[Transperitoneal laparoscopic adrenalectomy]. / Suprarrenalectomía laparoscópica transperitoneal.

OBJECTIVES: To present our results with transperitoneal laparoscopic adrenalectomy after completion of 70 procedures. MATERIAL AND METHODS: Between July 2002 and December 2010, transperitoneal laparoscopic adrenalectomy was performed in 70 patients with the following diagnoses: Conn syndrome (22 cases), nonfunctioning adenomas (18), Cushing syndrome (10), pheochromocytomas (7), myelolipomas (4), metastasis after treatment of primary nonadrenal tumors (6), ganglioneuroma (1), adrenal gland hematoma (1) and adrenal carcinoma (1). We describe the size, surgical and hospitalization times, blood loss, need for transfusion, surgical complications and rate of conversion to open surgery. RESULTS: Of 70 patients, 35 were men and 35 women (1:1) with a mean age of 58.2 years (range, 82.2- 29.1). The most common site was left (58%) compared to right (42%). The mean size of the surgical specimen was 5.11 cm, mean surgical time was 119.2 minutes (50-240) and mean operative bleeding was 140.6 (30-800) cc. Only 3 patients required blood transfusion. The mean time until oral feeding was 17 hours, and the mean hospital stay was 4.3 (2-15) days. Complications included 2 cases of surgical infections, 1 of prolonged paralytic ileus, and 1 of splenic laceration and 1 of intestinal perforation which both which required reconversion to open surgery (4.28%). CONCLUSIONS: Laparoscopic adrenalectomy is a safe procedure, with a low percentage of complications and a short hospital stay. The choice of this approach will depend on the surgeon's experience with the lesion etiology and size in each case.

Myelolipomatous adrenal masses causing Cushing's syndrome.

Adrenal myelolipomas are uncommon benign tumors, composed of mature adipose tissue and haematopoietic elements in varying proportions. They are usually asymptomatic, non-functioning adrenal incidentalomas, but there have been a few reports of myelolipomatous masses associated with adrenocortical hypersecretion. We report two cases of large mixed adrenal tumors, with heterogeneous appearance and areas of fat density in imaging techniques, and with autonomous cortisol production leading to Cushing's syndrome. Both underwent adrenalectomy and the histological study showed an adrenocortical adenoma with widespread myelolipomatous metaplasia. Hypercortisolism resolved in the one patient that could be evaluated after surgery. We review all the previous reported cases of hypercortisolism associated with adrenal myelolipomas. We also discuss the recommended diagnostic approach and therapeutic management of adrenal masses of lipomatous appearance.

[Hemoperitoneum and death due to hepatoesplenic metastasis rupture in a testicular tumor]. / Hemoperitoneo y muerte por rotura de metástasis hepatoesplénicas de tumor testicular.

We present a case of a mix germinal testicular tumor, in III-C (AJCC-UICC) stage, at a terminal phase due to massive methastasis rupture at hepatic and splenic methastasis locations.

[Giant adrenal myelolipoma: hypertension, renal failure and spontaneous rupture]. / Mielolipoma suprarrenal gigante: hipertensión, insuficiencia renal y rotura espontánea.

Adrenal myelolipoma is a rare, benign, slow-growing tumor composed of adipose tissue and hematopoietic elements. It is usually diagnosed incidentally, although there are reports of patients with symptoms and descriptions of retroperitoneal hemorrhage due to rupture of large tumors. The condition has been associated with obesity, high blood pressure and adrenal dysfunction. We present a patient with retroperitoneal hemorrhage due to spontaneous rupture of a myelolipoma, hypertension, and renal failure secondary to nephroangiosclerosis.

[Entero-neobladder ileal fistula: two cases report]. / Fístula entero-neovejiga ileal: a propósito de dos casos.

Fistulas between the orthotopic reservoir and the gastrointestinal tract have low incidence (1.5-2%). Simptomatology is variable, but it's frecuent to find fecaluria. Among 90 new intestinal bladders we show two fistule of new bladder to ileo, with nest postoperatory diagnosis, using retrograde cystografy; one was resolved with next postoperative treatment and the other with open surgery.

[Urachal pathology: an overview review and report of three clinical cases]. / Patología del uraco: revisión de conjunto y presentación de tres casos.

With the use of these two clinical cases (cyst and urachal adenocarcinoma) we did an overview of the urachal pathology. The urachus cyst is usually asyntomathic, it's detected randomly when we do other diagnostic tests or when we have any complications. The urachal adenocarcinoma is a rare pathology, it usually exhibit hematuria and we need to follow the same diagnostic tools as we use in vesical tumors (cystoscopy and transurethral vesical resection). Adenocarcinoma of the dome of the bladder is the main differential diagnosis. Partial cystectomy is the first choice treatment. Quimiotheraphy and radiotheraphy offer poor results.

