Volume 73, may - june 2013, Number 3 ISSN-0185

Transcripción

Volume 73, may - june 2013, Number 3
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
Vesicourethral anastomosis after radical prostatectomy using the Capio suturing system
Complications secondary to transrectal ultrasoundguided prostate biopsy
Correlation between PSA and IPSS values, type of
work, and educational level in a
Spanish occupational population
Transrectal ultrasound. A posterior
paravesical lesion is identified at the
seminal vesicle site. pp. 146-149
A review of our experience in treating male urinary
incontinence through the AMS800™ artificial urinary sphincter
Crystallographic analysis of 475 urinary tract calculi at
the Hospital San José Tec
Salud in Monterrey, N. L.
Urinary diversion postoperative complication
management
Simple computed tomography scan. The
image clearly shows a lesion at the left
lateral base of the bladder. pp. 146-149
Contrast-enhanced computed tomography scan that newly identifies the left
seminal vesicle lesion. pp. 146-149
www.elsevier.es
Primary diffuse large B-cell lymphoma of the prostate:
a case report
•CONTENIDO
•CONTENTS
editorial
editorial
Estratificar el riesgo genético del cáncer de próstata para predecir la progresión de la
enfermedad después de la prostatectomía radical
107
Stratifying genetic risk for prostate cancer to predict disease progression after radical
prostatectomy
J. Guzmán-Esquivel
J. Guzmán-Esquivel
ArtículoS originalES
ORIGINAL ARTICLES
Anastomosis vesico-uretral tras prostatectomía radical utilizando el sistema de sutura Capio
109
D. Hernández-Alcaraz, et al.
114
P. Cruz García-Villa, et al.
Complications secondary to transrectal ultrasound-guided prostate biopsy
114
P. Cruz García-Villa, et al.
Correlación entre los valores de APE, IPSS, tipo de trabajo y nivel educacional en población laboral
española
119
M. T. Vicente-Herrero, et al.
Correlation between PSA and IPSS values, type of work, and educational level in a
Spanish occupational population
119
M. T. Vicente-Herrero, et al.
Revisión de nuestra experiencia en el tratamiento de la incontinencia urinaria en el varón mediante
el esfínter urinario artificial AMS-800TM
125
F. X. Elizalde-Benito, et al.
A review of our experience in treating male urinary incontinence through the AMS800™ artificial urinary sphincter
125
F. X. Elizalde-Benito, et al.
Análisis cristalográfico de 475 cálculos de vías urinarias en el Hospital San José, Tec Salud, en
Monterrey, N.L.
A. R. Aragón-Tovar, et al.
Director General:
109
D. Hernández-Alcaraz, et al.
Complicaciones secundarias a biopsia transrectal de próstata guíada por ultrasonido
Editada por:
Vesicourethral anastomosis after radical prostatectomy using the Capio suturing system
107
130
Crystallographic analysis of 475 urinary tract calculi at the Hospital San José Tec
Salud in Monterrey, N. L.
A. R. Aragón-Tovar, 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
130
CasoS clínicoS
Manejo de las complicaciones postoperatorias en las derivaciones urinarias
CLINICAL CASES
136
E. Mayorga-Gómez, et al.
Linfoma primario prostático difuso de células B grandes. Reporte de un caso
140
Primary diffuse large B-cell lymphoma of the prostate: a case report
143
Scrotal angiomyolipoma: a clinical case
146
Leiomyoma of the seminal vesicle: a case report and literature review
A. J. Camacho-Castro, et al.
Comunicación breve
Brief report
A. J. Manrique, et al.
143
F. J. Flores-Murcio, et al.
A. J. Camacho-Castro, et al.
Aislamiento de ADN a partir de muestras de orina para la amplificación STR con un nuevo método
rápido y seguro
140
D. Ríos-Cruz, et al.
F. J. Flores-Murcio, et al.
Leiomioma de vesícula seminal reporte de un caso y revisión de la literatura
136
E. Mayorga-Gómez, et al.
D. Ríos-Cruz, et al.
Angiomiolipoma escrotal, presentación de caso clínico
Urinary diversion postoperative complication management
150
DNA isolation from urine samples for STR amplification with a rapid and safe new
method
A. J. Manrique, et al.
146
150
Rev Mex Urol 2013;73(3):107-108
www.elsevier.es/uromx
Editorial
Stratifying genetic risk for prostate cancer to predict disease
progression after radical prostatectomy
Estratificar el riesgo genético del cáncer de próstata
para predecir la progresión de la enfermedad después de
la prostatectomía radical
T
his year, in the month of April, practically one month
before the congress of the American Urological Association (AUA), the validation of a genetic test for stratifying risk groups for prostate cancer (CaP) progression1 was
published in the Journal of Clinical Oncology.
The principal author of this study, Dr. Matthew R. Cooperberg, has commented that with this genetic test, the decision can be made as to when and how to aggressively treat
CaP. These types of tests or biomarkers can provide us with
data that guide us in our decision-making.
CaP is the first cause of malignant tumors in adult men
and the second cause of death from malignant diseases.
However, many cases of CaP will never be clinically expressed even if they are left untreated.
Randomized studies that have compared radical
treatment such as surgery with active surveillance, have
shown the benefits of this first modality in moderate and
high risk CaP patients, but not in patients with low risk for
CaP. The Prostate Intervention Versus Observation Trial (PIVOT) study is the most recent of these studies.2
For a long time, stratifying the risk for progression of this
disease has been based on certain easily accessible variables, but ones that left a very important gap in relation to
low risk patients, who would very probable be over-treated.
All of us are aware of the morbidity and mortality resulting
from these treatments, even with minimally invasive therapeutic alternatives, and we cannot deny the high percentages
of complications in patients that could even die from a cause unrelated to the disease.
The test
The biomarker known as cell-cycle progression (CCP) identifies the expression of 31 genes related to CaP and 15 constitutive or normalization genes; their expression is quantified
with a reference to the value of 1, thus having values of
minus 1 or plus 1. After excluding patients that did not enter into the data analysis, 413 remained. These tests were
performed on them to determine the gene expression. The
CCP score was positive or negative if there was overexpression or underexpression of the genes, respectively.
To further strengthen this test, it was compared with and
added to a previously validated analysis known as the Cancer of
the Prostate Risk Assessment (CAPRA-S), a validated instrument
that predicts cancer-specific recurrence and mortality.
Finally, the combination of these 2 predictive tests of
risk, the CCP and CAPRA-S, was validated.
What does this validated instrument give us? It is definitely a useful tool, especially in relation to the uncertainty
of how to treat patients after radical prostatectomy.
Without a doubt, CCP is an advance in the knowledge of the
behavior of neoplastic cells.
Even though the test in now available, we still do not
know how much it will cost to carry it out, nor do we have
* Corresponding author: Zaragoza 377 centro, Colima, Col., México. Telephone: 31231 22121. Email: [email protected] (J. GuzmánEsquivel).
0185-4542 - see front matter © 2013. Revista Mexicana de Urología. Publicado por Elsevier México. Todos los derechos reservados.
108
knowledge about its reproducibility or its access in Mexico.
Objectively, we can see that not all the Mexican States are
equipped with molecular biology laboratories that can perform these tests and for those that are, the costs of carrying
them out would be a determining factor. Taking into consideration that the current expense for determining the expression of one gene is $1,500.00 MXN, the identification of
31 genes and their expression would be significantly higher.
We also know that there are microarrangements that could
simplify these processes, but it is not known how feasible
they would be in the short-term practice.
The information is now available, the tests are being performed, and the CCP system is validated. Now we must wait
and see how viable it will be in our environment. Every day
more knowledge is generated, some of which transcends,
benefitting the patients.
J. Guzmán-Esquivel
References
1. Cooperberg MR, Simko JP, Cowan JE, et al. Validation of a CellCycle Progression Gene Panel to Improve Risk Stratification in a
Contemporary Prostatectomy Cohort. J Clin Oncol
2013;31:1428-1434.
2. Wilt TJ, Brawer MK, Jones KM, et al. Radical prostatectomy
versus observation for localized prostate cancer. N Engl J Med
2012;367:203-213.
Dr. José Guzmán-Esquivel
Editor, Revista Mexicana de Urología
Rev Mex Urol 2013;73(3):109-113
Original article
Vesicourethral anastomosis after radical prostatectomy using the
Capio suturing system
D. Hernández-Alcaraz*, P. Moreno-Arcas, E. Carmona-Campos and A. Castro-León
Urology Service, Hospital Comarcal de Antequera, Málaga, Spain
KEYWORDS
Radical
prostatectomy;
Urinary continence;
Vesicourethral
reconstruction; Spain
Abstract
Background: Proper vesicourethral anastomosis after radical prostatectomy is fundamental for preventing urinary extravasations and subsequent strictures, as well as for achieving satisfactory continence. A simpler and more watertight suture was attempted through the Capio suturing system.
Methods: The 80 radical prostatectomies carried out at our service using the Capio suturing
system for vesicourethral reconstruction are presented. In all patients the neurovascular bundle
and bladder neck were spared. Six 2-0 sutures were used for the reconstruction and bladder
catheter was maintained for 10 days.
Results: The mean surgery duration was 163 minutes from the time of skin incision to the placement of the final staple. The mean suturing time was 20 minutes and the mean urinary drainage
volume was 100 cc the first day and 40 cc the second day; the fluid had serohematic characteristics. The drain was removed on the third day, if there were no complications. Mean hospital
stay was 4 days. Continence rates in our case series were: 35% after bladder catheter removal;
61% at 3 months; and 91.7% at one year. The results regarding continence were similar to those
described in the medical literature for this type of technique. The mean suturing time and hospital stay were lower, in relation to conventional suturing.
Conclusions: The Capio suturing system allows for simple and rapid vesicourethral sutures, obtaining good urethral realignment and reducing urinary leakage.
* Corresponding author at: Servicio de Urología, Hospital Comarcal de Antequera. Av. Poeta Muñoz Rojas, C.P. 29200, Málaga, España. Telephone: 69605 8697. Email: [email protected] (D. Hernández-Alcaraz).
110
Palabras clave
Prostatectomía
radical; Continencia
urinaria;
Reconstrucción
vesico-uretral;
España.
D. Hernández-Alcaraz et al
Anastomosis vesico-uretral tras prostatectomía radical utilizando el sistema de sutura
Capio
Resumen
Introducción: Una buena anastomosis vesico-uretral después de una prostatectomía radical es
fundamental para evitar extravasaciones urinarias y estenosis posteriores, así como para conseguir una buena continencia. Con el sistema Capio, intentamos realizar una sutura vesico-uretral
más sencilla y estanca.
Material y métodos: Presentamos 80 prostatectomías radicales realizadas en nuestro Servicio,
en las cuales hemos utilizado el sistema de sutura Capio para la reconstrucción vesico-uretral.
En todos los pacientes, se realiza preservación de bandeletas (cuando está indicado) y de cuello
vesical. Se utilizan 6 puntos de 2-0 para la reconstrucción. La sonda vesical se mantiene 10 días.
Resultados: La media de tiempo quirúrgico es de 163 minutos, desde la incisión en la piel hasta
la colocación del último agrafe. El tiempo de sutura medio es de 20 minutos. La media de drenaje urinario es de 100 cc el primer día y 40 cc el segundo día, de características serohemáticas.
El drenaje es retirado al tercer día, salvo complicaciones. La estancia media es de 4 días. Las
tasas de continencia tras retirada de la sonda vesical son en nuestra serie de: 35%, tras retirada
de ésta; 61% a los 3 meses y 91.7% al año. Los resultados en cuanto a continencia son similares
a los observados en la literatura médica, comparados con los descritos con este tipo de técnica.
El tiempo de sutura y la estancia media se reducen con respecto a la sutura convencional.
Conclusiones: El sistema de sutura Capio, permite realizar la sutura uretro-vesical de forma
sencilla y rápida; consiguiendo un buen realineamiento uretral y disminuyendo las fugas urinarias.
Introduction
The principal aim of radical prostatectomy is to eliminate
the prostate tumor. Secondary aims paid attention to, in
order of importance, are urinary continence and erectile
dysfunction.
Vesicourethral anastomosis after radical prostatectomy is
a simple procedure that can be difficult to perform in deep
pelvises or when there is not much of a urethral stump. A
well-performed suture is essential for preventing urinary
extravasations and later strictures, as well as for obtaining
good continence.
Urinary continence will depend on various factors such as
neurovascular bundle and the bladder neck preservation,
the size of the prostate, the experience of the surgeon, and
the urinary extravasations.
Through our suturing system, we attempt to reduce the
anastomosis operative time and urinary leaks; we have also
compared our functional results with those found in the
existing medical literature.
Methods
We present 80 radical prostatectomies performed at our
Service using the Capio suturing system for vesicourethral
reconstruction.
In all patients nerve bundles (when indicated) were spared, as was the bladder neck, with eversion of the mucosa
at the level of the bladder neck.
We used the Capio suturing system for vesicourethral
junction reconstruction. This instrument is a needle-driving
device that is introduced into the urethra with the help of a
bladder catheter. Once inside the urethra, by pressing the
device’s upper button, the needle driver places a suture in
the urethra from the inside outwards (fig.1).
The needle uses re-absorbable 2-0 suture and has a harpoon at the end that is introduced into the urethra; at the
opposite end it has a cylindrical Tapercut® needle that is
used to suture the bladder neck (figs. 2 and 3).
After placing 6 sutures at the level of the urethra, we
could place the suture at the bladder neck from the inside
towards the outside, by means of a conventional holder. We
used a 20 Ch 2-way silicon catheter with a perforated tip
(fig.4).
The bladder catheter was removed 10 days after the procedure, without imaging studies to confirm suture watertightness.
Results
The mean age of our patients that underwent radical prostatectomy was 59 years and the mean prostate-specific antigen (PSA) at the time of diagnosis was 7.39 ng/dL. The
characteristics of our case series are described in table 1
and the clinical and pathologic stages are described in tables 2 and 3.
The mean surgery duration was 163 minutes, from the
time of skin incision to the placement of the last staple. The
mean suturing time was 20 minutes (defined as the first suture at the level of the urethra to the confirmation of watertightness).
The mean urinary drainage was 100 cc the first day and
40 cc the second day; this drainage had serohematic characteristics. The drain was removed on the third day, if
there were no complications or suspicion of urinary
leakage.
Vesicourethral anastomosis after radical prostatectomy using the Capio suturing system 111
Figure 1 The suturing instrument is shown, as well as the
loading of the suture thread.
Figure 3 Placing one of the 6 sutures.
Figure 4 Finalized urethrovesical suture.
Figure 2 Bladder neck preservation.
The mean hospital stay of our patients was 4 days. Six
cases of urinary leakage were detected within the first 48
hours (due to high drain output, with an increase in creatinine values); and one case of delayed urinary leakage at 7
days after hospital release, associated with bladder catheter
manipulation and its obstruction due to coagulates. All cases were conservatively resolved.
The continence rates after bladder catheter removal in
our case series were: 35%, after removal; 61% at 3
months, and 91.7% at one year (table 4). Continence was
defined when the patient referred to having no urinary
leaks or no drops of urine requiring a compress for
protection.
112
D. Hernández-Alcaraz et al
Table 1 Descriptive variables of the case series presented
Minimum
Age (years)
Maximum
Mean
Typical deviation
49
71
59.09
4.95
Prostate volume(cm3)
16.7
80.00
39.40
16.40
Hospital stay (days)
4.00
10.00
6.03
1.40
90
240
163.33
45.55
Sum
6(3+3)
7(3+4)
7(4+3)
8(4+4)
8(5+3)
Percentage
66.7
15.2
6.1
6.1
3.0
Operative time (min)
Gleason Score
100
Table 3 Postoperative pathologic stage
Table 2 Clinical stage and percentage of cases
Percentage
Valid
percentage
Accumulated
percentage
T1c
78.8
78.8
78.0
T2a
12.1
12.1
90.9
T2b
9.1
9.1
100
Clinical stage
Total
100
100
Two percent of the patients presented with urethrovesical
junction stricture that was resolved through endoscopic
procedures.
Discussion
The main objective of radical prostatectomy is to eliminate
the prostate tumor. Secondary objectives given attention,
in order of importance, are urinary continence and erectile
dysfunction.
Urinary continence after radical prostatectomy is generally good and varies depending on the experience and skill of
the specialist. Surgeons that perform large numbers of radical prostatectomies obtain complete continence for more
than 90% of the patients. The return to continence is associated with the patient’s age; if the patients are under the
age of 50 years the continence rate is 95%, and if they are
above the age of 70 years, it is 85%. The small number of
patients that do not have a return to continence require the
placement of a suburethral sling or an artificial urinary
sphincter.1
Regarding robotic surgery, the Vatikuti Urology Institute
has published continence rates of 95.2% at 12 months, with
26% of the patients continent after bladder catheter removal, and 55% at 4 weeks after the procedure.2 Other authors
have achieved continence rates after bladder catheter removal of 25% after removal, 32% at one month, and 76% at
9 months.3
Pathologic
stage
Percentage
Valid
percentage
Accumulated
percentage
T2a
21.2
21-9
21.9
T2b
3.0
3.1
25.0
T2c
63.6
65.6
90.6
T3a
3.0
3.1
93.8
T3b
6.1
6.3
100
Total
100
Table 4 Urinary continence rate
Urinary
continence
1.5
months
3
months
6
months
12
months
35.0%
61.1%
80.0%
91.7%
The surgical technique employed is fundamental for
attaining correct continence and sparing the bladder
neck improves this function. 4 It was first described by
Gaker et al. in 1996, and in 2004 they presented the results of a retrospective study on 275 patients. There was
immediate total continence (without compress) after
catheter removal in 36% of the patients, in 69% at 14
days, and in 78% at 7 weeks, compared with 1%, 6%, and
41% of the 80 patients that underwent the standard technique. In addition, they described a reduction in bladder
neck strictures. Many articles have been published on
this subject, with a wide variety of results and with different approaches.5
Vesicourethral anastomosis after radical prostatectomy is
a simple procedure that can nevertheless become difficult
in deep pelvic cavities or when there is not much of a
Vesicourethral anastomosis after radical prostatectomy using the Capio suturing system urethral stump. A well-performed suture with mucosa-tomucosa coaptation and a lack of tension in the urethrovesical suture are essential for preventing urinary extravasations
and for attaining good continence.
