[Adequacy of urology departments in a health care model of hospitals network]. / Adecuación de Servicios de Urología en un Modelo Asistencial de Red de Hospitales.

UNLABELLED: The traditional health care model is currently facing new health requirements. The implementation of integrated urologic health systems can be one of the possible solutions to these needs. It is mandatory to explore a new health care model, which includes structural and organizational changes. The adequacy of the urology departments of IDCsalud-Madrid network hospitals, creating URORed, is a new system adaptable to constant changes, in order to offer professionalism and quality health care. OBJECTIVE: To describe the administrative/clinic management in the urology service of a health care model of Hospitals network (URORed at IDCsalud. Madrid), that has been included in a model of an Integrated network in a health care service. METHODS: In the period between November 2007 to October 2014, the urology departments of IDCsalud Madrid Group, have been included in a new organizational system, including 4 hospitals, currently with 27 urologists. Each center offers specific urologic services, sharing benefits and human resources. The same directive line leads all centers. RESULTS: The model offers an integrated and uniform urologic service to a specific population of 811.390 habitants (Population Census 2012), with capability to treat specific urologic diseases and to perform a correct clinical follow-up. CONCLUSIONS: Belonging to a health care model in network involves a change of attitude. It creates an organizational change, based on the processes and the results, which enables control of the management analytically, detecting the points that need to be optimized as well as those that are satisfactory. It implies developing a culture of learning and cooperation, so that the processes are fluent and have quality, to create clinical and technological projects in favor of new resource-generating research, based on the needs of the joint management of the hospitals network. The complexity of this model requires a work focused on the human resources, their concerns and their ability to coordinate actions to get results in terms of quality health care and professionalism.

[Relation between prostate gland volume and some histological markers of malignancy]. / Relación entre volumen de la glándula prostática y algunos marcadores histológicos de malignidad.

OBJECTIVES: The relationship between the total volume of the prostate gland or its weight after radical prostatectomy and the histological markers of malignancy in cases of prostate cancer is a controversial subject. We have analyzed 100 consecutive radical prostatectomy specimens in order to determine the relationship between volume or weight of the prostate gland and the biological aggressiveness of the tumor process by different histological markers. MATERIAL AND METHODS: One hundred consecutive radical prostatectomy specimens in patients who had not received pre-operative hormone treatment were retrospectively reviewed. These surgical samples were processed according to a standardized protocol. In a subsequent evaluation, the following were studied with greater detail: Gleason grade, tumor volume, multimodality, neural or vascular invasion, put stage, and presence of PIN foci. The histological findings were compared with the prostate gland weight using Windows SPAS, 13.0 statistical package with a significance value of p<0.05. According to the prostate gland weight, three groups were established: <40 g (33%), 40 - 90 g (61%), and >90 g (6%). RESULTS: A statistically significant association (p=0.001) was found between the prostate gland weight and tumor volume since 15 of the 33 glands with weight under 40 g accounted for more than 50% of the glands affected by tumor compared to none of the 6 patients with total weight over 90 g. A significant relationship was also found between the multimodality and weight. (P=0.03), so that 24 of the 33 glands under 40 g had bilateral multimodality compared to only 1 out of the 6 glands over 90 g. The neural invasion, number of PIN foci and the highest combined Gleason grade were frequent in low volume prostates, but the difference did not reach statistical significance. CONCLUSIONS: Our study indicates that large volume prostate glands have tumors with lower malignancy (tumor volume, bilateralism). This finding justifies the adequacy of using total volume of the prostate gland for diagnostic decision (indication of prostatic biopsy and their repetition) and the prognostic determination.

[Testosterone, endothelial function, cardiovascular health and androgen deficiency in the old man]. / Testosterona, función endotelial, salud cardiovascular y androgenodeficiencia del varón añoso.

