Revista mexicana de urologia最新文献

Introduction

Transurethral resection of the prostate (TURP) is a standard procedure for obstructive prostatic growth. Medical retreatment with anticholinergics, alpha-blockers, and 5 alpha reductase inhibitors is from 16 to 50%. A second surgical retreatment is associated with internal urethrotomy, cervicotomy, and re-TURP between 5 and 13% at 5 years. Re-TURP is associated with residual tissue.

Aim

To determine the incidence of and factors associated with the use of medications and surgical retreatment after TURP.

Material and methods

A retrospective study was conducted on patients that underwent TURP within the time frame of January 2010 and December 2011 with follow-up to the present. Preoperative, intraoperative, and postoperative variables were analyzed and the chi-square test was used for the statistical analysis.

Results

Follow-up was carried out on 158 patients that underwent TURP. The overall accumulated incidence of retreatment was 43%, surgical retreatment was 17.7%, and medical treatment was 30.4%. TURP retreatment was 7.6% and transvesical prostatectomy was 1.3%. The mean time until prostate surgery retreatment was 30.5 months. Postoperative medical treatment was: anticholinergics 17.1%, alpha-blockers 15.2%, 5 alpha reductase inhibitors 6.3%, and combination 8.2%. During follow-up, 22.8% of the patients had residual tissue, which was the main cause of retreatment. Preoperative prostatic volume > 80 g was associated with residual tissue (p = 0.024).

Conclusions

In our study, the incidence of surgical retreatment was higher than that reported in the literature, at 17.7% vs. 13%, respectively, and medical treatment was lower at 30.4% vs. 50%, respectively. Anticholinergics were the most utilized medications. Adequate patient selection will reduce complications and risk for retreatment.

The incidence of bulky kidney tumors has decreased thanks to the widespread use of radiographic studies that enable early diagnosis and treatment. However, there are still cases of giant tumors that are true surgical challenges.

A 47-year-old woman presented with right hemi-abdominal pain 3 years prior, along with increased abdominal circumference, fever, and poor general status. Tomography scan revealed a right kidney tumor (30 × 19 × 15 cm) occupying 80% of the abdominal cavity. Radical nephrectomy was performed at the midline with blood loss of 1,800 cc. The patient progressed favorably and was released 48 h after the procedure. The histopathologic study reported a stage III chromophobe carcinoma (pT3a) that measured 31 × 19 × 13 cm and weighed 4,630 g There was successful oncologic control at 6 months.

Large-volume kidney tumors are advanced stage lesions associated with poor outcome. Preoperative embolization plays an important role in reducing intraoperative blood loss. If the tumor is considered resectable, the open approach is preferred over the laparoscopic one. Flank approaches (subcostal, supracostal, or transcostal), thoracoabdominal, lumbotomy, or anterior approaches (subcostal, Chevron, midline or paramedian) have been described. The best approach should match the anatomy of the patient and the characteristics of the tumor.

Bulky renal masses are a surgical challenge. Therapeutic success depends on adequate perioperative evaluation of the patient and the tumor, establishing the ideal approach.

Background

Mesoblastic nephroma is a tumor that classically appears in childhood, and rarely in the adult. We present herein a case in an adult woman.

Methods

A 53-year-old woman presented with a palpable tumor, hematuria, and pain. A CAT scan revealed a heterogeneous left renal tumor. Left radical nephrectomy was performed.

Results

A lobulated tumor was obtained that measured 17 × 16 cm and weighed 1,850 g. When sliced, a solid, nodular, whitish tumor with a fibrous aspect was revealed. Microscopic study showed long spindle cells and thin vessels and tubules in the stroma. The tumor cells were positive for vimentin and there was no atypia.

Conclusion

The patient is recurrence-free at 2 years of surveillance. The tumor was a benign mesoblastic nephroma, but it was very large and with serious clinical repercussions. The patient requires continued surveillance because of possible large tumor recurrence.

