RCAAP Repository

PurposeTo evaluate the relationship between mean apparent diffusion coefficient (ADC) and post-surgical Gleason scores. To determine the diagnostic accuracy of multiparametric magnetic resonance imaging (mp-MRI) on a 1.5T magnet in distinguishing low, intermediate and high-grade prostate tumors.Material and methodsThis is a retrospective institutional-review-board-approved, single-center study including 30 patients (median age, 60 years) who underwent mp-MRI before prostatectomy for prostate cancer. Using histological reports for guidance, the tumors were localized in ADC maps, and mean ADCs were measured and examined for correlation with Gleason scores. 2 patients had 2 measurable foci, so a total of 32 tumors were studied. The diagnostic accuracy of the mean ADC was assessed by using the area under the receiver operating characteristic curve (ROC).ResultsIn the differentiation of tumors with a Gleason score of 6 from those with a Gleason score of at least 7, mean ADC yielded an AUC of 0.76 (95% confidence interval: 0.59, 0.93). In the differentiation of tumors with Gleason scores of 6 or 7 from those with a Gleason score of at least 8, mean ADC yielded an AUC of 0.94 (95% confidence interval: 0.86, 1.00).ConclusionMean ADC values may allow a correct assessment of the patient risk using a 1.5T magnet without ERC.

Introduction: Bladder cancer is the ninth common tumor worldwide and the most common malignant carcinoma of urinary system with an increasing incidence. Despite the high frequency and mortality associated with this carcinoma, little has evolved recently regarding the diagnosis and management of this type of tumor. In fact, cystoscopy and cytology are still standards for bladder cancer detection. The development of less invasive and more reliable diagnostic techniques of bladder cancer than cystoscopy and cytology is critical. In this sense, metabolomics has recently emerged as a promising technique for the diagnosis and orientation of oncological diseases. Evidence Acquisition: We searched PubMed, Medline and Web of Science for studies about metabolomics and bladder cancer published before October 2017. We performed a review of the literature, trying to clarify what is already known about the application of metabolomics in bladder cancer and what are the future prospects. Evidence Synthesis: The spectral acquisition is made using predominantly two analytic platforms: nuclear magnetic resonance and mass spectrometry. Regarding to bladder cancer, several metabolites were associated with the presence of bladder cancer, leading to the creation of a metabolomic profile capable of distinguishing between bladder cancer patients and control. Besides the diagnosis, the metabolomic has also been studied to stratify bladder cancer according to its aggressiveness. In this sense there are studies that used metabolomic analysis to distinguish between low-grade and high-grade bladder cancer. One investigation showed that the levels of carnitine were higher in muscle-invasive bladder cancer than in nonmuscle-invasive bladder cancer, which suggests that they may be correlated with bladder cancer aggressiveness. Conclusion: Biomarkers detected by metabolomics give an insight into cancer biology and tapped properly this can lead to new strategies for bladder cancer diagnosis and new drugs discovery.

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Self-inserted urethrovesical foreign bodies are rare in children.We present three cases and discuss the clinical presentation, diagnosis and management of such patients. In case 1, a 16-year-old boy introduced a wire into the urethra and partially into the bladder three days before. In case 2, a 4-year-old boy introduced a hairpin in the urethra in the same day. In case 3, a 11-year-old boy introduced a sewing needle in the urethra a few hours before. Cystourethroscopy and suprapubic cystotomy were used to remove the foreign bodies. The presentation of urethrovesical foreign bodies can vary widely, as can the type of object inserted. Foreign body retrieval is determined by its morphology and the patient’s conditions with the aim to minimise urothelial trauma and preserve erectile function. Definitive treatment is usually the endoscopic removal, however sometimes surgical intervention may be required. It is advocated follow-up with long duration, which is necessary to diagnose the long-term complications including urethral stricture.

