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OBJECTIVE: The use of prostate-specificantigen as a tumor marker has led to an importantadvancement in the diagnosis of prostate cancer. Primarycare physicians have started to request this test over thelast 5 or 6 years. However, an inadequate use of this tumormarker has been observed. This study analyzes the primarycare physicians' knowledge about PSA.METHODS: A cross-sectional and observational studywas conducted. A questionnaire with 12 closed questionson PSA was sent out to 350 primary care physicians in theCanary Islands (Spain) The study was confidential and thefollowing variables were analyzed: absolute frequencies,percentages and comparison of percentages (95% CI).RESULTS: We received 186 questionnaires (53.1%).To the question on whether the physician had sufficientknowledge about the test, 36% (67) answered ‘yes' and64% ‘no'. The items that showed a higher percentage ofcorrect answers were: "with the use of PSA, the utility ofDRE has dropped (91.9%), "PSA can increase in prostatecancer (88.7%)", "a PSA level < 4 ng/ml indicates noprostate cancer (88.2%)" and "PSA > 4 ng/ml indicatesprostate cancer" (86.6%). The percentages of correctanswers for the remaining questions were less than 70%.CONCLUSIONS: The study shows that primary carephysicians' knowledge about PSA is insufficient and acontinuing education program is necessary.
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OBJECTIVE: To describe the unusualclinical forms and rare associations of xanthogranulomatous pyelonephritis seen in a variable proportionof cases.METHODS: Analysis of our series of 83 cases and 2573cases reported in the literature showed 8 different and lessfrequent clinical forms and up to 7 rare associations,which are discussed in this study.RESULTS: There are different clinical forms under"renal infection", ranging widely from asymptomatic tosevere septic forms that affect patients of all ages - fromthe newborn to the elderly -, preferentially in associationwith conditions of immunosuppression, and other moreuncommon or rare forms in which xanthogranulomatouspyelonephritis is often incidentally discovered.CONCLUSIONS: These forms are not extremely raresince more than 2500 cases have been reported in theliterature. Knowledge about the different forms permitsstratification of this condition into different clinical formsof presentation and provides further insight into theassociated conditions, some of which are rare. Overall,such forms or associations have been reported to accountfor 20 to 40% of all cases, according to the studiesreported elsewhere. This overall incidence is rathersignificant and should be taken into account.
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OBJECTIVE: Clinical pathways constitutea powerful tool for reducing the variability that occurs inclinical practice. The results obtained with the use of aclinical pathway for patients undergoing transurethralresection for benign hyperplasia of the prostate (BPH) arepresented.METHODS: A prospective study was carried out on acohort of 80 consecutive patients that had undergonetransurethral resection for BPH after the application of aclinical pathway (5 days hospitalization) and comparedwith the results of a historical cohort of 80 consecutivepatients that had been treated before the application of theclinical pathway. The exclusion criteria were diabetesmellitus, anticoagulation therapy with dicoumarin andother pathologies that changed the length of thepreoperative stay established in the clinical pathway. Forthe evaluation of the degree of satisfaction, patients wereasked to fill out a questionnaire included in the pathwaydocuments.RESULTS: 73 patients met the inclusion criteria of theclinical pathway. 67 of the 80 patients that underwentsurgery before the application of the clinical pathwaywere valid for comparative analysis. No statisticallysignificant differences were found between both groupsfor age, prostate volume measured by DRE and US,previous treatment for prostatism, anesthetic risk andweight of the resected specimen. With the application ofthe pathway, the mean duration of hospital stay wasreduced from 6 (SD 1.7; range 4– 15) to 4.9 (SD 1.4; range3–13) days (p<0.0001) and the duration of urethralcatheterization from 4.5 (SD 1.4; range 3–13) to 3.8 (SD1.3; range 2–11) days (p < 0.01). Statistically significantdifferences were found before and after the application ofthe clinical pathway for degree of compliance of the preestablished antimicrobial prophylaxis guidelines duringhospitalisation and after discharge, and thromboembolicprophylaxis. The relative risk of complications afterdischarge was less after the application of the clinicalpathway (RR = 0.66), although it was not statisticallysignificant (CI: 0.41-1.05). 63 of the 73 patients includedin the clinical pathway submitted the questionnaire withoutidentifying themselves. Duration of hospitalization wasconsidered adequate by 89%, and coincided with theprogrammed and actual duration according to 82.5%.CONCLUSIONS: The application of a clinical pathwayfor patients undergoing transurethral resection for BPHhas reduced costs by reducing the length of hospital stayand adverse effects. Furthermore, reducing the variabilityof medical care has improved its quality.