Background

Leydig cell hyperplasia is a rare benign condition characterized by small, multifocal testicular nodules that are frequently bilateral. Its form can be primary or secondary. The former produces precocious puberty in boys and the latter presents as a testicular mass and produces gynecomastia in approximately 30% of the patients as a result of idiopathic supraphysiologic hormone stimulation, and has clinical manifestations similar to those of Leydig cell tumors.

Clinical case

A 30-year-old man with an unremarkable past history, the father of two children, was seen at a primary care hospital for pain and swelling of the right testis that was resolved with nonsteroidal antiinflammatory drugs. Ultrasound study revealed bilateral testicular tumor. The patient had no palpable testicular mass or gynecomastia or other relevant signs or symptoms. The ultrasound finding was confirmed by magnetic resonance imaging and retroperitoneal activity was ruled out from tomography scan results. Exploration of the right testis was carried out with the inguinal approach. The incisional intraoperative biopsy revealed a millimetric mass protruding from the healthy parenchyma. It was reported as undetermined in the intraoperative study and so radical orchiectomy was completed. The definitive histopathology study stated Leydig cell hyperplasia. The patient refused any invasive diagnostic procedure in the contralateral testis. His postoperative progression was favorable with no changes in imaging studies in the contralateral testis during follow-up.

Conclusion

This was a case of atypical secondary Leydig cell hyperplasia whose definitive diagnosis was made through the final histopathology study of the specimen, the only manner in which to accurately rule out a Leydig cell tumor.

Background

There are no reliable epidemiologic registers of cancer in Mexico. Genitourinary cancer represents 20% of all cancers. In 2012, prostate cancer represented 21.4% of all cancers, kidney cancer 2.13%, bladder cancer 2.2%, and testicular cancer 2.7%. An epidemiologic register carried out in 2011 reported a lower incidence than that described in the international literature.

Aim

To know the number of new cases of the different tumors affecting the genitourinary tract.

Material and methods

An analytic, retrospective study was conducted, carrying out a review of the medical records with genitourinary cancer diagnoses within the time frame of January 2004 and June 2014 obtained from the Department of Histology of this institution.

Results

We found a total of 861 cases. Prostate cancer represented 43.4% of the total (12-56.4%/year), cancer of the penis 5.6% (2.2-11.4%/year), kidney cancer 15.3% (11-24%/year), cancer of the upper urinary tract 1.27% (0.1-0.34%/year), bladder cancer 13% (2-22.7%/year), and testicular cancer 21.2% (13.2-56.2%/year).

Discussion

The results of our review are consistent with those reported in the international literature. The epidemiology of cancer in Mexico is underestimated due to the lack of reliable registers.

Conclusions

In our case series we observed an increase in the detection of new cases of genitourinary tumors. Increased knowledge in relation to the epidemiology of genitourinary cancer in Mexico is necessary so that the resources for treating these neoplasias can be optimized.

Rhabdomyosarcoma is the most common soft tissue sarcoma in childhood, more frequently affecting males, with an incidence of 8 children per one million. It is found in the genitourinary tract in 26% of cases. Differential diagnoses are ureteral polyps and ureterocele. The most frequent subtype in children is embryonal rhabdomyosarcoma and the botryoid variant with a polypoid form arises from the cavitied structures.

The characteristics of a case of botryoid rhabdomyosarcoma in the bladder cavity of a 6-month-old infant girl and the importance of its differential diagnoses are described.

We present herein a rare case of bladder tumor in the bladder cavity for a better understanding and recognition of this type of disease in pediatric urology.

Background

During testicular cancer progression, retroperitoneal activity can condition urinary compression, especially in advanced stages. When this presents, it requires urinary diversion.

Aim

To describe the clinical presentation of obstructive uropathy (OU) associated with testicular cancer at the time of diagnosis, correlating the variables of the neoplasia to establish associations between the 2 entities.

Material and methods

A retrospective study encompassing the time frame from July 2010 to June 2015 was conducted that included 98 patients with testicular cancer, evaluating the presence of OU through abdominal tomography and statistical analysis for the purpose of establishing significant associations between the variables.

