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1.  High-Intensity Focused Ultrasound in Small Renal Masses 
Advances in Urology  2008;2008:809845.
High-intensity focused ultrasound (HIFU) competes with radiofrequency and cryotherapy for the treatment of small renal masses as a third option among ablative approaches. As an emerging technique, its possible percutaneous or laparoscopic application, low discomfort to the patient and the absence of complications make this technology attractive for the management of small renal masses. This manuscript will focus on the principles, basic research and clinical applications of HIFU in small renal masses, reviewing the present literature. Therapeutic results are controversial and from an clinical view, HIFU must be considered a technique under investigation at present time. Further research is needed to settle its real indications in the management of small renal masses; maybe technical improvements will certainly facilitate its use in the management of small renal masses in the near future.
PMCID: PMC2612759  PMID: 19132094
2.  Sex Cord-Gonadal Stromal Tumor of the Rete Testis 
Advances in Urology  2008;2009:624173.
A 34-year-old tetraplegic patient with suppurative epididymitis was found on follow-up examination and ultrasonography to have a testicular mass. The radical orchiectomy specimen contained an undifferentiated spindled sex cord-stromal tumor arising in the rete testis. Testicular sex cord-stromal tumors are far less common than germ cell neoplasms and are usually benign. The close relationship between sex cords and ductules of the rete testis during development provides the opportunity for these uncommon tumors to arise anatomically within the rete tesis. This undifferentiated sex cord-stromal tumor, occurring in a previously unreported location, is an example of an unusual lesion mimicking an intratesticular malignant neoplasm.
PMCID: PMC2612754  PMID: 19125206
3.  Endourologic Management of Upper Tract Transitional Cell Carcinoma following Cystectomy and Urinary Diversion 
Advances in Urology  2008;2009:976401.
Traditionally, nephroureterectomy is the gold standard therapy for upper tract recurrence of transitional cell carcinoma (TCC) following cystectomy and urinary diversion. With advances in endoscopic equipment and improvements in technique, conservative endourologic management via a retrograde or antegrade approach is technically feasible with acceptable outcomes in patients with bilateral disease, solitary renal units, chronic renal insufficiency, or significant medical comorbidities. Contemporary studies have expanded the utility of these techniques to include low-grade, low-volume disease in patients with a normal contralateral kidney. The aim of this report is to review the current outcomes of conservative management for upper tract disease and discuss its application and relevance in patients following cystectomy with lower urinary tract reconstruction.
PMCID: PMC2610406  PMID: 19125199
4.  Outcome of Treatment of Anterior Vaginal Wall Prolapse and Stress Urinary Incontinence with Transobturator Tension-Free Vaginal Mesh (Prolift) and Concomitant Tension-Free Vaginal Tape-Obturator 
Advances in Urology  2008;2009:341268.
Objective. It is to assess the feasibility, effectiveness, and safety of transobturator tension-free vaginal mesh (Prolift) and concomitant tension-free vaginal tape-obturator (TVT-O) system as a treatment of female anterior vaginal wall prolapse associated with stress urinary incontinence (SUI). Patients and Methods. Between December 2006 and July 2007, 20 patients with anterior genital prolapse and voiding dysfunction were treated with the transobturator tension-free vaginal mesh (Prolift) and concomitant tension-free vaginal tape-obturator (TVT-O). Sixteen patients had stress urinary incontinence and 4 patients were considered at risk for development of de novo stress incontinence after the prolapse is repaired. All patients underwent a complete urodynamic assessment. All the patients underwent pelvic examination 4–6 weeks after the operation, and anatomical and functional outcomes were recorded. Results. Twenty cystocoeles were repaired: 6 grade II, 12 grade III, and 2 grade IV. There were no vessel or bladder injuries. Eighteen patients had optimal anatomic results and 2 patients had persistent asymptomatic stage I prolapse. Conclusion. These preliminary results suggest that Prolift system offers a safe and effective treatment for female anterior vaginal wall prolapse. However, a long-term followup is necessary in order to support the good result maintenance.
