Volume 44 | number 2 | March . Abril, 2018 – Lower pole renal stone: flexible ureteroscopy or shockwave lithotripsy? The anatomy is the key
Vol. 44 (2): 211-212, March – Abril, 2018
EDITORIAL in This Issue
The March-April 2018 issue of the International Braz J Urol presents original contributions with many interesting papers in different fields: BPH, Renal stones, Prostate Cancer, Renal Cell Carcinoma, Bladder Cancer, Uretrhal Strictures, Prostatitis, Urinary Incontinence, Urinary Tract Infections, Ureteropelvic Junction Obstruction, Laparoscopy and Renal Anomalies. The papers come from many different countries such as Brazil, USA, Turkey, China, Italy, Lebanon, Argentina, Spain, Canada, Thailand and India, and as usual the editor´s comment highlights some papers. We decided to comment the paper about a very interesting topic: The treatment of the lower pole stones.
Vol. 44 (2): 213-214, March – Abril, 2018
DIFFERENCE OF OPINION
Carlos A. R. Sacomani 1, Ricardo Vita Nunes 2
1 Departamento de Urologia, AC Camargo Cancer Center, SP, Brasil; 2 Divisão de Urologia, Universidade de São Paulo, USP, São Paulo, SP, Brasil
Keywords: Lasers; Therapeutics; Prostatic Hyperplasia; Transurethral Resection of Prostate
During the past decades, transurethral resection of the prostate (TURP) has been the gold-standard procedure for surgical treatment of benign prostatic hyperplasia (BPH) and became the second most common surgery in men in the Western world (1). A number of other techniques were developed through the years, trying to replace TURP, including vaporization, microwave thermotherapy, transurethral needle ablation (TUNA) and various types of laser therapies. The rational of looking for new therapies for BPH lies on the intention of delivering the same results with less complications and adequate length of stay at the hospital or even as an outpatient procedure. Indeed, morbidity and mortality following TURP are continuous issues. Reich et al. (2) evaluated 10,654 patients that underwent TURP in state of Bavaria, Germany.
Vol. 44 (1): 215-218, March – Abril, 2018
DIFFERENCE OF OPINION
Fernando G. Almeida 1, 2, Luciano Teixeira Silva 2
1 Departamento de Disfunções Urinárias, Urologia Feminina e Urodinâmica, 2 Departamento de Urologia, Universidade Federal de São Paulo, UNIFESP, Escola Paulista de Medicina, São Paulo, SP, Brasil
Keywords: Lasers; Therapeutics; Prostatic Hyperplasia; Transurethral Resection of Prostate
Benign prostate enlargement (BPE) is a highly prevalent pathology (1). The main consequence of BPE is Bladder Outlet Obstruction (BOO). Patients with BOO may be bothered by voiding lower urinary tract symptoms (LUTS). Those men with BOO and significant LUTS which did not respond to clinical approaches may be candidate to surgical procedures.
In patients with prostate volume inferior to 80-100 grams, monopolar transurethral resection of prostate (TURP) has been considered the gold standard for decades. The American Urological Association (AUA) considered TURP as standard treatment for BPH (2) and The European Urological Association considered TURP “the treatment of choice” for prostates sized 30 to 80 cm3 (3).
Efficacy of targeted therapy for advanced renal cell carcinoma: a systematic review and meta-analysis of randomized controlled trials
Vol. 44 (2): 219-237, March – Abril, 2018
Chao Wei 1, 2, Shen Wang 1 ,2, Zhangqun Ye 1, 2, Zhiqiang Chen 1, 2
1 Department of Urology and 2 Institute of Urology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
We conducted a systematic review and meta-analysis of the literature on the efficacy of the targeted therapies in the treatment of advanced RCC and, via an indirect comparison, to provide an optimal treatment among these agents. A systematic search of Medline, Scopus, Cochrane Library and Clinical Trials unpublished was performed up to Jan 1, 2015 to identify eligible randomized trials. Outcomes of interest assessing a targeted agent included progression free survival (PFS), overall survival (OS) and objective response rate (ORR). Thirty eligible randomized controlled studies, total twenty-fourth trails (5110 cases and 4626 controls) were identified. Compared with placebo and IFN-α, single vascular epithelial growth factor (receptor) tyrosine kinase inhibitor and mammalian target of rapamycin agent (VEGF(r)-TKI & mTOR inhibitor) were associated with improved PFS, improved OS and higher ORR, respectively. Comparing sorafenib combination vs sorafenib, there was no significant difference with regard to PFS and OS, but with a higher ORR. Comparing single or combination VEGF(r)-TKI & mTOR inhibitor vs BEV + IFN-α, there was no significant difference with regard to PFS, OS, or ORR. Our network ITC meta-analysis also indicated a superior PFS of axitinib and everolimus compared to sorafenib. Our data suggest that targeted therapy with VEGF(r)-TKI & mTOR inhibitor is associated with superior efficacy for treating advanced RCC with improved PFS, OS and higher ORR compared to placebo and IFN-α. In summary, here we give a comprehensive overview of current targeted therapies of advanced RCC that may provide evidence for the adequate targeted therapy selecting.
Keywords: Carcinoma, Renal Cell; Therapeutics; Meta-Analysis as Topic; Interferons
The association between the outcomes of extraperitoneal laparoscopic radical prostatectomy and the anthropometric measurements of the prostate by magnetic resonance imaging
Vol. 44 (2): 238-247, March – Abril, 2018
Sompol Permpongkosol 1, Supanun Aramay 2, Thawanrat Vattanakul 2, Sith Phongkitkarun 2
1 Division of Urology, Department of Surgery, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok 10400, Thailand; 2 Department of Diagnostic and Therapeutic Radiology, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
Introduction and objective: To determine the association between the anthropometric measurements by magnetic resonance imaging (MRI) and perioperative outcomes of extraperitoneal laparoscopic radical prostatectomy (ELRP).
Materials and Methods: From 2008 to June 2016, 86 patients underwent preoperative MRI prior to undergoing ELRP for localized prostate cancer. We analyzed the associations between anthropometric measurements of MRI and the perioperative outcomes of patients who underwent ELRP.
Results: The mean patient age was 69.61±8.30 years. The medians of operating time and blood loss were 2.30 hours and 725.30ml, respectively. The total post-surgical complication rate was 1.16%. The median hospital stay was 6.50 days. The pathological stages for T2 and T3 were 45.74% and 34.04%, respectively. The rate as positive surgical margins (PSMs) was 18.09% (pT2 and pT3; 6.38% and 9.57%). The angles between pubic bone and prostate gland (angle 1&2), were significantly associated with operative time and hospital stay, respectively (p<0.05). There was no correlation between the pelvimetry and positive surgical margin.
