Retractile Testis

Palpables
A retractile testis is one that has completed the process of descent
but may be found in the groin because of an overactive cremasteric
reflex. The cremasteric reflex is a function of the genitofemoral
nerve (L1) and is present in all boys older than 2 years
of age.46 When the reflex is elicited by tactile stimulation of the
thigh, the cremaster muscle contracts and draws the testis out of
the scrotum toward the inguinal canal. Teleologically, the cremaster
reflex protects the testis by drawing it out of harms way, but
it may cause a normal testis to mimic an undescended testis.
A retractile testis should be suspected in the 2- to 12-yearold
child with a possible undescended testis. A retractile testis
can be manipulated into the scrotum, where it will remain
(at least temporarily) after its release. In contrast, the undescended
testes retracts into the groin immediately. Retractile
testes are typically normal in size and consistency, whereas
undescended testes may be smaller and softer than normal.
However, retractile testes may not be normal and should be
annually monitored during childhood, because 30% descend,

38% remain retractile, and 32% ascend (become

undescended).
47 At orchiopexy for an undescended testis, examination
under anesthesia may reveal a scrotal testis, indicating
that it is really retractile and obviating the need for surgery.
However, orchiopexy via either an inguinal or a scrotal
approach may still have merit under these circumstances, to
prevent potential testicular ascent in the future.

Inguinal Hernia

About 90% of undescended testes are associated with an occult

inguinal hernia, especially those with minimal descent and
those coupled with epididymal abnormalities. Ectopic testes
are associated with an inguinal hernia in about 50% of cases.
Conversely, up to 6% of inguinal hernias are associated with
an undescended testis.101 Repair of the hernia, if present, is an
integral part of orchiopexy.

PUNTACIN DE GLEASON
La puntuacin de Gleason es el sistema ms utilizado para graduar el
adenocarcinoma de prstata. Slo puede evaluarse en material de
biopsia (biopsia con trocar o piezas quirrgicas) y no deben utilizarse
preparaciones citolgicas. La puntuacin de Gleason es la suma de los
dos patrones ms frecuentes (grado 1-5) de crecimiento tumoral
observados y oscila entre 2 y 10, siendo 2 el menos agresivo y 10 el ms
agresivo.
Puntuaciones de Gleason de 2- 4, 5-7 y 8- 10 corresponden a tumores
bien, moderado y pobremente diferenciados respectivamente.
Histopatolgicamente, el sistema de Gleason se ha representado en 5
grados as:

Gleason 1: glndulas uniformes, pequeas, en estrecho contacto con escaso

estroma. Patrn de crecimiento expansivo con bordes bien circunscritos.
Gleason 2: hay ligera variacin en forma y tamao de las glndulas con
mayor separacin entre ellas y mayor cantidad de estroma. Aunque el
patrn de crecimiento continua siendo expansivo los bordes son menos bien
circunscritos.
Gleason 3: marcada variacin en tamao y forma de las glndulas. Pueden
observarse areas cribiformes y papilares pero bien circunscritas. El patrn
de crecimiento se torna infiltrativo constituido por estructuras glandulares.
Gleason 4: masas de estructuras glandulares con patrn cribiforme, de
bordes irregulares. Puede observarse el patrn de clula clara conocido
como hipernefroide. Patrn de crecimiento infiltrativo, muy irregular,
constituido por estructuras cribiformes o cordones.
Gleason 5: patrn predominantemente slido, sin diferenciacin glandular.
Pueden observarse areas de comedocarcinoma con necrosis central

- See more at: http://encolombia.com/medicina/revistas-medicas/urologia/vu910/urologia9100-analisisconcordancia/#sthash.xubu3zSo.dpuf

Un tumor con puntaje de Gleason de 6 (3 + 3) es uniformemente de bajo grado. En la
diferenciacin de tumores de grado intermedio y alto, el patrn de Gleason predominante es el
determinante ms importante del riesgo biolgico. As, entre los tumores con puntaje Gleason de
7, aquellos asignados como 4 + 3 son ms agresivos que aquellos puntuados como 3 + 4.
PAG 374 SMITH

Grade
Pese a los numerosos sistemas de clasificacin existentes para la evaluacin
del adenocarcinoma de prstata, el sistema de puntaje de Gleason es el ms
ampliamente aceptado. El sistema Gleason se basa en el patrn glandular del
tumor identificado en campo de bajo poder.

