Comparison of thermal injury depth of the prostate between plasma kinetic electrode, holmium laser, green light laser and Nd:YAG laser.

OBJECTIVE: PlasmaKinetic electrode, holmium laser, green laser and Nd: YAG laser have been used for treating benign prostate hyperplasia (BPH). To compare the pathological changes of thermal injury by these different devices. MATERIAL AND METHODS: Tissues donated by several male patients with prostate cancer who have written a consent. The tissues were diced them into small squares with 1 cm long on a side. Cutting experiments were performed in the normal temperature circulating water environment, the specimens of the prostate tissue were fixed in 4% formalin. The sections were then undergone HE and NADH-NBT staining. RESULTS: The penetration depths and coagulation zone of tissue after treatment were ranked as Nd:YAG laser > plasma Kinetic electrode > green light laser > holmium laser respectively. CONCLUSION: Holmium laser might have less thermal damage to tissue, although it still needs more research including clinical study. Our results will provide clinicians with some alternative basis for the application.

Strength training protects against prostate injury in alcoholic rats.

Alcoholic injury can alter the hormonal signaling pathway and lead to glucose and lipid metabolism disorders. In this study, we investigated whether the strength training could exert protective effects against the alterations caused by ethanol consumption on prostatic metabolism. A UChB, ethanol-preferring rats were used in this study. Strength training was conducted for 3 days per week for 13 weeks, rats performed jumps in water carrying a weight load strapped to their chests as part of a strength training protocol. The reduced alcohol consumption by strength training was accompanied by increased glucose, serum lipid profile, total protein levels, and reduced hormonal levels. The results of protein expression of prostatic tissues in the ethanol- and strength training-treated groups indicated that "steroidal hormone receptors," "fatty acid translocation," and "cell regulation" were significantly different between ethanol- and strength training-treated groups. Taken together, these findings show that strength training effectively ameliorated prostatic injuries in alcoholic rats at least partially by acting on lipids receptors and steroidal hormone receptors pathway, suggesting the strength training as a potential novel therapeutic strategy for treating prostate injuries caused by ethanol.

Retained Bullet in the Prostate Causing Lower Urinary Tract Symptoms.

A 41-year-old man presented with a 5-month history of bothersome urinary urgency and frequency. He sustained a gunshot wound to the lower abdomen 15 months prior to presentation. Digital rectal examination revealed a metallic foreign body palpable within the right lobe of the prostate, which was suggestive of a retained bullet fragment within the prostate gland. Cystourethroscopy confirmed a bullet fragment lodged within the right lateral aspect of the prostatic urethra. X-ray of the pelvis illustrated 2 radiopaque foreign bodies projecting at the level of the pubis. The patient deferred surgical retrieval and opted for pharmacological management with anti-cholinergic medication.

¿Es posible aumentar la especificidad para la realización de biopsia prostática en pacientes con PSA entre 4-10 ng/ml con cociente PSA libre/PSA total < 20%? / Is it possible to increase the specificity for the performance of prostatic biopsy in patients with PSA between 4 and 10 ng/ml and free/total PSA ratio 20%?

