Volume 43 | number 1 | January . February, 2017 The January-February 2017 issue of the International Braz J Urol presents original contributions with a lot of interesting papers in different fields: Female Urinary
Incontinence, Male Urinary Incontinence/span>
Vol. 43 (1): 1-2, January – February, 2017
EDITORIAL in this Issue
Luciano A. Favorito
Professor Associado da Unidade de Pesquisa Urogenital da Universidade do Estado de Rio de Janeiro
Urologista do Hospital da Lagoa Federal, Rio de Janeiro
Editor Associado da International Braz J Urol
The January-February 2017 issue of the International Braz J Urol presents original contributions with a lot of interesting papers in different fields: Female Urinary Incontinence, Male Urinary Incontinence, Bladder Cancer, Pelvic-Ureteric Junction Stenosis, BPH, Prostate Cancer, Bladder Cancer, Renal Cancer, Testicular Cancer, Penile Cancer, Overactive Bladder Syndrome, Ureteral Obstruction, Pediatric Urology, Interstitial Cystitis and Urethral Stricture. The papers come from many different countries such as Brazil, USA, Turkey, Italy, Belgium, India, China, United Kingdon, Portugal, Taiwan and Serbia, and as usual the editor’s comment highlights some papers. We decided to comment 2 papers about a very usual and challenging topic in urologic practice: The Urethral Stricture…
Vol. 43 (1): 3-6, January – February, 2017
Stênio de Cássio Zequi 1, Diego Abreu Clavijo 2 and all other LARCG* Members**
1 Urology Divison, AC Camargo Cancer Center, São Paulo, Brasil; 2 Servicio de Urología, Hospital Pasteur Montevideo, Uruguay
As usually verified in many malignancies, the majority of the scientific information about renal cell carcinoma (RCC) is produced in developed countries mainly in North America and Europe. This knowledge is derived from great casuistries, joined in multi-institutional collaborative study groups or in International diseases consortiums.
Consistent epidemiologic and scientific data originated in the Latin America (LA) are lacking. LA is a large subcontinent, composed by more than 20 countries (much of them great economies), encompassing around 640 million habitants. Latin American population ethnicity is unique, due to an intense miscegenation, differing from northern hemispheric populations. The LA’s population was composed by several civilizations over the years: pre Colombians, (Amerindians), black slaves descendant’s (distinct groups of the African slaves that were sent to North America and Caribe). The predominance of Europeans in LA corresponded to Iberians, and Italians, few French and Germans. We have few Anglo-Saxon, Scandinavian and Northern and Eastern Europeans. Regarding Middle East and Africans, the more prevalent immigrants were Syrian, Lebaneses, Jewishs and few Armenians. Also, there are few Arabic, Persian and North African populations. From Asia, the predominance has been established by Japanese and in the last decades, by some Korean and Chinese. There is almost no people from South Asia, Oceania and Pacific Islands etc., differing from US, for example. The LA racial miscegenation resulted in particular genetic groups such as Mulattoes, Mestizos, Zambos, Cimarron’s, Cafuzzos, mamelucos etc (1, 2). In the era of molecular biology, and “omics”, it seems amazing to know the demographic, clinical, pathological and biomolecular profiles of several…
Vol. 43 (1): 7-9, January – February, 2017
DIFFERENCE OF OPINION
Antonio Augusto Ornellas 1,2, Paulo Ornellas 3, 4
1 Departamento de Urologia, Instituto Nacional do Câncer do Brasil (INCA); 2 Departamento de Urologia Hospital Mário Kröeff, Rio de Janeiro, Brasil; 3 Departamentos de Urologia, Hospital Souza Aguiar Hospital, Departamento de Patologia, Laboratório de Biometria Circulante; 4 Programa de Pós-Graduação em Ciências Médicas (PGCM), Universidade Estadual Rio de Janeiro State, Rio de Janeiro, Brasil
Keywords: prevention and control [Subheading]; Circumcision, Male; Penile Neoplasms; Phimosis
This theme is controversial because no major medical organization recommends universal neonatal circumcision and no major medical organization calls for banning it either. The argument that this procedure must be kept within the purview of medical professionals is found across all major medical organizations. In addition, the organizations advise medical professionals to yield to some degree to parents’ preferences, commonly based in cultural or religious views, in the decision to agree to circumcise (1). Circumcision may be used to treat pathological phimosis, refractory balanoposthitis and chronic, recurrent urinary tract infections (2, 3). Circumcision is contraindicated in infants with certain genital structure abnormalities, such as a misplaced urethral opening (as in hypospadias and epispadias), curvature of the head of the penis (chordee), or ambiguous genitalia, because the foreskin may be needed for reconstructive surgery. Circumcision is contraindicated in premature infants and those who are not clinically stable and in good…
Vol. 43 (1): 10-12, January – February, 2017
DIFFERENCE OF OPINION
Dominic H. Tang 1, Philippe E. Spiess 1
1 Department of Genitourinary Oncology, Moffitt Cancer Center, Tampa, Florida, USA
Keywords: prevention and control [Subheading]; Circumcision, Male; Penile Neoplasms; Phimosis
Routine neonatal circumcision remains a controversial topic. The most recent Canadian Paediatric Society does not recommend routine circumcision of every newborn male (1). And although prior statements from the American Academy of Pediatrics recommended against circumcision, the most recent recommendation states that circumcision outweigh the risk and the procedure’s benefits justify it for families who want it (2).
The benefits mentioned by the American Academy of Pediatrics included prevention of urinary tract infections, transmission of sexually transmitted infections, and penile cancer.
Prevention of penile cancer may be related to increasing daily hygiene and decreasing sexually transmitted infections such as human papilloma virus (HPV) in circumcised males. However, with improvements in daily hygiene and sexually transmitted infection prevention strategies, neonatal circumcision may not be critical for the prevention of penile cancer, especially in western countries.
Vol. 43 (1): 13-19, January – February, 2017
Theodora Stasinou 1, Andreas Bourdoumis 2, Junaid Masood 3
1 South Manchester University Hospitals NHS Foundation Trust, Manchester, UK; 2 North Manchester General Hospital, Acute Pennine Hospitals NHS Trust, Manchester, UK; 3 Homerton University Hospital NHS Foundation Trust, London, UK
Objectives: To investigate a possible causal relationship for stone formation in pelviureteric junction obstruction and to outline management options.
Materials and Methods: A literature search and evidence synthesis was conducted via electronic databases in the English language using the key words pelviureteric junction obstruction; urolithiasis; hyperoxaluria; laparoscopic pyeloplasty; flexible nephroscopy; percutaneous nephrolithotomy, alone or in combination. Relevant articles were analysed to extract conclusions.
