REVISTA ROMÂNÆ DE UROLOGIE

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2 REVISTA ROMÂNÆ DE UROLOGIE Editor Øef: Prof. Dr. Ioanel Sinescu Editor Fondator: Prof. Dr. Doc. Eugeniu Proca Comitet Editorial: 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 Redacflia: Centrul de Chirurgie Urologicæ, Dializæ øi Transplant Renal, Institutul Clinic Fundeni, Bucureøti Øos. Fundeni nr. 258, sect. 2, Bucureøti, România Tel./fax: ,

3 Program øtiinflific Topici de congres Scientific programme Congress topics Sesiuni postere Poster Sessions 1. Cancer de prostatæ Prostate Cancer 2. Urologie femininæ, incontinenflæ Female Urology, Incontinence 3. Oncologie Oncology 4. Varia Varia 5. Litiazæ Lithiasis 6. Tumori vezicale Bladder Tumors Sesiune Video Video Session

4 1.1. Rolul alfa-metilacil-coa racemazei øi a P63 în diagnosticul cancerului de prostatæ Amelia Petrescu 1, Gabriela Berdan 1, D. Rædævoi 1, O. Codreanu 1, D. Bædescu 1, Carmen Ardeleanu 2, V. Jinga 1 1 Spitalul Prof. Dr. Th. Burghele, Departamentul de Anatomie Patologicæ, Bucureøti 2 Institutul Victor Babeø, Departamentul de Histopatologie, Bucureøti Introducere: Diagnosticul cancerului prostatic poate fi uneori dificil de realizat doar in urma examenului histopatologic al fragmentelor prostatice obtinute prin punctie. Scopul acestui studiu a fost evaluarea folosirii cocktailului de anticorpi alfametilacil-coa racemazei (AMACR) si P63 in diagnosticul carcinomului prostatic. Am realizat un studiu prospectiv pe 50 de fragmente de prostatactomie radicala si 50 fragmente biopsice ce prezentau focare de carcinom prostatic minim, neoplazie intraepiteliala prostatica de grad inalt (HG-PIN) precum si zone de atrofie sau adenosis, in special cu nucleoli proeminenti, ce pot confundate cu aspectele de carcinom prostatic. Material øi Metodæ: Sectiuni histopatologice seriate din blocurile de parafina corespondente au fost colorate cu hematoxilin-eozina (HE), Van Gieson si imunohistochimic cu anticorpi pentru AMACR si P63 utilizand un cocktail de anticorpi prediluat pentru ambele proteine. Pentru a extinde utilizarea acestor markeri am combinat colorarea proteinei citoplasmatice AMACR cu aceea a proteinei nucleare P63, un marker al celulelor bazale prostatice care este absent in cancerul prostatic. Rezultate: Expresia AMACR a fost negativa in majoritatea fragmentelor de tesut normal. Cockteilul a fost foarte util pentru evidentierea cancerului prostatic asociat cu HG-PIN, a paternului cribriform de HG-PIN si a microfocarelor de carcinom prostatic. AMACR a fost pozitiv, cu colorare moderata si puternica, in aproape toate cazurile in care aspectul imunohistochimic a modificat diagnosticul initial de leziune atipica cu unul de carcinom prostatic. Cazurile diagnosticate initial ca leziune atipica si ulterior confirmate ca si cancer prostatic au prezentat o inalta suspiciune de cancer pe baza examenului histologic HE si a negativitatii markerilor celulelor bazale. Concluzii: Cocktailul de anticorpi poate avea utilitate diagnostica atunci cand fragmente limitate de tesut sau focare mici suspecte sunt disponibile pentru evaluare histopatologica pe fragmentele de punctie prostatica sau piesele operatorii. Combinarea markerilor AMACR si P63 poate realiza un pattern de colorare care sa faciliteaza identificarea celulelor maligne prostatice. Utility of alpha-methylacyl-coa racemase and P63 cocktail in the diagnosis of prostatic carcinoma Amelia Petrescu 1, Gabriela Berdan 1, D. Rædævoi 1, O. Codreanu 1, D. Bædescu 1, Carmen Ardeleanu 2, V. Jinga 1 1 Prof. Dr. Th. Burghele Clinical Hospital, Department of Histopathology, Bucharest, Romania; 2 Victor Babes Institute of Pathology, Department of Histopathology, Bucharest, Romania Introduction: The diagnosis of prostatic carcinoma can sometimes be challenging on needle core biopsies. Immunohistochemistry represent a further aid for the pathologist in setting up the diagnosis. The aim of this study was to assess the utility of alpha-methylacyl-coa racemase (AMACR)/P63 antibody cocktail for prostate cancer diagnosis. A prospective analysis of 50 consecutive radical prostatectomy specimens and 50 prostate needle biopsy semples was performed to select histological sections showing foci of prostatic carcinoma and/or minimal prostatic carcinoma, high grade prostatic intraepithelial neoplasia (HGPIN) as well as common benign mimickers of prostatic carcinoma to include atrophy and adenosis, especially with prominent nucleoli. Material and methods: Serial histological sections from the corresponding paraffin blocks were stained with hematoxylin and eosin (HE), Van Gieson and by immunostains for AMACR and P63 using a prediluted antibody cocktail comprising both. To extend the utility of these markers for prostate cancer we combined stained for cytoplsmic AMACR with staining for the nuclear protein P63, a basal cell marker in the prostate that is absent in prostate cancer. Results: Expression of AMACR was negative in the vast majority of normal tissues. The cocktail was very useful in highlighting prostatic carcinoma associated with HGPIN, flat and cribriform HGPIN and distorted foci of minimal prostatic carcinoma. AMACR was positive with moderate and strong staining in almost all cases for which the immunohistochemical result converted the expert review atypical diagnosis to a final cancer diagnosis. The cases whose diagnosis was changed from atypical to cancer were all highly suspicious for cancer based on HE histology and negative basal cell markers. Conclusions: This cocktail would be of diagnosis utility when only limited tissue is available for immunohistochemical evaluation of small diagnostically difficult foci on both prostate needle biopsy tissue and surgical specimens. Combined staining for AMACR and P63 resulted in a staining pattern that greatly facilitated the identification of malignant prostate cells. Cancer de Prostatæ nr. 2 / 2012 vol 11 Revista Românæ de Urologie 3

5 Cancer de Prostatæ 1.2. Rezultatele oncologice la 5 ani dupæ prostatectomie radicalæ în managementul de cancerul de prostatæ local avansat C. Surcel 1, C. Mirvald 1, C. Gîngu 1, I. Manea 1, A. Omer 1, S. Najjar 1, S. Pætræøcoiu 1, S. Margaritis 2, Carmen Savu 2, M.A. Manu 1, I. Sinescu 1 1 Centrul de Uronefrologie øi Transplant Renal 2 Clinica de ATI, Institutul Clinic Fundeni, Bucureøti Oncological outcomes at 5 years after radical prostatectomy in the management of locally advanced prostate cancer C. Surcel 1, C. Mirvald 1, C. Gîngu 1, I. Manea 1, A. Omer 1, S. Najjar 1, S. Pætræøcoiu 1, S. Margaritis 2, Carmen Savu 2, M.A. Manu 1, I. Sinescu 1 1 Center of Uronephrology and Renal Transplantation, Fundeni Clinical Institute 2 ICU Department, Fundeni Clinical Institute, Bucharest Introducere: Ghidurile EAU consideræ cæ prostatectomia radicalæ reprezintæ o opfliune pentru pacienflii selectafli cu cancer de prostatæ local avansat, însæ mulfli consideræ încæ radioterapia externæ (EBRT) øi tratamentul hormonal (HoT), ca primæ linie de tratament pentru aceøti pacienfli. Obiectiv: Acest articol prezintæ experienfla Clinicii noastre în tratamentul pacienflilor cu cancer prostatic local avansat folosind prostatectomia radicalæ deschisæ ca primæ etapæ în cadrul unui management multimodal. Material øi metodæ: Am realizat un studiu prospectiv desfæøurat între în Centrul nostru pe 105 pacienfli cu cancer de prostatæ local avansat, færæ tratament neoadjuvant, la care s-a practicat prostatectomie radicalæ retropubicæ deschisæ øi limfodisecflie ilio-obturatorie bilateralæ extinsæ (elnd). Tratamentul adjuvant a fost inifliat în momentul aparifliei recurenflei biochimice (EBRT ± HoT). Obiectivele principale au fost considerate supraviefluirea cancer specificæ (CSS), supraviefluirea globalæ (OS) øi recurenfla biochimicæ (BCR) la 5 ani. Am utilizat regresii Cox uni- øi multivariate pentru a identifica factorii cu impact semnificativ statistic în apariflia recurenflei biochimice øi asupra supraviefluirii færæ progresie a bolii (CPFS). Rezultate: Vârsta medie a fost de 68 de ani (interval, 52-74). Valoarea medie a antigenului prostatic specific (PSA) a fost de 14 ng/ml. La examenul anatomopatologic, 76% dintre pacienfli au prezentat tumori pt3-pt4, cu invazia veziculelor seminale în 50% din cazuri, iar margini pozitive (PSM) au fost raportate la 31% din pacienfli. O medie de 18 ganglioni/pacient au fost extraøi. Ratele de supraviefluire Introduction: The EAU guidelines on prostate cancer consider that radical prostatectomy is an option for selected patients with locally advanced prostate cancer, but many still consider external radiotherapy (EBRT) and hormonal treatment (HoT) as primary line of treatment for these patients. Objective: This article presents the experience of our Clinic in the management of patients with locally advanced prostate cancer using open radical prostatectomy as the first step in a multimodal approach. Material and Method: We conducted a prospective study during on 105 patientswith locally advanced prostate cancer with no neoadjuvant treatment that underwent open radical prostatectomy with extended bilateral pelvic lymph node dissection (elnd) in our Center. Adjuvant treatment was initiated at the time of biochemical recurrence (EBRT±HoT). Primary endpoints were considered cancer specific survival (CSS), overall survival (OS), biochemical recurrence (BCR) at 5 years. Cox uni- and multivariate regression analyses were used to identify predictive factors in BCR and clinical progression-free survival (CPFS). Results: Median age was 68 years (range, 52 to 74). Median prostate-specific antigen (PSA) was 14 ng/ml. At pathological examination 76% of the patients had pt3 pt4 tumors, 50% seminal vesicle infiltration and 31% positive surgical margins (PSM). A median of 18 nodes were removed per patient. Cancer-specific survival and overall survival rates at 5 years were 94.5% and 90.1%, respectively. Biochemical 4 Revista Românæ de Urologie nr. 2 / 2012 vol 11

6 Cancer de Prostatæ cancer specificæ øi de supraviefluire globalæ la 5 ani au fost de 94,5% øi 90,1%, respectiv. Recurenfla biochimicæ a fost detectatæ dupa o medie de 31 de luni p.o., iar 71% dintre pacienfli au primit tratament hormonal ca adjuvant, în monoterapie sau în asociere cu EBRT. Pacienflii cu scor Gleason mare (>7), margini pozitive øi extensie extracapsularæ au prezentat un risc mai mare de recurenflæ biochimicæ. Tratamentul adjuvant a îmbunætæflit rata de supraviefluire færæ BCR, dar nu a prezentat niciun impact asupra supraviefluirii globale la 5 ani. Concluzii: Datele noastre aratæ rezultate excelente pe termen lung pentru pacienflii cu cancer de prostatæ local avansat la care s-a practicat prostatectomie radicalæ ca primæ etapæ în cadrul unui management multimodal. Tratament adjuvant nu a prezentat niciun impact asupra supraviefluirii globale, iar momentul initierii acestuia este încæ neclar. progression was detected after a mean of 31 months p.o. and 71% of patients received HoT as adjuvant treatment alone or in combination with EBRT. Patients with high Gleason score (>7), positive surgical margins and extracapsular extension showed a higher risk for biochemical recurrences.adjuvant treatment improved BCR free survival rates, but with no impact on OS at 5 years. Conclusions: Our data showed excellent long-term outcome for patients with locally advanced prostate cancer treated with radical surgery as first step in a multimodal approach. Adjuvant treatment had no impact on overall survival and the timing for initiation is still unclear. nr. 2 / 2012 vol 11 Revista Românæ de Urologie 5

7 Cancer de Prostatæ 1.3. HistoBest Biopsy Chip ULTRA: o nouæ metodæ pentru imunohistochimie high-throughput pentru diagnostic øi cercetare în cancerul de prostatæ C.P. Farcaø 1,2, M.G. Hortopan 5, S. Muøat 3, M. Dumitrescu 1, B. Amuzescu 3,4, C.P. Ilie 1,2, O. Bratu 1, V. Madan 1,2, D. Mischianu 1,2 1 Spitalul Universitar de Urgenflæ Militar Central Carol Davila, Bucureøti 2 Universitatea de Medicinæ øi Farmacie Carol Davila, Bucureøti 3 HistoBest Diagnostics SRL, Bucureøti 4 Departamentul de Biofizicæ øi Fiziologie, Facultatea de Biologie, Universitatea Bucureøti 5 Institutul Clinic Fundeni, Serviciul de Anatomie HistoBest Biopsy Chip ULTRA: A New Method for High-Throughput Immunohistochemistry in Diagnosis and Prostate Cancer Research C.P. Farcaø 1,2, M.G. Hortopan 5, S. Muøat 3, M. Dumitrescu 1, B. Amuzescu 3,4, C.P. Ilie 1,2, O. Bratu 1, V. Madan 1,2, D. Mischianu 1,2 1 Carol Davila Central Military Emergency University Hospital, Bucharest 2 Carol Davila University of Medicine and Pharmacy, Bucharest 3 HistoBest Diagnostics SRL, Bucharest 4 Dept. of Biophysics and Physiology, Faculty of Biology, University of Bucharest 5 Fundeni Clinical Institute, Department of Anatomical Pathology, Bucharest Patologicæ, Bucureøti Introducere: Procedurile clasice de colorare deseori prezintæ limitæri în diagnosticarea cancerului de prostatæ, în timp ce imunohistochimia (IHC) creøte sensibilitatea, specificitatea øi valoarea predictivæ a histopatologiei. Totuøi, procedurile clasice pentru procesarea biopsiilor prostatice sunt greoaie, ineficiente øi adesea nu permit conservarea de flesut pentru studii ulterioare. Tissue microarrays (TMA) reprezintæ o nouæ dimensiune în acest domeniu prin combinarea de multiple biopsii pe aceeaøi lamæ. Prezentæm o nouæ metodæ TMA bazatæ pe HistoBest Biopsy Chip (patent pending). Materiale øi metode: Biopsii prostatice transrectale ecoghidate (8-12 puncflii per caz) au fost recoltate de la pacienfli cu suspiciune de cancer prostatic (PSA>2,5ng/ml øi/sau suspiciune clinicæ), dupæ obflinerea consimflæmântului informat øi aprobarea Comisiei locale de eticæ. Biopsiile au fost introduse øi procesate în matricile secflionabile dupæ protocoale standardizate. Dupæ identificarea zonelor sugestive de cancer prostatic, biopsiile suspecte precum øi zone normale (de control) au fost extrase din blocurile donor de parafinæ øi inserate în blocul recipient (HistoBest Biopsy Chip ULTRA). Secfliuni seriale la 4ìm au fost marcate cu anticorpi anti-p63, AMACR, cytokeratin 34 beta 12 øi anti- Introduction: Classical staining procedures often present limitations in diagnosing prostate cancer, while immunohistochemistry (IHC) increases sensitivity, specificity, and predictive power of histopathology. However, classical procedures for core biopsy processing are cumbersome, inefficient and most of the time fail to conserve tissue for research applications. Tissue microarrays (TMA) have provided a new dimension in this field by multiplexing the biopsies on a single slide. We present a new TMA method based on the HistoBest Biopsy Chip (patent pending). Material and methods: Transrectal ultrasound-guided prostate biopsies (8-12 cores per case) were collected from patients at risk of prostate cancer (PSA > 2.5 ng/ml and/or clinical criteria), upon informed written consent and with approval of the local Ethics Committee. The cores were included and processed in our patterned matrices, following standardized protocols. Upon identification of areas suggestive of prostate cancer, the suspect as well as control cores were removed from the donor paraffin blocks and inserted in a recipient matrix (HistoBest Biopsy Chip ULTRA). Serial paraffin sections were cut at 4 ìm and stained with anti-p63, AMACR, cytokeratin 34 beta 12 and anti-xmrv 6 Revista Românæ de Urologie nr. 2 / 2012 vol 11

8 Cancer de Prostatæ XMRV Envelope øi vizualizafli cu EnvisionFlex /HRP and DAB + (DAKO, Glostrup, Denmark). Rezultate: Interpretarea preparatelor IHC s-a dovedit expeditivæ øi la fel de precisæ ca øi metodele tradiflionale. De remarcat cæ unele cazuri prezentând træsæturi histologice de neoplazie s-au colorat pozitiv pentru XMRV, cu un pattern difuz în celulele stromale øi o tendinflæ de aglomerare în polul luminal al celulelor epiteliale în special în cazurile cu scor Gleason mic. Concluzii: HistoBest Biopsy Chip ULTRA reprezintæ o metodæ eficientæ pentru IHC high-throughput în diagnosticarea cancerului de prostatæ. Pe lângæ economiile substanfliale de reactivi, consumabile øi timp de lucru, HistoBest Biopsy Chip ULTRA permite condiflii optime de colorare, reduce variabilitatea øi faciliteazæ studiile comparative. Transferul de biopsii din blocurile donor în blocul recipient nu altereazæ structura tisularæ, permiflând un diagnostic de înaltæ calitate øi face posibile studii suplimentare de cercetare. Envelope antibodies and visualized with EnvisionFlex /HRP and DAB + (DAKO, Glostrup, Denmark). Results: Interpreting IHC slides proved expeditious and as accurate as when using traditional methods. Interestingly, several samples displaying prostate cancer features stained positively for XMRV, with a diffuse pattern in stromal cells and a tendency of clustering at the luminal pole in epithelial cells, especially in low Gleason score cases. Conclusions: HistoBest Biopsy Chip ULTRA provides a powerful method for high-throughput IHC in the diagnosis of prostate cancer. Beyond important savings in reagents, consumables and processing time, HistoBest Biopsy Chip ULTRA provides optimal staining conditions, thus reducing intersample variability and facilitating comparisons. The transfer of core biopsy samples from the original paraffin blocks to the ULTRA chip does not alter tissue structure, allowing highly accurate diagnosis and makes possible additional research studies. nr. 2 / 2012 vol 11 Revista Românæ de Urologie 7

9 Cancer de Prostatæ 1.4. Comparaflie între scorul Gleason preoperator øi postoperator la pacienflii cu prostatectomie radicalæ B. Braticevici, V. Ambert, D. Damian, C. Cælin, D. Diaconescu, R. Tomoøoiu, F. Benguø, S. Andrei, M. Mansour, C. Necoaræ, V. Jinga Spitalul Clinic,,Prof. Dr. Th. Burghele Bucureøti Comparison between preoperative and postoperative Gleason score in patients with radical prostatectomy B. Braticevici, V. Ambert, D. Damian, C. Cælin, D. Diaconescu, R. Tomoøoiu, F. Benguø, S. Andrei, M. Mansour, C. Necoaræ, V. Jinga Th. Burghele Clinical Hospital, Bucharest Obiective: Scopul nostru a fost de a face o analizæ comparativæ între stadializarea preoperatorie øi postoperatorie a scorului Gleason in cancerului de prostatæ. Material øi metodæ: Am analizat cazurile a 58 de pacienfli care au fost diagnosticafli cu adenocarcinom prostatic prin puncflie biopsie prostaticæ ecoghidatæ transrectal øi tratafli prin prostatectomie radicalæ în anul Evaluarea preperatorie a inclus examenul clinic, probele bioumorale, PSA, examenul ecografic abdominal, renovezicoprostatic øi transrectal, UIV, examenul CT sau RMN, examenul anatomopatologic al fragmentelor rezultate in urma puncfliei biopsie prostaticæ. S-a stabilit o stadializare preoperatorie care a fost apoi comparatæ cu stadializarea anatomopatologicæ postoperatorie ce a inclus scorul Gleason. Doua cazuri au fost excluse intrucat la PBP scorul Gleason nu a fost calculat (diagnostic imunohistochimic) si un alt caz a fost exclus din cauza lipsei de leziuni de ADK in piesa de prostatectomie radicala (wash-out cancer). Rezultate: Prin analizæ comparativæ am analizat scorul Gleason final. Rezultatele au arætat un scor Gleason mai mare la 24 de pacienti (43,6 % din pacienti) restul fiind stadializati corect. Concluzii: Este o crestere semnificativa a corului Gleason la 43,6 % din pacienti ce se coreleaza in majoritatea cazurilor cu un numar mai mic de 10 specimene obtinute prin PBP. Objective: Our goal was to make a comparison between preoperative and postoperative staging in prostate cancer Gleason score. Materials and methods: We analyzed the cases of 58 patients who were diagnosed with prostate adenocarcinoma by transrectal ultrasound guided prostate biopsy and treated by radical prostatectomy in Preoperative evaluation included clinical examination, blood samples, PSA, abdominal ultrasound, and transrectal ultrasound scan, IVP, CT scan or MRI and pathological examination of the fragments resulting from needle prostatic biopsy. Preoperative staging has been established which was then compared with postoperative anatomopathological staging that included Gleason score. Two cases were excluded whereas Gleason score was not calculated (diagnostic immunohistochemistry) and another case was excluded due to lack of ADK lesions in radical prostatectomy piece (washout cancer). Results: The comparative analysis we analyzed the final Gleason score. The results showed a Gleason score higher in 24 patients (43.6% of patients), the rest being staged properly. Conclusions: A significant increase to 43.6% Gleason chorus of patients who in most cases correlates with a lower number of 10 specimens obtained by NPB. 8 Revista Românæ de Urologie nr. 2 / 2012 vol 11

10 1.5. Rezultatele puncfliei bioptice a prostatei (PBP) ghidatæ ecografic efectuate în Clinica de Urologie a Spitalului Sf. Ioan Bucureøti I. Arabagiu, E. Constantinescu, D. Soroiu, E. Alexandrescu, D. Georgescu, G. Niflæ, C. Persu, M. Dræguflescu, M. Jecu, F. Stænescu, R. Mulflescu, B. Geavlete, M. Mirciulescu, M. Brægaru, P. Geavlete Clinica de Urologie, Spitalul Clinic de Urgenflæ Sf. Ioan, Bucureøti Transrectal ultrasound-guided prostatic biopsy (TRUS) Results Performed in Urology Clinic of the Hospital of St. John Bucharest I. Arabagiu, E. Constantinescu, D. Soroiu, E. Alexandrescu, D. Georgescu, G. Niflæ, C. Persu, M. Dræguflescu, M. Jecu, F. Stænescu, R. Mulflescu, B. Geavlete, M. Mirciulescu, M. Brægaru, P. Geavlete Department of Urology, Saint John Emergency Clinical Hospital, Bucharest Cancer de Prostatæ Obiective: Obiectivul studiului îl reprezintæ evidenflierea ratei de detecflie a ADK de prostatæ, la pacienflii internafli în Clinica de Urologie a Spitalului Clinic de Urgenflæ Sf Ioan Bucureøti. Pacienfli øi Metodæ: Au fost analizate rezultatele histopatologice ale fragmentelor prostatice obflinute prin PBP echoghidata transrectal la un numær de 80de pacienfli care au fost consultafli în ambulatoriul de specialitate în perioada ianuarie-decembrie de pacienfli au avut la dozarea PSA-ului total øi free PSA valori patologice, iar cinci dintre ei au avut suspiciune ADK de prostatæ doar la tuøeul rectal. Cei 80 de pacienfli au primit periintervenflional o cefalosporinæ IM/Iv, practicându-se PBP cu recoltarea a 6, 8 sau 12 fragmente. La 70 de pacienfli PBP s-a efectuat cu anestezie localæ, iar la 10 pacienfli a fost necesaræ sedoanalgezia.tofli pacienflii au fost externafli la câteva ore de la puncflie, recomandându-se tratament antibiotic 3-7 zile. Rezultate: La 20 de pacienfli (25%) rezultatul anatomopatologic a confirmat diagnosticul de ADK de prostatæ. La alfli 20 de pacienfli(25 %), rezultatul anatomopatologic suspicioneazæ ADK, recomandând efectuarea de examene imunohistochimice la Institutul Victor Babeø care confirma prezenta ADK de prostata la 18 dintre aceøtia. Rata globalæ de detecflie a ADK de prostatæ la pacienflii studiafli a fost de 48%. La 40 de pacienfli (50%) examenul anatomopatologic infirmæ prezenfla ADK de prostatæ, stabilind la 20 diagnosticul de adenom de prostata, la 10 diagnosticul de PIN HG, iar la 10 prezenfla inflamafliei cronice prostatice. Concluzii: Confirmarea histologica a ADK de prostatæ este obligatorie în stabilirea diagnosticului. Puncflia biopsie ecoghidatæ transrectalæ este metoda de elecflie pentru recoltarea fragmentelor de examinat. Uneori examenul anatomopatologic trebuie completat de teste suplimentare imunohistochimice. Objective: The objective of the study is to evaluate the detection rate of prostate cancer (PCa) in patients admitted to the Urology Clinic of St John Emergency Clinical Hospital Bucharest. Patients and Methods: Between January and December 2011, we analyzed the pathology results of prostate fragments obtained by TRUS from a total of 80 patients seen in the urology clinic. 75 patients had abnormal values of PSA and free PSA and 5 of them had only a suspicion of PCa at digital rectal examination. The 80 patients received a cephalosporin IM / IV for infection prophylaxis; 6, 8 or 12 samples were obtained during TRUS. The procedure was performed in 70 patients under local anesthesia and in 10 patients sedation was necessary. All patients were discharged from hospital a few hours after the TRUS and antibiotic treatment was recommended for 3-7 days. Results: The pathological results confirmed the diagnosis of PCa in 20 patients (25%) and also suspected PCa in other 20 patients (25%), requiring immunohistochemical tests in Victor Babes Institute, which confirmed PCa in 18 cases. The overall detection rate of PCa in our series was 48%. In 40 patients (50%), pathological examination infirms the presence of prostatic cancer, setting the diagnosis of 20 patients as having BPH, PIN HG in 10 cases and 10 with chronic prostatitis. Conclusions: Histologic confirmation of PCa is mandatory in the diagnosis. TRUS biopsy is the method of choice for sampling of fragments to be examined. Sometimes, pathological examination should be completed by additional immunohistochemical tests. nr. 2 / 2012 vol 11 Revista Românæ de Urologie 9

11 Cancer de Prostatæ 1.6. Experienfla Clinicii de Urologie Oradea în prostatectomia radicalæ retropubianæ A. Bumbu, M. Berechet, G. Isoc, G. Bumbu Clinica de Urologie, Spitalul Clinic Judeflean de Urgenflæ Oradea Introducere. Prezentarea face parte dintr-un studiu mai amplu care îøi propune sæ faca o analiza retrospectiva, al bolnavilor cu cancer de prostata (CaP) intre anii care s-au adresat Clinicii de Urologie a Spitalului Clinic Judeflean de Urgenta Oradea a caror diagnostic a fost pus in majoritatea covirsitoare a cazurilor prin punctie bioptica transrectala efectuata pentru valori de peste 4 ng/ml a PSAului. Material si metodæ. În prima parte a lucrærii sunt prezentate succint câteva rezultate statistice privitor la ceea ce înseamnæ prostatectomia radicalæ in maniera retropubianæ în clinica de urologie din Oradea, iar in partea a doua sunt expuse particularitæfli de tehnicæ operatorie precum øi o serie de rezultate preliminare ce rezidæ din cei unsprezece ani de experienflæ în realizarea acestei intervenflii. Retropubic radical prostatectomy Oradea Urology Clinic results A. Bumbu, M. Berechet, G. Isoc,G. Bumbu Urology Clinic Oradea Emergency Clinical County Hospital Introduction. This work is part of an retrospective study regarding prostate cancer patients admited in Oradea Urology Clinic between 2007 and 2012 and diagnosed based on transrectal prostate biopsy (PSA value more than 4ng/ml) Material and method. The target of the present work is double: first of all we want to present the experience of an operating team regarding retropubic radical prostatectomy. Second of all we do want to present the particular considerations of the authors regarding some interesting pre, intra and last but not least postoperative aspects. At the beginning, there are presented some statistics concerning retropubic radical prostatectomy in our clinic. Then, the authors are showing particular operating techniques as well as some preliminary results from our eleven years of experience. Rezultate øi concluzii. Se reliefeaza asadar experienfla unei echipe operatorii în ceea ce înseamnæ prostatectomia radicalæ dar totodatæ prezentarea considerafliilor particulare ale autorilor vis a vis de anumite aspecte pre, intra øi nu în ultimul rând postoperatorii. Rezultatele obflinute fac ca prostatectomia radicalæ retropubica sæ reprezinte gold standardul în tratamentul cancerului de prostatæ localizat. Results and conclusions. The results obtained in Oradea Urology Clinic with this intervention become a strong argument in saying that radical prostatectomy is the gold standard treatment for localized prostate cancer in our clinic. 10 Revista Românæ de Urologie nr. 2 / 2012 vol 11

12 1.7. Impactul tratamentului cu Dutasteridæ asupra densitæflii vascularizafliei prostatice øi a VEGF E. Alexandrescu, R. Mulflescu, M. Dræguflescu, B. Geavlete, P. Geavlete Clinica de Urologie, Spitalul Clinic de Urgenflæ Sf. Ioan, Bucureøti Introducere: Hematuria poate fi unul din simptomele hiperplaziei benigne a prostatei (HBP).Obiectivul acestui studiu a fost de a evalua independent densitatea microvascularæ øi respectiv expresia factorului endotelial de creøtere vascularæ (VEGF) la pacienflii cu HBP tratafli cu dutasteridæ. Material øi metodæ: Au fost evaluafli 30 de pacienfli cu HBP care au fost supuøi rezecfliei transuretrale (TURP).15 dintre aceøti pacienfli au urmat preoperator tratament cu dutasteridæ (6 pânæ la 18 luni) în timp ce restul de 15 au reprezentat lotul martor.hbp a fost confirmatæ histopatologic în toate cazurile.chip-urile de rezecflie din zona suburetralæ a prostatei au fost marcate imunohistochimic cu CD34,densitatea microvascularæ fiind determinatæ prin cuantificarea vaselor sanguine identificate cu ajutorul acestui anticorp monoclonal.pentru a evalua expresia VEGF a fost calculat un index VEGF cu scopul de a obfline scorul de colorare imunohistochimicæ (procentul celulelor marcate x intensitate). Fiecare specimen a fost analizat færæ ca anatomopatologul sæ cunoascæ apartenenfla la unul din cele 2 loturi.analiza statisticæ a fost realizatæ cu ajutorul testului Student. Rezultate: A fost înregistratæ o densitate microvascularæ øi respectiv o expresie a VEGF semnificativ mai mici în porfliunea suburetralæ a prostatei comparativ cu grupul de control(p<0.05).în ceea ce priveøte densitatea microvascularæ, valoarea medie a fost de 13,6 la grupul tratat cu dutasteridæ øi de 20,9 la grupul de control (p<0.5).indexul VEGF mediu a fost de 1,4 la grupul tratat cu dutasteridæ øi 2,4 la grupul de control(p<0.5).restul chip-urilor de rezecflie analizate nu au prezentat diferenfle semnificative între cele 2 grupuri. Concluzii: Studiul CD34 ca marker imunohistochimic pentru analiza densitæflii microvasculare la nivelul prostatei øi a expresiei VEGF ca factor important de creøtere care induce neovascularizaflia a demonstrat o inhibiflie semnificativæ a angiogenezei indusæ de dutasteridæ la nivelul flesutului prostatic suburetral. Dutasteride value in prostate microvessel density and vascular endothelial growth factor expresion E. Alexandrescu, R. Mulflescu, M. Dræguflescu, B. Geavlete, P. Geavlete Department of Urology, Saint John Emergency Clinical Hospital, Bucharest Introduction: Hematuria may be a symptom in benign prostatic hyperplasia (BPH). Our goal was to study the microvessel density and the vascular endothelial growth factor (VEGF), independently evaluated, in BPH patients treated with dutasteride. Material and methods: We evaluated 30 patients with BPH in which transurethral resection (TUR) has been performed. In 15 patients, dutasteride was given before surgery (6 to 18 months treatment period), and the remaining 15 patients have been used for comparison. In all cases prostatic hyperplasia was histologically confirmed. From the chips of the prostatic suburethral zone we applied immunohistochemical staining by using CD34 (microvessel density was determined by quantifying the number of blood vessels specific stained by this monoclonal antibody). For VEGF expression we established the VEGF index in order to obtain immunostaining score (percentage of cells x intensity). Analysis of each specimen was practiced in a blinded fashion. Statistical analysis was performed using Student s test. Results: We registered a significant lower microvessel density and VEGF expression in the suburethral portion of the prostate in the dutasteride series, compared to controls (p<0.05). Regarding the mean microvessel density data, we obtained 13.6 for dutasteride series and 20.9 for control series (p<0.5). The mean VEGF index data were 1.4for dutasteride series and 2.4 for control series (p<0.5). In the rest of the resected chips we did not find significative differences between the 2 groups. Conclusion: The study of CD34 as immunohistochemical marker for prostatic microvessel density analysis and VEGF expression as an important growth factor inducing neovascularization proved a significative angiogenesis inhibition induced by dutasteride in prostatic suburethral tissue. So, this drug may reduce prostatic urethral bleeding. Cancer de Prostatæ nr. 2 / 2012 vol 11 Revista Românæ de Urologie 11

13 Cancer de Prostatæ 1.8. Cancerul de prostatæ øi bolile asociate în cazuistica Clinicii de Urologie Târgu Mureø A. O. Vida, A. Szölösi, Buzsi Enikõ, Mártha Orsolya Spitalul Clinic Judeflean Mures, Clinica de Urologie Târgu Mureø Introducere: Cancerul de prostata este cancerul cel mai frecvent malignom urologic diagnosticat øi a doua cauzæ de deces în rândul bærbaflilor. Prevalenfla creøte constant cu vârsta. Studierea øi sumarizarea comorbiditæfliilor care afecteazæ mortalitatea este importantæ pentru eficientizarea activitæflii clinice. Materiale øi metode: Studiul nostru retrospectiv analizeazæ datele a 608 pacienfli, la care s-a efectuat puncflie biopsie prostaticæ în perioada , pentru suspiciunea de cancer de prostatæ. Diagnosticul de ADKP s-a confirmat la 277 (45,5%) pacienfli. Media de vârstæ a pacienflilor studiafli este de 71 ani (52-86 ani). La pacienflii cu punflie biopsie prostaticæ (ecoghidat în numær de 6-12) am evaluat incidenfla bolilor asociate atât urologice cât øi cele ne-urologice. Rezultate: Anual în clinica nosatræ s-au efectuat 202 puncflii biopsii prostatice ( ) pentru suspiciune de cancer de prostatæ. Bolile asociate urologice cele mai întâlnite la aceøti pacienfli au fost: HBP 278 (45,7%) cazuri, litiaza vezicalæ øi renalæ 11 (1.8%) cazuri, tumori de ordin urologic concomitent (vezical øi renal) 5 (0,8%) cazuri. Alte comorbiditæfli cu incidenflæ crescutæ au fost, bolile cardio vasculare (HTA, cardiopatie ischemicæ, fibrilaflie atrialæ, tratament anticoagulant) în numær de 76 ( 12,5%) pacienfli, diabetul zaharat, obezitatea, dislipedimia punându-se în evidenflæ la 35 ( 5,75%) de cazuri. În 10 cazuri (1,6%) puncflia biopsia s-a efectuat pentru confirmare de diagnostic, pacienflii prezentând metastazæ osoasæ. Prostate cancer and occurrence of associated diseases in our registered patients A. O. Vida, A. Szölösi, Buzsi Enikõ, Mártha Orsolya Mures County Hospital, Department of Urology Targu Mureø Introduction: Prostate cancer is a serious public health problem because it is the most commonly diagnosed urologic cancer and the second leading cause of death amongst men. The prevalence increases constantly with age. The investigation and summarizing related diseases affecting mortality is important for the therapeutical decision. Methods and materials: Our retrospective study analyzes data of 608 (100%) patients who underwent prostate biopsy at our clinic for prostate cancer suspicion between ADKP was confirmed in 277 (45.5%). The average age of our patients is 71 years (52-86 years). Sampling was conducted echo guided in number of In these patients we evaluated the incidence of associated diseases such urological and ne-urological comorbidites. Results: Annually at our clinic about 202 ( ) prostate biopsies were performed for suspicion of prostate cancer. The most common urological diseases associated in these patients were BPH 278 (45.7%) in cases, bladder and kidney stones in 11 (1.8%) cases, while urological tumors (bladder and kidney) in 5 (0.8%) cases. Other co morbidities with higher incidence were cardiovascular diseases (hypertension, ischemic heart disease, atrial fibrillation, anticoagulation therapy) in 76 (12.5%) cases. Diabetes mellitus, obesity, dyslipidemia in 35 (5.75%) cases. In 10 cases (1.6%) biopsy was performed to confirm the diagnosis, patients presenting bone metastasis. Concluzii: În tratamentul cancerului de prostatæ, fiind o patologie în prepondernflæ a pacienflilor vârstnici trebuie sæ flinem cont de bolile asociate. Studiul nostru evidenflieazæ incidenfla crescutæ a bolilor cardio vasculare asociate, a afecfliunilor urologice, diabetului zaharat øi sindromul metabolic. Din aceastæ cauzæ aceøti pacienfli au nevoie de mai multæ atenflie în pregætirea preoperatorie øi postoperator în stabilirea conduitei terapeutice pentru a evita complicafliile imediate chiar øi fatale (chiar øi în cazul puncfliei prostatice). CONFIRMARE: Aceastæ lucrare este parflial sprijinit de Programul Operaflional Sectorial pentru Dezvoltarea Resurselor Umane (POS DRU), finanflat din Fondul Social European øi de cætre Guvernul Român, cu numærul contractului POSDRU Conclusions: In the treatment of prostate cancer, pathology of the elderly, we must take account of the associated diseases. Our study points out the high incidence of associated cardiovascular disease, urological diseases, diabetes mellitus and metabolic syndrome. Therefore these patients need more attention in preoperative preparation and postoperative conduct, in establishing immediate treatment to avoid complications even fatal. It is important to mention that prostate cancer can occur concomitantly with other urological cancer. 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 Revista Românæ de Urologie nr. 2 / 2012 vol 11

14 1.9. Prostatectomia radicalæ: experienfla clinicii V. Ambert, B. Braticevici, D. Damian, I. Dragomiriøteanu, S. Andrei, C. Cælin, S. Iordan, D. Radavoi, V. Jinga Urologie, Spitalul Clinic Prof. Dr. Th. Burghele, Bucureøti Introducere: Cancerul de prostatæ este cea mai frecventa afecfliune malignæ la bærbafli. Incidenfla sa este în creøtere de la începutul anilor Nu tofli pacienflii cu cancer de prostatæ dezvoltæ manifestæri clinice ale bolii, prin urmare selecflionarea acestor cazuri reprezintæ o mare provocare clinicæ. Obiective: Am revizuit o experienflæ de 5 ani în efectuarea prostatectomiei radicale în clinicæ, pentru a evalua rezultatele øi a le compara cu literatura de specialitate. Pacienti si metode: Au fostincluøi 126 depacienfli cu cancer de prostatæ (T1c-T2) la care s-a practicat prostatectomia radicalæ între ianuarie 2007 øi martie Au fost înregistrate valoarea preoperatorie a PSA-ului, stadiul clinic øi scorul Gleason. Au fost evaluate durata intervenfliei, pierderile de sânge, durata spitalizærii øi complicafliile. Rezultatul oncologic a fost apreciat cu ajutorul progresiei biochimice a PSA-ului. Rezultate: Vârsta pacienflilor între ani, valoarea preoperatorie a PSA-ului între 2,9-18 ng/ml. Scorul Gleason preoperator prin puncflie biopsie prostaticæ între 5-7. Dintre pacienfli 33% au avut boala T1c, 53% pt2 øi 14%pT3. Nu s-a întregistrat nici un decesi intraoperator. Complicaflii majore zero. Complicaflii minore 20%. Durata medie a intervenfliei a fost de 248 min. Pierderea medie de sânge a fost de 420 ml iar rata medie de transfuzie de 1,2 unitæfli. Durata de spitalizare 8-14 zile. Continenfla øi funcflia erectilæ au fost evaluate la 6 luni postoperator. Concluzie: Rezultatele oncologice, dupæ prostatectomia radicalæ efectuatæ în clinica noastræ, îndeplineasc standardele globale cu o morbiditate acceptabilæ. Radical prostatectomy: outcomes at our clinic V. Ambert, B. Braticevici, D. Damian, I. Dragomiriseanu, S. Andrei, C. Cælin, S. Iordan, D. Radavoi, V. Jinga Urology, Clinical Hospital Prof. Dr. Th. Burghele, Bucharest Introduction: Prostate cancer is the most common malignant disease in men. The incidence of prostate cancer has been rising since the early 1990s. Not all men with prostate cancer will develop clinical disease. Therefore sorting this cases is a great clinical challenge. Purpose: We reviewed a 5-year experience performing open radical retropubic prostatectomy in our hospital, to assess outcomes and to compare them to the published literature. Materials and methods: Were included 126 patients with prostate cancer (T1c-T2) who underwent radical prostatectomy between January 2007 and March Value ofpreoperative PSA, clinical stage and Gleason score were recorded. Operative time, blood loss, duration of hospitalization and complications were assessed. Oncological result was assessed using biochemical PSA progression. Results: Patients age was between years, preoperative prostate specific antigen level was between 2,9-18 ng/dl. Gleason score on preoperative biopsy was 5-7. Of the patients 33% had T1c disease, 53% pt2, 14% pt3. No intraoperative deaths occurred. Major complications zero. Minor complications 20%. Mean operating time was 248 min. Average blood loss was 420 ml and average blood transfusion rate was 1.2 units. Length of stay 8-14 days. Continence and erectile function were assessed at 6 months postoperatively. Conclusions: Oncologic results after radical prostatectomy performed in our clinic, meet global standards with acceptable morbidity. Cancer de Prostatæ nr. 2 / 2012 vol 11 Revista Românæ de Urologie 13

15 Cancer de Prostatæ Experienfla clinicii noastre în depistarea cancerului de prostatæ A. Szöllösi 1, Á.O.Vida 2, Enikõ Buzsi 2, A. Maier 2, A. Brad 2, L. Lakatos 2, Orsolya Mártha 1,2, C. Catarig 2, D. H. Porav 1,2, B. Uzun 2 1 Spitalul Clinic Judeflean Mures, Clinica de Urologie Târgu Mureø 2 Universitatea de Medicinæ øi Farmacie Târgu Mureø Introducere/Obiectiv: Cancerul de prostatæ este cel mai des diagnosticat tip de cancer la bærbafli dupæ cancerul bronchopulmonar. Prin urmare, un screening corect øi complet efectuat în vederea stabilirii a diagnosticului, stadiului øi conduitei terapeutice este primordial. Scopul lucrærii noastre este de a evalua eficacitatea puncfliei biopsiei prostatice în stabilirea diagnosticului de cancer prostatic la Clinica de Urologie din Târgu Mureø. Material øi metode: Studiul a fost retrospectiv. Au fost introduøi tofli pacienflii la care s-a efectuat PBP echoghidatæ (566 pacienfli-100%) în perioada Pacienflii au fost grupafli în funcflie de vârstæ, valoarea PSA-ului, øi volumul prostatei. S-a urmærit: rata confirmærii histopatologice a cancerului, tipul histopatologic øi legætura dintre valoarea PSA-ului, scorului Gleason øi stadiul bolii (T). Rezultate: Majoritatea pacienflilor fæceau parte din grupa de vârstæ între 61 øi 80 de ani (74,02%), cu vârsta medie de 73 de ani. Valoarea PSA-ului varia în limite largi (1, ng/ml). Puncflia biopsia prostaticæ echoghidatæ efectuatæ la pacienfli cu PSA crescut, a confirmat prezenfla cancerului de prostatæ în doar 274 de cazuri (48,4%), în 3 cazuri (1,09%) pacienfli având vârsta sub 50 de ani. Adenocarcinoamele de prostatæ confirmafli au avut un scor Gleason între 6 øi 10. (Gl6-6,569%, Gl7-36,496%, Gl8-28,467%, Gl9-26,277%, Gl10-2,189%). În restul cazurilor EHP a avut urmætoarele rezultate: prostatite, HBP, ASAP, atrofie prostaticæ øi flesut prostatic normal. Deøi literatura de specialitate precizeazæ cæ eficienfla diagnosticæ a PBP echoghidatæ în cancerul de prostatæ (la cei cu PSA crescut) este de 60%-70%, în studiul nostru aceastæ valoare a fost 48,43%. Concluzie: Cancerul de prostatæ predominæ în cazul bærbaflilor vârstnici, dar poate fi întâlnit øi la bærbaflii sub vârsta de 50 de ani. În vedera creøterii eficienflei diagnostice a PBP este nevoie de mai multe rezultate de PSA consecutivi, stiind faptul cæ sunt multe elemente care pot duce la creøterea temporaræ a acestuia. Our clinic experience in screening of the prostate cancer A. Szöllösi 1, Á.O.Vida 2, Enikõ Buzsi 2, A. Maier 2, A. Brad 2, L. Lakatos 2, Orsolya Mártha 1,2, C. Catarig 2, D. H. Porav 1,2, B. Uzun 2 1 Mures County Hospital, Department of Urology Târgu Mureø 2 University of Medicine and Pharmacy Târgu Mureø Introduction/Objective: Prostate cancer is the most common cancer in men after the lung cancer. Therefore, an accurate and complete screening is very important to the diagnosis, to establish stage, and the therapy. The purpose of our work is to evaluate the effectiveness of prostate transrectal ultrasound biopsy in the diagnosis of prostate cancer at the Urology Clinic of Targu Mures. Material and methods: It is a retrospective study. We included in this study all patients with TRUS biopsy (566 patients-100%) between Patients were grouped according to age, PSA value and prostate volume. We followed: the rate of histopathology confirmation of cancer, histological type and the correlation between PSA value, Gleason score and stage of disease (T). Results: Most patients belonged to age group between 61 and 80 years (74.02%), the mean age was 73 year. PSA value varied widely (from 1.5 to 3900 ng / ml). Ultrasound guided prostate biopsy in patients with increased PSA, confirmed the presence of prostate cancer in only 274 cases (48.4%), in 3 cases (1.09%) patients age was under 50. In other cases EHP had the following results: prostatitis, BPH, ASAP, prostate atrophy, normal prostate tissue. Confirmed prostate adenocarcinoma had a Gleason score between 6 and 10 (Gl %, Gl %, Gl %, Gl %, and Gl %). Although the literature indicates that ultrasound guided prostate biopsy diagnostic efficiency in prostate cancer (those with high PSA) is between 60-70%, in our study this value was 48.43%. Conclusion: Prostate cancer predominate in older men, but can be met in men under 50 years old to. To increase diagnostic efficiency of PBP requires several consecutive PSA results, knowing that there are many factors that can increase it temporarily. 14 Revista Românæ de Urologie nr. 2 / 2012 vol 11

16 1.11. Particularitæfli tehnice ale alternativei laparoscopice în tratamentul malignitæflilor urologice, în experienfla Institutului Oncologic Prof. Dr. I. Chiricuflæ Cluj-Napoca B. Petrufl, M. Hogea, F. Nechita, B. fiintilæ, C. Codreanu, V. Gherman, V. Schiflcu, D. Feflea, I. Jurchiø, G. Seserman, D.S. Popescu, A. Irimie Institutul Oncologic Prof. Dr. I. Chiricuflæ Cluj-Napoca Technical particularities of the laparoscopic alternative in the treatment of urological malignancy: our experience at Prof. Dr. I. Chiricuta Oncological Institute in Cluj-Napoca B. Petrufl, M. Hogea, F. Nechita, B. fiintilæ, C. Codreanu, V. Gherman, V. Schiflcu, D. Feflea, I. Jurchiø, G. Seserman, D.S. Popescu, A. Irimie Prof. Dr. I. Chiricuta Oncological Institute in Cluj-Napoca Cancer de Prostatæ Introducere. Laparoscopia reprezintæ o tehnicæ minim invazivæ care poate constitui o alternativæ în tratamentul chirurgical al malignitæflilor urologice. Ne propunem o analizæ a rezultatelor øi a particularitæflilor tehnice ale acestui abord într-o gamæ variatæ de intervenflii, în experienfla serviciului nostru. Material øi metodæ. In perioada iulie 2010 februarie 2012, 91 de pacienfli au beneficiat de intervenflii laparoscopice, astfel: 47 prostatectomii radicale (stadiu T1c-T2b), 20 nefrectomii radicale (stadiu T1a-T2a), 12 nefrectomii parfliale (stadiu T1a-T1b), 4 nefroureterectomii radicale (stadiu T2), 4 cistectomii radicale (stadiu T2a-T2b), 4 suprarenalectomii. Rezultate. In cazul prostatectomiei radicale, timpul mediu de intervenflie a fost de minute (timp mediu excizie 82.5 minute, timp mediu anastomozæ 27.4 minute), înregistrându-se pierderi sangvine medii ml; similar, nefrectomia radicalæ timp mediu de intervenflie minute, hemoragie medie 163 ml; nefrectomia parflialæ timp mediu de intervenflie minute, timp mediu de ischemie 19.8 minute, pierderi sangvine medii ml; nefroureterectomia radicalæ timp mediu de intervenflie minute, pierderi sangvine medii ml; cistectomia radicalæ timp mediu de intervenflie 255 minute, derivaflie urinaræ aplicatæ - ureterstomia cutanatæ directæ în toate cazurile; suprarenalectomia timp mediu de intervenflie 180 minute (2 cazuri retroperitoneoscopic, 2 cazuri transperitoneal. A aparut necesitatea conversiei într-un singur caz (suprarenalectomie dreaptæ aderenfle strânse de Introduction. Laparoscopy is a minimally invasive technique considered an alternative in the surgical treatment of urological malignancies. The goal is to present some technical aspects with respect to the laparoscopic urooncological procedures performed at our institution. Materials and methods. From July 2010 until February 2012, 91 patients benefited from the laparoscopic approach: 47 radical prostatectomies (stages T1c-T2b), 20 radical nephrectomies (stages T1a-T2a), 12 partial nephrectomies (stages T1a-T1b), 4 radical nephroureterectomies (stages T2), 4 radical cystectomies (stages T2a-T2b), 4 suprarenalectomies. Results. In the case of radical prostatectomy, the mean operative time was minutes (mean excision time 82.5 minutes, mean anastomosis time 27.4 minutes), average blood loss of ml; radical nephrectomy mean operative time minutes, average blood loss 163 ml; partial nephrectomy mean operative time minutes, mean isquemia time 19.8 minutes, average blood loss ml; radical nephroureterectomies mean operative time minutes, average blood loss ml; radical cystectomies mean operative time 255 minutes; the chosen urinary diversion was direct cutaneous ureterostomy, in all cases; suprarenalectomy - mean operative time 180 minutes (2 cases retroperitoneoscopically, 2 cases transperitoneally). Conversion to the open approach was needed in a single case (right suprarenal gland with close adherence to the vena cava). Progression on the learning curve by gaining experience in time led to improvement of the operative nr. 2 / 2012 vol 11 Revista Românæ de Urologie 15

17 Cancer de Prostatæ vena cavæ). Parcurgerea curbei de învæflare prin acumularea de experienflæ în timp a dus la îmbunætæflirea progresivæ a rezultatelor. Oncologic, rata de margini de rezecflie negative a fost de 91.48% în cazul prostatectomiei, 90% pentru nefrectomia radicalæ øi margini negative în toate cazurile de nefrectomie parflialæ, nefroureterectomie øi cistectomie. Concluzii. Aplicarea tehnicii laparoscopice în tratamentul malignitæflilor urologice necesitæ o echipæ antrenatæ, øi poate asigura rezultate oncologice øi funcflionale comparabile cu abordul clasic, cu avantajul scæderii traumatismului chirurgical. O cadenflæ de 1-2 intervenflii/ sæptæmânæ/ echipæ asiguræ progresul pe curba de învæflare. parameters. Oncologically, the negative surgical margins rate was 91.48% in the case of prostatectomy, 90% for partial nephrectomy, and negative in all cases of radical nephrectomy, radical cystectomy and nephroureterectomy. Conclusions. The use of the laparoscopic approach in the treatment of urological malignancies requires a well trained team and is able to provide oncological and functional results comparable to the open approach, with the added benefit of reducing the surgical trauma. A rate of 1-2 interventions/ week/ team assures progression on the learning curve. 16 Revista Românæ de Urologie nr. 2 / 2012 vol 11

