Urology Journal
Volume:2 Issue: 2, Spring 2005

The aims of this review are one, to consider that congenital urethral anomalies are not a simple disease entity in all patients. This is accomplished by reviewing the evidence for presence of posterior urethral valve subtypes and comorbidity of various unexplained clinical conditions in some children leading to chronic renal failure. The review’s second aim is to describe the effects of fetal lower urinary tract obstruction on postnatal bladder function and the consequence of bladder dysfunction on the remaining postnatal renal function. The literature was extensively reviewed concerning the different types of congenital urethral outlet obstruction presentations, diagnosis, different types of treatment modalities, morbidity, mortality, and new concepts for this old problem. These findings were compared with conventional approaches to these anomalies. The 739 published papers on posterior urethral valves were evaluated, and a quarter of those are addressed. All radiologic presentations and figures in this review were selected from among the records of Iranian patients treated by the author during the last 25 years. A significant overlap of presentation before antenatally diagnosed era was observed. The natural history of these anomalies is becoming clear and the hypothesis of posterior urethral diaphragm is popular among several investigators in comparison to the original valves classification by Young in 1903. Further molecular investigation of the urinary tract is needed to better understand the pathophysiology of renal and bladder function in children who are born with antenatally diagnosed congenital urethral obstruction. These anomalies must be treated by urologists with a vast experience with valves and other rare congenital urethral anomalies.

This study aimed to compare urinary Tamm-Horsfall protein (THP), citrate, and other inhibitors and promoters of stone formation in calcium stone formers with those in healthy individuals. From January 2002 to June 2004, 100 calcium stone formers (mean age, 38.6 ± 10.3 years) who had at least 2 episodes of calcium stone formation were compared with 100 healthy individuals (mean age, 33.8 ± 9.7 years). Their 24-hour urine THP (using the sodium dodecyl sulfate polyacrylamide gel electrophoresis method), citrate, calcium, uric acid, oxalate, and magnesium values were measured and compared. The mean 24-hour urine THP was 3.3 ± 8.1 mg in patients in the study group and 4.6 ± 19.2 mg in controls (P = 0.5). However, THP in individuals with and without bacteriuria was significantly different (15.8 ± 33.6 versus 2.6 ± 10.2, P < 0.001). Mean 24-hour urinary calcium, citrate, and oxalate values were 232.6 ± 95.3 mg and 177.8 ± 82.7 mg (P < 0.001), 132 ± 103.2 mg and 395 ± 258.5 mg (P < 0.001), and 18.9 ± 22.5 mg and 10.4 ± 8.5 mg (P < 0.001) in patients in the study and control groups, respectively. There was a significant positive correlation between urinary citrate and promoters of stone formation, including urinary calcium, oxalate, and uric acid, in patients in the control group, but not in patients in the study group. THP in the urine of stone formers is not quantitatively different from that of healthy individuals, but it is different in patients with bacteriuria. Increased urinary excretion of calcium, oxalate, and uric acid in stone formers with no increase in urine citrate may play a role in the pathogenesis of recurrent stone formation.

Meatal stenosis almost always develops following neonatal circumcision, and it usually does not become apparent until the child is toilet trained. The present study was conducted to determine the value of diagnostic ultrasonography in patients with meatal stenosis. A descriptive study was performed on 120 patients with meatal stenosis, referred to Naghavi Hospital, Kashan, Iran, from July 2000 to March 2002. Symptoms and findings on physical examination were recorded for every patient, ultrasonography of the urinary tract, and urinalysis and urine culture were also performed. Mean age of the patients was 2.5 years (range, 3 months to 6 years). The common symptoms were dysuria (35%), decreased urine caliber (33.3%), and bloody spotting (15%), while 26.6% of the patients were asymptomatic. Paraclinical findings were microscopic hematuria (17.5%), bacteriuria (1.6%), and ureteral duplication (0.8%). No case of obstructive uropathy was detected by ultrasonography. Meatal stenosis rarely causes obstructive uropathy. Hence, urinary tract ultrasonography is rarely necessary, unless symptoms persist after meatotomy.

