in pubertal and postpubertal cases was 20 months. No recurrence of chordee or surgery related morbidity was observed after recurrent chordee repair by midline dorsal plication. CONCLUSIONS: Chordee may recur during puberty following successful chordee repair. The midline dorsal plication technique is simple, efficient and safe even in patients who have undergone multiple surgeries for hypospadias and chordee repair.

Can alpha-blocker therapy be an alternative to biofeedback for dysfunctional voiding and urinary retention? A prospective study.

PURPOSE: Traditional treatment of dysfunctional voiding in children with urinary retention involves retraining the pelvic floor muscles using biofeedback. Alpha-blockers are reported to also be effective in children with urinary retention and dysfunctional voiding. We compared the efficacy of biofeedback and alpha-blockers for dysfunctional voiding and urinary retention in terms of residual urine volume and urge incontinence episodes, mean flow rates and urinary tract infections. MATERIALS AND METHODS: A total of 28 patients with a mean age of 6.25 years (range 4 to 10) presented with symptoms of urinary incontinence, urgency and urinary tract infections without anatomic and neurogenic causes of urinary retention. All patients had increased post-void residual (PVR) urine volume (mean 59 ml, 32% of age expected capacity [AEC]). The biofeedback group consisted of 16 children (mean age 6.5 years) and the alpha-blocker group consisted of 12 children (mean age 5.9 years). Both groups were also on continued timed voiding, constipation treatment and anticholinergics, which had been used for at least the last 6 months. Biofeedback (median 10, range 6 to 16 sessions) and doxazosin (0.5 to 2 mg) were administered. At 3 and 6 months incontinence episodes, urinary tract infections, mean urinary flow rates, PVR and parental satisfaction grades (1 to 10) were reevaluated. Six refractory cases were started on alpha-blockers and biofeedback, and reevaluated after 1 month and 3 months. RESULTS: Pretreatment mean PVR was 54 ml (30% of AEC), and mean posttreatment PVR was 21 ml (12% of AEC) and 9 ml (5% of AEC) at 3 and 6 months in the biofeedback group (p <0.05). Pretreatment mean PVR was 64 ml (38% of AEC), and posttreatment mean PVR was 17 ml (12% of AEC) and 13 ml (8% of AEC) at 3 and 6 months in the alpha-blocker group (p <0.05). There was no statistical difference in posttreatment PVR between the 2 groups (p >0.05). High PVR persisted in 4 (25%) biofeedback cases and in 2 (16%) alpha-blocker cases. Complete improvement in urge incontinence episodes occurred in 10 (62.5%) and 7 (70%) children in the biofeedback and alpha-blocker groups, respectively. In therapy responsive children parental satisfaction was higher with alpha-blocker than with biofeedback (9.2 vs 7.9, p <0.05). Refractory high PVR decreased significantly after combination treatment with biofeedback and alpha-blocker in 5 of 6 children (mean 80 ml, 35% of AEC vs mean 15 ml, 7% of AEC). No drug related side effect was reported in the alpha-blocker group. CONCLUSIONS: Alpha-blocker therapy seems to be a viable alternative to biofeedback in dysfunctional voiding in children with urinary retention to improve bladder emptying. Combination treatment (biofeedback and alpha-blockers) can be used as additional therapy in refractory cases.

The effect of location of the ureteric orifice on the efficacy of endoscopic injection to correct vesico-ureteric reflux.

OBJECTIVE: To review our 11-year experience and identify the mechanisms responsible for the failure of endoscopic injection for vesico-ureteric reflux (VUR) with three different injectable agents, based on the location of the ureteric orifice on endoscopy. PATIENTS AND METHODS: We retrospectively reviewed the charts and endoscopic video-photographs of 46 patients (26 girls, 20 boys, median age 6 years, range 2-16) with VUR treated once or twice by subureteric injection with PTFE, or polydimethylsiloxane or dextranomer/hyaluronic acid copolymer, from 1992 to 2003. Five patients were lost to follow-up and six ectopic and/or duplicated ureters were excluded from the analysis; in all, 52 ureters were analysed. According to the international classification, the VUR was grades I to V in four (8%), 12 (23%), 16 (31%), 13 (25%) and seven (13%) ureters, respectively. RESULTS: After 3 months, voiding cysto-urethrography showed that VUR continued in six of 19, seven of 12 and eight of 21 ureters (38%), respectively, after subureteric PTFE, polydimethylsiloxane and dextranomer/hyaluronic acid copolymer injection; after the second injection, reflux continued in two of six, four of seven and three of eight ureters, respectively. Mound displacement and/or volume loss was the most common failure with all three bulking agents after both the first (62%) and second injections (44%) (P < 0.05). The first injection failed in 32% (11 of 35) normally located ureters and 10 of 17 lateral ureters (P < 0.05). The second injection failed in 11% (four of 35) normal and five of 17 lateral ureters (P < 0.05). CONCLUSIONS: A lateral ureteric orifice may decrease the efficacy of endoscopic injection, as the likelihood of a faulty injection is greater. However, a more careful second injection decreases the failure rate, particularly in those with low- to medium-grade refluxing ureters.

