Resumo em Inglês:

Cowper's syringocele is a rare but an under-diagnosed cystic dilation of the Cowper's ducts and is increasingly being recognized in the adult population. Recent literature suggests that syringoceles be classified based on the configuration of the duct's orifice to the urethra, either open or closed, as this also allows the clinical presentations of 2 syringoceles to be divided, albeit with some overlap. Usually post-void dribbling, hematuria, or urethral discharge indicate open syringocele, while obstructive symptoms are associated with closed syringoceles. As these symptoms are shared by many serious conditions, a working differential diagnosis is critical. Ultrasonography coupled with retro and ante grade urethrography usually suffices to diagnose syringocele, but supplementary procedures - such as cystourethroscopy, computed tomography scan, and magnetic resonance imaging - can prove useful. Conservative observation is first recommended, but persistent symptoms are usually treated with endoscopic marsupialization unless contraindicated. Upon reviewing the literature, this paper addresses the clinical anatomy, classification, presentation, diagnosis, and treatment of syringoceles in further detail.

Resumo em Inglês:

OBJECTIVES: Surgical treatment of "Ren Mobilis" has historically been associated with poor results and fairly high morbidity. We have used a transperitoneal laparoscopic approach in order to minimize morbidity. The goal of this study was to evaluate the success rate and to discuss the possible pathogenic mechanism, which has implications for the surgical strategy. MATERIALS AND METHODS: Seven women with a right mobile kidney were examined by intravenous pyelogram and CT scans. Symptoms were judged to emanate from the mobile kidney. Transperitoneal laparoscopic nephropexy was performed. The surgical treatment consisted of fixing the kidney to the dorsal abdominal wall using tissue glue (Tisseel®) after diathermy coagulation of the surfaces to induce fibrosis. The right colon was fixed with clips to the lateral abdominal wall, trapping the kidney in place. RESULTS: In 6 of the cases, there was an incomplete rotation of the ascending colon to the right side, allowing the kidney to move freely. In one case, the kidney moved into a retroperitoneal pocket of the mesocolon. The 6 cases with a lateral passage for the kidney were symptom-free at follow-up (30-80 months), but in the 7th case the patient's kidney quickly loosened and she underwent an open reoperation, after which she was symptom-free. CONCLUSION: Our series demonstrates that good results can be achieved with a transperitoneal laparoscopic approach, but also indicates that there is a common pathogenic mechanism with incomplete rotation of the ascending colon that can be corrected during surgery, which might contribute to the good results.

Resumo em Inglês:

PURPOSE: Diffusion-weighted (DW) magnetic resonance imaging (MRI) provides information about the biophysical properties of tissues such as cell organization and density. DW imaging (DWI) is becoming important in the assessment of malignant tumors. The purpose of our study was to evaluate the capability and reliability of DWI in the evaluation of upper urinary tract urothelial tumors. MATERIALS AND METHODS: DWI was performed in seventeen patients with upper urinary tract urothelial tumor, previously diagnosed by either CT or retrograde pyelography. An histological evaluation was performed after surgical resection. Each MRI was carried out using a 1.5T superconductive magnet MRI system. DWI images were obtained with b value of 1000 s/mm2 under normal breathing. The apparent diffusion coefficient (ADC) values were measured. RESULTS: In nine patients with renal pelvis tumors and seven patients with ureteral tumors, the lesions were shown as high-signal intensity in the corresponding region on DWI. In one patient with carcinoma in situ (CIS) of the ureter, the lesion was not depicted with DWI. The mean ADC value of the tumor was 1.125 ± 0.217 x 10-3 mm2/s and was significantly lower than those of the renal parenchyma (1.984 ± 0.238 x 10-3 mm2/s, p < 0.01) and the urine (2.941 ± 0.315 x 10-3 mm2/s, p < 0.01). CONCLUSIONS: In our study, the renal pelvic and ureteral tumors except CIS were shown clearly with DWI. Although further studies are required, DWI may take the place of invasive retrograde urography for detecting tumors of the upper urinary tract.

