Volume 73, july - august 2013, Issue 4
ISSN-0185-4542
ÓRGANO OFICIAL DE DIFUSIÓN DE LA SOCIEDAD MEXICANA DE UROLOGÍA
Editor Dr. José Guzmán Esquivel
Co-editor Miguel Maldonado Ávila
ISSN-0185-4542 * ARTEMISA * SSALUD * LILACS * IMLA * PERIODICA-UNAM * IMBIOMED * LATINDEX
Calcified double-J stent management at the Hospital
General “Dr. Manuel Gea González”
Experience in radical retropubic prostatectomy at the
Hospital Regional “Lic. Adolfo López Mateos”,
ISSSTE
Risk factors for developing urethral stricture in
patients that underwent transurethral resection of the
prostate
Stricture in the bulbous urethra with
measurements of length and depth. pp.
180-186
Oncologic effectiveness and safety of laparoscopic
renal cryosurgery guided by high definition laparoscopic ultrasound
Usefulness of urethral ultrasound imaging in urethral
stricture
Tumors of Cowper’s glands: a review of the literature
A new theory on albumin glomerular filtration and its
tubular reabsorption: disputing
the charge selectivity theory
A) and B) Voiding cystourethrogram that
shows stricture data at the penoscrotal
junction and the bulbous urethra. C) and
D) Urethral ultrasound that shows a
reduction in the caliber of the urethra
at the level of the penoscrotal junction
and the bulbous urethra. Spongiofibrosis
surrounding the tissue can be seen. pp.
180-186
www.elsevier.es
•CONTENIDO
•CONTENTS
Artículos originales
Manejo de catéteres doble J calcificados
en el Hospital General “Dr. Manuel Gea González”
ORIGINAL ARTICLES
155
A. J. Camacho-Castro, et al.
A. J. Camacho-Castro, et al.
Experiencia en prostatectomía radical retropúbica
en el Hospital Regional “Lic. Adolfo López
Mateos”, ISSSTE
160
P. Cruz García-Villa, et al.
166
P. Cruz García-Villa, et al.
160
Risk factors for developing urethral stricture in patients that underwent transurethral resection of
the prostate
166
P. Cruz García-Villa, et al.
Eficacia y seguridad oncológica de la criocirugía renal laparoscópica guiada con ultrasonido
laparoscópico de alta definición
175
J. G. Campos-Salcedo, et al.
Oncologic effectiveness and safety of laparoscopic renal cryosurgery guided by high definition
laparoscopic ultrasound
175
J. G. Campos-Salcedo, et al.
Utilidad ultrasonido uretral en estenosis de uretra
180
P. Cruz García-Villa, et al.
Usefulness of urethral ultrasound imaging in urethral stricture
180
P. Cruz García-Villa, et al.
Artículos de revisión
Tumores de las glándulas de Cowper: una revisión de la literatura
REVIEW ARTICLES
187
A. Lisker-Cervantes, et al.
Tumors of Cowper’s glands: a review of the literature
187
A. Lisker-Cervantes, et al.
Nueva teoría sobre la filtración glomerular de albúmina y su reabsorción tubular: refutado de
la teoría de la “selectividad por cargas”
B. Condado-Arenas, et al.
Director General:
Experience in radical retropubic prostatectomy at the Hospital Regional “Lic. Adolfo López Mateos”,
ISSSTE
P. Cruz García-Villa, et al.
Factores de riesgo para el desarrollo de estenosis de uretra en pacientes operados de resección
transuretral de próstata
Editada por:
Calcified double-J stent management at the Hospital 155
General “Dr. Manuel Gea González”
191
A new theory on albumin glomerular filtration and its tubular reabsorption: disputing
the charge selectivity theory
B. Condado-Arenas, et al.
MASSON DOYMA MÉXICO, SA. Av. Insurgentes Sur 1388,
Piso 8, Col. Actipan Del. Benito Juárez,
CP 03230, México, D.F. Tels.: 5524-1069, 5524-4920, Fax: 5524-0468.
Pedro Turbay Garrido
191
Casos clínicos
Esfínter urinario artificial para el manejo de la incontinencia urinaria posterior a prostatectomía
radical
CLINICAL CASES
195
G. Fernández-Noyola, et al.
Ectopia renal cruzada con fusión y litiasis múltiple, nefrectomía con abordaje paramedio anterior
200
Crossed renal ectopia with fusion and multiple renal calculi managed with nephrectomy
through the anterior paramedian approach
204
Application of dorsal buccal mucosa graft for penile urethral stricture treatment: technical
aspects
G. Fernández-Noyola, et al.
Manejo de la incontinencia urinaria masculina 208
posprostatectomía radical con cabestrillo transobturador
(AdVance®)
Management of post-radical prostatectomy male urinary incontinence with a transobturator
sling (AdVance®)
S. Ahumada-Tamayo, et al.
S. Ahumada-Tamayo, et al.
212
Management of recurrent stricture of the perineal meatus with the Blandy technique after penectomy
secondary to corpora cavernosa abscess
J. Á. Martínez, et al.
J. Á. Martínez, et al.
Nefrectomía parcial laparoscópica. Aspectos técnicos 216
Technical aspects of laparoscopic partial
nephrectomy
S. Ahumada-Tamayo, et al.
200
F. R. Zamora-Varela, et al.
G. Fernández-Noyola, et al.
Técnica de Blandy para el manejo de la estenosis recurrente de meato perineal, posterior a falectomía
secundaria a absceso de cuerpos cavernosos
195
G. Fernández-Noyola, et al.
F. R. Zamora-Varela, et al.
Aplicación de injerto dorsal de mucosa oral para el tratamiento de la estenosis de uretra peniana.
Aspectos técnicos
Urinary incontinence management with artificial urinary sphincter following radical
prostatectomy
S. Ahumada-Tamayo, et al.
204
208
212
216
Rev Mex Urol 2013;73(4):155-159
ÓRGANO OFICIAL DE DIFUSIÓN DE LA SOCIEDAD MEXICANA DE UROLOGÍA
www.elsevier.es/uromx
Original article
Calcified double-J stent management at the Hospital General “Dr.
Manuel Gea González”
A. J. Camacho-Castro*, V. Osornio-Sánchez, J. Á. Martínez, A. Urdiales-Ortiz, G.
Fernández-Noyola, S. Ahumada-Tamayo, F. García-Salcido, E. Muñoz-Ibarra, E. MayorgaGómez, G. Garza-Sainz, Z. A. Santana-Ríos, R. Pérez-Becerra, S. Fulda-Graue, C.
Martínez-Arroyo, M. Cantellano-Orozco, G. Morales-Montor and C. Pacheco-Gahbler
Department of Urology, Hospital General “Dr. Manuel Gea González”, Mexico City, Mexico
KEYWORDS
Encrustation; Ureteral
stent; Calcified;
Mexico.
Abstract
Background: Encrustation is a clinical problem that occurs in both external and internal urinary
diversion catheters; the chemical constituents of urine combine with the stent to produce a
matrix upon which a stone will later form.
Aims: The objective of this article was to describe the management and results obtained in patients with calcified double-J stents at the Hospital General “Dr. Manuel Gea González”.
Material and methods: A retrospective, observational, cross-sectional study was carried out. All
patients with a calcified ureteral stent at the Urology Service of the Hospital General “Dr. Manuel Gea González” within the time frame of January 2010 to July 2011 were taken into account. They were classified according to the FECal Ureteral Stent Grading System created by the
Department of Urology at the Loyola University Medical Center in Maywood, Illinois.
Results: Ten patients (5 men and 5 women) presented with calcified double-J stent and their
mean age was 46 years. The mean length of time with the indwelling double-J stent was 10.2
months; 4 of the patients were classified as grade II, 2 as grade III, 2 as grade IV, and 2 as grade
V. The problem was resolved in 3 of the patients through open surgery, in 3 through laparoscopy,
in 3 through endoscopy, and one patient underwent extracorporeal shock wave lithotripsy
(ESWL). At present all patients are free from residual stones.
Discussion: The management of retained and encrusted ureteral stents can be a surgical challenge for the urologist and represents an increased risk for patient morbidity. However, there
are a wide variety of therapeutic options for approaching this pathology.
Conclusions: The presence of a classification system and management protocol for calcified
ureteral stents enables a standardized approach to this phenomenon.
* Corresponding author at: Calzada de Tlalpan N° 4800, Colonia Sección XVI, Delegación Tlalpan, C. P. 14080, México D.F., México. Telephone: 4000 3000, ext. 3298. Email: ajcc7@hotmail.com (A. J. Camacho-Castro).
0185-4542 - see front matter © 2013. Revista Mexicana de Urología. Publicado por Elsevier México. Todos los derechos reservados.
156
Palabras clave
Incrustación; Catéter
ureteral; Calcificado;
México.
A. J. Camacho-Castro et al
Manejo de catéteres doble J calcificados en el Hospital General “Dr. Manuel Gea González”
Resumen
Introducción: La incrustación es un problema clínico que ocurre en los catéteres de derivación
urinaria tanto externos como internos; los constituyentes químicos de la orina se combinan con el
catéter para formar una matriz en donde posteriormente se formará un lito.
Objetivo: El objetivo del trabajo fue describir el manejo y los resultados obtenidos en los pacientes con catéter doble J calcificado, en el Hospital General “Dr. Manuel Gea González”.
Material y métodos: Estudio retrospectivo, observacional, transversal. Se tomaron en cuenta
todos los pacientes con catéter ureteral calcificado, manejados desde enero del 2010 hasta julio del 2011 en el Servicio de Urología, del Hospital General “Dr. Manuel Gea González”. Se
clasificaron de acuerdo al FECal Ureteral Stent Grading System, creado por el Departamento de
Urología del Centro Médico de la Universidad de Loyola en Maywood, Illinois, EUA.
Resultados: Diez pacientes con presencia de catéter doble J calcificado, 5 hombres y 5 mujeres, con
una edad promedio de 46 años y tiempo de colocación del catéter doble J de 10.2 meses; 4 se encontraron en grado II, 2 en grado III, 2 en grado IV y 2 en grado V; 3 se resolvieron por medio de cirugía
abierta, 3 por laparoscopía, 3 por endoscopía y uno por litotripsia extracorpórea por onda de choque
(LEOCH). A la fecha todos los pacientes se encuentran libres de presencia de lito residual.
Discusión: El manejo de catéteres ureterales retenidos e incrustados puede representar un reto
quirúrgico para el urólogo, constituyendo un riesgo aumentado en la morbilidad del paciente,
sin embargo se cuentan con amplias opciones para abordar esta patología.
Conclusiones: La presencia de un sistema de clasificación y protocolo de manejo de catéteres
ureterales calcificados, permite estandarizar la forma en que se aborda este fenómeno.
Introduction
The introduction of the ureteral stent in 1967 revolutionized the way urinary tract obstructions were managed and it
became one of the most widely used urologic accessories.
Current indications for its use include the prevention and
treatment of ureteral obstruction secondary to intrinsic, extrinsic, or iatrogenic causes such as urolithiasis, stricture,
and malignancy. A calcified ureteral stent is defined as one
that cannot be removed by cystoscopy in the first attempt
without the aid of other auxiliary measures due to encrustation or the formation of a stone within the stent (fig.1).1-3
Modern ureteral stents have a double-pigtail (double-J)
design and are made of synthetic polymers (polyurethane/
polyethylene). The ideal material for a ureteral stent is biocompatible, radiopaque, encrustation-resistant, prevents
infection, causes very little discomfort, is economically accessible, and effectively improves the urinary tract obstruction. However, currently no ureteral stent meets all
those requirements.4
The majority of polymer-based ureteral stents have a
mean indwelling time of 3 to 6 months. Current advances in
the stents are focused on preventing symptoms or complications associated with their placement, such as infection,
migration, dysuria, and calcification.5,6 These advances may
reduce the desire of the patient to have the stent removed
thanks to a decrease in the related symptomatology and
these data, together with an increase in stent use, can be
extrapolated to an increase in future calcified double-J
stents.7-9
In March 2009 the Department of Urology at the Loyola
University Medical Center in Maywood, Illinois published the
FECal Ureteral Stent Grading System, along with a management protocol that enable cases to be resolved with the
most effective methods depending on the classification grade of the stent10. The aim of the present study was to describe the management and results obtained in patients with
a calcified double-J stent seen at the Hospital General “Dr.
Manuel Gea González”.
Methods
A descriptive, retrospective, observational and cross-sectional study was carried out. All the patients presenting with a
calcified ureteral stent that were managed within the time
frame of January 2010 to July 2011 at the Urology Service of
Figure 1 Encrustation.
Calcified double-J stent management at the Hospital General “Dr. Manuel Gea González” 157
Table 1 Management by calcification grades
Grade
N
Management
I
0
NA
II
4
Endoscopic
III
2
Open/endoscopic
IV
2
Open
V
2
Laparoscopic/endoscopic
Grade IGrade IIGrade IIIGrade IVGrade V
Figure 2 Calcification grades.
the Hospital General “Dr. Manuel Gea González” were included in the study.
The stents were classified according to the FECal ureteral
stent grading system (fig. 2) as follows:
• Grade I: Minimal linear encrustation at either of the
pigtail loops
• Grade II: Circular encrustation that completely encloses either of the pigtail loops
• Grade III: Circular encrustation that completely encloses either of the pigtail loops, with some linear encrustation along the ureteral portion of the stent
• Grade IV: Circular encrustation that completely encloses both of the pigtail loops
• Grade V: Diffuse and bulky encrustation that completely encloses both of the pigtail loops, as well as the
entire ureteral portion of the stent
Results
A total of 92 double-J stents were placed during the abovementioned time frame, of which 10 patients (10.86%)
Figure 3 Radiologic calcification grades.
presented with calcified double-J stent. Those patients included 5 men and 5 women and their mean age was 46
years. The mean catheter indwelling time was 10.2 months
and according to the FECal ureteral stent grading system, 4
of the stents were grade II, 2 were grade III, 2 were grade
IV, and 2 were grade V (fig.3); 3 of the calcified stents were
resolved through open surgery, 3 through laparoscopy, and
one through ESWL (table 1). Only one patient had a failed
first attempt that was later resolved through ESWL. At present all of the patients are free from residual stone.
The differences in the management of the calcified double-J stents between the protocol suggested by the Medical
Center in Maywood and our institution are the approach
used for the proximal pigtail loop in grades II, III, and IV, as
well as in the grade V complete stent calcification. The suggested protocol is Holmium laser, ESWL, or percutaneous
nephrolithotomy (PNL), all of which we substituted with the
laparoscopic approach (fig. 4), given that holmium laser was
not available at that time at our hospital. Even so, the results were satisfactory and there was complete resolution in
the first procedure in 90% of the patients.
158
A. J. Camacho-Castro et al
Figure 4 Endoscopic and laparoscopic management.
Discussion
Conflict of interest
Retained and encrusted ureteral stent management can be
a surgical challenge for the urologist, as well as an increased risk for patient morbidity. However, there are many options for approaching this pathology that include open
surgery, laparoscopy, the percutaneous approach, and endoscopy with lithotripsy (hydraulic and laser). Taking into
account that the patient sample obtained in our hospital
was smaller that those reported in the medical literature,
we had pathology resolution with a single procedure in 90%
of our cases, as opposed to the 80% reported in other hospitals worldwide. The complications associated with calcified
double-J stent include infections, stent fracture, ureteral
obstruction, and loss of renal function.
The authors declare that there was no conflict of interest.
Conclusions
Having a classification system of and management protocol
for calcified ureteral stents enables a standardized approach to this phenomenon. However, due to the limited
access to all the management options in the different institutions, the treatment plan to follow should be individualized for each patient.
Financial disclosure
No financial support was received in relation to this article.
References
1. Lam JS, Mantu MG. Tips and Tricks for the Management of Retained Ureteral Stents. J Endourol 2002;16(10):733-741.
2. Bukkapatnam R, Seigne J, Helal M. 1-Step Removal of Encrusted Retained Ureteral Stents. J Urol 2003;170:111-1114.
3. Canales BK, Higgins LA. Presence of Five Conditioning Film Proteins Are Highly Associated with Early Stent Encrustation. J Endourol 2009;23(9):1437-1442.
4. Majid Rana A, Sabooh A. Management Strategies and Results for
Severely Encrusted Retained Ureteral Stents. J Endourol
2007;21(6):628-632.
5. Chin-Chung Y, Chieh-Hsiao C. A New Technique for Treating Forgotten Indwelling Ureteral Stents: Silk Loop Assisted Ureterorenoscopic Lithotripsy. J Urol 2004;171:719-721.
6. Cass AS, Kavaney P. Extracorporeal Shock Wave Lithotripsy for
Calcified Ureteral Stent. J Endourol 1993;7(1):7-10.
Calcified double-J stent management at the Hospital General “Dr. Manuel Gea González” 7. Monga M, Klein E, Castañeda-Zuñiga WR, et al. The Forgotten
Indwelling Ureteral Stent: A Urological Dilemma. J Urol
1995;153:1817-1819.
8. Aravantinos E, Gravas S. Forgotten, Encrusted Ureteral Stents:
A Challenging Problem with an Endourologic Solution. J Endourol 2006;20(2):1045-1049.
159
9. Vanderbrink BA, Rastinehad A.R. Encrusted Urinary Stents: Evaluation and Endourologic Management. J Endourol
2008;22(5):905-912.
10. Acosta-Miranda AM, Miner J. The FECal Double-J: A Simplified
Approach in the Management of Encrusted and Retained Ureteral Stents. J Endourol 2009;15(3):409-415.
Rev Mex Urol 2013;73(4):160-165
ÓRGANO OFICIAL DE DIFUSIÓN DE LA SOCIEDAD MEXICANA DE UROLOGÍA
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Original article
Experience in radical retropubic prostatectomy at the Hospital
Regional “Lic. Adolfo López Mateos”, ISSSTE
P. Cruz García-Villa*, M. Estrada-Loyo, D. López-Alvarado and E. Monroy-Bolaños
Urology Speciality Residency, Hospital Regional “Lic. Adolfo López Mateos”, ISSSTE, Mexico City, Mexico
KEYWORDS
Radical
prostatectomy;
Prostate cancer;
Complications;
Mexico.
Experience in radical retropubic prostatectomy at the Hospital Regional “Lic. Adolfo
López Mateos”, ISSSTE
Abstract
Background: Radical retropubic prostatectomy (RRP) is the curative surgical treatment for prostate cancer (CaP). When performing this complex surgery, the intention is to diminish the possibility of urinary incontinence and erectile dysfunction.
Aims: To describe the experience of patients that underwent RRP at our hospital.
Material and methods: A descriptive, cross-sectional, retrospective study was conducted on
patients that underwent RRP within the time frame of 2008 to 2011 at the Hospital Regional Lic.
Adolfo López Mateos of the ISSSTE in Mexico City.
Results: A total of 38 radical prostatectomies were performed. The mean age was 60 years. The
mean prostate specific antigen (PSA) value at the time of diagnosis was 10.2 ng/ml and the mean
Gleason score obtained through transrectal ultrasound (TRUS)-guided prostate biopsy was 5.6.
The previous clinical stage was T1c in 68.4% of the patients and the definitive histopathologic
study was positive in 71.1%; the surgical margins were positive in 15.8% of the cases and 45% of
the patients presented with erectile dysfunction.
Discussion: RRP as a cure requires experience and is not free from complications. The demographic, clinical, surgical, and morbidity data of our study were similar to those of other authors.
Conclusions: RRP continues to be the treatment of choice in confined CaP. This procedure has
specific morbidity and mortality. However, because of its curative potential, it is the most beneficial option in well-selected patients.
* Corresponding author at: Av. Universidad N° 1321, Colonia Florida, Delegación Álvaro Obregón, C.P. 01030, México D.F., México. Telephone: 5322 2300. Email: patricio_cruzgar@yahoo.com.mx (P. Cruz García-Villa).
0185-4542 - see front matter © 2013. Revista Mexicana de Urología. Publicado por Elsevier México. Todos los derechos reservados.
Radical prostatectomy at the Hospital López Mateos, ISSSTE Palabras clave
Prostatectomía
radical; Cáncer de
próstata;
Complicaciones;
México.
161
Experiencia en prostatectomía radical retropúbica en el Hospital Regional “Lic. Adolfo
López Mateos”, ISSSTE
Resumen
Introducción: El tratamiento quirúrgico curativo para el cáncer de próstata (CaP) es la prostatectomía radical retropúbica (PRR). Se intenta disminuir la posibilidad de incontinencia urinaria
y disfunción eréctil. La PRR es una cirugía compleja.
Objetivo: Describir la experiencia en PRR, en pacientes operados en nuestro Hospital.
Material y métodos: Se realizó un estudio descriptivo, transversal y retrospectivo de los pacientes sometidos a PRR de 2008 a 2011, en el Hospital Regional “Lic. Adolfo López Mateos” del
ISSSTE, México D.F.
Resultados: Se realizaron 38 prostatectomías radicales. La edad promedio fue de 60 años. El
antígeno prostático específico (APE) medio al diagnóstico fue de 10.2 ng/mL y la suma de Gleason por biopsia transrectal de la próstata (BTRP) fue de 5.6. El estadio clínico previo correspondía a T1c en el 68.4%. El estudio histopatológico definitivo fue positivo en el 71.1%. En el 15.8%
los márgenes fueron positivos. El 45% presentó disfunción eréctil.
Discusión: La PRR como tratamiento curativo requiere experiencia y no está libre de complicaciones. De acuerdo este estudio, encontramos datos demográficos, clínicos, quirúrgicos, y de
morbilidad similares a los de otros autores.
Conclusión: La PRR continúa siendo el tratamiento de elección en CaP confinado. Este procedimiento tiene morbilidad y mortalidad específica. Sin embargo, el ser potencialmente curativo lo
hace la opción de más valor en pacientes bien seleccionados.
Introduction
Prostate cancer (CaP) is the number two disease in regard to
mortality burden in the United States, just behind lung cancer, and it is the most common non-dermatologic tumor
affecting men in the Western world; radical prostatectomy
(RP) is the standard treatment in the majority of patients
with recently diagnosed, clinically localized disease, with
close to 50% of them undergoing surgery.1
The ideal result of RP is for the patient to have undetectable prostate-specific antigen (PSA) levels and no functional consequences.2
A critical component in the evaluation of oncologic effectiveness in the case series that have been published - and
that can be used in comparative analyses - is to be able to
measure the result that is going to be reported. At the
lowest level, establishing the measurement of the result of
interest becomes vitally importance for being able to answer the question patients most frequently ask: “What is
the surgery’s expected range of success?” Up to the present,
the most commonly reported measurement of cancer control after RP has been biochemical recurrence (PSA level).3
Whereas the principal aim of the surgery is complete removal of the primary tumor, patient satisfaction can be negatively affected by the resulting postoperative urinary
incontinence and/or erectile dysfunction. Therefore, it is
necessary to include both the oncologic and the functional
results in evaluating success after RP. In an attempt to improve the evaluation of RP results, the addition of postoperative complications and the status of the surgical specimen
margins have been proposed.1
The report on a large group of patients with CaP that have
undergone RP, their postoperative complications, biochemical recurrence, and erectile function and urinary incontinence
statuses is of great importance and should be carried out
both inside and outside the medical institutions so that
comparisons among them can be established. Such an analysis would result in the implementation of improved surgical
techniques and the strengthening of areas that require it.
Methods
A descriptive, analytic, cross-sectional, and retrospective
study was conducted on patients with CaP that received curative surgical treatment (radical retropubic prostatectomy,
RRP) within the time frame of 2008 to 2011 at the Hospital
Regional Lic. Adolfo López Mateos of the ISSSTE. The following variables were analyzed: age, comorbidities, diagnostic PSA, Gleason score from biopsy, clinical stage, prior
use of androgen blockade, intraoperative blood loss, surgery duration, hospital stay, definitive histopathologic result, positive surgical margins, seminal vesicles, lymph
nodes, control PSA at 3, 6, and 12 months, biochemical recurrence rate, adjuvant treatment, urinary incontinence
incidence at 6 months, erectile dysfunction at 6 months,
and other complications. Means, standard deviation, and
data frequency were reported. The paired Student’s t test
was used to compare the Gleason score from the TRUS-guided prostate biopsy with the definitive Gleason score.
Results
In the period corresponding to the years 2008, 2009, 2010,
and 2011, 38 open RRPs were registered. The mean age of
the patients was 60.89 ± 4.8 years (range: 49-69 years). A
total of 15.8% of the patients had a past history of diabetes
mellitus type 2 (DM2) and 31.6% of high blood pressure. The
162
P. Cruz García-Villa et al
Table 1 Demographic characteristics of the patients included
in the study
Age (years)
Diabetes mellitus type 2
60.89 ± 4.8
15.8%
High blood pressure
31.6%
Initial PSA (ng/mL)
10.2 ± 6.2
Total Gleason score of the
TRUS-guided prostate biopsy
5.6
3+3
36.8%
2+2
21.1%
3+4
15.8%
4+3
7.9%
Preoperative clinical stage
T1c
68%
T1b
7.9%
T2a
18%
T2b
5.3%
Total Gleason score of the
surgical specimen
6.3
Surgery duration (minutes)
257
Intraoperative blood loss (mL)
2000
Tumor-free margins
84.2%
Vesicle infiltration
15.8%
Hospital stay (days)
6.9 ± 4
Urinary continence (6 months)
75%
Erectile dysfunction
45%
p<0.005
PSA: prostate-specific antigen; TRUS: transrectal ultrasound.
mean PSA with which the TRUS-guided prostate biopsy was
carried out was 10.2 ± 6.2 ng/mL. The mean TRUS-guided
prostate biopsy result showed a Gleason score of 5.6; 36.8%
of the patients had 3+3, 21.1% had 2+2, 15.8% had 3+4, and
7.9% had 4+3. Clinical stage corresponded to T1c in 68% of
the patients, T2a in 18%, T1b in 7.9%, and T2b in 5.3%.
Androgen deprivation therapy was administered to 50% of
the patients at some point before surgery.
In relation to the surgical procedure, the mean surgery
duration was 257 minutes (range: 150-480 minutes), with a
mean blood loss of 2,000 mL (range: 350-5,000 mL). All patients underwent bilateral pelvic lymph node dissection.
The mean hospital stay was 6.9 ± 4 days. The definitive
histopathologic result was positive in 71% (n=27) of the patients. Immunohistochemistry with p63 and p504 was carried out in 2 patients for the definitive diagnosis. The mean
Gleason score result was 6.3. The paired Student’s t test
was used to compare the Gleason score from the TRUS-guided prostate biopsy and the surgical specimen and there
was a significant difference (p<0.005) (table 1).