OBJETIVO: En la actualidad sigue siendo un problema la toma de decisión para realizar biopsia de próstata en pacientes con PSA entre 4-10 ng/ml, a pesar del uso del cociente PSA libre/ PSA total. El objetivo de este estudio es investigar la manera de aumentar la especificidad en la toma de decisión de la realización de biopsia de próstata en este tipo de pacientes. MÉTODOS: Desde enero a diciembre de 2014, se incluyen en este estudio hombres con PSA entre 4-10ng/ml y cociente PSA libre/ PSA total <20%, candidatos a biopsia de próstata. Se excluyen del estudio pacientes que estén tomando inhibidores de la 5 alfa-reductasa y pacientes con biopsias de próstata previamente realizadas. Se analiza edad, PSA total, testosterona total, libre y biodisponible, FSH, LH, SHBG, 17-hidroxiprogesterona, Androstendiona, volumen prostático (medido por ecografía transrectal), cocientes testosterona total/PSA, testosterona libre/PSA, testosterona biodisponible/PSA y Densidad de PSA, testosterona total/volumen próstata, testosterona libre/volumen próstata y testosterona biodisponible/volumen próstata. Análisis estadístico con SPSS 20,0 y significación estadística p≤0,05. RESULTADOS: Un total de 109 pacientes se incluyeron, divididos en 2 grupos según resultado de la biopsia. Grupo 1: 49 pacientes con biopsia de próstata positiva; Grupo 2: 60 pacientes con biopsia de próstata negativa. Se observan diferencias estadísticamente significativas en relación al volumen prostático (Grupo 1: 37,6 cc; Grupo 2: 52,8 cc; p = 0,04), densidad PSA (Grupo 1: 0,24; Grupo 2: 0,17; p = 0,002), testosterona total/volumen próstata (Grupo 1: 0,15; Grupo 2: 0,10; p = 0,02), testosterona libre/volumen próstata (Grupo 1: 0,002; Grupo 2: 0,001; p = 0,01) y testosterona biodisponible/volumen próstata (Grupo 1: 0,06; Grupo 2: 0,04; p = 0,007). Se realiza curva ROC para determinación de punto de corte con especificidad 90%, observando que un volumen de próstata menor a 60,7cc, una densidad de PSA mayor a 0,27 y un valor testosterona biodisponible/volumen próstata mayor a 0,07. CONCLUSIÓN: La decisión de biopsia de próstata en pacientes con PSA entre 4-10 ng/ml con cociente PSA libre/PSA total < 20% sigue siendo controvertida, no obstante podemos optimizar la decisión utilizando otros parámetros como el volumen de próstata, la densidad PSA y el cociente testosterona biodisponible/volumen próstata

OBJECTIVE: To investigate the manner to increase specificity in the decision-making process for the performance of prostate biopsy. METHODS: We include in this study men with PSA between 4 and 10 ng/ml and free/total PSA < 20%, candidates for prostate biopsy. Patients receiving 5 alpha reductase inhibitors or with previous biopsies were excluded. Analyzed variables: total PSA, total testosterone, free and bioavailable testosterone, FSH, LH, SHBG, 17 hydroxyprogesterone, Androstenedione, prostatic volume measured by transrectal ultrasound, total testosterone/PSA, testosterone/free PSA, bio available testosterone/PSA and PSA density, total testosterone/prostate volume, free testosterone/prostate volume and bioavailable testosterone/prostate volume. RESULTS: A total 109 patients have been included, divided into 2 groups according to the results of the biopsy. Significant differences were observed in prostatic volume (Group 1: 36.6cc and Group 2: 52.8 cc; p = 0.04), PSA density (Group 1: 0.24 Group 2: 0.17; p = 0.002), total testosterone/prostate volume (Group 1: 0.15 and Group 2: 0.10; p = 0.02) free testosterone/ prostate volume (Group 1: 0.002 Group 2: 0.001; p = 0.01) and bioavailable testosterone/prostate volume (Group 1: 0.06 Group 2: 0.04; p = 0.007). CONCLUSION: The decision for a prostate biopsy on patients with a PSA between 4-10 ng/ml with free/total ratio < 20% continues to be an issue, however, we can optimize decision using other parameters such as prostate volume, PSA density and bioavailable testosterone/prostate volume

Monopolar versus Plasmakinetic™ Energy Effect on Prostatic Tissue Damage in Terms of PSA Levels: A Prospective Randomized Trial.

