The role of membranous urethral afferent autonomic innervation in the continence mechanism after nerve sparing radical prostatectomy: a clinical and prospective study

Purpose: We evaluated the somatic and autonomic innervation of the pelvic floor and rhabdosphincter before and after nerve sparing radical retropubic prostatectomy using neurophysiological tests and correlated findings with clinical parameters and urinary continence. Materials and Methods: From February 2003 to October 2005, 46 patients with prostate cancer were enrolled in a controlled, prospective study. Patients were evaluated before and 6 months after nerve sparing radical retropubic prostatectomy using the UCLA-PCI urinary function domain and neurophysiological tests, including somatosensory evoked potential, and the pudendo-urethral, pudendo-anal and urethro-anal reflexes. Clinical parameters and urinary continence were correlated with afferent and efferent innervation of the membranous urethra and pelvic floor. We used strict criteria to define urinary continence as complete dryness with no leakage at all, not requiring any pads or diapers and with a UCLA-PCI score of 500. Patients with a sporadic drop of leakage, requiring up to 1 pad daily, were defined as having occasional urinary leakage. Results: Two patients were excluded from study due to urethral stricture postoperatively. We evaluated 44 patients within 6 months after surgery. The pudendo-anal and pudendo-urethral reflexes were unchanged postoperatively (p = 0.93 and 0.09, respectively), demonstrating that afferent and efferent pudendal innervation to this pelvic region was not affected by the surgery. Autonomic afferent denervation of the membranous urethral mucosa was found in 34 patients (77.3%), as demonstrated by a postoperative increase in the urethro-anal reflex sensory threshold and urethro-anal reflex latency (p <0.001 and 0.0007, respectively). Six of the 44 patients used pads. One patient with more severe leakage required 3 pads daily and 23 showed urinary leakage, including 5 who needed 1 pad per day and 18 who did not wear pads. Afferent autonomic denervation at the membranous urethral mucosa was found in 91.7% of patients with urinary leakage. Of 10 patients with preserved urethro-anal reflex latency 80% were continent. Conclusions: Sensory and motor pudendal innervation to this specific pelvic region did not change after nerve sparing radical retropubic prostatectomy. Significant autonomic afferent denervation of the membranous urethral mucosa was present in most patients postoperatively. Impaired membranous urethral sensitivity seemed to be associated with urinary incontinence, particularly in patients with occasional urinary leakage. Damage to the afferent autonomic innervation may have a role in the continence mechanism after nerve sparing radical retropubic prostatectomy.

A importância da avaliação do assoalho pélvico após a prostatectomia radical e seu impacto na disfunção erétil

Pós-graduação em Bases Gerais da Cirurgia - FMB

Reabilitação do assoalho pélvico em pacientes com incontinência urinária pós prostatectomia radical

Fundação de Amparo à Pesquisa do Estado de São Paulo (FAPESP)

Valor prognóstico da avaliação urodinâmica e da força do assoalho pélvico na incontinência urinária pós prostatectomia radical

Fundação de Amparo à Pesquisa do Estado de São Paulo (FAPESP)

Laparoscopic management of iatrogenic lesions

Purpose: To present our series of patients who underwent laparoscopic correction of iatrogenic lesions and a review of the literature.Patients and Methods: We evaluated 23 patients who underwent laparoscopic correction of iatrogenic lesions. Thirteen patients had open surgery, 6 had an endoscopic procedure, and 4 had a laparoscopic approach as the first surgical procedure. Vesicovaginal fistulas (VVF) developed in seven patients after open abdominal hysterectomies, and 1 patient presented with a VVF after ureterolithotripsy. A urethral cutaneous fistula developed in one patient after a laparoscopic resection of endometriosis nodules, and 1 patient presented with a ureterovaginal fistula after a perineoplasty. Three patients presented with encrusted ureteral stents after ureterolithotripsy. Ureteral stenosis developed in seven patients: three after open abdominal surgery, three after ureteroscopy, and one after pyeloplasty. One patient had a ureteral injury during laparoscopic partial nephrectomy, and two patients had bowel injuries after a tension-free vaginal tape procedure and a laparoscopic radical prostatectomy.Results: All patients underwent laparoscopic correction of the iatrogenic injuries. One patient had an early recurrence of a VVF, and one patient had a recurrence of a ureteral stenosis. There was one conversion to open surgery because of technical difficulties and one major bleeding event that necessitated blood transfusion. A lower limb compartmental syndrome developed in one patient.Conclusion: Despite the small number of patients and different types of surgeries performed, laparoscopic management of iatrogenic lesions seems to be feasible and safe in experienced hands. Its precise role in the management of this stressful condition still needs to be determined.

