Resumo em Inglês:

When treating renal injuries, the goals of the urologic surgeon are preservation of maximal renal function with a minimal risk of complications. To meet these, accurate staging is essential. The combined use of clinical and radiologic findings, with intra-operative information where available, will enhance the practitioner’s ability to detect, classify, and treat renal injuries appropriately. We discuss our current approach to renal trauma and current indications and techniques for surgical exploration of the injured kidney.

Resumo em Inglês:

INTRODUCTION: Classification TNM 1997 defines renal cell carcinoma smaller than 7 cm and confined to the kidney as stage T1. Our goal is to discuss if tumors smaller than 4 cm have the same behavior characteristics then tumors between 4 and 7 cm, to compose the same stage of the disease. MATERIALS AND METHODS: Retrospective assessment of 138 patients in stage T1 (TNM - 97), divided into 2 groups; group-1: composed of 65 patients (47%) with tumors < 4 cm, and group-2: composed of 73 patients (53%) with tumors between 4 and 7 cm. The following prognostic factors were assessed in the recurrence of the disease and survival of patients: nuclear degree, microvascular invasion, sarcomatous degeneration, and involved lymph nodes. Statistical evaluation has been accomplished through the log rank test, chi-square test, and Fishers exact text. RESULTS: Average tumor size was 2.5 cm for group-1, and 5.3 cm for group-2. In group-2, there was the predominance of worse prognostic factors, with high-grade tumors (p = 0.01) and presence of microvascular invasion (p = 0.001). Sarcomatous tumors and involvement of lymph nodes did only happen in group-2. Disease-free survival for group-1, analyzed in the median period of 36 months, was 100%, and for group 2, in the median period of 31 months, was 81% (p = 0.008). CONCLUSION: The results obtained allow the conclusion that the present stage T1 for renal cell carcinoma gathers tumors of different evolution, being therefore recommendable the stratification in T1a for tumors smaller than 4 cm, and T1b for tumors between 4 and 7 cm.

Resumo em Inglês:

PURPOSE: To evaluate a new method designed for estimating the tumor extent in radical prostatectomy specimens. The tumor extent was correlated to preoperative PSA and to several pathologic findings in the surgical specimens as well. MATERIALS AND METHODS: Tumor extent was estimated in 118 consecutive radical prostatectomies through a simple point-count method. Drawn on a sheet of paper, each quadrant of the whole mount sections contained 8 equidistant points. During the microscopic slides examination, the tumor area was drawn over the correspondent quadrant of the paper sheet. According to the extent, tumors were classified in 5 groups: 1) very limited: £ 10 positive points; 2) limited: 11-19 positive points; 3) moderately extensive: 20-35 positive points; 4) extensive: 36-39 positive points; 5) very extensive: 70 positive points. This classification was based on a previous analysis of tumor extent in 109 radical prostatectomies. The distribution was quite normal up to 69 positive points, but asymmetric above that number, including cases exceeding far above that value. We considered the quartiles of the normal distribution up to 69 positive points (groups 1 to 4), and above that value a fifth group was considered. RESULTS: There was a statistically significant and direct correlation between the tumor extent and all variables studied: preoperative PSA (p = 0.03), Gleason score (p < 0.0001), primary grade in high-grade tumors (p < 0.01), surgical margins (p < 0.0001), extraprostatic extension (pT3a) (p < 0.0001), and seminal vesicle invasion (pT3b) (p = 0.01). CONCLUSIONS: The method, which is simple and well correlated to other prognostic factors, is accessible to those pathologists working in routine pathology laboratories. Whether this method will be used by other urology centers is yet to be seen.

Resumo em Inglês:

OBJECTIVE: Evaluate the ability of serum concentration of prostate specific antigen (PSA) between 2 cutting points to predict the existence of bone metastasis confirmed by bone scintigraphy in man with prostate cancer. MATERIALS AND METHODS: Two hundred and fourteen consecutive patients with prostate cancer were evaluated during the present study in the period from 1998 to 2001. From all patients, PSA serum concentrations and bone scintigraphy were obtained. For the study, 2 cutting points of PSA (10 and 20 ng/mL) were adopted to predict the existence of bone metastasis. RESULTS: From the 214 patients, 35 (16.3%) presented positive scintigraphic examinations for the presence of bone metastasis. No patient presented bone metastasis in scintigraphy if having PSA < 10 ng/mL, and in only 1 patient (0.46%) with bone metastasis PSA concentration was < 20 ng/mL. Therefore, when the cutting point adopted for PSA serum concentration was 10 ng/mL, a negative predictive value for bone metastasis was 100% with sensitivity rates of 100%. Nevertheless, the positive predictive value and the specificity of the method were, respectively, 24.5% and 39.7%. When the cutting point of PSA serum concentration was 20 ng/mL, an increment was observed in rates of positive predictive value and specificity (41.5% and 73.2%), respectively, without substantial changes in negative predictive value (99.2%) and sensitivity (97.1%) of the method. CONCLUSIONS: Data of present study allow for the conclusion that PSA serum concentration over 20 ng/mL was a more accurate cutting point than PSA serum concentration over 10 ng/mL to predict the presence of bone metastasis in scintigraphy.

