[Dilemma in the treatment of angiomyolipoma]. / Dilema en el tratamiento del angiomiolipoma.

OBJECTIVE: To present our experience with renal angiomyolipoma. METHODS: The series comprised 27 patients (26 female, 1 male) with renal angiomyolipoma. Twenty-three (85%) had unilateral renal involvement and of the 4 remaining patients (15%) with bilateral involvement, three (10%) had tuberous sclerosis. RESULTS: Due to the complications, three patients with bilateral and one patient with unilateral renal involvement required surgery. Mean patient follow-up was 38 months. CONCLUSIONS: Surgery is warranted in patients with tumors of more than 4 cm, symptomatic or associated with tuberous sclerosis. Regular control evaluation is indicated for tumors less than 4 cm.

Elevation of prostate specific antigen in cardiac surgery with extracorporeal cardiopulmonary circulation.

PURPOSE: We evaluated the correlation of prostate specific antigen (PSA) and cardiac surgery in a group of patients with symptomatic benign prostatic hyperplasia operated on with or without extracorporeal cardiopulmonary circulation. MATERIALS AND METHODS: A total of 30 men 54 to 72 years old (mean age 62 years) undergoing cardiac surgery had PSA measured preoperatively and postoperatively. To provide the baseline PSA value a first serum sample was obtained before surgery, and PSA measurements were repeated 12 hours and 7 days postoperatively. Cardiac surgery was performed with extracorporeal cardiopulmonary circulation in 20 cases and without cardiopulmonary bypass in 10, constituted the control group. An 18F Foley catheter was left indwelling for the first 24 hours in both groups. RESULTS: In the study group there was a significant increase in PSA postoperatively (p = 0.01). However, in the control group the PSA was not statistically different before or after surgery (p = 0.16). These results indicate that there was a physiological relationship between the extracorporeal cardiopulmonary circulation and PSA. CONCLUSIONS: Although the etiology of this elevation is unknown, based on our data we conclude that extracorporeal cardiopulmonary circulation can cause an alteration in serum PSA unrelated to cardiac operation without extracorporeal bypass.

A long follow-up on prostate specific antigen density and prostate biopsy.

OBJECTIVE: To determine prostate specific antigen density (PSAD) in a risk population without evidence of prostatic cancer, and to assess the long-term usefulness of PSAD as a parameter for determining the need for a prostatic biopsy in patients with a normal digital rectal examination (DRE) and transrectal ultrasound (TRUS). METHODS: The records of 582 patients referred to the clinic between February, 1992 and February, 1994 were studied retrospectively. All these patients with lower urinary tract symptoms (LUTS) were evaluated based on the following parameters: digital rectal examination, serum PSA levels, prostate volume measured using transrectal ultrasound and PSAD. Prostatic biopsy was performed on 431 patients who had a serum PSA level greater than 4.0 ng/mL. A total of 299 patients (69.3%) had PSA levels between 4.0 and 10.0 ng/mL and represented the target population. The study had two parts, in the first one cancer was diagnosed just by one biopsy and in part II, the patients with negative biopsy in part I were followed for a two-year period and required 2 or 3 biopsies for diagnosis. Of the total of patients who had a negative prostate biopsy in part I of the study, 269 were followed for a period of two years with repeated prostate biopsies. RESULTS: Overall prostate cancer was detected in 22/299 (13.9%) patients, 6/105 (5.7%) with PSAD up to 0.15 and 16/194 (8.2%) with PSAD over 0.15 (p = 0.569). CONCLUSION: PSAD is a useful indicator in decreasing the number of negative biopsies in patients with benign prostatic hyperplasia. However, in a long-term follow-up the PSAD (cutoff level 0.15) was unable to predict which patients had a positive biopsy. According to our results, 5.6% of patients with prostate cancer will be missed using the PSAD criteria.

Ureteroscopic stone removal in the distal ureter. Why change?