Only one patient presented with lymph node metastasis in
the definitive histopathologic study. Tumor-free margins
were reported in 84.2% (n=32) of the patients and tumor
infiltration into the seminal vesicles was reported in 15.8%.
In 25 patients the mean PSA at 3 months was .86 ng/mL
(range: 0.0 to 8.1). At 6 and 12 months, 37 patients had a
mean control PSA of .62 ng/mL (0.0-8.6) and .77 ng/mL
(0.0-17), respectively.
There was biochemical recurrence at some point in 60% of
the patients with a PSA of 0.04 ng/mL as the minimum range. Androgen bock was begun in 37.8% of the patients at
some point after surgery due to biochemical recurrence.
A total of 21% (n=8) patients had a histopathologic report
of positive margins or seminal vesicle infiltration, indicating
adjuvant radiotherapy.
Some degree of urinary incontinence was present in 25%
of the patients at 6 months after surgery, whereas 45.7%
presented with erectile dysfunction in the first semester after the procedure.
Discussion
Despite the emergence of new therapeutic forms for organconfined CaP, RP continues to be the only curative surgical
procedure. Even though it is a technique that has been perfected over time, this procedure is still associated with
mortality and morbidity.4-14 Adequate cancer staging, the
general conditions of the patient, the surgical technique,
and the experience of the surgeon or surgeons are factors
that directly affect the success of the RRP. Currently there
are also minimally invasive approaches such as laparoscopic
surgery and the more recent robot-assisted surgery.
Although these procedures offer advantages such as less
blood loss, better visualization, shorter surgery duration,
shorter hospital stay, and a lower rate of certain complications, many urology surgeons continue to perform open retropubic surgery with similar results.15
RP was first described by Young in 1901, and in 1947 Millen
depicted the retropubic approach. In 1982, Walsh et al. described the technique of nerve-sparing RRP.16 Also known as
nerve-sparing prostatectomy, this technique consists of the
extirpation of the prostate gland with early hemostatic control for achieving good visualization of the urethral sphincter, as well as the nerve bundles that innervate the corpora
cavernosa. According to Walsh, erection and urinary continence can be preserved with this technique in the majority
of patients and it has a reported surgical mortality of
0.5%.17-18 Walsh reported potency rates of 68% and continence rates of 92%. The technique described by Walsh is the
one that is currently performed in the majority of centers
carrying out this type of surgery.
In our institution, residents are trained based on the principles of the technique described by Walsh.
In our study population, the mean age was 60 years and
the mean PSA was 10.2 ± 6.2 ng/mL. The tumors had a mean
TRUS-guided prostate biopsy Gleason score of 5.6 and tumor
stage was T1c in 68%, T2a in 18%, T1b in 7.9%, and T2b in
5.3%. In the comparison of our data with other studies, the
results were similar in relation to age, PSA, TRUS-guided
prostate biopsy Gleason score, and clinical stage at the time
of diagnosis.6,20-29 The postoperative Gleason score was higher in relation to that obtained through the TRUS-guided
prostate biopsy and the difference was statistically significant. Just as in other studies, the TRUS-guided prostate
Radical prostatectomy at the Hospital López Mateos, ISSSTE Table 2 Positive margin comparison following radical
prostatectomy
Author
Year
No.
Positive margin
%
Ward20
2004
7,268
2,772 (38%)
Pettus21
2004
498
98 (20%)
Han22
2004
9,035
1,324 (14%)
Swindle23
2005
1,389
179 (13%)
Karakiewicz24
2005
5,831
1,554 (27%)
Simon
2006
936
2006
281
2007
2,242
275 (11%)
2008-2011
38
6 (16%)
25
Vis26
Eastham
27
Cruz et al.
163
Table 3 Comparison of different studies showing the urinary
continence percentages at one year after radical prostatectomy.
Continence %
6 months
Continence %
12 months
Hammerer y Hulland
85
91
Walsh et al.
80
93
Nandipati et al.
70
80
Lepor y Kaci
87
92
Stanford et al.
83
89
350 (37%)
Donellan et al.
72
84
66 (23.5%)
Cruz et al.
75
-
biopsy understaged the tumors, and higher Gleason scores
were obtained from the surgical specimen.
RRP is regarded as a difficult and highly complex surgery
whose oncologic and functional results depend on the technique. Due to the location of the prostate gland and the
vascular and nervous structures that surround it, RRP surgery is prone to the development of intraoperative and
postoperative complications. In a descriptive study of 1,000
RRPs, the most frequent intraoperative complication was
rectal injury. The most common immediate postoperative
complication was acute myocardial infarction, followed by
pulmonary thromboembolism and excessive blood loss. Of
the late postoperative complications, bladder neck stricture
was the most frequent, followed by seroma in the wound,
and acute urine retention. The causes of reintervention
were hemorrhage in 0.3% of the patients and anastomosis
failure in 0.2%. Hospital stay was 2.3 days and in our case
series it was 6.9 ± 4 days.6
As with any oncologic principle, complete tumor extraction is
a priority over function. The presence of malignant cells on the
surgical edge of the specimen means incomplete resection of
the prostate tumor. This confers a poor outcome on the patient
because the disease has now spread beyond the limits of the
prostate gland. Unfortunately, positive surgical margins signify
the failure of a treatment that was intended to be curative.
Despite the advances in the technique, positive margins in the
pathology specimen are not uncommon and this represents a
greater risk for biochemical recurrence and systemic disease. A
positive margin can be described as a tumor that extends to the
stained surface of the prostatectomy specimen.29 Positive margins can be classified as iatrogenic and non-iatrogenic. The former are those in which there was disruption of the capsule
during the surgery and therefore part of the gland was not extracted.27
According to the reviewed data, there was a 16% positive
margin rate in our population. In the comparison with other
authors, we found the incidence of positive margins to range from 11% to 38% (table 2).
References
Urinary incontinence is one of the complications that
most affects the quality of life of the patients after a RP.
The complex that forms the urethral sphincter is responsible for urinary continence. Due to the proximity of the prostatic apex, the sphincteric mechanism can be injured.
Urinary incontinence following radical prostate surgery is
defined as the involuntary exit of urine, preceded or not by
the accompanying sensation. This incontinence is generally
stress incontinence, and after surgery, with time, the
sphincteric function can be recovered, even up to 24 months
later. Even though it is difficult to measure the degree of
incontinence, in general an adequate manner is asking how
many protectors a patient needs to use daily. Another option is to apply a validated questionnaire. According to the
collected data of our patients, 75% of them were continent
at 6 months. Unfortunately the follow-up of some patients
was lost, making it impossible to determine that rate at 12
months. Loughlin and Prasad carried out a review of various
studies and found continence rates at 6 months that ranged
from 70% to 87% and that showed improvement at 12
months30 (table 3).
On the other hand, erectile dysfunction is defined as the
inability to achieve or maintain a penile erection that is
sufficient for penetration. As a consequence of the manipulation and excision of nerve fibers that innervate the corpora cavernosa, erectile dysfunction can become present or
worsen after radical retropubic surgery. According to studies, the percentage of erectile dysfunction after surgery
varies from 25% to 75%.31-33 In our study, the erectile dysfunction after surgery was 45.7% in the first semester. It
should be mentioned that erectile function before surgery
was not evaluated in our patients and so we cannot guarantee that these results are due completely to the prostatectomy in all of the patients. The use of 5-phosphodiesterase
inhibitors is well documented for early rehabilitation of
erectile function in this group of patients, accelerating recovery as well as quality of the erection.
Although RRP is regarded and performed as a curative
method, these patients are not exempt from presenting
with biochemical recurrence with the passage of time.
Some authors consider biochemical recurrence in patients
164
that have undergone RRP to be a PSA level greater than 0.04
ng/mL, while others use the value of 0.02 ng/mL. The expected PSA value after surgery is zero. In the group of patients operated on at our institution, 60% presented with
PSA values above 0.04 ng/mL at some point after surgery,
and so were regarded as presenting with biochemical failure. Of those patients, 37.8% were given androgen deprivation therapy.
Conclusions
RRP is a surgery that should be performed on well-selected
patients presenting with organ-confined prostate cancer.
Both the urologist and patient should analyze the cost/benefit of the surgery, as well as its risks and benefits. We believe
it is necessary to learn the technique of RRP, given that it
continues to be the recommended procedure in comparison
with laparoscopic or robot-assisted surgery. Not only the
early diagnosis of CaP, but also the mastery of the surgical
technique is important for achieving a low incidence of
complications and greater curative success. The knowledge
of institutional data enables the recognition of what was
done correctly and what was not, for the sole purpose of
improving the success and cure rates with the least number
of complications for the patient.
Conflict of interest
The authors declare that there was no conflict of interest.
Financial disclosure
No financial support was received in relation to this article.
References
1. Ficarra V, Sooriakumaran P, Novara G, et al. Systematic Review
of Methods for Reporting Combined Outcomes After Radical
Prostatectomy and Proposal of a Novel System: The Survival,
Continence, and Potency (SCP) Classification. Eur Urol
2012;61(3):541-548.
2. Boorjian S, Eastham J, Graefen M, et al. A Critical Analysis
of the Long-Term Impact of Radical Prostatectomy on Cancer Control and Function Outcomes. Eur Urol
2012;61(4):664-675.
3. Dahl D, Barry M, McGovern F, et al. Prospective Study of Symptom Distress and Return to Baseline Function After Open Versus
Laparoscopic Radical Prostatectomy. J Urol 2009;182(3):956965.
4. Walsh PC. Anatomic radical prostatectomy: evolution of the
surgical technique. J Urol 1998;160(6 Pt 2):2418-2424.
5. Steiner MS. Continence-preserving anatomical radical retropubic prostatectomy. Urology 2000;55(3):427-435.
6. Lepor H, Nieder AM, Ferrandino MN. Intraoperative and postoperative complications of radical retropubic prostatectomy in a
consecutive series of 1,000 cases. J Urol 2001;166(5):17291733.
7. Dillioglugil, O, Leibman BD, Leibman NS, et al. Risk factors for
complications and morbidity after radical retropubic prostatectomy. J Urol 1997;157(5):1760-1767.
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8. Hautmann RE, Sauter TW, Wenderoth U. Radical retropubic
prostatectomy: morbidity and urinary incontinence in 418 consecutive cases. Urology 1994;43(2 Suppl):47-51.
9. Hammerer P, Hubner D, Gonnermann D, et al. Perioperative
and postoperative complications in pelvic lymphadenectomy
and radical prostatectomy in 320 consecutive patients. Urologe
A 1995;34(4):334-342.
10. Davidson PJ, Van den Ouden D, Schroeder FH. Radical prostatectomy: prospective assessment of mortality and morbidity.
Eur Urol 1996;29(2):168-173.
11. Gaylis FD, Friedel WE, Armas OA. Radical retropubic prostatectomy outcomes at a community hospital. J Urol
1998;159(1):167-171.
12. Catalona WJ, Carvalhal GF, Mager DE, et al. Potency, continence and complication rates in 1,870 consecutive radical retropubic prostatectomies. J Urol 1999;162(2):433-438.
13. Gheiler EL, Lovisolo JA, Tiguert R, et al. Results of a clinical
pathway for radical prostatectomy patients in an open hospital-multiphysician system. Eur Urol 1999;35(3):210-216.
14. Arai Y, Egawa S, Tobisu K, et al. Radical retropubic prostatectomy: time trends, morbidity and mortality in Japan. BJU Int
2000;85(3):287-294.
15. Rassweiler J, Othmar S, Schulze M. Laparoscopic versus open
radical prostatectomy: A comparative study at a single institution. J Urol 2003;169(5):1689-1693.
16. Walsh PC, Donker PJ. Impotence following radical prostatectomy: insight into etiology and prevention. J Urol
1982;128(3):492-497.
17. Steiner MS, Morton RA, Walsh PC. Impact of anatomical radical
prostatectomy on urinary continence. J Urol 1991;145(3):512-514.
18. Walsh PC, Partin AW, Epstein JI. Cancer control and quality of
life following anatomical radical retropubic prostatectomy: results at 10 years. J Urol 1994;152(5 Pt 2):1831-1836.
19. Ward JF, Zincke H, Bergstralh EJ, et al. The impact of surgical
approach (nerve bundle preservation versus wide local excision) on surgical margins and biochemical recurrence following
radical prostatectomy. J Urol 2004;172(4 Pt 1):1328-1332.
20. Pettus JA, Weight CJ, Thompson CJ, et al. Biochemical failure
in men following radical retropubic prostatectomy: impact of
surgical margin status and location. J Urol 2004;172(1):129132.
21. Han M, Partin AW, Chan DY, et al. An evaluation of the decreasing incidence of positive surgical margins in a large retropubic
prostatectomy series. J Urol 2004;171(1):23-26.
22. Swindle P, Eastham JA, Ohori M, et al. Do margins matter? The
prognostic significance of positive surgical margins in radical
prostatectomy specimens. J Urol 2005;174(3):903-907.
23. Karakiewicz PI, Eastham JA, Graefen M, et al. Prognostic impact of positive surgical margins in surgically treated prostate
cancer: multi-institutional assessment of 5831 patients. Urology 2005;66(6):1245-1250.
24. Simon MA, Kim S, Soloway MS. Prostate specific antigen recurrence rates are low after radical retropubic prostatectomy
and positive margins. J Urol 2006;175(1):140-144.
25. Vis AN, Schroder FH, Van der Kwast TH. The actual value of the
surgical margin status as a predictor of disease progression in
men with early prostate cancer. Eur Urol 2006;50(2):258-265.
26. Eastham JA, Kuroiwa K, Ohori M, et al. Prognostic significance
of location of positive margins in radical prostatectomy specimens. Urology 2007;70(5):965-969.
27. Yossepowitch O, Bjartell A, Eastham J, et al. Positive surgical
margins in radical prostatectomy: outlining the problem and its
long-term consequences. Eur Urol 2009;55(1):87-99.
28. Mullins JK, Han M, Pierorazio PM, et al. Radical Prostatectomy
outcome in Men 65 Years Old or Older With Low Risk Prostate
Cancer. J Urol 2012;187(5):1620-1625.
Radical prostatectomy at the Hospital López Mateos, ISSSTE 29. Epstein JI, Amin M, Boccon-Gibod L, et al. Prognostic factors
and reporting of prostate carcinoma in radical prostatectomy
and pelvic lymphadenectomy specimens. Scand J Urol Nephrol
Suppl 2005;(216):34-63.
30. Loughlin KR, Prassad MM. Post-Prostatectomy Urinary Incontinence: A Confluence of 3 Factors. J Urol 2010;183(3):871-877.
31. Mirone V, Imbimbo C, Palmieri A, et al. Erectile dysfunction after surgical treatment. Int J Androl 2003;26(3):137-140.
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32. Robinson JW, Moritz S, Fung T. Meta-analysis of rates of erectile
function after treatment of localized prostate carcinoma. Int J
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33. Vale J. Erectile dysfunction following radical therapy for prostate cancer. Radiother Oncol 2000;57(3):301-305.
Rev Mex Urol 2013;73(4):166-174
ÓRGANO OFICIAL DE DIFUSIÓN DE LA SOCIEDAD MEXICANA DE UROLOGÍA
www.elsevier.es/uromx
Original article
Risk factors for developing urethral stricture in patients that
underwent transurethral resection of the prostate
P. Cruz García-Villaa,*, M. Schroede-Ugaldea, M. Landa Soler-Martínb and F. Mendoza-Peñac
a
Urology Speciality Residency, Hospital Regional “Lic. Adolfo López Mateos”, ISSSTE, Mexico City, Mexico
b
Department of Urology, Hospital Regional “Lic. Adolfo López Mateos”, ISSSTE, Mexico City, Mexico
c
Department of Urology Administration, Hospital Regional “Lic. Adolfo López Mateos”, ISSSTE, Mexico City, Mexico
KEYWORDS
Stricture; Urethra;
Transurethral
resection of the
prostate; Mexico.
Abstract
Background: Transurethral resection of the prostate (TURP) is currently one of the most widely used
treatments for managing prostatic hyperplasia. One of the risks of this procedure is the formation of
urethral stricture, defined as a narrowing of the urethral lumen secondary to cicatrization. Different
factors intervene in the formation of urethral narrowings in patients that undergo TURP.
Aims: To determine the risk factors for post-TURP urethral stricture.
Results: In accordance with the established criteria, a total of 63 patients were included in the
study; 30 belonged to the group that developed stricture (group A) and 33 belonged to the group
that did not (group B). The International Prostate Symptom Score (IPSS) was applied prior to the
TURP; group A had a mean score of 19.03 ± 3.78 points and group B of 19.48 ± 5.42. The mean
postoperative IPSS for group A was 16.27 ± 5.12 points and for group B was 8.88 ± 4.20 points. A
total of 36.7% of the patients that developed stricture had preoperative Foley catheter placement, whereas 69.7% of the patients that did not develop stricture had a catheter at some point
prior to surgery (p<0.005).
Mean surgery duration for group A was 57.17 ± 17.74 minutes vs. 57.12 ± 20.04 minutes for group
B. In group A, surgery lasted more than 60 minutes in 60% of the patients (n=18) and was under
60 minutes in 40% (n=12). In group B, surgery duration was over 60 minutes in 42.4% (n=14) of
the patients and under 60 minutes in 57.6% (n=19). In the patients presenting with stricture, the
transurethral Foley catheter remained in place after TURP for 8.90 ± 3.91 days vs. 5.15 ± 3.0
days in the patients with no stricture (p<0.05).
Conclusions: The principal risk factors for urethral stricture formation in patients that underwent TURP were a prostate volume greater than 80 g determined through transabdominal or
transrectal ultrasound prior to surgery, urethral dilation immediately prior to the procedure,
resection duration greater than 60 minutes, and the prolonged use of a transurethral catheter
following surgery (8.9 ± 3.91 days).
* Corresponding author at: Av. Universidad N° 1321, Colonia Florida, Delegación Álvaro Obregón, C.P. 01030, México D.F., México. Telephone: 5322 2300. Email: patricio_cruzgar@yahoo.com.mx (P. Cruz García-Villa).
0185-4542 - see front matter © 2013. Revista Mexicana de Urología. Publicado por Elsevier México. Todos los derechos reservados.
Risk factors for posterior urethral stricture following TURP
Palabras clave
Estenosis; Uretra;
Resección transuretral
de la próstata;
México.
167
Factores de riesgo para el desarrollo de estenosis de uretra en pacientes operados de
resección transuretral de próstata
Resumen
Introducción: La resección transuretral de la próstata (RTUP) es uno de los tratamientos más
utilizados actualmente, para el manejo de la hiperplasia prostática. Este procedimiento conlleva riesgos, entre ellos la formación de estenosis de uretra. La estenosis de uretra se define
como una estrechez de la luz uretral, secundaria a la formación de una cicatriz. Existen diferentes factores que intervienen en la formación de estrecheces uretrales, en pacientes operados
de RTUP.
Objetivo: El objetivo fue determinar los factores de riesgo para estenosis uretral post-RTUP.
Resultados: De acuerdo a los criterios establecidos, se incluyeron un total de 63 pacientes en el
estudio. De éstos, 30 pertenecen al grupo que desarrolló estenosis (grupo A) y 33 al grupo que
no desarrolló estenosis (grupo B). La escala internacional de síntomas prostáticos (IPSS, por sus
siglas en inglés), previo a la RTUP para el grupo A fue de 19.03 ± 3.78 puntos, y para el grupo B
de 19.48 ± 5.42. Por otra parte, el IPSS posquirúrgico para el grupo A fue de 16.27 ± 5.12 puntos,
y para el grupo B de 8.88 ± 4.20 puntos. El uso de sonda Foley previo a la cirugía prostática en
aquellos que desarrollaron estenosis de uretra fue de 36.7%, mientras que en el grupo que no
desarrolló estenosis, un 69.7% portó sonda en algún momento previo a la cirugía (p<0.005).
El tiempo quirúrgico para el grupo A fue de 57.17 ± 17.74 minutos vs. 57.12 ± 20.04 minutos para el
grupo B. En el grupo A, el 60% (n=18) tuvo una duración mayor de 60 minutos y el 40% menor a 60
minutos, mientras que en el grupo B el 42.4% (n=14) tuvo una duración mayor a 60 minutos y en el
57.6% (n=19) menor a 60 minutos. El tiempo de permanencia de la sonda Foley transuretral posterior
a la RTUP, en el grupo de pacientes con estenosis fue de 8.90 ± 3.91 vs. 5.15 ± 3.0 días (p<0.05).
Conclusiones: Los principales factores de riesgo para la formación de estenosis uretral en pacientes operados de RTUP son: la presencia de un volumen prostático por ultrasonido trans-abdominal o transrectal previo a la cirugía mayor de 80 g, la realización de dilatación inmediatamente
previa al procedimiento, un tiempo de resección mayor a 60 minutos y un uso prolongado de sonda
transuretral posterior a la cirugía (8.9 ± 3.91 días).
Introduction
Benign prostatic hyperplasia (BPH) is currently one of the
most frequent health problems affecting the adult male population. It is estimated that 10% of men present with BPH
at 30 years of age, 20% at 40 years, 50-60% at 60 years and
80% to 90% at 70 and 80 years of age.1
BPH is the result of the proliferation of fibroblasts, myofibroblasts, and glandular epithelial elements near the
urethra in the transitional zone of the prostate.2-5
An enlarged prostate is found in only some of the men
presenting with urinary symptoms. Taking into account that
the normal size of the prostate is from 20 to 30 mL in the
young adult, it has been established that a volume greater
than 30 mL represents clinical prostatic hyperplasia.6 Currently, the International Prostate Symptom Score (IPSS) is
used for clinical management in patients with lower urinary
tract symptoms. Some of the other instruments that are employed are the hyperactive bladder symptom scale, the urinary perception score, and the lower urinary tract symptom
result score (table 1).7,8
The clinical diagnosis of BPH is made through obtaining
the clinical history from the patient and carrying out the
complete medical interview and physical examination. Studies such as ultrasound imaging enable a more precise prostatic volume to be established. Cystourethroscopy has been
shown to be less precise in determining the size of the prostate gland. Nevertheless, the shape of the prostate gland
can be determined through this type of procedure, and its
macroscopic aspect, in accordance with studies carried out
by Randall in 1931, can be established.9,10
Treatment for prostatic hyperplasia is medical or surgical.
Recurrent urinary tract infections, bladder lithiasis, acute
urine retention, symptomatology that is not resolved
through medical management, bladder diverticula secondary to chronic prostatic obstruction, hematuria of prostatic origin, and elevated serum creatinine and urea due to
prostatic obstruction are some of the indications for surgical
management.
Transurethral resection of the prostate (TURP) is one of
the most widely used surgical treatments worldwide and is
considered to be the treatment of choice when drug therapy has not resolved the symptoms.
Despite its being performed routinely, this procedure is
not free from complications and they can be divided into
intraoperative and postoperative ones. The intraoperative
complications are blood loss, post-TURP syndrome, extravasation, and ureteral meatus injury.
There are early and late postoperative complications. An
early complication is bladder tamponade due to heavy clot
formation. Infection is rare, although one study reported its
presence in 21.6% of the patients. 11 Urinary retention,
168
P. Cruz García-Villa et al
Table 1 The International Prostate Symptom Scale (IPSS)
During the last 30 days...
Not at all
Less than 1 in 5
times
Less than half the
time
About half the
time
More than half the
time
Almost always
1. Over the past month, how often have you had a sensation of not emptying your bladder completely after you finish urinating?
0
1
2
3
4
5
4
5
3
4
5
2
3
4
5
2
3
4
5
3
4
5
4 times
5 times or more
2. How often have you to urinate again less than 2 hours after urinating?
0
1
2
3
3. How often have you found you stopped and started again several times when you urinate? 0
1
2
4. How often have you found it difficult to postpone urination?
0
1
5. How often have you had a weak urinary stream?
0
1
6. How often have you had to push or strain to begin urination?
0
1
2
During the last 30 days...
Not at all
1 time
2 times
3 times
7. How many times did you most typically get up to urinate from the time you went to bed at night until you got up in the
morning?
0
1
2
3
4
5
Total Score
0-7 Mild symptoms
8-19 Moderate symptoms
20-35 Severe symptoms
incontinence, retrograde ejaculation, and erectile dysfunction are late complications.12,13
Urethral stricture is another of the late postoperative
complications of TURP and is the subject of this article. The
rate of urethral stricture reported in the medical literature varies from 2.2% to 9.8%.14-19 It is believed that the incidence
of urethral stricture may be higher, because it depends on
how and when the diagnosis is made. The World Health Organization (WHO) defines urethral stricture as a narrowing
of the urethral lumen that is secondary to a scarring process
that affects the erectile tissue of the corpus spongiosum
causing spongiofibrosis. The contraction of the scar reduces
the urethral lumen. In the instant it is sufficiently reduced
to obstruct the exit flow of urine, urinary symptoms, particularly emptying ones, appear and the patient seeks medical attention. Urethral strictures or narrowings can be
divided into anterior and posterior ones. Those located in
the posterior urethra are invariably the consequence of
trauma or radical prostatectomy. It is necessary to recall
the anatomy of the urethra to adequately understand the
following pathologic description. The bulbous urethra is eccentrically placed in relation to the corpus spongiosum in
the bulbar portion of the urethra and is much closer to the
dorsum of the penile structures. As it gets closer to
Risk factors for posterior urethral stricture following TURP
169
B
C
A
D
Figure 1 Structure of the urethra. Anatomy and cross-sectional views. Different sites of the urethra are illustrated in the crosssectional views: A) at the bulbous level, B) the mid-penile level C) the distal penile level, and D) at the navicular fossa.
the glans penis, the urethra is located more centrally within
the corpus spongiosum (fig. 1). The corpus spongiosum receives its irrigation from the penile artery that, in turn, is a
branch of the internal pudendal artery.
Any situation causing the formation of a scar inside the
urethra is considered to be able to produce stricture.
However, the main cause of urethral stricture is trauma.
Unfortunately, iatrogenic trauma can be caused during any
urethral manipulation, such as the placement of a catheter
or diagnostic and/or therapeutic instrumentation in treating a urinary tract pathology. Some years ago, the frequency of urethral narrowings secondary to Neisseria
gonorrhoeae and Chlamydia infection was higher. Today
these infections are rare, thanks to the available
treatments. A very strong relation has been found principally between lichen sclerosus, or balanitis xerotica obliterans, and meatal stricture, as a consequence of the very
severe inflammatory process produced.