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Phalloplasty can be either performed as a penile reconstructive or phallic constructive procedure, mainly in penile trauma victims or female-to-male gender reassignment. After the introduction of the radial artery-based forearm free flap and with the further awareness of patient desire to void while standing, urethral reconstruction became a standard procedure and a main goal to attain in phalloplasty. Urethroplasty techniques can be broadly split in two main groups: as part of a tube-within-a-tube skin flap or as an independent other-than-skin graft. Urethral complications, such as fistula, stricture, or stones, are common and often recur after treatment. In this review, the main techniques of urethral reconstruction in phalloplasty are reviewed and compared. Urethral complications are also reviewed as well as their management.

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Introduction: Chronic bacterial prostatitis accounts for 5% - 10% of all prostatitis cases, inducing a significant decline in the quality of life of patients. The current therapeutic approach of chronic bacterial prostatitis is based on long-term antibacterial therapy with fluoroquinolones. However, many cases relapse with gained antibiotic resistance, requiring another treatment cycle, sometimes intravenous in inpatient care setting. This paper presents a review of the literature on the efficacy of oral antibiotics in the treatment of chronic bacterial prostatitis by microorganisms resistant to first-line antibiotics. Methods: Systematic review according to PICO methodology of the literature published in PubMed, using the keywords: “prostatitis”, “nitrofurantoin”, “macrolides”, “fosfomycin”, “amoxicillin”, “cephalosporins”, “tetracycline” and “doxycycline”. Results: 15 studies were included, which analyzed the clinical (clinical cure) and/or microbiological efficacy (bacterial eradication) in men with chronic bacterial prostatitis caused by various etiological agents treated with fosfomycin, amoxicillin, macrolides or tetracyclines. Discussion: In two case series, fosfomycin and amoxicillin-clavulanic acid combination showed efficacy in chronic bacterial prostatitis by multidrugresistant Enterobacteriaceae, hence they may be a therapeutic alternative. A fluoroquinolone-macrolide combination was also effective in chronic bacterial prostatitis caused by habitual bacterial agents. Good quality studies exist on the role of macrolides and tetracyclines in chronic bacterial prostatitis caused by intracellular atypical agents, where they present as first choice. Conclusion: The need for new alternatives in the treatment of resistant chronic bacterial prostatitis and the paucity of available information, warrant further research in this area.

Introduction: We intend to evaluate which factors are associated with unexpected hospital return (UHR) following transurethral resection of bladder tumor (TURBT). Material and Methods: Exploratory cross-sectional study of all TURBTs performed between 2015-2016. Results: A total of 499 TURBTs were performed in 389 patients. Within 30 days of surgery, there was an UHR in 16.8% of cases, 4.2% demanding hospital readmission. UHR occurred mainly because of urinary tract infection (UTI) (38.1%). There was a significantly increased UHR in cases of primary tumour, larger tumor size, incomplete tumour resection, need for additional endoscopic procedures, higher surgery time, longer urethral catheterization, higher values of preoperative C-reactive protein (CRP) and lower preoperative hemoglobin. In a multivariate logistic regression analysis, we found a strong and independent association between UHR and length of surgery (OR = 1.016), duration of urethral catheterization (OR = 1.059) and preoperative CRP (OR = 1.131). Conclusion: Early UHR after programmed TURBT occurred in almost 17% of cases, mainly because of UTI. For each additional minute of surgery, each additional day of UC and each additional unit (mg/dL) of preoperative CRP, there is an increased risk of UHR in 1.6%, 5.9% and 13.1% respectively. As CRP value is not a modifiable variable, it is up to the surgeon to optimize the operative time and mainly the length of UC in order to reduce the probability of UHR.

Introduction: The non-muscle invasive bladder tumors should be stratified into risk groups so the adjuvant treatment after surgery can be suited to each patient. The high risk tumors should be treated with one to three-year maintenance intravesical bacillus Calmette-Guérin (BCG). It has been reported shortages of intravesical BCG and our hospital center was affected in 2014/2015, leading to a treatment change of the patients who had indication to BCG. Gemcitabine could be a valid alternative because some studies show it may have a role in intermediate-risk patients, as an alternative to mitomycin C, and in high risk, BCG-refractory patients, with a better toxicity profile. Material and Methods: This is a descriptive, retrospective study that included patients with non-muscle invasive bladder tumors of high risk with onset of disease in 2013/2014, affected by the BCG shortage period at the Hospital Center. Results: At CHLC, 11 high-risk patients were treated with gemcitabine, only two exclusively, and the others sequentially with BCG. Only two patients, treated with both gemcitabine and BCG, had tumoral recurrence. However, a significant number (6 out of 11) had adverse events, two of whom had to stop treatment. Conclusion: Apparently, gemcitabine seems to be a good adjuvant treatment choice during the shortage of the gold standard treatment, due to the low number of recurrence, although adverse events reported were high.