Conclusions: The findings of the present study suggest that anthropometric measurements of the MRI are related to operative difficulties in ELRP. This study confirmed that MRI planning is the key to preventing complications in ELRP.
Keywords: Prostatectomy; Prostatic Neoplasms; Magnetic Resonance Imaging, Laparoscopy
High-intensity Focused Ultrasound (HIFU) as salvage therapy for radio-recurrent prostate cancer: predictors of disease response
Vol. 44 (2): 248-257, March – Abril, 2018
Shawn Dason 1, Nathan C. Wong 1, Christopher B. Allard 1, Jen Hoogenes 1, William Orovan 1 and Bobby Shayegan 1
1 Division of Urology, McMaster University, Hamilton, ON, Canada
Background: Some men with localized radio-recurrent prostate cancer may benefit from salvage high-intensity focused ultrasound (HIFU). Herein, we describe oncologic outcomes and predictors of disease response after salvage whole gland HIFU from our prospective cohort.
Materials and Methods: Patients with localized radio-recurrent prostate cancer were prospectively enrolled from January 2005 to December 2014. Participants had to meet both biochemical and histological definitions of recurrence. Exclusion criteria included the receipt of prior salvage therapy, presence of metastatic disease, and administration of ADT in the 6-months prior to enrollment. Participants were treated with a single session of whole-gland HIFU ablation with the AblathermTM device (EDAP, France). The primary endpoint was recurrence-free survival (RFS), defined as a composite endpoint of PSA progression (Phoenix criteria), receipt of any further salvage therapy, receipt of ADT, clinical progression, or death. Kaplan-Meier survival analysis was used to determine the primary end-point and stratifications were used to determine the significance of 6 pre-specified predictors of improved RFS (TRUS biopsy grade, number of study entry TRUS biopsy cores positive, palpable disease at study enrollment, pre-HIFU PSA, an undetectable post-HIFU PSA nadir, and receipt of prior hormone therapy). Survival analysis was performed on participants with a minimum of 1-year follow-up.
Results: Twenty-four participants were eligible for study inclusion with a median follow-up of 31.0 months. Median PSA at study entry was 4.02ng/ml. Median time to PSA nadir was 3 months after treatment and median post-HIFU PSA nadir was 0.04ng/ ml. Median 2-year and 5-year RFS was 66.3% and 51.6% respectively. Of our 6 pre-specified predictors, an undetectable PSA nadir was the only significant predictor of improved RFS (HR 0.07, 95% CI 0.02-0.29, log-rank P<0.001). One participant underwent an intervention for a urethral stricture. No participants developed osteitis pubis or rectourethral fistulae.
Conclusions: Salvage HIFU allows for disease control in selected patients with localized radio-recurrent prostate cancer. An undetectable PSA nadir serves as an early predictor of disease response.
Keywords: High-Intensity Focused Ultrasound Ablation; Prostatic Neoplasms; Erectile Dysfunction
Prostate cancer incidentally discovered at the time of radical cystoprostatectomy does not decrease overall survival: Results from a large Chinese medical center
Vol. 44 (2): 258-266, March – Abril, 2018
Shiying Tang 1, Han Hao 1, Dong Fang 1, Wei Zheng 1, Peng Ge 1, Xiaohong Su 1, Qun He 1, Xinyu Yang 1, Qi Shen 1, Xuesong Li 1, Wei Yu 1, Jian Lin 1, Liqun Zhou 1
1 Department of Urology, Peking University First Hospital, Institute of Urology, Peking University, National Urological Cancer Center, Beijing, China
Purpose: To investigate the incidence and pathologic characteristics of prostate cancer (PCa) incidentally discovered at the time of radical cystectomy and its impact on overall survival.
Materials and Methods: A single center retrospective study of 762 male patients who underwent radical cystoprostatectomy from Jan 1994 to Dec 2012.
Results: Of all included patients, 132 (17.3%) were found to have PCa. Patients with incidental PCa had a significantly higher mean age (69.2 vs. 62.2 years, P=0.015). Among the 132 patients with PCa, prostate specific antigen (PSA) analysis was available in 76 patients (57.6%), with a median value of 1.06ng/mL, and 61 (80.3%) patients had a PSA value below 4ng/mL. Four hundred and thirty-six patients (57.1%) were successfully followed, with a median duration of 46.5 months. The overall 5-year survival rate was 62.1%, and the 5-year cancer–specific survival rate was 72%. PCa recurrence was defined by two consecutive PSA values of >0.2 ng/mL and rising, and no PCa recurrence occurred. According to a univariate analyses, incidental PCa was not associated with cancer-specific survival (P=0.192) or overall survival (P=0.493). According to univariate analyses, the overall survival of patients with PCa was not associated with prostate cancer staging, PSA value, or Gleason score (All P values>0.05).
Conclusions: Prostate cancer incidentally discovered at the time of radical cystectomy does not decrease overall survival. Patients with incidental PCa were older than those without. The PSA value before operation is not helpful for predicting incidental prostate cancers.
Keywords: Urinary Bladder Neoplasms; Prostatic Neoplasms; Carcinoma
Comparative differences between T1a/b and T1e/m as substages in T1 urothelial carcinoma of the bladder
Vol. 44 (2): 267-272, March – Abril, 2018
Turgay Turan 1, Özgür Efiloğlu 1, Bilal Günaydin 1, Şeyma Özkanli 2, Emrah Nikerel 3, Gökhan Atiş 1, Turhan Çaşkurlu 1, Asif Yildirim 1
1 Department of Urology, Istanbul Medeniyet University, Faculty of Medicine, Istanbul, Turkey; 2 Istanbul Medeniyet University, Faculty of Medicine, Department of Pathology, Istanbul, Turkey; 3 Yeditepe Universitesi, Genetics and Bioengineering Istanbul, Turkey
Objective: To evaluate the prognostic value of the depth of lamina propria invasion in patients with T1 bladder cancer and to display comparative differences between the T1a/b and T1e/m substaging systems.
Patients and Methods: This study included 106 patients with primary stage T1 urothelial bladder tumours who underwent surgery between January 2009 and December 2014. Pathologic specimens were re-evaluated to confirm the diagnosis of T1 and substaging by the same pathologist using two systems: T1a and T1b, and T1m and T1e. Age, tumour size, multiplicity, associated carcinoma in situ, tumour grade, and T1 substaging system were investigated to detect the relation between disease progression and recurrence.
Results: The recurrence rate was 52% for T1a (n=42) vs. 76% for T1b (n=20) (p=0.028) and 55% for T1m (n=32) vs. 62% for T1e (n=30), respectively (p=0.446). There was no significant difference between the substaging groups for disease progression: T1a (n=12, 15%) vs. T1b (n=7, 27%), and T1m (n=8, 13.8%) vs. T1e (n=11, 23%) (p>0.05).
