The Journal of Urology
Volume 177, Issue 1 , Pages 1-3, January 2007

This Month in Clinical Urology

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Female Urethral Diverticulum 

Female urethral diverticulum is an acquired condition associated with distressing and chronic symptoms, and its recognition is increasing due to the greater awareness of urologists and gynecologists. Irritative symptoms including dysuria, dyspareunia and dribbling are common. In a retrospective review Ljungqvist et al (page 219) from Goteborg, Sweden assessed 68 women who underwent surgical correction. Medical records were reviewed and followup was obtained by telephone interview of 64 available patients. The postoperative course was uneventful in the majority of cases and no complications were noted. Relative stricture of the urethra developed in 1 patient and fistulae developed in 4. There were 11 patients who experienced diverticulum recurrence, 9 of whom underwent reoperation 8 to 36 months after the initial procedure. Urinary incontinence of varying degrees was common (initially in 27 patients) as was dyspareunia. Residual symptoms were common when patients were followed in the long term.

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Combined Electrohydraulic and Holmium:YAG Laser Ureteroscopic Nephrolithotripsy 

Most urologists would agree that percutaneous nephrolithotomy is a standard treatment for renal calculi larger than 2 cm. Flexible ureteroscopes, effective electrohydraulic lithotripsy and the holmium:YAG laser lithotrite have been effective treating branched calculi larger than 4 cm. Mariani (page 168) from Honolulu, Hawaii assessed the safety and efficacy of ureteroscopic nephrolithotripsy monotherapy for large (greater than 4 cm) branched renal calculi in 16 patients. Obesity (body mass index [BMI] greater than 30) was present in 81% of the patients, and 38% were morbidly obese (BMI greater than 40). An infectious etiology of the stone was present in 81% of patients and hard stone components were present in 94%. Lithotripsy was performed with a single deflection flexible ureteroscope, and electrohydraulic lithotripsy was predominantly used. All patients were rendered pain and infection-free, no one required blood transfusion and the serum creatinine remained unchanged. Stone-free status was achieved in 15 of 17 patients (88%) with a mean of 2.4 treatments, and 90% of treatments were performed on an outpatient basis. Operative time averaged 49 minutes per treatment and 115 minutes per calculus. Staged ureteroscopic nephrolithotripsy of large renal calculi is feasible with low morbidity and stone clearance rates that compare favorably with percutaneous nephrolithotomy.

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Demographic and Clinical Characteristics of Chronic Prostatitis 

Chronic prostatitis/pelvic pain syndrome (CP/CPPS) is the most difficult of the 4 currently recognized prostatitis syndromes to diagnose. Diagnosis depends on the presence of characteristic irritative symptoms in the absence of exclusion criteria such as active infections, other urological conditions, pelvic malignancies, chemotherapy, or neurological or gastrointestinal disorders. To better understand this condition, Lee et al (page 153) compared the demographic and clinical characteristics of the University of Sciences Malaysia-Penang Chronic Prostatitis Cohort (USM-CPC) to those of the National Institutes of Health Chronic Prostatitis Cohort (NIH-CPC). All participants met the same criteria for CP/CPPS. The NIH chronic prostatitis symptom index total scores, and pain and urinary subscores were similar for the 332 USM-CPC and 488 NIH-CPC participants. Differences included a worse quality of life subscore for the USM-CPC, location, number of sites and types of pain/discomfort between the 2 populations, and that USM-CPC participants received less prior treatment. The authors conclude that demographic characteristics and clinical presentation of CP/CPPS were similar in these 2 populations. Standardized assessment of varied populations may provide important insights into the factors that determine patient perception of CP/CPPS and perhaps clinical outcome.

