Resumo em Inglês:

In spite of considerable efforts to identify effective treatments for urolithiasis, this is a goal yet to be achieved. This review summarizes experimental and clinical data evaluating the effect of the plant Phyllanthus niruri, a plant with worldwide distribution, as a potential agent to prevent and/or to treat urolithiasis The review is based on data from the literature and on the results obtained by our group from either in vivo/in vitro experiments or clinical studies. Phyllanthus niruri has been shown to interfere with many stages of stone formation, reducing crystals aggregation, modifying their structure and composition as well as altering the interaction of the crystals with tubular cells leading to reduced subsequent endocytosis. The clinical beneficial effects of Phyllanthus niruri may be related to ureteral relaxation, helping to eliminate calculi or to clear fragments following lithotripsy, or also to a putative reduction of the excretion of urinary crystallization promoters such as calcium. No adverse renal, cardiovascular, neurological or toxic effects have been detected in either of these studies. Altogether, these studies suggest a preventive effect of Phyllanthus niruri in stone formation or elimination, but still longer-term randomized clinical trials are necessary to confirm its therapeutic properties.

Resumo em Inglês:

PCA3 is a prostate specific, nonprotein coding RNA that is significantly over expressed in prostate cancer, without any correlation to prostatic volume and/or other prostatic diseases (e.g. prostatitis). It can now easily be measured in urine with a novel transcription-mediated amplification based test. Quantification of PCA3 mRNA levels can predict the outcome of prostatic biopsies with a higher specificity rate in comparison to PSA. Several studies have demonstrated that PCA3 can be used as a prognostic marker of prostate cancer, especially in conjunction with other predictive markers. Novel PCA3-based nomograms have already been introduced into clinical practice. PCA3 test may be of valuable help in several PSA quandary situations such as negative prostatic biopsies, concomitant prostatic diseases, and active surveillance. Results from relevant clinical studies, comparative with PSA, are warranted in order to confirm the perspective of PCA3 to substitute PSA.

Resumo em Inglês:

PURPOSE: The incidence of renal cell carcinoma (RCC) has been rising by 2.3 to 4.3% every year over the past three decades. Previously, RCC has been known as the internist’s tumor; however, it is now being called the radiologist’s tumor because 2/3 are now detected incidentally on abdominal imaging. We compared patients who were treated toward the end of the 20th century to those treated during the beginning of the 21st century with regard to RCC size and type of surgical treatment. MATERIALS AND METHODS: The study included 226 patients. For analysis of tumor size, we considered a cut point of < 4 cm and > 4 cm. For analysis of type of surgery performed, we considered radical and partial nephrectomy. RESULTS: After the turn of the century, there was a reduction of 1.57 ± 0.48 cm in the size of the RCC that was operated on. Nephron sparing surgeries were performed in 17% of the cases until the year 2000, and 39% of the tumors were < 4 cm. From 2001, 64% of the tumors measured < 4 cm and 42% of the surgeries were performed using nephron sparing techniques. Mean tumor size was 5.95 cm (± 3.58) for the cases diagnosed before year 2000, and cases treated after the beginning of 21st century had a mean tumor size of 4.38 cm (± 3.27). CONCLUSIONS: Compared with the end of the 20th century, at the beginning of the 21st century due to a reduction in tumor size it was possible to increase the number of nephron sparing surgeries.

Resumo em Inglês:

PURPOSE: To evaluate prospectively the results obtained in 55 patients undergoing laparoscopic pyeloplasty through transperitoneal access. MATERIALS AND METHODS: From January 2005 to July 2009, fifty-five patients between 13 and 64 years old, were treated for ureteropelvic junction (UPJ) stenosis via a transperitoneal laparoscopy. All patients had clinical symptoms of high urinary obstruction and hydronephrosis confirmed by imaging methods. Anderson-Hynes dismembered pyeloplasty was performed in 51 patients and Fenger technique in the other 4 cases. Patients were clinically and imaging evaluated in the postoperative period at 3 and 6 months and then followed-up annually. RESULTS: The operative time ranged from 95 to 270 min. The mean hospital stay was 2 days. The average blood loss was 170 mL. The time to return to normal activities ranged from 10 to 28 days. Anomalous vessels were identified in 27 patients, intrinsic stenosis in 23 patients and 5 patients had high implantation of the ureter. Laparoscopic pyelolithotomy was successfully performed in 6 patients with associated renal stones. That series monitoring ranged from 1 to 55 months. One patient had longer urinary fistula (11 days), 3 patients had portal infection and 6 patients had prolonged ileus. There was one conversion due to technical difficulties. From the later postoperative complications, 2 patients had re-stenosis, one determined by Anderson-Hynes technique and the other by Fenger technique. The success rate was 95.65%. CONCLUSIONS: Laparoscopic pyeloplasty has functional results comparable to conventional open technique. It offers less morbidity, with aesthetic and post-operative convalescence benefits and lower complication rates.

