[Complications and incidences in our first 250 robotic radical prostatectomies]. / Incidencias y complicaciones en nuestras primeras 250 prostatéctomias radicales robóticas.

OBJECTIVE: To review the incidence of and analyze the factors contributing to perioperative complications in patients undergoing robotic radical prostatectomy in our experience of 250 procedures. MATERIALS AND METHODS: An analytical, descriptive, retrospective study was conducted of 250 consecutive patients who underwent robotic radical prostatectomy during a period of three years and two months (January 06-March 09). Data recorded included age, preoperative Gleason grade and PSA, and prostate volume. All procedures were performed by three surgeons through a transperitoneal approach using a four-arm da Vinci robotic system. Microsoft Excel support was used. Surgical variables recorded included setup time, console operation time, mean bleeding, transfusion rate, hospital stay, and urethral catheterization time. Incidences and intraoperative and postoperative late and early complications in these patients were reviewed. RESULTS: Demographic data recorded included: mean age, 61.5 years (47-74); mean preoperative PSA, 8.18 ng/mL (2.6-34 ng/mL); mean Gleason grade, 6.8 (2-9); and mean prostate volume 34.9 mL (12-124). Surgical variables recorded included: console setup time, 10.8 min (6-47): console operation time, 125 min (90-315); mean bleeding, 150 mL (50-1150); and a 3.6% (9/250) transfusion rate. There was no peroperative mortality, and no conversion to open or laparoscopic surgery was required. Ninety-six percent of patients (240/250) had an adequate postoperative course, with a mean hospital stay of 4.2 days (3-35) and urinary catheter removal after 8 (5-28) days. Overall complication rate was 10.6%, with major complications occurring in only 3.2% of patients (8/250) and consisting of five surgical and three medical complications. Repeat surgery was required in 1.6% of cases (4/250) due to late peritonitis for cecal perforation, bleeding from epigastric artery, perineal percutaneous drainage of retrovesical hematoma, and pelvic urinoma after bladder catheter dislodgment. One patient required selective arterial embolization for persistent hematuria due to vesical artery fistula. Medical complications included acute renal failure due to thrombotic purpura resolved with hemodialysis in one patient and late pulmonary embolism managed with anticoagulation in two patients. Robot malfunction with no surgical implications or need for surgical conversion occurred in four patients (1.6%). Surgical maneuvers required to resolve late complications included one umbilical hernia repair, one meatotomy for meatal stenosis, one bladder neck endoscopic incision after contracture, and one endoscopic extraction of Hem-o-lok and vascular clip following erosion-migration into the bladder. CONCLUSIONS: Robotic radical prostatectomy is a safe and reproducible procedure with optimal functional and oncological results, a shorter learning curve, greater comfort and vision for surgeons, and a complication rate similar to and even better than reported for open and laparoscopic surgery series. Complications decrease with the learning curve, but surgical team experience continues to be the key factor to achieve better results.

[Radical prostatectomy: evaluation of learning curve outcomes laparoscopic and robotic-assisted laparoscopic techniques with radical retropubic prostatectomy]. / Prostatectomía radical: comparación de los resultados obtenidos durante las curvas de aprendizaje de la técnica laparoscópica pura y de la técnica asistida por robot con la prostatectomía radical retropúbica.

INTRODUCTION/OBJECTIVE: Radical retropubic prostatectomy (RRP) is the gold standard for the surgical treatment of localized prostate cancer. New techniques are being developed with less invasive methods, including laparoscopic radical prostatectomy (LRP) and robotic-assisted laparoscopic radical prostatectomy (RALP). The aim of the study is to compare LRP and RALP outcomes during the learning curve with RRP, especially operative time and surgical complications. MATERIAL AND METHOD: We performed a retrospective observational study of all the RRP cases attended from January 2000, allthe LRPs performed at the Urology Department of the Galdakao Usansolo Hospital and the first 60 RALPs treated by the Clinic Urology group. Baseline parameters, operative and perioperative parameters (nerve preservation, positive margins, intraoperative bleeding, duration of catheterization, hospital stay) and surgical complications were assessed, and the three techniques were compared. RESULTS: The total number of patients was 192. The mean time operation was of 210 min in the RRP group, 345 min in the LRP group and 209.5 min in the RALP group (p = 0). Intraoperative bleeding was of 1500 mL in RRP, 1275 mL in LRP and 400 mL in RALP (p = 0) (Table 1). Six months after the procedure the continence rate was 60% in the RALP group, 45.90% in the RRP group and 36.40% in the group LRP (p = 0.001) (Table 2). CONCLUSIONS: Laparoscopic radical prostatectomy requires a longer learning curve than robotic-assisted prostatectomy. Operative time in RALP procedures was comparable to RRP cases. RALP showed benefits in terms of continence and intraoperative bleeding.

