The spiralling costs of antibiotic therapy, the appearance of multiresistant bacteria and more importantly for patients and clinicians, unsatisfactory therapeutic options in recurrent urinary tract infection (RUTI) calls for alternative and advanced medical solutions. So far no sufficient means to successfully prevent painful and disabling RUTI has been found. Even though long-term oral antibiotic treatment has been used with some success as a therapeutic option, this is no longer secure due to the development of bacterial resistance. One promising alternative is the use of live microorganisms (probiotics) to prevent and treat recurrent complicated and uncomplicated urinary tract infection (UTI). The human normal bacterial flora is increasingly recognised as an important defence to infection. Since the advent of antibiotic treatment five decades ago, a linear relation between antibiotic use and reduction in pathogenic bacteria has become established as medical conventional wisdom. But with the use of antibiotics the beneficial bacterial flora hosted by the human body is destroyed and pathogenic bacteria are selectively enabled to overgrow internal and external surfaces. The benign bacterial flora is crucial for body function and oervgrowth with pathogenic microorganisms leads to illness. Thus the concept of supporting the human body's normal flora with live microorganisms conferring a beneficial health effect is an important medical strategy.

Urinary tract infection (UTI) is a common problem in infants and children. Children at risk for UTI such as vesicoureteric reflux (VUR) commonly receive prophylactic antibiotics to prevent renal scarring, which may lead to complications such as hypertension or end-stage renal disease. Recurrent UTI, with or without VUR, is the most common reason for long-term antibiotic prophylaxis in infants and children. However, the efficacy and importance of long-term antibiotic prophylaxis have not been assessed in well-controlled, prospective studies. Nitrofurantoin, trimethoprim/sulfamethoxazole have been used as prophylactic antibiotics for the prevention of UTI in children. Such medications are mostly safe in children for the long-term prophylactic therapy. Serious side effects are extremely rare and most are reversible with discontinuation of therapy. Although it is difficult to perform prospective studies in children and many factors are involved in the clinical course and prognosis of these patients, further studies are needed to evaluate the actual benefits of prophylactic antibiotics. Meanwhile, in infants and children with risk factors, long-term antibiotic prophylaxis should be considered, at least until there is evidence that these patients are not endangered by avoiding it.

Objective: To understand role of mitochondrial (mt) mutations in genes regulating oxidative phosphorylation (OXPHOS) in pathogenesis of male infertility. Infertility affects approximately 15% of couples trying to conceive. Infertility is frequently attributed to defects of sperm motility and number. Mitochondrion and mitochondrial DNA (mtDNA) play an important role in variety of physiological process. They control the oxidative energy supply and thus are central to growth, development and differentiation. Mitochondrial function is controlled by a fine-tuned crosstalk between mtDNA and nuclear DNA (nDNA). As mitochondria supply energy by OXPHOS, any mutation in mtDNA disrupts adenosine triphosphate (ATP) production and thus result in an impaired spermatogenesis and impaired flagellar movement. As sperm midpiece has few mtDNA copies, thus enhanced number of mutant mtDNA results in early phenotypic defect which manifest as spermatogenic arrest or asthenozoospermia. Oxidative stress and mtDNA mutations are positively correlated and mutations in mitochondrial genome (mt genome) are implicated in the lowered fertilising capacity of the sperm and affects the reproductive potential of an individual. Materials and Methods: A thorough review of articles in the last 15 years was cited with reference to the below-mentioned keywords. The articles considered discuss the role of mt genome in the normal functioning of sperm and the factors associated with mt mutations and impact of these mutations on the reproductive potential. Results: Sperm motility is a very important factor for the fertilisation of ova. The energy requirements of sperm are therefore very critical for sperm. Mutations in the mitochondrial genes as COX II, ATPase 6 and 8 play an important role and disrupts ATP production affecting the spermatogenesis and sperm motility. Therefore, the aberrations in mt genome are an important etiopatholgy of male infertility. Conclusion: In the context of male infertility, mt mutations, generation of reactive oxygen species and lowered antioxidant capacity are interlinked and constitute a unified pathogenic molecular mechanism. In the era of assisted reproduction technique (ART), it is very important to distinguish between mutations in nuclear and mitochondrial genomes in sperm, as mtDNA mutations are better diagnostic and prognostic markers in infertile men opting for ART.

