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PURPOSE: To define the role of an antegrade occlusion balloon catheter in preventing migration of proximal ureteral stones to the dilated proximal ureter during endoscopic treatment. MATERIAL AND METHODS: An occlusion balloon catheter was used in 8 of 21 patients with proximal ureteral stones who underwent ureterorenoscopy. Five of the eight patients had solitary kidneys admitting with anuria and had percutaneous nephrostomy. In the other three patients, percutaneous nephrostomy and occlusion balloon catheters were placed a day before the procedure, since these patients had total obstruction and massive dilatation of the proximal ureter and renal collecting system. The balloons of occlusion catheters were inflated with 1 ml of sterile saline proximal to the stones just before ureterorenoscopy. RESULTS: All stones could be reached by ureterorenoscopy and treated successfully with the aid of an ultrasonic lithotripter, and no stone migration to the upper dilated collecting system was observed. Just after the operation, while the patient was still lying on the operation table, the occlusion catheter was removed. The nephrostomy catheter was removed a day later. All patients were totally stone-free after the procedures. CONCLUSION: Occlusion balloon catheters increase the ureteroscopic treatment success rate in proximal ureter stones. This should be kept in mind especially when dilatation of the proximal collecting system is prominent and in cases with unsuccessful previous intervention with a retrograde stone cone catheter.

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Erectile dysfunction (ED) is more frequent among end-stage renal failure patients than the normal population. Sildenafil citrate has been successfully used for the symptomatic treatment of erectile dysfunction. The aim of this study was to determine the efficacy and safety of sildenafil citrate in the treatment of ED in patients on hemodialysis. Fifty-five hemodialysis patients above 18 years suffering from ED with steady sexual partners were included in the study. The first five and fifteenth questions of the International Index of Erectile Function were employed to evaluate ED in the patient group. A Single 50-mg sildenafil citrate tablet was prescribed for each patient. The patients were encouraged to take it on the day after hemodialysis and 1 hour before sexual intercourse. The erectile function of the patients after the treatment was re-evaluated in the same manner by International Index of Erectile Function. The ages of the patients ranged between 30 and 73 years (mean 50.6 +/- 10.9). The overall response rate was 74.5% (38/51). Side effects were nausea (n = 2), palpitation (n = 2), flushing (n = 1), and angina (n = 1). Sildenafil citrate (50 mg) was observed to be safe and effective for treatment of hemodialysis patients with careful evaluation and proper patient selection.

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The most efficacious treatment for end-stage renal disease is renal transplantation. Because high-grade vesicoureteral reflux forecasts potential future complications, the patients studied were subjected to bilateral nephroureterectomy before transplantation. The aim of this study was to investigate the posttransplantation results of a subureteral injection performed before transplantation to treat high-grade vesicoureteral reflux in end-stage renal disease patients. Renal transplantation was performed on 14 of 52 end-stage renal disease patients that had undergone prior subureteral injection. Subureteral injection had been performed in 24 refluxing renal units of these 14 patients. Ten patients had bilateral and 4 patients unilateral reflux. The treatment criterion was reflux of at least grade III; however, when low-grade reflux was present in the contralateral renal unit, it was also treated during the same session. Success was determined as no (complete) or decrease to grade I (partial) reflux. The patient ages ranged between 13 and 46 years (mean 29.3 years). The reflux resolved in 20 of 24 renal units (83%) and was reduced to grade I in 3 of the others (12%), namely resulting in a total response rate of 95%. Except for 1 patient who was lost to follow-up, the other recipients were observed for 6 to 47 months (mean 23 months). Only 1 patient experienced symptomatic urinary tract infection or asymptomatic bacteriuria after renal transplantation. Acute rejection occurred in 5 and chronic rejection in 3 patients. In conclusion, subureteral injection instead of nephroureterectomy seems to be an efficient and minimally invasive alternative for renal transplant recipients with high-grade vesicoureteral reflux.

