Marcelo Hisano

Granulosa cell tumor of the adult testis: report of a case and review of the literature

A 59-year-old man, referred to us with a 2-year historyof a painless growing mass in the left testis without pasthistory of trauma, infection, or lower urinary tract symp-toms. Physical exams revealed a normal right epididymisand testis, and a 13-cm mass and hydrocele in the left tes-tis, without hernia. Ultrasonography showed a 15 x 11 x12 cm mass with solid and cystic components and a largehydrocele. Serum levels of alpha-fetoprotein, beta-hCG,and LDH were within normal ranges. He underwent in-guinal surgical exploration of the left testis in October2000, when a large testicular mass was found. A radicalorchiectomy was performed, and the hydrocele fluid wasanalyzed. No frozen section biopsy was performed. His-topathological examination showed a 9-cm yellow tumor,with a small degenerated cystic area. Final analysis revealeda granulosa cell tumor with oval nuclei having a longitu-dinal nuclear groove (coffee bean appearance – Figure 1),focal invasion of the tunica albuginea and rete testis, nomitotic figures, and no invasion of surgical margins, sper-matic cord, or epididymis. Cytological analysis of the hy-drocele fluid was negative for tumor cells. Immunohisto-chemical tests were positive for vimentin, actin HFN 35,desmin, and cytokeratin AE-1/AE-3, but negative for epi-thelial membrane antigen. These findings strongly suggestthe diagnosis of a granulosa cell tumor.Follow-up was carried out with determinations of se-rum levels of alpha-fetoprotein, beta-hCG, and LDH, aswell as computerized tomography of the abdomen and chestx-ray every 6 months for 4 years, with no clinical recur-rence or exam abnormalities.Described for the first time in 1952,

Cranberries and lower urinary tract infection prevention

Lower urinary tract infections are very common diseases. Recurrent urinary tract infections remain challenging to treat because the main treatment option is long-term antibiotic prophylaxis; however, this poses a risk for the emergence of bacterial resistance. Some options to avoid this risk are available, including the use of cranberry products. This article reviews the key methods in using cranberries as a preventive measure for lower urinary tract infections, including in vitro studies and clinical trials.

Modified Complete Supine Percutaneous Nephrolithotomy: Solving Some Problems

BACKGROUND AND PURPOSE Percutaneous nephrolithotomy (PCNL) is the gold standard treatment for patients with renal stones larger than 2 cm. In this article, we aim to describe our modified technique with the patient in a complete supine position for PCNL (csPCNL). PATIENTS AND METHODS A total of 117 patients (120 renal units) who underwent csPCNL for large stones from November 2008 to November 2011 were prospectively evaluated. One surgeon worked in two different institutions and performed all operations. All patients underwent CT preoperatively, and the stones were classified according to the Guy score. Patients were placed in the supine decubitus position with the posterior axillary line located just outside the border of the surgical table, and the flank was extended to increase the space between the last rib and the iliac crest. The csPCNL was performed without a rolled towel under the flank, and the patients remained in the same position during the entire procedure. Success was evaluated based on CT findings at the end of follow-up. RESULTS There was no failure of access. The median operative time was 100 (20-240) minutes. The immediate and final success rates were 72.5% and 90.4%, respectively. The complication rate was 16.8% (12.7% of Clavien I or II and 4.1% of Clavien III or IV). There were no colon injuries or deaths. The median hospital stay was 48 (24-840) hours. CONCLUSION Modified csPCNL is a safe and effective procedure with excellent outcomes and a low rate of major complications. It provides a good area for renal puncture and surgical instrumentation.

Primary reconstruction is a good option in the treatment of urinary fistula after kidney transplantation

