Valsalva leak point pressure to determine internal sphincter deficiency in stress urinary incontinence.

INTRODUCTION: Valsalva leak point pressure (VLPP) represents the global competence of the conjunctive forces around the urethra to support increased pressure from the abdominal cavity with transmission to the bladder. Assessment of VLPP has prognostic meaning, but measurement techniques are still subject to controversy. PATIENTS AND METHODS: One hundred and eight consecutive women with no genital prolapse or bladder hyperactivity exclusively presenting with urinary stress incontinence were submitted to VLPP determination during urodynamic evaluation using a rectal and urethral catheter. Rectal pressure measurement served as the landmark in the determination of Valsalva's maneuver. After determining the rectal pressure, the urethral probe was pulled out and the maneuver repeated. RESULTS: Eighty-four cases (group I) presented leakage during Valsalva's maneuver with the urethral catheter being in place. Group Ia (66.6%) had a reduction of 44.5 cm H(2)O in the rectal pressure after catheter removal. In group Ib, rectal leakage pressure increased after catheter removal from 76.5 +/- 18.7 to 79.5 +/- 24.7 cm H(2)O. Eight patients did not demonstrate urine leakage after catheter removal. In group II, 24 cases showed a rise in rectal leakage pressure to 76.2 +/- 22 cm H(2)O, but urinary leakage was only observed after catheter removal. In group IIa (19 cases), the VLPP decreased by 12.6 +/- 15 cm H(2)O, while in group IIb (5 cases) leakage occurred only in patients showing an increase of 22.2 +/- 7 cm H(2)O in the rectal pressure after the second maneuver with the urethral catheter in position. CONCLUSIONS: Precise determination of the abdominal leak point pressure through Valsalva's maneuver may be critical. The different techniques used for VLPP determination may render comparisons difficult. Rectal pressure measurement with no urethral catheter in place to monitor abdominal leak pressure seems to be more appropriate because it resembles clinical practice. Although lower abdominal leakage pressures may be found, this is not a uniform finding, and a higher incidence of type III incontinence may be expected, and critical analysis or painstaking repetition may be required in the case of lack of demonstration of urinary loss.

The percentage of positive biopsy cores as a predictor of disease recurrence in patients with prostate cancer treated with radical prostatectomy.

OBJECTIVE: To analyse the prognostic value of the percentage of positive biopsy cores (PPBC) in determining the pathological features and biochemical outcome of patients with prostate cancer treated by radical prostatectomy, as published data evaluating the prognostic value of PPBC in such patients have limitations. PATIENTS AND METHODS: A group of 534 patients with clinically localized prostate cancer was selected. The PPBC was defined as the number of positive biopsy cores/total number of biopsy cores x 100, and grouped into categories of <25%, 25.1-50%, 50.1-75% and 75.1-100%. Patients were divided in low-, intermediate- and high-risk groups according to the usual variables. RESULTS: The mean follow-up was 60.5 months. PPBC was associated with the preoperative serum prostate-specific antigen (PSA) level, biopsy Gleason score and clinical stage. On multivariate analysis, PPBC was a significant predictor of extraprostatic disease and seminal vesicle involvement. Of patients in the four PPBC categories, 16%, 27%, 33% and 60%, respectively, had biochemical recurrence (P < 0.001), and on Cox regression analysis, PPBC was an independent predictor of disease recurrence. After segregating patients into risk groups the PPBC further stratified patients using thresholds of 75% (P = 0.006), 25% (P = 0.026) and 50% (P = 0.011) for low-, intermediate- and high-risk groups, respectively. CONCLUSIONS: We confirmed, with a longer follow-up, the clinical utility of the PPBC in determining the pathological features and biochemical outcome of patients with prostate cancer treated with radical prostatectomy, and established thresholds for use in patients in the three risk groups.

Deep-seated sarcomas of the penis.

Mesenchymal neoplasias represent 5% of tumors affecting the penis. Due to the rarity of such tumors, there is no agreement concerning the best method for staging and managing these patients. Sarcomas of the penis can be classified as deep-seated if they derive from the structures forming the spongy body and the cavernous bodies. Superficial lesions are usually low-grade and show a small tendency towards distant metastasis. In contrast, deep-seated lesions usually show behavior that is more aggressive and have poorer prognosis. The authors report 3 cases of deep-seated primary sarcomas of the penis and review the literature on this rare and aggressive neoplasia.

Deep-seated sarcomas of the penis

Mesenchymal neoplasias represent 5 percent of tumors affecting the penis. Due to the rarity of such tumors, there is no agreement concerning the best method for staging and managing these patients. Sarcomas of the penis can be classified as deep-seated if they derive from the structures forming the spongy body and the cavernous bodies. Superficial lesions are usually low-grade and show a small tendency towards distant metastasis. In contrast, deep-seated lesions usually show behavior that is more aggressive and have poorer prognosis. The authors report 3 cases of deep-seated primary sarcomas of the penis and review the literature on this rare and aggressive neoplasia.

Alternative grafting technique for patients unsuited to heterotopic transplantation due to diseased pelvic conditions.

