Factors associated with treatment escalation among MS specialists and general neurologists: Results from an International cojoint study.

BACKGROUND: Previous studies in multiple sclerosis (MS) showed that therapeutic inertia (TI) affects 60-90% of neurologists and up to 25% of daily treatment decisions. The objective of this study was to determine the most common factors and attribute levels associated with decisions to treatment escalation in an international study in MS care. METHODS: 300 neurologists with MS expertise from 20 countries were invited to participate. Participants were presented with 12 pairs of simulated MS patient profiles described by 13 clinically relevant factors. We used disaggregated discrete choice experiments to estimate the weight of factors and attributes affecting physicians' decisions when considering treatment selection. Participants were asked to select the ideal candidate for treatment escalation from modest to higher-efficacy therapies. RESULTS: Overall, 229 neurologists completed the study (completion rate: 76.3%). The top 3 weighted factors associated with treatment escalation were: previous relapses (20%), baseline expanded disability status scale [EDSS] (18%), and MRI activity (13%). Patient demographics and desire for pregnancy had a modest influence (≤ 3%). We observed differences in the weight of factors associated with treatment escalation between MS specialists and non-MS specialists. CONCLUSIONS: Our results provide critical information on factors influencing neurologists' treatment decisions and should be applied to continuing medical education strategies.

Employment status monitoring in an Argentinian population of patients with multiple sclerosis: Particularities of a developing country.

BACKGROUND: Multiple sclerosis (MS) is a neurological chronic disease that causes a number of physical, cognitive and emotional symptoms. The identification of these factors will allow mitigating unemployment and improve quality of life of patients. The Buffalo Vocational Monitoring Survey (BVMS) is a tool to characterize Work-Challenged patients. OBJECTIVE: To describe and analyze BVMS data in people with multiple sclerosis (PwMS) from Argentina. To study the association with physical, cognitive and psychiatric morbidity in employed patients, comparing the performance of MS Work-Challenged and MS Work-Stable patients, with and without accommodations. METHODS: 119 MS patients were administered the Argentina adaptation of the BVMS, and completed measures of physical disability, fatigue, depression, cognitive processing speed, memory and verbal fluency. RESULTS: 65.54% of the patients were employed and 19.32% were unemployed, the remaining having roles of housewife, students and disability retirees. Within the employed subgroup, 60.26% were working as employees and 39.74% were self-employed. Cognitive and clinical variables differentiate patients with and without negative events and accommodations (p >  0.05). CONCLUSIONS: This Spanish version BVMS is considered a new tool to monitor employment difficulties in Spanish-speaking MS patients. MS Work-Challenged had a higher depression, fatigue and worse performance in cognitive variables.

[Argentinean consensus guidelines on the identification and clinical care of secondary progressive multiple sclerosis]. / Consenso sobre la identificación y seguimiento de la esclerosis múltiple secundaria progresiva en Argentina.

INTRODUCTION: The identification, diagnosis, follow-up, and treatment of patients with secondary progressive multiple sclerosis (SPMS) show significant differences between health care professionals in Argentina. AIM: To provide consensus recommendations on the management of patients with SPMS in Argentina to optimize patient care. DEVELOPMENT: A panel of expert neurologists from Argentina dedicated to the diagnosis and care of multiple sclerosis patients gathered during 2019 and 2020 to carry out a consensus recommendation on the diagnosis and treatment of SPMS patients in Argentina. To achieve consensus, the methodology of 'formal consensus-RAND/UCLA method' was used. Recommendations were established based on published evidence and the expert opinion. Recommendations focused on how to define SPMS and how to follow SPMS patients. CONCLUSION: The recommendations of this consensus guidelines attempt to optimize the care of SPMS patients in Argentina.

TITLE: Consenso sobre la identificación y seguimiento de la esclerosis múltiple secundaria progresiva en Argentina.Introducción. Existen diferencias significativas en el diagnóstico, la identificación y el seguimiento de pacientes con esclerosis múltiple secundaria progresiva (EMSP) entre los profesionales de la salud a cargo de su tratamiento. Objetivo. Proveer recomendaciones sobre el tratamiento de los pacientes con EMSP en Argentina con el fin de optimizar su cuidado. Desarrollo. Un grupo de neurólogos expertos en esclerosis múltiple de Argentina elaboró un consenso para el tratamiento de pacientes con EMSP en la región mediante metodología de ronda de encuestas a distancia y reuniones presenciales. Se establecieron 33 recomendaciones basadas en la evidencia publicada y en el criterio de los expertos que participaron. Las recomendaciones se enfocaron en el diagnóstico y el seguimiento de los pacientes con EMSP. Conclusión. Las recomendaciones establecidas en el presente consenso permitirían optimizar el cuidado y el seguimiento de los pacientes con EMSP en Argentina.

