Ehlers-Danlos syndrome (EDS) is a group of inherited connective tissue disorders due to mutations of the connective tissue genes. It is characterized by the triad of skin hyperelasticity, joint hypermobility, and connective tissue fragility. A 50-year-old man presented with acute clot hematuria and dysuria with no preceding trauma. He had a background of EDS and chronic lower urinary tract symptoms secondary to benign prostatic hyperplasia. The diagnosis of extraperitoneal bladder rupture was made on imaging. This is the first known reported case of spontaneous bladder rupture in an adult with EDS, although there have been 2 reports of children who spontaneously ruptured a bladder diverticulum. We suggest that patients with EDS and evidence of bladder outlet obstruction should be managed closely. Early surgical intervention may be needed. Care should also be taken so that the bladder is not overdistended during cystoscopic procedures.

Jeremiah de Leon, Shuo Liu, Wan Yi Ng, Roy McGregor, Vincent Tse

Submitted January 19, 2011 - Accepted for Publication January 31, 2011

KEYWORDS: Bladder rupture; Ehlers Danlos syndrome; Benign prostatic hyperplasia

CORRESPONDENCE: Shuo Liu, Department of Urology, Concord Repatriation General Hospital, Hospital Road, Concord, Sydney, NSW 2139, Australia ( This email address is being protected from spambots. You need JavaScript enabled to view it. ).

CITATION:UroToday Int J. 2011 Jun;4(3):art29. doi:10.3834/uij.1944-5784.2011.06.03

ABBREVIATIONS AND ACRONYMS: EDS, Ehlers-Danlos syndrome; TURP, transurethral resection of the prostate.

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Androgen insensitivity syndrome (AIS), also known as testicular feminization, encompasses a wide range of phenotypes that are caused by numerous different mutations in the androgen receptor gene. AIS is an X-linked recessive disorder that is classified as complete, partial, or mild based on the phenotypic presentation. The clinical findings include a female type of external genitalia, 46-XY karyotype, absence of Mullerian structures, presence of Wolffian structures to various degree, and normal to high testosterone and gonadotropin levels. The syndrome is illustrated by a 24-year-old phenotypic female who presented with an inability to conceive, normal-appearing external genitalia, an absent uterus and ovaries, and bilateral testes at the level of the internal inguinal ring. Management includes counseling, gonadectomy to prevent primary malignancy in undescended gonad, and hormone replacement. The karyotyping of family members is advocated because of known familial tendencies.

KEYWORDS: Androgen insensitivity syndrome; Androgen receptor gene; Testicular feminization syndrome; Gonadectomy

CORRESPONDENCE: Dr. Gajanan S. Bhat, Resident in Urology, Institute of Nephrourology, Victoria Hospital Campus, Fort Bangalore- 560 002, Karnataka, India ( This email address is being protected from spambots. You need JavaScript enabled to view it. ).

CITATION: UroToday Int J. 2011 Jun;4(3):art33. doi:10.3834/uij.1944-5784.2011.06.04

ABBREVIATIONS AND ACRONYMS: AIS, androgen insensitivity syndrome (CAIS, complete; MAIS, mild; PAIS, partial); AR, androgen receptor; LH, luteinizing hormone.

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INTRODUCTION: Voiding quality can theoretically be affected by voiding position. It is important to know the effect of voiding position on urometric parameters in order to obtain optimal diagnostic test results, compare data across research investigations, and make recommendations about voiding position for the management of voiding problems. This prospective study was designed to evaluate the effect of changes in voiding position on uroflowmetric findings of young, healthy men.

METHODS: The participants were 31 male volunteers who were asymptomatic of urological disorder. They had an average age of 29.2 years (range, 23-39 years). In each of standing, sitting, and squatting positions, 2 measurements were done (6 separate measurements for each case) and the mean of each pair was determined. Outcome measures were peak flow rate (Qmax), average flow rate, time to peak flow, flow time, and voided volume. A one-way ANOVA was used to compare the voiding positions; a probability value < .05 was considered statistically significant.

RESULTS: The results for the standing, sitting and squatting positions were: mean Qmax of 23.4, 24.4, and 25.8 mL/s, respectively (P = .618); mean for average flow rates of 13.4, 13.0, and 13.9 mL/s, respectively (P = .813); mean flow times of 23.9, 22.1, and 22.9 seconds, respectively (P = .822); mean time to peak flow of 7.8, 8.0, and 6.0 seconds, respectively (P = .119); and mean voided volume of 300, 275, and 290 mL, respectively (P = .631).