18 1.12. Volumul prostatei - factor determinant al toxicitæflii urinare øi rectale tardive în brahiterapia prin implant permanent cu I-125 în cancerul de prostatæ localizat B. Hæinealæ, C. Dudu, C. Baston, S. Voinea, I. Manea, C. Surcel, S. Margaritis, C. Codoiu, B. Bædescu, A. Omer, M. Hârza, I. Sinescu Centrul de Uronefrologie øi Transplant Renal, Institutul Clinic Fundeni, Bucureøti Prostate volume - determinant factor of late rectal and urinary toxicity in brachytherapy with I-125 permanent implant in localized prostate cancer B. Hæinealæ, C. Dudu, C. Baston, S. Voinea, I. Manea, C. Surcel, S. Margaritis, C. Codoiu, B. Bædescu, A. Omer, M. Hârza, I. Sinescu. Center of Uronephrology and Renal Transplantation, Fundeni Clinical Institute, Bucharest Cancer de Prostatæ Introducere øi obiective: Scopul studiului este de a stabili legætura între volumul prostatic øi afectarea uretralæ øi rectalæ tardivæ, secundare brahiterapiei prin implant permanent prostatic cu I-125, morbiditæfli cu un puternic efect asupra calitæflii vieflii pacienflilor. Materiale øi Metodæ: În perioada octombrie 2006 iulie 2011 au fost tratafli prin implant permanent cu I-125 un numær de 180 de pacienfli cu cancer de prostatæ, ca monoterapie, în stadiul T1c-T2a.Alfli 19 pacienfli au beneficiat de combinaflia terapeuticæ brahiterapie øi radioterapie externæ. Pentru a putea cuantifica gradul de afectare a pacienflilor a fost folositæ scala modificatæ a toxicitæflii tardive urinare øi rectale - RTOG. Analiza a fost efectuatæ pe un numær de 171 de pacienfli, un pacient decedând datoritæ unei afecfliuni coronariene, iar alfli opt au fost pierdufli din urmærire pe parcurs, din diverse motive. Toxicitatea urinaræ tardivæ (TUT) gradul I a fost prezentæ la 28 de pacienfli (16,37%), gradul II la 16 pacienfli (9,35%) iar gradul III la øase pacienfli (3,5%). Toxicitate rectalæ tardivæ (TRT) gradul I s-a manifestat la 12 pacienfli iar gradul II la trei pacienfli. Nu a fost înregistratæ toxicitate rectalæ gradul III. Rezultate: A fost analizat volumul mediu prostatic al pacienflilor færætoxicitate urinaræ sau rectalæ în comparaflie cu cel al pacienflilor cu diferite grade de afectare. Volumul mediu prostatic al pacienflilor færæ toxicitate uretralæ la 12 luni a fost 32,67 cc, a celor cu toxicitate uretralæ tardivæ gradul I a fost de 39,44 cc, cu toxicitate uretralæ gradul II a fost 46,20 cc iar cu TUT gradul III a fost de 57,40 cc. Volumul prostatic mediu al pacienflilor færæ toxicitate rectalæ tardivæ a fost de Introduction and Objectives: The aim of the study was to establish the corelation between prostate volume and late urethral and rectal toxicity, secondary to permanent prostate implant brachytherapy with I-125, morbidity with an important effect on quality of life. Materials and Methods: Between October July 2011 a total of 180 patients with prostate cancer staged T1c-T2a were treated with I-125 permanent implant, as monotherapy. Other 19 patients received brachytherapy combined with external beam radiation therapy. To quantify the degree of damage to patients, RTOG modified scale was used. Analysis was performed on a total of 171 patients, one patient died due to coronary heart disease and other eight were lost over time, for various reasons. Late urinary toxicity (LUT) first degree was present in 28 patients (16.37%), grade II in 16 patients (9.35%) and grade III in six patients (3.5%). Late rectal toxicity (LRT) first degree was observed in 12 patients and grade II in three patients. It wasn t recorded any grade III rectal toxicity. Results: The average prostate volume was analyzed in patients without urinary or rectal toxicity and compared to that of patients with different degrees of damage. Average prostate volume in patients without urethral toxicity at 12 months was cc, for those with first degree late urethral toxicity was cc, for second degree urethral toxicity was cc and for third grade was of cc. Average prostate volume in patients without late rectal toxicity was cc, for first degree LRT patients was cc, and for patients with second degree LRT was cc. nr. 2 / 2012 vol 11 Revista Românæ de Urologie 17

19 Cancer de Prostatæ 33,11 cc, a pacienflilor cu TRT gradul I a fost de 38,21 cc, iar pentru pacienflii cu TRT gradul II a fost de 52,17 cc. Concluzii: Morbiditatea urinaræ øi cea rectalæ tardivæ post brahiterapie prin implant permanent cu I-125 a fost una redusæ, comparabilæ cu datele publicate în literatura de specialitate. Volumul crescut al prostatei este unul din factorii predictivi ai toxicitæflii uretrale øi rectale tardive. Acest lucru a fost demonstrat statistic, diferenfla fiind evidentæ între toate gradele afectærii urinare øi doar pentru gradul I al afectærii rectale. Pentru gradul II al TRT numærul redus de pacienfli (trei) nu a permis o analizæ statisticæ riguroasæ. Conclusions: Late urinary and rectal morbidity post permanent implant brachytherapy with I-125 was low, comparable to data published in literature. Increased volume of the prostate is one of the predictive factors of late rectal and urethral toxicity. This was statistically validated, the difference is obvious between all levels of urinary damage and only for the first degree of rectal damage. For second degree of LRT, the number of patients (only three) did not allow a rigorous statistical analysis. 18 Revista Românæ de Urologie nr. 2 / 2012 vol 11

20 2.1. Tratamentul nocturiei la bærbatul cu simptome de tract urinar inferior (LUTS) rezultate inifliale V. D. Stanca, A. Boc, P. Prunduø, S. Bonafl, R. Maxim, Alexandra Andreea Poienar, I. Coman Secflia Clinicæ Urologie, Spitalul Clinic Municipal Cluj-Napoca Introducere. Nocturia afecteazæ circa o treime dintre pacienflii cu LUTS. Tratarea ei færæ identificarea mecanismului de apariflie duce de regulæ la rezultate nesatisfæcætoare. Am evaluat rezultatele tratamentului la pacienflii care au reclamat prezenfla acestui simptom. Material øi metodæ. În perioada noiembrie 2011-februarie 2012 am evaluat un numær de 27 de pacienfli cu vârsta peste 50 ani care reclamau faptul cæ trebuie sæ se trezeascæ noaptea pentru a urina øi sunt deranjafli de acest lucru (simptom unic sau în asociere cu alte LUTS). Bilanflul diagnostic standard a inclus øi jurnalul micflional. Pacienflii cu micfliuni nocturne secundare poliuriei nocturne (diurezæ nocturna superioaræ capacitæflii vezicale funcflionale maxime) au fost tratafli cu desmopresin 60 sau 120 micrograme/zi 30 zile; pacienflii cu micfliuni nocturne cu volume urinare mici au fost tratafli cu alfa 1 blocante cu sau færæ inhibitori de 5 alfa reductazæ sau antimuscarinice. Am evaluat rezultatele terapiei urmærind reducerea numærului de micfliuni nocturne cu cel puflin un episod øi efectele adverse. Treatment of nocturia in men with lower urinary tract symptoms (LUTS) - initial results V. D. Stanca, A. Boc, P. Prunduø, S. Bonafl, R. Maxim, Alexandra Andreea Poienar, I. Coman Clinical Municipal Hospital Cluj Napoca, Urology Department Introduction. A third of the patients with LUTS have nocturia. Initializing the treatment without identifying the mechanism of appearance usually leads to unsatisfying results. We have evaluated the results of treatment in patients that complained mainly of this symptom. Material and Methods. Between November 2011 and February 2012 we have evaluated a number of 27 patients aged 50 years or older. They complained of having to wake up at night to urinate (sole symptom or associated with other LUTS). Standard diagnosis workout included bladder voiding diary. Patients with secondary nocturia due to nocturnal polyuria (nocturnal diuresis superior to the maximum functional bladder capacity) were treated with desmopresin 60 or 120 micrograms/day for 30 days; patients with small volume nocturnal micturitions were treated with á1 blockers with or without 5á reductase inhibitors or antimuscarinics. We evaluated the results of this treatment by the reduction of nocturnal urination episodes by at least one and the side effects. Urologie femininæ, incontinenflæ Rezultate. Dintre tofli pacienflii cu micfliuni nocturne deranjante 81,5% (22 pacienfli) au prezentat micfliuni nocturne deranjante secundare poliuriei nocturne (între 2 øi 5 micfliuni/noapte); restul de 5 pacienfli prezentau micfliuni nocturne iritative. Tofli pacienflii cu poliurie nocturnæ au raportat reducerea numærului de treziri datorate nevoii de a urina; 4 din cei 5 pacienfli cu polakiurie nocturnæ iritativæ au avut de asemenea ræspuns favorabil la terapie. Nu am constatat efecte adverse cardiovasculare sau urologice. Cincisprezece pacienfli (68%) au continuat terapia cu desmopresin øi dupæ cele 30 zile de evaluare; cei care au renunflat au fæcut-o din motive financiare. Concluzii. Tratamentul cu desmopresin a fost bine tolerat. Rezultatele sugereazæ cæ tratamentul cu desmopresin 60/120 micrograme/zi este eficient la pacienflii cu micfliuni nocturne deranjante secundare poliuriei nocturne. Identificarea cauzei ce duce la apariflia micfliunilor nocturne este esenflialæ pentru alegerea unui tratament eficient. Results. Of the total number of patients with bothersome nocturnal urination episodes 81.5% (22patients) presented secondary nocturia due to nocturnal polyuria (2-5 urinations per night); 5 patients had irritative nocturia. All patients with nocturnal polyuria reported a reduction in number of times they had to wake up to urinate; 4 patients of 5 with nocturnal irritative polakiuria also had positive response to the therapy. We did not record any cardio-vascular or urological side effects. Fifteen patients (68%) continued therapy with desmopresin beyond the 30 days of evaluation; patients who chosed not to continue treatment had financial reasons to do so. Conclusions. The treatment with desmopresin was well tolerated. Our results suggest that treatment with desmopresin 60/120 micrograms/day is effective in patients with secondary nocturnal urinations due to nocturnal polyuria. Identifying the cause of nocturia is essential for establishing an efficient treatment. nr. 2 / 2012 vol 11 Revista Românæ de Urologie 19

21 Urologie femininæ, incontinenflæ 2.2. Tratamentul chirurgical al incontinenflei urinare la bærbat O. Bratu, C.P. Ilie, V. Mædan, C. Farcaø, D. Spânu, R. Popescu, A. Rædulescu, D. Mischianu Clinica de Urologie, Spitalul Universitar de Urgenflæ Militar Central Dr. Carol Davila, Bucureøti Introducere. Prezentæm posibila rezolvare chirurgicalæ a incontinenflei urinare la bærbat, folosind aplicarea unei plase (mesa) de polipropilenæ sub uretra bulbaræ, în manieræ aproximativ similaræ procedeului folosit la femeie (TOT). Material øi metodæ. Tratamentul chirurgical a fost utilizat la 4 pacienfli bærbafli prezentând incontinenfla urinaræ postintervenflionalæ, cum ar fi prostatectomie radicalæ, transuretrorezecflie a prostatei. Metoda ar putea fi folositæ øi pentru incontinenfla urinaræ determinatæ de cauze neurologice, cum sunt spina bifida sau mielomeningocelul. Evident, incontinenfla urinaræ prin prea plin nu intra în discuflia de faflæ Au fost folosite plase de polipropilenæ similare celor folosite pentru TOT la femeie sau plase special concepute pentru incontinenfla urinaræ la bærbat. Tehnica folositæ a constat în incizia perineului cu evidenflierea uretrei bulbare øi amplasarea plasei suburetral, în manieræ out-in, transobturator. Surgical treatment for urinary incontinence in men O. Bratu, C.P. Ilie, V. Mædan, C. Farcaø, D. Spânu, R. Popescu, A. Rædulescu, D. Mischianu Urology Department, University Emergency Central Military Hospital, Carol Davila Bucharest Introduction. We are presenting a new possible surgical approach for urinary incontinence in men using a polypropylene mesh placed under the bulbar urethra. This procedure is very much alike with TOT procedure for stress urinary incontinence in women. Material and Method. This surgical approach was used for 4 patients presenting urinary incontinence after radical prostatectomy and trans-urethral-resection of prostate. This method could also be used for neurological urinary incontinence like spina bifida or mielomeningocele. Obviously urinary incontinence due to chronic retention of urine was an exclusion criteria. We used polypropylene mesh placed similar to that used in TOT for women or special model made for men. The surgical technique consisted in dissection of the bulbous urethra through the perineum and placing the mesh under the urethra, trans-obturatory, in out-in manner. Rezultate. Recuperarea postoperatorie este rapidæ, cu suprimarea sondei uretro-vezicale în primele 24 de ore øi externarea pacienflilor la de ore. Urmærirea pacienflilor a demonstrat ameliorarea sau dispariflia incontinenflei urinare, absenfla reziduului postmicflional. Complicafliile operatorii au fost minime sau absente. Concluzii. Tehnica folositæ în tratamentul incontinenflei urinare la bærbat s-a dovedit eficientæ. Procedeul este puflin invaziv, tehnic facil øi relativ scurt ca duratæ a intervenfliei. Complicafliile intraoperatorii pot fi datorate leziunilor vasculare sau uretrale, dar pot fi evitate în mâini experimentate. Complicafliile postoperatorii sunt minime sau absente. În concluzie, tehnica folositæ reprezintæ o alternativæ de tratament al incontinenflei urinare la bærbat iatrogene, post-prostatectomie øi posibil de cauzæ neurologicæ, îmbunætæflind semnificativ calitatea vieflii pacienflilor. Results. Post-operatory outcome is simple, in 24 hours the urinary catheter is removed and in hours the patient is discharged. The follow-up showed the overall success of this procedure, the absence of post-mictional residue. Few or no operatory complications occurred. Conclusions. The surgical technique we used proved to be effective. The procedure is less invasive, not complicated and takes little operating time. Intraoperatory complications include vascular and urethral lesions which can be avoided by experienced surgeons. Post-operatory complications do not usually occur. This procedure is a real alternative in the cure of iatrogenic, neurological or post prostatectomy urinary incontinence, greatly increasing the quality of life. 20 Revista Românæ de Urologie nr. 2 / 2012 vol 11

22 2.3. Efectele tratamentului combinat hidrodistensie vezicalæ øi acid hialuronic intravezical la pacienflii cu Sindrom dureros vezical/cistitæ interstiflialæ Andreea Hetea 1, C. Mirvald 2, C. Surcel 2, C. Gîngu 2, R. Stoica 2, S. Najjar 2, V. Cerempei 2, A. Iordache 2, Manuela Chiriflæ 2, Carmen Savu 3, M.A. Manu 2, I. Sinescu 2 1 Studentæ la U.M.F. Carol Davila, Bucureøti, 2 Centrul de Uronefrologie øi Transplant Renal, Institutul Clinic Fundeni, 3 Clinica de ATI, Institutul Clinic Fundeni, Bucureøti Introducere: Sindromul vezicii urinare dureroase/cistitæ interstiflialæ (PBS/IC) reprezintæ o boalæ dizabilitantæ a vezicii urinare, iar etiologia øi tratamentul acesteia nu sunt încæ stabilite. Instilafliile intravezicale cu acid hialuronic (HA) pot determina regenerarea stratului de glicozaminoglicani deteriorat la aceøti pacienfli. Effects of Combination Treatment of Intravesical hyaluronic acid and bladder hydrodistention in Patients Painful Bladder Syndrome/Interstitial Cystitis Andreea Hetea 1, C. Mirvald 2, C. Surcel 2, C. Gîngu 2, R. Stoica 2, S. Najjar 2, V. Cerempei 2, A. Iordache 2, Manuela Chiriflæ 2, Carmen Savu 3, M.A. Manu 2, I. Sinescu 2 1 U.M.F. Carol Davila Student, Bucharest 2 Center of Uronephrology and Renal Transplantation, Fundeni Clinical Institute, 3 ICU Department, Fundeni Clinical Institute, Bucharest Introduction: Painful bladder syndrome/interstitial cystitis (PBS/IC) is a disabling disease of the urinary bladder and its etiology and treatment are not yet established. Intravesical instillations of hyaluronic acid (HA) may lead to regeneration of the damaged glycosaminoglycan layer in interstitial cystitis/bladder pain syndrome (IC/BPS). Urologie femininæ, incontinenflæ Obiectiv: Scopul acestui studiu a fost de a evalua siguranfla øi eficacitatea terapiei combinate hidrodistensie vezicalæ cu tratamentul instilaflional cu hialuronat de sodiu la pacienflii cu PBS/IC. Material øi metodæ: Am realizat un studiu prospectiv, nerandomizat în Centrul nostru de perioada , incluzând 28 de pacienfli cu IC/BPS, conform criteriilor consensului IC Evaluarea urodinamicæ nu a fost efectuatæ sistematic. Dupæ hidrodistensie, pacienflii au urmat tratamentul instaflional cu hialuronat de sodiu 1,6% (40 ml), o datæ pe sæptæmânæ, 6 sæptæmâni øi apoi lunar timp de 1 an. Am evaluat eficacitatea øi siguranfla tratamentului prin intermediul chestionarului O Leary-Saint (OLS), înainte de tratament, dupæ hidrodistensie øi dupa fiecare instilaflie. În funcflie de ræspunsurile la chestionarul OLS, am împærflit pacienflii în 4 grupe: ræspuns bun (OLS <10), ræspuns parflial (OLS=10-19), ræspuns slab (OLS=20-29) øi niciun raspuns (OLS=30-36). Objective: The aim of this study was to investigate the safety and effectiveness of the combination therapy of intravesical sodium HA and bladder hydrodistention in patients with PBS/IC. Matherial and method: We conducted a prospective, non randomized trial in our Center during on 28 patients with IC/BPS according to 2009 IC consensus criterias. The urodynamic evaluation was not systematic. After hydrodistention, all patients recieved intravesical instillations (40 ml) of sodium HA 1.6% once weekly for 6 weeks and afterwards monthly for 1 year. We evaluated the efficacy and safety of treatment using the O Leary-Saint (OLS) questionnaire before hydrodistension and after every instilation. According to the responses to the OLS questionnaire, we divided the patients in 4 groups: good response (OLS<10), partial response (OLS-10-19), poor response (OLS-20-29) and no response (OLS-30-36). Results: We obtained 64.2% positive response (18/28 patients) (good response and partial response) after 6 weeks nr. 2 / 2012 vol 11 Revista Românæ de Urologie 21

23 Urologie femininæ, incontinenflæ Rezultate: Am obflinut un ræspuns pozitiv la 64,2% din pacienfli (ræspuns bun sau parflial), dupæ 6 sæptæmâni de tratament øi o ratæ de ræspuns de 78% (23/28 pacienfli) la sfârøitul tratamentului. Numærul mediu de instilaflii/pacient a fost de 16. Pacienflii cu modificæri patologice la cistoscopie (leziuni glomerulare øi/sau ulceraflii Hunner) au avut cele mai mari rate de ræspuns. Nu au fost raportate efecte adverse. Concluzii: Tratamentul instilaflional cu acid hialuronic prezintæ o eficacitate pe termen lung la un numær considerabil de pacienfli BPS/IC, asociind un profil de siguranflæ øi tolerabilitate bun. Hidrodistensia este recomandatæ doar ca parte a unui tratament multimodal. of treatment and overall 78% (23/28 patients) at the end of the treatment. Mean instilation number per patient was 16. Patients with abnormal cystoscopy (glomerular lessions and/or Hunner ulcers) had the highest response rates. No side effects were reported. Conclusions: Intravesical hyaluronic acid shows long-term efficacy in a considerable number of BPS/IC patients and it is well tolerated. Hydrodistension is reccomended only as part of a multimodal treatment. 22 Revista Românæ de Urologie nr. 2 / 2012 vol 11

24 2.4. Instilaflia intravezicalæ cu DMSO pentru tratamentul sindromului de vezicæ dureroasæ rezultate preliminare G. Glück, R.Stoica, Manuela Chiriflæ, I. Sinescu Centrul de Uronefrologie øi Transplant Renal, Institutul Clinic Fundeni, Bucureøti Introducere: DMSO (dimetil sulfoxid), este aprobat de cætre FDA pentru instilaflii intravezicale în cazuri de cistitæ interstiflialæ/sindrom de vezicæ dureroasæ, datoritæ efectelor antiinflamatorii, analgezice, musculorelaxante øi posibilitæflii de a transporta alte molecule prin mucoasa vezicii urinare. Material øi metodæ: Am utilizat o combinaflie terapeuticæ pentru instilaflie intravezicalæ ce include soluflie de DMSO 50% (25 ml DMSO puritate 99,9% cu 25 ml apæ distilatæ). Soluflia preparatæ imediat înainte de instilaflie este introdusæ pe cateter Foley 18 Ch, dupæ anestezie localæ cu gel cu lidocainæ øi evacuatæ dupæ minute. Efectul a fost evaluat prin completarea chestionarului O Leary-Sant la înrolare øi apoi dupæ primele patru instilaflii sæptamânale. Rezultate: Am efectuat acest tratament pentru øase paciente care prezentau simptomatologie de tip sindrom vezical dureros, refractaræ la tratamentul curent (toate au urmat în antecedente 4-6 instilaflii sæptæmânale cu hialuronat de sodiu), doar dupæ certificarea absenflei infecfliei urinare. Scorul simptomelor a înregistrat o scædere medie de 25%. În toate cazurile durerea hipogastricæ a fost redusæ semnificativ pe parcursul tratamentului. Doar o singuræ pacientæ cu capacitate vezicalæ funcflionalæ de 100 ml nu a beneficiat din punct de vedere al remiterii simtomelor de stocare. Efectul benefic a fost resimflit de obicei dupæ a doua instilaflie. Durata de 20 de minute sau mai mult a instilafliei a dus la o exacerbare tranzitorie a simptomelor. DMSO intravesical instillation for painful bladder syndrome Early results G. Glück, R. Stoica, Manuela Chiriflæ, I. Sinescu Center of Uronefrology and Renal Transplantation, Fundeni Clinical Institute, Bucharest Introduction: DMSO (dimethyl sulfoxide) is a FDA approved substance for intravesical instillations in cases of interstitial cystitis and painful bladder syndrome on account of its antiinflammatory, analgesic, and muscle relaxant effects and also because of its ability of transporting molecules through the bladder wall. Material and methods: A mixture scheme was used for intravesical instillations. It includes 50% DMSO (25 ml DMSO 99.9% purity and 25 ml distilled water). The just made mixture was instilled through 18 Ch Foley, after local anesthesia with lidocaine gel and evacuated after minutes. The evaluation was made by using the O Leary-Sant questionnaire in the beginning and after the first 4 weekly instillations. Results: The study included 6 patients who presented with painful bladder syndrome symptomatology that did not ceased at usual therapy (all patients had underwent 4-6 weekly instillations with sodium hyaluronate). All patients had sterile urine cultures. The symptoms score decreased by 25%. In all cases the hypogastric pain was significantly reduced throughout treatment. Only one patient, with a functional bladder capacity of 100 ml did not show any improvement concerning the bladder storage symptoms. The beneficial effect of the therapy appeared usually after the second instillation. The instillation length 20 minutes or more, led to a transitory symptoms exacerbation. Urologie femininæ, incontinenflæ Concluzii: Rezultatele instilafliilor conform schemei prezentate sunt promiflætoare mai ales în cazul pacientelor cu eøec al terapiilor utilizate în practica curentæ, efectul analgezic øi remiterea simptomelor de stocare fiind semnificative. Efectul maxim necesitæ un minim de 4 instilaflii saptæmânale, pentru consolidarea rezultatelor este necesaræ terapie de întreflinere cu o instilaflie lunaræ, timp de 6 luni. Conclusions: The study reported encouraging results for DMSO intravesical instillations, especially for those patients with no response at usual therapy. The analgesic and bladder storage symptoms were significantly improved. The maximal effect is achieved after 4 weekly instillations at least, long term results necessitating maintenance therapy with one instillation per month, for 6 months period. nr. 2 / 2012 vol 11 Revista Românæ de Urologie 23

25 Urologie femininæ, incontinenflæ 2.5. Dozæ dublæ de solifenacin în tratamentul hiperactivitæflii detrusoriene neurologice C. Persu, V. Mirciulescu, G. Niflæ, I. Arabagiu, B. Pârâianu, P. Geavlete Clinica de Urologie, Spitalul Clinic de Urgenflæ Sf. Ioan, Bucureøti Introducere. Hiperactivitatea detrusorianæ cu etiologie neurologicæ este o condiflie complexæ, cu incidenflæ mare øi o multitudine de complicaflii asociate. Deøi antimuscarinicele sunt considerate terapie de primæ intenflie, existæ multe cazuri în care eficienfla terapeuticæ este nesatisfæcætoare, iar alternativele terapeutice nu sunt disponibile. Prezentæm datele dintr-un studiu prospectiv, în care s-au administrat douæ tablete de solifenacin 10 mg zilnic. Material øi Metodæ. Tofli pacienflii au început cu o tabletæ de 10 mg pe zi. Dupæ o lunæ, pacienflii care nu au avut rezultate satisfæcætoare au putut opta pentru dublarea dozei de solifenacin, iar ceilalfli au ræmas la doza iniflialæ pentru urmætoarele douæ luni. Evaluarea pacienflilor a inclus jurnal micflional pe 3 zile, examen de urinæ, cistometrie de umplere øi ecografie, efectuate la includere øi la finalul celor 3 luni. Reacfliile adverse øi observafliile pacienflilor au fost notate pe toatæ perioada studiului. La final, datele au fost comparate utilizând analiza t-test. Rezultate. Studiul a inclus un numær total de 29 pacienfli (19 bærbafli, 10 femei), cu patologie neurologicæ. Dupæ o lunæ, 13 pacienfli au trecut la doza de 20 mg. Datele de la final demonstreazæ o creøtere semnificativæ a capacitæflii vezicale øi a volumului reflex precum øi scæderea semnificativæ a numærului de micfliuni øi a presiunii intravezicale. S-a observat o scædere a numærului de episoade de incontinenflæ precum øi o creøtere a valorii rezidiului vezical, ambele færæ semnificaflie statisticæ. Pacienflii au raportat amelioræri începând cu a øaptea zi de tratament cu doza dublæ. S-a observat o creøtere a incidenflei øi intensitaflii reacfliilor adverse, dar nici un pacient nu a întrerupt tratamentul pe perioadea studiului. Concluzii. 20 mg solifenacin zilnic reprezintæ o alternativæ siguræ, eficientæ øi accesibilæ de tratament al hiperactivitæflii detrusoriene, datoritæ îmbunætæflirii parametrilor micflionali în condifliile menflinerii reacfliilor adverse la un nivel acceptabil. Double Dose of Solifenacin for the Treatment of Neurogenic Detrusor Overactivity C. Persu, V. Mirciulescu, G. Niflæ, I. Arabagiu, B. Pârâianu, P. Geavlete Department of Urology, Saint John Emergency Clinical Hospital, Bucharest Introduction. Neurogenic detrusor overactivity (NDO) is a bothersome condition, with increased incidence and a long list of subsequent complications. While antimuscarinics remain the first line therapy, there are many cases where the efficacy of treatment is sub-optimal, prompting for an alternative. We present our data from a prospective, open-label clinical trial with 20 mg of solifenacin a day. Material & Method. All the patients started with a dose of 10mg solifenacin a day. After one month, the patients who were not satisfied with the efficacy of the treatment were given the choice to opt for a double dose of the drug, while others remained stable on the initial dose, for the next two months. Patients evaluation included 3 days bladder diary, urinalysis, ultrasonography and filing cystometry, done at the inclusion and at the final visit. All adverse effects and observations of the patients were recorded during the study. We compared data from the bladder diary and cystometry between the two arms, at the end of the three months treatment, using the t-test analysis. Results. A total number of 29 patients completed the study (19 males, 10 females), with various neurological conditions: spinal cord injury (SCI) 10 cases, multiple sclerosis (6), Parkinson s disease (PD) 5 cases and stroke 6 cases. After one month, 13 patients switched to the 20 mg dose. Final data shows statistically significant improvements in voided volume, number of micturitions, Pdet max and reflex volume. There was a decrease in the number of incontinence episodes and an increase in post void residual volume (PVR), both without statistical significance (see table for actual data). Patients reported improvements as early as 7 days after shifting to the 20 mg dose. There was an obvious increase in the rate and intensity of common adverse reactions (dry mouth, constipation, dizziness, etc). By the end of the trial, no patient discontinued the treatment and no serious adverse events occurred. Conclusions. A 20 mg dose of solifenacin is a good conservative treatment option for NDO. The storage and voiding parameters are improved, and the rate of adverse reactions, although higher, is fully balanced by the benefits and still reasonable for the patient. 24 Revista Românæ de Urologie nr. 2 / 2012 vol 11

26 2.6. Efectul tratamentului cu alfa1 blocant øi antimuscarinic asupra simptomatologiei, calitæflii vieflii øi parametrilor de uroflowmetrie în cazul pacienflilor cu LUTS iritative øi obstructive V. D. Stanca, Alexandra Andreea Poienar, A. Boc, P. Prunduø, S. Bonafl, I. Coman Secflia Clinicæ Urologie, Spitalul Clinic Municipal Cluj-Napoca Introducere. Bærbaflii cu LUTS mixte iritative øi obstructive pot sæ nu ræspundæ favorabil la monoterapia cu alfa 1 blocant, cauza eøecului fiind persistenfla simptomelor iritative. În astfel de cazuri se impune folosirea øi a unui antimuscarinic; existæ temeri cu privire la riscul de retenflie acutæ de urinæ secundaræ acestei terapii la bærbatul cu adenom prostatic. Ne propunem sæ evaluæm efectul øi siguranfla terapiei combinate alfa 1 blocante øi antimuscarinice la bærbaflii peste 50 ani cu LUTS iritative øi obstructive. Material øi metodæ. Am evaluat un numær de 18 pacienfli cu vârsta peste 50 ani care reclamau LUTS iritative øi obstructive. Am inclus în studiu pacienfli cu PSA <4 ng/ml, RPM <100 ml, Qmax>4 ml/s øi IPSS >8. Bilanflul diagnostic a inclus uroflowmetria, IPSS, QoL øi King s Health Questionnaire (KHQ). Pacienflii au fost tratafli cu alfa 1 blocant în combinaflie cu antimuscarinic (cu sau færæ inhibitor de 5 alfa reductazæ). Dupæ 30 zile de tratament am evaluat efectul terapiei combinate asupra IPSS, QoL, KHQ øi Qmax. Treatment with alpha1 blockers and antimuscarinic on symptoms, quality of life and uroflowmetry parameters in patients with irritative and obstructive LUTS V. D. Stanca, Alexandra Andreea Poienar, A. Boc, P. Prunduø, S. Bonafl, I. Coman Clinical Municipal Hospital Cluj-Napoca, Department of Urology Introduction. Men with combined irritative and obstructive LUTS may not respond to monotherapy with á1 blockers, having residual irritative symptoms. In these cases the use of an antimuscarinic agent is necessary; there are concerns regarding acute urinary retention induced by this treatment in men with BPH. Our purpose is to evaluate the effect and safety profile of the combined therapy with á1 blockers and antimuscarinic agents in men over 50 years old that are complaining of irritative and obstructive LUTS. Material and Methods. We evaluated a number of 18 patients aged over 50 years that complained of irritative and obstructive LUTS. We included in our study patients with PSA<4 ng/ml, PVR<100 ml, Qmax>4 ml/s and IPSS>8. The patients were treated with á1 blockers combined with antimuscarinics (with or without 5á reductase inhibitors). We evaluated the effect on IPSS, Qmax, QoL and King s Health Questionnaire (KHQ) after 30 days of treatment. Urologie femininæ, incontinenflæ Rezultate. Pacienflii au avut o evoluflie clinicæ bunæ sub tratament: IPSS mediu a scæzut de la 12,16 la 4,33 (p <0,001); scorul mediu la testul KHQ a scæzut de la 189,83 la 99 (p=0,011), scorul QoL mediu a scæzut de la 2,83 la 1,5 (p <0,001). Nu am înregistrat cazuri de retenflie acutæ de urinæ; Qmax a ræmas nemodificat (a crescut de la 10,18 ml/s la 10,35 ml/s, p=0,97). Concluzii. Tratamentul combinat alfa 1 blocant øi antimuscarinic este eficient în cazul bærbaflilor cu vârsta peste 50 ani cu LUTS iritative øi obstructive øi nu cauzeazæ retenflie acutæ de urinæ, nici scæderea Qmax. Eficienfla øi siguranfla sa exprimate prin diminuarea simptomatologiei øi creøterea calitæflii vieflii pacienflilor îl recomandæ ca primæ linie de tratament simptomatic la pacienflii cu LUTS combinate iritative øi obstructive. Results. The patients had a good clinical evolution under treatment: average IPSS decreased from to 4.33 (p<0.001); average score on KHQ decreased from to 99 (p=0.011), QoL average score decreased from 2.83 to 1.5 (p<0.001). We did not record any cases of acute urinary retention; Qmax was not influenced (it increased from ml/s to ml/s, p=0.97) Conclusions. Combined treatment with á1 blockers and antimuscarinic is effective in men over 50 years old with irritative and obstructive LUTS and do not cause acute urinary retention, nor diminishes Qmax. Our results recommend it as first line symptomatic treatment in patients with irritative and obstructive LUTS. nr. 2 / 2012 vol 11 Revista Românæ de Urologie 25

27 Urologie femininæ, incontinenflæ 2.7. Studiu comparativ al debitului urinar mæsurat prin debitmetrie respectiv prin studiu presiune-debit C. Persu, D. Georgescu, G. Niflæ, B. Pârâianu, P. Geavlete Clinica de Urologie, Spitalul Clinic de Urgenflæ Sf. Ioan, Bucureøti Introducere: Explorærile urodinamice non-invazive au fost primele apærute cronologic în armamentariumul urologului, iar în prezent recâøtigæ teren tocmai datoritæ gradului redus de invazivitate. Studiul nostru analizeazæ comparativ parametrii debitului urinar mæsurafli prin debitmetrie simplæ, respectiv studiu presiune-debit, în scopul de a evalua valoarea debitmetriei ca metodæ de screening sau diagnostic. Material øi Metodæ: Am analizat retrospectiv 100 de exploræri urodinamice consecutive în care au fost disponibile atât debitmetria cât øi studiul presiune debit. Lotul include 67 femei (23-71 ani) øi 33 bærbafli (19-57 ani), cu simptomatologie de aparat urinar inferior. Dintre aceøtia, 43 pacienfli (21 bærbafli, 22 femei) aveau diagnostic de vezicæ neurologicæ. Examinarea s-a fæcut cu dispozitivul Medtronic Duet Logic, utilizând catetere 8 Fr, cu douæ sau trei cæi de mæsuræ øi pacientul în decubit dorsal. Manevrele s-au efectuat în conformitate cu recomandærile ICS. La final, au fost comparafli parametrii fluxului urinar debit maxim (Qmax), timpul pânæ la debitul maxim øi volumul urinat. Rezultatele au fost analizate separat pentru bærbafli, femei øi pacienfli neurologici. Rezultate: În grupul bærbaflilor, Qmax la debitmetrie a avut valori între 9 ml/sec øi 41 ml/sec, în timp ce la examenul invaziv valorile au fost cuprinse între 7 øi 24 ml/sec. Variaflia intraindividualæ este cuprinsæ între 9% øi 55%. Timpul pânæ la atingerea debitului maxim a fost întotdeauna mai lung la studiul presiune-debit, cu variaflii cuprinse între 15 øi 50%. În lotul femeilor, Qmax la debitmetrie a avut valori între 12 øi 31 ml/sec, iar dupæ examenul invaziv valorile au fost între 9 øi 29 ml/sec. Timpul pânæ la debitul maxim are un profil similar cu cel al bærbaflilor. În lotul pacienflilor cu vezicæ neurologicæ, Q max la debitmetrie a fost cuprins între 5 øi 24 ml/sec, respectiv 3 la 25 ml/sec dupæ studiul presiune-debit. Timpul pânæ la Q max a crescut sau scæzut færæ a putea fi corelat cu alfli parametrii. Volumul urinat a avut valori ce nu au permis comparaflie în cadrul loturilor. Free Uroflowmetry vs. Flow Rate during Pressure Flow Test a comparative study C. Persu, D. Georgescu, G. Niflæ, B. Pârâianu, P. Geavlete Department of Urology, Saint John Emergency Clinical Hospital, Bucharest Introduction. Non-invasive urodynamic tests were the first to appear chronologically in the armamentarium of urologists, and now they are regaining popularity specifically because of their non-invasivity. Our study focuses on comparing flow rate parameters obtained at free uroflowmetry and pressure-flow test (PF) in order to assess the reliability of uroflowmetry alone as a screening or diagnostic test. Material and Method. We retrospectively analyzed 100 consecutive urodynamic tests in which both free uroflowmetry and PF study were available. The series included 67 women (23-71 years old) and 33 men (19-57 years old) who were investigated for LUTS. 43 patients (21 men and 22 women) were referred with neurogenic bladder. Both tests were performed using the Medtronic Duet Logic urodynamic device and 8Fr urethral catheter with two or three lumina and with the patient in supine position for PF. The tests were performed according the ICS guidelines for good urodynamic practice. We compared the flow parameters (maximum flow rate, time to maximum flow and voided volume) obtained after each test in the same individual. Data was analyzed separately for men, women and neurogenic bladders. Results. In the males group, Qmax on free flowmetry had values between 9ml/sec and 41 ml/sec, while on PF values ranged from 7ml/sec to 24ml/sec. Intra-individual variation ranges from 9% to 55%. Time to maximum flow was always longer at PF, with variation between 15% and 50%. In the female group, Q max after free flow ranged between 12ml/sec to 31ml/sec, and after PF was between 9ml/sec and 29ml/sec. Time to maximum flow had a similar profile as in males. In the neurogenic group, Qmax at free flow had values between 5ml/sec to 24ml/sec, and from 3ml/sec to 25ml/sec after PF. Time to maximum flow had either increased or decreased at PF compared to free flow. Voided volume data could not be compared on the whole series. Concluzii: Debitul urinar este un parametru cu mare variabilitate intraindividualæ, iar, în condifliile unei exploræri invazive, variabilitatea creøte mai mult. Debitmetria simplæ este suficientæ pentru a caracteriza debitul urinar, în timp ce studiul presiune-debit permite diferenflierea sindromului obstructiv subvezical de detrusorul acontractil. Conclusion. Urinary flow rate alone is known to be variable in the same individual, and when invasive urodynamics is performed, the variance increases further. Free uroflowmetry seems to be more accurate in describing the actual flow rate, while the PF study is useful for differentiation between obstruction and underactive detrusor. 26 Revista Românæ de Urologie nr. 2 / 2012 vol 11

28 2.8. Asociere antimuscarinicelor cu tratamentul alfa-blocant la pacienflii cu adenom de prostatæ øi simptomatologie de tract urinar inferior D. Soroiu, C. Persu, V. Mirciulescu, G. Niflæ, C. Iacoboaie, P. Geavlete Clinica de Urologie, Spitalul Clinic de Urgenflæ Sf. Ioan, Bucureøti Introducere: Simptomatologia iritativæ de tract urinar inferior (LUTS) este o problemæ frecventæ la pacienflii cu adenom de prostatæ, iar multiplele alternative terapeutice disponibile în prezent se dovedesc uneori insuficiente. Studiul nostru îøi propune sæ analizeze rezultatele asocierii de antimuscarinic la tratamentul á-blocant la aceøti pacienfli. Material øi Metodæ: Studiul prospectiv s-a desfæsurat în perioada Ianuarie-Decembrie 2011, pe pacienfli cu adenom de prostatæ. Protocolul de investigaflie a inclus examen clinic, scor simptomatic IPSS, dozare PSA, ecografie øi debitmetrie. Pacienflii au fost reevaluafli dupæ 3 luni dupæ acelaøi protocol. Au fost incluøi un numær de 53 pacienfli cu polakiurie si disurie, cu volum prostatic sub 40ml, scor IPSS peste 20, rezidiu postmicflional nesemnificativ. La 27 dintre pacienfli s-a administrat tamsulosin, iar la 26 s-a administrat combinaflia de tamsulosin cu solifenacin 5mg. The use of antimuscarinics and alpha-blockers in patients with BPH and LUTS D. Soroiu, C. Persu, V. Mirciulescu, G. Niflæ, C. Iacoboaie, P. Geavlete Department of Urology, Saint John Emergency Clinical Hospital, Bucharest Introduction: Bothersome LUTS is a frequent problem in BPH patients with mild obstructive syndrome, where many of the treatments currently available fail to offer optimal results. Our study aims to analyze the results of the combination therapy with á-blockers and antimuscarinics in these patients. Matherial and Method: Our prospective study took place between January and December 2011, in patients with BPH. The evaluation protocol included clinical examination, IPSS questionnaire, PSA, ultrasonography and uroflowmetry. The patients were reevaluated after three months using the same protocol. A total number of 53 patients acusing dysuria and frequency were included. The inclusion criteria were: prostatic volume less than 40ml, IPSS score above 20, no PVR. 27 patients received tamsulosin and 26 received combination therapy: tamsulosin and solifenacin 5 mg. Urologie femininæ, incontinenflæ Rezultate: În lotul pacienflilor tratafli cu tamsulosin, s-a înregistrat o ameliorare a scorului IPSS cu o valoare medianæ de 5 puncte, øi o îmbunætæflire a debitului maxim cu o valoare medianæ de 2 ml/sec. Rezidiul postmicflional a ræmas la valori nesemnificative. Pacienflii care au primit tratament combinat au înregistrat o îmbunætæflire a scorului simptomatic cu o valoare medianæ de 7 puncte øi un debit urinar ce a crescut cu o valoare mediana de 2ml/sec. Rezidiul postmicflional a fost prezent la 19 din cei 26 pacienfli, cu valori cuprinse între 30 øi 75ml. Concluzie: Asocierea celor douæ clase terapeutice oferæ rezultate superioare în cazul pacienflilor færæ sindrom obstructiv subvezical sever, cu simptomatologie supærætoare. Principalele beneficii inregistrate au fost scæderea frecvenflei micfliunilor øi ameliorarea scorului simptomatic, færæ a se înregistra reacflii adverse importante. Results: In the group of patients treated with tamsulosin, the IPSS score decreased with a median value of 5 points and the urinary flow was improved by a median value of 2 ml/sec. No PVR was observed at the follow-up. The patients in the combination therapy group reported an improvement of their symptoms coresponding to a median value of 7 points, while the urinary flow was improved my a median value of 2ml/sec. Significant PVR was observed in 19 out of 26 patients, with values between 30 and 75 ml. Conclusions: The combination of the two drugs leads to superior results compared to á-blockers alone in patients without severe obstruction but bothersome symptoms. The main benefits are the improvement of the symptom score and an amelioration of frequency without significant adverse reactions. nr. 2 / 2012 vol 11 Revista Românæ de Urologie 27

29 Urologie femininæ, incontinenflæ 2.9. Factori de risc în incontinenfla de urinæ la femei Buzsi Enikõ, Mártha Orsolya, A. Szöllösi, O. Vida, A. Maier Clinica de Urologie, Tg. Mureø Introducere. Incontinenfla de urinæ, indiferent de faptul cæ ea este de efort, de imperiozitate sau mixtæ, afecteazæ grav calitatea vieflii. Studiul nostru, bazat pe detaliile unui screening efectuat într-un ambulator de specialitate evalueazæ factorii de risc în diferitele forme de incontinenflæ urinaræ la femei. Material øi metodæ. Screeningul a constat din completarea unui chestionar (întrebæri referitoare la tulburærile micflionale,circumstanflele aparifliei pierderii de urinæ involuntaræ, obiceiuri zilnice legate de actul micflional, factori favorizanfli, severitatea simptomatologiei, precum øi întreabæri legate de calitatea vieflii), a unui calendar micflional pe 3 zile consecutive, ecografie abdominalæ (determinarea rezidiului øi a capacitæflii vezicale), examen ginecologic, examen sumar de urinæ, la nevoie uroculturæ. Rezultate. Din cele 61 de paciente 39 (63,93%) au fost diagnosticate cu o formæ de incontinenflæ urinaræ. 31 (50,8%) au prezentat incontinenflæ de efort, 6 (9,83%) incontinenflæ de imperiozitate, iar 2 (3,27%) de tip mixt. Vârsta pacientelor a fost între de ani (vârsta medie 55,08 ani), pacientele peste 50 de ani au prezentat cea mai mare incidenflæ a incontinenflei (48,64%).Naøterea pe cale vaginalæ a fost prezentæ la 29 (93,54%) din cele cu incontinenflæ de efort øi 5 (83,33%) cu incontinenflæ de imperiozitate. Cezariana apare la 2 (6,45%) resp 1 (16,66%) paciente; menopauza la 22 (70,96%) resp 4 (66,66%), multiparitatea la 21 (67,74%) resp 5 (83,33%), diabetul zaharatla 5 (16,12%) resp. 2 (33,33%), bolile cardiovasculare la 7 (22,58%) øi 1 (16,66%), BMI peste 30 la 12 (38,7%) øi3 (50%); sedentarismul la 6 (19,35%). 15 (48,38%) aveau antecedente uroginecologice. Constipaflie habitualæ øi fumatul s-au identificat doar la cele cu incontinenflæ de efort 4(12,90%) resp. 2(6,45%). Concluzii. Prevalenfla incontinenflei de urinæ este mare în regiunea noastræ (63,93%), în special a celei de efort, aøadar are o importanflæ deosebitæ. Factori de risc potenfliali sunt vârsta înaintatæ, menopauza, constipaflia habitualæ, sedentarismul, naøterea pe cale vaginalæ, multiparitatea, obezitatea. Risk factors in female urinary incontinence Buzsi Enikõ, Mártha Orsolya, A. Szöllösi, O. Vida, A. Maier Tg. Mureø Urology Department Introduction. Urinary incontinencehas substantial and important impacts on quality of life, is highly prevalentand affects women of all ages. Our objective was to determine the prevalence and risk factors of urinary incontinence among women in our region. Materials and methods. All of the patients completed selfadministered questionnaires (including questions about voiding-related symptoms, circumstances of urinary leakage and other urinary disorders, predisposing factors, comorbidities, severity of simptoms and general well-being questions) and a 3-day bladder diary. We performed an abdominal ultrasound, gynecological examination, urinalysis and urine cultures. Results. The study subjects were 61 women aged 37 to 74 years in the general population (median age 55,08). The overall prevalence of urinary incontinence was 63,93% (39 of 61). 31 (50,8%) had stress urinary incontinence, 6 (9,83%) urge incontinence and 2 (3,27%) had mixed type urinary incontinence. The highest incidence (48,64%) was found among women who were >50 years. Vaginal delivery was present at 29 (93,54%) women with stress urinary incontinence and 5 (83,33%) who had urge incontinence. Caesarean section appeared at 2 (6,45%) respectively at 1 (16,66%) patient; 22 (70,96%) respectively 4 (66,66%) were postmenopausal women, 21 (67,74%) resp 5 (83,33%) were women who had more than 2 deliveries, 5 (16,12%) resp. 2 (33,33%) patient had diabetes, 7 (22,58%) resp 1 (16,66%) had cardiovascular comorbidities; BMI>30 appeared at 12 (38,7%) øi 3 (50%) women; sedentariness was found at 6 (19,35%) women. 15 (48,38%) have had urogynecological procedures in the past. Constipation and smoking appered only at women who had stress incontinence 4(12,90%) resp. 2(6,45%). Conclusion. The urinary incontinence has a great prevalence in our region (63,93%), especially the stress incontinence, hereby is very important. The main risk factors are old age, menopause, constipation, sedentary life, vaginal delivery, multiparity, BMI higher than Revista Românæ de Urologie nr. 2 / 2012 vol 11

30 2.10. Complicafliile chirurgiei incontinenflei øi prolapsului urogenital - cazuri clinice A. Bumbu, M. Berechet, R. Drægoi, M. Varlan, G. Isoc, G. Bumbu Clinica de Urologie, Spitalul Clinic Judeflean de Urgenflæ Oradea Introducere si obiective: Scopul lucrærii este de a descrie complicafliile asociate cu chirurgia prolapsului urogenital a a incontinenflei urinare de efort precum øi metodele chirurgicale de rezolvare a complicafliilor (perforaflii, eroziuni, etc...) Materiale øi metodæ: 23 de paciente prezent nd diferite complicaflii post operatorii, internate pe o perioada de 1 an Ón Clinica de Urologie din Oradea cu trimitere din alte servicii de specialitate. Rezultate øi concluzii: 1) Complicafliile postoperatorii asociate acestui tip de chirurgie sunt destul de frecvente si afecteazæ calitatea vieflii pacientelor. 2) Managementul chirurgical al acestor complicaflii este deseori dificil øi depinde de timpul scurs de la intervenflia precedentæ. 3) Femeile ar trebui informate preoperator despre aceste potenfliale complicaflii øi urmærite postoperator cu atenflie. 4) Alegerea celui mai sigur material este crucialæ datoritæ riscului de eroziune postoperatorie. 5) Complicafliile sunt cel mai adesea datorate indicafliei chirurgicale eronate c t øi tehnicii chirurgicale greøit aplicatæ. Complications of Urogenital Prolapse and Stress Urinary Incontinence Surgery Clinical Cases A. Bumbu, M. Berechet, R. Drægoi, M. Varlan, G. Isoc, G. Bumbu Urology Clinic, Oradea Emergency Clinical County Hospital Introduction and Objective. The aim of this study was to describe complications associated with Urogenital Prolapse and Stress Urinary Incontinence Surgery and means to surgically solve complications like erosions and injuries (perforation). Materials and Methods. 23 patients referred to Oradea Urology Clinic from different urological services with complication post surgery, during a period of 1 year. Results and Conclusions. The study is focused on surgical management of the complications: erosions, perforations, injury. 1) Post-operative complications are relatively frequent after this type of surgery and can impair patient s satisfaction. 2) Surgical management of this complication is more-often difficult and depends on the elapsed time from the first procedure. 3) Women should be informed of these potential complications preoperatively and require careful follow-up after the procedure. 4) Choice of the safest material is crucial as it is a risk factor for erosion. 5) The complications are due to wrong surgery indications but also due to the technique of the surgeon. Urologie femininæ, incontinenflæ nr. 2 / 2012 vol 11 Revista Românæ de Urologie 29

31 Urologie femininæ, incontinenflæ Analiza tratamentului cu meøe de polipropilenæ în prolapsul urogenital avansat pe o perioadæ de 5 ani M. Berechet, A. Bumbu, G. Bumbu, D. Purza Clinica de Urologie, Spitalul Clinic Judeflean de Urgenflæ Oradea Introducere si obiective. Prolapsul urogenital este o afectiune des intalnita cu precadere la femeile in varsta. Nasterea pe cale naturala, histerectomia si chirurgia efectuata pentru rezolvarea incontinentei urinare de efort reprezinta factori favorizanti. Materiale øi metodæ: Se prezintæ experinfla Clinicii de Urologie din Oradea în decurs de 5 ani pe 215 paciente ce au prezentat prolaps urogenital avansat. Tehnicile folosite au fost: 42 cazuri implant anterior, 40 - implant posterior, 85 - implant total, 31 - colposuspensie abdominala, 17 cazuri - colpohisterosuspensie. La 22 pacienti s-a diagnosticat si incontinenta oculta fiind rezolvati chirurgical prin implant total cu bandeleta TOT. Pentru diagnosticare s-a utilizat sistemul POPQ. Varsta media a pacientelor a fost de 62 de ani. S-a utilizat terapia cu estrogeni in anumite cazuri cu aproximativ doua saptamani inainte de interventia chirurgicala. Implantul de polipropilena trebuie sa fie plasat sub cistocel in maniera tension-free. In sacropexia infracoccigeala a fost necesara utilizarea unei mese de polipropilena cu un design ce a inclus doua brate de ancorare. In sacropexia pe cale abdominala s-a utilizat incizia pubo-ombilicala iar dupa fixarea mesei de polipropilena la vagin sau la vagin si cervixul uterin mesa s-a trecut extraperitoneal fiind apoi fixata la promontoriu. Rezultate øi concluzii: Nu s-au inregistrat complicatii postoperatorii imediate. Alte complicatii postoperatorii: un abces de fosa ischio-rectala, sapte hematoame perineale, 5 recidive dupa implant vaginal, 5 rectocele dupa abordul pe cale abdominala, 2 scleroze de perete vaginal, 5 eroziuni si 2 cazuri de retentie urinara dupa colposacrohisteropexie. Aceste interventii cu materiale de implant speciale din mese de polipropilena sunt metode foarte bune de rezolvare a prolapsului urogenital avansat. Polipropylene mesh surgical treatment in advanced urogenital prolapse. 5 years retrospective study M. Berechet, A. Bumbu, G. Bumbu, D. Purza Urology Clinic Oradea Emergency Clinical County Hospital Introduction and objectives: Urogenital prolapse is a frequent condition especially to elderly woman. Natural birth, hysterectomies and surgery for stress urinary incontinence are predisposing factors. Material and method: Oradea urology Clinic 5 year surgical experience on 215 patients with advanced urogenital prolapse is presented. The procedures used were - 42 anterior implants, 40 posterior implants, 85 total implants, 31 abdominal colposuspensions, and 17 colpohisterosuspensions). 22 patients had occult incontinence (total implant with T.O.T. tape). POPQ quantitative system was used. The average age of the patients was 62. Local estrogen therapy was performed on several patients two weeks before surgery. The mesh should be underneath the cystocele in a tension-free manner. For infra-coccigial sacropexy a specially constructed mesh that has two anchoring tails is necessary. In case of abdominal sacropexie, pubo-ombilical incision was used and after fixation of the device to the vagina or to the vagina and uterine cervix, we pulled the mesh extra peritoneal and than fixed it at the promontory. Results and conclusions: The results and the cosmetic aspect were very good. Complication: one right ischio-rectal abcess, seven perineal haematoma, five recidives after vaginal implant, five rectocels after abdominal approach, two vaginal wall scleroses, five erosions and two cases of urinary retention after colposacrohisteropexie. The techniques with special implant materials represent good means to treat advanced urogenital prolapse. 30 Revista Românæ de Urologie nr. 2 / 2012 vol 11

