ABSTRACT Purpose: False-negative urodynamic findings may mislead or prevent planned treatments due to unmatched findings with the clinical presentation. We hypothesized that the absence of urodynamic demonstration of SUI or OAB on urodynamics would interfere with clinical outcomes. Materials and Methods: Materials and Methods: We prospectively studied 124 women with (94) or without (30) demonstrable SUI after sling operations. Similarly, 64 women with OAB syndrome with (38) or without (26) demonstrable DO were also compared after treatment with anticholinergic agents. Patients were assessed with the UDI-6 and IIQ-7 questionnaires 3 and 6 months after treatment. Results: Only 76% of SUI patients demonstrated urine leakage during urodynamics. The UDI-6 score was higher in the demonstrable-SUI and demonstrable-DO groups, while the IIQ-7 score was comparable within the incontinence or urgency/frequency groups. Demonstrable and non-demonstrable SUI-operated patients showed similar outcomes. Patients with urgency syndromes with or without demonstrable DO had a similar rate of improvement with anticholinergic therapy. Conclusions: Women with clinical complaints of SUI objectively demonstrated on urodynamics presented the same subjective clinical outcome as those with SUI lacking objective demonstration when measured by the UDI-6 and IIQ-7 questionnaires. Similarly, patients with OAB syndrome with or without demonstrable DO had similar clinical improvement when treated with anticholinergics and measured using the same questionnaires.

Abstract Objectives To understand the clinical relationship between lower limbs functions and the recovery of spontaneous voiding after an acute urinary retention (AUR) in older patients admitted to hospitals for non-urological causes using clinical parameters. Materials and Methods 56 adult patients (32 men; mean age: 77.9 ± 8.3 and 24 women; mean age 82.1 ± 4.6) with AUR were prospectively followed with validated Physical Performance Mobility Exam (PPME) instrument to evaluate the relationship between the recovery of mobility capacity and spontaneous voiding. After a short period of permanent bladder drainage patients started CIC along evaluation by PPME during hospitalization and at 7, 15, 30 60, 90, and 180 days of discharge. Mann-Whitney U, chi-square test and ANOVA tests were used. Results All patients were hospitalized for at least 15 days (Median 26.3 ± 4.1 days). Progressive improvement on mobility scale measured by PPME was observed after leaving ICU and along the initial 7 days of hospitalization but with a deterioration if hospitalization extends beyond 15 days (p<0.03). Prolonged hospital stay impairs mobility in all domains (p<0.05) except step-up and transfer skills (p<0.02) although a recovery rate on spontaneous voiding persistented. Restoration of spontaneous voiding was accompanied by improvement on mobility scale (p<0.02). Recovery of spontaneous voiding was markedly observed after discharging the hospital. All patients recovered spontaneous voiding until 6 months of follow-up. Conclusions Recovery to spontaneous voiding after acute urinary retention in the hospital setting may be anticipated by evaluation of lower limbs function measured by validated instruments.

Objectives Determine what happens to patients after unsuccessful SUI operations and to explore the reasons why these patients change doctors. Materials and Methods One hundred consecutive failed patients treated for SUI were interviewed about the exams requested after persistence of the incontinence as well as the reasons they abandoned their primary doctors through a structured questionnaire. Results Among the patients with cases of anterior colporrhaphy, bladder suspensions or slings, 34.3%, 13.7% and 8.3%, respectively, were not offered any further type of investigative procedures to clarify the failure. Urodynamic evaluations were recommended in 75% of failed slings, and 66.6% of the patients proceeded with these tests. In contrast, only 31% of patients with bladder suspensions and 40% of patients with anterior colporrhaphy were recommended for urodynamic investigations, and only 44.4% and 28.5% of them, respectively, proceeded with the option. Patients´ delusions were reinforced by the doctors’ attitude toward the investigations. Vacuous justifications and the lack of intention to seek improvement were the driving forces causing the patients to change doctors. Conclusion Unsuccessful patients are evaluated in a non-protocol form. Difficulty in clarifying the reasons for surgical failure and the disruption of the doctor-patient relationship are the main reasons why patients abandon them.

