Urinary stone disease is an ailment afflicting human kind for many centuries. It can affect up to a quarter the population in certain geographic areas and hence poses a significant health problem. Various aetiological factors have been attributed to stone formation – hereditary, dietary, geographical, infective etc. Approximately 85% of the stones in human are calcium stones comprising oxalate and phosphate, either alone or combined. Though supersaturation of stone forming salts in urine is essential, abundance of these salts by itself will not always result in stone formation. The pathogenesis of calcium oxalate stone formation is a multi-step process and in essence includes – nucleation, crystal growth, crystal aggregation and crystal retention. Various substances in the body have an effect on one or more of the above stone forming processes, thereby influencing a person's ability to promote or prevent stone formation. Promoters of stone formation facilitate stone formation whilst inhibitors prevent it. Low urine volume, low urine pH, calcium, sodium, oxalate, and urate are known to promote stone formation. Many inorganic (eg. Citrate, magnesium) and organic (eg. Urinary prothrombin fragment 1, glycosaminoglycans, osteopontin) substances are known to inhibit stone formation. Organic inhibitory compounds adsorb to the surface of the crystal, thereby inhibiting crystal growth and nucleation. This review presents a comprehensive account of the basic principles of stone formation and role of urinary inhibitors/promoters in calcium oxalate crystallisation.
The authors review the biologic characteristics of the oral mucosa. In addition, the authors report a contemporary harvesting technique of the oral mucosa for urethral transplantation, using biologically sound principles, modified by current literature. We reviewed pertinent English literature from January 1966 through January 1, 2007 regarding the biologic properties of the oral mucosa. The oral mucosa is made up of a thick, nonkeratinized, squamous cell epithelium, overlying a thin lamina propia. It hosts a number of microorganisms, yet, the tissue's inflammatory response to these organisms is minimal. There are multiple immunologic processes intrinsic to the oral mucosa that makes it impervious to native oral flora colonization. Histologic studies have demonstrated that the oral mucosa is highly compatible with the urethral recipient site, at times being indistinguishable from the surrounding tissue. The harvesting surgeon should closely inspect the oral mucosa for any abnormalities prior to considering harvest. Wound healing in the oral mucosa is ameliorated by sound surgical principles, yet is mediated by biologic processes beyond the surgeon's control. When harvesting oral mucosa, the surgeon is advised to stay well away from pertinent anatomic landmarks to defer any aesthetic or functional defect to the donor site. Success of the oral mucosa graft for urethral surgery can be partially attributed to the tissue's biologic properties. When harvesting the tissue, anatomic landmarks should be considered to provide the best possible treatment for the patient while minimizing morbidity to the donor site.
Since Ulmsten and Petros's original description of the tension-free vaginal tape (TVT) procedure in 1995, the midurethral sling (MUS) has become first-line therapy for correction of female stress urinary incontinence (SUI). Cure rates are high for TVT and the recent tension-free trans-obturator tape (TOT) procedures, and the incidence of side effects is low. In the past few years although several studies have dealt with the incidence and prevalence of MUS-related complications, their surgical management remains an open issue. This paper presents the rationale for surgical management of MUS-linked complications, updates progress in new strategies, and tracks translation of recommendations on vaginal and urethral erosion, postoperative voiding difficulties, and de novo urgency into clinical practice.
Review the literature concerning transperineal transrectal ultrasound (TRUS)-guided prostate biopsy (PBx), providing an update on the topic. The literature review was performed using PubMed through a free text search strategy. The authors reviewed the abstracts of the retrieved records to select the relevant papers. The search retrieved 196 records; 68 were relevant to the issue. No high-level evidence recommends a particular kind of preparation/prophylaxis for transperineal PBx. It can be performed with a brachytherapy template under general or spinal anesthesia, or with a local periprostatic nerve block through a single-access fan technique. In the former case, up to 50 cores are obtained; in the latter, 12–26 cores. Prostate cancer detection rates range from 24% to 51%, with figures of 27–49% in patients undergoing their first PBx for a prostate-specific antigen level of 4–10 ng/ml. Such percentages are directly related to the number of cores obtained. In repeat biopsy and in prostates > 50 cc, the number of cores should be increased, paying particular attention in sampling the anterior zone. Among the studies comparing transrectal and transperineal PBx, only two demonstrated differences in detection rates in favor of the transperineal approach. Major complications are rare, with fever occurring in 0–5.2% and hospitalization in 0–1.4% of cases. Transperineal TRUS-guided PBx is a safe procedure, with high detection rates and wide applications both in first and in repeat sampling. Although having a strong rationale, the transperineal approach has so far not resulted in higher detection rates than transrectal biopsies. Although less used than its transrectal counterpart, transperineal transrectal ultrasound-guided prostate biopsy is a safe procedure, with high detection rates and wide applications both in first and in repeat prostate sampling.
