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Objective To conduct a systematic review on single scrotal incision orchiopexy. Materials and Methods A search was performed using Pubmed, through which 16 articles were selected out of a total of 133. The following conditions were considered exclusion criteria: other surgical methods such as an inguinal procedure or a laparoscopic approach, retractile testes, or patients with previous testicular or inguinal surgery. Results A total of 1558 orchiopexy surgeries initiated with a transcrotal incision were analyzed. Patients' ages ranged between 5 months and 21 years. Thirteen studies used high scrotal incisions, and low scrotal incisions were performed in the remainder of the studies. In 55 cases (3.53%), there was a need for inguinal incision. Recurrence was observed in 9 cases, testicular atrophy in 3, testicular hypotrophy in 2, and surgical site infections in 13 cases. High efficacy rates were observed, varying between 88% and 100%. Conclusions Single scrotal incision orchiopexy proved to be an effective technique and is associated with low rates of complications.

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Introduction To analyze the association between serum levels of folate and risk of biochemical recurrence after radical prostatectomy among men from the Shared Equal Access Regional Cancer Hospital (SEARCH) database. Materials and Methods Retrospective analysis of 135 subjects from the SEARCH database treated between 1991-2009 with available preoperative serum folate levels. Patients' characteristics at the time of the surgery were analyzed with ranksum and linear regression. Uni- and multivariable analyses of folate levels (log-transformed) and time to biochemical recurrence were performed with Cox proportional hazards. Results The median preoperative folate level was 11.6ng/mL (reference = 1.5-20.0ng/mL). Folate levels were significantly lower among African-American men than Caucasians (P = 0.003). In univariable analysis, higher folate levels were associated with more recent year of surgery (P < 0.001) and lower preoperative PSA (P = 0.003). In univariable analysis, there was a trend towards lower risk of biochemical recurrence among men with high folate levels (HR = 0.61, 95%CI = 0.37-1.03, P = 0.064). After adjustments for patients characteristics' and pre- and post-operative clinical and pathological findings, higher serum levels of folate were independently associated with lower risk for biochemical recurrence (HR = 0.42, 95%CI = 0.20-0.89, P = 0.023). Conclusion In a cohort of men undergoing radical prostatectomy at several VAs across the country, higher serum folate levels were associated with lower PSA and lower risk for biochemical failure. While the source of the folate in the serum in this study is unknown (i.e. diet vs. supplement), these findings, if confirmed, suggest a potential role of folic acid supplementation or increased consumption of folate rich foods to reduce the risk of recurrence.

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Objective There is evidence that reactive stroma in different cancers may regulate tumor progression. The aim of this study is to establish any possible relation of reactive stroma grading on needle prostatic biopsies to biochemical recurrence. Materials and Methods The study group comprised 266 biopsies from consecutive patients submitted to radical prostatectomy. Reactive stroma was defined as stroma surrounding neoplastic tissue and graded as 0 (absent), 1 (slight), 2 (moderate), and 3 (intense) according to tumor stroma area relative to total tumor area. Results From the total of 266 needle prostatic biopsies, 143 (53.8%), 55 (20.7%), 54 (20.3%), and 14 (5.3%) showed grades 0, 1, 2, and 3, respectively. Increasing reactive stroma grade was significantly associated with clinical stage T2, higher preoperative PSA, higher biopsy and radical prostatectomy Gleason score, more extensive tumors in radical prostatectomy, and pathologic stage > T2. Only grade 3 was significantly associated with time and risk to biochemical recurrence. On multivariate analysis only preoperative PSA and 2 methods of biopsy tumor extent evaluation were independent predictors. Conclusion Increasing reactive stroma grade on biopsies is significantly associated with several clinicopathologic adverse findings, however, only grade 3 predicts time and risk to biochemical recurrence following radical prostatectomy on univariate but not on multivariate analysis. We have not been able to show that reactive stroma grade 3 on biopsies is an independent predictor of biochemical recurrence beyond that of preoperative PSA and other pathologic findings on biopsy.

