Analysis of energy loss mediated by an alpha-1 blocker in patients with benign prostatic hyperplasia using a virtual urethra processed from an endoscopic video image

Abstract Purpose: To examine the efficacy of an alpha-1 blocker and its correlation to structural alteration of the prostatic urethra and the loss of energy in the urine flow using a virtual urethra processed from an endoscopic video image. Materials and Methods: Video images of the prostatic urethra were recorded during cystourethroscopy in 11 patients with benign prostatic hyperplasia (BPH) before and after treatment with an alpha-1 blocker, naftopidil. The three-dimensional (3D) structure of the prostatic urethra was reproduced from video files. Fluid dynamic analysis and hydraulic energy calculations were performed using the "virtual" 3D urethral images. Results: In 9 of 11 patients studied, an 11% improvement in the loss of energy (range, 1%-82%) was seen. Alpha-1 blocker treatment mediated the disappearance or decrease of the bulky vortex formation in seven patients, which led to an improved urinary stream. A positive correlation was found between improved energy loss and residual urine volume (P=0.0312). Conclusion: Alpha-1 blocker therapy led to a decreased energy loss in the urine flow in the prostatic urethra in relation to the improvement of clinical symptoms. The cystourethroscopy could be a tool to assess the urethral resistance in patients with BPH using image processing methodology.     

Two cases of ectopic prostatic tissue in the prostatic urethra

Two cases of ectopic prostatic tissue or adenomatous polyps with prostatic type epithelium in the prostatic urethra were reported. They were 30-and 33-year-old males suffering from gross-hematuria and from urethral pain on urination with terminal gross-hematuria. Endoscopic examination revealed papillary lesions from the dilated orifice of the prostatic utricle. Biopsied pathology demonstrated a tissue similar to that of the prostatic gland. PSA (prostatic specific antigen) stain using immunohistochemical methods was positive. Histogenesis and the importance of this lesion particularly as a cause of hematuria in the young male adult were discussed.     

Genitourinary neurofibromatosis mimicking posterior urethral valves

A 12-year-old boy, examined after an episode of acute urinary retention, was found to have neurofibromatosis of the bladder neck and prostatic urethra. His symptoms of bladder outlet obstruction and radiographic findings of a dilated prostatic urethra mimicked posterior urethral valves. Complete urologic investigation, including cystourethroscopy, revealed that the dilatation of the prostatic urethra was secondary to neural involvement of the external sphincter and posterior urethra without mechanical obstruction or posterior urethral valves.     

Clinical manifestations of 25 patients with prostatic-type polyps in the prostatic urethra

To clarify the clinical manifestations of prostatic-type polyps (PP) in the prostatic urethra, a sample of 25 patients with PP who presented themselves to our hospital with hematuria or hematospermia was reviewed with respect to their symptoms and endoscopic findings. Recurrence of the conditions was also investigated. The patients were 26 to 68 years old, with a mean age of 48.5 years. Sixteen patients (64%) had hematuria and 8 (32%) had hematospermia. A bloody urethral discharge was observed in 6 patients (24%). Analysis of the character of the hematuria showed that total hematuria occurred in 44% of the patients. In 38% of the patients with hematospermia there was the additional symptom of post-ejaculatory hematuria. PP developed beside the verumontanum in 18 patients (72%), on the posterior urethral wall lateral to the verumontanum in 4 patients (16%), and on the verumontanum in 7 patients (28%). The prognosis could be investigated only in 22 (88%) of the 25 patients. Two patients (9%) experienced reccurrence during the follow-up period (1 to 5.8 years, mean: 3.7 years). Consequently, special attention should be paid to the possibility of PP in the prostatic urethra, particularly the verumontanum and nearby area, during endoscopic examination, when diagnosing patients with hematuria, hematospermia or with bloody urethral discharge.     

Evaluation and management of traumatic posterior urethral disruption with flexible cystourethroscopy

BACKGROUND: We sought to consolidate evaluation and management of traumatic urethral disruption using cystourethroscopic evaluation without retrograde urethrogram or suprapubic cystostomy placement. METHODS: We review our experience with initial flexible cystourethroscopic evaluation of suspected urethral injury from blunt trauma with placement of a Council urethral catheter to provide primary endoscopic realignment of the urethra. RESULTS: Access into the bladder was achieved in 8 of 10 patients. After a mean follow-up of 18 months (range, 9-27 months) in the six living patients, only three have required treatment for urethral stricture--direct vision internal urethrotomy in two, and open perineal urethroplasty in one. Urinary continence has been achieved in five of six patients. CONCLUSION: Primary flexible cystourethroscopy with placement of a urethral catheter streamlines evaluation of traumatic posterior urethral injury. In the presence of partial disruption it provided stricture-free outcomes in three of three surviving patients.     