PURPOSE: We compared our experience with ureteroscopic stone basket manipulation under fluoroscopic guidance to ultrasound ureterolithotripsy for distal ureteral stone removal. MATERIALS AND METHODS: Retrospectively, we analyzed the medical records of 981 patients with ureteral calculi between January 1994 and December 1995, of whom 483 (49%) were treated for stones in the lower ureter and constituted our study group. The decision of when to perform lithotripsy (group 2) versus a basket procedure (group 1) was based on a prospective nonrandomized study and both groups were compared historically. All 322 patients in group 1 (mean age 49 years, range 14 to 86) primarily underwent ureteroscopic stone basket manipulation using the 4-wire Segura* basket. If the calculus could not be removed with the basket and another procedure was necessary, the case was considered a failure. The 161 patients in group 2 (mean age 37 years, range 14 to 74) underwent initially ultrasound ureterolithotripsy for stone fragmentation followed or not by removal of the fragments with the basket. Stone size did not differ significantly between groups 1 (mean 0.9 cm., range 0.6 to 1.7) and 2 (mean 0.8 cm., range 0.7 to 2.0). Ureteroscopy was performed in both groups with epidural anesthesia and on an outpatient basis in the majority of cases. RESULTS: The stone-free rate after 1 procedure was 98.1 and 95.6% in group 1 and 2, respectively. For group 2 versus group 1 the operative time was longer (mean 50, range 25 to 90 versus mean 19 minutes, range 11 to 40, respectively, p < 0.001), the complication rate was greater (16.1 versus 4.3%, respectively, p < 0.001) and average hospital stay was longer (2.1 versus 0.15 day, respectively, p < 0.001). CONCLUSIONS: Ureteroscopic stone treatment with basket manipulation under fluoroscopic guidance or ultrasound ureterolithotripsy provided a high stone-free rate. However, stone removal with the basket manipulation technique should be considered the first choice for treatment of small distal ureteral calculi based on the minimal morbidity, and short operative and recovery times.

Correlation between the International Prostatic Symptom Score and a pressure-flow study in the evaluation of symptomatic benign prostatic hyperplasia.

PURPOSE: We examined the relationship between the International Prostatic Symptom Score (I-PSS) and the occurrence of bladder outlet obstruction caused by benign prostatic hyperplasia (BPH). MATERIALS AND METHODS: The American Urological Association developed a questionnaire to quantify the severity of symptoms resulting from BPH. A further question relating the impact of BPH to the quality of life was subsequently added. This questionnaire has been adopted by the World Health Organization and is known as the I-PSS. There are 4 questions related to obstructive symptoms and 3 related to irritative symptoms. Scores of 0 to 7, 8 to 19 and 20 to 35 represent mild, moderate and severe symptoms, respectively. During an 18-month interval the I-PSS questionnaire was administered to 258 patients 50 to 81 years old (mean age 63 years) with BPH. A pressure-flow study was used to determine the presence of bladder outlet obstruction in 227 patients. Based on the scores, the patients were divided into 31 with mild, 116 with moderate and 111 with severe obstruction. The pressure-flow study was not conducted on patients with a mild symptom score. RESULTS: Of the patients with a severe symptom score 92 (82.9%) had bladder outlet obstruction, compared to 62 (53.4%) with a moderate symptom score. Statistical analysis (Pearson chi-square test) showed that there was a significant positive correlation between the symptoms and the presence of bladder outlet obstruction. Thus, when the I-PSS was greater than 28, the probability of bladder outlet obstruction was more than 0.91. Stratification of the results according to the obstructive (0 to 20) and irritative (0 to 15) symptoms of the I-PSS yielded a significant positive correlation between obstructive symptoms and the presence of bladder outlet obstruction. Thus, when the obstructive symptom score was greater than 15, the probability of bladder outlet obstruction was greater than 0.91. CONCLUSIONS: When the total I-PSS is greater than 28 or the obstructive symptom score is greater than 15, a pressure-flow study must be avoided.

Extracorporeal shock-wave lithotripsy in children.