In the multivariate analysis, tumour size >3 cm (p=0.008), multiplicity (p=0.049), and substaging T1b (p=0.043) were independent predictive factors for tumour recurrence.
According to the Kaplan-Meier actuarial method, recurrence-free survival was significantly different in patients with pT1a tumours compared with those with pT1b tumours (p=0.033).
Conclusions: Substaging T1 provides a prediction of disease recurrence. Regarding recurrence, T1a/b substaging can provide better knowledge of disease behaviour because it is predicted as more superior than T1 m/e, and it can help in determining the requirement for early cystectomy.
Keywords: Carcinoma; Urinary Bladder; Urinary Bladder Neoplasms
Vol. 44 (2): 273-279, March – Abril, 2018
Marcos Tobias-Machado 1, Cristiano Linck Pazeto 1, Oseas Castro Neves-Neto 1, Igor Nunes-Silva 2, Hamilton de Campos Zampolli 2
1 Departamento de Urologia, Faculdade de Medicina ABC, Santo André, SP, Brasil; 2 Instituto do Câncer Arnaldo Vieira de Carvalho – IAVC , São Paulo, SP, Brasil
Purpose: The LRP has a steep learning curve to obtain proficiency during which patient safety may be compromised. We present an adapted modular training system which purpose to optimize the learning curve and perform a safe surgery.
Materials and Methods: A retrospective analysis of the LRP safe learning protocol applied during a fellowship program over eight years (2008-2015).
The surgery was divided in 12 steps and 5 levels of difficulty. A maximum time interval was stipulated in 240 minutes. After an adaptation, the fellows had 120 minutes to perform all the corresponding modules to its accumulated skill. The participants gradually and safely pass through the steps and difficulty levels. Surgeries performed by fellows were analyzed as a single group and compared to a prior series performed by tutor.
Results: In eight years, 250 LRP were performed (25 per apprentice) during fellowship program and 150 procedures after completion. The baseline characteristics were comparable. Most cases operated were of intermediate risk. Mean operative time was longer in the fellow group when compared to the tutor (150 min). Mean estimated blood loss were similar among the groups. Functional and oncological outcomes were better in the Tutor´s group. No conversion to open surgery was performed.
Conclusions: The LRP safe learning protocol proved to be an effective method to optimize the learning curve and perform safe surgery. However, the tutor’s functional and oncological results were better, showing that this is a procedure with a steep learning curve and proficiency demands more than 25 cases.
Keywords: Prostatectomy; Education; Surgical Procedures, Operative
Laparoscopic nephrectomy outside gerota fascia and En bloc ligation of the renal hilum for management of inflammatory renal diseases
Vol. 44 (2): 280-287, March – Abril, 2018
Liang Ma 1, Yanlan Yu 1, Guangju Ge 1, Gonghui Li 1
1 Department of Urology, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou 310016, China
Objectives: This study aims to improve laparoscopic nephrectomy techniques for inflammatory renal diseases (IRD) and to reduce complications.
Materials and Methods: Thirty-three patients underwent laparoscopic nephrectomy for IRD, with a method of outside Gerota fascia dissection and en-bloc ligation and division of the renal pedicle. Operative time, blood loss, complications, analgesia requirement, post-operative recovery of intestinal function and hospital stay were recorded.
The degrees of perinephric adhesion were classified based on the observation during operation and post-operative dissection of the specimen, and the association of different types of adhesion with the difficulty of the procedures was examined.
Results: Among 33 cases, three were converted to hand-assisted laparoscopy, and one was converted to open surgery. Mean operative time was 99.6±29.2min, and blood loss was 75.2±83.5 mL. Postoperative recovery time of intestinal function was 1.6±0.7 days and average hospital stay was 4.8±1.4 days. By classification and comparison of the perinephric adhesions, whether inflammation extending beyond Gerota fascia or involving renal hilum was found to be not only an important factor influencing the operative time and blood loss, but also the main reason for conversion to hand-assisted laparoscopy or open surgery.
Conclusions: In laparoscopic nephrectomy, outside Gerota fascia dissection of the kidney and en-bloc ligation of the renal pedicle using EndoGIA could reduce the difficulty of procedure and operative time, with satisfactory safety and reliability. Inflammation and adhesion extending beyond Gerota fascia or involving renal hilum is an important predictor of the difficulty related to laparoscopic nephrectomy for IRD.
Keywords: Kidney Diseases; Laparoscopy; Nephrectomy
The effect of AST/ALT (De Ritis) ratio on survival and its relation to tumor histopathological variables in patients with localized renal cell carcinoma
Vol. 44 (2): 288-295, March – Abril, 2018
Lütfi Canat 1, Hasan Anil Ataly 1, Samir Agalarov 1, İlter Alkan 1, Fatih Alturende 1
1 Department of Urology, Okmeydani Training and Research Hospital, Istanbul, Turkey
Purpose: To assess the relationship between De Ritis (aspartate aminotransaminase [AST]/Alanine aminotransaminase [ALT]) ratio and pathological variables and whether it is an independent prognostic factor.
Materials and Methods: We analyzed 298 consecutive patients who underwent radical or partial nephrectomy for non-metastatic renal cell carcinoma (RCC) between 2006 and 2015. The association between De Ritis ratio and pathological variables including tumor size, presence of renal vein invasion, vena cava invasion, renal capsule infiltration, Gerota fascia invasion, renal sinus involvement, renal pelvic invasion, angiolymphatic invasion, adrenal gland involvement, lymph node involvement, tumor necrosis, and Fuhrman’s grade was tested. Multivariable Cox analysis was performed to evaluate the impact of this ratio on overall survival and cancer-specific survival.
Results: An increased preoperative De Ritis ratio was significantly associated with renal vein invasion, renal capsule infiltration and renal pelvis involvement (p<0.05) in non-metastatic RCC. On multivariate analysis we found that tumor size, Fuhrman grade and lymph node involvement were independent prognostic factors for cancerspecific survival. AST/ALT ratio had no influence on the risk of overall and cancerspecific survival.
Conclusion: An increased preoperative AST/ALT ratio had a significant association with renal vein invasion, renal capsule infiltration and renal pelvis involvement in patients with non-metastatic RCC. However, it does not appear to be an independent prognostic marker in non-metastatic RCC.
Keywords: Prognosis; Survival; Pathology
Vol. 44 (2): 296-303, March – Abril, 2018
Jagdeesh N. Kulkarni 1, Himanshu Agarwal 1
1 Department of Urology, Bombay Hospital and Medical Research Centre, Mumbai, India
Purpose: Conventional transperitoneal radical cystectomy (TPRC) is the standard approach for muscle invasive bladder cancer. But, the procedure is associated with significant morbidities like urinary leak, ileus, and infection. To reduce these morbidities, the technique of extraperitoneal radical cystectomy (EPRC) was described by us in 1999.
