Adverse Features of Rectourethral Fistula Requiring Extirpative Surgery and Permanent Dual Diversion: Our Experience and Recommendations.

INTRODUCTION: To report a series of men with a rectourethral fistula (RUF) resulting from pelvic cancer treatments and explore their therapeutic differences and impact on the functional outcomes and quality of life highlighting the adverse features that should determine permanent urinary or dual diversion. METHODS: A retrospective database search was performed in four centers to identify patients with RUF resulting from pelvic cancer treatment. Medical records were analyzed for the demographics, comorbidities, diagnostic evaluation, fistula characteristics, surgical approaches and outcomes. The endpoints analyzed included a successful fistula closure following a repair and the impact of the potential adverse features on outcomes. RESULTS: Twenty-three patients, aged 57-79 years (median 68), underwent an RUF reconstruction. The median follow-up (FU) was 54 months (range 18-115). The patients were divided into two groups according to the etiology: radiation/energy-ablation treatments with or without surgery (G1, n = 10) and surgery only (G2, n = 13). All of the patients underwent a temporary diverting colostomy and suprapubic cystostomy. Overall, a successful RUF closure was achieved in 18 (78%) patients. An interposition flap was used in six (60%) patients and one (7.7%) patient in groups G1 and G2, respectively (p = 0.019). The RUF was managed successfully in all 13 patients in group G2 as opposed to 5/10 (50%) in group G1 (p = 0.008). The patients in the radiation/energy-ablation group were more likely to require permanent dual diversion (50% vs. 0%, p < 0.0075). CONCLUSION: Radiation/energy-ablation therapies are associated with a more severe RUF and more complex reconstructions. Most of these patients require an abdominoperineal approach and flap interposition. The failure of an RUF repair with the need for permanent dual diversion, eventually combined with extirpative surgery, is higher after previous radiation/energy-ablation treatment. Therefore, permanent dual diversion as the primary treatment should always be included in the decision-making process as reconstruction may be futile in specific settings.

Quantitative estimation of thrombus-erythrocytes using MRI. A phantom study with clot analogs and analysis by statistic regression models.

BACKGROUND: Thrombus composition has the potential to affect acute ischemic stroke (AIS) treatment. OBJECTIVE: To evaluate in an in vitro test the correlation of clot composition, especially erythrocytes (red blood cells (RBCs)), with the variation of signal intensity ratio (SIR) obtained with MRI sequences used for AIS, and qualification of the susceptibility vessel sign effect using clot analogs. MATERIALS AND METHODS: Nine ovine clots were fixed in a gelatin-manganese solution and studied by MRI (T2GE, T2-weighted gradient echo; SWI, susceptibility-weighted imaging; FLAIR, fluid attenuated inversion recovery). RBC concentration was estimated using regression models (SLR, single linear regression; MLR, multiple linear regression; RF, random Forest; and ANN, artificial neural networking), which combined the SIR-histology relationship of three MRI sequences. RESULTS: Negative correlation was found between SIR and RBC concentration. T2GE SWI could not statistically distinguish clots with RBC content >54% and <23%. SLR was applied only to FLAIR images since T2GE and SWI demonstrated signal saturation. All four regression models showed a correlation between MRI and histology: SLR=0.981; MLR=0.986; RF=0.994, and ANN=0.971. One unknown clot was studied and agreement between SIR and histological analyses was found in all models. CONCLUSIONS: We presented a method to quantify RBC concentration in clot analogs, combining SWI, T2GE, and FLAIR. This in vitro study has some limitations, so clot collection after thrombectomy with simultaneous imaging analysis is necessary to validate this model.

The Impact of Sacral Neuromodulation on Sexual Dysfunction.

BACKGROUND/AIMS: Sacral neuromodulation (SNM) is a well-established treatment in several urinary and bowel dysfunctions, nevertheless its role on sexual dysfunction remains unclear. We evaluate the impact of SNM on sexual function and its association with age at SNM, functional diagnosis and post-void residual urine (PVR) before SNM. METHODS: Patients who had SNM were retrospectively analyzed. Sexual function was assessed before and after treatment with the International Index of Erectile Function (IIEF-5) for men and the Female Sexual Function Index (FSFI) for women. IIEF-5 and FSFI were also associated with age at SNM, functional diagnosis, and PVR. RESULTS: Fifteen females and 9 males, with a median age of 41 years (26-72 years), median follow-up 20.7 months (2-53 months) were enrolled. IIEF-5 improved in 4 patients (p = 0.06), and FSFI total score in 5 (p = 0.2). There was significant association between functional diagnosis and FSFI total score (p = 0.05), and FSFI specific domains of arousal (p = 0.03), lubrication (p = 0.04), and satisfaction (p = 0.03), with significant improvement showed in patients with detrusor overactivity with impaired contractility. CONCLUSION: Although gains observed in IIEF-5 and FSFI were modest, our preliminary results show that SNM may have favorable impact on sexual function.

