march 2012 edition - Fcm

edition
march 2012
Dr. Carlos D'Ancona
Dear readers, a new year started and we hope you benefit
from the Urovirt. In this number, the session of learning with
images we present the contribution of Magnetic
Resonance in identify suspicious recidivate lesions.
Perirenal hematoma after extracorporeal lithotripsy is
more frequent when is investigate with Computerize
Tomography than symptoms that patients relate, read
more in clinical case session. At the end in new
technologies is presented new technique to preserve the
neurovascular bundle during radical prostatectomy
procedure. Do not miss Urology News.
editorial
board
Associated Editor:
Editors:
Dr. Carlos D'Ancona
Dr. Paulo Palma
Dr. Daniel Carlos Silva
CO EDITORES
Co-editors:
Dr. Cassio Riccetto
Dr. Ricardo Miyaoka
Radiology - Editorial Committee
Dr. Adilson Prando
Dr. Ricardo Souza
Pathology - Editorial Committee
Dr. Athanese Billis
Editorial Committee
Dr. Guido Barbagli
Dr. Manoj Monga Dr. Mario João Gomes Dr. Mark Soloway
Dr. Matthias Oelke Dr. Philip van Kerrerbroek
clinical
CASE
edition: march 2012
Elaine Bronzatto, Daniel Carlos Silva
Division of Urology - Unicamp
Nefrectomia Parcial
uso de cola biológica no auxílio
da hemostasia
clinical
CASE
edition: March 2012
Elaine Bronzatto, Daniel Carlos Silva
Division of Urology - Unicamp
Fifty-six year-old male squash player has no symptoms. During routine check up exams a renal nodule is
noted at ultrassonography. He undergoes magnetic ressonance imaging (MRI) for further evaluation as
he has a history of allergy to iodated dye (Fig. 1 and 4).
Figures 1 and 2: MRI, T2 images, axial and coronal cuts; heterogenous mesorenal expansive lesion (arrows).
Figures 3 and 4: MRI, xial and coronal cuts, paramagnetic dye, shows mild heterogenous absorption. A well define dlesion can be seen
(yellow arrow) with a necrotic central area (*) close to the collecting system. At the second frame lesion is easily delineated (red arrow).
clinical
CASE
edition: March 2012
Elaine Bronzatto, Daniel Carlos Silva
Division of Urology - Unicamp
MRI study confirmed the presence of an exofitic solid nodular heterogeneous lesion at the convex aspect of the left kidney. Diagnostic
hypothesis included papiliferous carcinoma and oncocytoma. An option was made towards performing open partial nephrectomy
considering lesion location, its proximity to the collecting system and size.
Figure 5: Kidney ice cooling and vascular
pedicle clamping. Tumor lesion is pointed
(arrow).
Figure 8: sponge placement (arrow) over
the kidney bed, promoting quick
hemosthasis.
Figure 6: Kidney bed (arrow) after lesion
extraction. Collecting system and large
vessels are sutured.
Figure 9: sponge (arrow) is interposed into
renal parenchyma helping with
hemosthasis.
Figure 7: Fibrinogen and thrombin coated
sponge; must be wet before use.
Figure10: Tumoral lesion is ressected.
Figure 11: Longitudinal section show central
scar.
Pathology confirmed a diagnosis of oncocytoma. Patient presented a uneventful recovery and resumed his job tasks after 1 week and sports
practice after 30 days.
clinical
CASE
edition: March 2012
Elaine Bronzatto, Daniel Carlos Silva
Division of Urology - Unicamp
Commentary
se of biological sealants was first reported in the
90's in Austria. First formulas were made out of
bovine and equine collagen which led to
significant allergic reactions and hypersensibility.
At the 20th century with the advance of the
pharmaceutic industry, first reports using
biological sealants based on fibrinogen and
thrombin in humans came out with satisfying
clinical results in hepatic resections and surgical
interventions in Urology, Gynecology, vascular
surgery and cardiothoracic surgery.
There are several different types of hemosthatic
agents described in Literature among which
tissue biological and synthetic liquid sealant, fiber
hemosthatic support, collagen sponge,
cellulose; and finally the auxiliary diathermic
agents: eletrocautery, infrared, laser and argon.
Sealant reported as medicamentous sponge is
formed by a collagen matrix coated with
coagulation factors: fibrinogen and human
thrombin; active surface is defined by a yellowish
color composed by Riboflavin (B2 vitamin) which
indicates the surface which should face the
bleeding fresh tissue.
