[Kidney transplant future developments.] / Futuro del trasplante renal.

OBJECTIVE: Kidney transplantation process involves a series of challenges such as the shortage of organs worldwide for a population waiting for a first and subsequent kidney transplants and the search forthe most appropriate graft for each recipient, optimizing the ischemia time as much as possible, minimizing the impact of surgery and subsequent immunosuppressive therapy. METHODS: We carry out a review of the different advances and lines of research in the different areas involved in the kidney transplantation process from strategies focused on increasing the donor pool, enabling the expansion of living donor programs as well as orga preservation strategies previous to transplantation surgery.The arrival of robotic surgery in the field of kidney transplantation has been an important milestone in the last decade, showing improvements compared to traditional open surgery, maintaining satisfactory functional results, although its implementation is currently reduced with technical limitations in the extension to any type of recipient. New immunosuppressive agents that minimize potential side effects or reduce anticalcineurinic drugsdoses are also important lines of research. CONCLUSIONS: The future of kidney transplantation involves the search for increasingly global strategies to improve the supply of organs, improvements in the conditioning and preservation of grafts or the global development of minimally invasive surgery in the different areas of kidney transplantation. The weight of biotechnology and gene therapies represent promising tools in the field of tissue generation or targeted immunosuppressive therapies.

OBJETIVO: El proceso del trasplante renal conlleva una serie de retos como son la escasez de órganos para una población a la espera de un primery sucesivos trasplantes renales y la búsqueda del injertomás apropiado para cada receptor optimizando al máximo el tiempo de isquemia, minimizando el impactode la cirugía y posterior terapia inmunosupresora.MÉTODOS: Realizamos una revisión de los diferentes avances y líneas de investigación en las diferentes etapas que conlleva el proceso del trasplante renal desdelas estrategias centradas a incrementar el pool de donantes,posibilitar la expansión de programas de donante vivo así como las estrategias de preservación del órgano previamente a la cirugía del implante.El desembarco de la cirugía robótica en el campo del trasplante renal ha sido un hito importante en la últimadécada, arrojando mejoras frente a la tradicional cirugía abierta manteniendo unos resultados funcionalessatisfactorios aunque su implantación es reducida en la actualidad con limitaciones técnicas en la extensión a cualquier tipo de receptor. Nuevos agentes inmunosupresores que minimicen los potenciales efectos secundarios o consigan reducir las dosis de anticalcineurínicos son también líneas importantes de investigación. CONCLUSIONES: El futuro del trasplante renal pasa por la búsqueda de estrategias cada vez más globales para mejorar la oferta de órganos, mejoras en el acondicionamiento y preservación de los injertos o el desarrollo a escala global de la cirugía mínimamente invasiva en los diferentes ámbitos del trasplante renal. El peso de las biotecnologías y terapias génicas suponen herramientas prometedoras en el campo de la generación de tejidos o terapias inmunosupresoras dirigidas.

Laparoscopic radical prostatectomy with no anastomosis.

From the first radical prostatectomy (RP), this kind of surgeries have always led to the need of a vesicourethral anastomosis (VUA). We present a case of a 65 year-old patient with diagnosis of prostate cancer and candidate for laparoscopic RP. The approach was a conventional extraperitoneal access with complete urethral sparing that avoids the need of VUA. Bladder catheter was removed on the third postoperative day observing immediate urinary continence. The anatomopathological analysis revealed a pT2 adenocarcinoma with negative margins. We report for the first time, a minimally invasive technique that avoids the need of VUA with favorable functional results.

[Predictive factors of metachronous bladder neoplasm after nephroureterectomy]. / Factores predictivos de neoplasia vesical metacrónica tras nefroureterectomía.

