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Background. Long-term urologic complications after total hip arthroplasty are rare, and reports in the urologic literature are scant. We present a recent case and review the relevant literature. Case. A 77-year-old man was referred to the urology clinic for a single episode of gross painless hematuria, abnormal urine cytology, and pelvic mass. He had a significant smoking history. Surgical history included right total hip arthroplasty 21 years prior. Results. Pelvic ultrasound revealed a large mass abutting the right bladder wall. Subsequent computed tomography indicated that the mass was extrinsic to the bladder. Results of computed tomography-guided biopsy of the mass were consistent with foreign body granuloma. Surveillance imaging confirmed no growth or progression, and intervention was deferred. Conclusion. Long-term complications of total hip arthroplasty may present with signs and symptoms of urologic disease. Reports in the urologic literature are rare.

Purpose: An operative performance rating system for urology residents was developed for 6 sentinel urological procedures. We tested the reliability, validity and feasibility of the operative performance rating system for urology residents., Materials and Methods: The operative performance rating system of each procedure contained a 3-point case difficulty scale, 4 to 6 procedure specific items, 3 general items and an overall performance item. A Likert scale of 1 to 5 was used for each item. A single video/audio record of each procedure was evaluated by the faculty. Single item interrater agreement was measured by comparing the observed variance and random measurement error variance. Resident operative performance evaluations were completed on line. Internal consistency reliability was measured using Cronbach α. Overall scale scores by resident training postgraduate year level were compared using 1-way ANOVA., Results: Faculty evaluation of video/audio records showed an interrater agreement range of 0.71 to 0.92. Faculty evaluations of resident operative performance demonstrated an internal consistency reliability range of 0.91 to 0.95. Significant differences in overall scale scores between postgraduate year levels were noted for 3 of the 6 procedures (p ≤0.0016)., Conclusions: An operative performance rating system for urology residents is feasible using an Internet based resident management system. Interrater agreement and internal consistency reliability meet threshold limits for checklist evaluation instruments. The operative performance rating system can discriminate among postgraduate year levels of resident training. A validated operative performance rating system can offer residents immediate, objective feedback on surgical performance and enable program directors to monitor progress in resident operative performance., (Copyright © 2012 American Urological Association Education and Research, Inc. Published by Elsevier Inc. All rights reserved.)

Aim: Recent trends in surgery for the renal mass indicate that the type of surgery performed may depend largely on surgeon practice style. Since 2004 we have used an interdisciplinary approach for the surgical treatment of the renal mass. We report the results of this practice including oncologic and surgical outcomes., Methods: A prospective database of patients undergoing treatment for renal mass was analyzed. Minimally invasive surgery (MIS) was performed by a laparoscopist, and open surgery was performed by a urologic oncologist. Demographic and clinicopathologic data were compared between treatment groups using nonparametric analysis of variance., Results: Of 120 patients treated for renal mass, 34% were treated after internal referral, 34% with nephron sparing surgery (NSS), 68% with MIS, and 32% with open surgery. Internal referrals accounted for 77% of patients who underwent open partial nephrectomy (OPN), 32% who underwent open radical nephrectomy (ORN), and 26% who underwent MIS. There were no significant differences in gender, mean ASA, or smoking history between groups. Patients in the ORN group were more likely symptomatic (P<0.001). Patients undergoing ORN or LRN had larger tumors than those undergoing open or laparoscopic partial nephrectomy (OPN and LPN) (P<0.001). Tumor stage, grade, and positive margin rate were highest in the ORN group (P<0.001). Hospital stay was shortest in the MIS and NSS groups (P<0.001). Complications were not different between groups., Conclusion: An interdisciplinary approach to the treatment of renal mass involving both a laparoscopist and urologic oncologist may reduce the impact of surgeon practice style on the type of surgery performed.