Conflictos en la esfera sexual en adolescentes con Trastornos del Espectro Autista de alto funcionamiento / Conflicts in the Sexual Sphere in Adolescents with High-Functioning Autism Spectrum Disorders

Los Trastornos del Neurodesarrollo, en particular, los Trastornos del Espectro Autista (TEA) afectan la comunicación e interacción social, además de caracterizarse por conductas estereotipadas que en muchos casos se desajustan de la norma social. Dichas características nucleares de TEA pueden afectar el desarrollo afectivo-sexual y esto se puede ver exacerbado según el nivel de funcionamiento del niño o Adolescente. En este artículo revisaremos aspectos en conflicto en la sexualidad de Adolescentes con TEA de alto funcionamiento. Métodos: Se efectuó una revisión sistematizada de la evidencia reciente publicada y anexada a bases de datos en relación a conflictos en el área afectivo-sexual vivenciados por adolescentes con diagnóstico de Trastorno del Espectro Autista de alto funcionamiento. Se incluyeron estudios específicos respecto al tema, principalmente auto-reportes, denotando la escasez de revisiones sistemáticas. Se compara con literatura clásica de autismo. En la revisión se excluyó la población infantil con TEA, o sea, menores a 12 años al igual que jóvenes con TEA de bajo funcionamiento debido a las dificultades implícitas que la discapacidad intelectual y/o alteraciones del lenguaje generan en la interacción social y desarrollo afectivo-sexual. Resultados: En la revisión del tema se pesquisaron estudios enfocados en la comprensión de las dimensiones afectivo-sexuales afectadas en adolescentes con TEA de alto funcionamiento, comparaciones del desarrollo normativo en adolescentes sin TEA considerados casos controles y sus contrapartes con TEA, así mismo, se hizo énfasis en conflictos en común v/s conflictos específicos en TEA. Se evaluaron además, factores de riesgo en el ámbito sexual de jóvenes con TEA y las problemáticas en torno a educación sexual. Al respecto los estudios coincidieron en mayores porcentajes de conductas hipersexualizadas y parafílicas (principalmente fantasías sádicas y conductas voyeuristas y masoquistas) en adolescentes con TEA de alto funcionamiento. Además reportaron tasas más altas de orientación sexual "no heterosexual", disforia de género e identidad de género Trans. Discusión y Conclusiones: Del análisis de estudios en población específica de Adolescentes con diagnóstico de TEA catalogados como de alto funcionamiento, y en comparación con individuos controles sin TEA, la evidencia muestra un amplio espectro de dificultades relacionadas al desarrollo afectivo-sexual y su enfrentamiento en esta etapa del ciclo vital, así como la relación de los síntomas nucleares de TEA con conductas no normativas en torno a sexualidad del tipo "Hipersexualización" y "Parafilias". Se discuten además conflictos en orientación sexual e identidad de género. Se logró establecer una asociación entre las variables, lo que afecta su desempeño social global. Se evidenció además, la escasa educación sexual que reciben éstos adolescentes a nivel familiar y académico, lo que perpetúa tales conflictivas y establece un escenario de riesgo en su desarrollo. Se requiere mayor evaluación y utilización de escalas específicas adaptadas a TEA para mejorar y suplir tales falencias y así mejorar la calidad de vida de dichos jóvenes.