Los Patrones arquitectnicos primario (predominante) y secundario (segundo

ms frecuente) se identifican y se les asigna un puntaje de 1 5, siendo 1 el
grado ms diferenciado y 5 el menos diferenciado. Ambos patrones influyen en
la prediccin del pronstico, existe un puntaje Gleason obtenido de la suma de
los patrones ms predominantes.
Las puntuaciones de Gleason oscilan desde 2 (1 + 1), lo que representa tumores
compuestos de manera uniforme por el patrn de Gleason 1, hasta 10 (5 + 5), que
representa tumores completamente indiferenciado.
In radical prostatectomy
specimens, it has been demonstrated that tertiary (third
most common pattern) high-grade components adversely affect
biologic behavior, yet are not always equivalent to the sum of
the primary pattern and highest-grade pattern. It is recommended
that in radical prostatectomy specimens, the routine Gleason
score, consisting of the most prevalent and the second most
prevalent architectural patterns, be recorded along with a note
stating that there is a tertiary high-grade pattern (Pan et al, 2000;
Trock et al, 2009). There are a few exceptions to the
Gleason system, as described above. For needle biopsy
specimens in which the typical scenario includes tumors
with patterns 3, 4, and 5 in various proportions, both
the primary pattern and the highest grade should be
added to derive the Gleason score. Any amount of highgrade
tumor sampled on needle biopsy most likely indicates
a more significant amount of high-grade tumor
within the prostate because of the correlation of grade
and volume and the problems inherent with needle
biopsy sampling. In the setting of high-grade cancer,
one should ignore lower-grade patterns if they occupy less than 5% of the area of the
tumor. For example, a
tumor composed of 98% Gleason pattern 4 and 2%
Gleason pattern 3 should be diagnosed as Gleason score
4 + 4 = 8 (Epstein et al, 2005).
It is important to recognize Gleason pattern 4 tumors
because tumors with this pattern have a significantly
worse prognosis than those with pure Gleason pattern 3
(McNeal et al, 1990; Epstein et al, 1993b). It has also been demonstrated
in radical prostatectomy specimens that tumors with
Gleason score 4 + 3 = 7 have a worse prognosis than those with
Gleason score 3 + 4 = 7 (Chan et al, 2000). There is fairly good
interobserver reproducibility of the Gleason system
among uropathology experts and poorer reproducibility
among practicing pathologists (Allsbrook et al, 2001a,
2001b). It has been demonstrated that although current use of the
Gleason grading system is not optimal, significant improvements
can be made after participation in relatively brief educational
programs, such as those available on websites (e.g., www.isuporg.
org [International Society of Urological Pathology]).
The Gleason grade on biopsy material has also been shown to
correlate fairly well with that of the subsequent prostatectomy
specimen (Fine and Epstein, 2008). Several studies have demonstrated
that there is better correlation between the biopsy and
prostatectomy grade with extended as opposed to sextant needle
biopsy sampling. In general, a Gleason score less than or equal to
6 or greater than or equal to 7 on biopsy corresponds to a Gleason
score less than or equal to 6 or greater than or equal to 7 in the
radical prostatectomy, respectively, in 80% of cases. An unavoidable
cause of discordant grading between the biopsy and subsequent
prostatectomy specimen(s) concerns sampling errors with
the needle biopsy. One of the most frequent causes of discordant

