Resumo em Inglês:

Male infertility affects 10% of reproductive aged couples worldwide and is treatable in many cases. In addition to other well-described etiologies, genetic causes of male infertility are now more commonly diagnosed. Using principles of evidence-based medicine, this review outlines diagnostic and treatments options to inform clinical management. In order of importance, randomized controlled clinical trials, basic scientific studies, meta-analyses, case-controlled cohort studies, best-practice policy recommendations and reviews from peer-reviewed literature were incorporated that provide organized and timely guidelines to the current management of male infertility. The strength of evidence for treatment recommendations is also classified when appropriate.

Resumo em Inglês:

OBJECTIVES: urinary fistula is a morbid complication after renal transplantation leading to graft losses and patient death. We review and update our data on urinary fistula after renal transplantation and the outcome after surgical and conservative management. MATERIALS AND METHODS: the charts of 1046 renal transplants were reviewed. Transplants were performed through an extended inguinotomy; vascular anastomoses to the iliac vessels and urinary reconstruction accomplished through the Gregoir technique. Fistulae were diagnosed by urinary leaks through the incision or by the occurrence of a collection in the iliac fossa. Patient was treated surgically or conservatively according to the characteristics of the fistula and patient clinical status. RESULTS: Thirty one fistulae were diagnosed (2.9%). Twenty nine leaks due to ureteral necrosis and 2 due to reimplantation fault. The incidence of leaks among cadaver and live donor transplants was 3.22% and 2.63%, respectively (p = 0.73). Among diabetic and non diabetic patients the incidence of urinary leaks was 6.4% and 2.6%, respectively (p = 0.049). Treatment consisted in anastomosis of the graft ureter or pelvis with the ureter of the recipient in 17 cases with success in 13 (76.5%). Prolonged bladder drainage was employed in 7 cases and the fistula healed in 4 (57%). Ureteral reimplantation was performed in 3 cases and did not work in any of them. Ureteral ligature plus nephrostomy was employed in two cases and worked in one (50%). Percutaneous nephrostomy and ureteral stenting with double J catheter were employed in one case each and worked in both. CONCLUSIONS: The anastomosis of the graft ureter with the ureter of the recipient is a good method for treating urinary fistulae after renal transplantation when local and systemic conditions are good. Ureteral ligature associated to nephrostomy should be applied in cases of unfavorable local conditions or clinically unstable patients.

Resumo em Inglês:

OBJECTIVE: The aim of this study was to compare the renal function measured with either 99mTc-DTPA or 99mTc-EC dynamic scintigraphies with that measured using 99mTc-DMSA static scintigraphy. METHODS: the values of relative renal function measured in 111 renal dynamic scintigraphies performed either with 99mTc-DTPA (55 studies) or with 99mTc-EC (56 studies) were compared with the relative function measured using 99mTc-DMSA static scintigraphy performed within a 1-month period. The comparisons were performed using Wilcoxon signed rank test. The number of 99mTc-DTPA and 99mTc-EC studies that presented relative renal function different by more than 5% from that measured with 99mTc-DMSA, using chi square test were also compared. RESULTS: the relative renal function measured with 99mTc-EC is not statistically different from that measured with 99mTc-DMSA (p = 0.97). The relative renal function measured with 99mTc-DTPA was statistically different from that measured using 99mTc-DMSA, but with a borderline statistical significance (p = 0.05). The number of studies with relative renal function different by more than 5% from that measured with 99mTc-DMSA is higher for the 99mTc-DTPA scintigraphy (p = 0.04) than for 99mTc-EC. CONCLUSION: the relative renal function measured with 99mTc-EC dynamic scintigraphy is comparable with that measured with 99mTc-DMSA static scintigraphy, while the relative renal function measured with 99mTc-DTPA dynamic scintigraphy presents a significant statistical difference from that measured with 99mTc-DMSA static scintigraphy.

Resumo em Inglês:

OBJECTIVES: To review intraoperative and postoperative complications associated to the correction of cystocele and rectocele with polypropylene mesh macropore monofilament (Gynemesh PS) using transvaginal free tension technique. MATERIALS AND METHODS: Prospective study of patients that have been submitted to correction of cystocele and/or rectocele between November 2004 and August 2005 in the Urogynecology and Vaginal Surgery Unit of Gynecology and Obstetrics Department, Las Condes Clinic. Mesh was used in 31 patients: 9 for cystocele, 11 for rectocele, and 11 for concomitant meshes. Total mesh used 42. Media age 55 years old, weight 64 kilograms. In 7 patients we used a third mesh for correction of urinary incontinence by TVT-O technique. RESULTS: They did not present intraoperative complications, neither in immediate or delayed postoperative time. We did not observe hematoma, infection, erosion or exposition mesh. Healing of cystocele and rectocele was obtained in 100% of patients, with a pursuit between 1 and 8 months. DISCUSSION: The use of prosthetic polypropylene monofilament macropore mesh in the correction of cystocele and/or rectocele, by transvaginal route with tension free technique seems to be a safe and effective surgery procedure.

