[Three dimensional anatomy and virtual surgery for transobturator approach]. / Anatomía tridimensional y cirugía virtual para procedimientos transobturatrizes.

INTRODUCTION: Stress Urinary Incontinence (SUI) may be managed by transobturator approach. We developed a three-dimensional model, for understanding the surgical anatomy and manual training as well, in order to reduce the learning curve for pelvic surgeries. OBJECTIVE: To demonstrate in synthetic models, the anatomical basis for the management of SUI and cystocele. METHOD: The anatomical model includes: pelvic bones, the main layers of the pelvic muscles, ligaments and fascias. The surgical devices were transobturator needles, synthetic slings and meshes for anterior vaginal wall repair. The workshop was carried out with an anatomical overview and hands-on training in this tridimentional models and finally surgery in animals. At the end, a questionnaire was applied to verify the impact of this tool in the learning process and trainee satisfaction. RESULTS: As far as the anatomical concept, 90% (n=72) of the participants classified this model as very good and 10% (n=8) as good. As a tool for understanding the tridimentional pelvic floor anatomy applied to transobturator procedures there were 100% of approval. CONCLUSIONS: This synthetic model allows for understanding the pelvic floor tridimentional anatomy and surgical procedures as well. Further skill is got in the animal model reducing the learning curve for transobturator procedures.

Intermittent androgen replacement for intense hypogonadism symptoms in castrated patients.

OBJECTIVES: For locally advanced prostate cancer management, medical androgen deprivation and surgical castration are alternatives. These hormonal treatments may cause a myriad of side effects, such as osteoporosis with increased risk of fractures, anemia, behavioral changes and lack of sexual interest. We evaluated the feasibility of intermittent androgen replacement in surgically castrated patients with significant side effects. METHODS: Five patients with advanced prostate cancer, ranging from 71 to 77 years of age (mean age = 74 years), surgically castrated for at least 3 years, with important symptoms of hypoandrogenism received testosterone replacement. They were followed with PSA and testosterone measurement every other month and bone scans every 6 months. RESULTS: For the first year all patients improved significantly, none of them showed PSA increase over 10 ng/ml. There was no evidence of local recurrence or distant disease. After 18 months, only one patient (20%) had a significant PSA increase, controlled by androgen withdrawal. No side effects or metastasis were observed. CONCLUSIONS: Hormonal replacement in patients that underwent castration seems to be feasible in improving intense symptoms associated to androgen deprivation. After 18 months, no evidence of recurrence was noted. It is an experimental alternative for highly symptomatic patients, but the short follow-up and the small number of patients cannot allow for definitive conclusions and should be studied further.

[SAFYRE. A new concept for adjustable minimally invasive sling for female urinary stress incontinence]. / SAFYRE. Un nuevo concepto de cabestrillo ajustable mínimamente invasivo para la incontinencia urinaria por estrés femenina.

INTRODUCTION: SAFYRE is a new readjustable and minimally invasive sling for the treatment of stress urinary incontinence (SUI). Attempts to restore the normal suburethral hammock using an anatomical approach have been made in recent years. The authors report their experience with this device, which associates the efficacy of slings with readjustability. MATERIAL AND METHODS: A total of 100 consecutive patients with clinical and urodynamic diagnosis of SUI underwent SAFYRE sling procedure. The age range was from 40 to 71, mean age 63 years. Seventy-five patients (75%) presented previous failed anti-incontinence procedures. Physical clinical examination, stress test, pad use and a urodynamic study were performed before the surgery. All the patients presented symptoms of SUI and 30% also reported mild urgency. RESULTS: The average follow up period was 14 months (12-30 months). The mean operative time was of 25 minutes. Dystopia repair was performed whenever necessary, during the same procedure. The average hospital stay was 24 hours. In 3% of the implants, bladder perforation occurred. During the postoperative period, 26 patients developed urgency symptoms. During that follow up period, 92% were found to be continent, 3% reported an improvement and 5% were dissatisfied. CONCLUSION: SAFYRE is a safe and quick procedure that allows for postoperative readjustment. This technique may be an attractive alternative if the good result obtained so far proves to be long lasting.

