Multilocular cystic nephroma: A clinical case.

OBJECTIVE: To describe the clinical presentation, preoperative diagnostic possibilities, and treatment of cystic nephroma. METHODS: We describe a case of cystic nephroma in an adult male and show that, both in our patient and in the literature, a definitive diagnosis can only be obtained postoperatively, even when there is a reasonable clinical suspicion. CONCLUSIONS: Cystic nephroma is rare, and some authors consider it a questionable entity. However, it should be distinguished from renal cystic neoplasms, which can resemble the condition.

Paraurethral leiomyoma.

OBJECTIVE: To describe a case of para-urethral leiomyoma and to review the literature. METHODS: The usual preoperative diagnostic procedures and clinical manifestations are discussed. RESULTS: The mass was resected and, 6 years later, the patient remains asymptomatic and with no recurrence. CONCLUSIONS: Urethral or paraurethral leiomyomas are benign tumors that arise from the urethral or vaginal smooth muscle. Radiological findings (particularly magnetic resonance imaging) may suggest the origin of the tumor before surgery; however, the final diagnosis is determined by histology.

Adrenal ganglioneuroma.

OBJECTIVE: To present one case of adrenal ganglioneuroma incidentally diagnosed in an adult. METHODS/RESULTS: 44-year-old woman with a 2.3 cm incidentaloma in the left adrenal gland diagnosed by CT scan. At 6 months, MRI was performed and a left adrenal nodule 3.7 cm was shown. Due to the progressive growth of the mass, surgery was indicated and left laparoscopic adrenalectomy was carried out. The final pathologic diagnosis was adrenal ganglioneuroma. CONCLUSIONS: The ganglioneuroma is a tumor composed of Schwann cells and ganglion cells. Its location in the adrenal gland is unusual, most frequently affecting other regions. Being asymptomatic lesions, they are often detected incidentally when performing imaging tests. There are radiological features that differentiate them from other adrenal masses. The treatment of choice is surgery, with adrenalectomy.

Tubulocystic renal carcinoma (low grade collecting duct carcinoma).

OBJECTIVE: To report a case of tubulocystic renal carcinoma diagnosed in an adult, after a work up study for hematuria. METHODS/RESULTS: 59-year-old male, CT scan was performed during a study for self-limited hematuria showing a 4.2 cm solid mass with areas suspicious of pseudocystic malignancy. Due to its debut with hematuria and renal sinus involvement laparoscopic radical nephrectomy was performed, establishing the diagnosis of tubulocystic carcinoma (low grade collecting duct carcinoma). CONCLUSION: Tubulocystic carcinoma presents histological characteristics and a natural history that makes it different from the classic type of Bellini duct carcinoma, the latter being a rapidly growing tumor with poor prognosis which is usually diagnosed in advanced stages.

Vaginal metastasis of a clear renal cell carcinoma.

OBJECTIVE: Remember that kidney cancer is a disease whose incidence is increasing due to increased use of additional imaging tests, which is changing the way of diagnosis, making the classic clinical syndrome synonymous with advanced illness. METHODS: We report the case of a patient with a right renal tumor with renal vein involvement that in the natural course of the disease showed a vaginal metastasis of clear renal cell carcinoma, which was treated with surgical excision. RESULTS: This case is a clear example of how unpredictable is the clinical evolution of this disease and how little we know about the way of dissemination. CONCLUSIONS: Local excision, with or without radiotherapy, or radiotherapy alone are recommended in cases of unique metastasis after nephrectomy.

46,XX T testicular disorder of sex development. Case report.

OBJECTIVE: We present a case of X-Y translocation with male phenotype (46,XX testicular disorder of sex development) and review the literature. METHODS: Disorders of sex development with mismatch of genetic, gonadal and phenotypic sex are quite rare, and some are due to genetic or chromosomal abnormalities. The karyotype was investigated by a cytogenetic study of peripheral blood (phytohemagglutinin-timulated lymphocyte culture over 72 hours). G-banding analysis of 25 metaphases showed a 46,XX chromosome constitution (46 chromosomes with XX sexual composition). Fluorescence in situ hybridization (FISH) analysis with probes for X centromeres and the sex-determining region of the Y chromosome (SRY) (testis-determining factor gene) showed two X chromosomes. The analysis also showed the SRY signal in the telomeric region of the short arm of one of the chromosomes. RESULTS: In recent years, a number of other genes involved in disorders of sex development in animals and humans have also been identified. Genetic defects in the peptide hormone receptors, members of the steroid receptor superfamily, and other transcription factors, as well as any of a series of enzymes and cofactors involved in steroid biosynthesis can cause abnormal determination and differentiation. CONCLUSIONS: Although chromosomal abnormalities are rarely present in patients with apparently normal external genitalia, they should be considered in urology consultations by adolescents and adults, particularly in the investigation of gynecomastia or infertility.