Resumo em Inglês:

OBJECTIVE: Assess the results of salvage conformal radiotherapy in patients with biochemical failure after radical prostatectomy and identify prognostic factors for biochemical recurrence and toxicity of the treatment. MATERIALS AND METHODS: From June 1998 to November 2001, 35 patients were submitted to conformal radiotherapy for PSA > 0.2 ng/mL in progression after radical prostatectomy and were retrospectively analyzed. The mean dose of radiation in prostatic bed was of 77.4 Gy (68-81). Variables related to the treatment and to tumor were assessed to identify prognostic factors for biochemical recurrence after salvage radiotherapy. RESULTS: The median follow-up was of 55 months (17-83). The actuarial survival rates free of biochemical recurrence and free of metastasis at a distance of 5 years were 79.7% e 84.7%, respectively. The actuarial global survival rate in 5 years was 96.1%.The actuarial survival rate free of biochemical recurrence in 5 years was 83.3% with PSA pre-radiotherapy < 1, 100% when > 1 and < 2, and 57.1% when > 2 (p = 0.023). Dose > 70 Gy in 30% of the bladder volume implied in more acute urinary toxicity (p = 0.035). The mean time for the development of late urinary toxicity was 21 months (12-51). Dose > 55 Gy in 50% bladder volume implied in more late urinary toxicity (p = 0.018). A patient presented late rectal toxicity of 2nd grade. CONCLUSIONS: Conformal radiotherapy showed to be effective for the control of biochemical recurrence after radical prostatectomy. Patients with pre-therapy PSA < 2 ng/mL have more biochemical control.

Resumo em Inglês:

PURPOSE: Because laparoscopic radical prostatectomy remains a challenging procedure, rectal injury is always a potential complication. We review the incidence of rectal injuries at our institution in the first 110 consecutive laparoscopic extraperitoneal radical prostatectomies. MATERIALS AND METHODS: Nine (8%) out of the first 110 laparoscopic extraperitoneal radical prostatectomies performed between December 2001 and February 2004, were complicated by rectal injury. Mean patient age was 64.9 years (range 52 to 74) and mean prostate specific antigen was 11.45 ng/mL (range 4.8 to 37.4). Median preoperative Gleason score was 6 (range 4 to 8) and clinical stage was T1c, T2a, T2b in 6, 2 and 1 patient, respectively. Mean operative time was 228 minutes (range 150 to 300). RESULTS: From 9 injuries, 6 were diagnosed and repaired intraoperatively and 3 were diagnosed postoperatively. From the 6 cases of intraoperative diagnosis and repair, 3 patients healed primarily without colostomy and a recto-urinary fistula was evidenced by pneumaturia in the remaining three. These 3 patients were managed conservatively with urethral catheterization during 30 days. One of the patients required secondary fistula repair by anterior transphincteric, transanal surgical approach (ASTRA). Urinary fistula was diagnosed postoperatively on 3 patients. A diverting colostomy was performed on one patient with secondary fistula repair by ASTRA. Another patient required laparotomy due to peritonitis and urinary fistula was later managed with ASTRA. On the third patient conservative management with urethral catheter was successful. All fistulas repaired with ASTRA evolved uneventfully. There was no perioperative mortality. CONCLUSIONS: Rectal injury during laparoscopic radical prostatectomy can be managed intraoperatively or by a minimally invasive procedure without the need of colostomy. Laparoscopic radical prostatectomy is a challenging procedure and is associated with a very flat learning curve; the incidence of rectal injuries is prone to diminish with experience.

Resumo em Inglês:

OBJECTIVE: To prospectively determine the prevalence of testicular microlithiasis in symptomatic patients who were referred for scrotal ultrasound examination and to evaluate the possible association of testicular microlithiasis with testicular cancer and other conditions such as cryptorchidism or history of ascending testis. MATERIALS AND METHODS: 391 men who were referred to our institutions between July 2002 and May 2005 for any type of symptoms from the testicles, underwent physical and scrotal ultrasound examination. The presence of testicular microlithiasis, the number of lesions and the involvement of both testicles in relation to the symptoms as well as the coexistence of other lesions were studied. RESULTS: Eighteen (4.6%) of 391 men enrolled into the study had testicular microlithiasis. Two out of the eighteen patients (11%) had concomitant testicular cancer, which was confirmed by pathological evaluation of the orchidectomy specimen. One of the patients with testicular microlithiasis presented a rising in biochemical tumor markers (LDH, and HCG) and underwent orchidectomy one year later. Five of the remaining 373 (1.3%) patients without microlithiasis were diagnosed with testicular cancer. Thirty six men reported having a history of ascending testis, but none of them was found with testicular cancer. Two cases of testicular torsion in a cryptorchid position had testicular microlithiasis, but the orchidectomy specimen (after surgery) was negative for testicular cancer. The correlation between testicular cancer and testicular microlithiasis found in our study was statistically significant (p < 0.05). CONCLUSION: There seems to be an association between testicular microlithiasis and testicular cancer.

Resumo em Inglês:

We report a case of intrarenal pseudoaneurysm of the right kidney after percutaneous nephrolithotomy (PCNL) in supine position. Diagnosis was established by angiotomography with a 3-D reconstruction. Treatment was successfully achieved by endovascular occlusion using N-butyl-2-cyanoacrylate.

