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Treatment options for patients with nonmuscle invasive bladder cancer (NMIBC) refractory to intravesical bacillus Calmette-Guérin (BCG) therapy is reviewed in this article based on the recent published literature. Although intravesical BCG is the best bladder sparing treatment option for NMIBC to prevent recurrence and progression, about 1/3 of cases are refractory to this treatment. At this point radical cystectomy is the standard treatment of choice. If this option is not feasible, intravesical chemotherapy with docetaxel or gemcitabine, the combination of BCG and interferon (INF)-α or device-assisted intravesical strategies, such as mitomycin-EMDA or chemohyperthermia are some of the candidates for further treatment.
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OBJECTIVES: To create an innovative process to care for urological outpatient surgery patients in an outpatient clinic basis conducted by nursing staff.METHODS: Our centre covers a population of 153,266 inhabitants. A differentiated process for urological outpatient surgery patients has been implemented, conducted by nursing staff trained for the attendance of urologic patients (“phimosis”,”short penile frenulum”, and “vasectomy request” sent from Primary Care units). Planning and implementation phases have been carried out. In the control phase, a questionnaire was given after surgical procedures with 9 different items, in order to assess different issues of the process.RESULTS: A total of 224 patients were attended during the study period, and 175 valid questionnaires were collected (78.1%). The procedures performed were circumcision (11.7%), frenuloplasty (14.6%), and vasectomy (73.7%), with a median patient age of 36 years. Satisfaction level was high for all items of the questionnaire, with 98.2% of patients “very satisfied” or “rather satisfied” when asked for the overall quality of attention of the whole process. The lowest scores were obtained in items that assessed delay from the appointment to attendance date (5.1% of patients “little satisfaction or not satisfied”), and the perception of information supplied (2.3% “little satisfaction or not satisfied”). A lower satisfaction score was observed (in the delay from appointment to attendance) in younger patients (p=0.001) and in patients who underwent circumcision (p=0.004). No complaints with regard to this process were collected. No incorrect indications for interventions were observed.CONCLUSIONS: The attendance of urological outpatient surgery patients can be safely and effectively performed by nursing staff trained for the care of urologic patients, without observing a decrease of the level of user satisfaction. Focusing on a process strategy allows the identification of areas for improvement and makes possible total quality management.
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OBJECTIVES: The gold standard treatment for a non-metastatic, invasive bladder cancer is an open radical cystoprostatectomy (ORCP). Laparoscopic radical cystoprostatectomy (LRCP) continues being an experimental technique in evaluation. We describe our perioperative results defined as surgical complications and oncologic safety variables.METHODS: From January 2007 to July 2011, all patients undergoing laparoscopic radical cystoprostatectomy (LRCP) in the Urology Department of a public University Hospital were evaluated. We perform a descriptive retrospective analysis.RESULTS: We evaluated 84 patients, 72 males and 12 females, with a mean age of 68 years (44-79). A Bricker urinary diversion was performed in 80 patients, a Camey II bladder replacement was performed in 3 patients, and a Studer bladder replacement was performed in 1 patient. Seventeen patients (20.23%) presented with past medical history of abdominal surgery, and 6 patients (7.14%) history of urological surgery. The mean operative time was 257.57 minutes (180-420). Mean hospital stay was 11.875 days (standard deviation (SD): 6.28). The onset of oral tolerance occurred at 3.7 days (SD: 2.21). The transfusion rate after surgical intervention was 20.2%. The mean number of nodes removed, by means of iliac-obturator lymph node dissection, was 17 (13-19). There were no intraoperative complications. Complications occurred in 28 patients (33.3%) as early complications (less than 1 month after the intervention). There were no post-operative deaths. There were late complications (starting one month after the intervention) in 7 patients (8.3%).CONCLUSIONS: Our study demonstrated that LRCP is safe and reproducible and represents a minimally invasive option for patients with infiltrative bladder cancer.
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OBJECTIVES: To evaluate the usefulness of the Memorial Sloan Kettering Cancer Center (MSKCC) nomogram for prediction of recurrence probability in our series of patients who have undergone radical cystectomy for bladder cancer.METHODS: 397 patients underwent radical cystectomy for bladder cancer between 1986 and 2005. 165 patients were excluded: 21 due to exitus in the immediate postoperative period, 32 due to previous radiation therapy, 6 due to neoadjuvant chemotherapy, 5 due to inability to complete follow-up, 15 that did not undergo lymphadenectomy and 86 who were alive at the time of review with less than 5 years of follow-up. Patients were clasified into recurrence risk groups: organ-confined tumors (pT0-2 pN0), extra-bladder involvement (pT3-4 pN0) and lymph node involvement (pN+). Survival analysis was performed using the Kaplan-Meier method. Five-year recurrence-free survival by risk groups in our series was compared with the one estimated using the MSKCC nomogram using a ROC curve.RESULTS: We analyzed 232 patients. Follow-up in patients who died of cancer was 25 ± 25 months. For alive patients and those who died of other causes, follow-up was 120 ± 39 months. Pathology studies revealed 42.7% organ-confined tumors , 33.2% with extra-bladder involvement and 24.1% with lymph node involvement. The five-year recurrence free survival analysis according to the Kaplan-Meier method stratified by risk groups was: pT0-2 76%, pT3-4 51%, pN+ 31%. The probability of recurrence free survival according to the MSKCC nomogram in the same risk groups was: 85% ± 5%, 62% ± 10% and 25% ± 13%, respectively. The area under the ROC curve was 0.795 (95% CI 0.739-0.852)CONCLUSION: In our series, the MSKCC nomogram constitutes a useful tool for predicting 5-year cancer free survival in patients who undergo radical cystectomy.
