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edition march 2012


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:

Editors:

Dr. Carlos D'Ancona

Dr. Paulo Palma

Dr. Daniel Carlos Silva

CO EDITORES Co-editors:

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: march 2012 Elaine Bronzatto, Daniel Carlos Silva Division of Urology - Unicamp

Nefrectomia Parcial uso de cola biol贸gica no aux铆lio da hemostasia


clinical CASE edition: March 2012 Elaine Bronzatto, Daniel Carlos Silva

Division of Urology - Unicamp

Fifty-six year-old male squash player has no symptoms. During routine check up exams a renal nodule is noted at ultrassonography. He undergoes magnetic ressonance imaging (MRI) for further evaluation as he has a history of allergy to iodated dye (Fig. 1 and 4).

Figures 1 and 2: MRI, T2 images, axial and coronal cuts; heterogenous mesorenal expansive lesion (arrows).

Figures 3 and 4: MRI, xial and coronal cuts, paramagnetic dye, shows mild heterogenous absorption. A well define dlesion can be seen (yellow arrow) with a necrotic central area (*) close to the collecting system. At the second frame lesion is easily delineated (red arrow).


clinical CASE edition: March 2012 Elaine Bronzatto, Daniel Carlos Silva

Division of Urology - Unicamp

MRI study confirmed the presence of an exofitic solid nodular heterogeneous lesion at the convex aspect of the left kidney. Diagnostic hypothesis included papiliferous carcinoma and oncocytoma. An option was made towards performing open partial nephrectomy considering lesion location, its proximity to the collecting system and size.

Figure 5: Kidney ice cooling and vascular pedicle clamping. Tumor lesion is pointed (arrow).

Figure 8: sponge placement (arrow) over the kidney bed, promoting quick hemosthasis.

Figure 6: Kidney bed (arrow) after lesion extraction. Collecting system and large vessels are sutured.

Figure 9: sponge (arrow) is interposed into renal parenchyma helping with hemosthasis.

Figure 7: Fibrinogen and thrombin coated sponge; must be wet before use.

Figure10: Tumoral lesion is ressected.

Figure 11: Longitudinal section show central scar.

Pathology confirmed a diagnosis of oncocytoma. Patient presented a uneventful recovery and resumed his job tasks after 1 week and sports practice after 30 days.


clinical CASE edition: March 2012 Elaine Bronzatto, Daniel Carlos Silva

Division of Urology - Unicamp

Commentary se of biological sealants was first reported in the 90's in Austria. First formulas were made out of bovine and equine collagen which led to significant allergic reactions and hypersensibility. At the 20th century with the advance of the pharmaceutic industry, first reports using biological sealants based on fibrinogen and thrombin in humans came out with satisfying clinical results in hepatic resections and surgical interventions in Urology, Gynecology, vascular surgery and cardiothoracic surgery. There are several different types of hemosthatic agents described in Literature among which tissue biological and synthetic liquid sealant, fiber hemosthatic support, collagen sponge, cellulose; and finally the auxiliary diathermic agents: eletrocautery, infrared, laser and argon. Sealant reported as medicamentous sponge is formed by a collagen matrix coated with coagulation factors: fibrinogen and human thrombin; active surface is defined by a yellowish color composed by Riboflavin (B2 vitamin) which indicates the surface which should face the bleeding fresh tissue. The healing mechanism reproduces the last phase of physiologic coagulation and is set off by contact with blood and other corporal fluids when it is then replaced by a fibrin clot creating a rapid sealing. It can be used as a primary or secondary hemosthatic agent in multiple layers (secure application of up to 7 patches are reported with no pharmacological side effects whatsoever).

iological sealants have shown positive results reducing the need for intraoperative blood transfusion, reducing blood loss, reducing operative time, reducing hospitalization length and incidence of lymphocele formation after lymphadenectomy. It may be used in either open or laparoscopic surgery. As a maleable product the sealant adapts well to any organ surface and may applied even in sites difficult to access. Physiological degradation occurs within 12 weeks from application through phagocytosis and fibrinolysis and replacement by endogenous granulation tissue takes place. Imaging at post surgical follow up does not show notable tissue differences. It may be considered a safe tool with positive and promising perspectives. Adriano Angelo Cintra, MD; Carlos D'Ancona, MD, PhD

References:: 1

Simonato A et al. The use of a surgical patch in the prevention of lymphoceles after estraperioneal pelvic lymphadenectomy for prostate cancer: a randomized prospective pilot study. J Urol. 2009;182:2285-90.

