Scipedia: Collection of Urology Proceedings

Spigelian Hernia and Ipsilateral Cryptorchidism–Case Report

Scipedia content — Tue, 11 Apr 2017 11:46:49 +0200

Spigelian hernia (SH) is an uncommon clinical entity, being particularly rare in children. While it may be associated with acquired factors, most pediatric cases appear to be due to congenital changes. SH is often associated with other congenital defects, the most frequent association being with ipsilateral cryptorchidism. The testis is often seen in the hernia sac, with no identifiable gubernaculum or inguinal canal in some cases. Given the risk of incarceration and strangulation of the contents of HS, its early diagnosis and timely treatment are essential. Treatment consists of hernia repair and extradartos orchidopexy, which should be conducted through a subcutaneous tunnel if the inguinal canal is not observed. The frequency of the association of HS and ipsilateral cryptorchidism suggests that the presence of the testis should always be confirmed at diagnosis. This association should also be taken into consideration in cases of cryptorchidism with non‐palpable testis in its normal route. In this article we present the case of an infant with a spigelian hernia associated with cryptorchidism, who underwent hernia correction and extra‐dartos orchidopexy.

Retrospective analysis of the experience with 100 cases of retroperitoneoscopy in Centro Hospitalar do Tâmega e Sousa

Scipedia content — Tue, 11 Apr 2017 11:28:44 +0200

Since the introduction of minimal invasive surgery in the 90s, many international urologic centres have developed retroperitoneoscopy as access way for treatment of multiple urologic pathologies. The aim of this work is to analyze our initial experience in retroperitoneoscopy. Materials and methods: Retrospective analysis of the first 100 cases of retroperitoneoscopy by counsulting the clinical records. These operations were classified according to their technical difficulty and operative risk. Operative complications were stratified into five grades using the modified Clavien classification system (CCS). The first 100 retroperitoneoscopic procedures of our hospital were performed from January 2008 to July 2013 in 51 men and 49 women with a mean age of 52 years old (18‐84 years old). They were comprised of 22 renal cyst marsupialization, 36 Simple Nephrectomies, 4 Radical Nephrectomies, 2 Nephroureterectomies, 14 dismembered pyeloplasties, 1 lumbar ureterolithotomy and 21 Parcial Nephrectomies. Using the classification of surgical complexity European Scoring System for Laparoscopic Operations in Urology modified by Rassweiler in 2006, we classified 22 procedures as simple, 57 procedures as difficult and 21 procedures as very difficult. The mean operation time was 158 minutes (range: 67‐280 minutes). The mean operation time was 96, 157, and 220 minutes in simple, difficult and very difficult procedures, repectively. The open conversion rate was 3%. A total of 12 patients had postoperative complications: CCS Grade I in 4, CCS Grade II in 6 and CCS Grade IIIb in 2 patients. Discussion/Conclusions: The retroperitoneoscopy has proven to be a safe and a versatile access for a minimally invasive treatment of many urologic pathologies.

Metilação do gene MST1R como biomarcador de diagnóstico em tumores de células renais

Scipedia content — Tue, 11 Apr 2017 11:28:38 +0200

Renal cell tumors comprise both benign – oncocytoma – and malignant – clear cell renal cell carcinoma, papillary renal cell carcinoma, and chromophobe renal cell carcinoma – entities. Since the differential diagnosis among renal cell tumors is sometimes difficult on clinical, imaging and pathological grounds, and prognosis is quite dissimilar, epigenetic-based diagnostic biomarkers, specially promoter methylation, might be useful for accurate diagnosis and therapeutic planning. EpiTect Methyl II PCR Array was used to screen methylation status of 22 genes, involved in epithelial to mesenchymal transition. Quantitative real-time methylation specific polymerase chain reaction was performed for candidate gene validation, and methylation levels of renal cell tumors subtypes and normal kidney were determined and compared. MST1R promoter methylation level was significantly higher in clear cell renal cell carcinoma (median: 5367) compared to other renal cell tumors (median: papillary renal cell carcinoma – 1084, chromophobe renal cell carcinoma – 1023, oncocytoma – 1337) and normal kidney (median: 1125), allowing for accurate discrimination from other renal cell tumors with high sensitivity (>96.7%) and specificity (86.7%). Quantitative MST1R promoter methylation may be useful as biomarker for accurate diagnosis of clear cell renal cell carcinoma in problematic cases.