In general, patients present with obstructive and irritative urinary symptoms that are secondary to urinary infections. On occasion the patient complains of bifurcation and
progressive weakening of the urinary stream that can lead
to urinary retention. The introduction of a catheter can determine the presence and location of the narrowing. Before
deciding on management, it is important to precisely determine the location, length, depth, and density of the stricture. This can be done through well-validated imaging studies
such as urethrography and cystourethrography for establishing the location and length. Urethral ultrasound imaging
identifies the density and depth of the stricture. Stricture
can also be diagnosed through urethroscopy, but it is an invasive procedure and does not provide complete information about the stenosis. Once diagnosed, the stricture can
be identified according to the classification established by
Jordan in 1987 (fig. 2).20
The main causes of post-TURP urethral stricture are associated with location. Meatal strictures are related to a proctoscope size that is greater than the size of the urethra,
whereas bulbous strictures are related to the passage of
monopolar current through the sheath of the proctoscope
due to an insufficient amount of lubricant. It has been proposed that the lubricant should be applied to the meatus
and all along the length of the proctoscope and application
should be abundant and repeated in longer procedures.
Likewise, the monopolar current used should not be very
high so that urethral tissue damage is prevented.13,21,22 To
preserve the urethra’s normal physiology, there should be a
minimum of urethral manipulation, a small caliber proctoscope should be employed, there should be adequate blood
circulation, and the postoperative Foley catheter should be
used for the least amount of time possible.
The most frequent postoperative urethral stricture sites
are the external meatus, at the level of the penoscrotal
junction, the bulbous urethra, and under the sphincter.23,24
The most frequent late TURP complications are urethral
stricture and sclerosus of the bladder neck, which can present
in up to 9.2% of patients. Despite the technologic advances in the instrumentation, lubricants, and energy used,
170
P. Cruz García-Villa et al
A
D
B
E
C
F
Taken from: Wein AJ, et al.6
Figure 2 Jordan classification for urethral strictures. A) Mucosal fold. B) Iris constriction. C) Full-thickness involvement with
minimal spongiofibrosis. D) Full-thickness spongiofibrosis. E) Inflammation and fibrosis affecting tissues outside the corpus
spongiosum. F) Complex stricture complicated by a fistula.
these complication rates have not varied. Supposedly, the
use of new technologies such as laser and bipolar energy reduces the risk for stricture.25,26 However, recent publications have
compared the use of bipolar energy for resection with monopolar energy and reported a higher rate of urethral stricture (6.1
vs. 2.1); this was mainly attributed to having to use a wider resection sheath.27 Kuntz et al. reported similar urethral stricture
rates upon comparing the holmium laser for resection and
TURP, when a proctoscope was used for prostate tissue morcellation. 28,29 These results show a multifactorial risk for
the development of post-TURP urethral stricture that is dependent on factors such as technique, surgery duration, antibiotic regimen used, the use of a catheter, its material, and the
length of time it is indwelling, etc.11
Methods
A retrospective study was conducted after receiving authorization from the Research and Ethics Committee of the
Hospital Regional Lic. Adolfo López Mateos. All male patients over the age of 18 years that underwent TURP at the
Urology Service of the Hospital Regional Lic. Adolfo López
Mateos of the ISSSTE, and that had a preoperative diagnosis
of prostatic hyperplasia, were included in the study.
All patients with a past history of urethral trauma and/or
pelvic fracture, a history of lithuria, patients previously
treated with a modality other than TURP, not having studies
confirming urethral stricture, or presenting with a previous
urethral pathology were excluded. Those patients with no
case records were eliminated from the study.
Voiding cystourethrogram and/or cystoscopy study were
reviewed to confirm urethral stricture diagnosis in those patients with suggestive symptoms.
The patients were divided into 2 groups: group A: those
patients with post-TURP urethral stricture diagnosis and
group B: those patients that did not present with post-TURP
urethral stricture diagnosis.
The following variables were recorded and analyzed:
age, past history of pathology, diabetes mellitus diagnosis,
high blood pressure diagnosis, recurrent urinary tract infections, prostate size obtained through ultrasound, prostate-specific antigen (PSA) prior to surgery, IPSS, catheter
use prior to surgery, length of time of catheter use prior to
surgery, urethral dilation prior to surgery, urethral stricture at the time of surgery, type of prostatic growth, duration of resection in minutes, volume of intraoperative
blood loss, volume of resected prostate tissue, caliber of
postoperative transurethral catheter, material of postoperative transurethral catheter, length of time the postoperative
transurethral catheter was indwelling, the length of time between TURP and stricture diagnosis, stricture location, and
the method employed for stricture diagnosis.
Risk factors for posterior urethral stricture following TURP
171
Table 2 Demographic characteristics of group A and group B
Age
Group a (n = 30) with stricture
Group b (n = 33) without stricture
p
64.0 ± 8.35
68.48 ± 8.76
<0.005
Diabetes mellitus 2
16.7% (5)
18.2% (6)
NS
High blood pressure
36.7% (11)
27.3% (9)
NS
Previous UTI
33.3% (10)
27.3% (9)
NS
Prostate volume (g)
62.93 ± 27.58
87.30 ± 60.83
<0.005
PSA (ng/mL)
6.31± 4.73
6.15 ± 3.3
NS
Previous catheter
36.7% (11)
69.7% (23)
<0.005
Days with catheter
38.67 ± 76.87
82.61 ± 78.97
<0.005
Pre-TURP dilation
16 (53.3%)
16 (48.5%)
NS
Surgery duration
57.17 ± 17.74
57.12 ± 20.04
NS
60% (18)
42.4% (14)
NS
Time over 60 minutes
Time under 60 minutes
Approximate blood loss (mL)
Resected volume (g)
Days with post-TURP catheter
40% (12)
57.6% (19)
NS
333.33 ± 188.15
313.64 ± 136.51
NS
28.87 ± 12.42
32.0 ± 16.0
NS
8.90 ± 3.91
5.15 ± 3.0
<0.05
UTI: urinary tract infection; PSA: prostate-specific antigen; NS: not significant; TURP: transurethral resection of the prostate
After the data were collected, both groups were compared. The continuous variables were compared using the
Student’s t test. Means, standard deviation, frequencies,
and percentages of the collected data were obtained. Thirty patients for each group were analyzed.
Results
In accordance with the established criteria, a total of 63
patients were included in the study; 30 belonged to the
group that developed stricture (group A) and 33 to the group
that did not develop stricture (group B).
The demographic data are included in table 3. Of the
group A patients, 33.3% (n=10) had a history of urinary tract
infection prior to the TURP, whereas that figure was 27.3%
for the group B patients.
The prostate volume calculated by ultrasound prior to
surgery was significantly different in the 2 groups, with
62.93 ± 27.58 g for group A and 87.30 ± 60.83 g for group B
(p<0.005).
The PSA results were very similar in the 2 groups, with
6.31± 4.73 ng/mL for group A and 6.15 ± 3.3 ng/mL for group
B. The IPSS prior to the TURP for group A was 19.03 ± 3.78
points and for group B was 19.48 ± 5.42. The postoperative
IPSS for group A was 16.27 ± 5.12 points and for group B was
8.88 ± 4.20 points (table 3).
A Foley catheter prior to prostate surgery was used by
36.7% (n=11) of the patients that developed urethral stricture, and 69.7% (n=23) of the patients that did not develop
stricture used a catheter at some point before surgery
(p<0.005).
The length of time that the group A patients used a catheter at some time prior to TURP was 38.67 ± 76.87 days vs.
82.61 ± 78.97 days for group B, with a p<0.005.
Table 3 Pre and Post-TURP International Prostate Symptom
Scale (IPSS) in group A and group B
IPSS
Preoperative
Postoperative
Group A
19.03 ± 3.78
16.27 ± 5.12
Group B
19.48 ± 5.42
8.88 ± 4.20
Urethral dilation was performed in a total of 32 patients
prior to TURP; in 16 group A patients (53.3%) and in 16 group
B patients (48.5%).
It is important to mention that the transurethral resection
equipment used on all patients of both groups had a 25.6Fr
caliber sheath.
In accordance with the cystoscopic findings and the modified Randall classification for the macroscopic description of
the prostate gland, group A had one patient with type A, 13
patients with type B, 7 patients with type C, and 9 patients
with type D. Group B had one patient with type A, 7 patients with type B, 11 patients with type C, and 14 patients
with type D.
Surgery duration for group A was 57.17 ± 17.74 minutes vs.
57.12 ± 20.04 minutes for group B. In group A, 60% (n=18) of
the patients had a duration longer than 60 minutes and 40%
(n=12) had a duration under 60 minutes, whereas in group
B, 42.4% (n=14) had a duration longer than 60 minutes and
57.6% (n=19) had a duration under 60 minutes.
The intraoperative blood loss for group A was 333.33 ±
188.15 mL vs. 313.64 ± 136.51 mL for group B. The quantity
of resected tissue was 28.87 ± 12.42 g for group A and 32.0 ±
16.0 g for group B.
172
A 22Fr caliber catheter was used post-TURP in 28 group A
and in 28 group B patients. In all patients, the postoperative
catheter used was made of latex.
The post-TURP Foley catheter remained indwelling for
8.90 ± 3.91 days in the group with stricture vs. 5.15 ± 3.0
days in the group without stricture (p<0.05).
The mean presentation time of urethral stricture in the
post-TURP patients was 40 months.
Stricture location in the study group was distributed as
follows: meatal stricture 3.3% (n=1), penile stricture 33.33%
(n=10), bulbous stricture 73.3% (n=22), and bladder neck
sclerosis 10% (n=3). It is important to mention that some
patients presented with more than one stricture in different
locations.
Cystoscopy was carried out in 43.3% (n=13) of the patients
with stricture, whereas 63.3% (n=19) underwent voiding cystourethrography. Some patients had both of the diagnostic
studies done.
According to the Jordan classification for urethral strictures, they were distributed as shown in figure 3.
Discussion
Urethral stricture frequency as reported in the medical literature varies from 2.2% to 9.8%.14-19
The World Health Organization (WHO) defines urethral
stricture as a narrowing of the urethral lumen that is secondary to a scarring process, affecting the erectile tissue of
the corpus spongiosum that results in spongiofibrosis. Scar
contraction reduces the urethral lumen.
The study population was made up of 2 groups of patients:
group A were those with urethral stricture following a TURP
and group B were those that underwent TURP but did not
develop urethral stricture.
In relation to the demographic characteristics of both
groups, it should be stressed that there was a significant age
difference between the 2 groups; the mean age in group A
was 64.0 ± 8.35 years and it was 68.48 ± 8.76 years in group
B (p<0.005). The age in the group of patients with stricture
was significantly lower than that of the control group
without stricture. This finding can perhaps be explained by
the fact that there is better cicatrization and tissue repair
after an injury or trauma in younger patients. Studies such
as those by DuNuoy and Carrell found that cicatrization was
better in younger patients.30 This leads to the idea that advanced age could become a protective factor for the development of urethral stricture because repair would be less
intense at the site of the urethral damage, reducing the
amount of fibrosis and the consequential urethral narrowing.
Diabetes mellitus has been shown to substantially interfere with cicatrization processes in the entire organism. One
of the contributing factors is the reduced inflammatory reaction that is associated with hyperglycemia. Diabetes diminishes granulocyte chemotaxis, phagocyte function, and
cellular and humoral immunity. In addition, associated microangiopathy decreases the blood supply to the cicatrization site.31,32
The number of patients with diabetes mellitus was very
similar in the 2 groups (5 and 6 in group A and group B, respectively), representing a percentage lower than 20%. Our
P. Cruz García-Villa et al
3%
Type A
19%
25%
Type B
Type C
Type D
Type E
Type F
53%
Figure 3 Stricture distribution.
study results suggest that diabetes mellitus is not a risk factor for the development of urethral stricture. The same
holds true for high blood pressure and a history of urinary
tract infections, given that the figures did not show a tendency toward any specific group that could be interpreted
as a factor intervening in the development of urethral stricture.
With respect to prostate gland characteristics prior to
TURP, the volumes measured by transabdominal or transrectal ultrasound showed mean values that were lower for the
urethral stricture group, with 62.93 g vs. 87.3 g for the group
that did not develop stricture and a p<0.05. Those patients
with higher prostate volumes had a lesser tendency to develop urethral stricture. This is quite striking, given that a higher prostate volume implies a longer resection time. This
result could be attributed to the fact that prostate volume
measurement was indistinctly carried out, either transabdominally or transrectally, resulting in volume variability, depending on the method employed. Further studies could
corroborate whether these same findings are present in larger populations.
In relation to the high prostate volumes, it is not surprising that the PSA figures were above normal values in the 2
groups, and there was no difference between them.
In both groups the IPSS scale showed a decrease after
TURP. The mean initial IPSS in the 2 groups was found to be
in the moderate symptom range, with 19 points for each
group. After TURP, the group without stricture showed a
descent of 10 points on the scale vs. a descent of 3 points in
the patients that developed urethral stricture. It was not
possible to precisely know the postoperative IPSS at a determined point in time due to the fact that the measurements
were taken in the patients at different post-TURP moments.
Nevertheless, it is clear that the patients that presented
with stricture developed symptoms with greater frequency
and intensity than those that did not present with stricture
after TURP.
There were patients that had indwelling transurethral
catheters as temporary treatment at some point prior to
TURP in the 2 groups. Of those patients that did not develop
Risk factors for posterior urethral stricture following TURP
urethral stricture, 69.7% (n=23) had used a catheter at some
moment vs. 36.7% (n=11) of those patients that developed
stricture (p<0.05). Likewise, those that did not develop
stricture and that used a catheter prior to TURP had a mean
indwelling time of 82.6 days vs. 36.7 days in those patients
that developed stricture. This suggests that the prolonged
use of a transurethral catheter before TURP creates a
urethral inflammation episode that protects the patient or
is conducive to making the second inflammatory episode
from the placement of a catheter after TURP less intense
and shorter. In other words, the inflammatory process is not
so severe in those patients that have had previous contact
with the material of the catheter (latex, in the majority of
the cases), thus reducing the possibility of developing
urethral stricture.
As was to be expected, of those patients that developed
urethral stricture, 53% had received dilation prior to TURP
vs. 48% of the patients that did not develop stricture.
Urethral dilation is undeniably a risk factor for urethral
trauma with injury to the mucosa that can condition the
formation of spongiofibrosis and urethral stricture. Therefore, gentle dilation is recommended, using the adequate
amount of lubricant so as not to injure the urethra at any
point along its course.
The anatomic configuration of the prostate according to
the modified Randall classification showed that type B
(n=11) was the most frequent in the patients that developed
stricture (group A) followed by types D (n=9) and C (n=7). In
group B the most frequent type was the Randall D (n=14),
followed by types B (n=11) and C (n=7).
The mean surgery duration for both groups was 57.17 ±
17.74 minutes for group A and 57.12 ± 20.04 minutes for
group B. However, as established in the hypothesis, 60%
(n=18) of the patients that developed stricture (group A)
had a resection time above 60 minutes vs. 42.4% (n=14) of
the patients that did not develop stricture (group B). According to reports in the medical literature, resection time is
one of the most important factors for developing urethral
stricture.33,34 The results of our study showed a coinciding
tendency for a TURP duration greater than 60 minutes to be
a risk factor for the later development of urethral stricture,
although there was no statistically significant difference.
The intraoperative blood loss for both groups was very similar, with a mean 333 mL for group A and 313 mL for group
B. The quantity of resected tissue was also similar in the 2
groups, with a mean 28 g for group A and 32 g for group B.
In this aspect, it is worth mentioning that time, blood
loss, and resected volume were correlated, taking into account that resection time was intended to be no greater
than 60 minutes, and blood loss was calculated based on the
quantity of resected tissue, multiplying the resected volume by 10 mL.
After TURP, a difference in the indwelling time of the
transurethral catheter was observed between the 2 groups.
Those patients that had the indwelling catheter for a longer
period of time after the TURP had a higher percentage of
probability of developing stricture. In group A the mean
length of time with catheter after TURP was 8.90 ± 3.91
days and in group B it was 5.15 ± 3.0 days with a p<0.05.
This is due to the fact that the postoperative inflammatory process disappears within the first 48 to 72 hours. The
inflammatory process in those patients that have a catheter
173
for more time is more intense and prolonged as a consequence of the presence of a foreign body at the surgical site
and along the course of the urethra.
A descriptive analysis was done on the Group A patients.
In those patients the length of time from the TURP to the
appearance of stricture was a mean 40.7 months (range: 4
to 70 months).
In regard to stricture location the distribution was as follows: bulbous urethra 73% (n=22), penile urethra 33.3%
(n=10), bladder neck 10% (n=3), and meatus 3.3% (n=1).
Two strictures in 2 different locations were found in 6 patients. These results are in contrast to those of another study in which stricture incidence was greater in the meatus
(18.3%) than in the bulbous urethra (9.1%).1 This difference
could be due to the fact that the aim of that study was to
show a decrease in stricture using an irrigation solution at a
temperature of 36° C, which reduced the incidence of bulbous and penile strictures, but not meatal strictures.
Taking into account the Jordan classification described in
1987 based on spongiofibrosis configuration and extension,
the strictures were divided into type B 56.7% (n=17), type C
26.7% (n=8), type A 20% (n=6), and type D 3.3% (n=1).20 There was no type E stricture, albeit that this type was difficult
to determine, given that none of these patients had a
urethral ultrasound study to establish the extension of the
fibrosis into the corpora cavernosa (type E stricture). There
was no type F stricture (associated with fistula).
Of the 30 patients, 19 had voiding cystourethrography,
whereas 13 had cystoscopy in order to diagnose urethral
stricture. Both studies were carried out on 2 patients due to
inconclusive voiding cystourethrography. Urethral ultrasound was not done on any of these patients because it is
not a routine study in our service. Urethral ultrasound imaging is an important study because it determines stricture
depth, enabling appropriate classification, which in turn
results in more adequate treatment for these patients.
Conclusions
Based on the results of our study, the main risk factors for
the formation of urethral stricture in patients that have undergone TURP are a preoperative prostate volume greater
than 80 g that is determined through transabdominal or
transrectal ultrasound imaging, dilation of the urethra immediately prior to the procedure, a resection time greater
than 60 minutes, and the prolonged use (8.9 ± 3.91 days) of
a postoperative transurethral catheter.
According to the medical literature, there may be other
additional factors in the development of urethral narrowing,
such as an insufficient quantity of intraurethral lubricant
before and after the surgery, the use of a high level of energy for cutting and coagulating that causes the sheath to
heat up during the procedure, the use of a sheath with a
diameter greater than that of the urethra, the material
from which the catheter is made, and the temperature of
the irrigation solution during the procedure.
All these factors should continue to be analyzed, because
each one of them can have an effect on the process of
epithelial damage and the local inflammation that are later
produced, with the probability of causing scarring that results in a urethral stricture.
174
Conflict of interest
The authors declare that there is no conflict of interest.
Financial disclosure
No financial support was received in relation to this article.
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Rev Mex Urol 2013;73(4):175-179
ÓRGANO OFICIAL DE DIFUSIÓN DE LA SOCIEDAD MEXICANA DE UROLOGÍA
www.elsevier.es/uromx
Original article
Oncologic effectiveness and safety of laparoscopic renal
cryosurgery guided by high definition laparoscopic ultrasound
J. G. Campos-Salcedoa,*, G. Hernández-Martínezb, E. I. Bravo Castrob, A. SedanoLozanoc, J. C. López-Silvestred, M. Á. Zapata-Villalbae, L. A. Mendoza-Álvarezf, C. E.
Estrada-Carrascof, H. Rosas-Hernándezf, C. Díaz-Gómezf, C. Paredes-Calvaf y J. L. ReyesEquihuaf
a
Urology Service Administration, Hospital Central Militar, Mexico City, Mexico
b
Urology Speciality Residency, Escuela Militar de Graduados de Sanidad, Mexico City, Mexico
c
Clinical Administration of Medical Specialities, SEDENA, Mexico City, Mexico
d
Urology Ward Administration, Hospital Central Militar, Mexico City, Mexico
e
Urology Operating Room Administration, Hospital Central Militar, Mexico City, Mexico
f
Urology Service, Hospital Central Militar, Mexico City, Mexico
Abstract
KEYWORDS
Cryoablation; Renal
cryosurgery; Renal tumor; Cryocatheter;
Laparoscopic
cryotherapy; Mexico.
Background: The necessity and desire for definitive treatment in T1 tumors in patients that had
previously been considered inoperable has resulted in the addition of cryoablation to the
treatment armamentarium.
Aims: To determine the experience, results, and complications of this treatment in our hospital
center.
Material and methods: Laparoscopic renal cryoablation guided by laparoscopic ultrasound was surgically indicated in 8 renal tumor patients with multiple comorbidities at the Hospital Central Militar.
Results: The mean age of the patients was 54.3 years and the mean size of the lesions was 28
mm. The lesion reduction percentage average was 47%. There were no complications of conversion, urinary fistulas, or renal loss. The incidence of clear cell carcinoma was 75%, and angiomyolipoma was present in 25% of the lesions.
Discussion: The oncologic effectiveness of this management is still being defined; our results
suggest that it offers a feasible, safe, and effective treatment opportunity to those patients in
need of maximum nerve-sparing management.
Conclusions: After a decade of international experience, there have been few studies carried
out on the Mexican population. Given the favorable results of our study, we feel it is necessary
to continue and promote long-term studies, and we stress the importance that learning to perform this modality has for today’s urologist.
* Corresponding author at: Hospital Central Militar. Blvd. Manuel Ávila Camacho s/n, Lomas de Sotelo, Av. Industria Militar y General Cabral, Delegación Miguel Hidalgo, C.P. 11200, México D.F., México. Telephone: (01) 5557 3100, ext. 1246. Email: drjgaducampos@hotmail.com
(J. G. Campos-Salcedo).
0185-4542 - see front matter © 2013. Revista Mexicana de Urología. Publicado por Elsevier México. Todos los derechos reservados.
176
Palabras clave
Crioablación;
Criocirugía renal;
Tumor renal;
Criosonda; Crioterapia
laparoscópica;
México.
J. G. Campos-Salcedo et al
Eficacia y seguridad oncológica de la criocirugía renal laparoscópica guiada con ultrasonido
laparoscópico de alta definición
Resumen
Introducción: La necesidad y el deseo de tratamiento definitivo en tumores T1a en pacientes
que antes habrían quedado fuera de tratamiento quirúrgico, ha lanzado a la crioablación como
una herramienta más en su tratamiento.
Objetivo: Determinar la experiencia, resultados y complicaciones de nuestro centro hospitalario.
Material y métodos: Se realizó crioablación renal laparoscópica guiada por ultrasonido laparoscópico, a 8 tumores renales con indicación quirúrgica y múltiples comorbilidades, en el Hospital
Central Militar.
Resultados: La edad promedio de los pacientes fue 54.3 años. Las lesiones promedio de 28 mm,
porcentaje promedio de reducción de las lesiones de 47%; las complicaciones como conversión,
fístulas urinarias y pérdida renal del 0%, con incidencia de carcinoma de células claras en 75% y
angiomiolipoma en 25% de las lesiones.
Discusión: La eficacia oncológica sigue en definición. Nuestros resultados sugieren que ofrece
tratamiento factible, seguro y eficaz en pacientes que requieren un máximo esfuerzo preservador de nefronas, representando una oportunidad de tratamiento.
Conclusiones: A una década de experiencia en el mundo, en México se cuentan con escasos estudios en la población mexicana. Presentamos estos resultados concluyendo que es necesario
continuar e impulsar estudios a largo plazo dados los resultados favorables, y por lo tanto hacemos hincapié en la importancia de su aprendizaje para el urólogo actual.
Introduction
Methods
Twenty years ago, Dr. Andy Novick was one of the pioneers of
the concept of open partial renal surgery, in an effort to promote the nephron-sparing approach as part of the oncologic principles.1 Thanks to great technological advances, both the
oncologic principle and the maximum renal function are now
able to be preserved. Today, the situation is as Dr. Novick had
imagined it, but with the advantage that these technologies are
available in most parts of the world for all patients, offering an
excellent treatment alternative to the patient with multiple
comorbidities. New improvements are added daily to this renal
preservation that are minimally invasive and focus largely on
treatment. This is the case with laparoscopy, cryosurgery, and
high definition laparoscopic ultrasound, and the common objective is our patients’ wellbeing.
Cryotherapy has a lethal local effect resulting from 2 sequential synergic mechanisms. The first is the so-called direct cytotoxic lesion due to the formation of ice crystal
during the freezing phase, and is followed by the damage
from indirect ischemia due to the occlusion of the local microvasculature during the consequent thawing phase.2
In laparoscopic renal cryoablation, the cryocatheter can
be precisely positioned and the entire surgical event of ice
ball formation can be monitored in real time and under direct vision through ultrasound guidance.3
The growing enthusiasm surrounding minimally invasive
surgery and the need and desire for definitive treatment of
T1a incidental renal tumors has turned laparoscopic renal
cryoablation into another treatment alternative for small
renal tumors in patients who in the past would not have
been candidates for surgical treatment.4-6
A descriptive study was conducted on 8 selected patients
presenting with T1 aN0M0 renal masses indicated for nephron-sparing surgery for a variety of reasons that included
having only one kidney due to previous renal tumor, having
kidney failure, etc. The inclusion criteria are grouped together in table 1. The exclusion criterion was if the patient
did not comply with the follow-up measures dictated by our
hospital center.
All the patients underwent percutaneous renal biopsy, as
recommended in the urologic clinical guidelines of the European Association of Urology for ablative therapies in the
same surgical procedure as the renal cryoablation.5 Two cores per renal lesion were taken (fig.1).
Laparoscopic renal cryoablation guided by high definition
laparoscopic ultrasound was performed on 8 lesions characterized by tomography in patients with T1aN0M0 renal tumors. All the patients presented with multiple comorbidities
that did not form part of the inclusion, non-inclusion, or
exclusion criteria; they will be characterized further on in
the text.
In this case series there was no control group.
At the Hospital Central Militar, with the Cryocare Surgical System (Endocare Inc., Irvine, Calif, USA) equipment,
17Ga cryocatheters were used (figs. 2 and 3) that underwent
two 10-min freezing cycles. The real time formation of the
ice ball was observed with 10 mHz BK Pro-Focus 2202 high
definition laparoscopic ultrasonographic guide (fig. 4) until
it completely covered the tumor mass and surrounded it by
an approximate 8 mm margin (fig. 5).