PMCID: PMC2610388  PMID: 19125198
5.  A Novel Intraurethral Device Diagnostic Index to Classify Bladder Outlet Obstruction in Men with Lower Urinary Tract Symptoms 
Advances in Urology  2008;2009:406012.
Objectives. Using a urethral device at the fossa navicularis, bladder pressure during voiding can be estimated by a minimal invasive technique. This study purposes a new diagnostic index for patients with lower urinary tract symptoms (LUTSs). Methods. Fifty one patients presenting with LUTSs were submitted to a conventional urodynamic and a minimal invasive study. The results obtained through the urethral device and invasive classic urodynamics were compared. The existing bladder outlet obstruction index (BOOI) equation that classifies men with LUTSs was modified to allow minimal invasive measurement of isovolumetric bladder pressure in place of detrusor pressure at maximum urine flow. Accuracy of the new equation for classifying obstruction was then tested in this group of men. Results. The modified equation identified men with obstruction with a positive predictive value of 68% and a negative predictive value of 70%, with an overall accuracy of 70%. Conclusions. The proposed equation can accurately classify over 70% of men without resorting to invasive pressure flow studies. We must now evaluate the usefulness of this classification for the surgical treatment of men with LUTSs.
PMCID: PMC2610250  PMID: 19125194
6.  BPH Procedural Treatment: The Case for Value-Based Pay for Performance 
Advances in Urology  2008;2008:954721.
The concept of “pay for performance” (P4P) applied to the practice of medicine has become a major foundation in current public and private payer reimbursement strategies for both institutional and individual physician providers. “Pay for performance” programs represent a substantial shift from traditional service-based reimbursement to a system of performance-based provider payment using financial incentives to drive improvements in the quality of care. P4P strategies currently embody rudimentary structure and process (as opposed to outcomes) metrics which set relatively low-performance thresholds. P4P strategies that align reimbursement allocation with “free market” type shifts in cognitive and procedural care using evidence-based data and positive reinforcement are more likely to produce large-scale improvements in quality and cost efficiency with respect to clinical urologic care. This paper reviews current paradigms and, using BPH procedural therapy outcomes, cost, and reimbursement data, makes the case for a fundamental change in perspective to value-based pay for performance as a reimbursement system with the potential to align the interests of patients, physicians, and payers and to improve global clinical outcomes while preserving free choice of clinically efficacious treatments.
PMCID: PMC2605946  PMID: 19125179
7.  Benchmarking the Urology Practice 
Advances in Urology  2008;2008:729204.
The medical practice today is relentlessly challenged by medical progress, by rising costs, and by the mounting pressures of the managed care environment. It should be the approach of every medical practice manager and practitioner to seek out and measure up to the best standards so as to optimize patient care and business outcomes. This requires the resolute pursuit of good models, brought about by the fostering of key collaborative relationships that are both practical and strategic. Integral to this process is benchmarking: the way by which information is obtained from both internal and external sources to determine and set the standards for performance. Benchmarking is an invaluable strategic tool.
PMCID: PMC2605843  PMID: 19107215
8.  The Effect of Patient Arrival Time on Overall Wait Time and Utilization of Physician and Examination Room Resources in the Outpatient Urology Clinic 
Advances in Urology  2008;2008:507436.
