Port site metastasis after surgery for renal cell carcinoma: harbinger of future metastasis.

PURPOSE: Port site metastasis is a rare occurrence after minimally invasive treatment for renal cell carcinoma. However, its prognostic implications are unclear because reports in the literature are heterogeneous in detail and followup. We clarify the significance of port site metastasis in cancer specific survival and broaden our understanding of this phenomenon. MATERIALS AND METHODS: A MEDLINE® search for published studies of renal cell carcinoma port site metastasis was performed. Contributing factors to port site metastasis, stage, Fuhrman grade, pathology, port site metastasis treatment method, followup protocol and long-term outcomes were collected. The corresponding authors of each publication were contacted to fill in details and provide long-term outcomes. We added 1 case from our recent experience. RESULTS: A total of 16 cases from 12 authors (including ourselves) were found. Of the 12 authors 8 were available for correspondence and 9 cases were updated. Eventual outcomes were available for 11 of the 16 cases and survival curves showed poor prognosis with a 31.8% overall 1-year survival rate. Of the 16 cases 12 were radical nephrectomy and 4 were partial nephrectomy, and 13 involved multiple metastases in addition to the port site metastasis. Nine of the cases had no identifiable technical reason for port site metastasis formation such as specimen morcellation, absence of entrapment or tumor rupture. These tumors were uniformly aggressive, Fuhrman grade 3 or higher. CONCLUSIONS: Port site metastasis after minimally invasive surgery for renal cell carcinoma is a rare occurrence with a poor prognosis. In most cases port site metastasis is not an isolated metastasis but instead is a harbinger of progressive disease. While technical factors can have a role in port site metastasis formation, it appears that biological factors like high tumor grade also contribute.

Effects of Hibiscus sabdariffa supplementation on metabolism and bladder in obese rats.

PURPOSE: Hibiscus sabdariffa (HS) extract has several health benefits and anti-obesogenic effects. The aim of the present study was to assess whether the medicinal properties attributable to HS would prevent or mitigate bladder changes induced by obesity in an experimental model. METHODS: Forty-eight male Wistar rats were submitted to one of four different dietary interventions (12 animals each): G1, standard diet and water (controls); G2, standard diet and HS tea; G3, a palatable high-fat diet and water; and G4, high-fat diet diet and HS tea. The animals were monitored for body weight, feed, and water and tea intake, according to the allocated group. After 16 weeks, the animals were euthanized, and the levels of creatinine, inflammatory cytokines, testosterone, cholesterol, triglycerides, and electrolytes were evaluated. In addition, histopathological analysis of the animals' bladder was performed. RESULTS: Groups receiving HS (G2 and G4) showed decreased levels of the pro-inflammatory cytokine interleukin-1α. HS tea was able to reduce low-density lipoprotein and triglyceride levels in the G2 group compared to other groups. Only in the G3 there was a significant increase in the body weight when it was compared the 12th and 16th weeks. Leptin was shown to be elevated in the groups that received a high-fat diet. There was a significant decrease in the muscle fibers thickness and in the total collagen count in G4 bladder when compared with G1 and G3. CONCLUSIONS: HS has an anti-inflammatory role, can reverse hyperlipidemia in rats, and reduced deleterious effects of obesity on these animals' bladder.

A rare case of spontaneous bladder perforation with osteomyelitis and paravesical abscess due to CA-MRSA clone USA100/ST5.

Spontaneous rupture of the urinary bladder represents a rare condition that may complicate with paravesical abscess. Although Staphylococcus aureus may be a part of the intestinal tract flora, it is an unusual cause of abdominal or pelvic abscesses. We report the case of a male patient with spontaneous bladder perforation with osteomyelitis and paravesical abscess, secondary to community-acquired methicillin-resistant Staphylococcus aureus infection.

Comparative study between trimetazidine and ice slush hypothermia in protection against renal ischemia/reperfusion injury in a porcine model.