[Osseous lithiasis: an unusual condition]. / Litiasis ósea: patología excepcional.

Bone lithiasis is an uncommon disease unfrequent reported in the literature. Its origin is supported on urothelium and conjuctive tissue bone metaplasia. High suspicious index is needed to establish its diagnosis; where radiological signs and extracorporeal lithotripsy resistence drive to these uncommon entity. Definitive diagnosis is based on histological exam. We report a 49-year-old patient with left obstructive uropathy due to a high ureteral lumbar lithiasis who precised ureterolithectomy and partial ureterectomy after extracorporeal litotripsy failure. Histological exam confirmed bone lithiasis and squamous metaplasia. Epidemiologic, diagnostic and therapeutic aspects are briefly reviewed in literature. Bone calculus treatment includes lithectomy and urothelium resection to avoid posterior recurrence. Possible association to tumoral transformation suggests close evolutive follow-up.

[Infrequent left renal pseudomass: ectopic spleen]. / Pseudomasa renal izquierda infrecuente: ectopia esplénica.

Ectopic splenic tissue is uncommon in clinical practice, usually asymptomatic and generally unsuspected diagnosed. Interest from urological point of view is due to the possibility of mimicking left renal, adrenal and retroperitoneal tumours; as well as intrapelvic, inguinal and genital masses. We report a 42-years-old female patient with pseudotumoral upper pole left kidney mass with final diagnosis of ectopic spleen. Ethiopathogenic, diagnostic and therapeutical aspects are briefly reviewed in literature. We emphasized opportunity to include ectopic splenic tissue in differential diagnosis of left renal, adrenal and retroperitoneal masses. We recommend imaging studies as CT and MRI, complemented if necessary with liver/spleen radionuclide scan. We advocate for non-aggressive attitude in selected cases with asymptomatic extrapelvic ectopic spleen under confirmed diagnosis, deferring splenectomy in symptomatic instances or secondary portal hypertension cases.

[Epistaxis as initial manifestation of disseminated renal adenocarcinoma]. / Epístaxis como primera manifestación de un adenocarcinoma renal diseminado.

Peculiar renal carcinoma tendency to unusual distant metastases suggest this primary neoplasm to be accounted in differential diagnosis of metastases as first clinical symptom of cancer. Renal cell carcinoma present metastases in 26-30% of cases at the time of diagnosis. Head and neck metastases from renal carcinoma are said to be present in 8% (6-15.2%) of patients, and half of them are asented on paranasal sinuses. We report a 70-years-old patient with recurrent epistaxis as first clinical sign of a nasosinusal metastases from renal disseminated carcinoma, who precised selective embolization. Epidemyologic, diagnostic and therapeutical aspects are briefly reviewed in literature. Nasosinusal metastases are uncommon in clinical practice. We emphasized the need of primary tumor investigation in the organs most often responsible for these metastasic deposits as: kidney (50%), lungs, breast, gastrointestinal tract, urogenital ridge and thyroid gland. Individualized treatment depends on leasions number and localization. On routine follow up of hipernephroma nephrectomized patients a high suspect index has to be considered as paranasal metastases can eventually occur.

[Metachronous contralateral Leydig cell tumor of the testis: conservative treatment]. / Tumor testicular de células de Leydig contralateral metacrónico: tratamiento conservador.

Leydig cell tumors are the primary nongerm cell tumors of the testis, comprising approximately 1 to 3% of all testicular neoplasms. These tumors are bilateral in 5 to 10% of cases. Hypoechoic testicular nodule associated to a child virilising syndrome or adult gynecomastia with negative testis tumor markers (AFP, B-HCG) show a high index suspicion for this entity. We report a case of metachronous contralateral Leydig cell tumor in a 32 years old man with a 9 year interval between presentations, in which we performed local excision of the lesion. Diagnostic an therapeutic aspects are reviewed in literature. Since preoperative diagnosis of Leydig cell tumors in difficult and clinical course unpredictible, radical orchiectomy has been the standard treatment. Emphasis is made on conservative management opportunity in patients with only one testis, small tumors (less than 2.5 cm) with biopsies from tumor bed negative and wishes to remain fertile and/or refuses androgen supplementation. Follow-up is mandatory by performing scrotal ultrasounds. CT scan, Chest X-Ray, tumor markers and hormone determinations (testosterone, estradiol, progesterone, LH and FSH).

