Changes in benign prostatic hyperplasia management in Valencia: a real-world evidence analysis.

INTRODUCTION AND OBJECTIVES: A training program was developed to increase general practitioners' engagement in the optimal management of Benign Prostatic Hyperplasia (BPH). The goal of this study was to evaluate changes in BPH management after the implementation of a training program. MATERIAL AND METHODS: This observational retrospective cohort study was conducted between 2019 and 2020. Aggregated data were analyzed in three evaluation periods (2010, 2012 and 2015), addressing quality indicators for diagnosis, treatment, and treatment outcomes. RESULTS: Overall, 118 795 patients who presented any data points were included. All quality indicators (number of IPSS and PSA determinations) increased between the first period and the last. Combination (α-blocker + 5-ARI) therapy was increasingly prescribed during the study periods whereas the proportion of prescriptions for single-agent α-blocker showed no significant differences among the periods analyzed. However, the total number of patients eligible for combination therapy who actually received this treatment was low in all periods (7.5%, 17.9%, and 20.1%, in 2010, 2012, and 2015, respectively). The outcome indicators revealed a decrease in referrals to the urology unit mostly among newly diagnosed patients. Even though the proportion of patients who underwent BPH-related surgeries increased significantly from the first to the second period, the number of surgeries remained stable between the second and third periods. CONCLUSIONS: The training program had a generally positive impact on the management of BPH patients in PC, but the overall study period may be insufficient to show an effect on some outcome indicators such as the number of surgeries.

Magnetic double-J stent: Evaluation of tolerance and impact on quality of life compared to traditional double-J stent.

INTRODUCTION: The placement of a ureteral stent is one of the most widely performed procedures in urology. It can have a negative impact on the patients' quality of life, requiring a cystoscopy for its removal. The objective of this study is to evaluate the symptoms and impact on quality of life derived from the use of a magnetic double-J stent (Black Star®) and compare them to those presented in patients with a traditional double-J stent (OptiMed®). MATERIAL AND METHODS: We conducted a comparative, prospective, randomized study in 46 patients who underwent ureterorenoscopy with double-J stent placement between August 2019 and June 2020. Of all patients included, 23 had a traditional double-J stent placed (group A) and 23 had a magnetic double-J stent (group B) placed. We evaluated the results of the Ureteral Stent Symptom Questionnaire (USSQ) in both groups, assessed the technical difficulty related to stent removal and the pain during the procedure using the Visual Analogue Scale (VAS). We also reviewed the need for medical attention due to problems related to the stent or after its removal. RESULTS: There were no statistically significant differences between groups regarding the answers in the USSQ and the complications related to the use of the stent. Group B showed less pain (1.52 vs. 4, VAS, p = 0.001) and less difficulty during removal (1.61 vs. 3, p < 0.001) associated with a shorter procedure duration (11.65 min vs. 22.17 min p < 0.001). CONCLUSIONS: The tolerance shown by the use of magnetic double-J is comparable to the tolerance of traditional stent, since it does not cause an increase in urinary symptoms nor worsens the quality of life of patients during its use.

Treatment for rectourethral fistulas after radical prostatectomy with biological material interposition through a perineal access.

INTRODUCTION: Rectal injury is a rare complication after extraperitoneal laparoscopic radical prostatectomy. The development of rectourethral fistulas (URF) from rectal injuries is one of the most feared and of more complex resolution in urology. MATERIAL AND METHODS: Between 2013 and 2020 we have operated on a total of 5 patients with URF after extraperitoneal endoscopic radical prostatectomy through a perineal access using the interposition of biological material. All fistulas had a diameter of less than 6 mm at endoscopy and were less than 6 cm apart from the anal margin. RESULTS: The mean age of the patients was 64 years old. All patients had a previous bowel and urinary diversion for at least 3 months. Under general anesthesia and with the patient in a forced lithotomy position, fistulorraphy and interposition of biological material of porcine origin (lyophilized porcine dermis [Permacol®]) were performed through a perineal access. Mean operative time was 174 min (140-210). Most patients were discharged on the third postoperative day. The bladder catheter was left in place for a mean of 40 days (30-60). Prior to its removal, cystography and a Gastrografin® barium enema were performed, showing resolution of the fistula in all cases. CONCLUSIONS: The interposition of biological material from porcine dermis through perineal approach is a safe alternative with good results in patients submitted to urethrorectal fistulorraphy after radical prostatectomy.