Routine ureteral stenting after ureteroscopy for ureteral lithiasis: is it really necessary?

PURPOSE: We assessed the cost-effectiveness of routine ureteral stenting after ureteroscopic stone removal. MATERIALS AND METHODS: Of 295 consecutive patients who underwent rigid ureteroscopic stone removal 133 in group 1 and 162 in group 2 were randomized to receive and not receive a stent, respectively, after the procedure. Operative time, stone size, stone location, success rate, postoperative pain and complications were analyzed in each group. RESULTS: There were no statistically significant differences in the 2 groups regarding stone size, stone location, success rate, postoperative pain or complications. However, in group 1 operative time was significantly longer than in group 2 (chi-square test p = 0.019). The hospital charge per patient when placing and not placing a stent after ureteroscopy for stone removal was $9,900.95 and $3,661.78, respectively. The female patients with a stent without a suture required an extra charge for stent removal in the operating room, while no men had a stent with a suture. CONCLUSIONS: Routine catheter placement after ureteroscopic stone removal increased operative time and did not seem to improve patient outcome. The cost was 30% that without a stent.

Is transurethral vaporization a remake of transurethral resection of the prostate?

PURPOSE: Transurethral resection of the prostate (TURP) is still the gold standard method to treat benign prostatic hyperplasia (BPH). Transurethral vaporization of the prostate (TUVP) is compared with the transurethral resection of benign prostatic hyperplasia. PATIENTS AND METHODS: Over a 10-month period, 78 patients presenting with moderate and severe symptomatic BPH were randomized into two groups. A total of 38 patients underwent TURP, and 40 men underwent TUVP. The protocol included urinary flow rate (Qmax), symptomatology evaluated by the International Prostatic Symptom Score (I-PSS), and an ultrasonographic estimate of the postvoiding residual volume (PVR). The TUVP was carried out using a regular loop with the electrical source set at 250 to 300 W in the pure cutting mode. The same technique was used in the TURP, but the electrosurgical unit was set at 50 to 80 W for cutting and 50 W for hemostasis. The mean follow-up was 17 months (range 11-23 months). RESULTS: The data showed significant improvement in the symptom score, maximum flow rate, and postvoiding residual urine volume after treatment (P<0.01) in both groups. Comparing the symptom score, there was no difference between the two techniques (P = 0.88), the same occurring with the PVR (P = 0.78). However, the Qmax was higher after TURP (P = 0.02). The amount of tissue resected showed no statistical difference between the two techniques (P>0.05). Operative time, postoperative irrigation, catheter removal, and hospital stay were better with TUVP (P = 0.001). There was a statistically significant difference (P = 0.003) when we compared the occurrence of retrograde ejaculation with TURP (32%) and TUVP (65%) The TUVP using a regular loop, in addition to the advantage of the equipment and technique already being familiar to urologists, is efficient and reduces capital expenditure. CONCLUSION: The TUVP is a remake of TURP, with higher energy offering better results.

Evaluation of patients with bladder outlet obstruction and mild international prostate symptom score followed up by watchful waiting.

