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Lower urinary tract symptoms (LUTS) caused by benign prostatic hyperplasia (BPH) commonly affect older men. Fifty percent of men in their sixties and 80% of men in their nineties will be affected. Many of these men will seek care for their bothersome symptoms and decreased quality of life. There is a poor association between LUTS and objective measures such as post void residual, voided volumes, or maximal flow. Pressure flow studies are considered the gold standard for detecting bladder outlet obstruction. These studies tend to be cumbersome, expensive, and have exposure to ionizing radiation. There are several techniques which may offer noninvasive methods of detecting bladder outlet obstruction (BOO) in men.

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Purpose: To assess the changing presentation and treatment of nonseminomatous testicular germ cell tumors (NSGCT) and to investigate predictive factors for the status of metastasis at diagnosis and on relapse and death. Materials and Methods: Retrospective record review of 147 patients that underwent inguinal orchiectomy from 1987-2007. Follow-up data was available for 102 patients (median follow-up: 80 months (0-243); 96 patients alive). Results: Mean patients age increased (p = 0.015) and more patients were diagnosed in clinical stage I (CSI) (p = 0.040). The fraction of yolk sac (YS) elements inclined (p = 0.030) and pT2 tumors increased (p < 0.001). Retroperitoneal lymph node dissection (RPLND) declined whereas more patients were treated with chemotherapy (p < 0.001; p = 0.004). There was an increase in relapse free (RFS) and cancer specific survival (CSS) due to an improvement in patients with disseminated disease (p = 0.014; p < 0.001). The presence of YS and teratoma elements showed a reduction in the odds ratio (OR) for metastasis at diagnosis (p = 0.002, OR: 0.262; p = 0.009, OR: 0.428) whereas higher pT-stage was associated to their presence (p = 0.039). Patients with disseminated disease (CS > I) showed a declined CSS compared to CSI patients (p = 0.055). The presence of YS elements was associated to an improved RFS (p = 0.038). Conclusions: In our single institution study the face of NSGCT markedly changed over 20 years even after the introduction of Cisplatin-based chemotherapy. These changes were accompanied by an improvement in RFS and CSS. When dealing with NSGCT patients such observations now and in the future should be taken into account.

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Purpose: The aim of study was to evaluate the clinical outcomes of PNL in comparison with laparoscopic ureterolithotomy (LUL) in proximal ureteral stones larger than 1 cm. Materials and Methods: A total of 80 patients who were candidates for treatment of large ureteral stones in our urology center were enrolled in the study between September 2004 and September 2008. By using patient randomization, they were assigned into two forty-patient groups (PNL and LUL). After evaluating the patients with laboratory tests and IVP, PNL was performed under sonography guidance in the prone position or the patients were submitted to classic laparoscopic ureterolithotomy (LUL) transperitoneally. All patients underwent postoperative assessments including KUB and ultrasonography. Results: A hundred-percent success was achieved in both groups. The mean age of the patients were 39.4 (16-63) and 35.2 (18-57) years old in PNL and LUL groups, respectively. The mean stone size in PNL group was 14.2 (10-25) mm and in LUL group was 13.5 (10-28) mm. The duration of the operations were 54.35 (50-82) minutes, and 82.15 (73-180) minutes (P < 0.0001); and the average hospital stay days were 2.6 (2-5) and 3.5 (3-8) days (p = 0.011) in groups PNL and LUL, accordingly. The mean Hb decrease in PNL group was 0.9mg/dL and in LUL group was 0.4mg/dL (p = 0.001). No statistically significant differences in terms of blood transfusion, fever, ICU admission, and prolonged urinary leakage were detected in both groups. Conclusion: According to our study, percutaneous nephrolithotomy under ultrasonography guidance is comparable with the laparoscopic ureterolithotomy for the treatment of proximal ureteral stones larger than 1 cm.

