Salpingovesical fistula mimicking an enterovaginal fistula.

Fallopian tube fistula with the bladder can mimic an enterovaginal fistula. A 34-year-old woman presented with continuous urinary incontinence after hysterectomy. A cystogram confirmed a vesicovaginal fistula and a possible additional intestinal communication. Further imaging, however, ruled out an enterovaginal fistula and diagnosed a fallopian tube prolapse with salpingovesicovaginal fistula. This case demonstrates the importance of multiple imaging modalities in identifying and clearly delineating the anatomy of gynecologic fistulous connections. The case illustrates the fact that while salpingovesical fistula is a rare complication of hysterectomy, it is an important consideration in one's differential diagnosis.

Vesical clear cell adenocarcinoma arising from endometriosis: A mullerian tumor, indistinguishable from ovarian clear cell adenocarcinoma.

Endometriosis is associated with increased rates of ovarian, particularly clear cell, adenocarcinomas. Malignant transformation of ovarian endometriosis is most common but rare cases have been reported in the bladder, abdominal wall, diaphragm, and rectum. We present the case of a 44-year-old female with vesical clear cell adenocarcinoma arising in a background of endometriosis in the absence of other pelvic endometriosis. The malignancy was diagnosed on transurethral resection of bladder tumor and managed with radical surgery. Histology and immunohistochemical findings were consistent mullerian origin and indistinguishable from similar tumors arising in the female genital tract. Extrapolating from the gynecologic literature, the recommendation was made for adjuvant chemotherapy. Further studies are needed to clarify the optimal treatment paradigm for ovarian and bladder clear cell adenocarcinomas.

The gatekeeper disparity--why do some medical schools send more medical students into urology?

PURPOSE: Urology continues to be a highly desirable specialty despite decreasing exposure of students to urology in American medical schools. We assessed how American medical schools compare to each other in regard to the number of students that each sends into urological training. We evaluated the reasons why some medical schools consistently send more students into urology than others. MATERIALS AND METHODS: We obtained American Urological Association Match data for the 5 match seasons from 2005 to 2009. We then surveyed all successful participants. The survey instrument was designed to determine what aspects of the medical school experience influenced students to specialize in urology. Bivariate and multivariate analysis was then done to assess which factors correlated with more students entering urology from a particular medical school. RESULTS: Between 2005 and 2009 a total of 1,149 medical students from 130 medical schools successfully participated in the urology match. Of the 132 allopathic medical schools 128 sent at least 1 student into urology (mean ± SD 8.9 ± 6.5, median 8). A few medical schools were remarkable outliers, sending significantly more students into urology than other institutions. Multivariate analysis revealed that a number of medical school related variables, including strong mentorship, medical school ranking and medical school size, correlated with more medical students entering urology. CONCLUSIONS: Some medical schools launch more urological careers than others. Although the reasons for these findings are multifactorial, recruitment of urological talent pivots on these realities.

A case of pararenal angiomyolipoma arising from an existing exophytic angiomyolipoma.

A 52-year-old healthy woman with a congenital solitary right kidney presented with an incidentally found pararenal mass. Computed tomography and magnetic resonance imaging revealed an exophytic mass in the right kidney consistent with an angiomyolipoma and an additional enhancing pararenal mass that contained fatty elements. Differential diagnosis of the mass included liposarcoma and angiomyolipoma. Upon exploration, the exophytic angiomyolipoma was found to be contiguous with the pararenal mass via an isthmus of fatty tissue. Frozen sections were taken from both masses which confirmed that both were angiomyolipoma. This is the first case reported in the literature wherein an angiomyolipoma extended extrarenally and formed a significantly larger pararenal mass.

Clinical and urodynamic spectrum of bladder function in cerebral palsy.

