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Urologic pediatric retroperitoneoscopy has had three different stages that have conditioned, although not hindered, its development: 1) limited numberof indications in the pediatric age, because pediatric surgery itself is not much invasive; 2) adaptation of the technological development from adult to children; 3) overcoming the controversies between laparoscopic and non laparoscopic pediatric surgeons.After overcoming these stages, retroperitoneoscopy has become an indispensable tool for the treatment of various diseases of the kidney, being nephrectomy the gold standard among the indications for ablation, and pyeloplasty among reconstructive, through a complete or assisted retroperitoneoscopic approach.
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OBJECTIVES: Despite the high incidence of inguinal hernias. In the general population, only a small percentage of them involve the bladder. Bladder wall weakness and bladder outlet obstruction are involvedin its pathogenesis. We present our experience in the diagnosis and treatment of this rare disease.METHODS: A total of eight patients have been diagnosedof inguinoscrotal bladder hernia and treated in our centerover the last 18 years. In most cases, retrograde and voiding cystourethrograms, prostatic and bladder ultrasound, and uroflowmetry have been performed. The treatment varied depending on the characteristics of the herniated bladder tissues and bladder capacity. The treatment of bladder outlet obstruction varied depending on the etiology.RESULTS: Two patients presented at the emergency room of our centre, the others were diagnosed at the outpatientclinics of our department. Resection of the herniated bladder tissue was carried out in four patients due to the quality of the tissue; bladder-pexy to the abdominis rectus muscles was performed in one patient; herniarepair with bladder reintroduction was the treatment in the other four cases. Bladder outlet obstruction wastreated in six cases. Seven patients showed clinical improvement, showing normal bladder morphology on post operative cystogram.CONCLUSIONS: Bladder hernia is a rare pathologyoften presenting in mid age males. It should be suspected in every male with lower urinary tract obstructive symptoms and associated inguinal hernia. Retrograde and voiding cystourethrogram are the radiological diagnostic tests of choice to evaluate this disease. The treatment of choice is that of the hernia and bladder outlet obstruction.
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OBJECTIVES: The objective of our study was to evaluate patient tolerance to transrectal ultrasound guided prostate biopsy using anesthesia with 2 grams of intrarectal lidocaine gel, and to evaluate the complications of the test.METHODS: 148 prostate biopsies with intrarectal lidocainewere performed over a four month period. The same intrarectal ultrasound transducer and needle mechanism were employed for all patients. Biopsies were performedby 7 different urologists with 6 to 12 cores per biopsy. All patients received after the biopsy a questionnaire to evaluate their tolerance to the intervention. In the same way, the urologist performing the biopsy filled aquestionnaire about patient tolerance and complications of the test.RESULTS: Patient tolerance data were recorded in 147 biopsies. Twenty-five cases (16.9%) referred severe or unbearable pain, 45 patients (13.4%) referred no pain at all. A significant association between patients` and doctors’ results was obtained. Digital rectal examination was painful in 10 cases only; transducer insertion waspainful in 13, and 15 referred pain with the transducermovements inside the rectum. Almost all painful or unbearable core biopsies were taken in the apex. Therewas a significant association (p = 0.005) between the number of cores per biopsy and pain, being the pain more than expected when the number of cores was greater than six. Only 14 patients would not ever repeat the same biopsy or would request a different type of anesthesia and 133 (59.9%) of them would repeat it in the same way.CONCLUSIONS: In our experience, transrectal ultrasound guided prostatic biopsy is generally well tolerated with intrarectal gel as the only anesthesia. Nevertheless, the number of cores taken per biopsy has been the factor associated with pain, and if the number of biopsy cores increases additional anesthesia should be considered.