Neurodevelopmental Disorders, in particular Autism Spectrum Disorders (ASDs), affect social communication and interaction, as well as being characterized by stereotypical behaviors that in many cases are mismatched from the social norm. Such nuclear characteristics of ASD can have an impact on affective-sexual development and this may be exacerbated by the function level of the child or adolescent. In this article we will review conflicting aspects in the sexuality of adolescents with high-functioning ASD. Methods: A systematized review of recent evidence published and annexed to databases related to conflicts in the affective-sexual area lived by adolescents diagnosed with high-functioning Autism Spectrum Disorder was conducted. Specific studies were included on the subject, mainly self-reports, denoting the scarcity of systematic reviews. It was compared to classical autism literature. The review excluded the child population with ASD, i.e., under 12 years of age, as well as young people with low-functioning ASD due to the implicit difficulties that intellectual disability and/or language alterations generate in social interaction and affective-sexual development. Results: The review looked at studies focused on understanding the affective-sexual dimensions affected in adolescents with high-functioning ASD, comparisons of normative development in adolescents without ASD, considered control cases and their counterparts with ASD, as well as emphasizing common conflicts v/s specific conflicts in ASD. Risk factors in the sexual field of young people with ASD and sexual education issues were also assessed. In this regard, studies coincided with higher percentages of hypersexualized and paraphilic behaviors (mainly sadistic fantasies and voyeuristic and masochistic behaviors) in adolescents with high-functioning ASD. They also reported higher rates of "non-heterosexual" sexual orientation, gender dysphoria and transgender identity. Discussion and Conclusions: From the analysis of studies in the specific population of adolescents diagnosed with ASD listed as high functioning, and compared to individuals controls without ASD, the evidence shows a wide affective-sexual development and its confrontation at this stage of the life cycle, as well as the relationship of nuclear symptoms of ASD with non-normative behaviors around sexuality of the type "Hypersexualization" and "Paraphilias". Conflicts in sexual orientation and gender identity are also discussed. It was possible to establish a partnership between variables, which affects their overall social performance. It was also evident that these adolescents receive poor sex education within their families and at the academic levels, perpetuating such conflicts and establishing a scenario of developmental risk. Further evaluation and use of specific scales adapted to ASD are required to improve and supplement such false conditions and thus improve the quality of life of such young people.

In situ observation of the percolation threshold in multiphase magma analogues.

Magmas vesiculate during ascent, producing complex interconnected pore networks, which can act as outgassing pathways and then deflate or compact to volcanic plugs. Similarly, in-conduit fragmentation events during dome-forming eruptions create open systems transiently, before welding causes pore sealing. The percolation threshold is the first-order transition between closed- and open-system degassing dynamics. Here, we use time-resolved, synchrotron-source X-ray tomography to image synthetic magmas that go through cycles of opening and closing, to constrain the percolation threshold Φ C at a range of melt crystallinity, viscosity and overpressure pertinent to shallow magma ascent. During vesiculation, we observed different percolative regimes for the same initial bulk crystallinity depending on melt viscosity and gas overpressure. At high viscosity (> 106 Pa s) and high overpressure (~ 1-4 MPa), we found that a brittle-viscous regime dominates in which brittle rupture allows system-spanning coalescence at a low percolation threshold (Φ C ~0.17) via the formation of fracture-like bubble chains. Percolation was followed by outgassing and bubble collapse causing densification and isolation of the bubble network, resulting in a hysteresis in the evolution of connectivity with porosity. At low melt viscosity and overpressure, we observed a viscous regime with much higher percolation threshold (Φ C > 0.37) due to spherical bubble growth and lower degree of crystal connection. Finally, our results also show that sintering of crystal-free and crystal-bearing magma analogues is characterised by low percolation thresholds (Φ C = 0.04 - 0.10). We conclude that the presence of crystals lowers the percolation threshold during vesiculation and may promote outgassing in shallow, crystal-rich magma at initial stages of Vulcanian and Strombolian eruptions.

Gender ratio trends over time in multiple sclerosis patients from Argentina.

Several studies in multiple sclerosis (MS) suggest a trend of increasing disease frequency in women during the last decades. A direct comparison of gender ratio trends among MS populations from Argentina remains to be carried out. The objective of the study was to compare gender ratio trends, over a 50-year span in MS populations from Argentina. METHODS: multicenter study that included patients from 14 MS Centers of Argentina. Patients with definite MS with birth years ranging from 1940 to 1989 were included. Gender ratios were calculated by five decades based on year of birth and were adjusted for the F/M born-alive ratio derived from the Argentinean national registry of births. The F/M ratios were calculated using a multivariate logistic regression per five decades by the year of birth approach. Analyses were performed using Stata 10.1. RESULTS: 1069 patients were included. Gender ratios showed a significant increase from the first to the last decade in the whole MS sample (from 1.8 to 2.7; p value for trend=0.023). The Gender ratio did not show differences considering MS subtype. CONCLUSION: our study showed a modest increase of the F/M ratio (from 1.8 to 2.7) over time among patients affected by MS in Argentina.

