João Carlos Campagnari

DEEP-SEATED SARCOMAS OF THE PENIS

Mesenchymal neoplasias represent 5% of tumors affecting the penis. Due to the rarity of such tumors, there is no agreement concerning the best method for staging and managing these patients. Sarcomas of the penis can be classified as deep-seated if they derive from the structures forming the spongy body and the cavernous bodies. Superficial lesions are usually low-grade and show a small tendency towards distant metastasis. In contrast, deep-seated lesions usually show behavior that is more aggressive and have poorer prognosis. The authors report 3 cases of deep-seated primary sarcomas of the penis and review the literature on this rare and aggressive neoplasia.

Lymphocele: a possible relationship with acute cellular rejection in kidney transplantation

CONTEXT The incidence of lymphocele after renal transplantation varies between 0.6 and 18% of cases, and many factors have been associated to its etiology. Cellular rejection of the kidney allograft has been described as a possible causal factor of lymphocele. OBJECTIVE To analyze the possible relationship between lymphocele and acute cellular rejection. DESIGN A retrospective study. SETTING A referral hospital center. SAMPLE 170 patients submitted to kidney transplantation from March 1992 to January 1997. A standard technique for renal transplantation was used. RESULTS Of the 19 patients that developed lymphocele, 16 presented at least one episode of acute cell rejection (84%), and were treated with methylprednisolone. The relation between lymphocele and rejection was statistically significant (p = 0.04). Treatment of lymphocele consisted of peritoneal marsupialization in 3 patients (15.3%), percutaneous drainage in 7 (36.8%), laparoscopic marsupialization in 2 (10.5%), and conservative treatment in 7 patients (36.8%). Evolution was favorable in 15 patients (78.9%), 1 patient (5.3%) died due to a cause unrelated to lymphocele, and 3 (15.8%) lost the graft due to immunological factors. The average follow-up period was 24.5 months. CONCLUSION The high incidence of acute cell rejection in patients with lymphocele suggests a possible causal relationship between both conditions.

The percentage of positive biopsy cores as a predictor of disease recurrence in patients with prostate cancer treated with radical prostatectomy.

To analyse the prognostic value of the percentage of positive biopsy cores (PPBC) in determining the pathological features and biochemical outcome of patients with prostate cancer treated by radical prostatectomy, as published data evaluating the prognostic value of PPBC in such patients have limitations.

A randomized and prospective study on the value of antibiotic prophylaxis administration in transurethral resection of the prostate.

CONTEXT Antibiotic prophylaxis in transurethral resection of the prostate is a regular practice in urology. However, its prophylactic effect can be questioned when the antiseptic surgical technique is used. Nonetheless, urine culture-oriented antibiotic therapy is the gold standard for avoiding improper medication usage and bacterial resistance. OBJECTIVE To study the efficacy of antibiotic usage in patients with negative urine cultures, who were submitted to transurethral resection of the prostate. TYPE OF STUDY Prospective open labeled study. SETTING Tertiary care referral hospital. PARTICIPANTS 124 consecutive patients, who were randomly divided into two groups to receive antibiotic prophylaxis or not. MAIN MEASUREMENTS Cultures from meatus, urine, irrigation and antiseptic fluid, and prostate tissue chips, were compared and analyzed for bacterial sensitivity to the antibiotic used, according to the surgeons personal criteria. McLennans test was used for statistical analysis. RESULTS No statistically significant difference regarding clinical evolution was found between the groups that received or antibiotics or not. Statistical significance was found regarding the occurrence of positive urine cultures during the postoperative period for those not receiving antibiotics, but not in relation to fever, prostate chip culture or bacteremic episodes. Sixty-eight subjects (57.1%) presented positive prostatic tissue culture. There was no specific correlation between the recovered bacteria from the meatus, prostatic tissue chip and urine and the spectrum of the administered antibiotic. Six cases showed the same bacteria in the urine and prostatic tissue chip. Only fifteen cases (25%) in the antibiotic group showed the desired sensitivity directed to the collected bacteria. CONCLUSIONS Antibiotic prophylaxis for patients whose urine is sterile is debatable in patients who are candidates for transurethral resection of the prostate. Most of the time, the antibiotic agent used is not specific for any of the bacteria recovered from the various sources analyzed.

