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OBJECTIVE: To describe the urologicalapplications of three-dimensional ultrasonography, a newmethod that basically transforms the two-dimensionalinto three-dimensional images through complex dataprocessing for enhanced imaging.METHODS: Since the technology for three-dimensional studies was incorporated into our US equipment a fewmonths ago, we have performed three-dimensional USafter the conventional two-dimensional study in 30 renalunits, 15 bladders and 15 prostates, using the same wellestablished procedures for ultrasound assessment. Theimages obtained by both methods were compared to determine the diagnostic enhancements, if any, affordedby this new technology.RESULTS: Three-dimensional US offers morepossibilities for renal cortical volume measurement anddetermination of the extent of the tumor. It also appears tobe promising in regard to its capacity to determine thedegree of tumor infiltration in the bladder and permitseven more precise measurements of residual volume orbladder content. Transrectal ultrasound of the prostatemay benefit more since three-dimensional US permitsanalysis of focal changes from different perspectives andplanes without difficulty.CONCLUSIONS: Three-dimensional US was developedrecently. It has been utilized in gynecology and cardiology,but there is limited experience in urology. We have starteda clinical study to determine its possibilities and mainapplications in our field. Its impact on other diagnosticparameters or biopsy selection criteria are other interestingareas of research.
Case Report
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OBJECTIVE: To report a rare complicationof acute renal failure secondary to massive vesicoinguinalhernia. To our knowledge, only 4 cases have been previouslyreported in the literature.METHODS: Herein we describe a case of massivevesicoinguinal hernia in a patient that had presented atthe emergency services with symptoms of acute renalfailure. The diagnostic and therapeutic aspects of this rarecomplication are discussed.RESULTS: Patient evaluation showed a left inguinalhernia and benign hyperplasia of the prostate. Bloodanalytical findings were compatible with acute renalfailure. A left massive vesicoinguinal hernia was detectedon ultrasound evaluation and confirmed by retrogradecystography. Treatment was by surgical repair of theinguinal hernia, bladder repositioning and cervicoprostatotomyplus TUR of the excrescent bladder lesionsto resolve the obstruction.CONCLUSIONS: Massive vesicoinguinal hernia maygo undetected if the symptoms are unremarkable and maymimick those of acute renal failure.
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OBJECTIVE: To present our experience with squamous cell carcinoma of the penis.METHODS: We reviewed our series of 73 squamous cell carcinoma of the penis over the last 23 years. Patient mean age was 65.7 years. All lesions had been previously biopsied. Patient records were reviewed for a history of phimosis and related lesions. The histological, clinical and therapeutic aspects, and survival are analyzed.RESULTS: Most of the squamous cell carcinoma of the penis were superficial lesions (pT1). Treatment was by partial penile resection in 42 cases, total penile resection in 9, and emasculation in 2 cases. Conservative surgery was performed in 20 cases (tumor excision in 14 and posthectomy in 6 cases). Lymphadenectomy was performed in 11 patients. Eight patients received radiotherapy to the inguinal region. The rate of recurrence after surgery was 11% (8 cases). Five of the 8 patients with tumor recurrence had been treated by conservative surgery. The 5-year survival rate was 78%.CONCLUSIONS: Penile cancer is uncommon and accounts for less than 1% of tumors in the male in our setting. A higher incidence has been found in men with phimosis, poor hygiene and low sociocultural level. Partial penile resection is the treatment of choice for the primary lesion. The outcome is worse in patients with invasive tumor, poor cell differentiation, ulceroendophytic morphology, and above all in patients with metastatic adenopathy. Radiotherapy provided no benefits, made inguinal evaluation difficult and increased the morbidity in some cases. Patients with pT1 tumor and good cell differentiation showed no metastatic adenopathy during follow-up. Patient follow-up is fundamental to detect recurrence or metastatic adenopathy and to institute treatment immediately.
