Carlos Arturo Levi D’Ancona

Percutaneous Treatment of Bladder Stones

A total of 36 patients with bladder stones underwent percutaneous suprapubic cystolithotripsy. The successful rate was 89%. There were 11% failures due to nonfragmentation of the stones by the ultrasound probe. According to the presence of associated diseases 3 groups of patients were established. Two groups underwent concomitant treatments for benign prostatic hyperplasia and urethral stricture. No complications occurred even in patients with concomitant treatment. There was no statistically significant difference when these groups were compared (p > 0.05). Fluoroscopy was not necessary during the procedure. Since the technique is simple, safe and effective, it represents an alternative in the management of bladder stones.

Evaluation of patients with bladder outlet obstruction and mild international prostate symptom score followed up by watchful waiting

OBJECTIVES To examine the variability of bladder outlet obstruction and mild lower urinary tract symptoms in patients with benign prostatic hyperplasia (BPH) followed up by watchful waiting. METHODS The International Prostate Symptom Score (IPSS) has four questions related to voiding symptoms and three related to filling symptoms. Scores of 0 to 7, 8 to 19, and 20 to 35 represent mild, moderate, and severe symptoms, respectively. Over a period of 36 months the IPSS questionnaire was administered to 479 patients 50 to 81 years old (mean age 63) with BPH. A pressure-flow study was used to determine the presence of bladder outlet obstruction. On the basis of their scores, the patients were classified into 50 with mild, 227 with moderate, and 202 with severe symptoms. In the present study only patients with a mild score were analyzed. RESULTS Of 50 patients with mild symptoms, 16 (32%) had bladder outlet obstruction. After a period of 9 to 22 months (mean 17) of watchful waiting, these 16 patients were reviewed. Twelve (75%) of the 16 had bladder outlet obstruction reconfirmed by pressure-flow studies, and 3 (18.8%) of 16 had increased symptoms (moderate symptomatic) and underwent treatment (1 began pharmacologic treatment, and 2 chose transurethral resection). A total of 4 (25%) of 16 patients still had mild voiding disturbances and refused the second urodynamic evaluation. The remaining 34 patients with no obstruction had annual routine follow-up and had persistent mild symptom scores and normal uroflowmetric results. These patients did not undergo another pressure-flow evaluation. CONCLUSIONS A pressure-flow study is routinely avoided in patients with a mild IPSS. From symptoms alone it was not possible to diagnose bladder outlet obstruction in these patients. Pressure-flow studies and symptom profiles measure different aspects of the clinical condition. After a mean follow-up of 17 months of watchful waiting, 13 (81.2%) of 1 6 patients were clinically stable. Because the need for therapy is dictated by quality of life, it is difficult to propose treatment for patients with minimal symptoms, even in the presence of bladder outlet obstruction.

Insulin relaxes bladder via PI3K/AKT/eNOS pathway activation in mucosa: unfolded protein response-dependent insulin resistance as a cause of obesity-associated overactive bladder

•  Metabolic syndrome, obesity and insulin resistance are risk factors for overactive bladder, but little is known about the impact of insulin resistance on bladder functioning. •  We aimed to investigate the insulin effects in murine and human bladder, and whether its defective action contributes to the bladder dysfunction associated with obesity. •  Under physiological conditions, insulin relaxes urinary bladder through the release of nitric oxide from the mucosal layer, and this mechanism is impaired in bladders from insulin‐resistant obese mice. •  The defective insulin action in bladder mucosa from obese mice is due to endoplasmic reticulum stress, which remarkably contributes to the bladder overactivity in obesity conditions. •  Our results enable a better understanding of the mechanism of action of insulin in the urinary bladder and how its defective action in mucosa contributes to bladder dysfunction in conditions of obesity‐associated insulin resistance.

Internal Urethrotomy of the Prostatic Urethra or Transurethral Resection in Benign Prostatic Hyperplasia

Transurethral resection of the prostate is the most common technique for the treatment of benign prostatic enlargement. The inconveniences of prostatic resection are retrograde ejaculation and bladder neck stenosis in small prostates. A randomized prospective trial was done to compare the results of conventional transurethral resection of the prostate in 22 patients and urethrotomy of the prostatic urethra in 27 with respect to postoperative retrograde ejaculation, persistent urinary symptomatology and maximal flow rates. After a mean followup of 25 months we concluded that internal urethrotomy of the prostatic urethra is the operation of choice in patients with a prostate of up to 30 gm.

Leiomyosarcoma in Association With Incidental Adenocarcinoma of the Prostate

Abstract: We report a case of leiomyosarcoma of the prostate treated by radical cystectomy, radiation and chemotherapy. Microscopic examination revealed a mixture of incidental adenocarcinoma and leiomyosarcoma of the prostate. At 1-year followup the patient had no evidence of metastasis.