Isolated posterior urethral injury： an unusual complication and presentation following male coital trauma

We describe an unusual complication of coital trauma in a 29-year-old man who presented with a 3-year history of hematospermia and post-coital gross hematuria. Using urethroscopy under a semi-tumescent penis, an isolated urethral injury with active bleeding was detected at the prostatic urethra. The patient was successfully treated with transurethral fulguration. We suggest that isolated posterior urethral injury is one of the causes of male coital trauma, which might be asymptomatic when the penis is flaccid but show symptomatic bleeding when the penis is erect.     

单一后尿道损伤:一例罕见的男性性交外伤并发症

描述一例罕见的性行为后外伤并发症。患者为一名29岁年轻男子,有持续三年血精和性交后血尿的病史。在半勃起状态下,使用尿道镜检查,在前列腺尿道处发现一个尿道损伤出血点。我们使用经尿道电烧成功治疗这名病人。我们认为单一的后尿道损伤也可能是性行为后外伤的原因,在阴茎未勃起状态下可能毫无症状,而阴茎勃起后才开始有出血的症状。     

Inverted papilloma of the prostatic urethra: a report of two cases

Two men with inverted papilloma of the prostatic urethra are reported. Case 1 was a 67-year-old man with complaints of gross hematuria and urinary retention. Urethroscopy revealed a smooth-surface tumor with a stalk at the prostatic urethra. Case 2 was a 76-year-old man with complaints of gross hematuria and urinary retention. In these cases, the tumors were resected transurethrally and were consistent with inverted papilloma histopathologically.     

The role of computerized tomographic urography in the initial evaluation of hematuria

PURPOSE: We determined the usefulness of computerized tomographic urography for the initial evaluation of patients with hematuria as an alternative to excretory urography. MATERIALS AND METHODS: A total of 259 patients (140 men and 119 women), age range 20 to 100 (mean 59.4) years, underwent computerized tomographic urography for the evaluation of hematuria and were available for followup. A cohort of 253 patients (153 men, 100 women), age range 21 to 92 (mean 57.6) years, underwent conventional excretory urography and were evaluated for comparison. RESULTS: A source of hematuria was identified in 107 patients (41.3%) in the computerized tomographic urography cohort and in 103 patients (40.7%) in the excretory urography cohort. Computerized tomographic urography alone identified a source of hematuria in 25.5% of these patients with the most commonly diagnosed lesions being renal calculi (18.9%), ureteral calculi (2.7%) and renal pelvic masses (2.3%) in the upper tract (0.94 sensitivity), and bladder masses (8.1%), prostatic abnormalities (5.4%) and inflammatory disorders (3.5%) in the lower tract (0.40 sensitivity, 0.99 specificity). The overall detection rate (19.5%), most commonly diagnosed lesions, and lower urinary tract sensitivity and specificity were similar in the excretory urography cohort. However, excretory urography exhibited a markedly lower sensitivity in detecting upper tract lesions (0.50). CONCLUSIONS: Computerized tomographic urography exhibited a significantly higher sensitivity than conventional excretory urography in detecting upper tract pathology (94.1% vs 50%). However, sensitivity for detecting lower tract lesions was low (40% or less), suggesting that computerized tomographic urography offers a comprehensive alternative to excretory urography but does not obviate the need for adjunctive cystourethroscopy for accurate evaluation of the lower urinary tract.     

What is the ratio of urethral recurrence risk after radical cystoprostatectomy for bladder cancer?

