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edition february 2013

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 procedure. Do not miss Urology News.

editorial board Associated Editor:


Dr. Carlos D'Ancona

Dr. Paulo Palma

Dr. Daniel Carlos Silva


Dr. Cassio Riccetto

Dr. Ricardo Miyaoka

Radiology - Editorial Committee

Dr. Adilson Prando

Dr. Ricardo Souza

Pathology - Editorial Committee

Dr. Athanese Billis

Editorial Committee

Dr. Guido Barbagli

Dr. Manoj Monga Dr. Mario Jo達o Gomes Dr. Mark Soloway

Dr. Matthias Oelke Dr. Philip van Kerrerbroek

clinical CASE edition: february 2013 Daniel Carlos Silva Division of Urology Unicamp

Hemorrhagic shock following shockwave lithotripsy: oriented management

clinical CASE edition: februay 2013 Daniel Carlos Silva Division of Urology Unicamp

CLINICAL BACKGROUND Sixty-two year old female undergoes left extracorporeal shockwave lithotripsy (SWL) and presents intense lumbar pain 48 hours after the procedure. She refers pain worsening during the last 6 hours, besides dizziness, nausea and vomiting.

PHYSICAL EXAM Patient presents sudoresis, tachycardia (120 bpm), normal blood pressure (120 X 90cmH2O). Abdominal and left flank tenderness, Giordano sign(painful percussion) present on left side.

WORK UP Some diagnostic hypothesis were considered: Ÿimpacted calculi causing ureteral obstruction; Ÿpyelonephritis/ urinary sepsis; Ÿrenal trauma following SWL.

Labs were collected and abdominal CT scan was performed immediately after patient admission: 1) Labs: hemoglobine: 6,5g/dl hematocrit: 19% leucogram: 16.000 leucócitos/mm3 urea: 32mg/dl creatinine: 1,3mg/dl sodium: 138mEq/l potassium: 4,7mEq/l INR: 1,3 urinalysis: 1.200.000 red cells/ml; 2.000 leucocytes/ml 2) Abdominal CT scan (fig. 1)

Figure 1 – Abdominal CT scan in axial (A and B) and coronal cuts (C and D), after intravenous dye injection showing an extense perirenal hematoma on left side (arrows), with adequate renal perfusion bilaterally and delayed contrast output on left.

clinical CASE edition: februay 2013 Daniel Carlos Silva Division of Urology Unicamp

MANAGEMENT An option was made towards non surgical treatment. Patient was admitted in intensive care unit (ICU) under hemodynamic continuous surveillance, volume and blood derived reposition, hemoglobin, hematocrit and diuresis strict monitoring.

OUTCOME After 24 hours, patient presented improvement in consciousness and became hemodynamicaly stable. Urinary output (> 0,5 ml/kg/h), hemoglobine: 9,8 g/dl (after transfusion of 3 blood units). Patient was discharged from ICU after 48 hours of monitoring and discharged home at 72 hours. Patient remained stable at home and ultimately passed all fragmented stones uneventfully.

COMMENTS SWL is a safe and efficient method for renal calculi treatment, but may be associated with adverse events including kidney and adjacent organ injury. The most frequently reported complication is perirenal hematoma which may happen in 0.66% to 2.5% of cases (1,2). Some authors reported a 30% incidence rate of perirenal hematoma if routine CT scan following SWL is performed. However, this information has an uncertain significance since only 1% of patients present hematoma-related symptoms (3). Risk factors include: age over 60 years, obesity, coagulopathies, thrombocytopenia, Diabetes Mellitus, coronary disease and high blood pressure. The physiopathology involved in perirrenal hematoma formation is obscure but facilitating factors are known: elevated number of shocks given, elevated voltage used (electromagnetic source seems to be the most likely to cause hematoma), kidney size and renal anatomic disturbances (2, 3, 4). Although flank pain is a common complain after SWL, symptom worsening and hemodynamic instability may preclude renal lesion and/ or perirrenal hematoma formation. In this case, imaging is mandatory and abdominal CT scan in the most effective investigative approach. Management must always take into account the peculiarities of each case, but non surgical approach is efficient in most cases. Surgical treatment is the choice for grade V renal lesions and severe hemodynamic instability (5). In order to avoid this unfortunate outcome, treatment should be performed with 100 to 150 shocks with up to 18K voltage in order to diminish renal damage. Also, a low shock rate up to 60 per minute should be kept (4, 5).

