Magnetic resonance imaging to evaluate anterior pelvic prolapse: H line is the key.

INTRODUCTION: The aim of the study is to compare clinical staging of anterior pelvic prolapse with magnetic resonance imaging (MRI) staging, using the pubococcygeal line (PCL), the midpubic line (MPL), and the H line as reference lines. Moreover, we aim to analyze interrater reliability of each reference line. MATERIAL AND METHODS: Forty-two women with pelvic organ prolapse (POP) symptoms were studied using the pelvic organ prolapse quantification on physical examination. Two different observers calculated anterior POP using the three MRI reference lines, retrospectively. Agreement between MRI and clinical staging was estimated using Pearson correlation for the quantitative measurements and kappa index for the stages. Interrater reliability was estimated using the intraclass correlation coefficient (ICC). RESULTS: Correlation between physical examination and the H line was high by both observers (r = 0.86 and r = 0.76, p < 0.01). The correlation was lower using MPL (r = 0.76 and r = 0.65, p < 0.01). The results of comparing MRI staging and physical examination were: κ = 0.618 and κ = 0.602 for the H line, κ = 0.273 and κ = 0.267 for MPL and κ = -0.105 and κ = -0.140 for PCL. The results of interrater reliability were: ICC of 0.968 for the H line, ICC of 0.788 for MPL, and ICC of 0.737 for PCL. CONCLUSION: Anterior POP staging using MRI H line as a reference presents a better agreement with clinical staging than PCL or MPL. The H line has better interrater reliability. The H line could replace the current lines.

[Quality of care indicators for benign prostatic hyperplasia. A qualitative study]. / Indicadores de calidad en hiperplasia benigna de próstata. Un estudio cualitativo.

OBJECTIVE: To assess quality of care indicators for benign prostatic hyperplasia (BPH), and to evaluate their strengths and weaknesses for incorporation into health information systems. DESIGN: Structured expert meeting, using procedures adapted from the nominal group techniques and the Rand consensus method. SETTING: Valencian School of Health Studies. PARTICIPANTS AND/OR CONTEXTS: Forty panellists (74% doctors, 70% from primary care settings) with experience in the management of BPH from 15 departments of the Valencia Health Agency. METHOD: Three workshops were held simultaneously (examination and diagnosis, drug therapy, and appropriateness and results), and the 15 quality indicators selected by the coordination group were assessed. RESULTS: Eleven of the 15 indicators scored in the range of high relevance. The 5 best rated were: the use of alpha-blockers + 5-alpha reductase inhibitor from certain severity level, digital rectal examination in the initial assessment, follow-up with the International Prostate Symptoms Score (IPSS), the rate of urgent catheterization in Hospital Accident & Emergency Units, initial assessment with the IPSS and the use of alpha-blockers prior to catheter removal for acute retention of urine. CONCLUSIONS: Some of the assessed indicators can be useful for incorporation into health information systems.

Cysticlean® a highly pac standardized content in the prevention of recurrent urinary tract infections: an observational, prospective cohort study.

BACKGROUND: The present study was aimed at determining the prophylactic efficacy of American cranberry (AC) extract (Cysticlean®) in women with recurrent symptomatic postcoital urinary tract infections (PCUTI), non-consumer of AC extract in the past 3 months before inclusion, and to determine changes in their quality of life (QoL). METHODS: This was a single center, observational, prospective study in a total of 20 women (mean age 35.2 years; 50.0% were married). Patients were followed up for 3 and 6 months during treatment. RESULTS: The number of PCUTIs in the previous 3 months prior to start the treatment with Cysticlean® was 2.8±1.3 and it was reduced to 0.2±0.5 at Month 6 (P<0.0001), which represent a 93% improvement. At baseline, the mean score on the VAS scale (range from 0 to 100) for assessing the QoL was 62.4±19.1, increasing to 78.2±12.4 at Month 6 (P=0.0002), which represents a 20% improvement. All patients had an infection with positive urine culture at baseline, after 6 months there were only 3 symptomatic infections (P<0.001). The most common bacterium was Escherichia coli. CONCLUSIONS: Prophylaxis with American cranberry extract (Cysticlean®) could be an alternative to classical therapies with antibiotics. Further studies are needed to confirm results obtained in this pilot study.

Pharmacological Chemolysis of Uric Acid Lithiasis in A Patient with Crohn's Disease.

Patients with chronic diarrhoea or ileostomies suffer from electrolyte and urinary disorders and are prone to developing uric acid or calcium oxalate stones. Evidence is lacking regarding the management of uric acid stones in patients with inflammatory bowel diseases. We present the case of a male patient with Crohn's disease and carrying an ileostomy. He was diagnosed with uric acid urolithiasis (stone size of 11 mm located in the left pyeloureteral junction) after presenting to the emergency room during an episode of left renal colic. Results of the 24-hour urinalysis showed an acidic pH (pH <5), consistent with hyperuricosuria. The suspicion of uric acid lithiasis was confirmed after performing an X-ray diffraction analysis of a lithiasic fragment that passed during acute renal colic. The patient was prescribed with urinary alkalinisers (medical treatment) and dietary recommendations. After 12 months of treatment and urine pH monitoring, the patient achieved complete chemolysis while maintaining the stability of his underlying Crohn's disease. The patient had no complications during follow-up, referring adequate gastrointestinal tolerance to treatment and denying side effects. The patient remains asymptomatic and is being followed-up on an outpatient basis. He continues on prophylactic treatment (Lit-Control® pH Up) to maintain the pH in the non-acidic range.