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OBJECTIVES: To evaluate the effectiveness of ureteral Dacron-covered metallic stents in the management of malignant ureteral obstruction. METHODS: Covered metallic stents were placed unilaterally using a percutaneous approach in an antegrade fashion into nine ureters of 8 patients with bilateral malignant ureteral obstruction. The contralateral kidneys were drained by percutaneous nephrostomy in 7 patients. The primary diagnoses were rectal cancer in 5 patients and cervical, bladder, and prostate cancers in the remaining cases. RESULTS: Covered metallic stents could be successfully placed in all patients. Only one of nine ureters was stented with a double J-stent. In a mean follow-up of 9 months (range 1 to 14), 7 of 8 patients died because of their primary disease. During the follow-up period, none of the stents were obstructed, displaced, or infected. CONCLUSIONS: Dacron-covered metallic stents appear to be successful in the treatment of patients with malignant ureteral obstruction. The preliminary outcome encourages and justifies the application of this drainage method.

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Bladder neck contracture is usually a complication of prostatectomy and the treatment of choice in such a condition should be endoscopic surgery. However, in a few patients the bladder neck may be completely obstructed preventing retrograde access into the bladder. A case is presented of complete bladder neck obstruction occurring after transurethral resection of prostate, which was treated after an access was provided by using transurethral Seldinger technique.

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Neurofibromatosis, or von Recklinghausen's disease, is an autosomal dominant disease with multiple neurofibroma and café-au-lait spots. However, neurofibroma in the bladder wall is a rare condition in von Recklinghausen's disease. A 31-year-old man with neurogenic voiding dysfunction due to sacral meningocele and acute urinary retention with neurofibroma of the bladder wall is presented with detailed radiologic evaluation. Patients with von Recklinghausen's disease should be carefully evaluated if urological symptoms exist.

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Although posterior urethral valves are predominant as a cause of obstructive uropathy in children, anterior urethral valves may also appear as the underlying etiologic factor in end-stage renal disease that results from obstruction. Two cases are presented of anterior urethral valve patients that were admitted with end-stage renal disease. The first case was successfully treated with diverticulectomy and urethral reconstruction in preparation for renal transplantation. The second case, however, had been on cystostomy drainage for 6 years and also had a contracted bladder. A more extensive lower urinary tract reconstruction was delayed. Children with poor stream and recurrent infections should be evaluated carefully and anterior urethral valve or diverticula should be considered in differential diagnosis of obstructive lesions.

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Bladder stones occasionally develop because of foreign bodies in the bladder. Bladder stones in a 30-year-old woman were found to have formed around an intrauterine contraceptive device that had gone missing many years previously and had migrated into the bladder. Plain abdominal radiograms should be a part of the evaluation in patients with a history of an unretrieved intrauterine contraceptive device.

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A 35-year-old woman who underwent partial nephrectomy had prolonged postsurgical urinary extravasation that led to a percutaneous fistula. A double-J catheter used as a ureteral stent during surgery was in place. A percutaneous pigtail nephrostomy was inserted on the 15th postoperative day but drainage continued. Antegrade pyelography demonstrated extravasation at the lower pole calyx. The double-J stent was removed on the 21st postoperative day, and a retrograde pyelogram showed no obstruction. Because drainage still was excessive on the 25th postoperative day, the fistula tract was embolized percutaneously with N-butyl cyanoacrylate, a tissue adhesive material. Drainage ceased immediately after the procedure, and control pyelography confirmed no extravasation. The patient was discharged on the 28th postoperative day. The patient had no additional complications at 36-month follow-up.

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A 42-year old man was admitted with glans ulcer, meatal stenosis, urinary retention and impotence. He had undergone a Virag-I operation because of impotence at another hospital 2 months earlier. The deep dorsal vein was isolated under local anesthesia and blocked by coils and embolized by n-butyl cyanoacrylate in a retrograde fashion. After 2 months, the glans had healed completely. The patient has no further urinary problem and is potent.

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OBJECTIVES: To determine the risk of local recurrence and relapse in patients with Stage I nonseminomatous testicular cancer with scrotal violation. METHODS: From 1983 to 1998, 75 patients with clinical Stage I nonseminomatous testicular cancer who were initially treated with orchiectomy and surveillance alone were retrospectively reviewed. RESULTS: Of 75 patients with Stage I nonseminomatous testicular cancer, 13 had scrotal violation. The surgical margins and the spermatic cords were free of tumor in all patients. Five patients (38%) in the scrotal violation group and 17 patients (27%) in the inguinal orchiectomy group experienced relapses. The difference was not significant (P = 0.41). Local recurrence was not observed in either group. All relapses, except one in the standard inguinal orchiectomy group, were treated successfully with chemotherapy and postchemotherapy surgery, if needed. The progression rate and survival were not significantly different between the two groups. CONCLUSIONS: Scrotal violation without positive surgical margins and tumor spillage does not adversely affect relapse rate and survival. Therefore, scrotal violation per se is not an exclusion criterion for the surveillance-only policy in patients with Stage I nonseminomatous testicular germ cell cancer.