Increasing prevalence of multiple sclerosis in Buenos Aires, Argentina.

UNLABELLED: In 1996, the prevalence of multiple sclerosis (MS) for the metropolitan area of Buenos Aires using the capture-recapture method was estimated to be between 14 and 19.8 cases per 100,000 inhabitants. The aim of this study was to update the prevalence to 2014 following the same methodology. METHODS: Gran Buenos Aires is the denomination that refers to the megalopolis comprised by the autonomous city of Buenos Aires and the surrounding conurbation of the province of Buenos Aires. The study was carried out taking December 2014 as the prevalence month. We used the capture-recapture method to estimate the prevalence of MS cross-matching registries from 6 MS Centers from the metropolitan area of Buenos Aires. Log-linear model Poisson regression was used to estimate the number of affected MS patients not detected by any of the 6 sources considered. RESULTS: 1035 registries were obtained from the 6 lists from 910 different patients detected. The population of the area based on 2010 census was 12,806,866, the number of MS cases estimated amongst source interactions were 4901. The estimated prevalence was 38.2 per 100,000 inhabitants (95% CI 36.1-41.2). CONCLUSION: The study is an update almost 20 years after the first one in the area showing a significant increase in the previous reported prevalence. Our findings are in line with previous studies performed in other regions of the world.

Disease onset in familial and sporadic multiple sclerosis in Argentina.

UNLABELLED: The present study was carried out to assess if there is an anticipation of age at onset in younger generations of familial multiple sclerosis (FMS) vs. sporadic MS (SMS) in Argentina. METHODS: multicenter study that included patients from 14 MS Centers of Argentina. Patients were considered as FMS if they had in their family at least one relative of first or second degree diagnosed with MS; otherwise, patients were considered to have SMS. We compared the age at onset between familial and sporadic cases as well as the age at onset between relatives from different generations in FMS vs. SMS. RESULTS: 1333 patients were included, 97 of them were FMS (7.3%). A lower age at onset in the younger generations of FMS cases was found compared with older generations of FMS as well as. SMS cases (24.1±3.7 years vs. 30.3±5.7 years, and 32.4±9.4 respectively; p<0.001). No differences were observed between older generations of FMS vs. SMS cases (p=0.12). CONCLUSION: we observed an anticipation of age at onset of MS in younger generations of patients with FMS vs. older generations of FMS and SMS.

Diagnostic usefulness of the cytological study of the transport buffer in transrectal prostate core biopsies.

BACKGROUND: To evaluate the diagnostic usefulness of the cytological study of the transport buffer in the diagnosis of prostate adenocarcinoma in transrectal core biopsies. METHODS: A total of 256 consecutively biopsied patients have been included in the analysis, 100 of them diagnosed of prostate adenocarcinoma. The procedure included the cytological analysis of the transport buffer and conventional histology. Cytological evaluation was performed in a blind way by the same pathologist. RESULTS: Overall sensitivity, specificity, and positive and negative predictive values to detect malignancy in the cytological slides were 54%, 98%, 94% and 76%, respectively. When restricted the analysis to cases with Gleason score higher than 8, sensitivity and negative predictive value increased to 85% and 97%, respectively. Similarly, when the analysis focused exclusively to cases with more than 5mm of cancer in the biopsy, sensitivity and positive predictive value increased to 66% and 96%, respectively. CONCLUSIONS: This study shows that whilst specificity was maintained in 98%, sensitivity, and positive and negative predictive values significantly improved in high grade and high volume adenocarcinomas. Our findings confirm that the cytological study of the transport buffer may complement the histology in the diagnosis of prostate adenocarcinoma.

Multiparametric magnetic resonance imaging for the assessment of extracapsular invasion and other staging parameters in patients with prostate cancer candidates for radical prostatectomy.

