[Renal cell carcinoma with liver extension: a report of a new case and literature review]. / Tumor renal con invasión hepática: aportación de un nuevo caso y revisión de la literatura.

Locally advanced renal cell carcinoma (RCC) with involvement to adjacent organs is uncommon and the prognosis is poor. Radical surgery remains the only effective treatment. We report the case of a woman with RCC and direct liver extension who was surgically treated. A literature review is made.

[Prognostic significance of PIN and Atypical Small Acinar Proliferation on transrectal ultrasound-guided prostate biopsy]. / Significación pronóstica del PIN y la atípia glandular focal en la Biopsia Transrectal Ecodirigida de Próstata.

OBJECTIVE: To review the incidence of PIN and Atypical Small Acinar Proliferation (ASAP) on first biopsy, the risk to find cancer on following biopsies and what is the importance given to this findings, analizing how frequently and how long after the initial finding this patients are rebiopsied. METHOD: We selected 6000 patients who underwent TRUS biopsy between 1994 and 2002. Patients with prior cancer diagnosis were not included. 861 of them underwent more than one biopsy, adding up to a total of 7127 biopsies. A descriptive study has been done including percentages and percentiles for qualitative variables, mean and median for continuous variables. RESULTS: Incidence of cancer on the first biopsy was 39,1%. PIN and ASAP are stable or slightly increase from 2 and 2,1% respectively on the first biopsy to more than 6% on the fourth and fifth ones. Mean time between biopsies when ASAP or PIN are the initial findings is 180 +/- 221,6 and 264 +/- 213,8 days respectively. Just 42 and 40% of patients with prior PIN or ASAP diagnose are rebiopsied. On subsequent biopsies 45 and 40% of cancers were respectively found. CONCLUSIONS: Presence of PIN or ASAP implies a higher cancer risk on subsequent biopsies; in spite of that, less than half of them are biopsied again. Performing two more biopsies or an amplified biopsy can find most of the tumors associated.

[Renal metastasis of hepatocellular carcinoma]. / Metástasis renal de hepatocarcinoma.

OBJECTIVE: To report the case of a solitary renal metastasis secondary to hepatocellular carcinoma. METHODS: We report the case of a 51 year old patient who on abdominal ultrasonography was revealed a left renal tumour and a hepatic mass incidentally. A TAC showed the left renal tumor measuring 17 cm in size, possible involvement of left renal vein and a tumour mass in the right lobe of the liver. A TAC guided fine needle punction aspiration biopsy demonstrated a malignant hepatic lesion compatible with hepatocarcinoma, and malignant renal cells compatible with renal or adrenal carcinoma. Left radical nephrectomy and right hepatectomy was performed. RESULTS: Histopathologic study confirmed the diagnosis of moderately differentiated trabecular hepatocarcinoma with lymph node and left renal metastasis.

[Meningitis caused by multiresistant E. coli after an echo-directed transrectal biopsy]. / Meningitis por E. coli multirresistente tras biopsia transrectal ecodirigida.

Transrectal prostate biopsy is the most accurate method for prostate cancer diagnosis. Although an antimicrobial prophylaxis is employed in most cases, infectious complications are among the most severe. We present a case of E. coli multirresistant meningitis after transrectal prostate biopsy despite quinolone prophylaxis.

[Repetition of ultrasonography-guided prostatic biopsy for the detection of cancer. Study of a series of 192 re-biopsied patients]. / Repetición de la biopsia prostática ecodirigida para la detección de cáncer. Estudio de una serie de 192 pacientes re-biopsiados.