PURPOSE: The aim of the study was to compare the effects of renal ice slush hypothermia and the use of trimetazidine in the protection against ischemia/reperfusion (I/R) injury. MATERIALS AND METHODS: Fifteen farm pigs were submitted to left kidney ischemia and right nephrectomy during the same procedure. Animals were divided into three groups. Group 1 was submitted to warm ischemia; Group 2 was submitted to cold ischemia with ice slush; and Group 3 received trimetazidine 20 mg one day and 4 hours before surgery. Ischemia time was 120 minutes in all three groups. Serum creatinine (SCr) and plasma iohexol clearance (CLioh) were measured before surgery and on postoperative days (PODs) 1,3,7, and 14. Semi-quantitative analyses of histological alterations were performed by a pathologist. A p value of < 0.05 was considered significant. RESULTS: All groups showed elevation of serum creatinine in the first week. Serum creatinine was higher in Group 3 in the first and third postoperative days (Mean Cr: 5.5 and 8.1 respectively). Group 2 showed a lower increase in creatinine and a lower decrease in iohexol clearance than the others. Renal function stabilized in the fourteenth POD in all three groups. Analyses of histological alterations did not reach statistical significance between groups. CONCLUSION: Trimetazidine did not show protection against renal I/R injury in comparison to warm ischemia or hypothermia in a porcine model submitted to 120 minutes of renal ischemia.

Metabolic investigation of patients with staghorn calculus: is it necessary?

OBJECTIVE: To evaluate the prevalence of metabolic disorders in patients with staghorn calculi treated at the Regional Center of Lithiasis Metabolic Studies in central region of Såo Paulo State, Brazil. MATERIALS AND METHODS: Between February 2000 and February 2008, 630 patients with urinary calculi were evaluated in the lithiasis outpatient clinic. Thirty-seven of them had staghorn calculi (35 women and 2 men). The inclusion criteria for the metabolic investigation included the absence of urological manipulation 30 days before the examination, negative urine culture and creatinine clearance > 60 mL/min. The protocol for metabolic investigation consisted of qualitative search for cystinuria. Two non-consecutive 24-hour urine samples collected to measure calcium, phosphorus, uric acid, sodium, potassium, magnesium, oxalate and citrate, and serum calcium levels, phosphorus, uric acid, sodium, potassium, magnesium, chloride, parathormone and urine pH. RESULTS: Among patients with lithiasis, 5.9% (37/630) had staghorn calculus and in 48.6% (18/37) were diagnosed with urinary infection. The females were predominant for 94.5% of cases. The calculi were unilateral in 31 of cases and bilateral in six. Metabolic abnormalities were found in 68.2% of patients with hypercalciuria (64.2%) and hypocitraturia (53.3%) being the most common disorders. CONCLUSIONS: The presence of metabolic disorders in nearly 70% of patients with staghorn calculus reinforces the necessity for evaluation of these patients. The diagnosis and treatment of identified metabolic abnormalities can contribute to the prevention of recurrent staghorn calculi.

Effects of Hibiscus sabdariffa supplementation on metabolism and bladder in obese rats

Purpose: Hibiscus sabdariffa (HS) extract has several health benefits and anti-obesogenic effects. The aim of the present study was to assess whether the medicinal properties attributable to HS would prevent or mitigate bladder changes induced by obesity in an experimental model. Methods: Forty-eight male Wistar rats were submitted to one of four different dietary interventions (12 animals each): G1, standard diet and water (controls); G2, standard diet and HS tea; G3, a palatable high-fat diet and water; and G4, high-fat diet diet and HS tea. The animals were monitored for body weight, feed, and water and tea intake, according to the allocated group. After 16 weeks, the animals were euthanized, and the levels of creatinine, inflammatory cytokines, testosterone, cholesterol, triglycerides, and electrolytes were evaluated. In addition, histopathological analysis of the animals' bladder was performed. Results: Groups receiving HS (G2 and G4) showed decreased levels of the pro-inflammatory cytokine interleukin-1α. HS tea was able to reduce low-density lipoprotein and triglyceride levels in the G2 group compared to other groups. Only in the G3 there was a significant increase in the body weight when it was compared the 12th and 16th weeks. Leptin was shown to be elevated in the groups that received a high-fat diet. There was a significant decrease in the muscle fibers thickness and in the total collagen count in G4 bladder when compared with G1 and G3. Conclusions: HS has an anti-inflammatory role, can reverse hyperlipidemia in rats, and reduced deleterious effects of obesity on these animals' bladder.