Clinical value of perioperative levels of DNA and mRNA in plasma of patients with renal cell carcinoma.

INTRODUCTION: The current challenge on renal cell carcinoma (RCC) is to finding a non-invasive biomarker for improving their diagnostic and therapeutic management. In the present study, we analyzed the clinical value of plasma levels of cell-free DNA (cfDNA) and RNA (cfRNA) of two genes: glyceraldehyde 3-phosphate-dehydrogenase (GAPDH) and human telomerase reverse transcriptase (hTERT). MATERIALS AND METHODS: We recruited 82 patients with RCC, and 20 healthy subjects. Using RT-PCR techniques, plasma levels of cfDNA and cfRNA from hTERT and GAPDH genes were quantified pre- and post-operatively, and one year after surgery. Relationships between such plasma levels and clinicopathological features and evolution of disease were analyzed. RESULTS: Levels of GAPDH cfDNA and cfRNA were significantly higher in patients than in healthy subjects. hTERT cfDNA was detected in plasma from 35% of RCC patients and in none healthy subject. At diagnosis, plasma levels of GAPDH cfDNA were higher in advanced pT and TNM stages, and hTERT cfDNA in patients with 3-4 Fuhrman grade and affected lymph nodes. Levels of cfNAs were not related to the presence of metastasis. Following nephrectomy, GAPDH cfDNA levels dropped, and patients with higher levels before and after nephrectomy, showed lower overall survival (OS). However, Cox's multivariate model did not prove any association of the cfNA levels with progression. CONCLUSION: Plasma levels of cfDNA from GADPH and hTERT genes were correlated to tumor diagnosis and progression and, thus, such analyses might help to diagnosis and prognosis of RCC patients.

Primary retroperitoneal tumors: review of our 10-year case series.

OBJECTIVES: To investigate our case series of patients with primary retroperitoneal tumors over the past 10 years, analyzing clinical symptoms, diagnostic tests, tumor pathology, surgical data, concomitant cancer treatments, recurrence and survival rates. METHODS: Retrospective analysis of 37 patients with primary retroperitoneal tumors diagnosed at our hospital over the past 10 years. RESULTS: Computed tomography (CT) was the imaging technique used most often and the most accurate. Tumors were malignant in 83% of patients and benign in 17%. Complete tumor resection was performed in 73% of cases; the most common approach was midline laparotomy. Neighboring organs were also removed in 51.8% of cases in which radical resection was performed. The recurrence rate was 45% in patients who underwent surgery. Median time to onset of recurrence following open surgery was 23 months. Repeat resection was performed in 66% of cases with recurrence. Five-year survival following total resection of malignant tumors was 44%. The mean patient survival after repeat resection was 9.8 months. CONCLUSIONS: Primary retroperitoneal tumors are rare and usually malignant. Surgery is the treatment of choice and complete tumor resection is the main factor that determines prognosis.

Tumor inside an inguinoscrotal bladder hernia.

OBJECTIVE: To describe two cases of urothelial tumors in inguinoscrotal bladder hernias and comment on the low incidence of this condition. METHODS: Two patients were diagnosed and treated by partial cystectomy and hernia repair. RESULTS: The clinical outcome of both patients was good at two and three years, respectively, and neither patient experienced hernia or tumor recurrence. CONCLUSIONS: Inguinal bladder hernias are relatively common. However, few reports of tumor in the herniated bladder have been published. Treatment consists of tumor removal, hernia repair and treatment of any associated urethroprostatic condition.

[Urology clinics referral Patterns after initiation of a Primary Care BPH-LUTS protocol.] / Evolución de las derivaciones desde atención primaria a la consulta de urología tras la aplicación de un protocolo de pacientes con síntomas del tracto urinario inferior por hiperplasia benigna de próstata.