OBJECTIVES: To examine the variability of bladder outlet obstruction and mild lower urinary tract symptoms in patients with benign prostatic hyperplasia (BPH) followed up by watchful waiting. METHODS: The International Prostate Symptom Score (IPSS) has four questions related to voiding symptoms and three related to filling symptoms. Scores of 0 to 7, 8 to 19, and 20 to 35 represent mild, moderate, and severe symptoms, respectively. Over a period of 36 months the IPSS questionnaire was administered to 479 patients 50 to 81 years old (mean age 63) with BPH. A pressure-flow study was used to determine the presence of bladder outlet obstruction. On the basis of their scores, the patients were classified into 50 with mild, 227 with moderate, and 202 with severe symptoms. In the present study only patients with a mild score were analyzed. RESULTS: Of 50 patients with mild symptoms, 16 (32%) had bladder outlet obstruction. After a period of 9 to 22 months (mean 17) of watchful waiting, these 16 patients were reviewed. Twelve (75%) of the 16 had bladder outlet obstruction reconfirmed by pressure-flow studies, and 3 (18.8%) of 16 had increased symptoms (moderate symptomatic) and underwent treatment (1 began pharmacologic treatment, and 2 chose transurethral resection). A total of 4 (25%) of 16 patients still had mild voiding disturbances and refused the second urodynamic evaluation. The remaining 34 patients with no obstruction had annual routine follow-up and had persistent mild symptom scores and normal uroflowmetric results. These patients did not undergo another pressure-flow evaluation. CONCLUSIONS: A pressure-flow study is routinely avoided in patients with a mild IPSS. From symptoms alone it was not possible to diagnose bladder outlet obstruction in these patients. Pressure-flow studies and symptom profiles measure different aspects of the clinical condition. After a mean follow-up of 17 months of watchful waiting, 13 (81.2%) of 1 6 patients were clinically stable. Because the need for therapy is dictated by quality of life, it is difficult to propose treatment for patients with minimal symptoms, even in the presence of bladder outlet obstruction.

Transurethral resection of partially obstructed ejaculatory ducts: seminal parameters and pregnancy outcomes according to the etiology of obstruction.

PURPOSE: We determine how transurethral resection of the ejaculatory ducts performed for infertility affects seminal parameters and pregnancy outcomes in patients with partial ejaculatory duct obstruction due to a congenital or acquired etiological factor. MATERIALS AND METHODS: Based on history and physical examination, hormonal profiles, semen analyses, transrectal ultrasonography and vasography findings partial ejaculatory duct obstruction was diagnosed in 14 men a mean of 30 years old who presented for infertility evaluation. Patients were grouped according to congenital or acquired cause of obstruction. Transurethral resection of the ejaculatory ducts was performed using the standard resectoscope loop technique. Clinical outcome was assessed by postoperative analyses of seminal parameters and pregnancy reports. RESULTS: Transurethral resection of the ejaculatory ducts significantly improved semen quality (ejaculate volume and percentage of sperm motility) in all patients in the congenital group, while all but 1 (83%) had an improved sperm count. Pregnancy was achieved via sexual intercourse by 66% of the patients an average of 5.7 months postoperatively. Of the acquired etiological factor group 37.5% had improved semen quality after transurethral resection of ejaculatory duct and 12.5% achieved pregnancy via sexual intercourse. Postoperative complications occurred at a similar rate in each group (33%). However, complications in the congenital etiology group were minor, while 25% of the men in the acquired group had significant impairment of seminal parameters after transurethral resection of the ejaculatory ducts. CONCLUSIONS: Semen quality improvement and pregnancy outcome after transurethral resection of the ejaculatory ducts for partial ejaculatory duct obstruction differ significantly according to the main etiological cause of obstruction. An equivocal diagnosis of partial obstruction and technical problems during transurethral resection of the ejaculatory ducts may contribute to failure. However, in some cases the reason for failure remains unclear.

Repeated lipoinjections for stress urinary incontinence.

A total of 30 women with stress incontinence underwent periurethral injection of autologous fat under spinal anesthesia. The fat was harvested from the abdominal wall by liposuction. Preoperative evaluation consisted of history, physical examination, and urodynamic evaluation. For study purposes, some patients also underwent bladder and urethral ultrasonography and magnetic resonance imaging studies. The first 13 patients received a single periurethral lipoinjection, and the following 17 patients received sequential injections when needed at 3-month intervals. Results were assessed by subjective questionnaire performed at 3 and 12 months. All patients had intrinsic sphincteric deficiency. Of the first group, there were only four patients (31%) cured after 1 year of follow-up. On the other hand, in the group that received repeated injections, there were 11 patients (64%) cured with a mean of two injections at 1-year follow-up. Our results show that this procedure warrants continued clinical investigation because it may be useful in selected cases of urinary stress incontinence.

