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1.  Hematospermia and xanthogranulomatous prostatitis: An unusual onset of a rare diagnosis 
Canadian Urological Association Journal  2013;7(11-12):E820-E822.
Xanthogranulomatous prostatitis is a rare type of granulomatous prostatitis, with very few cases described. We report the clinical, radiological and pathological findings of 5 cases of xanthogranulomatous prostatitis. All patients came for recurrent episodes of hematospermia (associated with fever in 3 patients). All patients suffered from lower urinary tract symptoms and an increased prostate-specific antigen (PSA) level associated with a suspicious digital rectal examination (DRE); however, at biopsy, the results were negative for xanthogranulomatous prostatitis. Due to persistent severe bladder outlet obstruction, after unsuccessful medical treatments, all patients underwent transurethral resection of prostate (TURP). Final histological examination revealed a xanthogranulomatous prostatitis. The xanthogranulomatous prostatitis can be an incidental finding after TURP and it can simulate prostatic malignancy with PSA elevation.
doi:10.5489/cuaj.1525
PMCID: PMC3879734  PMID: 24475004
2.  Prostate Metastasis of Malignant Melanoma 
Korean Journal of Urology  2013;54(7):486-489.
Metastatic malignant melanoma of the prostate is extremely rare in clinical practice, and only one case has been reported in the English literature in the past 30 years. We report a case of malignant melanoma that metastasized to the prostate and review the current literature. A 50-year-old man with a history of malignant melanoma metastasis to the left axilla, which was excised 3 years ago, presented with lower urinary tract symptoms and gross hematuria. He underwent cystoscopy and transurethral resection of the prostate. The pathological examination showed metastatic malignant melanoma of the prostate gland. The patient died 6 months after the transurethral resection.
doi:10.4111/kju.2013.54.7.486
PMCID: PMC3715715  PMID: 23878694
Melanoma; Neoplasm metastasis; Prostate
3.  An Anteriorly Positioned Midline Prostatic Cyst Resulting in Lower Urinary Tract Symptoms 
Most prostatic cysts are not symptomatic and are found incidentally. There have been some reports of prostatic cysts presenting as an infravesical obstruction. Our case is the second published report of an anteriorly positioned midline prostatic cyst of the bladder neck. The prostatic cyst in a 41-year-old man presenting with lower urinary tract symptoms was located in the anterior and midline area of the prostate and was protruding into the bladder neck at the precise twelve o'clock position. The cyst obstructed the bladder neck by acting like a checking valve. Transurethral resection of the cyst was performed, and the obstructive symptoms successfully improved.
doi:10.5213/inj.2010.14.2.125
PMCID: PMC2989466  PMID: 21120223
Bladder outlet obstruction; Cyst; Prostate; Transurethral resection
4.  Adult posterior urethral valve: a case report 
Introduction: Posterior urethral valve (PUV) is a congenital obstructive defect of the male urethra with an incidence of 1/8,000 to 1/25,000 live births. PUV is the most common cause of lower urinary tract obstruction in neonates. The diagnosis of PUV is usually made early, and PUV cases have rarely been detected in adults.
Case presentation: Here we report the case of a 35 years old man presented with obstructive urinary symptoms. In spite of bladder neck rejection uroflowmetry pointed out infravesical obstruction with max. flow rate 9 ml/s and average flow rate 6 ml/s in uroflowmetry. During cystoscopy mild bladder trabeculation and resected bladder neck were seen. While the cystoscope was taken off, PUV were obtained.
Conclusion: Since PUV is a rare condition in adults and the diagnosis of PUVs is also difficult in these groups we must consider this situation during evaluation of adult patients with obstructive symptoms especially during cystourethroscopy.
doi:10.3205/000097
PMCID: PMC2850585  PMID: 20379394
urethral obstruction; adult; posterior urethral valve
5.  Unroofed Midline Prostate Cyst Misled Into a Stricture With Obliterative Bladder Neck Contracture Following a Laser Prostatectomy 
We report on a case of a 67-year-old man who presented with persistent lower urinary tract symptoms following a potassium titanyl phosphate laser photoselective vaporization of prostate. Upon further diagnostic examinations were performed, he was noted to have an obliterative bladder neck contracture with an incidental, misleading, and rare presence of an unroofed midline anterior prostatic cyst presenting as a stricture. As we were presented with this case, it was imperative to address these complications of bladder neck contracture and incompletely ablated prostatic cyst. This report brings to light underestimated complicating factors in the urinary tract, and the diagnostic and therapeutic interventions we had undertaken to rectify the identified complications and improve patien's quality of life. The patient underwent internal urethrotomy, resection of prostatic cyst wall and transurethral resection of the prostate directed to improve his quality of life and prevent urinary retention.
doi:10.5213/inj.2013.17.1.34
PMCID: PMC3627997  PMID: 23610710
Urinary bladder neck obstruction; Urethra; Prostate; Cysts
6.  Leiomyoma of the bladder presenting as acute urinary retention in a female patient: urodynamic analysis of lower urinary tract symptom; a case report 
BMC Urology  2010;10:13.
