Sílvio Henrique Maia de Almeida

Comparison between PSA density, free PSA percentage and PSA density in the transition zone in the detection of prostate cancer in patients with serum PSA between 4 and 10 ng/ml

OBJECTIVE Compare the capacity of the PSA density (PSAD), Free PSA percentage (%FPSA) and PSA transition zone density (PSATZ) in improving the sensitivity and specificity of the PSA to detect prostate cancer (PCa) in men with a PSA between 4 and 10 ng/mL. MATERIALS AND METHODS One hundred and forty five men with PSA between 4 and 10 ng/mL were prospectively studied. Blood collection for the total PSA and free PSA was performed as well as transrectal ultra-sound with prostate biopsy and measurement of the total prostate volume (TPV) and transition zone volume (TZV). Patients with initial negative biopsy were followed and the prostate biopsy was repeated in those that presented PSA increase. The capacity of the PSAD, %FPSA and PSADTZ in improving the sensitivity and specificity pf the PSA test to the detection of the PCa was assessed by univariate and multivariate analyses and through the ROC curve. RESULTS Of the 145 patients, 38 (26.2%) had PCa and in 107 (73.8%) a benign prostate disease was diagnosed. No difference among the PSAD, %FPSA and PSADTZ was found. The multivariate analysis showed that the PSADTZ, %FPSA, TZV and age were those more powerful and highly significant PCa predictors. CONCLUSION The determination of %FPSA and PSAD can allow a better discrimination between PCa and benign disease that the isolated use of PSA. The combination of PSADTZ, %FPSA, TZV and age promote a high accuracy for PCa detection.

Influence of sling material on inflammation and collagen deposit in an animal model

Aim:  Compare inflammation and collagen production induced by four sling materials in female rats.

Use of cadaveric fascia lata to correct grade IV cystocele

We describe a modification of the cadaveric prolapse repair and sling - CaPS technique that uses the sling surgery principles to correct grade IV cystocele. In this modification, the central and paravaginal defects reconstitution are performed using cadaveric fascia lata fixed over rectus abdominis muscle, eliminating the need of pubic fixation by screws, as proposed by the original technique. The modification described, besides presenting the benefits of CaPS, i.e., not using impaired tissues to reconstruct vesical support, and lower risks of perineal hypercorrection, also reduces the probability of complications of bone fixation.

Variables predictive of voiding disfunction following aponeurotic sling surgery: multivariate analysis

INTRODUCTION Aponeurotic sling surgeries can evolve with obstruction or voiding dysfunction in 5 to 20% of patients. There are few studies on factors that could possibly predispose to voiding difficulties or urinary retention. The objective of this work is to identify these potential clinical or urodynamic factors. MATERIALS AND METHODS Records from 130 patients who underwent aponeurotic sling surgeries were reviewed. All patients underwent a throughout urodynamic study during pre-operative investigation. The variables studied were age above 65 years, previous pelvic surgeries, concomitant surgeries, post-voiding residue higher than 100 mL, vesical obstruction (according to Blaivas-Groutz nomogram) and urinary flow under 12 mL/s. Post-voiding residue was assessed on the seventh post-operative day through vesical catheterization. Recovering of spontaneous voiding after 7 post-operative days or with a residue higher than 100 mL, was regarded as voiding dysfunction. Univariate analysis was performed with qui-square test and Fishers exact test, and multivariate analysis was performed by logistic regression with alpha = 5%. RESULTS Age in the studied group ranged from 41 to 83 years (mean 56.7 years), with 69 (53%) patients having urethral hypermobility and 61 (47%) having intrinsic urethral lesion. Normal voiding occurred in 97 (75.6%) women with 7 post-operative days. The only significant variable in the univariate (p = 0.014) and multivariate (p = 0.017) analysis was post-voiding residue higher than 100 mL. CONCLUSION Pre-operative presence of a post-voiding residual urine higher than 100 mL was the only variable predictive of voiding dysfunction.

Post-cheotherapy residual mass in non-siinomatous testicular cancer: the role of retroperitoneal lymph node dissection

PURPOSE To determine the role of RPLND for residual masses following chemotherapy in patients with non-seminomatous germ cell tumors (NSGCT) stage T1N2 and T1N3 (IIB and IIC). MATERIALS AND METHODS We have preformed retrospective analysis of 11 patients who underwent RPLND for residual masses following chemotherapy in an oncologic reference center between January 1997 and December 2002. All patients harbored either pure nonseminomatous or mixed tumors in the testis tissue and had undergone 4 cycles of primary chemotherapy with bleomycin, etoposide and cisplatin. The residual masses were assessed by abdominal computed tomography preoperatively. RESULTS There were perioperative complications in 3 cases owing to vascular iatrogenic lesion. One of who died in the early postoperative period due to extensive iliac thrombosis. The other 2 patients had an inferior vena cava injury owing to the difficulty in removing the attached lymph nodes. The injuries were repaired by continuous suture with Prolene 5-0. All patients had tumors in the final pathological report and were referred to other 2 cycles of chemotherapy with the same drugs. Seven patients (63.3%) had complete response and remained free of the disease in a mean follow up of 38.3 months (ranging from 12 to 72). The remaining 3 patients had disease progression, 2 of which died 6 and 12 months after surgery, respectively, and one patient missed the follow-up after salvage chemotherapy. CONCLUSION Retroperitoneal lymph node dissection for residual masses after chemotherapy is a high-morbidity procedure, even by experienced surgeons, although it remains an efficient modality of treatment in advanced germ cell carcinoma. The high frequency of tumor found in the RPLFN following chemotherapy might have been caused by the small number of patients in this study.