PURPOSE: To determine prognostic factors of bladder recurrence in patients with upper urinary tract (UUT) urothelial carcinoma, who underwent nephroureterectomy. MATERIAL AND METHODS: Patients (N = 51) with UUT transitional cell carcinoma who underwent nephroureterectomy. A retrospective and prospective observational cohort study was made during the period 1995-2007, at Arquitecto Marcide Hospital, Ferrol Health Area, La Coruña. Differences between groups with and without recurrence were analized by means of chi-squared test in qualitative variables and t-Student and U Mann-Whitney test in quantitative variables. Kaplan-Meier methodology was used in order to predict bladder recurrence free survival (BRFS), developing a multivariate Cox regression model to identify variables related to bladder recurrence. RESULTS: Mean age of patients was 68.51 +/- 12.11 (24-86). Histological grade distribution was as follows: 7 G1 (13.72%), 20 G2 (39.21%), 23 G3 (45.10%) and 1 undetermined case (1.97%). With regard to pT category, 19 cases were pT1 (37.25%), 12 pT2 (23.53%), 19 pT3 (37.25%) y 1 case undetermined (1.97%). Bladder recurrence was detected in 16 patients during follow-up (31.37%). 70.59% of recurrences were identified during first two years of follow-up. Differences related to follow-up period, presence of obstructive uropathy, microscopic growth pattern and tumour multifocality, were observed between patients without and with bladder recurrence. BRFS rates at 1, 2, 5 and 10 years were 85.10%, 67.90%, 56.60% y 31.80%, respectively. BRFS was significantly modified by tumour location (p = 0.019) and tumour multifocality (p = 0.002). Multivariate analysis showed that tumour multifocality was an independent factor in the prediction of bladder recurrence (RR = 7.35; 95% CI = 1.57-34.45; p = 0.011). CONCLUSIONS: The development of bladder recurrence after nephroureterectomy was observed in 31.37% of patients in our study, detecting most of events during the first two years of follow-up. Tumour multifocality in UUT constitutes the most important risk factor for the development of bladder recurrence.

[Chylous ascites following radical nephrectomy and retroperitoneal lymphadenectomy]. / Ascitis quilosa tras nefrectomía radical y linfadenectomía retroperitoneal.

Chylous ascites consists of the accumulation of chyle in the abdominal cavity. Postoperative presentation develops as a consequence of unrecognized injury of cisterna chyli or one of its major lumbar tributaries. It usually present as abdominal distention and pain or drainage of milky fluid from surgical wound or abdominal drain. Diagnosis is established by cytochemical analysis of fluid and staining with Sudan III, that shows fat globules, leukocytes with lymphocytic predominance and a high triglyceride content. We present a case of postoperative chylous ascites following radical nephrectomy and retroperitoneal lymphadenectomy for renal cancer, which successfully respond to conservative measures: total parenteral nutrition and octreotide.

[Renal infarction in the evaluation of lumbar pain]. / El infarto renal en la valoración de dolores lumbares.

OBJECTIVE: We report the case of a young patient without known cardiovascular risk factors, complaining of lumbar colic pain due to renal infarction. METHODS: Differential diagnosis of lumbar colic pain must include some rare events. We performed a review of the current knowledge on the topic. RESULTS/CONCLUSION: The increasing difficulty in the diagnosis of these pathology lies on its clinical suspect, which can be clear when having cardiovascular risk factors. Its diagnosis, on a rare scenario, needs leucocytosis and LDH rising as suspicious indicators. Computed tomography, MRI, radionuclids and arteriography may confirm diagnosis. Treatment is based on thrombolytic therapy, anticoagulants and ontiagregants.

[Metastasis of colon adenocarcinoma to the epididymis and spermatic cord]. / Metástasis de adenocarcinoma de colon en epidídimo y cordón espermático.

OBJECTIVE: To report the case of an epididymal and spermatic cord metastasis of a colon adenocarcinoma. METHODS/RESULTS: We present the case of a 67 years old man, who presents several months after subtotal left colectomy for a left colon adenocarcinoma (pT3 NoMo), with a symptomatic right palpable testicular tumour. Right orchiectomy was done, demonstrating colon adenocarcinoma metastasis. CONCLUSIONS: Epididymal and spermatic cord metastases are very infrequent and they usually are found incidentally after prostate cancer orchyectomy.

[Metastasis of a renal cell carcinoma in the corpora cavernosum of the penis. Case report and bibliographic review]. / Metastasis de carcinoma renal en cuerpo cavernoso, a propósito de un caso y revisión de la literatura.

