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ABSTRACT The incidence of small, lower risk well-differentiated prostate cancer is increasing and almost half of the patients with this diagnosis are candidates for initial conservative management in an attempt to avoid overtreatment and morbidity associated with surgery or radiation. A proportion of patients labeled as low risk, candidates for Active Surveillance (AS), harbor aggressive disease and would benefit from definitive treatment. The focus of this review is to identify clinicopathologic features that may help identify these less optimal AS candidates. A systematic Medline/PubMed Review was performed in January 2017 according to PRISMA guidelines; 83 articles were selected for full text review according to their relevance and after applying limits described. For patients meeting AS criteria including Gleason Score 6, several factors can assist in predicting those patients that are at higher risk for reclassification including higher PSA density, bilateral cancer, African American race, small prostate volume and low testosterone. Nomograms combining these features improve risk stratification. Clinical and pathologic features provide a significant amount of information for risk stratification (>70%) for patients considering active surveillance. Higher risk patient subgroups can benefit from further evaluation or consideration of treatment. Recommendations will continue to evolve as data from longer term AS cohorts matures.

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ABSTRACT Purpose: Most men with stage I testicular seminoma are cured with surgery alone, which is a preferred strategy per national guidelines. The current pattern of practice among US radiation oncologists (ROs) is unknown. Materials and Methods: We surveyed practicing US ROs via an online questionnaire. Respondent's characteristics, self-rated knowledge, perceived patient compliance rates with observation were analyzed for association with treatment recommendations. Results: We received 353 responses from ROs, of whom 23% considered themselves experts. A vast majority (84%) recommend observation as a default strategy, however this rate drops to 3% if the patient is believed to be noncompliant. 33% of respondents believe that survival is jeopardized in case of disease recurrence, and among these respondents only 5% support observation. 22% of respondents over-estimate the likelihood of noncompliance with observation to be in the 50-80% range. Responders with a higher perceived noncompliance rate are more likely to recommend adjuvant therapy (Fisher's exact p<0.01). Only 7% of respondents recommend observation for stage IS seminoma and 45% administer adjuvant RT in patients with elevated pre-orchiectomy alpha-fetal protein levels. Conclusions: Many US ROs over-estimate the likelihood that stage I testicular seminoma patients will be noncompliant with surveillance and incorrectly believe that overall survival is jeopardized if disease recurs on surveillance. Observation is quickly dismissed for patients who are not deemed to be compliant with observation, and is generally not accepted for patients with stage IS disease. There is clearly an opportunity for improved physician education on evidence-based management of stage I testicular seminoma.

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ABSTRACT Purpose: To evaluate the importance of preoperative neutrophil lymphocyte ratio (NLR) predicting malignancy in patients who undergo partial nephrectomy due to renal mass. Materials and Methods: Seventy nine patients who underwent open partial nephrectomy for renal masses were included in this retrospective study. In preoperative routine blood tests, renal ultrasonography and contrast-enhanced computed tomography were performed for all patients. Preoperative neutrophil lymphocyte ratio were compared in patients with clear cell renal cell carcinoma (Group1, 65 patients) and benign lesions (Group 2, 14 patients). The predictive ability of NLR was analyzed by ROC curves and Youden Index method was used to identify the cut-off value for NLR. Results: The mean age of patients was 59.8±11.7 years in Group1 and 57.4±12.6 years in Group 2 (p=0.493). The mean tumor size was 3.8±1.2 cm in Group 1 and 3.3±1.0 cm in Group 2 (p=0.07). The median NLR was 2.48 (1.04) in Group 1 and 1.63 (0.96) in Group 2 (p<0.001). The area under a ROC curve was 0.799 (p<0.001). Conclusions: Preoperative neutrophil lymphocyte ratio may predict renal masses that can not be distinguished radiologically. Our results must be confirmed by large and properly designed prospective, randomized trials.

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ABSTRACT Purpose: Renorrhaphy in partial nephrectomy may damage intraparenchymal vessels and compress the renal parenchyma, which may lead to the formation of renal artery pseudoaneurysms or vascularized parenchymal volume reduction. Using propensity score matching, we compared surgical outcomes following non-renorrhaphy and renorrhaphy techniques for open partial nephrectomy (OPN) for T1a renal tumors. Materials and Methods: We retrospectively analyzed data from 159 patients with normal contralateral kidneys who underwent OPN for T1a renal tumors and pre- and postoperative enhanced computed tomography between 2012 and 2015. Patient variables were adjusted using 1:1 propensity score matching between the two Groups: renorrhaphy (inner and outer layer sutures) and non-renorrhaphy (inner layer sutures only). Postoperative complications and renal function were compared between the two groups. Results: We matched 43 patients per Group. Operative time, estimated blood loss, cold ischemic time, and postoperative hospital stay were not significantly different between the two Groups. Urine leakage (Clavien-Dindo grade ≥3) occurred in 0 renorrhaphy cases and 2 non-renorrhaphy cases (0% versus 4.6%, P=0.49). Renal artery pseudoaneurysm (RAP) occurred in 6 renorrhaphy cases and in 0 non-renorrhaphy cases (13% versus 0%, P=0.02). Conclusions: The non-renorrhaphy technique may result in a lower risk of RAP but a greater risk of urine leakage. This technique needs further refinement to become a standard procedure for OPN.

