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edition may 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-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: May - 2012 Elaine Bronzatto , Daniel Carlos Silva Division of Urology and Department of Pathology - Unicamp

Salvage prostatectomy: post-radiotherapy and late biochemical recurrence


clinical CASE edition: May 2012 Elaine Bronzatto , Daniel Carlos Silva Division of Urology and Department of Pathology - Unicamp

Fifty eightyear-old male with a rising PSA is diagnosed with Gleason 7 prostate carcinoma with extended involvement of right lobe fragments, Baseline PSA: 2,54.No evidence of metastatic bone lesions at scintigraphy. As patient did not want to undergo surgery an option was made towards androgen blockade with flutamide and radiotherapy (Set/2006) → 73,8 GY. Biochemical recurrence occurred after a PSAnadirrise (Jun/2008): 0,36 → 2,76 (Set/2010).(Table 1).

Table 1: PSA curve.

A novel bone scintigraphy evidenced inconclusive lesionsat 6thand 9thcostal thoracic bones. SPECT/CT ruled out metastic lesions. Patient underwent radical prostatectomy with bilateral iliac and obturator lymphadenectomy. Post operatively, patient presented a urinary fistula from vesicourethral anastomosis resolved with urethral catheter. Pathological examination confirmed Gleason 3+4=7 (2/24) prostate carcinomaat the right lobe (limited tumor).Free surgical margins and seminal vesicles. Metastasis in 3 outof4nodeson right side (>1,5cm). Six negative nodes on left side. Histologic alterations secondary to radiotherapy were present. Patient is currently under androgen blockade with Leuprolide 22,5mg every 3 months.

Figure 1 and 2: Conventional bone scintigraphy on left and detail on right showing hyperintense areas on 6th and 9th ribs (arrows).


clinical CASE edition: May 2012 Elaine Bronzatto , Daniel Carlos Silva Division of Urology and Department of Pathology - Unicamp

Figure 3: Bone scintigraphy associated with SPECT/CT: CT scan and scintigraphy correlation rules out metastatic lesion. Arrows indicate a traumatic lesion on the 9th rib.

Figures 4 and 5: Picnotic nuclei in the first slide; tumor lesion details can be seen. In the second slide, fibrotic alterations secondary to radiotherapy are shown.

Commentary (nuclear medicine) Bone scintigraphy is a widely used method to scan for bone metastasis as it is economically accessible and highly sensitive.However, it alsopresents relatively low specificity as the pharmacologic agent accumulates in benign lesions as well.A recent advance in Nuclear Medicine equipment was able to partially address this issue: conventional CT images are fused with Nuclear tomographic images through the hybrid equipment known as SPECT / CT (Single Photon Emission Computed Tomography/CT). SPECT/CT consists in cut scintigraphic images associated with CT images which add anatomical information to the method and allow for a better distinction between benign and malignant conditions.In the present case, SPECT/CT imaging made it possible to distinguish enhanced areas in 6th and 9th ribs which corresponded to small traumatic injuries with no sign of metastasis. Celso Dario Ramos Chief - Departament ofNuclear Medicine FCM - UNICAMP


clinical CASE edition: May 2012 Elaine Bronzatto , Daniel Carlos Silva Division of Urology and Department of Pathology - Unicamp

Commentary on salvage Radical Prostatectomy Both patients who harbor a localized prostate cancer and those diagnosed with a locally advanced tumor may undergo curative treatment. The choice regarding initial approach must rely on clinical performance status, risk classification (Gleason) and cancer specific and overall survival expectancy.Currently, curative treatments include radical prostatectomy and radiotherapy (RT). Disease may recur regardless of the chosen initial approach(either surgery or RT). Risk of recurrence may reach 60% in subjects submitted to radiotherapy. In a recent study published in European Urology (1),patients who underwent salvage prostataectomy following RT, with no signs of extraprostatic disease, had a pathologic finding of a high grade tumor in 24% of cases (Gleason>/= 8), 16% presented lymph node metastasis and 25% positive margins.Ten years biochemical recurrence free survival was 37%,metastasis free survival was 77% e cancer specific survival was 83%.Influencing factors of surgery efficacy included tumor grade (Gleason) and PSA level at time of tumor recurrence. To better select patients who may benefit from salvage prostatectomy, image exams are key: bone scintigraphy, computerized tomography and magnetic resonance imaging (MRI). MRI has the advantage of identifying lesions only detected with the use of diffusion sequence technique. After recurrence is pathologically confirmed (biopsy), salvage prostatectomy has been recommended whenever overall survival is expected to be over 10 years. Ten year overall survival is expected to range between 54 and89% following salvage surgery. Adjuvant hormonal therapy was not shown to increase survival time. Complications include a 20% rate of urinary incontinence, 50% rate of erectile dysfunction and urethral stenosis in 10-30%; rectal fistula was observed in 6-15% of cases. A high cure rate and lower complication rate following salvage prostatectomy due to surgical technical refinement suggest this to be the best approach to address post radiotherapy tumor recurrence with no signs of metastasis.

