N. Rodrigues Netto

RESINIFERATOXIN FOR DETRUSOR INSTABILITY REFRACTORY TO ANTICHOLINERGICS

PURPOSE We have evaluated the clinical and urodynamic effects of intravesical instillation of resiniferatoxin in patients with idiopathic detrusor instability refractory to anticholinergics. MATERIALS AND METHODS There were 30 women, median age 56 years old with detrusor instability for over 6 months and a history of anticholinergic use with no response or intolerable collateral effects. A 50 nM solution of resiniferatoxin was prepared for intravesical instillation. All patients were evaluated for urinary symptoms, as well as for urodynamic assessments before and 30 days after instillation. Tolerability was analyzed during the instillation. RESULTS A clinical improvement was observed in 30% of the patients with urinary urgency and in 33% of the patients with urge-incontinence. The mean maximum cystometric capacity before application was 303.9 +/- 78.9 and after application 341 +/- 84.6. No significant difference was observed (p = 0.585). The mean maximum amplitude of the contractions diminished from 47.86 +/- 29.64 to 38.72 +/- 30.77 (p = 0.002). CONCLUSIONS Resiniferatoxin, in this concentration, proved to be useful in a small percentage of patients regarding clinical detrusor instability. Maximum amplitude of the involuntary contractions was significantly reduced and in 33% patients the involuntary contractions disappeared. Further studies with different concentrations are recommended.

The transverse colonic reservoir: the Unicamp technique

Objective To present the results of a continent and nonrefluxing transverse colonic urinary reservoir technique.

Histological and histochemical changes of the intestinal mucosa at the urothelial-enteric anastomotic site

OBJECTIVE The incorporation of bowel segments for urinary tract reconstruction may induce intestinal mucosal changes with the development of metabolic, nutritional, gastrointestinal and carcinogenic complications. The early histological and histochemical changes of the intestinal mucosa in contact with the feces-urine mixture, are evaluated in the present study. MATERIALS AND METHODS Twelve rats (operated group) were submitted to a vesico-colonic anastomosis, and 10 rats (control group) underwent a sham operation (the colon was opened and immediately sutured). On the operated group, the left colon was divided into 3 equal portions and the middle segment was used for the bladder-colonic anastomosis. After 20 weeks, the animals were sacrificed and the entire left colon in each group, as well as the bladder and the vesico-colonic anastomosis in the operated group, was removed. The proximal, middle (anastomotic site in the operated group and sutured portion in the control group) and distal colon were used for histological and histochemical studies. RESULTS Metaplasia, chronic inflammatory process and fibrosis were significantly greater at the anastomotic site compared to the middle segment of the control group. There were no differences in both groups in terms of dysplasia, atrophy and hypertrophy either on the proximal, middle or anastomotic area and distal portion of the left colon. All animals in the operated group showed a reduced presence of sulfomucin and an increase in the sialomucin content. CONCLUSION The histological changes observed in this study may suggest a precancerous phenomenon.

Uretrolisis transvaginal tras cirugía correctora de la incontinencia urinaria de esfuerzo

Resumen Objetivos Analizar los resultados de la uretrolisis transvaginal como medida terapeutica para la disfuncion miccional, en pacientes sometidas previamente a cirugia anti-incontinencia. Materiales y Metodos Fue realizado un estudio retrospectivo, en 20 pacientes quienes fueron sometidas a uretrolisis por obstruccion uretral secundaria a una cirugia anti-incontinencia. Pre-operatoriamente fueron realizados historia, examen fisico y estudio urodinamico. La edad media de las pacientes fue 48 anos. El tiempo de evolucion entre la cirugia y la uretrolisis, vario de 3 meses a 8 anos. Cuatro pacientes presentaron retencion urinaria y las demas referian sintomas irritativos. Las cirugias previas incluian: sling pubo vaginal en 11 pacientes, uretropexia retropubica en 3 y suspension del cuello vesical con aguja en 6. El seguimiento posterior a la realizacion de la uretrolisis fue de 14 meses. La evaluacion urodinamica demostro un flujo urinario promedio de 9,9 ml/s y presion detrusora media en el flujo maximo de 48cmH2O. Resultados Aproximadamente 70% de las pacientes presentaron mejoria subjetiva total de los sintomas. Dos pacientes presentaron falla del metodo y fueron sometidas a nueva uretrolisis con interposicion de flap de Martius. No hubo correlacion entre los parametros clinicos y urodinamicos encontrados en el pre operatorio y los resultados posteriores a la uretrolisis. Conclusion Tratamos de demostrar que la uretrolisis posterior a cirugia anti-incontinencia es un procedimiento efectivo, minimamente invasivo que permite resultados satisfactorios para el tratamiento de la disfuncion miccional que no se resuelve espontaneamente.