[Large renal leiomyoma]. / Leiomioma renal voluminoso.

Renal leiomyomas are uncommon between renal tumors, and they have a benign mesenchymatous origin. Because of their low incidence, unspecific symptomatology an not well-defined iconographic semiology, they often raise problems with differential diagnosis from kidney masses, although they are often big size lessions. We report a patients with incidentally diagnosis of big solid left renal mass, who underwent radical nephrectomy resulting kidney pelvis leiomyoma. Diagnostic, histological and therapeutic aspects are briefly review in literature. Emphasis is made on the relevance of a high index suspicion considering big solid asymptomatic renal masses in middle-age women. Specially in renal tumors with well-defined limits and abscence of locoregional and systemic dissemination. We emphasized usefulness of Magnetic Angioresonance, immunohystochemical test and conservative surgery opportunity in small renal leiomyomas preoperatively confirmed.

[Percutaneous kidney lithotripsy. Clinical course, indications, and current methodology in our Lithotripsy Unit]. / Litotricia renal percutánea. Evolución, indicaciones y metodología actual en nuestra Unidad de Litotricia.

OBJECTIVE: To review the history, development, indications and current methods of percutaneous renal lithotripsy. METHODS: The history and development of PNL is briefly reviewed. Its indications are analyzed, starting with large calculi and covering all the indications over the last 15 years of development of this technique and its current use. The PNL technique currently performed in our Lithotripsy Unit is described step by step. Technical details, equipment, instruments, complications and solutions are discussed. RESULTS/CONCLUSIONS: In our view, PNL continues to be the technique of choice for most of the calculi that are more than 2 cm in size. It is fundamental for the new generation of urologists to be familiar with all endourologic techniques since current technological advancements will allow us to perform procedures throughout the urinary tract using endoscopic methods.

[Renal carcinoma and von Hippel-Lindau disease]. / Carcinoma renal y enfermedad de Von Hippel Lindau.

Von Hippel Lindau disease is a highly uncommon autosomic dominant condition characterised by the presence of cerebellar hemangioblastomas, retina angioma, pancreas, kidney and epididymal cysts, and renal cells carcinoma. This article describes the case report of a male patient with Von Hippel Lindau disease which presented as a jaundice secondary to biliary obstruction due to pancreatic cystic mass. After urological examination, bilateral cystic lesions and right renal solid lesion were detected requiring surgical treatment. A review is made of the diagnostic and therapeutic aspects, highlighting the significance of early diagnosis and treatment.

[Giant inguinoscrotal bladder hernia associated with a bladder tumor]. / Hernia vesical inguinoescrotal gigante asociada a tumor vesical.

Inguinoscrotal bladder hernias are uncommon clinical facts more predominant in males aged between 50 and 70. This entity has no specific clinical character and diagnosis usually happens in the course of surgical repair of inguinal hernia. In about 3%-10% cases, it appears associated to inguinal hernia. Discussion of two case-reports of patients with giant inguinoscrotal bladder hernia; one patient with synchronous association to bladder transitional carcinoma. The literature on the clinical, diagnostic and therapeutic aspects is revised. The high index of suspicion for making a pre-operative diagnosis, specially in aged patients with inguinal hernia and expanded prostate signs and symptoms is highlighted. Emphasis is placed on the need for surgical hernia repair prior to prostate and/or bladder transurethral surgery.

[Testicular epidermoid cysts. Report of 2 cases]. / Quistes epidermoides testiculares. A propósito de dos observaciones.

Testicular epidermoid cysts are benign tumours which account for less than 1% of all testicular tumours. Their uncertain histogenesis, difficult pre-operative diagnosis and controversial therapeutic approach are at the base of this paper. Report on two patients, 20- and 21-year old, with testicular epidermoid cysts treated by inguinal radical orchiectomy and tumorectomy, respectively. Literature review focused on the diagnostic and therapeutic aspects. Emphasis on the relevance of ultrasound for pre-operative diagnosis. We also advocate for a conservative management if their presence is suspected or in the presence of negative tumoral markers.

[Pyourachal cyst. A diagnosis to keep in mind]. / Quiste piouracal. Un diagnóstico a tener en cuenta.