[Effectiveness of treatment with Pygeum africanum in patients with lower urinary tract symptoms and benign prostatic hyperplasia: a cross-sectional study in the real-world clinical practice in Spain (The PROFIT Study)]. / Efectividad del tratamiento con Pygeum africanum en pacientes con síntomas del tracto urinario inferior e hiperplasia benigna de próstata: estudio transversal en la práctica clínica real en España (Estudio PROFIT).

OBJECTIVES: To assess the effectivenessand tolerability of treatment with P africanum(P. africanum) in patients with lower urinary tractsymptoms (LUTS) associated with benign prostatichyperplasia (BPH) in routine clinical practice. MATERIAL AND METHODS: Cross-sectional observationalstudy in which 115 patients with LUTS/BPHtreated for 6 months with P. africanum (Tebetane® compuesto)in real-world clinical practice conditions wereincluded. The primary objective was to assess thequality of life (QoL) according to changes in the scoresof item 8 of the International Prostate Symptom Score(IPSS) questionnaire (a score ≥ 4 indicates a significantimpairment of QoL). Secondary objectives includedimprovement of urinary symptoms, urinary flow, satisfactionand compliance with treatment as well astolerability. Data were collected in a single scheduledvisit at 6 months of treatment with P. africanum andwere compared with data registered in the medicalrecords at the beginning of treatment. RESULTS: After 6 months of treatment withP. africanum, the percentage of patient with significantimpairment of QoL was 22.6% as compared with45.2% at the initiation of treatment (P 0,-001). Theoverall IPSS score showed a mean decreas of -4,-5points (median -4,0, interquartile range [IQR] -7,-0 to-2,0) and 69 patients (60%) showed a clinically significantimprovement (reduction of ≥ 4 points). Therewere significant decreases in IPSS subscales of storage(mean -1,-8; median -2,-0, IQR -3,-0 to 0 (P 0,-001)and voiding (mean -1,-9; median -2,-0, IQR -3,-0 to 0)(P 0,-001) symptoms. The degree of satisfaction and compliance with treatment was high with mean scores(median) of 6,9 (7,0) and 9,2 (10), respectively in the1-10 visual analogue scale. Treatment-related adverseeffects did not occur. CONCLUSIONS: Treatment with P. africanum during6 months improved significantly QoL and LUTS inpatients with BPH, with a high level of satisfaction andcompliance with treatment, without adverse events.

OBJETIVO: Evaluar la efectividad y latolerabilidad del tratamiento con Pygeum africanum (P.africanum) en pacientes con síntomas del tracto urinarioinferior (STUI) asociados a hiperplasia benigna depróstata (HBP) en la práctica clínica habitual.MATERIAL Y MÉTODOS: Estudio observacionaltransversal en el que se incluyeron 115 pacientes conSTUI/HBP tratados durante 6 meses con P. africanum (Tebetane® compuesto) en condiciones de prácticaclínica real. El objetivo primario fue evaluar la calidadde vida (CdV) en función del cambio en la pregunta 8del cuestionario de Puntuación Internacional de losSíntomas Prostáticos (IPSS) (puntuación ≥ 4 indicaafectación significativa de la CdV). Los objetivos secundariosincluyeron la mejoría de síntomas urinarios,flujo urinario, satisfacción y cumplimiento con eltratamiento, así como la tolerabilidad del mismo. Losdatos se recogieron en una única visita programada alos 6 meses de tratamiento con P. africanum y se compararoncon los registrados en la historia clínica alinicio del tratamiento. RESULTADOS: Tras 6 meses de tratamiento conP. africanum, el porcentaje de pacientes con afectaciónsignificativa de la CdV fue del 22,6% en comparacióncon un 45,2% al inicio del tratamiento (P 0,001).La puntuación global del IPSS disminuyó de mediaen -4,5 puntos (mediana -4,0, rango intercuartílico [RIQ] -7,0 a -2,0) y 69 pacientes (60%) mostraron unamejoría clínicamente significativa (disminución ≥ 4puntos). Se observaron disminuciones significativasen las subescalas del IPSS de los síntomas de llenado(media -1,8; mediana -2,0, RIQ -3,0 a 0) (P 0,001) yvaciado (media -1,9; mediana -2,0, RIQ -3,0 a 0) (P 0,001). El grado de satisfacción y cumplimiento con eltratamiento fue elevado con valores medios (mediana)de 6,9 (7,0) y 9,2 (10) respectivamente, en una escalaanalógica visual 1-10 cm. No se registraron efectosadversos relacionados con el tratamiento. CONCLUSION: El tratamiento con P. africanum(P. africanum) durante 6 meses mejoró significativamentela CdV y los STUI en pacientes con HBP, con unalto grado de satisfacción y cumplimiento con el tratamiento,sin registrarse reacciones adversas.

[Green light laser efficacy in patients with prostatic hyperplasia treatment with 5-alpha reductase inhibitors]. / Eficacia de la fotovaporización prostática con láser verde en el tratamiento de la hiperplasia prostática en pacientes en tratamiento con inhibidores de la 5-alfa-reductasa.

