Combined laparoscopic surgery for the treatment of pelvic organ prolapse and recurrent urinary incontinence. / Técnica quirúrgica para la corrección simultánea del prolapso de órganos pélvicos y la incontinencia urinaria recidivada mediante laparoscopia.

INTRODUCTION: Laparoscopic sacral colpopexy (LSC) is the gold standard treatment for apical pelvic organ prolapse (POP). Artificial urinary sphincter (AUS) has a high success rate in treating recurrent stress urinary incontinence (SUI). OBJECTIVE: To describe the first simultaneous LSC and AUS implantation through a vesicovaginal approach to the bladder neck. MATERIAL AND METHODS: Operation is performed through a transperitoneal approach. The rectovaginal space is created and the posterior mesh is fixed. The vesicovaginal and both laterovesical spaces are dissected. The vesicovaginal space is connected to both lateral spaces. This is main step of the procedure because it let us place the cuff around the bladder neck in a non-blind fashion. The anterior mesh is fixed to the vagina. The anterior side of the bladder neck is dissected and the cuff implanted. Both meshes are fixed to the promontory. Pressure-regulating balloon is inserted, the pump is placed in the labia majora and the components are connected. Peritoneum is closed. RESULTS: Surgical time was 180 minutes, bladder catheter was removed at 5th postoperative day, hospital stay was 5 days. The AUS was activated 6 weeks after surgery. No perioperative complications occurred. After 12 months the patient is pad-free and prolapse was objectively and subjectively cured. CONCLUSIONS: Vesicovaginal dissection is a shared step in this technique of LSC and AUS implantation. This approach could minimize the risk of bladder neck injury. We propose this technique in selected cases of prolapse and recurrent SUI.

Urinary sepsis after endourological ureterorenoscopy for the treatment of lithiasis. / Sepsis urinaria tras tratamiento endourológico de la litiasis por ureterorrenoscopia.

OBJECTIVE: To evaluate the incidence, clinical presentation and factors associated with the development of urinary sepsis after performing ureterorenoscopy. MATERIAL AND METHODS: Retrospective study of patients undergoing ureterorenoscopy for the treatment of lithiasis between July 2015 and October 2017. Patients who developed urinary sepsis during the 30 days following the intervention were identified. Personal, clinical, surgical and microbiological backgrounds were collected. Statistical analysis was performed with the Chi squared test (or Fisher's exact test), Student's t (or U Mann-Whitney) or logistic regression as appropriate. RESULTS: 246 ureterorenoscopies were performed, 184 (74.8%) on ureteral stones and 62 (25.2%) on kidney stones, with a mean age of 52 (44.5-59.5) years. After procedure, 18 (7.3%) patients developed urinary sepsis, 10 of them (55.5%) occurred in the first 24h. The urine culture showed enterobacteria (61.1%) and enterococci (38.9%). The antibiogram showed greater sensitivity to nitrofurantoins (100%) and quinolones (72%). The statistical analysis showed that female sex, the clinical debut of urolithiasis as urinary sepsis, having received antibiotic or having required urinary diversion by a double J during debut, positive presurgical uroculture and the persistence of residual lithiasis after surgery were significantly associated (P<.05) with the development of urinary sepsis after ureterorenoscopy. CONCLUSION: Urinary sepsis is a complication that appears after performing ureterorenoscopy, especially in female patients with a history of urinary sepsis, antibiotic therapy, double J, previous positive urine culture or residual lithiasis after the procedure.

Experience With Hypothermic Machine Perfusion in Expanded Criteria Donors: Functional Outcomes.

