Radical robot-assisted laparoscopic nephrectomy with thrombectomy in the vena cava. / Nefrectomía radical laparoscópica asistida por robot con trombectomía en vena cava.

BACKGROUND: Renal cell carcinoma has a natural tendency to extend through the renal vein. When the thrombus reaches the vena cava, thrombectomy and the necessary reconstruction of the vena cava are typically performed by open pathway. Robot-assisted technology provides advantages for performing this complex technique, using a minimally invasive access. MATERIAL AND METHODS: We present the technique we employed in the first case performed in our department. After performing renal artery embolisation, we conducted the surgery with the Vinci S robotic system. The main steps of the surgery are as follows: detachment and Kocher manoeuvre; release of the lower renal pole; clamping and sectioning of the renal artery; endocavitary ultrasound to locate the thrombus; placement of tourniquets in the vena cava below and above the renal veins and in the left renal vein; closure of the 3 tourniquets; opening of the vena cava; resection and extraction of the thrombus; suture of the vena cava; opening of the tourniquets; complete release of the kidney; bagging and extraction of the specimen. RESULTS: The surgery was performed without complications. The patient required a transfusion of 2 units of packed red blood cells and was discharged with modest renal failure (creatinine level of 1.60mg/dl). CONCLUSIONS: Radical nephrectomy with thrombectomy in the vena cava is a technique susceptible to severe complications and has, to date, been performed in few centres. We believe that the technique is reproducible and has clear advantages for our patients.

[Laparoscopic treatment of ovarian vein syndrome]. / Tratamiento laparoscópico del síndrome de la vena ovárica.

OBJECTIVE: We report a case of Ovarian Vein Syndrome, describe its clinical symptoms and discuss its diagnosis and management including laparoscopic surgery treatment. MATERIALS AND METHODS: A 36-year-old female with right kidney recurring pain was studied by means of abdominal RX, urography, CT, MRI and ultrasonography and finally diagnosed from Ovarian Vein Syndrome. The case was resolved with laparoscopic surgery. CONCLUSIONS: Ovarian Vein Syndrome is an uncommon disorder. Differential diagnosis must be done with external processes that cause ureteral obstruction. Surgery is the first line treatment when clinical symptoms are present and, in our opinion,laparoscopic surgery is the best approach to treat this pathology.

[Endopyelotomy. A definitive alternative to pyeloplasty?]. / Endopielotomía. Alternativa definitiva a la pieloplastia?

Endopyelotomy is a minimally invasive surgical alternative to the classic open surgery in the treatment of stenosis of the pyelo-ureteral attachment with similar success rates. This paper presents the results from 38 endopyelotomies performed between February 1989 and December 1993 in equal number of patients, 36 of them using percutaneous approach, 29 through the medium calix and 7 through the lower calix. Acucise's catheter was used in both cases. With the total of 38 endopyelotomies performed the complications and results obtained are presented as well as the results assessed by clinical, radiological and renographic criteria. The overall rate of success for endopyelotomy was 77.8%. When only improvement of urographic signs was evaluated, the success rate was lower (66.7%). In 4 clinically asymptomatic patients who showed no radiological improvement, a good response to diuretic therapy was seen in the renogram which was shown to be a basic test in the diagnosis, evaluation of results and follow-up of these patients. It is concluded that currently, endopyelotomy represents a choice technique in the treatment of stenosis of the pyelo-ureteral attachment with a low rate of intraoperative complications (3.4%). Also, it must be established that failure of this minimally invasive technique does not condition any added surgical difficulties to perform pyeloplasty.

[Prostatic melanosis]. / Melanosis prostática.

Melanin presence in the prostate can be accurately localized in epithelial cells (nevus) or in the stroma (prostatic melanosis). This article describes a new case and compiles all recorded cases as well as the theories concerning their origin.

[Ureteral stenosis of uretero-ileal anastomosis]. / Estenosis ureterales de las anastomosis urétero-ileales.

