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.

Median raphe cysts in men. Presentation of our experience and literature review. / Quistes de rafe medio en el varón. Presentación de nuestra experiencia y revisión de la literatura.

OBJECTIVES: To present our experience with the diagnosis and treatment of median raphe cysts treated in our department in the last 25years. MATERIAL AND METHOD: We conducted a retrospective study of 28men with median raphe cysts who underwent surgery in our department from June 1990 to March 2015. We analysed the age of presentation, reason for consultation, clinical manifestations, histological findings, treatment and outcome after exeresis. RESULTS: The majority of the patients (22; 79%) were asymptomatic and consulted for the aesthetic defect. Four cases (14%) presented urinary abnormalities, and 2 cases (7%) reported discomfort during sexual intercourse. In all cases, the treatment consisted of surgical extirpation of the cysts, with excellent aesthetic and functional results and no lesion recurrence in any of the patients during a mean follow-up of more than 10years. The most common histological type was the transitional cell type in 15 cases (54%), followed by the mixed type (transitional and squamous) in 11 cases (39%). One case (6%) was pure squamous type, and in another case (6%) the epithelium was glandular. CONCLUSIONS: Median raphe cysts are an uncommon type of disembryoplasia that can occur in any location of the median raphe, from the balanic meatus to the edges of the anus. These cysts are generally asymptomatic and their treatment of choice is surgical extirpation.

[Paratesticular fibrosarcoma. A rare malign neoplasm]. / Fibrosarcoma paratesticular: una neoplasia maligna muy infrecuente.

Hereby we wish to present the clinical and pathological results of a rare paratesticular sarcome of the spermatic cord. This tumor was a fibrosarcoma in a 55 year old male that started in a most unusual way and developed very quickly. We practised a radical orquitectomy with inguinal ligation of the pedicule without post-operatory therapy. After a 5 year follow up, there is no trace of clinical or radiological recurrence in the region or metastasis. We consider radical surgery to be the only therapeutic alternative, even for cases of fast developing, being in our case a good pronostic.

[Endoscopic treatment of the benign prostatic hyperplasia with local anesthesia and sedation in patients with high surgical or anaesthesical risk]. / Tratamiento endoscópico de la hiperplasia benigna de próstata bajo anestesia local-sedación en pacientes de alto riesgo.

INTRODUCTION AND OBJECTIVE: [corrected] The aging of the population causes an increase of the number of men affected by benign prostatic hyperplasia (BPH) with a large number of pathology associated that may limit its surgical treatment. In this study we try to show the effectiveness and security of local anaesthesia and sedation in the endoscopic treatment of the BPH in patients with high surgical-anaesthetic risk. METHODS: During the last 4 years, 38 patients underwent surgical treatment of BPH with ages between 78 and 86 years (average 81,4 +/- 3,2) with severe obstructive prostatic syndrome and high surgical-anaesthetic risk. 15 patients underwent, transurethral incision of prostate (TUIP) and in 23 patients, transurethral resection (TURP) was performed. The blockade anesthetic was made by transrectal periprostatic infiltration finger-guided with 10-15 millilitres of lidocaine 2%. During the procedure an intravenous perfusion of propofol and remifentanil was administered. The obtained results as well as the patient's satisfaction degree was evaluated by means of the elaboration of a questionnaire. RESULTS: The average length of the surgical treatment was of 12 +/- 5 minutes (rank 8 - 25), having itself not stated complications derived from the anesthetic technique. They referred a slight annoyance 4 patients (11%) that was treated increasing the rate of the sedative perfusión. The satisfaction's degree with the received treatment has been good in the 95% of patients. CONCLUSIONS: We considered that the TUIP as much as TURP made under local anesthesia with sedation are safe, effective methods and well tolerated, that fundamentally are indicated in aged patients and when the surgical-anesthetic risk is elevated.

