The treatment options in clinical stage I nonseminomatous germ cell tumor (NSGCT) of testis are either surveillance, chemotherapy or retroperitoneal lymph node dissection (RPLND). While open RPLND still serves as the gold standard, laparoscopic and robot assisted laparoscopic approaches are gaining popularity. In this report, we share our experience and technique of robot assisted laparoscopic RPLND in a patient with clinical stage Ib NSGCT of testis.

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Self-mutilations of the external genitals in psychiatric patients also known as Klingsor syndrome is a rare urologic trauma. Men with religious conflicts, low self-esteem, unresolved transsexual issues and feelings of guilt are the most vulnerable. This condition requires immediate surgical intervention. Currently replantation involves meticulous microsurgery and has become the primary method for managing these patients. In this paper, we report a case of self amputation of penis in a patient with a psychiatric history significant for schizopfrenia. Because of the unavailability of a microscope in our department, a non-microsurgical replantation without microscopic magnification was attempted. After surgery, normal appearance and function including a good normal voiding, sensation, and erections were observed.

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Sarcomatoid carcinoma of prostate is an extremely rare but aggressive neoplasm. It is generally associated with a poor prognosis. About 100 cases have so far been reported in the English literature. We report the case of a 64-year-old male with a very rapidly progressive disease that ultimately involved the whole lower urinary tract and rectum. The management of this case along with etio-pathogenesis and literature review is discussed.

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Aims: To analyze the results of balloon dilatation for short segment male urethral strictures. Materials and Methods: Retrospective analysis was done of 120 patients undergoing urethral balloon dilatation since January 2004 to January 2012. The inclusion criteria for analysis was a short segment (less than 1.5 cm) stricture, exclusion criteria were pediatric, long (more than 1.5 cm), traumatic, malignant strictures. The parameters analyzed included presentation of patients, ascending urethrogram (AUG) and descending urethrogram findings, pre- and postoperative International prostate symptoms score (IPSS), uroflowmetry (Q _max ), and post-void residue (PVR). Need for self calibration/ancillary procedures were assessed. Failure was defined as requirement for a subsequent endoscopic or open surgery. A urethral balloon catheter (Cook Urological, Spencer, Indiana) is passed over a guide wire after on table AUG and inflated till 180 psi for 5 minutes under fluoroscopy till waist disappears. Dilatation is followed by insertion of a Foley catheter. Patients were followed up at 1, 3, and 6 months. Results: Mean age was 49.86 years. Mean follow-up was 6 (2-60) months. IPSS improved from 21.6 preoperative to 5.6 postoperatively. Q _max increased from 5.7 to 19.1 and PVR decreased from 90.2 to 28.8 (P < 0.0001*) postoperatively. At 1, 3, and at 6 monthly follow-up, 69.2% ( n = 82) patients were asymptomatic. Conclusions: Balloon dilation is a safe, well-tolerated procedure with minimal complications. Further randomized studies comparing balloon dilatation with direct internal visual urethrotomy are warranted.

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Amyloidosis is a heterogeneous group of disorders characterized by extracellular deposition of amorphous proteinaceous material in various tissues. Amyloidosis of bladder is of significant clinical interest to the urologist because of its presentation as urothelial cancer. Transurethral resection and histology examination is essential to exclude malignancy and to establish the benign nature of amyloidosis. Apart from managing the localized bladder amyloidosis, it is important to exclude systemic amyloidosis. Here in we describe two cases of localized, primary amyloidosis and discuss briefly their management and follow-up.