OBJECTIVES: To analyze the efficacy and complication rates of extracorporeal shock-wave lithotripsy in children. METHODS: Between 1987 and 1994, 8760 patients with urinary calculi were treated at our institution. A total of 70 (0.8%) children 3 to 14 years old underwent lithotripsy using the Siemens Lithostar or the Lithostar Plus. A total of 100 calculi in 74 urinary tracts were treated, requiring 129 extracorporeal shock-wave lithotripsy sessions. There were 47 caliceal stones, 31 in the renal pelvis, 16 in the ureter, and 6 staghorn stones. The Lithostar Plus was used in 8 patients, for 3 caliceal, 3 pelvic, and 2 staghorn stones. Follow-up consisted of nephrotomogram or ultrasound 1 day and 1 to 3 months postoperatively. RESULTS: Complete removal of all stone fragments was achieved in 98.5% of the patients after 3 months. Re-treatment was necessary in 20 patients (29.4%). All patients were treated as outpatients, 51 (72.9%) with intravenous sedation and 19 (27.1%) without anesthesia. Complications were present in 7 patients (10%) who had colic and received medical treatment, and convalescence was uneventful. CONCLUSIONS: Extracorporeal shock-wave lithotripsy using the Lithostar and the Lithostar Plus has been demonstrated to be an effective noninvasive procedure to treat radiopaque and even radiolucent or slightly opaque urinary calculi in children.

The influence of patient education level on the International Prostatic Symptom Score.

The American Urological Association developed a questionnaire to quantify the severity of symptoms due to benign prostatic hyperplasia (BPH). An additional question relating to the impact of BPH on the quality of life was added, and this questionnaire became known as the International Prostate Symptom Score (I-PSS) and was adopted by the World Health Organization. The objective of our study was to determine the influence of education on the I-PSS and to analyze the relationship of the effect on the questionnaire when self-administered or administered by professional medical personnel. I-PSS was administered to 92 patients 50 to 81 years old (mean age 63) with BPH. Patients were assessed into 2 groups according to the level of education. Group 1 was composed of 68 patients considered literate and group 2 comprised 24 patients considered illiterate by UNICEF criteria. Patients received orientation about the questionnaire and the manner of completion. The symptom index was self-administered (subgroup P) and administered with physician help (subgroup D). Statistical analysis was done using Wilcoxon method for nonparametric samples and regression analysis. The difference between P and D subgroups in group 1 was not statistically significant (p = 0.55). However, the difference between subgroups P and D in group 2 was statistically significant (p < 0.001). There was no correlation between the mean I-PSS in subgroup D of literate and illiterate groups. Our study suggests that illiterate patients were not able to answer the questionnaire but with the help of professional medical personnel the I-PSS could be extended to this group of patients without impairing the quality.

The importance of the prostate weight in transurethral microwave thermotherapy.

OBJECTIVE: Transurethral resection of the prostate (TURP) is still the gold standard in the treatment of benign prostatic hyperplasia (BPH). Prostate weight could be of importance on the result of transurethral microwave thermotherapy (TUMT). The present study attempted to elucidate this point. MATERIAL AND METHODS: Transurethral microwave thermotherapy (TUMT) was administered to 106 men with BPH. The patients were classified into two groups according to the weight of the prostate. Group 1 comprised 69 patients, aged 52 to 84 years (mean 65 years), whose prostate weighed up to 50 gm. Group 2 comprised 37 men, aged 55 to 87 years (mean 68 years) whose prostate weighed more than 50 gm. Prostate weight was determined by transrectal ultrasound. The protocol included history and physical examination (particularly digital rectal examination), laboratory evaluation (particularly measurement of PSA), transrectal ultrasound and uroflowmetry. The post-void residual urine was measured by urethral catheterization and ultrasound examination. RESULTS: There were 5/106 (4.7%) failure; therefore, a total of 101 patients were followed from 3 to 27 months, mean 7.7 months. Postoperatively, both groups showed improvement of all the parameters analyzed, except PSA (p < 0.01). However, comparison of the two groups for irritative and obstructive symptoms score and uroflow showed no significant difference. The decrease of the post-void residual urine was statistically greater in group 1 (p < 0.01). Group 2 showed a larger reduction in weight in comparison to group 1 (p < 0.01). Complications were observed in 12/101 (11.9%) cases, with no statistical difference between groups. Of a total of 7 patients with ejaculatory disorders, 5 patients with smaller prostate were observed. Recovery was not seen at more than 6 months follow up. CONCLUSION: The results showed no correlation between the prostatic weight and the efficiency of TUMT in the treatment of BPH.

