Endoscopic treatment of a giant fibroepithelial polyp of the ureter.

SUMMARY OBJECTIVES: Fibroepithelial polyps are benign mesenchymal tumors with a morphology and clinical presentation very similar to transitional cell carcinomas, so that differential diagnosis is of paramount importance. METHODS/RESULTS: We present the case of a 42-year-old female patient, with history of mediastinal Hodgkin/s lymphoma, which came to the office reporting right low back colic pain and haematuria. CT scan showed pediculated neoformation of about 10 cm protruding into the bladder, with negative urine cytology. In view of the findings, and with the suspicion of fibroepithelial polyp, an endoscopic exploration was performed, confirming the diagnosis, followed by exeresis with Holmium laser. DISCUSSION: A differential diagnosis between fibroepithelial polyp and transitional cell carcinoma cannot be made with imaging tests alone. The suspicion must be established, and endoscopic exploration indicated, by means of ureterorenoscopy or percutaneous nephroureteroscopy, whatever is a better indication, with biopsy or definitive endoscopic treatment of the tumor. CONCLUSIONS: Endoscopic exploration is currently the procedure of choice for the diagnostic confirmation of this condition and its definitive treatment.

[Prognostic significance of the microscopic invasion of the renal vein wall in renal cell cancer]. / Valor pronóstico de la afectación microscópica de la vena renal en el cáncer de células renales.

OBJECTIVES: International TNM Staging System for renal cell carcinoma (RCC) classifies as T3b when "tumor grossly extends into the renal vein or its segmental branches, or vena cava below the diaphragm". The finding of microscopic invasion of the vein wall is not taken into account for TNM staging. We analyse its prognostic significance in localized and locally advanced RCC. METHODS: From January 1989 to July 2002, 257 RCC were surgically excised. Excluding Von Hippel-Lindau patients and stage IV (TNM 2002), 241 cases were studied in retrospect, with a median follow up of 50.96 months. Histopathological data from the renal vein were available in 216 specimens. There was renal vein wall invasion in 22. We compare the outcomes in this group vs. the group without microscopic involvement of the renal vein wall (n: 194). RESULTS: Mean age for the group with renal vein invasion (RVI) was 65.02 years. Mean tumour size in the same group was 9 cm, larger than in control group (p<0,001). Thrombus was found in 72.7% vs. 6.2% in the control group. Clear cell carcinoma (77.3%) was the predominant histological subtype. Nuclear grade 2 according to Fuhrman's Classification System accounts for 42.9% of the cases. Metastatic progression risk (HR: 4,86) and death risk (HR: 6,49) are significantly higher in RVI group. When renal vein thrombosis is found, progression and death risks are still higher (HR: 7.22 and 8.38, respectively). CONCLUSIONS: Microscopic invasion of the renal vein wall is a dependent prognostic factor for disease progression and death for RCC. Macroscopic renal vein involvement is an independent prognostic factor. When both factors are found together, disease outcome is worse.

[Atypical lymphatic dissemination of a testicular tumor from a cryptorquid testicle]. / Diseminación linfática atípica de un tumor testicular sobre un testículo criptorquídico.

OBJECTIVES: Atypical lymphatic spread of germ cell tumors to inguinal lymph nodes has been reported mostly related to prior surgical involvement of the inguinoscrotal region, as in orchiopexy. METHODS: A patient with cryptorchidism and failed orchiopexy in his childhood was diagnosed with a testicular neoplasm. Inguinal orchiectomy was performed. RESULTS: Pathological analysis showed classical seminoma spreading into a subcutaneous adjacent lymph node. Further metastatic disease was not found. Patient was treated with adjuvant chemotherapy. CONCLUSIONS: We emphasize the need for accurate staging and a multidisciplinary approach when dealing with onco-urological patients presenting with atypical disease.