Nuclear phenotypes and morphometry of human secretory prostate cells: A comparative study of benign and malignant lesions in Brazilian patients

Prostatic lesions in Brazilian patients with benign prostatic hyperplasia (BPH, 26 cases) or adenocarcinoma (AC, 25 cases) were compared by qualitative microscopy and morphometric analysis. In 12 cases of BPH, prostate regions with no histological alterations were considered as controls (Ct). Archival material consisted of formalin-fixed, paraffin-embedded specimens obtained from prostatic transurethral resection and radical prostatectomy. Haematoxylin/eosin (HE)-stained sections were used to estimate the nuclear areas, perimeters and form factor values. HE-stained sections from AC specimens were also used for Gleason grading. BPH, AC and Ct could be discriminated by their nuclear areas and nuclear perimeters, but not by the nuclear form factor parameter. No significant differences were found when the AC data were compared using the combined version or the predominant grade version of the Gleason score (p = 0.8380 for nuclear area; p = 0.6076 for nuclear perimeter; p = 0.9202 for nuclear form factor; n = 200 nuclei per patient). This finding indicates that there is extensive heterogeneity in the size and shape of the nucleus in AC cells. These results also show that although the nuclear morphometry served to discriminate BPH and AC from each other and from Ct, it was not sufficient to correlate AC lesions with their respective Gleason scores in the human population analyzed.

The role of TMPRSS2:ERG in molecular stratification of PCa and its association with tumor aggressiveness: a study in Brazilian patients

Fundação de Amparo à Pesquisa do Estado de São Paulo (FAPESP)

Radical scavenging activity of orange and tangerine varieties cultivated in Brazil

Four citrus fruit varieties cultivated in Brazil (two kinds of sweet orange and two kinds of tangerine) were analyzed for physicochemical characteristics contents of total phenolics, total carotenoids and ascorbic acid, and antioxidant activities. The antioxidant activities of aqueous, methanolic, and acetone extracts of the citrus fruit juices were assessed on the basis of their ability to scavenge 1,1-diphenyl-2-picrylhydrazyl (DPPH(center dot)). The cravo tangerine has the highest content of citric acid, while the pera orange is richest in ascorbic acid. The lima orange has the highest total phenolic contents, and the ponkan the highest total carotenoids. The antioxidant activities, expressed as the concentration of antioxidant able to scavenge 50% of the initial DPPH(center dot) (EC(50)), ranged from 139.1+/-27.3 to 182.2+/-28.8 g extract/l for juice of orange varieties and 186.3+/-29.6 to 275.5+/-3.3g extract/l for juice of tangerine citrus varieties. In methanolic extracts the EC(50) ranged from 192.5+/-43.1 to 267.4+/-41.4 g extract/l for orange varieties and from 225.2+/-69.8 to 336.3+/-27.2 g extract/l for tangerine varieties. For EC(50) values of acetone fractions, there were no statistically significant differences between the different varieties. For every citrus fruit in the present study, the radical scavenging capacity was higher in the aqueous than in the methanolic or acetone fractions.

Free radical scavenging profile and myeloperoxidase inhibition of extracts from antidiabetic plants: Bauhinia forficata and Cissus sicyoides

There is abundant evidence that reactive oxygen species are implicated in several physiological and pathological processes. To protect biological targets from oxidative damage. antioxidants must react with radicals and other reactive species faster than biological substrates do. The aim of the present study was to determine the in vitro antioxidant activity of aqueous extracts from leaves of Bauhinia forficata Link (Fabaceae - Caesalpinioideae) and Cissus sicyoides L. (Vitaceae) (two medicinal plants used popularly in the control of diabetes mellitus), using several different assay systems, namely, 2,2'-azino-bis(3-ethylbenzothiazoline-6-sulfonic acid) (ABTS) decolorization. superoxide anion radical (O-2 center dot-) scavenging and myeloperoxidase (MPO) activity. In the ABTS assay for total antioxidant activity, B. forficata showed IC50 8.00 +/- 0.07 mu g/mL, while C. sicyoides showed IC50 13.0 +/- 0.2 mu g/mL. However, the extract of C. sicyoides had a stronger effect on O-2 center dot- (IC50 60.0 +/- 2.3 mu p/mL) than the extract of B. forficata (IC50 90.0 +/- 4.4 mu g/mL). B. forficata also had a stronger inhibitory effect on MPO activity, as measured by guaiacol oxidation, than C. sicyoides. These results indicate that aqueous extracts of leaves of B. forficata and C. sicyoides are a potential source of natural antioxidants and may be helpful in the prevention of diabetic complications associated with oxidative stress.