grading is grading of tumors that straddle two grades. One way

the practice of Gleason scoring can be improved is by virtually
never assigning Gleason score 2 to 4 for adenocarcinoma of the
prostate on needle biopsy. The reasons for this approach are as
follows: (1) most tumors graded as Gleason score 2 to 4 on needle
biopsy are graded as Gleason score 5 to 6 or higher when reviewed
by uropathology experts (Steinberg et al, 2005); (2) there is poor
reproducibility in the diagnosis of Gleason score 2 to 4 on needle
biopsy even among uropathology experts (Allsbrook et al, 2001b);
and (3) most important, assigning Gleason score 2 to 4 to an
adenocarcinoma on needle biopsy can adversely affect the patients
care, because clinicians may incorrectly assume that all low-grade
cancers on needle biopsy do not need definitive therapy. Although
low volume, Gleason score 2 to 4 adenocarcinoma of the prostate,
on transurethral resection of the prostate, has a relatively indolent
course; low-grade cancer on needle biopsy does not. Pathologists,
in general, are less frequently overdiagnosing Gleason scores 2 to
4 on biopsy in recent years. In one study, 24% of pathologists
rendered a diagnosis of Gleason score 2 to 4 on biopsy in 1991,
which decreased to 2.4% in 2001 (Ghani et al, 2005).
The ultimate value of any grading system is its prognostic
ability. Both Gleasons data with 2911 patients and subsequent
studies with long-term follow-up have demonstrated a good correlation
between the Gleason sum and prognosis (Mellinger, 1977;
Sogani et al, 1985). When stage of disease is factored in with grade,
prognostication is enhanced. Some men with low-grade cancers
develop high-grade tumors after several years (Brawn, 1983). It is
not clear whether the residual low-grade cancer progressed or
whether there was a subsequent development of a multifocal,
more aggressive tumor. Although, in general, larger tumors are
high grade and small tumors are low grade, exceptions occur
(Epstein et al, 1994a). There is a tendency to hypothesize that scores. Over two thirds of the studies
using external beam radiotherapy
but none using brachytherapy showed prognostic significance
for perineural invasion. Given that perineural invasion is
readily identifiable in most cases, that it is prognostic in some
studies, although the data is conflicting, and that it is uncertain
what factors an individual clinician may consider in treatment
decisions, it is the opinion of these authors that perineural invasion
should be noted on the biopsy pathology report.
One can also use information from needle biopsy pathology
reports to help determine whether to sacrifice the neurovascular
bundle on a given side in cases with a higher likelihood of extraprostatic
extension (Shah et al, 2003; Ohori et al, 2004; Tsuzuki
et al, 2005).
There is emerging data that atrophy and associated inflammation
are linked with prostate carcinogenesis (DeMarzo et al, 2003).
However, the hypothesis is that these factors are involved in the
initiation of prostate cancer and are not proximately related to
cancer by the time atrophy is identified on needle biopsy. Atrophy
of all morphologic types are very common on needle biopsy and
are not associated with an increased risk of cancer or PIN on subsequent
biopsy (Postma et al, 2005).

Table 961.

2005 International Society of Urological Pathology

Modified Gleason System
Pattern 1
Circumscribed nodule of closely packed but separate, uniform,
rounded to oval, medium-sized acini (larger glands than
pattern 3)
Pattern 2

Like pattern 1, fairly circumscribed, yet at the edge of the tumor

nodule there may be minimal infiltration
Glands are more loosely arranged and not quite as uniform as
Gleason pattern 1
Pattern 3
Discrete glandular units
Typically smaller glands than seen in Gleason pattern 1 or 2
Infiltrates in and amongst non-neoplastic prostate acini
Marked variation in size and shape
Pattern 4
Fused microacinar glands
Ill-defined glands with poorly formed glandular lumina
Large cribriform glands
Cribriform glands
Hypernephromatoid
Pattern 5
Essentially no glandular differentiation, composed of solid sheets,
cords, or single cells
Comedocarcinoma with central necrosis surrounded by papillary,
cribriform, or solid masses

RETENCIN URINARIA AGUDA

DEFINICIN
Incapacidad dolorosa para orinar, con alivio del dolor despus de drenaje de la vejiga
por cateterismo.
La combinacin de la disminucin o ausencia de la orina y dolor en bajo abdomen no es
por si sola suficiente para realizar el diagnstico. Es fundamental para el diagnstico la
presencia de un gran volumen de la orina (500 800 mL) que, al ser drenado por
cateterismo, conduce a la resolucin del dolor.

