[Conservative approach in major renal trauma]. / Manejo conservador de los traumatismos renales de alto grado.

INTRODUCTION: Genitourinary trauma amount to an 8-10% of abdominal trauma with the kidney being the most affected organ in 50% of cases, especially the left one. The choice of treatment will depend on the kind of lesion found in the affected renal unit and on the patient's clinical conditions. OBJECTIVE: The aims of this study are twofold: to determine the applicability of conservative treatment in major renal trauma and to assess the evaluation and emergence of possible complications. MATERIAL AND METHODS: We have analysed 309 cases of renal trauma dealt with in our department between January 1984 and January 2006, analyzing such variables as the etiology of the trauma, associated lesions in other organs, the therapeutic approach adopted as well as the presence of complications, both in the long and short run. RESULTS: Out of a total of 309 renal trauma analyzed, a 94.1% (291 cases) were blunt renal trauma. The distribution by grade was: Grade I, 213 cases (69%); Grade II, 39 cases (12.6%); Grade III/IV, 32 cases (10.3%); Grade V, 25 cases (8%). We have given a conservative approach in the 84.6% of the grade III/IV cases (24 cases). 4 grade III nephrectomies were carried out in the Emergency Room because of haemodynamic instability, other 4 grade IV nephrectomies were done for the same reason, one of which was a partial nephrectomy, 48-72 hours after the trauma. The treatment for grade V was nephrectomy in 67%. CONCLUSIONS: According to our experience and in the light of the results obtained, we consider the conservative approach adequate for major renal trauma as long as the patient is haemodynamically stable.

[Complications of uretero-renoscopy]. / Complicaciones de la uretero-renoscopia.

INTRODUCTION: Since its clinical introduction ureteroscopy (URS) has experienced an impressive development due to the technical improvements of new and smaller urological armamentarium. Currently, ureteroscopy is a worldwide procedure with a varied number of diagnostic and therapeutic possibilities. However, the technique has complications. MATERIAL AND METHODS: We analyse the complications of URS in a series of 4.645 ureteroscopic procedures performed from january 1990 to december 2001, 2972 (64%) female and 1673 (36) male. The objectives of URS were diagnostic (haematuria) and therapeutic (ureteral stones, tumors, strictures and placement of stents). RESULTS: Fever was the most frequent complication (11.7%), with sepsis in 15 patients. Another complications were: ureteral perforation (1.2%), ureteral avulsion (0.06%), renal injury (0.04%), extrusion (0.4%) and uretero-iliac fistulae (0.02%). The most common treatment was conservative with endourological approach. CONCLUSION: Carefully performed ureteroscopy is a superb tool for the urologist either for diagnostic or therapeutic purposes with a low ratio of complications. The majority of these complications can be solved with conservative management.

[Pyeloureteral fungus ball in patients with urinary lithiasis. Treatment with ureterorenoscopy]. / Fungus ball pieloureteral en pacientes con litiasis urinaria. Tratamiento con ureterorrenoscopia.

INTRODUCTION: C. albicans is the most frequent fungus causing opportunist infections of the urinary tract. Agglutination of necrotic tissue nucleus (papilary necrosis), mucosus debri and chirurgic or lithiasic debri, originates a fungus ball, which can obstruct the urinary tract at any level. CLINICAL DATA: We present 2 patients with obstructive urinary lithiasis developing fungus ball in the dilated upper urinary tract. Patient 1 was bilaterally affected and never had systemic symptoms. Treatment consisted of uretherorrenoscope for removal of fungus ball, bilateral urinary diversion and anphotericine B irrigations and systemic. Patient 2 developed a candidemia and was treated with systemic liposomal anphotericine B, uretherorrenoscopy with removal of ureteric calculus and fungus ball, and placement of a double J catheter and nephrostomy tube for anphotericine B irrigation. DISCUSSION: Urinary lithiasis is a risk factor for fungal infection of the upper urinary tract, provided there is no other predisponent factor for opportunistic fungal infections. Calculi facilitates fungal growth by means of obstruction and subsequent retrograde estasis and creating a nucleus for growth, aggregation and ramification of mycelium. The infection pathway is probably ascendent and may turn into fungemia and septicaemia. Systemic antimicotics, urinary diversion and local irrigations with antimicotics, and endourologic technics, are the three basic items in the treatment. Ureterorrenoscopy plays an important roll as a diagnostic and therapeutic tool as it may solve the obstruction and allows removal of fungus ball.