INTRODUCTION: the proper evaluation of the extracapsular extension (ECE), the invasion of seminal vesicles and regional lymph nodes are necessary to plan the treatment of localized prostate cancer. A model that assesses the risk of ECE in the specimen considering the clinical, histological and imaging findings is defined. MATERIAL AND METHODS: prospective study in 85 patients with prostate cancer treated with radical prostatectomy. Prostate biopsy was performed 4 weeks before multiparametric study (mpMRI). mpMRI included T2-weighted endorectal magnetic resonance imaging (T2W-MRI), diffusion-weighted magnetic resonance imaging (DW-MRI) and dynamic contrast-enhanced magnetic resonance imaging (DCE-MRI). The apparent diffusion coefficient (ADC) was also measured. A study of consistency (k) was assessed comparing receiver operating characteristic (ROC) curve and area under the curve (AUC), which were obtained in each case (Z). Finally, a regression model was performed to predict ECE. RESULTS: the mean age was 63.7 ± 6.9 years and the mean value of PSA 12.6 ± 13.8. In 31.7% of cases, digital rectal examination was suspicious for malignancy. Prostatectomy specimen showed pT2a in 12 cases (14%), pT2b in 3 (3%), pT2c in 37 (43%), pT3a in 19(22%) and pT3b 14 cases (17%). ECE was evidenced in 33 (39%) of the specimens, seminal vesicle invasion in 14 (16.5%) and pelvic node involvement in 5 patients (6%). The consistency in the evaluation of ECE (image and pathological studies) was .35 for MRI (sensitivity .33, specificity .96) and .62 for mpMRI (sensitivity .58, specificity .98). Mean value of ADC was .76 ± .2 in patients with ECE. This value was not associated with Gleason score (P = .2) or with PSA value (P = .6). AUC value as predictor of ECE was of 65% for MRI, 78% for mpMRI and 50% ADC (Z = .008). Univariate analysis demonstrated that ECE probability increases with each Gleason score point, whilst this probability increases 1.06 times with each PSA point, and decreases .3 times with each point of ADC. Multivariate analysis confirmed that ADC value is a slight protective factor against ECE (OR = .01; CI 95% .002-.14). The consistency in the evaluation of seminal vesicles was .43 for MRI and .67 for mpMRI. AUC was 69% and 82% respectively (Z = .02). The consistency in the evaluation of positive lymph nodes was .4 for MRI and .7 for mpMRI. AUC was 68% and 88% respectively (Z = .36). CONCLUSIONS: multiparametric study allows to carry out a more proper preoperative evaluation of ECE than convectional MRI. The most reliable predictors of ECE are DW-MRI combined with DCE-MRI, ADC coefficient and Gleason score. The superiority of mpMRI is also demonstrated for detection of seminal vesicles invasion, but not for the evaluation of lymph nodes invasion.

[Mesenteric flow in an experimental model of ischaemia-reperfusion in rats]. / Flujo mesentérico en un modelo experimental por isquemia-reperfusión en ratas.

INTRODUCTION: Maintained acute occlusion followed by reperfusion of the superior mesenteric artery (SMA) in a few hours can trigger irreversible bowel damage. The aim of the study was to determine the changes in mesenteric flow measured by colour Doppler Ultrasound and correlating with histological lesions in an experimental model of ischaemia-reperfusion. METHOD AND MATERIAL: Three groups of Sprague-Dawley 17 day-old rats were studied (control, ischemia and reperfusion). The model used was ischaemia-reperfusion over the SMA. Intra-abdominal ultrasound was then performed. The parameters recorded were: Maximum systolic velocity (MSV), pulsatility index (PI), resistance (RI) and systole-diastole (S/D). The histological variables were: intestinal lesion (Wallace/Keenan-Chiu scale), morphometrics (mean villus height [MVH]), and goblet cells. The Spearman (rs) correlation was used. RESULTS: The MSV in the reperfusion group was 74.3 cm/s, the PI 7.33 and S/D 25.75 in the SMA, which were higher than the controls (41.35 cm/s; 3.12 and 12.45, respectively). A direct association (P<.01) was found between MSV, PI and S/D regarding: Wallace/Kennan scoring system (rs = 0.655; rs = 0.593; rs = 0.63) and the Chiu (rs = 0.569; rs = 0.522; rs = 0.47). While the correlation was the reverse (P<.01) when associated with the MVH (rs = -0,495; rs = -0,452; rs = -0,459) and goblet cells of the colon (rs = -0,525; rs = -0,45; rs = -0,518). CONCLUSIONS: The reperfusion phase increased mesenteric flow expressed by the MSV and PI and could significantly predict the potential bowel damage at macroscopic and microscopic level.