32 2.12. Tratamentul cu benzi de polipropilenæ în incontinenfla urinaræ de efort. Studiu retrospectiv pe 5 ani. M. Berechet, A. Bumbu, S. Kolumban, Dana Jovrea, G. Bumbu Clinica de Urologie, Spitalul Clinic Judeflean de Urgenflæ Oradea Introducere. Incontinenfla urinaræ de efort intereseazæ un procent cuprins între 10% øi 40% din populaflia de sex feminin afectând calitatea vieflii acestor paciente. Marea majoritate a acestora prezintæ de regulæ asociat øi un prolaps urogenital de diverse grade. Scopul lucrarii îl reprezintæ evaluarea eficacitæflii tratamentului cu benzi de polipropilena în tratamentul incontinenflei urinare de efort la femeie. Material øi metodæ. Între 2007 si 2012 în clinica de Urologie din Oradea s-a intervenit chirurgical utilizând benzi de polipropilenæ la 238 de paciente (cu vârsta medie de 61 de ani) ce au prezentat la diagnostic incontinenfla urinaræ de efort - pacientele au fost supuse mai întâi unui riguros examen clinic (Teste Boney, Valsalva, urodinamice etc.). Tehnica TOT începe printr-o incizie suburetralæ medianæ urmatæ de disecflia parauretralæ pânæ la osul pubian. Bandeleta este inseratæ apoi în maniera tension-free prin intermediul dispozitivelor speciale. Rezultate si concluzii. Tehnica TOT este rapidæ, puflin complicatæ, mai bine acceptatæ øi toleratæ de cætre paciente. Reprezintæ o opfliune viabilæ pentru pacienflii ce prezintæ adeziuni retropubice post intervenflii øi în cazul pacientelor obeze. Pentru o intervenflie reuøitæ se impune o selecflie adecvatæ a pacientelor. Repararea prolapsului urogenital asociat în anumite cazuri se poate realiza uøor în acelaøi timp operator de cætre un chirurg bine pregætit (urolog, ginecolog sau echipæ). Polipropylene tape surgical treatment in stress urinary incontinence. 5 year retrospective study. M. Berechet, A. Bumbu, S. Kolumban, Dana Jovrea, G. Bumbu Urology Clinic Oradea Emergency Clinical County Hospital Introduction and objectives. The stress urinary incontinence is a disease interesting 10-40% of the female population and affects their quality of life. Most of these female patients present also a genital prolapse. The aim of this study is to establish the efficiency of polipropylene tape surgical treatment in female stress urinary incontinence, the advantages and disadvantages. Materials and methods. Between 2007 and 2012, the author operated 238 female patients for stress urinary incontinence (average age was 61 years). In the same operative time, for 62 patients, the posterior bridge technique and straightening of the central tendon were performed for associated rectocele. In nine cases the vaginal hammock tensioning was necessary: seven paraurethral incisions with shortening of the external urethral ligaments and the fixation of the vaginal wall to the PCM muscle. Results and conclusions. T.O.T. out-in technique is quicker, easier, less complicated and better accepted and tolerated by patients. It is a good option for patients with retropubic adhesions after previous surgery, and obese patients. Urogenital prolapse repair is simple in the same time for a well trained surgeon (urologist, gynecologist or both). Urologie femininæ, incontinenflæ nr. 2 / 2012 vol 11 Revista Românæ de Urologie 31

33 Urologie femininæ, incontinenflæ Impactul profilaxiei infecfliilor urinare asupra evolufliei multirezistenflei bacteriilor la pacienflii cu cateter vezical pentru retenflie acutæ de urinæ A. Maier, C. Chibelean, O. Mælæu, D. Porav, A. Szollosi, A. Brad, R. Boja, Orsolya Martha Clinica Urologie Spitalul Clinic Judeflean Mureø Introducere: Infecfliile urinare asociate cateterelor urinare sunt o problemæ de actualitate în practica urologicæ cu o contribuflie la creøterea comorbiditæflii, în special în cazul infecfliilor multirezistente. Obiective: Studiul analizeazæ incidenfla infecfliilor urinare multirezistente, ulterioare tratamentului profilactic la pacienflii cu catetere urinare montate pentru retenflie acutæ de urinæ. Material øi metodæ: Evaluarea este prospectivæ øi se efectueazæ în perioada pe un grup de 51 pacienfli care se prezintæ în serviciul de urgenflæ cu retenflie acutæ de urinæ øi la care se monteazæ cateter uretro-vezical. Aceøtia prezintæ iniflial uroculturi sterile. Pacienflii sunt împærflifli în douæ loturi: un lot (A) care urmeazæ tratament profilactic cu Ciprofloxacinæ (500 mg, de douæ ori pe zi, 7 zile) øi un al doilea lot (B) care urmeazæ tratament cu dezinfectant urinar (Urisan de douæ ori pe zi, 7 zile). Tratamentul profilactic se efectueazæ atât la montarea cateterului cât øi la schimbarea acestuia (din 3 în 3 sæptæmâni), când se recolteazæ øi uroculturæ. Rezultate: Tofli pacienflii din cele douæ loturi prezintæ infecflie urinaræ asimptomaticæ la 3 sæptæmâni de la montarea cateterului; în sæptæmâna a 6-a lotul A, alcætuit din 33 pacienfli prezintæ infecflie multirezistentæ la 19 pacienfli (57,5%), reprezentatæ de: Proteus Mirabilis 8 pacienfli (42,1%), Serratia Marcescens 5 pacienfli (26,3%), Morganella Morganii 3 pacienfli (15,7%), E. Coli 1 pacient (5,26%) øi Enterococcus Faecalis 2 pacienfli (10,5%), iar lotul B alcætuit din 18 pacienfli prezintæ infecflie multirezistentæ doar la 3 pacienfli (16,6%) reprezentatæ de: Enterococcus Faecalis 2 pacienfli øi E. Coli 1 pacient. Ambele loturi prezintæ infecflie la 3 sæptæmâni de la montarea cateterului vezical, iar la 6 sæptæmâni urocultura deceleazæ deja infecflii multirezistente, in 57,5% din cazuri in lotul A raportat la lotul B care prezintæ doar in 16,6% din cazuri. Concluzii: este de preferat ca antibioterapia profilacticæ sæ se efectueze doar în cazuri bine selecflionate (cu infecflie urinaræ simptomaticæ øi la cazurile predispuse la infecflii urinare:diabet zaharat etc.). The impact of urinary infection prophylaxy on evolution of bacteria multi resistency in patients with bladder catheter for acute urinary retention A. Maier, C. Chibelean, O. Mælæu, D. Porav, A. Szollosi, A. Brad, R. Boja, Orsolya Martha Clinica Urologie Spitalul Clinic Judeflean Mureø Introduction: The urinary infections associate to bladder catheter are in present a problem in urological practice, contributing to increase the comorbidities, especially when we re facing to multi resistant bacteria. Objective: This study analyse prospectively the incidence of multi resistant urinary infections, after profilactic treatment in patients with urinary catheter for acute urinary retention. Material and method: The evaluation is a prospective one, performed between , based on a group of 51 patients, which are presenting at the emergency room with acute urinary retention and consequentely have had a bladder catheter. All this patients were with sterile urine culture. These patients are divided in two groups: group A which followed prophylactic treatment with ciprofloxacin (500mg, twice a day, 7 days), group B which followed prophylactic treatment with Urisan (twice a day, 7 days), Treatment was administered at the time of indwelling and changing of the bladder catheter (from 3 to 3 weeks), when the urine cultures were performed. Results: All these patients present asymptomatic infection after 3 weeks since the moment of indwelling of bladder catheter; at the sixth week among the 33 patients of the group A multi resistant infection is present in 19 patients (57,5%), represented by: Proteus mirabilis 8 patients (42,1%), Serratia marcescens 5 patients (26,3%), Morganella morganii 3 patients (15,7%), E. coli 1 patient (5,26%) and Enterococcus faecalis 2 patients (10,5%); and among the 18 patients of the group B multi resistant infection is present in 3 patients (16,6%) represented by: Enterococcus faecalis 2 patients and E. coli 1 patient. Both groups are infected after 3 weeks since the moment of indwelling of bladder catheter; after six weeks the urine culture develop already in group A multi resistant infection: 57,5% while group B present multi resistant infection in just 16,6% cases. Conclusions: As far as at 3 week all patients are colonised at urinary level, is highly recomended to administrate prophylactic antibiotics just in specific cases: with symptomatic urinary infection or with high risk for urinary infection: diabetes mellitus etc. 32 Revista Românæ de Urologie nr. 2 / 2012 vol 11

34 3.1. Rezultatele oncologiceale pacienflilor cu cancer penian øi determinæri inghinale voluminoase fixe (N3): Este nevoie de tratament chirurgical? C. Surcel 1, C. Mirvald 1, C. Gîngu 1, S. Pætræøcoiu 1, S. Margaritis 1, A. Omer 1, Carmen Savu 2, I. Sinescu 1 1 Centrul de Uronefrologie øi Transplant Renal, Institutul Clinic Fundeni 2 Clinica de ATI, Institutul Clinic Fundeni, Bucureøti Oncological outcomes of patients with penile cancer and bulky-fixed inguinal lymph nodes (N3): is surgical treatment needed? C. Surcel 1, C. Mirvald 1, C. Gîngu 1, S. Pætræøcoiu 1, S. Margaritis 1, A. Omer 1, Carmen Savu 2, I. Sinescu 1 1 Center of Uronephrology and Renal Transplantation, Fundeni Clinical Institute 2 ICU Department, Fundeni Clinical Institute, Bucharest Oncologie Introducere. Managementul adenopatiilor inghinale fixe în cancerul penian reprezintæ un subiect de dezbatere, întrucât niciun consens nu a fost stabilit în ceea ce priveøte diagnosticul, stadializarea øi tratamentul acestora. Obiectiv. Evaluarea rolului limfodisectiei inghinale extinse øi pelvine la pacienflii cu cancer penian care prezintæ mase inghinale voluminoase, fixe (N3), ca monoterapie sau în cadrul unei abordæri multimodale. Material øi metodæ. Am realizat în Clinica noastræ un studiu comparativ retrospectiv în perioada pe 24 de pacien?i cu adenopatii inghinale fixe voluminoase, færæ determinæri sistemice. Pacienflii au fost împærflifli în 3 grupe: 9 cu limfodisec?ie bilateralæ inghinalæ øi pelvinæ (elnd), færæ tratament adjuvant, 7 pacienfli cu elnd øi tratament adjuvant cu 3 cure de Cisplatin + 5-FU øi 5 au primit doar Cisplatin + 5- FU (trei cure). 3 pacienfli au refuzat orice formæ de tratament. Am evaluat supraviefluirea globalæ la 5 ani a celor 3 grupe prin intermediul curbelor Kaplan-Meyer. Rezultate. Supraviefluirea globalæ la 5 ani, a fost dupæ cum urmeazæ: grupa 1: 18, 6%, grupa 2: 28,5% øi 0% în grupa 3, respectiv. Ratele de complicaflii dupæ tratamentul chirurgical au fost similare între grupa 1 øi grupa 2 (55,5% øi 71,4%), cu un timp de spitalizare mediu de 28 øi 33 de zile, respectiv (p = 0,1). Concluzii. Numærul de pacienfli cu cancer penian avansat øi determinæri adenopatice inoperabile este supraevaluat. Limfodisecflia inghino-pelvinæ poate oferi rezultate oncologice satisfæcætoare pe termen lung, ca parte a unui tratament multimodal. Chimioterapia, ca modalitate unicæ de tratament, aduce un benificiu minim în supraviefluirea globalæ a acestor pacienfli. Introduction: Management of fixed inguinal nodes in penile cancer is still a matter of debate, as no consensus has yet been reached regarding their optimal diagnosis, staging and diagnosis. Objective: To assess the importance of LND in patients with penile cancer and fixed inguinal lymph nodes (N3) as definitive treatment or part of a multi-modal approach. Material and Method: We conducted in our Clinic a comparative retrospective study during on 24patients with bulkyfixed inguinal nodes, with no M+ disease. The patients were divided in 3 groups: 9 with bilateral inguinal and pelvic lymphadenectomy with no adjuvant treatment, 7 patients with extended lymph node dissection and adjuvant treatment with three courses of Cisplatin+5-FU and 5 were treated with Cisplatin + 5-FU only (three courses). 3 patients refused any form of treatment. We consider primary endpoint overall survival (OS) at 5 years (Kaplan-Meyer curves). Results: The OS rates at 5 years were as following: group 1: 18, 6%, group 2: 28.5 % and 0% in group 3, respectively. Overall complication rates after surgical treatment were similar between group 1 and group 2 (55.5% and 71.4%), with a mean hospitalization time of 28 and 33 days, respectively (p=0.1). Conclusion: The rate of bulky/unresecable disease in advanced penile cancer remains overrated. Surgery can provide good long term outcomes as part of a multimodal management. Chemotherapy as single treatment provides limited benefit on overall survival. nr. 2 / 2012 vol 11 Revista Românæ de Urologie 33

35 Oncologie 3.2. Carcinom verucos penian gigant management chirurgical C. Gîngu, A. fiurcanu, Vanghelifla Zogas, A. Dick, S. Pætræøcoiu, C. Surcel, M. Hârza, M.A. Manu, C. Bæløanu, B. Øtefan, F. Lupu, O. Himedan, Mihaela Mihai *, Liliana Domniøor **, I. Sinescu Centrul de Uronefrologie øi Transplant Renal, * Laboratorul de Anatomie Patologicæ, ** Laboratorul de Biologie Molecularæ øi Imunologie Giant verrucous carcinoma of the penis - surgical management C. Gîngu, A. fiurcanu, Vanghelifla Zogas, A. Dick, S. Pætræøcoiu, C. Surcel, M. Hârza, M.A. Manu, C. Bæløanu, B. Øtefan, F. Lupu, O. Himedan, Mihaela Mihai *, Liliana Domniøor **, I. Sinescu Center of Uronephrology and Renal Transplantation, * Pathology Laboratory, Institutul Clinic Fundeni, Bucureøti ** Molecular Biology and Immunology Laboratory, Fundeni Clinical Institute, Bucharest Introducere: Carcinomul verucos este o variantæ foarte bine diferenfliatæ de carcinom scoamos, cu o ratæ redusæ de creøtere øi reprezintæ aproximativ 5% din totalul tumorilor peniene maligne. Macroscopic, carcinomul verucos se prezintæ ca o formafliune tumoralæ vegetantæ, cu bazæ largæ de implantare. În majoritatea cazurilor, tumora are dimensiuni între 1-3 cm, deøi au fost descrise forme gigantice distructive. Metoda si Rezultate: Pacientul I.L., în vârstæ de 31 ani, cu antecedente personale de TBC pulmonar, cu o formafliune tumoralæ penianæ apærutæ în urmæ cu aproximativ 11 ani, cu evoluflie lentæ, ce a cuprins tot penisul øi o parte din scrot, færæ nici o evaluare medicalæ în antecedente. Examenul clinic local relevæ o formafliune tumoralæ voluminoasæ, sesilæ, de aspect conopidiform ce acoperæ glandul în regiunea meatului urinar øi restul penisului circumferenflial pe toatæ lungimea sa, cu extensie øi la nivelul scrotului, færæ adenopatii inghinale decelabile la palpare. În prima etapæ s-a practicat biopsie excizionalæ cu amputaflie parfliala de penis øi rezectia tegumentului scrotal afectat. Se decide temporizarea reconstrucfliei peniene din cauza defectului tegumentar important øi se practicæ înfundarea bontului penian în bursa scrotalæ cu uretrostomie cutanatæ. Rezultat histopatologic: carcinom verucos bine diferenfliat, G1. În a doua etapæ s-a practicat reconstrucflie penianæ cu grefæ de piele despicatæ efectuatæ la 3 luni de la prima intervenflie. Rezultate: Pacientul a prezentat, la examenul fizic la 9 luni postoperator, confort micflional bun, plagæ vindecata per primam, erecflie satisfæcætoare cu reluarea activitæflii sexuale. Færæ recidivæ locoregionalæ sau la distanflæ clinic øi imagistic. Concluzii: În tratamentul carcinomului verucos penian ræmâne de primæ intenflie excizia cât mai largæ a zonei afectate cu control oncologic satisfæcætor atât la nivel locoregional cât øi la distanflæ. Chirurgia conservatoare øi plastia penianæ asiguræ un confort micflional øi psihologic important pacienflilor afectafli de aceastæ maladie mutilantæ. Introduction: Verrucous carcinoma is a type of well differentiated scuamos carcinoma, with a reduced growth rate and it represents approximately 5% of penile malignant tumors. Macroscopically, verrucous carcinoma presents itself as an exophytic cauliflower-like tumor with broad-based implantation. In most cases the tumor is sized between 1-3 cm, although giant destructive forms have been described. Method and Results: Patient I.L., aged 31 years, with a history of pulmonary TB, had a penile tumor that appeared about 11 years ago, it slowly progressed; it included the entire penis and part of the scrotum, without any medical evaluation history prior. Local clinical examination revealed a bulky tumor, sessile, cauliflowerlike aspect, in the region of the glans near the urethral meatus and the entire circumferential length of the penis, with extension to the scrotum. No detectable inguinal lymph nodes on palpation. In the first stage of the surgical treatment, he underwent excisional biopsy with partial amputation of the penis and resection of the affected scrotal skin. We decided timing the reconstruction because of the important skin defect, and the possibility of local recurrence, therefore we buried the penile stump in a scrotal pouch and performed a cutaneous urethrostomy. The histopathological result was well differentiated verrucous carcinoma (G1). In the second stage the patient underwent penile reconstruction surgery with split skin graft performed at 3 months after the first intervention. Results: The 9 months follow-up revealed good mictional status, the wound healed normally and he resumed normal sexual activity with satisfactory erection. No local or distant clinical and imagistic recurrences. Conclusions: Wide excision of the affected area remains the first choice of treatment for verrucous carcinoma of the penis with satisfactory loco-regional and distant oncological outcome. Conservative surgery and penile plasty ensures important mictional and psychological comfort to patients affected by this mutilating disease. 34 Revista Românæ de Urologie nr. 2 / 2012 vol 11

36 3.3. Seminomul primar retroperitoneal C. Gîngu 1, A. Dick, S. Pætræøcoiu, C. Surcel, M. Hârza, M.A. Manu, T. Roøu, F. Lupu, O. Himedan, A. fiurcanu, A. Silaghi *, Liliana Domniøor **, Ileana Constantinescu ***, Mihaela Mihai ****, I. Sinescu Centrul de Uronefrologie øi Transplant Renal, * Institutul Oncologic Prof. Dr. Al. Trestioreanu Bucureøti ** Clinica de ATI Primary Retroperitoneal Seminoma C. Gîngu, A. Dick, S. Pætræøcoiu, C. Surcel, M. Hârza, M.A. Manu, T. Roøu, F. Lupu, O. Himedan, A. fiurcanu, A. Silaghi *, Liliana Domniøor, Ileana Constantinescu, Mihaela Mihai, I. Sinescu Center of Uronephrology and Renal Transplantation, * Prof. Dr. Al. Trestioreanu Oncological Institute, Bucharest ** ICU Department *** Pathology Laboratory, Oncologie *** Laboratorul de Biologie Molecularæ øi Imunologie **** Laboratorul de Anatomie Patologicæ, Institutul Clinic Fundeni, Bucureøti **** Molecular Biology and Immunology Laboratory, Fundeni Clinical Institute, Bucharest Introducere øi obiective. Seminomul primar retroperitoneal reprezintæ o formæ raræ de tumori retroperitoneale, în literatura de specialitate fiind raportate numai câteva zeci de cazuri. Originea embriologicæ este reprezentatæ de celule din creasta urogenitalæ restante la nivel lombar din timpul migrærii în perioada fetalæ. Sunt de asemenea descrise tumori germinale extragonadale la nivel mediastinal sau epifizar. Scopul acestei lucræri este prezentarea diagnosticului øi tratamentului unui caz de seminom retroperitoneal primitiv. Materiale øi metodæ. Pacient de 43 ani, færæ antecedente personale patologice semnificative, se prezintæ pentru anemie de cauzæ neprecizatæ. Examenul clinic evidenfliazæ la palpare abdominalæ profundæ o formafliune tumoralæ în flancul stâng, cu testicule în limite normale. La examen CT toraco-abdomio-pelvin se evidenfliazæ o formafliune tumoralæ masivæ, cu contur neregulat, la nivelul retroperitoneului lomboaortic øi iliac comun stâng. Analizele uzuale de sânge au gæsit hemoglobina, hematocritul øi numærul total de eritrocite scæzute. Cu diagnosticul de tumoræ retroperitonealæ se decide øi se practicæ ablaflia extensivæ a tumorii cu disecflia aortei øi a arterei iliace comune de la nivelul pediculului renal pânæ la bifurcaflia iliacei, printr-un abord anterior transperitoneal, prin incizie pararectalæ stângæ branøatæ subcostal. Examenul anatomopatologic este sugestiv pentru seminom matur. În Introduction and objectives. Retroperitoneal seminoma is a very rare form of cancer, in literature being reported only a few dozen cases. The embryologic origin is represented by some primordial germ cells from the urogenital ridges that are left behind during the fetal development. Extra genital germ cell tumors can also occur in the mediastinum or the pineal gland. The aim of this paper is to present the diagnosis and treatment of a patient with primary retroperitoneal seminoma. Materials and method. A 43-year-old patient, without any additional pathology, is admitted for anemia of unknown etiology. The clinical examination reveals through deep abdominal palpation a mass in the left flank, and normal testies. Thoraco-abdomino-pelvic CT scan shows a massive irregular tumor in the left lombo-aortic and common iliac retro peritoneum. The blood work finds low hemoglobin and hematocrit, and a low erythrocyte count. Having diagnosed this retroperitoneal tumor, it is decided to remove it. During the surgery we were required to dissect the tumor from the aorta and the common iliac artery, starting at the renal pedicle and ending at the iliac bifurcation. A left pararectal and sub costal incision was used, and the tumor was revealed through anterior transperitoneal approach. The histological examination was suggestive for mature seminoma. In light of the histological findings, postoperatory the patient was nr. 2 / 2012 vol 11 Revista Românæ de Urologie 35

37 Oncologie contextul dat postoperator se recolteazæ marker tumorali (LDH, âhcg, áfp), care se dovedesc a fi în limite normale. Reevaluarea testiculului stâng, clinic, ecografic øi RMN, nu a evidenfliat nicio modificare patologicæ. Ulterior, pacientul a urmat patru cure de chimioterapie (EP Etopsid øi Cisplatin). Rezultate. Reevaluarea RMN la 6 luni nu a arætat semne de recidivæ localæ sau determinæri la distanflæ. Pacientul urmeazæ sæ fie urmærit periodic la 6 luni, clinic, imagistic øi bioumoral. Concluzii. Seminomul primar retroperitoneal este o entitate tumoralæ raræ dezvoltatæ din celule restante la nivelul crestei urogenitale în contextul în care testiculul ipsilateral este normal. Excizia chirurgicalæ largæ øi tratamentul chimioterapic adjuvant pot duce la vindecarea acestor pacienfli în cazul în care diagnosticul nu se face în forma metastaticæ generalizatæ. tested for tumor markers ((LDH, âhcg, áfp), all values being within normal ranges. Also the left testicle was thoroughly reexamined, clinically, with echography and MRI scan, and no abnormalities were observed. Afterwards, the patient followed four courses of chemotherapy (EP - etoposide and cisplatin). Results. The MRI scan done 6 months after surgery found no signs of local or distal tumoral recurrence. The patient will be evaluated every 6 months, clinically, serologically and through imaging techniques. Conclusions. The primary retroperitoneal seminoma is a rare tumor that develops out of the urogenital ridge, while the testies are normal. Through radical excisional surgery and chemotherapy the patients that are diagnosed prior to metastatic dissemination can be cured. 36 Revista Românæ de Urologie nr. 2 / 2012 vol 11

38 3.4. Stadiul de diagnosticare al tumorilor renale - studiu retrospectiv pe 22 de ani G. Glück, T. Priporeanu, I. Sinescu Centrul de Uronefrologie øi Transplant Renal, Institutul Clinic Fundeni, Bucureøti Diagnostic stage of renal tumors - a 22 years retrospective study G. Glück, T. Priporeanu, I. Sinescu Center of Uronephrology and Renal Transplantation, Fundeni Clinical Institute, Bucharest Oncologie Introducere: Scopul lucrærii de faflæ este evaluarea stadiului de diagnosticare al tumorilor renale în momentul prezentærii pacientului la medic. Pacienfli øi metodæ: Am ales drept instrument de lucru un studiu retrospectiv, pe 22 de ani, cuprinzând o cohortæ de 214 pacienfli diagnosticafli øi tratafli în Centrul de Chirurgie Urologicæ øi Transplant Renal Fundeni. Rezultate: Din lotul total de 214 pacienfli 13,08% (28 de pacienfli) au fost diagnosticafli preoperator cu tumoræ renalæ în stadiul T1-28,03% (60 de pacienfli) în stadiul T2-41,61% (89 de pacienfli) în stadiul T3 øi 17,28% (37 de pacienfli) în stadiul T4. Se evidenfliazæ tendinfla ca pacienflii sæ se prezinte la medic în stadii deja avansate, T2, T3, necesitând intervenflii chirurgicale radicale. Vârsta medie de diagnosticare a fost de 54,47 de ani, cu extreme de vârstæ de 27, respectiv 80 de ani. Doar 13,3 % dintre pacienflii luafli în studiu s-au prezentat în stadiul T1, observându-se tendinfla de prezentare a pacienflilor la medic în stadii deja avansate ale tumorii, necesitând intervenflii chirurgicale radicale. Discuflie: Supraviefluirea specificæ bolii la 5 ani (Heng) la pacienflii diagnosticafli cu carcinom renal în stadiul T1 este de 95%, aceasta scæzând la 88% pentru cei aflafli în stadiul T2. Pacienflii diagnosticafli în stadiul T3 au avut o ratæ de supraviefluire la 5 ani de 59%, aceasta scæzând pânæ la 20% în cazul celor diagnosticafli în stadiul T4. Absenfla triadei clasice, hematurie macroscopicæ, durere în flanc øi formafliune tumoralæ palpabilæ duce la o adresabilitate scæzutæ în stadiile incipiente, sporind astfel valoarea examenului medical periodic, ce poate descoperi o astfel de formafliune înaintea aparifliei simptomatologiei. Concluzii: Pacienflii cu tumori renale se adreseazæ serviciilor medicale în stadii avansate ale bolii (T2 - T3), fenomen favorizat de lipsa unei simptomatologii pronunflate în evoluflia incipientæ a bolii øi de lipsa unui calendar sistematizat al examenelor medicale. Introduction: The goal of the present study is to evaluate de diagnostic stage of renal tumors at the time of the patient s medical consult. Patients and method: We have chosen to use a retrospective study, over a period of 22 years, with a study cohort of 214 patients, all treated by the same surgeon at the Fundeni Center for Urological Surgery and Renal Transplantation. Results. Of the total of 214 patients, 13.08% (28 patients) were diagnosed with T1 renal tumor at the time of their presentation, 28.03% (60 patients) were in T2, 41.61% (89 patients) were already in T3 and 17.28% (37 patients) sought medical help when they had a T4 renal tumor. The medium age for this diagnostic was years, with the youngest patient diagnosed at the age of 27, whilst the oldest was 80 years old. A tendency for patients to visit the doctor in already advanced stages of renal tumors can be observed, requiring radical surgical interventions. Only 13.08% of the patients introduced in this study were diagnosed with a T1 renal tumor. Discussion. The 5-year disease-specific survival rate(heng) in patients with T1 renal carcinoma is 95% and in those with stage T2 disease, 88%. Patients with T3 renal carcinoma have a 5-year survival rate of 59%, and those with T4 disease had a 5-year disease-specific survival rate of 20%. The absence of the classic triad - gross hematuria, flank pain and a palpable tumoral mass - leads to a low addressability in early stages, thus increasing the value of the periodic medical consult, which can reveal such a pathology before its symptomatic stages. Conclusions: Patients with renal tumors are diagnosed in advanced stages of the disease (T2-T3), a situation favored by the poor symptomatology in the early stages and by the lack of a systematized calendar for medical examinations. nr. 2 / 2012 vol 11 Revista Românæ de Urologie 37

39 Oncologie 3.5. Impactul limfodisecfliei locoregionale de stadiere în tumorile renale parenchimatoase asupra evolufliei pacienflilor intra- øi postoperator precoce A. Brad 1, C. Chibelean 1, B. Uzun 1, A. Chiujdea 1, O. Mælæu 1, D. Porav 1, L. Lakatos 1, Corina Golovei 2, Angela Borda 3, Orsolya Martha 1 1 Clinica Urologie, Spitalul Clinic Judeflean Mureø 2 Compartiment ATI-Urologie, Spitalul Clinic Judeflean Mureø 3 Laborator Anatomie patologicæ, Spitalul Clinic Impact of locoregional lymph node dissection for staging on intra- and early postoperative evolution in RCC A. Brad 1, C. Chibelean 1, B. Uzun 1, A. Chiujdea 1, O. Mælæu 1, D. Porav 1, L. Lakatos 1, Corina Golovei 2, Angela Borda 3, Orsolya Martha 1 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 Judeflean de Urgenflæ Tg. Mureø Introducere: În stadializarea øi tratamentul curativ radical al mai multor cancere urologice rolul limfodisecfliei este indubitabil, în timp ce, în cancerele renale ct1-4n0m0, acesta este cert în stadializare øi discutabil în ceea ce priveøte tratamentul curativ. Obiectivul studiului a fost analiza evolufliei intra- øi postoperatorii precoce la pacienflii cu tumori renale parenchimatoase nefrectomizafli în serviciul nostru în funcflie de efectuarea limfodisecfliei loco-regionale de stadializare. Material øi metodæ: Studiul a fost efectuat prospectiv în perioada pe un numær de 58 de pacienfli cu tumori renale parenchimatoase nefrectomizafli în serviciul nostru (26 cu limfodisecflie lot A øi 32 færæ limfodisecflie lot B). La lotul cu limfodisecflie (care a respectat limitele hærflii anatomice) abordul a fost exclusiv transperitoneal prin incizie Kocher subcostalæ øi s-a asociat suprarenalectomia la 18 pacienfli în timp ce la celælalt lot studiat abordul a fost transperitoneal la 24 de cazuri øi lombar la 8 cazuri, cu suprarenalectomie la 9 pacienfli. Am urmærit: durata medie operatorie, hemoragia intra/postoperatorie, apariflia limfocelului sau hematomului lombar postoperator, drenajul, durata medie de spitalizare postintervenflie la cele douæ loturi. Rezultate: Durata medie operatorie a fost mai mare cu 17,92 de minute la lotul A (155,00±24,482) comparativ cu lotul B (115,00±40,946), valoare nesemnificativæ statistic (p=0,1778). Introduction: The role of lymph node dissection in staging and radical curative treatment of a several urological cancer is unquestionable, while, in RCC (ct1-4n0m0) it is certain in staging but still arguable as regards of the curative treatment. The aim of this study was to analyze the intraoperative and early postoperative evolution in patients with RCC who underwent nephrectomy in our department, with/without locoregional lymph node dissection for staging. Materials and methods: The study was performed prospectively between 1st of September 2011 and 1st of March 2012 on 58 patients with RCC who underwent nephrectomy in our department (26 with lymph node dissection study group A and 32 without lymph node dissection study group B). For the study group with lymph node dissection (respecting the limits of the anatomical map) the approach was exclusively transperitoneal by subcostal Kocher incision, with suprarenalectomy performed on 18 patients, while for the other studied group, the approach was transperitoneal in 24 cases and by lombotomy in 8 cases, the suprarenalectomy being performed on 9 patients. We followed up: operative time, intra / postoperative bleeding, drainage time, occurrence of postoperative lymphocele or haematoma, length of postoperative hospital stay in the two groups. 38 Revista Românæ de Urologie nr. 2 / 2012 vol 11

40 Oncologie Intraoperator si postoperator nici unul din pacienfli nu a prezentat hemoragie care sæ impunæ transfuzia. In preziua externærii nu a fost evidenfliatæ prezenfla hematomului sau limfocelului la nici un pacient (ecografic). Drenajul prelungit nu a fost prezent la nici unul din cazuri (suprimare tub de dren la lotul A ziua 4,5 faflæ de 4.6 la lotul B; p=0,9951). Durata medie de spitalizare postintervenflie a fost mai scæzutæ la lotul A (5.8 zile), comparativ cu lotul B (6,4 zile) (p=0,4737). Concluzii: Efectuarea limfodisecfliei de stadiere la tumorile renale parenchimatoase prelungeøte minim durata intervenfliei chirurgicale, aceasta nefiind grevatæ de un procent mai mare de complicaflii sau de spitalizare prelungitæ faflæ de nefrectomia færæ limfodisecflie, confirmând siguranfla procedurii în procesul de stadializare corectæ a carcinoamelor renale. Results: The average operative duration was minutes longer in study group A (median operative time: ±24.482) than in study group B (115.00±40.946), which is no statistically significant value (p=0,1778). None of the evaluated patients required blood transfusion either intra- or postoperative due to bleeding. On the eve of discharge, there was no evidence of hematoma or lymphocele (ultrasonography). The drainage time was comparable in both groups (drainage tube removed on day 4.5 for study group A against 4.6 for study group B p = ). The average postoperative hospital stay was lower in the study group A (5.8 days), as compared to study group B (6.4 days) (p=0.4737). Conclusions: The staging lymph node dissection in RCC, minimally extends the time of the surgical intervention but the procedure is not overburdened by a higher ratio of complications or by extended hospital stay as compared to the nephrectomy without lymph node dissection, confirming the safety of the procedure for an accurate staging process of the RCC. nr. 2 / 2012 vol 11 Revista Românæ de Urologie 39

41 Oncologie 3.6. Model de implementare a chirurgiei robotice în practica urologicæ. Experienfla Centrului de Chirurgie Roboticæ Urologicæ Cluj-Napoca Nicolae Criøan 1, Iulia Pop 1, Andrei Boc 1, Horia Logigan 1, Ræzvan Mænescu 1, Deliu Victor Matei 2, Ottavio de Cobelli 2, Ioan Coman 1 1 Centrul de Chirurgie Roboticæ, Spitalul Clinic Municipal Cluj-Napoca 2 European Institute of Oncology A model of robotic surgery implementing in the urological field. An inside view from the Robotic Urologic Surgery Center of Cluj-Napoca Nicolae Criøan 1, Iulia Pop 1, Andrei Boc 1, Horia Logigan 1, Ræzvan Mænescu 1, Deliu Victor Matei 2, Ottavio de Cobelli 2, Ioan Coman 1 1 Robotic Surgery Center, Clinical Municipal Hospital, Cluj-Napoca 2 European Institute of Oncology Introducere. Chirurgia roboticæ a devenit standard pentru unele intervenflii chirurgicale din practica urologicæ. Obiectivul lucrærii este de a prezenta modelul de implementare a unui centru de chirurgie roboticæ în domeniul urologiei. Materiale øi metodæ. Implementarea chirurgiei robotice în practica urologicæ presupune parcurgerea a cinci etape: echipæ dedicatæ øi preocupatæ pentru minim invazivitate, conexiunea cu un centru important de chirurgie roboticæ pentru trainingul echipei, iniflierea primelor intervenflii robotice sub asistenfla centrului de formare, parcurgerea rapidæ a curbei de învæflare prin efectuare de intervenflii asistate de un preceptorship, lærgirea indicafliilor robotice cu efectuarea majoritæflii procedurilor urologice. Rezultate. În perioada noiembrie 2009 øi martie 2012 au fost efectuate 152 de intervenflii urologice robotice, fiind abordate toate tipurile de intervenflii chirurgicale din patologica urologicæ. Au fost realizate intervenflii de exerezæ: prostatectomia radicalæ (72 de cazuri), nefrectomia radicalæ øi parflialæ (24 de cazuri), suprarenalectomii (21 cazuri), dar øi intervenflii de reconstrucflie: pieloplastii (21 de cazuri), cistectomii radicale cu neovezicæ extra øi intracorporealæ (8 cazuri), cura fistulei vezico-vaginale (2 cazuri), ureter retrocav (1 caz), nefropexie (3 cazuri). Concluzii. Chirurgia roboticæ este o metodæ abord rapid asimilatæ în centrele cu experienflæ în lapasocopica standard permiflând implementarea facilæ a majoritæflii tehnicilor chirurgicale urologice øi presupune echipæ dedicatæ, preocupare pentru chirurgia minim invazivæ, disponibilitatea pentru depæøirea curbei de învæflare øi resurse financiare importante. Introduction. Robotic surgery can be considered a standard for some urological surgeries. The main objective of this paper is to evaluate the efficiency and specifics of implementing robotic surgery in a center with expertise in standard laparoscopy. Material and method. Implementing robotic assisted surgery in the urological field supposes crossing five main steps: gathering a team focused on minimal invasive surgery, establishing a collaboration with a center of excellence in robotics for trainings, performing the first robotic surgeries under the close guidance of the training team, shortening the learning curve by perfoming surgeries assisted by a preceptorship and expanding robotic indications through most urological procedures accomplished. Results. After implementing robotic surgery that followed standard laparoscopic urologic surgery, in a short period of time, from November 2009 until March 2012, our team performed 152 robotic urologic surgeries, approaching all surgeries in the urologic pathology. There have been performed excision surgeries like: radical prostatectomy (72 cases), radical and partial nephrectomy (24 cases), suprarenalectomy (21 cases) but also reconstruction surgeries like: pyeloplasty (21 cases), radical cystectomy with extra and intracorporeal neobladder (8 cases), vesico-vaginal fistula treatment (2 cases), retrocaval ureter (1 case) and nephropexy (3 cases). Conclusions. Robotic surgery represents an approach method that can be quickly taught to experienced laparoscopic centers and allows performing most urological surgical techinques, but also implies a dedicated team, concern for minimal invasive surgery, willingness to overcome learning difficulties and nevertheless significant financial resources. 40 Revista Românæ de Urologie nr. 2 / 2012 vol 11

42 3.7. Markeri de prognostic în tumorile retroperitoneale primitive O. Bratu, C.P. Ilie, V. Mædan, D. Spânu, R. Popescu, A. Rædulescu, D. Mischianu Clinica de Urologie, Spitalul Universitar de Urgenflæ Militar Central Dr. Carol Davila, Bucureøti Prognosis markers in primitive retroperitoneal tumors O. Bratu, C.P. Ilie, V. Mædan, D. Spânu, R. Popescu, A. Rædulescu, D. Mischianu Urology Department, University Emergency Central Military Hospital Carol Davila, Bucharest Oncologie Introducere. Datoritæ diversitæflii clinice øi anatomopatologice, a evolufliei lor de cele mai multe ori nefaste øi a diagnosticului tradiv, tumorile retroperitoneale primitive reprezintæ un tip tumoral complex pe care l-am analizat în cadrul unui proiect de cercetare prin prisma unor markeri pe care i-am denumit de prognostic. Material øi metodæ. Lotul de studiu a fost reprezentat de 32 de pacienfli cu tumori retroperitoneale primitive, de diverse tipuri histologice, diagnosticate histopatologic øi la care s-a exclus orice apartenenflæ de organ retroperitoneal sau de tumoræ secundaræ. Am recoltat material tumoral prin puncflie biopsie, laparotomie exploratorie sau exerezæ chirurgicalæ. Probele obflinute au fost analizate din punct de vedere imunologic øi genetic. S-a urmærit dinamica diverselor populaflii limfocitare în cadrul procesului imun tumoral, precum øi a anumitor oncogene sau alteraflii cromozomiale. Rezultate. În ceea ce priveøte ræspunsul imun s-a observat o scædere a amplitudinii acestuia, deøi diverse populaflii limfocitare au variat în sens pozitiv. Oncogenele analizate au avut comportamentul descris øi în literatura de specialitate, fiind factori independenfli de tipul tumoral øi corelându-se bine cu gradul de agresivitate øi capacitatea de metastazare. Concluzii. Privit în ansamblu, prognosticul acestor tumori nu este din cel mai bun, indiferent de metoda terapeuticæ aleasæ. Necesitatea unui diagnostic cât mai precoce este imperios necesaræ, deoarece intervenflia chirurgicalæ este singura în mæsura sa prelungeascæ viafla pacienflilor. Detecflia oncogenelor în materialul bioptic recoltat poate conduce cætre o chirurgie mai agresivæ sau poate ghida un tratament adjuvant mai precoce. Acest ultim deziderat se aplicæ în majoritatea tumorilor umane, indiferent de tipul tumoral. Odatæ cu descoperirea unor noi mecanisme ce intervin în oncogeneza øi a diverøilor factori ce intervin în aceasta vor apærea noi strategii de tratament, capabile sæ stopeze progresia tumoralæ øi, de ce nu, sæ determine involuflia acesteia. Introduction. Because of their late diagnosis, unfavourable evolution, anatomo-pathological and clinical diversity primitive retroperitoneal tumors represent a complex neoplasia which we analyzed by means of prognosis markers. Material and Methods. 32 patients with anatomopathological diagnosis of different histological types of primitive retroperitoneal tumors were included in the study. Any retroperitoneal neoplasia related to a secondary lesion or to any retroperitoneal organ was excluded from the group. The histo-pathological material was obtained through biopsy, exploratory laparotomy or surgical exeresis and was immunologically and genetically evaluated. Some particular oncogenes, chromosome alterations and lymphocytes dynamics in the immune tumoral process were followed. Results. Overall immune response decreased although some particular lymphocytes types responded. The oncogenes which were analyzed responded accordingly to our present knowledge, being independent of the tumor type. It was found a correspondence between oncogenes and tumor aggressiveness and metastasis. Conclusions. The prognosis for this type of neoplasms is not favourable. An early diagnosis is mandatory because surgery still remains the only method of prolonging the life expectancy for these patients. Early detection of specific oncogenes can lead to a more effective surgery or can better guide the adjuvant therapy. This is actually a wider aim applicable in all human neoplasia. With the discovery of new oncogenic mechanisms, new therapies will be developed, capable of stopping or why not, cure the neoplasm. nr. 2 / 2012 vol 11 Revista Românæ de Urologie 41

43 Oncologie de ani de experienflæ în managementul tumorilor retroperitoneale M.A. Manu, C. Gîngu, C. Surcel, I. Prie, A. Davidescu, Rucsandra Manu, Mihaela Mihai *, Monica Hortopan *, I. Sinescu Centrul de Uronefrologie øi Transplant Renal * Laboratorul de Anatomie Patologicæ, Institutul Clinic Fundeni, Bucureøti Managing the retroperitoneal tumors 23 years single center experience M.A. Manu, C. Gîngu, C. Surcel, I. Prie, A. Davidescu, Rucsandra Manu, Mihaela Mihai *, Monica Hortopan *, I. Sinescu Center of Uronephrology and Renal Transplantation, * Department of Pathology, Fundeni Clinical Institute, Bucharest Obiective. Atitudinea terapeuticæ în tumorile retroperitoneale reprezintæ o provocare chirurgicalæ. Prezentæm experienfla noastræ în acest domeniu. Material øi metodæ. În studiul nostru au intrat 166 de pacienfli, 108 bærbafli øi 58 femei, diagnosticafli cu tumori retroperitoneale primitive øi secundare pe o perioada de 20 de ani, între ianuarie 1989 øi ianuarie Simptomatologia clinicæ a fost dominatæ de durere, urmatæ de semnele tumorii clinice øi de semnele compresiei structurilor vecine. Examenele imagistice au fost reprezentate de urografie, care a avut ca semn cardinal distensia cæilor urinare, hidronefroza, ureterohidronefroza øi lipsa funcfliei renale. Examenul echografic a fost orientativ. TC øi RMN au reprezentat cheia de boltæ a imagisticii, fiind efectuate tuturor cazurilor. Imagistica a fost completatæ cu radiografia pulmonaræ, scintigrafia renalæ øi osoasæ, examenele radiologice ale tractului digestiv øi examenul Doppler. Puncflia echo øi tomoghidatæ a tumorilor nu a reprezentat o rutinæ în serviciul nostru. Rezultate. 160 de pacienfli au suferit intervenflii chirurgicale în centrul nostru. Abordul a fost reprezentat în 96% din cazuri de cel anterior, transperitoneal. S-au practicat tumorectomii simple radicale sau reducflionale, tumorectomie asociatæ cu nefrectomie tacticæ sau de necesitate øi adrenalectomie, rezecflie totalæ asociatæ de vena cavæ inferioaræ, pancreatectomie caudalæ, rezecflie de colon øi duoden ascendent, evacuarea, excizia øi drenajul unor hematoame vechi retroperitoneale, chistectomie retroperitonealæ, øi laparotomie exploratorie cu biopsie chirurgicalæ sau cu trocar. Histologia tumorilor retroperitoneale a fost dominatæ de diferite variante de sarcoame de cazuri. Alfli pacienfli au prezentat neuroblastoame (simpatoblastoame Objective: The aim of this study was to present our experience in managing retroperitoneal tumors knowing that these special tumors represent a big challenge for many surgeons. Material and methods: Beetwen January 1989 and January 2012 in our department were accepted 166 patients with retroperitoneal tumors, others than kidney or adrenal gland. 108 males and 58 female were diagnosticated with primary or secondary retroperitoneal tumors. Clinical findings were represented by lumbar pain, tumor, digestive symptoms, fever, reno-vascular hypertension, and signs of compression (vena cava, vena porta). Imagistic evaluation was represented by abdominal ultrasound, IVP with major signs of urinary tract obstruction. CT and MRI represented the gold standard examinations. Imagistic protocol was completed with pulmonary radiography, renal and bone scintigraphy, Doppler ultrasound for vessels and digestive endoscopy. CT or ultrasound guided biopsy was not a routine in our department. Results: Surgery was performed in 160 cases. The transperitoneal approach was considered in 96% of cases. Different operations were performed according to the extension and the stage of the tumor as follows: tumorectomy combined with nephrectomy and adrenalectomy, simple radical tumorectomy, vena cava resection, haematoma drainage, surgical cure of cyst, tumorectomy and bowel resection, duodenum resection, tumorectomy and caudal pancreatectomy, laparotomy and biopsy. The pathological study of retroperitoneal tumors was dominated by different sarcomatous types in 108 cases. Other patients presented various types of histological findings: neuroblastoma, benign soft tissue tumors, benign 42 Revista Românæ de Urologie nr. 2 / 2012 vol 11

44 Oncologie retroperitoneale), tumori conjunctive benigne, chiste benigne retroperitoneale, hematoame vechi pseudotumorale, limfoame maligne non-hodgkiniene, cât øi cazuri de tumori secundare retroperitoneale, metastatice. Concluzii. Tumorile retroperitoneale sunt grave datoritæ simptomatologiei nespecifice, a situafliei anatomice profunde øi a latenflei diagnostice. Simptomatologia este dominatæ de durere, de prezenfla tumorii clinice, øi de semnele compresiei. Cheia de boltæ a imagisticii o reprezintæ tomografia computerizatæ øi/sau rezonanfla magneticæ nuclearæ. Abordul transperitoneal se impune datoritæ avantajului rezolværii patologiei asociate øi a complicafliilor, cât øi datoritæ controlului eficient al vaselor mari. Tratamentul chirurgical reprezintæ soluflia curativæ, cunoscându-se cæ tumorile retroperitoneale, majoritar sarcomatoase, sunt chimio øi radiorezistente. cysts, old haematoma, lymphoma and some of them secondary, metastatic retroperitoneal tumors. Conclusions: Retroperitoneal tumors were detected frequently in advanced stages, due to non-specific clinical signs and to their deep position. Pain, tumor and compression represented the main clinical findings. CT and MRI were a must for the evaluation of these tumors. Transperitoneal approach was preferred and different conditions such were invasion of neighborhood structures, extension and lymph node dissection were solved using this way. Because retroperitoneal tumors were in many cases sarcomas, which are well-known chimio- and radio-resistent, surgery represented the main curative treatment. nr. 2 / 2012 vol 11 Revista Românæ de Urologie 43

45 Oncologie 3.9. Formæ raræ de cancer testicular - Prezentare de caz C. Todea, A. Chiujdea, D. Porav-Hodade, C. Chibelean, Angela Borda, Corina Golovei, Orsolya Martha Clinica de Urologie Târgu-Mures Rare form of testicular cancer Case report C. Todea, A. Chiujdea, D. Porav-Hodade, C. Chibelean, Angela Borda, Corina Golovei, Orsolya Martha Clinic of Urology Târgu-Mures Introducere øi obiective. Din punct de vedere histopatologic existæ o largæ varietate de forme ale cancerului testicular. In cazul de fafla vom prezenta un caz rar de tumoræ testicularæ. Material øi metoda. Pacientul RP, în varstæ de 28 de ani se prezintæ pentru o formafliune tumoralæ apærutæ în hemiscrotul drept. În urmæ cu 4 ani pacientul a suferit un politraumatism în urma unui accident rutier cu interesare penianæ øi scrotalæ. Ecografic se pune în evidenflæ un testicul stâng scleroatrofic de 2,5 cm în diametru. La nivelul testiculului drept se evidenfliazæ o formafliune tumoralæ cu diametrul de aproximativ 5 cm, neomogena cu vascularizaflie prezentæ la ecografia Doppler. Examenul computer tomografic nu pune în evidenflæ adenopatii sau metastaze la distanflæ. Valorile de laborator AFP=587 ng/ml, HCG=1020 mlu/ml, LDH=289 UI. Rezultate. Se practicæ orhiectomie inghinalæ dreaptæ. Examenul histopatologic pune în evidenflæ un teratom testicular pur la nivelul tumorii testiculare cu aspecte de neoplazie intratubularæ cu celule germinale neclasificate (ICGNU) în tubii seminiferi din parenchimul restant. Din punct de vedere oncologic conform deciziei comisiei de oncologie nu se indicæ tratament adjuvant chimio-radioterapic. Urmarirea postoperatorie se va efectua conform protocolului oncologic: consult clinic øi markeri tumorali de 4 ori/an, radiografie pulmonaræ øi tomografie abdominalæ de 2 ori/an în primii 2 ani apoi 1 control/an. Concluzii. Prezenfla neoplaziei intratubulare cu celule germinale neclasificate este extrem de raræ, ea fiind consideratæ o leziune precursoare a tumorilor testiculare mixte. Decelarea acesteia a fost posibilæ datoritæ prezenflei concomitente a unui teratom testicular pur. Introduction and objectives. There is a wide histopathological variety of testicular cancer types. In this case we present a rare case of right testicular tumor. Material and method. The patient R.P., 28 years old, presenting for a tumor appeared on the right side of the scrotum. About 4 years ago patient suffered a multiple trauma after a car accident involving also the penis and scrotum. Ultrasound revealed a scleroatrophic left testicle, 2.5 cm in diameter. At the right testis ultrasound shows a tumor, 5 cm diameter of inhomogeneous and with increased vascularisation at Doppler ultrasound investigation. Were not highlighted lymph nodes or distant metastasis at whole body computer tomography examination. Laboratory values: AFP=587 ng/ml, HCG=1020 mlu/ml, LDH=289 UI. Results. Right inguinal orchiectomy was performed. Histopathological exam shows a pure testicular teratoma at the level of the tumor but, in the same time, intratubular germ cell neoplasia, unclasified (ICGNU) aspect in seminiferous tubules of the remaining parenchyma. According to the oncological comission there was no indication for adjuvant chemo-radio therapy. Postoperative follow-up schedule: clinical checkup and markers 4 times / year, chest x-ray and abdominal CT 2 times / year for the first 2 years then 1 general checkup/year. Conclusions. This intratubular germ cell neoplasia, unclasified is extremely rare, it is considered a precursor lesion of mixed testicular tumors. Its detection was possible due to the presence of a concomitant testicular pure teratoma. 44 Revista Românæ de Urologie nr. 2 / 2012 vol 11

