Túlio M. Graziottin

LAPAROSCOPIC PROSTATECTOMY WITH VASCULAR CONTROL FOR BENIGN PROSTATIC HYPERPLASIA

Retropubic and suprapubic prostatectomy has been used as an alternative to transurethral prostatic resection in selected patients with large benign prostatic hyperplasia.1 Minimally invasive therapies such as visual laser ablation, electrovaporization and transurethral incision of the prostate are indicated for treatment of the early stages of benign prostatic hyperplasia.1 Recently, the use of holmium laser has been proposed as an alternative approach for the treatment of prostates weighing more than 100 gm.2 We describe the use of laparoscopic resection of large (greater than 75 gm.)1 hyperplastic prostatic adenomas as an alternative to open prostatectomy.

The effect of vascular endothelial growth factor on a rat model of traumatic arteriogenic erectile dysfunction

PURPOSE We tested the hypothesis that intracavernous injection of vascular endothelial growth factor (VEGF) can restore erectile function in a rat model of traumatic arteriogenic erectile dysfunction. MATERIALS AND METHODS Exploration of bilateral internal iliac arteries was performed in 50, 3-month-old male rats. A total of 44 rats underwent bilateral ligation of the internal iliac arteries and 6 that underwent exploration only served as the sham operated group. Minutes later intracavernous injection of phosphate buffered saline (PBS) plus bovine serum albumin in 16 rats, 2 microg. VEGF plus PBS plus BSA in 12 and 4 microg. VEGF plus PBS plus BSA in 16 was performed. At weeks 1, 2 and 6 about a third of the rats in each group underwent electrostimulation of the cavernous nerves to assess erectile function and were then sacrificed. Penile tissues were collected for histochemical and electron microscopy examinations. RESULTS No impairment of erectile function was noted in sham operated rats. Immediately after arterial ligation all rats showed little or no erectile response to neurostimulation. In PBS treated rats modest recovery of erectile function was noted at week 6. Significant recovery of erectile function was noted in VEGF treated rats at weeks 1 and 2 in the 4 microg. group only and at week 6 in the 2 and 4 microg. groups. Neuronal nitric oxide synthase staining showed a reduction in neuronal nitric oxide synthase positive nerve fibers in the dorsal or intracavernous nerves at week 1. Moderate recovery of neuronal nitric oxide synthase positive nerve fibers was noted in the 2 and 4microg. VEGF treated groups but not in the PBS treated group. Electron microscopy revealed no pathological change in sham operated rats. In dorsal nerves the atrophy of myelinated and nonmyelinated nerve fibers was noted in ligated plus PBS treated rats. Partial recovery was observed in VEGF treated rats. Scattered atrophic smooth muscle cells were seen in PBS and occasionally in VEGF treated rats but not in the sham operated group. The most dramatic findings in VEGF treated rats were hypertrophy and hyperplasia of the endothelial cells, especially those lining the small capillaries. CONCLUSIONS Ligation of bilateral internal iliac arteries produced a reliable animal model of traumatic arteriogenic erectile dysfunction. Intracavernous injection of VEGF minutes after arterial ligation facilitated the recovery of erectile function.

Long-term effect of ovariectomy and simulated birth trauma on the lower urinary tract of female rats.

PURPOSE Using an animal model we studied the long-term effects of ovariectomy and simulated birth trauma in the development of apoptosis as well as the urodynamic, histological and ultrastructural findings 9 months after such procedures. MATERIALS AND METHODS A total of 24 pregnant Sprague-Dawley female rats were used. Immediately after delivery 14 animals underwent vaginal ballooning and ovariectomy, while the remaining 10 served as controls. At 9 months the animals underwent urodynamic evaluation, which included the urethral pressure profile. The rats were then sacrificed and urogenital tissue was obtained for immunostaining using terminal deoxynucleotidyl transferase mediated deoxyuridine triphosphate nick end-labeling, histomorphometry evaluation and electron microscopy. RESULTS Immunostaining demonstrated a significant increase in the apoptotic index in the urethra of castrated/ballooning rats with a predominance in the submucosa layer. Maximum urethral closure pressure was significantly lower in that group, although there was no correlation of apoptosis with maximum urethral closure pressure measurement. Urodynamic evaluation revealed only discrete alterations in cystometric parameters. Morphometric evaluation showed increased connective tissue in the vagina. Electron microscopy of urethral smooth muscle demonstrated altered cellular shape, increased intercellular space with collagen deposition and some degeneration of the mitochondria. CONCLUSIONS Apoptosis in the urethra occurs 9 months after castration and simulated birth trauma. However, this finding was not seen in the muscle layers or in other urogenital tissues. Some ultrastructural changes also occurred that may explain some symptoms that women have after vaginal childbirth and menopause.

