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OBJECTIVES: To analyze a series of bigmasses excised in urologic surgery detailing the reasonsafter which the indications for surgery were set up,evaluating technical difficulties appeared during theprocedures and balancing them with the aimed benefits.METHODS/RESULTS: 10.581 Operative reports from1980 were retrospectively reviewed and 8 cases wereselected as fit with the concept of giant mass, being of moreor less weight depending on the organ they arose from.They vary in weight from a 350 gr. prostate with benignprostatic hyperplasia to a 5.150 gr. renal carcinoma. Allmasses diagnosed but not excised are excluded from theanalysis.CONCLUSIONS: Various difficulties appearing duringexcision were recorded depending on size, location, andetiology of each mass which resulted in operative time,transfusions, complications and outcomes. Only specificclinical cases seem to justify an, almost always, veryaggressive approach.
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OBJECTIVES: 1.- To evaluate the efficacyof the NMP-22 as a diagnostic test for bladder tumorrecidives; 2.- To compare the efficacy of NMP-22 vs. urinecytology.METHODS: 90 Patients with superficial bladder tumorswere included in the study, undergoing cytologic,cystoscopic and NMP-22 marker controls. NMP 22 testwas considered positive when the marker signal washigher than 10 U/ml. Cistoscopy was the reference test.RESULTS: Patients in the study had an average age of69 years, ranging from 45 to 91. 88% were males and 12%females. 61.2% of the tumors were Ta, 37.6% T1 and 1.2%Cis, being 17.8% grade I, 63.4% grade II and 18.8% gradeIII.NMP-22 showed a global sensitivity of 32.1%, and aspecificity of 5.1%. Positive predictive value (PPV) was75% and negative predictive value (NPV) 75.3% for arelapse rate of 27.7%. Urine cytology showed an overallsensitivity of 28.6%, 95.2% specificity, PPV 72.7% andNPV 74.7%. When both tests were used altogethersensitivity was 46.4%, specificity 90.3%, PPV 68.43%and NPV 78.9%.CONCLUSIONS: The NMP-22 marker has shown lowsensitivity so that control by cystoscopy may not beavoided. The combination of NMP-22 and urine cytology increases sensitivity minimally. It is not possible to replacecystoscopy in the follow-up of patients with superficialbladder tumors.
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OBJECTIVES: To analyze the series ofcases of endometriosis with urologic involvement reportedin our country.METHODS/RESULTS: We found a total of 26 cases ofendometriosis including our case, 15 affected bladder and11 ureter. Independently of ureteral or bladder location,the treatment performed varied, from transurethralresection and laser to cystectomy in cases involvingbladder, from segmental ureterectomy with ureteralreimplantation to nephrectomy in ureteral cases.CONCLUSIONS: Surgery is the definitive solution forurinary tract endometriomas. The definitive treatment ofendometriosis must be done by gynecologists, by means ofhormonal and surgical treatment depending on age, severityand location of the lesions, patient’s wishes for futurepregnancies, and tolerance to hormone therapy.
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OBJECTIVES: Prostatic brachytherapy with permanent 125I or 123Pd seeds implantation is a therapeutic option for organ-confined prostate cancer. We analyze the technique based on previous planning, our current intraoperative planning procedure and the reasons that moved us to introduce this change.METHODS: Changes in prostate volume and spatial localization observed between previous planning and intraoperative images, and possible difficulties for seed implantation due to pubic arch interference are some of the reasons that induce us to change technique.RESULTS: Before the operation, we calculate the prostatic volume by transrectal ultrasound; with this information we determine the total implant activity following Wu´s nomogram, and per-seed activity; therefore, it is an individual process for each patient. We perform a peripheral implant, placing 75-80% of the seeds within the peripheral prostatic zone, generally through 12-15 needles, the rest of the seeds are placed in the central prostatic zone using a maximum of 3-4 needles in high volume prostates. The day of intervention, after positioning and catheter insertion, volumetry is re-checked. Ultrasound images (from base to apex every 5 mm) are transferred to the planner were a suitable seed distribution is determined. Implantation is then performed placing all needles unloaded, and then intraoperative post-planning to allow us to check implant precision is performed after cistoscopically check that there is no urethral or bladder penetration by any needle. We finish with the insertion of seeds into the prostate. Total time for the procedure is around 90 minutes.CONCLUSIONS: Intraoperative planning is an additional step for the treatment of prostate cancer with permanent seeds brachytherapy, which avoids the disadvantages of previous planning and improves tumor inclusion in the ideal irradiation dose area, which will translate into better local disease control.
