Sperm retrieval and live birth rates in presumed Sertoli-cell-only syndrome in testis biopsy: a single centre experience.

We aimed to investigate sperm retrieval rates (SRR) by testicular sperm extraction (TESE), factors affecting SRR, and fertilization rate (FR), implantation rate (IR), clinical pregnancy rate (CPR) and live birth rate (LBR) in patients with presumed Sertoli-cell-only syndrome in testis biopsy (SCOS). We retrospectively evaluated files of 134 patients with SCOS who underwent TESE. Group I were patients in whom spermatozoa were retrieved and Group II were patients in whom no spermatozoa could be retrieved. SRR, Follicle stimulating hormone (FSH), Luteinizing hormone (LH), and testosterone levels, and the volume of testicles were compared between groups. In addition, FR, IR, CPR and LBR were determined. Sperm retrieval was achieved in 37 (27.6%) patients (Group I), and the remaining 97 (72.4%) patients made Group II. There were no significant differences in age, infertility time, testicular volume, serum FSH, LH and testosterone levels between Groups I and II (p > 0.05). Intracytoplasmic sperm injection (ICSI) was performed in 36 patients. FR, IR, and CPR were 60.86 ± 23.03, 36.53 ± 41.78 and 51.3% respectively. Cycle and patient based LBRs were 37.8 and 45.1% respectively. SRR in SCOS is lower than patients with non-obstructive azoospermia (NOA) in general. No parameters to predict spermatozoa retrieval were determined. In patients with SCOS, ICSI achieves similar live birth rate to other patients with NOA.

Ocular side-effects of tolterodine and oxybutynin, a single-blind prospective randomized trial.

AIM: To evaluate the effects of tolterodine and oxybutynin on visual accommodation, pupillary diameter, intraocular pressure and tear secretion in women with overactive bladder. METHODS: One hundred and four eyes from 52 consecutive female patients (age range: 22-60 years) with a urodynamic diagnosis of overactive bladder were prospectively investigated. Patients with a history of ocular disease or surgery were excluded. The subjects were randomly assigned to one of two groups: Group I received 2 mg tolterodine bid and Group II received 5 mg oxybutynin tid. All patients were evaluated at baseline (day 0) and after 1 month of treatment (day 28) by an ophthalmologist who was blinded to the medication. At each time point, a complete ophthalmic examination was performed and accommodation amplitude (AA), and pupillary diameter (PD) in dim and bright light were recorded. As well, tear secretion was assessed based on tear film break-up time and Schirmer I-test results. Statistical comparisons were made using the chi-square test, Student's t-test and Mann-Whitney U-test, as appropriate. RESULTS: Twenty-eight patients (56 eyes) received tolterodine and 24 patients (48 eyes) received oxybutynin. The mean ages of the two groups were similar (P = 0.523). After 4 weeks of treatment, AA was significantly lower in the oxybutynin treated group (P = 0.003, 95% CI 0.15, 0.62) whereas there was no significant change in AA in the tolterodine treated group (P = 0.155, 95% CI -0.042, 0.86). At day 28, PD in dim light was significantly larger in the tolterodine treated group (P = 0.031, 95% CI -0.82, -0.06), whereas no significant change in PD in dim light was noted in the oxybutynin treated group (P = 0.330, 95% CI -0.38, 0.18). Neither group showed a significant change in PD in bright light values on day 28 (P > 0.05 for both). In each group, the differences from day 0 to day 28 for intraocular pressure, and Schirmer-I results were insignificant (P > 0.05 for all). Both groups had significantly shorter tear film break-up time after 1 month of therapy (P = 0.014 (95% CI 0.47, 3.81) and P = 0.02 (95% CI 1.14, 4.61) for the tolterodine and oxybutynin treated groups, respectively). CONCLUSION: Four weeks of standard-dose oxybutynin treatment in women with overactive bladder decreases AA significantly, whereas the same duration of standard-dose tolterodine does not have this effect. However, tolterodine seemed to affect PD in dim light. One month of treatment with either of these anticholinergic drugs shortens tear film break-up time significantly. Concerning ocular side-effects, tolterodine seems to offer an advantage over oxybutynin because it does not affect AA, however, the shorter tear film break-up time with both agents suggests potential problems for patients who already have dry eye.

Extracorporeal shockwave lithotripsy for stones in abnormal urinary tracts: analysis of results and comparison with normal urinary tracts.