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OBJECTIVE: To describe two cases ofunilateral renal agenesis complicated by the associationof a urothelial carcinoma and review the literature.METHODS: After reviewing our series of transitionalcell carcinoma, we found two cases with associated unilateralrenal agenesis. Case 1: A 46-year-old male withgrade III stage C transitional cell carcinoma of theurinary bladder that was treated sequentially bytransurethral resection of the bladder, systemicneoadjuvant polychemotherapy (gemcitabin, taxol andcisplatin) before radical cystectomy and Bricker urinarydiversion were performed. Due to the extent of the tumor,complementary adjuvant therapy was administered, butthe patient died 10 months after cystectomy due to diseaseprogression. Case 2: An asymptomatic 71-year-old malein whom renal agenesis and ureteral pelvic filling defect,which was treated by ureterectomy, were incidentallydiscovered during a routine abdominal study. At one yearfollow-up, no evidence of tumor recurrence has beenobserved.RESULTS: 23 patients with unilateral renal agenesis inassociation with different endocrine or genitourinarycancers have been reported in the literature. In unilateralrenal agenesis anomalies of some of the genes involved inrenal development occur and may lead to dysplasticgrowth of the embryologically related organs and anincreased risk of developing tumors.CONCLUSIONS: 93% of the tumors reported in patientswith unilateral renal agenesis were found to arise from thegenitourinary organs.
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OBJECTIVE: The introduction of cisplatinin testis cancer therapy significantly reduced the mortalityrate. However, data from previous studies indicate thatmortality is higher than expected. The aim of our retrospective study in a single center was to evaluate themortality rate of testicular germ cell tumors. Further tothis, a failure analysis was carried out to determine thecause of death, taking the compliance of both the patientand clinician into consideration.METHODS: The mortality rate was evaluated in patientsreferred to and/or treated for testis cancer at the Departmentof Urology of the Mannheim University Hospital between1986 and 2000. The causes of death were determined inthis group of patients and divided into four categories: 1)death from tumor progression without management failure,2) death caused by toxicity or side effects of the treatment,3) death from poor patient compliance, 4) death from poorcompliance of the clinician.RESULTS: There were 16 deaths in 139 patients treatedup to 2000 (mortality rate 11.5%). The causes weredetermined as tumor progression and toxicity in 19%. In31% of the cases, poor compliance of both patient andclinician contributed significantly to the cause of death.CONCLUSIONS: Our study supports the theory thatnegligence to follow the guidelines specified for thetreatment of testis cancer may be related to the death ofpatients with this disease. This could be an explanation forthe discrepancy between the expected and actual mortalityrate. The quality management of testicular cancer byfurther standardized failure analysis could reduce themortality rate.
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OBJECTIVE: Our purpose was to determinewhich was the most reliable method for differentiatingglomerular from non-glomerular (lower urinary tract)hematuria by microscopic examination of urinary redblood cells: dysmorphic red cell count or acanthocytecount. The latter is a special type of dysmorphic red cellspecific to glomerular hematuria.METHODS: Urine samples of 170 patients withhematuria [73 had renal and 97 non-renal (urological)pathology] were analyzed. Urinary sediment phasecontrastmicroscopy was performed to determine thepercentage of dysmorphic red cells and acanthocytes ineach patient. Data were correlated with the diagnosis.RESULTS: Glomerular hematuria defined asdysmorphic red cell count > 35% showed a sensitivity andspecificity of 69% and 100%, respectively. Glomerularhematuria defined as acanthocytes > 5% showed asensitivity and specificity of 88% and 100%, respectively.CONCLUSIONS: Phase-contrast microscopy urinarysediment acanthocyte count is more effective thandysmorphic red cell count in the diagnosis of glomerularhematuria.
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OBJECTIVE: There are several proceduresfor the management and treatment of the neurogenicbladder. These are adjusted individually according to theresults of the clinical examination and complementarytests. This study evaluates the results of treatment withbotulinum toxin and its place in current therapeuticarmamentarium.METHODS: We reviewed the outstanding literature inthe field of neurourology on the criteria, indications, sideeffects and applications of botulinum toxin.RESULTS: Most of the authors have reported botulinumtoxin to be useful in the treatment of voiding disorderssecondary to neurological and pelvic floor muscledisorders.CONCLUSIONS: Intramuscular injection of botulinumtoxin in the detrusor or external sphincter of the bladderproduces a paralyzing (relaxing), therapeutic and reversibleeffect. The latter is one of its most importantcharacteristics. It has also been found to be effective fornon-specific perineal-prostatic pain, for which fewtreatments are available.