Objectives: The purpose of this study is to evaluate the utility of second opinion pathology in patients who are seen in consultation for urologic malignancy., Methods: We retrospectively reviewed the records of all patients who were seen at our institution in consultation for urologic malignancy from August 2002 to April 2008. All available pathologic slides were reviewed by the urologist and pathologist at the time of consultation and compared with the original diagnosis. Discrepant diagnoses were reviewed by at least 2 pathologists. Diagnostic disagreements were graded as minor or major according to the significance of their effect on treatment or prognosis. We report the proportion and types of diagnostic discrepancies and their impact on patient care., Results: A total of 264 patients were seen in consultation. Of these, 213 had pathologic material available for review: prostate cancer 117 (55%), bladder cancer 83 (39%), testis cancer 5 (2%), renal pelvis or ureteral cancer 5 (2%), retroperitoneal tumor 2 (1%), and kidney cancer 1 (0.5%). Disagreement with the original diagnosis was found in 22 cases (10%), of which 18 (8%) were classified as major, and 4 (2%) were classified as minor. Interventions avoided or delayed, as a direct result of second opinion pathology, were a prostate biopsy in 1 patient, management of metastatic prostate cancer in 1 patient, partial nephrectomy in 1 patient, management of urothelial carcinoma in situ (CIS) in 1 patient, and radical cystectomy in 5 patients. Interventions recommended or performed were radical prostatectomy in 1 patient, and radical cystectomy in another. Additional pathology from subsequent biopsy or surgery was available in 12 of the 22 patients, and the second opinion pathologic diagnosis was supported in all patients., Conclusions: A second opinion review of surgical pathology for urologic malignancy can result in major therapeutic and prognostic changes, which can impact patient care. Our results support the review of all pathology by the urologist and pathologist as part of the consultation in patients with urologic malignancy., (Copyright © 2011 Elsevier Inc. All rights reserved.)

Purpose: The purpose of this study was to evaluate the influence of potential contributing factors to the incidence of seed slippage and quality of prostate brachytherapy dosimetry comparing "coated" vs. "bare" seeds with a Mick applicator., Methods and Materials: Two consecutive groups of 89 patients were treated with (125)I prostate brachytherapy at a high treatment volume single institution. All the patients were evaluated with Day 0 plain films of the pelvis and CT-based dosimetry analysis. The incidence of seed slippage was quantified. The seed slippage outcome was evaluated with respect to source type (bare vs. coated). The Day 0 prostate V(100), V(150), D90%, rectal V(100), and urethra D(30) outcomes were evaluated with respect to source type., Results: A total of 13,512 seeds were placed in 178 patients. An average of 76 seeds and 16 needles were used for each patient. The bare seed group was significantly higher on fluoroscopy minutes (2.34 vs. 1.58 min), seed slippage (5 vs. 1.5 mm), volume of rectum receiving 100% of dose (0.05 vs. 0.0 cc), dose percentage received by 30% of urethra (119% vs. 113.64%), and volume of prostate receiving 100% of prescription dose (95.21% vs. 92.8%). No significant differences in volume of prostate receiving 150% of prescription dose, dose percentage received by 90% of prostate, vascular seed migration, or operating room procedure time were seen. No seed drift greater than 10mm outside the "packet" of other seeds was seen in the AnchorSeed (BrachySciences, a division of Biocompatibles, Inc. Oxford, CT) cohort., Conclusion: The report is the first to show the unique "fixity" of AnchorSeed to remain in position after deployment from the Mick applicator. Minimizing seed drag can reduce dose to the penile bulb, and maximize radiation coverage to the apex of the gland., (Copyright (c) 2010 American Brachytherapy Society. Published by Elsevier Inc. All rights reserved.)

Benign prostatic hyperplasia (BPH) is a frequent cause of lower urinary symptoms, with a prevalence of 50% by the sixth decade of life. Hyperplasia of stromal and epithelial prostatic elements that surround the urethra cause lower urinary tract symptoms (LUTS), urinary tract infection and acute urinary retention. Medical treatments of symptomatic BPH include; 1) the 5alpha-reductase inhibitors, 2) the alpha1-adrenergic antagonists, and 3) the combination of a 5alpha-reductase inhibitor and a alpha1-adrenergic antagonist. Selective alpha1-adrenergic antagonists relax the smooth muscle of the prostate and bladder neck without affecting the detrussor muscle of the bladder wall, thus decreasing the resistance to urine flow without compromising bladder contractility. Clinical trials have shown that alpha1-adrenergic antagonists decrease LUTS and increase urinary flow rates in men with symptomatic BPH, but do not reduce the long-term risk of urinary retention or need for surgical intervention. Inhibitors of 5alpha-reductase decrease production of dihydrotestosterone within the prostate resulting in decreased prostate volumes, increased peak urinary flow rates, improvement of symptoms, and decreased risk of acute urinary retention and need for surgical intervention. Interim results of the ongoing Combination of Avodart and Tamsulosin (CombAt) study have shown combination therapy with the 5alpha-reductase inhibitor dutasteride and the alpha1-adrenergic antagonist tamsulosin offer significant improvements from baseline compared with either drug alone.