INTRODUCTION: Bladder sarcomatoid carcinoma is a very rare variant of transitional cell carcinoma. With disputed nomenclature, the tumor has been described previously under a variety of names such as sarcomatoid carcinoma, pseudosarcoma, malignant mixed mesodermal/Müllerian tumor, metaplastic carcinoma and spindle cell carcinoma. This malignancy represents 0.3% of all bladder tumors and has an aggressive behavior yielding a poor prognosis despite radio and chemotherapy. CASE REPORT: An 81 y/o man presented with a transitional cell carcinoma and underwent a transurethral resection. Adjuvant onco-BCG was introduced. After 9 months of follow-up, a local tumoral recurrence occurred and a new transurethral resection revealed sarcomatoid carcinoma with osseous elements. A radical cystoprostatectomy was then carried out.

CONTEXTO: A profilaxia antibiótica nas ressecções transuretrais da próstata é uma prática regular e freqüente na clínica urológica. No entanto, seu efeito profilático e bactericida protetor pode ser contestado se procedimentos assépticos são utilizados na realização da cirurgia, sobretudo em pacientes com urina estéril. No caso de infecção urinária, a identificação dos germes para escolha do antibiótico adequado pode ser necessária. OBJETIVO: Verificar a eficácia da antibioticoprofilaxia em pacientes com urina estéril submetidos a ressecção transuretral de próstata. TIPO DE ESTUDO: Prospectivo num centro de referência de tratamento urológico, aberto. LOCAL: Hospital de referência terciária. PARTICIPANTES: 124 pacientes. VARIÁVEIS ESTUDADAS: 124 pacientes consecutivos foram randomicamente divididos em dois grupos para receber ou não antibioticoterapia profilática na ressecção transuretral de próstata. Cultura do meato uretral, urina, líquido irrigante e anti-séptico, além dos fragmentos de próstata ressecados foram analisados quanto a sensibilidade a antibióticos, escolhidos a critério do cirurgião, e determinada a partir de antibiograma com as cepas bacterianas identificadas nos sítios mencionados. RESULTADOS: Não se encontrou diferença estatisticamente significante na evolução clínica de ambos os grupos. Aqueles que receberam antibioticoprofilaxia apresentaram menor freqüência de cultura urinária positiva do que aqueles que não receberam profilaxia. No entanto, na observação da evolução clínica de ambos os grupos, o uso de antibiótico não mostrou qualquer benefício no que concerne à ocorrência de febre, positividade das culturas obtidas dos fragmentos de próstata ressecados ou episódios de bacteremia. 68 casos (57,1%) apresentaram cultura positiva do tecido prostático. Entretanto, não houve correlação entre a bactéria identificada a partir do tecido prostático e de outros locais, tais como meato, urina, líquido irrigante ou anti-séptico utilizado. Somente em seis casos foi encontrada a mesma bactéria no tecido prostático e na urina pós-operatória. Apenas em 15 casos (25%) do grupo antibiótico observou-se a sensibilidade esperada da bactéria identificada ao antibiótico utilizado. CONCLUSÃO: A profilaxia antibiótica em pacientes com urina estéril submetidos a ressecção transuretral de próstata poderia ser reavaliada, pois, na grande maioria das vezes, o antibiótico selecionado com finalidade profilática não apresenta especificadade às bactérias identificadas nos diversos sítios pesquisados.

