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OBJECTIVES: The objective of this studyis to perform a historical journey through the topic ofcircumcision from the Italian Renaissance to the SpanishBaroque.METHODS: We evaluated the paintings about circumcisionbetween both periods, including their most representativeworks.RESULTS AND CONCLUSIONS: Circumcision is afrequent topic in the religious painting in both periods.
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OBJECTIVES: To point out the efficacy of supra trigonal cystectomy with orthotopic substitution iliocystoplasty in the treatment of advanced interstitial cystitis (IC).METHODS: We study the results obtained in fourwomen suffering IC nonrespondent to conservative treatment who underwent the procedure. All patients comply with classic diagnostic criteria of IC, presenting long-lasting symptoms, between 4 and 8 years (mean 5.6), and voiding frequency of near one-hour day and night. RESULTS: Mean postoperative follow-up was 32 months (18 to 56); post operative evaluation included clinical evaluation, ultrasound, urodynamic studies, and radio-logical tests. Suprapubic pain disappeared in allcases, as well as pre-op lower urinary tract symptoms, with good control of urinary frequency day and night being evident in the immediate postoperative period. All patients referred high satisfaction with the outcome.CONCLUSIONS: When conservative treatment fails, supratrigonal cystectomy with orthotopic neobladder substitution is a valid therapeutic option in IC patients who comply with classic diagnostic criteria.
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OBJECTIVES: To analyze the results oftransrectal ultrasound (TRUS) guided biopsy of the prostatein 6000 patients, and their relation to common-useclinical parameters.METHODS: We collected PSA, digital rectal examination,TRUS characteristics, and pathology report in a data base including 6000 patients who underwent sextantTRUS biopsy from 1994 to December 2002. 861 ofthem underwent more than one biopsy, accounting fora total of 7127 biopsies. Sextant biopsy with samplesfrom the most lateral portions of the prostate was thestandard procedure so that they included peripheralzone only. We analyze pathological results and theirrelation with clinical variables.RESULTS: Total percentage of cancer in biopsy sampleswas 42.6%, with 39.1% in the first biopsy. Overall,repeated biopsies resulted in a 3.5% diagnostic yieldincrease. PIN or focal glandular atypia were detectedin 2.0% and 2.1% of the cases respectively. Thepercentage of patients with Gleason score =<6 increasedfrom 41.8% in the first biopsy to 70% in the third.Similarly, single core involvement increased from 21.%to 65%. Digital rectal examination and presence ofhypoechogenic nodules specificity were 82.6 and78.2% respectively. The incidence of prostate cancerwith PSA between 4 and 10 ng/ml was 29.6%,16.7% in those with PSA lower than 4 ng/ml.CONCLUSIONS: TRUS biopsy of the lateral prostaticareas offers a good diagnostic yield in comparison withmost series of extensive biopsies. The sensitivity of TRUShas decreased but it maintains a high specificity whichshould not be forgotten when planning the TRUSstrategy.
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OBJECTIVES: We review the results of6000 patients with the clinical suspect of prostate cancerwho underwent one or more prostate biopsies, analyzingthe role of PSA derived parameters in the probability ofhaving prostate cancer in the TRUS biopsy.METHODS: We selected 6000 patients who underwent TRUS biopsy between 1994 and 2002. 861 ofthem underwent more than one is biopsy, adding up toa total of 7127 biopsies. For the study of PSA derivedindexes we established ranges based on the 10thpercentile for the first biopsy for all patients and also forthose with PSA between 4 and 10 ng/ml. Severalpredictive models were determined by logistic regressionof the variables related with presence/no presence ofcancer.RESULTS: For first biopsies the ranges of PSAD establishedshowed a diagnostic effectiveness below 8% with PSAdensities lower than 0.11 ng/ml/cc. The free/totalPSA ratio is less discriminant in the ranges obtainedwith a 13.7% incidence of prostate cancer for valuesabove 0.24. In the case of second biopsies the groupof patients with PSAD below 0.12 had only a 5.3%incidence, and only one patient with F/T PSA ratio higherthan 0.24 had a prostate cancer (2.9%). All studiedparameters but F/T PSA ratio showed statisticalsignificance in the multivariant analysis.CONCLUSIONS: Although the establishment of a cutpoint for PSAD diminishes sensitivity, prostate biopsyhabits should be modified assuming the loss of tumors inpatients with low PSAD and increasing the number ofbiopsies in patients with total PSA values below 4ng/ml with higher densities.