Background
Most bladder tumors are derived from the urothelium. Benign mesenchymal tumors are rare. Leiomyoma of the bladder is the most common benign neoplasm. We present a case of leiomyoma of the bladder presenting with acute urinary retention in a female patient and report on the post-operative change in urodynamic findings. To our knowledge, few cases of this kind have been reported.
Case Presentation
A 56-year-old woman presented with acute urinary retention. Evaluations including ultrasound, magnetic resonance imaging, cystoscopy, and urodynamics contributed to a diagnosis of leiomyoma of the bladder. Various medications were ineffective for solving her lower urinary tract symptoms; therefore, a transurethral resection was performed. The final pathological report was leiomyoma. After the operation, her symptoms resolved; this improvement was confirmed by an urodynamic analysis. The postoperative urodynamics demonstrated a lower frequency of detrusor overactivity during filling cystometry and an increase in the uroflow rate, with reduced detrusor pressure in a pressure flow study.
Conclusions
Leiomyoma of the bladder can cause female outlet obstruction. A review of the literature and disease management is discussed.
doi:10.1186/1471-2490-10-13
PMCID: PMC2924335  PMID: 20684762
7.  Acute urinary retention in a patient with extended cystitis glandularis 
Cystitis glandularis (CG) is defined as glandular metaplasia of bladder urothelium. In most cases the course of CG is asymptomatic. However, some patients complain of hematuria and lower urinary tract symptoms (LUTS) of varying degrees. We present a case of 45-year-old man with an extensive CG causing acute urinary retention. Although it was initially treated as an infection, prompt ultrasound and cystoscopy helped to establish the diagnosis. Transurethral resection of the cyst with biopsy of the bladder mucosa was then performed. Immediately after surgery the patient noticed significant improvement in urine passing. During the 2-month follow-up there was no relapse.
doi:10.5173/ceju.2011.02.art11
PMCID: PMC3921714  PMID: 24578874
cystitis glandularis; urinary retention; LUTS
8.  Urinary bladder pyogenic granuloma: a case report 
Introduction
Although more than 100 cases of hemangioma of the urinary bladder have been reported, capillary-type hemangiomas of the bladder are rare. Pyogenic granulomas, which are common tumor-like vascular lesions of the skin and oral mucous membranes, reveal histopathological findings similar to capillary-type hemangiomas and are differentiated from ordinary hemangiomas by clinical features and etiologic factors. Little is known regarding the occurrence of pyogenic granulomas in the urinary bladder.
Case presentation
We present the case of a 78-year-old Japanese man who had developed a hemangiomatous lesion in his bladder which led to acute clot retention. He had a recent history of chemotherapy for pancreatic cancer. A solitary pedunculated mass measuring 1.2 cm was observed in the bladder. Histopathological analysis of the resected mass revealed marked lobular capillary proliferation with surface erosions.
Conclusion
Cystoscopic and pathologic findings in addition to possible predisposing factors supported a diagnosis of pyogenic granuloma of the urinary bladder.
doi:10.1186/1752-1947-6-149
PMCID: PMC3407711  PMID: 22704803
9.  Primary signet-ring cell carcinoma of the urinary bladder successfully managed with cisplatin and gemcitabine: a case report 
Introduction
Primary signet-ring cell carcinoma of the urinary bladder is a rare variant of mucus-producing adenocarcinoma constituting approximately 0.5% to 2.0% of all primary carcinomas of the bladder. This tumor initially presents as a high-grade, high-stage lesion and diffusely invades the bladder wall without forming intraluminal growth. The patients have no specific symptoms, which leads to delayed diagnosis and poor prognosis.
Case presentation
We report the case of a 51-year-old Moroccan Berber man consulting for gross hematuria. Ultrasonography and a computed tomography scan found a bladder tumor diffusely invading the bladder wall. A histopathological examination of the tumor chips from a transurethral resection of the bladder revealed signet-ring cell adenocarcinoma. The gastrointestinal tract exploration did not reveal any other tumor localization. A radical cystectomy and adjuvant cisplatin and gemcitabine chemotherapy were therefore performed resulting in 18 months of survival without metastasis and a good quality of life within that time.
