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OBJECTIVES: To evaluate and quantify theassociation between clinical, ultrasound and immunoserologicaldata and histologic type and stage oftesticular tumors.METHODS: We analyze a cohort of 80 patients whounderwent orchiectomy for testicular neoplasia. Meanpatient age was 30.4 years. Past medical history, firstsymptoms, time from first symptom to operation, physicalexamination and ultrasound data, and preoperativeserum levels of alpha-fetoprotein and beta HCG wereretrospectively collected.RESULTS: Patients with non seminomatous germ celltumor (NSGCT) had a significantly lower mean age(23.7 yr.) than patients with pure seminoma (41.3 yr.),and these latter a significantly lower age than patientswith non germinal tumors (50.7 yr.). Initial presentationwith general malaise or lumbar pain increased 2.56times the relative risk of having a tumor in advancedstage (higher than stage I) . Presence of gynecomastiaincreased 16.5 times the relative risk of having a nongerm cell tumor, due to the inclusion of Leydig`s tumorsin this group. Detection of heterogeneous nodules byultrasound increased 4.5 times the risk of having a nonseminomatous germ cell tumor. Preoperative elevationof alpha-fetoprotein ruled out the existence of seminomaand non germ cell tumor; whereas preoperative elevationof beta HCG increased 3.21 times the risk of havinga non seminomatous germ cell tumor. No significantassociation was shown between preoperative tumormarkers and tumor stage.CONCLUSIONS: The existence of gynecomastia, age,detection of heterogeneous nodules on ultrasound, andpreoperative alpha-fetoprotein and beta HCG are relevantdata in relation to histological type of tumor. Lumbarpain or malaise are clinical data associated with tumorstage.
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OBJECTIVES: To analyze therapeuticmanagement and survival of renal adenocarcinomawith tumor venous extension treated by surgery in ourexperience.METHODS: We retrospectively evaluate a series of 29cases of renal adenocarcinoma with venous thrombuswho underwent radical nephrectomy and thrombectomyfrom January 1986 to November 2003. Mean agewas 63.4 11.9 (29-79) years. 23 patients were males(79%) and 6 (21%) females. 17 (59%) patients had thetumor in the right kidney and 12 (42%) in the left kidney.Tumor thrombus level was: Level I (renal vein-inferiorvena cava) 13 (45%), Level II (infrahepatic vena cava)9 (31%), Level III (retrohepatic vena cava/suprahepatic)3 (10%), and Level IV (auricula) 4 (14%). 92% of thecases presented perirenal fat involvement. Survivalanalysis was performed including 24 cases of the 29.We analyzed overall and cancer-specific survival, aswell as possible influence of tumor thrombus level, fatinvolvement, and tumor grade as prognostic factors.RESULTS: Mean tumor size was 8.15 ± 2.25 cm (5-13). Surgical approach was purely abdominal in 23cases (79%) and thoraco-phreno-laparotomy in 6(21%). Hepatic mobilization maneuvers and hepaticpedicle clamping were performed in 5 (17%) patients.Venous clamping was: renal-cava 13 cases (44%),triple clamping 11 (37%) (9 infrahepatic and 2suprahepatic), and supradiaphragmatic-auricula 5(17%). Conventional extracorporeal circulation (CEC)with moderate hypothermia (26-28º C) was employedin 4 cases and CEC with heart arrest (4 min) in one.Mean follow-up was 52 months. At the time of review9 patients were alive,11 had died from tumor and 4had died from other causes. Mean overall survival was71 ± 12 months and cancer specific survival 86 ± 14months. Neither renal fat involvement (p=0,6) nortumor thrombus level (p = 0.9) were prognostic factorsfor survival in the univariant analysis, but tumor gradewas (p = 0.03).CONCLUSIONS: Patients with venous tumor extensionwithout lymph node involvement or metastasis should betreated by radical surgery with complete excision of thetumor thrombus. Tumor grade was a prognostic factorfor survival, but venous involvement level and presenceof perirenal fat involvement were not.