OBJECTIVE: We describe a rare case, the metastasis of a renal clear cell carcinoma in the corpora cavernosum of the penis. METHODS: 53-year-old patient presenting with a painful, hard tumor in the penis three months after right radical nephrectomy with cavotomy and thrombus excision. RESULTS/CONCLUSIONS: Imaging tests and biopsy led to the diagnosis of metastasis of a renal carcinoma in the corpus cavernosum, which was confirmed on the pathologic study of the specimen after penectomy. The appearance of renal carcinoma metastases in the penis is generally associated with advanced tumor stage, therefore associated with bad prognosis as in the reported case.

[Clinical-pathological study of incidental renal cell carcinoma]. / Estudio clinico-patologico de los adenocarcinomas renales incidentales.

OBJECTIVES: To determine the percentage of renal cell carcinomas incidentally diagnosed (IRCC) and to compare their clinical and pathological characteristics with symptomatic or non-incidentally diagnosed tumors (SRCC). METHODS: We retrospectively study 189 patients who were diagnosed of renal carcinoma between 1990 and 1999. 166 underwent surgery (149 radical nephrectomy; 17 nephron-sparing surgery). We determine the percentage of IRCC detected by radiological tests and compare them with the SRCC diagnosed after presenting with some of the classic symptoms or metastasis, with special focus on tumor size, pathology stage, tumor recurrence, progression and evolution. RESULTS: 87 SRCC (46%); 102 SRCC (54%). There are not differences in terms of age, gender, side, and postoperative hospital stay. Tumor size was higher in the SRCC (mean 8.5 cm) than in the IRCC (6.3 cm). SRCC tumor stage was: pT1 27.3%, pT2 27.3%, pT3a 23.8%, pT3b 16.6%, pT3c 2.3%, and pT4 2.3%; IRCC stage was: pT1 51.3%, pT2 25.6%, pT3a 10.9%, pT3b 10.9%, pT3c 1.2%, and no pT4. The percentage of patients with lymph node involvement was higher (p = 0.02) in the SRCC (15%) than in the IRCC (4.8%). The percentage of patients with metastasis at the time of diagnosis was higher in the SRCC group (26%) than in the IRCC (9.2%). Recurrences were more frequent in the SRCC Group (8.3%) than in the IRCC (1.2%) (p = 0.07). Tumor progression was more frequent in the SRCC group (34%) than in the IRCC (7.3%) (p<0.01). 76% of the patients undergoing nephron sparing surgery were IRCC. CONCLUSIONS: Currently, there is a high percentage of IRCC (46% in our series from 1990-99). Renal tumors presenting as IRCC have better prognosis, since they have significantly smaller size, lower stage, less advanced disease, less recurrences, and less progression than SRCC.

[Cutaneous metastasis of a renal carcinoma: case report and review]. / Metastasis cutánea del cáncer renal: caso clínico y revisión.

OBJECTIVES: To report another rare case of skin metastasis from a renal adenocarcinoma, analyzing the prognostic significance, response to therapy, and clinical presentation after a bibliographic review. METHODS/RESULTS: We report the case of a 65-year-old male with a cutaneous metastasis in the root of his inferior left extremity one year after right nephrectomy for a clear cell adenocarcinoma. CONCLUSIONS: Skin metastases usually present as solitary cutaneous lesions of variable macroscopic features and rapid growing; the diagnosis is made by histological analysis, being excision the treatment of choice whenever possible. Prognosis is better for solitary lesions appearing asynchronously with the primary tumor, and among them the longer the time after diagnosis of initial lesion they appear the better the prognosis.

[Urologic damage of the primary antiphospholipid syndrome]. / Manifestaciones urológicas del síndrome antifosfolípido primario. Vejiga neurógena.