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Purpose: To verify the association between lower urinary tract symptoms (LUTS) and erectile dysfunction (ED) and evaluate the influence of sildenafil and doxazosin either as single agents or combined on both symptoms. Material and Methods: A prospective randomized study including 150 patients presented with LUTS caused by BPH in association with clinically diagnosed ED, with age equal or more than 45 years from April 2010 to April 20011. They were categorized into three comparative groups each one containing 50 patients. These groups were comparable regarding pretreatment international prostate symptoms score (IPSS) and international index of erectile function (IIEF). The patients of the first group were given sildenafil 50 mg as monotherapy, those of the second group were given doxazosin 2 mg and those of the third group were given combination of both drugs for 4 months for each group. The main post-treatment parameters for assessment and comparison include assessment of patient's symptoms by repeated IPS Sand IIEF, uroflowmetry and assessment of PVR. The statistics was done by use of the Qui--square test. Results: Pre-treatment parameters were assessed and compared between the three groups. After 4 months of treatment, the comparative parameters were applied to all groups and the differences were measured post-treatment regarding IPSS, erectile function score, uroflowmetry, and post-void residual (PVR) urine. Sildenafil alone caused mild improvement in IPSS, more improvement in IIEF score, and little effect on flow rate and PVR urine. Doxazosin alone caused more improvement in IPSS, flow rate and PVR urine and less improvement in IIEF score. A combination of both sildenafil and doxazosin caused more improvement in all of the comparative parameters than when each drug was given alone. Conclusions: There is a strong relationship between LUTS and ED. Doxazosin or sidenafil as a single drug could be used in treating mild or mild to moderate symptoms but more severe symptoms may usually need a combination of both drugs.

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Purpose: To present our experience in the management of symptomatic ureteral calculi during pregnancy. Materials and Methods: Twenty-three pregnant women, aged between 19 and 28 years presented to the obstetric and urology departments with renal colic (17 cases, 73.9%) and fever and renal pain (6 cases, 26.1%); suggesting ureteric stones. The diagnosis was established by ultrasonography (abdominal and transvaginal). Outpatient follow-up consisted of clinical assessment and abdominal ultrasonography. Follow-up by X-ray of the kidneys, ureter, and bladder (KUB), or intravenous urography (IVU) was done in the postpartum period. Results: Double J (DJ) stent was inserted in six women (26%) with persistent fever followed by extracorporeal shock wave lithotripsy (ESWL) one month post-partum. Ureteroscopic procedure and pneumatic lithotripsy were performed for 17 women (distal ureteric stone in 10, middle ureter in 5, and upper ureteric stone in 2). Stone-free rate was 100%. No urologic, anesthetic, or obstetric complications were encountered. Conclusions: Ureteroscopy, pneumatic lithotripsy, and DJ insertion could be a definitive and safe option for the treatment of obstructive ureteric stones during pregnancy.

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Context: Long anterior urethral strictures are fairly common in developing world and the treatment is equally challenging. Aim: To assess the results and efficacy of Monsieur's Tunica Albuginea Urethroplasty (TAU) for anterior urethral stricture. Settings and Design: We analyzed the results in 10 consecutive patients with pan-anterior urethral stricture, who underwent Monsieur's urethroplasty. Materials and Methods: The procedure involves mobilization of strictured urethra and laying it open with a dorsal slit. Edges of the slit-open urethra are sutured to edges of the urethral groove to the tunica of corporal bodies with catheter in situ. Results were assessed postoperatively 3, 6, 9 and 12 months. Patients were categorized as success and failure by comparative analysis of patient satisfaction along with urethroscopy, retrograde urethrogram, uroflowmetry. All patients were taken for post-operative urethroscopic analysis at 6 months to allow better understanding of both successful and failed cases. Results: Mean follow-up of 15.2 (11-19) months showed an 80% success rate. Mean uroflow rate showed Qmax 24.5 cc/sec with 8 cases showing no residual or recurrent stricture. Two cases failed and required intervention. Urethroscopic visualization of the reconstruction site showed wide, patent and distensible neourethra appearing epithelized over roof formed by tunica albuginea of the corpora cavernosa in successful cases. Conclusion: Monsieur's TAU is effective technique in treatment of anterior urethral stricture especially cases with unavailable buccal mucosa, with results fairly acceptable at the end of one year.

