Urethroplasty is often successful for the treatment of male urethral stricture disease, but limited data exists on recurrence management. Our goal was to evaluate direct visual internal urethrotomy (DVIU) as a treatment option for isolated, recurrent strictures after urethroplasty.
We retrospectively identified male patients who underwent urethroplasty from 1999 to 2013 and developed an isolated, recurrent stricture at the urethroplasty site treated with DVIU. Success was defined as lack of symptomatology and no subsequent intervention. Comparative analysis identified characteristics and stricture properties associated with success.
A total of 436 urethroplasties were performed in 401 patients at our institution between 1999 and 2013. Stricture recurrence was noted in 64 (16%) patients. Of these, 47 (73%) underwent a DVIU. A total of 37 patients met inclusion criteria and underwent 50 DVIU procedures at the urethroplasty site. A single DVIU was successful in 13 of 37 patients (35%). A total of 4 of 6 patients required a second DVIU (67%). Overall, 17 of 43 (40%) of the total DVIUs were successful after urethroplasty. Success did not differ by age, stricture length or location, surgical technique, radiation history, prior urethroplasty or DVIU, time to failure, or etiology.
Post-urethroplasty DVIU for isolated, recurrent strictures may be offered as a minimally invasive treatment option. Approximately 40% of patients were spared further intervention.
Urethral strictures or fistulas are common complications after phalloplasty. Neourethral defects pose a difficult reconstructive challenge using standard techniques as there is generally insufficient ventral tissue to support a graft urethroplasty. We report our experience with local fasciocutaneous flaps for support of ventrally-placed buccal mucosal grafts (BMGs) in phalloplasty.
A retrospective review of patients who underwent phalloplasty and subsequently required revision urethroplasty using BMGs between 2011 and 2015 was completed. Techniques, complications, additional procedures, and outcomes were examined.
A total of three patients previously underwent phalloplasty with sensate radial forearm free flaps (RFFFs): two female-to-male (FTM) gender reassignment, and one oncologic penectomy. Mean age at revision urethroplasty was 41 years (range 31–47). Indications for surgery were: one meatal stenosis, four urethral strictures (mean length 3.6 ± 2.9 cm), and two urethrocutaneous fistulas. The urethral anastomosis at the base of the neophallus was the predominant location for complications: 3/4 strictures, and 2/2 fistulas. Medial thigh (2) or scrotal (1) fasciocutaneous flaps were used to support the BMG for urethroplasty. One stricture recurrence at 3 years required single-stage ventral BMG urethroplasty supported by a gracilis musculocutaneous flap. All patients were able to void from standing at mean follow up of 8.7 months (range 6–13). A total of two patients (66%) subsequently had successful placement of a penile prosthesis.
Our early results indicate that local or regional fasciocutaneous flaps enable ventral placement of BMGs for revision urethroplasty after phalloplasty.
Fournier’s gangrene (FG) is an acute progressive necrotizing fasciitis of the genital area and perineum with possible extension to the abdominal wall. Surgical debridement is the gold standard management modality of established patients. Equivocal (early) FG represents a challenge in diagnosis. The objective of this study was to compare conservative management and early exploration in cases of equivocal (early) FG.
This was an observational study where data of all patients diagnosed as early FG in our departments over 4 years (2011–2015) were enrolled. Patients were divided into two groups: group 1 with conservative treatment, and group 2 managed with urgent exploration with longitudinal hemiscrotal incision starting from external inguinal ring. All patients’ demographics, vital signs, laboratory finding and clinical findings were reported.
A total of 28 patients were enrolled in the study. Group 1 was managed with conservative treatment (17 patients) and group 2 underwent urgent exploration (11 patients). Overall, four patients (23.5%) out of 17 patients of group 1 showed a good response to conservative management without any surgical debridement. A total of 13 patients (76.5%) developed gangrenous discoloration and needed surgical debridement later. In group 2, four patients (36.4%) underwent scrotal exploration and release incision only without debridement and showed an excellent clinical outcome. A total of four patients (36.4%) underwent debridement with excision of doubtful deep subcutaneous and fascial tissues. The remaining three patients (27.2%) underwent debridement of necrotic fascia. The hospital stay was significantly shorter in group 2 patients than group 1 (7.5 ± 3.75 versus 13.4 ± 5.19 days p < 0.05). The mean number of debridement sessions was 3.74 ± 0.69 in group 1 versus 1.82 ± 0.34 in group 2.
Early exploration and debridement in equivocal (early) FG has a better clinical outcome with reduced hospital stay and number of debridement sessions than conservative treatment with delayed debridement.