Conclusion
The rarity and the successful management with carboplatin and gemcitabine as adjuvant chemotherapy of this entity, which is rarely reported in the literature, are two remarkable characteristics described in this case report.
doi:10.1186/1752-1947-7-37
PMCID: PMC3571875  PMID: 23388175
Primary signet-ring cell carcinoma; Adenocarcinoma; Urinary bladder; Chemotherapy
10.  Midline intraprostatic cyst: An unusual cause of lower urinary tract symptoms 
Symptomatic prostatic cyst presenting as obstructive lower urinary tract symptoms (LUTS) is an infrequent diagnosis in males. Midline cysts are much more likely to obstruct the bladder outlet. We report our experience with four such cases in the last one year, along with a short review of the literature. Two of these cases had additional presenting symptoms besides LUTS - febrile Urinary tract infection (UTI) with perinephric abscess and primary infertility. One case had an anterior midline prostatic cyst which is an extremely rare entity. The remaining three had midline posterior cysts. All cases were treated with transurethral marsupialization, had good relief of symptoms and no adverse effects.
doi:10.4103/0970-1591.38614
PMCID: PMC2684240  PMID: 19468371
Midline prostatic cyst; prostatic cyst; transurethral incision; transurethral marsupialization
11.  Update on the use of dutasteride in the management of benign prostatic hypertrophy 
Benign prostatic hyperplasia (BPH) is a frequent cause of lower urinary symptoms, with a prevalence of 50% by the sixth decade of life. Hyperplasia of stromal and epithelial prostatic elements that surround the urethra cause lower urinary tract symptoms (LUTS), urinary tract infection, and acute urinary retention. Medical treatments of symptomatic BPH include; 1) the 5α-reductase inhibitors, 2) the α1-adrenergic antagonists, and 3) the combination of a 5α-reductase inhibitor and a α1-adrenergic antagonist. Selective α1-adrenergic antagonists relax the smooth muscle of the prostate and bladder neck without affecting the detrussor muscle of the bladder wall, thus decreasing the resistance to urine flow without compromising bladder contractility. Clinical trials have shown that α1-adrenergic antagonists decrease LUTS and increase urinary flow rates in men with symptomatic BPH, but do not reduce the long-term risk of urinary retention or need for surgical intervention. Inhibitors of 5α-reductase decrease production of dihydrotestosterone within the prostate resulting in decreased prostate volumes, increased peak urinary flow rates, improvement of symptoms, and decreased risk of acute urinary retention and need for surgical intervention. The combination of a 5α-reductase inhibitor and a α1-adrenergic antagonist reduces the clinical progression of BPH over either class of drug alone.
PMCID: PMC2684085  PMID: 18044081
prostatic hyperplasia; 5α-reductase; dutasteride
12.  Combination therapy with dutasteride and tamsulosin for the treatment of symptomatic enlarged prostate 
Benign prostatic hyperplasia (BPH) is a frequent cause of lower urinary symptoms, with a prevalence of 50% by the sixth decade of life. Hyperplasia of stromal and epithelial prostatic elements that surround the urethra cause lower urinary tract symptoms (LUTS), urinary tract infection and acute urinary retention. Medical treatments of symptomatic BPH include; 1) the 5α-reductase inhibitors, 2) the α1-adrenergic antagonists, and 3) the combination of a 5α-reductase inhibitor and a α1-adrenergic antagonist. Selective α1-adrenergic antagonists relax the smooth muscle of the prostate and bladder neck without affecting the detrussor muscle of the bladder wall, thus decreasing the resistance to urine flow without compromising bladder contractility. Clinical trials have shown that α1-adrenergic antagonists decrease LUTS and increase urinary flow rates in men with symptomatic BPH, but do not reduce the long-term risk of urinary retention or need for surgical intervention. Inhibitors of 5α-reductase decrease production of dihydrotestosterone within the prostate resulting in decreased prostate volumes, increased peak urinary flow rates, improvement of symptoms, and decreased risk of acute urinary retention and need for surgical intervention. Interim results of the ongoing Combination of Avodart and Tamsulosin (CombAt) study have shown combination therapy with the 5α-reductase inhibitor dutasteride and the α1-adrenergic antagonist tamsulosin offer significant improvements from baseline compared with either drug alone.
PMCID: PMC2697590  PMID: 19554096
prostatic hyperplasia; 5α-reductase; dutasteride; tamsulosin
13.  Correlation of Male Overactive Bladder with Intravesical Prostatic Protrusion 
Korean Journal of Urology  2010;51(12):843-846.