Involuntary Detrusor Contraction Is a Frequent Finding in Patients with Recurrent Urinary Tract Infections

Objective: To check whether subtle voiding dysfunction is related to recurrent urinary tract infection (rUTI). Methods: 254 consecutive patients with at least four episodes of urinary tract infection (UTI) were studied. At least three repeat urodynamic evaluations with an additional ice water test to maximize the detection of involuntary detrusor contraction (IDC) were used. Stress urinary incontinence cases were used as controls. Nonparametric univariate and multivariate analyses were used for statistics. Results: IDC was detected in 83.6% of patients in the rUTI group and in 31.7% in the control group. IDC was <15 cm H2O in 54.7% whereas high-amplitude (>50 cm H2O) IDC was observed in 6.8% in the rUTI group. Female urinary tract obstruction was diagnosed in 16.8% of patients in the rUTI group and in 7.9% in the control group. Residual volume, PdetQmax and Qmax were not predictive of UTI recurrence. Symptoms were similar in both groups. Conclusions: Patients with rUTI present with covert bladder dysfunctions represented by detrusor overactivity.

Alternative Grafting Technique for Patients Unsuited to Heterotopic Transplantation due to Diseased Pelvic Conditions

Introduction: An alternative technique for kidney transplantation is presented for patients in whom the use of pelvic vessels is precluded. Patients and Methods: Of 482 cases of kidney or pancreas-kidney transplants, 4 were unsuited to heterotopic grafting, 1 due to multiple operations in the fossae and the 3 others due to extensive vascular occlusive disease. The patients were studied preoperatively by magnetic resonance angiography, which revealed extensive occlusive disease of the distal aorta and/or iliac vessels. Results: The patients received kidneys from living related donors as a third or second transplant opportunity in the orthotopic position (2 cases). Gross dissection of the aorta revealed a thickened wall, impeding direct anastomoses between the recipient’s arteries and the donated organ. After a termino-lateral Dacron graft to the aorta, all cases were stented for uretero-uretero anastomosis. Recovery with respect to the renal graft was uneventful for all cases. Conclusions: Alternative direct grafting from the aorta represents a viable and easy way to perform kidney transplants in patients unsuited to the heterotopic approach.

Valsalva Leak Point Pressure to Determine Internal Sphincter Deficiency in Stress Urinary Incontinence

Introduction: Valsalva leak point pressure (VLPP) represents the global competence of the conjunctive forces around the urethra to support increased pressure from the abdominal cavity with transmission to the bladder. Assessment of VLPP has prognostic meaning, but measurement techniques are still subject to controversy. Patients and Methods: One hundred and eight consecutive women with no genital prolapse or bladder hyperactivity exclusively presenting with urinary stress incontinence were submitted to VLPP determination during urodynamic evaluation using a rectal and urethral catheter. Rectal pressure measurement served as the landmark in the determination of Valsalva’s maneuver. After determining the rectal pressure, the urethral probe was pulled out and the maneuver repeated. Results: Eighty-four cases (group I) presented leakage during Valsalva’s maneuver with the urethral catheter being in place. Group Ia (66.6%) had a reduction of 44.5 cm H2O in the rectal pressure after catheter removal. In group Ib, rectal leakage pressure increased after catheter removal from 76.5 ± 18.7 to 79.5 ± 24.7 cm H2O. Eight patients did not demonstrate urine leakage after catheter removal. In group II, 24 cases showed a rise in rectal leakage pressure to 76.2 ± 22 cm H2O, but urinary leakage was only observed after catheter removal. In group IIa (19 cases), the VLPP decreased by 12.6 ± 15 cm H2O, while in group IIb (5 cases) leakage occurred only in patients showing an increase of 22.2 ± 7 cm H2O in the rectal pressure after the second maneuver with the urethral catheter in position. Conclusions: Precise determination of the abdominal leak point pressure through Valsalva’s maneuver may be critical. The different techniques used for VLPP determination may render comparisons difficult. Rectal pressure measurement with no urethral catheter in place to monitor abdominal leak pressure seems to be more appropriate because it resembles clinical practice. Although lower abdominal leakage pressures may be found, this is not a uniform finding, and a higher incidence of type III incontinence may be expected, and critical analysis or painstaking repetition may be required in the case of lack of demonstration of urinary loss.