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ABSTRACT Objectives: The clinical significance of positive surgical margin (PSM) after a Nephron Sparing Surgery (NSS) is controversial. The aim of this study is to evaluate the association between PSM and the risk of disease recurrence in patients with pT1 kidney tumors who underwent NSS. Materials and Methods: Retrospective cohort study. A total of 314 patients submitted to a NSS due to stage pT1 renal tumor between January 2010 and June 2015 were included. Recurrence-free survival was estimated. The Cox model was used to adjust the tumor size, histological grade, pathological stage, age, surgical margins and type of approach. Results: Overall PSM was 6.3% (n=22). Recurrence was evidenced in 9.1% (n=2) of patients with PSM and 3.5% (n=10) for the group of negative surgical margin (NSM). The estimated local recurrence-free survival rate at 3 years was 96.4% (95% CI 91.9 to 100) for the NSM group and 87.8% (95% CI 71.9 to 100) for PSM group (p=0.02) with no difference in metastasis-free survival. The PSM and pathological high grade (Fuhrman grade III or IV) were independent predictors of local recurrence in the multivariate analysis (HR 12.9, 95%CI 1.8-94, p=0.011 / HR 38.3, 95%CI 3.1-467, p=0.004 respectively). Fuhrman grade proved to be predictor of distant recurrence (HR 8.1, 95%CI 1.6-39.7, p=0.011). Conclusions: The PSM in pT1 renal tumors showed to have higher risk of local recurrence and thus, worse oncological prognosis.

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ABSTRACT Background and Purpose: Recent advances in cancer treatment have resulted in bet- ter prognosis with impact on patient's survival, allowing an increase in incidence of a second primary neoplasm. The development of minimally invasive surgery has provided similar outcomes in comparison to open surgery with potentially less mor- bidity. Consequently, this technique has been used as a safe option to simultaneously treat synchronous abdominal malignancies during a single operating room visit. The objective of this study is to describe the experience of two tertiary cancer hospitals in Brazil, in the minimally invasive treatment of synchronous abdominal neoplasms and to evaluate its feasibility and peri-operative results. Materials and Methods: We retrospectively reviewed the data from patients who were submitted to combined laparoscopic procedures performed in two tertiary hospitals in Brazil from May 2009 to February 2015. Results: A total of 12 patients (9 males and 3 females) with a mean age of 58.83 years (range: 33 to 76 years) underwent combined laparoscopic surgeries for the treatment of at least one urological disease. The total average duration of surgery was 339.8 minutes (range: 210 to 480 min). The average amount of intraoperative bleeding was 276.6mL (range: 70 to 550mL) and length of hospitalization was 5.08 days (range: 3 to 10 days). Two patients suffered minor complications regarding Clavien system during the immediate postoperative period. Conclusions: Combined laparoscopic surgery for the treatment of synchronous tumors is feasible, viable and safe. In our study, there was a low risk of postoperative morbidity.

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ABSTRACT Introduction: Vaginal cuff recurrence of tumor following radical cystectomy is a rare site of disease recurrence, however it has never been specifically studied. The aim of the study is to evaluate incidence, risk factors, and long-term oncologic outcomes of vaginal cuff recur- rence in a cohort of female patients treated with radical cystectomy for invasive urothelial carcinoma of the bladder. Materials and Methods: From 1985 to 2012, a prospectively maintained institutional blad- der cancer registry was queried for vaginal cuff recurrence post radical cystectomy. Over- all mortality and cancer-specific mortality were reported using the Kaplan-Meier method for patients with vaginal cuff recurrence, recurrence at another local or distant site, and those without evidence of recurrence. Comparisons were performed using the log-rank test. Cox proportional hazards regression model was performed to assess predictors of vaginal cuff recurrence. Results: From 469 women treated with radical cystectomy for bladder cancer, 34 patients (7.3%) developed vaginal cuff recurrence, 130 patients (27.7%) had recurrence involving ei- ther a local or distant site, and 305 patients (65%) had no evidence of recurrence. The 5-year overall mortality-free survival rate was 32.4% for vaginal cuff recurrence, but 25.0% for other sites of recurrence. Cancer-specific mortality-free survival rate was 32.4% for vaginal cuff recurrence, and 30.3% for the other sites of recurrence. Multivariate Cox proportional hazards regression analysis demonstrated that the presence of tumor in posterior location at radical cystectomy (Hazard Ratio [HR], 0.353 [95% CI, 0.159-0.783]) and anterior vaginec- tomy, compared to no vaginectomy (HR, 2.595 [95% CI, 1.077-6.249]) were independently associated with vaginal cuff recurrence. Conclusion: Anterior vaginectomy, despite our best attempts, is perhaps not sufficient to prevent vaginal cuff recurrence. Therefore, follow-up evaluation is essential, and further studies are necessary to address the optimal approach for initial management. Patient Summary: Although vaginal cuff recurrence is an unusual site of recurrence, careful evaluation is needed before cystectomy and during follow-up to identify patients at risk.