OBJECTIVES urinary fistula is a morbid complication after renal transplantation leading to graft losses and patient death. We review and update our data on urinary fistula after renal transplantation and the outcome after surgical and conservative management. MATERIALS AND METHODS the charts of 1046 renal transplants were reviewed. Transplants were performed through an extended inguinotomy; vascular anastomoses to the iliac vessels and urinary reconstruction accomplished through the Gregoir technique. Fistulae were diagnosed by urinary leaks through the incision or by the occurrence of a collection in the iliac fossa. Patient was treated surgically or conservatively according to the characteristics of the fistula and patient clinical status. RESULTS Thirty one fistulae were diagnosed (2.9%). Twenty nine leaks due to ureteral necrosis and 2 due to reimplantation fault. The incidence of leaks among cadaver and live donor transplants was 3.22% and 2.63%, respectively (p = 0.73). Among diabetic and non diabetic patients the incidence of urinary leaks was 6.4% and 2.6%, respectively (p = 0.049). Treatment consisted in anastomosis of the graft ureter or pelvis with the ureter of the recipient in 17 cases with success in 13 (76.5%). Prolonged bladder drainage was employed in 7 cases and the fistula healed in 4 (57%). Ureteral reimplantation was performed in 3 cases and did not work in any of them. Ureteral ligature plus nephrostomy was employed in two cases and worked in one (50%). Percutaneous nephrostomy and ureteral stenting with double J catheter were employed in one case each and worked in both. CONCLUSIONS The anastomosis of the graft ureter with the ureter of the recipient is a good method for treating urinary fistulae after renal transplantation when local and systemic conditions are good. Ureteral ligature associated to nephrostomy should be applied in cases of unfavorable local conditions or clinically unstable patients.

Retroperitoneoscopic adrenalectomy in pheochromocytoma

Since the first laparoscopic adrenalectomy, the technique has evolved and it has become the standard of care for many adrenal diseases, including pheochromocytoma. Two laparoscopic accesses to the adrenal have been developed: transperitoneal and retroperitoneal. Retroperitoneoscopic adrenalectomy may be recommended for the treatment of pheochromocytoma with the same peri-operative outcomes of the transperitoneal approach because it allows direct access to the adrenal glands without increasing the operative risks. Although technically more demanding than the transperitoneal approach, retroperitoneoscopy can shorten the mean operative time, which is critical for cases with pheochromocytoma where minimizing the potential for intra-operative hemodynamic changes is essential. Blood loss and the convalescence time can be also shortened by this approach. There is no absolute indication for either the transperitoneal or retroperitoneal approach; however, the latter procedure may be the best option for patients who have undergone previous abdominal surgery and obese patients. Also, retroperitoneoscopic adrenalectomy is a good alternative for treating cases with inherited pheochromocytomas, such as multiple endocrine neoplasia type 2A, in which the pheochromocytoma is highly prevalent and frequently occurs bilaterally.

Are total prostate-specific antigen serum levels in cirrhotic men different from those in normal men?

OBJECTIVES To determine the serum total prostate-specific antigen (tPSA) levels in cirrhotic men and compare them with those in noncirrhotic men. METHODS We prospectively evaluated 113 cirrhotic patients listed for liver transplantation using the serum tPSA, total testosterone level, and Child-Pugh liver function score according to age and severity of liver disease. The tPSA levels were compared with those of 661 healthy men. The Mann-Whitney U test was used for statistical analysis, with a significance level of .05. RESULTS The median age of the cirrhotic and noncirrhotic patients was 55 years (range 28-70) and 58 years (range 46-70), respectively (P < .01). However, when stratified by age group (<49, 50-59, and >60 years), this difference was not significant. The median serum tPSA level was 0.3 ng/mL (range 0.04-9.9) and 1.3 ng/mL (range 0.04-65.8) in the cirrhotic and noncirrhotic group, respectively (P < .0001). Stratifying both groups according to age, the cirrhotic patients had significantly lower tPSA levels than did the noncirrhotic patients. According to the Child-Pugh score (A, B, and C), Child-Pugh class C patients had significantly lower tPSA levels than did Child-Pugh class A patients and also had lower testosterone levels than did Child-Pugh class A and B patients. The tPSA levels correlated significantly with the testosterone levels in the cirrhotic patients (P = .028). CONCLUSIONS The results of our study have shown that cirrhotic patients have approximately 4 times lower serum tPSA levels than noncirrhotic men. Patients with more severe liver disease have lower tPSA and testosterone levels than patients less affected. The tPSA levels in cirrhotic men are affected by the total testosterone levels.

