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We present the laparoscopic management of genitourinary fistulae, mainly five types of fistulae, vesicovaginal, ureterovaginal, vesicouterine, rectourethral and rectovesical fistula. Vesicovaginal fistula (VVF) is mostly secondary to urogynecologic procedures in developed countries, abdominal hysterectomy being the main cause of this condition; they represent 84.9% of the genitourinary fistulae (1).Management has been described for this type of fistula, where low success rate (7-12%) has been reported. Ureterovaginal fistulas may occur following pelvic surgery, particularly gynecological procedures, or as a result of vaginal foreign bodies or stone fragments after shock wave lithotripsy, patients typically present with global and persistent urine leakage through the vagina, this causes patient discomfort, distress, and typically protection is used to stay dry, the initial management is often conservative but typically fails. Vesicouterine fistula is a rare condition that only occurs in 1 to 4% of genitourinary fistulas, the primary cause is low segment cesareansection, and clinically presents in three different forms, which will be described. Treatment of this type of fistulae has been conservative,with hormone therapy and surgery, depending on the presenting symptoms. Recto-urinary (rectovesical and rectourethral) fistulae (RUF) are uncommon and can be difficult to manage clinically. Although they may develop in patients with inflammatory bowel disease and perirectal abscesses, rectourethral fistula frequently result as an iatrogenic complication of extirpative or ablative prostate procedures. Rectovesical fistula usually develops following radical prostatectomy, and occurs along the vesicourethral anastomotic line or along the suture line of a posterior “racquet-handle” closure of the bladder. Conservative management consisting of urinary diversion, broad-spectrum antibiotics and parenteral nutrition is often initially attempted but these measures often fail. Timing of repair is often individualized mainly according to the etiology, delay of diagnosis, size of fistula, the first or subsequent repairs, and the general condition of the patient. Different surgical techniques for the management of RUF have been reported. Encouraged by our experience in minimally invasive surgery we present the laparoscopic approach.
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OBJECTIVES: Laparoscopic RadicalProstatectomy (LRP) is technically a very demandingprocedure and potentially even more challenging inpatients with previous trans-urethral resection (TURP).This study evaluates the impact of previous TURP on theshort-term functional outcome of patients undergoingextraperitoneal LRP.METHODS: Retrospective analysis of a prospectivelycollected database, comprising a single-surgeon cohortof 155 consecutive LRP cases, 19 of which had previoushistory of TURP. Demographics, clinical and functionaloutcomes were evaluated and compared amongpatients with and without previous TURP. Multivariateanalysis was performed to identify potential variablesindependently associated with continence outcomes.Incontinence was defined as the need of more than 1pad/day. Potency was defined as the ability for sexualintercourse with or without the use of phosphodiesteraseinhibitors.RESULTS: Demographic and clinical variables werecomparable among the two study groups. Neurovascularbundle preservation was possible in 26% and 37% ofpatients with and without previous TURP, respectively.No major complications were recorded and theincidence of minor complications was comparable.Overall continence rate at 3 months was 82,58%, forthe entire cohort. Subset analysis demonstrated a 3-month continence rate of 73.7% vs. 83.8% (p>0.05) inpatients with and without TURP, respectively. Multivariateanalysis demonstrated age, BMI and ASA werevariables independently associated with continenceoutcomes. In the cohort of patients with previous TURP,2 out of 7 undergoing preservation recovered erections,with a mean follow up of 15.5 months, comparable tothe 30% achieved in patients without TURP and nervesparing procedure.CONCLUSIONS: Laparoscopic Radical Prostatectomy inpatients with previous TURP is feasible, with complicationrates and short-term functional outcomes comparable tothose in patients without previous resection
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OBJECTIVES: To report our experience in early surgery of penile fractures.METHODS: We review retrospectively all the cases that underwent surgery at our center from 1989 to 2009, with a total of 24. RESULTS: The cause of the fracture was sexual intercourse in most cases, and in all of them, surgical management was performed according to clinical presentation and physical exploration. In only 7 cases an ultrasound was performed as a complementary test. DISCUSSION: Early surgery allows prompt resolution of the problem with excellent functional outcomes and little side effects. CONCLUSIONS: The prognosis after emergency surgery was excellent in this review.