Resumo em Inglês:

We report a pelvic liposarcoma originating from the left spermatic cord that recurred following inadequate excision. In our case, the tumor was resected without performing orchiectomy previously. The patient was managed by laparoscopic resection, before undergoing radical orchiectomy in the left inguinal region. To our knowledge, no case of laparoscopic resection for the recurrent liposarcoma has been described. In addition, the present case serves to demonstrate that radical orchiectomy with wide excision is needed for paratesticular tumor.

Resumo em Inglês:

Primary renal Angiosarcoma is a rare neoplasm and only 24 cases have been reported in specialized literature. We describe a case of primary renal angiosarcoma in a patient presenting with hematuria, palpable abdominal mass, left flank pain and anemia. A computerized tomography of the abdomen with contrast medium showed a tumor with 15 cm diameter, in the upper pole of the left kidney, with a low-density central area, suggesting necrosis or hemorrhage. Diagnosis was given in a morphologic base and proven by an immunohistochemical study. Primary renal angiosarcoma should be included among differential diagnosis of retroperitoneal hematoma and hemorrhagic renal tumors.

Resumo em Inglês:

OBJECTIVE: To characterize and determine whether patients with recurrent abdominal symptoms and associated ureteropelvic junction obstruction (UPJO) (Dietl's crisis) are effectively treated by pyeloplasty and to determine criteria for evaluating UPJO in childhood abdominal pain. MATERIALS AND METHODS: A retrospective chart review from 1998 to 2001 was performed to identify patients with Dietl's crisis and associated UPJO. Chart review included presenting symptoms, location of lesion, condition of the affected renal unit, referral method, and surgery success. RESULTS: Eight patients (7 male and 1 female) were identified with Dietl's crisis. All eight were initially misdiagnosed and spent at least a year with significant pain symptoms before being properly diagnosed. Only one patient had associated urologic complaints. Renal scan split functions of the affected renal unit ranged from 34% to 51%. One nephrectomy and seven pyeloplasties were performed and resolution of all patients' abdominal symptoms, including pain, resolved. CONCLUSIONS: Children with Dietl's crisis often suffer a delay in diagnosis; the clinical entity appears to be under-diagnosed. Renal parenchyma is typically preserved, and there is a paucity of associated urologic complaints. Once properly diagnosed, patients are well served by a pyeloplasty. Children with periumbilical pain and vomiting, particularly males, would benefit from ultrasound imaging.

Resumo em Inglês:

OBJECTIVE: To determine indications for circumcision revision and to identify the specialty of the person who performed unsatisfactory primary circumcision. MATERIALS AND METHODS: The authors reviewed medical records of 52 cases that underwent circumcision revision over a 6-year period (1998 to 2004). Sleeve surgical technique was used for revision in patients with redundant foreskin or concealed penis, penoplasty for partial or complete degloving of the penis and meatotomy for external meatal stenosis. The mean age of children was 32 months (range 6 months to 9 years). RESULTS: Most of unsatisfactory primary circumcisions (86.7%) were performed by laymen. All patients who underwent circumcision revision had good to excellent cosmetic results. CONCLUSION: Primary circumcision performed by laymen carry a high complication rate and serious complications may occur. A period of training and direct supervision by physicians is required before allowing laymen to perform circumcision independently.

Resumo em Inglês:

Aarskog-Scott syndrome (ASS) is an X-linked disorder characterized by facial, skeletal and genital anomalies, including penoscrotal transposition in males. We report on a girl from a family with ASS who exhibits a transposition of the clitoris.

Resumo em Inglês:

OBJECTIVE: Prospective study to objectively evaluate the benefits of pelvic floor strengthening exercises associated to biofeedback for the treatment of stress urinary incontinence. MATERIALS AND METHODS: Fourteen patients diagnosed with stress urinary incontinence (SUI) were selected for this study. All patients underwent a pelvic floor training associated to biofeedback for 12 consecutive weeks. Urodynamic tests, pad test and bladder diary were analyzed at the beginning of the study, at the end and after 3 months. The King's Health Questionnaire (KHQ) was applied before and after treatment to assess the impact in the quality of life. RESULTS: There was a significant reduction in the pad weight (from 14.21 g to 1 g), number of urinary leakage episodes (from 8.14 per day to 2.57 per day) and daytime frequency (from 7.93 per day to 5.85 per day). At urodynamics the authors observed a significant increase in Valsalva leak-point pressure (from 103.93 cm H2O to 139.14 cm H2O), cistometric capacity (from 249.29 mL to 336.43 mL, p = 0.0015) and bladder volume at first desire to void (from 145 mL to 215.71 mL). Those differences were kept during the first 3 months of follow up. The KHQ revealed significant differences except in the case of "general health perception", which covers health in general and not exclusively urinary incontinence. CONCLUSION: Treatment of SUI with pelvic floor exercises associated to biofeedback caused significant changes in the parameters analyzed, with maintenance of good results 3 months after treatment.