[Adenocarcinoma of the kidney pelvis]. / Adenocarcinoma de pelvis renal.

We present a case of primitive renal pelvis and calix adenocarcinoma. The clinical evaluation was carried out by means of UIV, echography and TC. Although the tumoral type diagnosis is histologic, the clinical manifestations of chronic renal infection-inflammation, whether associated with obstruction and/or lithiasis or not, are suggestive of this possibility.

[Extracorporeal shockwave lithotripsy in single kidneys. Our experience]. / Litotricia extracorpórea por ondas de choque en monorrenos. Nuestra experiencia.

Forty patients with renal lithiasis in single kidney were treated with extracorporeal shock wave lithotrity in our unit. Nine patients required emergency urinary by-pass, because of original picture of obstructive anuria, and in another 21 cases a double-J catheterism was conducted as prophylaxis prior to lithotrity. Treatment was carried out with analgesia and ambulatory, except for 10 patients with calculi of less than 10 mm where by-pass was not performed, and who were kept in preventive hospitalization for 24 hours. Average of sessions per patients was 1.59 (range 1-7). After 6 months follow-up there are 24 free renal units (60%), 12 (30%) with debris that can be expelled, failure in 4 (10%): 2 with debris that can be expelled and 2 which were not fragmented. Renal function has not deteriorated during follow-up, except for 2 patients with obstructive uropathy, that subsequently normalized following resolution of the condition. No significant differences were found in the treatment of calculi of less than 10 mm with or without double-J. ESWL is considered to be the choice approach for lithiasis in patients with one single kidney, due to is efficacy and low morbidity, safety in the ambulatory environment, even for calculi of less than 10 mm with no urinary by-pass.

[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.

[Extracorporeal shock-wave lithotripsy in the treatment of calculi in horseshoe kidneys. Our experience]. / Litotricia extracorpórea por ondas de choque en el tratamiento de la litiasis en riñones en herradura. Nuestra experiencia.

Thirty-one (31 renal units (RU) were treated with extracorporeal shock wave lithotrity (ESWL) in 27 patients with lithiasis in horseshoe kidneys (HK). Treatment was done in an out-patients environment and in two thirds of cases the patient was placed in prone-decubitus. An average of 2.42 sessions per patient (range 1-8) were performed freeing 15 RU, 10 with removable residues, and failure in 6:3 with non-removable residues in all asymptomatic cases, 2 where fragmentation was insufficient and 1 renal annulment post-ESWL. Overall, results were "good" in 80.6% cases, with a significant relationship between size of lithiasis and therapeutical results. Thus, for < or = 2 cm calculi the result was good in 100% cases but a greater number of cleaning were required in those < 1 cm (62.5 vs 46.15%). On the contrary, "therapeutic failures" were limited to just > 2 cm calculi. It can therefore be concluded that most patients with lithiasis in HK, specifically when calculi are < 2 cm, can be treated primarily and in monotherapy with ESWL.

[The treatment of ureteral lithiasis with a pulsed dye laser]. / Tratamiento de la litiasis ureteral con láser pulsado colorante.