Penile prosthesis in treatment of erectile dysfunction: 13‐year experience

Scipedia content — Tue, 11 Apr 2017 11:28:32 +0200

Penile prosthesis implantation is a common, well‐established treatment for correcting medical refractory erectile dysfunction. Although more invasive than some of the other currently available therapies, PP surgery has the advantages of high patient satisfaction rates. The aim of this study was to evaluate the surgical results and patient satisfaction after implantation of PP in 25 patients treated at the University Hospital of Coimbra (CHUC). We evaluated 25 patients with erectile dysfunction who underwent implantation of PP, inflatable and semi‐rigid, between November 2000 and November 2013. The information was obtained from medical records and telephone interviews and encompassed clinical severity, comorbidity, etiology, PP type, surgical complications, need for reintervention and degree of patient satisfaction. 88% of patients had severe ED. The main etiologies reported were: multifactorial (46.4%), atherogenic (24%) and neurologic (16%). Most devices implanted were inflatable prostheses (84%). In 80% of the cases there were no complications reported, the rate of re‐intervention was 20%. There were a high percentage of satisfied / very satisfied patients (65%). PP surgery remains an excellent alternative in restoring erectile function in patients whose medical therapies have failed. Despite its invasive nature, the implementation of PP has proven to be associated with a low rate of complications and a high degree of patient satisfaction.

Paratesticular adenomatoid tumor: a case report

Scipedia content — Tue, 11 Apr 2017 11:28:22 +0200

The adenomatoid tumor is a rare benign neoplasm of mesothelial origin, possible to occur in the genital tract in both sexes. It is commonly paratesticular, mainly in the epididymis. Surgical treatment consists of tumor resection and preservation of the testis whenever possible. We describe a case of a 40 years old man presenting scrotal discomfort, palpable lower pole mass of the right testicle and normal tumor markers. The patient underwent local excision of nodule with right testis preservation, as the neoplasm was unrelated with the albuginea. Subsequent pathology study (with histology and immunohistochemical markers) diagnosed a paratesticular adenomatoid tumor.

Intravesical bacilo de Calmette-Guérin therapy for bladder tumors / what we know so far

Scipedia content — Tue, 11 Apr 2017 11:28:17 +0200

The use of intravesical Bacillus Calmette-Guérin is a valid option in the treatment of non-muscle invasive bladder tumors, making it the main subject of a lot of publications. The aim of the present study is to review and consolidate the data available about this subject. A review of the data available was made on PubMed with the keywords: “intravesical BCG” and “non-muscle invasive bladder cancer”. Original and review articles written in English or Portuguese were selected. We present the discussion alongside the results for structural purposes. Scientific evidence strongly advises in favor of BCG use on intermediate and high risk tumors, due to its impact on the recurrence and possibly on the progression rates. It is important to be watchful for possible local and systemic side effects, that when detected call for a rightful therapeutically decision alongside the recommended schemes. The use of intravesical BCG with therapeutically purposes has strong evidence on the non-muscle invasive bladder tumors. More studies are needed in order to better understand the best administration scheme and its mechanism of action.

Effectiveness of penile vibratory stimulation after spinal cord injury

Scipedia content — Tue, 11 Apr 2017 11:28:12 +0200

Spinal cord injury in males is frequently associated with infertility, due to ejaculatory dysfunction and/or semen properties alterations. Penile vibratory stimulation can be used as a semen collecting method. The aim of this work is to disclose the use of this method in spinal cord injured male patients, evaluate its possible complications and clarify if the ejaculated semen is prone to fertilization. Vibratory stimulation was used in three spinal cord injured patients to collect semen and, after that procedure, the evaluation of sperm parameters was performed. Vibratory stimulation was efficient in all the subjects, in the majority of the sessions. The ejaculates present normal sperm concentration, but variable sperm progressive motility and morphology, when comparing with the standard criteria. Penile vibratory stimulation is an efficient procedure to induce ejaculation in spinal cord injured patients. Despite the considerable variability between the subjects, the ejaculates met the required quality to allow fertilization trough assisted reproductive technologies.

Complications of androgen deprivation therapy in prostate cancer / a review

Scipedia content — Tue, 11 Apr 2017 11:28:08 +0200

Androgen deprivation therapy (ADT) is the standard therapy for advanced prostate cancer. However, it encompasses several adverse effects, with impact on patient’s quality of life and, eventually, on overall survival. This article will review the most important side-effects associated with androgen deprivation therapy and the methods for minimizing their impact.