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ABSTRACT Background: The association of prostate cancer antigen 3 (PCA3) polymorphism (SNP, rs544190G>A) with metastatic prostate cancer in European descent has been reported. Our aim of the current study was to re-validate the effect of PCA3 polymorphism on prostate cancer risk in an Eastern Chinese population and then estimate possible genetic discrepancies among population. Materials and Methods: Taqman assay was employed to determine genotype of SNP rs544190 in 1015 ethnic Han Chinese patients with prostate cancer and 1032 cancer-free controls. Simultaneously, odds ratios (OR) and 95% confidence intervals (95%CI) for risk relationship were calculated by logistic regression models. Results: The statistically significant relationship between PCA3 rs544190G>A and higher prostate cancer risk was not found. Stratification analysis revealed that there was no remarkable association of rs544190 variant AG/AA genotype with prostate cancer risk in every subgroup, except for patients with Gleason score ≤7(3+4). Conclusion: Although the results demonstrated that SNP rs544190 was not involved in prostate cancer risk in Eastern Chinese descent, unlike in European population, these might have clinical implications on prostate cancer heterogeneity around the World. To validate these findings, well-designed studies with different ethnic populations are warranted.

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ABSTRACT Introduction: Nephrogenic adenoma (NA) was first described by Davis in 1949 as a “hamartoma” of the bladder. There are many proposed predisposing factors for NA including chronic inflammation, renal transplantation, and bladder cancer. We examined our experience with NA to determine predisposing factors and determine if there was any increased risk for development of subsequent malignancy. Materials and Methods: All patients with a pathologic diagnosis of bladder NA from 2001-2013 were included. Patient history, clinical factors including possible predisposing factors for NA, and follow-up were reviewed. Results: Among 60 patients, 68% were males with an average age of 61, an average BMI of 28.7, and 60% had a smoking history. In evaluating pro-inflammatory factors, 26.7% underwent either Bacillus Calmette-Guerin or mitomycin C, 30% had recurrent urinary tract infections, and 25% had a history of catheterization. Recurrence of NA after initial resection occurred only in 14.7% of patients who underwent follow-up cystoscopy. A history of concurrent bladder cancer was seen in 41.7% of patients, but there were no cases of de novo bladder cancer diagnosed after NA. Conclusion: To the best of our knowledge, this is the largest series of patients with NA of the bladder. NA occurs in a heterogeneous population of patients, but most often with underlying inflammation. NA occurred concurrent with bladder cancer; however there were no cases of de novo bladder cancer after NA, reassuring that NA is likely a benign reactive condition.

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ABSTRACT Purpose: Although the worldwide percutaneous nephrolithotomy (PCNL) practice pat- terns determined via a survey sent to members of the Endourological Society have been published, differences in PCNL practice patterns among Latin American urologists based on endourological or lithiasis training have not been published. To determine the PCNL practice patterns among Latin American urologists with and without training in endourology. Materials and Methods: The SurveyMonkey® web platform was used to develop a 27-item survey on PCNL for the treatment of renal stones, and the survey was sent via e- -mail and other electronic media to 2000 urologists from 15 Latin American countries. Endourology-trained (group 1) and nontrained urologists (group 2) were analyzed. The group results were compared using the chi-squared and Fisher's exact tests. SPSS version 20 for Windows was used for all analyses. Results: A total of 331 urologists responded to the survey (rate of 16.55%): 221 (66.7%) in group 1 and 110 (33.2%) in group 2). In groups 1 and 2, 91.9% and 63.2% performed PCNL, respectively: 85.1% and 58.5% used preoperative tomography, respectively; 12.7% and 4.7% used preoperative nephrolitometry nomograms, respectively: 45.2% and 32.1% used endoscopic combined intrarenal surgery, respectively: 68.3% and 38.7% used mul- tiple percutaneous tract realization, respectively: and 19.9% and 5.7% used minimally invasive PCNL, respectively (all p=0.0005). Conclusions: Statistically significant differences were observed in PCNL practice patterns of Latin American urologists with and without training in endourology. Specific training in endourology significantly influence the practice patterns of Latin American urologists.