Minimally invasive treatment for lower urinary tract symptoms due to benign prostatic hyperplasia. Our initial experience with Urolift® under local anaesthesia and sedation. / Tratamiento mínimamente invasivo de los síntomas del tracto urinario inferior por hiperplasia benigna de próstata. Nuestra experiencia inicial con Urolift® bajo anestesia local y sedación.

INTRODUCTION: The treatment for lower urinary tract symptoms secondary to benign prostatic hyperplasia with the Urolift® system has been carried out since 2005 with good results in the medium term. In this work, we present our experience performing this technique under local anaesthesia and sedation in 2 Spanish centres. MATERIAL AND METHODS: A prospective study was conducted with 20 patients treated with Urolift® under local anaesthesia and sedation between April 2017 and April 2018. The anaesthesia protocol consisted in the placement of 2 lubricants with cold lidocaine (the first one, 10min before the intervention, and the second one, just before introducing the cystoscopy). A prostate block (similar to the one employed in prostate biopsies) was administered to one third of the patients and 1mg of intravenous midazolam was added if required during the procedure. Our primary objective is to evaluate the tolerability of this procedure under local anaesthesia using the validated Visual Analogue Scale measurement instrument. RESULTS: The procedure has been performed under the same anaesthetic protocol to 20 patients from 2 different centres. The average pain scores on the Visual Analogue Scale were 1.37 for the cystoscopy procedure and 1.19 for the placement of the implants. When asked whether the pain sensations had been higher, lower or the same during the procedure or at the preoperative cystoscopy, only 18% of the patients responded it was higher. In all cases there was a good tolerance to the procedure, and changes to the anaesthesia protocols were never required. CONCLUSIONS: We consider that the Urolift® system under local anaesthesia and sedation is a well-tolerated, safe and effective method for the treatment of lower urinary tract symptoms secondary to benign prostatic hyperplasia.

High-intensity focused ultrasound therapy for the treatment of prostate cancer: Medium-term experience. / Terapia ultrasonido focalizado de alta intensidad (HIFU) para el tratamiento del cáncer de próstata: Experiencia a medio plazo.

INTRODUCTION: The treatment of localised prostate cancer seeks to minimise the impact on sexual function and urinary continence. In this respect, therapy with high-intensity focused ultrasound offers important results. We present our experience with this technique in 2 Spanish centres. MATERIAL AND METHODS: We conducted a retrospective review of 75 patients with localised prostate cancer treated with high-intensity focused ultrasound between March 2007 and July 2016. The oncological results and perioperative complications were assessed, as well as the impact on sexual function and continence. RESULTS: A total of 67 patients were analysed. The mean follow-up was 7.2 years. The PSA nadir was 0.2ng/mL (0-3), 24 patients (35.5%) presented biochemical recurrence, and 18 underwent a further biopsy, with 10 cases (55.5%) presenting disease recurrence. The overall biochemical relapse-free survival at 5 and 8 years was 93.2 and 80.5%, respectively. The cancer-specific survival at 5 and 8 years was 96% in both cases. In the postoperative period, 50 patients (74.6%) were continent, 16 (23.9%) reported mild incontinence, and one (1.5%) reported moderate incontinence. The median International Index of Erectile Function-5 before and after the surgery was 17 (5-25) and 16 (2-23) points, respectively. Nine patients reported de novo erectile dysfunction (13.5%). CONCLUSION: High-intensity focused ultrasound appears to be a safe alternative for the treatment of localised prostate cancer, especially for low-risk localised prostate cancer. In our experience, this technique offers advantages in preserving urinary continence, and the medium-term oncological results are encouraging. Given the natural progression of prostate cancer, long-term studies with a larger number of cases are needed to corroborate these results.