Purpose of Review: A cooperative patient is essential in maintaining stone targeting for optimal fragmentation during extracorporeal shock wave lithotripsy (ESWL). Therefore, it is important to choose an appropriate analgesic with minimal adverse effects. The guidelines for pain management during ESWL have not been established. Current Status: Various analgesic agents including opioids (morphine, pethidine, and fentanyl), nonsteroidal anti-inflammatory drugs (NSAIDS - diclofenac, propofol, ketorolac, and piroxicam), local anesthetic agents and a number of combinations have been used during ESWL by various techniques (general anesthesia, regional anesthesia, subcutaneous and intravenous injections, patient-controlled analgesia, and monitored anesthesia care). Cutaneous creams like eutectic mixture of local anesthesia (EMLA) whether used alone or in combination with oral NSAIDS have also been used and are able to reduce analgesic requirements. Topical application of a combination of dimethyl sulfoxide and lidocaine has also been found to be effective. Conclusion: The ideal analgesic, offering optimal pain control, minimal side effects, and cost-effectiveness is still elusive. Opioids administered using various techniques, provide effective analgesia, but require active monitoring of patient for potential adverse effects. Combination therapy (oral NSAID and occlusive dressing of EMLA, DMSO with lidocaine) offers an effective alternative mode for achieving analgesia with minimal morbidity. This therapy avoids the need for general anesthesia, injectable analgesics, and opioids along with their side effects.

Aim: Our aim was to review the current literature describing the endoscopic management of upper tract transitional cell carcinoma (TCC). Materials and Methods: Review of published, peer-reviewed articles relating the primary ureteroscopic or percutaneous management of upper tract TCC was performed using the MEDLINE database. Results: Historically, the gold-standard management for upper tract TCC consists of nephroureterectomy with excision of a bladder cuff. The employment of endoscopic management with these neoplasms was initially instituted in individuals with imperative indications, including bilateral disease, solitary kidney, and/or renal insufficiency. For individuals treated with ureteroscopy, recurrence rates range from 30 to 71% and cancer-specific survival rates from 50 to 93%. Results are dependent primarily on tumor grade and stage. In individuals with low-stage, low-grade tumors treated percutaneously, recurrence rates, and cancer-specific survival rates are 18-33% and 94-100%, respectively. Adjuvant therapy has been employed with thiotepa, mitomycin, and BCG, but none have been able to demonstrate a statistically significant difference in recurrence or cancer-specific survival rates. Conclusions: Endoscopic management is a safe and effective treatment alternative to nephroureterectomy in the management of upper tract TCC. Survival outcomes are comparable, but renal preservation therapy offers the advantage of reduced morbidity, complications, and the potential for better quality of life. Recurrence and disease progression are not uncommon and underscore the need for strict tumor surveillance.

Background: We report our experience with the treatment of classic exstrophy of the bladder in a small series of seven adult males. There are very few documented cases of adults presenting with exstrophy of bladder in literature. Materials and Methods: Adult males presenting with classic exstrophy of the bladder and complete epispadias underwent detailed evaluation including psychological assessment and counseling. All were explained regarding the surgical procedure and informed about the need for self-catheterization. Prior to 2002 all patients underwent cystectomy of the existing bladder plate, with creation of catheterizable modified Mainz pouch. Since 2002 patients were assessed for bladder reconstruction with augmentation ileocystoplasty, bladder neck reconstruction, and abdominal wall closure. Results: Seven adult males with classic exstrophy of the bladder and complete epispadias who had not received any previous treatment presented to us during the period 1991-2006. Five of these underwent cystectomy with continent pouch and the remaining two underwent bladder reconstruction. All have been doing well with improved self-esteem and social interaction. Two of these have married and leading a satisfactory sexual relationship. Conclusions: Surgical correction in adults with exstrophy of the bladder greatly improves self-esteem, confidence, and social relationship.