Our aim was to evaluate the effect of acute urinary retention on serum prostate-specific antigen (PSA) level. Men aged 50 years and older who presented with acute urinary retention were studied. Patients with urethral stricture, neurogenic bladder, prostate cancer, and those with a history of recent instrumentation or prostate biopsy were excluded. Blood samples for serum PSA measurement were obtained (PSA1), and an indwelling urethral catheter was inserted for 2 weeks. Before catheter removal, a second blood sample for measurement of serum PSA level (PSA2) was obtained. In patients who were able to void, a third sample was obtained 3 weeks later (PSA3). In the first and second visits, digital rectal examinations (DRE1, DRE2) were performed to assess prostate volume. Mean PSA levels (PSA1, PSA2, and PSA3) and prostate volumes (DRE1, DRE2) were compared. Forty-five patients with a mean age of 70.18 years (range 56 to 85 years) participated in this study. Mean PSA1 and PSA2 levels were 9.8 ng/mL and 5.05 ng/mL, respectively (P < 0.001; medians, 6.2 and 4.2 ng/mL). Mean prostate volumes at the time of retention and 2 weeks later were 43.4 mL and 37.8 mL, respectively (P < 0.001; medians, 45 and 40 mL). PSA3 was measured in 31 patients 2 weeks after catheter removal. In this group of patients, mean PSA2 and PSA3 levels were 5.03 ng/mL and 4.97 ng/mL, respectively (P = 0.49; medians, 4.3 and 4.1 ng/mL). Acute urinary retention can increase serum PSA levels by approximately 2 fold. In this series, we found that this effect may continue up to 2 weeks.

There is a paucity of data on long-term patient and graft survival in the older kidney recipients. Our aim was to evaluate the long-term outcomes of kidney transplantation in patients aged 50 years and older and compare them with outcomes in younger recipients. Forty-seven recipients aged 50 years and older and 47 recipients aged younger than 50 years were randomly assigned to two groups (groups 1 and 2, respectively). Patients who had received a cadaveric kidney allograft were excluded from the study. Data including demographic and clinical characteristics, early complications, early mortality, and actuarial patient and graft survival rates were collected, and the two groups were compared, accordingly. The rates of early complications and mortality were not different between the two groups. Patient survival rates at 1, 3, 5, and 7 years were 72%, 58%, 41%, and 41% for patients in group 1 and 95%, 86%, 86%, and 86% for patients in group 2, respectively (P = 0.007). Graft survival rates were 72%, 58%, 41%, and 41% for patients in group 1 and 95%, 85%, 85%, and 85% for patients in group 2, respectively (P = 0.006). Graft loss due to patient death was 33.33% in group 1 compared with 4.25% in group 2 (P < 0.001). Kidney transplantation should be considered in patients older than 50 years, since the graft survival rate is acceptable in this population, and early mortality and complications in this group are not different than those of younger recipients. Although older patients have a shorter life expectancy, they benefit from renal transplantation in ways similar to younger kidney transplant recipients

Unilateral or bilateral dilation of the ureters occurs commonly during pregnancy. Ultrasonography is a suitable diagnostic method for hydronephrosis; however, it cannot differentiate obstructive from nonobstructive hydronephrosis. Our aim was to evaluate measurable changes in hydronephrosis induced by a mother’s positional changes using ultrasonography to differentiate hydronephrosis during pregnancy from pathologic etiologies. Pregnant women presenting for routine ultrasonography were enrolled in this study. A patient history was taken, and a physical examination was performed. Ultrasonography was performed to determine gestational age, parity, fetal presentation, presence or absence of hydramnios, and hydronephrosis and its severity. Thirty minutes after changing position (flank position or on all fours), patients were reevaluated by ultrasonography to determine the severity of hydronephrosis. Of 59 pregnant women with an average age of 25.4 years, 33 (55.9%) had no urinary complaint during pregnancy. Forty-one women (69.5%) had hydronephrosis, 24 (58.5%) of whom only in right kidney. The severity of hydronephrosis in one kidney was related with the severity of hydronephrosis in the other kidney (P = 0.007). Fetal presentation and gestational age were not associated with hydronephrosis. Risk of hydronephrosis was higher in the first pregnancy (likelihood ratio = 6.8, P = 0.009). Thirty minutes after changing positions, the anteroposterior pelvis diameter significantly decreased in the right and left kidneys (P = 0.004, P = 0.001). Ultraonography in two steps with positional change (dynamic ultrasonography) may be used to differentiate hydronephrosis of pregnancy from other pathologies.

