30 Revista Românæ de Urologie

Transcription

REVISTA ROMÂNÆ DE UROLOGIE
Editor Øef: Prof. Dr. Ioanel Sinescu
Editor Fondator: Prof. Dr. Doc. Eugeniu Proca
Comitet Editorial Naflional:
Prof. Dr. Petriøor Geavlete, Bucureøti
Dr. Costicæ Novac, Iaøi
Dr. Radu Constantiniu, Bucureøti
Prof. Dr. Radu Boja, Târgu Mureø
Conf. Dr. Ioan Coman, Cluj-Napoca
Conf. Gabriel Glück, Bucureøti
Conf. Dr. Valentin Ambert, Bucureøti
Prof. Dr. Gheorghe Bumbu, Oradea
Prof. Dr. Viorel Tode, Constanfla
Prof. Dr. Ioan Ioiart, Arad
Comitet Editorial Internaflional:
Prof. Dr. John Denstedt (Ontario, Canada)
Prof. Dr. Imre Romics (Budapesta, Ungaria)
Prof. Dr. Rien Nijman (Groningen, Olanda)
Prof. Dr. Hendrik Van Poppel (Leuven, Belgia)
Prof. Dr. Andrzej Borowska (Varøovia, Polonia)
Peter Hammerer (Braunschweig, Germania)
Dr. Cælin Ciofu (Paris, Franfla)
Prof. Dr. Mircea Golimbu (New York, SUA)
Prof. Dr. Michael Marberger (Viena, Austria)
Prof. Dr. Dirk De Ridder (Leuven, Belgia)
Prof. Dr. Theo M. de Reijke (Amsterdam, Olanda)
Prof. Dr. Marek Sosnowski (Lodz, Polonia)
Per-Anders Abrahamsson (Malmö, Suedia)
Editor executiv:
Dr. Constantin Gîngu, Bucureøti
Editor executiv adjunct:
Dr. Cristian Surcel, Bucureøti
Redactori:
Dr. Sorin Titus Pætræøcoiu, Bucureøti
Dr. Robert Stoica, Bucureøti
Dr. Alexandru Dick, Bucureøti
Redacflia:
Centrul de Chirurgie Urologicæ, Dializæ øi Transplant Renal, Institutul Clinic „Fundeni“, Bucureøti
Øos. Fundeni nr. 258, sect. 2, 022328 Bucureøti, România
Tel./fax: 021-300 7570, e-mail: revista.urologie@gmail.com
Program øtiinflific
Scientific
programme
Topici de congres
Congress topics
Sesiuni postere
1.
2.
3.
4.
5.
6.
7.
Litiazæ
Transplant
Hipertrofie benignæ a prostatei
Cancerul de prostatæ
Uretræ, penis
Urologie funcflionalæ øi reconstructivæ
Tumori vezicale
Oncologie, Cancerul renal
Poster Sessions
Lithiasis
Transplantation
Benign Prostate Hyperplasia
Prostate Cancer
Urethra, Penis
Functional and reconstructive urology
Bladder Tumors
Oncology, Renal Cancer
Sesiuni postere nemoderate
Varia
Unmoderated Poster Sessions
Varia
Sesiune Video
Video Session
1.
2.
3.
4.
5.
Varia
Infertilitate
Hipertrofie benignæ a prostatei
Tumori vezicale
Urologie femininæ
Incontinenflæ
Litiazæ, Oncologie
Varia
Infertility
Benign Prostate Hyperplasia
Prostate Cancer
Bladder Cancer
Female Urology
Incontinence
Lithiasis, Oncology
1
1
1
V. Mitroi , L. Teodorescu , B. Mihai ,
1
2
1
A. Chuaibi , L. Pojoga , V. Cauni
1
Clinica de Urologie,
Spitalul Clinic Colentina, Bucureøti
2
Clinica de ATI,
Introducere. Scopul acestei lucræri este de a prezenta
experienfla noastræ iniflialæ în abordul litiazei renale dure
voluminoase prin litotritie mixtæ: laser (Ho: Yag) øi balisticæ
(Lithoclast).
Material øi metodæ. În perioada 1 iunie 2012 - 15 februarie
2013, 27 de pacienfli cu litiazæ renalæ duræ voluminoasæ
(calculi coraliformi øi pielici voluminoøi) au beneficiat de
nefrolitotomie percutanatæ (NLP) cu litotriflie combinatæ:
laser Holmium (Calculase II de 20 W) cu scopul de a scædea
rezistenfla calculului, urmatæ apoi de litotriflie balisticæ
(Lithoclast Calcusplit). Vârsta medie a pacienflilor a fost de 49
de ani, cu un timp operator mediu de 50 de minute. Mærimea
medie a calculului a fost de 4,8 cm. Au fost analizate ratele de
fragmentare øi de stone-free, timpul operator øi rata
complicafliilor.
Rezultate. Rata de fragmentare a fost de 88.8 %, iar rata de
stone-free a fost de 81,5 % (100% pentru calculii pielici øi
81.5% pentru calculii coraliformi). Litiaza rezidualæ imediatæ a
fost înregistratæ la 5 pacienfli (18.5%). Complicafliile
postoperatorii au fost reprezentate de febræ (11.1%), din care
1 pacient a prezentat sepsis. Sângerarea postproceduralæ a
fost minoræ øi nu a necesitat transfuzie.
Concluzii. Cazurile complexe de litiazæ renalæ impun accesul
la mai multe metode de fragmentare. În litiaza renalæ duræ
utilizarea doar a unei metode de fragmentare poate conduce
la creøterea ratei complicafliilor sau la scæderea ratei de
fragmentare øi de stone-free. Sursele de fragmentare trebuie
sæ fie utilizate în mod flexibil în funcflie de particularitæflile
fiecærui caz în parte, asocierea acestora conducând la
rezultate superioare.
nr. 2 / 2013 • vol 12
Combined lithotripsy methods in the
management of large hard renal
stones
1
1
Litiazæ
PM.1.1. Abordul terapeutic complex
al litiazei renale dure voluminoase
1
V. Mitroi , L. Teodorescu , B. Mihai ,
1
2
1
A. Chuaibi , L. Pojoga , V. Cauni
1
Urology Department,
Colentina Clinical Hospital, Bucharest
2
ICU Department,
Colentina Clinical Hospital, Bucharest
Introduction. The aim of this study is to present our
experience in combined Holmium laser (Ho Yag) and ballistic
(Lithoclast) lithotripsy for large renal lithyasis.
st
th
Patients and methods. Between 1 June 2012 – 27
February 2013, 27 patients with large renal lithyasis
(complete staghorn and pyelic calculi) underwent
percutaneous nephrolithotomy (PCNL) with combined
lithotripsy: laser Holmium lithotripsy using a 20 W Holmium
laser (Storz Calculase II) with the purpose of decreasing the
stone resistance followed by ballistic lithotripsy (Lithoclast
Calcusplit). The mean age of the patients was 49 years, with a
mean operative time of 50 minutes. The mean stone size was
4.8 cm. The stone-free rates and fragmentation rates,
operative time and complications were analyzed.
Results. The fragmentation rate was 88.8% and the stonefree rate was 81.5% (100% for pyelic stones and 81.5 % for
staghorn calculi). Immediate residual lithyasis was recorded
in 5 patients (18.5%). Postoperative complications were
represented by fever (11.1%), with one patient with urinary
sepsis. The bleeding after these interventions was minor; no
blood transfusions were required.
Conclusions. The complex cases of renal lithiasis require the
use of different methods of fragmentation. In large renal
lithyasis, the employment of a single method of
fragmentation can increase the complication rates or reduce
the fragmentation and stone – free rates. The lithotripsy
sources must be used in a flexible way depending on the
particularities of each case, the association of different
methods leading to much better results.
Revista Românæ de Urologie
3
Litiazæ
PM.1.2. Experienfla Clinicii de
Urologie ,,Prof. Dr. Theodor
Burghele’’ în nefrolitotomia
percutanatæ efectuatæ la 36 de
pacienfli cu rinichi unic
M. Merticariu, M. Dumitrache, S. Raøcu,
A. Rusu, D. Bædescu, V Jinga
Spitalul Clinic „Prof. Dr. Th. Burghele”, Bucureøti
Introducere: Nefrolitotomia percutanatæ este o intervenflie chirurgicalæ endoscopicæ de extragere a calculilor renali cu dimensiuni mai mari de 2 cm prin intermediul unei incizii minime cutanate. Complicafliile frecvente sunt reprezentate de sângerare,
perforaflie a cæii urinare sau a organelor învecinate, hidrotorax øi
sepsis. Nefrolitotomia percutanatæ reprezintæ o metodæ de
tratament minim invaziv în cazul litiazei urinare pe rinichi unic.
Obiective: Lucrarea urmæreøte experienfla clinicii din ultimii
3 ani în efectuarea nefrolitotomiei percutanate la pacienfli cu
rinichi unic.
Material øi metodæ: Au fost incluøi în studiu 36 de pacienfli
cu rinichi unic chirurgical sau congenital la momentul intervenfliei la care s-a practicat nefrolitotomie percutanatæ în
perioada martie 2010 - martie 2013. S-au urmærit urmætorii
parametrii: prevalenflæ, caracteristicile pacienflilor, tehnica
intraoperatorie, durata medie a intervenfliei, complicafliile
intra øi postoperatorii, incidenfla øi tipul reintervenfliilor.
4
“Prof. Dr. Theodor Burghele’’ Clinic
of Urology’s Experience with
Percutaneous Nephrolitotomy on
36 Patients with Solitary Kidney
M. Merticariu, M. Dumitrache, S. Raøcu,
Clinic of Urology,
„Prof. Dr. Th. Burghele” Hospital, Bucharest
Introduction: PCNL is an endoscopic procedure used for the
treatment of renal calculi greater than 2 cm using a minimum
skin incision. The most frequent complications related to the
procedure are bleeding, fever, perforation of the urinary tract
or adjacent organs, hydrothorax and sepsis. PCNL can be
safely used on patients with solitary kidney.
Background and Purpose: This paper reviews our 3 year
experience with PCNL on 36 patients with preexisting
solitary kidney.
Patients and Methods: In the study report we included 36
patients with preexisting solitary kidney (congenital or surgically removed) who underwent PCNL in the last 3 years. The
following variables were included: prevalence, patient
characteristics, surgical technique, mean time of intervention, intra and postoperative complications and the
incidence and type of reintervention.
Rezultate: Au fost analizate datele provenite de la 36 de
pacienti (reprezentând 2% din numærul total de pacienfli la care
s-a efectuat NLP în perioada urmæritæ) cu vârsta medie de 58 de
ani, dintre care 1/4 cu DZII, 1/3 cu factori de risc cardio-vasculari
øi 10% din pacienfli aflafli sub tratament anticoagulant. Aproximativ 1/3 au avut urocultura pozitivæ preoperator, iar raportul
calcul noncoraliform vs calcul coraliformi a fost de 2 la 1. La
majoritatea pacienflilor s-a practicat Tubeless NLP cu puncflionarea calicelui inferior øi montare de sondæ dublu J. Dilatarea
traiectului de puncflie s-a efectuat cu dilatatoare rigide sub control fluoroscopic în toate cazurile. Cele mai frecvente complicaflii
intraoperatorii øi postperatorii precoce au fost sângerarea la 5%,
febra la 20% din pacienfli remisæ sub tratament convenflional, iar
10% din pacienfli au necesitat ESWL postprocedural.
Results: We analyzed the data from 36 patients with preexisting
solitary kidney (representing 2% of the total number PCNL’s
performed in the last 3 years in our clinic. The mean patient age
was 58 years old of which 1/3 had diabetes mellitus, 1/4 had
associated cardio-vascular disease,1/3 had positive urine culture
and 10% were on anticoagulants prior to surgery. The ratio
staghorn calculi vs non-staghorn calculi was 1:2. On the majority
of patients we performed Tubeless PCNL with puncture of the
inferior calyx and double J uretheral stent placement. The access
was performed under radiological control and we used rigid
dilators in all cases. The most frequent intra and postoperative
complications were bleeding which occurred in 5% of patients
and fever in 20% of patients with remision under conventional
treatment. The most frequent type of reintervention was ESWL
which was performed on 10% of the patients.
Concluzii: În ciuda factorilor de risc mai mari comparativ cu
pacienflii cu ambii rinichi prezenfli; morbiditatea, mortalitatea
øi necesitatea reintervenfliilor aratæ cæ nefrolitotomia
percutanatæ se poate efectua în condiflii de siguranflæ în cazul
pacienflilor cu rinichi unic.
Conclusions: Despite the higher risks in patients with
solitary kidney compared with patients having bilateral
kidneys, the morbidity, mortality and risk of reintervention
demonstrates that PCNL can be safely performed on patients
with solitary kidney.
nr. 2 / 2013 • vol 12
B. Braticevici, Y.Salaheddin, F. Tænase,
M. Mansour, M. Pascu, R. Petca, V. Jinga
Spitalul Clinic „Prof Dr. Th. Burghele“
Percutaneous Nephrolithotomy
results in pacients with staghorn
calculi vs nonstaghon
B. Braticevici, Y. Salaheddin, F. Tænase,
M. Mansour, M. Pascu, R. Petca, V. Jinga
Spitalul Clinic „Prof Dr. Th. Burghele“
Obiectiv: Compararea rezultatelor nefrolitotomiei percutanate
(NLP) la pacienflii cu calculi coraliformi versus calculi noncoraliformi în Clinica de Urologie a Spitalului Prof. Dr. Th. Burghele.
Objective: Comparing results in patients with staghorn or
nonstaghorn stones who were treated with percutaneous
nephrolithotomy (PCNL) in Prof. Dr. Th. Burghele Clinical Hospital
Materiale øi metode: Studiu retrospectiv derulat pe o
perioadæ de un an de zile: între 01.01.2012 øi 31.12.2012 ce
include 615 pacienfli cu litiazæ renalæ la care s-a practicat NLP.
Vârsta medie a pacienflilor a fost de 53,3 ani. Au fost analizate
foile de observaflie øi s-au urmærit: caracteristicile pacienflilor,
abordul calculului, numærul de traiecte, complicafliile
postoperatorii øi durata spitalizærii.
Methods: This is a retrospective study over one year,
between 01.01.2012 and 31.12.2012. Data from 615 patients
treated for renal stones with PCNL were collected. The
following parameters were analyzed: patient characteristics,
access method, puncture frequency, complications and
duration of hospital stay.
Rezultate: Repartiflia pe sexe a fost - 58,5% femei øi 41,5%
bærbafli. 129 (20,9%) au avut litiazæ coraliformæ øi 486 (79,1%)
litiazæ noncoraliformæ. Incidenfla calculilor coraliformi a fost
mai mare la femei (23.3%) faflæ de bærbafli (17,6%). Urocultura
a fost pozitivæ la 29,4% dintre pacienflii cu litiazæ coraliformæ
vs 20,5 %. Au necesitat mai multe traiecte pacienflii cu calcul
coraliform (33,3% vs 9,4%). Litiaza restantæ a fost în 37,9%
dintre cazurile cu calculi coraliformi vs 10,6%. Spitalizarea
medie a fost mai mare în cazul litiazei coraliforme, fiind
crescutæ de complicafliile postoperatorii mai frecvente, dar øi
de necesitatea unei a doua intervenflii în unele cazuri.
Results: Patient average age was 53,3 years old. There were
129 (20,9%) patients with staghorn calculi and 486 (79,1%)
with nonstaghorn calculi. Incidence of stagohrn calculi were
higher in women (23,3%) comparing to men (17,6%). Positive
urine culture was 29,4% in staghorn and 20,5% in
nonstaghorn calculi. Patients with staghorn stones
underwent multiple punctures more frequently than those
with nonstaghorn stones (33,3% vs 9,4%). Stone free rates
were 62,1% vs 89.4% (staghorn vs nonstaghorn stones).
Duration of hospital stay was longer in patients with
staghorn calculi mostly because some of them needed a
second intervention.
Concluzii: Nefrolitotomia percutanatæ este o proceduræ
siguræ în litiaza renalæ. În litiaza renalæ coraliformæ NLP
reprezintæ intervenflia de elecflie. Pacienflii cu calculi
coraliformi necesitæ de multe ori o a doua intervenflie ceea ce
duce la o spitalizare mai lungæ.
Conclusions: PCNL is a safe procedure with good results in
renal stones treatment and represents first-line treatment in
staghorn calculi. Patients with staghorn stones have a longer
hospital stay due to more frequent complications and the
need for a second procedure.
nr. 2 / 2013 • vol 12
Litiazæ
PM.1.3. Rezultatele nefrolitotomiei
percutanate la pacienflii cu litiazæ
renalæ coraliformæ versus litiazæ
renalæ noncoraliformæ
5
Litiazæ
PM.1.4. Nefrolitotomia percutanatæ
în abordul litiazei renale –
experienflæ personalæ
D. Porav-Hodade, C. Todea
Universitatea de Medicinæ øi Farmacie,
Clinica de Urologie, Târgu Mureø
6
Percutaneous nephrolithotomy
approach for renal stones –
Personal experience
D. Porav-Hodade, C. Todea
University of Medicine and Pharmacy,
Department of Urology, Târgu Mureø
Introducere øi obiective. Nefrolitotomia percutanatæ (NLP)
reprezintæ tehnica de referinflæ în abordul litiazei renale Obiectivele acestei lucræri sunt reprezentate de evaluarea experienflei
inifliale personale în abordul percutanat al litiazei renale.
Introduction and objectives. Percutaneous Nephrolithotomy
(PCNL) is the reference technique for the kidney stone pathology.
The objectives of this paper are to evaluate the personal initial
experience of percutaneous approach for urolithiasis.
Material øi metodæ. Studiul retrospectiv s-a efectuat în perioada august 2009-martie 2013. În aceastæ perioadæ am efectuat 565 de intervenflii la nivelul aparatului urinar înalt (495
de NLP øi 70 de nefrostomii percutanate). Toate intervenfliile
au fost efectuate în anestezie rahidianæ sau epiduralæ.
Nefrostomia percutanatæ a fost pæstratæ pentru 48 de ore la
pacienflii cu NLP. Postoperator tofli pacienflii au urmat tratament antibiotic injectabil pe perioada internærii øi 7 zile tratament oral în regim ambulator.
Materials and methods. The retrospective study was
conducted from August 2009 to March 2013. During this
period I performed 565 intervention at the upper urinary
tract (495 PCNL and 70 percutaneous nephrostomy). All
interventions were performed in spinal or epidural
anesthesia. Percutaneous nephrostomy was kept for 48
hours in patients with PCNL. All patients were treated postop with intravenous antibiotic during hospitalization and
another 7 days with oral therapy.
Rezultate. Un numær de 436 de pacienfli au necesitat o singuræ øedinflæ de NLP, 59 de pacienfli (11,9%) necesitând mai
multe øedinfle de NLP si/sau alte tipuri de intervenflii
(ureteroscopie, ESWL). Durata medie de spitalizare postoperatorie a fost de 3,8 zile. 4 pacienfli au necesitat intervenflii
chirurgicale postoperatorii datoritæ unor complicaflii. Pentru
3 pacienfli s-a practicat laparoscopie exploratorie pentru urohemoperitoneu cu drenaj peritoneal øi retroperitoneal. O
pacientæ a necesitat lombotomie cu nefrorafie. Nu au fost
cazuri de nefrectomie de hemostazæ sau decese.
Results. A total of 436 patients required one session of PCNL,
59 patients (11.9%) requiring several sessions of PCNL and /
or other types of interventions (ureteroscopy, ESWL). The
average length of hospitalization was 3.8 days. 4 patient
required surgery due to complications after PCNL. For 3
patients was performed exploratory laparoscopy for urohaemoperitoneum with peritoneal and retroperitoneal
drenage. One patient required lombotomy with renal
parenchyma suture. There were no cases of nephrectomy for
hemostasis or deaths.
Concluzii. Rata complicafliilor precum øi rezultatele postoperatorii sunt comparabile cu cele ale literaturii de specialitate.
Conclusions. The rate of postoperative complications and
the results are comparable with those of the literature.
nr. 2 / 2013 • vol 12
1
1
Characteristics of percutaneous
nephrolithotomy in elderly patients
1
1
S. Nedelea , R. Borcæiaø , I. Dragomiriøteanu ,
1
1
1
D. Bædescu , V. Ambert , V. Salaheddin ,
2
2
M. Pascu , C. Mocanu
1
Spitalul Clinic “Prof. Dr. Th. Burghele”, Clinica
de urologie
2
Spitalul Clinic “Prof. Dr. Th. Burghele”,
Departamentul de radiologie
1
1
S. Nedelea , R. Borcæiaø , I. Dragomiriøteanu ,
1
1
1
D. Bædescu , V. Ambert , V. Salaheddin , M.
2
2
Pascu , C. Mocanu
1
“Prof. Dr. Theodor Burghele” Clinical Hospital,
Clinical Department of Urology
2
“Prof. Dr. Theodor Burghele” Clinical Hospital,
Department of Radiology
Introducere. Scopul studiului a fost reprezentat de evidenflierea caracteristicilor nefrolitotomiei percutanate practicate
în tratamentul litiazei reno-ureterale la pacienflii vârstnici.
Introduction. This study aimed to highlight de characteristic
of percutaneous nephrolithotomy as treatment for renoureteral lithiasis in elderly patients.
Material øi metode. A fost efectuat un studiu descriptiv øi
retrospectiv în care au fost incluøi pacienflii vârstnici, internafli
în perioada 1.01.2012-31.12.2012, cu litiaza reno-ureteralæ
pentru care s-a practicat nefrolitotomie percutanatæ. Am
definit ca pacienfli vârstnici pe cei cu vârsta mai mare sau
egalæ cu 70 de ani la data intervenfliei chirurgicale. Au fost
studiate comorbiditæflile, caracterele litiazei, aspecte ale
intervenfliei chirurgicale øi evoluflia postoperatorie.
Materials and methods. A descriptive and retrospective
study was performed. It included elderly patients admitted
from 01.01.2012 to 31.12.2012 diagnosed with reno-ureteral
lithiasis and treated by percutaneous nephrolithotomy.
Elderly patients were considered those 70 years old and
more. We studied comorbidities, stone type and location,
intervention and postoperative characteristics.
Rezultate. Au fost efectuate un numær de 61 de nefrolitotomii percutanate la vârstnici în cele 12 luni studiate,
reprezentând 9,91% din numærul total de 615 efectuate.
Vârsta medie în lotul studiat a fost de 74,26±3,04 ani. Durata
medie a internærii postoperatorii la aceøti pacienfli a fost de
7,10 zile foarte apropiatæ de a pacienflilor cu vârste mai mici,
de 6,84 zile. O pætrime din calculii întâlnifli la aceastæ
categorie de vârstæ au fost coraliformi. Cu excepflia
pacienflilor care au necesitat un al doilea timp operator, la
care s-a montat drenaj urinar extern între intervenflii, s-a
practicat în exclusivitate drenajul urinar intern postoperator.
Litiazæ
PM.1.5. Caracteristici ale
nefrolitotomiei percutanate
la pacienflii vârstnici
Results. 61 percutaneous nephrolithotomies were
performed, representing 9,91 % of the total of 615 performed
during the 12 months. Average age was 74,26±3,04 years.
Mean postoperative admission time was 7,10 days close to
the 6,84 days in younger patients. Staghorn calculi represent
a quarter of all lithiasis found in this group. Postoperative
external urinary drainage was only used for patients that
required additional percutaneous nephrolithotomies. We
have used internal urinary drainage for all the other patients.
Conclusions. Percutaneous nephrolithotomy in elderly
patients is similar to that in younger ones. Comorbidities may
slow postoperative recovery at elderly patients.
Concluzii. Nefrolitotomia percutanatæ la pacienflii vârstnici
are rezultate comparabile cu cele întâlnite la pacienflii mai
tineri. Comorbiditæflile pot încetini evoluflia postoperatorie la
aceøti pacienfli.
nr. 2 / 2013 • vol 12
7
Litiazæ
PM.1.6. Eficienfla øi siguranfla
nefrolitotomiei percutanate (NLP)
la pacienflii peste 70 de ani cu
litiazæ renalæ
C. Todea, D. Porav, R. Boja, S. Nedelcu,
Orsolya Martha
UMF Târgu Mureø, Clinica de Urologie,
Spitalul Clinic Judeflean, Clinica de Urologie
Introducere øi obiective. NLP reprezintæ principala indicaflie
pentru pacienflii cu calculi renali, chiar în prezenfla a
numeroase comorbiditæfli. În clinica noastra operafliile deschise pentru aceastæ patologie reprezintæ sub 0,5% din
totalul operafliilor pentru litiazæ renalæ. Obiectivul acestei
lucræri reprezintæ evaluarea siguranflei øi eficienflei acestei
proceduri la pacienflii având vârsta de peste 70 de ani.
Material øi metodæ. S-a efectuat un studiu retrospectiv pe o
perioadæ de 16 ani (1997-2012), pe 323 de pacienfli (162
femei, 161 bærbafli), cu vârste peste 70, având litiazæ renoureteralæ, rezolvatæ endoscopic prin NLP sau uretroscopie
anterogradæ (URSA). 85 pacienfli (26,31%) au avut comorbiditæfli care au fost diagnosticate øi tratate preoperator,
acolo unde a fost necesar.
Rezultate. Per ansamblu starea “stone free” la terminarea
operafliei a fost prezentæ la 263 pacienfli (81,42%). 60 pacienfli
(18,58%) au avut fragmente reziduale. Calculii reziduali s-au
rezolvat printr-o nouæ øedintæ de NLP, eliminare spontanæ,
sau ESWL. Cele mai frecvente complicaflii au fost hemoragia
øi infecflia. Nu am avut decese. NU am efectuat nefrectomii cu
scop hemostatic.
Concluzii. Comorbiditæflile recunoscute preoperator nu
constituie factori de risc particulari la vârstnici, dar se impune
o evaluare riguroasæ a lor în perioada preoperatorie, respectiv tratamentul acestora. Numærul, volumul øi complexitatea
calculului influenfleazæ direct starea “stone free” la terminarea intervenfliei de extragere a acestor calculi.
8
Percutaneous nephrolitotomy
(PCNL) efficacy and safety
in patients over 70 years
with kidney stones
C.Todea, D. Porav, R. Boja, S. Nedelcu,
Orsolya Martha
UMF Târgu Mureø, Clinic of Urology, County
Hospital, Department of Urology
Introduction and objectives. PCNL represent the main
indication for patients with kidney stones, even in the
presence of various comorbidities. In our clinic open surgery
for this pathology is less than 0.5% of all procedures for renal
stones. The objective of this paper is to assess the safety and
efficacy of this procedure in patients over 70 years.
Material and methods. A retrospective study was
performed for a period of 16 years (1997-2012), A totally of
323 patients entered in this study (162 women, 161 men),
aged over 70 with renal stones They were treated
endoscopically by PCNL or anterograde ureteroscopy. 85
patients (26.31%) had comorbidities that were
preoperatively diagnosed and treated where necessary.
Results. Overall status of „stone free“ at the end of surgery
was present in 263 patients (81.42%). 60 patients (18.58%)
had residual fragments. Residual stones were solved by a
new PCNL session, spontaneous elimination or ESWL. The
most common complications were bleeding and infection.
We had no deaths. No hemostasis nephrectomy was
necessary.
Conclusions. Recognized preoperative comorbidities do not
represent risk factors in elderly patients, but it requires a
rigorous evaluation in the preoperative period. The number,
size and complexity calculation directly influences the state
„stone free“ at the end of surgery.
nr. 2 / 2013 • vol 12
Improving the lifespan of the
flexible ureteroscopes
R. Mulflescu, R. Satalan, D. Georgescu,
B. Geavlete, P. Geavlete
Spitalul Clinic de Urgenflæ “Sf. Ioan”, Bucureøti
R. Mulflescu, R. Satalan, D. Georgescu,
B. Geavlete, P. Geavlete
Department of Urology, “Saint John”
Emergency Clinical Hospital, Bucharest
Introducere: Îmbunætæflirea durabilitæflii, miniaturizarea øi
tehnologia digitalæ au fost obiectivele principale de
dezvoltare ale ureteroscoapelor flexibile. Au fost analizate
metodele de prelungire a duratei de viaflæ a modelului Storz
Flex-Xc.
Introduction: Improved durability, miniaturization and
going digital were the development goals for flexible
ureteroscopes. We aimed to analyze the Storz Flex-Xc model
and to highlight methods to increase its lifespan.
Material øi metodæ: În perioada Mai-Decembrie 2012 au fost
analizate ureteroscopiile flexibile realizate cu douæ astfel de
ureteroscoape flexibile (douæ grupuri). Relocarea calculilor
din calicele inferior a fost realizatæ ori de câte ori posibil. În
cea de a doua serie, teaca de acces ureteral a fost retrasæ în
bloc cu endoscopul, pentru a preveni deteriorarea pærflii
distale a acestuia.
Methods: Betweend May-December 2012, flexible
ureteroscopic procedures performed with two Storz Flex-Xc
were analyzed. The patients were divided in two groups, one
for each endoscope. Relocation of the lower pole stones was
performed in all cases when possible. In the second series the
access sheath was retracted together with the flexible
ureteroscope to prevent the damages it may inflict on the
endoscope.
Rezultate: Au fost realizate 247 proceduri (229 pacienfli): 96
proceduri (90 pacienfli) în primul grup øi 151 proceduri (139
pacienfli) în al doilea grup. Teaca de acces ureteral a fost
utilizatæ în 72% din cazuri. Primul endoscop a fost utilizat
pentru 67,1 ore (timp procedural mediu de 8 minute pentru
cele diagnostice øi 45 minute pentru cele terapeutice) în timp
ce al doilea a fost utilizat 107,7 ore (timp procedural mediu
10 minute pentru cele diagnostice øi 49 de minute pentru
cele terapeutice). Calculii caliceali inferiori au fost prezenfli în
36,7% din cazuri din primul grup (27,7% fiind relocafli) øi în
38,8% din grupul al doilea (33,1% fiind relocafli). Reparaflii
majore au fost necesare dupæ deteriorarea înveliøului
exterior, respectiv deteriorarea sistemului de deflexie.
Results: 247 procedures were performed on 229 patients:
first group with 96 procedures (90 patients) and second
group of 151 procedures (139 patients). Ureteral access
sheath was used in 72% of the cases. The first endoscope was
used for 67.1 hours (mean procedural time of 8 minutes for
diagnostic and 45 minutes for therapeutic ones) while the
second lasted for 107.7 hours (mean procedural time of 10
minutes for diagnostic and 49 minutes for therapeutic ones).
Lower pole stone were recorded in 36.7% of patients of the
first group (27.7% being relocated), and in 38.8% of the
second group (33.1% being relocated). Major repairs were
needed after damages of the outer coating and deterioration
of the deflecting mechanism, respectively.
Concluzii: Flex-Xc pare un ureteroscop flexibil durabil.
Utilizarea tecii de acces ureteral øi evitarea suprasolicitærii
mecanismului de deflexie prin relocarea calculilor caliceali
inferiori pare sæ aibæ un aport semnificativ în relungirea
duratei de viaflæ a acestor endoscoape costisitoare.
Conclusions: Storz Flex-Xc seems to be a durable flexible
ureteroscope. Use of ureteral access sheath and avoidance of
overstressing the deflection mechanism by relocating lower
pole stones offers a substantial advantage in prolonging the
lifespan of these expensive instruments.
nr. 2 / 2013 • vol 12
Litiazæ
PM.1.7. Prelungirea duratei de
viaflæ a ureteroscoapelor flexibile
9
Litiazæ
10
PM.1.8. O comparaflie criticæ a
performanflelor øi limitærilor a trei
dintre ultimele modele de
ureteroscoape flexibile
A critical comparison of the
performances and limitations of
three of the latest models of flexible
ureteroscopes
R. Mulflescu, D. Georgescu, B. Geavlete,
M. Dræguflescu, R. Satalan, P. Geavlete
R. Mulflescu, D. Georgescu, B. Geavlete, M.
Dræguflescu, R. Satalan, P. Geavlete
Department of Urology, “Saint John” Emergency
Clinical Hospital, Bucharest
Introducere: În ultimele decade a fost urmæritæ continuu
îmbunætæflirea durabilitæflii, vizibilitæflii øi manevrabilitæflii
ureteroscoapelor flexibile. Au fost studiate comparativ trei
dintre ultimele modele de
ureteroscoape flexible.
Introduction: A continuous struggle to improve durability,
visibility and maneuverability of the flexible ureteroscopes
was undergone during the last decades. We aimed to
comparatively study three of the latest models of flexible
ureteroscopes.
Material øi metodæ: Karl Storz Flex-Xc, Olympus URF-Vo and
Wolf Cobra au fost evaluate pe parcursul a 90 de proceduri,
câte 20 terapeutice øi câte 10 diagnostice pentru fiecare din
ele. Uøurinfla inserfliei, manevrabilitatea øi vizibilitatea în cursul
fiecærei proceduri au fost notate de la 1 la 5. Fluxul irigafliei øi
deflexiunea maximæ au fost mæsurate ex vivo, cu canalul de
lucru gol, respectiv cu instrumente accesorii inserate.
Durabilitatea endoscoapelor a fost de asemenea evaluatæ.
Methods: Karl Storz Flex-Xc, Olympus URF-Vo and Wolf Cobra
were evaluated during 90 procedures, 20 therapeutic for
pyelocaliceal lithiasis and 10 diagnostic for each one. Ease of
insertion, maneuverability and visibility during each procedure
were scored from 1 to 5 and compared, while the irrigation flow
and maximal deflection was measured in an ex vivo setting,
with an empty working channel and with accessory
instruments in place. Instruments durability was also reviewed.
Rezultate: Toate modelele au demonstrat o bunæ
manevrabilitate, cu un uøor avantaj pentru Flex-Xc. În
procedurile diagnostice, întregul sistem pielo-caliceal nu a
putut accesat în 2 cazuri de cætre URF-Vo (tije caliceale
subfliri) øi într-un caz de Cobra (arhitecturæ calicealæ
complexæ). Modelele digitale au obflinut un scor similar
pentru vizibilitate, mai mare decât Cobra. Pierderea deflexiei
øi a irigafliei la inserflia diferitelor instrumente accesorii a fost
similaræ la toate modelele, Cobra oferind totuøi irigaflie
suplimentaræ prin canalul secundar. Pierderea deflexiei
maxime în timp a fost de 5% pentru URF-Vo, 9% pentru FlexXc øi 10% pentru Cobra. Calitatea imaginii modelelor digitale
a ræmas neschimbatæ, în timp ce la Cobra au fost înregistrate
58 de fibre optice rupte.
Results: All models demonstrated good maneuverability,
with a slight advantage for Flex-Xc. During diagnostic
procedures, failure to access the entire pyelocaliceal system
occurred in 2 cases for URF-Vo, both due to thin caliceal
infundibulum, and in 1 case for Cobra, due to complex
caliceal architecture. Regarding visibility, while the
performances of the digital models were similar, Cobra
achieved a lower score. Loss of deflection and irrigation
when using ancillary instruments was similar for all
endoscopes, but Cobra offered supplementary flow through
a secondary channel. Mean deflection loss was 5% for URFVo, 9% for Flex-Xc and 10% for Cobra. The visual quality of
the digital models remained unchanged during study, but in
the fiberoptic ureteroscope 58 optic fibers broke.
Concluzii: Ultimele modele de ureteroscoape flexibile se
dovedesc instrumente eficiente în intervenfliile destinate cæii
urinare superioare, cu un avantaj în ceea ce priveøte
vizibilitatea pentru cele digitale.
Conclusions: The latest models of flexible ureteroscopes
prove to be effective instruments for upper urinary tract
endoscopic interventions, with an advantage regarding
visibility for the digital ones.
nr. 2 / 2013 • vol 12
R. Mulflescu, D. Georgescu, M. Dræguflescu,
E. Alexandrescu, R. Satalan, P. Geavlete
Clinica de Urologie, Spitalul Clinic de Urgenflæ
“Sf. Ioan”, Bucureøti
Intracorporeal lithotripsy into
„dust” vs. extractable fragments in
renal stones treatment
R. Mulflescu, D. Georgescu, M. Dræguflescu,
E. Alexandrescu, R. Satalan, P. Geavlete
Introducere: Abordul calculilor pielocaliceali utilizând
ureteroscopul flexibil ridicæ o serie de probleme legate de
timpul operator, morbiditatea asociatæ øi costuri, în special
prin potenfliala deteriorare a endoscoapelor.
Introduction: Pyelocaliceal calculi flexible ureteroscopic
approach raises problems related with operative time,
associated morbidity and costs, especially by potential
endoscope damage.
Material øi metodæ: Au fost analizate 5 serii de câte 20 de
pacienfli cu litiazæ pielocalicealæ unicæ: Grupul I cu calculi < 1
cm fragmentafli „dust”, Grupul II cu calculi < 1 cm cu litotriflie
în fragmente, Grupul III cu calculi între 1-2 cm fragmentafli
„dust”, Grupul IV cu calculi între 1-2 cm cu litotriflie în
fragmente, Grupul V cu calculi între 1-2 cm la care s-a
practicat litotriflie “dust” pânæ la 1 cm dupæ care litotriflie în
fragmente extractabile. În toate cazurile a fost utilizat un
ureteroscop flexibil Storz Flex-Xc øi un laser Ho:YAG.
Methods: 5 series, each of 20 patients with single
pyelocaliceal lithiasis were analyzed: Group I with calculi < 1
cm fragmented to dust, Group II with calculi < 1 cm with
lithotripsy in fragments, Group III with calculi of 1-2 cm
fragmented to dust, Group IV with calculi of 1-2 cm with
lithotripsy in fragments, Group V with calculi of 1-2 cm
fragmented to dust until they reached 1 cm, and lithotripsy
in fragments afterwards. In all cases were used a flexible
Story Flex-Xc ureteroscope and Ho:YAG lithotripsy.
Rezultate: Teaca de acces ureteral a fost utilizatæ în 70% din
cazuri. Volumul mediu al calculilor în grupul I vs. II, respectiv
în grupurile II, III øi IV au fost similare. Rata de succes a
procedurilor a fost statistic similaræ în cele 5 grupuri. Timpii
operatori medii au fost de 39 minute în grupul I, 21 minute în
grupul II, 112 minute în grupul III, 72 minute în grupul IV, 51
minute în grupul V. Au fost înregistrate complicaflii minore în
7 cazuri øi o singuræ complicaflie majoræ, în Grupul IV.
Results: Ureteral access sheath was used in 70% of the cases.
Mean stone volume in groups I and II, and groups II, IV and V
were similar. Success rate in all groups was statistically
similar. Mean operating time was 39 min in group I, 21 min in
Group II, 112 min in group III, 72 min in group IV and 51 min
in group V. Minor complications occurred in 7 cases, while a
single major complication occurred in group IV.
Concluzii: Metoda cea mai eficientæ de litotriflie a calculilor
sub 1 cm pare a fi în fragmente extractabile. Pentru calculii
voluminoøi metoda este utilæ distrucflia în „dust” pânæ la 1
cm, apoi litotriflia putând fi realizatæ în fragmente.
nr. 2 / 2013 • vol 12
Litiazæ
PM.1.9. Litotriflia laser
intracorporealæ „dust” vs.
fragmente extractabile în
tratamentul litiazei renale
Conclusions: The optimal lithotripsy method of calculi < 1
cm seems to be in extractable fragments. Larger calculi
should be fragmented to dust until they reach 1 cm and then
the lithotripsy should be continued into extractable
fragments.
11
Litiazæ
PM.1.10. ESWL vs ureteroscopie
flexibilæ în tratamentul litiazei
renale
C. Persu, V. Mirciulescu, G. Niflæ,
A. Mihalache, P. Geavlete
12
SWL vs Flexible Ureteroscopy for
the treatment of renal stones –
a single center experience
C. Persu, V. Mirciulescu, G. Niflæ,
Introducere. Tehnica ESWL este de obicei perceputæ de
pacienfli ca fiind non-invazivæ, devenind astfel prima opfliune
în tratamentul litiazei renale. Scopul acestui studiu este sæ
compare prospectiv ESWL øi ureteroscopia flexibilæ cu
litotriflie cu Ho:Laser în tratamentul litiazei renale.
Introduction: SWL is usually perceived by the patients as
non-invasive, tending to become the first option for renal
stones. Our study aims to prospectively compare SWL with
flexible uretheroscopy with Ho:Laser lithotripsy for the
treatment of renal lithiasis.
Material øi metodæ. Între Ianuarie 2012 øi Ianuarie 2013, 85
pacienfli au fost tratafli prin ureteroscopie flexibilæ, iar 81
pacienfli au fost tratafli prin ESWL, pentru litiazæ renalæ cu
diametru maxim de 3 cm. Pacienflii au fost ulterior împærflifli în
douæ subgrupe, în funcflie de dimensiunea calculului: 96
cazuri cu pietre sub 1 cm, iar 71 au avut calculi peste 1 cm.
Analiza statisticæ a comparat ESWL øi ureteroscopia în cele
douæ grupe, urmærind rata de stone-free, timpul operator øi
incidenfla complicafliilor.
Materials and Methods: Between January 2012 and January
2013, 85 patients underwent flexible ureteroscopy with
Ho:Laser lithotripsy and other 81 patients were treated by
SWL for renal stones with a maximum diameter of 3cm. The
patients were further divided into two groups, according to
the size of the stone – 96 cases had stones less than 1 cm,
other 71 had stones over 1 cm. The statistical analysis
compared SWL and ureteroscopy in the two groups, looking
at stone free rate, operative time and complications.
Rezultate. Rata globalæ de succes dupæ o singuræ proceduræ
a fost de 87% dupæ ureteroscopie øi 55 % dupæ ESWL. Dupæ a
doua proceduræ, rata de stone-free a crescut la 98% dupæ
ureteroscopie øi 72 % dupæ ESWL. Timpul operator mediu a
fost de 24(±7) min dupæ ESWL øi 46(±17) min dupæ
uretroscopie. Rata globalæ a complicafliilor nu a avut
diferenfle semnificative statistic între cele douæ tehnici. În
grupul pacienflilor cu calculi sub 1 cm, cele douæ tehnici au
avut rate de succes similare (95%, respectiv 96%), iar timpii
operatori au fost asemnænætori. În cel de-al doilea grup, ESWL
a avut rate de succes inferioare uretroscopiei flexibile.
Results: The overall success rate after one procedure was
87% for ureteroscopy and 55% for SWL. After the second
procedure, the stone free rate was 98% for uretheroscopy
and 72% for SWL. The mean operating time was 24(±7) min
for SWL and 46(±17) min for ureteroscopy. The overall
complication rate showed no statistical significant
differences between groups or techniques. In the group of
stones under 1cm diameter, SWL and ureteroscopy showed
similar success rates (95% and 96% respectively) and
operating times. In the other group, SWL had significantly
lower success rates.
Concluzii. Ambele tehnici au demonstrat un profil de
siguranflæ foarte bun, dar uretroscopia oferæ o mai bunæ ratæ
de stone-free øi un timp mai scurt pânæ la eliminarea
completæ a calculului, în condifliile unei spitalizæri de duratæ
mai lungæ. ESWL ræmâne mai ieftin øi foarte potrivit ca
proceduræ ambulatorie.
Conclusions: While both techniques are safe, flexible
ureteroscopy offers a higher stone free rate and a shorter
time until complete removal of the stone, with a longer
hospital stay. SWL seems less expensive and very suitable as
an outpatient procedure.
nr. 2 / 2013 • vol 12
M. Dumitrache, M. Merticariu, S. Raøcu,
A. Rusu, D. Bædescu, V. Jinga
Spitalul Clinic „Prof. Dr. Th. Burghele”
Introducere. Colica renalæ la gravidæ reprezintæ o provocare
de diagnostic pentru medicul urolog datoritæ riscului
mutagen al acfliunii radiafliilor ionizante asupra fætului. De
asemenea, tratamentul, fie el chirurgical sau conservator
(medicamentos) comportæ riscuri atât materne cât øi fetale.
Materiale øi metodæ. Au fost analizate retrospectiv datele
de la 22 de cazuri de colicæ renalæ la gravide, paciente ale
clinicii noastre, în intervalul 2010-2013. S-au urmærit: vârsta
gestaflionalæ, sensibilitatea ecografiei ca metodæ diagnosticæ,
modificærile bio-umorale asociate, localizarea obstrucfliei øi
indicaflia terapeuticæ.
Rezultate. Vârsta gestaflionalæ medie a fost 22,36 de
sæptæmâni (trimestrul al 2-lea). Ecografia a identificat corect
calculul în 54% din cazuri, furnizând, de asemenea, detalii
despre gradul de distensie øi conflinutul SPC. În 7 cazuri a fost
suficientæ administrarea de tratament medicametos øi
monitorizare. 10 paciente (45%) au prezentat obstrucflie øi
retenflie septicæ în calea urinaræ. Drenaj urinar – sonda JJ sau
nefrostomie minimæ percutanatæ - s-a efectuat la 12
paciente. Într-un caz, simptomatologia algicæ a fost
determinatæ de sindrom de JPU, suspicionat ecografic øi
confirmat urografic post-partum.
Concluzii. Ecografia este metoda de elecflie pentru stabilirea
etiologiei colicii renale la gravide, deoarece nu prezintæ risc
fetal. Tratamentul conservator este de primæ intenflie, dar
abordarea endoscopicæ reprezintæ o alternativæ fezabila, în
cazurile complicate sau a celor care nu ræspund la tratament
medicamentos. Pacientele necesitæ urmarire pe toatæ
perioada gestaflionalæ øi definitivarea tratamentului urologic
postpartum.
nr. 2 / 2013 • vol 12
“Prof. Dr. Theodor Burghele’’
Urology Clinic’s Experience with the
management of renal colic in
pregnancy
Litiazæ
PM.1.11. Experienfla clinicii de
Urologie “Prof. Dr. Th. Burghele”
în managementul colicii renale
la gravidæ
M. Dumitrache, M. Merticariu, S. Raøcu,
Clinic of Urology,
„Prof. Dr. Th. Burghele” Hospital, Bucharest
Introduction. Renal colic during pregnancy represents a
diagnostic challenge for the urologist, due to the mutagen
risk of fetal exposure to X-rays. Medical and surgical
treatment alike, present risks for the fetus and the mother.
Materials and method. 22 cases of renal colic during
pregnancy, admitted in our clinic between 2010 and 2013,
were retrospectively analyzed. We analyzed the mean
gestational age, the sensibility of ultrasound as a diagnostic
tool, laboratory findings associated, level of the obstruction
and therapeutic approach.
Results. The mean gestational age was 22.36 weeks (second
trimester). Ultrasound correctly identified the stone and it’s
location, the degree of distension and characteristics of the
content of the urinary tract. In 7 cases, medical therapy and
follow-up was sufficient. 10 patients (45%) had obstruction
and associated UTI. Urinary drainage, either by JJ stent
insertion or nephrostomy, was performed in 12 patients. In 1
case the pain was determined by a UPJ obstruction, which
was discovered by ultrasound examination and confirmed by
IVP postpartum.
Conclusions. Ultrasound is the method of choice for
investigating renal colic during pregnancy, because it
represents no risk for the fetus. Conservatory management is
the first choice, but endoscopic treatment is also feasible in
complicated cases and for those patients in which
conservatory management fails. Patients need to be reevaluated throughout pregnancy. Completion of the
urological treatment sould be attempted postpartum.
13
Litiazæ
PM.1.12. Tratamentul intervenflional
al litiazei ureterale la gravide
D. Georgescu, R. Mulflescu, V. Mirciulescu,
B. Geavlete, E. Alexandrescu,
V. Iordache, P. Geavlete
Introducere: Litiaza urinaræ la gravide constituie o provocare
atât în ceea ce priveøte diagnosticul cât øi atitudinea
terapeuticæ. Scopul studiul a fost reprezentat de evaluarea
metodelor de tratament interventional la gravidele cu litiazæ
ureteralæ obstructive.
Material øi metodæ: În perioada ianuarie 2006- ianuarie
2012, în clinica noastræ, 54 de gravide au beneficiat de
tratament intervenflional activ al litiazei ureterale, la 38 dintre
ele efectuându-se abord ureteroscopic retrograd. Vârsta
medie a pacientelor a fost de 27,2 ani (între 20 øi 37 de ani)
sarcina fiind cuprinsæ între 12 øi 35 de sæptæmâni. Din acest
lot, 38 de paciente au prezentat hematurie microscopicæ, 18
leucociturie øi 6 infecflie urinaræ. Ureteroscopia retrogradæ
semirigidæ a reprezentat prima alternativæ terapeuticæ în
primele 2 trimestre, iar în trimestrul ultim, primele opfliuni
fiind abordul flexibil sau endoprotezarea ureteralæ. În 42 de
cazuri intervenflia s-a efectuat sub anestezie rahidianæ, iar în
12 sub anestezie generalæ.
Rezultate: Ureteroscopia semirigidæ a permis rezolvarea
litiazei în 28/32 de cazuri. La 17 paciente a fost necesaræ
fragmentarea balisticæ sau cu laser Ho:YAG a calculilor, în
timp ce în 11 cazuri s-a practicat extragerea intactæ a
acestora. La 5 paciente au fost înregistrate complicaflii
intraoperatorii minore: leziuni ale mucoasei ureterale, edem,
sângerare. Postoperator, 4 paciente au prezentat infecflii
urinare, 2 hematurie persistentæ, în 3 cazuri fiind descrise
simptome vezicale iritative. Ureteroscopia flexibilæ a fost
efectuatæ cu succes în toate cazurile, færæ complicaflii intra
sau postoperatorii. Toate pacientele au næscut la termen.
Concluzii: Ureteroscopia cu litotriflie pneumaticæ sau cu laser
Ho:YAG poate fi consideratæ o metodæ terapeuticæ de primæ
linie, eficientæ øi siguræ, la gravidele cu litiazæ ureteralæ care
necesitæ tratament intervenflional.
14
Active treatment of urolithiasis
during pregnancy
D. Georgescu, R. Mulflescu, V. Mirciulescu,
B. Geavlete, E. Alexandrescu,
V. Iordache, P. Geavlete
Department of Urology,
“Saint John” Emergency Clinical Hospital,
Bucharest
Introduction: Urolithiasis during pregnancy remains both a
diagnostic and treatment challenge. The aim of the study
was to assess the results of minimally invasive alternatives in
pregnant women with obstructive ureteral calculi.
Material & Methods: Between January 2006 and January
2012, in our clinical department, 54 pregnant women
underwent active treatment for ureteral lithiasis and in 38 of
these cases ureteroscopy was applied as definitive therapy.
The average patients’ age was 27.2 years (range 20-37 years)
and the gestation period varied between 12 to 35 weeks. In
this series, 38 patients had microscopic hematuria, 18
leucocituria and 6, urinary tract infection. Semirigid
ureteroscopy was the first choice alternative for the first 2
trimesters while flexible approach or double J indwelling
were preferred for patients in the last trimester of pregnancy.
Regional anesthesia was used in 42 cases and general
anesthesia in 12 patients.
Results: Semirigid ureteroscopy allowed stone treatment in
28/32 cases. In 17 patients, calculi fragmentation using
Ho:YAG laser or ballistic lithotripsy were performed, while in
11 cases, the stone was removed intact. Minor intraoperative
complications such as ureteral edema, mild ureteral
laceration, or bleeding were encountered in 5 patients.
Postoperatively, urinary tract infection developed in 4
patients, renal colic in 2 and prolonged hematuria in one
case, while 4 patients complained of stent-induced bladder
irritation. Flexible ureteroscopy was successfully completed
in all patients. There were no complications related to this
procedure. All pregnancies were carried out to full term.
Conclusions: Ureteroscopy with intracorporeal pneumatic
or holmium laser lithotripsy may be considered a safe and
effective first-line definitive therapeutic option in pregnant
patients requiring intervention for stone disease.
nr. 2 / 2013 • vol 12
Is it necessary to stent after
ballistic/laser shock wave
lithotriptoscopy?
S. fiîrlea, S. Ionescu, Beatrice Bunea
Spitalul Clinic pentru Copii “M.S. Curie”,
Bucureøti, România
S. fiîrlea, S. Ionescu, Beatrice Bunea
“M. S. Curie” Children Hospital,
Bucharest, Romania
Scop: Scopul acestui studiu este de a evalua eficacitatea
litotrifliei endoscopice, rezultatele obflinute la copiii øi
adolescenflii cu calculi ureterali, vezicii urinare sau uretrali
precum øi dacæ este necesar sau nu montarea unui stent.
Purpose: The aim of this study is to evaluate the endoscopic
lithotripsy efficiency and outcomes in pediatric patients with
ureteral, vesical and urethral calculi and if stenting is
necessary or not.
Metode: Am realizat analiza retrospectivæ a fiøelor medicale
la 75 de copii tratafli în perioada 1998-2011, la Spitalul Clinic
de Copii M.S. Curie, Bucureøti, cu calculi ureterali, ai vezicii
urinare sau uretrale; 50 de pacienfli au venit pentru
reevaluare.
Methods: A retrospective review of medical records of 75
patients with ureteral, vesical and urethral calculi, operated
between 1998-2011, in “M. S. Curie” Children Hospital,
Bucharest, was conducted; 50 patients came for the checkup.
Rezultate: În aceastæ perioadæ, 53 de pacienfli cu calculi
uretrali, 16 pacienfli cu calculi ai vezicii urinare øi 6 pacienfli cu
calculi uretral au fost tratafli utilizând aceastæ proceduræ
endoscopicæ. Copiii au vârste cuprinse între 6.8 - 16.5 ani. În
caz de localizare ureteralæ bilateralæ am realizat litotriflie în
douæ etape, a doua dupæ o perioadæ de douæ sæptæmâni.
Tratamentul medical conservator a fost ineficient în toate
aceste cazuri. Nu au fost incidente sau accidente grave în
timpul sau dupæ proceduræ. Dimensiunea calculilor a variat
între 1.2-3.5 cm în diametru. Stent Cook a fost utilizat la primii
21 de pacienfli cu calculi ureteral øi a fost scos dupæ 18-21 de
zile ca o proceduræ în ambulatoriu. La tofli pacienflii s-a pus
sonda urinaræ timp de 1-2 zile. Perioada de spitalizare a fost
de 3-4 zile. Profilaxie antibioticæ s-a fæcut prin administrarea
unei singure doze în timpul funcflionærii. Pentru localizæri
urterale, timpul de intervenflie mediu a fost de 45 de minute
øi a variat de la 75 minute (în primele cazuri) la 25 de minute
ulterior.
Results: In this period, 53 patients with ureteral calculi, 16
patients with vesical calculi and 6 patients with urethral
calculi underwent this endoscopic procedure. Children were
aged between 6.8-16.5 years. In case of ureteral bilateral
localization we realized two step lithotripsy, the second after
2 weeks period. The medical conservative treatment was
inefficient in all those cases. There were not significant
incidents or accidents, during or after the procedure. The size
of the calculi ranged between 1.2-3.5 cm in diameter. The
Cook stent was placed in the first 21 patients with ureteral
calculi and took out after 18-21 days, as an outpatient
procedure. In all patients a bladder catheter was placed for 12 days. We registered a hospitalization period of 3-4 days.
One single dose prophylactic antibiotherapy was
administrated during the operation. For urteral localizations,
the mean operating time was 45 minutes and varied from 75
minutes for the first cases to 25 minutes for the last ones.
Concluzii: Aceastæ tehnicæ este o metodæ siguræ øi eficientæ
de tratament a litiazei tractului urinar ce poate fi consideratæ
o alternativæ mai ieftinæ faflæ de ESWL. Plasarea unui stent
Cook nu este obligatorie.
nr. 2 / 2013 • vol 12
Litiazæ
PM.1.13. Este necesaræ montarea
unui stent dupæ litotriflie balisticæ
sau cu laser?
Conclusions: This technique is a safe, effective method of
treatment of urinary tract lithiasis. It can be considered a
cheaper alternative of ESWL. Placing a Cook stent is not
compulsory.
15
Litiazæ
PM.1.14. Decizia indicafliei
terapeutice în litiaza renalæ –
intervenflie deschisæ versus
intervenflie minim invazivæ
(percutanat, ESWL)
G. Bumbu, Daniela Jovrea, S. Kolumban,
D. Purza, M. Varlan, C. Cozma, C. Albu
Clinica de Urologie Oradea-Spitalul Clinic
Judeflean de Urgenfla Oradea
16
Indications decision in kidney
stones minimally invasive surgery
versus open surgery
G. Bumbu, Daniela Jovrea, S. Kolumban,
D. Purza, M. Varlan, C. Cozma, C. Albu
Oradea Department of urology, Oradea
Emergency County Clinical Hospital
Introducere: Litiaza renalæ, atât în forma ei simplæ cât øi cea
complexæ, reprezintæ o provocare pentru urolog, cunoscut
fiind faptul cæ tratamentele medicale sunt auxiliare pe de o
parte, iar pe de altæ parte s-au dezvoltat intervenfliile minim
invazive sau noninvazive care rezolvæ, la aceastæ datæ,
majoritatea cazurilor de litiazæ, chirurgia deschisæ pæstrânduøi încæ locul în arsenalul terapeutic.
Introduction. Kidney stones, both in its simple and its complex
form, presents a challenge for the practicing urologist, for it is
common knowledge that medical treatments are auxiliary on
one hand, while on the other hand, minimal invasive
interventions or even non-invasive ones that in the present time
solve most of kidney stone cases, have evolved, open surgery
keeps on maintaining a place in the terapeuthical arsenal.
Material øi metodæ: Studiul se bazeazæ pe experienfla Clinicii
de Urologie Oradea øi confline exemplificarea a 6 cazuri de
litiaza renalæ, uni sau bilateralæ, simplæ sau complexæ, calcul
coraliform, litiazæ multiplæ în care tehnica chirurgicalæ
abordatæ a fost diferitæ.
Materials and method. This study is based upon the
experience of the Urology Clinic of Oradea, and gives 6
different kidney stone cases, be it unilateral or bilateral, simple
or complex, coraliform or multiple stones, the surgical
technique employed beeing different from case to case.
Rezultate: Caz 1: Litiazæ coraliformæ bilateralæ pentru care sau practicat intervenflii minim invazive, ESWL øi NLP în mai
multe øedinfle operatorii, în decursul a patru luni. Caz 2:
Calcul coraliform RD, RS operat în antecedente, caz în care sa practicat intervenflie deschisæ. Caz 3: Calcul pielic de 1 cm,
care nu a putut fi fragmentat prin ESWL, se practicæ NLP, cu
reuøitæ la a doua tentativæ. Caz 4: Litiazæ renalæ dreaptæ
multiplæ, cu un NLP pe partea stângæ în urmæ cu 7 luni, cu
restanfle multiple caliceale neobstructive, la care se decide
oportunæ intervenflia deschisæ. Caz 5: Calcul coraliform
bilateral, rinichi stâng cu aspect de rinichi mic, compromis
morfofuncflional, pentru care se practicæ NLP pe partea
dreaptæ øi nefrectomie stângæ. Caz 6: Litiaza multiplæ
bilateralæ, obstructivæ pe partea dreaptæ, la o pacientæ cu
obezitate morbidæ øi la care se practicæ NLP drept.
Results. 1st Case: Bilateral coraliform stone, needed minimal
invasive interventions such as ESWL (Extracorporeal Shock Wave
Lithotripsy) and NLP (Percutaneous NephroLithotomy), in
multiple surgical sessions, in a 4-month time frame. 2nd Case: RD
Coraliform stone, RS previously had surgery, the case required
open surgery. 3rd Case: A pyelic stone, 1 cm in diameter, which
couldn’t be destroyed through ESWL, required NLP, the second
attempt being successful. 4th Case: Right multiple kidney stones,
NLP on the left side 7 moths earlier, multiple non obstructive
caliceal stone remnants, open surgery is considered appropriate.
5th Case: Bilateral coraliform stone, left kidney smaller in size,
morphofunctionaly compromised, requires NLP treatment on
the right side and a nephrectomy procedure on the left side. 6th
Case: Multiple bilateral stones, with obstruction on the right side,
at a morbidly obese pacient, requires a right side NLP procedure.
Concluzii. Nu tratæm litiaza renalæ, tratæm pacient litiazic.
Atitudinea chirurgicalæ pe care o decidem este dictatæ de
antecedentele urologice ale pacientului, prognosticul
urologic al pacientului, afecfliunile asociate, de aceea,
varianta aleasæ poate fi de multe ori dificilæ øi controversatæ.
Conclusions. We treat the kidney stone-pacient, not the
kidney stones. The surgical approach that we take is based
upon the pacients urological background, urological
prognosis, associated illnesses, therefore the choice can often
be difficult and controversial.
nr. 2 / 2013 • vol 12
1
1
1
1
2
Clinica de ATI, Spitalul Clinic Colentina, Bucureøti
Introducere. Scopul acestei lucræri este de a prezenta
experienfla noastræ iniflialæ în ureteroscopia semirigidæ cu
litotritiflie laser Holmium la pacienflii cu litiazæ ureteralæ.
Material øi metodæ. În perioada 1 iulie 2012 - 15 februarie
2013, 57 de pacienfli (grup 1) diagnosticafli cu calculi ureterali
au beneficiat de ureteroscopie semirigidæ øi litotriflie cu laser
Holmium Calculase II de 20 W. Vârsta medie a fost de 46 de
ani, timpul operator mediu a fost de 35 de minute, iar
diametrul mediu al calculilor a fost de 9,2 mm (interval 6-20
mm). Au fost analizate timpul operator, complicafliile, ratele
de stone-free si de migrare ale calcululilor ureterali cu diferite
localizæri comparativ cu un grup martor de pacienfli care au
beneficiat de ureteroscopie semirigidæ cu litotriflie balisticæ a
calculului (grup 2).
Rezultate. Rata de stone-free pentru pacienflii care au
beneficiat de litotriflie laser Holmium a fost de 79,5% (95%
pentru calculii ureterali distali øi 64% pentru calculii ureterali
proximali) comparativ cu 78% pentru lotul martor, în timp ce
rata de migrare a fost de 4% pentru primul grup comparativ
cu 16% pentru lotul martor. Nu au existat diferenfle
semnificative statistic între cele douæ grupuri în ceea ce
priveøte timpul operator øi complicafliile intraoperatorii.
Complicafliile postoperatorii au fost reprezentate de febræ
(4%), durere postproceduralæ (9%), hematurie (10,5%),
pielonefritæ (3,5%)øi sepsis cu punct de plecare urinar (1,75%).
Concluzii. Ureteroscopia semirigidæ cu litotriflie laser
Holmium este o metodæ siguræ øi eficientæ pentru tratamentul
calculilor ureterali. De asemenea, aceastæ metodæ prezintæ o
ratæ de migrare a calculilor ureterali mai micæ comparativ cu
ureteroscopia semirigidæ cu litotriflie balisticæ.
1
1
B. Mihai , V. Mitroi , A. Chuaibi ,
1
2
1
L. Teodorescu , I. Buraga , V. Cauni
1
B. Mihai , V. Mitroi , A. Chuaibi ,
1
2
1
L. Teodorescu , I. Buraga , V. Cauni
nr. 2 / 2013 • vol 12
Initial experience with semirigid
ureteroscopy and Holmium laser
lithotripsy for ureteral calculi
Litiazæ
PM.1.15. Experienfla iniflialæ în
tratamentul calculilor ureterali prin
ureteroscopie semirigidæ cu litrotiflie
cu laser Holmium
1
Urology Department, Colentina Clinical
Hospital, Bucharest
2
ICU Department, Colentina Clinical Hospital,
Bucharest
Introduction. The aim of this study is to present our initial
experience in semirigid ureteroscopy with Holmium laser
lithotripsy in patients with ureteral lithiasis.
st
th
Patients and methods. Between 1 July 2012 – 15
February 2013, 57 patients (group 1)diagnosed with ureteral
calculi underwent semirigid ureteroscopy and lithotripsy
with 20 W Holmium laser Calculase II . The mean age was 46
years, the mean operative time was 35 minutes and the
mean stone diameter was 9,2 mm (range 6-20 mm). The
operative time, complications, the stone free-rates and the
stone migration rates for ureteral calculi with different
locations were analyzed by comparing them with a group of
patients with ureteral lithiasis who underwent semirigid
ureteroscopy with ballistic lithotripsy (group 2).
Results. The stone-free rate for patients who underwent
Holmium laser lithotripsy was 79,5 % (95% for distal ureteral
calculi and 64% for proximal ureteral stones) comparative
with 78% for group 2, while the stone migration rate was 4%
for the group 1 and 16% in group 2. There were no significant
statistic differences regarding the operative time and
intraoperative complications between the two groups. The
postoperative complications were represented by (4%),
postprocedural pain (9%), hematuria (10,5%), pyelonephritis
(3,5%) and urinary sepsis (1,75%).
Conclusions. Semirigid ureteroscopy with Holmium laser
lithotripsy is a safe and efficient method for the treatment of
ureteral calculi. Furthermore, this method has a lower stone
migration rate by comparison with semirigid ureteroscopy
with ballistic lithotripsy.
17
Litiazæ
PM.1.16. Urinomul spontan
retroperitoneal în colica renalæ
R. Minciu, P. Boiborean, L. Daminescu,
G. Pupca, V. Bucuraø
Clinica Urologicæ, Spitalul Clinic Judeflean de
Urgenflæ Timiøoara, Universitatea de Medicinæ
øi Farmacie Victor Babeø Timiøoara
Obiective. Apariflia unei colecflii urinare spontane, secundare
obstrucfliei ureterale este descrisæ ca o complicaflie raræ. Ea
apare ca urmare a hiperpresiunii din cæile urinare instalate
brusc în colica renalæ.
Prezentare de caz. Vom prezenta un pacient de 60 ani care
a dezvoltat o colecflie retroperitonealæ pe fondul uropatiei
obstructive. Spre deosebire de alte cazuri prezentate, unde
colecflia s-a menflinut la nivel perirenal, de aceasta datæ ea sa dezvoltat predominant de-a lungul ureterului spre pelvis.
Aceasta localizare a fæcut dificil diagnosticul, chiar øi prin
tomografie computerizatæ. S-a montat un stent ureteral pe
lângæ un calcul pelvin, cu dispariflia stazei øi a reværsatului.
Ureteroscopia efectuatæ dupæ o lunæ a confirmat eliminarea
spontanæ a calcului.
Spontaneous retroperitoneal
urinoma in renal colic
R. Minciu, P. Boiborean, L. Daminescu,
G. Pupca, V. Bucuraø
Department of Urology, Timiøoara Emergency
County Clinical Hospital,
“Victor Babeø” University of Medicine and
Pharmacy, Timiøoara
Objective. The retroperitoneal urinoma following a ureteral
obstruction is a rare complication. It is caused by the
hiperpression in the urinary system during the renal colic.
Case presentation. We present the case of a 60 years old
patient with a retroperitoneal urine accumulation after a
renal colic. Usually, in other cases, the urinoma remained
perirenal, but in this case the localization of the fluid was
mostly along the ureter, to the pelvic area. Therefore, the
diagnosis was difficult and needed a CT examination. An
ureteral stent was placed beside a pelvic stone. The
postoperative ultrasonography showed no ureterohydronephrosis and no fluid accumulation.
Conclusions. The ureteral stenting proves to be an efficient
method for managing the spontaneous urinoma in renal colic.
Concluzii. Urinomul spontan, ce însofleøte colica renalæ se
rezolvæ eficient prin montarea unui stent ureteral.
18
nr. 2 / 2013 • vol 12
S. Badi, A. Drocaø, G. Mitroi, R. Ungureanu
Spitalul Clinic Judeflean de Urgenflæ Craiova –
Clinica de Urologie
Giant Urethral Calculus in Female –
A Rare Case of Acute Urinary
Retention. Case Report
S. Badi, A. Drocaø, G. Mitroi, R. Ungureanu
Emergency County Hospital Craiova –
Department of Urology
Introducere: Væ prezentæm un caz clinic interesant de litiazæ
urinaræ voluminoasæ, descoperitæ la o femeie în vârstæ de 77 ani
cu retenflie acutæ de urinæ. Calculii urinari sunt descoperifli
foarte rar în uretra femininæ, pufline cazuri fiind citate în
literatura de specialitate. Localizarea uretralæ reprezintæ mai
puflin de 1% din localizærile calculilor în cadrul bolii litiazice.
Introduction: We report an interesting clinical case of giant
urinary lithiasis, discovered on a 77-year old woman with
acute urinary retention. Urinary calculi are extremely rare in
the female urethra and only a few cases have been reported
previously. Urethral localization represents less than 1% of all
urinary stone diseases.
Material øi metodæ: Pacienta S.I., în vârstæ de 77 ani, færæ
antecedente urologice semnificative, cunoscutæ cu intervenflie
chirurgicalæ ortopedicæ la nivelul MI stâng urmatæ de clinostatism prelungit în ultimii 5 ani, cu multiple afecfliuni cardiorespiratorii neglijate, se prezintæ în serviciul de urgenflæ cu stare
generalæ influenflatæ, acuzând dureri hipogastrice, imposibilitatea de a urina. Pacienta avea istoric de simptomatologie de
tip iritativ neglijatæ, færæ antecedente de intervenflie chirurgicalæ
la nivelul perineului sau în sfera genitalæ. La examenul clinic
local se constatæ la nivelul meatului uretral o formafliune duræ la
palpare, gælbuie, obstructivæ, palpabilæ si la TV; vezica urinaræ
palpabilæ în hipogastru, percutabilæ, dureroasæ la palpare (glob
vezical). Radiografia renovezicalæ simplæ relevæ calcul
voluminos de aproximativ 7/4cm, ovalar blocat la nivelul
uretrei. VU destinsæ de volum cu aproximarea unui volum de
400cm3. Se monteazæ cistostomie suprapubianæ.
Material and method: The patient S.I., aged 77 years, with no
significant urological history, known to have undergone
orthopedic surgery at the left lower limb level, followed by
prolonged supine position in the last 5 years, with multiple
neglected cardio-respiratory diseases, came to the emergency
service with altered general state, accusing hypogastric pains,
impossibility to urinate. The patient had a history of neglected
irritative bladder symptoms, with no history of surgery at
perineum level or genital area. On local examination we found,
at the level of the urethral meatus, a formation hard on
palpation, yellowish, obstructive, also palpable on VT; bladder
is palpable in hypogastrium, tappable, painful on palpation
(bladder globe). Reno bladder radiography reveals a large
calculus of about 7/4 cm, oval, blocked at urethra level. The
bladder is increased in volume with the approximation of a
volume of 400 cm3. Suprapubic cystostomy is installed.
Rezultate: Dupæ echilibrare hemodinamicæ, cardio-respiratorie
øi managementul afecfliunilor asociate în clinica de TI, sub
rahianestezie se practicæ uretrolitotomie cu extragerea unui
calcul de 62/39/35 mm. Nu se descoperæ diverticuli la nivelul
uretrei. Se monteazæ SUV Foley pentru 21 zile. Evoluflie
postoperatorie favorabilæ, reluarea micfliunilor cu un grad mic
de incontinenflæ dupæ suprimarea SUV. Analiza chimicæ a
calcului a evidenfliat calcul cu compoziflie multiplæ: fosfat
amoniaco-magnezian, fosfat de calciu øi urat.
Results: After hemodynamic and cardio-respiratory balancing
and the clinical management of the associated disorders in the
ATI Department, under spinal anesthesia we have performed
urethral lithotomy and extracted a calculus of 62/39/35 mm.
No urethral diverticula are found. Foley SUV is fit in for 21 days.
The postoperative evolution is favorable, urination is resumed
with a low degree of incontinence after the suppression of the
SUV. The chemical analysis of the calculus composition
revealed a calculus with multiple compositions: ammoniamagnesium phosphate, calcium phosphate and uric acid.
Concluzii: Calculii uretrali pot fi luafli în considerare ca o cauzæ
de retenflie acutæ de urinæ la femei. Aceøtia se pot dezvolta local
inclusiv în absenfla unei patologii asociate (strictura, diverticul),
dar favorizatæ de anumifli factori secundari (clinostatism
prelungit, sensibilitate localæ redusæ, intervenflii chirurgicale).
Conclusions: Urethral calculi can be considered as a cause of
acute urinary retention in women. They can develop locally,
even in the absence of associated pathologies (stricture,
diverticula), but favored by certain secondary factors
(extended supine position, reduced local sensitivity, surgery).
nr. 2 / 2013 • vol 12
Litiazæ
PM.1.17. Calcul uretral voluminos la
femeie – un caz rar de retenflie
acutæ de urinæ. Prezentare caz clinic
19
Litiazæ
PM.1.18. Complicafliile litotrifliei
extracorporeale (ESWL) în funcflie de
numærul øi frecvenfla undelor de øoc
1
1
1
C. Maria , N. Turcitu , C. Nedelcuflæ ,
1
1
1
O. Drægoescu , G. Mitroi , S. Cælina ,
1
1
1
A. Pænuø , A. Gava , P. Tomescu
1
Clinica Urologie; Spitalul de Urgenflæ Craiova
20
Extracorporeal Shock Wave
Lithotripsy (ESWL) complications
depending on the shock wave rate
and number
1
1
1
C. Maria , N. Turcitu , C. Nedelcuflæ ,
1
1
1
O. Drægoescu , G. Mitroi , S. Cælina ,
1
1
1
A. Pænuø , A. Gava , P. Tomescu
1
Urology Department; Craiova Emergency Hospital
Introducere. Litotriflia extracorporealæ (ESWL) a revoluflionat
tratamentul calculilor tractului urinar øi este considerat tratamentul de primæ linie pentru mai mult de 75% dintre pacienflii cu
litiazæ renalæ, dar aceastæ metodæ prezintæ la rândul ei diverse
complicaflii. Acestea sunt în mare parte legate de fragmente reziduale, infecflii øi efecte asupra flesuturilor, cum ar fi asupra sistemului urinar, gastro-intestinal, cardiovascular, genital øi de reproducere. Forflele distructive atunci când sunt generate de colapsul
bulelor de cavitaflie sunt responsabile pentru fragmentarea finalæ
a calculului, cu toate acestea, ele pot provoca traumatisme ale
vaselor cu perefli subfliri din rinichi øi flesuturile adiacente.
Introduction. ESWL has revolutionized the treatment of
upper urinary tract calculi and is considered the first-line
therapy for more than 75% of the patients with urolithiasis
but it has been intuitively connected to various complications. These are mostly related to residual stone fragments,
infections, and other effects on tissues such as urinary,
gastrointestinal, cardiovascular, genital, and reproductive
systems. The destructive forces generated when cavitation
bubbles collapse are ultimately responsible for stone
fragmentation, however, they can also cause trauma to thinwalled vessels in the kidneys and adjacent tissues.
Obiective. Studiul nostru îøi propune sæ analizeze rata complicafliilor ESWL, având în vedere numærul øi frecvenfla
undelor de øoc.
Objective. Our study aims to analyze ESWL complications
rates, considering the shock waves number and frequency.
Metodæ. Studiul a fost realizat pe o perioadæ de 24 de luni øi a
inclus 344 de pacienfli cu calculi la nivelul tractului urinar. Tofli
pacienflii au fost tratafli prin ESWL, 167 cu o frecvenflæ a undei
de øoc de 120 pe minut, cu un numær mediu de unde de øoc
3697 ± 378, intensitate medie a undei de øoc a fost de 4,8 ± 0,9
kV( primul lot). Pentru 177 de pacienfli am folosit o frecvenflæ
mai micæ a undei de øoc 60 pe minut øi numærul mediu 2819 ±
980, cu o intensitate medie de 5,7 ± 0,6 kV (al doilea lot).
Method. The study was conducted over a 24 months period
and included 344 patients with upper urinary tract calculi.
All patients underwent ESWL, 167 with a shock wave
frequency of 120 shock waves per minute, with an average
number of shock waves of 3697 ± 378 and shock wave
average intensity was 4.8 ± 0.9 kV (first group). For 177
patients we used a lower shock wave frequency (60 per
minute) and number (2819 ± 980) with an average intensity
of 5.7 ± 0.6 kV (second group).
Rezultate. Nu au existat diferenfle semnificative statistic între
cele douæ grupuri în ceea ce priveøte vârsta, sexul, locul de
origine, simptome clinice sau antecedente personale, locaflie
sau numær. Procentele complicafliilor au fost mai mici în al
doilea grup, comparativ cu primul grup, dupæ cum urmeazæ:
hematuria 13 (7,3%) în al doilea lot, faflæ de 32 (19,2%) în primul, deteriorarea flesuturilor superficiale (echimoze/peteøii)
35 (19,8%) faflæ de 62 (37,1%), dureri lombare 21 (11,9%) øi 38
Results. There were no statistically significant differences
between the two groups regarding age, sex, place of origin,
clinical symptoms or presence of stone history, stone
location or number. Complications rates were lower in the
second group compared with the first group, as follows:
macrohematuria 13 (7.3%) and 32 (19.2%) in the first group,
superficial tissues damage 35 (19.8%) and 62 (37.1%), lumbar
pain 21 (11.9%) and 38 (22.8%), nausea 8 (4.5%) and 22
nr. 2 / 2013 • vol 12
Litiazæ
(22,8%), greaflæ 8 (4,5%) øi 22 (13,2%). Alte complicaflii au fost
similare, febræ 3 (1,7%) øi 2 (1,2%), fragmente reziduale mari
ce au condus la „steinstrasse” 16 (9,0%) øi 19 (11,4%).
(13.2%). Other complications were similar, fever 3 (1.7%) and
2 (1.2%), larger residual fragments that lead to steinstrasse 16
(9.0%) and 19 (11.4%).