Resumo em Inglês:

PURPOSE: To demonstrate the economical impact of surgical castration in comparison to the medical castration for patients with advanced prostate cancer. MATERIAL AND METHODS: Between January 2001 and December 2001, 32 patients with advanced prostate cancer underwent bilateral sub-capsular orchiectomy at our Hospital. The costs of this procedure were compared to the costs of medical castration with LH-RH analogues. RESULTS: The costs of the surgical procedure were extremely reduced when compared to published data on the medical treatment. Surgical castration did not have any stronger negative impact on the evolution of these patients when compared to medical castration. CONCLUSION: Surgical castration is an efficient and low cost treatment for advanced prostate cancer.

Resumo em Inglês:

OBJECTIVE: Comparing in human semen samples with low initial quality, the effects of 2 techniques of cryopreservation and dilution/centrifugation after thawing on the spermatic motility and vitality. MATERIALS AND METHODS: Semen samples from 15 oligo and/or asthenozoospermic individuals assisted in the infertility sector of a tertiary hospital were obtained through masturbation. The samples were divided into 2 portions of equal volume, and diluted (1:1; v/v) with the cryoprotector containing glycerol (Test yolk buffer). One portion was frozen through the technique of liquid nitrogen vapor with static phases (group I - GI), while the other was frozen through a programmable biological freezer with linear speed (Planer, Kryo 10, series III) (group II - GII). The following parameters were assessed before freezing and after thawing: percentage of spermatozoa with progressive motility (Prog%) and percentage of live spermatozoa (Vit%). After defrosting, Prog% was assessed before and after removal of cryoprotector diluent, in different time intervals (zero, 3 h, and 24 h). The statistical analysis has been accomplished by using the non-parametric tests of Wilcoxon and Friedman. RESULTS: There was significant reduction of Prog% and Vit% from before freezing to after defrosting in both groups, I and II (p < 0.001). Values of Prog% and Vit% were not statistically different between groups, after thawing. It has been observed a significant reduction in Prog% among portions frozen with the automated technique after dilution and centrifugation for removal of cryoprotector (p = 0.006). After cryoprotector removal, Prog% has been kept unaltered, in both groups, during the first 3 hours of incubation, although being superior in group I (p = 0,04). There was a significant decrease in Prog% after 24 hours of incubation, in both groups (p < 0,01). CONCLUSION: For human semen samples with low initial quality, freezing through vapor technique or through the automated technique showed to be equivalent in regarding recovery of live spermatozoa with progressive motility. The effects of dilution and centrifugation to remove the cryoprotector had a negative impact only in samples frozen through the automated technique. In both techniques, progressive motility is kept constant during the first 3 hours after thawing and removal of the cryoprotector, but is drastically diminished by the end of an incubation period of 24 hours.

Resumo em Inglês:

OBJECTIVES: Assessing the efficiency of repeated percutaneous epididymal sperm aspiration (PESA) in men with obstructive azoospermia, and also the possibility of cryopreservation of remaining material for future use in intracytoplasmic sperm injection (ICSI). METHOD: Retrospective study, in which 79 procedures of PESA were assessed in 58 patients (mean age = 45 years), whose partners had mean age of 34 years. Vasectomy was the most frequent cause of obstructive azoospermia (n = 46). RESULTS: Motile spermatozoa were obtained in 65 procedures (82%). PESA was twice repeated for 15 patients, 3 times for 5 patients, and 4 times for 1 patient. Spermatozoa were found in 13 (87%) patients in the second attempt, in 4 (80%) patients in the third attempt, and in the only patient that had accomplished 4 procedures. In 30 procedures (37%), we have obtained enough material for cryopreservation. In 12 among the 13 samples thawed (n = 13 patients), motile spermatozoa were found, and ICSI was accomplished. Four patients that did not use their samples requested the elimination of the material. Total rate of pregnancy per transference was 21/55 (38%). In 14 PESA procedures, it was not possible to find spermatozoa; in these cases, the patients opted for accomplishing the procedure of testicular sperm aspiration (TESA). CONCLUSION: PESA is an efficient and simple method of retrieving spermatozoa, allowing repeated procedures. Additionally, spermatozoa collected through PESA can be cryopreserved.

Resumo em Inglês:

Bilateral renal artery embolism is rare, but it is a significant cause of arterial hypertension and renal failure, and most often is associated with cardiac arrhythmias. We report a case of bilateral renal artery embolism with a satisfactory outcome following use of thrombolytic therapy. A 42 year-old Caucasian man presented a sudden complaint of intense abdominal pain, in mesogastrium and left flank with dorsal irradiation, 3 days after electrical cardioversion due to cardiac arrhythmia. Laboratory tests revealed slight leukocytosis, hematuria, and creatinine of 1.8 mg/dL. Chest radiography was normal and computerized tomography showed an area of massive ischemia in left kidney, and focal ischemia in right kidney and spleen. The patient was then submitted to systemic venous therapy with 1.5 million units of streptokinase, with an excellent outcome.