Introduction: Besides burn wound infections, burned patients are also more susceptible to other types of nosocomial infections. Catheter-associated urinary tract infections (CA-UTI) are one of the most common infections in this context, responsible for high morbidity, increased hospital stay and associated costs. The aim of this study was to characterize catheter-associated urinary tract infections in hospitalized burn patients and evaluate the frequency of microbiologic agents responsible for these infections. Material and Methods: Retrospective study, performed in a Burn Center (Coimbra Burns Unit) of a University Hospital (Centro Hospitalar e Universitário de Coimbra, Portugal – CHUC), based in the clinical data and urine cultures of burned patients who have performed at least once this exam between 1 January 2010 and 31 December 2014. Different variables such as date of infection, general characteristics of the population and the responsible pathogen were analyzed. Infections were further categorized taking into account the existence of previous episodes of CA-UTI, thereby defining primary infection, re- infection, relapse and over-infection. Results: Between January 2010 and December 2014, 213 CA-UTI were diagnosed in 143 patients. The most common uropathogens were E. coli (27.2%), Enterococcus faecalis (20.2%), Pseudomonas spp. (13.1%), Candida spp. (12.1%), Klebsiella spp. (10.8%) and Acinetobacter baumannii (9.9%). The most common microorganisms varied significantly depending on the gender of the patient. The CA-UTI analyzed corresponded to 143 primary infections, 44 reinfections, 17 relapses and nine over-infections. Relapse corresponded to 11% of infections in males and 5.7% in females and was significantly more frequent in infections due to Acinetobacter baumannii. Discussion/Conclusion: Catheter-associated urinary infections are common in intensive care units, particularly at Burn Units. The most common pathogens identified were similar to those reported in the literature. Pathogens responsible for polymicrobial infections were similar to those in monomicrobial infections, probably due to the short-term nature of urinary catheterization. Infections by Acinetobacter baumannii showed high susceptibility to relapse, which is probably related to its multi-drug resistance, common in this pathogen. The high relapse rate detected in males is probably related to the greater frequency of Acinetobacter baumannii infections in this gender. Candiduria was more frequent in the context of reinfection and over-infection, probably due to disruption of bacterial flora secondary to previous systemic antibiotics.

AimIn the evaluation of prostate cancer, clinical nomograms are commonly used to predict the probability of lymphatic and extra‐nodal spread. Those nomograms may suggest the presence and the extension of this cancer but do not allow a clear distinction between loco‐regional and distant disease. In this study, it was intended to evaluate the usefulness of 18F‐Fluorocoline positron emission tomography/computed tomography (18F‐FCH‐PET/CT) in the workup of patients with the initial diagnosis of prostate cancer and staged by this imaging technique.Material and methodsThe medical records of 39 patients with prostate cancer who underwent 18F‐FCH PET/CT for initial staging, between November 2010 and April 2015, were reviewed. Of these, 20 patients were excluded because they had already started hormonotherapy. In the other 19 patients, the performance of 18F‐FCH PET/CT for the detection of lymph node metastasis was evaluated by calculating the sensitivity, specificity, positive predictive value, negative predictive value and diagnostic accuracy. Six patients had performed pelvic lymphadenectomy (total of 69 lymph nodes), allowing histological confirmation. When there was no histological confirmation (total of 30 lymph nodes and 3 cases of bone metastasis), the findings of 18F‐FCH PET/CT were correlated with the values of PSA and the information from multiple imaging modalities such as CT, bone scan, magnetic resonance (MRI), 18F‐Sodium Fluoride (18F‐NaF) PET/CT of control.ResultsThe sensitivity, specificity, positive predictive value, negative predictive value and diagnostic accuracy for lymph node metastasis detection were, respectively, 96.8%, 80.9%, 69.8%, 98.2% and 85.8%. In our sample, this technique also allowed the identification of nodal extra pelvic or bone metastasis in 5 patients (26.3%) with implications in the treatment. It showed uptake suggestive of bone metastasis, corroborated by other diagnostic technics or by the follow‐up, in 3 patients, those with prostate specific antigen (PSA) of 9.5±2.9 ng/mL.Conclusion18F‐FCH PET/CT is an entire body and multi organ imaging modality that allows the identification, globally, of the sites of disease in patients with prostate cancer. In this study, 18F‐FCH PET/CT showed good results when used in the initial staging of these patients. It is highlighted the ability to detect distant disease, in particular bone metastasis, even with PSA<20ng/mL.

