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1.  Finasteride in the treatment of clinical benign prostatic hyperplasia: A systematic review of randomised trials 
BMC Urology  2002;2:14.
Benign prostatic hyperplasia affects older men. This systematic review determined efficacy and adverse effects of finasteride.
Review methods
PubMed, the Cochrane Library, reference lists of reports, and reviews were searched for randomised, double-blind trials of finasteride in benign prostatic hyperplasia. Outcomes included symptom score, urinary flow rate, prostate volume, discontinuation, and adverse effects. Relative risk and NNT or NNH were calculated for dichotomous data. Sensitivity analyses assessed influences of baseline symptom severity, initial prostate volume, a dominating trial, and previous interventions.
Three trials had active controls and 19 had placebo. In placebo-controlled trials, 8820 patients received finasteride 5 mg and 5909 placebo over 3–48 months. Over 48 months finasteride produced greater improvements in total symptom score, maximum urinary flow rate, and prostate volume. Significantly more sexual dysfunction, impotence, ejaculation disorder and decreased libido occurred with finasteride at 12 months; the NNH for any sexual dysfunction at 12 months was 14. Significantly fewer men treated with finasteride experienced acute retention or had surgery at 24 or 48 months than with placebo; at 12 months the NNT was 49 (31 to 112) to avoid one acute urinary retention and 31 (21 to 61) to avoid one surgery. Sensitivity analyses showed benefit with finasteride 5 mg to be constant irrespective of the initial prostate volume.
Information from many patients in studies of high quality showed beneficial effects of finasteride in terms of symptoms, flow rate and prostate volume. More utility would result if patient centred outcomes were reported in dichotomous form.
PMCID: PMC140032  PMID: 12477383
2.  Leiomyosarcoma presenting as a spontaneously ruptured renal tumor-case report 
BMC Urology  2002;2:13.
Ruptured renal neoplasms can be a catastrophic clinical presentation. Angiomyolipoma is the commonest renal tumor which presents in this fashion. Renal sarcomas are rare renal neoplasms. Renal leiomyosarcomas are the most common histological subtype of renal sarcomas, accounting for approximately 50–60% of the reported cases. These tumors are usually peripherally located and appear to arise from either the renal capsule or smooth muscle tissue in the renal pelvic wall.
Case presentation
A 70 years old male, with hypertension and ischemic disease, developed acute left flank pain. The general physician evaluated this using ultrasound, which showed a solid left renal mass. Two weeks later, he presented in the emergency room in a state of shock with a palpable flank mass. CT scan of the abdomen showed a large heterogeneous mass lesion in the left perinephric space with minimal post contrast enhancement. Per-operatively, large retroperitoneal hematoma was found within Gerota's fascia along with spleen plastered to the upper limit of hematoma. Nephrectomy and splenectomy were performed. Postoperative course was uneventful and patient was discharged on the 10th post-operative day. Histopathological evaluation of the specimen showed high-grade leiomyosarcoma
Spontaneous rupture of renal neoplasm is a rare clinical presentation. Angiomyolipoma is the commonest cause of spontaneous rupture of the kidney. Presentation of a leimyosarcoma as a ruptured renal neoplasm has not been previously reported in the English literature.
PMCID: PMC138801  PMID: 12441005
Non-traumatic; kidney rupture; kidney tumor; sarcoma
3.  Long-term result of Memokath urethral sphincter stent in spinal cord injury patients 
BMC Urology  2002;2:12.
Memokath urethral sphincter stents are used to facilitate bladder emptying in patients with spinal cord injury, but long term follow-up has not been reported.
Case series of ten men with spinal cord injury who underwent insertion of Memokath stents and were followed for up to nine years.
Within four years, the stent had to be removed in nine out of ten patients because of: extensive mucosal proliferation causing obstruction to the lumen of the stent; stone around the proximal end of the stent, incomplete bladder emptying, and recurrent urinary infections; migration of the stent into the bladder related to digital evacuation of bowels; large residual urine; concretions within the stent causing obstruction to flow of urine, and partial blockage of the stent causing frequent episodes of autonomic dysreflexia. In one patient the stent continued to function satisfactorily after nine years.