Meta-Analysis of the Sensitivity of Decision Support Systems in Diagnosing Diabetic Retinopathy.

Diabetic Retinopathy (DR) is one of the most common microvascular complications presenting by patients diagnosticated with diabetic diseases. Uncontrolled hyperglycemia may manifest as visual impairment and blindness. The early detection of DR is essential to minimize the risk and consequence of visual diminishing. The standard gold diagnoses tool relies on different imaging modalities and requires a judgment of expert photographers, which are not available in most of the primary care centers or remote location. In that scenario, an automate or semiautomated DR screening systems can contribute to improving the accuracy of the diagnostic. Thus, we performed a Systematic Review and Meta-Analysis to evaluate the Decision Support Systems (DSS) in diagnosing DR. The overall Diagnostic Odds Ratio was 73.15 (95%CI: 37.54-142.50), sensitivity was 97.70 (95%CI: 97.50-97.90) and specificity was 90.30 (95%CI: 90.00-90.60). Our results corroborate with the concept of usefulness of DSSs in early diagnosis, screening and preliminary evaluation of suspicious images of DR.

Laparoscopic Training in Urology Residency Programs: A Systematic Review.

BACKGROUND/AIMS: Laparoscopy is a widespread surgical approach for many urological conditions. Achieving prof-ciency in laparoscopic surgery requires considerable effort due to the steep learning curve. Several residency programs include standardized laparoscopic training periods in their curricula. Our aim was to systematically analyze the evidence on the current status of training in laparoscopy in different residency programs in urology. METHODS: We performed a systematic review of PubMed/Medline and the Cochrane library, in February 2018, according to the Preferred Reporting Items for the Systematic Review and Meta-Analyses Statement. Identified reports were reviewed according to the previously defined inclusion criteria. Eight publications, comprising a total of 985 urology residents, were selected for inclusion in this analysis. RESULTS: There was a wide variation between training programs in terms of exposure to laparoscopy. Most residents considered that training in lap-aroscopy was inadequate during residency and had a low degree of confidence in independently performing laparo-scopic procedures by the end of the residency. Only North American residents reported high degrees of confidence in the possibility of performing laparoscopic procedures in the uture, whereas the remaining residents, namely from European countries, reported considerably lower degrees of confidence. CONCLUSION: There were considerable differences between national urology residency programs in terms of exposure to laparoscopy. Most residents would prefer higher exposure to laparoscopy throughout their residencies.

Nine-year survival after iterative metastasectomies for renal cell carcinoma.

We report the case of a 24-year-old male, diagnosed with an incidental T3a papillary renal cell carcinoma (RCC), treated with left laparoscopic radical nephrectomy. After 7 months, nodal recurrence was identified and retroperitoneal lymph node dissection (RPLND) was performed. Four months later, due to local recurrence, the patient underwent salvage RPLND, partial psoas resection and left adrenalectomy, and remained without recurrence during the following 15 months, after which treatment with sunitinib was started due to multiple metastases in pelvic lymph nodes, lungs, and bone. After 4 years of stable disease, progression at the quadratus lumborum and psoas muscles led to subsequent metastasectomy. No evidence of progression was identified for 2 years, after which, despite multimodal treatment (axitinib and radiotherapy to bone lesions), widespread disease progression led to patient death. This uncommon case of prolonged survival with metastatic RCC highlights the possible role of iterative metastasectomies in the management of advanced stage disease, as well as its potential to extend the survival substantially, even when progressive on tyrosine kinase inhibitors.

Low-intensity shock wave therapy for erectile dysfunction and the influence of disease duration.

OBJECTIVE: Low-intensity shock-wave treatment (LiSWT) is a therapy for erectile dysfunction (ED) with good results reported in the literature. The aim of this study was to evaluate the results of LiSWT on patients treated for ED and the influence of ED duration in treatment outcomes. MATERIAL AND METHODS: We performed an open-label single-arm prospective study of patients treated with LiSWT for ED. Patients were assessed with the IIEF-5 at baseline and at six weeks and three months after LiSWT, and with penile dynamic Doppler ultrasound before treatment and six weeks after. Patients were divided into two groups accordingly to ED evolution time: ≤ 24 months and > 24 months. RESULTS: Twenty-five patients were enrolled, 13 had ED ≤ 24 months and 12 > 24 months. Median baseline IIEF-5 was 14, at 6 weeks post LiSWT was 16 (p < 0.001) and at 3 months post LiSWT was 18 (p < 0.001). Mean baseline peak systolic velocity (PSV) was 29.3 ± 13.0 cm/s, after LiSWT was 35.9 ± 15.2 cm/s (p 0.001). Mean baseline end-diastolic velocity (EDV) was 2.6 ± 4.8 cm/s and after LiSWT was 1.3 ± 4.3 cm/s (p 0.015). No statistical significative difference was identified between the two groups. CONCLUSIONS: LiSWT is a safe, harmless and repeatable treatment tool for ED with good outcomes reported. Our results suggest that length of disease duration doesn´t negatively influences treatment results.