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Purpose: Pneumoperitoneum (Pp) at 12 to 15 mmHg in rats is associated with kidney damage. However, Pp at 8 mmHg is now known to best correlate to working pressures used in humans. Thus the aim of this work was to study the kidney of rats submitted to prolonged Pp at 8 mmHg. Materials and Methods: Rats were divided into a Sham group (n = 14), submitted to anesthesia, and a Pp group (n = 14), submitted to Pp at 8 mmHg, followed by deflation. In both groups, 7 animals were immediately killed and their kidneys were used for oxidative stress analyses. The remaining 7 rats in each group were evaluated after 6 weeks for the number of glomeruli and podocyte morphology. Results: For all analyzed parameters Sham and Pp groups presented no statistical difference. Conclusion: When submitted to adequate Pp pressures (8 mmHg), no kidney damage occurs in rats.

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Objective: During partial nephrectomy, renal hypothermia has been shown to decrease ischemia induced renal damage which occurs from renal hilar clamping. In this study we investigate the infusion rate required to safely cool the entire renal unit in a porcine model using retrograde irrigation of iced saline via dual-lumen ureteral catheter. Materials and Methods: Renal cortical, renal medullary, bowel and rectal temperatures during retrograde cooling in a laparoscopic porcine model were monitored in six renal units. Iced normal saline was infused at 300 cc/hour, 600 cc/hour, 1000 cc/hour and gravity (800 cc/hour) for 600 seconds with and without hilar clamping. Results: Retrograde cooling with hilar clamping provided rapid medullary renal cooling and significant hypothermia of the medulla and cortex at infusion rates ≥ 600 cc/hour. With hilar clamping, cortical temperatures decreased at -0.9° C/min. reaching a threshold temperature of 26.9° C, and medullary temperatures decreased at -0.90 C/min. reaching a temperature of 26.1° C over 600 seconds on average for combined data at infusion rates ≥ 600 cc/hour. The lowest renal temperatures were achieved with gravity infusion. Without renal hilum clamping, retrograde cooling was minimal at all infusion rates. Conclusions: Significant renal cooling by gravity infusion of iced cold saline via a duel lumen catheter with a clamped renal hilum was achieved in a porcine model. Continuous retrograde irrigation with iced saline via a two way ureteral catheter may be an effective method to induce renal hypothermia in patients undergoing robotic assisted and/or laparoscopic partial nephrectomy.

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Aims: Describe the impact of surgery, radiotherapy and chemoradiation in the pelvic floor functions in cervical cancer patients. Materials and Methods: A prospective study with women submitted to radical hysterectomy (RH) (n = 20), exclusive radiotherapy (RT) (n = 20) or chemoradiation (CT/RT) (n = 20) for invasive cervical cancer. Urinary, intestinal and sexual function, as well as vaginal length and pelvic floor muscle contraction were evaluated. Comparisons between groups were performed by Kruskal-Wallis and Chi-square tests (p < 0.05). Results: The groups were similar in stress urinary incontinence incidence (p = 0.56), urinary urgency (p = 0.44), urge incontinence (p = 0.54), nocturia (p = 0.53), incomplete bowel emptying (p = 0.76), bowel urgency (p = 0.12) and soilage (p = 0.43). The CT/RT group presented a higher urinary frequency (p < 0.001) and diarrhea (p = 0.025). Patients in the RH group were more sexually active (p = 0.01) and experienced less dyspareunia (p = 0.021). Vaginal length was shorter in RT group (5.5 ± 1.9cm) and CT/RT(5.3 ± 1.5 cm) than in the RH group (7.4 ± 1.1 cm) (p < 0.001). Pelvic floor muscle contraction was similar (p = 0.302). Conclusions: RT and CT/RT treatment for cervical carcinoma are more associated to sexual and intestinal dysfunctions.