CONCLUSION: The present study revealed no statistically significant differences between the standing, sitting, or squatting voiding positions for any of the measured urodynamic parameters. A precise judgment about the effect of voiding position on the uroflowmetric measures of healthy young males needs more investigation using a large number of cases, preferably with heterogeneous typical voiding positions.

Mohsen Amjadi, Sakineh Hajebrahimi, Farzin Soleimanzadeh

Submitted February 7, 2011 - Accepted for Publication March 10, 2011

KEYWORDS: Urodynamics; Uroflowmetry; Voiding position

CORRESPONDENCE: Sakineh Hajebrahimi, Urology Department of Tabriz University of Medical Sciences, Tabriz, Iran ( This email address is being protected from spambots. You need JavaScript enabled to view it. ).

CITATION: UroToday Int J. 2011 Jun;4(3):art 35. doi:10.3834/uij.1944-5784.2011.06.06

ABBREVIATIONS AND ACRONYMS: AFR, average flow rate; Qmax, peak flow rate.

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Calcification in nonrenal carcinoid tumors is common, but it is extremely rare to find calcification in renal carcinoids. Neuroendocrine cells are not found in normal renal parenchyma. We report a case of a 45-year-old male who presented with vague abdominal pain. Investigations showed that he had a calcified mass in the left kidney. We performed a nephrectomy. Histopathological tests showed that it was a carcinoid tumor. The patient was investigated further, but there was no evidence of any extrarenal primary focus of a carcinoid tumor. Whenever a carcinoid of the kidney is diagnosed, a thorough evaluation for another focus of carcinoid tumor is mandated because 54% of reported cases have metastatic lesions at initial presentation. When present, calcification is considered a stigmata of long-term tumor growth and associated with a more indolent course.

Sanjay Kolte, Darshana Tote, Bhushan Wani, Shivashankar Reddy, Girish Moghe

Submitted December 20, 2010 - Accepted for Publication January 31, 2011

KEYWORDS: Renal calcification; Carcinoid tumor

CORRESPONDENCE: Dr. Sanjay Kolte, 35 Balraj Marg, Dhantoli, Nagpur, Maharashtra, 440012, India ( This email address is being protected from spambots. You need JavaScript enabled to view it. ).

CITATION: Urotoday Int J. 2011 Jun;4(3):art28. doi: 10.3834/uij.1944-5784.2011.06.02

ABBREVIATIONS AND ACRONYMS: CT, computed tomography; GI, gastrointestinal.

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Renal cell carcinoma (RCC) accounts for 2% of all cancers. Although it often results in lung metastasis, bony metastases are uncommon. RCC may not be diagnosed until after it has metastasized because the primary tumor can grow fairly large without creating symptoms such as flank pain or a mass in the abdomen. We report a 38-year-old male who presented with right loin pain typical of ureteric colic. Clear cell RCC was not diagnosed until histological evaluation was completed after a nephrectomy. A bone scan showed widespread skeletal metastasis. Use of bone scans and other diagnostic tests for suspected RCC is discussed.

Daben Dawam, Mohammed S Naseem, Paul Ryan, Eric Boye, Matin Sheriff

Submitted December 3, 2010 - Accepted for Publication January 26, 2011

KEYWORDS: Renal cell cancer; Diagnosis; Bone scan; Treatment

CORRESPONDENCE: Daben Dawam, 8 Hilton Road, Cliffe Woods, Rochester, Kent ME3 8LA, England ( This email address is being protected from spambots. You need JavaScript enabled to view it. ).

CITATION: UroToday Int J. 2011 Jun;4(3):art25. doi:10.3834/uij.1944-5784.2011.06.01

ABBREVIATIONS AND ACRONYMS: CT, computed tomography; ECOG, Eastern Cooperative Oncology Group; RCC, renal cell carcinoma.

 

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Renal leiomyosarcomas are rare tumors of the kidney, comprising 0.5% to 1.5% of all malignant renal tumors in adults. A 65-year-old male presented with generalized weakness and flank pain in the right lumbar area for the last 8 months. Radiological imaging revealed a heterogeneous mass in the right kidney, with no lymphadenopathy or venous thrombosis. The tumor measured 15 cm at its greatest axis and replaced almost the entire kidney. His metastatic work-up was negative. He underwent right radical nephrectomy. Histopathology revealed spindle-shaped sarcoma; immunohistochemistry confirmed a primary renal leiomyosarcoma. The patient is doing well 1 year after surgery.