Replacement plasty allows to perform oncology surgery while maintaining body image and preserving renal function. Entero-ureteral anastomosis is a significant element in this procedure where the main responsible for the loss of renal function are stenosis, infection and reflux. Our group has performed 206 orthotopical vesical replacements (November 1981-November 1998), using a direct Wallace-type uretero-ileal anastomosis. An intussusception valve system was used as antireflux mechanism. The number of obstructions, rate of stenosis at the uretero-ileal junction and incidence of valve stenosis were all analyzed as part of the complications occurred over a follow-up period of 54 months (6-183). Findings included 6 stenosis at the uretero-intestinal junction and 2 at the intussusception valve. Two (3.8%) of the uretero-ileal stenosis were earlier and associated to fistula; one was treated with open surgery and one had a double J placed through antegrade percutaneous access. Of the remaining late four, only one was treated with a double J catheter while the other three had to be re-operated. Stenoses of the valvular system (1.2%) were solved with open surgery. From our experience, we believe that direct uretero-ileal implantation with scraping of the ureter is a safe technique with little risk for stenosis at the uretero-ileal junction. Intussusception was used a antireflux system in all cases.

[Agenesis of vas deferens and cystic fibrosis]. / Agenesia de conductos deferentes y fibrosis quística.

Congenital bilateral absence of vasa deferens appears in 6% of obstructive azoospermia, and 60-70% of these patients also have cystic fibrosis mutations. Unilateral aplasia or agenesia of vasa deferens occurs in less than 1% male individuals and some studies have found that up to 43% cases show mutations in the cystic fibrosis gen. We contribute four case reports of bilateral agenesia who were seen for infertility, all of which showed presence of mutation. In none of the two cases of unilateral agenesia, who consulted for vasectomy, a mutation in the cystic fibrosis gen was found. Patients with bilateral agenesia and their partners should be screened for cystic fibrosis, prior to spermatic microaspiration and assisted fecundation.

[Tuberculosis and renal cancer]. / Tuberculosis y cáncer renal.

The association of tuberculosis and renal adenocarcinoma is very uncommon. In general, the condition presents clinically, radiologically and biologically, as a tuberculosis while the diagnosis of renal carcinoma came as a pathoanatomical finding following nephrectomy. We contribute one case report of tuberculosis and renal adenocarcinoma in association that initially presented with tumoral signs and symptoms in a 34-year-old female patient. The patient, with no previous background, was later diagnosed TBC. A review is made on the pathogenesis, epidemiology and pathoanatomical diagnosis of tuberculosis. It is hypothesized that the tuberculosis damage may be a reactivation secondary to a renal tumour.

[Primary abscess of the psoas. Report of a case]. / Absceso primario de psoas. A propósito de un caso.

Psoas abscess is an uncommon condition at the present time. The initial anodyne signs and symptoms make diagnosis difficult. It can be diagnosed and rated as primary when the origin is not found, or secondary when a focus for infection spreading is detected. Drainage either percutaneously or by open surgery, and antibiotic therapy are the choice treatment, achieving an important survival rate. This paper presents a new case of psoas abscess, including a revision of the diagnosis and treatment of this condition.

[Permanent endoprostatic prostheses in patient with obstruction caused by benign hyperplasia of the prostate]. / Prótesis endoprostáticas permanentes en pacientes con obstrucción por hiperplasia benigna de próstata.