PURPOSE: We reviewed the result of transrectal ultrasound (TRUS)-guided needle biopsies to find the re-biopsy criteria, emphasizing on the Focal Glandular Atypia (FGA) histological changes. MATERIAL AND METHOD: 192 cases were selected, from a total of 1957 patients older than 50, re-biopsied because of high PSA levels and/or abnormal DRE, or because of the histological findings on initial biopsies (high grade PIN and/or FGA). The results are related to the serum PSA levels and DRE characteristics. RESULTS: A 38.83% global positivity for cancer was obtained and 27.08% for re-biopsy. When the first biopsy was negative, the positivity of the re-biopsies was 19.37%; if it was negative for cancer but had high grade PIN and/or FGA changes, the positivity was 65.62%, being higher in FGA changes than in the PIN cases (68.00% vs. 57.14%). The abnormal DRE raised the positivity rate from 17.82% to, 35.75%. CONCLUSIONS: The positivity was especially related to abnormal DRE and/or PSA > or = 10 ng/ml. The tumor rate detected at second and third or successive biopsies was similar (19.28% vs 21.74%). The FGA changes (3.47% globally) had a cancer predictive value of 65.62%. We recommend re-biopsy in all patients with FGA changes.

[Testicular embryonal carcinoma with contralateral synchronous intratubular germ cell neoplasia: analysis of a case]. / Carcinoma embrionario testicular con neoplasia intratubular de células germinales sincrónica contralateral: análisis de un caso.

We report the case of a 20-year old male with a right testicular tumor. Bilateral orchidectomy was practised considering the synchronous clinical, ultrasonographical and histological (intraoperative biopsy) findings of the left testis. The definitive pathological report showed a right embryonal carcinoma with wide intratubular germ cell neoplasia (IGCN) of the contralateral testis. IGCN (formerly carcinoma in situ) is present in about 5% of cases in the contralateral gonad of those patients with a testicular neoplasm. More than 50% will develop cancer in that testis. Clinical and physical examination findings are usually unspecific. The diagnosis of IGCN is based on biopsy, although ultrasonography could give some data too, as some authors report. We analyze the therapy options for IGCN: (orchidectomy, chemotherapy, radiotherapy, or "wait and see"). In our case, the first one was made. Chemotherapy was used due to existence of retroperitoneal lymph node metastases, with an excellent follow-up afterwards.

[Echo-guided transrectal biopsy. An analysis of the results in a series of 1900 patients]. / Biopsia transrectal ecodirigida. Análisis de los resultados en una serie de 1900 pacientes.

OBJECTIVE: To compare the results of US-guided transrectal biopsy in 1,900 patients with the diagnostic yield of DRE, transrectal US, PSA, PSA density and free PSA/total PSA ratio and to describe our approach based on the results of the comparative study. METHODS: Over the last two years 1,900 patients have undergone biopsy; 4 to 6 specimens were obtained randomly from both prostatic lobes and areas identified by transrectal US and/or DRE as being suspicious. All patients underwent transrectal US, DRE and determination of serum total PSA and PSA density. Free PSA and free PSA/total PSA ratio were determined in 128 patients with PSA 4-10 ng/ml. Seventy had a second biopsy, 8 a third and 3 had a fourth biopsy. RESULTS: The overall diagnostic yield was 40%. Biopsy was positive in 27% of patients with PSA 4-10 ng/ml; of these, 64% showed a positive DRE, 21% showed a negative DRE and 13% were negative for both DRE and transrectal US. DRE was positive in 32% of patients with PSA greater than 10 ng/ml, 39% of those with PSA 10-20 ng/ml and 62% of those with PSA greater than 20 ng/ml; transrectal US was positive in 58% of patients with PSA 10-20 ng/ml and in 77% of those with PSA greater than 20 ng/ml. A high specificity was found for both DRE and transrectal US. In patients with PSA 4-10 ng/ml, PSA density at a cutoff of 0.15 ng/ml/cc showed a sensitivity of 81% and a specificity of 20%, respectively. A second biopsy was positive in 20% of patients with a persistently elevated PSA and the incidence of tumors theoretically of little importance was 13%. CONCLUSIONS: Patients aged less than 70 years whose general condition permit aggressive treatment of prostate cancer should undergo US-guided transrectal biopsy if PSA is greater than 4 ng/ml, regardless of DRE and ultrasound findings. PSA less than 20 ng/ml, PSA density and free PSA/total PSA ratio must be considered for a second biopsy. Sextant biopsy appears to have a good diagnostic accuracy and does not require taking additional specimens or including the transitional zone in the first biopsy. Before classifying a tumor as being of little importance on the basis of the biopsy findings, another biopsy must be performed.

