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Introduction of minimally invasive techniques has revolutionized the surgical management of renal calculi. Extracorporeal shock wave lithotripsy and percutaneous nephrolithotomy are now both well-established procedures. Each modality has advantages and disadvantages, and the application of each should be based on well-defined factors. These variables include stone factors such as number, size, and composition; factors related to the stone's environment, including the stone's location, spatial anatomy of the renal collecting system, presence of hydronephrosis, and other anatomic variables, such as the presence of calyceal diverticula and renal anomalies; and clinical or patient factors like morbid obesity, the presence of a solitary kidney, and renal insufficiency. The morbidity of each procedure in relation to its efficacy should be taken in to account. This article will review current knowledge and suggest an algorithm for the rational management of renal calculi with shock wave lithotripsy and percutaneous nephrolithotomy.

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PURPOSE: Demonstrate radiological findings of 127 angiomyolipomas (AMLs) and propose a classification based on the radiological evidence of fat. MATERIALS AND METHODS: The imaging findings of 85 consecutive patients with AMLs: isolated (n = 73), multiple without tuberous sclerosis (TS) (n = 4) and multiple with TS (n = 8), were retrospectively reviewed. Eighteen AMLs (14%) presented with hemorrhage. All patients were submitted to a dedicated helical CT or magnetic resonance studies. All hemorrhagic and non-hemorrhagic lesions were grouped together since our objective was to analyze the presence of detectable fat. Out of 85 patients, 53 were monitored and 32 were treated surgically due to large perirenal component (n = 13), hemorrhage (n = 11) and impossibility of an adequate preoperative characterization (n = 8). There was not a case of renal cell carcinoma (RCC) with fat component in this group of patients. RESULTS: Based on the presence and amount of detectable fat within the lesion, AMLs were classified in 4 distinct radiological patterns: Pattern-I, predominantly fatty (usually less than 2 cm in diameter and intrarenal): 54%; Pattern-II, partially fatty (intrarenal or exophytic): 29%; Pattern-III, minimally fatty (most exophytic and perirenal): 11%; and Pattern-IV, without fat (most exophytic and perirenal): 6%. CONCLUSIONS: This proposed classification might be useful to understand the imaging manifestations of AMLs, their differential diagnosis and determine when further radiological evaluation would be necessary. Small (< 1.5 cm), pattern-I AMLs tend to be intra-renal, homogeneous and predominantly fatty. As they grow they tend to be partially or completely exophytic and heterogeneous (patterns II and III). The rare pattern-IV AMLs, however, can be small or large, intra-renal or exophytic but are always homogeneous and hyperdense mass. Since no renal cell carcinoma was found in our series, from an evidence-based practice, all renal mass with detectable fat should be considered an AML.

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OBJECTIVE: To assess the prevalence of the main metabolic alterations found in patients with recent diagnosis of urolithiasis in the West region of Paraná state, Brazil. MATERIALS AND METHODS: We made a retrospective study on 425 patients with evidence of recent formation of renal stones. Laboratory assessment consisted in 3 samples of 24-hour urine with dosing of calcium, uric acid, citrate, oxalate, sodium and creatinine. A urine culture was also made and qualitative cystinuria and urinary pH following 12-hour fasting and water restriction were evaluated. RESULTS: In 96.5% of patients a cause was detected for the urolithiasis. Metabolic alterations most frequently found were: hypercalciuria (38.3%), hypocitraturia (29.6%) and hyperexcretion of uric acid (21.6%). Low urinary volume (17.9%), urinary tract infection (12.9%), hyperparathyroidism (3.3%), renal tubular acidosis (1.2%), cystinuria (0.9%) and anatomical alterations (12.7%) were also observed. CONCLUSIONS: Hypercalciuria, hypocitraturia and hyperuricuria are the most frequent metabolic disorders in the population under study and these data are in accordance to the literature.

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OBJECTIVE: Rupture of vesicourethral anastomosis following radical retropubic prostatectomy is a complication that requires immediate management. We evaluated the morbidity of this rare complication. MATERIALS AND METHODS: We analyzed retrospectively 5 cases of disruption of vesicourethral anastomosis during post-operative period in a consecutive series of 1,600 radical retropubic prostatectomies, performed by a single surgeon. RESULTS: It occurred in a ratio of 1:320 prostatectomies (0,3%). Management was conservative in all the cases with an average catheter permanence time of 28 days, being its removal preceded by cystography. Two cases were secondary to bleeding, 1 followed the change of vesical catheter and 2 by unknown causes after removing the Foley catheter. Only one patient evolved with urethral stenosis, in the period ranging from 6 to 120 months. CONCLUSION: Rupture of vesicourethral anastomosis is not related to the surgeon's experience, and conservative treatment has shown to be effective.

