Outcomes of urethral meatal preservation ventral urethroplasty for female urethral stricture: a series of cases

Abstract Objective: To present a series of cases with our initial experience and short-term outcomes of a modified vaginal mucosal flap urethroplasty. Methods: Patients diagnosed with urethral stricture and operated by the same operative technique between January 2012 and January 2018 were followed for at least 6 months. Uroflowmetry and clinical outcomes were evaluated. Results: Nineteen patients were included with an average age of 56.4 years, mean preoperative Qmax of 5.3 ml/s, and PVR of 101.4 mL. After 6 months of the procedure, the mean Qmax improved to 14.7 mL/s (p<0.05), PVR decreased to 47.3 mL (p<0.05), and 84.2% of all patients reported improvement in clinical self-reported symptoms. There was an improvement in symptoms such as voiding effort in 84.2% of patients, weak stream (89.5%), and recurrent urinary tract infection (85.7%). The success rate (absence of symptoms and normal Qmax with no significant PVR) of the procedure was 84.2%. Conclusion: The described technique was considered effective for the treatment of female urethra stricture, with a high clinical success rate and an objective improvement of Qmax and decrease in PVR after 6 months of the procedure.

Urethral leiomyoma: combined vaginal and abdominal approach - a case report / Mioma uretral: abordagem combinada vaginal e abdominal - um relato de caso

Abstract Introduction: leiomyomas are benign mesenchymal tumors of smooth muscle origin that can develop in various locations. Urethral leiomyomas are rare, with approximately only 120 cases reported in the literature. These tumors often occur in the third and fourth decades of life but are rare in menopausal patients. In general, treatment involves surgery, only three recurrence reports in the literature. Description: a case report on a 56-year-old woman; the patient had type II diabetes mellitus and chronic high blood pressure, was overweight (body mass index, 27.1 kg/m2), and a smoker. Besides this, the patient presented symptoms of urinary obstruction and had a large urethral leiomyoma. The tumor was completely removed with no associated urethral lesions using a complex, combined abdominalvaginal surgical approach. Discussion: the management and treatment on urethral leiomyomas is challenging and have not been established yet due to the rarity of these tumors.

Resumo Introdução: os leiomiomas são tumores mesenquimais benignos de origem muscular lisa, podendo manifestar-se em diversas localizações. Os leiomiomas uretrais são raros, tendo apenas aproximadamente 120 casos relatados na literatura. São mais comuns na terceira e quarta décadas de vida, sendo raros em pacientes menopausadas. Em geral, são tratados cirurgicamente, com apenas três relatos de recidivas na literatura. Descrição: relato de caso de uma paciente do sexo feminino, 56 anos, portadora de diabetes mellitus do tipo II, hipertensão arterial crônica, sobrepeso (IMC 27,1Kg/m2) e tabagismo. Além disso, com quadro de sintomas obstrutivos urinários e portadora de um grande leiomioma uretral, este que foi completamente removido, através de uma desafiadora abordagem cirúrgica combinada (abdominal e vaginal), sem lesões uretrais associadas. Discussão: os leiomiomas uretrais são tumores raros e seu manejo é desafiador e ainda não foi estabelecido.

Disfunción miccional en el adulto. Un artículo docente / Voiding dysfunction in the adult. A teaching article

Voiding dysfunction is defined as an abnormally slow and/or incomplete micturition, and can be divided in bladder outlet obstruction (BOO) and detrusor underactivity (or hypocontractility). BOO is characterized by reduced urine flow rate and increased detrusor pressure, and can be of anatomical or functional origin. Detrusor underactivity encompasses a reduced urine flow rate associated to low pressure and/or poorly sustained detrusor contraction, and its etiology is multifactorial. Lower urinary tract symptoms are classified as storage, voiding and post micturition symptoms, may be objectively quantified with specific questionnaires, and don't correlate properly with voiding dysfunction. Patients' evaluation requires a directed physical examination of the abdomen, pelvis and genitals focused to detect anatomical and neurological abnormalities. Voiding dysfunction can be demonstrated non-invasively using uroflowmetry and pelvic ultrasound. Uroflowmetry allows determining urinary flow characteristics and their most important parameters are voided volume, maximum flow rate and shape of the curve. Pelvic ultrasound permits to estimate prostatic size and post void residual, suspect detrusor hypertrophy (due to BOO) and detect bladder stones. Invasive test must be reserved for special cases of confirmed voiding dysfunction: cystoscopy when there is concomitant hematuria, urethrocystography to study urethral stenosis and urodynamics to differentiate BOO from detrusor underactivity. (AU)

Mejora de las variaciones en la ecografía vesical Evaluación del volumen de orina residual posmiccional en obstrucción moderada de la salida de la vejiga / Improving Variations in Bladder Ultrasound Assessment of Post-Void Residual Urine Volume in Moderate Bladder Outlet Obstruction