Laparoscopic renal cryosurgery 177
Tabla 1 Inclusion criteria. The patient and renal lesion inclusion criteria for undergoing laparoscopic renal cryoablation are
presented.
Inclusion criteria for nephron-sparing treatment through laparoscopic renal cryoablation
Patient factors
Unspecified sex
Unspecified comorbidities
Indication for nephron-sparing surgery according to the 2010 EAU Clinical
Guidelines for renal cancer treatment
Lesion characteristics
Unilateral or bilateral renal lesion whose greatest diameter is under 4 cm
Cortical renal lesion
Nonspecific metastatic disease
Tomographic enhancement of more than 20 HU
EAU: European Association of Urology; HU: Hounsfield units.
Results
The mean age of the patients analyzed was 54.3 years; 87%
(n=7) of the patients were operated on with the laparoscopic approach (fig. 6). Their lesions measured a mean 28 mm
(40-22 mm). Only the first patient was operated on with the
open technique; we decided to include this patient in our
case series for the purpose of showing oncologic control results. The sequential sizes of the lesions were reduced in
one case down to 0 mm, with an average lesion reduction
percentage of 47%. There were no complications of conversion to open surgery, urinary fistulas, renal loss, or the need
for dialysis. The mean preoperative creatinine value was 1
mg/dL and the post-cryosurgery value was 1.2 mg/dL. The
histopathologic report of the biopsies stated clear cell carcinoma in 75% of the lesions and angiomyolipoma in 25%.
These results are shown in table 2.
It should be mentioned that one of the patients died due
to causes other than the renal tumor and so the oncologic
Figure 1 Biopsy guided by laparoscopy
and high definition laparoscopic ultrasonography showing the Bard 15 Ga biopsy
forceps at the moment of puncture.
control could not be carried out. This patient was included
only for the immediate postoperative progression and was
eliminated in the tomographic control.
Discussion
The oncologic effectiveness of laparoscopic renal cryosurgery has not yet been completely defined due to the followup time in different case series, which has also been
documented in the cryosurgery tendencies in Mexico. However, our results suggest that it offers a feasible, safe, and
effective treatment for renal masses in patients that require maximum nephron-sparing management, providing them
with an opportunity for treatment.7-10
Conclusions
After more than 10 years of experience worldwide, there
are only a few long and medium-term studies on the results
Figure 2 The Cryocare Surgical System
(Endocare Inc., Irvine, Calif, USA) 17Ga
cryocatheter during renal cryoablation.
Figure 3 The Cryocare Surgical System
(Endocare Inc., Irvine, Calif, USA) 17Ga
cryocatheter. The red arrows signal the
depth of the cryocatheter needle, which
is correlated with the limit of the ice
ball formation (green arrows).
178
J. G. Campos-Salcedo et al
Figure 5 The high definition laparoscopic ultrasound showing the ecographically homogeneous renal parenchyma with
no lesion; the ice ball formation is seen
as a hypoechoic area in the center of the
renal parenchyma.
Figure 4 The high definition laparoscopic ultrasound in contact with the renal
parenchyma for cryoablation guide and
ice ball formation.
of this technique in the Mexican population, despite the numerous benefits it has shown. We have presented the results
of a medium-term follow-up at a Mexican tertiary care hospital where laparoscopic renal cryoablation guided by high
definition laparoscopic ultrasound is carried out. It is necessary to continue and promote long-term studies, given that
the results are becoming more and more favorable for patients. We corroborate the fact that the application of this
ablation therapy provides the patient with an opportunity
for treatment, and many improvement prospects. The patient is benefitted physically through a better quality of life
that is a characteristic of minimally invasive surgery, as well
Figure 6 Cryoablation. The ice ball
created by 2 cryocatheters in the first
cooling phase and formed over the renal
tumor lesion is shown.
as psychologically, given that the preoccupation caused by
being “surgically inoperable” is reduced, maintaining the
oncologic principles. For these reasons we stress the importance and great usefulness that learning this technique has
for the practicing urologist, as well as for those in training.
For the benefit of the patients, it should always be kept in
mind when making therapeutic decisions.
Conflict of interest
The authors declare that there is no conflict of interest.
Table 2 Result compilation. Specific results for each lesion. The first column to the left shows the lesion number and the second
column shows the TNM staging according to the 2010 European Association of Urology guidelines.
Age
(years)
TNM
Tumor
size
(mm)
Comorbidities
Pre-op
creat
DHS
Postop
creat
Post-op
UO ml/
kg/hr
Cryolesion
reduc (%)
HPS
1
31
T1aN0M0
39
Right single kidney due to
left Wünderlich syndrome
0.85
8
1.0
1.6
89.7
AML
2
31
T1aN0M0
42
Right single kidney due to
left Wünderlich syndrome
0.85
8
1.0
1.6
89.7
AML
3
38
T1aN0M0
20
DM
0.8
8
1.0
1.4
33
ccRCC
4
72
T1aN0M0
31
Sub. Mesenteric hepatic
thrombosis/DM2/HBP/
chronic liver disease
0.8
21
1.1
1.0
100%
ccRCC
5
75
T1aN0M0
30
ccRCC/PN 2004 and cryo
2007/CKF/HPO/HBP
1.8
11
2.6
0.1
89%
ccRCC
6
62
T1aN0M0
23
ccRCC 2007
1.1
4
1.7
0.5
15%
ccRCC
7
49
T1aN0M0
20
DM2
1.0
1
0.8
1.0
15%
ccRCC
8
79
T1aN0M0
22
DM2
0.8
3
1.2
1.0
0%
ccRCC
DM2: diabetes mellitus type 2; HBP: high blood pressure; Pre-op creat: preoperative serum creatinine; DHS: Days of hospital stay; Postop creat: Postoperative serum creatinine at 24 hours; UO: Urinary output; Cryolesion reduc: Cryolesion reduction percentage; HPS:
Histopathologic study report; AML: angiomyolipoma; ccRCC: Clear cell renal cell carcinoma.
Laparoscopic renal cryosurgery Financial disclosure
No financial support was received in relation to this article.
References
1. Gill IS, Remer EM, Hasan WA, et al. Renal Cryoablation. Outcome at 3 years. J Urol 2005;173(6):1903-1907.
2. Campbell SC, Palese MA. Opposing views. Laparoscopic cryoablation for a 3 cm nonhiliar renal tumor. J Urol 2011;185(1):1416.
3. Autorino R, Haber GP, White MA, et al. New developments in
focal therapy. J Endourol 2010;24(5):665-672.
4. Gill IS, Aron M, Gervais DA, et al. Clinical practice. Small renal
mass. N Engl J Med 2010;362(7):624-634.
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5. Ljungberg B, Cowan N, Hanbury DC, et al. Guidelines on Renal
Cell Carcinoma. Eur Urol 2010;58(3):398-406.
6. Davol PE, Fulmre BR, Rustalis DB. Long term results of cryoablation for renal cancer and complex renal masses. Urology
2006;68(1 Suppl):2-6.
7. Remer EM, Hale JC, Inderbir G, et al Technical Innovation. Sonographic Guidance of Laparoscopic renal cryoablation. AJR Am
J Roentgenol 2000;174(6):1595-1596.
8. Heuer R, Gill IS, Guazzoni G, et al. A critical analysis of the actual role of minimally invasive surgery and active surveillance
for kidney cancer. Eur Urol 2010;57(2):223-232.
9. Springer C, Hoda MR, Fajkovic H, et al. Laparoscopic vs open
partial nephrectomy for T1 renal tumours: evaluation of longterm oncological and functional outcomes in 340 patients. BJU
Int 2013;111(2):281-288.
10. Long CJ, Canter DJ, Smaldone MC, et al. Role of tumor location
in selecting patients for percutaneous versus surgical cryoablation of renal masses. Can J Urol 2012;19(5):6417-6422.
Rev Mex Urol 2013;73(4):180-186
ÓRGANO OFICIAL DE DIFUSIÓN DE LA SOCIEDAD MEXICANA DE UROLOGÍA
www.elsevier.es/uromx
Original article
Usefulness of urethral ultrasound imaging in urethral stricture
P. Cruz García-Villaa,*, M. Figueroa-Zarzab, D. López-Alvaradoa and F. Mendoza-Peñac
a
Urology Speciality Residency, Hospital Regional “Lic. Adolfo López Mateos”, ISSSTE, Mexico City, Mexico
b
Department of Urology, Hospital Regional “Lic. Adolfo López Mateos”, ISSSTE, Mexico City, Mexico
c
Department of Urology Administration, Hospital Regional “Lic. Adolfo López Mateos”, ISSSTE, Mexico City, Mexico
KEYWORDS
Stricture; Urethra;
Ultrasound; Mexico.
Abstract
Background: Urethral stricture is defined as a narrowing secondary to tissue scarring. Diagnosis
is made with contrast-enhanced imaging studies such as cystourethrography. Urethral ultrasound is a noninvasive imaging method that enables the diagnosis and classification of urethral
stricture.
Material and methods: Thirty patients with a past history of urethral stricture underwent
urethral ultrasound. The strictures were measured, a questionnaire on urethral ultrasound was
applied, and a descriptive data analysis was done.
Results: The mean age of the patients was 66 years. A total of 33.3% patients underwent cystoscopy and 73% had cystourethrography. In 50% of the patients, initial treatment was urethral dilation. Significant urethral stricture was found through ultrasound in 80% of the patients. The
mean stricture length was 0.84 cm and the mean depth was 0.37 cm. The patients experienced
less “discomfort” during the ultrasound procedure and would recommend it over voiding cystourethrography (VCUG) and/or cystoscopy.
Discussion: Urethral ultrasound is a noninvasive imaging method that identifies stricture location and length and evaluates the depth of the spongiofibrosis. Cystourethrography can underestimate stricture length and it does not provide information on depth and density. Ultrasound
imaging should be complementary in patients with urethral stricture and should be used for
surgical planning and adequate follow-up.
* Corresponding author at: Av. Universidad N° 1321, Colonia Florida, Delegación Álvaro Obregón, C.P. 01030, México D.F., México. Telephone: 5322 2300. Email: patricio_cruzgar@yahoo.com.mx (P. Cruz García-Villa).
0185-4542 - see front matter © 2013. Revista Mexicana de Urología. Publicado por Elsevier México. Todos los derechos reservados.
Urethral ultrasound Palabras clave
Estenosis; Uretra;
Ultrasonido; México.
181
Utilidad ultrasonido uretral en estenosis de uretra
Resumen
Introducción: La estenosis de uretra se define como una estrechez secundaria a tejido cicatrizal. El diagnóstico se realiza con estudios de imagen con medio de contraste, tal como la uretrocistografía. El ultrasonido uretral es un método de imagen no invasivo, que permite diagnosticar y clasificar la estenosis de uretra.
Material y métodos: Se realizó ultrasonido uretral en 30 pacientes con antecedente de estenosis
de uretra. Se midieron las estenosis. Se realizó un cuestionario sobre el ultrasonido uretral. Se
hizo un análisis descriptivo de los datos.
Resultados: La edad promedio fue de 66 años. El 33.3% tenía cistoscopia y el 73% uretrocistografía. En el 50% el tratamiento inicial fue con dilatación. En el 80% de los pacientes se encontró
estenosis de uretra significativa por ultrasonido. La longitud promedio fue de 0.84 cm y la profundidad promedio fue de 0.37 cm. Los pacientes sintieron menos “molestia” durante el ultrasonido, y lo recomendarían más que la uretrocistografía miccional (UCGM) y/o la cistoscopia.
Discusión: El ultrasonido uretral es no invasivo. Permite obtener la localización y la longitud, así
como la valoración de la profundidad de la espongiofibrosis. La uretrocistografía puede subestimar la longitud, y no informa la profundidad y densidad. El ultrasonido debe ser complementario en los pacientes con estenosis de uretra. El ultrasonido debe hacerse para una planeación
quirúrgica y un adecuado seguimiento.
Introduction
Methods
According to information from the U.S. Veterans Affairs hospital database the rate of urethral stricture was 193/100,000
for the year 2003. According to this database, the stricture
rate increased significantly in patients above the age of 55
years. However, the incidence of urethral stricture is unknown. Medical consultations for urethral stricture determined by the U.S. National Ambulatory Medical Care Survey
within the time frame of 1992 to 2000 were reported at a
rate of 229/100,000.1 Urethral stricture is defined as a narrowing of the urethral lumen secondary to scar tissue. Etiology can be infectious, iatrogenic, traumatic, or idiopathic.
These patients present with urinary symptomatology that
affects quality of life and they are often offered procedures
such as dilation or optical internal urethrotomy (OIU). In
some cases the patients may develop severe symptoms such
as kidney failure, acute urine retention, urethral carcinoma, Fournier’s gangrene, and bladder dysfunction as a consequence of the stricture.2 According to the same survey,
the number of retrograde urethrograms carried out on the
population over 65 years of age was 6,557/100,000 in 2001.
In other words, 6.5% of the patients above the age of 65
years with urethral stricture underwent that study.1
Numerous studies have shown that urethral ultrasound
imaging offers greater precision in determining stricture
length.3,4
Ultrasound as a diagnostic tool for urethral stricture
offers the advantages of being a non-invasive study that
enables the anterior urethral strictures to be seen rapidly,
simply, and precisely. Likewise, it measures stricture length
and depth more exactly than retrograde urethrography.
A descriptive study was conducted on 30 men using urethral
ultrasound as a support tool in the management of patients
presenting with urethral stricture. The study was carried
out at the Urology Service of the Hospital Regional Lic.
Adolfo López Mateos of the ISSSTE. Prior to their participation, all patients signed informed consent statements. The
ultrasound equipment used was the Esaote Mylab™ Desk
with a 7.5 mHz linear transducer. With the patient in the
dorsal decubitus position, a 12Fr Foley catheter was placed
in the navicular fossa and with a continuous drip through
the catheter, an ultrasound sweep of the anterior urethra
was carried out. All the studies were performed by the same
physician. The location, length, and depth of the strictures
found were recorded. After the ultrasound, a still non-validated questionnaire that was created in stages was applied
to identify the grade of discomfort of the ultrasound study, to
be compared with cystoscopy and retrograde urethrocystography.
A descriptive analysis of the data was done, obtaining
means, standard deviation, and frequencies.
Results
An ultrasound study of the urethra was carried out on 30
male patients. Their mean age was 66 ± 9.1 years. A total of
30% of the patients had a past history of diabetes mellitus
type 2, 46.7% high blood pressure, 13.3% heart disease, and
10% had a history of kidney failure. Ten percent of the patients had prostate cancer and 13.3% presented with some
other comorbidity. A total of 24 patients (80%) had a past
history of TURP and 21 (70%) had been treated with OIU.
A total of 13.3% of the patients had undergone open or
radical prostatectomy and 23.3% had some other surgery.
182
P. Cruz García-Villa et al
Figure 1 A) and B) Voiding cystourethrogram that shows stricture data at the penoscrotal junction and the bulbous urethra. C) and
D) Urethral ultrasound that shows a reduction in the caliber of the urethra at the level of the penoscrotal junction and the bulbous
urethra. Spongiofibrosis surrounding the tissue can be seen.
Of the patients with previous urologic surgery, the mean
time of stricture diagnosis after the surgery was 26.3 ± 24.5
months.
Thirty-three percent of the patients had a cystoscopic
study, whereas 73.3% had cystourethrography. Of the patients that had cystoscopy, 80% presented with urethral
stricture. Ninety-five percent of the patients that had cystourethrography presented with urethral stricture data (fig.
1).
Of the patients that had some kind of diagnostic study
(cystoscopy and/or cystourethrography), 70% presented
with stricture in the bulbous urethra, 20% in the penile
urethra, and 13% in the prostatic urethra.
Initial treatment was dilation or calibration in 46.7% of
the patients. OIU was done on 23.3%. Treatment was transurethral catheter placement or cystostomy in 16.7% of the
patients, and there was no initial treatment in 13% (table
1).
Prior to the ultrasound, the International Prostate Symptom Score (IPSS) questionnaire was applied to all the patients. Forty percent of them had a moderate score (8 to 19
points), 30% had a severe score (20 to 35 points), and 30%
had a mild score (1 to 7 points).
Urethral stricture was found in 80% (n=24) of the patients
that had ultrasound; it was situated in the penile urethra in
36.7%, in the bulbous urethra in 40%, and in the membranous urethra in 3.3%.
A second stricture was found in the bulbous urethra in 6
cases and a third stricture was found in the bulbous urethra
in 2 cases.
In 89.3% of the patients, the location of the stricture
found through ultrasound imaging coincided with the location found through cystoscopy and/or cystourethrography.
The mean number of strictures found was 1 ± 0.78, the
mean stricture length was 0.84 ± 0.50 cm, and the mean
depth was 0.37 ± 0.17 cm (table 2).
In relation to the responses to the questionnaire applied
after urethral ultrasonography, 79.3% of the patients said
there was less discomfort with the ultrasound study than
with the previous study (cystoscopy and/or cystourethrography), 17.2% stated there was more discomfort, and 3.4%
said the discomfort was the same. The ultrasound study was
regarded as less invasive by 75.9% of the patients and 86.2%
considered that it took less time than the previous study.
A total of 72.4% stated that they had felt pain with the
cystoscopy and/or cystourethrography. Of those patients,
the mean pain score was 5 ± 3.36 points, according to the
visual pain analog scale. On the other hand, 48.3% of the
patients stated they had felt pain with the ultrasound study
and had a mean pain score of 2.2 ± 2.7 points.
Urethral ultrasound 183
Table 1 General patient characteristics
Age (years)
66 ± 9.1
N=30
Table 2 Urethral stricture location percentage and length
and depth through ultrasonography
Patients with urethral ultrasound
Finding of stricture
DM2
30%
HBP
46.7%
Penile urethra
Heart disease
13.3%
Bulbous urethra
N=30
80% (24)
36.7%
40%
CKF
10%
Membranous urethra
Prostate cancer
10%
89.3% (25)
Previous TURP
80%
Coinciding with cystoscopy and/or
cystourethroscopy
Previous OIU
70%
Length (cm)
0.84 ± 0.50
Depth (cm)
0.37 ± 0.1
Cystoscopy
33.3%
Cystourethrography
73.3%
3.3%
Initial treatment
Dilation
46.7%
OIU
23.3%
Others
16.7%
Without treatment
13.3%
DM2: diabetes mellitus type 2; HBP: high blood pressure; CKF:
chronic kidney failure; TURP: transurethral resection of the
prostate; OIU: optical internal urethrotomy.
Thirty-one percent of the patients that had cystoscopy
and/or cystourethrography reported having had some kind
of complication such as hematuria, pain, micturition difficulty, infection, etc. A total of 55.2% of this group of patients presented with dysuria at some point after the
procedure.
Ninety-six percent of the patients said they had none of
the abovementioned complications after urethral ultrasonography and 6.7% of the patients in this group presented with
dysuria after the ultrasound study.
The greatest discomfort for the patients during the
urethral ultrasound study was when the Foley catheter was
placed in the navicular fossa.
A total of 96.6% of the patients would recommend
urethral ultrasonography rather than cystoscopy or cystourethrography.
A contrast-enhanced radiologic study of a normal urethra
can be clearly seen in figure 2A; figures 2B, 2C, and 2D show
ultrasound images of the anterior penile urethra, the posterior penile urethra, and the bulbous urethra.
Discussion
The age at which patients present with urethral stricture
can vary. It has been observed that as the individual ages,
the incidence of stricture is more frequent, with the greatest incidence in patients above the age of 55 years.1 The
mean age of the patients in the present study was 66.4
years. According to statistics in the United States, stricture
incidence for this age is calculated at 600/100,000. In relation to their etiology, strictures can be divided as follows:
idiopathic, traumatic, infectious, and iatrogenic. Eighty
percent of the patients studied had a previous TURP. In the
study by Greenwell et al., the TURP was the cause of the stricture in 33% of the patients.
According to a survey applied to urologists in the U.S., in
relation to all procedures included in the questionnaire, dilation and urethrotomy are used to treat stricture in 92.8%
and 85.6% of the cases, respectively. Of the 30 patients included in our study, 46.7% were managed with dilation and
23.3% had undergone a previous OIU.
Cystourethrography is currently regarded as the study of
choice for urethral stricture diagnosis. It offers the diagnostic advantages of complete visualization of the urethral
course from the navicular fossa to the bladder neck in a retrograde phase and a micturition phase. Nevertheless, some
disadvantages of cystourethrography are patient radiation
exposure, the use of iodized contrast mediums, the changing of positions for the taking of images, the length of time
of the study, the occasionally traumatic introduction of the
catheter for instilling the contrast medium, the low sensitivity for observing strictures that are not significant, and the
image interpretation variability. Moreover, stricture depth
cannot be measured with this method and it often underestimates stricture length.5-8
Spongiofibrosis refers to the presence of fibrous tissue beyond the urethral epithelium that affects the spongy body,
and in severe cases, the corpora cavernosa. The best
treatment can be chosen if the amount of spongiofibrosis
surrounding the stricture is known. Cystourethrography does
not have the ability to show this periurethral tissue.
Despite these disadvantages of cystourethrography, the
reason why ultrasound is not a routine study in patients with
urethral stricture or with urethral pathology in general is
most likely related to the cost, the time it takes, and the
lack of trained radiologists.
Ultrasound that is carried out with a linear transducer, as
was done in our study, has advantages over radiographic studies. It is possible to obtain real time longitudinal and transverse images, as well as objective measurements of the
length and diameter of the urethral lumen. It is a study that
is comfortable and well tolerated by patients and it does
not require the use of ionizing radiation or contrast medium. To the contrary, the urethra can be irrigated with
184
P. Cruz García-Villa et al
Figure 2 A) Cystourethrography with no data of urethral stricture. B) C) and D) Portions of the urethra (penile and bulbous) with
adequate compliance and no evidence of stricture.
physiologic solution or gel can be used to obtain adequate
visibility.
Perhaps one of the limitations of ultrasonography is the
impossibility to observe the posterior urethra. In 1988, McAninch et al. first demonstrated the poor correlation between cystourethrography and ultrasound imaging for
measuring stricture length. They showed how cystourethrography underestimated the length of the narrowings when
compared with the length measured during the surgical procedure, whereas the ultrasound measurements coincided
with the latter.9
Other studies followed, reporting their preliminary experience when evaluating urethral stricture with ultrasonography.10,11
In 1990 Merkle and Wagner predicted the success of the
OIU in relation to the evaluation of scar tissue observed
with ultrasound and found that 80% of the patients with ultrasonographic evidence of periurethral fibrosis had recurrences at 6 months from the surgery.12
Urethral ultrasound has various applications and one of
them is in presurgical planning, especially for strictures located in the bulbous urethra. The evaluation of the length
of the narrowing is perhaps the most important criterion for
determining the best treatment.13 According to a study by
Nash et al. in 1995, the length of the narrowing in the
bulbous urethra observed through ultrasound was very
highly correlated with the length found during the surgical
procedure (p<0.007), which was not the case with retrograde urethrography.7 Another application of ultrasound is in
severe strictures that are generally produced by perineal or
pelvic trauma in which the size of the fibrosis or stricture of
the bulbous urethra cannot be exactly defined through radiologic techniques.14
In our study, bulbar strictures presented in 40% of the patients, whereas penile strictures presented in 36.7%. This
coincides with another study in which bulbar strictures were
more frequent, presenting in 48.47% and penile strictures in
25.4%.15-17
The healthy urethral wall has special characteristics such
as elasticity, softness, and the capacity to dilate when a liquid is instilled inside it (compliance). In ultrasound imaging, spongiofibrosis is seen as a thickened and irregular
tissue with little compliance, projecting into the urethral
lumen. This fibrosis can be observed with increased echogenicity, even though the areas that do not distend can alter
the echogenicity. Unlike cystoscopy or cystourethrography,
ultrasonography has the capacity to adequately measure
the quantity of spongiofibrosis, which can be done by measuring the length and depth or by objectively measuring the
diameter of the urethral lumen. During maximum retrograde
Urethral ultrasound Figure 3 Stricture in the bulbous urethra with measurements
of length and depth.
distension, if the diameter of the urethral lumen measures
less than 3 mm, the spongiofibrosis is regarded as severe.
The presence of an acoustic shadow means that the fibrosis
185
is so dense that the ultrasound wavelengths cannot pass
through it. In our study we measured the length of the strictures and the depth of the spongiofibrosis at their maximum
points, obtaining a mean length of 0.84 ± 0.50 cm (0.20 to
2.27 cm) and a mean depth of 0.37 ± 0.1 cm (0.11 to 0.89
cm). We did not carry out a routine measurement of the
urethral lumen, but we believe that it can be another objective parameter for stricture diagnosis.13 The mean length
of the strictures found in our study was shorter than those
reported in other series15,16 (fig. 3).
When patients present with strictures that were already
operated on, cystoscopic evaluation may be impossible.
In those patients in whom a reconstruction with a scrotal
skin flap was done, ultrasound imaging can even identify the
presence of hair inside the urethra.
Other applications of urethral ultrasound are the visualization of urethral stones, diverticula, abscesses, false pathways,
and fistulas. In our series, we found a urethral diverticulum that
was also diagnosed through cystourethrography (fig. 4).
One of the limitations of our study was that not all patients had undergone cystourethrography and therefore we
were not able to compare means.
We believe that due to the complexity of the urethral
pathology and its management, it is essential to have as
much information on the stricture site as possible. Cystourethrography is a good diagnostic and detection method,
but it does not provide all the information necessary for
adequate treatment planning and choice. We join the other
authors that have proposed that ultrasound study of the
urethra be a complementary study in the evaluation and
follow-up of patients with urethral stricture.13,15,18- 20
Figure 4 A) Cystourethrography with the image of a urethral diverticulum in the penile urethra. B) Ultrasonographic longitudinal
view showing the diverticulum in the penile urethra. C) Transverse view in which the lumen of the diverticulum and the urethra
can be seen.
186
Conclusions
Urethral strictures present in men of all ages, with a greater
incidence after 55 years of age. Urethral pathology is a frequent cause of visits to the urologist and represents an important expense for the patient and the institution.
Urethral stricture treatment is complex and the majority
of urologists opt for dilation or OIU, treatments that have an
important recurrence rate. Urethroplasty in its different
modalities is the best treatment in well-selected patients.
Cystourethrography is regarded as the diagnostic study of
choice, however it is not a perfect method. Urethral ultrasound is a noninvasive, inexpensive, and available method
that provides objective information on the characteristics
of the urethral stricture.
We propose urethral ultrasound imaging as a complementary study to cystourethrography in all patients with
urethral stricture.