[Problem-based learning in urology training. The Faculty of Medicine of the Universidad de Castilla-La Mancha model]. / El aprendizaje basado en problemas en la enseñanza de la urologia. Modelo de la Facultad de Medicina de la Universidad de Castilla-La Mancha.

Ongoing changes in the social, economic, technological and scientific realms have generated new needs and led various organizations to suggest that educational institutions should reorient their educational strategies toward developing effective professionals with the skills to meet these needs. These "modern" strategies include problem-based learning, in which the student seeks and selects information, analyzes the data obtained, integrates both prior and newly acquired knowledge, and, finally, offers diagnostic and therapeutic options to resolve the problem posed, as would occur in professional practice. With this approach, prior skills and practical experience form the foundation of learning. Problem-based learning incorporates some aspects of cognitive psychology, a model that mainly centers on the nature of the knowledge structures found in active memory, the processes involved in information storage and retrieval and the various factors that activate these processes. At the Faculty of Medicine of the Universidad de Castilla-La Mancha, urology is part of a core subject (Medical and Surgical Pathology II) taught in the fifth year of coursework together with nephrology. Each course includes approximately 75 students, divided into five groups. The rotation lasts six weeks, with students spending a mean of two hours a day on theory (nephrology and/or urology) and the remaining time on rotations in the various activities: three weeks in nephrology and three weeks in urology. Upon completion of the rotation, the students write a combined theoretical examination with 100 multiple-choice questions (50 on urology) and take a practical skills examination. At the end of the course, another practical test consisting of an objective, structured clinical examination is taken, in which standard patients are used and the professor directly assesses the level of skills acquired with a "real" case.

[Surgery of large residual mass after chemotherapy in advanced testicular germ cell tumor]. / Cirugía de gran masa residual tras quimioterapia en tumor germinal testicular avanzado.

Treatment for testicular tumours has progress in such a manner in the last years that high cure percentages can at present be achieved. After chemotherapy, in most cases, residual mass can appear. In this cases surgery is considered a viable therapeutic option although it implies an advanced surgical training since it is a complex technique and implies serious implications. We submit the case of a patient who presented a large residual mass from a testicular germ cell tumour after being treated with orquiectomía and chemotherapy. Surgery was performed resulting in total and radical extirpation of residual mass.

[Nephron-sparing surgical treatment in renal tumors]. / Cirugía conservadora de parénquima en los tumores renales.

OBJECTIVE: A retrospective study on the nephron-sparing surgical treatment in patients with renal tumors, and in addition a literature review on the subject. MATERIAL AND METHODS: Since January 1988 until February 2002, 44 partial nephrectomies have been carried out in our unit because of renal tumors in 43 patients. The clinical protocols of these 43 patients have been reviewed, with an analysis of various clinical-pathological parameters, and utilizing in this analysis percentages, central tendency measures and dispersion and confidence intervals. RESULTS: The average age of the patients was 55.8 years (19-76), and 29 patients were males. Elective partial nephrectomy was carried out in 79.5% of the patients, while in the rest they were submitted to imperative surgery for various causes. The diagnosis of the tumors was mostly as an incidental finding upon carrying out some diagnostic test by another cause (68.2%). In the symptomatic cases, the most common presentation was the combination of pain and hematuria (11.4%). Histopathological study revealed malignant neoplasms in 88.7%, most of them (61.4%) clear cell carcinomas. A Furhman grade 2 was observed in 76.3% of tumors. The average size of the renal masses was of 4.53 cm (1,5-11). As a whole, 61.5% were pT1, 33.3% were pT2 and only one case was pT3. Operative complications were observed in 11.4% of the cases and postoperative complications in 25%. No patient showed local or distant recurrence, and all of them survived disease-free. A patient died after 74 months of the surgery for causes not related to the disease. Average follow-up was 49.77 months (1-168). CONCLUSIONS: Renal nephron-sparing surgery is such a valid therapeutic option as radical nephrectomy in selected patients with renal tumors, since the cancer-specific survival is 100%, which means that this can be considered a therapeutic indication even in patients with healthy contralateral kidney.

[Epididymal ectopic adrenal tumor]. / Tumor epididimario de restos adrenales.

OBJECTIVE: A case of a nonfunctioning ectopic adrenal tissue tumor in the epipidymis is described. METHODS/RESULTS: A case of a nonfunctioning ectopic adrenal tissue tumor in the epipidymis is presented. A left testicular mass had been incidentally detected in this patient. CONCLUSIONS: Tumors of this type localized in the juxtafuniculogonadal region are usually benign. However, resection and histological analysis are always indicated in order to detect metastasis or confirm the histiological type is normal.