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ABSTRACT Introduction: Ureteral access sheaths (UAS) facilitate flexible ureteroscopy in the treat- ment of urolithiasis. The physical properties of UAS vary by manufacturer and model. We compared three new UAS: Glideway (GW, Terumo, 11/13Fr, 12/14Fr), Pathway (PW, Terumo 12/14F) and Navigator HD (NHD, Boston Scientific, 11/13Fr, 12/14Fr) in the domains of safety characteristics, positioning characteristics, lubricity and radio- opacity. Materials and Methods: In vitro testing of the three UAS included safety testing-tip perforation force, sheath edge deformation and dilator extraction forces. Positioning characteristics tested included tip bending, stiffness (resistance to coaxial buckling forces), kinking (resistance to perpendicular forces), and insertion forces. Lubricity was assessed by measured frictional forces of the outer sheath. Finally, radio-opacity was tested utilizing fluoroscopic imaging of the three 12F sheaths and inner dilators. Results: The PW (0.245 lb) and GW (0.286 lb) required less force for tip perforation compared to the NHD (0.628 lb). The NHD sheath edge deformation was mild compared to more severe deformation for the PW and GW. The PW (1.008 lb) required greater force than the GW (0.136 lb) and NHD (0.043 lb) for inner dilator removal. The GW (3.69 lbs) and NHD (4.17 lb) had similar inner dilator tip stiffness when bent, while the PW had the weakest inner dilator tip, 1.91 lbs. The PW (0.271 lb) was most susceptible to buckling and kinking (1.626 lb). The most lubricious UAS was the NHD (0.055 lbs for 12F). The NHD (0.277 lbs) required the least insertional force through a biological model and possessed the greatest radio-opacity. Conclusions: Comparison of different commercially available UAS in various sizes reveals that there are mechanical differences in sheaths that may play a role clinically. The Terumo sheaths' (GW and PW) were outperformed by the Boston Scientific NHD in simulating safety, ease of use and radio-opacity.

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ABSTRACT Objective: To evaluate urodynamic alterations after sub-urethral sling surgery (SSU) in patients with post-prostatectomy urinary incontinence (PPUI). Materials and Methods: We evaluated data of 22 patients submitted to radical prosta- tectomy (RP) or transurethral resection of prostate (TURP) that presented post-surgical urinary incontinence and were treated with SSU implant in a pilot study previously performed in our institution. Methods: Those patients with PPUI were evaluated by urodynamic exam (UD) before and after surgery, and the parameters were compared, including uroflow, cystometry and micturition study. Exclusion criteria included patients without pre-operatory urodynamic study, those with urethral stenosis, those not healed of prostate cancer, pa- tients without clinical conditions to be submitted to urodynamic study and those with severe neurological diseases or that refused to sign the consent form. Results were analyzed statistically by Fisher, Wilcoxon or Mann-Whitney tests. Results: During free uroflow, none parameters showed any statistical significant differ- ences. During cystometry, there were also no statistical differences and the same was observed at pressure versus flow study; the exception was at maximal flow detrusor pressure (PdetQmax), that was lower at post-operatory (p=0.028). In relation to the presence of urinary dysfunctions associated to PPUI, we observed a significant reduc- tion of detrusor overactivity (p=0.035) in relation to pre-operatory period. Conclusion: SSU surgery significantly reduced detrusor overactivity and PdetQMax; however, there were no alterations of other evaluated urodynamic parameters.

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ABSTRACT Surgical correction is the most efficient treatment for stress urinary incontinence (SUI), and transobturator sling (TO) has optimal results. The high cost of commercially available sling kits makes it difficult the access in most Brazilian public health services. Hand-made polypropylene slings, on the other hand, have been previously reported. The aim of the present study was to compare the effectiveness and safety of commercial vs. hand-made polypropylene mesh slings. Data from 57 women who underwent consecutive TO sling surgery to treat SUI were pros- pectively collected between 2012 and 2014, and divided in two groups for further compa- rison. In Group-1, 31 women underwent surgery with commercial slings. In Group-2, 26 women underwent hand-made polypropylene slings. Women were compared according to epidemiological data, perioperative evaluation, quality of life, urodynamic study, cure and complication rates. Results were objectively (stress test with Valsalva maneuver, with at least 200mL vesical repletion) and subjectively evaluated by the Patient Global Impression of Improvement(PGI-I), Visual Analog Scale (VAS) and ICIQ-SF. Success was defined as PGI-I, VAS and negative stress test. Group-1 (n=31) and Group-2 (n=26) had a mean age of 60 vs. 58years (p=0.386). All de- mographic data were similar. The mean VLPP was 75.6cmH2O vs. 76.6cmH2O (p=0.88). The mean follow-up was 24.3 vs. 21.5months (p=0.96). Success rates were 74.2% vs. 80.2% (p=0.556), with ICIQ-SF variation of 12.6 vs.15.5 (p=0.139) and PGI-I of 71% vs. 80% (p=0.225). There was only one major complication (urethrovaginal fistula in Group-1). In conclusion, handmade and commercial slings have similar effectiveness and safety. The manufacture technique has important key-points stated in the present manuscript.

