Desde la popularización del test sérico del PSA, la incidencia del diagnóstico del cáncer de próstata y su detección como enfermedad órgano-confinada han aumentado signi- ficativamente, disminuyendo, solo ligeramente, su tasa de mortalidad. La evidencia de que la mayoría de los varones con cáncer prostático diagnosticado en un screening de PSA mueren por diferente causa a su enfermedad ha condicionado los conceptos de sobretratamiento y sobre- diagnóstico del mismo. El patólogo, que realiza el diagnóstico, tiene la responsabilidad de no sobrediagnosticar el cáncer, extremando su prudencia ante los focos tumorales minúsculos (en nuestra serie, el 8,57% de los tumores ocupaban menos del 3% del total del tejido de la biopsia) y los cambios histológicos de valoración dudosa, especialmente los de ASAP (AGF), así como los patrones tumorales 1 y 2 de Gleason que, en nuestra opinión (tras el estudio de más de 9.000 casos), son de difícil o imposible valoración en los cilindros de biopsia. Y el urólogo debe hacer una interpretación clínica de esos mínimos tumores, o de las lesiones sospechosas, en conjunción con las condiciones clínicas de los pacientes antes de establecer una actitud terapéutica, evitando el sobretratamiento.
OBJECTIVES: To report the experience in the management of penile necrosis at our hospital.METHODS: We performed a review of the medicalrecords with the diagnosis of penile necrosis at theDepartment of the Urology of the Hospital de Especialidades Centro Médico nacional Siglo XXI from January 1995 to March 2005.RESULTS: 18 cases of penile necrosis were found, with ages from 28 to 78 years (mean age 58.1 yr.). Diabetes mellitus and end stage renal disease were the mostfrequent associated diseases, with 10 and 11 cases respectively. Reasons for consultation were penile scars in 5 cases, purulent exudation, inflammation of the glans penis and prepuce in 3 , ischemic priapism in 2 , Fournier`s syndrome in 2, urethral bleeding in one , penile necrosis secondary to extrinsic compression in one, and periurethral abscess in another. Thirteen out of the 18 cases underwent partial or complete penectomy, and three of them died. Five patients were managed conservatively with antibiotics, one of them died. The pathology report showed ischemic necrosis in 3 cases, arterial and venous thrombosis, ischemic necrosis and dystrophic arterial and venous calcifications in 10 cases.CONCLUSIONS: Occlusive vascular changes are a conditioning factor in most patients with penile necrosis. This is more evident in patients with end stage renal disease, diabetes mellitus and hypertension. Clinical features of penile necrosis include scars, mummification, self-amputation, and superinfection, so that an early diagnosis and proper treatment are decisive for the evolution of this disease.
OBJECTIVES: To describe the technique of renal radiofrequency (RF) thermal ablation. Case report of a successful nephron-sparing surgery after failure of the RF thermal ablation of a renal adenocarcinoma in a patient with a single kidney.METHODS: A patient presenting with a renal adenocarcinoma in a single left kidney was treated by RF thermal ablation. The failure of the technique was patent on follow-up after demonstration of a central area of necrosis surrounded by a peripheral contrast enhancing area. Nephron sparing surgery was indicated as salvage procedure.RESULTS: Surgical excision of the tumor with a safety margin, without renal pedicle clamping was undertaken. Fat tissue and hemostatic synthetic material were placed in the surgical bed. Pathology report: renal adenocarcinoma with changes secondary to central necrosis. Twenty-four month postoperative follow-up: fatty renal nodule with small fibrous tracts inside in the area of the tumor. No evidence of contrast enhancing areas. Normal renal function (sCr 0.7 mg/dl, urea 24 mg/dl).CONCLUSIONS: Radiofrequency thermal ablation is a relatively new technique. Its oncological efficacy greatly depends on appropriate case selection. One of its main caveats is achieving an area of tissue ablation enough to completely destroy the tumor. When the technique fails, renal surgery (nephron sparing or not) seems to be the most recommended alternative.