VASCULAR ENDOTHELIAL GROWTH FACTOR PROMOTES PROLIFERATION AND MIGRATION OF CAVERNOUS SMOOTH MUSCLE CELLS

PURPOSE We investigated whether cavernous smooth muscle cells secrete vascular endothelial growth factor (VEGF), how they respond to VEGF and how age affects their ability to secrete and respond to VEGF. MATERIALS AND METHODS Corpus cavernous tissues were isolated from rats of various ages and grown as monolayer cell cultures. Smooth muscle identity was determined by immunofluorescence staining. Secreted VEGF was measured with a VEGF enzyme-linked immunosorbent assay kit. Cell proliferation was assayed with a cell titer kit. Cell migration was measured with Transwell chambers. VEGF receptor (VEGFR) messenger RNA and proteins were identified by reverse transcription-polymerase chain reaction and immunoblotting, respectively. RESULTS Cavernous smooth muscle cells from young (age 1 week) and old (age 28 months) rats secreted the least amounts of VEGF and those from 16-week-old rats secreted the most. VEGF stimulated the growth of cavernous smooth muscle cells at an optimal concentration of 12.5 ng./ml. At this concentration cavernous smooth muscle cells from 11-week-old and 28-month-old rats showed the highest and lowest growth rates, respectively. The optimal VEGF concentration for cavernous smooth muscle cell migration was 10 ng./ml. At this concentration cells from 4-week-old and 28-month-old rats showed the highest and lowest migratory rates, respectively. The expression of VEGFR-1 appeared to parallel the VEGF regulated growth rates of these cells. VEGFR-2 was undetectable in cavernous smooth muscle cells. CONCLUSIONS Cavernous smooth muscle cells from rats of different ages secreted different amounts of VEGF and showed different abilities to respond to VEGF. Cavernous smooth muscle cells responded to VEGF in terms of cell proliferation and migration. Cavernous smooth muscle cells from rats of different ages expressed different levels of VEGFR-1 but did not express VEGFR-2.

TRANSPERITONEAL PREPERITONEAL LAPAROSCOPIC LUMBAR INCISIONAL HERNIORRHAPHY

PURPOSE Flank incisions may be associated with flank hernias, which may be complicated by incarceration and strangulation. Furthermore, they may be the cause of significant patient dissatisfaction with the surgical outcome. To avoid an open surgical procedure with its associated morbidity for hernia repair we describe a novel laparoscopic technique for repairing flank hernias with minimal morbidity and an excellent outcome. MATERIALS AND METHODS Three cases of flank hernia were managed by the transperitoneal preperitoneal laparoscopic approach using polypropylene mesh to repair the fascial defect. An initial transperitoneal approach helps to identify the limits of the hernia. A 2 to 3 cm. margin of overlying peritoneum is incised around the hernia margin. It is important not to dissect overlying bowel. The mesh is placed behind the peritoneal envelope and secured with hernia staples. RESULTS All cases were managed successfully via laparoscopy. There were no intraoperative or postoperative complications. At a mean followup of 12 months cosmesis has been excellent and there have been no recurrences. CONCLUSIONS We describe a minimally invasive, versatile technique for laparoscopic repair of flank incisional hernias with excellent functional and cosmetic results. This approach avoids the significant morbidity associated with open repair of incisional flank hernias.

Long-term follow-up of penile curvature correction utilizing autologous albugineal crural graft

PURPOSE Peyronie s disease is an acquired connective tissue disorder of the penile tunica albuginea with fibrosis and inflammation. The disease produces palpable plaques, penile curvature and pain during erections. Usually it results in impairment of the quality of life. Our objective is to review the long-term results of the albugineal grafting harvested from the penile crura for the treatment of severe penile curvature. MATERIALS AND METHODS Thirty-three patients with Peyronie s disease were submitted to a grafting with tunica albuginea from the penile crura for the correction of penile curvature. The results were evaluated after 6 months of the procedure. Variables studied were overall satisfaction with the procedure, correction of the penile curvature, erectile capacity, penile shortening and the presence of surgical complications. RESULTS Mean follow-up after surgery was 41 months. Complete correction of the curvature was achieved in 30 patients (90%). The mean preoperative curvature was 91.8 degrees and median plaque length was 2 cm (ranged from 1 to 5 cm). Three patients (9%) experienced recurrence of the penile curvature and required a new procedure. In 30 men (90%) the procedure fulfilled their expectations and in 31 patients (93.9%) their opinions were that sexual partners were satisfied with the penile correction. Penile shortening or augmentation was referred in 6 (18.1%) and 1 (3%) patient, respectively. CONCLUSION Our series demonstrated that grafting the albugineal defect after incision of the tunica albuginea with tunica from the crus for the correction of penile curvature is safe and results in satisfactory straight erections during along-term follow-up.