2

Siemer S et al. Efficacy and safety of TachoSil as haemostatic tratement versus standard suturing in Kidney tumor resection: a randomised prospective study. Eur Urol. 2007;52(4):1156-63.

3 TachoSil. Summary of Product Characteristics. 2005 4

Schwartz M, Madariaga J, Hirose R, Shaver TR, Sher L, Chari R, et al. Comparison of a new fibrin sealant with standard topical hemostatic agents. Arch Surg. 2004;139:1148–54. [PubMed] Richter F, Schnorr D, Deger S, Trk I, Roigas J, Wille A, et al.

of hemostasis in open and laparoscopically 5 Improvement performed parital nephrectomy using a gelatin matrixthrombin tissue sealant (FloSeal) Urology. 2003;61:73–7. [PubMed]


learning by image edition: March 2012 Joรฃo Paulo de Pรกdua, Cรกssio Riccetto Division of Urology, FCM - UNICAMP

Management of bladder outlet obstruction secondary to anterior vaginal prolapse mesh repair


learning by image edition: March 2012 Joรฃo Paulo de Pรกdua, Cรกssio Riccetto Division of Urology, FCM - UNICAMP

During recent years, the use of synthetic meshes to correct vaginal prolapses has spread worldwide. As expected, surgical complication related to this innovative technology began to appear such as dyspareunia and mesh exposition. We present a case where a female patient underwent an anterior vaginal prolapse mesh repair and developed outlet obstruction afterwards. We discuss alternatives to manage these patients.

Case Report: Sixty-six year old female patient has a history of 3 pregnancies and 2 vaginal deliveries, preserved uterus. Patients underwent an anterior colporraphy 10 years before in order to have a grade III cystocele corrected. Besides the vaginal prolapse, patient presented a complaint of voiding difficulty with abdominal effort, incomplete bladder emptying, but denied urinary incontinence. She underwent urodynamic study (Figure 1) which revealed: normal bladder capacity, absence of stress urinary incontinence, max urinary flow of 4 ml/s and detrusor pressure at max flow of 70cmH2O. Postvoid residual volume was approximately 50% of total infused volume.

Figure 1: Urodynamics shows Qmx = 4 ml/s and Pdet.Qmax = 70 cm H20 confirming a diagnosis of outlet obstruction.


learning by image edition: March 2012 João Paulo de Pádua, Cássio Riccetto Division of Urology, FCM - UNICAMP

A diagnosis of bladder outlet obstruction secondary to the previous surgical intervention for cystocele repair was made. Patient underwent a semi circumferential urethrolisis with removal of periurethral fibrosis and placement of a synthetic polypropylene mesh anchored into the obturator foramen and sacrospinous ligament bilaterally. Patient presented acute urinary retention within 24 hours from surgery after bladder catheter was withdrawn. Retention persisted for over 2 weeks post operatively and an assumption was made towards an excessive compression of the urethra by the mesh aggravating the pre existent outlet obstruction. Patient underwent a novel surgical intervention with incision of the mid urethral portion of the mesh (Figure 2, Video 1) and complete urethrolisis, (Figure 3) associated with a Martius flap (Figure 4 , Video 2).

Figure 2 and Video 1: Mesh exposition under the mid urethra.

Figure 3: Extense periurethral circumferential dissection allowing fibrotic lysis (arrow: right angle clamp around the urethra).

Video 2: Subcutaneous tissue flap harvested from the vulvar labia (Martiu's flap) to be interposed up and around the urethra to avoid periurethral fibrosis.

