Resumo em Inglês:

PURPOSE: To review the literature and present a current picture of the evolution in radical prostatectomy from the laparoscopic point of view. MATERIALS AND METHODS: We conducted an extensive Medline literature search. Articles obtained regarding laparoscopic radical prostatectomy (LRP) and our experience at Institut Montsouris were used for reassessing anatomical and technical issues in radical prostatectomy. RESULTS: LRP nuances were reassessed by surgical teams in order to verify possible weaknesses in their performance. Our basic approach was to carefully study the anatomy and pioneer open surgery descriptions in order to standardized and master a technique. The learning curve is presented in terms of an objective evaluation of outcomes for cancer control and functional results. In terms of technique-outcomes, there are several key elements in radical prostatectomy, such as dorsal vein control-apex exposure and nerve sparing with particular implications in oncological and functional results. Major variations among the surgical teams' performance and follow-up prevented objective comparisons in radical prostatectomy. The remarkable evolution of LRP needs to be supported by comprehensive results. CONCLUSIONS: Radical prostatectomy is a complex surgical operation with difficult objectives. Surgical technique should be standardized in order to allow an adequate and reliable performance in all settings, keeping in mind that cancer control remains the primary objective. Reassessing anatomy and a return to basics in surgical technique is the means to improve outcomes and overcome the difficult task of the learning curve, especially in minimally access urological surgery.

Resumo em Inglês:

PURPOSE: The aim of this study was to discover if elderly patients exhibit comparable outcomes and survival benefits to those achieved in younger patients. MATERIALS AND METHODS: We assessed 35 patients over 80 years old treated by radical nephrectomy or nephroureterectomy for malignant and inflammatory conditions within the previous 4 years. A multivariate analysis regarding survival and recovery was conducted and included various preoperative parameters. The subjective opinion of patients or patient's relatives (in cases where the patient had past away) was estimated by answering the following questions: (a) are you satisfied with your decision to undergo the operation? (b) would you undergo it once more if needed? (c) would you advise it to a patient your age? RESULTS: The median age was 83.5 years. Radical nephrectomy with a flank approach was performed in 65.7% of cases and nephroureterectomy with a transabdominal approach in 34.3% of cases. The median recovery was 13 weeks. During a median follow-up of 31 months (range 12 to 53), 80% of patients were disease free. The remaining 20% passed away demonstrating a median survival of 25 months (range 13-38). Eighty-eight percent of patients were satisfied with their decision to undergo the operation, 91.4% would undergo it once more if needed and 91.4% would advise it to a patient their age. CONCLUSIONS: Radical nephrectomy and nephroureterectomy are safe and effective in well-selected patients over 80 years old. Elderly patients exhibit comparable preoperative outcomes and survival benefits to those achieved in younger patients. Various preoperative clinical variables that effect the survival of patients but not their recovery could be identified.

Resumo em Inglês:

PURPOSE: In Brazil, National data regarding the epidemiology of renal cell carcinoma (RCC) are scarce. The aim of this study was to describe the demographic, clinical, and pathologic characteristics of RCC diagnosed and treated by members of the SBU - Brazilian Society of Urology. MATERIALS AND METHODS: For this cross-sectional study, data were collected through an on line questionnaire available to the members of the Brazilian Society of Urology (SBU). Between May 2007 and May 2008, voluntary participant urologists collected data on demographic, clinical and pathological characteristics from patients diagnosed with RCC in their practice. RESULTS: Fifty SBU affiliated institutions contributed with patient information to the study. Of the 508 patients, 58.9% were male, 78.9% were white, and the mean age was 59.8 years. Smoking history, high blood pressure and a body mass index above 30 kg/m2 were present in 14.8%, 46.1% and 17.9% of the patients, respectively. Abdominal ultrasound and computed tomography were the main diagnostic methods. The majority of the cases were localized tumors and metastasis were presented in 9.5% of the patients; 98.4% underwent nephrectomy. Clear cell carcinoma was the most common histological type. In comparison with private institutions, stage IV disease was less frequent among patients treated at public health services (P = 0.033). CONCLUSIONS: RCC in Brazil is more common in white men in their sixth decade of life. Ultrasound is the main diagnostic tool for the diagnosis of clear cell carcinoma and we found that localized disease was predominant. A national registry of RCC is feasible and may provide valuable information.