We compared these two approaches and the data accrued forms the basis of this report.
Materials and Methods: All patients who underwent radical cystectomy for bladder cancer by the author (JNK) with follow-up for at least 5 years were included. A total of 338 patients were studied, with 180 patients in EPRC group and 158 in TPRC group.
Results: There were 3 mortalities within 30 days in TPRC group and one in EPRC group. Early complication rate was 52% and 58% in EPRC and TPRC groups. Urinary leak occurred in 31 (9.2%) patients (13 in EPRC, 18 in TPRC, p=0.19). Gastrointestinal complications like ileus occurred in 9 (5%) patients in EPRC group and in 25 (15.8%) patients in TPRC group, (p<0.001). Wound dehiscence occurred in 29, and 36 patients in EPRC and TPRC groups respectively. The reoperation rate was 6.1% and 12% in EPRC and TPRC groups, (p=0.08). Intestinal obstruction were significantly less in EPRC group (1.7% vs. 7.8% in TPRC group, p=0.002). Uretero-enteric anastomosis stricture was seen in 10 patients (4 in EPRC, 6 in TPRC, p=0.39).
Conclusions: The EPRC is associated with decrease gastrointestinal complications, ease of management of urinary leaks, and low reoperation rates. Thus EPRC appears safe functionally and oncologically.
Keywords: Urinary Bladder Neoplasms; Cystectomy; Retrospective Studies
Vol. 44 (2): 304-313, March – Abril, 2018
Carlos A. Batagello 1, Fabio Carvalho Vicentini 1, Giovanni Scala Marchini 1, Fabio Cesar Miranda Torricelli 1, Miguel Srougi 1, Willian Carlos Nahas 1, Eduardo Mazzucchi 1
1 Divisão de Urologia, Grupo de Endourologia Hospital das Clínicas Faculdade de Medicina da Universidade de São Paulo, São Paulo, SP, Brasil
Introduction: To present the current practice patterns on percutaneous nephrolithotomy (PCNL) in a developing country.
Materials and Methods: a survey was offered to Brazilian urologists during the II International Endourology Symposium held in Sao Paulo, in 2015. The first seven questions were related to demographic data while the 20 remaining were directed to urologists who performed PCNL. Results: From 250 participants, 100 replied to the survey, 81% performed PCNL and 60.4% of performers had been in practice for less than 15 years. Eighty-one percent were trained in the prone position and 64% in supine. PCNL was learned during the residency in 66.7% and 2.5% had fellowship training. Prone position was the preferred decubitus for simple or complex calculi, though for obese patients there was no difference.
Younger surgeons prefer supine while older surgeons prefer prone. The access was obtained by the surgeon in all cases, 96.3% use fluoroscopy and 3.7% prefer ultrasonography. Forty-seven percent use ultrasonic lithotripters and 4.1% laser. For kidney drainage, 71.6% place a nephrostomy tube. Double J stent is left in 77%. The postoperative image method was CT for 50%. Colonic injury was reported by 25%, predominantly in the senior group without statistically difference between positions.
Conclusions: from a selected group of urologists, we observe that Brazilian urologists usually gain their own access for PCNL guided by fluoroscopy. They predominantly prefer the prone position, use fascial dilators, ultrasonic lithotripters and place a nephrostomy tube when exiting the kidney. Fellowship programs, ultrasonography, flexible nephoscopy and tubeless procedures could be encouraged.
Keywords: Calculi; Nephrostomy, Percutaneous; Epidemiology
Flexible ureterorenoscopy is associated with less stone recurrence rates over Shockwave lithotripsy in the management of 10-20 millimeter lower pole renal stone: medium follow-up results
Vol. 44 (2): 314-322, March – Abril, 2018
Faruk Ozgor 1, Murat Sahan 1, Fatih Yanaral 1, Metin Savun 1, Omer Sarilar 1
1 Department of Urology, Haseki Teaching and Research Hospital, Istanbul, Turkey
Purpose: To identify the role of shock wave lithotripsy (SWL) and flexible ureterorenoscopy (f-URS) on the stone recurrence, in the management of 10-20 millimeter lower pole stone (LPS) with medium follow-up outcomes.
Materials and Methods: The patients’ charts which were treated with SWL or f-URS for LPS between January 2011 and September 2013 were analyzed, retrospectively.
Patients who had a solitary 10-20mm LPS were enrolled into the study. In both procedures, patient was accepted as stone free, if complete stone clearance was achieved in the 3rd month abdominal computed tomography. Only patients with a stone free status were evaluated in follow ups.
Results: The stone-free rate was 77.9% (88/113 patients) for the SWL group and 89% (114/128 patients) for the f-URS group (p=0.029). Stone recurrence was detected in 28 (35.4%) patients in SWL group and in 17 (17.2%) patients in f-URS group (p=0.009).
Stone types and 24 hour urine sample results were similar between groups (p=0.123 vs p=0.197, respectively). Multivariate regression analysis revealed that f-URS procedure and absence of abnormality in 24 hour urine analysis significantly decreased stone recurrence in medium term follow-up (p=0.001 and p<0.001, respectively).
Conclusions: Our study showed for the first time, that patients which underwent f-URS for LPS, faced less stone recurrence, independent from diet regimen and metabolic evaluation in medium term follow-up. Additionally, presence of abnormality in 24 hour urine analysis increase the stone recurrence risk in follow-ups.
Keywords: Calculi; Lithotripsy; Recurrence
Is circumferential urethral mobilisation an overdo? A prospective outcome analysis of dorsal onlay and dorso – lateral onlay BMGU for anterior urethral strictures
Vol. 44 (2): 323-329, March – Abril, 2018
Gaurav Prakash 1, Bhupendra Pal Singh 1, Rahul Janak Sinha 1, Ankur Jhanwar 1, Satyanarayan Sankhwar 1
1 Department of Urology, King George’s Medical University, Lucknow, India
Introduction: For dorsal onlay graft placement, unilateral urethral mobilization is less invasive than standard circumferential urethral mobilization. Apart from success in terms of patency of urethra, other issues like sexual function, overall quality of life and patient satisfaction remain important issues while comparing outcomes of urethroplasty.
Aim: To prospectively compare the objective as well as subjective outcomes of two approaches.
Materials and Methods: Between July 2011 and January 2015, 136 adult males having anterior urethral stricture with urethral lumen ≥ 6 Fr. were prospectively assigned between two groups by alternate randomization. Operative time, complications, success rate (no obstructive symptoms, no need of any postoperative intervention, Q max > 15mL/sec), sexual functions (using Brief Male Sexual Function Inventory) were compared.