[Diagnosis and management of cystic dysplasia of the seminal vesicle]. / Sobre el diagnóstico y tratamiento de la displasia quística de la vesícula seminal.

INTRODUCTION AND OBJECTIVES: Cystic dysplasia of the seminal vesicle represents a rare congenital urologic anomaly of which elective treatment is controversial. We present our experience in the diagnosis and management of this uncommon pathology. PATIENTS AND METHOD: During the last twelve years we have managed eight patients affected by this pathology. The diagnosis was incidental in the three asymptomatic patients, while the other five consulted because of low urinary tract sympthoms. Ectopic drainage of the ureter in the pathological seminal vesicle was found in three of the patients. Two of these patients presented large pelvic and ureteral ectasy. Other five patients presented renal agenesis. RESULTS: In asymptomatic patients we adopted an expectant attitude, while the other five patients underwent surgical treatment. We performed open surgery in the two cases presenting ureterohydronephrosis, whereas in the other three we performed transurethral incision of the seminal vesicle. We obtained excellent results in all of them, with no evidence of symptomatic pseudodiverticulum. CONCLUSIONS: Transurethral incision of the seminal vesicle cyst is a minimal invasive procedure with low morbidity. We have proved in all of our cases that the retraction of the cyst was practically complete, this has led us into believing that transurethral incision is the elective treatment. Therefore, open surgery would only be indicated in cases of failure of the procedure due to existence of symptomatic pseudodiverticulum, or in patients presenting renoureteral ectasy associated.

Long-term follow-up for the treatment of male urinary incontinence with the Remeex system. / Seguimiento a largo plazo en el tratamiento de la incontinencia urinaria masculina con el sistema Remeex.

OBJECTIVES: To relate our experience in treating postprostatectomy stress urinary incontinence (SUI) with the male Remeex system (MRS). We also list the elements that comprise this system, the implantation technique and its proper adjustment. Similarly, we attempt to determine whether the latest changes made to this device, which constitute the MRS-II, have resulted in fewer mesh readjustments. MATERIAL AND METHOD: From March 2007 to March 2014, we operated on 24 men with postprostatectomy SUI between the ages of 55 and 78 years (mean, 67 years), through the placement of a Remeex suburethral tension-adjustable sling. All patients had severe urinary incontinence, with considerable impact on their quality of life. RESULTS: All patients, except for 2 who required the removal of the system, remained continent. Nine of the patients (39%) occasionally required incontinence pads when performing intense physical exercise. The mean number of adjustments was 2.4 (range 0-6). The score on the Incontinence Impact Questionnaire (IIQ 7) performed before the surgery and 6 months after, went from 79±7 points to 11±3, with a very high degree of satisfaction. CONCLUSIONS: The MRS is a valid therapeutic option for postprostatectomy incontinence and is a reproducible technique that is easy to perform, has a low rate of complications and provides excellent and lasting results. There is also a clear trend towards reducing number of adjustments with the new MRS-II.

[Selective arterial embolization in a case of renal cell carcinoma as therapeutic choice]. / Embolización arterial selectiva en un caso de carcinoma de células renales como alternativa terapéutica.

We show a big renal cell carcinoma case in an aged woman with many pathology associated. In view of the family refuse to make the radical surgery and the high surgical risk we decided to apply transarterial embolization treatment with polivinil alcohol particles (PVA). 28 months later the patient becames with no symptoms and with high quality life. We come to the conclusion that embolization is an effective therapeutic for the symptoms control in selectionated cases.

[Endoscopic electrofulguration of intraurethral condylomata acuminata]. / Electrofulguración endoscópica de los condilomas acuminados intrauretrales.