Objectives: This study aimed to assess the accuracy of post-void residual (PVR) urine volume measurements in patients with moderate bladder outlet obstruction. Materials and Methods: This prospective observational study was conducted between January and December 2019. The inclusion criteria were male patients with symptoms of moderate bladder outlet obstruction. On the other hand, patients with a history of diabetes, symptoms of urinary tract infection, and positive urine for pyuria, as well as patients using medications, such as diuretics, alphablockers, and anticholinergic drugs, were excluded. The patients were asked to drink 1000 mL of water one to two hours before the initial ultrasound scan. Pre-void bladder capacity was measured, followed by a post-void ultrasound for residual urine volume measurement at three intervals: immediately after voiding, 15-20 minutes after the first void, and one week later with an empty bladder. Assessment of per-void capacity was carried out, based on the patient's subjective sensation of bladder fullness (a strong desire to void). Results: A total of 78 male patients, with the mean age of 60 years, were included in this study (27 cases in group I; 37 cases in group II; and 14 cases in group III). The mean PVR volume was 92 mL in the first measurement, 62 mL in the second measurement, and 60 mL in the third measurement. Significant differences were found between the first and second PVR measurements and between the first and third PVR measurements (P<0.05). However, no significant difference was found between the second and third PVR measurements (P=0.107). On the other hand, significant differences were found between groups I and II and between groups I and III (P<0.05) in the three PVR measurements. Nevertheless, there was no significant difference between groups II and III in the three PVR measurements (P=0.204, 0.56, and 0.487 for the first, second, and third PVR measurements, respectively). Conclusion: A bladder ultrasound must be performed and interpreted carefully to avoid further unnecessary medications, investigations, or procedures. We recommend a second PVR measurement in patients with bladder outlet obstruction. Also, it is suggested to conduct similar studies in different conditions to confirm our findings.

Detrusor underactivity versus bladder outlet obstruction clinical and urodynamic factors

ABSTRACT Objectives: To evaluate the lower urinary tract symptoms, classified by the International Prostate Symptom Score (IPSS), urodynamic results (Watts Factor (WF), Bladder Contractility Index (BCI), and post void residual (PVR), in order to differentiate Detrusor Underactivity (DU) from Bladder Outlet Obstruction (BOO). Methods: Retrospective observational study performed from 2011 to 2018 at the Hospital das Clínicas of Unicamp. Two phases were done: first, to estimate sample size, and second, to evaluate the predicted parameters. Male patients with range age from 40 to 80 years were included. Patients were divided into two groups: Group 1, without BOO and with DU; Group 2, with BOO. Variables analyzed: age, comorbidities, symptoms, urodynamic data (BCI and WF) and PVR. Results: Twenty-two patients were included in each group, with medians of 68 (Group 1) and 67.5 years old (Group 2) (p = 0.8416). There was no difference for comorbidities. In relation to IPSS, medians were: 16.5 and 20.5, respectively (p = 0.858). As for symptoms, there was predominance of combination of storage and voiding symptoms in the two groups (p = 0.1810). Regarding PVR, 15 patients in Group 1 and 16 in Group 2 presented PVR> 30mL (p = 0.7411). BCI presented median values of 75 and 755.50 for Group 1 and Group 2, respectively (p <0.0001), while WF had medians of 22.42 and 73.85 (p <0.0001). Conclusion: Isolated symptoms, classified by IPSS and PVR, could not differentiate patients with DU from those with BOO, but it was possible using urodynamic data.

A new surgical technique: transvesical prostate resection

ABSTRACT Objectives: Surgical treatment is indicated in patients where medical therapy fails to prove beneficial or in patients who develop complications related with bladder outlet obstruction. In our study, we developed a new surgical technique which can be defined as Transvesical Resection of Prostate (TVRP) without using the urethra. This method was previously described in our articles (1). Materials and Methods: A 62-years-old male patient, using an alpha blocker agent for 5 years, reported increased discomfort with urination. His findings were as follows: PSA: 1.2 ng/dL, prostate volume: 45 cc, digital rectal examination: benign, IPSS: 30, QoL: 5, Qmax: 6, urine volume: 225 cc, post-mictional residue: 65 cc. Eventually the patient was informed and prostate resection decision was made. Results: Suprapubic catheter was removed 1 day after surgery and the patient was discharged. Urethral catheter was removed 4 days after urine output became clear. No complications developed after the operation. At postoperative 1st month, Qmax was 22, urine volume was 260 cc, post-mictional residue was 40 cc, IPSS was 8, QoL was 1, and the pathology was benign prostate tissue. Conclusions: Urethral stricture is one of the most important postoperative complications of TURP. The incidence of urethral stricture is reported between 2.2% and 9.8% in different series (2-5). In this technique which we developed, urethra is not used and prostate is removed through the bladder, similar to open prostatectomies. For this reason, we suggest that it has an advantage over TURP, regarding urethral stricture development.