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OBJECTIVES: To analyze the outcomes, predictors of success and predictors of need for hospital admission in our series of patients who underwent ureteroscopy (URS) as a major outpatient surgery (MOS) procedure.METHODS: We carried out a retrospective analysis of 402 patients who had undergone semi-rigid URS for ureteral calculi as a MOS procedure in our center between 2004 and 2012. Patients with previous DJ catheter were excluded. We classified the calculi according to their location (lumbar, pelvic, iliac), size (< or > 1cm) and number (single or multiple). Follow-up was done by plain X-ray of the abdomen and ultrasound one month after surgery. The procedure was considered successful when patients were free from the treated calculi or had ureteral fragments < 3 mm one month after surgery. Univariate and multivariate analyses were carried out to identify the factors involved in success and hospitalization not being required.RESULTS: A total of 269 patients were included. The majority of the stones were single (92.2%), < 1 cm in size (76.6%), pelvic (62.1%), and left-sided (57.2%). 89.6% of the procedures were performed as MOS and 82.2% were considered to be successful. In the multivariate analysis, left-sided (p< 0.001) and pelvic location of the calculi (p=0,01) were found to be independent predictors for the success of the procedure In terms of hospital admission, the only independent predictor was the presence of intraoperative complications (p=0.006).CONCLUSIONS: Left-sided and pelvic locations were the independent predictors for the success of the URS. A lack of intraoperative complications was the independent predictor for not requiring hospitalisation.
Case Report
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OBJECTIVE: To report one case of advanced fibrous pseudotumour.METHODS: A 34-year-old patient presented with a painless lump on the right side of the scrotum. Examination revealed a hard tissue thickening attached to the tail and body of the right epididymis. The results of the ultrasound study were not clear and multiple differential diagnosis were considered. The lesion was surgically removed by partial right epididymectomy and resection of the affected tunica vaginalis and ductus deferens for anatomopathological study.RESULTS: The histopathological study revealed an evolved fibrous pseudotumour with bone metaplasia.CONCLUSION: Fibrous pseudotumour is a benign paratesticular lesion that grows slowly and painlessly. It is usually diagnosed by chance or in associated processes such as hydrocele. Differential diagnosis with malignant tumors avoids unnecessary radical treatment.
Case Report
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OBJECTIVE: To describe one case of hematocele secondary to rupture of an abdominoscrotal hydrocele in an adult patient.METHODS AND RESULTS: We report a huge hematocele in a patient with this unusual type of hydrocele that suffered a minimal scrotal trauma. It was a hydrocele that extended through the inguinal canal to the retroperitoneal space.CONCLUSIONS: Abdominoscrotal hydrocele is a rare condition in children and even rarer in adults. The presence of a hematocele requires early surgical treatment.
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OBJECTIVE: To analyze the management of prenatal urinoma and Ureteropelvic Junction Obstruction (UPJO) postnatally by a case report and literature review.METHODS: We report a case of an UPJO and urinoma in a newborn. After birth, renal function was absent, and nephrectomy was performed. The literature from 1985 to date has been reviewed.DISCUSSION: By the analysis of the literature, we can observe mainly, that prenatally diagnosed urinoma and UPJO are managed conservatively. After birth, different attitudes have been carried out, independently of residual renal function, such as radical or reconstructive surgery, or conservative treatment.CONCLUSION: Intrauterine management is not indicated. Urinary diversion is indicated in symptomatic cases secondary to renal trauma or endoscopic procedure. In non-functional kidney, nephrectomy is indicated.
Case Report
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OBJECTIVE: To review two cases with the diagnostic suspicion of urinary tract tumor by clinical picture and imaging tests in which pathology of the surgical specimen revealed metastasis of gastric adenocarcinoma.METHODS: 82 and 68 year-old patients with past history of gastric adenocarcinoma that had undergone surgical treatment 6 months and 6 years before urology consultation, respectively. They were diagnosed upper urinary tract tumors by CT scan.RESULTS: Definitive pathologic diagnosis of urinary tract metastasis of gastric adenocarcinoma was obtained after radical surgery in both cases.CONCLUSIONS: Clinical and radiologic presentation of urothelial metastases of gastric adenocarcinoma may simulate de novo urothelial tumors. Evolution in these patients is usually bad although we currently don`t have enough information to issue a therapeutic guide to follow.
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OBJECTIVE: To report a very uncommon case of penile auto-mutilation in a 51-year-old man, selfmade with a biting object.METHODS: 51-year-old man presenting at the Emergency Department guarded by the Police after auto-cutting his penile while he was urinating, causing him an almost complete circular section that required immediate surgical management.RESULTS: early surgical management showed the section of almost the whole penile circumference, from ventral to dorsal, including the urethra and both cavernous bodies, respecting only dorsal vascular penile complex. We performed a primary anastomosis of damaged structures and carefully haemostasis of the penis.CONCLUSIONS: open traumas to the penis usually require an urgent surgical examination, being mandatory to try a primary reconstruction if global clinical situation allows it. Cosmetic and functional postoperative results advise this attitude.
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