References 1Salvage Radical Prostatectomy for Radiation-recurrent Prostate Cancer: A Multiinstitutional Collaboration. Eur Urol 60(2011): 205-210

Fernandes Denardi Division of Urologia, FCM - UNICAMP


learning by image edition: May 2012 Elaine Bronzatto, Daniel Carlos Silva, Daniel Lahan Division of Urology - Unicamp, Division of Radiology – Vera Cruz Hospital

Post surgical renal artery thrombosis: case report


learning by image edition: May 2012 Elaine Bronzatto, Daniel Carlos Silva, Daniel Lahan Division of Urology - Unicamp, Division of Radiology – Vera Cruz Hospital

Fifty three year-old diabetic, hypertensive and obese female (IMC: 38 Kg/m2). Patient underwent a reductive gastroplastybyFobiCapela technique. On the fourth post operative day patient initiated with abdominal pain, vomiting fever, tachycardia and high blood pressure. Initial diagnostic hypothesis was an enteric fistula which was not confirmed by radiologic study with oral contrast. Further investigation with abdominal computerized tomography (CT) identified an arterial thrombus partially occluding the aortic lumen and extending into the left renal artery; multiple infarction areas in the ipsilateral kidney;a 3cm nodule in the right adrenal gland (adenoma). (Fig.1 e 2)

Figure 2: abdominal CT, coronal cut, nephrographic phase, showing arterial aortic thrombus with extension into the renal artery (yellow arrow) and focal infarction areas (red arrow)and adrenal nodule (adenoma).

Figure 1: abdominal CT with venous dye, nephrographic phase showing triangular hypodense areas compatible with focal infarction areas (red arrow) and anarterial thrombus partially occluding the aorta (yellow area).

DMSA scintigraphy confirmed left renal non function (9% relative function). (Fig.3)

Vascular surgery team oriented full anticoagulation with enoxaparin associated with an antiplatelet agent (Acetylsalycilic acid). Hematologic evaluation further investigated existing thrombophilic conditions: Negative Anticardiolipin, Lupic anticoagulant: 1,53 (<1,3), S Protein: 106,6% (60-130), Leiden'sFactor V: negative. A cumarinic agent replaced the enoxaparin aiming to maintain an INR between 2,5-3,0. Figure 3: DMSA renal scintigraphy, with left renal relative function of 9%.

Patient presented improvement in abdominal pain and was discharged home on the 16th post operative day. Abdominal CT scan confirmed renal exclusion at 2 months follow up (Fig. 4).

Figure 4: Abdominal tridimensional CT scan showing poor left renal perfusion (arrow).


learning by image edition: May 2012 Elaine Bronzatto, Daniel Carlos Silva, Daniel Lahan Division of Urology - Unicamp, Division of Radiology – Vera Cruz Hospital

FOLLOW UP: Patient is followed in our clinic with routine renal function monitoring.

FINAL MESSAGE: Aortic thrombus not associated with aortic dissection is an occasional finding. Thrombus can occur spontaneously or as consequence of a traumatic, inflammatory or cancerous event.The pathological mechanism involves lesion to the aortic wall and most frequent clinical phenomenon is distal arterial embolization, notably to the inferior limbs; however, complete occlusion may occur leading to a severe ischemic status. Renal artery thrombosis is also reported in the Literature following blunt abdominal trauma, associated with thrombophilic conditions, secondary to aorticand iliacdissection, and following diverse surgical procedures including heart peacemakers, pulmonary resections and cancerous gynecological conditions. In the present case, thrombosis might have occurred as a consequence of direct mechanical compression, although this type of lesion is more often seen in iliac vessels during pelvic surgeries. The complete thrombus resolution within 60 days following anticoagulation confirms its recent status.Modern imaging tools as duplex ultrasonography and abdominal angio CT scan allow for an immediate diagnosisof renal artery thrombosis and endovascular intervention with local infusion of thrombolitic agents, thrombus aspiration and angioplasty with stent placement when needed.Open surgery may also be required when a bilateral thrombus is diagnosed. It is important to focus on trying to minimize the time of renal ischemia which demands immediate arterial desobstruction within the first hours following the ischemic event. Late intervention is associated with increased morbidity and poorer chance of renal parenchyma sparing.