Correlation of tools for objective evaluation of infravesical obstruction of men with lower urinary tract symptoms

ABSTRACT Purpose To identify how the most frequently used parameters in daily clinical practice diagnosing bladder outlet obstruction (BOO) due to benign prostate hyperplasia (BPH) correlate to each other. Materials and methods The study included 452 patients with lower urinary tract symptoms (LUTS) of the UNICAMP urology outpatient clinic of LUTS. Inclusion criteria: patients with BOO due to BPH who agreed to participate in the study. Exclusion criteria: patients with urinary tract infection, neurological diseases that compromised the lower urinary tract, prior prostatic surgery, radiotherapy or urethral stenosis. Patient assessment: history, international prostate symptoms score (IPSS), nocturnal quality of life score (NQoL) questionnaires, physical and digital rectal examination (DRE), PSA, transabdominal ultrasound with intravesical prostate protrusion (IPP), post-mictional residue and free uroflowmetry. Results There was no strong Spearman correlation among the studied variables. The only moderate correlations occurred between IPSS and NQoL (p <0001; c=0.56) and between IPP and prostate volume (p <0001; c=0.57). Weak correlations between IPP and post-mictional residue (p <0001; c=0.31) and free uroflowmetry (p <0001; c=-0.26); and between IPSS and free uroflowmetry (p <0001, c=-0.21) were observed. Conclusion In this study, we found moderate, weak, very weak and absent correlation among the various parameters used in the diagnosis and management of BOO due to BPH. As the value of these tools is variable, the creation of a logical and objective algorithm was not possible and the treatment is based on the interpretation of clinical symptoms.

Safety and effectiveness evaluation of open reanastomosis for obliterative or recalcitrant anastomotic stricture after radical retropubic prostatectomy

ABSTRACT Purpose: To evaluate safety, efficacy and functional outcomes after open vesicourethral re - anastomosis using different approaches based on previous urinary continence. Materials and Methods: Retrospective study of patients treated from 2002 to 2017 due to vesicourethral anastomosis stricture (VUAS) post radical prostatectomy (RP) who failed endoscopic treatment with at least 3 months of follow-up. Continent and incontinent patients post RP were assigned to abdominal (AA) or perineal approach (PA), respectively. Demographic and perioperative variables were registered. Follow-up was completed with clinical interview, uroflowmetry and cystoscopy every 4 months. Success was defined as asymptomatic patients with urethral lumen that allows a 14 French flexible cystoscope. Results: Twenty patients underwent open re-anastomosis for VUAS after RP between 2002 and 2017. Mean age was 63.7 years (standard deviation 1.4) and median follow-up was 10 months (range 3 - 112). The approach distribution was PA 10 patients (50%) and AA 10 patients (50%). The mean surgery time and median hospital time were 246.2 ± 35.8 minutes and 4 days (range 2 - 10), respectively with no differences between approaches. No significant complication rate was found. Three patients in the AA group had gait disorder with favorable evolution and no sequels. Estimated 2 years primary success rate was 80%. After primary procedures 89.9% remained stenosis - free. All PA patients remained incontinent, and 90% AA remained continent during follow-up. Conclusion: Open vesicourethral re - anastomosis treatment is a reasonable treatment option for recurrent VUAS after RP. All patients with perineal approach remained incontinent while incontinence rate in abdominal approach was rather low.

Factores de riesgo de estenosis de cuello vesical asociada a prostatectomía radical por carcinoma prostático ­ experiencia en un único centro / Risk Factors of Bladder Neck Contracture after Radical Prostatectomy ­ A Single Institutional Experience

Objetivo La estenosis de la anastomosis uretrovesical (EAU-V) afecta al 8,4% de pacientes intervenidos de prostatectomía radical retropúbica por cáncer. Nuestro propósito fue estudiar los factores de riesgo de estenosis de cuello vesical asociada a prostatectomía radical por carcinoma prostático en nuestro centro. Material y Métodos Estudio de casos-controles en una cohorte constituida por 120 pacientes intervenidos por adenocarcinoma prostático entre 2005 y 2012. Realizamos un análisis descriptivo de la muestra y el cálculo de la incidencia de EAU-V, un análisis univariante de los factores asociados mediante la t de Student y la chi cuadrado de Pearson, un análisis del tiempo transcurrido hasta la aparición de estenosis y una predicción del riesgo de EAU-V. Resultados La incidencia de EAU-V tras prostatectomía radical en nuestro servicio fue del 22,5%. Encontramos mayor riesgo en aquellos pacientes con débito por drenaje Jackson-Pratt (J-P) mayor de 500cc, drenaje J-P retirado después del tercer día, estancia superior a 8 días, hemoglobina postoperatoria baja, PSA preoperatorio bajo, densidad de PSA elevada o que fueron intervenidos por el cirujano 1 o 5. Todas las estenosis se produjeron en los 3 primeros años tras la cirugía. Los pacientes con un débito del drenaje por encima de 500cc y en los que el drenaje se retiró después del tercer día tienen 7,7 y 3,2 veces, respectivamente, más riesgo de padecer una EAU-V. Conclusiones Nuestra incidencia de EAU-V y sus factores asociados coinciden con los publicados. El modelo predictivo desarrollado tiene utilidad meramente teórica ya que no abarca la totalidad de los factores que pueden influir en la aparición de la estenosis