Resumo em Inglês:

Klippel-Trenaunay-Weber syndrome is characterized by cutaneous hemangiomas, varicosity and bony hypertrophy of extremities. Urinary tract hemangiomas may occur in 3 to 6% of these patients. This work intends to report a case of a patient with a huge vesical hemangioma, who presented this syndrome. A 5 year-old boy with Klippel syndrome sought our services due to 3 episodes of gross hematuria in the past 30 days. Excretory urography and computerized tomography were performed, indicating the presence of a swelling in vesical dome. An exploratory cystotomy was conducted and the dark colored mass in vesical dome was excised by partial cystectomy. The histopathologic finding confirmed that it was a vesical hemangioma. Though rare, urinary tract hemangiomas must always be considered in patients with Klippel-Trenaunay syndrome.

Resumo em Inglês:

INTRODUCTION: Aiming at promoting and facilitating learning and training in percutaneous renal surgery, we have created an easy to assemble, reproducible and cheap laboratory model. The model was built using pig kidney, foam layer, plastic catheter, linen or cotton holding sutures, and wide scotch tape. SURGICAL TECHNIQUE: The kidney with catheterized ureter is fixed and involved in a foam layer. It stays hidden, and is visible only through radioscopy. This model is positioned and fixed to a radiological table in such a way that it simulates the patient’s lumbar region. After that, contrast medium is injected through the ureter, and the urinary system is examined through radioscopy. All percutaneous maneuvers can be accomplished, from the puncture, tract dilation, insertion of Amplatz sheath, and introduction of nephroscope, allowing lithotripsy and endopielotomy, as well as other types of percutaneous surgeries. COMMENTS: The great advantage of this model is its easy construction, by using very cheap and widely available material. Foam can be several times washed and reused. After treatment, the model can be immediately open, and a critical analysis can be made, being then possible to verify if the place of renal puncture was well chosen, if dilation was correctly accomplished, and if the collecting system has been preserved. Therefore, this model can represent a great advance for the learning and training in percutaneous surgery.

Resumo em Inglês:

INTRODUCTION: The use of flaps or grafts is mandatory in patients with longer and complex strictures. In 1995-96 we described a new dorsal onlay graft urethroplasty. Over time, our original technique was better defined and changed. Now this procedure (also named Barbagli technique) has been greeted with a fair amount of enthusiasm in Europe and in the United States. SURGICAL TECHNIQUE: The patient is placed in normal lithotomy position, and a midline perineo-scrotal incision is made. The bulbar urethra is then free from the bulbo-cavernous muscles, and is dissected from the corpora cavernosa. The urethra is completely mobilized from the corpora cavernosa, it is rotated 180 degrees, and is incised along its dorsal surface. The graft (preputial skin or buccal mucosa) or the flap is fixed and quilted to the tunica albuginea of the corporal bodies. The right mucosal margin of the opened urethra is sutured to the right side of the patch-graft. The urethra is rotated back into its original position. The left urethral margin is sutured to the left side of the patch graft and to the corporal bodies, and the grafted area is entirely covered by the urethral plate. The bulbo-cavernous muscles are approximated over the grafted area. A 16F silicone Foley catheter is left in place. COMMENTS: Dorsal onlay graft urethroplasty is a versatile procedure that may be combined with various substitute materials like preputial skin, buccal mucosa grafts or pedicled flaps.

Resumo em Inglês:

INTRODUCTION AND OBJECTIVES: Chagas' disease causes specific parasympathetic denervation and in its digestive clinic form promotes also functional alterations in bladder. Thus, the aim was to investigate the existence of balance between sympathetic and parasympathetic systems in lower urinary tract, as occurs in other organs. We verified the urethral closing pressure before and following parasympathetic stimulus. PATIENTS AND METHODS: For that, the urethral closure pressure was studied before and after the injection of 5 mg of bethanechol chloride subcutaneously in 28 voluntary female patients, divided into 4 groups. The constitution of theses groups was: A) normal control = 6 patients; B) Chagas' disease with positive serology only = 5 patients; C) Chagas' disease with cardiac disease = 6 patients, and D) Chagas' disease with digestive disease and vesical hyporeflexia = 11 patients. Urethral profilometry was performed through perfusion urethral catheter with a 6.5 ml/minute flow and a traction rate of 5 mm/minute. RESULTS: Means and standard deviations for urethral closure pressure before bethanechol chloride were respectively: group A = 67.3 ± 7.1; group B = 69.2 ± 7.4; group C = 95.8 ± 5.1; group D = 82.1 ± 8.4. After bethanechol chloride they were: group A = 66.0 ± 6.6; group B = 77.0 ± 7.6; group C = 98.3 ± 8.8; group D = 45.9 ± 6.2. The Kruskal Wallis statistical test did not show statistically significance difference between groups A, B, C. However, it was statistically significant between groups C and D with p = 0.003. Wilcoxon test showed p = 0.001, only for values in group D before and following bethanechol chloride. CONCLUSIONS: Chagas' disease in its intestinal form seems to alter urethral function as well. Parasympathetic stimulation decreased urethral pressure, indicating potential modulation by the parasympathetic system over the sympathetic system.