Resumo em Inglês:

Contemporary, the management of overactive bladder (OAB), a medical condition characterized by urgency, with or without urge urinary incontinence, frequency and nocturia, in absence of genitourinary pathologies or metabolic factors that could explain these symptoms, is complex, and a wide range of conservative treatments has been offered, including bladder training, biofeedback, behavioral changes, oral or intravesical anticholinergic agents, S3 sacral neuromodulation and peripheral electrical stimulation. Clinical efficacy of these treatments remains an open issue and several experimental and clinical studies were carried out in the last years improving the results of medical treatment. Here we review the pathophysiology of micturition reflex, the current therapies for OAB and the rationale for alternative treatments. Furthermore we critically address the potential use of medications targeting the central nervous system (CNS) and the primary sensory nerves of the bladder wall, we review the use of agonists of nociceptin/orphanin protein (NOP) receptor and finally we report the results obtained by intradetrusor injection of botulinum toxin.

Resumo em Inglês:

OBJECTIVE: To report our experience with laparoscopic-assisted nephroureterectomy for upper tract transitional cell carcinomas after radical cystectomy and urinary diversion. MATERIALS AND METHODS: Seven patients (53-72 years-old) underwent laparoscopic-assisted nephroureterectomy 10 to 53 months after radical cystectomy for transitional cell carcinoma at our institution. Surgical technique, operative results, tumor features, and outcomes of all patients were retrospectively reviewed. RESULTS: Mean operative time was 305 minutes with a significant amount of time spent on the excision of the ureter from the urinary diversion. Estimate blood loss and length of hospital stay averaged 180 mL and 10.8 days, respectively. Intraoperative and postoperative complications occurred in two patients each. There was one conversion to open surgery. Pathology confirmed upper-tract transitional cell carcinoma in all cases. Metastatic disease occurred in two patients after a mean follow-up of 14.6 months. CONCLUSIONS: Nephrouretectomy following cystectomy is a complex procedure due to the altered anatomy and the presence of many adhesions. A laparoscopic-assisted approach can be performed safely in properly selected cases but does not yield the usual benefits seen with other laparoscopic renal procedures.

Resumo em Inglês:

OBJECTIVE: We have analyzed our institutional experience with simple enucleation for the treatment of small renal tumors for elective indications. MATERIALS AND METHODS: A total of 30 patients underwent elective nephron-sparing surgery (NSS) from May 1997 to January 2001. All patients underwent NSS by means of enucleation. The tumor bed was coagulated carefully for haemostatic and partly for oncological reasons. Median follow-up was 71 months (range: 49-91 months). RESULTS: Pathological review according to the 2002 TNM classification showed that 70 % (21 of 30) of tumors were pT1a, 26.7 % (8 of 30) pT1b and 3.3 % (1 of 30) pT3a. Median tumor size was 3.7 cm. (range: 3.0 - 5.5 cm). There was no perioperative mortality (within the first 30 days). Bleeding had not been recorded during perioperative period. Urinary leakage was observed in 1 patient (3.3%). No case of local recurrence was observed. Five and 7-year cumulative survival was 96.6% and 93.3%, respectively. Five and 7-year cancer specific survival was 100% and 96.5%, respectively. CONCLUSIONS: Simple tumor enucleation is a safe and acceptable approach for elective NSS. It provides excellent long-term progression-free and cancer specific survival rates, and is not associated with an increased risk of local recurrence compared to partial nephrectomy.

Resumo em Inglês:

OBJECTIVE: To assess the occurrence of upper urinary tract urothelial tumors (UUTT) in Brazil. MATERIALS AND METHODS: We performed a clinical and histopathologic study of 33 patients who were diagnosed with a malignant neoplasm in the renal pelvis or ureter in the period of 1994 to 2004, in a single institution. RESULTS: Among the patients with upper urinary tract carcinoma, 70% were males and 30% females, with mean age of 65 ± 16 years (ranging from 31 to 91 years). Nineteen patients presented renal pelvis tumor (58%), 9 ureteral tumor (27%) and 5 synchronic pelvic and ureteral tumors (15%). Renal pelvis tumors represented 2.8% of all the urothelial neoplasms, and 11.4% of all renal neoplasms treated in the same period. Ureteral tumors represented 1.6% of all the urothelial malignancies surgically managed in these 11 years. Tobacco smoking was the most common risk factor, and analgesic abuse was not reported by those patients. Most carcinomas were high-grade and muscle-invasive. Mean time to diagnosis was 7 months, being hematuria the most common symptom. CONCLUSIONS: A high association was also found between UUTT and bladder urothelial carcinoma. UUTT were mostly seen in men in their seventies and related to a high overall and cancer-related mortality rate. The overall disease-specific survival was 40%, much lower than found in most of the reported series.