Objective: There is always a risk of urethral recurrence after radical cystoprostatectomy in patients with bladder transitional cell cancer. Taking these risk factors of urethral recurrence into account, orthotopic neobladders or urinary diversions without using the urethra are performed. But urethral tumour recurrence occurs much less than the expected. We assessed the etiological factors that affect the urethral recurrence in orthotopic and nonorthotopic urinary diversion cases. Methods: Sixty-four patients with bladder cancer who underwent radical cystoprostatectomy and urinary diversion between 1994 and 2002 were included this study. Conventional risk factors effecting the selection of operation type and urethral recurrence were evaluated in these patients. Cystoscopy and biopsy were done and pathologic specimen was obtained preoperatively, and cystoscopy and urethral washout cytology were done postoperatively. Routine bladder biopsies were done in uncertain cases at follow-up. Risk factors increasing the urethral recurrence are as follows: papillary and multiple tumours, tumour invading bladder neck and trigone, extensive CIS, prostatic stromal and urethral invasion, positive surgical margin and history of upper urinary tract tumour. In 31 patients having one or more of these criteria, continent nonorthotopic urinary diversion was performed, but 33 patients without these risk factors underwent orthotopic urinary diversion. Simultaneous urethrectomy was not done in any of these patients. Results: Among the patients who underwent radical cystoprostatectomy, none was with positive surgical margin in the distal end of the prostatic urethra. In preoperative cystoscopy, tumoural mass was seen near to collum in eight patients and in the prostatic urethra in three patients. Histopathological examination of cystoprostatectomy specimen displayed transient epithelial cell carcinoma of prostatic urethra in three patients, transient epithelial cell metaplasia inside the prostate in five patients and invasion to the urothelium of bladder neck in three patients. There were not any transient epithelial cell cancer metastases in prostatic stroma in any of these patients. One patient underwent urethrectomy, since atypical cells were observed in postradical prostatectomy urethral washout cytology but there was no tumour found in pathological examination of the specimen. Therefore, urethral tumour recurrence did not occur after 25 months follow up. Conclusion: These findings suggest that some of the conventional risk factors of urethral recurrence were exaggerated. We may also conclude that there is no need for prophylactic urethrectomy unless there is urethral cancer or cancer in the surgical margin. But if utilization of urethra is planned, evaluation of prostatic stroma by TUR biopsies and urethral anastomose margin by frozen section during the operation is necessary.     

Brunn's nests and glandular metaplasia: normal urothelial variants in the supramontanal prostatic urethra

Sections of 292 transurethral prostatic resection specimens and 52 intact prostatic urethral specimens from male patients 10 to 89 years old were examined for the presence of Brunn's nests and glandular metaplasia in the urothelium of the supramontanal prostatic urethra. The complex pitted urethral mucosa at and below the verumontanum was not assessed. Either or both lesions were present focally in 211 transurethral prostatic resection specimens (72 per cent) and in 51 intact urethral specimens (97.5 per cent). Brunn's nests and glandular metaplasia consisted chiefly of transitional cells but in 47 transurethral prostatic resection cases glandular metaplasia contained prostatic acinar-type cells and in 1 case intestinal-type goblet cells were noted. Brunn's nests and glandular metaplasia were associated with inflammation in only 27 per cent of the cases and were not associated with dysplasia or urethral tumors except for 1 benign papilloma. We conclude that Brunn's nests and glandular metaplasia are so common in the supramontanal prostatic urethra that they represent normal urothelial variants in this segment of the urinary tract.     

Papillary adenoma of the prostatic urethra

Acquired polyps of the male urethra often present with hematuria and sometimes hemospermia. The histogenesis of these tumors has been debated. We report a case of a prostatic urethral polyp that proved to be of prostatic epithelial differentiation, as demonstrated by immunohistochemical identification of prostatic acid phosphatase and prostatic specific antigen within the tumor cells.     

DOES PROSTATE TRANSITIONAL CELL CARCINOMA PRECLUDE ORTHOTOPIC BLADDER RECONSTRUCTION AFTER RADICAL CYSTOPROSTATECTOMY FOR BLADDER CANCER?

Purpose

We determined if urethral preservation and orthotopic bladder replacement in patients with transitional cell carcinoma within the prostatic urethra or prostate placed these patients at risk for urethral recurrence or death.

Materials and Methods

The clinical course of all patients undergoing urethral preservation and orthotopic bladder replacement was reviewed. The urethra was sacrificed only if the distal prostatic urethral margin was positive for transitional cell carcinoma. The pathological T stage and the grade of the primary malignancy, local recurrence, site of recurrence (urethral, pelvic, distant) and death were documented.

Results

Of 81 patients, 70 were evaluated (June 1996) with a mean followup of 35 months. Of the 70 patients 48 were alive without evidence of disease for a mean of 38 months (range 8 to 107) and 5 died without evidence of disease. Eight of these 53 patients (15%) had prostatic involvement (carcinoma in situ in 6, intraductal carcinoma in 1 and stromal invasive transitional cell carcinoma in 1). Of the 70 patients 17 had disease recurrence (13 died of disease and 4 are alive, 1 of whom had urethral recurrence without initial prostatic transitional cell carcinoma). Of the 17 patients (35%) 6 had transitional cell carcinoma prostatic involvement (carcinoma in situ in 4 and stromal invasion in 2), and 5 of these 6 died, none with or of urethral recurrence but of the primary bladder pathology. Of these 5 patients 1 had stromal invasive transitional cell carcinoma of the prostate and experienced a bulbar urethra recurrence at 1 month and a pelvic recurrence at 3 months, and died at 5 months. Death was not secondary to the urethral recurrence. Thus, of the 14 patients who had prostatic transitional cell carcinoma, only 1 had urethral recurrence (7%), and this recurrence did not present as the cause of death.