46 3.10. Rezultatele nefrectomiei laparoscopice pe cale transperitonealæ I. Chira, V. Ambert, V. Jinga, S. Gutue, T. Radu, I. Dragomiriøteanu, D. Diaconescu, Y. Salaheddin Clinica de Urologie Spitalul Prof. Dr. Th. Burghele, Bucureøti Results following laparoscopic transperitoneal nephrectomy I. Chira, V. Ambert, V. Jinga, S. Gutue, T. Radu, I. Dragomiriøteanu, D. Diaconescu, Y. Salaheddin Clinca de Urologie Spitalul Prof. Dr. Th. Burghele Bucuresti Romania Oncologie Introducere øi Obiective. Nefrectomia laparoscopica reprezinta standardul in abordul chirurgical al rinichiului. Rezultatele obtinute pe un lot de 82 de pacienti nefrectomizati laparoscopic transperitoneal sunt obiectul acestei analize. Material øi Metoda. Interventiile au fost efectuate intr-o perioada de 22 de luni. Au inregistrate si analizate urmatoarele date: indicatia operatorie, tehnica operatorie, durata ineterventiei, complicatiile intraoperatorii si postoperatorii, conversiile si cauzele acestora, tipurile de interventii, durata stationarii in sectia ATI, durata spitalizarii post operatorii. Rezutate. Neoplasmele renale sau de cale au fost principala indicatie de tratatment (42 de cazuri). Tehnica utilizata a fost cea clasica decrisa de Clayman, Laguna. Accesul cu acul Veres sau cel Hasson au fos utilizate aproape la paritate. Durata medie a interventiei a fost de 4h si 10min pentru primele 50 de cazuri scazind cu o ora pentru urmatoarele. Intilnita in 9 cazuri, singerarea a fost principala complicatie intraoperatorie. Pierderea intraoperatorie de singe a fost de 50 cc in 63 de cazuri (77%) pierderi mai mari de 200 cc fiind intilnite in 9 cazuri. Conversia a fost necesara in 12 cazuri (14%). Principala cauza de conversie a fost singerarea intilnita in 6cazuri, urmata de infiltrarea neoplazica sau inflamatorie a pediculului (in 4 cazuri). Adrenalectomia a fost asociata nefrectomiei in 4 cazuri ce prezentau implicarea imagistica acesteia. In patru dintre tumorile de cale (in care leziunile erau limitate la bazinet), ureterectomia a fost realizata pe cale laparoscopica. In rest nefrectomia a fost realizata inafara capsulei Gerota, limfadenectomia fiind utilizata in cinci cazuri. Post operatoriu mentionam doua cazuri de insuficienta renala acuta, unul necesitind dializa. In 77 de cazuri stationarea in sectia ATI a fost sub 24 de ore. In cazurile necomplicate 67pacienti - 82%) spitalizarea post operartorie a fost de 5 zile. Concluzii. Consideram aceste rezultate drept multumitoare. Atunci cind sunt judecate, trebuie avut in vedere ca reprezinta rezultatul munci a sapte chirurgi, deci sapte curbe de invatare, cu toate implicatiile care decurg de aici. Introduction and Objectives. Laparoscopic nephrectomy is the standard for renal surgery.analyzeing data of 82 laparoscopic transperitoneal nephrectomies was our study s objective. Material and Method. Study period was 22 month. All recorded data were analysed according to next 3 criteria: 1) Surgical procedure: indication, technique, type, duration, complications intra and postoperative, 2) Conversions : causes; 3) Postoperative hospital stay : in intensive care unit, in ward. Results. 1) Renal cel carcinoma and TCC of upper tract were the main surgical indications(42 cases). Classical transperitoneal technique as described by Clayman and Laguna was used. Veres and Hasson entry techniques were equaly used. Mean surgery time was 4h and 10min for first 50 cases and decreased to 3 h for the followings. Recorded in 9cases, bleeding was the main intraoperative complication. Blood loss was no more than 50cc in 63 cases (77%). In 9 cases recorded bleeding was over 200 cc. Adrenalectomy was associated to nephrectomy in 4 case in which involvment of the gland was proved.totaly laparoscopic nephroureterectomy was performed in 4 cases (TCC limited to renal pelvis). In all the others nephrectomy was performed outside the Gerota fascia. Limfadenectomy was associated in 5 patients. Regardind postoperative complications we underline two cases of acute renal failure.in one dialisys was needed. 2) Conversion to open surgery was necesary in 12 patients (14%). Main conversion cause was bleeding encountered in 6cases followed by pedicle not sutable for disection due to infiltration (4 cases). 3) In 77cases (93%) patient stay in intensive care unit was less than 24 hours. Uncomplicated cases, represented 82 % of the whole. For these post operative stay was 5 days. Conclusions. We consider results as being fair. When jugeing them take in account that they include 7 different learning courves from 7 diferent surgeons. nr. 2 / 2012 vol 11 Revista Românæ de Urologie 45

47 Oncologie Tumoræ neuroectodermalæ renalæ la adult: prezentare de caz Gabriela Berdan 1, Amelia Petrescu 1, D. Rædævoi 1, I. Dragomiriøteanu 1, Mihaela Mihai 2, Daniela Moiøanu 1, V. Jinga 1 1 Spitalul Prof. Dr. Th. Burghele, Bucureøti 2 Institutul Victor Babeø, Bucureøti Primitive neuroectodermal tumor of the kidney in an adult: a case report Gabriela Berdan 1, Amelia Petrescu 1, D. Rædævoi 1, I. Dragomiriøteanu 1, Mihaela Mihai 2, Daniela Moiøanu 1, V. Jinga 1 1 Prof. Dr. Th. Burghele Clinical Hospital, Bucharest 2 Victor Babes Institute of Pathology, Bucharest Introducere: Tumorile neuroectodermale primitive (PNETs) sunt reprezentate de un grup de tumori cu malignitate crescuta, alcatuite din celule mici, rotunde, de origine neuroectodermala. Prezentam un caz de PNET renal la un barbat in varsta de 52 de ani care s-a prezentat pentru hematurie intermitenta si dureri in flancul drept cu debut in urma cu aproximativ 6 luni. Examenul CT si ecografia au evidentiat o masa solida de aproximativ 8 cm la nivelul polului inferior renal drept ce depasea capsula renala. S-a practicat nefrectomie radical dreapta. Examenul macroscopic al piesei operatorii a evidentiat prezenta unei mase tumorale multinodulare de culoare gri, 8.7/7/6 cm, tumora prezentand zone de necroza si hemoragie. Material øi metoda: Sectiuni histopatologice seriate din blocurile de parafina corespondente au fost colorate cu hematoxilin-eozina, Van Gieson si s-a realizat analiza imunohistochimica pentru 20 de anticorpi (MNF 116, AE1-AE3, VIM, CD56, NSE, MIC2/CD99, FLI-1, WT1, EMA, CD10, CK7, CK20, CK34βE12, P63, CROMO, SYN, CD57, NFT, TTF1, CLA). Rezultate: Examenul anatomopatologic a evidentiat prezenta unei populatii uniforme de celule nediferentiate, de dimensiune mica-medie, dispuse in pattern de crestere alveolar-insular, cu nuclei rotunzi si ovali, nucleoli foarte mici, numeroase semne de mitoza si apoptoza celulara. S-a evidentiat prezenta zonelor de necroza. Tumora invada grasimea perinefretica iar trei dintre ganglionii limfatici retroperitoneali rezecati prezentau diseminare metastatica. Celule tumorale dispersate au fost pozitive pentru vimentin. Rare cellule tumorale au fost positive pentru MNF116. Expresia CD56 a fost pozitiva intr-un numar mare de cellule tumorale si o zona tumorala a prezentata reactive slab pozitiva pentru NSE. MIC2 a fost slab pozitiv in numeroase celule tumorale. Ceilalti marker tumorali au prezentat reactive negative in tumora. Concluzii: Tumorile neuroectodermale primitive renale sunt foarte rar intalnite. Diagnosticul diferential se pune cu celelalte tipuri de tumori cu celule mici, rotunde. Diagnosticul este dificil de precizat si se poate realiza pe baza examenului anatomopatologic si a celui imunohistochimic Introduction: Primitive neuroectodermal tumors (PNETs) are a group of highly malignant tumors composed of small round cells of neuroectodermal origin. We report a case of renal PNET in a 52-year-old male presented with a 6-month history of rightsided abdominal pain and intermittent hematuria. CT and ultrasonography showed a 8 cm solid mass in the inferior right kidney pole that penetrated kidney capsule. The patient underwent a radical nephrectomy. Macroscopically, the inferior pole of the right kidney was replaced by a multinodular, grey, glistening tumour measuring 8.7/7/6 cm, with foci of necrosis and hemorrhage. Material and methods: Serial histological sections from the corresponding paraffin blocks have been assessed using hematoxylin-eosin and Van Gieson stain and the indirect immunohistochemical analysis for 20 antibodies (MNF 116, AE1- AE3, VIM, CD56, NSE, MIC2/CD99, FLI-1, WT1, EMA, CD10, CK7, CK20, CK34βE12, P63, CROMO, SYN, CD57, NFT, TTF1, CLA). Results: Histological examination revealed a uniform population of undifferentiated, small-to medium-sized tumor cells, arranged in alveolar-insular growth patterns, with round to oval nuclei, very small nucleoli, numerous signs of mitosis and scattered apoptosis. Geographic zones of necrosis were encountered. There was tumor infiltration of the perinephric fat and histological evidence of metastasis in three resected retroperitoneal lymph nodes. Dispersed cells showed cytoplasmic vimentin positivity favouring the diagnosis of PNET. Few tumoral cells appeared positive for MNF116. Expression of CD56 was positive in a large number of tumoral cells and an area of the tumour exhibit a milder reaction which has the appearance of positive NSE. MIC2 was positive with moderate staining in numerous tumoral cells. The rest of tumoral markers were negative in the tumoral tissue. Conclusions: PNETs of the kidney are extremely rare disease entities. Histologically, several other small round cell tumors enter into the differential diagnosis. Diagnosis is based on histology and immunohistochemistry but pathological evaluation can be challenging even with these modalities. 46 Revista Românæ de Urologie nr. 2 / 2012 vol 11

48 3.12. Nefrectomia radicalæ laparoscopicæ la pacienflii obezi: rezultate øi consideraflii tehnice G. Niflæ, C. Copæescu, B. Mihai, C. Persu, P. Geavlete Clinica de Urologie, Spitalul Clinic de Urgenflæ Sf. Ioan, Bucureøti Laparoscopic radical nephrectomy in obese patients: outcomes and technical considerations G. Niflæ, C. Copæescu, B. Mihai, C. Persu, P. Geavlete Department of Urology, Saint John Emergency Clinical Hospital, Bucharest Oncologie Obiective. Obezitatea a fost consideratæ un factor de prognostic nefavorabil pentru diverse intervenflii chirurgicale, reprezentând o contraindicaflie relativæ pentru abordul laparoscopic. Scopul acestei lucræri este reprezentat de analiza experienflei noastre privind nefrectomia radicalæ laparoscopicæ (NRL) la pacienflii obezi. Material øi metodæ. Au fost evaluafli retrospectiv tofli pacienflii (21 cazuri) care au beneficiat de NRL în perioada Pacienflii cu indicele de masæ corporalæ (Quetelet s index) mai mare de 30 au fost definifli ca fiind obezi. Modificærile tehnice au inclus presiuni de insuflare mærite øi poziflii mai laterale pentru locafliile trocarelor. Grupul de pacienfli obezi tratafli laparoscopic a fost comparat cu grupul de pacienfli nonobezi. Rezultate. Din 21 de pacienfli care au beneficiat de NRL, 12 au fost normoponderali iar 9 au fost obezi. Nu au fost observate diferenfle semnificative statistic între cele douæ grupuri în ceea ce priveøte analiza datelor operatorii. Timpul operator mediu care a fost de 220 øi respectiv 242 de minute. Alfli factori analizafli au fost durata de spitalizare øi rata de complicaflii, care nu au evidenflat diferenfle semnificative statistic. Conversia la operaflia deschisæ a fost realizatæ într-un singur caz din cele 21. Concluzii. NRL poate fi efectuatæ în condiflii de siguranflæ cu modificæri tehnice minime.selectarea corectæ a pozifliilor trocarelor øi creøterea presiunii de insuflare au fost esenfliale pentru succesul intervenfliei.obezitatea nu reprezintæ o contraindicaflie a nefrectomiei laparoscopice. Objectives. Obesity has been considered a potential risk factor for poor outcomes in a variety of surgical procedures and has been considered a relative contraindication to laparoscopy. To review our experience with laparoscopic radical nephrectomy (LRN) in the obese patient population. Material and Methods. Retrospective data were obtained for all patients who underwent LRN from 2005 to A body mass index (Quetelet s index) greater than 30 was used to define obese patients. Technical modifications included slightly greater insufflation pressures and a lateral shift in trocar sites. The obese laparoscopic group was compared with the nonobese laparoscopic group. Results. Of 21 patients who underwent LRN, 12 were not obese and 9 were obese. No statistically significant differences were observed in any of the analyzed operative data between the both groups. The mean operative time was 220 and 242 minutes, respectively. Other factors assessed were the length of hospital stay and complication rate, which also demonstrated no statistically significant difference. Only one conversion to an open procedure was required in both the obese and the nonobese laparoscopic groups. Conclusions. With minor technical modifications, LRN can be safely performed in obese patients. Proper trocar site selection and greater insufflation pressures were critical for success. Obesity should not be considered a contraindication to laparoscopic nephrectomy. nr. 2 / 2012 vol 11 Revista Românæ de Urologie 47

49 Oncologie Urmærirea modalitæflilor de tratament în cazul pacienflilor cu cancer penian stadializafli clinic TxN3M0 C. Codoiu, B. Hæinealæ, C. Baston, C. Surcel, C. Dudu, R. Lazær, S. Margaritis, B. Bædescu, I. Sinescu Centrul de Uronefrologie øi Transplant Renal, Insitutul Clinic Fundeni, Bucureøti Treatment modalities outcome for patients with clinically staged TxN3M0 penile cancer C. Codoiu, B. Hæinealæ, C. Baston, C. Surcel, C. Dudu, R. Lazær, S. Margaritis, B. Bædescu, I. Sinescu Center of Uronephrology and Renal Transplantation, Fundeni Clinical Institute, Bucharest Introducere: Lucrarea îøi propune sæ analizeze retrospectiv, din punct de vedere al rezultatelor oncologice obflinute, diferitele modalitæfli de tratament pentru pacienflii cu tumoræ penianæ care, în momentul diagnosticului, prezintæ adenopatii inghinale masive, fixe la planurile superficiale øi/sau profunde, uneori însoflite de supuraflii øi necrozæ tegumentaræ. Pacienfli øi metodæ: Au fost analizate pe o perioadæ de 11 ani (ianuarie 2000 martie 2010) cazurile stadializate clinic TxN3Mo. Din cei 22 de pacienfli, în afara de tratamentului leziunii primare, 10 au beneficiat de limfodisecflie inghinalæ øi/sau pelvinæ ca primæ intenflie terapeuticæ, urmatæ de chimioterapie adjuvantæ, iar 12 au fost supuøi tratamentului chimioterapic sistemic øi, ulterior, în cazul ræspunsului favorabil, tratamentului chirurgical. În toate cazurile, rezultatul histopatologic al leziunii primare a fost de carcinom scuamocelular. Rezultate: Supraviefluirea generalæ la 2 ani a fost de 36,36%. În grupul cu limfodisecflie øi chimioterapie adjuvantæ supraviefluirea a fost de 60%, faflæ de 16,66% în grupul cu chimioterapie sistemicæ iniflialæ. Au existat 3 decese datorate efectelor chimioterapiei. Rata complicafliilor limfodisecfliei a fost scæzutæ, fiind prezentæ la numai 25% dintre pacienfli (necrozæ tegumentaræ, edem scrotal, seroame, edemul extremitæflilor inferioare, infecflii de plagæ, limfocel, tromboflebitæ øi limforee). Nu a fost înregistratæ mortalitate intraoperatorie. Concluzii: Limfodisecflia inghino-femuralæ realizatæ ca primæ intenflie asociatæ cu chimioterapia creøte semnificativ statistic supraviefluirea faflæ de chimioterapia neoadjuvantæ. Tehnicile chirurgicale actuale au redus rata de complicaflii post limfodisecflie inghinalæ. În baza experienflei centrului nostru, recomandæm efectuarea ILND øi a chimioterapiei adjuvante la pacienflii cu tumori peniene cu N3Mo, ce nu prezintæ contraindicaflii pentru tratamentul chirurgical. Introduction: This study aims to retrospectively analyze, in terms of oncological results, various treatment modalities for patients with penile tumor, presenting superficial or deep massive, fixed inguinal adenopathy, sometimes accompanied by suppuration and skin necrosis, at the time of diagnosis. Patients and methods: We have analyzed clinically staged TxN3Mo cases over an 11 year period (January March 2010). In addition to the primary lesion treatment, out of 22 patients, 10 have received inguinal and/or pelvic lymph node dissection as first line therapy followed by adjuvant chemotherapy and 12 were subjected to systemic chemotherapy and subsequently, in case of favorable response, surgery. In all cases, histopathological result of the primary lesion was squamous cell carcinoma. Results: The 2 year overall survival rate was 36.36%. Survival rate in the lymph node dissection and adjuvant chemotherapy group was 60%, compared to 16.66% in the systemic chemotherapy group. There were 3 deaths due to chemotherapy effects. The complication rate for lymph node dissection was low, being present in only 25% of patients (skin necrosis, scrotal edema, serome, lower extremity edema, wound infection, limph drainage, thrombophlebitis and limphoragy). No intraoperative mortality was recorded. Conclusions: Lymph node dissection associated with chemotherapy performed as first line treatment significantly increases survival rate compared to neoadjuvant chemotherapy. Current surgical techniques have reduced the rate of complications after inguinal lymph node dissection. Fallowing our center s experience, we recommend performing ILND and adjuvant chemotherapy in patients with penile tumor staged N3Mo without medical contraindications for surgery. 48 Revista Românæ de Urologie nr. 2 / 2012 vol 11

50 3.14. Carcinom papilar în chist renal stâng rupt cu hematom retoperitoneal G. Glück, Cristina Vlæduflescu *, R. Stoica, Manuela Chiriflæ, I. Sinescu Centrul de Uronefrologie øi Transplant Renal * Clinica de ATI, Institutul Clinic Fundeni, Bucureøti Papillary carcinoma rupture with burts renal cyst with retroperitoneal haematoma G. Glück, Cristina Vlæduflescu *, R. Stoica, Manuela Chiriflæ, I. Sinescu Center of Uronephrology and Renal Transplantation * ICU Department, Fundeni Clinical Institute, Bucharest Oncologie Introducere. Prezentarea unui caz adresat clinicii cu tumoræ renalæ stângæ în chist rupt retroperitoneal. Prezentare de caz. Pacient de 57 de ani, cu fenomene de colicæ renalæ stângæ cu debut de cca 48 de ore se adreseazæ clinicii pentru stare generalæ profund alteratæ, febræ 38,5 grade C, puls 145 /minut, TA 11 cm Hg, leucocite/mmc. Examenul computer tomograf evidenfliazæ o formafliune chisticæ de 8/7 cm la nivelul rinichiului stâng øi o colecflie retroperitonealæ perirenalæ care fuzeazæ în regiunea iliacæ de aceiaøi parte. Se pune problema unui diagnostic deferenflial între un abces renal stâng rupt în retroperitoneu øi o tumoræ renalæ ruptæ. Dupæ o prealabilæ reechilibrare volemicæ, electroliticæ, acidobazicæ, administrare de antibiotice cu spectru larg dupæ recoltare de uroculturæ øi hemoculturi, se intervine chirurgical de urgenflæ, gæsindu-se un chist renal stâng voluminos (diametru de cca 8 cm) situat pe fafla anterioaræ a rinichiului, cu o soluflie de continuitate de cca 5 cm prin care se scurge flesut tumoral necrozat; în jurul rinichiului se gæseøte un hematom voluminos, de la diafragm pânæ în regiunea iliacæ stângæ, cu zone extinse de necrozæ øi fragmente de flesut tumoral. Se practicæ nefrectomie stângæ radicalæ cu limfodisecflie interaorticocavæ, pre, latero øi retroaorticæ cu scopul îndepærtærii masei tisulare necrozate. Examenul bacteriologic al lichidului din retroperitoneu: Pseudomonas aerogenes, sensibil la Meronem, Colistin, Tazocin, Levofloxacin. Pacientul este externat a 9-a zi p.o., vindecat chirurgical. Examen histopatologic (Dr. Hortopan M): Carcinom renal papilar tip 1, grad nuclear Fuhrman 2, pt1pn0mx. Concluzii. Carcinomul renal papilar este o entitate raræ (10-17%) între carcinoamele rinichiului. În forma de prezentare clinicæ descrisæ mai sus este greu de diferenfliat de abcesul renal rupt sau chist renal complicat. Introduction: A case study of a left cystic renal tumor ruptured into the retroperitoneum. Case report: A 57 years old man, with left renal colic symptoms for about 48 h presents to our clinique with acute distress - fever of 38.5 degrees Celsius, heart rate > 145 bpm, a blood pressure reading of 110 mmhg and a WBC of 25000/mmc. The CT-scan reaveled 8/7 cm cystic mass in the left kidney and a perirenal collection in the retroperitoneum which extended to the ipsilateral iliac region. A difficult differential diagnosis is made between a left renal abscess rupture into the retroperitoneal space and a ruptured renal tumor. Emergency surgery is undertaken after the patient is fluid-electrolyte balanced and broad spectrum antibiotics are administrated after urine cultures and hemocultures are performed. At surgery a voluminous left renal cyst (about 8 cm diameter) is found on the anterior surface of the kidney with a 5 cm passage through which necrotic tumoral tissue is drained. Also a perirenal hematoma is found, extending from the diaphragm to the iliac region with extensive necrotic areas and tumoral tissue. Radical left nephrectomy and pre-, inter- and retroaortic lymph node dissection is performed in order to remove the necrotic tissue. The retroperitoneal bacteriological fluid exam shows positive results for a Pseudomonas Aeruginosa infection, sensitive for Meronem, Colistin, Tazocin and Levofloxacin. By postoperative day 9 the patient goes home, surgically healed. Histopathological findings: type 1 papillary renal cell carcinoma, Fuhrman grade II, pt1bn0mx. Conclusions: Papillary renal cell carcinoma is a rare malign entity of the kidney (10-17%). As presented in the case report above it is difficult to make the differential diagnosis between ruptured renal abscess or complicated renal cyst. nr. 2 / 2012 vol 11 Revista Românæ de Urologie 49

51 Varia 4.1. Complicafliile urologice dupæ transplantul renal Managementul terapeutic? I. Sinescu, M. Hârza, C. Baston, B. Øtefan, I. Manea, M. A. Manu, V. Cerempei, B. Hæinealæ, A. Preda, S. Guler Margaritis, B. Bædescu Centru de Uronefrologie øi Transplant Renal, Institutul Clinic Fundeni, Bucureøti Urological complications after renal transplantation Therapeutical management I. Sinescu, M. Hârza, C. Baston, B. Øtefan, I. Manea, M. A. Manu, V. Cerempei, B. Hæinealæ, A. Preda, S. Guler Margaritis, B. Bædescu Center of Uronephrology and Renal Transplantation, Fundeni Clinic Institute, Bucharest Introducere. Complicafliile urologice pot afecta rezultatele transplantului renal prin creøterea morbiditæflii øi a mortalitæflii, favorizand inclusiv pierderea grefei renale. Obiectivul acestui studiu a fost determinarea incidenflei complicafliilor urologice øi a modalitæflilor terapeutice adoptate în centrul nostru. Material øi metodæ. O serie de 796 transplanturi renale consecutive au fost efectuate între 1 ianuarie 2004 øi 31 decembrie Rinichii s-au prelevat în 594 de cazuri (74,62%) de la donatori în viaflæ øi în 202 de cazuri (25,38%) de la donatori în moarte cerebralæ. Raportul pe sexe a fost de 1,77/1 în favoarea celui masculin. Vârsta medie a receptorilor a fost de 35,16± 12,79 ani. În 683 cazuri (85,8%) grefarea s-a efectuat în FID, iar în restul de 113 (14,2%) în FIS. Referitor la tipul de ureteroneocistostomie, în 62,1% (494) din cazuri s-a utilizat un procedeu tip Leadbetter-Politano modificat, iar în 37,9% (302) tip Lich-Gregoire. Stentarea ureterala JJ a fost utilizatæ în 138 cazuri (17,34%). Rezultate. Incidenfla globalæ a complicafliilor urologice a fost de 7,78% (62 cazuri). S-au întâlnit 25 (3,14%) stenoze ureterale, 16 (2,01%) fistule ureterale, 13 (1,63%) limfocele, 3 (0,37%) hematoame perigrefon cu obstrucflie ureteralæ, 2 cazuri (0,26%) de litiazæ pe rinichi transplantat, 3 cazuri (0,37%) de obstrucflie prin cheaguri. Metodele utilizate pentru tratamentul complicafliilor urologice au fost: reimplantarea ureterovezicalæ (24 cazuri %), stentare JJ (16 cazuri - 2,02%), drenaj percutanat în 7 cazuri (0,88%), evacuare chirurgicalæ cu fenestrare peritonealæ (12 cazuri - 1,5%), stentare JJ øi ESWL (2 cazuri - 0,25%), ureteropielostomie cu utilizarea ureterului nativ (1 caz - 0,12%). Concluzii. Complicafliile urologice legate de fistule sau stenoze pot fi tratate, în cazuri selecflionate, minim invaziv sau, prin reimplantarea ureterului grefonului în vezica urinaræ. Complicafliile urologice nu au determinat creøterea morbiditæflii øi a mortalitæflii pe termen lung. Introduction. Urological complications can affect the outcome of kidney transplantations by increasing the morbidity and mortality, including the loss of the renal graft. The aim of this study is to determine the incidence of urological complications, occurring after renal transplantation, in our center and evaluation of therapeutic measures. Materials and Methods. A series of 796 consecutive renal transplantations were performed between 1st of January 2004 and 31st of December The mean age: 35.16±12.79 years old with a male to female ratio 1.77/1. Renal grafts were obtained in 594 cases (74.62%) from living-related and in 202 cases (25.38%) from cadaveric donors. In 683 (85.8%) cases transplantation was carried out into the right iliac fossa, and only 113 (14.2%) cases in left iliac fossa. In 494 (62.1%) cases we performed Leadbetter-Politano ureteroneocystostomy and in 302 (37.9%) a Lich-Gregoire technique. A JJ ureteral stent was placed in 138 cases (17.34%). Results. The overall incidence of urological complications was 7.78% (62 cases). We recorded 25 ureteral stenosis (3.14%), 16 ureteral fistulas (2.01%), 13 lymphoceles (1.63%), three hematoma with ureteral obstruction (0.37%), three cases of obstruction due to clot formation (0.37%) and two cases (0.26%) of hydronephrosis due to stone formation in the transplanted kidney. Therapeutical measures for treating urological complications were: vesicoureteral re-anastomosis in 24 cases (3.01%), double pigtail stenting in 16 cases (2.01%), percutaneous drainage performed in 7 cases (0.88%), surgical evacuation and open surgical peritoneal fenestration in 12 cases (1.51%), double pigtail stenting and ESWL in two cases (0.25%) and one ureteropyelostomy (0.12%). Conclusions. Urological complications related to leakage or stenosis can be treated minimally invasive in selected cases or by surgical vesicoureteral reimplantation. Early diagnosis and treatment will help maintain renal graft function. In our study, graft survival after successful treatment has been similar for all the patients. 50 Revista Românæ de Urologie nr. 2 / 2012 vol 11

52 4.2. Pseudo-sindrom Prune-Belly cu agregare familialæ G. Glück 1, Oana Marica 3, V. Sabæu 2, R. Stoica 1, I. Sinescu 1 1 Centrul de Uronefrologie øi Transplant Renal, Institutul Clinic Fundeni, Bucureøti 2 Secflia de Urologie Ploieøti 3 Clinica de Radiologie øi Imagisticæ Medicalæ, Familial aggregation of Prune-Belly pseudo-syndrome G. Glück 1, Oana Marica 3, V. Sabæu 2, R. Stoica 1, I. Sinescu 1 1 Center of Uronephrology and Renal Transplantation, Fundeni Clinical Institute, Bucharest 2 Ploieøti Urology Department Varia Institutul Clinic Fundeni, Bucureøti 3 Department of Radiology and Medical Imaging, Fundeni Clinical Institute, Bucharest Scop: Sindromul Prune-Belly sau sindromul Eagle-Barett este o afecfliune congenitalæ, caracterizatæ prin lipsa musculaturii abdominale, criptorhidie, vezicæ urinaræ hipotonæ øi dilatatæ, uretere tortuoase. Prezentæm 3 pacienfli înrudifli (frafli) care prezintæ aceste caracteristici în diferite asociaflii, cu excepflia lipsei musculaturii abdominale, ce este normal dezvoltatæ la cei trei. Prezentare de cazuri: Pacietul S.C., în vârsta de 23 de ani, se prezintæ în aprilie 2008 în Clinica de Urologie Fundeni, cu ureterohidronefrozæ bilateralæ gradul IV, megavezicæ urinaræ øi insuficienflæ renalæ cronicæ (creatininæ sericæ 3 mg/dl). Se intervine chirurgical øi se efectueazæ ureterostomie cutanatæ dreaptæ splintatæ (12 Ch), cu evolutie ulterioaræ favorabilæ. Pacientul S.E., în vârsta de 19 ani se prezintæ în martie 2012 în Clinica de Urologie, pentru criptorhidie bilateralæ diagnosticatæ tomografic (testicul drept retrovezical, testicul stâng prevezical). În cursul investigafliilor este diagnosticat cu ureterohidronefrozæ bilateralæ gradul III øi reziduu vezical cca 600 ml; efectueazæ debitmetrie) Qmax=35 ml/sec, Qmed=15 ml/sec) øi examen urodinamic ce relevæ capacitate vezicalæ crescutæ (2500 ml), cu alterarea senzafliilor øi cresterea complianflei, hipocontractilitate vezicalæ, reziduu vezical 800 ml. Videocistouretrografia retrogradæ infirmæ existenfla refluxului vezicoureteral. Pacientul urmeazæ indicaflia de autosondaj evacuator, cu complianflæ clinicæ bunæ. Pacientul S.M., în vârstæ de 28 de ani este în evidenfla clinicii de nefrologie cu ureterohidronefrozæ bilateralæ grd. II, færæ ræsunet biologic. Nu prezintæ alte aspecte caracteristice sindromului. Concluzii: Tratamentul afecfliunilor urologice din cadrul sindromului Prune-Belly øi variantelor fenotipice ale acestuia, ridicæ probleme legate alegerea modului de tratament (conservator sau chirurgical), de vârsta la care tratamentul trebuie aplicat øi de indicafliile acestuia, care nu trebuie limitate la aspectele clinice, ci trebuie completate cu investigaflii radiologice øi funcflionale. Purpose: Prune-Belly or Eagle-Barett syndrome is a congenital condition characterized by absent abdominal wall musculature, criptorchid testes, dilated hypotonic bladder and tortuous ureters. We here present the case of 3 blood related patients (brothers) that sum up features of the disease in different associations, exception making the absence of the abdominal wall musculature, which seems to be well developed in all three brothers. Cases study: S.C. is a 23 years old patient, who presents in April 2008 to Fundeni Urology Clinique, with stage IV bilateral ureteronephrosis, an enlarged urinary bladder and chronic kidney failure (serum creatinine = 3 mg/dl). The patient underwent surgical intervention for urinary diversion right cutaneous ureterostomy with 12 Ch splints. Postoperative evolution is satisfactory. S.E. is a 19 years old patient, who presents in March 2012 to Fundeni Urology Clinique for bilateral criptorchid testes revealed by a CT-scan (a right retrovesical testicle and a left prevesical testicle). During medical investigations the patient is found with stage III bilateral ureteronephrosis and an aproximately 600 ml bladder residue. The urinary flow rate is measured (Qmax=35 ml/sec, Qmed=15 ml/sec) and an urodynamic examination is performed which shows an increased bladder capacity (2500ml), with altered sensations and increased compliance, hypocontractile bladder and 800 ml baldder residue. The videourodynamic study shows no vesicoureteral reflux. The patient is encouraged to perform intermittent catheterization, with a satisfactory clinical compliance. S.M. is a 28 years old patient, under the care of the Nephrology Department, diagnosed with stage II bilateral ureteronephrosis and no biologic implications. He does not imply any other features of the syndrome. Conclusions: The urological implications of Prune-Belly syndrome represent a problem in choosing the right treatment pattern (conservatory or surgery). Age is an important factor in choosing the indicated therapy, which should not be limited only to clinical manifestations, but also radiologically and functionally documented. nr. 2 / 2012 vol 11 Revista Românæ de Urologie 51

53 Varia 4.3. Aplicafliile ecografiei cu contrast în patologia renalæ øi a vezicii urinare Applications of contrast-enhanced ultrasound in renal and bladder pathology Oana Luiza Marica *, Ioana Gabriela Lupescu *, M. Grasu *, C. Surcel, C. Mirvald, A. Iordache, V. Cerempei, M.A. Manu, I. Sinescu * Clinica de Radiologie Imagisticæ Medicalæ Centrul de Uronefrologie øi Transplant Renal, Institutul Clinic Fundeni, Bucureøti Oana Luiza Marica *, Ioana Gabriela Lupescu *, M. Grasu *, C. Surcel, C. Mirvald, A. Iordache, V. Cerempei, M.A. Manu, I. Sinescu * Department of Radiology and Medical Imaging Center of Uronephrology and Renal Transplantation, Fundeni Clinical Institute, Bucharest Dezvoltarea în domeniul agenflilor de contrast folosifli în ecografie, precum øi a soft-urilor consacrate în detecflia microbulelor, a îmbunætæflit considerabil rezoluflia ecografiei cu contrast, ceea ce împreunæ cu excelenta rezoluflie spaflialæ øi temporalæ a achizifliei ecografice în general, face ca ecografia cu contrast (CEUS) sæ fie potrivitæ pentru aplicaflii în patologia renalæ øi a vezicii urinare. Agenflii de contrast folosifli la ora actualæ sunt agenfli de contrast intravasculari ( blood pool agents ), ceea ce înseamnæ cæ spre deosebire de alte medii de contrast, nu pæræsesc circulaflia vascularæ; aceastæ caracteristicæ ne ajutæ în delimitarea flesuturilor cu diferenfle de perfuzie øi pentru a urmæri în dinamicæ distribuflia agenflilor de contrast, atât la nivelul vaselor mari, cât øi în microcirculaflia intraparenchimatoasæ a organelor, respectiv de la nivelul richichilor øi pereflilor vezicii urinare. Lucrarea de faflæ îøi propune sæ prezinte aplicafliile ecografie cu contrast în rinichiul normal, rinichiul transplantat, vezica urinaræ, cât øi în patologia asociatæ: indicaflii, contraindicaflii øi limitele metodei. The development of ultrasound contrast agents and dedicated software for the detection of microbubbles has improved the potential contrast resolution of ultrasound and this, added to the already spatial and temporal resolution, makes contrast-enhanced ultrasound (CEUS) well suited for the study of renal and bladder pathology. The contrast agents in clinical use today are so called blood pool agents meaning that, contrary other contrast media, they do not leave the blood vessels. This provides us with an excellent tool for delineating tissues with perfusion differences and for following the dynamic phases of contrast enhancement, in both large vessels and the microcirculation in parenchymatous organs, namely the kidney and the bladder wall.this paper aims to present applications of contrast-enhanced ultrasound in normal kidney, transplanted kidney, bladder, and associated pathology: indications, contraindications and limitations of the method. 52 Revista Românæ de Urologie nr. 2 / 2012 vol 11

54 4.4. Testiculul feminizant sindromul de rezistenflæ androgenicæ completæ C. Gîngu, A. Dick, S. Pætræøcoiu, C. Surcel, M. Hârza, M.A. Manu, C. Bæløanu, F. Lupu, O. Himedan, C. Mirvald, A. fiurcanu, Liliana Domniøor *, Ileana Constantinescu **, I. Sinescu Centrul de Uronefrologie øi Transplant Renal, * Clinica de ATI, ** Laboratorul de Biologie Molecularæ øi Imunologie, Institutul Clinic Fundeni, Bucureøti Testicular Feminization Androgen Insensitivity Syndrome C. Gîngu, A. Dick, S. Pætræøcoiu, C. Surcel, M. Hârza, M.A. Manu, C. Bæløanu, F. Lupu, O. Himedan, C. Mirvald, A. fiurcanu, Liliana Domniøor *, Ileana Constantinescu **, I. Sinescu Center of Uronephrology and Renal Transplantation, * ICU Department. ** Molecular and Immunology Laboratory, Fundeni Clinical Institute, Bucharest Varia Introducere si obiective. Testiculul feminizant este un sindrom în cadrul cæruia un bærbat, genotipic XY, din cauza unor variate malformaflii la nivelul cromozomului X, are rezistenflæ la acfliunea hormonilor androgeni, ceea ce împiedicæ formarea organelor genitale masculine øi conferæ un fenotip de femeie. Sindromul de rezistenflæ androgenicæ are o incidenflæ de 1 la de naøteri, øi poate fi incomplet (variate ambiguitæfli sexuale) sau complet (fenotip feminin). Scopul acestei lucræri este prezentarea diagnosticului øi tratamentului unui caz de testicul feminizant. Materiale øi metodæ. Pacienta de 22 ani, se prezintæ la ginecologie pentru amenoree primaræ. La examen clinic se observæ fenotip feminin: sâni dezvoltafli, pilozitate axilaræ øi pubianæ absente, labii mici hipoplazice, meat urinar normal inserat øi vulvæ nepigmentatæ. Examenul ginecologic evidenfliazæ himen prezent, øi un vagin de 1,5 cm lungime, iar fosa uterinæ este liberæ la tuøeul rectal. Endocrinologic este dozat nivelul serologic al gonadotrofinelor, care este normal (FSH 3,18 mu/ml, LH 15 mu/ml), progesteronul este de 5,79 nmol/l, estradiolul 82,390 pmol/l, iar testosteronul este 4,27 nmol/l. Se efectueazæ cariotipul pentru a se putea face diferenfla între sindromul de rezistenflæ androgenicæ øi alte anomalii genetice, cum ar fi sindromul Klinefelter (46XXY), sindromul Turner (45X0), dissinergism gonadal mixt (45XO/46XY) sau chimerism tetragametic (46XX/46XY). Acesta confirmæ suspiciunea de testicul feminizant (46XY). Examenul CT pelvin identificæ agenezie utero-ovarianæ, hipoplazie vaginalæ øi testicule intraabdominale prepsoice. Se decide extirparea acestora, pentru a elimina riscul de transformare malignæ. Se practicæ orhidectomie bilateralæ laparoscopicæ. Introduction and objectives. Testicular feminization is the syndrome when a male, genetically XY, because of various abnormalities of the X chromosome, is resistant to the actions of the androgen hormones, which in turn stops the forming of the male genitalia and gives a female phenotype. The androgen insensitivity syndrome occurs in 1 out of births and can be incomplete (various sexual ambiguities) or complete (the person appears to be a woman). The aim of this paper is to present the diagnosis and treatment of a case of testicular feminization. Materials and method. A 22-year-old patient is admitted at Gynecology for primary amenorrhea. The clinical examination shows a female phenotype: the breasts are normally developed, but there s no hair in the groins and axillary areas, the labia are small and hypoplastic, the urinary meatus is normally inserted, and the vulva is unpigmented. The gynecological exam reveals that the hymen is present, the vagina has 1.5 cm in length, while the uterus is absent. At Endocrinology the levels of gonadotropins were measured and found normal (FSH 3.18 mu/ml, LH 15 mu/ml), the progesterone was 5.79 nmol/l, estradiol was pmol/l and the testosterone was 4.27 nmol/l. The karyotype was mapped in order to differentiate the androgen insensitivity syndrome from other genetic abnormalities, like the Klinefelter syndrome (46XXY), Turner syndrome (45X0), mixed gonadal dyssynergia (45XO/46XY) or tetragametic chimerism (46XX/46XY). These tests confirm the suspected diagnosis - testicular feminization (46XY). The pelvic CT scan reveals the lack of uterus and ovaries, hypoplastic vagina, and intraabdominal prepsoic testies. The testies are removed nr. 2 / 2012 vol 11 Revista Românæ de Urologie 53

55 Varia Rezultate. Chirurgical pacientul a avut evoluflie simplæ, cu externare în ziua a doua postoperator, øi s-a instituit tratament substitutiv hormonal cu estrogeni. Psihic, pacientul se consideræ în continuare femeie, øi a fost læsatæ la latitudinea pærinflilor decizia de a i se comunica adeværul sau nu. Concluzii. Testiculul feminizant este o afecfliune raræ, diagnosticul øi tratamentul acestor cazuri presupunând o colaborare multidisciplinaræ între ginecolog, endocrinolog, genetician, urolog øi psihiatru. Orhidectomia bilateralæ laparoscopicæ este procedura de elecflie pentru excizia testiculelor intraabdominale, necesaræ pentru a evita transformarea lor malignæ. in order to avoid the malignant risk. We performed laparoscopic bilateral orchiectomy. Results. Surgically the patient had a simple evolution, being discharged in the second day postoperatory, and estrogen therapy was started from that moment on. Mentally the patient kept thinking she was a woman, so the decision of telling her the truth was left to the parents. Conclusions. Testicular feminization is a rare disease that must be diagnosed and treated through close work between gynecologists, endocrinologists, geneticians, urologists and psychiatrists. Bilateral laparoscopic orchiectomy is the best procedure to remove the intraabdominal testies, in order to avoid their malignant transformation 54 Revista Românæ de Urologie nr. 2 / 2012 vol 11

56 4.5. Prezentare de caz Fracturæ penianæ complexæ cu rupturæ bilateralæ corporealæ penianæ øi secflionarea parflialæ a uretrei S. Pætræøcoiu, C. Gîngu, A. Dick, V. Laiu, O. Creflu, C. Surcel, N. Vlaicu, R. Constantiniu, C. Mirvald, F. Lupu, I. Sinescu Centrul de Uronefrologie øi Transplant Renal, Institutul Clinic Fundeni, Bucureøti Case report Complex penile fracture with bilateral corporeal rupture and partial urethral disruption S. Pætræøcoiu, C. Gîngu, A. Dick, V. Laiu, O. Creflu, C. Surcel, N. Vlaicu, R. Constantiniu, C. Mirvald, F. Lupu, I. Sinescu Center of Uronephrology and Renal Transplantation, Fundeni Clinical Institute, Bucharest Varia Introducere øi obiective: Fractura penianæ este o leziune caracterizatæ de ruptura tunicii albuginee ce acoperæ corpul spongios. Leziunea poate interesa øi corpul spongios øi se poate însofli de ruptura parflialæ, mai rar completæ a uretrei. Fractura penianæ este o urgenflæ urologicæ ce poate avea importante consecinfle fiziologice øi psihologice dacæ tratamentul nu este cel indicat. Cu toate acestea, aplicând un diagnostic prompt øi un tratament adecvat, evoluflia este excelentæ, iar complicafliile sunt minime chiar în cazurile complexe. Materiale øi metodæ. Se doreøte prezentarea cazului unui bærbat de 52 ani, care s-a prezentat în Serviciul Urologie dupæ 14 ore de la producerea traumatismului penian în timpul actului sexual. Pacientul a descris o senzaflie de sfâøiere, urmatæ de detumefiere rapidæ, durere severæ, øi scurgere uretralæ de sânge proaspæt. Acesta a acuzat disurie øi imposibilitatea golirii vezicii urinare timp de 5 ore dupæ traumatism. Examenul clinic a evidenfliat un penis edematos cu hematom ce cuprindea prepuflul, scrotul, perineul øi regiunea hipogastricæ. La nivelul meatului s-a observat prezenfla sângelui proaspæt, iar abdomenul inferior se prezenta dureros ca urmare a retenfliei acute de urinæ. Locul rupturii tunicii a fost imposibil de palpat clinic datoritæ tumefacfliei øi hematomului local. Primul pas al operatiei l-a reprezentat montarea unui cateter 10 Fr suprapubian pentru a trata retenflia urinaræ acutæ. Chiar dacæ clinic a fost imposibil de determinat locul tupturii tunicii, s-a presupus cæ se aflæ la baza penisului, pe partea stângæ datoritæ gradului înalt de tumefacflie øi uøoarei deviaflii de partea opusæ leziunii. S-a practicat o incizia longitudinalæ pe partea stângæ a penisului, în apropierea bazei, urmatæ de evacuarea hematomului, debridarea øi expunerea locului rupturii. S-a observat o rupturæ transversalæ a corpului cavernos stâng pe partea ventralæ øi o rupturæ a corpului spongios. Dupæ disecflia corpului spongios de corpii cavernoøi, s-a observat cæ Introduction & Objectives. Penile fracture is an injury characterized by rupture of the tunica albuginea enveloping the corpus cavernosum.the rupture can also affect the corpus spongiosum. It can be accompanied by partial or rarely complete urethral rupture. Penile fracture is a urological emergency that may have important physiological and psychological consequences if the therapeutic management is inappropriate. However with prompt diagnosis and competent surgical management outcomes remain excellent and complications are minimal even in complex cases. Matherial and Method. We present the case of 52 year old male who presented to our department 14 hours following blunt injury of the penis during sexual intercourse. The patient reported a tearing/popping sensation, rapid detumescence, severe penile pain and frank blood per urethra. He also presented semnificative dysuria and was unable to void 5 hours after the injury. Physical examination revealed a tender and swollen penis with hematoma extended over the penile shaft, scrotum, perineum and hypogastric region. Blood was visible at the urethral meatus. He also presents severe pain in the lower abdomen due to acute urinary retention. Clinically the site of the tunical disruption was impossible to palpate due to penile hematoma and swelling. First step of the operation was placing a suprapubic tube 10 Fr catheter in order to solve the acute urinary retention. Even that clinically was impossible to clear locate the place of rupture we presumed that it was near the penile base on the left side due to the extensive swelling and mild deviation on the contra lateral side. We performed o longitudinal incision on the left side near the penile base. Following exposure the hematoma was evacuated, the fracture site debrided and clearly exposed. We observed a transverse corporeal tear of the left cavernosum on the ventral part and the tear of the nr. 2 / 2012 vol 11 Revista Românæ de Urologie 55

57 Varia ruptura era pe o suprafaflæ mare øi ne confruntam cu o leziune transversalæ corporealæ bilateralæ pe partea ventralæ a penisului øi rupturæ parflialæ a uretrei pe partea dorsalæ. S-a închis defectul corporeal utilizând Vicryl 2.0, iar defectul uretral a fost rezolvat utilizând PDS 4.0. S-a montat un cateter Foley, iar cateterul suprapubian a fost suprimat. S-a aplicat pansament uøor compresiv, iar pacientului i s-au instituit antibiotice i.v. pentru 24 de ore. Rezultate. Pacientul s-a recuperat bine în spital øi a fost externat în ziua a 3-a postoperator urmând tratament antibiotic øi cu cateterul Foley pe loc. Catererul uretral a fost suprimat în ziua 21. La 6 luni dupæ intervenflie aspectul cosmetic este satisfæcætor, potenfla este pæstratæ, cu erecflii nedureroase, iar pacientul relateazæ micfliuni normale. Cocluzii. Explorarea øi tratamentul chirurgical de urgenflæ trebuie adoptate pentru a avea rezultate favorabile pe termen lung. Leziunile uretrale trebuie suspectate în fracturile peniene mai ales în acele cazuri cu rupturi bilaterale de corpi cavernoøi sau simptomatologie clinicæ sugestivæ. Indicatorii cheie ai leziunii uretrale sunt reprezentafli de sânge proaspæt la nivelul meatului uretral, hematurie, disurie, retenflie acutæ de urinæ. Cazurile complexe, ca cel prezentat, ar trebui operate de chirurgi cu experienflæ în chirurgia penisului øi a uretrei. spongiosum. After dissection of the spongiosum from the corporeal bodies we observed that the rupture was extensive and we have to deal with a bilateral transverse corporeal tear on the ventral aspect of the penis and partial disruption of the urethra on the dorsal side. We close the defect of the corpora using 2.0 Vicryl and the urethral defect using PDS 4.0. A Foley catheter was met in place and the suprapubic tube was removed. Mild compressive dressing was applied and the patient was kept on i.v. antibiotics 24 h. Results. The patient recovered well in hospital and was discharged in postoperative day 3 on antibiotics with Foley catheter. The urethral catheter was removed on day 21 postop. 6 months after the procedure the cosmetic aspect is very good, potency is preserved with painless erections and the patient reported normal voiding. Conclusions. Urgent surgical exploration and repair should be done in order to improve outcomes. Urethral injury should be suspected in penile fracture especially in those cases with bilateral cavernosal ruptures or suggestive clinical features. The key indicators of urethral injury include blood at the meatus, gross haematuria, dysuria or acute urinary retention. Complex cases such the one presented should be operated by surgeons with experience in penile and urethral surgery. 56 Revista Românæ de Urologie nr. 2 / 2012 vol 11

58 4.6. Fractura penianæ Experienfla de 12 ani a Institutului Clinic Fundeni S. Pætræøcoiu, C. Gîngu, V. Laiu, O. Creflu, C. Surcel, N. Vlaicu, R. Constantiniu, C. Mirvald, F. Lupu, I. Sinescu Centrul de Uronefrologie øi Transplant Renal, Institutul Clinic Fundeni, Bucureøti Penile fracture Fundeni Clinical Institute experience of 12 years S. Pætræøcoiu, C. Gîngu, V. Laiu, O. Creflu, C. Surcel, N. Vlaicu, R. Constantiniu, C. Mirvald, F. Lupu, I. Sinescu Center of Uronephrology and Renal Transplantation, Fundeni Clinical Institute, Bucharest Varia Introducere øi obiective. Fractura penianæ este definitæ ca ruptura tunicii albuginee a corpului cavernos al penisului. Incidenfla leziunii uretrale concomitente este de pânæ la 20% în literatura de specialitate. Acesta este un traumatism rar întâlnit øi o urgentæ urologicæ. Clinic este destul de uøor de recunoscut, dar tratamentul nu este standardizat øi de multe ori este controversat. Rezolvarea chirurgicalæ a rupturilor peniene a fost pentru prima datæ descrisæ de Fettre øi Gartman în Scopul chirurgical îl reprezintæ aducerea penisului la starea pre-traumaticæ, prezervarea lungimii penisului, a funcfliei erectile øi pæstrarea abilitætii de a urina din ortostatism. Obiectivul nostru este de a prezenta experienfla noastræ în diagnosticul øi tratamentul chirurgical al fracturilor peniene. Materiale øi metodæ. Intre ian ian am înregistrat 24 de cazuri de traumatisme peniene. Diagnosticul s-a bazat pe examenul clinic al zonei afectate. Tratamentul a fost chirurgicat în toate cazurile. Din punct de vedere chirurgical, planul terapeutic a constat în explorarea imediatæ a leziunii, debridare, repararea primaræ a rupturii de la nivelul tunicii albuginea si repararea primaræ a leziunii uretrale. Rezultate. Perioada de follow-up a fost de 8-14 luni. Vârsta pacientilor a fost între ani cu o medie de 31 ani. Fractura penianæ s-a datorat actului sexual în 19 cazuri, cædere pe penisul în erecflie în 2 cazuri, traumatism penian prin obiect contondent (penis în erecflie) 1 caz øi 3 cazuri cu cauzæ nedeterminatæ (posibil tot în urma actului sexual). 11 pacienti s-au prezentat în clinicæ în primele 4 ore de la producerea traumatismului, 4 pacienti s-au prezentat între ore dupæ incident, iar 9 dupæ un interval mai mare de 24 ore (între 1-14 zile). S-a practicat incizie circumferenflialæ subcoronalæ urmatæ de derularea flesutului cutanat (degloving) la 10 pacienfli øi incizie directæ la locul de fracturæ la 14 pacienfli. Perioada de spitalizare medie a fost de 4 zile (între 2 øi 9 zile). Nu s-au înregistrat alte complicaflii postoperatorii exceptând infecflia plægii în 2 cazuri. Compli- Introduction & Objectives. Penile fracture is defined as rupture of the tunica albuginea of corpus cavernosum of the penis. The incidence of concomitant urethral injury in reported cases was up to 20% of cases. This is a rare condition and an urological emergency. Clinically is quite easy to recognize, but the treatment is not standardized and sometimes remains controversial. The surgical repair for penile fracture was first described by Fettre and Gartman in The surgical goals are restoration of penis to pre-injury state, preservation of penile length, erectile function and maintenance of the ability to void while standing. Our objectives are to present our experience with diagnosis and surgical management of penile fracture. Matherial & Method. Between Jan Jan we registred 44 cases of penile trauma in our department. The diagnosis was based on clinical presentation and physical examination. The treatment was surgical in all cases. Our surgical plan, consisted of immediate exploration, debridement and primary repair of the tear in the tunica albuginea and also primary urethral repair in case of urethral lesion. Results. The follow up period was between months. The patients age was range between yrs with a median age of 31 yrs. Penile fracture was due to sexual maneuvers in 38 (86.36%) cases, fall onto erect penis in 2 (4.54%) cases, external blunt trauma on erect penis 1 (2,27%) case and undetermined (probably also due to sexual intercourse) in 3 (6.81%) cases. 22 (50%) patients presented during first 4 hours after the injury; 8 (18.18%) patients presented in the period of hours after trauma and 9 (20.45%) patients presented late, after 24 hours from the traumatic event( range between 1-14 days). We performed a circumferential sub coronal incision with subsequent penile degloving in 16 pts and direct incision on the rupture place in 28 cases. The mean hospitalization time was 4 days (range 2-12 days). No significant early postoperative complications except wound infection in 2 cases were registered. Late nr. 2 / 2012 vol 11 Revista Românæ de Urologie 57