Results

Twenty patients (20.2%) presented with OU, with a mean age of 24 years, ECOG 1, and a progression time of 305 days. Eight patients had seminomatous tumor (40%) and 12 had nonseminomatous tumor (60%), of which the most frequent histology was endodermal sinuses (66%), followed by embryonal carcinoma and teratoma (50%, respectively). The mean size of the lymph node conglomerate was 4.3 cm, 65% of the patients had metastasis upon diagnosis, and the most frequent clinical stage was IIIC (50%). Forty percent of the patients had elevated creatinine.

There were no statistically significant results between the development of retroperitoneal disease and histology (P = 0.72), progression time (P = 0.44), or laterality (P = 0.44).

Testicular tumor size was correlated with the development of OU (P < 0.05), the same as was stage pT (P < 0.05), stage N (P < 0.05), metastases (P = 0.001), LDH (P < 0.05), clinical stage (P < 0.05), and young age (P < 0.05)

Conclusions

OU is a comorbidity associated with germ cell testicular cancer that usually involves advanced stages. Young patients with poor functional status, with large tumors, and elevated LDH levels after orchiectomy should be evaluated to rule out urinary compression.

Background

Extracorporeal lithotripsy effectiveness is limited in lower calyx stones. Ureteroscopy currently enables complete access to the collecting system. Stones located in the lower pole at an infundibulopelvic angle < 70°, infundibular length > 3 cm, and infundibular width < 5 mm have a greater risk for residual stones.

Aim

To determine whether the anatomic variants of the left pole hinder stone resolution with flexible ureteroscopy.

Material and methods

A retrospective, analytic study was conducted. It included 109 cases of patients that underwent flexible ureteroscopy for lower pole stones (5-20 mm) diagnosed through tomography within the time frame of 2010-2015.

Results

Infundibular length was: 31.10 ± 7.53 and 27.27 ± 5.4 mm (p = 0.151), infundibular width: 10.36 ± 2.66 and 9.13 ± 2.1 mm (p = 0.094), and infundibulopelvic angle: 61.36 ± 7.23 and 74.63 ± 8.75° (p = 0.001) in patients with residual stones and in those with no evidence of stone burden, respectively.

Discussion

An infundibulopelvic angle < 70° has a 38-fold greater risk for residual stones in our population (95% CI: 4.24-29.12).

Conclusions

The infundibulopelvic angle had a statistically significant influence on stone-free status in patients in our population with stones in the lower pole that underwent flexible ureteroscopy.

Background

Schwannomas are well-encapsulated tumors arising from the peripheral nerve sheaths and they appear in young or middle-aged adults. These tumors make up 0.5-2.7% of retroperitoneal tumors. The majority of schwannomas are benign and single, although multiple tumors have been described. There are reports of malignant cases associated with von Recklinghausen's disease and melanocytic nevus in children, with hypercalcemia of parathyroid origin.

Clinical case

A 54-year-old woman had a past history of tubular adenoma of the colon. Her current illness began with lower urinary tract symptoms, mainly of storage, along with total gross hematuria with no clots. An abdominal tomography scan revealed a 21 mm contrast-enhanced left kidney upper pole lesion and a 53 × 48 × 32 mm solid lesion adjacent to the left adrenal gland. The latter had well-defined regular edges that anteriorly displaced the pancreas and splenic artery, with punctiform intraparenchymal calcifications. Left partial nephrectomy of the upper pole was performed and the histopathology study reported clear cell carcinoma limited to the kidney, Fuhrman 2, with no lymphovascular invasion.

Discussion

Schwannomas in the retroperitoneum are rare, making up approximately 1% of retroperitoneal tumors. Patient age at the time of diagnosis varies from 20 to 50 years. Incidence has been observed to be slightly more frequent in women than in men. When symptoms present, the most frequent are abdominal pain, abdominal distension, and lumbalgia.

Conclusions

Retroperitoneal schwannoma is a rare disease. Its presentation is nonspecific and it is generally an incidental finding. Computed tomography and magnetic resonance are useful for the preoperative approach.