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OBJECTIVES: To analyze the role oforchiectomy in the management of metastasic prostatecancer in our environment.METHODS: We studied 76 patients with the diagnosis ofprostate cancer who underwent subcapsular orchiectomy.RESULTS: Mean age was 72 years, median Gleasonscore was 7, and only 17% had organ confined tumors.Mean follow-up was 2.3 yr. and hospital stay medianthree days. Ten of the 76 patients in the study died fromcancer, being overall five-year survival 75%. Regardingcost analysis, surgical castration was cheaper in thelong-term but has the disadvantage of its greaterpsychological impact.CONCLUSIONS: Orchiectomy is a valid hormonalblockade option when estimated patient survival is longerthan one year.
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OBJECTIVES: To evaluate the clinical and urodynamic characteristics of a series of women with lower urinary tract symptoms (bladder filling phase) presenting various rates of cystocele.METHODS: 119 female patients were included in this study; mean age was 55.8 yr. (range 15-87). All patients underwent urogynecologic physical examination (cystocele was graded 0-3) and complete urodynamic study. Urodynamic terminology and measurements comply with the ICS (InternationaL Continence Society) standards. Statistical significance was establishedbelow 0.05. Quantitative variables were compared by the Student’s t and non parametric variables byPearson`s chi-square.RESULTS: The most frequently reported symptom was urinary incontinence when coughing (77/118,65.3%), followed by urge incontinence (71 patients, 60.2%). The grade of cystocele was 0 in 31.1%, 1 in 25.2%, and 2 in 26.1%, and 3 in 17.6%. There was a statistically significant association between grade of cystocele and the symptom “vaginal bulge”(p=0,00002). The presence of cystocele did not show any statistical association with lower urinary tract symptoms of the filling phase. Mean cystomanometric bladder capacity was 224.8 ml. Involuntary contractions of the detrusor muscle appeared in 38 cases (21.9%), stress urinar y incontinence in 19 (16%), mixed incontinence in 8 (6.7%) and absence of evidence of urinary incontinence in 58 (48.7%). Patients withurgency had a lower bladder capacity than patients without it (p = 0.02), as did patients with urge incontinence (p = 0.02). Nocturia (p = 0.05), urgency (p = 0.02) and urge incontinence (p = 0.01) were significantly associated to bladder capacity. The existence of involuntary contractions was statistically associated with urge incontinence (p = 0.01). Patients with involuntary contractions during the filling phase showed increased diurnal voiding frequency (p = 0.02), as well as patients without a stress urinary incontinence (p = 0.04) and cases without a stress urinary incontinence (p = 0.04).The symptom incontinence with coughing had a significant statistical association with the urodynamic diagnosis of stress urinary incontinence (p= 0.01). Bladder capacity was augmented in grade 3 cystocele (p= 0.003). The existence of cystocele was not associated with bladder hyperactivity (p = 0.65), neither was the diagnosis of a stress urinary incontinence (p = 0.37).CONCLUSIONS: No relationship has been demonstrated between existence and degree of cystocele and functional lower urinary tract symptoms of the filling phase, on the one hand, and urodynamic evidence of bladder hyperactivity and incontinence on the otherhand. This could have important therapeutic implications.