Laparoscopic repair of vesicovaginal fistula.

PURPOSE: Vesicovaginal fistula (VVF) is one of the most devastating surgical complications that can occur in women. The primary cause remains an abdominal hysterectomy. Approach to this condition can be transvaginal or transabdominal. Laparoscopic repair of VVF may be an alternative approach to this treating rare condition. We present seven cases of VVF treated with transperitoneal laparoscopic technique and our results. METHODS: We retrospectively reviewed the charts of 7 women ranging from 37 to 74 years in age (mean age 52.8 years) at our institution who underwent laparoscopic transperitoneal repair of VVF between February 2004 and March 2006. Etiology of the VVF, surgical technique, operative time, length of hospital stay, and complications were reviewed. RESULTS: Six of the seven VVFs we repaired laparoscopically resulted from gynecologic procedures, and one patient presented with a VVF after a ureterolithotripsy. Mean operative time ranged from 130 to 420 minutes (mean 280 minutes), and mean hospital stay was 7 days. In one patient conversion to open surgery was necessary due to prolonged operative time. Two complications occurred: a urinary tract infection in one patient and an inferior limb compartment syndrome in another. CONCLUSION: Transvaginal laparoscopic repair of VVF is feasible and safe and provides excellent results. It is a good alternative to the abdominal approach. However, advanced laparoscopic skills are mandatory.

The effects of pharmacist interventions on health outcomes in patients with advanced prostate cancer in Brazil

Abstract This study examined the effects of pharmacist interventions for patients with advanced prostate cancer. A pre-post study was conducted between October 2014 and August 2017 in a community pharmacy in Brazil for outpatients with advanced prostate cancer, aged ≥ 18 years, using cyproterone acetate and/or goserelin. The patients had face-to-face meetings with a pharmacist who dispensed antiandrogenic drugs and performed interventions aimed at solving and/or preventing drug-therapy problems. Primary outcomes regarding prostate-specific antigen (PSA) and testosterone levels were compared at 0, 6, and 12 months, whereas secondary outcomes-medication adherence and quality of life-were compared at baseline and at the 12-month follow-up. Medication adherence was assessed using the Morisky-Green test, and quality of life was measured by the Medical Outcomes Study 36-item Short Form (SF-36) and the Functional Assessment of Cancer Therapy-Prostate (FACT-P). The analysis included 20 patients; 311 drug-therapy problems were identified and most of them were related to adverse reactions (78.5%). The most common adverse reactions were reduced libido, erectile dysfunction, hyperglycemia, fatigue, and gynecomastia. Testosterone levels significantly decreased at 6 months, and PSA levels at 6 and 12 months. No significant changes in adherence were noted at the end of the study. A significant increase in the "pain" domain and an improvement trend in the "physical aspects" and "vitality" domains were observed based on the SF-36 instrument. The findings show that pharmacist interventions were able to improve PSA and testosterone levels, and some domains of quality of life of patients.

Synthetic torso for training in and evaluation of urologic laparoscopic skills.

BACKGROUND: The expanding use of advanced minimally invasive surgical techniques demands more advanced training methods, objective measures of resident performance, and more realistic and anatomically correct training models. MATERIALS AND METHODS: A new synthetic torso for urologic laparoscopy training was developed and assessed. The trainer, Lapman, was based on the Visible Human Model and has the exact shape of a human torso. The torso models the outer shape of the body and the abdominal and pulmonary cavities. Animal or synthetic models of the abdominal organs may be placed in the abdominal cavity. An abdominal wall provides access and seals the cavity and can be replaced after repeated punctures with laparoscopic instruments. The thoracic cavity connects to a pneumatic pump to simulate breathing. In order to render realistic mechanic properties, the torso is cast of materials with elastic properties similar to those of soft tissue and incorporates a synthetic skeleton. These similar mechanical properties and the thoracic insufflation create realistic ventilatory motion simulation. RESULTS: Twenty-five individuals--medical students, residents, and attending urologists--participated in a study comparing Lapman with a standard training box. Lapman presented several advantages over the traditional training box, specifically with regard to internal and external views and the incorporation of a realistically shaped abdominal wall. A significant and recurrent theme was the value of the synthetic wall as a tool to gain a greater appreciation of the importance of port placement. Study participants at all levels of training appreciated that Lapman gives a more realistic approximation of the operative procedure. CONCLUSIONS: The novelty of the trainer consists in its anatomic shape, realistic mechanical properties, and ventilatory simulation. This paper reports on its design, construction, and preliminary tests.