Conflict of interest
The authors declare that there is no conflict of interest.
Financial disclosure
No financial support was received in relation to this article.
References
1. Santucci RA, Jocye GF, Wise M. Male Urethral Stricture Disease
J Urol 2007;177(5):1667-1674.
2. Romero Perez P, Mira Llinares A. Complications of the lower urinary tract secondary to urethral stenosis. Actas Urol
Esp 1996;20(9):786-793.
3. Choudhary S, Singh P, Sundar E, et al. A comparison of sonourethrography and retrograde urethrography in evaluation of anterior urethral stricture. Clin Radiol 2004;59(8):736-742.
4. Gupta N, Dubey D, Mandhani A, et al. Urethral stricture assessment: a prospective study evaluating urethral ultrasonography
and conventional radiological studies. BJU Int 2006;98(1):149153.
P. Cruz García-Villa et al
5. Gupta S, Majumdar B, Tiwari A, et al. Sonography in the evaluation of anterior urethral strictures: Correlation with radiographic urethrography. J Clin Ultrasound 1993;21(4):231-239.
6. Das S. Ultrasonographic evaluation of urethral stricture disease. Urology 1992;40(3):237-242.
7. Nash PA, McAninch JW, Bruce JE, et al. Sonourethrography in
the evaluation of anterior urethral strictures. J
Urol 1995;154(1):72-76.
8. Morey AF, McAninch JW. Role of preoperative sonourethrography in bulbar urethral reconstruction. J Urol 1997;158(4):13761379.
9. McAninch JW, Laing FC, Jeffrey RB Jr. Sonourethrography in the
evaluation of urethral strictures: a preliminary report. J
Urol 1988;139(2):294-297.
10. Merkle W, Wagner W. Sonography of the distal male urethra -a
new diagnostic procedure for urethral strictures: results of a
retrospective study. J Urol 1988;140(6):1409-1411.
11. Gluck CD, Bundy AL, Fine C, et al. Sonographic urethrogram:
comparison to roentgenographic techniques in 22 patients. J
Urol 1988;140(6):1404-1408.
12. Merkle W, Wagner W. Risk of recurrent stricture following internal urethrotomy: prospective ultrasound study of distal male
urethra. Br J Urol 1990;65(6):618-620.
13. Morey AF, McAninch JW. Sonographic staging of anterior urethral strictures. J Urol 2000;163(4):1070-1075.
14. Morey AF, McAninch JW. Ultrasound evaluation of the male urethra for assessment of urethral stricture. J Clin Ultrasound 1996;24(8):473-479.
15. Gong EM, Martinez Rios Arellano C, Chow JS, et al. Sonourethrogram to Manage Adolescent Anterior Urethral Stricture. J
Urol 2010;184(4 Suppl):1699-1702.
16. Nuss GR, Granieri MA, Zhao LC, et al. Presenting Symptoms of
Anterior Urethral Stricture Disease: A Disease Specific, Patient
Reported Questionnaire to Measure Outcomes. J
Urol 2012;187(2):559-562.
17. Greenwell TJ, Castle DE, Andrich JT, et al. Repeat Urethrotomy
and Dilation for the treatment of Urethral Stricture are neither
clinically effective nor Cost-Effective. J Urol 2004;172(1):275277.
18. Bullock TL, Brandes SB. Adult Anterior Urethral Strictures: A National Practice Patterns Survey of Board Certified Urologists in
the United States. J Urol 2007;177(2):685-690.
19. Andrich DE, Mundy AR. Urethral Strictures and their surgical
treatment. BJU Int 2000;86(5):571-580.
20. Selbold J, Werther M, Alloussi S, et al. Urethral Ultrasound as a
Screening Tool for Stricture Recurrence after oral mucosa Graft
Urethroplasty. Urology 2011;78(3):696-700.
Rev Mex Urol 2013;73(4):187-190
ÓRGANO OFICIAL DE DIFUSIÓN DE LA SOCIEDAD MEXICANA DE UROLOGÍA
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Review Article
Tumors of Cowper’s glands: a review of the literature
A. Lisker-Cervantes, G. Romero-Vélez, C. I. Villeda-Sandoval, M. Sotomayor-de Zavaleta
and R. Castillejos-Molina*
Department of Urology, Instituto Nacional de Ciencias Médicas y Nutrición “Salvador Zubirán”, Mexico City, Mexico
KEYWORDS
Tumor; Cowper’s
glands; Diagnosis;
Treatment; Mexico.
Palabras clave
Tumor; Glándulas de
Cowper; Diagnóstico;
Tratamiento; México.
Abstract The bulbourethral glands, or Cowper’s glands, originate as evaginations of the epithelium that cover the urogenital sinus. Their secretion neutralizes urine and lubricates the urethra
prior to ejaculation. Occasionally, they can become infected or be the site of tumors or congenital disorders.
Among the most frequently seen pathologies are congenital tumors, malignant tumors, and inflammatory processes. The first 2 should be considered when carrying out the physical examination. Correct diagnosis requires a high degree of suspicion and knowledge of this entity.
Treatment should be individualized. Even though the authors state that resection is ideal for
disease-free survival, conclusions about treatment cannot be made, given that there is insufficient information available on these disorders.
Tumores de las glándulas de Cowper: una revisión de la literatura
Resumen Las glándulas bulbouretrales o glándulas de Cowper se originan como evaginaciones
del epitelio, que recubre el seno urogenital. Su secreción neutraliza la orina, además de lubricar la uretra previo a la eyaculación. Ocasionalmente, pueden infectarse o ser asiento de neoplasias o trastornos congénitos.
Entre los trastornos vistos con mayor frecuencias están los tumores congénitos, tumores malignos y procesos inflamatorios. Los 2 primeros deben considerarse cuando se realiza la exploración física. El diagnóstico correcto requiere de un alto grado de sospecha y el conocimiento de
esta entidad. El tratamiento debe ser individualizado. Aunque los autores concluyen que la resección es óptima para la sobrevida libre de enfermedad, no se pueden realizar conclusiones
sobre el tratamiento basados en la información disponible.
* Corresponding author at: Vasco de Quiroga N° 15, Colonia Sección XVI, Delegación Tlalpan, C.P. 14000, México D.F., México. Telephone:
5487 0900, ext. 2163. Fax: 5485 4380. Email: rcastillejos@hotmail.com (R. Castillejos-Molina).
0185-4542 - see front matter © 2013. Revista Mexicana de Urología. Publicado por Elsevier México. Todos los derechos reservados.
188
Introduction
The bulbourethral glands originate as evaginations of the
epithelium that cover the urogenital sinus. Their secretion
neutralizes urine in addition to lubricating the urethra prior
to ejaculation.1,2 They are called Cowper’s glands after William Cowper, who first described them in 1699. Diseases
affecting these glands are rarely identified; however, they
can be host to infections, tumors, and congenital disorders.2,3 The most frequently isolated microorganisms are
Escherichia coli, Neisseria gonorrhea and Chlamydia trachomatis.1
Congenital tumors
Syringocele consists of a cystic dilation of the Cowper’s
glands and is a rare congenital anomaly. Nevertheless, according to Watson et al.,4 it is becoming more common. And
according to Maziels et al., these lesions were formerly
classified into 4 different groups: simple, perforated, imperforate, and ruptured.5 The recent medical literature suggests a classification based on 2 groups: open and closed,
depending on their communication with the urethral lumen.4
These lesions are most commonly found in the pediatric
population, with only 11 cases reported on in adults.6 According to Bevers et al., syringoceles in adults are lesions that
are acquired secondarily to infection and trauma.7 Open
syringoceles present with dysuria, urinary frequency, incontinence, terminal dripping, and hematuria, whereas closed
syringoceles present with infravesical obstruction. Differential diagnosis should be made with synechiae, diverticula,
valves, and periurethral abscesses, due to the not very specific syringocele symptomatology.6,8
Melquist et al. suggest a diagnostic algorithm based on a
review of the literature.8 The first imaging study recommended for syringocele evaluation is transrectal ultrasound
(TRUS), followed by cystourethrography (CUG). Closed
syringoceles look like cystic lesions in the TRUS and the
open ones appear to be filling defects when observed in
the CUG.6-8 Magnetic resonance imaging (MRI) and computed axial tomography (CAT) can also be useful in evaluating
closed syringoceles.4,8
Follow-up is adequate treatment, given that the symptomatology can improve without interventions.7,8 If the symptomatology persists, the patient can undergo endoscopic
and open treatments. Endoscopic deroofing of the cysts has
been reported with good results. 4,7,8 When endoscopic
treatment fails, conduit ligature or open glandular excision
are options.8,9
Malignant tumors
Primary carcinomas of the bulbourethral glands are extremely rare, with only 21 reported cases in the medical literature. Adenocarcinomas are the predominant histopathologic
type with 17 reported cases3,10-13; the rest are cases of cystadenocarcinoma.2,14-16 The last case was reported in 2003 by
Hitsamatu et al.14 Due to their low incidence rate there is
not enough information available to characterize these tumors.
A. Lisker-Cervantes et al
The clinical presentation varies in each of the reported
cases (table 1). Syringocele is more common in the sixth
decade of life and the patients did not report any other comorbidity. The majority presented with lower urinary tract
symptoms that progressed to acute urine retention, or as a
painful perineal tumor. The incidental finding of this tumor
has also been reported; 2 during rectal examination and
another during flexible urethroscopy.2,12,15 It has been described that in the rectal examination a petrous tumor can be
delimited separate from the prostate. Bourque et al. suggest that syringocele should be suspected in patients presenting with painful tumors in the perineum or with
incidental findings of narrowings in the bulbous or membranous urethra.10
Prostate-specific antigen (PSA) was introduced in 198017
and so its value was not reported in all the cases; however,
when it was, the value was not elevated. Those cases before
1980 reported normal values of prostatic acid phosphatase
(PAP). PSA and other laboratory studies are not diagnostic,
but they can be useful in the differential diagnosis of prostate tumors. There is no laboratory finding that helps evaluate these tumors.
CUG was used during the initial evaluation in the first cases but it was not useful in the majority of them.11 Bourque
reported a narrowing of the posterior urethra that led to
the suspicion of Cowper’s gland involvement.10 One of the
cases was an incidental finding during a urethroscopy study.
Cystoscopy in another patient produced no important findings, only extrinsic compression of the bulbous urethra.11
Small et al. used TRUS in their report and demonstrated a
large, hypoechogenic cystic tumor inferior to the apex of
the prostate that was later staged through CAT and MRI.15
We believe that TRUS is an adequate study for the initial
approach, nevertheless, CAT or MRI should be considered for
completing the evaluation, because they can provide more
information with respect to extension and surgical planning.
The final diagnosis will depend on the pathology study.
Cowper’s glands are tubuloalveolar glands that are covered
by a pseudo-stratified epithelium. Immunohistochemistry is
positive for high molecular weight cytokeratin, mucin, and
actin, whereas it is negative for PSA and PAP.1,14
Complete tumor excision is performed in the majority of
patients. Excision extension varies depending on each case,
from tumorectomy to pelvic exenteration. The adjuvant use
of 5-fluorouracil (5-FU) was reported by Keen et al.3 with no
benefits, whereas Hisamatu et al.14 used cisplatin and epirubicin together with radiotherapy and reported symptomatology improvement and non-quantified tumor reduction.
Radiotherapy results vary depending on the regimen reported,
as well as on clinical stage.2,3,14,15 Bourque et al.10 determined that these tumors are not hormone-dependent, making
orchiectomy useless. The majority of authors agree that
surgical treatment offers the best results.
The reports do not conclude whether these tumors are
aggressive or not. The majority of information has been extrapolated from cystic adenocarcinomas in the head and
neck.14 As previously mentioned, surgical excision is the best
treatment when the tumors are localized; a survival period
of 13 years was reported for one of the patients.2 Not all the
reports describe metastatic extension, but metastasis was reported in at least 6 out of 21 patients.10,11,14 Those patients
have a worse outcome, with a 2-year survival period.
Tumors of Cowper’s glands: a review of the literature 189
Table 1 Characteristics of the patients with adenocarcinoma and cystic adenocarcinoma of the Cowper’s glands
Author
Year
Clinical
presentation
Tumor
Treatment
Commentary
Paquet et al.
1884*
Sur un cas d’epithélioma de la glande Cowper. J de l’anat. Et de la physiol.
Pitrzikowski E, et al.
1885*
Ein Fall von primären Carcinom der Cowperschen Drüsen. Ztschr. F. Heilk
Blanc W, et al.
1910*
Cancer of Cowper’s glands. La Loire Mèdicale
Di Maio G
1928*
Primary carcinoma of Cowper’s gland. Gazz. D’osp.
Uhle CA, et al.
1935*
Primary carcinoma of Cowper’s gland. J. Urol
Gutierrez R
1937*
Primary carcinoma of Cowper’s gland. Surg., Gynec. & Obst.
Griseau WA, et al.
1951*
Carcinoma of Cowper’s gland. J. Urol
Urteaga OB, et al.
1956*
Adenocarcinoma of Cowper’s glands. Arch. Peru. Pat. Clinic
Marshall VF, et al.
1957*
Carcinoma of Cowper’s gland. J. Urol
Le Duc E
1962*
Carcinoma of Cowper’s gland, report of the eleventh case. Calif. Med.
Tomoyoshi T, et al.
1967*
Adenocarcinoma of the Cowper’s gland. Acta. Urol. Jap.
Derrick FC, et al.
1968*
Cowper’s gland carcinoma. Report of a case. J.S. Carolina Med. Ass.
Arduino LJ, et al.
1969
Carcinoma
Prostatism
En bloc excision
DF at 30 months
Bourque JL, et al.
1970
Adenocarcinoma
Perineal pain, AUR
En bloc excision
Radiotherapy
Symptomatic metastases
2-year survival
Keen MR, et al.
1970
Adenocarcinoma
Hematuria, AUR,
perineal tumor
Radiotherapy
Chemotherapy (5FU)
First chemotherapy
1.5-year survival
Carpenter AA, et al.
1971
Cystic adenocarcinoma
Prostate tumor
Tumor excision
Radiotherapy
DF at 13 years
Small JD, et al.
1992
Cystic adenocarcinoma
Prostate tumor,
LUTS
Pelvic exenteration
Radiotherapy
Surgical support +
radiotherapy
Symptomatic metastases
Follow-up loss
(2 years)
Steimberg S, et al.
1993
Adenocarcinoma
LUTS, hematuria
Urethrectomy +
Chemotherapy (5FU)
Madersbacher S, et
al.
2001
Adenocarcinoma
Recurrent pyelonephritis
RRP
Posterior ureterectomy
Bladder exstrophy
DF at 5 years
Trnski D, et al.
2003
Cystic adenocarcinoma
AUR
TURB and tumorectomy
DF at 6 months
Hisamatsu H, et al.
2003
Cystic adenocarcinoma
Perineal pain,
rectal tumor
Radiotherapy
Chemotherapy
(cisplatin-epirubicin)
Pulmonary metastases
5-year survival
DF: disease-free; AUR acute urine retention; 5FU: 5-Fluorouracil; LUTS: lower urinary tract symptoms; RRP: radical retropubic
prostatectomy; TURB: transurethral resection of the bladder. *Cases compiled by Bourque JL, et al.10
Conclusions
Tumors of the Cowper’s glands are rare. The correct diagnosis requires a high degree of suspicion and knowledge of this
entity. There are no defined algorithms and so treatment
must be individual. Even though the authors state that resection is ideal for disease-free survival, no conclusions can
be made in relation to treatment based on the existing
data. It is necessary to publish more information and the
urologist must be aware of the diseases involving these
glands.
Conflict of interest
The authors declare that there is no conflict of interest.
190
Financial disclosure
No financial support was received in relation to this article.
References
1. Chughtai B, Sawas A, O´Malley RL, et al. A neglected gland: a
review of Cowper`s gland. Int J Andrology 2005;28:74-77.
2. Carpenter AA, Bernardo JR. Adenoid cystic carcinoma of
Cowper`s gland: case report. J Urology 1970;106:701-703.
3. Keen MR, Golden RL, Richardson JF, et al. Carcinoma of
Cowper`s gland treated with chemotherapy. J Urol
1970;104:854-859.
4. Watson RA, Lassoff MA, Sawczuk I, et al. Syringocele of
Cowper`s gland duct: an increasingly common rarity. J Urology
2007;178:285.
5. Maizels M, Stephens FD, King LR, et al. Cowper’s syringocele: a
classification of dilatation of Cowper’s gland duct based upon
clinical characteristic of 8 boys. J Urol 1983;129:111-114
6. Kumar J, Kumar A, Babu N, et al. Cowper’s syringocele in an
adult. Abdom Imaging 2007;32:428-430.
7. Bevers RFM, Abbekerk EM, Boon TA. Cowpers syringocele:
Symptoms, classification and treatment of an unappreciated
problem. J Urol 2000;163:782-784.
A. Lisker-Cervantes et al
8. Melquist J, Sharma V, Sciullo D, et al. Current Diagnosis and
Management of Syringocele: A Review. Intl Braz J Urol
2010;36(1):3-9.
9. Santin BJ, Pewitt EB. Cowper’s duct ligation for treatment of
dysuria associated with Cowper’s syringocele treated previously with transurethral unroofing. Urology 2009;73(3):681.
10. Bourque JL, Charghi A. Primary carcinoma of Cowper`s gland. J
Urol 1970;103:758-761.
11. Arduino LJ, Nuesse WE. Carcinoma of Cowper`s gland: Case report. J Urol 1969;102:224-229.
12. Madersbacher S, Treuthardt C. Paraurethral gland carcinoma in
a man with bladder exstrophy diagnosed 41 years after bladder
plate resection. J Urol 2001;166:2306-2307.
13. Steimberg S, Daneil A, Varcasia DA, et al. Adenocarcinoma de la
glándula de Cowper. Revista Argentina de Urología
1993;58(4):177-179.
14. Hisamatsu H, Sakai H, Igawa T, et al. Adenoid cystic carcinoma
of Cowper`s gland. BJU International 2003;91:1-2.
15. Small JD, Albertsen PC, Graydon JR, et al. Adenoid cystic carcinoma of Cowper`s gland. J Urol 1992;147:699-701.
16. Trnski D, Custovic Z, Soric T, et al. Primary adenoid cystic carcinoma arising in the region of Cowper`s gland. BJU International
2003;91:1.
17. De Angelis G, Rittenhouse HG, Mikolajczyk SD, et al. Twenty
years of PSA: from prostate antigen to tumor marker. Rev Urol
2007;9(3):113-123.
Rev Mex Urol 2013;73(4):191-194
ÓRGANO OFICIAL DE DIFUSIÓN DE LA SOCIEDAD MEXICANA DE UROLOGÍA
www.elsevier.es/uromx
Review article
A new theory on albumin glomerular filtration and its tubular
reabsorption: disputing the charge selectivity theory
B. Condado-Arenas* and G. Pascual-Macfú
School of Medicine and Health Sciences, Instituto Tecnológico y de Estudios Superiores de Monterrey, Monterrey, N. L.,
Mexico
KEYWORDS
Radical Glomerular
sieving coefficient;
Charge selectivity;
Tubular reabsorption
of albumin;
Albuminuria
mechanisms;
Glomerular filtration;
Mexico.
Palabras clave
Coeficiente de
tamizaje glomerular;
Selectividad por
cargas; Reabsorción
tubular de albúmina;
Mecanismos de
albuminuria; Filtración
glomerular; México.
Abstract The aim of this article is to demonstrate that the glomerular charge selectivity
theory, which has been the basic tenet in the field of nephrology, is an erroneous concept, given
that there are other mechanisms different from those proposed in that theory, such as albumin
reabsorption at the proximal tubule. That the glomerular capillary wall is permeable to albumin
through the novel glomerular sieving coefficient for albumin, an aspect that has been described
in different studies, is also shown. This evidence has been compiled in the present article to
demonstrate the veracity of the new theory of tubular reabsorption of albumin.
Nueva teoría sobre la filtración glomerular de albúmina y su reabsorción tubular: refutado
de la teoría de la “selectividad por cargas”
Resumen El presente artículo tiene la finalidad de demostrar que la teoría de “selectividad por
cargas” del glomérulo -la cual ha constituido un principio básico en el campo de la nefrología-,
es un concepto erróneo, ya que diversos mecanismos diferentes a los planteados en esta teoría
se llevan a cabo, tales como la reabsorción de albúmina en el túbulo proximal. También se demuestra que, la pared capilar glomerular es permeable a la albúmina. Esto se expuso mediante
el nuevo coeficiente de tamizaje glomerular para albúmina, que se prueba mediante diversos
estudios. En el presente escrito se recopilan estas evidencias para probar la veracidad de la
nueva teoría de reabsorción tubular de albúmina.
* Corresponding author at: Privada Carmelita N° 1600, Interior 464, Colonia Loma Larga, Monterrey, N. L., México. Telephone: (81) 1537
4423. Email: bernardocondadoarenas@gmail.com (B. Condado-Arenas).
0185-4542 - see front matter © 2013. Revista Mexicana de Urología. Publicado por Elsevier México. Todos los derechos reservados.
192
Introduction
When glomerular filtration capacity is studied, it is commonly understood that the capillary wall has this capacity
due to its ability to filter molecules according to their size
and charge.1-6 Many studies have come to conclusions in favor of the theory of “charge selectivity”, based on research
using anionic polysaccharides; however, recent studies have
shown that the electrical repulsion of some anionic polysaccharides by the glomerular capillary wall is not equivalent,
and therefore does not explain the apparent low selectivity
for albumin.7
The present article attempts to explain the glomerular
filtration of albumin as a more complex system in which
there is no filtration by charges, showing that albumin passes through the glomerular capillary wall after being taken
up and processed by the proximal tubular cells. 1,3,7-10 This
theory has not yet been accepted;9 it is a recent one that
provides a more effective explanation as to why changes in
capillary wall permeability result in massive changes in albumin excretion in nephrotic ranges.
The role of the glomerular capillary wall in the
development of albuminuria
The processes leading to albuminuria are complex and they
involve hemodynamic, tubular absorption, and diffusion
gradient elements. A description of the factors directly related to the glomerular capillary wall is presented herein.
The glomerular capillary wall is made up of endothelial
cells, the basal membrane, and the visceral epithelium.1,2,10
Historically, the basal membrane has been recognized as the
structure that plays the most important role in the process
of glomerular filtration. It is now sustained that podocytes
have a more relevant role in this process. The main components of the glomerular basal membrane are type IV collagen, proteoglycans, and laminins. Proteoglycans are
heterogeneous molecules composed of a protein that functions as a nucleus to which negatively charged lateral glycosaminoglycan chains are bound.10 This is the basis of the
theory of filtration through charges.
Nevertheless, in studies on transgenic mice that do not
have the lateral chains of the main proteoglycan, heparan
sulfate, these mice do not develop proteinuria,11-13 showing
that the charges are not important in the filtration.11 One of
these studies using agrin mutant mice showed that the loss
of agrin, the molecule that binds to laminin, dystroglycan,
and integrin receptors in the podocytes, also resulted in the
loss of heparan sulfate at the level of the glomerular basal
membrane and, in turn, the basal membrane charge, but it
showed no effect at all on glomerular filtration.12 Another
study on mutant mice in which the loss of negative charges
in the basal membrane was achieved showed no difference
in the excretion of the negatively charged substance, Ficoll®, with respect to the control mice.13 Another study in
which mice were mutated to lose heparan sulfate showed
that with the loss of this proteoglycan, contrary to expectations, no protein was found in the urine, and there were no
manifestations of renal dysfunction even after 18 months.11
Podocytes play an important role in the development of
albuminuria and nephrotic syndrome.14 Effacement of the
B. Condado-Arenas y G. Pascual-Macfú
podocyte foot processes is a common characteristic in proteinuric diseases.2,10 Different studies have been conducted
that show severe proteinuria in genetic deficiencies of certain podocyte components.10 A study showed that rats injected with puromycin aminonucleoside developed massive
proteinuria. Through electron microscopy it was discovered
that the glomerulus displayed loss of the podocyte foot processes and that they had been replaced by epithelial cytoplasm.15
Current findings for the glomerular sieving
coefficient for albumin
The glomerular sieving coefficient (GSC) for albumin refers
to the ratio of albumin concentration in Bowman’s space to
the albumin concentration in plasma.8 The GSC is directly
proportional to the concentration of a certain molecule in
Bowman’s space and inversely proportional to the concentration of that same molecule in the plasma. For a freely
filtered solute, the GSC is equal to one, whereas the GSC is
equal to zero for a completely rejected solute. The total
GSC corresponds to the sum of the individual GSCs for each
layer; in other words, the total GSC corresponds to the sum
of a GSC for the endothelium, a GSC for the basal membrane, and a GSC for the epithelium.16 This implies that an increase in the GSC of albumin, and thus of albuminuria,
could be the result of a change in the GSC of the basal membrane, in the GSC of the endothelium, or in the GSC of the
epithelium.
Different studies with renal micropuncture have suggested that the GSC for albumin is 0.0006.17 The selectivity by size of the inert molecules that are similar in size
to albumin gives them a GSC of 0.01-0.118. It is believed
that the difference between the GSC of these molecules
and that of albumin is explained by the “charge selectivity”.
Different studies have analyzed the interaction of albumin with the glycoaminoglycans, using the 2-photon microscopy method. These studies concluded that the repulsive
electrostatic interactions and the bases of “charge selectivity” do not exist under physiologic conditions.18 This has
been confirmed by similar studies with negatively charged
polysaccharides, that again did not show “charge selectivity”.18 Another study with negatively charged dextran sulfate
showed that it is desulfated by a cellular mechanism during
its filtration and that this desulfation was responsible for
the differences in dextran sulfate sieving compared with
non-charged dextran,19 which had given erroneous results in
previous studies. However, studies continue to be carried
out whose results favor the theory of “charge selectivity”
and they assert that adequate methods were used in other
previous studies. 20,21
An important study conducted by Russo and Comper (the
2 main proponents of the theories presented herein), et al.
in 2007, established the new parameters for describing the
glomerular filtration process. The most significant finding of
that study was that the GSC for marked albumin measured
in non-proteinuric rats was 0.034, a value much higher than
those previously reported. The study by Russo and Comper
et al. posited other important explanations that will be discussed further ahead in this article.