INTRODUCTION: High prevalence of BPH and gradual ageing of the population, combined with the existence of effective medical treatments for this condition, has led to an increasing use of surgery in patients on long-term treatment with 5-alpha reductase inhibitors (5-ARIs). Initially, patients treated with 5-ARIs were not considered good candidates for photoselective vaporization of the prostate with green laser. OBJECTIVE: To assess, using a retrospective study based on our experience, wheter long-term treatment (longer than 6 months) with 5-alpha reductase inhibitors decreases effectiveness of photoselective vaporization of the prostate with green light laser in BPH. MATERIALS AND METHODS: From September 2005 to January 2008, 102 patients underwent photoselective vaporization of the prostate with green light laser. Of these, 25 patients (24.5%) had been treated with 5-ARIs for at least 6 months, and the remaining 77 patients (75.5%) were used as controls. A retrospective study was conducted to compare the pre- and postoperative clinical and functional parameters of patients with and without prior 5-RAI therapy. RESULTS: No statistically significant differences were found between the treated and control groups in preoperative prostatic volume (50 mL vs 49 mL), IPSS (17.6 vs 17.8), postvoiding residue (16% vs 18%), or PSA (1.4 ng/mL vs 2.2 ng/mL). Similarly, while differences were seen in energy spread (180 kJ vs 175 kJ for the treated and control groups respectively) and operating time (63 min vs 57 min), these were not statistically significant. No between-group differences were found either in clinical or flow rate parameters one month after surgery (IPSS 13.8 vs 14 and Qmax 13.9 mL/s vs 14.5 nL/s in the treated and control groups respectively). Surgeons reported a better visualization of the endoscopic field that was attributed to less bleeding during the procedure. CONCLUSIONS: Our results show no statistically significant differences in peroperative and preoperative parameters between patients with and without treatment with 5-alpha reductase inhibitors. We therefore think that photoselective vaporization of the prostate with green light laser is a safe and effective technique in patients treated with 5-ARIs.

[Urinary tract hemangiopericytoma treated with radical surgery and neoadjuvant chemotherapy. Report of two cases.] / Hemangiopericitoma en la via urinaria tratados con cirugía radical y quimioterapia neoadyuvante. A propósito de dos casos.

OBJECTIVE: Hemangiopericytoma is a tumor of vascular origin. It is very rare in the prostate. They are generally aggressive tumors. Currently, the treatment of choice is radical surgery. In the literature, there are less than 50 cases described, and neoadjuvant treatment has not been reported in any article. This treatment presents positive responses in another type of sarcomas. Our goal is to report two cases of malignant hemangiopericytoma. The first case was treated with radical surgery and the second case was treated with neoadjuvant chemotherapy before surgery. METHODS: The first case is a 40 year old male. Obstructive urinary symptoms were his first symptoms. A prostate mass with tumor characteristics was seen on ultrasound. After transrectal biopsy, he was diagnosed with hemangiopericitoma. Because the tumor size, neoadjuvant chemotherapeutic prior to radical surgery was decided. The second case is a 77 year old male with an incidental diagnosis of renal mass. After radical nephrectomy, he was diagnosed with hemangiopericitoma. He did not receive adjuvant chemotherapy. RESULTS: In the first case, after neoadjuvant therapy, tumor size was reduced significantly. A pelvic exenteration with radical cystoprostatectomy and rectal resection and Bricker type urinary diversion and colostomy were carried out. In the second case controls after radical nephrectomy were correct and he did not need any treatment. CONCLUSIONS: In urinary tumors, the prostate hemangiopericytoma is a rare entity. Currently, neoadjuvant chemotherapy is not established as treatment for these tumors. For other sarcomas neoadyuvant treatment has good response. In our case, a good result was obtained with neoadjuvant chemotheraphy before surgery. However, a greater number of cases are necessary to establish the use of neoadjuvant chemotherapy in urinary hemangiopericytomas.

OBJETIVO: El hemangiopericitoma es un tumor de origen vascular muy infrecuente en la próstata. Son tumores de características agresivas y actualmente el tratamiento de elección es la cirugía radical. En la literatura existen descritos menos de 50 casos de hemangiopericitomas, y ninguno con tratamiento neoadyuvante. Dicho tratamiento neoadyuvante está descrito en otro tipo de sarcomas con buenas respuestas. Presentamos dos casos de un hemangiopericitoma maligno, uno tratado sólo con cirugía radical y otro con neoadyuvancia quimioterápica previa a la cirugía radical.MATERIAL Y MÉTODOS: El primer caso es un varón de 40 años con síntomas urinarios obstructivos. Se diagnosticó de hemangiopericitoma tras realización de biopsia transrectal. Se decidió neoadyuvancia quimioterápica previa a la cirugía. El segundo paciente es un varón de 74 años con hallazgo accidental de masa renal. Tras nefrectomía radical se diagnosticó de hemangiopericitoma. RESULTADOS: Tras la neoadyuvancia, en el primer paciente, se realizó una cistoprostatectomía radical y una resección de recto con derivación urinaria tipo Bricker y colostomía. El segundo paciente no precisó tratamiento adyuvante tras la cirugía radical. CONCLUSIONES: El hemangiopericitoma es una entidad rara en los tumores urinarios. Actualmente la neoadyuvancia quimioterápica no está establecida como pilar del tratamiento de estos tumores, aunque en otros campos donde los sarcomas son más frecuentes, si que se objetiva mejor respuesta. En nuestro caso obtuvimos una buena respuesta con dicha neoadyuvancia previa a la cirugía, aunque es necesario un mayor seguimiento a una mayor cohorte de pacientes para establecer el uso de la quimioterapia neoadyuvante en los hemangiopericitomas urinarios.

[Report of two cases of malignant mesothelioma of the tunica vaginalis.] / Analisis de dos casos de mesotelioma maligno de la túnica vaginal.