PURPOSE: We reviewed our experience with SWL for stones in abnormal urinary tracts and compared the results with those in normal urinary tracts. PATIENTS AND METHODS: The study group was composed of 2566 renal units (RU) treated on the Siemens Lithostar lithotripter at our SWL unit whose treatment and follow-up at 10 to 12 weeks were completed. Sixty-eight RUs (2.7%) belonged to 52 patients who had congenital upper urinary tract abnormalities. Logistic regression analysis was performed to analyze the impact of age, stone size, location, and the type of abnormality on the outcome of the SWL in the abnormal RU. The student t-, chi-square, and Fisher's exact tests were used for the comparison of stone load, number of treatment sessions, catheter placement, and success rates of the patients with normal and abnormal RU. Results of long-term follow-up for available patients (38 RU; 56%) were also evaluated. RESULTS: Age, stone load, stone location, and the type of abnormality did not have a statistically significant impact on the outcome of SWL for abnormal RU. The average stone load was 2.1 +/- 2.8 cm2 in the abnormal and 1.4 +/- 1.3 cm2 in the normal RU. Thus, the stone load was significantly higher in the abnormal RU (P < 0.05). In the abnormal group, 56% of the RU became stone free, 37% had nonobstructive and noninfectious clinically insignificant residual fragments < or = 4 mm (CIRF), and SWL failed in 7%. In the normal group, 78% of the RU became stone-free, 18.5% had CIRF, and SWL failed in 4%. There was no significant difference in the success rates in the groups if success was defined as stone free and CIRF together (P > 0.05). However, there was significant a difference when stone-free, CIRF, and failure rates were evaluated separately (P < 0.05). Recurrence, regrowth, and retreatment rates in abnormal RU were 50%, 37%, and 34%, respectively. CONCLUSIONS: Although the fragmentation rates were similar, clearance of the fragments was hampered in abnormal urinary tracts. Thus, especially for large stones, other endourologic treatment options should be considered. High recurrence and regrowth rates warrant careful monitoring and consideration for medical treatment during follow-up.

Prognostic assessment of nonmetastatic renal cell carcinoma: a clinically based model.

OBJECTIVES: Determining the recurrence risk in patients treated for renal cell carcinoma (RCC) is important for providing prognostic information and planning potential surveillance strategies. The pathologic stage has been the most widely used single prognostic variable. However, with minimally invasive treatment modalities, the pathologic stage may not be readily available. We developed a biostatistical prognostic model for postoperative RCC that is independent of the pathologic stage. METHODS: The records of 296 patients who underwent open nephrectomy for RCC at Johns Hopkins Hospital between 1990 and 1999 were reviewed. Cox proportional hazards regression analysis was used to generate a prognostic model. RESULTS: The recurrence risk (R(rec)) was determined from this model: R(rec)=1.55 x presentation (0-1)+0.19 x clinical size (in centimeters). Using this equation, 79% of patients were identified as low risk compared with 45% of patients considered low risk by pathologic stage (pT1). Moreover, the separation between the high and low-risk survival curves increased. CONCLUSIONS: This model is the first to our knowledge that uses purely clinical variables to assess the postoperative prognosis in patients with RCC. These results, although not validated, provide substantial evidence that preoperative clinical variables may be used instead of the pathologic stage to determine the risk of recurrence. Uncoupling the reliance on pathologic stage for prognostic information removes a potential barrier to novel minimally invasive treatments for renal malignancy and provides a standard to which observation protocols can be compared. In the future, this model may facilitate selection of appropriate patients for less toxic adjuvant or neoadjuvant therapies.

Metastatic adenocarcinoma of the prostate to the uvea as the initial presenting symptom in a 49-year-old man.

We report a case of a 49-year-old man who presented with symptoms related to his right eye. Subsequent workup revealed carcinoma of the prostate metastatic to the uvea. On ophthalmologic evaluation, choroidal metastasis was noted. His prostate was firm on digital rectal examination, and the serum prostate-specific antigen level was 124 ng/mL. Prostate biopsy was consistent with adenocarcinoma, Gleason score 9. The patient was treated with total androgen blockade and radiation to the eye. Although his ocular lesions disappeared, the patient died of hormone-refractory disease 32 months after the diagnosis. The first case of prostate cancer metastatic to the uvea was reported more than 1 century ago; however, only a few cases have been reported subsequently. To our knowledge, we present the first published report in the urological literature of a patient in whom ocular complaints were the presenting symptoms that led to the diagnosis of prostate cancer. The urologist should be cognizant of the distinct possibility of ocular metastasis if a patient with prostate cancer presents with complaints related to the eye.

Unusual cause of early preeclampsia: bladder paraganglioma.