The effect of pH on horseradish peroxidase-catalyzed oxidation of melatonin: production of N-1-acetyl-N-2-formyl-5-methoxykynuramine versus radical-mediated degradation

There is a g-rowing body of evidence that melatonin and its oxidation product, N-1-acetyl-N-2-formyl-5-methoxykynuramine (AFMK), have anti-inflammatory properties. From a nutritional point of view, the discovery of melatonin in plant tissues emphasizes the importance of its relationship with plant peroxidases. Here we found that the pH of the reaction mixture has a profound influence in the reaction rate and products distribution when melatonin is oxidized by the plant enzyme horseradish peroxidase. At pH 5.5. 1 mm of melatonin was almost completely oxidized within 2 min, whereas only about 3% was consumed at pH 7.4. However, the relative yield of AFMK was higher in physiological pH. Radical-mediated oxidation products, including 2-hydroxymelatonin a dimer of, 2-hydroxymelatonin and O-demethylated dimer of melatonin account for the fast consumption of melatonin at pH 5.5. The higher production of AFMK at pH 7.4 was explained by the involvement of compound III of peroxidases as evidenced by spectral studies. on the other hand, the fast oxidative degradation at pH 5.5 was explained by the classic peroxidase cycle.

Surgical treatment of renal cell carcinoma recurrence at the renal fossa following radical nephrectomy

CONTEXTO: A recorrência local única do carcinoma renal de células claras em seu leito renal após nefrectomia radical é um evento raro. Estima-se que essa situação ocorra em 0,8% a 3,6% do total de procedimentos. Comumente, seu diagnóstico é realizado através de tomografia computadorizada de abdômen ou ultra-som renal usados no acompanhamento desses pacientes. É polêmico qual o melhor tratamento dessa rara condição entre urologistas e oncologistas devido aos poucos relatos em literatura. RELATO DE CASO: Relatamos um caso de recidiva neoplásica única no leito renal após quatro anos e meio da nefrectomia radical por adenocarcinoma de células claras, sem evidência de metástases a distância em outros órgãos. O diagnóstico foi realizado por meio de tomografia abdominal em acompanhamento ambulatorial, observando-se massa retroperitoneal em topografia renal. A massa foi retirada por meio de uma incisão subcostal ampliada, em cirurgia sem intercorrências. O paciente evoluiu bem no pós-operatório. Após um ano e meio do procedimento, foi evidenciada uma metástase no pulmão esquerdo, e seis meses após, outra recorrência metastática na nona costela anterior à direita, mesmo com paciente totalmente assintomático. O tratamento cirúrgico agressivo em recorrência local única é um bom método para controlar essa rara doença. Tomografia computadorizada de abdômen deve ser feita em acompanhamento de carcinoma renal por longos períodos após a nefrectomia radical para o diagnóstico de recorrências tardias e o tratamento deve ser feito como o de uma metástase recorrente única.

Tratamento cirúrgico na recidiva retroperitoneal tardia por carcinoma renal de células claras após nefrectomia radical

Late renal cell carcinoma recurrence in the renal fossa is a rare event. This condition occurs in 1 to 2% of radical nephrectomies. We reported a late recurrence at the renal fossa about four and half years after radical nephrectomy due to a renal cell carcinoma (RCC) without metastasis elsewhere. Diagnosis in an outpatient follow-up was made during an abdominal computed tomography and we observed a retroperitoneal mass in the renal fossa. The excision at the recurrence area was made through a subcostal transversal incision without any difficulty. After 6 months from this second procedure, there was no evidence of recurrence. The surgical aggressive treatment for late retroperitoneal RCC recurrence is a good method in this rare situation. Abdominal computed tomography must be done during long periods of follow-up for patients with radical nephrectomy for RCC to search for late retroperitoneal recurrences.

Pro-oxidant activity of apocynin radical

Fundação de Amparo à Pesquisa do Estado de São Paulo (FAPESP)