Presentation of the results obtained using the intraprostatic prosthesis UroLume in 78 patients wit BPH obstruction, 69 of which presented high surgical risk (ASA IV). Mean age was 79.8 years (r: 62-93). All patients carried urethral catheters, except 4 (5.1%) who had a provisional metal coil that required replacement. Prosthesis were implanted successfully in 72 cases (93.3%). The most significant exclusion criterion was an excessive length of prostate urethra. Mean follow-up was 15.3 months (r: 3-38). Mean maximum flow at 1 year after implant was 12.7 mL/sec; mean symptoms score (I-PSS score) was 6.2 points and in most prosthesis, epithelization had taken place. Three patients required implant of another prosthesis, either during the same surgical procedure (1 case) or later due to retention or dysuria (2 cases). Due to acute urine retention (AUR) during the immediate postoperative, resection of the middle lobe was performed in one case while a second case required late resection of intraluminal hyperplastic tissue. Three patients (4.1%) had haematuria that forced hospital admission some months after the implant, and three cases (4.1%) required removal of the prosthesis; at patient's request (1 case), due to calcification (1 case) and for stress incontinence (1 case). After a follow-up of over three years, it can be concluded that the UroLume prosthesis is an effective alternative to TUR in patients at high surgical risk.

[Laparoscopic approach of Dielt's syndrome]. / Tratamiento laparoscópico del síndrome de Dielt.

Dielt's syndrome is generally known as nephritic colic due to the dilation of the urinary tract that results from a renal ptosis. In spite of renal ptosis being a commonly seen occurrence, sometimes it can be the cause of a serious painful clinical manifestation. This paper presents one case successfully treated through laparoscopic nephropexy. It also includes a discussion on the various diagnostic and therapeutical techniques.

[Quality of life in patients treated with orthotopic bladder substitution versus cutaneous ileostomy]. / Estudio de la calidad de vida en pacientes sometidos a sustitución vesical ortotópica versus ileostomía cutánea.

PURPOSE: Nowadays, psychcological and social aspects of treatment of urinary diversion after cystectomy, have become of utmost importance. Body image, potency, continence, emotional distress and dissatisfaction, functional and social activities are majors factors to improve quality of life after surgery. The aim of this study is to compare health-related quality of life after bladder substitution with ileal conduit diversion. MATERIALS AND METHODS: We developed a questionnaire based upon a literature review, to compare health related quality of life between bladder substitution and ileal conduit (45 multiple choice mailed questionnaire). We examined functional and social activities, sexual dysfunction, urinary problems, and body image dissatisfaction. RESULTS: 78 male patients with bladder cancer, were interviewed. 91% of the questionnaires were answered, 48.7% by patients' family and 42.3% by the patients themselves. 6 patients underwent ileal conduit and 27 underwent bladder substitution. Patients with ileal consuit presented higher body image dissatisfaction than those who underwent bladder substitution. When urine leakage occurred it caused more distress to the conduit patients, indicating urinary leakage as their main problem. Bladder substitution patients did not consider continence problems as very important, they had not interrupted social activities such as travelling or seeing friends. 100% of bladder substitution patients would not mind to undergo this operation again, while only 66% of ileal conduit patients would. CONCLUSION: Health-related quality of life is higher after bladder substitution. In our opinion we should use bladder substitution as the standard method of diversion after radical cystectomy for bladder cancer.

[Paratesticular lipoma]. / Lipoma paratesticular.

In spite of being the most frequent benign tumour of the spermatic cord, absolute frequency of this neoplasia is very low. We discuss here a case report of an spermatic cord lipoma with several years evolution. Although ultrasound is useful for clinical diagnosis, exploratory scrototomy and surgical exeresis of the mass is the only reliable diagnosis and viable treatment.

[Testicular epidermoid cyst]. / Quiste epidermoide testicular.

Epidermoid cysts are benign tumours that can affect testicles. Incidence is rare, having been described until now in less than 200 cases. Contribution of one study case of testicular epidermoid cyst and discussion of issues on histogenesis, ultrasound diagnosis and therapy approaches.

[Laparoscopic radical prostatectomy. Preliminary experience]. / Prostatectomía radical laparoscópica: experiencia preliminar.