[Partial cystectomy as treatment of infiltrating transitional carcinoma of the bladder]. / La cistectomía parcial como tratamiento del ca. transicional infiltrante de vejiga.

UNLABELLED: The most widespread opinion, and until recently the only option, is that every vesical transitional cancer invading the muscle is, regardless its extent, candidate for radical cystectomy and that in spite of nobody questioning the advantages of partial cystectomy. MATERIAL AND METHODS: 45 patients with vesical infiltrant cancer T2 or higher, followed between 9 and 258 months and managed with partial cystectomy, were analyzed. Only patients with no radiotherapy were included and only in one patient pre-operative chemotherapy was used. RESULTS: In 8 patients no tumour was found in the specimen (pTO). Tumour grade was pTa in 2; pT1 in 11; pT2 in 5; pT3a in 4; pT3b in 11; and pX in 4 patients. Eight (8) patients had nodal involvement. Twenty-one (21) cases showed bladder relapse. In six (6), vesical infiltrant relapse was associated to metastasis. One case showed vesical relapse, pelvic mass and metastasis, and 4 only metastasis. Extravesical disease-free time and survival are better than in the group treated with radical cystectomy. But this is a highly selected group. CONCLUSIONS: With the same prospects of extravesical disease-free time and survival we offer: shorter, less risky surgery with low post-surgical morbidity and mortality and less hospitalization and proportion of late sequela. Better quality of life, with no skin stoma, incontinence or impotence Although the risk of vesical relapse persists, the procedures required to resolve vesical shunt or replacement complications are more aggressive than TUR sufficient to treat most relapses, and when recurrence is infiltrant radical cystectomy may be used as a rescue measure. This is so even now with the profusion of the so-called "mini-invasive" procedures. We believe that neither radio- and/or chemotherapy combinations contribute nothing to partial cystectomy alone. They may even be harmful and have significant side-effects. It is plain that POs are the result of total removal by TUR. Due to the little reliability when defining T, it is very hard to evaluate the contribution of adjuvant measures. Patients with no vesical tumour (pTOs) or pT1-pT2 tumours, and even up to pT3a, should not be included in protocols to evaluate the efficacy of combined cytostatic agents since their use is superfluous. Radiotherapy makes no contribution to this type of tumour in terms of local relapse and apparently has no effect on the metastasis.

[Clinical utility of available diagnostic tests in prostatic carcinoma. Results of 500 biopsies. I. PSA, PSA density, and predicted PSA]. / Utilidad clínica de las pruebas diagnósticas disponibles en el carcinoma prostático. Resultados sobre 500 biopsias. Parte I: PSA, densidad de PSA y PSA predecible.

OBJECTIVE: To study the utility of PSA density and predicted PSA results in the diagnosis of prostatic cancer using gland volume. METHODS: 500 patients suspected as having prostatic cancer underwent ultrasound-guided transrectal biopsy. Prostate volume and ultrasound characteristics, serum PSA density, predicted PSA and the difference between both were determined. RESULTS: 44.8% of the patients showed evidence of cancer in the biopsy specimen. These patients had a significantly smaller prostate. The 0.1 and 0.15 PSA density cutoffs had a sensitivity of 96% and 94%, specificity of 10% and 20% and positive predictive value of 46% and 49%, respectively. The statistical values for PSA difference of 1 and 2 were 94% and 92%, 13% and 18%, 47% and 48%, respectively. CONCLUSION: PSA density and predicted PSA results could be useful to avoid biopsies in patients with PSA between 4 and 10 ng/ml and no malignant tumor of the prostate.

[Clinical utility of available diagnostic tests in prostatic carcinoma. Results of 500 biopsies. II. Rectal palpation, PSA, and transrectal echography]. / Utilidad clínica de las pruebas diagnósticas disponibles en el carcinoma prostático. Resultados sobre 500 biopsias. Parte II: Tacto rectal, PSA y ecografía transrectal.