PURPOSE: The nature of voiding function and dysfunction associated with cerebral palsy is described in the literature without concurrence of opinion. We correlated urodynamic findings with voiding patterns to better understand and manage voiding dysfunction in children with cerebral palsy. MATERIALS AND METHODS: Voiding patterns and urodynamic studies in our last 31 patients with cerebral palsy were reviewed. Patients and families were surveyed on the child ability to void spontaneously, clean intermittent catheterization requirement, daytime incontinence and enuresis. Urodynamics consisted of slow fill water cystometry and patch electromyography. Measured parameters were bladder capacity based on age, capacity pressure, compliance, uninhibited contractions, bladder sensation and external sphincter activity. Patients were stratified by voiding status and statistical analysis was performed with p <0.05 considered significant. RESULTS: The 15 boys and 16 girls were 4.5 to 16.6 years old. Three children required clean intermittent catheterization for bladder drainage and 28 (90.3%) voided spontaneously. Diapers were worn by 24 patients (77.4%). There were daytime incontinence and enuresis in 12 patients (38.7%), daytime incontinence only in 11 (35.5%) and enuresis in 1 (3.2%). Seven patients (22.6%) were continent day and night. When correlated with urodynamic parameters, continent children tended to have a larger bladder, lower bladder capacity pressure, higher compliance, fewer uninhibited contractions and similar sphincter activity. The only statistically significant difference was in bladder sensation. CONCLUSIONS: There is a spectrum of clinical and urodynamic bladder function in children with cerebral palsy. Of these children 77.4% void spontaneously but are incontinent. Incontinence is more likely present during the day and rarely limited to enuresis. Urodynamically continent children have a similar storage profile and differ from children with daytime or nocturnal incontinence in the ability to sense bladder fullness.

Successful treatment for giggle incontinence with biofeedback.

PURPOSE: Giggle incontinence is the involuntary and often unpredictable loss of urine during giggling or laughter in the absence of other stress incontinence. The pathophysiology is unclear, urodynamics are seldom helpful, and the efficacy of timed voiding and pharmacotherapy is limited. We postulated that improving sphincter tone and muscle recruitment using biofeedback techniques might be helpful in children with giggle incontinence. MATERIALS AND METHODS: The charts of 12 patients with giggle incontinence were reviewed. Giggle incontinence severity, voiding patterns, associated symptoms and medical history including prior treatment were reviewed. Children were evaluated with uroflowmetry-electromyography and ultrasound measurement of post-void residual urine. They were assessed by the ability to isolate, contract and relax perineal muscles. They were taught Kegel exercises and instructed to perform them at home between weekly-biweekly sessions. Clinical success was characterized as a full or partial response, or nonresponse as defined by the International Children's Continence Society. RESULTS: The 10 females and 2 males were 6 to 15 years old. Only 1 child had a partial response to first line therapy with timed voiding and bowel management. Seven children were treated with anticholinergic agents and/or pseudoephedrine with a partial response in 3. The 9 children with refractory giggle incontinence underwent biofeedback with a median of 4.5 sessions per child (range 2 to 8). The 6 patients who underwent 4 or more sessions had a full response that endured for at least 6 months and the 3 with fewer than 4 sessions had a partial response. CONCLUSIONS: Patients with giggle incontinence can heighten external urinary sphincter awareness and muscle recruitment using biofeedback techniques. Treatment with education and pharmacotherapy only led to a partial response in some cases. Biofeedback supplemented this treatment or avoided pharmacotherapy when at least 4 sessions were performed. Biofeedback therapy should be incorporated in the treatment algorithm for giggle incontinence in children and it should be considered before pharmacotherapy.

Outcomes of varicocelectomy treatment: an updated critical analysis.

This article provides an updated analysis of the varicocele literature published since 1994. The present authors have followed the format of the previous review and have included a summary of the results from the 1994 article at the end of each section.

Systemic antibiotic prophylaxis not needed for microsurgical varicocelectomy.

OBJECTIVES: Although systemic antibiotic prophylaxis is not recommended for class I (clean) cases according to the Centers for Disease Control and Prevention guidelines, they are often used for varicocelectomy. This study was designed to determine whether antibiotic prophylaxis is necessary for varicocelectomy. METHODS: We conducted a retrospective review of 278 patients who had undergone microsurgical varicocelectomy. No antibiotics were used. All patients were seen within 4 weeks of surgery and evaluated for signs of infection. RESULTS: Only 2 patients developed culture-positive infection. Five additional patients had signs of infection as defined by the Centers for Disease Control and Prevention. CONCLUSIONS: The results of this study have shown that antibiotic prophylaxis is not warranted for patients undergoing varicocelectomy.

Effect of combination therapy with enalapril and the TGF-beta antagonist 1D11 in unilateral ureteral obstruction.