OBJECTIVE: Paratesticular mesothelioma isan infrequent tumor and only 250 cases have been published.It originates in the scrotal tunica vaginalis. It represents0.3-1.4% of mesotheliomas and it predominates inpatients with history of asbestos exposure and old age. Itsdiagnosis is usually casual. Our objective is to present thecases that occurred in our service with malignant paratesticularmesothelioma and to carry out a review of the currentliterature on this pathology. METHODS: We report two cases diagnosed with malignantparatesticular mesothelioma that happened in the lasttwo years. RESULT: The first case was a 73-year-old male with asymptomatichydrocele. The second was a 57-year-oldmale who had testicular pain and hydrocele. Both werediagnosed of mesothelioma after hydrocelectomy. The firsttreatment was radical orchiectomy in both cases. The firstpatient did not need more treatments. The second patientpresented pulmonary nodules, lymphadenopathy and localrelapse, which was treated with chemotherapy and localresection. CONCLUSION: Paratesticular mesothelioma is an infrequenttumor. Scrotal mass associated with hydrocele is thetypical form of presentation. Surgical treatment consists ofradical orchiectomy. They have poor prognosis because inmost cases there is rapid local and dissemination.

OBJETIVO: El mesotelioma paratesticular es  un tumor infrecuente, con menos de 250 casos publicados, originado en la túnica vaginal escrotal. Representa el 0,3-1,4% de los mesoteliomas. Predomina en pacientes añosos, con la exposición al asbesto y su diagnóstico sueleser casual. Nuestro objetivo es presentar dos casos ocurridos en nuestro servicio con mesotelioma paratesticular maligno y realizar una revisión de la literatura actual sobre dicha patologia.MÉTODO: Aportamos dos casos diagnosticados de mesotelioma paratesticular maligno acontecidos en nuestro servicio durante los últimos dos años. RESULTADO: El primer caso es un varón de 73 años que debutó con hidrocele sin dolor. El segundó es un varón de 57 años que inició su clínica con un cuadro de dolor testicular e hidrocele. En ambos se diagnostica de mesotelioma maligno de la túnica vaginal tras hidrocelectomía. Se realiza como tratamiento inicial una orquiectomía radical en ambos pacientes. El primer paciente no precisó ningún tratamiento adicional. El segundo paciente presentó nódulos pulmonares y adenopatías junto con recidiva local, que se trató con quimioterapia y resección local.CONCLUSIÓN: El mesotelioma paratesticular es un tumor infrecuente, sin una clínica especifica. Su forma típica de presentación es una masa escrotal indolora asociada a hidrocele.El tratamiento quirúrgico consiste en orquiectomía radical. En la mayoría de los casos existe una rápida diseminación local y a distancia que otorgan a estos tumores un mal pronóstico.

Efectividad del tratamiento con pygeum africanum en pacientes con síntomas del tracto urinario inferior e hiperplasia benigna de próstata: estudio transversal en la práctica clínica real en españa (estudio profit) / Effectiveness of treatment with Pygeum africanum in patients with lower urinary tract symptoms and benign prostatic hyperplasia: a cross-sectional study in the real-world clinical practice in Spain (The PROFIT Study)

OBJETIVO: Evaluar la efectividad y latolerabilidad del tratamiento con Pygeum africanum (P.africanum) en pacientes con síntomas del tracto urinario inferior (STUI) asociados a hiperplasia benigna depróstata (HBP) en la práctica clínica habitual.MATERIAL Y MÉTODOS: Estudio observacionaltransversal en el que se incluyeron 115 pacientes conSTUI/HBP tratados durante 6 meses con P. africanum (Tebetane® compuesto) en condiciones de prácticaclínica real. El objetivo primario fue evaluar la calidadde vida (CdV) en función del cambio en la pregunta 8del cuestionario de Puntuación Internacional de losSíntomas Prostáticos (IPSS) (puntuación ≥ 4 indicaafectación significativa de la CdV). Los objetivos secundarios incluyeron la mejoría de síntomas urinarios, flujo urinario, satisfacción y cumplimiento con eltratamiento, así como la tolerabilidad del mismo. Losdatos se recogieron en una única visita programada alos 6 meses de tratamiento con P. africanum y se compararon con los registrados en la historia clínica alinicio del tratamiento.RESULTADOS: Tras 6 meses de tratamiento conP. africanum, el porcentaje de pacientes con afectaciónsignificativa de la CdV fue del 22,6% en comparacióncon un 45,2% al inicio del tratamiento (P < 0,001).La puntuación global del IPSS disminuyó de mediaen -4,5 puntos (mediana -4,0, rango intercuartílico [RIQ] -7,0 a -2,0) y 69 pacientes (60%) mostraron unamejoría clínicamente significativa (disminución ≥ 4puntos). Se observaron disminuciones significativasen las subescalas del IPSS de los síntomas de llenado(media -1,8; mediana -2,0, RIQ -3,0 a 0) (P < 0,001) yvaciado (media -1,9; mediana -2,0, RIQ -3,0 a 0) (P <0,001). El grado de satisfacción y cumplimiento con eltratamiento fue elevado con valores medios (mediana)de 6,9 (7,0) y 9,2 (10) respectivamente, en una escalaanalógica visual 1-10 cm. No se registraron efectosadversos relacionados con el tratamiento.