OBJECTIVE: To analyze and compare the diagnostic yield of transrectal ultrasound versus digital rectal examination (DRE) and PSA. METHODS: 500 patients with a suspicion of carcinoma of the prostate were evaluated by US-guided transrectal biopsy, PSA determination and DRE. The sensitivity, specificity and predictive values of these diagnostic methods, utilized alone or in combination, were analyzed. RESULTS: 44.8% of the patients had evidence of cancer in the biopsy specimen. DRE disclosed an indurated prostate in 32% and 45% of the ultrasound scans were suspicious of malignancy (74.2% of those in whom a tumor was demonstrated and 20.4% of those with no tumor, p < 0.001). DRE, PSA > 4 ng/ml and transrectal ultrasound had a sensitivity rate of 52%, 93% and 74%, and a specificity of 85%, 10% and 79%, respectively. The highest sensitivity rate was obtained when biopsy was indicated by an indurated prostate on DRE or PSA > 4 ng/ml or a suspicious transrectal ultrasound scan (96%). The highest diagnostic accuracy, with a specificity of 96%, was obtained in patients with PSA > 10 ng/ml and positive DRE and transrectal ultrasound. CONCLUSION: The combined use of the different tests is fundamental to early diagnosis of prostatic cancer. In our experience, transrectal ultrasound was the method which independently obtained the best predictive values, offering a high sensitivity and specificity.

[Chronic prostatic inflammation: a confounding factor in the diagnosis of prostatic cancer]. / Inflamación prostática crónica: un factor de confusión en el diagnóstico del cáncer prostático.

OBJECTIVES: To evaluate the influence of inflammatory foci of the prostate on the efficacy of PSA and transrectal ultrasound in the diagnosis of prostatic cancer. METHODS: Ultrasound-guided transrectal biopsy was performed in 399 patients. The results of serum PSA, PSA density and ultrasound characteristics were compared with the pathological findings. RESULTS: The mean prostatic volume was greater in the cases with BPH and chronic inflammatory foci than those with prostatic cancer (p < 0.001). Twenty percent of the patients showed suspicious areas vs 75.1% of the cancers (< 0.001); 66.7% of those with chronic inflammatory foci showed classifications vs 40.6% of the cancers (p < 0.001). The patients with chronic inflammatory foci had PSA values that fell in between those of the BPH and cancer groups (p < 0.05). PSA density also showed intermediate values, although they were not significantly different. CONCLUSIONS: The presence of chronic prostatic inflammatory foci can increase serum PSA levels. To date, it is not possible to identify this group of patients to avoid a biopsy.

[Analysis of 34 cases of infiltrating carcinoma of the bladder treated exclusively with partial cystectomy (part 1)]. / Análisis de 34 casos de carcinoma infiltrante de vejiga tratados con cistectomía parcial exclusivamente (1a parte).