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Traditional Foley Catheter Systems and Bladder Drainage 

It is assumed that Foley catheter drainage systems continuously and completely empty the bladder. However, drainage characteristics of the Foley catheter are poorly understood. Garcia et al (page 203) from San Francisco, California investigated unrecognized retained urine with Foley catheter drainage systems by measuring bladder volumes of hospitalized patients (75 in intensive care unit) with bladder scan ultrasound volumetrics. Additionally, an in vitro benchtop mock bladder and urinary catheter system were developed to understand the etiology of residual urine volumes. Mean residual volume was 96 ml (range 4 to 290) in the 75 patients in the intensive care unit and 136 ml (range 22 to 647) in the remaining patients. In the experimental model the authors found that for every 1 cm in tube curling, obstruction pressure increased by 1 cm H2O in the artificial bladder. In contrast, a novel spiral-shaped drainage tube demonstrated rapid (0.5 cc per second), continuous, complete reservoir drainage in all patients. The authors conclude that Foley catheter drainage systems evacuate the bladder suboptimally, and that outlet obstruction is caused by airlocks that develop within curled redundant drainage tubing segments.

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The Role of Medical Simulation in American Urological Residency Training Programs 

Although medical simulation opportunities are increasingly available, resident training to date has primarily involved hands-on subjective assessments. Because the role of simulation and computer based training for urology residents remains unknown, Le et al (page 288) from Rochester, Minnesota evaluated the current status of medical simulation in urological training programs in the United States. An anonymous questionnaire was mailed to 119 accredited United States urology training programs documenting prior experience of the responder with medical simulation, as well as the current status of simulation at their institution. Of the 41 (35%) respondents, 76% had access to a laparoscopy simulator. In comparison, reported access to cystoscopy, ureteroscopy, transurethral resection and percutaneous access simulators was 16%, 21%, 8% and 12%, respectively. Respondents indicated that these simulators were good educational tools, realistic and easy to use. Among the respondents a high level of access to laparoscopic simulators for urology residents was coupled with low levels of access to other endoscopic trainers.

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Quality of Life for Men Undergoing Second Treatment for Prostate Cancer 

Many patients treated initially with radical prostatectomy for localized prostate carcinoma subsequently undergo a second treatment because of disease recurrence. Arredondo et al (page 273) from San Francisco, California analyzed 897 men with localized disease initially treated with radical prostatectomy who completed at least 1 health related quality of life (HRQOL) questionnaire before and after surgery. Of this group 175 men underwent a second treatment including radiation or androgen suppressive therapy. The men who had a second treatment presented for radical prostatectomy with more severe disease and had worse general HRQOL. Although HRQOL differed significantly over time for the 2 groups (radical prostatectomy only vs radical prostatectomy plus second treatment), most domains for the second treatment group improved or remained stable until 15 months before the second treatment, at which point they declined. Scores in sexual functioning and role-physical domains showed clinically and statistically significant patterns of decrease over time. HRQOL is affected following second treatment but starts to decline approximately 1 year before that treatment. Not all aspects of HRQOL are affected and this information is vital to men with prostate cancer who are undergoing radical prostatectomy. (CME credit article)

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Surveillance Protocol following Post-Chemotherapy Retroperitoneal Lymph Node Dissection 

Currently there is no consensus as to the optimal surveillance strategy for patients following post-chemotherapy retroperitoneal lymph node dissection (PC-RPLND). To gain further insight regarding surveillance strategy, Spiess et al (page 131) from Houston, Texas evaluated local and distal recurrence patterns following PC-RPLND. Between 1980 and 2003, 236 patients with clinical stage IIA-III nonseminomatous germ cell testicular tumor underwent PC-RPLND. A total of 38 patients were excluded from analysis because of increased preoperative tumor marker resulting in 198 patients for analysis. Of the 198 patients recurrence developed in 23% and 11% died of disease at a median followup of 41 months (range 6 to 250) after RPLND. The clinical stage of testicular cancer was IIA in 17, IIB in 49, IIC in 83 and III in 49 patients. Of the 45 patients with postoperative recurrence 16 had concomitant multiple sites of recurrence for a total of 64 sites reported. Recurrence was noted in 46.7% of patients with clinical stage III, 40% with stage IIC and 11.8% with stage IIB disease. The most frequent site of recurrence was the chest (49%), followed by the abdomen (22%), supraclavicular lymph nodes (13%), brain (8%) and other sites (5%). Based on the recurrence pattern, the authors propose stage specific surveillance guidelines for the followup of patients after PC-RPLND. (CME credit article)