Background Postprostatectomy vesicourethral anastomotic stenosis (VUAS) occurs in 8.4% of prostate cancer patients undergoing retropubic radical prostatectomy (RRP). Our purpose was to study the risk factors of bladder neck contracture after radical prostatectomy in our center. Materials and Methods Retrospective nested case-control study in a hospital-based cohort consisting of 120 patients underwent open or laparoscopic RRP from 2005 to 2012. We performed a descriptive analysis of the sample and calculated the incidence of postsurgical VUAS, a univariate analysis of factors associated with VUAS by Student t test and Pearson chi-square test, an analysis of time to onset of stricture and a prediction of risk of stricture in patients undergoing RRP. Results The incidence of VUAS after radical prostatectomy in our department was 22.5%. We found a higher risk in patients in which surgical drainage was over 500cc, the Jackson-Pratt drain was removed after the third day, length of stay >8 days, a low postoperative haemoglobin, a low preoperative PSA, an elevated PSA density and/or were operated on by surgeon 1 or 5. All strictures occurred within the first 3 years after surgery. We predicted that patients with total drainage volume over 500cc and removal day after the third day would be 7.72 and 3.21 times more likely to have VUAS, respectively. Conclusions Data from VUAS incidence and its associated factors are similar to those found in the literature. The developed predictive model has only a theoretical utility, because it does not cover all the influencing factors of the onset of the stricture.

Oxidative stress in the bladder of men with LUTS undergoing open prostatectomy: a pilot study

ABSTRACT Purpose: This study aims to evaluate the link between preoperative parameters and oxidative stress (OS) markers in the bladder wall of men undergoing open prostatectomy. Materials and Methods: From July 2014 to August 2016, men aged ≥ 50 years and presenting with LUTS were prospectively enrolled. Preoperative assessment included validated questionnaires (IPSS and OAB - V8), lower urinary tract ultrasound and urodynamics. Bladder biopsies were taken during open prostatectomy for determination of OS markers. Increased OS was defined by increased concentration of malondialdehyde (MDA) and / or decreased concentration of antioxidant enzymes (superoxide dismutase and / or catalase). P<0.05 was regarded as statistically significant. Results: Thirty - eight consecutive patients were included. Mean age was 66.36 ± 6.44 years, mean prostate volume was 77.7 ± 20.63 cm3, and mean IPSS was 11.05 ± 8.72 points. MDA concentration was increased in men with severe bladder outlet obstruction (BOO grade V - VI according to the Schaefer's nomogram) in comparison with BOO grade III - IV (p = 0.022). Patients with severe LUTS also had higher MDA concentration when compared to those with mild LUTS (p = 0.031). There was a statistically significant association between increased post - void residual urine (cut off ≥ 50 mL) and not only higher levels of MDA, but also reduced activity of SOD and catalase (p < 0.05). Conclusions: This pilot study showed that severity of LUTS and BOO were associated with increased MDA concentration in the bladder wall of men undergoing open prostatectomy. Further studies are still needed to assess the role of non - invasive biomarkers of OS in predicting bladder dysfunction in men with LUTS.

A new surgical technique: transvesical resection of prostate - case series

ABSTRACT Objective: To protect the urethra from instrumentation related urethra injures and stricture, we developed a new surgical technique which can be defined as transvesical resection of prostate without using urethra. Materials and Methods: Our study included 12 consecutive bladder outlet obstruction patients treated with transvesical prostate resection in our clinic between March 2016 and May 2016. Detailed anamnesis, results of physical examination, digital rectal examination, routine lab tests, international prostate symptoms score, transrectal ultrasound, measurement of prostate-specific antigen levels and uroflowmetry was performed in all patients prior to surgery. Results: Hospitalization period following surgery was 1 day. Foley catheter and suprapubic cystostomy catheters were removed in a median period of 3.6 days and 1 day. Median mass of resected adenomas was measured as 21.8 gr. Median maximum flow rate was measured as 6mL/s. Median postvoid residual urine volume was 70.6 cc and median international prostate symptoms score and quality of life scores were 9 and 1.4, respectively. Conclusion: In this study, we would like to show the possible practicality of transvesical resection of prostate technique in this patient group. However, we think that this technique is very useful in special patient groups such as patients with bladder stones, priapism and penile prosthesis.