Results: Concomitant pelviureteric junction obstruction (PUJO) and renal lithiasis has been reported only scarcely in the literature. Although PUJO has been extensively studied throughout the years, the presence of calculi in such a patient has not received equal attention and there is still doubt surrounding the pathophysiology and global management.
Conclusions: Metabolic risk factors appear to play an important role, enough to justify metabolic evaluation in these patients. Urinary stasis and infection are well known factors predisposing to lithiasis and contribute to some extent. The choice for treatment is not always straightforward. Management should be tailored according to degree of obstruction, renal function, patient symptoms and stone size. Simultaneous treatment is feasible with the aid of minimally invasive operative techniques and laparoscopy in particular.
Keywords: Pelviureteric Junction Obstruction; Calculi; Urolithiasis; Nephrostomy, Percutaneous
Vol. 43 (1): 20-28, January – February, 2017
Renato Lains Mota 1
1 Departamento de Urologia, Centro Hospitalar de Lisboa Ocidental, EPE e Universidade Lusófona de Lisboa, Portugal
Urinary incontinence is a common problem among women and it is estimated that between 15 and 55% of them complain of lower urinary symptoms. The most prevalent form of urinary incontinence is associated with stress, followed by mixed urinary incontinence and urge urinary incontinence. It is a symptom with several effects on quality of life of women mainly in their social, familiar and sexual domains. Female reproductive and urinary systems share anatomical structures, which promotes that urinary problems interfere with sexual function in females.
This article is a review of both the concepts of female urinary incontinence and its impact on global and sexual quality of life. Nowadays, it is assumed that urinary incontinence, especially urge urinary incontinence, promotes anxiety and several self-esteem damages in women. The odour and the fear of incontinence during sexual intercourse affect female sexual function and this is related with the unpredictability and the chronicity of incontinence, namely urge urinary incontinence.
Female urinary incontinence management involves conservative (pelvic floor muscle training), surgical and pharmacological treatment. Both conservative and surgical treatments have been studied about its benefit in urinary incontinence and also the impact among female sexual function. Unfortunately, there are sparse articles that evaluate the benefits of female sexual function with drug management of incontinence.
Keywords: Urinary Incontinence; Sexuality; Quality of Life
Vol. 43 (1): 29-35, January – February, 2017
Gustavo Cardoso Guimaraes 1, Walter Henriques da Costa 1, Renato Almeida Rosa 1, Stênio Zequi 1, Ricardo Favaretto 1
1 Núcleo de Urologia, Departamento de Cirurgia Pélvica, AC Camargo Cancer Center, SP, Brasil
Objectives: to evaluate the predictive value of TRIMprob test to detect prostate cancer (PCa) in patients referred to prostate biopsy (PB).
Material and Methods: Patients with PSA <10ng/mL and rectal exam without findings suggestive of prostate cancer were selected for TRIMprob evaluation.
Exam was performed by a single operator through transperineal approach.
Patients admitted for the study were submitted to TRIMprob and multiparametric magnetic resonance (mpMRI) and posteriorly to PB.
Results: In total, 77 patients were included. TRIMprob showed evidences of PCa in 25 (32.5%) and was negative in 52 patients (67.5%). The rate of detection of prostate cancer at biopsy was higher in patients with positive TRIMprob (16/25; 64.0%) than in patients with negative TRIMprob (11/52; 21.1%; p<0.001). Sensitivity, specificity, positive predictive value, negative predictive value and accuracy of TRIMprob were respectively 61.5%, 82.0%, 64.0%, 80.3% and 74.0%. ROC curve showed the following areas under the curve values for TRIMprob, mpMRI and combination of TRIMprob + mpMRI: 0.706; 0.662 and 0.741 respectively. At combined analysis, when both TRIMprob and mpMRI were negative for prostate cancer, accuracy was 96.3% or only 1 in 27 PB was positive (3.7%).
Conclusions: Trimprob had similar predictive value for PCa in patients submitted to PB as mpMRI. Combined TRIMprob and mpMRI showed higher accuracy than when performed singly.
Keywords: Magnetic Resonance Imaging; Prostatic Neoplasms; Diagnosis
Lack of evidence of HPV etiology of prostate cancer following radical surgery and higher frequency of the Arg/Pro genotype in Turkish men with prostate cancer
Vol. 43 (1): 36-46, January – February, 2017
Merve Aydin 1, Aliseydi Bozkurt 2, Aytekin Cikman 1, Baris Gulhan 1, Mehmet Karabakan 2, Aysun Gokce 3, Murat Alper 3, Murat Kara 1
1 Department of Medical Microbiology, Faculty of Medicine, Erzincan University, Erzincan, Turkey; 2 Department of Urology, Erzincan University, Mengucek Gazi Training and Research Hospital, Erzincan, Turkey; 3 Department of Pathology, Dıskapı Training and Research Hospital, Ankara, Turkey
Objectives: The aim of this study was to assess the possible role of HPV in the development of prostate cancer (PCa) and investigate the distribution of the p53 codon 72 polymorphism in PCa in a Turkish population.
Materials and methods: A total of 96 tissues, which had been obtained using a radical surgery method, formalin-fixed and parafin-embedded, were used in this study. The study group consisted of 60 PCa tissues (open radical prostatectomy) and the control group contained 36 benign prostatic hyperplasia tissues (BPH) (transvesical open prostatectomy). The presence of HPV and the p53 codon 72 polymorphism was investigated in both groups using real-time PCR and pyrosequencing.
Results: The results of the real-time PCR showed no HPV DNA in any of the 36 BPH tissue samples. HPV-DNA was positive in only 1 of the 60 PCa samples (1.7%). The HPV type of this sample was identified as HPV-57. The distribution of the three genotypes, Arg/Arg, Arg/Pro and Pro/Pro was found to be 45.6, 45.6, and 8.8% in the PCa group and 57.1%, 34.3% and 8.6% in the control group, respectively. Compared with the control group, patients with PCa had a higher frequency of the Arg/Pro genotype and Proline allele (odds ratio (OR)=1.67, 95% confidence interval (CI)=0.68-4.09, p=0.044; OR=1.13, 95% CI=0.76-1.68, p=0.021, respectively).
Conclusions: The results of the study do not support the hyphothesis that prostate cancer is associated with HPV infection but indicated that Proline allele can be a risk factor in the development of PCa in the Turkish population.
Keywords: Papillomaviridae; Prostatic Neoplasms; Tumor Suppressor Protein p53
Editorial Comment: Lack of evidence of HPV etiology of prostate cancer following radical surgery and higher frequency of the Arg/Pro genotype in Turkish men with prostate cancer
Vol. 43 (1): 47-47, January – February, 2017
Jose Pontes Jr.