[Treatment of benign prostate hypertrophy using Prostatron: a study of the effects of treatment temperature elevation]. / Traitement de l'hypertrophie bénigne de prostate par Prostatron: étude des effets d'une augmentation de la température de traitement.

Transurethral microwave thermotherapy was administered to 91 consecutive men with moderate to severe benign prostatic hyperplasia. Mean patient age was 68 years, with a range of 55 to 87 years. Treatment was given in one 60-minute session, on an outpatient basis and without anesthesia. Of the 91 original patients 67 (73.6%) were followed from 3 to 18 months, mean 6.1 months. The microwave emission was continuously monitored to permit the control of the urethral temperature level. Patients were prospective and randomly assessed into 2 groups: group 1 (34 patients) who underwent treatment with urethral temperature between 42 and 43 degrees C and group 2 (33 patients) treated with higher temperature ranging between 43.1 and 45 degrees C. There was improvement of the irritative and obstructive symptoms, prostate weight and residual urine, in both groups after treatment (p < 0.001). PSA did not show a statistically significant difference after TUMT in both groups. Uroflow improved in both groups after the treatment; however, only the group treated with higher temperature showed statistically significant difference (p < 0.001). In the lower temperature group there were 2/34 (5.8%) failures; both patients were still obstructed and underwent transurethral resection. A total of 2/33 (6%) failures were observed in the higher temperature group. Patients showed no general conditions which might allow the use of anesthesia. Therefore, they underwent a second postoperative microwave treatment after 2 and 3 months with uneventful clinical recovery at an early follow-up. No systemic complications were encountered. There were minor complications such as epididymitis, urethral bleeding and severe micturition discomfort within the first 30 days postoperative.(ABSTRACT TRUNCATED AT 250 WORDS)

The importance of hyperprolactinemia in impotence.

The role of serum prolactin in sexual dysfunction has not yet been clarified. Moderate elevations of prolactin levels, without any associated disorder, occur frequently. A random group of 600 patients was studied to determine the level of prolactin in which medical treatment was necessary. Among these patients 23 (3.8%) presented hyperprolactinemia and were divided into two groups: Group 1--Twelve patients with prolactin levels ranging from 20 to 40 ng/ml, and Group 2--Eleven patients with levels higher than 40 ng/ml. In Group 1, prolactin of all patients returned to normal levels after treatment, but only one patient (8.3%) achieved full erection; on the other hand, in Group 2, nine out of eleven patients prolactin returned to normal after treatment and 77.7% achieved full erection.

[Extracorporeal lithotripsy or ureteroscopy for the treatment of calculi of the lower ureter]. / Lithotritie extracorporelle ou urétéroscopie pour le traitement des calculs du bas uretère.