Pseudotumor vesical a causa de un dispositivo intrauterino / Vesical pseudotumor due to an intra-uterine device

Se describe el caso clínico de una paciente atendida en el Hospital Oncológico Docente Provincial Conrado Benítez García de Santiago de Cuba por presentar una perforación en la vejiga y desplazamiento de un dispositivo intrauterino hacia la cavidad vesical, lo cual generó la formación de litiasis y, consecuentemente, la aparición de frecuentes infecciones urinarias y dolor en bajo vientre, sin mejoría alguna ante la terapéutica aplicada. Se decidió realizar una cistotomía para extraer la litiasis compacta junto con la T de cobre; la paciente evolucionó favorablemente y los síntomas desaparecieron

The case report of a patient assisted in Conrado Benítez García Teaching Provincial Cancer Hospital in Santiago de Cuba is described, due to a bladder perforation and displacement of an intra-uterine device toward the vesical cavity, which generated the lithiasis formation and, consequently, emergence of frequent urinary infections and pain in lower abdomen, without any improvement with therapy. It was decided to carry out a cystotomy to extract the lithiasis compacted with the copper T; the patient had a favorable clinical course and the symptoms disappeared

Obstrução do Trato Urinário Baixo Fetal / Fetal lower urinary tract obstruction

A obstrução do trato urinário baixo fetal (fetal lower urinary tract obstruction - LUTO) é uma patologia caracterizada por dilatação da bexiga e hidronefrose bilateral causada por obstrução do trato urinário inferior. Sua incidência é de 2,2 em cada 10.000 nascimentos. A etiologia da LUTO inclui a válvula da uretra posterior (VUP), atresia ou estenose uretral. O diagnóstico é feito por ultrassom, que mostra bexiga dilatada, com paredes espessas (megabexiga), e uretra posterior aumentada. O tratamento cirúrgico clássico (derivação vésico-amniótica guiada por ultrassom) estaria indicado quando o líquido amniótico normal começa a diminuir, com aumento da distensão vesical e da hidronefrose. O tratamento inclui a colocação de derivação vésico-amniótica guiado pelo ultrassom e fetoscópica com coagulação a laser. De acordo com a gravidade, a LUTO é classificada nos estágios 1,2 e 3.(AU)

The Fetal Lower Urinary Tract Obstruction (LUTO) is a spectrum of diseases characterized by bladder distension and bilateral hydronephrosis in consequence of the LUTO. The incidence is approximately 2.2 in 10,000 births and it is commonly diagnosed during the late first or early second trimester of pregnancy. The etiologies of LUTO include posterior urethral valves, urethral atresia and urethral stenosis. Complete bladder outlet obstruction (severe LUTO) is associated with high perinatal mortality due to pulmonary hypoplasia and severe renal impairment/damage. The prenatal intervention includes vesicoamniotic shunt placement guided by ultrasound and fetoscopic laser coagulation. It is suggested that LUTO patients could be categorized in three stages according to disease gravity: Stages 1, 2 and 3.(AU)

Surgical treatment of detrusor underactivity: a short term proof of concept study

ABSTRACT Objectives To compare the surgical outcomes of men with bladder outlet obstruction (BOO) due to benign prostatic obstruction (BPO) to those with detrusor underactivity (DU) or acontractile detrusor (DA). Materials and Methods This retrospective, IRB approved study included men who underwent BPO surgery for refractory LUTS or urinary retention. Patients were grouped based on videourodynamic (VUDS) findings: 1) men with BOO, 2) men with DU and 3) men with DA. The primary outcome measure was the Patient Global Impression of Improvement (PGII). Secondary outcome measures included uroflow (Qmax), post-void residual volume (PVR) and the need for clean intermittent catheterization (CIC). Results One hundred and nineteen patients were evaluated: 1) 34 with BOO, 2) 62 with DU and 3) 23 with DA. Subjective success rate (PGII) was highest in the BOO group (97%) and those with DU (98%), while DA patients had a PGII success of 26%, (p<0.0001). After surgery, patients with BOO had the lowest PVR (68.5mL). Fifty-six patients (47%) performed CIC pre-operatively (47% of BOO, 32% of DU and 87% of DA patients). None of the patients in the BOO and DU groups required CIC post operatively compared to16/23 (69%) of patients in the DA group (p<0.0001). Conclusions BPO surgery is a viable treatment option in men with presumed BOO and DU while DA is a poor prognostic sign in men who do not void spontaneously pre-operatively.

Effects of nitric oxide inhibitors in mice with bladder outlet obstruction

ABSTRACT Purpose To investigate the lower urinary tract changes in mice treated with L-NAME, a non-selective competitive inhibitor of nitric oxide synthase (NOS), or aminoguanidine, a competitive inhibitor of inducible nitric oxide synthase (iNOS), after 5 weeks of partial bladder outlet obstruction (BOO), in order to evaluate the role of constitutive and non-constitutive NOS in the pathogenesis of this experimental condition. Materials and Methods C57BL6 male mice were partially obstructed and randomly allocated into 6 groups: Sham, Sham + L-NAME, Sham + aminoguanidine, BOO, BOO + L-NAME and BOO + aminoguanidine. After 5 weeks, bladder weight was obtained and cystometry and tissue bath contractile studies were performed. Results BOO animals showed increase of non-voiding contractions (NVC) and bladder capacity, and also less contractile response to Carbachol and Electric Field Stimulation. Inhibition of NOS isoforms improved bladder capacity and compliance in BOO animals. L-NAME caused more NVC, prevented bladder weight gain and leaded to augmented contractile responses at muscarinic and electric stimulation. Aminoguanidine diminished NVC, but did not avoid bladder weight gain in BOO animals and did not improve contractile responses. Conclusion It can be hypothesized that chronic inhibition of three NOS isoforms in BOO animals leaded to worsening of bladder function, while selective inhibition of iNOS did not improve responses, what suggests that, in BOO animals, alterations are related to constitutive NOS.