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OBJECTIVES: Ultrasound guided prostatebiopsy is the most effective test for prostate cancer diagnosis, but its sensitivity is not higher than 80% so thatbiopsy repetition must be considered in patients withpersistent diagnostic doubts after a previous negativeone. However, the majority will be negative as it happenedin the first biopsy and the percentage of normal biopsiesincreases successively.Various indexes based on PSA are proposed to determine which patients have a higher risk of cancer detection bybiopsy.We evaluate the efficacy of PSA density (PSAD), free/total PSA ratio (F/T PSA) and PSA velocity (PSAV) toselect patients with high PSA and previous negativebiopsy.METHODS: 546 patients who underwent more thanone prostate biopsy were included in the study. 121patients underwent 3 biopsies, 25 underwent 4 biopsiesand 7 five biopsies, for a total of 1245 biopsies. Patientsalready diagnosed of prostate cancer who had receivedtreatment, and postoperative urethrovesical anastomosisbiopsies were excluded. Between 4 and 6 samples wereobtained; transitional zone was included if previous biopsywas negative; sextant biopsy was repeated in high gradePIN, and 4 or 5 cores were taken from the affected side incases with non conclusive glandular atypia. Therelationship between PSAD, PSAV and F/T PSA and thediagnosis of cancer was evaluated, as well as its sensitivity,specificity, positive and negative predictive values.RESULTS: 21.2% patients presented cancer on 2ndbiopsy and 26 % overall. Mean age was 68.3 years (51-84). Patients with cancer and negative biopsy showedsignificant differences in F/T PSA and PSAD, but not inPSAV. Sensitivities for PSAD higher than 0.15 ng/ml/ml,F/T PSA lower than 0.18 and PSAV higher than 0.75 ng/ml/year were 0.89, 0.9 and 0.49 respectively andspecificities were 0.28, 0.2 and 0.4 respectively. ROCcurve areas were calculated for these indexes being 0.63for F/T PSA, and 0.47 for PSAV.CONCLUSIONS: Although their specificity is low, freeto total PSA ratio and PSA density showed the highestsensitivity; PSAV is almost non valid to discriminate theresult in the biopsy. Although we could slightly diminishthe number of repeat biopsies loosing a few tumors, onlythe urologist can determine when biopsies should berepeated in patients with elevated PSA, taking intoconsideration all concurrent factors (Baseline status, age,risk-benefit ratio of new biopsies,…).
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OBJECTIVES: To review the role ofcomputerized tomography on the diagnosis of intradiverticulumbladder cancer. We present images of variouscases and perform a bibliographic review.METHODS: 5 cases of intra-diverticulum bladdercancer were identified after a retrospective review. Allcases had pathological confirmation. Radiological findingsare reviewed for this technique and compared with thoseobtained by other diagnostic tests.RESULTS: CT scan allowed the diagnosis of the diseaseand its extension. Lateral wall was the most frequentdiverticulum location and intra-diverticulum mass wasthe most frequent clinical presentation. Two patientsshowed tumor calcification, one in the peripheral area,the other allover the tumor area. Vascular behavior ofthese tumors is similar to the rest of non intra-diverticulumbladder neoplasms. Two cases showed main lumeninvolvement as well. All tumors were transitional cellcarcinomas.CONCLUSIONS: CT scan is an efficient diagnosticmethod for the intra-diverticulum carcinoma as well as forextension determination, and it is essential for surgicalplanning.