59 Varia caflii postoperatorii tardive s-au înregistrat în 4 cazuri (toate în categoria pacienflilor care s-au prezentat între 1-14 zile dupæ traumatism ) øi au constat în încurbarea uøoaræ a penisului (mai puflin de 20 ) 3 cazuri øi încurbare penianæ (70 ) 1 caz. 3 din aceste 4 cazuri au prezentat erecflii dureroase cu penis deformat. S-au înregistrat øi 3 pacienti cu o nouæ rupturæ tunicii în interval de 3 luni 1 an dupæ evenimentul iniflial. Conduita terapeuticæ în aceste cazuri a fost tot chirurgicalæ cu rezultate favorabile. Ruptura completæ a uretrei s-a înregistrat la 1 pacient, iar ruptura parflialæ la 3 pacienfli. Concluzii. Cum funcflia genitalæ are un impact puternic asupra calitæflii vieflii, mai ales la pacienflii tineri, este important ca medicul curant sæ cunoascæ anatomia aparatului genital ca øi tratamentul imediat sau reconstructiv al leziunilor. Cazurile complexe ca cel prezentat ar trebui tratate chirurgical de cætre chirurgi cu experienflæ în chirurgia uretralæ øi penianæ. Explorarea chirurgicalæ imediatæ urmatæ de reconstrucflie sunt necesare pentru a avea rezultate favorabile. Leziunile uretrale ar trebui suspectate în cazul fracturilor peniene mai ales în acele cazuri cu rupturæ bilateralæ de corpi cavernoøi. Indicatorii cheie pentru leziunile uretrale includ prezenfla sângelui proaspæt la nivelul meatului, hematurie marcatæ, disurie øi retenflie acutæ de urinæ. postoperative complications were registered in 4 cases (all of them from the category of pts presented late ( between 1-14 days) and consisted in mild penile curvature ( less than 20 ) 3 cases and severe penile curvature (70 ) 1 case. Three of this four cases presented painful markedly deformed erection. We also registered in 3 patients a re-rupture of the albuginea in the interval 3 months-1 year after primary traumatic event. The management of this case was also surgical with good outcome. Complete urethral disruption was registered in 1 patient and partial urethral disruption in 3 patients. Conclusions. As genital function has a strong impact on quality of life especially in young patients, it is important that the treating physician for genital trauma be knowledgeable about genital anatomy, as well as its immediate treatment and eventual reconstruction. Complex cases should be operated by surgeons with experience in penile and urethral surgery. Urgent surgical exploration and repair should be done in order to improve outcomes. Urethral injury should be suspected in penile fracture especially in those cases with bilateral cavernosal ruptures or suggestive clinical features. The key indicators of urethral injury include blood at the meatus, gross haematuria, dysuria or acute urinary retention. 58 Revista Românæ de Urologie nr. 2 / 2012 vol 11

60 4.7. Efectul varicocelectomiei subinghinale microscopice unilaterale comparativ cu cea bilateralæ asupra calitæflii spermei studiu prospectiv non-randomizat S. Voinea, C. Gagiu, I. Manea, B. Hæinealæ, C. Chibelean *, M. Hârza, I. Sinescu Centrul de Uronefrologie øi Transplant Renal Institutul Clinic Fundeni, Bucureøti * Clinica de Urologie, Spitalul Clinic Judeflean Mureø Unilateral versus bilateral varicocelectomy There is any difference? S. Voinea, C. Gagiu, I. Manea, B. Hæinealæ, C. Chibelean *, M. Hârza, I. Sinescu Center of Uronephrology and Renal Transplantation Fundeni Clinical Institute, Bucharest * Urology Department, Mureø County Clinical Hospital Varia Introducere øi obiective. Varicocelul reprezintæ cea mai frecventæ cauzæ a infertilitæflii masculine. Majoritatea autorilor raporteazæ o îmbunætæflire a calitæflii spermei øi a ratei de obflinere a sarcinii dupæ varicocelectomie unilateralæ. Odatæ cu introducerea varicocelectomiei microscopice subinghinale (VMS) rezolvarea într-o singuræ sesiune chirurgicalæ a varicocelului bilateral devine atractivæ, însæ, efectul ei asupra calitæflii spermei comparativ cu varicocelectomia unilateralæ constituie o problemæ aflatæ încæ în discuflie. Obiectivul prezentærii este studiul comparativ al efectului VMS unilaterale comparativ cu cea bilateralæ asupra calitæflii spermei. Material øi metode. În perioada , 51 pacienfli - Grup 1 (G1) øi 11 pacienfli Grup 2 (G2) cu varicocel unilateral respectiv bilateral au fost incluøi prospectiv în studiu, folosind urmætoarele criterii: varicocel palpabil clinic, valori normale ale hormonilor implicafli în reproducere, cel puflin un parametru spermatic anormal. S-a practicat VMS unilateralæ pentru G1 øi bilateralæ pentru G2 în aceeaøi sesiune, de cætre aceeaøi echipæ chirurgicalæ. Au fost înregistrafli parametrii spermatici, durerea postoperatorie, cât øi complicafliile. Rezultate. Raportul incidenflei varicocel unilateral/ varicocel bilateral a fost de 4,6/1. 10 din 11 pacienfli (91%) din G2 au avut varicocel stâng gradul 3 si drept gradul 1. Perioada de urmærire medie a fost de 8 luni (între 3 øi 18 luni). Concentraflia medie a spermatozoizilor a crescut dupæ operaflie în G1 de la 7,5 to 18,1 milion/ml øi în G2 de la 7,1 to 26,7 million/ml (p=0,003). Nu a existat o diferenflæ semnificativæ între creøterea medie a motilitæflii øi a morfologiei spermatozoizilor postoperator, între intensitatea durerii postoperatorii øi între rata complicafliilor între cele douæ grupuri. Concluzii. VMS bilateralæ este asociatæ cu o creøtere mai mare a concentrafliei spermatozoizilor decât cea unilateralæ. VMS bilateralæ intr-o singuræ sesiune chirurgicalæ este varianta optimæ de tratament în cazul pacienflilor cu varicocel bilateral øi alterarea calitæflii spermei. Identificarea øi tatamentul chirurgical al varicocelului bilateral creøte øansa concepfliei naturale la cuplurile cu infertilitate de cauzæ masculinæ. Introduction & Objectives: Varicocele represents the most common cause of male infertility. The majority of authors report that unilateral varicocelectomy for palpable varicocele has a beneficial effect on male fertility and pregnancy outcome. Subinguinal microscopic varicocelectomy (SMV) is an appealing procedure to treat the patients with bilateral varicocele in a single session. Little is known about the morbidity and outcome for unilateral versus bilateral repair. Material and Methods: From 2008 and 2010, 51 (group 1) and 11 patients (group 2) with unilateral respectively bilateral varicocele were prospectively included using the next criteria: clinical palpable varicocele, normal reproductive hormones, at least 1 abnormal semen parameter. Unilateral (group1) and concomitant bilateral (group2) SMV was performed by a single urologist. Semen parameters, immediate postoperative pain, immediate (swelling, wound infection, bleeding) and late (hydrocele formation, tests atrophy, recurrence, numbness of scar area) complications were recorded. Results: The incidence of unilateral/bilateral varicocele was 4.1/1. The mean postoperative surveillance period was 8 month (3 to 18 month). The mean sperm concentration increased after surgery in group 1 from 7.5 to 18.1 million/ml and in group 2 from 7.1 to 26.7 million/ml. There was no difference in grade of pain, minor and major complications between groups. Conclusions: Bilateral varicocelectomy is associated with greater improvement in sperm concentration than unilateral varicocelectomy. Concomitant SMV is a best choice for patients with bilateral disease and abnormal semen analysis. Identifying and treating the patients with bilateral varicocele increase the chance of natural conception in couples with male infertility cause. nr. 2 / 2012 vol 11 Revista Românæ de Urologie 59

61 Varia 4.8. MicroTESE O tehnicæ nouæ de recoltare a spermatozoizilor la pacienflii cu azoospermie non-obstructivæ: Rezultate inifliale S. Voinea 1, C. Gagiu 1, I Manea 1, B. Hæinealæ 1, M. Matei 2, M. Hârza 1, I. Sinescu 1 1 Centrul de Uronefrologie øi Transplant Renal Institutul Clinic Fundeni, Bucureøti, 2 Genesis Fertility Center, Bucureøti MicroTESE A new technique to retrieve sperm from patient with non-obstructive azoospermia S. Voinea 1, C. Gagiu 1, I. Manea 1, B. Hæinealæ 1, M. Matei 2, M. Hârza 1, I. Sinescu 1 1 Center of Uronephrology and Renal Transplantation, Fundeni Clinical Institute, Bucharest 2 Genesis Fertility Center, Bucharest Introducere øi obiective. Azoospermia nonobstructivæ (ANO) reprezintæ patologia cea mai dificil de tratat din cadrul infertilitæflii de cauzæ masculinæ. În trecut, aceøti pacienfli erau considerafli candidafli pentru fertilizare in vitro (FIV) cu donator de spermæ sau adopflie. Introducerea a douæ tehnici avansate: extracflia spermatozoizilor din testicul (TESE) øi, ulterior, microtese, a crescut øansa de a recolta spermatozoizi din testiculele bærbaflilor cu ANO. Obiectivul prezentærii este raportarea rezultatelor øi complicafliilor microtese la un grup de pacienfli cu ANO. Material øi metode. În perioada martie martie 2012, 5 pacienfli cu ANO au fost incluøi prospectiv în studiu, folosind urmætoarele criterii: azoospermie la douæ spermograme consecutive, volum testicular <10 cc, nivel FSH seric >12 mui/l, biopsie/ aspiraflie testicularæ anterioaræ uni/bilateralæ în care nu s-au identificat spermatozoizi øi teste genetice normale. MicroTESE a fost practicatæ în conjuncflie cu recoltarea ovocitului, astfel încât sæ fie folosifli spermatozoizi proaspefli la FIV. Dupæ o incizie de 2 cm pe rafeul scrotal, inciza øi eversia vaginalei, s-a adus în câmpul operator un microscop (X 25) øi s-a efectuat o incizie ecuatorialæ transversalæ a albugineei testiculare (cel puflin 270 grade), urmatæ de deschiderea testiculului ca o carte într-un plan a/hipovascular. Fiecare hemitesticul a fost evaluat atât în suprafaflæ, cât øi în profunzime, pentru a identifica øi recolta tubuli seminiferi dilatafli øi albicioøi care au fost evaluafli intraoperator in timp real de cætre un embriolog cu experinflæ pentru identificarea spermatozoizilor. În lipsa identificærii spermatozoizilor, s-a practicat microtese pe testiculul contralateral. Au fost înregistrate complicaflii postoperatorii imediate (sângerare) sau tardive (scæderea nivelului testosteronului plasmatic). Rezultate. La 3 din 5 pacienfli au fost identificafli spermatozoizi cu care s-a efectuat FIV. Nu s-au intregistrat complicaflii postoperatorii. Concluzii. Deøi MicroTESE nu este o proceduræ minim invazivæ, folosirea microscopului operator poate identifica spermatozoizi la pacienflii cu ANO în cazurile în care alte proceduri (aspiraflie/biopsie teasticularæ) au eøuat. Recoltarea unor cantitæfli foarte mici de flesut øi hemostaza bipolaræ minuflioasæ asistate microscopic duc la evitarea complicafliilor imediate øi tardive. Introduction and Objective. Nonobstructive azoospermia (NOA) is the most difficult to treat male infertility disorder. In the past, the men with NOA were managed by adoption or sperm donor in vitro fertilization (IVF). Testicular sperm extraction (TESE) and, subsequently, microtese are new techniques which increase the chance to retrieve sperm for patients with NOA. The aim of our study was to report the result and complications of microtese in a group a patients with NOA. Material and methods. Between March 2011 and March 2012, 5 patients with NOA were prospectively included using the next criteria: azoospermia (at least 2 semen analyses), testicle volume < 10 cc, level of FSH > 12 mui/l, prior uni/bilateral testis biopsy/aspiration with no sperm identification and normal genetic tests. MicroTESE was performed concomitant with follicular puncture, in order to use fresh sperm for IVF. A median raphe scrotal incision and exposure of the testis was performed. An operative microscope (optical magnification X25) was brought into the operatory field. An equatorial transversal incision of the testis for at least 270 degrees was performed and testis was opened widely to split it into an upper and lower pole. Each part of the testicle was carefully inspected for presence of dilated and opaque seminiferous tubules. These tubules were evaluated by a skilled embryologist for presence of spermatozoa. If no spermatozoa were identified, a contralateral microtese procedure was performed. The early and late complications were recorded. Results. The spermatozoa were identified in 3 out of 5 patients. No postoperative complications were performed. Conclusion. MicroTESE is not a minimally invasive treatment but, because of using an operative microscope, it can succeed to identified spermatozoa in patients with NOA were other procedures fail. The complications of microtese are low because the amount of tissue removed out of the testis is small and the bipolar coagulation is accurate. 60 Revista Românæ de Urologie nr. 2 / 2012 vol 11

62 4.9. Comparaflie între funcflia întârziatæ sau încetinitæ øi funcflia imediatæ a grefei renale la transplantul renal de la donatorul în moarte cerebralæ M. A. Manu, M. Hârza, B. Øerbænescu, B. Øtefan, C. Baston, Dorina Tacu, Eminee Kerezsy, Liliana Domniøor *, Rucsandra Manu, I. Sinescu Centrul de Uronefrologie øi Transplant Renal * Clinica de ATI, Institutul Clinic Fundeni, Bucureøti The importance of slow and delayed graft function vs. Immediate graft function on cadaver renal transplant outcomes M. A. Manu, M. Hârza, B. Øerbænescu, B. Øtefan, C. Baston, Dorina Tacu, Eminee Kerezsy, Liliana Domniøor *, Rucsandra Manu, I. Sinescu Center of Uronephrology and Renal Transplantation * ICU and Anesthesiology Department, Fundeni Clinical Institute, Bucharest, Romania Varia Introducere: În concordanflæ cu funcflia iniflialæ a grefei renale, pacienflii transplantafli renal pot fi clasificafli în 3 grupe: funcflie imediatæ a grefei (IGF creatinina sericæ în ziua a 5-a postoperatorie < 3 mg/dl), funcflie încetinitæ a grefei (SGF creatininæ sericæ în ziua a 5-a > 3 mg/dl, færæ dializæ) øi funcflie întârziatæ a grefei (DGF creatininæ sericæ în ziua a 5- a > 3 mg/dl, cu dializæ). Funcflia întârziatæ a grefei renale este o complicaflie comunæ la transplantele de la donatorii în moarte clinicæ, având o definiflie arbitraræ. Existæ un nonsens privind impactul pe care îl pot produce funcflia încetinitæ sau întârziatæ a grefei renale asupra viitorului transplantului renal de la donatorul cadavru. Scopul studiului nostru este de a analiza impactul celor trei categorii funcflionale ale grefei asupra viitorului pacientului transplantat, factorii determinanfli implicafli în funcflionalitatea primelor zile ale grefei fiind vârsta donatorului øi reconstrucflia adiflionalæ vascularæ. Metodæ: În perioada Iunie 1997 Iulie 2011 s-au efectuat în Centrul nostru 1232 transplante renale, (960 de la donatori în viaflæ øi 272 de la donatori în moarte cerebralæ, 1169 adulfli øi 63 copii), cu o medie de 85 transplante/an (116 transplante în 2007). În studiul nostru au intrat 105 de pacienfli transplantafli de la donatori cadavru, iar funcfliile grefelor renale au fost urmætoarele: 72 de cazuri au fost clasificate IGF, 21 au fost clasificate SGF øi 12 cazuri DGF. Episoadele de rejet acut (AR), nivelurile creatininei serice øi supraviefluirea grefei au fost analizate 3 luni, 6 luni øi un an postoperator. Au fost luafli în considerare øi alfli factori: donatori tineri sau în vârstæ (peste 60 ani) øi pediculul normal sau reconstruit adiflional. Rezultate: Pacienflii din grupa SGF au prezentat rezultate Introduction: According to the initial graft function, kidney transplant patients could be divided into three groups: immediate graft function (IGF postoperative day 5 serum creatinine < 3 mg/day), slow graft function (SGF day 5 creatinine >3mg/dl, no dialysis) and delayed graft function (DGF day 5 creatinine >3mg/dl and dialysis). Delayed graft function is a common complication in cadaver kidney transplants sometimes with an arbitrary definition. There is disagreement about the impact of slow and delayed graft function on renal transplant outcomes. Our study was designed to assess the impact of the above three categories in transplant outcomes, and factors involved in first days graft function such was donor age and additional vascular reconstruction. Methods: From June 1997 until July 2011, 1232 renal transplantations (960 living and 272 cadaver, 1169 adults and 63 pediatric transplants) with an average of 85 /year (116 in 2007), were performed in our center. 105 cadaver transplants entered in our study and renal grafts developed function as follows: 72 transplants were IGF, 21 were SGF and 12 DGF. Acute rejection episodes (AR), serum creatinine level and graft survival were analyzed three months, six month and one year after surgery. Young donors and old donors (the edge of 60), normal pedicle and reconstructed pedicle were considered. Results: SGF patients showed worse results considering acute rejection, creatinine level and graft survival in comparison with IGF but better than DGF group. Donor age and additional vascular reconstruction did not significantly nr. 2 / 2012 vol 11 Revista Românæ de Urologie 61

63 Varia slabe privind rejetul acut, creatinina sericæ øi supraviefluirea grefei în comparaflie cu grupa pacienflilor IGF, dar mai bune comparativ cu grupa pacienflilor DGF. Rezultatele nu au fost semnificativ influenflate de vârsta donatorilor sau reconstrucflia vascularæ adiflionalæ. Supraviefluirea grefei la un an a fost mai bunæ în grupa pacienflilor IGF decât a pacienflilor din celelalte douæ grupe. Creatinina sericæ a fost superioaræ la grupa SGF decât la grupa IGF 1.9±- 0.7 mg/dl vs. 1.3±0.7 mg/dl, dar inferioaræ celei din grupa DGF 2.5±0.5 mg/dl la 12 luni; rata rejetului acut a fost 19,44% (14) în grupa IGF, 38,09% (8), în grupa SGF øi 58,33% (7) în grupa DGF. Concluzii: Trebuie sæ luæm în considerare funcflia încetinitæ a grefei renale în aprecierea la distanflæ a disfuncfliei transplantului renal. Pacienflii ce au dezvoltat SGF au un prognostic mai rezervat decât pacienflii din grupa IGF, dar similar sau în unele cazuri mai bun decât pacienflii din clasa DGF. În ciuda faptului cæ nu necesitæ dializæ, pacienflii din grupa SGF au prezentat niveluri ale creatininei serice mai crescute, rate mai crescute de rejet acut øi supraviefluire a grefei diminuatæ, comparativ cu pacienflii din grupa IGF. Chiar øi disfuncflia post-transplant uøoaræ/moderatæ poate avea un impact negativ asupra funcflionalitæflii grefei øi a supraviefluirii pacientului transplantat. modify the outcomes. One year graft survival was better in IGF group than other two groups. Creatinine was worse in SGF group than IGF group 1.9±0.7 mg/dl vs. 1.3±0.7 mg/dl, but better than DGF group 2.5±0.5 mg/dl at 12 months, AR rate was 19.44% (14) in IGF group, 38.09% (8) in SGF group and 58.33% (7) in DGF group. Conclusions: Slow graft function has to be considered in appreciation of graft dysfunction. Patients developing SGF have a worse outcome than patients with IGF but similar, or in special cases better than patients developing DGF. Despite they did not need dialysis, SGF patients show worse creatinine level and graft survival and higher acute rejection than IGF. Even mild to moderate post-transplant dysfunction can have a negative impact in graft function and survival. 62 Revista Românæ de Urologie nr. 2 / 2012 vol 11

64 4.10. Stenoza congenitalæ de joncfliune pieloureteralæ la copil Rezultate în chirurgia deschisæ M.A. Manu, C. Gîngu, C. Surcel, V. Mitroi, I. Prie, A. Davidescu, Rucsandra Manu, I. Sinescu Centrul de Uronefrologie øi Transplant Renal, Institutul Clinic Fundeni, Bucureøti Congenital ureteropelvic junction obstruction in pediatric patients open surgery results M.A. Manu, C. Gîngu, C. Surcel, V. Mitroi, I. Prie, A. Davidescu, Rucsandra Manu, I. Sinescu Center of Uronephrology and Renal Transplantation, Fundeni Clinical Institute, Bucharest, Romania Varia Introducere: Acest studiu retrospectiv a fost realizat pentru a evalua rezultatele imediate øi tardive post pieloplastie deschisæ la copil. Material øi metode: În departamentul nostru au fost admiøi 74 copii care sufereau de stenozæ congenitalæ de joncfliune pielo-ureteralæ, ce au intrat în studiu în perioada ianuarie ianuarie Vârsta minimæ a fost de 1,1 ani, iar vârsta maximæ a fost de 15,7 ani cu o medie de 10,3 ani. 64 copii au avut stenozæ unilateralæ de joncfliune, iar la 10 copii obstrucflia a fost bilateralæ. În studiu au intrat 84 de unitæfli renale, fiind luatæ în considerare clasificarea internaflionalæ a hidronefrozei. 9 unitæfli au avut hidronefrozæ gradul II, 30 unitæfli au avut gradul III, 33 unitæfli au avut gradul IV øi 12 unitæfli au avut hidronefrozæ gradul V. În scopul diagnosticærii au fost realizate atât examenul clinic, ultrasonografia, urografia intravenoasæ convenflionalæ øi diuretic-stimulatæ cât øi în unele cazuri scintigrafie renalæ, CT øi IRM cu substanflæ de contrast. Rezultate: Pieloplastia Hynes-Anderson a reprezentat gold standard ca øi proceduræ chirurgicalæ. Aceasta a fost realizatæ în 76 cazuri, într-unul din cazuri fiind efectuatæ anastomoza calico-ureteralæ. Abordarea transperitonealæ pe cale anterioaræ a fost luatæ în considerare la 5 cazuri cu rinichi în potcoavæ. Descruciøarea vascularø (18 cazuri), litotomia (14 cazuri) øi ESWL-ul (4 cazuri) s-au asociat pieloplastiei. Reconstrucflia de joncfliune a fost urmatæ de proceduri diferite de drenaj. Nefrectomia per primam s-a realizat la 8 cazuri, iar nefrectomia tardivæ secundaræ în 3 cazuri. În funcflie de momentul operafliei perioada de urmærire a fost în 24 cazuri de 1-5 ani, iar în 31 cazuri de la 5 la 10 ani. Protocolul de urmærire a inclus examenul clinic, ecografia, urografia, nivelul seric al creatininei øi ureei, urocultura øi calitatea vieflii. 7 unitæfli renale cu hidronefrozæ gradul II s-au normalizat postchirurgical. În cazurile cu grad III de hidronefrozæ rezultatele au fost urmætoarele: normalizare la 18 cazuri, scæderea gradului de hidronefrozæ la 2 cazuri øi un Introduction: This retrospective study was done to assess the early and late results after open surgery pyeloplasty in children patients. Material and Methods: 74 children suffered of congenital uretero-pelvic junction obstruction were admitted in our department and entered in this study from January 2000 to January The youngest was 1.1 years old, the oldest was 15.7, with an average of kids had unilateral junction obstruction and 10 kids had bilateral obstruction. 84 renal units entered in the study and international classification of hydronephrosis was considered. 9 units had grade II hydronephrosis, 30 units had grade III, 33 units had grade IV and 12 units had grade V hydronephrosis. Clinical and ultrasound examination, conventional and diureticstimulated urography and in selected cases radionuclide renography, CT and MRI urography were performed in order to reach the diagnostic. Results: Dismembered Hynes-Anderson pyeloplasty represented the golden standard surgical procedure. It was performed in 76 cases, and in one case uretero calico anastomosis was done. In five cases of horseshoe kidney anterior trans-peritoneal approach was considered. Vascular de-crossings (18 cases), surgical lithotomy (14 cases), ESWL (4 cases) completed the pyeloplasty. Different procedures of drainage followed the junction reconstruction. Primary nephrectomy was performed in 8 cases and secondary late nephrectomy in 3 cases. According to the moment of operation the follow-up period was 1-5 years in 24 cases and 5-10 years in 31 cases. The follow-up protocol included clinical examination, ultrasound, urography, BUN, serum creatinine level, urine culture and quality of life. 7 renal units with grade II hydronephrosis normalized after surgery. In grade III cases the results were as follows: 18 cases normalization, 2 cases the grade of hydronephrosis decreased and in one case the grade increased. For grade IV dilatation the results were as follows: 8 cases - normalization nr. 2 / 2012 vol 11 Revista Românæ de Urologie 63

65 Varia singur caz în care hidronefroza a crescut. Pentru dilataflia de grad IV, rezultatele au fost: normalizare postchirurgicala la 8 cazuri, scæderea sau staflionarea hidronefrozei la 9 cazuri, iar în 3 cazuri hidronefroza a crescut. Hidronefroza de grad IV s-a ameliorat postchirurgical la 8 cazuri, 3 cazuri necesitând nefrectomie. Concluzii: Diagnosticul øi tratamentul precoce au ameliorat rezultatele pieloplastiei. Gradul de dilatare preoperatorie a influenflat rezultatele operatorii finale. Chirurgia deschisæ poate rezolva eventuala patologie asociata - litiazæ, malformaflii, anomalii vasculare, etc. Ecografia în timpul vieflii intrauterine ar trebui sæ reprezinte test de screening pentru diagnosticul corect al stadiilor incipiente ale bolii. after surgery, 9 cases - stationary or the hydronephrosis grade decreased, and in three cases the hydronephrosis increased despite the reconstructive surgery. In 8 cases of grade V hydronephosis surgery ameliorated the dilatation but in three cases we removed the renal unit. Conclusions: Early diagnostic and treatment ameliorated pyeloplasty results. The preoperative grade of dilatation influenced the final surgery result. Open surgery could solve the associate pathology lithiasis, malformations, etc. In utero ultrasonography should represents the screening test in order to reach the diagnostic in early stages of the disease. 64 Revista Românæ de Urologie nr. 2 / 2012 vol 11

66 4.11. Tratamentul chirurgical al hipospadiasului: aspecte tehnice øi rezultate V. D. Stanca, P. Prunduø, S. Bonafl, A. Boc, Alexandra Andreea Poienar, I. Coman Spitalul Clinic Municipal Cluj-Napoca, Secflia Clinicæ de Urologie, Departamentul de Urologie Pediatricæ Surgical treatment of hypospadias: surgical technique and results V. D. Stanca, P. Prunduø, S. Bonafl, A. Boc, Alexandra Andreea Poienar, I. Coman Clinical Municipal Hospital Cluj Napoca, Pediatric Urology Department Varia Introducere. Hipospadiasul poate avea ræsunet important asupra vieflii sexuale øi a fertilitæflii adolescentului øi adultului tânær. Prezentæm rezultatele obflinute în serviciul nostru prin diverse tehnici de uretroplastie adresate defectelor uretrale congenitale. Material øi metodæ. Am evaluat datele pacienflilor tratafli în serviciul nostru pentru hipospadias între anii În caz de hipospadias proximal am utilizat uretroplastie în manieræ Tiersch-Duplay sau Duckett iar pentru varietatea distalæ am preferat tehnica Snodgrass. Am asigurat drenajul urinii prin cateterul uretral øi printr-un cateter vezical suprapubian. Am înregistrat tipul de uretroplastie efectuatæ, rezultatele obflinute øi rata de complicaflii. Rezultate. În departamentul nostru au fost tratafli 25 de bæiefli cu hipospadias de diverse grade de severitate. Doar 14 copii au fost operafli pentru prima datæ de cætre noi, restul având în antecedente multiple uretroplastii efectuate în alte servicii medicale. Rezultatele au fost bune din punct de vedere cosmetic øi funcflional în urma primei intervenflii chirurgicale la 90% dintre pacienflii cu hipospadias distal (coronal øi glandular) øi la 45% dintre cei cu meat la nivelul corpului penian sau perineal. La pacienflii cu hipospadias proximal am înregistrat o ratæ de eøec a uretroplastiei (dehiscenflæ totalæ sau fistulæ uretro-cutanatæ) de 55%, aceste cazuri necesitând reintervenflie; pentru copiii cu hipospadias distal procentul de complicaflii postoperatorii (stenozæ uretralæ) a fost de doar 10%. Nu am înregistrat incidente legate de montarea trocarului suprapubian. Concluzii. Hipospadiasul (în special varianta proximalæ) este o afecfliune care încæ ridicæ probleme din punct de vedere terapeutic. Utilizarea de rutinæ a drenajului vezical suprapubian øi a lambourilor vascularizate de dartos a permis ameliorarea rezultatelor. Introduction. Hypospadias may have a major impact on the sexual life and fertility of the teenager and young adult. We present the results obtained in our department through various techniques of urethroplasty addressed to the congenital urethral defects. Materials and methods. We evaluated the data of the patients treated in our department for hypospadias between 2004 and For urethroplasty we used Tiersch-Duplay, Duckett and Snodgrass techniques. A urethral catheter and a suprapubic bladder catheter were used for bladder drainage in the postoperative period. We recorded the type of urethroplasty, the results and complication rate. Results. Twenty-five boys with different grades of severity of hypospadias were treated in our department. Fourteen children were treated only in our department; the other 11 children had antecedents of multiple urethroplasties done in other medical services. We opted for the Tiersch-Duplay or Duckett technique for proximal hypospadias and we preferred the Snodgrass technique for the distal variety. We recorded a failure rate after the first surgical intervention (urethro-cutaneous fistula) of 55% on patients with proximal hypospadias; the results were improved only after the routine use of a dartos flap for covering the neo-urethra. For patients with distal hypospadias, the percentage of postoperative complications (urethral stenosis) was 10%. We did not record any incidents during the suprapubic bladder drainage. Conclusions. Hypospadias (especially proximal hypospadias) is still a challenging disease. Routine use of the suprapubic bladder drainage and of dartos flaps offers better results. nr. 2 / 2012 vol 11 Revista Românæ de Urologie 65

67 Varia Leziuni uretrale iatrogene la camera de gardæ experienfla Clinicii de Urgenflæ Sf. Ioan Bucureøti E. Constantinescu, R. Mulflescu, B. Geavlete, R. Satalan, L. Adou, P. Geavlete Clinica de Urologie, Spitalul Clinic de Urgenflæ Sf. Ioan, Bucureøti Iatrogenic urethral lesions in the emergency room St. John Emergency Clinical Hospital experience E. Constantinescu, R. Mulflescu, B. Geavlete, R. Satalan, L. Adou, P. Geavlete Department of Urology, Saint John Emergency Clinical Hospital, Bucharest Introducere: Leziunile iatrogene ale uretrei sunt o patologie frecventæ la camera de gardæ. Rezolvarea acestor leziuni poate ridica o serie de probleme specifice. Material øi metodæ: În perioada Ianuarie 2009 Ianuarie 2012, 419 pacienfli cu retenflie completæ de urinæ øi leziuni iatrogene ale uretrei post tentativæ de cateterizare uretrovezicalæ s-au prezentat la camera de gardæ urologie. Au fost evaluate retrospectiv modul de producere a leziunilor precum øi modul de manageriere a acestor leziuni în urgenflæ. Rezultate: Tentativa iniflialæ de cateterizare a fost practicatæ de personal medical mediu în 181 cazuri (43,2%) øi de cætre medici în 207 cazuri (49,4%). În 31 de cazuri nu a putut fi identificatæ calificarea persoanei care a tentat cateterizarea. Modalitatea de rezolvare a retenfliei complete de urinæ a fost reprezentatæ de montare simplæ a unei sonde uretro-vezicale (128 cazuri), montare asistatæ de mandren (107 cazuri), montare sub control endoscopic (86 cazuri), montare cistostomie suprapubianæ (98 cazuri). Numai 308 dintre aceøti pacienfli au revenit pentru urmærire, 28% dintre aceøtia prezentând la 3 luni stricturi uretrale. Concluzii: Producerea leziunilor iatrogene uretrale post tentativæ de cateterism uretro-vezical nu pare sæ se coreleze cu pregætirea personalului ce tenteazæ manevra. Rezolvarea retenfliei complete de urinæ poate necesita manevre diverse, adaptate fiecærui caz în parte. Introduction: Iatrogenic uethral lesions are a frequent pathology in the emergency room. Solving these lesions may raise some specific problems. Material and methods: Between January 2009 January 2012, 419 patients with complete urinary retention and iatrogenic urethral lesions following unsuccessful urethravesical catheterization were treated in the emergency room. We evaluated in a retrospective manner the circumstances in whichthe lesions were produced as well as the management of these patients. Results: The initial catheterization attempt was performed by nurses in 181 cases (43,2%), doctors in 207 cases (49,4%). In 31 cases the qualification of the personnel attempting the catheterization could not be determined. The complete urinary retention was solved by simple urethra-vesical catheterization (128 cases), using a rigid obturator (107 cases), endoscopically assisted catheterization (86 cases), suprapubic cistostomy (98 cases). Only 308 cases returned during follow-up, 28% of them presenting urethral strictures after 3 months. Conclusion: Iatrogenic urethral lesions following urethrovesical catheterization attempts don t seem to be correlated with the qualification of the personnel performing it. Management of the complete urine retention may require various maneuvers, adapted to the particularities of each case. 66 Revista Românæ de Urologie nr. 2 / 2012 vol 11

68 4.13. Uretroplastia cu grefæ din mucoasa bucalæ fixatæ ventral, pentru stricturile uretrei peniene: Eøec previzibil? V. Voinescu, M. Hurduc Spitalul Clinic Prof. Dr. Theodor Burghele, Bucureøti Ventral Buccal Mucosa Graft Urethroplasty for Penile Urethral Strictures: A predictable failure? V. Voinescu, M. Hurduc Prof. Dr. Theodor Burghele University Hospital, Bucharest Varia Introducere: În cazul uretroplastiilor cu grefæ din mucoasæ bucalæ (GMB) la nivelul uretrei peniene (UP), se preferæ fixarea dorsal deoarece fixarea ventral (FV) nu ar asigura GMB un suport nutriflional øi mecanic suficient, flesutul spongios de la acest nivel fiind insuficient pentru a o acoperi. Ar rezulta astfel mai frecvent stricturi,fistule øi evacuarea involuntaræ de picæturi de urinæ posmicflional. Deoarece FV a GMB presupune doar o incizie ventralæ a segmentului uretral stenozat øi nu afecteazæ vascularizaflia uretrei øi integritatea albugineei corpilor cavernoøi, iar in literatura de specialitate nu sunt studii axate doar pe FV a GMB la nivelul UP, am conceput un studiu prospectiv legat de aceastæ localizare. Pacienfli øi Metodæ: Ne-am propus selectarea pacienflilor (p) care aveau stricturi la nivelul UP cu alte etiologii decât lichen sclerosis sau multiple operaflii pentru hipospadias, iar lumenul uretral în porfliunea stenozatæ nu era mic de 2 mm. În perioada ianuarie noiembrie 2011 au corespuns acestor criterii 27 p. Dintre aceøtia 4 au avut afectatæ øi fosa navicularæ.lungimea stricturilor a fost cuprinsæ între 2 øi 12 cm (media 3 cm). S-a folosit urmætoarea tehnicæ chirurgicalæ: incizia circularæ a tegumentului penian sub gland øi decolarea acestuia, færæ dartos, pânæ la baza penisului, incizia medianæ ventralæ a segmentului uretral stenozat, croirea GMB peste sondæ Foley din silicon 22 Ch øi fixarea acesteia la marginile mucoasei uretrale, acoperirea GMB cu 2 lambouri laterale din dartos, acoperite la rândul lor cu tegumentul penian readus la nivelul subcoronar.sonda s-a scos dupæ 10 zile. Rezultate: Perioada de urmærire a fost cuprinsæ între 4 øi 35 luni (media 21 luni) constând în examen clinic, uroflowmetrie øi ecografie uretralæ. La 1 p s-a produs o fistulæ uretralæ, iar la 2 p diafragm fibros la extremitatea proximalæ a neouretrei, rata de succes fiind astfel de 88,89%.Tofli p au fost mulflumifli de aspectul penisului øi de activitatea sexualæ ulterioaræ operafliei iar lumenul uretral s-a menflinut între 6 øi 7 mm. Concluzii: FV a GMB, prin tehnica descrisæ, reprezintæ o soluflie cu rezultate bune pentru cazuri selecflionate cu stricturi ale UP. Introduction: In the case of buccal mucosa graft (BMG) urethroplasty for penile urethral strictures (PUS), the dorsal graft inlay or onlay is preferred, as it is supposed that the ventral onlay (VO) would not assure to BMG sufficient nutritional and mechanical support, the spongy tissue at this level being insufficient to cover it. Thas it`s supose to be more frequent strictures, fistulas and dribbling. Because VO of BMG requires only one ventral incision of the stenotic urethral segment and does not affect the urethral vasculature and the integrity of the tunica albuginea of the corporal bodies, and literature studies focused only to VO of BMG for PUS are scarce, we have design a prospective study related to this issue. Patients and Methods: We selected patients (pts) with PUS other than due to lichen sclerosus or to multiple operations for hypospadias, and with stenotic urethral lumen no less than 2 mm. Between January 2009 and November 2011, 27 pts have met these criteria. Four pts had also fossa navicularis involvement. The strictures` length was between 2 and 12 cm (mean 3 cm). We used the following surgical technique: circular incision of the penile skin just below the glans, degloving without dartos down to the penile base, ventral median incision of the stenosed urethral segment, tailoring of the buccal mucosa graft over a 22 Ch silicone catheter and fixation at the urethral mucosa edges, covering the graft with two lateral dartos flaps, witch are covered with penile skin, pulled back and sutured at the subcoronary level. The catheter was removed after 10 days. Results: Followup ranged from 4 to 35 months (mean 21 months) consisting of clinical examination, uroflowmetry, and urethral ultrasonography. In one patient urethral fistula occurred and in two patients a fibrous diaphragm at the proximal end of the neourethra appeared. For the rest of the p the neourethra lumen was stable between 6 and 7 mm at urethral ultrasonography control, the succes rate being 88.89%. All patients were satisfied with the cosmetic appearance of the penis and with the sexual activity after surgery. Conclusion: The VO of BMG by the technique described, is a good solution for selected patiets with PUS. nr. 2 / 2012 vol 11 Revista Românæ de Urologie 67

69 Varia Proteza penianæ SPECTRA: Experienfla noastræ V. Voinescu, A. H. Ateia *, M. Vizireanu * Spitalul Clinic Prof. Dr. Theodor Burghele, Bucureøti * Medas - Spitalul Clinic Sf. Maria, Bucureøti AMS SPECTRA Penile Concealable Prosthesis: Our experience V. Voinescu, A. H. Ateia *, M. Vizireanu * Prof. Dr. Theodor Burghele University Hospital, Bucharest * Medas - Sf. Maria University Hospital, Bucharest Introducere: Lansatæ pe piafla medicalæ în luna mai 2009, proteza semirigidæ SPECTRA (American Medical Systems, Inc. Minneapolis) prezintæ o serie de avantaje faflæ de predecesoarele ei, atât pentru medic (adaptare lungimii cu prelungitoare proximale (PP) la trei variante de grosime) cât øi pentru pacient (p) (rigiditate fermæ combinata cu uøurinfla îndoirii plastice ventrale, aspect cosmetic excelent, uøor de manevrat). Obiective: Prezentarea experienflei noastre privind problemele legate de tehnica implantærii protezei semirigide SPECTRA, precum øi rezultatele pe care le-am obflinut. Pacienfli øi metodæ: În perioada septembrie-decembrie 2011 am implantat 5 proteze SPECTRA la 4 p cu vârste cuprinse între 36 øi 55 ani (media 49 ani) pentru: disfuncflie erectilæ (DE) postpriapism (1p), DE vascularæ (1p), înlocuire protezæ penianæ artizanalæ (2p) øi protezæ SPECTRA (1p). Anestezia a fost rahidiana iar p a fost aøezafli în poziflie de litotomie dupæ care s-a pus sondæ Foley16 Ch. Incizia corpilor cavernoøi s-a fæcut prin abord penoscrotal la 2p øi penoscrotal øi subcoronar la 3p Dilataflia s-a relizat cu dilatatoare metalice Hegar exceptând p la care s-a înlocuit proteza SPECTRA unde dilataflia nu a fost necesaræ. Dimensiunile celor doi cilindri [grosime (mm) / lungime (cm) / PP (cm)] : 9,5/16/0 (1p), 12/20/2 (1p), 12/20/1,5 (1p), 12/20/2 (1p), 14/20/4 (1p). Preoperator s-a administrat iv profilactic vancomicinæ øi gentamicinæ, continuatæ 7 zile pospoperator, iar în timpul operafliei s-a facut lavajul intermitent al corpilor cavernoøi cu soluflie de vancomicinæ øi gentamicinæ. Sonda Foley s-a extras dupæ 24 ore iar pansamentul dupæ 2 zile. p au avut permisiunea sæ înceapæ activitatea sexualæ dupæ 6 sæptæmâni. Rezultate: Evoluflia postoperatorie a fost færæ complicaflii p pæræsind spitalul dupæ 3 zile.urmærirea s-a fæcut pe o perioadæ cuprinsæ între 3 øi 6 luni (media 4 luni). Tofli p øi-au început viafla sexualæ øi sunt mulflumifli atât ei cât øi partenerele lor. Concluzii: Proteza semirigidæ SPECTRA reprezintæ o opfliune pentru p cu indicaflie pentru implantarea unei proteze peniene øi care doresc una uøor de manevrat la un cost rezonabil. Background: Launched on the medical market in May 2009, AMS SPECTRA concealable penile prosthesis (American Medical Systems, Inc.. Minneapolis) has some advantages over its predecessors, both for the doctor (length adjustment with Snap-fit Rear Type extenders (RTE) at three different cylinder diameter) and also for the patient (p) (firm rigidity combined with ease in ventral plastic bending, excellent cosmetic appearance, easy to handle) Objectives: Presenting our experience on technical issues and outcome regarding the AMS SPECTRA concealable penile prosthesis implantation. Patients and Methods: Between September - December 2011 we have implanted 5 SPECTRA prostheses on 4 patients aged between 36 and 55 years (mean 49years) for: erectile dysfunction (ED) postpriapism (1p), vascular ED(1p), replacement of hand made penile prosthesis (2p) and AMS SPECTRA prosthesis replacement(1p). We used spinal anesthesia, the patients were placed in lithotomy position and a 16 Ch Foley catheter was placed. The incisions of the corporeal bodies was performed by penoscrotal approach in 2 cases and by both penoscrotal and subcoronary approach in 3 cases. The dilatation was performed with Hegar metal dilators in all cases except in the case of SPECTRA prosthesis replacement, where it has not been necessary. We used the following dimensions of two cylinder [width (mm) / length (cm) / RTE (cm)]: 9.5 / 16/0 (1p), 12/20/2 (1p), 12/20/1, 5 (1p), 12/20/2 (1p), 14/20/4 (1p). Preoperatively the patients received i.v. vancomycin and gentamicin as profilaxy, treatment which continued for 7 days after surgery. During the operation, intermittent corporeal body washing with vancomycin and gentamicin solution was performed. The Foley catheter was removed after 24 hours and the bandage after 2 days. Patients were allowed to begin sexual activity after 6 weeks. Results: The postoperative evolution was straightforward, the patients leaving hospital after 3 days. The follow up was between 3 to 6 months (median 4 months). All patients have started their sexual activity and both they and their partners are satisfied. Conclusions: AMS SPECTRA concealable penile prosthesis is an option for patients with indication for implantation of a penile prosthesis who want an easy to use at a reasonable cost one. 68 Revista Românæ de Urologie nr. 2 / 2012 vol 11

70 4.15. Pseudochist suprarenalian drept infectat urgenflæ urologicæ N. Dobromir, N. Stoican, A. Filip, A. Tætæranu, O. Dobromir Secflia Urologie, Spitalul Judeflean Suceava Right adrenal infected pseudocyst urological emergency N. Dobromir, N. Stoican, A. Filip, A. Tætæranu, O. Dobromir Urology Department, Suceava Emergency County Hospital Varia Scop. Rezolvarea chirurgicala de urgenta a fost impusa de simptomatologia secundara compresiei efectuate de pseudochistului suprarenalian voluminos drept ml - si de componenta septica. Material øi metodæ. B.M., F.O , 56 ani, veche diabeticæ insulino-dependentæ se interneaza in urma cu 7 zile in serviciul de Boli de Nutritie pentru dureri in hipocondrul drept cu intensitate progresiva, tulburari de tranzit. Dupa o scurta reechilibrare hidroelectrolitica, sub tratament cu fluorochinolona (2 zile) se transfera in serviciul de Boli Infectioase. Se recolteaza hemocultura si se instituie tratament cu Meropenem. Persistenta sindromului algic abdominal si febrei impun transfer la sectia Chirurgie se efectueaza examen C.T. de urgenta si se deceleaza dg. Chist suprarenalian drept voluminos infectat; Maladie polichistica hepato-renala. Febra si durerea lancinanta in hipocondrul si lomba dreapta decid explorarea chirurgicala urologica de urgentæ. Prin abord transperitoneal: incizie Giuliani se evidentiaza hemicupola anterioara subhepatica a chistului in tensiune.se punctioneaza si se extrage 20 ml. lichid piohematic pentru ex. bacteriologic. Tentativa esuata de excizie a chistului dictata de topografia sa, compresia cavo-hepatica, starea febrilæ prelungita, si tarele asociate (polichistoza hepatorenala, diabet zaharat insulinodependent) impune rezectia hemicupolei anterioare a chistului (ex. H-P) si se evacueaza continutul (700 ml). Dupa lavajul cavitatii restante cu ser fiziologic se instituie drenaj cu doua tuburi siliconatate exteriorizate in flancul drept ( unul in cavitatea chistica si unul interhepatorenal drept) si dren in Douglas-ul exteriorizat in fosa iliaca stanga. Postoperator febra se remite brusc, durerea abdominalæ dispare si starea generala se amelioreaza progresiv prin continuarea terapiei antiinfectioase si monitorizarea glicemiei sub insulina. Concluzii. Caz extrem de rar, cu debut febril si sindrom algic abdominal la o bolnava cu diabet zaharat si polichistoza hepatorenala. Precizarea diagnosticului in contextul ex. clinic si a ex. paraclinice a fost decisiva prin ex. C.T. Rezolvarea chirurgicala de urgenta a fost impusa de persistenta febrei si amploarea sindromului algic abdominal secundar compresiei de vecincatate. Postoperator evolutia se amelioreaza prin continuarea tratamentului antiinfectios sustinut. La externare se recomanda monitorizarea echografica la 30 zile, apoi la luni a evolutiei cavitatii chistice restante, clinica, ex. de laborator. Purpose. Emergency surgical solving was imposed by symptoms of secondary compression performed of right adrenal pseudocyst volume -700 ml - and septic component. Material and methods. B.M., F.O , 56 years old insulindependent diabetic is hospitalized 7 days ago in Nutrition Diseases Service for right upper quadrant pain with progressive intensity, transit disorders. After a short rebalancing electrolyte equilibrium, with fluoroquinolone therapy (2 days) is transferred in the Service of Infectious Diseases. Blood culture is harvested and establish treatment with Meropenem. Persistent painful abdominal syndrome and fever imposed transfer to the Surgery Section - emergency CT is performed and the diagnosis reveals Bulky right infected adrenal cyst, hepato-renal polycystic disease. Fever and lancinant pain in the right upper quadrant and lomb required Urologic emergency surgical exploration. The transperitoneal approach by Giuliani incision reveals subhepatic anterior hemicupola of the cyst. The puncture draws 20 ml. piohematic liquid for bacteriologic examination. Failed attempt excision of the cyst - was dictated by topography, cavo-hepatic compression, patient status and comorbidities, prolonged fever (hepato-renal policystosis, insulinodependent diabetes). Surgical resection of the anterior cyst hemicupola (HP ex.) and the content is discharged (700 ml). After cavity lavage with saline, drainage is established with two siliconatated tubes in the right flank (one in the cystic cavity and one in in the right interhepatorenal space). Douglas drained and the tube is externalized in right iliac fossa. Postoperative - sudden fever resolves, general abdominal pain disappears, gradually improvement of general status. Conclusions. The case is extremely rare, onset with fever and painful abdominal syndrome to a patient with diabetes and hepato-renal policystosis. The diagnosis in the context of clinical examination and laboratory tests was decisive by using CT examination. Emergency surgical solving was required for persistent fever and painful abdominal syndrome. Postoperative evolution is improved by further supported antibiotic treatment. Ultrasound monitoring is required to discharge, to 30 days, then at months for the remaining cystic cavity evolution. nr. 2 / 2012 vol 11 Revista Românæ de Urologie 69

71 Varia Ureaplasma urealyticum agent infecflios cu frecvenflæ crescândæ în infecfliile genitale masculine Enikõ Barabás-Hajdu 1, Orsolya Mártha 2, Enikõ Nemes-Nagy 3, Noémi Pakuts, A. Martonos 1 UMF Tg. Mureø, Departmentul de Microbiologie øi Farmacie Clinicæ 2 Departmentul de Urologie Ureaplasma urealyticum a microorganism with increasing frecquency in the etiology of male genital infections Enikõ Barabás-Hajdu 1, Orsolya Mártha 2, Enikõ Nemes-Nagy 3, Noémi Pakuts, A. Martonos 1 UMPh Tg. Mureø, Clinical Pharmacy - Microbiology Department 2 Urology Department 3 Departmentul de Biochimie 3 Biochemistry Department Introducere. Reprezentanflii familiei Mycoplasmataceae, ca Mycoplasma hominis (M) øi Ureaplasma urealyticum (U) sunt frecvent prezente pe mucoasele genitale masculine øi feminine, rolul lor etiopatogenic fiind incert. Se presupune cæ, împreunæ cu alte microorganisme, ca øi chlamydiile, declanøeazæ uretrite nongonococice (UNG). Datoritæ faptului, cæ nu au perete celular, sunt rezistente faflæ de antibioticele care flintesc aceste structuri. Medicaflia de primæ intenflie constæ în administrarea antibioticelor cu spectru larg, cum ar fi tetraciclinele, deoarece rezistenfla faflæ de fluoroquinolone (ciprofloxacinæ, ofloxacinæ) este în continuæ creøtere. Pentru stabilirea unei conduite terapeutice adecvate, este foarte importantæ efectuarea antibiogramei. În studiul nostru am urmærit apariflia multirezistenflei la antibiotice a tulpinilor de U izolate de la pacienflii unui cabinet ambulator de urologie. Material øi metodæ: între øi , s-au recoltat 527 de secreflii uretrale de la pacienfli acuzând disurie øi scurgeri genitale. Din fiecare produs patologic s-au efectuat frotiuri øi culturi pe mediul Mycoplasma IST2 fæcând posibilæ detectarea M øi U, concomitent cu determinarea cantitativæ a sensibilitæflii lor faflæ de 9 antibiotice cum ar fi: doxiciclina (DOT), josamicina (JOS), ofloxacina (OFL), eritromicina (ERY), tetraciclina (TET), ciprofloxacina (CIP), azitromicina (AZY), claritromicina (CLA), øi pristinamicina (PRI). Aceste antibiotice sunt testate pe mediu în 2 concentraflii, ce permite alegerea terapiei cât mai eficiente, de ex. DOT 4 mg/l 8 mg/l. Interpretarea testelor se face la 24, respectiv 48 de ore de la însæmânflare, apariflia culorii ciclamen denotând creøterea bacteriei. Dacæ acest fenomen apare în godeul marcat cu 104 unitæfli formatoare de colonii, UFC, pe ml, persoana Introduction: Mycoplasma hominis (M) and Ureaplasma urealyticum (U) like other members of the Mycoplasmataceae family, are frequently present as comensals on the male and female genital mucosa. Their etiopatogenic role is not well defined, but there are theories suggesting that, with other microorganisms like chlamydia, they may cause nongonococcal urethritis (NGU). Because they lack cellular wall, the NGU caused by them cannot be treated with antibiotics targeting these structures. Medication should be started with broad- spectrum substances, such as tetracycline, because fluoroquinolon- resistance is increasing (ciprofloxacin, ofloxacin). The most efficient antibiotic should always be chosen through an antibiotic sensitivity test (AST), which lends also information about appearance of multi resistant strains. Our work studies the frequency and antibiotic sensitivity of U strains isolated form patients attending to an ambulatory Urology ward. Material and methods: between and , 527 urethral samples were collected from male patients complaining of dysuria and genital discharges. Each sample was tested microscopically and cultivated on liquid Mycoplasma IST2 medium, which enables detection and simultaneously AST of M and U isolates. The use of 9 antibiotics, doxycycline (DOT), josamycin (JOS), ofloxacin (OFL), erythromycin (ERY), tetracycline (TET), ciprofloxacin (CIP), azithromycin (AZY), clarithromycin (CLA), and pristinamycin (PRI) in two different concentrations enables us to choose the best medication with the most useful concentration, e.g. DOT 4 mg/l - 8 mg/l. Reading of the tests is performed after 24 and 48 hours. Appearance of cyclamen 70 Revista Românæ de Urologie nr. 2 / 2012 vol 11

