Antonio Gugliotta

Digital Rectal Examination Standardization for Inexperienced Hands: Teaching Medical Students

Objectives. To standardize digital rectal examination (DRE) and set how it correlates with the comprehensive evaluation of lower urinary tract symptoms (LUTS). Methods. After scaled standardization of DRE based on fingertips graphical schema: 10 cubic centimeters—cc for each fingertip prostate surface area on DRE, four randomly selected senior medical students examined 48 male patients presenting with LUTS in an outpatient clinical setting, totaling 12 DRE each. Standardized DRE, international prostate symptom score (IPSS), serum PSA, transabdominal ultrasound (US), urodynamic evaluation, and postvoid residue were compared. Results. The mean and median PVs were US—45 and 34.7 cc (5.5 to 155) and DRE—39 and 37.5 cc (15 to 80). Comparing DRE and US by simple linear regression: US PV = 11.93 + 0.85 × (DRE PV); P = 0.0009. Among patients classified as nonobstructed, inconclusive, and obstructed, the US PVs were 29.8, 43.2, and 53.6 cc (P = 0.033), and DRE PVs were 20, 35, and 60 cc (P = 0.026), respectively. Conclusion. This is the first attempt to DRE standardization focusing on teaching-learning process, establishing a linear correlation of DRE and US PVs with only 12 examinations by inexperienced hands, satisfactorily validated in an outpatient clinical setting.

Litotricia extracorpórea en niños: Eficacia y evaluación a largo plazo de la lesión del parénquima renal mediante gammagrafía con DMSA-99mTc

Objetivo: determinar la eficacia de la litotricia extracorporea por ondas de choque (LEOC) y los posibles efectos nocivos en el parenquima renal de ninos sometidos a tratamiento de la litiasis renal mediante gammagrafia renal con acido dimercaptosuccinico marcado con 99mTc (DMSA-99mTc). Pacientes y metodos: desde enero de 2004 a noviembre de 2007 se sometio a 18 ninos (de 3-10 anos) a LEOC (Philips-Dornier) por urolitiasis renal. A todos los pacientes se les realizo una evaluacion preoperatoria, que incluyo una exploracion fisica, cultivo de orina, pruebas de imagen y gammagrafia renal con DMSA-99mTc. La evaluacion tras el tratamiento consto de una exploracion clinica, determinacion de la presion arterial, cultivo de orina, ecografia renal y DMSA-99mTC, repetidas a los 3, 6 y 12 meses, que se compararon con las exploraciones obtenidas antes de la LEOC para determinar posibles cambios morfologicos o funcionales. Resultados: se fragmentaron con exito los calculos en todos los casos; en 9 pacientes (50%) con una sesion de LEOC, en 6 (33%) con dos sesiones y en tres pacientes (17 %) con tres sesiones de LEOC. Solo un paciente (5%) mostro un cambio de tamano del rinon derecho con descenso de la funcion tubular, sin hipertension ni otros cambios importantes despues de tres sesiones de LEOC y 6 meses de seguimiento. En los demas casos se comprobo la ausencia de hipertension hasta los 12 meses de seguimiento, de hematomas en la ecografia o de cicatrices renales importantes en las exploraciones gammagraficas. Conclusion: la LEOC es eficaz y segura para tratar la litiasis renal en ninos. Pueden aparecer lesiones del parenquima renal precozmente tras el tratamiento, pero estas lesiones son pasajeras y se resuelven espontaneamente en practicamente todos los casos. No existen generalmente lesiones renales irreversibles asociadas con la LEOC, ni siquiera despues del periodo de seguimiento con exploracion clinica y ecografica y gammagrafia con DMSA-99mTc.

Extracorporeal lithotripsy in children. The efficacy and long-term evaluation of renal parenchyma damage by 99mTc-DMSA scintigraphy

Abstract Purpose To determine the effectiveness of extracorporeal shock-wave lithotripsy (ESWL) and possible deleterious effects on renal parenchyma of children subjected to treatment of renal lithiasis, using renal scintigraphy with 99mTc dimercapto-succunic acid (DMSA). Patients and methods From January 2004 to November 2007, 18 children (age 3–10 years) underwent ESWL (Philips-Dornier) for kidney urolithiasis. All patients underwent preoperative evaluation, including physical examination, urine culture, image exams and renal scintigraphy with 99mTC-DMSA. Evaluation after treatment consisted of a clinical examination, blood pressure measurement, urine culture, renal ultrasound and 99mTCDMSA, repeated at 3, 6 and 12 months, which were compared to the scans obtained before ESWL to determine possible morphological or functional changes. Results Success in the stones fragmentation was achieved in all cases – in 9 patients (50%) with one session of ESWL, in 6 (33%) with two sessions and in 3 patients (17%) with 3 sessions of ESWL. Only one patient (5%), after three sessions of ESWL and 6 months of follow-up showed change in size of right kidney with a decrease in tubular function, without hypertension or other major changes. In the other cases, there was absence of hypertension up to 12 months of follow-up, absence of renal hematomas detected by ultrasound or significant renal scars in scintigraphic examinations. Conclusion ESWL is effective and safe for treating renal lithiasis in children. Renal parenchyma lesions may occur early after treatment, but these lesions are transients and resolve spontaneously in virtually all cases; generally, there are no irreversible renal lesions associated with ESWL, even after the follow-up period with clinical examination, ultrasound examination and 99mTc-DMSA scintigraphy.