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OBJECTIVES: To calculate the bladdersoftening factor, elastic constant and contractile potency.METHODS: For the analysis we considered bladderbehavior like that of a spring. See articles 1 and 2published in this issue. Using flowmetry, Dopplerultrasound and abdominal pressure (Transrectal pressureregister catheter) an analytical solution that permitscalculation of factors defining bladder behavior waslooked for.Doppler ultrasound allows us to know urine velocitythrough the prostatic urethra and, therefore, to calculatebladder contractile potency.RESULTS: Equations are solved reaching an analyticalsolution that allows calculating those factors that define bladder behavior: Bladder contractile potency, detrusorelastic constant, considering it behaves like a spring, andcalculation of muscle resistance to movement. All thanksto Doppler ultrasound that allows to know urine speed.CONCLUSIONS: The bladder voiding phase is definedwith the aforementioned factors; storage phase behaviorcan be indirectly inferred. Only uroflowmetry curves,Doppler ultrasound and abdominal pressure value areused. We comply with the so called non invasiveurodynamics although for us it is just another phase in thebiomechanical study of the detrusor muscle.Main conclusion is the addition of Doppler ultrasoundto the urodynamist armamentarium as an essentialinstrument for the comprehension of bladder dynamicsand calculation of bladder behavior defining factors. It isnot a change in the focus but in the methods, gainingknowledge and diminishing invasion.
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OBJECTIVE: In 1998, we designed a robot for transurethral resection that consisted of a master arm and a slave arm that reproduced the movements of the master. We describe the innovative master arm developed in two university departments that supersedes the mere "joystick" concept to become a true, operative surgical instrument. METHODS: The new master arm was developed from a conventional resectoscope working element integrated into a robotic manipulative device and fitted with angular displacement sensors. Each sensor, part of a computer- controlled feed back system commands the position and movements of the slave arm which, in turn, move the resectoscope. The surgeon freely chooses and manages precisely within a three-dimensional surgical field four basic resectoscope maneuvers; horizontal and vertical displacement, penetration-withdrawal, and rotation; he also controls the movements and operation of the resectoscope cutting loop. Additional computer-programs provide the surgeon with an error-free, fail-safe surgical instrument that denies any movements outside the planned surgical field. RESULTS: The fact that the new easily used instrument is similar in shape and works like conventional resectoscopes greatly helps familiarization and training. Advanced technology reduces the number of errors usually associated with fatigue or inexperience of the surgeon. CONCLUSIONS: The new surgical instrument handles just like conventional instruments so surgeons do not need to change their usual operating procedures. In addition, an early-warning program detects instantly and denies inappropriate maneuvers. This facility confers peace of mind to the surgeon and ensures patient satisfaction.
