This guideline’s purpose is to provide direction to clinicians and patients regarding how to: recognize non-neurogenic overactive bladder (OAB); conduct a valid diagnostic process; and, approach treatment with the goals of maximizing symptom control and patient quality of life while minimizing adverse events and patient burden. The strategies ...
In this review, the role of surgery in patients with adverse tumor characteristics and a high risk of tumor progression are discussed. In the current PSA era the proportion of patients presenting with high risk prostate cancer (PCa) is estimated to be between 15% and 25% with a 10-year cancer specific survival in the range of 80-90% for those receiving active local treatment. The treatment of high risk prostate cancer is a contemporary challenge. Surgery in this group is gaining popularity since 10-year cancer specific survival data of over 90% has been described. Radical prostatectomy should be combined with extended lymphadenectomy. Adjuvant or salvage therapies may be needed in more than half of patients, guided by pathologic findings and postoperative PSA. Unfortunately there are no randomized controlled trials comparing radical prostatectomy to radiotherapy and no single treatment can be universally recommended. This group of high risk prostate cancer patients should be considered a multi-disciplinary challenge; however, for the properly selected patient, radical prostatectomy either as initial or as the only therapy can be considered an excellent treatment.
OBJECTIVES: Prostate cancer is the second most common cancer in men after skin cancer, screening is used to detect early stage cancer using serum prostate specific antigen(PSA). A level of PSA > 4.0ng/m as a cut-off point or abnormal digital rectal examination (DRE) are used to indicate a prostate biopsy. Nevertheless, non-malignant pathologies can increase serum PSA level so that 70% of biopsies are negative for cancer, and thus potentially unnecessary, causing anxiety, costly clinical tests and prolonged follow-up. Thus the search for new biomarkers is important. Circulating primary prostate cells (CPCs) may be such a marker. We analyze a cohort of patients using CPCs to detect prostate cancer in men with a serum PSA >4.0ng/ml or abnormal DRE in terms of cost-benefit.METHODS: A cohort of 263 patients with a PSA >4.0 ng/ml and a test to detect CPCs who underwent prostate biopsy were analyzed. The results of both tests were compared with biopsy results; sensibility, specificity, and predictive values were calculated. Costs of each test, process, drug costs and complications were determined as well as indirect costs.RESULTS: Of the 263 patients, 77 (28.6%) had prostate cancer detected, for the test using CPCs there was a sensibility of 85.7%, specificity of 90.3% and negative predictive value of 93.9%. Thus men CPC negative may not need a prostate biopsy. Potential savings for the 263 patients were between €32,068 in a public health service and €69,253 for inpatient private health insurance patients. Follow up cost were higher in false-positive CPC patients but, as there were fewer false positive patients, total costs were lower.CONCLUSIONS: The use of primary CPC detection as a complementary test in men with a serum PSA >4.0ng/ml to indicate prostate biopsy is a specific, cost effective test, eliminating approximately 70% of prostate biopsies. This results in a significant health care saving both in direct and indirect costs, in the costs of complications. Implementation costs were minimal as equipment and reagents are part of the routine clinical laboratory. The method deserves further investigation to confirm the results.
OBJECTIVES: To study the impact of treatments prescribed in usual practice to control Overactive Bladder (OAB) on health-related quality of life (HRQoL) of patients with associated pathologies.METHODS: 1.434 patients over 60 years with newly diagnosed OAB and at least one associated pathology (urinary or genital-skin infections, sleep disorders, depression, hypertension) were recruited in 300 urological/gynecological practices in Spain. During the first visit, socio-demographic and basic clinical information were registered and the therapeutic strategy for OAB was prescribed following usual clinical practice. The patients filled out the HRQoL SF-12 questionnaire. On the second visit (4-6 months later) the HRQoL was re-evaluated. HRQoL was compared between sexes (Mann-Whitney) and between visits (Wilcoxon for related samples). Multiple regression models were performed in order to study the variables independently associated with HRQoL.RESULTS: Valid data is given for 1,274 patients for visit 1 and 1,153 for visit 2. 71.51% of the sample were female. Mean age was 68.17 (6.19). A significant improvement in the HRQoL was found on the second visit. Factors independently associated with lower score in both summary index of SF-12: first visit, female gender and Charlson Index. Additional factors associated with reduction of the physical component score: age, all associated pathologies and treatment using vaginal pessaries. Additional factors associated with the mental component score: treatment for depression, sleep disorders, use of vesical reeducation and the modification of treatment using diuretics.CONCLUSIONS. The treatments prescribed in usual clinical practice to alleviate OAB are effective in notably improving the HRQoL of patients in general, both physically and mentally.