The effects of ejaculation on serum prostate specific antigen.

PURPOSE: We evaluated the correlation of prostate specific antigen (PSA) and ejaculation in patients with symptomatic benign prostatic hyperplasia and an active sexual life. MATERIALS AND METHODS: In a study of 40 patients 50 to 60 years old (mean age 55) with prostatic symptoms serum PSA was evaluated before as well as 1 and 7 days after ejaculation. Due to clinical significance of PSA in diagnosis and monitoring of prostate cancer, we included men at risk age and with an active sex life. RESULTS: The results were compared to those of a control group of 10 asymptomatic (without coitus) men 50 to 60 years old (mean age 55 years). There were no statistically significant differences in PSA levels before and after ejaculation or between the groups. These results suggested that there was no physiological relationship between ejaculation and PSA level. CONCLUSIONS: Based on our data we conclude that sexual activity does not preclude the use of PSA to screen men for prostatic cancer.

Percutaneous treatment of bladder stones.

A total of 36 patients with bladder stones underwent percutaneous suprapubic cystolithotripsy. The successful rate was 89%. There were 11% failures due to nonfragmentation of the stones by the ultrasound probe. According to the presence of associated diseases 3 groups of patients were established. Two groups underwent concomitant treatments for benign prostatic hyperplasia and urethral stricture. No complications occurred even in patients with concomitant treatment. There was no statistically significant difference when these groups were compared (p > 0.05). Fluoroscopy was not necessary during the procedure. Since the technique is simple, safe and effective, it represents an alternative in the management of bladder stones.

Renal calculi in lower pole calices: what is the best method of treatment?

Percutaneous nephrolithotomy and extracorporeal shock wave lithotripsy (ESWL*) can be used in the treatment of lower pole caliceal calculi. In a retrospective analysis these 2 therapies were compared for treatment of solitary lower pole caliceal calculi to evaluate morbidity. During a 2-year period 23 patients treated with percutaneous nephrolithotomy and 24 who underwent ESWL with the Siemens Lithostar were analyzed in regard to the success rate, effectiveness quotient, complication rate, length of hospitalization and disability period. Followup consisted of ultrasound and/or a plain film of the kidneys, ureters and bladder 1 day and 1 to 3 months postoperatively. A nephrotomogram was included in the ESWL group. Complete removal of all stone fragments was achieved in 93.6% of the patients treated percutaneously without retreatment. In the ESWL group the success rate was 79.2% with a 41.6% retreatment rate. On the other hand, the ESWL group had a shorter hospitalization and an earlier return to normal physical activities. Among the patients who underwent a percutaneous operation 13% had complications compared to 4.1% in the ESWL group. The recurrence rate was higher in the former group (13% within a median of 18 months, compared to 8.3% within a median of 11 months in the ESWL group). The mean stone diameter was 1.42 cm. in the percutaneous group and 1.22 cm. in the ESWL group. Stone composition was similar in both groups. Since ESWL is an effective noninvasive procedure without the need for routine anesthesia and hospitalization, and with prompt return of the patient to a normal life it must be considered the method of choice for lower caliceal stones less than 2 cm. in diameter. However, percutaneous nephrolithotomy will continue to have a primary role in the management of larger stones.

Vasography: experimental study.

Vasography may cause stricture of the vas deferens. The probable causes of this obstruction are traumatic lesion at the puncture site and the radiological contrast material used. Because of this problem we performed an experimental study using Wistar rats, which were divided into four groups: Group A - Control, Group B - injection of a saline solution, Group C - hypaque injection, Group D - hypaque plus saline solution. According to the results obtained it was concluded that the needle puncture is not responsible for stricture of the vas deferens. Hypaque is responsible for 5% of strictures and the use of a saline solution to wash the vas did not show any benefit.

Comparison between percutaneous nephrolithotomy and open stone procedures.