There are numerous studies in the medical literature in
which improvements in the suturing technique have been
attempted, as well as those reporting on techniques that
endeavor to optimize the urinary continence rate.
The continence rates described in the literature with this suture system are 86.6% after catheter removal, 90% at 1.5
months, and 98% at one year.6,7 The continence rates of our
case series were somewhat lower after immediate catheter removal, and similar in relation to the other times. It should be
kept in mind that the differences can be due to the multiple
surgical techniques among centers, the diverse skills of the surgeons, and even on the definition given to continence.
The literature describes 4.6% cases of vesicourethral
stricture at 8 weeks after bladder catheter removal that
have been satisfactorily resolved through a single endoscopic procedure.6,7 In our case series 2% of the cases presented
with stricture at 3 months after bladder catheter removal.
The literature also shows that the rates of urine leakage
at the suture associated with a higher rate of incontinence
and fibrosis of the anastomosis9 have gone down.
The urethrovesical suture time and the mean hospital stay
were reduced with respect to conventional suture.9,10
Conclusions
The Capio suturing system enables simple and rapid urethrovesical suture, obtaining good urethral alignment with a reduced number of urine leaks.
Financial disclosure
No financial support was received in relation to this article.
113
Conflict of interest
The authors declare that there was no conflict of interest.
References
1. Catalona WJ, Han M. Definitive Therapy for Localized Prostate
Cancer-An Overview. En: Campbell-Walsh. Urology. 9Th edition.
Philadelphia: Saunders; 2007.
2. Menon M, Shrivastava A, Kaul S, et al. Vattikuti Institute prostatectomy: contemporary technique and analysis of results. Eur
Urol 2007;51:648-658.
3. Rocco B, Gregori A, Stener A, et al. Posterior Reconstruction of
the Rhabdosphincter Allows a Rapid Recovery of Continence after Transperitoneal Videolaparoscopic Radical Prostatectomy.
European Urology 2007;51:996-1003.
4. Freire MP, Weinberg AC, Ley Y. Anatomic Bladder Neck Preservation During Robotic-Assisted Laparoscopic Radical Prostatectomy: Description of Technique and Outcomes. European Urology 2009;56:972-980.
5. Gaker D, Steel B. Radical prostatectomy with preservation of
urinary Continence: pathology and long-term results. J Urol
2004;172:2549-2552.
6. Consultado el 28 de mayo de 2013. http://www.ics.org/Abstracts/Publish/47/000016.pdf se
7. Consultado el 28 de mayo de 2013. http://www.ics.org/Abstracts/Publish/47/000546.pdf
8. Borboroglu PG, Sands JP, Roberts JL. Risk factors for vesicourethral anastomotic strictures after radical prostatectomy. Urology 2000;56:96-100.
9. Walsh PC, Partin AW. Anatomic Radical Retropubic Prostatectomy. In: Campbell-Walsh. Urology. 9Th edition. Philadelphia:
Saunders; 2007.
10.Barré C, Pocholle P, Chauveau P. Improving bladder neck
division in radical retropubic prostatectomy by prior dissection of the seminal vesicles and vasa deferentia. Eur
Urol 1999;36(2):107-110.
Rev Mex Urol 2013;73(3):114-118
Original Article
Complications secondary to transrectal ultrasound-guided prostate
biopsy
P. Cruz García-Villaa,*, D. López-Alvaradoa, H. Castellanos-Hernándezb, M. Estrada-Loyoa,
E. Monroy-Bolañosa and M. Schroeder-Ugaldea
a
Urology Speciality Residency, Urology Service, Hospital Regional “Lic. Adolfo López Mateos”, ISSSTE, Mexico City, Mexico
b
Uro-oncology Speciality, Hospital Regional “Lic. Adolfo López Mateos”, ISSSTE, Mexico City, Mexico
KEYWORDS
Biopsy; Prostate;
Complications; Mexico.
Abstract
Background: Transrectal ultrasound (TRUS)-guided prostate biopsy is a definitive procedure for
diagnosing prostate cancer (CaP) and it can have complications.
Aims: To report the frequency of complications following TRUS-guided prostate biopsy.
Methods: An analytic, descriptive, retrolective, cross-sectional study of 245 patients having
undergone TRUS-guided prostate biopsy was conducted.
Results: The mean age was 68 years and patients had a mean prostate-specific antigen (PSA)
value of 20.2 ng/ml. They presented with hematuria for a mean 1.7 days and hematochezia for
a mean 0.5 days. Mean prostate volume was 62.4 cc. A total of 35.6% of the patients had a positive malignancy result. Fever presented in 5.7% of the patients and hematospermia in 9.8%. A
total of 69% of the patients presented with hematuria and 2.4% with acute urine retention.
Discussion: The use of antibiotics, dietary measures, and intestinal preparation ensures a low
frequency of infectious complications with this method. Our results coincide with those reported on in the medical literature. The low frequency of complications makes it the method of
choice for the definitive diagnosis of CaP.
Conclusions: TRUS-guided prostate biopsy is not innocuous. The use of prophylactic antibiotics
has resulted in a low complication frequency rate for the procedure, making it the definitive
diagnostic method for CaP.
* Corresponding author at: Av. Universidad N° 1321, Colonia Florida, Delegación Álvaro Obregón, C.P. 01030, México D.F., México. Telephone: 5322 2300. Email: [email protected] (P. Cruz García-Villa).
Complications secondary to prostate biopsy Palabras clave
Biopsia; Próstata;
Complicaciones;
México.
115
Complicaciones secundarias a biopsia transrectal de próstata guíada por ultrasonido
Resumen
Introducción: La biopsia transrectal de próstata (BTRP) es el procedimiento definitivo para el
diagnóstico de cáncer de próstata (CaP). La BTRP tiene posibles complicaciones.
Objetivo: Reportar la frecuencia de complicaciones posterior a la BTRP.
Material y método: Estudio transversal, analítico, descriptivo, retrolectivo de 245 pacientes con
BTRP.
Resultados: Edad promedio de 68 años. Los pacientes tenían un antígeno prostático específico
(APE) de 20.2 ng/mL. Presentaron hematuria 1.7 días y hematoquezia 0.5 día. El volumen prostático medio fue de 62.4 cc. El 35.6% tuvieron un resultado positivo para malignidad. Se presentó fiebre en el 5.7%, hemospermia en el 9.8%. El 69% presentó hematuria y el 2.4% retención
aguda de orina.
Discusión: El uso de antibióticos, médidas dietéticas y preparación intestinal hacen que éste sea
un método con baja frecuencia de complicaciones infecciosas. Nuestros resultados coinciden
con lo reportado en la literatura médica. La baja frecuencia de complicaciones la hacen el método de elección, para el diagnóstico definitivo de CaP.
Conclusiones: La BTRP guíada por ultrasonido (USG) no es inocua. El uso de antibióticos profilácticos ha logrado una frecuencia de complicaciones baja. La BTRP es el método diagnóstico definitivo para el CaP.
Introduction
Methods
Early detection of prostate cancer (CaP) has greatly benefitted from efforts of systematic detection, with the introduction of prostate-specific antigen (PSA) and the refinement of
transrectal ultrasound (TRUS)-guided prostate biopsy techniques.1
Taking into account the figures from the National Health
Data System (SINAIS for its initials in Spanish), CaP in Mexico
is the eighth cause of death in men above the age of 65
years, with 4,435 deaths from this pathology reported in
2007. In 2008, it was reported as the twelfth cause of death
in men of all ages, representing 1.7% of the deaths in the
male population. Of the total of deaths by cancer in the country, Mexico City holds first place with 478 deaths
(15.7/100,000 inhabitants), followed by Jalisco with 473
(21/100,000 inhabitants), and the State of Mexico with
411 (12.2/100,000 deaths).2
TRUS-guided prostate biopsy is currently regarded as the
criterion standard for CaP diagnosis in patients presenting
with elevated PSA or abnormal digital rectal examination
(DRE).
As with any procedure, TRUS-guided prostate biopsy is not
free from complications.
An average of 250 TRUS-guided prostate biopsies are
annually performed in our hospital, making it one of the
most frequently carried out procedures in our daily clinical
practice; therefore it is important to analyze its main complications in an effort to improve study and prevention protocols.
The aim of this study was to report the frequency of complications following TRUS-guided prostate biopsy performed
at the Hospital Regional “Lic. Adolfo López Mateos” del
ISSSTE.
From a total of 420 biopsied patients at our hospital, a
cross-sectional, analytic, descriptive, and retrolective study
was conducted on 245 patients that, after undergoing biopsy, answered a telephone questionnaire applied to investigate if there were any complications.
All the patients underwent TRUS-guided prostate biopsy
with the same technique. Twenty-four hours prior to the
procedure patients were given a liquid diet, and 12 and 6
hours before biopsy they were given an enema. They also
received antibiotic prophylaxis of 500 mg oral ciprofloxacin
every 12 hours 2 days prior to the procedure. All patients
gave their signed informed consent before undergoing TRUSguided prostate biopsy. All biopsies were performed with
ESAOTE My LabTM Desk ultrasound equipment using a 12 Hz
intracavitary transducer. Anesthetic infiltration of the periprostatic segments was done with simple 2% xylocaine under ultrasound control with an 18G shiba needle. The
biopsies were performed with a 22G needle. A total of 12
cores were taken, using the sextant regimen for each lobe.
In patients having had a previous negative biopsy, a total of
18 cores were taken.
After the procedure, the patients were given a bland diet,
500 mg oral ciprofloxacin every 12 hours for 3 more days,
and 500 mg oral paracetamol every 8 hours for 3 days. They
were informed as to alarm signs and symptoms and had
open emergency room appointments.
The frequencies, means, standard deviations, and percentages of the results were analyzed using the IBM SPSS v.
19 program.
116
P. Cruz García-Villa et al
Table 1 Result comparison with a previous study
2011 (N=117)
3
2012 (N=45)
Age
69 ± 8
68.4 ± 8.8
High blood pressure
25.6%
24.9%
Type 2 DM
12.8%
10.6%
20.4 (4.53 – 273)
20.2 (3.3 – 273)
57.1 ± 25 (15.6 – 130)
62.4 ± 31.7 (15.6 – 189)
Normal
78.6%
77.4%
Suspicious
21.4%
22.6%
PSA (ng/mL)
Prostate volume (mL)
Digital rectal exam
Result
Positive for malignancy
33.3%
35.6%
Negative for malignancy
66.7%
64.4%
Acute urine retention
5.1%
2.4%
6%
5.7%
Fever
Hematospermia
10.3%
9.8%
Days with hematuria
2.14
1.78
Days with hematochezia
1.5
0.5
DM: diabetes mellitus; PSA: prostate-specific antigen.
Results
Of the 245 patients that answered the questionnaire, the
mean age was 68.4 ± 8.8 years with a 42 to 89-year interval.
A total of 24.9% of the patients had a past medical history of
high blood pressure and 10.6% presented with type 2 diabetes mellitus. A total of 14.3% of the patients had more than
one comorbidity. The mean PSA was 20 ng/mL, with an interval of 3.3 to 273 ng/mL. The mean prostate volume measured by TRUS at the time of biopsy was 62.4 ± 31.7 mL.
Unremarkable DRE was found in 77.4% of the patients at the
time of biopsy, whereas some abnormality was suspected in
22.6% of the patients. The procedure was the first biopsy for
77.1% of the patients (189 cases), the second for 15.1% (37
cases), and the third for 6.9% (17 cases). Of the patient total (245 cases), 35.6% presented with positive malignancy in
the biopsy (table 1).
In relation to the corresponding complication data, hematuria presented in 68.6% of the patients. The mean hematuria duration was 1.78 days with an interval of 0 to 20 days.
Hematospermia presented in 9.8% (24 cases) and was second in frequency. Some type of symptomatology suggestive
of a vasovagal reaction during biopsy presented in 8.6% of
the patients. A total of 6.9% (17 cases) referred to hematochezia after biopsy that lasted a mean of 0.5 days. A total of
8.6% (21 cases) of the patients referred to difficulty in initiating micturition after TRUS-guided prostate biopsy and
2.4% (6 cases) presented with acute urine retention that required a bladder catheter. A total of 42% (103 cases) complained of dysuria after TRUS-guided prostate biopsy. The
mean duration of dysuria was 1.5 days. According to the visual analog scale for pain, the mean score was 4.5 ± 2.6
points. A total of 2% (5 cases) of the patients said they selfmedicated after the procedure (fig. 1).
Only 5.7% (14 cases) of the patients presented with fever,
and only 2.9% (7 cases) required hospitalization for some
reason. There were no cases of severe sepsis and no deaths
related to the biopsy.
Discussion
In 2011, our group first published the results related to the
frequency of complications due to prostate biopsy at our
hospital.3 In the present study, we reported the results from
a larger sample for the purpose of determining whether our
figures remained the same or were modified (table 1).
TRUS-guided prostate biopsy is the procedure of choice
for CaP diagnosis. Indications for performing prostate biopsy
are the presence of elevated PSA or an increase in prostatic
consistency or nodule upon DRE.
The utilization of TRUS of the prostate, first described by
Watanabe in 1968, expanded to include its systematic clinical use with the advances in ultrasound technology and the
introduction of sextant biopsy protocols, guided by the Hodge protocols in 1989.1,4
TRUS-guided prostate biopsy has been very widely used in
the diagnosis of CaP. The procedure can be associated with
significant morbidity in a small proportion of patients. Hemorrhagic complications are the most frequent, followed by
infection presenting as simple urinary tract infection (1.2%
to 11.3%) or complicated with fever (1.4% to 4.5%).1,5
The mortality rate following a TRUS-guided prostate biopsy is
estimated at 0.09%.6 Other much less frequent complications
are acute urine retention and prolonged rectorrhagia.7
Complications secondary to prostate biopsy 117
2%
Hematuria
42%
Hematospermia
Vasovagal reaction
Hematochezia
Urinary stress
2.40%
Urinary retention
68.60%
8.60%
Dysuria
Self-medication
6.90%
8.60%
9.80%
Figure 1 Complication percentage after TRUS-guided prostate biopsy.
In our study, hematuria was the most frequent complication, with a percentage of 68.6%, followed by hematospermia at 9.8%. In accordance with other studies, hematuria
can present from 12% up to 60%, whereas hematospermia on
average appears in 10%.3
Fever presented in 5.7% of the patients. The fact that we
did not carry out control urine culture after the biopsy is a
limitation of our study. Because of this, we cannot determine the precise number of urinary infections directly related
to biopsy.
Following the recommendation of the American Academy
of Urology regarding prophylaxis with fluoroquinolones prior
to TRUS-guided prostate biopsy, we administered 500 mg of
oral ciprofloxacin every 12 hours to all patients 2 days prior
to the biopsy and 3 days after.8,9 Upon comparing our present results of fever after TRUS-guided prostate biopsy
(5.7%) with the figures from our previous study (6%), we
found that there was no increase in the clinical cases of infection, nor data that suggested resistance to ciprofloxacin
use.10 We consider prior intestinal preparation to be useful
in reducing infection. The mechanical sweeping of bacteria
found in the rectum through the use of laxatives, promotes
a reduction in the risk for infections from gram-negative
bacteria.
A slight increase in the positive biopsy rate of 35.6% was striking in the present study. This result could be due to a certain
bias, given that this study only included patients that answered
the questionnaire, whereas in another study conducted by our
group on 420 patients, the percentage of positivity was 33.8%,
the same as in the study published in 2011.
TRUS-guided prostate biopsy is an adequate detection
method because it is safe, accessible, ambulatory, and tolerable. The use of antibiotic prophylaxis and previous
anesthesia makes it well tolerated by patients.
Despite taking all the precautionary measures for reducing the risks for infection and hemorrhage, they can still
persist. Therefore, we believe that TRUS-guided prostate
biopsy should only be performed when there is an indication
justifying it. Likewise, the opportune suspension of anticoagulants or anti-platelet drugs, the absence of urinary infection, the initiation of antibiotic prophylaxis, and intestinal
preparation are all factors that we feel are necessary for
carrying out biopsy. It is also our opinion that those patients
needing anticoagulant maintenance that have an increased
risk for bleeding should be hospitalized to undergo biopsy.
This way, there can be strict surveillance before and after
the procedure.
Today there are recommendations and guidelines supported by different associations with respect to TRUS-guided
prostate biopsy. However, we believe that the experience at
each hospital and in each country can have variations and
therefore it is important to carry out pertinent modifications to the protocol being used in order to offer the patient
a procedure that has a minimum of risks and a maximum
detection rate.
Conclusions
TRUS-guided prostate biopsy continues to be the definitive
diagnostic procedure for CaP. Even though there is a risk for
complications, their low percentage makes it a suitable and
relatively safe method. When certain preventive measures
are carried out, such as antibiotic prophylaxis, intestinal
preparation, and the suspension of anticoagulants, the risk
for complications is reduced.
The authors declare that there is no conflict of interest.
References
1. Djavan B, Waldert M, Zlotta A, et al. Safety and morbidity of
first and repeat transrectal ultrasound-guided prostate needle
biopsies. Results of a prospective European prostate cancer detection study. J Urol 2001;166(3):856-860.
118
2. Consultado el 29 de mayo de 2013. Sinais.salud.gob.mx.
3. Castellanos-Hernández H, Cruz García-Villa P, Navarro-Vargas
JC, et al. Frecuencia de complicaciones de la biopsia transrectal de próstata ecodirigida. Rev Mex Urol 2011;71(2):81-86.
