Octavio Arango

Holmium Laser Enucleation of Prostate: Outcome and Complications of Self-taught Learning Curve

OBJECTIVES To analyze the self-learning curve of a single surgeon with holmium laser enucleation of the prostate and to evaluate the safety, effectiveness, and outcome of the procedure after 2 years of experience. METHODS The data from the first 125 patients who underwent holmium laser enucleation of the prostate were retrospectively analyzed. The patients were assessed preoperatively and at 1, 3, 12, and 24 months postoperatively. The patient evaluations included serum prostate-specific antigen measurement, peak urinary flow rate determination, postvoid residual volume measurement, and symptom scores. To assess the effect of the learning curve on the perioperative data and complications, the patients were divided into subgroups of 25 consecutive patients. RESULTS The mean patient age was 71.4 years. The average prostate volume was 75.8 mL, and the mean weight of the enucleated tissue was 46.7 g. The average operative time was 109.8 minutes. The operative times and enucleation and morcellation efficiency rates improved significantly during the learning process. The mean hemoglobin loss was 1.7 g/dL. The median catheter time and hospital stay was 44 and 30 hours, respectively. Compared with baseline, at 1 year postoperatively, the median postvoid residual urine volume had declined by 99 mL, the mean peak urinary flow rate had increased by 19 mL/s, and the mean American Urological Association symptom score had decreased by 16.5 points. All changes observed were significant and regardless of the prostate size. Persistent stress urinary incontinence (4.8%) occurred with the first enucleations of large-size prostates. Other complications included bladder neck contracture (4%) in small-size prostates and bulbar urethra stricture (1.6%). CONCLUSIONS Holmium laser enucleation of the prostate is a safe, reproducible and effective surgical modality. Case selection is necessary to avoid the morbidity associated with the first stages of the self-taught learning curve, mainly urinary incontinence.

Massive renal infarction due to mucormycosis in an AIDS patient

SummaryIsolated renal infection byMucor spp. occurs very rarely, even in the immunocompromised host. The mortality of the different forms of mucormycosis reaches 75–100% in most series. Infection of the kidney is usually diagnosed post-mortem. Thus, when renal infection is recognized, aggressive treatment including surgery and amphotericin B is required. We present a case in which a massive left renal infarction was the unique manifestation of mucormycosis in an AIDS patient. Administration of amphotericin B and left nephrectomy were necessary to achieve satisfactory outcome.ZusammenfassungIsolierte Mucor-Infektionen der Niere sind auch bei abwehrgeschwächten Patienten eine Seltenheit. In den meisten Serien liegt die Letalität der verschiedenen Formen der Mucormykose bei 75 bis 100%. Meist wird die Infektion der Niere erst autoptisch diagnostiziert. Die Mucormykose der Niere erfordert eine aggressive Therapie mit Operation und Amphotericin B-Behandlung. Wir stellen einen AIDS-Kranken vor, bei dem sich die Mucormykose nur an der Niere manifestierte. Durch operative Entfernung der linken Niere und Behandlung mit Amphotericin B konnte ein zufriedenstellendes Ergebnis erzielt werden.

Effect of antibiotic treatment on serum PSA and percent free PSA levels in patients with biochemical criteria for prostate biopsy and previous lower urinary tract infections

BACKGROUND Controversy exists as to the influence of inflammatory foci on total and free prostate-specific antigen (PSA) concentrations. The objective was to analyze the biological variations of PSA and percent free PSA (%f-PSA) in patients with biochemical criteria for prostate biopsy (PSA higher than 4 ng/mL and normal rectal examination) and compare them with the variation induced by antibiotic treatment in a cohort of patients with a history of lower urinary tract infections and no clinical evidence of prostatitis. METHODS Ninety patients with a history of lower urinary tract infections, non-suspicious digital rectal examination and PSA between 4 and 20 ng/mL were analyzed. PSA concentration and %f-PSA were determined. Forty-five patients were treated with three weeks of ofloxacin, following which marker determination was repeated. All patients underwent ultrasound-controlled transrectal six-core prostate biopsy. RESULTS Sixty-seven patients presented benign prostatic hyperplasia (BPH) (30 with prostatitic foci) and 23 cancer. Significant variations in PSA (6.97 ng/mL vs. 5.82 ng/mL, p=0.001) and %f-PSA (14.84% vs. 17.53%, p=0.01) were found only in the treated patients. These differences were significant for patients with BPH-associated prostatitic foci and not for patients with BPH or cancer. The tendency was for PSA to decrease (15 treated patients with PSA <4 ng/mL vs. six non-treated patients) and for %f-PSA to increase. The median variation of %f-PSA was greater than that of PSA. When the cutoff for %f-PSA was set at 25%, 18.9% of unnecessary biopsies after the first determination and 20% after the second could be avoided. By associating the reduction in PSA, up to 46% could be avoided in treated patients. CONCLUSION Biochemical criteria for prostate biopsy may be modified in patients with a history of lower urinary tract infections due to variations greater than those explained by intraindividual biological variations, and may be influenced by the antibiotic treatment. These results suggest that subclinical inflammatory foci may influence PSA and %f-PSA.

A new biaxial epilated scrotal flap for reconstructive urethral surgery.