CONTEXT: Antibiotic prophylaxis in transurethral resection of the prostate is a regular practice in urology. However, its prophylactic effect can be questioned when the antiseptic surgical technique is used. Nonetheless, urine culture-oriented antibiotic therapy is the gold standard for avoiding improper medication usage and bacterial resistance. OBJECTIVE: To study the efficacy of antibiotic usage in patients with negative urine cultures, who were submitted to transurethral resection of the prostate. TYPE OF STUDY: Prospective open labeled study. SETTING: Tertiary care referral hospital PARTICIPANTS: 124 consecutive patients, who were randomly divided into two groups to receive antibiotic prophylaxis or not. MAIN MEASUREMENTS: Cultures from meatus, urine, irrigation and antiseptic fluid, and prostate tissue chips, were compared and analyzed for bacterial sensitivity to the antibiotic used, according to the surgeon's personal criteria. McLennan's test was used for statistical analysis. RESULTS: No statistically significant difference regarding clinical evolution was found between the groups that received or antibiotics or not. Statistical significance was found regarding the occurrence of positive urine cultures during the postoperative period for those not receiving antibiotics, but not in relation to fever, prostate chip culture or bacteremic episodes. Sixty-eight subjects (57.1%) presented positive prostatic tissue culture. There was no specific correlation between the recovered bacteria from the meatus, prostatic tissue chip and urine and the spectrum of the administered antibiotic. Six cases showed the same bacteria in the urine and prostatic tissue chip. Only fifteen cases (25%) in the antibiotic group showed the desired sensitivity directed to the collected bacteria. CONCLUSIONS: Antibiotic prophylaxis for patients whose urine is sterile is debatable in patients who are candidates for transurethral resection of the prostate. Most of the time, the antibiotic agent used is not specific for any of the bacteria recovered from the various sources analyzed.

OBJETIVOS: Pacientes com carcinoma de células renais (CCR) quando diagnosticados precocemente têm maior possibilidade de cura com o tratamento cirúrgico. Este estudo tem como objetivo analisar as características anatomopatológicas dos espécimes cirúrgicos que justificam a diferença da história natural dos pacientes com CCR incidental e sintomático. MÉTODOS: Foram estudados retrospectivamente 115 pacientes submetidos a nefrectomia por CCR esporádico, divididos em Grupo 1: 59 pacientes assintomáticos com diagnóstico incidental e Grupo 2: 56 pacientes sintomáticos. A média de idade dos pacientes foi de 59 anos, com 86 homens e 29 mulheres. Cirurgia radical foi realizada em 96 pacientes e cirurgia conservadora em 19 casos. Foram analisadas as características anatomopatológicas, incluindo grau nuclear, estadio patológico, tamanho do tumor e presença de invasão microvascular intratumoral, sendo estes parâmetros comparados com a sobrevida dos pacientes. RESULTADOS: Ao compararmos os dois grupos, confirmou-se que os tumores incidentais têm menor grau nuclear (p=0,003), menor tamanho (p=0,001), menor incidência de invasão microvascular (p<0,001) e mais baixo estadio (p<0,001). A probabilidade de sobrevida do grupo incidental foi significativamente maior quando comparada ao grupo sintomático (p<0,001). CONCLUSÃO: Os CCR descobertos incidentalmente têm características anatomopatológicas mais favoráveis e estes pacientes têm maiores chances de sobrevida livre de doença quando comparados com os CCR sintomáticos.

BACKGROUND: Patients with early diagnosis of renal cell carcinoma (CCR) have higher chance of cure following surgical treatment. This study was set to compare the pathological characteristics between the surgical specimens and the survival of the patients with incidental and symptomatic CCR. METHODS: One hundred and fifteen patients with sporadic CCR were studied retrospectively following nephrectomy and divided into two groups. Group 1; 59 patients with incidental diagnosis and Group 2; 56 symptomatic patients. The mean age of the patients was 59 years, with 86 men and 29 women. Radical nephrectomy was performed in 96 patients and the conservative surgery was performed in the remaining 19. Comparison parameters included pathological outcome, specifically nuclear grade, pathological stage, size of the tumor and presence of microvascular invasion intratumoral and patients survival. RESULTS: Comparison between the two groups confirmed that the incidental tumors have smaller nuclear grade (p=0,003), smaller size (p=0,001) smaller incidence of micro vascular invasion (p< 0,001) and lower stage (p<0,001). Disease specific survival and recurrence free survival of the incidental group were statistically higher than the symptomatic group (p<0,001). CONCLUSION: Incidentally discovered CCR have more favorable pathological characteristics; the patients have disease free survival when compared to symptomatic CCR.