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OBJECTIVES: To determine the percentageof renal cell carcinomas incidentally diagnosed (IRCC)and to compare their clinical and pathologicalcharacteristics with symptomatic or non-incidentallydiagnosed tumors (SRCC)METHODS: We retrospectively study 189 patients whowere diagnosed of renal carcinoma between 1990and 1999. 166 underwent surgery (149 radicalnephrectomy; 17 nephron-sparing surgery). Wedetermine the percentage of IRCC detected byradiological tests and compare them with the SRCCdiagnosed after presenting with some of the classicsymptoms or metastasis, with special focus on tumorsize, pathology stage, tumor recurrence, progressionand evolution. RESULTS: 87 SRCC (46%); 102 SRCC (54%). Thereare not differences in terms of age, gender, side, andpostoperative hospital stay. Tumor size was higher inthe SRCC (mean 8. 5 cm) than in the IRCC (6.3 cm).SRCC tumor stage was: pT1 27.3%, pT2 27.3%, pT3a23.8%, pT3b 16.6%, pT3c 2.3%, and pT4 2.3% ;IRCC stage was: pT1 51.3%, pT2 25.6%, pT3a10.9%, pT3b 10.9%, pT3c 1.2%, and no pT4. Thepercentage of patients with lymph node involvementwas higher (p = 0.02) in the SRCC (15%) than in theIRCC (4.8%). The percentage of patients with metastasisat the time of diagnosis was higher in the SRCC group(26%) than in the IRCC (9.2%). Recurrences were morefrequent in the SRCC Group (8.3%) than in the IRCC(1.2%) (p = 0.07). Tumor progression was morefrequent in the SRCC group (34%) than in the IRCC(7.3%) (p<0.01). 76% of the patients undergoingnephron sparing surgery were IRCC.CONCLUSIONS: Currently, there is a high percentageof IRCC (46% in our series from 1990-99). Renaltumors presenting as IRCC have better prognosis, sincethey have significantly smaller size, lower stage, lessadvanced disease, less recurrences, and less progressionthan SRCC.
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OBJECTIVES: To evaluate the clinical andurodynamic characteristics of a series of adult maleswith BPH and bladder diverticula, and to analyze thechanges in urodynamics in patients undergoing lowerurinary tract surgery to relieve obstruction, with orwithout associated diverticulectomy.METHODS: We studied 91 patients in two groups:Group 1- BPH: 67 cases (73.6%) and Group 2-BPH +diverticulum: 24 cases (25%). Mean age was 65.04years. All patients underwent urological physicalexamination and complete urodynamic study includingcystogram. In addition, we studied 19 patients withBPH and bladder diverticula (mean age 64.58 years)who underwent either endoscopic surgery (11 cases;57.9%) or endoscopic surgery plus diverticulectomy (8cases, 42.1%). Complete clinical study and urodynamics(including cystogram) were performed preoperative andthree months after surgery. Statistical significance wasestablished at 0.05.RESULTS: Comparative study between group 1(BPH)and group 2 (BPH with diverticulum): there were significantdifferences in clinical data: acute urinary retention(6.1% vs. 25%;p<0.01), and urinary tract infection(3.1% vs. 21.7%;p=0,004). All evaluated cases hadsingle diverticula(8 cases). Urodynamic studies showed:1) Post-void residual after free flowmetry: 45.9 ml vs.221.4 ml, p = 0.008. 