OBJECTIVES: A first experience was carried out in three research centers using a new urethral sling for the treatment of male and female pediatric and young adult population with urinary incontinence caused by neurogenic sphincteric incompetence.METHODS: This was a prospective pilot study of patients with neurogenic sphincteric incompetence needing clean intermittent catheterization. All patients were treated by the implantation of Nephis® mini-sling (Promedon, Argentina) over the proximal urethra. Twenty-eight patients were included, 19 females and 9 males. Mean age was 13.4 (SD 7.8 years). The median follow-up was 16.5 (12-24) months. Urodynamic studies were carried out pre and postoperatively to assess the nature of the incontinence and to quantify the outcomes after implantation. A voiding diary was also used to evaluate the Daytime Dryness Intervals between catheterization.RESULTS: Leak point pressure increased from a preoperative mean value of 24.3 cmH2O (SD 6.5) to 51.0 cmH2O (SD14.3) (p< 0.0005). The initial mean for Daytime Dryness Interval was 60.4min (SD 9.1) and postoperatively rose to 195.6 (SD 59.4) (p< 0.0005). Only one major complication was registered: a sling had to be removed due to erosion in a patient who underwent a concomitant bladder neck reconstruction due to an ectopic ureter repair.CONCLUSIONS: The mini-sling was easy to implant and urodynamic results suggest it is effective in the treatment of neurogenic sphincteric incompetence. This statement is also supported by voiding diary records
OBJECTIVE: To study lytic lesions in a patient with past history of renal cancer.METHODS: A 62 year-old man was admitted to hospital for investigation of the cause of polyostotic bone pain.RESULTS: Brown tumors due to hyperparathyroidism turned out to be the cause of bone pain.CONCLUSIONS: Differential diagnosis is important in daily practice in order to provide a correct treatment for each condition.
OBJECTIVE: To report a case of paratesticular rhadomyosarcoma and to perform a bibliographic review.METHODS: We report the case of a 16-year-old male referred to our Department because of a left paratesticular hard tumor with progressive growth. Ultrasound examination showed a paratesticular heterogeneous mass with Internal flow on Doppler.RESULTS: The patient underwent left inguinal orchiectomy, with pathological diagnosis of rhabdomyosarcoma. He refused adjuvant chemotherapy. After being disease-free for 13 months, he presented with left colic pain. Ultrasound and CT examinations showed a left paraaortic retroperitoneal mass causing grade III ureterohydronephrosis, and lung metastases. Despite rescue chemotherapy treatment, there was no response and the abdominal mass progressed. A surgical approach was not possible since patient showed a rapid clinical worsening leading to his death a few weeks later.CONCLUSIONS: Paratesticular sarcomas are very uncommon tumors with poor prognosis.
OBJECTIVE: To report our initial experience in 3 cases of laparoscopic partial nephrectomy with selective parenchymal clamping using a novel laparoscopic clamp.METHODS: A total of 3 laparoscopic partial nephrectomies were performed using the Simon clamp (Aesculap). Mean patient age was 67 years (range 60 to 74 years), two patients were males. All patients had an ASA score of 2. Mean tumor size was 2.2 cm (range 2 to 2.4 cm) and all tumors were of the lower pole. Two tumors were on the right kidney and one on the left kidney.RESULTS: Mean operative time was 100 minutes (range 70 to 120 min). Mean operative bleeding was 16 ml (range 0 to 50 ml). Mean warm ischemia time of the renal pole was 33 minutes (range 30 to 40 min). All patients were discharged on postoperative day 2. There was no intra or postoperative complications. Surgical margins were negative in all cases.CONCLUSION: The Simon clamp allows for tumor resection without bleeding and for renal defect repair without collateral renal injury. We hope that in the future the development of other instruments will allow for selective clamping in any tumor location.
OBJECTIVE: To describe a case of adrenal cavernous hemangioma in a 67 year old man who presented left lumbar pain.METHODS: Abdominal ultrasound, contrast enhanced ultrasound of the lesion, abdominal-pelvic CT scan, and then left adrenalectomy and pathology were performed.RESULTS: Imaging studies showed a large solid-cystic mass with 12 x 11 cm diameters in the left adrenal gland, well defined, with calcifications, which showed peripheral arterial globular contrast enhancement on CT and ultrasound. The lesion displaced neighboring structures without other findings in the abdominopelvic study. The pathology report after adrenalectomy was: cavernous hemangioma with calcifications, ossifications and necrosis.CONCLUSIONS: Cavernous hemangioma is a rare cause of adrenal mass. The globular peripheral contrast uptake and gradual filling of the lesion on dynamic imaging studies (Ultrasound or CT) and phlebolith type calcifications suggest the diagnosis of typical angioma. However, the presence of thrombosis, necrosis and calcifications in large lesions confer an unusual dynamic behavior and force pathology for definitive diagnosis.
OBJECTIVE: We present a case of intrarrenal pseudoaneuysm after percutaneous nephrolithotomy. The treatment was selective embolization of the pseudoaneurysm. We discuss the role of computerized angiotomography and angiography in these cases. We present a review of the related literature.METHODS: A computerized angiotomography (angio CT) was performed because of suspicion of a delayed vascular lesion after percutaneous nephrolithectomy. Faced with the findings of the angio CT an selective renal artery arteriography and selective embolization was performed.RESULTS: The angiotomography shows an enhanced nodular contrast in the lower third of the left kidney with a scarred area at this level suggestive of hemorrhage due tovascular lesion.Through puncture of the right common femoral artery, arteriography was performed on the left renal artery with, objectifying an amputated artery related to the bleeding situation in the calyx. After localization of the point of hemorrhage, the vessel was embolized with a 3 mm metallic microspiral GCD, 6 cm in length After embolization, the evolution of the patient was satisfactory.CONCLUSIONS: Intrarenal pseudoaneurysm is the most frequent cause of late bleeding after percutaneous nephrolithotomy. The most common symptom is hematuria that can be severe and require active treatment in order to inhibit the hemorrhage. In these cases, computerized angiotomography and angiography take on a very important diagnostic role, the latter offering the possibility to treat the hemorrhage through selective embolization of the pseudoaneurysm