Endoscopic treatment of ureteric strictures: acucise, cold-knife endoureterotomy and wall stents as a salvage approach.

OBJECTIVE: To evaluate the factors influencing the results of endoureterotomy using cold-knife and cutting balloon dilatation, and permanent ureteral wall stents in patients with benign ureteral strictures after different operations affecting the ureter. MATERIALS AND METHODS: Over a 4-year period, in 18 patients, endoscopic cold-knife and Acucise endoureterotomies were performed in 13 and 7 renal units, respectively. Eight Memoterm permanent ureteral wall stents were inserted into 7 patients when endoureterotomy failed. Successful outcome was defined by the absence of re-stricture assessed both clinically and radiologically. RESULTS: The strictures were secondary to ureterolithotomy in 6, ureteroscopy in 3, gynecological procedures in 4, abdominal surgeries in 2, transplantation in 2 and continent urinary diversion in 1. The right and left ureters were unilaterally affected in 5 and 11 patients, respectively (5 of them had a solitary kidney), while the remaining 2 patients had bilateral ureteral strictures. We achieved total ureteral patency of 3 (43%) and 7 (54%) renal units with Acucise and cold-knife incision, respectively. Obstructive uropathy was resolved in 6 renal units (75%) of 8 using ureteral wall stents. CONCLUSION: Endoureterotomy with cold-knife or Acucise cutting balloon dilatation is effective in the treatment of iatrogenic ureteral strictures, but only in a selected group. Based on our results, the favorable prognostic criteria for endoureterotomy are the length (< or =1.5 cm), the nonischemic nature of the stricture and adequate renal function. As a salvage approach, permanent self-expanding ureteral wall stents with a 75% success rate may provide a satisfactory outcome for decompression of an obstructed system.

Should we switch over to tolterodine in every child with non-neurogenic daytime urinary incontinence in whom oxybutynin failed?

OBJECTIVES: To assess the clinical efficacy of tolterodine prescribed to children with non-neurogenic daytime urinary incontinence secondary to overactive bladder who had previously failed to improve with oral oxybutynin treatment and its relation to the side-effect profile and compliance status. METHODS: We evaluated 92 children presenting with daytime wetting, with or without nocturnal enuresis, who were receiving oral oxybutynin treatment. Children with chronic urinary tract infections, a neurologic lesion, an anatomic abnormality of lower urinary tract, voiding abnormality, and less than 1 year of oxybutynin treatment were excluded. Of the remaining 41 children (mean age 7.2 years, range 5 to 14 years), 30 agreed to switch to tolterodine and 11 continued receiving oxybutynin. Anticholinergic side effects, compliance, and clinical efficacy were assessed in the follow-up. RESULTS: Of the 30 patients who switched to tolterodine, a complete response was in 18 patients (60%), partial improvement in 11 (37%), and no improvement in 1 (3%) after a mean of 14.4 months (range 12 to 16 months) of oxybutynin treatment. The anticholinergic side-effect score was 7.2, 9.3, and 11, respectively, for those with a complete response, partial improvement, and no improvement in the compliant group. The noncompliant group had the greatest side-effect score (16.9). The fairly compliant group had a side-effect score of 12.3. After a mean of 7.1 months (range 6 to 9 months) of tolterodine use, a complete response was reported in 24 patients and partial improvement in 5 (17%). In 1 patient, treatment failed completely. However, his side-effect score decreased from 11 to 2. All tolterodine users were compliant with treatment. CONCLUSIONS: The results of this study in children with non-neurogenic daytime urinary incontinence have shown that tolterodine may increase the efficacy of pharmacotherapy, particularly in patients noncompliant to oxybutynin. Additional investigation of the anticholinergic side-effect scores and compliance tables is required to improve the clinical results of pharmacotherapy in incontinence due to overactive bladder in children.