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Use of minimally invasive surgical (MIS) techniques continues to expand in the field of urologic oncology; however, proficiency in these techniques is subject to a learning curve. Current training paradigms have incorporated MIS, but in a non-standardized fashion. Residency work-hour restrictions and ethical concerns may influence efforts to deliver adequate training during a defined residency period. Post-residency fellowships or mini-courses may help urologists gain proficiency in these skills, but are time-consuming and may not provide adequate exposure. Surgical simulation with dry labs and augmentation with virtual reality are important adjuncts to operative training for MIS. The urologic oncologist must be familiar with open and MIS techniques to effectively treat cancer in the least morbid way possible and adapt to the ever-changing field of MIS with dynamic training paradigms.
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OBJECTIVES: Radio-induced cystitis (RADC) is an inflammatory bladder disease that presents as anemic-hematuria in its most serious form. Classic treatments can not control the disease in the mid-tolong term because they don`t treat the pathogenesis of the disease. Thus, we evaluated the effectiveness of hyperbaric oxygen (HBO) therapy as a potential treatment for patients with RADC. METHODS: This prospective study included 38 patients, 21 men and 17 women, mean age of 66.5 years (46-75), who had been subjected to pelvic radiotherapy (RT), with the diagnosis of RADC with or without radioinduced proctitis (RADP), gross hematuria and lower urinary tract symptoms. HBO treatment was applied in a multi-place chamber; patients breathed pure oxygen (100%) at 2-2.5 atmospheres of pressure (ATAs). Patients received an average of 31.2 sessions (10-48 sessions) and the median follow-up period was 56 months (4-72 months).RESULTS: Hematuria was completely resolved in 34 of the 38 patients. After HBO 6 patients required readmission, 5 for anemic hematuria and 1 for acute obstructive pyelonephritis. In general, patients tolerated treatment well; however, one patient experienced barotrauma requiring myringotomy.CONCLUSIONS: HBO can be used to satisfactorily treat RADC, leading to clinical improvements that begin during the initial sessions in the majority of cases, and with a more than acceptable level of patient tolerance.
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OBJECTIVES: To test which is the best treatment for chronic obstructive uropathy: urinary diversion using a conventional double-J ureteral stent or the metal thermo-expandable Memokath 051 prosthesis.METHODS: We collected cost data of the insertion of a double-J stent taking into account preoperative and postoperative visits and surgery. Structural, medical, consumables and the prosthesis costs were considered. The estimated survival of the patient, number of spare stents and cost of each therapeutic measure were computed. Then, a simulation of the cost of inserting a Memokath 051 prosthesis was conducted, based on data of ureteral catheterization.We performed a decision tree and Cost Effectiveness economic analysis to measure the effectiveness of both health interventions.RESULTS: Cost data of each procedure were: 1275.44 € for the double J catheter in a program of day case surgery (DCS), 4865.16 € for the metal thermo-expandable prosthesis as DCS, and 1424.52 € for the double J stent with 1 day admission and 5014.24 € for the prosthesis with 1 day admission.The cost difference between ureteral stent and metal thermo-expandable prosthesis is 3589.72 € per treatment for the ureteral stent as DCS.CONCLUSIONS: Despite its high initial cost, the metal thermo-expandable prosthesis potentially offers economic advantages over the conventional double-J ureteral stent in the treatment of long evolution ureteral obstruction. After the third change of double-J stent, and if the patient survival is long enough, the metal prosthesis as DCS should be the most cost effective option.
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OBJECTIVE: To examine the connection between preoperative thrombocytosis and hematocrit and survival in a group of patients operated for renal cell carcinoma.METHODS: Retrospective study with descriptive and statistical analysis of 139 patients with renal cell carcinoma treated surgically over the last 4 years in our Urology clinical unit. 116 (83,45%) were diagnosed at a localized clinical stage, whereas 23 (16,54%) presented as locally advanced or metastatic disease. We collected data about survival and time on surveillance, imaging and histological characteristics of the tumor and analytical parameters. Data were analyzed by the SPSS statistical software.RESULTS: The average platelet count and hematocrit before surgery were 260,930 cells/mm3 and 41.10%, respectively. We found a statistical correlation between platelet count at the time of diagnosis and survival. Patients with platelet counts higher than 350,000 cells/mm3 had a poor survival (OR: 2.94; CI 95% 1.04- 8.27). We also found that patients with high hematocrit at diagnosis presented a lower risk of death (OR: 0.92; CI 95% 0.85- 0.99). The global survival at the end of the study was 88.4%. Multivariate analysis did not show any significant result because of the low number of deaths.CONCLUSION: The presence of high platelet count or low hematocrit correlate with poor survival in a group of surgically treated renal cell carcinoma patients. Nevertheless more studies with longer surveillance and higher number of patients are needed.
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OBJECTIVES: The aim of this paper is to describe the clinical-surgical characteristics of patients who underwent laparoscopic procedures for the management of urinary tract stone disease when performing extracorporeal, percutaneous or endourological procedures was not available.METHODS: A descriptive study based on information from the medical records of patients who underwent surgical laparoscopic management of urinary stone disease between January 2001 and May 2010 at a third level hospital. Epidemiological, clinical and procedure-related variables were taken from the medical records. Univariate analysis was performed with the statistical software STATA 10.1.RESULTS: There were 29 procedures (27 patients) for treatment of urinary stone disease in adults. The average age was 45 years. 55% of patients were men. 17 stones were found on the right side, 5 were pyelic, 19 of the proximal ureter, 4 of the medium ureter and 1 distal. All patients underwent laparoscopic surgery as first surgical option. Average operative time was 142 ± 32 minutes. Three procedures were defined as failures. Hospital stay presented a median of 2 days. There were seven complications.CONCLUSION: Laparoscopic surgery is a good surgical option for the management of urinary tract stone disease in adults.