OBJECTIVES: Urinary lithiasis has amultifactorial origin with participation of physical, chemicaland anatomical factors. Physical-chemical factors ofrenal-prerenal origin are the consequence of exogenous or endogenous agents, which are integrated under the name of systemic diseases associated with urinary lithiasis. The objective of the urinary metabolic study is to know and to analyze the physical-chemical factors by which each of these diseases or clinical entities participate in the lithogenesis.METHODS: We performed a study on 320 casesdistributed in two groups: Group A: 70 healthy subjects without past medical history or family history of urinary lithiasis. Group B: 250 patients with history of renal lithiasis who had passed calculi spontaneously, afterextracorporeal shock wave lithotripsy or surgery.Computerized urinary metabolic study (EMUSYS) was performed in all cases.RESULTS: 24% of the patients in the control group presentedone metabolic abnormality and 52% more than one; in group B, 17% of the patients presented one metabolic abnormality and 81% more than one. There were statisticallysignificant differences in the percentage of hyperoxaluria,hipocitraturias and hyperalciurias. There were no differencesin the subtypes of type III absorptive and excretoryresorptive hyperalciuria, hipomagnesiuria, and tubular acidosis, but these abnormalities were not detected in the control group. Moreover, some abnormalities were frequently observed in the control group, similarly to the patients group: enterorenal hyperuricosuria 34%, calciumsupersaturation 13%, elevated excretion of sodiumchloride 14%, type II absorptive hyperalciuria 8%,alimentary abnormalities, and low diuresis.CONCLUSIONS: People without lithiasis presentbiochemical urinary abnormalities in relation with life and alimentary habits similar to those found in patients,what concedes a role to the anatomical and hydrodynamicalfactors in lithogenesis. Patients with lithiasis present biochemical abnormalities such as calcium supersaturation,type II absorptive hyperalciuria, marginal absorptivehyperuricosuria, enterorenal hyperuricosuria, deficit of inhibitors, which may be controlled with adequate diet. Non dietetic hyperalciurias and hyperoxalurias,abnormalities of the urinary pH, and endogenoushyperuricosuria may be subject of diagnosis andtreatment.
OBJECTIVES: Complete or partial sacral agenesis is a rare malformation consisting in the absence of one or more sacral vertebrae. It is part of a caudal regression syndrome and it may be associated with other congenital anomalies (Currarino Syndrome). It does not have an established etiology but is associated with insulin-dependent diabetes mellitus in the mother (1%). The objective of this is study was to retrospectively analyze the urological outcome of patients with sacral agenesis in our case series.METHODS: Retrospective analysis of 14 patients between 1975 and 2005. We evaluated reason for consultation, urological status, continence outcome, urological complications, hospital admissions and number of ofﬁce visits. RESULTS: No patient had history of diabetic mother. The number of male/female patients were similar. Mean age at ﬁrst visit was 13.2 years and main reason for consultation was urinary incontinence. 60% of the patients presented associated myelomeningocele. 70% had a normal upper urinary tract at the beginning of follow-up; 10 patients presented some degree of incontinence (70%). Mean follow-up was 19.7 years (7-30): 50% of the patients keep a normal upper urinary tract. All of them have presented symptomatic urinary tract infection. The main urological reason for hospital admission was programmed surgery (7). The mean number of visits per year was 1.9.CONCLUSIONS: Sacral agenesis is a rare congenital malformation requiring an early diagnosis to avoid mid-term urological complications. These patients need life-long urological follow-up. The mean reason for consultation is urinary incontinence secondary to neurogenic bladder which may be satisfactorily treated in most cases.
OBJECTIVES: To compare the results of the Blaivas and Groutz nomogram in the diagnosis of female urinary obstruction with videourodynamic tests.METHODS: We performed a transverse study in aseries of 52 female patients with ages between 20 and 81 years (mean age: 48.7 years; standard deviation: 14.4 years) and functional lower urinary tract symptoms referred for videourodynamic studies. All patientsunderwent free flowmetry and voiding videourodynamic study. From the scores of free flowmetry and maximum detrusor pressure in the detrusor pressure/voiding flow test of the urodynamic study they were classified in one offour categories following the Blaivas and Groutz nomogram. Following urodynamic data they were classified into three categories: absence of obstruction, bladder neck obstruction and urethral obstruction.The nomogram results were compared with the videouro-dynamic data using the Pearson chi-square statistical test. The diagnostic sensitivity and specificity of the nomogram were also determined.RESULTS: The Blaivas and Groutz nomogram showed a significant association with the videourodynamic data (p = 0.000). Its diagnostic sensitivity for obstruction was 100%, but its specificity was only 67.5%. The percentage of diagnostic discrepancies was maximal in the mild obstruction, where one third of the patients were obstructed following the videourodynamic data.CONCLUSIONS: The Blaivas and Groutz nomogram is a sensitive method for the diagnosis of obstruction, but its specificity is low so that it has the tendency to overdiagnose the presence of obstruction in the female patient