Resumo em Inglês:

PURPOSE: Define a group of patients with newly diagnosed prostate cancer, whose risk of bone metastasis is low enough to omit a bone scan staging study. MATERIALS AND METHODS: From 2003 to 2009, the medical records of patients who were newly diagnosed with prostate cancer were retrospectively reviewed. The data collected included: age, digital rectal examination, serum prostate specific antigen (PSA), Gleason score, clinical T stage, and bone isotope scan. Patients were divided into two groups according to the results of bone isotope scan; positive group and negative group. A univariate and multivariate binary logistic regression was used to analyze the results. RESULTS: Of the 106 patients, 98 had a complete data collection and were entered into the study. The median age of the patients was 70.5 years and patients with a positive bone scan was 74 years, significantly higher than for patients with negative scans (69 years) (p = 0.02). Bone metastasis was detected in 39 cases (39.7%). In all patients with clinical T1-2 stage, a Gleason score of < 8 and PSA = 20 ng/mL, the bone isotope scans were negative. In univariate analysis, PSA (> 20 ng/mL) and Gleason score (> 7) were independently predictive of positive bone scan, while clinical stage was not. CONCLUSION: Staging bone scans can be omitted in patients with a PSA level of = 20 ng/mL, and Gleason score < 8. Our results suggest that by considering the Gleason score and PSA, a larger proportion of patients with prostate cancer could avoid a staging bone scan.

Resumo em Inglês:

PURPOSE: Evaluate the results of urinary continence on patients who had undergone radical perineal prostatectomy (RPP) for clinically localized prostate cancer. MATERIALS AND METHODS: We analyzed the continence data of 120 patients with pathology of cT1-cT2N0M0 prostate cancer and who had undergone RPP. Continence was assessed on the day of catheter removal, at the end of the first and third month, and the first year postoperatively. The patients who were continent immediately after catheter removal were classified in the group of “immediately continent” while the patients who became continent during the 3 postoperative months were classified as “early continent.” RESULTS: Mean duration of catheterization was 10 (10-25) days. Of 120 patients, 44 (36.7%) were immediately continent. At the end of the first and third months, 65 (54.1%) and 87 (72.5%), respectively, were early continent. At the one-year follow-up, 95.3% of 107 cases whose one-year follow-up data were available were continent. When the relationship between patients’ age and continence was analyzed, it was found that the early continence rates were 77.7% (7/9), 73.3% (33/45), 73.4% (36/49), and 64.7% (11/17) in the groups of = 49, 50-59, 60-69, and = 70 years, respectively (p = 0.68). CONCLUSIONS: The majority of patients who underwent RPP rapidly regained continence within 3 months. RPP is an exceptional alternative approach for radical surgery in the treatment of localized prostate cancer.

Resumo em Inglês:

PURPOSE: To observe hypogonadal men undergoing testosterone replacement therapy (TRT) and assess racial differences in hypogonadal improvement and prostate-specific antigen (PSA) levels. MATERIALS AND METHODS: In a retrospective analysis, 75 hypogonadal men were followed for an average 34 months after initiating TRT. Total testosterone and PSA levels were assessed every 6 months, and patients diagnosed with prostatitis or prostate cancer during treatment were excluded. RESULTS: For 16 African American men, the average age at diagnosis of hypogonadism was 53.5 years, compared with 57.8 years in 59 Caucasian men (p = NS). Pre- and post-treatment testosterone was 219 ng/dL and 310 ng/dL in African American men, and 247 ng/dL and 497 ng/dL in Caucasian men (p = NS). Symptomatic response was 81% in African American men and 93% in Caucasian men (p = NS). Baseline PSA level was 1.32 ng/mL in African American men and 1.27 ng/mL in Caucasian men, and there was no significant difference in PSA between racial groups at 6-month intervals, although there was a small decreasing trend in the PSA of African Americans compared with Caucasians. CONCLUSIONS: Hypogonadal African American men have a similar normalization of testosterone and symptomatic response as hypogonadal Caucasian men, and PSA levels remain stable over time in both groups. In this hypogonadal cohort, in contrast to studies of eugonadal men, higher PSA levels in African Americans were not observed.