Introduction and objective. We examined patient waiting times, physician utilization, and exam room utilization in order to identify process improvements that may improve patient satisfaction. Methods. Time patient arrived to clinic, time patient was placed in the exam room, time the physician arrived in the exam room, and time physician discharged the patient from the exam room were prospectively recorded for 226 outpatient visits. Results. Overall, 63.2% of patients were on time for their scheduled appointment with 14.8% patient “no-shows.” On-time patients were found to have a longer wait time once in the exam room for the physician than those that were late (14.8 ± 9.2 minutes versus 11.0 ± 8.4 minutes, P = .005); however, those patients spent a significantly longer time with the physician (10.7 ± 6.0 minutes versus 8.9 ± 5.8 minutes, P = .041). Exam room utilization was lower for late patients (28.9% versus 44.7%, P = .03) with physician utilization lower in clinics with 3 or more late patients when compared to clinics with 2 or fewer (59.7% versus 68.7%, P = .004). Conclusions. Late patients had significantly less time with the physician than on-time patients. Late patients also decreased the overall efficiency of the clinic; therefore, measures to reduce late patients are vital to improve clinic efficiency.
PMCID: PMC2602945  PMID: 19096713
9.  Comprehensive Management of Upper Tract Urothelial Carcinoma 
Advances in Urology  2008;2009:656521.
Urothelial carcinoma of the upper urinary tract represents only 5% of all urothelial cancers. The 5-year cancer-specific survival in the United States is roughly 75% with grade and stage being the most powerful predictors of survival. Nephroureterectomy with excision of the ipsilateral ureteral orifice and bladder cuff en bloc remains the gold standard treatment of the upper urinary tract urothelial cancers, while endoscopic and laparoscopic approaches are rapidly evolving as reasonable alternatives of care depending on grade and stage of disease. Several controversies remain in their management, including a selection of endoscopic versus laparoscopic approaches, management strategies on the distal ureter, the role of lymphadenectomy, and the value of chemotherapy in upper tract disease. Aims of this paper are to critically review the management of such tumors, including endoscopic management, laparoscopic nephroureterectomy and management of the distal ureter, the role of lymphadenectomy, and the emerging role of chemotherapy in their treatment.
PMCID: PMC2600411  PMID: 19096525
10.  Peyronie's Reconstruction for Maximum Length and Girth Gain: Geometrical Principles 
Advances in Urology  2008;2008:205739.
Peyronie's disease has been associated with penile shortening and some degree of erectile dysfunction. Surgical reconstruction should be based on giving a functional penis, that is, rectifying the penis with rigidity enough to make the sexual intercourse. The procedure should be discussed preoperatively in terms of length and girth reconstruction in order to improve patient satisfaction. The tunical reconstruction for maximum penile length and girth restoration should be based on the maximum length of the dissected neurovascular bundle possible and the application of geometrical principles to define the precise site and size of tunical incision and grafting procedure. As penile rectification and rigidity are required to achieve complete functional restoration of the penis and 20 to 54% of patients experience associated erectile dysfunction, penile straightening alone may not be enough to provide complete functional restoration. Therefore, phosphodiesterase inhibitors, self-injection, or penile prosthesis may need to be added in some cases.
PMCID: PMC2593786  PMID: 19081785
11.  Penile Reconstructive Surgery 
Advances in Urology  2008;2008:564032.
PMCID: PMC2593396  PMID: 19081838
12.  Preservation of Cavernosal Erectile Function after Soft Penile Prosthesis Implant in Peyronie's Disease: Long-Term Followup 
Advances in Urology  2008;2008:646052.
The aim of this retrospective study is to evaluate the long-term followup of soft penile SSDA prosthesis, without plaque surgery in the treatment of Peyronie's disease. This study included 12 men with Peyronie's disease who underwent placement of a penile prosthesis. All patients were followed for at least 6 years. Prosthesis straightened the penile shaft in all cases, restoring patient sexual satisfaction. No operative or postoperative complications occurred, and no reoperations were needed. All patients have undergone further examination with basal and dynamic eco color Doppler. The findings are encouraging as the penis preserves the ability to enhance the tumescence and penile girth. We can conclude that SSDA penile prosthesis is safe and effective in Peyronie's disease.
PMCID: PMC2593409  PMID: 19081839
13.  Genetic Counseling in Renal Masses 
Advances in Urology  2008;2008:720840.
