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OBJECTIVES: Varicocele in adolescent men is one of the most challenging topics in pediatric urology. What should be considered as a good indication for treatment and at what age? Does treatment improve fertility? Can we wait? What is the best surgical and minimal invasive treatment? To answer these questions we provide a guideline to use in daily practice.METHODS: We performed a search of the English literature of the last ten years through the Pub Med database using the following key words “varicocele”, “diagnosis”, “treatment”, “fertility” and “adolescent”. We then summated and compared the results of these studies. CONCLUSION: Adolescents with varicocele need regular follow-up including clinical examination and ultrasound measurements of the testis. Those with a persistent discrepancy between left and right testis size of more than 20% over a period of 12 months and those with pain need varicocelectomy independent of patient age, Tanner stage or varicocele size. The peak retrograde flow (PRF) seems to be a good diagnostic non-invasive tool in the follow-up and can be of help to select patients for surgery. PRF≥38 cm/s in combination with testicular asymmetry ≥20% is a reason for surgery independent of age, Tanner stage or varicocele size. PRF<30 cm/s in combination with testicular asymmetry<20% should be followed annually. In case of worsening PRF or asymmetry surgery must be performed. Patients suitable for conservative management should be followed until semen analysis is possible. We present a flow-chart to use in the management of adolescent varicocele. The best results of varicocele treatment are obtained with microscopic subinguinal and laparoscopic lymphatic spearing techniques as shown in a meta-analysis performed in this review.
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OBJECTIVES: To check the degree of concordance in renal ultrasound examination between two nurses and one experienced urologist with the aim of testing nurses’ competence performing renal ultrasound.METHODS: The echographic aspect of both kidneys (normal or abnormal) was evaluated. Every abnormal finding resulted in the automatic classification of the kidney as ‘abnormal’. The agreement between observers was tested using the Kappa concordance index.RESULTS: Eventually, 75 and 45 consecutive examinations performed by the urologist and nurse MM, and the urologist and nurse NJ, respectively,were evaluable. Overall, the study tested 120 patients. Prevalence of ‘abnormal’ kidneys was intermediate (28-36%). The overallagreement percentage exceeded 88% (88,8-92%). Kappa coefficient was always 0.7.CONCLUSIONS: Urological ultrasound examination by qualified well-trained nurses provides records very similar to those delivered by an experienced urologist.
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OBJECTIVES: The administration of empirical anticholinergic treatment is widespread in women with urinary incontinence and has produced varied results. The objective of our paper is to determine the effectiveness of anticholinergics for the treatment of female urinary incontinence and to determine by urodynamicsthe possible causes that may explain the resistance to anticholinergics to obtain urodynamic predictors of success or failure.METHODS: We evaluated 182 women over 14 years of age with urinary incontinence that had previously been treated with anticholinergics for at least three months. The patients underwent a complete medical history including clinical history, physical examination, and urodynamic and lower urinary tract video-radiologic studies. Statistical analysis was performed using SPSS 17.0 for Windows.RESULTS: Clinical therapeutic efficacy was demonstrated in 39.6% of cases. Cystometric bladder capacity was decreased in 89.2% of patients that did not improve clinically with anticholinergics (p=0.01). Detrusor overactivity was urodynamically demonstrated in 51% of cases (p = 0.05) among patients without clinical improvement with anticholinergic treatment. This hyperactivity was demonstrated during early bladder filling (p< 100ml). Urodynamic stress urinary incontinence (SUI) was demonstrated in 26.5% of patients without clinical improvement after treatment (p=0.04). Lower urinary tract obstruction was urodynamicallydemonstrated in 20.6% of patients with no clinical improvement (p=0.05). Urodynamic data did not demonstrate a relationship between detrusor overactivity, a high-grade cystocele (37.4% of total), and irregular bladder morphology (11.5% of total).CONCLUSIONS: It is important to conduct urodynamic study before starting anticholinergic treatment of females with urinary incontinence to identify therapeutic data of poor prognosis, such as SUI and lower urinary tract obstruction, thus optimizing the therapeutic efficacy of anticholinergics
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OBJECTIVES: Vesicovaginal fistulas are uncommon and remain a surgical challenge. Abdominal hysterectomy remains their main cause. We present our experience in laparoscopic repair of vesicovaginal fistula. METHODS: Between January 2006 and January 2008, 8 laparoscopic transvesical procedures for VVF repair were performed at our institution (O´Connor technique). For each case we analyzed demographic and surgical variables as well as the outcome. Surgical technique is also described. RESULTS: Average patient age was 45 years. All patients had past history of hysterectomy and subsequent history of urine leak through vagina, with a mean evolution time of 22 months. The average operative time was 150 minutes and the mean hospital stay 4.7 days. All patients evolved without complications except one who had urinary tract infection (Pseudomonas aeruginosa) that was treated with antibiotics. After a mean follow up of 32 months, there were no recurrences.CONCLUSION: In experienced hands, transvesical transabdominal laparoscopic vesicovaginal fistula repair is a feasible and safe procedure, preserving all the advantages of minimally invasive surgery