New Method for Minimally Invasive Urodynamic Assessment in Men with Lower Urinary Tract Symptoms

OBJECTIVES Urodynamic studies are considered the reference standard to diagnose bladder outlet obstruction. However, the procedure is invasive, expensive, and time-consuming. The purpose of this study was to evaluate a new minimally invasive urodynamic assessment model and compare the results with those of conventional urodynamic evaluation. METHODS The study included 50 male patients who presented with lower urinary tract symptoms. Their mean age was 62 years (range 34 to 82). After undergoing a conventional urodynamic study, they underwent the minimally invasive evaluation. The urethral device is a conical apparatus that adapts to the urethral meatus and fossa navicularis. The isometric bladder pressure and interrupted flow were recorded. The results of the conventional assessment were classified according to the Abrams-Griffiths number and a logistic regression fit was applied to the minimally invasive method. RESULTS Only two variables demonstrated the predictive capacity: the isometric pressure and interrupted flow. In addition to selecting the relevant variables, logistic regression analysis is a more adequate model that provides a binary result of obstructed and unobstructed, used to predict the normal and equivocal categories of the Abrams-Griffiths classification, and taken as the reference standard. The sensitivity and specificity of the new method was 67% and 79%, respectively. CONCLUSIONS The urethral device proved to be simple and easy to use. The minimally invasive method was able to detect most patients with bladder outlet obstruction; thus, the conventional urodynamic assessment could be avoided. We consider this method to have a place as a first-line noninvasive examination.

Continent urinary diversion in patients with pelvic irradiation : An alternative utilizing transverse colon reservoir

The use of radiation therapy in pelvic malignancies increases the risk of urinary complications, sometimes being necessary urinary diversion. The risk of utilizing previously irradiated bowel should be avoided. The use of transverse colon is a safe and effective alternative. We present a heterotopic continent colonic reservoir with an easily catheterizable conduit.

Oral or Intravesical Bacillus Calmette-Guerin Immunoprophylaxis in Bladder Carcinoma

A total of 71 patients with superficial transitional cell carcinoma underwent transurethral resection of bladder tumor. All patients had stage pTa or pT1 transitional cell carcinoma or carcinoma in situ without other concurrent malignancies. The patients were assigned to 3 treatment groups: control group--transurethral resection discontinued within the study, oral bacillus Calmette-Guerin (BCG) group--transurethral resection of bladder tumor plus BCG (Moreau) and intravesical BCG group--transurethral resection of bladder tumor plus BCG. Of 9 patients in the control group 8 (89%) experienced tumor recurrence during a mean followup of 20 months. Of the 28 patients in the oral BCG group 11 (39.3%) had recurrence during a mean followup of 36 months. Of the 34 patients in the intravesical group 6 (18%) had recurrence in a 24-month mean followup. The incidence of complications was higher in the intravesical (41.2%) than in the oral BCG group (28.5%). These results show that intravesical BCG is a more effective immunotherapy; however, oral BCG can be used in patients who do not accept intravesical BCG administration.

Percutaneous nephrectomy in nonfunctioning kidneys: a preliminary report.

Nephrectomy is indicated for the removal of highly damaged kidneys. Several times patients are asymptomatic, and although the operation has a low morbidity rate they will refuse it. The development of new endourological techniques of percutaneous access to the kidney in experimental studies on liquefaction and aspiration of tissues, and the idea taken from the old resectoscope models using nonelectrical aids served to inspire our technique of percutaneous nephrectomy. Our patient presented with a nonfunctioning kidney due to ureteral obstruction and ultrasound demonstrated a severe decrease in renal parenchyma. Percutaneous access to the kidney was performed through the conventional manner and the remaining parenchyma was removed with biopsy and Lowsley forceps. Bleeding was minimum and a 22F nephrostomy Foley catheter was kept in place for 72 hours. As far as new instruments are developed, percutaneous nephrectomy represents a surgical option to remove nonfunctioning kidneys in highly selected patients.

Parameters of two-dimensional perineal ultrasonography for evaluation of urinary incontinence after Radical Prostatectomy

INTRODUCTION Urinary incontinence remains a major concern for patients undergoing radical prostatectomy. Its prevalence can reach 20% in the late postoperative period. MATERIALS AND METHODS This clinical study investigated the differences of a dynamic evaluation of the urethra and pelvic floor contraction using perineal ultrasound in men without prostate surgery and in men submitted to radical prostatectomy with and without stress urinary incontinence. Ninety two male patients were included, which 70% of them underwent radical prostatectomy (RP) for more than one year. Thirty one men with clinically post prostatectomy incontinence were compared by two-dimensional (2D) perineal ultrasound to 34 patients without post prostatectomy incontinence and to 27 men without surgery in two centers in Brazil. RESULTS Our results showed that the continent group presented the urethral angle at rest significantly lower than the prostate group (p = 0.0002). We also observed that the incontinent group showed the displacement of the anterior bladder neck during contraction significantly lower than the continent group (p = 0.008). CONCLUSIONS We found that the continent group presented the urethral angle at rest significantly lower than the prostate group. The incontinent group also showed the anterior bladder neck displacement during contraction significantly lower than the continent group. It was more evident when the severe incontinent group and the continent group were compared.