OBJECTIVE: To determine the appropriatetechnique for each case of urethral stricture, according toits length, depth, localization, etiology and age of thepatient.METHODS: 83 urethroplasties for urethral strictureperformed from 1992-1998 were reviewed. The stricturesinvolved different levels of the urethra. The techniquesutilized were analyzed (substitution urethroplasty withpedicle skin graft and free grafts using buccal mucosa andextragenital skin, excision and anastomotic repair,regeneration techniques with internal urethrotomy andplacement of intraluminal prosthesis, and two-stage repairprocedures).RESULTS: The overall functional results were good in93% of the cases (78 good, 5 poor), but the morphologicalresults demonstrated by the radiological findings were notas good in 24% of the cases, which correponded to thosethat had received preputial pedicle grafts and buccalmucosa free grafts.CONCLUSION: Using the appropriate urethroplastytechnique is essential to achieve good functional results.The substitution techniques require well-vascularizedgrafts and/or recipient sites. The foregoing must be takeninto account in the selection of the appropriate graft anddeciding on the stricture length and localization.
OBJECTIVE: To analyze the outcome,complications and functional results in patients undergoingbladder substitution with the Studer continent urinarypouch. METHODS: The clinical records of 6 male patientswho underwent radical cystectomy for invasive bladdercancer and bladder substitution with the Studer reservoirat our hospital from January 1996 to February 2000 werereviewed. Patient mean age was 54.2 years and meanfollow-up was 14 months. Follow-up evaluation includedabdominopelvic CT, chest x-ray, urinalysis, bloodbiochemistry, venous gasometry and ultrasonography withevaluation of postvoid residual urine.RESULTS: Transitional cell carcinoma was found to bethe most frequent histopathological type. Distribution bygrade and pathological stage showed they were all highgrade infiltrating tumors localized to the bladder. Fourpatients are free of disease, one died from metastaticdisease and one patient with tumor progression andmultiple lung metastases at two months’ follow-up iscurrently on chemotherapy. The mean operating time wassignificantly longer for this procedure than for the noncontinent Bricker urinary diversion (mean 7.2 hours vs 3.5hours, respectively). The immediate postoperative complications were: ileus(>7 days) in two patients, diarrhea (>3 days) in two,occlusive ileus due to fecaloma in one, metabolic acidosisin one, wound seroma in one, and wound infection in twopatients. The early and late postoperative complications were:incontinence for up to one month after removing theurethral catheter in three patients (two of these patientsare still incontinent at two months’ follow-up), woundinfection in two and impotence in 6 patients.CONCLUSION: Reservoir function in the mediumterm is good; spontaneous urethral micturition andcontinence are maintained. To achieve good results,patients should be followed carefully and should be givendetailed information about postoperative care andmanagement.
OBJECTIVE: To study the results of the second round in the subjects with negative tests in the first round of a prostate cancer screening program and to analyze the characteristics of the tumors that were not detected in the first round. METHODS: Of 5188 males evaluated in a prostate cancer screening program, 976 with negative tests in the first round (804 with PSA ≤ 4 ng/ml; 172 with PSA > 4 ng/ml and a negative biopsy) accepted to undergo subsequent tests. During the second round, 163 biopsies were indicated. The biopsy results and the characteristics of the tumors detected were analyzed. RESULTS: The biopsy yield was higher (but not significantly) in the first round (80 cancers/481 biopsies; 16.6%) than in the second round (13 cancers/115 biopsies; 11.3%). Of the 163 biopsies indicated in the second round, 115 were performed and 13 cancers were detected (10 of these patients had a high PSA in the first round). The univariate analysis showed no differences for age, PSA, PSA density, prostate volume, transrectal US findings, or Gleason score in the cases diagnosed in the first round and those detected in the second round. However, there was a higher proportion of tumors with abnormal DRE in the cancers detected in the first round than in the second round, (31.3% vs 7.7%, respectively; p = 0.02). There was a higher proportion of tumors clinically detected in the second round than in the first round (100% vs 75%, respectively; p = 0.043). The multivariate analysis only showed differences for the DRE findings (p = 0.045). CONCLUSION: A significant number of tumors are undetected in prostate cancer screening programs. Although the biopsy yield may be slightly lower in subsequent rounds, there is a strong trend of detecting more localized tumors (and therefore potentially curable). We have found no correlation between a greater prostate volume and tumors that were undetected in the first round.
