edition june 2012 -...

june 2012 edition

Dr. Carlos D'Ancona

Urologia Virtual (UROVIRT) é o órgão de divulgação da Disciplina de Urologia da Faculdade de Ciências Médicas da Unicamp na Internet.

Urovirt é editada mensalmente trazendo revisões de assuntos das diversas subespecialidades da urologia, novidades, controvérsias, bem como informações da Disciplina de Urologia da Unicamp.

editorialboardeditorialboard

Dr. Guido Barbagli Dr. Manoj Monga Dr. Mark Soloway

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

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

Urotelial Carcinoma of the Renal Pelvis

Edition: June 2012

Thiago G. Pereira, Fernandes Denardi

Division of Urology - Unicamp

clinicalCASE

64 year-old male with a complaint of left lumbar pain associated with a 7-kg weight loss. He also presents afternoon fever, but denies hematuria.

Comorbidities: Type 2 diabetes and hypertension

Edition: June 2012Thiago G. Pereira, Fernandes Denardi Division of Urology - Unicamp

Physical exam:

Good performance status, good peripheric perfusion, anemic (++/4);

Palpable mass in left abdomen;

Diagnostic work up:

1)Labs:Ÿ Hemoglobin 10.2 g/dl;Ÿ Hematocrit 32%;Ÿ Urea 45 ng/dl;

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1)Urinalysis: 80.000 red cells/ ml;

15.000 white cells/ ml; 2)Culture negative;

2)Abdominal CT scan (figures 1 and 2)

Figure 1. Abdominal CT with axial cuts, nephrographic phase: solid lesion occupying all left renal parenchyma (red arrow), with apparent infiltration of the collecting system, associated with paraaortic lymphadenomegaly (yellow arrow).

Abdominal CT with coronal reconstruction: this view offers better visualization of the lesion (red arrows) as well as the paraaortic lymphadenomegaly (yellow arrow). Renal parenchyma sparring and medial positioning of the lesion suggests urothelial carcinoma as possible diagnosis.

clinicalCASE

Management:

Patient underwent radical left nephrectomy with lymphadenectomy (Figures 3 to 5).

Investigação:

Isolation of left renal artery (yellow arrow) and vein (black arrow).

Paraaortic lymphadenopathy in detail.

Figure 5. en bloc resection of renal mass and lymphadenopathy

Pathology:

ŸHigh grade renal pelvis urothelial carcinoma with diffuse infiltration of renal sinus and parenchyma;

ŸFrequent thrombi in renal hylum vesselsand renal vein;

ŸPositive margins;

ŸMetastasis in 21 lymph nodes;


clinicalCASE

Commentary:

Upper urinary tract urothelial carcinoma is an aggressive disease with a tendency of local invasiveness and high potential for systemic dissemination. Treatment is mainly based upon radical nephroureterectomy which can be accomplished through either open or laparoscopic approach whenever possible.

References:

Rai BP, Shelley M, Coles B, Somani B, Nabi G. Surgical management for upperurinarytracttransitionalcell carcinoma (UUT-TCC): a systematicreview. BJU international. 2012. Epubaheadofprint: 2012/07/05.

Mouracade P, Velten M, Gigante M, Alenda O, Ploussard G, Obadia F, et al. Factorsimpactingsurvival in patientswithuppertracturothelial carcinoma undergoing radical nephroureterectomy. The Canadianjournalofurology. 2012;19(1):6105-10.

Yeshchina O, Badalato GM, Wosnitzer MS, Hruby G, RoyChoudhury A, Benson MC, et al.

Relativeefficacyofperioperativegemcitabineandcisplatin versus methotrexate, vinblastine, adriamycin, andcisplatin in the management oflocallyadvancedurothelial carcinoma ofthebladder. Urology. 2012;79(2):384-90.

Young A, Kunju LP. High-grade carcinomas involvingthe renal sinus: reportof a case andreviewofthedifferentialdiagnosisandimmunohistochemical expression. Archivesofpathology&laboratory medicine. 2012;136(8):907-10.

Ristau BT, Tomaszewski JJ, Ost MC. Uppertracturothelial carcinoma: currenttreatmentandoutcomes. Urology. 2012;79(4):749-56.

Lymphadenectomy in the absence of adenomegaly is controversial. Ureteral tumors are related to a worse prognosis when compared with pelvic ones.

When considering systemic treatment, risk factors adopted for invasive bladder cancer are also taken into account. Similarly, it is possible to deliver neoadjuvant treatment with chemotherapy (M-VAC or CG).

Recommendations based on high level of evidence are scarce as the disease is rare. Neoadjuvant treatment is also challenging as chemotherapy depends on histologic diagnosis. Differential diagnosis includes collecting ducts carcinoma, medullar renal carcinoma, papillary renal carcinoma, and clear cell carcinoma.

The most patients are treated with radical surgery without previous chemotherapy. However, when have doubt of the diagnosis, it is possible to recommend a biopsy of the tumor before treatment.