OBJECTIVE: In the Spanish health system, General Practitioners (GPs) play a key role in regulating the flow of patients to hospital care. Most of patients with BPH can be managed through out the evolution of the disease exclusively by the GPs.  METHODS: A pre-experimental study was carried outin two periods, before (pre-test) and after (post-test) of the dissemination of a management protocol for patients with BPH. The protocol was trialled in the health area of Villarrobledo and included all referrals to the urology clinic for BPH from Primary Care. We analyzed the appropriate referrals according with the criteria set for thin the protocol and compared the complementary tests through statistical study (descriptive, a bivariate, multivariate analysis and rate calculation) using version 21of the SPSS. RESULTS: Referral rate decreased after the application of the protocol but did not increase the rate of appropriated referrals. Patients referred after setting forth protocol by GPs that assisted to the education program were younger. There were referred less patients with elevated PSA and more patients with clinical progression. These GPs used less test to achieve diagnosis. The GPs whodid not attend were significantly younger, mainly women, with no previous specific training in BPH and without a full time GP position. CONCLUSIONS: The implementation of a protocol has reduced the referral rate, but it has not improved the appropriate referrals. More research is required to understand the determinants of inequalities in referral from primary care.

OBJETIVO: Los médicos de Atención Primaria (MAP) son fundamentales en la regulación del flujo de pacientes desde Atención Primaria (AP), por tanto,es esencial buscar métodos de adecuada gestión de la demanda asistencial y así optimizar recursos. En la hipertrofia benigna de próstata (HBP) se estima que 2/3 de los pacientes pueden ser manejados íntegramentedesd e AP a lo largo de todo el proceso de la HBP.MATERIAL Y MÉTODOS: Hemos realizado un estudio pre experimental en dos períodos, antes (pre-test) y después (post-test) de la creación de un protocolo de manejo y derivación de pacientes con HBP. Analizamos la adecuación a los criterios de derivación y el uso de los estudios complementarios para llevar a cabo el diagnóstico, realizando un análisis estadístico (descriptivo, bivariante, multivariante y cálculo de tasas) utilizando SPSS (versión 21). RESULTADOS: La tasa de derivación disminuyó tras la aplicación del protocolo, pero no logró mejorar la adecuación. Los pacientes derivados por los MAP que asistieron al programa educativo fueron más jóvenes. Se remitieron menos pacientes con PSA elevado y más pacientes con progresión clínica. Se utilizaron menos estudios complementarios. Los MAP que no acudieron a la formación eran más jóvenes, principalmente mujeres, sin formación especifica en HBP y con contrato temporal. CONCLUSIONES: A pesar de reducir la tasa de derivación no se consiguió mejorar la adecuación de la derivación de los pacientes. Consideramos necesario analizar la problemática de los MAP y valorar otras intervenciones que podrían mejorar la calidad en la transferencia de responsabilidades.

Median raphe cyst. Report of two cases and literature review.

OBJECTIVES: To report 2 cases of median raphe cysts, 1 in the penis and the other in the perineum. METHOD: Two cases of median raphe cyst are described; the first was treated by surgery and the second required no treatment. RESULTS: The surgical patient experienced no complications and was asymptomatic with no recurrence at 2 years. CONCLUSIONS: Median raphe cysts are a rare, benign condition of uncertain etiology. Treatment consists on simple excision.

Diagnostic and prognostic value of the detection of hTERT mRNA in renal tumors.

INTRODUCTION: Elevated mRNA expression of human telomerase reverse transcriptase (hTERT mRNA) is common in many types of tumors, participating in tumor growth and progression. Such expression has not been sufficiently examined in renal cancer. The goal of the present study was to quantify it and analyze its possible clinical value in the management of this pathology. PATIENTS AND METHODS: The study included 111 patients who underwent surgery for renal cell carcinoma (RCC) between 2015 and 2017. Tumor samples were taken from all patients and, in 94 of them, healthy renal tissue adjacent to the tumor was also sampled. The 2 types of tissue were histologically confirmed, after which mRNA was extracted. Using real-time quantitative PCR, the expression of hTERT and glyceraldehyde-3-phosphate dehydrogenase (as endogenous control) were indirectly quantified using the crossing point (CP), which is inversely correlated with the number of sample replicates yielding positive results. These values were correlated with patient socio-demographic variables and clinical-pathological factors of the RCC. RESULTS: The majority of patients were males, with an average age of 60.5 years (SD: 14.02). Most tumors (69.4%) were clear cell carcinomas. The most frequent stages were pT2 or lower (73%), while 5% were pN1 and 12% pM1. The majority of tumors (58%) were Fuhrman grades 1 or 2 (low grade). All samples of tumor and nontumor tissue expressed glyceraldehyde-3-phosphate dehydrogenase mRNA, with the CP in the tumor sample significantly lower than in the nontumor tissue (P < 0.001). The expression of hTERT mRNA was detected in 68% of tumor tissues and significantly correlated with histopathology: 100% in sarcomatoid RCC and 77.9% in clear cell carcinomas (P < 0.0001). The CP was lower in pN1 (P = 0.018), pM1 (P = 0.046), and TNM IV stages (P = 0,041). A greater number of hTERT mRNA replicas were detected in M1 patients (P = 0.0005) and TNM IV stage (P = 0.017). There was no correlation of hTERT mRNA expression with Fuhrman grade. CONCLUSIONS: The quantitation of hTERT mRNA expression in RCC might be useful as a complementary diagnostic tool as well as for assessing aggressiveness of the tumor.