72 Varia respectivæ suferæ de infecflie cu U sau M. Antibiograma se citeøte simultan øi se interpreteazæ conform standardelor internationale, CLSI, în vigoare. La 2 sæptæmâni de la terminarea tratamentului, pacienflii sunt supuøi unei testæri noi, de verificare. Rezultatele noastre au arætat infecflie cu U la 68 (12,09%) dintre pacienflii testafli. Nu s-a depistat nici un caz cu M. Tetracyclinele au fost eficiente, numai 6% dintre tulpini erau rezistente (R) la DOT øi TET, ele fiind multirezistente øi la alte antibiotice. Dupæ sistarea tratamentului cu TET, având în vedere cæ este un agent bacteriostatic øi pot apærea recæderi chiar øi la tulpinile sensibile, pacienflii au fost retestafli. Nu am observat recæderi dupæ terapia cu TET. Datoritæ folosirii pe scaræ largæ a fluorochinolonelor (CIP, OFL), multe bacterii au devenit rezistente faflæ de ele, cum a fost øi în cazul pacienflilor noøtri, 85% fiind R. Se cunoaøte faptul cæ rezistenfla la fluorochinolone se datoreøte mutafliilor. Prevenirea lor poate reduce semnificativ apariflia tulpinilor rezistente. Macrolidele, cum ar fi ERY s-au dovedit utile la testærile in vitro în 80% a cazurilor, dar sensibilitatea in vitro trebuie aplicatæ cu precauflii în sfera acidæ a genitalelor. In vivo, dar øi in vitro AZY, CLA sunt mai active, fapt demonstrat øi prin rezulatele noastre; din toate tulpinile testate numai una a fost rezistentæ la CLA. Tulpinile testate la macrolidele JOS øi PRI au demonstrat sensibilitate (S), numai o tulpinæ a fost intermediar S la JOS. Dintre pacienflii infectafli cu U, 6% gæzduiau tulpini multirezistente la cel puflin 5 antibiotice: DOT, TET, OFL, ERY øi CIP, însæ toate au ræmas S la JOS, CLA øi PRI. Aceste medicamente pot servi ca o alternativæ în tratamentul tulpinilor multirezistente În concluzie, folosirea mediului Mycoplasma IST2 a fæcut posibilæ cultivarea acestor bacterii foarte exigente, øi totodatæ tratarea flintitæ a bolnavilor pe baza antibiogramei. Având în vedere apaiflia din ce în ce mai frecventæ a tulpinilor rezistente la fluorochinilone, de altfel uøoare de administrat, ele nu pot fi aplicate ca tratament de primæ intenflie, acesta ræmânând tetraciclinele. colored media show the growth of U or M in the wells. If this phenomenon appears in the well, which is marked with 104 colony forming units, CFU/ ml, the person has U or M infection. The AST may be read at the same time and interpreted accordingly, by CLSI standards. Two weeks after treatment, patients are retested for the same infection. Results: showed U infections in 68 (12,09%) patients. No M infection was detected. Tetracyclines were efficient, only 6% of the isolates proved resistant (R) to both DOT and TET, beeing also multiresistant to other antibiotics. Because TET is a bacteriostatic agent, relapses may occur even in sensitive isolates, so patients were retested after treatment, without having any relapses in our cases. The overuse of fluoroquinolones (CIP, OFL), led to generations of resistant strains, even in our patients, 85% of the U isolates beeing R. It is well-known that fluoroquinolon- resistance is caused by mutations in the bacteria. Preventing mutations may reduce significantly appearance of R strains. Macrolides, like ERY are useful in vitro in 80% of the isolates, but results most be applied with precautions in the acid environment of the genital mucosa. AZY and CLA are more active in vivo and in vitro, proved also by our results, were each isolate was sensitive to AZY and only one proved R to CLA. All isolates tested for the macrolides JOS and PRI demonstrated sensitivity (S), except one intermediate S to JOS. Of all U infected patients, 6% had infections with multi resistant strains, being R to at least five antibiotics: DOT, TET, OFL, ERY and CIP. All of these strains stayed S to JOS, CLA and PRI, medicines which may be chosen as alternatives in the treatment of multi resistant strains. In conclusion, the use of Mycoplasma IST2 medium makes us possible to cultivate these difficult-to grow bacteria and enables us the simultaneous AST so that patients can be treated efficiently. Because U isolates are frequently R to fluoroquinilones, otherwise easy to administrate to the patients, they cannot be used in the initial treatment of the infection, the first choice remaining the tetracycline. nr. 2 / 2012 vol 11 Revista Românæ de Urologie 71

73 Litiazæ 5.1. Rata complicafliilor la pacienflii cu NLP post ESWL V. Mirciulescu, G. Niflæ, D. Georgescu, C. Persu, R. Mulflescu, M. Dræguflescu, C. Ene, M. Alexandrescu, B. Mihai, C. Moldoveanu, B. Geavlete, I. Arabagiu, P. Geavlete Clinica de Urologie, Spitalul Clinic de Urgenflæ Sf. Ioan, Bucureøti The complications rate of the patients with PNL after SWL V. Mirciulescu, G. Niflæ, D. Georgescu, C. Persu, R. Mulflescu, M. Dræguflescu, C. Ene, M. Alexandrescu, B. Mihai, C. Moldoveanu, B. Geavlete, I. Arabagiu, P. Geavlete Department of Urology, Saint John Emergency Clinical Hospital, Bucharest Introducere. NLP (nefrolitotomia percutanatæ) este procedura minim invazivæ care practic a înlocuit chirurgia deschisæ în tratamentul calculilor renali. SWL (extracorporeal shockwave lithotripsy), pe de alta parte, a creat un nou standard în ceea ce priveste tratamentul non-invaziv al litiazei renale. Obiective. Evaluarea ratei complicafliilor la pacientii care au efectuat SWL øi la care s-a intervenit ulterior prin NLP. Material øi metodæ. În perioada august 2009 decembrie 2100 în Clinica de urologie a Spitalului Clinic de Urgenflæ «Sfântul Ioan» Bucureøti s-a practicat NLP pe un numær de 53 de pacienfli la care iniflial s-a tentat tratamentul calculilor prin SWL. Dimensiunea calculilor a fost cuprinsæ între 1 øi 1,8 cm, iar localizarea lor a fost în bazinetul renal sau calicele inferior. NLP a fost practicat în 4 cazuri la 2 sæptæmâni dupæ SWL, la 24 de bolnavi între 1 øi 2 luni, iar în restul cazurilor tardiv la cel puflin 2 luni dupæ proceduræ. La un pacient se practicaseræ 10 øedinfle SWL într-un interval de 2 luni, iar la restul o medie de 3 øedinfle într-un interval cuprins între 2 sæptæmâni øi 1 lunæ. Rezultate: Din totalul pacienflilor incluøi în studiu, 17% au prezentat complicaflii, cele mai importante fiind reprezentate de nefrectomie datoratæ hemoragiei renale (3 pacienfli - 5,6%), hematurie persistentæ (20,8%) în unele cazuri impunându-se transfuzii, febræ (24,3%), infecflie de plagæ (6,6%), urinom lombar (2 pacienfli - 3,7%). Durata medie de spitalizare a fost de 6,7 zile. Intervenflia operatorie a avut o duratæ medie de 32 minute. Având în vedere rezultatele obflinute, s-a observat o incidenflæ mai crescutæ a complicafliilor øi o duratæ a spitalizarii mai mare la grupul de pacienfli care a efectuat NLP sub 2 luni de la SWL, comparativ cu grupul de pacienfli care a efectuat NLP la 3 luni sau mai mult dupæ SWL. Concluzii. Rata complicafliilor la pacienflii cu NLP post SWL este cu atât mai mare cu cât durata între SWL øi NLP este mai micæ. De remarcat cæ în cazul intervenfliilor care au avut loc la mai mult de 2 luni de la efectuarea SWL, rata complicafliilor a fost similaræ cu cea a pacienflilor la care nu s-a efectuat SWL în antecedente. Introduction. PLN (percutaneous nephrolithotomy) is a minimal invasive procedure which tends to replace open surgery in the treatment of the renal calculi. SWL (extracorporeal shockwave lithotripsy), on the other side, creates a new standard concerning the non-invasive treatment of the renal lithiasis. Objectives. Assessing the rateof complications in patientswith PNL after SWL procedure. Material and method. Between August 2009 and December 2011 in Urological Clinic of Saint John Emergencz Clinical Hospital we performed PNL in a group of 53 patients that had undergone SWL. The calculi size was 0,8 to 1,8 cm located in renal pelvis or inferior calix. PNL was performed in 4 cases at 2 weeks after SWL, in 24 patients between 1 and 2 months and in the other cases, late, in at least 2 months after the procedure. One of our patient has performed 10 sessions of SWL within 2 months, the other ones performing an average of 3 sessions in a range between 2 weeks and one month. Results. Of all patients in our study, 17% had complications, the most important being represented by nephrectomy due to renal hemorhage (3 cases- 5.6%), persistent hematuria (20.8%) in some cases imposing transfusion, fever (24.3%), woundinfection(6.6%), lumbarurinoma(2patients- 3.7%). The average length of hospitalization was 6.7 days. The surgical intervention had an average of 32 minutes. Given the results, there was an increased incidence of complications and a higher duration of hospitalization in patients who performed PNL under 2 months from SWL, compared with the group of patients who performed PNL at 3 months or more after SWL. Conclusions. The complications rate in patients with PNL after SWL is greater as the duration between SWL and PNL is lesser. Note that the interventions which took place more than 3 months after SWL, the complications rate was similar to patients who had not undergone SWL before. 72 Revista Românæ de Urologie nr. 2 / 2012 vol 11

74 5.2. Abord endoscopic retrograd pentru calculi ureterali proximali impactafli V. Mirciulescu, R. Mulflescu, D. Soroiu, D. Georgescu, B. Geavlete, G. Niflæ, M. Dræguflescu, C. Ene, P. Geavlete Clinica de Urologie, Spitalul Clinic de Urgenflæ Sf. Ioan, Bucureøti Retrograde ureteroscopic approach for impacted proximal ureteral stones V. Mirciulescu, R. Mulflescu, D. Soroiu, D. Georgescu, B. Geavlete, G. Niflæ, M. Dræguflescu, C. Ene, P. Geavlete Department of Urology, Saint John Emergency Clinical Hospital, Bucharest Litiazæ Introducere øi obiective: Ghidurile EAU / AUA pentru litiazæ prezintæ rezultate similare ale tratamentului ureteroscopic sau prin SWL a calculilor ureterali proximali. Cu toate acestea calculi ureterali sunt mai dificil de tratat prin SWL. Studiul evalueazæ eficienfla, siguranfla øi complicafliile ureteroscopiei retrograde în tratamentul caculilor ureterali superiori impactafli. Material øi metodæ: În perioada iunie 1995 decembrie 2011, 5895 au fost tratafli prin ureteroscopie retrogradæ (6282 proceduri). În 208 cazuri procedura a fost efectuatæ pentru calculi ureterali proximali impactafli cu dimensiuni cuprinse între 8 øi 24 mm. Protocolul de urmærire a inclus ecografie, RRVS øi în cazuri selecflionate CT. Rezultate: Procedura a fost practicatæ cu succes în 192 cazuri (92,3%). În restul cazurilor fragmente litiazice au migrat la nivel pielo-caliceal impunând folosirea ureteroscopului flexibil în 8 cazuri, SWL în 7 cazuri øi NLP într-un caz. Rata complicafliilor a fost de 4,3%: hematurie persistentæ (4 cazuri), febræ (3 cazuri) øi perforaflie ureteralæ (2 cazuri). Doi pacienfli au dezvoltat stenoze ureterale la locul de impactare. Concluzii: Folosirea ureteroscopiei semirigide în tratamentul calculilor impactafli are rezultate bune cu complicaflii minime. Incidentele intraoperatorii pot necesita abord endoscopic complex. Introduction and Objectives: The AUA/EAU Ureteral Stones Guideline Panel reports similar results for SWL or ureteroscopy in proximal ureteral stones. However, impacted ureteral calculi are more difficult to treat by SWL. The aim of our study was to assess the efficacy, safety, and complications of retrograde ureteroscopy for impacted upper ureteral stones. Materials and Methods: Between June 1995 and December 2011, 5895 patients underwent retrograde ureteroscopy (6282 ureteroscopic procedures). This type of procedure was performed in 208 cases with impacted proximal ureteral stones ranging between 8 and 24 mm. The follow-up protocol included ultrasonography, KUB and, in selected cases, CT. Results: The procedure was successfully completed in 192 cases (92.3%). In the other cases, stone fragments migrated in the pyelocaliceal system imposed their retrieval with the flexible ureteroscope in 8 cases, SWL in 7 cases and percutaneous nephrolithotomy in 1 case. The complication rate was 4.3%: persistent hematuria (4 cases), fever (3 cases) and ureteral perforation (2 cases). Two patients developed ureteral strictures at the impaction site. Conclusions: In experienced hands, the use of semirigid ureteroscopy in impacted upper ureteral stones has very satisfactory results with minimal complications. Various intraoperative incidents may require complex endoscopic approach. nr. 2 / 2012 vol 11 Revista Românæ de Urologie 73

75 Litiazæ 5.3. Tratamentul stenozelor de joncfliune pieloureteralæ (JUP) prin endopielotomie retrogradæ laser I. Arabagiu, G. Niflæ, R. Mulflescu, V. Mirciulescu, C. Persu, M. Dræguflescu, M. Brægaru, P. Geavlete Clinica de Urologie, Spitalul Clinic de Urgenflæ Sf. Ioan, Bucureøti The Treatment of the Ureteropelvic Junction (UPJ) Stenosis by Retrograde Laser Endopyelotomy I. Arabagiu, G. Niflæ, R. Mulflescu, V. Mirciulescu, C. Persu, M. Dræguflescu, M. Brægaru, P. Geavlete Department of Urology, Saint John Emergency Clinical Hospital, Bucharest Obiective: Prezentæm experienfla Clinicii de Urologie a Spitalului Sf Ioan Bucureøti în tratamentul stenozelor de JUP prin endopielotomie ureteroscopicæ retrogradæ cu Laser (Diodæ, Holmium-Yag). Pacienfli øi metodæ: În perioada Ianuarie 2011 Februarie 2012 s-au efectuat 25 de endopielotomii retrograde utilizându-se fibra Laser. 20 pacienfli au prezentat stenozæ de JUP primitivæ, iar 5 pacienfli stenoze de JUP recidivate. Pacienflii au fost investigati clinic, ecografic,rrvs, UIV si UPR preproceduræ. S-a exclus prezenfla vasului polar inferior prin ecografie Doppler øi la 3 pacienti prin Angio RMN. Endopielotomia s-a practicat sub rahianestezie. Incizia s-a efectuat în cadranul posteroinferior sub control fluoroscopic. În 13 cazuri s-a folosit Laserul Diodæ, iar în 12 cazuri Holmium-Yag. Postintervenflional s-a montat sondæ JJ la 11 pacienfli pentru o perioadæ de 6-8 sæptæmâni, iar la 14 pielostent pentru aceeaøi perioadæ. Rezultatele tratamentului au fost evaluate clinic, ecografic øi urografic la o lunæ, 6 luni øi apoi se vor evalua anual. Rezultate: Durata medie a intervenfliei a fost de 35 minute (20-50 minute), iar a spitalizærii a fost de trei zile. Doi pacienfli au avut drept complicaflie postoperatorie pielonefrita acutæ, 5 pacienfli au prezentat hematurie de scurtæ duratæ. 19 pacienfli au avut evoluflie bunæ cu menflinerea unei joncfliuni pieloureterale largi la suprimarea drenajului. 6 pacienfli au prezentat restenozarea JUP dupæ 3 luni. La un pacient cu recidivæ a stenozei dupæ endopielotomie retrogradæ cu fibræ laser s-a repracticat o nouæ proceduræ de endopielotomie cu evoluflie favorabilæ, iar 5 pacienfli au beneficiat de pieloplastie. Concluzii: Endopielotomia retrogradæ cu fibra Laser este o proceduræ siguræ, cu morbiditate redusæ øi cu duratæ de spitalizare scurtæ. Aceastæ tehnicæ minim invazivæ poate fi propusæ stenozelor de JUP primitive sau secundare dar este necesaræ eliminarea pacienflilor cu vas polar inferior. Objective: To present the experience of the Urology Clinic of the St. John Emergency Clinical Hospital, Bucharest, concerning the treatment of UPJ stenosis by endoscopic retrograde Laser endopielotomy (Diode, Holmium-Yag). Patients and method: Between January 2011 and February 2012, we performed 25 retrograde endopyelotomies, using the Laser fiber. 20 patients had primitive UPJ stenosis, and 5 patients had reccurent UPJ stenosis. All patients were investigated evaluated by clinical examination, ultrasound, RRVS, IVP and retrograde pyelography prior to the procedure. The presence of crossing vessels was excluded using the Doppler ultrasound and in 3 cases we performed Angio MRI. The endopyelotomy was performed under spinal anesthesia. The incision was made in the postero-inferior quadrant under fluoroscopic control. In 13 cases we used the Diode Laser, and in 12 cases the Holmium-Yag. After the procedure, a JJ stent was indwelled in 11 patients for 6-8 weeks, and in 14 patients we used a pyelostent for similar periods. The treatment results were evaluated clinically, ultrasonographically, and by IVP at one month, 6 months and then annually. Results: The mean duration of surgery was 35 minutes (20-50 minutes), and the period of hospitalization was three days. Two patients had acute pyelonephritis as postoperative complications and 5 patients had hematuria of short duration. 19 patients had good evolution, maintaining a large UPJ after the suppression of the drain. After 3 months, 6 patients presented recurrent UPJ stenosis. One patient with recurrent stenosis after retrograde endopyelotomy with Laser fiber underwent a new procedure of endopyelotomy with favorable evolution and 5 patients underwent pyeloplasty. Conclusions: Retrograde endopyelotomy with Laser fiber is a safe procedure, with low morbidity and short hospitalization period. This minimally invasive technique may be proposed for primitive or secondary UPJ stenosis but it is necessary to eliminate patients with crossing vessels. 74 Revista Românæ de Urologie nr. 2 / 2012 vol 11

76 5.4. Defecfliuni ale instrumentarului endoscopic - experienflæ dupæ 6282 proceduri D. Georgescu, R. Mulflescu, M. Dræguflescu, B. Geavlete, P. Geavlete Clinica de Urologie, Spitalul Clinic de Urgenflæ Sf. Ioan, Bucureøti Ureteroscopic instrument damage - experience after 6282 ureteroscopies D. Georgescu, R. Mulflescu, M. Dræguflescu, B. Geavlete, P. Geavlete Department of Urology, Saint John Emergency Clinical Hospital, Bucharest Litiazæ Introducere: Defecfliunile endoscoapelor sau ale instrumentelor accesorii în cursul ureteroscopiei sau a altor intervenflii endourologice reprezintæ un incident intraoperator care poate impune oprirea procedurii sau manevre suplimentare pentru extragerea endoscopicæ. Scopul acestui studiu a fost reprezentat de evaluarea acestor incidente pe un numær semnificativ de intervenflii. Material øi metodæ: În perioada iunie decembrie 2011, în clinica noastræ 5895 de pacienfli au beneficiat de ureteroscopie retrogradæ (6282 proceduri ureteroscopice). Ureteroscopia flexibilæ a fost efectuatæ în 418 cazuri, în timp ce 5864 de proceduri au fost efectuate folosind ureteroscoape rigide. Au fost reevaluate defecfliunile instrumentarului înregistrate în cursul acestor proceduri. Rezultate: Defecfliuni importante ale endoscoapelor care au impus schimbarea instrumentului au fost înregistrate în 7 cazuri (0.1%): deteriorarea sistemului optic (1 caz) øi ruperea completæ (1 caz) a ureteroscopului semirigid 10 F, respectiv deteriorarea tecii externe (1 case), perforarea canalului de lucru (1 caz) øi ruperea majoritæflii fibrelor sistemului optic ( 3 cazuri) ale ureteroscoapelor flexibile. Defecfliunile instrumentarului accesor au survenit în alte 22 de cazuri (0.3%): ruperea sondelor extractoare (6 cazuri, 1 pentru eliberare unui calcul impactat), ruperea penselor extractoare (4 cazuri), spargerea balonaøului sondei de dilataflie (1 caz), ruperea ghidurilor (5 cazuri) øi ruperea probelor de litotriflie (6 cazuri). 10 din aceste situaflii au impus masuri active de extragere a corpilor stræini rezultafli (pærfli ale instrumetelor accesorii). Concluzii: Defecfliunile instrumentarului în cursul procedurilor ureteroscopice reprezintæ un incident intraoperator relativ rar în condifliile unui centru cu experientæ în endourologie. Totuøi, analiza acestor cazuri, este importantæ pentru evitarea altor incidente similare. Introduction: Damage of the endoscopes or accessory instruments during ureteroscopy as well as other endourological interventions represents an intraoperative incident sometimes imposing the termination of the procedure or supplementary maneuvers for endoscopic removal. Our study aimed to review such incidents after a significant experience. Material and methods: Between June December 2011, 5895 patients underwent retrograde ureteroscopy (6282 ureteroscopic procedures). Retrograde flexible ureteroscopy was performed in 418 cases, while 5864 procedures were performed using the semirigid ureteroscope. The instrumental damage encountered during all these procedures was reviewed. Results: Severe damages to the endoscopes requiring their replacement was encountered in 7 cases (0.1%): deterioration of the optical system (1 case) and complete breakage (1 case) of the semirigid 10F ureteroscopes, respectively deterioration of the outer sheath (1 case), perforation of the working channel (1 case) and breakage of the majority of fibers composing the optical system (3 cases) of the flexible ureteroscopes. Damage of the accessory instruments occurred in other 22 cases (0.35%): basket fracture (6 cases, 1 for impacted calculus release), grasping extractors breakage (4 cases), balloon dilator tearing (1 case), guidewire fracture (5 cases) and lithotripsy probes breakage (6 cases). 10 of these cases necessitated active removal maneuvers of the foreign bodies (parts of accessory instruments). Conclusions: Instrumental damage during ureteroscopic procedures is not a very frequent intraoperative incident in a center with high experience in this field. However, analysis of these cases is crucial in order to avoid future similar accidents. nr. 2 / 2012 vol 11 Revista Românæ de Urologie 75

77 Litiazæ 5.5. Ureteroscopia flexibilæ digitalæ de diagnostic: experienfla Clinicii de Urologie Sf. Ioan R. Mulflescu, D. Georgescu, B. Geavlete, P. Geavlete Clinica de Urologie, Spitalul Clinic de Urgenflæ Sf. Ioan, Bucureøti Digital diagnosis flexible ureteroscopy: experience of St. John Emergency Clinical Hospital R. Mulflescu, D. Georgescu, B. Geavlete, P. Geavlete Department of Urology, Saint John Emergency Clinical Hospital, Bucharest Introducere øi Obiective: Ureteroscopia flexibilæ a devenit, în multe centre, o proceduræ practicatæ de rutinæ. Scopul acestui studiu a fost evaluarea indicafliilor øi limitelor ureteroscopiei flexibile digitale de diagnostic.tehnologia NBI permite o mai bunæ identificare a leziunilor maligne. Material øi metodæ: În perioada Ianuarie 2010-Ianuarie 2012, în Clinica de Urologie a Spitalului Clinic Sf. Ioan s-au practicat 62 de exploræri de tip ureteroscopie flexibilæ digitalæ de diagnostic. Indicafliile au fost: stabilirea etiologiei unei imagini lacunare la nivelul tractului urinar superior (19 cazuri), hematurie unilateralæ (17 cazuri), obstrucflie la nivelul cæii urinare superioare (4 cazuri dintre care 2 pacienfli cu ureterostomie cutanatæ), teste citologice urinare modificate (11 cazuri), urmærirea tumorilor uroteliale de cale urinaræ superioaræ tratate conservator (11 de proceduri la 7 pacienfli). În toate cazurile a fost utilizat un ureteroscop Olympus URF-Vo. Rezultate: Ureteroscopia flexibilæ de diagnostic a identificat leziuni de tract urinar superior în 49/51 cazuri (96%): tumori pielocaliceale (28 cazuri), litiazæ (6 cazuri), leziuni vasculare la nivel caliceal (9 cazuri), necrozæ papilaræ (5 cazuri), leziuni sugestive de tuberculozæ urinaræ confirmate ulterior de examenul bacteriologic (1 caz). În douæ cazuri de hematurie totalæ nu au fost înregistrate leziuni sugestive. În 2 cazuri calibrul crescut al ureteroscopului flexibil nu a permis accesul pe tije caliceale având calibru redus. Tehnologia NBI a permis identificarea unor leziuni maligne suplimentare în 7 cazuri. La unul din cei 7 pacienfli cu tumori uroteliale de cale urinaræ superioaræ tratate conservator a fost identificatæ recidivæ tumoralæ. Concluzii: Ureteroscopia flexibilæ retrogradæ este o metodæ utilæ de diagnostic a patologiei cæii urinare superioare, în special atunci când metodele imagistice nu evidenfliazæ modificæri la acest nivel. Tehnologia modernæ a rezolvat problemele de vizibilitate asociate ureteroscoapelor flexibile. Totuøi, o serie de probleme de accesibilitate la nivel caliceal necesitæ încæ rezolvare. Introduction and Objectives: Flexible ureteroscopy become, in many centers a routine procedure. The aim of our study was to evaluate indications and limits of diagnosis digital flexible ureteroscopy. NBI technology allows a better detection of malignant lesions. Material and methods: Between January 2010-January 2012, 62 diagnosis digital flexible ureteroscopic procedures were performed in the Department of Urology of St. John Emergency Clinical Hospital. Indications were upper urinary tract filling defects (19 cases), unilateral hematuria (17 cases), upper urinary tract obstruction (4 cases, 2 of which in patients with urinary derivations), abnormal urinary cytology (11 cases), follow-up of conservative treated upper urinary tract urothelial tumors (11 procedures in 7 cases). An Olympus URF-Vo ureteroscope was used in all cases. Results: Diagnosis flexible ureteroscopy identified upper urinary tract lesions in 49/51 cases (96%): pyelocaliceal tumors (28 cases), lithiasis (6 cases), caliceal vascular lesions (9 cases), papillary necrosis (5 cases), lesions suggestive for urinary tuberculosis (1 case). In 2 cases with total hematuria no suggestive lesions were found. In 2 cases, the large tip of the ureteroscope prevented the access in thin caliceal infundibulum. NBI technology allowed detection of supplementary malignant lesions in 7 cases. Tumoral recurrence was found in 1 of the 7 cases with conservative treated upper urinary tract tumors Conclusions: Flexible retrograde ureteroscopy is a useful diagnosis method in upper urinary tract pathology, especially when imaging data are equivocal. Modern technology solved the visibility issues related to flexible ureteroscopies. However, a series of accessibility issues still require attention. 76 Revista Românæ de Urologie nr. 2 / 2012 vol 11

78 5.6. Istoria naturalæ a fragmentelor litiazice reziduale clinic nesemnificative un studiu retrospectiv R. Mulflescu, M. Dræguflescu, B. Geavlete, V. Iordache, R. Satalan, P. Geavlete Clinica de Urologie, Spitalul Clinic de Urgenflæ Sf. Ioan, Bucureøti Natural history of clinically insignificant residual stone fragments a retrospective study R. Mulflescu, M. Dræguflescu, B. Geavlete, V. Iordache, R. Satalan, P. Geavlete Department of Urology, Saint John Emergency Clinical Hospital, Bucharest Litiazæ Introducere øi obiective: Persistenfla fragmentelor litiazice reziduale clinic nesemnificative intræ în definiflia succesului ureteroscopiei pentru litiazæ. Totuøi, nu existæ o definiflie unanim acceptatæ a ceea ce înseamnæ clinic nesemnificativ. Scopul acestui studiu a fost de a determina istoria naturalæ a fragmentelor litiazice reziduale dupæ abord retrograd. Material øi metodæ: Au fost evaluafli retrospectiv 82 de pacienfli tratafli în Clinica de Urologie a Spitalului Clinic de Ugenflæ Sf. Ioan prin abord ureteroscopic retrograd pentru litiazæ pielo-calicealæ øi care au prezentat urmætoarele criterii de includere: fragmente litiazice reziduale cu dimensiuni apreciate vizual intraoperator între 1-6 mm, perioadæ de urmærire de minimum 12 luni postoperator, færæ evidenfle imagistice postoperatorii de fragmente litiazice mai mari. Rezultate: Din cei 82 de pacienfli, 28 (34,1% - Grupul I) au eliminat spontan fragmentele litiazice, în 39 de cazuri (47,6% - Grupul II) acestea au persistat asimptomatic øi nemodificate ca dimensiuni de-a lungul perioadei de urmærire, în timp ce 15 (18,3% - Grupul III) au prezentat un eveniment ce a necesitat tratament (colicæ renalæ sau hidronefrozæ persistentæ). 93,3% dintre pacienflii din acest ultim grup au prezentat fragmente de cel puflin 4 mm. Proporflia acestora printre pacienflii din Grupul I a fost de 21,4%. Concluzii: Fragmentele aøa-zis clinic nesemnificative pot genera episoade acute în cursul urmæririi postoperatorii. Riscul acestor evenimente poate creøte în cazul fragmentelor cu dimensiuni mai mari de 3 mm. Introduction and objectives: Clinically insignificant residual stone fragments may be accepted in the definition of a successful procedure. However, there is no universal definition of what clinical insignificant means. The aim of our study was to determine the natural history of residual stone fragments after ureteroscopy. Material and method: We retrospectively evaluated a number of 82 patients treated in the Department of Urology of St. John Emergency Clinical Hospital by retrograde ureteroscopy for pyelocaliceal lithiasis. The inclusion criteria were: residual stone fragments with diameters between 1-6 mm, a follow-up period of at least 12 months, no postoperative imaging evidence of larger stone fragments. Results: In 28 patients (34.1% - Group I) spontaneous passage of the stone fragments was encountered, in 39 (47.6% - Group II) they persisted asymptomatic and with constant dimensions during the follow-up period, while in 15 cases (18.3% - group III) they presented an event which imposed treatment (renal colic or persistent hydronephrosis). 93.3% of the patients in the last group presented stone fragments of at least 4 mm in diameter. Proportion of these fragments in the Group I was 21.4%. Conclusions: The so-called clinically insignificant stone fragments may generate acute episodes during follow-up. The risk of these events is higher in fragments larger than 3 mm. nr. 2 / 2012 vol 11 Revista Românæ de Urologie 77

79 Litiazæ de ani de experienflæ în rezolvarea prin ESWL a litiazei reno-ureterale Rucsandra Manu, R. Constantiniu, M. A. Manu, G. Glück, M. Hârza, C. Gîngu, B. Øtefan, C. Surcel, C. Baston, Ruxanda Tulbure *, M. Brânzan *, Eliza Burchiu *, Antoaneta Alamæ *, Liliana Domniøor *, Carmen Savu *, Cristina Vlæduflescu *, Iulia Mitroi *, Iulia Negru *, I. Sinescu Centrul de Uronefrologie øi Transplant Renal, * Clinica de ATI, Institutul Clinic Fundeni, Bucureøti 20 years of experience using ESWL in renal stone treatment Rucsandra Manu, R. Constantiniu, M. A. Manu, G. Glück, M. Hârza, C. Gîngu, B. Øtefan, C. Surcel, C. Baston, Ruxanda Tulbure *, M. Brânzan *, Eliza Burchiu *, Antoaneta Alamæ *, Liliana Domniøor *, Carmen Savu *, Cristina Vlæduflescu *, Iulia Mitroi *, Iulia Negru *, I. Sinescu Center of Uronephrology and Renal Transplantation, * ICU Department, Fundeni Clinical Institute, Bucharest Introducere: Lithotripsia extracorporealæ cu undæ de øoc reprezintæ o alternativæ modernæ, eficientæ, în tratamentul minim invaziv al litiazei reno-ureterale. Cu toate cæ a fost introdusæ în practica medicalæ de peste 40 de ani, necunoaøterea indicafliilor corecte ale metodei precum øi nerespectarea protocoalelor terapeutice conduc øi în prezent la intervenflii chirurgicale sau manevre endourologice nenecesare. Studiul nostru îøi propune trecerea în revistæ a indicafliilor ESWL, tehnica ESWL øi a complicafliilor acestei proceduri, precum øi a rezultatelor pe termen lung la 5, 10 øi 15 ani post ESWL. Pacienfli øi metode: Între 1991 øi 2011, în Centrul nostru au fost tratafli prin ESWL pacienfli cu vârste cuprinse între 3 øi 96 de ani, efectuându-se de proceduri. Protocolul de investigaflii pre-eswl a cuprins: ecografia reno-vezicalæ, examenul radiourografic, probe bioumorale (uree, creatininæ, acid uric, hemoleucogramæ, probe de coagulare, sumar de urinæ øi uroculturæ). În 6655 de cazuri calculul a fost localizat în bazinet, în 1395 de cazuri pacienflii prezentau calcul caliceal unic, 858 de cazuri litiazæ calicealæ multiplæ, 629 de cazuri litiazæ pielocalicealæ, 966 calcul ureteral lombar, 177 calcul coraliform øi 54 de cazuri litiazæ ureteralæ pelvinæ. Dimensiunea calculilor a fost în 27% din cazuri <10 mm, în 53% între mm, în 16% între mm øi în 4% > 30 mm de pacienfli au fost tratafli cu anestezie general i.v. Introduction: Extracorporeal shockwave lithotripsy (ESWL) represents a well-established and effective treatment of urinary stones in adult patients. Even after 40 years of experience with ESWL ignorance about indication varieties and side effect of ESWL still causes unnecessary stone surgery or unnecessary endourological procedures. Our study was designed to assess the indications varieties of ESWL, the technique, complications and long term results of ESWL. Follow-up series at 5, 10 and 15-years were analyzed. Patients and methods: Between 1991 and 2011, patients (the youngest 3 years, the oldest 96 years) were treated by ESWL for urinary stones in our center ESWL procedures were performed. Investigational protocol: reno-vesical ultrasound, IVP exam, bioumoral exams: urea, creatinine, hemoleucogram, coagulogram, urinalysis, uroculture. In 6655 cases the calculus was located in the renal pelvis, in 1395 cases a single calculus was located in the calyx, 858 had multiple caliceal lithiasis, 629 cases had pyelocaliceal lithiasis, in 966 cases the calculus advanced in the lumbar ureter, 177 had stag horn lithiasis and 54 patients had distal ureteral lithiasis. Stone size was in 27% < 10 mm, in 53% mm, 16% mm and in 4% larger than 30 mm. General intravenous anesthesia has been used in 5488 cases. Results: The overall stone free rate was 91% (9768 patients). CIRF (Clinical Insignificant Residual Fragments) 78 Revista Românæ de Urologie nr. 2 / 2012 vol 11

80 Litiazæ Rezultate: Rata generalæ SF (stone free) a fost de 91% (9768 pacienfli), rata CIRF (concremente reziduale nesemnificative clinic) 3,5% din cazuri (în general, pacienflii cu litiazæ multiplu operafli în antecedente øi hidronefrozæ rezidualæ postoperatorie). 590 de cazuri (5,5%) au fost operate datoritæ eøecului ESWL sau al complicafliilor post ESWL. Nu au fost înregistrate deformæri osoase, alteræri ale funcfliei renale sau hipertensiune arterial la distanflæ post ESWL. Concluzii: ESWL reprezintæ o metodæ eficientæ de tratament modern minim invaziv al litiazei reno-ureterale cu o ratæ stone-free de 91%. Procedura poate fi efectuatæ în condiflii de siguranflæ, respectând indicafliile, contraindicafliile øi cunoscând limitele metodei. ESWL poate fi efectuatæ ca unic tratament sau în cadrul tratamentului multimodal al litiazei reno-ureterale. were noticed in 3,5% of cases with multiple operated lithiasis and residual hydronephrosis. In 590 cases (5,5%) the ESWL was inefficient and the patients underwent surgery. For the follow-up we analyzed renal function (BUN and creatinine level, renal ultrasound, IVP or renal scintigraphy), blood pressure and skeletal radiography. No late complications (renal failure, skeletal deformation) were noticed during a mean follow-up period of 48 months. Conclusions: ESWL is effective in patients with urinary stones - stone-free rate was 91%. It can be safely performed without long term side effects nr. 2 / 2012 vol 11 Revista Românæ de Urologie 79

81 Litiazæ 5.8. Tratamentul endovascular al complicafliilor hemoragice post nefrolitotomie percutanatæ B. Braticevici, V. Ambert, Y. Salaheddin, M. Popescu, D. Diaconescu, D. Radavoi, B. Dorobæfl, V. Jinga Clinica de Urologie a Spitalului Prof. Dr. Th. Burghele, Bucureøti Endovascular treatment for percutaneous nephrolithotomy hemorrhagic complications B. Braticevici, V. Ambert, Y. Salaheddin, M. Popescu, D. Diaconescu, D. Radavoi, B. Dorobæfl, V. Jinga Department of Urology, Prof. Dr. Th. Burghele Clinical Hospital, Bucharest Introducere: Nefrolitotomia percutanatæ (NLP) reprezintæ o proceduræ siguræ øi eficientæ în tratamentul chirurgical al litiazei renale. Printre complicafliile hemoragice ale acestei proceduri se numæræ: sângerarea intraoperatorie, hematomul, fistula arteriovenoasæ øi pseudoanevrismul. În majoritatea cazurilor sângerærile sunt autolimitate øi nu necesitæ intervenflie chirrugicalæ. Scopul acestui studiu este de a dovedi eficienfla abordului endovascular renal øi a embolizærii selective/supraselective în controlul hemoragiilor severe post NLP. Material øi metodæ: Studiu retrospectiv desfæøurat în perioada iulie februarie 2012 pe un numær de 1650 de pacienfli cu litiaza pielocalicealæ. La aceøti pacienfli s-au înregistrat 205 complicaflii hemoragice post NLP; 19 pacienfli (1,15%) au prezentat hemoragii severe care au necesitat efectuarea angiografiei øi/sau embolizare pentru controlul sângerærii. Abordul arterial a fost realizat pe cale femuralæ (5 cazuri) sau brahialæ (14 cazuri). Dupæ efectuarea aortografiei inifliale, se efectueazæ o arteriografie renalæ selectivæ. Leziunile vasculare au fost embolizate folosind microsfere sau spirale metalice. Rezultate: Durata medie de timp între momentul efectuærii NLPului øi cel al angiografiei a fost de 7.2 zile pentru pacienflii internafli øi de 16 ore în cazul celor cu sângerare tardiva post-nlp (2 cazuri). Arteriografia renalæ a evidenfliat fistula arterio-venoasæ la 4 pacienfli (21%), pseudoanevrism la 12 pacienfli (63.5%) øi absenfla leziunii la 3 pacienfli (15.7%). Hematuria a persistat postembolizare într-un singur caz, pacientul necesitând embolizare de urgenflæ. Spiralele metalice au fost utilizate la 8 pacienfli, microsferele la 5 pacienfli øi la 3 pacienfli s-au folosit atât microsfere cât øi spirale metalice. Cantitatea medie de unitæfli transfuzate post NLP pânæ la embolizare a fost de 2.6 unitæfli. Rata de succes a fost de 93.75%. Concluzii: 1) Incidenfla complicafliilor hemoragice severe post NLP este scæzutæ (1,1%), ceea ce aratæ eficienfla øi siguranfla acestei tehnici chirurgicale. 2) Tratamentul gold standard al leziunilor vasculare renale post NLP este reprezentat de embolizarea vascularæ selectivæ. Introduction. The percutaneous nephrolithotomy (PCNL) represents a safe and efficient procedure in the surgical management of renal lithiasis. The hemorrhagic complications include: intraoperative bleeding, hematoma, arterio-venous fistula and pseudo-aneurysm. In most of the cases the injuries are self-limited and do not need a surgical intervention. The purpose of this study is to prove the efficacy of the endovascular renal approach with selective/over selective embolisation in the control of severe post-pcnl hemorrhages. Method and material. We retrospectively analyzed 1650 patients who had undergone PCNL for removal of renal calculi between July 2007 and February A number of 205 hemorrhagic complications were observed, but only 19 (1.15%) patients presented severe post PCNL hemorrhage that required angiography and/or embolization for bleeding control. The arterial approach was femoral (five cases) or brachial (fourteen cases). After initial aortography a selective renal arteriography is performed. Vascular lesions are embolised using micro-sphere or metallic coils. Results: The mean time between PCNL and moment of angiography was 7.2 days for the hospitalized patients and 16 hours for those with late post PCNL bleeding (two cases). Renal arteriography revealed arteriovenous fistula in 4 patients (21%), pseudoaneurysm in 12 (63.5%) and no lesion in 3 patients (15.7%). The hematuria persisted after the embolisation in one case and an emergency nephrectomy was necessary. Metallic coils were used in eight patients, microspheres in five, and coils plus microspheres in three patients. The average of the transfused units was of 2.6 units. The rate of success was 93.75%. Conclusions. 1) The incidence of post PCNL severe hemorrhagic complications is low (1.1%) which indicates PCNL as a safe and efficient surgical technique. 2) The gold standard treatment in post PCNL vascular renal lesions is the selective angioembolization. 80 Revista Românæ de Urologie nr. 2 / 2012 vol 11

82 5.9. Litotriflia endoscopicæ pneumaticæ în tratamentul litiazei vezicale voluminoase R. Croitoru, J. Corcan, V. Lineschi, G. Beg, I. Secaøan Spitalul Judeflean de Urgenflæ Reøifla Endoscopic pneumatic lithotripsy for voluminous bladder calculi R. Croitoru, J. Corcan, V. Lineschi, G. Beg, I. Secaøan Reøifla Emergency County Hospital Litiazæ Introducere. Pentru calculii vezicali voluminoøi care nu pot fi rezolvafli prin cistolitotriflia Punch. opfliunile terapeutice ræmân cistolitotomia deschisæ sau alte metode de fragmentare endoscopicæ. Material øi metodæ. În secflia noastræ am început efectuarea de cistolitotriflie endoscopicæ pneumaticæ în iulie Am contabilizat numærul de cistolitotriflii endoscopice pneumatice øi am comparat numærul de cistolitotomii deschise efectuate cu un an înainte de introducerea metodei øi de atunci pânæ în prezent. Rezultate. În perioada septembrie 2010 iunie 2011 au fost înregistrate 14 cistolitotomii deschise. Din iulie 2011 pânæ în prezent au fost efectuate 13 cistolitotriflii endoscopice pneumatice pentru calculi cu diametru între 3 5,5 cm; 3 cistolitotomii deschise una pentru un calcul de 10 cm diametru, alta în cazul a trei calculi de 4-5 cm diametru fiecare øi într-un caz unde s-a efectuat øi adenomectomie transvezicalæ. Concluzii. Cistolitotriflia endoscopicæ pneumaticæ este eficientæ în tratamentul calculilor vezicali voluminoøi dar utilizarea sa este limitatæ in cazul masei litiazice extreme øi nu mai este aplicabilæ în cazul altei intervenflii deschise concomitente (adenomectomie). Introduction. Open cystolithotomy or some endoscopic lithotripsy interventions are needed in case of voluminous bladder calculi that cannot be treated by Punch procedure. Materials and methods. In our department we started to do endoscopic pneumatic lithotripsy in July We have accounted the number of endoscopic pneumatic lithotripsy procedures. We have compared the number of open cystolithotomies done previous and after introduction of endoscopic pneumatic procedure. Results. Between September 2010 June 2011, 14 open cystolithotomies have been registered. Since July 2011 to today 13 endoscopic pneumatic lithotripsy procedures have been done for bladder stones of cm diameter. In the same time we did 3 open cystolithotomies - one for a 10 cm stone, one for 3 stones of 4-5 cm diameter each and the last in case were transvesical prostatectomy was done simultaneously. Conclusions. Endoscopic pneumatic lithotripsy has efficacy treating voluminous bladder stones but its use is limited regarding huge lithiasic mass. Also it is not applicable when a open procedure like prostatectomy for adenoma is needed. nr. 2 / 2012 vol 11 Revista Românæ de Urologie 81

83 Litiazæ Pieloplastia laparoscopicæ prin abord transperitoneal - experienfla iniflialæ cu 19 cazuri D. Diaconescu, I. Dragomireøteanu, I. Chira, B. Braticevici, Y. Salaheddin, V. Ambert, M. Popescu, C. Cælin, V. Jinga Spitalul Prof. Dr. Th. Burghele, Bucureøti Transperitoneal Laparoscopic Pyeloplasty: Initial Experience with 19 Cases D. Diaconescu, I. Dragomireøteanu, I. Chira, B. Braticevici, Y. Salaheddin, V. Ambert, M. Popescu, C. Cælin, V. Jinga Prof. Dr. Th. Burghele Hospital Bucharest Obiective: Evaluarea rezultatelor obtinufle dupæ efectuarea pieloplastiei laparoscopice prin abord transperitoneal pentru 19 pacienfli diagnosticafli cu sindrom de joncfliune pieloureteralæ. Material øi metodæ: În perioada 1 ianuarie februarie 2012 în clinica Spitalului Prof Dr Th Burghele au fost efectuate un numær de 19 intervenflii chirurgicale laparoscopice pentru diagnosticul de sindrom de joncfliune pieloureteralæ. Tehnica utilizatæ a fost pieloplastia laparoscopicæ prin abord transperitoneal. Vârsta medie a pacienflilor a fost de 36.7 ani (21-62 ani). Tofli pacienflii au fost clinic simptomatici. Diagnosticul a fost confirmat imagistic prin utilizarea ecografiei abdominale, a urografiei IV øi a tomografiei computerizate abdomino-pelvine cu substanflæ de contrast. Pieloplastia tip Heynes - Anderson a fost efectuatæ în 18 cazuri, iar pieloplastia tip Fenger a fost efectuatæ într un singur caz. Evaluarea clinicæ øi imagisticæ a pacienflilor s-a fæcut la 3 luni postoperator. Rezultate: Durata medie a unei intervenflii chirurgicale a fost de 164 minute ( minute). Perioada medie de spitalizare a fost de 5,57 zile (4-12 zile). Cantitatea medie de sânge pierdutæ intraoperator a fost de 80 ml. Anomalii vasculare au fost întâlnite în % din cazuri. Litiaza renalæ secundaræ a fost întâlnitæ într un singur caz. Conversia la chirurgia clasicæ a fost necesaræ într un singur caz. Complicafliile postoperatorii precoce au fost: drenaj prelungit, colecflie intraperitonealæ, ileus prelungit, iar complicafliile postoperatorii tardive au fost: peritonitæ cu plastron peritoneal la 3 zile dupæ extragerea sondei JJ øi infecflia urinaræ. Rata de succes a fost de 94.7 %. Concluzie: Pieloplastia laparoscopicæ are rezultate comparabile cu chirurgia clasicæatunci când abilitæflile tehnice ale echipelor chirurgicale pot fi comparate. Aceastæ chrirurgie oferæ o reducere a zilelor de spitalizare, o convalescenflæ redusæ øi rezultate estetice superioare faflæ de chirurgia clasicæ. Purpose: Our aim is to evaluate the results obtained in 19 patients undergoing laparoscopic pyeloplasty through transperitoneal access for ureteropelvic junction (UPJ) stenosis. Materials and Methods: From January 2011 to February 2012, we performed nineteen laparoscopic interventions for ureteropelvic junction (UPJ) stenosis via a transperitoneal laparoscopy. Mean age was 36.7 years (21-62 years). All patients had clinical symptoms of high urinary obstruction and the hydronephrosis confirmed by ultrasound, KUB and abdomino-pelvin CT. Anderson-Hynes dismembered pyeloplasty was performed in 18 patients and Fenger technique in 1 case. Patients were clinically and imagistically evaluated in the postoperative period at 3 months. Results: The mean operative time was 164 min ( min). The mean hospital stay was 5.57 days. The average blood loss was 80 ml. Anomalous vessels were identified in 47.3 %. Laparoscopic pyelolithotomy was successfully performed in 1 case. Conversion to conventional surgery was necessary in one case. Early postoperative complications were: prolonged drainage, prolonged ileus, intraperitoneal collection, The later postoperative complications were: urinary tract infections, peritonitis with peritoneal inset at 3 days after extraction a JJ stent. The success rate was 94.7%. Conclusions: Laparoscopic pyeloplasty has results comparable to conventional open technique, when conventional surgical teams technical skills, can be compared. It offers less days of hospitalization, postoperative convalescence with aesthetic benefits. 82 Revista Românæ de Urologie nr. 2 / 2012 vol 11

84 5.11. Vaporizarea bipolaræ cu plasmæ versus TURP în scleroza secundaræ de col vezical comparaflie pe termen mediu B. Geavlete, C. Moldoveanu, R. Mulflescu, D. Georgescu, M. Jecu, F. Stænescu, C. Iacoboaie, P. Geavlete Clinica de Urologie, Spitalul Clinic de Urgenflæ Sf. Ioan, Bucureøti Bipolar plasma vaporization versus standard TUR in secondary bladder neck sclerosis A medium term comparison B. Geavlete, C. Moldoveanu, R. Mulflescu, D. Georgescu, M. Jecu, F. Stænescu, C. Iacoboaie, P. Geavlete Department of Urology, Saint John Emergency Clinical Hospital, Bucharest Litiazæ Obiective: Acest studiu pe termen mediu a urmærit demonstrarea eficienflei, siguranflei øi rezultatelor postoperatorii ale vaporizærii bipolare cu plasmæ comparativ cu rezecflia monopolaræ transuretralæ standard (TURP) în scleroza secundaræ de col vezical. Material øi metodæ: A fost inclus în studiu un numær total de 60 de pacienfli cu sclerozæ de col vezical secundaræ TURP în 41 cazuri, adenomectomiei transvezicale în 14 cazuri øi prostatectomiei transvezicale în 5 cazuri. Tofli pacienflii au fost evaluafli preoperator øi la 1, 3, 6 øi 12 luni dupæ intervenflie prin intermediul IPSS, Qol øi Qmax. Rezultate: Timpul operator mediu, perioada medie de cateterizare øi durata medie de spitalizare au fost semnificativ reduse în lotul de studiu (9,2 øi 17,4 minute, 18 øi 46,5 ore øi respectiv 34,5 øi 73 ore). Perforaflia capsularæ a apærut la 2 cazuri în lotul TURP, în timp ce rata simptomelor iritative a fost similaræ în cele douæ serii (16,7% øi 13,3%). La 1, 3, 6 øi 12 luni au fost evidenfliafli parametri de urmærire superiori pentru lotul de studiu comparativ cu grupul martor în ceea ce priveøte IPSS (3,4 versus 6.3, 3,6 versus 6,5, 3,7 versus 6,8 øi respectiv 3,7 versus 7,1) øi Qmax (23,8 versus 21,1 ml/s, 23,7 versus 20,6 ml/s, 23,0 versus 20,7 ml/s øi respectiv 23,4 versus 20,3 ml/s). În acelaøi interval de timp, QoL a prezentat îmbunætæfliri semnificative în ambele serii (1,2 versus 1,4, 1,4 versus 1.6, 1,4 versus 1,7 øi respectiv 1,3 versus 1,7). Numai 2 pacienfli din grupul TURP au necesitat reintervenflie. Concluzii: Vaporizarea bipolaræ cu plasmæ reprezintæ o alternativæ valoroasæ de tratament în cazurile de sclerozæ secundaræ de col vezical. Aceastæ metodæ a evidenfliat o eficacitate superioaræ, un profil de siguranflæ satisfæcætor øi a îmbunætæflit semnificativ pe termen mediu parametrii de urmærire comparativ cu abordul standard. Objectives: This medium term trial aimed to assess the efficiency, safety and postoperative results of the bipolar plasma vaporization (BPV) by comparison to monopolar transurethral resection (TUR) in cases of secondary bladder neck sclerosis (BNS). Methods: A total of 60 patients with BNS secondary to TURP (41 cases), open prostatectomy for BPH (14 cases) and radical prostatectomy for prostate cancer (5 cases) were enrolled in the trial. The inclusion criteria consisted of Qmax < 10 ml/s and IPSS >19. All patients were evaluated preoperatively and at 1, 3, 6 and 12 months after surgery by International Prostate Symptom Score (IPSS), quality of life score (QoL) and maximum flow rate (Qmax). Results: The mean operation time, catheterization period and hospital stay were significantly reduced in the BPV series (9.2 versus 17.4 minutes, 18 versus 46.5 hours and 34.5 versus 73 hours). Capsular perforation only occurred in 2 cases of the TUR study arm, while the rate of irritative symptoms was similar in the 2 series (16.7% versus 13.3%). The 1, 3, 6 and 12 months follow-up emphasized superior parameters for the BPV group by comparison to the TUR series in terms of IPSS (3.4 versus 6.3, 3.6 versus 6.5, 3.7 versus 6.8 and 3.7 versus 7.1, respectively) and Qmax (23.8 versus 21.1 ml/s, 23.7 versus 20.6 ml/s, 23.0 versus 20.7 ml/s and 23.4 versus 20.3 ml/s). At the same time intervals, QoL was also significantly improved in the BPV arm (1.2 versus 1.4, 1.4 versus 1.6, 1.4 versus 1.7 and 1.3 versus 1.7). Only 2 patients of the TUR group required re-treatment. Conclusions: BPV constitutes a valuable endoscopic treatment alternative for secondary BNS. The method emphasized superior efficacy, a satisfactory safety profile and significantly improved short-term follow-up parameters by comparison to standard TUR. nr. 2 / 2012 vol 11 Revista Românæ de Urologie 83