Benign prostatic hyperplasia (BPH) is a frequent cause of lower urinary symptoms, with a prevalence of 50% by the sixth decade of life. Hyperplasia of stromal and epithelial prostatic elements that surround the urethra cause lower urinary tract symptoms (LUTS), urinary tract infection, and acute urinary retention. Medical treatments of symptomatic BPH include; 1) the 5alpha-reductase inhibitors, 2) the alpha1-adrenergic antagonists, and 3) the combination of a 5alpha-reductase inhibitor and a alpha1-adrenergic antagonist. Selective alpha1-adrenergic antagonists relax the smooth muscle of the prostate and bladder neck without affecting the detrussor muscle of the bladder wall, thus decreasing the resistance to urine flow without compromising bladder contractility. Clinical trials have shown that alpha1-adrenergic antagonists decrease LUTS and increase urinary flow rates in men with symptomatic BPH, but do not reduce the long-term risk of urinary retention or need for surgical intervention. Inhibitors of 5alpha-reductase decrease production of dihydrotestosterone within the prostate resulting in decreased prostate volumes, increased peak urinary flow rates, improvement of symptoms, and decreased risk of acute urinary retention and need for surgical intervention. The combination of a 5alpha-reductase inhibitor and a alpha1-adrenergic antagonist reduces the clinical progression of BPH over either class of drug alone.

Purpose: We report on 4 patients who presented with nonpalpable testicular masses discovered on scrotal ultrasound, and offer treatment recommendations based on our experience and a review of the literature., Materials and Methods: Four patients underwent intraoperative ultrasound guided localization and excisional biopsy of nonpalpable testicular parenchymal masses. Radical orchiectomy was performed in 2 patients because of testicular cancer. Patient age, clinical presentation, ultrasound results, frozen section and permanent pathology results are reported., Results: During a 3-year period 1,040 scrotal ultrasounds were performed for indications other than retroperitoneal mass at a single institution, and nonpalpable testicular parenchymal masses were discovered in 4 patients with an age range of 22 to 31 years. Testis mass size ranged from 5 to 6 mm in maximum diameter and serum tumor markers were negative in all patients. Frozen section pathology indicated benign lesions in all patients and permanent pathology revealed seminoma in 2 of the patients who underwent delayed radical orchiectomy. Permanent pathology of orchiectomy specimens did not reveal residual invasive tumor., Conclusions: Intraoperative ultrasound guided localization and excisional biopsy is a reasonable treatment option for patients with nonpalpable incidental testicular masses. Excisional biopsy with margins that show normal testicular tissue is essential in testis sparing surgery and patients must be cautioned that final pathology may indicate the need for delayed radical orchiectomy.

Purpose: We evaluated how naturally occurring heterophile antibodies in patient serum interfered with prostate specific antigen (PSA) immunoassay, resulting in over treatment for prostate cancer., Materials and Methods: Serum samples were treated with heterophilic blocking reagent (Scantibodies Laboratory, Inc., Santee, California). Treated and untreated samples were tested by the Medics (Tosoh, Foster City, California ) Tandem-R (Beckman-Coulter Inc., Chaska, Minnesota) and Elecsys (Roche Molecular Biochemical, Indianapolis, Indiana) PSA assays. Heterophile antibodies were measured directly in treated and untreated samples by the human anti-mouse antibody immunoradiometric assay and heterophilic antibody identification enzyme immunoassay (Scantibodies Laboratories, Inc.)., Results: Human anti-mouse Ig heterophile antibodies in patient serum caused false-positive PSA test findings after radical prostatectomy, resulting in over treatment for presumed disease recurrence., Conclusions: If PSA is detectable after radical prostatectomy and the likelihood of incomplete resection or systemic disease is low, the presence of heterophile antibodies should be considered.

Prostaglandins of the E series (PGE) were measured in the culture supernatants of peripheral blood mono-nuclear cells (PBMC) obtained from patients with human immunodeficiency virus (HIV) infection. Cell culture supernatants from 6 patients with acquired immunodeficiency disease (AIDS) and 11 patients with AIDS-related complex contained significantly higher concentrations of PGE than those from a group of 6 healthy HIV-negative male homosexual control subjects. The PGE producer cells were among the population of plastic-adherent PBMC. Transformed B lymphocyte cell lines spontaneously derived from the blood of patients with AIDS secrete a factor that stimulates normal donor adherent PBMC to produce PGE. The HIV permissive H9 cell line stimulated a significantly lower level of PGE production, which was not associated with HIV infection.