2) Bladder capacity oncystometrogram: 211.2 ml vs. 350.8 ml, p = 0.024.3) Voiding pressure/flow study: a) Voiding withabdominal press 23.9% vs. 50%, p = 0.02. b) URA36.5 cm H2O vs. 48.5 cm H2O, p= 0.04, c) postvoid residual 70.7ml vs. 210.3 ml, p= 0.004. d)Bladder contractility measurements (Wmax- isometriccontractility- and W 80, W20— isotonic contractility)did not show significant differences between groups.Bladder contractility duration was significantly decreasedin group 2. In the analysis of patients undergoingsurgery to relieve obstruction (Group A- Surgery withoutdiverticulectomy; Group B Surgery with diverticulectomy)there were not differences between groups in clinicaldata. Urethral resistance parameters (URA) decreased inboth groups. Group A: from 43 cm H2O to 26.3 cmH2O. Group B: from 60.6 cm H2O to 48 cm H2O.This decrease was similar after either TURP ormyocapsulotomy. Post void residual diminished in bothgroups. There were no statistical differences betweengroups in Wmax, W 80-20, or volume, number andsite of the diverticula. On the contrary, bladdercontractility duration diminished after diverticulectomy.CONCLUSIONS: Bladder diverticula appear in thecases with highest ureteral resistance values (lowerurinary tract obstruction). Standard bladder contractilityparameters were not diminished. Duration of detrusorcontraction was the only contractility parameter significantlyaffected in cases of bladder diverticula and presenteda significant association with the use of abdominal presswhile voiding. Diverticulectomy showed an improvementof bladder contractility with longer detrusor contractionduration, which supports its use in cases of BPHassociated diverticula. Both TURP and transurethralincision of the prostate diminished urethral resistance ina similar way, so that they may be considered alternativeoptions. Our data should be confirmed with a biggersample size.
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OBJECTIVES: Botulinum toxin A (BT A)has gained popularity among urologists in the treatmentof detrusor muscle dysfunctions. The aim of this articleis to review our experience with this therapy.METHODS: From 2001 we used BT A in 28 patients.It was injected in the bladder wall under cystoscopicalvision. We analyze the indication of treatment, clinicaldata and urodynamics before and after treatment.RESULTS: We treated 28 patients. 71 percent hadneurogenic hyperreflexic bladder, 18% idiopathicunstable bladder and 11% other diseases. No directcomplications were observed. Neurogenic hyperreflexicbladder (n = 20): Mean preoperative bladder capacitywas 220 cc, improving to 430 cc after treatment. Noninhibited contractions disappeared. All patientsexcept one with multiple sclerosis, who had spontaneousvoiding, required self catheterization after injection.Average time interval between injections was 8.6months. Idiopathic unstable bladder (n = 5): a lowerdose was used, with an average of 100 U. Noninhibited contractions disappeared and all patientswere able to maintain spontaneous voiding with postvoid residuals under 50 ml. No patients required selfcatheterization. Bladder capacity improved from 128ml to 370 ml. Average number of voidings per daydiminished from 16 to 7 times. Other diseases (n = 3):results were poor in these patients. There were no changesin either bladder function studies or average voidingfrequency (15 times per day). These patients requiredsurgery for bladder augmentation in 2 cases and continentdiversion in 1 case.CONCLUSIONS: BT A has a role in the treatment ofneurogenic hyperreflexic bladder diminishing incontinenceand improving bladder capacity. In cases of idiopathicunstable bladder without anatomical changes its resultsare promising, but a limited number of patients does notallow a definitive conclusion. In other bladder diseaseswith anatomical changes results are poor and its useshould not be routinely recommended.
