[Urolift®, a new minimally invasive treatment for patients with low urinary tract symptoms secondary to BPH. Preliminary results]. / Urolift®, un nuevo tratamiento mínimamente invasivo para los síntomas de tracto urinario inferior secundarios a HBP. Resultados preliminares.

OBJECTIVES: To report the preliminary results of one of the first series of patients treated with a new simple surgical technique for the treatment of lower urinary tract symptoms (LUTS) due to benign prostatic hyperplasia (BPH) and to evaluate its safety and feasibility. METHODS: We have performed a novel surgical treatment of BPH, the UroLift® System (Neotract, Inc). It opens the urethra directly by retracting the obstructing prostatic lobes without applying incisions, surgical resection or thermal injury to the prostate. RESULTS: The procedure was carried out in 20 patients with a mean age of 74.3 (43 hyphen;-90) years, with mean prostate volume of 42.6 mL (19 hyphen;109) using the same operative protocol in all case subjects. Mean operative time was 19.1 min (range: 12-45). International Prostate Symptom Score (IPSS) ) at 4 weeks reduced from 26.7 to 16.7 and peak urinary flow rate (Qmax) increased from 8.6 mL/s to 13.2 mL/s. No major complications were encountered, neither sexual dysfunction. Mean follow-up: 12.3 (2-22) months. CONCLUSIONS: The UroLift® System procedure appears to be safe and efficient at short term. This technique minimizes the bleeding of the urethra and, therefore, makes bladder catheter not always necessary, and can preserve sexual function with low morbidity. Further studies are warranted to determine long-term outcome.

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.

[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.

[Antimigration devices during endoscopic lithotripsy with holmium: yag laser]. / Dispositivos antimigración durante la litotricia endoscópica con láser de holmium:yag.

OBJECTIVES: Lithiasic pathology continues being very prevalent in our environment. There are multiple approaches and treatments to solve it in current urology. Lately, endourological techniques have suffered a spectacular advance which has permitted to increase their success rates, diminishing also their comorbidity very much. Nevertheless, despite all improvements we still face a series of complications that may reduce the success of the procedure. Among all of them, we emphasize stone retropulsion during endoscopic lithotripsy, because it appears in an important number of procedures and, it does not only diminish the range of stone free patients, but also is associated with a longer surgical time, and occasionally will make necessary the employment of additional procedures that increase cost and treatment morbidity. To reduce the incidence of this retropulsion classical manoeuvres have been employed: antitrendelenburg, decrease of the intensity of the irrigaton flow, modification of laser parameters, or pneumatic balloons. Currently, we have other more effective mechanisms to combat it, among them: the devices that occlude the ureteral lumen, and nitinol baskets/forceps. Adequate selection of the stone extraction device may be definitive for completion of the ureterorenoscopic procedure with success, and in the programmed time. The election of an inadequate device may make the procedure impossible or cause iatrogenic damage to the urinary tract. For all it, specific instruments to entrap and extract stones (baskets and ureteral lumen occlusion devices) is an armamentarium that every endourologist should be familiar with.