Purpose
Male overactive bladder (OAB) may be caused by prostatic pathologies such as bladder outlet obstruction (BOO). Intravesical prostatic protrusion (IPP) has been found to correlate with BOO and acute urinary retention. We investigated the interrelation between male OAB symptoms and IPP for estimating anatomical changes to the prostate.
Materials and Methods
We assessed 179 consecutive men aged >40 years who presented with lower urinary tract symptoms. The initial evaluation included International Prostate Symptom Score (IPSS) and quality of life assessments, transrectal ultrasonography (TRUS), uroflowmetry, and postvoid residual urine volume. The degree of IPP was determined by the distance from the tip of the protrusion to the circumference of the bladder at the base of the prostate gland. Patients with IPP <0.5 cm were defined as group A (n=114), and patients having 0.5 cm≤IPP<1 cm were defined as group B (n=38). The others were defined as group C (n=27).
Results
A total of 51 patients complained of urgency in group A, 38 patients in group B, and 27 patients in group C. Likewise, 14 patients had a history of acute urinary retention in group A, 8 patients in group B, and 16 patients in group C. IPP grade had a statistically significant relation with both OAB and a history of acute urinary retention.
Conclusions
The results of our study have shown that male OAB is correlated with IPP. However, larger scale studies are needed to confirm these results.
doi:10.4111/kju.2010.51.12.843
PMCID: PMC3016430  PMID: 21221204
Overactive bladder; Prostatic hyperplasia; Ultrasonography
14.  Bladder neck leiomyoma presenting with acute retention of urine in an elderly female 
Journal of Mid-Life Health  2014;5(1):45-48.
Acute painful retention of urine in a female is uncommon presentations. Bladder neck tumor presenting as acute painful retentions is rare clinical scenario. We present a case of the urinary bladder neck leiomyoma in a 45-year-old peri-menopausal female who presented with acute painful retention of urine without prior history of lower urinary tract symptoms. Patient was managed with cystoscopy and transurethral endoscopic resection of the tumor.
doi:10.4103/0976-7800.127793
PMCID: PMC3955047  PMID: 24672207
Leiomyoma; neoplasm; urinary bladder
15.  An 82-year-old Caucasian man with a ductal prostate adenocarcinoma with unusual cystoscopic appearance: a case report 
Introduction
Ductal adenocarcinoma is a rare variety of the common acinar adenocarcinoma. It usually presents with refractory symptoms, and during cystoscopy, it is seen as an exophytic lesion at the area of the verumontanum.
Case presentation
An 82-year-old Caucasian man was diagnosed with ductal adenocarcinoma of the prostate after undergoing transurethral resection of the prostate for urinary retention. Immunohistochemistry confirmed the nature of the tumor. The patient was treated with triptorelin, 3.75 mg once/month, and bicalutamide, 50 mg 1 × 1. The serum prostate-specific antigen at three, six and 12 months after transurethral resection of the prostate was 0.1 ng/ml. The patient remains asymptomatic, and he entered a six-month follow-up protocol.
Conclusion
Ductal adenocarcinoma often involves the central ducts of the gland and may present as an exophytic papillary lesion in the prostatic urethra. This is why it usually presents with refractory symptoms. The outcome for men with prostatic ductal adenocarcinoma is, in most studies, worse than the outcome for men with prostatic acinar adenocarcinoma. Aggressive management is indicated, even with low-volume metastatic disease.
doi:10.1186/1752-1947-5-4
PMCID: PMC3024288  PMID: 21223563
16.  A Case of Subcutaneous Hemangioma Presenting as a Preauricular Sinus 
Korean Journal of Audiology  2013;17(1):32-34.
Hemangioma is one of the most common benign neoplasm involved on head and neck. However, cavernous hemangiomas are relatively rare in preauricular sinus space and has rarely been reported around the world. Recently, a 44-year-old female patient came to our clinic with cavernous hemangioma involving the preauricular sinus. This case was surgically managed via excision. Preoperatively, it was difficult to differentiate the mass of hemangioma clinically and diagnostically from a preauricular fistula, a salivary gland tumor, or an enchondroma. This case report describes the subcutaneous hemangioma on a preauricular sinus, which is rarely seen in Korea. The clinical presentation and management are discussed with a review of the literature.