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Purpose To report the prevalence and risk factors of penile lesions/anomalies in a Metropolitan Brazilian city. Materials and Methods All participants undergoing prostate cancer screening in the city of Curitiba were systematically examined to identify penile lesions including cutaneous mycosis, sexually transmitted diseases, penile cancer, meatal stenosis, hypospadias, and Peyronie's disease. Outcomes of interest included the prevalence and the relative risk and 95% confidence intervals of the lesions/anomalies according to age, school level, race, personal history of diabetes, arterial hypertension, nonspecific urethritis, and vasectomy. Results Balanoposthitis occurred in 11.8% of all participants, with an increased risk in those with diabetes (RR = 1.73), or past history of nonspecific urethritis (RR = 1.58); tinea of the penis was present in 0.2%; condyloma acuminata in 0.5%; herpes virus infection in 0.4%; urethral discharge in 0.2%; genital vitiligo in 0.7%, with an increased prevalence in non-white men (RR = 4.43), and in subjects with lower school level (RR = 7.24); phimosis in 0.5%, with a nearly 7-fold increased risk in diabetics; lichen sclerosus in 0.3%; stenosis of the external urethral meatus in 0.7%, with a higher prevalence in subjects with lichen sclerosus (RR = 214.9), and in those older than 60 years of age (RR = 3.57); hypospadia in 0.6%; fibrosis suggestive of Peyronie's disease in 0.9%, especially in men older than 60 years (RR = 4.59) and with diabetes (RR = 3.91); and penile cancer in 0.06%. Conclusion We estimated the prevalence and risk factors of commonly seen penile diseases in an adult cohort of Brazilian men.

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Purpose The objective of the study was to evaluate the synergistic transdermal permeation effect of chemical enhancers and iontophoresis technique on tolterodine tartrate (TT) transdermal gel and to evaluate its pharmacokinetic properties. Materials and Methods Taguchi robust design was used for optimization of formulations. Skin permeation rates were evaluated using the Keshary-chein type diffusion cells in order to optimize the gel formulation. In-vivo studies of the optimized formulation were performed in a rabbit model and histopathology studies of optimized formulation were performed on rats. Results Transdermal gels were formulated successfully using Taguchi robust design method. The type of penetration enhancer, concentration of penetration enhancer, current density and pulse on/off ratio were chosen as independent variables. Type of penetration enhancer was found to be the significant factor for all the responses. Permeation parameters were evaluated when maximum cumulative amount permeated in 24 hours (Q24) was 145.71 ± 2.00µg/cm2 by CIT4 formulation over control (91.89 ± 2.30µg/cm2). Permeation was enhanced by 1.75 fold by CIT4 formulation. Formulation CIT4 containing nerolidol (5%) and iontophoretic variables applied (0.5mA/cm2 and pulse on/off ratio 3:1) was optimized. In vivo studies with optimized formulation CIT4 showed increase in AUC and T1/2 when compared to oral suspension in rabbits. The histological studies showed changes in dermis indicating the effect of penetration enhancers and as iontophoresis was continued only for two cycles in periodic fashion so it did not cause any skin damage observed in the slides. Conclusion Results indicated that iontophoresis in combination with chemical enhancers is an effective method for transdermal administration of TT in the treatment of overactive bladder.

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Aim To evaluate acute toxicity and symptoms palliation of a weekly hypofractionated 3DCRT schedule as radical treatment in elderly patients with organ confined bladder cancer cT1-2N0. Materials and Methods Between February 2005 and June 2011, 58 prospectively selected patients diagnosed with organ confined bladder cancer were treated with external 3DCRT (4-field arrangement). All candidates were medically inoperable, with poor performance status, and with age ranged from 75 to 88 years (median 78). A dose of 36 Gy in 6 weekly fractions was prescribed. The primary study endpoints were the evaluation of haematuria, dysuria, frequency and pain palliation as well as the acute toxicity according to the RTOG/EORTC scale: an assessment was performed at baseline, during and 3 months after radiotherapy, while the maximum reported score was taken into account. Results The gastrointestinal acute toxicities were 13/58 (22.4%) and 5/58 (5.6%), for grade I and II respectively. The genitourinary acute toxicities were 19/58 (32.7%) and 10/58 (17.2%), for grade I and II respectively. In terms of clinical outcome, 55/58 patients (94.8%) reported palliation of haematuria, while 19 out of 58 reported no change in frequency and dysuria. All patients reported significant improvement (P < 0.01) for pain, concerning the visual analogue score before and after radiotherapy. The median progression free survival was 14 months. CONCLUSIONS The incidence of patient-reported acute toxicity following weekly hypofractionated external 3DCRT is low while the symptom palliation compares very favorably with other reported outcomes.