OBJECTIVES: To assess the effectiveness and tolerability of treatment with P africanum(P. africanum) in patients with lower urinary tractsymptoms (LUTS) associated with benign prostatichyperplasia (BPH) in routine clinical practice.MATERIAL AND METHODS: Cross-sectional observational study in which 115 patients with LUTS/BPHtreated for 6 months with P. africanum (Tebetane® compuesto) in real-world clinical practice conditions wereincluded. The primary objective was to assess thequality of life (QoL) according to changes in the scoresof item 8 of the International Prostate Symptom Score(IPSS) questionnaire (a score ≥ 4 indicates a significantimpairment of QoL). Secondary objectives includedimprovement of urinary symptoms, urinary flow, satisfaction and compliance with treatment as well astolerability. Data were collected in a single scheduledvisit at 6 months of treatment with P. africanum andwere compared with data registered in the medicalrecords at the beginning of treatment.RESULTS: After 6 months of treatment withP. africanum, the percentage of patient with significant impairment of QoL was 22.6% as compared with45.2% at the initiation of treatment (P < 0,-001). Theoverall IPSS score showed a mean decreas of -4,-5points (median -4,0, interquartile range [IQR] -7,-0 to-2,0) and 69 patients (60%) showed a clinically significant improvement (reduction of ≥ 4 points). Therewere significant decreases in IPSS subscales of storage(mean -1,-8; median -2,-0, IQR -3,-0 to 0 (P < 0,-001)and voiding (mean -1,-9; median -2,-0, IQR -3,-0 to 0)(P < 0,-001) symptoms. The degree of satisfaction and compliance with treatment was high with mean scores(median) of 6,9 (7,0) and 9,2 (10), respectively in the1-10 visual analogue scale. Treatment-related adverseeffects did not occur.CONCLUSIONS: Treatment with P. africanum during 6 months improved significantly QoL and LUTS inpatients with BPH, with a high level of satisfaction

Pharmacological Chemolysis of Uric Acid Lithiasis in A Patient with Crohn’s Disease

Patients with chronic diarrhoea or ileostomies suffer from electrolyte and urinary disorders and are prone to developing uricacid or calcium oxalate stones. Evidence is lacking regarding the management of uric acid stones in patients with inflammatorybowel diseases. We present the case of a male patient with Crohn’s disease and carrying an ileostomy. He was diagnosed with uricacid urolithiasis (stone size of 11 mm located in the left pyeloureteral junction) after presenting to the emergency room during anepisode of left renal colic. Results of the 24-hour urinalysis showed an acidic pH (pH <5), consistent with hyperuricosuria. Thesuspicion of uric acid lithiasis was confirmed after performing an X-ray diffraction analysis of a lithiasic fragment that passedduring acute renal colic. The patient was prescribed with urinary alkalinisers (medical treatment) and dietary recommendations.After 12 months of treatment and urine pH monitoring, the patient achieved complete chemolysis while maintaining the stabilityof his underlying Crohn’s disease. The patient had no complications during follow-up, referring adequate gastrointestinal toleranceto treatment and denying side effects. The patient remains asymptomatic and is being followed-up on an outpatient basis.He continues on prophylactic treatment (Lit-Control® pH Up) to maintain the pH in the non-acidic range. (AU)

Indicadores de calidad en hiperplasia benigna de próstata. Un estudio cualitativo / Quality of care indicators for benign prostatic hyperplasia. A qualitative study

OBJETIVO: Valorar posibles indicadores de calidad de la atención a la hiperplasia benigna de próstata (HBP) y sus fortalezas y debilidades para su incorporación a los sistemas de información sanitaria. DISEÑO: Reunión de expertos, estructurada siguiendo procedimientos adaptados de las técnicas de grupo nominal y método de consenso Rand. Emplazamiento: Escuela Valenciana de Estudios de la Salud. Participantes y/o contextos: Participaron 40 panelistas (74% médicos, 70% del ámbito de la atención primaria) con experiencia en el manejo de la HBP pertenecientes a 15 Departamentos de la Agencia Valenciana de Salud. MÉTODO: Se realizaron 3 talleres simultáneos (exploración y diagnóstico, tratamiento farmacológico y adecuación y resultados) en los que se valoraron los 15 indicadores seleccionados por el grupo coordinador. RESULTADOS: Once de los 15 indicadores obtuvieron puntuaciones en el rango de alta relevancia. Los 5 mejor valorados fueron: el uso de alfabloqueante + inhibidores de la 5 alfa-reductasa a partir de determinado nivel de gravedad, el tacto rectal en la valoración inicial, el seguimiento con el Índice Internacional de Síntomas Prostáticos (IPSS), la tasa de sondaje urgente en urgencias hospitalarias, la valoración inicial con el IPSS y el uso de alfabloqueante previo a la retirada de sonda por retención aguda de orina. CONCLUSIONES: Parte de los indicadores valorados pueden ser útiles para su incorporación a los sistemas de información sanitaria

OBJECTIVE: To assess quality of care indicators for benign prostatic hyperplasia (BPH), and to evaluate their strengths and weaknesses for incorporation into health information systems. DESIGN: Structured expert meeting, using procedures adapted from the nominal group techniques and the Rand consensus method. Setting: Valencian School of Health Studies. Participants and/or contexts: Forty panel lists (74% doctors, 70% from primary care settings)with experience in the management of BPH from 15 departments of the Valencia Health Agency. METHOD: Three workshops were held simultaneously (examination and diagnosis, drug therapy, and appropriateness and results), and the 15 quality indicators selected by the coordination group were assessed. RESULTS: Eleven of the 15 indicators scored in the range of high relevance. The 5 best rated were: the use of alpha-blockers + 5-alpha reductase inhibitor from certain severity level, digital rectal examination in the initial assessment, follow-up with the International Prostate Symptoms Score (IPSS), the rate of urgent catheterization in Hospital Accident & Emergency Units, initial assessment with the IPSS and the use of alpha-blockers prior to catheter removal for acute retention of urine. CONCLUSIONS: Some of the assessed indicators can be useful for incorporation into health information systems