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OBJECTIVES: To evaluate the clinical and urodynamic features of a series of women with post void residual urine (disbalanced voiding ) and various degrees of associated cystocele. METHODS: 119 female patients were studied by clinical evaluation, urodynamics, and imaging tests (VCUG). All patients underwent history and genitouro- logical examination (evaluating cystoceles from grade 0 to 3), neuro-urological examination, and complete urodynamic study. Fifty patients (42%) underwent radio- logical studies of the upper urinary tract. Disbalanced voiding was defined as existence of post void residual greater than 20% of the voided volume. Urethral resistance was measured by URA. Structural obstruction was characterized by PURR (CHESS classification). Functional obstruction was studied by DURR and perineal EMG (associated with flowmetry). Detrusor con- tractile power was evaluated by W max, W 80-20, and duration of contraction. Urodynamic terminology and measurements complied with the International Continence Society (ICS) standards. Statistical significance was established at 0.05. Statistical analysis was done by Student’s t for quantitative variables , and Pearson`s chi-square for non parametric variables. RESULTS: 119 patients were enrolled. Mean age was 55.84 yr. (range 15-87). Regarding post void residual (114 valid uroflowmetry studies), 25 patients were classified as voiding disbalance (21.9%) and 89 as balanced (74.8%). Regarding clinical data, there were only significant differences between groups in voiding difficulty. For uroflowmetry, only the percentile of the Maximal flow (Qmax) showed significant differences (35 vs. 22 for balanced/disbalanced voiding respectively, p = 0.02). Pressure/volume studies demonstrated bladder hyperactivity in 16 cases (64%) in the group of disbalanced voiding and 31 cases (34.8%) in the normal voiding group (p = 0.008), which presented associated with increased urethral resistance (URA)(p = 0.01) . In the pressure/flow study, there were significant differences in the URA (14.7 vs. 25.3, p = 0,001). There were statistically significant differences in the degree of constrictive (0.5 vs. 1.1, p = 0.009) and compressive (0.5 vs. 1.1; p = 0.04) obstruction (Chess classification). There were not significant differences in the analysis of isometric contractility (Wmax), but there were in the isotonic contractility (W80-20) and detrusor contraction duration. These latter differences presented significant association with the degree of cystocele. DURR and perineal EMG data did not show differences between groups. Radiological abnormalities of urethral morphology were statistically different between groups, presenting in 10% of the patients with normal voiding and 50% of the disbalanced voiding group, although there was not statistical association with obstruction (p = 0.64) . The existence of cystocele did not show a statistical association with these variables either. CONCLUSIONS: Disbalanced voiding appeared with organic obstruction of the lower urinary tract (constrictive most significantly), as well as detrusor abnormal contractility, but whereas the first was not significantly asso- ciated with presence and grade of cystocele, the second showed such association.
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OBJECTIVES: To retrospectively review allcases of epididymal cysts registered over the last fiveyears; 15 cases have been included. Simple epididymalcysts are a rare pathology in childhood, being most ofthem diagnosed in puberty. Currently, due to the scarcecase series, there is not consensus about the mostadequate therapy.METHODS/RESULTS: Mean age at presentation was11.5 yr. (1-16). 50% were diagnosed incidentally and29% presented increased scrotal size. 46% of thecases had associated left varicocele (n = 6) and 26%had history of orchiepididymitis. Diagnosis was based on physical examination and confirmed by ultrasound.40% of the patients underwent surgery and the remainderreceived conservative treatment without evidence ofcomplications on follow-up.CONCLUSIONS: Due to the benign character andgood evolution of all cases of epididymal cysts treatedconservatively and the absence of benefit after surgicaltreatment, we believe that management should beconservative with clinical and ultrasound controls,leaving surgery for cysts with complications. The frequentassociation between epididymal cysts and varicocele isrelated to coincidence of both pathologies in theprepuberal age.
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OBJECTIVES: Proximal migration of stonefragments during ureteroscopic lithotripsy is a commonproblem influenced by pressure of irrigation solution,type of energy for lithotripsy, site and degree of fixationof the stone to the ureteral wall, and degree of proximal ureteral dilation. The Stone Cone TM (Boston Scientific＆ Spencer) is a device that helps to prevent proximalmigration of fragments and favours a safe extractionduring ureteroscopic lithotripsy.TECHNIQUE: The Stone Cone TM is an helical devicemade of stainless steel and nitinol alloy, which consistsof an internal guide wire and a sheath-like radiopaquecatheter with a 3 Fr. calibre. Once the cone is placedabove the stone it is maintained in that position duringlithotripsy to avoid fragment migration. The externalcatheter is used to coil and unroll the cone, and allowsaccess to place the cone above the stone.METHODS: We describe two cases of urinary calculi inthe left lumbar ureter treated by ureteroscopy andintracorporeal lithotripsy with holmium YAG laser usingthe Stone Cone TM to avoid migration of fragments.RESULTS: One month after surgery no lithiasic fragmentswere observed in the imaging tests.CONCLUSIONS: The Stone Cone TM decreases theneed to perform repeated ureteral instrumentations, andis also a safer and simpler method for the extraction ofstone fragments. The use of Stone Cone TM seems tohave more advantages than Dormia`s basket duringureteroscopic lithotripsy in terms of lower incidence ofresidual fragments and reoperation rate.