Bilateral synchronous testicular seminoma: A rare presentation of a rare disease.

OBJECTIVE: To present a case of a bilateral synchronous testicular seminoma in a young male clinical stage IIB. MATERIAL AND METHOD: A 37 years old man presented a bilateral testicular mass with elevated tumoral markers. Histology of frozen section revealed bilateral seminoma and bilateral radical orchiectomy was performed. RESULT: Enhanced chest and abdominopelvic staging CT scan revealed a lymphadenopathy of 30 mm within the inter-aortocava nodal chain (stage IIB). Patient received three cycles of BEP. Three months later 18F-FDG PET showed no evidence of hypermetabolic activity and serum tumoral markers were normal. CONCLUSION: Bilateral testicular germ cell tumors are a rare disease. Management of this tumors is controversial. Bilateral radical orchiectomy is the standard of care, nevertheless, in order to preserve fertility and androgen production, an organsparing surgery can be attempted in selected cases. Although prognosis is good, with overall survival rates similar to patients with unilateral disease, life-long close follow-up may be advocated due to relapse risk.

Incidental Detection of Occult Thyroid Carcinoma with 11C-Choline PET/CT for High Risk Prostate Cancer.

We report a case of a 65-year-old male patient with high-risk prostate cancer, re-staged with 11C-choline positron emission tomography/computed tomography (PET/CT) for prostate specific antigen recurrences 3 years after radical prostatectomy and adjuvant radiation therapy. In addition to 2 suspicious presacral lymph nodes which were resected and proven to be metastatic, PET/CT revealed a very high uptake in a calcified thyroid nodule. Evaluation with fine needle aspiration was suspicious for thyroid carcinoma and the patient underwent total thyroidectomy, confirming a non-metastatic encapsulated follicular variant of papillary thyroid carcinoma. To our knowledge, this is the first report of a thyroid cancer diagnosed with 11C-choline PET/CT for prostate cancer staging.

"Horrendoplasty" - A case of total perineal destruction by agricultural implement.

Although posterior urethral injury occurs almost always in association with pelvic fracture, it may result from severe trauma to the perineum with its associated potential lethality and severe morbidity. Early primary endoscopic realignment over a urethral catheter can be attempted, although an immediate suprapubic tube placement remains the standard of care. Definitive treatment consists of elective open posterior anastomotic urethroplasty through a perineal approach. The authors present a 53-year-old man who sustained total, massive perineal destruction resulting from work accident with an agricultural implement. Immediate suprapubic tube placement was performed followed by delayed elective transperineal anastomotic posterior urethroplasty. A major multidisciplinary approach was necessary in the management strategy, including orthopedic, general, plastic, vascular surgeries, and reconstructive urology teams. At a later stage, with the patient stabilized and recovered from major, life-threatening lesions dealt with by a multidisciplinary team, urethral reconstruction can be undertaken with ultimate good functional outcomes.

Hutch bladder diverticulum - unusual cause of adult obstructive uropathy.

OBJECTIVE: To present a case of a Hutch bladder diverticulum containing the ureteral opening. MATERIAL AND METHODS: An 83-year-old man presented a giant bladder diverticulum causing obstructive azotemia due to bilateral ureteral compression. Endoscopy revealed an unusual and potentially harmful anatomical alteration: the left ureteral orifice was inside in the diverticulum. Despite bladder emptying, the diverticulum remained full, causing bilateral ureteral compression. The patient underwent diverticulectomy with ureteroneocystostomy. RESULT: Post-operative follow-up showed renal and voiding functions restoration. CONCLUSION: Although clinical watching is a valid option in patients with Hutch diverticulum, reconstructive surgical approach, especially when complications are present, should be the standard of care.