Resumo em Inglês:

PURPOSE: To determine the prevalence of different approaches to the difficult urethral catheterization (DUC) among urology residents (UR) in the United States (US). MATERIALS AND METHODS: An email invitation to participate in an online survey regarding DUC was sent to 267 UR and to 22 urology program coordinators for them to forward to their residents. 142 UR completed the survey. RESULTS: After the initial unsuccessful attempt by a nurse, 92% of UR attempted a catheter prior to resorting to other modalities. The most common choice of the first catheter was a Coude (76%) size 18F (51%). For situations where multiple sizes and types of catheters (12 - 20F) were used without success, 3 scenarios were proposed: 1) Catheter passed the bulbomembranous urethra (BMU) and patient had previous history of transurethral resection of the prostate or radical retropubic prostatectomy, 2) Catheter passed the BMU and no urologic history, 3) Catheter did not pass the BMU and no urologic history. Flexible cystoscopy was used in 74%, 62% and 63%; blind passage of a glidewire was second with 15%, 23% and 20%; and blind use of filiforms and followers was chosen in 7%, 9% and 9% of the scenarios respectively. CONCLUSIONS: The most common approach to the DUC among UR in the US involves using an 18F Coude catheter first. After trying one or more urethral catheters, UR most commonly resort to flexible cystoscopy as opposed to the blind placement of glide wires or filiforms/followers.

Resumo em Inglês:

PURPOSE: To confirm the feasibility of the laparoendoscopic Pfannenstiel nephrectomy using conventional laparoscopic instruments. MATERIALS AND METHODS: Since March 2009, laparoscopic nephrectomy through a Pfannenstiel incision has been performed in selected patients in our service. The Veress needle was placed through the umbilicus which allowed carbon dioxide inflow. One 5 mm (or 10 mm) trocar was placed at the umbilicus for the laparoscope, to guide the placement of three trocars over the Pfannenstiel incision. Additional trocars were placed as follows: a 10 mm in the midline, a 10 mm ipsilateral to the kidney to be removed (2 cm away from the middle one), and a 5 mm contralateral to the kidney to be removed (2 cm away from the middle one). The entire procedure was performed using conventional laparoscopic instruments. At the end of the surgery, trocars were removed and all three incisions were united into a single Pfannenstiel incision for specimen retrieval. RESULTS: Five nephrectomies were performed following this technique: one atrophic kidney, one kidney donation, two renal cancers and one bilateral renal atrophy. Median operative time was 100 minutes and median intraoperative blood loss was 100 cc. No intraoperative complications occurred and no patients required blood transfusion. Median length of hospital stay was 1 day (range 1 to 2 days). CONCLUSIONS: The use of the Pfannenstiel incision for laparoscopic nephrectomy seems to be feasible even when using conventional laparoscopic instruments, and can be considered a potential alternative for traditional laparoscopic nephrectomy.

Resumo em Inglês:

PURPOSE: To compare the efficacy and safety of the electromagnetic lithotripter in the treatment of pediatric lithiasis to that of the earlier electrohydraulic model. MATERIALS AND METHODS: Two groups of children with lithiasis aged between 10 and 180 months who underwent extracorporeal shock wave lithotripsy (ESWL). In the first group (26 children), ESWL was performed by using the electrohydraulic MPL 9000X Dornier lithotripter between 1994 and 2003 while in the second group (19 children) the electromagnetic EMSE 220 F-XP Dornier lithotripter was used from April 2003 to May 2006. RESULTS: In the first group, 21/26 children (80.7%) were stone free at first ESWL session. Colic pain resolved by administration of an oral analgesic in 6 (23%), brief hematuria (< 24 h) resolved with increased fluid intake in 5 (19.2%), while slightly elevated body temperature (< 38°C) occurred in 4 (15.3%). Four children (15.3%) failed to respond to treatment and were treated with ureteroscopy. In the second group 18/19 children were completely stone free at first ESWL session (94.7%). Complications were infrequent and of minor importance: colic pain treated with oral analgesic occurred in 1 (5.26%), brief hematuria (< 24 h), resolved with increased fluid intake in 4 (21%) and slightly elevated body temperature (< 38°C) monitored for 48 hours occurred in 6 (31.5%). Statistical analysis showed that electromagnetic lithotripter is more efficacious and safer than the earlier electrohydraulic model. CONCLUSIONS: Technological development not only has increased efficacy and safety of lithotripter devices in treating pediatric lithiasis, but it also provided less painful lithotripsy by eliminating the need for general anesthesia.