doi:10.7874/kja.2013.17.1.32
PMCID: PMC3936520  PMID: 24653902
Preauricular sinus; Hemangioma
17.  Primary Urachal Mucinous Adenocarcinoma of the Urinary Bladder 
Urinary bladder cancer is the second most frequent tumour of the genitourinary tract with bladder adenocarcinoma comprising for about 0.5-2% of all malignant bladder tumours. Other primary sites for such tumours include rectum, stomach, endometrium, breast, prostate, seminal vesicles and ovaries. Such non-urothelial bladder tumours with intramural bladder tumour growth may delay the onset of symptoms which may lead to a delay in the diagnosis and thereby adversely affecting the prognosis as compared to urothelial bladder tumours. Traditionally bladder adenocarcinomas were believed to be resistant to both chemotherapy and radiotherapy, but recent advancements have shown encouraging responses with adjuvant chemotherapy and radiotherapy. We present here a case of primary urachal mucinous adenocarcinoma of the urinary bladder highlighting their relative rarity of occurrence and the difficulties encountered in diagnosing primary bladder mucinous adenocarcinoma.
doi:10.7860/JCDR/2013/5597.2973
PMCID: PMC3681068  PMID: 23814741
Adenocarcinoma urinary bladder; Urachal adenocarcinoma; Cancer bladder
18.  Female urethral diverticulum: cases report and literature 
Introduction
A female urethral diverticulum is an uncommon pathologic entity. It can manifest with a variety of symptoms involving the lower urinary tract. Our objective is to describe the various aspects of the diverticulum of the female urethra such as etiology, diagnosis and treatment.
Cases presentation
We report five female patients, without prior medical history. They had different symptoms: dysuria in four cases, recurrent urinary tract infection in three cases, stress incontinence in two cases and hematuria in two cases. All patients had dyspareunia. The physical exams found renitent mass located in the endovaginal side of urethra which drained pus in two cases. Urethrocystography found a diverticulum of urethra in all cases. Our five patients underwent diverticulotomy by endovaginal approach. The course after surgical treatment was favorable. The urinary catheter was withdrawn after ten days. Some recurrent symptoms were reported.
Conclusion
Evaluation of recurrent urinary complaints in young women can lead to the finding of a diverticulum of urethra. Urethrocystography can reveal this entity. Diverticulectomy by endovaginal approach is the best choice for treatment.
doi:10.1186/1750-1164-8-1
PMCID: PMC3930819  PMID: 24528809
Urethra; Diverticulum; Woman; Diverticulectomy; Endovaginal approach
19.  Hemangioma of penile urethra—treatment with simple transurethral excision: a case report 
Cases Journal  2009;2:6199.
Urethral hemangiomas are rare benign vascular tumors with varying size and usually present as urethral bleeding and/ or hematuria. Treatment depends on the size and site of the lesion. We present a 27 year old male with a two year history of intermittent episodes of urethral bleeding. Cystourethroscopy showed a solitary hemangioma in the penile urethra. The patient was treated with simple transurethral excision with the biopsy forceps. The catheter was removed 48 hours later. He remains symptom free four months later. Simple excision of small hemangiomas may be an effective treatment especially for young patients in order to avoid the side effects of diathermy and when facilities such is laser are not available.
doi:10.4076/1757-1626-2-6199
PMCID: PMC2740086  PMID: 19829771
20.  Metastatic primary neuroendocrine carcinoma of the genitourinary tract: A case report of an uncommon entity 
Patient:
Male, 59
Final Diagnosis:
Neuroendocrine carcinoma of urinary bladder
Symptoms:
Dysuria • hematuria
Medication:
Clinical Procedure:
MRI • cystoscopy
Specialty:
Urology • oncology
Objective:
Rare disease
Background:
Neuroendocrine carcinomas of the genitourinary tract are rare but distinct and important entities because they are very aggressive tumors and are usually advanced or metastatic at the time of diagnosis. A high index of suspicion must be held by the pathologist viewing the specimen, as it can easily be misdiagnosed as a high grade urothelial carcinoma. Specific, proven treatment algorithms have been formulated over the years for the latter, whilst neuroendocrine carcinomas of the genitourinary tract are rare and treatment regimes have not yet been proven to show a significant improvement in survival in the majority of cases, so accurate diagnosis is important.
Case Report:
We report the case of a 59-year-old man who presented with a short history of dysuria and frank hematuria. Imaging and cystoscopy revealed a large exophytic mass in the base of the urinary bladder, which extended into the bladder neck. Metastatic deposits were already present in his liver and vertebrae. Histology revealed a neuroendocrine carcinoma.
Conclusions:
A comprehensive review of the existing literature regarding this rare but aggressive tumor is presented, including advances in classification, pathogenesis, and treatment.
doi:10.12659/AJCR.883908
PMCID: PMC3700487  PMID: 23826453
bladder; neuroendocrine carcinoma; small cell
21.  Inverted Papilloma of the Prostatic Urethra Arising in a Juvenile 
The World Journal of Men's Health  2012;30(3):192-194.