4. Hodge KK, McNeal JE, Terris S, et al. Random systematic versus
directed ultrasound-guided transrectal core biopsies of the
prostate. J Urol 1989;142(1):71-74.
5. Aus G, Ahlgren G, Bergdahl S, et al. Infection after transrectal
core biopsies of the prostate-risk factors and antibiotic prophylaxis. Br J Urol 1996;77(6):851-855.
6. Ismail M, Saini A, Nigam R. Ciprofloxacin-resistant infection after transrectal ultrasonography-guided prostate biopsy: should
we reassess our practice? BJU Int 2011;108(3):305-306.
P. Cruz García-Villa et al
7. Dodds Pr, Voucher JD, Shield DE. Are complications of transrectal ultrasound-guided biopsies of the prostate gland increasing?
Conn Med 2011;75(8):453-457.
8. Wolf JS Jr, Bennett CJ, Dmochowski RR et al. Best practice policy statement on urologic surgery antimicrobial prophylaxis. J
Urol 2008;179(4):1379-1390.
9. Kapoor DA, Klimberg IW, Malek GH, et al. Single dose oral ciprofloxacin versus placebo for prophylaxis during transrectal
prostate biopsy. Urology 1998;52(4):552-558.
10. Loeb S, Ballentine C, Berndt SI, et al. Complications after prostate biopsy: Data From SEER-Medicare. J Urol 2011;186(5):18301834.
Rev Mex Urol 2013;73(3):119-124
Original article
Correlation between PSA and IPSS values, type of work, and
educational level in a Spanish occupational population
M. T. Vicente-Herreroa,*, Á. A. López-Gonzálezb, M. V. Ramírez-Iñiguez de la Torrec, L.
M. Capdevila-Garcíad and M. J. Terradillos-Garcíae
a
Occupational Medicine Speciality, Grupo Correos-Valencia, Grupo de Investigación en Medicina del Trabajo (GIMT), Spain
Occupational Medicine Speciality, Grupo de Investigación del IUNICS, Grupo de Investigación en Medicina del Trabajo
(GIMT), Spain
b
c
Occupational Medicine Speciality, Grupo Correos-Albacete, Grupo de Investigación en Medicina del Trabajo (GIMT), Spain
Occupational Medicine and Family Medicine Speciality, Servicio de Prevención Mancomunado MAPFRE, Grupo de
Investigación en Medicina del Trabajo (GIMT), Valencia, Spain
d
e
Occupational Medicine Speciality, INSS-Madrid, Spain
KEYWORDS
Benign prostatic
hyperplasia; Prostate
cancer; Prostate
disease; Occupational
health; Occupational
medicine; Urology;
Spain.
Abstract
Background: By way of the Occupational Health Department and the occupational physician, the
International Prostate Symptom Score (IPSS) questionnaire was used to screen for benign prostatic hyperplasia (BPH), and prostate-specific antigen (PSA) was used as a biomarker for the
diagnosis, staging, and monitoring of prostate cancer (CaP).
Aims: The aim of our study was to evaluate the influence of the workplace and the educational
level of white-collar and blue-collar workers on IPSS and PSA values.
Methods: PSA, IPSS, type of work, and educational level of 620 workers from the service sector
above the age of 40 years were included. Data were collected during the periodic company
health monitoring check-ups. The chi-square test was used for proportion differences and the
Student’s t test for the differences in the mean values of age, IPSS, and PSA, according to the
type of work and the level of education.
Results: There were statistically significant differences in the mean IPSS and PSA values according to
the type of work and educational level of the workers, and in the proportions, according to IPSS cataloguing related to the type of work performed. There were no statistically significant differences
* Corresponding author at: Telephone: 963 102 752. Spain. Emails: [email protected], [email protected] (M. T. Vicente-Herrero).
120
M. T. Vicente-Herrero et al
regarding level of education. Conclusions: The PSA and IPSS values were higher in the white-collar
workers and the PSA values were also higher in workers with a low educational level.
Palabras clave
Hipertrofia benigna de
próstata; Cáncer
de próstata;
Enfermedad
prostática; Salud
laboral; Medicina del
trabajo; Urología;
España.
Correlación entre los valores de APE, IPSS, tipo de trabajo y nivel educacional en
población laboral española
Resumen
Introducción: En Salud Laboral y por el médico del trabajo, se recurre al IPSS como screening de
hiperplasia benigna de próstata (HBP) y al antígeno prostático específico (APE), como biomarcador para diagnóstico, estadificación y seguimiento del cáncer de próstata (CaP).
Objetivo: El objetivo de nuestro estudio es valorar la influencia que sobre los valores del Índice
Internacional de la Sintomatología Prostática (IPSS, International Prostate Symptom Score, por
sus siglas en inglés) y APE, tiene el puesto de trabajo desempeñado (white collar-blue collar) y
el nivel educacional de los trabajadores.
Material y métodos: Se incluyen 620 trabajadores del sector servicios, de más de 40 años valorando APE, IPSS, tipo de trabajo y nivel de estudios, con captación realizada durante los
reconocimientos periódicos de vigilancia de la salud. Se aplica el test de ji cuadrada para la
diferencia de proporciones y el test de la t-Student para las diferencias en los valores medios de
edad, IPSS y APE según tipo de trabajo y nivel de estudios.
Resultados: Se observan diferencias estadísticamente significativas en los valores medios del
IPSS y APE, según tipo de trabajo y nivel de estudios de los trabajadores, y en las proporciones,
según catalogación del IPSS de acuerdo al trabajo realizado. No se observan diferencias significativas según el nivel académico.
Conclusiones: Los valores de IPSS y APE son más altos en los trabajadores no manuales (white
collar). Los valores de APE son más altos en trabajadores con bajo nivel de estudios.
Introduction
Benign prostatic hyperplasia (BPH) is a disease with a high
prevalence among men over 50 years of age, both in Spain,
as well as in countries of a similar sociocultural environment. Approximately 16.5% of the patients with lower urinary tract symptomatology have scores regarded as
moderate or severe on the International Prostate Symptom
Score (IPSS) that affect quality of life (IPSS ≥ 8).1 Diagnosis
can be made through adequate anamnesis, lower urinary
tract symptom evaluation through the IPSS, physical examination with a digital rectal exam (DRE), and prostate-specific antigen (PSA) values. All these tests are recommended by
the different guidelines for the initial evaluation and they
are within reach of all physicians.2,3
Prostate cancer (CaP) is the most frequent tumor in men
and is the second cause of death by cancer in men, behind
lung cancer. Its early detection and treatment continue to
be a pressing and controversial problem.4 The traditional
PSA value for indicating prostate biopsy is 4 ng/mL. However, there is an important number of tumors below this value that are not detected unless they are palpable or visible,
resulting in the research that has been carried out in recent
years on more sensitive and specific next-generation CaP
biomarkers.5
The patient’s medical history, IPSS, DRE, and PSA are accessible tools in the Occupational Medicine environment
that enable the adequate diagnosis of prostate pathology.
The consensus criteria established by the primary attention
scientific societies (Sociedad Española de Médicos de Atención Primaria, SEMERGEN; Sociedad Española de Medicina
General, SEMG; Sociedad Española de Medicina de Familia y
Comunitaria, semFYC) and the Asociación Española de Urología (AEU), are also applicable in the workplace, so there
can be coordinated action on the part of the specialities
involved.6
The IPSS (Level 3 Evidence, Grade B Recommendation) is
a standardized, validated, and self-applicable scale that
should not replace the medical interview, but that aids in
evaluating the need for treatment and in monitoring the
progression of symptom severity during follow-up. There is a
validated Spanish version that includes a question on the
impact of symptoms on the patient’s quality of life.6
PSA is a prostate tissue marker that is not CaP specific.
Various diseases in addition to cancer can cause elevated
antigen levels: urinary tract infections (UTIs), BPH, and
prostatitis. PSA use is not recommended without a previous
DRE. The combination of the two is the most effective
method for early CaP detection.
Normal values vary with age, but in general a PSA < 4 is
regarded as normal; however, 25% of men with CaP have PSA
values < 4. Likewise, a high PSA value does not confirm the
presence of cancer and a PSA > 10 demands ultrasound-guided biopsy.
Correlation between PSA and IPSS values, type of work, and educational level in a Spanish occupational population Table 1 Mean sample values: age, IPSS, PSA
Mean
TD
95%CI
Median
Range
Age
52.6
4.4
52.3-52.9
52
42-67
IPSS
5.1
4.7
4.7-5.5
3.5
0-29
PSA
1.2
1.1
1.1-1.3
0.95
0.1-6.4
TD: typical deviation; CI: confidence interval.
121
Table 2 Sample characteristics: type of work and educational
level n
%
White-collar*
337
54.4
Blue-collar**
283
45.6
With no studies/ primary school
149
24
Junior high and High school
310
50
University
161
26
*Manual laborers. ** Non-manual laborers.
IF PSA is between 4 and 10, the free/total PSA coefficient and
PSA velocity must be evaluated. A free/total PSA coefficient >
0.2 (> 20%) suggests BPH, but a free/total PSA coefficient < 0.2
(< 20%) suggests CaP and makes a biopsy necessary. An increase
in PSA > 0.75 ng/mL/year also suggests CaP.
PSA (Level 3 Evidence, Grade B Recommendation) should
be ordered in all patients being seen for prostatism that are
over 50 years of age (or before 40-45 years of age if there is
a family history of CaP). The high level of this antigen is
linked to an increased possibility of developing CaP.2
Given the abovementioned, prostate pathology requires
healthcare continuity among the different existing levels in
Spain, especially those of primary attention and specialized
attention. This is where Occupational Medicine acquires
special preventive and diagnostic relevance in the population it has access to. According to the National Statistics
Institute (NSI) 2011 data, this population reached 18,104,500
employed workers of all ages, more than 3,346,000 of which
are men over the age of 50 years that can be incorporated
into prostate pathology prevention campaigns.6
Even though there are multiple studies relating, among
other things, the correspondence of results between IPSS
and PSA in prostate pathology, few studies have related these values with the educational level or with the type of
work performed; there have been studies relating the rejection by patients of DRE to their cultural or educational level, with family income, or with socioeconomic status.7-9 For
this reason, we felt it was interesting to introduce the lessstudied parameters of type of work performed and educational level of the worker, together with a much more
standardized PSA and IPSS evaluation, in an attempt to find
earlier and more effective preventive support strategies of
special interest in the workplace.
The aim of this study was to establish a possible correspondence between the IPSS and PSA value results obtained
in the Spanish blue-collar and white-collar working population with the type of work performed and the cultural and
educational level of the participants.10,11 The blue-collar
and white-collar concepts have been used in health promotion to evaluate highly prevalent pathologies such as the
cardiovascular diseases and the risk for developing them12,
or in addictions to alcohol13 or tobacco.14
Methods
A total of 620 Spanish workers above the age of 40 years
participated in the study. They belonged to the service sector and were randomly selected during the periodic health
monitoring check-ups carried out by their companies. Randomization was done by choosing the first and last worker
per day that fit the selection criteria. The sample size that
provided a 95% confidence interval and 3% accuracy was
made up of 615 persons. During the study period from January 2010 to December 2011, 658 men over the age of 40
years had a medical check-up; from that total, 29 had a past
medical history of prostate problems and 9 refused to participate in the study, leaving a final sample size of 620 persons.
The selection criteria were: men over 40 years of age, not
being treated for any neoplastic or hyperplastic prostate
pathology, and willingly participating in the study.
Informed consent was obtained for epidemiologic use of
the data and the study was approved by the Safety and
Health Committees of the corresponding companies.
PSA values were determined, lower urinary tract symptomatology was evaluated through the validated IPSS, the
type of work was established (blue collar/manual laborers,
white collar/non-manual laborers), as well as the level of
education (no studies/primary school, junior high and high
school, university).
Concerning the statistical analysis of the results, the chisquare test was applied for the difference in proportions
and the Student’s t test for the difference in the mean values of age, IPSS, and PSA according to the type of work and
level of education.
Results
Sample characteristics
The sample consisted of 620 workers with a mean age of 52.6
years, a mean IPSS score of 5.1, and a mean PSA value of 1.2
(table 1). Of the workers, 337 were white collar and 283 were
blue collar. In regard to the educational level, 149 had no studies or only primary school, 310 attended junior high or high
school, and 161 had attended university (table 2).
122
Table 3 Sample distribution according to IPSS and PSA values
IPSS*
%
Mild
484
78.1
Mean
TD
95% CI
p*
Moderate
131
21.1
Age
Blue-collar
52.3
4.3
51.8-52.8
> 0.05
5
0.8
White-collar
52.9
4.5
52.4-53.4
Primary
school
53.2
4.5
52.5-53.9
Junior high
and High
school
52
3.9
51.6-52.4
Severe
PSA**
Table 4 Correlations between age, IPSS, PSA, and the type
of work and educational level
n
Normal
596
96.1
Elevated
24
3.9
* IPSS: 0-7 mild, 8-19 moderate, ≥ 20 severe. ** PSA: elevated
starting from 4.
IPSS
A total of 484 workers had mild UTI symptoms (IPSS 0-7),
131 had moderate symptoms (IPSS 8-19), and 5 presented
with severe symptoms (IPSS ≥ 20). PSA values regarded as
normal (< 4) were found in 596 workers and 24 presented
with elevated figures (≥4) (table 3).
Correlation study
No difference was observed in relation to age, the type of
work, and the educational level (p > 0.05). There was statistical difference in regard to IPSS values and the type of
work (p < 0.05), but it was not related to the educational
level; statistically significant differences were observed in
the PSA values and the type of work and also in the educational level (p < 0.05) (table 4).
The cataloging of IPSS severity values according to the
type of work and educational level was statistically significant. The chi-square test was applied in order to see the
difference in proportions (table 5).
The cataloging of PSA values that were regarded as pathologic (≥ 4) was statistically significant in relation to the level of
education (p < 0.05), but not for the type of work (table 6).
Discussion
Occupational medicine as a preventive speciality is legally
based on the 1995 Ley de Prevención de Riesgos Laborales15
and the 1997 Reglamento de los Servicios de Prevención16.
The functions of the preventive service occupational physician are part of the Occupational Medicine speciality program (approved in 2005) and also include other international
recommendations sustained by the ILO (recommendations
161, 171) and the WHO, the majority of which appear in the
Framework Directive 89/391/EEC17.
A company’s Preventive Service, which incorporates Occupational Medicine, «is a set of necessary human and material resources for carrying out the preventive activities for
guaranteeing adequate worker safety and health protection
by advising and aiding the businessperson, workers, and
their representatives and the organs of specialized representation». Article 37 of the RD 39/97 lists the higher level
functions, which include occupational medicine, and section 3 states the specific actions with respect to health surveillance. This is the principal, and most well known, sphere
PSA
University
53.2
5.1
52.4-54
Blue-collar
4.1
4.7
3.6-4.6
White-collar
5.9
4.6
5.4-6.4
Primary
school
5.4
4.9
4.6-6.1
Junior high
and High
school
4.8
4.4
4.3-5.3
University
5.4
5.1
4.7-6.2
Blue-collar
1.1
0.9
1-1.2
White-collar
1.3
1.3
1.2-1.4
Primary
school
1.9
1.8
1.6-2.2
Junior high
and High
school
1
0.8
1-1.1
University
0.8
0.6
0.7-0.9
> 0.05
< 0.05
> 0.05
< 0.05
< 0.05
*p < 0.05: statistically significant; TD: typical deviation; CI:
confidence interval.
of action, perhaps due to traditionally being carried out before it was signed into Law. Health promotion is also included and in the area of healthcare, diagnosis, treatment,
and follow-up of common diseases, redirecting the process
to the corresponding healthcare level; thus prostate pathology is a priority, taking into account that the current occupational age is up to 65 years and this pathology has a high
prevalence in this group of workers.
Diseases of the prostate can be initially diagnosed by the
preventive service occupational physician if the material
means for doing so are available. This is especially true in
relation to BPH as a highly prevalent disease and to early
CaP diagnosis, always being managed as a coordinated action with the specialized medical attention; this justifies
the necessity of having systematized criteria as to when a
patient with prostate pathology should be referred to the
urologist. This coordinated action is now established and
protocoled with family medicine and primary healthcare
specialists. In contrast, it is an area that is deficient in
the speciality of Occupational Medicine.
Of all the risk factors for CaP, those that have shown the
greatest evidence (strength of evidence B) are: causal
Correlation between PSA and IPSS values, type of work, and educational level in a Spanish occupational population 123
Table 5 IPSS severity value cataloguing according to the type of work and educational level
Mild
Moderate
Severe
Χ²*
p**
N
%
N
%
N
%
Blue collar
234
82.7
44
15.5
5
1.8
15.1
0.0005
White collar
250
74.2
87
25.8
0
0
Primary school
100
67.1
47
31.6
2
1.3
16.1
0.0029
258
83.2
50
16.1
2
0.7
University
126
78.3
34
21.1
1
0.6
* χ²: chi-square. ** p < 0.05: statistically significant.
Table 6 PSA severity value cataloging according to the type of work and educational level
Normal
Elevated
Χ²*
p**
N
%
N
%
Blue collar
276
97.5
7
2.5
2.7
0.09
White collar
320
95
17
5
Primary school
129
86.6
20
13.4
48.6
< 0.0001
306
98.7
4
1.3
University
161
100
0
0
* χ²: chi-square. ** p < 0.05: statistically significant.
association with antioxidants (vitamin E, lycopene, and
selenium), fertilizers used in the rural environment,
overweight, low intake of fruit, high intake of calcium, fats,
and meats. Likewise, in the labor environment, a relation to
exposure to cadmium18,19, herbicides, and pesticides used in
agriculture, ionizing radiations, exposure to agent orange,
ultraviolet radiation, and mineral substances used in the
manufacture of tires and batteries has been observed.20
Of all the screening techniques, PSA determination in
blood has been shown to have the greatest use, with 84.5%
sensitivity and 98% specificity; DRE has a sensitivity of 69%
and a specificity of 92%. Even though it varies with age, PSA
serves as a tumor extension indicator. Different international and prestigious associations such as the American Cancer Society (ACS), the American Urological Association
(AUA), and the Preventive Services Task Force (USPSTF, U.S.)
recommend screening for CaP (PSA determination) for men
starting at 50 years of age.