[Prevalence of lower urinary tract symptoms related with benign prostatic hyperplasia. Study of 1804 men aged 40 or older in Madrid]. / Prevalencia de síntomas del tracto urinario inferior relacionados con la hiperplasia benigna de próstata. Estudio de 1804 hombres de 40 años o más residentes en Madrid durante 1999-2000.

INTRODUCTION: Lower urinary tract symptoms (LUTS) related with benign prostatic hyperplasia (BPH) are present nowadays in approximately 20 to 30% of the Spanish male population from the age of 50 onwards. The purpose of this study was to assess clinical and epidemiological characteristics of patients with LUTS. METHODS: A cross-sectional study was performed, between 1999 and 2000, among 1,804 men aged 40 or older who were living in Madrid. Subjects were interviewed by telephone; socio-demographic information was requested and the presence of LUTS was assessed using the International Prostate Symptoms Score. Informed consent was requested, Association between qualitative variables was evaluated by chi2 or Fisher's test. A logistic regression model was performed to control confusion. RESULTS: Prevalence of moderate/severe LUTS was 16.6% (95%CI: 14.8-18.3). Nearly 90% of the subjects consumed olive oil, 71.5% alcohol, 63.1% did not smoke and 96.9% did not consume drugs. A 27.7% of the subjects had hypertension and 8.8% referred diabetes. Men aged 70 or older had a threefold increased frequency of serious symptoms compared to younger men (OR: 3.31; 95%CI: 2.10-5.22). Low level of studies increased this frequency by a factor of 2.2 (95%CI: 1.42-3.46) and men who consumed only seed oil had twice more serious symptoms than those who consumed olive oil (OR: 1.86; 95%CI: 0.98-3.55). CONCLUSIONS: Family history of urological diseases, age, low level of studies, hypertension, diabetes and seed oil consumption were independently associated with more serious symptoms, while medium alcohol consumption and mild smoking habit were associated with slighter symptoms.

[Percutaneous treatment of calyceal diverticulum associated with lithiasis]. / Tratamiento percutáneo de divertículo calicial asociado a litiasis.

OBJECTIVES: To report the case of a 47-years-old woman with several small stones located inside a calyceal diverticulum of the right kidney and to highlight the importance of minimally invasive endourological treatment in these cases. METHODS: Owing to the presence of diverticular calculi and clinical symptoms of recurrent infection, we decided to perform percutaneous nephrolithotomy (PNL). After Holmium-YAG laser calculi fragmentation and removal of all stone material, we fulgurated the diverticular lining and infundibulum with a resectoscope and a rollerball electrode. RESULTS: The patient is free of symptoms after 6 months follow-up. The disappearance of the calculi and diverticulum is confirmed with excretory urogram. CONCLUSIONS: Endourological approach for diverticular calculi, such as percutaneous nephrolithotomy (PNL), is a minimally invasive treatment with excellent results and low morbidity. Using this procedure we are able to perform stone removal and cavity fulguration. According to this, we think that endourological techniques, and specially PNL could be the first option for treatment in selected cases of this pathology.

[Usefulness of the holmium:yag laser in the endoscopic section of ureteral stenosis]. / Utilidad del láser de holmium:yag en la sección endoscópica de la estenosis ureteral.

OBJECTIVES: The incidence of ureteral stenosis is frequent in our environment. Lately, due to the massive use of endourological techniques its incidence has increased. Etiology represents a decisive factor for the final result of treatment, but there are also common characteristics to all stenosis that influence very importantly the final success: time of evolution, length of the stenosis, side and function of the affected renal unit. Over the last years, the use of endourological techniques for the treatment of upper urinary tract stenosis, that substitute the traditional open technique, have increased. Holmium:YAG laser endoureterotomy presents advantages in comparison with other endourological techniques, because it enables a precise incision with direct vision of the ureteral stenosis. Moreover, with laser fibers ureteroscopes achieve a degree of flexibility/deflection that enables us to reach in most cases the stenotic area. At the time of incision of the ureteral wall, it should be complete, acting on all ureteral layers down to the periureteral fat, always having in mind the anatomic relationships of the ureter with neighbour structures, mainly vascular, to avoid injuries. Its effectiveness and easy management permits a high success rate, with resolution of the stenosis and a very low complication rate. After all the anterior, holmium laser retrograde endoureterotomy should be included as a first line treatment for benign ureteral stenosis.