REFERENCES 1) Semins MJ, Trock RJ,Matlaga BR- The effect of Shock wave rate on the outcome of shock wave lithotripsy: a meta-analysis-J Urol 2008;179:194-7 2) Matlaga BR, Lingeman JE –Surgical management of upper urinary tract calculi – Campbell-Walsh Urology 10 edition 2012.Chapter 48 3) Dahr NB,Thornton J,Steem SB- A multivariate analysis of risk factors asso- ciated with subcapsular hematoma formation following eletromagnetic shock wave lithotripsy- J Urol 2004Dec;172: 2271-2274 4) Silberstein J, Lakin CM,Parsons JK- Shock Wave Lithotripsy and Renal Hemorrhage – Rev Urol 2008;10(3):236-241 5) Lambert EH,Walsh R,Moreno MW, Gupta MEffect of escalating versus fixed voltage treatment on Stone comminution and renal injury during extracorporeal shock wave lithotripsy: a prospective randomiized Trial – J Urol 2010 Feb;183 (2): 580-584 Antonio Gugliotta Division of Urology Unicamp

learning by image edition: february 2013 Elaine Bronzatto, Wagner Eduardo Matheus, Daniel Silva Division of Urology Unicamp

Prostate adenocarcinoma late recurrence – The role of Magnetic Ressonance Imaging

learning by image Edition: february 2013 Elaine Bronzatto, Wagner Eduardo Matheus, Daniel Silva Division of Urology Unicamp

CLINICAL BACKGROUND Sixty-two year old male undergoing prostate evaluation.

PHYSICAL EXAMINATION Good performance status with no comorbidities. DRE: 50g prostate, regular fibroelastic consistency.

WORKUP Total PSA of 5,1ng/dl (free PSA/total PSA= 5%) Patient underwent a prostate biopsy which resulted in a Gleason 3.3 (4/13 positive fragments in the left side). Bone scintigraphy showed no metastatic lesions. Patient underwent a radical prostatectomy in 2005. Surgical specimen pathology revealed a prostate adenocarcinoma Gleason 4.3 on the left side with negative nodes and negative margins.

FOLLOW UP After 7 years of follow up, patient presented a PSA rise and a local recurrence was suspected (tab.1). Table 1: PSA curve shows total PSA rise

In order to evaluate a likely local recurrence patient underwent Magnetic Ressonance Imaging (MRI) with an endorectal coil device. The exam showed a suspicious area (fig. 1 e 2). Figure1C: MRI, axial cut, T1 weighed image with dynamic contrast shows lesion enhancement confirming local recurrence suspicion.

Figure 1A : MRI, axial cut , T2 weighed image , shows a hiperintense signal in anastomotic area on the left (arrow).

Figure 1B: MRI, axial cut, T2 weighed image , superposed with a T1 weighed image. Diffusion shows that suspicious area in T2 weighed image at anastomotic region shows diffusion restriction (arrow).

learning by image Edition: february 2013 Elaine Bronzatto, Wagner Eduardo Matheus, Daniel Silva Division of Urology Unicamp

MANAGEMENT After MRI diagnosis ultrasound transrectal prostate biopsy was performed at the suspicious area. Pathology confirmed cancerous recurrence (adenocarcinoma Gleason 4.3). Patient was referred to conformational radiotherapy.