Given this background, PSA determination, as one aspect of
the periodic medical check-up (health surveillance) in men
over the age of 45, has been included in an important part of
company preventive and occupational health services.
A large number of clinical trials from the perspectives of
primary care and urology have been conducted to determine the usefulness of IPSS and PSA values in the detection,
control, and follow-up of prostate pathologies, as well as
the concordance between their values and validity for establishing standardized protocols.21 These are patterns that
are also applicable to Occupational Medicine, even though
no formal coordination has been organized between this
speciality and others, despite the high number of workers
receiving this regular follow-up. This represents a deficiency in the health chain that includes occupational health as
part of Public Health.
In carrying out his or her preventive or healthcare activities, the occupational physician has access to specific information related to workplace exposures and, as in the
present study, to aspects related to the jobs of workers with
specific positions or to their educational levels. Even though
these aspects have been less frequently addressed, they
have been evaluated in regard to cardiovascular risks and
addictions to tobacco or alcohol in white-collar and bluecollar workers, analyzing the type of work and its influence
on certain pathologies.
The agreement among results obtained here indicates
that there is a tendency for these concrete aspects to have
an influence on prostate pathology. However, the results
must be confirmed through studies that have larger worker
samples and that provide more specific aspects related to
the type of work. The same was also true for the educational or socioeconomic level; the data appear to indicate a
tendency to have repercussions on these pathologies. There
124
are published studies on the influence of socioeconomic and
racial aspects in relation to lower urinary tract pathologies,22,23 but not with the occupational aspects considered in
the present study. We recommend continuing this line of
study on greater numbers of workers and coordinating specific aspects that could corroborate the tendency observed
herein.
At any rate, Occupational Medicine can and must collaborate on preventive campaigns that are begun at the different healthcare levels, especially that of Public Health. It
should also be included in the coordinated protocols that
are already being established with great efficacy, together
with other first level specialities. Occupational health can
incorporate important information that is not accessible
from other healthcare levels, providing mutual benefit and
optimizing the available resources.
References
1. Chong C, Fong L, Lai R, et al. The prevalence of lower urinary
tract symptoms and treatment-seeking behaviour in males over
40 years in Singapore: a community-based study. Prostate Cancer Prostatic Dis 2012;15(3):273-277.
2. Castiñeiras J, Cozar JM, Fernández-Pro A, et al. Referral criteria for benign prostatic hyperplasia in primary care. Actas Urol
Esp 2010;34(1):24-34.
3. Molero JM, Pérez-Morales D, Brenes F, et al. Benign prostatic
hyperplasia referral criteria for primary care, 2011 version.
Aten Primaria 2012;44(6):371-373.
4. Granado de la Orden S, Saá Requejo C, Quintás Viqueira A. Epidemiological situation of prostate cancer in Spain. Actas Urol
Esp 2006;30(6):574-582.
5. Prensner JR, Rubin MA, Wei JT, et al. Beyond PSA: the next generation of prostate cancer biomarkers. Sci Transl Med
2012;4(127):127rv3.
6. Consultado el 15 de diciembre de 2012. http://www.ine.es/jaxiBD/menu.do?divi=EPA&his=1&type=db&L=0
7. Romero FR, Romero KR, Brenny FT, et al. Reasons why patients
reject digital rectal examination when screening for prostate
cancer. Arch Esp Urol 2008;61(6):759-765.
8. Woods VD, Montgomery SB, Herring RP, et al. Social ecological
predictors of prostate-specific antigen blood test and digital
rectal examination in black American men. J Natl Med Assoc
2006;98(4):492-504.
9. Lim LS, Sherin K. ACPM Prevention Practice Committee.
Screening for prostate cancer in U.S. men ACPM position
statement on preventive practice. Am J Prev Med
2008;34(2):164-170.
10. Rundle A, Neckerman KM, Sheehan D, et al. A prospective study
of socioeconomic status, prostate cancer screening and incidence among men at high risk for prostate cancer. Cancer Causes Control 2013;24(2):297-303.
11. DeVault IA. White collar/blue collar [Electronic version]. Sons
and daughters of labor: Class and clerical work in turn-of-thecentury Pittsburgh. Ithaca, NY: Cornell University Press; 1990.
p. 1-8.
12. Alexy B. Workplace health promotion and the blue collar worker. AAOHN J 1990;38(1):12-16.
13. Sánchez-Chaparro MA, Calvo E, González-Quintela A, et al.
High cardiovascular risk in Spanish workers.
Nutrition,Metabolism & Cardiovascular Diseases. 2011;21:231236.
14. Holmila M, Mustonen H, Rannik E. Alcohol use and its control in
Finnish and Soviet marriages. Br J Addict 1990;85(4):509-520.
15. White V, Hill D, Siahpush M, et al. How has the prevalence of
cigarette smoking changed among Australian adults? Trends in
smoking prevalence between 1980 and 2001. Tob Control
2003;12(Suppl 2):ii67-74.
16. España. Ley 31/1995, de 8 de noviembre, de Prevención de
Riesgos Laborales.
17. España. Real Decreto 39/1997, de 17 de enero, por el que se
aprueba el Reglamento de los Servicios de Prevención. BOE nº
27 31-01-1997.
18. Consultado el 15 de diciembre de 2012. http://www.upf.edu/
udmt/_pdf/programaesp.pdf (consultado 15/12/2012)
19. Directiva 89/391/CEE del Consejo, de 12 de junio de 1989, relativa a la aplicación de medidas para promover la mejora de la
seguridad y de la salud de los trabajadores en el trabajo. Doce
183/L, de 29-06-89
20. Granado de la Orden S, Saá Requejo C, Quintás Viqueira A. Epidemiological situation of prostate cancer in Spain. Actas Urol
Esp 2006;30(6):574-582.
21. Mullins JK, Loeb S. Environmental exposures and prostate cancer. Urol Oncol 2012;30(2):216-219.
22. Cozar JM, Solsona E, Brenes F, et al. Clinical management of
patient with benign prostatic hyperplasia in Spain. Actas Urológicas Españolas 2011;35(10):580-588.
23. Fowke JH, Munro H, Signorello LB, et al. Urologic Diseases of
America Project. Association between socioeconomic status
(SES) and lower urinary tract symptom (LUTS) severity among
black and white men. J Gen Intern Med 2011;26(11):1305-1310.
Rev Mex Urol 2013;73(3):125-129
Original article
A review of our experience in treating male urinary incontinence
through the AMS-800™ artificial urinary sphincter
F. X. Elizalde-Benito*, Á. G. Elizalde-Benito, M. Urra-Palos and Á. G. Elizalde-Amatria
Hospital Clínico Universitario Lozano Blesa, Zaragoza, Spain
KEYWORDS
Artificial sphincter;
Urinary incontinence;
Post-prostatectomy
incontinence; Spain.
Abstract
Background: Since 1983, the AMS-800™ artificial urinary sphincter has been a therapeutic procedure in the management of urinary incontinence due to incompetent sphincter. We present
herein treatment results and effectiveness according to our experience.
Methods: Within the time frame of 1997 to 2012, this prosthesis has been implanted in 50 patients presenting with incontinence due to sphincterial incompetence that was secondary to
prostate surgery in 90% of the cases. It was placed in the bulbar urethra in men and in the
bladder neck in women, implanting a single cuff, between 4 and 5.5 cm, with reservoir pressures of 60 to 70 cm of water.
Results: The answers “very much better” and “much better” on the Patient Global Impression of
Improvement (PGI-I) questionnaire and the need to use fewer than 2 compresses/day were regarded
as the treatment outcome criteria. There was cure or improvement in 42 of the patients (84%). Eight
patients (16%) presented with complications and a total of 8 patients (16%) were re-operated on for
artificial sphincter removal and reimplantation, with good results in 3 patients.
Conclusions: Treatment with the AMS-800™ prosthesis for severe urinary incontinence in men due to
sphincterial incompetence is an effective therapeutic alternative. Nevertheless, the procedure is not
without complications and other techniques with similar results are preferred for women.
*Corresponding author at: Paseo Ruiseñores 22-24, puerta 12, C.P. 50006, Zaragoza, España. Telephone: (0034) 6467 35167. Fax: (0034)
97627 8904. Email: [email protected] (F. X. Elizalde-Benito).
126
Palabras clave
Esfínter artificial;
Incontinencia
urinaria;
Incontinencia
posprostatectomía;
España.
F. X. Elizalde-Benito et al
Revisión de nuestra experiencia en el tratamiento de la incontinencia urinaria en el
varón mediante el esfínter urinario artificial AMS-800TM
Resumen
Introducción: El esfínter urinario artificial AMS-800TM es un procedimiento terapéutico, en el
manejo de la incontinencia urinaria por incompetencia esfinteriana desde 1983. Presentamos los
resultados y eficacia del tratamiento según nuestra experiencia.
Material y métodos: Se ha implantado esta prótesis a 50 pacientes, desde 1997 hasta 2012, con
incontinencia debida a incompetencia esfinteriana secundaria a cirugía prostática en el 90% de
los casos. En hombres se han colocado en uretra bulbar, y en mujeres en cuello vesical, implantado un solo manguito entre 4 y 5.5 cm, con presiones del reservorio de 60 a 70 cm de agua.
Resultados: Se evaluó como criterio de curación las respuestas “muchísimo mejor” o “mucho
mejor” del cuestionario Patient Global Impression of Improvement (PGI-I) y la necesidad de menos
de 2 compresas/día, siendo de curación o mejoría en 42 (84%) pacientes. Se observaron complicaciones en 8 pacientes (16%) y se reintervino a un total de 8 pacientes (16%) para la retirada
del esfínter artificial, usándose el reimplante con buenos resultados en 3 pacientes.
Conclusiones: El tratamiento de la incontinencia urinaria severa en el varón por incompetencia
esfinteriana mediante el uso de la prótesis AMS-800TM, es una alternativa terapéutica eficaz, sin
olvidar sus posibles complicaciones, prefiriéndose en mujeres la utilización de otras técnicas de
similares resultados.
Introduction
Urinary incontinence has an important psychological and social impact and affects the patient’s quality of life. There
are many therapeutic alternatives for the treatment of
stress incontinence. Since 1983, AMS-800TM artificial urinary
sphincter implantation1,2 (fig. 1) has been a good alternative
in treating severe urinary incontinence in men due to
sphincterial incompetence, with much experience in its
use.3-5 We present herein our experience using the AMS800TM artificial urinary sphincter, evaluating both the effectiveness and complications in the treatment of severe
urinary incontinence with the AMS-800TM artificial urinary
sphincter, by means of a retrospective analysis of the etiology of incontinence, the functional results, and the surgical
and postoperative complications.
Methods
We conducted a descriptive and retrospective study within
the time frame of 1997 to 2012 during which this prosthesis
was implanted in a total of 50 patients, 47 men and 3 women. Before implantation, all the patients underwent
urethrocystoscopy to rule out stricture and foreign bodies
and they also had a complete urodynamics study (cystometry and pressure-flow study).
The cause of incontinence has always been sphincterial
incompetence secondary to:
✓ Prostate surgery:
• Radical prostatectomy: 36 cases.
• TURP: 6 cases.
• Adenomectomy: 3 cases.
✓Neurologic origin:
• Moyamoya disease: one case.
• Intrinsic sphincterial incompetence: one case.
• Ependymoma of the filum terminale: one case.
✓ Radical cystoprostatectomy and neobladder: one case.
✓ Failure of previous incontinence surgery: one case.
The procedure was performed with the technique habitually used with the AMS-800TM artificial urinary sphincter
(fig. 2). A single cuff has always been implanted, varying
between 4 and 5.5 cm, with reservoir water pressures of 60
to 70 cm; it was placed in the bulbar urethra in men and the
bladder neck in women.
Mean postoperative hospital stay was 1.13 days, with a
postoperative check-up at one month and activation of the
artificial sphincter device. Patients answered the Patient
Global Impression of Improvement (PGI-I) questionnaire6,
which collects data on the current status of urinary symptoms in comparison with the situation prior to surgery. El
PGI-I consists of a single question that asks the patient to
classify the relief obtained from the treatment on a 7-point
Likert scale as: “very much better”; “much better”; “a little better”; “no change”; “a little worse”; “much worse”; or
“very much worse”. The established cure criteria were
the answers “very much better” or “much better” (all the
other answers were defined as treatment failure), together
with the need for fewer than 2 compresses/day. Although
the PGI-I has only been applied to women with stress urinary incontinence and urogenital prolapse, its use has not
been established in men and women with other urinary
tract symptoms or conditions. However, the PGI-I is an overall index that can be used to evaluate the response of a
condition to a therapy (transition scale). It is a simple, direct,
easy-to-use scale that is intuitively comprehensible for clinicians, which is why it was chosen for this study.
A review of our experience in treating male urinary incontinence through the AMS-800™ artificial urinary sphincter Figure 1 AMS-800TM prosthesis: cuff in the bulbar urethra,
pump, reservoir, and connecting tubes.
Results
The functional results showed that 24 patients (48%) achieved complete continence and 18 patients (36%) had minimum incontinence (defined as the use of 1-2 compresses/
day). There was procedure failure in 8 cases (16%). These
results were correlated with the PGI-I questionnaire in
which 42 patients (84%) referred to being “very much
better”/“much better” and the remaining 8 patients (16%)
did not.
A total of 8 patients (16%) were reoperated on, removing
the artificial urinary sphincter and replacing it with a new
implant. There were good results in 3 of those patients; 2
were reoperated on due to mechanical failure of the artificial urinary sphincter and the other because of infection of
the prosthetic material. In these cases the AMS-800TM artificial urinary sphincter (inhibizone) covered with rifampicin
and minocycline was implanted.
Of the women operated on, 2 had to have the sphincter
removed due to vaginal and internal urethral erosion, with
no new reimplantation. The other female patient had no
clinical improvement and the sphincter was maintained, but
inactive.
There were complications in 8 patients (16%) and the
most frequent was internal urethral erosion (fig. 3) in 3 cases, as shown in table 1, resulting in the necessity for removal of the prosthesis. Only one patient presented with
infection of the artificial urinary sphincter, ending in its consequent removal (fig. 4).
Discussion
There are currently many options for urinary incontinence
treatment due to sphincterial incompetence in men, such as
pelvic floor rehabilitation exercises, drug treatments, transurethral injections of space-occupying substances like collagen and other polymers, or male slings, all with different
results and complications. Since 1947 when Foley designed
the first artificial catheter -a cuff that was inflated and
127
Figure 2 Cuff implantation in the bulbar urethra during the
procedure.
Table 1 Complications
Complications*
N° of
patients
%
Internal urethral erosion
3
6%
Vaginal erosion
1
2%
Control pump failure
1
2%
Reservoir shift
1
2%
Scrotal hematoma
1
2%
1
2%
Infection
* Complications after AMS-800
implantation.
TM
artificial urinary sphincter
deflated around the penis-7 many sphincters have been developed. The AMS-800TM artificial urinary sphincter (American Medical Systems) was first implanted in 1983,1,2 and has
been progressively improved,8 with an average success rate
of 82%.9,10
The AMS-800TM artificial urinary sphincter is a device with
a hydraulic mechanism that has 3 fundamental components
connecting to one another: the occlusive cuff, reservoir,
and control pump.
The cuff is made up of a silicon band with an inflatable
balloon in its inner side that measure from 4 to 11 cm in
length and 2 cm in width that can be placed around the
bladder neck or the bulbar urethra.5,10,11
The reservoir is preferably placed intraperitoneally, because at the paravesical level it can cause fibrosis at the
level of the reservoir, altering its function and not letting it
reach the adequate pressure. It is the component that regulates the occlusive cuff pressure with a capacity of 22 cc.
Continence should be produced with a minimum of pressure
to avoid obstruction, atrophy, and erosion that can be caused by high pressure. 5,10 There are 5 different pressure
128
F. X. Elizalde-Benito et al
Figure 3 Urethrocystoscopy showing the internal urethral erosion at the level of the bulbar urethra.
Figure 4 Artificial urinary sphincter after removal due to infection.
ranges, but the most widely used are 51-60, 61-70, and 7180 cm of water. The recommended pressure values are: in
men 71-80 in the bladder neck and 61-70 in the urethra;
in women 61-70 in the bladder neck; and in children 61-70 in
the bladder neck and 51-60 in the urethra.5,10
The control pump is placed in the scrotum or labia majora. A system of valves in its interior directs the passage of
the filling liquid in one direction or another, letting the cuff
inflate or deflate, allowing for micturition during 3 to 5 minutes. Continence is re-established subsequent to sufficient
time for micturition. The pump has a button that deactivates the prosthesis, emptying the occlusive cuff.5,11
The artificial urinary sphincter is indicated in all patients
with genuine stress incontinence, men or women, and of
any age, that have the ability to manipulate the control
pump.10 There are a series of previous conditions such as
bladder capacity > 200 mL, stable bladder, sterile urine, and
absence of obstruction prior to implantation; therefore it is
elective in the patient with irreversible sphincterial insufficiency and normal bladder function.5,11
Indications for the prosthesis, in order of frequency, are
incontinence after radical prostatectomy or transurethral
resection of the prostate, congenital malformation, spinal trauma, neurogenic bladder, and stress incontinence in
women when other surgical techniques have failed.4,10 The
group of patients with sphincterial deficiency after radical
prostatectomy is the most important group that recurs most
often to incontinence management with an artificial sphincter. In approximately 70% or more of the patients with implants, the cause of their incontinence is an aftereffect of
radical prostate surgery.3 In our case series, this was also
the main cause of incontinence in the patients with implantation, with a total of 36 patients (72%).