[Greenlight Laser Photoselective vaporization of the prostate (PVP). Surgical advantages in risk patients]. / Fotovaporización prostática (FVP) mediante láser verde. Ventajas quirúrgicas en pacientes de riesgo.

It is more and more common to have patients in our clinics with the diagnosis of BPH and indication for surgery who present limitations due to their medications, age, associated morbidity or psychosocial conditions. Transurethral resection of the prostate, though it is the surgical standard of reference, is not free from complications such as reabsorption syndrome, bleeding, or even blood transfusion in a percentage of cases. Laser PVP may be a valid alternative in this subgroup of patients. We review our experience with this procedure, as well as the published articles on this topic, and describe technical recommendations we consider useful to avoid complications when possible during surgery or the immediate postoperative period.

[Ancient urology in the Kingdom of Valencia. Height and declivity]. / Urología antigua en el Reino de Valencia. Apogeo y declive.

During the second half of the XVIth century the interest of the clinicians moves towards the venereal ailments and the urethral carnosities (narrowness) to the detriment of the litiasic processes. They are of special relevancy for us, in the period summit of the medical sciences in Valencian lands, Miguel Juan Pascual who in his work "Morborum internorum" (1555) there synthesizes everything known on the syphilis in this epoch, its origin, diagnosis and treatment, Juan Calvo considered one of the best surgeons of the XVIth century and Miguel de Leriza author of the "Tractatus of the way of treating the carnosities and corns of the route of the urine". The baroque was an epoch of general crisis in Spain and in the ancient Kingdom of Valencia, specially clear in fields as the anatomy and the surgery. The serious decadence that suffered during these years the scientific Valencian production turns out to be evident. Not even an alone anatomical text was published in the first half of the XVIIth century, whereas in the surgical area the "Summary of everything about the theoretical and practice of Surgery", of Alonso Romano can be considered deigns of mention. The illustration brought new reformists airs and around the flourishing scientific academies, there congregated the most select of the Valencian intellectuality. Andres Piquer Arrufat is considered to be the maximum figure of the Valencian medicine of this period. Not even after the war of independence and the reign of Fernando VII who died in 1833 when there sit down the bases of the modern urology and the consolidation as speciality at the end of the XIXth. The Valencian principal figures of this period are Miguel Más y Soler, Alejandro Settler and especially Rafael Mollá y Rodrigo.

[Ancient urology in the Kingdom of Valencia. Origins]. / Urologia antigua en el Reino de Valencia. Orígenes.

When we speak about ancient Urology we try to revise the ways of diagnosing and treating during the last epochs the genitourinary diseases, sufferings that are recognizable for us in the classic descriptions. We try to place the urology knowledge in Valencian lands, in the historical general current, relating it to the social, political and economic structure in every moment. Are outlined the innovative legislations that regulated the medical occupation, the influence of the European currents in the development of the medicine and surgery at Valencia up to the renaissance, the creation of the School of Surgery in 1462, the obtaining of the royal privilege in 1478 to dissect human corpses, the foundation of the University of Valencia in 1502, by the Valencian pope Alejandro VI, and license of the king Fernando Catholic and the unification of the set of hospital centres of the city of Valencia in 1512, constituting the General Hospital. In this period they are of special relevancy for us Arnau de Vilanova who wrote the "Tractatus against calculum" the first text related to the urologic pathology, written with monographic character, in the medical European literature, Gaspar Torrella who in 1497 realized the first clinical and therapeutic study of the epoch on the syphilis, considered like the most valuable original description of the new disease and Pedro Jimeno and Luis Collado as visible heads of the flourishing anatomical Valencian school whom Francisco Diaz, author in 1588 of first Urology Tractatus in the History of the medicine, recognizes as his teachers during his staying in Valencia.