The aim of this work was to study the factors affecting the stability of working patients in antimuscarinic (AM) drug treatment.
The prevalence of urge urinary incontinence (UUI) is an average of between 8.2% and 16.0% of the population. UUI is a condition that adversely affects the health-related quality of life. The first-line therapy in managing UUI is AM treatment.
In 1006 patients between 18 and 60 years old (627 women, 379 men, mean age 69.4) who received AM treatment for one year, the possible demographic, socioeconomic and health factors influencing compliance were studied. Also, the functional state of the lower urinary tract (LUT) was studied in this randomized, prospective survey. The study instruments were the documents of employers, tax offices, outpatient records, OABq-SF (overactive bladder - short form) questionnaires, MOS SF-36 (Medical Outcomes Study short form-36), voiding charts, and uroflowmetry data.
The compliance to AM treatment within 6 months was retained in 49.5% patients; during the year, in 32.3% of patients. The average time for reaching the 30-day break in taking trospium was 194 days. In the course of the experiment it was revealed that compliance to AM treatment was significantly higher in patients taking solifenacin and trospium in high dosages (p <= 0.01, p <= 0.05), suffering from severe symptoms of urgency (p <= 0.01), and having a low level of side effects (p <= 0.01). A satisfactory level of compliance is characteristic of patients with a high level of monthly and annual income (p <= 0.01, p <= 0.01), a low percentage of expenses to AM (p <= 0.05), and rarely changing employers (p <= 0.05). In addition, the compliance to treatment is higher in older adults (p <= 0.05), living in the urban district (p <= 0.01), and working in educational (p <= 0.05) and health (p <= 0.01) institutions, having a high level of the indices of Social Functioning (p <= 0.05), Role-Emotional (p <= 0.05), and Mental Health (p <= 0.01).
As a result of this study, under the control of the objective functional state of LUT, the influence of various factors on the patients’ stability in the treatment with AM drugs was revealed.
Chronic lymphocytic leukemia (CLL) is a rare hematologic disorder with affected patients having complications of frequent infections and possible transformation to a more aggressive malignancy. The occurrence of CLL in the bladder is a rare event, with few reported cases. As a result, its aggressiveness and the optimal course for treatment are unknown. Despite this, its presence in the bladder warrants continued surveillance, as recurrence and progression to other bladder malignancies are possible. We present a 71-year-old woman initially diagnosed with CLL who was plagued by recurrent hematuria and dysuria for over a decade, which lead to multiple negative urologic workups. However, these continued workups eventually lead to her diagnosis of bladder CLL with a subsequent finding of carcinoma in situ that was prompted by a suspicious surveillance cystoscopy performed 4 months after her initial bladder diagnosis. Hence, infiltration of CLL in the urinary bladder merits close follow up, including additional urologic procedures.
Epidemiological data link erectile dysfunction (ED) and benign prostatic hyperplasia (BPH)-associated lower urinary tract symptoms (LUTS), two highly prevalent conditions in aging men, assuming common pathophysiological pathways. Tadalafil 5 mg once daily has been approved for the treatment of men with LUTS with or without comorbid ED. The aim of this review is to provide an overview of current knowledge on the epidemiological and pathophysiological links between ED and LUTS and to focus on tadalafil as a new treatment option in men with BPH-associated LUTS.
A Medline search was completed using the Medical Subject Headings (MESH® keywords) ‘prostatic hyperplasia’ and ‘phosphodiesterase inhibitors’. This search revealed 125 relevant references (entire Medline database up to 11 March 2014). The efficacy of tadalafil 5 mg once daily for the treatment of LUTS has been reported by several well-designed studies. Tadalafil improves significantly the total International Prostate Symptom Score (IPSS), the voiding and storage subscores, the IPSS Quality of Life (QoL) and the BPH Impact Index (BII). Its efficacy is irrelevant to the erectile function status of the patients. However, in the majority of these studies tadalafil is not associated with improvement in maximum urine flow or post-void residual volume (PVR). Its safety profile is well established and no new or unexpected adverse events other than those reported in ED studies have been recorded. Tadalafil is today a new treatment alternative to other established drugs for LUTS such as the α-adrenergic antagonists or 5α-reductase inhibitors. However, it is not just an alternative, since sexual adverse events associated with these drugs are avoided and tadalafil is the only drug that can treat both ED and LUTS at the same time.
