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OBJECTIVES: We evaluate the indication and results in the treatment of complex urethral stenosis by the Barbagli`s technique. METHODS: We retrospectively review 8 patients undergoing dorsal onlay urethroplasty with foreskin mucosa free graft. We analyze their preoperative characteristics. Mean stenosis length was 6.25 cm and the site was bulbar urethra in seven cases and penile in one. Mean preoperative flow was 8.78 ml/sec. We describe the technique and present our results. RESULTS: There are 87.5% of goods results (cure of the stenosis) with 22 months of mean follow-up. Only one patient required a second operation (end to end anastomosis) with good outcome. CONCLUSIONS: The dorsal onlay urethroplasty with foreskin mucosa free graft is an effective technique in long and complex urethral stenosis, and we consider it the technique of first choice in view of our results.
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OBJECTIVES: Upper urinary tract (UUT) tumors are a relatively low incidence pathology which often represents a diagnostic challenge for the urologist, because several imaging tests are usually necessary to achieve the final diagnosis. Over the last years CT scan has suffered a notable development and nowadays, with the arrival of new image processing hardware and software, it is possible to detect small urothelial lesions and to perform 3-D urinary tract reconstruction and virtual endoscopic navigation. METHODS: Between January 2004 and June 2005 we performed a total of 15 examinations in 15 patients for the study of asymptomatic hematuria of probable upper urinary tract origin. The technique included three phases to obtain images: basal phase, vascular phase and excretory phase. Processing and image analysis was performed by one radiologist. RESULTS: A total of 10 tumors were diagnosed, with pathological confirmation in all cases. We did not register any complication secondary to the technique, and all patients tolerated well the exam. CONCLUSIONS: The CT urography is a safe, well-tolerated, highly sensitive and efficient imaging test, very useful in the diagnosis of renal and UUT pathology. It may become the only imaging test performed in the study of asymptomatic hematuria and the test of choice for the study of urological tumoral pathology.
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OBJECTIVES: Paratesticular liposarcomas are rare; most published cases are single cases. We report the clinical, histological and immunohistochemicalcharacteristics of three cases of paratesticular liposarcomas.METHODS: We performed clinical, histological andimmunohistochemical studies with expression of ki 67 and p 53 markers in three cases of tumors of the spermaticcord.RESULTS: Patient age ranged from 36 to 67 years, with a mean of 54 years. All tumors were big, multinodular and predominant histological type was well-differentiated(2/3), being one case undifferentiated (1/3). All cases were treated by surgical excision; one of them had arelapse five years later (33%) as a low-grade undifferentiatedliposarcoma. None of the patients have developedmetastases after a long follow-up (10, 7, and 5 yr.).CONCLUSIONS: Paratesticular liposarcomas havefavourable prognostic markers (histological type, low proliferation index Ki 67 and p 53). The evaluation of this masses should be based on imaging tests, but a biopsy is necessary to determine their nature both in the case of primary tumors and recurrences. Surgical treatmentshould include complete excision with free margins to avoid recurrences.
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OBJECTIVES: To evaluate the clinical and laboratory findings in pediatric patients with urolithiasis in a case control study and to obtain variables predictinga low risk of having urolithiasis.METHODS: Retrospective analysis of 24 cases of childrenwith urolithiasis (age range 3 to 17 years old) admitted to the pediatric emergency room or the hospital ward. Clinical and laboratory information was obtained from the clinical charts and compared with a control group of 29 patients with history of abdominal pain admitted to the hospital. Binary logistic regression and recursive partitioning analysis were used to obtain variablespredicting a low risk of having urolithiasis.RESULTS: There was no difference in age, gender,dysuria or nausea (p>0.2) between groups. A difference regarding the presence of fever (p=0.007), haematuria (p=0.001), costovertebral angle tenderness (p=0.004), family history (p=0.007) and abdominal pain lasting more than 48 hs (p=0.04) was detected. After logistic regression and using recursive partitioning, the presence or history of fever, absence of gross haematuria and no family history of urolithiasis showed a 100% negative predictive value and sensitivity (95% CI 84.7 to 100 and 89.2 to 100 respectively).CONCLUSIONS: Children with abdominal pain presenta low risk of having urolithiasis if there is a history or presence of fever, absence of gross haematuria and a negative family history of urolithiasis in a first degree relative.
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OBJETIVES: The treatment of patients with a great burden of stones is very difficult and often requires complex treatments including different kinds of surgery, associated in some cases with ureteral stents.METHODS: We present the case of a patient with complex renoureteral stone disease in whom we used the stone sweeper stent before SWL. The catheter is a 6.5 Fr radial expanding stent with small baskets, a special structure designed to extract small stones <5mm.RESULTS: The placement and retrieval of bilateral stents were performed without complications, extracting several small stones inside the baskets.CONCLUSIONS: The Stone Sweeper stent may play an important role in the treatment of patients with great stone burden; by dilating the ureter and helping the passage of stones and capturing small residual fragments it may decrease the need of new treatments. Currently, more clinic and research tests with this stent are necessary to determine proper indications and associated complications.
