Vol. 44 n. 2 Mar . Apr, 2018

Volume 44 | number 2 | March . April, 2018 -Lower pole renal stone: flexible ureteroscopy or shockwave lithotripsy? The anatomy is the key

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 doi: 10.1590/S1677-5538.IBJU.2017.0173 ORIGINAL ARTICLE Lütfi Canat 1, Hasan Anil Ataly 1, Samir Agalarov 1, İlter Alkan 1, Fatih Altunrende 1 1 Department of Urology, Okmeydani Training and Research Hospital, Istanbul, Turkey   ABSTRACT 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 [Full...

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Transperitoneal vs. extraperitoneal radical cystectomy for bladder cancer: A retrospective study

Vol. 44 (2): 296-303, March – Abril, 2018 doi: 10.1590/S1677-5538.IBJU.2017.0441 ORIGINAL ARTICLE Jagdeesh N. Kulkarni 1, Himanshu Agarwal 1 1 Department of Urology, Bombay Hospital and Medical Research Centre, Mumbai, India   ABSTRACT 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 [Full...

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Current trends of percutaneous nephrolithotomy in a developing country

Vol. 44 (2): 304-313, March – Abril, 2018 doi: 10.1590/S1677-5538.IBJU.2017.0292 ORIGINAL ARTICLE 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 ABSTRACT 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 [Full...

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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 doi: 10.1590/S1677-5538.IBJU.2017.0483 ORIGINAL ARTICLE 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 ABSTRACT 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 [Full...

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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 doi: 10.1590/S1677-5538.IBJU.2016.0599 ORIGINAL ARTICLE 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   ABSTRACT 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 [Full...

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Overactive bladder syndrome and bladder wall thickness in patients with obstructive sleep apnea syndrome

Vol. 44 (2): 330-337, March – Abril, 2018 doi: 10.1590/S1677-5538.IBJU.2017.0253 ORIGINAL ARTICLE 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   ABSTRACT   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 [Full...

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Validation of the urgency questionnaire in Portuguese: A new instrument to assess overactive bladder syndrome

Vol. 44 (2): 338-347, March – Abril, 2018 doi: 10.1590/S1677-5538.IBJU.2017.0147 ORIGINAL ARTICLE 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 ABSTRACT 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 [Full...

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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 doi: 10.1590/S1677-5538.IBJU.2017.0213 ORIGINAL ARTICLE Leandro Cristian Arribillaga 1, Marta Ledesma 1, Ariel Montedoro 1, Florencia Pisano 1, Rubén Guillermo Bengió 1 1 Centro Urológico Profesor Bengió, Córdoba, Argentina ABSTRACT 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 [Full...

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Single perineal incision placement of artificial urinary sphincter with cadaveric correlation of sub-dartos pump placement

Vol. 44 (2): 355-361, March – Abril, 2018 doi: 10.1590/S1677-5538.IBJU.2017.0097 ORIGINAL ARTICLE 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 ABSTRACT   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 [Full...

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Sonographic patterns of Peyronie’s disease in patients with absence of palpable plaques

Vol. 44 (2): 362-369, March – Abril, 2018 doi: 10.1590/S1677-5538.IBJU.2017.0298 ORIGINAL ARTICLE Lucio Dell’Atti 1, Andrea Benedetto Galosi 1 1 Department of Urology, Polytechnic University of Marche Region, University Hospital “Ospedali Riuniti”, Ancona, Italy ABSTRACT 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 [Full...

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