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OBJECTIVES: To evaluate the efficacy ofJJ catheter as urinary diversion in the treatment of lumbarureteral lithiasis by ESWL.METHODS: Results obtained in our ESWL unit betweenjanuary1990 and October 2000 are compared. 680 casesof lithiasis are divided into 5 groups for analysis:Group A: Lumbar ureter non obstructive lithiasis. 200cases.Group B: Lumbar ureter obstructive lithiasis withouturinary diversion. 307 cases.Group C: Lumbar ureter obstructive lithiasis with JJcatheter. 90 cases. Group D: Lumbar ureter lithiasis with percutaneousnephrostomy. 32 cases.Group E: Lumbar ureter lithiasis pushed up to renalcavities by JJ catheter. 51 cases.RESULTS: Groups are compared for stone size, numberof ESWL sessions and average number of shock waves.Repeated ESWL, complications and success rates are alsoanalyzed. Statistical analysis of these results and itscomparison by 2 proportion comparison tests show thatgroups B and C are homogeneous in size. We analyze thesegroups for complete success rate, partial success, andfragmentation index; it is derived from this analysis thatGroup C maintains the same level of fragmentation but notfragment expulsion, being this due to the only differencebetween groups B and C, which is the JJ catheter.CONCLUSIONS: In our series JJ catheter makesfragment expulsion difficult after treatment of the lumbarureter lithiasis although it minimises the incidence ofrenal colic, the most frequent post-ESWL complication
Case Report
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OBJECTIVE: To describe radiological, histological findings and cytometric features of perirenal masses: an unusual involvement pattern of the kidney by Waldenström disease. This pattern, not associated with nodal regional disease should be considered in the differential diagnosis of perirenal pathology (extramedullary hematopoiesis, liposarcoma, haematoma...). METHODS/RESULTS: A 68-year-old man, with Waldenström macroglobulinemia presented in ultrasound exploration bilateral perirenal hypoecogenic mass. Histopathological examination and cytometric determination of fine-needle aspiration biopsy showed a monoclonal lymphoplasmocitoid proliferation of B-cells arranged in a diffuse pattern. CONCLUSION: Although perirenal involvement of the kidney by non Hodgkin lymphoplasmocitoid lymphoma is a rare phenomenon, this disease should be considered in differential diagnosis of perirenal pathology. Histological and cytometric examination are essential for diagnostic evaluation.
Case Report
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OBJECTIVES: We report one case of adrenalepithelioid angiosarcoma.METHODS: We review the clinical and histopathological featuresof this rare adrenal sarcoma and perform a bibliographic review.RESULTS: A 60 year old male without past medical historypresented with a six week flank pain. CT scan and MRI showed a bigadrenal tumor without renal involvement. Definitive diagnosis wasobtained by histopathological study and immunohistochemicaltechniques.CONCLUSIONES: Although adrenal sarcomas are rare,angiosarcoma must be considered in the differential diagnosis ofevery adrenal tumor. Surgery is the treatment of choice with orwithout adjuvant chemotherapy/radiotherapy, depending onpathological stage and prognostic factors derived from thehistopathological study
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OBJECTIVE: To report a case of urinary ascitissecondary to an urinoma produced by a pielic and proximal ureterfistula after kidney transplantation in a 21 year old male patient.METHODS: Diagnosis was established by biochemical analysisof the perirenal fluid collection and ascitic fluid, and conservativemanagement of the urinary tract by percutaneous nephrostomy wasundertaken.RESULTS: Surgical repair of the fistulae solved the case.CONCLUSIONS: Urinary ascites is an unusual complicationafter kidney transplantation. Urinary tract fistula is the etiology inmost of the cases although it can be idiopathic. In the case of urinarytract fistulae, conservative management can solve the case andsurgical repair is the option when conservative treatment fails.
Case Report
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OBJECTIVE: An uncommon case of medullarysponge kidney with congenital hemihypertrophy complicated bynephrocalcinosis and nephrolithiasis is reported here.METHODS/RESULTS: A 29 year old female patient with multipleepisodes of renal colic is presented. Clinical features, radiologicalfindings and differential diagnosis in a patient with Cacchi-Riccidisease are discussed. At least twenty-nine cases associated withcongenital hemihypertrophy have been reported previously.CONCLUSIONS: A significant number of patients with medullarysponge kidney are asymptomatic. In many cases the diagnosis ismade when a patient is evaluated by intravenous urography for someunrelated problem.However, medullary sponge kidney has been reported inassociation with rare congenital anomalies (Beckwith-Wiedemannsyndrome and congenital hemihypertrophy) and these patients appearto be at risk of malignant neoplasms of the adrenal gland, kidney andliver, therefore they must be followed closely