PURPOSE We describe a new type of perineum based scrotal flap with biaxial vascularization supplied by both superficial perineal arteries. Flap length of up to 20 cm. may be attained for urethral reconstruction. MATERIALS AND METHODS A total of 37 men with complex urethral stenosis of different etiologies underwent surgery using 1 of 3 urethroplasty techniques based on this new flap. The whole anterior urethra, including pendulous and bulbar segments, was reconstructed with a scrotal patch in 10 patients. A scrotal tubular flap was used as a substitute for the bulbar urethra in 7 patients and for the membranous portion in 4. Bulbar urethroplasty with a scrotal island patch was performed in 16 patients. RESULTS Of the patients 86% achieved normal voiding after 1-stage urethroplasty. Mean followup was 39.5 months. CONCLUSIONS The excellent axial vascularization of this new flap permits successful resolution of the most complex urethral stenoses regardless of extension, location and etiology.

Intravesical Migration and Spontaneous Expulsion of a Hem-o-lok Polymer Ligating Clip After Laparoscopic Radical Prostatectomy

We present a rare postoperative complication occurring after a laparoscopic radical prostatectomy with nerve-sparing procedure carried out with the placement of 3 Weck Hem-o-lok-L clips in the right neurovascular bundle, in a patient with clinically localized prostate cancer. The procedure was completed without any complications and the urethral catheter was removal at 15 days. We report a case of intravesical migration and subsequent calculus formation with spontaneous expulsion of Hem-o-lok clip. To date, this is the only reported case of intravesical migration and subsequent calculus formation with a spontaneous expulsion.

Scrotal Flap Epilation in Urethroplasty: Concepts and Technique

PURPOSE We describe our technique of scrotal epilation and the advantages of using the resultant glabrous scrotal skin in reconstructive urethral surgery. MATERIALS AND METHODS An insulated needle model adapted to scrotal hair characteristics and a thermocoagulation current generator were used. RESULTS An average of 3 epilatory sessions with a 4-week interval between treatments was the optimal schedule. No cutaneous infection was noted. CONCLUSIONS The good results permitted the conversion of predetermined scrotal zones into wide areas of alopecia to be used as excellent skin flaps in complex urethral stenosis surgery in postpubertal male patients.

Arteries of the scrotum: a microvascular study and its application to urethral reconstruction with scrotal flaps

To study scrotal microvascularization and apply the findings to the design of reliable skin flaps for reconstructive surgery of complex urethral or panurethral stenoses.

A Longer Duration of Neo-Adjuvant Combined Androgen Blockade Prior to Radical Prostatectomy May Lead to Lower Tumour Volume of Localised Prostate Cancer

OBJECTIVES To analyse tumour volume (TV) in clinically localised prostate cancer patients treated with neo-adjuvant combined androgen blockade (CAB) therapy prior to radical prostatectomy. PATIENTS AND METHODS Two hundred consecutive patients treated between 1996 and 2000 were retrospectively analysed. Fifty patients underwent radical prostatectomy alone and 45 were treated with CAB for 1-3 months, 83 for 4-6 months and 22 for more than 6 months before surgery. Logistic regression analysis was performed to identify the strongest independent prognosticator of organ-confined disease. RESULTS No evidence of residual cancer was found in 11 specimens (5.6%). Regarding TV, 20 specimens showed less than 0.1cc, 33 between 0.1 and 0.49cc and 86 more than 0.5cc. Smaller TV was found in CAB-treated patients. Significant correlation was observed between treatment duration and TV. In logistic regression analysis, only CAB duration and TV were significantly correlated with organ-confined disease. CONCLUSIONS Prominent regressive features and lower TV were found after neo-adjuvant CAB. It seems that more prolonged treatment may lead to greater tumoural regression. Only tumour burden and length of CAB therapy were independent variables significantly correlated with pathologically localised prostate cancer.

Hemiscrotectomy With Contralateral Testicular Transposition for Scrotal Cancer

PURPOSE Wide excision of scrotal tumors results in serious defects to such an extent that in some cases the contents of the scrotum cannot be preserved. We describe a hemiscrotectomy technique with transposition of the testis to the contralateral hemiscrotum that facilitates closure of the surgical wound and allows preservation of the testis. MATERIALS AND METHODS Our procedure was used in 3 patients with scrotal neoplasia, including 2 with squamous cell carcinoma and 1 with extramammary Pagets disease. After excision of the hemiscrotum affected by the tumor, which includes all layers of the scrotal wall, the testis is transposed into the contralateral hemiscrotum through a slit made in the medial scrotal septum. The defect is easily closed by apposing the surgical wound edges. RESULTS The 3 men were disease-free 8, 7 and 4 years after surgery, respectively. After intervention they remained pain-free. None had hydrocele or epididymitis secondary to placement of the 2 testes in the same hemiscrotum. CONCLUSIONS In appropriate candidates this technique allows the scrotal defect to be easily reconstructed after tumor excision without any need for skin flaps or free skin grafts. The procedure makes it possible to preserve the scrotal content and perform more radical treatment since the scrotal wall is completely excised.

Reversible azoospermia in a patient treated with triazolam.

This is a report of a 26-year-old schizophrenic man treated with triazolam, levomepromazine, trifluoperazine and biperiden, who showed complete absence of spermatozoa in seminal analysis with normal plasma hormone levels. Sperm count reached 151 x 10(6)/ml after 6 months of triazolam withdrawal. A reversible effect of triazolam is suggested at the level of the germinal cells which are differentiating, without affecting the stem cells.