INTRODUCTION: We investigated the monopolar and bipolar energy effects on prostate and correlated the results with the type of pathology, thus determining the relationship between tissue damage and the PSA level. MATERIAL AND METHODS: One hundred and twenty four patients underwent TURP and according to the energy source, 2 groups were designed as monopolar (Group 1) and bipolar energy (Group 2). Hemoglobin and free and total PSA were measured preoperatively and 6 hours postoperatively, and differences were calculated. The weight of resected tissue and operation time were also recorded. Two groups were also formed later according to the pathology as chronic prostatitis (CP) and BPH. The findings were analyzed. RESULTS: There were no statistical differences between the groups in terms of age; prostate volumes; resected tissue; operation times; pre- and postoperative Hb, total-free PSA, IPSS, PVR, and quality of life scores; or postoperative maximum flow rates. Changes in total-free PSA (25.7 and 10.8 ng/dl for PSA; 13.2 and 5.76 ng/dl for free PSA for Groups 1 and 2, respectively) were significantly different between Groups 1 and 2. There was a statistical difference in total PSA between the groups among CP patients (28.18 and 11.73 ng/dl for Groups 1 and 2, respectively). But no statistical difference existed among BPH patients. The change in Hb differed based on pathological results. CONCLUSION: Bipolar TURP is less invasive than monopolar TURP on the basis of postoperative PSA levels. In addition, bleeding during TURP is affected not by the kind of energy, but by the pathology.

Um método de contagem de pontos adaptado como uma estratégia prática de quantificação do volume do tumor e percentagem do envolvimento da próstata por carcinoma, em produtos de prostatectomia / A method of counting points adapted as a practical strategy for the quantification of tumor volume and percentage involvement by prostate cancer, radical prostatectomy in product

Introdução. É consenso que o laudo anatomopatológico de produtos de prostatectomia radical deve relatar de forma quantitativa a extensão do carcinoma prostático, mas qual o método a ser usado não é consensual. Objetivos. Relatar a experiência de um método de contagem de pontos adaptado em produtos de prostatectomias (n= 143) adaptado de Billis et al., Int Braz J Urol. 2003.29:113-120. Material e métodos. As margens basal e apical foram processadas pelo método do cone. O restante da próstata foi dividido em 12 regiões em forma de quadrantes: cada uma representada com duas secções. Em cada fragmento, oito pontos equidistantes foram marcados diretamente sobre a lamínula com caneta permanente. Os pontos presentes dentro da área do tumor foram contados e expressos na forma de percentagem de envolvimento por carcinoma (PEC) ou como volume do tumor (VT). Estes foram comparados com o método quantitativo mais usual de número de secções envolvidas (NSE). Resultados. Os três métodos apresentaram correlação moderada significante com níveis pré-operatórios de PSA, mas esta foi maior para os métodos baseados na contagem de pontos: NSE (r = 0.32), PEC (r = 0.39) e VT (r = 0.44). Quando estratificados em três categorias, os três métodos mostraram associação com escore de Gleason ≥7, Gleason primário ≥4, invasão angiolinfática e perineural, extensão extraprostática, envolvimento de vesículas seminais e margens positivas. Conclusão. Os três métodos quantitativos estão associados a marcadores morfológicos de progressão do carcinoma da próstata. Os métodos baseados na contagem de pontos proposta apresentam mais forte correlação com níveis pré-operatórios de PSA sérico.

Objective: To evaluate a modified point-count method for quantifying carcinoma in prostatectomy specimens (n=143), adapted from Billis et al., Int Braz J Urol. 2003.29:113-120. Methods: The basal/apical margins were sampled using the cone method. The remainder of the gland was divided into 12 quadrant-shaped regions which had two slices sampled. Eight equidistant points were marked directly on the coverslip over each fragment. The points inside the tumoral areas were counted and expressed as the percentage of prostate gland involvement by carcinoma (PGI) and as the tumor volume (TV). Results: A significant correlation between the preoperative PSA level and each of the three quantitative estimations was found, but it was higher for both values (PGI and TV) obtained using the point-count method, viz.: number of slices involved (NSI) (r = 0.32), PGI (r = 0.39) and TV (r = 0.44). When the data sets were stratified into three categories, all three methods correlated with Gleason scores ≥7, primary Gleason scores ≥4, perineural / angiolymphatic invasion, extraprostatic extension, seminal vesicle invasion and positive margins. Conclusion: All three quantitative methods were associated with morphologic features of tumor progression. The results obtained using the modified point-count method correlated better with the preoperative PSA levels.