Purpose: Since 1982 the Kock ileal reservoir has been the primary form of urinary diversion in patients requiring lower urinary tract reconstruction at our institution. The intussuscepted afferent nipple valve of the Kock ileal reservoir is designed to prevent reflux and protect the upper urinary tract. Problems associated specifically with the afferent antireflux valve have been few. We defined and characterized all complications associated with the Kock pouch antireflux nipple valve., Materials and Methods: From November 1984 through July 1992, 802 patients underwent construction of a continent Kock ileal reservoir. All complications associated with the afferent antireflux valve in this group and their management were identified., Results: Overall, 79 of 802 patients (9.8%) had a total of 84 complications of the afferent antireflux valve (10.4%), including formation of stones on staples securing the afferent nipple valve in 42 cases (5.2%), stenosis of the afferent valve in 35 (4.3%) and prolapse of the valve in 7 (0.9%). A total of 81 patients required surgical intervention to correct the afferent valve complication: 56 (7.0%) were treated endoscopically and 25 (3.1%) required open surgical revision., Conclusions: We report an overall complication rate of 10.4% associated with the afferent antireflux nipple valve in the Kock ileal reservoir. Most complications can be treated endoscopically without difficulty on an outpatient basis with the use of local sedation. With these results, and only a 3% incidence of open surgical correction of all afferent nipple problems, we encourage the continued use of the intussuscepted afferent nipple valve whenever continent urinary diversion is performed.

Purpose: Entero-conduit fistulas have been reported in patients with ileal and jejunal conduit urinary diversions, and entero-pouch fistulas have been reported in those with Kock pouch and other ileal neobladders. We now report that entero-pouch fistula is a rare complication of continent urinary diversion using the right colon., Materials and Methods: A review of the charts of 146 patients who had undergone right colon urinary diversion during the last 6 years revealed that entero-pouch fistula developed in 3. A total of 36 patients had had previous pelvic radiation, including the 3 with entero-pouch fistulas. Two patients presented with nausea, vomiting and abdominal pain, and 1 presented with diarrhea and food particles in the urine. Hyperchloremic metabolic acidosis was present in 2 of the patients and radiography of the pouch confirmed the diagnosis in all 3., Results: Conservative therapy, which included a low residue diet and continuous drainage of the pouch, was successful in 2 of the 3 patients and surgical excision of the entero-pouch fistula was required in 1 since the fistula did not close after 12 weeks., Conclusions: Although rare, an entero-pouch fistula should be suspected in patients who present with gastrointestinal symptoms and hyperchloremic metabolic acidosis after right colon reservoir urinary diversion. Conservative therapy is recommended initially.

Perspective and prospective considerations of the immunoregulatory properties of seminal plasma and their biological and/or clinical relevance are presented. Further understanding of the interactions of the immune system with exocrine products of the male reproductive system may contribute to improvements in reproductive health and to an understanding of the antithetical aspects of the immune response represented by such biological phenomena as insemination, pregnancy and malignancy.

We have defined the nature of genetic control of humoral immunity to sperm cell surface (TSDA) and acrosome (Ac) antigens. A sperm immunization dose that distinguishes between high-responder (BALB/c) and low-responder (B10) strains of mice was identified. B10 mice were unresponsive, whereas BALB/c and F1 hybrid mice responded to sperm of both parental strains. The ratio of nonresponder to responder mice in the B10 X F1 backcross and F1 X F1 inbred generations indicates anti-TSDA or anti-Ac antibody responsiveness is controlled through more than a single gene. The significant correlation found between the anti-TSDA and anti-Ac responses is consistent with the possibility that one or more genes controls antibody responsiveness against determinants common to both the Ac and sperm cell surface. Neither anti-TSDA nor anti-Ac antibody responses were linked to the I-A subregion of the responder H-2d MHC haplotype. In addition to a genetic difference in the control of humoral immunity to sperm, a difference in sperm immunogenicity among strains was observed. Antigens of the Ac of B10 sperm are more immunogenic than those of BALB/c sperm, and this trait is linked to the B10 Y chromosome.