All urologists have faced patients suffering a renal cancer asking for the occurrence of the disease in their offspring and very often the answer to this question has not been well founded from the scientific point of view, and only in few cases a familial segregation tree is performed. The grate shift seen in the detection of small renal masses and renal cancer in the last decades will prompt us to know the indications for familial studies, which and when are necessary, and probably to refer those patients with a suspected familial syndrome to specialized oncological centers where the appropriate molecular and familial studies could be done. Use of molecular genetic testing for early identification of at-risk family members improves diagnostic certainty and would reduce costly screening procedures in at-risk members who have not inherited disease-causing mutations. This review will focus on the molecular bases of familial syndromes associated with small renal masses and the indications of familial studies in at-risk family members.
PMCID: PMC2581790  PMID: 19009041
14.  Laparoscopic Nephroureterectomy: Oncologic Outcomes and Management of Distal Ureter; Review of the Literature 
Advances in Urology  2008;2009:826725.
Introduction. Laparoscopic radical nephroureterectomy (LNU) is being increasingly performed at several centers across the world. We review oncologic outcomes after LNU procedure and the techniques for the management of distal ureter. Materials and Methods. A comprehensive review of the literature was performed on the oncological outcomes and management of distal ureter associated with LNU for upper tract transitional cell carcinoma (TCC). Results and Discussion. LNU for upper tract TCC is performed pure laparoscopically (LNU) or hand-assisted (HALNU). The management of the distal ureter is still debated. LNU appears to have superior perioperative outcomes when compared to open surgery. Intermediate term oncologic outcomes after LNU are comparable to open nephroureterectomy (ONU). Conclusions. Excision of the distal ureter and bladder cuff during nephroureterectomy remains controversial. Intermediate term oncologic outcomes for LNU compare well with ONU. Initial long-term oncologic outcomes are encouraging. Prospective randomized comparison between LNU and open surgery is needed to define the role of these modalities in the current context.
PMCID: PMC2581730  PMID: 19020656
15.  Review of Topical Treatment of Upper Tract Urothelial Carcinoma 
Advances in Urology  2008;2009:472831.
A select group of patients with upper tract urothelial carcinoma may be appropriate candidates for minimally invasive management. Organ-preserving endoscopic procedures may be appropriate for patients with an inability to tolerate major surgery, solitary kidney, bilateral disease, poor renal function, small tumor burden, low-grade disease, or carcinoma in situ. We review the published literature on the use of topical treatment for upper tract urothelial carcinoma and provide our approach to treatment in the office setting.
PMCID: PMC2581728  PMID: 19020655
16.  Laparoscopic Nephroureterectomy: The Distal Ureteral Dilemma 
Advances in Urology  2008;2009:316807.
Transitional cell carcinoma affecting the upper urinary tract, though uncommon, constitutes a serious urologic disease. Radical nephroureterectomy remains the treatment of choice but has undergone numerous modifications over the years. Although the standard technique has not been defined, the laparoscopic approach has gained in popularity in the last two decades. The most appropriate oncological management of the distal ureteral and bladder cuff has been a subject of much debate. The aim of the nephroureterectomy procedure is to remove the entire ipsilateral upper tract in continuity while avoiding extravesical transfer of tumor-containing urine during bladder surgery. A myriad of technical modifications have been described. In this article, we review the literature and present an overview of the options for dealing with the lower ureter during radical nephroureterectomy.
PMCID: PMC2581726  PMID: 19020654
17.  Surveillance for the Management of Small Renal Masses 
Advances in Urology  2008;2008:196701.
Surveillance is a new management option for small renal masses (SRMs) in aged and infirm patients with short-life expectancy. The current literature on surveillance of SRM contains mostly small, retrospective studies with limited data. Imaging alone is inadequate for suggesting the aggressive potential of SRM for both diagnosis and followup. Current data suggest that a computed tomography (CT) or magnetic resonance imaging (MRI) every 3 months in the 1st year, every 6 months in the next 2 years, and every year thereafter, is appropriate for observation. The authors rather believe in active surveillance with mandatory initial and followup renal tumor biopsies than classical observation. Since not all SRMs are harmless, selection criteria for active surveillance need to be improved. In addition, there is need for larger studies in order to better outline oncological outcome and followup protocols.