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OBJECTIVE: To determine the utility of prostate ultrasound in the diagnosis of infravesical obstruction (IVO) and detrusor hyperactivity(DH).METHODS: Prospective study with 39 patients consulting for LUTS. Clinical history was compiled, IPSS was determined, a digital rectal exam was performed, abdominal ultrasound was used to calculate detrusor thickness/weight, prostate volume, and middle lobe length (MLL). Urodynamic study (UD) was performed with determination of the Abrams-Griffiths number and ICS nomogram. Mean values were compared with Mann-Whitney U-test, and ROC curves were plotted determining the cutoff points for optimum sensitivity/specificity.RESULTS: Mean age was 63.1 years (SD: 7.8), with a mean IPSS score of 14 (SD: 6). 53.8% of the patients presented IVO at UD evaluation, and 43.6% DH. The differences between free flowmetry Qmax(p=0.015) and MLL (p=0.003) between patients with and without IVO proved significant. The ROC curves yielded an AUC for middle lobe length of 0.772, with a maximum sensitivity and specificity cutoff point at 10.5 mm (sensitivity 90%, specificity 73%, PPV 76%, NPV 85%). There were no significant differences in any parameter between patients with and without DH.CONCLUSION: Ultrasound MLL measurement in patients with LUTS offers high sensitivity/specificity in diagnosing IVO, with a cutoff point of 10.5 mm. In our study it wasn’t effective in the noninvasive diagnosis of DH.
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OBJECTIVE: To review the presentation, diagnosis and treatment of primary renal lymphoma through a new case report.METHODS: We report the case of a 73-year-old man who presented at A&E with constitutional symptoms and weight loss of 9 kilograms over 3 months.RESULTS: Laboratory analysis showed impaired renal function, anemia and hypercalcemia. Imaging tests showed a large solid mass in the right perirenal area with infiltration of the parenchyma and Gerota`s fascia surrounding the hilum of the kidney, as well as a solid mass in the inferior pole of the left kidney. Pathology showed the presence of lymphoid-like monomorphic cells. After establishing the diagnosis of bilateral primary renal lymphoma it was decided to start treatment with CHOP-Rituximab-type combination chemotherapy.CONCLUSIONS: Primary renal lymphoma is a rare entity and the diagnostic technique of choice is CT. Definitive diagnosis is confirmed on histology. In view of its aggressive nature and poor prognosis, it is important to make an early diagnosis in order to start treatment promptly. The treatment of choice is systemic chemotherapy using a CHOP regimen.
Case Report
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OBJECTIVE: To assess Latzko´s colpocleisis with bilateral Martius flap as a solution for vesico vaginal fistula secondary to radiotherapy.METHOD: 65 year old woman with past medical history of cervix adenocarcinoma treated with hysterectomy, pelvic radiotherapy and brachytherapy. She also had terminal colostomy for recto-vaginal fistula. She complained of a 2-year history of continuous urinary escape through vagina. On cistoscopy, the ureteral orifices were close to the loss of substance. Colpocleisis following Latzko´s technique was performed.RESULTS: Complete resection of the fistulous tract and tension free closure is a surgical challenge not always achieved, and with a high recurrence rate. Latzko´s colpocleisis is a simple and safe option in patients that have previously undergone a hysterectomy. Bilateral Martius flap increases vascular support of the affected tissues, which is of pivotal importance in patients subjected to radiotherapy.CONCLUSION: Latzko´s colpocleisis is a valid therapeutic option in those histerectomised patients with vesico vaginal fistulas due to radiotherapy who are not eligible for fistulorraphy.
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OBJECTIVE: To present the case of a woman with the diagnosis of transitional cell carcinoma of the bladder and Stauffer´s syndrome.METHOD: The clinical and radiological files were analyzed, and a bibliographic review was performed.RESULTS: We present an 82 year old female with a four month history of hematuria, presenting in the emergency room where abnormal hepatic profile was documented. The diagnosis of bladder tumor was established and she underwent transurethral bladder resection. The pathological report showed transitional cell bladder cancer, with complete resection. Metastasis and infectious hepatic dysfunction were discarded. The hepatic profile became normal days later, so Stauffer´s syndrome diagnosis was performed.CONCLUSION: This is the first report to our knowledge of this paraneoplastic syndrome in transitional cell carcinoma of the bladder.
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OBJECTIVE: To describe the histopathologic features and clinical presentation of two primary mucinous neoplasms of the renal pelvis.METHODS: We describe two cases and its correlation with histopathologic findings.RESULTS: Primary mucinous neoplasm of the renal pelvis was diagnosed by histopathology in two patients who received medical treatment for abdominal tumor.CONCLUSIONS: Primary mucinous neoplasms of the renal pelvis are extremely rare; the first symptom is usually abdominal growth, followed by hematuria and flank pain; it is difficult to suspect the diagnosis before surgery, because in most cases it is established with biopsy.
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