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Purpose We attempted to detect, for the first time in a Brazilian cohort, differences in protein expression between clear-cell renal cell carcinoma (ccRCC) and their normal adjacent tissues, aiming to identify biomarkers and/or therapeutic target candidates for this disease. Material and Methods Twenty-four ccRCC and adjacent normal tissues were collected after surgery and their protein extracts were quantified, pooled and separated by two-dimensional polyacrylamide gel electrophoresis (2DE), followed by statistical analysis of the stained gels. Spots of interest were excised from the gels, digested with trypsin and identified by MALDI-TOF-TOF mass spectrometry. Results Twenty-six differential spots were detected between the two classes of tissues, among which twenty were identified by mass spectrometry and sixteen were found to be non-redundant. Eleven proteins were either underexpressed or undetected in the ccRCC extracts, such as prohibitin and peroxiredoxin-3, whereas five were found to be overexpressed or exclusively detected in the ccRCC extract, including αβ crystalin and heat shock protein 27. CONCLUSIONS Several proteins were detected at differential levels when compared to normal adjacent tissues, and, moreover, many have been previously described by their relationship with RCC. Therefore, this work corroborates previous reports on the search for biomarkers for ccRCC, as well as it points out new candidates that may be validated in future studies.

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Purpose Bladder cancer (BC) is the second most common malignancy of the urinary tract, with high mortality. The knowledge of the molecular pathways associated with BC carcinogenesis is crucial to identify new diagnostic and prognostic biomarkers. MicroRNAs (miRNAs) are short non-coding RNA molecules that play important roles in the regulation of gene expression by acting directly on mRNAs. miR-145 has been considered as a tumor suppressor, which targets the c-MYC, MUC-1 and FSCN1 genes. Our aim was to evaluate the expression profile of miR-145 in low-grade non-invasive and high-grade invasive bladder urothelial carcinomas. Materials and Methods We studied 30 specimens of low-grade, non-invasive pTa and 30 of pT2/pT3 high-grade invasive UC obtained by transurethral resection or radical cystectomy, followed over a mean time of 16.1 months. Normal controls were represented by five samples of normal bladder biopsy from patients who underwent retropubic prostatectomy to treat BPH. miRNA extraction and cDNA generation were performed using commercial kits. Analysis was performed by qRT-PCR, and miR-145 expression was calculated using the 2-∆∆ct method; we used RNU-43 and RNU-48 as endogenous controls. Results miR-145 was under-expressed in 73.3% and 86.7% of pTa and pT2/pT3, respectively, with expression means of 1.61 for the former and 0.66 for the last. There were no significant differences in miR-145 expression and histological grade, tumor stage, angiolymphatic neoplastic invasion and tumor recurrence. Conclusion miR-145 is under-expressed in low-grade, non-invasive and high-grade invasive urothelial bladder carcinoma and may play an important role in the carcinogenesis pathway, being an interesting candidate diagnostic marker.

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Purpose In this paper we present our experience with dissolution therapy of radiolucent calculi. Materials and Methods This was a retrospective analysis of patients who were offered urinary dissolution therapy between January 2010 and June 2011. Patients were treated with tablets containing potassium citrate and magnesium oxide. Partial dissolution was defined as at least a 50% reduction in stone size. Patients with complete or partial dissolution were classified in the successful dissolution group. Patients with no change, inadequate reduction, increase in stone size and those unable to tolerate alkali therapy were classified as failures. Patient sex, stenting before alkalinization, stone size, urine pH at presentation and serum uric acid levels were analyzed using Fisher t-test for an association with successful dissolution. Results Out of 67, 48 patients reported for follow up. 10 (15%) had complete dissolution and 13 (19%) had partial dissolution. Alkalinization was unsuccessful in achieving dissolution in 25 (37%). Stenting before alkalinization, patient weight (< 60 vs. > 75kg) and serum uric acid levels (≤ 6 vs. > 6) were the only factors to significantly affected dissolution rates (p = 0.039, p 0.035, p 0.01 respectively). CONCLUSIONS A policy of offering dissolution therapy to patients with radiolucent calculi had a successful outcome in 34% of patients.