OBJECTIVES: To perform a review and update of the antiphospholipid syndrome summarizing its urological presentations. METHODS: A complete bibliographic search was performed through PubMed MEDLINE and articles were reviewed with special attention to those bibliographic references about urological presentations. We document the unique and unpublished case of a patient with neurogenic bladder secondary to antiphospholipid syndrome. RESULTS/CONCLUSIONS: The antiphospholipid syndrome is an acquired autoimmune systemic disease generating a permanent hypercoagulability status with recurrent multiorgan thrombotic events due to circulating antiphospholipid antibodies. It may be secondary to a heterogeneous group of diseases (mainly lupus) and drugs, or primary if it appears isolated without any demonstrable systemic disease or concomitant medication. It is mainly characterized by venous or arterial recurrent thrombosis, recurrent abortion, thrombocytopenia, and circulating antiphospholipid auto-antibodies. Treatment with anticoagulants and correction of the hypercoagulable status contributing factors, arterial or venous thrombosis, and vascular risk aim to avoid new thrombosis episodes. Genitourynary system may be affected in any of its parts, generally by arterial or venous thrombosis. Kidney is the most frequently affected organ, in addition to transplanted kidney grafts, adrenal glands, bladder and testicles. There is a relationship between antiphospholipid syndrome and infertility. For the first time, we describe bladder involvement presenting as hyperreflexic neurogenic bladder with detrusor-sphincter dyssynergia after spontaneous spinal cord thrombosis in an asymptomatic adolescent with primary antiphospholipid syndrome which was unknown before.

[Age of onset of urolithiasis: relation to clinical and metabolic risk factors]. / Edad de comienzo de la enfermedad litiásica: relación con factores clínicos y de riesgo metabólico.

OBJECTIVES: To determine the age of onset of urolithiasis in patients with urinary calcium stones and to establish the relationship between age of onset and clinical profile and metabolic risk factors. METHODS: A total of 500 patients with the diagnosis of calcium urinary lithiasis (average age 47.4 years, range 20-75) were asked regarding the age of onset of the disease. Age of onset of urinary stone disease was compared with other factors such as gender, family history of lithiasis, clinical course, unique or recurrent episodes, and metabolic disturbances found in a comprehensive metabolic evaluation, using the chi-square test for categorical variables and analysis of variance (one way-ANOVA) with the Scheffe test for continuous variables. RESULTS: Mean age of onset of urinary stone disease was 38 years (range 4-73 years). This age of onset was lower in patients with low diuresis (31 years), family history of urolithiasis (32 years), hypercalciuria (36 years), recurrent disease (37 years), and hyperuricosuria (37 years). Significant differences were found in patients who had family history of urolithiasis (32 years) vs. those who did not have (40 years) (p < 0.01); patients with recurrent disease (37 years) vs. patients with a unique lithiasic episode (43 years) (p < 0.001); patients with hypercalciuria (36 years) vs. those who did not have (39 years) (p < 0.05); and also patients with low diuresis (31 years) vs. those with higher diuresis (39 years) (p < 0.001). CONCLUSIONS: The average age of onset of urolithiasis is significantly earlier in patients with low fluid intake habits, family history of urolithiasis, hypercalciuria and recurrent stone disease.

[Measuring the degree of patient satisfaction treated at an extracorporeal lithotripsy unit]. / Medición del grado de satisfacción del paciente tratado en una Unidad de Litotricia Extracorpórea.

OBJECTIVES: To determine by questionnaires the level of satisfaction of patients diagnosed of urinary lithiasis treated by extracorporeal shock wave lithotripsy (ESWL) in our Renal Stone Centre. METHODS: A total of 100 patients with urinary lithiasis who underwent ESWL, 54 males and 46 females with an average age of 50 years, answered a Lickert type questionnaire (score 1 to 5) consisting of 6 questions to evaluate the patient satisfaction regarding the treatment received. The relationship between answers to each question and patient's clinical characteristics were analyzed applying chi-square and linear regression to determine the level of significance of these relationships. RESULTS: General satisfaction level was high, with a mean score of 4.33 for the six questions. The most valued question was the one referred to assistance received in relation to the planned medical one. Questions referred to treatment suitability, expected timing, and absence of complexity were also highly valued. The least valued question was the one referred to pain level during treatment, which level was kept in a good approval degree with a mean score of 3.81 despite the fact that some patients said they suffered more pain than expected. CONCLUSIONS: ESWL resulted in a high level of satisfaction among patients treated for urinary lithiasis, revealed not only by its suitability, easy planning and performance, but also by its low level of complexity. Pain experienced by these patients during treatment was well-tolerated, so that general use of anesthesia was not required.