Congenital genitourinary abnormalities in children with Williams–Beuren syndrome

OBJECTIVE Williams-Beuren syndrome (WBS) is an autosomal dominant disorder caused by a gene deletion on chromosome 7q11.23. Patients with WBS usually show a group of features such as developmental delay, cardiovascular anomalies, mental retardation, and characteristic facial appearance. Abdominal wall defects, external genitalia anomalies, and structural abnormalities of the urinary tract have been scarcely evaluated and were the focus of our study. MATERIALS AND METHODS We prospectively evaluated 41 boys and 38 girls with WBS, with a mean age of 8.8 ± 4.1 (range 3-19 years). All patients were examined for the evaluation of inguinal and umbilical hernias and genital anomalies. All patients were offered a radiological evaluation, including urinary tract ultrasound, voiding cystourethrogram, and dimercaptosuccinic acid renal scintigraphy (DMSA scan). RESULTS Of the 41 boys, 30 (73.1%) had abnormalities on physical examination, including bilateral undescended testis in 13 (31.7%), retractile testis in four (9.7%), hypospadias in four (9.7%), and unilateral cryptorchidism in three (7.3%) patients. Of the 38 female subjects, 17 (44.7%) had at least one abnormality, including umbilical hernia in 11 (28.9%), unilateral inguinal hernia in four (10.5%), and bilateral inguinal hernia in three (7.8%) patients. Uroradiological abnormalities were found in 41 patients (51.9%). On sonography, six (7.6%) patients had unilateral hydronephrosis, three (3.8%) had a duplicated collecting system, and two (2.5%) had kidney stones. On DMSA, performed in 36 patients, four (11.1%) had unilateral renal scarring and two (5.5%) had bilateral renal scarring. Cystourethrography was obtained from 56 patients, of whom 27 (48.2%) had bladder diverticulum, 18 (32.1%) had bladder wall trabeculation, and three (5.3%) had vesicoureteral reflux. We found no association of urological abnormalities with cardiovascular defects. CONCLUSIONS Patients with WBS have a high prevalence of abdominal wall, external genitalia, and urological abnormalities, emphasizing the importance of proper physical examination and radiological investigation in this population.

Urological manifestations of chronic schistosomal myeloradiculopathy

To describe the clinical and urodynamic features of patients with chronic voiding dysfunction secondary to schistosomal myeloradiculopathy (SM), as the clinical involvement of the spinal cord is a well recognized complication of Schistosomiasis mansoni infection.

Secondary Hypertension Caused by Massive Renal Lymphangiomatosis

Renal lymphangiomatosis is a rare disease characterized by lymphatic vessel proliferation. We present a case of an adult patient with chronic flank pain, hypertension, and a right kidney mass. The magnetic resonance imaging findings were consistent with unilateral renal lymphangiomatosis. Technetium-99m dimercaptosuccinic acid renal scintilography revealed decreased ipsilateral renal function. From these findings, the patient underwent right nephrectomy, which resulted in complete remission of his hypertension and pain.

The Bacterial Spectrum and Antimicrobial Susceptibility in Female Recurrent Urinary Tract Infection: How Different They Are From Sporadic Single Episodes?

OBJECTIVE To analyze and compare the etiological uropathogens and the susceptibility profile findings on urine culture between sporadic cases of community-acquired, uncomplicated urinary tract infection (UTI) and recurrent UTI cases in women. MATERIALS AND METHODS We retrospectively analyzed the clinical data of 1629 women with uncomplicated UTI evaluated at our hospital between January 2007 and December 2012. Patients were divided into 2 groups: (1) no recurrent UTI and (2) recurrent UTI. We analyzed the microbiological findings and compared susceptibility profiles between groups. RESULTS A total of 420 women were included. Group 1 had 233 (55.5%) patients and group 2 had 187 (44.5%). Escherichia coli was the most common agent in both groups (76.4% and 74.3%, respectively; P = .625), whereas Staphylococcus saprophyticus (8.2%) was the second most common in group 1, and Enterococcus faecalis was the second most common in group 2 (8.0%). Nitrofurantoin was the only oral agent that maintained the susceptibility profile in both groups (87.1% and 88.7%, respectively; P = .883). For E coli infections, only nitrofurantoin and amoxicillin/clavulanate maintained susceptibility rates more than 90% in both groups. CONCLUSION UTI episodes in patients with recurrent UTI had similar bacterial spectra, but different susceptibility profiles compared with those from patients with nonrecurrent infections. The susceptibility rate for nitrofurantoin in patients with recurrent UTI remained high and comparable to the observed in patients with sporadic UTI, reinforcing its indication for empirical treatment while waiting for urine culture results.