Acanthosis Nigricans associated with clear-cell renal cell carcinoma.

Acanthosis nigricans (AN), an entity recognized since the 19th century, is a dermatopathy associated with insulin-resistant conditions, endocrinopathies, drugs, chromosome abnormalities and neoplasia. The latter, also known as malignant AN, is mostly related to abdominal neoplasms. Malignant AN occurs frequently among elderly patients. In these cases, the onset is subtle, and spreading involves the flexural regions of the body, particularly the axillae, palms, soles, and mucosa. Gastric adenocarcinoma is the most frequent associated neoplasia, but many others have been reported. Renal cell carcinoma (RCC), although already reported, is rarely associated with malignant AN. The authors report the case of a woman who was being treated for depression but presented a long-standing and marked weight loss, followed by darkening of the neck and the axillary regions. Physical examination disclosed a tumoral mass in the left flank and symmetrical, pigmented, velvety, verrucous plaques on both axillae, which is classical for AN. The diagnostic work-up disclosed a huge renal mass, which was resected and further diagnosed as a RCC. The post-operative period was uneventful and the skin alteration was evanescent at the first follow-up consultation. The authors call attention to the association of AN with RCC.

Measurement of needle-tip bioimpedance to facilitate percutaneous access of the urinary and biliary systems: first assessment of an experimental system.

RATIONALE AND OBJECTIVES: Percutaneous access to the renal collecting system or biliary system is most frequently performed under image guidance. However, current techniques lack a feedback mechanism to help confirm successful access. A percutaneous needle system has been developed consisting of a modified 18-gauge percutaneous access needle that measures tissue impedance at its needle tip. Initial results in utilizing this novel system to determine successful access into dilated kidney and gall bladder specimens are reported. METHODS: Impedance measurements were recorded as the needle was precisely advanced through ex vivo kidney and liver/gall bladder specimens. In an anesthetized porcine model, impedance values were recorded with laparoscopic visualization as the needle was advanced percutaneously through abdominal wall, liver, and into gall bladder. RESULTS: A characteristic, reproducible drop in impedance was noted with successful entry into ex vivo distended kidney and gall bladder specimens. This feature was also noted during in vivo percutaneous cholecystostomy. CONCLUSIONS: A measurable, characteristic drop in tissue impedance signifies successful entry into the urinary and biliary systems. This impedance needle system may facilitate current percutaneous access techniques.

Laparoscopic treatment of retroperitoneal fibrosis.

BACKGROUND AND PURPOSE: Retroperitoneal fibrosis (RPF) is an uncommon cause of ureteral obstruction. Surgical treatment is required in most cases. Open ureterolysis, although effective, is associated with significant morbidity and mortality rates. We present data on a series of 13 patients undergoing laparoscopic ureterolysis for RPF. PATIENTS AND METHODS: Between December 1994 and October 2000, 13 patients with RPF underwent laparoscopic ureterolysis at our institution. Operative time, complications, estimated intraoperative blood loss, time to oral intake, amount of parenteral analgesics used, and length of hospital stay were reviewed. Postoperative pyelography or diuretic urography was performed to assess ureteral patency. RESULTS: Laparoscopic ureterolysis was successful in 11 patients (85%); two conversions to open surgery were needed (15%). One patient required a laparoscopic Boari flap on one side because of intense fibrosis. Four postoperative complications (30%) were managed with conservative measures. At a mean follow-up of 30 months, intravenous urography or renal scan showed relief of obstruction in 92% of the patients. CONCLUSIONS: Laparoscopic ureterolysis is an option to treat RPF. It is not free of complications and failures, and its precise role in the treatment of RPF still needs to be judged with longer follow-up and larger number of patients.

