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PURPOSE: To review and compare the different methods for difficult male urethral catheterization described in selected literature. MATERIALS AND METHODS: A PubMed search was done with the terms "difficult", "failed", or "complications" and "urethral catheterization", "transurethral catheterization", "Foley catheter", "urethral catheter" or "filiforms and followers". All articles addressing the issue of difficult adult male urethral catheterization were included. RESULTS: Six main approaches were identified on the 14 articles included for review: 1) Passage of either a Glidewire, guide wire or filiform under direct vision; 2) Blind passage of a filiform, guide wire, Glidewire or hydrophilic catheter; 3) "The Peel-away® sheath placed on a cystoscope/resectoscope technique"; 4) "The rigid ureteroscope placed inside the 22F Foley technique"; 5) Suprapubic catheterization; and 6) "The instillation of 60 cc of saline through the catheter as it is advanced technique". CONCLUSION: There is a paucity of prospective data comparing the benefits, risks, success rates and complications of the different approaches for difficult Foley catheter placement. Our suggested approach starts with the initial attempt at urethral catheterization with an 18F coude and a 12F silicone catheter. If these fail, using a flexible cystoscope or the blind Glidewire technique are reasonable alternatives. If dilatation of a stricture is necessary, ureteric dilatators or a urethral balloon dilatator are recommended.

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PURPOSE: Patients with muscle-invasive bladder cancer and concomitant upper urinary tract tumors may be candidates for simultaneous cystectomy and nephroureterectomy. Other clinical conditions such as dialysis-dependent end-stage renal disease and non-functioning kidney are also indications for simultaneous removal of the bladder and kidney. In the present study, we report our laparoscopic experience with simultaneous laparoscopic radical cystectomy (LRC) and nephroureterectomy. MATERIALS AND METHODS: Between August 2000 and June 2007, 8 patients underwent simultaneous laparoscopic radical nephroureterectomy (LNU) (unilateral-6, bilateral-2) and radical cystectomy at our institution. Demographic data, pathologic features, surgical technique and outcomes were retrospectively analyzed. RESULTS: The laparoscopic approach was technically successful in all 8 cases (7 males and 1 female) without the need for open conversion. Median total operative time, including LNU, LRC, pelvic lymphadenectomy and urinary diversion, was 9 hours (range 8-12). Median estimated blood loss and hospital stay were 755 mL (range 300-2000) and 7.5 days (range 4-90), respectively. There were no intraoperative complications but only 1 major and 2 minor postoperative complications. The overall and cancer specific survival rates were 37.5% and 87.5% respectively at a median follow-up of 9 months (range 1-45). CONCLUSIONS: Laparoscopic nephroureterectomy with concomitant cystectomy is technically feasible. Greater number of patients with a longer follow-up is required to confirm our results.

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PURPOSE: To describe and classify 80 cases of urogenital tuberculosis in seven groups of similar clinical and radiological presentation. MATERIALS AND METHODS: 80 patients (56 males, 70%; median age 34 years; age range 12 to 75) with urogenital tuberculosis were retrospectively reviewed. The patients were divided in seven groups: 1) Bilateral parenchymatous renal lesions; 2) No or minimal changes on radiographic examination; 3) Unilateral renal tuberculosis; 4) Contracted bladder; 5) Contracted bladder with renal failure; 6) Tuberculosis on a transplanted kidney; 7) Isolated genital tuberculosis. RESULTS: 1) Seven (8.8%) patients had multiple bilateral parenchymatous renal lesions with fever and malaise, characteristic of miliary tuberculosis. Three of these patients had AIDS. 2) Six (7.5%) cases had an early diagnosis, with minimal or no radiographic lesions. Two did not have any urologic symptoms. 3) Twelve (15%) patients had unilateral renal tuberculosis with partial (1 case) or total non-function kidney. 4) Thirty-seven (46.3%) patients had contracted bladder associated with unilateral partial (1 case) or total non-function kidney. 5) Ten (12.5%) patients had end stage renal disease due to tuberculosis with contracted bladder. 6) Four (5.0%) patients had tuberculosis on a transplanted kidney, with graft loss in half the cases. 7) Four (5.0%) patients had prostate or epididymis tuberculosis without associated renal lesion. CONCLUSIONS: Urogenital tuberculosis is a destructive disease of the urogenital tract with variable clinical and radiographic presentation. A classification according to similar patterns correlating with disease stage is feasible although early diagnosis is the only prevention of the most severe forms.