In unilateral ureteral obstruction (UUO), the kidney is characterized by increased fibrosis and apoptosis. Both transforming growth factor-beta (TGF-beta) and ANG II have been implicated, and ANG II may mediate its effects through TGF-beta. Previous studies demonstrated amelioration of renal damage when either TGF-beta or ANG II has been individually targeted. In this study, we sought to determine whether combining 1D11 (monoclonal antibody to TGF-beta) and an ACE inhibitor, enalapril, would be more effective in UUO than either individual treatment, as has been shown in diabetic and glomerulonephritic models. Rats underwent UUO and were given either control monoclonal antibody, 1D11 or enalapril, or 1D11/enalapril combination, for 14 days. Kidneys were harvested and examined for fibrosis [trichrome; collagen (real-time PCR, Sircol assay) and fibroblast-specific protein expression (immunohistochemistry), apoptosis (TUNEL), macrophage infiltration (immunohistochemistry), and TGF-beta expression (real-time PCR and tubular localization with immunohistochemistry)]. UUO was found to induce fibrosis, apoptosis, macrophage infiltration, and TGF-beta expression in the obstructed kidney. Administration of either 1D11 or enalapril individually significantly decreased all these changes; when 1D11 and enalapril were combined, there was little additive effect, and the combination did not provide full protection against damage. The results demonstrate that, for the most part, combination therapy is not additive in UUO. This could be due to the continued presence of a physical obstruction or to biochemical differences between UUO and other renal disease models. Furthermore, it suggests that other targets may be amenable to pharmacological manipulation in UUO.

Angiotensin receptor blockade decreases fibrosis and fibroblast expression in a rat model of unilateral ureteral obstruction.

PURPOSE: Unilateral ureteral obstruction is characterized by histopathological changes including interstitial fibrosis, fibroblast specific protein expression, tubular atrophy and apoptosis, and macrophage infiltration. Angiotensin II has been implicated in some of these changes. We examined the effect of angiotensin blockade on markers of renal injury, including fibroblast specific protein expression, fibrosis, apoptosis and macrophage infiltration. We used losartan, an angiotensin II antagonist, in a unilateral ureteral obstruction model and studied animals 3 weeks after unilateral ureteral obstruction, a time at which renal damage is well established. MATERIALS AND METHODS: Rats underwent unilateral ureteral obstruction and were given either drinking water or losartan for 21 days. Kidneys were harvested and examined for fibrosis (trichrome and the Sircol assay for collagen), apoptosis (TUNEL), and fibroblast specific protein expression and macrophage infiltration (immunohistochemistry). RESULTS: Unilateral ureteral obstruction was found to induce fibrosis, apoptosis, fibroblast expression and macrophage in the obstructed kidney. Losartan significantly decreased apoptosis and macrophage infiltration in the obstructed kidney. It also decreased fibrosis, as measured by either trichrome staining assessed by a pathologist, the Sircol assay for collagen or fibroblast specific protein expression. However, approximately 50% of the changes were not affected by the current treatment, suggesting that other factors contribute to renal damage in unilateral ureteral obstruction. CONCLUSIONS: We observed the direct contribution of angiotensin II to both apoptotic and cellular transition processes (epithelial mesenchymal transition) and fibrosis in unilateral ureteral obstruction. Because these processes are active not only in unilateral ureteral obstruction, but also in other renal diseases, the value of angiotensin II blockade as an important part of the antifibrotic armamentarium has been confirmed.

Renal damage progresses despite improvement of renal function after relief of unilateral ureteral obstruction in adult rats.

Progression of renal damage after relief of unilateral ureteral obstruction (UUO) has been demonstrated, especially in neonatal rats. We evaluated renal function and renal damage after relief of 3-day UUO in five groups of adult rats: group 1, no treatment; group 2, 3-day UUO; groups 3-5, 3-day UUO followed by relief; group 3, 7-day relief; group 4, 14-day relief; and group 5, 28-day relief. Glomerular filtration rate (GFR), renal blood flow (RBF), tissue transforming growth factor-beta (TGF-beta), interstitial fibrosis and fibroblast expression, tubular apoptosis, macrophage infiltration, expression of nitric oxide synthases (NOS), and urinary nitrate/nitrite (NO(2)/NO(3)) were evaluated. RBF and GFR were decreased to <10% of baseline by 3 days of UUO. GFR and RBF in a previously obstructed kidney (POK) returned to baseline by 14 days after relief. Both tissue TGF-beta(1) and interstitial fibrosis were significantly higher in POK of groups 3-5 compared with groups 1 and 2 . In group 5, the numbers of infiltrating macrophages, fibroblasts, and apoptotic tubular cells were higher in POK compared with group 1. Urinary NO(2)/NO(3) was significantly higher than baseline from 3 to 27 days after relief of UUO. Expression of NOS isoforms was increased in tubules. As interstitial fibrosis contributes to decreased renal function, these results suggest that the acute recovery in function may be compromised in the long term by the progressive renal fibrosis which was found. Furthermore, pharmacological intervention at the time of relief of UUO, targeted to fibrotic processes, may contribute to long-term recovery of renal function.