Use of multiparametric MR with neurovascular bundle evaluation to optimize the oncological and functional management of patients considered for nerve-sparing radical prostatectomy.

INTRODUCTION: To obtain the best results with radical prostatectomy, either from an oncological or a functional point of view, a correct selection of cases and planning of surgery are crucial. Multiparametric magnetic resonance imaging (MRI) promises to make it a successful imaging tool for improving many aspects of prostate cancer management. AIM: The aim of this study is to evaluate whether a modern multiparametric MRI can help either to better select prostate cancer cases for a nerve-sparing radical prostatectomy or to improve the functional evaluation related to neurovascular bundles preservation. MAIN OUTCOME MEASURES: The effect of preoperative MRI on neurovascular bundle management was examined for the frequency and the appropriateness of changes of the surgical plane on the basis of MRI indications. METHODS: In a prospective study, 125 consecutive patients with biopsy proven prostate cancer who were scheduled to undergo bilateral nerve-sparing surgery. All patients included into the study were submitted to a preoperative multiparametric MRI. On the basis of MRI evaluation, patients were divided into two groups. Patients in group A were then submitted to a bilateral nerve-sparing (NS) radical prostatectomy (RP), whereas patients in group B were submitted to unilateral NS or non-NS RP. RESULTS: In group A, the confirmation from the MRI study to perform a bilateral NS procedure was appropriate in 70 of 73 cases (95.9%), whereas in group B, the surgical plan was appropriate in 28 of 32 cases (87.5%). On the contrary, MRI findings suggested a change in the initial surgical plan (group B) for 32 of 105 cases (30.5%). Of these 32 cases in group B, MRI suggested to perform a unilateral NS procedure in 21 of 32 cases (65.6%) and a non-NS procedure in 11 of 32 cases (34.4%). CONCLUSIONS: Multiparametric MRI analysis can significantly improve the standard selection and management of prostate carcinoma cases considered for an NS RP.

Perineural invasion predicts increased recurrence, metastasis, and death from prostate cancer following treatment with dose-escalated radiation therapy.

PURPOSE: To assess the prognostic value of perineural invasion (PNI) for patients treated with dose-escalated external-beam radiation therapy for prostate cancer. METHODS AND MATERIALS: Outcomes were analyzed for 651 men treated for prostate cancer with EBRT to a minimum dose ≥75 Gy. We assessed the impact of PNI as well as pretreatment and treatment-related factors on freedom from biochemical failure (FFBF), freedom from metastasis (FFM), cause-specific survival (CSS), and overall survival. RESULTS: PNI was present in 34% of specimens at biopsy and was significantly associated with higher Gleason score (GS), T stage, and prostate-specific antigen level. On univariate and multivariate analysis, the presence of PNI was associated with worse FFBF (hazard ratio = 1.7, p <0.006), FFM (hazard ratio = 1.8, p <0.03), and CSS (HR = 1.4, p <0.05) compared with absence of PNI; there was no difference in overall survival. Seven-year rates of FFBF, FFM, and CCS were 64% vs. 80%, 84% vs. 92%, and 91% vs. 95% for those patients with and without PNI, respectively. On recursive partitioning analysis, PNI predicted for worse FFM and CSS in patients with GS 8-10, with FFM of 67% vs. 89% (p <0.02), and CSS of 69% vs. 91%, (p <0.04) at 7 years for those with and without PNI, respectively. CONCLUSIONS: The presence of PNI in the prostate biopsy predicts worse clinical outcome for patients treated with dose-escalated external-beam radiation therapy. Particularly in patients with GS 8-10 disease, the presence of PNI suggests an increased risk of metastasis and prostate cancer death.