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Purpose Little is known about the effects of literacy levels on prostate cancer screening. This study evaluates the association between literacy, compliance with screening, and biopsy findings in a large Brazilian screening study. Materials and Methods We analyzed 17,571 men screened for PCa with digital rectal examination (DRE) and total and free prostate-specific antigen (PSA) from January 2004 to December 2007. Of those, 17,558 men had information regarding literate status. Full urological evaluation in a specialized cancer center was recommended in the case of: a) suspicious DRE, b) PSA > 4.0 ng/mL, or c) PSA 2.5-3.9 ng/mL and free/total PSA (f/tPSA) ratio < 15%. Transrectal ultrasound guided prostate biopsy (14 cores) was performed upon confirmation of these findings after the patient's consent. Patients' compliance with screening recommendations and biopsy results were evaluated according to literacy levels. Results an abnormal PSA, a suspicious DRE, or both were present in 73.2%, 19.7%, and 7.1% of those men who underwent biopsy, respectively. PCa was diagnosed in 652 men (3.7%). Previous PSAs or DREs were less common among illiterate men (p < 0.0001). Additionally, illiterate men were less prone to attend to further evaluations due to an abnormal PSA or DRE (p < 0.0001). PSA levels > 10 mg/mL (p = 0.03), clinical stage > T2a (p = 0.005), and biopsy Gleason > 7 (p = 0.02) were more common among illiterate men. Conclusions In a screened population, literacy levels were associated with prior PCa evaluations and with compliance with screening protocols. Illiterate men were at higher risk of being diagnosed with more advanced and aggressive PCa.

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Integrins are transmembrane glycoprotein receptors that regulate cell-matrix interactions, thus functioning as sensors from the environment. They also act as cell adhesion molecules that are responsible for the maintenance of the normal epithelial phenotype. Some studies have reported a correlation between carcinogenesis and changes in integrin expression, especially β1 integrin, however its role in prostate cancer (PC) is unclear. The aim of our study was to evaluate the expression of β1 integrin in localized PC and to correlate the pattern of expression with recurrence after surgical treatment. Methods For this case-control study, we retrospectively selected surgical specimens from 111 patients with localized PC who underwent radical prostatectomy. Recurrence was defined as a PSA level exceeding 0.2ng/mL after surgery, and the median follow-up was 123 months. Integrin expression was evaluated by immunohistochemistry in a tissue microarray containing two samples from each tumor. We employed a semiquantitative analysis and considered a case as positive when the expression was strong and diffusely present. Results: There was a loss of 11 cases during the tissue micro array assembling. β1 expression was positive in 79 of the 100 evaluated cases (79%). The univariate and multivariate analyses showed that the negative expression of β1 integrin was associated with biochemical recurrence (p = 0.047) and time to recurrence after radical prostatectomy (p = 0.023). When β1 was negative, the odds ratio for recurrence was 2.78 times higher than that observed in the positive cases [OR = 2.78, p = 0.047, IC 95% (1.01-7.66)]. Conclusions: The loss of β1 integrin immune expression was correlated with biochemical recurrence in patients treated with radical prostatectomy for localized PC.

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Objectives Validation of the Expanded Prostate Cancer Index Composite (EPIC) questionnaire translated to Portuguese. This is an evaluation tool of the effects of treatment on quality of life of patients with prostate cancer. Materials and Methods In order to translate and validate, several recommended methodological techniques in the literature were included: initial translation, synthesis of translation, board committee review and back translation. Sample included 40 patients with localized prostate cancer submitted to surgical retropubic radical prostatectomy from 2008 to 2010. Results The internal consistency analysis of the scales of the questionnaire resulted in alpha Cronbach coefficients “very good” (> 0.9) and “good” (> 0.8) to 8 of 14 domains. The higher coefficients (0.94) were assigned to sexual score, subscales incontinence and sexual function. Post-operatory follow-up ranged from 3 to 35 months, median 18.7 months. Conclusions The Brazilian version of EPIC is reliable and valid, and is a useful tool to evaluate the impact of retropubic radical prostatectomy on quality of life of Brazilian patients with localized prostate cancer, in national and internationals studies.