Resumo em Inglês:

OBJECTIVE: We compared the efficacy of extracorporeal shock wave lithotripsy (ESWL) and ureteroscopy (URS) for the treatment of distal ureteral calculi with respect to patient satisfaction. MATERIALS AND MHETODS: This is a prospective study where a total of 212 patients with solitary, radiopaque distal ureteral calculi were treated with ESWL (n = 92) using Dornier lithotriptor S (MedTech Europe GmbH) or URS (n = 120). Patient and stone characteristics, treatment parameters, clinical outcomes, and patient satisfaction were assessed for each group. RESULTS: The 2 groups were comparable in regard to patient age, sex, stone size, and side of treatment. The stone-free status for ESWL and URS at 3 months was 81.5% and 97.5%, respectively (p < 0.0001). In addition, 88% of patients who underwent ESWL versus 20% who underwent URS were discharged home the day of procedure. Minor complications occurred in 3.3% and 8.3% of the ESWL and URS groups, respectively (p = 0.127). No ureteral perforation or stricture occurred in the URS group. Postoperative flank pain and dysuria were more severe in the URS than ESWL group, although the differences were not statistically significant (p = 0.16). Patient satisfaction was high for both groups, including 94% for URS and 80% for ESWL (p = 0.002). CONCLUSIONS: URS is more effective than ESWL for the treatment of distal ureteral calculi. ESWL was more often performed on an outpatient basis, and showed a trend towards less flank pain and dysuria, fewer complications and quicker convalescence. Patient satisfaction was significantly higher for URS according to the questionnaire used in this study.

Resumo em Inglês:

OBJECTIVE: Current published data regarding the prognostic value of microvascular invasion (MVI) in patients with prostate cancer (PCa) have yielded mixed results. Furthermore, most important series had surgical procedures performed by multiple surgeons and surgical specimens analyzed by multiple pathologists. We determined the relation of MVI with other pathologic features and whether this finding can be used as an independent prognostic factor in patients with PCa. MATERIALS AND METHODS: We selected 428 patients with clinically localized PCa treated with radical prostatectomy (RP). MVI was correlated to other pathologic features. The Kaplan-Meier method was used to evaluate survival curves and statistical significance was determined by the log-rank test. Multivariate analysis was performed through a Cox proportional hazards regression model. RESULTS: Eleven percent out of the 428 patients presented MVI. Except for the lack of association with biopsy Gleason score, MVI was related to all clinical and pathologic features of RP specimens. Mean follow up after surgery was 53.9 ± 20.1 months. Patients with MVI presented a recurrence rate of 44.6% compared to only 20.2% for patients without MVI (Log-rank test - p < 0.001). After Cox regression analysis, MVI was an independent prognostic feature related to biochemical recurrence. CONCLUSIONS: MVI is associated to advanced pathologic features of PCa and is an important prognostic factor regarding disease recurrence in patients treated with RP. These findings support the recommendations to the routine evaluation of this variable in pathologic reports of RP specimens.

Resumo em Inglês:

The term splenosis applies to the autotransplanted splenic tissue resulting from seeding in the context of past splenic trauma or surgery. We report a 42-year-old man with a history of splenectomy observed for an incidentally found retrovesical mass thought to be an ectopic testicle. The abdominal laparotomy revealed multiple focuses of pelvic splenosis. As splenosis can be diagnosed through specific imaging studies one should always consider it in differential diagnosis of a mass discovered years after splenic surgery or trauma.

Resumo em Inglês:

Adenocarcinoma arising in urinary bladder or prostatic urethra is uncommon. When they occur, the tumor can be mistaken for metastatic lesions, especially from the colon. Here we report the fifth case of a primary urothelial-type adenocarcinoma arising in the prostate which showed enteric differentiation. The patient was a 55 year-old male whose prostatic needle core biopsy showed a high grade adenocarcinoma which was initially thought to be metastatic colon cancer. A follow-up colonoscopy was unremarkable. Subsequent prostatectomy revealed a high grade adenocarcinoma which was positive for cytokeratins 7 and 20, carcinoembryonic antigen, CDX2, and high molecular weight cytokeratin, and negative for prostate specific antigen, prostate specific acid phosphatase and AMACR. A diagnosis of urothelial-type adenocarcinoma of the prostate was rendered. We review the literature regarding this entity, and discuss the differential diagnosis, emphasizing utility of immunohistochemistry in making the diagnosis. Finally, we speculate on the behavior of these rare tumors.