Thresholds for thermal damage to normal tissues: an update.

The purpose of this review is to summarise a literature survey on thermal thresholds for tissue damage. This review covers published literature for the consecutive years from 2002-2009. The first review on this subject was published in 2003. It included an extensive discussion of how to use thermal dosimetric principles to normalise all time-temperature data histories to a common format. This review utilises those same principles to address sensitivity of a variety of tissues, but with particular emphasis on brain and testis. The review includes new data on tissues that were not included in the original review. Several important observations have come from this review. First, a large proportion of the papers examined for this review were discarded because time-temperature history at the site of thermal damage assessment was not recorded. It is strongly recommended that future research on this subject include such data. Second, very little data is available examining chronic consequences of thermal exposure. On a related point, the time of assessment of damage after exposure is critically important for assessing whether damage is transient or permanent. Additionally, virtually no data are available for repeated thermal exposures which may occur in certain recreational or occupational activities. For purposes of regulatory guidelines, both acute and lasting effects of thermal damage should be considered.

Technical note: calculation of normal tissue complication probability using Gaussian error function model.

PURPOSE: The Gaussian error function was first used and verified in normal tissue complication probability (NTCP) calculation to reduce the dose-volume histogram (DVH) database by replacing the dose-volume bin set with the error function parameters for the differential DVH (dDVH). METHODS: Seven-beam intensity modulated radiation therapy (IMRT) treatment planning was performed in three patients with small (40 cm3), medium (53 cm3), and large (87 cm3) prostate volume, selected from a group of 20 patients. Rectal dDVH varying with the interfraction prostate motion along the anterior-posterior direction was determined by the treatment planning system (TPS) and modeled by the Gaussian error function model for the three patients. Rectal NTCP was then calculated based on the routine dose-volume bin set of the rectum by the TPS and the error function model. The variations in the rectal NTCP with the prostate motion and volume were studied. RESULTS: For the ranges of prostate motion of 8-2, 4-8, and 4-3 mm along the anterior-posterior direction for the small, medium, and large prostate patient, the rectal NTCP was determined varying in the ranges of 4.6%-4.8%, 4.5%-4.7%, and 4.6%-4.7%, respectively. The deviation of the rectal NTCP calculated by the TPS and the Gaussian error function model was within +/- 0.1%. CONCLUSIONS: The Gaussian error function was successfully applied in the NTCP calculation by replacing the dose-volume bin set with the model parameters. This provides an option in the NTCP calculation using a reduced size of dose-volume database. Moreover, the rectal NTCP was found varying in about +/- 0.2% with the interfraction prostate motion along the anterior-posterior direction in the radiation treatment. The dependence of the variation in the rectal NTCP with the interfraction prostate motion on the prostate volume was found to be more significant in the patient with larger prostate.

Pelvic fracture-related injuries of the bladder neck and prostate: their nature, cause and management.