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Purpose To study the surgical outcomes of radical nephrectomy with thrombectomy and to determine prognostic factors for survival of Korean patients with renal cell carcinoma (RCC) and venous tumor thrombus. Materials and Methods A total of 124 patients with RCC and venous tumor thrombus who underwent radical nephrectomy and thrombectomy were included in this retrospective study. Cancer-specific survival (CSS) and recurrence-free survival (RFS) rates were analyzed retrospectively according to various prognostic factors. Results The median overall follow-up period for all patients was 29.0 months; the median survival period was 50.0 months. The 2-, 5- and 10-year CSS rates for all patients were 64.2%, 47.1% and 31.7%, respectively. Those for 76 patients (pN0/xM0) without metastasis at presentation were 80.9%, 64.5% and 44.9%, respectively. For all patients, lower body mass index (BMI), higher Fuhrman grade, presence of symptoms, perinephric fat invasion, invasion of inferior vena cava (IVC) wall, lymph node (LN) involvement and distant metastasis at presentation were independent predictors for decreased CSS on multivariate analysis, while thrombus level was not. For non-metastatic patients, lower BMI, presence of symptoms and tumor size were independently associated with decreased CSS. In terms of RFS, lower BMI, presence of perinephric fat invasion were prognostic factors for recurrence. Conclusions Our data suggest that obesity is independently associated with better survival or lower risk of tumor recurrence in Korean patients undergoing radical nephrectomy with tumor thrombectomy. Also, our results indicate that Fuhrman grade, presence of symptoms, perinephric fat invasion and invasion of IVC wall, LN involvement and distant metastasis at presentation are independent predictors for survival.

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Purpose In 76% of radical cystectomy patients there is discrepancy between the initial stage at transurethral resection and the final pathological stage of the cystectomy specimen. More specifically in contemporary series the absence of tumor at radical cystectomy specimens (stage pT0) is estimated at 5-25%. Our aim was to determine which factors contributed to the absence of tumor in our series of radical cystectomy patients. Materials and Methods Fifty one patients were submitted to radical cystectomy in our department over the last 10 years (January 2002-January 2012). A thorough analysis of the patients' files with no residual tumor on the cystectomy specimen (pT0) was performed. Possible factors contributing to such a result were described and a systematic analysis of the relevant literature was performed. Results Five patients had a pT0 stage after radical cystectomy. Four of them had transitional cell carcinoma and one of them had squamous cell carcinoma of the bladder on the initial transurethral resection. None of the tumors presented lymphovascular invasion. Four patients are still alive and one died 45 months postoperatively from a cardiac cause. Conclusions Four factors were identified in our study to contribute towards a pT0 cystectomy result. Those included the absence of lymphovascular invasion, the completeness of transurethral resection, the experience of the surgeon and the use of a standardized technique for the transurethral resection. The time to cystectomy in our series did not have a negative effect on pT0 final pathology result.

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Purpose To ensure patient safety and surgical efficiency, much emphasis has been placed on the training of laparoscopic skills using virtual reality simulators. The purpose of this study was to determine whether laparoscopic skills can be objectively quantified by measuring specific skill parameters during training in a virtual reality surgical simulator (VRSS). Materials and Methods Ten medical students (with no laparoscopic experience) and ten urology residents (PGY3-5 with limited laparoscopic experience) were recruited to participate in a ten-week training course in basic laparoscopic skills (camera, cutting, peg transfer and clipping skills) on a VRSS. Data were collected from the training sessions. The time that individuals took to complete each task and the errors that they made were analyzed independently. Results The mean time that individuals took to complete tasks was significantly different between the groups (p < 0.05), with the residents being faster than the medical students. The residents' group also completed the tasks with fewer errors. The majority of the subjects in both groups exhibited a significant improvement in their task completion time and error rate. Conclusion The findings in this study demonstrate that laparoscopic skills can be objectively measured in a VRSS based on quantified skill parameters, including the time spent to complete skill tasks and the associated error rate. We conclude that a VRSS is a feasible tool for training and assessing basic laparoscopic skills.