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OBJECTIVES: Since the first publishedreport in 1992, laparoscopic adrenalectomy has been widespread and it is now accepted as the standard treatment option in most of benign diseases of the adrenal gland. Aim of the present study is to describe our initial experience with laparoscopic adrenalectomy.METHODS: Between May 2001 and December 2005, 15 patients were submitted to laparoscopic adrenalectomyfor benign diseases of the adrenal gland. We analyzedpatients characteristics (sex, age, initial diagnosis),operative and perioperative results (operative time, blood loss, time to first oral intake) and complications.RESULTS: Mean operative time was 143 minutes. Blood loss was minimal. Mean hospital stay was 90 hours. There was no need for open conversion and complication rate was low.CONCLUSIONS: Laparoscopic surgery of the adrenal gland is a safe and effective option which offers quality of life benefits to the patients.
Case Report
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OBJECTIVE: The prevalence of the disease is 1/3000 newborns; it is more frequent in men than in women with a 3:1 ratio in all races. Genitourinary tract neurofibromas usually arise from the pelvic and bladder nerves, and the prostatic plexus. Bladder is the mostfrequently affected organ of the urinary tract; bladderneurofibromatosis may present as a diffuse infiltrative process or an isolated neurofibroma. Bladder neurofibromas arise from nervous ganglia of the bladder wall and stain positive for protein S-100 and type IV collagen withimmunohistochemical techniques.METHODS: We performed a bibliographic review about urinary tract neurofibromas, and specifically of bladder neurofibroma. We report the case of a 45-year-old female consulting for voiding symptoms and recurrent urinary tract infections. Imaging tests showed a mass in the left lateral wall of the bladder and diffuse thickening of the bladder wall. The thickening of the bladder wall is the most characteristic finding in imaging tests, which may also be present in other diseases such as inflammatory pseudotumor and leiomyoma, so that final diagnosis should be achieved by pathologic study.RESULTS: The case is relevant for the absence of previous diagnosis of neurofibromatosis, being bladder involvement its clinical debut. This is why it was difficult to suspect the final diagnosis: the absence of other characteristic clinical manifestations of the disease. Transurethral resection of the tumor was performed and pathologic and immunohistochemical studies offered the final diagnosis. The patient was followed in the urology clinic and also sent to the internal medicine department to rule out other organs involvement of the disease.CONCLUSIONS: Neurofibromatosis is a rare systemic disease, and urinary tract involvement is rarer. Bladder is the most frequently involved organ in the urinary tract, generally as a diffuse infiltration or more rarely a solitary tumor. The final diagnosis is pathological and immunohistochemical. Treatment is usually conservative. The patient should be worked up to rule out other manifestations of the disease, and followed to evaluate the development of new lesions.
Case Report
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OBJECTIVE: To describe the case of thepatient with history of Crohn’s disease presenting metastatic extension to the penile foreskin.METHODS: Circumcision was carried out and the skin was sent to the pathology department.RESULTS: Pathologic study of the specimen showed anulcerated granuloma without caseum, typically associated with metastatic Crohn’s disease. After one year of follow-up there is no evidence of recurrence.CONCLUSIONS: Crohn’s disease is a disease of unknown origin, the main characteristic of which is the development of non necrotizing granulomas that may involved not only the gastrointestinal tract. When the extraintestinal involvementis not produced by continuity we call it metastatic disease. Such metastases may be found in the genitourinary tract, and other sites. This involvement may include lithiasis, amyloidosis,... and the presence of lesions in the genital skin, as in our case.
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OBJECTIVES: We report a rare case of intrascrotal neurofibroma in an adult patient not affected by neurofibromatosis (NF1).METHODS: Clinical diagnosis of asymptomatic right scrotallipoma and left symptomatic inguinal hernia carried thepatient to the surgical treatment. After the first surgical step of left hernia repair, we proceeded to the excision by an inguinoscrotal approach of a voluminous whitish neoplastic mass occupying the whole left scrotum and not involving homolateral testis.RESULTS/CONCLUSIONS: The histopathologic diagnosis was of neurofibroma, a benign neoplasm of peripheral nerveswhich rarely occurs at genital level.
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OBJECTIVE: We report a new case of bladder leiomyosarcoma in a young female patient. We review its features and different treatment options.METHODS: The patient underwent neoadyuvant chemotherapyand surgical excision.RESULTS: A partial response was achieved with neoadyuvantchemotherapy and remains still alive 60 moths after radical cystectomy.CONCLUSION: Despite the poor prognosis of this disease,multimodal treatment may improve results. Neoadyuvant chemotherapy and subsequent radical excision could be a good combination therapy for these aggressive tumors.
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OBJECTIVE: Adrenal myelolipoma is a rare benign tumor, well limited, variable in size, composed of fatty and hematopoietic tissues, the finding of which is usually incidental. If they reach a big size they may produce the feeling of abdominal mass, pain, neighbour organscompression and acute intratumoral or retroperitonealhemorrhage.METHODS: We report the case of a 57-year-old maleadmitted to the hospital with acute abdominal pain. CT scan with IV contrast and adrenal biopsy were performed.RESULTS: Radiological findings: 9 x 10 cm right adrenal mass, well defined, hypodense, with a small calcification in its posterior area. Pathologic findings: benign tumor,encapsulated, with a mixture of mature fatty tissue andhematopoietic cells.CONCLUSIONS: The presence of fat within an adrenal mass is essential for the diagnosis. Differential diagnosis should be done with all adrenal tumors with a fat component. When no radiological diagnosis is made, pathologicconfirmation is necessary.
