C.F. Heyns

TREATMENT OF MALE URETHRAL STRICTURES: IS REPEATED DILATION OR INTERNAL URETHROTOMY USEFUL?

PURPOSEnWe evaluate the efficacy of repeated dilation or urethrotomy as treatment of male urethral strictures.nnnMATERIALS AND METHODSnBetween January 1991 and January 1994, 210 men with proved urethral strictures were prospectively randomized to undergo filiform dilation (106) or internal urethrotomy (104). Followup was scheduled at 3, 6, 9, 12, 24, 36 and 48 months. Dilation or internal urethrotomy was repeated at the first and second stricture recurrence. The Kaplan-Meier method was used to estimate survivor function for the treatment methods (survival time being the time to first stricture recurrence) and the log rank test was used to compare the efficacy of different treatments.nnnRESULTSnFollowup (mean 24 months, range 2 to 63) was available in 163 patients (78%). After a single dilation or urethrotomy not followed by re-stricturing at 3 months, the estimated stricture-free rate was 55 to 60% at 24 months and 50 to 60% at 48 months. After a second dilation or urethrotomy for stricture recurrence at 3 months the stricture-free rate was 30 to 50% at 24 months and 0 to 40% at 48 months. After a third dilation or urethrotomy for stricture recurrence at 3 and 6 months the stricture-free rate at 24 months was 0 (p <0.0001).nnnCONCLUSIONSnDilation and internal urethrotomy are useful in a select group (approximately 70% of all patients) who are stricture-free at 3 months, and of whom 50 to 60% will remain stricture-free up to 48 months. A second dilation or urethrotomy for early stricture recurrence (at 3 months) is of limited value in the short term (24 months) but of no value in the long term (48 months), whereas a third repeated dilation or urethrotomy is of no value.

Prospective evaluation of the American Urological Association symptom index and peak urinary flow rate for the followup of men with known urethral stricture disease.

PURPOSEnWe prospectively evaluated the American Urological Association (AUA) symptom index and maximum urine flow for predicting urethral stricture recurrence in men with a previous diagnosis of urethral stricture disease.nnnMATERIALS AND METHODSnPatients were recruited at our urethral stricture clinic, where all newly diagnosed and previously treated men with urethral stricture present and are treated. The AUA symptom index was completed and uroflowmetry was done. The stricture was calibrated using Jacques catheters. If an 18Fr catheter could not be passed, a retrograde urethrogram was performed. Patients were treated with filiform dilation or direct vision internal urethrotomy. Uroflowmetry was repeated when the catheter was removed 3 days later and the AUA symptom index was repeated 1 month later.nnnRESULTSnData on 49 patients (170 consultations) between March 2000 and August 2001 were analyzed. Average patient age was 48 years. There was a significant negative correlation of urethral diameter with AUA symptom index and of AUA symptom index with maximum urine flow as well as a significant positive correlation of urethral diameter with maximum urine flow. We evaluated the usefulness of AUA symptom index and maximum urine flow at different cutoff levels for predicting urethral stricture in our study group. Using an AUA symptom index of greater than 10 or maximum urine flow of less than 15 ml. per second as cutoff values provided 93% sensitivity, 68% specificity, 78% positive predictive value, 89% negative predictive value and 82% overall accuracy. This method could have prevented further invasive studies in 34% of patients, while a clinically significant stricture would have been missed in only 4.3%.nnnCONCLUSIONSnAUA symptom index combined with maximum urine flow is an accurate, time-saving and cost-effective tool for predicting recurrent stricture in patients with a known urethral stricture. It can be used to direct decision making on further invasive studies and treatment.

Pelvic lipomatosis associated with cystitis glandularis and adenocarcinoma of the bladder

Pelvic lipomatosis is a rare condition characterized by an overgrowth of normal fat in the perivesical and perirectal spaces. Cystitis glandularis, cystica or follicularis has been observed in 75% of the patients with pelvic lipomatosis. Although cystitis glandularis is widely regarded as premalignant few reports have documented its transition to adenocarcinoma. We describe a 41-year-old man with pelvic lipomatosis in whom primary adenocarcinoma of the bladder developed 6 years after a histological diagnosis of cystitis cystica and glandularis was established. To our knowledge this is the second case reported of pelvic lipomatosis associated with proliferative cystitis and adenocarcinoma of the bladder, indicating that intestinal metaplasia of the urothelium may be a precursor of malignancy in these patients.