Concluzii. Scæderea numærului, a frecvenflei øi a intensitæflii undelor de øoc pot îmbunætæfli siguranfla ESWL, reducând incidenfla hematuriei, deteriorarea flesuturilor superficiale, dureri
lombare, greaflæ. Pot fi luate mæsuri preventive pentru a reduce
frecvenfla acestor efecte secundare. Litotritoarele moderne
sunt din ce în ce mai uøor de folosit, tratamentul este doar
moderat dureros, dar selectarea pacienflilor øi optimizarea
protocoalelor de tratament sunt necesare pentru a maximiza
procentajul de „stone-free” øi a minimiza efectele secundare.
Conclusion. Decrease of shock wave number, rate and energymay improve ESWL safety, reducing the incidence of
macrohematuria, superficial tissues damage, lumbar pain,
nausea. Preventive measures can be taken to minimize the
frequency of these side effects. Modern lithotripters are
optimized to be user friendly, and treatment is only
moderately painful, but patient selection and an optimized
treatment protocols are necessary to maximize stone-free
rate and to minimize side effects.
nr. 2 / 2013 • vol 12
21
Litiazæ
PM.1.19. Litiaza renalæ recidivatæ
cu hipercalciurie este însoflitæ de
turnover osos accentuat øi
niveluri scæzute ale vitaminei D
1
2
3
1
2
3
C. Pricop , D.D. Bræniøteanu , D.N. Øerban ,
4
3
Didona Ungureanu , Ionela Læcræmioara Øerban
1
Clinica Urologicæ, UMF Gr. T. Popa, Iaøi
2
Clinica Endocrinologicæ, UMF Gr. T. Popa, Iaøi
3
Departamentul de Fiziologie,
UMF Gr. T. Popa, Iaøi
4
Departamentul de Biochimie,
UMF Gr. T. Popa, Iaøi
C. Pricop , D.D. Bræniøteanu , D.N. Øerban ,
4
3
Didona Ungureanu , Ionela Læcræmioara Øerban
1
Clinic of Urology, “Gr. T. Popa” University of
Medicine and Pharmacy, Iasi
2
Departament of Endocrinology, “Gr. T. Popa”
University of Medicine and Pharmacy, Iasi
3
Department of Physiology and Center for Study
and Therapy of Pain, “Gr. T. Popa” University of
Medicine and Pharmacy, Iasi
4
Departament of Biochemistry, “Gr. T. Popa”
University of Medicine and Pharmacy, Iasi
Introducere øi Obiective. Pacienflii cu litiazæ calcicæ recidivatæ
prezintæ frecvent o excreflie crescutæ a calciului urinar, chiar øi în
absenfla hiperparatiroidismului primar. Originea acestei hipercalciurii este, deocamdatæ, neclaræ.
Introduction and Objectives. Patients subjected to relapsing
kidney lithiasis frequently have an increased urinary calcium
excretion, even in the absence of primary hyperparathyroidism.
The origin of this hypercalciuria is, however, unclear.
Material øi Metodæ. Pentru a investiga particularitæflile metabolismului osos la pacienflii cu litiazæ renalæ am imaginat un studiu
transversal unde, pacienflii cu litiazæ recidivatæ au fost comparafli
în ceea ce priveøte calciu seric øi urinar øi parametrii metabolismului osos cu persoane færæ litiazæ cu vârstæ øi indice de masæ corporalæ similare.
Material and Methods. In order to investigate the particularities
of bone metabolism in patients with kidney lithiasis, we
designed a cross sectional study where patients with relapsing
lithiasis were compared with age and BMI-matched non-lithiasic
controls with respect to calcium and bone metabolic parameters.
Rezultate. Am constatat la grupul cu litiazæ recidivatæ cæ, atât excreflia calciului cât øi parametrii turnover-ului osos au fost semnificativ mai mari comparativ cu lotul martor (p<0.05 by Student’s
t test). Densitatea mineralizarii osoase lombare evaluatæ prin DXA
a fost semnificativ mai scæzutæ în grupul pacienflilor cu litiazæ
recidivatæ (p < 0.05), ceea ce sugereazæ cæ aceøti pacienfli au un
risc mai mare de pierdere a masei osoase øi osteoporozæ. Deøi în
intervalul valorilor normale, media valorilor PTH seric a fost mai
mare la pacienflii grupului litiazic, indiferent de sex, comparativ cu
lotul martor, în timp ce nivelul vitaminei D a fost semnificativ mai
scæzut, comparativ cu acelaøi lot (p < 0.05).
Concluzii. Pacienflii cu hipercalciurie se pare cæ au, pe lângæ un
risc crescut de a dezvolta litiaza øi un turnover osos mai mare, ce
este posibil sæ se asocieze øi cu un risc crescut de pierdere a masei
osoase. Hipovitaminoza D ar putea juca un rol în declanøarea
unui turnover osos accentuat prin creøterea secrefliei de PTH. În
aceste condiflii atât vitamina D, cât øi terapia antiresorbativæ ar
putea avea efecte benefice nu numai în prezervarea masei osoase cât øi în prevenirea recidivei litiazice.
22
Idiopathic relapsing lithiasis with
hypercalciuria is accompanied
by high bone turnover and
low vitamin D levels
Results. Calcium excretion, but also bone turnover parameters were increased in the groups with relapsing lithiasis
(p < 0.05 by Student’s t test). Lumbar bone mineral density
evaluated by DXA was also significantly lower in the llithiasis
groups (p < 0.05), suggesting that patients with relapsing
lithiasis may have a higher risk of bone loss and osteoporosis.
Although within the normal range, mean serum PTH was
significantly higher in both lithiasic males and females when
compared to the non-lithiasic control groups, whereas 25OH
vitamin D levels were lower (p < 0.05).
Conclusions. Hypercalciuric patients seem to have, aside an
increased risk of lithiasis, also a higher bone turnover,
possibly accompanied by a higher risk of bone loss. Vitamin
D deficiency may play a role in triggering high bone turnover
through an increase in PTH secretion. Both vitamin D
repletion and antiresorptive therapy may have beneficial
effects not only in preserving bone mass, but also in
decreasing relapse risk in kidney lithiasis.
nr. 2 / 2013 • vol 12
I. Sinescu, M. Hârza, C. Baston, A. Preda,
B. Øtefan, I. Manea, B. Hæinealæ, B. Bædescu
Centrul de Uronefrologie øi Transplant Renal,
Institutul Clinic Fundeni, Bucureøti
Introducere. Incidenfla complicafliilor urologice dupæ transplantul renal ræmâne ridicatæ, în pofida progreselor semnificative apærute în diagnosticul øi tratamentul acestora. Reconstrucflia tractului urinar dupæ transplantul renal se face, de cele mai multe ori,
prin tehnici diverse de ureteroneocistostomie. În acest studiu am
evaluat rezultatele a douæ tehnici diferite de ureteroneocistostomie folosite în centrulnostru: tehnica transvezicalæ LeadbetterPolitano (L-P) fli tehnica extravezicalæ Lich-Gregoir (L-G).
Material øi Metodæ. În intervalul cuprins între 1 ianuarie 2006 31 decembrie 2011 s-au efectuat, în centrul nostru, 584 de transplanturi renale consecutive, în 324 cazuri folosindu-se tehnica LP (55,48%) øi în 260 cazuri tehnica L-G (44,52%). Grefele renale au
fost obflinute de la donatori aflafli în moarte cerebralæ, în 163 de
cazuri (27,91%) øi de la donatori vii înrudifli în 421 cazuri (72.09%).
Stentarea ureterului a fost efectuatæ în 115 cazuri (19,69%).
Rezultate. În grupul de pacienfli cu ureteroneocistostomie prin
tehnica L-P complicafliile urologice au apærut la 26 din cazuri
(8,34%). Cele mai frecvente complicaflii au fost stenoza ureteralæ
(3,39%) øi fistula ureteralæ (2,77%). Comparativ cu tehnica de
ureteroneocistostomie L-P, tehnica L-G a fost asociatæ cu mai
pufline complicaflii generale (6,15% vs. 8,34%, p = 0,06), o ratæ mai
micæ a stenozei ureterale (2.31% vs. 3.39%, p = 0,08) øi o ratæ similaræ a fistulelor ureterale. Cu toate acestea, analiza statisticæ nu a
relevat diferenfle semnificative între cele douæ tehnici (p = 0,06).
În plus, nu am observat nici o diferenflæ în supraviefluirea grefei øi
a pacientului între cele douæ grupuri.
Concluzii. În studiul nostru, tehnica extravezicalæ L-G are o ratæ
mai micæ de complicaflii urologice comparativ cu procedura
transvezicalæ L-P, dar færæ diferenfle semnificative statistic. În plus,
tehnica L-G este mai uøor de efectuat, mai rapidæ, evitæ o cistotomie separatæ øi necesitæ un ureter mai scurt. În concluzie,
consideræm cæ tehnica de ureteroneocistostomie tip L-G
reprezintæ metoda de preferat pentru refacerea continuitæflii
tractului urinar în transplantul renal.
nr. 2 / 2013 • vol 12
Urological complications after kidney
transplantation: A comparison
between transvesical LeadbetterPolitano versus Extravesical LichGregoir Technique
I. Sinescu, M. Hârza, C. Baston, A. Preda,
B. Øtefan, I. Manea, B. Hæinealæ, B. Bædescu
Center of Uronephrology and Kidney
Transplantation, Fundeni Clinical Institute,
Bucharest
Background. Incidence of urological complications after
kidney transplantation remains high despite improvements
in diagnosis and surgical techniques. Urinary tract reconstruction is usually done by ureteroneocystostomy, of which
there are several techniques. In this study we evaluate the
outcomes of two different techniques of ureteroneocystostomy performed in our department, the transvesical
Leadbetter-Politano (L-P) and the extravesical Lich-Gregoir
(L-G) technique.
Methods. During 1st of January 2006 and 31st of December
2011 we performed 584 consecutive renal transplants, 324
cases using L-P technique (55.48%) and 260 cases with L-G
technique (44.52%). Renal grafts were obtained from
cadaveric donors in 163 cases (27.91%) and from livingrelated donors in 421 cases (72.09%). Ureteral stenting was
performed in 115 cases (19.69 %).
Results. Urological complications after kidney transplantation
occurred in 27 cases in the L-P ureteroneocystostomy group
(8.34%). The most common complications were ureteral
stenosis (3.39%) and leakage (2.77%). Compared with the L-P
ureteroneocystostomy technique, the L-G technique was
associated with fewer overall complications (6.15% vs. 8.34%;
p=0.06), a lower rate of ureteral stenosis (2.31% vs. 3.39%;
p=0.08) and a similar rate of leakage. However, statistical
analysis revealed no significant differences between the two
techniques (p= 0.06). In addition, we did not notice any
differences in graft and patient survival between two groups.
Transplant, Hipertrofie benignæ a prostatei
PM.2.1. Complicafliile urologice
dupæ transplantul renal: analizæ
comparativæ între tehnicile de
implantare uretero-vezicalæ
Leadbetter-Politano øi Lich-Gregoir
Conclusions. In our study, the extravesical L-G technique has
a lower urological complications rate compared to
transvesical L-P procedure but without statistical significant
differences. Furthermore, L-G technique is easier to perform,
faster, avoids a separate cystotomy and requires a shorter
ureteral length. In conclusion, we recommend L-G technique
as the technique of choice in kidney transplantation.
23
PM.2.2. Impactul stentærii ureterale
asupra complicafliilor urologice
dupæ transplantul renal: Experienfla
Centrului de Chirurgie Urologicæ øi
Transplant Renal ”Fundeni”
M. Hârza, C. Baston, I. Manea, B. Øtefan,
A. Preda, B. Hæinealæ, B. Bædescu, I. Sinescu
M. Hârza, C. Baston, I. Manea, B. Øtefan,
A. Preda, B. Hæinealæ, B. Bædescu, I. Sinescu
Bucharest
Introducere. Complicafliile urologice posttransplant, pot
afecta semnificativ evoluflia acestuia prin creøterea
morbiditæflii øi a mortalitæflii, putând duce inclusiv la
pierderea grefonului renal. În literatura de specialitate, existæ
încæ controverse în ceea ce priveøte rolul folosirii stenturilor
în transplantul renal. Scopul acestui studiu retrospectiv a fost
de a evalua rolul stentærii ureterale în transplantul renal.
Background. Urological complications such as ureteral
strictures, ureteral leakage can affect the outcome of kidney
transplantation by increasing the morbidity and mortality,
including the graft loss. Controversy still exists regarding the
role of stents in renal transplantation. The aim of this study
was to evaluate the role of ureteral stenting in kidney
transplantation.
Material øi Metodæ. În perioada cuprinsæ între 1 ianuarie
2004 øi 31 decembrie 2011, au fost efectuate, în centrul
nostru, 798 transplanturi renale consecutive. Vârsta medie a
receptorilor a fost de 35.17 ± 12.73 ani. Grefele renale au fost
obflinute, în 199 cazuri (24,93%) de la donatori aflafli în
moarte cerebralæ øi în 599 cazuri (75,07%) de la donatori în
viaflæ, înrudifli. Stenturi ureterale JJ au fost utilizate în 152
cazuri (19,1%) din numærul total (grupul cu stenturi) øi s-au
îndepærtat între 2-4 sæptæmâni postoperator.
Methods. A series of 798 consecutive renal transplantations
were performed between 1st of January 2004 and 31st of
December 2011. Recipient mean age: 35.17-12.73 years old.
Renal grafts were obtained in 199 cases (24.93%) from
cadaveric and in 599 cases (75.07%) from living-related
donors. Ureteral stents were used in 152 cases (19.1%) of
total (stent group) and were removed between 2 - 4 weeks
postoperatively.
Rezultate. Incidenfla complicafliilor urologice a fost de 7,89%
(63 cazuri). Stenoza ureteralæ (3,13%) øi fistula ureteralæ
(2,38%) au fost cele mai frecvente complicaflii întâlnite. 39,7%
(25 cazuri) dintre complicaflii au fost înregistrate în prima
lunæ posttransplant (complicaflii precoce), iar complicafliile
ulterioare au fost considerate tardive (60,3%). Rata
complicafliilor ureterale a fost de 2,6% în grupul cu stenturi,
comparativ cu 8,9% în grupul færæ stenturi (p = 0,04).
Stentarea nu influenfleazæ incidenfla complicafliilor urologice
în relaflie cu tipul de donator sau cu sexul receptorilor (p>
0,05). Cu toate acestea, utilizarea acestora a fost asociatæ cu o
creøtere semnificativæ a ratei de ITU în grupul cu stenturi
(51,3%) comparativ cu grupul færæ stenturi (17,9%) (p = 0,03).
Concluzii. În studiul nostru, utilizarea stenturilor ureterale a
scæzut semnificativ rata complicafliilor urologice
posttransplant, dar s-a asociat cu o creøtere semnificativæ a
riscului de ITU. În concluzie, stentarea ureteralæ de rutinæ în
transplantul renal ar trebui sæ se facæ punând in balanflæ
beneficiile în ceea ce priveøte scæderea complicafliilor
urologice cu anumite riscuri de a dezvolta UTI.
24
Impact of ureteral stenting on
urological complications after
kidney transplantation surgery:
a single center experience.
Results. The overall incidence of urological complications
was 7.89% (63 cases). Ureteral stenosis (3.13%) and ureteral
leakage (2.38%) were the most common complications.
39.7% (25 cases) complications were recorded in the first
month after transplantation (early complications) and after
this interval were considered late complications (60.3%).
Ureteral complications rate was 2.6% in stent group
compared to 8.9% in no-stent group (p= 0.04). Stents did not
influence the incidence of urological complications in
relationship with donor type or gender of the recipients (p>
0.05). However, stent use was associated with increase of UTI
rate in stent group (51.3%) compared to no-stent group
(17.9%) (p= 0.03).
Conclusions. In our study the use of ureteral stents
significantly decreases urological complications in kidney
transplant recipients but increases risk of developing UTI.
Routine ureteral stenting in renal transplantation should
balance the benefits of urological complications with certain
risks of developing UTI.
nr. 2 / 2013 • vol 12
Quality of life in patients with
kidney transplant
O. Himedan, M. Hârza, C. Gîngu, Dorina Tacu,
A. Dick, F. Lupu, A. fiurcanu, I. Sinescu
O. Himedan, M. Hârza, C. Gîngu, Dorina Tacu,
A. Dick, F. Lupu, A. fiurcanu, I. Sinescu
Introducere. Afecfliunile renale cronice au o incidenflæ øi
prevalenflæ în ascensiune, asociatæ creøterii speranflei de viaflæ
øi creøterii prevalenflei diabetului zaharat, hipertensiunii
arteriale øi aterosclerozei. Transplantul renal este tratamentul
de elecflie pentru pacienflii cu insuficienflæ renalæ terminalæ de
aproape orice etiologie. Totuøi efectele secundare ale
agenflilor imunosupresori, stressul øi teama de rejet, au ca
rezultat diferite grade de afectare a calitæflii vieflii din punct
de vedere fizic øi psihic.
Introduction. The kidney chronic diseases have an
ascending incidence and prevalence, associated with the
extension of the lifespan and the growing frequency of the
hyperglycemia, high blood pressure and atherosclerosis. The
kidney transplant is the elected treatment for the patients
with end stage kidney disease of almost any etiology. Still,
the side effects of the immunosuppressive agents, along
with stress and fear of graft rejection have an important
impact on the quality of life, at different levels, both
physically and mentally.
Obiective. Cuantificarea calitæflii vieflii la pacienflii cu transplant
renal, evaluarea modului în care pacienflii cu transplant renal
din România îøi percep calitatea vieflii øi aprecierea impactului
pe care afecfliunea îl are asupra vieflii lor.
Material, metodæ øi rezultate. Unui lot de 63 de pacienfli cu
transplant renal, 36 bærbafli øi 27 femei, cu vârste cuprinse
între 18 øi 64 de ani, programafli pentru evaluare periodicæ
post-transplant la Institutul Clinic Fundeni din Bucureøti, în
perioada 1 aprilie -30 iunie 2010 am aplicat chestionarul
MOS-SF-36, unul dintre cele mai larg utilizate instrumente
generice de mæsurare a calitæflii vieflii. Formularul a fost auto
administrat øi conflinea 36 de întrebæri ce evalueazæ opt
domenii ale sænætæflii: 1) limitæri ale activitæflii fizice, 2) limitæri
ale activitæflii sociale, 3) limitæri ale funcflionalitæflii normale de
naturæ fizicæ, 4) durerea, 5) stare psihicæ generalæ, 6) limitæri
ale funcflionalitæflii normale datoritæ problemelor emoflionale,
7) vitalitate, 8) percepflia pacientului asupra stærii de sænætate
generalæ. S-a obflinut un scor global pentru întreg grupul de
pacienfli, de 54 (DS=18,42), domeniile sænætæflii percepute de
cætre pacienfli ca fiind cele mai afectate fiind: funcflionalitatea
normalæ fizicæ øi funcflionalitatea normalæ emoflionalæ.
Aspectele cel mai puflin grevate de problemele de sænætate
au fost: activitatea socialæ, starea psihicæ øi vitalitatea.
Discuflii. Calitatea vieflii pacienfliilor este un obiectiv
important dupæ transplantul renal, totuøi existæ în continuare
neajunsuri legate de acest aspect. Utilizarea unor metode
standardizate de evaluare a pacienflilor poate sæ conducæ la
aprecierea obiectivæ a ratei de succes în cadrul diverselor
grupuri populaflionale øi la o îmbunætæflire a capacitæflii de
soluflionare a problemelor care afecteazæ calitatea vieflii
posttransplant.
nr. 2 / 2013 • vol 12
Objectives. Quantification of the quality of life at patients with
kidney transplant, the evaluation of how patients with kidney
transplant from Romania perceive their quality of life and how
they regard the impact of their status upon their lives.
Material, method and results. We have applied the MOS-SF36 questionnaire, one of the most commonly used generic
instruments for quality of life measurement, to a group of 63
patients with kidney transplant, 36 men and 27 women, with
ages ranging from 18 to 64 years old, scheduled for a periodic
post-transplant evaluation at the Fundeni Clinical Institute,
between the 1st of April and the 30th of June 2010. The
questionnaire was self administrated and contained 36
questions evaluating eight health related fields: 1) physical
activity limitations, 2) social activity limitations, 3) limitations
of the normal day by day physical activities, 4) pain, 5) general
state of mind, 6) limitations of the normal the normal day by
day activities caused by emotional problems, 7) vitality, 8) the
patient’s perception on his general health status. The global
score for the entire group of patients, was 54 (DS= 18.42), the
health fields perceived by the patients as being the most
affected were: normal physical and emotional day by day
activities. The aspects that were least affected were: social
activity, state of mind and vitality.
PM.2.3. Calitatea vieflii la pacienflii
cu transplant renal
Conclusions. High quality of life in patients is an important
objective after a kidney transplant, but there are still
shortcomings in these aspects. Using standard evaluation
methods can lead to an objective appreciation of the success
rate within different population groups and to an
improvement of the capacity to resolve problems that affect
the quality of life after the transplant.
25
PM.2.4. Sindromul vezicii
hiperactive la bærbaflii cu HBP
D. Soroiu, C. Persu, C. Ene, P. Geavlete
D. Soroiu, C. Persu, C. Ene, P. Geavlete
Obiectiv: Cele mai supærætoare simptome de tract urinar
inferior ale bærbatului în vârstæ se datoreazæ obstrucfliei
subvezicale prin HBP, asociatæ cu hiperactivitate
detrusorianæ. Scopul acestui studiu retrospectiv este
evaluarea alternativelor terapeutice la aceøti pacienfli.
Objective: Most troublesome LUTS of the aging male are
due to bladder outlet obstruction caused by BPH, associated
with detrusor overactivity. We reviewed the evolution of
detrusor overactivity in patients with BPH who underwent
several treatment alternatives.
Material øi metodæ: Studiul a inclus 130 de bærbafli cu
simptomatologie de tract urinar inferior, diagnosticafli cu
HBP øi având simptomatologie sugestivæ pentru sindromul
de vezica hiperactivæ. Vârsta minimæ a pacienflilor a fost de 50
de ani øi au fost excluøi cei cu patologie neurologicæ
cunoscutæ. Pacienflii au completat scorul IPSS si chestionarul
de calitate a vieflii. În toate cazurile s-a practicat debitmetrie
liberæ øi determinarea rezidiului postmicflional. Pacienflii au
efectuat studiu presiune-debit pentru evaluarea hiperactivitæflii detrusoriene øi a gradului de obstrucflie subvezicalæ.
Pacienflii au fost reevaluafli conform aceluiaøi protocol dupæ 6
respectiv 12 luni. În funcflie de opfliunea terapeuticæ aleasæ,
pacienflii au fost împærflifli în patru grupe: A. Supraveghere –
19 pacienfli, B. Terapie medicalæ pentru HBP – 20 cazuri, C.
Terapie medicalæ pentru HBP øi anticolinergic – 33 pacienfli,
D. TURP – 58 cazuri.
Materials and Methods: 130 men with lower urinary tract
symptoms have been selected, after being diagnosed with BPH
and having a medical history suggestive for bladder
overactivity. All patients were older than 50 years of age and hid
not have any neurological disease. Patients had to complete the
IPSS score and the Quality of Life index. Free uroflowmetry and
abdominal ultrasound examination with measurement of the
post mictional residual urine have been performed. All patients
underwent a pressure-flow study, as the single most useful
investigation providing evidence both for bladder outlet
obstruction and detrusor overactivity. Patients have been
reevaluated using the same protocol 6 to 12 months after
treatment. Considering our treatment options, patients have
been divided into 4 groups: A. Surveillance – 19 patients; B.
Medical therapy for BPH – 20 cases; C. Medical therapy for BPH
and anticholinergics – 33 patients; D. TURP – 58 patients.
Rezultate: Grupul A a înregistrat o agravare constantæ a
simptomelor, iar patru pacienfli au dezvoltat retenflie acutæ
de urinæ. În grupul B, starea pacienflilor s-a ameliorat sub
tratament, iar în 5 cazuri simptomele de vezicæ hiperactivæ au
dispærut. În grupul C, ameliorarea simptomaticæ a fost
semnificativæ, cu diminuarea simptomatologiei obstructive
dar øi a celei de vezicæ hiperactivæ. Nu s-au înregistrat
episoade de retenflie acutæ øi nici creøetri semnificative ale
rezidiului vezical. În grupul pacienflilor operafli (TURP),
evolufliile au fost diferite: în patru cazuri persistæ atât
simptomatologia obstructivæ cât øi cea de vezicæ hiperactivæ,
în 19 cazuri semnele de vezicæ hiperactivæ au impus
tratament specific, iar 35 de pacienfli sunt asimptomatici.
Results: Patients of the A group showed an overall
worsening of the symptomatology. 4 patients of this group
developed acute urine retention which imposed surgical
treatment. In the B group, the patients’ condition was better
after treatment. In 5 cases, signs of bladder overactivity
disappeared. In the C group, patients’ condition improved
significantly. Bladder overactivity and outlet obstruction
became less bothering for the patient, with no case of acute
urinary retention and no increase in the volume of residual
urine. Patients treated with TURP (D group) had different
evolutions: 4 patients still have symptoms of overactivity and
obstruction. 19 patients have detrusor overactivity requiring
medical treatment. 35 patients are asymptomatic, thus not
requiring any kind of therapy.
Concluzii: Hiperactivitatea detrusorianæ persistæ sau se
agreveazæ în absenfla tratamentului specific; terapia
medicalæ pentru HBP poate reduce simptomele de vezicæ
hiperactivæ, færæ a putea fi consideratæ un tratament eficient
în acest sens. Asocierea anticolinergicelor la tratamentul
adenomului de prostatæ este siguræ øi eficientæ, færæ reacflii
adverse semnificative. TURP, prin reducerea gradului de
obstrucflie subvezicalæ, duce la dispariflia simptomatologiei
de hiperactivitate vezicalæ în peste jumætate dintre cazuri.
26
Overactive bladder
in patients with BPH
Conclusions: Detrusor overactivity persists or aggravates in
the absence of treatment. Medical therapy for BPH may
reduce bladder overactivity, but cannot be considered
effective. Association of anticholinergics with usual
medication for BPH is safe and effective by decreasing
symptoms without causing acute urinary retention or
increasing the residual volume. 60% of patients with detrusor
overactivity are completely asymptomatic after TURP.
nr. 2 / 2013 • vol 12
1
1
2
C. Ene , V. Mirciulescu , Corina Nicolae ,
2
1
Oana Coman , P. Geavlete
1
2
UMF „Carol Davila”, Catedra de Farmacologie
øi Farmacoterapie
The relation zinc- PSA
in patients with BPH
1
1
2
C. Ene , V. Mirciulescu , Corina Nicolae ,
2
1
Oana Coman , P. Geavlete
1
2
UMF „Carol Davila”, Department of
Pharmacology and Pharmacotherapy
Introducere: Antigenul Specific Prostatic (PSA) reprezintæ
unul din elementele esenfliale în diagnosticul hiperplaziei
benigne de prostatæ, existând însæ un real interes pentru
descoperirea de noi parametri biologici care sæ ajute la
creøterea specificitæflii diagnostice.
Introduction: Prostatic Specific Antigen (PSA) represents an
important element in the diagnosis of benign prostatic
hyperplasia (BPH), but there is still a real interest for the
discovery of new biological parameters that help to increase
diagnostic specificity.
Obiective: Evaluarea relafliei dintre PSA øi zinc la pacienflii cu
hiperplazie benignæ de prostatæ (HBP).
Objectives: The Assessment of the relationship between PSA
and zincin patients with benign prostatic hyperplasia (BPH).
Material øi metodæ: S-a efectuat un studiu observaflional în
perioada 2012- 2013, pe un numær de 60 de bærbafli cu vârsta
medie de 56,2 ani, ce au fost împærflifli în douæ loturi:
diagnosticafli cu HBP (30 pacienfli) øi færæ patologie prostaticæ (30
de voluntari). Criteriile de includere au fost: vârsta, PSA, examenul
ecografic, examenul anatomopatologic, status nutriflional
adecvat, precum øi absenfla de patologii asociate sau de
tratamente medicamentoase în curs. S-au determinat PSA seric,
zincul seric øi cel urinar prin metode de lucru automatizate.
Material and methods: An observational study was
conducted during 2012 - 2013, on a total of 60 men with a
mean age of 56.2 years, which were divided into two groups:
diagnosed with BPH (30 patients) and without prostate
pathology (30 volunteers) . The inclusion criteria were: age,
PSA, ultrasound, pathological examination, adequate
nutritional status and the absence of associated pathology or
ongoing medical treatments. We determined serum PSA,
serum and urinary zinc by automated working methods.
Rezultate: În lotul de studiu, valoarea PSA a fost de
3,85±0,07ng/mL, cea a zincului seric de 77± 7,2µg/dL, iar cea a
zincului urinar a fost de 612±122µg/ 24 de ore. În lotul martor
valoarea PSA a fost de 0,9±0,7 ng/mL, cea a zincului seric de
94±4,5µg/dL, iar cea a zincului urinar a fost de 417±101µg/ 24
de ore. S-au obflinut diferenfle cu semnificaflie statisticæ între
bærbaflii cu HBP øi lotul control pentru: PSA, Zn seric, Zn urinar
(IC= 95%, p< 0,05). O relaflie negativæ, cu semnificaflie statisticæ,
a fost observatæ între zincul seric øi PSA, asociere inexistentæ în
lotul martor (r= - 0,186, IC= 95%, p= 0,048).
Results: In the study group, the PSA value was 3.85 ± 0.07 ng
/ mL, the serum zinc level of 77 ± 7.2 mg / dL, and the urinary
zinc was 612 ± 122 mg / 24 hours. In the control group the
PSA value was 0.9 ± 0.7 ng / mL, the serum zinc level of 94 ±
4.5 mg / dL, and the urinary zinc was 417 ± 101 mg / 24 hours.
It was obtained differences with statistical significance
between men with BPH and control, for: PSA, serum Zn,
urinary Zn (IC= 95%, p< 0,05). A negative relation with
statistical significance was observed between PSA and serum
Zn, but this ssociation is not present for the control (r= 0,186, IC= 95%, p= 0,048).
Concluzii: Se poate constata cæ zincul prezintæ o variaflie
discordantæ în relaflie cu PSA, ceea ce ne motiveazæ pentru a
afla dacæ într-adevær zincul meritæ folosit alæturi de PSA în
diagnosticul HBP.
nr. 2 / 2013 • vol 12
PM.2.5. Relaflia zinc-PSA în
hipertrofia benignæ de prostatæ
Conclusions: It can be seen that zinc presents a discordant
variation in it’s relation with PSA, that motivates us to find
whether zinc worth using with PSA in the diagnosis of BPH.
27
PM.2.6. Hiperplazia benignæ de
prostatæ la pacienflii cu obezitate
1
2,3
2,3
Benign prostatic hyperplasia in
patients with obesity
1
2,3
2,3
F. Rusu , Emilia Rusu , Gabriela Radulian ,
1
1
1
1
V. Mædan , O. Bratu , M. Dinu , C. Farcaø ,
1
1
1
1
O. Pacu , D. Spînu , C. Iatagan , C. Stænescu ,
1
1
1
R. Popescu , A. Rædulescu , A. Marincaø ,
1
1,2
C. Ilie , D. Mischianu
1
Spitalul Universitar de Urgenflæ Militar Central
“Carol Davila”
2
Universitatea de Medicinæ øi Farmacie
“Carol Davila”
3
Institutul Naflional de Diabet, Nutriflie øi Boli
Metabolice „Prof. N. Paulescu”
F. Rusu , Emilia Rusu , Gabriela Radulian ,
1
1
1
1
V. Mædan , O. Bratu , M. Dinu , C. Farcaø , O.
1
1
1
1
Pacu , D. Spînu , C. Iatagan , C. Stænescu , R.
1
1
1
1
Popescu , A. Rædulescu , A. Marincaø , C. Ilie ,
1,2
D. Mischianu
1
Emergency Military Hospital “Carol Davila”
2
University of Medicine and Pharmacy “Carol
Davila”
3
Diabetes, Nutrition and Metabolic Diseases
Institute „Prof. N. Paulescu”
Introducere. Multe studii au evidenfliat cæ obezitatea este
asociatæ cu un nivel scæzut al antigenului specific prostatic
(PSA) øi un volum al prostatei mai mare. Scopul acestui studiu
a fost de a analiza dacæ volumul prostatei øi PSA-ul sunt
corelate cu indicele de masæ corporalæ (IMC).
Introduction. Many studies showed that obesity is associated
with low levels of prostate specific antigen and bigger
prostate volume. The aim of this study was to analysis if
prostate size and PSA is correlated with body mass index (BMI).
Material øi metode. Am selectat 151 de pacienfli cu sindrom
metabolic (IDF 2006); aceøtia au fost stratificafli în 3 loturi:
lotul A, 58 de pacienfli cu IMC 27-34,9 kg/m2, lotul B - 54 de
pacienfli IMC 35,0-39,9 kg/m2 øi lotul C - 39 pacienflii cu IMC>
40 kg/m2. Hiperplazia benignæ de prostatæ (HBP) a fost
definitæ ca un volum prostatic peste 25 ml øi un scor IPSS ≥ 8.
Rezultate. Vârsta medie a fost de 54,3±8,7 ani în grupul A,
55,41±7,59 ani în grupul B øi 53,46±6,41 ani în grupul C.
Nivelul PSA a fost 0,921±0,23 pmol/l în grupul A, 0,623±0,31
pmol/l în grupul B øi 0,64±0,25 pmol/l în grupul C (p=0,034).
Nivelurile de PSA liber nu a fost semnificativ statistic diferite
între grupuri. Dimensiunea prostatei a fost mai mare în
grupul C (p=0,02). Nivelul testosteronului a fost similar în
grupul A øi B, dar mai mic în grupul C (4,24±1,39 ng/ml vs
4,57±1,46 ng/ml vs 3,61±1,42 ng/ml). În analiza univariatæ
IMC a fost corelat cu nivelul PSA, testosteronului, adiponectinei øi valorile leptinei, mærimea prostatei.
Concluzie. Obezitatea este asociatæ cu un nivel scæzut al
testosteronului, iar producflia PSA-ului este sub controlul
androgenic, ceea ce poate sugera cæ obezitatea ar putea fi
asociatæ cu niveluri scæzute de PSA.
Material and methods. We selected 151 patients with metabolic syndrome (IDF 2006) and divided in 3 groups: group A,
58 patients with BMI 27 – 34.9 kg/m2, group B - 54 patients
BMI 35.0-39,9 kg/m2 and group C – 39 patients with BMI > 40
kg/m2. BPH was defined as a PV≥25 ml and International
Prostate Symptom Score IPSS?8, which are commonly used
as clinical BPH criteria
Results. The average age was 54.3±8.7 in group A,
55.41±7.59 in group B and 53,46±6,41 in group C. PSA levels
were 0.921±0.23 pmol/l in group A, 0.623±0.31pmol/l in
group B and 0.64±0.25 pmol/l in group C (p=0.034). Free PSA
levels don’t differ between groups with significant statistics.
Prostate size was bigger in group C (p=0.02). Testosterone
levels were similar in groups A and B but lower in group C
(4.24±1.39 ng/ml vs 4.57±1.46 ng/ml vs 3.61±1.42 ng/ml).
BMI was correlated with PSA levels, testosterone,
adiponectin and leptin values, prostate size (all p<0.05).
Conclusion. Obesity is associated with a low level of
testosterone and PSA production is under androgen control,
which may suggest that obesity might be associated with
low levels of PSA.
Conflict of interest. None
Conflict de interese. Færæ
Finanflare. Acest studiu a fost finanflat de UEFISC ca parte a
programului PNCID 2 ADENODIAG 41-085/2007.
28
Funding. This study was supported by the Romanian
National Authority for Scientific Research as a part of the
PNCDI 2 program ADENODIAG 41-085/2007.
nr. 2 / 2013 • vol 12
C. Moldoveanu, F. Stænescu, M. Jecu,
B. Geavlete, L. Adou, C. Ene, C. Bulai,
P. Geavlete
A new technological advancement
in endoscopic surgery of the benign
prostatic hyperplasia – continuous
bipolar plasma vaporization
P. Geavlete
Obiective: Acest studiu a urmærit eficacitatea øi siguranfla
unei noi surse de energie care sæ permitæ o vaporizare
bipolaræ continuæ a hipertrofiei benigne de prostatæ (HBP) în
cazul adenoamelor medii de prostatæ.
Introduction and Objectives: This study evaluated the
efficiency and safety of a new energy source enabling a
continuous bipolar plasma vaporization of the prostate (CBPVP) to be achieved in medium size BPH cases.
Material øi metodæ: În studiu a fost inclus un numær de 60 de
pacienfli cu un volum al HBP cuprins între 30 øi 80 ml, Qmax
< 10 mL/s si IPSS > 19. Tofli pacienflii au fost evaluafli
preoperator øi la 1, 3 øi 6 luni dupæ intervenflie prin intermediul IPSS, Qmax, Qol øi PVR.
Materials and Methods: A total of 60 BPH patients with
prostate volume between 30 and 80 mL, maximum flow rate
(Qmax) below 10 mL/s and International Prostate Symptom
Score (IPSS) over 19 were introduced for C-BPVP. All cases
were evaluated preoperatively and at 1, 3 and 6 months after
surgery by IPSS, Qmax, quality of life score (QoL) and postvoiding residual urinary volume (PVR).
Rezultate: Timpul operator mediu a fost de 31, 5 minute.
Rata de perforare capsularæ a fost de 1,7 %, iar sângerarea
intraoperatorie a apærut într-un singur caz, în timp ce
scæderea medie a hemoglobinei a fost de 0,4 g/dl. De
asemenea, perioada medie de cateterizare øi durata medie
de spitalizare au fost de 24,1 ore øi respectiv 2,1 zile. Rata de
recateterizare pentru retenflia urinaræ acutæ a fost descrisæ la
un singur pacient (1,7%). La 1, 3 øi 6 luni parametrii de urmærire au fost IPSS øi Qmax (4,9 versus 24,1 mL/s, 4,5 versus 24,4
mL/s, øi respectiv 4,2 versus 24,9), Qol si PVR (1,2 versus 32,6
ml, 0,9 versus 26 ml, øi respectiv 0,9 versus 22,8 ml).
Concluzii: Vaporizarea bipolaræ continuæ a redus timpul
operator prin utilizarea unei noi surse de enegie, a subliniat
siguranflæ perioperatorie øi a îmbunætæflit parametrii de urmærire postoperatori.
nr. 2 / 2013 • vol 12
Results: The mean operation time was 31.5 minutes.
Capsular perforation rate was 1.7% and intraoperative
bleeding occurred in one case while mean hemoglobin
drops was 0.4 g/dL. Also, the mean catheterization period
and hospital stays were 24.1 hours and 2.1 days, respectively.
The rate of re-catheterization imposed by acute urinary
retention (1.7% and 1.7% versus 6.7%) was described in one
patient (1.7%). At 1, 3 and 6 months follow-up parameters
were IPSS and Qmax (4.9 versus 24.1 mL/s, 4,5 versus 24.4
mL/s, 4.2 versus 24.9, respectively), Qol and PVR (1.2 versus
32.6 ml, 0.9 versus 26 ml, 0.9 versus 22.8 ml, respectively).
PM.2.7. Un nou progres tehnologic în
chirurgia endoscopicæ a hiperplaziei
benigne de prostatæ – vaporizarea
bipolaræ cu plasma continuæ
Conclusions: The new technical improvement of the BPVP
procedure was able to reduce the surgical time. The plasmabutton vaporization approach emphasized perioperative
safety and improved follow-up voiding and symptom scores’
parameters.
29
PM.2.8. TURIS-P – experienflæ pe
30 de luni (oct. 2010 – martie 2013)
TURIS-P – Our experience in
30 months (oct. 2010 - mar. 2013)
N. Stoican, A. Filip, N. Dobromir
Spitalul Judeflean “Sf. Ioan Cel Nou” Suceava –
Secflia Urologie
N. Stoican, A. Filip, N. Dobromir
Emergency County Hospital of Suceava –
Obiectiv. Experienfla serviciului nostru în rezolvarea patologiei prostatei – pe 724 cazuri demonstreazæ avantajele
metodei comparativ cu TUR-P.
Objective. Our service experience in dealing prostate
pathology - on 724 cases, demonstrates the advantages of
the method compared with TUR-P.
Material øi metodæ. Pe 724 de cazuri rezolvate în 30 de luni
(oct. 2010 – mar. 2013) am efectuat TURis-p la pacienfli cu o
medie de vârstæ de 64 ani. 610 cazuri – HBP, 80 cazuri - ADKp (T3-4); sclerozæ de col vezical - 40 cazuri. Timp operator
20min-60min. Hemostaza intraoperatorie perfect controlatæ.
Nu s-a înregistrat nici un sindrom postTURp. Suprimarea
sondei postoperator – 1-4 zile. Complicaflii postoperatorii
secundare procedurii au fost minime. Incontinenfla urinaræ
(HBP) tranzitorie – 9 cazuri – 72 ore dupæ suprimarea drenajului U-V. Incontinenfla urinaræ ortostaticæ (ADK-p) – 5 cazuri.
Hematurii importante care au necesitat transfuzii -5 cazuri.
Stricturi uretrale (la peste 30 zile) – 16 cazuri (3- 6 luni); scleroza de col vezical – 8 cazuri – dupæ 6 luni – la pacienfli cu
multiple cateterisme uretro-vezicale în antecedente, infecflii
urinare, diabetici.
Material and method. In 724 cases resolved within 30
months (Oct. 2010 - Mar. 2013) we performed TURis-P in
patients with a mean age of 64 years. 610 cases – BPH; 80
cases – prostate neoplasia (pT3-4); 40 cases - bladder neck
sclerosis. Operating time 20min-60min. Perfectly controlled
intraoperative hemostasis. Not recorded any postTUR-P
syndrome. Suppression of postoperative urethral catheter 1-4 days. Postoperative complications were minimal after the
procedure. Urinary incontinence (BPH) was transient - 9 cases
- 72 hours after the removal of drainage catheter. Orthostatic
urinary incontinence (PCa) - 5 cases. Significant hematuria
requiring transfusion - 5 cases. Urethral strictures (more than
30 days) - 16 cases (3-6 months); bladder neck sclerosis - 8
cases - after 6 months - in patients with a history of multiple
bladder catheterisation, urinary infections, diabetes.
Comentariu. Metodæ relativ nouæ, scurteazæ durata medie
de spitalizare. Complicaflii minime, de regulæ tranzitorii.
Calitatea hemostazei øi a lojei prostatice restante post TURisp este superioaræ TUR-p. TURis-p exclude sindromul
postTUR-p. Nu putem aprecia pe timp îndelungat rezultatele
TURis-p (experienflæ scurtæ). Tratament accesibil – de scurtæ
duratæ – antibioterapie, anticoagulante, antiinflamatorii.
Prognostic – favorabil, cu recuperare rapidæ øi complicaflii
minime. Dispensarizare – clinicæ, imagisticæ, laborator.
Comment. Relatively new method, shorten the average
length of hospitalization (ALH). Minimal complications,
usually transient. Quality haemostasis and the postoperative
aspect of the prostate after TURis-P is superior to TUR-P.
TURis-P excludes postTUR-P syndrome. We can not
appreciate the long-term results for the procedure (TURis-P)
(short experience). Relatively inexpensive treatment - shortterm - antibiotics, anticoagulant, anti-inflammatory. Prognosis - favorable, with rapid recovery and minimal complications. Follow-up- clinic, imaging, lab.
Concluzii. Metodæ relativ nouæ – eficientæ (DMS scæzutæ – 15 zile); Complicaflii minime; Rezultate postoperatorii superioare TUR-p; Recuperare superioaræ TUR-p; Nu dispunem de
o experienflæ de duratæ care sæ ne permitæ evaluarea pe timp
îndelungat a rezultatelor.
30
Conclusions. - Relative new method - effective (ALH - low 1-5 days); - Minimal complications; - Superior postoperative
results vs. TUR-P; - Recovery superior vs. TUR-P; - We do not
have a lasting experience that enables us long evaluation of
the results.
nr. 2 / 2013 • vol 12
A.Cumpænaø, M. Mokdad, C. Iacob,
A.Pæunescu, C. David, R.Bardan,
M. Botoca, V. Bucuraø
Introducere. Obiective. Ghidurile actuale privind tratamentul chirurgical al hiperplaziei benigne a prostatei (HBP)
recomandæ tratamentul chirurgical doar în caz de episoade
repetate de retenflie acutæ de urinæ. Obiectivul studiului a fost
de a urmæri pe o perioadæ de 3 ani evoluflia pacienflilor cu HBP
care au dezvoltat un episod de retenflie acutæ de urinæ øi au
ræspuns favorabil la TWOC (trial without catheter –
cateterism uretrovezical 2-3 zile – cu sau færæ tratament alfablocant – urmat de îndepærtarea cateterului).
Material øi metodæ. Am inclus în studiu 100 cazuri de
pacienfli cu retenflie acutæ de urinæ prin HBP care au ræspuns
favorabil la TWOC øi care au fost ulterior urmærifli timp de 3
ani. Conduita iniflialæ a fost TWOC cu alfa blocant 2-3 zile
dupa care cei care au ræspuns favorabil - incluøi în studiu – au
urmat tratament cu tamsulosin + dutasteridæ, fie în
combinaflie fixæ (capsulæ unicæ), fie în dublæ asociere timp de
3 ani. Pacienflii care au dezvoltat al doilea episod de RAU au
fost operafli.
Rezultate. Rata de succes – definitæ ca absenfla RAU sau a
chirurgiei pentru HBP – a fost de 54% la 1 an dupæ episodul
de RAU øi s-a menflinut la 49% la 2 ani, respectiv 46% la 3 ani.
Pacienflii non-responsivi la tratament – care au dezvoltat
retenflie acutæ de urinæ sub tratament combinat – aveau
vârsta øi volumul iniflial al prostatei semnificativ mai mari faflæ
de al celor care au ræspuns la tratament, situaflie întâlnitæ atât
la evaluarea de la 1 an, cât øi la cea de la 2 øi 3 ani post TWOC.
nr. 2 / 2013 • vol 12
Is TWOC followed by combined
medical treatment an efficient
method in treating patients
with BPH complicated with
acute urinary retention?
A.Cumpænaø, M. Mokdad, C. Iacob,
A.Pæunescu, C. David, R.Bardan,
M. Botoca, V. Bucuraø
„Victor Babeø” University of Medicine and
Introduction. Objectives. BPH guidelines recommend the
surgical treatment for recurrent acute urinary retention
(AUR) only. The aim of our study was to evaluate, for a 3years period, the evolution of patients with AUR due to
BPH, which favorably responded to TWOC.
Material and method. 100 consecutive patients who
favorably responded to TWOC were included in the study
and followed-up for a 3-years period. After the TWOC the
responder patients were treated with combined medical
treatment (tamsulosin + dutasteride) for 3 years. Patients
experiencing the second AUR episode were excluded from
the study and underwent surgery.
Results. The success rate- defined as the absence of any
further AUR episode or need for BPH surgery – was 54%
after the first year, 49% after 2 years and 46% after 3 years
from the initial AUR episode. Patients with treatment failure
had higher prostate volumes and were older at the initial
AUR episode comparing with those which successful
responded to the treatment (p<0.001). Diabetes mellitus
were statistical significant more frequent encountered in
treatment-failures cases than in successful cases in the first
year follow-up but not for the second and the third year of
follow-up.
PM.2.9. Este cateterismul uretrovezical
pe termen scurt (TWOC) urmat de
terapia medicamentoasæ combinatæ
o metodæ eficientæ de tratament al
pacienflilor cu hiperplazie benignæ de
prostatæ complicatæ cu retenflie acutæ
de urinæ?
Conclusion. TWOC followed by combined medical
treatment is an efficient method of treatment for the first
31
32
Prezenfla diabetului zaharat a fost mai frecvent consemnatæ
la pacienflii non-responsivi care au dezvoltat RAU în primul
an de la episodul initial de retenflie, dupæ care diferenfla între
cele douæ grupuri a ræmas nesemnificativæ statistic.
episode of AUR. Good success rates can be expected at
younger patients with smaller prostates.
Concluzii. TWOC reprezintæ o modalitate eficientæ de
tratament a primului episod de RAU la pacienflii cu HBP, cu
rezultate bune pe termen mediu. Majoritatea pacienflilor care
au ræspuns la TWOC fli nu au dezvoltat RAU în primul an dupæ
episodul iniflial de retenflie nu au necesitat ulterior tratament
chirurgical. Vârsta fli volumul iniflial al prostatei par a fi factori
predictivi ai evolufliei ulterioare a pacienflilor.
nr. 2 / 2013 • vol 12
A. Mihalache, E. Alexandrescu, R. Mulflescu,
G. Niflæ, C. Persu, C. Moldoveanu, P. Geavlete
Obiectiv: Abcesul prostatic reprezintæ o afecfliune raræ, dar
potenflial severæ în lipsa tratamentului adecvat. Am evaluat
eficienfla abordului transuretral al abcesului prostatic øi am
analizat caracteristicile pacienflilor.
Endoscopic approach in
prostatic abscesses
A. Mihalache, E. Alexandrescu, R. Mulflescu,
G. Niflæ, C. Persu, C. Moldoveanu, P. Geavlete
Objective: Prostatic abscess is a rare, but potentially severe
urologic disease if not treated properly. We have evaluated
the efficiency of the transurethral resection in prostatic
abscesses and we have also assesed the features of the
patients diagnosed with this condition.
Material øi metodæ: În perioada martie 1998 – decembrie
2012, în clinica noastræ au fost internafli 29 de pacienfli cu
abces prostatic. Tofli pacienflii au beneficiat de rezecflie
transuretralæ, concomitent s-a instituit antibioterapia cu
spectru larg.
Material and method: Between March 1998 and December
2012, we have admitted 29 patients with prostatic abscesses in
our urology department. All patients sustained transurethral
resection and also received broad spectrum antibiotherapy.
Rezultate: Vârsta medie a pacienflilor a fost 61 de ani. Din cei
29 de pacienfli, 19 (65,5%) au avut diabet zaharat øi 5 pacienfli
(17%) au avut ciroza hepaticæ. Semnele øi simptomele
frecvente au fost: febræ de cel putin 38.5 grade Celsius la
19/29 din pacienfli (65.5%), retenflie acutæ de urinæ în 16/29
din cazuri (55%) øi disurie în 13/29 din cazuri (45%). De
asemenea, a fost semnalatæ durerea perinealæ 17,2% øi
hipogastricæ 38%. Principalele investigaflii au fost tuøeul
rectal (mærirea de volum a prostatei, fluctuenflæ), ecografia
endorectalæ (imagini hipoecogene cu perete subflire) øi CT
(colecflii cu densitate lichidæ). În toate cazurile, abordul
transuretral a permis evacuarea completæ a abcesului si un
lavaj corespunzætor al acestuia. La doi pacienfli s-a practicat
reintevenflie la douæ, respectiv patru zile. În 4 cazuri pacienflii
au prezentat sepsis. Nu au fost înregistrate decese øi recidive
în perioada de follow-up (6 - 48 de luni).
Results: The average age of patients was 61 years. 19
patients (65,5%) suffered from diabetes mellitus and 5
patients (17%) had hepatic cirrhosis. Signs and symptoms
included: fever of at least 38.5 degrees Celsius in 19/29 of
patients (65.5%) , acute urinary retention in 16/29 of the
cases ( 55%) and dysuria in 13/29 cases (45%). Perineal pain
in 17,2% of patients and hipogastric discomfort in 38% of the
cases were reported. The main investigations were digital
rectal examination (enlargement and fluctuation of the
prostate), transrectal ultrasound (hypoechoic thin-walled
images) and CT (fluid density collections). In all cases, the
transurethral resection approach allowed complete abscess
drainage with an adequate lavage. Two patients needed
reintervention after two, respectively four days. There were
declared 4 cases with sepsis. During the follow-up period (6
to 48 months), no deaths or relapses were reported.
Concluzii: Abcesul prostatic este o patologie mai frecventæ
la pacienflii vârstnici øi tarafli. Rezecflia transuretralæ
endoscopicæ reprezintæ un tratament sigur øi eficient al
abcesului prostatic.
Conclusions: Prostatic abscesses occur mostly in elderly
patients, with multifactorial diseases. Endoscopic
transurethral resection is a safe and efficient treatment for
prostatic abscesses.
nr. 2 / 2013 • vol 12
PM.2.11. Tratamentul endoscopic al
abcesulului prostatic
33
PM.3.1. Diagnosticul cancerului de
prostatæ: posibilitæfli øi limite
1,2
1,2
1,2
1,2
Orsolya Mártha , A. Szöllösi ,
1,2
1
1
D. Porav Hodade , S. Nedelcu , O. Mælæu ,
1
1
1,2
A. Chiujdea , C. Catarig , C. Chibelean
1
Spitalul Clinic Judeflean Mureø,
Clinica de Urologie Târgu Mureø
2
Universitatea de Medicinæ øi Farmacie Târgu Mureø
Orsolya Mártha , A. Szöllösi ,
1,2
1
1
D. Porav Hodade , S. Nedelcu , O. Mælæu ,
1
1
1,2
A. Chiujdea , C. Catarig , C. Chibelean
1
Mureø County Hospital,
Department of Urology Târgu Mureø
2
University Of Medicine and Pharmacy Târgu Mureø
Introducere: Diagnosticul precoce în cancerul de prostatæ
reprezintæ o problemæ care ridicæ din ce în ce mai multe întrebæri.
Când øi cine (medicul de familie, urologul etc.) indicæ efectuarea
primului PSA, care sunt vârstele limitæ, ce semnificaflie are o
valoare normalæ cu rezultat histopatologic de ASAP sau o valoare
crescutæ cu examen histopatologic de flesut prostatic normal etc.
Introduction: Early diagnosis in prostate cancer represents a
problem which arises many questions. Who (general
practitioner, urologist etc.) and in which cases indicates the
first PSA, which are the limits of age, what significance has a
normal PSA value with a histopathological finding of ASAP or
an elevated PSA with a negative biopsy result etc.
Scopul lucrærii: Studiul nostru retrospectiv prezintæ prin prisma
a 754 de bolnavi puncflionafli ecoghidat transrectal pentru
suspiciunea de cancer de prostatæ, în perioada 2009-2012,
experienfla Clinicii de Urologie din Tg Mureø în acest domeniu.
Material øi metode: În decurs de 4 ani (2009-2012) am practicat
puncflie biopsie ecoghidatæ transrectalæ pentru suspiciunea de
cancer de prostatæ (PSA crescut, tuøeu rectal pozitiv, cæutarea
punctului de plecare în cazul metastazelor la distanflæ etc.) la 754
de pacienfli având o vârstæ medie de 70,05 ani.
Rezultate: Din cei 754 de pacienfli (100%) în doar 47,68% (361)
de cazuri s-a confirmat cancerul de prostatæ, în 5,57% a
pacienflilor rezultatul a fost ASAP. Majoritatea pacienflilor
diagnosticafli cu cancer de prostatæ au fæcut parte din grupa de
vârstæ 71-75 de ani (27,15%), limitele de varsta fiind 49-92 de
ani. Adenocarcinoamele de prostatæ confirmate au avut un scor
Gleason 7 (la 137 de cazuri din 361) øi Gleason 8 (122 de cazuri).
Din punct de vedere al numærului de puncflii efectuate per
pacient, s-au practicat între 6-8-12 puncflii, sau în unele cazuri
puncflii saturate mergând pânæ la 14-16 puncflii, depinzând de
volumul prostatei øi de vârsta pacientului. În 94,9%, PBP s-a
efectuat pentru un PSA crescut – valoarea medie a PSA-ului:
47,16 ng/ml (cu limite între 2,3 øi 2689,98 ng/ml).
Concluzii: În cadrul procesului de depistare precoce a
cancerului de prostatæ, determinarea PSA-lui are valoare
determinantæ. Creøterea valorii PSA-ului nu înseamnæ
obligatoriu prezenfla cancerului de prostatæ, dar necesitæ
efectuarea unei punctii biopsii prostatice. În vederea creøterii
acurateflii diagnostice, se recomandæ deci efectarea a mai
multor determinari PSA prebiopsie, iar în majoritatea
cazurilor, mai ales la cei apartinand grupei de varsta de 70-75
ani, urologul sa fie cel care dupæ un examen de specialitate sæ
recomande efectuarea acestei probe.
34
Prostate cancer diagnosis:
possibilities and limits
Aim of the study: In our retrospective study we processed
the histopathological results of 754 ultrasound guided
transrectal prostate biopsies, performed between 2009-2012
in the Urology Clinic of Targu Mures.
Materials and Methods: Between 2009-2012 in the Clinic of
Urology of Tg Mures we performed transrectal biopsies in
prostate cancer suspicion in 754 cases (increased PSA level,
positive digital rectal examination, and search starting point
for distant metastasis, etc).
Results: With ultrasound guided prostate biopsy performed
on the 754 patients, we confirmed adenocarcinoma of the
prostate in just 47.68% (361 cases), and the result was ASAP in
5,57% of the patients. Most patients diagnosed with prostate
cancer belonged to age group 71-75 years (27.15%).
Confirmed prostate adenocarcinoma had a Gleason score 7
(in 137 of 361 cases) and Gleason 8 (122 cases). In terms of the
number of biopsies we performed 6-8-12 punctures, or in
some cases saturated punctures extending to 14-16
punctures, depending on patient age and prostate volume. In
94.9%, PBP was made for increased PSA: mean PSA was 47.16
ng / ml (PSA value was between 2.3 and 2689.98 ng / ml).
Conclusions: In the process of early diagnosis of prostate
cancer the determination of PSA is of determinant value. An
increasing value of PSA does not mean in all of the cases the
presence of prostate cancer, but requires a prostate biopsy.
In order to increase the efficiency of the biopsies, several
determinations of PSA before the biopsies are required, and
the urologist has to recommend this probe especially in the
cases of patients belonging to the group of ages 70-75 years.
nr. 2 / 2013 • vol 12
1
1
1
M. Botoca , C. Secæøan , L. Daminescu ,
1
1
2
A. Cumpænaø , V. Bucuraø , I. Sporea
1
Clinica Urologicæ
2
Clinica de Gastroenterologie, Universitatea de
Medicinæ øi Farmacie „Victor Babeø” Timiøoara
Introducere. Stadiul actual al cunoaøterii. În prezent, puncflia
biopsie în scopul depistærii cancerului de prostatæ constæ în
prelevarea a cel puflin 10 fragmente de flesut prostatic prin
ghidaj ecografic. Ultrasonografia are o specificitate øi o sensibilitate limitatæ datoritæ imposibilitaflii detecfliei zonelor neoplazice
cu aspect izoecogen. O alternativæ de actualitate a ultrasonografiei este elastografia, tehnicæ imagisticæ ce poate evalua
elasticitatea flesuturilor. Existæ studii care aratæ cæ neoplasmele
în majoritatea cazurilor prezintæ densitate celularæ crescutæ ce
determinæ o modificare a elasticitæflii/rigiditæflii flesuturilor
afectate. Elastografia în timp real este metoda ce poate oferi
informaflii imagistice asupra densitæflii flesuturilor devenind
astfel o investigaflie inovatoare în detectarea cancerului.
Obiective, material øi metode. Studiul de faflæ îøi propune ca
prim obiectiv achiziflia de imagini si mæsurætori elastografice
comparative între aspecte variate de flesut prostatic: normal,
adenomatos øi malign. Un al doilea obiectiv constæ în achiziflia
de imagini ultrasonografice standard øi elastografice în cazuri
cu suspiciune de adenocarcinom prostatic, cærora li s-a practicat apoi puncflie biopsie ecoghidatæ flintitæ pe zonele ce prezintæ aspectele cele mai sugestive imagistic pentru o transformare malignæ. Am beneficiat de un elastograf AIXPLORER
Supersonic Imagine.
Rezultate preliminarii. În prima etapæ a studiului am
obflinut un lot de 120 de imagini elastografice caracteristice
flesutului prostatic normal, adenomatos øi neoplazic. De
asemenea am încercat sæ ne perfecflionæm tehnica de
examinare cu scopul limitærii artefactelor.
Concluzii. Elastografia pare o metodæ promiflætoare pentru
ameliorarea rezultatelor puncfliei bioptice echoghidate. Implementarea metodei este limitatæ de prezenfla unor artefacte øi
necesitæ parcurgerea unei curbe de învæflare. Obflinerea unor
rezultate satisfæcætoare va putea încuraja efectuarea unor puncflii biopsii prostatice transrectale strict ghidate elastografic.
nr. 2 / 2013 • vol 12
Real Time Elastography. A useful
method in the diagnosis of prostate
cancer
1
1
1
M. Botoca , C. Secæøan , L. Daminescu ,
1
1
2
A. Cumpænaø , V. Bucuraø , I. Sporea
1
2
Department of Gastroenterology,
„Victor Babeø” University of Medicine and
PM.3.2. Elastografia în timp real.
Metodæ adjuvantæ de diagnostic în
cancerul prostatic
Introduction. Actual level of knowledge. In our days
detection of prostate cancer relies on ultrasound guided
prostate biopsy with prelevation of at least 10 cores.
Ultrsonography however has a limited specificity and
sensitivity in detecting isoechoic prostate cancer areas. A
modern alternative of ultrasound is elastography which can
assume the density of tissues. It is known that neoplastic
tissue density affects the elasticity of the tissue as revealed
by elastography. Real time elastography becomes this way a
promising adjuvant method in detecting prostate cancer.
Objectives. Material and method. This study has as a first
objective to collect a set of elastographic images and data in
order to compare various prostatic tissues: normal, BPH and
cancer. The second objective is to obtain a library of standard
ultrasonic and elastographic images in patients suspicious
for prostate adenocarcinoma, which are about to have a
transrectal ultrasound guided prostate biopsy. For these
purposes we used an AIXPLORER Supersonic Imagine
elastograph.
Preliminary results. In the first step of the study we
collected 120 elastographic images and data from normal
subjects and patients with BPH or prostate cancer. We also
tried to minimize the artefacts and technical biases.
Conclusions. Elastography is a promising method in order to
improve the results of prostate biopsy. The method has some
limitations related to the presence of artifacts and the need
of learning curve. Obtaining satisfactory results could
prompt to the elastographic guided focal prostate punction.
35
PM.3.3. Rezultatele repetærii PBP
echoghidate transrectal la bolnavii
cu suspiciune de ADK de prostatæ
The Results of Repeated Echoguided
TRUS in Patients Suspected of
Prostate cancer
M. Brægaru, I. Arabagiu, E. Constantinescu,
D. Soroiu, E. Alexandrescu, D. Georgescu,
Ghe. Niflæ, C. Persu, M. Dræguflescu, M. Jecu,
F. Stænescu, R. Mulflescu, B. Geavlete,
V. Mirciulescu, P. Geavlete
M. Brægaru, I. Arabagiu, E. Constantinescu,
D. Soroiu, E. Alexandrescu, D. Georgescu,
Ghe. Niflæ, C. Persu, M. Dræguflescu, M. Jecu,
F. Stænescu, R. Mulflescu, B. Geavlete,
V. Mirciulescu, P. Geavlete
Introducere: Am urmærit evaluarea ratei de detecflie a ADK
de prostatæ la pacienflii cu suspiciune biochimicæ la care s-a
practicat o repetare a PBP echoghidate transrectal.
Material øi metodæ: În perioada ianuarie 2011- iulie 2012, au
fost analizate rezultatele histopatologice ale fragmentelor
prostatice obflinute prin PBP echoghidatæ transrectal la 42 de
pacienfli cu prima biopsie prostaticæ negativæ pentru ADK de
prostatæ (lot iniflial de 80 pacienfli). PBP a fost repetatæ la 6
luni de la prima puncflie. Pacienflilor le-a fost administratæ
preinterventional o dozæ de cefalosporinæ im/iv,
practicându-se PBP cu recoltarea a 12 fragmente la 18
pacienfli øi 16 fragmente la 24 de pacienfli. PBP s-a efectuat cu
anestezie localæ. Tofli pacienflii au fost externafli la câteva ore
de la puncflie, recomandându-se tratament antibiotic 7 zile.
Rezultate: La repetarea puncfliei a fost diagnosticat ADK de
prostatæ la 9/42 pacienfli (rata de detecflie de 21.4%). Restul
de 33 de pacienfli au ræmas în evidenfla Clinicii
nediagnosticafli deøi valorile PSA suspicioneazæ prezenfla
ADK de prostatæ. Ei se aflæ în urmærire, eventual urmând sæ se
repete PBP. Rata globalæ de detecflie a ADK de prostatæ la cei
80 de pacienfli de la care a pornit studiul a fost de 69.42 %, 48
% diagnosticafli dupæ prima puncflie prostaticæ øi 21,42%
diagnosticafli dupæ a doua puncflie prostaticæ.
Concluzii: Confirmarea histologicæ a ADK de prostatæ este
obligatorie în stabilirea diagnosticului. Puncflia biopsie
ecoghidatæ transrectalæ este metoda de elecflie pentru
recoltarea fragmentelor de examinat. Repetarea PBP se
impune la pacienflii cu suspiciune clinicæ øi biochimicæ ADK
de prostatæ.
36
Introduction: The study aims to assess the detection rate of
prostate cancer in patients with biochemical suspected
prostate cancer who underwent repeated transrectal
echoguided biopsy.
Subjects and method: Between January 2011 and July 2012 we
analyzed the results of histopathological prostatic fragments
obtained by transrectal echoguided biopsy on a number of 42
patients with the first prostate biopsy negative for prostate
cancer - initial group of 80 patients. After 6 months from the first
puncture PBP was repeated. Patients received preinterventional
a cephalosporin IM / IV, practicing the PBP with a collection of 12
pieces from 18 patients and 16 fragments in 24 patients. PBP
was performed with local anesthesia. All patients were
discharged a few hours after the puncture, and were
recommended antibiotic treatment for 7 days at home.
Results: Prostate cancer was diagnosed through repeated
puncture in a number of 9 from 42 patients (detection rate of
21.42%). The remaining number of 33 patients was left
undiagnosed in evidence of the Clinic, although PSA values
raised suspicion of prostate cancer. They are in follow up,
eventually planning to repeat the biopsy. The overall detection
rate of prostate cancer to the 80 patients who started the study
was 69.42%, 48% diagnosed after the first biopsy prostate and
21.42% diagnosed after the second prostate biopsy.
Conclusions: Histological confirmation is mandatory for
prostate cancer diagnosis. Transrectal echoguided biopsy is
the method of choice for the collection of the fragments to
be examined. Repeating the biopsy is necessary in patients
with clinical and biochemical suspicion of prostate cancer.
nr. 2 / 2013 • vol 12
G. Opriø
Spitalul Clinic Theodor Burghele – Bucureøti
Complications and deterioration
of quality of life after rectal
ultrasound guided biopsyretrospective study
G. Opriø
Theodor Burghele Hospital, Bucharest
Introducere øi obiective. Studiul are ca scop evaluarea
morbiditæflii asociate cu procedeul biopsiei transrectale
ghidatæ ecografic.
Introduction. The present study aims to assess the
morbidity associated with ultrasound-guided transrectal
biopsy procedure.
Materiale øi metode. Au fost luafli în calcul un numær de 120
de pacienfli, pe parcursul a doi ani (2011 si 2012), urmærifli cu
ajutorul unui chestionar în timpul a 2 întâlniri consecutive.
Vârsta pacienflilor a fost în medie 68,5 ani (57-80 ani).
Valoarea medie a PSA a fost: 18,6 ng/ml (6,6- 32,8 ng/ml.
Cancerul de prostatæ a fost diagnostic în 70 (58,33%) din
cazuri. Valoarea scorului Gleason a fost în medie 6,4 +/- 1,5.
Pacienflii au primit cu 24 de ore înainte antibiotic: 89 %
chinolone øi 10 % aminoglicozide.
Material and method. Were studied using a questionnaire
consisting of 13 questions in 120 patients with prostate
cancer was diagnosed in 58, 33% of cases. In these patients
with a mainly administered before biopsy, quinolone
antibiotic preventive medication.
Rezultate. Înainte de biopsie: 8,5% (10) dintre pacienfli au
raportat tulburæri sexuale rezultate din anticiparea efectuærii
acestei proceduri. 50 % din pacienfli au raportat anxietate. În
timpul biopsiei: 98,33% din pacienfli au avut durere øi
disconfort. Jumætate dintre pacienfli au raportat durere øi
disconfort diferite de ceea ce se aøteptau, în 2/3 din cazuri a
fost mai micæ decât se aøteptau. Dupæ biopsie: 50% din
pacienfli au raportat durere pelvinæ ce a durat 1-2 zile. 60%
din pacienfli au raportat hematurie ce a durat 5-7 zile dupæ
efectuarea biopsiei. Hematospermia a fost raportatæ la 29,1%
(35) din pacienfli. Sângerarea rectalæ a fost raportatæ la 40%
din pacienfli si a durat 2,2 +/- 1,5 zile. 25% (30) din pacienfli au
raportat dificultæfli de golire vezicalæ øi 5% (6) dintre ei au
avut retenflie acutæ de urinæ. 5 pacienfli au avut febræ. 85%
(102) din pacienfli au avut anxietate în aøteptarea rezultatului
histologic al investigafliei bioptice.
PM.3.4. Complicafliile øi
deteriorarea calitæflii vieflii dupæ
biopsia rectalæ ghidatæ ecografic –
studiu retrospectiv
Results. Results of the questionnaire revealed that patients in the
study reported sexual disorders and anxiety before performing
the procedure and pain, hematuria, hematospermia, rectal
bleeding urine retention, bladder emptying and anxiety unable
pending the outcome of prostate biopsy.
Conclusions. All these complications reveal once again that
this invasive procedure has some negative impact on patient
quality of life.
Concluzii. Biopsia de prostatæ poate fi cauza obiønuitæ a unei
varietæfli de complicaflii øi are un substanflial impact asupra
stærii de sænætate a pacienflilor.
nr. 2 / 2013 • vol 12
37
PM.3.5. Corelaflii între examenul
histopatologic (invazie perineuralæ)
al puncfliei biopsie prostaticæ øi
rezultatul examinærii de rezonanflæ
magneticæ nuclearæ în cancerul de
prostatæ
C.P. Ilie, V. Mædan, F. Rusu, O. Bratu, M. Dinu,
C. Farcaø, O. Pacu, D. Spînu, C. Iatagan,
C. Stænescu, R. Popescu, A. Rædulescu,
A. Marincaø, D. Mischianu
Clinica de Urologie, Spitalul Universitar de
Urgenflæ Militar Central “Carol Davila” Bucureøti
Correlations between prostatic
biopsy pathological result
(perineural invasion) and MRI
in prostate cancer
Urology Clinic, University Emergency Central
Military Hospital “Carol Davila”, Bucharest
Introducere: Stadializarea în cancerul de prostatæ are
implicaflii majore în ce priveøte prognosticul, dar øi managementul pacienflilor. S-a realizat un studiu retrospectiv pentru a
evidenflia noi corelaflii între examenul histopatologic al
puncfliei biopsie prostatice øi rezultatul examinærii RMN.
Introduction: Staging in prostate cancer is important for
prognosis as well as for the management of the patients. We
present a retrospective study with the aim to highlight new
correlations between the pathological report after prostatic
biopsy and the MRI result.
Material øi metodæ: Lotul studiat a constat din pacienflii nou
diagnosticafli cu cancer de prostatæ în perioada iunie 2012martie 2013. Din totalul pacienflilor s-au selectat doar
pacienflii cu cancer de prostatæ localizat care se încadrau în
grupa de risc redus øi intermediar (PSA ≤ 20, scor Gleason ≤
7) øi care puteau beneficia de tratament radical (speranfla de
viaflæ de cel puflin 10 ani øi lipsa de comorbiditæfli care sæ
contraindice tratamentul radical). Tuturor pacienflilor li s-a
efectuat examen RMN, iar în cazurile de cancer de prostatæ cu
risc intermediar øi scintigrafie osoasæ, în vederea stadializærii.
Material and Method: We have studied the patients newly
diagnosed with prostate cancer between June 2012 and
March 2013 in a single centre. We have selected only the
patients with low and intermediate risk disease (PSA ≤ 20,
Gleason Score ≤ 7) and with indication for radical treatment
(at least 10 years life expectancy and no major
comorbidities). All patients had MRI and some of them
(intermediate risk disease patients) also bone scans.
Rezultate: S-a identificat un numær de 77 de pacienfli: 34 se
aflau în grupul de risc redus øi 43 în grupul de risc
intermediar. Zece dintre aceøtia au prezentat stadiu local
avansat în urma examinærii RMN. Corelaflia între invazia
perineuralæ la examenul histopatologic øi stadiu avansat la
examenul RMN este semnificativæ statistic atât în cazul
întregului lot p=0.02 (testul Fisher exact) cât øi în cazul
pacienflilor cu risc intermediar (p=0.0415).
Results: We found 77 patients: low risk disease 34 and
intermediate risk 43. Ten of those had locally advanced
prostate cancer on MRI scan. We found statistically
significant corellation between perineural invasion and MRI
scan result for both population groups (p=0.02 Fisher exact
test), and also for intermediate risk disease (p=0.0415).
Conclusion: Perineural invasion on pathological report can
be used to select patients with risk of extracapsular disease
on MRI examination.
Concluzii: Invazia perineuralæ decelatæ la examenul
histopatologic poate fi utilizatæ pentru a selecta cazurile cu
risc de extensie tumoralæ extracapsularæ la examenul RMN.
38
nr. 2 / 2013 • vol 12
Ø. Raøcu, A. Rusu, M. Merticariu, B. Braticevici,
V. Ambert, D. Damian, I. Dragomiriøteanu,
M. Dumitrache, D. Bædescu, V. Jinga
Clinica de Urologie, Spitalul Clinic
“Prof. Dr. Th. Burghele”, Bucureøti
Radical retropubic prostatectomy:
Outcomes in our clinic 2008-2013
Ø. Raøcu, A. Rusu, M. Merticariu, B. Braticevici,
V. Ambert, D. Damian, I. Dragomiriøteanu,
M. Dumitrache, D. Bædescu, V. Jinga
Urology Department, Clinical Hospital
“Prof. Dr. Th. Burghele”, Bucharest
Introducere: Cancerul de prostatæ este cea mai frecventæ afecfliune malignæ la bærbafli, cu o incidenflæ aflatæ în creøtere încæ de
la începutul anilor 1990. Nu tofli pacienflii cu cancer de prostatæ
dezvoltæ însæ manifestærile clinice ale bolii, prin urmare
selecflionarea acestor cazuri reprezintæ o mare provocare clinicæ.
Introduction: Prostate cancer is the most common
malignancy in men, its incidence of prostate cancer has been
rising since the early 1990s. Not all men with prostate cancer
will develop clinical disease, therefore sorting these cases is a
great clinical challenge.
Obiective: Am revizuit experienfla de 5 ani în efectuarea prostatectomiei radicale în clinica noastræ, pentru a evalua rezultatele
obflinute øi a le compara cu literatura de specialitate.
Purpose: We reviewed a 5-year experience performing open
radical retropubic prostatectomy in our hospital, in order to
assess outcomes and to compare them to the published
literature.
Pacienfli øi metode: În studiu au fost incluøi 214 pacienfli cu
cancer de prostatæ localizat la care s-a practicat prostatectomie radicalæ între ianuarie 2008 øi martie 2013. Au fost
înregistrate øi urmærite valoarea preoperatorie a PSA-ului,
stadiul clinic øi scorul Gleason. Au fost evaluate durata
intervenfliei, complicafliile intervenfliei, dar øi durata spitalizærii. Radicalitatea oncologicæ a fost apreciatæ cu ajutorul
evolufliei biochimice a PSA-ului.
Materials and methods: 214 patients with localized
prostate cancer who underwent radical prostatectomy
between January 2008 and March 2013 were included in our
study. The value of preoperative PSA, clinical stage and
Gleason score were recorded. Operative time, surgery
complication and duration of hospital stay were assessed.
Oncological results were assessed using biochemical PSA
evaluation.
Rezultate: Vârsta pacienflilor a fost cuprinsæ între 53-75 ani, iar
valoarea preoperatorie a PSA-ului între 2,7-18 ng/ml. Scorul
Gleason preoperator, evaluat pe fragmentele obflinute prin
puncflie biopsie prostaticæ, a fost între 4-8, dintre aceøti pacienfli
37% au prezentat carcinom prostatic în stadiul T1, 53% T2 øi 10%
T3. Nu s-a întregistrat niciun deces intraoperator, complicaflii
majore una, complicaflii minore 18%. Durata medie a intervenfliei a fost de 240 minute. Pierderea medie de sânge a fost de 385
ml, iar rata medie de transfuzie de 1,2 unitæfli. Durata de spitalizare 7-14 zile. Continenfla øi funcflia erectilæ au fost evaluate la 1
lunæ postoperator.
Results: Patients’ age was between 53-75 years, preoperative prostate specific antigen levels were between 2,7-18
ng/dl. Gleason score on preoperative biopsy was 4-8. Out of
these patients 37% had T1 disease, 53% T2 and 10% T3. No
intraoperatory deaths occurred, no major complications
occurred, while minor complications were 18%. Mean
operating time was 240 minutes. Average blood loss was 385
ml and average blood transfusion rate was 1.2 units. Length
of hospitalization was 7-14 days. Continence and erectile
function were assessed at 1 month post-surgery.
Concluzie: Rezultatele oncologice, dupæ prostatectomie radicalæ efectuatæ în clinica noastræ, îndeplinesc standardele global
acceptate pentru aceastæ intervenflie cu o morbiditate redusæ.