Two therapies, ureterolithotripsy (URL) and extracorporeal shock wave lithotripsy (ESWL) can be used in the treatment of lower ureteral calculi. In a retrospective analysis ureterolithotripsy and extracorporeal shock wave lithotripsy for lower ureteral calculi were compared to evaluate morbidity. During a 3 year period 161 patients treated with ureterolithotripsy and 71 who underwent extracorporeal shock wave lithotripsy (Siemens Lithostar) were analysed as to the success rate, effectiveness quotient, complication rate and length of hospitalization. Followup consisted of ultrasound and a plain film of the kidneys, ureteres and bladder 1 day and 1 to 3 months postoperatively. Complete removal of all stone fragments was achieved in 95.5% of the patients treated endourologically with a 1.2% retreatment rate. In the group treated with extracorporeal shock wave lithotripsy success rate was 82.1% with a 19.6% retreatment rate. Among the patients who underwent ureteroscopy and stone removal 16.1% had complications compared to 10.7% in the ESWL group. The mean stone diameter was 0.8 cm in the endourological group and 0.7 cm in the ESWL group. Stone size was not a determining factor for the stone free rate and effectiveness quotient in the patients treated endourologically. Indeed, in patients who underwent ESWL for large stones the stone-free rate and effectiveness quotient decreased to 78.9% and 57.7%. Ureterolithotripsy will continue to have a primary role in the management of lower ureteral stones. As extracorporeal shock wave lithotripsy is an effective noninvasive procedure, requiring no anesthesia and hospitalization as routine, it may be considered an alternative either primarily or after failed ureteroscopy.

Urinary tract involvement in EEC syndrome: a clinical study in 25 Brazilian patients.

We have evaluated 25 patients (14 isolated and 11 familial cases) with the EEC syndrome for genitourinary (GU) tract anomalies through intravenous pyelogram (IVP), voiding urethrocystography, and sonographic examination. Fifty-two percent of the patients (7 isolated and 6 familial cases) had involvement of the urinary tract, with no significant difference between isolated and familial cases. The present data seem to reflect the best estimate of the prevalence of genitourinary anomalies in patients with the EEC syndrome.

Immunoprophylaxis of superficial bladder cancer: a prospective and randomized comparison of oral versus intravesical Bacillus Calmette-Guerin.

A total of 84 patients with superficial transitional cell carcinoma underwent transurethral resection of bladder tumor. All patients had stage pTa or pT1 transitional cell carcinoma or carcinoma in situ without other concurrent malignancies. The patients were assigned to three treatment groups: I. Control group-transurethral resection (TUR-BT) discontinued within the study. II. Oral BCG group-TUR-BT plus BCG (Moreau). III. Intravesical BCG group-TUR-BT plus BCG. Of 9 patients in the control group, 8 (89%) experienced tumor recurrence during a mean follow-up of 20 months. Of the 33 patients in the oral BCG group, 13 patients (39.3%) had recurrence during a mean follow-up of 39 months. Of the 42 patients in the intravesical group, 8 patients (19%) had recurrence in a 30-month mean follow-up. The incidence of complications was higher in the intravesical (33.4%) than in the oral BCG group (24.2%). These results showed that intravesical BCG is a more effective immunotherapy; however, oral BCG can be utilized in patients who do not accept intravesical BCG administration.

Treatment options for ureteral calculi: endourology or extracorporeal shock wave lithotripsy.

Two therapeutic methods, endourology and extracorporeal shock wave lithotripsy (ESWL), can be used in the treatment of ureteral calculi. In a retrospective analysis during a 2-year period 236 patients treated with endourological procedures and 71 who underwent ESWL with a Siemens Lithostar were analyzed as to the success rate, effectiveness quotient, complication rate and hospitalization. The mean stone size was 1.12 cm. in the endourology group and 1.03 cm. in the ESWL group. Complete removal of all stone fragments was achieved in 93.6% of the patients treated endourologically and without retreatment. In the ESWL group success was obtained in 90.1%, with an 11.2% retreatment rate. The retreatment rate was higher (25.0%) for calculi in the mid ureter. The group treated endourologically had a better success rate and no retreatment was necessary. On the other hand, the group treated with ESWL had a shorter hospitalization and a lower complication rate. Followup ranged from 11 to 60 months (mean 48 months) in the endourology group and 7 to 29 months (mean 11 months) in the ESWL group. These observations showed that in situ ESWL therapy with the Siemens Lithostar device is the method of choice for upper ureteral stones. Lower ureteral calculi should be treated endoscopically. Mid ureteral stones larger than 1 cm. had better results with endoscopic procedures and those smaller than 1 cm. had better results with ESWL.