There are substantial variations in the literature in both
the complication as well as the success rates. This can largely be explained by the heterogeneity of the studies and in
the different definitions used to classify the results.9 In relation to incontinence improvement, our case series reported
improvement of 84%, compared with other series that vary
from 61.4% to 90.4%.3-5,12-16
There are different types of complications and they vary
from 2.7% to 49.5%, depending on the series. In our case
series the complication rate was 16%, and 16% of the patients were re-operated on; this is comparable to other series described in the literature (1.3% to 44%).3-5,12-16
When these devices were introduced, the mechanical failures of the equipment were an important cause of complications; there is a 7% to 53% incidence with an average of
13.8% reported on in the literature.3,4,17 Over time, this type
of complication has been reduced, thanks to improvements
in the devices themselves, and today’s prostheses are longlasting and reliable systems.8 In general the problems arise
from damage to the control pump or perforations resulting
in the exit of the system’s liquid. The average prosthesis is
calculated to have a useful life of approximately 10 years.10
The most devastating complication in the entire prosthetic procedure is infection; it is estimated that infection of
the prosthesis makes up approximately 12.9% of the possible
complications,4 and the seriousness of this is, that in order
to resolve the infection, the artificial urinary sphincter almost always must be removed.10 Fundamental preventive
measures are required to prevent this from happening; there must be scrupulous surgical asepsis and a meticulous surgical procedure. Additionally, in our case, we administered
preoperative antibiotic prophylaxis to all our patients, with
aminoglycosides and beta-lactam antibiotics in combination
with the recommended antimicrobials as established by the
chemoprophylaxis protocol of surgical procedures, with
strength of evidence B, level III.18 We also carried out constant irrigations of the surgical site and all the components
of the prosthesis with an antibiotic solution containing gentamycin.
In relation to prosthetic material erosion, the incidence in
different case series varies from 12% to 14%.9 It can present
as an internal erosion, when the protrusion of the components (generally the cuff) is toward the bladder neck or the
urethra; or external erosion, when the component (the control pump, reservoir and/or connecting tubes) protrude
through the skin. The form most frequently reported in
A review of our experience in treating male urinary incontinence through the AMS-800™ artificial urinary sphincter the literature is the internal erosion of the cuff toward the
bulbar urethra, which can be caused by an excess of pressure in the system, infection, or progressive ischemia.10
Conclusions
The treatment of urinary incontinence due to sphincterial
incompetence through the use of the AMS-800TM prosthesis is
an effective therapeutic alternative, keeping in mind its
possible complications. In women, the use of other techniques is preferred. The most frequent indication is after
prostate surgery and the most favorable results are obtained in these cases. In our experience, placement of the
AMS-800TM prosthesis at the level of the bulbar urethra is
the location of choice.
References
1. Englemann UH, Felderman TP, Scott FB. The use of the AMS-AS
800 artificial sphincter for continent urinary diversion. Investigations including pressure-flow studies, using rabbit intestinal
loops. J Urol 1095;134:183.
2. Englemann UH, Felderman TP, Scott FB. Evaluation of the AMSAS 800 artificial sphincter for continent urinary diversion using
intestinal loops. Urology 1985;25:620.
3. Elliot DS, Barrett DM. Mayo Clinic longterm analysis of the functional durability of the AMS-800 artificial urinary sphincter: A
review of 323 cases. J Urol 1998;159:1206.
4. Hajivassiliou CA. A review of the complications and results of
implantation of the AMS artificial urinary sphincter. Eur Urol
1999;35:36.
5. Sanz Mayayo E, Gómez García I, Fernández Fernández E, et al.
Esfínter artificial AMS-800. Nuestra experiencia en los últimos
20 años. Arch Esp Urol 2003;56(9):989-997.
129
6. Yalcin I, Bump RC. Validation of two global impression questionnaires for incontinence. Am J Obstet Gynecol 2003;189(1):98101.
7. Foley FEB. An artificial sphincter: a new device and operation for control of enuresis and urinary incontinence. General considerations, indications and results. J Urol
1947;58:250.
8. Hajivassiliou CA. The development and evolution of artificial
urethral sphincters. J Med Eng Technol 1998;22:154-159.
9. Silva LA, Andriolo RB, Atallah AN, et al. Surgery for stress urinary incontinence due to presumed sphincter deficiency after
prostate surgery. Cochrane Database of Systematic Reviews
2011, Issue 4. Art. No.: CD008306. DOI:10.1002/14651858.
CD008306.pub2.
10. García Montes F, Gómez Sancha F, Mundy A. El esfínter urinario
artificial. Arch Esp Urol 2000;53:201.
11. Briones Mardones G, Jiménez Cidre M, Fernández Fernández E,
et al. Tratamiento de la incontinencia urinaria de esfuerzo femenina con el sistema TVT (Tension free vaginal tape): nuestra
experiencia. Actas Urol Esp 2001;25(6):423-429.
12. Batista JE, Arañó Bertrán P, Errando Smet C. Esfínter artificial
en incontinencia urinaria severa: nueve años de experiencia.
Arch Esp Urol 2000;53:409-416.
13. Kip A, İmamoğlu MA, Tuygun C, et al. Long-term results of artificial urinary sphincter implantation for the treatment of urinary incontinence. Journal of Ankara Medical School
2003;25(4):185-190.
14. Bosch JL, Klijn AJ, Schroder FH, et al. The artificial urinary
sphincter in 86 patients with intrinsic sphincter deficiency: satisfactory actuarial adequate function rates. Eur Urol
2000;38:156-160.
15. Mottet N, Boyer C, Chartier-Kastler E, et al. Artificial Urinary
Sphincter AMS 800 for Urinary Incontinence after Radical Prostatectomy: The French Experience. Urol Int 1998;60:25-29.
16. Kuznetsov DD, Kim HL, Patel RV, et al. Comparison of artificial
urinary sphincter and collagen for the treatment of postprostatectomy incontinence. Urology 2000;56:600.
17. Light JK. Controversies and Innovations in Urological surgery.
London: Springer- Verlag; 1989. p. 235-252.
18. Dellinger EP, Gross PA, Barret TL, et al. Quality standard for
antimicrobial prophylaxis in surgical procedures. Clin Infect Dis
1994;18:422-427.
Rev Mex Urol 2013;73(3):130-135
Original article
Crystallographic analysis of 475 urinary tract calculi at the
Hospital San José Tec Salud in Monterrey, N. L.
A. R. Aragón-Tovara,* and M. Á. Hernández-Faríasb
a
Head of Urology Service , Unidad Médica de Alta Especialidad N° 25, IMSS, Monterrey, N. L., Mexico
b
Bachelor of Medicine, Escuela de Medicina de Ignacio Santos, Tecnológico de Monterrey, Monterrey, N. L., México
KEYWORDS
Lithiasis; Urinary
calculus;
Epidemiology;
Crystallography;
Mexico.
Abstract
Background: Calculi are the third most common disease of the urinary tract, surpassed only by
urinary tract infections and pathologic conditions of the prostate.
At present there are no epidemiologic studies on patients seeking medical attention at the Hospital San José Tec Salud, or any other hospital in Mexico, for problems related to kidney stones.
Aims: The principle aim of our study was to statistically determine the chemical composition of
urinary tract calculi in patients admitted to the Hospital San José Tec Salud and to extrapolate
the data to Monterrey and its metropolitan area.
Results: The cases were obtained retrospectively from the database of the laboratory of the
Hospital San José Tec Salud and from patient medical records within the time frame of July
2009 to October 2012.
In the data analysis, 313 (66%) cases were men and 162 (34%) were women, resulting in a 2:1
ratio. The age of greatest prevalence was between 30 and 50 years.
Discussion: The analysis of the crystallography results, together with the medical record review,
provides information on how many of these patients will be attended to and on the crystallographic type of calculi they will present with in the near future at the Hospital San José Tec
Salud. This data can then be extrapolated to Monterrey and its metropolitan area.
* Corresponding author at: Dr. F. Guajardo N° 160-307, Colonia Doctores, C.P. 64710, Monterrey, N. L., México. Telephone/Fax: (818)
3489169. Cell phone: (818) 0206633. Email: [email protected] (A. R. Aragón-Tovar).
Crystallographic analysis of 475 urinary tract calculi at the Hospital San José Tec Salud in Monterrey, N. L. Palabras clave
Litiasis; Cálculo
urinario;
Epidemiología;
Cristalografía;
México.
131
Análisis cristalográfico de 475 cálculos de vías urinarias en el Hospital San José, Tec
Salud, en Monterrey, N.L.
Resumen
Introducción: Los cálculos son la tercera afección más común del tracto urinario, excedida únicamente por las infecciones del mismo y las condiciones patológicas de la próstata. A la fecha
no hay estudios epidemiológicos de los pacientes que acuden al Hospital San José, Tec Salud, así
como ningún otro hospital de México con problemas de litiasis renal.
Objetivo: El objetivo principal es determinar estadísticamente la composición química de cálculos de vías urinarias, en los pacientes ingresados al Hospital San José, Tec Salud, y extrapolarlo
a Monterrey y su área metropolitana.
Resultado: Los casos se obtienen retrospectivamente mediante la base de datos del laboratorio
del Hospital San José, Tec Salud, y expediente clínico, del periodo comprendido entre julio de
2009 a octubre de 2012.
En el análisis de los datos 313 (66%) casos fueron masculinos y 162 (34%) casos femeninos, obteniendo una relación 2:1. La edad de mayor prevalencia fue entre los 30 y 50 años.
Discusión: El análisis del resultado de cristalografía en conjunto con la revisión de su expediente
clínico, aporta información de cuántos casos serán atendidos y el tipo cristalográfico de cálculos
en los pacientes que se atenderán en un fututo cercano en el Hospital San José, Tec Salud, y
extrapolarlo a Monterrey y su área metropolitana.
Introduction
Calculi are the third most common disease of the urinary
tract, surpassed only by urinary tract infections and pathologic conditions of the prostate.1 The worldwide prevalence
of renal lithiasis is estimated to be between 1% and 15%,1-4
and the probability varies according to age, sex, race, climate, occupation, social class, nutritional factors, genetic
particularities, and geographic location.2,3,5-7
Methods
A retrospective, cross-sectional study using descriptive statistics was conducted that included 475 cases of urinary
tract lithiasis within the time frame of July 2009 and October 2012. The information was obtained from the laboratory
registers and the clinical case records of the Hospital San
José, Tec Salud that contained 100% of the data. The sample
was determined with a prevalence of 10%, a 95% confidence
interval, and a 5% margin of error. There was a minimum
result of 384 cases required, but the sample size was increased for more reliability. Measures of central tendency and
dispersion were carried out, showing a homogeneously distributed population.
Results
Of the 475 cases, 66% were men (313 cases) and 34% were
women (162 cases), with a frequency ratio of 2:1. In men,
the mean age of appearance of lithiasis was 42 years ± 14.41
and in women it was 41 years ± 15.27. The peak appearance
in both sexes was between 30 and 49 years; 49% of the sample fit in this age range (92% was between 20 and 69 years of
age). Nineteen (4%) cases were under 20 years of age and
15 (3%) were over the age of 70 years. In relation to women,
their age distribution was the same as that of the men; this
was not the expected result, given the reported increase of
lithiasis after menopause8,9 (tables 1 and 2). Lithiasis frequency rose to 40% (19 cases per month) during the warm
months (May, June, July, August), in correlation with the
mean (12 cases).
With respect to the crystallographic composition, 20% (97
cases) of the calculi were pure, and 80% (378 cases) were
mixed. Calcium oxalate was the most common of the pure
calculi for both sexes, with 13% (41 cases) in men and 12%
(20 cases) in women. It was followed by uric acid calculi in
men with 6% (19 cases) and by carbonate apatite in women
with 5% (8 cases). In regard to the mixed calculi, the most
common composition was calcium oxalate plus calcium
phosphate, representing 52% (247 cases) of the total sample, 52% (164 cases) of the total of calculi in men, and 51%
(83 cases) in women. It was the most common in both sexes,
as well as in all ages. The second in frequency in men was
the calcium oxalate calculus plus carbonate apatite with
17% (53 cases) and in women it was the calcium oxalate
calculus plus calcium phosphate plus calcium hydrogen
phosphate, with 17% (27 cases). There was an increase in
the frequency of uric acid calculi (pure and mixed) after the
age of 50 years, with more than 70% of the uric acid calculi
in patients above that age. The mean weight of the stones
was 55.21 mg (fig. 1).
A total of 97% of the patients were from the State of Nuevo León, and of that percentage, 95% resided in Monterrey
and its metropolitan area. The sample’s most common place
of origin was Monterrey with 189 cases (40%), followed by
San Pedro Garza García with 99 (21%), Ciudad Guadalupe 44
(9%), San Nicolás de los Garza 42 (9%), Santa Catarina 23
(5%), Apodaca 19 (4%), and Escobedo with 13 (3%) (fig. 2).
132
A. R. Aragón-Tovar et al
Table 1 Number of cases according to composition, age, and sex
Composition/age
0/9
19/19
29/29
30/39
40/49
50/59
60/69
70/79
80/89
Total
CO
1
1
4
6
5
3
-
-
-
20
UA
-
-
-
1
-
3
1
-
-
5
CA
-
1
1
4
1
-
1
-
-
8
PA
-
-
-
-
-
-
1
-
-
1
1
2
5
11
6
6
3
0
0
34
50/59
60/69
70/79
80/89
Total
Women
Composition/age
0/9
19/19
29/29
30/39
40/49
CO
-
1
7
9
13
6
4
1
-
41
UA
-
-
2
3
5
3
3
2
1
19
CA
1
-
-
2
-
-
-
-
-
3
PA
-
-
-
-
-
-
-
-
-
0
1
1
9
14
18
9
7
3
1
63
Men
CO: calcium oxalate; UA: uric acid; CA carbonate apatite; PA: protein (albumin).
80
Women
70
Men
60
Both
50
40
30
20
10
0
0
5
10
15
20
25
30
35
40
45
50
55
60
65
70
75
80
85
90
Figure 1 Number of cases according to age and sex.
Discussion
Nephrolithiasis is one of the most common pathologies of
modern society and in recent years has increased up to 50%
in the industrialized countries.5,6,8 Due to the frequency of
stone recurrence, the development of a prophylactic program to reduce this persistence is imperative. 1,4,7-10 .
Without medical intervention, recurrence can be as high as
50% at 5 years; it can be even more frequent in uric acid
calculi.7,8,11
The metabolic and crystallographic study aids in establishing and understanding the etiology and pathogenesis of
the patient’s calculi.8,10,11 In this manner, with medical fol-
low-up, recurrences are reduced, and consequently, there
are fewer surgical procedures and patient comorbidities.8,10
The presentation of lithiasis before the age of 20 years and
after the age of 70 years is rare and the prevalence peaks are
between the fourth and sixth decades of life;8,9 these are international data that coincide with our study sample. According to
international reports, women show a bimodal distribution in
the formation of calculi, demonstrating in these studies a second incidence peak in the sixth decade of life that corresponds
to the post-menopause period. This finding, together with that
of a lower lithiasis incidence in the pre-menopause period,
compared with men, suggests a protective effect of estrogen
for the formation of calculi.8,9 Such an effect was not seen in
Crystallographic analysis of 475 urinary tract calculi at the Hospital San José Tec Salud in Monterrey, N. L. 133
Table 2 Number of cases according to age and sex
Men
Composition/age
0-9
10-19
20-29
30-39
40-49
50-59
60-69
70-79
80-89
Total
CO+CP
1
6
27
49
47
21
9
3
1
164
CA+CO
-
2
10
14
11
15
1
-
-
53
CO+UA
-
-
1
2
1
3
2
3
-
12
CO+CHP
-
-
-
-
-
-
-
-
-
0
CP+MAP
-
-
-
-
-
-
-
-
-
0
CP+CHP
-
-
-
1
-
-
-
-
-
1
CO+UA+CP
-
-
-
-
2
1
7
-
-
10
CO+CP+CHP
-
-
-
2
1
-
-
-
3
CO+CA+UA
-
1
-
-
-
-
-
-
-
1
CO+CP+MAP
-
-
-
1
-
1
-
-
-
2
CO+CA+MAP
-
-
-
-
-
-
-
-
-
0
CO+UA+CP+MAP
-
-
-
-
-
1
-
-
-
1
CO+UA+CP+AAU
-
-
-
-
-
2
-
-
-
2
UA+MAP+AAU+UA
-
-
-
-
-
-
-
-
-
0
UA+MAP+AAU+UA
-
-
-
1
-
-
-
-
-
1
1
9
38
70
62
44
19
6
1
250
Women
0-9
10-19
20-29
30-39
40-49
50-59
60-69
70-79
80-89
Total
CO+CP
Composition/age
-
4
19
19
17
11
11
2
-
83
CA+CO
-
-
-
1
1
-
-
-
-
2
CO+UA
-
-
-
1
1
2
2
-
-
6
CO+CHP
-
-
-
-
-
1
-
-
-
1
CP+MAP
-
-
-
-
-
1
1
-
-
2
CP+CHP
-
-
-
-
-
-
-
-
-
0
CO+UA+CP
-
-
-
-
-
2
1
-
-
3
CO+CP+CHP
-
1
4
9
6
3
3
1
-
27
CO+CA+UA
-
-
-
-
-
-
-
-
-
0
CO+CP+MAP
-
-
-
-
-
-
-
-
-
0
CO+CA+MAP
-
-
-
-
-
-
1
-
-
1
CO+UA+CP+MAP
-
-
-
-
-
1
-
-
-
1
CO+UA+CP+AAU
-
-
-
-
-
-
-
-
-
0
UA+MAP+AAU+UA
1
-
-
-
-
-
-
-
-
1
UA+MAP+AAU+UA
-
-
-
-
-
-
1
-
-
1
1
5
23
30
25
21
20
3
0
128
CO: calcium oxalate; CP: calcium phosphate; UA: uric acid; CA: carbonate apatite; PA: protein (albumin); CHP: calcium hydrogen
phosphate; MAP: magnesium ammonium phosphate (struvite); AAU: ammonium acid urate; T: triamterene.Bibliografía
134
A. R. Aragón-Tovar et al
Sex
A
Composition
B
34%
20%
Women
Men
66%
Pure calculi
Mixed calculi
80%
Place of origin
C
3%
5%
Monterrey
4%
San Pedro Garza García
5%
Guadalupe
4%
San Nicolás de los Garza
40%
9%
Apodaca
Santa Catarina
Escobedo
9%
21%
Other cities of NL
Other States
Figure 2 A) Percentage of stones by sex. B) Percentage of stones by composition. C) Place of origin of the patients in the sample.
the Hospital San José, Tec Salud population; in contrast, a homogeneous distribution was observed in the frequency of lithiasis in pre and post-menopausal women, differing, as mentioned
above, from the results published in the international literature.