Results: Baseline parameters were similar in both groups (68 in each group). Overall success rate was similar in both groups (89 % and 91 % respectively). Improvement in total LUTS scores was similar in groups. Changes in overall health status (VAS and EQ 5D) was equal in both groups. Erectile function score was significantly decreased in DO than DL group while ejaculatory function and sexual desire remained stable after urethroplasty in both groups.
Conclusions: In anterior urethral stricture buccal mucosa graft provides satisfactory results as onlay technique. No technique whether dorsolateral and dorsal techniques is superior to other. Dorsolateral technique needs minimal urethral mobilization and should be preferred whenever feasible.
Keywords: Urethral Stricture; Lower Urinary Tract Symptoms; Buccal mucosa
Overactive bladder syndrome and bladder wall thickness in patients with obstructive sleep apnea syndrome
Vol. 44 (2): 330-337, March – Abril, 2018
Zahide Yilmaz 1, Bekir Voyvoda 2, Pinar Bekdik Şirinocak 1
1 Clinic of Neurology, Health Sciences University, Kocaeli Derince Training and Research Hospital, Turkey; 2 Clinic of Urology, Health Sciences University, Kocaeli Derince Training and Research Hospital, Turkey
Objective: The main objective of the present study was to evaluate the presence of overactive bladder (OAB) syndrome, nocturia, urgency, and urge incontinence in patients with obstructive sleep apnea syndrome (OSAS), and measure bladder wall thickness (BWT) in these patients.
Materials and Methods: The patient group was composed of 38 patients with OSAS. The control group was composed of 15 healthy individuals. All patients were evaluated using the Epworth Sleepiness Scale (ESS) and Overactive Bladder Symptom Score (OABSS). The bladder wall thickness was measured by transabdominal ultrasound (US). The presence of nocturia, urinary urgency, and urge incontinence were also evaluated.
Results: The mean OABSS was significantly higher in the patient group compared with the control group (p=0.048). The minimum oxygen saturation (Min.SO2) of patients with urgency was found to be significantly lower (p=0.014). The time spent below 90% of oxygen saturation (SO2) was significantly longer in patients with urinary urgency (p=0.009). There was no difference in BWT measurements between the patient group and the control group. There was a significant relationship between BWT values and OABSS in patients with OSAS (p=0.002).
Conclusion: The results of the present study suggest that OSAS is associated with OAB syndrome. As a key symptom of OAB, urgency correlates with hypoxia in cases with OSAS. Although the present study did not observe any difference in BWT measurements between the patients and the control group, there was a correlation between BWT measurements and OABSS in patients with OSAS.
Keywords: Urinary Bladder, Overactive; Urinary Bladder; Nocturia
Validation of the urgency questionnaire in Portuguese: A new instrument to assess overactive bladder syndrome
Vol. 44 (2): 338-347, March – Abril, 2018
Rodolfo Pacheco de Moraes 1, Jonas Lopes da Silva 2, Adriano Almeida Calado 2, Geraldo de Aguiar Cavalcanti 2, 3
1 Divisão de Urologia, Hospital da Polícia Militar de Pernambuco (PMPE), Derby, Recife, PE, Brasil; 2 Divisão de Urologia, Hospital Universitário Oswaldo Cruz – Universidade de Pernambuco (HUOC-UPE) Santo Amaro, Recife, PE, Brasil; 3 Divisão de Urologia, Departamento de Cirurgia – Universidade Federal de Pernambuco (UFPE) Cidade Universitária, Recife, PE, Brasil
Purpose: Overactive Bladder (OAB) is a clinical condition characterized by symptoms reported by patients. Therefore, measurement instruments based on reported information are important for understanding its impact and treatment benefits. The aim of this study was to translate, culturally adapt and validate the Urgency Questionnaire (UQ) in Portuguese.
Materials and Methods: Initially, the UQ was translated and culturally adapted to Portuguese.
Sixty-three volunteers were enrolled in the study and were interviewed for responding the Portuguese version of the UQ and the validated Portuguese version of the Overactive Bladder Questionnaire short-form (OABq-SF), used as the gold standard measurement for the validation process. Psychometric properties such as criterion validity, stability, and reliability were tested. Results: Forty-six subjects were included in the symptomatic group (presence of “urgency”), and seventeen were included in the asymptomatic group (control group). There was difference between symptomatic and asymptomatic subjects on all of the subscales (p≤0.001). The UQ subscales correlated with the OABq-SF subscales (p≤0.01), except the subscale “time to control urgency” and the item “impact” from the visual analog scales (VAS). However, these scales correlated with the OABq-SF – Symptom Bother Scale. The UQ subscales demonstrated stability over time (p<0.05), but the subscale “fear of incontinence” and the item “severity” of the VAS did not. All of the UQ subscales showed internal consistencies that were considered to be good or excellent.
Conclusion: The Portuguese version of the UQ proved to be a valid tool for the evaluation of OAB in individuals whose native language is Portuguese.
Keywords: Urinary Bladder, Overactive; Validation Studies [Publication Type]; Urinary Incontinence; Psychometrics
OAB score: a clinical model that predicts the probability of presenting overactive detrusor in the urodynamic study
Vol. 44 (2): 348-354, March – Abril, 2018
Leandro Cristian Arribillaga 1, Marta Ledesma 1, Ariel Montedoro 1, Florencia Pisano 1, Rubén Guillermo Bengió 1
1 Centro Urológico Profesor Bengió, Córdoba, Argentina
Purpose: To create a predictive model of involuntary detrusor contraction (IDC) to improve the diagnostic accuracy of overactive detrusor (OAD), associating overactive bladder (OAB) symptoms with other clinical parameters in the female population.
Materials and Methods: A total of 727 women were studied retrospectively. In all of them, urodynamic study was conducted for urogynecological causes. Demographics information, personal history, symptoms, physical exam, a 3-day frequency/volume chart and urinary culture, were collected in all patients and they subsequently underwent uroflowmetry and urodynamic studies. A logistic regression model was performed in order to determine independent predictors of presence of IDC. Odd ratio (OR) estimation was used to assign a score to each one of the significant variables (p≤0.05) in the logistic regression model. We performed a ROC curve in order to determine the predictive ability of the score in relation to the presence of OAD.
Results: presence of OAD was evident in 210 women (29%). In the logistic regression analysis, independent predictors of OAD were urgency, urgency incontinence, nocturia, absence of SUI symptoms, diabetes mellitus, reduction of vaginal trophism and bladder capacity below 150 mL. The probability of IDC diagnosis increases as the score raises (Score 0: 4% until Score ≥10: 88%). Sensitivity was 71% and specificity 72%. The area under the curve of OAB score was 0.784 (p>0.001).
Conclusions: OAB score is a clinical tool that shows higher diagnostic accuracy than OAB symptoms alone to predict overactive detrusor.