Inverted papilloma of the urinary tract is a rare benign lesion. We report, to our knowledge, the first case of inverted papilloma of the prostatic urethra arising in a juvenile. Our patient was referred for evaluation of painless, gross hematuria and voiding difficulty. Transrectal sonography demonstrated a 1.4 cm papillary lesion on the medial aspect of the prostatic urethra. Cystoscopy showed a solitary, papillary tumor on the prostatic urethra. Transurethral resection was performed and histological examination showed an inverted papilloma.
doi:10.5534/wjmh.2012.30.3.192
PMCID: PMC3623537  PMID: 23596612
Prostate; Papilloma; Inverted; Juvenile
22.  A multicentre single-blind randomized controlled trial comparing bipolar and monopolar transurethral resection of the prostate 
Introduction:
Monopolar transurethral resection of the prostate (TURP) is the gold standard surgical therapy for men with lower urinary tract symptoms due to benign prostatic hyperplasia. Although generally considered safer, TURP experience is limited in Canada.
Methods:
Forty-three patients from 5 Canadian centres were randomized to TURP with either bipolar or monopolar platforms. Patients underwent baseline determinations of American Urological Association (AUA) symptom score, peak urinary flow rate, post-void residual bladder volume and transrectal ultrasound prostate volume. Primary outcome measures were improvement in AUA symptom score, quality of life assessment and bother assessment. Secondary outcomes included procedural times, duration of catheterization, length of hospitalization, complications and the degree of thermal artifact in tissue specimens. Patients were followed for 6 months.
Results:
Twenty-two patients were treated with bipolar and 21 with monopolar TURP. Preoperative demographics were not statistically different between groups. Postoperative data collection times were equivalent in AUA symptom, quality of life, bother and sexual function assessments. No differences were observed in the procedure time (60.7 min, bipolar vs. 47.4, monopolar) or the duration of urethral catheterization (1.5 days, bipolar vs. 1.1, monopolar). More patients in the bipolar group were discharged on the same day of surgery. There were no differences in the degree of tissue thermal artifact or complication rate.
Conclusion:
This trial suggests equivalent short-term outcomes for men undergoing monopolar or bipolar TURP.
doi:10.5489/cuaj.10199
PMCID: PMC3235201  PMID: 22154630
23.  Energy Delivery Systems for Treatment of Benign Prostatic Hyperplasia 
Executive Summary
Objective
The Ontario Health Technology Advisory Committee asked the Medical Advisory Secretariat (MAS) to conduct a health technology assessment on energy delivery systems for the treatment of benign prostatic hyperplasia (BPH).
Clinical Need: Target Population and Condition
BPH is a noncancerous enlargement of the prostate gland and the most common benign tumour in aging men. (1) It is the most common cause of lower urinary tract symptoms (LUTS) and bladder outlet obstruction (BOO) and is an important cause of diminished quality of life among aging men. (2) The primary goal in the management of BPH for most patients is a subjective improvement in urinary symptoms and quality of life.
Until the 1930s, open prostatectomy, though invasive, was the most effective form of surgical treatment for BPH. Today, the benchmark surgical treatment for BPH is transurethral resection of the prostate (TURP), which produces significant changes of all subjective and objective outcome parameters. Complications after TURP include hemorrhage during or after the procedure, which often necessitates blood transfusion; transurethral resection (TUR) syndrome; urinary incontinence; bladder neck stricture; and sexual dysfunction. A retrospective review of 4,031 TURP procedures performed by one surgeon between 1979 and 2003 showed that the incidence of complications was 2.4% for blood transfusion, 0.3% for TUR syndrome, 1.5% for hemostatic procedures, 2.8% for bladder neck contracture, and 1% for urinary stricture. However, the incidence of blood transfusion and TUR syndrome decreased as the surgeon’s skills improved.
During the 1990s, a variety of endoscopic techniques using a range of energy sources have been developed as alternative treatments for BPH. These techniques include the use of light amplification by stimulated emission of radiation (laser), radiofrequency, microwave, and ultrasound, to heat prostate tissue and cause coagulation or vaporization. In addition, new electrosurgical techniques that use higher amounts of energy to cut, coagulate, and vaporize prostatic tissue have entered the market as competitors to TURP. The driving force behind these new treatment modalities is the potential of producing good hemostasis, thereby reducing catheterization time and length of hospital stay. Some have the potential to be used in an office environment and performed under local anesthesia. Therefore, these new procedures have the potential to rival TURP if their effectiveness is proven over the long term.