The city of Monterrey and its metropolitan area experience high temperatures in the summer, and together with
heat exposure and dehydration, these are risk factors that
explain the higher lithiasis frequency in hot, arid, and dry
climates (mountains, deserts, or the tropics).8,9,11 In addition, an increase has been observed in the prevalence of lithiasis related to seasonal temperature, due to the fact that
a higher temperature augments the imperceptible losses
of liquids and increased exposure to the sun causes an
increment in vitamin D and calcium absorption.2,3,6,9,12 The
risk for lithiasis is greater when there is low water intake,
high protein intake, and a sedentary lifestyle.2,3 Moreover,
genetic and dietary influences may be more important
than geographic factors.8
One of the factors that may also play a role is the hardness of the drinking water (as is the case in Monterrey13),
which can also increase the presentation of stones, although
some studies have found no difference.2
It should be noted that the population of Monterrey includes
many heavy consumers of animal meat and beer. Even though a
protein-rich diet is regarded as a factor in the formation of uric
acid calculi, no increase in the number of cases in Monterrey in
relation to other studies was observed.2,9
Crystallographic analysis of 475 urinary tract calculi at the Hospital San José Tec Salud in Monterrey, N. L. Beer also predisposes to the forming of stones by causing
elevated diuresis, followed by dehydration and urinary stasis, promoting the formation of calcium oxalate and uric
acid calculi. Moreover, beer contains purines, the precursors
of uric acid, and together with purine-rich foods, increases
the excretion of uric acid in urine.14
Nevertheless, age was determined as the main risk factor
for uric acid stones, given that prevalence rises especially
after 60 years of age.9 In the study population that presented with calculi composed of uric acid (pure and mixed), 70%
were patients above the age of 50 years, with a prevalence
in men, resulting in a 4.6:1 ratio.
The increased prevalence with age is attributed to the
progressive defect in ammoniagenesis in urine, which is
the principal factor in low pH.9,11 Hyperuricemia, low urinary pH, ammoniagenesis reduction, and insulin-resistance
are characteristics of metabolic syndrome, catalogued as
stone recurrence factors in uric acid calculi.9,11 Metabolic
syndrome is also more frequent with age.
It has been suggested that an elevated body mass index
(BMI) increases the excretion of supersaturated urine, increasing the risk for lithiasis.1,6 Supersaturated urine depends on the urinary pH, ionic charge, and concentration of
solutes. 1,6 For this reason, drinking abundant quantities
of water prevents the formation of stones.9
The stone composition most frequently observed in the
study and the reviewed bibliography, is that of calcium oxalate. The majority of patients with this kind of stone have
no systemic disease and so its origin is thought to be idiopathic.2,3,6,7,9,15,16 Secondary causes can be hyperparathyroidism, calcium metabolism disorders, gut-related
hyperoxaluria, and genetic disorders of oxalate metabolism.
In conclusion, crystallographic analysis and metabolic
study is essential for the medical management of patients
with nephrolithiasis; it enables us to identify the pathologies that are the precursors of urinary lithiasis, to correct
them, and to prevent stone recurrence and complications
characteristic of the pathology and of the surgical treatments.
Acknowledgments
The authors wish to thank Dr. Carlos Díaz Olachea, Head of
the Laboratory of the Hospital San José, Tec Salud and QFB
Cruz Palacios for their contribution in accessing information,
135
and to also thank Dr. Homero Decanini Livas, Head of the
Department of Urology and the medical staff of the Hospital
San José, Tec Salud.
References
1. Stoller ML. Urinary Stone Disease. In: Tanagho EA, McAninch JW
(editors). Smith´s General Urology, 17ª Ed. Estados Unidos de
América: Editorial McGraw-Hill; 2008.
2. Batista LA, Pelegrini L, Bertinato L, et al. Investigation of nephrolithiasis in the West of Paraná. J Bras Nefrol 2011;33(2):160165.
3. Trinchieri A. Epidemiology of urolithiasis: an update. Clin Cases
Miner Bone Metab 2008;5(2):101-106.
4. Raif O, Ipek B, Orturk U, et al. Metabolic Evaluation in Stone
Disease Metabolic Differences Between the Pediatric and
Adult Patients With Stone Disease. Urology 2010;76(1):238241.
5. Romero V, Akpinar H, Dean G. Kidney Stones: a global picture of
prevalence, incidence, and associated risk factors. Rev Urol
2010;12(2-3);86-96.
6. Fredic LC, Andrew E, Elaine W. Kidney Stone Disease. J Clin Invest 2005;115(10):2598-2608.
7. Ribeiro da Silva, Cordeiro de Matos, Leite da Silva, et al. Chemical and morphological analysis of kidney stones. A double blind
comparative study. Acta Cirúrgica Brasileira 2010;25(5):444448.
8. Pearle MS, Lotan Y. Urinary Lithiasis: Etiology, Epidemiology,
and Pathogenesis. In: Wein AJ, Kavoussi LR, Partin AW (editors).
Wein: Campbell-Walsh Urology. 10ª Orlando, FL: Editorial Elsevier; 2011.
9. Daudon M, Doré JC, Jungers P, et al. Changes in stone composition according to age and gender of patients: a multivariate
epidemiological approach. Urol Res 2004;32:241-247.
10. Pak C, Poindexter JR, Adams-Huet B, et al. Predictive Value of
Kidney Stone Composition in the Detection of Metabolic Abnormalities. Am J Med 2003;115:26-32.
11. Ansari M, Narmada G, Ashok H, et al. Spectrum of stone composition: structural analysis of 1050 upper urinary tract calculi
from northern India. International Journal Urology 2005;12:1216.
12. Costa-Bauzá A, Ramis M, Montesinos V, et al. Type of renal calculi: variation with age and sex. World J Urol 2007;25:415-421.
13. Consultado el 01 de marzo de 2013. http://www.google.com/
url?sa=t&rct=j&q=&esrc=s&source=web&cd=6&ved=0CEsQFjAF
&url=http%3A%2F%2Fwww.inegi.gob.mx%2Fprod_serv%2Fconte
nidos%2Fespanol%2Fbvinegi%2Fproductos%2Fintegracion%2Fsoc
iodemografico%2Fmedioambmty%2F2001%2Femazmm01-2.
pdf&ei=U0oxUba_J_KA2QW sYDQAQ&usg=AFQjCNEkkr-D5hHcTaBJwX-gmkV24e64bQ&bvm=bv.43148975,d.b2I
14. Rayhan Z, Yoshihide O, Sanehiro H, et al. Urolithiasis in Okinawa, Japan: A relatively high prevalence of uric acid stones. International Journal Urology 2003;10:411-415.
15. Curhan GC. Epidemiology of Stone Disease. Urol Clin N Am
2007;34:287-293.
16. Ross AE, Handa S, Lingeman JE, et al. Kidney stones during
pregnancy: an investigation into stone composition. Urol Res
2008;36:99-102.
Rev Mex Urol 2013;73(3):136-139
Clinical case
Urinary diversion postoperative complication management
E. Mayorga-Gómez*, V. Cornejo-Dávila, A. Palmeros-Rodríguez, I. Uberetagoyena-Tello
de Meneses, G. Garza-Sainz, V. Osornio-Sánchez, A. Camacho-Castro, F. García-Salcido,
E. Muñoz-Ibarra, S. Ahumada-Tamayo, G. Fernández-Noyola, A. Martínez, M. CantellanoOrozco, C. Martínez-Arroyo, G. Morales-Montor and C. Pacheco-Gahbler
Urology Division, Hospital General “Dr. Manuel Gea González”, Mexico City, Mexico
KEYWORDS
Cancer; Bladder;
Complications;
Treatment; Mexico.
Palabras clave
Cáncer; Vejiga;
Complicaciones;
Tratamiento; México.
Abstract Bladder cancer is the fourth most common malignant tumor in the developed countries. The treatment of choice for high grade muscle-invading and non-muscle-invading tumors
that do not respond to intravesical BCG application continues to be radical cystoprostatectomy
in men and anterior pelvic exenteration in women, both associated with extended pelvic lymphadenectomy. Before 1990, case series reported a mortality rate close to 15%; however, in the
last 10 years that rate has been reduced to 0%-3%. We present herein a special case of radical
cystectomy (RC) due to bladder cancer with multiple complications, describing some of their
management alternatives.
Manejo de las complicaciones postoperatorias en las derivaciones urinarias
Resumen El cáncer de vejiga es el cuarto tumor maligno más común a nivel mundial, en países
desarrollados. El tratamiento de elección para los tumores músculo invasores y no músculo invasores de alto grado que no responden al manejo con aplicación intravesical de BCG, continúa
siendo la cistoprostatectomía radical en los hombres y la exenteración pélvica anterior en las
mujeres, ambas asociadas a linfadenectomía pélvica extendida. Antes de 1990, las series reportaban una mortalidad cercana al 15%, sin embargo en los últimos 10 años se ha logrado reducir
la mortalidad al 0%-3%. Se presenta un caso especial de cistectomía radical (CR) por cáncer de
vejiga con múltiples complicaciones; se pretende dar a conocer las alternativas de manejo
de las mismas.
* Corresponding author at: Hospital General “Dr. Manuel Gea González”, División de Urología. Av. Calzada de Tlalpan N° 4800, Colonia
Sección XVI, Delegación Tlalpan, C.P. 01480, México D.F., México. Email: edgar_mg18@hotmail. (E. Mayorga-Gómez)
Urinary diversion postoperative complication management Introduction
137
A 56-year-old man from Mendoza, Argentina, residing in
Mexico City, has a past medical history of intense smoking
from the age of 20 years to the present, smoking 15 cigarettes a day with a smoking index of 15. He also has a 10-year
progression of high blood pressure that is treated with losartan. His present illness began in December 2011 with total
gross hematuria, the presence of amorphous coagulates,
but with no other added symptomatology. The hematuria
lasted 15 days and then remitted spontaneously.
Physical examination revealed a normal head and neck,
well-ventilated pulmonary fields with no abnormal sounds,
rhythmic heart sounds of adequate intensity and frequency,
a distended abdomen due to the adipose panniculus that
was soft, depressible, non-painful, and with no peritoneal
irritation data. There were no palpable tumors or enlarged
organs. His superior and inferior extremities had no alterations in their form, strength, function, or neurovascular status. Upon digital rectal examination, palpation of the anal
sphincter showed a normal tone and a non-suspicious grade
1 adenomatous prostate.
Hematuria protocol was begun (table 1) ordering laboratory tests. A urotomography (UroCAT) scan identified a bladder tumor that was dependent on the left lateral wall.
Cystoscopy with transurethral resection of the bladder
(TURB) was performed, finding a 3 cm bladder tumor on the
left lateral wall; it had a papillary aspect and was completely resected (16/01/2012) (fig. 1). The histopathologic
report stated high grade urothelial papillary carcinoma with
detrusor muscle invasion. Biopsies of the bladder neck and
prostate were carried out later and were negative for malignancy (24/02/12). The patient was programmed for radical
cystoprostatectomy with urinary diversion through a Studer
orthotopic neobladder (12/03/12) and it was performed
with no perioperative complications (fig. 2). On the third
postoperative day, serohematic matter began to come out
through the surgical wound; it was managed as a seroma,
with drainage and wound dressings. The patient began to
eat food on the sixth postoperative day and tolerated it
well: he presented with fever of 38.5°C without leukocytosis. On 22/03/12 there was evidence of dehiscence of the
aponeurosis, and exploratory laparotomy (ex-lap) revealed
the dehiscence and purulent matter in the abdominal cavity
that was managed with an open abdomen and Bogotá bag
(fig. 3). Once again, on 27/03/12, serohematic matter came
out of the Bogotá bag. An x-ray study showed a contrast
medium leak through the urethrointestinal anastomosis and
so the patient underwent surgery performing a surgical
Figure 1 Urotomography scan.
Figure 2 Studer-type neobladder.
Bladder cancer is the fourth most common malignant tumor
in the developed countries and the ninth on a worldwide
level. In Mexico, it is in fourth place among the urogenital
tumors, with 1,136 cases reported from 2007 to 2009, according to the latest regional statistics update.1-3
The treatment of choice for muscle-invading and nonmuscle-invading high grade tumors that do not respond
to management with intravesical BCG application continues to be radical cystoprostatectomy in men and anterior
pelvic exenteration in women, both associated with extended pelvic lymphadenectomy. Radical cystectomy
(RC) provides the best cancer-specific survival rate for
muscle-invading urothelial cancer4, with recurrence-free
survival rates at 10 years of up to 60% and a total survival rate of 45%.5,6
RC with urinary diversion is a procedure that attempts to
reduce morbidity, provide rapid postoperative rehabilitation, reduce hospital stay, and finally, reduce costs. These
are the goals towards which modern surgery aims, but they
have been very difficult to achieve.
Before 1990, case series reported a mortality rate close to
15%, but in the last 10 years it has been reduced to 0%-3%;7,8
nevertheless, morbidity continues to be elevated, reaching
up to 68% in the large case series.9 Late complications are
from 19% to 58%. The important reduction in perioperative
morbidity reflects both the current effort of multidisciplinary teams in managing the surgeries and the recognition
and adequate treatment of early complications.
Case presentation
138
E. Mayorga-Gómez et al
Table 1 Pre-TURB
Date
16/01/12
Parameter
Result
Reference
Hemoglobin
14.8
13.5-17 g/dL
Hematocrit
43.3
47-55%
Platelets
135
150-450x103
Leukocytes
7.6
4.5-11x103
Neutrophils
84.4
40-85%
Glucose
117
70-115 mg/dL
BUN
17.7
8-20 mg/dL
Creatinine
0.99
0.70-1.2 mg/dL
Na+
134
136-144 mEq/L
K
3.3
3.6-5.1 mEq/L
Cl-
106
101-111 mEq/L
PT
11.2
12.5-15.9 sec
PTT
38.4
23-40 sec
0.80
0.8-1.2
+
INR
Na : sodium; K : potassium; Cl : chloride; PT: prothrombin time;
PTT: partial thromboplastin time; INR: International Normalized
Ratio.Bibliografía
+
+
-
lavage, abdominal wall closure, transurethral catheter
relocation, and neocystostomy. A frozen abdomen and minimal dehiscence of the anastomosis was found. On 28/03/12
there was output of serohematic matter from the surgical
wound; A Bogotá bag was placed once again and surgical lavage was done. Due to the presence of Zulkhe IV intra-abdominal adherences, the patient was managed with a
change of the Bogotá bag every 2 days and surgical lavages,
getting the neocystourethral anastomosis wound to behave
like a controlled neocystocutaneous fistula. On 24/04/12 bilateral percutaneous nephrostomies were placed without
complications, resulting in a reduction of the output through
the surgical wound. On 25/04/12 a vacuum-assisted closure
(VAC) system was placed in an attempt to close the anastomosis and the surgical wound (fig. 4). Replacement of the
VAC system every 2 days was begun. On 12/05/12 the patient was released from the Service and continued the VAC
therapy as an outpatient, with re-admittance once a week
for system replacement. This management resulted in 80%
closure of the surgical wound, however the exit of urine
persisted through the inferior third of the wound because
the urethrointestinal anastomosis dehiscence persisted. On
27/06/12 ex-lap was performed and the Studer neobladder
was dismantled, the urinary diversion was reconstructed
with an ileal conduit using the Bricker technique, and the
abdominal wall was closed. The patient had good postoperative progression with no complications and adequate functioning of the ileal conduit with no intestinal or urinary
complications. He was released on the fifth postoperative
day. In the outpatient follow-up he remained free of complications derived from the urinary diversion.
Figure 3 Cystogram with anastomosis dehiscence.
Figure 4 VAC system.
Discussion
In the whole of the case series reviewed, 64% of all cystectomies have some kind of complication and 13% of the patients present with a high-grade complication. The mean
Urinary diversion postoperative complication management hospital stay is 9 days for radical cystoprostatectomy, with
grade 2-3 complications. Twenty-six percent of patients require re-admittance and 34% have emergency consultations
once they have been released. Five percent of the patients
require admittance to the Intensive Care Unit, 2% require a
second surgery during their first hospitalization, and only 1%
require re-intervention within the first 90 after being released.10 Hospital mortality is 0.7% and rises to 2.7% within the
first 90 days; cardiopulmonary events are the principal cause of death. Among the complications, the most common
were gastrointestinal (40%), infectious (39%) and bleeding
(16%).11 Opportune detection of a complication in the postoperative period and its early intervention determine the patient outcome. Adequate diversion of the urinary tract,
fistula management, and control with the VAC system are an
alternative for the management of an open abdomen in patients with abdominal complications resulting from RC. To
reduce the number of complications derived from highly
complex procedures such as RC, it is necessary to establish
multidisciplinary teams that perform a high number of surgeries.
The authors declare there is no conflict of interest.
References
1. Ploeg M, Aben KK, Kiemeney LA. The present and future burden
of urinary bladder cancer in the world. World J Urol
2009;27(3):289-293.
