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Introduction of retrograde flexible ureteroscopy represented a leap forward in upper urinary tract endourology. Nowadays, areas of the pyelocaliceal system accessible otherwise only by percutaneous or open surgery, can be approached in a retrograde fashion, using the anatomical pathways. The flexible ureteroscopes evolved from the limited deflectable first generation ones to the digital very maneuverable models. The ancillary instruments and the energy sources underwent a similar evolution. Flexible ureteroscopy is a very useful investigative method, especially in patients with equivocal data provided by the imaging. Introduction of this procedure decreased significantly the number of cases with so called “essential” hematuria. The conservatively treated upper urinary tract tumors can be also followed-up more efficiently, the recurrence being identified before becoming radiological obvious. Initially reserved only for diagnostic purposes, flexible uretero-pyeloscopy may be used also in the treatment of various pathological conditions of the upper urinary tract such as lithiasis, stenosis, tumors, pyelocaliceal abnormalities etc. However, technical limitations regarding the visibility and access are still influencing the outcome of the method. The characteristics of the available flexible endoscope, and how they are influenced by the energy sources and ancillary instruments used is crucial for achieving the best performances. Also the particularities of the lesion and upper urinary tract anatomy have a significant impact over the flexible ureteroscopic approach. Despite the efficacy already achieved, the technological progress may still allow various improvements of the method, including robotic flexible ureteroscopy.
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OBJECTIVES: To determine whether lower serum prostate-specific antigen (PSA) concentration in obese men is caused by plasma hemodilution and/or decreased serum testosterone levels.METHODS: A sample of 413 men, from 45 to 75 years old, were randomly selected for the study among those who participated in prostate cancer screening at 2 urban urology practices in Argentina and Puerto Rico. Weight, height, serum testosterone and total PSA concentration were determined. Body mass index (BMI), body surface, plasma volume, and PSA mass were calculated. Prostate volume was estimated by transrectal ultrasound using the prolate ellipsoid formula.RESULTS: Mean age was 59 years old (range, 45 to 75) and mean BMI was 28.8 kg/m2 (range, 24 to 46). Mean serum PSA concentration was 1.43 ng/ml in normal weight patients (n=68), 1.4 ng/ml in overweight patients (n=222), 1.05 ng/ml in obese patients (n=114), and 0.85 ng/ml in morbidly obese patients (n=9). BMI was directly correlated with plasma volume (r= 0.687; p= 0.001) and inversely correlated with serum PSA concentration (r= -0.235; P= 0.001). PSA mass tended to be lower in obese and morbidly obese patients (P= 0.0063) compared to normal weight and overweight subjects. Serum testosterone concentration (P= 0.91) and prostate volume (P= 0.068) were similar among all BMI groups.CONCLUSIONS: Obese men had lower serum PSA concentrations than normal weight men mainly due to plasma hemodilution. PSA mass tended to be lower in obese patients, but it is unlikely a consequence of lower serum testosterone concentrations.
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OBJECTIVES: The present study is a continuation of an earlier article published on the incidence, clinical manifestations, treatment and risk factors associated with postlithotripsy renal hematomas (1).To assess the possible influence of the size and radiodensity of kidney stones on the incidence and clinical behavior of renal postlithotripsy hematomas.METHODS: Observational prospective study of 324 renal units in the same number of patients undergoing extracorporeal renal lithotripsy. The variables “calculus size” and “radiographic calculus density” were evaluated statistically by means of the IPSS 0.15 program on the basis of 42 postlithotripsy hematomas diagnosed and grouped according to their clinical behavior.RESULTS: Higher incidence of hematomas was observed in hiperdense calculi (25%) versus medium density calculi (7,4%), this difference was significant in the asymptomatic hematoma group.CONCLUSIONS: Calculus size was unrelated to the incidence of renal hematoma, but there was a significant association between renal hematoma and radiographic calculus density, probably due to the relation of radiographic density to chemical composition and, ultimately, to hardness and ultrastructure. Ultrastructure is yet another factor, among others, to be taken into account as a potential conditioning factor for this complication.