[Retrograde laser endopyelotomy]. / Endopielotomía retrógrada con láser.

Ureteropyelic junction obstruction (UPJO) is the most frequent congenital anomaly of the upper urinary tract. Until some years ago, the treatment of first choice was open pyeloplasty, but the development of endoscopic surgery and the clinical improvement on instruments, enables the treatment in a minimally invasive fashion, offering the advantages of shorter operative time, less morbidity, reduction of post operative analgesic requirements, shorter hospital stay, and shorter convalescence period. Retrograde endopyelotomy represents the natural evolution of the minimally invasive surgical treatment of the UPJO by eliminating the need of a percutaneous renal tract and its possible complications. It may be performed in three ways: semirigid ureteroscope and electrocautery, cold knife or laser incision; flexible ureteroscope and electrocautery or laser incision; and under x-ray control with the Acucise cutting balloon catheter. Currently, the development of smaller ureterorenoscopes (semirigid and flexible) and the use of safer and more effective energy sources, such as holmium:YAG laser, have improved the results of this technique. We present the technique step-by-step and a bibliographic review.

[Lower calyx lithiasis: usefulness of the laser]. / Litiasis en cáliz inferior: utilidad del láser.

There is controversy yet about which is the best treatment modality for lithiasis of the lower calyx. The range of lithiasis clearance of the stones localized in the lower calyx will depend on various factors such as size, composition of the stone, type of lithotripter employed, type of urinary transport, and anatomy of the lower calyx. The role of flexible ureteroscopy in the treatment of intrarenal pathology has experimented a dramatic evolution, impulsed by the improvements in design of flexible ureterscopes, their degree of deflection, and better quality of image, in the great diversification of small calibre accessory instruments, and the use of the holmium laser for lithotripsy. Its development makes possible to offer it as a therapeutic option for the failures of extracorporeal lithotripsy in stones smaller than 1 cm and as first-line treatment for stones smaller than 1 cm in size if they are cystine stones or they have an attenuation level over 1000 HU; also in obese patients or those with coagulation problems.

[Adenomatoid tumor of the epididymis. Report of two cases]. / Tumor adenomatoide de epidídimo. Aportación de dos casos.

OBJECTIVE: Tumors of the epididymis are rare. They are unusually benign and adenomatoid tumors are the most frequent. Report of two cases of this kind of tumor of the epididymis. METHODS/RESULTS: We report two cases of adenomatoid tumor of the epididymis diagnosed at our hospital during last year. Two males, 35 and 54 years old respectively asked for urology consultation about a palpable scrotal mass. They didn't have any other symptoms. Imaging techniques revealed a solid epididymal mass. Epididymectomy was performed. Pathological diagnosis was adenomatoid tumor. CONCLUSIONS: The majority of epididymal tumors follow a benign course. In the finding of an epididymal mass, after palpation and imaging tests, organ sparing surgery (epididymectomy) is recommended. We will avoid unnecessary orchiectomies.

[Blue prostatic nevus. Case report]. / Nevus azul prostático. Aportación de un nuevo caso.

OBJECTIVE: To state the scarce incidence of this prostatic pathology and the relative confusion with terminology applied to the presence of intraprostatic melanin pigments. METHODS/RESULTS: 66-year-old patient with elevated serum PSA with the diagnosis of prostatic blue nevus after biopsy. CONCLUSIONS: This diagnostic finding has not clinical or prognostic significance. They are benign lesions that must not be confused with other similar more aggressive lesions.