Resumo em Inglês:

PURPOSE: To compare the results of percutaneous and open drainage for perinephric abscess. MATERIALS AND METHODS: The files of 86 patients who underwent drainage for perinephric abscesses from April 2001 through March 2008 were evaluated. The method of drainage for each patient was performed according to the clinical decision of the treating physician. Percutaneous tube drain (PCD) was used for drainage of the abscess in 43 patients (group 1), while the other 43 patients were managed with open drainage (group 2). Cure was defined as complete obliteration of the abscess cavity. The cure rates, complications, and hospital stay were compared between both groups. RESULTS: The study included 50 males and 36 females with mean age 44.2 ± 17.3. The most common predisposing factors were diabetes mellitus and/or stones. Open drainage of perinephric abscesses resulted in a statistically significant higher cure rate (98% versus 69%, p < 0.001) and shorter hospital stay than PCD (3.6 versus 6 days, p < 0.001). Failure of complete drainage of multilocular abscess was observed in 8 of 13 cases (61.5%) in group 1 and one of 38 cases (2.6%) in group 2 (P < 0.001). Complications were observed in 7% of group 1 and 11.5% in group 2 (P = 0.45). After mean follow-up of 19 months, 9 of 46 patients (19.6%) had recurrence; 7 of them were in group 1. CONCLUSIONS: Percutaneous drainage of perinephric abscess is an effective minimally invasive treatment. However, PCD is not the optimal method for drainage of multilocular abscess because open surgical drainage provided higher cure rates and shorter hospitalization than PCD.

Resumo em Inglês:

PURPOSE: Evaluate the initial experience of laparoscopic ureteral reimplant for ureteral stenosis. MATERIALS AND METHODS: From January 2004 to June 2008, 10 patients underwent 11 laparoscopic reconstruction surgeries for ureteral stenosis. Seven cases of stenosis of the distal ureter, two at the level of iliac vessels, a case of bilateral distal stenosis and one in the medium third. Eight ureteroneocystotomies were performed by extravesical technique with anti-reflux mechanism, two cases of vesical reimplant with Boari technique and one case using the psoas hitch technique. RESULTS: The average surgical time was 166 minutes (115-245 min), mean blood loss was 162 mL (100-210 mL) and the average hospital stay was 2.9 days (2-4 days). There were two complications: a lesion of the sigmoid colon identified peroperatively and treated with laparoscopic sutures with good evolution, and a case of ureteral stone obstruction at the 30th day postoperative, treated by laser ureterolitotripsy. All patients had resolution of the stenosis at an average follow-up period of 18 months (3-54 months). CONCLUSIONS: Laparoscopic surgery represents a feasible, safe and low morbidity technique for ureteral reimplant in ureteral stenosis.

Resumo em Inglês:

PURPOSE: When faced with biochemical recurrence after definitive radiotherapy for prostate cancer, clinicians must determine whether the recurrence is local or systemic. Post radiotherapy prostate biopsies to detect persistent local disease are difficult to interpret histopathologically and are subject to sampling error. Our study examines outcomes for patients with a negative prostate biopsy performed for rising prostate-specific antigen (PSA) levels after prostate radiation. MATERIALS AND METHODS: We performed a retrospective review of 238 prostate cancer patients with a negative biopsy following definitive radiotherapy. Seventy-five of these patients had biochemical recurrence at the time of biopsy. A negative biopsy was defined as the absence of prostate cancer without radiation-treatment effect in the specimen. RESULTS: Patients underwent biopsy at a mean of 41 months after the completion of radiation. They had a mean PSA of 6. Patients were followed for an average of 63 months. Thirty-two patients (43%) developed metastasis, and 11 (15%) died of prostate cancer despite a negative post-radiation biopsy. Five of nine patients (56%) with sequential biopsies had a positive second biopsy. CONCLUSIONS: Patients with PSA recurrence and a negative post-radiation biopsy have a high chance of persistent local disease, progression, and death from prostate cancer. Furthermore, an initial negative biopsy does not rule-out local recurrence. Patients with biochemical recurrence after radiotherapy for prostate cancer need to be evaluated earlier for local recurrence.