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OBJECTIVES: To determine the prevalen-ce and risk factors of erectile dysfunction (ED) and theprevalence of hypogonadism symptoms in Buluba, a ru-ral population in Uganda.METHODS:Prospective, consecutive, cross-sectionalstudy was conducted between September and Decem-ber 2010. 902 men attending the outpatient clinic ofSaint Francis Hospital in Buluba were enrolled. Fromthese 902 men, 204 had been previously diagnosedas HIV+ followed in a specific HIV outpatient clinic inthe same centre. Variables age, weight, height, tobacco use and drinking habits, Erection Hardness Score andAging Male Symptoms Scale (AMSS), as well as Hyper-tension, Diabetes, Dyslipidemia, lung diseases, pepticulcer, urinary symptoms and HIV were prospectively re-corded. A multivariate analysis was used to analyze thevariables related to erectile function and AMSS.RESULTS: Mean age was 39±11,8 years. ED rate was47,8% (Mild ED 28,8%; Moderate 14%; Severe 5%).In the multivariate analysis, variables age (Odds ratio(OR) 1,032), HIV+ (OR 11,280), AMSS (OR 1,138)and AMSS≥50 (OR 1,164) were related to ED. Whenexcluding HIV+ population, 36,8% of men suffered ED(Mild ED 23%; Moderate 10,2%; Severe 3,6%). 5,7%of men had severe symptoms (≥50) of hypogonadismaccording to AMSS. No clinical variable was related tothe presence of AMSS≥50 in the multivariate analysis.CONCLUSIONS: The rate of ED in a rural milieu inUganda is high. Variables age, AMSS and AMSS ≥50and HIV+ were related to ED. The rate of AMSS≥50was 5,7%. No variable was found to be related toAMSS≥50
Case Report
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OBJECTIVE: To report a new case of secondary bladder amyloidosis, beinginvolvement of the urinary bladder by amyloidosis infrequent on the basis of very few references in the literature (we estimate the number of cases of secondary vesical amyloidosis reported to be around 30). METHODS/RESULTS: The case presented here corresponds to secondary bladder amyloidosis in a patient suffering from Still’s disease, who began with hematuria and ended dying.CONCLUSION: Secondary bladder amyloidosis constitutes a very infrequent pathology, and we can distinguish between primary forms of bladder amyloidosis and systemic forms of amyloidosis that affect the urinary bladder (secondary bladder amyloidosis). It is associated in the majority of patients with rheumatoid arthritis that has evolved over a long period. Clinical diagnosis is difficult, and it is necessary to carry out differential diagnosis with bladder tumours. The pathological and immunohistochemical studies confirm the diagnosis.
Case Report
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OBJECTIVE: Renal angiomyolipoma is a mesenchymal neoplasm composed ofdysmorphic blood vessels, smooth muscle, and adipose tissue. Epithelioidangiomyolipoma is an uncommon variant considered potentially malignant. Wereport a case of renal epithelioid angiomyolipoma suspicious for urothelialcarcinoma of renal pelvis.METHODS: A 50-year-old woman with a 3-day history of macroscopic hematuria and CT-scan showing a tumor arising from the left renal pelvis suspicious for urothelialcarcinoma. Nephrectomy was analysed in multiple slides of hematoxilineosinand immunohistochemistry.RESULTS: Left nephrectomy was performed. Tumor sized 8cm and showed pathologic findings of epithelioid angiomyolipoma with a little component of classic angiomyolipoma. We studied differential diagnosis and pathologic characteristics for the prognosis.CONCLUSIONS: Pathologic study in detail is fundamental for differential diagnosisand prognosis of this tumor. Our patient`spathology showed good prognosis, however follow-up is important due the malignant potential of the neoplasm.
Case Report
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OBJECTIVE: We present the case of a patient with eosinophilic ureteritis.METHODS: The patient was admitted with pain on the right renal fossa, and after several imaging tests, a mass was found on the right ureter, compatible with urothelial neoplasia on the right ureter.RESULTS: Right nephroureterectomy was performed and the histopathologicaldiagnosis was eosinophilic ureteritis.CONCLUSION: Eosinophilic ureteritis is a rare entity with an unclear etiology,which is not easily distinguished from urothelial tumours. In the differential diagnosis we must take it into accountwhenever we find a ureteral mass associated to eosinophilia.
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OBJECTIVE: Inverted papilloma of the urinary bladder is an uncommon urothelial neoplasm that may be specially difficult to distinguish from urothelial carcinoma.METHODS: Two patients with obstructive symptoms and hematuria have been studied. In the transurethral resection, accidentally, one showed a papillary lesion in the context of nodular hyperplasia of the prostate, where as the other showed a polypoid tumor of the urinary bladder.RESULTS: Histologically, in both cases, a bladder inverted papilloma was demonstrated, originating from the surface transitional epithelium. Basal cells exhibited peripheral palisading pattern in the trabecular form. In the glandular type, Dogiel or umbrella cells into the gland-like structures, were recognized. Immunohistochemical stains for p53 and Ki-67 were negative. Umbrella cells were positive for cytokeratin 20.CONCLUSIONS: Two cases of bladder inverted papilloma with relevant morphological aspects are presented, which we consider useful for the differential diagnosis with urothelial carcinoma.
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OBJECTIVE: To report an unusual case of renal tumor and review the literature.METHODS: We present a 20 years old female with a history of acute right pyelonephritis. The ultrasound study revealed a tumor-like image in the lower pole of the right kidney . The CT-scan showed a mixed solid and cystic mass of 7 cm. in the lower pole of the right kidney.RESULTS: A right laparoscopic partial nephrectomy was performed. The total operative time was 90 minutes, with 24 minutes of warm ischemia. The estimated blood loss was 50 ml. and the length of stay (LOS) 36 hours. The pathology findings confirm a mixed epithelial and stromal tumor (MEST) of the kidney.CONCLUSION: Mixed epithelial and stromal tumor (MEST) of the kidney is a benign and rare condition that doesn’t show a clear difference with other renal tumors in image studies. Nephron-sparing surgery with margin study is the standard treatment when is feasible.