[The Conn syndrome. The clinical and surgical aspects of 18 cases of adrenal adenoma]. / Síndrome de Conn. Aspectos clínicos y quirúrgicos sobre 18 casos de adenoma suprarrenal.

OBJECTIVES: Presentation of a series of 18 patients who underwent surgery of aldosterone-producing adrenal adenoma (Conn's syndrome) over the last 10 years. Assessment of the most significant clinical and pathological aspects from a surgical point of view. METHODS: Retrospective study evaluating a broad range of features: clinical, analytical, hormonal, imaging, types of anaesthesia, approaches, technique used, intra and post-operative morbidity and mortality, evolution and pathoanatomical diagnosis. RESULTS: The most frequent clinical data of primary hyperaldosteronism were: 94.4% volume-dependent HBP, 50% headaches and dizziness, 27.8% epistasis and/or episodes of angor or acute myocardial infarction, and 22.2% heart failure. The biochemical study and hormonal testing evidenced: hypokalemia in 88.9%, metabolic alkalosis 66.7% and hypernatremia in 61.1%. Mean aldosterone levels were 517.5 pg/mL, and urinary levels 85.9 mcg/day. Resting plasma renin activity (PRA) < 0.2 ng/mL/h in 77.8% cases and positive aldosterone stimulation test in 61.1%: captopril test positive. Imaging diagnosis was based in CAT which was conclusive in 88.9% and ultrasound which was diagnostic in 27.8% cases. The surgical approach was: lumbotomy (over the 11th or 12th rib) in 14 patients and transpleurodiaphragmatic in all remaining patients. The intraoperative complications reported were placement of endothoracic tube due to iatrogenic pneumothorax in two occasions. Duration of the procedure (mean 136.1 min) and post-operative hospitalization (mean 7.76 days), as well as post-surgery follow-up for up to 96 months were also studied. At final time point there was 66.7 asymptomatic patients, 33.3% cases of HBP, and no deaths. CONCLUSIONS: Primary hyperaldosteronism due to adrenal adenoma is an uncommon reason for HBP, but in most cases can be cured with surgery. Biochemical and hormonal testing is determinant to research a diagnosis. Ultrasound and CAT are essential for imaging diagnosis, and occasionally NMR can be of help. Lumbotomy is considered the choice approach for these small tumours as it is a familial technique for urologists with a low complications rate.

[Ruptured syringocele of the Cowper's gland. Report of a case]. / Siringocele roto de la glándula de Cowper. Presentación de un caso.

Contribution of the case report of an 18-year old patient who consulted for an early picture of haematuria with symptoms of mictional syndrome with a history of several years of urinary infection. After the urological study, the presence of a ruptured syringocele in Cowper's gland was documented in the retrograde and mictional uretrography. The treatment approach was the incision, widening the communication between the urethra and the syringocele; all manifestations disappeared after the endoscopic treatment. The etiology of syringoceles and cystic dilations of Cowper's duct and gland are usually congenital, and there is a likely association with the presence of Cobb's collar. There are four morphological types: simple, perforated, imperforated and ruptured. Most cases are asymptomatic, basically affecting children and adolescents. The usual manifestations are haematuria, symptoms of urinary infections and/or various symptoms of urethral obstruction. Diagnosis is achieved through uretrography and endoscopy. Treatment, when appropriate, is endoscopic through incision or syringocele marsupialization. In some cases, perineal incision and surgical resection of the syringocele with urethral closure has been performed.

[Wilms tumor in adults. Case description]. / Tumor de Wilms del adulto. Descripción de un caso clínico.

OBJECTIVE: To report a case of adult Wilms' tumor, a kidney tumor that is more common in children and has a scanty incidence in adults. METHODS/RESULTS: A case of Wilms' tumor in a young male, aged 16 years, is described. The patient underwent partial surgical resection initially and nephrectomy due to tumor recurrence, with postoperative chemotherapy and radiotherapy. CONCLUSIONS: Although approximately 200 cases of adult Wilms' tumor have been reported in the literature, few meet currently accepted diagnostic criteria. The diagnosis of adult Wilms' tumor based on the findings of currently available diagnostic methods is only presumptive until the surgical specimen is analyzed. Most cases are treated as renal tumor and it is the findings of the pathological analysis that defines its nature and the need for chemotherapy and/or radiotherapy, as well as long-term follow-up. The application of therapeutic protocols for children to adults has not obtained the same percentage of cure or prognosis, although a large multicenter study is warranted to confirm the foregoing.

[Retroperitoneal cystic mesothelioma and lymphangioma]. / Mesotelioma y linfangioma quísticos retroperitoneales.