The healing mechanism reproduces the last
phase of physiologic coagulation and is set off by
contact with blood and other corporal fluids
when it is then replaced by a fibrin clot creating a
rapid sealing. It can be used as a primary or
secondary hemosthatic agent in multiple layers
(secure application of up to 7 patches are
reported with no pharmacological side effects
whatsoever).
iological sealants have shown positive results
reducing the need for intraoperative blood
transfusion, reducing blood loss, reducing
operative time, reducing hospitalization
length and incidence of lymphocele
formation after lymphadenectomy. It may be
used in either open or laparoscopic surgery.
As a maleable product the sealant adapts
well to any organ surface and may applied
even in sites difficult to access. Physiological
degradation occurs within 12 weeks from
application through phagocytosis and
fibrinolysis and replacement by endogenous
granulation tissue takes place. Imaging at
post surgical follow up does not show notable
tissue differences. It may be considered a safe
tool with positive and promising perspectives.
Adriano Angelo Cintra, MD; Carlos
D'Ancona, MD, PhD
References::
1
Simonato A et al. The use of a surgical patch in the
prevention of lymphoceles after estraperioneal pelvic
lymphadenectomy for prostate cancer: a randomized
prospective pilot study. J Urol. 2009;182:2285-90.
2
Siemer S et al. Efficacy and safety of TachoSil as
haemostatic tratement versus standard suturing in Kidney
tumor resection: a randomised prospective study. Eur Urol.
2007;52(4):1156-63.
3 TachoSil. Summary of Product Characteristics. 2005
4
Schwartz M, Madariaga J, Hirose R, Shaver TR, Sher L, Chari
R, et al. Comparison of a new fibrin sealant with standard
topical hemostatic agents. Arch Surg. 2004;139:1148–54.
[PubMed]
Richter F, Schnorr D, Deger S, Trk I, Roigas J, Wille A, et al.
of hemostasis in open and laparoscopically
5 Improvement
performed parital nephrectomy using a gelatin matrixthrombin tissue sealant (FloSeal) Urology. 2003;61:73–7.
[PubMed]
learning
by image
edition: March 2012
João Paulo de Pádua, Cássio Riccetto
Division of Urology, FCM - UNICAMP
Management of bladder outlet
obstruction secondary to anterior
vaginal prolapse mesh repair
learning
by image
edition: March 2012
João Paulo de Pádua, Cássio Riccetto
Division of Urology, FCM - UNICAMP
During recent years, the use of synthetic meshes to correct vaginal prolapses has spread worldwide. As
expected, surgical complication related to this innovative technology began to appear such as
dyspareunia and mesh exposition. We present a case where a female patient underwent an anterior
vaginal prolapse mesh repair and developed outlet obstruction afterwards. We discuss alternatives to
manage these patients.
Case Report:
Sixty-six year old female patient has a history of 3 pregnancies and 2 vaginal deliveries, preserved uterus.
Patients underwent an anterior colporraphy 10 years before in order to have a grade III cystocele
corrected.
Besides the vaginal prolapse, patient presented a complaint of voiding difficulty with abdominal effort,
incomplete bladder emptying, but denied urinary incontinence. She underwent urodynamic study
(Figure 1) which revealed: normal bladder capacity, absence of stress urinary incontinence, max urinary
flow of 4 ml/s and detrusor pressure at max flow of 70cmH2O. Postvoid residual volume was
approximately 50% of total infused volume.
Figure 1: Urodynamics shows Qmx = 4 ml/s and Pdet.Qmax = 70 cm H20 confirming a diagnosis of outlet obstruction.
learning
by image
edition: March 2012
João Paulo de Pádua, Cássio Riccetto
Division of Urology, FCM - UNICAMP
A diagnosis of bladder outlet obstruction secondary to the previous surgical intervention for
cystocele repair was made. Patient underwent a semi circumferential urethrolisis with removal of
periurethral fibrosis and placement of a synthetic polypropylene mesh anchored into the obturator
foramen and sacrospinous ligament bilaterally.
Patient presented acute urinary retention within 24 hours from surgery after bladder catheter was
withdrawn.
Retention persisted for over 2 weeks post operatively and an assumption was made towards an
excessive compression of the urethra by the mesh aggravating the pre existent outlet obstruction.
Patient underwent a novel surgical intervention with incision of the mid urethral portion of the mesh
(Figure 2, Video 1) and complete urethrolisis, (Figure 3) associated with a Martius flap (Figure 4 ,
Video 2).
Figure 2 and Video 1: Mesh exposition
under the mid urethra.
Figure 3: Extense periurethral
circumferential dissection allowing
fibrotic lysis (arrow: right angle clamp
around the urethra).
Video 2: Subcutaneous tissue flap
harvested from the vulvar labia (Martiu's
flap) to be interposed up and around the
urethra to avoid periurethral fibrosis.