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

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INTRODUCTION: The treatment of benign prostate hyperplasia (BPH) presents 2 options: medical or surgical, and there are doubts about what is the best treatment since 80% of patients who undergo surgery become asymptomatic and 10 to 40% of those under medical regimen undergo surgery within a 5 years period. It is difficult to assess the actual costs of treating BPH in Brazil due to several factors, among them regional particularities and the scarcity of current statistical data. PATIENTS AND METHODS: Recently, in the Ribeirão Preto area, São Paulo, Brazil, the IPSS (International Prostatic Symptoms Score) and quality of life were verified in 934 volunteers. It was determined the percentage of individuals with ages ranging from 40 to 79 years with moderate symptoms (score 8-19) and with severe symptoms (score 20-35), values for which are indicated medical and surgical treatment, respectively, according to the Brazilian Society of Urology consensus on BPH. Data on Brazilian population in that age range were obtained from the Brazilian Institute of Geography and Statistics referent to the year of 2000. It was determined the number of patients, according to the criteria above, subjected to either one of the treatments mentioned. Surgical costs of prostate transurethral resection were researched according to Unified Health System - SUS tables (US$ 173) and of Brazilian Medical Society - AMB with a mean cost in 3 hospitals of US$ 933. Drug costs were calculated by the annual mean price (US$ 355) of 4 alpha-blockers (tamsulosin, alfuzosin, doxazosin and terazosin). RESULTS: The estimated population for medical treatment was 5,397,321 individuals, with a cost corresponding to US$ 1,916,489,055.00. The estimated population for surgical treatment was 2,040,299 men, what would represent a cost of US$ 353,291,204.00 based on the SUS table and of US$ 1,904,279,066.00 based on AMB with hospital expenses included. CONCLUSION: All theses facts induce us to predict that the treatment of BPH in a not-so-far future can become a public health problem for Brazilian society, since the current estimate would be, approximately, costs around 2.26 - 3.83 billion dollars, added by the yearly increase in the risk population (24.99%) for the group under medical treatment and over the non-operated amount of the surgical group.

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Renal clear cell carcinoma (RCCC) is a neoplasia resistant to radio and chemotherapy, with surgical treatment being the procedure that is recognized for its curative treatment. This case report demonstrates the success of an aggressive surgical treatment for consecutive and late metachronous metastases following radical nephrectomy. CASE REPORT: Asymptomatic 50-year old man. During a routine examination, an incidental mass was found by renal ultrasonography. He underwent right radical nephrectomy due to RCCC in June 1992. During the follow-up metastases were evidenced in cerebellum on the seventh year, and in left lung and pancreas on the eighth year following the radical nephrectomy, with all of them successfully treated by surgical excision. COMMENTS: The surgical excision of consecutive and late metachronous metastases in different organs arising from RCCC is feasible, being a good therapeutic alternative in selected cases.

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INTRODUCTION: Nephrobronchial fistula is a rare complication of xanthogranulomatous pyelonephritis, a disease that can fistulize to lungs, skin, colon and other organs. CASE REPORT: A 37-year old patient presented a chronic history of lumbar pain and thoracic symptoms such as cough, dyspnea and oral elimination of pus. Patient went to several services and was submitted to 2 thorax surgeries before definitive treatment (nephrectomy) was indicated. After nephrectomy, the patient presented an immediate improvement with weight gain (8 kg / 1 month) and all his symptoms disappeared. CONCLUSION: This clinical case illustrates the natural history of nephrobronchial fistula, the importance of clinical history for diagnosis and the relevance of early treatment of renal lithiasis.

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INTRODUCTION: Even though it is uncommon, uterine prolapse can cause compression of ureters and bilateral hydronephrosis, predisposing to arterial hypertension and renal failure. Hydronephrosis consequent to cystocele and to vaginal prolapse is even rarer. CASE REPORT: This paper reports on a 59 year-old patient, Caucasian, obese and hysterectomized who presented complete vaginal prolapse with bilateral hydronephrosis and slight alteration in serum urea and creatinine. Patient underwent correction of vaginal prolapse by endoscopic suspension technique with improvement of hydronephrosis and normalization of renal function. This work emphasizes the rarity of such case and the requirement of surgical approach.

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Bladder leiomyomas are rare benign mesenchymal tumors, which account for less than 0.43% of all bladder tumors with approximately 200 cases described in the literature. These tumors may be classified into 3 different locations: endovesical, intramural and extravesical. Endovesical is the most common form, accounting for 63-86% of the cases, while intramural occurs in 3-7% and extravesical in 11-30%. The intramural form, especially small tumors, may not produce symptoms hardening detection. We report two cases of intramural bladder leiomyomas in asymptomatic men observed incidentally by transabdominal ultrasonography during the follow-up of benign prostatic hyperplasia. We discuss the diagnosis and management of these lesions.

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Ultrasonography is the main non-invasive technique for screening of ureterocele, but presents some difficulties for its diagnosis. Other supplementary diagnostic methods have the disadvantage of being invasive or using ionizing radiation. Magnetic resonance (MR) has a high sensitivity for diagnosing urinary tract malformations in adults and children. We report one case of ureterocele in a 1-year old child with the purpose of presenting its diagnosis through MR

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Transurethral resection of the prostate (TURP) remains the gold standard for treatment of benign prostatic hyperplasia (BPH). In general, while this procedure is safe, patients require a spinal, epidural, or general anesthesia and often several days of hospital stay; the potential morbidity and mortality limits the use of TURP in high-risk patients. Pharmacotherapy has been recommended as a first-line therapy for all patients with mild to moderate symptoms. Patients are oftentimes enthusiastic if they are offered a one-time method to treat lower urinary tract symptoms secondary to BPH, provided that the method offers reduced risk and allows an efficacy equal to that of medical therapy. One such method is transurethral microwave thermotherapy (TUMT). TUMT involves the insertion of a specially designed urinary catheter with a microwave antenna, which heats the prostate and destroys hyperplastic prostate tissue. TUMT allows the avoidance of general or regional anesthesia, and results in minimal blood loss and fluid absorption. In this review, the authors discussed the current indications and outcome of TUMT, including the history of the procedure, the mechanism of action, the indications for TUMT, the pre-operative considerations, the patient selection, the results in terms of efficacy, by comparing TUMT vs. Sham, TUMT vs. Alpha-blocker and TUMT vs. TURP. Finally, the complications are presented, as well as other uses and future directions of the procedure. The authors concluded that TUMT is a safe and effective minimally invasive alternative to treatment of symptomatic BPH.