Archives of Clinical
Increased of Langerhans Cells in Smokeless
Tobacco-Associated Oral Mucosal Lesions
Érica Dorigatti de Ávila1, Rafael Scaf de Molon2, Melaine de Almeida Lawall1, Renata Bianco
Consolaro1, Alberto Consolaro1
Bauru Dental School
University of São Paulo
Objective: To evaluate the changes in the number of Langerhans Cells (LC) observed in the epithelium of
Eea-Like Bladder Herniation
smokeless tobacco (SLT-induced) lesions.
carried out in the buccal mucosa of twenty patients, who were
Araraquara Dental Scho
São Paulo State Universit
chronic users of smokeless tobacco (SLT), were utilized. For the control group, twenty non-SLT users of SLT
Received: February 05, 20
Department of Radiology
with normal mucosa were selected. The sections were studied with routine coloring and were immunostained
Accepted: February 29, 2
for S-100, CD1a, Ki-67 and p63. These data were statistically analyzed by the Student’s t-test to investigate
Arch Clin Exp Surg 2012
Inguidifferences in the expression of immune markers in normal mucosa and in SLT-induced leukoplakia lesions.
Department of Radiology
on radiological examinations
the time normal
in the immunolabeling
of all markers
Medical AcademyCorresponding author
and SLT-induced lesions (p<0.001). The leukoplakia lesions in chronic SLT users demonstrated a significant
Dorigatti de Avila
by sonography, intravenous pyelography (IVP), and computerized tomography (CT).
İstanbul, Turkey Departamento de Estoma
increase in the number of Langerhans cells and in the absence of epithelial dysplasia.
da Faculdade de Odontol
in the number
cells represents the initial stage of leukoplakia.
Received: June 12,Bauru
Accepted: July 04, 2012
Key words: Smokeless tobacco, leukoplakic lesions, cancer, langerhans cells, chewing tobacco.
Universidade de São Pau
Arch Clin Exp Surg 2013;X: X-X
Avenida Alameda Octávi
Pinheiro Brizola, 9-75, 17
cystocele and urinary bladder
Onur Sıldıroğlu, MD
hernia (UBH) are the most common terms termittent
more alkaline environment, its products
is a false beused to
years. Concerning the patient’s complaint, Gulhane Military
even be more aggressive to tissue .
is not are
of theit UBHs
we needed to compress the inguinal canal Haydarpasa Training Hospital
Selimiye M. Tıbbiye C.
which leads many
Uskudar, İstanbul, Turkey
reducand start using SLT . However, SLT conyoung
is therefore a
dominance and an increasing prevalence by ible leftamong
tains higher concentrations of nicotine than
age. Early and accurate diagnosis is very im- left hemiscrotum
carciportant to plan the surgery and to avoid the and superficial Ultrasonography (US) were
effects of SLT on the
N-nitrosamines (TSNA), which is formed
during the aging process of the tobacco, [2-4]
oral mucosa demonstrated the formation of
white lesions induced by chronic exposure to
Cuce F et al.
and inguinal hernia. US images showed that the left side
of the bladder wall was extending into the suprapubic
left parietal zone and that there was also an anechoic
cystic mass surrounded by a half-thick wall in the inguinal canal. In the latest phase of IVP, contrast mate-
Figure 1. Contrast-filled bladder in IVP demonstrates elongation of
the bladder base to the left side, and contrast medium is being superposed to left inguinal region (arrow).
Figure 2. In the late phase of the contrast-enhanced pelvic CT images, a bladder with lumen-filled contrast medium extending inferiorly to the left inguinal canal (arrow).
Figure 3. The 3D CT reconstruction image shows a dog left ear-like,
left-sided inguinal bladder hernia (arrow).
Arch Clin Exp Surg
rial extended beyond the left side of the bladder corpus
and a contrast enhancement was superposed at the left
obturator foramen, but we could not visualize the relationship between them (Figure 1). The cross-sectional
CT images demonstrated elonging of the bladder to the
left inguinal canal with contrast-filled lumen; in reconstruction images, this was like a dog ear (Figure 2,3).
UBH is a rare pathology that has been reported in 1
to 4 % of cases of inguinal hernias, whereas digestive or
omental hernias are frequently observed [1-6].
The main factor for the herniation mechanism is
bladder outlet obstruction (benign prostate hyperplasia, prostatitis, and urethral stricture). The other factors are obesity (especially in elderly males) and loss of
bladder tonus with weakness of the surrounding supporting structures [1-3]. The unidentified reason for
UBH is much more common in the right side; on the
contrary, our patient’s hernia is left-sided .