Resumo em Inglês:

OBJECTIVE: To evaluate the role of elective appendicovesicostomy in association with Monfort abdominoplasty to avoid urinary tract infection (UTI) and renal damage in the post-operative follow-up of patients with prune belly syndrome. MATERIALS AND METHODS: We followed 4 patients operated in our institution (UNIFESP) (Monfort, orchidopexy and Mitrofanoff) and compared them to 2 patients treated similarly, but without an appendicovesicostomy, in a second institution (UFBA). We evaluated postoperative clinical complications, UTI and preservation of renal parenchyma. Patients were followed as outpatients with urinalysis, ultrasonography (US) and occasionally with renal scintigraphy. RESULTS: Mean follow-up was 23.5 months. Immediate post-operative course was uneventful. We observed that only one patient with the Mitrofanoff channel persisted with UTI, while the 2 patients used as controls persisted with recurrent pyelonephritis (> 2 UTI year). CONCLUSION: Our data suggest that no morbidity was added by the appendicovesicostomy to immediate postoperative surgical recovery and that this procedure may have a beneficial effect in reducing postoperative UTI events and their consequences by reducing the postvoid residuals in the early abdominoplasty follow-up. However, we recognize that the series is small and only a longer follow-up with a larger number of patients will allow us to confirm our suppositions. We could not make any statistically significant assumptions regarding differences in renal preservation due to the same limitations.

Resumo em Inglês:

OBJECTIVE: Klippel-Trenaunay-Weber syndrome (KTWS) is a congenital condition characterized by vascular malformations of the capillary, venous and lymphatic systems associated to soft tissue and bone hypertrophy in the affected areas. This syndrome may involve bladder, kidney, urethra, ureter and genitals. We report the treatment of 7 KTWS patients with urogenital involvement. MATERIALS AND METHODS: From 1995 to 2005, 7 patients with KTWS were evaluated and the charts of these patients were reviewed. RESULTS: Patients’ median age was 19-years (range 4 to 46-years) and only 1 was female. The clinical presentation included genital deformities in 3 cases, hematuria in 2 and urethrorragia in 2, one of which associated with cryptorchidism and phimosis. Three patients had an association of pelvic and genital malformations, including 2 patients with hematuria due to vesical lesions and 1 patient with left ureterohydronephrosis due to a pelvic mass. Two patients had urethral lesions. Treatment included endoscopic laser coagulation for 1 patient with recurrent hematuria and 1 patient with urethrorrhagia, pelvic radiotherapy for 1 patient with hematuria and circumcision in 2 patients with genital deformities. One patient required placement of a double-J catheter to relieve obstruction. Hematuria and urethrorragia were safely and effectively controlled with laser applications. Circumcision was also effective. The patient treated with radiotherapy developed a contracted bladder and required a continent urinary diversion. CONCLUSIONS: Urogenital involvement in patients with KTWS is not rare and must be suspected in the presence of hematuria or significant cutaneous deformity of the external genitalia. Surgical treatment may be warranted in selected cases.

Resumo em Inglês:

INTRODUCTION & OBJECTIVES: Studies of motor conduction for the efferent functional assessment of the pudendal nerve in women with pelvic dysfunctions have been conducted through researching distal motor latency times. The transrectal approach has been the classic approach for this electrophysiological examination. The objective of the present study is to verify the viability of the transvaginal approach in performing the exam, to establish normal values for this method and to analyze the influence of age, stature and parity in the latency value of normal women. MATERIALS AND METHODS: A total of 23 volunteers without genitourinary pathologies participated in this study. In each, pudendal motor latency was investigated through the transvaginal approach, which was chosen due to patient’s higher tolerance levels. RESULTS: The motor response represented by registering the M-wave was obtained in all volunteers on the right side (100%) and in 13 volunteers on the left side (56.5%). The mean motor latency obtained in the right and left was respectively: 1.99 ± 0.41 and 1.92 ± 0.48 milliseconds (ms). There was no difference between the sides (p = 0.66). Latency did not correlate with age, stature or obstetric history. The results obtained in the present study were in agreement with those found by other researchers using the transrectal approach. CONCLUSION: The vaginal approach represents an alternative for pudendal nerve distal motor latency time, with similar results to those achieved through the transrectal approach. Normative values obtained herein might serve as a comparative basis for subsequent physiopathological studies.

Resumo em Inglês:

Experimental models of organ transplantation play a crucial role in establishing the principles of transplantation immunobiology. Murine transplant models of vascularized organs are particularly useful for immunobiological studies because there are more immunological tools available. However, the technique of kidney transplant in mice is very challenging. A difficult aspect of this model is urinary reconstruction, which is frequently associated to complications. In this article, the technique of mouse kidney transplantation using an anti-reflux system (modified extravesical ureteroneocystostomy) is described and illustrated for the first time. Although technically demanding, this procedure is feasible and may reduce the incidence of urine leakage and reflux.