85 Litiazæ Enucleerea bipolaræ cu plasmæ a prostatei O tehnicæ inovatoare în tratamentul adenomului de prostatæ voluminos B. Geavlete, R. Mulflescu, D. Georgescu, M. Jecu, F. Stænescu, C. Moldoveanu, C. Iacoboaie, P. Geavlete Clinica de Urologie, Spitalul Clinic de Urgenflæ Sf. Ioan, Bucureøti Bipolar plasma enucleation of the prostate An innovative technique in large BPH endoscopic treatment B. Geavlete, R. Mulflescu, D. Georgescu, M. Jecu, F. Stænescu, C. Moldoveanu, C. Iacoboaie, P. Geavlete Department of Urology, Saint John Emergency Clinical Hospital, Bucharest Obiective: În acest studiu am avut ca scop evaluarea unei noi alternative de tratament a adenomului de prostatæ voluminos, enucleerea bipolaræ cu plasmæ, în ceea ce priveøte eficienfla chirurgicalæ, siguranfla øi rezultatele clinice pe termen scurt. Material øi Metodæ: Un numær total de 30 de pacienfli cu volume ale prostatei mai mari de 80 ml au fost incluøi în studiu. Toate cazurile au fost evaluate preoperator øi la 1, 3, 6 øi 12 luni dupæ operaflie prin scorul IPSS, scorul calitæflii vieflii (QoL), fluxul urinar maxim (Qmax) øi ecografie abdominalæ øi transrectalæ. Rezultate: Valorileparametrilor preoperatori au inclus un volum prostatic mediu de 137 ml, scorul IPSS de 23,5, scorul QoL de 4,3,Qmax mediu de 7,2 ml/s øi volumul rezidual (VR) de 215 ml. Toate procedurile au fost efectuate cu succes sub anestezie rahidianæ. Timpii de medii de enucleere øi morselare au fost de 69,8 øi respectiv 18,5 minute, în timp ce greutatea flesutului morselat a fost de 77 grame. Scæderea medie a hemoglobinei a fost de 0,8 g/dl, iar perioadele medii de cateterizare øi spitalizare au fost de 26,5 ore øi respectiv 2,3 zile. Nu a fost înregistrat niciun caz de perforaflie capsularæ, transfuzii de sânge, leziuni ale peretelui vezical consecutive morselærii, reintervenflie sau retenflie prin cheaguri.rata de simptome iritative precoce a fost de 10%. La 1, 3, 6 øi 12 luni au fost raportate îmbunætæfliri semnificative în ceea ce priveøte IPSS (5,3, 4,8, 4,9 øi 5,1), QoL (1,2, 1,1, 1,2 øi 1,3), Qmax (25,9, 25,1, 24,6 øi 24,9 ml/s) øi VR (34, 25, 22 øi 29 ml). Concluzii: Enucleerea bipolaræ cu plasmæ reprezintæ o metodæ promiflætoare de tratament în cazurile de adenoame voluminoase de prostatæ, caracterizatæ printr-o bunæ eficienflæ chirurgicalæ, morbiditate perioperatorie redusæ, recuperare postoperatorie precoce øi parametri de urmærire satisfæcætori. Objectives: The present trial aimed to evaluate a new endoscopic treatment alternative for large benign prostatic hyperplasia (BPH) cases,thebipolarplasmaenucleation of the prostate (BPEP), interms of surgical efficiency and safety as well as short term postoperativeresults. Patients and Methods: A total of 30 patients with prostates larger than 80 ml were included in the study. All cases were investigated preoperatively and at 1, 3, 6 and 12 months after surgery by international prostate symptoms score (IPSS), quality of life score (QoL), maximum flow rate (Qmax) and abdominal and transrectal ultrasound. Results: The preoperative parameters included 137 ml for prostate volume, 23.5 for IPSS, 4.3 for QoL, 7.2 ml/s for Qmax and 215 ml for the postvoiding residual urinary volume (RV). All procedures were successfully performed under spinal anesthesia. The enucleation and morcellation times were 69.8 minutes and 18.5 minutes, while the morcellated tissue weight was 77 grams. The mean hemoglobin drop in this series was 0.8 g/dl and the mean catheterization period and hospital stay were 26.5 hours and 2.3 days. There were no cases of prostatic capsule perforation, blood transfusion, bladder wall injury secondary to morcellation, reintervention or clot retention. The rate of early irritative symptoms was 10%. At 1, 3, 6 and 12 months, significant improvements were determined concerning the IPSS (5.3, 4.8, 4.9 and 5.1), QoL (1.2, 1.1, 1.2 and 1.3), Qmax (25.9, 25.1, 24.6 and 24.9 ml/s) and RV (34, 25, 22 and 29 ml). Conclusions: BPEP may represent a promising treatment modality in large BPH cases, characterized by good surgical efficacy, reduced morbidity, fast postoperative recovery and satisfactory follow-up parameters. 84 Revista Românæ de Urologie nr. 2 / 2012 vol 11

86 5.13. Vaporizarea bipolaræ cu plasmæ a prostatei Un nou standard în 2012? B. Geavlete, M. Dræguflescu, R. Mulflescu, D. Georgescu, M. Jecu, F. Stænescu, C. Moldoveanu, C. Iacoboaie, P. Geavlete Clinica de Urologie, Spitalul Clinic de Urgenflæ Sf. Ioan, Bucureøti The bipolar plasma vaporization of the prostate A new standard in 2012? B. Geavlete, M. Dræguflescu, R. Mulflescu, D. Georgescu, M. Jecu, F. Stænescu, C. Moldoveanu, C. Iacoboaie, P. Geavlete Department of Urology, Saint John Emergency Clinical Hospital, Bucharest Litiazæ Obiective: Studiul de faflæ a urmærit o analizæ retrospectivæ pe termen lung a vaporizærii bipolare cu plasmæ la pacienflii cu adenom mediu de prostatæ. Pacienfli øi metodæ: Lotul de studiu a fost reprezentat de 170 de pacienfli cu debit urinar maxim (Qmax) < 10ml/s, scor simptomatic (IPSS) > 19 øi volum prostatic între 30 øi 80 ml. Evaluarea efectuatæ preoperator øi la 1, 3, 6, 12 øi 18 luni postoperator a inclus IPSS, scorul de calitate a vieflii (QoL), Qmax øi ecografie abdominalæ si transrectalæ. Rezultate: Volumul prostatic mediu preoperator a fost de 54,1 ml. Intervenfliile au fost realizate cu succes sub rahianestezie. Procedura a fost însoflitæ de rate scæzute de perforaflie capsularæ (1,2%), sângerare intraoperatorie (1,8%), hematurie postoperatorie (2,9%), transfuzii sangvine (1,2%) øi retenflie prin cheaguri (0,6%), precum øi de o scædere medie a hemoglobinei de micæ amploare (0,5 g/dl). Timpul operator mediu (39,7 min), durata medie de cateterizare (47,5 ore) øi spitalizare (2,8 zile) au fost de asemenea reduse. Ratele de recateterizare, reinternare pentru hematurie secundaræ øi a prezenflei simptomatologiei iritative s-au dovedit satisfæcætoare. Pe termen lung, au fost descrise rate scæzute ale stricturilor de uretræ (4,7%), sclerozei de col vezical (0,6%) øi reintervenfliilor (3,5%). La 1, 3, 6, 12 øi respectiv 18 luni, pacienflii tratafli prin vaporizare bipolaræ cu plasmæ au prezentat rezultate superioare ale IPSS (4,2-5,0), Qmax (23,7-24,9) øi QoL (0,8-1). Concluzii: Vaporizarea bipolaræ cu plasmæ reprezintæ o alternativæ valoroasæ de tratament endoscopic în cazurile de adenom mediu de prostatæ, cu eficacitate superioaræ øi o ratæ satisfæcætoare a complicafliilor. Objectives: The study aimed to perform a retrospective long term analysis of bipolar plasma vaporization of the prostate (BPVP) in average size benign prostatic hyperplasia (BPH) cases concerning the perioperative and follow-up parameters. Patients and Methods: A total of 170 patients with maximum flow rate (Qmax) < 10 ml/s, international prostate symptoms score (IPSS) > 19 and prostate volume between 30 and 80 ml were enrolled in the trial. All cases were evaluated preoperatively and at 1, 3, 6, 12 and 18 months after surgery by IPSS, quality of life score (QoL), Qmax and abdominal and transrectal ultrasonography. Result: The mean preoperative prostate volume was 54.1 ml. All procedures were successfully carried out under spinal anesthesia. The technique emphasized decreased capsular perforation (1.2%), intraoperative bleeding (1.8%), postoperative hematuria (2.9%), blood transfusion (1.2%) and clot retention (0.6%) rates as well as a low mean hemoglobin drop (0.5 g/dl). The operation time (39.7 min), catheterization period (47.5 hours) and hospital stay (2.9 days) were also reduced. The rates of re-catheterization (1.8%), re-hospitalization for secondary hemorrhage (0.6%) and irritative symptoms (12.4%) emphasized satisfactory results. In the long term, minimum urethral strictures (4.7%), bladder neck sclerosis (0.6%) and re-treatment (3.5%) rates were described. During the 1, 3, 6, 12 and 18 months followup, BPVP patients presented superior parameters in terms of IPSS ( ), Qmax ( ml/s) and QoL (0.8-1). Conclusions: BPVP represents a valuable endoscopic treatment alternative for BPH patients, with significantly superior efficacy and satisfactory complication rate. The long term follow-up emphasized durable improvements of the postoperative parameters for this type of approach. nr. 2 / 2012 vol 11 Revista Românæ de Urologie 85

87 Tumori vezicale 6.1. Tumorile vezicale rare în cazuistica Clinicii de Urologie Târgu Mureø Orsolya Mártha, L. Lakatos, C. Chibelean, D. Porav, O. Mælæu, A. Chiujdea, S. Nedelcu, A. Brad, O. Vida UMF Tg Mures Clinica de Urologie Rare bladder tumours in the casuistry of the Clinic of Urology Tg. Mureø Orsolya Mártha, L. Lakatos, C. Chibelean, D. Porav, O. Mælæu, A. Chiujdea, S. Nedelcu, A. Brad, O. Vida UMF Tg Mures Clinica de Urologie Introducere øi obiective: Tumorile de vezicæ altele decât cele uroteliale sunt rare. Datele din literatura de specialitate sunt pufline. Acest studiu retrospectiv evalueazæ pe o perioadæ de 7 ani, cazuistica clinicii noastre cu privire la aceste tipuri rare de tumori vezicale. Material øi metodæ: Între , la Clnica de Urologie Tg Mureø, s-au efectuat 1454 (100%) TURV pentru tumori vezicale., 79% bærbafli, 21 % femei, vârsta medie 65,8 ani (93,14%) de rezecflii au avut ca rezultat tumori uroteliale, pe când în 81 (5,57%) cazuri forme rare (vârsta medie 61,2 ani). Rezultate: În cazul carcinomului urotelial gradingul tumoral s-a situat dupæ cum urmeazæ: 260 (18,93%)G1, 708 (51,56%) cazuri de G2 øi 405 (29,49%) G3, iar din punct de vedere al stadiului 520 (37,87%) Ta, 444 (32,33%) T1, 254 (18,41%) T2 øi 155 (11,28%) pacienfli cu T3. În grupa formelor rare ( %) rezultatele histopatologice ne-au evidenfliat: cc. cu cel. scuamoase 7 bærbafli, ( 11,57% T2 1, T3 6 ), adenocarcinom vezical în 26 (32,09% 5 T1, 9 T2, 12 T3), cc. de uracæ 2 (2,46%), leiomiosarcoma 9 (11,11% 3 T2 6 T3), cc. epidermoid keratinizat 28 (34,56% 6 T1 9 T2 13 T3), cc. cu celule mici 8 (9,87%) øi o femeie cu feocromocitom vezical (1,23%). Concluzii: În cazul tumorilor vezicale rare elementul cheie este rezultatul histo-patologic. Aceste forme se pun în evidenflæ în stadii mai avansate øi la pacienfli mai tineri decât cele uroteliale. Introduction and objectives: Bladder tumours other than urothelial carcinoma are rare, there is less scientific data available. This retrospective study reveals our casuistry concerning rare bladder tumours. Materials and methods: Between , in the Clinic of Urology of Tg Mures we have performed 1454 (100%) TURB for bladder tumours, 79% men, 21% women, mean age 65,8 years. From the total of 1454 (100%) procedures, 1373 (93,14%) were done for urothelial tumours, in 81 (5,57%) cases for rare bladder tumours. Results: In the cases of bladder urothelial cancer the grading was: 260 (18,93%)G1, 708 (51,56%) cases of G2 and 405 (29,49%) G3, as of the tumour staging 520 (37,87%) Ta, 444 (32,33%) T1, 254 (18,41%) T2 and 155 (11,28%) patients witht3. In the group of rare tumours 81 (100%) we diagnosed squamos cell carcinoma 7 males( 11,57% T2 1, T3 6 ), adenocarcinoma of the bladder 26 (32,09% 5 T1, 9 T2, 12 T3), urachal cc of the bladder 2 (2,46%), leiomyosarcoma 9 (11,11% 3 T2 6 T3), epidermoid cc. 28 (34,56% 6 T1 9 T2 13 T3), small cell cc. 8 (9,87%) and one woman (1,23%) of pheochromocytoma. Conclusions: Correct pathology is of great importance, non transitional bladder tumours are diagnosed in more advanced stages than urothelial cc, they are more aggressive and patient are of younger age. 86 Revista Românæ de Urologie nr. 2 / 2012 vol 11

88 6.2. Cistectomia paliativæ G. Glück, R. Stoica, R. Andrei, Manuela Chiriflæ, I. Sinescu Centrul de Uronefrologie øi Transplant Renal, Institutul Clinic Fundeni, Bucureøti Palliative cystectomy G. Glück, R. Stoica, R. Andrei, Manuela Chiriflæ, I. Sinescu Center of Uronephrology and Renal Transplantation, Fundeni Clinical Institute, Bucharest Tumori vezicale Scop. Prezentarea atitudinii terapeutice faflæ de o patologie tumoralæ a vezicii urinare la care gestul chirurgical NU îndeplineøte criteriul de radicalitate oncologicæ. Pacienfli øi metodæ. Sunt prezentafli 44 de pacienti cu cistectomie paliativæ reprezentînd 12,2% dintr-un lot personal de 360 de pacienfli cu cistectomie radicalæ, operafli între bolnavi au fæcut doar cistectomia, iar 32 au avut si tratament adjuvant. Sunt analizate complicafliile postoperatorii øi durata de spitalizare. Nu au fost decese postoperatorii în acest grup de pacienfli. Supravietuirea în prima grupæ este de 3-6 luni, iar în a doua grupæ de 12 luni. Discuflii. Cistectomia a fost definitæ ca paliativæ la pacienflii cu tumoræ vezicalæ cu flesut tumoral restant în fosa vezicalæ dupæ cistectomie, adenopatie pelvinæ nerezecabilæ (prin dimensiuni øi invazie a structurilor vasculare) sau adenopatie extraregionalæ, metastaze viscerale sau osoase. Indicaflia de extirpare a vezicii urinare a fost impusæ, în majoritatea cazurilor prin hematuria masivæ, necontrolabilæ endoscopic, pe care o prezentau aceøti bolnavi la admisia în spital. Alte ori suferinfla clinicæ datæ de cistita neoplazicæ, retenflia azotatæ au impus cistectomia. Concluzii. Chirurgia asociatæ cu tratamentul adjuvant (chimio øi radioterapie) a avut un impact net asupra ameliorærii calitæflii vieflii øi duratei de supraviefluire a acestor bolnavi. În cazuri selecflionate, tratamentul multimodal incluzând excizia metastazei a dus la supraviefluiri de peste 4 ani. Purpose: To present the therapeutic strategy in tumoral bladder pathology that does not submit to the criteria of radical surgery. Materials and Methods: This study includes 44 patients with palliative surgery (12.2%) from a group of 360 patients with radical cystectomy, treated between 1990 and Cystectomy alone was performed in the case of 12 patients, while 32 patients also undergone adjuvant therapy. Postoperative complications and the lenght of hospitalization were analized. No postoperative deaths were recorded. Survival for palliative surgery varies between 3 to 6 months, while survival for the patients with surgery and adjuvant treatment (chemo ± irradiations) is 12 months. Results: Cystectomy was considered palliative when there was residual tumoral tissue in the vesical fossa, pelvic adenophaties could not be resected (because of size, vascular invasion, huge plaques of atheroma), presence of retroperitoneal adenophaties, bone or visceral metastasis. Indication for cystectomy was masive hematuria with no endoscopic control, neoplasic cystities or upper urinary tract obstruction with azotaemia, urocutaneous neplasic fistulas. Conclusions: The association of surgery and adjuvant therapy (chemoradiotherapy) had a significant impact on the quality of live and survival. In selected cases, distant metastasis resection along with multimodal therapy concluded in up to 4 years survival. nr. 2 / 2012 vol 11 Revista Românæ de Urologie 87

89 Tumori vezicale 6.3. Maladia de câmp urotelial Este excizia incompletæ de tract urinar (EITU) un tratament eficace? - Prezentare de caz C. Surcel, A. Omer, B. Hæinealæ, C. Mirvald, C. Gîngu, I. Manea, Carmen Savu *, I. Sinescu Centrul de Uronefrologie øi Transplant Renal, * Clinica de ATI, Institutul Clinic Fundeni, Bucureøti Syncronous multiple transitional cell carcinoma is incomplete urinary tract excision (IUTE) an outdated treatment? - Case report and bibliographic review C. Surcel, A. Omer, B. Hæinealæ, C. Mirvald, C. Gîngu, I. Manea, Carmen Savu *, I. Sinescu Center of Uronephrology and Renal Transplantation, * ICU Department, Fundeni Clinical Institute, Bucharest Introducere. Carcinomul cu celule tranziflionale (TCC) reprezintæ a doua cea mai frecventæ afecfliune neoplazicæ a tractului urogenital, dupæ cancerul de prostatæ, carcinomul vezicii urinare fiind cea mai frecventæ formæ de carcinom urotelial cu o prevalenflæ de 90-95%. Una dintre caracteristicile sale este faptul cæ acesta are o evoluflie multifocalæ, în 8-13% TCC al tractului urinar superior fiind asociat cu afectarea concomitentæ a vezicii urinare. Materiale øi metode. Pacient în vârstæ de 52 de ani, cunoscut cu tumoræ vezicalæ multiplu operatæ transuretral (TUR), într-o altæ instituflie, cu rezultat histopatologic (HP) de carcinoma urotelial pt2g3, se interneazæ în clinica noastræ pentru hematurie persistent øi dureri lombare. Ecografia evidenfliazæ o masæ renalæ stângæ localizatæ medio-renal, confirmatæ prin tomografie computerizatæ (TC) ca fiind tumoræ urotelialæ asociatæ cu o îngroøare neuniformæ la nivelul peretelui postero-lateral stâng al vezicii urinare cu ureterohidronefrozæ secundaræ grad 2. Cistoscopic au fost decelate numeroase tumori la nivelul uretrei prostatice øi o formafliune tumoralæ extinsæ la nivelul peretelui lateral stâng øi posterior al vezicii urinare cu includerea orificiului ureteral stâng. Se practicæ excizia în bloc a întregului tract urinar cu prezervarea rinichiului drept (IUTE), limfodisecflie endopelvinæ øi ureterostomy cutanatæ dreaptæ. Rezultatul histopatologic al piesei de rezecflie confirm carcinomul cu cellule tranziflionale sincron la nivelul uretrei prostatice (pt1g3), vezicii urinare (pt2g1n0) øi caliceal stâng (pt2g1). Evoluflia postoperatorie a fost favorabilæ, pacientul externându-se în ziua a 10-a dupæ intervenflie. Introduction. Transitional cell carcinoma (TCC) is the second most common tumour of the urogenitaltractafter prostate cancer, with bladder carcinoma being the most frequent urothelial carcinoma accounting for 90-95%. One of its characteristics is that it has a multifocal evolution; in 8-13%, upper urinary tract transitional cell carcinoma (UUT-TCC) is associated with bladder TCC. Case presentation. A 52-year-old man who underwent transurethral resection (TUR) for multiple bladder tumours in January 2012 in another institution with a pathological finding of high grade muscle invasive TCC(pT2G3), was admitted into our Clinic for persistent hematuria and lumbar pain. Ultrasonography has shown a left middle-renal tumour, which was further confirmed on Computed tomography (CT) exam. In addition, an irregular thickening of left urinary bladder wall with secondary grade II ureterohydronephrosis were revealed. Cystoscopic examination found multiple prostatic urethral tumours associated with a largeexophytic bladder tumour localized on posterior and left lateral wall extended to ureteral orifice. An incomplete en-bloc urinary tract extirpation with endopelvic lymphadenectomy and right ureterostomy was performed. The final pathological report confirmed a multiple synchronous TCC pt1g3 prostatic urethra, pt2g3 N0 bladder tumour and pt2g1left upper caliceal tumor. Conclusion. There are few reports on complete or incomplete en-bloc urinary tract extirpation (IUTE-CUTE) for surgical treatment of synchronous multiple sites TCC. We consider that open IUTE en-bloc with urethral excision along with extended lymphadenectomy is the gold standard in 88 Revista Românæ de Urologie nr. 2 / 2012 vol 11

90 Tumori vezicale Concluzii. Existæ câteva raportæri privind excizia completæ sau incompletæ en-bloc a tractului urinar (IUTE-CUTE) pentru tratamentul chirurgical al TCC sincron. Consideræm cæ excizia completæ a tractului urinar afectat împreunæ cu uretra, asociatæ cu limfadenectomia extinsæ reprezintæ standardul în tratamentul acestei patologii, oferind cel mai bun rezultat din punct de vedere oncologic cu morbiditatea cceptabilæ postoperator. Practicarea rezecfliei en-bloc în TCC împiedicæ însæmânflarea tumoralæ care ar putea apærea în cazul exciziei în piese separate. Uretrectomia în acelaøi timp operator cu IUTE previne atât însæmânflarea tumoralæ øi scuteøte pacientul de o altæ intervenflie. treating these cases, providing an reasonable oncological outcome and an acceptable preoperative morbidity. Performing en-bloc resection in TCC prevents tumoral leakage into the operating field thus avoiding tumor cell seeding. Resecting the urethra at the same time with intraabdominal specimen prevents both tumoral seeding and spares the patient undergoing another operation. nr. 2 / 2012 vol 11 Revista Românæ de Urologie 89

91 Tumori vezicale 6.4. Tratamentul adjuvant intravezical cu BCG în tumorile vezicale neinvazive cu risc mediu/crescut G. Glück, Manuela Chiriflæ, I.Sinescu Centrul de Uronefrologie øi Transplant Renal, Institutul Clinic Fundeni, Bucureøti The role of adjuvant intravesical BCG therapy for medium/high risk non-invasive bladder tumours G. Glück, Manuela Chiriflæ, I.Sinescu Center of Uronephrology and Renal Transplantation, Fundeni Clinical Institute, Bucharest Scop: Evaluarea rolului tratamentului cu o dozæ de Epirubicin postoperator urmatæ de un ciclu de instilaflii intravezicale cu BCG în tumorile vezicale superficiale cu risc intermediar øi mare, operate TURV, în prevenirea recurenflei øi progresiei tumorale. Material øi metodæ: Între , 146 de pacienfli cu tumori vezicale superficiale au fost operafli TURV de acelaøi chirurg. În perioada august 2002 ianuarie 2012, 75 de pacienfli au fost tratafli conform protocolului EAU 2011 (grupul A de studiu). Grupul a inclus 16 pacienfli cu risc intermediar øi 59 de pacienfli cu risc mare tumoral (16 cazuri Ta øi 59 cazuri T1). Din punct de vedere al gradului de diferenfliere tumoralæ au fost identificafli 26 de pacienti cu G1, 43 de pacienfli cu G2 øi 6 pacienfli cu G3. Împærflirea pe sexe a fost urmætoarea: 21 de femei øi 54 de bærbafli. Vârsta medie a fost de 62 de ani (între ani), iar urmærirea medie de 58 de luni (între luni). Între anii au fost tratafli 71 de pacienfli numai prin TURV, fiind încadrafli în grupul B de studiu. Retrospectiv, au fost identificafli în acest grup 40 de pacienfli cu risc intermediar øi 31 de pacienti cu risc mare tumoral. În funcflie de stadiu, au existat 36 de cazuri pta øi 35 de cazuri pt1, iar gradul histologic al tumorii a variat între 42 de cazuri cu G1, 25 de cazuri cu G2 øi 4 cazuri cu G3. În ceea ce priveste împærflirea pe sexe, grupul a avut în alcætuire 16 femei øi 55 de bærbafli. Vârsta medie a fost de 67 de ani, variind între ani. Urmærirea medie a fost de 86 de luni, între luni. Criteriile de administrare a terapiei cu BCG au fost urmætoarele: tumori vezicale multiple la prezentare, dimensiunea tumoralæ mai mare de 3 cm, carcinom in situ asociat, grad tumoral crescut, recurenflæ timpurie, rata crescutæ de recurenflæ. Tofli pacienflii au beneficiat de instilaflie postoperatorie în primele 6 ore cu Epirubicin 50 mg. Instilafliile intravezicale cu BCG au fost începute la 14 zile post TURV, utilizând BCG 150 mg. Tofli pacientii au urmat un ciclu cu BCG 6 instilaflii. În anumite cazuri (30 de pacienfli) s-a utilizat terapia de întreflinere cu BCG, iar 17 cazuri au necesitat re-rezecflie TURV. Purpose: To assess the role of one single-shot Epirubicin instillation associated with intravesical BCG therapy after transurethral resection in order to prevent recurrence and progression in medium/high risk, non-invasive bladder tumours. Patients and methods: Between , 146 patients with non-invasive bladder tumours were treated by the same surgeon (Dr. G. Glück). The group A included 75 patients and were treated between August 2002 January 2012 according to the 2011 EAU protocol, with one single-shot Epirubicin instillation associated with intravesical BCG therapy after TUR-BT. There were 16 patients with intermediate risk and 59 patients with high risk bladder tumor (16 Ta and 59 T1). Stratifications according to the grading was: 26 G1, 43 G2 and 6 G3. From the total of 75 patients, 21 were female and 54 male. The mean age in this group was 62 years (ranged between years) with a mean follow-up of 58 months (range between months). The control group (group B) consisted of 71 patients treated between with TUR-BT only. Retrospectively, we found in this group 40 patients with intermediate risk tumours and 31 with high risk non-invasive bladder tumours. Stratification according to the stage was: 36 pta and 35 pt1, while stratification according to the grading was as follows: 42 patients with G1, 25 patients with G2 and 4 patients with G3. Regarding the gender, there were 16 female and 55 male patients. Mean age was 67 years, ranged between years. The mean follow-up was 86 months, ranged between months. The criterias for BCG administration were the following: multiple tumors at first presentation, tumour size more than 3 cm, associated Cis, high grade, early recurrency, high rate of reccurency. All patients received one instillation with 50 mg of Epirubicin in the first 6 hours post TUR-BT. The BCG therapy began at 14 days post TUR-BT, using 150 mg BCG instillation. All patients received 6 BCG instillations. If a patient developed reccurence, the tumour 90 Revista Românæ de Urologie nr. 2 / 2012 vol 11

92 Tumori vezicale Rezultate: În grupul A, în cazul a 17 de pacienfli (22,7%) au fost decelate 23 de recurenfle, 5 pacienfli evoluând spre progresie tumoralæ (6,7%). S-au evidenfliat reacflii adverse la tratamentul cu BCG precum cistitæ, artritæ, vasculitæ sau gonartritæ în cazul a 5 pacienfli tratafli cu BCG (6,7%). Un numær de 4 decese au fost înregistrate în acest grup de studiu (niciunul de cauzæ oncologicæ). În grupul B, 33 de pacienfli (46,4%) au prezentat recurenfle (36 de cazuri), în timp ce 14 pacienfli (19,7%) au evoluat cætre progresie tumoralæ. Au fost înregistrate 28 de decese (11 de cauza oncologicæ). Concluzii: A fost confirmat faptul cæ terapia intravezicalæ cu BCG poate fi eficientæ în tratamentul adjuvant al tumorilor vezicale superficiale. Rata de recurenflæ este redusæ cu 23,7%, iar rata progresiei cu 13%. was resected followed by another cycle of 6 BCG instillations. In selected cases (30 patients) was used the maintenance therapy. In 17 cases re-turb-bt was performed. Results. In group A, 17 patients (22.7%) had 23 recurrencies and 5 patients developed tumor progression (6.7%). A number of 5 patients (6.7%) developed complications like cystitis, arthritis, vasculitis or gonarthritis. There were 4 deaths recorded in this group of study (none of oncological cause). In group B 33 patients (46.4%) developed recurrencies (36 recurrencies ), while 14 patients (19.7%) developed tumor progression. There were 28 deaths recorded (11 oncological). Conclusions. It was confirmed that intravesical BCG insillation can be an efficient tool in the adjuvant treatment of non-muscle invasive bladder tumours. The recurrence rate was reduced by 23.7%, with a reduction in the progression rate of 13% during follow-up. nr. 2 / 2012 vol 11 Revista Românæ de Urologie 91

93 Tumori vezicale 6.5. Sarcinæ dusæ la termen la pacientæ cu cistectomie øi derivaflie urinaræ G. Glück 1, E. Tænase 2, G. Mitulescu 3, Ruxandra Stoica 2, T Priporeanu 1, R. Stoica 1, I. Sinescu 1 1 Centrul de Uronefrologie øi Transplant Renal, Institutul Clinic Fundeni, Bucureøti 2 Clinica de Obstetricæ-Ginecologie, Spitalul Clinic CF2 Bucureøti 3 Clinica de Chirurgie Generalæ øi Transplant Hepatic Fundeni, Bucureøti Full-term pregnancy in a patient with cystectomy and urinary diversion G. Glück 1, E. Tænase 2, G. Mitulescu 3, Ruxandra Stoica 2, T Priporeanu 1, R. Stoica 1, I. Sinescu 1 1 Center of Uronephrology and Renal Transplantation, Fundeni Clinical Institute, Bucharest 2 Obstetrics and Gynecology Clinic, CF2 Clinical Hospital, Bucharest 3 Fundeni General Surgery and Hepatic Transplantation Clinic, Bucharest Scop: Prezentarea evolufliei øi complicafliilor unei paciente cu cistectomie øi derivaflie urinaræ øi sarcinæ dusæ la termen. Prezentare de caz: Pacientæ în vârstæ de 28 de ani, cunoscutæ cu tumoræ intervezico-rectalæ operatæ în iunie 2007 (tumoræ de cca 10/8 cm, duræ ce infiltreazæ baza vezicii urinare øi peretele anterior vaginal), când s-a practicat excizia tumorii în bloc cu cistectomie totalæ øi colpectomie anterioaræ, cu ureterosigmoidostomie bilateralæ în maniera Le Duc Camey. Evoluøia postoperatorie a fost favorabilæ, rezultat histopatologic - disembriom. Controalele postoperatorii aratæ ureterohidronefrozæ dreaptæ grd III, toleranflæ clinicæ bunæ a derivafliei urinare, grevatæ de câteva episoade de pielonefritæ acutæ. În ianuarie 2011, pacienta este decelatæ cu sarcinæ în evoluflie, pe care decide sæ o ducæ la termen. Evoluflia sarcinii este normalæ pânæ la 23 de sæptæmâni, când se descoperæ incompetenflæ cervicoistmicæ, în contextul asocierii cu suferinfla renalæ urmând spitalizarea continuæ a pacientei pânæ la termen, sub tratament antibiotic continuu. În luna octombrie 2011, se decide terminarea sarcinii prin intervenflia cezarianæ segmento-transversalæ, cu naøterea unui fæt viu, sex feminin, greutate 3200 gr, scor Apgar 9. Intervenflia este complicatæ de leziune a colonului sigmoid placat la nivelul feflei anterioare a uterului ce este suturatæ cu fire separate. În a øaptea zi postoperator, pacienta dezvoltæ drenaj stercoral la nivelul plægii operatorii, motiv pentru care este transferatæ în Clinica de Urologie Fundeni. Intervenflia constæ în colectomie tip Hartman, cu închiderea bontului rectal øi colostomie stângæ, histerectomie øi anexectomie bilateralæ øi ureterostomie cutanatæ dreaptæ splintatæ. Evoluflia postoperatorie cu vindecare per-primam. Pacienta Objective: The purpose of the paper is to present the evolution and complications of a patient with a urinary derivation and full-term pregnancy. Case study: 28 year old patient, who underwent surgery for a tumor located between the urinary bladder and the rectum in June 2007 (the size of the tumor was 10/8 cm, hard, infiltrating the base of the urinary bladder and the anterior wall of the vagina), when a bloc excision of the tumor was performed, as well as a radical cystectomy and an anterior colpectomy, with a bilateral Le Duc Camey ureterosigmoidostomy. The post-operatory evolution was favorable, histopathological result - dysembrioma. Post-procedural follow-ups reveal stage III ureterohydronephrosis on the right side, a good clinical tolerance of the urinary diversion, marked by a few episodes of acute pyelonephritis. In January 2011 the patient is diagnosed with an ongoing pregnancy. She decides to carry the pregnancy to full term. The pregnancy has a normal evolution up to the 23rd week, when developed a cervico-isthmic incompetence. The continuous hospitalization of the patient is decided until the birth of the child, under permanent antibiotherapy. In October 2011 it is decided to terminate the pregnancy through a segment transverse cesarean, with the birth of a living female fetus, weighting 3200 g, with an Apgar score of 9. The intervention is complicated by a sigmoid colon lesion, plated on the anterior wall of the uterus, which is sutured. On the 7th postoperative day the patient develops stercoral leakage from the wound, thus prompting the decision to transfer her to Fundeni Urology Clinic. The surgical intervention consists of a Hartman colectomy, with the 92 Revista Românæ de Urologie nr. 2 / 2012 vol 11

94 Tumori vezicale urmeazæ în martie 2012 o intervenflie de repunere în tranzit digestiv, cu desfiinflarea colostomiei stângi. Concluzii: Sarcina produsæ dupæ o derivaflie urinaræ poate ridica probleme complexe pentru mamæ øi fæt. Pânæ în 1972 se recomandæ întreruperea sarcinii. Încæ nu se cunoaøte ce tip de derivaflie este recomandatæ la o femeie care doreøte o sarcinæ. Dupæ informafliile pe care le deflinem este primul caz din România cu sarcinæ dusæ la termen la o pacientæ færæ vezicæ urinaræ. În lume sunt cca. 188 de femei cu 252 de sarcini duse la termen (2 cazuri pentru tumori). closure of the rectal stump and left colostomy, hysterectomy and adnexectomy and a right barreled cutaneous ureterostomy. Postoperative evolution is favorable, with perprimam healing. In March 2012 a new surgical intervention is performed in order to restore the bowell continuity. Conclusions: A pregnancy occurring after a urinary diversion can raise problems for both the mother and the fetus. Until 1972 abortion was recommended. It is yet to be established what type of urinary derivation is ideal for a woman desiring a pregnancy. From our information it is the first case reported in Romania of a full-term pregnancy in a patient without a urinary bladder. There are 188 cases known worldwide, with 252 pregnancies carried to full term (2patients underwent radical cystectomies for tumors). nr. 2 / 2012 vol 11 Revista Românæ de Urologie 93

95 Tumori vezicale 6.6. Leiomiom vezical voluminos Prezentare de caz G. Glück, Manuela Chiriflæ, A. Iordache, I. Sinescu Centrul de Uronefrologie øi Transplant Renal, Institutul Clinic Fundeni, Bucureøti Giant urinary bladder leiomyoma Case study G. Glück, Manuela Chiriflæ, A. Iordache, I. Sinescu Center of Uronephrology and Renal Transplantation, Fundeni Clinical Institute, Bucharest Scop. Prezentarea algoritmului de diagnostic øi tratament a unui caz de tumoræ vezicalæ benign. Prezentare de caz. Pacient în vârsta de 39 de ani, din mediul urban, cunoscut cu diagnosticul de pancreatitæ acutæ cu chiste øi abcese pancreatice operate øi colecistectomie practicatæ în 2009, se interneazæ în clinica noastræ, cu suspiciune imagisticæ (ecografie abdominalæ) de tumoræ vezicalæ, decelatæ în urma controlului de rutinæ efectuat pentru afecfliunea prezentatæ anterior. Examenul obiectiv nu relevæ prezenfla semnelor patognomonice afecfliunii urologice, pacientul fiind asimptomatic.acesta este evaluat bioumoral øi paraclinic în vederea deciziei asupra unei conduite terapeutice. Urografia deceleazæ la nivelul vezicii urinare o formafliune cu dimensiune axialæ maximæ de 7 cm, ce asociazæ imagine de semiton, cu întreruperea conturului, în regiunea peretelui lateral drept, sugestivæ pentru o afecfliune malignæ. Ulterior se practicæ uretrocistoscopie de evaluare, ce nu identificæ la nivelul endovezicii nicio formafliune tumoralæ, însæ este descrisæ o zonæ de comprimare extrinsecæ a peretelui vezical drept, ce impune examinare tomograficæ. Tomografia computerizatæ evidenfliaza la nivelul peretelui vezical lateral drept øi postero-inferior o formafliune extrinsecæ înclocuitoare de spafliu cu diametrul de 5,5 cm, având densitate tisularæ, moderat iodofilæ, contur polilobat, færæ caractere infiltrative, venind în raport, færæ interfaflæ de demarcaflie, cu prostata. În urma evaluærii imagistice øi endoscopice se decide practicarea unei exploræri chirurgicale pelvine, ce identificæ la nivelul peretelui vezical drept o formafliune tumoralæ de aproximativ 8/7/6 cm, de consistenflæ relativ duræ, bine delimitatæ, neinvadând orificiul ureteral drept, care se excizeaza cistectomie parflialæ. Piesa obflinutæ øi marginile chirurgicale sunt trimise pentru examen histopatologic extemporaneu, ce confirmæ diagnosticul de afecfliune vezicalæ benignæ leiomiom øi integritatea marginilor de rezecflie. Evoluflia postoperatorie a pacientului este favorabilæ, cu vindecare per primam. Concluzii: Deøi rare, formafliunile tumorale benigne gigant de la nivelul vezicii urinare reprezintæ o problemæ de diagnostic cu reverberaflii importante asupra conduitei terapeutice ulterioare. Examenul histopatologic extemporaneu este singura modalitate prin care se poate pune un diagnostic de certitudine, impunând astfel øi indicaflia de cistectomie parflialæ. Purpose: To present the diagnosis and treatment patterns in the case of a voluminous benign vesical tumor. Case study: A 39 years old male patient with a medical history of acute pancreatitis with cholecystectomy and surgical excision of multiple cysts and pancreatic abscess, presented to our clinic with a diagnosis of vesical tumor revealed on an ultrasound performed at the usual follow up for the pancreatic condition. The physical examination findings were unremarkable, the patient being asymptomatic. Investigations: Intravenous pyelography revealed a 7 cm filling defect in the right lateral bladder wall, relevant for a malignant disease. Cystoscopy is performed, but does not confirm any bladder mass. Instead, an extrinsic compression is visualised in the right lateral bladder wall, a tomography examination being indicated. The CT-scan showed in the postero-inferior and right lateral bladder wall a 5.5 cm extrinsic space-filling mass, with tissular density and isointense areas, without any invasive features. The patient underwent pelvic surgical evaluation which identified a well defined, hard consistency, round shaped mass in the right vesical wall, of aproximately 8/7/6 cm with no invasion of the right ureteral orifice. Partial cystectomy is performed. Extemporaneous histologic examination diagnosed the tumoral mass as being a leiomyoma. The patient s surgical outcome was satisfactory. Conclusions: Despite of the fact that voluminous benign bladder tumors have a low rate of incidence, they represent a problem in the diagnosis and treatment patterns. Intraoperative histologic examination is the only investigation that confirms the diagnosis and gives the surgical indication for partial cystectomy. 94 Revista Românæ de Urologie nr. 2 / 2012 vol 11

96 6.7. Avantajele unui nou abord de diagnostic øi de tratament în cazul tumorilor vezicale non-invazive voluminoase cistoscopia NBI øi vaporizarea bipolaræ cu plasmæ B. Geavlete, F. Stænescu, R. Mulflescu, D. Georgescu, M. Jecu, C. Moldoveanu, C. Iacoboaie, P. Geavlete Clinica de Urologie, Spitalul Clinic de Urgenflæ Sf. Ioan, Bucureøti Advantages of a new diagnostic and treatment approach in cases of large non-muscle invasive bladder tumors NBI cystoscopy and bipolar plasma vaporization B. Geavlete, F. Stænescu, R. Mulflescu, D. Georgescu, M. Jecu, C. Moldoveanu, C. Iacoboaie, P. Geavlete Department of Urology, Saint John Emergency Clinical Hospital, Bucharest Tumori vezicale Obiective: Studiul a evaluat acurateflea diagnosticæ, rezultatele perioperatorii øi de urmærire ale cistoscopiei narrow band imaging (NBI) asociatæ cu vaporizarea bipolaræ cu plasmæ în cazurile de tumori vezicale non-invazive voluminoase. Material øi metodæ: Un numær de 110 pacienfli cu tumori vezicale peste 3 cm au fost incluøi în studiu. Cistoscopia standard øi cistoscopia NBI urmate de vaporizare bipolaræ cu plasmæ au fost efectuate în fiecare caz sub rahianestezie. Pacienflii cu tumori vezicale non-invazive au urmat Re-TUR standard la 4 sæptæmâni dupæ procedura iniflialæ, 1 an de terapie intravezicalæ cu BCG øi øi cistoscopie standard de urmærire la 3, 6, 9 øi 12 luni. 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. Vaporizarea bipolaræ cu plasmæ a oferit rate satisfæcætoare referitoare la stimularea nervului obturator (3,2%) øi perforafliile peretelui vezical (1,1%). De asemenea, s-au înregistrat valori reduse pentru scæderea medie a hemoglobinei (0,2 g/dl), perioada medie de cateterizare (47,2 ore) øi respectiv de spitalizare (2,9 zile). 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. La 1 an, rata globalæ a tumorilor vezicale non-invazive (7.9%) øi rata de recurenfle heterotopice (3.4%) au fost de asemenea reduse. Concluzii: Cistoscopia NBI a îmbunætæflit semnificativ acurateflea diagnosticæ în cazurile de tumori vezicale non-invazive voluminoase, în timp ce vaporizarea bipolaræ cu plasmæ a evidenfliat o eficienflæ chirurgicalæ øi o siguranflæ superioare. Aceastæ tehnicæ combinatæ a oferit o ratæ satisfæcætoare de tumori reziduale la Re-TUR datoratæ numærului scæzut de recurenfle ortotopice, precum øi o ratæ de recurenflæ redusæ la 1 an consecutiv unei frecvenfle scæzute a recurenflelor heterotopice. Objectives: The trial evaluated the diagnostic accuracy, perioperative and follow-up results of narrow band imaging (NBI) cystoscopy associated with bipolar plasma vaporization (BPV) in cases of large non-muscle invasive bladder tumors (NMIBT). Patients and Methods: A total of 110 patients with bladder tumors over 3 cm were included in the trial. WLC and NBI cystoscopy followed by BPV were performed in every case under spinal anesthesia. NMIBT patients underwent standard Re-TUR 4 weeks after the initial procedure, one year BCG intravesical therapy and follow-up standard cystoscopy at 3, 6, 9 and 12 months. Results: The CIS (94.6% versus 67.6%), pta (93% versus 82.4%) and overall NMIBT (94.9% versus 84.3%) tumors detection were significantly improved for NBI cystoscopy by comparison to standard WLC. 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), catheterization period (47.2 hours) and hospital stay (2.9 days). The overall (6.3%) and primary site (4.2%) residual tumors rates at Re-TUR were decreased for the NBI-BPV approach. The overall NMIBT (7.9%) and other site (3.4%) one year recurrence rates were also reduced in this series of patients. Conclusions: NBI cystoscopy significantly improved the diagnostic accuracy in cases of large NMIBT, while BPV emphasized superior surgical efficacy and safety. This combined technique provided a low residual tumors rate at Re-TUR due to fewer primary site recurrences as well as a reduced one year recurrence rate subsequent to less other site recurrences. nr. 2 / 2012 vol 11 Revista Românæ de Urologie 95

97 Tumori vezicale 6.8. Cistoscopia NBI în cancerul vezical non-invaziv O comparaflie prospectivæ cu metoda standard B. Geavlete, M. Jecu, R. Mulflescu, D. Georgescu, F. Stænescu, C. Moldoveanu, C. Iacoboaie, P. Geavlete Clinica de Urologie, Spitalul Clinic de Urgenflæ Sf. Ioan, Bucureøti NBI cystoscopy in non-muscle invasive bladder cancer A prospective comparison to the standard approach B. Geavlete, M. Jecu, R. Mulflescu, D. Georgescu, F. Stænescu, C. Moldoveanu, C. Iacoboaie, P. Geavlete Department of Urology, Saint John Emergency Clinical Hospital, Bucharest 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, cu definirea de hærfli vezicale separate ale leziunilor descoperite. 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 rezultate fals-pozitive a fost similaræ statistic pentru cele douæ metode (13,6% versus 11,5%). 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. Introduction: A single centre, prospective trial was performed aiming to assess the impact of narrow band imaging (NBI) cystoscopy in cases of non-muscle invasive bladder cancer (NMIBC) by comparison to standard white light cystoscopy (WLC). 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 followed by NBI cystoscopy, resulting in separate bladder maps of all WL and respectively NBI diagnosed lesions. White light TURBT was performed for all lesions visible at standard cystoscopy, while NBI resection was applied for lesions observed in NBI alone. 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%). The rate of false positive results was statistically similar for NBI and WLC (13.6% versus 11.5%). Subsequent to these diagnostic findings, the postoperative instillation treatment was improved due to NBI cystoscopy in a significantly larger number of NMIBC cases (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. 96 Revista Românæ de Urologie nr. 2 / 2012 vol 11

98 6.9. Nefroureterectomia cu abord endoscopic primar al ureterului intramural folosind vaporizarea bipolaræ cu plasmæ P. Geavlete, D. Georgescu, R. Mulflescu, B. Geavlete Clinica de Urologie, Spitalul Clinic de Urgenflæ Sf. Ioan, Bucureøti Nephroureterectomy with primary endoscopic approach of the intramural ureter using bipolar plasma vaporization P. Geavlete, D. Georgescu, R. Mulflescu, B. Geavlete Department of Urology, Saint John Emergency Clinical Hospital, Bucharest Tumori vezicale Introducere øi obiective: Nefroureterectomia cu cistectomie perimeaticæ reprezintæ gold standard-ul de tratament în tumorile de cale urinaræ superioaræ. Abordul endoscopic a fost propus ca metodæ complementaræ pentru a evita o a doua incizie. Scopul studiului a fost de a evalua eficienfla øi siguranfla unei noi metode de abord primar al ureterului terminal: tehnica pluck folosind vaporizarea cu plasmæ. Material øi metodæ: În ultimii 2 ani în clinica noastræ au fost efectuate 62 de nefroureterectomii cu abord endoscopic primar al ureterului terminal folosind vaporizarea bipolaræ cu plasmæ: 23 de cazuri cu tumori pta, 18 pt1, 12 pt2 øi 9 pt3. Tumorile au fost pielocaliceale în 44 de cazuri, ureterale în 16 cazuri øi combinate (ureterale øi pielocaliceale) în 2 cazuri. La tofli pacienflii s-a efectuat dezinserflia ureterului intramural folosind vaporizarea bipolaræ cu plasmæ ca prim timp al nefroureterectomiei. Urmærirea pacienflilor s-a realizat prin cistoscopie, citologie urinaræ, ecografie øi urografie intravenoasæ.perioada medie de urmærire a fost de 18 luni (8-3 de luni). Rezultate: Toate intervenfliile au fost efectuate cu succes. Rata complicafliilor a fost de 4,8%: 3 cazuri de hematurie, dintre care unul a impus reintervenflie endoscopicæ. În cursul perioadei de urmærire 7 pacienfli au prezentat recidive vezicale, într-un caz a fost evidenfliatæ o tumoræ de lojæ renalæ, iar 2 pacienfli au prezentat invazie limfaticæ. Mortalitatea speficæ bolii a fost de 4,8%. Concluzii: Abordul endoscopic al ureterului terminal folosind vaporizarea bipolaræ cu plasmæ ca prim timp al nefroureterectomiei reprezintæ o proceduræ siguræ eficientæ øi facilæ, oferind rezultate favorabile din punct de vedere oncologic. Introduction & Objectives: Nefroureterectomy with perimeatal cystectomy is the gold standard in the treatment of urothelial upper urinary-tract carcinoma (UUTC). Ureteral endoscopic surgery was proposed as a complementary first step in nephroureterectomy in order to obviate the low abdominal incision. Our goal was to establish the value of a novel method of endoscopic distal ureteral management in one step nephroureterectomy for UUTC: pluck technique using bipolar plasma vaporization. Material and Methods: In the last two years, 62 nephroureterectomies with endoscopic distal ureteral approach were performed for UUTC (pta in 23 cases, pt1 in 18 cases, pt2 in 12 cases, pt3 in 9 cases). The tumor was pyelocaliceal in 44 cases, ureteral in 16 cases, and both ureteral and pyelocaliceal in 2 cases. All these patients underwent pluck transurethral detachment of the intramural ureter. The follow-up was performed by cystoscopy with urinary cytology, ultrasonography and intravenous urography. The mean follow-up was 18 months (range 8 to 33 months). Results: All procedures were completed successfully. The complication rate was 4.8%: 3 cases of hematuria, one imposing endoscopic approach and other two treated conservatively. During follow-up, 7 patients had bladder recurrences, 1 had renal fossa tumors and 2 had secondary lymph-node invasion. The disease-specific mortality rate was 4.8%. Conclusions: The endoscopic approach of the terminal ureter with bipolar plasma vaporization as part of one-step nephroureterectomy is a safe, facile and effective method offering good oncological results. nr. 2 / 2012 vol 11 Revista Românæ de Urologie 97

99 Tumori vezicale Factori de prognostic pentru tumorile uroteliale de cale urinaræ superioaræ tratate cu laser G. Niflæ, D. Georgescu, R. Mulflescu, M. Dræguflescu, B. Mihai, C. Persu, B. Geavlete, I. Arabagiu, P. Geavlete Clinica de Urologie, Spitalul Clinic de Urgenflæ Sf. Ioan, Bucureøti Prognostic factors in laser treatment of upper urinary tract urothelial tumours G. Niflæ, D. Georgescu, R. Mulflescu, M. Dræguflescu, B. Mihai, C. Persu, B. Geavlete, I. Arabagiu, P. Geavlete Department of Urology, Saint John Emergency Clinical Hospital, Bucharest Introducere. Tratamentul standard al carcinoamelor uroteliale de cale urinaræ superioaræ (UUT-UCCs) este reprezentat de nefroureterectomia totalæ cu cistectomie perimeaticæ. Scopul acestui studiu a fost analiza retrospectivæ a rezultatelor pe termen lung în cazul pacienflilor cu UUT-UCCs tratafli endoscopic. Material øi metodæ. In perioada în cadrul Clinicii de Urologie a Spitalului Clinic de Urgenflæ Sf. Ioan Bucureøti au fost diagnosticafli øi tratafli pentru UUT-UCCs un numær de 187 pacienfli. Dintre aceøtia la 65 cazuri s-a utilizat abordul endoscopic. Ablaflia tumoralæ s-a realizat utilizând electrorezecflia sau un laser Nd:YAG. Perioada medie de urmærire a fost de 60 luni (între 6 øi 120 luni). Protocolul de urmærire a inclus tomografie computerizatæ sau urografie intravenoasæ, citologie urinaræ (cazuri selecflionate), cistoscopie øi ureteroscopie. S-a analizat retrospectiv rata de recidivæ fiind identificafli factorii care o influenfleazæ. Rezultate. În timpul perioadei de urmærire un numær de 31 (47.6%) pacienfli au dezvoltat recidive tumorale la nivelul tractului urinar sperior. La 20 cazuri (30.7%) s-au înregistrat recidive vezicale. 18 pacienfli (27.69%) au necesitat ulterior nefroureterectomie. Ratele de supraviefluire færæ recidivæ la 1, 3 øi respectiv 5 ani de la diagnostic au fost de 61% (40 pacienfli), 55.3% (36 pacienfli) respectiv 52.3% (34 pacienfli). Rata de recidivæ pentru tumorile pielo-caliceale a fost de 53.84% (21 din 39 cazuri) øi doar 45.45% (10 din 26 cazuri) pentru localizærile ureterale. Rata de recurenflæ pentru tumorile lowgrade a fost de 36,36% (16 din 44 cazuri) øi de 71.42% (15 din 21 cazuri) pentru tumorile high-grade. Tumorile peste 1.5 cm s-au însoflit de o ratæ a recurenflelor semnificativ mai ridicatæ (mai ales recurenfle locale) comparativ cu cele sub 1.5 cm (64.2 versus 43.13%). Concluzii. Cei mai importanfli factori de prognostic pentru evoluflia UUT-UCCs sunt reprezentafli de localizare, dimensiune øi mai ales gradingul tumoral. Complianfla pacienflilor este foarte importantæ pentru depistarea recidivelor. ntroduction. The standard treatment for upper urinary tract urothelial cell carcinoma (UUT-UCCs) is radical nephroureterectomy with bladder cuff excision. The purpose of this study was the retrospective analysis of the factors that can influence the prognosis of the patients withuut-uccs who underwent endoscopic treatment. Patients and method. We identified 187 patients who where diagnosed and treated for UUT-UCCs between at the Urology Department of St. John s Clinical Emergency Hospital Bucharest. The endoscopic treatment was used in 65 cases. Tumor ablation was performed using electroresection or Nd:YAG laser. The mean follow-up period was 60 months (range between 6 and 120 months). The follow-up protocol included computed tomography or intravenous urography, urinary cytology (selected cases), cystoscopy and ureteroscopy. The recurrence rates were reviewed by retrospective analysis. Results. During follow-up 31 patients (47.6%) presented upper urinary tract recurrence. In 20 cases (30.7%) bladder recurrence was present. 18 patients (27.69%) underwent subsequent nephroureterectomy. The survival rates without recurrence at 1, 3 and 5 years were 61% (40 patients), 55.3% (36 patients) and 52.3% (34 patients). The most significant prognostic factors were: history of bladder tumour, tumour location and size, tumour stage and grade. The recurrence rate for pyelocaliceal tumours was 53.84% (21 out of 39 cases) and only 45.45% (10 out of 26 cases) for ureteral tumours. The recurrence rate for low-grade tumours was 36.36% (16 out of 44 cases) and 71.42% (15 out of 21 cases) for high-grade tumours. The tumours over 1.5 cm were associated with a higher recurrence rate compared with tumours below 1.5 cm (64.2 versus 43.13%). Conclusions. The most important prognostic factors for UUT-UCCs evolution are tumours location, size and mostly tumour grade. The patients compliance is very important for detecting recurrences. 98 Revista Românæ de Urologie nr. 2 / 2012 vol 11