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The Natural Progression and Remission of Erectile Dysfunction 

Erectile dysfunction (ED) affects more than 150 million men and is strongly associated with cardiovascular disease. Although a 1992 NIH consensus development panel identified ED progression and spontaneous remission as priorities for investigation, there have been few data describing the natural course of this disorder following its initial presentation. Travison et al (page 241) from Watertown, Massachusetts estimated the frequency of ED progression and remission in aging men, and assessed the relation of progression/remission to demographics, socioeconomic factors, comorbidities and modifiable lifestyle characteristics. Data from the Massachusetts Male Aging Study, a longitudinal study of 401 men 40 to 70 years old, were analyzed to assess ED severity following initial presentation of symptoms. ED remission was noted in 141 men (35%), and of 323 men with minimal or moderate baseline ED 33% exhibited ED progression. The 78 patients with complete ED were considered ineligible for progression and 58% of them exhibited complete ED at followup. Natural remission and progression occurred in a substantial number of men with ED. Age and BMI were associated with progression and remission, while smoking and self-assessed health status were associated only with progression, both of which offer potential avenues for facilitating remission and delaying progression through nonpharmacological intervention. (CME credit article)

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Clinical and Psychological Predictors of Erectile Dysfunction in Patients with Type 2 Diabetes 

De Berardis et al (page 252) from S. Maria Imbaro, Italy evaluated predictors of erectile dysfunction in patients with type 2 diabetes mellitus, and identified subgroups of patients in whom the interaction between clinical and psychological characteristics determined an increase in the risk of erectile dysfunction. The presence of erectile dysfunction and the severity of depressive symptoms were investigated in 670 men with a questionnaire completed every 6 months for 3 years. Overall erectile dysfunction developed in 192 cases with an incidence of 166.3 cases per 1,000 person-years. Age, insulin treatment, hemoglobin A1C greater than 8.0%, total cholesterol greater than 3.88 mmol/l and the severity of depressive symptoms represented independent predictors of erectile dysfunction. Patients with low levels of depressive symptoms and hemoglobin A1C 8.0% or less demonstrated the lowest risk of erectile dysfunction. Patients with a higher level of depressive symptoms who were treated with insulin had a 3-fold risk of erectile dysfunction. Age, smoking, high cholesterol levels and neuropathy were globally predictive variables associated with an increased risk of erectile dysfunction. Even in cases of diabetes psychological problems, in addition to organic causes, can contribute to the pathogenesis of erectile dysfunction. (CME credit article)

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Penile Length Changes after Androgen Suppression Plus Radiation for Prostate Cancer 

There appears to be no prospective study to evaluate stretched penile length changes after hormonal therapy plus radiation therapy for localized or locally advanced prostate cancer. Haliloglu et al (page 128) from Ankara, Turkey conducted a prospective study to determine penile length alterations after such treatment. From November 2000 to November 2005, 47 patients were enrolled in this prospective study and after clinical staging all received luteinizing hormone releasing agonist every 3 months for a total of 3 injections. At month 7 of hormonal therapy radiation therapy was begun (70 Gy) for 7 weeks. Stretched penile length measurements were performed before starting androgen suppression therapy and every 3 months thereafter, and with the initiation of therapy a gradual decrease in stretched penile length was observed. Penile shortening was statistically significant at a mean followup of 18 months (mean 14.2 to 8.6 cm, p <0.001). These findings support observations of decreased penile length after neoadjuvant hormone therapy plus external beam radiation therapy for local or locally advanced prostate cancer. Patients should be counseled before therapy that penile shortening may occur. (CME credit article)

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Book Review 

On page 409 Appell reviews Vaginal Surgery.

PII: S0022-5347(06)02521-3

doi:10.1016/j.juro.2006.09.080

The Journal of Urology
Volume 177, Issue 1 , Pages 1-3, January 2007

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