Testosterone determination in an old men population has demonstrated its about the as general health marker, not only sexual, prompting a greater in to arrest for this analytic determination and the potential relations of testosterone with other markers of cardiovascular health, obesity, hypertension, erectile dysfunction, sarcopenia, metabolic syndrome, ageing, and other conditions. We specifically review the relationship between cardiovascular health, erectile dysfunction, and androgen deficiency, processes easily recognizable, prevented and treated. Current information gives such a prominence to testosterone as a health reference that its determination seems to be inexcusable in the ageing male consult.

[Renal transplantation with living donors. A critical analysis of surgical procedures based on 40 years of experience]. / Transplante renal de donante vivo: un análisis crítico de estrategias quirúrgicas basado en 40 años de experiencia.

INTRODUCTION: Absolute priority in an LDKT programme are donnor safety and kidney optimal anatomical and functional preservation. Reduced donnor morbidities, both at short and long term, are important objectives. Excellent technical grafting is a must as are the strategies employed for facilitatig it. We revised the incidences of our whole LDKT programme (40 years 243 donors) to confirm if these exigences have been acomplished or a change to new surgical procedures is recommended. MATERIAL AND METHODS: Between 1968-2008 243 nephrectomies and grafting has been performed, a reduced number per year (A cadaver programme has been running simultaneously since 1964). For the nephrectomies a Turner-Warrick apprach was inititialy used and since 1973 a miniincisional, anterior, extraperitoneal approach of approximately 10 cm in length. The right kidney was removed in 75% of the cases and the right iliac area for the implant in 85% In adjacent opperating rooms, one team performs the nephrectomy while the other prepares and dissects free the grafting vessels. Most of the time the same senior surgeon performed both operatios: the nephrectomy and the implant. Peroperative and postoperative complications were evaluated by urologists and nephrologists in charge. RESULTS: No donors dead, organs lost or major complications in the donors have been documented. Minor complications such as intestinal paresia, wound infection, persistent incisional pain were common. Miniincisional abdominal approach reduced postoperative pain and hospital stay (4 days). At long term no incisional hernia or abdominal paresia have been documented. Simultaneous work reduces ischemia time (30-45 s warm: 30-45 min cold) and opperatig room occupation(patient preparation plus anesthesia plus operation) estimated in 90-120 min for the nephrectomy and 120-160 for the grafting. The responsibility of the senior surgeon in both procedures facilitates vessel selection for the grafting. CONCLUSIONS: No reasons have been found to reconvert our current nephrectomy procedure to laparoscopic or modify current surgical strategy. Superior safety of open surgery for donors and organs is confirmed. Pain and recovery time are reduced in laparoscopic surgery but not as much when compared with miniincisional approach. Open surgery permits optimal anatomical and functional organ extration facilitatig the quality of the implant. As numbers matter in laparoscopic surgery open nephrectomy is recommended for reduced LDKT programmes.

[Synchronous bilateral urothelial carcinoma of the upper urinary tract]. / Carcinoma urotelial ureteral bilateral sincrónico.

OBJECTIVE: Report a case of a synchronous bilateral urothelial carcinoma of the upper urinary tract without bladder affectation. METHODS: We describe the diagnosis and treatment of a case of a bilateral upper urothelial carcinoma. CONCLUSIONS: Synchronous bilateral urithelial carcinoma of the upper urinary tract without bladder affectation in an unusual occurance (1-5% of urothelial tumors) and radical surgery continues to be the treatment of choice, although it is possible to take a less aggressive approuch with selected groups of patient, in which we can achiese a survival rate similar to that which we obtain with radical surgery.

[Erectile dysfunction: the role of laboratory in the diagnostic and pronostic evaluation]. / Disfunción eréctil: papel del laboratorio en la evaluación diagnóstica y pronóstica.