Resumo em Inglês:

PURPOSE: Evaluation of the beneficial effect of nephrectomy of the atrophic kidney on blood pressure (BP) and renal function. MATERIALS AND METHODS: A retrospective study of 51 patients with renovascular hypertension (RVH), bearers of atrophic kidney due to severe stenosis or occlusion of the renal artery. Average age was 47.1 ± 15 years, the median creatinine clearance was 54 mL/min, average systolic BP (SBP) 149.6 ± 22.5 mm Hg, average diastolic BP (DBP) 90.8 ± 17 mm Hg and the median number of hypotensors 3 (1 to 5) per patient per day. Blood pressure and serum creatinine were analyzed from 12 to 60 months after the nephrectomy. RESULTS: There was a significant improvement in the average SBP in the periods from 12 to 36 months (p ≤ 0.028) and for the average DBP from 12 to 48 months after the nephrectomy (p ≤ 0.045), accompanied by a significant reduction in the use of hypotensors from 12 to 48 months (p < 0.05). One year after the nephrectomy, there was a 69% improvement in blood pressure and 63.8% improvement in renal function of patients. CONCLUSION: The removal of atrophic kidney in patients with RVH is a safe procedure which presents benefits for the control of arterial hypertension and renal function in bearers of renovascular hypertension.

Resumo em Inglês:

INTRODUCTION: Tubeless percutaneous nephrolithotomy (PCNL) in selected patients has been found to be safe and can reduce postoperative discomfort without increasing complications. The challenges of tubeless PCNL via supracostal access are inadequate drainage and postoperative bleeding, conditions that may increase pulmonary complications. We compare the efficacy and safety of the tubeless supracostal versus the standard supracostal PCNL. MATERIALS AND METHODS: Supracostal PCNL with one percutaneous renal access, no significant bleeding, extravasation and residual stone was performed in 95 patients. Of these, 43 were tubeless PCNL (Group-I) and 52 were PCNL with standard routine postoperative nephrostomy tube (Group-II). In group-I, PCNL was done by the standard supracostal technique with the placement of a postoperative external ureteral catheter for 48 hours. The operative time, success rate, hospital stay and ensuing complications were compared between group-I and group-II. RESULTS: Patients in the tubeless PCNL group (Group-I) were 90.7% stone -free while those with standard routine postoperative nephrostomy tube(Group-II) were 84.6% stone -free. Additionally, stone fragments of less than 4 mm in diameter were found in 9.3% of patients in group-I and 25.4% in group-II. The success rate, hematocrit change and complication were not significantly different between both groups. The analgesic requirement, operative time and hospital stay were all significantly less in the tubeless supracostal group (Group-I). None of group I and only one patient of group II needed intercostal drainage. CONCLUSION: Tubeless supracostal percutaneous nephrolithotomy in selected patients is effective with acceptable complications. This technique offers the advantage of lower analgesic requirement, shorter operative time and hospital stay. The pulmonary complication is the same as the standard supracostal percutaneous nephrolithotomy.

Resumo em Inglês:

PURPOSE: Many urologists recommend a six-week time interval between a prostate biopsy and a total prostatectomy (TP) to allow the biopsy induced inflammation to subside. Our aim was to assess whether the time interval between prostate biopsy and TP has an impact on the surgical outcome. MATERIALS AND METHODS: A retrospective analysis was performed on data from patients who underwent a TP by a single surgeon from 1992 to 2008. The patients were divided into two groups according to the time interval between biopsy and TP, Group 1 ≤ 6 weeks and Group 2 > 6 weeks. Relevant perioperative variables and outcome were analyzed. RESULTS: 923 patients were included. There was a significant difference between the two groups in the surgeons' ability to perform a bilateral nerve sparing procedure. Those who had a TP within six weeks of the biopsy were less likely to have a bilateral nerve sparing procedure. No significant difference was noted in the other variables, which included Gleason score, surgical margin status, estimated blood loss, post-operative infection, incontinence, erectile function, and biochemical recurrence. CONCLUSIONS: TP can be safely performed without any increase in complications within 6 weeks of a prostate biopsy. However, a TP within six weeks of a biopsy significantly reduced the surgeon's perception of whether a bilateral nerve sparing procedure was performed.