[Testicular dislocation. Report of 2 new cases and review of the literature]. / Dislocación testicular. Aportación de 2 nuevos casos y revisión de la literatura.

We report 2 new cases of testicular luxation. A review of current literature is made. Testis was located inguinal after scrotal trauma in both cases. Early close reduction was unsuccessfully. A delayed reduction was found in one case at the moment of surgery. A surgical replacement of the testis was carried out in the other patient. Follow-up control revealed a benign course in both. Testicular dislocation is a rare complication after scrotal trauma (only 152 cases reported). Physician have to be aware of this possibility following perineal trauma. Oftenly, a surgery reduction is required.

[Renal and perirenal abscess]. / Abscesos renales y perirrenales.

Renal and perirenal abscesses are rare infections of the urinary tract traditionally caused by Staphylococcus aureus. Today however there is a predominance of abscesses secondary to coliform bacteria such as E. coli. This paper presents a revision of our series over the last ten years (1987-1996). A total of 11 abscesses (3 renal and 8 perinephritic) were recorded. The most frequent symptom for visiting the clinic was back pain. All patients had predisposing associated conditions. The microbiological analysis revealed E. coli in most abscesses. An HIV+ patient had bilateral renal abscess secondary to Aspergillus fumigatus. CAT appears to be the most specific method for imaging diagnosis, and ultranosography is useful not only to guide percutaneous puncture but also in the follow-up of abscesses after antibiotic treatment. Two renal abscesses resolved with parenteral antibiotic therapy and subsequent observation. Three cases required ultrasound guided percutaneous puncture and intravenous antibiotic therapy. Surgical drainage was required in four. A revision of our experience and the recent literature verified the changes that have taken place in the last few years both in the etiopathogenesis as well as the diagnostic and therapeutical methodology of renal and perinephritic abscesses.

Paraureteral extrusion of calculi after endoscopic pulsed-dye laser lithotripsy.

Laser lithotripsy has become an effective and low-morbidity procedure for the treatment of ureteral calculi. Nevertheless, ureteral endoscopy is not free of side effects and complications. Lithiasis extrusion is one of the early complications of this procedure, and usually, the diagnosis is carried out by means of urographic findings because it is not easily recognized during ureteroscopy. Between January 1990 and May 1996, a total of 1047 endoscopic lithotripsies with the pulsed-dye laser were performed in our department. The 3-month stone-free rate as a single treatment was 76.5%. We found 11 cases (1.05%) of calculi extrusion after ureteral endoscopic treatment. Only one case was diagnosed intraoperatively. The evolution after a mean follow-up period of 18 months (range 6-34 months) was satisfactory in all cases. No urinary extravasation, infection, or secondary ureteral strictures were found. According to the absence of side effects, it was considered unnecessary to remove the extruded calculi. Extrusion of noninfected calculi into the periureteral tissues after laser lithotripsy causes no significant consequences and can be successfully managed conservatively. Knowledge of this possible complication is the best way to avoid it. A careful technique and a low irrigant flow will be very helpful.

[Treatment of benign hyperplasia of the prostate using thermal transurethral needle ablation (TUNA)]. / Tratamiento de la hiperplasia benigna de próstata mediante ablación térmica transuretral con aguja (TUNA).