Case Report
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OBJECTIVE: To describe a case of eosiniphilic cystitis diagnosed during follow-up for bladder cancer.METHODS: Based on the suspicion of a bladder fibrous tumor, the patient was submitted for partial cystectomy.RESULT: The histological analysis revealed eosinophylic cystitis and the patientcompleted a 3-month course of antihistamines. 35 and 31 months, respectively, after the diagnosis ofhigh grade papillary urothelial carcinoma and eosinophilic cystitisthepatient remains asymptomatic and without evidence (clinical or imaging) of recurrentdisease.CONCLUSIONS: Eosinophilic cystitis is a rare disease. The clinical, imaging andcystoscopy findings are nonspecific, so its diagnosis is histological. Although its pathogenesis isnot yet fully understood, the association between eosinophilic cystitis and bladdercancer is already known
Case Report
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OBJECTIVE: To present a new case of an infected simple renal cyst, its diagnosis and the treatmentcarried out.METHODS: 30 year-old female patient admitted to the Internal Medicine ward suffering a prolonged fever syndrome. On physical examination she presented tachycardia and pain inthe left hypochondrium on deep palpation. Abdominal ultrasound revealed the existence of a great size left renal cyst with a highly echogenic content; this liquid hyperdensity was confirmed by simple and i.v. contrastCT scan. RESULTS: Cyst punction was performed through a lumbar via, getting approximately 400 millilitres of a clear and odourless yellow liquid; then it was sclerosed with ethanol. The microbiological study of the extracted liquid was negative. The patient’s clinical evolution has been satisfactory and renal ultrasound controls were normal. CONCLUSIONS: Faced with a simple infected renal cyst whose location allows percutaneous lumbar approach, punction with synchronic sclerosis plus parenteral antibiotic therapy with ciprofloxacin is the recommended treatment.
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OBJECTIVE: Testicular tumours are rare in paediatric patients, accounting for only 1% of tumours in boys. Leydig cell tumours are the most common gonadal stromal tumours. Since these tumours are functionally active, secreting testosterone, they characteristicallyproduce isosexual pseudoprecocious puberty (IPP), the customary therapeutic choicebeing radical orchiectomy.Nowadays, considering that Leydig cell tumour in boys are invariablybenign, some authors suggest a more conservative choice of therapy.METHODS: This article presents the case of a patient with a cytological and Immunohistochemical diagnosis of Leydig cell tumour with no clinical symptoms ofIPP. The treatment carried out was enucleation of the tumour through a transcrotal accesswith subsequent follow-up monitoring.RESULTS: After 2 years of follow up the patient remains free of symptoms and showsa degree of sexual development corresponding to his age.CONCLUSIONS: We consider enucleation of the tumour to be a safe and effectivetherapy as an alternative to radical orchiectomy
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OBJECTIVE: To describe a case of retroperitoneal metastasis of a gonadal germ cell tumour with the “burned-out” phenomenon in a 35 year old patient with a suspected diagnosis of retroperitoneal tumour of neurogenic origin.METHODS: With the clinical and radiological suspicion of retroperitoneal tumour of neurogenic origin the tumour was removed, via the retroperitoneal space.RESULTS: Pathology showed classic seminoma with foci of atypical or anaplastic seminoma, confined to the tissue sample. After a genital examination showing no alterations, a scrotal ultrasound was requested. This revealed a badly delimited hypoechogenic mass with microcalcifications in the left testis and a heterogeneous echostructure in the right testis, with hypoechogenic areas and some microcalcification. Bilateral orchiectomy was performed, with a pathological study compatible with residual scar tissue in the left testicle and focal findings of germ cell neoplasia, with no intratubular seminoma in the right testis.CONCLUSIONS: The suspicion of an extragonadal germ cell tumour with the “burned-out” phenomenon modifies the therapeutic attitude, which should begin with orchiectomy, followed by systemic chemotherapy and the surgery kept in reserve for those cases where residual malignant tissue persists
Case Report
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OBJECTIVE: Mondor’s disease is a superficial thrombophlebitis and usually occurs in theanterior and lateral chest. The scrotal vein thrombosis is a fairly rare disease.METHODS: Thirty-four year old male who consulted for inguinal tumor andpain in the postoperative period of an umbilical hernia repair, which resulted in a subsequent scrotal vein thrombosis treated conservatively.RESULTS: It was resolved with conservative treatment, with recanalization of the scrotalveins.CONCLUSION: Mondor’s disease is a rare entity, related to multiple etiological factors. The diagnosis is made easily with Doppler ultrasound and most resolve withconservative treatment.
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