Resumo em Inglês:

OBJECTIVES: The aim of this study was to assess the analgesic efficacy and safety of nonsteroidal anti-inflammatory drugs (NSAIDs), administered as intramuscular diclofenac in comparison with intravenous paracetamol after transurethral resection of the prostate (TURP). MATERIALS AND METHODS: Fifty men, aged 55 to 75 years, undergoing TURP at our hospital were included in this study. Patients were divided randomly and prospectively into two groups (25 patients in each group). Group I (NSAID) received 75 mg of diclofenac i.m. at the end of the operation followed by 75 mg of diclofenac i.m. for 24 hours (75 mg x 2 once a day = 150 mg/24 h) postoperatively. The other group (Group II) consisted of patients who received 1g/100 mL i.v. paracetamol 15 minutes twice daily as postoperative analgesia. Postoperative pain scores were evaluated at 30 minutes, 1, 2, 4 and 6 hours after administration of each analgesic, using a visual analogue scale (VAS). Furthermore, preoperative and postoperative hemoglobin (Hb) levels and hemostatic variables (bleeding time, prothrombine time and the international normalized ratio?, i.e. the ratio of a patient's prothrombin time to a normal [control] sample) were recorded in all patients. RESULTS: The pain score changes during a 4 hour period between the two groups was similar (p = 0.162). Thirty minutes after surgery, pain scores were high (> 3 cm) in both groups and without differences between groups (p = 0.11) but 6 hours after surgery, pain scores were significantly higher with paracetamol compared to diclofenac (p < 0.05). No significant difference was observed between the groups regarding the amount of resected tissue, operating time, preoperative-postoperative Hb levels and hemostatic variables. In the both groups, no patient required blood transfusion postoperatively. CONCLUSIONS: NSAIDs are not a contraindication to TURP and should be used for the control of postoperative pain if indicated.

Resumo em Inglês:

PURPOSE: Varicocelectomy is used in the treatment of scrotal pain. We report our results with microsurgical subinguinal varicocele ligation to treat pain. MATERIALS AND METHODS: A total of 284 men underwent subinguinal microsurgical varicocele ligation for scrotal pain. All patients were asked to return for a follow-up evaluation 3 months after surgery, which included a physical examination, as well as questions on pain severity, number of days required before their return to work and development of any postoperative complications. RESULTS: Median patient age at the time of varicocele ligation was 23.7 years (range 16-38 years). The average duration of pain before presentation was 11.2 months (range 1 month to 40 months). In 85.6% patients there was complete resolution of pain and 6.3% had partial resolution. Pain persisted postoperatively in 19 cases (8.1%). There were statistically non-significant differences in the characteristics of the pain and grade of varicocele between postoperative groups. A significant difference was observed in postoperative success between patients who had long period and those who had short period of pain. CONCLUSIONS: Sub-inguinal microsurgical varicocele ligation is an effective treatment for painful varicocele. The duration of pain preoperatively may predict outcomes in selected patients.

Resumo em Inglês:

OBJECTIVE: The growing consensus on the negative impact of cigarette smoking on fertility prompted us to compare the rate of sperm respiration in smokers and non-smokers. MATERIALS AND METHODS: Semen samples from 20 smokers and 58 non-smokers consulting at the andrology laboratory for fertility evaluation were used. Smoking was defined as consumption of at least a half a pack per day. A phosphorescence analyzer that measures O2 concentration in sperm suspensions as function of time was used to determine the rate of respiration. In a sealed vial, the rate of sperm respiration (k) was defined as -d[O2]/dt; where [O2] was obtained from the phosphorescence decay rate of a palladium phosphor. [O2] in solutions containing sperm and glucose declined linearly with time, showing the kinetics of O2 consumption was zero-order. Inhibition of O2 consumption by cyanide confirmed the oxidations that occurred in the sperm mitochondrial respiratory chain. RESULTS: There were no differences (p > 0.28) between smokers and non-smokers for ejaculate volume, motility, concentration, normal morphology, viability and hypo-osmotic swelling test. The rate (mean ± SD, in µM O2/min/108 sperm) of sperm mitochondrial O2 consumption in the smokers was 0.96 ± 0.58 and in the non-smokers 1.39 ± 0.67 (p = 0.004). CONCLUSIONS: The rate of sperm respiration was significantly lower in smokers. This negative impact of cigarette smoking on sperm aerobic metabolism may, in part, explain the lower rate of fertility in smokers.