[The use of the Stone Sweeper catheter for stone disease of the upper urinary tract]. / Utilización del catéter "Stone Sweeper" en la patología litiásica del tracto urinario superior.

OBJECTIVES: The treatment of patients with a great burden of stones is very difficult and often requires complex treatments including different kinds of surgery, associated in some cases with ureteral stents. METHODS: We present the case of a patient with complex renoureteral stone disease in whom we used the stone sweeper stent before SWL. The catheter is a 6.5 Fr radial expanding stent with small baskets, a special structure designed to extract small stones < 5mm. RESULTS: The placement and retrieval of bilateral stents were performed without complications, extracting several small stones inside the baskets. CONCLUSIONS: The Stone Sweeper stent may play an important role in the treatment of patients with great stone burden; by dilating the ureter and helping the passage of stones and capturing small residual fragments it may decrease the need of new treatments. Currently, more clinic and research tests with this stent are necessary to determine proper indications and associated complications.

[Renal transplant in a patient with aortobifemoral bypass]. / Trasplante renal en paciente con bypass aortobifemoral.

OBJECTIVES: Over the last few years we see an increase in the number of patients with vascular disease who need a renal transplant. We discuss their management and different therapeutic options available. METHODS/RESULTS: We report the case of a female patient with history of systemic vascular disease having undergone multiple surgical procedures for it, including aortobifemoral bypass, presenting with end stage renal disease. A kidney transplant into the right iliac fossa was carried out with end to side vascular anastomosis to the iliac vein and arterial vascular prosthesis, respectively. The main difficulty came from the existence of an important fibrosis around the prosthesis, which forced a much more careful dissection of the iliac vein. Immediate postoperative course was uneventful, and the graft shows a normal function two years after surgery. CONCLUSIONS: The coexistence of vascular and renal disease is not a contraindication for kidney transplantation. Larger experience is required, but published data to date do not show significant differences on graft or patient survival.

[Ipsilateral metanephric adenoma and clear-cell carcinoma. Personal experience and review of the literature]. / Adenoma metanéfrico y carcinoma de células claras ipsilaterales. Experiencia personal y revisión de la literatura.

OBJECTIVES: To perform an update in such an infrequent pathology and to report our own experience. METHODS: We report two new cases and review the national and international literature. RESULTS: We report two cases of ipsilateral metanephric adenoma and clear cell carcinoma. The first case, metachronous, was detected after 15 months of follow-up in a patient who underwent partial nephrectomy due to clear cell carcinoma. The second one, synchronic, was incidentally discovered in the surgical specimen. CONCLUSIONS: Metanephric adenoma is as infrequent neoplasia; its diagnosis is histological, being difficult to suspect by complementary diagnostic tests, so that most cases undergo surgical treatment in spite of its benign character.

[Influence of recipient age on renal transplantation performed with organs coming from child donors]. / Influencia de la edad del receptor en el trasplante renal realizado con órganos procedentes de donantes infantiles.

OBJECTIVES: To evaluate the influence of receptor's age on the outcomes of kidney transplants with organs from donors below the age of three years and/or weighting less than 15 Kg. METHODS: We retrospectively studied the renal transplants with organs from donors below the age of three years and/or weighting less than 15 Kg performed at the Hospital Clínico San Carlos between 1991 and 1999. Receptors were divided into two groups depending on the age at the time of transplantation; group I included patients younger than 50 years and group II patients older than 50. RESULTS: We study 49 kidney transplants with pediatric donors (8.6%); 22 of them were included in group I and 27 in group II. There were no deaths among receptors younger than 50 years. Five-year survival for group II was 75.99%. Five-year graft survival what's 81.82% for group I, and 88.89% for group II (p 0.45). CONCLUSIONS: Receptor's age does not seem to influence graft survival when this kind of organs are used; we consider that the lower incidence of acute rejection in patients older than 50 years may explain the excellent response.