Histological response to platelet-rich plasma added to polypropylene mesh implemented in rabbits.

ABSTRACT Introduction: The platelet-rich plasma (PRP) is part of a set of biotechnologies, providing some growth factors that promote repair of different tissues. The polypropylene meshes (PPM) are applied in the correction of abdominal defects, pelvic floor and urinary incontinence, however, they induce many significant complications, as a result of an inappropriate inflammatory response. Purpose: To investigate the changes caused by PRP associated with the implantation of PPM in the abdomen of female rabbits, in the production of collagen I and III and the inflammatory infiltrate (ININ). Materials and Methods: We performed implant meshes with and without PRP in adult rabbits (n=30) and euthanasia at 7, 30 and 90 days. Two plates were prepared from each animal and analyzed in five different fields. The ININ was evaluated by quantification of inflammatory cells using hematoxylin-eosin and the collagen by Sirius red method. The results were analyzed applying the Wilcoxon, Kruskal-Wallis, Junckheere and Friedmann tests. Results: There was a significant difference in the number of inflammatory cells between the groups with and without PRP (p=0.01) at 90 days. There was increased production of collagen I, III and total with the use of PRP, at seven days. Conclusion: The PPM coating with PRP was associated with increased ININ at the implant area, and an increasing trend during the process of tissue repair. The PPM coated with PRP was related to increased concentration of collagen I, collagen III and the concentration of total collagen increased after seven days of implantation.

Small-bowel obstruction and bladder injury due to retropubic sling malposition in the peritoneal cavity

We report a case of small-bowel obstruction caused by an internal hernia produced by the presence of an intraperitoneal sling mesh. A woman with a history of multiple abdominal surgeries was referred from another center after a sling procedure. On the fifth day after surgery, she developed small-bowel obstruction. Exploratory laparotomy showed the distal ileum compressed between the visceral peritoneum of the bladder and a loop mesh sling. The segment of ileum was repositioned into the peritoneal cavity and the sling segment was resected. In cases of small-bowel obstructions after a mesh surgery, one must be aware of the possibility of bowel entrapment and that the mere presence of intraperitoneal tape can trigger the obstruction.

Purple urine-bag syndrome

Described in 1978, the purple urine-bag syndrome (PUBS) is a rare condition in which the urine and the collection bag become predominantly purplish [1]. PUBS has a strong correlation with intestinal constipation, female gender, urinary tract infection (UTI), and, of course, the use of an indwelling catheter, which may be present in the short term, as in the postoperative period [2]. It is an ucommon occurrence, but prevalence of PUBS has been reported to be as high as 9.8% in institutionalized patients with long-term indwelling urinary catheter use. The mechanism of PUBS (Fig. 1) originates from the dietary digestion and absorption of tryptophan in the bowel. Bacteria in the intestine metabolize the tryptophan to indole, and in addition, hepatic enzymes form the conjugate indoxyl sulfate for secretion into urine by the kidneys. In the urinary tract, gram-negative bacteria phosphatases and sulfatases metabolize the indoxyl sulfate to indoxyl and complete oxidation, which may convert to indigo and indirubin [3]. PUBS indicates infection of the urinary tract with gram-negative organisms; however, it may present as an asymptomatic bacteriuria also. Considering the risk of progression to septicemia, PUBS should be treated appropriately. The differential diagnosis includes hematuria, porphyria, alkaptonuria, and consumption of food such as blackberries, beetroots, carrots, fava beans, and oral aloe therapy. Also, ibuprofen, phenytoin, propofol, and L-dopa can cause urine discoloration.

Intravesical human papillomavirus (IHPV) infection-endoscopic resection.

A 38-year-old woman, with a history of urinary tract infections. She denied other diseases and complained of painful urination. The genital examination, cervical cytology and colposcopy were normal. Urinalysis showed leukocytosis, but a negative culture. The ultrasound was normal. A cystoscopy was performed, showing polypoid growth on the bladder mucosa followed of the TR. Histopathologic analysis (HA) confirmed IHPV (in situ hybridization positive for 6, 18, 31 subtypes), associated a Bladder Squamous Metaplasia (BSM). The patient recurrence-free was for 5 years when a cystoscopy demonstrated BSM, which was resected. The patient had not any other sites (urethral, genital or anal) of recurrence during the period of follow-up.

Endoscopic use of cyanoacrylate glue in the treatment of urethral fistula.

PURPOSE The aim of this video is to demonstrate an endoscopic and minimally invasive repair of an urethrocutaneous fistula with cyanoacrylate glue. MATERIALS AND METHODS A 56 year-old-man with post-infectious urethral stricture and recurrent perineal abscess formation due to urethral fistulas. RESULTS The operative time was 60 minutes, no major complications were observed perioperatively and postoperatively. At a follow-up time of 6 months the patient had no evidence of recurrent fistula and abscess formation. CONCLUSIONS The endoscopic use of cyanoacrylate glue represents a safe and minimally invasive approach that might be offered as a first line option for the treatment of urinary fistulas in selected patients, especially those with narrow and long tracts.