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Aim: This study aimed to identify the differences between primary and secondary vesicoureteric reflux (VUR) and the effect of associated bladder abnormalities on kidney function. Patients and Methods: We retrospectively reviewed the medical records of children with VUR who were followed up at King Abdulaziz University Hospital from January 2005 to December 2010. The review included results of radiological investigations and kidney function tests. We used Chi-square test for statistical analysis and paired t-test to compare group means for initial and last creatinine levels. Results: Ninety-nine children were included in this study. Twenty (20.2%) had primary VUR, 11 had high-grade VUR, while 9 had low-grade reflux. All children with low-grade VUR had normal dimercaptosuccinic acid (DMSA). Renal scars were present in 72% of the children with high-grade VUR. The mean creatinine levels (initial and last) for both groups were normal. Seventy-nine (79.8%) children had secondary VUR, which was due to posterior urethral valves (PUV) (46.8%), neurogenic bladder caused by meningomyelocele (25.3%), non-neurogenic neurogenic bladder (NNB) (21.5%), or neurogenic bladder associated with prune belly syndrome (6.3%). Children with NNB, meningomyelocele and PUV had high creatinine at presentation with no considerable worsening of their kidney functions during the last visit. Renal scars were present in 49.4% of the children with secondary VUR. Conclusion: Children with primary VUR and normal bladder had good-functioning kidneys, while those with secondary VUR associated with abnormal bladder caused by NNB, spina bifida or PUV had abnormal kidney functions. DMSA scans were useful in predicting higher grades of VUR in children with primary reflux.

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Association between Prune belly syndrome (PBS) and urethral hypoplasia is an unusual condition. It is usually fatal unless there is a communication between the fetal bladder and the amniotic sac. We report a case of PBS with urethral hypoplasia and congenital vesico-cutaneous fistula in a male neonate. Patient underwent cutaneous vesicostomy and was discharged for close follow up of his renal function and for future reconstruction.

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Aim: To report the result of vesicovaginal fistula (VVF) repair using the transabdominal approach with flap interposition. Materials and Methods: Between January 2004 and the end of 2011, operative reports data and medical records systems were reviewed for all VVF cases operated and followed in Urology Department. All patients had detailed history taking and physical exam followed by intravenous pyelograms or contrast CT abdomen and pelvis to rule out the presence of ureterovaginal fistulae. We utilized the infra-umbilical transabdominal approach and transpose an omental flap or peritoneal flap between the vaginal and bladder incisions in all cases. Results: Twenty-six patients with an average age of 46 years were managed for VVF through transabdominal route with interposition of omental flap or peritoneal flap by a single surgeon. Twelve cases of VVF were secondary to lower segment cesarean section (LSCS) and twelve cases of VVF were secondary to lower segment cesarean section (LSCS) and 14 cases following hysterectomies. We had 16 complex VVF with 4 cases that failed the previous abdominal repair outside the hospital. More than 95% (25) of our patients were cured at the first attempt, with no recurrence at a mean follow-up of 28.6 (range 8-73) months. Conclusion: Successful repair of VVF depends on the experience of the surgeon and adhering to basic surgical principles. Very high success rate was seen when flap interposition had been used.

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Context: Penile allotransplantation might be a viable option for patients who need penile reconstruction. Aims: A successful autotransplantation rat model is the first step toward proceeding for allotransplantation. We herein evaluate autotransplantation following transaction of the rat penis just distal to the urethral bulb. Settings and Design: Experimental animal study. Materials and Methods: Five Sprague-Dawely rats weighing 520 g (SD 19) were used. Utilizing a magnification of 6-40, transection and immediate anastomosis of the tunica albuginea, urethra, dorsal vein and nerves were carried out. Vesicostomy was made to divert urine. The glandular skin was sutured to the perineum and the abdominal wall was closed in layers. Statistical Analysis Used: Descriptive statistics. Results: Average surgery time was 8 h. The first two rats had no vesicostomy and died in the first postoperative day from retention. Three rats tolerated well the procedure and survived to the end point. One rat was sacrificed at day 10 and histopathology showed 30-50% necrosis of the implanted penis. Another rat was sacrificed at day 20 and showed normal cavernous tissue. The fifth rat was sacrificed 3 months postoperatively and showed evidence of moderate corporal fibrosis. Urethral fistula and necrosis of corpus spongiosum, dorsal nerve necrosis and dorsal vein occurred in all animals. Conclusions: Penile autotransplantation in rats is feasible and provides the basis for evaluation of the corpora cavernosa in an allotransplantation model. Long-term urethral continuity and dorsal neurovascular bundle survival in this model is difficult to establish.

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A 77-year-old female, who suffered from rheumatoid arthritis and hypothyroidism, developed severe muscle weakness. Clinical features, blood results and muscle biopsy suggested a possible diagnosis of dermatomyositis. A computed tomography of the chest, abdomen and pelvis showed a solid mass in the left kidney. She underwent a left laparoscopic nephrectomy and histology confirmed conventional (clear cell) renal cell carcinoma. She recovered slowly and almost back to normal life after 6 months. Early appreciation of the typical skin rash may provide a clue to the diagnosis and screening for neoplasm may improve prognosis.