Provide an overview of the use of the sentinel node (SN) technique in prostate carcinoma. The relevance of nodal staging in the several stages of prostate carcinoma, technical aspects of the SN technique, indications, and lessons learned from it are discussed. The lymph node status is relevant in all M0 tumour stages. In early prostate cancer the changes of nodal involvement are so low that invasive diagnostics are superfluous. However, the definition of this early stage is narrowing since the results of extensive node dissection have shown that previously assumed low-risk patients may harbour positive lymph nodes. On the other hand, in locally advanced cases, if the decision for external-beam radiation on the lymph node basins in combination with radiation of the prostate and 3 yr of hormonal therapy has been made, a lymph node dissection seems superfluous. SN dissection may be performed in open surgery or as a laparoscopic technique. A radioactive tracer is injected into the prostate and on γ-camera imaging it is decided which lymph nodes are the possible first landing zones for the prostate tumour. During the radioguided surgery, the excision of the SNs, a handheld γ probe is used to identify the radioactive nodes. On introducing the method in a clinic, it is important to do a conformal extensive pelvic lymph node dissection as well to ensure that logistics and the performance are reliable. SN dissection is as reliable as a diagnostic tool as extended pelvic lymph node dissection. Because it may show cancer-bearing nodes outside of the region of the extended lymph node dissection, such as the presacral area, it may on occasion be even more sensitive. The SN technique is likely to have fewer complications compared to the extended lymph node dissection. On the other hand, an extended lymph node dissection may still be indicated when the SN procedure yields only a few positive lymph nodes and definite cure is still the aim. Weighing the advantages and disadvantages of the laparoscopic versus the open SN technique is not different than in any other procedure. In the near future, sophisticated imaging techniques will identify nodes that are suspicious for micrometastases. This will make minimal invasive methods to confirm the nodal status not superfluous, but more in demand. When the nodal stage is important for treatment decisions, only extended dissections or the SN method will provide accurate staging. The SN procedure is less invasive and will avoid an extensive node dissection in the majority of cases.
The successful use of metal stents (MSs) in the vascular and biliary systems led several investigators to propose their use in urology. In the present study, we review the current literature and present the latest developments with the application of MSs in the urinary tract. The application of MSs in the urinary tract has improved clinical outcome in the treatment of urinary tract strictures and is currently thought to be a useful tool in urology practice. Considerable efforts are being made to optimise stent biomaterial, the coating, and, in general, the ureteral stent design. Continuing the research interest seems to be essential for further clinical improvement, aiming to minimise stent-related morbidity.
Training in laparoscopy is still a challenge for the urologic community. Surgeons in training must learn the laparoscopic techniques, possibly without having ever performed the conventional procedure. In the present study, we provide a nonstructured literature review pertaining to laparoscopic training and discuss the training design and the modular concept. A thorough literature search was performed with the Medline database and different training procedures were analysed. Due to increasing time constraints, cost, stress, and ethical considerations, the modern operating room is not the ideal learning environment. Various simulators and models for laparoscopic training in urology and general surgery with different levels of validity and reliability are available. Wide acceptance of the use simulators has been hampered by the lack of standard and valid methods to measure and certify competence in basic psychomotor skills. Besides, it is unclear if trainees have enough access to these programmes and if they are sufficient enough to develop the required skills. Whether complex urologic procedures can be performed by beginners without open surgical expertise and whether experience in open surgery is definitely required before mastering laparoscopic techniques are still matters of issue. The lack of a standardised, evaluated training procedure needs to be overcome. Structured training programmes and transference of gained experience into daily practice are essential to provide urology with expert laparoscopists.
More than a decade ago, several investigators found serum PSA levels in cancer-free men to correlate directly with age and prostatic volume. This provided the basis for the establishment of age-specific reference ranges for PSA constituting an attempt to improve sensitivity and specificity of serum PSA as a marker for prostate cancer. Differing age-specific reference ranges for PSA were established in whites, African Americans, Asians, and Orientals. Moreover, since the introduction of different molecular forms of PSA with the inherent capability to differentiate between benign and malignant disease, age-specific reference ranges for free and complexed PSA have also been established. Subsequent studies sought to evaluate whether the standard 4.0 ng/ml cutoff should be replaced by age-adjusted cutoffs. Multiple trials involving various test modalities yielded inconclusive results. More recently, attempts were made to integrate principles of PSA density and PSA velocity into concepts of age-adjusted cutoffs for PSA envisioning more sensitive and specific PSA driven screening regimens. Hypothetical approaches involving age in association with prostatic growth or longitudinal data of PSA changes in individual men await further evaluation in prospective clinical trials. In conclusion, the usefulness of age-specific PSA ranges remains controversial because of concerns that the use of age-adjusted cutoffs for counselling men to undergo prostate biopsy runs the risk of missing a high proportion of clinically significant cancers in older men and augments the rate of unnecessary biopsies in younger men.