Suresh Kumar, Proshan Jeet, Ranjit Kumar Das, Anup Kumar Kundu, Sandeep Gupta

Submitted December 8, 2010 - Accepted for Publication February 27, 2011

KEYWORDS: Renal mass; Radical nephrectomy; Leiomyosarcoma

CORRESPONDENCE: Dr. Suresh Kumar, Department of Urology, Institute of Post Graduate Medical Education and Research, Seth SukhLal Karnani Memorial Hospital, 601, Doctors PG Hostel, 242 AJC Bose Road, Kolkata- 700020, West Bengal, India ( This email address is being protected from spambots. You need JavaScript enabled to view it. ).

CITATION: UroToday Int J. 2011 Jun;4(3):art34. doi:10.3834/uij.10.3834/uij.1944-5784.2011.06.05

ABBREVIATIONS AND ACRONYMS: CT, computed tomography; RCC, renal cell carcinoma.

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A renal artery pseudoaneurysm (RAP) is created by high-pressure blood passing from a lacerated artery into the renal parenchyma. It has been reported to occur after trauma, renal biopsy, percutaneous nephrostomy, percutaneous nephrolithotomy (PCNL), and open or laparoscopic partial nephrectomy. The incidence of this rare, potentially life-threatening complication is likely to increase with the increasing popularity of endoscopic renal procedures. We present a case of a 60-year-old male who received PCNL for a calculus in the lower calyx of the left kidney. Twenty days after the PCNL, the patient was readmitted due to severe gross hematuria and clot retention. Angiography revealed a pseudoaneurysm arising from the interlobar artery of the lower pole. RAP is often difficult to diagnose and requires a high index of suspicion. We successfully performed coil angiographic embolization, which is considered the most appropriate treatment. Other treatment options are discussed.

Siavash Falahatkar, Hossein Hemmati, Gholamreza Mokhtari, Ahmad Assadollahzadeh, Aliakbar Allahkhah

Submitted January 16, 2011 - Accepted for Publication March 6, 2011

KEYWORDS: Intrarenal; Pseudoaneurysm; Percutaneous nephrolithotomy; Complication; Minimally invasive surgery

CORRESPONDENCE: Dr. Hossein Hemmati, Urology Research Center, Guilan University of Medical Sciences, Sardare Jangal Street, Rasht, Guilan 41448, Islamic Republic of Iran ( This email address is being protected from spambots. You need JavaScript enabled to view it. ).

CITATION: UroToday Int J. 2011 Jun;4(3):art36. doi:10.3834/uij.1944-5784.2011.06.07

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An appendicular mass was discovered in a 44-year-old female recipient of a living donor kidney at the beginning of the transplant surgery. The donor nephrectomy was put on hold while the mass was explored. A perforated appendix was found and an appendectomy was completed with suture ligation of its stump. Because all infected tissue was eliminated, we proceeded with the kidney transplant. Immunosuppression treatment was tailored to the special circumstances. Only antithymocyte globulin was used until the patient had return of bowel function. She was discharged home on regular triple immunosuppression and doing well at the 6-month follow-up examination. The incidental discovery of an appendicular mass at the time of transplant surgery may not be an absolute contraindication to immediate kidney transplantation, if the patient meets specific selection criteria.

Toufeeq Khan, Mirza Anzar Baig, Abdul Haleem

Submitted January 1, 2011 - Accepted for Publication April 8, 2011

KEYWORDS: Live donor kidney transplantation; Immunosuppression; Appendicular mass; Appendectomy

CORRESPONDENCE: Dr. Taqi F Toufeeq Khan MD FRCS, Riyadh Military Hospital, P.O. Box 7897/624, Riyadh, 11159, Kingdom of Saudi Arabia ( This email address is being protected from spambots. You need JavaScript enabled to view it. ).

CITATION: Urotoday Int J. 2011 Jun;4(3):art39. doi:1944-5784.2011.06.09

ABBREVIATIONS AND ACRONYMS: ATG, antithymocyte globulin; DSA, donor-specific antibodies; IG, immune globulin; IV, intravenous; MMF, mycophenolate mofetil; MP, methylprednisone; PE, plasma exchange; WBC, white blood cell.

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INTRODUCTION: Some studies of primary realignment of urethral stricture show higher long-term complication rates than those observed in patients treated with delayed repair, but the results are not thoroughly documented. The purpose of this study was to evaluate the results of early endoscopic management of posttraumatic posterior urethral stricture by visual internal urethrotomy (VIU).