Keywords: Urinary Bladder, Overactive; Urodynamics
Single perineal incision placement of artificial urinary sphincter with cadaveric correlation of sub-dartos pump placement
Vol. 44 (2): 355-361, March – Abril, 2018
Cooper R. Benson 1, Hajar I. Ayoub 1, O. Lenaine Westney 2
1 University of Texas Health Science Center At Houston McGovern Medical School, USA; 2 University of Texas MD Anderson Cancer Center, USA
Purpose: We present a novel AUS implantation technique using a single perineal incision for single device placement or in combination with an inflatable penile prosthesis (IPP). Urinary and sexual dysfunction following the management of prostate cancer has a significant impact on the quality of life of our patients. While there are marginal changes in the prosthetic devices, we strive to reduce post-operative morbidity while maximizing efficacy.
Materials and Methods: We retrospectively reviewed the outcomes of 6 patients who underwent single perineal incision placement of a virgin AUS in 2014, 3 with simultaneous IPP placement. In all cases, the pressure regulating balloons (PRB) were placed in a high sub-muscular ectopic position and the pumps were placed into a sub-dartos pouch through the perineal incision, which was also validated using a cadaveric model.
Results: The mean patient age was 61 (SD, 7.5 years) with mean body mass index of 31 (SD, 5.9). The average pre-operative pad usage was 7.7 (SD 1.63) pads per day. The mean follow-up was 13.9 months (SD 9.45). Four out of the six patients reported utilizing ≤1 pad daily at follow-up. The one patient who was not initially dry required downsizing of his cuff to 3.5cm; the remaining patient was lost to follow-up. There were no identifiable perioperative or post-operative complications.
Conclusions: We present our initial report of using a single perineal incision for AUS implantation with a validated sub-dartos pump location, which is safe and effective for implantation of an AUS as a single or double implantation in well-selected patients.
Keywords: Urinary Incontinence, Stress; Urinary Sphincter, Artificial; Prostatic Neoplasms
Vol. 44 (2): 362-369, March – Abril, 2018
Lucio Dell’Atti 1, Andrea Benedetto Galosi 1
1 Department of Urology, Polytechnic University of Marche Region, University Hospital “Ospedali Riuniti”, Ancona, Italy
Purpose: Non-palpable isolated septal plaques of the penis are likely present in a significant number of patients affected by erectile dysfunction (ED) and penile pain without deformity or curvature. The aim of this study was to evaluate the ultrasound (US) patterns observed in patients investigated for ED or penile pain without curvature.
Materials and Methods: We reviewed the medical records of 386 patients who underwent an initial colour-Doppler ultrasonography (CDU) of the penis for DE and/or penile pain without curvature. After satisfying inclusion criteria, 41 patients were individualized.
All patients had a non-palpable plaque with involvement of the penile septum.
Three US patterns were identified: focal hyperecoic thickening of the intercavernosum septum (IS) with acoustic shadow (pattern 1), non-calcified thickening (isoechoic or slightly hyperechoic (pattern 2), and microcalcifications in the IS without associated acoustic shadow (pattern 3).
Results: Patients’ mean age was 51.3±16.7. ED was the predominant disorder in 73.2% of patients, followed by penile pain and length loss in 19.5% and 7.3% of patients, respectively. 32(78.1%) patients showed the pattern 1, 6 (14.6%) pattern 2, and 3 (7.3%) pattern 3. Plaques size varied from 3 to 13 mm. The penile hemodynamic response to CDU reported abnormal findings distally to the septal plaques in 20 patients (<25cm/ sec). Median left and right cavernosum artery flows measured a peak systolic velocity of 31cm/sec and 33 cm/sec, respectively.
Conclusions: We believe that an US study with CDU provides a way to characterize, localize, and deliver treatment choice in patients with Peyronie’s Disease.
Keywords: Erectile Dysfunction; Ultrasonography; Penis
Transperitoneal laparoscopic pyeloplasty in children: does upper urinary tract anomalies affect surgical outcomes?
Vol. 44 (2): 370-377, March – Abril, 2018
João Arthur Brunhara 1, Paulo Renato Marcelo Moscardi 1, Marcos Figueiredo Mello 1, Hiury Silva Andrade 1, Paulo Afonso de Carvalho 1, Bruno Nicolino Cezarino 1, Francisco Tibor Dénes 1, Roberto Iglesias Lopes 1
1 Unidade de Urologia Pediátrica, Faculdade de Medicina da Universidade de São Paulo – São Paulo, SP, Brasil
Objective: to assess the feasibility and outcomes of laparoscopic pyeloplasty in children with complex ureteropelvic junction obstruction (UPJO) and compare to children with iso-lated UPJO without associated urinary tract abnormalities.
Material and Methods: Medical records of 82 consecutive children submitted to trans¬peri-toneal laparoscopic pyeloplasty in a 12-year period were reviewed. Eleven cases were con-sidered complex, consisting of atypical anatomy including horseshoe kid¬neys in 6 patients, pelvic kidneys in 3 patients, and a duplex collecting system in 2 patients. Patients were di-vided into 2 groups: normal anatomy (group 1) and complex cases (group 2). Demographics, perioperative data, outcomes and complications were recorded and analyzed.
Results: Mean age was 8.9 years (0.5-17.9) for group 1 and 5.9 years (0.5-17.2) for group 2, p=0.08. The median operative time was 200 minutes (180-230) for group 1 and 203 minutes (120-300) for group 2, p=0.15. Major complications (Clavien ≥3) were 4 (5.6%) in group 1 and 1 (6.3%) in group 2, p=0.52. No deaths or early post¬operative complications such as: urinoma or urinary leakage or bleeding, occurred. The success rate for radiologic improvement and flank pain improvement was com¬parable between the two groups. Re-garding hydronephrosis, significant improve¬ment was present in 62 patients (93.4%) of group 1 and 10 cases (90.9%) of group 2, p=0.99. The median hospital stay was 4 days (IQR 3-4) for group 1 and 4.8 days (IQR 3-6) for group 2, p=0.27.
Conclusions: Transperitoneal laparoscopic pyeloplasty is feasible and effective for the management of UPJO associated with renal or urinary tract anomalies.
Keywords: Laparoscopy; Urinary Tract; Surgical Procedures, Operative
Vol. 44 (2): 378-383, March – Abril, 2018
Rhaiana Gondim 1, Roberta Azevedo 1, Ana Aparecida Nascimento Martinelli Braga 1, Maria Luiza Veiga 1, Ubirajara Barroso Jr. 2
1 Centro Pediátrico de Distúrbios Urinários (CEDIMI), Salvador, BA, Brasil; 2 Departamento de Urologia, Unidade de Urologia Pediátrica, Faculdade de Medicina e Saúde Pública da Bahia e Universidade Federal da Bahia, Salvador, BA, Brasil
Purpose: To identify which independent variable would be strong predictor of febrile urinary tract infection (UTI) in children and adolescents with overactive bladder.