Mitomicina C: Una Nueva Alternativa para la Estenosis de Cuello Vesical / Mitomycin C: A New Alternative for Bladder Neck Stenosis

Introducción: La mitomicina C es un agente quimiotera-péutico en virtud a su actividad antiproliferativa y anti-biótica. Se evalúa el resultado de la cervicotomía radial endoscópica combinada con la inyección intralesional de mitomicina C para el tratamiento de las estenosis severas de cuello vesical luego del fracaso del trata-miento tradicional. Materiales y método: Revisión retrospectiva de los pa-cientes con estenosis severa de cuello vesical intervenidos entre julio de 2013 y agosto de 2015 con la utilización de mitomicina C. El 54.5% de los pacientes había fracasado al menos una vez con la realización de cervicotomía interna y/o resección endoscópica de cuello vesical. En nuestra intervención se realizaron tres o cuatro incisiones endoscópicas con corte frío en el cuello de la vejiga, seguido por la inyección intralesional de 0.3 a 0.4 mg/ml de mitomicina C en cada sitio de incisión. Resultados: Un total de 11 pacientes fueron tratados con incisión endoscópica con corte frío en el cuello de la vejiga combinado con la inyección de mitomicina C. Antes de la operación, 4 pacientes (36%) eran usuarios de cistotomía. En un seguimiento medio de 9 meses (rango 1-20) 9 pacientes (82%) se encuentran con micción espontánea posterior a un procedimiento, mientras que 2 pacientes (18%) lograron dicho objetivo después de 2 procedimientos con utilización de mitomicina C. Conclusiones: El tratamiento para la estenosis del cuello vesical con cervicotomía radial endoscópica con corte frío combinada con inyección intralesional de mitomicina C, resultó en la permeabilidad del cuello vesical en el 82% de los pacientes después de 1 procedimiento y en el 100% después de 2 procedimientos. Aunque los primeros resultados son prometedores, se requiere de estudios prospectivos y aleatorizados con seguimiento prolongado en el tiempo para validar estos hallazgos.

Introduction: The mitomycin C is a chemotherapeutic agent by virtue of its antiproliferative and antibiotic ac-tivity. We evaluated the outcome of endoscopic radial cervicotomy combined with intralesional mitomycin C injection for the treatment of severe bladder neck ste-nosis after traditional treatment failure.Materials and methods: It was a retrospective review of patients with severe bladder neck stenosis who had a surgery between July 2013 and August 2015 with mi-tomycin C. The 54.5% of patients had failed at least 1 time with internal cervicotomy and/or endoscopic re-section of the bladder neck. In our intervention, three or four endoscopic incisions were performed with a cold cut in the neck of the bladder, followed by intralesio-nal injection of 0.3 to 0.4 mg / ml of the mitomycin C at each incision site.Results: A total of 11 patients were treated with endos-copic incision with a cold cut in the neck of the bladder combined with mitomycin C injection. Before the sur-gery 4 patients (36%) were cystostomy users. At a mean follow-up of 9 months (range 1-20), 9 patients (82%) had spontaneous urine after 1 procedure, while 2 patients (18%) achieved this goal after 2 procedures using mi-tomycin C.Conclusions: The treatment for bladder neck stenosis with endoscopic radial cervicotomy with cold cut com-bined with intralesional mitomycin C injection resulted in bladder neck permeability in 82% of patients after 1 procedure and 100% after 2 procedures. Although the first results are promising, some prospective and rando-mized studies with long-term monitoring are required to validate these findings.

Analysis of risk factors leading to postoperative urethral stricture and bladder neck contracture following transurethral resection of prostate

ABSTRACT Purpose: To determine risk factors of postoperative urethral stricture (US) and vesical neck contracture (BNC) after transurethral resection of prostate (TURP) from perioperative parameters. Materials and Methods: 373 patients underwent TURP in a Chinese center for lower urinary tract symptoms suggestive of benign prostatic obstruction (LUTS/BPO), with their perioperative and follow-up clinical data being collected. Univariate analyses were used to determine variables which had correlation with the incidence of US and BNC before logistic regression being applied to find out independent risk factors. Results: The median follow-up was 29.3 months with the incidence of US and BNC being 7.8% and 5.4% respectively. Resection speed, reduction in hemoglobin (ΔHb) and hematocrit (ΔHCT) levels, incidence of urethral mucosa rupture, re-catheterization and continuous infection had significant correlation with US, while PSA level, storage score, total prostate volume (TPV), transitional zone volume (TZV), transitional zone index (TZI), resection time and resected gland weight had significant correlation with BNC. Lower resection speed (OR=0.48), urethral mucosa rupture (OR=2.44) and continuous infection (OR=1.49) as well as higher storage score (OR=2.51) and lower TPV (OR=0.15) were found to be the independent risk factors of US and BNC respectively. Conclusions: Lower resection speed, intraoperative urethral mucosa rupture and postoperative continuous infection were associated with a higher risk of US while severer storage phase symptom and smaller prostate size were associated with a higher risk of BNC after TURP.