The Technology Being Reviewed
The following energy-based techniques were considered for assessment:
transurethral electrovaporization of the prostate (TUVP)
transurethral electrovapor resection of the prostate (TUVRP)
transurethral electrovaporization of the prostate using bipolar energy (plasmakinetic vaporization of the prostate [PKVP])
visual laser ablation of the prostate (VLAP)
transurethral ultrasound guided laser incision prostatectomy (TULIP)
contact laser vaporization of the prostate (CLV)
interstitial laser coagulation (ILC)
holmium laser resection of the prostate (HoLRP)
holmium laser enucleation of the prostate (HoLEP)
holmium laser ablation of the prostate (HoLAP)
potassium titanyl phosphate (KTP) laser
transurethral microwave thermotherapy (TUMT)
transurethral needle ablation (TUNA)
Review Strategy
A search of electronic databases (OVID MEDLINE, MEDLINE In-Process & Other Non-Indexed Citations, EMBASE, The Cochrane Library, and the International Agency for Health Technology Assessment [INAHTA] database) was undertaken to identify evidence published from January 1, 2000 to June 21, 2006. The search was limited to English-language articles and human studies. The literature search identified 284 citations, of which 38 randomized controlled trials (RCTs) met the inclusion criteria.
Since the application of high-power (80 W) KTP laser (photoselective vaporization of the prostate [PVP]) has been supported in the United States and has resulted in a rapid diffusion of this technology in the absence of any RCTs, the MAS decided that any comparative studies on PVP should be identified and evaluated. Hence, the literature was searched and one prospective cohort study (3) was identified but evaluated separately.
Findings of Literature Review and Analysis
Meta-analysis of the results of RCTs shows that monopolar electrovaporization is as clinically effective as TURP for the relief of urinary symptoms caused by BPH (based on 5-year follow-up data).
Meta-analysis of the results of RCTs shows that bipolar electrovaporization (PKVP) is clinically as effective as TURP for the relief of urinary symptoms caused by BPH (based on 1-year follow-up data).
Two of the three RCTs on VLAP have shown that patients undergoing VLAP had a significantly lesser improvement in urinary symptom scores compared with patients undergoing TURP.
RCTs showed that the time to catheter removal was significantly longer in patients undergoing VLAP compared with patients undergoing TURP.
Meta-analysis of the rate of reoperation showed that patients undergoing VLAP had a significantly higher rate of reoperation compared with patients undergoing TURP.
Meta-analysis showed that patients undergoing CLV had a significantly lesser improvement in urinary symptom scores compared with TURP at 2 years and at 3 or more years of follow-up.
Two RCTs with 6-month and 2-year follow-up showed similar improvement in symptom scores for ILC and TURP.
Time to catheter removal was significantly longer in patients undergoing ILC compared with patients undergoing TURP.
The results of RCTs on HoLEP with 1-year follow-up showed excellent clinical outcomes with regard to the urinary symptom score and peak urinary flow.
Meta-analysis showed that at 1-year follow-up, patients undergoing HoLEP had a significantly greater improvement in urinary symptom scores and peak flow rate compared with patients undergoing TURP.
Procedural time is significantly longer in HoLEP compared with TURP.
The results of one RCT with 4-year follow-up showed that HoLRP and TURP provided equivalent improvement in urinary symptom scores.
The results of one RCT with 1-year follow-up showed that patients undergoing KTP had a lesser improvement in urinary symptom scores than did patients undergoing TURP. However, the results were not significant at longer-term follow-up periods.
Two RCTs that provided 3-year follow-up data reported that patients undergoing TUMT had a significantly lesser improvement in symptom score compared with patients undergoing TURP.
RCTs reported a longer duration of catheterization for TUMT compared with TURP (P values are not reported).
The results of a large RCT with 5-year follow-up showed a significantly lesser improvement in symptom scores in patients undergoing TUNA compared with patients undergoing TURP.
Meta-analysis of the rate of reoperation showed that patients undergoing TUNA had a significantly higher rate of reoperation compared with patients undergoing TURP.
Based on the results of RCTs, TURP is associated with a 0.5% risk of TUR syndrome, while no cases of TUR syndrome have been reported in patients undergoing monopolar or bipolar electrovaporization, laser-based procedures, TUMT, or TUNA.
Based on the results of RCTs, the rate of blood transfusion ranges from 0% to 8.3% in patients undergoing TURP. The rate is about 1.7% in monopolar electrovaporization, 1.4% in bipolar electrovaporization, and 0.4% in the VLAP procedure. No patients undergoing CLV, ILC, HoLEP, HoLRP, KTP, TUMT, and TUNA required blood transfusion.
The mean length of hospital stay is between 2 and 5 days for patients undergoing TURP, about 3 days for electrovaporization, about 2 to 4 days for Nd:YAG laser procedures, and about 1 to 2 days for holmium laser procedures. TUMT and TUNA can each be performed as a day procedure in an outpatient setting (0.5 and 1 day respectively).