Our aim was to determine the relationship between genuine premature ejaculation and serum and seminal plasma magnesium. In a case-control study carried out between January 2002 and December 2003, 19 patients with premature ejaculation were evaluated and compared with 19 patients without premature ejaculation. Patients with organic and psychogenic causes were excluded. Seminal plasma and serum magnesium levels were measured using atomic absorption spectrophotometery. Seminal plasma magnesium levels in study patients (94.73 ± 10.87 mg/L) were significantly lower than they were in controls (116.68 ± 11.63 mg/L, P < 0.001), but there were no such differences regarding serum magnesium levels (study patients, 20.26 ± 2.66 mg/L; controls, 20.73 ± 2.80 mg/L). Semen–to–serum-magnesium ratio was significantly lower in patients with premature ejaculation (P < 0.001). Also, a reverse relationship between body mass index and genuine premature ejaculation was found (P = 0.027). Genuine premature ejaculation has a significant relationship with decreased levels of seminal plasma magnesium. Further studies are needed to clarify the actual role of magnesium in the physiology of the male reproductive tract, especially its association with premature ejaculation.

Elevated nitric oxide (NO) levels have been shown to have toxic effects on sperm function and motility. This study was conducted to compare NO levels in the seminal fluid of infertile men with varicocele with those of infertile and fertile men without varicocele. Semen samples were obtained from 40 infertile men with varicocele (group 1), 40 infertile men without varicocele (group 2), and 40 fertile volunteers without varicocele (group 3). NO levels in the seminal plasma of patients in each group were measured and compared. In infertile men with varicocele, semen parameters, including sperm count and motility, and grade of varicocele were also determined. Mean NO concentrations were 52.34 ± 26.62 µmol/L, 37.06 ± 20.39 µmol/L, and 33.7 ± 18.99 µmol/L in groups 1, 2, 3, respectively. Concentrations in group 1 were significantly higher than were those in groups 2 and 3 (P = 0.001). In group 1, no significant correlations were seen between NO concentrations and grades of varicocele, sperm count, sperm motility, or ages of the patients. Data from the current study suggest a possible role of NO in damaging the sperm function in varicocele as demonstrated by an increased concentration of NO in the seminal fluid of infertile men with varicocele compared with the seminal fluid of fertile and infertile men without varicocele.

Urethral reconstruction in complex hypospadias poses a significant challenge. We report our experience using buccal mucosa to repair complex hypospadias. From February 2001 to September 2003, 16 urethral reconstructions were performed using buccal mucosal graft. Twelve of the patients had previously failed urethroplasties, while the other 4 had perineal or scrotal hypospadias. Grafts were harvested from the lower lip. Onlay grafts were used in 8 cases, and tubularized grafts were used for the others. After 14 to 27 months’ follow-up, 11 of 16 (69%) patients developed complications, including meatal stenosis in 2 (12.5%), urethral stricture in 5 (31%), and urethrocutaneous fistula in 4 (25%). No oral complications were seen, and all of the urethroplasty complications were managed successfully. Urethroplasty using a buccal mucosal graft may be accompanied by a relatively high complication rate, which is more common in patients with tubularized graft; however, all complications can be managed successfully. We believe that urethroplasty using buccal mucosal graft in complex hypospadias is an acceptable treatment modality.