Francisco J. Martínez Portillo

PERCUTANEOUS NEPHROSTOMY VERSUS URETERAL STENTS FOR DIVERSION OF HYDRONEPHROSIS CAUSED BY STONES: A PROSPECTIVE, RANDOMIZED CLINICAL TRIAL

PURPOSE Urinary diversion with percutaneous nephrostomy or ureteral stent is indicated by symptoms, such as persistent colic, high temperature and uremia, of hydronephrosis caused by stones. We evaluate which of these 2 methods is superior concerning the course of procedure, relief of accompanying symptoms and quality of life in regard to patient age and sex. MATERIALS AND METHODS A total of 40 patients with stone induced hydronephrosis were randomized into either percutaneous nephrostomy or stent insertion groups. These patients were then evaluated by procedure (use of analgesics, x-ray exposure, success of insertion), relief of accompanying symptoms (duration of diversion, intravenous administration of antibiotics for high temperature) and quality of life (questionnaire immediately and 2 to 4 weeks postoperatively). RESULTS Two comparable groups of patients were formed, with an average age of 55 versus 49 years and a male-to-female ratio of 12:8 versus 9:11 for those who underwent percutaneous nephrostomy versus those who received a stent, respectively. Percutaneous nephrostomy was successfully completed in 100% of patients and stents were successful in 80%, with a 20% conversion to percutaneous nephrostomy. The x-ray exposure was shorter in the percutaneous nephrostomy group (p = 0.052). Administration of analgesics was more frequent in the stent group (p = 0.061). Percutaneous nephrostomy indwelling time was shorter (50% less than 2 weeks) than that of stents (25% less than 2 weeks, p = 0.043). Antibiotics were administered for greater than 5 days in 0% of patients who underwent percutaneous nephrostomy versus 64% in those with stents (p = 0.174). Reduction in quality of life was moderate but more pronounced in patients with stents compared to those who underwent percutaneous nephrostomy, and was more distinct in males and younger patients. The quality of life progressively improved in the course of diversion with percutaneous nephrostomy but deteriorated with stents. CONCLUSIONS Our results demonstrated that percutaneous nephrostomy is superior to ureteral stents for diversion of hydronephrosis caused by stones, especially in patients with a high temperature, as well as in males and juveniles.

Penile Carcinoma (pT1 G2): Surveillance or Inguinal Lymph Node Dissection?

Background: Due to the low incidence of squamous cell penile cancer and lack of well-designed studies, controversies persist over the therapeutic approach in patients with pT1 G2 carcinoma. Patients and Methods: Between 1992 and 2003, 16 patients with T1 squamous penile cancer were treated in our institution either by surveillance or by inguinal lymph node dissection (ILND). Results: A total of 8 primary lesions were classified as pT1 G2 carcinoma with 4 tumors developing early or delayed inguinal metastatic disease. Conclusions: The natural behavior of pT1 G2 squamous penile carcinoma and its metastatic potential has been underestimated in recent literature. Since morbidity after early ILND has markedly decreased and its superiority over delayed ILND has been shown, we advocate the early modified inguinal lymph node dissection until strong prognostic factors for positive inguinal lymph nodes have been validated.

Color Duplex sonography vs. computed tomography: accuracy in the preoperative evaluation of renal cell carcinoma.

Purpose: Accurate imaging is essential for correct operative planning and successful surgical intervention in renal cell carcinoma (RCC). Our objective was the comparison of color duplex sonography with spiral computed tomography (CT) and surgical–pathological findings in the evaluation of renal masses to determine tumor localization, size, tumor thrombus extent and lymph node metastases. Methods: We evaluated 60 patients with a renal mass in a prospective study. Both color duplex sonography and CT were performed by different investigators without knowledge of the supposed diagnosis. The color Doppler findings were compared to CT and surgical pathological findings. Results: The sensitivity of color duplex sonography in the detection of RCC and lymph node metastases is comparable to that of CT (100%). Color duplex sonography was superior in the detection of renal vein involvement. Color duplex sonography alone allowed correct planning of the surgical procedure without intraoperative changes in all patients. Conclusion: Duplex sonography provides exactly the same information as CT. Although duplex sonography is less expensive with lower exposure to radiation, most surgeons will still probably demand CT for diagnosis, especially as this method is unerring and duplex sonography highly depends on the expertise of the person using it.

Microscopic and biochemical fertility characteristics of semen after shockwave lithotripsy of distal ureteral calculi.

PURPOSE To elucidate the frequency and adversity of the effects of shockwave lithotripsy (SWL) on the male reproductive system. We investigated the possible alterations in the quality of semen in patients treated by SWL for pelvic ureteral stones. PATIENTS AND METHODS The semen of 10 men was examined 1 day before and 5 and 90 days after SWL for distal ureteral stones, in accordance with the World Health Organisation guidelines. The results were compared with those from the semen samples of 10 healthy male volunteers undergoing SWL for calculi of the upper urinary tract. RESULTS Microscopic analysis of the semen samples revealed a transient decline in sperm density (24.7%), sperm motility (10%), sperm vitality (8%), and seminal fructose (27.5%) after SWL for distal ureteral stones. A distinctly higher number of spermatozoa of pathological origin was detected after SWL in the same group. There was no trace of microscopic hemospermia before shockwave treatment, but it was detected in 90% of the patients with lower ureteral calculi after SWL. Macroscopic hemospermia was detected in two of these nine patients. No deterioration of the semen characteristics and no hemospermia was observed after treatment in the control group with upper urinary stones. CONCLUSIONS Our investigations confirmed a transient deterioration in semen quality after SWL for distal ureteral calculi, whereas no deterioration was observed after SWL for upper ureteral stones. Impaired sperm quality values returned to normal within 12 weeks after SWL, clearly indicating a damaging effect of SWL on seminal vesicle or ejaculatory duct function. The initial procreative capacity was restored in all patients.