Oral or intravesical bacillus Calmette-Guerin immunoprophylaxis in bladder carcinoma.

A total of 71 patients with superficial transitional cell carcinoma underwent transurethral resection of bladder tumor. All patients had stage pTa or pT1 transitional cell carcinoma or carcinoma in situ without other concurrent malignancies. The patients were assigned to 3 treatment groups: control group--transurethral resection discontinued within the study, oral bacillus Calmette-Guerin (BCG) group--transurethral resection of bladder tumor plus BCG (Moreau) and intravesical BCG group--transurethral resection of bladder tumor plus BCG. Of 9 patients in the control group 8 (89%) experienced tumor recurrence during a mean followup of 20 months. Of the 28 patients in the oral BCG group 11 (39.3%) had recurrence during a mean followup of 36 months. Of the 34 patients in the intravesical group 6 (18%) had recurrence in a 24-month mean followup. The incidence of complications was higher in the intravesical (41.2%) than in the oral BCG group (28.5%). These results show that intravesical BCG is a more effective immunotherapy; however, oral BCG can be used in patients who do not accept intravesical BCG administration.

Comparative study of the fertility potential of men with only one testis.

The fertility potential of 54 men aged between 19 and 42 years, who had undergone unilateral orchidectomy was evaluated. In all cases the remaining testis was of normal volume and consistency. The patients were divided into four groups according to the cause of the orchidectomy: group I--cryptorchism (n = 19), group II--testicular torsion (n = 14), group III--testicular cancer (n = 12) and group IV--accidental (n = 9). The time between orchidectomy and seminal analysis varied from 6 months to 30 years (median 5 years). All semen samples were examined at the same laboratory, and no differences in sperm concentration were found among the groups. 53% in group I, 57% in group II, 50% in group III, and 56% in group IV had sperm counts of less than 20 million/ml. Our results suggest that unilateral orchidectomy leads to a considerable decrease in fertility potential, whatever the reason for it.

Endourological management of ureteral strictures.

We reviewed the records of 20 patients (21 ureters) treated during the last 5 years for ureteral stricture disease. The causes of stricture formation included ureterolithotripsy in 47.7% of the patients, open ureterolithotomy in 9.5%, other urological procedures in 23.8%, general surgical and gynecological procedures in 9.5% and miscellaneous factors in 9.5%. A total of 20 patients (21 ureters) underwent endourological treatment with balloon dilation (19) or balloon dilation and internal ureterotomy (2), with good results in 57.1% and a mean followup of 24 months. Of the 9 patients who failed endourological management 3 underwent successful open repair, 3 underwent nephrectomy, and 3 had a relatively large ureteral lumen and became asymptomatic, receiving no further treatment. The interval between injury and treatment was not a decisive factor. The length of ureteral stricture assumes the most significant parameter to predict success in the treatment of ureteral stricture. There were no intraoperative or postoperative complications. The association of balloon dilation and incision by special endoureterotomy scissors is a potentially useful technique.

Cavernosometry: corroboratory method to surgical treatment of impotence due to venous leakage.

There are still controversies about the mechanism of penile erection. Arterial aspects of impotence have received considerable attention, but just recently the venous component became widely recognized. Twenty patients with abnormal cavernosometry (flow rate over 280 mL/min) and no rigid erections (intracavernosal pressure lower than 80 mm Hg) were analyzed. Surgical ligation of the dorsal veins was performed in 12 cases, 9 of which also required ligation of the crus of each corpus cavernosum. After these ligations, erection improved sufficiently to allow satisfactory intercourse in 9 of 12 patients. Two patients became impotent after eight months of normal sexual performance. The 3 failures showed persistently high flow rates and one leakage by the crural edge which had not been ligated at surgery. In selected patients with organic impotence the venous abnormalities should be assessed routinely and dorsal veins and the crural edge of the corpus cavernosum should be ligated in an attempt to restore erectile function.