Aim: Atypical adenomatous hyperplasia (AAH) is a small glandular proliferation that has histological similarities with Gleason grade 1 and 2 prostatic adenocarcinoma (PACG1,2). There are no distinct histomorphological criteria distinguishing these two lesions from each other and other small glandular proliferations. Because treatment approaches are different for these lesions, it is necessary to determine histological criteria. The aim of this study is to review the histological features of these two lesions and to define new histological criteria distinguishing AAH from PACG1,2. We, therefore, assessed 18 anatomical and structural parameters. Materials and Methods: We found 11 AAH (22 foci) and 15 PACG1,2 (22 foci) cases in 105 radical prostatectomy specimens. Basal cell-specific antikeratin was applied to these lesions. We assumed that PACG1,2 lesions did have not basal cells and we grouped the lesions as AAH and PACG1,2 based on this assumption. Results: We found differences between AAH and PACG1,2 lesions for some parameters including the number of glands, structures such as the main ductus and basal cells. We found similar properties in the two lesions for the following parameters: localization, multiplicity, diameter of the lesion, focus asymmetry, distance between glands, inflammatory cells in and out of the lesions, secretory cell shape on the luminal side, papillary projection towards the luminal side of gland, the shape of the outer gland, the infiltrative pattern of the gland, glandular pleomorphism, biggest gland diameter and median gland diameter. Conclusion: We determined that concurrent evaluation of histomorphological features was important to differentiate between AAH and PACG1,2.

Objectives: Examining the clinical efficacy on the interferential low frequency therapy (IF) for elderly nonneurogenic (idiopathic) overactive bladder patients with urgent urinary incontinence (wet OAB) prospectively, for whom anticholinergics were not effective. Materials and Methods: Subjects are elderly 80 patients (69-78, median age 72.0) with urinary incontinence, who are clinically diagnosed with wet OAB without urodynamics (pressure/flow study). For 3 months, they were administered anticholinergics (propiverine hydrochloride 20 mg/once per day in the morning), but all their quality of life (QOL) score were 4 or over due to poor control of storage symptoms and urinary incontinence. We selected patients for whom anticholinergics were not effective (above-mentioned 80 patients) and they were provided with IF alone for 3 months with informed consent. Before and after IF, the followings were examined. (1) frequency of IF treatment required to show optimal effects, (2) average weekly frequency of incontinence, (3) 60-min pad test, (4) frequency and voided volume in the daytime and nighttime, (5) fluid intake volume, (6) International Prostate Symptom Score, quality of life score, (7) Uroflowmetry, (8) postvoid residual urine volume, (9) specific gravity of urine, (10) average hours spent outdoors, (11) average radius of action and activities of daily life score, (12) standing blood pressure (BP) and heart rate, (13) clinical laboratory findings, (14) adverse events, (15) plasma osmotic pressure (OP), and (16) Brain natriuretic peptide (BNP). Results: (1) The patients showed improvements for eight treatments (median). Improvement was observed in the followings: (2), (3), (4) voiding frequency, (6), (7) voided volume, maximum and average flow rate, (10), (11), (12) BP, (15) OP, and (16). Conclusions: The IF has safe and better effects than anticholinergics on the elderly wet OAB patients.

Background: Overactive bladder (OAB) is a bothersome condition affecting the quality of life, financial constraint on the individual, and community. Anticholinergic drugs cannot be used for long term due to adverse side effects. Botulinum toxin has recently shown promising and encouraging result in management of OAB. Aim: Aim was to study the safety, efficacy, tolerability, and duration of effect of 200 units of botulinum toxin in refractory idiopathic detrusor overactivity. Materials and Methods: Thirty-nine female patients (average age of 52 years) clinically and urodynamically diagnosed as idiopathic OAB were injected 200 units of botulinum toxin-A mixed with 20 ml of normal saline, intradetrusally at the rate of 1 mL at each site for 20 such sites sparing the trigone and ureteric orifices. Follow up at 3rd, 6th, 9th, and 12th month with clinical and urodynamical questionnaire was done. Results: There were 4 dropouts and 35 patients were evaluated, of which 30 patients (85.7%) showed improvement in clinical features like frequency, urgency, nocturia, and incontinence within 1 week of injection, which lasted for mean period of 7 months (varying from 6 to 9 months). Volume at first desire to void improved from median baseline of 104-204 ml and maximum cystometric capacity of bladder increased from mean baseline value of 205-330 ml. The detrusor pressure decreased by 49% from the baseline and postresidual urine volume increased by 30% of maximum cystometric capacity of bladder. There was no adverse effect on our patient. Conclusion: Intradetrusor injection of Botox-A in management of refractory overactive idiopathic bladder is not only safe and well tolerated, but also very effective with practically no side effects.