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OBJECTIVE: Based on theclinicopathological findings of two additional cases ofsarcomatoid chromophobe renal cell carcinoma and areview of the literature, we analyzed the prognosis in thisand other forms of sarcomatoid carcinoma to determinethe differences, if any, and their histopathological basis.METHODS: Of 139 cases of renal cell carcinoma thatwere surgically resected during the period 1977-1999,two were sarcomatoid chromophobe renal cell carcinoma,accounting for 15% of 13 cases of chromophobe cellcarcinoma and 18% of 11 cases of sarcomatoid cellcarcinoma in the same series.RESULTS: The first case was a 73-year-old male witha locally advanced, non-metastatic tumor. Palliativeresection was performed and the histological analysisshowed a predominantly sarcomatoid mass with smallepithelial foci with the morphological, histochemical andimmunohistochemical characteristics of chromophoberenal cell carcinoma. The patient died 11 months later.The second case was a 70-year-old female who presentedwith flank and lumbar pain and episodes of grosshematuria. Anatomopathological analysis showed achromophobe cell carcinoma with sarcomatous foci, stagepT2pN0M0. The patient is disease-free at 46 months'follow-up.Immunohistochemically, in both cases the sarcomatoidcomponent was found to be strongly positive for vimentinand focally for EMA, and negative for actin, desmin andmyoblogin; isolated cells were positive for AE1 and AE3in the second case. The epithelial component was positivefor AE3 and EMA, and negative for AE1, vimentine andCD68.CONCLUSIONS: Like our first case, most of thereported cases of sarcomatoid chromophobe renal cellcarcinoma show a sarcomatoid mass with foci ofcarcinoma, and a poor prognosis. In our view, as in allrenal cell carcinomas, prognosis depends on tumor gradeand stage, which is the highest for sarcomatoidchromophobe renal cell carcinoma. Furthermore,although the epithelial component (chromophobe,chromophilic, clear cells, etc.) may probably have littlesignificance, the influence that the proportion of epithelialand sarcomatoid component might have in these tumorscannot be completely discarded.
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OBJECTIVE: To analyze the prognosticfactors of incidentally diagnosed bladder carcinomaswith special reference to the complementary diagnostictests.METHODS: 308 cases of carcinoma of the bladderwere reviewed. These were divided into two groups: thosethat had been diagnosed on the basis of the clinicalfeatures and those that had been incidentally detected.The prognostic factors of size, grade, histological type,and pathological stage were analyzed.RESULTS: Local tumor stage was the only statisticallysignificant prognostic factor. 14.7% of the superficial and3.6% of the infiltrating carcinomas had been incidentallydiagnosed. Ultrasound was the most frequently utilizeddiagnostic method (87.2%).CONCLUSIONS: In our series, the incidentallydiagnosed carcinoma of the bladder has a higherprobability of being a superficial lesion than those that aresymptomatic and therefore the prognosis is better. Sinceultrasound was the most frequently utilized diagnosticmethod, it might be advisable to assess the bladder inpatients undergoing abdominal ultrasound evaluation
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OBJECTIVE: To analyze the cause-effect relationship of bladder dynamics and flow rate. METHODS: A theoretical study was performed using the mathematical equations obtained by other authors. RESULTS: We have developed equations for bladder dynamics, flow rate and the detrusor, which is considered to act like a spring from experimental studies on anesthesized animals. CONCLUSIONS: The relaxation constant, urinary stream velocity and area of urethral section can now be determined from the flow rate equation.
Case Report
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OBJECTIVE: Two cases of oliguric acute renalfailure in HIV+ patients treated with indinavir are described.METHODS: Patient evaluation included blood analysis,urinalysis, abdominal x-rays, renal US and IVP.RESULTS: Both cases resolved with discontinuation of drugtherapy, administration of fluids and urine acidification.CONCLUSIONS: Severe acute renal failure is an uncommoncomplication in HIV+ patients treated with indinavir. This drug hasa great tendency to precipitate in urine. The severity of the crystalluriadepends on the drug dose and urinary pH, and can causetubulointerstitial nephritis and urinary calculi with obstruction ofthe urinary tract
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OBJECTIVE: To describe a case of atypical stromalhyperplasia of the prostate.METHODS: A 62-year-old patient presented with prostaticsyndrome. Physical examination disclosed an indurated prostateand PSA determination showed increased levels. A prostate biopsywas performed.RESULTS: The histological analysis showed atypical stromalproliferation with elongated nuclei and immunohistochemicalexpression for vimentine, smooth muscle actin and CD34 withglandular hyperplasia. The diagnosis was that of atypical stromalhyperplasia of the prostate (prostatic stromal proliferation ofuncertain malignant potential).CONCLUSIONS: A careful histological study is necessary tomake the correct diagnosis of prostatic stromal proliferation ofuncertain malignant potential. CD34 expression is a characteristicfinding. As its name indicates, its evolution is uncertain
Case Report
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Case Report
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OBJETIVE: To report on a case of small cell lungcarcinoma presenting as adrenal hemorrhage.METHODS: A case of small cell lung carcinoma presenting asadrenal hemorrhage in a 60-year-old male is presented. The mostimportant features of this tumor type and the adrenal metastasis aredescribed.RESULTS: Treatment with carboplatin and VP-16 wasunsuccessful. A brain CT scan showed several space occupyingparenchymal lesions. Palliative radiotherapy was administered. Thepatient's condition has progressively become worse. He is currentlyreceiving only palliative treatment.CONCLUSIONS: The adrenal gland is a common site of metastasis.One of the tumor types that frequently metastasize to the adrenals issmall cell lung carcinoma, which is characterized by early local andsystemic dissemination, associated paraneoplastic syndromes andits sensitivity to cytostatic agents. Adrenal metastasis from lungcarcinoma should be suspected in patients with a large, heterogeneous,bilateral lesion.