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OBJECTIVES: In solitary kidney patients with renal cell carcinoma (RCC), radiofrequency ablation (RFA) could be effective in achieving complete tumor necrosis without increasing the risk of complications or renal failure.To analyze the outcomes of a group of solitary kidney patients treated for RCC by RFA considering tumor size and location, renal function involvement and complications. METHODS: A transversal retrospective study was performed, in which we selected 11 solitary kidney patients with 19 tumors in total treated by RFA for one or more renal tumors. A CT protocol was used for follow up. It included unenhanced series and contrast enhanced series at 1 month, 3-6 months, 12 months and yearly after RFA. Serum creatinine levels of each patient, pre RFA and within the first 48 hours after RFA, were collected.RESULTS: Complete ablation was achieved in 17 tumors (89.4%) after one or two RFA sessions. 100% of exophytic and parenchymal tumors, and 3 cm size or smaller, were completely ablated. Renal failure, immediate complications or more than 24 hours hospitalization were not observed in 10 (90.1%) of our patients.CONCLUSIONS: RFA treatment for RCC in solitary kidney patients has a high success rate; it does not affect renal function and achieves complete initial tumor necrosis, especially in exophytic, parenchymal and 3 cm or smaller lesions.
Case Report
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OBJECTIVE: To present the case and iconography of a rectoprostatic fistula as a form of presentation of a prostatic abscess and to review the literature on the diagnosis and treatment of this pathology.METHODS: 69-year-old male with multiple pathologic conditions who presents an orifice in the prostatic fossa on digital rectal examination in the scenario of a urinary tract infection with fever. CT scan and colonoscopy showed a prostatic abscess fistulizing to rectum.RESULTS: Due to spontaneous drainage of the abscess, conservative treatment with intravenous fluid therapy and antibiotics was chosen.CONSCLUSIONS: Prostatic abscess is often difficult to diagnose because of its low prevalence and unspecific symptomatology. Since the introduction of antibiotics, cases in which abscess fistulises or opens spontaneously to neighboring structures like urethra or rectum have decreased.
Case Report
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OBJECTIVE: To report two cases of prostatic abscess of difficult management and review the literature on diagnosis and management of this entity.METHODS /RESULTS: We describe two patients with prostatic abscess. The first one, a 73-year-old diabetic male, was treated using a more passive approach with percutaneous transrectal drainage; after a slow response, the patient passed away due to sepsis. The second case was a 59-year-old male who experienced a negative clinical response to antibiotic treatment. While under antibiotic ambulatory care the patient was treated with a transurethral resection of the prostate, which yielded a successful outcome.CONCLUSION: Prostatic abscess is a rare entity that affects individuals experiencing weakness and can be a serious condition. Measures taken to arrive at a resolution must be rapid and appropriate.
Case Report
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OBJECTIVE: We report one case of a spontaneous resolution of a uretero-vaginal fistula, and we review the current diagnostic and therapeutic features of this condition in the literature.METHODS: We present the case of a 41-year-old woman who, during the late postoperative period of a radical hysterectomy, presented episodes of daily and nocturnal incontinence with episodic flank pain compatible with uretero-vaginal fistula.RESULTS: One month after diagnosis the patient does not report incontinence during day or night, and the lumbar pain has disappeared. An intravenous urography shows that there has been a spontaneous resolution of the uretero-vaginal fistula.CONCLUSIONS: Spontaneous resolution of a uretero-vaginal fistula is rare. Most fistulas require endourological or surgical treatment.
Case Report
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OBJECTIVE: To present a case of synchronous bilateral seminoma and perform a bibliographic review about this rare presentation of testicular neoplasia, with important physical and psychological consequences.METHODS: 25-year old man with bilateral multifocal testicular neoplasias and azoospermia. We performed a bilateral inguinal radical orchiectomy, with the pathologic exam diagnosing bilateral seminoma. Adjuvant lumbar-aortic radiotherapy was initiated. More than a year after the surgery the patient is asymptomatic and without evidence of disease, although dependent of testosterone supplement.RESULTS: Germ cell testicular neoplasias are more frequent in young men between 15 and 35 years old. There is a 2-3% incidence of bilateral neoplasm, either synchronous or metachronous. Bilateral radical orchiectomy remains as standard of treatment, rendering the patient infertile and depending on exogenous androgens, which causes several psychological problems. However, a testis-sparing surgery could be performed in selected cases; our patient, having multiple bilateral neoplasias, was not eligible for this procedure. With a great incidence of carcinoma in situ on spared testicular parenchyma, scrotal radiotherapy is indicated. In spite of infertility, this treatment presents very good oncological results with androgen independence and consequent physical and psychological advantages.CONCLUSION: Bilateral orchiectomy still remains as “gold-standard” treatment for bilateral seminoma. However, there are other possibilities of treatment, such as partial orchiectomy, feasible in selected cases of small volume testicular tumours in solitary testis / bilateral tumour in men without preoperative androgen deficiency and who could be object of close clinical and imaging follow-up. This way you could avoid additional loss of quality of life, without any prejudice on oncological results