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OBJECTIVES: To objectively demonstratethe advantages provided by TURP with saline solution(an adjustment made possible thanks to the technologicaldevelopment of new high frequency current generators),although it surprisingly has been received with scepticismin the urological community.METHODS: A first group of 51 patients (group A)underwent low hydraulic pressure TURP with a pulsedbipolar system (Gyrus Plasmakinetic, with large loop)using physiologic saline solution as irrigation. A secondgroup of 49 patients underwent low hydraulic pressureTURP with a conventional monopolar system (Erbe 350)using glycine-ethanol solution.RESULTS: A better surgical performance was obtainedin the first group, as well as a lower degree of bleeding.No intraoperative complications appear in eithergroup. Only one case of late hematuria was registeredone month after surgery in a patient of group A.CONCLUSIONS: Pulsed bipolar TURP has a minimalthermal in-depth diffusion, achieves vessel hemostasisby dessication instead of charring, has an extremelyprecise cutting quality, does not produce neuromuscularstimulation, and makes the use of saline solution irrigationpossible. All these translate to lower tissue injury, nullrisk of sequelae secondary to electric current leak, afiner technique, a lower risk of accidental perforation,and the possibility of duplicate or triplicate the surgicaltime without risk, especially when working with lowhydraulic pressure.
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OBJECTIVES: Primary localized amyloidosisof the urinary bladder generally has a benign course.On the contrary, secondary amyloidosis, a consequenceof systemic amyloidosis, may have massive bleedingand produce complications such as bladder rupture orlife-threatening hemodynamic problems requiring desperatehemostatic procedures such as hypogastric arteryembolization or ligature, or cystectomy. We report onecase in which hemostasis was achieved by a Mickulicztransurethral bladder tamponage.METHODS: 58 year old female with very aggressiverheumatoid arthritis and secondary renal amyloidosisunder chronic hemodialysis presenting with severehematuria after hip replacement. An inflamed bladderwas found, the biopsy of which showed edema in alllayers with blood vessel walls enlarged by amiloyd deposits. After several unsuccessful transurethral hemostaticprocedures, intravesical formalin irrigation was carriedout together with a Mikulicz type gauze packaging afterurethral dilation. The gauze was withdrawn three dayslater without bleeding recurrence; however she presentedsubsequent neurological impairment and finally died 14days after the last urological procedure.CONCLUSIONS: Transurethral packaging of the urinarybladder in a woman with massive hematuria is ahemostatic option that we recommend to be used beforeother more dramatic or invasive options are chosen.
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OBJECTIVES: To report one case ofpseudotumoral lesion of the iliac ureter with obstructiveuropathy leading to loss of function of the renal unit.METHODS: 66-year-old male being studied for BPHwho presents with a self-limited monosymptomatichematuria.RESULTS: Renal ultrasound detected grade II pyelocaliectasisof the right kidney. IVU showed absence offunction of the right kidney. Urine cytology was consistentwith low-grade transitional cell carcinoma.Percutaneous nephrostomy was performed confirmingirreversible function loss. Antegrade pyelography showeda filling defect in the right iliac ureter. Radicalnephroureterectomy with bladder cuff was carried outwith good results. Pathology reported chronicpyelonephritis and parietal inflammatory lesion of theureter obliterating the lumen with inflammatory infiltrates,urothelial erosion and presence of actinomyces.CONCLUSIONS: Actinomycosis is a chronic bacterialinfection, with A. israeli being the most common pathogen.It is part of the normal flora of the oral cavity and GItract, and cervical-facial region is the most frequentclinical involvement (60% of the cases). Urinary tractinfection is exceptional. No other focus was found inthe long-term follow-up.