The Memokath stent has a role as a temporary measure for treatment of detrusor-sphincter dyssynergia in selected SCI patients who do not get recurrent urinary infection and do not require manual evacuation of bowels.
PMCID: PMC137607  PMID: 12427256
4.  Single session endoscopic management of intrinsic ureteropelvic junction obstruction and concomitant renal stone disease in a child: a case report 
BMC Urology  2002;2:11.
Percutaneous nephrolithotomy is a well known therapeutic modality for stone diseases of childhood. Antegrade and retrograde endopyelotomies are also well defined options of treatment for secondary ureteropelvic junction obstruction. Yet there are few reports regarding endoscopic therapy of intrinsic ureteropelvic junction obstruction. To our knowledge, there exist only a few reports of endosurgical treatment of children with stone disease and with concomitant intrinsic ureteropelvic junction obstruction, in the literature.
Case presentation
We present the endoscopic management of stone disease and concomitant intrinsic ureteropelvic junction obstruction of a child in one session.
Percutaneous nephrolithotomy and antegrade endopyelotomy is combined safely with successful outcome in a child.
PMCID: PMC130023  PMID: 12296974
5.  Severe renal bleeding caused by a ruptured renal sheath: case report of a rare complication of percutaneous nephrolithotomy 
BMC Urology  2002;2:10.
Percutaneous nephrolithotomy is a minimally invasive intervention for renal stone disease. Complications, which are rare and usually presented as case reports, are diversified as the utilization of the procedure is expanded. The procedure causes less blood loss and less morbidity when compared to open surgical procedures. Yet, there are some reports involving severe bleeding and relevant morbidity during surgery. These are usually related with the surgical technique or experience of the surgeon.
Renal sheaths are designed to cause minimal trauma inside the kidney and, to our knowledge, there are no reports presenting the rupture of a sheath causing severe bleeding during the procedure.
Case report
We present an adult patient who had severe bleeding during percutaneous nephrolithotomy due to parenchymal injury caused by a ruptured renal sheath. During retrieval, due probably to rough handling of the equipment, a piece of stone with serrated edges ruptured the tip of the sheath, and this tip caused damage inside the kidney. The operation was terminated and measures were taken to control bleeding. The patient was transfused with a total of 1600 ml of blood, and the stones were cleared in a second look operation.
Although considered to be a minimally invasive procedure, some unexpected complications may arise during percutaneous nephrolithotomy. After being fragmanted, stone pieces may damage surgical equipment, causing acute and severe harm to the kidney. Surgeons must manipulate the equipment with fine and careful movements in order to prevent this situation.
PMCID: PMC128810  PMID: 12236904
6.  How should an infected perinephric haematoma be drained in a tetraplegic patient with baclofen pump implanted in the abdominal wall? – A case report 
BMC Urology  2002;2:9.
We present a case to illustrate controversies in percutaneous drainage of infected, perinephric haematoma in a tetraplegic patient, who had implantation of baclofen pump in anterior abdominal wall on the same side as perinephric haematoma.
Case presentation
A 56-year-old male with C-4 tetraplegia had undergone implantation of programmable pump in the anterior abdominal wall for intrathecal infusion of baclofen to control spasticity. He developed perinephric haematoma while he was taking warfarin as prophylactic for deep vein thrombosis. Perinephric haematoma became infected with a resistant strain of Pseudomonas aeruginosa, and required percutaneous drainage. Positioning this patient on his abdomen without anaesthesia, for insertion of a catheter from behind, was not a realistic option. Administration of general anaesthesia in this patient in the radiology department would have been hazardous.
Results and Conclusion
Percutaneous drainage was carried out by anterior approach under propofol sedation. The site of entry of percutaneous catheter was close to cephalic end of baclofen pump. By carrying out drainage from anterior approach, and by keeping this catheter for ten weeks, we took a risk of causing infection of the baclofen pump site, and baclofen pump with a resistant strain of Pseudomonas aeruginosa. The alternative method would have been to anaesthetise the patient and position him prone for percutaneous drainage of perinephric collection from behind. This would have ensured that the drainage track was far away from the baclofen pump with minimal risk of infection of baclofen pump, but at the cost of incurring respiratory complications in a tetraplegic subject.