Cognitive and neuropsychiatric disorders among multiple sclerosis patients from Latin America: Results of the RELACCEM study.

BACKGROUND: Cognitive impairment and psychiatric symptoms impact many aspects of the lives of people with multiple sclerosis [MS]. This literature is based largely on North American and Western European samples, and little is known about these aspects of MS disability in Latin America. OBJECTIVE: RELACCEM is a longitudinal, multicenter study including MS centers in Argentina, Chile, Columbia, Venezuela, Uruguay and Mexico. The goal is to determine the prevalence of cognitive impairment (two or more cognitive domains under the 5th percentile of healthy controls performance) and the full range of neuropsychiatric symptoms in these regions, and how these symptoms relate to caregiver burden and employment. METHODS: Participants were 110 patients with relapsing-remitting [RR] course and less than five years of disease duration. Thirty-four healthy controls were also recruited. All participants were evaluated in one of 14 specialized centers. RESULTS: In additional to overall neurological disability, both cognition and neuropsychiatric symptoms distinguished patients and controls. The prevalence of cognitive impairment was 34.5% and 20.9% presented with clinically significant neuropsychiatric symptomatology. Cognitive impairment was a significant predictor of employment status. CONCLUSIONS: This is the first multicenter epidemiological study of MS-associated cognitive and neuropsychiatric symptoms in Latin America. Results indicate that cognitive dysfunction and psychiatric decline symptoms, fatigue, depression and caregiver burden are already apparent at an early stage of the disease. The presence of neuropsychiatric abnormalities indicates the need for appropriate interventions as early as possible to mitigate psychosocial consequences of caregiver burden.

Evaluation of risk of muscle invasion, perivesical and/or lymph node affectation by diffusion-weighted magnetic nuclear resonance in the patient who is a candidate for radical cystectomy.

INTRODUCTION: Preoperative staging of bladder cancer using imaging methods has serious limitations. The accuracy of the abdominal diffusion-weighted magnetic resonance (DW-MRI) to predict residual muscle invasion, perivesical and/or lymph node affectation in the cystectomy specimen is evaluated. MATERIAL AND METHODS: A prospective study was performed on 20 patients with high grade muscle invasive bladder cancer who received transurethral resection of the bladder (TURB) in a period of <1 month. The DW-MRI was performed before the radical cystectomy and the radiologist predicted muscle invasion, extravesical affectation and lymph node affectation, being blind to the histopathological study. Sensitivity (S), specificity (sp), positive predictive value (PPV), negative predictive value (NPV) and accuracy (Ac) of the test were analyzed. The medians of the apparent diffusion coefficient (ADC) value (Mann-Whitney) were compared and the ROC curves study for DW-MRI and ADC was carried out. RESULTS: Distribution by categories was: pT0 1(5%), pT1 6(30%), pT2 2(10%), pT3 8(40%) and pT4 3(15%). There was agreement in the T-pT assignment in 17(85%). In 7(35%) there was lymph node affectation (pN1-2). Consistency of the DW-MRI for muscle affectation was k=.89 (CI .67-1; S=1.0, Sp=,86, PPV=.93, NPV=1.0, Ac=.95), for perivesical fat affectation k=.6 (CI .25-.95; S=.8, Sp=.8, PPV=.8, NPV=.8, Ac=.8) and for lymph node affectation k=.89 (CI .67-1; S=.86, Sp=1.0, PPV=1.0, NPV=.93, Ac=.95). Mean value of ADC was greater in G2 tumors (OMS1987) compared to G3 (p=.08). Evaluation of DW-MRI imaging and ADC numerical value showed equivalent areas under the curve for muscle (.93 and .9; Z=.7), fat (.8 and .91; Z=.31) and lymph node (.93 and .97; Z=.36) affectation, respectively. CONCLUSIONS: DW-MRI allows for good pre-operative evaluation of the patient who is a candidate for cystectomy, especially for the prediction of muscle (

[Ureterectomy in the treatment of urothelial carcinoma of the distal ureter]. / La ureterectomía distal laparoscópica en el tratamiento del carcinoma urotelial del uréter distal.