OBJECTIVE: Laparoscopic technique has been developed with the aim to decrease the morbidity of the open radical prostatectomy. MATERIAL AND METHODS: From january 2002 to may 2002, 8 patients were treated for prostate cancer with laparoscopic radical prostatectomy. Unilateral linfadenectomy has been carried out in only one patient. We usually employ the transperitoneal technique published by the Montsouris Institute, with some modifications. RESULTS: The main surgical time was 356 minutes (540-240). Transfusion wasn't needed in any case. Intraoperative complications were: 2 bladder injuries, 1 bleeding of the epigastric artery. Postoperative complications were: 1 ileus, 2 compressive neurapraxia, 4 anastomotic fistutas. All complications were treated conservatively. No patient were converted to open surgery. Surgical limits were negatifs in all cases, and the PSA rate was less than 0.1 ng/ml in the first month follow up. CONCLUSION: Laparoscopic radical prostatectomy is a difficult technique, but we think that, the learning curve is getting lower and lower than in the first series. Oncologic results with this technique is similar to the open one. However, laparoscopic approach shows us some benefits such as less bleeding, less time catheterisation, less hospital stay, better continence, better sexual function, better stetic result, less postoperative pain, and finally an earlier back to work.

[Treatment of psoas abscess: percutaneous drainage or open surgery]. / Traitement de l'abcès du psoas: drainage percutané ou chirurgie ouverte.

OBJECTIVE: Psoas abscess is currently an uncommon disease and is often difficult to diagnose because of its minor initial symptoms. We compare treatment by percutaneous drainage and surgery. MATERIAL AND METHODS: Five patients, all immunodepressed, which appears to be an important factor in the aetiology and pathogenesis of psoas abscess. Computed tomography appears to be the best diagnostic method. RESULTS: Three subjects underwent open surgery and developed serious complications in contrast with two patients treated by CT-guided percutaneous drainage, preceded by antibiotics. CONCLUSION: First-line percutaneous drainage appears to be the best approach at the present time, reserving open surgery for very large abscesses.

[Stenosis following a direct uretero-ileal anastomosis technique in substitutive enterocystoplasty]. / Sténoses après une technique d'anastomose urétéro-iléale directe dans les entérocystoplasties de substitution.

OBJECTIVES: Stenosis of the uretero-ileal anastomosis and reflux are the commonest causes of secondary deterioration of renal function following enterocystoplasty. Various direct anastomosis and antireflux techniques have been proposed in order to reduce the risk of stenosis and reflux. In this retrospective study, the authors evaluated the risk of stenosis and reflux after right uretero-ileal anastomosis on an invaginated ileal loop. MATERIAL AND METHODS: The authors evaluated the uretero-ileal anastomosis stenosis and reflux rate and problems of the invaginated ileo-ileal valve in 157 patients after bladder replacement enterocystoplasty. RESULTS: The anastomosis stenosis rate was 3.8% (6/157 patients) and all 6 patients were reoperated. Stenotic complications on the valve were observed in 1.2% of cases (2/157 patients). The total stenosis morbidity was 5% (8/157 patients). CONCLUSION: Direct end-to-end uretero-ileal anastomosis is the simplest technique associated with the lowest risk of stenosis. The low stenosis rate associated with invaginated valves is due to a modification of the valvular system (limitation of the mesenteric exclusion manoeuvre, external anchorage of the invagination and fixation by two lines of resorbable staples).

Nefrectomía radical laparoscópica asistida por robot con trombectomía en vena cava / Radical robot-assisted laparoscopic nephrectomy with thrombectomy in the vena cava

