february 2012edition

Dr. Carlos D'Ancona

Dear readers, a new year started and we hope you benefit from the Urovirt. In this number, the session of learning with images we present the contribution of Magnetic Resonance in identify suspicious recidivate lesions. Perirenal hematoma after extracorporeal lithotripsy is more frequent when is investigate with Computerize Tomography than symptoms that patients relate, read more in clinical case session. At the end in new technologies is presented new technique to preserve the neurovascular bundle during radical prostatectomy p r o c e d u r e . D o n o t m i s s U r o l o g y N e w s .

editorialboard

Dr. Carlos D'Ancona Dr. Paulo Palma Dr. Daniel Carlos Silva

Co-editors:

Dr. Cassio Riccetto Dr. Ricardo Miyaoka Dr. Ricardo Souza

Radiology - Editorial Committee

Dr. Adilson Prando Dr. Athanese Billis

Editorial Committee

Dr. Guido Barbagli Dr. Manoj Monga Dr. Mario João Gomes Dr. Matthias Oelke Dr. Philip van Kerrerbroek Dr. Mark Soloway

Editors: Associated Editor:

Pathology - Editorial Committee

clinicalCASE

Mitrofanoff Procedure

Impact on quality of life in a femalemyelomeningocele patient

edition: February - 2012

Elaine Bronzatto, Daniel Carlos Silva

Department of Urology, FCM - UNICAMP

Nineteen year-old female patient with a lumbar (L2-L3) myelomeningocele corrected at birth, bilateral hip dysplasia and paraplegia. She has a history of recurrent UTI episodes and incontinence during her childhood. At the age of 6 years she underwent a urethral elongament by Pippi-Salle technique and bladder ileocystoplasty.

During clinical follow up no UTIs were detected and she was fully continent on CIC every 6 hours. Patient is not able to perform self catheterism in sitting position due to her hip dysplasia. Her mom's help is needed to catheterize in horizontal position and to help her spread her legs apart. The dependency on her caregiver limited her daily activities including job tasks.

In order to promote her independency a continent catheterizable channel as described by Mitrofanoff was done (Figures 1 to 5). Patient became able to self catheterize and improved her self esteem.

clinicalcaseedition: February - 2012 Elaine Bronzatto, Daniel Carlos Silva Department of Urology, FCM - UNICAMP

Figure 1 - Appendix dissection and preservation of vascular supply (arrow).

Figure 3 - Skin incision through the umbilicus where Mitrofanoff channel will be sutured (arrow).

Figure 2 - Apendiceal implantation according to Abol Eneim technique into the ileal part of the augmented bladder.

Figure 4 - Appendix sutured to the umbilicus. Continence was tested by injecting 300 mL of saline into the reservoir with no sign of extravasation.

Figure 5 - Final aspect; silicon catheter is placed inside the channel.

Clean self intermittent catheterism initiated a new era in neurogenic bladder treatment as it allows for urinary continence, upper urinary tract preservation and reduction of UTI episodes. Male patients can face off more difficulty when catheterizing as their urethra is longer. Lubrication is needed to avoid urethral injury, but locating the urethral meatus is easier than in the female patient. The technique may be performed in sitting position.

For female patients however, this is rather challenging and impossible at times. The need for the patient to lie down in order to perform bladder catheterism is disturbing and may prevent her to engage in routine and job tasks. The possibility of external abdominal continent urinary diversion made it possible for these patients to become independent from caregivers.

A great advance was achieved after continence technique description by Abol-Enein to prevent channel reflux. The technique basically consists in anchoring the intestinal loop in a plicature around the catheterizable channel which may be the appendix or a Monti tube. Ease to catheterise and reservoir continence are both maintained.

Message

Carlos D'AnconaProfessor Chief of Urology, FCM - UNICAMP

clinicalcaseedition: February - 2012 Elaine Bronzatto, Daniel Carlos Silva Department of Urology, FCM - UNICAMP

Retroperitoneal mixoid tumor

learningby imageEdition: February - 2012

Franciso Carlos Lopes, Daniel Carlos Silva e Elaine Ingrid Amstalden

Division of Urology and Department of Pathology, School of Medical Sciences - UNICAMP.

learningby imageEdition: February - 2012Franciso Carlos Lopes, Daniel Carlos Silva e Elaine Ingrid Amstalden Division of Urology and Department of Pathology, School of Medical Sciences - UNICAMP

Mensagem

Sixty three year-old male complains of a 2 years long right lumbar pain. Abdominal CT scan shows a 12 cm large lesion adjacent to the right kidney with no other associated pathological findings. (Figures 1 and 2).

Figure 1 - CT scan, axial cuts: hiperdense solid lesion at posterior aspect of right kidney (arrow).

Figure 2 - CT scan sagital cuts: retroperitoneal lesion with associated hemorrhage (arrow).