[Effect of recipient age on transplants performed using organs from donors in asystole]. / Influencia de la edad del receptor en el trasplante realizado con órganos procedentes de donantes en asistolia.

OBJECTIVES: To evaluate the influence of receptor's age on the outcomes of kidney transplants with organs from non heart beating donors. METHODS: Observational study of the historic cohort of 570 kidney transplants performed at the Hospital Clínico San Carlos between 1991 and 1999. Receptor's were divided into two age groups, group 1 younger than 50 years, and group 2 older than 50 years. All organs where harvested from non heart beating donors. RESULTS: We studied 110 kidney transplants coming from non heart beating donors; 52 belonged to group 1, and 57 to group 2. Three-year patient survival for receptor's younger than 50 years was 100%. The probability of three-year survival for receptor's older than 50 years was 79.39% (p 0.07). Graft survival was 88.46%, 86.54%, and 86.54% at 12, 24, and 36 months respectively for receptor's younger than 50 years. When receptors were older than 50 years the probability of functioning graft in the same periods of time was 89.20%, 89.20%, and 86.32% respectively. CONCLUSIONS: Receptor's age doesn't seem to influence graft survival when kidneys from non heart beating donors are used.

[Renal transplantation in donors over 60 years of age]. / Trasplante renal en receptores mayores de 60 años.

OBJECTIVES: To evaluate the impact of receptor's advanced age on kidney transplant outcomes. METHODS: We reviewed all transplants performed between January 1990 and December 1999. Among 570 patients receiving grafts, 115 patients were 60 years or older at the time of transplantation. We compared this group with receptors younger than 60 years. We studied possible prognostic variables and compared patient and graft outcomes. RESULTS: Mean age 63.81 (typical deviation (TD): 2.96). Mean follow-up time for elderly receptors was 41.6 months (TD: 26.58). 55.7% patients were males (p: 0.4). The most frequent cause for end stage renal disease was unknown etiology in group 1 and glomerular in the younger group (p: 0.01). 42% patients older than 60 years presented initial graft dysfunction, in comparison to 28.1% among younger than 60 (p: 0.006). Three-year graft survival was 90.42% for receptors 60 years old or older compared to 88.72% for group 2, without significant differences (p: 0.5). The most frequent graft loss etiology was patient death. (67.7%). (p = 0.005). Patient survival was 81.01% in group 1 and 95.25% in group 2, being differences significant (p < 0.001). CONCLUSIONS: Renal grafts in receptors over the age of 60 years show a greater incidence of delayed graft function, although it doesn't seem to influence final graft survival. The most frequent cause for graft loss is receptor's death. Receptor's age does not represent a contraindication for transplant.

[Collecting duct carcinoma. Personal experience and review of the literature]. / Carcinoma de los conductos colectores. Experiencia personal y revisión de la literatura.

OBJECTIVE: To present our experience with renal collecting duct carcinoma and review the literature. METHODS: We reviewed our experience with collecting duct carcinoma of the kidney. We found 6 cases out of 176 nephrectomies (3.4%), which accounts for one of the largest series reported in the literature. The radiological, histological and immunohistochemical findings are analyzed. RESULTS: The histological and immunohistochemical findings showed a specificity for high molecular weight cytokeratins and Ulex europeaeus but the imaging findings were not distinct from those of other renal tumors. According to the anatomopathological findings, we have classified the patients into three groups with three distinct courses. All patients underwent radical nephrectomy and one patient received adjuvant therapy. CONCLUSIONS: We have identified a subgroup of low grade collecting duct carcinoma of the kidney with a particularly favorable behavior in two patients of our series. At 56 and 41 months' follow-up, both patients remain disease-free. As reported in the literature, patients with high grade and stage collecting duct carcinoma of the kidney have a poor outcome. They develop severe complications and die less than one year after the diagnosis, despite adjuvant immunotherapy.