1 Departamento de Urologia Hospital das Clincas da FMUSP, Instituto Central São Paulo, SP, Brasil
The authors retrospectıvely evaluated the presence of HPV and the p53 polymorphism distribution by RT-PCR in a series of 60 surgical specimens of localized prostate cancer and 36 BPH samples.
They found HPV in only one prostate cancer case and no HPV in BPH cases. They also demonstrated that Ar72Pro polymorphism and the Proline allele were more frequently found in cancer. They concluded that there is no association between prostate cancer and HPV and also postulate that the Proline allele can be a risk factor for the development of PCa in the Turkish population.
Predictive value of [-2]propsa (p2psa) and its derivatives for the prostate cancer detection in the 2.0 to 10.0ng/mL PSA range
Vol. 43 (1): 48-56, January – February, 2017
I. Vukovic 1, D. Djordjevic 1, N. Bojanic 1, U. Babic 1, I. Soldatovic 2
1 Clinic of Urology, Clinical Center of Serbia, School of Medicine, University of Belgrade, Serbia; 2 Institute of Medical Statistics and Informatics, Belgrade, Serbia
Introduction: To assess predictive value of new tumor markers, precursor of prostate specific antigen (p2PSA) and its derivates-%p2PSA and prostate health index (PHI) in detection of patients with indolent and aggressive prostate cancer (PC) in a subcohort of man whose total PSA ranged from 2 to 10ng/mL.
Materials and Methods: This cross-sectional study included 129 consecutive male patients aged over 50 years, with no previous history of PC and with normal digital rectal examination findings, but with serum PSA in interval between 2 and 10ng/mL. All patients underwent standard transrectal ultrasonography guided prostate biopsy for the first time. For all patients, serum PSA, free PSA (fPSA) and p2PSA were measured and PHI and %p2PSA were calculated.
Results: PHI and %p2PSA levels were significanlty higher in patients with PC compared to those without this malignancy. The same findings have been observed in group of patients with Gleason score ≥7 compared to those with Gleason score <7.
ROC analysis reveled the highest area under the curve with these two markers. Multivariate logistic regression showed significant improvement in PC detection and its agressive form (assumed as Gleason score ≥7).
Conclusions: New markers, derivates of p2PSA (especially %p2PSA and PHI), represente potentially very important clinical tool for predicting presence of PC, and even more important, to discriminate patients with Gleason score <7 from those with Gleason score ≥7 with total PSA in range from 2 to 10ng/mL.
Keywords: Biomarkers; Prostatic Neoplasms; Prostate-Specific Antigen
Laparoscopic radical cystectomy with novel orthotopic neobladder with bilateral isoperistaltic afferent limbs: initial experience
Vol. 43 (1): 57-66, January – February, 2017
Nian-Zeng Xing 1, Ning Kang 1, Li-Mming Song 1, Yi-Nong Niu 1, Ming-Shuai Wang 1, Jun-Hui Zhang 1
1 Department of Urology Beijing Chao Yang Hospital, Affiliate of Capital Medical University, Beijing, Republic of China
Purpose: To introduce a new method of constructing an orthotopic ileal neobladder with bilateral isoperistaltic afferent limbs, and to describe its clinical outcomes.
Materials and Methods: From January 2012 to December 2013, 16 patients underwent a new method of orthotopic ileal neobladder after laparoscopic radical cystectomy for bladder cancer. To construct the neobladder, an ileal segment 60cm long was isolated approximately 25cm proximally to the ileocecum. The proximal 20cm of the ileal segment was divided into two parts for bilateral isoperistaltic afferent limbs. The proximal 10cm of the ileal segment was moved to the distal end of the ileal segment for the right isoperistaltic afferent limb, and the remaining proximal 10cm ileal segment was reserved for the left isoperistaltic afferent limb. The remaining length of the 40cm ileal segment was detubularized along its antimesenteric border to form a reservoir. The neobladder was sutured to achieve a spherical configuration.
Results: All procedures were carried out successfully. The mean operative time was 330 min, mean blood loss was 328mL, and mean hospital stay was 12.5 days. The mean neobladder capacity 6 and 12 months after surgery was 300mL and 401mL, respectively. With a mean follow-up of 22.8 months, all patients achieved daytime continence and 15 achieved nighttime continence. The mean peak urinary flow rate was 11.9mL/s and 12.8mL/s at 6 and 12 months postoperatively, respectively.
Conclusions: This novel procedure is feasible, safe, simple to perform, and provides encouraging functional outcomes. However, comparative studies with long-term follow-up are required to prove its superiority.
Keywords: Urinary Bladder Neoplasms; Cystectomy; Laparoscopy; surgery [Subheading]
Can neutrophil to lymphocyte ratio predict lamina propria invasion in patients with non muscle invasive bladder cancer?
Vol. 43 (1): 67-72, January – February, 2017
Haci Ibrahim Cimen 1, Fikret Halis 1, Hasan Salih Saglam 1, Ahmet Gokce 1
1 Department of Urology, Sakarya Training and Research Hospital, Sakarya University, Sakarya, Turkey
Objective: Recent studies have demonstrated the role of systemic inflammation in the development and progression of cancer. In this study, we evaluated whether preoperatively measured neutrophil-to-lymphocyte ratio (NLR) can predict lamina propria invasion in patients with non-muscle-invasive bladder cancer (NMIBC).
Material and Methods: We reviewed the medical records of 304 consecutive and newly diagnosed patients with bladder cancer who had been treated with transurethral resection between January 2008 and June 2014. In total, 271 patients were included in the study and the patients were divided into two groups according to the pathological stage (Group 1: Ta, Group 2: T1). NLR was calculated by dividing the absolute neutrophil count (N) by the absolute lymphocyte count (L).
Results: In total, 271 patients (27 women and 244 men) were enrolled. Mean age was higher in Group 2 than in Group 1 (67.3±10.8 vs. 62.9±10.8, p<0.001). Furthermore, the presence of high grade tumors and tumors ≥3cm in size was statistically higher in Group 2 than in Group 1 (70.9% vs. 9.9%, p=0.0001; 71.8% vs. 36%, p=0.0001, respectively). While the mean white blood cell (WBC) and N counts were statistically insignificant (7.63±1.87 vs. 7.69±1.93, p=0.780; 4.72±1.54 vs. 4.46±1.38, p=0.140; respectively), L was significantly lower and NLR was significantly higher in Group 2 than in Group 1 (2.07±0.75 vs. 2.4±0.87, p=0.001; 2.62±1.5 vs. 2.19±1.62, p=0.029; respectively).