Post operatively patient reported little improvement of symptoms with a persistent postvoid residual
volume of 250 ml. She was then proposed to undergo a novel intervention with an internal urethrotomy.
Urethra was endoscopically incised at 7 o'clock position with a Collins knife as shown in Video 3.
Video 3: Uretrotomia Interna com Utilização da Faca de Collins
http://www.youtube.com/watch?v=w0Q9oCqdqkc
Outlet obstruction and satisfactory spontaneous voiding were achieved but patient developed a mild
stress urinary incontinence. After 3 months, patient became fully continent with no further voiding
complaints and complete resolution of vaginal prolapse.
learning
by image
edition: March 2012
João Paulo de Pádua, Cássio Riccetto
Division of Urology, FCM - UNICAMP
Commentary
Bladder outlet obstruction following vaginal prolapse correction with synthetic mesh is not a common
complication but it imposes a significant detrimental impact onto patient's quality of life as she becomes
dependent on urinary catheterization if not treated. This case illustrates our plan of action in such cases:
ŸMesh incision under the mid urethra portion as this may cause extrinsic urethral compression
and therefore obstruction. This should be done as soon as obstruction is diagnosed.
ŸUrethral circumferential dissection associated with Martius flap. This is a rescue procedure in
case mesh incision fails; and also when diagnosis is performed at late postoperative stages
when periurethral adherenceand fibrosis is expected to be more intense.
ŸFemale internal urethrotomy with Collins knife. Ultimate rescue procedure, should be
considered experimental as supporting scientific evidence is scarce.
ŸIntegration defects (exposition, extrusion, erosion, contraction) still represent an important
barrier to the wide implementation of synthetic meshes in prolapse repair and research must
focus on developing more biocompatible materials.
ŸAs in any other surgical intervention, best treatment is prevention. Points to be observed in
order to avoid outlet obstruction during mesh placement include:
ŸOs defeitos de integração (exposição, extrusão, erosão e contração) representam, ainda
limites para o emprego generalizado de próteses no assoalho pélvico feminino e a pesquisa
na área de biomateriais avança no sentido de se obter próteses com maior
biocompatibilidade.
ŸComo no caso do tratamento da incontinência aos esforços com slings sintéticos, a melhor
ŸMesh adjustment at the level of mid urethra; anchoring stitches may be used if necessary
fixating the mesh at the pre pubic insertion of pubourethral ligaments bilaterally.
ŸUse of a Metzenbaum scissors between the urethra and mesh at time of adjustment which
should slide freely allowing for a gap of 3-4 mm.
ŸMesh flattening under the bladder area; reducing mesh folding and avoids more intense
local fibrosis.
ŸNo need for vaginal wall tailoring as it will naturally accommodate in the post operative
period.
ŸUse of low weight prosthesis and only specific materials approved for use in female prolapse
repair.
The above mentioned procedures are believed to be effective and safe for managing infravesical
outlet obstruction resulting for anterior vaginal prolapse mesh repair using commercially available
polypropylene prosthesis.
Cassio Riccetto
Professor of Urology - Unicamp
new
TECHNOLOGIES
edition: March 2012
Carlos D'Ancona
Division of Urology - Unicamp
New paradigm to treat prostate cancer
novas
TECNOLOGIAS
edição: Março de 2012
Carlos D'Ancona
Disciplina de Urologia, FCM - UNICAMP
With greater use of PSA and concern of male population in relation to prostate cancer, there is an
increase of diagnosis of this disease in its early stages.
Conventional radical therapies comprise radical surgery and radiation therapies are indicated in
localized prostate cancer. These techniques are considered as efficacious but, despite technological
refinements in radiation therapy and surgery, they are associated with a high rate of comorbidities such
as erectile dysfunction (30-70%), urinary incontinence (5-10%), and rectal symptoms (5-20%) of treated
patients.
To change this side effects a new idea was presented at the EAU Meeting in Paris, the Tookad® Soluble
Vascular Targeted Photodynamic Therapy. The treatment consists of administration of Tookad
intravenously and activated by laser light. The laser fibers are inserted into the prostate under ultrasound
guidance through the perineum.
The drug destroys the illuminated blood vessels, choking the blood supply and starving the cancer of
nutrients without damaging surrounding healthy tissue. In experimental studies, marked hemorrhagic
necrosis of the prostate was observed. Tookad Photodynamic Therapy can provide an effective
alternative for the treatment of localized prostate cancer.
USO CLÍNICO
Carlos D'Ancona
Professor and Head of Urology
Sponsors:
Realization:
edition
march 2012
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