[Nephron sparing renal surgery as salvage treatment after failure of radiofrequency thermal ablation in a patient with a single kidney and renal adenocarcinoma]. / Cirugía renal conservadora de nefronas como tratamiento de rescate tras fracaso de la termoablación mediante radiofrecuencia en paciente monorreno con adenocarcinoma renal.

OBJECTIVES: To describe the technique of renal radiofrequency (RF) thermal ablation. Case report of a successful nephron-sparing surgery after failure of the RF thermal ablation of a renal adenocarcinoma in a patient with a single kidney. METHODS: A patient presenting with a renal adenocarcinoma in a single left kidney was treated by RF thermal ablation. The failure of the technique was patent on follow-up after demonstration of a central area of necrosis surrounded by a peripheral contrast enhancing area. Nephron sparing surgery was indicated as salvage procedure. RESULTS: Surgical excision of the tumor with a safety margin, without renal pedicle clamping was undertaken. Fat tissue and hemostatic synthetic material were placed in the surgical bed. Pathology report: renal adenocarcinoma with changes secondary to central necrosis. Twenty-four month postoperative follow-up: fatty renal nodule with small fibrous tracts inside in the area of the tumor. No evidence of contrast enhancing areas. Normal renal function (sCr 0.7 mg/dl, urea 24 mg/dl). CONCLUSIONS: Radiofrequency thermal ablation is a relatively new technique. Its oncological efficacy greatly depends on appropriate case selection. One of its main caveats is achieving an area of tissue ablation enough to completely destroy the tumor. When the technique fails, renal surgery (nephron sparing or not) seems to be the most recommended alternative.

[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.

[Prevalence of incidental prostatic adenocarcinoma after suprapubic adenomectomy with or without previous prostatic biopsy]. / Prevalencia de adenocarcinoma prostático incidental tras adenomectomía suprapúbica con o sin biopsia prostática previa.

OBJECTIVES: To establish the prevalence of incidental prostate cancer after transrectal ultrasound guided prostatic biopsy and subsequent suprapubic prostatic adenomectomy and to compare it with a similar group of patients who did not underwent biopsy before surgery. To evaluate treatment, outcomes, and disease progression in patients with incidental prostate cancer. METHODS: Retrospective study of 549 suprapubic adenomectomy performed between 1996-2001 (6 yr.), comparing the group of patients with biopsies before surgery vs. the group of patients without biopsies. RESULTS: 291 (53%) patients did not undergo biopsy before adenomectomy. 258 (47%) underwent biopsies. 25 incidental prostate cancers were detected, 19 (76%) in the group of no biopsy and 6 (24%) in the biopsy group. 88% pT1a and 12%pT1b. Mean Gleason score 4.5 (3-7). 84% of the patients did not receive treatment (21) ("wait and see"); 8% (2) androgen blockade; 8% (2) finasteride (2). Three patients (12%) in the group of no biopsy had disease progression. Mean follow-up was 48.1 months (22-96). No case of cancer-specific mortality was detected. CONCLUSIONS: Global prevalence of incidental prostate cancer in our series of patients undergoing suprapubic prostatic adenomectomy was 4.55%. Prevalence was higher in the group of patients without previous biopsy (3.46%) than in the biopsy group (1.09%). Tumor progression was 12% and cancer specific survival 100% after a mean follow-up of 48.1 months (22-92). Previous prostatic biopsy in patients with suspicions digital rectal examination or elevated PSA diminishes the prevalence of incidental prostate cancer. Watchful waiting may be a valid option in some cases.

[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.

[Staging of infiltrating bladder cancer. Role of C.T. scan]. / Estadiaje del cáncer de vejiga infiltrante. Papel de la T.A.C.

OBJECTIVES: To analyse the role of CT-scan on preoperative determination of bladder and lymph node involvement of infiltrative bladder cancer, and its possible impact on the surgical management of these patients. METHODS: Retrospective study including 115 patients with the diagnosis of infiltrative bladder cancer between 1984 and 1999. The ability of CT-scan for bladder and lymph node staging was evaluated comparing results with the findings after radical surgery. Potential impact of this imaging technique on change of surgical attitudes was evaluated. RESULTS: Perivesical involvement estimation by CT-scan was right in 36.5%, underestimated in 49.6% and overestimated in 14%. The more advanced the perivesical involvement the lower the sensitivity for CT-scan in perivesical staging. The more locally advanced tumour the higher specificity, oscillating between 44% for pT2 and 94% for pT4. In reference to lymph node staging, it was correct in 71.3% of the cases, although this percentage depended almost exclusively on patients with negative nodes (N-). However, there was a 24.3% understaging rate which corresponded to the majority of N+ patients. These data offer a 28% sensitivity, 93% specificity, 68% positive predictive value, and 72% negative predictive value. Finally, the reliability of bladder staging in patients with lymph node involvement (N+) (39 patients) was established; it was correctly estimated in as low as 30% of the cases with a 70% understaging rate. CT-scan would have modified surgical attitudes in only 6 patients (5%), all of them with advanced tumours. CONCLUSIONS: The impact of CT-scan on infiltrative bladder cancer clinical staging is relatively low. The highest benefit is obtained in patients suspect of having advanced disease. Limitation to this group would result in significative cost reductions with low risk for unappropriate surgical management.

[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.

[Bladder choriocarcinoma: retrospective analysis of the de-differentiation of a transitional-cell papillary bladder carcinoma. Apropos of a case]. / Coriocarcinoma vesical; análisis retrospectivo de la desdiferenciación de un carcinoma vesical papilar de células transicionales a propósito de un caso.

OBJECTIVE: To report a case of choriocarcinoma of the bladder during the different periods of its evolution. The anatomopathological study showing dedifferentiation of a transitional cell tumor is presented and the histogenesis of this rare tumor is discussed. METHODS: A case of a rapidly progressing transitional cell tumor of the bladder that dedifferentiated into choriocarcinoma is presented. The pathological findings of the first resections of the transitional cell tumor that progressed to choriocarcinoma are presented and the histogenesis is discussed. RESULTS/CONCLUSIONS: Choriocarcinoma of the bladder is very rare, highly malignant and carries a poor prognosis. Its origin is widely accepted to be in the dedifferentiation of a transitional cell tumor. The use of immunohistochemistry and the positivity of HCG support the diagnosis.

[Ureteroplasty using the appendix: apropos of a case]. / Ureteroplastia con apéndice: a propósito de un caso.

OBJECTIVE: To report a case of ureteroplasty using the vermiform appendix. METHODS: Herein we describe a patient who underwent partial resection of the ureter due to a neoplasm. The ureteral defect was repaired using the vermiform appendix. The surgical technique and the results achieved are presented and the literature is briefly reviewed. RESULTS/CONCLUSIONS: The few cases reported in the literature and the case described herein show the utility of the vermiform appendix for ureteral substitution in specific cases where this procedure is indicated.