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ABSTRACT Objectives: Evaluate the demographic data, etiology, operative findings and results of surgical treatment of penile fracture (PF) in men who have sex with men(MSM) with emphasis on sexual complications. Materials and Methods: We studied 216 patients underwent surgical correction of PF at our hospital. Patients self-identified as MSM were followed for at least 6 months. Demographic data, presentation, operative findings, International Index of Erection Function - 5 (IIEF-5) and the Premature Ejaculation Diagnostic Tool. Results: Of 216 PF cases, 4 (1.8%) were MSM. All cases resulted from sexual activity and all patients reported using the “doggy style” position during anal intercourse. Unilateral or bilateral injury of corpus cavernosum was found in 2 patients each. One (25%) patient had complete urethral injury associated with bilateral corpus cavernosum lesion. During the follow-up period, all patients developed some type of sexual complication. One patient reported penile pain during intercourse. Another patient experienced low sexual desire and premature ejaculation. This patient was also dissatisfied with the aesthetic result of the surgical scar and complained about decreased penis size after surgery. The third case developed delayed ejaculation. The fourth patient experienced mild to moderate erectile dysfunction. This same patient presented with penile curvature. Finally, palpable fibrotic nodules in the operative area were observed in all cases. Conclusions: Sexual activity in the “doggy style” position was the commonest cause of PF in MSM. Sexual dysfunction is always present in gay man after surgery for PF. However, additional studies with larger samples should be coinducted.

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ABSTRACT Introduction: The study was aimed to assess the presence of actual differences between the objective and the perceived magnitude of a curvature between patients affected by Peyronie's disease (PD) and congenital penile curvature (CPC). Materials and Methods: Wee analysed a cohort of 88 consecutive patients seeking medi- cal help for either CPC or PD. All patients were invited to provide a self-made drawing of their penis in erection in order to obtain self-provided description of the deformity. An objective measurement of the deformity was also performed drawing two intersecting lines through the center of the distal and proximal straight section of the penile shaft. Results: Our findings showed significant differences between patient self-estimation and the objective measurements of the penile angulation performed by trained experts, with only 32% of patients correctly assessing their own curvature. Overall, patients tended to overestimate (56%) their degree of curvature, but the results are different in patients with PD than those with CPC. In the 60 men (68%) who did not accurately assess their curvature, PD patients generally overestimated their curvature versus CPC patients (67% vs 16%). On the contrary CPC patients underestimated their curvature compared to PD (42% vs. 4%). Conclusion: In order to improve patients' satisfaction rates, the surgeon needs to take into consideration the patient's perception of the deformity when planning the type of surgical correction.

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ABSTRACT Men have most likely been affected by varicocele since the assumption of the upright position. In De Medicina, written during the first century AD, Celsus credits the Greeks with the first description of a varicocele, and he recorded his own acute observation: “The veins are swollen and twisted over the testicle, which becomes smaller”. Celsus himself is credited with the distinction between varicocele (dilation of surface veins) and “cirsocele” (dilation of deep veins). There has been a long history of treatment attempts and failures, some of which are remarkably strange, that have sometimes cul- minated in tragedy, as in the case of French professor Jacques-Mathieu Delpech (1772-1832). Although some questions regarding the etiopathology and treatment of varico- cele remain unanswered, a succession of more or less conservative attempts involving all medical cultures has been performed throughout history. The report by W.S. Tulloch in 1952 brought varicocele into the era of modern evidence-based medicine, and varicocele surgery finally progressed beyond the aim of merely relieving scrotal pain and swelling. From 1970 to 2000, varicocelectomies gained worldwide attention for the treatment of male infertility. Several innovative procedures to correct varicoceles began to appear in the world's literature as interventional radiology, microsurgery, laparoscopy, and robotics, while comprehensive review articles were also published on the subject of varicocelectomies. Microsurgery is nowadays used worldwide and it can be considered to be the gold standard for correcting infertility linked to varicocele.

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ABSTRACT Objective: Dynamic renal scintigraphy complemented by late gravity assisted postvoid images to 60 minutes is a frequently used diagnostic test in the evaluation of hydrone- phrosis. The objective of this study is to evaluate the effectiveness in acquiring images at 180 minutes to calculate the late output fraction (LOF) of 99mTc-DTPA in the diagno- sis of ureteropelvic junction obstruction (UPJO). Materials and Methods: A retrospective study of 177 patients (196 renal units) of sus- pected cases of clinical UPJO was conducted. The patients were submitted to at least two dynamic renal scintigraphies of 99mTc-DTPA, with the addition of furosemide (F0), with a mean age of 4.3±3.8 years for the first study, and a follow-up of 2.7±2.5 years. Results: For diagnosis based on renal curves, a 100% sensitivity, 82.2% specificity, positive predictive value (PPV) of 10.4% and negative predictive value (NPV) of 100% were estimated. For diagnosis based on LOF, a 100% sensitivity, 96.3% specificity, PPV of 35.7% and NPV of 100% were estimated. Conclusion: A LOF <10% is indicative of UPJO, and a LOF ≥15% is indicative of no UPJO. The data demonstrate that LOF presents equivalent sensitivity and NPV, and higher specificity and PPV in comparison to diagnosis based on renal curves, and is useful in the evaluation and follow-up of suspected cases of UPJO.