Case Report
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To report a case of renal infarction ina patient on anticoagulant therapy for aortic and tricuspidvalvulopathy, with special reference to the diagnostic difficulty.METHODS: The most common causes of this condition, its formsof presentation, diagnostic methods, and therapeutic approachesare discussed.RESULTS/CONCLUSIONS: Renal infarction should be suspectedin the presence of abdominal pain of sudden onset that is refractoryto treatment with analgesics, especially in patients with a history ofembolism, recent surgery or trauma. It is frequent to find increasedlevels of SGOT, SGPT, LDH, alkaline phosphatase and micro orgross hematuria and proteinuria. Arteriography or isotopic renogramis utilized to confirm the diagnosis, although IVP or CT is useful if theforegoing are not available. Early treatment is important for achievingrecovery of the compromised renal parenchyma. In recent years,surgery has been displaced by the good results obtained withintraarterial infusion of fibrinolytics.
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OBJECTIVE: To describe uncommon forms ofdissemination of hypernephroma.METHODS: A case of hypernephroma that metastasized to thelaryngeal vallecula and bronchi is presented. Our findings werecompared with those reported in the literature. The diagnostic,radiological, clinical aspects and route of dissemination of someatypical sites of metastasis are discussed.RESULTS/CONCLUSIONS: It is important to be familiar withthese atypical sites of metastasis since these lesions may appear atthe same time or before the primary tumor is detected. A high indexof suspicion will make a major impact on treatment and prognosis.The radiological findings are undoubtedly of enormous value,although histological confirmation is necessary in order to make thecorrect diagnosis.
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OBJECTIVES: To discuss the modernimaging techniques and preoperative management ofpheochromocytoma and to report on one additional case.METHODS: A 66-year-old male with an incidentallydiscovered left adrenal mass is described. The adrenalmedulla strongly accumulated 131 I-metaiodobenzylguanidine(MIBG). The patient underwent left adrenalectomy afterpreoperative therapy with alpha and β-blockers. Therecent literature on pheochromocytoma modern imagingtechniques and preoperative management is reviewed.RESULTS: MIBG scintigraphy diagnosed a benignfunctioning adrenal pheochromocytoma, allowingpreoperative medical management. Postoperative workup was unremarkable. Diagnosis of pheochromocytoma wasconfirmed by immunohistopathology. At 18 months' followup, the patient is alive and disease-free.CONCLUSIONS: Incidentally discovered adrenalmasses have to be investigated to detect malignancy andsubtle hormonal overproduction. MIBG scintigraphy hasa high specificity (100%) in detecting pheochromocytoma,metastasis, surgical residual tumor, local relapse andother adrenal crest tumors. Positive results of octeotridescintigraphy in detecting malignant pheochromocytomahave been reported. Currently, pheochromocytomaremoval is a safe operation with mortality rates rangingfrom 0 to less than 3%. Preoperative alpha adrenergicblockade with phenoxybenzamine or prazosin is importantin decreasing the operative risk. Beta-blockers may benecessary for cardiac arrhythmia. Intraoperative invasivemonitoring of hemodynamic variables may be bothdiagnostic and therapeutic of inadequate preoperativemanagement. Lifelong follow-up for patients withpheochromocytoma is important.