Urachal conditions are relatively exceptional, cystic formations being the most commonly reported. Urachal cysts remain silent and are not diagnosed except for the presence of associated complications such as: infection, lithiasis, re-permeabilization and malignant degeneration. This paper presents one patient with an infected urachal cyst (pyourachal) which required surgical exeresis. A literature revision is made of the clinical, diagnostic and therapeutic aspects. Emphasis is made on the relevance of a high index of suspicion considering its small incidence, the absence of specific clinical sings and the possibility of mimicking different abdominal pictures. Also the usefulness of ultrasound and computerized axial tomography in the diagnosis, and the need for surgical exeresis, including a vesical cup rim, are emphasised.

[Advanced tubercular disease of urogenital tract]. / Enfermedad tuberculosa avanzada del tracto urogenital.

OBJECTIVE: The genitourinary tract is one of the most common sites of extrapulmonary tuberculosis (30%-33%), followed by the lymphatic tissue, skeletal system and gut. Due to the diagnostic methods and therapeutic modalities currently available, it is infrequent to find advanced tuberculosis with extensive genitourinary involvement. METHODS/RESULTS: Herein we describe a patient with advanced genitourinary tuberculosis characterized by loss of right renal unit, left hydronephrosis due to ureterovesical junction stricture, contracted bladder, prostatic caseation and urethral stricture. Right nephrectomy and bladder substitution ileocystoplasty were performed. The clinical features, diagnostic and therapeutic aspects are discussed and the literature briefly reviewed. CONCLUSION: Extensive genitourinary tuberculosis is uncommon. The importance of early diagnosis and treatment is emphasized in order to avoid the irreversible sequelae.

[Mixed urogenital schistosomiasis]. / Esquistosomiasis genitourinaria mixta.

Urinary schistosomiasis is a parasitosis caused by Schistosoma Haematobium which affect in a diffuse manner all the genitourinary tract. Presentation of 5 patients (4 male, 1 female) with mixed Bilharziosis that was detected after the study of a young male that came to the clinic with a complaint of haematuria and who underwent transurethral resection under the suspicion of a vesical urothelial neoformation. Sch. Hameatobium eggs were detected in the urine and Sch. Mansoni in the semen of all 4 male. All of them evolved favourably with Praziquantel. Considering the rarity of schistosomiasis in our environment and its increased incidence in endemic areas, this process should be included in the algorithm of differential diagnosis in young patients reporting dysuric syndromes associated to haematuria; the relevance of an epidemiological anamnesis so as to institute early treatment and avoid the consequences of chronic infection is pointed out.

[Ureteral obstruction secondary to inflammatory iliac aneurysm]. / Obstrucción ureteral secundaria a aneurisma ilíaco inflamatorio.

Inflammatory iliac aneurysms are uncommon and account for 1-2% of total abdominal aneurysms. These aneurysms are more susceptible to present urological symptoms and are difficult to diagnose because of their uncommon incidence and location in the deep pelvis which makes them little accessible to physical examination. This case report presents one patient with right obstructive uropathy secondary to extrinsic ureteral trapping due to inflammatory iliac aneurysm which evolved favourably after ureterolysis, endoaneurysmectomy and interposition of aortoiliac graft. A brief review of diagnostic and therapeutic aspects in the literature is included. The relevance of a high degree of suspicion to diagnose this entity in patients with otherwise explainable vesical irritative symptoms, haematuria or renal failure is highlighted.

[Synchronous association of Bellini collecting ducts and pyelic transitional cell carcinoma]. / Asociación sincrónica de carcinoma de los conductos colectores de Bellini y carcinoma transicional pielico.

Bellini's collecting ducts carcinoma represent a subgroup within renal carcinoma with an incidence of 0.4 to 2% of all renal tumours. The collecting ducts share their embryological origin in Wölf's duct with the calices, renal pelvis and ureter. This common embryological origin could justify the association of carcinoma originated in the collecting ducts with transitional urothelial carcinoma. This paper contributes two patients with Bellini's collecting ducts carcinoma associated to "in situ" carcinoma and transitional papillar carcinoma in the adjacent renal pelvis respectively. The authors review the diagnostic, pathoanatomical and therapeutical aspects found in the literature. A high index of suspicion is required to diagnose a case of Bellini's carcinoma in the face of predominantly central-medullar renal solid lesions, with infiltrating growth that causes morphological changes in the excretory system without deforming the external renal outline. The authors highlight the value of immunohistochemical studies to reach a diagnosis, considering the natural history and the sombre prognosis of this uncommon renal neoplasia.

[Primary prostatic infiltration by Burkitt's lymphoma]. / Infiltración prostática primaria por linfoma de Burkitt.