Introducción: El carcinoma de células renales tiene una tendencia natural a extenderse a través de la vena renal. Cuando el trombo alcanza la vena cava, la trombectomía y la necesaria reconstrucción de la vena cava se realiza habitualmente por vía abierta. La tecnología robótica proporciona ventajas para poder realizar esta técnica compleja mediante acceso mínimamente invasivo. Material y métodos: Presentamos la técnica que hemos utilizado en el primer caso operado en nuestro servicio. Previa embolización renal, se realiza la intervención con sistema robótico Da Vinci(R) Si. Los principales pasos de la intervención son: decolación y maniobra de Kocher; liberación de polo inferior renal; clipaje y sección de arteria renal; ecografía endocavitaria para localizar el trombo; colocación de torniquetes en cava por debajo y por encima de las venas renales, y en la vena renal izquierda; cierre de los 3 torniquetes; apertura de la vena cava; resección y extracción del trombo; sutura de la vena cava; apertura de los torniquetes; se completa la liberación del riñón; embolsado y extracción de la pieza. Resultados: La intervención se realizó sin complicaciones. Fue necesario transfundir 2 concentrados de hematíes y fue dada de alta con una discreta insuficiencia renal (creatinina de 1,60 mg/dl). Conclusiones: La nefrectomía radical con trombectomía en vena cava es una técnica susceptible de complicaciones graves, que hasta ahora se ha realizado en pocos centros. Pensamos que es una técnica reproducible y con evidentes ventajas para nuestros pacientes

Background: Renal cell carcinoma has a natural tendency to extend through the renal vein. When the thrombus reaches the vena cava, thrombectomy and the necessary reconstruction of the vena cava are typically performed by open pathway. Robot-assisted technology provides advantages for performing this complex technique, using a minimally invasive access. Material and methods: We present the technique we employed in the first case performed in our department. After performing renal artery embolisation, we conducted the surgery with the Vinci S robotic system. The main steps of the surgery are as follows: detachment and Kocher manoeuvre; release of the lower renal pole; clamping and sectioning of the renal artery; endocavitary ultrasound to locate the thrombus; placement of tourniquets in the vena cava below and above the renal veins and in the left renal vein; closure of the 3 tourniquets; opening of the vena cava; resection and extraction of the thrombus; suture of the vena cava; opening of the tourniquets; complete release of the kidney; bagging and extraction of the specimen. Results: The surgery was performed without complications. The patient required a transfusion of 2 units of packed red blood cells and was discharged with modest renal failure (creatinine level of 1.60 mg/dl). Conclusions: Radical nephrectomy with thrombectomy in the vena cava is a technique susceptible to severe complications and has, to date, been performed in few centres. We believe that the technique is reproducible and has clear advantages for our patients

[Bilateral pheochromocytoma]. / Feocromocitoma bilateral.

We report a case of bilateral adrenal pheochromocytoma in a young, male patient who consulted for arterial hypertension. The adrenal tumors had been accurately diagnosed by abdominal ultrasonography and confirmed by CT. The incidence of bilateral involvement in pheochromocytoma is briefly discussed and the methods currently utilized for topographic localization of the tumor are described.

[Why is intussusception an antireflux mechanism?]. / Por qué la intususcepción como mecanismo antirreflujo?

One of the aims of bladder substitution or augmentation using the intestine is to preserve renal function. If reflux impairs renal function, an antireflux mechanism should be attempted. Direct ureteroileal reimplantation with spatulation of the ureter is safer and carries a lower risk of stenosis. The antireflux mechanism is created by ileoileal or ileocecal intussusception without involvement of the ureter. Thus we can diminish the risk of stenosis and reflux at the same time.

[Ileal ureteroplasties]. / Ureteroplastias ileales.

When the ureter is extensively compromised, preservation of the kidney without recurring to external diversion may be attempted by a psoas bladder procedure, transureteroureterostomy, renal autotransplantation or ureteral substitution using the intestine. The first two are not always possible and transplantation is perhaps extremely disproportionate. We therefore recur to ureteral substitution using the intestine. Ureteral substitution may be partial or total, although it is recommended to preserve the upper segment of the lumbar ureter whenever possible. The procedure can be performed using the entire ileal segment with or without modelling to the appropriate thickness. Reducing the diameter of the ileal graft will enhance urine propulsion, reduce mucus secretion and improve antireflux dynamics. Nine cases of ureteral substitution are described herein. Treatment depended on the underlying pathology, extent of ureteral compromise and location. The techniques employed were ureteral substitution with or without modelling and ureteral substitution combined with a bladder repair procedure.