PMCID: PMC2515364  PMID: 18704192
18.  Familial Syndromes Coupling with Small Renal Masses 
Advances in Urology  2008;2008:413505.
During the past two decades, several new hereditary renal cancers have been discovered but are not yet widely known. Hereditary renal cancer syndromes can lead to multiple bilateral kidney tumors that occur at a younger age than that at which the nonhereditary renal cancers occur. The aim of our work is to review the features of hereditary renal cancers, the basic principles of genetic relevant to these syndromes, and the various histopathologic features of renal cancer. In addition, we will describe the known familial syndromes associated with small renal masses.
PMCID: PMC2495021  PMID: 18695737
19.  Robotic-Assisted Laparoscopic Management of Vesicoureteral Reflux 
Advances in Urology  2008;2008:732942.
Robotic-assisted laparoscopy (RAL) has become a promising means for performing correction of vesicoureteral reflux disease in children through both intravesical and extravesical techniques. We describe the importance of patient selection, intraoperative patient positioning, employing certain helpful techniques for exposure, and recognizing the limitations and potential complications of robotic reimplant surgery. As more clinicians embrace robotic surgery and more urology residents are trained in robotics, we anticipate an expansion of the applications of robotics in children. We believe that it is necessary to develop robotic surgery curricula for novice roboticists and residents so that patients may experience improved surgical outcomes.
PMCID: PMC2494606  PMID: 18682821
20.  Antibiotic Prophylaxis for Children with Primary Vesicoureteral Reflux: Where Do We Stand Today? 
Advances in Urology  2008;2008:217805.
The main goal of the management of vesicoureteral reflux (VUR) is prevention of recurrent urinary tract infections (UTIs), and thereby prevention of renal parenchymal damage possibly ensuing from these infections. Long-term antibiotic prophylaxis is common practice in the management of children with VUR, as recommended in 1997 in the guidelines of the American Urological Association. We performed a systematic review to ascertain whether antibiotics can be safely discontinued in children with VUR and whether prophylaxis is effective in the prevention of recurrent UTIs and renal damage in these patients. Several uncontrolled studies indicate that antibiotic prophylaxis can be discontinued in a subset of patients, that is, school-aged children with low-grade VUR, normal voiding patterns, kidneys without hydronephrosis or scars, and normal anatomy of the urogenital system. Furthermore, a few recent randomized controlled trials suggest that antibiotic prophylaxis offers no advantage over intermittent antibiotic therapy of UTIs in terms of prevention of recurrent UTIs or new renal damage.
PMCID: PMC2494604  PMID: 18682820
21.  The PIC Cystogram: Its Place in the Treatment Algorithm of Recurrent Febrile UTIs 
Advances in Urology  2008;2008:763620.
Purpose. A common pediatric dilemma involves management of children with recurrent febrile urinary tract infections (UTIs) who have normal voiding cystourethrograms. Vesicoureteral reflux (VUR) has been demonstrated in such cases by performing a cystogram which positions the instillation of contrast (PIC) at the ureteral orifice. We describe the evidence supporting this diagnostic test. Materials and Methods. The literature was searched to identify and subsequently evaluate all studies investigating PIC cystography. Results. In patients with febrile UTIs and negative VCUGs, the PIC cystogram has been demonstrated to identify occult reflux (PIC-VUR). When identified and treated, these patients have a significant reduction in the incidence of febrile UTIs. Conclusions. Although the current literature on PIC cystography is limited, it appears to be a clinically useful test in a select group of patients with recurrent febrile UTIs, that are not found to have VUR on a conventional VCUG. A prospective randomized trial is underway to further define its role in the treatment algorithm of febrile UTIs.