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Purpose Many medicinal plants have been employed during ages to treat urinary stones though the rationale behind their use is not well established. Thus, the present study was proposed to evaluate the effect of coconut water as a prophylactic agent in experimentally induced nephrolithiasis in a rat model. Materials and Methods The male Wistar rats were divided randomly into three groups. Animals of group I (control) were fed standard rat diet. In group II, the animals were administrated 0.75% ethylene glycol in drinking water for the induction of nephrolithiasis. Group III animals were administrated coconut water in addition to ethylene glycol. All the treatments were continued for a total duration of seven weeks. Results and Conclusion Treatment with coconut water inhibited crystal deposition in renal tissue as well as reduced the number of crystals in urine. Furthermore, coconut water also protected against impaired renal function and development of oxidative stress in the kidneys. The results indicate that coconut water could be a potential candidate for phytotherapy against urolithiasis.

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Purpose To evaluate the efficacy of standard and biofeedback bladder control training (BCT) on the resolution of dysfunctional elimination syndrome (primary outcome), and on the reduction of urinary tract infections (UTI) and the use of medications such as antibacterial prophylaxis and/or anticholinergic/alpha-blockers (secondary outcome) in girls older than aged least 5 years. Materials and Methods 72 girls, median age of 8 years (interquartile range, IQR 7-10) were subjected to standard BCT (cognitive, behavioural and constipation treatment) and 12 one-hour sessions of animated biofeedback using interactive computer games within 8 weeks. Fifty patients were reevaluated after median 11 (IQR, 6-17) months. Effectiveness of BCT was determined by reduction of dysfunctional voiding score (DVS), daytime urinary incontinence (DUI), constipation, UTI, nocturnal enuresis (NE), post void residual (PVR), and improvements in bladder capacity and uroflow/EMG patterns. Results BCT resulted in significant normalization of DUI, NE, constipation, bladder capacity, uroflow/EMG, while decrease of PVR didn't reach statistical significance. In addition, the incidence of UTI, antibacterial prophylaxis and medical urotherapy significantly decreased. There were no significant differences in DVS, DUI, NE, bladder capacity and voiding pattern at the end of the BCT and at the time of reevaluation. The success on BCT was supported by parenteral perception of the treatment response in 63.9% and full response in additional 15.3% of the patients. Conclusion Combination of standard and biofeedback BCT improved dysfunctional elimination syndrome and decreased UTI with discontinuation of antibacterial prophylaxis and/or anticholinergic/alpha-blockers in the majority of the patients. Better training results are expected in patients with higher bladder wall thickness as well as in those with vesicoureteral reflux, while presence of nocturnal enuresis may be a negative predictor of the training effect.

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Purpose Proteins constitute a major portion of the organic matrix of human calcium oxalate (CaOx) renal stones and the matrix is considered to be important in stone formation and growth. The present study evaluates the effect of these proteins on oxalate injured renal epithelial cells accompanied by a 2D map of these proteins. Materials and Methods Proteins were isolated from the matrix of kidney stones containing CaOx as the major constituent using EGTA as a demineralizing agent. The effect of more than 3kDa proteins from matrix of human renal (calcium oxalate) CaOx stones was investigated on oxalate induced cell injury of MDCK renal tubular epithelial cells. A 2D map of >3kDa proteins was also generated followed by protein identification using MALDI-TOF MS. Results The >3kDa proteins enhanced the injury caused by oxalate on MDCK cells. Also, the 2D map of proteins having MW more than 3kDa suggested the abundance of proteins in the matrix of renal stone. Conclusion Studies indicate that the mixture of >3kDa proteins in the matrix of human renal stones acts as promoter of calcium oxalate crystal nucleation and growth as it augments the renal epithelial cell injury induced by oxalate. The effect of promoters masks the inhibitors in the protein mixture thereby leading to enhanced renal cell injury. 2D map throws light on the nature of proteins present in the kidney stones.