Hypothermic machine perfusion (HMP) decreases delayed graft function (DGF) and improves 1-year graft survival in expanded criteria donors (ECDs). Time of HMP could be associated with incidence of DGF. OBJECTIVE: To analyze functional outcomes of ECD grafts preserved totally (local grafts) or partially (imported grafts) with HMP. MATERIALS AND METHODS: We analyzed prospectively collected data from a cohort of first ECD graft receptors, with a minimum follow-up of 6 months. A total of 119 imported and 74 local grafts were included. Local ECD kidneys were preserved with HMP after retrieval. Imported ECD kidneys were preserved with simple cold storage and HMP. Vascular thrombosis, acute rejection, DGF, 1-year glomerular filtration rate, and 1-year graft survival were assessed. Univariate and estimative multivariate logistic regression was applied for analysis of DGF. A Cox proportional hazards model was applied to estimate graft survival. RESULTS: DGF occurred in 14 recipients of local grafts and in 33 recipients of imported grafts (28.0 vs 18.1%, P = .13); 1-year graft survival was better in the group of local grafts (80.3 vs 91.9%, P = .03). No differences in vascular thrombosis (5.9 vs 5.4%, P = .88), acute rejection (12.3 vs 9.8%, P = .91), or 1-year glomerular filtration rate (41.2 vs 40.5 mL/m/1.73m2, P = .87) were observed. In multivariate analysis, adjusted odds ratio for DGF was 1.20 (P = .79) and adjusted hazard ratio for graft survival was 1.93 (P = .31). CONCLUSIONS: There is a trend that complete HMP reduces the risk of DGF and improves 1-year graft survival in ECD kidneys.

MicroRNAs in Kidney Machine Perfusion Fluid as Novel Biomarkers for Graft Function. Normalization Methods for miRNAs Profile Analysis.

MicroRNAs (miRNAs) are post-transcriptional regulators that have emerged as promising biomarkers in kidney transplantation. Quantification of miRNAs can be analyzed by means of biological normalization. The purpose of normalization is to remove technical variation in data, which is not related to the biological changes under investigation. Proper normalization is critical for the correct analysis and interpretation of results. MATERIAL AND METHODS: A prospective cohort study was conducted on graft dysfunction in kidney transplantation from expanded criteria donors. After RNA extraction quantitative real-time polymerase chain reaction was performed. The exogenous spike-in normalization was used as technical normalization. Relative expression was calculated using the 2-ΔΔCt method and UniSp2 spike-in was used as reference for normalization. Results obtained were further analyzed by the application of the mean expression value that uses the calculated mean of all miRNAs in a given sample. RESULTS: The mean expression value approach confirmed the significance of a subset of the miRNAs previously identified for delayed graft function development and composed by miRNAs miR-486-5p, miR-144-3p, miR-142-5p, and miR-144-5p. CONCLUSIONS: MicroRNAs are becoming increasingly important as biomarkers in multiple disease processes including kidney transplantation. Perfusion fluid, particularly during hypothermic machine perfusion, provides a valuable pretransplantation source for identification of organ viability biomarkers. Although there is no clear consensus concerning the normalization technique, the mean expression value method shows the better normalization strategy.

Comparison between percutaneous nephrolithotomy and flexible ureteroscopy for the treatment of 2 and 3cm renal lithiasis. / Comparación entre nefrolitotomía percutánea y ureteroscopia flexible para el tratamiento de litiasis renales de entre 2 y 3cm.

CONTEXT AND OBJECTIVES: The first-line treatment for >2cm lithiasis is percutaneous nephrolithotomy (PNL), leaving flexible ureteroscopy (fURS) as a second option. In the present review, the stone-free rate and the complications of both techniques were evaluated in the treatment of 2-3cm stones. MATERIAL AND METHODS: Systematic review of studies that compared both techniques. Studies that were not comparative, as well as those carried out in the pediatric population or with <2cm or>3cm stones, were excluded. Two researchers independently performed the investigation, obtaining 5 studies that made up a total of 815 patients: 252 belonged to the fURS group and 563 to the PNL group. Four studies were retrospective, and one was non-randomized prospective. RESULTS: Stone-free rate ranged between 47.0% and 95.0% for the fURS and between 87.0% and 100% for the PNL. The complication rate was 8.8-29.0% in the fURS and 11.9-27.0% in the PNL. fURS required a greater number of procedures, and had a lower decrease in haemoglobin and creatinine rise compared to PNL. CONCLUSIONS: The stone-free rate was higher for PNL, although the fURS could reach comparable results at the expense of performing several procedures. Both techniques have a similar frequency of complications, but the PNL has more postsurgical analytical alterations.

A new approach to laparoscopic implantation of the artificial urinary sphincter: Vesicovaginal approach to the bladder neck. / Nueva aproximación al implante laparoscópico del esfínter urinario artificial: abordaje vesicovaginal al cuello vesical.