Sparing surgery for testicular tumors

Scipedia content — Tue, 11 Apr 2017 11:28:03 +0200

Malignant germ cell tumors represent the majority of testicular masses, according to current knowledge, radical orchiectomy remains the standard of care in the management of this type of cancer. However, testis‐sparing surgery (TSS) can be an alternative to radical surgery in selected cases, particularly in patients with small testicular masses (STM). The authors conducted a review of the current indications for performing testicular sparing surgery as well as functional and oncological results of it. We conducted a literature search in Medline database (PubMed) using the keywords: “testis sparing surgery”, “partial orchiectomy”, ‘testis tumor’, ‘small testicular mass/tumor’. The search was limited to article in English language, published from 2010 to the current date. randomized controlled trials/studies with high level of evidence that compare TSS with radical orchiectomy were not found. Indications for TSS are still controversial, particularly in patients with normal contralateral testis. The organ sparing surgery seems a viable therapeutic option for patients with small non‐palpable testicular mass (with

Use of acetylsalicylic acid, metformin and statins and prostate cancer: Impact on the pathological characteristics and risk of biochemical recurrence

Scipedia content — Tue, 11 Apr 2017 11:27:49 +0200

The impact of using ASA (acetylsalicylic acid), metformin and statins on the prostate cancer may be significant, but is not clear and findings from previous studies are inconsistent. This study aims to evaluate the relationship between the use of ASA, metformin and statins and the pathological characteristics and risk of biochemical recurrence (BCR) of prostate cancer. A total of 311 patients submitted to radical prostatectomy (RP) at Hospital de Braga between January 2010 and June 2014 were analyzed. Data were obtained from clinical records and the crude and adjusted association between the use of a specific drug and prostate specific antigen (PSA), pathological stage, Gleason score, positive surgical margin and risk of biochemical recurrence were calculated. Overall, 26 (8.4%) of the patients used ASA, 35 (11.3%) metformin and 112 (36%) statins. The ASA users had a lower PSA compared with the non users (5.9 vs. 8.9 ng/m, p = 0.008). Its use was an independent predictor of positive surgical margin (OR = 3.77, IC 95%: 1.45‐9.78). The use of metformin was associated with advanced pathological stages, more precisely pT3b (20% vs. 7.7%, p = 0.048). No other differences were detected between ASA, metformin and statins users. The use of ASA, metformin and statins has no beneficial effect on prostatic cancer patients. On the opposite, an association between the use of metformin and advanced pathological stages was observed. These results should be validated in other larger samples and longer follow‐up. The association between the use of ASA and lower PSA was already detected in other studies, whose mechanism should be clarified in future

Hyperbaric oxygen therapy for radiation‐induced hemorrhagic cystitis

Scipedia content — Tue, 11 Apr 2017 11:27:45 +0200

Due to considerable morbidity and mortality rates, radiation‐induced hemorrhagic cystitis is an important complication of pelvic irradiation. The available conservative treatment techniques show limited results. Hyperbaric oxygen has shown to be effective in the treatment of radiation‐induced lesions, including radiation cystitis. Our aim was to analyze the effectiveness and safety of hyperbaric oxygen therapy for refractory radiation‐induced hemorrhagic cystitis. Clinical records of 176 patients with refractory radiation‐induced hemorrhagic cystitis treated at our centre were retrospectively analyzed. The evolution of macroscopic hematuria was the main therapeutic outcome analyzed. 23, 9% of patients showed other radiation‐induced soft tissue lesions. After an average of 37 sessions of hyperbaric oxygen, 89, 8% of patients showed resolution of hematuria. Adverse events were reported in 1, 7% of patients. Hyperbaric oxygen was a safe and effective therapy for radiation‐induced hemorrhagic cystitis. Concomitant radiation‐induced soft tissue lesions were relatively frequent, which makes hyperbaric oxygen an excellent choice as first line treatment in those patients.

Considerations in the treatment of Peyronie disease

Scipedia content — Tue, 11 Apr 2017 11:27:41 +0200

Augmentation Cystoplasty using modified Studers Orthotopic Ileal Neobladder tecnhique

Scipedia content — Tue, 11 Apr 2017 11:27:37 +0200

Although exceedingly rare in developed countries nowadays, we still come across some devastating sequels of genitourinary tuberculosis, requiring careful medical evaluation and expertise on surgical reconstruction. A 58‐year‐old man, previously submitted to a right nephrectomy, developed a life‐threatening episode of urosepsis, leading to the need of a percutaneous nephrostomy due to a long stricture of the terminal ureter of the remaining left kidney. The patient had also developed very severe urinary frequency related to an extremely crippled bladder, with a capacity under 20 mL. After medical treatment of the tuberculosis, an augmentation cystoplasty was performed but in a patient‐tailored way, using an ileal neobladder constructed following the Studer technique that was anastomosed to the remaining bladder tissue with implantation of the healthy segment of the shortened ureter on the afferent limb of the reservoir. The normalisation of bladder capacity (over 250 mL), with preserved filling sensation allowed an excellent patient adaptation. The combination of a severely decreased bladder capacity with a stenosis of the terminal ureter of a single kidney led to a need of a great capacity reservoir as well as a reimplantation of a shortened ureter. The use of an orthotopic ileal neobladder as a large ileocystoplasty patch was the solution adopted.