Magnetohyperthermia for treatment of gliomas: experimental and clinical studies / Magnetohipertermia para o tratamento de gliomas: estudos experimentais e clínicos

Gliomas comprise a group of heterogeneous primary tumors of the central nervous system that originate from glial cells. Malignant gliomas account for the majority of primary malignant CNS tumors and are associated with high morbidity and mortality. Glioblastoma is the most frequent malignant glioma, and despite recent advances in diagnosis and new treatment options, its prognosis remains dismal. New opportunities for the development of effective therapies for malignant gliomas are urgently needed. Magnetohyperthermia consists of heat generation in the region of the tumor through the application of magnetic nanoparticles subjected to an alternating magnetic and has shown positive results in both preclinical and clinical assays. The aim of this review was to assess the relevance of hyperthermia induced by magnetic nanoparticles in treating gliomas and to describe possible variations of the technique and its implication in the effectiveness of treatment. An electronic search in the literature of articles published from January 1990 to November 2009 was performed, in databases ISI Web of Science and PubMed, and after screening according to the inclusion criteria, 11 articles were selected. Animal models showed that magnetohyperthermia was effective in promoting tumor cell death and reducing tumor mass or increasing survival of the animals. One clinical study demonstrated that magnetohyperthermia could be applied safely and with few adverse effects. Some studies suggested that mechanisms of cell death, such as apoptosis, necrosis, and antitumor immune response were triggered by magnetohyperthermia. Based on these data, it was concluded that the technique proved to be effective in most experiments, and improvement of the nanocomposites, as well as of the alternating magnetic equipment, can contribute towards establishing magnetohyperthermia as a promising tool to treat malignant gliomas.

Gliomas compõem um grupo de tumores primários heterogêneos do sistema nervoso central (SNC) derivados de células gliais. Gliomas malignos representam a maioria dos tumores primários malignos do SNC e estão associados a índices altos de morbidade e mortalidade. Glioblastoma é o glioma mais frequente e maligno e, apesar dos avanços recentes no diagnóstico e das novas opções de tratamento, seu prognóstico permanece obscuro. Novas oportunidades para o desenvolvimento de terapias efetivas para gliomas malignos são urgentemente necessárias. A magnetohipertermia, a qual consiste na geração de calor na região do tumor por meio da aplicação de nanopartículas magnéticas submetidas a um campo magnético alternado, tem apresentado resultados positivos em testes pré-clínicos e clínicos. O objetivo desta revisão foi verificar a relevância da hipertermia induzida por nanopartículas magnéticas no tratamento de gliomas e notar as possíveis variações da técnica e sua implicação na efetividade do tratamento. Realizamos uma busca eletrônica na literatura científica de publicações de Janeiro de 1990 a Novembro de 2009, nos bancos de dados ISI Web of Science e PubMed e, após a aplicação do critério de inclusão, obtivemos um total de 11 artigos. Estudos baseados em modelos animais demonstraram que a magnetohipertermia foi efetiva em promover a morte celular tumoral e reduzir a massa do tumor ou aumentar a sobrevida dos animais. Um estudo clínico mostrou que a magnetohipertermia pode ser aplicada seguramente e com poucos efeitos adversos. Alguns estudos sugerem que mecanismos de morte celular, tais como apoptose, necrose e resposta imune antitumoral foram desencadeadas por magnetohipertermia. Com base nesses dados podemos concluir que a magnetohipertermia foi efetiva na maioria dos experimentos e que o aperfeiçoamento dos nanocompostos, assim como dos equipamentos de campo magnético alternado, podem contribuir para o estabelecimento da magnetohipertermia como uma ferramenta promissora no tratamento dos gliomas malignos.

Magnetohyperthermia for treatment of gliomas: experimental and clinical studies.

Gliomas comprise a group of heterogeneous primary tumors of the central nervous system that originate from glial cells. Malignant gliomas account for the majority of primary malignant CNS tumors and are associated with high morbidity and mortality. Glioblastoma is the most frequent malignant glioma, and despite recent advances in diagnosis and new treatment options, its prognosis remains dismal. New opportunities for the development of effective therapies for malignant gliomas are urgently needed. Magnetohyperthermia consists of heat generation in the region of the tumor through the application of magnetic nanoparticles subjected to an alternating magnetic field and has shown positive results in both preclinical and clinical assays. The aim of this review was to assess the relevance of hyperthermia induced by magnetic nanoparticles in treating gliomas and to describe possible variations of the technique and its implication in the effectiveness of treatment. An electronic search in the literature of articles published from January 1990 to November 2009 was performed, in databases ISI Web of Science and PubMed, and after screening according to the inclusion criteria, 11 articles were selected. Animal models showed that magnetohyperthermia was effective in promoting tumor cell death and reducing tumor mass or increasing survival of the animals. One clinical study demonstrated that magnetohyperthermia could be applied safely and with few adverse effects. Some studies suggested that mechanisms of cell death, such as apoptosis, necrosis, and antitumor immune response were triggered by magnetohyperthermia. Based on these data, it was concluded that the technique proved to be effective in most experiments, and improvement of the nanocomposites, as well as of the alternating magnetic field equipment, can contribute towards establishing magnetohyperthermia as a promising tool to treat malignant gliomas.