A new theory on albumin glomerular filtration and its tubular reabsorption: disputing the charge selectivity theory The finding in the study by Russo and Comper et al. that
the GSC for albumin was 0.034 is of vital importance because it means that even though the glomerular capillary wall is
a great albumin barrier, that barrier is not albumin-impermeable.8 This corresponds to previous observations that
when the glomerular blood flow is detained, albumin can be
seen in the tubular lumen,22 given that the function of the
glomerular barrier depends on the maintenance of a normal
blood flow.22 This would not occur if the GSC for albumin
were 0.0006.8
A recently published article objectively criticized the first
studies carried out through the renal micropuncture method
and more recently through that of 2-photon microscopy.23
The first method turned out to be unreliable because it was
easy to underestimate albumin concentration. The 2-photon
microscopy method was more reliable. This study concluded
that the effect of the GSC of albumin was superior to that
established by the renal micropuncture method and was
close to the result obtained by Russo and Comper et al. with
the 2-photon microscopy method.23
Albumin reabsorption at the tubular level
The urinary exit flow for a substance basically depends on 3
factors described by the following equation:9
Urinary exit flow for albumin = filtration + secretion – reabsorption.
It is logical that if under normal conditions there is no albuminuria, the right side of the equation should add up to
zero. Stated differently, if it was previously maintained that
albumin is filtered through the glomerular capillary wall and
it is not secreted, then the value for filtration plus secretion
would be above zero. Therefore it is logical that reabsorption plays an important role in returning the equation to
zero urinary albumin.
The study conducted by Russo and Comper et al. establishes the fact that the filtered albumin must be reabsorbed
again into the bloodstream and it appears that this occurs
through a recovery that is carried out by the cells of the
proximal tubule. This was primarily determined by the fact
that in vivo and in the isolated kidney, albumin clearance
remains fractional.7 Immunogold study showed that diabetes-induced rats had less albumin reabsorption by endosomes and lysosomes in the S1 segment of the proximal
tubule, leading to albuminuria in the early stages of diabetes.24
The same study by Russo and Comper et al. presented
evidence of the existence of an albumin recovery pathway
in the proximal tubule cells. They observed cytoplasmic vesicles with large quantities of albumin that were fused to
the basolateral plasma membrane, resulting in the release
of albumin into the peritubular capillary. 7 Other studies
have demonstrated that albumin is degraded during its
renal passage, probably by cells of the tubule.25 This is correlated with the observation through 2-photon microscopy
of the presence of charged albumin structures, and that
they extend from the apical to the basolateral part of the
proximal tubule cells.
A study supporting these assertions has shown that the
filtered albumin is returned to the bloodstream through a
high capacity pathway that transports albumin. 26 This
193
pathway has been identified under physiologic conditions in
vivo and in the perfused isolated kidney. This pathway is
inhibited in the non-filtering kidney; that is to say, in the
kidney whose glomerular flow is detained. This same study
concluded that the majority of the albuminuric states are a
consequence of the poor functioning of this pathway.26
Another study using radio-iodized albumin, that would be
a disadvantage with respect to other studies, found that
there were large quantities of albumin fragments in urine,
98% of which were highly degraded and 2% were intact.27
Nevertheless, a more recent alternative in accordance with
a GSC of 0.034, suggests that the majority of the albumin is
taken by this reuptake pathway that is mediated by HK-2
cells of the proximal tubule and returned to the bloodstream, approximately 95% intact.7,18,26 The other 5% is destined for lysosomal degradation and posterior urinary
excretion, coinciding quantitatively with other studies.18,28
One of the characteristics of the nephrotic states is that
the changes in albuminuria are very big, compared with those in other molecules that are the same size as albumin.8,17
The lack of change in the filtration of these molecules
that are different from albumin suggests that the increase
in albumin excretion is not a problem of permeability of the
glomerular capillary wall, nor is it a problem of diffusion.
This albumin excretion in the nephrotic state is associated
with the partial inhibition of the reuptake and degradation
pathways, and results in a net increase in the ratio of intact
forms of excreted albumin.8,29
Conclusions
Both theories can cause confusion due to the great difference between what Haraldsson refers to in his article on glomerular filtration and the new theory being posited now.
The basic principle of “charge selectivity” was a very important concept in the field of nephrology but recent physicochemical and renal clearance studies have shown that such
a thing does not exist. And so it remains to be demonstrated
that a normal glomerulus filters nephrotic levels of albumin,
and if they are not reabsorbed, it will result in nephrotic
ranges of albumin excretion.8
Therefore it is of the utmost importance that the tubule
not be subjected to harmful processes, because in order for
albuminuria to be present, there must be damage to the
functions of the tubule that would prevent it from carrying
out the normal albumin reabsorption process.
However, further research and studies are necessary so
that the theory described in this article is universally accepted and replaces what has been a fundamental principle of
nephrology, the theory of “charge selectivity”.
Conflict of interest
The authors declare that there was no conflict of interest.
Financial disclosure
No financial support was received in relation to this article.
194
References
1. Kanwar YS, Linker A, Gist Farquhar M. Increased permeability
of the glomerular basement membrane to ferritin after removal of glycosaminoglycans (heparan sulfate) by enzyme digestion. J Cell Biol 1980;86:688-693.
2. Alpers CE, Kumar V, Abbas AK, et al. The Kidney. In: Robbins and
Cotran pathologic basis of disease. 8th Ed. Philadelphia: Saunders Elsevier; 2010. p. 905-969.
3. Comper WD, Haraldsson B, Deen WM. Resolved: normal glomeruli filter nephrotic levels of albumin. J Am Soc Nephrol
2008;19:427-432.
4. Bohrer MP, Baylis C, Humes HD, et al. Permselectivity of the
glomerular capillary wall facilitated filtration of circulating polycations. J Clin Invest 1978;61:72-78.
5. Chang RLS, Deen WM, Robertson CR, et al. Permselectivity of
the glomerular capillary wall: III restricted transport of polyanions. Kid Int 1975;8:212-218.
6. Rennke HG, Patel Y, Venkatachalam MA. Glomerular filtration of
proteins: clearance of anionic, neutral, and cationic horseradish peroxidase in the rat. Kid Int 1978;13:278-288.
7. Russo LM, Sandoval RM, McKee M, et al. The normal kidney filters nephrotic levels of albumin retrieved by proximal tubule
cells: retrieval is disrupted in nephrotic states. Kid Int
2007;71:504-513.
8. Comper WD, Russo LM. The glomerular filter: an imperfect barrier is required for perfect renal function. Curr Opin Nephrol
Hypertens 2009;18:336-342.
9. Gekle M. Renal albumin handling: a look at the dark side of the
filter. Kid Int 2007;71:479-481.
10. Patrakka J, Tryggvason K. New insights into the role of podocytes in proteinuria. Nat Rev Nephrol 2009;5:463-468.
11. Rossi M, Morita H, Sormunen R, et al. Heparan sulfate chains of
perlecan are indispensable in the lens capsule but not in the
kidney. EMBO J 2003;22:236-245.
12. Harvey SJ, Jarad G, Cunningham J, et al. Disruption of glomerular basement membrane charge through podocyte-especific
mutation of agrin does not alter glomerular permselectivity. Am
J Pathol 2007;171:139-152.
13. Goldberg S, Harvey SJ, Cunningham J, et al. Glomerular filtration is normal in the absence of both agrin and perlecan-heparan sulfate from the glomerular basement membrane. Nephrol
Dial Transplant 2009;24:2044-2051.
14. Tryggvason K, Patrakka J, Wartiovaara. Hereditary proteinuria
syndromes and mechanisms of proteinuria. N Engl J Med
2006;354:1387-1401.
B. Condado-Arenas y G. Pascual-Macfú
15. Graeme BR, Morris JK. An ultrastructural study of the mechanisms of proteinuria in aminonucleosidenephrosis. Kid Int
1975;8:219-232.
16. Deen WM. What determines glomerular capillary permeability?
J Clin Invest 2004;114:1412-1414.
17. Tojo A, Endou H. Intrarenal handling of proteins in rats using
fractional micropuncture technique. AJP Renal Physiol
1992;263:601-606.
18. Comper WD, Hilliard LM, Nikolic-Paterson DJ, et al. Diseasedependent mechanisms of albuminuria. Am J Physiol Renal Physiol 2008;295:1589-1600.
19. Comper WD, Tay M, Wells X, et al. Desulphation of dextran
sulphate during kidney ultrafiltration. Biochem J 1994;297:3134.
20. Ohlson M, Sörensson J, Haraldsson B. Glomerular size and charge selectivity in the rat as revealed by FITC-ficoll and albumin.
Am J Physiol Renal Physiol 2000;279:84-91.
21. Deen WM, Lazzara MJ, Myers BD. Structural determinants of
glomerular permeability. Am J Physiol Renal Physiol
2001;281:579-596.
22. Graeme BR, Morris JK. Distribution of endogenous albumin in
the rat glomerulus: Role of hemodynamic factors in glomerular
barrier function. Kid Int 1976;9:36-45.
23. Tanner GA. Glomerular sieving coefficient of serum albumin in
the rat: a two-photon microscopy study. Am J Physiol Renal
Physiol 2009;296:F1258-F1265.
24. Tojo A, Onozato M, Ha H, et al. Reduced albumin reabsorption
in the proximal tubule of early-stage diabetic rats. Histochem
Cell Biol 2001;116:269-276.
25. Osicka TM, Pratt LM, Comper WD. Glomerular capillary wall
permeability to albumin and horseradish peroxidase. APSN
1996;2:199-212.
26. Eppel GA, Osicka TM, Pratt LM, et al. The return of glomerular
filtered albumin to the rat renal vein. Kid Int 1999;55:18611870.
27. Gudehithlu KP, Pegoraro AA, Dunea G, et al. Degradation of albumin by the renal proximal tubule cells and the subsequent
fate of its fragments. Kid Int 2004;65:2113-2122.
28. Park CH, Maack T. Albumin absorption and catabolism by isolated perfused proximal convoluted tubules of the rabbit. J Clin
Invest 1984;73:767-777.
29. Greive KA, Nikolic-Paterson DJ, Guimaraes MAM, et al. Glomerular permselectivity factors are not responsible for the increase in fractional clearance of albumin in rat glomerulonephritis.
Am J Pathol 2001;159:1159-1170.
Rev Mex Urol 2013;73(4):195-199
ÓRGANO OFICIAL DE DIFUSIÓN DE LA SOCIEDAD MEXICANA DE UROLOGÍA
www.elsevier.es/uromx
Clinical case
Urinary incontinence management with artificial urinary sphincter
following radical prostatectomy
G. Fernández-Noyolaa,*, S. Ahumada-Tamayoa, J. Á. Martíneza, A. J. Camacho-Castro, F.
García-Salcidoa, E. Muñoz-Ibarraa, G. Garza-Sainza, E. Mayorga-Gómeza, V. OsornioSáncheza, V. Cornejo-Dávilaa, A. Palmeros-Rodrígueza, I. Uberetagoyena-Tello de
Menesesa, M. Cantellano-Orozcoa, G. Morales-Montora, C. Martínez-Arroyoa, R. W. SantaCruzb and C. Pacheco-Gahblera
a
Department of Urology, Hospital General “Dr. Manuel Gea González”, Mexico City, Mexico
b
Kendall Regional Medical Center, Miami, FL, USA
KEYWORDS
Urinary incontinence;
Artificial sphincter;
Radical
prostatectomy;
Radiotherapy; Mexico.
Abstract The aim of this article is to present the technical aspects of placing the AMS-800™
artificial urinary sphincter for managing total postoperative urinary incontinence.
A 73-year-old man with a past medical history of prostate cancer (CaP) underwent radical retropubic prostatectomy in the year 2000. The histopathologic report was stage pT4 adenocarcinoma of the prostate with a Gleason score of 4+5=9. He was managed with maximum androgen
blockade and adjuvant radiotherapy, receiving a total of 112 Gy. After the radiotherapy, he
presented with total urinary incontinence that required the use of 6 to 8 diapers daily. The patient underwent the placement of an AMS-800™ artificial urinary sphincter with no complications, obtaining total urinary continence and an important improvement in his quality of life.
The management of urinary incontinence following radical prostatectomy with the AMS-800™
artificial urinary sphincter has been shown to be effective and is regarded as the gold standard
by many urologists. The majority of patients using this device achieve urinary continence and
their quality of life is significantly improved.
* Corresponding author at: Calzada de Tlalpan N° 4800, Colonia Sección XVI, Delegación Tlalpan, C.P. 14080, México D.F., México. Telephone: 3624 5676, 4000 3044. Email: gerardofernandeznoyola@gmail.com (G. Fernández-Noyola).
0185-4542 - see front matter © 2013. Revista Mexicana de Urología. Publicado por Elsevier México. Todos los derechos reservados.
196
Palabras clave
Incontinencia
urinaria; Esfínter
artificial;
Prostatectomía
radical; Radioterapia,
México.
G. Fernández-Noyola et al
Esfínter urinario artificial para el manejo de la incontinencia urinaria posterior a
prostatectomía radical
Resumen Se expondrán los aspectos técnicos de la colocación del esfínter artificial AMS-800TM,
para el manejo de la incontinencia urinaria total postoperatoria.
Se presenta hombre de 73 años de edad, con antecedente de cáncer de próstata (CaP), postoperado de prostatectomía radical retropúbica en el año 2000, con reporte histopatológico de
adenocarcinoma de próstata Gleason 4+5=9 pT4, por lo que se manejó con supresión androgénica máxima y radioterapia adyuvante, recibiendo en total 112 Gy. Posterior a la radioterapia
inició con incontinencia urinaria total, que ameritó el uso de 6 a 8 pañales diarios. Se le colocó
un esfínter urinario artificial AMS-800TM sin complicaciones, tras lo cual el paciente refiere una
continencia urinaria total y una mejora importante en la calidad de vida.
El manejo de la incontinencia urinaria posterior a prostatectomía radical con el esfínter artificial AMS-800TM ha demostrado ser efectivo, siendo considerado como el “gold standard” por
muchos urólogos. Usando este dispositivo, la mayoría de los pacientes se encuentran sin pérdida
urinaria, mejorando significativamente su calidad de vida.
Introduction
There are postoperative complications from the management of prostate cancer (CaP) with radical prostatectomy
that can significantly deteriorate patient quality of life. One
of these is urinary incontinence and it is a common symptom
in patients that have been recently operated on. However,
the majority of patients recover urinary continence, so
much so, that one year after surgery this symptom persists
in only 7% of the patients. In patients that receive adjuvant
radiotherapy, the risk for urinary incontinence increases
from 6% to 10%, depending on the dose and the modality
employed.1-3
According to symptom frequency and the quality of life
deterioration it causes, postoperative urinary incontinence
can be classified as mild, moderate, or severe. The latter 2
significantly benefit from surgical treatment. The majority
of authors agree that a postoperative follow-up period of at
least one year is required before the final grade of incontinence can be determined.4-6
The idea of an artificial urinary sphincter was developed
in the mid-twentieth century. In 1947, Foley designed the
first artificial sphincter; it was a cuff that was inflated and
deflated around the penis that was later developed as a surgical technique to be implanted around the urethra. The
new era of the artificial urinary sphincters arrived in 1972
with Scott, Bradley, and Timm, with the elaboration of the
AS-721™. This device required a laborious surgical act and
had a high failure rate.
The AMS-800™ artificial urinary sphincter has been used to
treat moderate to severe urinary incontinence for 30 years.
It has had excellent results with rates of 88% to 95% success
at 5 years or more. The complication rates vary depending
on the case series, and the most frequent complication is
malfunction of the sphincter (11% to 23%), followed by system extrusion (8% to 20%), urethral erosion (8% to 10%), and
infection (4% to 6%).7-9
In relation to the results of the artificial sphincter in patients that have received radiation therapy, a high incidence
of urethral atrophy, erosion, and infection that has required
surgical re-intervention has been reported, in comparison with
those patients that have not undergone radiotherapy (41% vs.
11%). However, long-term continence and patient satisfaction
do not appear to be affected by this modality.10-12
The persistence of stress incontinence can occur in more
than 15% of the patients after artificial sphincter placement. This has been corrected by situating a more proximal
cuff, or even by placing a second cuff, if system malfunction
has been ruled out.12
Case presentation
A 73-year-old man had a past medical history of CaP and
underwent radical retropubic prostatectomy in 2000. The
histopathologic report was prostate adenocarcinoma with a
Gleason score of 4+5=9 and stage pT4 for which he was given maximum androgen blockade and adjuvant radiotherapy, receiving a total of 112 Gy. The patient presented with
total urinary incontinence after the radiotherapy, requiring
the use of 6 to 8 diapers daily. During his progression, he
received multiple treatments with anticholinergics and serotonin reuptake inhibitors with no improvement. In the
evaluation protocol, cystourethrography revealed a bladder
capacity of 450 mL, as well as permeability of the entire
urethra, total bladder emptying, and absence of the shadow
of the urinary sphincter (fig. 1). Cystoscopy corroborated
the lack of a functional sphincteric mechanism. The placement of an artificial urinary sphincter was proposed and the
procedure was carried out with no complications. The patient was released on the second postoperative day. Eight
weeks after surgery the sphincteric mechanism was activated and the patient achieved total urinary continence and
an important improvement in his quality of life.
Surgical technique
After the placement of a bladder catheter and by the perineal approach, the bulbous urethra was located and dissected
Esfínter urinario artificial para el manejo de la incontinencia urinaria posterior a prostatectomía radical
197
Figure 1 Cystourethrogram showing the absence of the shadow
of the external urethral sphincter.
Figure 2 Longitudinal midline incision, dissecting up to the
urethra.
Figure 3 Complete dissection of the bulbous urethra.
Figure 4 Placement of the sphincter at the chosen site of the
urethra, after having measured its diameter.
(fig. 2), sparing the bulbocavernosus muscle as much as possible. The urethra was dissected at the level where the occlusive cuff was to be placed, until the dissector could pass
the measuring tape through with ample space (fig. 3).
Once the measuring tape was in place, the urethral circumference was measured, followed by the length of the
cuff (fig. 4). The pressure-regulating balloon was then put in
the prevesical space so that it barely lay over the muscle
and the fascia through the suprapubic incision. Once the
balloon was in position, it was filled with 22-23 cc of injectable solution. The connecting tube of this element was
subcutaneously moved along until it exited at the level of
the suprapubic incision, using the tubing passer that is one
of the system components, and the 3 elements were connected (fig. 5). The control pump was placed in the scrotal
sac in a subdartos pouch (fig. 6). The wounds were closed
and the functioning of the mechanism and the urethral lumen occlusion were corroborated using a flexible cystoscope (fig. 7).
The system was maintained inactive for 8 weeks after
which it was then activated. This has reduced the infection
rate and system extrusion.
198
A
G. Fernández-Noyola et al
B
Figure 5 A and B Placement of the sphincter system components, first through suprapubic incision and then with the subcutaneous passage of the connecting tubes.
A
B
Figure 6 The sphincter control pump is placed in the scrotum
through a subdartos pouch.
Conclusions
Urinary incontinence management after radical prostatectomy with the AMS-800™ artificial urinary sphincter has been
shown to be effective and is regarded as the gold standard
by many urologists. Its placement is a simple procedure with
low morbidity in the hands of the experienced surgeon and
it provides the patient with satisfactory functional and
esthetic results that significantly improve quality of life.
Figure 7 A and B Cystoscopy identifies the open urethra without
the effect of the sphincter, and then with the functioning
sphincter.
Esfínter urinario artificial para el manejo de la incontinencia urinaria posterior a prostatectomía radical
Conflict of interest
The authors declare that there is no conflict of interest.
Financial disclosure
No financial support was received in relation to this article.
References
1. Fowler FJ, Barry MJ, Lu-Yao G, et al. Patient-reported complications and follow-up treatment after radical prostatectomy.
The national Medicare experience: 1988-1990. Urology
1993;42(6):622-629.
2. Herr H. Quality of life of incontinent men after radical prostatectomy. J Urol 1994;151(3):652-654.
3. McCammon KA, Klom P, Main B, et al. Comparative quality of
life analysis after radical prostatectomy or external beam radiation for localized prostate cancer. Urology 1999;54(3):509516.
4. Jonler M, Messing EM, Rhodes PR, et al. Sequelae of radical
prostatectomy. Br J Urol 1994;74(3):352-358.
199
5. Donnellan SM, Duncan HJ, MacGregor RJ, et al. Prospective assessment of incontinence after radical retropubic prostatectomy: Objective and subjective analysis. Urology
1997;49(2):225-230.
6. Scott FB, Bradley WE, Timm GW. Treatment of urinary incontinence by implantable prosthetic sphincter. Urology
1973;1(3):252-259.
7. Tomaschi W, Suster G, Holtl W. Bladder neck strictures after
radical retropubic prostatectomy: Still an unsolved problem. Br
J Urol 1998;81(6):823-826.
8. Chao R, Mayo ME. Incontinence after radical prostatectomy:
Detrusor or sphincteric causes. J Urol 1995;154(1):16-18.
9. Meulen PH, Zambon V, Kessels AG, et al. Quality of life, functional outcome and durability of the AMS 800 artificial urinary
sphincter in patients with intrinsic sphincter deficiency. Urol Int
2003;71(1):55-60.
10. Wilson SK, Delk JR 2nd, Henry GD, et al. New surgical technique for sphincter urinary control system using upper transverse
scrotal incision. J Urol 2003;169(1):261-264.
11. Litwiller SE, Kim KB, Fone PD, et al. Post-prostatectomy incontinence and the artificial urinary sphincter: a long-term study
of patient satisfaction and criteria for success. J Urol
1996;156(6):1975-1980.
12. Gomha MA, Boone TB. Artificial urinary sphincter for post-prostatectomy incontinence in men who had prior radiotherapy: a
risk and outcome analysis. J Urol 2002;167(2 Pt 1):591-596.
Rev Mex Urol 2013;73(4):200-203
ÓRGANO OFICIAL DE DIFUSIÓN DE LA SOCIEDAD MEXICANA DE UROLOGÍA
www.elsevier.es/uromx
Clinical case
Crossed renal ectopia with fusion and multiple renal calculi managed
with nephrectomy through the anterior paramedian approach
F. R. Zamora-Varelaa, V. M. González-Tejedalb and A. González-Ambrizc
a
Urology Speciality Residency, Hospital Regional “Dr. Valentín Gómez Farías”, ISSSTE, Guadalajara, Jal., Mexico
b
Transplantation Administration, Hospital Civil “Dr. Miguel Silva”, Morelia, Mich., Mexico
c
Department of Urology, Hospital Civil “Dr. Miguel Silva”, Morelia, Mich., Mexico
KEYWORDS
Crossed renal ectopia;
Renal fusion; Renal
lithiasis; Mexico.
Abstract Congenital renal anomalies are not common. Crossed renal ectopia (CRE) is the second most frequent abnormality after horseshoe kidney. Its diagnosis is usually incidental in the
third or fourth decade of life or when the patient presents with urinary tract infections, hematuria, lithiasis, or renal-ureteral colic.
The aim of this article was to present the case of a patient with the classic symptoms of renalureteral colic who was diagnosed with CRE with an inferiorly fused, non-functioning kidney secondary to multiple renal calculi, and to describe the management with nephrectomy through
the extraperitoneal anterior paramedian approach.
A 39-year-old man presented with a classic case of renal-ureteral colic and during his evaluation
multiple renal calculi outside of the normal renal topography were found. An abdominal computed tomography (CT) scan was done and CRE was diagnosed. The non-functioning inferiorly
fused kidney was revealed in the contrast-enhanced and three-dimensionally reconstructed CT,
and management with nephrectomy was decided upon. We believe that the extraperitoneal anterior
paramedian approach provides good access for this type of congenital anomaly, given the anterior location of the renal unit.
* Corresponding author at: Paseo de las brisas N° 4128-302, Colonia Lomas Altas, C.P. 45128. Zapopan, Jal., México. Telephone: (33) 3749
3944. Email:dr.zamora@hotmail.com (F. R. Zamora-Varela).
0185-4542 - see front matter © 2013. Revista Mexicana de Urología. Publicado por Elsevier México. Todos los derechos reservados.
Crossed renal ectopia with fusion and multiple renal calculi managed with nephrectomy through the anterior paramedian
approach201
Palabras clave
Ectopia renal cruzada;
Fusión renal; Litiasis
renal; México.
Ectopia renal cruzada con fusión y litiasis múltiple, nefrectomía con abordaje
paramedio anterior
Resumen Las anomalías renales congénitas son poco frecuentes. La ectopia renal cruzada
(ERC) es la segunda anomalía más frecuente tras el riñón en herradura. Su diagnóstico suele ser
incidental hacia la tercera o cuarta década de la vida, o al cursar con infecciones de vías urinarias, hematuria, litiasis o cólico reno-ureteral.
El objetivo es presentar el caso de un paciente que cursó con la sintomatología clásica de un
cólico reno-ureteral, diagnosticándolo con ERC con fusión inferior y exclusión del riñón fusionado secundaria a litiasis múltiple, así como exponer el manejo mediante nefrectomía por abordaje paramedio anterior extraperitoneal.
Se presenta paciente masculino de 39 años de edad, con cuadro clínico clásico de cólico renoureteral, durante su estudio se encontró litiasis múltiple fuera de la topografía normal renal,
por lo que se realizó una tomografía computada (TC) abdominal mediante la cual se diagnosticó
la ERC, se reconstruyó tridimensionalmente con contraste y se encontró la exclusión del riñón
fusionado inferior, por lo cual se manejó con nefrectomía. Consideramos que el abordaje paramedio anterior extraperitoneal es un buen acceso para este tipo de anomalía congénita, debido
a la situación anterior de la unidad renal.
Introduction
Crossed renal ectopia (CRE) with fusion represents 85% to
90% of the published cases and the most frequent variety is
the unilateral fused kidney with inferior ectopia. CRE is defined as the position in the retroperitoneum different from
the normal one, in which the kidney crosses the midline and
is situated contralaterally to the side where its ureter normally inserts into the bladder. Diagnosis is incidental in the majority of cases and symptomatology is vague, simulating
renal-ureteral colic in some cases. It is associated with urinary tract obstruction due to bridles or abnormal vascular
supply to the ectopic kidney. It is also associated with other
abnormalities such as vesicoureteral reflux, ureterocele,
and anorectal malformation. Diagnosis is made through excretory urogram and contrast-enhanced three-dimensional
computerized tomography (CT) and treatment is directed at
the complications, more than at the anatomical anomaly,
itself.
Case presentation
A 39-year-old man had illness onset 4 years earlier, with the
clinical presentation of right renal-ureteral colic that was
never managed by a physician. The patient self-medicated
with anti-inflammatory agents for pain control. However, 7
months ago he presented with similar but more intense
symptoms, to which were added fever, hematuria, and irritative urinary symptoms. He sought private medical attention and the physician ordered a simple abdominal x-ray and
referred the patient to our hospital for management.