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ABSTRACT Introduction: Durasphere® EXP (DEXP) is a compound of biocompatible and non--biodegradable particles of zirconium oxide covered with pyrolytic carbon. The aim of this study is to evaluate the durability of off-label use of DEXP in the treatment of primary vesicoureteral reflux in children. Materials and Methods: Patients who underwent subureteric injection of DEXP for the correction of primary VUR were retrospectively reviewed. Patients aged >18 years as well as those who had grade-I or -V VUR, anatomic abnormalities (duplicated system, hutch diverticulum), neurogenic bladder or treatment refractory voiding dysfunction were excluded. Radiologic success was defined as the resolution of VUR at the 3rd month control. Success was radiographically evaluated at the end of the first year. Results: Thirty-eight patients (9 boys, 29 girls; mean age, 6.3±2.7 years) formed the study cohort. Forty-six renal units received DEXP (grade II: 22; grade III: 18; grade IV: 6). Mean volume per ureteric orifice to obtain the mound was 0.70±0.16mL. First con- trol VCUG was done after 3 months in all patients. After the first VCUG, 6 patients had VUR recurrence. Short-term radiologic success of DEXP was 84.2%. Rate of radiologic success at the end of the first year was 69.4% (25/32). Lower age (p:0.006) and lower amount of injected material (p:0.05) were associated with higher success rates at the end of 1 year. Conclusion: This is the first study to assess the outcomes of DEXP for treatment of primary VUR in children. After 1 year of follow-up, DEXP had a 69.4% success rate.

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ABSTRACT Objective To assess the role of high-barrier plastic wrap in reducing the number and size of polyps, as well as decreasing the inflammation and allergic reactions in exstro- phy cases, and to compare the results with the application of low-barrier wrap. Materials and Methods Eight patients with bladder exstrophy-epispadias complex (BEEC) that had used a low density polyethylene (LDPE) wrap for coverage of the exposed polypoid bladder in preoperative care management were referred. The main complaint of their parents was increase in size and number of polyps. After a period of 2 months using the same wrap and observing the increasing pattern in size of polyps, these patients were recommended to use a high-barrier wrap which is made of polyvinylidene chloride (PVdC), until closure. Patients were monitored for the number and size of polyps before and after the change of barriers. The incidence of para-exstrophy skin infection/inflammation and skin allergy were assessed. Biopsies were taken from the polyps to identify histopathological characteristics of the exposed polyps. Results The high barrier wrap was applied for a mean ± SD duration of 12±2.1 months. Polyps' size and number decreased after 12 months. No allergic reaction was detected in patients after the usage of PVdC; three patients suffered from low-grade skin allergy when LDPE was applied. Also, pre-malignant changes were observed in none of the patients in histopathological examination after the application of PVdC. Conclusion Polyps' size and number and skin allergy may significantly decrease with the use of a high-barrier wrap. Certain PVdC wraps with more integrity and less evaporative permeability may be more “exstrophy-friendly”.

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ABSTRACT Objectives: Apoptosis effect of oral alpha-blockers is known in the prostate. Apoptosis index of silodosin has not been proved, yet. Aims are to present apoptosis index of silodosin in prostate and to compare this with other currently used alpha-blocker's apoptosis indexes together with their clinical effects. Materials and Methods: Benign prostatic hyperplasia (BPH) patients were enrolled among those admitted to urology outpatient clinic between June 2014 and June 2015. Study groups were created according to randomly prescribed oral alpha-blocker drugs as silodosin 8mg (Group 1; n=24), tamsulosin 0.4mg (Group 2; n=30), alfuzosin 10mg (Group 3; n=25), doxazosin 8mg (Group 4; n=22), terazosin 5mg (Group 5; n=15). Pa- tients who refused to use any alpha-blocker drug were included into Group 6 as control group (n=16). We investigated apoptosis indexes of the drugs in prostatic tissues that were taken from patient's surgery (transurethral resection of prostate) and/or prostate biopsies. Immunochemical dyeing, light microscope, and Image Processing and Analy- sis in Java were used for evaluations. Statistical significant p was p<0.05. Results: There were 132 patients with mean follow-up of 4.2±2.1 months. Pathologist researched randomly selected 10 areas in each microscope set. Group 1 showed statisti- cal significant difference apoptosis index in immunochemical TUNEL dyeing and im- age software (p<0.001). Moreover, we determined superior significant development in parameters as uroflowmetry, quality of life scores, and international prostate symptom score in Group 1. Conclusions: Silodosin has higher apoptosis effect than other alpha-blockers in prostate. Thus, clinic improvement with silodosin was proved by histologic studies. Besides, static factor of BPH may be overcome with creating apoptosis.