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OBJECTIVES: The best treatment of clinicalstage I non-seminomatous germ cell testicular cancer (NSGCTC) is controversial. Lymphadenectomy allows an adequate retroperitoneal staging and cures up to 70% of patients in pathological stage II. The objective of this study is to analyse our experience in the treatment of this patients with radical orchiectomy and reducedretroperitoneal lymphadenectomy (RRL) as the initialtreatment. METHODS: Retrospective study of patients with clinical stage I NSGCTC submitted to radical orchiectomy and RRL at the Urology Service of the University of ChileClinical Hospital, from January 1990 to December 2000. Inclusion criteria: retroperitoneal staging with computed tomography (CT), normal tumor markers after orchiectomy and testicular and retroperitoneal biopsy informed at our hospital. The following metastatic risk factors in the testicular biopsy were checked: vascular invasion (venous and/or lymphatic), infiltration of tunica albuginea, rete testis, epididymis, and spermatic cord. RESULTS: 36 patients with 37 testicular tumors were analysed (1 bilateral case). Average age 28 years old. Twenty nine mixed tumors (78%); most frequent histology embryonal carcinoma (76%). Average surgery time 2hr 7min; average dissected lymph nodes 13. Intraoperativecomplications: 2,8%; postoperative complications: a) early 5,6%; b) late: 5,6%. No mortality, no secondsurgeries nor blood transfusions. Four cases of positive RRL (11%). Only retroperitoneal relapses in 2 cases (8%), one out of the limits of dissection. Chemotherapy in 7 patients (19%) a total of 18 cycles. Four cases ofcontralateral tumor during follow-up (11%). Hundred percent survival at 76 months (16-160). We described sensibility, specificity, positive and negative predictivevalue of metastatic risk factors. Only epididymis infiltrationwas a significant predictor of metastasis (p=0,04).CONCLUSIONS: In our hands RRL is a safe surgery, with 5,6% mayor complications. The low false negative rate of CT in staging (11%) and the high number ofretroperitoneal relapses (8%) in our study contrast with those of other publications. Limited by the size of our study group, the epididymis infiltration was the onlystatistically significant predictor of metastasis. Clinical stage I NSGCTC initially managed with RRL has a 100% survival.
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OBJECTIVES: To analyze the currentindications for renal autotransplantation, as well as the technical features, complications and long-term followup of the technique.METHODS: From 1990 to 2005 we have performed autotransplantation in 10 patients, 7 adults and 3 children. The indication was established due to vascular pedicle pathology in 8 cases and ureteral lesion in 2. The cause of vascular pathology was: atherosclerotic stenosis (4), dysplastic stenosis (2), Takayasu’s disease stenosis (1),and renal artery aneurysm (1). The patients with ureterallesion had ureteral stenosis secondary to Crohn’s disease in one case, initially solved by ureteral stent and subsequently obstructed by lithiasic encrustation, and ureteral avulsion in the other case. The vascular grafts employed in the 8 cases with vascular reconstruction were: hypogastric artery 7 cases, and saphena vein in one case. Ureteral reimplantation was necessary in 5 cases after bench surgery; in other five cases vascular reconstructionwas performed without ureteral division. All grafts were perfused with 4ºC lactate ringer or Wisconsin solution and protected with surface cold ischemia. Ischemia timesranged from 42 to 89 minutes.RESULTS: Nine kidneys (90%) functioned after autotransplantation, 8 of them had immediate function, and one had delayed graft function after a six-day period of acutetubular necrosis. The kidney with arterial stenosissecondary to Takayasu’s disease never functioned. The cause of graft loss was renal vein thrombosis. Postoperativemortality was zero. After a mean follow-up of 72+/- 13 months mean serum creatinine is 1.6+- 0.4 mg/dl (1.1-2.4) and 70% (7/10) of the patients have normal blood pressure without antihypertensive medication.CONCLUSIONS: Currently, renal autotransplantation, with or without extracorporeal vascular reconstruction, is a complex technique with exceptional indications, but it allows recovering renal units with vascular pathology not amenable to angioplasty or in situ revascularization. It is also a valid alternative to ileal ureteral substitution in cases of extensive ureteral lesion.