INTRODUCTION: Approximately 85% of patients who die from prostate cancer have bone metastases. Even though the radiological aspect of such metastases is osteoblastic, we currently know that these lesions are mixed, with coexisting blastic and lytic lesions, always beginning with bone lysis by osteoclast proliferation. Treatment options are palliative and have poor response, and when there is an improvement it is usually short-lived. This work intends to study the effect of clodronate in the treatment of skeletal complications of prostate cancer. MATERIALS AND METHODS: In an open prospective study 32 patients with hormone refractory prostate cancer with metastases to bones were assessed, in the period between November 2000 and September 2002. Mean age was 69 years (51 to 83 years). Patients were previously assessed by a pain scale and Karnofsky index. They underwent bone scintigraphy, X-ray, dosage of prostate specific antigen (PSA) and biochemical tests before and following treatment (administration of intravenous clodronate every 28 days). The Student's t-test was used for statistical analysis. RESULTS: Twenty-nine patients (90.6%) showed improvement after the first and the 2nd cycles, which persisted for at least 4 months. Average on the pain scale improved from 7.7 to 2.1 and Karnofsky index raised from 42 to 71. Radiological aspect of the metastases improved in 15 patients (46.8%) and side effects were low (only 2 patients - 6.2%). CONCLUSION: Bisphosphonate was effective in the treatment of skeletal complications of prostate cancer, presenting an objective response in 90.6% of treated patients, with a marked improvement in the pain scale, Karnofsky index and consequently in the quality of life of patients, and with low side effects.

OBJETIVOS: O comportamento do carcinoma de células renais estádio PT1 não está completamente esclarecido. Nós estudamos a presença de fatores prognósticos e tamanho tumoral na recorrência e sobrevida do carcinoma de rim esporádico após tratamento cirúrgico. MÉTODOS: Foram revisados retrospectivamente 120 pacientes, 93 PT1, nove PT2, 11 PT3, sete PT4, seguidos após nefrectomia. Foram analisadas sobrevida e recorrência da doença dentro de três grupos de tumores: grupo 1: < 4cm, grupo 2: 4-7 cm e grupo 3: >7 cm e os fatores prognósticos preditivos avaliados foram grau nuclear, invasão microvascular, presença de gânglios comprometidos e degeneração sarcomatosa RESULTADOS: A freqüência de fatores prognósticos adversos aumenta à medida que aumenta o tamanho do tumor. No grupo 1 tivemos apenas quatro tumores de alto grau e somente um apresentou invasão microvascular não havendo gânglios comprometidos ou degeneração sarcomatosa. No grupo 2 havia 16 tumores de alto grau, quatro sarcomatosos, dois com invasão microvascular positiva e dois com gânglios positivos. No grupo 3, encontraram-se 18 tumores de alto grau, 15 com invasão microvascular e sete com gânglios positivos e cinco sarcomatosos. Houve significância estatística na sobrevida câncer específica (p=0,002) e livre de doença (p=0,0002) entre os três grupos. CONCLUSÃO: A evolução dos tumores PT1 é distinta para tumores menores de 4 cm e de 4-7 cm cabendo a subdivisão destes dois grupos em T1a e T1b.

OBJECTIVE: The behavior of the renal cells carcinoma stage PT1 is not completely clarified. We studied the presence of factors after prognostics and tumoral size in the recurrence of survival of the sporadic kidney carcinoma after surgical treatment. METHODS: 120 patients followed after nephrectomy had been revised retrospectively 93 PT1, 9 PT2, 11 PT3, 7 PT4, It was analyzed survival and recurrence of the disease inside of three groups of tumors: Group 1: < 4cm, group 2: 4-7cm and group 3: > 7cm, and the prognostics factors above-mentioned evaluated were nuclear degree, microvascular invasion, presence of committed ganglia and sarcomatous degeneration. RESULTS: The frequency of adverse prognostics factors increase as the tumor size increase. In the group 1, we had only four tumors of high degree and only one shown microvascular invasion that does not committed ganglia or sarcomatous degeneration. In group 2 there was 16 tumors of high degree, 4 sarcomatoses, two with positive microvascular invasion and two with positive ganglia. In group 3, was found 18 tumors of high degree, 15 with microvascular invasion and 7 with positive ganglia and 5 sarcomatoses. There was statistical significance in the specific cancer survival (p=0.002) and free of illness (p=0.0002) between the three groups. CONCLUSION: The evolution of tumors PT1 is distinct for lesser tumors of 4 cm and 4-7 cm fitting the subdivision of these two groups in T1a and T1b.