INTRODUCTION: Segmental ureterectomy with preservation of the kidney is a treatment option for the low grade urothelial carcinoma (LG-UC) in distal ureter that is not a candidate for endoscopic resection. Laparoscopic distal ureterectomy (LDU) with ureteral reimplantation is common in benign conditions (stenosis, iatrogenic lesion, endometriosis). However, it has been hardly described in malignant ureteral condition. The literature is reviewed in this regards and the surgical technique described. MATERIAL AND METHODS: The experience regarding two cases of LDU due to low grade urothelial carcinoma in distal ureter is presented. In both, previous bladder transurethral resection (RTU) was performed. The urinary cytology was negative and the imaging studies identified urinary obstruction and distal ureter filling defect. One of the patients had a background of T1G3 bladder cancer and suffered renal failure. In both, the ureter was ligated early. Segmental ureterectomy was performed using a combined endoscopic and laparoscopic procedure with ureteral desinsertion in one case. In the other, it was exclusively laparoscopic. Both were done with 4 trocars. Ureteral reimplantation was conducted with continuous hermetic suture and without tension. In one case with background of high grade bladder tumor, pelvic lymphadenectomy was also performed. RESULTS: Operating time was 180 and 240 min, respectively, with estimated bleeding of 100 and 250 ml. Hospitalization time was 6 and 4 days. The only post-operatory complication was paralytic ileum (Clavien I) in the first case. With a 20 and 12 month follow-up, there is no evidence of recurrence or dilatation. In the patient with renal failure, creatinine clearance improved. CONCLUSIONS: The LDU with ureteral reimplantation is a complex technique. However, it represents a feasible and effective alternative for the treatment of LG-UC in distal ureter, as long as the oncological and reconstructive principles are respected.

[Current state of single-port transumbilical surgery in urology: challenges and applications]. / Estado actual de la cirugía transumbilical por puerto único en urología: retos y aplicaciones.

CONTEXT: Laparoscopic surgery in urology is considered to be an important advance, although it is not exempt from some morbidity associated to the use of multiple trocars and specifically to the extraction of the specimen. In order to decrease this morbidity and improve esthetics, other techniques are being developed, such as natural orifice transluminal endoscopic surgery (NOTES) and laparoendoscopic single-site surgery (LESS). It is aimed to review the current status of laparoendoscopic single site surgery in urology. ACQUISITION OF EVIDENCE: A nonsystematic review has been carried out by means of the bibliographic search using the terms LESS and Urology from 2007 to 2012. The current LESS experience in urology is described, and its principal indications and the different single site devices and instruments available on the market are described. SYNTHESIS OF EVIDENCE: LESS surgery arose as one more step in the constant evolution of minimally invasive surgery in an attempt to improve esthetics, reduce surgical trauma and decrease pain and the post-operative complications associated to the conventional laparoscopy with multiple trocars. Since it was first described in 2007, the experience has been increasing exponentially and the LESS technique, whether assisted or not by robot, is becoming consolidated for a large spectrum of urological indications (both in oncological and reconstructive surgery) on a much greater scale than the NOTES technique. Even though most of the existing data are not randomized and very rarely comparative, with the selection bias that this represents, it seems clear that the esthetic benefit and analgesic control associated to the LESS surgery is real and reproducible. The complications associated to it are greater in cases of major oncology surgery and are due more to the technique itself then to the approach. CONCLUSIONS: Although the real benefit of the LESS surgery in urology cannot be appropriately quantified, the cosmetic improvement, less pain and greater patient satisfaction with their wound are clear. Appropriate training in this type of procedures in centers having large volumes and the continuous technical improvements in the instrumental development by the biomedical industry has resulted in the fact that the transumbilical LESS technique in urology has been born to stay.

[Laparoendoscopic radical cystectomy with orthotopic ileal neobladder through umbilical single port]. / Cistectomía radical laparoendoscópica con neovejiga íleal ortotópica a través de puerto único umbilical.