Conclusion: Oncological outcome after radical prostatectomy
performed in our clinic meets global standards accepted for
this type of intervention with acceptable morbidity.
nr. 2 / 2013 • vol 12
PM.3.6. Prostatectomia
radicalæ retropubicæ:
experienfla clinicii 2008-2013
39
PM.3.7. Prostatectomia radicalæ
retropubianæ – 5 ani de experienflæ
N. Grigore, A. Haøegan, M.V. Pîrvufl
Facultatea de Medicinæ “Victor Papilian”,
Clinica de Urologie Sibiu
Introducere øi obiective: Prostatectomia radicalæ este un tratament de elecflie pentru pacienflii cu cancer de prostatæ localizat
(PT1-T2) øi speranflæ de viaflæ de peste 10 ani. Scopul studiului de
faflæ este o evaluare retrospectivæ a pacienflilor cu cancer de
prostatæ care au fost supuøi prostatectomiei radicalæ retropubianæ deschise (PRRD) øi limfodisecflie ilio-obturatorie bilateralæ.
Material øi metodæ: Am analizat retrospectiv 133 de pacienfli
supuøi PRRD pentru cancerul de prostata în perioada 2008 - 2013.
Rezultate: Vârsta medie a pacienflilor a fost de 62.7 ani. Nivelul
preoperator al PSA-ului a fost între 3.5 - 19.3 ng / ml (medie 7,4
ng / ml). Stadiul tumoral preoperator a fost T1-T2, în 120 de cazuri
(90,2%) øi T3a de 13 pacienfli (9,8%). Scorul Gleason în urma
puncfliei biopsie prostaticæ a relevat faptul ca 92 de pacienfli
(69,2%) au avut un scor ≤ 6; 31 de pacienfli (23,3%) au avut un scor
de 7 øi 10 pacienfli (7,5%) au avut un scor ≥ 8. Din totalul de
pacienfli, 57 pacienfli (42,8%) au beneficiat de PRRD cu
prezervarea bilateralæ a bandeletelor neuro-vasculare øi 18
pacienfli (13,5%) au beneficiat de PRRD cu prezervarea unilateralæ
a bandeletelor neuro-vasculare. Postoperator 8 pacienfli (6%) au
avut margini chirurgicale pozitive øi 9 pacienfli (6,7%) au
prezentat limfo-noduli pozitivi øi au primit terapie complementaræ. Niveluri ale PSA-ului sub 0,1 ng/ml evaluate la 12 sæptæmâni
postoperator au fost prezente la 107 pacienfli (80,4%). Un total de
57 de pacienfli au prezentat hemoragie intra øi postoperatorie
care a necesitat transfuzie. În ceea ce priveøte rezultatul funcflional, 99 de pacienfli (74,4%) au fost complet continenfli dupæ
îndepærtarea cateterului vezical. Funcflia erectilæ a fost evaluatæ la
53/133 de pacienfli la 6 luni care au beneficiat de prezervarea
bilateralæ sau unilateralæ a bandeletelor neuro-vasculare, 34
dintre ei au avut erecflii satisfæcætoare pentru actul sexual, færæ a fi
nevoie de nici un medicament. Principalele limitæri ale acestui
studiu sunt un design retrospectiv øi perioada scurtæ de urmærire.
Concluzii: Pentru pacienflii atent selectionafli cu cancer de
prostatæ în stadiu localizat, PRRD reprezintæ un tratament
sigur øi eficient, cu intenflie curativæ. Aceastæ proceduræ
chirurgicalæ nu este færæ complicaflii, dar oferæ rezultate
oncologice bune, cu speranflæ lungæ de viaflæ øi o bunæ
calitate a vieflii.
40
Radical retropubic prostatectomy –
5 years experience
Facultatea de Medicinæ “Victor Papilian”, Clinica
de Urologie Sibiu
Introduction: Open radical retropubic prostatectomy
(ORRP) is a common treatment for patients with localized
prostate cancer (pT1-T2) and life expectancy of more than 10
years. The purpose of the present study is a retrospective
evaluation of a group of patients with prostate cancer who
have undergone ORRP and bilateral internal iliac and
obturator lymphadenectomy.
Material and method: We retrospectively analyzed 133
patients who underwent ORRP for clinically localized
prostate cancer between January 2008 and February 2013.
Results: Average age of the patients was 62.7 years. PreORRP PSA level was between 3.5 – 19.3 ng/ml (average 7.4
ng/ml). Preoperative tumor stage was T1-T2 in 120 cases
(90.2%) and T3a for 13 patients (9.8%). The biopsy Gleason
score revealed that 92 patients (69.2 %) had a score ≤ 6; 31
patients (23.3%) had a score of 7 and 10 patients (7.5%) had
a score ≥ 8. Overall, 57 patients (42,8%) benefit of ORRP with
bilateral nerve sparing technique and 18 patients (13,5%)
benefit of unilateral nerve sparing technique. A total of 8/133
patients (6%) had positive surgical margins, and 9/133
patients had (6,7%) positive lymph nodes and received
complementary therapy. Postoperative PSA levels below 0,1
ng/ml at 12 weeks was found in 107 patients (80.4%). A total
of 57 patients presented intraoperative and postoperative
bleeding that required transfusion. Concerning the
functional outcome, 99 patients (74.4%) were totally
continent after bladder catheter removal. Erectile function
was evaluated in 53/133 patients at 6 months after nerve
sparing ORRP and 34 of them had erections satisfactory for
intercourse without the need of any medication. The main
limitations of this study are its retrospective design and the
follow-up period.
Conclusion: For carefully selected patients with organ-confined
cancer, ORRP represents a safe and effective, but aggressive
treatment, with curative intention. This surgical procedure it is
not without complications but offers good oncological results
with long life expectancy and good quality of life.
nr. 2 / 2013 • vol 12
O. Bratu, M. Dinu, D. Spînu, A. Rædulescu,
V. Mædan, R. Popescu, C. Farcaø, C. Iatagan,
F. Rusu, O. Pacu, C. Stænescu, A. Marincaø,
C.P. Ilie, D. Mischianu
Clinica de Urologie a Spitalului Universitar de
Urgenflæ Militar Central „Dr. Carol Davila“, Bucureøti
Obiectiv: Prezentæm o analizæ retrospectivæ a pacienflilor cu
adenocarcinom prostatic operafli în clinica noastræ atât prin
prisma diagnosticului clinic, cât øi prin complicafliile intra øi
postoperatorii imediate øi tardive cu accent asupra
procedeului chirurgical folosit.
Material øi metodæ: Un numær de 64 de prostatectomii radicale
retropubiene au fost efectuate între septembrie 2008 øi martie
2013. Grupul de pacienfli a avut urmatoarele caracteristici: vârsta
medie 65,09 ani, PSA total între 2 øi 20,59 ng/ml (media - 9,16
ng/ml), volumul prostatic a variat între 22 øi 78 cc, numærul de
fragmente biopsiate între 6 øi 24. Scorul Gleason a fost cuprins în
intervalul 1-9. Încadrarea în clasificarea TNM a fost urmætoarea:
T1 a øi b - 3 pacienfli, T1 c - 55 de cazuri, T2 a - douæ cazuri, T2 b un caz, T3 a - trei cazuri. Limfodisecflia pelvinæ standard sau
extinsæ a fost efectuatæ la patruzeci øi doi de pacienfli cu PSA
între 10 øi 20 ng/ml. Protocolul diagnostic standard a inclus:
examen clinic, PSA total øi liber, tuøeu rectal, ecografie øi biopsie
transrectalæ. Prostatectomia radicalæ retropubicæ cu
limfadenectomie standard sau extinsæ a fost procedura
chirurgicalæ de elecflie folositæ în cadrul acestui grup de pacienfli.
Rezultate: Numai trei pacienfli din grupul de studiu nu au
beneficiat de rezultat oncologic; ei fiind ulterior incluøi în
protocolul de radio- øi chimioterapie. Un pacient a decedat
în urma unui edem pulmonar acut la øapte zile postoperator. La patru ani de la intervenflie tofli pacienflii, chiar øi
cei trei în stadiul T3 b au menflinut nivelul PSA sub 0,01
ng/ml. Cele mai frecvente complicaflii postoperatorii
imediate au fost drenajul urinar øi limfatic prelungit, infecflii
ale plægii øi, nu în ultimul rând, hematuria macroscopicæ.
Dintre cele mai frecvente complicaflii tardive enumeræm:
incontinenflæ urinaræ uøoaræ, impotenfla øi scleroza de col
vezical. Pe cea din urmæ am întâlnit-o din ce în ce mai des în
ultima perioadæ.
nr. 2 / 2013 • vol 12
Radical retropubic prostatectomy
in treatment of
prostate cancer - statistics
O. Bratu, M. Dinu, D. Spînu, A. Rædulescu,
V. Mædan, R. Popescu, C. Farcaø, C. Iatagan,
F. Rusu, O. Pacu, C. Stænescu, A. Marincaø,
C.P. Ilie, D. Mischianu
Urology Clinic, Central Military Emergency
University Hospital “Dr. Carol Davila”,
Bucharest, Romania
retropubicæ în tratamentul
cancerului de prostatæ – o analizæ
statisticæ
Objective: An updated retrospective analysis on CaP
patients as seen through, clinical diagnosis, intra and postoperative early and late complications with a focus on the
surgical procedure.
Design and setting: 64 radical retropubic prostatectomies
were performed from September 2008 till March 2013. The
selected group of patients had the following features:
average age 65,09 years, total PSA between 2 and 20.59 ng/ml
(average - 9,16 ng/ml), prostate volume varies from 22 to 78
cc, number of biopsies between 6 to 24. Gleason score was
between 2 and 9, TNM classification was as it follows: T1 a and
b -3 cases, T1 c -55 cases, T2 a – 2 cases, T2 b – 1 case, T3 a – 3
cases. Forty-two patients with PSA between 10 and 20 ng/ml
underwent standard or extended pelvic lymph node
dissection Clinical exam, free and total PSA, digital rectal
examination, transrectal ultrasonography and guided biopsy,
was the standard diagnose protocol. Operating procedure
used was radical retropubic prostatectomy with various
schemes of lymph node dissection (standard and extended).
Results: Oncological results were achieved for all
patients except for three undergraded patients who later
received radiotherapy and hormone therapy. One patient
deceased from acute pulmonary edema seven days after
surgery. At four years after the surgery all the patients
including the three staged T3 b maintained PSA levels
under 0,01 ng/ml. Prolonged urinary and lymphatic
drainage, wound infections and macroscopic haematuria
were the most frequent early complications. Main late
complications were: mild urinary incontinence,
impotence and bladder neck sclerosis. Bladder neck
sclerosis seems to be one of the most frequent late
complications we came across lately.
41
42
Concluzii: În opinia noastræ prostatectomia radicalæ
retropubicæ ræmâne „gold standardul“ tratamentului
adenocarcinomului prostatic. Limfadenectomia pelvinæ fie
ea standard sau extinsæ are o importanflæ vitalæ în atingerea
dezideratului oncologic. Speranfla de viaflæ øi beneficiile
intervenfliei la distanflæ sunt greu de interpretat prin
experienfla proprie, iar datele preliminare sunt în
concordanflæ cu literatura de specialitate.
Conclusions: We consider that CaP gold standard treatment
remains radical retropubic prostatectomy. Pelvic lymph node
dissection is a must, greatly increasing the end result of this
treatment. The overall survival and surgical benefits are hard
to asses through our own experience but our preliminary
data is in accordance with the literature.
nr. 2 / 2013 • vol 12
Radical retropubic prostatectomy –
Early complications
C. Costache, B. Novac, C. Ciutæ,
Oana Costæchescu, C. Costandache, V. Radu,
C. Ristescu, R. Andriciuc, C. Novac
Clinica de Urologie øi Transplant Renal, Iaøi,
România
C. Costache, B. Novac, C. Ciutæ, Oana
Costæchescu, C. Costandache, V. Radu, C.
Ristescu, R. Andriciuc, C. Novac
Department of Urology and Kidney
Transplantation, Iaøi, Romania
Introducere: Scopul acestui studiu a fost de a evalua
experienfla primelor cazuri de prostatectomie radicalæ
retropubianæ øi de utilizare a rezultatelor în consilierea
pacienflilor øi optimizarea deciziei terapeutice.
Material øi metodæ: În perioada ianuarie 2011 – martie 2013,
26 de pacienfli cu vârsta cuprinsæ între 56-69 ani (media 62,6
ani) au beneficiat de prostatectomie radicalæ retropubianæ.
Studiul retroprospectiv a cuprins analizarea elementelor
semnificative din foile de observaflie, protocoalele operatorii
øi controalele ambulatorii postoperatorii, urmærindu-se cu
precædere indicafliile, complicafliile intra- øi postoperatorii
precoce (pânæ la 30 de zile) øi durata spitalizærii.
Rezultate: Antigenul specific prostatic (PSA) preoperator a
fost cuprins între 4,5-27,2 ng/mL (media 9,5 ng/mL), iar scorul
Gleason a fost 5 la un pacient, 6 la 22 dintre aceøtia øi 7 în 3
cazuri. Stadiul clinic a fost T1 la 6 pacienfli (23,1%), T2 la 18
(69,2%) øi T3 în 2 (7,7%) cazuri. Pierderile de sânge
intraoperator au fost cuprinse între 400-2500 mL (media 1214
mL), iar 19 pacienfli au primit transfuzii de sânge. Complicafliile
postoperatorii au cuprins insuficienflæ renalæ acutæ în 3 cazuri,
extravazarea substanflei de contrast la cistografia retrogradæ
la 4 pacienfli, infecflie urinaræ în 5 cazuri øi dehiscenfla plægii
operatorii la 2 pacienfli. Durata spitalizærii postoperatorii a fost
cuprinsæ între 13-43 zile (cu o medie de 19,57 zile).
Concluzii: Prostatectomia radicalæ retropubianæ poate fi
efectuatæ în condiflii de siguranflæ, asociind un risc redus de
complicaflii. Pentru majoritatea pacienflilor cu stadiu localizat
al cancerului de prostatæ, prostatectomia radicalæ reprezintæ
cea mai bunæ opfliune terapeuticæ.
nr. 2 / 2013 • vol 12
Introduction: To evaluate our experience with the first cases
of radical retropubic prostatectomy and to use the results for
patient counseling and optimizing therapeutic decision.
retropubianæ – complicaflii precoce
Material and Method: In the interval January 2011 - March
2013, 26 patients aged 56-69 years (mean age 62.6 years)
were treated by radical retropubic prostatectomy. The
retroprospective study included an analysis of the significant
data in the case records, surgical protocols and outpatient
postoperative check-ups, special attention being given to
indications, intra- and early postoperative complications
(within 30 days) and hospital stay.
Results: Preoperatively, prostate specific antigen (PSA)
ranged between 4.5 and 27.2 ng/mL (mean 9.5 ng/mL), and
Gleason score was 5 in one patient, 6 in 22, and 7 in 3 patients.
Clinical stage was T1 in 6 patients (23,1%), T2 in 18 (69,2%)
and T3 in 2 (7,7%). Mean intraoperative blood loss was 1214
mL (range 400-2500 mL), and 19 patients received blood
transfusions. Postoperative complications included acute
renal failure in 3 cases, extravasation of contrast medium
during retrograde cystography in 4 patients, urinary infection
in 5 cases and wound dehiscence in 2 patients. The average
postoperative hospital stay was 19.57 days (range 13-43).
Conclusions: Radical retropubic prostatectomy is a safe
technique, involving a reduced risk of complications. For
most patients with localized prostate cancer, radical
prostatectomy is the best treatment option.
43
PM.3.10. Managementul cancerului
de prostatæ cu risc înalt – între
teorie øi practicæ urologicæ
C. Surcel, C. Mirvald, O. Altan, C. Gîngu,
C. Pavelescu, I. Manea, M. Manu, I. Sinescu
Introducere. Variafliile în evaluarea preoperatorie øi în tratamentul pacienflilor cu cancer prostatic cu risc crecut pot avea
impact asupra rezultatelor oncologice pe termen lung. În
absenfla unor studii prospective sau a unor ghiduri clinice
care sæ sugereze superioritatea unei forme de tratament
activ, preferinflele urologului pot conduce la variaflii substanfliale în aplicarea tratamentului chirurgical. Ne-am propus sæ
evaluam practicile curente la nivel naflional privind managementul pacienflilor cu cancer de prostatæ cu risc øi posibilele
implicaflii asupra rezultatelor oncologice.
Material øi metodæ. Un sondaj naflional web-based a fost
realizat în perioada ianuarie-martie 2013, care a fost trimis
prin e-mail la tofli membri activi din Asociaflia Românæ de
Urologie. 75 ræspunsuri au fost înregistrate. Analiza statisticæ
a ræspunsurilor a fost realizat cu ajutorul SPSS.
Rezultate. Cei mai mulfli (37,2%) lucreazæ într-un spital
universitar, cu peste 10 ani de experienflæ. Cea mai acceptatæ
definiflie a cancerului prostatic cu risc înalt cuprinde prezenfla
unei valori a PSA >20 ng/dl sau a unui stadiul clinic>T3 sau un
scor Gleason> 8 (67% dintre ræspunsuri), în timp ce 27,1%
consideræ stadiul clinic T2b ca fiind cu grad ridicat de risc. Deøi
73% dintre respondenfli au IRM disponibil în spital, numai
43%îl recomandæ preoperator, iar 46,9% consideræ utilæ o
evaluare CT pelvinæ. 63% din urologi consideræ nomogramele,
tabelelele Partin øi clasificarea D’Amico fiind cele mai utile în
evaluarea riscului preoperator. 43,8% realizeazæ mai puflin de
50 de prostatectomii anual, abordul retropubic fiind cel mai
comun. 35.8% din respondenfli efectueazæ limfodisecflie
pelvinæ extinsæ în toate cazurile, în timp ce 28% consideræ
cazul inoperabil în caz de invazie a ganglionilor limfatici la
examenul extemporaneu. Doar 69% din urologi au încredere
în evaluarea anatomopatologicæ efectuatæ în spitalul lor.
Concluzii. Urologii care lucreazæ în spitalele universitare sunt
mai implicafli în managementul pacienflilor cu cancer de
prostatæ cu risc ridicat, faflæ de cei din spitalele judeflene.
Evaluarea IRM preoperatorie este utilizatæ insuficient.
Utilizarea unor definiflii diferite pentru cancerul de prostatæ
cu risc înalt øi a template-urilor pentru LND pot avea impact
asupra rezultatelor oncologice ale acestor pacienfli.
44
Management of high risk prostate
cancer –from theory to practice
C. Surcel, C. Mirvald, O. Altan, C. Gîngu,
C. Pavelescu, I. Manea, M. Manu, I. Sinescu
Center of Uronephrology and Renal
Bucharest
Introduction: Variations in patterns of care and treatment
outcomes suggest differences in the quality of care for men
treated for high risk prostate cancer. In the absence of highlevel evidence or clinical guidelines supporting an active
treatment approach over another, urologist’s preferences
may lead to substantial variation in treatment use. We aimed
to assess the current practices regarding the treatment of
patients with high risk prostate cancer in Romania and their
possible implications in treatment management.
Matherial and methods. A national Web-based survey was
conducted between Jan-March 2013 that was sent via e-mail
to all active member of the Romanian Association of Urology.
75 responses were registered. Statistical analysis of the
responses was done using SPSS.
Results. Most of the responders (37.2%) work in an academic
hospital, with a mean experience of treating prostate cancer
of more than 10 years. A PSA = 20 ng/ml or clinical stage> T3
or biopsy GS >8 is considered by 67% of responders as the
definition of high risk prostate cancer, while 27.1% consider a
T2b stage as high risk. Although 73% of responders have MRI
available in their hospital only 43% of them use it. 46.9%
consider pelvic CT useful for preoperative imaging evaluation.
63% of urologists use nomograms for preoperative risk
assessment, Partin Tables and D’Amico risk classification
being the most frequent used to assess the pretreatment risk
of patients. 43.8% perform less than 50 prostatectomies/year
with the retropubic approach being the most common.35.8%
of responders performs extended LND in all cases, while 28%
abandon the procedure if lymph node invasion is proven.
Only 69% of responders have confidence in their pathologist
Conclusions. Urologists working in academic hospitals are
more involved in the management of high risk prostate
cancer than those working in county hospitals. Imaging with
MRI for preoperative evaluation is underused. The usage of
different definitions for high risk prostate cancer and
templates for LND may impact the outcome of these patients.
nr. 2 / 2013 • vol 12
F. Stænescu, M. Jecu, C. Moldoveanu,
B. Geavlete, L. Adou, C. Ene, C. Bulai, P. Geavlete
“Sf. Ioan”, Bucureøt
Obiective: Acest studiu retrospectiv a evaluat eficienfla,
siguranfla øi rezultatele postoperatorii pe termen mediu ale
vaporizærii bipolare cu plasmæ în cazurile de cancer de
prostatæ asociat cu retenflie completæ de urinæ.
Objectives: This retrospective analysis evaluated the
efficiency, safety and medium term postoperative results of
bipolar plasma vaporization (BPV) in prostate cancer (PCa)
cases associating complete urinary retention.
Material øi metodæ: O serie de 40 de pacienfli diagnosticafli
cu cancer de prostatæ local avansat sau metastatic, aflafli în
retenflie completæ de urinæ care a necesitat cateterizare cu
sondæ Foley, au urmat vaporizare bipolaræ cu plasmæ cu scopul de a restaura micfliunile spontane. Un total de 35 de pacienfli au completat protocolul de evaluare de 1 an care a
constat în scorul internaflional al simptomelor datorate
prostatei (IPSS), indicele de calitate a vieflii (QoL), debitului
urinar maxim (Qmax) øi ecografiei abdominale cu determinarea volumului urinar rezidual postmicflional (RV).
Patients and Methods: A series of 40 patients diagnosed
with locally advanced or metastatic PCa and complete
urinary retention requiring a Foley catheter indwelling
underwent BPV aiming to restore spontaneous voiding. A
total of 35 patients completed the one year evaluation
protocol consisting of International Prostate Symptom Score
(IPSS), quality of life score (QoL), maximum flow rate (Qmax)
and post-voiding residual urinary volume (PVR), measured at
1, 3, 6 and 12 months after surgery.
Rezultate: Vaporizarea bipolaræ cu plasmæ a fost efectuatæ cu
succes în toate cazurile cu o eficienflæ satisfacætoare, confirmatæ
de timpul operator mediu (42,8 minutes) øi de scæderea medie
a hemoglobinei survenitæ intraoperator (0,7 g/dl). O perioadæ
de recuperare postoperatorie rapidæ øi siguræ a fost descrisæ în
aceastæ serie (hematurie postoperatorie – 7,5%; perioada
medie de cateterizare – 36 ore; perioada medie de spitalizare –
2,5 zile; rata simptomelor iritative precoce – 15%). La 1, 3, 6 øi 12
luni s-au înregistrat rezultate satisfæcætoare în ceea ce priveøte
IPSS, Qmax, QoL øi RV. Aceøti parametri au înregistrat o evoluflie
stabilæ pe parcursul întregii perioade de urmærire, 88,6 % dintre
pacienfli øi-au menflinut micfliunile spontane.
Concluzii: Studiul de faflæ a confirmat vaporizarea bipolaræ cu
plasmæ ca un abord terapeutic promiflætor în cazurile de cancer
de prostatæ asociat cu retenflie completæ de urinæ. Aceastæ
tehnicæ a demonstrat o bunæ eficienflæ, o morbiditate
perioperatorie redusæ, o convalescenflæ scurtæ øi parametri
urodinamici øi ai scorurilor simptomatice satisfæcætori în timpul
perioadei de urmærire de un an. POSDRU/107/1.5/S/82839.
nr. 2 / 2013 • vol 12
PM.3.11. Vaporizarea bipolaræ cu
Bipolar plasma vaporization in locally
plasmæ în cancerul de prostatæ local
advanced/metastatic prostate cancer
avansat/metastazat asociind retenflie
patients with complete urinary
completæ de urinæ – un tratament
retention – A palliative treatment for
paliativ pentru o complicaflie frecventæ
a frequent complication
Results: BPV was successfully performed in all cases with
satisfactory efficiency, as confirmed by the mean operation
time (42.8 minutes) and hemoglobin drop (0.7 g/dl). A fast
and safe postoperative recovery period was described in this
series (hematuria rate – 7.5%; mean catheterization period –
36 hours; mean hospital stay – 2.5 days; early irritative
symptoms’ rate – 15%). At 1, 3, 6 and 12 months, satisfactory
values were determined in terms of IPSS, Qmax, QoL and
PVR. These parameters emphasized a stable evolution
throughout the entire follow-up, as 88.6% of the patients
maintained spontaneous voiding.
Conclusions: The present trial confirmed the plasma-button
vaporization as a promising therapeutic approach in PCa
cases associating complete urinary retention. The technique
displayed good efficacy, low periopearative morbidity, short
convalescence and satisfactory urodynamic and symptom
score parameters during the one year follow-up period.
POSDRU/107/1.5/S/82839.
45
PM.3.12. Experienfla iniflialæ cu
HIFU în tratamentul cancerului
de prostatæ localizat
Ghe. Niflæ, P. Geavlete
Introducere øi obiective. Tratamentul standard al
cancerului de prostatæ localizat este reprezentat de
prostatectomia radicalæ. Riscul de dezvoltare a complicafliilor
postoperatorii a determinat introducerea unor alternative
minim invazive cu morbiditate redusæ. Deøi aflatæ încæ în
stadiu experimental, ablaflia termicæ a cancerului prostatic
prin HIFU a fost utilizatæ la peste 11000 pacienfli, în 30 de flæri.
Scopul acestei lucræri este analiza experienflei inifliale pe
termen mediu a unui singur centru.
Introduction and objectives. The standard treatment for
localised prostate cancer is radical prostatectomy. Due to the
risk of postoperative complications, a new, minimally
invasive alternative has been introduced, which associates
lower morbidity rates. Though still in its experimental phase,
thermal ablation using HIFU for the treatment of prostate
cancer has been used on 11000 patients, in 30 countries. The
purpose of this study is to describe the medium-term
outcome of the initial experience in a single centre.
Material øi metodæ. În perioada ianuarie - decembrie 2012,
tehnica HIFU a fost utilizatæ la 12 pacienfli cu cancer de
prostatæ localizat (T1-2NxM0) folosind dispozitivul Sonablate
500. Tofli pacienflii au avut PSA sub 15 ng/ml, scor Gleason ≤
7 øi un volum prostatic < 40 cc. Recurenfla biochimicæ a fost
definitæ folosind criteriile Phoenix (valoarea PSA nadir + 2).
Material and Method. From january 2012 to december
2012, the HIFU technique was employed on 12 patients
suffering from localised prostate cancer (T1-2NxM0), using
the Sonablate 500 device. Every patient had a PSA of under
15 ng/ml, a Gleason score ≤ 7 and a prostate volume of less
than 40 cc. The biochemical recurrence was defined by using
the Phoenx criteria (value of PSA Nadir + 2).
Rezultate. Valoarea medie a PSA nadir a fost de 0,18 ng/ml
(între 0,02 øi 3 ng/ml), fiind obflinutæ în medie la 5 luni dupæ
intervenflie. Recurenfla biochimicæ a apærut la 2 pacienfli
(16,6%) dupæ 8, respectiv 12 luni de la tratament. Repetarea
puncfliei prostatice a confirmat eøecul terapeutic.
Complicafliile au fost repezentate de disfuncflie erectilæ (1 caz,
8,33%), incontinenflæ urinaræ (2 cazuri, 16,6%) remisæ spontan
dupæ 6 luni øi orhiepididimitæ (1 caz).
Concluzii. Tratamentul cu HIFU al pacienflilor cu ADK
prostatæ localizat cu risc scæzut sau intermediar permite
controlul biochimic al afecfliunii. Metoda ræmâne însæ una
investigaflionalæ, fiind necesare studii randomizate pe
termen lung pentru stabilirea indicafliilor øi rezultatelor
acestei tehnici.
46
Initial experience with HIFU
in the treatment of localised
prostate cancer
Results. The mean PSA Nadir value was 0.18 ng/ml (between
0,02 and 3ng/ml), obtained on average 5 months after the
intervention. Biochemical recurrence was observed in 2 out
of the 12 patients (16,6%), after 8 and 12 months,
respectively, after receiving treatment. Treatment failure was
confirmed after repeating the prostate punch biopsies.
Complications: one case of erectile disfunction (8,33%), 2
cases of urinary incontinence (16.6%) which spontaneously
resolved after 6 months, and one case of orchiepididymitis
(8.33%).
Conclusions. HIFU treatment of prostate adenocarcinoma
for patients who present low or intermediate risk allows
biochemical control of the disease. That being said, this
method remains experimental, and it is necessary to conduct
several randomised long-term outcome trials to establish the
indications and results of this technique.
nr. 2 / 2013 • vol 12
1,2
1,2
1,2
1
A. Szöllösi , Á. O. Vida , A. Maier , A. Brad ,
1
1
1
L. Lakatos , Veronica Maria Ghirca , C. Catarig ,
1,2
1
1,2
D. H. Porav , B. Uzun , Orsolya Mártha
1
Spitalul Clinic Judeflean Mures, Clinica de
Urologie Târgu Mureø
2
Role of the TUR-P in management of
the prostate cancer
1,2
1,2
1,2
1
A. Szöllösi , Á. O. Vida , A. Maier , A. Brad ,
1
1
1
L. Lakatos , Veronica Maria Ghirca , C. Catarig ,
1,2
1
1,2
D. H. Porav , B. Uzun , Orsolya Mártha
1
Mures County Hospital, Department of Urology
Târgu Mureø
2
Introducere/Obiectiv: Cancerul de prostatæ este cel mai des
diagnosticat tip de cancer la bærbafli dupæ cancerul bronhopulmonar. În diagnosticarea cancerului de prostatæ, procedura
gold standard este puncflia biopsie prostaticæ ecoghidatæ,
efectuatæ în cazul suspiciunii clinice øi paraclinice. TUR-P-ul reprezintæ principala modalitate terapeuticæ de rezolvare chirurgicalæ
a obstrucfliei subvezicale cauzate de hiperplazia benignæ de
prostatæ øi cancer de prostatæ, dar poate sæ aibæ øi un rol diagnostic, în depistarea accidentalæ a cancerului din prostatæ din
flesutul prostatic rezecat. Scopul lucrærii este de a examina rolul øi
locul rezecfliei transuretrale a prostatei în diagnosticarea øi terapia cancerului de prostatæ la Clinica de Urologie din Târgu Mureø.
Introduction/Objective: Prostate cancer is the most
frequently diagnosed cancer in men after the bronchopulmonary cancer. The diagnosis of prostate cancer the gold
standard procedure is the ultrasound guided prostate biopsy,
performed in case of clinical or laboratory suspicion. TUR-P is
the main therapeutic method used in surgery of bladder outlet
obstruction caused by prostate pathology like BPH or PC, but
may also have a diagnostic role in the incidental detection of
prostate cancer. Aim of this paper is to examine the role and
place of transurethral resection of the prostate in diagnosis and
therapy of prostate cancer in the Urology Clinic Târgu Mures.
Material øi metode: Studiul este retrospectiv, efectuat în perioada 2011-2013 pe un lot de 106 pacienfli (100%) la care s-a practicat TUR-P, cu scop terapeutic pentru HBP, dar la care s-a confirmat ADKP (32 cazuri - 28,301%), la pacienflii diagnosticafli cu
ADKP la care s-a practicat TUR-P de deblocare (23 cazuri 23,943%) øi la cei care s-a practicat TUR-P în scop diagnostic,
având PSA crescut øi repetate PBP negative (50 cazuri - 47,169%).
Materials and Methods: This retrospective study presents
106 (100%) of patient who underwent TUR-P for BOO,
between 2011-2013 in the Clinic of Urology of Targu Mures.
In 32 of cases (28,301%) the histopatological examination
revealed prostate cancer, in 23 cases TUR-P was performed in
already diagnosed prostate cancer cases, while in 50 cases,
patients with elevated PSA level but several prostate biopsies
with negative results, TUR-P was done for diagnostic reasons.
Rezultate: În perioada 2011-2013 s-au practicat 474 de TUR-Puri, din care 106 cazuri (22,362%) se încadrau în criteriile de
alegere a pacienflilor. Pacienflii aleøi în studiu aveau vârstæ între 50
øi 91 de ani, cu vârsta medie de 71,86 ani. Tofli pacienflii au avut
acuze urinare joase de golire. La aceøti pacienfli s-a practicat TURP cu scop terapeutic în 75 de cazuri (70,754%), cu scop terapeutic
øi diagnostic împreunæ cu PBP ecoghidatæ în 26 cazuri (24,528%)
iar în 4 cazuri am practicat øi TUR-V (3,773%). În 21 cazuri, anterior
TUR-P-ului s-a practicat PBP (rezultat negativ) pentru PSA crescut.
În 5 cazuri de HBP, rezultatul histopatologic a confirmat un mic
focar de ADKP a zonei de tranzitie, cu Gleason între 2 øi 6, iar în 8
cazuri cu PSA crescut, dar cu PBP anterioaræ negativæ, s-a
confirmat ADKP a zonei periferice cu Gleason între 7-9.
Concluzie: TUR-P ræmâne intervenflia chirurgicalæ de elecflie
în terapia obstrucfliei subvezicale (HBP+ADKP). Având în
vedere volumul mai mare de flesut prostatic rezultat în urma
efectuærii TUR-P, acesta poate sæ ne ajute în depistarea
cancerului de prostatæ în faze incipiente, la pacienflii cu PSA
normal sau la pacienflii cu PSA crescut, dar la care cu PBP nu
s-a reuøit confirmarea cancerului de prostatæ.
nr. 2 / 2013 • vol 12
PM.3.13. Rolul TUR-P în managementul cancerului de prostatæ
Results: In a period of 2 years from the total of 474 TUR-P, 106
cases (22.362%) fit the selection criteria. Patients selected in this
study were aged between 50 and 91 years, with a mean age of
71.86 years. All patients had obstructive lower urinary
complaints. In these patients we performed TUR-P with
therapeutic purposes in 75 cases (70.754%) with therapeutic and
diagnostic purposes together with ultrasound guided prostate
biopsy in 26 cases (24.528%), and also TUR-V in 4 cases (3.773%).
21 of the cases had several previous negative PBP for increased
PSA. In 5 cases with BPH, histological results confirmed a small PC
with Gleason between 2 - 6 of the transition zone, and 8 cases
with increased PSA but previous negative PBP was confirmed
ADKP of the peripheral zone with Gleason between 7- 9.
Conclusion: TUR-P remains the elective surgical therapy of
the bladder outlet obstruction caused by (BPH + PC).
Resulting a greater volume of prostate tissue can help detect
prostate cancer in its early stages in patients with normal
PSA, or in patients with increased PSA, but that the PBP failed
to confirm prostate cancer.
47
PM.3.14. Cancerul de prostatæ cu
diferenfliere neuro-endocrinæ –
boalæ cu potenflial letal, încæ sub
evaluatæ øi insuficient raportatæ
1
1
1
1
1
1
1
1
C. Surcel , O. Altan , C. Mirvald , C. Gîngu ,
1
1
1
1
C. Pavelescu , V. Olaru , S. Najjar , S. Pætræøcoiu ,
2
1
1
Carmen Savu , M.A. Manu , I. Sinescu
1
Centrul de Uronefrologie øi Transplant Renal
2
Clinica de Anestezie øi Terapie Intensivæ,
Institutul Clinic Fundeni, Bucureøti, România
C. Surcel , O. Altan , C. Mirvald , C. Gîngu ,
1
1
1
1
C. Pavelescu , V. Olaru , S. Najjar , S. Pætræøcoiu ,
2
1
1
Carmen Savu , M.A. Manu , I. Sinescu
1
Center of Uronephrology and Renal Transplantation
2
ICU Department, Fundeni Clinical Institute,
Bucharest
Introducere. Diferenflierea neuroendocrinæ (NED) reprezintæ o
caracteristicæ rar întâlnitæ în cancerul de prostatæ, un numær de
studii indicând faptul cæ aceasta induce rezistenflæ la tratamentul
hormonal, fiind asociatæ cu forme agresive de boalæ.
Background. Neuroendocrine differentiation (NED) is a
feature rarely seen in prostate carcinoma and a number of
studies pointed out that its extent is associated to
hormonetherapy refractory and aggressive disease
Pacient, material øi metodæ. Pacient în vârstæ de 55 de ani este
trimis cætre centrul nostru pentru simptomatologie de tract
urinar inferior, PSA de 7.8 ng/mL. Tuøeul rectal relevæ prostatæ
uøor mæritæ cu nodul la nivelul lobului prostatic stâng. S-au
efectuat ultrasonografie transrectalæ øi puncflie biopsie prostaticæ
cu rezultat histopatologic de adenocarcinom de prostata scor
Gleason 7 (3+4). Examinarea IRM nu se evidenfliazæ adenopatii,
iar la nivelul lobului stâng prostatic se vizualizeazæ o tumoræ færæ
efracflie capsularæ. S-a practicat prostatectomie radicalæ øi
limfodisecflie ilio-obturatorie. La un an postoperator pacientul
este readmis în unitatea noastræ pentru simptomatologie de
tract urinar inferior øi dureri perineale. Valoarea PSA este 0.003
ng/mL, iar examenul IRM ridicæ suspiciunea de recurenflæ localæ la
nivelul anastomozei uretro-vezicalæ. S-a efectuat TUR la nivelul
anastomozei cu rezultat histopatologic ce sugereazæ recidivæ
localæ cu diferenfliere neuroendocrinæ confirmatæ prin
imunohistochimie (IHC). Reevaluarea IHC a specimenului de
prostatectomie relevæ reacflie intens pozitivæ pentru
cromogranina A (CgA) si enolazæ specific neuronalæ (NSE).
Pacientul este supus radioterapiei øi chimioterapiei de salvare
(docetaxel), cu ræspuns slab øi apariflia determinærilor secundare
osoase la 6 luni de la diagnosticarea recurenflei locale.
Patient, materials and methods. A 55-year-old patient was
referred toour center for LUTS and a PSA of 7.8 ng/dL. The DRE
reveals a slightly enlarged prostate with a firm nodule in the
left lobe. TRUS and needle biopsy were performed with a
histopathological result of prostate adenocarcinoma Gleason
7 (3+4). Pelvic MRI examination reveals no pelvic adenopathies
and a prostate confined tumor in the left prostatic lobe.
Radical prostatectomy and standard lymph node dissection
was performed. After one year, the patient presents with LUTS
and perineal pain. The PSA was 0.003 ng/dL. MRI raises a
suspicion of a local recurrence at the anastomosis site.
Cystoscopy and TUR is performed and HP examination
suggests a local recurrence with a neuroendocrine pattern,
which is confirmed through IHC exam. IHC reevaluation of the
primary specimen revealed intense positive staining for
cromogranin and neuron specific enolase. Salvage EBRT and
chemotherapy (docetaxel vs. etoposide+ carboplatin) was
initiated with a poor response, with bone disease diagnosed
six months after local recurrence.
Concluzii. Cancerul de prostatæ cu diferenfliere neuroendocrinæ
este o entitate raræ, asociatæ frecvent cu prognostic slab, iar PSAul la momentul diagnosticului nu poate indica tumorile
prostatice cu diferenfliere neuroendocrinæ. Este necesaræ o
înflelegere profundæ a mecanismelor fiziopatologice pentru a
îmbunatæfli prognosticul acestor pacienfli.
48
Prostate cancer with
neuroendocrine differentiation –
a potential lethal disease, still
underevaluated and unreported
Conclusion. NED in PCa is rare and often associated with
poor prognostic, PSA are diagnosis does seem to predict the
presence NED tumors. Additional understanding of the
pathogenic mechanism is needed in order to improve the
outcome of these patients.
nr. 2 / 2013 • vol 12
J. Aurelian, V. Ambert, V. Jinga, B. Braticevici,
A.G. Grasu, P. Armean
Spitalul Clinic “Prof. Dr. Th. Burghele”
Sexual function in patients with
prostate cancer prior radical
prostatectomy – pilot study
J. Aurelian, V. Ambert, V. Jinga, B. Braticevici,
A.G. Grasu, P. Armean
Clinical Hospital „Prof. Dr. Th. Burghele”
Introducere. Disfuncflia erectilæ este una dintre complicafliile
intervenfliilor chirurgicale pelvine. Importanfla disfuncfliei
erectile postoperatorie, în special dupæ prostatectomia
radicalæ constæ în impactul major pe care îl are asupra calitæflii
vieflii pacienflilor øi mai ales asupra vieflii sexuale a acestora.
Deoarece potenfla preoperatorie reprezintæ un factor determinant al recuperærii funcfliei erectile postoperatorii, pacienflii cu
indicaflie de prostatectomie radicalæ ar trebui sæ fie potenfli.
Introduction. Erectile dysfunction is one of the complications associated with pelvic surgery. Postoperative erectile
dysfunction is very important, mainly after radical
prostatectomy, because it has a major impact on the patients
quality of life and especially on the patients sexual life.
Preoperative potency is a determinant factor for recovery of
postoperative erectile function and therefore the patients
should be potent before radical prostatectomy.
Material øi metodæ. Scopul acestui studiu a fost de a evalua
funcflia sexualæ preoperator, a pacienflilor cu cancer de prostatæ
cu indicaflie de prostatectomie radicalæ. Studiul s-a desfæøurat în
perioada 2012 – 2013 pe 42 pacienfli care au completat
chestionarul EORTC QLQ-PR25, cu o zi înaintea operafliei.
Chestionarul EORTC QLQ-PR25 evalueazæ calitatea vieflii
pacienflilor cu cancer de prostatæ, este validat pentru România
øi confline 6 întrebæri legate de viafla sexualæ a pacienflilor.
Ræspunsul la întrebæri este notat de la 1 la 4, corespunzætor
pentru „deloc”, „puflin”, „destul de mult” øi „foarte mult”.
Material and method. The aim of this study was to assess
preoperative sexual function in patients with prostate cancer
undergoing radical prostatectomy. A total of 42 patients
were evaluated between years 2012-2013 with the EORTC
QLQ-PR25 questionnaire, one day before surgery. The EORTC
QLQ-PR25 questionnaire evaluates the quality of life in
patients with prostate cancer, is validated for Romania and it
contains 6 questions regarding the patients sexual life. There
are 4 possible answers for each question: “not at all”, “a little”,
“quite much” and “very much”.
Rezultate. Vârsta medie a pacienflilor a fost de 64,4 ani (între
49 øi 76 ani), 30 de pacienfli fiind sub 70 ani (71,43%), iar 12
pacienfli (28,57%) având vârsta peste 70 ani. S-a constatat cæ
6 pacienfli (14,28%) au declarat cæ nu suferæ de tulburæri de
erecflie, în timp ce 42% dintre pacienfli (18 pacienfli) au
declarat cæ erecflia este afectatæ „destul de mult” øi „foarte
mult”. La întrebarea legatæ de tulburærile de ejaculare, 16
pacienfli (38,09%) au afirmat cæ nu au întâmpinat tulburæri de
ejaculare, iar 18 pacienfli (42,85%) au apreciat cæ ejacularea
este „puflin” afectatæ. Doar 12 pacienfli (28,57%) au apreciat
actul sexual cu calificativul „foarte mult”, deøi pentru nici
unul dintre ei nu a reprezentat o experienflæ neplæcutæ.
Results. The mean age of patients was 64.4 years (range 49
to 76), with 30 patients (71.43%) under 70 years and 12
patients (28.57%) older than 70 years. 6 patients (14.28%)
declared they did not have previous erectile dysfunction,
while in 42% of patients (18) erection was affected “quite
much” and “very much”. Regarding ejaculatory disorders, 16
patients (38.09%) did not have any ejaculatory related
problems while in 18 patients (42,85%) ejaculation was “a
little” affected. Only 12 patients (28.57%) evaluated their
sexual act with “very much”, although none found it to be an
unpleasant experience.
Concluzii. Disfuncflia erectilæ øi afectarea funcfliei sexuale
reprezintæ complicaflii postoperatorii ale prostatectomiei
radicale. Urmærirea acestor parametrii înainte de intervenflia
chirurgicalæ este insuficient studiatæ, majoritatea pacienflilor
peste 50 ani având deja aceste componente afectate.
nr. 2 / 2013 • vol 12
PM.3.15. Aprecierea funcfliei sexuale
a pacienflilor cu cancer de prostatæ
înaintea prostatectomiei radicale –
studiu pilot
Conclusions. Erectile dysfunction and impairment of sexual
function are postoperative complications of radical
prostatectomy. The preoperative follow-up of these
parameters is insufficient, many of the patients above 50
years of age already presenting impairment of sexual and
erectile function.
49
PM.3.16. Calitatea vieflii în rândul
pacienflilor cu prostatectomie
radicalæ – evaluarea în dinamicæ
a unei serii de pacienfli
M. Hogea, V. Schiflcu, D. Feflea, Alexandra Alb,
V. Buda, T. Calistru, A. Kozan, B. Petrufl
Clinica de Urologie, Institutul Oncologic
„Prof Dr I Chiricuta“ Cluj Napoca
M. Hogea, V. Schiflcu, D. Feflea, Alexandra Alb,
V. Buda, T. Calistru, A. Kozan, B. Petrufl
Department of Urology, Cluj Napoca
„Prof Dr I Chiricuta“ Oncological Institute
Introducere. Prostatectomia radicalæ reprezintæ standardul
de aur în terapia cancerului de prostatæ localizat. În ciuda
morbiditæflii perioperatorii relativ mici, aceastæ intervenflie
asociazæ riscul incontinenflei øi al impotenflei, având un impact
semnificativ asupra calitæflii vieflii pacienflilor. Psihometria
calitæflii vieflii legatæ de sænætate evalueazæ o multitudine de
parametri, prin intermediul unor chestionare validate, în
vederea cuantificærii øi aprecierii evolufliei acesteia în timp.
Introduction. Radical prostatectomy is the gold standard
treatment for localized prostate cancer. Despite a relatively
low perioperative morbidity, this surgery associates a risk for
incontinence and impotence, with a significant impact on
the patient’s quality of life. Quality of life psychometrics
evaluates a multitude of parameters through the use of
validated questionnaires, with the aim of quantifying and
evaluating its evolution in time.
Obiectiv. Evaluarea în dinamicæ a calitæflii vieflii legate de
sænætate a pacienflilor cu prostatectomie radicalæ.
Objective. Dynamic evaluation of health related quality of
life in patients undergoing radical prostatectomy.
Material øi metodæ. În perioada mai 2010 – decembrie 2012,
au fost incluøi 39 pacienfli ce au beneficiat de prostatectomie
radicalæ retropubicæ sau laparoscopicæ în cadrul Institutului
Oncologic “Prof Dr Ion Chiricuflæ” din Cluj-Napoca. Evaluarea
calitæflii vieflii legate de sænætate s-a realizat prin intermediul
chestionarelor validate EORTC QLQ-C30 øi EORTC QLQ-PR-25,
aplicate pre øi postoperator, la 3, 6 respectiv 12 luni de la
intervenflie. Urmærirea medie a fost de 9 luni.
Material and method. 39 patients, undergoing retropubic or
laparoscopic radical prostatectomy at the „Prof Dr Ion Chiricuflæ”
Oncological Institute in Cluj Napoca, between May 2010 and
December 2012, were included in the study. The patients’ health
related quality of life was evaluated using the EORTC QLQ-C30
and EORTC QLQ-PR-25 validated questionnaires, applied
preoperatively as well as postoperatively at 3, 6 and 12 months.
Mean follow-up was 9 months.
Rezultate. Postoperator, la 3 luni de la intervenflie, s-a mæsurat
un scor global de calitate a vieflii 63,49%, scor de funcflionalitate
80,38%, scor de simptomatologie 16,66%. La 6, respectiv 12
luni de la intervenflie, scorul global de calitate a vieflii a fost de
67,94% respectiv 59,25%, scorul de funcflionalitate 84,3%
respectiv 81,92%, scorul de simptomatologie 14,9% respectiv
15,63%. Parametrii de activitate øi funcflionalitate sexualæ,
precum øi cei referitori la complicafliile urinare au fost cei mai
afectafli, independent de metoda chirurgicalæ. Tendinfla
generalæ a parametrilor psihometrici a fost spre îmbunætæflire
progresivæ pe parcursul primului an postoperator.
Results. Postoperatively, at 3 months, a global quality of life
score of 63,49% was measured, with a functionality score of
80,38%, and a symptoms score of 16,66%. At 6, and respectively
at 12 months postoperatively, the global quality of life score was
67,94% respectively 59,25%, functionality score of 84,3%
respectively 81,92%, and a symptoms score of 14,9% respectively
15,63%. Sexual activity and functionality parameters, as well as
urinary complication scores were most affected, regardless of
surgical technique. The overall trend of the psychometric
parameters was towards improvement over the first year.
Concluzii. Impactul asupra calitæflii vieflii pacienflilor este maxim
în primele luni dupæ intervenflie, cu recuperare ulterioaræ
gradualæ. Majoritatea pacienflilor prezintæ un nivel ridicat pe
scara funcflionalitæflii, dar eforturi trebuiesc depuse în limitarea
incontinenflei øi impotenflei postoperatorii, prin îmbunætæflirea
tehnicii chirurgicale, a materialelor utilizate intraoperator
precum øi prin educaflia pacientului øi suport social crescut.
50
Quality of Life among Patients with
Radical Prostatectomy – Dynamic
Evaluation of a Series of Cases
Conclusion. The quality of life impact of surgery is most
significant in the first few months after surgery, with a
gradual recovery afterwards. Most patients show a high level
on the functionality scale, however efforts must be made to
limit postoperative incontinence and sexual dysfunction
through improved surgical technique or materials, or their
quality of life impact through patient education along better
social support.
nr. 2 / 2013 • vol 12
N. M. Chirca, V. A. Iconaru, V. Ambert,
V. Jinga, I. Dragomiriøteanu
Spitalul Clinic de Urologie
“Prof. Dr. Th. Burghele” Bucureøti
Introducere: - evaluarea incidenflei rupturilor de corpi cavernoøi la pacienflii internafli øi operafli in Clinica Th. Burghele în
perioada 1998-2013;
Materiale øi metode: - s-a evaluat un numær de 57 de pacienfli
internafli øi operafli pentru rupturæ de corpi cavernoøi; evaluarea preoperatorie: examen clinic general øi local, examen
bioumoral, ecografie penianæ (transductor superficial); pacienflii au fost operafli în clinicæ, cu excepflia unuia care a
refuzat intervenflia chirurgicalæ; - s-a practicat evacuarea
hematomului øi sutura albugineei øi în 2 cazuri sutura uretrei; control postoperator la 1 lunæ (examen clinic øi ecografic).
Rezultate: - cauze: contact sexual (48), masturbare (4),
traumatisme (5); - localizari: ventro-laterale (24), dorso-laterale
(22), laterale (7), ventrale (4); - rezultate postoperatorii: potenfli
(57), parestezii tranzitorii (9), laterodeviaflie penianæ (49),
scurtare minoræ (31).
Concluzii: - e o urgenflæ urologicæ; - necesitæ evaluare preoperatorie (clinic øi ecografic) øi tratament chirurgical (evacuare
hematom øi sutura rupturii); - rezultatele postoperatorii sunt
favorabile (tofli pacienflii sunt potenfli) cu efecte secundare
minore (parestezii, laterodeviaflie, scurtare minoræ).
nr. 2 / 2013 • vol 12
Penile fracture
N.M. Chirca, V.A. Iconaru, V. Ambert, V. Jinga,
I. Dragomiristeanu
“Prof. Dr. Th. Burghele” Urology Clinic Bucharest
Uretræ, penis
PM.4.1. Rupturæ traumaticæ
a penisului
Introduction: - we wanted to estimate the rate of incidence
for the penile fracture (the rupture of corpus casvernosum)
for the patients treated in “Prof. Dr. Th. Burghele” Urology
Clinic Bucharest from 1998 to 2013.
Material & Method: - we evaluated a number of 57 patients
hospitalized for the rupture of corpus casvernosum; preoperatory evaluation: clinical exam, bioumoral
evaluation, penile echography; - all patients have been
surgically treated except one who refused the intervention. during the operation it was done the evacuation of the
hematoma and the suture of the albugineea and in 2 cases
the suture of the urethra; - postoperative evaluation at 4
weeks (clinical and echography exam);
Results: - induction: during sex practice (48), masturbation (4),
other trauma (5); - localization: anterolateral (24), posterolateral
(22), lateral (7), anterior (4); - postoperatory results: sexually
potent (57), temporary penile hypoesthesia (9), penile lateral
deflection (49), minor penile shortening (31);
Conclusions: - it is a urological urgency; - needs preoperative
evaluation (clinical and echographic exam) and surgically
treatment (hematoma evacuation and the suture of the rupture);
- postoperative results are good (all patients are sexually potents)
with minor side effects (lateral deflection, minor shortening).
51
Uretræ, penis
PM.4.2. Corporoplastie cu grefæ
din Pelvicol TM pentru încurbarea
penisului în boala Peyronie:
Experienfla noastræ
1
1
2
Corporoplasty with Pelvicol TM graft
for penile curvature in Peyronie`s
disease: Our experience
1
1
V. Voinescu , V.Jinga , A. H. Ateia , M. Hurduc
1
Spitalul Clinic Prof. Dr. Theodor Burghele, Bucureøti
2
Medas – Spitalul Clinic Sfânta Maria, Bucureøti
Introducere: Boala Peyronie poate produce o încurbare a
penisului care sæ împiedice contactul sexual sau sæ îl facæ
foarte dificil. Dacæ pacientul are o erecflie bunæ, îndreptarea
penisului se poate face prin corporoplastie. Când curbura
este sub 60 – 70 grade penisul poate fi îndreptat prin tehnici
de plicaturare a albugineei, dar când curbura este mai mare
se preferæ corporoplastia cu grefæ pentru a se evita pe cât
posibil, scurtarea penisului.
52
1
2
1
V. Voinescu , V. Jinga , A.H. Ateia , M. Hurduc
1
Spitalul Clinic Prof. Dr. Theodor Burghele,
Bucureøti
2
Medas – Spitalul Clinic Sfânta Maria, Bucureøti
Introduction: Peyronie`s disease (PD) can produce a
curvature of the penis which prevent sexual contact or make
it very difficult. If the patient have strong sexually induced
erection the penile curvature correction can be done
through corporoplasty. When the curvature is less then 60-70
degrees the penis can be straightened through tunica
plication techniques but when the curvature is greater,
plaque incision or partial excision and grafting is preferred in
order to preserve as much as possible the length of the penis.
Obiective: Prezentarea experienflei noastre privind îndreptarea penisului în boala Peyronie prin corporoplastie cu grefæ
din Pelvicol TM.
Objective: To present our experience of streightening the
penis in PD through Pelvicol TM graft corporoplasty.
Material øi metodæ: În perioada iunie – noiembrie 2012, s-au
prezentat trei pacienfli cu boala Peyronie opritæ în evoluflie
pentru imposibilitatea de a avea contact sexual datoritæ
încurbærii peniene. Vârsta pacienflilor (p) a fost 47 (p1), 54 (p2)
øi 56 (p3) ani, cu erecflie bunæ evidenfliatæ clinic øi prin
ecografie penianæ Doppler dupæ injectare de Caverject.
Încurbarea penianæ a fost dorsalæ de 90 (p1), 75 (p2) øi 85
grade (p3). Tofli pacienflii au avut diverse tratamente
nechirurgicale înainte de prezentare. Îndreptarea penisului sa efectuat prin corporoplastie cu o singuræ grefæ din Pelvicol
TM(4/7 cm). Postoperator, dupæ ziua 10, s-a administrat Cialis
5 mg /zi pânæ la apariflia erecfliilor nocturne spontane.
Material and method: From June to November 2012, three
patients with stable PD has presented for inability to have
sexual intercourse due to penile curvature. The patients(p)
were 47 (p1), 54 (p2) and 56 (p3) years old with good
erections proved by clinical examination and Doppler
ultrasound of the erect penis after Caverject injection. Penile
curvature was dorsal : 90 (p1), 75 (p2) and 85 (p3) degrees. All
the patients had failed conservative therapy. Straightening
of the penis was carried out by corporoplasty with a single
Pelvicol TM graft (4/7 cm). Postoperatively, after day 10, Cialis
5 mg od was given until the emergence of spontaneous
nocturnal erections.
Rezultate: Nu au fost complicaflii postoperatorii. Tofli
pacienflii øi-au reînceput viafla sexualæ dupæ 2 luni. Pacientul
1 a prezentat o reducere a rigiditæflii peniene rezolvatæ prin
administrarea sporadicæ de Cialis 20 mg. La trei luni p1
prezenta o curburæ rezidualæ de 15 grade øi o scurtarea a
penisului de 0,5 cm, p2 avea penisul drept færæ scurtare, iar
p3 o curburæ rezidualæ de 10 grade færæ scurtare.
Results: There have been no post-operative complications.
All patients resume sex life after two month. Patient 1
presented a reduction of penile rigidity solved by sporadic
administration of Cialis 20 mg. After three month p1 had a
residual curvature of 15 degree and a shortening of 0,5 cm,
p2 had straight penis without shortening and p3 a rezidual
curvature of 10 degrees without shortening.
Concluzii: Corporoplastia cu grefæ din Pelvicol TM oferæ
pacienflilor cu încurbarea severæ a penisului datoritæ boli
Peyronie, posibilitatea de a relua activitatea sexualæ, având
un penis drept sau cu o curburæ minoræ “funcflionalæ” cu
erecflia pe care o aveau înainte sau îmbunætæflitæ prin
administrarea de inhibitori de PDE 5.
Conclusions: Pelvicol TM corporoplasty is a good solution
for the patients with severe curvature of the penis in the
stable PD, giving them the possibility to resume sexual
activity with a straight penis or with a minor “functionally”
curvature and the erection they already have or impruved by
PDE 5 inhibitors.
nr. 2 / 2013 • vol 12
Introducere øi obiective: Despre chirurgia uretrei s-a spus
cæ este, deopotrivæ, artæ øi øtiinflæ. De-a lungul timpului au
fost imaginate numeroase modalitæfli de reconstrucflie a
lumenului uretral, cu rezultate mai mult sau mai puflin
mulflumitoare. Mai recent grefa de mucoasæ bucalæ
reprezintæ un standard al abordærii chirurgicale în stricturile
uretrale. Obiectivul acestei prezentæri este de a aduce în
discuflie avantajele øi dezavantajele mucoasei bucale ca
material biologic de substituflie în plastiile uretrale, alæturi de
experienfla clinicii noastre în acest domeniu.
Material øi metodæ: În perioada 2009-2012 au fost
diagnosticafli cu stricturi uretrale recidivante 32 de bærbafli cu
vârsta cuprinsæ între 29 øi 68 ani øi operafli folosind mucoasæ
bucalæ pentru augmentarea lumenului uretral. Diagnosticul
a fost stabilit pe baza examenului clinic, uroflowmetrie,
uretrografie retrogradæ øi micflionalæ, cateterism uretral
explorator, ecografie de aparat urinar øi uretrocistoscopie.
Rezultatele postoperatorii au fost apreciate clinic (satisfacflia
pacientului) øi prin efectuarea uroflowmetriei, uretrografie
retrogradæ øi micflionalæ øi uretrocistoscopie.
Rezultate: Stricturile uretrale au fost clasificate în funcflie de
etiologie, localizare øi lungime. Astfel 13 pacienfli (40,6%) au
prezentat stricturi posttraumatice, 15 pacienfli (46,9%)
stricturi postinflamatorii incluzând øi lichenul plan øi 4
pacienfli (12,5%) cu stricture postcorecflie chirurgicalæ a
hipospadiasului. Lungimea medie a segmentului uretral
stricturat a fost de 4,2 cm. Localizarea stricturii a fost pe
uretra anterioaræ penianæ în 11 cazuri (34,4%), iar 21 pacienfli
(65,6%) cu localizare pe uretra posterioaræ bulbaræ.
Recoltarea mucoasei bucale s-a efectuat de la nivel vestibular
în 30 cazuri (93,7%) øi de la nivel lingual în 2 cazuri (6,3%).
Uretroplastia s-a efectuat în manieræ dorsal onlay graft în 18
cazuri (56,3%), ventral onlay graft în 7 cazuri (21,9%), dorsal
inlay graft la 5 pacienfli (15,6%), øi tubularizare la 2 pacienfli
(6,2%). Durata medie de urmærire a pacienflilor a fost de 7.2
luni. Rezultate bune funcflional øi estetic s-au obflinut la 26
nr. 2 / 2013 • vol 12
Buccal mucosa urethroplasty for
urethral strictures
Uretræ, penis
PM.4.3. Uretroplastia cu mucoasæ
bucalæ pentru stricturi uretrale
Introduction: About urethral surgery was said to be alike, art
and science. Over time there have been many ways imagined
for urethral reconstruction, with results more or less
satisfactory. More recently buccal mucosa graft is a standard
surgical approach for urethral strictures. The objective of this
presentation is to bring into question the advantages and
disadvantages of buccal mucosa grafts as biological
substitution material used in urethral reconstruction,
alongside our department experience in this field.
Material and method: Between 2009-2012 were diagnosed
with recurrent urethral strictures 32 men with age between
29 and 68 years. They were operated using buccal mucosa
graft for urethral lumen augmentation. The diagnosis was
based on clinical examination, uroflowmetry, retrograde and
voiding urethrography, exploratory urethral catheterization,
urinary tract ultrasonography and urethrocystoscopy.
Postoperative results were assessed clinically (patient
satisfaction) and with uroflowmetry, retrograde and voiding
urethrography and urethrocystoscopy.
Results: Urethral strictures were classified according to
etiology, location and length. Thus 13 patients (40.6%) had
posttraumatic strictures, 15 patients (46.9%) had post
inflammatory strictures including lichen planus and 4
patients (12.5%) with postoperative stricture after
hypospadias surgery. The average length of urethral stricture
segment was 4.2 cm. Stricture location was the penile
urethra in 11 cases (34.4%) and 21 patients (65.6%) with
location on bulbar urethra. Buccal mucosa harvesting was
performed from jugal region in 30 cases (93.7%) and from
lingual region in 2 cases (6.3%). Urethroplasty was performed
in dorsal onlay graft manner in 18 cases (56.3%), ventral
onlay graft manner in 7 cases (21.9%), dorsal inlay graft
manner in 5 patients (15.6%) and 2 patients (6.2%) with
tubularized buccal mucosa. The mean duration of patients’
follow-up was 7.2 months. Good functional and aesthetic
results were obtained in 26 patients (81.2%), consisting of
53
Uretræ, penis
pacienfli (81,2 %), constând în micfliuni facile øi jet urinar bun,
menflinute pe perioada de urmærire. Complicaflii imediate au
fost reprezentate de dehiscenfla plægii în 2 cazuri (6,2%) øi
fistulæ urinaræ apærutæ la 1 pacient (3,1%). Complicafliile
tardive au fost reprezentate de stricturi la nivelul
anastomozelor proximale sau distale, apærute la 6 pacienfli
(18,7%), care au necesitat dilataflii uretrale sau uretrotomie
internæ opticæ.
Concluzii: Fiind uøor de recoltat øi de manipulat, cu
proprietæfli biologice, histologice øi mecanice remarcabile,
mucoasa bucalæ reprezintæ o soluflie idealæ pentru corecflia
chirurgicalæ a stricturilor uretrale. Tehnica chirurgicalæ
adecvatæ tipului de stricturæ uretralæ este o cerinflæ esenflialæ
pentru obflinerea unui rezultat funcflional øi estetic
multumitor pentru pacient.
54
good urinary flow maintained during follow-up. Immediate
complications were represented by wound dehiscence in 2
cases (6.2%) and urinary fistula occurred in 1 patient (3.1%).
Late complications were the strictures in the proximal or
distal anastomosis, occurred in 6 patients (18.7%), which
required urethral dilatation or optical internal urethrotomy.
Conclusion: Being easily harvested and handled with
remarkable biological, histological and mechanical
properties, buccal mucosa is an ideal solution for surgical
correction of urethral strictures. Surgical technique suitable
for the type of urethral stricture is an essential requirement
for achieving a functional and aesthetically satisfactory result
for the patient.
nr. 2 / 2013 • vol 12
Multistage urethroplasty
in hypospadias
C. Tica, F.D. Enache, D. Teacæ
Facultatea de Medicinæ, Universitatea OVIDIUS
Constanfla, Disciplina de Chirurgie øi Ortopedie
Pediatricæ
C. Tica, F.D. Enache, D. Teacæ
Faculty of Medicine, „Ovidius“ University of
Constanta, Discipline of Pediatric and
Orthopedic Surgery
Introducere. Hipospadiasul multiplu operat cu fistule øi
cicatrici prezintæ dificultæfli de reconstrucflie øi intræ într-un ciclu
vicios. Sunt necesare douæ intervenflii pentru corecflia prin
aceastæ metodæ. Se reface placa uretralæ cu grefæ din prepufl
sau mucoasæ bucalæ, apoi uretroplastie într-un alt timp.
Rationale. Multiple operated hypospadias with fistulae and
scars with difficulties of reconstruction enter in a vicious circle.
Material øi metodæ. În stadiul unu se realizeazæ excizia
fistulei si cicatricilor, corectarea eventualelor cuduri, grefa
pentru refacerea plæcii uretrale. Stadiul doi reprezintæ
uretroplastia la distanflæ, minimum øase luni.
Rezultate. Hipospadiasul cu fistule, cicatrici multioperat
prezintæ dificultæfli de reconstrucflie, motiv pentru care se
excizeazæ toate flesuturile øi se reface placa uretralæ pentru
uretroplastie secundaræ.
Concluzii. Rezultatele sunt mai bune în urma folosirii acestei
tehnici dec‚t corecflia separatæ a fistulelor, noua placæ uretralæ
fiind un material bun pentru uretroplastie.
nr. 2 / 2013 • vol 12
Uretræ, penis
PM.4.4. Uretroplastia multistadialæ
pentru corecflia hipospadiasului
Objective. Multistage urethroplasty in hypospadias, a method of
treatment for the patients who suffered multiple interventions
with one or more urethral fistulas as complications.
Methods and Results. In first stage it is solved the cudure of
the penis (if present) and it is made a urethral bed from the
prepuce or oral mucosa. In the second intervention the
neourethra is made.
Discussion. Hypospadias with fistulae and multiple scars
presents difficulties in reconstruction. So, it is recommended
to eliminate all the inappropriate tissues and reconstruct the
urethral bed for a second urethroplasty. Results are better
using this technique then the separate reconstruction of the
defects (fistulas), the new urethral bed represents a good
support for urethroplasty.
55
Uretræ, penis
PM.4.5. “Augmented roof
anastomosis” – tehnica de
elecflie pentru stricturile întinse
de uretræ bulbaræ
C. Gîngu, A. Dick, S. Pætræøcoiu, C. Surcel,
V. Zogas, M. Hârza, M. Manu, F. Lupu,
O. Himedan, M. Cræsneanu, Mihaela Mihai,
Liliana Domniøor, I. Sinescu
V. Zogas, M. Hârza, M. Manu, F. Lupu,
Center of Uronephrology and Kidney Transplantation,
Fundeni Clinical Institute, Bucharest
Introducere. Deøi principiile chirurgiei reconstructive
uretrale sunt bine definite, îmbunætæfliri continue ale
tehnicilor øi indicafliilor operatorii reprezintæ obiective de
atins. Stricturile de uretræ se întâlnesc cel mai frecvent la nivel
bulbar, øi au etiologie, lungime øi calibru variabile. De regulæ,
o anastomozæ primaræ termino-terminalæ este indicatæ
pentru stricturile posttraumatice, cu lungime de pânæ la 2
cm, în timp ce stricturile mai întinse au nevoie de o formæ de
uretroplastie de substituflie.
Introduction. Although the principles of reconstructive
urethral surgery are well known, continuous improvements
of the techniques are made and indications are refined by
the urologists. The bulbar urethra is the most common site
for urethral strictures, etiology, length and depth of the
spongiofibrosis being variable. Usually a primary end to end
anastomosis is indicated for up to 2 cm posttraumatic
strictures, while longer ones require a form of substitution
urethroplasty.
Obiective. Scopul acestei lucræri este de a prezenta tehnica
chirurgicalæ øi rezultatele “augmented roof anastomosis”, o
combinaflie între uretroplastia anastomoticæ øi cea de
substituflie.
Objectives. The aim of this paper is to present the
intervention and results of augmented roof anastomosis, a
combined technique between an anastomotic and
substitution urethroplasties.
Materiale øi metodæ. În ultimii 10 ani (2003-2013) am
efectuat 528 de uretroplastii pentru o patologie uretralæ
variatæ. În 224 din cazuri strictura a fost localizatæ la nivel
bulbar, practicându-se 78 de uretroplastii anastomotice
termino-terminale, 114 uretroplastii de substituflie cu grefæ
de mucoasæ bucalæ (GMB) sau grefæ de prepufl, øi 32
uretroplastii tip “augmented roof anastomosis”. Aceastæ
tehnicæ a fost folositæ pentru stricturi de 2-6 cm lungime, øi
presupune mobilizarea extensivæ a uretrei bulbare, cu
stricturotomie dorsalæ øi spatularea a câte 1 cm de uretræ
sanatoasæ la ambele capete. Segmentul de stricturæ strânsæ
(calibru <6 Ch) este rezecat, cu sau færæ transecflia uretrei.
Partea ventralæ este anastomozatæ, în timp ce pe partea
dorsalæ anastomoza este augmentatæ cu grefæ de mucoasæ
bucalæ (în 27 de cazuri) sau de prepufl (în 5 cazuri). O sonda
Foley de 18-20 Ch este menflinutæ timp de 14-21 de zile.
Materials and methods. During the last 10 years (20032013) we have performed 528 urethroplasties for different
urethral pathologies. 224 cases had bulbar urethral strictures,
and we performed 78 direct end to end anastomoses, 114
substitution urethroplasties with BM or prepuce skin graft,
and 32 augmented roof anastomoses. This technique was
used for strictures of 2-6 cm in length, and consists of
extensive mobilization of the bulbar urethra, and dorsal
stricturotomy with 1 cm spatulation of the healthy margins.
The narrow segment of the stricture (< 6 Ch) is resected using
a transecting or nontransecting technique. Then a ventral
strip anastomosis is performed while the dorsal part of the
anastomosis is augmented with buccal mucosa graft (in 27
cases) or prepuce skin graft (in 5 cases). An 18-20 Ch Foley
catheter is left in place for 14-21 days.
Rezultate. Pacienflii au fost externafli dupæ 3-8 zile
postoperator. Doi dintre ei au dezvoltat hematoame perineale suprainfectate, care au necesitat drenaj suplimentar.
56
Augmented roof anastomosis – the
technique of choice for long bulbar
urethral strictures
Results. The patients were discharged between 3 to 8 days
postoperative. Two of them developed infected perineal
hematomas that required further drainage. After a median
18 months follow-up (6-54 months), stricture recurrence was
nr. 2 / 2013 • vol 12
Uretræ, penis
Dupæ o supraveghere medie de 18 luni (6-54 luni), recurenfla
stricturii a fost observatæ la 2 pacienfli (6,2%), proximal de
grefæ øi anastomozæ. Tratamentul a fost UOI (1 caz) sau
replastie cu GMB (1 caz). 30 de pacienfli (93,8%) urineaza cu
peste 15 ml/sec, færæ reziduu postmicflional. Nu am
înregistrat încurbare penianæ ventralæ semnificativæ.
Concluzii. “Augmented roof anastomosis” este o tehnicæ
chirurgicalæ siguræ øi eficientæ. Ea combinæ avantajele
rezecfliei zonei de stricturæ strânsæ cu cele ale uretroplastiei
substitutive, asigurând astfel reconstrucflia uretrei în cazul
stricturilor întinse de uretræ bulbaræ, færæ încurbare
semnificativæ penianæ postoperatorie.
nr. 2 / 2013 • vol 12
registered in 2 patients (6.2%), proximal to the graft and
anastomosis. They were managed through DVIU (1 case) or
redo BMG (1 case). 30 patients (93.8%) are voiding at more
than 15 ml/sec, without residual urine. No significant ventral
penile chordee was registered.
Conclusions. Augmented roof anastomosis is a safe and
effective surgical technique. It combines the advantages of
the resection of the narrow part of the stricture with those of
a dorsal graft augmentation, and ensures the optimal
reconstruction of long bulbar urethral strictures without
significant ventral chordee.
57
Uretræ, penis
58
PM.4.6. Eritroplazia Queirat –
experienfla noastræ
Erythroplasia of Queirat – our
experience
S. Pætræøcoiu, C. Gîngu, A. Dick, L. Militaru,
O. Creflu, M. Hârza, C. Surcel, M. Manu,
A. Iordache, N. Vlaicu, R. Constantiniu,
I. Sinescu
S. Pætræøcoiu, C. Gîngu, A. Dick, L. Militaru,
O. Creflu, M. Hârza, C. Surcel, M. Manu,
A. Iordache, N. Vlaicu, R. Constantiniu,
I. Sinescu
Center of Uronephrology and Renal Transplantation,
Fundeni Clinical Institute, Buchares
Introducere øi obiective. Eritroplazia Queirat (EQ) este o
patologie raræ, întâlnitæ în special la nivelul glandului øi
prepuflului. Ea este clasificatæ ca øi carcinom in situ al penisului
(CIS), iar diagnosticul se pune histopatologic. Progresia spre
carcinom scuamos are loc în aproximativ 30% din cazuri.
Aceastæ lucrare are ca obiectiv prezentarea experienflei noastre
cu aceastæ boalæ raræ. Si subliniazæ faptul cæ orice leziune
eritematoasæ în placa de la nivelul glandului sau prepuflului care
nu se vindecæ ridicæ suspiciunea de EQ øi ar trebui biopsiatæ.
Introduction & Objectives. Erythroplasia of Queirat (EQ) is a rare
condition that mainly occurs on the penile glans or prepuce. This
disease is classified as carcinoma in situ (CIS) of the penis and the
diagnosis is histopathological. Progression to squamous-cell
carcinoma occurs in up to 30% of cases. Our objectives are to
present our experience with this rare disease and to emphasize
that every time that a non-healing erythematous plaque of the
penile glans or prepuce is encountered, EQ should be suspected
and a biopsy should be done.
Materiale øi metode. În perioada ianuarie 2006 øi ianuarie
2013 am înregistrat 9 cazuri de EQ. Leziunea a fost singularæ
la 8 dintre ele (88.88%), øi multiplæ la al 9-lea (11.11%). La 2
pacienfli cu afectare prepuflialæ (22.22%) am efectuat
circumcizie. La ceilalfli 7 pacienfli (77.77%), cu leziuni de
gland, dupæ biopsie s-a aplicat local 5-FU (sub formæ de
cremæ). La 5 dintre aceøtia (71.42%) tratamentul topic a fost
eficient, leziunile dispærând, iar biopsiile ulterioare fiind
negative pentru malignitate. La ultimii 2 pacienfli (28.57%)
boala nu a fost astfel controlatæ øi a fost nevoie de glansectomie øi glandectomie cu grefæ de piele plasatæ pe corpii
cavernoøi pentru un aspect cosmetic superior.
Materials and Methods. During January 2006 – January 2013
we encountered 9 cases of EQ. We registered a single lesion for
8 patients (88.88%) and multiple lesions for the 9 patient
(11.11%). For 2 patients (22.22%) with prepuce lesions we
performed circumcision. For 7 patients (77.77%) with glans
lesions, after biopsy, our first treatment was topical 5-FU (5fluorouracil cream). After the topical treatment, the result was
effective in 5 cases out of 7 (71.42%), the lesions having
disappeared and the biopsies being negative for malignancy.
In 2 patients (28.57%) the lesions were not adequately
controlled and glansectomy was required, with skin graft on
the corporal heads for better functional and cosmetic aspects.
Rezultate. Vârsta medie a fost de 65 de ani (între 52 øi 72 de
ani). Timpul mediu de urmærire post tratament a fost de 36
de luni (între 6 øi 85 de luni). Nu s-au înregistrat complicaflii
imediate sau tardive, nici recurente locale sau la distanflæ.
Circumcizia sau glandectomia cu grefæ de piele pe capetele
corpilor cavernoøi au asigurat un aspect cosmetic bun øi au
asigurat funcflionarea normalæ a penisului.
Results. The median age was 65 years (range 52 – 72 years).
The median follow-up was 36 months (range 6 – 85 months).
No immediate or late complications were registered, with no
local recurrence or metastasis detected. The circumcision
and glansectomy with skin graft on the corporal heads
provided a great cosmetic aspect, and didn’t impair in any
way the functionality of the penis.
Concluzii. Din cauza prezentærii sale ciudate øi a raritæflii sale,
Eritroplazia Queirat nu este diagnosticatæ øi, implicit, terapia
sa nu este instituitæ. Tratamentul local este destul de eficient,
însæ când nu funcflioneazæ, trebuie sæ se recurgæ la excizia
chirurgicalæ a leziunii. Circumcizia øi glansectomia cu grefæ
de piele plasatæ pe corpii cavernoøi sunt intervenflii care
asiguræ controlul oncologic al bolii øi au rezultate estetice øi
funcflionale foarte bune.