Introduction: Congenital obstructive megaureter may be treated with endoscopic balloon dilatation, particularly in children under one year of age. We report our experience over a six year period. Patients and methods: All patients with diagnosis of primary obstructive megaureter (POM) treated with endoscopic balloon dilatation from 2009 to 2014 (6 years) were included. The diagnosis of POM was based on dilatation of the distal ureter greater than 7 mm, obstructive curve on MAG 3 diuretic renogram and absence of vesicoureteral reflux (VUR). After diagnosis, conservative management was maintained with antibiotic prophylaxis in all patients. The indications for surgery were a combination of clinical, ultrasonographic and renographic findings. Under general anesthesia and after retrograde ureteropielography, high pressure balloon dilation of the ureterovesical junction was performed under direct and fluoroscopic vision until the disappearance of the narrowed ring. A double-J catheter was positioned. Follow-up was performed with ultrasonography and diuretic renogram. The success of the intervention was defined by improvement of HUN (at least 2 grades). Results: A total of nine patients underwent this procedure on a single ureter, two girls and seven boys, with a mean age of 7. 6 months (range 1-14) at the intervention. Five were left sided and four were right sided. All patients had prenatal diagnosis of hydroureteronephrosis (HUN). No patients were lost to follow-up (average 46.7 months). They all had HUN greater than grade 3 and preoperative MAG3 diuretic renogram was obstructive in all cases.  Mean differential function of the affected kidney was 46.2% (range 40-53%). The main indication for surgical treatment was progressive HUN. All patients were treated endoscopically with no intraoperative complications. Ultrasound showed improvement of the HUN in six patients (66.7%). Three patients were reimplanted (33.3%). The mean differential renal function (DRF) after the procedure was 47.4% (range 41-53%). At the latest follow-up assessment, all patients remained asymptomatic. Discussion: Endoscopic balloon dilatation is a useful option in the management of POM requiring surgical intervention and may be considered first line treatment in small children.

Introduction: In this study, we evaluated the initial results of this procedure in our hospital, aiming to evaluate retrograde intrarenal surgery efficacy and safety and possible success predictors of this technique. Material and Methods: After collecting data from the medical records and imaging studies of all patients undergoing retrograde intrarenal surgery in 2014 e 2015 at Centro Hospitalar de São João, and applying our exclusion criteria, we analyzed the data of 138 patients (total of 179 retrograde intrarenal surgery). The primary outcomes of our study were the immediate success rate, assessed by the surgeon’s perception intraoperatively, and postoperative success rate, assessed by image control. Residual lithiasis was considered significant in the presence of calculi > 3 mm. Results: The overall success rate was 67.0%, considering the surgeon’s perception. Considering the image control, the success rate was 66.7% for calculi smaller than 150 mm2 and located outside the ICG, but smaller in other locations or bigger calculi. In the univariate analysis, stone burden, calculi number and location were statistically significant predictors of retrograde intrarenal surgery success. Conclusion: Location in the ICG was considered a predictor of retrograde intrarenal surgery failure and, in this location, RIRS was more effective for calculi < 150 mm2; this differenced was not encountered for calculi outside the ICG. It is a safe intervention, which allows a staged use.