PMCID: PMC128809  PMID: 12220481
7.  Problems in early diagnosis of bladder cancer in a spinal cord injury patient: Report of a case of simultaneous production of granulocyte colony stimulating factor and parathyroid hormone-related protein by squamous cell carcinoma of urinary bladder 
BMC Urology  2002;2:8.
Typical symptoms and signs of a clinical condition may be absent in spinal cord injury (SCI) patients.
Case presentation
A male with paraplegia was passing urine through penile sheath for 35 years, when he developed urinary infections. There was no history of haematuria. Intravenous urography showed bilateral hydronephrosis. The significance of abnormal outline of bladder was not appreciated. As there was large residual urine, he was advised intermittent catheterisation. Serum urea: 3.5 mmol/L; creatinine: 77 umol/L. A year later, serum urea: 36.8 mmol/l; creatinine: 632 umol/l; white cell count: 22.2; neutrophils: 18.88. Ultrasound: bilateral hydronephrosis. Bilateral nephrostomy was performed. Subsequently, blood tests showed: Urea: 14.2 mmol/l; Creatinine: 251 umol/l; Adjusted Calcium: 3.28 mmol/l; Parathyroid hormone: < 0.7 pmol/l (1.1 – 6.9); Parathyroid hormone-related protein (PTHrP): 2.3 pmol/l (0.7 – 1.8). Ultrasound scan of urinary bladder showed mixed echogenicity, which was diagnosed as debris. CT of pelvis was interpreted as vesical abscess. Urine cytology: Transitional cells showing mild atypia. Bladder biopsy: Inflamed mucosa lined by normal urothelial cells.
A repeat ultrasound scan demonstrated a tumour arising from right lateral wall; biopsy revealed squamous cell carcinoma. In view of persistently high white cell count and high calcium level, immunohistochemistry for G-CSF and PTHrP was performed. Dense staining of tumour cells for G-CSF and faintly positive staining for C-terminal PTHrP were observed. This patient expired about five months later.
This case demonstrates how delay in diagnosis of bladder cancer could occur in a SCI patient due to absence of characteristic symptoms and signs.
PMCID: PMC126229  PMID: 12201902
8.  A study of cytokeratin 20 immunostaining in the urothelium of neuropathic bladder of patients with spinal cord injury 
BMC Urology  2002;2:7.
Normal urothelium is characterised by terminally differentiated superficial cells, which express cytokeratin 20 in the cytoplasm. In contrast, cultured human stratified urothelium, which does not undergo complete terminal differentiation of its superficial cells, does not express cytokeratin 20. If spinal cord injury (SCI) affects urothelial differentiation or induces squamous or other metaplastic change undetected by histological analysis, the superficial urothelial cells of the neuropathic bladder might be expected to show absence of immunostaining for cytokeratin 20.
Patients and Methods
We studied immunostaining for cytokeratin 20 in bladder biopsies taken from 63 consecutive SCI patients. Immunostaining was performed on paraffin-embedded tissue using a mouse monoclonal antibody (clone: Ks20.8).
Of 63 biopsies, the epithelium was scarce in two. Eight biopsies showed squamous metaplasia and immunostaining for cytokeratin 20 was absent in all the eight biopsies. Of the remaining 53 cases, in which the umbrella cell layer of the urothelium was intact, immunostaining for cytokeratin 20 was seen only in ten biopsies.
Superficial cells in the transitional epithelium showed immunostaining for cytokeratin 20 in 10 of 53 bladder biopsies taken from SCI patients. The reasons for this could be either that there is an underlying metaplasia or that changes in the neuropathic bladder affect urothelial differentiation. Taken with evidence from other systems, such as loss of cytokeratin 20 expression from static organ cultures of urothelial tissue, this might suggest that other factors, such as impairment of voluntary voiding in SCI patients, could affect expression of markers such as cytokeratin 20.