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PURPOSE: To assess the efficacy of extracorporeal shockwave lithotripsy (ESWL) for ureteral calculi during acute renal colic. MATERIALS AND METHODS: From January 2002 to March 2007, 108 patients were treated by ESWL for obstructing ureteral stones causing acute renal colic. ESWL was performed within 24 hours of the onset of renal colic. RESULTS: The mean age of the patients was 39.5 years (11-72 years). Male/female ratio was 85/23. Mean stone size was 8.45 mm (4-20 mm). They were located in the pelvic (n = 53), iliac (n = 28) or lumbar (n = 27) region. Fragmentation after a single session was complete in 56 patients (52%), incomplete in 28 (26%), and absent in 24 (22%). Patients presenting incomplete fragmentation underwent a second (n = 28) or even a third session (n = 11). Of the 24 patients in whom ESWL had no impact on the stone, 21 underwent ureteroscopy, and in one case open ureterolithotomy for a patient with a hard 17 mm stone, while spontaneous passage occurred in two patients with small stones. CONCLUSION: Emergency ESWL for obstructing ureteral stones has a satisfactory success rate and very low morbidity. The stone-free rate of retreating ureteral calculi with ESWL decreases significantly after failed initial treatment. Stone size may be the main predictive factor for retreatment. We suggest that no more than 3 treatments should be given for a particular stone due to minimal improvement in the subsequent cumulative treatment success rate.

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PURPOSE: To evaluate erectile function (EF) and voiding function following primary targeted cryoablation of the prostate (TCAP) for clinically localized prostate cancer (CaP) in a contemporary cohort. MATERIALS AND METHODS: We retrospectively reviewed all patients treated between 2/2000-5/2006 with primary TCAP. Variables included age, Gleason sum, pre-TCAP prostate specific antigen (PSA), prostate volume, clinical stage, pre-TCAP hormonal ablation, pre-TCAP EF and American Urologic Association Symptom Score (AUASS). EF was recorded as follows: 1 = potent; 2 = sufficient for intercourse; 3 = partial/insufficient; 4 = minimal/insufficient; 5 = none. Voiding function was analyzed by comparing pre/post-TCAP AUASS. Statistical analysis utilized SAS software with p < 0.05 considered significant. RESULTS: After exclusions, 78 consecutive patients were analyzed with a mean age of 69.2 years and follow-up 39.8 months. Thirty-five (44.9%) men reported pre-TCAP EF level of 1-2. Post-TCAP, 9 of 35 (25.7%) regained EF of level 1-2 while 1 (2.9%) achieved level 3 EF. Median pre-TCAP AUASS was 8.75 versus 7.50 postoperatively (p = 0.39). Six patients (7.7%) experienced post-TCAP urinary incontinence. Lower pre-TCAP PSA (p = 0.008) and higher Gleason sum (p = 0.002) were associated with higher post-TCAP AUASS while prostate volume demonstrated a trend (p = 0.07). Post-TCAP EF and stable AUASS were not associated with increased disease-recurrence (p = 0.24 and p = 0.67, respectively). CONCLUSIONS: Stable voiding function was observed post-TCAP, with an overall incontinence rate of 7.7%. Further, though erectile dysfunction is common following TCAP, 25.7% of previously potent patients demonstrated erections suitable for intercourse. While long-term data is requisite, consideration should be made for prospective evaluation of penile rehabilitation following primary TCAP.

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PURPOSE: Catheter-based medical devices are an important component of the urologic armamentarium. To our knowledge, there is no population-based data regarding normal male urethral length. We evaluated the length of the urethra in men with normal genitourinary anatomy undergoing either Foley catheter removal or standard cystoscopy. MATERIALS AND METHODS: Male urethral length was obtained in 109 men. After study permission was obtained, the subject's penis was placed on a gentle stretch and the catheter was marked at the tip of the penis. The catheter was then removed and the distance from the mark to the beginning of the re-inflated balloon was measured. Alternatively, urethral length was measured at the time of cystoscopy, on removal of the cystoscope. Data on age, weight, and height was obtained in patients when possible. RESULTS: The mean urethral length was 22.3 cm with a standard deviation of 2.4 cm. Urethral length varied between 15 cm and 29 cm. No statistically significant correlation was found between urethral length and height, weight, body mass index (BMI), or age. CONCLUSIONS: Literature documenting the length of the normal male adult urethra is scarce. Our data adds to basic anatomic information of the male urethra and may be used to optimize genitourinary device design.