Conclusions. Due to its odd look and rarity, Erithropasia of
Queirat is not recognized, and therefore its therapy can’t be
administered. Topical treatment is quite effective, but when it
fails, surgery should be performed. Circumcision and glansectomy with skin graft on the corporal heads are safe oncological
procedures, with good functional and cosmetic results.
th
nr. 2 / 2013 • vol 12
1
1
1
1
Primary Kaposi’s sarcoma of the
penis - A diagnosis that urologists
should consider
1
1
1
1
S. Pætræøcoiu , A. Dick , C. Gîngu , M. Manu ,
3
2
1
R. Olteanu , Monica Hortopan , L. Militaru ,
1
1
1
N. Vlaicu , R. Constantiniu , I. Sinescu
1
Centrul de Uronefrologie øi Transplant Renal
2
Laboratorul de Anatomie Patologicæ, Institutul
Clinic Fundeni, Bucureøti
3
Clinica de Dermatologie, Spitalul Colentina,
Bucureøti
S. Pætræøcoiu , A. Dick , C. Gîngu , M. Manu ,
3
2
1
R. Olteanu , Monica Hortopan , L. Militaru ,
1
1
1
N. Vlaicu , R. Constantiniu , I. Sinescu
1
Bucharest
2
Colentina Dermatology Clinic
3
Pathology Department, Fundeni Clinical Institute
Introducere øi obiective. Sarcomul Kaposi (SK) a fost prima
datæ raportat de Moritz Kaposi în 1872, descriind o patologie
malignæ a endoteliului vascular cu origine multifocalæ, ce
afecteazæ cu precædere extremitatea inferioaræ a corpului.
Prezentarea primaræ la nivelul penisului este raræ, fiind mai
frecvent observatæ la pacienflii cu SIDA. Aceøtia, de cele mai
multe ori, dezvoltæ o formæ agresivæ, iar în 2-3% din cazuri
leziunile peniene de SK sunt prima manifestare a bolii. În
aceastæ lucrare vrem sæ prezentæm douæ cazuri de SK primar
de la nivelul penisului tratate în centrul nostru.
Introductions and Objectives. Kaposi’s sarcoma (KS) was
first reported by Moritz Kaposi in 1872, to describe a
malignant disease of the vascular endothelium that has
multifocal origin and occurs primarily on the lower
extremities. Primary presentation on the penis is rare and it is
more often observed in AIDS patients. They usually develop
an aggressive form, and in approximately 2-3% of cases
penile KS lesions are the first manifestation of the disease. In
this paper we want to present two cases of primary KS of the
penis that were registered in our department.
Materiale øi metode. Din câte øtim noi, mai puflin de 50 de
cazuri de SK clasic, neasociat imunosupresiei (cum ar fi SIDA)
sunt raportate în literaturæ. Primul caz prezintæ un bærbat de
68 de ani, cu tumoræ penianæ de 12 luni. La examenul fizic sau observat øi multiple leziuni la nivelul glandului, în
apropierea meatului urinar øi al øantului coronal, cu
infiltrarea distalæ a corpului penian. Aspectul acestor leziuni
era patognomonic pentru SK, dar tumora semæna mai mult
cu un carcinom scuamos. Pacientul nu prezenta adenopatie
ingino-femuralæ. S-a practicat amputaflie penianæ parflialæ, cu
rezecflia concomitentæ a leziunilor de piele. Examenul
anatomopatologic a arætat margini chirurgicale negative øi
un aspect de SK clasic. La 6 luni de la intervenflie o leziune de
5 mm a apærut pe penisul restant. Sub anestezie localæ,
aceasta a fost excizatæ, iar rezultatul anatomopatologic a fost
tot de SK. La 14 luni postoperator nu au mai fost înregistrate
semne de recurenflæ sau progresie localæ, iar serologia HIV a
fost în fiecare etapæ negativæ. Al doilea caz prezintæ un
bærbat de 40 de ani, cu o leziune penianæ la nivelul glandului
de 16 luni (situatæ în apropierea øanflului coronal, ce fusese
Material and methods. To our knowledge less than 50 cases
of isolated classic KS without any association with AIDS or
immunosuppression were reported in the literature. The first
case: a 68 year old man, with a 12 months history of penile
tumor. Physical examination revealed multiple lesions on the
penile glans near the external meatal and coronal sulcus and
also infiltration of the distal penile shaft. The clinical aspect of
these lesions was patognomonic for KS but the clinical
aspect of the penile tumor was closer to SCC. The
inguinofemoral nodes were not enlarged. We performed
partial penile amputation and also resect the skin lesions.
The anatomopathological report showed negative margins
for all lesions, and an aspect compatible with classic KS. 6
months after the surgical intervention a 5 mm lesion
appeared on the restant penile shaft. Under local anesthesia
we resected it and the histopathological report showed KS
again. At 14 months follow-up no signs of progression or
local recurrence were registered. Also HIV serology was
always negative. The second case: a 40 year old man with a
16 month history of a lesion of the glans (near the coronal
nr. 2 / 2013 • vol 12
Uretræ, penis
PM.4.7. Sarcomul Kaposi primar al
penisului – un diagnostic pe care
urologul ar trebui sæ-l aibæ în vedere
59
Uretræ, penis
deja rezecatæ). Pacientul nu prezenta adenopatie inginofemuralæ la momentul prezentærii. Pe baza examenului
anatomopatologic de la rezecflia anterioaræ, s-a pus
diagnosticul de SK clasic. Cum marginile chirurgicale erau
pozitive, s-a practicat glansectomie, cu reconstrucflia
glandului cu grefæ de piele plasatæ pe corpii cavernoøi. La 24
de luni postoperator nu au fost observate semne de recidivæ
localæ sau la distanflæ, iar serologia HIV a fost negativæ pe
parcursul urmæririi.
Rezultate. Acestea sunt singurele 2 cazuri de SK primar al
penisului documentate øi prezentate în literatura medicalæ
din România. Intervenfliile chirurgicale nu au fost grevate de
complicaflii. Primul pacient a fost externat în ziua a IV-a
postoperator, iar al doilea în ziua a IX-a postoperator.
Rezultatele oncologice au fost bune în ambele cazuri, cu
aspecte funcflionale øi cosmetice pozitive. Istoricul øi testele
efectuate nu au evidenfliat nicio cauzæ de imunosupresie.
Concluzii. Deøi rar, SK izolat al penisului trebuie sæ fie inclus
în diagnosticul diferenflial al leziunilor nespecifice ale
penisului, mai ales când sunt observate macule roøii-purpurii.
Excizia chirurgicalæ este cea mai siguræ metodæ de tratament,
cu morbiditate minimæ. Deøi nu existæ o urmærire
postoperatorie eficientæ, recurenfla localæ este raræ dacæ
leziunea primaræ este complet rezecatæ. Apariflia de leziuni
noi la distanflæ poate fi observatæ dupæ 1-2 ani.
60
sulcus that had previously been excised). The inguinofemoral
nodes were normal at physical examination. Based on the
previous histopathological report, nodular phase of classic
Kaposi’s sarcoma was diagnosed. Positive surgical margins
were also mentioned. We performed glansectomy and penile
reconstruction with skin graft on the corporal heads. 24
months follow-up showed no evidence of local or distant
recurrence, and HIV serology was negative.
Results. These 2 cases are the single ones documented and
reported as primary KS of the penis in Romanian medical
literature. Surgical interventions were uneventful. First
patient was discharged in the 4
th
postoperative day, the
th
second patient was discharged in the 9 postoperative day.
The oncologic outcome was good in both cases, with
positive esthetic and functional results. Medical history and
tests didn’t reveal immunosuppression in any of the patients.
Conclusions. Although rare, isolated KS of the penis must be
considered among the differential diagnosis of non specific
lesions of the penis, especially when red-wine spots are
noted. Surgical excision is the safest method of treatment
with the lowest morbidity. Although no consistent follow-up
data exists, local recurrence is rare if the lesion is completely
removed. Onset of distant new lesions may be observed after
1 - 2 years.
nr. 2 / 2013 • vol 12
1
1
1
Veronica Ghirca , L. Lakatos , B. Uzun ,
1,2
1,2
1,2
O. Vida , C. Todea , A. Szollosi ,
1,2
1,2
C. Chibelean , Orsolya Martha
1
Spitalul Clinic Judeflean Mureø, Clinica de
Urologie, Târgu Mureø
The role of urodynamic
investigations in diagnosis of
voiding disorders on young men
under the age of 40
1
1
1
Veronica Ghirca , L. Lakatos , B. Uzun ,
1,2
1,2
1,2
O. Vida , C. Todea , A. Szollosi ,
1,2
1,2
C. Chibelean , Orsolya Martha
1
Mureø County Hospital, Department of Urology
Târgu Mureø
2
Obiectivul acestei lucræri constæ în evidenflierea rolului
determinærilor urodinamice în stabilirea diagnosticului tulburærilor de evacuare la bærbatul tânær având vârsta sub 40 de ani.
The objective of this study consist in revealed the role of
urodynamics in establishing the diagnosis of voiding
disorders on young men under the age of 40.
Material øi metodæ: Acest studiu a fost realizat pe o
perioadæ de 12 luni (ianuarie- decembrie 2012) la Clinica
Urologicæ din Târgu Mureø unde au fost internafli 1177 de
pacienfli cu retenflie de urinæ. Dintre aceøtia, la un numær de
17 bærbafli cu vârsta sub 40 de ani s-au efectuat determinæri
urodinamice în vederea stabilirii cauzei de retenflie de urinæ.
Materials and method: We performed a retrospective study
over 12 months (January-December 2012) at Department of
Urology from Târgu Mureø where there were 1177 pacients
hospitalised with urinary retention.On 17 pacients under 40
years old was performed urodynamic tests for establishing
the cause of urinary retention.
Rezultate: 4 dintre pacienfli au prezentat în momentul
internærii retenflie completæ de urinæ, fiind purtætori de sondæ
uretro-vezicalæ øi 13 pacienfli, retenflie incompletæ de urinæ
având un rezidiu post-micflional cuprins între 20-250 ml
(evidentiat ecografic). Cauzele retenfliei de urinæ au fost
predominant organice: stricturæ uretralæ în cazul a 5 pacienfli,
stricturæ uretralæ øi stenozæ de meat uretral în cazul a 5 pacienfli,
fimozæ, 2 pacienfli. În aceste cazuri, debitmetria a evidenfliat
valori scæzute ale Qmax, cuprinse între 3,3-16,2. În aceste cazuri
debitmetria a fost suficientæ în stabilirea cauzei organice,
respectiv tipul acesteia. 5 dintre pacienfli au prezentat curbe
debitmetrice normale având un rezidiu post-micflional cuprins
între 80-200 ml. În aceste cazuri, cistomanometria respectiv
determinærile flux-presiune au reuøit sæ stabileascæ existenfla
unei vezici neurogene (dissinergie vezico-sfincterianæ, vezica
hipoactivæ). 6 dintre pacienfli au prezentat infecflie urinaræ
asociatæ, 4 prostatitæ cronicæ øi 1 pacient TBC urogenital. 3
dintre pacienfli erau cunoscufli cu afecfliuni neuro-psihice:
tetraparezæ spasticæ, tulburæri de personalitate, Sdr Down.
Results: 4 of the pacients presented in the moment of
hospitalisation complete urinary retention having a urinary
catheter and 13 pacients presented incomplete urinary
retention having a residual urine between 20-250 ml
(ultrasound revealed). The causes of urinary retention were
majority organics: urethral stricture, 5 pacients, urethral
stricture and urethral meatal stenosis, 5 pacients, phimosis, 2
pacients. In those cases uroflowmetry emphasised low
values of Qmax between 3,3-16,2. In those cases the
uroflowmetry was enough to establish the organic cause and
it’s type. 5 of the pacients presented normal uroflowmetry
curves having a residual urine between 80-200 ml. In those
cases the cistometry and flow-pressure investigations
succeeded to establish the diagnosis of neurogenic bladder
(bladder sphincter dyssynergia, underactive bladder). 6 of
the pacients presented urinary infection associated, 4 of
them cronic prostatitis and one pacient, urogenital TBC. 3 of
the pacients were known having neuro-psychiatric diseases:
spastic paraparesis, personality disorders, Down syndrome.
Concluzii: Determinærile urodinamice reprezintæ metode de
investigaflie, cu un rol esenflial în stabilirea diagnosticului
etiologic al tulburærilor de evacuare la pacienflii tineri. O curbæ
debitmetricæ normalæ la un pacient cu rezidiu post-mictional
nu exclude existenfla unei cauze funcflionale de retenflie urinaræ.
Conclusions: The urodynamics represent methodes of investigation which have an essential role in establishing the etiological
diagnosis in voiding disorders on young men. A normal uroflowmetry curve to a pacient with residual urine do not exclude the
existence of a functionality cause of urinary retention.
2
nr. 2 / 2013 • vol 12
PM.5.1. Rolul determinærilor
urodinamice în diagnosticul
tulburærilor de evacuare la bærbatul
tânær cu vârsta sub 40 de ani
61
62
PM.5.2. Prolaps de boltæ gradul IV
dupæ histertectomie totalæ.
Prezentare de caz
M.C. Berechet, A. Bumbu, G. Bumbu
Spitalul Clinic Judeflean de Urgenflæ Oradea –
Clinica de Urologie, Universitatea din Oradea
Grade IV vault prolapse after total
hysterectomy. Case presentation
M.C. Berechet, A. Bumbu, G. Bumbu
Oradea Emergency Clinical County Hospital –
Urology Clinic, University of Oradea
Introducere. Pacientæ în vârstæ de 41 de ani se interneazæ în
clinicæ pentru prolaps de boltæ grad IV dupæ histerectomie totalæ.
Introduction. 41 years old patient is admitted presenting
grade IV vault prolapse after total hysterectomy.
Material øi metodæ. Se practicæ colposacropexie abdominalæ. La 30 zile postoperator se practicæ colporafia anterioaræ
øi posterioaræ cu refacerea centrului tendinos.
Material and method. Abdominal colposacropexy is performed.
30 days after this procedure, anterior and posterior colporaphy
with straightening of the central tendon is performed.
Rezultate. Evoluflie postoperatorie favorabilæ. Pacienta
ræmâne în observaflie cu recomandarea de a veni la control
urologic periodic. Va continua o terapie localæ cu unguente
de estrogeni øi va evita efortul fizic pe o perioadæ de 3 luni.
Results. Good post-surgery evolution. The patient is
discharged with recommandation for periodic urological
consult, local estrogenic therapy and the necessity to avoid
physical effort for a period of three month.
Concluzii. Având în vedere cæ este o pacientæ tânæræ cu o
viafla sexualæ activæ, se decide o fixare a vaginului prin abord
abdominal øi o colporafie anterioaræ øi posterioaræ clasicæ
spafliat la 30 de zile postoperator.
Conclusions. In this case, considering that it is a young
patient with active sex life, a vaginal reconstruction through
abdominal approach combined after 30 days with anterior
and posterior classic colporrhaphy is decided.
nr. 2 / 2013 • vol 12
1
1,2
1,2
L. Lakatos , C. Chibelean , A. Szöllösi ,
1
1,2
1
1,2
A. Brad , O. Vida , Veronica Ghirca , A. Maier ,
1
1,2
A. Nechifor-Boilæ , Orsolya Mártha
1
Clinica de Urologie Târgu Mureø
2
Universitatea de Medicinæ øi Farmacie
Târgu Mureø-Urologie
Chronic urine retention in women –
urodynamic aspects
1
1,2
1,2
L. Lakatos , C. Chibelean , A. Szöllösi ,
1
1,2
1
1,2
A. Brad , O. Vida , Veronica Ghirca , A. Maier ,
1
1,2
A. Nechifor-Boilæ , Orsolya Mártha
1
Department of Urology Târgu Mureø
2
University of Medicine and Pharmacy Târgu Mureø
Introducere, obiective. Retenflia cronicæ de urinæ cu cât este
mai frecventæ la bærbafli, cu atât este mai raræ la femei.
Examinærile urodinamice (debitmetria, cistomanometria) sunt
determinærile cele mai importante în stabilirea diagnosticului
etiopatogenic al retenfliei cronice de urinæ. În aceastæ lucrare
retrospectivæ am urmærit pacientele diagnosticate în clinica
noastræ cu retenflie cronicæ de urinæ în cursul anului 2012.
Introduction, objectives. Chronic retention of urine, the more
common it is in men, the rarer it is in women. Urodynamic
examinations (uroflow, pressure-flow study, cistometry) are the
most important measurements in determining the
etiopathogenic diagnosis of chronic urine retention. In this
retrospective study we followed patients diagnosed in our
clinic with chronic urine retention over the course of 2012.
Material øi metodæ. În perioada studiatæ (anul 2012) la Clinica
Urologie Târgu Mureø au fost diagnosticafli în total 1177
(100%) de pacienfli cu retenflie cronicæ de urinæ, dintre care 19
au fost femei (1,61%). La toate pacientele incluse în studiu am
efectuat pe lângæ examinærile clinice, paraclinice, imagistice
uzuale (ex. de laborator, ecografie, urografie intravenoasæ) øi
determinæri urodinamice (debitmetrie, studiu flux-presiune,
cistomanometrie), respectiv control uretro-cistoscopic.
Materials and methods. Over the studied period (2012), at the
Urology Clinic of Târgu Mureø, there were a total of 1177 (100%)
patients diagnosed with chronic urine retention, of which 19
were women (1.61%). To all the women patients included in the
study we conducted in addition to clinical examination:
laboratory, common imaging examinations (eg ultrasound,
intravenous urography), urodynamic measurements (uroflow,
pressure-flow study, cistometry) and control urethro-cystoscopy.
Rezultate. Din punct de vedere al etiologiei retenfliilor la
femei, obstrucflia subvezicalæ a fost principala cauzæ, dintre
care stenoza de meat uretral extern a fost prezentæ în 6
cazuri, polip de meat uretral extern 3 cazuri, cistocel 3 cazuri,
stricturæ uretralæ 2 cazuri, abces periuretral 1 caz, TOT în
antecedente la 1 pacientæ. Dintre cauzele funcflionale ale
retenfliei cronice au fost prezente urmætoarele: vezicæ
neurogenæ 6 cazuri, vezicæ hipoactivæ/acontractilæ 4 cazuri,
disinergie detrusoro-sfincterianæ 2 cazuri, vezicæ hiperactivæ
1 caz. Dintre antecedentele personale patologice cele mai
frecvente au fost: afectarea coloanei vertebrale dorsolombare (11), tumorile genitale maligne (8 cazuri),
majoritatea iradiate (cu o singuræ excepflie), litiaza renalæ (4),
tumorile vezicale (3), spinæ bifidæ (2), paraplegie flascæ øi
meningo-mielocel câte un caz, diabet zaharat 2 cazuri.
Results. Examining urine retention in women from an
etiologycal point of view, bladder outlet obstruction was found
to be the main cause, of which external urethral meatus
stenosis was present in 6 cases, external urethral meatus polyp
3 cases, 3 cases of cystocele, 2 cases of urethral stricture, 1 case
of periurethral abscess, TOT in the medical history of one
patient. From among the functional causes of chronic retention
the following were present: 6 cases of a neurogenic bladder,
underactive /non- contractile bladder 4 cases, 2 cases of
detrusoro-sphincter disinergy, one overactive bladder. From
the personal medical history, the most common causes were:
impaired spinal function (11), malignant genital tumors (8
cases), most were irradiated (with one exception), kidney
stones (4), bladder tumors (3), spina bifida (2), flaccid paraplegia
and meningo-mielocel in one case, 2 diabetes cases.
Concluzii: În caz de retenflie cronicæ de urinæ în general, dar mai
ales la femei trebuie sæ acordæm atenflie specialæ pentru
stabilirea diagnosticului øi determinarea conduitei terapeutice,
în care au un rol central investigafliile urodinamice. Diagnosticul
cert al retenfliei cronice de urinæ øi a cauzei acestuia este imposibil/inimaginabil færæ determinæri urodinamice.
Conclusions. For the cases of chronic retention of urine in general, but especially in the case of women special attention must be
payed to the diagnosis and the determination of therapeutic
conduct, where urodynamic investigations have a central role.
Clear diagnosis of chronic urine retention and its causes is
impossible / unimaginable without urodynamic measurements.
nr. 2 / 2013 • vol 12
PM.5.3. Retenflia cronicæ de urinæ la
femei – aspecte urodinamice
63
Tumori vezicale
PM.6.1. Evaluarea citologiei urinare:
comparaflie între citologia urinaræ în
mediu lichid tehnica NOVA prep®vial
test øi citologia urinaræ convenflionalæ
1
2
Evaluation of urine cytology:
a comparison of NOVA prep® vial
test liquid-based cytology and
conventional smear
1
2
Amelia Petrescu , Elena Magheran ,
3
3
3
R.D. Mulflescu , C. Moldovan , V. Mirciulescu ,
3
3
B. Geavlete , E. Constantinescu ,
3
1
F.V. Iordache , V. Jinga
1
Spitalul Clinic “Prof. Dr. Th. Burghele”, Bucureøti,
România
2
“S.C. Gral Medical S.R.L.”, Departamentul de
Patologie, Bucuresti, România
3
Spitalul Clinic “Sf. Ioan”, Bucureøti, România
Amelia Petrescu , Elena Magheran ,
3
3
3
R.D. Multescu , C. Moldovan , V. Mirciulescu ,
3
3
B. Geavlete , E. Constantinescu ,
3
1
F.V. Iordache , V. Jinga
1
“Prof. Dr.Th.Burghele“ Hospital, Bucharest,
Romania
2
“S.C. Gral Medical S.R.L”, Department of
Pathology, Bucharest, Romania
3
“Sfantul Ioan“ Hospital, Bucharest, Romania
Introducere: Eøantioanele de citologie urinaræ sunt, în mod
obiønuit, întâlnite în practica medicalæ øi includ probele
eliminate de pacient, urina recoltatæ prin cateterizare øi spælæturile vezicale, ureterale sau ale pelvisului renal. Examinarea citologicæ a eøantioanelor de urinæ reprezintæ adesea
primul pas pentru screeningul øi diagnosticul cancerului
vezical. Totuøi, existæ o scaræ largæ în ceea ce priveøte
senzitivitatea øi specificitatea diagnosticului carcinoamelor
uroteliale de grad scæzut versus carcinoame uroteliale de
grad înalt parflial datoritæ aspectelor nucleare “liniøtite”
prezentate de leziunile de grad scæzut.
Scopul acestui studiu a fost de a compara aspectele morfologice
øi eficacitatea diagnosticæ a citologiei urinare în mediu lichid
utilizând tehnica NOVA prep®vial cu metoda convenflionalæ.
Introduction: Urine cytology specimens are commonly
encountered in daily practice and include voided/
catheterized urines and washing from bladder, ureters and
renal pelvis. Cytologic examination of urine specimens is often
the initial step for bladder cancer screening and diagnosis.
However, there is a wide range in the sensitivity and specificity
in the diagnosis of low-grade versus high-grade urotelial
carcinomas partially due to the bland nuclear features
exhibited by the low grade lesions. The aim of this study was
to compare the morphologic features and diagnostic efficacy
of NOVA prep® vial test liquid-based cytology (LCB) and
conventional smear (CS) method of testing urine.
Material øi metode: Au fost incluse în studiu un numær de 30 de
cazuri de eøantioane de urinæ colectate în perioada Decembrie
2011 – Septembrie 2012. Toate probele de urinæ au fost în mod
egal testate utilizând atât metoda convenflionalæ prin
centrifugare, cât øi tehnica în mediu lichid NOVA prep®vial test.
Rezultate: Preparatele citologice obflinute prin tehnica în
mediu lichid au demonstrat o mai mare celularitate, un fond
mai curat øi aspecte citomorfologice mai bune.
Material and methods: A total of 30 cases of urine specimens
collected from December 2011 to September 2012 were
included. All specimens were divided equally for the
preparation of NOVA prep® vial test LCB and CS for each case.
Results: NOVA prep® vial test LCB revealed more cellularity,
a cleaner background and a better cytomorphologic features.
Conclusions: The NOVA prep® vial test LCB showed an
improved quality of slides and provided better diagnostic
accuracy, thus NOVA prep vial test could be a first line
screening tool in urinary tract cytology.
Concluzii: Citologia urinaræ în mediu lichid prin tehnica
NOVA prep®vial test a îmbunætæflit calitatea preparatelor
citologice øi a prezentat o mai bunæ acuratefle diagnosticæ.
Astfel NOVA prep®vial test ar putea fi un instrument de
screening de primæ linie în citologia de tract urinar.
64
nr. 2 / 2013 • vol 12
M. Jecu, F. Stænescu, C. Moldoveanu,
P. Geavlete
Obiective: Studiul prospectiv de faflæ, la nivelul unui singur
centru, a avut ca scop evaluarea impactului cistoscopiei
narrow band imaging (NBI) în cazurile de tumori vezicale
non-invazive comparativ cu cistoscopia standard.
Material øi Metodæ: Un numær de 95 pacienfli consecutivi cu
suspiciune de cancer vezical non-invaziv a fost inclus în
studiu. Criteriile de includere au fost reprezentate de
hematurie totalæ, citologie urinaræ pozitivæ øi/sau suspiciune
ecograficæ de tumoræ vezicalæ. În toate cazurile s-a practicat
cistoscopie în luminæ albæ urmatæ de cistoscopie NBI.
Rezecflia standard a fost practicatæ pentru toate tumorile
vizibile în luminæ albæ, în timp ce rezecflia în NBI a fost
aplicatæ doar în cazul leziunilor observate exclusiv în NBI.
Rezultate: Ratele de detecflie pe pacienfli, per global precum øi
în cazurile de CIS au fost semnificativ îmbunætæflite la cistoscopia
NBI comparativ cu cea standard (96,2% versus 87,2% øi 100%
versus 66,7%). De asemenea, în ceea ce priveøte detecflia per
leziuni, modul NBI a evidenfliat o superioritate semnificativæ în
cazurile de CIS, pTa precum øi per global (95,2% versus 61,9%,
93,9% versus 85,2% øi respectiv 94,8% versus 83,9%).
Cistoscopia NBI a descoperit tumori suplimentare într-o
proporflie semnificativ mai ridicatæ în comparaflie cu metoda
standard în cazurile de CIS, pTa, pT1 precum øi per global (55,5%
versus 11,1%, 26,5% versus 10,2%, 30% versus 10% øi respectiv
30,8% versus 10,3%). Rata de margini tumorale pozitive dupæ
rezecflia în luminæ albæ, confirmatæ la examenul histopatologic a
fost de 10,3% dupæ cistoscopia în NBI. Tratamentul instilaflional
postoperator a fost ameliorat datoritæ noii tehnici pentru un
numær semnificativ de pacienfli (16,7% versus 5,1%).
Concluzii: Cistoscopia NBI reprezintæ o alternativæ de
diagnostic valoroasæ în cazurile de tumori vezicale non-invazive, prin îmbunætæflirea vizualizærii øi detecfliei tumorale.
Aceasta a demonstrat o ameliorare semnificativæ a tratamentului cancerului vezical.
nr. 2 / 2013 • vol 12
A prospective comparison between
NBI and standard white light
cystoscopy in cases of non-muscle
invasive bladder cancer
M. Jecu, F. Stænescu, C. Moldoveanu,
P. Geavlete
Tumori vezicale
PM.6.2. Cistoscopia NBI în cancerul
vezical non-invaziv – o comparaflie
prospectivæ cu metoda standard
Objectives: The trial aimed to assess the impact of narrow
band imaging (NBI) cystoscopy in cases of non-muscle
invasive bladder cancer (NMIBC). A single centre, prospective
comparison to the standard white light cystoscopy (WLC)
was performed.
Materials and Methods: A total of 95 NMIBC suspected
consecutive cases were enrolled. The inclusion criteria were
hematuria, positive urinary cytology and/or ultrasound
suspicion of bladder tumors. All patients underwent WLC and
NBI cystoscopy. Standard resection was performed for all lesions
visible in WL and NBI-TURBT for only NBI observed tumors.
Results: The overall NMIBC and CIS patients’ detection rates
were significantly improved for NBI (96.2% versus 87.2% and
100% versus 66.7%). Also, on a lesions’ related basis, NBI
cystoscopy emphasized a significantly superior detection
concerning the CIS, pTa and overall tumors (95.2% versus
61.9%, 93.9% versus 85.2% and 94.8% versus 83.9%,
respectively). Additional tumors were diagnosed by NBI in a
significant proportion of CIS, pTa, pT1 and NMIBC patients
(55.5% versus 11.1%, 26.5% versus 10.2%, 30% versus 10%
and 30.8% versus 10.3%) More over, pathologically
confirmed positive tumoral margins secondary to white light
TURBT were found at the NBI control in 10.3% of the cases.
The postoperative treatment was significantly improved due
to NBI results (16.7% versus 5.1%).
Conclusions: NBI cystoscopy represents a valuable
diagnostic alternative in NMIBC patients, with significant
improvement of tumor visual accuracy as well as detection.
This approach provided a substantial amelioration to the
bladder cancer therapeutic management.
65
Tumori vezicale
PM.6.3. Tehnologia bipolaræ øi NBI
în tumorile vezicale non-invazive
voluminoase
F. Stænescu, M. Jecu, C. Moldoveanu, B. Geavlete,
L. Adou, C. Ene, C. Bulai, P. Geavlete
Obiective: Acest studiu retrospectiv pe 3 ani a evaluat ratele
de recurenflæ pe termen lung ale abordului combinat
cistoscopie NBI øi vaporizare bipolaræ cu plasmæ în cazurile
de tumori vezicale non-invazive voluminoase.
Material øi metodæ: Un numær de 110 pacienfli cu cel puflin o tumoræ vezicalæ non-invazivæ aparentæ peste 3 cm au fost incluøi
în studiu pe baza ecografiei abdominale, tomografiei computerizate øi cistoscopiei flexibile. Cistoscopia standard øi cistoscopia
NBI urmate de vaporizare bipolaræ cu plasmæ au fost efectuate
în fiecare caz. O singuræ instilaflie postoperatorie cu epirubicinæ,
Re-TUR monopolar la 4 sæptæmâni øi 1 an de terapie intravezicalæ
cu BCG au fost efectuate în toate cazurile de tumori non-invazive. Protocolul de urmærire a inclus ecografie, citologie urinaræ
øi cistoscopie standard efectuatæ la fiecare 3 luni pe o perioadæ
de 2 ani øi apoi la 6 luni în al treilea an.
Rezultate: Ratele de detecflie pentru CIS (94,6% versus 67,6%),
pTa (93% versus 82,4%) øi per global pentru tumorile vezicale
non-invazive (94,9% versus 84,3%) au fost semnificativ îmbunætæflite pentru cistoscopia NBI în comparaflie cu cea standard.
Cistoscopia NBI a diagnosticat semnificativ mai multe cazuri de
tumori adiflionale (30,5% versus 9,5%) ca øi margini tumorale
extinse în cazul a 10,5% dintre pacienfli. Vaporizarea bipolaræ cu
plasmæ a oferit rate satisfæcætoare referitoare la stimularea nervului obturator (3,2%) øi perforafliile peretelui vezical (1,1%), ca
øi scæderea medie a hemoglobinei (0.2 g/dl) øi sângeræri postoperatorii (1.1%) reduse. Perioada medie de cateterizare (47,2
ore) øi respectiv de spitalizare (2,9 zile) au fost scæzute. Ratele de
tumori reziduale la Re-TUR, globalæ (6,3%) øi pentru leziunile
ortotopice (4,2%) au fost scæzute pentru abordul cistoscopie
NBI - vaporizare bipolaræ cu plasmæ. Ratele de recurenflæ pentru
tumorile vezicale non-invazive la un an (7,9%), doi ani(11,5%) øi
trei ani (16,3%) au fost reduse pentru grupul de studiu.
Concluzii: Cistoscopia NBI a îmbunætæflit semnificativ acurateflea, în timp ce vaporizarea bipolaræ cu plasmæ a evidenfliat o
eficienflæ chirurgicalæ superioaræ, o morbiditate redusæ øi o recuperare postoperatorie rapidæ diagnosticæ în cazurile de tumori
vezicale non-invazive voluminoase. Tehnica combinatæ NBIvaporizare bipolaræ cu plasmæ a oferit ratæ redusæ de tumori
reziduale la Re-TUR ca øi rate de recurenflæ scæzute la 1,2 øi 3 ani.
POSDRU/107/1.5/S/82839.
66
Bipolar technology and NBI in large
non-muscle invasive bladder tumors
P. Geavlete
Objectives: This three-year retrospective study aimed to
evaluate the long term recurrence rates of combined narrow
band imaging (NBI) cystoscopy and bipolar plasma
vaporization (BPV) in cases of large non-muscle inavsive
bladder tumors.
Patients and Methods: A total of 110 patients with at least one
apparently non-muscle invasive bladder tumor (NMIBT) over 3
cm were included in the trial based on abdominal ultrasound,
computer tomography and flexible WLC. The patients
underwent WLC, NBI cystoscopy followed by BPV. A single
postoperative epirubicin instillation, standard monopolar ReTUR at 4 weeks and one year’ BCG immunotherapy were applied
in all NMIBT cases. The follow-up protocol included ultrasound,
urinary cytology and WLC, performed every 3 months for a
period of 2 years and every 6 months in the third year.
Results: The CIS (94.6% versus 67.6%), pTa (93% versus
82.4%) and overall NMIBT (94.9% versus 84.3%) detection
rates were significantly improved for NBI cystoscopy by
comparison to WLC. NBI diagnosed significantly more cases
of additional tumors (30.5% versus 9.5%) as well as extended
tumoral margins in 10.5% of patients. BPV provided
satisfactory obturator nerve stimulation (3.2%) and bladder
wall perforation (1.1%) rates, as well as reduced mean
hemoglobin drop (0.2 g/dl) and postoperative bleeding
(1.1%). The catheterization period (47.2 hours) and hospital
stay (2.9 days) were shorter subsequent to BPV. The overall
(6.3%) and primary site (4.2%) residual tumors’ rates at ReTUR were decreased for the NBI-BPV approach. The one
(7.9%), two (11.5%) and three (16.3%) years’ NMIBT
recurrence rates were reduced in the NBI-BPV group.
Conclusions: NBI cystoscopy displayed significantly
improved diagnostic accuracy and BPV emphasized superior
efficacy, reduced morbidity and faster postoperative
recovery in large NMIBT cases. The NBI-BPV technique
provided a lower Re-TUR residual tumors’ rate as well as
reduced 1, 2 and 3 years’ recurrence rates.
POSDRU/107/1.5/S/82839.
nr. 2 / 2013 • vol 12
1
1
2
M. D. Vartolomei , R.M. Boja , A. Maier ,
1
2
2
D. Muntoi , Andrada Loghin , Orsolya Martha ,
2
G.A. Dogaru
1
Spitalul Clinic Judeflean Mureø, Clinica de Urologie
2
Universitatea de Medicinæ øi Farmacie,
Disciplina Urologie, Tîrgu Mureø
Introducere/Obiectiv: Cancerul vezical este cea mai frecventæ afecfliune malignæ a aparatului urinar; al 7-lea cel mai
frecvent cancer la bærbafli øi a 17-a cea mai frecventæ
afecfliune malignæ la femei. TUR-V este gold standard
terapeutic în tumorile vezicale superficiale. Scopul lucrærii
este de a identifica frecvenfla recidivei în funcflie de
stadializarea anatomopatologicæ -low grade (G1,G2) øi high
grade (G3).
Material øi metode: Studiul este retrospectiv cu o perioadæ
de urmærire în medie de 38 luni, efectuat pe un lot de 207
pacienflii la care s-a practicat TUR-V în scop terapeutic, în
perioada ian.2006 - dec 2007.
Rezultate: În perioada amintitæ s-au efectuat 207 TUR-V
pentru tumori vezicale superficiale din care 51/207 cazuri
24,63% (T1 sau CIS), 15/207 cazuri 7,24% (G1pTa) , 112/207
cazuri 54,10 % (G2pTa) øi 29/207 cazuri 14 % (G3pTa). Au fost
42/207 (20,28%) femei øi 165/207 (79,72%) bærbafli, cu vârste
cuprinse între 21 ani øi 89 ani, cu o vârstæ medie 64 ani.
Majoritatea pacienflilor s-au prezentat cu hematurie
macroscopicæ. La pacienflii cu tumori vezicale G1pTa s-a
evidenfliat o ratæ a recidivelor de 3/15 (20%) în timp ce la
cazurile cu G2pTa 27/112 (24,10%), iar la pacienflii cu G3pTa
rata recidivei a fost de 16/29 (55,17%). 26/112 pacienfli din
lotul G2pTa au beneficiat de instilaflii cu BCG pânæ la 2 ani.
Am observat o incidenflæ a recidivei de 4 cazuri 15,38% ,
numai la pacienflii care aveau varsta peste 65 ani.
Concluzii: TUR-V reprezintæ varianta optimæ de tratament în
cazul pacienflilor cu tumori vezicale superficiale neinvaziv
muscular. În cazuri bine selecflionate, tratamentul cu BCG
poate scædea semnificativ rata recidivei tumorilor vezicale cu
9,72% în G2pTa. La pacienflii G3pTa, monoterapia TUR-V este
urmatæ de o ratæ ridicatæ a recidivei.
nr. 2 / 2013 • vol 12
Recurrence after TUR-V in nonmuscle invasive bladder tumors
classified pTa
1
1
2
M. D. Vartolomei , R.M. Boja , A. Maier ,
1
2
2
D. Muntoi , Andrada Loghin , Orsolya Martha ,
2
G.A. Dogaru
1
Târgu Mureø
2
Tumori vezicale
PM.6.4. Recidiva dupæ TUR-V în
tumorile vezicale non-muscular
invazive clasificate pTa
Introduction / Objective: Bladder cancer is the most
common cancer of the urinary system, the 7th most common
cancer in men and the 17th most common malignancy in
women. TUR-V is the gold standard therapy in superficial
bladder tumors. The purpose of this paper is to identify the
recurrence rate by staging anatomopathological - low grade
(G1, G2) and high grade (G3).
Material and Methods: The study is a retrospective with
follow-up period averaging 38 months, conducted on a
sample of 207 patients who underwent TUR-V in therapy,
during January 2006 - December 2007.
Results: In the above-mentioned period were performed
207 TUR-V superficial bladder tumors in the 51/207 24.63%
cases (T1 or CIS), 15/207 cases 7.24% (G1pTa), 112/207 cases,
54, 10% (G2pTa) and 29/207 cases, 14% (G3pTa). There were
42/207 (20.28%) women and 165/207 (79.72%) men, aged
between 21 years and 89 years, with an average age 64 years.
Most patients were presented with macroscopic haematuria.
G1pTa bladder cancer patients showed a recurrence rate
3/15 (20%), while in case of G2pTa 27/112 (24.10%), and in
patients with G3pTa recurrence rate was 16/29 (55.17%).
26/112 patients in group G2pTa received BCG instillation 2
years. We observed an incidence of relapse of 4 cases 15.38%,
only in patients who were older than 65 years.
Conclusions: TUR-V is the best choice of treatment in
patients with superficial bladder tumors non-muscle
invasive. In well selected cases, BCG therapy can significantly
decrease relapse rate of 9.72% of bladder tumors in G2pTa.
G3pTa patients, monotherapy TUR-V is followed by a high
rate of recurrence.
67
Tumori vezicale
PM.6.5. Tratamentul instilaflional cu
BCG în cancerul urotelial neinvaziv al
vezicii urinare: eficienfla tratamentului
dupæ 6 ani de experienflæ
Á. O. Vida, A. Szöllösi, D. Muntoi, A. Chiujdea,
Orsolya Mártha
Á. O. Vida, A. Szöllösi, D. Muntoi, A. Chiujdea,
Orsolya Mártha
Târgu Mureø
Introducere: Prin definiflie cancerul vezical superficial este o
tumoræ papilaræ limitatæ la nivelul mucoasei care este
clasificatæ ca øi Ta, tumora care invadeazæ lamina propria este
clasificatæ ca øi stadiu T1 dupæ stadializarea TNM. Ta øi T1 se
pot îndepærta prin rezecflie transuretralæ. Deøi se consideræ cæ
prin TUR-V se pot eradica tumorile vezicale din stadiul Ta, T1,
în multe cazuri acestea recidiveazæ øi pot progresa spre
stadiul de cancer vezical musculo invaziv. Din cauza acestor
observaflii se consideræ necesitatea terapiei adjuvante la tofli
pacienflii cu tumori vezicale superficiale. Instilaflia endovezicalæ cu BCG se consideræ a fi o opfliune viabilæ øi eficientæ
la aceøti pacienfli, cu efecte secundare majore apærute la mai
puflin de 5% dintre pacienfli.
Introduction: By definition the superficial bladder cancer is
a papillary tumor confined to the bladder mucosa which is
classified as Ta, tumors which invades lamina propria are
classified as T1 after TNM staging. Ta and T1 can be removed
by transurethral resection. Although it is considered that the
TUR-V can eradicate bladder tumors in stage Ta, T1, in many
cases they can recur and progress to muscle invasive bladder
cancer. Because of these observations needed to be
considered further adjuvant intravesical therapy in all
patients with superficial bladder tumors. Intravesical
treatment with BCG is considered to be a viable and effective
option in these patients, with major side effects occurred in
less than 5% of patients.
Material øi metodæ: În studiul nostru retrospectiv am
analizat datele pacienflilor cu tumoræ vezicalæ superficialæ
tratafli în clinica noastræ prin TUR-V øi instilaflii endovezicale
pe perioada 2006-2012. Am analizat datele a 208 pacienfli
care au fost selectafli pentru tratament topic cu BCG, dintre
care 135 pacienfli au terminat perioada de tratament. În
clinica noastræ folosim pentru tratamentul instilaflional
soluflia pregætitæ preinstilaflie cu BCG Medac, dupæ schema de
tratament LAMM.
Materials and methods: In our retrospective study we
analyzed the data of patients with superficial bladder
tumors treated in our clinic by TUR-V and intravesical BCG
instillation in period 2006-2012. We analyzed the data of
208 patients who were selected for topical treatment with
BCG, of which 135 patients completed the treatment. In our
clinic we use for treatment BCG Medac after LAMM
regimen.
Rezultate: Vârsta medie a pacienflilor incluøi în studiu a fost 61
ani (20- 85 ani). Raportul pe sexe a fost 3,35:1 (bærbafli:femei),
examenul histopatologic a prezentat urmætoarele tipuri TaG1 38 (28,1%) pacienfli, TaG2 - 70 (51,85%) pacienfli, TaG3 - 15
(11,11%) pacienfli, T1G1 - 2 (1,48%) pacienfli, T1G2 - 2 (1,48%)
pacienfli, T1G3 - 8 (5,92%) pacienfli. Recidive dupæ sau în timpul
tratamentului instilaflional s-au confirmat la 7 (5,18%) pacienfli.
În timpul tratamentului am avut ca øi efecte adverse hematurie
macroscopicæ, febræ (temperaturæ 38-38,5°C), cistitæ, uretritæ la
18 pacienfli (13,3%), respectiv un pacient a prezentat cistitæ TBC.
68
Intravesical treatment with BCG
(Bacillus Calmette-Guérin) in
noninvasive urothelial bladder
cancer: treatment effectiveness after
6 years of experience
Results: The mean age was 61 years (20-85 years), the sex
ratio was 3,35:1 (male: female). The histopathological
examination showed the following results TaG1-38 (28.1%)
patients, TaG2-70 (51.85%) patients, TaG3-15 (11, 11%)
patients, T1G1-2 (1.48%) patients, T1G2-2 (1.48%) patients,
T1G3-8 (5.92%) patients. Recurrences were confirmed in 7
(5.18%) cases. During treatment we observed adverse events
like macroscopic haematuria, fever (temperature 38 to
38.5°C), cystitis, urethritis in 18 patients (13.3%) and one
patient experienced tuberculous cystitis.
nr. 2 / 2013 • vol 12
Tumori vezicale
Concluzii: Tratamentul instilaflional cu BCG la pacienflii
diagnosticafli cu tumoræ vezicalæ superficialæ (Ta, T1) este
viabil øi eficient. Rata de recidivæ apærutæ 5% dintre pacienflii
noøtri aratæ cæ este o metodæ terapeuticæ eficientæ în
prevenirea recidivei respectiv în consolidarea rezultatelor
tratamentului chirurgical.
Conclusions: Treatment with intravesical BCG in patients
diagnosed with superficial bladder tumors (Ta, T1) is viable
and effective. The recurrence rate of 5% in our patients
shows that this therapeutical method is effective in
preventing recurrence, respective in strengthening the
results of surgical treatment.
Confirmare: Aceastæ lucrare este parflial sprijinitæ de
Programul Operaflional Sectorial pentru Dezvoltarea
Resurselor Umane (POS DRU), finanflat din Fondul Social
European øi de cætre Guvernul Român, cu numærul
contractului POSDRU 80641.
Acknowledgement: This paper is partly supported by the
Sectorial Operational Programme Human Resources
Development, financed from the European Social Fund and
by the Romanian Government under the contract number
POSDRU 80641.
nr. 2 / 2013 • vol 12
69
Tumori vezicale
PM.6.6. Calitatea vieflii pacienflilor
cu tumori vezicale
non-musculoinvazive dupæ TURV
øi tratament adjuvant cu BCG
Study regarding the quality of life in
patients with non-muscle invasive
bladder cancer post TURV and
adjuvant treatment with BCG
G. Glück, Manuela Chiriflæ, I. Sinescu
G. Glück, Manuela Chiriflæ, I. Sinescu
Transplantation Fundeni Clinical Institute,
Bucharest
Scop. Terapia intravezicalæ cu BCG adresatæ pacienflilor cu
tumori vezicale nonmusculoinvazive îmbunætæfleøte
considerabil prognosticul bolii, scæzând numærul
recurenflelor øi progresia tumoralæ. Deøi complicafliile majore
ale tratamentului sunt rar descrise în literatura de
specialitate, efectele adverse locale ale instilafliilor
intravezicale cu BCG precum disuria, tenesmele vezicale,
micfliunile frecvente cu senzaflie de imperiozitate pot afecta
calitatea vieflii pacienflilor. Prin acest studiu am dorit sæ
evaluæm impactul efectelor adverse locale ale tratamentului
adjuvant cu BCG asupra calitæflii vieflii pacienflilor.
Material øi metodæ. Simptomatologia øi efectele adverse al
terapiei instilaflionale cu BCG au fost înregistrate de-a lungul
celor 6 sæptæmâni ale tratamentului de inducflie, dupæ
rezecflia vezicalæ transuretralæ, în cazul a 18 pacienfli. Calitatea
vieflii pacienflilor a fost evaluatæ prin intermediul unui
chestionar (QLQ30 – BLS24 EORTC) completat înainte de
începerea tratamentului, în timpul acestuia øi la final.
Rezultate. Interpretarea chestionarelor s-a fæcut într-o
manieræ obiectivæ, datoritæ spectrului larg al efectelor
adverse locale øi al simptomatologiei descrise øi cuprinse în
chestionarul utilizat. Calitatea vieflii pacienflilor a fost descrisæ
ca fiind satisfæcætoare, færæ a fi afectatæ considerabil de-a
lungul tratamentului, deøi au fost prezente efecte adverse
locale. Acestea au fost adecvat corelate cu evaluarea proprie
a pacientului asupra calitæflii vieflii.
Concluzii. Deøi studiul a fost efectuat pe un lot relative mic
de pacienfli, rezultatele obflinute sunt considerate a fi
relevante în ceea ce priveøte calitatea vieflii pacienflilor cu
tumori vezicale nonmusculoinvazive în tratament adjuvant
cu BCG. Concluzia, astfel extrasæ în urma evaluærii pacienflilor,
susfline faptul cæ terapia intravezicalæ cu BCG nu are un
impact major în ceea ce priveøte calitatea vieflii pacienflilor.
70
Purpose. The intravesical BCG therapy in patients with nonmuscle invasive bladder cancer is an important stage in the
treatment of the condition, considerably improving the
outcome and reducing the rate of recurrence and tumoral
progression. Despite of the fact that major systemic side
effects of the therapy are rarely mentioned in the medical
literature, common local side effects like dysuria, frequent
voiding, urgency or bladder spasms can affect the patient’s
quality of life. The aim of this study is to assess the impact of
BCG therapy local side effects on patients’ quality of life.
Material and methods. Symptoms and adverse effects of
the BCG intravesical treatment was recorded before, during
and after the six-weeks induction phase after TUR-BT in the
case of 18 patients. The quality of live was evaluated by using
the EORTC QLQ30 – BLS24 questionnaire which was given
weekly to the patients.
Results. Due to the variety of symptoms and local side
effects encompassed in the questionnaire, the assessment of
the results was done in an objective manner. Patients
described as sastifactory the quality of life and was not
greatly impaired by the intravesical BCG therapy. The side
effects encountered correlated with the patient’s subjective
evaluation.
Conclusions. Although the study was conducted on a
restrained number of patients, that did not interfere with the
results which were considered to be of relevance. The study
concluded that the adjuvant treatment of non-muscle
invasive bladder cancer with BCG instillations does not have
a great impact on the patients’ quality of life, which was
considered to be satisfactory.
nr. 2 / 2013 • vol 12
G. Glück, M. Hortopan, Manuela Chiriflæ,
B. Georgescu, R. Stoica, I. Sinescu
Outcomes of invasive urothelial
cancer, squamous differentiation
carcinoma and squamous carcinoma
after radical cystectomy –
comparative Study
Bucharest
Scop. Evaluarea rezultatelor tratamentului chirurgical la
pacienflii cu carcinom urotelial vs carcinom scuamos impur vs
carcinom scuamos pur dupæ cistectomie radicalæ.
Purpose. To asses the outcome of radical surgery in patients
with urothelial carcioma, squamous differentiation
carcinoma and squamous carcinoma of the bladder.
Pacienfli øi metodæ. Lotul de studiu a cuprins 389 de pacienfli
cu tumori vezicale invazive operafli între 1990-2013, tipurile
histopatologice (HP) tumorale regæsite fiind urmætoarele:
297 de pacienfli au prezentat tumori uroteliale pure (carcinoame tranziflionale), 57 de pacienfli carcinoame uroteliale
impure: carcinom urotelial (52 de pacienfli – carcinom
scuamos; 3 pacienfli - carcinom scuamos cu arii de
adenocarcinom øi 2 pacienfli - adenocarcinom) øi un numær
de 35 de pacienfli cu tumori nonuroteliale. Din lotul de
pacienfli cu carcinoame uroteliale (A) a fost posibilæ
retrasarea evolufliei a 258 de pacienfli. Vârsta medie a fost de
61 de ani, 18 pacienfli fiind de sex femenin. Stadierea a
cuprins 18 cazuri cu pT1, 114 cazuri pT2, 72 de cazuri pT3 øi
54 de cazuri pT4. Un numær de 95 de pacienfli au prezentat
N0, 18 pacienfli N1, 21 pacienfli N2 øi 12 pacienfli N3. În 112
cazuri nu s-a efectuat limfodisecflie. La momentul
diagnosticului 8 pacienfli au fost decelafli cu metastaze.
Gradingul tumoral a cuprins 8 cazuri cu G1, 111 cazuri cu G2,
109 cazuri cu G3 øi 6 cazuri cu G4 (în 24 de cazuri nu s-a putut
retrasa gradingul). Lotul de 52 de pacienfli cu diferenfliere
scuamoasæ (B) a fost constituit din 44 de bærbafli øi 8 femei cu
o vârsta medie de 61,7 ani (între 44-78 ani). Stadierea
tumoralæ a inclus: 1 pacient cu pTa, 1 pacient cu pT1, 6
pacienfli cu pT2, 28 pacienfli cu pT3 øi 16 pacienfli cu pT4.
Dintre aceøtia, 18 pacienfli au avut ganglionii regionali
pozitivi (8 - N1, 10 - N2), 25 de pacienfli au avut N0, iar în 9
cazuri nu s-a efectuat limfodisecflie. Grading-ul tumoral a
cuprins: 12 cazuri - G2, 39 cazuri - G3, 1 caz - G4. Un singur
pacient inclus în acest grup a prezentat metastazæ hepaticæ
la momentul diagnosticului. În lotul de 13 pacienfli (C) cu
carcinom vezical scuamos invaziv (tofli de sex masculin)
Methods. The study included 389 patients with infiltrating
bladder cancer operated between 1990/2013. The histological diagnosis included tumoral variants such as urothelial
carcinoma (transitional cell carcinoma - 297 patients),
divergent differentiation urothelial carcinoma (57 patients:
squamous differentiation - 52 patients, squamous and
adenocarcinoma differentiation - 3 patients, adenocarcinoma differentiation - 2 patients) and nonurothelial
carcinoma (35 patients). Group A – urothelial carcinoma –
included 258 patients(39patients were lost from follow-up).
The mean age of the group was 61 years (18 females and 240
males). The tumoral staging included 18 patients with pT1,
114 patients with pT2, 72 patients with pT3 and 54 patients
with pT4. Lymph nodes involvement was present in 18
patients with N1, 21 patients with N2, 12 patients with N3, 95
cases being identified with N0 and 112 cases with Nx. When
the tumor grading was assessed 8 patients presented with
G1, 111 patients with G2, 109 patients with G3 and 6 patients
with G4. Group B - impure squamous carcinoma – included
52 patients (8 females and 44 males) with a mean age of 61.7
years, range 44-78. Tumoral staging detected was: 1 patient
with pTa, 1 patient with pT1, 6 patients with pT2, 28 patients
with pT3 and 16 patients with pT4. Lymph nodes
involvement was present in 18 patients (8 - N1, 10 - N2), 25
cases being identified with N0 and 9 cases with Nx. When the
tumor grading was assessed 12 patients presented with G2,
39 patients with G3, 1 patient with G4. Group C – pure
squamous carcinoma – consisted of 13 male patients, with a
mean age of 59 years. Staging varied from 1 caz with pT1, 3
cases with pT2, 7 cases with pT3 to 2 cases with pT4. Positive
lymph nodes were detected in 6 patients (N1- 3, N2 - 3), the
nr. 2 / 2013 • vol 12
Tumori vezicale
PM.6.7. Studiu comparativ: carcinom
invaziv urotelial, scuamos pur øi
scuamos impur la pacienfli tratafli
prin cistectomie radicalæ
71
Tumori vezicale
vârsta medie a fost 59 de ani. Stadierea a fost urmætoarea:
pT1 – 1 caz, pT2 – 3 cazuri, pT3 – 7 cazuri, pT4 – 2 cazuri.
Ganglioni pozitivi au fost decelati în 6 cazuri (N1- 3, N2 - 3), cu
N0 - 6 pacienfli øi Nx – 1 pacient. Nu au fost decelate
metastaze la momentul diagnosticului. Gradingul tumoral
raportat a inclus 7 cazuri cu G2 øi 6 cazuri cu G3.
Rezultate. În lotul cu carcinom urotelial, 44% dintre pacienfli
sunt în viaflæ cu o medie de supraviefluire de 73 de luni. 56%
dintre pacienfli au decedat, cu o medie de supraviefluire de 47
luni. În grupul ce a inclus pacienfli diagnosticafli cu carcinom
scuamos asociat carcinomului urotelial urmærirea medie a
fost de 36 de luni (între 1-156 de luni). 17 bolnavi (33%) sunt
în viaflæ la 50 de luni postoperator. În grupul de pacienfli cu
carcinom scuamos pur supraviefluirea medie a fost de 10 luni.
Discuflii. În lotul A 50% dintre pacienfli au prezentat stadiu
local avansat, tumora extinzându-se în afara peretelui vezical.
În lotul B 84,6% dintre pacienfli au fost în stadiu local avansat,
iar în lotul C 70% dintre pacienfli au fost în stadiu local
avansat la prezentare.
rest having N0 (6) or Nx (1). Tumor grading reported: G2 – 7
patients, G3 – 6 patients.
Results. Group A had a median survival rate of 73 months,
44% of the patients survived. Death event was recorded in
56%, median survival period being 48 months. Group B had a
median survival period of 36 month, range 1-156 months. At
50 months postoperatively 33% (17) of the patients are alive.
Finally, group C had a median survival period if 10 months.
Discussions. Advanced local stage disease with bladder wall
extension represented 50% of the cases in group A. The
percentage was even higher in group B – 84.6% and group C
– 70%.
Conclusions. It seems that the squamous component
influences the outcome of the disease due to its biological
characteristics in the evolution of squamous carcinoma, with
advanced local stage disease at diagnosis – late onset of
symptoms and lack of response at adjuvant treatment.
Concluzii. Aparent elementul scuamos decelat la examenul
histopatologic constituie un factor negativ în ceea ce priveøte
prognosticul acestor bolnavi. Evoluflia nefavorabilæ ar putea fi
explicabilæ prin particularitæflile biologice evolutive ale
carcinomului scuamos prin diagnosticul în stadii mai avansate
poate datoritæ unei evoluflii paucisimptomatice, dar øi lipsei
de ræspuns la tratamentul adjuvant.
72
nr. 2 / 2013 • vol 12
G. Glück, Monica Hortopan, Manuela Chiriflæ,
R. Stoica, B. Georgescu, I. Sinescu
Treatment outcome of divergent
differentiation in urothelial bladder
carcinoma – Retrospective study on
57 patients
R. Stoica, B. Georgescu, I. Sinescu
Scop. Evaluarea rezultatelor în tratamentul tumorilor
invazive uroteliale impure ale vezicii urinare.
Purpose. Assessing the therapeutic outcomes of divergent
differentiation in urothelial bladder carcinoma.
Pacienfli øi metodæ. Lotul de studiu a cuprins 389 de pacienfli cu
tumori vezicale invazive operafli între 1990/2012, tipurile
histopatologice (HP) tumorale regæsite fiind urmætoarele: 297 de
pacienfli au prezentat tumori uroteliale pure (carcinoame
tranziflionale), 57 de pacienfli carcinoame uroteliale impure (52
de pacienfli – carcinom scuamos; 3 pacienfli - carcinom scuamos
cu arii de adenocarcinom øi 2 pacienfli - adenocarcinom) øi un
numær de 35 de pacienfli cu tumori nonuroteliale. Lotul de 52 de
pacienfli cu diferenfliere scuamoasæ (A) a inclus 44 de bærbafli øi 8
femei, vârsta medie fiind de 61,7 ani (între 44-78 ani). Stadierea
tumoralæ a fost urmætoarea: 1 caz - pTa, 1 caz - pT1, 6 cazuri - pT2,
28 cazuri - pT3, 16 cazuri - pT4. Dintre aceøtia, 18 pacienfli au avut
ganglionii regionali pozitivi (8 - N1, 10 - N2), 25 de pacienfli au
avut N0, iar în 9 cazuri nu s-a efectuat limfodisecflie. Grading-ul
tumoral a cuprins: 12 cazuri - G2, 39 cazuri - G3, 1 caz - G4. Un
singur pacient inclus în acest grup a prezentat metastazæ
hepaticæ la momentul diagnosticului. Grupul cu mai multe
componente histologice (B) a cuprins 3 pacienfli cu carcinom
urotelial, scuamos øi adenocarcinom: 1 pacient - T3, 2 pacienfli T4, cu interesare ganglionaræ într-un singur caz (1 pacient - N0, 1
pacient - N2 øi 1 pacient - Nx). In toate cazurile gradingul tumoral
a fost G3. A mai fost constituit un grup (C) ce a inclus 2 pacienfli
cu carcinom urotelial øi adenocarcinom (1 caz - T3 øi 1 caz - T4 cu
un caz N0 øi un caz N2; gradingul tumoral - G3).
Methods. The study included 389 patients with invasive bladder
cancer treated between 1990-2012. The histological diagnosis
included tumoral variants such as urothelial carcinoma – 297
patients, variants of urothelial bladder cancer – 57 patients
(squamous carcinoma – 52 patients squamous carcinoma and
adenocarcinoma – 3 patients and adenocarcinoma – 2 patients)
and non-urothelial bladder cancer – 35 patients. The squamous
carcinoma (A) group included 52 patients (8 females and 44
males) with a mean age of 61.7 years. Moreover, the tumoral
staging included 1 patient with pTa, 1 patient with pT1, 28
patients with pT3 and 16 patients with pT4. Lymph nodes
involvement was present in 18 patients (N1 - 8 patients, N2 - 10
patients), 25 cases being identified with N0 and 9 cases with Nx.
When the tumoral grading was assessed 12 patients had G2, 39
patients had G3 and 1 patient had G4. One patient included in
the study presented with liver metastases. In the multiple
histopathologic variants group (B) there were 3 patients with
urothelial, squamous and adenocarcinoma. All patients
presented with G3 disease: 1 patient – T3 and 2 patients – T4,
with adenopathies in one case (N0 – 1 case, N2 – 1 case and Nx –
1 case). The last group (C) included 2 patients with urothelial and
adenocarcinoma: T3 – 1 patient, T4 – 1 patient, with positive
lymph nodes (N2) in only one case. Detected tumor grading was
G3 in all cases.
Rezultate. Urmærirea medie în grupul A a fost de 36 de luni
(1-156 luni). 17 bolnavi (33%) sunt în viaflæ la 50 de luni
postoperator. În grupul B media de supraviefluire a fost de 13
luni, în grupul C de 4,5 luni.
Results. Average survival period in group A was 36 months
(between 1-156 months). About 33% of patients (17) are alive
at 50 months postoperatively. In group B was 13 months,in
group C 4,5 months.
Concluzii. Se pare cæ mixajul carcinom urotelial/diferenfliere
scuamoasæ NU reprezintæ un factor major de agravare a
prognosticului acestor bolnavi, având în vedere rata destul de
bunæ de supraviefluire la 3 ani. Mixajul carcinom urotelial,
scuamos øi adenocarcinom a scæzut supraviefluirea la 13 luni, pe
când mixajul uroteliu adenocarcinom a dus la o supraviefluire
de 4,5 luni. Se pare cæ adæugarea adenocarcinomului schimbæ
total prognosticul acestor bolnavi.
Conclusions. The study revealed the fact that urothelial –
squamous carcinoma association does not worsen the
prognosis if we take into account the survival rate at 3 years.
Despite that, when adenocarcioma component is found
along with the other two components the prognosis is
radically changed, survival period decreasing.
nr. 2 / 2013 • vol 12
Tumori vezicale
PM.6.8. Rezultatele tratamentului
tumorilor invazive uroteliale impure
ale vezicii urinare: analiza unui lot
de 57 de pacienfli
73
Tumori vezicale
74
PM.6.9. Variante histologice ale
tumorilor invazive nonuroteliale de
vezicæ urinaræ øi tratamentul acestora
– rezultate (studiu pe un lot de
36 de pacienfli)
R. Stoica, I. Sinescu
Histological variants of infitrating
nonurothelial carcinoma –
Therapeutic implications. Study
results in 36 patients
Bucharest
Scop. Evaluarea rezultatelor în tratamentul tumorilor invazive nonuroteliale ale vezicii urinare.
Purpose. Assessing the therapeutic implications of
infiltrating nonurothelial carcinoma.
cu tumori vezicale invazive operafli între 1990/2012, tipurile
histopatologice (HP) tumorale regæsite fiind urmætoarele: 297
de pacienfli au prezentat tumori uroteliale pure (carcinoame
tranziflionale), 57 de pacienfli carcinoame uroteliale impure (52
de pacienfli – carcinom scuamos; 3 pacienfli - carcinom
scuamos cu arii de adenocarcinom øi 2 pacienfli adenocarcinom) øi un numær de 35 de pacienfli cu tumori
nonuroteliale (13 pacienfli - carcinom scuamos pur, 9 pacienfli adenocarcinom, 8 pacienfli - carcinom micropapilar, 2 pacienfli
- neuroendocrin øi 3 pacienfli - alte forme carcinosarcom,
leiomiosarcom sau nediferenfliat). Lotul de 35 de pacienfli (9%)
constituie obiectul prezentærii noastre. Vârsta medie a lotului a
fost de 58,7 ani (3 femei øi 32 de bærbafli). Dintre aceøtia, 30 de
pacienfli au beneficiat de cistectomie radicalæ, 4 pacienfli de
cistectomie parflialæ în bloc cu uraca øi ombilicul, un singur
pacient cu neoplasm neuroendocrin beneficiind de
chimioterapie. In cadrul pacienflilor cu tratament chirurgical
derivafliile urinare folosite au fost: ureterosigmoidostomie – 8
cazuri, ureterostomie cutanatæ – 14 cazuri, conduita ileala tip
Bricker – 2 cazuri, cistoplastie de substituflie – 5 cazuri, Indiana
pouch – 1 caz. Cazurile incluse în studiu au prezentat
urmætoarea stadiere: 1 pacient cu pT1, 11 pacienfli cu pT2, 17
pacienfli cu pT3 øi 6 pacienfli cu pT4. Ganglionii limfatici au fost
evaluafli histopatologic în 32 de cazuri cuprinzând: 17 pacienfli
cu N0, 4 pacienfli cu N1, 5 pacienfli cu N2, 5 pacienfli cu N3 si 4
pacienfli cu Nx. Evaluarea gradului de diferenfliere tumoralæ a
decelat 1 caz G1, 18 cazuri G2, 15 cazuri G3 øi 1 caz G4.
Tratamentul adjuvant sub forma chimioterapiei a fost urmat
de 10 pacienfli, dintre care 2 pacienfli au asociat øi radioterapie.
Methods. The study included 389 patients with infiltrating
bladder cancer operated between 1990/2012. The histological
diagnosis included tumoral variants such as pure urothelial
carcinoma (transitional cell carcinoma - 297 patients), impure
urothelial carcinoma (57 patients: squamous differentiation 52 patients, squamous and adenocarcinoma differentiation - 3
patients, adenocarcinoma differentiation - 2 patients) and
nonurothelial carcinoma (35 patients: squamous cell
carcinoma – 13 patients, micropapillary carcinoma – 8
patients, neuroendocrine carcinoma – 2 patients and other
variants like sarcoma, leiomyosarcoma or undifferentiated – 3
patients). The nonurothelial carcinoma group (9%) represents
the main subject of our study. The mean age of the study
group was 58.7 years (3 females and 33 males). From the total
of 35patients, 30 patients had undergone radical cystectomy,
4 patients partial cystectomy en bloc with the urachus and
belly and 1 patient diagnosed with neuroendocrine carcinoma
beneficiated of chemotherapy. In the radical cystectomy
cohort, the urinary diversions consisted of 8
ureterosigmoidostomies, 14 cutaneous ureterostomies, 2
Bricker ileal conduits, 2 neobladders and 1 Indiana pouch.
Moreover, the tumoral staging included 1 patient with pT1, 11
patients with pT2, 18 patients with pT3 and 6 patients with
pT4. Lymphnodes involvement was present in 4 patients with
N1, 5 patients with N2, 5 patients with N3, 17 cases being
identified with N0 and 4 cases with Nx. When the tumoral
grading was assessed 1 patient presented with G1, 18 patients
with G2, 15 patients with G3 and 1 patient with G4. Adjuvant
chemotherapy was given in 10 patients of whom 2 patients
also followed radiotherapy.
nr. 2 / 2013 • vol 12
Tumori vezicale
Rezultate. La prezentare 74% dintre pacienfli au avut stadiu
local avansat, înregistrându-se douæ decese postoperator. În
41% din cazuri s-au decelat ganglioni pozitivi (2 cazuri cu
adenopatie extraregionalæ). In ceea ce priveøte supraviefluirea globalæ, 11 pacienfli (30,5%) sunt în viaflæ cu o medie de
urmærire de 3 ani (având între 4 øi 44 de luni). Supraviefluirea
medie pe tipuri histopatologice este de 27,5 luni pentru
carcinomul scuamos (2 pacienfli), 70 de luni pentru
adenocarcinom (4 pacienfli), 15 luni pentru carcinomul
micropapilar (3 pacienfli) øi 4 luni pentru carcinomul
neuroendocrin. Cei 20 pacienfli care au decedat au înregistrat
o medie de supraviefluire de 10,5 luni (8,8 luni pentru 10
pacienfli cu carcinom scuamos, 20 de luni pentru 3 pacienfli
cu adenocarcinom øi 12,25 de luni pentru 4 pacienfli cu
carcinom micropapilar).
Concluzii. Tumorile nonuroteliale sunt forme de cancer vezical
extrem de agresive cu stadiile de prezentare avansate (stadiul
local avansat a fost prezent la 75% dintre bolnavi, ganglionii
pozitivi în 41% de cazuri). Tratamentul electiv este cistectomia
radicalæ ce trebuie însoflitæ de o limfodisecflie cât mai extinsæ øi
minuflioasæ. Tratamentele adjuvante sunt puflin eficiente.
nr. 2 / 2013 • vol 12
Results. Locally advanced disease was found in 74% of the
patients at time of diagnosis with 2 postoperative deaths.
Adenopathy was present in 41% of the cases which included 2
cases of extra-regional adenopathy. Overall survival was 3
years , between 4 and 44 months, 11 patients (30.5%) currently
being alive. The median survival time was 27.5 months for SCC
(2 cases), 70 months for ADK (4 cases), 15 months for
micropapillary (3 patients) and 4 months for neuroendocrine
carcinoma. A median survival time of 10.5 months was
recorded in all 20 deceased patients (8.8 months – SCC (10), 20
months – ADK (3), 12.25 months – micropapillary (4)).
Conclusions. Nonurothelial bladder carcinoma are rare and
extremely aggressive tumors, with advanced disease at the
moment of diagnosis (75% of the cases, 41% positive
lymphnodes). Standard treatment approach for such cases is
radical cystectomy with elaborate extensive lymphadenectomy.
Adjuvant treatments have a lower response rate.
75
Tumori vezicale
PM.6.10. Carcinomul micropapilar
invaziv al vezicii urinare
G. Glück, Monica Hortopan1, R. Stoica,
Manuela Chiriflæ, I. Sinescu
1
Laboratorul de Anatomie Patologicæ,
1
G. Glück, Monica Hortopan , R. Stoica,
Manuela Chiriflæ, I. Sinescu
Transplantation,
1
Pathology, Fundeni Clinical Institute, Bucharest
Scop. Carcinomul micropapilar al vezicii urinare este o formæ
raræ øi foarte agresivæ a cancerelor uroteliale, ce trebuie
cunoscutæ de urolog pentru a putea adopta o atitudine
terapeuticæ adecvatæ.
Purpose. Micropapillary carcinoma of the urinary bladder is
a rare and aggressive form of urothelial cancers that must be
known by the urologist in order to adopt the most
appropriate treatment pattern.
Pacienfli øi metodæ. Lucrarea de faflæ constituie un studiu
retrospectiv (2009-2012) al unui lot de 8 pacienfli (1 femeie øi
7 bærbafli) cu tumori vezicale invazive care au beneficiat de
cistectomie radicalæ, iar examenul histopatologic a pus
diagnosticul de carcinom micropapilar. Vârsta medie a fost
de 60,2 ani. Derivafliile urinare au fost reprezentate de 5
ureterostomii cutanate, 2 derivaflii Bricker si de o cistoplastie
de substituflie.
Material and methods. A retrospective study had been
undergone over a period of four years, between 2009-2012,
including eight patients (one woman and seven men)
diagnosed with invasive bladder cancer who benefited from
radical cystectomy and in which cases the histopathological
examination confirmed the presence of micropapillary
carcinoma. The mean age reported was 60.2 years. Concerning
the urinary diversion, there was a number of five cutaneous
ureterostomies, two ileal conduits and one neobladder.
Rezultate. Stadierea tumoralæ a fost urmætoarea: T2 - 3
pacienfli, T3 - 3 pacienfli øi T4b - 2 pacienfli. În 6 cazuri pacienflii
au avut diagnosticul anatomopatologic de carcinom papilar
pur, iar pentru celelalte 2 cazuri alæturi de carcinom papilar sau regæsit øi elemente scuamoase, respectiv scuamos øi
adenocarcinom. Ganglionii limfatici au fost negativi în 2
cazuri øi pozitivi la 6 pacienfli: 2 cazuri N1, 2 cazuri N2 øi 2
cazuri cu ganglioni extraregionali. Supraviefluire: 3 pacienfli
sunt în viaflæ la 40, 10 øi 10 luni postoperator, unul cu recidivæ
localæ. 5 pacienfli au decedat având o medie de supraviefluire
de 13,25 luni. Dintre cei 5 pacienfli decedafli 2 erau cu R2, 2 cu
T4N2. 4 pacienfli erau G3.
Concluzii. Carcinomul micropapilar al vezicii urinare, deøi
este o formæ raræ, este extrem de agresiv. Diagnosticarea în
faze precoce øi tratamentul chirurgical radical par sæ fie
singurele soluflii terapeutice pentru aceøti pacienfli.
76
Micropapillary carcinoma of the
urinary bladder
Results. The tumoral stage found was T2 for 3 patients, T3 for
three patients and T4b for two patients. Pure micropapillary
carcinoma was diagnosed in six cases, while the other two
cases presented either squamous elements together with
micropapillary
carcinoma
or
squamous
plus
adenocarcinoma elements. Negative lymph nodes were
present in only two cases, the rest having positive lymph
nodes as follows: two cases of N1, two cases of N2 and two
cases of extra regional adenopathies. 3 patients are alive at
40, 10 and 5 months from surgery,1 with local recurrence.5
patients died with 13,25 months average survival: 2 with R2,
2 T4N2, 4 with G3.
Conclusions. Though micropapillary carcinoma is a rare
form of urothelial cancer, it is very aggressive. Early diagnosis
and radical surgical treatment can lead to acceptable results
regarding survival.
nr. 2 / 2013 • vol 12
G. Glück, Manuela Chiriflæ, B. Georgescu,
Institutul Clinic Fundeni
Gynecologic – Tract Sparing extra
peritoneal radical cystectomy
in female patient
G. Glück, Manuela Chiriflæ, B. Georgescu,
Bucharest
Scop. Prezentarea rezultatelor cistectomiei radicale extraperitoneale într-un caz de carcinom urotelial vezical la femeie.
Purpose. To present the outcome of extraperitoneal radical
cystectomy in a case of urothelial bladder cancer in woman.
Material øi metode. Pacientæ în vârstæ de 77 de ani,
diagnosticatæ în altæ unitate sanitaræ cu tumoræ vezicalæ
infiltrativæ este adresatæ clinicii noastre în vederea
tratamentului de specialitate. Se practicæ cistectomie
radicalæ retrogradæ extraperitonealæ cu prezervarea uterului,
anexelor, vaginului øi a uretrei, cu crearea de ureterostomie
cutanatæ bilateral splintatæ “în fleavæ de puøcæ”.
Patients and methods. A 77 years old female is diagnosed with
invasive bladder cancer in another Urology Department and
referred to our Clinique for definitive treatment. The patient
undergoes radical cystectomy, retrograde sparing of the uterus,
adnexa, vagina and distal urethra with cutaneous ureterostomy.
Rezultate. Durata intervenfliei chirurgicale a fost de circa 150
minute, cu pierdere sanguinæ minimæ (250 ml), cu reluarea
tranzitului intestinal în a 2-a zi postoperator øi externarea
pacientei la 6 zile de la data intervenfliei chirurgicale.
Concluzii. Cistectomia radicalæ extraperitonealæ cu prezervarea
organelor genitale interne la femeie reprezintæ o proceduræ
terapeuticæ viabilæ în cadrul tumorilor vezicale infiltrative, ce
oferæ atât siguranflæ oncologicæ, cât øi o îmbunætæflire semnificativæ a calitæflii vieflii pacientului postoperator. Tehnica chirurgicalæ practicatæ derivæ din protocolul operator al cistectomiei
radicale la bærbat, unde putem mefliona o cazuisticæ importantæ.
nr. 2 / 2013 • vol 12
Tumori vezicale
PM.6.11. Cistectomia radicalæ
retrogradæ extraperitonealæ cu
prezervarea organelor genitale
interne la femeie
Results. Operating time expanded to 150 minutes, with minimal
blood loss (250 ml), resumption of bowel activity second day
postoperatively, the patient going home 6 days after surgery.
Conclusions. Gynecologic – tract sparing extra peritoneal
radical cystectomy in female patient proofs its value as a viable
surgical procedure for invasive bladder cancer, offering both
oncological safety and improved quality of life postoperatively. The surgical technique derives from the same
procedure undergone in men with successful outcomes.
77
Tumori vezicale
PM.6.12. Profilul de risc
histopatologic al pacienflilor cu
tumori invazive de vezicæ urinaræ
Risk profile of histopathological
findings with invasive bladder
tumors patients
Transplantation, Fundeni Clinical Institute, Bucharest
Scop. Evaluarea rezultatelor cistectomiei radicale în tratamentului tumorilor uroteliale pure invazive ale vezicii urinare comparativ
cu cele impure (carcinom urotelial + altæ variantæ histologicæ), respectiv cele nonuroteliale (scuamos, adenocarcinom, micropapilar, neuroendocrin, sarcoame etc).
Pacienfli øi metodæ. Lotul de studiu a cuprins 389 de pacienfli cu tumori vezicale invazive operafli între 1990-2013, tipurile histopatologice (HP) tumorale regæsite fiind urmætoarele: 297 de pacienfli au prezentat tumori uroteliale (TU) pure (carcinoame tranziflionale), 57 de pacienfli carcinoame uroteliale impure (carcinom urotelial + carcinom scuamos - 52 de pacienfli; TU+carcinom scuamos
cu arii de adenocarcinom - 3 pacienfli øi TU+ adenocarcinom - 2 pacienfli) øi un numær de 35 de pacienfli cu tumori nonuroteliale.