GSTT1, GSTM1, and CYP1B1 gene polymorphisms and susceptibility to sporadic renal cell cancer.

PURPOSE: To estimate the prevalence and importance of GSTT1, GSTM1, and CYP1B1 genotypes in renal cell carcinoma (RCC), and to identify their value as a prognostic factor. MATERIALS AND METHODS: Cross-sectional study of a group of patients diagnosed with RCC (n = 133) and a control group (n = 208) with benign conditions and no history of tumor. Controls were selected by cumulative samples and mixed pairing. All subjects pertained to the catchment area for our hospital. Sociodemographic variables, anatomical pathology features, and presence of GSTT1, GSTM1, and CYP1B1 polymorphisms by multiplex PCR and sequencing techniques. RESULTS: There were no differences in the genotype distribution of the GSTT1 and GSTM1 genes between cases and controls. In the case of CYP1B1, the GG genotype (Ala119) was more prevalent in patients with RCC (OR = 2.08; 95% CI: 1.32-2.28) and may be implicated in 34.3% (95% CI: 16.3-52.2) of RCCs. In patients with GSTT1 deletion, TNM stages III to IV were more common (39.1%); whereas in Val432 homozygous patients in CYP1B1, Fuhrman grades 3 to 4 (54.6%) were more common. Because this was a cross-sectional study, longitudinal studies are needed in the future to confirm these data. CONCLUSIONS: No relationship between GSTT1 and GSTM1 genotypes and RCC risk was observed. Homozygous subjects with Ala119 in CYP1B1 had twice the risk of RCC as homozygous for Ser119 or heterozygotes. Patients with GSTT1 deletion had tumors of more advanced stages, and those with Val432 polymorphism in CYP1B1 had tumors of higher Fuhrman grade.

Vesical nephrogenic adenoma: an unusual presentation of a bladder tumour.

Vesical nephrogenic adenoma is a rare, benign entity that appears most commonly in middle-aged males. Its etiology is unknown, but it has been linked to chronic irritating factors, such as infection, trauma, urological surgery, kidney stones, foreign bodies and chemical agents, such as Bacille Calmette-Guerin. We report 2 new cases with a history of transurethral resection of the bladder and the prostate and a history of prolonged voiding symptoms. In both cases, the findings of encysted tubular structures lined with flattened cuboidal cells without atypia were consistent with the diagnosis of vesical nephrogenic adenoma.

Evolución de las derivaciones desde atención primaria a la consulta de urología tras la aplicación de un protocolo de pacientes con síntomas del tracto urinario inferior por hiperplasia benigna de próstata / Urology clinics referral Patterns after initiation of a Primary Care BPH-LUTS protocol

OBJETIVO: Los médicos de Atención Primaria (MAP) son fundamentales en la regulación del flujo de pacientes desde Atención Primaria (AP), por tanto, es esencial buscar métodos de adecuada gestión de la demanda asistencial y así optimizar recursos. En la hipertrofia benigna de próstata (HBP) se estima que 2/3 de los pacientes pueden ser manejados íntegramente desde AP a lo largo de todo el proceso de la HBP. MATERIAL Y MÉTODOS: Hemos realizado un estudio pre experimental en dos períodos, antes (pre-test) y después (post-test) de la creación de un protocolo de manejo y derivación de pacientes con HBP. Analizamos la adecuación a los criterios de derivación y el uso de los estudios complementarios para llevar a cabo el diagnóstico, realizando un análisis estadístico (descriptivo, bivariante, multivariante y cálculo de tasas) utilizando SPSS (versión 21). RESULTADOS: La tasa de derivación disminuyó tras la aplicación del protocolo, pero no logró mejorar la adecuación. Los pacientes derivados por los MAP que asistieron al programa educativo fueron más jóvenes. Se remitieron menos pacientes con PSA elevado y más pacientes con progresión clínica. Se utilizaron menos estudios complementarios. Los MAP que no acudieron a la formación eran más jóvenes, principalmente mujeres, sin formación especifica en HBP y con contrato temporal. CONCLUSIONES: A pesar de reducir la tasa de derivación no se consiguió mejorar la adecuación de la derivación de los pacientes. Consideramos necesario analizar la problemática de los MAP y valorar otras intervenciones que podrían mejorar la calidad en la transferencia de responsabilidades

