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Currently the debate on the role of urodynamictests in the preoperative evaluation of femalestress urinary incontinence is alight. Although urodynamicinvestigation (UDI) has been considered mandatorybefore surgery in all female patients affected by stressurinary incontinence, nowadays international guidelinesare more cautious.Literature on this topic has been reviewed in order to clarifythe role of UDI before surgery for “complicated” and“uncomplicated” stress urinary incontinence in femalepatients. We focused on if and how UDI may improveclinical outcomes and alter clinical decision making.In conclusion, we believe that in most patients (the “complicated”ones) the role of UDI has not been fully evaluated.In “uncomplicated” cases, pretreatment UDI mightnot improve clinical outcomes but it could give importantinformations (voiding dysfunction in about 10% of cases)offering a valuable guide to the surgeon and tothe patient. Interestingly though, UDI could alter clinicaldecision making being a valuable tool in counseling ourpatients with the aim of cure their symptoms, never riskingof worsening them or causing further discomfort.
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OBJECTIVE: Laparoscopic adenomectomy (LA) is an effective procedure for the treatment of benign prostatic hyperplasia (BPH), which reproduces the surgical steps of the open adenomectomy (OA) by a minimally invasive approach to obtain the favorable results of open surgery in combination with the benefits offered by laparoscopic techniques. We performed a comprehensive bibliographic review of the technique and its current results in order to describe the evolution of the surgical technique and present the current evidence on the LA. METHODS: A comprehensive review about LA was conducted from 2002 to 2016 in PubMed and Google Scholar. We included articles with perioperative data and abstracts presented at international urological meetings using the search words “laparoscopic adenomectomy” and “laparoscopic simple prostatectomy”. A total of 110 publications were reviewed, including articles in indexed journals, not indexed journals, chapters in medical books and abstracts presented at meetings. RESULTS: A total of 50 articles were selected, thirty of which relate to LA, 17 to the technique of Robot-assisted LA (R-LA), 3 to Laparoendoscopic Single-site Surgery-LA, 13 to comparative studies with other techniques, 5 are review articles and 2 large volume multicenter studies. The evolutionary history of the LA technique was presented with an update on the current results evidenced in studies. CONCLUSION: LA and R-LA are procedures under continuous “development” of some complexity that require experience in laparoscopy and/or robotics. These techniques offer significant advantages compared to the OA, so they are reasonable alternatives, effective and safe in the treatment of BPH in laparoscopic or robotic centers or with interest in the development of these techniques.
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OBJECTIVES: The intraoperative goal-directed fluid therapy (GDT) has become the base of perioperative management in the fast-track protocols. This program using technology to estimate cardiac output, with the aim of minimizing splanchnic hypoperfusion. However, there is insufficient evidence to confirm its application in radical laparoscopic cystectomy. METHODS: In a retrospective study, we have included 52 patients that were scheduled for radical cystectomy. In group A (n=32) patients were treated following GDT. Group B (n=18) included patients before the GDT introduction in our practice. The main objective was to assess the length of hospital stay and the permanence in intensive care units. Other variables of the study were the use of intraoperative blood products, fluid-therapy and medical and surgical complications. Statistical analysis was performed using the Mann Whitney U test for non-parametric variables and the Chi-square test for qualitative variables. Fisher’s exact test was used when the sample size required it. RESULTS: The average length of hospital stay was 13.4 SD (11.0-15.9) days in group A versus 11.6 SD (8.9-14.3) days in group B (p <0.364). The average stay in critical care unit was 25.4 hours (16.1-34.6) in group A versus 21.0 (14.9-27.1) hours in group B with no significant differences between groups. The use of blood products was 0.41 packed red blood cells in group A versus 0.49 in group B with no statistically significant differences. The average volume of crystalloid administered was 1145 ml in group A versus 2382 ml in group B (p <0.001). In group A 656 ml of colloids were administered versus 266 ml in group B (p <0.001). There were no statistically significant differences in the incidence of complications. CONCLUSIONS: The use of a Goal Directed Fluid Therapy in radical cystectomy is related to a greater use of colloids than crystalloids, although its implementation does not affect hospital stay length or postoperative complications. In a multimodal perioperative program a single factor, as it is for the GDT, has little effect as an independent variable, and the combination of strategies has, more likely, a greater effect.
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OBJECTIVE: Extracorporeal shock wave lithotripsy (ESWL) represents one of the most frequently used methods to treat urinary tract calculi. However, sometimes we do not obtain the fragmentation expected. The aim of this study is to evaluate the parameters that may influence ESWL final results, developing a classification for better patient’s selection and outcome optimization. METHODS: 270 patients with renal or ureteral stones were retrospectively reviewed after ESWL treatment, recording both clinical parameters (age, sex, location, laterality, body mass index [BMI]), and CT-Scan parameters (stone size and volume, skin-to-stone distance (SSD), mean and maximal stone density). Cutoff values were determined for each parameter based upon ROC curves, and final score (ESWL score) was calculated based on the number of parameters lower than the cutoff values.RESULTS: Of the 270 patients treated, 186 (68.8%) were considered as ESWL success, without significant differences between success and failure group.Parameters that showed significant difference after multivariate analysis were: size (cut off: 9.3 mm), volume (237.2 mm3), mean density (951 UH), SSD (133 mm) and BMI (26.9 kg/m2). AUC of ROC curve including all of these parameters, was 0.807. Stone free status was 17.6% for score 0, 25% (score 1), 48.8% (score 2), 74.1% (score 3), 86.3% (score 4) and 92.2% for score 5.CONCLUSIONS: Patient classification before ESWL treatment seems to allow us better selection, improving treatment success.