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OBJECTIVE: To determine the expression of the cytokines transforming growth factor-β1 (TGF-β1), interferon-γ (IFN-γ), interleukin-6 (IL-6), and tumor necrosis factor-α (TNF-α) in serum from patients with Peyronie's disease (PD) compared to healthy controls. MATERIALS AND METHODS: Ninety-one consecutive PD patients aged 20 - 74 years were included in this study. All patients were diagnosed with symptomatic PD for the first time and had a palpable penile plaque. The patients previously had the disease for 6 - 72 months. None of the patients had a severe infectious disease or known systemic illness. For cytokine analyses, peripheral venous blood samples were obtained before treatment. Fifty healthy male blood donors aged 22 - 64 years served as the control group. TGF-β1, IFN-γ, Il-6, and TNF-α were analyzed quantitatively with commercial immunoassays. RESULTS: Mean cytokine levels in serum from patients were increased for TGF-β1 and IFN-γ compared to healthy controls. The difference for TGF-β1 was considered statistically significant (p < 0.001). IL-6 was not detectable in PD patients (p < 0.01) and TNF-α was decreased (p < 0.0001). CONCLUSION: The significantly elevated serum level of the profibrotic TGF-β1 cytokine underscores the effect of cytokines in the pathophysiology of PD. The significantly decreased TNF-α serum level suggested no acute immunomodulatory process. Therefore, the relevance for therapeutic administration of TNF-α should be further investigated. Quantification of TGF-β1 in serum of PD patients provides a possible diagnostic tool and target for therapy. The data on altered cytokine levels in PD patients also provide a new understanding for etiopathogenesis of PD, which warrants further investigation.

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OBJECTIVE: To determine the prevalence of human papillomavirus (HPV) DNA in penile cancers in Rio de Janeiro, Brazil. MATERIALS AND METHODS: We studied, prospectively, 80 consecutive cases of patients with penile cancers who underwent surgical treatment at three different Hospitals in Rio de Janeiro between March 1995 and June 2000. Of these patients, 72 were diagnosed with invasive squamous cell carcinoma and 8 patients with verrucous carcinoma. The following parameters were observed: presence or absence of HPV DNA viral type, histological subtypes, clinical stage and overall survival. RESULTS: HPV DNA was detected in 75% of patients with invasive carcinomas and in 50% of patients with verrucous carcinomas. High risk HPVs were detected in 15 of 54 (27.8%) patients with HPV positive invasive tumors and in 1 of 4 (25%) patients with HPV positive verrucous tumors. HPV 16 was the most frequent type observed. No correlation was observed between HPV status and histological subtype (p = 0.51) as well as HPV status and stage stratification (p = 0.88). HPV status was also not significantly associated with the presence of regional metastases (p = 0.89). The overall survival was related to the presence of lymph node metastases (p < 0.0001). CONCLUSIONS: HPV infection may have contributed to malignant transformation in a large proportion of our penile cancer cases but only inguinal metastasis was a prognostic factor for survival in these patients with penile carcinoma.

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OBJECTIVE: The aim of this prospective study was to compare the resistive index (RI) values, which is a parameter of testicular parenchymal perfusion, in testicular microlithiasis (TM) cases and normal cases. MATERIALS AND METHODS: 2179 volunteers, all healthy men (17-42 years of age) from the Annual Army Reserve Officer Training Corps training camp were included in the study. A screening scrotal ultrasound was performed and all men diagnosed with TM underwent a scrotal Doppler ultrasonography scan (US). US examinations were performed for subjects with TM and without TM as a control group and RI was determined. RESULTS: 53 men with TM were identified in the 2179 US. Spectral Doppler examination was applied to 50 randomly selected cases (100 testicles) without TM and 92 testicles with TM, 39 cases (78 testicles) with bilateral and 14 cases with unilateral involvement. However, 48 normal testicles (17 bilateral and 14 unilateral) and 47 testicles with TM (15 bilateral and 17 unilateral, 10 of which were cases with bilateral TM) where flow from the centripetal artery could be obtained and analyzed were included in the statistical analysis for resistive indices. There was no significant difference regarding the RI and spectral examinations between subjects with and without TM. An interesting finding was the twinkling artifact observed in three cases. CONCLUSION: Microliths did not alter the RI values and thus had no influence on testicular perfusion on Doppler US examination.