Ten to twenty percent of paragangliomas occur at extra-adrenal locations and less than 1% are at the urinary bladder. The most common presenting symptom of bladder paraganglioma is hypertensive attacks precipitated by micturition and hematuria. Paraganglioma of the urinary bladder occurring at pregnancy is extremely rare. We present a case of bladder paraganglioma as an unusual cause of early preeclampsia. After termination of the pregnancy, surgical resection was performed and the histopathologic diagnosis of paraganglioma confirmed. At 24 months of follow-up the patient felt well and was normotensive without any foci of paraganglioma. Although rare, paraganglioma must be considered in the differential diagnosis of early preeclampsia.

Long-term results of Burch colposuspension.

BACKGROUND: We aimed to determine the long-term results of Burch colposuspension. METHODS: Patients who had undergone Burch colposuspension due to stress urinary incontinence (SUI) in our department between 1991 and 1995 were asked to participate in the study by telephone or mail. Fifty of 78 patients (64%) responded and these formed the study group. Patients were evaluated by a detailed questionnaire, pelvic examination, uroflowmetry and postvoid residual urine determination. Provocative stress test and urodynamic evaluations were performed in those who claimed leakage. Additionally, follow-up charts were retrospectively reviewed from the patients' files. RESULTS: Mean follow-up time was 50.6 months. The subjective cure rate was 52% and the surgical success rate was 84%. The patient satisfaction rate in terms of incontinence was 86%. No correlation was found between pre-operative patient characteristics (i.e. age, number of vaginal deliveries and pregnancies, menopause, previous anti-incontinence surgery and presence of detrusor instability) and outcome of surgery. Although no patient was performing clean intermittent catheterization in the long term, two patients had significant residual urine and obstructive flows. Three patients had severe pelvic prolapse that required surgical correction. CONCLUSIONS: Our results indicate that Burch colposuspension operation is an effective and durable choice of treatment with low complication rates for the treatment of SUI.

A case of metastatic malignant melanoma presenting with hematuria.

We report a case of metastatic malignant melanoma that presented with macroscopic hematuria and lower urinary tract symptoms. Effective palliation of urinary tract symptoms was achieved with transurethral resection of metastatic lesions in the bladder. However, the patient was lost due to widespread disease despite systemic therapy. Solitary or multiple dark blue-black nodular or vegetating lesions encountered during cystoscopy should raise the suspicion of metastasis of malignant melanoma and be investigated accordingly.

Reconstructive surgery in voiding dysfunction: experience with 69 patients.

OBJECTIVES: To present our reconstructive surgery experience with voiding dysfunction due to both neurologic and non-neurologic etiology. METHODS: From March 1993 to January 2000, 69 patients (43 men and 26 women) with voiding dysfunction underwent lower urinary tract reconstruction. Mean patient age at the time of surgery was 34. 5 years (range 9 to 75). Voiding dysfunction had a neurologic etiology in 65.2% of the patients and a non-neurologic etiology in 34.8%. Urodynamic investigation revealed poor bladder compliance in 52%, detrusor hyperreflexia in 19%, and a combination of the two in 29% of the patients. Thirteen patients (19%) had coexistent intrinsic sphincteric deficiency. A total of 56.5% of the patients had upper urinary tract deterioration. Most patients (78%) had severe urinary incontinence. Augmentation cystoplasty was performed in 60 patients. Nine patients had augmentation cystoplasty with a continent stoma. Concomitant procedures were performed in 11 patients. RESULTS: Mean follow-up was 36.6 months (range 8 to 108). Marked improvement of the upper tracts was documented in 79% of the patients in the neuropathic and 73% in the non-neuropathic group. High continence rates were achieved in both groups (82% and 94%, respectively). Intermittent catheterization rate was 88.6% in the neuropathic and 44% in the non-neuropathic groups and patient satisfaction rate was 84% and 94%, respectively. Three major complications in 2 patients required surgery. CONCLUSIONS: Surgical reconstruction to treat urinary incontinence and upper urinary tract deterioration gives satisfactory results in voiding dysfunction in the case of medical treatment failure.

Retrovesical leiomyosarcoma.

A case of retrovesical leiomyosarcoma in a male patient is described. The preoperative radiological and laboratory studies were inconclusive in determining the primary origin of the tumor. Diagnosis of a malignant tumor with smooth muscle origin was suggested by needle biopsy. However, the definitive diagnosis and the primary site of origin could only be determined by surgical exploration and subsequent histopathologic examination after excision. No sign of recurrence or metastasis was present 12 months after complete surgical resection.

Application of continent retubularized ileal stoma (Monti procedure) to an ileocecal pouch.