OBJECTIVE: In the Spanish health system, General Practitioners (GPs) play a key role in regulating the flow of patients to hospital care. Most of patients with BPH can be managed throughout the evolution of the disease exclusively by the GPs. METHODS: A pre-experimental study was carried out in two periods, before (pre-test) and after (post-test) of the dissemination of a management protocol for patients with BPH. The protocol was trialled in the health area of Villarrobledo and included all referrals to the urology clinic for BPH from Primary Care. We analyzed the appropriate referrals according with the criteria set forth in the protocol and compared the complementary tests through statistical study (descriptive, a bivariate, multivariate analysis and rate calculation) using version 21 of the SPSS. RESULTS: Referral rate decreased after the application of the protocol but did not increase the rate of appropriated referrals. Patients referred after setting forth protocol by GPs that assisted to the education program were younger. There were referred less patients with elevated PSA and more patients with clinical progression. These GPs used less test to achieve diagnosis. The GPs who did not attend were significantly younger, mainly women, with no previous specific training in BPH and without a full time GP position. CONCLUSIONS: The implementation of a protocol has reduced the referral rate, but it has not improved the appropriate referrals. More research is required to understand the determinants of inequalities in referral from primary care

[Impact of surgical treatment of female stress urinary incontinence on the quality of life of patients]. / Impacto de la cirugía de la incontinencia urinaria de esfuerzo en la calidad de vida de las pacientes.

OBJECTIVES: To evaluate the quality of life of patients with stress urinary incontinence (SUI) operated in the Department of Urology at the Complejo Hospitalario Universitario in Albacete (CHUA). METHODS: Between November 2001 and December 2005, 126 patients with SUI have completed a questionnaire in our centre, before and after undergoing surgery with sling techniques. The questionnaire was the King's Health Questionnaire (KHQ), which is a specific instrument for the measurement of quality of life in patients with urinary incontinence. RESULTS: Mean patient's age was 57.09 years (DE: 9.57). Twelve women (9.5%) had history of previous urinary incontinence surgery. Mean urinary incontinence evolution time was 114.48 months, with a median of 96 months. 38 patients (30.2%) did not present cystocele, 61 (48.4%) presented grade III cystocele, 25 (19.8%) grade II, and 2 (1.6%) grade I. Before surgery, the scale with best score was Personal relationships, with a mean score of 26.8, whereas the scale with worst scores was Impact of urinary incontinence, with a mean score of 82.96. All operations performed consisted in various techniques of transvaginal slings, except one case (0.8%) in which the Kelly technique was performed. Impact of urinary incontinence was the scale with a greater number of patients improving after surgery; 82.9% of the patients (101 cases) gave a better score. The scales showing greater differences of the mean value comparing before/after surgery were impact of urinary incontinence, limitation on the daily life activity, and limitation on social activity. Personal relationships and General health were the two with the smallest improvements. CONCLUSIONS: Surgery demonstrated to improve the symptoms secondary to this disease, therefore, it results in an improvement of the quality of life that is evident in all scales of the questionnaire, mainly in the impact of urinary incontinence, limitations on physical activity, limitations on daily life, and limitation on social activity scales.

[Spermatic cord sarcomas: current status and report of four cases]. / Sarcomas de cordón espermático: estado actual y presentación de cuatro casos clínicos.

OBJECTIVE: To study and review spermatic cord sarcomas, including symptoms, diagnosis, and treatment. METHODS/RESULTS: We review the Spanish and international literature and report 4 new cases: 2 patients with well-differentiated spermatic cord liposarcomas (1 treated by simple tumorectomy), 1 patient with liposarcomatous degeneration of a previously excised atypical lipoma, and 1 patient operated for a malignant retroperitoneal fibrous histiocytoma with subsequent local recurrence in the paratesticular region. CONCLUSIONS: Spermatic cord sarcomas are rare entities that usually appear as painless paratesticular mass. They are diagnosed by imaging studies (ultrasound, computed tomography, magnetic resonance) and confirmed by histological examination. Spermatic cord sarcomas are treated surgically; the efficacy of adjuvant treatments such as chemotherapy or radiation therapy is still under debate.