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ABSTRACT Purpose: To identify the fetal stem cell (FSC) response to maternal renal injury with emphasis on renal integrity improvement and Y chromosome detection in damaged maternal kidney. Materials and Methods: Eight non-green fluorescent protein (GFP) transgenic Sprague-Dawley rats were mated with GFP-positive transgenic male rats. Renal damage was induced on the right kidney at gestational day 11. The same procedure was performed in eight non-pregnant rats as control group. Three months after delivery, right ne- phrectomy was performed in order to evaluate the injured kidney. The fresh perfused kidneys were stained with anti-GFP antibody. Polymerase chain reaction (PCR) assay was also performed for the Y chromosome detection. Cell culture was performed to detect the GFP-positive cells. Technetium-99m-DMSA renal scan and single-photon emission computed tomography (SPECT) were performed after renal damage induction and 3 months later to evaluate the improvement of renal integrity. Results: The presence of FSCs was confirmed by immune histochemical staining as well as immunofluorescent imaging of the damaged part. Gradient PCR of female rat purified DNA demonstrated the presence of Y-chromosome in the damaged maternal kidney. Moreover, the culture of kidney cells showed GPF- positive cells by immuno- fluorescence microscopy. The acute renal scar was repaired and the integrity of dam- aged kidney reached to near normal levels in experimental group as shown in DMSA scan. However, no significant improvement was observed in control group. Conclusion: FSC seems to be the main mechanism in repairing of the maternal renal injury during pregnancy as indicated by Y chromosome and GFP-positive cells in the sub-cultured medium.

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ABSTRACT Objective: To investigate the effect of papaverine and alprostadil on testicular torsion-detorsion injury in rats. Materials and Methods: A total of 40 male Wistar-Albino rats were used in this study. Four hours of right testicular torsion was applied to each group, excluding sham oper- ated group. The torsion-detorsion (T/D), T/D + papaverine and T/D + alprostadil groups received saline, papaverine and alprostadil at the same time as surgical detorsion, respectively. At 14 days after the surgical detorsion, ischaemic changes and the degree of damage were evaluated with Cosentino scoring and the Johnson tubular biopsy score (JTBS). Results: JTBS was determined as 8.8±2.7 in the Sham group, 5.08±1.9 in the T/D+papaverine group, 5.29±2.3 in the T/D +alprostadil group and 2.86±1.9 in the TD group. The JTBS was determined to be statistically significantly high in both the T/D + papaverine group and the T/D + alprostadil group compared to the T/D group (p=0.01, p=0.009). In the T/D + papaverine group, 3 (43%) testes were classified as Cosentino 2, 3 (43%) as Cosentino 3 and 1 (14%) as Cosentino 4. In the T/D +alprostadil group, 5 (50 %) testes were classified as Cosentino 2, 3 (30 %) as Cosentino 3 and 2 (20%) as Cosentino 4. Conclusion: The present study indicated that spermatic cord administration of alprostadil and papaverine showed a protective effect against ischemia/reperfusion injury after right-side testes torsion and histological changes were decreased after testicular ischemia reperfusion injury.

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ABSTRACT Objective: To present our technique of ureteroileal bypass to treat uretero-enteric stric- tures in urinary diversion. Materials and Methods: One hundred and forty-one medical records were reviewed from patients submitted to radical cystectomy to treat muscle-invasive bladder cancer between 2013 and 2015. Twelve (8.5%) patients developed uretero-enteric anastomotic stricture during follow-up. Five patients were treated with endoscopic dilatation and double J placement. Four were treated surgically with standard terminal-lateral im- plantation. Three patients with uretero-enteric anastomotic stricture were treated at our institution by “ureteroileal bypass”, one of them was treated with robotic surgery. Results: All patients had the diagnosis of uretero-enteric anastomotic stricture via computerized tomography and DTPA renal scan. Time between cystectomy and diag- nosis of uretero-enteric anastomotic stricture varied from five months to three years. Mean operative time was 120±17.9 minutes (98 to 142 min) and hospital stay was 3.3±0.62 days (3 to 4 days). Mean follow-up was 24±39.5 months (6 to 72 months). During follow-up, all patients were asymptomatic and presented improvement in ure-terohydronephrosis. Serum creatinine of all patients had been stable. Conclusions: Latero-lateral ureter re-implantation is feasible by open or even robotic surgery with positive results, reasonable operation time, and without complications.