OBJECTIVE: Genitourinary tract involvement arising from non-Hodgkin lymphoma occurs in 10% of patients; prostatic infiltration is uncommon and accounts for less than 0.1%. The uncommon clinical onset of this infrequent condition prompted us to report on the present case. METHODS/RESULTS: A 41-year-old male patient with lower urinary tract outflow obstruction arising from prostatic enlargement secondary to non-Hodgkin lymphoma (Burkitt's lymphoma) is described. Treatment with chemotherapy achieved good results. The clinical features, diagnostic and therapeutic aspects are discussed and the literature briefly reviewed. CONCLUSION: The present case emphasizes the need to include non-Hodgkin lymphoma in the differential diagnosis of lower urinary tract outflow obstructive symptoms in young men with prostatic enlargement.

[Usefulness of magnetic resonance angiography in the diagnosis of polar vessel in stenosis of the pyeloureteral junction]. / Utilidad de la angioresonancia magnética en el diagnóstico del vaso polar en la estenosis de la unión pieloureteral.

OBJECTIVES: To present the results of a prospective study that had been conducted to determine the accuracy of magnetic resonance angiography (MRA) in the detection of accessory or polar vessels associated with ureteropelvic junction (UPJ) stricture, in order to utilize the most appropriate surgical procedure in the management of this condition. METHODS: From October, 1994 to September, 1996, 30 MRA procedures were done in 12 males and 18 females, aged 14 to 73 years (mean 38.12), with symptomatic UPJ obstruction. When the MRA was positive for polar vessels, the patients underwent open dismembered pyeloplasty; surgical correlation and a true positive result could be established. Percutaneous endopyelotomy was offered when the MRA was negative. The findings at open surgery and an unremarkable clinical course and radiological findings at one year follow-up established a true negative result. RESULTS: Accessory or polar vessels (11 arteries; 4 veins) were found in 11 patients (36.4%). MRA had a sensitivity of 92.3% (15/16) for detection of accessory vessels. Fourteen patients underwent open surgery (11 dismembered pyeloplasties; 3 nephrectomies) and the MRA findings were confirmed in each case (8 positive; 6 negative). Surgery disclosed an accessory vein that had not been detected on MRA in only one patient. This patient also had a polar artery that had been observed on MRA and demonstrated at surgery; thus, the sensitivity of MRA for detection of UPJ stenosis with polar vessel is 100% (11/11). Each vessel described on MRA was confirmed at surgery; there were therefore no false positives and the specificity was 100%. CONCLUSIONS: Although this is a preliminary study with a short follow-up and with some limitations, the results indicate that MRA is a simple, non-invasive technique with a high sensitivity and specificity for detection of polar vessels associated with UPJ stenosis, and appears to be a useful preoperative diagnostic procedure due to the surgical implications.

[Multiple giant ureteral lithiasis]. / Litiasis ureteral gigante múltiple.

OBJECTIVES: Ureteral calculi are usually small and arise from the kidney. The term 'giant' has been applied to ureteral stones that are more than 5 cms in length and/or 50 gms or more in weight. The low incidence of this condition prompted us to report this case. METHODS/RESULTS: Herein we describe a patient with multiple giant ureteral calculi with no evidence of underlying ureteral lesion, who required nephroureterectomy due to the damage caused to the renal unit by the obstructive uropathy. The literature is briefly reviewed, with special reference to the diagnostic and therapeutic aspects. CONCLUSIONS: Giant ureteral calculi are uncommon. They may cause scanty urological symptoms and might therefore be missed. If undiagnosed, renal function may be compromised by the obstructive uropathy.

[Inappropriate antidiuretic hormone secretion syndrome: a rare manifestation of prostatic adenocarcinoma]. / Síndrome de secreción inadecuada de hormona antidiurética: una rara manifestación de adenocarcinoma prostático.

OBJECTIVE: Prostatic cancer can produce signs and symptoms by local growth, direct invasion or distant metastases. In rare occasions, these tumors can show a clinical variance due to trophic factors, biologically active, secreted in neoplastic environment but with systemic relevance. These syndromes are called paraneoplastic syndromes. This uncommon condition is described herein. METHOD/RESULTS: We report a case of inappropriate antidiuretic hormone secretion as the presenting feature of advanced prostatic carcinoma. The pathogenic features, diagnostic and therapeutic aspects are reviewed. CONCLUSIONS: Although its frequency is low, we must consider prostatic carcinoma in patients with inappropriate antidiuretic hormone secretion syndrome. When the acute situation is resolved, hormonal treatment in disseminated carcinomas will return to normal the clinical and analytical parameters derived from this syndrome.