The purpose of this article is to review normal developmental bladder physiology in infants and bladder dysfunction in conditions such as neurogenic bladder, posterior urethral valves and high grade vesicoureteric reflux. We contrast the classical concept that bladder function in nontoilet-trained children is thought to be ‘reflexive’ or ‘uninhibited’, with the results of more recent research showing that infants most commonly have a stable detrusor. The infant bladder is physiologically distinct from the state seen in older children or adults. The voiding pattern of the infant is characterized by an interrupted voiding stream due to lack of proper urinary sphincter relaxation during voiding. This is called physiologic detrusor sphincter dyscoordination and is different from the pathologic ‘detrusor sphincter dyssynergy’ seen in patients with neurogenic bladder. Urodynamic abnormalities in neonates born with spina bifida are common and depend on the level and severity of the spinal cord malformation. Upper neuron lesions most commonly lead to an overactive bladder with or without detrusor sphincter dyssynergy while a lower neuron lesion is associated with an acontractile detrusor with possible denervation of the external urinary sphincter. In infants with neurogenic bladder, the role of ‘early prophylactic treatment (clean intermittent catheterization and anticholinergics)’ versus initial ‘watchful waiting and treatment as needed’ is still controversial and needs more research. Many urodynamic-based interventions have been suggested in patients with posterior urethral valves and are currently under scrutiny, but their impact on the long-term outcome of the upper and lower urinary tract is still unknown. Cumulative data suggest that there is no benefit to early intervention regarding bladder function in infants with high-grade vesicoureteric reflux.
In its 2012 global report on tuberculosis, the World Health Organization estimated that 3–7% (range 2.1–5.2%) of new cases and 20% (range 13–26%) of previously treated cases had multidrug-resistant tuberculosis (defined as tuberculosis caused by Mycobacterium tuberculosis isolates that are resistant to rifampicin and isoniazid). In many countries in Eastern Europe and central Asia, 9–32% of new patients and more than 50% of previously treated patients have multidrug-resistant tuberculosis.
Ninety-three patients with suspected prostate tuberculosis were enrolled in this study and all underwent prostate biopsy. This method allowed confirmation of diagnosis in 32 patients (34.4%): 23 by histology, six by culture and five by polymerase chain reaction (PCR) (among them, two also had positive culture).
The efficiency of an optimized scheme for the therapy of prostate tuberculosis (the second part of the study) was estimated in 53 patients. The first group (25 patients) was treated with a standard scheme of chemotherapy; the second group (28 prostate tuberculosis patients) received ofloxacin in addition for 2 months during the intensive phase. The phase continuation in both groups was identical, with rifampicin and isoniazid administered for 6 months. Optimization of the standard therapy by additional administration of ofloxacin improved results of the treatment in 33.8% of patients.
Advances in the management of Wilms’ tumor have been dramatic over the past half century, not in small part due to the institution of multimodal therapy and the formation of collaborative study groups. While different opinions exist in the management of Wilms’ tumors depending on where one lives and practices, survival rates have surpassed 90% across the board in Western societies. With more children surviving into adulthood, the concerns about morbidity have reached the forefront and now represent as much a consideration as oncologic outcomes these days. Innovations in treatment are on the horizon in the form of potential tumor markers, molecular biological means of testing for chemotherapeutic responsiveness, and advances in the delivery of chemotherapy for recurrent or recalcitrant tumors. Other technological innovations are being applied to childhood renal tumors, such as minimally invasive and nephron-sparing approaches. Risk stratification also allows for children to forego potentially unnecessary treatments and their associated morbidities. Wilms’ tumor stands as a great example of the gains that can be made through protocol-driven therapy with strenuous outcomes analyses. These gains continue to spark interest in minimization of morbidity, while avoiding any compromise in oncologic efficacy. While excitement and innovation are important in the advancement of treatment delivery, we must continue to temper this enthusiasm and carefully evaluate options in order to continue to provide the highest standard of care in the management of this now highly curable disease.
Introduction: A better understanding of ejaculatory disorders has led to an increasing interest in nonpremature ejaculatory dysfunction (non-PE EjD). Current reviews on the subject use a symptom-based classification to describe ejaculatory dysfunction even when it is a single case report. While these reviews provide important information on the disorder, a clearer picture of the prevalence of non-PE EjD in relation to the community and various pathophysiologic states is needed.
Objectives: The objective of this study was to provide a systematic review of studies of non-PE EjD excluding single case reports.
Methods: A systematic review of Medline for terms including ejaculation, orgasm or hematospermia. Association with terms delay, pain or headache was made. The search was restricted to male gender and articles written in English. Abstracts were reviewed and those mainly concerned with premature ejaculation were excluded.