Analisis de dos casos de mesotelioma maligno de la túnica vaginal / No disponible

Objetivo: El mesotelioma paratesticular es un tumor infrecuente, con menos de 250 casos publicados, originado en la túnica vaginal escrotal. Representa el 0,3-1,4% de los mesoteliomas. Predomina en pacientes añosos, con la exposición al asbesto y su diagnóstico suele ser casual. Nuestro objetivo es presentar dos casos ocurridos en nuestro servicio con mesotelioma paratesticular maligno y realizar una revisión de la literatura actual sobre dicha patologia. Método: Aportamos dos casos diagnosticados de mesotelioma paratesticular maligno acontecidos en nuestro servicio durante los últimos dos años. Resultado: El primer caso es un varón de 73 años que debutó con hidrocele sin dolor. El segundó es un varón de 57 años que inició su clínica con un cuadro de dolor testicular e hidrocele. En ambos se diagnostica de mesotelioma maligno de la túnica vaginal tras hidrocelectomía. Se realiza como tratamiento inicial una orquiectomía radical en ambos pacientes. El primer paciente no precisó ningún tratamiento adicional. El segundo paciente presentó nódulos pulmonares y adenopatías junto con recidiva local, que se trató con quimioterapia y resección local. Conclusión: El mesotelioma paratesticular es un tumor infrecuente, sin una clínica especifica. Su forma típica de presentación es una masa escrotal indolora asociada a hidrocele. El tratamiento quirúrgico consiste en orquiectomía radical. En la mayoría de los casos existe una rápida diseminación local y a distancia que otorgan a estos tumores un mal pronóstico

Objective: Paratesticular mesothelioma is an infrequent tumor and only 250 cases have been published. It originates in the scrotal tunica vaginalis. It represents 0.3-1.4% of mesotheliomas and it predominates in patients with history of asbestos exposure and old age. Its diagnosis is usually casual. Our objective is to present the cases that occurred in our service with malignant paratesticular mesothelioma and to carry out a review of the current literature on this pathology. Methods: We report two cases diagnosed with malignant paratesticular mesothelioma that happened in the last two years. Result: The first case was a 73-year-old male with asymptomatic hydrocele. The second was a 57-year-old male who had testicular pain and hydrocele. Both were diagnosed of mesothelioma after hydrocelectomy. The first treatment was radical orchiectomy in both cases. The first patient did not need more treatments. The second patient presented pulmonary nodules, lymphadenopathy and local relapse, which was treated with chemotherapy and local resection. Conclusion: Paratesticular mesothelioma is an infrequent tumor. Scrotal mass associated with hydrocele is the typical form of presentation. Surgical treatment consists of radical orchiectomy. They have poor prognosis because in most cases there is rapid local and dissemination

Hemangiopericitoma en la via urinaria tratados con cirugía radical y quimioterapia neoadyuvante. A propósito de dos casos / Urinary tract hemangiopericytoma treated with radical surgery and neoadjuvant chemotherapy. Report of two cases

Objetivo: El hemangiopericitoma es un tumor de origen vascular muy infrecuente en la próstata. Son tumores de características agresivas y actualmente el tratamiento de elección es la cirugía radical. En la literatura existen descritos menos de 50 casos de hemangiopericitomas, y ninguno con tratamiento neoadyuvante. Dicho tratamiento neoadyuvante está descrito en otro tipo de sarcomas con buenas respuestas. Presentamos dos casos de un hemangiopericitoma maligno, uno tratado sólo con cirugía radical y otro con neoadyuvancia quimioterápica previa a la cirugía radical. Material y métodos: El primer caso es un varón de 40 años con síntomas urinarios obstructivos. Se diagnosticó de hemangiopericitoma tras realización de biopsia transrectal. Se decidió neoadyuvancia quimioterápica previa a la cirugía. El segundo paciente es un varón de 74 años con hallazgo accidental de masa renal. Tras nefrectomía radical se diagnosticó de hemangiopericitoma. Resultados: Tras la neoadyuvancia, en el primer paciente, se realizó una cistoprostatectomía radical y una resección de recto con derivación urinaria tipo Bricker y colostomía. El segundo paciente no precisó tratamiento adyuvante tras la cirugía radical. Conclusiones: El hemangiopericitoma es una entidad rara en los tumores urinarios. Actualmente la neoadyuvancia quimioterápica no está establecida como pilar del tratamiento de estos tumores, aunque en otros campos donde los sarcomas son más frecuentes, si que se objetiva mejor respuesta. En nuestro caso obtuvimos una buena respuesta con dicha neoadyuvancia previa a la cirugía, aunque es necesario un mayor seguimiento a una mayor cohorte de pacientes para establecer el uso de la quimioterapia neoadyuvante en los hemangiopericitomas urinarios