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Objectives To examine the effect of surgical approach on perioperative morbidity and mortality after partial nephrectomy. Materials and Methods Within the Nationwide Inpatient Sample, patients who underwent RAPN or LPN between October 2008 and December 2009 were identified. Propensity-based matching was performed to adjust for potential baseline differences between the two groups. The rates of intraoperative and postoperative complications, blood transfusions, prolonged length of stay, and in-hospital mortality, stratified according to RAPN vs. LPN, were compared. Results Overall, 851 (72.5%) patients underwent RAPN and 323 (27.5%) underwent LPN. For RAPN and LPN respectively, the following rates were recorded in the propensity-score matched cohort: blood transfusions, 4.5 vs. 6.8% (p = 0.223); intraoperative complications, 5.2 vs. 2.6% (p = 0.096); postoperative complications, 10.6 vs. 13.5% (p = 0.268); prolonged length of stay, 6.8 vs. 9.4% (p = 0.238); in-hospital mortality, 0.0 vs. 0.0%. Conclusions RAPN has supplanted LPN as the predominant minimally invasive surgical approach for renal masses. Perioperative outcomes after RAPN and LPN are comparable. Interpretation of these findings needs to take into account the lack of adjustment for case complexity and surgical expertise.

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Purpose The aim of the study was to evaluate the efficacy and safety of bilateral single-session retrograde intrarenal surgery in the treatment of bilateral renal stones. Materials and Methods From December 2008 to February 2012, 42 patients who had undergone bilateral single-session retrograde intrarenal surgery (RIRS) and laser lithotripsy were included in the study. The procedures were performed in the lithotomy position on an endoscopy table under general anesthesia, beginning on the side in which the stone size was smaller. Plain abdominal radiography, intravenous urograms (IVU), renal ultrasonography (USG) and / or non-contrast tomography (CT) scans were conducted for all patients. The success rate was defined as patients who were stone-free or only had residual fragment less than 4 mm. Results A total of 42 patients (28 male, 14 female) with a mean age 39.2 ± 14.2 were included in the present study. The mean stone size was 24.09 ± 6.37 mm with a mean operative time of 51.08 ± 15.22 minutes. The stone-free rates (SFR) were 92.8% and 97.6% after the first and second procedures, respectively. The average hospital stay was 1.37 ± 0.72 days. In two patients (4.7%), minor complications (Clavien I or II) were observed, whereas no major complications (Clavien III-V) or blood transfusions were noted in the studied group. Conclusions Bilateral single-session RIRS and laser lithotripsy can be performed safely and effectively with a high success rate and low complication rate in patients with bilateral renal stones.

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Introduction Published data suggest that patients with acromegaly have an increased prevalence of prostate disorders. Objective To evaluate prostatic disorders in acromegalic patients comparing these results after one year of treatment of acromegaly and with a group of healthy men. Materials and Methods This study was composed of two parts: sectional study comparing patients with healthy controls (baseline) and prospective, longitudinal study (at baseline and after one year of treatment). Forty acromegalic patients were enrolled and evaluated at baseline and after one year with the application of international prostatic symptoms score (IPSS), digital rectal examination, measurements of growth hormone (GH), insulin-like growth factor-I (IGF-I), insulin-like growth factor-binding protein-3 (IGFBP-3), sex hormone-binding globulin (SHBG), prolactin, luteinizing hormone (LH), follicle-stimulating hormone (FSH), total testosterone, total and free prostate-specific antigen (PSA) levels and prostate ultrasonography (US). Thirty healthy men were selected as control group. Results We stratified patients and controls according to age, considering 40 years-old as cut off. Healthy controls under 40 had IPSS values lower than acromegalic patients. When considering only older patients and controls prostate hyperplasia and structural abnormalities were more frequent in acromegalics. After one year of treatment there was significant decrease in GH, IGF-I and prostate volume in acromegalics over 40 years-old. Conclusions Acromegalics under 40 have more urinary symptoms according to IPSS and above 40 years-old higher frequency of structural changes and increased prostate volume than healthy men. Significant reduction of GH and IGF-I levels during treatment of acromegaly leads to decrease in the prostate volume.