PURPOSE: Pulsed dye laser lithotripsy has shown to be an effective and safe procedure for treatment of ureteral calculi. We report our experience. MATERIAL AND METHODS: A total of 1000 patients were treated with pulsed dye laser between January 1990 and February 1996. In 450 patients the procedure was performed under general or regional anaesthesia; the remaining 550 patients were treated with the aid of a mild sedation. RESULTS: In the mild sedation group a total of 417 out of 550 patients (75.8%) had their calculi completely cleared (85.6% of effectiveness in women with pelvic lithiasis). Different facts caused the treatment to fail in the remaining patients: severe pain, vagal reaction and technical difficulties. In the anesthesia group the procedure was effective in 346 cases (76.9%). Laser failed to clear calculi in 104 patients in this group due to technical impossibility and persistence of ureteral fragments. Additional treatment options in order to achieve resolution of the calculi were: ESWL, both ESWL and laser, Dormia basket, Zeiss stent, three-prong grasping forceps, ureterolithotomy and nephrectomy. Morbidity was higher in the group treated under anesthesia, being haematuria the most frequent adverse effect. CONCLUSIONS: We believe that ureteroscopy and laser lithotripsy is an effective, safe and low morbidity procedure for the treatment of ureteral calculi in women with distal calculi. It is often suitable to perform it with mild sedation with the subsequent benefit for both the patient and health care system regarding to cost-effectiveness balance.

[Renal involvement in Burkitt's lymphoma]. / Afectación renal por linfoma de Burkitt.

Review of one case of Burkitt's lymphoma in a 60 year-old male diagnosed with a renal tumour based on the symptomatology, intravenous urography (IVU), ultrasound and CT. In spite of the chemotherapy applied, the patient died 31 days after hospitalization. Burkitt's lymphoma is an infrequent tumour in our setting and renal invasion is rarely observed. The tumour's nature is neither revealed by IVU or ultrasound, CT being the most appropriate imaging technique showing a mass of decreased density that surrounds and infiltrates the tumour. The therapeutical approach for renal tumours is the same as for Burkitt's lymphoma. Besides the rarity of Burkitt's lymphoma, our patient was an atypical case for the age of presentation, early stage of renal invasion and fulminant evolution.

[Diagnosis and treatment of renal angiomyolipoma]. / Diagnóstico y tratamiento del angiomiolipoma renal.

Fourteen cases of angiomyolipoma have been diagnosed and treated at our center since it opened 19 years ago. The diagnostic methods and therapeutic approach have changed since then. Noninvasive imaging techniques like CT and ultrasound have significantly enhanced the accuracy of diagnosis. The mode of presentation, number, size and the differential diagnosis may decide between conservative or surgical management of these tumors. A small tumor mass only requires observation. For larger ones, the treatment of choice is preferably by conservative surgery or highly selective embolization if permitted by the severity of the disease. Surgery is warranted when doubt exists on CT and ultrasonography.

[Carvernosometry in impotence: method and standardization of normal values]. / Cavernosometría en la impotencia: método y estandarización de valores normales.

Cavernosometry and cavernosography in conjunction with artificial erection have been included in the protocol for the evaluation of sexual dysfunction in the male. The device is comprised of a volumetric infusion pump with a digital flow indicator, and the technique employed is bilateral puncture of the corpora cavernosa. Pressures are recorded by one needle while saline and contrast medium are introduced through the other. Eight males with no organic disorder were assessed for erection flow (EF) and maintenance flow (MF) to determine the normal and pathologic values for this method of evaluation. These values have a normal distribution. Calculation using formulas with a 99% reliability gave the following as pathological values: EF greater than 181 ml/min. or MF greater than 99 ml/min.

[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.

[Treatment of calcium kidney lithiasis. ESWL, NLP, open surgery]. / Tratamiento de la litiasis renal cálcica. LEOC, NLP, cirugía abierta.

OBJECTIVE: To review current management of renal calcium stones. METHODS: Data from our experience are presented and the literature is reviewed. The results and indications of treatment are analyzed. RESULTS/CONCLUSIONS: Pyelic calculi are the best indication for ESWL. The success rate ranges from 33%-90% and is influenced particulary by stone size and composition. Similar results are achieved for calyceal calculi, although the overall complete resolution rate is 50%-75% for stones in the lower calyces versus 90% for PNL. Furthermore, the resolution rate is even lower if the infundibulo-pyelic angle is less than 90 degrees. The resolution rate ranges from 4%-58% for intradiverticular calculi and the best results are obtained when the calculus is small and the neck of diverticulum can be visualized at urography. The staghorn stone is the most complex and offers more difficulties to treatment by ESWL. Good results are achieved only in the staghorn type I (72% resolution; mean 3.5 sessions per patient).