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ABSTRACT A 32-year-old 22-week pregnant hypertensive woman with sporadic episodes of headaches, sweating, and facial flushing was diagnosed with pheochromocytoma through biochemical and imaging tests. Perioperative management included a multidisciplinary approach, symptom stabilization with α blockade followed by β blockade, and tumor resection by laparoscopic adrenalectomy at 24 weeks gestation. The diagnosis was confirmed by histopathological examination and immuno-histochemistry tests. The decision for surgical removal of the tumor was based on maternal symptoms, tumor size, gestational age, the possibility of doing a laparos-copy, and the expertise of the surgical team.

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ABSTRACT Case Hypothesis: Surgical removal is the standard treatment for artificial sphincter extrusion. However in some specific situations is possible to maintain the prosthesis with good results. Case report: We report a 60 years old patient presenting sphincter pump extrusion one month after artificial urinary sphincter (AUS) AMS 800™ placement for treating post-radical prostatectomy urinary incontinence (PRPUI). He also had a penile pros- thesis implant one year before that was replaced in the same surgery the sphincter was implanted. As patient refused sphincter removal and there were no signals of active infection he was treated by extensive surgical washing with antibiotics and antiseptics. Pump was repositioned in the opposite side of the scrotum. Patient had good evolution with sphincter activation 50 days later. After 10 months of follow up, patient is socially continent and having regular sexual intercourse. Savage surgery may be an option in select cases of artificial sphincter extrusion. Promising future implications: Like in some patients with penile prosthesis some pa- tients with artificial sphincter extrusion can be treated without removing the device. This may be a line of research about conservative treatment of artificial sphincter complications.

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ABSTRACT Renal replacement lipomatosis is a condition characterized by varying degrees of renal parenchymal atrophy and perirenal fibrofatty proliferation secondary to chronic inflammation such as xanthogranulomatous pyelonephritis. In severe cases, imaging findings can be misdiagnosed as retroperitoneal liposarcoma.

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ABSTRACT Introduction: Inguinal lymphadenectomy is an integral part in the management of penile cancer. Video endoscopic inguinal lymphadenectomy (VEIL) is emerging as a minimally invasive treatment to reduce postoperative complications. Materials and Methods: 62 years old man underwent glansectomy for a squamous cell carcinoma (pT1b). At the physical examination one left inguinal lymph node was detectable (cN1). The chest-abdomen-pelvis CT was negative for metastasis. A 10-mm optical trocar and two 5mm operating trocar were placed. The optical trocar was placed in the apex of Scarpa's triangle after a skin incision and after the creation of a subcutaneous space by blunt finger dissection. The pCO2 was 8-10mmHg. The surgical technique involved the removal of superficial lymph nodes according to the scheme described by Deseler and of the deep lymph nodes. Sparing main venous structures and closing lymphatic vessels is important to reduce post operative complications. At the end of the procedure, a suction drain was placed per side. Results: Operative time was 90 minutes per side. Drains were removed on the seventh postoperative day. Hospital stay was 8 days and no postoperative complications occurred. The total number of nodes removed was 16 (8 per side) with 2 superficial positive nodes on the left side. Conclusion: ILND is burned by a high complication rate. VEIL provides a less invasive approach and a saphenous-sparing technique ensures a lower complication rate, reducing lymphorrhea, skin necrosis and wound complications (1–3). In experienced laparoscopic hands, VEIL is a safe and effective treatment.

Resumo em Inglês:

ABSTRACT Introduction and Objectives: Nephrectomy is occasionally required due to severe extra-renal symptom(s) such as dyspepsia in patients with autosomal dominant polycystic kidney disease (ADPKD), wherein a large incision is required for specimen extraction. Considering problems such as hernia, wound dehiscence, incidental bowel injury, and poor wound healing in such cases, we would like to present retroperitoneoscopic nephrectomy and morcellation of the kidney as an ideal minimally invasive technique. Materials and Methods: A 53-year-old man who was undergoing hemodialysis for 6 years due to ADPKD visited the outpatient clinic with a complaint of severe dyspepsia. Kidney length (long axis) was greater than 28 cm. Nephrectomy was the last option to restore his digestive system which was mechanically compressed by an extremely enlarged polycystic kidney. Retroperitoneoscopic nephrectomy was performed using 3 ports. When it was difficult to continue the dissection due to limited space, large cysts were punctured and aspirated to create additional working space. The specimen was extracted by a morcellator (KARL STORZ GmbH & Co. KG, Tuttlingen, Germany) introduced through a 12mm trocar. Results: Operating time was 230 minutes, wherein the time for morcellation was 52 minutes. No additional incision was required for specimen extraction. He underwent hemodialysis on post-operative days #1 and #3. He was discharged on post-operative day #4 (total hospital stay was 6 days.). Dyspepsia dramatically improved without post-operative complications. Conclusions: Retroperitoneoscopic nephrectomy is feasible for treatment of ADPKD. By using a morcellator, an additional incision is not required and wound complication would not occur.