OBJECTIVES: The widely accepted and, until recently, the only alternative in muscle-infiltrating transitional cell carcinoma of the bladder, whatever the extent of muscle infiltration, has been radical cystectomy, although the advantages of partial cystectomy has not been questioned. METHODS: We reviewed the records of 34 patients with infiltrating carcinoma of the bladder stage T2 or higher and a follow-up ranging from 3 to 194 months, who underwent partial cystectomy. The patient received no radiotherapy and only one patient was treated with preoperative chemotherapy. RESULTS: The surgical specimen was tumor free (pTO) in 7 patients, pT1 in 7 pts, pT2 in 4 pts, pT3 in 4, pT3b in 8 and Px in 4. Six patients showed lymph node involvement. Eleven patients had bladder recurrence; 3 had bladder recurrence and metastasis; 1 had bladder recurrence, a pelvic mass and metastasis and 2 had metastasis alone. We performed radical cystectomy in 2 cases; one for a prostatic cancer and the other for an upper urothelial tumor in a solitary kidney. Both bladders were tumor free. The extravesical disease free interval and survival were better that those of patients submitted to radical cystectomy, although this was a highly selected group. CONCLUSIONS: With the same possibilities relative to the extravesical disease free interval and survival, this approach requires a shorter operating time, carries less risk, low postoperative morbidity and mortality, requires less hospitalizations, and has less late sequelae. It affords a better quality of life, with no cutaneous stoma, incontinence or impotence. The risk of bladder recurrence persists, although the procedures required to resolve the complications of bladder diversion or substitution are more aggressive than TUR, which is sufficient for most of the recurrences, and if the recurrence is an infiltrating tumor, one can always recur to radical cystectomy. This is the current situation, even in the era of the so-called "minimally invasive techniques". We believe that in this group of patients combination preoperative radio- and chemotherapy would have contributed little to the partial cystectomy. In our series, it is evident that the pT0 is the result of complete resection by TUR. The differences in tumor definition make it very difficult to evaluate the benefits of the neoadjuvant measures. Patients with no bladder tumor (pT0) or pT1-pT2, and even pT3a tumors, should not be included in protocols for evaluating the efficacy of combination cystostatic therapy; many of them can be overtreated. Preoperative radiotherapy adds nothing with respect to local recurrence of this tumor type and it evidently has no effect on metastasis. We should not forget that the cytostatic agents currently utilized in combination therapy have severe side effects and are therefore only indicated in patients at higher risk of distant dissemination at diagnosis. Some studies, however, have indicated that the cytostatics may have some negative tumoral effect.

[Treatment of complex fistula and urinary stenosis in renal transplantation]. / Tratamiento de la fístula y la estenosis urinaria complejas en el trasplante renal.

OBJECTIVES: Urological complications in renal transplantation occasionally denote the failure of a technique intended to provide the patient on hemodialysis a significant improvement of quality of life. Our experience in the management of these complicated cases which could not be resolved by conventional measures is described. METHODS: Since the transplantation program began, our department has performed 530 renal transplants. There have been 40 fistulae (7.5%) and 23 stenoses (4.3%) of graft urinary tract. All the foregoing complications had been treated by endourological procedures (nephrostomy or ureteral stent) and/or simple ureteral reinsertion. There were 5 unresolved or recurrent fistulae (0.9%) and 2 stenoses (0.4%) that were repaired using the recipient's ipsilateral urinary tract (6 pyeloureterostomies and 1 pyelopyelostomy). RESULTS: Good results were achieved in all of the cases with adequate urinary tract function. CONCLUSIONS: Urological complications following renal transplantation can be successfully treated by surgical correction (pyeloureterostomy or pyelopyelostomy).

[Potential of ultrasonography in urologic diagnostic algorithms]. / Posibilidades de la ecografía en los algoritmos diagnósticos urológicos.

OBJECTIVES: The present study analyzed the place of ultrasound in the urological diagnostic protocols. Currently, most of the patients undergo some type of ultrasonographic evaluation at the outset or at some time during follow up. Our experience concerning the results, limitations and errors of this imaging technique are presented. METHODS: We reviewed the indications for US in different pathologies and its use together with other diagnostic techniques. Simple, cost-efficient algorithms are described. RESULTS: Its excellent performance permits making a correct diagnosis in many patients and remarkably simplifies evaluation in others. Its accuracy obviates the need for other explorations in certain pathologies. CONCLUSIONS: Ultrasound must be included in the urological armamentarium and should be considered as an extension of physical examination. Its accuracy and efficacy have been demonstrated. Furthermore, it is simple and easy to use, low-cost, and remarkably simplifies our diagnostic algorithms.

[Assessment of arterial hypertension associated with renal transplantation using Doppler ultrasonography]. / Evaluación mediante eco-Doppler de la hipertensión arterial asociada al trasplante renal.