Case Report
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OBJECTIVES: To report this case of bladderleiomyoma, benign tumor of the bladder, due to its low frequency(0.43%) and to perform a bibliographic review.METHODS AND RESULTS: Case of a 46 year old female whorefers a history of voiding symptoms, macroscopic haematuria withclots, asthenia, anorexia and right flank pain for 15 days prior toconsultation. After blood tests, X ray tests, ultrasound and CT scanshe underwent hysterectomy, anexectomy, radical cystectomy andureteral reimplantation to a Mainz II sigmoid pouch. Currently, 44months after surgery her outcome has been satisfactory.CONCLUSION: Bladder leiomyoma, a disease without specificsymptoms, is occasionally found in pathological evaluation; biopsyis the confirmative diagnostic test. They are rarely found outside theuterus and gastrointestinal tract
Case Report
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OBJECTIVES: To report a case of renal arteryembolism. To review the clinical, diagnostic and therapeutic featuresof this disease interesting for the urologist.METHODS/RESULTS: Case of a 47 year old male with historyof cardiovascular disease who presents in the emergency room withleft flank pain. Radiological studies (Intravenous pyelogram (IVP)and ultrasound) ruled out urinary tract obstruction and oriented torenal vascular disease. Arteriography was performed showing leftrenal artery embolism. Fibrinolytic therapy was successful.CONCLUSIONS: Renal artery embolism is an unusual nontraumatic vascular urologic emergency. Generally, it appears inpatients with emboligenous heart diseases, mainly auricularfibrilation associated with mitral stenosis. More than half the casesare asymptomatic; if they have symptoms, the most commonpresentation is sudden onset of intense flank pain, resistive toanalgesia. Laboratory tests show hematuria, pyuria, proteinuria,leucocytosis, increased LDH, GOT and alkaline phosphatase, andvariable renal function impairment. An ultrasound showing nosigns of obstructive uropathy and absent function in the IVP lead todiagnosis. In the case of early diagnosis, intra-arterial fibinolysis isthe treatment of choice, leaving surgery for cases where renalfunction is in danger. Main complications are vasculorenalhypertension and renal failure.
Case Report
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OBJECTIVES: To report one case of malignant melanoma metastasis into the urinary tract, diagnosed after excision of the primary lesion.METHODS: Case of a 75 year old male with history of malignant melanoma in the scapular region excised 7 years before who presents with lower urinary tract symptoms (LUTS), hematuria and a hypogastric mass, 12 cm in diameter, located superficially and anterior to the bladder. He underwent partial cystectomy for excision of the mass, prostate adenomectomy and lithiasis extraction.RESULTS: Pathological study showed neoplasic cell proliferation with tendency to form sparse round nests or sheaths; cells had wide, polygonal cytoplasms and occasionally melanocitic pigment. Protein S-100 detection by Immunohistochemical tests was positive, being the final diagnosis malignant melanoma metastasis.CONCLUSIONS: Bladder metastatic disease is unusual and rarely clinically evident. Nevertheless, it is frequent for bladder metastases to be caused by melanoma. Bladder metastatic lesions are rarely symptomatic, although approximately 15% of the cases are symptomatic, being hematuria the most common presentation. Although radical cystectomy seems to be the treatment of choice in potentially curable patients with solitary metastasis, to date no patient has survived more than three years, demonstrating the aggressive natural history and ominous prognosis of this disease.
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OBJECTIVES: Analysis of 95 consecutiveadult and adolescent males with urinary tract infections todetermine the pattern, bacteriology and the predisposingcauses.METHODS: The period was 12 months, and the numberof patients was 95 consecutive cases. They were adult andadolescent males with urinary tract infection. Their ageranged from 13 - 100 years, (median 55,mean 53.3 years)RESULTS: Hospital and community acquired urinarytract infections occurred in 40% and 60% of patientsrespectively. E. coli was isolated from 66.7% of communityacquired infections, which was well below the reportedliterature of 80 - 90%.CONCLUSIONS: Enterococci and Enterobacter spp.Appear to be emerging as important hospital and communityacquired urinary tract pathogens in males. Bladder outflowobstruction accounted for over 50% of all genito urinary causes of urinary tract infections, while genitourinarymalignancy occurred in nearly 20% of patients. Theimplications of these findings are discussed.