-OBJECTIVE: Laparoscopy has not reachedthe same levels of development in Urology as it has inother surgical specialties. Consequently, the averageurologist is not sufficiently accustomed to usinglaparoscopic trocars, a difficulty which becomes evenmore noteworthy since treatment is occasionally preferablyby the extraperitoneal approach (preperitoneoscopy andretroperitoneoscopy). Our experience with differentvisualizing trocars is presented.METHODS: We reviewed our experience with differentvisualizing trocars. The advantages and inconveniencesof each type, utilized in different approaches, are discussed.RESULTS: Active visualizing trocars are preferredbecause they are safe and permit pre and retroperitonealblunt dissection without difficulty. However, cost is themajor disadvantage of these instruments because they arenot reusable.CONCLUSION: Lately, we are more inclined to utilizethe reusable visualizing trocars with the helicoidal cannula,which are very safe for the transperitoneal and perhapsslightly less for the extraperitoneal approach. Theseinstruments cause less injury when they go through theabdominal wall and, furthrmore, they cost less.
OBJECTIVE: To review thepathophysiology, diagnostic methods and treatments ofpriapism, with special reference to alternative treatmentoptions.METHODS: The different surgical options are presentedand discussed, with special emphasis on the oral drugsand intracavernous therapy for priapism. The advantagesand inconveniences of the different agents and surgicaltechniques are discussed. The publications in MEDLINE1980-2000, our experience and the results of our studiespreviously reported in the literarture were reviewed.RESULTS/CONCLUSIONS: Complete detumescenceand recovery of normal arterial blood flow can be achievedin a majority of the cases by systematic and standardizedmanagement. Sedatives, alpha-adrenergic agents or oralketamine hydrochlorate can be utilized. However, due tothe importance of the time factor, intracavernosal therapyshould be the priority for persistent erection, using alphaadrenergic agonists or other alternatives, such as methyleneblue, which do not have the well-recognized risks of the conventional agents. The etiology of the priapism should be clearly established by metabolic and hemodynamicstudies, since treatment will be based on the underlyingdisorder. In veno-occlusive low flow priapism, surgicalshunting should be performed if aspiration ofintracavernosal blood and other treatments are notsuccessful. Arterial embolization and surgical ligationshould be performed for high flow persistent priapism.
- OBJECTIVE: To present a case of priapism associatedwith systemic lupus erythematosus and nephrotic syndrome.METHODS: A 29-year-old male patient with a history of multiplepathologies consulted at the emergency services with painful priapismof 12 hours’ duration. The intracavernosal aspirated blood had avenous appearance. Among the risk factors analyzed, systemic lupuserythematosus and nephrotic syndrome are recognized to causehypercoagulability, a condition that can lead to low flow priapism.RESULTS: There was no response to lavage-aspiration orintracorporeal administration of an alpha-adrenergic agonist. Thehigh surgical risk of the patient advised against surgery. The priapismgradually diminished until complete remission on the sixth day. Thepatient has remained without spontaneous erection.CONCLUSION: Systemic lupus erythematosus and nephroticsyndrome can cause low flow priapism. The best treatment is byprevention with adequate antithrombotic prophylaxis
To report a case of adrenocorticalcarcinoma and primary aldosteronism as the sole endocrinemanifestation.METHODS/RESULTS: A 39-year-old male with adrenocorticalcarcinoma and primary aldosteronism is presented. Following completehormonal and radiological evaluation, right adrenalectomyand nephrectomy were performed (pT2pN0M0, stage II). Bloodpressure, serum potassium and aldosterone levels returned to normal.The patient received adjuvant therapy with carboplatin andetoposide. After 15 months’ disease-free interval, lung metastasiswas diagnosed, without evidence of local recurrence until 5 monthslater, when hypertension and primary hyperaldosteronismreappeared. There were no other endocrine disorders. Treatmentwith spironolactone, 5-FU and adriamycin was instituted with notumor response and the patient died 3 years later from complicationsof endobronchial metastasis.CONCLUSION: Adrenocortical carcinoma with isolated primaryhyperaldosteronism is uncommon and consequently there is no wideexperience in regard to its diagnosis and treatment. Althoughrandomized studies are not available, adjuvant therapy using otheragents instead of mitotane (o,p-DDD), such as the combination ofcisplatin and etoposide (VP-16), seems reasonable in the locallyadvanced stages. Mitotane may be useful when hypercortisolism ispresent, but its efficacy as an antitumor agent has been controversial.