Rezultate:
Histologie
Nr. pacienfli
Stadiu local
TU puræ
TU impuræ
258 + 39
57
50%
68%
35
74%
Tumoræ
nonurotelialæ
Histologie
TU
TUimpuræ
Tumoræ
nonurotelialæ
Nr pt
258+ 39
57
35
N+
avansat
34%
35%
(10 Nx)
G3-4
Urmærire Medie
44%
75%
49,5
31 luni
41%+
50%
18,6
(4-44 luni)
Nr pt
TCC+SCC
Tu+SCC+ADK
TCC+ADK
SCC
ADK
mP
NE
Cs.s,G4
52
3
2
13
9
8
2
1
În viaflæ
(luni)
44% – 73luni
30%
17 pts
50 luni
30%
11 pts
3 ani
În viaflæ
44%-73 luni
17(33%) la 50 luni
0
0
27,5 (2ps)
70 (4pt)
20 (3)
4,5
0
Tabel 1.
Decedafli
56% – 44 luni
70%
35 pts
(5 x)
18 luni
70%
24 pts
10,5 luni
Tabel 2.
Decese (luni)
56% -44 luni
25
13
4,5
8,8 luni-11 pts
20 luni-3 pts
13.25-5 pt
4luni
Concluzii. Tumorile nonuroteliale sunt forme de cancer vezical extrem de agresive, cu stadii de prezentare avansate (stadiul local
avansat a fost prezent la 74% dintre bolnavi, ganglionii pozitivi în 41% de cazuri). Pe o scalæ a agresivitæflii acestor tumori, pe primul
loc se situeazæ cele neuroendocrine (celule mici) øi sarcoamele. Sunt urmate de carcinomul cu celule scuamose øi cel micropapilar.
De asemenea, mixajul carcinom urotelial+carcinom scuamos+adenocarcinom sau carcinom urotelial+adenocarcinom par sæ fie
cele mai agresive.
78
nr. 2 / 2013 • vol 12
Tumori vezicale
Purpose. Assessment of disease aggressiveness in invasive bladder cancer patients with radical cystectomy according to tumor
histopathology.
Methods. The study included 389 patients with invasive bladder cancer treated between 1990-2013. The histological diagnosis
included 297 cases of urothelial carcinoma (TCC); 57 patients with divergent differentiation urothelial carcinoma (urothelial and
squamous cell carcinoma – 52 patients; urothelial, squamous and adenocarcinoma – 3 patients; urothelial and adenocarcinoma –
2 patients) and 35 patients with non-urothelial carcinoma.
Results.
Histology
No patients
258+ 39x
Locally
advanced stage
50%
Divergent
differentiation
57
68%
35%
(10 Nx)
75%
31
(1-156)
Non-urothelial
carcinoma
35
74%
41%+
50%
18,6 (4-44 months)
TCC
Histology
TCC
Divergent
differentiation
Non-urothelial
carcinoma
N+
G3-4
34%
44%
No patients
258+ 39
57
35
Median
survival (months)
49,5
Table 1.
Death event
Alive
44% -73 months
30%
17 pts
50 months
30%
11 pts
3 years
No patients
Alive months/pts
TCC+SCC
52
44%=73 months
17 (33%) at 50 months
Tu+SCC+ADK
TCC+ADK
SCC
ADK
mP
NE
Cs.s,G4
3
2
13
9
8
2
1
0
0
27,5 (2pts)
70 (4pts)
20 (3pts)
4,5
0
56%
44 months
70%
35 pts (5x)
18 (1-60)
70%
24 pts
10,5 months
Table 2.
Death event
(months)
56% 44 months
25p-23m
5x
13m
4,5m
8,8 months-11pts
20 months-3pts
113,25 months-5 pts
4 months
Conclusions. Nonurothelial bladder carcinoma are rare and extremely aggressive tumors, with advanced disease at the moment
of diagnosis (75% of the cases, 41% positive lymph nodes). Needed to be underlined is the fact that neuroendocrine tumors,
followed by sarcomas were the most aggressive neoplasia. Also, squamous cell carcinoma and micropapillary carcinoma come to
complete the scale of aggressiveness. Combination of tumor variants such as urothelial carcinoma+squamous cell
carcinoma+adenocarcinoma or urothelial carcinoma+adenocarcinoma tend to be more aggressive than all other tumors.
nr. 2 / 2013 • vol 12
79
Tumori vezicale
PM.6.13. Impactul histopatologiei
tumorilor vezicale asupra
rezultatului chimioterapiei
adjuvante dupæ cistectomie radicalæ
Scop. Evaluarea rezultatelor chimioterapiei adjuvante în
funcflie de tipul histopatologic al tumorii vezicale la pacienflii
cu cistectomie radicalæ.
Purpose. To evaluate the role of adjuvant chemotherapy in
different bladder tumors histologies in patients with radical
cystectomy.
cu tumori vezicale invazive, operafli între 1990-2010. Pe baza
rezultatului examenului histopatologic s-a fæcut indicaflia de
tratament adjuvant (chimioterapie øi/sau radioterapie).
Dintre cei 70 de pacienfli, 51 au avut carcinom urotelial, 12
carcinom urotelial impur, 5 carcinom scuamos, 1 carcinosarcom øi 1 micropapilar. In cadrul lotului de pacienfli cu
carcinom urotelial (1 femeie øi 50 de bærbafli) cu vârsta medie
de 59 de ani, stadierea a fost urmætoarea: pT1-2 cazuri, pT216 cazuri, pT3-21 cazuri, pT4-12 cazuri; N0-18 cazuri, N1-10
cazuri, N2-10 cazuri, N3-2 cazuri, Nx-11 cazuri; G2-11 cazuri,
G3-37 cazuri, G4 -3 cazuri. În grupul de pacienfli cu carcinom
urotelial øi diferentiere scuamoasæ stadierea a fost: pT1 -1
caz, pT2 -2 cazuri, pT3-4 cazuri, pT4 5 cazuri; N0 -2 cazuri, N12 cazuri, N2-5 cazuri, N3 – 1 caz, Nx - 2 cazuri; G2-2 cazuri, G311 cazuri. În cadrul lotului cu carcinom scuamos, tofli pacienflii
au fost de sex masculin, cu o vârstæ medie de 56 de ani.
Stadializarea a cuprins urmatoarele grupe: pT1 -1 caz, pT2-1
caz, pT3-2 cazuri, pT4-1 caz; N0-1 caz, N1-2 cazuri, N2-1 caz,
Nx-1 caz; G2-3 cazuri, G3-2 cazuri. Pacientul cu carcinosarcom a prezentat boala pT3aNxM0G3, iar cel cu carcinom
micropapilar pT2bN1M0G3.
Material and methods. The study included 70 patients with
invasive bladder cancer treated between 1990-2010. Adjuvant
chemotherapy was indicated accordingly to the histopathological diagnosis (chemotherapy +/- radiotherapy). The
patients were diagnosed with urothelial carcinoma (51),
urothelial carcinoma with divergent differentiation (12),
squamous cell carcinoma (5), carcinosarcoma (1) and
micropapillary carcinoma (1). The urothelial carcinoma group
(1 female and 50 males) had a median age of 59 years with the
following staging: : pT1-2 cases, pT2-16 cases, pT3-21 cases,
pT4-12 cases; N0-18 cases, N1-10 cases, N2-10 cases, N3-2
cases, Nx-11 cases; G2-11 cases, G3-37 cases, G4 -3 cases. All
patients with squamous cell carcinoma were males, with a
median age of 56 years. Stage disease was classified as: pT1 -1
case, pT2-1 case, pT3-2 cases, pT4-1 case; N0-1 case, N1-2
cases, N2-1 case, Nx-1 case; G2-3 cases, G3-2 case. The
carcinosarcoma and micropapillary carcinoma had
pT3aNxM0G3, respectively pT2bN1M0G3 disease.
Rezultate. În cadrul grupului cu carcinom tranziflional, media
de supraviefluire a fost de 37 de luni. 8 pacienfli sunt în viaflæ
cu o medie de supraviefluire de 88 de luni (16-216 luni), 41 de
pacienfli decedând, supraviefluirea medie fiind de 27 de luni
(2 øi 156 de luni) - 5 decese nononcologice. 2 pacienfli sunt
pierdufli din evidenflæ. Ceilalfli 36 de pacienfli au înregistrat 16
recidive locale, 13 au dezvoltat metastaze, iar în 7 cazuri nu
se cunoaøte cauza decesului. În grupul urotelial impur media
80
The impact of bladder tumor
histology on adjuvant
chemotherapy after radical
cystectomy
Results. Median survival period was 37 months for the TCC
group. 8 patients are alive with a median survival period of
88 months (range 16-216 months), while 41 are dead with a
median survival period of 27 months (range 2-156 months) –
5 non-oncological deaths. 2 patients were reported lost from
follow up. Moreover, 16 patients developed local recurrences
and 13 patients metastases. Death event of unknown cause
was recorded in 7 cases. Urothelial carcinoma with divergent
differentiation had a 33 months median survival period, 3
patients being alive with a median survival period of 71
months and 8 being dead with a median survival period of 18
months. One patient was lost from follow up. Squamous cell
nr. 2 / 2013 • vol 12
Tumori vezicale
de supraviefluire a fost de 33 de luni. Un numær de 8 pacienfli
au decedat cu o medie de supraviefluire de 18 luni, 3 fiind în
viaflæ, cu o medie de supraviefluire de 71 de luni. Un singur
pacient a fost pierdut din evidenflæ. Grupul ce a inclus cazurile
de carcinom scuamos a raportat o medie de supraviefluire de
17,2 luni. Pacientul cu carcinosarcom a decedat la 6 luni de la
operaflie, iar pacientul diagnosticat cu carcinom micropapilar
a decedat la 24 de luni prin recidivæ localæ.
Discuflii. În evaluarea rolului tratamentului la aceøti bolnavi
trebuie sæ flinem seama de stadiu local avansat la prezentare
(65% în grupul urotelial pur) øi de gradul de diferenfliere
tumoralæ (78% G3 øi G4). Mai mult, 7 pacienfli au fost cu R2. În
grupul impur 75% (9 pacienfli) au fost diagnosticafli în stadiu
local avansat, 91% având G3, iar în grupul scuamos 60% (3
pacienfli) au fost în stadiu local avansat.
Concluzii. Cele mai agresive tumori se dovedesc a fi cele
scuamoase (medie de supraviefluire-17,2 luni), totuøi superior
faflæ de media de 12,7 luni a cazurilor de carcinom scuamos (13
pacienfli) care nu au beneficiat de tratament adjuvant. Pe
urmætorul loc în aceastæ clasificare urmeazæ pacienflii cu tumori
mixte, (uroteliu+scuamos), având o medie de supraviefluire de
33 de luni øi cele uroteliale cu 37 de luni supraviefluire.
nr. 2 / 2013 • vol 12
carcinoma group had a median survival period of 17.2
months. Death event occurred at 6 months after surgery for
carcinosarcoma and at 24 months for micropapillary
carcinoma by local recurrence.
Discussions. Advanced disease (65% in urothelial carcinoma
group) and tumor grading (78% G3 and G4) must be taken
into consideration when adjuvant treatment is
recommended. Moreover, 7 patients had R2 disease.
Urothelial carcinoma with divergent differentiation group
reported 75% cases (9 cases) of locally advanced disease,
91% having G3 tumor grading, while the SCC groupreported
60% cases (3 patients) of locally advanced disease.
Conclusions. SCC proofs to be the most aggressive disease
(median survival period – 17.2 months), adjuvant treatment
offering life prolonging (12.7 months median survival period
for patients without chemotherapy). Going further, divergent
differentiation offered a better prognosis (33 months median
survival period), while urothelial carcinoma had the longest
survival period (37 months median survival period).
81
Tumori vezicale
PM.6.14. Adenocarcinomul de
uracæ – este omfalectomia
necesaræ în toate cazurile?
1
1
Urachal adenocarcinoma
– is omphalectomy
necessary in all cases?
1
C. Mirvald , Alexandra Dobrescu , C. Surcel ,
1
1
1
C. Gîngu , C. Pavelescu , A. Iordache ,
1
1
2
V. Olaru , S. Pætræøcoiu , Carmen Savu ,
1
1
M.A. Manu , I. Sinescu
1
2
Clinica de Anestezie øi Terapie Intensivæ,
1
1
Introducere. Adenocarcinomul de uracæ reprezintæ
aproximativ 1% din totalul neoplasmelor vezicale, cu
dezvoltare extravezicalæ, având ca punct de plecare restul
embrionar al uracæi. Tradiflional, tratamentul constæ în
cistectomie parflialæ cu rezecflia în bloc a ligamentului uracal,
domului vezical øi ombilicului. Nepracticarea omfalectomiei
a fost asociatæ cu un control inadecvat al bolii øi un risc mai
crescut al recurenflei locale.
Introduction. Urachal carcinoma represents approximately
1% of all bladder tumors, frequently involving the midline or
dome of the bladder due to direct extension from the urachal
ligament. Traditionally, a partial cystectomy with en-bloc
resection of the urachal ligament with the bladder dome and
umbilicus is recommended to appropriately control the
disease. Leaving the umbilicus in place provides inadequate
control and has been associated with a higher risk of relapse.
Scop. Obiectivul acestui studiu este de a evalua rezultatele
oncologice a pacienflilor cu adenocarcinom de uracæ la care
s-a practicat cistectomie parflialæ cu rezecflia în bloc a
ligamentului uracal cu prezervarea ombilicului.
Aim. The objective of this study is to evaluate the
oncological outcomes of patients with urachal carcinoma, in
which cystectomy with en-bloc resection of the urachal
ligament with the bladder dome, leaving the umbilicus in
place, has been performed.
Material øi metodæ. Am realizat un studiu retrospectiv al
cazurilor de adenocarcinom uracal tratate în clinica noastræ
în perioada 2002-2012. Criteriile de includere au fost:
localizarea tumorii pe CT/IRM în domul vezical, cu excluderea
unei neoplazii primare extravezicale, absenfla cistitei
glandulare sau chistice øi prezenfla unei mase palpabile
suprapubiene øi/sau la tuøeul bimanual. Am înregistrat 13
cazuri ce întrunesc aceste criterii. În toate cazurile s-a
practicat cistectomie parflialæ cu rezecflia ligamentului uracal
øi a domului vezical, cu prezervarea ombilicului øi
limfodisecflie iliobturatorie standard. Rezultatele oncologice
au fost evaluate folosind curbe Kaplan-Meyer.
Rezultate. Mediana de vârstæ a pacienflilor a fost de 55 de
ani. Perioada medie de urmærire a fost de 3.5 ani, iar rata de
supraviefluire la 5 ani 77.5%. 38% (5 pacienfli) au fost pierdufli
în timpul urmæririi, færæ semne de recidivæ la ultimul control.
82
1
C. Mirvald , Alexandra Dobrescu , C. Surcel ,
1
1
1
C. Gîngu , C. Pavelescu , A. Iordache ,
1
1
2
V. Olaru , S. Pætræøcoiu , Carmen Savu ,
1
1
M.A. Manu , I. Sinescu
1
Transplantation
2
ICU Department, Fundeni Clinical Institute,
Bucharest
Material and method. We conducted a retrospective
analysis of all urachal cases treated in our Department
between 2002-2012. Inclusion criterias were: location in the
bladder dome on CT/MRI with exclusion of a primary
neoplasia outside the bladder, absence of cystitis glandularis
or cystitis cystica, and the presence of a palpable suprapubic
mass. We recorded 13 patients matching these criteria. A
partial cystectomy with en-bloc resection of the urachal
ligament with the bladder dome with preservation of the
ombilicus was performed in all cases with standard pelvic
LND. We evaluated the oncologic outcomes using KapplanMeier curves.
Results. Median age was 55.0 years. The median follow-up
period was 3.5 years and the survival rate at 5 years was
77.5%. 38% (5 patients) were lost to follow-up, with no
nr. 2 / 2013 • vol 12
Tumori vezicale
Nu au fost înregistrate recurenfle la nivel ombilical. 53.8% (7
pacienfli) au fost asimptomatici, fiind trimiøi în Centrul nostru
pentru evaluarea unei mase hipogastrice descoperite
incidental la CT/IRM. Cele mai frecvente simptome au fost
hematuria øi simptomatologie urinaræ joasæ de stocare. 23%
(3 pacienfli) au prezentat metastaze la momentul
diagnosticului. Variabilele asociate cu supraviefluirea pe
termen lung au fost prezenfla marginilor pozitive (p = 0.004)
øi absenfla adenopatiilor (p = 0.01). 30% (4 pacienfli) au primit
tratament adjuvant cu 5-fluorouracil øi cisplatin, cu boalæ
stabilæ dupæ 2 ani.
Concluzii. Rezecflia cu margini de siguranflæ oncologicæ
asiguræ o supraviefluire pe termen lung satisfæcætoare.
Rezecflia ombilicului este inutilæ în cele mai multe cazuri, fiind
rezervatæ stadiilor avansate. Tratamentul adjuvant
chimioterapic are efect asupra determinærilor secudare, însæ
impactul asupra supraviefluirii globale este neclar.
nr. 2 / 2013 • vol 12
relapse at the last presentation. No umbilical recurrences
were recorded. 53.8% (7 patients) were asymptomatic, being
referred to our center for evaluation of a sub-ombilical mass
discovered at CT/MRI. The most common complaints were
hematuria and storage symptoms. 23% (3 patients) had
metastatic disease at presentation. Covariates associated
with long-term survival were negative surgical margins (p =
0.004) and absence of nodal involvement (p=0.01). 30% (4
patients) received adjuvant chemotherapy with 5fluorouracil and cisplatin with stable disease after 2 years.
Conclusions. Long-term survival following radical resection
is high. The resection of the umbilicus is unnecessary in most
cases, it can be reserved for locally advanced disease.
Adjuvant chemotherapy can induce objective responses in
metastatic disease but it’s effect on global survival is not yet
demonstrated
83
Tumori vezicale
PM.6.15. Managementul uretrei la
bolnavii cu tumori vezicale
infiltrative tratafli cu cistectomie
radicalæ
Management of urethral
involvement/reccurence in patients
with invasive bladder cancer treated
by radical cystectomy
G. Glück, Manuela Chiriflæ, R. Stoica,
B. Georgescu, I. Sinescu
G. Glück, Manuela Chiriflæ, R. Stoica,
B. Georgescu, I. Sinescu
Scop. Evaluarea rezultatelor uretrectomiei asociate cistectomiei
radicale în raport cu pacienflii cu cistectomie radicalæ la care uretrectomia s-a efectuat din diverse motive în timp operator
secundar.
Pacienfli øi metodæ. Pe o perioadæ de 23 de ani (1990-2013)
au fost luafli în evidenflæ 29 de pacienfli cu uretrectomie: 21 de
pacienfli (Grup A) au beneficiat în aceeaøi øedinflæ operatorie
de cistectomie radicalæ øi uretrectomie, în timp ce 8 pacienfli
(Grup B) au beneficiat de uretrectomie (grup B1 – 4 pacienfli),
respectiv emasculaflie (grup B2 – 4 pacienfli) la distanflæ de
intervenflia chirurgicalæ primaræ pentru recurenflæ uretralæ cu
sau færæ invazie de corpi cavernoøi. Indicaflia de uretrectomie
asociatæ cistectomiei a fost pusæ de prezenfla proliferærii
tumorale la nivelul uretrei, tumoræ vezicalæ infiltrativæ la
nivelul colului vezical, tumoræ vezicalæ infiltrând prostata sau
uretra prostaticæ, Cis difuz, tumoræ vezicalæ voluminoasæ
musculoinvazivæ papilaræ. În grupul B uretrectomia a fost
efectuatæ atunci când s-a decelat tumoræ uretralæ apærutæ la
distanflæ de cistectomie (1 caz cu margine uretralæ pozitivæ) øi
în 4 cazuri prin prezenfla de metastaze în corpii cavernoøi.
Rezultate. În grupul A au fost 18 pacienfli cu vârsta medianæ
de 62 de ani, urmærifli pe o perioadæ medie de 37 luni (între 6
øi 93 luni). În grupul A nu s-au înregistrat recidive locale de-a
lungul urmæririi. Metastaze la distanflæ au fost diagnosticate
în 3 cazuri. Dintre aceøtia, 9 pacienfli au decedat (6 decese
non-oncologice øi 3 decese oncologice), perioada medie de
urmærire fiind de 32 luni (între 6 øi 68 luni). In prezent 9
pacienfli sunt în viaflæ, cu o perioadæ medie de urmærire de 42
luni (între 7 øi 90 luni). În grupul B, la care vârsta medianæ a
fost 65 de ani, a inclus douæ subgrupuri: grupul B1 – 4
pacienfli cu uretrectomie postcistectomie, dintre care 3 au
decedat (perioada medie de urmærire cistectomieuretrectomie - 22 luni, între 1 øi 48 luni/perioada medie de
84
Purpose. To assess the outcome of urethrectomy associated
with radical cystectomy versus urethrectomy alone after
radical cystectomy.
Patients and Methods. The study included 26 patients with
urethrectomy treated between 1990-2013: in 18 cases (Group
A) the urethrectomy was performed in the same operative
session, while for 8 patients (Group B) urethrectomy (group
B1) or emasculation (group B2) was performed after
cystectomy, during a secondary intervention for urethral
recurrence with or without corpora cavernosa invasion.
Results. Group A consisted of 18 patients with a median age
of 62 years and an average follow-up of 37 months (ranging
from 6 to 93 months). In group A, no local recurrences were
reported over the whole follow-up period. Three patients
developed distant metastases. From the total of 18 patients,
9 patients died (6 non-oncological deaths and 3 oncological
deaths) with an average follow-up of 32 months (between 668 months), while 9 patients are still alive at median followup of 42 months (between 7-90 months). In group B, the
median age was 65 years, with 4 patients undergoing
secondary urethrectomy (B1) - 3 deaths reported
(urethrectomy-cystectomy median follow-up of 22 months,
between 1-48 months/urethrectomy-death event median
follow-up of 19 month, between 8- 36 months). In group B2
there were 4 patients with emasculation (B2) of whom 3 died
(urethrectomy-emasculation median follow-up was 7,25
months, between 3-11 months/emasculation-death event
median follow-up was 15 months, between 9-24 months).
Discussions. After radical cystectomy, many recurrences
occur at the site of the remaining urethra, therefore careful
follow-up must be conducted. Urethral recurrence is
responsible for a morbidity and mortality similar to the
nr. 2 / 2013 • vol 12
Tumori vezicale
urmærire uretrectomie-deces - 19 luni, între 8 øi 36 luni) øi
grupul B2 - 4 pacienfli cu emasculaflie, dintre care 3 pacienfli
au decedat (perioada medie de urmærire cistectomieemasculaflie - 7,25 luni, între 3 øi 11 luni/perioada medie de
urmærire emasculaflie-deces - 15 luni, între 9 øi 24 luni).
Discuflii. Dupæ cistectomia radicalæ, uretra restantæ trebuie
luatæ în consideraflie în evaluarea postoperatorie, deoarece
constituie un sediu important de recurenflæ tumoralæ, cu o
morbiditate øi mortalitate similaræ cu cea a bontului ureteral
restant dupæ nefrectomie subtotalæ pentru tumorile de
uroteliu înalt.
remaining uretheral stump after subtotal nephrectomy for
upper urinary tract tumors.
Conclusions. We underline the fact simultaneous radical
cystectomy and urethral extirpation proofs its utility when
performed in high-risk patients for urethral recurrence after
radical cystectomy. Although the association of urethral
excision extends the primary intervention by 25-30 minutes,
it is technically easier to perform with a reduced blood loss,
and a better oncological outcome.
Concluzii. Datele de mai sus aratæ utilitatea exerezei uretrale
concomitente cu cistectomia la pacienflii cu risc de recidivæ
uretrale dupæ cistectomie radicalæ. Asocierea cistectomie
radicalæ-uretrectomiei prelungeøte intervenflia chirurgicalæ
cu circa 25-30 de minute, cu o abordare tehnicæ mult mai
facilæ, o pierdere sanguinæ mult redusæ øi un rezultat
oncologic mult mai bun.
nr. 2 / 2013 • vol 12
85
Tumori vezicale
PM.6.16. Ureterostomia cutanatæ
(USC) dupæ cistectomia radicalæ: în
ce condiflii mai este acceptabilæ
astæzi?
1
1
1
A. Brad , A. Nechifor-Boilæ , Veronica Ghirca ,
1
1
2
A. Szollosi , L. Lakatos , Corina Golovei ,
3
1
1
Angela Borda , D. Porav , Orsolya Martha ,
1
C. Chibelean
1
Clinica Urologie, Spitalul Clinic Judeflean Mureø
2
Compartiment ATI-Urologie, Spitalul Clinic
Judeflean Mureø
3
Laborator Anatomie patologicæ, Spitalul Clinic
Judeflean de Urgenflæ Tg. Mureø
1
1
1
A. Brad , A. Nechifor-Boilæ , Veronica Ghirca ,
1
1
2
A. Szollosi , L. Lakatos , Corina Golovei ,
3
1
1
Angela Borda , D. Porav , Orsolya Martha ,
1
C. Chibelean
1
The Urology Clinic, Mureø County Clinical Hospital
2
Anesthesia and Intensive-Care Unit, Mureø
County Clinical Hospital
3
Pathology laboratory, Mureø County Emergency
Clinical Hospital
UMF Tg Mures Clinica de Urologie
Obiectivul studiului a fost acela de a determina condifliile în
care USC poate fi utilizatæ cu eficienflæ clinicæ apropiatæ de
cea a derivafliei urinare cutanate incontinente (Bricker)
consacratæ în practica curentæ.
Objective: to determine the conditions under which CSU
may be performed with a clinical efficiency close to that of
cutaneous urinary incontinent bypass (Bricker) used in
current practice.
Materiale øi metodæ: Studiul s-a desfæøurat retrospectiv, pe
o perioadæ de 2 ani (1 Ianuarie 2011-1 Ianuarie 2013). Am
evaluat 23 pacienfli cu diagnosticul de tumoræ vezicalæ ≥T2,
18 dintre aceøti pacienfli beneficiind de cistectomie radicalæ
cu USC, iar 5 doar de derivaflia urinaræ cutanatæ unilateralæ în
contextul inoperabilitæflii tumorii primare.
Nu am inclus în studiu pacienflii cu cistectomie radicalæ care
au beneficiat de alt tip de derivaflie urinaræ.
Materials and method: The study was retrospectively
Rezultate: La 9 pacienfli s-a efectuat cistectomie radicalæ cu
USC drept ( 50%), 2 pacienfli cu USC stâng, 7 pacienfli cu USC
“în fleavæ de puøcæ”. Dintre pacienflii cu USC unilateralæ (øi
cistectomizafli) la 7 a fost necesaræ nefrectomia concomitentæ
a rinichiului controlateral, unul avea rinichi drept unic
congenital, iar 3 au venit în serviciul nostru cu rinichi unic
chirurgical (nefrectomizafli anterior pentru diverse patologii).
Mediana vârstei pacienflilor din lotul studiat a fost de
62,82±8,33 ani, 21 pacienfli fiind de sex masculin (91,3%).
Controlul efectuat la pacienflii cu USC unilateralæ la 6
sæptæmâni a permis sevrajul stentului ureteral în toate
cazurile (100% catheter free). Doar la 2 pacienfli dintre cei cu
USC în fleavæ de puøcæ, stenturile ureterale s-au putut extrage
la 6 sæptæmâni (28,57% catheter free). Aceeaøi situaflie s-a
menflinut la controalele de la 3 øi 6 luni.
86
Cutaneous ureterostomy (CUS) after
a total cystectomy: when still
acceptable nowadays?
st
st
performed over a two year period (1 of January 2011 – 1 of
January 2013). The study group was composed of 23 patients
hospitalized in our clinic, diagnosed with ≥T2 bladder tumor;
on 18 of these patients total cystectomy was performed with
CUS, while on 5 of them only unilateral urinary diversion was
performed, cystectomy being non-feasible.
The patients with radical cystectomy with other type of
urinary derivation were not included in this study.
Results: The total cystectomy was performed on 9 patients
with right cutaneous ureterostomy (50%), on 2 patients with
left cutaneous ureterostomy and on 7 patients with right
“double-barrel” ureterostomy. On 7 of the patients with
single cutaneous ureterostomy (and with cystectomy) the
contralateral kidney was removed, one of the patients had
congenital solitary kidney on right side and 3 patients were
hospitalized with solitary kidney after surgery (previously
nephrectomized).
The mean age of the patients in the study group was
62,82±8,33 years, 21 of them were male patients (91,3%).
The check-up conducted after 6 weeks on the patients with
single cutaneous ureterostomy allowed the withdrawal of
the ureteral stent in all cases (100% catheter free). Among
nr. 2 / 2013 • vol 12
Tumori vezicale
Concluzii: USC poate fi øi astæzi varianta de electie de
derivaflie urinaræ la pacienflii cu BMI sub 25, cu rinichi unic. La
pacienflii vârstnici cu comorbiditæfli asociate sau speranflæ de
viaflæ micæ datoritæ stadiului neoplazic avansat se poate
recurge la USC, chiar bilateral, cu necesitatea menflinerii
cateterelor ureterale în peste 70% din cazuri.
nr. 2 / 2013 • vol 12
the patients with double-barrel cutaneous ureterostomy, the
withdrawal of both ureteral stents after 6 weeks was possible
on only 2 patients (28.57% catheter free). The same situation
maintained on 3 and 6 months follow-up.
Conclusions: CUS may be the first choice option today for
urinary bypass in patients with BMI below 25, with solitary
kidney. In elderly patients with associated comorbidities or
lower life expectancy due to an advanced neoplastic stage
CUS may be used, even bilaterally, with the necessity of
maintaining ureteral catheters in over 70% of the cases.
87
Tumori vezicale
PM.6.17. Uretrostomia perinealæ – o
metodæ de acces rapid pentru TURV
în cazurile care asociazæ stricturi
întinse de uretræ penianæ
Perineal urethrostomy – a fast and
safe access for TURB in cases with
associated long penile urethral
strictures
C. Gîngu, M. Cræsneanu, A. Dick, S. Pætræøcoiu,
C. Surcel, F. Lupu, M. Hârza, M. Manu,
V. Cerempei, O. Himedan, Mihaela Mihai,
C. Gîngu, M. Cræsneanu, A. Dick, S. Pætræøcoiu,
C. Surcel, F. Lupu, M. Hârza, M. Manu,
V. Cerempei, O. Himedan, Mihaela Mihai,
Bucharest
Introducere øi obiective. TURV ræmâne standardul în
tratamentul tumorilor vezicale superficiale, dar uneori
accesul transuretral este dificil sau imposibil datoritæ unor
stricturi întinse de uretræ penianæ. În aceastæ lucrare
încercæm sæ subliniem importanfla uretrostomiei perineale,
ca o metodæ rapidæ de acces pentru TURV la pacienflii care
asociazæ o stricturæ uretralæ penianæ întinsæ.
Introduction and Objectives. TURB remains the standard
treatment in non muscle invasive bladder tumours but
sometimes the transurethral access is difficult or impossible
because of long penile urethral strictures. In this paper we
are trying to draw attention on perineal urethrostomy as an
easy and fast access for TURB in patients with associated long
penile urethral strictures.
Materiale øi metode. Între anii 2008 øi 2013 am efectuat 46
de uretrostomii perineale pentru diverse patologii uretrale:
carcinom penian sau uretral, stricturi uretrale întinse
recurente cu periuretritæ sau lichen scleros asociat. În 4 cazuri
uretrostomia perineala a fost efectuatæ pentru a permite
realizarea TURV la pacienfli cu tumoræ vezicalæ superficialæ øi
stricturæ întinsæ de uretræ penianæ imposibil de cateterizat.
Cu pacientul asezat în poziflie de litotomie se efectueazæ o
incizie verticala la nivelul tegumentului perineal øi al
flesutului adipos subcutanat. Muøchiul bulbocavernos este
disecat la nivelul liniei mediane. Uretra bulbaræ este expusæ
între douæ fire de sprijin øi se realizeazæ o incizie verticalæ de
2-3 cm la nivelul corpului spongios. La maturarea
uretrostomiei, în suturæ se încorporeazæ 3 straturi: mucoasæ
uretralæ, adventicea corpului spongios øi tegumentul. Corpul
spongios nu este înglobat în suturæ, pentru a-i prezerva
fluxul sangvin. Dupæ maturarea uretrostomiei perineale, se
efectueazæ TURV, dupæ procedeul standard, folosindu-se un
rezectoscop 26 Fr.
Materials and methods. Between 2008 and 2013 we
performed 46 perineal urethrostomies for different urethral
pathologies: penile or urethral carcinoma, recurrent long
anterior urethral strictures associated with adverse
conditions like periurethritis or lichen sclerosus. In 4 ocasions
perineal urethrostomy was performed for TURB access in
cases with bladder tumors associated with long penile
urethral strictures impossible to be catheterized. With the
patient in a lithotomy position, a vertical perineal incision of
the skin and subcutaneous tissue is made. The
bulbocavernous muscle is splitted on midline. The bulbar
urethra is exposed and a 2-3 cm vertical incision of the
spongiosum is performed between stay sutures. When
maturating the urethrostomy, 3 layers are incorporated in
the suture: the urethral mucosa, the adventitia of the
spongiosum and the skin. The body of the spongiosum is not
taken in the sutures in order to preserve the lateral blood
flow. After the maturation of the perineal urethrostomy a
TURB is performed in a standard manner with a 26 Fr
resectoscope.
Rezultate. Cu ajutorul uretrostomiei perineale s-a obflinut un
acces bun pentru TURV în toate cele 4 cazuri. Timpul
operator a fost de 20 de minute. Reconstrucflia uretralæ cu
grefæ de mucoasæ bucalæ øi închiderea uretrostomiei se pot
88
Results. Through the perineal urethrostomy a good access
for TURB was obtained in all 4 cases. The operating time was
20 minutes. An urethral reconstruction with BMG and the
nr. 2 / 2013 • vol 12
Tumori vezicale
efectua la 6 luni dupæ douæ controale cistoscopice
consecutive normale.
closure of the urethrostomy can be attempted 6 months
after two consecutive normal cystoscopic evaluations.
Concluzii. Uretrostomia perinealæ este o metodæ rapidæ øi
siguræ de acces la pacienflii cu tumori vezicale superficiale
care prezintæ asociatæ o stricturæ uretralæ penianæ întinsæ, øi
ar trebui sæ fie prezentæ în arsenalul oricærui urolog. Prin
intermediul acestui abord se evitæ o intervenflie chirurgicalæ
deschisæ sau o cistostomie cu riscul sau de diseminare
tumoralæ. Reconstrucflia uretralæ se poate efectua într-un
timp secundar, dupæ realizarea controlulului oncologic al
tumorii vezicale.
Conclusions. Perineal urethrostomy is a fast and safe access
for TURB in patients with non muscle invasive bladder
tumors associated long penile urethral strictures and it
should be present in the armamentarium of any urologist.
Through this approach an open surgery for bladder tumors
or a cystostomy with the consequent risk of tumor spread are
avoided. A second intervention for urethral reconstruction
can be considered after the oncological control of the
bladder tumors.
nr. 2 / 2013 • vol 12
89
PM.7.1. Oncocitomul renal –
tumoræ renalæ benignæ
cu posibilæ evoluflie malignæ?
M. Manu, C. Gîngu, C. Surcel, I. Prie,
A. Davidescu, Rucsandra Manu, C. Dudu,
*
S. Pætræøcoiu, Liliana Domniøor ,
*
**
Carmen Savu , Monica Hortopan , I. Sinescu
*
Clinica de ATI,
**
Laboratorul de Anatomie Patologicæ, Institutul
Clinic “Fundeni”, Bucureøti
A. Davidescu, Rucsandra Manu, C. Dudu,
*
S. Pætræøcoiu, Liliana Domniøor ,
*
**
*
ICU Department,
**
Pathology Department, Fundeni Clinic Institute,
Bucharest
Introducere. Primele 13 cazuri au fost descrise drept entitæfli
patologice distincte de Klein øi Valensi în 1976. Frecvenfla
oncocitomului renal este de 3-7% din tumorile renale.
Preoperator nu existæ elemente clinice sau imagistice de
diagnostic diferenflial cu celelalte tumori maligne renale,
anatomia patologicæ având rolul cardinal.Tumora este bine
circumscrisæ, maronie, cu cicatrice centralæ, iar microscopic se
caracterizeazæ prin prezenfla eozinofilelor rotunde øi poligonale
øi a mitocondriilor. Diagnosticul, clasificarea, tratamentul øi
urmærirea oncocitomului renal reprezintæ încæ un subiect
controversat. Prezentæm experienfla centrului nostru.
Objective. First 13 cases reported as distinct clinicopathologic
entity – 1976 – Klein and Valensi, oncocytoma represents 3% 7% of solid renal mass. Tumors are light brown, homogenous
well circumscribed with central scar but they are not truly
encapsulated. Microscopy – round or polygonal eosinophilic
cells in nested on organoid pattern with numerous large
mitochondria. Positive and differential diagnostic, clasification,
management and follow-up still represent a subject of
controversy. The aim of the study was to present our
experience in managing oncocytoma and to analize the cases
with malignant evolution.
Material øi metodæ. Din iunie 1997 pânæ în ianuarie 2013, 82
pacienfli cu oncocitom renal au fost operafli în centrul noastru.
55 bærbafli øi 27 femei cu vârste cuprinse între 45 øi 74 ani (vârsta
medie = 62 ani) au fost incluøi în studiul nostru. Clinica a fost
minoræ, dureri lombare, hematurie, febræ, dureri abdominale,
iar 44 cazuri au fost descoperite incidental. Protocolul de
investigaflii a inclus: examenul clinic, UIV, ecografia abdominalæ,
CT øi în cazuri selecflioante RMN øi angiografia renalæ.
Preoperator, diagnosticul de oncocitom a fost considerat în 23
cazuri, examenul histopatologic fiind cardinal.
Matherial and method. Beetwen June 1997 and January
2013 in our department were operated 82 patients with renal
oncocytoma, 55 males and 27 females with an average of 62
years old. 39 cases were incidentaloma, clinical findings were
minor, lumbar pain, hematuria, fever. Clinical examination,
IVP, abdominal ultrasound with Doppler exam, CT and MRI
were performed at admission. Prior to surgery, imaging the
lesion, renal oncocytoma was considered in 23 cases.
Rezultate. În Centrul Fundeni, atitudinea terapeuticæ în RCC
este nefrectomia radicalæ. Deoarece preoperator criteriile
clinice øi imagistice pentru diagnosticul oncocitomului sunt
foarte neclare, consideræm nefrectomia radicalæ obligatorie.
7 cazurile s-au pretat la chirurgie conservatoare, iar puncflia
biopticæ TC ghidatæ øi aspiraflia biopticæ cu ac fin nu s-au
practicat. Tumorile au fost clasificate astfel: T1a - 4 cazuri, T1b
- 3 cazuri,T2 – 37 cazuri, T3a – 28 cazuri, T4 – 10 cazuri. Invazia
ganglionaræ limfaticæ øi metastazele în momentul operafliei
nu au fost observate. Limfodisecflia loco-regionalæ a fost
practicatæ în cazurile de nefrectomie. Examenul
histopatologic a indicat oncocitom în toate cazurile. 60 cazuri
90
Renal oncocytoma –
possible to be malignant?
Results. In our department, atitude in RCC is radical
nephrectomy and in selected cases nephro-sparing surgery.
This procedure was considered in all cases and nephronsparing surgery were performed, as long as preoperative
criteria for oncocytoma remains unclear. Fine needle
aspiration under CT control was not performed. Clasification
for tumors was as followes: T1a-4cases, T1b-3cases,T237cases, T3a-28cases and T4-10cases. We did not find lymphnodes invasion or distant metastasis and standard
lymphadenectomy was performed in all cases. Pathological
examinatin indicated renal oncocytoma in all cases. Lowgrade anaplastic oncocytoma was proved in 60 cases, 6 cases
proved a combination of renal oncocytoma and
angiomiolipoma and in 11 cases high-grade anaplastic renal
nr. 2 / 2013 • vol 12
Concluzii. În Centrul Fundeni, oncocitomul renal respectæ
incidenfla internaflionalæ. Atitudinea noastræ a fost nefrectomia
radicalæ øi în unele cazuri nephro-sparing surgery. Evoluflia
postoperatorie a fost aceeaøi pentru toate tumorile depistate
indiferent de mærime, tipul de oncocitom øi invazie. Cazurile
neclare histologic, unde carcinomul cromofob a fost implicat
au evoluat spre metastaze, care au fost tratate specific, cu
rezultate bune. Confirmarea diagnosticului este histologicæ.
Rata de supraviefluire a fost de 100%.
nr. 2 / 2013 • vol 12
oncocytoma were found. Postoperative complication were
minor. Follow-up protocol included: clinical examination,
ultrasound, CT and/or MRI every 6 months in first 2 years and
then yearly. Three cases developed metastasis but histology
was unclear – possible cromophobe RCC.
au fost oncocitom cu grad scæzut de anaplazie, 6 cazuri de
oncocitom renal øi angiomiolipom øi 11 cazuri de oncocitom
cu grad înalt de anaplazie. În 3 cazuri diagnosticul diferenflial
histopatologic cu carcinomul renal cromofob a fost dificil de
realizat. În aceste cazuri evoluflia a fost cætre metastazare cu
atitudine ulterioara specificæ, ablaflia tumorilor, Sutent.
Evoluflia postoperatorie a fost bunæ, færæ complicaflii notabile.
Urmarirea s-a facut cu ecografic, CT øi/sau RMN, øi reprezintæ
protocolul de urmærire în toate cazurile. Protocolul constæ în
examinæri la fiecare 6 luni, în primii 2 ani, iar apoi anual.
Conclusions. In our center, renal oncocytoma respects the
international incidence among renal tumors. Our attitude
was radical nephrectomy or nephro-sparing surgery - in all
cases, considering that no preoperative investigation could
certify the diagnosis. Evolution after surgery was good for all
tumors despite the size, type or invasion. The confirmation of
diagnostic was pathological. Long term surviving rate after
surgery was 100%. Three cases developed metastatic disease
and specific treatment was performed.
91
92
PM.7.2. Suprarenalectomia
retroperitoneoscopicæ în decubit
ventral
F. Lupu, M. Hârza, M. Manu, B. Øtefan,
Introducere øi obiective. Pentru excizia tumorilor benigne
suprarenaliene, cele mai bune opfliuni sunt abordurile
laparoscopice sau retroperitoneoscopice. Scopul acestei
lucræri este de a evalua rezultatele experienflei noastre inifliale
cu suprarenalectomia retroperitoneoscopicæ efectuatæ în
decubit ventral.
Materiale øi metode. Între 2005 øi 2013, 54 de tumori
suprarenaliene benigne au fost operate endoscopic în clinica
noastræ. 18 dintre ele au fost abordate laparoscopic
transperitoneal, iar 36 au fost suprarenalectomii retroperitoneoscopice. La 32 dintre pacienfli abordul a fost în decubit
lateral, în timp ce la ultimele 4 cazuri am preferat decubitul
ventral (3 au fost tumori de suprarenalæ dreaptæ øi 1 stangæ).
Dupæ anestezia generalæ în decubit dorsal, pacientul este rotat
în decubit ventral. Sunt inserate cele 3 trocare (cel din mijloc de
12 mm la vârful coastei a XII-a, cel median de 10 mm lângæ
muøchiul para-spinal, iar cel lateral de 5 mm la vârful coastei a
XI-a). Retroperitoneul este inflat cu CO2 la o presiune de 14-20
mmHg. Iniflial este disecat polul superior al rinichiului, apoi
glanda suprarenalæ este separatæ de rinichi øi de vena cavæ (sau
de aortæ) folosindu-se un bisturiu ultrasonic. Disecflia este
finalizatæ, iar organul este extras într-un dispozitiv tip endobag.
Retroperitoneoscopic
Adrenalectomy in a Prone Position
F. Lupu, M. Hârza, M. Manu, B. Øtefan,
Bucharest
Introduction and objectives.
Laparoscopic
or
retroperitoneoscopic approaches are the options of choice
for removing benign adrenal tumor masses. The aim of this
paper is to assess the results of our initial experience with
retroperitoneoscopic adrenalectomy in a prone position.
Materials and methods. Between 2005 and 2013 there were
54 cases of benign adrenal tumor masses that received
endoscopic treatment in our center. 18 of them underwent a
laparoscopic and 36 a retroperitoneoscopic adrenalectomy.
For 32 of these patients the surgery was performed in a flank
position and for the other 4 in a prone position (3 on the right
and 1 on the left). After the general anesthesia in the supine
position, the patients were flipped in a prone position. 3
th
trocars were inserted (middle 12 mm at the tip of the 12 rib,
median 10 mm next to the para-spinal muscle, lateral 5 mm
th
close to the tip of the 11 rib). The retroperitoneum was
inflated with CO2 at 14-20 mmHg. Firstly the upper pole of
the kidney was dissected, then the adrenal gland was
separated from the kidney and the vena cava (or aorta) with
a harmonic scalpel. The dissection was finalized, and the
organ was removed in an endocatch bag.
Rezultate. Nu au fost înregistrate complicaflii locale sau la
distanflæ, pierderi semnificative de sânge sau alte probleme
cardiovasculare. Timpul mediu operator a fost de 75 de
minute. Dimensiunea medie a tumorilor a fost de 4,3 cm.
Examenul histopatologic a evidenfliat adenoame corticale
nesecretante în toate cele 4 cazuri.
Results. No immediate or late complications were
encountered, with no significant blood loss and no
cardiovascular problems. Mean operation time was of 75
minutes. Mean tumor size was 4.3 cm. Histology revealed
nonsecretory cortical adenomas in all 4 cases.
Concluzii. Suprarenalectomia retroperitoneoscopicæ în decubit ventral reprezintæ cel mai bun abord pentru tumorile
benigne de suprarenalæ pentru cæ asiguræ cel mai uøor acces la
glanda suprarenalæ, evitând alte organe sau eventualele
aderenfle intraabdominale. Iar pentru cæ sunt suficiente 3 trocare, este øi cea mai facilæ øi rapidæ proceduræ. Totodatæ permite presiuni de inflaflie mai mari, færæ a afecta întoarcerea
venoasæ øi poate fi practicatæ în siguranflæ øi la pacienflii obezi.
Conclusions. Retroperitoneoscopic adrenalectomy in a
prone position is the best approach for benign adrenal
tumors because it provides the easiest access to the adrenal
gland, avoiding intraabdominal adhesions and other organs.
Requiring only 3 trocars it also is the simplest and fastest
method. And it allows higher inflation pressures without the
risk of a decrease in venous return, and can be safely
performed, even in obese patients.
nr. 2 / 2013 • vol 12
O. Azis, F. Voinea, S. Osman, I.C. Iorga
Spitalul Clinic Judeflean de Urgenflæ Constanfla
Retroperitonealtumors – eperience
of Constanfla Urology Clinic
O. Azis, F. Voinea, S. Osman, I.C. Iorga
Constanfla County Emergency Hospital
Introducere. Realizat în Spitalul Clinic Judeflean de Urgenflæ
Constanfla, studiul de faflæ din perioada 2008 – 2012 cu privire
la tumorile retroperitoneale primitive.
Introduction. Made in Constanta County Emergency
Hospital, this study during 2008 - 2012 on primitive
retroperitoneal tumors.
Material øi metodæ. Articolul de faflæ în acest fel este parte
integrantæ dintr-un studiu multicentric clinico-epidemiologic, descriptiv øi observaflional, longitudinal bidirecflional,
efectuat prospectiv øi retrospectiv din douæ loturi de
pacienfli, în total 67 de cazuri.
Material and Method. This article thus is part of a multicenter
clinical-epidemiological, descriptive and observational,
longitudinal bidirectional conducted prospectively and
retrospectively in two groups of patients, a total of 67 cases.
Rezultate øi Concluzii. Marker fidel al succesului terapeutic,
analiza supraviefluirii la pacienflii cu tumori retroperitoneale
primitive permite conturarea unei imagini globale asupra
evolufliei acestor tumori, dar øi comparaflia pertinentæ cu alte
studii de specialitate. Decesele perioperatorii înregistrate în
cazuistica studiului de faflæ au numærat 6 pacienfli, 8,73% din
cazuri. Simptomatologia tumorilor retroperitoneale primitive
este nespecificæ; aspecte clinice precum durerea abdominalæ,
palparea transabdominalæ a tumorii retroperitoneale, scæderea
în greutate, au putut fi identificate ca date clinice cu relevanflæ
crescutæ în diagnosticul acestor tumori. Fiecare tip de tumoræ
retroperitonealæ primitivæ prezintæ particularitæfli intraoperatorii,
pornind de la dimensiunea sa, delimitarea sa øi pânæ la relaflia cu
structurile adiacente. Nu rar, aspectul intraoperator poate diferi
major faflæ de imaginea diagnosticæ preoperatorie a unei tumori
retroperitoneale. Explorarea intraoperatorie a tumorii
retroperitoneale este foarte importantæ pentru definirea
caracterului sæu primitiv, dar øi pentru adoptarea tacticii øi
tehnicii chirurgicale cele mai adecvate cazului respectiv.
Întotdeauna tratamentul chirurgical trebuie sæ urmæreascæ
îndepærtarea completæ a tumorii retroperitoneale respective,
biopsia tumoralæ fiind un minim obligatoriu de realizat în scop
diagnostic final øi terapeutic adjuvant.
nr. 2 / 2013 • vol 12
PM.7.3. Formafliuni tumorale
retroperitoneale – experienfla
Clinicii de Urologie Constanfla
Results and Conclusions. Accurate marker of therapeutic
success, survival analysis in patients with retroperitoneal
tumors primitive allows the creation of a global picture of the
evolution of these tumors, but also meaningful comparison
with other studies. Casuistry perioperative deaths recorded
in this study included 6 patients, 8.73% of cases. Primitive
retroperitoneal tumors is nonspecific symptoms, clinical
aspects such as abdominal pain, palpation of the
retroperitoneal tumor, weight loss, have been identified as
relevant clinical data in the diagnosis of these tumors
increased. Each type of primitive retroperitoneal tumor the
intraoperative features, from its size and to delimit its
borders with adjacent structures. Not infrequently,
intraoperative appearance may differ from image major
preoperative diagnosis of retroperitoneal tumors. Exploring
intraoperative retroperitoneal tumor is very important to
define its primitive character, and to adopt tactics and
techniques most appropriate surgical case. Surgery should
always seek the complete removal of retroperitoneal tumor
respective tumor biopsy is the minimum required to achieve
the final diagnostic and therapeutic adjuvant.
93
PM.7.4. Tumora cu celule Leyding –
prezentare de caz
1
1
Leydig cell tumor-case report
1
1
Amelia Petrescu , Gabriela Berdan , F. Bengus ,
1
2
1
D. Damian , Mihaela Mihai , V. Jinga
1
România
2
“Synevo”, Departamentul de Histopatologie,
Bucureøti, România
Introducere: Tumorile cu celule Leydig aparflin grupului de
tumori ale cordoanelor sexuale øi stromei reprezentând aproximativ 2% din tumorile testiculare. Aproximativ 20% sunt
diagnosticate în prima decadæ de vârstæ, 25% între 10 øi 30 ani,
30% între 30 øi 50 ani øi 25% dupæ aceastæ vârstæ. Prezentæm
cazul unui pacient în vârstæ de 37 ani spitalizat în Secflia de Urologie a Spitalului Clinic “Prof. Dr. Th. Burghele” pentru scæderea
libidoului øi a fertilitæflii. Examenul ecografic a evidenfliat o
formafliune tumoralæ. S-a decis orhiectomia. Examenul ecografic
a evidenfliat o formafliune de aspect tumoral, bine delimitatæ, cu
diametre de 2.7/2 cm, lobulatæ prin septe fibroase, solidæ, de
culoare gælbuie, localizatæ aproape de tunica albuginee.
Material øi metode: Fragmente tumorale numeroase au fost
fixate în formaldehidæ 10%, incluse în parafinæ, secflionate øi
colorate standard cu HE øi VG. Au fost apoi examinate la
microscop optic (Nicon Eclipse 600). S-au efectuat teste
imunohistochimice pe secfliuni cu o grosime de 3 microni
utilizând urmætorii anticorpi: Inhibina alpha (Cell Marque),
Clona R1 øi CONFIRMTM anti-ki-67 Rabbit Monoclonal
Primary Antibody (Ventana), clona 30-9.
Rezultate: Examenul microscopic a evidenfliat o proliferare tumoralæ alcætuitæ din celule mari poligonale, cu citoplasmæ abundentæ, eozinofilæ, uøor granular øi nuclei rotunzi, regulafli, unii cu
nucleoli bine vizibili. Vacuole citoplasmatice creeazæ, uneori,
aspect microchistice. În alte zone cuiburi de celule sunt separate
de o stromæ edematoasæ øi hialinizatæ. Rata mitozelor este scæzutæ, mai puflin de cinci mitoze pe 10 câmpuri microscopic mari.
Mare numær de vase sinusoidale de tip endocrin. Necroza øi
invazia limfovascularæ sunt absente. Evaluarea imunohistochimicæ a arætat o coloraflie difuz pozitivæ pentru Inhibina alpha în
celulele tumorale, Ki 67 pozitiv în circa 5% din celulele tumorale.
Concluzie: S-a stabilit diagnosticul de tumoræ cu celule
Leydig care trebuie diferenfliatæ de hiperplazia cu celule
Leydig, malokoplakia, tumorile cu celule Sertoli, limfoamele
maligne øi carcinomul prostatic slab diferenfliat metastatic.
94
1
1
Amelia Petrescu , Gabriela Berdan , F. Bengus ,
1
2
1
D. Damian , Mihaela Mihai , V. Jinga
1
“Prof. Dr.Th.Burghele“ Hospital, Bucharest,
Romania
2
“Synevo”, Histopathology Department,
Bucharest, Romania
Introduction: Leydig cells tumors are sex cord-stromal tumors
and account for about 2% of testicular neoplasm.
Approximately 20% are detected in the first decade of life, 25%
between 10 and 30 years and 25% beyond that age. We present
the case of a 37 years old man hospitalized in the Department of
Urology from the “Prof. Dr.Th.Burghele“ Hospital for a decrease
in libido and fertility. Ultrasonography showed a tumoral mass
and orchiectomy was performed. Macroscopically there was a
tumoral mass, sharply circumscribed, sized 2,7/ 2 cm in
diameter, lobulated by a fibrous septa, solid and yellow,
localized near the tunica albuginea.
Material and methods: Many tissue samples were fixed in
10% formaldehyde, paraffin embedded, sectioned and
standard HE and VG stained then examined by light
microscopy (Nikon Eclipse 6). Immunohistochemistry was
performed on 3 ìm thick sections with following antibodies:
Inhibin alpha (Cell Marqu), R1 clone, CONFIRMTM anti–Ki 67
Rabbit Monoclonal Primary Antibody (Ventana), 30-9 clone.
Results: The histopathological features revealed a tumor
proliferation composed by large and polygonal cells with
abundant, slightly granular, eosinophilic cytoplasm and
regular round nuclei, some with visible nucleoli. Prominent
cytoplasmic vacuoles create a microcystic pattern. Clusters of
cells are separated by a hialinized and edematous stroma.
The mitotic rate is low, <5 of 10 HPF, a large number of
sinusoidal – endocrine vessels. Necrosis and limphovascular
invasion are absent. Immunohistochemical stains showed a
diffuse positive staining in tumoral cells, Ki 67 positive
staining in about 5% of tumoral cells.
Conclusions: A diagnosis of Leydig cells tumor was
established and must be differentiated from Leydig cells
hyperplasia, malakoplakia, Sertoli cells tumors, malignant
lymphomas, metastatic prostate carcinoma.
nr. 2 / 2013 • vol 12
1
2
2
A. T. Szora , F. Dobrotæ , N. Criøan ,
2
3
4
P. Prunduø , P. Dorel , Rodica Morar , Andrei
4
5
6
Iulia , Cætælina Bungærdean , B. Mreneø ,
2
6
1
I. Coman , M. Buruian , R. Badea
1
Disc. Imagisticæ Medicalæ, Universitatea de
Medicinæ øi Farmacie Cluj Napoca
2
Disc. Urologie Universitatea de Medicinæ øi
Farmacie Cluj Napoca
3
Disc. Anatomie Universitatea de Medicinæ øi
Farmacie Cluj Napoca
4
Lab. Radiologie, Spitalul Clinic Municipal Cluj
Napoca
5
Lab. Antomie Patologicæ, Spitalul Clinic
Municipal Cluj Napoca
6
Disc. Radiologie,Universitatea de Medicinæ øi
Farmacie Târgu Mureø “Sf. Ioan”, Bucureøti
1
2
2
A. T. Szora , F. Dobrotæ , N. Criøan ,
2
3
4
P. Prunduø , P. Dorel , Rodica Morar , Andrei
4
5
6
Iulia , Cætælina Bungærdean , B. Mreneø ,
2
6
1
I. Coman , M. Buruian , R. Badea
1
Imaging Department, University of Medicine
and Pharmacy Cluj Napoca
2
Urology Department, University of Medicine
3
Anatomy Department, University of Medicine
4
Department of Radiology, Cluj Napoca
Municipal Hospital
5
Pathology Department, Cluj Napoca Municipal
Hospital
6
Radiology and Imaging Department, University
of Medicine and Pharmacy Târgu Mureø
Introducere. Tehnicile ultrasonografice (US) moderne care
folosesc agenfli de contrast (AC) pot fi utilizate pentru
evaluarea angioperfuzionalæ a tumorilor renale. Cunoscutæ
fiind venofilia acestor tumori, metoda poate aduce beneficii
privind stabilirea extensiei venoase. Prezentul studiu are ca
scop evaluarea rolului US, a ultrasonografiei cu agent de
contrast (CEUS) øi a parametrilor curbelor timp intensitate
(TIC) în cancerul cu celule renale.
Introduction. Modern utlrasonographic (US) techniques
which use second generation contrast agents (CA) can be
used to examine the perfusion patterns of renal tumors. Due
to the tumor’s venous extension capability, the method can
be beneficial in establising venous involvement. The present
study was done to assess the role US, contrast enhanced
ultrasound (CEUS) and Time Intensity Curve (TIC) parameters
in the evaluation of renal cell carcinoma.
Material øi Metodæ. Studiul s-a realizat între noiembrie 2011
– ianuarie 2013, implicând 29 de pacienfli cu formafliuni
tumorale renale. Dintre aceøtia, trei pacienfli prezentau
contraindicaflii pentru alte examinæri radio-imagistice cu AC.
Tofli pacienflii au fost examinafli prin US în modul B, Doppler
Color øi CEUS preoperator.Pentru fiecare tumoræ s-a urmærit
øi comportamentul angioperfuzional în funcflie de timp la
nivelul zonelor de interes (ROI): parenchim renal normal,
parenchim tumoral în intregime. În douæ cazuri metoda a
fost flintitæ øi asupra venei renale. Parametrii obflinufli cu
ajutorul TIC au fost: timpul pânæ la punctul maxim al captærii
Material and Methods. From November 2011 to January
2013 29 patients with renal masses were prospectivelly
enrolled in the study. Three patients had restrictions for
other radiological imaging procedures that employ CA. Each
patient underwent examination with B mode US, Color
Doppler and CEUS prior to surgery. Time dependent contrast
enhancement was also measured, from Regions of Interest
selected in the entire tumor, the most enhancing and the
most unenhancing parts of the tumor and in the normal
parenchyma. Parameters obtained from the TIC were: time to
contrast enhancement peak (TTP), rise time (RS), mean transit
nr. 2 / 2013 • vol 12
PM.7.5. Explorarea ecograficæ cu
Contrast enhanced ultrasound in
contrast i.v. în caracterizarea tumorilor the characterisation of renal tumors.
renale. Studiu critic pe 29 de cazuri øi
Critical study on 29 cases and
analiza corelafliilor cu tipul tumoral
correlations with tumor type
95
(TTP), timpul de creøtere (RT) , timpul mediu de tranzit (mTT).
Cazurile au fost examinate corelativ cu Computer
Tomografia. Tofli pacienflii au fost operafli. S-a efectuat analiza
anatomopatologicæ a tuturor tumorilor sub aspectul
stadiului, caracteristicilor histologice.
Rezultate. Analiza pieselor de rezecflie a identificat în toate
cazurile cancer cu celule renale. S-au identificat urmætoarele
tipuri tumorale: cancer cu celule clare (n=24), cu celule
cromofobe (n=3), cu celule mixte clare øi cromofobe (n=1) øi
papilar (n=1). Evaluarea US a venei renale nu a fost posibilæ în
6 cazuri. Acurateflea ultrasonografiei în identificarea extensiei
tumorale în vena renalæ a fost de 90%, iar în vena cavæ
inferioaræ de 100%. Examinarea CEUS flintitæ asupra venei
renale, în douæ cazuri cu suspiciune de trombozæ a contribuit
la identificarea naturii tumorale a trombului. Cu excepflia a
douæ cazuri formafliunile au prezentat captare inomogenæ a
AC, prin prezenfla de zone hipocaptante localizate central,
periferi sau mixt. În general formafliunile au prezentat o
captare mai slabæ decât parenchimul normal (n=20). S-a
constatat cæ parametrul TTP al tumorilor a fost mai prelungit
comparativ cu prenchimul renal (24.74s vs 21,1s; p<0.05). RT
a fost de asemenea prelungit în cazul tumorilor (19.1vs 15.1;
p< 0.05). Prin gruparea formafliunilor în stadiile pT1-pT2 øi
pT>2, s-a constatat cæ atât TTP cât øi RT au fost diferifli între
grupuri (25.6s vs 24.9s; p<0.05 øi 20.5s vs 18.1s; p<0.05).
Concluzii. CEUS împreunæ cu cuantificarea TIC prezintæ un
potenflial important în caracterizarea, diagnosticul øi
stadializarea cancerului cu celule renale. Metoda CEUS este
neiradiantæ, repetabilæ, øi poate fi consideratæ o alternativæ în
cazul pacienflilor cu contraindicaflii pentru examinarea cu
contrast prin CT sau rezonanflæ magneticæ.
96
time (mTT). The cases were examined in correlation with the
Computed Tomography. All the patients underwent surgery
and pathological assessment of tumor stage and histology
was made.
Results. Pathological results from all 29 patients revealed
renal cell tumors divided into 24 with clear cells, 3
chromophobe, one mixed - clear cell and chromophobe and
one papillary. US examination of the renal vein was not
achievable in 6 cases. Accuracy of US in identifying tumoral
venous extension to the renal vein and inferior vena cava were
90% and 100% respectively. CEUS focused on the renal vein in
2 patients with suspected venous extension contributed to the
correct characterisation of the thrombus. Except two cases
which presented homogenous enhancement, all the masses
had unenhancing areas, either central, marginal or mixed. In
general tumors had a maximum enhancement less than the
normal parenchyma, (n=20). The TTp of cancer was longer
than normal parenchyma (24.74vs 21,11; p<0.05). RT of cancer
was also longer than in the normal parenchyma (19.1vs 15.1;
p< 0.05). When tumors were analysed grouped in pT1-pT2 and
pT>2, the TTP of tumors and RT were different between the
two groups (25.6vs 24.9; p<0.05 and 20.5 vs 18.1; p<0.05).
Conclusions. CEUS using objective quantification through TIC
is a promising tool in the diagnosis and staging of renal cancer.
The method does not employ radiation, is repeatable and can
be considered an alternative in the case of patients that cannot
be subjected to contrast agent examination with CT or MRI.
nr. 2 / 2013 • vol 12
1
1
Renal clear cells carcinoma in
pregnancy - case report
1
1
Amelia Petrescu , Gabriela Berdan ,
1
2
1
I. Dragomiriøteanu , Florina Vasilescu , V. Jinga
1
România
2
Institutul de Patologie “Victor Babeø”, Bucureøti,
România
Amelia Petrescu , Gabriela Berdan ,
1
2
1
I. Dragomiriøteanu , Florina Vasilescu , V. Jinga
1
“ Prof. Dr.Th.Burghele “ Hospital, Bucharest,
Romania
2
“Victor Babes”, Institute of Pathology,
Bucharest, Romania
Introducere: Tumorile renale, în perioada sarcinii. sunt rare
øi apar cu o incidenflæ de 5 la 100000 de cazuri pe an.
Carcinomul cu celule clare este cea mai obiønuitæ tumoræ
renalæ diagnosticatæ în sarcinæ însumând aproximativ
jumætate din tumorile renale primitive în perioada sarcinii.
Peste 80 de cazuri au fost comunicate în literatura medicalæ
de limbæ englezæ. Pacienta noastræ a fost o femeie în vârstæ
de 29 ani, însærcinatæ la care s-a diagnosticat incidental o
tumoræ renalæ cu ocazia unei ecografii efctuate în timpul
programului de supraveghere a evolufliei sarcinii. De
asemenea pacienta a prezentat øi valori crescute ale presiunii
arteriale. Nefrectomia a fost efectuatæ la douæ luni dupæ
naøtere. Nu am avut date despre aspectul macroscopic øi
microscopic al evaluærii placentei. Pacienta nu a primit
tratament oncologic adjuvant. La examenul macroscopic am
constatat o formafliune tumoralæ bine delimitatæ cu
dimensiuni de 7 cm x 6 cm x 4 cm, culoare cenuøiu-albicioasæ
cu zone de hemoragie intratumoralæ. fiesut fibroadipos
perirenal øi hilar færæ aspect de infiltrare neoplazicæ. Vase
mari sinusale (arteræ øi venæ renalæ) libere.
Introduction: Renal tumors are rare in pregnancy and occur
in approximately 5 per 100000 cases per year. Renal cell
carcinoma (RCC) is the most common renal tumor reported
in pregnancy accounting for about half of all primary renal
tumors during pregnancy. Over the 80 cases has been
reported in English Language medical literature. Our patient
was a 29 year-old-pregnant women who were accidentally
find to have a renal mass during routine antenatal
ultrasonography and increase of blood pressure values. All
blood test were unremarkable. The patient underwent left
radical nephrectomy two months after she delivered a
normal term baby. We haven’t data about macroscopic and
microscopic evaluation of placenta. She received no
adjuvant therapy. Pathological examination revealed a 7cm x
6cm x 4cm renal mass, well circumscribed, grey color with
haemorrhage intratumoral areas. There was no gross
evidence of extension of the tumor into renal artery, renal
vein or renal sinus.
Material øi metode: Fragmente tumorale au fost fixate în
formaldehidæ 10% øi incluse în parafinæ. S-au efectuat
secfliuni de 4 microni grosime care au fost colorate standard
cu HE øi VG pentru examinarea microscopicæ. Secfliuni
suplimentare au fost utilizate pentru evaluarea
imunohistochimicæ cu tehnica avidin –biotin peroxidoza. Sau folosit urmætorii anticorpi: E – cadherin (clona ECH-6),
CD10 (clona 56C6), EMA (clona E29), CK7 (clona OV-TL 12/30),
RCC (clona PN-15) Ventana Medical Systems Inc, Tucson,
Arizona, SUA øi BerEP4 (clona M0804) - Dako Cytomation,
Carpenteria, California, SUA.
Rezultate: Examenul microscopic a arætat o proliferare
carcinomatoasæ malignæ alcætuitæ din celule clare øi
eozinofile cu o arhitecturæ alveolaræ, grad III nuclear
Fuhrmann. Stroma cu aspect vascular øi prezentæ de noduli
hialini øi foliculi gigantoepitelioizi cu celule gigante reactive.
nr. 2 / 2013 • vol 12
PM.7.6. Carcinomul renal cu celule
clare øi sarcinæ – prezentare de caz
Material and methods: Tumoral tissues were fixed in 10%
buffered formalin solution and embedded in paraffin blocks.
Four micrometer thick sections were obtained with HE and
VG for microscopic examination. Additional sections were
used to perform immunohistochemical studies using an
avidin–biotin peroxidase technique: E cadherin (clone ECH6), CD 10 ( clone 56C6), EMA (clone E 29), CK7 (clone OV-TL
12/30), RCC (clone PN-15), Ventana Medical Systems Inc,
Tucson, Arizona, USA, BerEP4 (clone M0804, Dako
Cytomation, Carpenteria, California, USA).
Results: Microscopic findings showed carcinomatous
proliferation of malignant clear and eosinophilic cells
arranged in alveolar patterns, Fuhrman nuclear grade 3. The
stroma was vascular with hyaline nodules and gigant
epithelioides follicles with reactive giant cells presence. The
immunohistochemical results: E cadherin and EMA, positive
stains in rare tumoral cells; CK 7, CD 10, RCC and BerEP4
negative stains in tumoral cells.
97
Evaluarea imunohistochimicæ: E – cadherina øi EMA reacflie
pozitivæ în rare celule tumorale; CD10, CK7, RCC, BerEP4
reacflie negativæ în celulele tumorale.
Concluzii: În timp ce creøterea numærului de cazuri de
carcinoame renale cu celule clare ar putea fi interpretatæ ca
risc întâmplætor, existæ dovezi cæ ar exista un risc de
dezvoltare a unor tumori (inclusiv carcinoame renale cu
celule clare) în timpul sarcinii posibil legat de modificærile
hormonale (creøterea valorilor de estrogeni øi beta HCG).
Recomandarea intervenfliei chirurgicale în primul øi al treilea
trimestru de sarcinæ este deja universal acceptatæ, dar în
trimestrul al doilea este controversatæ. S-ar putea considera
cæ întârzierea intervenfliei chirurgicale ar putea fi potenflial
riscantæ pentru dezvoltarea metastazelor.
98
Conclusions: While the increasing numbers of case reports
of RCC arising during pregnancy could represent a chance
occurrence, there is some evidence that there may be an
increased risk of the development of some neoplasms
(including RCC), during pregnancy possibly related to
hormonal changes (estrogen and beta HCG). The
recommendation of surgery during the first and third
trimester of pregnancy is universally accepted, but the
recommendation of surgery during the second trimester is
controversial. It should be considered that delaying surgery
can potentially be harmful for the risk of metastasis.
nr. 2 / 2013 • vol 12
1
1
1,2
Veronica Ghirca , A. Brad , D. Porav ,
1
1,2
1,2
B. Uzun , A. Nechifor-Boilæ , A. Maier ,
1,2
1,2
Orsolya Martha , C. Chibelean
1
2
The correspondence between pT
and pN stage in pacients with
parenchymal renal tumors
evaluated No on preoperative CT
1
1
1,2
1
Veronica Ghirca , A. Brad , D. Porav , B. Uzun ,
1,2
1,2
A. Nechifor-Boilæ , A. Maier ,
1,2
1,2
Orsolya Martha , C. Chibelean
1
Târgu Mureø
2
Obiectivul studiului constæ în evidenflierea corespondenflei
dintre stadiul pT øi pN la pacienflii diagnosticafli cu tumori
renale parenchimatoase evaluafli preoperator prin computer
tomografie (T1-4 N0M0) pentru care s-a practicat
nefrectomie radicalæ cu limfadenectomie de stadiere.
The objective of this study consist in revealed the
correspondence between the pT and pN stage in patients
diagnosed with parenchymal renal tumors evaluated on
preoperative CT (T1-4 N0M0) for which was performed
radical nephrectomy with staging lymph node dissection.
Material øi metodæ: Am efectuat un studiu retrospectiv pe o
perioadæ de 16 luni (noiembrie 2011-martie 2013) în care au
fost incluøi 52 de pacienfli. Criteriile de includere au fost
prezenfla tumorii renale evidenfliatæ prin CT efectuatæ
preoperator, færæ metastaze la distanflæ, færæ adenopatie
tumoralæ decelabilæ (criterii CT). Rezultatele CT au fost
comparate cu rezultatele examenului histopatologic (EHP).
Materials and method. We performed a retrospective study
over a period of 16 months (November 2011- March 2013) in
which we included 52 patients. The inclusion criteria were the
presence of the renal tumor revealed on preoperative CT, without distance metastases, without detected tumoral lymphadenopathy. The CT results were compared with the histopathological results.
Rezultate: 32 dintre pacienfli au fost de sex masculin øi 20 de
sex feminin. 27 dintre pacienfli au fost diagnosticafli cu tumoræ
renalæ stangæ øi 25 cu tumoræ renalæ dreaptæ. Postoperator,
EHP a evidenfliat stadiul tumoral pT1a în 10 cazuri, pT1b în 12
cazuri, pT2a în 7 cazuri, pT2b în 6 cazuri, pT3a în 10 cazuri,
pT3b în 5 cazuri øi pT4 în 2 cazuri. În majoritatea cazurilor
incluse în acest studiu, stadiile N determinate preoperator
prin CT corespund cu diagnosticul postoperator evaluat prin
rezultatul EHP. În 49 dintre cazuri, rezultatul EHP nu a
evidenfliat metastaze ganglionare (pN0). Douæ dintre cazurile
pT3 au prezentat ganglioni pozitivi (pN1 si pN2), øi un caz pT4
–pN1, nedecelabili prin CT efectuatæ preoperator.
Results. 32 of the patients were male and 20 female. 27 of the
patients were diagnosed with left renal tumor and 25 with
renal tumor on the right side. Postoperative histopathological
examination revealed pT1 stage in 10 patients, pT1b in 12
patients, pT2a in 7 patients, pT2b in 6 patients, pT3a in 10
patients, pT3b in 5 patients and pT4 in 2 patients. In majority
of the cases included in this study, the N stages determined on
preoperative CT correspond to the postoperative diagnostic
evaluated on the histopathological examination. In 49 of the
cases the histopathological examination did not revealed
metastases in lymph nodes: pN0. Two of the cases, stage pT3
presented positive lymph nodes (pN1 and pN2) and one case
in stage pT4-pN1 that were not detected on preoperative CT.
Concluzii: Deøi limfadenectomia de stadiere este recomandatæ, în stadiile pT1 øi pT2 chirurgia conservatoare constituie
uneori, o opfliune ce exclude limfodisecflia, ca urmare øi
nefrectomia simplæ ar putea urma acelaøi model. Valoarea
limfodisecfliei apare în stadiile pT3 øi pT4 când la 3 cazuri
(17,64%) EHP restadializeazæ diagnosticul din punct de
vedere N, fæcând ca supravegherea øi tratamentul oncologic
sæ poatæ fi modulate corespunzætor.
nr. 2 / 2013 • vol 12
PM.7.7. Corespondenfla dintre
stadiul pT øi pN la pacienflii cu
tumori renale parenchimatoase
evaluafli tomografic preoperator No
Conclusions. Even if the staging lymph node dissection is
recommended, in pT1 and pT2 stages the conservative
surgery represent occasionally an option which exclude the
lymph node dissection, so that simple nephrectomy also
could follow the same model. The value of the lymph node
dissection emerge in pT3 and pT4 stages when in 3 cases
(17,64%) histopathological examination reestablished the
diagnosis according pN, so that the patients can benefit to an
adequate surveillance and oncologic treatment.
99
PM.7.8. Bypass-ul veno-venos al venei
cave inferioare în trombectomia
tumoralæ pentru carcinoamele renale
cu celule clare, cu tromb tumoral la
nivel diafragmatic: prezentare de caz
1
2
3
Veno-venous by-pass of the inferior
vena cava in tumor thrombectomy
for renal cell carcinoma with caval
tumor thrombus at the level of
diaphragm: case report
1
2
3
I. A. Nechifor-Boila , H. Suciu , Irina Modrigan ,
4
4
1
Andrada Loghin , Angela Borda , A. Maier ,
1
1
1
A. Brad , Veronica Ghirca , Orsolya Martha ,
1
C. Chibelean
1
Clinica de Urologie, Spitalul Clinic Judeflean
Târgu-Mureø
2
Clinica de Chirurgie Cardiovasculara, Spitalul
Clinic Judeflean de Urgenflæ Târgu-Mureø
3
Clinica de Anestezie-Terapie Intensivæ, Spitalul
4
Laboratorul de Anatomie Patologicæ, Spitalul
I. A. Nechifor-Boila , H. Suciu , Irina Modrigan ,
4
4
1
Andrada Loghin , Angela Borda , A. Maier ,
1
1
1
A. Brad , Veronica Ghirca , Orsolya Martha ,
1
C. Chibelean
1
Clinic of Urology, Târgu-Mures County Hospital
2
Clinic of Cardiovascular Surgery, Târgu-Mures
Emergency Hospital
Introducere. Carcinoamele renale cu celule clare (CRCC)
prezintæ o tendinflæ specificæ de extensie la nivelul Venei
Cave Inferioare (VCI), constituind o provocare în planificarea
intervenfliei chirurgicale. Dorim sæ prezentæm un caz de
tumoræ renalæ de graniflæ T3b/T3c care a fost tratatæ folosind
o tehnicæ chirurgicalæ modificatæ ce nu a necesitat by-pass
cardio-pulmonar øi oprirea cordului.
Introduction. Renal cell carcinomas (RCC) have a specific
tendency of extension to the Inferior Vena Cava (IVC), a
challenge in surgical planning. We aim to present a case of
borderline T3b/T3c renal tumor that was treated using a
modified surgical technique that avoided cardiopulmonary
bypass and cardiac arrest.
Prezentare de caz. Dorim sæ prezentæm cazul unei paciente
de 58 ani care a fost diagnosticatæ cu o tumoræ renalæ dreaptæ
de graniflæ T3b/T3c. S-a luat decizia de tratament chirurgical øi
a fost formatæ o echipæ operatorie mixtæ, urologicæ øi
cardiovascularæ. S-a folosit o incizie tip chevron modificatæ.
Iniflial a fost mobilizat rinichiul drept øi artera renalæ ligaturatæ.
Apoi, VCI a fost preparatæ iar colateralele ei lombare ligaturate.