Diethylstilbestrol 1 mg in the Treatment of Acute Urinary Retention due to Prostatic Obstruction in the Elderly: A Preliminary Study

Patients who failed a catheter-free trial after acute urinary retention and one week of full dose alpha-blocker and 5-alpha-reductase inhibitor were offered Diethylstilbestrol 1 mg plus Aspirin 100 mg over 4 weeks. Prostate volume, age, serum creatinine, and initial retention drained urine volume were recorded. After excluding cardiovascular morbidity (n = 7), upper urinary tract dilation (n = 3), compromised renal function (n = 2), urinary tract infection (n = 2), neurological diagnosis (n = 2), or preferred immediate channel transurethral resection of prostate (n = 5), 48 of 69 consecutive patients ≥70 years were included. Mean age was 76.6 years (70–84), mean prostate volume 90 cm3 (42–128), and mean follow-up 204 days; 58% (28/48) were passing urine and 42% (20/48) were catheter dependent after 4 weeks Diethylstilbestrol trial. Mean age and drained urine volume of catheter dependent patients were 82.4 years and 850 mL compared with 74.6 years and 530 mL in catheter-free men, respectively. Age and drained urine volume were independent predictors of catheter-free trial (both P < 0.01). Seventy-five percent (6/8) of patients 80 years and older were catheter dependent. Transient nipple/breast tenderness and gynecomastia were the only adverse effects reported by 21% (10/48) and 4% (2/48), respectively. No patient presented severe complications.

Long-Term Results of Anderson–Hynes Pyeloplasty in Children: How Long Follow-Up Is Necessary?

PURPOSE After a successful pyeloplasty at 3 to 6 months, the question remains whether children need a long follow-up. METHODS The medical charts of patients with long-term follow-up (> 5 years), who underwent dismembered pyeloplasty for uretero-pelvic junction obstruction (UPJO) from May 1998 to May 2007, excluding those with bilateral UPJO, solitary kidney, associated vesicoureteral reflux or other abnormalities, and inconclusive renogram due to poor renal function, were retrospectively reviewed. Ultrasonography, differential renal function (DRF, DMSA), and renal drainage on diuretic renography (diethylene-triamine-pentaacetate technetium-99 or DTPA-Tc99) were performed at 3 and 6 months every year. RESULTS Complete data were available for 28 consecutive patients (28 renal unities) with 2 months to 12 years (mean age, 2.4 years) at surgery, of whom 21 (75%) were boys, 17 diagnosed prenatally (61%) and 18 unities (64.3%) were left, with median follow-up of 10.7 years. Images were graded according to the Society for Fetal Urology grading system: Grade III in 11 (49%) and grade IV in 17 (61%). All cases presented > 10% DRF (DMSA) and obstructed DTPA-Tc99. The T1/2 (the half-time of drainage) less than 20 minutes at 3 months was found in 21 cases (75%) and less than 25 minutes in 7 cases (25%). Renal function and patency were maintained during follow-up for all units with 8% maximum fluctuation of DRF. One index case (3.6%) of renal function deterioration presented DRF fluctuation > 8% at 3 months (from 23 to 32%) and progressive hydronephrosis and indeterminate DTPA at 6 months. CONCLUSIONS Satisfactory diuretic renogram at 3 to 6 months after pyeloplasty with maintained renal function and stable hydronephrosis suggests no need for further follow-up and indicates no functional loss with time. More than 8% DRF fluctuation might be a significant cutoff for further intervention aiming nephron preservation.

Comparative, prospective, and randomized study between urotherapy and the pharmacological treatment of children with urinary incontinence

ABSTRACT Objective: To verify and compare the results of behavioral modification plus pelvic floor muscle training and behavioral modifications plus oxybutynin chloride in children with nonmonosymptomatic enuresis. Methods: A total of 47 children were randomized using opaque and sealed envelopes sequentially numbered. Group I was composed of 21 children who underwent antimuscarinic treatment (oxybutynin), and Group II was composed of 26 patients who underwent pelvic floor muscle training. Both groups were instructed as to behavioral modifications. Results: The voiding diary results were compared each month between Groups I and II. In the first month of treatment, children in Group I presented 12.2 dry nights, 13.4 in the second month, and 15.9 in the last month. In Group II, the results were: 14.9 dry nights in the first month, 20.8 dry nights in the second and 24.0 dry nights in the last month. There was a significant difference between the groups in second and third months. Conclusion: Pelvic floor exercises associated with behavioral changes were more effective than pharmacological treatment in children with urinary incontinence.