OBJECTIVE: To report a case of leiomyoma of thebladder, a benign tumor that accounts for 0.43% of bladder tumors.The literature is briefly reviewed.METHODS/RESULTS: A 64-year-old male with prostaticsyndrome is described. The preoperative evaluation showed bladderlithiasis and signs compatible with prostatic hypertrophy, but noevidence of a bladder tumor. Endoscopic evaluation, however,revealed a tumor in the bladder neck. Transurethral resection of thetumor, prostate and endoscopic lithotripsy of the bladder were performed. The anatomopathological findings showed leiomyoma ofthe bladder. The postoperative course was unremarkable.CONCLUSION: Leiomyoma of the bladder does not presentspecific symptoms and is frequently an incidental finding. Thediagnosis is based on the results of the anatomopathological analysisof the specimen.
OBJECTIVE: To analyze the therapeutic approachin epidermoid or squamous cell carcinoma of the scrotum, a raretumor that is of interest for clinical and historical reasons.METHODS/RESULTS: A case of epidermoid carcinoma of thescrotum is described. The patient had undergone urethroplasty in1972, using preputial free graft, according to the technique of BenJohnson. Right scrotectomy and orchidectomy were performed andpartial urethrectomy with inguinal lymphadenectomy 6 weeks later.At 24 months' follow-up, the patient has no tumor recurrence.CONCLUSION: Malignant tumors of the scrotum are rare.Squamous cell carcinoma is the most frequent tumor type. Radicalsurgery with inguinal lymphadenectomy is the treatment of choice. Itmust be distinguished from verrucous carcinoma, a tumor thatrequires a different therapeutic approach and for which radicalsurgery is not indicated.
OBJECTIVE: To report a case of giant fibroepithelial polyp of the ureter and review the literature with special reference to the diagnosis and treatment of this benign condition. METHODS: A young male patient with a nonfunctioning left kidney caused by a giant fibroepithelial polyp of the ureter is presented. The diagnostic methods and treatment options are discussed. RESULTS: Following the diagnosis of obstructive uropathy with loss of left renal unit function, a left nephroureterectomy was performed which revealed a giant polypoid mass. CONCLUSION: Fibroepithelial polyp of the ureter is a benign condition that is difficult to diagnose with current endoscopic techniques. Endoscopy should be the first therapeutic option if loss of renal function is not irreversible.
OBJECTIVE: To present an additional case ofleiomyoma of the bladder, a rare tumor that is frequently discoveredincidentally, and to review the few cases reported in the Spanishliterature, with special reference to the clinical aspects,complementary tests and treatment.METHODS: A case of leiomyoma of the bladder in a patient whohad come to deliver after a full-term pregnancy is presented. Routinephysical examination on admission revealed a tumor in the anterioraspect of the vagina. Ultrasound, radiological and endoscopicstudies were performed. The Spanish literature is reviewed withspecial reference to the clinical aspects, complementary tests andtreatment.RESULTS: After the diagnosis of a bladder tumor had beenconfirmed and the effects on the adjacent structures determined, TURbiopsy was performed. The anatomopathological analysisdemonstrated leiomyoma of the bladder.CONCLUSION: The ultrasound and radiological images ofleiomyoma localized to the bladder are sufficient to suspect thenature of the lesion, but the definitive diagnosis is based on theanatomopathological findings. The choice of the type of surgery,open or endoscopic, is based on tumor localization and size.
OBJECTIVE: Penile erection followingepidural anesthesia is an infrequent occurrence of unclearetioogy. It is very troublesome to perform the procedureduring penile erection and attempting it leads to variouscomplications. Three such cases are reported herein. Theliterature on the pathophysiology and management ofitnraoperative penile erection is discussed.METHODS: Eighteen hundred patients who receivedepidural anesthesia for various transurethral procedureslike cystoscopy, ureterorenoscopy, transurethral resectionof prostate and bladder tumors form the clinical material.RESULTS: Out of 1800 cases, we have encounteredpenile erection only in three cases. Two cases weremanaged with local application of cold saline and coldsponging followed by terbutaline. The third case could bemanaged with local application of cold saline and coldsponging of scrotum and penis. Afterwards the procedurecould be performed safely.Intraoperative penile erectionT. HARI SIVA GURUNADHA RAO1, WAHEED ZAMAN2 and RAJNEESH KUMAR JAIN3.Department of Urology and Anaesthesia. Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow (UP), India.1Assistant Professor, Urology.2Senior Resident, Urology.3Asisstant Professor, Anesthesia.Address correspondence to:Dr. T. Hari Siva1624-D, SW 40th TerraceGainesville, Fl. 32607 - 4086USAe-mail: email@example.comAccepted for publication 1 January, 2000.CONCLUSION: The pathophysiology and managementof intraoperative penile erection is poorly understood.With the onset of erection during an operative procedure,the anesthesiologist must quickly initiate the therapy, asduration of erection is the critical factor in thedetumescence of the penis.