Repeated semen deposition in the gut may be linked to the development of viral infections in homosexual men. Other investigators have suggested that rectal insemination may diminish immune responsiveness. We approximated conditions of human insemination by infusing 2 ml of pooled human seminal plasma (SP) into the rectum and/or vagina of rhesus monkeys. This resulted in increased blood plasma concentrations of the bicycloderivative of prostaglandin E (PGEM-II) which reached peak concentrations 2 h after rectal SP instillation in seven of eight test monkeys, but not the controls. The rate of PGE2 diffusion appeared to occur more rapidly across vaginal than rectal mucosa. Suppression of peripheral cellular immune functions was not demonstrated after the single exposure of this study, although persistent and repeat exposures could lead to local or generalized suppression of host defense mechanisms. Absorption of PGE's from the gut may be a cofactor in the development of sexually transmitted viral diseases.

Human seminal plasma has an anticomplement effect that can be measured by a standard immune hemolytic assay. We found that about 20% of samples lack complement-inhibiting activity. To determine the anatomical origin of a complement inhibitor, inhibition of hemolysis was measured in seminal plasma samples that were primarily of prostatic, vesicular, or epididymal/testicular origin, as well as in seminal plasma from vasectomized men. All samples contained complement-inhibiting activity, although epididymal fluid showed nearly twice the amount. Therefore, the factor (or factors) is ubiquitous in secretions of the male reproductive tract. Complement-inhibiting activity is eluted in two high-molecular-weight peaks upon gel filtration. We found evidence that the inhibitory factor is not lactoferrin, a proteinase, or one of the proteinase inhibitors known to be present in human seminal plasma. It seems likely that the complement inhibitor in seminal plasma protects gametes and reproductive tissues from complement-mediated damage.

Mouse seminal plasma (SP), a mixture of aqueous extracts of prostate, seminal vesicle, and epididymis, exerts potent immunosuppressive effects in vivo. The SP mixture completely suppressed both primary and secondary humoral immune responses in mice to low immunizing doses of antigen (bovine serum albumin or washed epididymal sperm), and also significantly suppressed the antibody response to high doses of immunizing antigen. The humoral immune response to epididymal sperm was also suppressed when sperm were incubated in SP and then washed before immunization and when SP was administered at a secondary site (i. p.) at the time of sperm immunization (subcutaneous). When SP components were tested individually in in vitro assays, all of them (prostate, seminal vesicle, and epididymis) suppressed mitogen-induced lymphocyte transformation. Prostatic fluid also inhibited complement-mediated hemolysis in a standard immune hemolytic assay. These data indicate that potent immunosuppressive factors are present at several locations within the male reproductive tract; these factors may serve to protect sperm from immunologic damage and prevent sensitization of females to sperm antigens after insemination.

Human seminal plasma (SP) was found to contain a potent suppressor of human natural killer (NK) cell cytotoxic activity against the K562 erythroleukemia target in vitro. Pooled and filter-sterilized SP reduced the NK cell activity of normal blood donors in a concentration-dependent manner; strong reduction of target cell lysis was observed at a final dilution of 1/400. Possible toxic effects of SP on NK cells were ruled out, because donor leukocytes incubated in a final SP dilution of 1/100 remained greater than 99 percent viable as determined by trypan blue exclusion. SP did not affect the lysability of the tumor targets, but suppressed the cytotoxic activity of the effector leukocytes, an effect that was reversed after washing the leukocytes free of the SP. The suppressive action of SP was retained after heating to 95 degrees C for 10 min, but was removed after adsorption with activated charcoal (Norit-A). Lipids extracted from SP were tested for suppression of NK cell cytotoxic activity, and the active principle was identified with the acidic lipid fraction. Components of the acidic lipid fraction of a single freshly obtained SP sample were separated by high pressure liquid chromatography, and suppression of NK cell cytotoxic activity was found to be associated with the predominant prostaglandins (PG) in this fraction, 19-OH-PGE1 and 19-OH-PGE2. Suppression of cellular immune functions by SP has been described; however, the identity of the suppressor factor (or factors) is unknown. The 19-OH-PGE are present in high concentration in primate semen, and may minimize immunologic sensitization to sperm in females after insemination. In addition, these compounds may suppress NK cell antitumor and antiviral activities in the vagina, as well as in their tissues of origin.