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Purpose Nocturnal enuresis is a serious health problem affecting a significant portion of the population. In this study, we investigated the frequency of punishment methods in nocturnal enuresis (NE) in Turkey and its relationship with other parameters. Materials and Methods A total of 501 children (301 boys and 200 girls) who were admitted to our outpatient clinic due to nocturnal enuresis were included in the study. Mean age was 9.39 years (range 5-18). Prepared questionnaire form inquiring educational status of the family, frequency and implementation and duration of punishment methods was applied to patients and families. Results At least one punishment method was applied to 291 (58.1%) of children with NE. Punishment methods of parents were detected as condemnation (257 patients, 51.3%), depriving desires of the child (120 patients, 23.9%), humiliating the child in the presence of other children (113 patients, 22.6%), reprimanding- threatening with punishment (203 patients, 40.5%). This application was found to continue for longer than 1 year in 52% of punished children. Families graduated of high school and above were found to use punishment methods significantly more than others. Conclusion According to the results of our study, a quite high proportion of enuretic children were detected to be exposed to punishment methods. Even, some parents consider that these methods are a part of nocturnal enuresis treatment. We, the doctors, should endeavor more for raising awareness of the community in order to diminish this worrisome behavior.

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Introduction One of the main problems faced by surgeons involved in male genitalia surgeries, in particular in children with hypospadias, is the type of dressing and its use during the post-operatory period. Materials and Methods From a multidisciplinary project involving the use of sugarcane biopolymer membrane developed in the last 10 years, produced by bacterial action over sugarcane molasses, we developed a multiperforated pellicle that, when applied around the penis, protects the surgical field. It is a proven inert material that does not induce any reaction on the surgical field and can be left in situ maintaining the same characteristics during a long period of time without the need of replacement. This multiperforated tape can involve several times the penis shaft and due to its adhesiveness it hardly loosens. We compared the use of this dressing with a commercial one (made by polyurethane). Thirty patients with hypospadias were randomly selected for the use of this new type of dressing in the last 18 months. A similar group of patients used a similar commercial dressing made of polyurethane (Tegaderm©) according to the same criteria of use. For safety reasons, we applied one or two sutures without the inclusion of the skin using an absorbable suture in order to prevent early detachment. A small gauze was left for 24 hours in order to absorb any possible bleeding. We recommended the irrigation of the dressing with water or saline at least three or four times a day and the patient was allowed to bath. The dressing did not need any special care and if not removed it usually detached spontaneously after 10 to 14 days. Results The tolerance to the material was satisfactory and there were no adverse reactions on the penile surface. In two cases of the biopolymer group the dressing detached spontaneously on the first and third days, respectively. In two cases of the polyurethane group it was observed major edema. The grade of satisfaction of the patients and their relatives was excellent on the biopolymer group. Conclusion This dressing produced by a polysaccharide is a promising alternative for the treatment of children and adolescents submitted to genital surgery. Its main advantage is the possibility of several washes along the day without the need of any other manipulation.

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Objective To assess the integration of decellularized heterologous collagen matrices into the urethra, when implanted with no cells or when seeded with autologous smooth muscle cells. Materials and Methods Eighteen New Zealand rabbits were randomly assigned to two groups: Group I (n = 9) - animals undergoing urethral segment resection with interposition of a patch of heterologous collagen matrix seeded with autologous smooth muscle cells; Group II (n = 9) - animals undergoing resection of a urethral segment with interposition of a decellularized heterologous collagen matrix patch. Two animals from each group were sacrificed on postoperative days seven, fourteen and twenty-eight; three animals from each group were sacrificed at the end of three postoperative months. At the end of the third month one animal from each group underwent urethroscopy for urethral integrity assessment and one animal from each group had its microcirculation image captured by a SDF device (Side-stream Dark Field - Microscan Analysis Software). One animal from each group in each euthanasia period underwent cystourethrography so as the urethra could be viewed at flow time. The matrices integration was assessed through histological examination using hematoxylin and eosin (H&E), Masson trichrome (MT), Picrosirius red and Von Willebrand staining. In a blind study with two pathologists all the slides were studied. Results The matrices whether seeded or not with autologous muscle cells were able to restore the architecture of the urethra, but were eliminated from the first week on, before incorporation. Microcirculation of the neourethra, at the end of the third month, showed the same characteristics as a normal urethra in both groups of animals. Conclusion Natural heterologous matrices implanted in the urethra as onlay graft were not incorporated into its walls but were able to fully restore the cell architecture of the organ, regardless of being seeded or not with autologous muscle cells.