Conclusion: Our data indicate that high NLR and low L are statistically associated with T1 stage, whereas low L are able to predict lamina propria invasion in patients with NMIBC. These findings suggest that pretreatment measurement of NLR may provide valuable information for the clinical management of patients with NMIBC. Prospective studies are now required to further validate the role of NLR as a risk factor in NMIBC.
Keywords: Urinary Bladder; Neoplasms; Inflammation
Vol. 43 (1): 73-79, January – February, 2017
Myiasis associated with penile carcinoma: a new trend in developing countries?
Leandro Koifman 1, Rodrigo Barros 1, Lucas Schulze 1, Antonio Augusto Ornellas 2,3, Luciano A. Favorito 4
1 Hospital Municipal Aguiar Souza, RJ, Brasil; 2 Serviço de Urologia, Hospital Mário Kröeff, RJ Brasil; 3 Departamento de Urologia, Instituto Nacional de Câncer, RJ, Brasil; 4 Unidade de Pesquisa Urogenital – Universidade do Estado do Rio de Janeiro, Brasil
Objectives: The aim of this study is to report an unusual form of penile cancer presentation associated with myiasis infestation, treatment options and outcomes.
Materials and Methods: We studied 10 patients with suspected malignant neoplasm of the penis associated with genital myiasis infestation. Diagnostic assessment was conducted through clinical history, physical examination, penile biopsy, larvae identification and computerized tomography scan of the chest, abdomen and pelvis. Clinical and pathological staging was done according to 2002 TNM classification system. Radical inguinal lymphadenectomy was conducted according to the primary penile tumor pathology and clinical lymph nodes status.
Results: Patients age ranged from 41 to 77 years (mean=62.4). All patients presented squamous cell carcinoma of the penis in association with myiasis infestation caused by Psychoda albipennis. Tumor size ranged from 4cm to 12cm (mean=5.3). Circumcision was conducted in 1 (10%) patient, while penile partial penectomy was performed in 5 (50%). Total penectomy was conducted in 2 (20%) patients, while emasculation was the treatment option for 2 (20%). All patients underwent radical inguinal lymphadenectomy.
Prophylactic lymphadenectomy was performed on 3 (30%) patients, therapeutic on 5 (50%), and palliative lymphadenectomy on 2 (20%) patients. Time elapsed from primary tumor treatment to radical inguinal lymphadenectomy was 2 to 6 weeks. The mean follow-up was 34.3 months.
Conclusion: The occurrence of myiasis in the genitalia is more common in patients with precarious hygienic practices and low socio-economic level. The treatment option varied according to the primary tumor presentation and clinical lymph node status.
Keywords: Penile Neoplasms; Myiasis; Lymph Node Excision
The percentage of resected and ischemic volume determined by a geometric model is a significant predictor of renal functional change after partial nephrectomy
Vol. 43 (1): 80-86, January – February, 2017
Wei-Hsuan Huang 1, Chao-Hsiang Chang 1,2, Chi-Ping Huang 1, Hsi-Chin Wu 3, Po-Fan Hsieh 1
1 Department of Urology, China Medical University Hospital, Taichung, Taiwan; 2 School of Medicine, China Medical University, Taichung, Taiwan; 3 Department of Urology, An-Nan Hospital, Tainan, Taiwan
Purpose: The percentage of parenchyma preserved plays a predominant role in predicting renal function after partial nephrectomy (PN). Currently there is no standard method to estimate preserved renal parenchyma. In this study we propose a formula of the percentage of resected and ischemic volume (PRAIV) determined by a geometric model and evaluate the relationships between renal functional change and PRAIV as well as other clinical parameters.
Materials and Methods: We identified 71 patients who underwent open PN between January 2004 and April 2014. Assuming the kidney to be an ellipsoid with bilaterally equal volume and tumor to be a sphere, we calculated PRAIV by integral calculus. Nadir estimated glomerular filtration rate (eGFR) between postoperative 3 and 12 months were recorded. The correlation between percent eGFR reduction, PRAIV, and other clinical parameters were examined.
Results: On univariate analysis, age (p=0.03), depth of tumor invasion (p=0.004), C index (p=0.003), RAIV (p=0.04), and PRAIV (p<0.001) were correlated with percent reduction of eGFR. However, only age (p=0.007) and PRAIV (p<0.001) were significantly correlated with percent reduction of eGFR on multivariate analysis. Depicting these values along the regression line, we found R2 was 0.194 and 0.073 for PRAIV and age, respectively.
Conclusions: PRAIV determined by a geometric model is a significant predictor of renal functional change after PN. Using PRAIV, we can estimate percent eGFR reduction preoperatively for better patient consultation and surgical planning.
Keywords: Nephrectomy; Delayed Graft Function; Kidney Neoplasms
Cystoscopy-assisted laparoscopy for bladder endometriosis: modified light-to-light technique for bladder preservation
Vol. 43 (1): 87-94, January – February, 2017
Rafael Mamprin Stopiglia 1, Ubirajara Ferreira 1, Daniel Gustavo Faundes 2, Carlos Alberto Petta 3
1 Grupo de Urologia Oncológica, Universidade de Campinas, UNICAMP, SP, Brasil; 2 Centro de Reprodução Humana Campinas, SP, Brasil; 3 Departamento de Ginecologia, Universidade de Campinas, UNICAMP, SP, Brasil
Introduction: Endometriosis is a disease with causes still unclear, affecting approximately 15% of women of reproductive age, and in 1%-2% of whom it may involve the urinary tract. The bladder is the organ most frequently affected by endometriosis, observed around 85% of the cases. In such cases, the most effective treatment is partial cystectomy, especially via videolaparoscopy.
Study Objective, Design, Size and Duration: In order to identify and delimit the extent of the intravesical endometriosis lesion, to determine the resection limits, as well as to perform an optimal reconstruction of the organ aiming for its maximum preservation, we performed a cystoscopy simultaneously with the surgery, employing a modified light-tolight technique in 25 consecutive patients, from September 2006 to May 2012. Setting: Study performed at Campinas Medical Center – Campinas – Sao Paulo – Brazil.
Participants/materials, setting and methods: Patients aged 27 to 47 (average age: 33.4 years) with deep endometriosis with total bladder involvement were selected for the study. The technique used was conventional laparoscopy with a transvaginal uterine manipulator and simultaneous cystoscopy (the light-to-light technique). A partial videolaparoscopic cystectomy was performed with cystoscopy-assisted vesical reconstruction throughout the entire surgical time. The lesions had an average size of 2.75cm (ranging from 1.5 to 5.5cm). The average surgical time was 137.7 minutes, ranging from 110 to 180 minutes.
Main Results: Postoperative follow-up time was 32.4 months (12-78 months), with clinical evaluation and a control cystoscopy performed every six months. No relapse was observed during the follow-up period.