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OBJECTIVES: The surgical procedures for the insertion of tension free vaginal tapes in the treatment of female stress urinary incontinence (SUI) are simple and can be done as outpatient operations. The aim of this study was to perform a budget study comparing TVT in an outpatient basis with transobturator tape (TOT) with hospital admission.METHODS: Retrospective analysis of the medical recordsof 23 patients undergoing surgery for SUI betweenOctober 2004 and October 2005. 13 patients were treated by TVT in an outpatient basis (group 1, Departmentof Urology), 10 patients were treated by TOT with hospitaladmission (Group 2, Department of Gynaecology).Cost analysis was carried out by the construction of a Marcov model, incorporating the time sequence of the treatment, including adverse events and results.Variables considered for the analysis: number of visits, preoperative tests, operative time, tape cost, hospital stay, unpredicted visits in the first postoperative month at the outpatient clinics or emergency room, and hospital readmissions. Statistical analysis was performed with the G-Stat software. Student’s t test was used to compare quantitative variables. RESULTS: 11/13 patients (84.6%) in group 1 completedthe day-surgery protocol. Mean surgical time was 61.7 min. (SD 16.2; 35-100) and 61.6 min. (SD 8.3; 50-73) for groups 1 and 2 respectively. Two cases in group 1 had perioperative complications (15.4%); no patient in group 2 had perioperative complications. Meanhospital stay was 1.3 days for group 1 (SD 0.85; 1-4) and 2.9 days for group 2 (SD 0.31; 2-3). Threepatients in group 1 (23%) and 2 in group 2 (20%)presented postoperative complications. Mean cost per process was 4740 EUR for group 1 and 7099 EUR for group 2.CONCLUSIONS: SUI correction by tension free tapes as day surgery is a valid option which saves a substantialamount of resources.
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OBJECTIVES: Our objetive was to relatethe tobacco with seminal spermatogenic parameters such as sperm morphology, concentration of spermatozoidsand germinal cells in samples of semen from men with idiopatic infertility.METHODS: A prospective study was carried out on a population of 131 men with idiopatic infertility thatattended the Reproduction Service of Centenario Hospitalin Rosario from may 2004 to june 2006. Sperm study according to WHO was carried out evaluating germinalcells and sperm morphology with Papannicolaou. The concentration of spermatozoids was determined by means of a subjective method with Neubauer camera. The studied population was divided in the three groups: G1: smokers more of 20 cigarettes/day, G2: smokers under 20 cigarettes/day, G3 non smokers. The smokers had had the habit for over a year.RESULTS: Results were analyzed with the student’s t-test. Statistically significant differences between G1 vs G3 (p< 0.001) and G2 vs G3 (p< 0.005) were found for the three variables. No significant difference was found between the groups of smokers G1 vs G2 (p>0.1).CONCLUSIONS: The results show that tobacco alters sperm concentration and morphology with an increase of immature forms, demonstrating an altered spermatogenesis process. The consumption of tobacco should be evaluated to carry out the integral study of infertile man.
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OBJECTIVES: To show the lumboscopy technique developed in our department, our case series and its results.METHODS: From August 15th 1997 to date 606 patientswere operated on by means of the lumboscopy technique. 152 nephrectomies, 18 partial nephrectomies, 103 pyeloplasties, 5 adrenalectomies, 89 pyelolithotomies, 153 ureterolithotomies, 44 renal cyst unroofing and other 42 procedures were performed.RESULTS: We perform the retroperitoneal access in the inferior lumbar triangle, with digital blunt dissection only and direct pneumatic dissection with a high flowinsufflator, without balloon or balloon trocar dissection. We describe the development of the working space with perirenal fat flaps, as well as the various types of pathology operated and our complications.CONCLUSIONS: The working space in lumboscopy must be created by the surgeon beyond using a balloon or direct digital dissection technique. The technique we describe is easy and reproducible, creating an adequatesurgical space and requires the anatomical knowledge to be able to identify landmarks.