Relação entre a qualidade seminal e o equilíbrio oxidativo nos espermatozoides

Scipedia content — Tue, 11 Apr 2017 11:27:32 +0200

Infertility is a clinical disorder affecting approximately 15% of reproductive-aged couples worldwide. Recently, the influence of oxidative stress (OS) in decreased semen quality has been discussed. OS corresponds to an imbalance between oxidants and antioxidants defenses, present in the organism. High levels of reactive oxygen species (ROS) damage biomolecules present in sperm cells and may lead to the loss of membrane integrity, DNA fragmentation or even to death by apoptosis. This study aimed to evaluate the correlation between human semen clinic parameters and parameters that assessed the presence of OS. A total of 32 semen samples, obtained from a randomized group of donors, were included in this study. Basic semen parameters were analyzed according to the WHOs guidelines. The total antioxidant capacity of sperm cells was measured as well as the expression of certain antioxidant proteins, namely superoxide dismutase (SOD) and glutathione peroxidase 4 (GPx4), by colorimetric techniques and immunoblotting, respectively. The effect of ROS in spermatozoa protein oxidation was analyzed by determining the presence of 3-nitrotyrosine and carbonyl groups, by slot blot. Lipid peroxidation was evaluated, by performing the thiobarbituric acid reactive substances (TBARS) assay with colorimetric tests. The results indicated that SOD was negatively correlated with viscosity (p = 0.035), volume (p = 0.004) and carbonyl groups presence (p = 0.005). This protein also showed a positive correlation with the presence of tail defects in sperm cells (p = 0.044). In turn, GPx4 showed a negative correlation with the presence of non-progressive motile spermatozoa (p = 0.012). TBARS assay revealed a negative correlation with the concentration of sperm cells (p = 0.000) and the total number of spermatozoa (p = 0.026), but, in turn, this assay showed a positive correlation with the volume of semen (p = 0.038). It was concluded that the seminal quality is affected by the oxidative balance in sperm cells. The obtained results suggest that lipid peroxidation leads to a reduction in sperm concentration, antioxidant proteins protect the spermatozoa against protein oxidation and contribute to an increased sperm motility and normal semen viscosity. Thus, evaluation of oxidative parameters may be a useful tool for male infertility diagnosis and follow-up of antioxidant treatments.

Microsurgical vasovasostomy: our experience

Scipedia content — Tue, 11 Apr 2017 11:27:27 +0200

To describe the initial experience of CHVNG/E in microsurgical vasovasostomy. The two‐layer technique was applied under microscope magnification in every patient by the same surgeon. 8 bilateral vasovasostomies were performed for vasectomy reversal between 2008 and 2014 at our unit. All the patients were available for follow‐up, with a mean follow‐up time of 6 months. Mean patient age was 38.8 ± 8.7 years and the interval between vasectomy and recanalization of 6 ± 1.5 years. Overall spermatozoid patency rate was 100%, with mobile spermatozoa in the ejaculate of all patients (median 12 x 106 /mL, interquartile interval [7 x 106 /mL‐21 x 106 /mL]). Four of the 8 patients fathered after the procedure. Our results were comparable to the ones described in the literature, confirming the performance of a good surgical technique. Microsurgical vasovasostomy constitutes a very safe method of vasectomy reversal, enabling couples to obtain pregnancies without additional medical treatment. To our knowledge, this is the first group of patients treated by this method in Portugal.

Ureteral reimplantation in urinary diversions: its the laparoscopy an option?

Scipedia content — Tue, 11 Apr 2017 11:27:22 +0200

The ureterointestinal stenosis is a relatively frequent complication after urinary diversions. The laparoscopic approach is rarely used but stay a therapeutic option. Show the surgical technique, step by step, of the laparoscopic ureteral/ureterointestinal estenosis correction. A vídeo of a distal ureteral stenosis laparoscopic correction, on a patient that undergone laparoscopic radical cystectomy with orthotopic neobladder confection, was presented. It was possible the laparoscopic correction of a distal right ureter estenosis with good results and no complications. The laparoscopic approach proved effective for treating ureter/ureterointestinal anastomosis stenosis and should be taken as a good option of treatment.