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OBJECTIVE: Persistence of a patent urachus is a relatively rare occurrence; however; the persistence of urachal remnants is common. The pathologic lesions of the urachus include benign and malignant neoplasms. The majority of malignant urachal neoplasms are adenocarcinomas. METHODS AND RESULTS: We report a case of papillary urothelial carcinoma of urachus in a 73-year-old woman. The patient was treated with complete surgical extirpation and partial cystectomy. COCLUSION: The recognition of urachal remnants as vestigial structures and pathologic lesions of the urachus is important.
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OBJECTIVE: To present a case of tubulovillousrenal pelvis adenocarcinoma.METHODS/RESULTS: An 81 year-old patient presented at Emergency Departament with sepsis. CT scan showed a staghorn calculus with signs suggestive of pyonefrosis. A nephrectomy was performed and pathological exam revealedtubulovillous renal pelvis adenocarcinoma.CONCLUSIONS: Renal pelvis adenocarcinoma is a rare disease. It is usually accompanied by chronic urinaryinfections, an inflammatory state and staghorn calculi. The best therapeutic option is nephrectomy and the prognosis is poor.
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OBJECTIVE: We describe the case of a young male presenting with non-specific abdominal symptoms on follow-up after radical nephrectomy for renal carcinoma leading to the finding of local recurrence and peritoneal metastases. A second exploratory laparotomy was carried out for tumor reduction, but it was followed by fast peritoneal recurrence. Despite the treatment with alpha interferon, three months later he developed multiple hepatic metastases.CONCLUSIONS: Peritoneal involvement by renal cell carcinoma is rare and implies a bad prognosis.
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OBJECTIVE: Low dose rate (LDR) prostate brachytherapy (permanent 125I or 103Pd seeds) is an accepted treatment option for low risk prostate cancer patients. However, differences in prostate spatial location, volume and gland deformation between the images obtained during pre-planning and later on during the implant procedure prevent the pre-planned intended dose to be accurately delivered. We are reporting on a new technique based on interactive real-time dynamic intra-operative dose calculation with avoidance of post-implant CT for final dosimetry. The reasons leading us to implementing this new technique are discussed and preliminary results reported.
METHODS: A pre-planning TRUS for volumetric analysis is performed in all our patients prior to implantation. This TRUS accomplishes two objectives: 1) assessment of implantability of the gland, of organs at risk and anatomical considerations and 2) determination of seed activity and total number of seeds. On the day of the implant, new TRUS images from base to apex are obtained using a motorized stepper connected to the ultrasound and planning system. Each real time needle position placed on the target is identified and capture by the planning system in the true position. Once all real needle positions have been captured, dosimetry is performed intra-operatively and the physician approves the corresponding isodoses on real time. Flexible cystoscopy is then performed followed by seed placement. Each seed implanted is then identified upon withdrawing the needle using TRUS guidance. This allows real-time intra-operative dosimetric analysis, allowing for correction of under-dosed zones during implantation in an interactive dynamic manner. Peripheral loading is used.RESULTS: We began our LDR prostate brachytherapy program on 1999. While we have treated >700 patients with LDR, the last 63 patients were treated with our real time dynamic intra-operative planning system. The median time duration for the procedure was 90 minutes. The median follow up time for these 63 patients was 20 months with a range of 10-36 months. At presentation, Stage T1c was seen in 55%, T2a in 36% and 9% as T2b. The Gleason grade was < 7 in 81% of the patients. The median PSA value was 9 ng/ml (range 4.2-30). The median age was 64 years (range 47-78 years). For the real time intra-operative dosimetric analysis the following values were obtained: a median of 98% (90%-100%) for V90, of 60% (22%-76%) for V150 and 24% (9%-34%) for V200. The median intra-operative D90 obtained was 16,817 cGy with a range of 13,743 to 19,553 cGy. The median dose point calculation to the rectum maximum was 12,936 cGy and for the maximum in urethra was 21,880 cGy. For the real-time dynamic planning, the acute GU grade 1& 2 toxicity was reduced from 28% and 21% to 16% and 6% respectively. Acute urinary retention was seen in 2/63 or 3% requiring a temporary post-implant bladder catheter. In addition, a decrease in chronic GU grade 1-2 toxicity was also seen from16% and 17% to 11% and 2% respectively. No change in GI toxicity pattern was noted. No severe grade 3-4 intra-operative complications were noted.CONCLUSION: Real-time intra-operative planning was successfully implemented in our center. It avoids the possible implant quality and dose delivery disadvantages of the standard post-implant CT-based dosimetry by improving the accuracy of seed placement on real time, which was translated in lower rates of acute and chronic GU morbidity. In addition, avoids the unnecessary time, effort and cost of post-implant CT-based dosimetry.