PMCID: PMC125297  PMID: 12147174
9.  Sildenafil (Viagra) for male erectile dysfunction: a meta-analysis of clinical trial reports 
BMC Urology  2002;2:6.
Evaluation of company clinical trial reports could provide information for meta-analysis at the commercial introduction of a new technology.
Clinical trial reports of sildenafil for erectile dysfunction from September 1997 were used for meta-analysis of randomised trials (at least four weeks duration) and using fixed or dose optimisation regimens. The main outcome sought was an erection, sufficiently rigid for penetration, followed by successful intercourse, and conducted at home.
Ten randomised controlled trials fulfilled the inclusion criteria (2123 men given sildenafil and 1131 placebo). NNT or NNH were calculated for important efficacy, adverse event and discontinuation outcomes. Dose optimisation led to at least 60% of attempts at sexual intercourse being successful in 49% of men, compared with 11% with placebo; the NNT was 2.7 (95% confidence interval 2.3 to 3.3). For global improvement in erections the NNT was 1.7 (1.6 to 1.9). Treatment-related adverse events occurred in 30% of men on dose optimised sildenafil compared with 11% on placebo; the NNH was 5.4 (4.3 to 7.3). All cause discontinuations were less frequent with sildenafil (10%) than with placebo (20%). Sildenafil dose optimisation gave efficacy equivalent to the highest fixed doses, and adverse events equivalent to the lowest fixed doses.
This review of clinical trial reports available at the time of licensing agreed with later reviews that had many more trials and patients. Making reports submitted for marketing approval available publicly would provide better information when it was most needed, and would improve evidence-based introduction of new technologies.
PMCID: PMC115867  PMID: 12049673
10.  The method of bladder drainage in spinal cord injury patients may influence the histological changes in the mucosa of neuropathic bladder – a hypothesis 
BMC Urology  2002;2:5.
In spinal cord injury (SCI) patients, no correlation was found between the number of bladder infections per year, the period since injury, the neurologic level of the spinal cord lesion and the histopathology of the urinary bladder mucosa. The use of chronic indwelling urethral and/or suprapubic catheters in SCI patients is often associated with inflammatory and proliferative pathological conditions in neuropathic bladder.
Presentation of the hypothesis
We propose a hypothesis that the type of bladder drainage in SCI patients influences the histological changes in the mucosa of neuropathic bladder. This hypothesis implies that SCI patients with long-term indwelling urinary catheters develop certain histological changes in bladder mucosa, which are seen less frequently in SCI patients, who do not use long-term indwelling catheters. The latter group includes patients, who perform regular intermittent catheterisation and those, who wear a penile sheath and empty their bladders satisfactorily by reflex voiding.
We hypothesise that the following histological lesions are seen more frequently in the neuropathic bladder of SCI patients with long-term indwelling catheters.
(1) Papillary or polypoid cystitis; (2) widespread cystitis glandularis; (3) moderate to severe, acute and chronic inflammatory changes in bladder mucosa; (4) follicular cystitis; (5) squamous metaplasia; and (6) urothelial dysplasia
As per this hypothesis, it is postulated that the above pathological conditions are seen less often in SCI patients, who achieve complete, low-pressure emptying of the neuropathic bladder by regular intermittent catheterisation, and SCI patients with penile sheath drainage, who empty their bladders satisfactorily by reflex voiding.
Testing the hypothesis
A large prospective study of bladder biopsies in SCI patients practising different methods of bladder drainage is required to validate this hypothesis that the histological changes in bladder mucosa are related to the method of bladder drainage in SCI patients.
Implications of the hypothesis
We propose a hypothesis that the method of bladder drainage in SCI patients influences histological changes in the bladder mucosa. If this hypothesis is validated, methods of bladder drainage such as intermittent catheterisation, which do not require the use of chronic indwelling catheters, should be recommended, in order to minimise adverse histological changes in the mucosa of neuropathic bladder of spinal cord injury patients.
PMCID: PMC113259  PMID: 11980583
11.  Oral sildenafil (Viagra™) in male erectile dysfunction: use, efficacy and safety profile in an unselected cohort presenting to a British district general hospital. 
BMC Urology  2002;2:4.