Local hemostasis during laparoscopic partial nephrectomy using biodegradable hydrogels: initial porcine results.

BACKGROUND AND PURPOSE: Despite the advance of laparoscopic partial nephrectomy, significant technical limitations remain with regard to control of bleeding and closure of the collecting system. An attractive approach on the horizon for local hemostatic and wound control is the use of local tissue sealants. To date, sealants remain largely derived from natural biologic products and are difficult to apply laparoscopically with precise local control. In this study, we examined the novel strategy of forming occlusive tissue-adherent hydrogels utilizing a synthetic biodegradable polyethylene glycol-lactide copolymer (PEG-lactide) as an in situ occlusive barrier for hemostasis and wound control. Specifically, the objects of this study were to determine if PEG-lactide hydrogels could be formed intraperitoneally on renal tissue, to test the adhesiveness of the hydrogels to injured renal parenchyma, and to evaluate the ability of adherent hydrogel barriers to limit renal parenchymal bleeding and collecting system leakage following renal pole amputation or wedge excision. MATERIALS AND METHODS: Five kidneys from three female pigs were used in a nonsurvival study. A standardized model for laparoscopic partial nephrectomy was created by performing wedge excision or polar amputation under vascular control using a laparoscopic Satinsky clamp. Bleeding briskness following injury was assessed utilizing a scoring system and free blood quantitated comparing a conventional "clamp and wait" strategy with an adherent hydrogel strategy. For the hydrogel group, PEG-lactide hydrogel primer and macromer were applied through laparoscopic ports. The hydrogel was polymerized using a xenon light source, and the pedicle clamp was released to observe for bleeding. A subsequent opposite polar injury was created to confirm renal perfusion and the sites were compared. The kidneys were removed, and the adhesion of the hydrogel to the renal parenchyma was examined. RESULTS: The PEG-lactide macromer was effectively applied to five kidneys following partial nephrectomy. In all cases, successful intraperitoneal in situ polymerization was achieved, with resultant hydrogel formation. Polymeric hydrogel adhesion to the cut renal parenchyma was assessed semiquantitatively following vigorous cyclic washing. In all cases, polymer gels remained adherent without any evidence of peeling, delamination, or separation from the underlying tissue surface. In the control group, the mean bleeding score was 2.63 +/- 0.48 v 0.00 +/- 0.00 in the gel-treated group (P < 0.001). Blood loss in the control group was 56 +/- 5 ml v 0.00 +/- 0.00 in the gel-treated group (P < 0.001). In an ex vivo retrograde ureteral perfusion, no leakage was observed at pressure as high as 100 mm Hg. CONCLUSIONS: In this feasibility study, a biodegradable PEG-lactide polymer system photopolymerized rapidly in situ on exposed renal parenchymal surfaces, forming adherent hydrogel barriers. When applied during vascular clamping, an adequate physical bond and patch-like cap was created to prevent bleeding at physiologic renal perfusion pressures. Use of locally applied occlusive hydrogels holds promise for hemostasis and local wound control during laparoscopic urologic procedures.

Telementoring between Brazil and the United States: initial experience.