Retroperitoneal cysts are uncommon entities of difficult diagnosis because of their insidious symptomatology. Urinary apparatus involvement is quite often the mode of presentation and the reason for calling on the urologist. The origin of many of these retroperitoneal cysts remains practically unknown. Surgery with exeresis is the choice management method. Follow-up is necessary for cystic mesothelioma because of the highly frequent relapses. The outlook of hormonal conservative therapy for relapses appears as a future alternative to treatment.

[Eosinophilic cystitis and glandular-cystic cystitis as pseudotumor lesions]. / Cistitis eosinofílica y cistitis glánduloquística como lesiones seudotumorales.

OBJECTIVES: To report on two different types of cystitis presenting as pseudotumor. The differential diagnosis between the foregoing lesions and true tumors can only be established by biopsy. METHODS: We report two cases of cystitis (eosinophilic cystitis and glandular-cystic cystitis) with clinical, radiological and endoscopic features of a bladder tumor. The diagnosis, etiopathological aspects, clinical course and treatment of both types of cystitis are reviewed. RESULTS/CONCLUSIONS: Hematuria is the most frequent and most important symptom of these uncommon lesions. They present as space occupying lesions in more than 50% of the cases and have no specific diagnostic features. The diagnosis can only be made by pathological examination following TUR-biopsy.

[Survival of patients with upper urothelial tumor]. / Estudio de supervivencia en pacientes con tumor de urotelio superior.

OBJECTIVE: A descriptive analysis of 35 patients with transitional cell carcinoma of the upper urinary tract is presented. The actuarial survival was analyzed to determine which circumstances associated with superficial bladder cancer had a prognostic significance. METHODS: The records of 35 patients with upper urothelial tumor diagnosed from 1987 to 1993 were retrospectively analyzed. A descriptive statistical analysis was performed on all the variables. Correlation was determined by Pearson's Xi2 test, Yates' and Fisher's exact test. McNemar's test was used to determine which diagnostic method had the highest yield. The actuarial survival data were analyzed with the Kaplan-Meier and Mantel-Haenzel test. RESULTS: Patient mean age was 67.74 yrs, mean follow up was 26.83 months, 40% were ureteral tumors, 25.7% were pelvic tumors, 60.6% were superficial tumors and 62.6% were GI and GII, 48.5% were associated with bladder tumors and no correlation was found between the grade and stage of bladder relapses and the upper urinary tract tumors. Intravenous urography demonstrated function was abolished in 45.5%. Cytology gave the highest diagnostic yield (84.6%). Nephroureterectomy with perimeatal cystectomy was the surgical technique most frequently used (57.1%). To date, 71.4% of the patients have survived. Significantly women demonstrated the most undifferentiated cellular grade (p < 0.001), although no prognostic value was found for sex. 95% of the patients with non-infiltrating tumor stages and 95% of the patients with GI-GII tumors survived, whereas 61.5% of the patients with infiltrating tumors and 58.3% of those with GIII tumors did not survive (p < 0.002). Evidently, the grade of cellular differentiation and the stage of infiltration were interrelated (p < 0.002). Analysis of the actuarial survival data showed that the probability of survival after 24 months (mean follow up) was 67.07% and the probability of reaching 74 months (maximum follow up) was 60.04%. CONCLUSIONS: After a comparative analysis of the survival with the Mantel-Haenzel test, it was found that the grade of cellular differentiation (p < 0.001) and stage of infiltration (p < 0.01) had significant differences in the survival curves.

[Bladder endometriosis: a new case and review of the literature]. / Endometriosis vesical: un nuevo caso y revisión de la literatura.

OBJECTIVES: The diagnostic and therapeutic aspects of endometriosis of the bladder is reviewed. Although it is relatively uncommon, it should be taken into account when making the differential diagnosis in young females presenting with dysuria. METHODS/RESULTS: A young female patient with dysuria and hypogastric pain caused by endometriosis of the bladder is described. CONCLUSIONS: Diagnosis is basically by cystoscopic exploration and histological analyses of the specimens obtained by electrofulguration. Hormone therapy with Danazol may be effective in some cases. The most effective treatment is excision of the lesion by TUR or conventional surgery. Furthermore, laser could be useful in the treatment of this pathology.

[Keratinizing squamous metaplasia (cholesteatoma) of the upper urinary tract]. / Metaplasia escamosa queratinizante (colesteatoma) del tracto urinario superior.

Presentation of four cases of keratinizing squamous metaplasia (KSM), two of the renal pelvis, one pyelocaliceal and one ureteral. Nephrouretetectomy was performed in all cases. All our patients showed good evolution. A review of the literature is made discussing all the etiological, diagnostic and therapeutical aspects of the condition. Its benign evolution is highlighted as well as the current need, once a better knowledge of the condition's natural history is available, of using a conservative approach.