Adjuvant chemotherapy may be indicated although its applicability depends on preserved renal function. Cysplatine cannot be used otherwise. Metastatic disease is associated with a poor prognosis and is usually treated with CG scheme in good performance patients with preserved renal function, based on its similarity with bladder urothelial carcinomas.

Andre Sasse Clinical Oncology – UNICAMP


clinicalCASE

edition: June 2012

Thiago Pereira, M.D.; Ricardo Miyaoka, M.D.

R5 - UNICAMP

Pyeloureteral Junction Anomaly

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edition: June 2012 Thiago Pereira, M.D.; Ricardo Miyaoka, M.D. R5 - UNICAMP

Eleven year-old female presents a complaint of recurrent left lumbar pain for one year. She refers having colic episodes once a month of moderate intensity and worse following liquid ingestion.

She denies having UTIs.

Physical exam is without abnormalities.

Labs:

ŸUrea: 22 mg/dl;ŸCreatinine: 0,48 mg/dl;ŸNormal urinalysis;ŸNegative culture;

Ultrasound report: Left pelvicalyceal dilationŸComplementary investigation with abdominal

CT scan shows a severe pelvic renal dilation on left with an abnormal crossing vessel

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Commentary:

Dismembered pyeloplasty was first described by Anderson and Hynes in 1949, for the treatment retrocaval ureter. It has been considered the gold standard of treatment as it offers a cure rate above 95% (1). With the advent of percutaneous access, this pathology was addressed by endopyelotomy with a 80% success rate.

According to Paul Van Cangh, this rate may drop to 42% when an abnormal crossing vessel is present (2). However, since the first pediatric laparoscopic nephrectomy, this minimally invasive approach has become a very attractive as it maintains the success rate while offering better cosmetic results.

Osamu Ikari Urology - Unicamp

Hashim Hashim , Christopher R.J. Woodhouse : Eur Urol 2012;11 :25-32 Van Cangh,P.J.,Wilmart,J.F.,Opsomer,R.J.,Abi-Aad, A.,Wese,F.X. : J. Urol.,151:934,1994

Renal scintigraphy:

Right kidney 49%; left kidney 51%Normal tubular function bilaterally with no signs of parenchymal scars.

Poor elimination even after diuretic administration suggests obstruction.

Treatment decision was for laparoscopic dismembered pyeloplasty(movie below)

References:

edition: June 2012 Thiago Pereira, M.D.; Ricardo Miyaoka, M.D. R5 - UNICAMP

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Edition: June 2012

Isaac A. Thangasamy a, Venu Chalasani b, Alexander Bachmann c, Henry H. Woo d,*

Review Benign Prostatic Obstruction

newTECHNOLOGIES

Edition: June 2012 Isaac A. Thangasamy a, Venu Chalasani b, Alexander Bachmann c, Henry H. Woo d,*

Photoselective Vaporisation of the Prostate Using 80-W and 120-W Laser Versus Transurethral Resection of the Prostate for Benign Prostatic Hyperplasia:

A Systematic Review with Meta-Analysis from 2002 to 2012 EUROPEAN UROLOGY 62 (2012) 315–323

Meta-analysis comparying prostate TUR versus photoselective laser vaporisation in the treatment of BPH. In this review 9 randomized trials published since 2002 were included with a minimum follow up of 6 months (total 889 patients: 448 vaporisation and 441 TUR).

In photoselective vaporisation, laser is conducted through water and absorbed by hemoglobin with rapid intracellular water heating. This allows coagulation during vaporisation. Due to short laser optical penetration with a beam wave lenght of 532 nm, potenct is confined to the superficial layer of the prostate.

Vaporisation therapy offers the advantage of using this technology in patients under anticoagulation therapy, antiplatelet agents, and does not imply the risk of hydric intoxication as irrigation is performed with saline solution instead of glycine.

In this review, vaporisation was superior to TUR considering time with bladder catheter after surgery (1.9 days reduction) and hospital stay (2.13 reduction). It was related with less need for blood transfusion (84% less chance) and clot formation. However, TUR mean surgical time was shorter (19.64 min).

At one year follow up, functional results following both techniques were similar (considering Qmax and IPSS score). No difference could be seen in both techniques regarding risk of urinary retention, infection, macroscopic hematuria, hospital readmission/ reoperation, urethral stenosis (meatal or bladder neck).

This work does present some flaws like data heterogeneity, absence of series using more potent laser fountains (180W), short follow up (1 year). In discussion section, the author comments on the cost effectiveness of vaporization when compared to TUR. However, one must evaluate this matter taking into account each specific country / institution. TUR remains as a more solid treatment for BPH with known good long term results. It is interesting to wait on longer follow up in patients treated with this novel techniques to run a more reliable comparison against TUR.

Results:

newTECHNOLOGIES

Realization:Sponsors:

June 2012 edtion

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edition june 2012 -...

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