The clinical presentation of UBH is variable, and
nonspecific symptoms like dysuria, urinary frequency,
urgency, and recurrent urinary tract infection were accompanied by a scrotal mass. The important complaint
casting doubt in an elderly patient with scrotal mass is
two-phased voiding: after a normal spontaneous urination, the patient evacuates the bladder with manual
compression and it is defined as the second phase of
In patients suffering from groin swelling with twophase urination, US is preferred as the first-line diagnostic choice; it is cost-effective, easy to access, and
atraumatic - safety is achieved . In bladder inguinoscrotal herniation, a hipoechoic cystic mass from the
bladder through the inguinal canal can be seen. The US
can evaluate a bladder hernia according to its relationship with the inferior epigastric artery (generally direct
as medial to vessel) and bladder outlet obstruction,
such as an enlarged prostate or any subtle sign on IVP
[1,2,4]. Being medial to the inferior epigastric artery,
our patient’s herniation was an extraperitoneal direct
type. In differential diagnosis, US can differentiate the
herniated bladder from cystic scrotal mass as hydrocele, spermatocele, and epididymal cyst .
The second radiological investigation in exhibiting
a bladder hernia is IVP and cystography. Both of them
Year 2013 | Volume:X | Issue:X | X-X
have low-level sensitivity [1,2]. During IVP, the patient
position is supine and contrast material may not fill the
hernia sac because of this position. Post-voiding, prone
or erect radiographies must be obtained . The diagnostic triad-suggested bladder hernia in IVP consists of
a small bladder, incomplete visualization of the bladder
base, and an ipsilateral distal third of ureter displacement to the hernia side [1-3].
Other radiological techniques are cystography and
CT. CT has a radiation disadvantage, but it gives more
detailed information about a hernia than cystography.
Extension of the lesion can be easily revealed by multi-slice CT. This can be important information about
scheduling a surgery technique. For example, a bladder
diverticulum mimics UBH, which is treated with an abdominal approach to resect , whereas surgical repair
of bladder herniation is generally done via an inguinal
incision, and resection of an uncomplicated UBH gets
additional risks in the postoperative period [1,4,7].
We have underlined that inguinoscrotal hernia content is rarely vesical. The clinical suspicion is raised if
there is a large groin hernia with double-phase voiding
symptoms. US should be the first radiological investigation, but CT clearly assesses and distinguishes the
bladder from other entities before surgery.
Conflict of interest statement
We didn’t have any financial support or conflict of
interest for this project
Shih-Chieh Huang, Shih-Tsung Huang, Ming-Li
Hsieh, Ke-Hung Tsui, Phei-Lang Chang. Inguinoscrotal Bladder Herniation:Report of 2 Cases and
Literature Review. J Urol R.O.C. 2001;12:135-138.
N. Verbeeck, C. Larrousse, S. Lamy. Diagnosis of
inguinal bladder hernias: the current role of sonography. JBR–BTR, 2005;88: 233-236.
Osman Raif Karabacak, Alper Dilli, İdil Güneş Tatar, M.Nurettin Sertçelik. Massive Inguino-Scrotal
Urinary Bladder Herniation. Ankara Tıp Fakültesi
Mecmuası 2009; 62(4):191-193.
Kate H. Kraft, Sarah Sweeney, Aaron S. Fink, Chad
W.M. Ritenour, Muta M. Issa. Inguinoscrotal bladder hernias: report of a series and reviewof the literature. Can Urol Assoc J 2008;2 (6): 619-23.
Shiu-Dong Chung, Hsiao-Chun Chang Pai-Feng
Liu, Bin Chiu. Bladder Outlet Obstruction Associated with Inguinal Bladder Hernia. Incont Pelvic
Floor Dysfunct 2008; 2 (2): 77-78.
Burcu ESEN AKKAŞ, Gülin UÇMAK VURAL,
Sait ASLAN, MD,Celaleddin SASANİ, Nur ERÇAKMAK. Bladder Herniation Detected By PET/
CT in A Patient with Thyroid Papillary Carcinoma.
Turk J Nucl Med 2009;18(3):98-101.
Kishore Kumar, Anil Kumar Sakalecha, Deepak
Das,Ponnam Bharath Kumar. Urinary bladder
herniation rare preoperative incidental finding radiological features. Int J Biol Med Res. 2012; 3(1):
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