OBJECTIVE: To review and to update the different laboratory tests recommended for etiologic diagnostic of erectile dysfunction and to evaluate the effect these tests could have on the pronostic and therapeutic strategy of this pathology. MATERIAL AND METHODS: We review the last articles related with etiopathogenics and pathophysiologics mechanisms of erectile dysfunction, including our studies on endothelial dysfunction and erectile dysfunction. RESULTS: The depth and extension of the laboratory protocol in erectile dysfunction is not necessaryly the same in all situations. The age, coincidence of comorbilities, set a different limit between patients demanding complementaries investigations that go beyond the basic request. CONCLUSIONS: The etiopathogenic laboratory work up in erectile dysfunction is currently changing incorporating news tests. The traditional search of commorbilities like diabetes, hepatic dysfunction, hypogonadism, hyperglucemia is getting broad with recents analitics evaluations related with potential markers of endothelial disease.

BPH and inflammation: pharmacological effects of Permixon on histological and molecular inflammatory markers. Results of a double blind pilot clinical assay.

INTRODUCTION: The role of infiltrating cells (I.C.), commonly observed in the adenoma interstitial tissue, is unknown. We tested the hypothesis that I.C. are related with BPH progression by: phenotypically characterising these cells; quantifying the expression of lymphokines and growth factors; investigating the response to Permixon (P) in a clinical study. Permixon is a lipido sterolic extract of Serenoa repens possessing pharmacological activities and widely used in the treatment of men with BPH. MATERIAL AND METHODS: A multicenter open pilot study of two parallel groups on BPH patients was carried out. They were randomized to receive either oral Permixon (P) 160 mg bid for three months or to be followed for 3 weeks without any treatment before surgery (control group C). Strict inclusion and exclusion criteria were applied to conform homogeneous groups, avoiding interferences of inflammatory drugs or others. Baseline clinical profile was almost identical in both groups in terms of age (65.7+/-5.1 vs. 67.1+/-5.8 years), IPSS (19.8+/-6.1 vs. 19.0+/-5.8), prostate volume (64.8+/-18.9 vs. 71.5+/-29.3cc), Q(max) (9.6+/-3.2 vs. 10.6+/-2.6 ml/s), and Q(L) (4.0+/-1.1 vs. 3.5+/-0.7). Surgery was ultimately performed on 29 patients (17C, 12P) by TURP or retropubic adenomectomy. Adenoma samples were routinely stained with HE and later prepared for immunohistochemical studies using CD3, CD20 and CD68 antibodies. Counting of positives cells, lymphoid aggregates and foci were done using EnVision technique and the Tech Mate processor. Cytokines, growth factors and eicosanoids were determined by Elisa kits following the manufactured recommendation. RESULTS: HISTOLOGICAL: A difference was observed in the number of lymphocytes B between C (91.4+/-44.1) and P treated (58.2+/-53.7) groups (p=0.097). BIOLOGICAL MARKERS: TNFalpha and IL-1beta were dramatically lower in the Permixon treated group. Other parameters did not show significant changes. CLINICAL: IPSS in the Permixon treated group was significantly reduced (p<0.006) from 20.0+5.9 to 14.9+3.8 after three months of treatment. COMMENTS: The BPH inflammatory hypothesis was tested in humans. Our pilot study shows a significant reduction of some inflammatory parameters in prostatic tissues of patients treated with Permixon. These biological findings justify a pharmacological effect of this drug on the inflammatory status of the adenoma. A correlation with clinical improvement was observed.

[Giant cyst of the seminal vesicle associated with ipsilateral renal agenesis]. / Quiste gigante de vesícula seminal asociado con agenesia renal ipsilateral.

Cyst of the seminal vesicles represent a rare but illustrative type of embryologic malformation whose etiology is associated with an abnormal development of the mesonephric or Wolffian duct. Frequently these malformations are associated with an abnormal development of the ipsilateral upper urinary tract. The initial evaluation of the majority of cases is performed with abdominal or transrectal ultrasound. Considering the possible need of other diagnostic procedures to confirm the diagnosis, ultrasonography is safe in the majority of cases. The treatment of these urologic malformations should be restricted to symptomatic cases and usually consists of vesiculectomy, with of without, removal of the displastic or histoplastic kidney. We present a case of a right mesonephric duct malformation with a giant seminal vesicle associated with ipsilateral kidney agenesis and severe oligozoospermia, that presented with sporadic episodes of hemospermia and urinary complaints.