PMCID: PMC2494587  PMID: 18682816
22.  Current Status of Gil-Vernet Trigonoplasty Technique 
Advances in Urology  2008;2008:536428.
Significant controversy exists regarding vesicoureteral reflux (VUR) management, due to lack of sufficient prospective studies. The rationale for surgical management is that VUR can cause recurrent episodes of pyelonephritis and long-term renal damage. Several surgical techniques have been introduced during the past decades. Open anti-reflux operations have high success rate, exceeding 95%, and long durability. The goal of this article is to review the Gil-Vernet trigonoplasty technique, which is a simple and highly successful technique but has not gained the attention it deserves. The mainstay of this technique is approximation of medial aspects of ureteral orifices to midline by one mattress suture. A unique advantage of Gil-Vernet trigonoplasty is its bilateral nature, which results in prevention from contralateral new reflux. Regarding not altering the normal course of the ureter in Gil-Vernet procedure, later catheterization of and retrograde access to the ureter can be performed normally. There is no report of ureterovesical junction obstruction following Gil-Vernet procedure. Gil-Vernet trigonoplasty can be performed without inserting a bladder catheter and drain on an outpatient setting. Several exclusive advantages of Gil-Vernet trigonoplasty make it necessary to reconsider the technique role in VUR management.
PMCID: PMC2494586  PMID: 18682815
23.  The Outcome of Surgery versus Medical Management in the Treatment of Vesicoureteral Reflux 
Advances in Urology  2008;2008:437560.
Evaluation of the relative merits of medical versus surgical management of vesicoureteral reflux (VUR) has been limited by the few prospective studies comparing these strategies. Among those trials that have been reported, the only consistent positive finding has been that incidence of febrile UTI is lower among children undergoing surgical treatment in comparison with medical treatment. Studies have not found significant differences in overall incidence of UTI, or in rates of new renal scarring or progression of existing scarring. It is likely that there is a subset of children with VUR who do benefit from aggressive treatment of their VUR, but we are not yet able to fully determine which children these are. It is hoped that future research will further clarify which treatments are useful in which children.
PMCID: PMC2479883  PMID: 18670634
24.  Vesicoureteral Reflux, Reflux Nephropathy, and End-Stage Renal Disease 
Advances in Urology  2008;2008:508949.
Objective. To review the contribution of vesicoureteral reflux and reflux nephropathy to end-stage renal disease. Data Source. Published research articles and publicly available registries. Results. Vesicoureteral reflux (VUR) is commonly identified in pediatric patients and can be associated with reflux nephropathy (RN), chronic kidney disease (CKD), and rarely end-stage renal disease (ESRD). Patients with reduced GFR, bilateral disease, grade V VUR, proteinuria, and hypertension are more likely to progress to CKD and ESRD. Because progression to ESRD is rare in VUR and often requires many decades to develop, there are limited prospective, randomized, controlled trials available to direct therapy to prevent progression to ESRD. Conclusions. Identification of patients with increased risk of progression to CKD and ESRD should be the goal of clinical, biochemical, and radiological evaluation of patients with VUR. Treatment of patients with VUR should be directed at preventing new renal injury and preserving renal function.
PMCID: PMC2478704  PMID: 18670633
25.  Vesicoureteral Reflux and Duplex Systems 
Advances in Urology  2008;2008:651891.
Vesicoureteral reflux (VUR) is the most common anomaly associated with duplex systems. In addition to an uncomplicated duplex system, reflux can also be secondary in the presence of an ectopic ureterocele with duplex systems. Controversy exists in regard to the initial and most definitive management of these anomalies when they coexist. This paper will highlight what is currently known about duplex systems and VUR, and will attempt to provide evidence supporting the various surgical approaches to an ectopic ureterocele and duplex system and the implications of concomitant VUR.
PMCID: PMC2475582  PMID: 18663382

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