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Background: We reviewed the success rates of orchidopexies performed for non-palpable testes at our institution and correlated preoperative and intraoperative findings to eventual outcomes. Materials and Methods: We retrospectively reviewed ninty five medical records of patients who underwent laparoscopic exploration for the assessment of a non-palpable testes between 1996 and 2009. Intra-operative data for one hundrad eight non-palpable testes were collected. Operative success was defined as a testis comparable in size or slightly smaller than the contra-lateral testis with normal consistency on the last follow-up. Results: There were seventy (65%) viable testes at exploration, thirty one nubbins (29%) removed and 7 (6%) absent. In the seventy six unilateral cases, contra-lateral hypertrophy was found in twinty five (33%) testes. Of which, twinty one (84%) were associated with absent testes or finding of a nubbin rather than a viable testis. In contrast, absent testes or finding of a nubbin was noted in 12 of 51 (23.5%) patients without contra-lateral hypertrophy. The difference was statistically significant (P < 0.001). Mean follow-up was seventeen months. Of the fifty testes in which the testicular artery was preserved, 7 were lost to follow-up and 3 of the remaining fourty three (7%) were atrophic. The twinty testes that underwent Fowler-Stephens orchidopexy (FSO) had a similar rate of atrophy, with only 1 (5%) atrophic testis identified following staged FSO (P > 0.83). Interpretation: Testicular atrophy rate was similar in both artery sparing and Fowler-Stephens orchidopexies. Contra-lateral hypertrophy was significantly associated with absent testes or finding of a nubbin rather than a viable testis.

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Context: Impalement injuries of the rectum with bladder perforation have been rarely reported. Such lesions have been associated with increased postoperative morbidity. A well-conducted preoperative evaluation of the lesions tends to prevent such complications. Aims: To increase awareness about patients with rectal impalement that involve bladder injuries and to examine the significance of thorough clinical examination and complementary investigation for these patients' management. Materials and Methods: Retrospectively, we identified three patients with rectal impalement and bladder perforation treated in University Hospital Hassan II, Fez, Morocco. We recorded the symptoms, subsequent management, and further follow-up for each patient. All available variables of published cases were reviewed and analyzed. Results: Evident urologic symptoms were present in only one patient. Bladder perforation was suspected in two other patients on the basis of anterior rectal perforation in digital exam. Retrograde uroscanner could definitely confirm the diagnosis of bladder perforation. Fecal and urine diversion was the basis of the treatment. No postoperative complications were noted. We have reviewed 14 previous reports. They are presented mainly with urine drainage through the rectum. Radiologic investigation (retrograde cystography and retrograde uroscanner) confirmed bladder perforation in 10 patients (71.4%). Unnecessary laparotomy was performed in six patients (42.8%). Fecal diversion and urinary bladder decompression using urethral catheter were the most performed procedures in bladder perforation [6/14 patients (42.8%)]. No specific postoperative complications were reported. Conclusions: A high index of clinical suspicion is required to make the diagnosis of bladder perforation while assessing patients presenting with rectal impalement. Meticulous preoperative assessment is the clue of successful management.

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Objective : The on-going discussion about extent and best template for pelvic lymph dissection (PLND) motivated us to analyse pre-prostatic tissue (PPT) for lymph nodes and metastases. Materials and Methods: From December 2010 to August 2011 PPT was sent for histopathological evaluation during 80 robotic assisted radical prostatectomies (RARP) and one extended staging lymph node dissection. All patients had either a limited (lPLND, n = 44) or an extended lymph node dissection (ePLND, n = 36). Clinical data were retrospectively analyzed and compared to histopathological findings. Results: Lymph nodes were found in PPT in 10/80 (12.5%) patients after RARP and in the one patient after staging ePLND. Mean number of lymph nodes detected in PPT of them was 1.2 (range 1-3). Clinically no differences were found between patients with or without lymph nodes in PPT. In the standard template of either ePLND or lPLND the average number of lymph nodes was 13 (range 2-56). Herein metastases were found in 10 (12.5%) patients after RARP and in the patient after staging ePLND. A metastasis in PPT was only found after staging ePLND. Conclusions: Pre-prostatic tissue might contain lymph nodes that potentially harbour metastases. In the intention to perform the most accurate staging this tissue should be considered for histopathological evaluation.