Ficatul a fost mobilizat spre stânga dupæ ce ligamentele
(rotund, falciform, triunghiular øi coronar superior) au fost
secflionate. Echipa cardiovascularæ a instalat un by-pass al VCI
între atriul drept øi VCI infrarenalæ prin sternotomie. S-a
efectuat manevra Pringle. Pentru a asigura decompresia
hepaticæ, VCI infrarenalæ, vena renalæ contralateralæ, venele
suprahepatice øi VCI intrapericardicæ au fost clampate în
aceastæ ordine. A fost inifliat by-pass-ul. S-a efectuat cavotomie
circumferenflialæ øi trombul tumoral a fost înlæturat (øi verificat
3
Clinic of Anestesiology and Intensive care,
Târgu-Mures Emergency Hospital
4
Department of Pathology, Târgu-Mures
Emergency Hospital
Case report. We present the case of a 58 year-old female
patient that was diagnosed with a borderline T3b/T3c renal
cell carcinoma in her right kidney. The decision for surgical
treatment was taken and a combined urologicalcardiovascular surgical team was formed. A modified
Chevron incision was used. First, the right kidney was
mobilized, the renal artery ligated. The IVC was exposed, its
lumbar branches ligated. Then, the liver was mobilized to the
left after the division of the teres, falciform, triangular and
superior coronary ligaments. The cardiovascular team
performed a caval by-pass between the right atrium and the
infrarenal vena cava using sternotomy. Then, Pringle’s
maneuver was undertaken. In order to ensure hepatic
decompression, several minutes later, the infrarenal IVC, the
contralateral renal vein, suprahepatic veins and
intrapericardic IVC were occluded, in that order. By-pass was
initiated. A circumferential cavotomy was performed and the
nr. 2 / 2013 • vol 12
pentru integritate) împreunæ cu rinichiul drept øi vena
corespunzætoare. Apoi a fost clampatæ VCI inferior de
suprahepatice øi a fost eliberatæ cea intrapericardicæ. Manevra
Pringle øi clampajul suprahepaticelor au fost întrerupte,
minimizând astfel ischemia øi congestia hepaticæ. Dupæ
cavorafie, toate pensele au fost înlæturate øi by-pass-ul
suprimat. Pacienta a prezentat o evoluflie favorabilæ, cu o
recuperare bunæ øi a fost externatæ 12 zile mai târziu.
Concluzii. Øuntarea de tip veno-venos a VCI este o metodæ
foarte utilæ ce permite menflinerea presiunii venoase centrale
(prin asigurarea returului sangvin) precum øi un control bun
al trombului tumoral (prevenind emboliile pulmonare), færæ
riscurile unei hemoragii excesive sau cele ale by-pass-ului
cardiopulmonar.
nr. 2 / 2013 • vol 12
tumor thrombus was removed (and checked for integrity)
together with the right kidney and vein. Afterwards, the IVC
was clamped right below the hepatic veins, releasing the
intrapericardic clamp. The Pringle’s maneuver and
suprahepatic veins were released, thus minimizing hepatic
ischaemia and congestion. After cavoraphy, all clamps were
removed and the venous by-pass suppressed. The patient
had a favorable postoperative outcome, with good recovery,
and was discharged 12 days later.
Conclusion. Veno-venous IVC shunting is a highly useful
technique that allows maintaining of central venous
pressure (by ensuring blood return) together with good
tumor thrombus control (excluding risk of pulmonary
embolism), all of these without significant bleeding or the
potential risks of cardiopulmonary by-pass.
101
PM.7.9. Rolul chirurgiei conservatorii
în tratamentul tumorilor renale
localizate
The role of conservative
Nephron-Sparing surgery in the
therapy of localized renal tumors
V. Bucuraø, R. Bardan, C. Secæøan, A. Cumpænaø,
A. Mureøan, Cristina Bælærie
V. Bucuraø, R. Bardan, C. Secæøan,
A. Cumpænaø, A. Mureøan, Cristina Bælærie
Obiective: Am urmærit evaluarea experienflei noastre în
chirurgia de tip „nephron-sparing”, la pacienflii diagnosticafli
cu cancer renal.
Objectives: We have evaluated our experience in nephronsparing surgery, in patients diagnosed with renal cancer.
Material øi metode: Am efectuat o analizæ retrospectivæ a
perioadei 1997-2012, interval de timp în care am efectuat
816 intervenflii chirurgicale de exerezæ a unor tumori renale
confirmate ulterior histopatologic ca øi carcinoame renale.
Am evaluat tipul operafliei, tipul de indicaflie pentru
efectuarea unei intervenflii conservatorii (absolutæ sau de
elecflie), stadializarea TNM, sexul øi vârsta pacienflilor,
rezultatele examenelor histopatologice, precum øi detalii
privind modul de desfæøurare al intervenfliilor chirurgicale.
Material and methods: We have done a retrospective
analysis of the period 1997-2012, time interval during which
we have performed 816 surgical interventions for renal
tumors that were confirmed later as renal carcinoma, at the
pathology report. We have evaluated the type of surgery, the
indication category for doing nephron-sparing surgery
(absolute or elective), the TNM staging, age and gender of
patients, the pathology exam results, along particular
technical details of the surgical interventions.
Rezultate: În perioada de 17 ani evaluatæ, am efectuat un
numær de 46 de intervenflii chirurgicale conservatorii, ceea ce
reprezintæ 5,6% din totalul cazurilor de tumori renale maligne
operate în perioada menflionatæ. Dintre acestea, 26 au fost
tumorectomii (20 tumorectomii unice øi 6 tumorectomii
multiple), 14 au fost nefrectomii parfliale polare, iar 6 au fost
de tip “wedge resection”. Indicaflia de operaflie “nephronsparing” a fost în 22 cazuri absolutæ øi în 24 cazuri electivæ.
Raportul între bærbafli øi femei a fost de 24/22 iar vârsta medie
a pacienflilor a fost de 53,3 ani. Am obflinut o diferenflæ
semnificativæ statistic între vârsta medie a grupului de
pacienfli cu indicaflie absolutæ (56,8 ani) øi cea a grupului cu
indicaflie electivæ (50,1 ani). Stadiul tumoral predominant a
fost T1 (42 cazuri), iar forma anatomo-patologicæ cea mai
frecventæ a fost carcinomul cu celule clare (39 cazuri).
Results: During the 17-year period which was evaluated, we
have performed a number of 46 nephron-sparing surgical
interventions, which represent 5.6% of all renal tumors
operated in the mentioned period. Of the 46 interventions,
26 were tumorectomies (20 single tumor and 6 multiple
tumor resections), 14 were partial polar nephrectomies, and
6 were wedge resections. The indication for nephron-sparing
surgery was in 22 cases absolute and in 24 cases elective. The
male/female ratio was 24/22, while the average age at the
moment of the intervention was 53.3 years. We have found a
statistically significant difference between the average age of
the patient group with absolute indication (56.8 years) and
that of the group with elective indication (50.1 years). The
most frequent tumor stage was T1 (42 cases), while the most
frequent pathological form was clear-cell carcinoma (39
cases).
Concluzii: Chirurgia de tip “nephron-sparing” este o opfliune
terapeuticæ importantæ pentru pacienflii cu tumori renale
localizate, care poate aduce o îmbunætæflire semnificativæ a
calitæflii vieflii în perioada postoperatorie. O cercetare
ulterioaræ va aduce informaflii cu privire la evoluflia acestor
pacienfli, inclusiv din punct de vedere oncologic.
Conclusions: Nephron-sparing surgery is an important
therapy option for patients with localized renal tumors,
bringing a significant improvement of their quality of life in
the postoperative period. Further research will bring
information regarding the evolution of these patients,
including the long-term oncological follow-up.
nr. 2 / 2013 • vol 12
Management of a complex case of
bilateral kidney tumors associated
with Hodgkin lymphoma
C. Gîngu, F. Lupu, A. Dick, C. Surcel, S. Pætræøcoiu,
M. Hârza, V. Cerempei, M. Manu, B. Øtefan,
O. Himedan, M. Cræsneanu, Liliana Domniøor,
Mihaela Mihai, Ileana Constantinescu, I. Sinescu
C. Gîngu, F. Lupu, A. Dick, C. Surcel, S. Pætræøcoiu,
M. Hârza, V. Cerempei, M. Manu, B. Øtefan,
O. Himedan, M. Cræsneanu, Liliana Domniøor,
Mihaela Mihai, Ileana Constantinescu, I. Sinescu
Introducere. Cancerul renal este unul din cele mai frecvente
cancere ale adultului, reprezentând aproximativ 3% din
totalul acestora. Asocierea dintre tumorile renale øi alta
neoplazie este raræ. Strategia terapeuticæ øi valuarea
limfodisecfliei reprezintæ incæ un subiect de dezbatere.
Introduction. Renal cell carcinoma is one of the most
common tumors in adults, accounting for approximately 3%
of all cancers. Association of renal tumors and other
neoplasia is a rare event. Surgical treatment strategy of
bilateral renal tumors and the value of lymph node
dissection are subjects of debate.
Obiectiv. Scopul acestei lucræri este prezentarea managementului unui caz complex de tumoræ renalæ bilateralæ
asociatæ cu limfom Hodgkin.
Objective. To present the management of a complex case of
bilateral kidney tumors associated with Hodgkin lymphoma.
Materiale øi metodæ. Prezentæm cazul unei paciente în
vârstæ de 64 de ani internatæ pentru dureri abdominale,
inapetenflæ øi scædere ponderalæ. Tomografia abdominalæ
a arætat o tumoræ renalæ mare cu extensie in vena cava
inferioaræ subhepaticæ, cu adenopatii lateroaortice,
interaorticocave si laterocave øi o tumora renalæ dreaptæ
de 4 cm situatæ la polul superior. Nu au fost decelate
metastaze pe tomografia toracicæ. Strategia terapeuticæ
stabilita a presupus efectuarea unei nefrectomii radicale
stângi, cu trombectomie si limfodisectie extensivæ ca prim
pas. Se practicæ o incizie subcostalæ bilateralæ branøatæ
xifoidian øi decolare coloparietalæ bilateralæ. Iniflial se
abordeazæ partea dreaptæ pentru a se diseca vena cava
inferioaræ, trombozatæ. Artera renalæ stângæ se leagæ la
originea din aortæ. Se aplicæ tourniquet pe vena cavæ
inferioaræ imediat deasupra trombului tumoral, pe vena
cavæ infrarenalæ øi pe vena renala dreapta. Se incizeazæ
vena cavæ inferioaræ la nivelul abuøærii venei renale stângi
øi se extrage trombul tumoral urmat de cavorafie. Dupæ
aceasta se abordeazæ partea stângæ si se practicæ
nefrectomie perifascialæ standard in bloc cu
trombectomia. Având în vedere ca nu a fost læsat flesut
tumoral pe loc øi datoritæ unei largi expuneri a rinichiului
drept, se decide øi se practicæ nefrectomie polaræ
superioaræ cu hemostaza tip ligasure si plombare a patului
tumoral cu lambou de grasime.
Materials and methods. We present the case of a 64 years-old
woman admitted for abdominal pain, loss of appetite and
weight. Abdominal CT showed a massive left kidney tumor
with lateroaortic, interaoticocaval and laterocaval lymph
node enlargement and extension in the subhepatic inferior
vena cava, and a 4 cm upper pole tumor of the right kidney.
No distant metastases were revealed on the thoracic CT. The
surgical strategy involved a left radical nephrectomy, caval
thrombectomy and extensive lymph node dissection as the
first step. We made an anterior transperitoneal triradiate
incision with bilateral coloparietal dissection. First we went
on the right side in order to approach the thrombosed
inferior vena cava. The left renal artery is ligated near the
aorta. We applied a tourniquet on the suprarenal caval vein
just above the tumor thrombus, on the infrarenal cava vein
and on the right renal vein. Next we incised the inferior vena
cava at the ostium of the left renal vein with the extraction of
the thrombus and caval wall suture. Then we moved to the
left side and standard perifascial nephrectomy and en bloc
thrombectomy was performed. After that we performed an
extensive periaortocaval lymph node dissection. Considering
that we had no restant tumor tissue, and there was a wide
exposure of the right kidney, we decided to perform a right
superior polar nephrectomy in the same intervention, with
electrothermal bipolar sealing system and a fat flap
compression of the tumor bed.
nr. 2 / 2013 • vol 12
PM.7.10. Managementul unui caz
complex de tumoræ renalæ bilateralæ
asociatæ cu limfom Hodgkin
103
Rezultate. Postoperator creatinina a crescut la 2,5 mg/dl si
apoi a sczut uøor catre valori normale. Rezultatul
histopatologic a pus diagnosticul de carcinom renal cu celule
clare grad Fuhrman II øi III si limfom Hodgkin pe piesa de
limfodisecflie. Drept urmare a fost inifliat tratamentul specific
pentru limfomul Hodgkin (chimioterapie dupa schema EVA –
etoposid, vinblastin si doxorubicin). Ræspunsul a fost
favorabil si rezultatul oncologic bun la 1 an postoperator.
Results. Postoperative creatinine rose to 2.5 mg/dl and then
slowly decreased to a normal value. Histopathological
examination sowed bilateral clear cell carcinoma Fuhrman II
and III and Hodgkin lymphoma in the LND specimen.
Consequently specific treatment for Hodgkin lymphoma
(chemotherapy with an EVA protocol - etoposide, vinblastine
and doxorubicin) was initiated. Favorable response and
oncological outcome were registered at 1 year follow-up.
Concluzii. Chiar dacæ tratamentul chirurgical al tumorii
renale bilaterale presupune douæ operaflii consecutive, prima
adresatæ tumorii mai mari, o operaflie concomitentæ se poate
realiza in cazuri selecflionate. Limfodisectia in cancerul renal
are rol dublu, diagnostic øi terapeutic, øi drept urmare ar
trebui realizatæ. Tratamentul adecvat în cazul a douæ tumori
simultane poate asigura vindecarea sau îmbunætæfli
supraviefluirea.
Conclusions. Although bilateral renal tumors surgical
strategy usually involves two consecutive operations, first
addressed to the largest tumor, a concomitant operation is
possible in selected cases. LND in RCC has a double role,
diagnostic and therapeutic and must be performed. Proper
treatment of two simultaneous neoplasia could provide
healing or increase the patients’ survival.
nr. 2 / 2013 • vol 12
C. Gîngu, A. Dick, V. Cerempei, M. Hârza,
M. Manu, B. Øtefan, S. Pætræøcoiu, C. Surcel,
F. Lupu, O. Himedan, M. Cræsneanu,
Florentina Bealcu, Mihaela Mihai,
Liliana Domniøor, Ileana Constantinescu,
I. Sinescu
Usefulness of intraoperative
ultrasonography in a case of centrally
located solitary kidney tumor
C. Gîngu, A. Dick, V. Cerempei, M. Hârza,
M. Manu, B. Øtefan, S. Pætræøcoiu, C. Surcel,
F. Lupu, O. Himedan, M. Cræsneanu,
Florentina Bealcu, Mihaela Mihai,
Liliana Domniøor, Ileana Constantinescu,
I. Sinescu
Introducere øi obiective. Incidenfla totalæ a cancerului metacron
de rinichi este de 0,8% la 20 de ani, mai ridicatæ la tineri (aproximativ 1,5% la 10 ani). În cazul unui rinichi unic, nefrectomia
parflialæ este imperativæ pentru a putea fi evitatæ dializa.
Dificultatea intervenfliei chirurgicale fline mai mult de localizarea
tumorii decât de dimensiunile acesteia. Scopul acestei lucræri
este de a prezenta necesitatea ecografiei intraoperatorii într-un
caz de tumoræ renalæ solitaræ localizatæ central la un rinichi unic.
Introduction and objectives. Cumulative incidence of
metacronous renal tumors is 0.8% at a 20 year follow-up, higher
in younger patients (approximately 1.5% within 10 years). In
the case of a solitary kidney, NSS is imperative in order to avoid
dialysis. The difficulty of NSS is related to the position of the
tumor rather than its dimensions. The objective of this paper is
to present the usefulness of intraoperative ultrasonography in
a case of centrally located solitary renal tumor.
Materiale øi metodæ. Væ prezentæm cazul unui pacient de 62 de
ani, cu antecedente de tumoræ renalæ dreaptæ operatæ cu 10 ani
înainte (nefrectomie radicalæ), diagnosticat întâmplætor cu
tumoræ mediorenalæ stângæ. Aceasta avea un diametru de 3,5
cm, øi era observatæ CT la nivelul valvei posterioare renale. Luând
în considerare toate aspectele, s-a decis efectuarea unei
nefrectomii parfliale, pentru a pæstra funcflia renalæ. Intervenflia
chirurgicalæ a debutat cu lombotomie si disectia grasimii
perirenale. Din cauza cæ nu puteam identifica tumora pe
suprafafla rinichiului (nu bomba cortexul renal), am decis sæ
efectuæm o ecografie intraoperatorie pentru a decela limitele
tumorii (cu un Siemens Acuson X300 cu sondæ liniaræ de 13
MHz), în loc sæ consideræm nefrectomia radicalæ øi dializa. Apoi
am marcat limitele respective pe suprafafla rinichiului cu ajutorul
electrocauterului. Dupæ care am practicat enucleorezecflia, cu
hemostazæ tip LigaSure pe vasele importante intrarenale øi
plombarea cavitæflii restante cu lambou de græsime perirenalæ.
Clamparea arterei renale de scurtæ duratæ (5 minute) a fost
necesaræ pentru a scædea pierderile de sânge din timpul
hemostazei finale øi al suturii leziunilor de sistem pielocaliceal.
Materials and methods. We present the case of a 62 year old
male patient with a history of a right renal tumor operated 10
years prior (radical nephrectomy), who came with an incidental
diagnosis of central left renal tumor. The tumor had a diameter of
3.5 cm, and the CT scan found it to be closer to the posterior
aspect of the renal sinus. Considering all the angles we decided a
NSS was best suited, in order to preserve the renal function. The
surgical technique involved a lombotomy and perirenal fat
dissection. Because we were not able to identify the expression of
the tumor on the renal surface (it did not bulge the renal cortex),
we decided to perform an intraoperative ultrasound (using a
Siemens Acuson X300 with a 13 MHz linear array transducer) to
distinguish the limits of the tumor, instead of going directly for a
radical nephrectomy and dialysis. We then marked these limits on
the surface of the kidney with an electrocautery. We afterwards
performed an enucleoresection using LigaSure sealing system on
the main intrarenal vessels and tumor bed compression with a
perirenal fat flap. Short term (5 minutes) renal artery clamping was
needed, to reduce the blood loss while suturing the pyelocaliceal
concomitant lesions and conducting the hemostasis.
Rezultate. A fost observatæ o creøtere iniflialæ a creatininei
pânæ la 2 mg/dl, care apoi s-a remis. Postoperator a fost
Results. A temporary rise of creatinine to 2 mg/dl observed.
Postoperative urine drainage was registered and
nr. 2 / 2013 • vol 12
PM.7.11. Necesitatea ecografiei
intraoperatorii într-un caz
de tumoræ renalæ localizatæ central
pe rinichi unic
105
identificatæ o fistulæ urinaræ, fiind necesaræ introducerea unei
sonde JJ. Examenul anatomopatologic a identificat un
carcinom renal cu celule clare, grad Fuhrman 3, în stadiul
pT1a. La 6 luni dupæ intervenflie examenul CT toracic a
identificat o serie de noduli pulmonari, sugestivi pentru
determinæri secundare. S-a instituit imediat tratamentul cu
Sunitinib. La reevaluarea de 1 an pacientul nu prezintæ
semne de progresie a bolii, iar funcflia renalæ este normalæ.
Concluzii. Nefrectomia parflialæ este tratamentul de elecflie
ce permite evitarea dializei în cazurile de tumori renale pe
rinichi unic. Tumorile renale localizate central sunt cele mai
dificile astfel de cazuri. Ecografia intraoperatorie este
imperativæ pentru decelarea limitelor unei tumori care nu are
expresie pe suprafafla rinichiului.
consequently a double J stent was inserted. The
histopathological report revealed a clear cell carcinoma
Fuhrman grade 3, stage pT1a. 6 months after surgery the
patient developed pulmonary nodes suggestive for
metastasis and underwent Sunitinib treatment. At the 1 year
follow-up the patient is alive, without oncologic progression
and a normal renal function.
Conclusions. NSS avoids dialysis in cases with solitary kidney
and is the treatment of choice. Centrally located renal tumors
are the most difficult cases for NSS. Intraoperative
ultrasonography is mandatory for determining the borders
of a tumor without an expression on the kidney surface.
nr. 2 / 2013 • vol 12
B. Hæinealæ, C. Baston, M. Hârza, C. Dudu,
B. Bædescu, R. Lazær, A. Preda, C. Codoiu,
S. Margaritis, A. Nastas, C. Petcu, I. Sinescu
The treatment of renal tumors
in patients with preoperative
chronic anticoagulation and
antiplatelet therapy
B. Hæinealæ, C. Baston, M. Hârza, C. Dudu,
B. Bædescu, R. Lazær, A. Preda, C. Codoiu,
S. Margaritis, A. Nastas, C. Petcu, I. Sinescu
Introducere. În acest moment, nu existæ ghiduri clare legate de
managementul chirurgical al pacienflilor ce necesitæ tratament
cronic anticoagulant øi antiagregant. Acest studiu îøi propune o analizæ retrospectivæ a urmæririi perioperatorii a pacienflilor cu tumori renale, ce au nevoie de tratament anticoagulant permanent.
Introduction. At this moment, there are not clear guidances
about the surgical management of patients requiring chronic
anticoagulation and antiplatelet therapy. The aim of the study is
a retrospective analysis of postoperative follow-up of patients
with renal tumors who needed permanent anticoagulation.
Material øi metodæ. În perioada ianuarie 2008 – decembrie 2012
au fost operafli pentru tumori renale un numær de 1239 de pacienfli. Dintre aceøtia, 184 (14,85%) au urmat tratament antiagregant cronic øi 159 (12,83%) au urmat tratament anticoagulant
permanent. Patologia pentru care a fost urmat tratamentul a fost
reprezentat de fibrilaflie atrialæ 34 pacienfli (9,91%),proteze vasculare 46(13,41%), proteze valvulare 29 (8,45%), accident vascular cerebral 54 (15,74%), I.M.A. stentat 29 (8,45%), IMA nestentat
26 (7,58%), trombozæ venoasæ profundæ 25 (7,28%), cardiopatie
ischemicæ 79 (23,03%), trombembolism pulmonar în antecedente 7 (2,04%), tahicardie parxistica supraventricularæ 14(4,08%).
Materials and Method. Between January 2008 - December
2012 a number of 1,239 patients underwent surgery for renal
tumors. Out of these, 184 (14.85%) followed chronic antiplatelet
treatment and 159 (12.83%) followed permanent anticoagulation. Anticoagulation and antiplatelet therapy was for the treatment of: atrial fibrillation 34 patients (9.91%), vascular prosthesis
46 patients (13.41%), prosthetic valve 29 patients (8.45%), stroke
54 patients (15.74 %), acute myocardial infarction stented 29 patients (8.45%), acute myocardial infarction unstented 26 patients
(7.58%), deep vein thrombosis 25 patients (7.28%), ischemic
heart disease 79 patients (23.03%), history of pulmonary
embolism 7 patients (2.04%), supraventricular tachycardia 14 patients (4.08%).
Rezultate. Tuturor pacienflilor le-a fost oprit tratamentul
antiagregant timp de 7 zile si cel anticoagulant timp de 4 zile
preoperator øi a fost înlocuit cu heparinæ cu greutate moleculara micæ. Dintre pacienflii cu tratament anticoagulant cronic,
un numær de 41 (11,95%) a necesitat transfuzii cu mai puflin de
2 mese eritricitare, un numær de 15 (4,37%) a necesitat mai
mult de 2 mese eritrocitare, faflæ de 7,64 % respectiv 3,65% cât
au necesitat restul grupului. Complicafliile postoperatorii ale
pacienflilor cu tratament anticoagulant øi antiagregant cronic
faflæ de restul grupului au fost reprezentate de: trombembolism pulmonar 26 pacienfli (7,58%) respectiv 52 (5,80%),
infarct miocardic acut 11 pacienfli (3,20%) respectiv 17 (1,89%),
A.V.C. hemoragic 4 pacienfli (1,16%) respectiv 9 (1%) , trombozæ venoasæ profundæ 17 pacienfli (4,95%) respectiv 36
(4,01%), hematoame 21 pacienfli (6,12%) respectiv 49 (5,46%).
Concluzii. Pacienflii cu tumori renale cu tratament cronic antiagregant øi anticoagulant necesitæ o pregatire øi urmærire perioperatorie specialæ, fiind nevoie de un atent echilibru între riscul
de sângerare øi riscul de trombembolism. Nu a existat o creøtere
importantæ a ratei complicafliilor sau a mortalitæflii în cazul pacienflilor cu tratament anticoagulant sau antiagregant cronic de
aceea acesta nu trebuie sæ reprezinte un impediment în calea
abordului chirurgical al acestora.
nr. 2 / 2013 • vol 12
PM.7.12. Tratamentul tumorilor
renale în cazul pacienflilor cu
tratament anticoagulant øi
antiagregant cronic preoperator
Results. All patients had stopped antiplatelet therapy for 7 days
and the anticoagulant for 4 days preoperatively and the therapy
was replaced with low molecular weight heparin. Out of patients
with chronic anticoagulant therapy, a total of 41 (11.95%) required transfusions of less than 2 BU, a total of 15 (4.37%) required for
more than 2 BU, compared to 69 patients (7.70%) and 32 (3.57%)
as required the rest of the group. Postoperative complications in
patients with chronic anticoagulant and antiplatelet therapy
compared to the rest of the group were: pulmonary embolism 26
patients (7.58%) vs. 52 (5.80%), acute myocardial infarction 11
patients (3.20%) vs. 17 (1.89%), stroke hemorrhagic 4 patients
(1.16%) vs. 9 (1%), deep vein thrombosis 17 patients (4.95%) vs 36
(4.01%), hematomas 21 patients (6.12%) vs. 49 (5, 46%).
Conclusion. Patients with renal tumors and chronic antiplatelet and anticoagulant therapy require special perioperative preparation and medical care, providing a careful balance between the risk of bleeding and the risk of thromboembolism. There was no significant increase in complications or mortality rate in patients with chronic anticoagulation or antiplatelet therapy, that is why it should not be an
impediment to their surgical approach.
107
PM.7.13. Nefrectomia parflialæ
laparoscopicæ asistatæ de robotul
Da Vinci Si FullHD (RAPN)
L. Grad, N. Criøan, T. Hodor, T. Botezan,
R. Mænescu, I. Coman
Secflia Clinicæ de Urologie,
Spitalul Clinic Municipal Cluj-Napoca
Robot-assisted (Da Vinci Si FullHD)
laparoscopic partial nephrectomy
(RAPN)
L. Grad, N. Criøan, T. Hodor, T. Botezan,
R. Mænescu, I. Coman
Department of Urology,
Municipal Hospital Cluj-Napoca
Introducere øi obiective. Învazivitatea minimæ øi conservarea funcfliei renale sunt obiectivele impuse de progresele
tehnice înregistrate în ultimii ani în chirurgia tumorilor renale
aflate în stadiul T1. Prezentæm experienfla inifliala, precum øi
tehnica operatorie practicatæ în cazul nefrectomiei parfliale
laparoscopice asistata robotic.
Introduction and Objectives. Minimal invasiveness and
preservation of renal function are the targets imposed by
technical progress in recent years in urologic surgery in stage
T1 of renal tumors. We present the initial experience and
surgical technique practiced for robot-assisted laparoscopic
partial nephrectomy.
Materiale øi Metodæ. Se practicæ abordul lomboscopic cu 5
trocare dupæ cum urmeazæ: - trocarul de 12 mm pentru optica
robotului, - douæ trocare de 8 mm pentru braflele robotului, un trocar de 10 mm øi unul de 5 mm pentru ajutor. Incizia
fasciei Gerota este urmatæ de disecflia circumferenflialæ a
rinichiului cu izolarea pediculului renal øi identificarea venei øi
arterei renale. În continuare se izoleazæ formafliunea tumoralæ
cu incizia capsulei renale circumferenflial tumorii. Se
clampeazæ vena øi artera renalæ cu notarea timpului de debut
al ischemiei calde. Excizia formafliunii tumorale øi hemostaza
cu fire resorbabile 2.0. Se declampeazæ elementele
pediculului vascular cu observarea transei de rezecflie. În final
se monteazæ drenaj lombar øi se închid punctele de abord.
Materials and methods. Lomboscopic approach with 5
trocars is practiced as follows: - 12 mm optical robot trocar, two 8 mm trocars for robotic arms, - a 10-mm and a 5-mm
trocars for assistant. Gerota fascia incision followed by
circumferential dissection of the kidney with renal pedicle
isolation and identification of the renal vein and artery. It
further isolates the tumor with tumor circumferential
incision kidney capsule. The renal artery and vein clamping;
noting the time of onset of warm ischemia. Excision of tumor
formation and haemostasis with absorbable suture 2.0.
Declamping of the vascular pedicle elements and
observation of resection trance. Finally lumbar drainage is
installed and close approach points.
Rezultate. În perioada ianuarie 2010–martie 2013 am
practicat un numær de 14 nefrectomii parfliale laparoscopice
asistate robotic. Timpul operator mediu a fost de 298 (220370) minute, iar timpul de ischemie caldæ a fost de 25 (19-32)
minute, cu o pierdere sangvinæ medie de 305 (210-520) ml. În
ceea ce priveøte rezultatele oncologice, 13 din 14 pacienfli au
prezentat margini de rezecflie negative.
Results. During january 2010-march 2013 a total of 14
robotic-assisted laparoscopic partial nephrectomies are
practiced. The average operative time was 298 (220-370)
minutes and warm ischemia time was 25 (19-32) minutes,
with a mean blood loss of 305 (210-520) ml. Regarding
oncologic outcomes 13 of 14 patients had negative resection
margins.
Concluzii. RAPN este o metodæ siguræ øi fezabilæ în mâinile
unui chirurg experimentat în laparoscopie. Beneficiile RAPN
sunt: estetic, invazivitatea minimæ, timpul de spitalizare scurt.
Sub aspect oncologic trebuie evaluate rezultatele pe termen
lung printr-o bunæ urmærire a pacienflilor postoperator.
Conclusions. RAPN is safe and feasible in the hands of an
experienced laparoscopic surgeon. Benefits of RAPN are:
aesthetically, minimal invasiveness, short hospitalization
time. In terms of oncological long-term results patients
should be evaluated by a proper follow up after surgery.
nr. 2 / 2013 • vol 12
Partial nephrectomy versus radical
nephrectomy – indication and
postoperative evolution
G. Plugaru, V. Florescu, I. Lica, D. Toma
Chirurgie Generalæ II, Compartiment Urologie,
Spitalul Clinic de Urgenflæ Bucureøti
G. Plugaru, V. Florescu, I. Lica, D. Toma
General Surgery II, Urology Department,
Emergency Clinic Hospital Bucharest
Introducere. Tumorile renale parenchimatoase reprezintæ
2%-3% din totalul neoplasmelor maligne ale populafliei adulte.
Introduction. Parenchymal renal tumors represent 2% -3%
of all malignant neoplasms of the adult population.
Material øi metodæ. Înperioada 2005 2012 au fost efectuate
104 intervenflii chirurgicale pentru tumori renale
parenchimatoase dintre care 74 nefrectomii radicale si 30 de
nefrectomii parfliale, vârsta pacienflilor fiind cuprinsæ intre 17
øi 82 de ani iar diametrul tumorii renale fiind între 1, 5 si 35 de
cm. Diametrul tumorilor renale la care s-a efectuat
nefrectomie parflialæ a fost între 1,5 si 7,5 cm. Limita de
siguranflæ oncologicæ a fost între 0,1 si 1 cm.
Material and method. Between 2005 and 2012 were
performed 104 surgical operations for renal parenchymal
tumors of which 74 radical nephrectomy and 30 partial
nephrectomy, patient age ranging between 17 and 82 years
and renal tumor diameter was between 1, 5 and 35 cm.
Diameter of the renal tumors undergoing partial
nephrectomy was between 1.5 and 7.5 cm. Oncological
safety margin was between 0.1 and 1 cm.
Rezultate øi concluzii. Pacienflii care au fost tratafli chirurgical
prin nefrectomie parflialæ (chirurgie roboticæ sau chirurgie
clasicæ) au prezentat evoluflie postoperatorie simplæ. Un caz
deosebit a fost al unei paciente in vârstæ de 20 de ani care la 3
ani postoperator a dat naøtere la doi gemeni.
Nefrectomia parflialæ prezintæ o opfliune de tratament siguræ cu
rezultate excepflionale in timp, pentru pacienfli bine selecflionafli.
Results and conclusions. Patients who were treated
surgically by partial nephrectomy (robotic surgery orclassical
surgery) had simple postoperative evolution. A special case
was of a patient aged 20 years who gives birth twins after 3
years since surgery.
Partial nephrectomy represents a reliable treatment option
with very good results over time for well selected patients.
nr. 2 / 2013 • vol 12
PM.7.14. Nefrectomia parflialæ
versus nefrectomia radicalæ –
indicaflie øi evoluflie postoperatorie
109
PM.7.15. Rezultatele tratamentului
adjuvant cu Sutent la pacienflii cu
nefrectomie citoreductivæ în
tumorile renale – stadiul regional
avansat sau/øi cu metastaze
1
2
Outcome of patients with
cytoreductive nephrectomy and
adjuvant treatment with angiogenesis
inhibitors for renal tumors in local
advanced stage ± metastases
3
G. Glück , Dana Stænculeanu , Monica Hortopan ,
1
1
Manuela Chiriflæ , I. Sinescu
1
2
„Alexandru Trestioreanu” Oncologic Institute
Bucharest
3
Department of Anatomopathology, Fundeni
Clinical Institute
Scop. Evaluarea tratamentului adjuvant cu inhibitori ai
angiogenezei la pacienflii cu nefrectomie citoreductivæ
pentru cancer renal local avansat/metastazat.
Purpose. Management of angiogenesis inhibitors therapy in
patients with cytoreductive nephrectomy for locally
advanced disease/metastases in renal tumors.
Pacienfli øi metodæ. Un numær de 9 pacienfli au fost incluøi în
studiu. Evaluarea preoperatorie a pacienflilor a constat în recoltarea analizelor sanguine curente, ecografie abdominalæ, examinare tomograficæ abdominalæ, radiografie toracopulmonaræ sau
tomografie de torace în caz de suspiciune de metastaze pulmonare. Lotul analizat cuprinde 6 bærbafli øi 3 femei, cu diagnosticul
de carcinom renal cu celule clare în 8 cazuri øi un caz de carcinom
renal cu celule cromofobe. Stadierea postoperatorie a relevat T2
în 2 cazuri øi T3 în 7 cazuri, N0 în 5 cazuri, N1 în 4 cazuri, cu metastaze prezente la 8 pacienfli, dintre care 6 la momentul diagnosticului (pulmonare – 6 cazuri, incluzând øi un caz de metastaze
pulmonare în asociere cu metastaze în ambele glandele suprarenale, osoase – 1 caz, glande suprarenale – 2 cazuri). Pacienflii au
fost urmærifli pe o perioadæ medianæ de 42 luni (între 3 øi 93 luni).
Patients and methods. The study included 9 patients, 6 men
and 3 women with histopathologic diagnosis of clear cell renal
carcinoma in 8 cases and cromophobe cell renal carcinoma in
one case. Postoperative follow-up protocols consisted of
blood tests, abdominal echography and CT scan, chest
radiography or CT scan if lung metastases are suspected. There
were 2 cases reported with T2 and 7 cases with T3 and positive
lymphnodes in 4 cases. 8 patients were detected with
metastases, of which 6 had systemic disease at time of
presentation (6 patients with lung metastases, including one
case with both lung and adrenal metastases, 1 patient with
bone metastases and 2 cases of adrenal metastases). Median
follow-up was 42 months (between 3 and 93 months).
G. Glück , Dana Stænculeanu , Monica Hortopan ,
1
1
Manuela Chiriflæ , I. Sinescu
1
Clinica de Chirurgie Urologicæ øi Transplant
Renal - Institutul Clinic „Fundeni”
2
Institutul Oncologic Bucureøti „Alexandru
Trestioreanu”
3
Serviciul de Anatomie Patologicæ – Institutul
Clinic „Fundeni”
Rezultate. Tofli pacienflii incluøi în studiu sunt în viaflæ, cu o supraviefluire medianæ de 42 luni (între 3 øi 93 de luni). Tratamentul
adjuvant a avut indicaflie postoperatorie în 6 cazuri decelate cu
metastaze (5 pacienfli) sau boala avansatæ locoregional (1 pacient) la momentul diagnosticului øi la distantæ în 3 cazuri când
tomografic s-a decelat evoluflie de boalæ. Pe tot parcusul
tratamentului cu Sutent pacienflii au prezentat status ECOG = 0.
Concluzii. Tratamentul integrat chirurgical (nefrectomia citoreductivæ) alæturi de cel adjuvant la pacienflii cu tumori renal
metastazate reprezintæ o soluflie optimæ în astfel de cazuri, oferind un prognostic favorabil în ceea ce priveøte evoluflia bolii neoplazice øi prelungind astfel durata de viaflæ. Nu sunt de neglijat
costurile unei asemenea medicaflii, cât øi efectele secundare.
1
2
3
Results. All patients included in the study are alive, with a
median survival period of 42 monts (between 3 and 93 months).
Adjuvant treatment was indicated postoperative in 6 cases - 5
patients with metastases and 1 patient with locally advanced
disease. 3 patients were put under adjuvant treatment when CT
scan revealed tumoral progression. All patients had ECOG = 0 at
each follow-up during treatment with Sutent.
Conclusions. The association between surgery and adjuvant
therapy for metastatic renal cancer offers a fair option for
such cases, leading to a better prognosis and prolonging
survival time. Also, it is of great significance to take into
consideration the costs of the treatment and even more, its
side effects.
nr. 2 / 2013 • vol 12
Ultrasound guided percutaneous
nephrostomy in urological practice
A.Tænase, D. Tænase, E. Ceban, A. Oprea,
I. Dumbræveanu, A. Galescu
USMF “N.Testemiflanu”, Clinica Urologie, Spitalul
Clinic Republican, Chiøinæu, R. Moldova
A.Tænase, D. Tænase, E. Ceban, A. Oprea,
I. Dumbræveanu, A. Galescu
State University of Medicine and Pharmacy
„N. Testemiflanu“, Departament of Urology,
Republican Clinical Hospital, Chiøinau, Republic
of Moldova
Obiective: Evaluarea metodei de derivaflie urinaræ prin
nefrostomie percutanatæ ecoghidatæ în obstrucfliile cæilor
urinare superioare.
Objectives: Evaluation of urinary derivation method by
percutaneous ultrasound guided nephrostomy (PUGN) in
the obstruction of the upper urinary tract.
Materiale øi metode: Au fost studiate rezultatele a 118
intervenflii în perioada anilor 2007-2012, efectuate în clinica
de Urologie a IMSP Spitalul Clinic Republican, Chiøinæu,
Republica Moldova. Indicafliile pentru instalarea nefrostomiei
percutanate au fost: 1) Uropatia obstructivæ litiazicæ, cu sau
færæ IRA, urmatæ de grave tulburæri metabolice øi
hidroelectrolitice øi/sau stare septicæ asociatæ; 2) Obstrucflia
ureterului a unicului rinichi chirurgical sau congenital; 3)
Leziuni iatrogene a ureterului în urma intervenfliilor
ginecologice (ureter ginecologic); 4) Obstrucflia urinaræ
cauzatæ de stenoza joncfliunii pieloureterale (JPU), ca prim
pas în deblocarea rinichiului; 5) Obstrucflia cæilor urinare prin
compresiunea ureterului (ureterelor) de cætre neoplasme cu
punct de plecare din micul bazin sau intestine; 6)
Hidronefrozæ de gradul III-IV complicatæ cu pionefrozæ.
Contraindicaflii pentru instalarea nefrostomei: Absenfla
abordului liniar al puncfliei ecoghidate prin triunghiul de
acces Petite. Din 118 pacienfli, 66 (56,4%) - femei øi 52 (43,6%)
- bærbafli, vârsta fiind cuprinsæ între 26 øi 80 ani, cu o medie de
54,14 ± 6,8 ani. Intervenfliile au fost efectuate cu ajutorul
ecografului Philips HD3 dotat cu un transductor special
pentru puncflie-biopsie. În toate cazurile au fost utilizate
seturi de nefrostome de o singuræ folosinflæ. Suportul
anestetic a fost îmbinat: anestezie localæ + i/v.
Materials and Methods: We retrospectively evaluated the
results of 118 PUGN performed between 2007-2012. All of
interventions were made in the Departament of Urology,
Republican Clinical Hospital, Chisinau, Republic of Moldova.
The indications for installation PUGN were: 1) Lithiasic
obstructive uropathy with or without Acute Renal Failure,
followed by severe metabolic and electrolyte disorders and /
or associated sepsis;
2) reteral obstruction in a unique kidney (congenital or
surgical); 3) Ureteral injury during gynecologic surgery; 4)
Urinary obstruction caused by pyeloureteral junction
stenosis, as a first step towards unlocking the kidney; 5)
Urinary obstruction by extrinsec compression of the ureter cancers that start in the pelvic or bowels; 6) Hydronephrosis
grade III and IV complicated with pionephrosis.
Contraindications for install nephrostomy: Absence of linear
puncture approach through Petite triangle access. From 118
patients, 66 (56.4%) - females and 52 (43.6%) - males, age
ranging between 26 and 80 years, with an average of 54.14 ±
6.8 years. Interventions were performed using Philips HD3
ultrasound device has a special biopsy transducer. In all cases
were used nephrostomy sets for single use. Anesthetic
support was combined - local and intravenous.
Rezultate: Patologiile care au necesitat efectuare nefrostomiei
percutanate au fost urmætoarele: 1) Ureterohidronefroze
obstructive uropatice cu IRA secundaræ – 66 (55,9%) cazuri; 2)
Obstrucflii prin compresiune de origine neoplasicæ – 26 (22,0%)
cazuri; 3) Hidronefroze gr. III-IV infectate pânæ la pionefroze –
16 (13,6%) cazuri; 4) Leziuni iatrogene a ureterului (ureter
ginecologic) – 5 (4,2%) cazuri
1. Hidronefroze prin stenoza JPU – 4 (3,4%) cazuri; 5) Litiaza
rinichiului transplantat – 1 (0,9%) caz;
nr. 2 / 2013 • vol 12
Varia
PN.1. Nefrostomia percutanatæ
ecoghidatæ în practica urologicæ
Results: Pathologies requiring installation of PUGN were: 1)
Obstructive uropathy, ureterohydronephrosis with
secondary acute renal failure - 66 (55.9%) cases; 2) Urinary
obstruction by extrinsec tumors compression of the ureter 26 (22.0%) cases; 3) Hydronephrosis grade III and IV
complicated with pionephrosis - 16 (13.6%) cases; 4) Ureteral
injury during gynecologic surgery - 5 (4.2%) cases. 5)
Hydronephrosis caused by pyeloureteral junction stenosis - 4
(3.4%) cases; 6) Lithiasis in transplanted kidneys - 1 (0.9%)
cases.
111
Varia
Concluzii: 1) Aplicarea nefrostomiei percutanate în uropatiile
obstructive, cu sau færæ IRA, este o metodæ de elecflie în
prevenirea unor complicaflii majore incompatibile cu viafla øi o
etapæ importantæ pânæ la efectuarea intervenfliilor radicale
(uretero-pielolitotomia, etc.). 2) La pacienflii septici
decompensafli, preponderent în etate, nefrostomia ad minima
are indicaflii vitale øi reprezintæ soluflia de elecflie în
tratamentul indicat. 3) Nefrostomia percutanatæ în caz de
pionefrozæ a permis efectuarea ulterior a nefrectomiei la rece.
4) În leziunile ureterale iatrogene – ureterul ginecologic,
nefrostomia percutanatæ permite pæstrarea funcfliei rinichiului
afectat pânæ la intervenflia chirurgicalæ indicatæ în mod
planificat (neoureterocistoanastomoza). 5) În obstrucflia cæilor
urinare de origine neoplasicæ, nefrostomia percutanatæ poate
fi o metodæ temporaræ, pânæ la rezolvarea definitivæ a unei
alte derivaflii urinare sau permanentæ, pe tot parcursul vieflii. 6)
Aplicarea nefrostomiei percutanate ecoghidate în obstrucfliile
cæilor urinare superioare a îmbunætæflit atât diagnosticul, cât øi
tratamentul de urgenflæ a patologiilor renale obstructive.
Conclusions: 1) Application of PUGN in obstructive uropathy
with or without Acute Renal Failure, is a method of choice in
the prevention of major complications incopatibile of life
and an important step to make radical interventions
(ureteropyelolithotomy). 2) At the patients with severe sepsis
and older age - percutaneous nephrostomy have a vital
indications and a solution of choise in the treatment. 3) In
pyonephrosis the percutaneous nephrostomy give a
possibility to make a planic operation.4) In ureteral injury
during gynecologic surgery the percutaneous nephrostomy
give a posibility to keep the function of affectet kidney until
planned operation is indicate - implatation of the ureter in
urinary bllader. 5) In urinary obstruction by tumors
percutaneous nephrostomy can be a temporary method
until the permanent and final urination derivation. 6
)Application of percutaneous guided nephrostomy in
obstructions of the upper urinary tract improved the
diagnosis and the emergency treatment in the obstructive
kidney disease.
nr. 2 / 2013 • vol 12
1
2
1
3
Successful endovascular exclusion of
a arterio-ureteral fistula
1
2
1
3
R. Stoica , L. Zarma , G. Glück , R. Dumitru ,
1
I. Sinescu
1
2
3
Clinica de Chirurgie Cardiovascularæ, Clinica de
Radiologie, Institutul Clinic Fundeni, Bucureøti
R. Stoica , L. Zarma , G. Glück , R. Dumitru ,
1
I. Sinescu
1
2
Urology Department, Cardiovascular
3
Department, Radiology Department
“Fundeni Clinical Institute”, Bucharest, Romania
Introducere. Fistula uretero-arterialæ este o patologie foarte
raræ øi cu risc vital crescut de hematurie.
Introduction. Uretero-arterial fistula is a rare but lifethreatening cause of hematuria.
Prezentare de caz. Prezentæm cazul unei paciente în vârstæ
de 72 de ani cu hematurie severæ la nivelul uereterostomiei
cutanate survenitæ dupæ înlocuirea stenturilor într-un
serviciu secundar. Pacienta a suferit în urmæ cu 2 ani, pentru
cancer de col uterin, radioterapie neoadjuvantæ øi ulterior
exenteraflie pelvinæ anterioaræ roboticæ cu ureterostomie
cutanatæ stentatæ 8 Ch bilateral. Examenul CT relevæ:
hidronefrozæ stângæ gr.III, cu multiple cheaguri în pelvisul
renal øi ureterul lombar øi ridicæ suspiciunea unei fistule
uretero-vasculare. Angiografia confirmæ prezenfla fistulei
între ureter øi artera iliacæ comunæ stângæ. În acelaøi timp
angiografic, se practicæ angioplastie percutanæ utilizând
stent-graft autoexpandabil (30/10 mm). Evoluflia postop a
fost favorabilæ cu remiterea hematuriei, pacienta urmând
tratament antiagregant permanent. Controlul la 4 luni
postprocedural aratæ reiterea hidronefrozei øi a hematuriei.
Case presentation. We report a case of intermittent severe
bleeding through a cutaneous urostomy in a 72 yrs old
female patient. She had radiation therapy and underwent
robotic anterior pelvic exenteration for cervix cancer,
cutaneus urostomy with 8 Fr. ureteral stent placement. After
two years she is admitted for severe anemia and intermittent
gross hematuria appeared after ureteral stents replacement
in a secondary unit. CT scan reveals: stage III left
hydronephrosis, multiple blood cloths on left renal pelvis
and lumbar ureter and suspects uretero-vascular fistula.
Angiography reveals uretero-arterial fistula between the left
ureter and the left common iliac artery. Percutaneous
angioplasty using autoexpandable graft stent (30/10 mm)
with occlusion of the fistula was performed and the left
ureteric stent was withdrawn at the aponevrotic level.
Postoperative evolution was favourable under permanent
antiaggregant therapy.
Concluzii. Istoricul de chirurgie pelvinæ cu sau færæ terapie de
iradiere reprezintæ un factor de risc ridicat pentru dezvoltarea fistulelor uretero-vasculare la pacientul cu derivaflii
urinare cutanate. Angioplastia cu stent-graft reprezintæ o
tehnicæ minim-invazivæ eficientæ în rezolvarea acestor fistule
cu condiflia unui diagnostic precoce øi identificærii cu
acuratefle a sediului fistului.
nr. 2 / 2013 • vol 12
Varia
PN.2. Fistulæ arterio-ureteralæ –
rezolvare angioplasticæ percutanatæ
Conclusions. Urologists should consider the risk of this
clinical entity after long term ureteral stenting with a history
of pelvic surgery and/or pelvic irradiation. Percutaneous
stent graft placement appears to be an effective and safe
therapeutic alternative, especially in these patients who
frequently present surgical risk factors.
113
Varia
PN.3. Fistulæ uretero-aorticæ. Status
postcistectomie radicalæ cu
ureterostomie cutanatæ dreaptæ în
„fleavæ de puøcæ“
A. Filip, N. Stoican, N. Dobromir
Spitalul Judeflean „Sf. Ioan Cel Nou“ Suceava –
Secflia Urologie
Uretero-aortic fistula after total
cystectomy with a single stoma
cutaneous ureterostomy right
A. Filip, N. Stoican, N. Dobromir
Emergency County Hospital of Suceava –
Introducere. Fistula uretero-aorticæ reprezintæ o complicaflie
rarisimæ dupæ stentare ureteralæ prelungitæ a ureterului stâng
la pacienflii cu ureterostomie dreaptæ, care necesitæ trecerea
peste aortæ a ureterului stâng.
Introduction: Uretero-aortic fistula is a very rare
complication after prolonged ureteral stenting in patients
with left ureter cutaneous ureterostomy stoma right aorta
requiring crossing left ureter.
Prezentare de caz. Pacientul T.N. de 67 ani, operat în nov. 2012
pentru tumoræ vezicalæ infiltrativæ pT3G3, prin cistectomie
radicalæ øi ureterostomie cutanata dreaptæ ’’în fleavæ de puøcæ’’,
uretere cateterizate bilateral cu splint 8 Ch, se prezintæ la spital
de urgenflæ pentru hematurie totalæ intermitentæ de
aproximativ 3 zile pe splintul ureteral stâng, stare generalæ
alteratæ, febræ, anemie severæ. CT abdomino-pelvin: rinichi stâng
de aspect pielonefritic, cu prezenfla a multiple hematoame
pielo-caliceale. Se practicæ nefrectomie stângæ pe cale lombaræ
cu rezecflia ureterului juxta-aortic. La sfârøitul intervenfliei
prezenfla unei fistule aorto-ureterale este diagnosticatæ prin
persistenfla hematuriei masive pulsatile pe bontul ureteral
restant stâng, motiv pentru care se intervine de urgenflæ prin
laparotomie medianæ xifo-ombilicalæ, cu izolarea ureterului
restant stâng, secflionarea si dubla ligaturæ juxta-aorticæ dreaptæ,
cu pæstrarea unui lambou ureteral la nivelul fistulei aortice øi
abandonarea bontului ureteral restant. Evoluflie postoperatorie
favorabilæ, cu îmbunætæflirea stærii generale.
Case presentation: Patient T.N. for 67 years, operated Nov.
2012 for infiltrative bladder tumor pT3G3 by radical
cystectomy with cutaneous ureterostomy stoma, ureters
catheterized bilaterally with 8ch stenting is presented to the
hospital emergency total intermittent hematuria about 3
days left ureteral stenting, malaise, fever, severe anemia
computed tomography (CT): left kidney pyelonephritis
aspect, the presence of multiple hematomas pelvis
pyelonephritis. In practice left nephrectomy through the
lumbar ureter juxta-aortic resection. At the end of the
intervention the presence of aorto-ureteral fistula is
diagnosed by persistent hematuria pulsatile mass on the
remaining ureteral stump left, which is why urgent action
xifo-umbilical median laparotomy with isolation of the left
ureter remaining, cutting and double ligature right juxtaaortic while keeping an aortic flap ureteral fistula and the
ureteral stump remaining abandonment. Postoperative the
overall condition was favourable.
Discuflii si Concluzii: Deøi formarea fistulei între tractul
urinar øi sistemul arterial este o manifestare clinicæ raræ, critic
øi esenflial pentru a salva pacientul este diagnosticul corect øi
tratamentul chirurgical de urgenflæ. Fistula uretero-aorticæ
poate sæ aparæ în asociere cu cateterismul ureteral prelungit,
chirurgie pelvinæ, radioterapie anterioare, boala vascularæ øi
patologie vascularæ. Opfliunile sunt diferite în ceea ce
priveøte tratamentul fistulei uretero-aortice. El ar trebui sæ
includæ repararea arterei øi ureterului dupæ caz, în parte. Rata
morbiditæflii øi mortalitatea pentru aceastæ categorie de
pacienfli ræmâne ridicatæ (20-30%- literatura americanæ).
Discussion and Conclusions: Although fistula formation
between the arterial system and the urinary tract is a rare
clinical manifestation, critical and essential to save the
patient’s correct diagnosis and emergency surgery. Ureteroaortic fistula may occur in association with prolonged
ureteral catheterization, pelvic surgery, previous
radiotherapy, vascular disease and vascular disease. The
options differ in the treatment of uretero-aortic fistula. It
should include repairing the artery and ureter after case.
Morbidity and mortality in these patients remains high (2030% - American literature).
nr. 2 / 2013 • vol 12
The management of ureteropelvic
junction obstruction
D. Diaconescu, B. Braticevici, Y. Salaheddin,
V. Ambert, M. Popescu, V. Jinga, F. Benguø,
I. Dragomireøteanu, G. Roøoga, M. Mansour,
C. Cælin, C. Necoaræ
Departamentul de urologie, Spitalul
“Prof. Dr. Th. Burghele”, Bucureøti, România
D. Diaconescu, B. Braticevici, Y. Salaheddin,
V. Ambert, M. Popescu, V. Jinga, F. Benguø,
I. Dragomireøteanu, G. Roøoga, M. Mansour,
C. Cælin, C. Necoaræ
Department of urology, “Prof. Dr. Th.Burghele”
Clinical Hospital Bucharest, Romania
Introducere. Pieloplastia ræmâne “gold standard-ul” tratamentului sindromului de joncfliune pieloureteralæ. Tehnicile minim invazive laparoscopice øi endoscopice deflin un rol important în
managementul stenozei de joncfliune pieloureteralæ. În scopul
identificærii limitelor metodelor øi a unei mai bune stabiliri a indicafliilor, am realizat un studiu retrospectiv bazat pe cazurile rezolvate în clinicæ.
Material øi metodæ. Studiul a fost efectuat pe o perioadæ de 3 ani:
ianuarie 2010 – decembrie 2012 øi include 131 pacienfli (68 femei
øi 63 bærbafli), cu vârste cuprinse între 17 øi 70 ani (36.9 ani), cu
stenoze ale joncfliunii pieloureterale primare sau secundare. Tehnicile utilizate în tratamentul obstrucfliei de joncfliune pieloureteralæ sunt: endopielotomia anterogradæ transpielicæ (13 pacienfli),
pieloplastia laparoscopicæ transperitonealæ (46 cazuri) asistatæ sau
nu robotic (5 cazuri) øi pieloplastia clasicæ (67 pacienfli). Evaluarea
preoperatorie a cuprins analizarea probelor bioumorale, urocultura, ecografia (Doppler - vase aberante), UIV, ureteropielografia
retrogradæ preoperator øi/sau tomografia computerizatæ abdominalæ cu substanflæ de contrast scintigrafia renalæ.
Rezultate. În grupul pacienflilor cu pieloplastie laparoscopicæ
rata de succes a fost de 95.65%, durata medie a intervenfliei
chirurgicale a fost de 160 de minute øi durata de spitalizare
postoperatorie a fost de 5.43 de zile, în timp ce în grupul
pacienflilor cu endopielotomie percutanatæ rata de succes a
fost de 92,3%, cu un timp operator de 50 minute øi o perioadæ
de spitalizare de 6.9 zile, în condifliile în care în grupul
pacientilor cu pieloplastie clasica tip Heynes-Anderson rata
de success a fost de ( 97,01% ), cu timp operator de 80 de
minute øi o perioadæ de spitalizare de 8,68 de zile. Evaluarea
clinicæ øi imagisticæ (ecografie RV,UIV øi scintigrafie renalæ) a
pacienflilor s-a fæcut la 3 luni postoperator.
Concluzii. Pieloplastia ræmâne “gold standard-ul” tratamentului
sindromului de joncfliune pieloureteralæ. Pieloplastia laparoscopicæ are rezultate comparabile cu chirurgia clasicæ atunci când
abilitæflile tehnice ale echipelor chirurgicale pot fi comparate.
Endopielotomia anterogradæ transpielicæ reprezintæ o metodæ
terapeuticæ minim invazivæ cu o ratæ de succes importantæ în
cazul stabilirii corecte a indicafliei chirurgicale, rezultatele
depinzând, însæ, semnificativ de experienfla operatorului.
nr. 2 / 2013 • vol 12
Varia
PN.4. Tratamentul sindromului de
joncfliune pielo-ureteralæ
Purpose. The open pyeloplasty remains the gold standard
for treating ureteropelvic junction obstruction. The
minimally invasive technique, endourology and laparoscopy
have an important role in the management of upper tract
stenosis. We present our results for the treatment of
ureteropelvic junction obstruction.
Material and methods. This is a retrospective study which took
place between 01.01.2010 and 31.12.2012 in the “Prof Th
Burghele” hospital, on a number of 131 patients with ureteropelvic junction obstruction. A total of 68 females and 63 males
with a mean age of 36.9 years suffering from ureteropelvic
junction obstruction were treated with percutaneous endopyelotomy and laparoscopic or open dismembered pyeloplasty
and followed for 3 months. Diagnosis was based on findings of
ultrasound, excretory urography, retrograde ureteropyelography. In cases of ureteral kinking color duplex sonography and
spiral computerized tomography were performed. In 13 patients
with UPJ stenosis percutaneous endopyelotomy was performed,
while the 113 patients remaining were treated with open
pyeloplasty (67 cases) and laparoscopic pyeloplasty (46 cases).
Results. In the laparoscopic group (success rate 95.65%),
mean operation time was 160 minutes, days of hospitalization
were 5.43. In the endopyelotomy group (success rate of
92.3%) the aforementioned variables were 50 minutes, 6.9
days, respectively. In the open group (success rate of 97.01%)
aforementioned variables were 80 minutes, 8,68 days. Shortterm follow up excretory urography and/or diuretic renal scan
demonstrated improvement in all patients.
Conclusions. The open pyeloplasty remains the gold
standard for treating ureteropelvic junction obstruction.
Laparoscopic dismembered pyeloplasty, although technically
challenging, provides excellent results for primary or
secondary ureteropelvic junction stenosis Percutaneous
endopyelotomy should be the treatment for selected cases of
ureteropelvic junction obstruction, if the surgery is performed
by an experienced percutaneous surgeon.
115
Varia
PN.5. Tratamentul endoscopic al
ureterocelului ortotopic cu sau færæ
litiazæ secundaræ
Endoscopic management of adult
orthotopic ureterocele and
associated calculi
M. Manu, C. Gîngu, C. Surcel, I. Prie, A. Davidescu,
Rucsandra Manu, C. Dudu, S. Pætræøcoiu,
1
1
Liliana Domniøor , Carmen Savu , I. Sinescu
1
Clinica de ATI, Institutul Clinic “Fundeni”,
Bucureøti
M. Manu, C. Gîngu, C. Surcel, I. Prie, A. Davidescu,
Rucsandra Manu, C. Dudu, S. Pætræøcoiu,
1
1
Liliana Domniøor , Carmen Savu , I. Sinescu
Transplantation,
1
ICU Department, Fundeni Clinic Institute,
Bucharest
Introducere. Ureterocelul este definit ca o dilataflie sacularæ
a ureterului terminal intramural, protruziva în vezica urinaræ,
posibil cauzatæ de o posibilæ stenozæ congenitalæ a meatului
ureteral. Aceasta malformaflie nu este aøa raræ, uneori trece
nedescoperitæ øi diagnosticul poate fi dificil øi færæ un
tratament corect poate duce la pierderea unitæflii renale.
Introduction. Ureterocele is defined to be a “saccular
dilation of the terminal portion of the ureter that protrudes
into the lumen of the urinary bladder, probably due to a
congenital stenosis of the ureteric orifice meatus”. This
malformation is not so rare, and can conduct without a
proper treatment to severe renal damage and finally to
kidney lost.
Pacienfli øi metode. Studiul nostru se întinde pe o perioadæ
de 10 ani, între ianuarie 2003 øi ianuarie 2013, în Centrul
noastru au fost admiøi 46 de pacienfli adulfli cu ureterocel
ortotopic. 42 cazuri au prezentat ureterocel unilateral øi 4
cazuri bilateral, cu un total de 50 de ureterocele. 28 de cazuri
au prezentat litiazæ secundaræ în ureterocel øi 9 cazuri litiazæ
renalæ secundaræ pe unitatea renalæ implicatæ. Tratamentul
de elecflie a fost endoscopic øi a implicat rezecflia
ureterocelului asociatæ când a fost cazul cu extragerea
calculului øi litotriflia sa balisticæ, mecanicæ sau laser. În 9
cazuri de litiazæ renalæ asociatæ s-a procedat ESWL cu rezultat
stone free 90%. 38 pacienfli au putut fi urmærifli ecografic øi
urografic la 6 luni øi la 12 luni, færæ a se putea evidenflia
restanfla sau recidiva ureterocelului. Refluxul vezico-ureteral,
uneori prezent la controlul imediat, a dispærut total la 12 luni
în cazurile færæ litiazæ secundaræ.
Concluzii. Rezecflia endoscopicæ a ureterocelului reprezintæ
„golden standard“ pentru aceastæ malformaflie øi
decomprimæ eficient unitatea renalæ. Prezenfla litiazei joase
sau înalte complicæ rezolvarea iniflialæ dar rata de stone free
este mare, cu rezultate bune øi stabile pe termen lung.
Patients and methods. From January 2003 to January 2013,
46 adult patients suffering by orthotopic ureterocele were
admitted in our center. Single ureterocele were discovered in
42 cases and bilateral ureterocele in 4 cases with a total of 50
orthotopic ureterocele. 28 cases had secondary stone in the
ureterocele and 9 cases had secondary renal lithiasis. The
main symptoms were: abdominal pain, back pain, blood in
the urine, burning pain while urinating - dysuria, fever, flank
pain, frequent and urgent urination urinary tract infection.
Endoscopic surgery was considered in all cases. Incision of
the ureter was the golden standard and extraction of the
calculi were performed preceded in some cases by ballistic or
laser lithotripsy. The procedure was uneventful in all
patients. In 9 cases we performed ESWL for renal lithiasis with
a stone free rate of 90%. 38 patients were available for followup at 6 months and one year (ultrasound and IVP). None of
these patients had any evidence of residual ureterocele
when evaluated with intravenous urography at12 months.
No reflux was found with MCU at 12 months in cases without
ureterocele lithiasis.
Conclusions. Endoscopic resection of adult orthotopic
ureterocele with or without associated calculi effectively
decompressed the kidney and removed stones in all patients
without any significant postoperative morbidity. Low-grade
VUR and hydronephrosis may occur postoperatively in cases
with secondary lithiasis.
nr. 2 / 2013 • vol 12
1
Segmentar ureterectomy to a
patient with gigantic left inguinoscrotal hernia
1
D. Purza, M. Zdrânca , S. Kolumban, M. Vârlan,
C. Cozman, C. Albu, G. Bumbu
Clinica de Urologie Oradea,
1
Clinica Chirurgie I Oradea
D. Purza, M. Zdrânca , S. Kolumban, M. Vârlan,
C. Cozman, C. Albu, G. Bumbu
Urology Clinic Oradea,
1
Surgery I Clinic Oradea
Introducere. Prezentarea unui caz de hernie inghino-scrotalæ
stângæ gigantæ, neglijatæ, care antreneazæ ureterul stâng.
Introduction. This presentation is about a gigantic left
inghino-scrotal hernia, neglected, that mobilizes the left ureter.
Material øi metodæ. Pacientul de 65 ani S.A. se prezintæ în
cabinetul de urologie din policlinicæ cu lombalgii stângi
vechi de intensitate redusæ. Examenul clinic deceleazæ hernie
inghino-scrotalæ stângæ, prin alunecare, voluminoasæ
ireductibilæ. La ecografie se observæ hidronefrozæ stângæ
gradul II, cu dilatarea ureterului proximal øi ptozæ renalæ
stângæ. Cliøeul urografic tardiv la 3 ore deceleazæ rinichiul
stâng ptozat cu sistem pielocaliceal dilatat øi ureter
nevizualizabil. S-a efectuat ureteropielografie retrogradæ
evidenfliindu-se ureterul stâng în scrot împreunæ cu sacul
herniar. S-a intervenit chirurgical prin abord inghinal cu
izolarea ureterului, excizie ureteralæ segmentaræ øi
anastomozæ termino-terminalæ a ureterului pe stent JJ. S-a
deschis sacul herniar care conflinea colonul sigmoid øi s-a
repus în cavitatea abdominalæ cu refacerea peretelui
abdominal øi orhiectomie stângæ.
Material and method. The patient S.A, with the age of 65
years, presents in the urology ambulatory with old, left
lombar pain of reduced intensity. The clinical examination
reveals a gigantic left inguino-scrotal hernia that was
irreductible. At the ultrasound examination we observe
grade II left hydronephrosis, with the expansion of the
proximal ureter and left renal ptosis. The late urographic
cliché at 3 hours reveals the ptosis of the left kidney with the
expansion of the pielocaliceal system and unviewed ureter.
We performed retrograde ureteropielography emphasizing
the left ureter in the scrotum with the hernial sac. We made a
surgical intervention with an inguinal approach with the
isolation of the ureter, segmentary ureteral abscission and
termino-terminal anastomosis on a double J stent. We
opened the hernial sac that contained sigmoid colon and we
restored it in the abdominal cavity with the suture of the
abdominal wall and left orchiectomy.
Rezultate. Evoluflia a fost favorabilæ cu suprimarea sondei JJ
la 3 luni postoperator, aspect ecografic øi urografic normal al
rinichiului stâng.
Concluzii. Sunt rare cazurile cu ureter antrenat în procesul
herniar, dar trebuie avutæ în vedere øi aceastæ posibilitate
atunci când sacul herniar confline colon sigmoid.
nr. 2 / 2013 • vol 12
Varia
PN.6. Ureterectomie segmentaræ la
pacient cu hernie inghino-scrotalæ
stângæ gigantæ
Results. The evolution was favorable with the suppression of
the double J stent at three mounths after the surgical
intervention, normal ultrasound and urographic aspect of
the left kidney.
Conclusions. The cases with the ureter mobilized by the
hernial process are rare, but this possibility should be
considered when the hernial sac contains sigmoid colon.
117
Varia
PN.7. Implicaflii clinice øi chirurgicale
ale diverticulului vezical congenital
E. Constantinescu, D. Georgescu, R. Mulflescu,
L. Adou, P. Geavlete
Clinical and surgical implications in
congenital bladder diverticulum
pathology
E. Constantinescu, D. Georgescu, R. Mulflescu,
L. Adou, P. Geavlete
Introducere: Diverticulul vezical congenital este o patologie
raræ, dar care ridicæ probleme de diagnostic diferenflial øi
tratament cu diverticulii dobândifli.
Introduction: Congenital bladder diverticulum is a rare
pathology which raises problems of differential diagnosis and
treatment by comparison to the acquired bladder diverticulum.
Material øi metodæ: În ultimii 10 ani în Clinica de Urologie
„Sf. Ioan” Bucureøti a fost diagnosticat øi tratat 1 caz cu
diverticul vezical congenital. Au fost analizate particularitæflile de diagnostic øi tratament.
Methods: During the last 10 years in the „St. John” Urology
Department 1 case of congenital bladder diverticulum was
diagnosed and treated. The diagnosis and treatment
particularities were analyzed.
Rezultate: Pacientul, de 32 de ani, se prezintæ pentru
retenflie completæ de urinæ. Ecografic diverticul vezical
voluminos, la nivelul peretelui lateral drept, ce se insinueazæ
sub trigonul vezical, prostata de dimensiuni normale. Uretrocistoscopic færæ obstrucflie la nivel subvezical. Se practicæ
excizia chirurgicalæ a diverticulului prin abord transvezical,
dupæ stentarea JJ a ureterului drept pentru protecflie.
Examenul anatomo-patologic al peretelui diverticular excizat
evidenfliazæ fibre musculare.
Results: The 32 years old patient presented with complete urine
retention. Ultrasonography demonstrated a voluminous
bladder diverticulum on the right side bladder wall, which
insinuated under the bladder trigone, normal size prostate.
Urethro-cystoscopy demonstrated no lower urinary tract
obstruction. Surgical excision of the diverticulum by transvezical
approach was performed after JJ stent indwelling on the right
ureter for protection. Histopathological examination of excised
diverticular wall highlights muscle fibers.
Concluzii: Deøi o patologie relativ simplæ, diverticulii vezicali
congenitali ridicæ o serie de probleme de diagnostic øi
tratament, simptomatologia de debut fiind diversæ.
Paradoxal, deøi færæ o cauzæ obstructivæ iniflialæ, simptomatologia de debut a fost reprezentatæ de retenflia completæ de
urinæ, determinatæ de poziflia diverticulului.
Conclusions: Although a relatively simple pathology,
congenital bladder diverticula raises a number of issues of
diagnostic and treatment, onset being diverse. Paradoxically,
although without initial obstructive cause, the onset
symptom in this case was represented by complete retention
of urine, determined by the diverticulum position.
nr. 2 / 2013 • vol 12
C. Persu, P. Geavlete
UTI prevention in neurogenic
bladder patients using a weekly
dose of antibiotics
C. Persu, P. Geavlete
Introducere: Infecflia de tract urinar este una dintre cele mai
frecvente complicaflii ale vezicii neurologice, necesitând
tratamente complexe øi ducând la o scædere semnificativæ a
calitæflii vieflii. Deoarece administrarea zilnicæ de antibiotic nu
este recomandabilæ datoritæ riscului de apariflie al rezistenflei
bacteriene, am desfæøurat un studiu prospectiv cu scopul
evaluærii eficienflei øi siguranflei administrærii unei doze
sæptæmânale de antibiotic pentru profilaxia infecfliilor urinare.
Introduction: Urinary tract infection is one of the most
frequent complications of the neurogenic bladder,
associating complex treatments and a significant decrease in
the quality of life. Since daily antibiotics are not
recommended because of their risk to produce bacterial
resistance, we conducted a prospective trial aiming to assess
the safety and efficacy of a weekly dose of antibiotic for UTI
prevention.
Material øi metodæ: Studiul a inclus pacienfli cu traumatism
medular sau scleozæ multiplæ, cu istoric de cel puflin 12 luni.
Opfliunea micflionalæ sau tratamentele curente nu au fost
schimbate pe perioada studiului. Diagnosticul de infecflie
urinaræ s-a bazat pe uroculturæ øi simptomatologia clinicæ.
Tratamentul antibiotic a fost inifliat în funcflie de antibiogramæ
øi toleranfla pacientului. Pacienflii au fost reevaluafli la patru
sæptæmâni, timp de un an, fiind urmærite starea generalæ,
urocultura, complianfla la tratament øi reacfliile adverse.
Datele obflinute au fost comparate pentru fiecare pacient,
înainte øi dupæ tratament, folosind metoda t-test.
Material and methods: The study included patients with SCI
or MS, in which medical history was available for at least 12
months. Current voiding option or treatment were not
changed during the study. UTI was diagnosed by clinical
symptoms and positive culture. Antibiotic treatment was
initiated according to bacterial sensibility and tolerance.
Patients were reevaluated every four weeks for at least 12
months, and general status, treatment compliance and
adverse reactions were recorded. Urine culture was repeated
monthly during treatment. Data was compared for each
patient before and after treatment, using the t-test method.
Rezultate: Au fost incluøi un numær de 60 pacienfli, dintre
care la finalul studiului au ajuns 46 (25 bærbafli, 21 femei), cu
vârste între 16 øi 64 ani (23,3% drop-out). Înainte de
tratamentul profilactic, pacienflii aveau 8.78 ± 2.34 episoade
de infecflie urinaræ anual, iar sub tratament, valoarea a scæzut
la 4.20 ± 1.44 episoade (p< 0.0001). Numærul episoadelor
febrile a scæzut de la 6.58 ± 1.76 la 1.26 ± 1.08 (p< 0.0001). 31
% dintre pacienfli nu au avut nici un episod de infecflie urinaræ
simptomaticæ pe perioada studiului. Nu s-a înregistrat nici o
reacflie adversæ semnificativæ în timpul tratamentului. Analiza
bacteriologicæ a demonstrat ca 68% dintre infecflii sunt
monobacteriene, 8% dintre pacienfli au raportat reacflii
adverse ce ar putea fi datorate tratamentului.
Results. A total of 46 patients (25 men, 21 women), aged 16
to 64, finished the study, out of 60 enrolled (23.3% drop-out
rate). Before treatment, the patients had 8.78 ± 2.34 UTI
episodes in 12 months. During the treatment, the incidence
decreased to 4.20 ± 1.44 episodes (p< 0.0001). The number
of febrile episodes dropped from 6.58 ± 1.76 to 1.26 ± 1.08
(p< 0.0001). 31% of the patients had no clinical significant
UTI during treatment. No serious adverse events were
recorded. 68 % of the infections were monobacterial, and
only 8% of the patients reported adverse events that might
be due to the treatment.
Concluzie: Antibioterapia în dozæ sæptæmânalæ este o
metodæ siguræ øi eficientæ de profilaxie a infecfliei urinare la
pacienflii cu vezicæ neurogenæ, cu beneficii efective ce
depæøesc costul tratamentului.
nr. 2 / 2013 • vol 12
Varia
PN.8. Profilaxia infecfliilor urinare
simptomatice prin tratament
antibiotic sæptæmânal la pacienflii
cu vezicæ neurologicæ
Conclusion: Weekly antibiotic treatment is a safe and feasible
prophylactic measure for UTI in neurogenic bladder patients,
with benefits that overcome the apparent increased cost and
burden of therapy.
119
Varia
PN.9. Rezistenfla la Fluoroquinolone
în tratamentul Ureaplasmei
Urealyticum în infecfliile
urogenitale la bærbat
The resistance of fluoroquinolones
in treatment of Ureaplasma
Urealyticum in male urogenital
infections
A. Maier, Eniko Hajdu Barabas, C. Chibelean,
O. Mælæu, O. Vida, M. Vartolomei,
Orsolya Martha
Clinica de Urologie Spitalul Clinic Judeflean
Mureø
A. Maier, Eniko Hajdu Barabas, C. Chibelean,
O. Mælæu, O. Vida, M. Vartolomei,
Orsolya Martha
Department of Urology, Clinical Hospital Center
Târgu Mureø
Introducere/obiective: Ureaplasma Urealyticum face parte
din familia Mycoplasmataceae, cunoscutæ ca biovar 2, fiind
clasificatæ ca specie nouæ din 1999. Se transmite pe cale
sexualæ øi poate fi izolatæ de asemenea din uretræ la bærbaflii
sænætoøi. Caracteristica lor constæ în faptul cæ nu au perete
bacterian, astfel ele pot fi rezistente la unele antibiotice cum
sunt penicilinele. Scopul acestui studiu este de a evalua
sensibilitatea la antibiotice a Ureaplasmei Urealyticum
izolatæ de la bærbaflii simptomatici.
Introduction/objectives: Ureaplasma urealyticum (U) is a
member of the Mycoplasmataceae family. Known earlier as
biovar 2, it was classified as a new species in 1999. It spreads
by sexual route and can be isolated from the urethra of
healthy men. This bacterium lacks cell wall and cannot be
destroyed by antibiotics targeting this area such as penicillin.
The aim of our study is to follow up the antibiotic sensitivity
of U strains isolated from symptomatic male patients.
Material øi metodæ: Studiul a fost efectuat în perioada Ianuarie
2010- Octombrie 2012, pe un lot de 205 bærbafli cu vârsta între
19-70 de ani, de la care s-au prelevat secreflii uretrale øi care au
acuzat disurie øi dureri uretrale. Probele au fost cultivate pe
mediul Mycoplasma IST2. Rezultatele identificærii øi sensibilitatea
la antibiotice au fost citite dupæ 48 de ore de la însæmânflare. În
acest studiu am testat Ureaplasma la 9 antibiotice: doxiciclinæ,
josamycinæ, ofloxacinæ, eritromicinæ, tetraciclinæ, ciprofloxacinæ,
azitromicinæ, claritromicinæ øi pristinamicinæ.
Rezultate: Au fost diagnosticafli cu infecflie 44 de pacienfli, cei mai
mulfli cu vârsta între 21- 50 de ani. În 2011 øi 2012 am testat 24 de
pacienfli, 12 în 2011 øi 12 în 2012. Sensibilitatea s-a menflinut de
100% pentru josamicinæ øi pristinamicinæ, dar a scæzut pentru
tetracicline de la 100% la 83,83%, iar claritromicinæ de la 100% la
91,66%. Sensibilitatea la fluoroquinolone s-a menflinut scæzutæ,
aproape de 50% pentru ofloxacin, în timp ce nici un caz nu a fost
sensibil la ciprofloxacinæ.