OBJECTIVE: To report our experience of bladder neck injuries, which are a well recognized but rare consequence of pelvic fracture-related trauma to the lower urinary tract, as we have been unable to find any reference in the English literature to their specific nature, cause and management in adults. PATIENTS AND METHODS: In the last 10 years we have treated 15 men with bladder neck injuries after pelvic fracture. Two were treated at our centre by delayed primary repair. Thirteen were initially treated elsewhere and presented to us 3 months to 5 years after their injury with intractable incontinence and various other symptoms most notably recurrent urinary infection and gross haematuria. Twelve of the injuries were at or close to the anterior midline and associated with lateral compression fractures or 'open-book' injuries. Five of them were confined to the bladder neck and prostatic urethra; the other seven extended into the subprostatic urethra. Four of these were associated with a coincidental typical rupture of the posterior urethra. All had an associated cavity involving the anterior disruption of the pelvic ring. Two of the injuries, following particularly severe trauma, were a simultaneous complete transection of the bladder neck and of the bulbo-membranous urethra with a sequestered prostate between. We have seen this in children before but not in adults. Another injury, also after particularly severe trauma, was an avulsion of the anterior aspect of the prostate. We have not seen this described before. Fourteen patients underwent lower urinary tract reconstruction and one underwent a Mitrofanoff procedure. All of the 14 had a layered reconstruction of the prostate and bladder neck and in 13, this was supplemented with an omental wrap. RESULTS: In all patients with an anterior midline rupture, the primary injury appeared to be to the prostate and prostatic urethra with secondary involvement of the bladder neck and the subprostatic urethra. The Mitrofanoff procedure was successful. Of the 14 patients with a layered reconstruction one, without an omental wrap, broke down but was successfully repaired on a subsequent occasion. The four patients who also had a ruptured urethra had a simultaneous bulbo-prostatic anastomotic urethroplasty, two of which required further attention. Eight of the 14 reconstructed patients underwent implantation of an artificial urinary sphincter (AUS) for sphincter weakness incontinence, in seven of whom this was successful. Two of these had previously undergone implantation of an AUS with an unsatisfactory outcome and were made continent by bladder neck reconstruction. The other six patients had acceptable urinary incontinence by reconstruction of the bladder neck and urethra alone. CONCLUSIONS: The primary injury is to the prostate and prostatic urethra. The bladder neck and subprostatic urethra are involved secondarily by extension. These injuries have a particular cause and a particular location with a predictable outcome. They need to be identified and treated promptly as they do not heal spontaneously and otherwise cause considerable morbidity. We also describe two particular types of bladder neck injury that we have not seen described before in adults.

Gastrointestinal bleeding in the cancer patient.

Gastrointestinal bleeding is a common occurrence in patients with cancer and is a frequent indicator of a gastrointestinal malignancy. Rapid evaluation and treatment is key for the hemodynamically unstable patient. Endoscopy remains the cornerstone of diagnosis and management for cancer patients with gastrointestinal bleeding. The emergency physician should also be aware of other diagnostic and treatment modalities that may be needed to take care of these patients.

MRI-guided cryoablation: In vivo assessment of focal canine prostate cryolesions.

PURPOSE: To analyze the appearance of acute and chronic canine prostate cryolesions on T1-weighted (T1w) and T2-weighted (T2w) magnetic resonance imaging (MRI) and compare them with contrast-enhanced (CE) MRI and histology for a variety of freezing protocols. MATERIALS AND METHODS: Three different freezing protocols were used in canine prostate cryoablation experiments. Six acute and seven chronic (survival times ranging between 4-53 days) experiments were performed. The change in T2w signal intensity was correlated with freezing protocol parameters. The lesion area on T2w MRI was compared to CE-MRI. Histopathologic evaluation of the cryolesions was performed and visually compared to the appearance on MRI. RESULTS: The T2w signal increased from pre- to postfreeze at the site of the cryolesion, and the enhancement was higher for smaller freeze area and duration. The T2w lesion area was between the CE nonperfused area and the hyperenhancing CE rim. The appearance of the lesion on T1w and T2w imaging over time correlated with outcome on pathology. CONCLUSION: T1w and T2w MRI can potentially be used to assess cryolesions and to monitor tissue response over time following cryoablation.

Infiltración asintomática de la próstata por leucemia linfática crónica / Assymptomatic prostatic infiltration by chronic lymphocytic leukemia

Objetivo: Presentar un caso de infiltración leucémica de la próstata como hallazgo incidental en una prueba de imagen. Métodos: Describimos el caso de un varón de 60 años en seguimiento por una leucemia linfática crónica, al que se realiza un TAC de rutina apreciando adenopatías múltiples y un nódulo hipodenso en el lóbulo prostático izquierdo. El paciente es remitido a nuestro servicio para la realización de ecografía transrectal y biopsias prostáticas. No refiere clínica urinaria. Resultados: Al tacto rectal la próstata está mal delimitada y con aumento difuso de consistencia. La ecografía transrectal muestra una glándula mal delimitada, con parénquima heterogéneo y varias áreas hiperecoicas. El informe anatomopatológico describe la infiltración difusa de la glándula por una leucemia linfática crónica. Conclusiones: Aunque la extensión de tumores hematológicos a la próstata ha sido descrita previamente, no existe en nuestro conocimiento ningún caso publicado de hallazgo incidental en una prueba de imagen de infiltración prostática por leucemia en un paciente asintomático (AU)