Conclusions: A cystoscopy-assisted partial laparoscopic cystectomy with a modified light-to-light technique is a method that provides adequate identification of the lesion limits, intra or extravesically. It also allows a safe reconstruction of the organ aiming for its maximum preservation.
Keywords: Endometriosis; Urinary Bladder; Cystoscopy
Preliminary assessment of Neck Circumference in Benign Prostatic Hyperplasia in Patients with Metabolic Syndrome
Vol. 43 (1): 95-103, January – February, 2017
Yigit Akin 1, Hakan Gulmez 2, Erhan Ates 3, Mehmet Gulum 4, Murat Savas 5
1 Department of Urology, Harran University School of Medicine, Sanliurfa, Turkey; 2 Department of Family Medicine, 14th Family Healthcare centre, Konya, Turkey; 3 Department of Urology, Necip Fazil State Hospital, Kahramanmaras, Turkey; 4 Department of Urology, Hacettepe University School of Medicine, Ankara, Turkey; 5 Department of Urology, Antalya Training and Research Hospital, Antalya, Turkey
Objectives: To investigate the impact of neck circumference (NC) in the treatment of bening prostatic hyperplasia (BPH) patients with metabolic syndrome (MtS). Additionally, we determined dose response to alpha-blockers and cut-off values for NC and waist circumference (WC), in these patients.
Materials and Methods: Non-randomized, open-labelled, and multi-centre study was conducted between March 2014 and September 2015. The BPH patients were enrolled and were divided into 2 groups: with MtS (Group 1; n=94) and without MtS (Group 2; n=103). Demographic data, anthropometric measurements, blood analyses, uroflowmetric parameters, post voiding residual urine (PVR), prostate volume, quality of life (QoL) index, NC and WC were recorded. Both groups were administered oral alphablockers and response to treatment was evaluated. Receiver-operating characteristic (ROC) curves were obtained and significant p was p<0.05.
Results: In total, 197 patients were enrolled with mean age of 60.5±8.1 years. Mean NC and WC were higher in MtS patients (p<0.001). Uroflowmetry parameters and QoL indexes were comparable between groups before treatment. International prostate symptom score, uroflowmetry parameters, and QoL significant improved in Group 2 than Group 1, at 1st and 6th months of treatment with alpha-blockers. Success rate of treatment was significant higher in Group 2 than Group 1 (p<0.001). Cut-off values were 42.5cm and 113.5cm for NC and WC respectively, for response to alpha-blockers in BPH patients with MtS.
Conclusions: MtS can be related with BPH and can negatively affect the response to alpha-blocker treatment. NC can be used for predicting response to alpha-blocker treatment in BPH patients with MtS.
Keywords: Prostatic Hyperplasia; Quality of Life; Patients
Vol. 43 (1): 104-111, January – February, 2017
Robert A. Goldfarb 1, Yunhua Fan 1, Stephanie Jarosek 1, Sean P. Elliott 1
1 Department of Urology, University of Minnesota, Minneapolis, Minnesota, USA
Purpose: Ureteral obstruction in cervical cancer occurs in up to 11% of patients, many of whom undergo ureteral stenting. Our aim was to describe the patient burden of chronic ureteral stenting in a population-based cohort by detailing two objectives: (1) the frequency of repeat procedures for ureteral obstruction; and, (2) the frequency of urinary adverse effects (UAEs) (e.g., lower urinary tract symptoms, flank pain).
Materials and Methods: From SEER-Medicare, we identified 202 women who underwent ureteral stent placement prior to or following cervical cancer treatment. The frequency of repeat procedures and rate ratios were compared between treatment modalities.
The rates and rate ratios of UAEs were compared between our primary cohort (stent + cervical cancer) and the following groups: no stent + cervical cancer, stent + no cancer, and no stent + no cancer. The “no cancer” group was drawn from the 5% Medicare sample.
Results: 117/202 women (58%) underwent >1 stent procedure. The frequency of additional procedures was significantly higher in patients who received radiation as part of their treatment. UAEs were very common in women with stent + cancer. The rate of UTI was 190 (per 100 person-years), 67 for LUTS, 42 for stones, and 6 for flank pain. These rates were 3-10 fold higher than in the no stent + no cancer control group; rates were also higher than in the no stent + cancer and the stent + no cancer women.
Conclusions: The burden of disease associated with ureteral stents is higher than expected and urologists should be actively involved in stent management, screening for associated symptoms and offering definitive reconstruction when appropriate.
Keywords: Survivors; Neoplasms; Ureteral Obstruction
Vol. 43 (1): 112-120, January – February, 2017
Jeová Nina Rocha 1
1 Departamento de Urologia Hospital das Clínicas da FMRP-USP Ribeirão Preto, São Paulo, Brasil
Objective: cystometric evaluation of the bladder after autotransplant and isogeneic transplant in female rats.
Material and Methods: two groups were constituted: (A) bladder autotransplant with two subgroups: R1 – (control) and R2 – (bladder transplant); (B) isogeneic bladder transplant with three subgroups; T1 – (control); T2–T3, two subgroups observed for 30 and 60 days after transplant, respectively. All animals underwent cystometric evaluation. Afterwards, the bladders were removed for histological study.
Results: the transplanted bladders did not show significant changes in filling/storage and emptying/micturition functions after 30 and 60 days of evolution. Upon macroscopical evaluation, there was good revascularization and the tissue was well preserved. Cystometry results: did not show significant differences in the micturition pressure in subgroups T2-T3, but did between subgroups R1−R2, T1−T2, and T1−T3. Significant differences were verified in the micturition interval between T1−T3, T2−T3, but not between R1−R2, T1−T2. There was significant difference in the micturition duration between T1−T3 but not between R1−R2, T1−T2 and T2−T3. No fistula was noted on the suture site nor leakage of urine in the abdominal cavity or signs of necrosis or retraction were observed.
Conclusions: transplant of the bladder was shown to be a viable procedure. The results indicate that there was structural and functional regeneration of transplanted bladders, and these results indicate that it is possible that vascular endothelium growth and neurogenesis factors are involved and activated in the process of the preservation or survival of the transplanted organ.
Keywords: Transplantation; Urinary Bladder; Patients
Percutaneous tibial nerve stimulation versus electrical stimulation with pelvic floor muscle training for overactive bladder syndrome in women: results of a randomized controlled study
Vol. 43 (1): 121-126, January – February, 2017
Carlo Vecchioli Scaldazza 1, Carolina Morosetti 2, Rosita Giampieretti 3, Rossana Lorenzetti 3, Marinella Baroni 3
1 Operating Unit of Uro-gynecology; 2 Clinical Phatology; 3 Physical Medicine and Rehabilitation. ASUR, Area Vasta n 2, Jesi, Italy
Introduction: This study compared percutaneous tibial nerve stimulation (PTNS) versus electrical stimulation with pelvic floor muscle training (ES + PFMT) in women with overactive bladder syndrome (OAB).