Análisis comparativo entre la colocación medio-uretral de malla sintética (cinta vaginal sin tensión [TVT] y cinta a través del músculo obturador [TOT]); en el tratamiento quirúrgico de la incontinencia urinaria de esfuerzo en mujeres en un período de tiempo de 3 años (2009-2012) / Comparative analysis between the mid-urethral synthetic tape (tension-free vaginal tape [TVT] and transobturator tape [TOT]); in the surgical treatment of stress incontinence in women in a three-year period (2009 ­ 2012)

Introducción: la incontinencia urinaria de esfuerzo es la pérdida involuntaria de orina debido al aumento de presión intra- abdominal. El abordaje vaginal por cinta mediouretral es actualmente el método quirúrgico de elección para el tratamiento de IUE con las técnicas: cinta vaginal sin tensión (TVT) y cinta a través del músculo obturador (TOT). Objetivo: determinar la eficacia y complicaciones observadas after the placement of synthetic midurethral sling for the surgical treatment of urinary incontinence in a period of 3 years at HCAM. posterior a la colocación mediouretral de malla sintética TVT y TOT en el tratamiento quirúrgico de la incontinencia urinaria de esfuerzo en un período de 3 años en el HCAM. Materiales y métodos: se realizó un análisis retrospectivo en pacientes que fueron sometidas a cirugía con la colocación de malla mediouretral para IUE en el HCAM. 218 pacientes fueron estudiados, se registraron datos clínico-demográficos, perioperatorios, transoperatorios, y del seguimiento postoperatorio incluidas complicaciones y mejoría clínica de la IU para evaluar la eficacia y seguridad de los métodos. TVT en la apreciación subjetiva y objetiva de la mejoría clínica (87% vs 82% y 92% vs 90% respectivamente). La perforación vesical se presentó en el 14% en el grupo TVT vs 0.5% del grupo TOT. Complicaciones graves que llevaron a reoperación se presentaron mayoritariamente en el grupo TVT (4.8% vs 2.25% / p= 0.356). Conclusiones: comparativamente, ambas técnicas mostraron similar eficacia a través del tiempo de estudio. Sin embargo TOT tendría menos complicaciones, especialmente en referencia a la perforación vesical. Además, TVT requirió mayor tiempo operatorio, estancia hospitalaria.

Introduction: stress urinary incontinence is the involuntary loss of urine due to increased intra-abdominal pressure. The vaginal approach using midurethral slings is now the most common surgical method for the treatment of SUI with two main techniques: tension free vaginal sling [TVT] and transobturator midurethral sling [TOT]. Objective: to determine the efficacy and complications observed after the placement of synthetic midurethral sling for the surgical treatment of urinary incontinence in a period of 3 years at HCAM. Materials and methods: a retrospective analysis was performed in patients who underwent surgery with placement of midurethral sling for the surgical treatment of SUI at HCAM. 218 patients were studied; clinical-demographics, perioperative, intraoperative, and postoperative complications including monitoring data and clinical improvement of SUI were recorded to assess the efficacy and safety of methods. Results: the TOT group prevailed in effectiveness with no statistically significant difference with respect to the TVT group in assessing subjective and objective clinical improvement (87% vs 82 % and 92 % vs 90 % respectively). Bladder perforation occurred in 14% in the TVT group vs. 0.5 % of the TOT group. Severe complications leading to re operation were mainly presented in the TVT group (4.8 % vs 2.25 % / p=0.356). Conclusions: comparatively, both techniques showed similar efficacy over time of study. However TOT would have fewer complications, bladder perforation being the most important. In addition, TVT required longer operative time, hospital stay.

Effects of chronic administration of tamsulosin and tadalafil, alone or in combination, in rats with bladder outlet obstruction induced by chronic nitric oxide deficiency

Purpose The aim of this study was to define if tadalafil causes detrusor muscle impairment and to observe the effect of combination of tadalafil with tamsulosin on the lower urinary tract of rats with bladder outlet obstruction (BOO) induced by chronic nitric oxide deficiency. Materials and Methods Thirty-one male rats were randomized to following groups: 1 - control; 2 - L-Nitroarginine methyl ester (L-NAME); 3 - Tamsulosin + L-NAME, 4 Tadalafil+L-NAME; and 5 - Tamsulosin + Tadalafil + L-NAME. At the end of the treatment period (30 days), all animals were submitted to urodynamic study. Results The administration of L-NAME increased the number of non-voiding contractions (NVC) (1.04 ± 0.22), volume threshold (VT) (1.86 ± 0.35), and micturition cycle (MC) (1.34 ± 0.11) compared with control (0.52 ± 0.06, 0.62 ± 0.06, and 0.67 ± 0.30), respectively. The administration of tamsulosin reduced the number of NVC (0.57 ± 0.42) and VT (0.76 ± 0.24 ) compared with L-NAME group. Co-treatment with tadalafil decreased the number of VT (0.85 ± 0.53) and MC (0.76 ± 0.22) compared with L-NAME group. The combination of tamsulosin with tadalafil improved the number of NVC (0.56 ± 0.18), VT (0.97 ± 0.52) and MC (0.68 ± 0.30) compared with L-NAME group. Conclusion In rats with BOO induced by chronic nitric oxide deficiency, tadalafil did not cause impairment in detrusor muscle and seems to have an addictive effect to tamsulosin because the combination decreased non voiding contractions as well the number of micturition cycles. .