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PURPOSE: To determine the activity of seminal plasma catalase (CAT), superoxide dismutase (SOD) and glutathione peroxidase (GPX) and their relationship with malondialdehyde (MDA), as a marker of lipid peroxidation, content of spermatozoa and seminal plasma in normozoospermic and asthenozoospermic males. MATERIALS AND METHODS: Semen samples were obtained from 15 normozoospermic and 30 asthenozoospermic men. RESULTS: We observed inverse correlations between activities of CAT (k/mL) and SOD (U/mL) in seminal plasma with MDA content of spermatozoa from normozoospermic samples (r =- 0.43, p < 0.05 and r =- 0.5, p < 0.05, respectively). Significant correlations were observed between total activity CAT (k/total seminal plasma) with total SOD (U/total seminal plasma) and GPX activity (mU/total seminal plasma) in seminal plasma from normozoospermic samples (r = 0.67, p = 0.008 and r = 0.455, p = 0.047, respectively). Furthermore, we found positive correlations between total activities of CAT, SOD and GPX with total content of MDA in seminal plasma (nmoL/total seminal plasma) from normozoospermic samples (r = 0.67, p = 0.003; r = 0.73, p = 0.003; r = 0.74, p = 0.004, respectively). In asthenozoospermic samples, there were no significant correlations observed between activities of CAT (k/mL), SOD (U/mL) and GPX (mU/mL) of seminal plasma with MDA content of spermatozoa. However, we found significant correlations between total activities of CAT (k/total seminal plasma) and SOD (U/total seminal plasma) with total content of MDA in seminal plasma (r = 0.4, p = 0.018 and r = 0.34, p = 0.03, respectively). CONCLUSION: These findings indicate a protective role for antioxidant enzymes of seminal plasma against lipid peroxidation of spermatozoa in normozoospermic samples.

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PURPOSE: Renal cell carcinoma (RCC) is the most lethal among the common urologic malignancies, comprising 3% of all human neoplasias; approximately 40% of patients eventually die of cancer progression. One third of patients who present with metastatic disease and up to 40% treated for localized disease generally experience recurrence. RCCs are characterized by high resistance to chemo-, radio- and immunotherapy. We recently discovered an endogenous enzymatic activity, which is particularly expressed in tumorigenic cell, endogenous non-telomerase reverse transcriptase (RT) of retrotrasposon / retroviral origin, as a specific target to induce proliferation arrest in a number of human carcinogenesis in vitro culture cell lines. METHODS: To address this possibility, we have employed RCC primary cell culture testing pharmacological inhibition, in vitro, by two characterized non nucleosidic RT inhibitors, nevirapine and efavirenz; next, we assessed morphological effects and analyzed putative modulation on gene expression profile. RESULTS: Both treatments reduced cell proliferation rate and induced morphological differentiation and gene expression reprogramming in different RCC analyzed tumor biomarkers. CONCLUSION: In this study we describe a new potential therapeutic approach to obtain considerable future benefits in renal carcinoma cure and attempt to establish a new possible pharmacological therapy based on oral drugs administration in renal RCC treatment.

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PURPOSE: We reproduced a non-bacterial experimental model to assess bladder inflammation and urinary glycosaminoglycans (GAG) excretion and examined the effect of dimethyl sulfoxide (DMSO). MATERIALS AND METHODS: Female rats were instilled with either protamine sulfate (PS groups) or sterile saline (control groups). At different days after the procedure, 24 h urine and bladder samples were obtained. Urinary levels of hyaluronic acid (HA) and sulfated glycosaminoglycans (S-GAG) were determined. Also to evaluate the effect of DMSO animals were instilled with either 50% DMSO or saline 6 hours after PS instillation. To evaluate the effect of DMSO in healthy bladders, rats were instilled with 50% DMSO and controls with saline. RESULTS: In the PS groups, bladder inflammation was observed, with polymorphonuclear cells during the first days and lymphomononuclear in the last days. HA and S-GAG had 2 peaks of urinary excretion, at the 1st and 7th day after PS injection. DMSO significantly reduced bladder inflammation. In contrast, in healthy bladders, DMSO produced mild inflammation and an increase in urinary HA levels after 1 and 7 days and an increase of S-GAG level in 7 days. Animals instilled with PS and treated with DMSO had significantly reduced levels of urinary HA only at the 1st day. Urinary S-GAG/Cr levels were similar in all groups. CONCLUSIONS: Increased urinary levels of GAG were associated with bladder inflammation in a PS-induced cystitis model. DMSO significantly reduced the inflammatory process after urothelial injury. Conversely, this drug provoked mild inflammation in normal mucosa. DMSO treatment was shown to influence urinary HA excretion.