Nonsystemic review of the literature was done for timing of surgery, preoperative evaluation and plan, anesthesia, suture materials, magnification, tissue handling, stent and diversion problems, intra and postoperative care, dressing, and follow-up protocol. The best time for hypospadias repair is between 6 and 18 months. Preoperative evaluation in proximal hypospadias includes hormonal and radiological examination for intersex disorders, as well as for upper tract anomalies along with routine evaluation. General anesthesia is a rule but local blocks help in reducing the postoperative pain. Magnification, gentle tissue handling, use of microsurgical instruments, and appropriate-sized stent for adequate period help in improving the results. Hormonal stimulation is useful to improve growth and vascularity of urethral plate and decrease the severity of chordee in poorly developed urethral plate with severe curvature. Urethral plate preservation urethroplasty with spongioplasty is the procedure of choice in both proximal and distal hypospadias. Algorithms are proposed for management of hypospadias both with curvature and without curvature. Two-stage urethroplasty has its own indications. A good surgical outcome may be achieved following basic surgical principles of microsurgery, fine suture materials, choosing one or two-stage repair as appropriate, proper age of surgery, and with good postoperative care. Future of hypospadiology is bright with up coming newer modalities like laser shouldering, robotics, and tissue engineering.

Purpose: Recognition the urethral plate comprises tissues that normally should have created the urethra was an important milestone in hypospadias surgery, giving rise to new operative repairs - most notably the tubularized incised plate technique. This article reviews the current state of the art for hypospadias repair using tubularized, incised plate (TIP). Materials and Methods: Personal experience and literature reports were reviewed to summarize use of TIP urethroplasty for distal, proximal, and re-operative hypospadias repairs. Results: The TIP can be used to correct all distal and most proximal hypospadias. The major contraindication is ventral curvature that leads to urethral plate transection for straightening, which is only necessary in some proximal cases. Reoperations can also be performed using TIP provided the urethral plate has been maintained and is not grossly scarred. Complication rates are comparable to previously used techniques, while cosmetic appearance after TIP is considered superior to other available procedures. Conclusions: Recognition of the urethral plate and its incorporation into the neourethra has revolutionized hypospadias repair. The most commonly used operative procedure today is TIP.

The modern hypospadiologist must be proficient in the use of both vascularized flaps and free grafts. When choosing a repair for any given patient with hypospadias, one must consider the length of the urethroplasty, the presence and degree of ventral curvature and perhaps most importantly, the surgeon's own experience. Not all repairs are created equally and different complication rates and cosmetic outcomes can be seen among different surgeons utilizing the same technique. Each surgeon tends to infuse their own modifications to any given technique and many of these modifications go unreported. It is incumbent upon each surgeon to be familiar with a wide variety of techniques, which invariably includes the use of flaps and grafts. We present a spectrum of the uses of flaps and grafts in modern hypospadiology.

Perineal and penoscrotal hypospadias were often managed by two-stage urethroplasty with variable results and significant number of these may need third surgery. Though modified Koyanagi one-stage repair has a learning curve, it has all the advantages of two-stage repair. The aim was to review the results of modified Koyonagi repair from the literature and our own centre experience.