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OBJECTIVE: To determine the lithogenic risk index and its evolution after treatment of paraguayan lithiasic patients. METHODS: This experimental study of temporal series included 28 lithiasic patients of both sexes that attended to the Instituto de Prevision Social in 2012. Basal evaluation included metabolic study and urinary saturation indexes determined by EQUIL software. With this data, a specific treatment was selected for each patient. The follow up included a medical consultation monthly and the metabolic evaluation after 6 month. The study was approved by an ethical committee.RESULTS: Basal evaluation showed hypocitraturia, hypercalciuria and hyperoxaluria in 50%, 46.4% and 14.3% of patients, whereas 42.9% showed diuresis lower than 2 L/day. Crystallization risk for calcium oxalate, sodium urate, hidroxiapatite and uric acid was observed in 1,3, 12 and 12 patients respectively. After treatment, a decrease in the frequency of hypercalciuria and hypocitraturia was observed, just like the urinary saturation risk for all types of crystals studied. Statistical analysis showed a significant variation of diuresis (p 0,0001) and uric acid urinary saturation (p 0,002) after treatment.CONCLUSIONS: The lithogenic risk factors more frequently detected were hipocitraturia and hypercalciuria. Therapeutic measures achieved the decrease of saturation risk indexes for all the crystals analyzed, registering significant effects in the increase of diuresis and uric acid saturation decrease. The use of software tools for the calculation of crystallization risk is an important innovation in Paraguay.
Case Report
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Renal cell carcinoma is an unpredictable malignancy. Sometimes, metastases are the disease debut. On the other hand, metastases could present years after treatment of the primary tumor. Four clinical cases of atypical metastases in the head and neck location are presented: parotid gland, mandibular bone, attached molar gingiva and masticator space. Physiopathology, clinics, histology and management of metastatic renal cell carcinoma at those anatomical regions are reviewed.
Case Report
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OBJETIVE: To review the presentation, diagnosis and treatment of the renal artery aneurysms. Also, to report a non-described complication like the presence of an ureteroarterial fistula, its diagnosis, treatment and complications.METHODS: We report the case of a patient with a renal artery aneurysm that presents a ureteroarterial microfistula on a CT scan, his presenting symptoms, the diagnosis, treatment and management of the subsequent complications.RESULTS: Ureteroarterial fistula is an unusual complication of renal artery aneurysms. Currently, by the application of minimally invasive techniques and the use of new biodegradable materials we can treat a wide range of diseases endovascularly, although we often don´t know the complications that can result.CONCLUSIONS: Renal artery aneurysms are not a prevalent disease and sometimes not described complications like ureteroarterial fistula may occur. There is no clear consensus on the management and treatment, but minimally invasive endovascular techniques could represent the gold standard nowadays.
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OBJECTIVES: To compare the success of the ‘tubularized incised plate urethroplasty’ (TIPU)’ and ‘Onlay island flap urethroplasty’ (OIFU) techniques for the repair of primary proximal hypospadias. MATERIAL AND METHODS: A retrospective evaluation was made of the medical records of 68 patients with primary, non-complicated hypospadias, who were operated on in the Department of Urology, Ministry of Health Ankara Education and Research Hospital, between January 1997 and December 2012. Patients who underwent hypospadias surgery with TIPU were labelled as Group 1 and the OIFU technique as Group 2. Patient age, native meatus localization, operation time, diversion type, surgical success and complication rates were all assessed. Surgical success was evaluated with direct vision of voiding and uroflowmetry at the time of catheter removal, then at 2 weeks, 6 weeks, 6 months and 1 year. RESULTS: Group 1 consisted of 43 patients and Group 2 of 25 patients. The mean age of patients was 6.4±3.1 years in Group 1 and 8.0±4.6 years in Group 2 (p=0.09). The mean operating time was significantly lower in Group 1. (Group 1- 104.8±16.8 min, Group 2-125.4±24.7min; p<0.001) The distribution of meatus localization was similar in both groups. At 1 year postoperatively, urethrocutaneous fistula was the only complication and the definitive success rates were 81.6% in Group 1 and 72% in Group 2. CONCLUSION: Despite less frequent usage since the description and popularization of TIPU for proximal hypospadias repair, OIFU remains a valuable technique as a single-stage procedure in cases where the urethral plate is insufficient. Currently, both TIPU and OIFU are used successfully in the treatment of patients with proximal hypospadias.