Rizotomía sacra percutánea por radiofrecuencia en el tratamiento de la hiperactividad del detrusor neurogénico en pacientes con lesiones de la médula espinal

INTRODUCTION To evaluate the effects of percutaneous radiofrequency sacral rhizotomy in spinal cord injured (SCI) patients on urodynamic parameters (maximum cystometric capacity - MCC and detrusor pressure at maximum cystometric capacity - PdetMCC). MATERIAL AND METHODS This prospective study assessed eight patients with SCI (four men and four women) with a mean age of 31.3years (22 to 41). Mean interval period between spinal cord lesion and rhizotomy was 53.5 months (20 to 96). All patients underwent an anesthetic block of the 3rd sacral root bilaterally using 0.5% bupivacaine under fluoroscopic control. Those who responded with an increase on bladder capacity were selected to undergo the percutaneous radiofrequency sacral rhizotomy. All patients underwent urodynamic evaluation at 6 and 12 months following the procedure. MCC and P(det)MCC were recorded. RESULTS All patients presented a significant improvement on MCC after 12 months. The mean vesical volume increased from 100.2±57.1 to 282.9±133.4ml (p<0.05). The P(det)MCC reduced from 82.4±31.7 to 69.9±28.7cmH(2)O (p=0.2). Three patients with autonomic dysreflexia had complete relief of symptoms after the procedure. At 12 months, recurrence of detrusor hyperactivity was observed in all patients. One patient presented abolishment of reflex erections after the procedure. No major complications related to the rhizotomy were noted. CONCLUSIONS Percutaneous radiofrequency sacral rhizotomy is a minimally invasive technique with low morbidity able to increase MCC. There is a trend towards the reduction of the P(det)MCC in SCI patients at 12 months, although statistical significance was not reached.

Seguimiento a largo plazo del soporte uretral tendinoso: un enfoque anatómico para incontinencia urinaria de esfuerzo

Los procedimientos tipo sling han sido utilizados por decadas para el manejo de la incontinencia urinaria de esfuerzo (IUE) femenina, pero solo en la decada pasada han llegado a ser la tecnica de eleccion. Los procedimientos minimamente invasivos son el procedimiento de eleccion en algunos centros por su eficacia y baja morbilidad. El soporte uretral tendinoso (TUS) representa un enfoque anatomico que consiste en colocar una cincha de baja tension a nivel de la uretra media, anclada al arco tendineo de manera bilateral. De febrero 1999 a octubre 2000, 25 pacientes femeninas con IUE y con una edad media de 53 anos fueron intervenidas mediante TUS. De ellas, 23 pudieron evaluarse a largo plazo con un seguimiento un maximo 72 meses. Despues de 6 meses, 20 pacientes (87%) se encontraban secas, 2 (8,7%) mejoraron y 1 (4,3%) era incontinente. Sin embargo, al final del seguimiento, 15 pacientes estaban continentes (65,2%), 3 (13%) mejoraron y 5 (21%) seguian incontinentes. Por lo que, el TUS es un concepto que merece investigaciones adicionales.

Urodynamic studies in the surgical treatment of benign prostatic hyperplasia

OBJECTIVE We compared the clinical and urodynamic outcome of men with lower urinary tract symptoms with and without previous urodynamic evaluation submitted to transurethral resection of the prostate. MATERIALS AND METHODS A prospective and randomized study was performed in 315 patients who underwent transurethral resection of the prostate. In 151 patients (group A) with a mean age of 63 years, transurethral resection of the prostate was performed without a prior urodynamic study, and group B, 164 patients with a mean age of 61 years, underwent a urodynamic study prior to surgical procedure. In group B, only obstructed patients were selected for surgery. All patients had I-PSS higher than 15 and underwent at least 2 uroflowmetry and flow was lower than 10 ml/sec. At 6-month follow up, patients in both groups underwent the I-PSS questionnaire and pressure / flow study. RESULTS The symptomatology and uroflowmetry did not display different behavior between the groups. The mean postoperative score for group A was 8.87 + 3.27 and for group B was 9.32 + 3.14 (p = 0.22). The mean postoperative uroflow for group A was 17.0 + 2.1 mL/s and for group B was 16.6 + 2.2 mL/s (p = 0.15).Postoperative, in group A, 27 patients (17.8%) were obstructed and in group B, 16 patients (9.75%) were obstructed (p = 0.03). CONCLUSION The study suggests that the previous urodynamic study is not the only factor related to the success of surgical outcome; and therefore, the symptomatology and uroflowmetry associated would be enough during the preoperative routine studies for BPH patients.