Nephrogenic adenoma of the urinary bladder: A case report and review of the literature

Scipedia content — Tue, 11 Apr 2017 11:27:15 +0200

Nephrogenic adenoma of the urinary bladder (NAB) is a rare and benign urothelial tumor. The existing literature is scarce regarding its etiology, clinical symptoms and therapeutic options. This paper presents the first reported case of a patient with HIV‐1 infection to whom an NAB was diagnosed. We report a case of a female patient of 49 years old, seropositive for HIV‐1, with pollakiuria, mictional urgency, feeling of incomplete bladder emptying and intermittent macroscopic hematuria. The patient was submitted to TURB of a suspected intravesical lesion. Histopathological examination of the resected material was consistent with an NAB. The patient is in follow‐up, having completed one year with no sign of lesion recurrence. NAB is a metaplastic lesion of the urothelial tissue. Its etiology is not fully understood. NAB is associated with chronic inflammatory processes or to a state of immunosuppression. Its diagnosis is histological, characterized by the presence of tubular structures similar to renal tubules. This work is particularly relevant because it is the first described case of NAB in a patient immunodepressed by HIV‐1 infection.

Mais um passo a caminho do objectivo - a excelência

Scipedia content — Tue, 11 Apr 2017 11:27:10 +0200

Efficacy of botulinum toxin type A in the treatment of neurogenic lower urinary tract disfunction due to spinal cord injury

Scipedia content — Tue, 11 Apr 2017 11:27:06 +0200

The prevalence of neurogenic lower urinary tract disfunction (NLUTD) is unknown, but the risk of developing NLUTD associated with spinal cord injury (SCI) is high. Verify the changes of intradetrusor BTX‐A injection on urodynamic parameters and in the QoL of NLUTD patients due to SCI. Retrospective study of 38 patients with SCI submitted to BTX‐A injection in our departments. Urodinamic studies were performed before and 3 to 6 months after treatment. QoL was evaluated by the Qualiveen questionnaire applied to 20 patients. Statistical analysis was performed with correlation tests for paired samples. Mean age was 38 years (Min = 23, Máx = 63), with 63.2% of males. The most frequent level of SCI was thoracic (52.6%). The average period between the SCI and the first treatment was 92 months (15 to 240 months). The patients had a mean of 3 treatments (min = 1, máx = 8), with 3 episodes of side effects ‐ transient and mild hypoasthenia. We collected data of urodynamic studies in 35 patients that showed increase in bladder capacity (p = 0, 24) and compliance (p

Cognitive Fusion targeted Prostate Biopsy after Multiparametric Magnetic Resonance Imaging. Comparison with traditional Randomized Biopsy

Scipedia content — Tue, 11 Apr 2017 11:26:57 +0200

Multiparametric Magnetic Resonance Imaging of the prostate (Mp‐MRI) allows the detection, localization and characterization of suspicious lesions for prostate cancer (PCa). When done prior to the diagnosis it also allows targeting of the biopsy, significantly improving the performance of the standard random prostate biopsy. Our goal is to compare a targeted biopsy technique (cognitive fusion) with the standard double sextant randomized prostate biopsy, and to determine which has better accuracy in the detection of cinically significant prostate cancer. 30 patients aged 61‐67 were selected with a PSA greater than 4 ng/mL (PSA between 5.6 – 19.2) and with suspicious PCa lesions on Mp‐MRI (Pi‐RADS 3‐5). A total of 75 suspicious lesions were detected. All biopsies were performed by the same Urologist (JMP), using trans‐rectal ultrasound guidance and after previous visualization of MRI images. Sampling was targeted to the area considered suspicious on MRI, using a Cognitive Fusion Technique, collecting two samples per area. After that, a double‐sextant standard prostate biopsy was also done in all patients. The variables used for statistical analysis were PCa detection rate and amount of cancer per sample. 22 patients were diagnosed with PCa. In 5 patients, cancer was only detected on targeted cores. Targeted biopsies diagnosed 17% more PCa when compared to random biopsies, and almost doubled the amount of cancer per sample. The overall PCa detection rate was 61% for all samples. 360 fragments were collected from standard randomized prostate biopsy, of which 169 were positive for PCa (47%), with a median Gleason score of 6 (3+3). The average amount of cancer per sample was 25% (5%‐85%). 105 of 150 fragments collected by cognitive fusion targeted biopsies were positive for PCa (70%). The median Gleason score was 7(3+4) with a median amount of cancer per sample of 45% (10%‐90%). Multiparametric prostatic MRI detects areas highly suspicious for PCa, allowing targeted biopsies, which increases diagnostic accuracy and improves the detection of clinically significant PCa.