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OBJECTIVE: Pure testicular choriocarcinoma is a relatively infrequent neoplasia with an ominous prognosis.METHODS: We report the necropsy study of a 21-year-old male patient with generalized metastases of a primary pure testicular choriocarcinoma.RESULTS: The aggressiveness of this neoplasia is demonstrated by extensive tumor dissemination in early stages, in which testicular clinical manifestations are often absent.CONCLUSIONS: In front of any choriocarcinoma it is imperative to perform an extensive sampling of the lesion with the aim to detect possible foci of germ cell neoplasia which constitute a mixed pattern.
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OBJETIVE: To report our experience in the management of one case of perirenal myxoliposarcoma.METHODS: We report the case of an 86-year-old male consulting for occasional dizziness. Examination revealed a left flank abdominal mass. CT scan reported the presence of a 12 cm multiloculated cystic mass at the lower pole of the right kidney. Hand-assisted right laparoscopic nephrectomy was carried out.RESULTS: The operation was uneventful and the pathologic study reported a kidney with preserved architecture and a tumor showing characteristics of grade 1-2 myxoliposarcoma with undifferentiation to grade 3 myxofibrosarcoma in intimate contact with the lower pole.CONCLUSIONS: We believe that laparoscopic surgery permits the surgical solution of this type of lesion without compromising the oncological principles, and offers the well-known advantages of a minimally invasive approach.
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OBJECTIVE: We present nephron sparing renal surgery as a therapeutic option for the conservative treatment of renal cancer by reporting one case of de novo renal cell carcinoma (RCC) presenting in a functioning renal graft.METHODS/RESULTS: We describe one case of de novo RCC presenting in a functioning renal graft 51 months after transplantation. Tumorectomy was carried out with a margin of normal parenchyma and the base was free of tumor.Definitive pathologic study showed type I papillary renal cell carcinoma, Fuhrman grade 2, pathological stage I with free margins. There were not post operative complications and immunosuppression therapy was not modified. After almost three years of follow-up there is no evidence of tumorrecurrence and an adequate renal function.CONCLUSIONS: Renal graft RCC is rare. Conservative surgery in selected patients may be a safe and effectivetechnique when the tumor appears in a functioning graft,because it offers good oncological control and preservesrenal function, avoiding transplant nephrectomy and the need of haemodialysis.
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OBJECTIVE: We report a clinical case with a diagnosis of nonvenereal sclerosing lymphangitis of the penis and revision of the literature existing on this pathology.CLINICAL CASE: We describe the case of a 28 years old man who has presented for 10 days an induration of cartilaginous consistence next to the sulcus coronarius penis and symptomatic during the erections, compatible with the diagnosis of sclerosing lymphangitis.RESULTS: Sexual abstinence was recommended and we kept an expectating attitude so ceasing the process after 4 weeks.CONCLUSIONS: Nonveneral sclerosing lymphangitis of the penis is a process of unknown etiology, related to an increase of sexual activity, wich is during the erection and it has a self-limited character, so the initial treatment is conservative.
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OBJECTIVE: We report the clinical case of a 21-year-old male presenting with a 36 hour history of low flow priapism, its diagnosis and treatment.METHODS: We performed a bibliography review on the etiology, physiopathology, diagnosis and treatment options.RESULTS: The patient underwent unsuccessful punction-aspiration of intracavernous blood with phenylephrineinjection and cavernous irrigation with saline solution. A cavernous-spongiosum shunt was performed subsequently, firstly using the Winter technique and followed by theAlGorab technique with a final positive response.CONCLUSIONS: The performance of a sapheno-cavernous shunt is an effective treatment for the low flow priapism resistant to usual medical-surgical treatment.