Objective: Report of a case of leukemic infiltration of the prostate as an incidental CT finding. Methods: We describe a case of a 60-year-old male suffering from chronic lymphocytic leukemia. A routine-performed CT showed multiple lymphadenopathies and an hypodense area in the left prostatic lobe. The patient was sent to our department to carry out a transrectal ultrasound and prostatic biopsy. He didn’t relate any urinary symptoms. Results: By the prostate rectal examination the gland felt hard and with no well defined limits. The transrectal ultrasound showed heterogene parenchyma and several hyperechoic areas by a bad circumscribed prostate. The pathological analysis reported a diffuse infiltration of the gland by chronic lymphocytic leukemia cells. Conclusions: Although the relapse of hematological tumors to the prostate has been described previously, there is no published case to our knowledge of a leukemic prostate infiltration in an assymptomatic patient as an incidental finding by an imaging procedure (AU)

Transurethral resection syndrome detected and managed using transesophageal Doppler.

Transurethral resection syndrome during transurethral resection of the prostate (TURP) results from excessive absorption of electrolyte-free irrigation fluids causing acute hypervolemia and hyponatremia. Neuraxial anesthesia is often recommended for TURP procedures because early signs of neurological deterioration can be detected. However, in patients requiring general anesthesia, other continuous and noninvasive measures are needed. Acute intravascular hypervolemia should be reflected by changes in hemodynamic values. Transesophageal Doppler ultrasonography of the aorta allows determination of stroke volume and other advanced hemodynamic variables related to intravascular volume status. We describe the first case of intraoperative detection of a TURP syndrome by noninvasive Doppler monitoring of hemodynamic variables during TURP.

[Gunshot wound with a bullet lodged in the prostate]. / Bala alojada en la próstata.

OBJECTIVE: We describe a most unusual urological emergency: a firearm wound in which the blunt-nosed hand-gun bullet was lodged in the prostate. A bibliographic search of the literature revealed no similar case. METHODS: The patient was admitted presenting a gunshot wound with the entrance hole on the right buttock. There was no exit wound. An X-ray revealed the bullet behind the pubic symphysis. We introduced a suprapubic catheter and then carried out a laparotomy making a discharge colostomy Urethrogram revealed a pathway of contrast to the rectum. Several days later, we reached the bladder with an urethrotome and introduced an 18 Fr catheter. Under radiological control we made an open approach to the retropubic space, palpated the bullet within the prostate and then removed it. DISCUSSION/CONCLUSIONS: The velocity of a rifle or hand-gun bullet is the main determinant of the severity of this type of injury. As there was no exit wound, we knew that the entrance velocity was low, therefore tissue damage would probably be small. In these cases, a preparatory suprapubic cystostomy is essential to be able to carry out a urethral reconstruction later. Radiological control during the procedure proved extremely useful to precisely locate the bullet. Our conservative approach of simply leaving in place the catheter helped us later to avoid a difficult repair of a recto-urethral fistula.