Chronic Prostatitis Syndrome (CPS) is a frequent disease. Before the PSA era, data from various sources showed that there were more outpatient visits for CPS than for BPH or prostate cancer. CPS has a very negative impact on the patients’ quality of life. However, this debilitating disease stimulates relatively little enthusiasm in the urological world. The classification proposed by the National Institutes of Health is widely adopted. The disease is described as “Chronic Prostatitis/Chronic Pelvic Pain Syndrome” and considers four categories. Category III includes Chronic Inflammatory Prostatitis and Prostatodynia. Universally accepted guidelines for diagnostic work-up are not available; so that the number of cases diagnosed as Chronic Bacterial Prostatitis differs significantly according to the investigations employed by various working groups. The role of Chlamydia and Ureaplasma as causative agents for CPS is still controversial, although many data are in favour of their responsibility in a relatively high number of patients with CPS. Diagnosis of CPS rests fundamentally on symptoms and on the physician's clinical judgement. CPS and interstitial cystitis may share common pathogenetic mechanisms. The first part of this review covers epidemiology, definition, classification, aetiology and physiopathology, natural history, complications, clinical manifestations and diagnostic work-up. Treatment will be dealt with in a subsequent review article.
Renal cell carcinoma (RCC) is the most deadly urological malignancy with only 62% of all patients surviving 5 years in all stages. Approximately 20–30% present initially with metastatic disease as well as 20–40% of patients who will develop systemic spread after surgery. New insights in angiogenesis lead to the development of new drugs directed against receptors and downstream signaling molecules of angiogenetic regulation mechanisms. The results of clinical trials with these drugs will lead to a change of paradigm in the systemic treatment of RCC patients. Specially Sutent, Sorafenib and Temsirolimus proved efficacy in metastatic disease and should be added substantially to the therapeutic armamentarium when surgery of the primary or metastases is impossible.
Since decades plant extracts belong to the most popular drugs for lower urinary tract symptoms (LUTS) due to benign prostatic hyperplasia (BPH)/benign prostatic enlargement (BPE). Herein we review biological mechanisms, the placebo effect, results of clinical trials, the role of meta-analyses and guideline recommendations. Review of the literature with particular reference to long-term (study period ≥6 months) controlled trials and of BPH-guideline recommendations. Only few of the large number of available studies meet the criteria defined by the WHO-BPH consensus conference. The few, placebo-controlled, long-term (study period ≥6 months) studies suggest a positive effect of some extracts (saw palmetto, ß-sitosterol, urtica, saw palmetto/urtica combination) on LUTS, an effect on uroflow, post-void residual volume, prostate volume and PSA was not consistently demonstrable. Randomised trials against active comparators (α1-blocker, 5α-reductase inhibitors) are difficult to interpret. Due to the lack of prospective studies, several meta-analyses have been published that can not replace prospective studies according to WHO-BPH recommendations. None of the BPH-guidelines currently recommends plant extracts, yet universally conclude that this is an interesting approach. Further prospective studies according to WHO-standards are required to reliably determine the role of plant extracts in contemporary LUTS-management.
The role of the pelvic osteotomy at the time of bladder exstrophy closure has been better defined over the past three decades. Modern radiographic imaging provides greater insight into the pelvic bony and muscular defects encountered with these children and has forced surgeons to reconsider the importance of reconstructive efforts beyond the genitourinary tract. Surgical series from several of the world's specialist centers clearly identify the use of osteotomy as a positive predictor for overall success of the management provided to these patients. Osteotomies decrease the tension placed on the soft tissues at the time of initial closure, thereby decreasing the risk of early dehiscence or prolapse. Long-term studies have discovered benefits with respect to urinary continence and orthopedic function when efforts have been made to restore the anatomic integrity of the pelvic muscles and bones. This review summarizes the most current knowledge of anatomy in classic bladder exstrophy and suggests the indications, methods, and expected outcomes for the use of pelvic osteotomies during bladder exstrophy closure. Most of this report derives from the authors’ experience with the modern staged repair of exstrophy at the Johns Hopkins Hospital. However, the benefits of pelvic osteotomies at the time of closure should extend to all patients, regardless of the specific genitourinary reconstructive strategy chosen.