REFERENCES: EM, LABROUSSE LM, MADONNA FP, DEVILLE C. Mobile thrombus of the thoracic aorta: diagnosis and treatment in 9 1CHOUKROUN cases. Ann VascSurg 2002;16(6):714e22. JM, LUBE MW, SMITH CP, ANDRIOLE J. Traumatic Renal Artery Occlusion in a Patient with a Solitary Kidney: Case Report of 2DOWLING Treatment with Endovascular Stent and Review of the Literature. Am Surg 2007; 73(4):351-3. K, SCHIFF J, ROAYAIE S, RAHAMAN J, NAGARSHETH NP. Renal artery thrombosis following secondary cytoreduction in a 3ZAKASHANSKY patient with ovarian cancer.Gynecologic Oncology 2007; 105:536–8. MI, SHAIKHA A, ULLAHE A, AKHTERF TS, RANGINWALAG S, MOHAMMEDH MI, MISICKC L. Acute renal artery thrombosis treated 4 SYEDA with t-PA power-pulse spray rheolyticthrombectomy. Cardiovascular Revascularization Medicine 2010; 11:264.e1–264.e7.

Fabio Menezes Division of Vascular Surgery FCM - UNICAMP


new TECHNOLOGIES edition: May 2012 Ricardo Souza Division of Urology - Unicamp

Prospective randomized trial to evaluate the impact of transurethral resection with narrow band imaging in the recurrence of non invasive bladder cancer


new TECHNOLOGIES edition: May 2012 Ricardo Souza Division of Urology - Unicamp

Naselli A, Introini C, Timossi L, Spina B, Fontana V, Pezzi R, Germinale F, Bertolotto F, Puppo P. This prospective randomized study was published in May edition of the European Urology presents a comparative analysis on the risk of bladder urothelial tumor recurrence evaluated according with the type of light used for transurethral bladder resection (TURB): classic white light (WL) versus narrow Band Imaging (NBI). NBI consists in 2 centered light streams centered in 415nm (blue) and 540 nm (green) which are absorbed by hemoglobin and penetrate only into tissue superficial layer. This allows for a better visualization of capillary vessels and mucosa. This type of light permits easier identification of tumor focuses which would ultimately reduce post TURB recurrence rate.

Two groups were enrolled with a total of 148 patients: 72 patients underwent widely used classic WL TURB and 76 underwent NBI. Those harboring muscle invasive histologic proven cancer or lacking cancer diagnosis were excluded. Study was designed to test a difference of 10% between groups in 1 year.

Results:

Conclusion: TURB associated with NBI was able to reduce more than 10% (aprox. 20%) urothelial non invasive bladder cancer recurrence.

Commentary: Editorial comment by Brausi highlights the existing bias regarding complementary treatment with BCG or Mytomicin between the 2 groups: 74,2% (23/31) of patients with high grade tumor in the WL group versus 91,9% (34/37) in NBI group. Besides, the real benefit of using NBI technology is questioned as experienced urologists are able to detect recurrence rates up to 3% in 3 months using the traditional white light cystoscopy. The author also observes that the use of adjuvant chemotherapy or BCG bladder instillation may cure a tiny tumor not detected by TURB in 50-60% of cases. Besides, small papillary tumors have a low risk of progression to muscle invasive disease (1-3%). Finally, Brausiobserves the lack of follow up studies using NBI technology able to show a reduction in mortality or in disease progression to muscle invasive status; cost effectiveness must also be demonstrated. Mauricio Brausi Eur. Urol. 2012, 61: 914-6.

Counterpoint by authors: Authors reply that adjuvant therapy was applied according to EAU guidelines. NBI is indeed a simple optical filter to the white light which would add a very low cost to the currently used technology. Authors agree on the need for further investigation on the theme.


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