BACKGROUND AND PURPOSE: To assess the safety and feasibility of transcontinental telementored and telepresence surgery, we report on two procedures carried out with participation by surgeons in Baltimore in the United States and São Paulo and Recife in Brazil. PATIENTS AND METHODS: Over a period of 3 months, a laparoscopic bilateral varicocelectomy and a percutaneous renal access for a percutaneous nephrolithotomy were performed. The mentoring surgeon (LRK) was the same for both procedures. He used a 650-MHz personal computer fitted with a Z360 video COder/ DECoder (CODEC) and a Z208 communication board (Zydacron Corp, Manchester, NH) that comprise the core of the telesurgical station. In the first case, a surgical robot, AESOP 3000 (Computer Motion Inc.), was attached to a laparoscope, and the remote surgeon drove the robot via a controller on the remote computer. In the second case, another robot (Percutaneous Access to the Kidney; PAKY) was used for percutaneous needle placement into the renal collecting system. RESULTS: The two procedures were completed successfully. In the first case, the operative time was 25 minutes, with minimal estimated blood loss. The patient was discharged home the next day. At 3-month follow-up, there was no scrotal pain or varicocele. In the second case, access to the urinary tract was achieved with the first needle pass, and percutaneous nephrolithotomy was uneventful. Blood loss was minimal, and the patient was discharged home on the second postoperative day. At 3-month follow-up, the patient was free of urinary stones and of symptoms. CONCLUSIONS: The first transcontinental telementored and telepresence urologic surgical procedures have been reported previously. The success observed with the novel surgical techniques has motivated great interest. The cases reported here demonstrate that several types of procedures can be mentored safely and effectively with telemedicine technology.

Granulosa cell tumor of the testis in a newborn.

Testicular neoplasms are uncommon tumors of childhood. These tumors comprise the germ cell tumors, and other tumors that may originate from histological testicular components, which are unrelated to the germinal lineage. Among the latter are the sex cord-stromal tumors (SCST), an important entity in newborns. SCSTs comprise, among others, granulosa cell tumors, which are more common in the ovary, but in rare cases may develop in the testis. The prognosis is excellent since it is universally benign. Diagnosis, which is sometimes challenging, is usually made after orchiectomy and pathological examination, which is characterized by morphological features and positive expression of inhibin, calretinin, and vimentin, and negative for alpha-fetoprotein. The authors present the case of a newborn with a right enlarged testis detected during the first examination after birth. Ultrasonography showed a heterogeneous solid/cystic mass in the right testis, without retroperitoneal lymphadenopathy. A right inguinal orchiectomy was performed 21 hours after birth. Pathologic examination revealed a juvenile granulosa cell tumor of the right testicle. After 4 years of follow-up, as expected, the child presented an uneventful outcome.

Unusual presentation of high-grade neuroendocrine carcinoma of the Urinary bladder with small-cell and large-cell features.

High-grade neuroendocrine carcinoma of the urinary bladder comprehends small-cell and large-cell variants. It is a rare and aggressive neoplasm, mostly diagnosed in advanced stages. It is more frequently encountered among Caucasian men in the sixth decade of life. Urinary symptoms are the most common clinical presentation. Diagnosis is generally not troublesome once the lesions are easily detectable by imaging exams and cystoscopy. This neoplasia is associated with tobacco smoking, and is frequently associated with other carcinomatous components such as urothelial carcinoma, adenocarcinoma, and sarcomatoid carcinoma. The authors report a case of an apparently healthy female patient who presented cervical lymph node enlargement not accompanied by systemic symptoms. The supraclavicular lymph node biopsy revealed metastatic small cell carcinoma. The computed tomography scan showed a bladder wall nodular thickening, enlarged lymph nodes along the iliac, periaortic, mediastinal, cervical and supraclavicular chains, as well as an insufflating lytic bone lesion in the right iliac wing. The positron emission tomography-fluorodeoxyglucose (PET-FDG) added to these findings, the presence of a paraesophageal lymph node, lymphadenomegaly in the gluteal region and a vertebral lytic lesion in T10. Resected specimen of the bladder tumor revealed a high-grade neuroendocrine carcinoma with small-cell and large-cell features.

Comparative study between porcine small intestinal submucosa and buccal mucosa in a partial urethra substitution in rabbits.