Materials and Methods: 60 women with OAB were enrolled. Patients were randomized into two groups. In group A, women underwent ES with PFMT, in group B women underwent PTNS.
Results: A statistically significant reduction in the number of daily micturitions, episodes of nocturia and urge incontinence was found in the two groups but the difference was more substantial in women treated with PTNS; voided volume increased in both groups. Quality of life improved in both groups, whereas patient perception of urgency improved only in women treated with PTNS. Global impression of improvement revealed a greater satisfaction in patients treated with PTNS.
Conclusion: This study demonstrates the effectiveness of PTNS and ES with PFMT in women with OAB, but greater improvements were found with PTNS.
Keywords: Transcutaneous Electric Nerve Stimulation; Pelvic Floor; Urinary Bladder, Overactive
Does MRI help in the pre – operative evaluation of pelvic fracture urethral distraction defect? – A pilot study
Vol. 43 (1): 127-133, January – February, 2017
Rajadoss Muthukrishna Pandian 1, Nirmal Thampi John 1, Anu Eapen 2, B. Antonisamy 3, Antony Devasia 1, Nitin Kekre 1
1 Department of Urology, Christian Medical College and Hospital, Vellore, Tamil Nadu, India; 2 Department of Radiology, Christian Medical College and Hospital, Vellore, Tamil Nadu, India; 3 Department of Biostatistics, Christian Medical College and Hospital, Tamil Nadu, India
Objectives: To study the usefulness of MRI in preoperative evaluation of PFUDD. Can MRI provide additional information on urethral distraction defect (UDD) and cause of erectile dysfunction (ED)?
Materials and Methods: In this prospective study, consecutive male patients presenting with PFUDD were included from Feb 2011 till Dec 2012. Those with traumatic spinal cord injury and pre-existing ED were excluded. Patients were assessed using IIEF questionnaire, retrograde urethrogram and micturating cystourethrogram (RGU+MCU) and MRI pelvis. Primary end point was erectile function and secondary end point was surgical outcome.
Results: Twenty patients were included in this study. Fourteen patients (70%) were ≤40years; fifteen patients (75%) had ED, seven patients (35%) had severe ED. MRI findings associated with ED were longer median UDD (23mm vs. 15mm, p=0.07), cavernosal injury (100%, p=0.53), rectal injury (100%, p=0.53), retropubic scarring (60%, p=0.62) and prostatic displacement (60%, p=0.99). Twelve patients (60%) had a good surgical outcome, five (25%) had an acceptable outcome, three (15%) had a poor outcome.
Poor surgical outcome was associated with rectal injury (66.7%, p=0.08), cavernosal injury (25%, p=0.19), retropubic scarring (18.1%, p=0.99) and prostatic displacement (16.7%, p=0.99). Five patients with normal erections had good surgical outcome. Three patients with ED had poor outcome (20%, p=0.20).
Conclusions: MRI did not offer significant advantage over MCU in the subgroup of men with normal erections. Cavernosal injury noted on MRI strongly correlated with ED.
Role of MRI may be limited to the subgroup with ED or an inconclusive MCU.
Keywords: Surveys and Questionnaires; Pelvis; Magnetic Resonance Imaging; Erectile Dysfunction
A prospective randomized controlled multicentre trial comparing intravesical DMSO and chondroïtin sulphate 2% for painful bladder syndrome/interstitial cystitis
Vol. 43 (1): 134-141, January – February, 2017
Manuela Tutolo 1, Enrico Ammirati 2, Giulia Castagna 3, Katrien Klockaerts 4, Hendrik Plancke 5, Dieter Ost 6, Frank Van der Aa 1, Dirk De Ridder 1
1 Department of Urology, University Hospitals, KU Leuven, Belgium; 2 Division of Urology, Città della Salute e della Scienza, Molinette Hospital Hospital, University of Studies of Turin, Turin, Italy; 3 Department of Urological Research Institute, IRCCS Ospedale San Raffaele, Division of Oncology/Unit of Urology, Milan, Italy; 4 Department of Urology, St. Lucas Hospital, Gent, Belgium; 5 Department of Urology, Imelda Hospital, Bonheiden, Belgium; 6 Urology, St. Blasius Hospital, Dendermonde, Belgium
Objective: To compare effectiveness of intravesical chondroïtin sulphate (CS) 2% and dimethyl sulphoxide (DMSO) 50% in patients with painful bladder syndrome/interstitial cystitis (PBS/IC).
Materials and methods: Patients were randomized to receive either 6 weekly instillations of CS 2% or 50% DMSO. Primary endpoint was difference in proportion of patients achieving score 6 (moderately improved) or 7 (markedly improved) in both groups using the Global Response Assessment (GRA) scale. Secondary parameters were mean 24-hours frequency and nocturia on a 3-day micturition dairy, changes from baseline in O’Leary-Sant questionnaire score and visual analog scale (VAS) for suprapubic pain.
Results: Thirty-six patients were the intention to treat population (22 in CS and 14 in DMSO group). In DMSO group, 57% withdrew consent and only 6 concluded the trial. Major reasons were pain during and after instillation, intolerable garlic odor and lack of efficacy. In CS group, 27% withdrew consent. Compared with DMSO group, more patients in CS group (72.7% vs. 14%) reported moderate or marked improvement (P=0.002, 95% CI 0.05-0.72) and achieved a reduction in VAS scores (20% vs. 8.3%). CS group performed significantly better in pain reduction (-1.2 vs. -0.6) and nocturia (-2.4 vs. -0.7) and better in total O’Leary reduction (-9.8 vs. -7.2). CS was better tolerated. The trial was stopped due to high number of drop-outs with DMSO.
Conclusions: Intravesical CS 2% is viable treatment for PBS/IC with minimal side effects. DMSO should be used with caution and with active monitoring of side effects. More randomized controlled studies on intravesical treatments are needed.
Keywords: Cystitis, Interstitial; Dimethyl Sulfoxide; Chondroitin Sulfates
Female sexual function following a novel transobturator sling procedure without paraurethral dissection (modified-TOT)
Vol. 43 (1): 142-149, January – February, 2017
Burak Arslan 1, Ozkan Onuk 1, Ali Eroglu 1, Tugrul Cem Gezmis 1, Memduh Aydın 1
1 Department of Urology, Istanbul Taksim Training and Research Hospital, Turkey
Purpose: To determine whether there is a difference in sexual function after modified and classical TOT procedures.