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Objective To assess the morphological changes of penile vascular structures and the corpus cavernosum area in alloxan-induced diabetic rabbits. Materials and Methods Twenty male rabbits (2 months old) were divided into two groups with 10 rabbits each, the control group (CG) and the diabetic group (DG). The animals from DG received an intravenous injection of alloxan (100mg/kg) to induce the diabetes. Ten weeks after the induction of diabetes, all animals were euthanized. Two fragments of the penile shaft were harvested and samples were processed and paraffin embedded. Sections (5µm) were cut and stained for histological and immunohistochemical markers. Results Nuclear protrusion toward the lumen, and cytoplasmic vacuolization were observed in the tunica intima of the dorsal artery of the penis in DG. The thicknesses of the tunica media increased significantly in DG (p = 0.0350). It was also observed a significant increase in the area of the tunica media (p = 0.0179). There was no significant change in smooth muscle cell density in the tunica media of the dorsal artery of the penis (p = 0.0855). The collagen fiber pattern of the tunica adventitia of the dorsal artery of the penis was different between the control and diabetic groups. There was a significant decrease in the area occupied by the cavernous sinuses in DG (p = 0.0013). Conclusion Alloxan-induced diabetes mellitus in rabbits promotes important changes in penile vascular structures, thereby decreasing blood supply and affecting penile hemodynamics, leading to erectile dysfunction.

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The case of a 71-year-old woman who presented with one year history of pelvic pain and occasional dysuria is reported. Computed tomography and Magnetic Resonance Imaging revealed a well defined intramural bladder mass. The histological findings of the surgical specimen confirmed a leiomyoma of the urinary bladder. The clinical presentation, imaging findings and management of this relatively rare benign tumor are discussed.

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Objective About 10% of renal pelvis are bifids and not so there is a larger index of kidney disease over the normal pelves. The laparoscopy and minimally invasive techniques treat the ureteropelvic junction disease in a low agressive manner. We showed a video of an atypical pyeloplasty of ureteropelvic junction obstruction of a lower unit. The patient is a 33 year-old woman with an intermitent lumbar pain for 3 years. Your image exams showed a bifid left pelvis with a stenosis of the lower unit. We chose to do the fix of this pathology laparoscopically. Materials and Methods We positioned the patient in a right lateral decubitus and 3 trocars was placed, we identify the obstructed junction and a terminolateral anastomosis was performed. Results: The procedure lasted 95 minutes, with little blood loss and the patient was discharged in 2 days. We withdraw the double J catheter after 1 month, a pyelography and a ureteroscopy was performed which showed a pervious anastomosis. After 2 months of follow-up the patient is doing well. Conclusions As far as we know, this is the first case of literature with correction by laparoscopy. The stenosis of ureteropelvic junction in the lower unit of a bifid pelvis can be corrected effectively by laparoscopic surgery.

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Introduction Rare foci of sperm production may be found in up to 60% of men with nonobstructive azoospermia (NOA). Sperm production, if present, is minimal for sperm appearance in the ejaculate. Given that there are no treatment options to restore fertility, sperm retrieval is the only alternative to find testicular sperm than then can be used for in vitro fertilization (IVF). Among sperm acquisition methods, micro-TESE has higher success rates at obtaining sperm compared with testicular sperm extraction and testicular sperm aspiration. Materials and Methods This video describes the operative aspects of micro-TESE, performed on an outpatient basis, in a man with NOA and history of cryptorchidism in whom orchidopexy was performed at age 6. The concept of micro-TESE is to identify areas of sperm production within the testes with the aid of optical magnification (15-25X) and based on the size and appearance of the seminiferous tubules (ST). Conclusion Micro-TESE allowed the identification and extraction of sperm-containing STs with minimum tissue excision and marked reduction in time processing of testicular specimens for sperm injection.