Pathological findings (figures 3 and 6):

Large retroperitoneal low grade mixoid tumor.

Figure 3 - Macroscopy: 13,4 cm large tumor weighing 930g. Smooth external aspect filled partially with fat tissue. Ipsilateral adrenal gland is intact. Well defined tumor with jelly aspect and pale yellowish necrotic component and firm consistency.

Figure 4 - Microscopy: elongated cell proliferation, star-like cells at times surrounded by loose matrix with mixoid pattern and very well vascularized. There are no atypia cells nor mitosis figures. There extense necrotic areas and some vascular and stromal hialinization. (H&E- original 20x).

Following negative functional hormonal testing surgical removal was undertaken.

Mensagem

Immunochemistry

Fig. 5 (Vimentine - original 10x)- High diffuse positivity in tumoral cells for Vimentine antibodies.

Fig. 6 (CD34 - original 20x)- High diffuse positivity in tumoral cells for CD34.

Highly positive for Vimentine and CD34. No expression of epithelial markers (citoqueratins) nor neural markers (S-100 Protein and NSE). Low cellular proliferation index (< 1%).

This case illustrates a high volume low grade retroperitoneal mixoid tumor. Low grade tumors may silently grow and reach large volumes in “hidden” locations such as the retroperitoneum where they can continuously develop for long time.

Large volume may explain the central necrotic area of the tumor. In order to distinguish among the multiple mixoid tumors variants immunochemistry may be used. No criteria wa found to determine low grade Evans fibromixoid sarcoma and the lack of neuromarkers does not support the diagnosis of Schwannoma.

Message

Eliane M. Ingrid AmstaldenDepartment of Pathology, UNICAMP

learningby imageEdition: February - 2012Franciso Carlos Lopes, Daniel Carlos Silva e Elaine Ingrid Amstalden Division of Urology and Department of Pathology, School of Medical Sciences - UNICAMP

newTECHNOLOGIESEdition: February - 2012

Ricardo Souza

Division of Urology - Unicamp

Laser treatment of benign prostatic obstruction: basic and physical differences

newTECHNOLOGIESedição: Fevereiro de 2012Ricardo Souza Division of Urology - Unicamp

This is an interesting review over the use of laser in the surgical treatment of benign prostatic obstruction (data from the second meeting of the European Association of UrologySectioin of Uro-Technology – ESUT).

TURP and open prostatectomy remain the gold standard treatments for BPH. The larger the prostate the more common associated surgical complications. This is the rationale for the pursuit of newer technologies and endoscopic approaches.

Laser stands for light amplification by stimulated emission of radiation. In BPH treatment different types of laser can be used. They differ regarding the stimulating source and active mean which result in distinct wave lengths and emission modes.

Thermal effects over the prostate are produced after laser interaction and absorption by the tissue. The absorbed energy leads to molecular excitation and temperature elevation resulting in vaporization, carbonization and coagulation necrosis. The influencing variables which ultimately determine the final laser effects include wave length and targeting tissue (prostate has 2 main targets: Hemoglobin molecules and intracellular water).

Com o aquecimento produzido pela absorção da energia, o aumento térmico pode não atingir o ponto de ebulição e assim levar a necrose de coagulação tecidual. Se este nível térmico é ultrapassado, surge a vaporização. Geralmente, os 2 fenômenos ocorrem simultaneamente: vaporização na superfície e necrose nas camadas mais profundas.

The resultant heat from energy absorption rise the tissue temperature but may not reach the ebullition point causing tissue coagulation necrosis. If this thermal level is surpassed vaporization occurs. In general, both processes occur simultaneously: vaporization in the superficial layers and necrosis in the deeper ones.

There 3 options of laser use for BPH treatment:

1) Adenoma vaporization from the prostatic urethra through the prostate capsule;

2) Resection of prostate fragments just like TURP;

3) Enucleation: resulting from a inner capsule i n c i s i o n f o l l o w e d b y m o r c e l l a t i o n ;

Choosing the adequate laser fiber for the adequate laser procedure is key. Vaporization requires side-firing laser fiber directing the laser beam towards the prostatic urethra. For prostate enucleation laser must be fired from the fiber very tip mimicking the surgeon's own finger.

CLINICAL APPLICATIONS

There 3 options of laser use for BPH treatment:

Laser source is also dependent on the chosen procedure. Enucleation requires minimal laser penetrance not to damage adjacent structures to the prostate pseudocapsule (rectum, neurovascular bundle). High coagulation capacity is optimal to treat patients with bleeding disorders. Adenoma deep penetrance and hemoglobin molecules absorption may both be advantageous as the there is a fairly large distance to prostate pseudocapsule.Lasers that are typically used for vaporization include green light and diode laser (evidence-based benefit on IPSS reduction and improvement in urinary flow).For enucleation and/or resection Thilium and Holmium laser are better choices. They both provide minimal tissue penetrance.

February 2012 edition

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