Materials and Methods: A search was made of the institute’s database for all patients diagnosed with overactive bladder over the preceding four years. Children and adoles¬cents under 18 years of age with overactive bladder and no neurological or anatomi¬cal alterations of the lower urinary tract were included in the study. The independent variables were: sex, age, ethnicity (Brazilians of African descendence/others), the pres¬ence of urinary urgency, daytime incontinence, enuresis, frequent urination, infrequent voiding (≤3 voids/day), nocturia, holding maneuvers, straining to void, intermittent urinary flow, constipation and encopresis. An analysis was conducted to identify pa¬tients with febrile UTI and subsequently determine predictors of this condition. Uni¬variate and multivariate analyses were performed.
Results: Overall, 326 patients (214 girls/112 boys) were evaluated. The mean age of the patients was 7.7±3.19 years (± standard deviation). The incidence of febrile UTI was 39.2%. Being female and infrequent voiding were factors significantly associated with febrile UTI, both in the univariate and multivariate analyses.
Conclusions: These results show that being female and infrequent voiding constituted significant risk factors for a diagnosis of febrile UTI in these children.
Keywords: Urinary Tract Infections; Lower Urinary Tract Symptoms; Urinary Bladder, Overactive
Vol. 44 (2): 384-389, March – Abril, 2018
Denilson José Silva Feitosa Junior 1, Luan Teles Ferreira de Carvalho 1, Ingrid Rodrigues de Oliveira Rocha 1, Camila Noura de Brito 1, Rodrigo Alencar Moreira 2, Carlos Alberto Villacorta de Barros 3
1 Laboratório de Cirurgia Experimental, Universidade Estadual do Pará, Belém, PA, Brasil; 2 Departamento de Pesquisa Cirúrgica e Experimental, Universidade Estadual do Pará, Belém, PA, Brasil; 3 Departamento de Cirurgia Experimental e Anestesiologia, Universidade Estadual do Pará, Belém, PA, Brasil
Introduction: The appropriate closure of the urinary bladder is important to many urologic procedures to avoid the formation of fistulas and strictures by excessive fibrosis. This paper presents the alterations in the bladder healing process of rats after the topical use of Copaiba oil (Copaifera reticulata).
Material and Methods: Ten male Wistar rats were used and randomly divided into two groups: Control group (CG): injected 1ml/kg of saline solution on the suture line; and Copaiba group (CpG): 0.63ml/kg of copaiba oil applied to the suture line. Euthanasia was performed on the seventh day after surgery. The criteria observed were adherences formation, histopathological modifications and stereology for collagen.
Results: Both groups showed adhesions to the bladder, with no statistically significant difference (p=0.1481). The microscopic evaluation revealed a trend to more severe acute inflammation process on the CpG, but there was statistical difference only in the giant cells reaction (p=0.0472) and vascular proliferation (p=0.0472). The stereology showed no difference.
Conclusion: The copaiba oil modified the healing process, improving the quantity of giant cells and vascular proliferation, but not interfered in the collagen physiology.
Keywords: Urinary Bladder; Wound Healing; Plants, Medicinal; Collagen
Acquired Hemophilia presenting as Gross Hematuria following Kidney Stone – A Case Report and Review of the Literature
Vol. 44 (2): 390-392, March – Abril, 2018
CHALLENGING CLINICAL CASES
Max Schmidt-Bowman 1, Lael Reinstatler 2, Eric P. Raffin 2, Joseph E. Yared 2, John D. Seigne 2, Einar F. Sverrisson 2
1 Geisel School of Medicine at Dartmouth, Hanover, NH; 2 Department of Surgery, Section of Urology, Dartmouth Hitchcock Medical Center, Lebanon, NH
A rare condition in itself, acquired hemophilia A, seldom presents as isolated gross hematuria. It is a serious condition with a high mortality rate and thus clinical suspicion followed by prompt diagnosis is imperative (1). In fact, only 8 cases of such presentation of this condition have been reported thus far in the literature. Of these, none describe the initial presentation of hematuria with the inciting event of a kidney stone. We present a case of a 67-year-old man with signs and symptoms of nephrolithiasis accompanied by profuse hematuria, who was subsequently found to have developed expression of factor VIII inhibitor leading to acquired hemophilia A.
Keywords: Hematuria; Nephrolithiasis; Factor 8 deficiency, acquired [Supplementary Concept]
Vol. 44 (2): 393-396, March – Abril, 2018
CHALLENGING CLINICAL CASES
Lorenzo 1, E. Martínez-Cuenca 1, E. Broseta 1
1 Hospital Universitario y Politécnico La Fe, Valencia, Espanha
Bilateral testicular torsion is a very uncommon emergency, with a challenging differential diagnosis. We describe the case of a 15-year-old patient with a left testicular torsion of 48 hours of duration and a sudden onset of right scrotum pain during his stay at the emergency area. Bilateral testicular torsion was diagnosed after repeat physical examination and doppler ultrasound, which had been normal for right testis in a first evaluation. Surgical exploration was performed with orchiectomy in left testis and fixation in right testis. In previous literature, there are reported bilateral torsion only in four adolescents and five adults. With this case, we demonstrate that bilateral spermatic cord torsion may be easily overlooked in a patient with acute scrotum and we emphasize the importance of bilateral exploration in testicular torsion.
Keywords: Testis; Spermatic Cord Torsion; Adolescent
Vol. 44 (2): 397-399, March – Abril, 2018
Eduardo Kaiser Ururahy Nunes Fonseca 1, Oskar Grau Kaufmann 1, Layra Ribeiro de Sousa Leão 1, Cassia Franco Tridente 1, Fernando Ide Yamauchi 1, Ronaldo Hueb Baroni 1
1 Hospital Israelita Albert Einstein, São Paulo, Brasil
Tuberculous prostatitis is a rare and often overlooked entity that may mimic prostatic adenocarcinoma on imaging exams, especially multiparametric magnetic resonance imaging (MRI) of the prostate. Detection of a prostatic abscess is a clue to the correct diagnosis.
Keywords: Prostate; Tuberculosis; MRI; Radiology
Left ureteral appendiceal interposition: Exercise caution and do not be mislead By postoperative radiological obstruction
Vol. 44 (2): 400-402, March – Abril, 2018
Aderivaldo Cabral Dias Filho 1, Carlos Alberto Toledo Martinez 1, Maria Bianca Côrte 2, Marcus Vinicius Osorio Maroccolo 1
1 Unidade de Urologia, Hospital de Base do Distrito Federal, Brasília, DF, Brasil; 2 Unidade de Proctologia, Hospital de Base do Distrito Federal, Brasília, DF, Brasil
Postoperative imaging after appendiceal ureteral interposition may be difficult to interpret, misguiding the urologist towards intervention. We present a case in which radiological obstruction was not endorsed by a 99TcDTPA nephrogram, with favorable outcome after conservative treatment.