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.

Correlación entre los prolapsos urogenitales y la presencia de detrusor hiperactivo

Resumen Objetivo Evaluar la relacion entre el prolapso urogenital y la presencia de hiperactividad del detrusor en mujeres con incontinencia urinaria de esfuerzo. Materiales y Metodos Se evaluaron en forma prospectiva, desde enero 1999 a septiembre 2001, en el ambulatorio de Uroginecologia de la Universidad Estatal de Campinas (UNICAMP), 92 mujeres con diagnostico clinico de incontinencia urinaria de esfuerzo que fueron sometidas a estudio urodinamico. La edad vario entre 29 y 75 anos, con una media de 48 ± 10 anos. Se analizo la relacion entre la presencia de prolapsos urogenitales, sus diferentes grados, y la ocurrencia de hiperactividad del detrusor. Resultados De acuerdo con el examen clinico y el estudio urodinamico se observaron los siguientes resultados: prolapso anterior en 65 (70,6 %) de las mujeres y prolapso posterior en 31 (33,6 %). La hiperactividad del detrusor estaba presente en 13 de los prolapsos anteriores (20 %) y 6 de los prolapsos posteriores (19,3%). No se observo diferencia significativa en ninguno de los prolapsos examinados en relacion a la presencia de hiperactividad del detrusor: anterior (p=0,1639) y posterior (p=0,1849). Conclusion Los prolapsos urogenitales, en sus diferentes grados, no se relacionan con la incidencia de hiperactividad del detrusor en mujeres con incontinencia urinaria de esfuerzo.

Cuál es el valor de la biopsia aleatoria en el seguimiento del carcinoma uroterial superficial de vejiga

Resumen Introduccion Los pacientes con tumor de vejiga de tipo Carcinoma de Celulas Transicionales (CCT) presentan enfermedad generalizada de todo el urotelio. El seguimiento de los pacientes con diagnostico de CCT superficial es sumamente importante por la potencialidad de progresion tumoral. Algunos servicios de urologia defienden la biopsia aleatoria de forma rutinaria, sin embargo, otros servicios juzgan ese metodo innecesario y utilizan la cistoscopia asociada a la citologia urinaria como metodo de seguimiento. Materiales y Metodos Fueron analizados, retrospectivamente, 49 pacientes portadores de tumor superficial de vejiga (pTa y pT1), en el periodo de 10 anos. El seguimiento de este grupo se realizo a traves de examenes de cistoscopia, trimestrales en el primer ano, semestrales en el segundo y tercer ano, y anuales en el cuarto y quinto ano. Durante las cistoscopias se realizaron analisis de citologia de la orina y lavado vesical, biopsias de areas sospechosas y biopsias aleatorias. Resultados En el grupo de biopsias aleatorias (total de 1.489) se observaron 15 biopsias positivas (1%) y en el grupo de biopsias de areas sospechosas (total de 38) hubo 4 biopsias positivas (10,5%). Los resultados se consideraron positivos en presencia de tumor urotelial y carcinoma in situ. La citologia y/o el lavado vesical se presentaron positivas en 50 (17,4%) de las 288 cistoscopias realizadas. La sensibilidad de la biopsia, incluyendo las aleatorias y las dirigidas, fue de 31%, y su especificidad, de 85,2%, mientras que la asociacion de la citologia y el lavado urinario obtuvieron sensibilidad de 48% y especificidad de 86,5%. Conclusion La biopsia aleatoria no demostro mayor eficiencia en el diagnostico de recidiva tumoral de CCT superficiales cuando fue comparada a la citologia urinaria y el lavado vesical, los cuales presentan buenas tasas de sensibilidad y especificidad.