He was first evaluated at the emergency room and was
found to be in good general health. A complete blood count,
blood chemistry, serum electrolytes, and urinalysis were ordered. The blood tests reported leukocytosis of 11,800, hemoglobin 12.2 g/dl, platelets 352,000, glucose 98,
creatinine 0.8, and urea 17. The urinalysis showed a pH of
5.5, leukocyturia, erythrocyturia, and bacteriuria. The abdominal x-ray (fig. 1) revealed radiopaque images suggestive of
stones measuring approximately 2 cm x 1.5 cm in the right
lower quadrant above the iliac crest. An abdominal CT scan
showed the absence of the left kidney and an enlarged right
kidney with calcifications under the lower pole (fig. 2A); other
views displayed an image that could correspond to an ectopic
left kidney with multiple stones in its interior that was fused
with the right kidney (figs. 2B and 2C). There was inadequate
contrast material uptake by the fused ectopic kidney shown in
the urotomographic reconstruction (fig. 3A).
The patient was evaluated together with the transplantation service. An angiotomography scan (fig. 3B) revealed a
single artery and vein and inadequate vascular supply to the
ectopic kidney. Nephrectomy through the extraperitoneal
paramedian approach was performed on the ectopic kidney.
It was carried out with no complications and the total surgery duration was one hour 10 minutes. Blood loss was 500
cc. Nine stones measuring 2.5 cm x 1.5 cm were extracted
from the surgical specimen. The patient was released from
the hospital after 72 hours.
Discussion
Lithiasis in kidneys that have some type of anatomical alteration is a particularly great challenge for the urologist, due
to the fact that the abnormal anatomy prevents the use of
the same disintegration or extraction access routes that are
utilized in normal kidney units.1
Embryologically, the definitive kidney originates at the
fifth week of intrauterine life and its development depends
on the chemical interaction of the ureteric bud near its joining with the continuous mass of non-differentiated mesenchymal cells called the metanephric blastema. This union
ascends from its pelvic position toward the ipsilateral renal
fossa, turning inwards on its longitudinal axis until the definitive renal-ureteral unit is formed during the following 3
202
F. R. Zamora-Varela et al
Figure 1 X-ray showing the multiple renal calculi.
weeks. Pelvic kidney, ectopic kidney, or renal malformation are
explained by developmental defects in the migration stage.2,3
Normal fetal and embryonic development of the kidney
can be altered by various factors that, in turn, are associated with other urinary tract malformations. A total of 35% to
40% of the congenital abnormalities are located in the genitourinary tract and 10% of all living beings are born with
some type of urinary tract anomaly.2
A
B
The ectopic kidney is defined as one that is congenitally in
a position different from its usual location in the lumbar
region due to a flaw in the process of its ascent, and that
crosses the midline and becomes situated on the opposite
side from where it normally connects to the bladder.2,4 CRE
is the second most frequent anomaly with fusion after horseshoe kidney. The first case was published by Pamarolus in
1654 and in 1957 it was classified by McDonald and McClellan.3,5 Their classification is the one currently in use: crossed ectopia with fusion, which makes up 85% of the cases;
inferior crossed ectopia without fusion; solitary crossed
ectopia; and bilateral crossed ectopia. The fused varieties
are divided into: unilateral fused kidney with inferior ectopia; sigmoid or S-shaped kidney; L-shaped kidney; lump kidney; disc kidney; and unilateral fused kidney with superior
ectopia.5-8 Various theories have been proposed, but the
precise mechanisms by which CRE occurs are not known.5
Among them are the mechanical theory, the ureteral theory,
the theory of biochemical stimuli-induced migration, the
teratogenic theory, and the theory of the abnormal rotation
of the caudal end of the developing fetus.3,5
CRE with fusion is a rare malformation with an incidence
of 1:7,500; 6 it is more frequent in men with a ratio of
1.4:1,7 and the left-to-right ratio is 3:1.3
Its clinical presentation is asymptomatic in the majority of
cases and it generally develops in the third or fourth decade
of life.9 Because irrigation is different from the norm, kinking or
compression of the urinary tract can cause ureteropelvic
junction stricture, usually of the ectopic kidney, resulting in
hydronephrosis with or without lithiasis in 9% of the cases,1-3,6
hematuria, non-specific abdominal pain, recurrent urinary infections, and renal-ureteral pain, among others.3
Its diagnosis is based on intravenous urography; contrastenhanced 3-dimensional CT is usually the best imaging technique for detailing the situation of the ectopic kidney.2,3,5,7,8
Treatment should be opportune and directed at the complications rather than at the congenital anomaly itself, and
includes antibiotic prophylaxis, extracorporeal lithotripsy,
C
Figure 2 Computerized tomography scan. A) Left renal agenesis; calcifications are starting to be seen outside the right kidney. B)
Image corresponding to the left ectopic kidney with multiple stones. C) Left kidney fusion.
Crossed renal ectopia with fusion and multiple renal calculi managed with nephrectomy through the anterior paramedian
approach203
A
B
Figure 3 A) Urotomography scan showing the left renal ectopia and the multiple stones in the fused
kidney with no contrast medium uptake. B) Angiotomography scan showing inadequate vascularization of the crossed ectopic kidney.
ureterolithotripsy, percutaneous nephrolithotomy, pyelolithotomy, pyeloplasty, and in cases of non-functioning kidney, nephrectomy.1,7
Conclusions
Our patient presented with the classic symptoms of renalureteral colic and during his evaluation multiple renal calculi
outside the normal kidney topography were found. Abdominal CT scan was done and CRE was diagnosed. Contrast-enhanced 3-dimensional reconstruction revealed a fused
non-functioning kidney with inferior ectopia for which nephrectomy was performed. In our opinion, the extraperitoneal anterior paramedian approach is a good access route
for this type of congenital anomaly, given the anterior situation of the renal unit.
Conflict of interest
The authors declare that there is no conflict of interest.
Financial disclosure
No financial support was received in relation to this article.
References
1. Gupta M, Lee MW. Treatment of stones with complex or Anomalous Renal Anatomy. Urol Clin North Am 2007;34(3):431-441.
2. Montell Hernández OA, Vidal Tallet A. Pielonefritis en ectopia
renal cruzada y fusionada. Presentación de caso. Revista médica electrónica 2010;32(4).
3. Sousa Escandón MA, González Rodríguez A, García Figueiras R,
et al. Ectopia renal cruzada: posibilidades radiológicas de la
TAC helicoidal. Actas Urol Esp 2002;26(5):313-319.
4. Lizado BJR, Godoy MJG. Ectopia renal simple. Informe de un
caso y revisión de la literatura. Rev Med Hondur 2011;79(1):1921.
5. Aguilera Tubet C, Del Valle Schaan JI, Martín García B, et al.
Tumor renal en ectopia renal cruzada con fusión. Actas Urol
Esp 2005;29(10):993-996.
6. Durán Álvarez S, Guerra Rodríguez M, Díaz Zayas N, et al. Ectopia renal cruzada con fusión, reflujo vesicoureteral y riñón ectópico afuncional: informe de un caso. Rev Cub Pediatr
2010;8(1).
7. Aguilar-Cota JJ, Alvarado-García R, Ramón-Garrido J. Ectopia
renal cruzada no fusionada con malformación anorrectal y ureterocele en un niño. Acta Pediatr Mex 2009;30(5)5:254-257.
8. Aysel T, Tülay O, Turhan C. Multidetector CT urography of renal
fusion anomalies. Diagn Interv Radiol 2009;15(2):127-134.
9. Ghosh BC, DeSantis M, Kleyner Y, et al. Crossed Fused Renal
Ectopia with Calculi. J Am Coll Surg 2008;206(4):753.
Rev Mex Urol 2013;73(4):204-207
ÓRGANO OFICIAL DE DIFUSIÓN DE LA SOCIEDAD MEXICANA DE UROLOGÍA
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Clinical case
Application of dorsal buccal mucosa graft for penile urethral
stricture treatment: technical aspects
G. Fernández-Noyolaa,*, S. Ahumada-Tamayoa, J. Á. Martíneza, A. J. Camacho-Castroa, F.
García-Salcidoa, E. Muñoz-Ibarraa, G. Garza-Sainza, E. Mayorga-Gómeza, V. OsornioSáncheza, V. Cornejo-Dávilaa, A. Palmeros-Rodrígueza, I. Uberetagoyena-Tello de
Menesesa, M. Cantellano-Orozcoa, G. Morales-Montora, C. Martínez-Arroyoa, E. A.
Ramírez-Pérezb, J. C. López-Silvestreb and C. Pacheco-Gahblera
a
Department of Urology, Hospital General “Dr. Manuel Gea González”, Mexico City, Mexico
b
Centro de Cirugía Reconstructiva Uretral, Mexico City, Mexico
KEYWORDS
Urethral stricture; Urethroplasty; Buccal
mucosa; Dorsal graft;
Mexico.
Abstract The aim of this article was to present the technical aspects of dorsal urethroplasty
with buccal mucosa graft for penile urethral stricture treatment.
A 46-year-old man had a past medical history of sexually transmitted infections from 14 years
prior that were undocumented, but nevertheless resolved, with parenteral antibiotics. The patient had lower urinary tract symptomatology that began 10 years ago, with documented stricture of the penile urethra, managed through internal urethrotomy. Progression was satisfactory,
but 2 years ago he presented once again with lower urinary tract symptoms and penile urethral
stricture, for which a second internal urethrotomy was performed. One year later the patient
was seen at our institution for symptom persistence. Cystourethrography revealed a 3 cm long
stricture of the penile urethra. Urethroplasty was carried out with a dorsal buccal mucosa free
graft with no complications and the patient was released on the second postoperative day. The
transurethral catheter was removed 4 weeks later, after which the patient presented with adequate micturition and symptom remission.
Dorsal urethroplasty with buccal mucosa free graft is an effective technique in long and complex stricture of the urethra and it should be regarded as the technique of choice for this type
of urethral stricture.
* Corresponding author at: Calzada de Tlalpan N° 4800, Colonia Sección XVI, Delegación Tlalpan, C.P. 14080, México D.F., México. Telephones: 4000 3044, 3624 5676. Email: gerardofernandeznoyola@gmail.com (G. Fernández-Noyola).
0185-4542 - see front matter © 2013. Revista Mexicana de Urología. Publicado por Elsevier México. Todos los derechos reservados.
Application of dorsal buccal mucosa graft for penile urethral stricture treatment: technical aspects Palabras clave
Estenosis uretra;
Uretroplastía; Mucosa
oral; Injerto dorsal;
México.
205
Aplicación de injerto dorsal de mucosa oral para el tratamiento de la estenosis de
uretra peniana. Aspectos técnicos
Resumen Se expondrán los aspectos técnicos de la uretroplastía dorsal con injerto de mucosa
oral, para el tratamiento de la estenosis de uretra peniana.
Se presenta hombre de 46 años de edad, con antecedente de infecciones de transmisión sexual
hace 14 años, la cual no se documentó, sin embargo resolvió con antibióticos parenterales. Inició hace 10 años con sintomatología del tracto urinario bajo, documentándose estenosis de
uretra peniana manejada en medio externo con uretrotomía interna, evolucionando satisfactoriamente; sin embargo, hace 2 años presenta nuevamente sintomatología del tracto urinario
bajo, evidenciándose nuevamente estenosis de uretra peniana, por lo cual se le realiza una segunda uretrotomía interna. Un año después acude a nuestra Institución por persistencia de la
sintomatología, se realizó cistouretrografía observando una estenosis de la uretra peniana de 3
cm de longitud. Se realizó plastía de uretra con injerto dorsal libre de mucosa oral sin complicaciones, egresándose al segundo día de postoperatorio. Se retiró la sonda transuretral a las 4
semanas, tras las cuales presentó una adecuada micción y remision de la sintomatología.
La uretroplastía dorsal con injerto libre de mucosa oral es una técnica efectiva en estenosis de
uretra larga y compleja, que por los resultados obtenidos se le debe considerar como la técnica
de primera elección en este tipo de estenosis uretrales.
Introduction
Management of complex stricture of the urethra has significantly changed in the last few years. Today, graft techniques are regarded as the first treatment of choice, given
that there is a high 70% recurrence rate with internal
urethrotomy. The good results obtained with dorsal urethroplasty with buccal mucosa free graft for the treatment of
long and complex strictures at any level of the urethra have
led to its being considered the gold standard of graft techniques. 1,3 The use of buccal mucosa for the treatment of
urethral stricture was first described by Kasaby in 1993. In
1995 Guido Barbagli reported the technique of dorsal
urethroplasty with mucosa free graft and since then longterm results have shown success rates of 92% to 97%. Then
in 1996 Morey and McAninch described the technique with
ventral buccal mucosa free graft for 2 cm to 5 cm bulbar
strictures.4,5 Buccal mucosa has important advantages over
skin as a graft material, that include its being available in
all patients, it is a humid epithelium, it can be easily obtained,
it lends itself to surgical manipulation, it can be thinned
without damaging its vascularity, it has immunologic benefits making it less prone to infection, and it is more resistant
to stricture recurrence. In addition, it has a submucosa with
a dense capillary network that facilitates the prompt absorption of nutrients from the tissue bed, enabling early
neovascularization. The dorsal approach is considered to be
more favorable than the ventral or lateral approaches because at that level the corpus spongiosum is not as thick and
the attachment of the buccal mucosa to the corpora cavernosa reduces graft contraction, making neovascularization
easier and avoiding the risk for sacculation, fistulas, and
stricture recurrence.6-9 Moreover, because the ventral approach lacks a rigid and stable support, the graft runs the
risk of becoming sacculated, giving rise to post-micturition
dribble, infections, and ejaculatory disorders.10
In regard to the site of choice for extracting the buccal
mucosa to be grafted, it canbe obtained either in the region of
the cheek anterior to Stensen’s duct or in the region
of the inferior lip, depending on the urethral length required
for the reconstruction. However, the majority of authors opt
for the cheek mucosa because it has a better consistency
and thus is easier to manipulate than the inferior lip.11,12
Case presentation
A 46-year-old man had an undocumented past medical history of sexually transmitted infections 14 years prior that
were resolved with parenteral antibiotics. Ten years ago he
began to present with lower urinary tract symptoms that
resulted in penile urethra stricture. He was managed with
internal urethrotomy and progressed satisfactorily. However, 2 years ago the patient again presented with lower urinary tract symptoms and a recurrent stricture of the penile
urethra for which he underwent a second internal urethrotomy. One year later he sought medical attention at our institution for symptom persistence. The study protocol was
initiated and cystourethrography identified a stricture of
the penile urethra (fig. 1). Urethroplasty with a dorsal buccal mucosa free graft was performed with no complications
and the patient was released on the second postoperative
day. The transurethral catheter was removed 4 weeks later
and the patient then presented with adequate micturition
and symptom remission.
Surgical technique
We began the procedure with urethrocystoscopy with placement of the hydrophilic guidewire to the bladder. Then 15
cc of methylene blue were instilled through the urethra and a
14Fr Nelaton catheter was placed at the stricture site and
the skin was marked. A 5 cm midline perineal incision was
206
G. Fernández-Noyola et al
Figure 1 Retrograde cystourethrogram
that clearly identifies the narrowing of the
anterior or penile urethra.
Figure 2 Longitudinal midline incision
in the perineum.
Figure 3 Complete dissection of the anterior and posterior urethra up to the
narrowing site.
Figure 4 The taking of the buccal mucosa
graft, with care not to injure any glands.
Figure 5 Cleaning the graft and making
the cut along its length and diameter.
Figure 6 Graft placement and suturing
on the strictured urethra.
made and dissection by planes was done avoiding excessive
manipulation of the urethra (fig. 2). The body of the penis
was then inverted to expose it at the perineal incision (fig.
3). Mobilization of the urethra at the level of the left lateral
surface was begun so its dorsal portion could be exposed,
taking care to maintain a 45° angle between the corpus cavernosum and the mobilized urethra. A dorsolateral incision
of the urethra was made along the entire stricture and simultaneously a 3 cm long buccal mucosa graft was taken
from the right cheek, making sure not to injure the parotid
duct (fig. 4). After that, the buccal mucosa was placed at
the dorsolateral penile level, attaching it to the corpus cavernosum with Vicryl™ 5-0, joining the lateral edge of the
buccal mucosa with the lateral end of the urethra. A 14Fr
silicon Foley transurethral catheter was placed and the
other lateral end of the urethra was then completely closed
with Vicryl™ 5-0 (figs. 5 and 6).
Conclusions
Dorsal urethroplasty with buccal mucosa free graft is an
effective technique for treating complex stricture of the
penile urethra associated with moderate spongiofibrosis.
In experienced hands, it is a relatively simple procedure
with little morbidity. Given the results obtained with this
approach in large case series, it should be regarded as
the first-choice technique for this type of urethral stricture.
Application of dorsal buccal mucosa graft for penile urethral stricture treatment: technical aspects Conflict of interest
The authors declare that there is no conflict of interest.
Financial disclosure
No financial support was received in relation to this article.
References
1. Berger B, Sykes Z, Freedman M. Patch graft urethroplasty for
urethral stricture disease. J Urol 1976;115(6):681-684.
2. El-Kasaby AW, Fath-Alla M, Noweir AM, et al. The use of buccal
mucosa patch in the management of anterior urethral strictures. J Urol 1993;149(2):276-278.
3. Grady JD, McCammon K, Schlossberg SM. Buccal mucosa graft
for penile urethral strictures. J Urol 1999;161:375A.
4. Gupta NP, Ansari MA, Dogra PN, et al. Dorsal buccal graft
urethroplasty by a ventral sagittal urethrotomy and minimalaccess perineal approach for anterior urethral stricture. BJU
Int 2004;93(9):1287-1290.
207
5. Wessells H, McAninch JW. Use of free grafts in urethral stricture
reconstruction. J Urol 1996;155(6):1912-1915.
6. Wessells H. Ventral onlay graft techniques for urethroplasty.
Urol Clin North Am 2002;29(2):381-387.
7. Barbagli G, Palminteri E, Guazzoni G, et al. Bulbar Urethroplasty using buccal mucosa grafts placed on the ventral, dorsal or
lateral surface of the urethra: are results affected by the surgical technique? J Urol 2005;174(3):955-957.
8. Elliot SP, Metro MJ, McAninch JW. Long-term followup of the
ventrally placed buccal mucosa onlay graft in bulbar urethral
reconstruction. J Urol 2003;169(5):1754-1757.
9. Barbagli G, Guazzoni G, Palminteri E, et al. Anastomotic fibrous
ring as cause of stricture recurrence after bulbar onlay graft
urethroplasty. J Urol 2006;176(2):614-619.
10. Eppley BL, Keating M, Rink R. A buccal mucosal harvesting technique for urethral reconstruction. J Urol 1997;157(4):1268-1270.
11. Tolstunov L, Pogrel MA, McAninch JW. Intraoral morbidity following free buccal mucosal graft harvesting for urethroplasty.
Oral Surg Oral Med Oral Pathol Oral Radiol Endod
1997;84(5):480-482.
12. Ramirez P, López S, Pérez E, et al. Uretroplastia de mínima invasion con mucosa oral para el manejo de estenosis complejas de
uretra anterior en un solo tiempo. Rev Mex Urol 2012;72(2):63-71.
Rev Mex Urol 2013;73(4):208-211
ÓRGANO OFICIAL DE DIFUSIÓN DE LA SOCIEDAD MEXICANA DE UROLOGÍA
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Clinical case
Management of post-radical prostatectomy male urinary
incontinence with a transobturator sling (AdVance®)
S. Ahumada-Tamayo*, R. Santa-Cruz, J. Á. Martínez, G. Fernández Noyola, F. GarcíaSalcido, E. Muñoz-Ibarra, A. J. Camacho-Castro, E. Mayorga-Gómez, V. Osornio-Sánchez,
G. Garza-Saenz, V. Cornejo-Dávila, A. Palmeros-Rodríguez, I. Uberetagoyena-Tello de
Meneses, C. Martínez-Arroyo, M. Cantellano-Orozco, J. G. Morales-Montor and C.
Pacheco-Gahbler
Department of Urology, Hospital General “Dr. Manuel Gea González”, Mexico City, Mexico
KEYWORDS
Stress urinary
incontinence;
Post-radical
prostatectomy;
Transobturator sling;
Mexico.
Abstract Urinary incontinence (UI) is a disorder that in general affects 1 to 39% of men. It has
various etiologic causes and the main one is UI secondary to radical prostatectomy (RP). Stress
UI (SUI) secondary to RP continues to be a problem with a significant impact on patient quality
of life. Treatment depends on whether the UI is mild, moderate, or severe. Severe UI requires
more intense methods that simulate urethral sphincter activity. The options are the transobturator sling or artificial urinary sphincter implantation, accepted as the gold standard.
A 68-year-old man had onset of lower urinary tract symptomatology in 2006. Study protocol reported
a prostate-specific antigen (PSA) value of 7.02 ng/ml and a free PSA fraction of 17%. The histopathologic study (HPS) of the prostate biopsy specimens reported prostate cancer (CaP). RP was performed
and the HPS reported a Gleason score of 4 + 4 = 8 and stage pT2c disease. The patient later presented
with moderate SUI that did not improve with medical treatment. Cystourethrography revealed dilation of the bulbous urethra and cystoscopy showed an integral sphincter, so surgical management with
transobturator sling (AdVance®) placement was decided upon.
It is suggested that in the majority of cases all of the following should be carried out prior to surgery:
a complete medical history, physical examination, laboratory studies, international UI scale questionnaire, cystoscopy, and urodynamics study. Sling placement is currently indicated in the management
of mild to moderate UI and external artificial sphincter is indicated in moderate to severe cases.
SUI management after RP continues to be a challenge for the urologist, despite the available therapeutic options. The urethral sling has become a useful and less expensive treatment option, with a
lower complication rate compared with the artificial sphincter, especially in patients with UI that is
not severe.
* Corresponding author at: Calzada de Tlalpan N° 4800, Colonia Sección XVI, Delegación Tlalpan, C.P. 14080, México D.F., México. Telephone: 4000 3044 (S. Ahumada-Tamayo).
0185-4542 - see front matter © 2013. Revista Mexicana de Urología. Publicado por Elsevier México. Todos los derechos reservados.
Management of post-radical prostatectomy male urinary incontinence with a transobturator sling (AdVance®) Palabras clave
Incontinencia urinaria
de esfuerzo;
Posprostatectomía
radical; Cabestrillo
transobturador;
México.
209
Manejo de la incontinencia urinaria masculina posprostatectomía radical con
cabestrillo transobturador (AdVance®)
Resumen La incontinencia urinaria (IU) es un padecimiento que en general afecta a los hombres en 1% a 39%; tiene varias causas etiológicas, siendo la principal secundaria a prostatectomía radical (PR). La IU de esfuerzo (IUE) secundaria a una PR, continúa siendo un problema con
un impacto importante en la calidad de vida del paciente. El tratamiento para la IU depende si
se trata de una clasificación leve, moderada o severa. En la IU severa se requiere métodos más
intensos, que semejen la actividad del esfínter uretral. Las opciones son el cabestrillo transobturador o implantación de esfínter urinario artificial, aceptado como “gold standard”.
Se presenta hombre de 68 años de edad, quien inició en el 2006 con sintomatología obstructiva
urinaria baja, se realizó protocolo de estudio con antígeno prostático específico (APE) de 7.02
ng/mL, fracción libre 17%, se realizaron biopsias de próstata con reporte histopatológico (RHP)
de cáncer de próstata (CaP); se efectuó PR. El RHP evidenció Gleason 4+4=8 y pT2c. Posteriormente cursa con IUE, moderada, sin mejoría al tratamiento médico. La uretrocistografía mostró
dilatación de la uretra bulbar y en la cistoscopia se observó el esfínter íntegro, por lo que se
decidió su manejo quirúrgico con la colocación de cabestrillo transobturador (AdVance®).
Se sugiere que previo a la cirugía se debe realizar en la mayoría de los casos historia clínica
completa, exploración física, estudios de laboratorio, cuestionario de la escala internacional de
IU, cistoscopia y estudio de urodinamia. En la actualidad, la colocación del cabestrillo está indicada en el manejo de la IU de leve a moderada, y el esfínter artificial externo en el caso de
moderada a severa.
El manejo de la IU de esfuerzo posprostatectomía radical (PPR), continúa siendo un reto para el
urólogo a pesar de las opciones terapéuticas que se tienen en estos momentos. El cabestrillo
uretral se convierte en la actualidad en una opción útil de tratamiento menos costosa, con disminución de la tasa de complicaciones en comparación al esfínter artificial, sobre todo en los
pacientes con IU no severa.
Introduction
Case presentation
Urinary incontinence (UI) is a condition that generally
affects 5% to 69% of women and 1% to 39% of men. The etiology in each sex varies and the most frequent causes in men
are advanced age, lower urinary tract symptoms (LUTS) plus
infections, functional and cognitive deterioration, neurologic disorders, and radical prostatectomy (RP) as the principal cause.
Stress urinary incontinence (SUI) secondary to RP continues to be a problem that has a significant impact on patient quality of life. The rate of UI after 12 postoperative
months is reported to be from 5% to 30%. SUI after RP is
mainly due to intrinsic sphincterial deficiency and less often
to detrusor instability or pure extrinsic sphincterial deficiency.1
Among the initial treatment options for low-grade UI that
can be implemented are pelvic floor exercises, electric stimulation, or drug therapy. A possibility is the injection of
bulking agents to thicken the urethra, as well as the artificial sling described by Kaufman in 1970; he was the first to
report on and utilize synthetic material as a sling or balloon
compression devices. In cases of severe UI more intense
methods that simulate urethral sphincter activity are necessary. An option prior to the artificial sphincter is the transobturator sling (AdVance®). Its application is easier and it has
satisfactory success results. And finally, when total continence is desired, the option accepted as the gold standard
is the artificial urinary sphincter.1-3
A 68-year-old man presented with lower urinary tract symptoms in 2006. Evaluation protocol produced a prostate-specific antigen (PSA) of 7.02 ng/mL and a free PSA fraction of
17%. The histopathologic study (HPS) of the prostate biopsies reported prostate cancer. RP was performed and the
HPS reported a Gleason score of 4 + 4 = 8 and stage pT2c
disease. The patient later presented with moderate SUI that
did not improve with medical treatment.