FISIOPATOLOGA
La miccin normal requiere:

Impulsos aferentes al tallo cerebral y a la corteza cerebral

Relajacin coordinada del esfnter externo
Contraccin sostenida del detrusor
Ausencia de obstruccin anatmica del tracto de salida de la vejiga

Cuatro mecanismos que podran llevar a retencin urinaria:

Resistencia uretral aumentada (Obstruccin de la cmara de salida de la vejiga)
Presiones vesicales bajas
Interrupcin de la inervacin motora o sensitiva de la vejiga
Falla central para la coordinacin entre la contraccin de la vejiga y la relajacin
del esfnter externo

CAUSAS
CAUSAS EN HOMBRES

CAUSAS EN AMBOS SEXOS

CAUSAS EN MUJERES

- Hiperplasia
Prosttica - Hematuria, llevando a
obstruccin por
Benigna
cogulos
- Agrandamiento
por - Medicamentos (anestsicos, anticolinrcios,
malignidad de la prstata
agentes simpaticomimticos como la
- Estenosis uretral, absceso
efedrina en descongestionantes nasales).
prosttico
- Dolor (estimulacin adrenrgica del cuello
de la vejiga)
- Retencin post operatoria
- Lesin de la mdula sacra (S2-4)
- Compresin o dao de los nervios sacros
(S2-4), resultando en arreflexia del
detrusor- compresin de la cauda equina
secundaria
al
prolapso
del
disco
intervertebral entre L2-L3 o L3-L4
presionando las races del nervio sacro de
la cauda equina, trauma vertebral o
tumores benignos o metastsicos.
- Lesin de la mdula por encima del nivel
sacro (resulta en prdida e la coordinacin
entre la relajacin del esfnter externo y la
contraccin del detrusor (disinergismo
vesico- esfinteriana, de modo que el
esfnter externo se contrae cuando la
vejiga se contrae)
- Ciruga radical de pelvis con lesin al plexo
parasimptico
plvico
(histerectoma
radical,
reseccin
abdominoperineal):
lesin
unilateral del plexo
plvico
(parasimptico preganglionar y simptico
postganglionar) desenerva la inervacin
motora del msculo detrusor
- Fractura plvica que lesione la uretra (ms
probable en hombres que en mujeres).
- Virus que afecten los ganglios de la raz
dorsal de S2-S4 (Herpes simplex o zoster)
- Esclerosis mltiple: retencin causada por
arreflexia del detrusor o disinergismo
vesico- esfinteriana.
- Mielitis transversa
- Cistopata diabtica (causa disfuncin
motora y sensitiva)
- Dao a la columna o mdula dorsal
causando prdida sensitiva vesical (tabes
dorsal, anemia perniciosa).

Prolapso plvico (cistocele,

rectocele,
uterino);
estenosis
uretral;
divertculo uretral.
Postquirrgico
por
incontinencia de estrs
Masas
plvicas
(masas
ovricas)
Sndrome de Fowler: se
puede
registrar
la
actividad electromiogrfica
del
esfnter
urinario
externo de las mujeres con
esta patologa (el cual
tiene
un
volumen
aumentado
en
ultrasonografa)
y
se
piensa
que
causa
alteracin en la relajacin
del esfnter externo; ocurre
en
mujeres
premenopusicas,
usualmente en asociacin
con ovarios poliqusticos.