Hypospadias surgery continues to evolve. The enthusiasm for flap-based urethroplasty is waning and instead there is an increasing preference for urethroplasty that uses either the urethral plate alone or in combination with grafts. From the vast armamentarium of hypospadias repairs that are still in use, the author suggests a simple protocol of just three closely related procedures with which we can now repair almost all hypospadias. The tubularised incised plate (TIP) repair and the 'Snodgraft' modification of the TIP principle are simple and effective one-stage solutions when partial circumference urethroplasty is required. Conversely, the Bracka two-stage graft repair remains an ideal and versatile solution when a full circumference urethroplasty is required. It is particularly appropriate for severe primary hypospadias associated with a poor plate and marked chordee and also to replace a scarred, hairy or balanitis xerotica obliterans diseased urethra in re-operative salvage hypospadias.

The tubularized incised plate (TIP) urethroplasty or Snodgrass procedure has gained worldwide acceptance for distal hypospadias repair due to its low complication rate, good cosmetic result, and technical simplicity. As a result, several articles have been published concerning various aspects and subtle variations of this procedure. The aim of this review is to critically and systematically analyze the published complication rates of TIP repair for distal hypospadias in children. We also reviewed the surgical modifications that have been introduced to the original technique and discussed the potential impact on the final outcome of the Snodgrass procedure.

We provide the reader with a nonsystematic review concerning the use of the two-stage approach in hypospadias repairs. A one-stage approach using the tubularized incised plate urethroplasty is a well-standardized approach for the most cases of hypospadias. Nevertheless, in some primary severe cases, in most hypospadias failures and in selected patients with balanitis xerotica obliterans a two-stage approach is preferable. During the first stage the penis is straightened, if necessary and the urethral plate is substituted with a graft of either genital (prepuce) or extragenital origin (oral mucosa or postauricular skin). During the second stage, performed around 6 months later, urethroplasty is accomplished by graft tubulization. Graft take is generally excellent, with only few cases requiring an additional inlay patch at second stage due to graft contracture. A staged approach allows for both excellent cosmetic results and a low morbidity including an overall 6% fistula rate and 2% stricture rate. Complications usually occur in the first year after the second stage and are higher in secondary repairs. Complications tend to decrease as experience increases and use of additional waterproofing layers contributes to reduce the fistula rate significantly. Long-term cosmetic results are excellent, but voiding and ejaculatory problems may occur in as much as 40% of cases if a long urethral tube is constructed. The procedure has a step learning curve but because of its technical simplicity does not require to be confined only to highly specialized centers.

Many classifications of hypospadias have been published, mainly based on the position of the ectopic meatus, which is an insufficient criterion to define the severity of this malformation. What really marks the proximal landmark of this malformation is the level of division of the corpus spongiosum, which is always proximal to the ectopic meatus. In this article, we will focus on the most severe forms of hypospadias which include those with a proximal division of corpus spongiosum (below the midshaft), important chordee and a poor development of the ventral radius, reflecting a marked hypovirilization of the genital tubercle, and cripple hypospadias resulting from several previous failed surgical procedures. The principle of hypospadias surgery will be reviewed together with the outcome of the current surgical techniques. Furthermore, common complications will be outlined. There is no minor or major hypospadias and all forms require a solid experience of the surgeon, as minor looking hypospadias may turn out to be far more complex to repair than they appear once the ventral radius of the penis has been dissected.

Purpose: Complications in hypospadias surgery are higher than other reconstructive procedures. The incidence of complications can be reduced if proper preventive measures are taken. The review aims to highlight incidences, causes, and preventive measures of acute complications of hypospadias repair. Materials and Methods: Literature reports were reviewed in Pubmed by giving the key word acute complications of hypospadias repair, wound infection, wound dehiscence, flap necrosis, edema, penile torsion, urethral fistula, bleeding and hematoma and urethral stents problems. Summaries of all articles were reviewed with full text of relevant article and results were analyzed. Results: Besides mentioning the complications of hypospadias repair in individual articles on the subject, we did not come across any separate article on this subject in the published English literature. Fistula is the commonest complication followed by edema and penile torsion. Conclusions: Most acute complications can be prevented with adherence to principles of plastic and microsurgery, meticulous preoperative planning, and judicious postoperative care. Deviation from these principles may lead to disaster and even failure of the repair. The aim in hypospadias surgery should be following these principles and bring down the complication rates <5% in distal hypospadias and <10% in proximal hypospadias.