Results: A total of 333 articles on non-PE EjD were identified. The condition was reported in community-based studies. In certain patient populations, non-PE EjD was commonly reported in association with antidepressant and antipsychotic treatments, in patients with chronic prostatitis/chronic pelvic pain syndrome, patients with lower urinary tract symptoms particularly in association with medical or surgical treatment, patients with retroperitoneal surgery and in patients with neurological diseases. Few articles were concerned with treatment options.
Conclusion: There is a significant prevalence of non-PE EjD in the community and in association with particular disease states or as a side effect of medical or surgical interventions. There is a need to direct efforts to prevent and treat these conditions.
Holmium laser enucleation (HoLEP) was developed in the 1990s as a more efficient and cost effective method of benign prostatic hyperplasia surgery than laser vaporization and resection techniques. As a true anatomical enucleation it mimics open prostatectomy and is as durable. There is a significant body of level 1 evidence in support of HoLEP, including 2 meta-analyses and 14 randomized trials which compare HoLEP with a number of other procedures. This review describes the development of and summarizes the evidence for HoLEP.
The use of biomarkers for prostate cancer (PCa) screening, detection, and prognostication have revolutionized the diagnosis and management of the disease. Current clinical practice has been driven largely by the utilization of prostate-specific antigen (PSA). The lack of specificity of PSA for PCa has led to both unnecessary biopsies and overdiagnosis of indolent cancers. The recent controversial recommendation by the United States Preventive Services Task Force against PCa screening has highlighted the need for novel clinically useful biomarkers. We review the literature on PCa biomarkers in serum, urine, and tissue. While these markers show promise, none seems poised to replace PSA, but rather may augment it. Further validation and consideration of how these novel markers improve clinical outcome is necessary. The discovery of new genetic markers shows promise in stratifying men with aggressive PCa.
Focal therapy for prostate cancer is a nascent and emerging field. As such, the patient selection criteria for this new treatment paradigm are evolving in parallel to both the technology on which this approach depends and to our unfolding understanding of the natural history of prostate cancer. Until, and while, prospective trials of focal therapy are being reported, patient selection criteria will be flexible and very dependent on the therapeutic goals. We must carefully define the therapeutic intentions of focal therapy before engaging in the actual process of determining optimal patient selection. The therapeutic intent will define the most appropriate candidate for such therapy. Patient selection encompasses multiple complex issues including the type of prostate biopsy (12 core transrectal versus mapping transperineal) to the type of imaging (multiparametric magnetic resonance imaging or enhanced ultrasound) to the specific anatomical location of the disease within the prostate (apex, mid-prostate, base) and a comprehensive assessment of the patient’s overall health and life expectancy. It is not as simple as saying a patient with a certain grade or a certain number of cores is or is not appropriate for focal therapy. There are many more considerations for a reasonable and thoughtful approach to this new treatment.
The landscape of treatment for advanced/metastatic renal cell carcinoma (mRCC) has advanced significantly in the last decade and continues to evolve with the approval of new drugs targeting the vascular endothelial growth factor (VEGF) and its receptors and mammalian target of rapamycin (mTOR). Currently available oral VEGF tyrosine kinase inhibitors (TKIs) approved for treatment of mRCC include sorafenib, sunitinib, pazopanib, and axitinib. This review focuses on pazopanib, a multikinase VEGF TKI indicated for patients with treatment-naïve and cytokine-refractory mRCC. This article describes the preclinical and clinical evolution of pazopanib, with an emphasis on its development and role in mRCC. Pivotal trials are discussed that demonstrate the efficacy and safety of pazopanib and its important role in the treatment of patients with mRCC in comparison to other available treatment options. The clinical path of pazopanib continues to develop further, with several ongoing studies exploring its role in neoadjuvant and adjuvant RCC. Furthermore, its potential role in sequential and combination studies with other VEGFR and non-VEGFR targeted agents is discussed. Overall, pazopanib is a unique VEGF TKI, with a different and more favorable safety profile compared with other members of the VEGF TKI family and represents an attractive alternative for patients with mRCC.
Prostate cancer (PCa) is a heterogeneous disease with a wide spectrum of aggressiveness. Evidence-based guidelines are invaluable but cannot be expected to be extensive enough to provide detailed guidance on the management of all patients. As such, the use of individualized, risk-adapted approaches to the management of PCa is indispensable. However, wide variation in treatment approaches observed for patients in practice suggests that there is an unmet need to improve the individualized approach towards patient care. A holistic approach that encompasses guidelines and evidence-based medicine could be used to guide individualized care for patients with PCa, from first contact through to final outcomes. As a result of an international expert meeting, this paper proposes this approach and highlights some of the factors that can be considered when aiming to identify patients’ profiles; individualize treatment; and improve communication between patients and the healthcare teams.