Cystourethrography showed dilation of the bulbous
urethra (figs. 1 and 2) and cystoscopy revealed an integral
sphincter, leading to the decision of surgical management
with the placing of a transobturator sling (AdVance®) (figs.
3 to 6). The postoperative progression was adequate.
Discussion
We know that in the case of post-radical prostatectomy
(PRP) SUI, the external artificial sphincter is the gold standard and has a continence rate of 73% to 90%. Nevertheless,
there have been important complications and re-interventions up to 57% in the follow-up of these patients. Among
the complications are erosions, infections, UI, and mechanical problems of the sphincter requiring re-intervention, all
of which imply greater cost to the patient and surgical procedures for non-physiological urinary emptying. Therefore it
is necessary to contemplate a less invasive alternative to
the external artificial sphincter, such as the transobturator
210
S. Ahumada-Tamayo et al
Figure 1 Voiding cystourethrogram in
the elimination phase: the bulbous
urethra can be seen.
Figure 2 Voiding cystourethrogram: a
greater opening of the bulbomembranous urethra can be seen.
Figure 3 The lithotomy position with the
areas for approach marked on the skin in
the perineum and under the tendon of
the adductor magnus muscle.
Figure 4 Insertion of the helical needle
from the obturator fossa to the perineum.
Figure 5 The sling with the 2 ends of the
external mesh can be seen in the bulbous urethra position.
Figure 6 Visualization of the bulbous
urethra with the mesh now in place and
the floor of the urethra elevated.
sling.3 The first pioneers to carry out these types of transobturator sling procedures in which the posterior urethra has a
more proximal relocation and thus better continence were
Rehder and Gozzi.3,4 They conducted studies on cadavers
and then on male patients and they had an incontinence
cure rate of 40%, an incontinence improvement rate of 30%,
and a minimal morbidity rate.4
It is suggested that prior to surgery in the majority of cases a complete anamnesis, physical examination, laboratory
studies, international urinary incontinence scale questionnaire, cystoscopy, and urodynamics study should be carried
out. Currently, transobturator sling placement is indicated
in the management of mild to moderate UI and external artificial sphincter is indicated in moderate to severe UI.5-7 An
important point to consider is that in case of sling failure,
external artificial sphincter placement can be offered.1,4,8
Conclusions
The management of PRP SUI continues to be a challenge for
the urologist despite the current therapeutic options. A determining factor for treatment success is the experience of
the surgeon in managing the different treatment modalities.
The urethral sling has presently become a useful and less
expensive treatment option with a lower complication rate
compared with the artificial sphincter, especially in patients
that do not present with severe UI.
Conflict of interest
The authors declare that there is no conflict of interest.
Financial disclosure
No financial support was received in relation to this article.
References
1. Hubert J. Bulbourethral composite suspension: a new operative
technique for post-prostatectomy incontinence. J Urol
2004;171(5):1866-1870.
2. Thüroff JW, Abrams P, Andersson KE, et al. Guía clínica sobre la
incontinencia urinaria. Actas Urol Esp 2011;35(7):373-388.
3. Cornel EB, Elzevier HW, Putter H. Can Advance Transobturator
Sling Suspension Cure Male Urinary Postoperative Stress Incontinence? J Urol 2010;183(4):1459-1463.
Management of post-radical prostatectomy male urinary incontinence with a transobturator sling (AdVance®) 4. Rehder P, Gozzi C. Transobturator Sling Suspension for Male Urinary Incontinence Including Post-Radical Prostatectomy. Eur
Urol 2007;52(3):860-866.
5. Castle EP, Andrews PE, Itano N, et al. The male sling for postprostatectomy incontinence: mean followup of 18 months. J
Urol 2005;173(5):1657-1660.
211
6. Inci K, Ergen A, Bilen CY, et al. A new device for the treatment
of post-prostatectomy incontinence: adjustable perineal male
sling. J Urol 2008;179(2):605-609.
7. Han JS, Brucker BM, Demirtas A, et al. Treatment of Post-Prostatectomy Incontinence With Male Slings in Patients With Impaired Detrusor Contractility on Urodynamics and/or Who Perform Valsalva Voiding. J Urol 2011;186(4):1370-1375.
Rev Mex Urol 2013;73(4):212-215
ÓRGANO OFICIAL DE DIFUSIÓN DE LA SOCIEDAD MEXICANA DE UROLOGÍA
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Clinical case
Management of recurrent stricture of the perineal meatus with
the Blandy technique after penectomy secondary to corpora
cavernosa abscess
J. Á. Martíneza,*, E. A. Ramírez-Pérezb, A. J. Camacho-Castroa, V. Osornio-Sáncheza, S.
Ahumada-Tamayoa, G. Fernández-Noyolaa, F. J. García-Salcidoa, E. L. Muñoz-Ibarraa, E.
Mayorga-Gómeza, G. Garza-Sainza, M. Cantellano-Orozcoa, J. G. Morales-Montora, C.
Martínez-Arroyoa and C. Pacheco-Gahblera
a
Department of Urology, Hospital General “Dr. Manuel Gea González”, Mexico City, Mexico
b
Centro de Uretra México, Mexico City, Mexico
KEYWORDS
Perineal
urethrostomy;
Perineal meatus;
Blandy technique;
Mexico.
Management of recurrent stricture of the perineal meatus with the Blandy technique
after penectomy secondary to corpora cavernosa abscess
Abstract Perineal urethrostomy stricture is a frequent complication and its management is difficult
to treat. The aim of this article was to describe the specific aspects related to the Blandy technique.
A 62-year-old man had a past medical history of drainage of an idiopathic abscess of the corpora
cavernosa. One year later he presented with necrosis of the glans penis and the corpora cavernosa and underwent partial penectomy. He then presented with complex stricture of the urethra
that was resolved with first-stage Johanson repair. The patient was seen at the Plastic and Reconstructive Surgery Service and underwent resection of the penile remnant and the formation
of a neophallus with a radial forearm free flap. He presented with necrosis and flap loss. Total
penectomy and perineal urethrostomy were performed. One year later the patient presented
with a decrease in urinary stream caliber and acute urinary retention that was resolved through
cystostomy and perineal urethrostomy reconstruction. He presented with re-stricture that was
treated with urethral dilations. The gradual diminishing of the urinary stream caliber persisted
and so a perineal meatoplasty with the Blandy technique was performed.
The surgical correction of perineal urethrostomy stricture with the Blandy technique is a valid
and effective option in the treatment of this complication.
* Corresponding author at: Calzada de Tlalpan N° 4800, Colonia Sección XVI, Delegación Tlalpan, C.P. 14080, México D.F., México. Telephone: 4000 3044. Email: doctorangel25@hotmail.com (J. Á. Martínez).
0185-4542 - see front matter © 2013. Revista Mexicana de Urología. Publicado por Elsevier México. Todos los derechos reservados.
Blandy technique for the management of recurrent stricture of the perineal meatu
Palabras clave
Uretrostomía perineal;
Meato perineal;
Técnica de Blandy;
México.
213
Resumen La estenosis de la uretrostomía perineal es una complicación frecuente, el manejo
de la misma es un problema de difícil tratamiento. El objetivo del presente artículo es demostrar los aspectos específicos relacionados a la técnica de Blandy.
Se presenta hombre de 62 años de edad, con antecedente de drenaje de absceso idiopático de
cuerpos cavernosos. Un año despues presentó necrosis de glande y cuerpos cavernosos, por lo cual
fue sometido a falectomía parcial. Presentó estenosis compleja de uretra, que se resolvió con
primer tiempo de Johanson. Acudió al Servicio de Cirugía Plástica y Reconstructiva donde fue
sometido a resección de remanente peniano y formación de neofalo con colgajo radial libre,
presentando necrosis y pérdida del colgajo. Se realizó falectomía total y formación de uretrostomía perineal. Un año despues presentó disminución del calibre del chorro urinario y retención
aguda urinaria, que se resolvió con cistostomía y plastía de uretrostomía perineal. Presentó reestenosis tratada con dilataciones uretrales, persistiendo disminución gradual del calibre del
chorro urinario, por lo que se practicó plastía del meato perineal con técnica de Blandy.
La corrección quirúrgica de la estenosis de la uretrostomía perineal con técnica de Blandy, es
una opción válida y efectiva en el tratamiento de esta complicación.
Introduction
Perineal urethrostomy is a widely accepted option for the
management of complex stricture of the anterior urethra
and is most often used as the first stage in the reconstruction by stages or when total urethral restoration is not feasible.1 Stricture at the site of the perineal urethrostomy
presents with a certain frequency in patients requiring this
type of urethral reconstruction and its management is often
a problem that is difficult to treat. Published information on
the surgical correction of this complication is limited.2 Barbagli et al. recently published their 30-year experience with
the posterior flap technique in perineal urethrostomy, which
can also be used for the correction of perineal meatus stricture.3 This technique, originally described by Blandy as the
hybridization of the principles established by TurnerWarwick, requires that the surgeon first determine the necessary length of the flap before making the incision in the
skin. This procedure is especially difficult in obese patients
or in those patients that present with abnormal perineal
anatomy.4
The Turner-Warwick technique was modified by Blandy
because he found this procedure to be extremely difficult,
with problems of stricture recurrence of the flap’s vertex
near the verumontanum. In 1968, Blandy described the inverted U-shaped scrotal flap urethroplasty, which was much
easier to perform and did not appear to result in recurrent
stricture. Some time later, Blandy again described how he
had developed this surgical technique, believing it to be an
original one, but then he realized that it had already been
described by Leadbetter, Gil-Vernet, Wells, and Williams.4
Over the years, the two-stage procedures have been widely modified. In 1984 Schreiter described a new technique
in stages using a skin graft5 and Venn and Mundy introduced
the buccal mucosa graft in procedures by stages for patients
with lichen sclerosus.6
In the era of single-stage procedure repair, there were
still indications for urethroplasty in stages. The strictures
associated with adverse local conditions such as fistula, false pathway, abscess, cancer, or a previous urethroplasty due
to complex stricture, are better treated with procedures in
stages. Perineal urethroplasty can be a temporary or a permanent solution to a complex penile, bulbar, or posterior
urethral stricture. Some patients choose not to undergo any
type of second or third-stage reconstruction and prefer to
continue carrying out micturition through the perineal
urethroplasty, and thus turning the first-stage procedure
into the only one that is performed.7
The aim of this article was to demonstrate the technical
aspects of the surgical management of perineal urethrostomy stricture following penectomy.
Case presentation
A 62-year-old Catholic man born and living in Mexico City,
divorced, and retired had a past medical history of abscess
of the corpora cavernosa that spontaneously originated in
July 2006. He underwent exploratory surgery, abscess drainage, and partial penectomy. He later presented with complex urethral stricture that was resolved with first-stage
Johanson repair. He spontaneously sought medical attention
at the Plastic and Reconstructive Surgery Department with
the intention of having penile reconstruction. He underwent
stump resection and the formation of a neophallus with radial forearm flap. He presented with necrosis of the radial
forearm flap and therefore underwent flap resection, total
penectomy, and perineal urethrostomy formation. One year
later he presented with a weakening of the urinary stream
caliber through the perineal urethrostomy and so had
urethral dilations with a urethral dilating balloon. He presented with acute urinary retention that was resolved
through percutaneous cystostomy and later perineal
urethrostomy reconstruction in December of 2009. One year
after the perineal urethrostomy reconstruction he presented with recurrent stricture for which urethral dilations
were begun, but there was a gradual decrease in the caliber
214
J. Á. Martínez et al
A
Figure 1 Identification of the perineal
meatus and marking of the surgical site.
B
Figure 2 A) Incision over the previously marked lines and B) perineal incision
outline.
Figure 3 Dissection of the urethra and
identification of the posterior urethra
with the rhinoscope.
of the urinary stream despite the dilations. Due to the failure of the perineal urethrostomy with balloon dilations, a
new urethral meatoplasty was performed. On this occasion
it was carried out with the Blandy technique, sparing the
posterior urethral plate in order to reduce the risk for devascularization of the urethral remnant and in turn, providing a lower possibility of recurrent stricture.
Description of the surgical technique
Under peridural block, the patient was placed in the lithotomy position and antisepsis of the perineal region was
done. The perineal meatus was cannulated with a 6Fr ureteral stent and instilled with gentian violet dye to pigment the
urethral mucosa (fig. 1). A perineal incision in the shape of
an inverted U was made (fig. 2). A posterior flap was formed
with sufficient fatty tissue to preserve adequate tissue irrigation and the urethra was completely dissected keeping
the posterior urethral plate intact. An automatic Scott separator was placed for adequate exposure of the anatomy of the
region to be operated on. The urethra was spatulated with a
6 o’clock cut and the urethral lumen was inspected with
a rhinoscope for verumontanum visualization (fig. 3).
Figure 4 Perineal cutaneous flap plication.
Absorbable 4-0 suture with a modified needle was used to
move the skin of the flap up to the spongy tissue found immediately in front of the verumontanum. Three sutures
were placed in this position; they were adjusted and in this
way moved the edge of the inverted U-shaped perineal skin
flap toward the edge of the urethral mucosa (fig. 4). The
margins of the perineal skin were sutured to the margin of
the bulbous urethral plate and a 20Fr silicon transurethral
catheter was placed. A capillary drain was placed, which is
normally removed on the third to fifth postoperative day,
prior to the patient’s release. The procedure was performed
with no complications. The patient was released on the second postoperative day and the transurethral catheter was
removed on postoperative day 21. He currently presents
with adequate urine flow and no signs of stricture (fig. 5).
Postoperative surveillance is carried out at 3, 6, and 9
months and then yearly. All patients undergo uroflowmetry
and a physical examination with rhinoscope through the perineal meatus in order to evaluate adequate stoma permeability. The primary results analyzed are treatment success
or failure, which are defined as no evidence of stricture recurrence and evidence of stricture recurrence, respectively.4
Blandy technique for the management of recurrent stricture of the perineal meatu
A
215
B
Figure 5 A) Layer closure. B) Appearance of the final results.
Discussion
Conflict of interest
The success rate of perineal urethrostomy success rate according to the etiology of the stricture has been shown to be
high in patients with failed hypospadias repair (87.5%),
compared with patients with stricture secondary to infectious processes (33.3%). It is likely that any type of stricture
loses its identity with time and all the strictures, regardless
of their etiology, become an identical pathologic process due to
the repeated treatments (dilations, urethrotomy, urethroplasty), making it appear that the original etiology of the
stricture does not influence the final result.8
The lack of a tool for evaluating the result of urethral reconstructive surgery should motivate us elaborate questionnaires that can measure the most important aspects of the
health status of a patient that has undergone perineal
urethrostomy. In the future, it will be obligatory to develop
questionnaires that specifically deal with urethral pathology
based on a clearly defined conceptual framework indicating
the importance of the patient’s perspective and expectations.3
The authors declare that there is no conflict of interest.
Conclusions
Perineal urethrostomy stricture is a frequent complication
whose treatment is complex due to the high rate of stricture recurrence that presents when the adequate technique is
not performed. Surgical correction of a urethrostomy stricture with the Blandy technique is a valid and effective option in the treatment of this complication.
Financial disclosure
No financial support was received in relation to this article.
References
1. French D, Hudak SJ, Morey AF. The “7-Flap” Perineal Urethrostomy. Urology 2011;77(6):1487-1489.
2. Blandy JP, Singh M, Tresidder GC. Urethroplasty by scrotal flap
for long urethral strictures. Br J Urol 1968;40(3):261-267.
3. Barbagli G, De Angelis M, Romano G, et al. Clinical Outcome
and Quality of Life Assessment in Patients Treated With Perineal
Urethrostomy for Anterior Urethral Stricture Disease. J Urol
2009;182(2):548-557.
4. Blandy JP. One-stage and two-stage urethroplasty. In: Reconstructive Urologic Surgery; Pediatric and Adult. Baltimore: Williams & Wilkins; 1977. p. 275-286.
5. Schreiter F. Mesh-graft urethroplasty: our experience with a
new procedure. Eur Urol 1984;10(5):338-344.
6. Venn SN, Mundy AR. Urethroplasty for balanitis xerotica obliterans. Br J Urol 1998;81(5):735-737.
7. Secrest CL. Staged urethroplasty: indications and techniques.
Urol Clin North Am 2002;29(2):467-475.
8. Barbagli G, De Angelis M, Romano G, et al. Long-term followup
of bulbar end-to-end anastomosis: a retrospective analysis of
153 patients in a single center experience. J Urol
2007;178(6):2470-2473.
Rev Mex Urol 2013;73(4):216-219
ÓRGANO OFICIAL DE DIFUSIÓN DE LA SOCIEDAD MEXICANA DE UROLOGÍA
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Clinical case
Technical aspects of laparoscopic partial nephrectomy
S. Ahumada-Tamayo*, J. Á. Martínez, G. Fernández-Noyola, F. García-Salcido, E. MuñozIbarra, A. J. Camacho-Castro, E. Mayorga-Gómez, V. Osornio-Sánchez, G. Garza-Saenz,
V. Cornejo-Dávila, A. Palmeros-Rodríguez, I. Uberetagoyena-Tello de Meneses, C.
Martínez-Arroyo, M. Cantellano-Orozco, J. G. Morales-Montor and C. Pacheco-Gahbler
Department of Urology, Hospital General “Dr. Manuel Gea González”, Mexico City, Mexico
KEYWORDS
Renal cell carcinoma;
Laparoscopic partial
nephrectomy; Open
partial nephrectomy;
Mexico.
Abstract Renal cell carcinoma (RCC) represents 3% of all malignant tumors in the adult, with a
man:woman ratio of 2:1. It is more frequent between the ages of 60 and 70 years, and 80% of
the patients present with the histologic clear cell variant. Currently, 50% of patients are diagnosed incidentally.
A 71-year-old man had illness onset in March 2012 with gross hematuria, developing symptoms
of acute urine retention. A transurethral catheter (TUC) was placed and the hematuria remitted. Study protocol was carried out, and the urotomography (UroCAT) scan identified a heterogeneous tumor on the lateral surface of the upper pole of the right kidney that measured 45 x
40 mm and had a radiodensity of 20 HU with up to 120 HU enhancement, plus a simple left
Bosniak 1 renal cyst. A right laparoscopic partial nephrectomy (LPN) was performed using the
transperitoneal abdominal approach with dissection of the renal unit. Upon locating the renal
mass, the renal hilum was clamped under warm ischemia. The tumor was resected, bovine
thrombin (Floseal®) was placed at the resection site, and mattress sutures were used to suture
the fatty tissue patch. The histopathologic study reported the eosinophilic variant of
chromophobe carcinoma, pT1b NO MO.
There has been a significant increase in nephron-sparing surgery (LPN) to date and its main usefulness has been in localized tumors. Depending on tumor location, the approaches are transperitoneal, retroperitoneal, and hand-assisted. LPN has the important benefit of being minimally invasive, maintaining the function of the rest of the renal parenchyma.
LPN is an alternative to open partial nephrectomy (OPN) when performed by an experienced
surgeon and on selected patients. The ideal indication for LPN is a small, peripheral renal tumor.
* Corresponding author at: Calzada de Tlalpan N° 4800, Colonia Sección XVI, Delegación Tlalpan, C.P. 14080, México D.F., México. Telephone: 4000 3044. (S. Ahumada-Tamayo).
0185-4542 - see front matter © 2013. Revista Mexicana de Urología. Publicado por Elsevier México. Todos los derechos reservados.
Technical aspects of laparoscopic partial nephrectomy Palabras clave
Carcinoma de células
renales; Nefrectomía
parcial laparoscópica;
Nefrectomía parcial
abierta; México.
217
Nefrectomía parcial laparoscópica. Aspectos técnicos
Resumen El carcinoma de células renales (CCR) representa 3% de todas las neoplasias malignas
del adulto, con una relación hombre:mujer de 2:1; se presenta más frecuente entre los 60 y 70
años de edad, con una variante histológica de células claras en el 80%. Actualmente, el 50% se
diagnostica en forma incidental.
Se presenta hombre de 71 años de edad, inicia su padecimiento en marzo de 2012 con hematuria macroscópica, desarrollando cuadro de retención aguda de orina. Se colocó sonda transuretral (STU), remite la hematuria y se realiza protocolo de estudio, encontrando en la urotomografía
(UROTAC) tumor renal en polo superior de riñón derecho, en la cara lateral, heterogéneo, de 45
x 40 mm, 20 UH, que refuerza hasta 120 UH, sumado a un quiste renal simple izquierdo Bosniak
I. Se realiza nefrectomía parcial laparoscópica (NPL) derecha. Técnicamente: abordaje abdominal transperitoneal con disección de la unidad renal, al localizar la masa renal se realiza isquemia caliente en hilio renal, se reseca tumor, se coloca trombina bovina (Floseal®) en lecho de
resección y parche de tejido graso, se dan puntos de colchonero. Reporte histopatológico: carcinoma cromófobo variante de células eosinófilas, pT1bN0M0.
La cirugía conservadora de nefronas (NPL) ha tenido un aumento importante a la fecha, con
principal utilidad en tumores localizados. Dentro de los aspectos técnicos existe el abordaje
transperitoneal, retroperitoneal y mano asistida, dependiendo de la ubicación del tumor. La NPL
tiene importancia en el beneficio de mínima invasión, manteniendo la función del resto del
parénquima renal.
En manos expertas y con pacientes seleccionados, la NPL es una alternativa a la nefrectomía
parcial abierta (NPA). La indicación óptima de la NPL es un tumor renal pequeño y periférico.
Introduction
Renal cell carcinoma (RCC) represents 3% of all malignant
tumors in the adult, with a man:woman ratio of 2:1. It is
more frequent in the fourth and sixth decades of life and
80% of the cases are the clear cell histologic variant. Currently, 50% of the cases are diagnosed incidentally, the majority through imaging techniques such as ultrasonography
and computerized tomography (CT). Partial nephrectomy
has gained importance in cases of localized tumors, with
the modalities of open partial nephrectomy (OPN) and laparoscopic partial nephrectomy (LPN).1-4 The latter, minimally
invasive, surgery was introduced by McDougall and Winfield
in 1993, and over the years has had greater reproducibility.
Indications for LPN are: absolute (a single anatomic or
functioning kidney), relative (an affected contralateral kidney with deteriorating kidney function), and optional (localized unilateral kidney cancer with a healthy contralateral
kidney).5
Case presentation
A 71-year-old man was diagnosed with high blood pressure
in 1999 and is in treatment with metoprolol. He has a past
medical history of TURP in 2001. His present disease onset
was in March 2012 with gross hematuria, developing symptoms of acute urine retention (AUR). A transurethral catheter (TUC) was placed and the hematuria remitted. In the
study protocol, a urotomography (UroCAT) scan revealed a
heterogeneous renal tumor on the lateral surface of the upper pole of the right kidney that measured 45 x 40 mm and
had a radiodensity of 20 HU with up to 120 HU enhancement, plus a simple left Bosniak I renal cyst (figs. 1 and 2). A
right LPN through the transperitoneal abdominal approach
was performed with dissection of the complete renal unit.
When the renal mass was located, warm ischemia at the
renal hilum was carried out. The tumor was resected, bovine thrombin (Floseal®) was placed at the resection site,
along with gelfoam and a fatty tissue patch, and sutured
with mattress sutures (figs. 3 to 6).
The histopathologic report stated eosinophilic variant of
chromophobe renal cell carcinoma with a 4.6 x 4.2 x 3.3 cm
tumor with no lymphovascular infiltration and stage pT1bN0M0 disease. The patient is presently continuing his oncologic follow-up.
Discussion
There has been an important increase to date in nerve-sparing LPN surgery and its principal use is in localized T1a or
T1b tumors. The transperitoneal, retroperitoneal, and hand
assisted approaches are among its technical aspects. 1 A
transperitoneal approach is simpler in anterior tumors that
are located in the lower pole, than in those on the posterior
or superior surface, which are ideal candidates for a retroperitoneal approach. However, total kidney dissection can
make complete renal exposure possible in a transperitoneal
approach. Hand-assisted surgery can be useful in concrete
cases of large-volume tumors, enabling better control of
hemorrhage with manual compression, thus prolonging the
work time and therefore minimizing the warm ischemia period in cases of difficult access or large tumor volume.6,7
It is important to see the location of the tumor. In the
case of the transperitoneal approach the patient is positioned at a 30⁰ angle and 4 to 5 trocars are placed. The kidney
is dissected, mannitol is administered, proceeding to warm
ischemia (a time not over 30 to 40 min is essential) and to
the partial nephrectomy with a monopolar device. A
218
S. Ahumada-Tamayo et al
Figure 1 Arterial phase of the urotomography scan: it shows a tumor on the
upper pole of the right kidney and a Bosniak I simple cyst on the left kidney.
Figure 2 Elimination phase of the urotomography scan: it shows a tumor on the
right kidney and a simple cyst on the left
kidney.
Figure 3 Dissection of the right kidney
and its hilum reference point.
Figure 4 The tumor can be seen on the
pole of the right kidney and part of
the partial nephrectomy.
Figure 5 Floseal® placement at the partial nephrectomy surgical site.
Figure 6 Gelfoam placement at the
right partial nephrectomy surgical site.
cold-knife incision is made at the level of the renal medulla,
bovine thrombin (Floseal®) is placed at the surgical site
with Monocryl™ 3-0 mattress sutures, interposed with gelfoam. A drain is placed and the trocar area is closed.2,5
LPN is a complex technique, even for the experienced
surgeon, and it has a high complication rate that includes
intra and postoperative bleeding and urinary fistulas. Positive surgical margins are the most important complications.8,9
Although it is true that surgery duration is longer with LNP
than with OPN and the postoperative complication rate is
greater (kidney failure, urinary fistulas, blood loss) these
factors will decrease in relation to the learning curve. The
importance of this surgery is the benefit of minimal invasion, maintaining the function of the rest of the renal parenchyma.1,2,5
Conclusions
In the hands of experienced surgeons and with selected patients, LPN is an alternative to OPN. The ideal indication for
LPN is a small and peripheral tumor. Long-term kidney
function is dependent on the length of time of the intraoperative ischemia. LPN has a higher complication rate than
open surgery, but it is now known that the result in the oncologic follow-up is similar to that obtained with OPN.
Conflict of interest
The authors declare that there is no conflict of interest.
Financial disclosure
No financial support was received in relation to this article.
References
1. Colombo JR Jr, Gill IS. Nefrectomía parcial laparoscópica: Técnica y resultados. Actas Urol Esp 2006;30(5):501-505.
2. Cáceres, Núnez Mora, Cabrera, García Mediero, García Tello,
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