Materials and Methods: Of the 80 sexually active women with SUI, 36 underwent na original outside-in TOT as described by Delorme, and 44 underwent modified TOT procedure, between 2011 and 2015. The severity of incontinence and sexual function were evaluated using International Consultation on Incontinence Questionnaire-Short Form (ICIQ-SF) and Female Sexual Function Index (FSFI) questionnaires preoperatively and 3 months after surgery.
Results: The postoperative ICIQ-SF score was significantly lower than the preoperative ICIQ-SF score in both groups (p=0.004 for modified TOT and p=0.002 for classical TOT). There was no significant difference in the ICIQ-SF score reduction between the two groups (14.1±2.1 vs. 14.4±1.9; p=0.892). Complication rates according to the Clavien-Dindo classification were also similar in both groups.
In both groups, difference between preoperative and postoperative FSFI scores revealed a statistically significant improvement in all domains.
Comparison of postoperative 3-month FSFI scores of modified and classical TOT groups showed statistically significant differences in arousal, lubrication and orgasm domains. Desire, satisfaction, pain and total FSFI scores did not differ significantly between two groups.
Conclusion: The modified TOT technique is a simple, reliable and minimal invasive procedure. The cure rate of incontinence and complication rates are the same as those of the classical TOT technique. However, due to the positive effects of minimal tissue damage on sexual arousal and orgasmic function, modified TOT has an advantage over the classical TOT.
Keywords: Urinary Incontinence, Stress; Suburethral Slings; Dyspareunia
Artificial urinary sphincter for urinary incontinence after radical prostatectomy: a historical cohort from 2004 to 2015
Vol. 43 (1): 150-154, January – February, 2017
Augusto Cesar Soares dos Santos Junior 1,2, Luíza de Oliveira Rodrigues 1,2, Daniela Castelo Azevedo 1,2, Lélia Maria de Almeida Carvalho 1,2, Mariana Ribeiro Fernandes 1,2, Sandra de Oliveira Sapori Avelar 1,2, Maria da Glória Cruvinel Horta 1,2, Silvana Márcia Bruschi Kelles 1,2
1 Grupo de Avaliação de Tecnologia em Saúde, Unimed BH, MG, Brasil; 2 Núcleo de Avaliação de Tecnologia em Saúde, Hospital das Clínicas, Universidade Federal de Minas Gerais (UFMG), MG, Brasil
This study aimed to retrospectively evaluate a cohort of patients with prostate cancer and persistent urinary incontinence after radical prostatectomy. From January 2004 to December 2015, eighty-six individuals were identified to have received an AUS implant, provided by a private nonprofit HMO operating in Belo Horizonte, Brazil. On total, there were 91 AUS implants, with a median interval between radical prostatectomy and AUS implant of 3.6 years (IQR 1.9 to 5.5). The rate of AUS cumulative survival, after a median follow-up of 4.1 years (IQR 1.7-7.2 years), was 44% (n=40). The median survival of AUS implants was 2.9 years (IQR 0.5-7.9 years). Thirty-seven AUS implants (40.7%) resulted in grade III surgical complications. There were 5 deaths at 2.1, 4.7, 5.7, 5.7 and 6.5 years of follow-up, but none due to causes directly associated to the AUS implant. Persistent severe incontinence was documented in 14 (15.3%) additional patients. From the 51 AUS implants which resulted in grade III surgical complications or persistent severe incontinence, 24 (47.1%) underwent surgical revisions. Explantation of the sphincter or its components was observed in 6 cases (25.0%). Mechanical failure, described as fluid loss and/or inability to recycle the AUS device, was observed in 4 devices (16.7%). In conclusion, although AUS implants are recommended as the gold-standard treatment of severe urinary incontinence after prostatectomy, the observed high rates of malfunction and grade III adverse events are a matter of concern warranting further assessment on the safety and efficacy of these devices.
Keywords: Urinary Incontinence; Prostatectomy; Prostatic Neoplasms; Urinary Sphincter, Artificial
Vol. 43 (1): 155-162, January – February, 2017
Amilcar Martins Giron 1, Marcos Figueiredo Mello 1, Paulo Afonso Carvalho 1, Paulo Renato Marcelo Moscardi 1, Roberto Iglesias Lopes 1, Miguel Srougi 1
1 Divisão de Urologia do Departamento de Cirurgia, Universidade de São Paulo, SP, Brasil
Introduction: The surgical correction of bladder exstrophy remains challenging. In our institution, the repair has evolved from a staged repair to one-stage reconstruction. The one-stage reconstruction includes; bladder closure, Cantwell-Ransley neourethroplasty and abdominoplasty using groin flaps, without the need of pelvic ostheotomies. Repair of urinary continence (UC) and vesicoureteral reflux (VUR) is done after development of the infant.
Objective: To present our experience of our modified one-stage reconstruction of bladder exstrophy in male patients.
Materials and Methods: Medical records of male patients submitted to one-stage reconstruction of bladder exstrophy were analyzed retrospectively. Fifteen exstrophy bladder patients with mean age 4.2±7 years were treated at our institution between 1999-2013.
Results: Eleven patients were referred to us after previous surgery. Sixteen procedures were performed; one patient had complete wound dehiscence and needed another reconstruction (6.7%). Mean follow up was 10.3±4.5 years. No patient has had a loss of renal function. Postoperative complications: four patients (26.6%) presented small fistulas, one presented penile rotation. Eleven patients (73.3%) patients underwent bladder-neck surgery. Five (33.3%) required bladder augmentation. Three cases (20%) needed subsequent treatment of VUR.
At the time of our review nine (60%) patients achieved UC, two (13.3 %) patient without additional procedure. A mean of 3±1.1 procedures (2-5) was accomplished per children.
Conclusions: One-stage reconstruction minimizes the number of surgical procedures required to achieve UC and potentiates bladder-neck function. The advantages of using groin flaps over current techniques for complete repair are the small risk for penile tissue loss and the avoidance of ostheotomies.
Keywords: Bladder Exstrophy; Reconstructive Surgical Procedures; Male; Patients
Intraoperative breakage of Sachse’s knife blade: A rare complication of optical internal urethrotomy (one case managing experience)
Vol. 43 (1): 163-165, January – February, 2017
CHALLENGING CLINICAL CASES
Gautam Kumar Kanodia 1, Satyanarayan Sankhwar 1, Ankur Jhanwar 1, Ankur Bansal 1, Manoj Kumar 1, Ashok Gupta 1
1 King George Medical University, Lucknow, Uttar Pradesh, India
Optical internal urethrotomy (OIU) is the most common procedure performed for short segment bulbar urethral stricture worldwide. This procedure most commonly performed using Sachse’s cold knife. Various perioperative complications of internal urethrotomy have been described in literature including bleeding, urinary tract infection, extravasation of fluid, incontinence, impotence, and recurrence of stricture. Here we report a unique complication of breakage of Sachse knife blade intraoperatively and its endoscopic management.