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OBJECTIVE: Chronic hematoceles are rare scrotal masses. Most of them include trauma, torsion, tumor, and surgery as possible causes. We describe the case of an old diabetic patient, who is attended for presenting a markedincrease in size of the right hemiescrotum and pain. METHODS: We described computed tomography andsonographic findings.RESULTS/CONCLUSIONS: Frequently, a varicocele is an associated finding. Presumibly, minor trauma results in ruptureof dilated vessels. In sonographic exploration, they have a more complex heterogeneous appearance with echogenic debris and septations. Most hematoceles spontaneouslyresolve with conservative therapy.
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OBJECTIVE: To report one case of transitional cell carcinoma with areas of small cell carcinoma presenting in its evolution an adrenal metastasis with the neuroendocrine component only. We perform a bibliography review for the cases of small cell carcinoma of the bladder, its epidemiology, prognosis and treatment.METHODS: We describe the clinical case and perform a Medline review.RESULTS: Small cell carcinoma of the bladder is a rare entity, with a more aggressive behaviour and poorer prognosis than transitional cell carcinoma. The pathologic characteristics allow differentiation of primary tumor and metastatic disease. In the bibliographic search we did not find any previous report of exclusive dissemination of the neuroendocrine histological component in cases of mixed tumors.CONCLUSIONS: There is no standard treatment for small cell carcinoma of the bladder. For metastatic disease the most commonly used combination is cisplatin and etoposide.
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OBJETIVE: Ewing´s sarcoma/Primitive neuroectodermal tumor (ES/PNET) is an extraordinarily rare primary tumor in the kidney. We re-port herein the clinical, histological, and immunohisto-chemical features of a primary renal ES/PNET.METHODS: A 19-year old male referred a two weeks history of constant, colic, left flank pain, and fever. A left radical nephrectomy was performed. Gross pathologic examination showed pink-tan, lobulated solid tumor, localized at the superior pole. RESULTS: Histologically, the tumor was solid with necrosis. The neoplastic cells showed a small amount of clear cytoplasm, and had vesicular nuclei with small nucleoli. Immunohistochemical studies showed strongly and diffusely positive staining for CD99 in a membranous pattern. CONCLUSIONS: This case represents a typical ES/PNET, affecting a young male patient. Adequate diagnosis is important because this neoplasm has an aggressive behaviour.
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OBJETIVE: Many physical or medical therapeutic approaches, systemic or local, have been suggested for treatment of Peyronie’s disease. These approaches claim a discrete percentage of success in terms of clinical stabilization or improvement. The aim of our work was to evaluate the “natural history” of this disease.METHOD: 110 patients affected by Peyronie’s disease have been observed for at least five years. At the first visit all patients maintained sexual activity not requiring surgical approach. No medical or physical treatments have been performed on these patients. All patients underwent twelve months follow up for at least 5 years evaluating the natural progression of the disease by means of ultrasound and clinical examination. We made statistical analysis (Odds ratio, P for trend) to check if there is association between clinical worsening requiring surgical treatment and: 1- age of patients, 2- diabetes, 3- presence of close relative pattern for diabetes and 4-Dupuytren contracture.RESULTS: Regarding curvature, number and size of fibrous plaques, a consistent tendency to stabilization has been observed in the group of patients above 50 years of age. 68% of the patients belonging to the group under 50 years showed a progressive worsening of the disease requiring surgical therapy, while in the other group only 31,5% of the patients required surgery. The statistical analysis confirmed that PD worsening is more probable in the group under 50 years of age (OR=3.5, CI:2-8) and in the patients affected by diabetes (age adjusted OR=6, CI:2-19). Statistical analysis has not shown significant differences in the evolution of Peyronie’s disease regarding the presence of close relative pattern for diabetes and Dupuytren contracture.CONCLUSION: The patients presented a discrete tendency to spontaneous stabilization. The patients who are diagnosed under the fifties have a greater probability that the disease will worsen, requiring a surgical approach. The data regarding the natural history of Peyronie’s disease in not treated patients should induce caution in awarding efficacy to new pharmacological and physical treatments.