Resumo em Inglês:

INTRODUCTION: Transurethral resection syndrome is an uncommon but potentially life threatening complication. Various irrigating solutions have been used, normal saline being the most physiological. The recent availability of bipolar cautery has permitted the use of normal saline irrigation. MATERIAL AND METHODS: In a randomized prospective study, we compared the safety and efficacy of bipolar cautery (using 0.9% normal saline irrigation) versus conventional monopolar cautery (using 1.5% glycine irrigation). Pre and postoperative hemoglobin (Hb) and hematocrit values were compared. Hemodynamics and arterial oxygen saturation were monitored throughout the study. Safety end points were changes in serum electrolytes, osmolarity and Hb/PCV (packed cell volume). Efficacy parameters were the International Prostate Symptom Score (IPSS) and Qmax (maximum flow rate in mL/sec) values. RESULTS: Mean preoperative prostate size on ultrasound was 60 ± 20cc. Mean resected weight was 17.6 ± 10.8 g (glycine) and 18.66 ± 12.1 g (saline). Mean resection time was 56.76 ± 14.51 min (glycine) and 55.1 ± 13.3 min (saline). The monopolar glycine group showed a greater decline in serum sodium and osmolarity (4.12 meq/L and 5.14 mosmol/L) compared to the bipolar saline group (1.25 meq/L and 0.43 mosmol/L). However, this was not considered statistically significant. The monopolar glycine group showed a statistically significant decline in Hb and PCV (0.97 gm %, 2.83, p < 0.005) as compared to the bipolar saline group (0.55 gm % and 1.62, p < 0.05). Patient follow- up (1,3,6 and 12 months postoperatively) demonstrated an improvement in IPSS and Qmax in both the groups. CONCLUSION: We concluded that bipolar transurethral resection of prostate is clinically comparable to monopolar transurethral resection of prostate with an improved safety profile. However, larger number of patients with longer follow up is essential.

Resumo em Inglês:

PURPOSE: A considerable percentage of patients with benign prostatic hyperplasia (BPH) also have additional cardiac pathologies, which often require anticoagulant therapy. The aim of this study was to evaluate the efficacy and safety of photoselective vaporization of the prostate (PVP) for BPH in cardiac patients receiving anticoagulant therapy. MATERIALS AND METHODS: A total of 67 patients suffering from BPH and high risk cardiac pathologies were operated on using laser prostatectomy. All patients had cardiac pathologies with bleeding disorders requiring anticoagulant use, and underwent standard urologic evaluation for BPH. Patients were treated with laser prostatectomy for relief of the obstruction using the KTP/532 laser energy at 80 W. RESULTS: The mean patient age was 71.4 years (range 55-80). Mean prostate volume on transrectal ultrasonography was 73.2 mL (range 44-120). Operation time ranged from 40 to 90 min, with an average value of 55 min. The average hospital stay was 48 hours (range 12-72) and the Foley catheters were removed within 48 hours, with a mean catheterization time of 34.2 ± 5.9 hours (0-48). No patient required an additional procedure due to severe bleeding necessitating intervention during the early postoperative phase. Mean International symptoms scoring system (IPSS) values and post voiding residual volume decreased and peak urinary flow rate increased (p < 0.001). Our results showed that the mean prostate volume had decreased by 53% at 6 months. CONCLUSIONS: High-power photo selective laser vaporization prostatectomy is a feasible, safe, and effective alternative for the minimal invasive management of BPH, particularly in cardiac patients receiving anticoagulant therapy.

Resumo em Inglês:

PURPOSE: Penile carcinoma is a rare but mutilating malignancy. In this context, partial penectomy is the most commonly applied approach for best oncological results. We herein propose a simple modification of the classic technique of partial penectomy, for better cosmetic and functional results. TECHNIQUE: If partial penectomy is indicated, the present technique can bring additional benefits. Different from classical technique, the urethra is spatulated only ventrally. An inverted "V" skin flap with 0.5 cm of extension is sectioned ventrally. The suture is performed with vicryl 4-0 in a "parachute" fashion, beginning from the ventral portion of the urethra and the "V" flap, followed by the "V" flap angles and than by the dorsal portion of the penis. After completion of the suture, a Foley catheter and light dressing are placed for 24 hours. CONCLUSIONS: Several complex reconstructive techniques have been previously proposed, but normally require specific surgical abilities, adequate patient selection and staged procedures. We believe that these reconstructive techniques are very useful in some specific subsets of patients. However, the technique herein proposed is a simple alternative that can be applied to all men after a partial penectomy, and takes the same amount of time as that in the classic technique. In conclusion, the "parachute" technique for penile reconstruction after partial amputation not only improves the appearance of the penis, but also maintains an adequate function.