INTRODUCTION: An alternative technique for kidney transplantation is presented for patients in whom the use of pelvic vessels is precluded. PATIENTS AND METHODS: Of 482 cases of kidney or pancreas-kidney transplants, 4 were unsuited to heterotopic grafting, 1 due to multiple operations in the fossae and the 3 others due to extensive vascular occlusive disease. The patients were studied preoperatively by magnetic resonance angiography, which revealed extensive occlusive disease of the distal aorta and/or iliac vessels. RESULTS: The patients received kidneys from living related donors as a third or second transplant opportunity in the orthotopic position (2 cases). Gross dissection of the aorta revealed a thickened wall, impeding direct anastomoses between the recipient's arteries and the donated organ. After a termino-lateral Dacron graft to the aorta, all cases were stented for uretero-uretero anastomosis. Recovery with respect to the renal graft was uneventful for all cases. CONCLUSIONS: Alternative direct grafting from the aorta represents a viable and easy way to perform kidney transplants in patients unsuited to the heterotopic approach.

International prostate symptom score - IPSS - AUA as discriminat scale in 400 male patients with lower urinary tract symptoms (LUTS)

OBJECTIVE: This study analyzed the total symptom score, irritative and obstructive domains of IPSS questions regarding quality of life and the urodynamic diagnosis in 400 men with LUTS. MATERIALS AND METHODS: Four hundred consecutive male patients were prospectively enrolled after being submitted to full urodynamic evaluation and IPSS. Obstructed and non-obstructed patients were compared regarding the symptoms score and quality of life. Results were assessed through Wilcox, ANOVA and Student-t tests. RESULTS: 80.2 percent were diagnosed as urodynamically obstructed of which 42.4 percent presented detrusor instability in the filling phase. In obstructed patients there were no statistical difference concerning obstructive or irritative questions from IPSS (p = 0.50). It was not possible either to predict which patients presented detrusor instability based on the questionnaire (p = 0.65). Out of seventy-nine cases unobstructed (19.8 percent), 65.4 percent revealed detrusor instability. These cases could not be distinguished from all obstructed men based on the clinical questions measured by IPSS (p = 0.87). Obstructive and irritative questions did not present different indexes than obstructed cases (p = 0.63). Subjective quality of life index did not discriminate obstruction nor it could predict detrusor instability in both groups. CONCLUSION: Clinical symptoms and quality of life index measured by the IPSS as well as its obstructive and irritative domains do not have discriminating power to predict the presence of infravesical obstruction in males with LUTS, demanding objective tools to demonstrate obstruction.

International Prostate Symptom Score--IPSS-AUA as discriminat scale in 400 male patients with lower urinary tract symptoms (LUTS).

OBJECTIVE: This study analyzed the total symptom score, irritative and obstructive domains of IPSS questions regarding quality of life and the urodynamic diagnosis in 400 men with LUTS. MATERIALS AND METHODS: Four hundred consecutive male patients were prospectively enrolled after being submitted to full urodynamic evaluation and IPSS. Obstructed and non-obstructed patients were compared regarding the symptoms score and quality of life. Results were assessed through Wilcox, ANOVA and Student-t tests. RESULTS: 80.2% were diagnosed as urodynamically obstructed of which 42.4% presented detrusor instability in the filling phase. In obstructed patients there were no statistical difference concerning obstructive or irritative questions from IPSS (p = 0.50). It was not possible either to predict which patients presented detrusor instability based on the questionnaire (p = 0.65). Out of seventy-nine cases unobstructed (19.8%), 65.4% revealed detrusor instability. These cases could not be distinguished from all obstructed men based on the clinical questions measured by IPSS (p = 0.87). Obstructive and irritative questions did not present different indexes than obstructed cases (p = 0.63). Subjective quality of life index did not discriminate obstruction nor it could predict detrusor instability in both groups. CONCLUSION: Clinical symptoms and quality of life index measured by the IPSS as well as its obstructive and irritative domains do not have discriminating power to predict the presence of infravesical obstruction in males with LUTS, demanding objective tools to demonstrate obstruction.

Localized prostatic cancer in patients submitted to renal transplant.

OBJECTIVE: An attempt is made to evaluate the incidence of prostate cancer in patients who have previously undergone a kidney transplant surgery and to determine the best therapeutic approach to this target group. MATERIAL AND METHODS: All kidney transplant male patients over 40 years of age were studied with respect to diseases unrelated to the transplants, which later affected them, mainly focusing on neoplastic disease and, more specifically, prostate cancer. RESULTS: Of 397 kidney-transplanted patients, 146 (37%) were males, at least 40 years old. Among the 10 of them (6.8%) who developed neoplastic diseases, there were two cases (1.4%) of prostatic cancer. Both were treated with a radical retropubic prostatectomy with no technical difficulty, in spite of the presence of a graft in one of the iliac fossa. CONCLUSIONS: Prostate cancer incidence in kidney transplant patients is still low (1.8%), but it will certainly heighten as transplants are performed in increasingly older people and as better immunosuppressive drugs are introduced to lengthen the survival of grafts and patients. Because these cancers are expected to be more aggressive as a consequence of continuous immunosuppression, early diagnosis is of critical importance, and those patients should be made aware of the need for frequent screening for prostate cancer.