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OBJECTIVES: To report the experience inlumbar extraperitoneal laparoscopy surgery obtainedwhile perfectioning the technique over a six-yearperiod.METHODS: We perform a prospective study with 168cases of extra peritoneal laparoscopic surgery for thetreatment of various kidney-ureter and adrenal diseasesbetween 1999 and 2004. Operations were classifiedby organ and complexity (ablative or reconstructive).We describe the number of cases, surgical time, mayorand minor complications, number of open conversions,hospital stay, time to return to daily-life activities, advantagesand disadvantages, as well as comparative analysiswith data from bibliography.RESULTS: Extraperitoneal access was employed in 168laparoscopic operations: 44 renal biopsies, 8 renalcyst marsupializations, 49 nephrectomies (22 benigndiseases/27 neoplasias).15 nephroureterectomies.22adrenalectomies.15 pyelolithotomies/ureterolithotomies,1 neprhropexy, 2 partial nephrectomies.11 pyeloplastiesand 1 correction of retrocaval ureter. Operative timedecreased significant only after the initial adaptation,with an average of 118 minutes in 138 ablativeoperations and 163 minutes in 30 reconstructiveprocedures. There was only one conversion in thesecond case of the series. The incidence of mayor andminor complications was 5.07% and 4.34% respectivelyfor ablative surgery and 3.33% and 6.66% forreconstructive surgery. Average hospital stay variedfrom 1-4 days. Return to daily life activities took anaverage of 7 to 30 days in relation with procedurecomplexity.CONCLUSIONS: Lumbar extra peritoneal laparoscopicaccess is an excellent option of minimally invasiveapproach to ablative surgery, offering the advantagesof avoidance of the peritoneal cavity and low complicationindex. Reconstructive surgery is feasible but technicallymore challenging, depending of the ability andadaptation of the surgeon to a smaller surgicalworkspace.
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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 bladde was found, the biopsy of which showed edema in alllayers with blood vessel walls enlarged by amiloyddeposits. 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
Case Report
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OBJECTIVES: To report one case of giantinguinal scrotal bladder hernia associated with incipientbilateral obstructive uropathy.METHODS: We report the case of a 54-year-old malepatient presenting with two-time interrupted voiding, withthe need of scrotal compression to complete voiding.Physical examination showed a great left inguinal scrotalhernia with significant post void residual before compression.Serum creatinine was 1.7 mg/dl. Voiding cystourethrogramand intravenous urography confirmed the diagnosisof bladder hernia with mild hydronephrosis. Inguinalhernioplasty with bladder hernia reduction was indicated.RESULTS: Morphologically and functionally satisfactory.Clinical and analytical normalization.CONCLUSIONS: We emphasize the rarity of bilateralsupravesical obstructive uropathy secondary to bladderhernia. We concur with other authors in the validity of conservativereconstructive surgery in cases such as the onereported.
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OBJECTIVES: Due to the fact that melanomaof the penis is rare, we perform a bibliographic reviewabout the subject and analyze the diagnostic criteria,clinical stages and therapeutic options.METHODS: We report one case that was diagnosed andtreated in our department.RESULTS: 85-year-old male who presented with hematuriaand a red brownish irregular elevated lesion in the glanspenis. Partial penectomy was performed.CONCLUSIONS: Melanoma of the penis is a rare tumoralentity. It accounts for about 1% of all penile malignantpathologies. It has bad prognosis due to fast metastasicdissemination (regional lymph nodes and other organs)and delayed diagnosis. First choice treatment is partialpenectomy with or without bilateral inguinal lymphadenectomy(depending upon degree of tumor invasiveness). In caseswith metastasis treatment is palliative with chemotherapyand immunotherapy.