FACTORES DE RIESGO PARA RETENCIN URINARIA EN HOMBRES

La edad avanzada es un fuerte predictor del riesgo para retencin urinaria en hombres.
Otros factores que predicen el riesgo de retencin urinaria son la presencia de
sntomas del tracto urinario inferior (puntuacin alta de sntomas prostticos). Un
volumen post miccional elevado y el uso de medicamentos anticolinrgicos no parecen
predecir el riesgo de retencin.
La retencin urinaria en hombres puede ser espontnea o precipitada por un evento. La
retencin precipitada probablemente no vuelva a repetir una vez se ha resuelto la
causa que lo desencaden. La retencin espontnea es ms probable que recurra tras
la remocin del catter y por lo tanto requerir un manejo definitivo (Ejm. Reseccin
transuretral de prstata). Eventos precipitantes incluyen anestsicos y otros
medicamentos (anticolinrgicos, simpaticomimticos), ciruga abdominal no prosttica
Urinary retention in men is either spontaneous or precipitated by an event.
Precipitated retention is less likely to recur once the event, which caused it,
has been removed. Spontaneous retention is more likely to recur after
trial of catheter removal and therefore, to require defi nitive treatment
(e.g. TURP). Precipitating events include anaesthetic and other drugs (anticholinergics,

sympathomimetic agents such as ephedrine in nasal decongestants);

non-prostatic abdominal or perineal surgery; immobility following
surgical procedures.

FACTORES DE RIESGO PARA RETENCIN POST OPERATORIA

-

Instrumentacin del tracto urinario inferior

Ciruga perineal o anorectal
Ciruga ginecolgica
Sobredistensin vesical
Disminucin sensitiva de la vejiga
Obstruccin prosttica pre existente
Anestesia epidural

MANEJO
MANEJO INICIAL
Cateterizacin urinaria para alivio del dolor (cateterizacin suprapbica si no es posible
realizarlo por va uretral). Registrar el volumen drenado, ya que esto confirma el
diagnstico, determina el manejo a seguir y provee informacin pronostica con respecto a
los resultados de ese tratamiento.
MANEJO DEFINITIVO EN HOMBRES

Defi nitive management in men

Discuss trial without catheter (TWOC) with the patient. Precipitated
retention often does not recur; spontaneous retention often does. Fifty
percent with spontaneous retention will experience a second episode
of retention within the next week or so and 70% within the next year.
A maximum fl ow rate (Qmax) <5mL/s and low voiding detrusor pressure
predict subsequent retention. Thus while most will require defi nitive
treatment (e.g. TURP), a substantial minority will get away without needing
surgery.
In men, mortality in the fi rst year after acute urinary retention is
23 times higher than the general male population. Not surprisingly it
increases with age (Table 4.5). A substantial proportion of this increased
mortality seems to be linked to comorbidity in these men.1 Thus when
deciding whether to subject a man to TURP for retention, remember that
acute retention represents a harbinger of severe systemic disease. A careful
assessment for comorbidity (cardiovascular disease, diabetes, chronic
pulmonary disease) should be made and referral for appropriate specialist
advice on management of this comorbidity should be considered.
Table 4.5 One-year mortality rates in men with acute retention
Age (y) Spontaneous acute
retention (%)
Precipitated acute
retention (%)
4554 4 10
85 or
over
33 45
All ages 15 25

Options to avoid TURP

Prostate shrinking drugs followed by a TWOC several months later

(5-reductase inhibitors in those with benign-feeling prostates,
luteinizing hormone-releasing hormone (LHRH) agonists in those
with malignant feeling prostates on DRE, confi rmed by TURS-guided
prostate biopsy).
Prostatic stents.
Long-term urethral or suprapubic catheter.
Clean intermittent self-catheterization (CISC)not a realistic option
for most men, but some will be able and happy to do this.

Defi nitive management in women

CISC, either until normal voiding function recovers or permanently if

it does not. Fowlers syndromesacral neuromodulation (e.g. Medtronic

Interstim).

Risks and outcomes of TURP for retention

Relative risks of TURP for retention vs TURP for LUTS: post-operative
complications, 26:1; blood transfusion, 2.5:1; in-hospital death, 3:1. 1,2
Failure to void after initial catheter removal: high retention volume,
greater age, and low maximum detrusor pressure are predictive for failure
to void after TURP. Ten percent in those with acute retention of urine
and 40% in those with acute-on-chronic retention fail to void after initial
post-TURP TWOC. Overall, 1% of men will fail to void after subsequent
TWOCs and will require long-term catheterization.3