Objective: Hemangiopericytoma is a tumor of vascular origin. It is very rare in the prostate. They are generally aggressive tumors. Currently, the treatment ofchoice is radical surgery. In the literature, there are less than 50 cases described, and neoadjuvant treatment has not been reported in any article. This treatment presents positive responses in another type of sarcomas. Our goal is to report two cases of malignant hemangiopericytoma. The first case was treated with radical surgery and the second case was treated with neoadjuvant chemotherapy before surgery. Methods: The first case is a 40 year old male. Obstructive urinary symptoms were his first symptoms. A prostate mass with tumor characteristics was seen on ultrasound. After transrectal biopsy, he was diagnosed with hemangiopericitoma. Because the tumor size, neoadjuvant chemotherapeutic prior to radical surgery was decided. The second case is a 77 year old male with an incidental diagnosis of renal mass. After radical nephrectomy, he was diagnosed with hemangiopericitoma. He did not receive adjuvant chemotherapy. Results: In the first case, after neoadjuvant therapy, tumor size was reduced significantly. A pelvic exenteration with radical cystoprostatectomy and rectal resection and Bricker type urinary diversion and colostomy were carried out. In the second case controls after radical nephrectomy were correct and he did not need any treatment. Conclusions: In urinary tumors, the prostate hemangiopericytoma is a rare entity. Currently, neoadjuvant chemotherapy is not established as treatment for these tumors. For other sarcomas neoadyuvant treatment has good response. In our case, a good result was obtained with neoadjuvant chemotheraphy before surgery. However, a greater number of cases are necessary to establish the use of neoadjuvant chemotherapy in urinary hemangiopericytomas

[Urinary lithiasis secondary to medication in HIV+ patients receiving Indinavir]. / Litiasis medicamentosa en pacientes VIH+ en tratamiento con Indinavir.

OBJECTIVES: Therapy with protease inhibitors is commonly used in patients infected by human inmunodeficency virus (HIV). 20% of the administered dose is excreted by the kidney, and when alkaline urine is present, indinavir may crystallize forming stones and patients may experience renal colic due to this fact. METHODS: Between January 1998 and June 2005, 26 patients receiving antiretroviral treatment with protease inhibitors received care at our hospital because of renal colic or flank pain. All of them underwent physical examination, echography and urography as well as blood and urine analysis. Patients were treated ambulatory excepting those in whom oral analgesics were insufficient to control the pain. RESULTS: All patients had been treated with indinavir for longer than 12 months. They represented 4% of all patients treated with the recommended dose of Crivixan. Most of them presented flank pain, associated in most cases to microhaematuria. Five of them required hospitalization because of persistent pain in spite of endovenous analgesia. Imaging tests (echography and urography) showed functional delay of the kidney (2 cases), ureteral stasis (4 cases) and little lithiasic concretions of mild radiologic density (5 cases). Urinalysis revealed suggestive christaluria and alkaline pH. All patients required hidratation and analgesic treatment. In 3 patients indinavir dose was reduced, it was retired in another one, and 100 mg of rito-navir were added in another one. Unsuccesfuly ureteral cateterization was tried in one patient. All of them presented symptomatic improvement. CONCLUSIONS: We ought to know the capability of indinavir to form urolithiasis in HIV patients treated with protease inhibitors, although its use is decreasing along time. Prevalence of urolithiasis in these patients seems to be higher as length of treatment becomes longer. Metabolic alterations in urine have been proved in these patients, contributing to a higher incidence of lithiasis than in general population.

[Penile cellulitis after oral sex]. / Celulitis de pene tras sexo oral.

OBJECTIVE: Nowadays, there is the high prevalence of sexual intercourse including oral sex, which implies some peculiarities in the infections, balanitis and ceIlulitis they may produce. METHODS: We report two new cases of penile cellulitis treated in the urology department in our hospital. DISCUSSION: We review the indications of prophylaxis, and the medical and surgical treatment both referred in the literature and carried out in our patients. CONCLUSIONS: When dealing with balanitis and penile cellulitis, the history should include explicit references to the practice of oral sex. Early medical or surgical treatment has a favourable influence on the evolution of the lesions.

[Greenlight KTP-laser photovaporization. Initial experience in a public hospital]. / Fotovaporización prostática con láser verde-KTP. Experiencia inicial en un hospital público.

OBJECTIVES: Despite the fact that transurethral resection of the prostate (TURP) continues being the gold standard for the surgical treatment of benign prostatic hyperplasia (BPH), the good results obtained with the use of new energy sources have led to their use in daily practice. METHODS: Between September 2005 and January 2007, we have treated 63 patients with KTP laser photoselective vaporization of the prostate (PVP) in our service. Preoperatively we asked for IPSS, performed physical exam, digital rectal exam, abdominal , renal, bladder and prostatic ultrasound measuring postvoid residual volume, as well as flowmetry and PSA determination. Patients were revised after 1, 3, 6 and 12 months, undergoing uroflowmetry, IPSS, ultrasound and PSA; a satisfaction survey was also fulfilled at this interviews. RESULTS: Mean age was 67 years (range 58-85) and mean preoperative prostatic volume was 48cc (range 34-67), mean preoperative IPSS was 17.7 and mean maximum flow 8.1 mL/s. 12 patients presented post void residual volume larger than 100 mL. Most patients presented medium or high anaesthetic risk. Mean operative time was 64 minutes (range 45-95). In most cases we used just one fibre, and mean energy released was 175,000 Joules (range 85,000-24,000). Mean hospital stay was 32.2 hours (range 19-55). In postoperative revisions we could state a significant decrease of IPSS, improvement in maximum flow, and also good or very good satisfaction degree in about 80% of the patients. Only 3 of them presented hematuria that needed to be attended by the urologist, none of them needed transfusion. One patient was admitted for severe urinary infection and eight patients referred irritative low urinary tract symptoms in their first postoperative checkup. CONCLUSIONS: KTP laser PVP is a safe, reproducible technique with optimal short and middle term outcomes, which should be considered as the first choice surgical treatment in elderly patients, patients with chronic anaemic diseases or anticoagulated, and patients with high anaesthesic or surgical risk.