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Invasive urothelial carcinoma has a potential to show divergent differentiation. Several uncommon morphological variants have been described in the recent past. One such rare type is the nested variant of urothelial carcinoma. Most of the published reports depict occurrence of this variant in the urinary bladder. We report an unusual presentation of this uncommon entity in the renal pelvis of a 54-year-old lady who presented with widespread skeletal metastases without any urinary symptoms.

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Objectives: There is a paucity of data on the long-term outcome of genital reconstruction of female children with congenital adrenal hyperplasia (CAH) as they become adult women. We report on the surgical outcome general condition and marriage status. Materials and Methods: We reviewed the medical records of women 20 years or older with CAH who had genital reconstruction. We interviewed married patients utilizing the female sexual function index (FSFI-6) questionnaire and compared them to age-matched controls. Results : We identified 43 women with CAH with a median age of 24.2 ± 3.9 years and a median follow-up of 23.4 ± 4.6 years. Salt wasting and the severity of virilization affected most patients, parents were commonly cousins, children were reared as boys for a protracted period and surgical reconstruction was usually complex. Only five women had married. Compared with single women, married women had significantly more frequent normal menses, emergency hospital admissions and number of repeated reconstructive surgery. There was no significant difference in FSFI score between patients and controls. Four women conceived and three gave birth to one healthy child. There was no significant difference in the number of children between patients and controls. Conclusions: CAH has a significant impact on adult women in our region. Most of the patients remain single. Few women get married and these are able to lead a nearly normal sexual life and give birth to healthy children.

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Ectopic adrenal tissue may be present along the path of the testis and discovered during groin surgery. The condition has been mainly reported in the pediatric population and very rarely in adults. Here, we report on the case of an adult male with undescended testis who received orchidectomy, and ectopic adrenal tissue was discovered in the removed specimen. The clinical significance of such a condition is discussed.

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Background: The pressure-flow study (PFS) is considered the gold standard for the detection of bladder outlet obstruction (BOO) in men. However, several studies have raised the possibility that transurethral catheterization might have an obstructive effect on PFS while others did not. Objectives: To evaluate the effect of a 6 Fr transurethral catheter on the pressure-flow study and to evaluate its clinical implication in men. Materials and Methods: A retrospective chart review study of 515 men referred for an evaluation of lower urinary tract symptoms and who underwent an urodynamic study (UDS). Of those, 133 met our inclusion/exclusion criteria. Non invasive free-flow studies (NIFFS) were performed before every UDS. Cystometrogram and PFS were performed through a 6 Fr transurethral catheter. Results: The maximal flow rate (Q _max ) was significantly higher ( P < 0.001) in the NIFFS (15.0 mL/s (range 9.0-23.0)) than in the PFS (11.0 mL/s (range 7.0-18.5)). This difference became greater (18.5 mL/s (range 10.0-30.3) vs. 13.0 mL/s (range 6.0-25.0), in favor of the NIFFS) when we analyzed only the patients ( n = 34) who voided a similar volume. According to the International Continence Society (ICS) nomogram, the use of the PFS alone would have resulted in the upstaging of 14% of cases (10/71) in the overall population and 24% (4/17) in the sub-analyzed group. Conclusion: A 6 Fr transurethral catheter significantly lowers the maximal flow rate by 4 mL/s. Its presence resulted in an upstaging on the ICS nomogram. However, further studies will be necessary to confirm this upstaging.

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Superior vena cava (SVC) syndrome is caused by compression or obstruction of the SVC. We report here in a case of SVC syndrome due to lymph node metastasis from urothelial cancer to the mediastinum and lung. The origin of metastasis was determined by computed tomography (CT)-guided biopsy of metastases. After radiotherapy to the mediastinum with glucocorticoid failed, anticancer pharmacotherapy including paclitaxel, gemicitabine, and cisplatin proved effective and SVC syndrome resolved. But patient died from cerebral bleeding from newer brain metastases 10 months later.

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