OBJECTIVES: The incidence of arterial hypertension post-renal transplantation has been reported to be 48.6%. The present study investigated the usefulness of echo Doppler in detecting renal artery stenosis and the effects of arterial pressure control and hypotensive agents on the vascular resistance of the renal graft. METHODS: A total of 234 echo Doppler studies were done in 110 patients. The pulsatility index (PI), resistance index (RI), acceleration and mean velocity (MV), maximum systolic (SVMX) and minimum diastolic (DVMN) velocities of the external iliac, renal, segmental, interlobar and arcuate arteries were determined. RESULTS: In the stenotic segment, an elevation of SVMX was observed, followed by turbulent flow in the post-stenotic segment in 73% of the cases with arterial stenosis. The hypertensive patients had a higher external iliac artery RI than the normotensives. The beta-blockers reduced the RI in large vessels (external iliac), the vasodilators in medium-sized extraparenchymal vessels (segmental) and the calcium antagonists changed the PI in the smaller caliber intraparenchymal vessels (interlobar and arcuate). CONCLUSIONS: Evaluation by echo Doppler is the first diagnostic approach in patients suspected as having arterial stenosis of the renal graft. It permits evaluating blood flow changes from hypertension and hypotensive agents.

[Pre-transplantation evaluation with echo-Doppler of the receptor's vascular risk factors]. / Evaluación pretrasplante mediante eco-Doppler de los factores de riesgo vascular del receptor.

A total of 51 potential recipients of a renal transplant (RT) have been evaluated with an Eco-Doppler study of the posterior femoral, popliteal and posterior tibial corteries. Acceleration (AC), mean rate (MR), maximum systolic rate (MXSR) and minimal diastolic rate (MNDR), as well as pulsatility (PI) and resistance index (RI) were measured. Arterial high blood pressure (HBP), smoking, time in haemodialysis (HD) and cholesterol and triglycerides levels, were evaluated as vascular risk factors. RI and PI were maximal, and MXSR, MR and AC minimal at the popliteal artery level. Smoking (number of cigarettes/day) (R = 0.77), systolic blood pressure (BP) (R = 0.43), time of HBP evolution (R = 0.044), cholesterol level (R = 0.43) and time in HD (R = 0.35) correlate with Eco-Doppler parameters. Fifteen of these 51 patients underwent transplantation, and increased RR and PR with decreased MR and MXSR were seen post-RT in the ipsilateral popliteal and posterior tibial arteries. Eco-Doppler is a useful technique to evaluate the vascular risk of potential RT recipients.

[Comparative analysis of lithiasic fragmentation induced by extracorporeal and direct contact sources]. / Análisis comparativo de la fragmentación litiásica inducida por las fuentes extracorpóreas y de contacto directo.

An in vitro experimental study on stone fragmentation was conducted on 114 calculi analyzed by infrared spectrophotometry. Four energy sources were utilized: electrohydraulic, piezoelectric, ultrasound and pulsed laser. We analyzed stone susceptibility to fragmentation (particles < 3 mm), pulverization (particles < 1 mm) and stone fragility (amount of energy/mg of calculus fragmented into particles < 3 mm) for each type of energy source of each of the following 6 stone compositions: calcium oxalate monohydrate, calcium oxalate dihydrate, magnesium ammonium phosphate, phosphate carbonate, uric acid and phosphate oxalate. The calcium oxalate dihydrate calculi were the most susceptible to fragmentation and the infective calculi (magnesium ammonium phosphate and phosphate carbonate) were the most susceptible to pulverization. The piezoelectric energy showed the highest capacity for fragmentation and pulverization of calculi. Stone fragility depended on each stone type and the energy source utilized.

Leiomyoma of the urinary bladder floor: diagnosis by transvaginal ultrasound.

We studied a case of leiomyoma of the bladder floor in a woman with excretion urography, voiding cystourethrography, abdominal echography, computed tomography scan, and transvaginal echography. This last technique gave us the most accurate information about localization of the mass and its relation to adjacent organs. With these data we were able to indicate the most suitable surgical access. We think that this new application of the transvaginal echography should be included in the study of bladder flow masses in the female.