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OBJECTIVE: To determine the more useful parameters of urethral resistance and bladder contractile power to explain the values of maximum flow and postvoid residual urine observed in free uroflowmetry and appropriately assess the voiding dynamics in childhood. METHODS: A cross-sectional study was carried out in 68 children (46 girls and 22 boys) with a mean age of 8.9 years. These children were subjected to free uroflowmetry in order to determine the maximum flow rate and the postvoid residual urine, and to a complete urodynamic study with perineal surface electromyography in order to determine the parameters of urethral resistance and bladder contractile power. A univariate linear regression model was built from these parameters for explanatory purposes. The independent variables were the parameters of the urodynamic study and the outcome variables were the value of the maximum flow in the free uroflowmetry and the proportion of postvoid residual urine in relation to the voiding volume of the free uroflowmetry. The resulting models were validated in order to determine its loss of predicting power (shrinkage). For this purpose, we used two other independent series: one comprised 50 patients (34 girls and 16 boys) extracted from the same sample as the derived model, and the other comprised 85 patients (53 girls and 32 boys) from another population.RESULTS: The multivariate model demonstrated that the maximum flow of the free uroflowmetry has a direct relationship with the square root of the voiding volume and the bladder contractile power [measured by Schafer's projected isometric pressure (PIP)] and an inverse relationship with the urethral resistance measured by means of a parameter (URA) and with the presence of electromyographic perineal activity (EMG) during voiding. Similarly, the proportion of postvoid residual urine has a direct relationship with the urethral resistance (measured by means of the parameter URA) and with the inverse function of the projected isometric pressure (I/PIP). The shrinkage of the multivariate models, when compared with other series, ranged from 26.9% and 1.3%. CONCLUSIONS: The urodynamic evaluation of the lower urinary tract in childhood can be carried out appropriately by means of the determination of the urethral resistance by the parameter URA and of the bladder contractile power by the projected isometric pressure (PIP), obtaining as a limit of normal values a URA of 16 cm H2O and a PIP of 105 cm H2O.
Case Report
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OBJECTIVE: To report an additional case ofliposarcoma of the spermatic cord.METHODS: A 69-year-old male presented with an indolent leftinguinal mass that he had noted one month earlier and had graduallyincreased in size. Two irregular mobile nodular left inguinal lesionswere detected on physical examination. Analytical tests were normal. An ultrasound showed three nodular lesions in the left spermaticcord. CT attenuation values indicated predominantly fat tissue in thelesion. The patient underwent a radical left orchidectomy andfuniculectomy.RESULTS: The histopathological analysis of the surgical specimenshowed a well-differentiated liposarcoma of the spermatic cord.CONCLUSIONS: Liposarcoma of the spermatic cord isuncommon. Some imaging techniques are useful in making thediagnosis. Like other authors, we believe that orchifuniculectomy isthe treatment of choice in these patients
Case Report
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OBJECTIVE: To describe a case of endometriosis ofthe urinary bladder in a patient with a previous history of cesareansection. Its possible relationship is discussed.METHODS: A 31-year-old female that had undergone cesareansection 8 years earlier is described. She had been referred by thegynecologist for further evaluation of a hyperechogenic area ofabout 2.5 cm in the posterior bladder wall. The patient had mildpollakiuria. Physical examination and analytical studies were nor-mal except for microhematuria. CT suggested a possible uterineorigin of the lesion. Endoscopic examination showed a lesion with abullous appearance. Exploration and TUR with electrocoagulationof the bed were performed under anesthesia. Three small recurrences0.5 cm in size were observed at 18 months' follow-up. TUR wasrepeated and the patient received complementary hormone therapyfor 6 months.RESULTS: Histopathological analyses of both TUR specimensdemonstrated bladder endometriosis. At control evaluation 12 monthsafter the second TUR, the patient is asymptomatic and the analyticaland cystoscopic evaluation showed no significant findings.CONCLUSIONS: There may be a possible relationship betweensome cases of endometriosis and previous cesarean section. Diagno-sis is confirmed by histological analysis of tissue obtained byendoscopy. TUR and complementary hormone therapy is analternative treatment option. The need for subsequent control follow-up is emphasized
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OBJECTIVE: To report a case of a simple left renal cyst in a patient who presented with spontaneous pain and acute anemia due to intracystic hemorrhage.METHODS: Diagnostic imaging techniques such as assessment of the urinary tract with contrast medium, ultrasound CT and MRI were utilized for correct preoperative diagnosis and surgical management.RESULTS: The patient was able to return to normal active work. CONCLUSIONS: Rarely as in the case described renal cysts can collect blood at the expense of the renal parenchyma. Ultrasound and CT are very useful diagnostic imaging techniques in renal pathologies.