INTRODUCTION: The artificial urinary sphincter (AUS) is not used extensively in the treatment of female urinary stress incontinence (USI) due to the poor reproducibility of the techniques used. We describe a new approach to laparascopic implantation, of which dissection of the vesicovaginal space is an essential step. This enables an approach under direct vision to the posterior surface of the bladder neck. MATERIAL AND METHODS: We present two cases where this approach was used. A transperitoneal approach was made in the Trendelenburg position. The main steps were: creating the vesicovaginal space until identifying the bladder neck, creating two laterovesical spaces, communicating these with the vesicovaginal space, and dissecting the anterior surface of the bladder neck, attempting to preserve the pubovesical ligament. The cuff and reservoir were inserted through the 12mm infraumbilical trocar. The connections were externalised through a left suprapubic incision and a subcutaneous tunnel created up to the labia majora where the activation pump was placed. The procedure was completed with closure of the peritoneum. It is essential to use a vaginal valve to facilitate dissection. RESULTS: Surgery time: 140 and 135minutes, with no intraoperative complications. After removing the urinary catheter, one patient had elevated postvoid residual urine volume, which was managed conservatively. Hospital stay: 72h. At 3 and 9 months the patients were fully continent. CONCLUSIONS: We present the preliminary results of laparoscopic implantation of an AUS through a vesicovaginal approach to the posterior surface of the bladder neck, which might reduce potential complications that have been observed after the routine techniques.

Forensic efficiency parameters of the Investigator Argus X-12 kit in women from two Mestizo and seven Amerindian populations from Mexico.

Allele frequency distribution and statistical parameters of forensic efficiency concerning the Investigator Argus X-12 kit (Qiagen, Hilden, Germany) were determined in a total sample of 641 unrelated Mexican females, including two Mestizo-admixed- populations (n=309) and seven Amerindian groups (n=332) from the main regions of the country. Most of the 12 X-STRs were in agreement with Hardy-Weinberg expectations in all nine Mexican populations. The power of discrimination in females (PD) and Median exclusion chance for trios (MECT) and duos (MECD) of this genetic system based on X-STRs were >99.99%. Although Mexican populations showed significant pairwise differentiation, a closer relationship was evident between Amerindian groups and nearby Mestizos, in agreement with historical records, previous genetic studies, and X-linked inheritance pattern expectations.

[The use of ureteral stents and catheters in renal transplantation.] / Empleo de catéteres y stents ureterales en el trasplante renal.

Mayor urological complications, fistulae and stenosis, mainly affect the vesicoureteral anastomosis and present in the early post-transplant period. The systematic use of ureteral catheters keeps selecbeing controversial with many groups using them only selectively depending on the existence of pretransplant or intraoperative risk factors. METHODS: We performed a bibliographic review through automatized search in the Medline bibliographic database, as the main bibliographic source, and also in Clinical Key. The search strategy included the following terms: "stent" AND "kidney transplantation". RESULTS: The bibliographic search revealed the protective effect of the use of ureteral catheters in the transplant ureteroneocystostomy for both development of fistulae (RR 0.29, 0.12 to 0.74, p=0.009) and stenosis (RR 0.27, 0.09 to 0.81, p=0.02). The use of catheters in immunosuppressed patients was associated with significant increase of the incidence of post-transplant urinary tract infections (RR 1.49 IC 95% 1.04 to 2.15, p=0.03) that was prevented by antibiotic prophylaxis with cotrimoxazole directed against pneumocistis carinii. The rates of permeability of self-expandable metallic stents and extra-anatomic bypasses in the treatment of ureteral stenosis after renal transplantation in high surgical risk patients or after the failure of previous surgery, has varied from 50% to 100%, with a limited number of patients included. CONCLUSIONS: The use of ureteral catheters in the extravesical ureteroneocystostomy reduces the incidence of anastomotic complications. Surgery is the treatment of choice of post-transplant ureteral stenosis. The use of metallic stents and extra-anatomic bypasses should be limited to complex ureteral stenosis when primary therapy has failed, in high surgical risk patients or chronic graft dysfunction.