CONTEXTO: O carcinoma de células renais é a terceira neoplasia geniturinária em frequência, havendo atualmente um aumento no diagnóstico incidental de tumores restritos ao rim. OBJETIVO: Verificar a sobrevida dos pacientes com tumores de rim incidentais e sintomáticos submetidos a nefrectomia. TIPO DE ESTUDO: Retrospectivo. LOCAL: Hospital Sírio Libanês e Beneficência Portuguesa de São Paulo. PARTICIPANTES: 115 pacientes com diagnóstico de carcinoma de células renais e operados por um mesmo grupo de cirurgiões, avaliados por um único patologista. VARIÁVEIS ESTUDADAS: Sexo, idade e método diagnóstico, analisados em dois grupos conforme o diagnóstico do tumor: Grupo 1 com diagnóstico incidental e Grupo 2, com tumores sintomáticos. São também avaliadas as características anatomopatológicas da peça operatória e sobrevida dos pacientes nestes dois grupos. Foi realizada análise estatística através do teste t de Student, qui quadrado, log rank test e Kaplan-Meyer. RESULTADOS: Dos pacientes estudados, 59 (51%) tinham diagnóstico incidental, sendo 78% diagnosticados pelo exame ultra-sonográfico, 20% por tomografia computadorizada e 2% em transoperatório; já 56 pacientes (49%) apresentaram-se sintomáticos. Houve um equilíbrio quanto à lateralidade, sendo a cirurgia conservadora em 24% dos incidentais e 9% dos sintomáticos. No grupo incidental, apenas um paciente teve progressão e nenhum óbito, ao passo que os sintomáticos tiveram 5 progressões e 10 óbitos. A sobrevida câncer-específica em cinco anos foi de 100% para incidentais e 80% para os sintomáticos (p = 0,001) e a sobrevida livre de doença foi de 98% para os incidentais e 62% para os sintomáticos (p < 0,001). CONCLUSÃO: O tumor de rim diagnosticado incidentalmente oferece melhor prognóstico, proporcionando maior sobrevida livre de doença.

CONTEXT: Renal cell carcinoma is the third most frequent genitourinary neoplasia, and there is currently an increase in the incidental diagnosis of tumors confined to the kidneys. OBJECTIVE: To study the survival of patients with incidental and symptomatic renal tumors who have undergone nephrectomy.DESIGN: Retrospective. SETTING: Hospital Sírio Libanês and Beneficência Portuguesa de São Paulo. PARTICIPANTS: 115 patients with diagnosis of renal cell carcinoma, operated on by the same group of surgeons and evaluated by a single pathologist. MAIN MEASUREMENTS: Sex, age and diagnosis method, analyzed in two groups, according to the tumor diagnosis: Group 1 with incidental diagnosis and Group 2 with symptomatic tumors. The anatomopathological characteristics and patient survival in both groups were evaluated. A statistical analysis was performed using the Student t, chi-squared, log rank and Kaplan-Meyer tests. RESULTS: Among the studied patients, 59(51%) had an incidental diagnosis, with 78% diagnosed by ultrasonography, 20% by computerized tomography scan and 2% during surgeries; 56 patients (49%) were symptomatic. Tumor locations were equally distributed between the two kidneys, and the surgery was conservative for 24% of the incidental and 9% of the symptomatic group. In the incidental group only one patient had tumor progression and there was no death, while in the symptomatic group there were 5 progressions and 10 deaths. The 5-year specific cancer-free survival was 100% in the incidental and 80% in the symptomatic group (p = 0.001) while the disease-free rate was 98% in the incidental and 62% in the symptomatic group (p < 0001). CONCLUSION: Incidental renal tumor diagnosis offers better prognosis, providing longer disease-free survival.