Transurethral needle ablation of the prostate (TUNA) is a new, fast and minimally invasive device that produce a selective necrosis of the prostatic gland by delivering low level radiofrequency energy. We describe our experience with this new technique. A total of 42 patients suffering from symptomatic BPH were treated with this procedure. The original generator was used in 27 patients (group 1). A new generator allowing a more homogeneous application of intraprostatic temperature was used in 15 patients (group 2). The patients pretreatment evaluation consisted of World Health Organization symptom score and quality of life, digital rectal examination, uroflowmetric parameters, residual volume, transrectal ultrasound and PSA. Follow-up was performed using the same pretreatment parameters at one month, three months, six months and twelve months. All patients were treated using urethral xylocaine with intravenous or intramuscular sedation (petidine clorhidrate) and tolerance was good. IPSS and quality of life decreased significantly in both groups at first month after treatment and kept low up to twelve-month control. Peak flow rate increased from 7.7 +/- 3.7 ml/sec to 10 +/- 4.1 ml/sec at the twelve-month control in group 1 (p > 0.05), and from 7.6 +/- 2 ml/sec to 9.8 +/- 3.3 ml/sec in group 2 (p > 0.05). Residual volume decrease was statistically significant in group 2 (p < 0.05). No significant complications were encountered. Five patients in group 1 and one patient in group 2 required TURP some time in the follow-up (14%). In our experience, after one year of follow-up, improvement in subjective parameters is evident, although uroflowmetric improvement is moderate and with no statistically significance. No differences were found between both groups of treatment.

[Cystadenoma of seminal vesicles]. / Cistadenoma de vesículas seminales.

Cystadenoma of the seminal vesicles is a extremely rare pathology. To our knowledge only eight cases have been reported in the literature. We report a new case of this benign tumor, bilaterally located and incidentally found at surgery. Literature is reviewed and clinical, diagnostic and therapeutic aspects of these are discussed.

[Subcutaneous metastasis as the first manifestation of kidney cancer dissemination]. / Metástasis subcutáneas como primera manifestación de la diseminación del cáncer renal.

Presentation of an uncommon form of distant primary dissemination of renal adenocarcinoma (RA) 5 years after radical surgery, the subcutaneous metastasis. The patient underwent surgical resection of metastasis, and later developed early pulmonary, mediastinal and new skin metastasis. A review is made of the incidence, therapeutical approach and prognostic value of skin metastasis due to RA.

[Treatment of benign prostatic hyperplasia with finasteride. Results after 7 years of follow-up]. / Tratamiento de la hiperplasia benigna de próstata con Finasteride. Resultados a los siete años de seguimiento.

Our centre took part in an international, multicentre, Phase III trial with Finasteride (MK-906) in the treatment of BPH. In the first year, this was a double-blind, randomised, placebo-controlled study which included 25 patients who were randomly assigned: 9 to treatment with placebo, 8 to finasteride 1 mg and 8 to finasteride 5 mg. After the first year, all patients were assigned to finasteride 5 mg as a single daily dose taken before breakfast. Of the 25 patients who started the trial, 7 have completed 7 years treatment (28%): 1 from the placebo group. 1 from finasteride 1 mg, and 5 who took finasteride 5 mg throughout the study. Total symptoms score, assessed by the modified Boyarsky questionnaire, improved during the first year 4.97 points (51%) and remained unchanged up to year 7 with a final reduction of 6.2 points (64%). Percentual increase in peak urinary flow during follow-up ranged between 21 and 45.9% with an absolute increase at 7 years of 4.2 mL/seg (47.5%) and a reduction in prostate volume of 26%. Finasteride tolerance was excellent at all times, and no serious clinical reaction was seen in laboratory parameters. Two patients reported decreased libido and sexual potency and 1 decreased libido. In summary, since after 7 years of treatment efficacy is maintained in at least 30% of patients with an excellent safety profile, finasteride can be considered an alternative in the medical treatment of BPH.

[Extragonadal germinal tumors of retroperitoneal localization]. / Tumores germinales extragonadales de localización retroperitoneal.

Extragonadal germ cells tumors can arise primarily in the retroperitoneum. It has been suggested that these neoplasms might be metastasis from an occult testicular lesion which would have regressed later. We report our experience with seven retroperitoneal germ cell tumors without testicular involvement. The most frequent symptoms were lumbar or abdominal pain and paraneoplastic syndrome. Abdominal palpable mass was noticeable in 85% of patients. We point out the computerized tomography and echography as the most sensitive exploration for diagnosis. The confirmation of retroperitoneal tumor was achieved preoperatively in all cases. Surgical and chemotherapy treatment was performed. Radiotherapy was employed in two cases. The mean survival was 9.5 months (6-24 m.). Retroperitoneal lymphadenectomy after chemotherapy has not improved the survival. Relapses of the diseases were noticed after and apparently partial or complete response to chemotherapy.