SIU/ICUD Consultation on Urethral Strictures: Dilation, internal urethrotomy, and stenting of male anterior urethral strictures.

Male urethral stricture is one of the oldest known urologic diseases, and continues to be a common and challenging urologic condition. Our objective was to review all contemporary and historial articles on the topic of dilation, internal urethrotomy, and stenting of male anterior urethral strictures. An extensive review of the scientific literature concerning anterior urethral urethrotomy/dilation/stenting was performed. Articles were included that met the criteria set by the International Consultation on Urological Diseases (ICUD) urethral strictures committee and were classified by level of evidence using the Oxford Centre for Evidence-Based Medicine criteria adapted from the work of the Agency for Health Care Policy and Research as modified for use in previous ICUD projects. Using criteria set forth by the ICUD, a committee of international experts in urethral stricture disease reviewed the literature and created a consensus statement incorporating levels of evidence and expert opinion in regard to dilation, internal urethrotomy, and stenting of male anterior urethral strictures.

Proliferation of Gubernaculum Cells Induced by a Substance of Low Molecular Mass Obtained From Fetal Pig Testes

To investigate the hormonal control of gubernacular development and testicular descent we determined the effect of gonadal extracts and various hormones on the proliferation of gubernaculum cell cultures established from 55 male pig fetuses obtained at 60 to 90 days gestation. The percentage of descended testes was 0 at 60, 8% at 70, 40% at 80 and 87% at 90 days gestation. Significant proliferation (as measured by [3H]thymidine incorporation) of gubernaculum, but not 3T3, cells was induced by crude testicular but not ovarian extracts, and was directly related to its protein concentration. Significant proliferation of gubernaculum cells was induced by low molecular mass (< 30 kD) testicular, but not by high molecular mass (> 30 kD), testicular and low or high molecular mass ovarian extracts obtained by centrifugation of crude extracts in microspin filter membranes with a molecular cut-off mass of 30 kD. Proliferation of gubernaculum cells induced by the low molecular mass (<30 kD) testicular extract was significantly greater than that stimulated by testosterone or dihydrotestosterone. Polyacrylamide gel electrophoresis demonstrated a unique protein band at approximately 26 kD in the crude and low molecular mass testicular, but not in the ovarian, extracts. It is possible that this represents a novel peptide hormone secreted by the fetal testis, responsible for stimulating the growth of the gubernaculum, thereby mediating testicular descent.

Clinical Features of Confirmed Versus Suspected Urogenital Tuberculosis in Region With Extremely High Prevalence of Pulmonary Tuberculosis

OBJECTIVESnTo compare the characteristics of confirmed vs suspected cases of urogenital tuberculosis (UGTB) in a geographic region with an extremely high prevalence of pulmonary tuberculosis. UGTB is notoriously difficult to diagnose.nnnMETHODSnA retrospective clinical record review was performed of 68 patients treated from March 1998 to July 2007. Group 1 (n = 45) had UGTB confirmed by microbiologic or histologic examination. Group 2 (n = 23) had a high suspicion of UGTB because of the clinical features, but no microbiologic or histologic confirmation. The data were collected and statistically analyzed using Students t test for parametric data and Fishers exact test for contingency tables (P < .05 was accepted as statistically significant).nnnRESULTSnThe clinical characteristics were not significantly different statistically, except for flank pain (14% vs 43%), renal cavitation (14% vs 44%), urolithiasis (0% vs 25%), and ureteral stricture formation (7% vs 39%) in groups 1 and 2, respectively. Anti-TB medication was given to 7 patients (30%) in group 2 despite the lack of a confirmed diagnosis. The outcome in terms of complications and renal function loss was not significantly different between the 2 groups.nnnCONCLUSIONSnFlank pain, renal cavitation, urolithiasis, and ureteral stricture formation were significantly more common in the group with suspected UGTB than in those with confirmed UGTB. However, other clinical characteristics did not differ significantly between the 2 groups. In patients with clinical features highly suspicious of UGTB, it appears reasonable to institute anti-TB treatment, despite the lack of a confirmed diagnosis.

A true hermaphrodite with some unusual features

A fifteen-month-old boy with ambiguous external genitalia was found to have a 46XX karyotype, an ovotestis in the right labioscrotal fold, and an absent left gonad. He also had a rudimentary uterus and fallopian tubes and a blind-ending vagina lined with squamous epithelium. These features are compared with those more commonly found in true hermaphroditism.