CONTEXTO: Diversos fatores genéticos e ambientais têm sido relacionados à oncogênese e progressão do câncer de próstata. A principal dificuldade na conduta clínica frente a esses tumores consiste no fato de não existirem marcadores prognósticos precisos, e que tratamentos eficazes dos tumores hormônio-resistentes não estão ainda disponíveis. Entre os reguladores mais importantes para avaliar a taxa de apoptose, destaca-se a expressão da proteína bcl-2. Os níveis elevados dessa proteína podem contribuir na progressão dos tumores prostáticos para um estado metastático e/ou hormônio independente, que caracteristicamente não apresenta resposta satisfatória ao tratamento quimioterápico. OBJETIVO: Investigar a expressão da proteína bcl-2 como fator prognóstico em portadores de tumores prostáticos. TIPO DE ESTUDO: Estudo retrospectivo. LOCAL: Disciplina de Urologia da Universidade Federal de São Paulo. TESTE DIAGNÓSTICO: Exame anatomopatológico convencional por hematoxilina-eosina (HE) e imunohistoquímico. VARIÁVEIS ESTUDADAS: Expressão prognóstica da proteína bcl-2, por técnica imunohistoquímica em portadores de adenocarcinoma da próstata submetidos a prostatectomia radical. AMOSTRA: 28 amostras de tumores de próstata fixadas em parafina, provenientes de pacientes submetidos à prostatectomia radical sem ablação androgênica prévia, avaliadas por HE e por imunohistoquímica para a caracterização da expressão da proteína bcl-2. A expressão foi correlacionada ao grau de diferenciação do tumor, dividindo-se os tumores em dois grupos, segundo o escore de Gleason, em baixo (escore 2 a 4), e alto grau (8 a 10), sendo que os grupos foram divididos em 18 e 10 pacientes, respectivamente. RESULTADOS: Observou-se associação estatisticamente significativa (P < 0, 001) entre expressão elevada da proteína e os casos que apresentavam um escore de Gleason mais elevado (83, 3%), enquanto que no grupo de escore de baixo grau não foi detectada expressão da bcl-2 em 90% das amostras. CONCLUSÕES: O aumento na expressão da proteína bcl-2 em tumores de próstata com escore de Gleason elevado pode estar associado à progressão do adenocarcinoma de próstata.

CONTEXT: Multiple genetic and epigenetic factors have been implicated in the oncogenesis and progression of prostate cancer. The major difficulty is in that the clinical management stems from the reality that reliable and accurate prognostic biomarkers are not available and that effective treatment regimens forming hormone-resistant prostate cancers are yet to be developed. Among the most important regulators of apoptosis and programmed cell death is the bcl-2 gene and its related proteins. Elevated levels of bcl-2 protein may contribute to the progression of prostate cancers to a metastatic and hormone-insensitive state characterized by poor responses to chemotherapy. OBJECTIVE: To characterize the expression of bcl-2 proteins as a prognostic factor in humans. DESIGN: A retrospective approach. SETTING: Urology section, Federal University of São Paulo. DIAGNOSTIC TEST USED: Immunohistochemical analysis using bcl-2 protein antibody and normal staining by hematoxylin-eosin. MAIN MEASUREMENTS: Prognostic relations and protein expression were evaluated considering the total sample (28) divided into two groups, high (8 to 10) and low (2 to 4), separated according to the histological differentiation grade (Gleason score) with 10 and 18 samples, respectively. RESULTS: The differentiation of grade into two groups separated according to the Gleason score in low and high types presented different bcl-2 expression (P < 0.001). CONCLUSION: The higher frequency of bcl-2 immunostaining in tumor samples was observed in association with more advanced Gleason scores and suggests that an increase in the ratio of this anti-apoptotic protein often occurs during progression of prostate cancers.