Conclusions

The guidelines for urethral resection can be relaxed, increasing the opportunities for orthotopic reconstruction, without placing the patients at increased risk for death of transitional cell carcinoma.     

Papillary adenoma of the prostatic urethra: Report of two cases

Papillary adenoma of the prostatic urethra is a rare cause of hematuria, hemospermia and lower urinary tract obstruction, especially in young adults. We report two cases of papillary adenoma and their endoscopic views. One of the patients had a lesion located on the verumontanum and presented with hematuria, hemospermia and symptoms of lower urinary tract obstruction. The other patient had papillary lesions located in the paramontanal gutter and presented with persistent painless hematuria. The origin of both lesions was proven to be prostatic epithelial differentiation using immunohistochemical identification of prostate-specific antigen. Papillary adenoma is believed to be benign, therefore, both lesions were carefully excised and fulgurated transurethrally.     

A case of papillary adenocarcinoma of the prostate which was difficult to diagnose]

We report a case of papillary adenocarcinoma of the prostate found by urethroscopy. An 84-year-old male visited our hospital complaining of initial hematuria in July 1997. No abnormal findings were detected despite repeated urological examinations until endoscopic examination revealed fine papillary tumors in the prostatic urethra along with benign prostatic hyperplasia-like prominent left lobe of the prostate in June 2000. Serum prostate specific antigen (PSA) level was 4.1 ng/ml. He underwent transurethral resection of the urethral tumors and the prominent lobe, which was found to contain packed papillary tumors. Both of these tumors were well differentiated papillary adenocarcinoma most likely originating from the prostate because PSA immunostaining was positive. The prostate was irradiated postoperatively. Papillary adenocarcinoma localized in the prostate is difficult to diagnose preoperatively.     

Utricular papilloma

A benign prostatic utricular papilloma was found in a twenty-seven-year-old man complaining of urethral bleeding and intermittent hematuria after sexual intercourse. Local endoscopic resection was performed. Since the natural history of this lesion is not known, follow-up cystourethroscopy will be performed.     

Papillary prostatic epithelial hyperplasia of the urethra: a cause of hematuria in young men

We describe 4 cases of gross hematuria in young men due to papillary urethral lesions composed of prostatic-type epithelium. The clinical presentation, cystourethroscopic and pathological findings, and management are reviewed. A possible histogenesis is proposed based on a comparison of surgical biopsy tissues from 4 cases with prostatic urethral sections of 8 autopsy cases with no known genitourinary problems.     

Urethral calculi.

The diagnosis and management of 34 men and 13 women with urethral calculi are reviewed. A majority of patients presented with dysuria, weak stream and perineal pain. Diagnosis was made radiographically in only 42 per cent but was confirmed in all patients who underwent cystourethroscopy. All patients had lower urinary tract lesions or previous prostatic operations and 47 per cent were infected. Migrant urethral calculi were encountered 10 times more often than were native stones and a metabolic cause was found in 10 of 18 patients studied. In men penile urethral calculi were removed transurethrally and all bulbous and most posterior urethral stones were guided endoscopically into the bladder. Most of these stones were irrigated out or removed by transurethral litholapaxy; the remaining few, together with vesical calculi, required cystolithotomy. In all 13 women calculi were removed at the time of urethral diverticulectomy. A majority of 17 men (76.5 per cent) and the 4 women who were followed for an average of 5.3 years have remained free of trouble.     

Effects of indwelling catheters on the urethral mucosa (polypoid urethritis)

Indwelling catheters are almost invariably associated with characteristic mucosal lesions of the urinary bladder, commonly referred to as polypoid cystitis. In the present study, 20 male patients with indwelling catheters (due to benign prostatic hyperplasia) for 1-12 months were studied. Three non-catheter bearing male patients served as controls. Biopsies were taken from the posterior urethra in all patients and from the bladder in 16 of the 20 patients with indwelling catheters. All patients with catheters had endoscopic lesions in the urethra. The lesions varied from polypoid to bullous or oedematous, with or without hemorrhagic discoloration. In 11 of 20 patients the urethral lesions were histologically almost identical to polypoid cystitis. In the remaining 9 patients the reaction was less pronounced, and oedema, with or without mucosal hemorrhage, dominated. Due to the similarity between the catheter associated bladder lesions and the urethral lesions we suggest the term polypoid urethritis for the urethral lesions. There was no correlation between type of catheter used or how long it was used and the mucosal lesions. The results suggest mechanical irritation and/or pressure exerted by the catheter on the mucosa is responsible for the development of polypoid urethritis.