Magnetic Spheres as Foreign Body into the Bladder

INTRODUCTION A great variety of foreign bodies in the lower urinary tract have been described; many of them are self-inflicted by the patient with masturbatory purposes. Depending on the nature of the foreign body the diagnostic and management might be challenging. AIMS We report a case of an unusual magnetic self-inserted foreign body into the bladder for autoerotism and briefly discuss the diagnostic and therapeutic implications in this challenging situation. METHODS We describe all the steps we have used to adequately diagnose the problem, describe the foreign body and treatments for the patient. Related articles were found by utilizing the PubMed database and are summarized in this study. RESULTS   The management approach must be planned according to the nature of the foreign body and should minimize bladder and urethral trauma. However, most of cases can be managed endoscopically. CONCLUSION Removal of magnetic foreign body may be quite challenging, requiring high-level surgical skills and minimally invasive techniques resulting in fast recovery and low complication rate.

Long-term survival of autotransplanted major pelvic ganglion in the corpus cavernosum of adult rats.

PURPOSE Neurogenic impotence is a common complication after radical pelvic surgery, irradiation or perineal trauma. Neuronal transplantation is a new frontier for treating neurological disorders. We investigated whether the major pelvic ganglion can survive and become functional after being implanted into the corpus cavernosum in adult rats. MATERIALS AND METHODS Adult male rats (13) were divided into 3 groups and sacrificed at 3 time points, namely 30 (4), 60 (5) and 90 (4) days. All rats underwent excision of the right major pelvic ganglion and left cavernous nerve. The right ganglion was implanted into the right crus of the penis. Electrostimulation was applied to the left major pelvic ganglion and cavernous nerve (1.5 mA.) and right crus (10 mA.) at sacrifice. The crural region and left ganglion were then excised for immunostaining of neuronal nitric oxide synthase (nNOS), protein gene product 9.5 and growth associated protein 43. Image analysis was used to calculate the area stained in pixels. Electron microscopy of the implanted area was performed to assess neuronal survival. RESULTS Although the degree varied, all neuronal implants survived after transplantation. The response to electrostimulation was insufficient to produce erection. No difference was noted among the areas of nNOS staining when specimens from the 3 time points were compared. The area of expression of nNOS, protein gene product 9.5 and growth associated protein 43 was larger in the implanted area than in the surrounding cavernous tissue. Under electron microscopy most surviving implants showed normal ultrastructure, although areas of fibrotic replacement were seen in several implants. CONCLUSIONS Our results show that the autotransplanted major pelvic ganglion expresses nNOS, protein gene product 9.5 and growth associated protein 43, and survived up to 90 days after implantation into the corpus cavernosum. Further studies with fetal neuronal tissue seem warranted.

937 SPERMATOGENESIS IN THE TESTICULAR PARENCHYMA IPSILATERAL TO GERM CELL TUMORS

INTRODUCTION AND OBJECTIVES: Introduction: Testicular cancer is the most common malignancy in young men at the peak of their reproductive potential. Due to the high cure rates in patients with testicular tumors, there has been an increasing clinical importance towards fertility?s protection. However, the act of sperm collecting with masturbation might be a huge issue for young adolescents and certain religions. The aim of this study is to assess the spermatogenesis in the testicular parenchyma ipsilateral to germ cell tumors in patients who underwent radical orchiectomy and estimate the feasibility of sperm retrieval synchronously during radical orchiectomy. METHODS: The archived histological specimens of 54 patients who had undergone radical orchiectomy for primary testicular cancer between 2002 and 2011 were reviewed. The area of normal testicular parenchyma was examined to evaluate spermatogenesis using the modified Johnsen score. A minimum of 10 and maximum of 20 seminiferous tubules were scored per case. RESULTS: The predominant histological pattern was hypospermatogenesis in 24% of the cases. Mature spermatozoa was identified in 35% of the testicular sections. In an univariate analysis, LDH, tumor volume, tumor staging and nodal metastatic disease were all inversely related to the probability of identifying mature spermatozoa in the testis (p 0.001, p 0.001, p 0.01 and p 0.002, respectively) Spermatogenesis in the parenchyma ipsilateral to seminoma tumor compared to nonseminoma tumor had a lower Johnsen score (p 0.0001). In a multivariate analysis, only tumor volume and nodal metastasis disease independently predicted the Johnsen score (p 0.004 and p 0.003, respectively). CONCLUSIONS: A 35% probability of recovering spermatozoa ipsilateral to the germ cell tumors was found in archived histological specimens. Sperm retrieval at the time of radical orchiectomy is a feasible fertility option for patients with testicular cancer in which age and religion might be limiting factors for sperm collecting with masturbation.