COMMENTS In patients in whom local prostate neoplastic recurrence is suspected, ultrasound guided-transrectal biopsy can be performed or MRI evaluation using an endorectal coil (when a 1,5 Tesla equipment is used) or not (when a 3 Tesla equipment is used)(1,2) . The advantage of initiating patient investigation with transrectal US guided biopsy relies on the straight forward approach. If positive, investigation is terminated. However, only 40% of patients present a positive result at first approach and one third of them will need two or three biopsies to reach a definitive diagnosis (3). In this scenario, MRI offers the possibility to study prostatic region while also evaluating the whole pelvic region including lymphatic nodes and pelvic bones. When performing MRI study it is mandatory to perform a parametric evaluation represented by the association of T2 weighed images, with diffusionweighed images and also with contrast enhanced images. Multiparametric evaluation allows for a better distinction between cancer recurrence and normal prostate remainings, fibrotic scars and even residual hiperplastic prostatic tissue.

REFERENCES 1) Casciani E, Polettini E, Carmenini E , Endorectal and Dynamic Contrast-Enhanced MRI for Detection of Local Recurrence After Radical Prostatectomy. AJR. 2008; 190; 1187-1192 2) Rischke HS, O Schäfer AO, Ursula Nestle U,et. Al. Detection of local recurrent prostate cancer after radical prostatectomy in terms of salvage radiotherapy using dynamic contrast enhanced-MRI without Endorectal coil Radiation Oncology 2012, 7:185.1186/1748 3) Scattoni V, Roscigno M, Raber M, Consonni P, Da Pozzo L, Rigatti P. Biopsy of the vesico-urethral anastomosis after radical prostatectomy: when and how. Eur Urol 2002;38:89 –95 Adilson Prando Department of Radiology, Hospital Vera Cruz. Campinas

new TECHNOLOGIES edition: february 2013 Michael A. Liss, M.D., Douglas Skarecky, B.S., Blanca Morales, B.S., and Thomas E. Ahlering, M.D. Department of Urology, University of California, Irvine, Orange, California J Endourol. 2012, 26: 1553-7.

Aplicação de hipotermia transrretal durante prostatectomia radical: melhora do dano inflamatório cirúrgico com intuito de preservar a continência

novas TECNOLOGIAS edição: Fevereiro de 2013 Michael A. Liss, M.D., Douglas Skarecky, B.S., Blanca Morales, B.S., and Thomas E. Ahlering, M.D. Department of Urology, University of California, Irvine, Orange, California J Endourol. 2012, 26: 1553-7.

J Endourol. 2012, 26: 1553-7. This paper presents the results of regional hypothermia used during robotic radical prostatectomy to reduce damage to the neurovascular bundles in 500 patients in the University of California. The idea behind this technology is that lowering local temperature could reduce the inflammation caused by surgical trauma and therefore minimize urinary incontinence and/or erectile dysfunction. Preemptive cooling (started before the beginning of dissection) would prepare the tissue to best react to surgical damage by reducing metabolic activity and allowing cells to dive into a hibernating state of low energetic expenditure. As lesions occurs, energetic reserve would be available to repair and revert anaerobic metabolism (with less lactic acid formation) preserving proteic synthesis, and suppressing inflammatory cascade and free radical formation. Ultimately, a reduction in cell apoptosis would be expected. In this study, regional hypothermia was performed through a rectal catheter. This catheter was designed with 2 balloons which were inflated with saline and connected to a cooling system (patented system waiting for FDA approval). Patients routinely underwent rectal enema for adequate fecal clearance (feces may diminish thermal transmission). Cooling temperature reached negative 30 degrees Celsius and no major post operative complications or severe discomfort were reported by patients. Urinary continence was defined as no use of pad/ dippers after 1 year of follow up. Hypothermia increased continence rates from 87% to 96% - older patients (over 70 years of age) benefited more having their continence rates migrating from 72% to 92%. These results show a 70% reduction in incontinence rate (from 13% to 4% - p<0.001). Regarding sexual performance, results were considered “modest, but significant” with improvement of IIEF score. This paper represents an interesting idea about the possibility of minimizing morbidity related to one of the most common surgeries in Urological field. It must however have its results validated with a wider sample of patients and further studies. If this improvement is confirmed, regional hypothermia may be routinely incorporated in radical prostatectomy approach given its simplicity and apparent cost-effectiveness. Ricardo Souza Division of Urology Unicamp



edition februay 2013

Urovirt february2013