Post operatively patient reported little improvement of symptoms with a persistent postvoid residual volume of 250 ml. She was then proposed to undergo a novel intervention with an internal urethrotomy. Urethra was endoscopically incised at 7 o'clock position with a Collins knife as shown in Video 3. Video 3: Uretrotomia Interna com Utilização da Faca de Collins http://www.youtube.com/watch?v=w0Q9oCqdqkc Outlet obstruction and satisfactory spontaneous voiding were achieved but patient developed a mild stress urinary incontinence. After 3 months, patient became fully continent with no further voiding complaints and complete resolution of vaginal prolapse.


learning by image edition: March 2012 João Paulo de Pádua, Cássio Riccetto Division of Urology, FCM - UNICAMP

Commentary Bladder outlet obstruction following vaginal prolapse correction with synthetic mesh is not a common complication but it imposes a significant detrimental impact onto patient's quality of life as she becomes dependent on urinary catheterization if not treated. This case illustrates our plan of action in such cases: ŸMesh incision under the mid urethra portion as this may cause extrinsic urethral compression

and therefore obstruction. This should be done as soon as obstruction is diagnosed. ŸUrethral circumferential dissection associated with Martius flap. This is a rescue procedure in

case mesh incision fails; and also when diagnosis is performed at late postoperative stages when periurethral adherenceand fibrosis is expected to be more intense. ŸFemale internal urethrotomy with Collins knife. Ultimate rescue procedure, should be

considered experimental as supporting scientific evidence is scarce. ŸIntegration defects (exposition, extrusion, erosion, contraction) still represent an important

barrier to the wide implementation of synthetic meshes in prolapse repair and research must focus on developing more biocompatible materials. ŸAs in any other surgical intervention, best treatment is prevention. Points to be observed in

order to avoid outlet obstruction during mesh placement include: ŸOs defeitos de integração (exposição, extrusão, erosão e contração) representam, ainda

limites para o emprego generalizado de próteses no assoalho pélvico feminino e a pesquisa na área de biomateriais avança no sentido de se obter próteses com maior biocompatibilidade. ŸComo no caso do tratamento da incontinência aos esforços com slings sintéticos, a melhor ŸMesh adjustment at the level of mid urethra; anchoring stitches may be used if necessary

fixating the mesh at the pre pubic insertion of pubourethral ligaments bilaterally. ŸUse of a Metzenbaum scissors between the urethra and mesh at time of adjustment which

should slide freely allowing for a gap of 3-4 mm. ŸMesh flattening under the bladder area; reducing mesh folding and avoids more intense

local fibrosis. ŸNo need for vaginal wall tailoring as it will naturally accommodate in the post operative

period. ŸUse of low weight prosthesis and only specific materials approved for use in female prolapse

repair. The above mentioned procedures are believed to be effective and safe for managing infravesical outlet obstruction resulting for anterior vaginal prolapse mesh repair using commercially available polypropylene prosthesis. Cassio Riccetto Professor of Urology - Unicamp


new TECHNOLOGIES edition: March 2012 Carlos D'Ancona Division of Urology - Unicamp

New paradigm to treat prostate cancer


novas TECNOLOGIAS edição: Março de 2012 Carlos D'Ancona Disciplina de Urologia, FCM - UNICAMP

With greater use of PSA and concern of male population in relation to prostate cancer, there is an increase of diagnosis of this disease in its early stages. Conventional radical therapies comprise radical surgery and radiation therapies are indicated in localized prostate cancer. These techniques are considered as efficacious but, despite technological refinements in radiation therapy and surgery, they are associated with a high rate of comorbidities such as erectile dysfunction (30-70%), urinary incontinence (5-10%), and rectal symptoms (5-20%) of treated patients. To change this side effects a new idea was presented at the EAU Meeting in Paris, the Tookad® Soluble Vascular Targeted Photodynamic Therapy. The treatment consists of administration of Tookad intravenously and activated by laser light. The laser fibers are inserted into the prostate under ultrasound guidance through the perineum. The drug destroys the illuminated blood vessels, choking the blood supply and starving the cancer of nutrients without damaging surrounding healthy tissue. In experimental studies, marked hemorrhagic necrosis of the prostate was observed. Tookad Photodynamic Therapy can provide an effective alternative for the treatment of localized prostate cancer.

USO CLÍNICO

Carlos D'Ancona Professor and Head of Urology


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