Sildenafil (Viagra®) is one of the drugs used in the first line therapy of male erectile dysfunction (MED). We have recorded outcomes, adverse events and acceptability of Sildenafil (Viagra) therapy in an unselected group of men presenting with ED to a British district general hospital.
In this prospective observational study, 147 men with ED were seen since Oct 1999. Study patients were reviewed at 4, 12 and 52 weeks. All the patients filled the International Index of Erectile Function (IIEF) questionnaire and were asked about their willingness to pay (WTP) for treatment.
All suitable men accepted Viagra as first line therapy. 91% of our patients found sildenafil treatment successful. 80% of these patients were willing to continue with sildenafil therapy. Side effect profile of sildenafil was different in this study with much higher incidence of headache, dyspepsia, flushing and abnormal vision. 92% of men with ED expect to be treated by the NHS. Of those men eligible for treatment in the NHS, 30% qualify under the clinical categories and 18% under the 'distress' category. Only 55% of those with cardiovascular risk factors qualify for NHS treatment.
Sildenafil is widely accepted as first line therapy among British men with ED and has a success rate of 91%. Nearly half of men with ED qualify for NHS treatment. Nearly half of those with vascular risk factors do not qualify for NHS treatment. Most men with ED could possibly be managed in primary care.
PMCID: PMC111060  PMID: 12006106
12.  Effects of testicular microlithiasis on Doppler parameters: report of three cases 
BMC Urology  2002;2:3.
Testicular microlithiasis is a rare, usually asymptomatic, non-progressive disease of the testes associated with various genetic anomalies, infertility and testicular tumors. According to our literature search, there is no specific data about Doppler findings in this disease.
Case presentation
Doppler findings of three cases of testicular microlithiasis during last two years in our institution are presented.
Although our hypothesis was to find increased Doppler parameters due to intratesticular arterial compression, our findings suggest that there are no Doppler findings specific to testicular microlithiasis.
PMCID: PMC65702  PMID: 11869457
13.  The effectiveness of reducing the daily dose of finasteride in men with benign prostatic hyperplasia 
BMC Urology  2002;2:2.
Finasteride, a 5 alpha reductase inhibitor, is an established treatment for benign prostatic hyperplasia. The recommended dosage is 5 mg a day, however case reports have show effectiveness with lower doses. The objective of the current study was to determine in men with benign prostatic hyperplasia, previously treated for at least one year with finasteride 5 mg daily, if they will maintain subjective and objective improvements in urinary obstruction when treated with 2.5 mg of finasteride daily for one year.
In an open label, prospective study, 40 men with benign prostatic hyperplasia, previously treated for at least one year with 5 mg of finasteride, took 2.5 mg of finasteride daily for one year. Measurements included AUA symptom score, maximum flow rate, voided volume and PSA.
There were no significant changes in maximum flow rate, voided volume, or AUA symptom score after one year of finasteride 2.5 mg daily therapy. PSA increased significantly, p < .01, after one year of finasteride 2.5 mg daily, 2.0 +1.4 ng/ml, when compared to finasteride 5 mg daily, 1.4+ 1.0 ng/ml.
The daily dose of finasteride can be reduced to 2.5 mg daily without significant effect on subjective and objective measures of urinary obstruction. Although statistically significant increases in PSA are noted when reducing the daily finasteride dose from 5 mg to 2.5 mg, the clinical significance of a mean .6 ng/ml increase in PSA is questionable.
PMCID: PMC65043  PMID: 11818031
14.  Primary renal carcinoid natural history of the disease for ten years: case report 
BMC Urology  2002;2:1.
Primary renal carcinoid is extremely rare and there are few reports on the natural history of the disease.
Case presentation
A 68-year-old male with a right renal mass who lost to follow-up for ten years has been presented. His only complaint was a mild flank pain. Upon admission to the hospital for his renal mass, he underwent a right radical nephrectomy and pathological examination revealed the diagnosis of primary renal carcinoid.
In light of the presented case, primary renal carcinoma may have a prolonged natural history with no distant metastasis and any change in the quality of life of the patient.
PMCID: PMC65042  PMID: 11818030

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