Hypospadias is a highly prevalent congenital anomaly. The impact of the defect and operative interventions on sexual and reproductive function has been addressed by few publications. It is essential to know the possible outcomes of intervention for appropriate counseling, operative planning, and follow-up. English articles indexed in Pubmed dealing with the long-term sexual and reproductive outcome following hypospadias repair from 1965 to 2007 were reviewed. To our knowledge, there was no prospective trial comparing the impact of various techniques on sexual outcome. There is considerable discordance in literature regarding the effects on sexual function. A few publications report patient and partner dissatisfaction with the appearance of genitalia. Sexual dissatisfaction is often attributed to penile size. Ejaculatory disturbances range between 6 and 37% of operated individuals. There is no convincing evidence for impaired fertility. The long-term follow-up is essential to identify problems and to address them appropriately. Literature documenting the outcome of specific operative procedures and analysis based on severity of hypospadias will be informative. The long-term follow-up of the newer techniques which are more commonly used are awaited.

Epitheloid hemangioendothelioma is an uncommon vascular neoplasm and has an unpredictable clinical behavior. It is characterized by round or spindle-shaped endothelial cells with cytoplasmic vacuolation. Most often, epitheloid hemangioendothelioma arise from the soft tissues of the upper and lower extremities and it has borderline malignant potential. We describe the first reported case of epitheloid hemangioendothelioma in the urinary bladder, which was treated by transurethral resection. The diagnosis was confirmed by immunohistochemistry.

A patient who was treated for renal cell carcinoma and transitional cell carcinoma, later presented with end stage renal disease. He was managed with hemodialysis and later underwent successful renal transplantation. There was no evidence of tumor recurrence nearly nine years post-renal transplantation.

A case of 14-year-old girl is reported who presented with features of tuberculous subacute intestinal obstruction. Exploratory laparotomy revealed a urachal cyst associated with pseudomyxoma peritonei (PMP). Histopathology confirmed a moderately differentiated mucin secreting adenocarcinoma of urachal cyst associated with PMP. The adenocarcinoma of urachal cyst associated with PMP is further reviewed.

Malakoplakia of the ureter is a rare pathological entity. We discuss a 15-year-old girl with malakoplakia of the ureter. She presented with obstructive uropathy associated with left flank pain. Radiological investigations showed left lower ureteric stricture without bladder or kidney involvement. She was treated by excision of terminal ureter and ureteroneocystostomy. Histopathologic examination of the excised specimen showed malakoplakia. Postoperative course was uneventful and on follow-up, she has normal serum creatinine and no recurrence of the disease.

External urinary drainage devices are in wide clinical uses. There are only a few reports of complications from improper use of condom catheters. We present a case of fibroepithelial polyp of the penis, due to long-term usage of condom catheter. The lesion affected the ventral aspect of the penis. He was successfully treated with wide local excision. The histopathological diagnosis was a fibroepithelial polyp.

The repair of midshaft or more proximal hypospadias generally leads to a deficiency of ventral penile skin. Transposition of dorsal/lateral skin flaps may lead to redundant skin folds or shoulders. In most cases, redundant skin can be avoided by appropriate tailoring and positioning of the flaps. We describe a simple method to correct these folds when they are unavoidable.

Sarcomatoid carcinomas are biphasic tumors, which can occur at any site in the human body. Very few cases have been reported in the literature as arising from the penis. A few studies consider these tumors as a variant of squamous cell carcinoma or a metaplastic differentiation of the mesenchyme. Their clinical behavior is aggressive with both blood borne and lymphatic metastases. Treatment is by surgical excision, and dissected lymph nodes have shown both epithelial and sarcomatous components. We report a 50-year-old gentleman, with a sarcomatoid carcinoma of the penis, which was confirmed immunopathologically. The rarity of this entity makes it a clinicopathologic curiosity.

Vesicouterine fistula (VUF) the least common of the urogynecological fistulae. Hysterosalphingography is the gold standard investigation in demonstrating the fistulous track. It is an invasive investigation. We report a case of VUF where magnetic resonance imaging was useful to diagnose the condition in a non-invasive manner especially when the clinical picture was confusing.