Case Report
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OBJECTIVES: After taking care of apatient with suspicion of upper urinary tract neoplasiawhich was finally diagnosed of renal pelvis subepithelialhematoma (Antopol-Goldman lesion), we decided toreview such unfrequent pathology with the aim tosummarize its main characteristics.METHODS: The patient presented clinically andradiologically as an upper urinary tract tumor andunderwent nephroureterectomy. Past history was significantfor oral anticoagulative treatment after deep veinthrombosis.RESULTS: Pathologic study of the nephrectomy specimenreported absence of urothelial tumor and presence of asubepithelial hematoma of the renal pelvis, whichexplained both clinical manifestations and radiologicalfindings. Our case is very similar to the other 27 publishedin the bibliography.CONCLUSIONS: Subepithelial hematoma of the renalpelvis is a benign lesion, more frequent in females,which appears between the fourth and sixth decades oflife. Not much is known about its etiopathogenesis, itprobably is a multifactorial process. It simulates anupper urinary tract urothelial tumor, both clinically andradiologically, and so is treated in most publishedcases. It is necessary to know this entity as possible differentialdiagnosis of upper urinary tract radiologicalstudy filling defects to avoid non necessary nephrectomies.
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OBJECTIVES: To report one case of associatedrenal cancer and ipsilateral pheochromocytomatreated by laparoscopic surgery.METHODS: We describe the case of a 67-year-oldfemale presenting with left lumbar pain and recurrent urinarytract infections. Ultrasound and abdominal CTscan were performed revealing renal carcinoma andipsilateral adrenal mass, which was confirmed by MRI.With the diagnosis of left renal carcinoma and possibleadrenal metastasis, laparoscopic left nephrectomy andadrenalectomy were performed.RESULTS: Pathologic study of the specimen reported achromophobic renal cell carcinoma and adrenal pheochromocytoma.CONCLUSIONS: The association of renal carcinomaand pheochromocytoma is unfrequent, as suggested bythe limited available bibliography on the topic. The presenceof an adrenal mass in a patient with history of primarytumor is frequently secondary to metastasic disease,although primary adrenal neoplasia should not bediscarded.
Case Report
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OBJECTIVE: We report a case of a giantmyelolipoma of the adrenal glandMETHODS/RESULTS: A case of a giant myelolipoma ofthe adrenal gland, an uncommon non-functioning tumour ofthe adrenal cortex comprised of haematopoietic and adiposetissue, that had been detected incidentally duringevaluation with CT because of its characteristic fatty composition.The clinical features, diagnosis and treatment arediscussed.
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OBJECTIVES: To demonstrate the presence of neoplasic degeneration within non descended testicles and the effect that late orchydopexy could have in the increased incidence. METHODS: We review the medical records of 22 patients with the diagnosis of malignant testicular tumor cared for at the Department of Urology of the Hospital CQ D Comandante M. Fajardo between 1982 and 2004, looking for history of cryptorchidism, age at the time of orchydopexy (if carried out), histological diagnosis and stage, and post operative outcome. We include one case which did not belong to this series because it was not reported previously. RESULTS: Four patients with history of cryptorchidism were found, the youngest was 12 years old and the time of orchydopexy and the oldest 57. All cases of tes- ticles outside the scrotum at the time of diagnosis were seminomas. The only case with successful orchydopexy presented teratocarcinoma and died before two years from orchiectomy. All cases of seminoma received radiotherapy and are disease-free with negative tumor markers. CONCLUSIONS: Cryptorchid testicles operated after the age of two years only provide hormonal supply ade- quate for development of secondary sexual features but not fertility, so that in unilateral cases late orchydopexy would only help to detect neoplasic degeneration befo- re the appearance of pain or symptoms from metasta- ses. If there are not important psychological or cosme- tic reasons orchiectomy should be the first therapeutic option for adult’s cryptorchidism.
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