[Review of complications of urinary diversions performed during a 6-year period in the era of orthotopic neobladders]. / Revisión de las complicaciones de las derivaciones urinarias realizadas en un periodo de 6 años en la era de las neovejigas ortotópicas.

OBJECTIVE: To compare the morbidity of different types of permanent urinary diversion. METHODS: We reviewed the postoperative and longterm complications observed in 85 patients who underwent permanent urinary diversion from December, 1986 to January, 1993: cutaneous ureterostomy (16 pts.), transintestinal incontinent cutaneous ureterostomy (41 pts.), orthotopic neobladder (27 pts.). All patients underwent radical cystectomy for bladder carcinoma. The surgical technique utilized for the construction of the orthotopic neobladders were as follows: Camey 1 (4 cases), Camey II (6 cases), Mainz (2 cases), Hautman (6 cases), detubularized sigmoid (6 cases). We also reviewed and used for comparison 18 augmentation cystoplasties that underwent simple subtotal cystectomy. Augmentation cystoplasty was performed with the sigmoid (n = 8), ileon (n = 5) and ileocecal segment (n = 4). RESULTS: The incidence of postoperative complications was similar for all types of urinary diversion (64.3% for cutaneous ureterostomy, 61% for transintestinal intermittent cutaneous ureterostomy, 59.3% for orthotopic neobladder), although patients with orthotopic neobladders required surgery more frequently (7.1% for cutaneous ureterostomy, 22% for transintestinal cutaneous ureterostomy, 41% for orthotopic neobladder). The incidence of postoperative complications was much lower in patients who underwent augmentation cystoplasty (complications 17.7%; none required surgery). The percentage of longterm complications was 71.4% for cutaneous ureterostomy, 74.2% for cutaneous transintestinal ureterostomy, 86.9% for orthotopic neobladders and 100% for augmentation cystoplasties. The patients who required surgery were 14.3%, 19.3%, 26% and 47%, respectively. Twelve out of 24 patients in whom metalic staples were employed for the construction of the neobladders and cystoplasties developed bladder stones; 78.3% of the patients with orthotopic neobladders showed perfect daytime continence, 65.2% night-time incontinence and 21.7% stress incontinence. The figures for augmentation cystoplasties were 94.1%, 5.9% and 5.9%; 4.3% of patients with orthotopic neobladders and 29.4% of patients with augmentation cystoplasties required self intermittent catheterization. Patients with larger neobladders showed best continence rates. Fifty-three ureters were reimplanted in the orthotopic neobladders of augmentation cystoplasties with the Le Duc technique; 17% developed ureteral stenosis and 15.1% vesicoureteral reflux. CONCLUSION: Patients who undergo permanent urinary diversion have a far from negligible number of postoperative and long-term complications. Orthotopic intestinal neobladders have a slightly higher rate of serious complications than incontinent cutaneous diversions.

[Prognostic value of lymphatic metastasis in bladder cancer]. / Valor pronóstico de las metástasis ganglionares en el cáncer vesical.

OBJECTIVE: The presence of lymph node metastasis in bladder cancer is considered to be a sign of poor prognosis. The present study was performed to analyze the influence of the number of positive lymph nodes on survival and the therapeutic value of lymphadenectomy in pN+patients. METHODS: From January, 1983 to January, 1993, 160 patients aged 39 to 77 years (mean 61.8) underwent radical cystectomy and pelvic lymphadenectomy for carcinoma of the bladder. The records of 122 patients were available for review. The UICC 1978 classification system was used. RESULTS: Cancer-specific mortality was 22.8% (16/70) for pNo patients, 44.4% (4/9) for pN1 patients and 88.9% (16/18) for pN2-4 patients. We obtained the following cancer-specific mortality by stratifying according to T category: 5.4% (2/37) for pNoT1-T3a, 42.4% (14/33) for pNoT3b-T4, 0% (0/2) for pNIT1-T3a, 57.1% (4/7) for pNIT3b-T4 and 88.9% (16/18) for pN2-4T3b-T4. CONCLUSION: The presence of only 1 positive regional lymph node (pN1) appears to worsen patient survival, particularly when the primary tumor is T3b or worse. In these cases cancer-specific mortality after patient discharge increased from 42% for the pNo patients to 57% for the pN1 patients (p > 0.05). Radical cystectomy was highly effective and curative in 95% of T1-T3apNo-1 patients (37/39). The presence of multiple positive lymph nodes carries a very poor prognosis, with 89% of the patients dying at a mean of 12 months.