CONTEXT: Radical cystectomy with orthotopic derivation is one of the most complex urological techniques, although laparoscopic surgery has made this procedure increasingly less invasive. OBJECTIVE: To provide an up-dated review of the single port approach to carry out radical surgery due to bladder cancer. EVIDENCE ACQUISITION: A comprehensive review of the literature was performed using Medline and Embase to discover the accumulated experience of the viability of carrying out laparoendoscopic radical cystectomy, pelvic lymphadenectomy and orthotopic neobladder using the laparoendoscopic single site surgery (LESS) approach. Our experience with this approach is also presented and the technique used with the reusable KeyPort(®) system developed by Richard Wolf is described. EVIDENCE SYNTHESIS: Radical treatment of bladder cancer is possible in men and women using a single port and even performance of ileal neobladder, as reconstructive procedure in these patients. The surgical technique, post-operative cares and result obtained in our center are described. The accumulated experience worldwide describes 25 cases of radical cystectomy performed using different single port systems, 14 of them with orthotopic intestinal neobladder. CONCLUSION: The KeyPort(®) umbilical cystectomy constitutes in our setting the least possible invasive alternative to efficiently treat muscle-invasive bladder cancer, with excellent esthetic result, minimum post-operative pain and short hospital stay. The umbilical scar decreases the analgesic requirements and it ends up being practically invisible. This supposes an important step in the development of the minimally invasive surgery for bladder cancer.

[Onset of a training program for single-port laparoscopic urology]. / Puesta en marcha de un programa de entrenamiento para laparoscopia urológica por puerto único.

OBJECTIVES: To describe the onset of a single port laparoendoscopic program to carry out oncology surgery in a Urology Service. We present the initial experience in the laboratory and in the Animal Facility with rigid precurved instruments and KeyPort reusable access element (Richard Wolf). MATERIAL AND METHODS: Two surgeons experienced in laparoscopic surgery and with the help of four assistants performed a training program based on predetermined tasks performed in simulation boxes (pelvitrainer) and porcine model following the requirements of the Regional Community of Madrid to handle experimental animals. RESULTS: The participants in this program were initially divided into pairs made up of an experienced surgery and assistant for the predetermined multiple tasks in simulator box in order to become familiarized with the instruments. After, 20 animal sessions were conducted in which the following were performed: (retroperitoneal or pelvic) lymph node dissections (n = 20), nephrectomies (n = 40), cystorrhaphy with suture (n = 20) and uterine-vesical anastomosis (n = 20). Times needed to perform the exercises and the principal errors perceived during the performance of each one of the tasks were recorded. The tasks, of growing complexity, were performed with the instruments described in increasingly less time and with less difficulty. An accessory trocar of 3.5 mm was required to perform the in vivo sutures. CONCLUSIONS: The KeyPort approach has potential application in different urological applications. Standardized training allows the acquirement of skills and makes the successful implementation possible of a laparoendoscopic surgery program in humans.

[Treatment of lymphangioma with OK-432 infiltration]. / Manejo del linfangioma con infiltración de OK-432.

UNLABELLED: The management of lymphangioma using sclerotherapy has proven to be an effective therapeutic. Our aim was to evaluate the therapeutic efficacy of OK-432 (Picibanil) in patients with lymphagioma. METHODS: The study was performed from November 2010 to July 2011. Fifteen patients of both genders were diagnosed with lymphangioma, 12 days to 12 years old. All patients were infiltrated with OK-432. The studied variables were: previous surgery, localization, type of lymphangioma, number of effective injections, reduction of mass valued as excellent (100% reduction), good (reduction > 50%) and bad (reduction < 50%), presence of recurrence and complications. RESULTS: 40% of pacients had prior surgery and 53.3% were located in the cervical-face region. The type of macrocystic lymphangioma was present in 40% of the series, mixed type in 46.6% and microcystic type in 13.4%. The number of effective infiltrations were 3. In 6 cases (40%) the result was excellent in 5 cases (33.4%) the result was good and in 4 cases (26.6%). We had 1 recurrence (6.6%) and we haven't had complications. CONCLUSION: Injection of OK-432 in macrocystic lymphangioma and mixed had a safe therapeutic modality with satisfactory results. So it is a valid alternative to conventional surgery.

[Aphallia associated to urethrorectal fistula: a case report]. / Afalia asociada a fístula recto-uretral: reporte de un caso.

Aphallia had an incidence of 1/30.000.000 newborn. This is a rare genitourinary anomaly derived from a faulty development of the genital tubercles. It usually coexists with series of other anomalies which are incompatible with normal life. This article presents a description of a 2 years old patient.