Resumo em Inglês:

PURPOSE: Calculation of PSA is possible in human fluids even if it presents in very low concentrations with the help of hypersensitive immunodiagnostic methods. The periurethral glands represent one of the potential sources of urine prostate specific antigen (uPSA) in both sexes but the purpose of studying PSA levels in children is still unclear in the literature. In this pilot study we studied uPSA in a small cohort of normal, pre and post pubertal children, in relation to standard anthropometric variables. MATERIALS AND METHODS: The study cohort consisted of 58 children 5-14 years old (42 boys/16 girls). Height, weight, body mass index (BMI) and the respective stature-for-age, weight-for-age and BMI-for-age percentiles of the sample were determined. uPSA levels were measured using a third generation immunodiagnostic method (DPC Immulite®) that has a lower limit of detection of 3 ng/L. When levels of PSA were above the upper limit of detection, uPSA levels were assessed using the ROCHE technique. RESULTS: uPSA levels tend to be higher in male than female children (p = 0.091, linear regression analysis). uPSA was measurable only in 3/16 girls (18.75%). Measurable uPSA was found in 18/42 boys (42.8%). The range of urine PSA in boys was 0-161000 ng/L (mean 10561.9 ± 31830.48 ng/L). Statistical analysis with linear regression showed correlation with height and age in boys. CONCLUSIONS: The use of hypersensitive assays allows calculation of uPSA in childhood. The values of this variable are measurable in both sexes and related with gender. In boys, uPSA was correlated with age and height but not with other variables tested. Further studies are required to clarify this field.

Resumo em Inglês:

PURPOSE: This prospective study was performed to achieve visualization of the reestablishment of anatomy after reconstructive surgery in the different pelvic compartments with non-absorbable radiopaque meshes, providing valuable anatomic information for surgeons implanting meshes. MATERIALS AND METHODS: A total of 30 female patients with stress urinary incontinence (SUI), anterior and posterior vaginal wall prolapse, or both underwent surgical repair using radiopaque meshes after written informed consent. Patients with SUI underwent five different surgeries. Patients with anterior vaginal prolapse underwent a procedure using a combined pre-pubic and transobturator mesh, and those with posterior vaginal prolapse underwent posterior slingplasty. Three-dimensional reconstruction using helical CT was performed four weeks postoperatively. RESULTS: In all cases, the mesh was clearly visualized. Transobturator slings were shown at the midurethra, and the anchoring tails perforated the obturator foramen at the safety region. Mini-slings were in the proper place, and computed angiography revealed that the anchoring system was away from the obturator vessels. In patients undergoing procedure for anterior vaginal prolapse, both pre-pubic armpit and obturator slings were clearly seen and the mesh was in the proper position, supporting the bladder base and occluding the distal part of the urogenital hiatus. Transcoccygeal sacropexy revealed indirectly a well-supported "neo rectovaginal fascia" and the anchoring tails at the level of ischial spines. CONCLUSION: Three-dimensional helical tomography images of the female pelvis using radiopaque meshes have a potential role in improving our understanding of pelvic floor reconstructive surgeries. These radiopaque meshes might be the basis of a new investigative methodology.

Resumo em Inglês:

PURPOSE: To determine why community-dwelling women aged 80 years or over were referred for urodynamic evaluation despite their advanced age and which urodynamic diagnosis was made. MATERIALS AND METHODS: One hundred consecutive females (80-93 years) were referred to our urodynamics outpatient clinic for evaluation of lower urinary tract symptoms (LUTS) between 2005 and 2008. Clinical evaluation comprised of a previous history of LUTS, previous medical history of neurological disease or dementia, pelvic floor dysfunction or prior pelvic surgery. Exclusion criteria were complete retention and severe dementia involving failure to understand simple instructions. Assessed items were results of uroflows (free flow and intubated flow), cystometry and urethral pressure profilometry, and final urodynamic diagnosis. RESULTS: The main complaint evoked by the patients was incontinence (65.0%) of which 61.5% was "complicated" and urgency was reported by 70.0%. Interpretable free flow at arrival was very low (44.0%). Prevalence of detrusor overactivity was high, found in 45 patients of whom 16 had detrusor hyperactivity with impaired detrusor contractility. Detrusor overactivity and urgency were strongly associated (p = 0.004). Twenty-five patients had intrinsic sphincteric deficiency alone and 15 detrusor underactivity. CONCLUSION: In this particular community-dwelling with an elderly female population, urodynamics is easily feasible. Incontinence, mainly "complicated" is the more frequent complaint and urgency the more frequent symptom. Urodynamic diagnosis underlines the high incidence of detrusor overactivity as well as impaired detrusor function.