Case Report
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OBJECTIVES: To report one case of unilateralacute orchiepididymitis due to Brucella and to review itsdiagnosis and treatment in the related literature.METHOD: We report the case of a 37-year-old-male withundulant fever, scrotal pain and swelling and osteoarticularinvolvement. Diagnosis was obtained by anamnesis,blood cultures and specific serologic tests for Brucella.RESULTS: Antibiotic therapy with orally administeredDoxycycline (6 weeks) and im-administered Streptomycin(3 weeks). Complete clinical resolution was achieved.CONCLUSIONS: We must perform an exhaustiveanamnesis looking for a history of contact with animals oringestion of contaminated dairy products in endemic areasof Brucella when facing the case of orchiepididymitisresistant to usual antibiotic therapy. The diagnosis is basedon Brucella spp. isolation in blood cultures and on positiveserologic tests (Rose Bengal test, standard seroagglutinationtest, anti-Brucella Coombs test, Brucellacapt test).Doxycycline with Streptomycin or Rifampin for 6 weeksseems to be the most adequate combinations of antibiotics.Surgical treatment only in exceptional cases.
Case Report
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OBJECTIVES: Primary adenocarcinomaof the female urethra is a rare malignancy. We report twocases and a review of the latest articles focused onclassification and treatment of this kind of neoplasm.METHODS: We present two females diagnosed of urethraladenocarcinoma, describing clinic and pathologicalfeatures, diagnosis and treatment.CONCLUSIONS: Female urethral adenocarcinoma is anuncommon neoplasm with a heterogeneous histogenesis.The distal urethral carcinoma is more amenable totreatment, and the prognosis is better than that of proximalor entire urethral carcinoma, which is often associated withextensive local invasion and metastasis.
Case Report
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OBJECTIVES: To report our experience withpancreatic fistula after left nephrectomy to point out thisunfrequent complication.METHODS: We perform a chart review of 3 cases ofpancreatic fistula after left nephrectomy experienced in ourinstitution between 1983-2004.RESULTS: All patients were males, with an average age of51 years. Indications for nephrectomy were renal cellcarcinoma, renal abscess and pyonephrosis. Classic Israelincision was the surgical approach in all three cases, withaccidental opening of the peritoneum. Wound inflammatorysigns appeared on third postoperative day, drainage ofpancreatic juice on postoperative day 4. Treatment consistedon NPO 7 days, and intravenous hydration, atropin andwide spectrum antibiotics. Mean duration of pancreaticjuice drainage was 8 days.CONCLUSIONS: Pancreatic tail injury is a possiblecomplication of left nephrectomy due to the closeanatomical vicinity of both organs, that may be altered bytumoral or inflammatory disease of the kidney. If notrecognized, it may lead to a pancreatic fistula, thediagnosis and treatment of which should be known by theurologist.
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OBJECTIVES: To report one case of retroperitoneal cystic lymphangioma in an adult patient. METHODS: We describe the case of a 70-year-old female patient who complained of periumbilical pain and progressive increases of abdominal perimeter over a few months. Physical examination showed a great abdominal mass; CT scan confirmed its cystic nature. The indication of surgery was established. RESULTS: complete lesion excision. Pathology report showed the definitive diagnosis of cystic lymphangioma. No evidence of disease after one year. CONCLUSIONS: We emphasize that it is an unfrequent type of retroperitoneal neoplasias in the adult age. We concur with other authors in the importance of complete excision.
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OBJECTIVE: To report a rare case of aSpontaneous perirenal haematoma due to Polyarteritisnodosa treated with a selective embolización of thebleeding aneurysm. Polyarteritis nodosa (PAN) is oneof a spectrum of diseases thet belongs to the pathologiccategory of necrotizing vasculitis. Spontaneous perirenalhaematoma (SPH) is an unusual complication of PAN.METHODS: We are introducing a patient with SPH dueto PAN.RESULTS: The patient was treated with embolization ofa left renal bleeding aneurysm of the upper interlobarartery. Pan is the most frequent vascular diseaseassociated with spontaneous renal hematoma.Therefore the diagnosis may be difficult to determine.CONCLUSIONS: A selective embolization of the bleedinganeurysm is a therapeutical maneuver to be considered.