Robot-assisted laparoscopic bladder diverticulectomy and greenlight laser anatomic vaporization of the prostate
Vol. 44 (2): 403-404, March – Abril, 2018
Luca Cindolo 1, Manuela Ingrosso 1, Michele Marchioni 2, Ambra Rizzoli 2, Francesco Berardinelli 2, Luigi Schips 1
1 Department of Urology, ASL Abruzzo 2, Chieti, Italy; 2 Department of Urology, SS Annunziata Hospital, “G. D’Annunzio” University of Chieti, Chieti, Italy
No Abstract available
Laparoscopic – assisted percutaneous nephrolithotomy as an alternative in the treatment of complex renal calculi in patients with retrorenal colon
Vol. 44 (2): 405-406, March – Abril, 2018
Petronio Augusto de Souza Melo 1, Fabio Carvalho Vicentini 1, David Jacques Cohen 1, Marcelo Hisano 1, Claudio Bovolenta Murta 1, Joaquim Francisco de Almeida Claro 1
1 Divisão de Urologia, Centro de Referência da Saúde do Homem, Hospital Brigadeiro, São Paulo, SP, Brasil
No Abstract available
video section Vol. 44 (2): 407-408, March – Abril, 2018
Rodrigo Uliano Moser da Silva 1, Fernando Jahn da Silva Abreu 1, Gabriel M. V. Da Silva 1, João Vitor Quadra Vieira dos Santos 1, Nelson Sivonei da Silva Batezini 1, Brasil Silva Neto 1, Tiago Elias Rosito 1
1 Departamento de Urologia, Hospital de Clínicas de Porto Alegre, Porto Alegre, RS, Brasil
Introduction: After the diagnosis of transsexualism is confirmed therapy commences with psychotherapeutic preparation for the conversion, and after conversion, long-term patient rehabilitation is maintained for at least two years. The indication for surgery is chronic discomfort caused by discord with the patient’s natural gender, intense dislike of developing secondary sex characteristics and the onset of puberty. The surgical conversion of transsexuals is the main step in the complex care of these problematic patients (1). This surgery was first described by Benjamin H, using a flap of inverted penile skin (2) and is considered the gold standard since then. Male-to-female transsexual surgical techniques are well defined and give good cosmetic and functional results. Sex reassignment surgery promotes the improvement of psychological aspects and social relationships as shown in the World Health Organization Quality of Life Assessment applied in the patients submitted to this procedure (3). Techniques include the creation of a normal appearing female introitus, a vaginoplasty allowing sexual intercourse and the capability of clitoral orgasm (4). Various methods for neovaginoplasty have been described and can be classified into five categories, i.e. pedicled intestinal transplants, penile skin grafts, penile skin flaps, non-genital skin flaps and non-genital skin grafts (5). In our Hospital, we use penile and scrotal skin flaps.
Until now, 174 procedures have been performed by our team using this technique with high rates of satisfaction (3).
Patients and methods: We present a step-by-step male to female transsexual surgery.
Conclusion: Surgical gender reassignment of male transsexuals resulted in replicas of female genitalia which enabled coitus with orgasm (1). With this video we show step by step that a surgery using penile skin flaps is able to be performed with good cosmetic results.
An unusual presentation of urethral duplication presenting with chronic bladder retention, left scrotal transposition and left renal agenesis
Vol. 44 (2): 409-410, March – Abril, 2018
Antonio Macedo Jr. 1, Marcela Leal da Cruz 1, João Luiz Gomes Parizi 1, Gustavo Marconi Caetano Martins 1, Riberto Liguori 1, Sérgio Leite Ottoni 1, Bruno Leslie 1, Gilmar Garrone 1
1 Universidade Federal de São Paulo, São Paulo, Brasil
Introduction and objective: Urethral duplication is a rare congenital anomaly, with roughly 200 cases reported in the literature (1). It is more frequent in males, with few cases reported in females. The clinical presentation differs according to the anatomical variant present. The duplication most commonly occurs in the sagittal plane with one urethra located ventrally and the other dorsally (2). Usually the ventral urethra is the more functional of both. Duplications occurring in the coronal plane are quite rare and they are usually associated with bladder duplication (3). The purpose of this paper was to present a video of a boy with an unusual urethral duplication form.
Materials and Methods: Patient was born premature due to oligohydramnios at 7 months-gestational age and he has initial diagnosis of hypospadia. Since then, he presented at least 7 febrile UTI and mother complained of difficult micturition and a presence of a mass at lower abdomen. Patient was referred to our institution and we identified urethral duplication with a glandar and scrotal meatus, palpable bladder and left penile-hemiscrotum transposition. US and CT-scan showed left kidney agenesis and overdistended bladder. VCUG and retrograde urethrography showed duplication, presence of contrast in the seminal vesicles and complete catheterizing of both urethras was not possible.
Results: The topic urethra was dysplastic and not patent to a 4Fr plastic tube so we were unable to access it endoscopically.
We performed initially a Mitrofanoff procedure to allow CIC and treat chronic retention. Six months later, we assessed both urethras surgically and concluded that dorsal urethra was dysplastic after 3cm still in the penile area and scrotal urethra was not possible to be catheterized. We excised the ventral urethra because of dribbling complaints up to bulbar area and reconstructed the scrotal transposition, keeping the topic urethra for cosmetic issues. Patient had excellent outcome, performs CIC every 4 hours and has not presented further UTI episodes.
Discussion and conclusion: The urethral duplication is an anomaly that has multiple anatomical presentations. There are several theories about the etiology, but none can explain all types of presentations. There is also more than one rating available, and the Effmann classification is the most detailed. The case exemplifies this varied spectrum of anatomic urethral duplication. It resembles the urethral duplication type IIa-Y, however, ventral urethra meatus was located in penoscrotal area and both urethras were at least partially hypoplastic/dysplastic associated with obstruction and bladder retention. In determining how to best manage a patient with Y-type urethral duplication, the caliber and quality of the orthotopic urethra must first be assessed. Published reports suggest that best outcomes are those using the ventral duplicated urethra for the reconstruction (4). In this case, none of urethras were functional and a supravesical outlet channel had to be provided. The treatment of this condition requires an individualized planning and a vast technical knowledge of reconstructive surgery.
Re: An unanswered question in pediatric urology: the post pubertal persistence of prepubertal congenital penile curvature correction by tunical plication
Vol. 44 (2): 411-412, March – Abril, 2018