OBJECTIVES: Male stress urinary incontinenceis usually a consequence or sequel of a prostatic surgicalprocedure (radical prostatectomy, surgery for BPH or bladder neck sclerosis: adenomectomy, conventional and/or bipolar transurethral resection, laser...). This kind of surgery may have undesirable effects on the quality of life and patients` expectations, although we should bear in mind that the primary objective in patients with prostate adenocarcinoma is to cure cancer and for patients with obstructive lower urinary tract symptoms to improve their voiding quality.Over the last decade, surgical procedures to compress the bulbar urethra with slings have been employedsuccessfully in the treatment of male stress urinaryincontinence, being considered highly effective in the treatment of post-prostatectomy incontinence in the long-termby groups with large experience.To describe the elements of the Argus system, its indications,and the surgical technique for its implant and adjustment,modified from Schäeffer and carried out by VictorRomano.METHODS: Argus system: The sling has three components:radiopaque cushioned system with silicone foam, 42 mm x 26 mm x 9 mm, which is waterproof to body fluids; two silicone columns formed by multiple conical elements, which allow system readjustment; and tworadiopaque silicone washers (15 mm diameter and 2.9 mm width) which enable proper fixation and readjustment(Figure 1).Once the system is open, it is recommended to place the sling within antibiotic solution until implantation.CONCLUSIONS:1. It is a safe, easy to implant, reproducible system, with few complications and a good cost-benefit relation.2. Results are comparable to the gold standard, but it has the following advantages: immediate voiding control recovery and no need for patient training.3. This article does not intend to show our short experiencewith only five cases, but we want to mention that all of them are continent with a good quality of life.4. Our objective will be to publish our results when we can show a minimal follow-up.
OBJECTIVES: To describe the surgicaltechnique of the right laparoscopic nephroureterectomy.METHODS/RESULTS: With the patient in the lithotomy position we performed an endoscopic section of theureteral meatus. Once the patient is placed in thelumbotomy position and trocars are placed, theretroperitoneal space is accessed. The gonadal vein, and the ureter medial to it, are identified. We proceedto dissect and clip it. Posteriorly, the Kocher maneuver on the duodenum is performed, identifying the inferior vena cava. We dissect the renal artery and vein placing Hemolock clips on both. Once the vascular control is achieved, we free the upper pole with the help of the Ligasure Atlas instrument. When the kidney is free we continue with the ureter down.CONCLUSIONS: Laparoscopic nephroureterectomy is a feasible technique for groups with experience inlaparoscopic surgery.
OBJECTIVE: The sarcomatoid pattern represents the histological type of renal carcinoma with the poorest prognosis, receiving the grade 4 of the Furhman classification consistently.METHODS: We report the case of a 80-year-old male who underwent nephroureterectomy with the pathologic diagnosis of sarcomatoid renal carcinoma with areas of chondro and osteosarcoma, as well as squamous cell differentiation. It is an exceptional case because it is rare to find all these elements in the same tumor.RESULTS: The study of the surgical specimen enables in most cases the identification of some of the classic histological patterns of renal carcinoma, nevertheless an immunohistochemical study is of great value for proper classification of the neoplasia and differential diagnosis with other renal lesions, mainly sarcomas.CONCLUSIONS: The presence of malignant heterologous elements, as in our case, will confirm the.prognosis of these neoplasias, which really don’t have an effective treatment.
OBJECTIVE: To report one case ofparaurethral cyst in the male, located in the subglandular penile urethra, an extremely rare pathology.METHODS/RESULTS: 46-years-old male patient with the diagnosis of Littre`s gland paraurethral cyst. Diagnosis and subsequent treatment.CONCLUSIONS: Paraurethral cysts of non traumatic origin are very rare, only two cases are described in the literature, one cyst located at the penoscrotal angle dependent from the corpus spongiosum without connection to the urethra, and another case of inflammation of the periurethral Littre`s glands simulating a tumor.
OBJECTIVE: To describe the clinical case of a patient presenting complications after the implantation of a Prolene mesh as reinforcement for the correction of a recurrent cystocele.METHODS /RESULTS: Seventy-five-years-old femalepatient with history of previous cystocele repair with Prolene mesh presenting urinary incontinence and vaginal erosion of the mesh.CONCLUSIONS: The use of mesh for the repair of cystoceleshas the advantage of providing greater support to thecolporrhaphy and avoiding recurrences. Nevertheless, it may present complications as in our reported case with mesh migration, fistula, infection, or intolerance.
Nephroblastoma or Wilms tumor is the most common renal neoplasia in children, representing 1/5 of the malignant tumors in this group. Nevertheless, the incidence of such tumor in adults is much rarer with less than 250 cases reported. Due to the low-frequency of this pathology in adults there is not a world widely accepted treatment modality. Currently, the therapeutic options derive from the National Wilms Tumor Study (NWTS). We report a new case with the radiological images, histologic findings, outcomes and follow-up.