139
2. Consultado el 28 de mayo de 2013. http://globocan.iarc.fr/
factsheets/populations/factsheet.asp?uno=962
3. Jiménez Ríos MA. Panorama epidemiológico del cáncer genitourinario en la Zona Centro de México. Rev Mex Urol 2011;71(Supp
3):3-6.
4. Meyer JP, Blick C, Arumainayagam N, et al. A three-centre experience of orthotopic neobladder reconstruction after radical
cystectomy: revisiting the initial experience, and results in 104
patients. BJU Int 2009;103(5):680-683.
5. Cookson MS, Chang SS, Wells N, et al. Complications of radical
cystectomy for nonmuscle invasive disease: comparison with
muscle invasive disease. J Urol 2003;169(1):101-104.
6. Colombo R. Editorial comment on: defining early morbidity of
radical cystectomy for patients with bladder cancer using a
standardized reporting methodology. Eur Urol 2009;55(1):175176.
7. Maffezzini M, Campodonico F, Canepa G, et al. Current perioperative management of radical cystectomy with intestinal urinary reconstruction for muscle-invasive bladder cancer and reduction of the incidence of postoperative ileus. Surg Oncol
2008;17(1):41-48.
8. Charbit L, Beurton D, Cukier J. Mortality and morbidity after
total cystectomy for cancer [in French]. J Urol (Paris)
1984;90(1):39-46.
9. Skinner DG, Crawford ED, Kaufman JJ. Complications of radical
cystectomy for carcinoma of the bladder. J Urol
1980;123(5):640-643.
10. Shabsigh A, Korets R, Vora KC, et al. Defining early morbidity of
radical cystectomy for patients with bladder cancer using a
standardized reporting methodology. Eur Urol 2009;55(1):164174.
11. Lawrentshuck N, Colombo R, Hakenbergc OW, et al. Prevention
and management of complications following radical cystectomy
for bladder cancer. Eur Urol 2010;57(6):983-1001.
Rev Mex Urol 2013;73(3):140-142
Clinical case
Primary diffuse large B-cell lymphoma of the prostate: a case
report
D. Ríos-Cruza,*, J. Valerio-Ureñab and J. Hernández-Ascencioa
a
General Surgery Speciality Residency, Hospital Regional de Alta Especialidad de Veracruz, Veracruz, Ver., Mexico
b
Surgery Division Administration, Hospital Regional de Alta Especialidad de Veracruz, Veracruz, Ver., Mexico
KEYWORDS
Prostate cancer;
Lymphoma of the
prostate; Mexico.
Palabras clave
Cáncer de próstata;
Linfoma prostático;
México.
Abstract Lymphoma of the prostate is an extremely rare entity with very few cases reported on in the medical literature. It can present as primary disease in the gland or be secondary to extraglandular invasion. Great diagnostic suspicion is required given that it manifests
with a similar symptomatology to benign diseases. We present herein the case of a patient with
lymphoma of the prostate, along with a literature review in relation to diagnosis and management.
Linfoma primario prostático difuso de células B grandes. Reporte de un caso
Resumen El linfoma de próstata es una entidad sumamente rara, con pocos casos reportados en la literatura médica. Puede presentarse de manera primaria en la glándula o, secundariamente debido a invasión extraglandular. Se requiere de una gran sospecha diagnóstica, ya que cursa con una sintomatología similar a la de los padecimientos benignos.
Presentamos el caso de un paciente con linfoma prostático, y hacemos una revisión de la
literatura en cuanto a diagnóstico y manejo.
* Corresponding author at: Callejón JF Oca N° 43, Interior 4, entre Hernández y Hernández y Amado Nervo, Fraccionamiento Flores Magón,
C.P. 91900, Veracruz, Ver., México. Telephone: 229780 6611. Email: [email protected] (D. Ríos-Cruz).
Primary diffuse large B-cell lymphoma of the prostate: a case report Introduction
Prostate cancer is a health problem with an elevated mortality rate. A total of 90% of cases correspond to adenocarcinomas and hematologic tumors represent 0.2% of cases.1
Lymphomas of the prostate can be primary or secondary.
They are extremely aggressive and have a poor short-term
outcome. We present herein the clinical case of a primary
lymphoma of the prostate that was diagnosed as a consequence of prostate symptoms.
Case presentation
A 54-year-old man presented with a 6-month illness characterized by weight loss of 10 Kg, night sweats, fever, and
constipation requiring laxatives; he had reduced urine
stream caliber, bladder strain, post-micturition dripping,
dysuria, and acute urine retention that conditioned transurethral catheter placement. He was evaluated by the Urology Service and was found to have tegumentary paleness
and a distended abdomen due to the adipose panniculus.
Upon digital rectal examination the prostate was enlarged,
hard, had a fibro-adenomatous consistency, weighed approximately 70 g, and had irregular edges. The laboratory
work-up reported elevated creatinine of 6.3 mg/dL and
urea of 146 mg/dL, BUN was 68 mg/dL, creatinine depuration was 10.06 mL/min/24 hours, hemoglobin 10.8 g/dL,
hematocrit 29.5%, and leukocytes, platelets, prostate-specific antigen (PSA), and alkaline phosphatase were all normal. The patient underwent transurethral resection of the
prostate with no complications. The histopathologic study
revealed images consistent with anaplastic, large B-cell
lymphoma with an extranodal diffuse pattern as a primary
disease of the prostate. Immunohistochemistry showed
CD45 and CD20 expression, with Bcl-2, Bcl-6, CD3, Ki67 and
MIB-1 co-expression, and a proliferation rate of 80% (fig. 1).
ß2microglobulin was measured, reporting 6,273 ng/mL and
LDH of 614 U/L. A scintigram image revealed an increase in
the ionic bone turnover in the bilateral scapulohumeral
joint, the coxofemoral joint, the pubis, the sacroiliac joints,
the sacrum, and the anterior-superior and inferior iliac
spines, as well as ectasia of the left renal pelvis (fig. 2). The
disease was cataloged as stage IV extranodal prostate lymphoma. The proposed treatment was based on 15 sessions of
30Gy of radiotherapy plus chemotherapy based on 4 cycles
of cyclophosphamide, doxorubicin, vincristine, and prednisone. However, the patient died before completing the
treatment.
141
other more frequent pathologic processes of the prostate
that present as lower obstructive symptoms.3 Our patient
manifested the classic symptoms of a benign prostate pathology, with the exception of fever, sweats, and weight
loss, which led to the suspicion of a lymphoproliferative
problem. However, due to its remote frequency it was not
taken as the first diagnostic option.
Primary lymphomas are less frequent than secondary
ones. Initially, the possibility that the prostate could present with this type of tumor was questioned, due to the scarcity of its lymphatic tissue. Nevertheless, Furkase described
the existence of intraprostatic lymphatic nodules. This, together with the recognition of extranodal lymphomas and
the histologic confirmation of lymphomas limited to the
prostate, has resulted in the acceptance and confirmation
of the existence of lymphomas of prostatic origin.1
It has been proposed that the classification of lymphomas
of the prostate follow the Working Formulation according to
the Ann Arbor classification5:
Stage I. Involvement of a single nodal or extranodal group.
Stage II. Separate nodal areas on the same side of the diaphragm.
Stage III. Two nodal groups on both sides of the diaphragm.
Discussion
Lymphomas are a group of malignant diseases of the lymphoreticular system, in potential. They can present in the urinary
tract in the following 3 forms: primary extranodal disease, primary nodal disease, or advanced-sate disseminated lymphoma.2 Lymphomatous infiltration of the kidney, ureter, bladder,
prostate, penis, and testes has been described.3
Lymphoma of the prostate has an incidence of 0.09% to
0.1% of all prostate tumors,4 with fewer than 200 reported
cases in the medical literature.1 Its clinical diagnosis requires a high degree of suspicion because it can simulate
Figure 1 Microscopic view showing the positive immunohistochemistry markers for Ki67 and Bcl-6.
142
D. Ríos-Cruz et al
unfortunately not with the same results as those just described.
We could argue that his fatal outcome was due to the advanced
stage of the disease, with involvement of neighboring structures, as well as distant metastasis. In general, prognosis is bad,
regardless of the patient’s age, the histologic type and stage of
the disease, and the treatment.10
Conclusion
Lymphoma of the prostate is an extremely rare tumor, with
obstructive manifestations of the lower urinary tract. Diagnosis requires a high degree of suspicion and is made
through immunohistochemistry. Treatment is directed at
alleviating the obstructive symptoms, centering on radiotherapy and/or chemotherapy, but despite this, the
short-term outcome is very poor.
Figure 2 Scintigram revealing the bone metastases sites.
Stage IV. One nodal area and one non-nodal area that are
not adjacent.
Our patient presented with stage IV disease. Presentation
age is the seventh decade of life and cases rarely present in
patients under 30 years of age.6 Our patient was 54 years
old.
Generally, PSA parameters are normal, as was the case
with our patient.7,8 Radiologically, the disease behaves like
an advanced prostate tumor with infiltration into the bladder floor and compression of both ureters.9 Definitive diagnosis is made through immunohistochemistry.
In the majority of cases initial treatment is surgery, for
resolving the obstructive problem, along with systemic chemotherapy. We found different proposed regimens in the
medical literature with varying results, such as the one described by Rodríguez-Ledesma et al. They employed a CHOP
(cyclophosphamide, adriamycin, vincristine, and prednisone) regimen in a patient with non-Hodgkin’s B-cell lymphoma, who after 28 months of follow-up was in complete
remission.8
Ochoa-Undargarain et al. used radiotherapy, in addition
to surgery, with good results.3 The association of radiotherapy with chemotherapy after the surgical event has been
described in the medical literature with favorable results.
Fernandez-Marichal used a combination of VP 16, doxorubicin, cyclophosphamide, and prednisolone, together with radiotherapy, in a patient with non-Hodgkin’s lymphoma,
achieving improvement, and after a 3-year follow-up he had
a normal-sized prostate.7 In our patient, in addition to surgery, we used chemotherapy and radiotherapy, but
References
1. Rioja Zuazu J, Iglesias R, Rosell Costa D, et al. Linfoma Prostático y revisión de la literatura. Actas Urol Esp 2009;33(6):686690.
2. Amat CM, Romero Pérez P, Ignacio Sevilla F. Linfomas del tracto
genitourinario. Revisión de conjunto y aportación de dos casos
de localización testicular. Arch Esp de Urol 1994;47:992.
3. Ochoa Undargarain O, Hermida Perez J, Ochoa Montes de Oca
J, et al. Linfoma Linfocítico, Bien diferenciado de la próstata,
Presentación de un caso y breve revisión de la literatura. Arch
Esp Urol 2006;59(5):538-541.
4. Martin Plata C, Rojo Todo F, Tremps Velásquez D, et al. Linfoma
Primario de Próstata: Presentación de un caso clínico-patológico
y revisión de la literatura. Actas Urol Esp 2000;24(5):437-441.
5. Sarris A, Dimopoulos M, Pugh W, et al. Primary lymphoma of the
prostate: good outcome with doxorrubicin-based combination
chemotherapy. J Urol 1995;153:1852-1854.
6. National Cancer Institute Sponsored study of classification of
non-Hodgkin´s lymphomas: summary and description of a working formulation for clinical usage. The non-Hodgkin´s lymphoma Pathologic Classification Project. Summary and description
of a working formulation for clinical usage: Lymphoma Pathologic Classification Project. Cancer 1982;49(10):2112-2135.
7. Fernandez Marichal F, Pila Pérez R, Chavez Olivera R. Linfoma
no Hodgkin de próstata: Informe de un nuevo caso. Arch Esp
Urol 1996;49:521.
8. Rodriguez Ledesma J, López Tello J, Picaso L. Linfomas de tracto urinario. Arch Esp Urol 1996;49:587.
9. Peyri E. Linfoma Primario de Próstata. Act Urol Esp 1991;405.
10. Bostwick DG, Iczkowski KA, Amin MB, et al. Malignant lymphoma involving the prostate. Report of 62 cases. Cancer
1998;83(4):732-738.
Rev Mex Urol 2013;73(3):143-145
Clinical case
Scrotal angiomyolipoma: a clinical case
F. J. Flores-Murcioa,*, M. P. Ávila-Bozab and D. E. Aguirre-Quezadac
a
Urology Service, Hospital Regional de Tlalnepantla ISSEMyM, Tlalnepantla, Mex., Mexico
b
General Surgery Speciality Residency, Hospital Regional de Tlalnepantla ISSEMyM, Tlalnepantla, Mex., Mexico
c
Pathology Service, Centro Oncológico Estatal ISSEMyM, Toluca, Mex., Mexico
KEYWORDS
Angiomyolipoma,
Scrotal tumor;
PEComa; Mexico.
Palabras clave
Angiomiolipoma;
Tumor escrotal;
PEComa; México.
Abstract A case of scrotal angiomyolipoma is presented herein. A 22-year-old man was evaluated due to left orchialgia. Physical examination showed an increase in scrotal volume dependent on the left side with apparent hydrocele and grade III varicocele, and the so-called “bag
of worms” in the scrotum. During surgery a highly vascularized paratesticular mass was found
that extended from the inguinal region along the entire tract of the spermatic cord to the perineal region. The mass was excised and the histopathologic study reported a tumor composed of
adipose tissue, smooth muscle, and blood vessels, corresponding to scrotal angiomyolipoma.
This benign tumor is rare and there are very few cases reported on at the scrotal level.
Angiomiolipoma escrotal, presentación de caso clínico
Resumen Se presenta el caso de un angiomiolipoma escrotal. Paciente masculino de 22 años
de edad, con valoración por orquialgia izquierda; se realiza exploración física mostrando
aumento de volumen escrotal dependiente de lado izquierdo, con aparente hidrocele y varicocele grado III, con escroto en bolsa de gusanos. En el transoperatorio se encontró masa paratesticular con gran vascularidad, que se extendía desde región inguinal en todo el trayecto del
cordón espermático hasta región perineal, se realiza excisión de la misma, el reporte histopatológico mostró tumor compuesto por tejido adiposo, músculo liso y vasos sanguíneos, correspondiente con angiomiolipoma escrotal. Este tumor benigno es raro, con pocos casos reportados a
nivel escrotal.
* Corresponding author at: Hospital Regional Tlalnepantla. Paseo del F.C. s/n, Unidad Habitacional Los Reyes Ixtacala 1ra Sección, C.P.
54090, Tlalnepantla, Méx., México. Telephone: (55) 2626 9200. Email: [email protected] (M. P. Ávila-Boza).
144
Introduction
Angiomyolipoma is a rare tumor (0.13% to 0.3% in the general population) that mainly involves the kidneys, presents in
women over 50 years of age, 1 and is particularly associated
with tuberous sclerosis. Originally described by Fischer in
1911, Morgan gave it its present name in 1951.
Angiomyolipoma is a benign tumor consisting of thick-walled, aneurysmal blood vessels, smooth muscle, and adipose
tissue. It was initially regarded as a form of hamartoma or
choristoma, but today is considered to be a tumor derived
from perivascular epithelioid cells (PEC), or PEComas. They
include the angiomyolipoma, clear cell “sugar” tumor
(CCST), and lymphangioleiomyomatosis (LAM), in addition
to the clear cell myomelanocytic tumor (CCMMT). PEComas
can affect the visceral organs including the kidney, lung,2
liver3, nasal cavity4, small and large intestine,5 prostate,
and uterus, as well as the retroperitoneum,6,7, pelvis8, pancreas9, skin10,11, testis,12 and scrotum.13
Case presentation
A 22-year-old man was evaluated for left orchialgia and increased left scrotal volume of 2-year progression, and scrotal varicose veins. His past medical history was
unremarkable. Physical examination revealed an increase in
scrotal volume that was dependent on the left side, with
apparent hydrocele and grade III varicocele. The scrotum
had the so-called “bag of worms” aspect. An ultrasound (US)
study showed data of orchiepididymitis, grade III left varicocele and associated hydrocele, and the right testis had no
alterations. He was programmed for hydrocelectomy plus
varicocelectomy, but in the intraoperative period the increase in volume was observed to be dependent on a paratesticular mass with great vascularity that extended from
the inguinal region, all along the spermatic cord, to the
Figure 1 Microscopic appreciation of a benign tumor composed
of adipose tissue and mature smooth muscle, as well as abundant blood vessels (hematoxylin & eosin X10).
F. J. Flores-Murcio et al
perineal region. The mass was completely excised, obtaining adipose-type tissue with abundant adhered vessels; the
tumor diameter was approximately 13 cm.
The histopathologic study reported a 12 x 8 x 7 cm scrotal
lesion that weighed 224 g. Diagnosis was angiomyolipoma
with chronic inflammation and organized vascular thrombosis (figs. 1-3).
Only a few cases of scrotal localization of this benign tumor derived from blood vessels, adipose tissue, and smooth
muscle are referred to in the medical literature.
Discussion
The anatomic origin of scrotal tumors is extratesticular in
the majority of cases. They arise from the spermatic cord
and the epididymis and include different mesenchymal tumors.13 Many of the tumors within the scrotal sac are derived from paratesticular tissue. The paratesticular region is
a complex anatomic area that includes the spermatic cord,
the testicular tunica, epididymis, and vestigial remnants
such as the appendix epididymis and the appendix testis:
histogenetically, this area is composed of a variety of
epithelial, mesothelial, and mesenchymal elements. Therefore, the neoplasms originating from this region form a heterogeneous group of tumors with distinct behavior
patterns; on rare occasions they can have distant metastases.14 The proximity, and in some cases, the communication
between the testicular and paratesticular structures results
in a diversity of masses and lesions that resemble tumors
and as a whole are a formidable diagnostic challenge due to
their rareness and morphologic overlapping. Their main approach continues to be the classic histopathologic analysis
with the prudent incorporation of contemporary immunohistochemical markers.15,16 Solid tumors of paratesticular tissue
are rare, although they have a reported prevalence that varies from 3% to 16% of all the patients for whom scrotal US
Figure 2 Blood vessels, adipose tissue, and mature smooth
muscle at a higher magnification (hematoxylin & eosin X40).