Concluzii: Frecvenfla rezistenflei Ureaplasmei la fluoroquinolone
s-a pæstrat ridicatæ. Tetraciclinele pot fi folosite ca øi terapie de
primæ linie deoarece rezistenfla s-a menflinut scæzutæ pe toatæ
perioada studiului. Deoarece rezistenfla la antibiotice este în
continuæ creøtere, este necesaræ testarea la antibiotice înainte
de iniflierea tratamentului.
Material and methods: between January 2010 and October
2012, 205 urethral swabs were collected from male patients
aged 19-70, accusing dysuria and urethral discharge.
Culturind was performed on Mycoplasma IST2 medium.
Identification and antibiotic susceptibility testing were done
and results were red after 48 hours. We used 9 antibiotics for
testing their susceptibility: doxycycline, josamycin, ofloxacin,
erythromycin, tetracycline, ciprofloxacin, azythromycin,
clarithromycin and pristinamycin.
Results: U infections were found in 44 patients (21,08%),
mostly in patients aged 21- 50. In the 2011 and 2012 we
tested 24 patients for their sensitivity 12 in 2011 and 12 in
2012. Their sensitivity maintained almost 100% for josamycin
and pristinamycin, but decreased to tetracyclines from 100%
to 83,83%, and clarithromycin from 100% to 91,66%. On the
other hand the sensitivity remains at low level to ofloxacin
50% and to ciprofloxacin was resistant.
Conclusion: the frequency of fluoroquinolones resistant U
strains was high. Tetracyclines can be used as first intention
therapy, because the resistance against them remained low
throughout the investigated period. Due to increased
resistance, susceptibility testing is recommended in
conditions that need treatment with antibiotics.
nr. 2 / 2013 • vol 12
Fournier gangrene – experience of
the Timisoara Urological Clinic in
the last 12 years
G. Pupca, L. Daminescu, A. Mureøan, R. Minciu,
M. Georgescu, C. Câmpean, M. Mezin, V. Bucuraø
Urgenflæ Timiøoara, Universitatea de Medicinæ øi
Farmacie Victor Babeø Timiøoara
G. Pupca, L. Daminescu, A. Mureøan, R. Minciu,
M. Georgescu, C. Câmpean, M. Mezin, V. Bucuraø
County Clinical Hospital
Obiective: Gangrena Fournier este consideratæ o boalæ raræ,
dar extrem de gravæ la bærbat, cu o mortalitate care ræmâne
ridicatæ la 20-30%. Lucrarea prezintæ experienfla clinicii
noastre în tratamentul acestei afecfliuni în ultimii 12 ani, între
anii 2001 - 2012.
Objectives: The Fournier gangrene is a rare but very severe
disease, with a mortality which stays high between 20 and
30%. We evaluate the experience of our clinic in the
treatment of this pathology in the last 12 years, between
2001 and 2012.
Material øi metodæ: În perioada studiatæ au fost internafli de
urgenflæ 25 pacienfli cu diagnosticul de gangrenæ Fournier. Vârsta
pacienflilor a variat între 53-91 ani , cu o medie de 67,3 ani. La tofli
pacienflii diagnosticul a fost stabilit uøor pe baza tabloului clinic
caracteristic, în diverse faze evolutive. Prezentarea la medic sub
48 ore de la debutul bolii s-a înregistrat doar la 11 pacienfli (44%).
Starea septicæ s-a înregistrat la 12 pacienfli (48%). Etiologic sursa
a fost genito-urinaræ la 20 pacienfli (80%) (orhiepididimita, stricturi uretrale cunoscute øi neglijate, traumatisme uretrale), la 3
pacienfli punctul de plecare a fost ano-rectal (flegmon de fosa
ischiorectalæ sau cancer de rect), în timp ce doi pacienfli au prezentat hematoame peno-scrotale suprainfectate. Tofli pacienfli
prezentau boli asociate, diabetul zaharat fiind afecfliunea cea mai
frecventæ între acestea (48%). La 7 pacienfli (28%) s-a constatat øi
o stare de igienæ precaræ. Intervenflia chirurgicalæ s-a efectuat în
toate cazurile în primele 2-4 ore de la stabilirea diagnosticului. 13
pacienfli (52%) au necesitat una sau mai multe reintervenflii, în 14
cazuri a fost necesaræ orhiectomia, într-un caz s-a recurs la
amputaflia penianæ parflialæ. La doi pacienfli s-au practicat ulterior
intervenflii plastice reconstructive (grefe tegumentare).
Material and method: In this period of time, 25 patients
were admitted as emergencies with Fournier gangrene. The
patients were between 53 and 91 years old (mean 67.3). The
diagnosis was easily established in all cases, based on the
characteristic clinical examination. Only 11 patiens asked
medical help in the first 48 hours after they noticed the first
symptoms. Septic shock was diagnosed in 12 cases (48%).
The ethiology was a genital or urinary disease in 20 patients
(80%) (orhiepididimitis, neglected urethral stricture, urethral
trauma); in 3 patients the gangrene started from a rectal
disease (rectal cancer or perirectal abcess) while in two cases
the cause was an infected scrotal hematoma. All patients had
at least one associated pathological condition, diabetes
being the most frequent (48%). In 7 patients (28%) a poor
hygiene condition was also obvious. The surgical treatment
was performed in every case in the first 2-4 hours after
diagnosis. 13 patients needed at least one more surgery;
orhiectomy was performed in 14 cases and one case needed
partial penile amputation. A plastic surgery (dermal graft)
was performed later in two patiens.
Rezultate: Rata de supraviefluire a fost de 76% (19 pacienfli), cele
6 decese fiind consecinfla unor evoluflii supraacute cu soc toxicoseptic (4 cazuri) sau decompensærii bolilor asociate (2 cazuri).
Results: The survival rate was 76% (19 patients); six patients
died due to severe septical shock (4 cases) or due to
associated diseases (2 cases).
Concluzii: Gangrena Fournier este o afecfliune gravæ, ce necesitæ un diagnostic precoce øi o atitudine medico-chirurgicalæ
rapidæ øi sustinutæ, adaptatæ co-morbiditatilor pacientului.
Reintervenfliile chirurgicale, complicafliile medicale øi rata de
supraviefluire înregistrate în cazuistica noastræ au depins foarte
mult de prezentarea precoce la medic, starea de igienæ øi imunitaræ a pacientului, cât øi de gravitatea patologiei asociate.
Conclusion: The Fournier gangrene is a severe condition, which
needs an early diagnosis, quick surgical intervention and sustained and intense treatment, adapted to the associated diseases
of the patient. The need for secondary surgeries, the medical
complications and the survival rate depended on how early the
diagnosis was established, the hygenic and immunity condition
of the patient and on how severe the associated diseases were.
nr. 2 / 2013 • vol 12
Varia
PN.10. Gangrena Fournier –
experienfla Clinicii Urologice
Timiøoara în ultimii 12 ani
121
Varia
PN.11. Fistula colovezicalæ,
o complicaflie a diverticulitei
sigmoidiene
C. Gîngu, V. Olaru, A. Dick, S. Pætræøcoiu,
C. Surcel, B. Øtefan, M. Hârza, M. Manu,
O. Himedan, M. Cræsneanu, C. Mirvald,
Mihaela Mihai, Liliana Domniøor, I. Sinescu
Introducere. Fistulele vezicoenterice reprezintæ comunicæri
anormale între vezica urinaræ øi tractul intestinal, cel mai
frecvent întâlnite în diverticulita sigmoidianæ, cancerul
colorectal øi bolile inflamatorii intestinale. Diverticulita
colonicæ reprezintæ cea mai frecventæ cauzæ de fistule
colovezicale fiind întâlnitæ în 71-75% din cazuri. În jur de 3%
dintre pacienflii cu diverticulitæ de-a lungul timpului dezvoltæ o
fistulæ colovezicalæ. Abordul terapeutic reprezintæ o provocare,
de cele mai multe ori fiind necesare echipe chirurgicale mixte,
complicafliile ajungând pânæ la 50% din cazuri.
Materiale øi metode. Pacient, în vârstæ de 48 de ani, færæ un
istoric medical semnificativ, se interneazæ în clinica noastræ
pentru apariflia fecaluriei, acompaniatæ de polakiurie øi dureri
abdominale difuze. Examenul clinic nu pune în luminæ nicio
particularitate deosebitæ. Tuøeul rectal relevæ o prostatæ
normalæ, în schimb examinarea bimanualæ sub rahianestezie
evidenfliazæ prezenfla unei mase tumorale pelvine la palparea
profundæ. Examinærile CT øi RMN indicæ o tumoræ abdominopelvinæ cu punct de plecare colonul sigmoid. În continuare se
practicæ cistoscopie în scop diagnostic, aceasta evidenfliind
traiect fistulos la nivelul peretelui vezical posterolateral drept
cu structurile învecinate (cel mai probabil colonul sigmoid
luând în vedere datele clinice øi imagistice). Se preleveazæ o
biopsie de la nivelul leziunii ce indicæ flesut inflamator de
naturæ incertæ. Se pune indicaflia de colonoscopie
diagnosticæ, aceasta neputând fi realizatæ datoritæ unui
obstacol imposibil de depæøit de la nivelul buclei
sigmoidiene. Se decide efectuarea laparotomiei ce relevæ
masa tumoralæ aparent de naturæ neoplazicæ la nivelul
colonului sigmoid cu invazie în vezica urinaræ. Se practicæ
cistectomie parflialæ cu rezecflie în limite oncologice øi
reimplantare ureteralæ dreaptæ cu cateter ureteral autostatic
“JJ” datoritæ implicærii ureterului drept în procesul inflamator
peritumoral. În continuare echipa noastræ multidisciplinaræ
Colovesical fistula, a complication
of sigmoid diverticulitis
C. Gîngu, V. Olaru, A. Dick, S. Pætræøcoiu,
C. Surcel, B. Øtefan, M. Hârza, M. Manu,
O. Himedan, M. Cræsneanu, C. Mirvald, Mihaela
Mihai, Liliana Domniøor, I. Sinescu
Bucharest
Introduction. Vesicoenteric fistulae are abnormal
communications between the bladder and the intestinal
tract, most commonly found in diverticulitis, colorectal
carcinoma and inflammatory bowel diseases. Diverticulitis
represents the most frequent cause of colovesical fistulae,
being involved in 71% to 75% of cases. Approximately 3% of
patients with diverticulitis develop a colovesical fistula. The
most common symptom of a vesicoenteric fistula is
pneumaturia followed by fecaluria. The treatment strategy is
challenging, requiring a multidisciplinary approach,
complications being reported in up to 50% of cases.
Materials and Methods. A 48 year old patient, without any
significant medical history, was admitted with fecaluria, also
complaining of polakiuria and diffuse abdominal discomfort.
Standard medical examination was free of other signs or
symptoms. Digital rectal examination showed a normal
prostate, bimanual examination indicating a profound
abdomino-pelvic mass. CT and MRI revealed a large
abdomino-pelvic tumor. Cystoscopy was performed and an
abnormal communication between the half-right posterior
bladder wall and a near structure (giving the clinical and
imaging particularities, probably sigmoid colon) was
discovered. A biopsy was taken. The result revealed mainly
uncertain inflammatory type tissue. Colonoscopy was
indicated, but unfortunately it could not be carried out
because of an obstacle located at the sigmoid loop. A
laparotomy was performed and a large mass was discovered
involving the sigmoid loop and posterior bladder wall. We
approached it as sigmoid cancer with bladder invasion. A
partial cystectomy within oncological safety margins was
performed, with right double J stented ureteral
reimplatation, because the right ureter was clinging in the
peritumoral inflamatory tissue. Our multidisciplinary team
consisting of urologic and general surgeons then isolated
nr. 2 / 2013 • vol 12
Varia
formatæ din chirurgi urologi øi generaliøti izoleazæ masa
tumoralæ øi practicæ o rezecflie sigmoidianæ urmatæ de
restabilirea continuitæflii digestive prin anastomoza terminoterminalæ joasæ.
the mass and performed a rectosigmoid resection with a low
end to end anastomosis.
Results. The postoperative period was uneventful. Normal
rd
bowel function was established in the 3 day. The Foley
Rezultate. Perioada postoperatorie a fost færæ complicaflii,
pacientul reluându-øi tranzitul intestinal în ziua a III-a. În ziua
a X-a postoperator se suprimæ cateterul uretrovezical,
pacientul fiind externat în ziua a XI-a. Examinarea
histopatologicæ pune în evidenflæ diverticul sigmoidian
abcedat de dimensiuni mari cu fistulæ vezico-sigmoidianæ øi
flesut inflamator perilezional.
Concluzii. Pneumaturia øi fecaluria reprezintæ simptome de
primæ prezentare în cazul pacienflilor cu fistule vezicosigmoidiene. Deøi aspectul macroscopic intraoperator de
cele mai multe ori orienteazæ chirurgul spre o leziune de
naturæ neoplazicæ, fistulele vezico-sigmoidiene apar cel mai
frecvent în cazul bolii diverticulare colonice complicate.
Fistulele vezico-sigmoidiene trebuie considerate neoplasme
pânæ la proba contrarie, tratamentul de elecflie în viziunea
noastræ fiind cistectomia parfliala în limite de securitate
oncologicæ øi rezecflie rectosigmoidianæ.
nr. 2 / 2013 • vol 12
th
catheter was removed in the 10 , the patient being
discharged after 11 days. The pathological examination
displayed an abscessed sigmod diverticulum with a sigmoidvesical fistula and inflammatory surrounding tissue.
Conclusions. Pneumaturia and fecaluria are the first
presenting symptoms in patients with sigmoid-vesical
fistulae. Even though the macroscopic intraoperative
appearance can be deceiving because of the inflammatory
surrounding tissue, most cases turn up after histopathological
examination as abscessed diverticulitis. Sigmoid masses with
sigmoid-vesical fistulae must be treated as cancer until
further proof, the standard therapy being partial cystectomy
within oncological margins and a rectosigmoid resection.
123
Varia
PN.12. Sinus urogenital la adultul
tânær. Prezentare de caz
G. Plugaru, V. Florescu, I. Licæ, D. Toma
Chirurgie Generalæ II, Compartiment Urologie,
Spitalul Clinic de Urgenflæ Bucureøti
Persistent urogenital sinus in young
adult. Case presentation
G. Plugaru, V. Florescu, I. Licæ, D. Toma
General Surgery II, Urology Department,
Emergency Clinic Hospital Bucharest, Romania
Introducere. Sinusul urogenital persistent reprezintæ una
dintre cele mai complexe afecfliuni ale chirurgiei pediatrice iar
în cazul adulflilor ale chirurgiei urologice. Sinusul urogenital
reprezintæ o comunicare persistentæ între uretræ øi vagin, de
obicei vaginul se deschide în treimea distalæ a uretrei.
Introduction. Persistent urogenital sinus is one of the most
complex disorders in adults and pediatric surgery in
urological surgery. Urogenital sinus is a persistent
communication between the urethra and vagina, vagina
usually open in the distal third of the urethra.
Material øi metodæ. Pacientæ de 30 de ani diagnosticatæ în
copilarie cu uter bicorp, cu hemihisterectomie la vârsta de 12
ani. Examenul RMN pune în evidenflæ anatomia aparatului
urogenital cu evidenflierea zonei de confluenflæ a vaginului cu
uretra distalæ. Intervenflia chirurgicalæ efectuatæ este de
mobilizare urogenitalæ totalæ descrisæ de Pena în 1997 øi
modificatæ de Rink. Postoperator pacienta efectueazæ
dilataflii vaginale la domiciliu, control la douæ luni, cavitate
vaginalæ ce permite introducerea a douæ degete.
Material and method. Patient aged 30 years, diagnosed in
childhood with bicornuate uterus and with hemihisterectomie
at age 12. MRI reveals urogenital anatomy emphasizing the
confluence area of the vagina with distal urethra. Surgery that
was performed was total urogenital mobilization as it is
described by Pena in 1997 and amended by Rink in 1999.
Postoperatively the patient made øøvaginal dilatation at home
and clinical control after two months revealed vaginal cavity
that allows the introduction of two fingers.
Rezultate øi concluzii. Perioada optimæ pentru tratamentul
chirurgical al sinusului urogenital persistent o reprezintæ
perioada de preadolescenflæ dar chiar øi la adulflii tineri poate
fi reparatæ cu rezultate bune.
Results and conclusions. Optimum time for surgical
treatment of persistent urogenital sinus is the preadolescent
period. However young adults can be surgically treated with
good results.
nr. 2 / 2013 • vol 12
The effect of the transition zone
resection rate for transurethral
resection of the prostate (TURP)
versus saline resection of the
prostate (TURis)
A. Davidescu, S. Pætræøcoiu, Rucsandra Manu,
C. Dudu, S. Pætræøcoiu, Liliana Domniøor,
1
2
1
Laboratorul de Anatomie Patologicæ,
2
Clinica de ATI, Institutul Clinic Fundeni,
Bucureøti
A. Davidescu, S. Pætræøcoiu, Rucsandra Manu,
C. Dudu, S. Pætræøcoiu, Liliana Domniøor,
1
2
1
ICU Department,
2
Pathology Department, Fundeni Clinic Institute,
Bucharest
Introducere: Introducerea noilor metode endoscopice TURis
øi Plasma Vaporizarea în rezolvarea endoscopicæ a adenomului
de prostatæ reprezintæ o provocare pentru metoda clasicæ “golden standard”, respectiv TURP. Quantum-ul zonei
tranziflionale în volumetria prostaticæ reprezintæ un factor
important în tratamentul acestei afecfliuni. Rata de rezecflie din
prostata tranziflionalæ reprezintæ de asemenea un element de
luat în consideraflie pentru bunele rezultate ale chirurgiei
endoscopice adresate BPH.
Introduction: Introduction of new methods, TUR-is and
Plasma Vaporization represents a challenge for TURP.
Transurethral resection of prostate (TURP) still represents the
gold standard for patients suffering by BPH. The quantum of
the transition zone (TZ) is important for treating BPH. As long
as hyperplasia is developed mainly in the transition zone, the
resection rate of the transition zone (RRTZ) represents the
key of surgery. The effect of the transition zone resection rate
of TURP was evaluated according to the prostate volume.
Metode: Studiul a fost efectuat în perioada iunie 2011 – iunie
2012 pe un lot de 48 de pacienfli. 28 de pacienfli au fost tratafli
prin TURP øi 20 prin TURis. În funcflie de rata de rezecflie din
prostata tranziflionalæ, pacienflii au fost împærflifli în înca douæ
grupe, cu rezecflie sub 75% din volumul acesteia øi peste 75%
din prostata tranziflionalæ. Urmærirea, analiza øi evolutia s-au
efectuat prin clinicæ, ecografie, ecografie transrectalæ, IPSS,
uroflowmetrie øi volumetrie tranziflionalæ øi totalæ prostaticæ,
înainte øi dupæ intervenfliile endoscopice.
Methods: Between June 2011 and June 2012, 48 patients
with BPH entered in this study. 28 patients were treated by
TURP and 20 by TURIS. All the patients were again divided
into two groups, according to the resected rate of the
transition zone – below 75% and above 75%. They were
evaluated using ecography, TRUS, IPSS, uroflowmetry and
volumetry of the prostate and the transition zone before and
after surgery.
Rezultate øi concluzii: Simptomatologia majoræ obstructivæ
iritativæ prostaticæ a fost semnificativ amelioratæ postoperator
indiferent de metoda endoscopicæ folositæ. IPSS øi Qmax s-au
îmbunætæflit semnificativ în ambele grupuri, dar cu rezultate mai
bune în grupul în care rata de rezecflie a prostatei tranziflionale a
depæflit 75%, atât în cazul TURP cât øi în cazul TURis.
nr. 2 / 2013 • vol 12
Varia
PN.13. Importanfla ratei de rezecflie
a zonei tranziflionale TURP versus
TURis în rezultatele chirurgiei
endoscopice a hipertrofiei benigne
de prostatæ
Results and conclusion: The main symptoms of BPH were
significantly improved after surgery, no matter what resection
method was performed. Postoperative IPSS and Qmax were
significantly improved in both groups but better when the
resection exclude more than 75% of the transition zone.
125
Video – Varia
V.1.1. Heminefrectomia laparoscopicæ
a rinichiului în potcoavæ
Laparoscopic heminephrectomy of
a horseshoe kidney
D. Diaconescu, B. Braticevici, V. Jinga,
G. Roøoga
Departamentul de urologie, Spitalul “
Prof. Dr. Th. Burghele”, Bucureøti, România
D. Diaconescu, B. Braticevici, V. Jinga,
G. Roøoga
Department of Urology ,“Prof. Dr. Th. Burghele”
Clinical Hospital Bucharest
Introducere: Rinichii în potcoavæ sunt cea mai frecventæ
anomalie renalæ de fuziune. Cazuri particulare precum
anomaliile de poziflie ale rinichiului, de vascularizaflie øi istmul
renal reprezintæ provocæri pentru chirurgia laparoscopicæ.
Utilizarea tehnicilor minim invazive a scæzut morbiditatea øi a
îmbunætæflit recuperarea postoperatorie. Væ prezentæm un caz
de heminefrectomie laparoscopicæ pentru rinichi în potcoavæ.
Introduction: Horseshoe kidney is the most common renal
fusion anomaly. Particular cases like abnormal kidney
location, aberrant vasculature and the renal isthmus present
technical challenges for the laparoscopic approach.
Minimally invasive surgery decreased the morbidity and
improved the postoperative recovery. We present a case of
heminephrectomy using laparoscopic techniques.
Material øi metodæ: Pacienta de 25 ani cu antecedente
urologice de pielonefritæ acutæ a fost diagnosticatæ imagistic
(ecografic, UIV øi CT) cu rinichi drept hipoplazic, malrotat,
funcflional, cu nefrograma diminuatæ polar inferior. A fost
efectuatæ heminefrectomie transperitonealæ dreaptæ
laparoscopicæ. Tehnica operatorie: - poziflia pacientei - decubit
lateral stâng la 45 grade; - s-au utilizat 4 trocare în poziflie
standard ( 2 trocare de 10 mm øi 2 de 5 mm); - identificarea
ureterului øi disecflia ascendentæ a acestuia spre basinet; identificarea pediculilor vasculari multipli, ligaturarea acestora
cu clipuri Hemolock; - identificarea istmului cu electrorezecflia
acestuia; - tub de dren latero-colic drept. Diagnosticul de
rinichi în potcoavæ a fost pus intraoperator.
Methods: A 25 year-old female patient with acute
pyelonephritis an year ago was diagnosed (ultrasound, IVU,
CT) with hypoplastic, malrotated, functional right kidney, with
a decreased lower pole nephrogram. A right transperitoneal
laparoscopic heminephrectomy was performed. Surgical
technique: - the patient is placed in right kidney position at an
angle of 45 degrees; - 4 ports placed in standard position
(10mmX2, 5mmX2); - identification and dissection of the
ureter; - identification, clipping and dividing the multiple
vascular pedicles; - identification and electroresection of the
isthmus, - right latero-colic drainage. The horseshoe kidney
diagnosis was an intraoperatory one.
Rezultate: Timpul operator a fost de 180 minute, cu o
pierdere de sânge de 70 ml. Nu au existat complicaflii
intraoperatorii sau postoperatorii. Durata de spitalizare a fost
de 4 zile postintervenflie. La 2 luni de la operaflie pacienta
este asimptomaticæ, cu funcflie renalæ stângæ pæstratæ.
Rezultatul histopatologic: pielonefritæ cronicæ în focare,
“tiroidizare”, metaplazie oncocitaræ.
Concluzii: Tehnica laparoscopicæ reprezintæ o opfliune siguræ
de tratament în aceste cazuri, oferind o duratæ de spitalizare
redusæ, convalescenflæ mai scurtæ øi rezultate cosmetice
superioare chirurgiei clasice.
Results and conclusions: The operative time was 180
minutes, with an estimated blood loss of 70 ml. There were no
intraoperative and postoperative complications. The patient
was discharged on postoperative day 4 and remains
asymptomatic 2 month after the procedure with stable left
renal function. Histopathology results: chronic pyelonephritis,
oncocytic metaplasia. Laparoscopic heminephrectomy is a
feasible option in these cases and can be performed safely
using a transperitoneal approach with minimal morbidity,
short convalescence and better cosmetics.
nr. 2 / 2013 • vol 12
V. Cucu, G. Seserman, F. Dobrotæ,
Carmen Læpuøan, I. Coman
Centrul de Chirurgie Roboticæ Urologicæ –
Spitalul Clinic Municipal Cluj-Napoca
Robotic assisted laparoscopic
pyeloplasty by retroperitoneal
approach - surgical technique step
by step
V. Cucu, G. Seserman, F. Dobrotæ, Carmen
Lapuflan, I. Coman
Center for Robotic Surgery in Urology –
Municipal Hospital Cluj-Napoca
Introducere: Gold standard-ul în tratamentul obstrucfliei
joncfliunii pielo-ureterale este pieloplastia. Laparoscopia
asistatæ robotic a câøtigat în ultimii ani tot mai mult teren în
chirurgia urologicæ. Acest trend este motivat de gradul mare
de mobilitate al braflelor robotice ce permit manevre
complexe precum reconstrucflia intracorporealæ.
Introduction: Gold standard in the treatment of the
pyeloureteral junction stenosis is open approach pyeloplasty.
Robotic assisted laparoscopy has gained in recent years more
and more ground in urologic surgery. This trend is motivated
by the high degree of mobility of robotic arms that allow
complex maneuvers for intracorporeal reconstruction.
Material si metodæ: În experienfla Centrului de Chirurgie
Roboticæ Urologicæ avem pânæ la ora actualæ 19 cazuri de
hidronefrozæ prin sindrom de joncfliune pieloureteralæ operate
cu robotul Da Vinci SI. În videofilm sunt prezentate particularitæflile tehnicii robotice a principalilor timpi operatori. Am
folosit platforma chirurgicalæ roboticæ DaVinci Si HD. Pacientul
este poziflionat în decubit lateral, cu elevatorul mesei chirurgicale ridicat la nivel lombar. Spafliul retroperitoneal este
disecat cu balonul disector în maniera Gaur. Trocarele se poziflioneazæ triunghiular cu o distanflæ de 8 cm între ele. Primul
trocar este poziflionat la intersecflia dintre muøchiul paravertebral øi coasta 12, al doilea trocar robotic este plasat la 1-2 cm
deasupra crestei iliace, iar cel de-al treilea la întâlnirea liniei dea lungul coastei 12 si linia axilaræ anterioaræ. Al 4-lea trocar de
ajutor, de 12 mm, se plaseazæ medial de spina iliacæ anterioaræ.
Tehnica preferatæ a fost Hynes Anderson.
Material and Methods: The Center for robotic surgery in
urology has an experience of 19 cases of hydronephrosis due
to pyeloureteral junction syndrome operated with the Da
Vinci SI surgery system. This video presents the peculiarities
of all the steps for the robotic pyeloplasty. We used the Da
Vinci Si surgical system. The patient is positioned in lateral
decubitus with high surgical table lift in the lumbar region.
We use a dissection balloon in Gaur manner for
retroperitoneal dissection. Trocars are positioned at a
distance of 8 cm from each other in a triangular shape. The
first trocar is positioned at the intersection of paravertebral
muscle and the 12th rib, the second robot trocar is placed at
1-2cm above the iliac crest, and the third at the intersection
along the coast line 12 and anterior axillary line. The 4th
12mm assistant trocar is place medial from the anterior iliac
crest. Anderson Hynes technique was preferred.
Rezultate: Timpul operator mediu a fost de 95 minute. Mobilizarea precoce în primele 24 h. - Tranzit reluat dupæ 24
h. - Tub de dren lombar suprimat în medie dupæ 3,5 zile. Sondæ uretro-vezicalæ suprimatæ în medie dupæ 8,4 zile. Stent ureteral autostatic suprimat în medie dupæ 28 zile. Timpul minim de follow-up: 3 luni. - Rezultate funcflionale
bune dupæ toate intervenfliile.
Results: The average operating time was 95 minutes. - Early
mobilization in the first 24 hours. - Transit resumed after 24
hours. - Lumbar drain tube suppressed on average after 3.5
days. - Foley catheter suppressed on average after 8.4 days. Double J stent suppressed on average after 28 days. - The
minimum follow-up: 3 months. - Good functional results
after all interventions.
Concluzii: Pieloplastia retroperitonealæ laparoscopicæ
asistatæ robotic reprezintæ un concurent serios al pieloplastiei clasice øi al celei laparoscopice standard prin curba
de învæflare abruptæ øi rezultatele funcflionale bune.
Conclusions: Robot assisted laparoscopic retroperitoneal
pyeloplasty is a serious competitor for the open and
standard laparoscopic surgery through the steep learning
curve and good functional results.
nr. 2 / 2013 • vol 12
Video – Varia
V.1.2. Pieloplastia laparoscopicæ
asistatæ robotic prin abord
retroperitoneal – tehnica
chirurgicalæ pas cu pas
127
Video – Varia
V.1.3. Reparaflia laparoscopicæ a
unei injurii iatrogene de venæ renalæ
Laparoscopic repair of iatrogenic
renal vein injury
B. Petrufl, V. Schiflcu, D. Feflea, Alexandra Alb,
V. Buda, T. Calistru, A. Kozan, M. Hogea
„Prof. Dr. I. Chiricuflæ“ Cluj Napoca
V. Buda, T. Calistru, A. Kozan, M. Hogea
„Prof. Dr. I. Chiricuflæ“ Oncological Institute
Abordul laparoscopic în tratamentul tumorilor renale este
conform ghidurilor Asociafliei Europene de Urologie, o
alternativæ siguræ abordului clasic. Nefrectomia radicalæ este
consideratæ standard de aur în tratamentul cancerului renal în
stadiul T1 øi T2 unde rezecflia parflialæ nu este posibilæ. Accesul
retro- sau trans-peritoneal trebuie sæ respecte aceleaøi
principii oncologice ca øi în chirurgia deschisæ. Astfel, disecflia
pediculului renal reprezintæ un pas crucial în realizarea
intervenfliei, iar posibila lezare a vaselor renale poate avea
consecinfle dramatice. Ne-am propus prezentarea unui caz de
nefrectomie parflialæ în timpul cæruia a intervenit o injurie a
venei renale, care a fost tratatæ cu succes prin suturæ
laparoscopicæ. Urmærirea ulterioaræ a pacientului a pus în
evidenflæ perfuzia corespunzætoare a parenchimului renal
restant. Aceastæ experienflæ aratæ fezabilitatea tratamentului
laparoscopic al anumitor leziuni vasculare renale, sub rezerva
necesitæflii unei experienfle mari din partea echipei operatorii
øi a unei urmæriri atente postoperator.
The laparoscopic approach in the treatment of renal tumors
is, according to the European Association of Urology, a safe
alternative to the open approach. Radical nephrectomy is
considered the gold standard treatment of T1 and T2 renal
tumor where nephron sparing surgery is not feasible. Either
the retro- or trans-peritoneal approach must follow the same
oncological principles as the classic approach. Thus, the
dissection of the renal pedicle is a crucial step during surgery,
and vascular injury during its preparation can have dramatic
consequences. We present a case of laparoscopic partial
nephrectomy during which an injury of the renal vein
occurred, that was successfully managed laparoscopically via
suturing. Postoperative follow-up imaging showed
satisfactory perfusion of the renal parenchyma. This case
shows the feasibility of laparoscopic repair of vascular injury
in renal surgery, but its success is dependent on the expertise
of the operating surgeon and close postoperative follow-up.
nr. 2 / 2013 • vol 12
V. Buda, T. Calistru, A. Kozan, D.S. Popescu,
M. Hogea
Suprarenalectomia laparoscopicæ este o alternativæ la
abordul clasic, oferind rezultate funcflionale øi oncologice
comparabile, cu avantajul unei morbiditæfli postoperatorii
reduse. Totuøi, limitærile tehnice ale laparoscopiei (spre
exemplu viziunea bidimensionalæ cu absenfla profunzimii
imaginii, absenfla simflului tactil) cresc nivelul de dificultate al
intervenfliei, reducând numærul de pacienfli care beneficiazæ
de ea. Sistemele video folosite în laparoscopie au evoluat,
actualmente încercându-se trecerea de la viziunea de înaltæ
definiflie la viziunea tridimensionalæ de înaltæ definiflie. Neam propus evaluarea impactului pe care acest progres tehnic
îl are asupra operatorului principal, a asistenflilor, luând în
considerare øi aspectul cost-beneficiu, în comparaflie cu
experienfla anterioaræ (imagine video bidimensionalæ).
Utilitatea sistemului a ieøit in evidenflæ în urma mai multor
intervenflii, notându-se un confort sporit pentru operator øi
precizie crescutæ în manoperele chirurgicale, lucru reflectat
în timpi operatori reduøi.
nr. 2 / 2013 • vol 12
Subjective evaluation of the
laparoscopic 3D video system as
used in adrenal surgery
V. Buda, T. Calistru, A. Kozan, D.S. Popescu,
M. Hogea
Video – Varia
V.1.4. Evaluarea subiectivæ a
sistemului 3D în intervenfliile
laparoscopice ale glandei
suprarenale
Laparoscopic adrenalectomy is considered an alternative to
the classical approach, offering similar functional and
oncological outcomes with the advantage of lowered
postoperative morbidity. Technical limitations of
laparoscopy (including bidimensional vision with absence of
the depth of field, lack of tactile sense) increase the overall
difficulty of the intervention, reducing the number of
patients that could benefit from it. Laparoscopic vision
systems have evolved over the years, with the current trend
being the introduction of high definition 3d video systems.
We aimed to evaluate the impact this technical progress has
on the surgeon, the assistants, and cost benefit ratio in
comparison with the service’s previous experience with
bidimensional vision system. Over several procedures during
which the system was used, operators noticed increased
comfort during surgery due to the operative field’s depth
which enabled increased precision for maneouvers, reflected
in part in decreased surgical times.
129
Video – Varia
V.1.5. Impactul sistemului video 3D
asupra intervenfliilor laparoscopice
ale rinichiului
B. Petrufl, M. Hogea, V. Schiflcu, Alexandra Alb,
V. Buda, T. Calistru, A. Kozan, D. Feflea
Nefrectomia laparoscopicæ este o alternativæ siguræ în
abordul tumorilor renale în stadiul T1 øi T2 conform
ghidurilor Asociafliei Europene de Urologie, laparoscopia
fiind consideratæ standard de aur în realizarea nefrectomiei
radicale în situafliile în care prezervarea de parenchim nu este
posibilæ. Intervenflia laparoscopicæ trebuie sæ urmeze aceleaøi
principii oncologice ca øi abordul clasic. Controlul primar al
pediculului renal, excizia formafliunii tumorale, nefrorafia,
sunt paøi ce necesitæ o bunæ orientare a chirurgului în câmpul
operator øi un grad mare de îndemânare în manipularea
instrumentarului. Prin îmbunætæflirea viziunii intracorporeale
øi oferirea unei dimensiuni în plus în timpul intervenfliei,
sistemele video 3D încearcæ sæ sporeascæ confortul øi
siguranfla în timpul intervenfliilor laparoscopice. Ne-am
propus evaluarea sistemului de vizualizare tridimensionalæ în
chirurgia laparoscopicæ renalæ din punctul de vedere
subiectiv al operatorului principal, al asistenflilor øi al
raportului cost beneficiu. Pe parcursul unui numær de
intervenflii a ieøit în evidenflæ utilitatea viziunii
tridimensionale în ceea ce priveøte orientarea în câmpul
operator, precizia manipulærii instrumentarului øi, în final,
scurtarea timpilor operatori.
The impact of 3d video systems on
laparoscopic renal surgery
B. Petrufl, M. Hogea, V. Schiflcu, Alexandra Alb,
V. Buda, T. Calistru, A. Kozan, D. Feflea
Laparoscopic nephrectomy is, according to the European
Association of Urology, a safe alternative for the treatment of
stage T1 and T2 renal tumors. It is considered the gold
standard for radical nephrectomy in cases where nephron
sparing surgery is not applicable. The laparoscopic approach
must follow the same principles as the open approach.
Primary control of the renal pedicle, tumor excision, renal
sutures - all require good orientation in the surgical field and
high skills in instrument handling. By improving on the
intracorporeal vision and offering an extra dimension during
surgery, 3d video systems aim to increase comfort and safety
during laparoscopy. Our aim was to evaluate the 3d video
system in laparoscopic renal surgery from the viewpoint of
the main operator, the assistants, with mentions regarding
the cost-benefit ratio. During several procedures the 3d
system’s depth of field proved useful for surgical field
orientation and intracorporeal instrument handling, which
translated into reduced operative time.
nr. 2 / 2013 • vol 12
S. Voinea, C. Gagiu, I. Manea, T. Priporeanu,
M. Hârza, I. Sinescu
Institutul Clinic Fundeni
Intussusception microsurgical
vasoepididymostomy technique tips and tricks
Transplantation, Fundeni Clinic Institute,
Bucharest
Introducere. Vasoepididimostomia microscopicæ (VES) este
consideratæ operaflia care necesita cel mai mare grad de
îndemânare dintre procedurile reconstructive ale tractului
genital masculin. VES este tratamentul de elecflie pentru
azoospermia secundaræ obstrucfliei epididimului, cu o
patenflæ øi o ratæ de obflinere a sarcinii pe cale naturalæ de 6095%, respectiv 27-49%. În cazul primilor 47 pacienfli în clinica
noastræ a fost folositæ tehnica Berger modificatæ, cu o patenflæ
øi o ratæ de obflinere a sarcinii pe cale naturalæ de 81%,
respectiv 36,4%. În vederea îmbunætæflirii rezultatelor am
identificat øi aplicat unele modificæri ale acestei tehnici.
Obiective. Prezentarea tehnicii de VES longitudinalæ cu
invaginarea tubului seminifer în ductul deferent.
Introduction. Microsurgical vasoepididymostomy (VES) is
considered the most technically challenging type of surgery
for the male reproductive system. VES is the preferred
approach for azoospermia secondary to epididymal
obstruction, with reported patency and natural pregnancy
rates of 60 -95% and respectively 27-49%. Our approach for
the first 47 patients was a modified Berger technique with a
patency and natural pregnancy rates of 81% and 36.4 %. In
order to obtain a better result, some technical modifications
was identified and applied.
Metode. Funiculul spermatic a fost abordat bilateral printr-o
incizie scrotalæ înaltæ prelungitæ pânæ la proiecflia orificiului
inghinal superficial. S-a expus testiculul în plagæ, apoi
vaginala testicularæ a fost deschisæ øi eversatæ. S-a identificat
coada epididimului øi s-a plasat microscopul în câmpul
operator. S-a disecat un singur tub seminifer, cât mai
aproape de coada epididimului. La nivelul tubului s-au plasat
douæ ace, orientate longitudinal, cu fir 10.0, de 2,5 cm. Tubul
sa incizat între cele douæ ace øi fluidul aspirat a fost examinat
la microscopul optic în sala de operaflie pentru identificarea
spermatozoizilor vii. Dacæ aceøtia au fost identificafli ductul
deferent a fost secflionat øi disecat pânæ la orificiul inghinal
extern. Firele au fost trecute dinspre interior spre exterior
prin lumenul deferentului. Suturile au fost strânse, ducând la
invaginarea tubului seminifer în lumenul deferenflial,
finalizând astfel anastomoza.
Methods. The spermatic cord and the testis were
approached bilateral by a high scrotal incision up to the level
of external inguinal canal. The testis was delivered and the
vaginalis tunica was opened and reversed. The tail of the
epididymis was identified and a microscope was brought
into the operatory field. A single epididymal tubule was
exposed as caudal as possible. Two parallel double arm
fishhook needle, 10.0, 2.5 cm long sutures are placed in the
selected epididymal tubule, oriented longitudinally. Tubule
is incised between the two needles. The epididymal fluid was
aspirated and a small amount was examined immediately by
light microscope into operating room for viable sperm. If
they were present, the vas deferent was cut and dissected up
to the external inguinal ring. The double-arm needles are
placed in-to-out through the vasal lumen. The sutures was tie
down allowing the epididymal tubule to be intussuscepted
into the vasal lumen, completing the anastomosis.
Concluzii. Principalele modificæri aduse tehnicii sunt o disecflie
mai amplæ a ductului deferent, utilizarea unui fir mai scurt
dublu armat øi incizia longitudinalæ a tubului seminifer.
Acestea duc la ratæ de patenflæ mai mare la 3 luni de la operaflie,
comparativ cu tehnica Berger modificatæ (81% vs 54%).
nr. 2 / 2013 • vol 12
Video – Infertilitate
V.2.1. Vasoepididimostomia
microscopicæ - tips and tricks
Objective. The objective is to present our microsurgical
longitudinal end-to-side double arm intussusception VES.
Conclusion. The main modifications of our technique
consist of a longer dissection of deferent vas, using 10.0
double arm fishhook needle 2.5 cm long suture and
longitudinal incision of the epididymal tubule. These
modifications lead to a faster return of sperm into ejaculate 3
months after surgery compared with the Berger modified
technique (81% versus 54%).
131
V.2.2. Varicocelectomia
microscopicæ subinghinalæ cu
expunerea retrogradæ a testiculului
A. fiurcanu, B, Hæinealæ, M Hârza, I Sinescu
Introducere. Varicocelul este cel mai frecvent factor etiologic al
infertilitæflii masculine. O varicocelectomie idealæ ar trebui sæ realizeze urmætoarele obiective: prezervarea tuturor arterelor (în
special artera spermaticæ internæ – principala sursæ de vascularizaflie testicularæ), cruflarea vaselor limfatice øi a ductului deferent cu artera øi venele aferente, ligaturarea øi secflionarea tuturor
venelor spermatice interne øi externe, a venelor gubernaculului
testicular, realizate printr-o mini incizie, færæ secflionarea sau
dilacerarea fasciei øi/sau a musculaturii øi færæ expunere la raze X.
Obiectiv. Prezentarea tehnicii noastre de varicocelectomie
microscopicæ subinghinalæ (VMS), cu expunerea retrogradæ a
testiculului.
Material øi metodæ. Funiculul spermatic a fost abordat printro incizie transversalæ de 2 cm, centratæ pe orificiul inghinal
extern. S-a realizat expunerea retrogradæ a testiculului, cu
ligaturarea venelor spermatice externe øi ale gubernaculului øi
repoziflionarea testiculului la nivelul scrotului. La pacienflii care
au acuzat orhialgii s-a excizat un segment din nervul
ilioinghinal, cu ligatura capetelor restante. În timpul urmætor,
funiculul spermatic a fost expus øi etalat pe o pensæ Baraya. Sa poziflionat microscopul în câmpul operator, paøii urmætori
fiind realizafli sub un grad de magnificare de X8-X15. Toate
venele de la nivelul funiculului au fost ligaturate (cu excepflia
venelor deferenfliale) cu fir Vicryl 5.0 sau coagulate cu ajutorul
unei pense bipolare. Au fost prezervate ductul deferent øi
vasele asociate, arterele spermatice øi cremasteriene, precum
øi vasele limfatice. Principalul criteriu de identificare a arterelor
a fost pulsaflia la nivelul vasului.
Concluzii. Având în vedere cæ tehnica prezentatæ îndeplineøte
toate criteriile unei varicocelectomii ideale, a devenit standard
în clinica noastræ. În experienfla noastræ VMS cu expunerea
retrogradæ a testiculului este o tehnicæ minim invazivæ care
oferæ o ratæ de concepflie naturalæ de 31% în primul an øi 52%
în al doilea an, cu o incidenflæ foarte scæzutæ a complicafliilor
(sângerare 0%, hidrocel clinic 0%, atrofie testicularæ 0%,
recidivæ 2,3%).
Microsurgical subinguinal
varicocelectomy with delivery
of the testicle
A. fiurcanu, B, Hæinealæ, M Hârza, I Sinescu
Transplantation Fundeni Clinical Institute,
Bucharest
Introduction. Varicocele represents the most common
cause of male infertility. An ideal varicocelectomy should
respect the following criteria: spare all arteries (especially the
internal spermatic artery – the main blood supply of the
testicle), spare lymphatic vessels, as well as the deferent vas
with its vessels, cut all gubernacular, internal and external
spermatic veins use a mini incision without splitting the
fasciae or muscle and no X-ray exposure.
Objective. The objective is to present our microsurgical
subinguinal varicocelectomy technique (MSV) with delivery
of the testicle.
Materials and methods. The spermatic cord was
approached through a 3-4 cm transverse incision centered
over the external inguinal ring. The testis was delivered
through the incision and all the gubernacular and external
spermatic veins were ligated. The testis was placed inside the
scrotum. For patients complaining of testicular pain, a
segment from the ilio-inguinal nerve was excised and the
remaining segments were ligated. The spermatic cord was
then exposed and placed over a Baraya clamp. The operative
microscope was brought into the operating field and all the
following steps were performed under X8–X15 magnification.
All the veins within the cord (without deferential veins) were
transected and ligated with 5.0 Vicryl or coagulated. The vas
deferens and associated vessels, lymphatics, as well as the
spermatic and cremasteric arteries were all preserved. The
main criterion for identifying the internal or external
spermatic artery was the pulsation of the vas.
Conclusions. Considering that MSV with delivery of the
testicle meets all the requirements of an ideal cure for
varicocele, it has become standard practice in our clinic. In
our experience, this procedure offers a high pregnancy rate
(31% in the first year and 52% in the second year) and a very
low rate of complications (bleeding 0%, infections 1%, clinic
hydrocele 1%, atrophy 0%, recurrence 1%).
nr. 2 / 2013 • vol 12
Introducere. Azoospermia este prezentæ la 1% din bærbaflii
din populaflia generalæ øi la 10-15 % din bærbaflii infertili.
Azoospermia poate sæ aparæ în douæ situaflii clinice diferite:
testiculele produc spermatozoizi dar aceøtia nu sunt ejaculafli
datoritæ obstrucfliei de cale spermaticæ – azoospermie
obstructivæ sau nu existæ/este foarte scæzutæ producflia de
spermatozoizi – azoospemia nonobstructivæ. Infertilitatea
cauzatæ de azoospermia nonobstructivæ este severæ øi dificil
de tratat. Pânæ în urmæ cu câfliva ani singurele opfliuni constau
în efectuarea de FIV cu donator de spermæ sau adopflie, însæ,
cercetærile recente au schimbat radical aceastæ viziune.
Barbaflii cu azoospermie nonobstructivæ au spermatogeneza
sever alteratæ dar neuniformæ. Histologia testicularæ la
barbatii cu azoospermie nonobstructivæ este întotdeauna
anormalæ prezentand o combinaflie de Sertoli cell-only øi oprirea maturizærii spermatozoizilor asociate cu arii microscopice
de hipospermatogenezæ. Biopsia testiculara recolteazæ <5%
din tubii seminiferi “la întâmplare”, cu øanse foarte scæzute de
a recolta flesut din zonele, de obicei inframilimetrice, cu spermatogenezæ prezentæ. MicroTESE este cea mai eficientæ
metodæ de a recolta spermatozoizi la pacienflii cu azoospermie nonobstructivæ.
Obiectiv. Obiectivul este prezentarea tehnicii microTESE la
un pacient la care nu s-au identificat spermatozoizi la biopsia
testicularæ.
Material øi metode. MicroTESE constæ în deschiderea largæ a
testicului øi disecflia asistatæ microscopic (X20-X30) a flesutului
testicular în scopul identificærii unor tubuli dilatafli øi albicioøi
care, frecvent, conflin spermatozoizi ce pot fi folosifli pentru FIV.
Concluzii. MicroTESE este singura tehnicæ care poate recolta
spermatozoizi acolo unde alte tehnici (puncflia, aspiraflia sau
biopsia testicularæ) au dat greø. MicroTESE are trei avantaje:
creøte øansa recoltærii spermatozoizilor (50-70% din cazuri),
recolteazæ o cantitate micæ de flesut testicular (se evitæ
insuficienfla testicularæ postoperatorie) øi scade riscul de
lezare a vaselor testiculului øi atrofia testicularæ ulterioaræ.
nr. 2 / 2013 • vol 12
Micro TESE – how to perform sperm
retrieval when other techniques
have failed
Transplantation, Fundeni Clinic Institute,
Bucharest
Introduction. The incidence of azoospermia is 1% in the
general male population and 10-15% of the infertile males.
Azoospermia has two different clinical expressions: the
testicles produce spermatozoa, but they are not ejaculated
due to spermatic tract obstruction - obstructive azoospermia,
or spermatozoa production is insufficient/absent - nonobstructive azoospermia (NOA). Infertility caused by NOA is
severe and difficult to treat. Until a few years ago, the only
options were in vitro fertilization (IVF) with a sperm donor, or
adoption, but recent research lead to a radical change in its
therapeutic approach. Men with non-obstructive
azoospermia have a severely altered spermatogenesis, but
non-uniform. The testicular histology of men suffering from
NOA is always modified, revealing a combination of Sertolycell-only, spermatogenesis arrest, associated with
microscopic areas of hypospermatogenesis. Testicular biopsy
randomly harvests <5% of the seminiferous tubules, with a
very small chance of finding the usually <1mm areas where
the sperm are product. MicroTESE is the most efficient
method of retrieve spermatozoa from patients with NOA.
V.2.3. Micro TESE – cum recoltæm
spermatozoizi când alte tehnici
au dat greø
Objective.To present the microTESE technique for a patient
who underwent previous negative testicular biopsy.
Materials and method. MicroTESE consists of a wide
incision of the testicle and the microscopic dissection (x20x30) of the testicular tissue with the purpose of identifying
whitish, dilated tubules which frequently contain
spermatozoa suitable for IVF.
Conclusions. MicroTESE is the only technique that can be
used to retrieve spermatozoa from patients who underwent
other procedures (puncture, aspiration, testicular biopsy),
without finding sperm. MicroTESE presents three
advantages: it increases the chances of harvesting spermatozoa (50-70%); it takes a small amount of testicular tissue
(avoiding post operatory testicular insufficiency) and has a
low risk of damaging the testicular vessels and consequent
testicular atrophy.
133
Video – Hipertrofie benignæ a prostatei
V.3.1. Vaporizarea bipolaræ cu
plasmæ în scleroza secundaræ de col
vezical – avantaje pe termen lung
Bipolar plasma vaporization in
secondary bladder neck sclerosis –
a long-term advantages
Obiective: Acest studiu a urmærit demonstrarea eficienflei,
siguranflei øi rezultatelor postoperatorii ale vaporizærii
bipolare cu plasmæ în scleroza secundaræ de col vezical pe
termen lung.
Introduction and objectives: This prospective long-term
trial aimed to assess the efficiency, safety and postoperative
results of the bipolar plasma vaporization (BPV) in cases of
secondary bladder neck sclerosis (BNS).
Material øi metodæ: În studiu a fost inclus un numær de 35 de
pacienfli cu sclerozæ de col vezical secundaræ rezecfliei
monopolare transuretrale standard (TURP) în 23 de cazuri,
adenomectomiei transvezicale în 9 cazuri øi prostatectomiei
transvezicale în 3 cazuri. Criteriile de includere au fost
reprezentate de Qmax < 10 mL/s øi IPSS > 19. Tofli pacienflii au
fost evaluafli preoperator øi la 1, 3, 6, 12 øi 18 luni dupæ
intervenflie prin intermediul IPSS, Qmax ,Qol øi PVR.
Materials and methods: A total of 35 patients with BNS
secondary to TURP (35 cases), open prostatectomy for
benign prostatic hyperplasia (BPH – 9 cases) and radical
prostatectomy for prostate cancer (3 cases) were enrolled in
the trial. The inclusion criteria consisted of maximum flow
rate (Qmax) below10 mL/s and International Prostate
Symptom Score (IPSS) over 19. All patients were evaluated
preoperatively as well as at 1, 3, 6, 12 and 18 months after
surgery by IPSS, quality of life score (QoL), Qmax and postvoiding residual urinary volume (PVR).
Rezultate: Timpul operator mediu, perioada medie de
cateterizare øi durata medie de spitalizare au fost în lotul de
studiu de 10,3 minute, 0,75 zile øi respectiv 1,1 zile. Un singur
pacient a necesitat reintervenflie (2,8%). La 1, 3, 6, 12 øi 18 luni
au fost evidenfliafli parametrii de urmærire în ceea ce priveøte
IPSS øi Qmax (3,8 versus 23 mL/s, 3,6 versus 23,2 mL/s, 3,5
versus 23,5 mL/s, 3,3 versus 23,9 mL/s, øi respectiv 3,4 versus
23,8 mL/s), Qol si PVR (1,4 versus 31 ml, 1,2 versus 24 ml, 1,1
versus 22 ml, 1,1 versus 19 ml øi respectiv 1,2 versus 21 ml).
Concluzii: Vaporizarea bipolaræ cu plasmæ reprezintæ o
metodæ valoroasæ de tratament în cazurile de sclerozæ
secundaræ de col vezical. Aceastæ proceduræ a evidenfliat o
eficacitate bunæ, un profil de siguranflæ satisfæcætor øi a
îmbunætæflit parametrii de urmærire pe termen lung.
Results: The mean operation time, catheterization period
and hospital stay were in the study group following 10.3
minutes, 0.75 days and 1.1 days, respectively. The long-term
re-treatment requirements due to BNS recurrence was in the
BPV trial for one patient (2.8%). At the 1, 3, 6, 12 and 18
months’ follow-up parameters were found regarding in
terms of IPSS and Qmax (3.8 versus 23 mL/s, 3.6 versus 23.2
mL/s, 3.5 versus 23.5 mL/s, 3.3 versus 23.9 mL/s, 3.4 versus
23.8 mL/s, respectively), Qol and PVR (1.4 versus 31 ml, 1.2
versus 24 ml, 1.1 versus 22 ml, 1.1 versus 19 ml, 1.2 versus 21
ml).
Conclusions: BPV constitutes a valuable endoscopic
treatment approach for secondary BNS patients. The method
emphasized good efficacy, a satisfactory safety profile and
improved long-term follow-up features.
nr. 2 / 2013 • vol 12
M. Jecu, F. Stænescu, C. Moldoveanu, B. Geavlete,
Long term results of the bipolar
plasma enucleation of the prostate
in BPH cases over 80 mL
M. Jecu, F. Stænescu, C. Moldoveanu, B. Geavlete,
Obiective: În acest studiu retrospectiv, pe termen lung, am
avut ca scop evaluarea viabilitæflii enucleerii bipolare cu
plasmæ în cazurile de prostate voluminoase, în ceea ce
priveøte eficienfla chirurgicalæ, morbiditatea perioperatorie øi
parametrii clinici.
Introduction and objectives: This long term, retrospective
trial, aimed to evaluate the viability of the bipolar plasma
enucleation of the prostate (BPEP) in cases of large prostates
concerning surgical efficacy, perioperative morbidity and
follow-up parameters.
Material øi metodæ: Un numær total de 70 de pacienfli cu
volume ale prostatei mai mari de 80 ml, flux urinar maxim
(Qmax) sub 10 mL/s øi un scor IPSS peste 19 au fost incluøi în
studiu. Toate cazurile au fost evaluate preoperator øi la
fiecare 6 luni dupæ operaflie, timp de doi ani prin scorul IPSS,
Qmax, scorul calitæflii vieflii (QoL), reziduul vezical postmicflional, volumul postoperator al prostatei øi nivelul PSA.
Materials and methods: A total of 70 benign prostatic
hyperplasia (BPH) patients with prostate volume over 80 mL,
maximum flow rate (Qmax) below 10 mL/s and International
Prostate Symptom Score (IPSS) over 19 were included in the
trail. All patients were assessed preoperatively and every 6
months after surgery for a period of 2 years by IPSS, Qmax,
quality of life score (QoL), post-voiding residual urinary
volume (PVR), postoperative prostate volume and PSA level.
Rezultate: Volumul prostatic mediu a fost de 132,6 mL.
Timpul operator mediu a fost de 91,4 minute în timp ce
greutatea flesutului rezecat a fost de 108,3 grame. Parametrii
postoperatori ca rata de hematurie (2,9%), scæderea medie a
hemoglobinei (1,7 g/dL), perioada de cateterizare (1,5 zile) øi
durata de spitalizare (2,1 zile) au fost satisfæcætoare. Rata de
recateterizare pentru retenflie acutæ de urinæ a fost de 1,4%,
în timp ce rata de simptome iritative precoce a fost de 11,4%.
În timpul perioadei de urmærire de doi ani au fost înregistrate
rezultate bune în ceea ce priveøte IPSS, Qmax, QoL, reziduu
vezical post-micflional, nivelul PSA øi volumul postoperator al
prostatei. În acelaøi timp, volumul calculat al prostatei øi
nivelul PSA au scæzut (83,0-84,7%, respectiv 90,6-92,5%) în
comparaflie cu valorile preoperatorii.
Concluzii: Enucleerea bipolaræ cu plasmæ reprezintæ o
metodæ promiflætoare de tratament în cazurile de adenoame
voluminoase de prostatæ, caracterizatæ printr-o bunæ
eficienflæ chirurgicalæ. Pacienflii supuøi enucleerii cu plasmæ
au prezentat complicaflii semnificativ reduse, perioadæ de
convalescenflæ scurtæ, scoruri simptomatice øi parametri
micflionali satisfæcætoare pe termen lung.
nr. 2 / 2013 • vol 12
Results: The mean prostate volume was 132.6 mL. The BPEP
mean operating times was 91.4 minutes meanwhile resected
tissue weights was 108.3 grams. The postoperative
parameters like hematuria rate (2.9%) as well as the mean
hemoglobin drop (1.7 g/dL), catheterization period (1.5 days)
and hospital stay (2.1 days) were satisfacatory for BPEP. The
re-catheterization rate for acute urinary retention was 1.4%,
while the rate of early irritative symptoms was 11.4%. During
the 2 year’ follow-up period, good results were determined
in terms of IPSS, Qmax, QoL, PVR, PSA level and
postoperative prostate volume. Consequently, the
calculated prostate volume decrease (83.0-84.7%) and PSA
level was reduced (90.6-92.5%) by comparison to the
preoperative measurements.
V.3.2. Rezultate pe termen lung ale
enucleerii bipolare cu plasmæ a
prostatei în cazurile de adenom de
prostatæ voluminos
Conclusions: BPEP represents a promising endoscopic
approach in large BPH cases, characterized by good surgical
efficiency and similar BPH tissue removal capabilities. Plasma
enucleation patients benefited from significantly reduced
complications, shorter convalescence period and satisfactory
long term follow-up symptom scores and voiding
parameters.
135
V.3.3. Vaporezecflia adenomului de
prostatæ cu Laser Thulium: tehnicæ
operatorie øi rezultate inifliale
Introducere øi obiective: Tratamentul cu laser al
adenomului de prostatæ reprezintæ o alternativæ utilizatæ mai
ales la pacienflii cu terapie anticoagulantæ cronicæ sau pentru
a evita riscul de sindrom post TURP. Momentan sunt folosite
4 categorii de lasere: KTP, diodæ, holmium øi thulium. Scopul
acestei lucræri este analiza tehnicii operatorii øi a rezultatelor
pe termen scurt a vaporezecfliei cu laser Thulium, cel mai nou
laser introdus în tratamentul adenomului de prostatæ.
Material øi metodæ: Vaporezecflia laser thulium (ThuVARP) a
fost folositæ la 8 pacienfli cu adenom de prostatæ aflafli în
tratament cronic cu anticoagulante. Protocolul de diagnostic
a inclus tuøeu rectal, PSA, IPSS, uroflowmetrie, examen sumar
de urinæ øi uroculturæ. S-a utilizat un laser Vela XL de 120 W,
cu o lungime de undæ de 1,9 µm. Intervenfliile au fost
efectuate în mediu salin, conform tehnicii clasice (tehnica
‘tangerine’), folosind un rezectoscop laser Stortz. Pacienflii au
fost urmærifli la 1 øi 3 luni postoperator.
Rezultate: Volumul prostatic mediu a fost de 40 cc (între 30
øi 50 cc). Timpul operator mediu a fost de 60 min (între 30 øi
80 min). Timpul de cateterism postoperator a fost de 24 ore.
Scæderea medie a hemoglobinei a fost de 0,80 g/dl,
sângerarea intraoperatorie fiind practic absentæ datoritæ
proprietæflilor hemostatice ale laserului Thulium. Nu s-au
înregistrat complicaflii intraoperatorii øi postoperatorii
imediate. Tofli parametrii preoperatori au înregistrat o
îmbunætæflire semnificativæ la 1 øi 3 luni postoperator.
Concluzii: Vaporezecflia laser Thulium a prostatei reprezintæ
o alternativæ eficientæ de tratament a pacienflilor cu adenom
de prostatæ mediu, cu o morbiditate redusæ øi duratæ minimæ
de spitalizare.
Vaporesection of benign prostatic
hyperplasia using Thulium Laser :
operative technique and
initial results
ntroduction and objectives: Laser treatment for benign
prostatic hyperplasia is an alternative therapy especially for
patients undergoing chronic anticoagulation therapy, and it
also avoids the risk of TURP syndrome. At the moment, there
are 4 categories of lasers : KTP, diode, holmium and thulium.
The purpose of this study is to analyse the operative
technique and short-term outcomes of vaporesection using
Thulium Laser, the newest type of laser used in the treatment
of benign prostatic hyperplasia.
Material and method: Thulium Laser vaporesection
(ThuVARP) has been employed on 8 patients with benign
prostatic hyperplasia, who were undergoing chronic
anticoagulation therapy. The diagnostic protocol included a
prostate exam, PSA dosing, IPSS, uroflowmetry, urinalysis
and uroculture. A Vela XL 120 W laser with a 1,9 µm
wavelengh was used. The interventions were performed in a
classic saline enviroment („tangerine“ technique), using a
Stortz laser resectoscope. One month and 3 month postoperative follow-ups were performed on all patients.
Results: Mean prostate volume 40 cc (between 30 and 50 cc).
Average surgery time was 60 minutes (between 30 and 80
minutes). Post-operative catheterization time was 24 hours.
Mean hemoglobin drop was 0,80 g/dl, and intra-operative
bleeding was almost nill thanks to the Thulium laser’s
hemostatic properties. There were no intra-operative, or
immediate post-operative complications. All pre-operative
parameters were significantly improved at the 1 month and
3 month post-operative follow-ups.
Concluzii: Vaporesection of the prostate using the Thulium
Laser is an efficient treatment option for patients with
medium sized benign prostatic hyperplasia, and boasts
reduced morbidity and a minimal hospitalization time.
nr. 2 / 2013 • vol 12
D. V. Stanca, M. Z. Attila, A.Boc, I. Juravle,
S. Nicolescu, I. Coman
Clinica Urologicæ Endo Plus Cluj-Napoca, România
D. V. Stanca, M.Z. Attila, A.Boc, I. Juravle,
S. Nicolescu, I. Coman
Endo Plus Urological Clinic Cluj-Napoca, Romania
Introducere øi obiective. Morbiditatea TURP a dus la modificæri
ale tehnologiei øi tehnicii standard de lucru. Prezentæm tehnica
de lucru øi rezultatele obflinute prin TURP în ser fiziologic øi
plasma-vaporizarea prostatei (TURis – PVP) pentru tratamentul
obstrucfliei subverzicale prin adenom prostatic.
Introduction and Objective. The morbidity of transurethral
resection of the prostate necessitates constant attempts at
modifications of the standard equipment and technique. We
present the surgical technique and our results with
transurethral resection in saline and bipolar plasma electro
vaporization of the prostate (TURIS-PVP) for treatment of
bladder outlet obstruction (BOO) due to benign prostatic
hyperplasia (BPH).
Material øi Metodæ. În intervalul ianuarie-decembrie 2012 am
tratat prin TURis – PVP 123 pacienfli. Bilanflul diagnostic
preoperator a inclus IPSS, Qol øi mæsurarea prin ecografie
abdominala a volumului prostatic øi a reziduului vezical
postmicflional (RPM). Pacienflii au fost reevaluafli la 6 sæptæmâni
postoperator utilizând acelaøi bilanfl diagnostic. Am înregistrat
necesarul de transfuzii øi rata de complicaflii precoce.
Rezultate. Vârsta medie a pacienflilor a fost de 65,5 ani (51-82
ani, SD 7,28). Volumul prostatic mediu a fost de 62 mL, timpul
operator mediu de 75 minute (35-150 minute, SD 23,2).
Majoritatea pacienflilor au fost externafli dupæ 24 ore (34%)
sau 36 ore (56%); restul dupæ 3 sau 4 zile (6% øi respectiv 4%).
Cateterul uretro-vezical a fost suprimat dupæ 7 zile.
Preoperator valorile medii ale IPSS, QoL øi RPM au fost de 19,
4 øi respectiv 80 mL; postoperator acestea au ajuns la 7, 3 øi
respectiv 10 mL. Un pacient a necesitat recateterizare pentru
7 zile. Cinci pacienfli au necesitat transfuzie de sânge; nu am
înregistrat alte complicaflii intraoperatorii. Postoperator 15
pacienfli au prezentat incontinenflæ urinaræ uøoaræ la
suprimarea cateterului; la 6 sæptæmâni 4 pacienfli mai
prezentau pierderi urinare necontrolate, pentru ca, la 3 luni
postoperator, sæ nu mai înregistræm incontinenflæ urinaræ.
Concluzii. Rata de complicaflii intraoperatorii în caz de TURis
– PVP este redusæ. În urma intervenfliei recuperarea este
rapidæ, cu rezultate funcflionale foarte bune pe termen scurt.
Material and Methods. Between January and December
2012 TURIS-PVP was performed in 123 men with BOO due to
BPH. The preoperative investigation protocol included IPSS,
QoL score and abdominal ultrasonography assessing
prostate volume and post-voiding residual urinary volume
(PVR). The patients were evaluated 6 weeks after surgery
using IPSS, QoL and PVR. We recorded the necessity of blood
transfusion and early complications rate.
Results. The median age of the patients was 65.5 years (5182 years, SD 7.28). The average BPH size was 62 ml, the mean
operating time was 75 minutes (35-150 minutes, SD 23.2).
The majority of the patients were discharged after 24 hours
(34%) or 36 hours (56%). The rest were discharged at 3 or four
days (6 and 4% respectively). The catheterization time was 7
days. Preoperatively, the mean value of IPSS was 19, the
mean QoL score was 4, the mean RV was 80 ml. Five patients
required blood transfusions; there were no other significant
intraoperative complications. Postoperatively one patient
required re-catheterization for 7 days. We recorded 15
patients with mild early postoperative urinary incontinence
(4 patients still incontinent at 6 weeks, no incontinence after
3 months). The mean postoperative IPSS score was 7 and the
mean PVR 10 ml.
V.3.4. Rezecflia transuretralæ în ser
Transurethral resection in saline and
fiziologic øi plasma-vaporizarea
plasma vaporization of the prostate:
prostatei: tehnica chirurgicalæ,
surgical technique and evaluation
siguranfla øi rezultatele pe termen scurt
of safety and short-term results
Conclusions. The intraoperative and early postoperative
complications rate is very low. The procedure has a fast
postoperative recovery time, good short-term functional
outcome and good hemostatic efficiency.
nr. 2 / 2013 • vol 12
137
Video – Cancerul de prostatæ, Tumori vezicale
V.4.1. Ligatura selectivæ a
Selective suture ligation of the dorsal
complexului dorsal în cadrul
vascular complex during open
prostatectomiei radicale retropubice
retropubic radical prostatectomy
S. Pætræøcoiu, C. Gîngu, A Dick, L. Militaru,
C. Surcel, M. Manu, M. Hârza, A. Iordache,
N. Vlaicu, R. Constantiniu, I. Sinescu
Centrul de Uronefrologie si Transplant Renal,
S. Pætræøcoiu, C. Gîngu, A Dick, L. Militaru,
C. Surcel, M. Manu, M. Hârza, A. Iordache,
N. Vlaicu, R. Constantiniu, I. Sinescu
Center of Uronephrology and Renal Transplantation
Introducere øi Obiective. Nu am gæsit o introducere mai bunæ
pentru aceastæ prezentare video decât cuvintele clasice ale lui
Pat Walsh: “În trecut rata incontinenflei era foarte ridicatæ.
Înaintea dezvoltærii tehnicii anatomice, chirurugul tæia complexul
venos dorsal în apropierea planøeului pelvin. CVD se retracta în
afara razei vizuale øi nu putea fi controlat, iar porfliunea anterioaræ
a sfincterului striat era excizatæ. Prin metode îmbunætæflite de
hemostazæ, partea anterioaræ din sfincterul striat este pastratæ”
(Walsh J Urol, 1998). Væ prezentæm în acest film rafinamentul
tehnic al acestei etape cruciale a intervenfliei de prostatectomie
radicalæ, cheia asigurærii celor trei obiective.
Introduction and Objectives. I couldn’t find a better introduction
for this video presentation than the classic words of Pat Walsh: “In
the past the rates of incontinence were very high. Before the
anatomical approach was developed the surgeon cut the dorsal
vein complex next to the pelvic floor. The DVC retracted out of
sight and could not be controlled, and the anterior portion of the
striated sphincter was excised. With improved approaches to the
control of hemostasis, more of the anterior striated sphincter was
preserved.” (Walsh J Urol 1998). We present in this video the
technical refinements of this crucial part of this surgical procedure
that represent the key of achieving trifecta.
Materiale øi Metode. Chiar dacæ prostatectomia radicalæ
retropubicæ este acum o proceduræ standardizatæ, existæ multe
detalii tehnice care o pot uøura. Abordul optim este încæ subiect
de discuflie, øi multe metode de ligaturæ a CVD au fost descrise.
Consideræm cæ ligatura selectivæ a CVD este tehnic fezabilæ, øi
permite o disecflie mai precisæ a apexului prostatic. De obicei
folosim 2-3 fire de suturæ (PDS 4x0, cu ac UR-6), care sunt trecute
superficial prin CVD. Læsæm aceste fire pe loc øi le folosim ca
repere pentru hemostaza ulterioaræ CVD. Aceastæ ligaturæ ce
implicæ numai ramurile superficiale ale plexului venos asiguræ
diviziunea finæ øi controlul separat al sângerærii reziduale, prin
intermediul aceloraøi fire de PDS 4x0 plasate iniflial øi læsate în
asteptare. Când toate focarele de sângerare de la nivelul plexului
Santorini sunt oprite, numai o zonæ micæ de la nivelul anterior al
sfincterului striat ar trebui sæ fie vizibilæ. Dezvoltând planurile de
disecflie inter sau intrafasciale de pe fafla anterioaræ a prostatei
este asiguratæ izolarea completæ a sfincterului striat extern.
Material and Methods. Despite the fact that open radical
retropubic prostatectomy is now a standard procedure, there are
still many surgical refinements (tips and tricks) that can make this
operation a less challenging one. The optimal approach is still
debatable. Many techiques regarding DVC control have been
described. We believe that selective ligation of DVC is technically
feasible and allows a precise apical dissection. Usually we use 2 or
3 sutures (PDS 4x0, UR-6 needle) that are passed just superficial
in DVC. We let these sutures in place and use them as stay sutures
for subsequent DVC hemostasis. This superficial ligation that
pulls together only the superficial branches of the plexus allows
for its sharp division and subsequent control of residual bleeding
with the same initial PDS 4x0 sutures placed at a second step.
When all bleeders from the Santorini’s plexus are controlled only
a small area of the anterior aspect of the rhabdosphincter should
be visible. Developing the interfascial or intrafascial planes of
dissection on the anterolateral aspect of the prostate we obtain
a complete dissection of the external striated sphincter.
Rezultate. Aceastæ tehnicæ asiguræ o disecflie sub control vizual a
sfincterului striat, minimalizând potenflialele injurii chirurgicale
de la acest nivel. Timpul necesar acestor manevre fine este de 30
de minute. Pierderile medii de sânge sunt sub 100 ml. Tehnica de
ligaturæ selectivæ a CVD scade timpul de vindecare
postoperatorie øi de recuperare a continenflei.
Concluzii. Disecflia apexului prostatei øi ligatura CVD sunt factori
predictivi intraoperatori importanfli pentru rezultatele
oncologice øi functionale ale intervenfliei. Pierderile de sânge,
marginile pozitive apicale, continenfla øi potenfla dupæ
prostatectomia radicalæ retropubicæ sunt în corelaflie strictæ cu
disecflia de la nivelul apexului prostatic.
Results. This technique allows approaching the rhabdosphincter under direct vision and for this reason it limits possible
damage during the dissection. The operative time of this careful
dissection is less than 30 min. The median blood loss is less than
100 ml. We feel that the presented technique has an impact on
the time to recovery of full continence.
Conclusions. Apical dissection and control of the DVC are
important intraoperative predictive factors for oncologic and
functional outcomes. Blood loss, apical positive margins,
continence and potency after open radical retropubic
prostatectomy are in strict correlation with apical dissection.
nr. 2 / 2013 • vol 12
S. Nicolescu, H. Logigan, M. Mureøan, N.
Criøan, C. Manea, I. Coman
Centrul de Chirurgie Roboticæ Urologicæ, Spitalul
Municipal Cluj-Napoca
Robotic-Assisted Laparoscopic
radical Prostatectomy (RALP)
– surgical technique
S. Nicolescu, H. Logigan, M. Mureøan, N.
Criøan, C. Manea, I. Coman
Urologic Robotic Surgery Center, Municipal
Hospital Cluj Napoca, Romania
Introducere. Prostatectomia radicalæ laparoscopicæ asistatæ
robotic a devenit o metodæ siguræ øi eficientæ în tratamentul
chirurgical al cancerului de prostatæ datoritæ multiplelor
avantaje oferite: vedere binocularæ 3D, reducerea tremorului,
dexteritate øi control oferite de cele 7 grade de libertate ale
braflelor robotului, comfortul oferit chirurgului.
Introduction.
Robotic-assisted
laparoscopic
radical
prostatectomy (RALP) has become a safe and efficient method
for the surgical treatment of prostate cancer due to the multiple
advantages it provides: binocular 3D vision, decreased
trembling, dexterity and control confined in the 7 degrees of
freedom of the arms of the robot, comfort for the surgeon.
Material øi metodæ. În experienfla Centrului de Chirurgie Roboticæ Urologicæ Cluj Napoca avem 112 cazuri de prostatectomie
radicalæ laparoscopicæ asistatæ cu robotul daVinci SI cu 4 brafle. În
video film sunt prezentate particularitæflile tehnice ale
principalilor timpi operatori. Am utilizat un abord transperitoneal
cu 6 trocare (4 trocare pentru braflele robotului øi 2 pentru
asistent). Primul pas implicæ incizarea peritoneului øi pætrunderea
în spafliul prevezical Retzius. Urmeazæ prepararea øi incizarea
fasciilor endopelvice, incizarea ligamentului pubo-prostatic,
ligatura øi incizia complexului venos dorsal Santorini. Dupæ
incizia colului vezical se disecæ planul posterior cu identificarea øi
izolarea veziculelor seminale øi a ductelor deferente. În situafliile
în care este posibil am practicat nerve sparing în vederea pæstrærii
funcfliei erectile. Ulterior se izoleazæ øi secflioneazæ pediculii
prostatici laterali, se disecæ apexul prostatic øi se sectioneazæ
uretra, izolându-se astfel complet prostata. Ultima etapæ a
intervenfliei constæ în efectuarea anastomozei uretro-vezicale. La
pacienflii cu riscul de invazie ganglionaræ> 6% conform
nomogramelor am practicat limfadenectomie pelvinæ bilateralæ.
Material and methods. In Cluj Napoca Urology Center of
Robotic Surgery we have peformed 122 Robotic-Assisted
Laparoscopic radical Prostatectomys (RALP) with the daVinci SI
robot. In this video are presented the technical characteristics of
the main surgical steps.
Rezultate. Din cele 112 cazuri la 59 din cazuri am practicat
limfadenectomie pelvinæ. Timpul operator mediu a fost de 170
minute cu o sângerare medie de 250 ml. Dintre acestea, 60 de
cazuri (53,3%) în stadiul pT2 cu o ratæ a marginilor pozitive de
12,1% øi 52 de cazuri (46,7%) în pT3 cu rata marginilor pozitive de
27,3%. Perioada medie de spitalizare øi de menflinere a
cateterului Foley a fost de 7 zile. La 6 luni postoperator 93,9%
prezintæ nivele nedetectabile ale PSA; 88,9 % utilizeazæ cel mult
un tampon/zi. În cazul pacienfliilor activi sexual anterior
intervenfliei a fost posibilæ efectuarea unei tehnici de nerve
sparing unilateral 27,6%, bilateral 49,4%; 47,9% dintre aceøtia
prezintæ funcflie erectilæ la 6 luni postoperator.
Concluzii. RALP oferæ o ratæ de morbiditate minimæ cu
rezultate oncologice øi funcflionale bune pe termen mediu
deoarece pacientul beneficiazæ de pierderi de sânge minime,
durere postoperatorie redusæ, recuperare rapidæ, pæstrarea
continenflei urinare øi a funcfliei erectile.
nr. 2 / 2013 • vol 12
We have used a transperitoneal approach with 6 ports (4 ports
for the robotic arms, 2 ports for the assistant surgeon). The space
of Retzius is created by dividing the anterior peritoneum. After
the incision of the endopelvic fascia, the dorsal venous complex
(Santorini’s plexus) is isolated and ligated. After the bladder neck
dissection the seminal vesicles and vas deferens are isolated and
dissected. When it was possible we performed unilateral or
bilateral nerve sparing. In the next surgical steps the lateral
prostatic pedicles are isolated and dissected, the apical
dissection is performed, the urethra is divided and the prostate
can be completely isolated. The last surgical step consists in
performing the urethrovesical anastomosis. We performed
bilateral pelvic lymphadenectomy in patients who had an
invasion risk >6% according to nomograms.