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INTRODUCTION The retrocaval ureter is a rare congenital anomaly. The extrinsic compression may be responsible for obstruction and pain symptoms. The laparoscopic approach has been used with good results and less morbidity than the open surgery. Herein we describe a case of retrocaval ureter treated with LESS. To our knowledge, this represents the second such case reported in the literature, and the first without using any special devices, such as, single port or bended instruments. PRESENTATION Female, 23 years, complaining of right low back pain for a long time and recurrent urinary tract infection. Renal ultrasound demonstrated right-sided hydronephrosis and intravenous urography suggested the presence of retrocaval ureter. DTPA renal scintigraphy confirms delay in the elimination of contrast through the right kidney. A laparoendoscopic single-site repair was planned. The patient was placed in rightside-up modified flank position. A semicircular intra-umbilical incision was made and the conventional trocars (one 10 mm and two 5 mm) were inserted through the same incision on different points of the aponeurosis. The colon was dissected medially and the proximal ureter lateral to the vena cava was identified and dissected. An extra corporeal repair with Vycril 2-0 was used to facilitate the ureteral dissection and the anastomosis. A segment of ureter was ressected due to the tortuosity. Two 4-0 Vycril sutures were used to perform a running anastomosis. An ureteral stent was placed after the posterior layer on an antegrade fashion. A suction drain was left through the umbilicus. RESULTS The total operative time was 145 min. The blood loss was minimal. The patient was discharged on the third postoperative day and resumed total activity about 10 days after surgery. The double J was removed within 4 weeks. DISCUSSION Albeit technically challenging, LESS repair for retrocaval ureter might represent a feasible new treatment option for this rare anatomic anomaly. Special devices could help on the procedure, however they are not essencials.

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Introduction and Objective: Ureteral duplication is the most common urologic abnormality. The upper pole ureter can sometimes be associated with a ureterocele. In rare cases the ureteral insertion is extravesical and can result in significant hydroureteronephrosis. Patients can present with urinary tract infection, abdominal mass or urinary obstruction. Traditional procedures include ureteral reimplantation, ureteroureterostomy or heminephroureterectomy. These reconstructive procedures are technically challenging in small infants, especially when the hydroureteronephrosis is severe. In some cases a distal cutaneous ureterostomy is performed for immediate drainage followed by definitive surgery when the child is older. We describe our initial experience with a novel cystoscopic technique which provides drainage of the upper pole ureter and avoids the need for an incision or stoma. Materials and Methods: A 3 month-old boy presented with urinary tract infections and failure to thrive. Ultrasound revealed severe upper pole hydroureteronephrosis. Voiding cystourethrography did not reveal vesicoureteral reflux or the presence of a ureterocele. The patient underwent cytoscopy. The ectopic ureteral orifice was not identified. A transurethral, transvesical needle puncture and confirmatory ureteropyelography was used to access the dilated upper pole ureter. Guidewire passage, followed catheter dilation then allowed creation of a new ureteral orifice using a holmium laser. Results: The patient tolerated the procedure well. He was discharged after overnight observation. The hydronephrosis improved, urinary tract infections have not recurred and the patient rapidly improved feeding and weight gain. Conclusion: Trans-Urethral Neo-Orifice creation is a minimally invasive option for initial decompression for patients with obstructive ureteral ectopia.

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Purpose: Demonstrate two alternatives that permit a warm ischemia time reduction during laparoscopic partial nephrectomy. Materials and Methods: In this video, two cases of intermediate complexity renal tumors according to the RENAL nephrometry renal scoring system illustrating the techniques and our preliminary experience: a 65 year old man with a 4 cm right, posterior renal tumor. This patient underwent an early unclamping and parenchymal suturing using a greek bar continuous suture with hem-o-lock clips attached to the respective extremities of the suture; The second patient is a 49 year old man with a 3 cm renal tumor. The technique utilized was no clamping resection following the ABC Medical School technique: dissection of renal hilum for eventual clamping if necessary, a frontal 360 degrees visualization of tumor limits, pneumoperitoneum pressure elevated to 25mmHg during tumor resection, spiral excavation of normal parenchyma around the tumor and resection with negative margins. Results: We previously performed 15 cases utilizing the early unclamping technique. The mean clamp time was 15 minutes with a mean blood loss of 285 mL. Only 1 patient had focal positive surgical margins, without recurrence demonstrated at 30 months. Fifteen partial nephrectomies were previously performed with on demand clamping. In 3 cases, clamping was necessary with a mean ischemia time of 11 minutes. The mean blood loss was 390 mL and 2 cases required a perioperative blood transfusion. One case presented with a positive focal margin without recurrence demonstrated at 24 months of follow-up. Renal function was preserved in all cases regardless of the technique applied. Conclusion: Warm ischemia time can be reduced and kidney function can be preserved during laparoscopic nephrectomy if either early unclamping or on demand clamping are selectively applied.