[Inguinoscrotal bladder hernias]. / Hernias Vesicales inguinoescrotales.

OBJECTIVES: Despite the high incidence of inguinal hernias. In the general population, only a small percentage of them involve the bladder. Bladder wall weakness and bladder outlet obstruction are involved in its pathogenesis. We present our experience in the diagnosis and treatment of this rare disease. METHODS: A total of eight patients have been diagnosed of inguinoscrotal bladder hernia and treated in our center over the last 18 years. In most cases, retrograde and voiding cystourethrograms, prostatic and bladder ultrasound, and uroflowmetry have been performed. The treatment varied depending on the characteristics of the herniated bladder tissues and bladder capacity. The treatment of bladder outlet obstruction varied depending on the etiology. RESULTS: Two patients presented at the emergency room of our centre, the others were diagnosed at the outpatient clinics of our department. Resection of the herniated bladder tissue was carried out in four patients due to the quality of the tissue; bladder-pexy to the abdominis rectus muscles was performed in one patient; hernia repair with bladder reintroduction was the treatment in the other four cases. Bladder outlet obstruction was treated in six cases. Seven patients showed clinical improvement, showing normal bladder morphology on post operative cystogram. CONCLUSIONS: Bladder hernia is a rare pathology often presenting in mid age males. It should be suspected in every male with lower urinary tract obstructive symptoms and associated inguinal hernia. Retrograde and voiding cystourethrogram are the radiological diagnostic tests of choice to evaluate this disease. The treatment of choice is that of the hernia and bladder outlet obstruction.

[The usefulness of virtual endoscopy and CT urography in the diagnosis of upper urinary tract tumors]. / Utilidad de la endoscopia virtual y el Uro-Tc en el diagnóstico de tumores del tracto urinario superior.

OBJECTIVES: Upper urinary tract (UUT) tumors are a relatively low incidence pathology which often represents a diagnostic challenge for the urologist, because several imaging tests are usually necessary to achieve the final diagnosis. Over the last years CT scan has suffered a notable development and nowadays, with the arrival of new image processing hardware and software, it is possible to detect small urothelial lesions and to perform 3-D urinary tract reconstruction and virtual endoscopic navigation. METHODS: Between January 2004 and June 2005 we performed a total of 15 examinations in 15 patients for the study of asymptomatic hematuria of probable upper urinary tract origin. The technique included three phases to obtain images: basal phase, vascular phase and excretory phase. Processing and image analysis was performed by one radiologist. RESULTS: A total of 10 tumors were diagnosed, with pathological confirmation in all cases. We did not register any complication secondary to the technique, and all patients tolerated well the exam. CONCLUSIONS: The CT urography is a safe, well-tolerated, highly sensitive and efficient imaging test, very useful in the diagnosis of renal and UUT pathology. It may become the only imaging test performed in the study of asymptomatic hematuria and the test of choice for the study of urological tumoral pathology.

[Evolution of the knowledge of urethral pathology in Valencia from the end of the XIX century to the middle of XX century. Historical documentary analysis]. / Evolución del conocimiento en patología uretral en Valencia desde finales del siglo XIX hasta mediados del siglo XX. Análisis documental histórico.

OBJECTIVES: Urethral pathology has always been an interesting topic for study, being present in texts from 600 years B.C, where wood and metallic dilators are described. First external urethrotomies appear in the Jewish-Muslim period, and Francisco Diaz describes in 1588 the treatment of the prostate in his book "Tratamiento de las carnosidades de la verga". With Civiale and Maisoneuve, between 1700 and 1800, appears the description of the urethrotome, and finally in the middle XIX century starts the search for adequate tissues to replace urethra. METHODS: We review all articles on the topic of urethral pathology from authors from Valencia in that period, mainly published in the journal "Revista Valenciana de Ciencias Médicas". RESULTS: We emphasize the use of bulbs and sounds in the approach to urethral stenosis by several authors, with their advantages and limitations. We also emphasize the description of external urethrotomy by Prof. Molla. Finally, we point out the treatment of a posterior urethra fracture by tunneling reported by Dr. Alfredo Tramoyeres. CONCLUSIONS: Despite not being a topic with a high volume of publications, it has always interested authors. We describe all treatments, and sound insertion and dilation techniques as first option.

[Bladder squamous metaplasia: report of one case and bibliographic review]. / Metaplasia escamosa vesical, a propósito de un caso. Revisión de la uteratura.

OBJECTIVES: We report a new case of squamous metaplasia because of its interest and subtle differential diagnosis with other bladder pathologies. METHODS: We report the case of a male patient with history of previous neoplasia with an exophytic lesion of the bladder wall discovered on follow-up. Pathological diagnosis after TUR was bladder squamous metaplasia. RESULTS: Follow-up is performed by ultrasound, cystoscopy, and urine cytology in adherence to clinical guidelines due to the possibility of transformation into squamous cell carcinoma. CONCLUSIONS: Urothelium is able to develop non neoplastic transformations such as squamous metaplasia. The importance of such transformations depends on proper diagnosis and follow-up due to their ability to transform into a neoplastic process.