METHODS: Participants were 14 males with posterior urethral strictures following a car accident. All patients had partial injuries to the urethra. The strictures were 1-2 cm long. Participant mean age was 21 years (range, 18-26 years). Patients were evaluated by medical history, clinical examination, laboratory investigations, and radiological imaging. VIU was done within 2 weeks of trauma. Follow-up examinations were done at 1, 3, 6, 12, and 24 months after surgery. Outcome measures were flow rates and postoperative complications.

RESULTS: All patients were continent with satisfactory flow rates. One patient had impotence, but his condition was improved at the 6-month follow-up. Other complications included dysuria (n = 5), urinary tract infection (UTI) (n = 2), and urge incontinence associated with UTI (n = 1). After 12 months, 1 patient required surgical intervention due to a decrease in flow rate and recurrence of stricture.

CONCLUSION: Based on this report of 14 patients, early endoscopic urethral realignment surgery is a safe procedure with few complications. Endoscopic restoration of urethral continuity may be considered for early treatment of posttraumatic posterior urethral stricture.

Ahmed Shelbaia

Submitted March 15, 2011 - Accepted for Publication April 8, 2011

KEYWORDS: Stricture posterior urethra; Early management; Visual internal urethrotomy

CORRESPONDENCE: Dr.Ahmed Shelbaia, MD, Borg Elatbaa, Faisal Street, 5th Floor, Flat 5, Giza, Egypt ( This email address is being protected from spambots. You need JavaScript enabled to view it. ).

CITATION: UroToday Int J. 2011 Jun;4(3):art43. doi:10.3834/uij.1944-5784.2011.06.13.

ABBREVIATIONS AND ACRONYMS: UTI, urinary tract infection; VIU, visual internal urethrotomy.

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INTRODUCTION: The effect of a transurethral catheter on urodynamic pressure-flow studies has been questioned, especially for patients with bladder outlet obstruction (BOO). The purpose of this retrospective study was to compare urodynamic outcomes measured during free uroflowmetry with pressure-flow studies using a transurethral catheter.

METHODS: We retrospectively reviewed the records of 22 adult patients who had voided volume that did not differ by more than 20% during 2 assessments: free uroflow and pressure-flow with a transurethral 5 Fr catheter in situ. The outcome measures were maximum flow (Qmax), average flow rate, voiding time, time to Qmax, and flow acceleration. Free uroflow and pressure-flow outcomes were compared using paired t tests. A Bonferroni adjustment was applied; probability < .01 was considered statistically significant.

RESULTS: There were 17 males and 5 females. The mean age was 39.9 years (range, 18-80 years). The urodynamic findings were reported as: normal (n = 6), hypocontractile detrusor (n = 5), BOO (n = 5), overactive bladder symptom complex (n = 4), and low pressure-low flow system (n = 2). Qmax was significantly higher during free uroflow than during pressure-flow recordings (P = .001). Average flow rate was also significantly higher during free uroflow (P < .001). Voiding time was significantly slower and acceleration was significantly faster during free uroflow (both with P = .001). There was no significant difference between recording conditions in the time to Qmax.

CONCLUSION: There appears to be a significant decrease in some uroflow measurements with a 5 Fr urethral catheter in situ during pressure-flow studies, which is contrary to the previous claim that any catheter smaller than 6 Fr does not alter the results. This measurement artifact needs to be considered when interpreting urodynamic studies, particularly if the patient has BOO. To compensate for differences between the free uroflow rate and uroflow rate with a catheter, the free uroflow rate and detrusor pressure may need to be considered when evaluating the degree of BOO.

Gajanan S Bhat, Girish G Nelivigi, Chandrashekhar S Ratkal, Venkatesh G K

Submitted February 19, 2011 - Accepted for Publication March 10, 2011

KEYWORDS: Bladder outlet obstruction; Urodynamics

CORRESPONDENCE: Dr. Gajanan S. Bhat, Resident in Urology, Institute of Nephrourology, Victoria Hospital Campus, Fort Bangalore- 560 002, Karnataka, India ( This email address is being protected from spambots. You need JavaScript enabled to view it. ).

CITATION: UroToday Int J. 2011 Jun;4(3):art37. doi:10.3834/uij.1944-5784.2011.06.08

ABBREVIATIONS AND ACRONYMS: BOO, bladder outlet obstruction; Pdet, detrusor pressure; Qmax, maximum flow.

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