OBJECTIVE: To report the clinical characteristicsand therapeutic options of penile torsion.METHODS: We report the case of a male with asymptomaticpenile torsion as an incidental finding after consultation for other reasons.RESULTS: The patient was treated conservatively becauseit was not an important aesthetic trouble and it wasasymptomatic.CONCLUSIONS: Penile torsion is rare. Surgical treatment is reserved for very important degrees of torsion, symptomaticpatients or, when patient feels discomfort with the aesthetic alteration.
OBJECTIVE: We present a clinical case of inverted papilloma of the anterior urethra in a male patient. M E T H O D S / R E S U LT S : 4 0 y e a r s - o l d m a n , w i t h o u t antecedents. The patient presented with dysuria and urethral bleeding on three occacions. Preliminary studies included radiographic voiding urethrocystography which revealed anterior urethral ﬁlling defect. Cystourethroscopy under anaesthetic was performed, allowing endoscopic resection of the tumour causing the filling defect. The Pathologic study of the resected specimen reported urethral inverted papilloma. CONCLUSIONS: Inverted papilloma located in the male urethra is rare. The most frequent clinical manifestations are dysuria and haematuria, although urethral bleeding may present when located in the anterior urethra. Diagnosis is based on clinical symptoms, ultrasound, endoscopy and mictional urethrocystography which allows detection of urethral ﬁlling defect. Treatment consists of transurethral resection of the lesion. Annual post-operative endoscopiy control is recommended.
OBJECTIVE: We report the case of a patient consulting with a four-year history of priapism, its diagnosis and subsequent therapeutic management.METHODS: We reviewed the literature for etiology, types of presentation, discussion of the clinical and radiological findings, and differential diagnosis.RESULTS: The patient underwent the embolization of the internal pudendal artery with excellent results.CONCLUSIONS: The embolization of the internal pudendalartery is an effective treatment for the resolution of high flow priapism secondary to arterial venous fistula.
OBJECTIVE: Vesical perforation during transurethral resection of the prostate (TURP) is usuallyrelated to high increases in intravesical pressure. However,it may rarely be related to explosion precipitated by the contact of the electrocautery with some gases produced during the resections. The authors present a case of vesicalexplosion, discuss its mechanism and suggest some measures for prevention.METHODS/RESULTS: A 71-years-old male underwent TURP and hemostasy of bleeding from the bladder neck due to persistent hematuria. A wire loop electrode set at a cutting and coagulating current of 80 watts was used. During coagulation of a bleeding in the anterior aspect of the vesical neck when the bladder was empty, a loud pop was heard and a jolt was felt at the lower abdomen. Inspection revealed a hole in the dome of the bladder with loops of small bowel visible. A low midline incision was done, and the intraperitoneal bladderrupture was repaired.CONCLUSION: Although uncommon, vesical explosion during TURP may occur and some preventive measures, discussed herein, can be performed to avoid thiscomplication.
OBJECTIVES: There are few studies on crystalluria in the developing countries. The aim of the present study was carrying out a first study in Morocco onthe frequency and the chemical nature of the crystalluria according to the sex and the age of human individuals living in the Tadla Azilal moroccan area.METHOD: 200 samples resulting from the morning urinesof morning fasting individuals of the two sexes and differentages were collected. The pH was measured by a portablepH-meter “Pocket pH-meter ad 110 pH”.The identification of the chemical nature of the crystalluriawas carried out using a polarized light microscope “Olympus BX41”. Such identification was based on morphology, polarization, and the pH of the urinary crystals. RESULTS: In this series the positive frequency of crystalluriawas 25.4 % and was distributed on 3 age groups so that 27.9% in the youngest group, 32.6% in the middle aged group and 39.5% in the oldest one. The distributionon the sex is such as 53.4% in the man and 46.5% in the woman. A large majority (83.7%) of the crystalluria consists of homogeneous crystalluria. In the man, the Weddellite is dominant (69.6%) in the crystalluria while in the woman the Weddellite yields the place to the two phases of the uric acid (60%).CONCLUSIONS: The studied series presents a non high frequency of crystalluria, which increases with the age. The factor sex has weakly increased the frequency of crystalluria in the man compared to the woman. The oxalocalcic nature is dominant in the crystalluria resultingfrom the man while it is the uric nature that is so in the woman. Other studies are necessary to be able tounderstand the etiology of a such difference, in thechemical nature of the crystalluria, between the two sexes.