Análise do perfil de expressão dos marcadores de angiogênese e das neurotrofinas na persistência da hiperatividade detrusora em pacientes submetidos à ressecção transuretal da próstata / Analysis of the expression profile of angiogenesis markers and neurotrophins in the persistence of detrusor overactive after transurethral resection of the prostate for treatment of bladder outlet obstruction due to benign prostatic hyperplasia

Introdução: A HD está presente em aproximadamente 50% dos pacientes com OIV devido HPB e 30% dos casos não apresentarão melhora após o tratamento cirúrgico. Até o momento, nenhuma característica clínica pode predizer acuradamente quais pacientes serão beneficiados. Neste estudo nós analisamos o papel de seis marcadores moleculares na resolução da HD após a RTUP. Método: Um estudo prospectivo e controlado analisou 43 pacientes com OIV devido HPB, submetidos a RTUP de 2011 a 2012. O grupo controle foi composto por espécimes de músculo vesical de 10 pacientes com menos de 60 anos, submetidos a prostatectomia radical devido câncer de próstata, apresentando IPSS menor que 8 e volume prostático menor que 30 gramas. Todos os pacientes realizaram estudo urodinâmico no pré-operatório e com 6 meses de pós-operatório. Nós analisamos a presença, o período de início (primeira vs segunda metade do enchimento vesical) e a amplitude (< 40 vs > 40 cmH2O) das CVIs, assim como sua resolução após 6 meses de tratamento cirúrgico. Uma biópsia de músculo vesical foi efetuada no final da RTUP para análise do perfil de expressão gênica do NGF, NGFr, VEGF, CD-105, CHRM2 e CHRM3. Para este propósito foi utilizado a técnica de qRT-PCR. Além disso, correlacionamos variáveis clínicas pré-operatórias com a evolução da HD no pós-operatório. Resultados: A idade média dos pacientes foi 63 anos (50 a 75). A HD estava presente em 21 (48,8%) pacientes. De acordo com aferições pré-operatórias, a média de expressão gênica do NGF foi 3,3 vezes maior nos pacientes que iniciaram CVI precocemente quando comparados àqueles que iniciaram as contrações na fase final de enchimento vesical (p=0,047). A presença e a amplitude das CVIs não apresentaram correlações estatísticas com os genes estudados. Em relação a resolução da HD, a média de expressão de CHRM2 foi 2 vezes maior entre os pacientes que evoluíram com melhora da HD (p=0,072). Após 6 meses da RTUP, 77,8% dos pacientes que possuíam...

Objective: Non-inhibited contractions (NIC) are present in about 50% of patients with bladder outlet obstruction (BOO) due to benign prostatic hyperplasia (BPH) and 30% of cases persist after surgery. To date, no clinical characteristic can predict accurately which patients are going to improve. We analyzed the role of six detrusor molecular markers in the resolution of NIC after transurethral resection of the prostate (TURP). Methods: We performed a prospective and controlled analysis of 43 patients with BOO due to BPH who underwent TURP from 2011 to 2012. The control group comprised 10 bladder specimens from patients younger than 60 years who underwent radical prostatectomy with an IPSS < 8 and prostate volume < 30 grams. All patients underwent urodynamic analysis pre and post operatively after 6 months. We analyzed the presence, time to occurrence (first vs second half of the filling phase) and grade (<40 vs >40 cmH2O) of NIC as well as its resolution after 6 months of surgery. A biopsy of the bladder muscle was performed at the end of TURP for analysis of nerve growth factor receptor (NGFr), nerve growth factor (NGF), vascular endothelial growth factor (VEGF), endoglin (CD105), muscarinic cholinergic receptor 2 (CHRM2) and muscarinic cholinergic receptor 3 (CHRM3) genes expression. For this purpose, we used the quantitative real time polymerase chain reaction method (qRT-PCR). Results: Mean patient age was 63 years (50 to 75). NIC were present in 21 (48.8%) patients. According to pre-operative measures, NGF gene expression was 3.3 times greater in patients who presented early NIC as compared to those who presented late contractions (p=0.047). The presence or grade of NIC failed to present statistical correlations with the genes. With regard to the outcome, CHRM2 expression was 2.0 times greater among patients who presented resolution of NIC (p=0.072). After 6 months of TURP, 77,8% of patients with DO resolution had increased expression...