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OBJECTIVE: To describe a case of pyonephrosis ina child with special reference to the importance of scintigraphy in itsevaluation.METHODS: We studied the correlation of the findings ofconventional radiology (abdominal x-ray), ultrasound, abdominalCT, scintigraphy and anatomopathology (left kidney) in a 5-year-oldboy with a history of renal lithiasis that was seen at our pediatricemergency services. The patient's clinical course and the scinscanfindings using two tracers (Tc-99m DMSA, Ga-67 citrate) showed aseverely compromised left renal function. The foregoing finding andthe risk of major life-threatening complications prompted surgicaltreatment. Pathological analysis showed pyonephrosis of left kidney.RESULTS: X-ray, ultrasound and abdominal CT showed leftrenal lithiasis, an enlarged left kidney, poor cortico-medullarydifferentiation and parenchymal destructuring with areas suggestiveof cortical abscesses. A Ga-67 citrate scintiscan showed a notable intensity that completely affected the left renal parenchyma with noother changes. On the other hand, Tc-99m DMSA showed no uptakein the left kidney and normal uptake in the right kidney. A leftnephrectomy was performed. Histological analysis demonstratedpyonephrosis of left kidney.CONCLUSIONS: Tc-99m DMSA and Ga-67 citrate scintigraphyand the patient's poor clinical course showed the extent and severityof the underlying condition that was underestimated by the otherimaging techniques.
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OBJECTIVE: To report a case of bilateral orthotopicureterocele in a 22-year-old male who presented a sudden cessationof urinary stream due to bladder neck obstruction caused by a large,intravesical ureterocele. The differential diagnosis of voidingsyndrome and the current approach to ureteroceles are discussed.METHODS: The literature is reviewed with special reference tothe clinical and radiological findings. The nomenclaturerecommended by the Section on Urology of the American Academyof Pediatrics is utilized, which classifies ureteroceles as intravesical(located entirely within the bladder) or ectopic (if any portion of theureterocele is located permanently at the bladder neck or in theurethra).RESULTS/CONCLUSIONS: Bilateral orthotopic ureterocele isan uncommon pathology. Much less common is a simple occlusion ofthe bladder neck by a non-prolapsing intravesical ureterocele, as inthe case described herein. The prolapse is more common with ectopicureterocele but can also occur with intravesical ureterocele. Webelieve that a conservative endoscopic procedure in patients with anintravesical ureterocele reduces the need for major open surgery.However, patients with an ectopic ureterocele require open surgerymore frequently. Performing endoscopic puncture initially, facilitatessubsequent open surgery.
Case Report
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OBJECTIVE: To describe a case of calcification ofthe tunica vaginalis testis.METHODS: A 66-year-old patient with right hydrocele andsuperficial carcinoma of the bladder who underwent TUR and wastreated with mitomycin prophylactic instillations, is described. Thepatient presented a bulbar urethral stricture. A retrogradeurethrogram demonstrated calcification of the tunica vaginalistestis. An ultrasound scan confirmed the diagnosis.RESULTS: The surgical and histopathological findings confirmedthe diagnosis of hydrocele with calcification of the tunica vaginalis.CONCLUSIONS: Calcification of the tunica vaginalis testis isuncommon. It is therefore difficult to make the preoperative diagnosis, although radiological and ultrasound evaluation can be useful.The histopathological analysis confirmed the nature of the lesion inthe case described herein.
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OBJECTIVES: We report our experiencewith posterior preperitoneal prosthetic herniorrhaphy foringuinal hernia in patients undergoing concomitant pelvicsurgery for both benign and malignant urologicalpathologies.METHODS: 116 patients with either unilateral orbilateral inguinal hernia underwent posterior preperitonealprosthetic herniorrhaphy during a pelvic operation forvarious urological pathologies. The technique describedby Mahorner and Goss was used for unilateral hernia,while the modified Stoppa technique was used for bilateralhernia.RESULTS: All patients had a complication-free periandpost-operative course, except for one patient whodeveloped a spontaneously resolving small peri-prosthetichematoma. In the follow-up of all patients (mean 35.7months, range 4-72) we did not observe any herniarecurrence. CONCLUSIONS: Posterior preperitoneal prostheticinguinal herniorrhaphy during pelvic surgery for urologicalpathologies is a relatively simple and safe procedure toperform and a recurrence rate of zero, or very close tozero, is to be expected.