Human schistosomiasis, the second most devastating parasitic disease, is common in developing countries, but rare in Europe. Urogenital tract involvement is mainly due to Schistosoma haematobium infection. Schistosomiasis has long been associated with malignant neoplasia. Some authors have hypothesized a causal relationship between schistosomiasis and carcinoma of the bowel, kidney, bladder and prostate. To data only 17 cases of concomitant prostatic adenocarcinoma and gland schistosomiasis have been described. As an uncommon example of a potential complication of an untreated schistosomiasis, we report a case of an incidentally diagnosed urinary schistosomiasis after a radical prostatectomy for prostate adenocarcinoma in a 62-year-old African man living in a non-endemic area.

Introduction: Transrectal ultrasound guided prostate biopsy (TRUS-Bx), according to the literature, can lead to urinary tract infections in up to 11% and sepsis in up to 2% of patients. We evaluate whether an original way to apply povidone-iodine rectal preparation just prior to TRUS-Bx can reduce infectious complications. Material and Methods: Between January 2014 and September 2016, 94 men in private office were prospectively randomized to two groups, before TRUS-Bx: • Rectal cleansing (an original transrectal “prostate massage” for about half a minute with 2.5 mL of betadine dermic solution 100 mg/mL) (n=47) or • No cleansing (n=47). All of the patients received prophylactic antibiotics: levofloxacin 500 mg PO for 7 days, beginning the day before procedure. Patients completed a telephone interview 4 days after undergoing the biopsy and went to the office 2 weeks after biopsy. The primary end point was the rate of infectious complications. An infectious complication when one or more of the following events occurred: 1) fever greater than 38.0Cº, 2) urinary tract infection or 3) sepsis (standardized definition). Student t test and multivariate regression analysis were used for data analysis. Results: Infectious complications developed in 6 cases (12.7%) in the non-rectal preparation group: five patients had fever without sepsis (11%) and one had sepsis (2%). In the povidone-iodine rectal preparation group there were no infectious complications (0.0%). Multivariate analysis did not identify any patient subgroups at significantly higher risk of infection after prostate biopsy. Of the 94 men who underwent TRUS-Bx 45 (47.9%) were diagnosed with prostate cancer and 3 (3.2%) had ASAP in the result. The hospital admission rate for urological complications within 30 days of the procedure was 1%, and only for infection related reasons (sepsis). Conclusion: The administration of quinolone-based prophylactic antibiotics and the simple use of 2.5 mL of povidone-iodine dermic solution in a transrectal prostate massage for Introduction: Transrectal ultrasound guided prostate biopsy (TRUS-Bx), according to the literature, can lead to urinary tract infections in up to 11% and sepsis in up to 2% of patients. We evaluate whether an original way to apply povidone-iodine rectal preparation just prior to TRUS-Bx can reduce infectious complications. Material and Methods: Between January 2014 and September 2016, 94 men in private office were prospectively randomized to two groups, before TRUS-Bx: • Rectal cleansing (an original transrectal “prostate massage” for about half a minute with 2.5 mL of betadine dermic solution 100 mg/mL) (n=47) or • No cleansing (n=47). All of the patients received prophylactic antibiotics: levofloxacin 500 mg PO for 7 days, beginning the day before procedure. Patients completed a telephone interview 4 days after undergoing the biopsy and went to the office 2 weeks after biopsy. The primary end point was the rate of infectious complications. An infectious complication when one or more of the following events occurred: 1) fever greater than 38.0Cº, 2) urinary tract infection or 3) sepsis (standardized definition). Student t test and multivariate regression analysis were used for data analysis. Results: Infectious complications developed in 6 cases (12.7%) in the non-rectal preparation group: five patients had fever without sepsis (11%) and one had sepsis (2%). In the povidone-iodine rectal preparation group there were no infectious complications (0.0%). Multivariate analysis did not identify any patient subgroups at significantly higher risk of infection after prostate biopsy. Of the 94 men who underwent TRUS-Bx 45 (47.9%) were diagnosed with prostate cancer and 3 (3.2%) had ASAP in the result. The hospital admission rate for urological complications within 30 days of the procedure was 1%, and only for infection related reasons (sepsis). Conclusion: The administration of quinolone-based prophylactic antibiotics and the simple use of 2.5 mL of povidone-iodine dermic solution in a transrectal prostate massage for