Cluster condyloma is currently one of the sexually transmitted diseases of higher incidence. The most common sites for condyloma in males are the balanopreputial sulcus, frenulum and the glans' mucosa. Associated to penis condyloma there can be urethral lesions in 5% of patients which in 80% of cases develop less than 3 cm from the meatus. This paper presents a series of 14 cases of cluster intraurethral condyloma managed by transurethral electrofulguration. The technique consists in the introduction of a coagulation probe through the urethrotome and the application of electrofulguration to the condyloma base. Results have been satisfactory although relapse has occurred in 2 cases (14%), and in one of them the procedure had to be repeated up to 3 times. There has been no complications such as stenosis in the loop resections. The authors conclude that due to the difficulties in the medical management of these lesions, the use of invasive techniques, of which transurethral electrofulguration of the condyloma base with endoscopic urethrotome is the choice because of its simplicity and effectiveness, is justified.

[Pheochromocytoma: a review of our own cases]. / Feocromocitoma: revisión de nuestra casuística.

Presentation of 6 cases of pheochromocytoma, diagnosed and treated in our Unit over the last 5 years. Five were adrenal pheochromocytomas and 1 an abdominal paraganglioma in a 42 year-old woman. Distribution by gender was 4 male and 2 female, and mean age at presentation was 45.2 years ranging from 35 to 55 years. Clinically, all patients were hypertensive. Two of the 5 cases with adrenal location presented with catecholaminic crisis with BP > 240/140 mmHg. The paraganglioma was diagnosed while studying a case of sustained HBP in a 42 year-old female referred from another unit. With regard to diagnosis, the sensitivity of urinary tests was 100%, and gammagraphy with meta-iodine-benzyl-guanidine (MIBG) was particularly useful in the extra-adrenal location case. In all our patients, computerized tomography (CT) was the choice procedure to locate the tumour. Treatment was surgical in all cases, access being transperitoneal in 3 cases, thoracoabdominal in 2 and classic lumbotomy in 1. All our patients received prior treatment with alpha-blocking agents, and intraoperative complications were 1 arrythmic crisis, 1 hypotensive picture and 1 hypertensive crisis, all of which resolved successfully. Currently, 5 patients remain disease free. Mild HBP controlled with low dose captopril still persists in one patient.

[Urologic impact of Crohn disease]. / Sobre las repercusiones urológicas de la enfermedad de Crohn (EC).

Presentation of two cases of Crohn's disease seen in our Service in which the urological symptoms were of special relevance. One patient presented clinically with a picture of anaemic gross haematuria. The other one, was a patient already diagnosed with Crohn's disease who developed an enterovesical fistula in spite of receiving medical treatment. Both cases were resolved surgically. The clinical aspects, natural history and treatment of this uncommon form of urinary tract involvement are discussed.

[Burned out testicular tumor]. / Tumor testicular fundido "Burned out".

OBJECTIVE: Extragonadal germ cell tumor is a rare condition. The present study reports an additional case of this uncommon disease. METHODS/RESULTS: A 24-year-old male with retroperitoneal disease and a testicular lesion detected by ultrasonography is described. Histopathological analysis of the orchiectomy specimen disclosed a 'burned out' tumor. The anatomopathological features of this tumor type are discussed. CONCLUSION: Extragonadal germ cell tumor is a rare condition. It derives from the germ cells that exist in the gonad and is located in every anatomical region but the gonad itself. Ultrasonography must be performed if an extragonadal germ cell tumor is suspected.

[Adrenal gland myelolipoma: review of the bibliography regarding a case]. / Mielolipoma suprarrenal: revisión bibliográfica a propósito de un caso.

OBJECTIVE: To describe an additional case of this rare disease entity, with special reference to its diagnosis and treatment, and to briefly review the literature. METHODS: We report on an 82-year-old male with adrenal myelolipoma that had been incidentally discovered during evaluation for another condition. A left adrenalectomy was performed due to the large size of the tumor and in order to determine its benign or malignant nature. RESULTS: The histopathological findings disclosed an andrenal myelolipoma. CONCLUSIONS: Adrenal myelolipoma is an uncommon tumor type. CT is the most effective diagnostic method. Surgery is advocated in symptomatic cases and in asymptomatic cases with a large tumor mass.