Based on a prospective cohort study, PVP is clinically as effective as TURP for the relief of urinary symptoms caused by BPH (based on 6-month follow-up data). Time to catheter removal was significantly shorter in patients undergoing PVP than in those undergoing TURP. Operating room time was significantly longer in PVP than in TURP. PVP has the potential to reduce health care expenses due to shorter hospital stays.
Economic Analysis
In the three most recent fiscal years (FY) reported, an average of approximately 5,000 TURP procedures per year were performed in Ontario. From FY 2002 to FY 2004, the total number of surgical interventions decreased by approximately 500 procedures. During this time, the increase in costs of drugs to the government was estimated at approximately $10 million (Cdn); however, there was a concurrent decrease in costs due to a decline in the total number of surgical procedures, estimated at approximately $1.9 million (Cdn). From FY 2002 to FY 2004, the increase in costs associated with the increase in utilization of drugs for the treatment of BPH translates into $353 (Cdn) per patient while the cost savings associated with a decrease in the total number of surgical procedures translates into a savings of $3,906 (Cdn) per patient.
The following table summarizes the change in the current budget, depending on various estimates of the total percentage of the 5,000 TURP procedures that might be replaced by other energy-based interventions for the treatment of BPH in the future.
Budget Impact With Various Estimates of the Percentage of TURP Procedures Captured by Energy-based Interventions for the Treatment of BPH
All costs are in Canadian currency. Parentheses indicative of cost reduction.
PMCID: PMC3379165  PMID: 23074487
24.  Small Cell Neuroendocrine Carcinoma of the Urinary Tract Successfully Managed with Neoadjuvant Chemotherapy 
Case Reports in Urology  2013;2013:598325.
Introduction. Small cell neuroendocrine carcinomas of the urinary tract is an extremely rare entity and very few cases have been reported in the literature. Small cell neuroendocrine carcinoma of the urinary tract (SCC-UT) is the association between bladder and urinary upper tract-small cell carcinoma (UUT-SCC). It characterized by an aggressive clinical course. The prognosis is poor due to local or distant metastases, and usually the muscle of the bladder is invaded. Case Presentation. We report a rare case of a 54-year-old Arab male native of moroccan; he is a smoker and was referred to our institution for intermittent hematuria. Following a diagnosis of small cell neuroendocrine carcinomas of the ureter and the bladder, thoracoabdominal-pelvic CT was done, and the staging of the tumor was done in the bladder (T2N0M0) and (T1N0M0) in the ureter. Neoadjuvant alternating doublet chemotherapy with ifosfamide/doxorubicin and etoposide/cisplatin was realized, and nephroureterectomy associated to a cystoprostatectomy was carried out. After 24 months of followup, no local or distant metastasis was detected. Conclusion. The purpose of this review is to present a rare case of pure small cell neuroendocrine carcinoma of the urinary tract and review the literature about the place of neoadjuvant chemotherapy in this rare tumors.
doi:10.1155/2013/598325
PMCID: PMC3759270  PMID: 24024065
25.  Degeneration of the symphysis pubis presenting as a submucosal urinary bladder tumour 
Urinary bladder sonography is a sensitive diagnostic technique used for visualizing urinary bladder tumours. The aim of our communication is to present a case of a pseudotumour of the urinary bladder originating from the symphysis pubis syndesmosis. A 58-year-old woman was seen by a urologist with symptoms of lower urinary tract infection. Urinary bladder sonography was performed, followed by magnetic resonance imaging. Sonographic images of the bladder showed an exophytic mass on the urinary bladder's anterior wall. A transurethral resection of the tumour was performed. A histopathological examination revealed a necrotic extramural mass, without traits of malignancy. The mass reappeared in the follow-up vesical sonography. Subsequently, its transurethral resection was repeated with the same histopathological findings. The next urinary bladder sonography revealed the presence of the mass again. Pelvic magnetic resonance imaging was performed, which showed advanced degenerative changes in the pubic symphysis syndesmosis that protruded into the bladder, imitating a urinary bladder tumour. To avoid unnecessary surgery, both radiologists and urologists should be made aware that there is a possibility of similar cases in patients. Magnetic resonance imaging enabled correct determination of the primary site of the growth, which, together with the histopathological examination results, influenced the choice of the implemented therapeutic procedures.
doi:10.5114/wiitm.2011.25622
PMCID: PMC3516965  PMID: 23256002
urinary bladder; ultrasound; magnetic resonance imaging; transurethral resection of the bladder tumour

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