100 6.11. Calitatea vieflii pacienflilor cu tumori vezicale non-musculoinvazive øi tratamentul adjuvant cu BCG G. Glück, Manuela Chiriflæ, Florentina Bealcu, I. Sinescu Centrul de Uronefrologie øi Transplant Renal, Institutul Clinic Fundeni, Bucureøti Quality of life in patients with non-muscle invasive bladder cancer and BCG adjuvant treatment G. Glück, Manuela Chiriflæ, Florentina Bealcu, I. Sinescu Center of Uronephrology and Renal Transplantation, Fundeni Clinical Institute, Bucharest Tumori vezicale Scop: Terapia intravezicalæ cu BCG adresatæ pacienflilor cu tumori vezicale non-musculoinvazive 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 Metode: 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 6 pacienfli. Calitatea vieflii pacientilor 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 mic de pacienfli, rezultatele obflinute sunt considerate a fi relevante în ceea ce priveøte calitatea vieflii pacienflilor cu tumori vezicale superficiale 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. 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 recurrency 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 were recorded before, during and after the six-weeks induction phase after TUR-BT in the case of 6 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 / 2012 vol 11 Revista Românæ de Urologie 99

101 Tumori vezicale Cancerul de vezicæ urinaræ T2a - rezultatele rezecfliei transuretrale asociatæ cu terapia intravezicalæ cu BCG G. Glück, Manuela Chiriflæ, A. Iordache, I. Sinescu Centrul de Uronefrologie øi Transplant Renal, Institutul Clinic Fundeni, Bucureøti TUR-BT and BCG instillations in T2a urinary bladder cancer patients G. Glück, Manuela Chiriflæ, A. Iordache, I. Sinescu Center of Uronephrology and Renal Transplantation, Fundeni Clinical Institute, Bucharest Scop: În cadrul acestui studiu retrospectiv am evaluat efectul combinat al rezecfliei transuretrale pentru cancerului vezicii urinare musculo-invaziv (T2a) øi imunoterapia cu bacilul Calmette-Guérin (BCG) la pacienflii improprii pentru cistectomie radicalæ sau care au refuzat terapia agresivæ. Materiale øi metode: Un total de 15 pacienti cu o vârsta medie 60,5 ani au fost incluøi în studiu în perioada august 2003 februarie Criteriile de includere au fost reprezentate de: diagnosticul histologic de carcinom invaziv cu celule tranziflionale al vezicii urinare, pacienflii improprii pentru cistectomie radicala sau refuzul unei terapii mai agresive. Tofli pacienflii au beneficiat de o instilaflie cu Farmarubicin 50 mg în primele 6 ore post TURV øi 6 instalaflii intravezicale cu BCG de 81 mg pe sæptæmânæ. Terapia cu instilaflii intravezicale a fost începutæ la de zile dupæ rezecflia transuretralæ a tumorii. Urmærirea s-a efectuat conform ghidurilor EAU 2011, la 3 luni incluzând examinare cistoscopicæ, citologie urinaræ, ecografie abdominalæ øi radiografie toracicæ. La 6 luni au fost efectuate examinæri tomografice ale etajului abdomeninal øi oaselor. Rezultate: Dintre cei 15 pacienti, 5 au prezentat progresie tumoralæ øi au acceptat cistectomia radicalæ. Doi pacienfli cu progresie tumoralæ au decedat un singur caz fiind de natura oncologicæ. Cei 3 pacienfli care au beneficiat de tratament chirurgical cu intenflie de radicalitate sunt încæ în viata. În perioada de urmærire august 2003 februarie 2011 (între 1-8 ani perioada de urmærire), un numær de 3 pacienfli dintre cei 10 ræmaøi în studiu au dezvoltat recidive; 2 cazuri cu recidivæ au apærut în primul an de la diagnostic øi un singur caz de recidivæ a fost înregistrat la doi ani de la diagnostic. A fost inregistrat un singur caz de deces non-oncologic (infarct miocardic acut) în cadrul pacienflilor færæ progresie tumoralæ. De asemenea, a fost raportat un singur caz de reacflie adversæ la terapia intravezicalæ cu BCG, asociind prostatita øi cistita acutæ. Concluzii: Datele aratæ rezultate încurajatoare în ceea ce priveøte rezecflia transuretralæ a tumorilor vezicale T2a care asociazæ tratament adjuvant cu BCG, la pacienfli selectafli cu cancer de vezica urinaræ T2a, care nu sunt candidafli pentru cistectomie radicalæ. Purpose: To assess the effectiveness of TUR-BT associated with BCG instillations in muscle-invasive urinary bladder cancer patients who are not fit for radical surgery or refuse the intervention. Materials and methods: The study conducted between August 2003 February 2011, included 15 patients with a mean age of 60.5 years. Criteria of inclusion were the following: histologic diagnosis of invasive transitional cell cancer, patient not fit for radical surgery or he refuses the intervention. All patients included in the study received a 50 mg Farmarubicin intravesical instillation in the first 6 hours after TUR-BT and 6 BCG instillations at days after TUR- BT. According to 2011 EAU guidelines, the 3 months followup included cystoscopic evaluation, urinary cytology, abdominal ultrasound and chest X-Ray. Abdominal and bone CT-scans were performed at 6 months follow-up. Results: From the total of 15 patients, 5 presented tumoral progression and underwent radical surgery. Two patients with tumoral progression died, but only one death was due to the invasive bladder cancer. 3 patients with tumoral progression are still alive. Between August 2003 February 2011 (1 to 8 years follow up period), 3 patients from the total of 10 without tumoral progression, developed recurrencies 2 in less than a year from diagnosis and 1 in less than 2 years. One patient developed BCG therapy side effects such as prostatitis and cystitis. Conclusions: The results of the study are promising regarding the association between TUR-BT and BCG intravesical therapy for T2a bladder cancer patients who are not fit for radical surgery. 100 Revista Românæ de Urologie nr. 2 / 2012 vol 11

102 6.13. Aspecte statistice în tumorile vezicale D. Purza, M. Vârlan, A. Bumbu, S. Kolumban, R. Drægoi, M. Berechet, D. Jovrea, G. Isoc, G. Bumbu Clinica de Urologie, Spitalul Judeflean Oradea Statistical aspects of bladder tumors D. Purza, M. Vârlan, A. Bumbu, S. Kolumban, R. Drægoi, M. Berechet, D. Jovrea, G. Isoc, G. Bumbu Urology Department, Oradea County Hospital Tumori vezicale Introducere øi obiective. Tumorile vezicale revendicæ atât la nivel european øi mondial, cât øi la nivel naflional, un numær tot mai mare de pacienfli, transformându-se într-o realæ problemæ de epidemiologie. Material øi metodæ. au fost analizafli statistic un numær de 503 pacienfli diagnosticafli cu tumoræ vezicalæ în intervalul , cærora li s-a practicat rezecflie transuretralæ a formafliunilor tumorale endovezicale (TUR-V). Rezultate. Au fost analizafli diferifli parametrii: încadrarea pacienflilor pe grupe de vârstæ, repartiflia pe sexe, repartiflia pacienflilor în funcflie de gradul de diferenfliere tumoral, gradul de corelare al aprecierii macroscopice ct respectiv microscopice pt. Concluzii. Rezultatele au fost analizate procentual în directa corelaflie cu datele din literatura de specialitate. Introduction and objectives. Bladder tumors account for a growing number of patients as among the Europeans but for the local population as well transforming into an epidemiological issue. Material and method. A number of 503 patients known with bladder tumors were statistically analyzed between 1st of January 2007 and 31st of December They were performed TUR-BT. Results. Different parameters were taken in account: distribution of patients according to age groups, sex, depending on the tumoral grading, correlation grade between macroscopic ct appreciation and microscopic pt evaluation. Conclusions. The results were analyzed in percentage in direct correlation with the data in the specialty literature. nr. 2 / 2012 vol 11 Revista Românæ de Urologie 101

103 Tumori vezicale Cistectomia radicalæ extraperitonealæ cu neovezicæ ilealæ operaflie simultanæ N. Dobromir, A. Filip, N. Stoican, D. Stænescu, F. Terteliu, A. Pascal, O. Dobromir Secflia Urologie, Spitalul Judeflean Suceava Extraperitoneal radical cystectomy with ileal new bladder simultaneous surgery N. Dobromir, A. Filip, N. Stoican, D. Stænescu, F. Terteliu, A. Pascal, O. Dobromir Urology Department, Suceava Emergency County Hospital Introducere. Tratamentul deelecflie al tumorilor vezicale infiltrative este cistectomia radicalæ. Alegerea tehnicii chirurgicale (transperitonealæ, extreaperitonealæ, laparoscopic) este la titudinea chirurgului. Efectuarea unei cistoplastii de substituflie impune o serie de condiflii medico-chirurgicale øi evaluarea patologiei asociate a pacientului. Alegerea tratamentului chirurgical adecvat confera la rezultate satisfacatoare atâta pentru pacient cat øi pentru medic. Prezentare de caz. Pacientul V.P. de 52 ani, cunoscut din 2007 cu tumoræ vezicalæ operat (TUR-V), recidivatæ în 2008, 2009 si VII.2011 tratatat prin rezecflii endoscopice + imunoterapie intravezicalæ cu citostatice, se prezintæ de urgenflæ (II.2012) pentru hematurie totalæ, anemie secundaræ severæ, stare generala alteratæ. Examenul RMN øi cistoscopia stabilesc diagnosticul de formafliune tumoralæ expansivæ intravezicalæ la nivelul peretelui antero-superior. Dupæ pregatire preoperatorie, sub AG-IOT, se practicæ cistectomie radicalæ extraperitonealæ (incizia practicata fiind mediana pubo-ombilicala). Luându-se în considerare radicalitatea operafliei, intervenflia chirurgicala fara incidente (sângerare minimæ), varsta pacientului (52 ani) se decide confecflionarea neovezicii ileale tehnica Camey II prin efectuarea unei breøe peritoneale minime. Evoluflia postoperatorie favorabilæ, cu reluarea tranzitului în a 3-a zi post-operator. Suprimarea cateterelor ureterale la 14 zile øi a sondei uretro-neovezicale in a 20-a zile, prezentând micfliuni fiziologice. Concluzii. Statusul preoperator al bolnavului, dupæ reechilibrare hemodinamicæ øi electroliticæ în contextul recidivelor repetate în ultimii 3 ani cu hematurii totale trenante, anemie severæ øi a vârstei bolnavului (52 ani) au impus opfliunea intervenfliei chirurgicale simultane (cistectomie extraperitonealæ + derivaflie ortotopicæ). Introduction. Elective treatment of infiltrating bladder tumors is radical cystectomy. Choice of surgical technique (transperitoneal, extreaperitoneal, laparoscopy) is the ability of the surgeon. Making a substitution cystoplasty requires exclusion importance associated pathology of the patient. Choosing the correct surgical treatment leads to satisfactory results for both patients and doctor. Case presentation. Patient V.P. of 52 years, known from 2007 with bladder tumor surgery (TUR-V), recurred in 2008, 2009 and VII.2011 treated by endoscopic resection and intravesical immunotherapy with chemotherapy, emergency presents (II.2012) for total hematuria, severe secondary anemia, altered general condition. MRI and cystoscopy the diagnosis of intravesical tumor expanding the anterosuperior wall. After preoperative preparation, under general OTI anesthesia, is practiced extraperitoneal radical cystectomy (practiced the median incision pubo-umbilical). Taking into account the radical operation, good walking surgery (minimal bleeding), patient age (52 years), deciding making ileal new bladder (Camey II technique). Favorable postoperative course, with the resumption of transit in the 3rd postoperative day. Suppression of ureteric catheters at 14 days and a uretral catheters in the 20 th day, showing physiological micturition. Conclusions. Preoperative status of the patient, after hemodynamic and electrolytic rebalancing in the context of repeated relapses last three years with total hematuria train, severe anemia and patient age (52 years) required simultaneous surgical option (extraperitoneal cystectomy + orthotopic extension). 102 Revista Românæ de Urologie nr. 2 / 2012 vol 11

104 V.1. Ureteroscopia flexibilæ cu litotriflie Holmium laser pentru litiaza renalæ experienfla iniflialæ G. Niflæ, R. Mulflescu, V. Mirciulescu, D. Georgescu, B. Geavlete, I. Arabagiu, F. Stænescu, B. Mihai, C. Moldoveanu, C. Persu, P. Geavlete Clinica de Urologie, Spitalul Clinic de Urgenflæ Sf. Ioan, Bucureøti Flexible ureteroscopy with Ho laser lithotripsy for renal stones initial experience G. Niflæ, R. Mulflescu, V. Mirciulescu, D. Georgescu, B. Geavlete, I. Arabagiu, F. Stænescu, B. Mihai, C. Moldoveanu, C. Persu, P. Geavlete Department of Urology, Saint John Emergency Clinical Hospital, Bucharest Video Obiective: Scopul acestei lucræri este analiza experienflei inifliale privind ureteroscopia flexibilæ cu litotriflie Holmium laser pentru litiaza renalæ. Material øi metodæ: În perioada ianuarie martie 2012, au fost evaluafli un numær de 40 pacienfli cu litiazæ renalæ tratafli prin ureteroscopie flexibilæ cu litotriflie laser. 16 pacienfli (40%) au prezentat calculi multiplii unilateral, iar 7 (17,5%) au prezentat litiazæ multiplæ. Litiaza renalæ a fost asociatæ obstrucfliei ureterale în 13 cazuri (32,5%). 28 pacienfli (70%) s-au prezentat dupæ eøecul procedurii ESWL. In 29 de cazuri, calculul a fost localizat la nivelul grupului caliceal inferior. Evaluarea a vizat perioada perioperatorie precum øi costurile implicate. Rezultate: În perioada analizatæ s-au practicatun numær de 45 proceduri la 40 pacienfli. Dimensiunea medie a masei litiazice evaluatæ preoperator a fost de 13,5±6 mm.timpul operator mediu a fost de 45± 25.5 min. Rata stone-free a fost de 94% dupæ o proceduræ, crescând la 98% dupæ a doua proceduræ. Rata globalæ a complicafliilor nu a depæøit 2%. Succes terapeutic au înregistrat 92%, respectiv 93%dintre pacienflii cu ESWL eøuat, respectiv litiazæ în grupul caliceal inferior. Eøecul primei intervenflii a fost asociat cu prezenfla calculilor de peste 20 mm diametru (p=0,007), færæ a fi corelat statistic cu localizarea în calicele inferior (p=0,09). Materialele consumabile sunt responsabile pentru 78% din costul total al procedurii. Concluzii: Ureteroscopia flexibilæ cu laser Holmium este o proceduræ siguræ øi eficientæ pentru tratamentul litiazei de tract urinar înalt, fiind totodatæ o opfliune alternativæ în situaflia eøecului litotrifliei extracorporeale sau a litiazei cu localizæri multiple. Diametrul de peste 2 cm al masei litiazice asociazæ rate mai mari de rezolvare incompletæ dupæ prima intervenflie. Objective: To assess the initial experience of flexible ureteroscopic lithotripsy with holmium laser for upper tract calculi. Materials & Methods: Between January and March 2012, 40 patients treated for upper tract stone with flexible ureteroscopic lithotripsy were evaluated. Renal stones were associated with collecting system obstruction in 13 patients (32.5%), unilateral multiple stones in 16 patients (40%), and multiple stones in 7 (17.5%). Failed extracorporeal shockwave lithotripsy (SWL) occurred in 28 patients (70%). In 29 cases, the stone was located in the inferior calyx. Perioperative and financial outcomes were also evaluated. Results: 45 procedures were performed in 40 patients. The mean stone burden on preoperative evaluation was 13.5 ± 6 mm. The mean operative time was 45 ± 25.5 min. The stone free rate was 94% after one procedure and 98% after a second procedure, with overall complication rate of 2%. Therapeutic success occurred in 92% and 93% of patients with lower pole stones and SWL failure, respectively. Treatment failure of a single session was associated with presence of a stone size larger than 20 mm (p = 0.007), but not associated with inferior calyx location (p = 0.09). Surgical disposables were responsible for 78% of overall costs. Conclusion: Flexible ureteroscopy using holmium laser is a safe and effective option for the treatment of upper urinary tract calculi. In addition, it can be considered an attractive option as salvage therapy after SWL failure or kidney calculi associated with ureteral stones. Stone size larger than 20 mm is associated with single session treatment failure. nr. 2 / 2012 vol 11 Revista Românæ de Urologie 103

105 Video V.2. Este vârsta un factor limitant pentru recuperare postoperatorie rapidæ (enhanced recovery) în nefrectomia laparoscopicæ? C.P. Ilie, A. Pantalon, V. Mædan, F. Rusu, O. Bratu, M. Dinu, C. Farcaø, W. Lukianski *, R. Calleja *, P. Maheshkumar *, D. Mischianu Clinica de Urologie, Spitalul Universitar de Urgenflæ Militar Central Carol Davila Bucureøti * The Queen Elizabeth Hospital King s Lynn NHS Is age a limiting factor for enhanced recovery in laparoscopic nephrectomy? C.P. Ilie, A. Pantalon, V. Mædan, F. Rusu, O. Bratu, M. Dinu, C. Farcaø, W. Lukianski *, R. Calleja *, P. Maheshkumar *, D. Mischianu Urology Department, University Emergency Central Military Carol Davila Bucharest * Urology Department, The Queen Elizabeth Hospital King s Lynn NHS Foundation Trust, UK Foundation Trust, UK Introducere: Recuperarea postoperatorie rapidæ combinæ o serie de elemente: analgezie adecvatæ, tehnici chirurgicale minim invasive precum øi o reabilitare postoperatorie agresivæ. Studiile actuale au arætat cæ aceastæ alternativæ este siguræ, reduce complicafliile minore postoperatorii, scurteazæ perioada de convalescenflæ øi reduce durata spitalizærii. Studiile însæ, exclud pacienflii aflafli la vârste extreme. Prezentæm cazul unei paciente în vârstæ de 80 de ani, diagnosticatæ cu tumora renalæ stângæ, la care s-a practicat nefrectomie laparoscopicæ. Metode: Pentru practicarea nefrectomiei s-a folosit o cale de abord transperitonealæ. Dupæ incizia peritoneului parietal, ureterul este identificat øi disecflia este continuatæ ascendent spre pedicolul renal. Vena øi artera sunt identificate øi izolate. Artera øi apoi vena sunt triplu clipate cu Hem-o-Lock øi secflionate. Rinichiul este izolat øi extras. Pacienta a urmat un protocol de recuperare rapidæ. Rezultate: Pacienta a fost externatæ în ziua a treia postoperator. Evoluflia postoperatorie a fost simplæ. Concluzii: Recuperarea rapidæ dupa nefrectomia laparoscopicæ este fezabilæ, pentru pacienflii aflafli la vârste extreme, însæ trebuie evaluat pentru fiecare pacient în parte. Introduction: Enhanced recovery after surgery combines a number of elements: optimal pain relief, minimally invasive techniques and aggressive post-operative rehabilitation. Current studies indicate that this approach is safe, reduces minor post operative complications, increase rate of recovery and reduces hospital stay. Randomized studies exclude patients at the extremes of ages. We report a case of a left renal tumor in an 80 years old patient treated with laparoscopic nephrectomy. Methods: A transperitoneal laparoscopic approach is used to perform nephrectomy. After incision of the parietal peritoneum, the ureter is identified and the dissection is carried up towards the renal pedicle. The vein and the artery are identified and isolated. The artery and then the vein are triple clipped with Hem-o-Lock and cut. Then the kidney is isolated and removed. Patients followed an enhanced recovery. Results: The patient was discharged after three days. No complications occurred. Conclusion: Enhanced recovery in laparoscopic nephrectomy is feasible for patients at the extremes of age but needs to be considered individually for every patient. 104 Revista Românæ de Urologie nr. 2 / 2012 vol 11

106 V.3. Tratamentul laparoscopic al sindromului de joncfliune pielo-ureteralæ C.P. Ilie, A. Pantalon, V. Mædan, F. Rusu, O. Bratu, M. Dinu, C. Farcaø, W. Lukianski *, R. Calleja *, P. Maheshkumar *, D. Mischianu Clinica de Urologie, Spitalul Universitar de Urgenflæ Militar Central Carol Davila Bucureøti * The Queen Elizabeth Hospital King s Lynn NHS Laparoscopic management of the pelvi-ureteric obstruction C.P. Ilie, A. Pantalon, V. Mædan, F. Rusu, O. Bratu, M. Dinu, C. Farcaø, W. Lukianski *, R. Calleja *, P. Maheshkumar *, D. Mischianu Urology Department, University Emergency Central Military Carol Davila Bucharest * Urology Department, The Queen Elizabeth Hospital King s Lynn NHS Foundation Trust, UK Video Foundation Trust, UK Introducere: Abordul laparoscopic s-a impus ca una dintre alternativele de tratament în sindromul de jonfliune pieloureteralæ. Obiectivul lucrærii este prezentarea rezultatelor postoperatorii imediate ale intervenfliei chirurgicale. Material øi Metodæ: În ultimele trei luni am efectuat un numær de patru pieloplastii laparoscopice folosind calea de abord transperitonealæ. Se prezintæ pas cu pas tehnica folositæ: accesul transperitoneal, identificarea ureterului øi disecflia ascendentæ spre joncfliunea pielo-ureteralæ, excizia zonei stenozate, realizarea reconstrucfliei pielo-ureterale în maniera Hynes-Anderson, montarea de stent ureteral autostatic precum øi de tub de dren. Rezultate: Evoluflia postoperatorie a fost simplæ Tubul de dren peritoneal a fost menflinut douæ zile, iar sonda ureteralæ patru sæptæmâni. Durata medie de spitalizare a fost de patru zile. Concluzii: Pieloplastia laparoscopicæ se va impune ca principalæ metodæ de tratatment al sindromului de joncfliune pieloureteralæ, tehnica chirurgicalæ fiind bine standardizatæ. Introduction: Laparoscopic pyeloplasty is one of the treatment options for pelvi-ureteric obstruction. The objective is to present the immediate postoperative results of the laparoscopic pyeloplasty. Methods: In the last three months we have performed four laparoscopic pyeloplasties using the transperitoneal approach. It is presented step by step the surgical technique: transperitoneal approach, isolation of the ureter and dissection towards the pelvi-ureteric obstruction, removal of stenotic area, pelvi-ureteric reconstruction (Anderson- Hynes), and placement of the ureteric stent as well as the tube drain. Results: Postoperative recovery was uneventful. The tube drain was removed in the second postoperative day and the double J stent after four weeks. The medium hospital stay was four days. Concluzii: The laparoscopic pyeloplasty will become the main treatment option for the pelvi-ureteric obstruction, surgical technique being well standardized. nr. 2 / 2012 vol 11 Revista Românæ de Urologie 105

107 Video V.4. Incidente intraoperatorii în laparoscopia urologicæ: experienfla clinicii noastre C.S. Gutue, I. Chira, M. Pisoschi, B. Braticevici, V. Ambert, V. Jinga Spitalul Clinic de Urologie Prof. Dr. Theodor Burghele, Bucureøti Intraoperative incidents in laparoscopic urology: experience of our clinic C.S. Gutue, I. Chira, M. Pisoschi, B. Braticevici, V. Ambert, V. Jinga Prof. Dr. Theodor Burghele Urology Clinic, Bucharest Obiectiv: Prezentarea inregistrarilor video cu tipuri specifice de leziuni intraoperatorii (gastrointestinale, vasculare si urologice) cat si solutiile alese pentru rezolvarea acestora, in interventiile laparoscopice urologice realizate in clinica noastra. Materiale øi metodæ: Au fost analizate inregistrarile video ale interventiilor laparoscopice efectuate in clinica noastra intervalul ianuarie 2010 februarie S-au analizat si se vor prezenta in materialul video acele incidente care au fost produse prin deficitul de tehnica operatorie. Rezultate: Din totalul de 156 interventii laparoscopice (abord transperitoneal) efectuate in clinica noastra in intervalul de timp amintit, au fost inregistrate 14 conversii: 10 cazuri prin leziuni vasculare, 1 caz prin leziune intestinala, 1 caz prin leziune ureterala, 2 cazuri prin lipsa de progresare a interventiei pe cale laparoscopica pe o durata mai mare de 30 de minute. In materialul video se vor prezenta si analiza mecanismele de producere ale acestor leziuni. Concluzii: Leziunile intraoperatorii laparoscopice pot fi reduse prin respectarea timpilor operatori si printr-o buna coordonare a echipei operator-cameraman-asistenta. Objective: To present different types of intraoperative incidents (gastrointestinal, vascular and urological) as well as the solutions to resolve them, during laparoscopic urological interventions performed in our clinic. Materials and methods: We analyzed video recordings of laparoscopic interventions performed in our clinic between January February There were analyzed and will be presented in the video session different types of incidents caused by deficiency in the performed surgical technique. Results: Of the 156 laparoscopic interventions performed in our clinic (transperitoneal access) during the time mentioned, there have been 14 conversions: 10 cases with vascular lesions, 1 case with bowel injury, 1 case with ureteric injury, 2 cases of by lack of progression in laparoscopic manner for a period exceeding 30 minutes. The video will present and analyze the mechanism of producing these type of lesions. Conclusions: Intraoperative laparoscopic injuries can be reduced by following the correct operating steps of each procedure and also a better coordination of operatorcameraman-scrub nurse team. 106 Revista Românæ de Urologie nr. 2 / 2012 vol 11

108 V.5. Cervicopexia transobturatorie - tehnicæ originalæ în tratamentul prolapsului uterovaginal de grad mare M. Berechet, A. Bumbu, G. Bumbu Clinica de Urologie Spitalul Clinic Judeflean de Urgenflæ Oradea Transobturator Cervicopexy original technique in the treatment of advanced uterovaginal prolapse M. Berechet, A. Bumbu, G. Bumbu Urology Clinic Oradea Emergency Clinical County Hospital Video Introducere øi obiective: Se prezintæ tehnica originala de rezolvare a prolapsului uterovaginal prin cervicopexie transobturatorie. Materiale øi metodæ: Autorul prezintæ tehnica øi experinfla pe un lot iniflial cuprinzând 14 paciente cu prolaps uterovaginal având vârsta cuprinsæ între 52 øi 73 de ani. Rezultate øi concluzii: Se constatæ o evoluflie postoperatorie færæ complicaflii, cu micfliuni facile dupæ îndepærtarea sondei vezicale. Perioada relativ scurtæ de timp øi numærul redus de cazuri pânæ în acest moment nu ne permite o evaluare exactæ a tehnicii, rezultatele înregistrate ne permit totuøi constatarea cæ acestæ tehnicæ poate fi consideratæ o metodæ foarte bunæ de rezolvare a prolapsului uterovaginal. Introduction and objectives: The author presents an original approach using transobturator cervicopexy for uterovaginal prolapse. Material and method. Initial experience with fourteen 52 to 73 years old patients with uterovaginal prolapse. Results and conclusions. Postoperatory evolution without complications with easy micturitions after removal of the catheter. The relative short period of time and the asmall number of patients do not allowed an accurate evaluation of the technique. Nevertheless the initial results indicate this technique as a good mean to solve uterovaginal prolapse. nr. 2 / 2012 vol 11 Revista Românæ de Urologie 107

109 Video V.6. Nefrectomia parflialæ laparoscopicæ-asistatæ robotic experienfla iniflialæ Robotic-assisted laparoscopic partial nephrectomy - initial experience D. Diaconescu 1, B. Braticevici 1, V. Ambert 1, T. Radu 1, M. Popescu 1, D. Bædescu 1, Deliu Victor Matei 2, Ottavio de Cobelli 2, V. Jinga 1 1 Spitalul Clinic de Urologie Prof Dr Th Burghele, Bucuresti, Romania 2 European Institute of Oncology D. Diaconescu 1, B. Braticevici 1, V. Ambert 1, T. Radu 1, M. Popescu 1, D. Bædescu 1, Deliu Victor Matei 2, Ottavio de Cobelli 2, V. Jinga 1 1 Prof. Dr. Th.Burghele Urology Clinic Hospital, Bucharest, Romania 2 European Institute of Oncology Obiective: Nefrectomia partiala este indicata in tumora renala, de dimensiuni mici, descoperita incidental. Nefrectomia partiala este o interventie in care timpul joaca un rol important in succesul interventiei. Material øi metodæ: Inregistratrea video consemneaza tehnica folosita in clinica noastra in efectuarea nefrectomiei partiale laparoscopice asistata robotic. Rezultate: Pacient M.N de 54 de ani, asimptomatic, diagnosticat imagistic cu o formatiune tumorala situata la nivelul polului renal inferior drept cu dimensiunea de 30/20 mm. Tehnica: 1. Obtinerea pneumoperitoneului prin tehnica Verres. 2. Montarea standard a trocarelor - cu utilizarea a 3 brate ale robotului. 3. Izolarea pediculului renal si clamparea arterei renale. 4.Identificarea formatiunii tumorale renale si excizia la rece a formatiunii cu foarfeca curba. 5. Renorafia cu fire de Vicril O blocate de hemolock si utilizarea de Surgicell. 6 Indepartarea buldogilor vasculari si examinarea transei de sutura. 7. Indepartarea formatiunii tumorale in endobag, 8. Inchiderea peritoneului si drenajul retroperitoneal. Concluzie: Sistemul Davinci ofera chirurgului abilitatea de a efectua proceduri complexe laparoscopice cu o dexteritate mult imbunatatita. Objectives: The treatment of choice in small, incidentally discovered, low-stage renal tumors (RCC) is partial nephrectomy. Partial nephrectomy is a procedure where time plays an important role in the success of the intervention. Patients and Methods: The movie recorded our technique used in robotic -assisted laparoscopic partial nephrectomy. Results: Patient M.N, 54 years old, asymptomatic, was diagnosed with a kidney tumor located in the right lower pole, with diameter of 30/20 mm. Tehnique: 1. The Verres needle tehnique is used for pneumoperitoneum establishment 2. The 3-arm configuration of the robot with standard position of the trocars is used 3. The bulldog clamp is used only on the renal artery, after the renal vein and artery are freed. 4 The identification of the kidney tumor and the dissection of the tumor is done cold with the robotic curved scissors 5. For the closure of the renal defect are used Surgicell and Vycril 0 - blocked with hemolock. 6. The artery clamping is removed and the lesion is observed for bleeding.7 The tumor is placed in an Endocatch bag and is retrived. 8.The peritoneum is closed and a wound drain is introduced through one of the ports. Conclusion: The DaVinci surgical system gives the surgeon the ability to perform complex procedures laparoscopically with more dexterity. Robotic partial nephrectomy is still an operation in it s infancy, but may offer ease of reconstruction after tumor excision. mor excision. 108 Revista Românæ de Urologie nr. 2 / 2012 vol 11

110 V.7. Øuntul safeno-cavernos - tratamentul priapismului vechi C. Gîngu, F. Lupu, A. Dick, S. Pætræøcoiu, C. Surcel, M. Hârza, V. Cerempei, C. Bæløanu, O. Himedan, C. Mirvald, A. fiurcanu, Liliana Domniøor *, Ileana Constantinescu **, I. Sinescu Centrul de Uronefrologie øi Transplant Renal, * Clinica de ATI, ** Laboratorul de Biologie Molecularæ, Imunologie, HLA øi Virusologie, Institutul Clinic Fundeni, Bucureøti Saphenocavernosum shunt - treatment of refractory priapism C. Gîngu, F. Lupu, A. Dick, S. Pætræøcoiu, C. Surcel, M. Hârza, V. Cerempei, C. Bæløanu, O. Himedan, C. Mirvald, A. fiurcanu, Liliana Domniøor, Ileana Constantinescu, I. Sinescu Center of Uronephrology and Renal Transplantation, * ICU Department, ** Molecular Biology and Immunology Laboratory, Fundeni Clinical Institute, Bucharest Video Introducere øi obiective. Priapismul reprezintæ o erecflie persistentæ, patologicæ, færæ legæturæ cu stimularea sexualæ, pe o perioadæ mai mare de 4 ore. Priapismul este o urgenflæ urologicæ, de aceea tratamentul trebuie instituit cât mai repede posibil. Abordarea terapeuticæ trebuie sæ se facæ în etape, obiectivele tratamentului fiind suprimarea erecfliei, calmarea durerii øi prezervarea erecfliei. Scopul lucrærii noastre este de a prezenta modalitatea de rezolvare a cazurilor de priapism vechi, rezistent la metodele minim invazive clasice de tratament. Materiale øi metodæ. Experienfla noastræ cuprinde 5 cazuri de priapism vechi, între 7-40 zile, refractare la alte metode de tratament, rezolvate prin shunt safeno-cavernos. Prezentæm cazul unui pacient în vârstæ de 21 ani, færæ APP semnificative, care se interneazæ pentru priapism low flow debutat în urmæ cu 11 zile, færæ o etiologie precizatæ, probabil indus medicamentos. Pacientul a fost internat în alt serviciu unde s- au practicat multiple manevre de lavaj intracavernos cu diluflie de efedrinæ øi ser fiziologic øi trocardizare cavernoasæ transglandularæ bilateralæ (øunt Winter), færæ rezultat. Ecografia Doppler a corpilor cavernoøi nu a evidenfliat semnal Doppler la acest nivel øi pune diagnosticul de priapism venos vechi refractar la tratament. Se decide intervenflia chirurgicalæ; se practicæ o incizie la baza corpului cavernos stâng cu evacuarea cheagurilor vechi øi a sângelui lacat din corpii cavernoøi. Dupæ lavajul abundent cu ser fiziologic heparinat se obfline detumescenfla øi prezenfla unui flux sangvin arterial la nivelul corpilor cavernoøi, cu refacerea priapismului la obstruarea breøei din corpul cavernos. Se decide øi se practicæ izolarea trunchiului comun al venei Introduction and objectives. Priapism represents a pathological persistent erection, without any association with sexual stimulation, which lasts longer than 4 hours. Priapism is an urologic emergency, so the treatment must be applied as quickly as possible. The therapeutic approach must be done in stages, the objectives of the treatment being erection suppression, distress relief and the preservation of sexual function. Materials and methods. Our experience comprises of 5 cases of delay priapism from 7 to 40 days, refractory to other methods of treatment, resolved by saphenocavernosum shunt. In this video we are presenting the case of a 21 years old patient without priors who was admitted for low flow priapism dated 11 days before, with no known etiology, probably drug induced. The patient was admitted in another clinic where there were performed repeated intracavernous irrigations, injections with alpha adrenergic agent and a Winter shunt, without positive outcome. Doppler echography of the corpora cavernosa showed no signal at this level, establishing the diagnosis of old venous priapism refractory to ordinary treatment methods: blood evacuation, irrigation of corpora cavernosa and distal spongiocavernosal shunt. We decided to proceed with surgical intervention. An incision was performed at the base of left corpus cavernosum, followed by drainage of blood and old clots. After abundant irrigation with heparinated serum we obtained a detumescence and regained an arterial flow in the corpus cavernosum. The priapism is reestablished by obstructing the cavernosum breach, so we decided to isolate the common trunk of left saphenous vein and perform a nr. 2 / 2012 vol 11 Revista Românæ de Urologie 109

111 Video safene stângi, ce este secflionat øi anastomozat terminolateral la corpul cavernos stâng. Rezultate. Evoluflia postoperatorie a fost favorabilæ cu detumescenflæ penianæ stabilæ øi vindecare chirurgicalæ per primam. La 3 sæptæmâni postoperator pacientul începe recuperarea funcfliei sexuale. Administrarea de inhibitori 5PDE cu stimulare sexualæ a dus la intumescenfla a 2/3 proximale a penisului øi glandului cu reluarea unei activitæfli sexuale acceptabile. Concluzii. Øuntul safeno-cavernos este o metodæ eficientæ de rezolvare a cazurilor de priapism vechi la care metodele clasice minim invazive au eøuat. Chiar øi în cazurile de priapism prelungit, prin aceastæ metodæ se poate recupera parflial erecflia øi funcflia sexualæ. termino-lateral anastomosis with the left corpus cavernosum. Results. The postoperative evolution was favorable with stable remission of the priapism. Three weeks postoperative the administration of 5 PDE inhibitors combined with sexual stimulation allowed erection in the 2/3 of the proximal penis and glans, with an acceptable sexual intercourse. Conclusions. The saphenocavernosum shunt is an efficient method of solving old priapism cases, refractory to classical minimal invasive treatments. Even in prolonged priapism cases this approach can regain partial erection and sexual function. 110 Revista Românæ de Urologie nr. 2 / 2012 vol 11

112 V.8. Intervenflie chirurgicalæ conservatorie pentru tumoræ renalæ pe rinichi stâng unic funcflional V. Bucuraø, R. Bardan, A. Cumpænaø, A. Mureøan, Cristina Bælærie, L. Dragoø Clinica Urologicæ Timiøoara Nephron-sparing surgery for renal tumor in a left solitary functioning kidney V. Bucuraø, R. Bardan, A. Cumpænaø, A. Mureøan, Cristina Bælærie, L. Dragoø Department of Urology, Timiøoara Video Filmul prezintæ cazul unei paciente de 64 de ani, diagnosticatæ în mod incidental cu o tumoræ renalæ stângæ. Tomografia computerizatæ (Uro-CT) øi examinarea ecograficæ au confirmat prezenfla unei tumori cu diametrul de 3 cm situatæ în imediata vecinætate a hilului renal stâng, precum øi un rinichi contralateral sclero-atrofic, nefuncflional. flinând cont de indicaflia absolutæ, am decis sæ efectuæm o intervenflie de tip nephron-sparing. Cele mai importante etape ale tumorectomiei stângi sunt prezentate în film, accentul fiind pus pe dificultæflile date de poziflia tumorii în raport cu vasele renale øi cu bazinetul. The film presents the case of a 64 years old female patient, incidentally diagnosed with a left renal tumor. The Uro-CT and abdominal ultrasonography have confirmed the presence of a 3 cm tumor situated in immediate proximity of the left renal hylum, with a small, non-functioning contralateral kidney. Taking into account this particular situation, we have decided to perform a nephron-sparing procedure, as absolute indication. The most important stages of the left tumorectomy are shown in the movie, focusing on the technical issues posed by the position of the tumor in relationship with the renal vessels and the renal pelvis area. nr. 2 / 2012 vol 11 Revista Românæ de Urologie 111

113 Video V.9. Noua dimensiune a accesului la câmpul operator intra-abdominal: depærtætorul/ retractor ALEXIS V. Bucuraø, R. Bardan, A. Mureøan, A. Cumpænaø Clinica Urologicæ Timiøoara A new dimension of intraabdominal operative field access: The ALEXIS wound retractor V. Bucuraø, R. Bardan, A. Mureøan, A. Cumpænaø Department of Urology, Timiøoara Filmul prezintæ modul de aplicare al depærtætorului autostatic de tip Alexis (produs de Compania Applied Medical). În cadrul mai multor intervenflii intraabdominale sunt evidenfliate uøurinfla în utilizare, precum øi avantajele acestuia un acces intracavitar mai rapid, aplicarea atraumaticæ øi reducerea riscului de infecflie a plægii operatorii. The film presents the new Alexis wound retractor, made by Applied Medical Corporation. The easy intraoperative application is showed during several intra-abdominal interventions. The presentation is focused on the utilization advantages: rapid intra-abdominal access, atraumatic retraction, and reduced risk of wound infection. 112 Revista Românæ de Urologie nr. 2 / 2012 vol 11

114 Autor / numær rezumat Author / abstract number Index autori A Adou L Alamæ Antoaneta 5.7 Alexandrescu E. 1.5, 1.7 Alexandrescu M. 5.1 Ambert V. 1.4, 1.9, 3.10, 5.8, 5.10, V4, V6 Amuzescu B. 1.3 Andrei R. 6.2 Andrei S. 1.3, 1.9 Arabagiu I. 1.5, 2.5, 5.1, 5.3, 6.10, V1 Ardeleanu Carmen 1.1 Ateia A.H B Bædescu B. 1.12, 3.13, 4.1, Bædescu D. 1.1, V6 Bælærie Cristina V8 Bæløanu C. 3.2, 4.4, V7 Bardan R. V8, V9 Baston C. 1.12, 3.13, 4.1, 4.9, 5.7 Bealcu Florentina 6.11 Beg G. 5.9 Benguø F. 1.4 Berdan Gabriela 1.1, 3.11 Berechet M. 1.6, 2.10, 2.11, 2.12, 2.13, V5 Boc A. 2.1, 2.6, 3.6, 4.11 Boja R Bonafl S. 2.1, 2.6, 4.11 Borda Angela 3.5, 3.9 Brad A. 1.10, 2.13, 3.5, 6.1 Brægaru M. 1.5, 5.3 Brânzan M. 5.7 Braticevici B. 1.4, 1.9, 5.8, 5.10, V4, V6 Bratu O. 1.3, 2.2, 3.7, V2, V3 Bucuraø V. V8, V9 Bumbu A. 1.6, 2.10, 2.11, 2.12, 6.13, V5 Bumbu G. 1.6, 2.10, 2.11, 2.12, 6.13, V5 Burchiu Eliza 5.7 C Cælin C. 1.4, 1.9, 5.10 Calleja R. V2, V3 Catarig C Cerempei V. 2.3, 4.1, 4.3, 6.5, V7 Chibelean C. 2.13, 3.5, 3.9, 4.7, 6.1 Chira I. 3.10, 5.10, V4 Chiriflæ Manuela 2.3, 2.4, 3.14, 6.2, 6.4, 6.6, 6.11, 6.12 Chiujdea A. 3.5, 3.9, 6.1 Codoiu C. 1.12, 3.13 Codreanu C Codreanu O. 1.1 Coman I. 2.1, 2.6, 3.6, 4.11 Constantinescu E. 1.5, 4.12 Constantinescu Ileana 3.3, 4.4, V7 Constantiniu R. 4.5, 4.6, 5.7 Copæescu C Corcan J. 5.9 Creflu O. 1.1 Criøan N. 3.6, 4.5, 4.6 Croitoru R. 5.9 Cumpænaø A. V8, V9 D Damian D. 1.4, 1.9 Davidescu A. 3.8, 4.10 de Cobelli O. 3.6, V6 Diaconescu D. 1.4, 3.10, 5.8, 5.10, V6 Dick A. 3.2, 3.3, 4.4, 4.5, V7 Dinu M. V2, V3 Dobromir N. 4.15, 6.14 Dobromir O. 4.15, 6.14 Domniøor Liliana 3.2, 3.3, 4.4, 4.9, 5.7, V7 Dorobæfl B. 5.8 Drægoi R. 2.10, 6.13 Dragomiriøteanu I. 1.9, 3.10, 3.11, 5.10 Dragoø L. V8 Dræguflescu M. 1.5, 1.7, 5.1, 5.2, 5.3, 5.4, 5.6, 5.13, 6.10 Dudu C. 1.12, 3.13 Dumitrescu M. 1.3 nr. 2 / 2012 vol 11 Revista Românæ de Urologie 113

115 Index autori E Ene C. 5.1, 5.2 Enikõ B.H Enikõ Buzsi 1.8, 1.10, 2.9 Enikõ N.N F Farcaø C.P. 1.3, 2.2, V2, V3 Feflea D Filip A. 4.15, 6.14 G Gagiu C. 4.7, 4.8 Geavlete B. 1.5, 1.7, 4.12, 5.1, 5.2, 5.4, 5.5, 5.6, 5.11, 5.12, 5.13, 6.7, 6.8, 6.9, 6.10, V1 Geavlete P. 1.5, 1.7, 2.5, 2.7, 2.8, 3.12, 4.12, 5.1, 5.2, 5.3, 5.4, 5.5, 5.6, 5.11, 5.12, 5.13, 6.7, 6.8, 6.9, 6.10, V1 Georgescu D. 1.5, 2.7, 5.1, 5.2, 5.4, 5.5, 5.11, 5.12, 5.13, 6.7, 6.8, 6.9, 6.10, V1 Gherman V Gîngu C. 1.2, 2.3, 3.1, 3.2, 3.3, 3.8, 4.4, 4.5, 4.6, 4.10, 5.7, 6.3, V7 Glück G. 2.4, 3.4, 3.14, 4.2, 5.7, 6.2, 6.4, 6.5, 6.6, 6.11, 6.12 Golovei Corina 3.5, 3.9 Grasu M. 4.3 Gutue C.S. 3.10, V4 H Hæinealæ B. 1.12, 3.13, 4.1, 4.7, 4.8, 6.3 Hârza M. 1.12, 3.2, 3.3, 4.1, 4.4, 4.7, 4.8, 4.9, 5.7, V7 Hetea Andreea 2.3 Himedan O. 3.2, 3.3, 4.4, V7 Hogea M Hortopan M.G. 1.3, 3.8 Hurduc M I Iacoboaie C. 2.8, 5.11, 5.12, 5.13, 6.7, 6.8 Ilie C.P. 1.3, 2.2, 3.7, V2, V3 Iordache A. 2.3, 4.3, 6.6, 6.12 Iordache V. 5.6 Iordan S. 1.9 Irimie A Isoc G. 1.6, 2.10, 6.13 J Jecu M. 1.5, 5.11, 5.12, 5.13, 6.7, 6.8 Jinga V. 1.1, 1.4, 1.9, 3.10, 3.11, 5.8, 5.10, V4, V6 Jovrea Dana 2.12, 6.13 Jurchiø I K Kerezsy Eminee 4.9 Kolumban S. 2.12, 6.13 L Laiu V. 4.5, 4.6 Lakatos L. 1.10, 3.5, 6.1 Lazær R Lineschi L. 5.9 Logigan H. 3.6 Lukianski W. V2, V3 Lupu F. 3.2, 3.3, 4.4, 4.5, 4.6, V7 Lupescu I. Gabriela 4.3 M Mædan V. 1.3, 2.2, 3.7, V2, V3 Maheshkumar P. V2, V3 Maier A. 1.10, 2.9, 2.13 Mælæu O. 2.13, 3.5, 6.1 Manea I. 1.2, 1.12, 4.1, 4.7, 4.8, 6.3 Mænescu R. 3.6 Mansour M. 1.4 Manu M.A. 1.2, 2.3, 3.2, 3.3, 3.8, 4.1, 4.3, 4.4, 4.9, 4.10, 5.7 Manu Rucsandra 3.6, 3.8, 4.9, 4.10, 5.7 Margaritis S. 1.2, 1.12, 3.1, 3.13, 4.1, Marica Oana 4.2, 4.3 Mártha Orsolya 1.8, 1.10, 2.9, 2.13, 3.5, 3.9, 4.16, 6.1 Martonos A Matei D.V. 3.6, V6 Matei M. 4.8 Maxim R. 2.1 Mihai B. 3.12, 5.1, 6.10, V1 Mihai Mihaela 3.2, 3.3, 3.8, 3.11, Mirciulescu M. 1.5, Mirciulescu V. 2.5, 2.8, 5.1, 5.2, 5.3, V1 Mirvald C. 1.2, 2.3, 3.1, 4.3, 4.4, 4.5, 4.6, 6.3, V7 Mischianu D. 1.3, 2.2, 3.7, V2, V3 Mitroi Iulia 5.7 Mitroi V Mitulescu G. 6.5 Moiøanu Daniela 3.11 Moldoveanu C. 5.1, 5.11, 5.12, 5.13, 6.7, 6.8, V1 Mulflescu R. 1.5, 1.7, 4.12, 5.1, 5.2, 5.3, 5.4, 5.5, 5.6, 5.11, 5.12, 5.13, 6.7, 6.8, 6.9, 6.10, V1 Mureøan A. V8, V9 Muøat S Revista Românæ de Urologie nr. 2 / 2012 vol 11

116 N Najjar S. 1.2, 2.3 Nechita F Necoaræ C. 1.4 Nedelcu S. 6.1 Negru Iulia 5.7 Niflæ G. 1.5, 2.5, 2.7, 2.8, 3.12, 5.1, 5.2, 5.3, 6.10, V1 O Omer A. 1.2, 1.12, 3.1, 6.3 P Pantalon A. V2, V3 Pârâianu B. 2.5, 2.7 Pakuts Noémi 4.16 Pascal A Pætræøcoiu S. 1.2, 3.1, 3.2, 3.3, 4.4, 4.5, 4.6, V7 Persu C. 1.5, 2.5, 2.7, 2.8, 3.12, 5.1, 5.3, 6.10, V1 Petrescu Amelia 1.1, 3.11 Petrufl B Pisoschi M. V4 Poienar Al. Andreea 2.1, 2.6, 4.11 Pop Iulia 3.6 Popescu D.S Popescu M. 5.8, 5.10, V6 Popescu R. 2.2, 3.7 Porav D. 1.10, 2.13, 3.5, 3.9, 6.1 Preda A. 4.1 Prie I. 3.8, 4.10 Priporeanu T. 3.4, 6.5 Prunduø P. 2.1, 2.6, 4.11 Purza D. 2.11, 6.13 R Rædævoi D. 1.1, 1.9, 5.8, 3.11 Radu T. 3.10, V6 Rædulescu A. 2.2, 3.7 Roøu T. 3.3 Rusu F. V2, V3 S Sabæu V. 4.2 Salaheddin Y. 3.10, 5.8, 5.10 Satalan R. 4.12, 5.6 Savu Carmen 1.2, 2.3, 3.1, 5.7, 6.3 Schiflcu V Secaøan I. 5.9 Seserman G Silaghi A. 3.3 Sinescu I. 1.2, 1.12, 2.3, 2.4, 3.1, 3.2, 3.3, 3.4, 3.8, 3.13, 3.14, 4.1, 4.2, 4.3, 4.4, 4.5, 4.6, 4.7, 4.8, 4.9, 4.10, 5.7, 6.2, 6.3, 6.4, 6.5, 6.6, 6.11, 6.12, V7 Soroiu D. 1.5, 2.8, 5.2 Spânu D. 2.2, 3.7 Stanca V.D. 2.1, 2.6, 4.11 Stænescu D Stænescu F. 1.5, 5.11, 5.12, 5.13, 6.7, 6.8, V1 Stoica R. 2.3, 2.4, 3.14, 4.2, 6.2, 6.5 Stoica Ruxandra 6.5 Stoican N. 4.15, 6.14 Surcel C. 1.2, 1.12, 2.3, 3.1, 3.2, 3.3, 3.8, 3.13, 4.3, 4.4, 4.5, 4.6, 4.10, 5.7, 6.3, V7 Szölösi A. 1.8, 1.10, 2.9, 2.13 Ø Øerbænescu B. 4.9 Øtefan B. 3.2, 4.1, 4.9, 5.7 T Tacu Dorina 4.9 Tænase E. 6.5 Tætæranu A Terteliu F Todea C. 3.9 Tomoøoiu R. 1.4 Tulbure Ruxanda 5.7 fi fiurcanu A. 3.2, 3.3, 4.4, V7 fiintilæ B U Uzun B. 1.10, 3.5, V Vârlan M. 2.10, 6.13, Vida A.O. 1.8, 1.10, 2.9, 6.1, Vizireanu M Vlæduflescu Cristina 3.14, 5.7 Vlaicu N. 4.5, 4.6 Voinea S. 1.12, 4.7, 4.8 Voinescu V. 4.13, 4.14 Z Zogas Vanghelifla 3.2 Index autori nr. 2 / 2012 vol 11 Revista Românæ de Urologie 115

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