[Granulomatous prostatitis. Analysis of 15 cases and review of the literature]. / Prostatitis granulomatosa. Análisis de 15 casos y revisión de la literatura.

OBJECTIVES: The present study describes our experience with granulomatous prostatitis, an uncommon disease entity, with special reference to the etiological factors and the clinical and pathological features. METHODS: 15 cases of granulomatous prostatitis seen at our department over a 2-year period were retrospectively analyzed. RESULTS: The most frequent etiological factor was surgery (TUR) or prostatic needle biopsy (53%). Prostate cancer was suspected in 8 patients based on the findings of DRE. CONCLUSIONS: The diagnosis of granulomatous prostatitis is based on the histological findings. Despite its low incidence, it is currently diagnosed more frequently due to the increase in TURP and prostatic biopsy procedures and the widespread use of intravesical BCG therapy for some superficial bladder tumors.

[Secondary bladder melanoma. Report of a case concomitant with urothelial tumor of the bladder]. / Melanoma vesical secundario. A propósito de un caso coincidente con tumor urotelial de vejiga.

OBJECTIVES: To report on a case of melanoma, a rare tumor type metastatic to the bladder. METHOD/RESULTS: A case of melanoma metastatic to the bladder was incidentally discovered in a patient with urothelial cancer. The clinical features, diagnostic and therapeutic aspects are described. CONCLUSIONS: In a patient with malignant melanoma presenting irritative micturion syndrome and/or hematuria, endoscopic bladder exploration with multiple random biopsy must be performed to rule out melanoma metastatic to the bladder metastasis.

[Bladder sarcomatoid carcinoma. Bladder carcinoma simulating lymphoma]. / Carcinoma sarcomatoide vesical. Carcinoma vesical simulando un linfoma.

OBJECTIVE: To describe an unusual type of vesical carcinoma (sarcomatoid carcinoma) associated with the spread of inflammation. The article discusses the diagnostic difficulties and prognosis. METHOD/RESULTS: We describe a patient with vesical sarcomatoid carcinoma associated with the spread of inflammation that practically obscured the undifferentiated area, mimicking a lymphoma. This is interpreted as a favourable immunological reaction, despite the highly aggressive behaviour of the sarcomatoid component. CONCLUSIONS: Only on rare occasions do vesical carcinomas present such a prominent degree of spindle-shaped cells. This finding could create some diagnostic confusion, hence an immunohistochemical study is essential. The identification of sarcomatoid carcinoma has important implications both for treatment and for prognosis. The literature refers to the marked aggressiveness of this type of tumour. The peculiarity of the case resides in the associated spread of inflammation which improved the prognosis.

[Urethroplasty with lyophilized human dura mater]. / Uretroplastia con duramadre humana liofilizada.

OBJECTIVE: This article reports our experience with lyophilized human dura in the treatment of complex urethral stenosis. METHOD: Seven patients with iatrogenic/inflammatory urethral stricture underwent a 13 cms long x 1.5 cms wide medial urethral augmentation. RESULTS: During a mean follow-up of 23 months, good results accounted for 85.7%. CONCLUSION: Lyophilized dura patches constitute a suitable choice in selected patients who, for local or systemic reasons, are not good candidates for other urethroplasty procedures.