Keywords: Urethra; Recurrence; Methods
Vol. 43 (1): 166-166, January – February, 2017
Anibal Wood Branco 1
1 Departamento de Urologia Hospital Cruz Vermelha, Curitiba, Brasil
Vascular injury in accidental punctures may occur in large abdominal vessels, it is known that 76% of injuries occur during the development of pneumoperitoneum. The aim of this video is to demonstrate two cases of vascular injury occurring during access in laparoscopic urologic surgery.
The first case presents a 60-year old female patient with a 3cm tumor in the superior pole of the right kidney who underwent a laparoscopic partial nephrectomy. After the Verres needle insertion, output of blood was verified. During the evaluation of the cavity, a significant hematoma in the inferior vena cava was noticed. After the dissection, a lesion in the inferior vena cava was identified and controlled with a prolene suture, the estimated bloos loss was 300mL.
The second case presents a 42-year old female live donor patient who had her right kidney selected to laparoscopic live donor nephrectomy. After the insertion of the first trocar, during the introduction of the 10mm scope, an active bleeding from the mesentery was noticed. The right colon was dissected and an inferior vena cava perforation was identified; a prolene suture was used to control the bleeding, the estimated blood loss was 200mL, in both cases the patients had no previous abdominal surgery.
Urologists must be aware of this uncommon, serious, and potentially lethal complication. Once recognized and in the hands of experienced surgeons, some lesions may be repaired laparoscopically. Whenever in doubt, the best alternative is the immediate conversion to open surgery to minimize morbidity and mortality.
Vol. 43 (1): 167-167, January – February, 2017
Nikhil Sapre 1, Homayoun Zargar 1, 2
1 Royal Melbourne Hospital, Melbourne, VIC, Australia; 2 Australian Prostate Cancer Research Centre, Melbourne, VIC, Australia
Branco et al. (1) describe two cases of injuries during laparoscopic renal surgery; both recognized immediately and repaired laparoscopically. Laparoscopic entry complications are an uncommon but potentially life-threatening complication of laparoscopic surgery. Most such injuries occur during initial trocar insertion and most commonly involve major vessels and/or bowel. Failing to recognize these immediately is a leading cause of death in patients (2). A review by the U.S. Food and Drug Administration (FDA)…
Vol. 43 (1): 168-168, January – February, 2017
Jose Jaime Correa 1
1 Department of Urologic Oncology, Hospital Pablo Tobon Uribe, Medellin, Colombia
In the video by Branco et al. (1) two vascular injuries are shown. The video is very illustrative on how injuries are recognized and more important the way they are repaired. A quick intraoperative diagnosis of the injury and an appropiate management was performed by the surgeons…
Laparoscopic Cystoprostatectomy for Bladder Cancer in a Male patient combined with open ileal conduit urinary diversion
Vol. 43 (1): 169-170, January – February, 2017
Rafael P. Arruda 1, Mirandolino B. Mariano 1, Clovis Fraga T. Pereira 1, Guilherme C. Lima 1, Thiago N. Lessa 1, Moacir C. de A. Neto 1
1 Departamento de Urologia, Instituto de Medicina Integral Prof. Fernando Figueira – IMIP, Recife – PE, Brasil
No abstract available
Vol. 43 (1): 171-171, January – February, 2017
Fabio C. M. Torricelli 1, Denis Jardim 2, Giuliano B. Guglielmetti 2, Vipul Patel 3, Rafael F. Coelho 2
1 Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, SP, Brasil; 2 Instituto do Câncer do Estado de São Paulo (ICESP), SP, Brasil; 3 Global Robotics Institute, Orlando, Florida, EUA
Introduction and objective: Retroperitoneal lymph node dissection (RPLND) is indicated for patients with non-seminomatous germ cell tumor (NSGCT) with residual disease after chemotherapy. Although the gold standard approach is still the open surgery, few cases of robot-assisted laparoscopic RPLND have been described. Herein, we aim to present the surgical technique for robot-assisted laparoscopic RPLND.
Patient and method: A 30 year-old asymptomatic man presented with left testicular swelling for 2 months. Physical examination revealed an enlarged and hard left testis. Alpha-fetoprotein (>1000ng/mL) and beta-HCG (>24.000U/L) were increased. Beta-HCG increased to >112.000U/L in less than one month. The patient underwent a left orchiectomy. Pathological examination showed a mixed NSGCT (50% embryonal carcinoma; 30% teratoma; 10% yolk sac; 10% choriocarcinoma). Computed tomography scan revealed a large tumor mass close to the left renal hilum (10x4x4cm) and others enlarged paracaval and paraortic lymph nodes (T2N3M1S3-stage III). Patient was submitted to 4 cycles of BEP with satisfactory response. Residual mass was suggestive of teratoma. Based on these findings, he was submitted to a robot-assisted RPLND.
Results: RPLND was uneventfully performed. Operative time was 3.5 hours. Blood loss was minimal, and there were no intra- or postoperative complications. The patient was discharged from hospital in the 1st postoperative day. Pathological examination showed a pure teratoma. After 6 months of follow-up, patient is asymptomatic with an alpha-fetoprotein of 2.9ng/mL and an undetectable beta-HCG.
Conclusion: Robot-assisted laparoscopic RPLND is a feasible procedure with acceptable morbidity even for post chemotherapy patients when performed by an experienced surgeon.
Vol. 43 (1): 172-173, January – February, 2017
Antonio Macedo Jr. 1, Sérgio Leite Ottoni 1, João Luiz Gomes Parizi 1, Gustavo Marconi Caetano Martins 1, Gilmar Garrone 1, Marcela Leal da Cruz 1
1 Universidade Federal de São Paulo, SP, Brasil
No Abstract available
Editorial Comment: Megalourethra and urethrorectal fistula: a rare presentation and a challenging reconstruction
Vol. 43 (1): 174-174, January – February, 2017
Hubert Swana 1
1 Pediatric Urology, Nemours Children’s Hospital Orlando, Orlando, FL, USA
Macedo et al. (1) present a video that elegantly demonstrates a one-stage repair for a child with a urethrorectal fistula along with a megalourethra. The anterior sagital trans-ano-rectal approach (ASTRA) was first described by Di Benedetto and Di Benedetto for use in clitoro-vaginoplasty (2). The ASTRA approach allows careful separation of the urethra and the rectum. It has proven to be useful in the treatment of urethral trauma, urogenital sinus anomalies, and urethral duplications (3)…