Resumo em Inglês:

PURPOSE: To evaluate the efficacy of botulinum toxin type A injections in the detrusor muscle in patients with spinal cord injury and urinary incontinence due to detrusor overactivity and refractory to anticholinergic agents. MATERIALS AND METHODS: We prospectively evaluated 22 patients with spinal cord injuries, whose bladders were emptied by intermittent catheterization. All patients had detrusor overactivity and urinary incontinence that proved difficult to treat, despite using high doses of two different anticholinergics. The pre-treatment assessment included a complete urodynamic study and ultrasonography of the kidneys and urinary tract. A one-month follow-up was completed with urodynamic evaluation and the clinical response was evaluated through outpatient consultations and telephone contact. RESULTS: After the procedure, the maximum cystometric capacity and the bladder reflex volume increased, whereas the maximum detrusor pressure and compliance decreased. The mean duration of continence was 7 ± 7 months. In 18 patients (81.8%), it was necessary to administer anticholinergics to achieve continence. Five patients (22.7%) had indication of reinjection, and augmentation cystoplasty was indicated in 9 patients (40.9%). CONCLUSION: The use of botulinum toxin in the treatment of neurogenic detrusor overactivity refractory to anticholinergics is an option before more invasive treatments, such as augmentation cystoplasty, are attempted. In our study as well as in the literature, there was improvement in most urodynamic parameters. Overall, 40.9% of patients underwent augmentation cystoplasty and 81.8% of patients needed anticholinergic agents to reach urinary continence. Further studies are necessary to improve the procedure and to achieve better clinical results.

Resumo em Inglês:

PURPOSE: To design a simple, cost-effective system for gaining rapid and accurate calyceal access during percutaneous nephrolithotomy (PCNL). MATERIALS AND METHODS: The design consists of a low-cost, light-weight, portable mechanical gantry with a needle guiding device. Using C-arm fluoroscopy, two images of the contrast-filled renal collecting system are obtained: at 0-degrees (perpendicular to the kidney) and 20-degrees. These images are relayed to a laptop computer containing the software and graphic user interface for selecting the targeted calyx. The software provides numerical settings for the 3 axes of the gantry, which are used to position the needle guiding device. The needle is advanced through the guide to the depth calculated by the software, thus puncturing the targeted calyx. Testing of the system was performed on 2 target types: 1) radiolucent plastic tubes the approximate size of a renal calyx (5 or 10 mm in diameter, 30 mm in length); and 2) foam-occluded, contrast-filled porcine kidneys. RESULTS: Tests using target type 1 with 10 mm diameter (n = 14) and 5 mm diameter (n = 7) tubes resulted in a 100% targeting success rate, with a mean procedure duration of 10 minutes. Tests using target type 2 (n = 2) were both successful, with accurate puncturing of the selected renal calyx, and a mean procedure duration of 15 minutes. CONCLUSIONS: The mechanical gantry system described in this paper is low-cost, portable, light-weight, and simple to set up and operate. C-arm fluoroscopy is limited to two images, thus reducing radiation exposure significantly. Testing of the system showed an extremely high degree of accuracy in gaining precise access to a targeted renal calyx.

Resumo em Inglês:

PURPOSE: The etiology of obstructive bladder dysfunction includes free radical damage to mitochondria. Feeding rabbits a standardized grape suspension protects the ability of the bladder to contract and empty in part by preventing mitochondrial damage, thus maintaining smooth muscle and mucosal metabolism. The objective of the current study is to determine the direct effect of this grape suspension on the response of mitochondria to the oxidative effects of hydrogen peroxide. MATERIALS AND METHODS: Six male rabbits were anesthetized with sodium pentobarbital and the bladders excised. Four full thickness strips were obtained for contractile studies and the balance separated into smooth muscle and mucosa compartments by blunt dissection. The effect of hydrogen peroxide on the contractile response to field stimulation was quantitated. Each tissue was homogenized and the effects of increasing concentrations of hydrogen peroxide in the presence and absence of grape suspension on citrate synthase activity was determined. RESULTS: Citrate synthase activity was significantly higher in the mucosa than in the muscle. The grape suspension had no effect on control citrate synthase activity. However, the grape suspension provided significant protection of both smooth muscle and mucosal citrate synthase activity. CONCLUSIONS: These studies support the conclusion that the grape suspension provides direct protection of mitochondrial function.