  Introduction: Spermatic cord liposarcomas are rare diseases, with only a few reported studies published. In this study we present 2 clinical cases of spermatic cord liposarcoma. Case Report: Case 1: A 76-years-old man was evaluated for a painless left inguinal mass. Imaging studies demonstrated a solid mass, of 38 x 31 cm, located in the left inguinal region. Case 2: A 55-years-old men, evaluated for a painless left scrotal mass, with imaging studies demonstrating a solid lesion of 28 x 27 mm near the left testicle. Both patients underwent left radical orchiectomy, with wide local excision. Histological examination revealed liposarcoma in both situations and the patients performed adjuvant radiotherapy. The patients remain free of disease during follow-up, of eight years in case 1 and four years in the case 2. Conclusion: The recommended treatment of spermatic cord liposarcomas is radical orchiectomy with wide local excision. Adjuvant radiotherapy can reduce de incidence of local recurrence. Considering the recurrence probability, a long follow- up period is recommended for these patients.

Horseshoe kidney is a common congenital renal anomaly and is often associated with urinary tract infections and renal calculi as a consequence of anatomical changes that impair the efficient drainage of the urine. The treatment of urinary stones in these cases becomes a challenge due to the underlying anatomical abnormalities requiring an adaptation of the techniques normally used for the treatment of renal lithiasis. We report the case of a 44-year-old woman with a past history of Cohen left ureteral reimplantation due to vesico-ureteral reflux in childhood and renal lithiasis. The patient had two 12 and 10 mm stones in the upper calix of the left hemi-kidney, with a narrow infundibulum. A flexible ureteroscopy with laser Holmium lithotripsy was performed by placement of a ureteral sheath over the narrowed infundibulum and the patient was left stone-free at the end of the procedure. It is important, in cases of horseshoe kidney stones, to think and adapt the various techniques available for the treatment of renal lithiasis, and to choose the one that will provide a higher success rate with fewer complications.

Robotic surgery allows complex oncological renal surgery with at least equivalent safety and outcomes profiles when comparing to open and laparoscopic approach. We describe a robotic partial nephrectomy of an endophytic tumor with intraoperative ultrasound support and 10th month follow-up outcome.

Introduction: The posterior urethral valves (PUV) are an important cause of congenital urinary tract obstruction affecting male children. Our aim in this study was to characterize the evolution of a children group with PUV with identification of possible risk factors to chronic kidney disease (CKD). Methods: Retrospective analysis of PUV children diagnosed between January 1999 and January 2017 in a level III hospital. Data collected included: clinical, analytical and imagiological findings, treatment and evolution. Statistical tests were realized using: Excel 2016® e Epi Info 7®, with p < 0.05 considered significant. Results: During the studied period, we identified 23 cases of VUP. The diagnosis was prenatal in 16 and four of seven were diagnosed before age one. The clinical presentation was: acute renal failure (n= 11), isolated urinary tract infections (UTI) (n= 4) and poor urinary stream (n= 3). Median creatinine was 151 μmol/L. All 23 children presented renal and upper urinary tract dilatation, (bilateral in 22), 21 had parenchymal changes and 19 had thickened wall bladder. Cistouretrography confirmed the diagnosis and revealed vesicoureteral reflux (VUR) in 15 cases, bilateral in 10. The main treatment was valve ablation by endoscopic fulguration, performed in all cases, one of them with a previous vesicostomy. The mean follow-up was 7.5 years. During that time, 14 presented recurrent UTI’s, seven remained with VUR and 11 with bladder dysfunction. Some needed other surgical procedures, like VUR correction (n= 3) and unilateral nephrectomy (n= 2). Five cases (21.5%) presented CKD stage ≥ 3, with four cases needing dialysis around 9.3 years of mean age. The recurrent UTI’s and bilateral VUR were associated with evolution to that stage (p 0.03 and p 0.049 respectively). Conclusion: PUV remains a frequent aetiology of CKD, despite timely and accurate diagnosis and treatment.