Fibromyxoid pseudosarcoma of the urinary bladder. Case report and review of the literature of a rare disease

ZusammenfassungPseudosarkomatöse Tumoren der Harnblase sind seltene benigne Neubildungen, bestehend aus Fibroblastenproliferationen der Blasenwand mit unbekannter Ätiologie. Der zelluläre Pleomorphismus und die infiltrative Natur dieser Neubildungen können leicht zu einer Fehlinterpretation als Sarkom führen. In der Literatur sind radikal chirurgische, verstümmelnde Therapien beschrieben.Dieser Fallbericht präsentiert einen 27-jährigen Mann mit pseudosarkomatösem Fibromyxoidtumor der Blase ohne urologische Vorerkrankungen, Traumen oder Operationen des Urogenitaltraktes. Die Befunde klinischer Untersuchungen, bildgebender Verfahren und der Histopathologie sind ebenso wie die Therapieoptionen und Literaturdaten dargestellt.Bisher wurden, dieser Fall eingeschlossen, 73 derartige Tumoren in der Literatur beschrieben.AbstractPseudosarcomatous fibromyxoidtumors (PSF) of the bladder are rare, benign tumors consiting of myofibroblastoid bladder wall prolifertions of unknown etiology. Misinterpretation as a sarcoma is common and due to infiltrative growth and cellular pleomorphism and may leed to false radical treatment.We present a 27 year old man with PSF presenting with microhematuria. Results of clinical, radiological and histopathological examinations and therapy are presented. A. review of the literature data of the to our knowledge 73 cases that have been reported in the literature is given.

Current problems and needs in the treatment of pT1 G3 bladder carcinoma

Let us assume we would have to inform a patient about his pT1 G3 bladder carcinoma and about the subsequent treatment options. And if we are sincere, we have to recognize our lack of knowledge in a few but decisive key points. We are faced with a number of important and difficult tasks. The main problem of T1 G3 bladder tumors is how to select the patients for aggressive surgical or for conservative therapy, knowing that about 33% of the patients will die of their bladder cancer [1]. Is therefore only the transurethral resection and the histopathological analysis decisive? A routine cystectomy is clearly an overtreatment, in view of the known risks and the fact that many nonsurgical approaches are now available for patients who want to preserve their bladder function. But observation alone following TUR is associated with a progression rate of about 50% five years after diagnosis [2,3]. The clinical dilemma arises: how to identify prospectively the patients at risk of disease or stage progression? Can tumor markers identify the patients that are at highest risk for disease progression? And if we decided a conservative treatment, which is the best one? But if we decided to perform a radical surgical treatment, when is the accurate moment to perform the cystectomy? Finally the patient must be monitored for the development of subsequent tumors. What we really know, is that life has more pleasure with a intact bladder. With this up-dated overview we want to clarify and focus some of the major discussed points in the management of the pT1 G3 bladder carcinoma, knowing that it will still be a matter of discussion. Prognostic parameters

Preoperatively evaluated bladder wall tension as a prognostic parameter for postoperative success after surgery for bladder outlet obstruction

OBJECTIVES To evaluate a novel method for the determination of bladder wall tension (BWT) and to correlate these findings with postoperative persistent residual urine, postoperative uroflow, International Prostate Symptom Score, and quality-of-life index in patients with bladder outlet obstruction. METHODS In 28 male patients with prostate enlargement or bladder neck sclerosis undergoing surgical treatment, the preoperative BWT was determined after urodynamic investigation and ultrasound determination of bladder weight. The patients were divided into two groups: group 1 (n = 24), postoperative residual urine volume less than 50 mL; and group 2 (n = 4), persistent residual urine volume greater than 50 mL. Five patients in group 1 were unobstructed in accordance with the Abrams-Griffiths nomogram. This group was compared separately with group 2, in which all 4 patients were also classified as unobstructed. RESULTS The preoperative BWT in group 1 was 5.2 +/- 4.1 N/cm(2), significantly different from the preoperative BWT in group 2 (0.98 +/- 0.3 N/cm(2)). The BWT in the 5 unobstructed patients in group 1 (3.4 +/- 1.3 N/cm(2)) was significantly greater than that in patients in group 2. BWT was the sole parameter that was distinctly different between these 5 patients and the patients in group 2, with a significant influence on postoperative uroflow, International Prostate Symptom Score, and quality-of-life index. CONCLUSIONS The results of this pilot study show that the determination of BWT allows further evaluation of the detrusor function. Especially in patients classified as unobstructed according to the Abrams-Griffiths nomogram, preoperative determination of the BWT could become a supplemental and important parameter with predictive value for postoperative success in patients with prostate enlargement or bladder neck sclerosis.