We describe the application of a retubularized ileal stoma (Monti procedure) to an ileocecal pouch in a patient with a spinal cord injury who required a continent urinary diversion. When constructing a continent diversion with an ileocecal pouch, this technique seems a good choice, with significant advantages over the other alternatives.

Extracorporeal shockwave lithotripsy in the pediatric population.

BACKGROUND: Shockwave lithotripsy (SWL) is being used increasingly as a therapeutic modality for childhood urolithiasis. We reported our experience and results of SWL in the pediatric population. METHODS: The 59 renal units (RU) of 54 patients were retrospectively reviewed. The mean patient age was 10+/-3.5 years. All patients were treated with the Lithostar lithotripter in outpatient settings. Those with positive culture results were treated under appropriate antibiotic coverage. Seven patients were treated under general anesthesia and the rest under sedoanalgesia. Shielding of the lung fields or gonads was not used. For the upper pole stones, protection of the lungs was accomplished by elevating the upper half of the body with supportive pillows, thus moving the kidney away from the lung fields. Six RUs were catheterized via double-pigtail ureteral catheters or by percutaneous nephrostomy tube prior to treatment. The average stone load was 1.8+/-2.5 cm2. RESULTS: Patients were treated with an average of 2.5 sessions. A total of 1000 to 2500 shockwaves were delivered between 14.5 and 17.8 kV. Routine spasmolytic treatment was not initiated. The stone-free rate was 64%, and clinically insignificant residual fragments (CIRF) were present in 29% of RUs; thus, the success rate was 93%. Fever that necessitated hospitalization occurred in one patient. No other complications were seen except skin bruising and early hematuria. CONCLUSION: Shockwave lithotripsy is a safe and effective treatment modality for childhood stones of appropriate size and radiologic characteristics.

Urologic screening for men with Behçet's syndrome.

OBJECTIVES: To establish the urologic status of men with Behcet's syndrome, because studies assessing the urologic aspect of Behçet's syndrome are rare. METHODS: During a 2.5-year period, we evaluated 104 male patients with Behçet's syndrome, 16 to 50 years old (mean 31+/-7), using a urologic questionnaire and modified Boyarsky symptom score; 44 healthy men, 20 to 46 years old (mean 29+/-7), were used as control subjects. RESULTS: The frequency of epididymitis in patients with Behçet's syndrome was 19.2% in this study. The mean irritative symptom score was 1.22+/-1.37 (significantly higher than the control group). The frequency of lower urinary tract symptoms (eg, dysuria, urgency, nocturia, terminal dribbling, and intermittency) was significantly higher in patients with Behcet's syndrome. CONCLUSIONS: In this study, the frequency of epididymitis in men with Behcet's syndrome was much higher than previously reported. Because some lower urinary tract symptoms were significantly more frequent in these patients, we conclude that screening of such patients with urologic questionnaire and symptom scoring is essential to identify those who need further urologic evaluation.

Impact of transition zone biopsies in detection and evaluation of prostate cancer.

OBJECTIVE: To analyze the impact of 2 systematic transition zone (TZ) biopsies in addition to systematic sextant biopsies in an effort to establish the importance of cancer detected in the transition zone. METHODS: Between November 1995 and October 1996, TRUS-guided systematic sextant peripheral zone (PZ) and two additional TZ biopsies were performed on 189 consecutive men. Radical retropubic prostatectomy (RRP) was performed to 13 patients with organ-confined prostate cancer. The biopsy results of the 52 patients with cancer and the pathological specimens of the patients who underwent surgery were compared. RESULTS: Of the 189 patients, 52 (27.5%) had prostate cancer of whom 20 (38.5%) both in the PZ and TZ, 31 (59.6%) only in the PZ, and 1 (1.9%) in the TZ only. Of the 96 patients with high serum PSA levels despite normal DRE, 14 had prostate cancer. TZ cancer only rate was 7.1% (1 in 14 patients) in this group. RRP was performed to 8 patients who had cancer only in the PZ and 5 patients in both TZ and PZ. The pathological stages of the postoperative specimens and extracapsular extension rates of those with cancer in the PZ and TZ were significantly higher (p = 0.029 and p = 0.008, respectively). CONCLUSIONS: Routine TZ biopsy does not substantially increase the prostate cancer detection rate, however it can be useful in selected patient groups. If further studies reveal the relationship of cancer in the transition zone, higher capsular extension rate (pT3 cancer) and higher pathological stage after radical surgery, then TZ biopsies may yield additional information that might influence the therapeutic approach.