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Castleman's disease, or angiofollicular lymph node hyperplasia, is a fairly rare benign tumor of lymphoid origin. The expected localization is mediastinum and rarely retroperitoneum. An asymptomatic case is reported with multimodality imaging and postoperative findings. The lesion was detected incidentally on routine chest radiogram. Surgical exploration revealed a retroperitoneal mass and the mass was resected successfully through a thoracoabdominal flank incision. Castleman's disease should be included in the list of differential diagnosis of retroperitoneal masses which are mostly malignant tumors.

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BACKGROUND: The aim of the present study was to assess the possible etiologic role of human papillomaviruses (HPV) in bladder tumors. METHODS: Forty-two fresh biopsy specimens from different grades and stages of bladder tumor cases and 10 normal bladder mucosa biopsies were studied. Specimens were analyzed by polymerase chain reaction (PCR) with HPV-specific general primer set for the detection of viral DNA. Polymerase chain reaction-positive samples were also tested with HPV 16- and 18-specific primers by the same method. RESULTS: We found two samples (4.8%) containing HPV DNA among the TaG1 bladder tumors. All other specimens, including the control group, were found to be negative by PCR. Neither of the two HPV-positive patients had immune deficiency and/or genital wars. Human papillomavirus 16 was detected by type-specific primers in one sample, but the other HPV-positive sample could not be typed. CONCLUSIONS: The low prevalence of HPV in this and many previous studies does not support an etiologic role of HPV in bladder carcinogenesis. We detected the virus in two early stage tumors, but none was detected in the high-grade samples. However, to clarify the positivity of HPV in these occasional cases, future studies must be designed by using in situ PCR techniques, including samples from tumors and normal bladder mucosa from the same patient.

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PURPOSE: Following intravesical bacillus Calmette-Guerin (BCG) instillation, we attempted to detect BCG in the blood using the polymerase chain reaction (PCR) method and correlate these findings with the occurrence of major complications due to this treatment. MATERIALS AND METHODS: Intravesical BCG immunotherapy was given to 22 consecutive patients with superficial bladder tumors. In 2 patients the BCG instillation had to be discontinued due to serious side effects of therapy. Blood samples (252 aliquots) were obtained from 126 BCG courses in 22 cases, and 2 additional samples (4 aliquots) were obtained from 1 patient 1 and 3 months after cessation of therapy. All blood samples were analyzed by the PCR technique for detection of deoxyribonucleic acid tuberculosis Mycobacterium tuberculosis. RESULTS: Of the 126 blood samples 9 (7.1%) were PCR positive for M. tuberculosis. These 9 positive samples belonged to 3 patients, all of whom were among those 4 patients who had major clinical side effects. CONCLUSIONS: We demonstrated that rapid and sensitive detection of mycobacteremia by PCR correlated with the clinical course of these patients. We also demonstrated that PCR can be used to monitor BCG in the blood after antituberculous therapy. The early, fast and accurate diagnosis of BCG in the blood by PCR may alter the serious clinical course of these patients by initiation of specific treatment early. However, further extensive studies are needed to validate these results.

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Among 190 patients with metastatic testicular cancer who were treated by platinum-based combination chemotherapy and achieved complete remission, 4 (2.1%) developed gynecomastia 2 to 5 months after the cessation of chemotherapy. All of these patients had normal serum levels of the beta subunit of human chorionic gonadotropin and testosterone levels at the lower range of normal, but they had elevated levels of follicle-stimulating hormone, luteinizing hormone, and estradiol. The cause of gynecomastia in our patients was probably these increased levels of gonadotropins that, in turn, stimulated increased secretion of testicular estrogen, thus altering the normal estradiol-testosterone ratio. Treatment-related gynecomastia, which may occur several months after the cessation of cytotoxic chemotherapy, does not necessarily mean the return of disease. It is important to recognize this fact so as to prevent unnecessary investigations that will cause psychological distress in a young patient with testicular cancer.

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