[Lithiasis of the transplanted kidney: therapeutical potential]. / Litiasis en el riñón trasplantado: posibilidades terapéuticas.

OBJECTIVES: The formation of calculus in the transplanted kidney is an uncommon complication. Metabolic derangements, infectious or obstructive processes, factors related with the surgical technique and the presence of ureteral catheters have been implicated in its etiopathogenesis. The therapeutic possibilities have changed in the last decade. The different factors related with stone formation in the transplanted kidney, the indications and treatment utilized in each case are analyzed. METHODS: We analyzed the cases of lithiasis following renal transplantation in our series of 800 renal transplants. The metabolic anomalies and other associated lithogenic factors in 5 cases that required treatment are described. RESULTS: All 5 patients were treated by ESWL. Complete resolution of the lithiasis was achieved in 4 cases whose kidney graft is currently stone free with preserved renal function, except one patient with hyperuricemia and hyperuricosuria who is again on hemodialysis for chronic rejection. In the fifth case fragmentation of the caliceal stone was not achieved after 4 sessions of ESWL. Subsequem ultrasound control evaluations have disclosed no changes in stone size or location. CONCLUSIONS: In our view, the approach to renal lithiasis in the transplanted kidney is similar to that of patients with solitary kidney, although stone size for treatment by ESWL should be limited to 2 cms. If stone size is between 1 and 2 cms, placement of a double-J catheter prior to ESWL is recommended, whenever possible. For stones larger than 2 cms, percutaneous nephrolithotomy is more effective and has less complications. Surgery is reserved for those patients in whom these techniques are unamenable or have failed.

[Renal traumatism: diagnostic protocol and therapeutic indications]. / Traumatismos renales: protocolo diagnóstico e indicaciones terapéuticas.

Review of 158 cases of renal traumatism attended ar the Urology Service of "La Fe" Hospital from 1984 to 1995. We analyze the indications of radiological study of the polytraumatized patient, the different classifications of renal traumatism and the changes produced in the diagnosis protocol, after substituting urography and arteriography for ultrasonography and CT in the Urgencies Area. We explain the treatment, complications and evolution of the patients in our series. 153 of the cases are closed traumatism and 5 of them are penetrating. Following the Chatelain's classification, 78.5% of the reviewed cases can be describes as traumatism grades I and II and in all the instances a conservative treatment was followed. Grades III and Iv (18.3%) were mostly treated surgically (82.7%) with 20.8% of complications that were solved conservatively except for one case, which required surgery. Every penetrating traumatism was dealt surgically and we practised nephrectomy in one of them (20%). We finally suggest, as the best moment for the reconstructive surgery, the period between the 3rd and the 10th day after the traumatism, due to the high rate of nephrectomy on the previous days and the technical difficulties which the haematoma fibrosis conveys on the subsequent.

[Verrucous carcinoma of the penis]. / Carcinoma verrucoso de pene.

Verrucous carcinoma includes approximately 5% of all neoplasias of the penis and is a tumoral variety of benign behaviour and differentiated histology. Our 10-case experience of penial verrucous carcinoma is reported here. In nearly all cases, partial penectomy was the definitive approach. No dissemination, locorregional or distant, was found in any of the report cases. Since prognosis of these tumours is good, we see no justification in performing lymphadenectomy, although it is advisable to adopt and expectant attitude when faced to inguinal adenopathies.

[Scrotal verrucous carcinoma]. / Carcinoma verrucoso escrotal.

Cancer of scrotum is of interest, despite its relative infrequency, because of its historical importance (was the first known occupational cancer) and also of its aggressive behavior. We report a rare case of verrucous carcinoma in a 67 years old man, without recrudescence six months after surgical treatment.