Urodynamic after-contraction waves: a large observational study in an adult female population and correlation with bladder and ureter emptying functions in women.

Objective: To evaluate different patterns of after-contraction (A-C) waves detected during urodynamic evaluation in women. Patients and Methods: 4,110 women were prospectively observed regarding the presence of A-C waves upon urodynamic evaluation. Intravenous pyelography and ultrasound were requested. Paired t test, χ2 test, Wilcoxons rank sum test and correlation analysis were performed with a 95% significance level. Results: There were three distinguishing patterns of A-C: type I - detrusor contraction after the regular voiding phase, type II - detrusor contraction persisting after the flow rate had stopped, and type III - rebound of the detrusor contraction after the flow. A-C was observed in 13.9% of the women. Type I A-C wave patterns were present in 68 patients (11.8%), type II A-C wave patterns in 477 patients (83.2%), and type III A-C wave patterns in 28 patients (10.3%). Studies with intravenous pyelography and ultrasound very frequently showed bladder mucosa, muscle thickening or trabeculation. Secondary ureterectasis related to A-C waves was also observed. Additionally, watts factor, maximum flow rate, detrusor pressure and opening detrusor pressure were markedly elevated in patients with type III A-C, suggesting enhanced detrusor contraction in these A-C waves. Conclusion: A-C waves are a real urodynamic entity with different patterns of presentation and with clinical and morphological alterations.

Slings may not fail as frequently as believed for stress urinary incontinence: the misinterpretation of postoperative voiding dysfunction as failure based on patient report.

Objective: Sling operations may obstruct the urethra, promoting voiding dysfunction and secondary urine leakage that are incorrectly attributed to surgical failure. Methods: We prospectively evaluated the evolution of urinary symptoms in the postoperative follow-up of 108 polypropylene sling cases. Patients presented for follow-up at 1, 3, 6, 12, 18, 24, 36, and 48 months for review of individual urinary symptoms. Statistical analysis used Fisher exact test. Results: On the 30th postoperative day, 100% of the cases were cured of stress urinary incontinence, although frequency (62.9%), urgency (29.6%), urge-incontinence (23.1%), nocturia (28.6%), incomplete voiding sensation (11.1%), and poor stream (11.1%) persisted. At 3 months, 16.6% reported frequency, 38% complained of urgency, and 29.6% were troubled by nocturia. True urinary leakage under stress was resolved in 100% of cases by the first visit and did not show any further decrease when specifically questioned. Pad usage decreased after 3 months but did not completely disappear after 48 months. A total of 94.4% of the cases achieved total continence and clinical satisfaction after 4 years of follow-up, in parallel with the steady disappearance of voiding dysfunction observed in the early postoperative period. Conclusions: Voiding dysfunction after sling procedures is frequent but transitory. As symptoms improve or disappear, patients tend to miss their follow-up. In this study, 94.4% of the cases had complete dryness and satisfaction with the operation.

Can We State Stable Bladder? How Many Repetitions Should We Do for an Appropriate Demonstration of Involuntary Detrusor Contraction?

Aims: Involuntary Detrusor Contraction (IDC) may alter therapeutic plans; therefore, urodynamic demonstration (UD) is pivotal. We explore if same session repetitions enhance its demonstration and minimize false-negative results. Methods: Two hundred fifty two women (mean age 47 ± 5.7) had 4 full repetitions of UD with the last round filled with 4°C fluid (Ice-water test). IDC was diagnosed if with at least 3 cm H2O after artifacts were ruled out. Results: 44.4% of the cases showed IDC in the first round of the exam but it could be demonstrated in 88.5% of the women if 4 rounds are taken into account. Only 2 cases showed IDC exclusively in the first round. Nine cases (3.5%) showed IDC in the first round and only on Ice-test, while all other IDC-detected cases revealed it in scattered patterns along the repetitions. Likewise, IDC detection on the second, third and fourth rounds varied widely and unpredictably, many failing to show a consistent pattern of presentation after its detection. IDC wave amplitude did not show any correlation to the detection. Conclusions: Urodynamic repetition is a necessary procedure where IDC is important to demonstrate, as its false-negative rate is high and its unpredictable pattern of detection may be improved by repetition.