Bala alojada en la próstata / Gunshot wound with a bullet lodged in the prostate

Objetivo: Describimos un caso de herida de arma de fuego con el proyectil alojado en la próstata. La rareza de este tipo de heridas en nuestro medio, así como el hecho de no haber encontrado ningún caso similar en la literatura nos han animado a escribir este artículo. Métodos: Se trata de un paciente que nos llega con una herida de bala con orificio de entrada por la nalga y sin orificio de salida. En el estudio radiológico se encuentra una bala situada detrás de la sínfisis del pubis. En principio se pone un catéter suprapúbico, se hace una laparotomía y se realiza una colostomía de descarga. Después se realiza una uretrografía y se comprueba que hay paso de contraste hacia el recto. Unos días más tarde, mediante un uretrotomo, se llega hasta la vejiga y se deja una sonda del número 18 Fr. A continuación, vía abierta se llega al espacio retropúbico, mediante control radiológico se identifica la bala, después se consigue palparla alojada dentro de la próstata y por último se extrae. Discusión/Conclusiones: Es muy importante conocer la velocidad del proyectil para saber la gravedad de la lesión. En este caso, al no haber orificio de salida, sabemos que el proyectil es de baja velocidad, lo que hace que la gravedad del traumatismo sea mucho menor. La cistostomía suprapúbica inicial es imprescindible en estos casos para luego hacer en un segundo tiempo la reconstrucción uretral. El control radiológico durante la intervención es muy útil para localizar el proyectil. En este caso se demuestra que teniendo una actitud conservadora, dejando simplemente una sonda evitamos una cirugía difícil como puede ser la reparación de una fístula recto-uretral (AU)

Objective: We describe a most unusual urological emergency: a firearm wound in which the blunt-nosed hand-gun bullet was lodged in the prostate. A bibliographic search of the literature revealed no similar case. Methods: The patient was admitted presenting a gunshot wound with the entrance hole on the right buttock. There was no exit wound. An X-ray revealed the bullet behind the pubic symphysis. We introduced a suprapubic catheter and then carried out a laparotomy making a discharge colostomy. Urethrogram revealed a pathway of contrast to the rectum. Several days later, we reached the bladder with an urethrotome and introduced an 18 Fr catheter. Under radiological control we made an open approach to the retropubic space, palpated the bullet within the prostate and then removed it. Discussion/Conclusions: The velocity of a rifle or hand-gun bullet is the main determinant of the severity of this type of injury. As there was no exit wound, we knew that the entrance velocity was low, therefore tissue damage would probably be small. In these cases, a preparatory suprapubic cystostomy is essential to be able to carry out a urethral reconstruction later. Radiological control during the procedure proved extremely useful to precisely locate the bullet. Our conservative approach of simply leaving in place the catheter helped us later to avoid a difficult repair of a recto-urethral fistula (AU)

Role of magnetic resonance imaging in assessment of posterior urethral distraction defects.

OBJECTIVES: To determine the clinical usefulness of magnetic resonance imaging (MRI) in the assessment of posterior urethral distraction defects. METHODS: A total of 21 male patients, 6 to 35 years old, with posterior urethral distraction defects underwent MRI of the pelvis and combined antegrade retrograde urethrography before surgical repair. Repair was performed with a bulboprostatic urethral anastomosis through the perineum in 13 patients and transpubically in 8. The MRI and urethrographic findings were compared and correlated with the operative findings. The MRI findings were also correlated with the incidence of posttraumatic impotence. RESULTS: On MRI, the length of urethral defect and type of prostatic displacement could be correctly determined in 86% and 89% of the patients, respectively. Also, MRI precisely delineated the extent of scar tissue, which varied according to the type and magnitude of the original trauma. Furthermore, MRI revealed the presence of paraurethral false tracks in 3 patients. In addition, MRI demonstrated avulsion of the corpus cavernosum, as well as lateral prostatic displacement in all 6 patients with posttraumatic impotence. CONCLUSIONS: Preoperative MRI can provide useful information that might help determine the appropriate surgical repair. It correctly estimates the length of the urethral defect, clearly demonstrates the type and degree of prostatic displacement, precisely delineates the site and density of scar tissue, and reveals the presence of paraurethral false tracks. Also, MRI can identify the cause of posttraumatic impotence such as avulsion of the corpus cavernosum and thus might predict the potency outcome in these cases.