PURPOSE: Several urethral conditions may require tissue substitution. One collagen-base biomaterial that recently emerged as an option is small intestinal submucosa (SIS). The aim of this study was to compare the results of SIS and buccal mucosa for urethral substitution in rabbits. MATERIALS AND METHODS: Thirty-six North Folk male rabbits were randomized into three groups. In all animals, a 10 × 5 mm urethral segment was excised, and the urethral defect was repaired using a one-layer SIS patch (group I [GI]); four-layer SIS (group II [GII]); or buccal mucosa (group III [GIII]). Urethrography was performed preoperatively and after 12 weeks. After sacrifice, graft retraction was objectively measured using Scion Image(®) computer analysis and by calculation of ellipse area. The grade of fibrosis, inflammatory reaction, vascular/epithelial regeneration, and collagen III/I ratio were analyzed by hematoxylin/eosin and Picrosirius red staining. RESULTS: Urethrography confirmed a wide urethral caliber without any signs of strictures after surgery. Urethral fistulae was diagnosed in 8.3% of cases (1 animal each group). Average graft shrinkage was 55.2% in GI; 44.2% in GII; and 57.2% in GIII (p<0.05). The intensity of chronic inflammation, fibrosis, epithelium regeneration, and neovascularization was similar in all groups (p>0.05). Collagen III/I ratio was higher in GII (GI: 119.6; GII: 257.2 and GIII: 115.0); p<0.01. CONCLUSIONS: The four-layer SIS is more advantageous than the one-layer SIS and buccal mucosa for urethral substitution in rabbits.

Current practices in the management of patients with ureteral calculi in the emergency room of a university hospital.

OBJECTIVE: Urinary lithiasis is a common disease. The aim of the present study is to assess the knowledge regarding the diagnosis, treatment and recommendations given to patients with ureteral colic by professionals of an academic hospital. MATERIALS AND METHODS: Sixty-five physicians were interviewed about previous experience with guidelines regarding ureteral colic and how they manage patients with ureteral colic in regards to diagnosis, treatment and the information provided to the patients. RESULTS: Thirty-six percent of the interviewed physicians were surgeons, and 64% were clinicians. Forty-one percent of the physicians reported experience with ureterolithiasis guidelines. Seventy-two percent indicated that they use noncontrast CT scans for the diagnosis of lithiasis. All of the respondents prescribe hydration, primarily for the improvement of stone elimination (39.3%). The average number of drugs used was 3.5. The combination of nonsteroidal anti-inflammatory drugs and opioids was reported by 54% of the physicians (i.e., 59% of surgeons and 25.6% of clinicians used this combination of drugs) (p = 0.014). Only 21.3% prescribe alpha blockers. CONCLUSION: Reported experience with guidelines had little impact on several habitual practices. For example, only 21.3% of the respondents indicated that they prescribed alpha blockers; however, alpha blockers may increase stone elimination by up to 54%. Furthermore, although a meta-analysis demonstrated that hydration had no effect on the transit time of the stone or on the pain, the majority of the physicians reported that they prescribed more than 500 ml of fluid. Dipyrone, hyoscine, nonsteroidal anti-inflammatory drugs, and opioids were identified as the most frequently prescribed drug combination. The information regarding the time for the passage of urinary stones was inconsistent. The development of continuing education programs regarding ureteral colic in the emergency room is necessary.

Spindle-cell carcinoma of the prostate.

Sarcoma of the prostate and sarcomatoid carcinoma of the prostate are rare conditions, both characterized by a poor prognosis. Sarcomatoid carcinoma of the prostate typically arises from the evolution of an underlying adenocarcinoma, occasionally featuring heterologous elements, bulky disease being possible but rare. In contrast, sarcoma of the prostate derives from non-epithelial mesenchymal components of the prostatic stroma, shows rapid growth, and frequently presents as massive pelvic tumors obstructing the urinary tract at the time of diagnosis. We report the case of a 55-year-old patient with a two-month history of symptoms of urinary obstruction. The patient presented with an extremely enlarged heterogeneous prostate, although his prostate-specific antigen level was low. The lack of a history of prostatic neoplasia led us to suspect sarcoma, and a transrectal prostate biopsy was carried out. An immunohistochemical study of the biopsy specimen did not confirm the clinical suspicion. However, in view of the clinical features, we believe that sarcoma of the prostate was the most likely diagnosis. The patient received neoadjuvant chemotherapy followed by radiation therapy. At this writing, surgical resection had yet to be scheduled.