Resumo em Inglês:

PURPOSE: To report our experience with the use of the botulinum toxin-A (BoNT/A) formulations Botox® and Prosigne® in the treatment of neurogenic detrusor overactivity (NDO). MATERIALS AND METHODS: At a single institution, 45 consecutive patients with refractory urinary incontinence due to NDO received a single intradetrusor (excluding the trigone) treatment with botulinum toxin type A 200 or 300 units. Botox was used for the first 22 patients, and Prosigne for the subsequent 23 patients. Evaluations at baseline and week 12 included assessment of continence and urodynamics. Safety evaluations included monitoring of vital signs, hematuria during the procedure, hospital stay, and spontaneous adverse event reports. RESULTS: A total of 42 patients were evaluated (74% male; mean age, 34.8 years). Significant improvements from baseline in maximum cystometric capacity (MCC), maximum detrusor pressure during bladder contraction, and compliance were observed in both groups (P < 0.05). Improvement in MCC was significantly greater with Botox versus Prosigne (+103.3% vs. +42.2%; P = 0.019). Continence was achieved by week 12 in 16 Botox recipients (76.2%) and 10 Prosigne recipients (47.6%; P = 0.057). No severe adverse events were observed. Mild adverse events included 2 cases of transient hematuria on the first postoperative day (no specific treatment required), and 3 cases of afebrile urinary tract infection. CONCLUSIONS: Botox and Prosigne produce distinct effects in patients with NDO, with a greater increase in MCC with Botox. Further evaluation will be required to assess differences between these formulations.

Resumo em Inglês:

PURPOSE: To compare the efficacy and costs of circumcision versus topical treatment using a prospective pharmacoeconomic protocol. MATERIALS AND METHODS: We treated 59 patients (3-10 years of age) randomized into two groups: 29 underwent an 8-week course of topical treatment with 0.2% betamethasone-hyaluronidase cream twice a day; and 30 underwent circumcision. Topical treatment success was defined as complete exposure of the glans. In cases of treatment failure, circumcision was performed and its cost imputed to that of the initial treatment. The pharmacoeconomic aspects were defined according to the Brazilian National Public Health System database and the Brazilian Community Pharmacies Index. RESULTS: The two groups were statistically similar for all clinical parameters evaluated. Topical treatment resulted in complete exposure of the glans in 52% of the patients. Topical treatment was associated with preputial pain and hyperemia. However, treatment suspension was unnecessary. Minor complications were observed in 16.6% of the surgical group patients. The mean cost per patient was US$ 53.70 and US$ 125.20, respectively, for topical steroid treatment (including the costs related to treatment failure) and circumcision. The total costs were US$ 2,825.32 and US$ 3,885.73 for topical treatment and circumcision, respectively. CONCLUSIONS: Topical treatment of phimosis can reduce costs by 27.3% in comparison with circumcision. Therefore, topical treatment of phimosis should be considered prior to the decision to perform surgery.

Resumo em Inglês:

AIMS: To determine whether α1-blocker treatment, in chronic bladder outlet obstruction (BOO), influences bladder tissue ischemia. MATERIALS AND METHODS: This prospective study included 60 patients with BOO, of which 40 were under α1-blocker medication and 20 without treatment. Patients underwent transurethral resection of the prostate (TURP) or suprapubic prostatectomy (SPP). Ten patients with non-muscle invasive bladder cancer underwent transurethral resection of the bladder tumor and served as the control group. Tissue specimens were immunohistochemically stained for hypoxia inducible factor-1α (HIF-1α). RESULTS: Bladder tissue from obstructed subjects showed high immunoreactivity to HIF-1α. The specimens from the control group, showed no or weak, mainly cytoplasmic immunoreactivity to HIF-1α. Patients under α -blocker treatment did not differ in the number of HIF-1α positive cells compared to subjects with no treatment (median number 86.8 [20-150] and 88.6 [0-175], respectively) (p > 0.05). The lowest bladder pressure at which HIF-1α was up regulated, was detected at detrusor pressure Qmax (PdetQmax) = 60 cm H2O. CONCLUSIONS: Treatment with α-blockers in obstructed patients considered as non-responders, does not result in HIF-1α down regulation, thus bladder continues to be under chronic stress.