Scrotal angiomyolipoma: a clinical case 145
References
Figure 3 Photomicrography showing disorganized mature
smooth muscle segments without atypia (hematoxylin & eosin
X40).
studies are ordered. Even though scrotal US is the modality
of choice for initial evaluation of pathologic scrotal alterations, given its wide availability, low cost, and high sensitivity for paratesticular disease detection, US findings are
often not conclusive;17 in such cases MR can provide additional information necessary for modifying their management.18
In contrast to testicular tumors, these neoplasms affect
patients of all ages, and they have an asymptomatic presentation as a non-fluctuating or firm mass of varying growth; it
is not unusual for the patient to complain of a firm mass of
rapid growth.
Conclusion
Angiomyolipoma is an uncommon, benign tumor that is rarely located in the scrotum. Its management should take
into account the size of the tumor, the presence of symptoms and factors characteristic of the patient, particularly
the risk for hemorrhage; the majority of symptomatic angiomyolipomas measure around 4 cm.
Even though US is usually an adequate study for evaluating the scrotal region and the testes, its findings can be
inconclusive in the case of angiomyolipomas.
Histopathologic study regularly provides the definitive
diagnosis and there should always be diagnostic suspicion
when dealing with uncommon tumors such as angiomyolipoma, since tumor treatment and approach must be modified
according to each case.
1. Yang L, Feng XL, Shen S, et al. Clinicopathological analysis of
156 patients with angiomyolipoma originating from different
organs. Oncol Lett 2012;3(3):586-590.
2. Marcheix B, Brouchet L, Lamarche Y, et al. Pulmonary angiomyolipoma. Ann Thorac Surg 2006;82(4):1504-1506.
3. Tryggvason G, Blöndal S, Goldin RD, et al. Epithelioid angiomyolipoma of the liver: case report and review of the literature. APMIS 2004;112(9):612-616.
4. Stodulski D, Stankiewicz C, Rzepko R, et al. Angiomyolipoma of
the larynx: case report. Eur Arch Otorhinolaryngol
2007;264(1):89-92.
5. Lin CY, Chen HY, Jwo SC, et al. Ileal angiomyolipoma as an unusual cause of small-intestinal intussusception. J Gastroenterol
2005;40(2):200-203.
6. Tseng CA, Pan YS, Su YC, et al. Extrarenal retroperitoneal angiomyolipoma: case report and review of the literature. Abdom
Imaging 2004;29(6):721-723.
7. Yener O, Ozçelik A. Angiomyolipoma of the right adrenal gland.
ISRN Surg 2011;2011:10274.
8. Gronchi A, Diment J, Colecchia M, et al. Atypical pleomorphic
epithelioid angiomyolipoma localized to the pelvis: a case report and review of the literature. Histopathology
2004;44(3):292-295.
9. Gleeson FC, de la Mora Levy JG, Zhang L, et al. The differential
broadens. EUS FNA appearance and cytological findings of pancreatic angiomyolipoma. JOP 2008;9(1):67-70.
10. Mikoshiba Y, Murata H, Ashida A, et al. Case of a cutaneous angiomyolipoma in the ear. J Dermatol 2012;39(9):808-809.
11. Singh K, Pai RR, Kini H, et al. Cutaneous angiomyolipoma. Indian J Pathol Microbiol 2009;52(2):242-243.
12. Saito M, Yuasa T, Nanjo H, et al. A case of testicular angiomyolipoma. Int J Urol 2008;15(2):185-187.
13. Hosseini MM, Geramizadeh B, Shakeri S, et al. Intrascrotal solitary neurofibroma: A case report and review of the literature.
Urol Ann 2012;4(2):119-121.
14. Khoubehi B, Mishra V, Ali M, et al. Adult paratesticular tumours.
BJU Int 2002;90(7):707-715.
15. Amin MB. Selected other problematic testicular and paratesticular lesions: rete testis neoplasms and pseudotumors, mesothelial lesions and secondary tumors. Mod Pathol 2005;18(Suppl
2):S131-145.
16. Womack C, Turner AG, Fisher C. Paratesticular liposarcoma
with smooth muscle differentiation mimicking angiomyolipoma. Histopathology 2000;36(3):221-223.
17. Syed Ali A, Tawfeeq Amjadali S, Syed Zafar HJ, et al. Multimodality Imaging of Paratesticular Neoplasms and Their Rare Mimics. RadioGraphics 2003;23:1461-1476.
18. Cassidy FH, Ishioka KM, McMahon CJ, et al. MR imaging of scrotal tumors and pseudotumors. Radiographics 2010;30(3):665683.
Rev Mex Urol 2013;73(3):146-149
Clinical case
Leiomyoma of the seminal vesicle: a case report and literature
review
A. J. Camacho-Castro*, V. Osornio-Sánchez, J. A. Martínez, G. Fernández-Noyola, G.
Recinos-Carrera, S. Ahumada-Tamayo, F. García-Salcido, E. Muñoz-Ibarra, E. MayorgaGómez, G. Garza-Sainz, I. Uberetagoyena-Tello de Meneses, A. Palmeros-Rodríguez, V.
Cornejo-Dávila, C. Martínez-Arroyo, M. Cantellano-Orozco, J. G. Morales-Montor and C.
Pacheco-Gahbler
Urology Division, Hospital General “Dr. Manuel Gea González”, Mexico City, Mexico
KEYWORDS
Seminal vesicle;
Leiomyoma; Mexico.
Abstract Seminal vesicle anomalies can be classified as abnormalities of number (agenesis,
fusion), canalization (cysts), and maturation (hypoplasia). Their importance lies in the frequency with which they are related to developmental abnormalities of other mesonephric derivatives. Primary tumors of the seminal vesicles are extremely rare and mesenchymal tumors are
less frequent than those of epithelial origin.
The aim of this article was to describe a case of leiomyoma of the seminal vesical and its management at the Hospital General “Dr. Manuel Gea González”.
A 37-year-old man with a past medical history of insulin-treated type 2 diabetes mellitus had
symptom onset 7 days prior to seeking medical attention for moderate, continuous, colicky
lumbar pain irradiating to the left flank and iliac fossa. Digital rectal examination found a nonsuspicious, grade 1 adenomatous prostate. A kidney and suprapubic ultrasound revealed an
image suggestive of a 2 x 2 cm, left paravesical lesion that was hyperechoic, homogeneous, and
had well-defined edges. A urotomography (UroCAT) scan identified a dense, solid, 3 x 2 cm lesion
between the base of the bladder and the left seminal vesicle. A transrectal ultrasound showed a
lesion that was dependent on the left seminal vesicle. Diagnostic cystoscopy found a left parameatal extrinsic compression. A 3 x 2 cm tumor of the left seminal vesicle was then laparoscopically resected and the histopathologic study reported leiomyoma of the seminal vesicle.
Ideal management data for seminal vesicle tumors are limited due to the lack of reported cases.
Nevertheless, resection is the preferred option for these lesions.
There are 75 accepted cases of primary tumors of the seminal vesicle and 8 of them are benign:
one schwannoma and 7 leiomyomas.
*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: [email protected] (A. J. Camacho-Castro).
Leiomyoma of the seminal vesicle: a case report and literature review Palabras clave
Vesícula seminal;
Leiomioma; México.
147
Leiomioma de vesícula seminal reporte de un caso y revisión de la literatura
Resumen Las anormalidades de las vesículas seminales pueden ser categorizadas en anormalidades de número (agenesia, fusión), canalización (quistes) y maduración (hipoplasia); la importancia de éstas reside en la frecuencia con que se relacionan con anormalidades del desarrollo de otros derivados mesonéfricos. Los tumores primarios de las vesículas seminales son
extremadamente raros, y los tumores mesenquimales son encontrados con menor frecuencia
que los de origen epitelial.
El objetivo del presente artículo es describir el caso y manejo de un leiomioma de vesícula seminal, en el Hospital General “Dr. Manuel Gea González”.
Se presenta hombre de 37 años de edad, con antecedente de diabetes mellitus tipo 2 tratado
con insulina. Inició 7 días previos a acudir a valoración, con dolor lumbar irradiado a flanco y
fosa ilíaca izquierda, tipo cólico, de moderada intensidad, continúo. Al tacto rectal con próstata adenomatosa grado 1, no sospechosa, se realizó ultrasonido (USG) renal y suprapúbico, donde
se encontró imagen sugestiva de lesión paravesical izquierda, hiperecoica, homogénea, de bordes bien definidos, de 2 x 2 cm. La urotomografía (UroTAC) reporta lesión de densidad sólida,
entre base de vejiga y vesícula seminal izquierda, de 3 x 2 cm. Ultrasonido transrectal con lesión dependiente de vesícula seminal izquierda. En la cistoscopía diagnóstica se encontró compresión extrínseca parameatal izquierda. Posteriormente, se realizó resección de neoplasia de
vesícula seminal izquierda por vía laparoscópica de 3 x 2 cm, con resultado de histopatología
de leiomioma de vesícula seminal.
Los datos en el manejo óptimo de las neoplasias de vesícula seminal se encuentran limitados debido
a la falta de casos reportados, sin embargo la resección de dichas lesiones es la opción preferida.
Existen 75 casos aceptados de tumores primarios de la vesícula seminal, de los cuales 8 son
benignos: un schwannoma y 7 leiomiomas.
Introduction
Seminal vesicle anomalies can be categorized into abnormalities of number (agenesis, fusion), canalization (cysts), and
maturity (hypoplasia); their importance lies in the frequency with which they are related to developmental abnormalities of other mesonephric derivatives. Primary tumors of the
seminal vesicles are extremely rare and mesenchymal tumors are found less frequently than those of epithelial origin. In 1910, Emmerich reported the first case of
cystomyoma of the seminal vesicle, and since then isolated
cases of benign tumors have been reported. Ideal management data of seminal vesicle tumors are limited, due to the
lack of reported cases. However, resection of these lesions
is the preferred option. Open exploration can be performed
through a variety of approaches, which can be retropubic,
transvesical, perineal, transrectal, and trans-sacral. The
approach can also be combined with removal of the complete seminal vesicle; likewise there are reports of laparoscopic lesion excision.1,2
Benign tumors are usually asymptomatic and can be discovered incidentally during surgery or autopsy.
The seminal vesicles are paired, sacculated structures located between the bladder and the rectum. The upper pole
ends in a blind point, whereas the lower pole forms a
straight duct that joins with the contralateral duct, becoming the ejaculatory duct. Asymmetry in shape and form of
the seminal vesicles is normal and the right gland is generally slightly larger in one third of men.3-5
The seminal vesicles develop in puberty and are androgen-dependent organs. During ejaculation, the secretions of
the male reproductive tract are sequentially released
and the final portion consists mainly of seminal vesicle fluid.
The exact physiological role of the seminal vesicles is unknown, but its secretions can optimize the conditions for
spermatic motility, transport, and survival.6-8
The aim of the present article is to describe the case and
management of a leiomyoma of the seminal vesicle at the
Hospital General “Dr. Manuel Gea González”.
Case presentation
A 37-year-old man with a past medical history of type 2 diabetes mellitus treated with insulin (20 U intermediate and
15 U rapid) had symptom onset of his present illness 7 days
prior to seeking medical attention. His symptoms were moderate, colicky, and continuous lumbar pain irradiating to
the left flank and iliac fossa. At the physical examination,
digital rectal exam identified a non-suspicious, grade 1,
adenomatous prostate. A suprapubic renal ultrasound (US)
study revealed an image suggestive of a left, hyperechoic,
homogeneous 2 x 2 cm paravesical lesion with well-defined
edges (fig. 1). A urotomography (UroCAT) scan corroborated the image of the lesion, with a solid density between
the base of the bladder and the left seminal vesicle that
measured 3 x 2 cm (figs. 2 and 3). A transrectal US showed a
lesion dependent on the left seminal vesicle (fig. 1). Diagnostic cystoscopy found a left parameatal extrinsic compression. A laparoscopic resection of the 3 x 2 cm left
seminal vesicle tumor was performed (fig. 4) and the histopathologic study reported leiomyoma of the seminal
148
A. J. Camacho-Castro et al
Figure 1 Transrectal ultrasound. A posterior paravesical lesion
is identified at the seminal vesicle site.
Figure 2 Simple computed tomography scan. The image clearly
shows a lesion at the left lateral base of the bladder.
Figure 3 Contrast-enhanced computed tomography scan that
newly identifies the left seminal vesicle lesion.
Figure 4 Surgical specimen.
vesicle. The patient is presently in the follow-up period and
his progression is good.
other anatomic abnormalities of the bladder.3 Imaging studies such as US, computed tomography, and magnetic resonance have improved diagnostic ability.6
Discussion
Transrectal and abdominopelvic US in the most useful initial
diagnostic tool for patients with prolonged pelvic pain and
other suspicious findings in the medical interview or physical examination; a subsequent computed abdominopelvic
tomography scan can be ordered to evaluate renal abnormalities and define the presence of some other pathologic
process of the pelvis. Other imaging studies such as excretory urography, magnetic resonance, and seminovesiculography can also be done when there is doubt about the
etiology of the disease. Cystoscopy can identify an absent
ipsilateral hemitrigone, an intravesical protrusion, and
Conclusions
There are 75 accepted cases of seminal vesicle primary tumors, 49 of which are adenocarcinomas, 5 are sarcomas,
and one is squamous cell carcinoma, contrasting with the
benign tumors that are extremely rare with only 8 reported
cases: one schwannoma and 7 leiomyomas.
Leiomyoma of the seminal vesicle: a case report and literature review Financial disclosure
References
1. Moudouni SM, Tligui M, Doublet JD, et al. Laparoscopic excision
of seminal vesicle cyst revealed by obstruction urinary symptoms. Int J Urol 2006;13(3):311-314.
2. Buck AC, Shaw RE. Primary Tumours of the retro-vesical region
with special reference to mesenchymal tumours of the seminal
vesicles. Br J Urol 1972;44(1):47-50.
149
3. Lee CB, Choi HJ, Cho DH, et al. Cystadenoma of the seminal
vesicle. Int J Urol 2006;13(8):1138-1140.
4. Yasunaga Y, Ueda T, Kodama Y, et al. Poorly differentiated neuroendocrine carcinoma of the seminal vesicle. Int J Urol
2012;19(4):370-372.
5. Agrawal V, Kumar S, Sharma D, et al. Primary leiomyosarcoma
of the seminal vesicle. Int J Urol 2004;11(4):253-255.
6. Patel B, Gujral S, Jefferson K, et al. Seminal vesicle cysts and
associated anomalies. BJU Int 2002;90(3):265-271.
7. Hoshi A, Nakamura E, Higashi S, et al. Epithelial stromal tumor
of the seminal vesicle. Int J Urol 2006;13(5):640-642.
8. Abe H, Nishimura T, Miura T, et al. Cystosarcoma phyllodes of
the seminal vesicle. Int J Urol 2002;9(10):599-601.
Rev Mex Urol 2013;73(3):150-151
Brief report
DNA isolation from urine samples for STR amplification with a rapid
and safe new method
Aislamiento de ADN a partir de muestras de orina para la
amplificación STR con un nuevo método rápido y seguro
A. J. Manriquea,b, I. C. Ortiz-Trujilloc,*, L. M. Martínez-Sánchezc, C. A. Agudeloc,d, D. A.
Vásquez-Hincapiéc, A. E. Toro-Montoyac, I. C. Barguil-Díazc, D. P. Cuesta-Castroc, M. L.
Bravob, D. P. Aguirreb y J. J. Builes-Gómeza,b
a
The Biology Institute, Universidad de Antioquia, Medellín, Antioquia, Colombia
b
Laboratorio Genes Ltda., Medellín, Antioquia, Colombia
c
The Faculty of Medicine, The School of Health Sciences, Universidad Pontificia Bolivariana, Medellín, Antioquia, Colombia
d
Clínica Universitaria Bolivariana, Medellín, Antioquia, Colombia
Urine can be very useful for isolating DNA because it is
non-invasive, the sample volume is not restricted, and it is easily obtained.1 Forty-six urine samples from healthy volunteers (24 men and 22 women) were obtained. They were
immediately centrifuged at 13,000 rpm for 20 minutes and
maintained at a temperature of 4°C overnight. All the study
participants provided their informed consent. DNA isolation
was carried out with a modified salting out protocol.2 The
median values were 29.25 ng for the men and 29.20 ng for
the women. PCR with 5 STR markers was used to analyze
DNA quality: D16S539, D7S820, D13S317, D5S818, and Penta D.
The PCR products were separated by means of electrophoresis in silver-stained denaturing polyacrylamide gels.
All the markers were successfully typed with an 85% yield
and the rate was reduced in relation to the length of the
amplicon. The amplification percentage showed a tendency
to decrease with respect to the length of the amplicon, as
occurred in other studies.3 These results indicate that urine
is a suitable sample for DNA amplification and the modified
procedure has a very low cost compared with the high cost
of commercial kits.
* Corresponding author at: Carrera 72a N° 78b-50, Medellín, Antioquia, Colombia. Telephone: (57) 493 6300, ext. 854. Cell phone: (300)
6036234. Email: linam.martinez @upb.edu.com (I. C. Ortiz-T).
DNA isolation from urine samples for STR amplification with a rapid and safe new method
References
1. Botezatu I, Serdyuk O, Potapova G, et al. Genetic analysis of
DNA excreted in urine: a new approach for detecting specific
genomic DNA sequences from cells dying in an organism. Clin
Chem 2000;46(8):1078-1084.
151
2. Miller SA, Dykes DD, Polesky HF. A simple salting out procedure
for extracting DNA from human nucleated cells. Nucleic Acids
Res 1988;16(3):1215.
3. Cheong-Sik K, Jin Hee-K, Daehee K, et al. Gene Amplification
using DNA from Human Spot Urine Samples. Asian Pacific J Cancer Prev 2006;7(2):318-320.

Volume 73, may - june 2013, Number 3 ISSN-0185

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