A total of 205 patients have undergone stone extraction surgery. Three groups were studied: in 70 patients the stones were removed by flank incision, in 20 patients by posterior incision and 80 patients were treated by percutaneous nephrolithotomy. Patients submitted to percutaneous nephrolithotomy had a shorter hospitalization, operative time and a significantly reduced period of recuperation, allowing earlier return to work and decreased disability. Narcotic drugs were demanded in a lower amount in the percutaneous nephrolithotomy group.

Concentrations of norfloxacin in prostatic tissues following oral administration in patients with benign prostatic hyperplasia.

For assessing plasma and tissue concentrations of norfloxacin after oral administration, twelve patients with benign prostatic hypertrophy (BPH) were given two doses of 400 mg norfloxacin approximately 12 hours apart prior to transurethral resection of the prostate (TURP). Prostatic tissue samples and blood samples were collected and assayed for norfloxacin content by HPLC. The mean peak norfloxacin concentration in plasma was 1.63 micrograms/ml (range 0.63 to 3.38 micrograms/ml). The mean peak concentration in prostatic tissue was 1.63 micrograms/g (range 0.75 to 3.30 micrograms/g). The plasma and prostatic tissue levels of norfloxacin exceeded the MIC's of most urinary tract pathogens. The data suggest that norfloxacin may be useful in the treatment of chronic bacterial prostatitis.

Varicocele: medical and surgical treatment.

Varicocele is the most frequent finding in male infertility. Thirty percent of infertile male patients requesting treatment present with varicocele. Between December 1971 and December 1984, 151 infertile patients presenting varicocele were treated in this study: 28 underwent medical treatment, 38 surgical treatment, and 23 both medical and surgical treatment. The spermograms of all the patients were studied before and after treatment. The following variables were considered: volume, sperm count, percentages of general motility and of grade III sperm, and of oval forms. There was not a significant statistical difference in the analysis of the spermogram parameters before and after treatment in the three groups. The pregnancy rate for the medical-surgical group was 60.9% and for the surgical group 47.4%--not a statistically significant difference. The purely medically treated group had a pregnancy rate of 25%, which is significantly lower than the other groups.

Bilateral carcinoma in situ of testis in infertile man.

Abnormal seminiferous epithelium with atypical germ cells was studied in 2 previous cases. Embryonal carcinoma occurred within four and one-half years of testicular biopsy. Herein is reported another case of bilateral carcinoma in situ of the testis, presenting abnormal germinal morphology and infertility. The abnormal cells differed considerably from normal spermatogonia, presenting an increased diameter and dense chromatin masses. Apparently normal tubules were also present with normal spermatogenesis. Serum gonadotropins and chromosome study were normal. After bilateral biopsy patient was submitted to a right orchiectomy and left varicocelectomy.

The surgical repair of posterior urethral strictures by the transpubic urethroplasty or pull-through technique.

The management of strictures of the posterior urethra is reviewed in 75 adults and 19 children. Of the patients 66 were treated by a perineal pull-through technique and 28 underwent a transpubic approach. The transpubic approach provided excellent exposure to the damaged urethra with minimal morbidity, and good results were obtained in 89 per cent of the children and 69 per cent of the adults. Three patients had partial incontinence postoperatively but 2 recovered completely after 6 months. With the perineal pull-through technique, good results were achieved in 80 per cent of the children and 66 per cent of the adults. Worsening of sexual function was not seen in either treatment group as a consequence of the operation. As a result of this experience the transpubic approach is preferred in cases of complex urethral strictures, cases in which the length of the damaged urethra exceeds 3 cm. or in small children, reserving the pull-through technique for low-lying urethral strictures less than 3 cm. long.

Bacillus Calmette-Guerin immunotherapy of infiltrating bladder cancer.

Oral administration of bacillus Calmette-Guerin was used to treat 10 patients with muscle invasive transitional cell carcinoma of the bladder. The treatment induced tumor regression in 7 patients (70 per cent), including 1 who died without evidence of recurrent tumor. Skin test reactivity was correlated with response to treatment. Only 1 patient had marked skin test reactivity at the time of tumor recurrence. Our data demonstrated that patients with invasive bladder cancer may derive benefit from immunotherapy.