Results. We have performed bilateral pelvic lymphadenectomy
in 59 patients. The medium operating time was 170 minutes with
a medium blood loss of 250 ml. We had 60 cases (53.3%) in pT2
stage with positive surgical margins in 12.1% and 52 cases
(46.7%) in pT3 stage with positive surgical margins in 27.3%. The
medium hospital stay was 7 days, and the Foley catheter was
removed after 7 days. After 6 months post-operatory, 93.9% of
patients had undetectable PSA levels; 88.9% of patients were
using maximum one tampon/day. For sexually active patients
prior to surgery, we were able to use unilateral nerve sparing
technique in 27.6% and bilateral sparing in 49.4% of the cases;
47.9 % had normally erectile function after 6 months.
V.4.2. Prostatectomia radicalæ
laparoscopicæ asistatæ robotic (RALP)
– tehnica chirurgicalæ pas cu pas
Conclusions. RALP brings a minimum rate of morbidity with
good medium term oncologic and functional results due to
minimum blood loss, decreased pain after surgery, fast recovery,
maintaining of urinary continence and erectile function.
139
V.4.3. Beneficiile sistemului video 3D
în prostatectomia radicalæ
laparoscopicæ
Benefits of the 3D video system as
used in laparoscopic radical
prostatectomies
B. Petrufl, M. Hogea, D. Feflea, Alexandra Alb,
V. Buda, T. Calistru, A. Kozan, V. Schiflcu
Clinica de Urologie, Institutul Oncologic „Prof.
Dr. I. Chiricuflæ“ Cluj Napoca
B. Petrufl, M. Hogea, D. Feflea, Alexandra Alb,
V. Buda, T. Calistru, A. Kozan, V. Schiflcu
Department of Urology, Cluj Napoca „Prof. Dr. I.
Chiricuflæ“ Oncological Institute
Laparoscopia este o alternativæ la abordul clasic în
numeroase proceduri chirurgicale urologice, cu rezultate
funcflionale øi oncologice cel puflin comparabile. Totuøi,
aplicaflia ei este limitatæ datoritæ curbei de învæflare dificile øi
timpului mare necesar perfecflionærii manualitæflii. Sistemele
de vizualizare tridimensionalæ, iniflial rezervate intervenfliilor
asistate robotic, au fost recent introduse øi în laparoscopia
uzualæ. Sub ipoteza scurtærii curbei de învæflare øi a
îmbunætæflirii timpilor operatori, ne-am propus evaluarea
sistemului de vizualizare tridimensionalæ în chirurgia
laparoscopicæ urologicæ în cadrul prostatectomiei radicale,
evaluând impactul subiectiv asupra operatorului principal øi
asistenflilor, precum øi a raportului cost-beneficiu. În urma
unui numær de intervenflii aceastæ ipotezæ a fost confirmatæ,
viziunea tridimensionalæ fiind de un real folos în orientarea în
câmpul operator, lucru reflectat în manevræri mai precise ale
instrumentarului øi timpi operatori mai scurfli.
Laparoscopy is an alternative to the open approach in
various urological procedures, with comparable functional
and oncological results. Still, its application is limited
because of the difficult learning curve and time required to
perfect the technique. Initially reserved for robotically
assisted interventions, three dimensional video systems have
been recently introduced in conventional laparoscopy as
well. Under the hypothesis that this technical advancement
could shorten the learning curve and improve surgical
parameters, we aimed to evaluate the 3D video system
during laparoscopic radical prostatectomies, assessing its
subjective impact on the main and assistant surgeons as well
as the cost-benefit ratio. Following a number of
interventions, three dimensional vision proved useful in
offering improved operating field orientation, which in turn
enabled increased precision in surgical instrument
manipulation and shorter operative times.
nr. 2 / 2013 • vol 12
Robot-assisted radical cystectomy
with intracorporeal ileal neobladder
- initial experience
Cristina Ivan, A. Boc, N. Crisan, I. Coman
Clinica de Urologie, Spitalul Municipal Cluj-Napoca
Cristina Ivan, A. Boc, N. Crisan, I. Coman
Clinical Department of Urology, Cluj-Napoca
Municipal Hospital, Romania
Intoducere øi Obiective: Cistectomia radicalæ este standardul
pentru tratamentul cancerul vezical infiltrativ. Interesul pentru
tehnici minim invazive precum cistectomia radicalæ asistatæ
robotic este în creøtere în centrele din întreaga lume. În video
film prezentæm experienfla iniflialæ øi tehnica chirurgicalæ în
cazul cistectomiei radicale asistate robotic.
Introduction and Objectives: Radical cystectomy is the
standard treatment for infiltrating bladder cancer. The interest
in minimally invasive techniques and robot-assisted radical
cystectomy is growing in medical centers worldwide. In the
video footage we are presenting the initial experience and the
surgical technique used in robot-assisted radical cystectomy.
Materiale øi Metode: În perioada ianuarie 2010 øi martie 2013
am practicat 10 cistectomii radicale asistate robotic pentru cancer vezical infiltrativ ( 9 bærbafli øi 1 femeie), dintre care 3 pacienfli
au fost supuøi procedurii de reconstrucflie vezicalæ intracorporealæ. Am evaluat parametrii perioperatori ( timpul operator,
pierderile de sânge, complicafliile), rezultatele oncologice (marginile pozitive, numærul de noduli limfatici) øi rezultatele funcflionale (continenflæ, erecflie, funcflie renalæ) la 6 luni postoperator.
Material and Methods: Between January 2010 and March
2013, we performed 10 robotic radical cystectomies for
infiltrating bladder tumour (9 men and 1 woman), out of
which 3 patients had intracorporeal ileal neobladder. We
assessed the perioperative parameters (operating time, blood
loss, complications), oncological results (positive margins,
number of lymph nodes) and functional results (continence,
erection, kidney function) at 6 months postoperatively.
Rezultate: Timpul operator pentru procedurile chirurgicale au
fost de 725 de min, 550 de min, respectiv 490 de minute pentru
fiecare dintre cele 3 cazuri. Pierderile de sânge au fost de 450
ml, 600 ml øi 350 ml. În toate cazurile, marginile de rezecflie au
fost negative, iar nodulii limfatici excizafli au fost negativi.
Tehnica de nerve-sparing a fost utilizatæ în cazul a doi pacienfli
care au prezentat erecflie sub tratament cu inhibitori de 5 PDE,
iar continenfla urinaræ a fost parflial prezervatæ. Evaluærile
imagistice la 6 luni au arætat aspect normal al sistemului
pielocaliceal øi lipsa de recurenflæ localæ sau la distanflæ.
Results: The duration of surgical procedures for the 3
intracorporeal ileal neobladder procedures amounted to 725
minutes, 550 minutes and 490 minutes respectively, while
blood loss added up to 450 ml, 600 ml and 350 ml respectively.
There were no positive margins. We performed extended
pelvic lymphadenectomy, all of them being negative. Daytime
and night-time continence was partially preserved, as patients
used one pad / day and one pad / night. Nerve sparing
technique was used for patients 2 and 3, as they presented
erections under PDE 5 inhibitors. Postoperative imaging
evaluation at 6 months showed normal appearance of the
pyelocaliceal system without local or distant recurrence.
Concluzii: Cistectomia radicalæ asistatæ robotic cu neovezica
intracorporealæ este o tehnicæ fezabilæ øi siguræ pentru
tratamentul cancerului de vezicæ infiltrativ. Disecflia øi sutura
sunt facilitate de vederea 3D øi libertatea oferitæ de sistemul
chirurgical DaVinci SI. Experienfla noastræ iniflialæ confirmæ
morbiditatea minimæ a acestei intervenflii cu rezultate
oncologice øi funcflionale pe termen scurt.
nr. 2 / 2013 • vol 12
V.4.4. Cistectomia radicalæ asistatæ
robotic cu neovezicæ
intracorporealæ – experienfla iniflialæ
Conclusions: Robot-assisted radical cystectomy with with
intracorporeal ileal neobladder is a feasible and safe
technique for the treatment of infiltrating bladder cancer,
with minimal morbidity and comparable oncological and
functional results.
141
V.4.5. Prolaps de boltæ grad IV. Meøæ
de polipropilenæ generaflia a III-a.
Prezentare de caz
M. C. Berechet, A. Bumbu, G. Bumbu
Clinica de Urologie. Universitatea din Oradea
Introducere: Pacientæ de 65 de ani, din mediul rural, cu
histerectomie totalæ în urmæ cu 2 ani, se prezintæ în Clinica de
Urologie Oradea dupæ o lungæ perioadæ de palpare a unei
formafliuni de dimensiunea unei mingi de tenis prezentæ la
introitul vaginal. Asociat, pacienta prezintæ tulburæri urinare,
micfliunea øi defecaflia fiind facilitate prin presiune digitalæ.
Material si metodæ: La examenul obiectiv s-a constatat un
prolaps de boltæ grad IV pentru care s-a indicat intervenflie
chirurgicalæ. Dintre posibilitæflile terapeutice efectuate în
clinica (colposacropexie øi intervenflia pe cale vaginalæ) s-a
ales abordul vaginal.
Tratamentul chirurgical a constat în tehnica Bridge modificatæ pentru cistocel prin defect central øi fixarea vaginului în
3 puncte la ligamentul sacro-spinos (tehnica AMI), la
muøchiul iliococcigian øi la membrana iliopelvinæ utilizând o
meøæ de polipropilenæ de generaflia a III-a.
Rezultate: Evoluflie bunæ postoperatorie. Dupæ extragerea
sondei uretro-vezicale, s-a externat în curs de vindecare (2-4
zile) cu recomandæri.
Grade IV vault prolapse. Third
generation polypropylene mesh.
Case presentation
M. C. Berechet, A. Bumbu, G. Bumbu
Urology Clinic.University of Oradea
Introduction: 65 years old patient, from rural areas, with a
total hysterectomy 2 years ago, is admitted to Oradea
Urology Clinic after a long period of palpation formation size
of a tennis ball located at the vulvar vestibulae. Associated
with urinary disorders patient presents, micturition and
defecation being facilitated by digital pressure. Urinary
disorders are also presented, micturition and defecation
being facilitated by applying finger pressure.
Material and method: Objective examination found a grade
IV vault prolapsed for which surgery was indicated; vaginal
approach was elected. Central defect cystocele modified
Bridge technique was performed together with 3 point
vaginal fixation at the sacro-spinous ligament (AMI
technique), at the iliococcigian muscle and at the iliopelvin
membrane using a third generation polypropylene mesh.
Results: Good post-surgery evolution. After extracting the Foley
catheter, the patient was discharged with recommendations.
Conclusions: The combined surgical technique used in this
case lead to complication free intra- and post-surgery evolution.
Concluzii: Tehnica chirurgicalæ combinatæ folositæ în acest
caz a dus la rezolvarea patologiei prezentate færæ înregistrarea de complicaflii intra øi post operatorii.
nr. 2 / 2013 • vol 12
A. Bumbu, M.C. Berechet, G. Bumbu
TOT out-in for stress urinary
incontinence. Case presentation
Introducere: Pacientæ în vârstæ de 63 de ani cu incontinenflæ
urinaræ de efort doveditæ la examenul clinic (teste Boney,
Valsalva, urodinamicæ).
Introduction: 63 years old patient with stress urinary
incontinence diagnostic after clinical examination (Boney,
Valsalva and urodynamic tests).
Material øi metodæ: Se efectueazæ intervenflia TOT out-in
prin plasarea unei benzi de polipropilenæ. Se poate observa
în video fixarea bandeletei la ora 12, dar øi la ora 6 pentru a-i
asigura stabilitatea øi de a evita deplasarea ei.
Material and method: TOT out-in procedure is done using a
polypropylene tape. The tape is fixed at 12 and 6 o’clock in order
to ensure the stability and to avoid the movement of the tape.
Rezultate: Evoluflie bunæ postoperatorie. Pacienta îøi reia
micfliunile cu jet urinar bun, este continentæ øi nu are rezidiu
postmicflional vezical.
Concluzii: Fixarea bandeletei la ora 12 øi la ora 6 este o
opfliune selectatæ de autor în urma unor observaflii asupra
deplasærii bandeletei la pacientele cu incontinenflæ urinaræ de
efort persistentæ sau recurentæ. Unii autori, pentru a evita
acest lucru, practicæ incizii suburetrale transversale, alflii
practicæ intervenflia in-out sau montarea de mini-sling-uri,
situaflii în care deplasarea bandeletei nu se produce.
nr. 2 / 2013 • vol 12
Results: Good post-surgery evolution. The patient has good
micturition, is continent and no post void residual urine is noted.
Conclusions: Fixing the tape at 12 and 6 o’clock is an option
selected by the author as a result of observations related to
the movement of the tape in patients with persistent or
recurrent stress urine incontinence. Some authors in order to
avoid this used suburethral transverse incisions in order to
avoid this; others practice TOT in-out or mini-sling
procedures, thus avoiding the movement of the tape.
V.4.6. TOT out-in pentru
incontinenflæ urinaræ de efort.
Prezentare de caz
143
V.4.7. Bandeletæ suburetralæ trecutæ
transobturator în tratamentul
incontinenflei urinare
postprostatectomie
The transobturatorsuburethral sling
in the treatment of urinary
incontinence following radical
prostatectomy
B. Braticevici, C. Cælin, R. Danæu, R. Tomoøoiu
Spitalul Clinic “Prof. Dr. Th. Burghele”
B. Braticevici, C. Cælin, R. Danæu, R. Tomoøoiu
Clinical Hospital „Prof. Dr. Th. Burghele”
Introducere: Incontinenfla urinaræ postprostatectomie
radicalæ este un simptom ce apare la 5-30% din pacienfli øi are
un efect important asupra calitæflii viefliilor. În general, la un an
de la intervenflia chirurgicalæ, mai puflin de 5% dintre pacienfli
mai prezintæ aceastæ afecfliune. Implantarea unui sfincter
artificial rezolvæ aceastæ problemæ, implicând totuøi o ratæ
crescutæ a costului øi a morbiditæflii. Væ prezentæm o metodæ
de abordare a incontinenflei urinare postprostatectomie,
printr-o tehnicæ chirurgicalæ de montare a unei bandelete
suburetrale transobturator.
Introduction: The urinary incontinence following radical
prostatectomy it’s a symptom that affects about 5% to 30% of
the patients that underwent this procedure and has an
important impact on their wellbeing. Generally, one year after
the surgical procedure, less than 5% of the patients are still
affected by this condition. Using an artificial sphincter may
resolve this problem, but at a very high cost and morbidity.
Next we will present the approaching method of the male
incontinence following radical prostatectomy through a
surgical technique of setting a transobturator suburethral sling.
Material øi metodæ: Prezentæm cazul unui pacient diagnosticat
cu adenocarcinom prostatic, la care s-a practicat prostatectomie
radicalæ, cu evoluflie postintervenflionalæ simplæ, cu incontinenflæ
urinaræ, în evoluflie de un an, iniflial severæ, ulterior moderatæ.
Intervenflia a fost efectuatæ sub rahianestezie, cu pacientul în
poziflie de litotomie. A fost montatæ o sondæ uretro-vezicalæ 18
Ch. S-a incizat pe linie medianæ perineul øi s-au disecat straturile
anatomice. S-a evidenfliat muøchiul bulbo-spongios, care s-a
incizat median, cu descoperirea uretrei bulbare. S-a montat
transobturator bandeleta suburetralæ în maniera “in-out” øi s-a
fixat apoi “in manta” subcutanat.
Material and method: We are presenting the case of a patient
diagnosed with adenocarcinoma which underwent radical
prostatectomy with a favorable post operatory evolution, with
urinary incontinence that was initially severe and evolved to
moderate incontinence within a period of one year. The
intervention was performed under spinal anesthesia, with the
patient in a lithotomy position. An urethro-bladder probe
18CH was inserted. Post the median incision of the anterior
perineum and the dissection of the anatomical layers up to the
bulbospongiosus muscle, the bulbal urethra is exposed. At this
point the suburethral sling, with its characteristic aspect, is
transobturatory placed using an “in-out” method, being
anchored in the subcutaneous tissue.
Rezultate: Timpul operator a fost de 120 minute, færæ
pierderi semnificative de sânge. Sonda uretrovezicalæ a fost
suprimatæ la 3 zile post intervenflional. Postoperator imediat,
la 3, 6 øi 12 luni, pacientul a fost perfect continent, atât în
repaus, cât øi la efort. Controlul imagistic nu a evidenfliat
rezidiu vezical, iar uroflowmetria a fost în limite normale.
Concluzii: Bandeleta suburetralæ reprezintæ o opfliune în
terapia incontinenflei urinare postprostatectomie cu o duratæ
de spitalizare redusæ øi rezultate bune, al cærei dezavantaj îl
reprezintæ costul ridicat al bandeletei specifice. Proba
timpului este cea care va stabili dacæ montarea bandeletei
suburetrale reprezintæ o alternativæ fiabilæ øi cu costuri mai
reduse faflæ de sfincterul artificial.
Results: The surgical intervention lasted for 120 minutes,
without any significant blood loss. The urethro-bladder probe
was removed 3 days post surgery. Following surgery, at 3, 6 and
12 months the patient was perfectly continent, both while being
at rest, as well as at effort. The imagistic exam did not show any
vesical residual and the uroflowmetry was in clinical limits.
Conclusions: The suburethral sling represents an option in
the urinary continence following radical prostatectomy, with
a reduced length of stay and good results, whose main
inconvenience is the high cost of the characteristic sling. The
test of time is the one to establish whether the insertion of
the suburethral sling represents a reliable alternative with
lower costs than the one of the artificial sphincter.
nr. 2 / 2013 • vol 12
Vesico-Vaginal Fistula Repair
assisted by the DaVinci SI HD
Surgical Robot
T. Coroi, V. Gherman, F. Dobrotæ, V. Ona,
N. Criøan, I. Coman
Secflia Clinicæ Urologie, Spitalul Clinic Municipal
Cluj-Napoca, România
T. Coroi, V. Gherman, F. Dobrotæ, V. Ona,
N. Criøan, I. Coman
Urology Clinical Department, Cluj-Napoca
Introducere. Fistulele vezico-vaginale au frecvenfla cea mai
înaltæ dintre toate celelalte tipuri de fistule dobândite
localizate la nivelul tractului urinar. Alternativ tratamentului
chirurgical clasic, existæ posibilitatea chirurgiei minim
invazive, reprezentatæ de laparoscopie sau chirurgie
roboticæ. Chirurgia asistatæ robotic este din ce în ce mai mult
folositæ în domeniul urologiei, mai ales datoritæ faptului cæ
înlesneøte considerabil abordul în regiunea pelvinæ, abord
dificil de realizat în alte situaflii. Ne propunem sæ prezentæm,
prin intermediul unui video-film, tehnica chirurgicalæ asistatæ
robotic a curei operatorii a fistulei vezico-vaginale.
Introduction. Vesico-vaginal fistulas are the most common
acquired fistula of the urinary tract. Alternatively to the
classic approach, the possibility of minimal-invasive surgery
exists, such as laparoscopy or robot assisted surgery. In the
field of Urology, robotic surgery is more and more used,
especially because of the fact that it considerably facilitates
the accession within the pelvic region, which is otherwise
extremely difficult. Our purpose is to present through video
means, the surgical technique used in the robotic assisted
vesico-vaginal fistula repair.
Material øi metodæ. S-a folosit Platforma chirurgicalæ
roboticæ DaVinci SI. Folosind abordul transperitoneal, se
realizeazæ incizia longitudinalæ a vezicii, disecflia între planul
vezicii øi al vaginului, excizia traiectului fistulos, iar la final
sutura separatæ a inciziilor cu interpoziflia de epiploon.
Material and method. The robotic system DaVinci SI has
been used. Using a transperitoneal approach, a longitudinal
incision of the bladder is performed, followed by the
dissection between the bladder and the vaginal wall. The
fistula is then excised and finally, the separate suture of
incisions, while interposing part of the epiploon is performed.
Rezultate. Începând cu noiembrie 2009 øi pânæ în prezent au
fost realizate 5 astfel de intervenflii. Durata medie a intervenfliei
chirurgicale a fost de 240 minute. Sonda Foley a fost suprimatæ
dupæ o duratæ medie de 14 zile. Cantitatea medie de sângerare
a fost 100 ml, iar perioada medie de spitalizare a fost 15 zile.
Tranzitul intestinal a fost reluat dupæ o perioadæ medie de 3
zile. Nu au fost înregistrate cazuri de recidivæ.
Results. From November 2009 until the present day, 5 such
repairs have been performed. The mean operating time was
240 minutes. The Foley Catheter has been extracted after a
mean period of 14 days. Blood loss was on average 100 ml,
and hospital discharge occurred on the 15th day. Bowel
transit reoccurred after an average of 3 days. There were no
recorded cases of relapse.
Concluzii. Cura operatorie a fistulei vezico-vaginale folosind
Sistemul DaVinci reprezintæ o alternativæ beneficæ atât pentru
pacient, cât øi pentru chirurg. Chirurgia roboticæ oferæ o
alternativæ favorabilæ chirurgiei laparoscopice prin sistemul
de vizualizare tridimensional, care oferæ chirurgului o imagine
în adâncime a spafliului operator. Instrumentele prevæzute cu
articulaflii eliminæ conceptul de manevrare «în pârghie»
necesar în situaflia laparoscopiei, înlesnind astfel
manevrabilitatea øi aplatizând considerabil curba de învæflare.
Conclusions. The robotic approach used for the repair of
vesico-vaginal fistula is beneficial for the patient as well as for
the surgeon. Robotic surgery offers a favorable alternative to
laparascopic surgery through its three-dimensional vision
system, which provides an in-depth view of the operating
area. The joint-fitted instruments eliminate the <<lever>>
system used in laparoscopic surgery, thus facilitating the
handling and flattening the learning curve.
nr. 2 / 2013 • vol 12
V.4.8. Cura operatorie a fistulei
vezico-vaginale asistatæ de cætre
Robotul Chirurgical DaVinci SI HD
145
Video – Litiazæ, Oncologie
V.5.1.Abordul ureteroscopic flexibil
retrograd în stenoza de tijæ calicealæ
M. Dræguflescu, R. Mulflescu, D. Georgescu,
G. Niflæ, C. Moldoveanu, M. Brægaru, P. Geavlete
Flexible ureteroscopic retrograde
approach for
caliceal infundibular stenosis
M. Dræguflescu, R. Mulflescu, D. Georgescu,
G. Niflæ, C. Moldoveanu, M. Brægaru, P. Geavlete
Introducere: Stenoza de tijæ calicealæ reprezintæ o patologie
raræ, ce ridicæ o serie de probleme de tratament. Au fost
evaluate particularitæflile øi eficienfla abordului ureteroscopic
flexibil retrograd în aceastæ entitate patologicæ.
Introduction: Caliceal infundibular stenosis represents a rare
pathology which poses certain issues regarding treatment.
We evaluate the characteristics and the efficacy of the
flexible ureteroscopic retrograde approach in this pathology.
Material øi metodæ: În perioada Ianuarie 2012-Ianuarie 2013
în Clinica de Urologie “Sf. Ioan” au fost diagnosticate øi
tratate 5 cazuri cu stenozæ de tijæ calicealæ øi litiazæ
supraiacentæ. În 4 cazuri a fost utilizat un ureteroscop flexibil
Storz Flex-Xc, iar într-un caz unul Olympus URF-Vo. În toate
cazurile a fost utilizat un laser Ho:YAG.
Methods: Between January 2012 - January 2013 5 cases with
caliceal infundibular stenosis and related lithiasis were
diagnosed and treated in the Department of Urology of “St.
John” Clinical Hospital. A flexible Storz Flex-Xc ureteroscop
was used in 4 cases and an Olympus URF-Vo ureteroscop in 1
case. In all cases was used an Ho-YAG lithotripsy.
Rezultate: Stenoza a fost localizatæ la nivelul tijei caliceale
superioare (4 cazuri) sau mijlocie (1 caz). Trei cazuri au
prezentat litiazæ coraliformæ tip D, un caz litiazæ multiplæ øi un
caz litiazæ unicæ de 1 cm. Succesul intervenfliei a fost definit
astfel: recalibrarea satisfæcætoare a zonei stenozate, litotriflia
øi extragerea completæ a fragmentelor litiazice sau
fragmente litiazice restante < 2 mm. Patru cazuri au necesitat
o singuræ intervenflie în timp ce cazul cu litiazæ calicealæ
multiplæ a impus douæ intervenflii. La tofli pacienflii s-a montat
un stent JJ cu bucla superioaræ în calicele operat care a fost
menflinut 4 sæptæmâni. Nu au fost înregistrate complicaflii
majore. În cursul urmæririi tofli pacienflii au ræmas „stone-free”.
Într-un caz a survenit restenozarea tijei caliceale la 4 luni de
la intervenflie, impunând incizia iterativæ a acesteia.
Results: In 4 cases stenosis was located in superior caliceal
infundibulum and in one case in the middle caliceal
infundibulum. A type D coraliform lithiasis was diagnosed in
3 cases, multiple calculi in one case and a single 1cm stone in
one case. A successful intervention was defined by: a good
recalibration of the stenosis, lithotripsy with complete
removal of stone fragments or remaining stone fragments
under 2mm diameter. A reintervention was needed only in
the multiple calculi case. A double JJ stent with superior loop
was placed in the respective caliceal infundibulum for 4
weeks in all cases. No major complications occurred. All
patients remained stone-free during follow-up. Restenosis of
the caliceal infundibulum occurred in one case after 4
months, requiring reintervention.
Concluzii: Abordul ureteroscopic flexibil retrograd este o
metodæ eficientæ de tratament a stenozei de tijæ calicealæ cu
litiazæ supraiacentæ. Intervenflia este asociatæ cu morbiditate
redusæ øi permite rezolvarea concomitentæ a ambelor patologii.
Conclusion: Flexible ureteroscopic retrograde approach
represents an efficient treatment option in caliceal infundibular
stenosis with related lithiasis. The method is associated with
low morbidity and allows solving both pathologies.
nr. 2 / 2013 • vol 12
E. Alexandrescu, R. Mulflescu, G. Niflæ,
C. Moldoveanu, M. Dræguflescu,
Flexible retrograde ureterescopic
approach in a rare disorder:
nephrocalcinosis
E. Alexandrescu, R. Mulflescu, G. Niflæ,
C. Moldoveanu, M. Dræguflescu,
Introducere: Nefrocalcinoza este o patologie raræ, cu un
management chirurgical nestandardizat. Am urmærit
descrierea particularitæflile abordului ureteroscopic flexibil
retrograd la pacienfli cu aceastæ patologie.
Introduction: Nephrocalcinosis is an uncommon pathology
with a non-standardized surgical management. Our purpose
was to describe the characteristics of the flexible retrograde
ureteroscopic approach in patients with this condition.
Material øi metodæ: În perioada Septembrie 2011-Ianuarie
2013 4 pacienfli cu nefrocalcinozæ au beneficiat de abord
ureteroscopic flexibil retrograd. Trei cazuri s-au prezentat la
camera de gardæ pentru dureri colicative lombare øi unul cu
hematurie totalæ. Tofli pacienflii au prezentat urolculturi
pozitive. În trei cazuri a fost utilizat un ureteroscop flexibil
Olympus URF-Vo, iar într-un caz unul Storz Flex-Xc. În toate
cazurile a fost utilizat un laser Ho:YAG.
Method: Between September 2011 - January 2013, 4
patients with nephrocalcinosis were treated using flexible
retrograde ureteroscopic approach. Three cases have
presented in the emergency department for colic lumbar
pain and one patient had total hematuria. All patients had
positive urine cultures. In three cases we used an Olympus
URF-Vo flexible ureteroscope and a Storz Flex-Xc was utilized
for one patient. A Ho:YAG laser was applied in all four cases.
Rezultate: Timpul operator mediu a fost de 85 min. (variind
între 60 øi 132 min.). Un caz a necesitat o singuræ intervenflie,
douæ cazuri douæ intervenflii øi într-un caz au fost necesare 3
proceduri. La tofli pacienflii au fost îndepærtafli în totalitate
calculii ureterali, pielocaliceali øi, parflial, cei localizafli în
cavitæfli pseudo-diverticulare din parenchimul renal. În
urmærire, doi pacienfli au prezentat infecflii urinare recurente
øi unul litiazæ ureteralæ obstructivæ recurentæ.
Results: The average operating time was 85 minutes (with a
variation between 60 and 132 min.). One case required a single
intervention, two cases needed two interventions and three
procedures were necessary for one patient. In all 4 cases, we
removed entirely the ureteral and pyelocaliceal calculi and only
partially the ones located in pseudo-diverticular cavities.
During the follow-up, two patients had recurring urinary tract
infections and one had a recurrent obstructive ureteral lithiasis.
Concluzii: Managementul chirurgical al pacienflilor cu nefrocalcinozæ este dificil øi nestandardizat. Îndepærtarea unei cantitæfli
cât mai mari din masa litiazicæ øi antibioterapia adecvatæ sunt
esenfliale. Reducerea presiunii intraductale prin extragerea
calculilor intraparenchimatoøi poate contribui la ameliorarea
simptomatologiei dureroase, alæturi de îndepærtarea calculior
obstructivi de la nivelul cæii urinare superioare.
Conclusions: The surgical management in patients with
nephrocalcinosis is difficult and non-standardized. Adequate
antibiotherapy and removing as much as possible from the
stone burden are essential. Reducing intraductal pressure by
extraction of the calculi from the renal parenchyma can lead to
the improvement of pain symptomatology together with the
removal of obstructive calculi from the upper urinary tract.
nr. 2 / 2013 • vol 12
V.5.2. Abordul ureteroscopic flexibil
retrograd într-o patologie raræ:
nefrocalcinoza
147
V.5.3.Ureteroscopia flexibilæ
în abordul retrograd al
diverticulului pielocaliceal
Retrograde flexible ureteroscopic
approach of
pyelocaliceal diverticula
V. Mirciulescu, R. Mulflescu, G. Niflæ,
M. Dræguflescu, B. Geavlete, C. Ene, P. Geavlete
V. Mirciulescu, R. Mulflescu, G. Niflæ,
M. Dræguflescu, B. Geavlete, C. Ene, P. Geavlete
Introducere: În ultima perioadæ, tehnologia minim invazivæ
a schimbat radical modul de abordare øi de tratament al
diverticulilor pielocaliceali. Scopul studiului a fost evaluarea
eficienflei abordului endoscopic retrograd în tratamentul
pacienflilor cu diverticuli pielocaliceali simptomatici.
Introduction: Recently, the minimally invasive technologies
radically changed the management and treatment of
pyelocaliceal diverticula. Our goal was to evaluate the
efficiency of retrograde endoscopic approach in the treatment
of patients with symptomatic pyelocaliceal diverticula.
Material øi metodæ: În perioada februarie 1993- ianuarie
2013, au fost evaluafli øi tratafli 18 pacienfli cu DP simptomatic
(4 caliceale superioare, 7 caliceale medii øi 7 caliceale
inferioare). Simptomatologia a inclus: durere lombaræ (14 din
18 cazuri), hematurie (3 din 18 cazuri) øi infecflii recurente de
tract urinar (10 din 18 cazuri). 17 pacienfli au prezentat litiazæ
intradiverticularæ, iar un pacient a prezentat “milk of calcium
stone” intradiverticular. Ureteroscopia flexibilæ retrogradæ a
fost utilizatæ în toate aceste cazuri.
Methods: Between February 1993-January 2013, 18 patients
with symptomatic PD (4 of the superior, 7 of the medium and
7 of the inferior calices) were evaluated and treated.
Symptoms included: lumbar pain (14/18 cases), hematuria
(3/18 cases) and recurrent urinary tract infections (10/18
cases). 17 patients had intradiverticular lithiasis and one
patient presented intradiverticular milk of calcium stone.
Retrograde flexible ureteroscopic approach was attempted
in all these cases.
Rezultate: În 15 cazuri (incluzând pacientul cu “milk of calcium
stone”), s-a realizat abordul retrograd al istmului stenozat prin
incizie øi litotriflia calculilor. Incizia cu laserul a fost efectuatæ în 9
cazuri, pentru restul fiind utilizatæ incizia electricæ. La 3 pacienfli
cu diverticul inferior caliceal, imposibilitatea efectuærii unei
incizii retrograde a impus efectuarea unui abord percutanat.
Complicafliile postoperatorii au fost reprezentate de sângerare
persistentæ (3 cazuri), febræ (un caz), durere lombaræ (3 cazuri).
Evaluarea post-operatorie la 12 luni a demonstrat un pasaj larg
între diverticulul pielocaliceal øi sistemul colector la 14 pacienfli.
Într-un singur caz, recurenfla litiazicæ la 10 luni, a impus
repetarea intervenfliei de manieræ retrogradæ.
Results: In 15 cases (including the “milk of calcium stone”
patient), retrograde approach of the narrow isthmus and
stone removal were successful. Laser incision was performed
in 9 cases and electric incision in the others. In the other 3
cases with inferior calyx diverticulum, failure of retrograde
incision imposed percutaneous approach. Postoperative
complications were represented by persistent bleeding (3
cases), fever (one case) and flank pain (3 cases). Postoperative
evaluation at 12 months demonstrated a large passage
between pyelocaliceal diverticulum and collecting system in
14 patients. In 1 case, stone recurrence at 10 months imposed
repeated intervention in a retrograde fashion.
Concluzii: Scopul tratamentului este reprezentat de crearea
unei comunicæri non obstructive între diverticul øi sistemul
pielocaliceal. Procedurile minim invazive ar putea fi utilizate
ca primæ opfliune de tratament în aceastæ patologie.
Conclusions: This treatment intends to provide a large non
obstructive communication between the diverticula and the
pyelocaliceal system. Minimally invasive procedures may be
used as first treatment option in this pathology.
nr. 2 / 2013 • vol 12
Digital flexible ureteroscopy in lower
caliceal stones
I. Arabagiu, M. Dræguflescu, R. Mulflescu,
V. Mirciulescu, C. Moldoveanu, G. Niflæ,
P. Geavlete
I. Arabagiu, M. Dræguflescu, R. Mulflescu,
V. Mirciulescu, C. Moldoveanu, G. Niflæ,
P. Geavlete
Obiective: Calculii caliceali inferiori ridicæ o serie de probleme de management endoscopic. Am urmærit evaluarea
eficienflei abordului ureteroscopic flexibil retrograd în
aceastæ patologie.
Material øi metodæ: Au fost evaluafli 158 pacienti diagnosticafli cu litiazæ calicealæ inferioaræ cu diametru maxim 2 cm.
Intervenfliile au fost realizate sub rahianestezie la majoritatea
pacienflilor, numai la 5 dintre aceøtia fiind necesaræ anestezia
generalæ. Au fost utilizate ureteroscoape flexibile Olympus
URF-Vo, Storz Flex-Xc øi Wolf Cobra. În 112 cazuri s-a utilizat
litotriflia Ho:YAG laser. Perioada medie de urmærire a fost 3,2
luni (variind între 1 øi 14 luni).
Rezultate: La 46 pacienfli calculul a fost extras în piesæ unicæ
din calicele inferior folosind sonda cu coøulefl. La 74 pacienfli
calculul a fost relocat înainte de litotriflie în bazinet sau
calicele superior. La un numær de 38 de pacienfli calculul a fost
fragmentat in situ. La 91 pacienfli s-a practicat stentarea JJ.
Pacienflii au fost externafli la 24 de ore de la intervenflie. Rata
de succes a fost de 91,1% dupæ o intervenflie, respectiv 98,1%
dupæ a doua. În 3% din cazuri, în cursul urmæririi, a fost
necesaræ extragerea unor fragmente litiazice migrate ureteral.
Complicaflii minore au fost înregistrate în 17 cazuri. Nu au fost
înregistrate complicaflii tardive pe perioada de urmærire.
Concluzii: Ureteroscopia flexibilæ digitalæ, cu litotriflie laser
Ho:YAG este o metodæ eficientæ de rezolvare a calculilor
caliceali inferiori. Intervenflia este caracterizatæ de o ratæ
redusæ a complicafliilor øi o duratæ minimæ de spitalizare,
putând fi propusæ în condiflii de internare de zi.
nr. 2 / 2013 • vol 12
Objectives: Caliceal inferior stones raise a number of
endoscopic management issues. I followed the efficiency of
retrograde flexible ureteroscopy in this pathology.
Subjects and method: We assessed 158 patients diagnosed
with lower caliceal stones having a maximum diameter of 2
cm. Interventions were performed under spinal anesthesia in
most patients, only 5 of which were required general
anesthesia. There were used flexible ureteroscopes Olympus
URF-Vo, Storz Flex-Xc and Wolf Cobra. In 112 cases it was
used Ho:YAG laser. Mean follow-up period was 3.2 months
(range 1 to 14 months).
V.5.4. Ureteroscopia flexibilæ digitalæ
în litiaza calicealæ inferioaræ
Results: In 46 patients the stone was extracted as a unique
piece from the lower calix using baskets. In 74 patients the
stone was relocated in the renal pelvis or superior calix. In 38
patients the stone was fragmented in situ. In 91 patients was
necessary to use JJ stenting. Patients were discharged 24 hours
after surgery. Success rate was 91.1% after the first intervention
and 98.1% after the second. In 3% of the cases, during followup, it was necessary to extract lithiasic fragments migrated to
the ureter. Minor complications were observed in 17 cases.
There were no late complications during follow-up.
Conclusions: Flexible digital ureteroscopy, with Ho:YAG
laser lithotripsy is a minimally invasive method for solving
lower caliceal calculi. The intervention has a low
complication rate and minimum duration of hospitalization
and can be suggested in regime of day admission.
149
V.5.5.Tratamentul litiazei renale
prin ureteroscopie flexibilæ cu
litotriflie laser Holmium la pacienflii
cu malformaflii renale
Treatment of renal lithiasis using
flexible ureteroscopy and Holmium
laser lithotripsy in patients with
renal malformations
Ghe. Niflæ, R. Mulflescu, V. Mirciulescu,
C. Persu, B. Geavlete, I. Arabagiu,
C. Moldoveanu, P. Geavlete
Ghe. Niflæ, R. Mulflescu, V. Mirciulescu,
C. Persu, B. Geavlete, I. Arabagiu,
C. Moldoveanu, P. Geavlete
Introducere: Incidenfla litiazei renale la pacienflii cu anomalii
congenitale este mai mare comparativ cu populaflia normalæ
datoritæ drenajului urinar necorespunzætor øi a stazei
consecutive. Existæ mai multe alternative terapeutice ale
acestor cazuri. Scopul studiului este analiza tehnicii
operatorii øi a rezultatelor ureteroscopiei flexibile (URSF) cu
litotriflie laser Holmium în aceste cazuri particulare.
Introduction: The incidence of renal lithiasis in patients with
congenital malformations is greater than that of the general
population because of inadequate urinary drainage and
secondary stasis. There are numerous treatment options in
these cases. The purpose of this study is to analyse the
operative technique and results of using flexible ureteroscopy
(FURS) and Holmium laser lithotripsy for these specific cases.
Material øi metodæ: În ultimul an, URSF a fost utilizatæ la 292
pacienfli cu litiazæ renalæ, dintre care 12 cazuri au prezentat
malformaflii reno-ureterale: rinichi ectopic pelvin (3 cazuri),
rinichi în potcoavæ (4 cazuri), duplicitate pielo-ureteralæ (5
cazuri). S-au utilizat ureteroscoape flexibile Storz øi Olympus,
fibre laser de 270 microni, litotriflia realizându-se cu un laser
Holmium Dornier Medilas de 20 W. S-au urmærit complicafliile
intra øi postoperatorii precum øi rata de stone free.
Material and method: During the last year, FURS has been
employed on 292 pacients that suffered from renal lithiasis, 12
of which had renoureteral malformations : ectopic pelvic
kidney (3 cases), horseshoe kidney (4 cases), pieloureteral
duplication (5 cases). Storz and Olympus flexible ureteroscopes
were used, along with 270 micron laser fibres and lithotripsy
was performed using a Dornier Medilas 20 W Holmium laser.
Intra-operative and post-operative complications were
observed and documented, along with the stone free rates.
Rezultate: Dimensiunea medie a calculilor a fost de 1,6 cm
(între 1 øi 2,2 cm). Distribuflia calculilor a inclus: bazinet (2
cazuri), calice inferior (5 cazuri), calice superior (3 cazuri),
litiaza calicealæ multiplæ (2 cazuri). Stentarea preoperatorie
cu sonda JJ s-a impus la 3 cazuri. Douæ cazuri au asociat øi
litazæ ureteralæ care a fost rezolvatæ într-un prim timp
operator. Rata de stone free dupæ prima proceduræ a fost de
75% (9 cazuri), la 3 cazuri fiind necesare 2 proceduri.
Complicafliile postoperatorii au fost reprezentate de:
hematurie (2 cazuri), dureri lombare (2 cazuri), infecflie (1 caz).
Results: The average calculi size was 1,6 cm (between 1 and 2,2
cm). Calculi distribution was as follows : basinet (2 cases), minor
calyx (5 cases), major calyx (3 cases), multiple calyceal lithiasis (2
cases). Pre-operative „double J“ stenting was necessary in 3
cases. Two cases presented with associated ureteral lithiasis,
which was resolved beforehand. The stone free rate after the
first procedure was 75% (9 cases). The other 3 cases required a
second FURS procedure. Post-operative complications: 2 cases
of hematuria, 2 cases of lumbar pain and 1 case of infection.
Concluzii: Tratamentul modern al litiazei renale la pacienflii
cu malformaflii reno-ureterale poate reprezenta o provocare
pentru urolog. URSF cu litotriflia laser Holmium reprezintæ o
alternativæ eficientæ cu complicaflii minime.
Conclusions: Modern treatment of renal lithiasis in patients
with renoureteral malformations can be a challenge for the
urologist. FURS and Holmium laser lithotripsy represents an
efficient treatment alternative with minimal complications.
nr. 2 / 2013 • vol 12
Recidivated multiple lithiasis in
horseshoe kidney. Case presentation
Introducere: Pacient de 62 ani, vine din extrateritoriu (ClujNapoca) cu litiazæ coraliformæ recidivatæ dupæ o intervenflie
deschisæ în urmæ cu 2 ani.
Introduction: 62 year old patient, from another county (Cluj)
admitted to Oradea Urology Clinic with recidivated multiple
lithiases after a previous two years old open surgery.
Material øi metodæ: Radiografia renovezicalæ øi urografia
evidenfliazæ un rinichi în potcoavæ cu litiazæ multiplæ pe
unitatea renalæ dreaptæ. Se decide abord percutanat (NLP) pe
rinichiul drept, dupæ montarea sondei ureterale. Iniflial s-a
efectuat o puncflie într-un calice posterior, dupæ avansarea
mandrenului s-a apreciat cæ aceastæ puncflie nu va permite
accesul în calicele inferior (unde erau cantonafli calculii) motiv
pentru care se puncflioneazæ un calice anterior care permite
dilataflia øi introducerea færæ dificultate a nefroscopului.
Material and method: Simple reno-vesical X-ray and
intravenous urography shows a horseshoe shape kidney
with multiple lithiasis on the right renal unit. A percutaneous
approach (PCNL) on the right renal unit is done after placing
a ureteral catheter.
Rezultate: Evoluflie postoperatorie bunæ, pe radiografia
renovezicalæ la 72 ore s-au evidenfliat douæ restanfle
calculoase mici – s-a montat sonda double J øi s-a recomandat
o øedinflæ de ESWL.
Concluzii: Delimitarea între calicele anterior øi cel posterior a
fost posibilæ dupæ efectuarea ureteropielografiei øi folosirea
fenomenului de paralaxæ. Puncflia în acest calice øi dilataflia
intrarenalæ au permis miøcærile ample necesare pentru
extragerea calculilor din calicele inferior.
nr. 2 / 2013 • vol 12
Results: Good post-surgery evolution; after observing two
small remaining stones on72 hours simple reno-vesical X-ray,
a double J stent was placed and the patient receive the
recommendation to undergo an ESWL procedure.
Video – Litiazæ, oncologie
V.5.6.Litiazæ recidivatæ multiplæ
pe rinichi în potcoavæ.
Prezentare de caz
Conclusions: Delimitation between the anterior and the
posterior calyx was possible after intravenous urography and
the use of parallax phenomenon. Punctioning the anterior
calyx and the intrarenal dilatation allowed the necessary
ample movements to extract the stones from the inferior calyx.
151
V.5.7.Adrenalectomia asistatæ de
robotul DaVinci SI pentru tumorile
de suprarenalæ
The adrenalectomy assisted by the
DaVinci SI robot for
suprarenalian tumors
R. Coufli, C.D. Pop, F. Dobrotæ, N. Criøan, I. Coman
Clinica de Urologie, Spitalul Municipal Cluj-Napoca
R. Coufli, C.D. Pop, F. Dobrotæ, N. Criøan, I. Coman
Oradea Department of urology, Oradea
Emergency County Clinical Hospital
Introducere. Adrenalectomia efectuatæ laparoscopic øi-a
dovedit pânæ la ora actualæ caracterul minim invaziv øi
avantajele faflæ de metoda clasicæ în tumorile suprarenaliene
secretante cât øi în cele nesecretante. Adrenalectomia
laparoscopicæ asistatæ robotic de cætre sistemul DaVinci SI
este din ce în ce mai utilizatæ în centrele urologice care
dispun de dotare adecvatæ.
Introduction. Laparoscopic adrenalectomy has proved its
minimally invasive character and shown its advantages compared to laparotomy in the treatment of both secreting and nonsecreting adrenal tumors. The laparoscopic robotic-assisted
adrenalectomy, using the DaVinci SI system, is being used
increasingly in urology centers that dispose of such endowment.
Obiective. Prezentarea particularitæflilor tehnice pas cu pas
ale adrenalectomiei robotice transperitoneale (film video).
Objective. The step by step presentation of the technical
aspects of the robotic-assisted transperitoneal adrenalectomy (video).
Materiale øi metodæ. În Centrul de Chirurgie Roboticæ
Urologicæ Cluj-Napoca au fost efectuate din noiembrie 2009
pânæ în prezent 18 adrenalectomii. Am evaluat parametrii
perioperatorii (timp operator, pierderi de sânge, complicaflii),
numærul zilelor de spitalizare post operator, timpul de reluare a
tranzitului intestinal øi momentul de mobilizare al pacientului.
Materials and Methods. From November 2009 untill present,
18 adrenalectomies were performed in the Cluj-Napoca Urology
Center of Robotic Surgery. We have evaluated the perioperative
parameters (operative time, blood loss, complications),
hospitalization days, bowel movement rehabilitation and the
mobilization of the patient following surgery.
Rezultate. Investigafliile clinice corelate cu examenul histopatologic au relevat 6 feocromocitoame, 12 adenoame din care 2
sindrom Conn, 3 tumori secretante de cortizol øi 7 adenoame
nesecretante. Un numar de 15 intervenflii au fost efectuate
transperitoneal iar 3 retroperitoneal. Media timpului operator a
fost 120 minute. Pierderile de sânge au fost în medie sub 150 ml.
Intraoperator nu au existat incidente øi nu au fost realizate
conversii. Mobilizarea pacientului a avut loc în prima zi postoperator, tranzitul s-a reluat în medie la 36 ore iar externarea în
medie dupæ 5 zile. Nu au existat incidente anestezice în
intervenfliile asistate robotic pentru feocromocitom.
Results. A correlation of the clinical data and the histopathology
results have revealed 6 cases of pheochromocytoma and 12
adenomas among which 2 cases of Conn’s syndrome, 3 cortisol
secreting tumors and 7 non-secreting adenomas. A lateral
transperitoneal approach was used in 15 patients and a lateral
trans-retroperitoneal approach in the other 3 cases. The mean
operative time was 120 minutes with an average blood loss
below 150 ml. No intra-operatory incidents were reported and
no conversions were performed. The mobilization took place
during the first day after surgery, bowel movement was
reestablished in average after 36 hours and the patient was
discharged after 5 days. There were no anesthesia incidents in
the robotic-assisted surgery for pheochromocytoma.
Concluzii. Adrenalectomia asistatæ robotic este o alternativæ
viabilæ atât a intervenfliei clasice cât øi laparoscopice standard
prin prisma rezultatelor peri-operatorii øi post-operatorii
obflinute. Disecflia øi manevrele intra-operatorii sunt facilitate de
vederea 3D øi gradele de libertate oferite de sistemul chirurgical
DaVinci SI, avantaje utile mai ales in cazurile de feocromocitom.
Conclusions. The Robotic-assisted adrenalectomy is a viable
alternative to both the classical and laparoscopic approaches
due to its perioperative and postoperative outcomes. The
dissection and intraoperative maneuvers are facilitated by
the 3D perspective and the multiple degrees of freedom
provided by the DaVinci SI surgical system, advantages most
useful in the treatment of pheochromocytoma.
nr. 2 / 2013 • vol 12
Laparoscopic nephrectomy and
nephro-ureterectomy: initial results
Military Hospital “Carol Davila” Bucharest
Introducere: Nefrectomia laparoscopicæ este din ce în ce
mai frecventæ: fie ca øi standard de aur în tratamentul
tumorilor renale, fie pentru nefrectomiile simple, respectiv ca
parte integrantæ a nefroureterectomiei. Obiectivul lucrærii
constæ în analiza prospectivæ a variabilelor perioperatorii în
vederea creøterii eficienflei duratei de spitalizare precum øi
reducerea complicafliilor postoperatorii.
Introduction: Laparoscopic nephrectomy is more and more
frequent: either as gold standard for treatment of kidney
tumours, or for simple nephrectomies or as a part of the
nephro-ureterectomies. The objective is to protectively
analyze the perioperative data in order to increase the
efficiency regarding hospital stay and postoperative
complications.
Material øi Metodæ: Se prezintæ tehnicile utilizate, cu
variafliile fiecærei proceduri în parte precum øi rezultatele øi
complicafliile secundare implementærii acestora într-un
serviciu de urologie færæ experienflæ laparoscopicæ.
Methods: We present the operative technique with
variations for each procedure as well as the initial result and
complications, after starting those procedures in a urological
department.
Rezultate: In perioada Februarie 2012 – Martie 2013 au fost
efectuate un numær de 17 intervenflii chirurgicale care
corespund criteriilor de mai sus: 12 nefrectomii øi 5
nefroureterectomii. Indicaflia operatorie a fost determintæ în
marea majoritate a cazurilor (88%) de prezenfla de tumori. Nu
a fost înregistratæ nici o conversie. Sângerarea intraoperatorie
a fost minimæ în toate cazurile. Marginile de excizie ale
pieselor chirurgicale au fost negative. Postoperator au fost
înregistrate trei complicaflii, clasificare Clavien Dindo: gradul I,
II, respectiv IIIb. Durata medianæ de spitalizare a fost de 5 zile
cu observarea unui trend descendent.
Results: Between Feb 2012 and March 2013 we have
performed 17 procedures that match the above criteria: 12
nephrectomies and five nephroureterectomies. In great
majority 88% the indication was caused tumors. There was
no conversion to open surgery. There was minimal
intraoperative bleeding in all cases. All specimens have
negative surgical margins. We had three postoperative
complications Clavien Dindo grade: I, II and IIIb. Median
hospital stay was 5 days.
Concluzii: Aderarea riguroasæ la tehnicile consacrate
permite obflinerea unor rezultate bune øi implementarea cu
succes a chirurgiei laparoscopice renale.
nr. 2 / 2013 • vol 12
V.5.8. Nefrectomia øi nefroureterectomia
laparoscopicæ: rezultate inifliale
Conclusion: By strictly following the surgical technique, the
results can be good and the introduction of laparoscopic
surgery a success.
153
V.5.9. Nefroureterectomie
laparoscopicæ pentru tumoræ de
uroepiteliu cu localizare multiplæ
1
2
2
Laparoscopic nephroureterectomy
for urothelial tumor
with multiple locations
1
2
2
A. Breda , A. Mureøan , A. Pæunescu ,
2
2
2
R. Bardan , M. Georgescu , V. Bucuraø
1
Departamentul de Transplant Renal,
Spitalul Fundacio Puigvert,
Universitatea Barcelona, Spania,
2
Clinica Urologicæ, Universitatea de Medicinæ
øi Farmacie ‘’Victor Babeø’’ Timiøoara
A. Breda , A. Mureøan , A. Pæunescu ,
2
2
2
R. Bardan , M. Georgescu , V. Bucuraø
1
Renal Transplantation Department,
Fundacio Puigvert Hospital,
Barcelona University, Spain,
2
Urology Department, Timiøoara ‘’Victor Babeø’’
Medicine and Pharmacy University
Vom prezenta cazul unui pacient de sex masculin în vârstæ de
56 de ani, care a fost diagnosticat prin tomografie
computerizatæ cu substanflæ de contrast (uro-CT) cu douæ
tumori de uroepiteliu, localizate la nivelul bazinetului/calicelui superior stâng øi în ureterul terminal stâng. Filmul
prezintæ în mod succint disecflia laparoscopicæ a rinichiului
stâng, urmatæ de secflionarea vaselor renale øi de disecflia
ureterului stâng, în cele douæ treimi superioare. În finalul
intervenfliei, s-a practicat o incizie paravezicalæ stângæ
minimæ, de tip Gibson, prin care s-au extras rinichiul øi
ureterul stâng, dupæ rezecflia rondelei vezicale.
We will present the case of a 56 years old male patient, who
was diagnosed by computerized tomography (uro-CT) with
two urothelial tumors, located at the level of the left renal
pelvis/superior calyx, and in the left terminal ureter. The film
presents the laparoscopic dissection of the left kidney,
followed by the sectioning of the renal vessels, and the
laparoscopic dissection of the two superior thirds of the left
ureter. Finally, a Gibson left paravesical incision was
performed, allowing the extraction of the left kidney and
ureter, after the resection of a bladder cuff.
nr. 2 / 2013 • vol 12
A complete laparoscopic
nephroureterectomy with a sealed
bladder cuff excision initial experience
Introducere: Nefroureterectomia cu cistectomie perimeaticæ este
Introduction: Radical nephroureterectomy with bladder cuff
standardul de aur în tratamentul carcinomului urotelial de cale
urinaræ superioaræ. Accesul deschis sau laparoscopic par a fi
echivalente în termeni de eficacitate, însæ ambele aborduri trebuie
sæ urmeze principiile oncologice. Obiectivul lucrærii constæ în analiza
prospectivæ a datelor perioperatorii consecutive utilizærii unei noi
tehnici laparoscopice în managementul ureterului terminal, în
contextul nefroureteroectomiei laparoscopice.
excision is the gold standard treatment for upper urinary tract
transitional cell carcinoma. Open and laparoscopic access seems to
be equivalent in term of efficacy, but both procedures must comply
with oncological principles. The aim of the paper is to prospectively
analyze the perioperative data after introducing a novel technique
for the management of the distal ureter during the laparoscopic
nephoureterectomy.
Material øi metodæ: În perioada mai 2012 - martie 2013 am
Materials and methods: From May 2012 to March 2013 we have
decelat patru pacienfli la care s-a practicat nefroureterectomie totalæ
laparoscopicæ în aceastæ manieræ. Nu a fost necesaræ nici schimbarea
pozifliei pacientului, nici a trocarelor operatorii poziflionate iniflial.
Pentru disecflia ureterului terminal s-a folosit sigilarea øi ablaflia
folosind LigaSure.
performed four complete transperitoneal laparoscopic nephroureterectomies without changing the position of the patient. For the
lower end we have used LigaSure sealing/ablation technique.
Rezultate: Raportul femei bærbafli a fost de 1:1. Diagnosticul a fost:
carcinom cu celule tranzitionale, în trei cazuri, respectiv rinichi
ureterohidronefrotic, nefuncflional. Evoluflia postoperatorie a fost
simplæ cu suprimarea tubului de dren în ziua a doua. Sonda uretrovezicalæ a fost menflinutæ pânæ în ziua a 14-a postoperator. Durata
medie de spitalizare a fost de 4,5 zile.
V.5.10. Nefroureterectomie
laparoscopicæ cu cistectomie
perimeaticæ prin sigilare/ablaflie –
experienflæ iniflialæ
Results: Female to male ratio was 1:1. Diagnosis was upper tract
transitional cell carcinomas in three cases and one non-functioning
kidney. Postoperative recovery was uneventful. The drain was
removed in day 2. The urinary catheter was removed in the 14th
postoperative day. Mean hospital stay was 4.5 days.
Conclusion: Complete laparoscopic nephrouretectomy is feasible
with no compromise of the oncological principles.
Concluzie: Nefroureterectomia laparoscopicæ totalæ cu sigilarea
ureterului terminal este fezabilæ færæ a se compromite principiile
oncologice.
nr. 2 / 2013 • vol 12
155
V.5.11. Tumoræ urotelialæ de cale
urinaræ superioræ, tratament
paleativ: prezentare de caz
Upper urinary tract transitional cell
carcinoma, palliative treatment:
case report
Scop: Prezentarea unei intervenflii de ureteroscopie flexibilæ
cu laser-ablaflie a unei formafliuni tumorale voluminoase.
Aim: To present a flexible ureteroscopy and laser-ablation for
a large tumour.
Prezentare de caz: Pacienta J.G., în vârstæ de 93 de ani,
cunoscutæ cu tumoræ de cale urotelialæ superioaræ,
diagnosticatæ în urmæ cu aproximativ un an, se prezintæ cu
hematurie macroscopicæ. Se practicæ iniflial tratament
conservator însæ, datæ fiind persistenta sângerærii, se
procedeazæ la practicarea de ureteroscopie flexibilæ cu laserablatie tumoralæ în scop hemostatic. Evoluflia postoperatorie
a fost favorabilæ, cu externarea în prima zi postoperator.
Case report: Patient JG, 93 years old, diagnosed one year
ago with upper tract transitional cell carcinoma is admitted
with visible haematuria. After conservative management,
because of persisting haematuria, flexible ureteroscopy and
laser – ablation is performed in order to control the bleeding.
She had a simple postoperative recovery with discharge on
the next day.
Concluzii: Laserablaflia formafliunilor tumorale de cale urinaræ
superioaræ a devenit posibilæ datoritæ evoluflei tehnicilor
endoscopice øi poate reprezenta o soluflie în cazuri atent
selecflionate, însæ standardul de aur ræmâne nefroureterectomia.
Conclusion: Laser ablation of upper urinary tract tumors is
possible due to technical advances, but the gold standard is
nephro-ureterectomy.
nr. 2 / 2013 • vol 12
P. Geavlete, D. Georgescu, R. Mulflescu,
V. Mirciulescu, B. Geavlete
Introducere: Ureteroscopia flexibilæ de diagnostic a devenit
o proceduræ de rutinæ. Cu toate acestea identificarea
caracteristicilor sugestive pentru malignitate a unor leziuni
este dificilæ. În acest context, tehnologia NBI, introdusæ
relativ recent, permite un diagnostic mai precis. Scopul
studiului a fost reprezentat de evaluarea rolului
ureteroscopiei flexibile cu NBI în diagnosticul tumorilor de
cale urinaræ superioaræ.
Material øi metodæ: În perioada Ianuarie 2010 - Septembrie
2012, în Clinica de Urologie a Spitalului Clinic de Urgenflæ ”Sf.
Ioan” au fost efectuate 64 de ureteroscopii diagnostice în
luminæ albæ øi NBI, împærflite în 2 grupe. Grupul I (50 de
cazuri) a inclus pacienfli la care procedura a fost efectuatæ
pentru defecte de umplere la nivelul cæii urinare superioare
(20 de cazuri), hematurie unilateralæ (19 cazuri) sau citologie
pozitivæ (11 cazuri). Cel de-al doilea grup a inclus 14
proceduri efectuate pentru urmærirea a 7 cazuri cu tumori
uroteliate înalte tratate conservator. În toate cazurile a fost
utilizat un ureteroscop Olympus URF-Vo.
Improving the diagnosis of upper
urinary tract tumors: NBI technology
P. Geavlete, D. Georgescu, R. Mulflescu,
V. Mirciulescu, B. Geavlete
Introduction: Diagnosis flexible ureteroscopy become a
routine procedure. However, identifying characteristics
suggestive for a malignant nature of a lesion and consequently
the indication for biopsy is difficult. In this regard, the relatively
new NBI technology allows a better detection. Our study aimed
to determine the value of digital flexible ureteroscopy
combined with NBI in upper urinary tract pathology diagnosis.
Materials and Methods: Between January 2010- September
2012, 64 white light and NBI digital flexible ureteroscopic
procedures were performed in the Department of Urology of
“St. John” Emergency Clinical Hospital which were divided in
two groups. Group I (50 cases) included patients in which the
procedures were performed for: upper urinary tract filling
defects (20 cases), unilateral hematuria (19 cases), abnormal
urinary cytology (11 cases). The second group (14 procedures
in 7 cases) included follow-up cases with conservative treated
upper urinary tract urothelial tumors. An Olympus URF-Vo
ureteroscope with NBI capability was used in all cases.
Rezultate: Utilizarea tecii de acces ureteral a fost necesaræ în
10,9% din cazuri. Doar în 6,2% din cazuri s-a impus
prestentarea datoritæ accesului ureteral dificil. În 2 cazuri, nu a
fost posibilæ depæøirea infundibulului caliceal ingustat. În
grupul I, ureteroscopia flexibilæ a permis identificarea
leziunilor cæii urinare superioare în 98% din cazuri: tumori
maligne la 14 pacienfli øi leziuni benigne la 7. În 4 cazuri
tumorile au fost identificate doar prin NBI, în alte 3 cazuri, prin
aceastæ tehnologie, fiind evidenfliate leziuni suplimentare.
Într-un caz, biopsia efecuatæ sub NBI a fost benignæ. În cel deal II-lea grup, a fost identificatæ recurenfla tumoralæ la un caz,
aceasta fiind vizibilæ atât în luminæ albæ cât øi în NBI (dupæ o
urmærire medie de 12 luni, între 6 øi 30 de luni).
Results: Ureteral access sheath was used in 10.9% of the cases.
Only 6.2% of the cases were pre-stented due to difficult ureteral
access. In 2 cases, the large tip of the ureteroscope prevented
the access in thin caliceal infundibulum. In Group I, diagnosis
flexible ureteroscopy identified upper urinary tract lesions in
98%: malignant tumors in 14 cases and benign lesions in 35
cases. The malignant lesions were identified by both white light
and NBI in 7 cases. Only NBI detected the tumors in 4 cases,
while in 3 cases it identified supplementary lesions. In 1 case an
unnecessary biopsy was performed (biopsy taken under NBI
proved to be benign). In Group II, tumoral recurrence was found
in 1 of the 7 cases with conservative treated upper urinary tract
tumors, visible both in white light and NBI (after a mean followup of 12 months, ranging between 6 and 30 months).
Concluzii: Ureteroscopia flexibilæ în NBI reprezintæ o metodæ
utilæ de diagnostic a patologiei de trat urinar superior, în
special atunci când datele imagistice sunt echivoce øi sunt
suspectate leziuni maligne.
Conclusions: Flexible retrograde ureteroscopy with NBI
capability is a useful diagnosis method in upper urinary tract
pathology, especially when imaging data are equivocal and
malignant lesions are suspected.
nr. 2 / 2013 • vol 12
V.5.12. Creøterea acurateflii
diagnosticului tumorilor de
cale urinaræ superioaræ prin
tehnologia NBI
157
V.5.13. Limfadenectomia roboticæ
retroperitonealæ pentru cancerul
testicular. Premieræ naflionalæ
Robotic retroperitoneal
lymphadenectomy for testicular
cancer. National premiere
I. Juravle, F. Dobrota, N. Criøan, C. Manea,
C. Læpuøan, I. Coman
Centrul de Chirurgie Roboticæ Urologicæ,
Spitalul Clinic Municipal, Cluj-Napoca, România
I . Juravle, F. Dobrota, N. Criøan, C. Manea,
C. Læpuøan, I. Coman
Robotic Urological Surgery Center, Cluj-Napoca
Pacient P.C., 24 ani, cu seminom testicular pur, drept. La 3
luni dupæ ultima curæ de chimioterapie, imagistic se
evidenfliazæ imagini ganglionare retroperitoneale øi un bloc
adenopatic mixt, anteroinferior de hilul renal drept cu
dimensiuni de aproximativ 3 cm AP/2,2 cm LL/4 cm CC.
Comisia oncologicæ opiniazæ pentru extirparea maselor
ganglionare retroperitoneale reziduale. Limfadenectomia
roboticæ retroperitonealæ este una dintre tehnicile
chirurgicale de maximæ dificultate chiar øi cu ajutorul
robotului DaVinci SI cu 4 brafle, care se gæseøte în dotarea
Spitalului Clinic Municipal, Cluj-Napoca. În februarie 2013, a
fost efectuatæ prima limfadenectomie retroperitonealæ
roboticæ în serviciul nostru, tehnicæ pe care o prezentæm întrun film video. Sunt respectafli în principal timpii operatori øi
aria de limfadenectomie retroperitonealæ pentru un cancer
testicular drept, conform ghidurilor EAU. Sunt reliefate în
prezentarea video, vizibilitatea excepflionalæ oferitæ de
robotul DaVinci SI precum øi facilitatea manevrabilitæflii
instrumentarului robotic, care a permis extirparea maselor
ganglionare færæ incidente hemoragice øi cu o evoluflie
postoperatorie ce a permis reinserflia socio-profesionalæ
rapidæ a pacientului, acesta fiind externat dupæ 48 de ore.
Patient PC, 24 years with testicular pure right seminoma.
Three months after the last treatment of chemotherapy,
retroperitoneal lymph node images and an adenopathy
mixed block are imagistically highlighted, anteroinferior the
right renal hilum measuring about 3 cm AP / 2,2 cm LL / 4
inches CC. The commission of cancer opines for the removal
of residual retroperitoneal lymph node masses. Robotic
retroperitoneal lymphadenectomy is one of the most
difficult surgical techniques even using the SI DaVinci robot
with four arms, equipment found in the Municipal Hospital
from Cluj-Napoca. In February 2013, it was performed the
first robotic retroperitoneal lymphadenectomy in our service,
an outstanding technique which we will present in a video.
Time operators and retroperitoneal lymphadenectomy area
for a right testicular cancer are mainly followed according to
EAU guidelines. In this video is highlighted the exceptional
visibility offered by SI DaVinci robot and the facility of
handling the robotic instrumentation. The SI DaVinci robot
allowed not only the removal of lymph node masses with a
postoperative evolution and without bleeding incidents but
also a fast socio-professional reintegration of the patient
who was discharged after 48 hours.
nr. 2 / 2013 • vol 12
Index autori
Autor / numær rezumat
Author / abstract number
A
Adou
Alb Alexandra
Alexandrescu E.
Altan O.
Ambert V.
Andriciuc R.
Arabagiu I.
Armean P.
Ateia A.H.
Attila M.Z.
Aurelian J.
Azis O.
V.3.2, PM.2.7, PM.3.11, PM.6.2, PM.6.3,
PN.7, V.3.1
PM.3.16, V.1.3, V.1.4, V.1.5, V.4.3,
PM.1.14, PN.6
PM.1.12, PM.1.9, PM.2.11, PM.3.3, V.5.2
PM.3.10, PM.3.14
PM.1.5, PM.3.15, PM.3.6, PM.4.1, PN.4
PM.3.9
PM.3.3, V.5.4, V.5.5
PM.3.15
PM.4.2
V.3.4
PM.3.15
PM.7.3
B
Badea R.
Bædescu B.
Bædescu D.
Badi S.
Bælærie Cristina.
Bardan R.
Baston C.
Bealcu Florentina
Benguø F.
Berdan Gabriela
Berechet M.C.
Boc A.
Boiborean P.
Boja R.
Borcæiaø R.
Borda Angela
Botezan T.
Botoca M.
Brad A.
Brægaru M.
Bræniøteanu D.D.
Braticevici B.
Bratu O.
Breda A.
Bucuraø V.
nr. 2 / 2013 • vol 12
PM.7.5
PM.2.1, PM.2.2, PM.7.12
PM.1.2, PM.1.11, PM.1.5, PM.3.6
PM.1.17
PM.7.9
PM.2.9, PM.7.9, V.5.9
PM.2.1, PM.2.2, PM.7.12
PM.7.11
PM.7.4, PN.4
PM.7.4, PM.7.6
PM.5.2, V.4.5, V.4.6, V.5.6
V.3.4, V.4.4
PM.1.16
PM.1.6, PM.6.4
PM.1.5
PM.6.16, PM.7.8
PM.7.13
PM.2.9, PM.3.2
PM.3.13, PM.5.3, PM.6.16, PM.7.7, PM.7.8
PM.3.3, V.5.1
PM.1.19
PM.1.3, PM.3.6, PM.3.15, PN.4, V.1.1, V.4.7
PM.2.6, PM.3.5, PM.3.8, V.5.10, V.5.11,
V.5.8
V.5.9
PM.1.16, PM.2.9, PM.3.2, PM.7.9,
PN.10, V.5.9
Buda V.
Bulai C.
PM.3.16, V.1.3, V.1.4, V.1.5, V.4.3
PM.2.7, PM.3.11, PM.6.2, PM.6.3, V.3.1,
V.3.2
Bumbu A.
PM.5.2, V.4.5, V.4.6, V.5.6
Bumbu G.
PM.1.14, PM.5.2, PN.6, V.4.5, V.4.6,
V.5.6
Bunea Beatrice
PM.1.13
Bungærdean Cætælina PM.7.5
Buraga I.
PM.1.15
Buruian M.
PM.7.5
C
Cælin C.
Cælina S.
Calistru T.
Câmpean C.
Catarig C.
Cauni V.
Ceban E.
Cerempei V.
Chibelean C.
PN.4, V.4.7
PM.1.18
PM.3.16, V.1.3, V.1.4, V.1.5, V.4.3
PN.10
PM.3.1, PM.3.13
PM.1.15, PM.1.1
PN.1
PM.6.17, PM.7.10, PM.7.11
PM.3.1, PM.5.1, PM.5.3, PM.6.16,
PM.7.7, PM.7.8, PN.9,
Chirca N.M.
PM.4.1
Chiriflæ Manuela
PM.6.10, PM.6.11, PM.6.12, PM.6.13,
PM.6.15, PM.6.6, PM.6.7, PM.6.8,
PM.6.9, PM.7.15,
Chiujdea A.
PM.3.1, PM.6.5
Chuaibi A.
PM.1.1, PM.1.15
Ciutæ C.
PM.3.9
Codoiu C.
PM.7.12
Coman I.
PM.7.13, PM.7.5, V.1.2, V.3.4, V.4.2,
V.4.4, V.4.8, V.5.13, V.5.7
Coman Oana
PM.2.5
Constantinescu E.
PM.3.3, PM.6.1, PN.7
Constantinescu Ileana PM.7.10, PM.7.11
Constantiniu R.
PM.4.6, PM.4.7, V.4.1
Coroi T.
V.4.8
Costache C.
PM.3.9
Costæchescu Oana
PM.3.9
Costandache C.
PM.3.9
Coufli R.
V.5.7
Cozma C.
PM.1.14
Cozman C.
PN.6
Cræsneanu M.
PM.4.5, PM.6.17, PM.7.11, PM.7.2,
PN.11, PM.7.10
159
Index autori
Creflu O.
Criøan C.
Criøan F.
Criøan N.
Cucu C.
Cumpænaø A.
PM.4.6
V.4.8
V.5.7
PM.7.13, PM.7.5, V.4.2, V.4.4, V.5.13,
V.1.2
PM.2.9, PM.3.2, PM.7.9
Georgescu B.
Georgescu M.
Gherman V.
Ghirca Veronica
D
Gîngu C.
Damian D.
Daminescu L.
Danæu R.
David C.
Davidescu A.
Diaconescu D.
Dick A.
Glück G.
PM.3.6, PM.7.4
PM.1.16, PM.3.2, PN.10
V.4.7
PM.2.9
PM.7.1, PN.5, PN.13
PN.4, V.1.1
PM.2.3, PM.4.5, PM.4.6, PM.4.7,
PM.6.17, PM.7.10, PM.7.11, PM.7.2,
PN.11, V.4.1
Dinu M.
PM.2.6, PM.3.5, PM.3.8, V.5.10, V.5.11,
V.5.8
Dobrescu Alexandra PM.6.14
Dobromir N.
PM.2.8, PN.3
Dobrotæ F.
PM.7.5, V.1.2, V.4.8, V.5.13, V.5.7
Dogaru G.A.
PM.6.4
Domniøor Liliana
PM.4.5, PM.6.17, PM.7.1, PM.7.10,
PM.7.11, PM.7.2, PN.11, PN.5, PN.13
Drægoescu O.
PM.1.18
Dragomiriøteanu I.
PN.4, PM.1.5, PM.3.6, PM.4.1, PM.7.6
Dræguflescu M.
PM.1.8, PM.1.9, PM.3.3, V.5.1, V.5.2,
V.5.3, V.5.4
Drocaø A.
PM.1.17, PM.7.1, PM.7.12, PN.5, PN.13
Dumbræveanu I.
PN.1
Dumitrache M.
PM.1.11, PM.1.2, PM.3.6
Dumitru R.
PN.2
E
Enache F.D.
Ene C.
PM.4.4
PM.2.4, PM.2.5, PM.2.7, PM.3.11,
PM.6.2, PM.6.3, V.3.1, V.3.2, V.5.3
Feflea D.
Filip A.
Florescu V.
PM.2.6, PM.3.5, PM.3.8, V.5.10, V.5.11,
V.5.8
PM.3.16, V.1.3, V.1.4, V.1.5, V.4.3,
PM.2.8, PN.3
PM.7.14, PN.12
G
Gagiu C.
Galescu A.
Gava A.
Geavlete B.
Geavlete P.
H
Hæinealæ B.
PM.2.1, PM.2.2, PM.7.12
Hajdu Barabas Eniko PN.9
Hârza M.
PM.2.1, PM.2.2, PM.2.3, PM.4.5, PM.4.6,
PM.6.17, PM.7.10, PM.7.11, PM.7.12,
PM.7.2, PN.11, V.2.1, V.2.2, V.2.3, V.4.1
Haøegan A.
PM.3.7, PM.4.3
Himedan O.
PM.2.3, PM.4.5, PM.6.17, PM.7.10,
PM.7.11, PM.7.2, PN.11
Hodor T.
PM.7.13
Hogea H.
V.4.3
Hogea M.
PM.3.16, V.1.3, V.1.4, V.1.5
Hortopan Monica
PM.4.7, PM.6.9, PM.6.10, PM.6.12,
PM.6.13, PM.6.7, PM.6.8, PM.7.1,
PM.7.15, PN.13
Hurduc M.
PM.4.2
I
Iacob C.
Iatagan C.
F
Farcaø C.
Golovei Corina
Grad L.
Grasu A.G.
Grigore N.
V.2.1, V.2.2, V.2.3
PN.1
PM.1.18
PM.1.12, PM.1.7, PM.1.8, PM.2.7,
PM.3.11, PM.3.3, PM.6.1, PM.6.2,
PM.6.3, V.3.1, V.3.2, V.5.12,V.5.3, V.5.5
PM.1.10, PM.1.12, PM.1.7, PM.1.8,
PM.1.9, PM.2.11, PM.2.4, PM.2.5, PM.2.7,
PM.3.11, PM.3.12, PM.3.3, PM.6.2,
PM.6.3, PN.7, PN.8, V.3.1, V.3.2, V.3.3,
V.5.1, V.5.12, V.5.2, V.5.3, V.5.4, V.5.5
PM.1.8, PM.6.11, PM.6.12, PM.6.13,
PM.6.15, PM.6.7, PM.6.8, PM.1.12, PM.1.7,
PM.1.9, PM.3.3, PN.7, V.5.1, V.5.12
PN.10, V.5.9,
V.4.8
PM.3.13, PM.5.1, PM.5.3, PM.6.16,
PM.7.7, PM.7.8
PM.2.3, PM.3.10, PM.3.14, PM.4.5,
PM.4.6, PM.4.7, PM.6.14, PM.6.17,
PM.7.1, PM.7.10, PM.7.11, PM.7.2,
PN.11, PN.5, PN.13, V.4.1,
PM.6.10, PM.6.11, PM.6.12, PM.6.13,
PM.6.15, PM.6.6, PM.6.7, PM.6.8, PM.6.9
PM.7.15, PN.2
PM.6.16
PM.7.13
PM.3.15
PM.3.7, PM.4.3
Iconaru V.A.
Ilie C.P.
Iordache A.
Iordache F.V.
Iorga I.C.
Iulia Andrei
Ivan Cristina
PM.2.9
PM.2.6, PM.3.5, PM.3.8, V.5.10, V.5.11,
V.5.8,
PM.4.1
PM.2.6, PM.3.5, PM.3.8, V.5.10, V.5.11,
V.5.8
PM.3.14, PM.6.14, PM.4.16, V.4.1,
PM.6.1, PM.1.12
PM.7.3
PM.7.5
V.4.4
J
Jecu M.
Jinga V.
Jovrea Daniela
Juravle I.
PM.2.7, PM.3.11, PM.3.3, PM.6.2,
PM.6.3, V.3.1, V.3.2
PM.1.11, PM.1.2, PM.1.3, PM.3.15,
PM.3.6, PM.4.1, PM.4.2, PM.6.1, PM.7.4,
PM.7.6, PN.4, V.1.1
PM.1.14
V.3.4, V.5.13
nr. 2 / 2013 • vol 12

30 Revista Românæ de Urologie

Transcription

Similar documents

citeste tot articolul - Spitalul Clinic de Urgenta "Sf. Ioan"

Descarcă revista în format PDF

edition

edition

Nr. 1/2006