Histo-morpho-biochemical findings of the residual prostate (III): (undetectable) PSA maintained after retropubic adenomectomy for BPH.

SUMMARY OBJECTIVES: To present 4 cases with "undetectable" PSA levels (PSA <0.15 ng/ml) long-term postoperative follow-up after retropubic adenomectomy for BPH METHODS: They come from a series of 70 consecutive cases of retropubic prostatic adenomectomies, monitored and controlled at the hospital in their biochemical, histological and morphometric analysis for 5 years following the intervention. RESULTS: Four patients have demonstrated PSA levels <0.15 in all controls after surgery. Mean follow-up of the global series: 45.25 months. There is correlation between this determination and histological and morphometric data, when they were achieved. CONCLUSIONS: "Undetectable" PSA after open prostatic adenomectomy could be an equivalent to the expression of "radical cure"of BPH, and a reliable marker for monitoring neo-hyperplasia.

[Biochemical-histo-morphometric findings of the residual prostate (II): long-term PSA behavior after retropubic adenomectomy for BPH. Relationship with prostate volume, histology and its implications in the diagnosis of subsequent adenocarcinoma]. / Hallazgos bioquímico- histo- morfométricos de la próstata residual (II): comportamiento del PSA,A largo plazo, tras adenomectomía retropúbica por H.B.P. Interrrelaciones con el volumen e histología de la próstata residual y sus implicaciones en el diagnóstico ulterior de adenocarcinoma.

SUMMARY OBJECTIVES: To evaluate the changes experienced by the amount of PSA in patients diagnosed with BPH undergoing retropubic adenomectomy (with vesico-capsule plasty) in the short and long term, and the relationships between weight and /or prostate volume calculated preoperatively, volumes and histology of the surgical tissue and residual tissue remaining immediate and on the long term. METHODS: A consecutive series of 70 cases of BPH surgery and followed up beyond 5 years with preoperative PSA and transrectal ultrasound, histology of the piece, postoperative transrectal ultrasound, PSA annually until the fifth year and ultrasound. Within this group, residual prostate histology was obtained in 30 patients between 12 and 36 months after adenomectomy. RESULTS: In accordance to our own confirmed studies, the ATH (transcervical hemostatic adenomectomy) removes by enucleation 76% of the entire volume reported by preoperative ultrasound, including capsule. In our cases, PSA has dropped 83% at one year after surgery compared with the preoperative value, and in most cases that have already reached 5 years of follow-up, this percentage remains with little variation. Having being established a strong relationship between PSA and glandular volume, we must evaluate the need for new cut-off values giving more value to the PSA density in relation to the volume of residual prostate, attempting to improve early diagnosis of carcinoma in these particular cases, in which will be useful a new protocol design. CONCLUSIONS: PSA decline, histology of the prostate after adenomectomy and the morphometric changes after surgery and at mid-term, advise a more accurate value of PSA in patients who underwent open surgery, in order to detect a carcinoma in the residual prostate gland.

[Acquired male urethra diverticula. Report of seven cases. Bibliographic review]. / Divertículos adquiridos de uretra masculina. A propósito de siete casos. Revisión de la literatura.

OBJECTIVES: To report our personal experience in a rare urethral pathology in relation with iatrogenic sequelae from surgical treatment of lower urinary tract pathologies. METHODS: We analyze the causes, type of presentation, and surgical treatment of seven cases of urethral diverticula, which account for 2.18% of the urethral procedures performed in our department, this latter representing 2.3% of a total of 11,845 surgical procedures in a period of 25 years. RESULTS/CONCLUSIONS: Male urethra diverticula go unnoticed because their initial symptoms are very similar to other lower urinary tract entities. But there is a definitive sign once the case is advanced: the appearance of a "lump" in the ventral side of the anterior urethra, the compression of which empties urinary content, sometimes fetid; or also the feeling of having a bag with stones if they host lithiasis. Surgical reconstructive treatment is very important to guarantee the absence of an obstacle distal to the cavity as well as to achieve a consistent ventral floor for the urethra to avoid recurrence, and that, as we will see, maybe obtained by various procedures. The attention to the original disease which indirectly had been the cause of the problem completes the therapeutic scheme for each case.

[William Cheselden: singular lithotomist and great illustrator of the XVIII Century]. / William Cheselden, singular litotomista y gran ilustrador inglés del siglo XVIII.

We present a brief historic reference of who probably was the most famous English urologist-surgeon of the 18th century, and who, following the chronicle writers, holds the record for extraction of a bladder stone (between 24 and 54 seconds). He also was an example of humanism related to the medical profession: he was an extraordinary illustrator of his own books with the help of the "dark chamber", so frequently used by Renaissance artists, contributed to the design and performance of civil architectonic work, had relationships with the literature world through poetry, and decisively influenced the reformation and separation of barbers and surgeons, which ultimately lead to the creation of the Royal College of Surgeons.

[Histomorphometric findings in the residual prostate and prostatic hollow after retropubic surgery for BPH: (I) baseline data obtained from the last 70 consecutive cases]. / Hallazgos histomorfométricos de la próstata residual y celda prostática tras la cirugía retropúbica por H.B.P.: (I) datos basales obtenidos en los últimos 70 casos consecutivos.

OBJECTIVES: To present the data obtained from surgical specimens and biopsies of residual prostate and prostatic capsule, which in addition to the information provided by imaging tests give us the baseline situation of the prostatic surgical bed and residual prostate after transcervical hemostatic adenomectomy with capsule plasty. All this is the first step for the long-term study of its evolution and possible implications in the genesis of new obstructive or neoplastic pathology. METHODS: 70 consecutive cases of transcervical hemostatic adenomectomy with the variation of capsule plasty, recently developed, after a previous experience of 1033 retropubic surgeries. We analyze the histologic findings in surgical specimens, biopsies of residual gland and prostate capsule, and confirmed the immediate changes surgery causes, measuring the volumes of residual prostate by ultrasound. As the base for comparisons we analyzed residual prostates from prostatectomies or radical cystoprostatectomy specimens in "young" patients. RESULTS/CONCLUSIONS: We obtained objective data about predominant and associated histological lesions found in adenomectomy specimens. In the same way, the same data were obtained from biopsies of peripheral residual prostate together with the volume of such zone, which should establish, if our hypothesis is right, the mid-long-term prognostic criteria for the approach to the so-called post operative reexpansion of the prostatic hollow and the possible establishment of new obstructive pathology.

[Indications, morbidity and mortality of the open nephrectomy. Analyses of 681 cases and bibliographic review]. / Indicaciones y morbimortaudad de la nefrectomía abierta. Análisis de 681 casos y revisión de la literatura.

OBJECTIVES: To have data about the indications, morbidity and mortality of the nephrectomy by the open approach, to obtain information that could be compared with the laparoscopic approach. To our knowledge there is not a similar review in the Spanish literature since the 60's. METHODS: We analyzed 681 nephrectomies accounting for a 5.7% of a total of 11.845 operative reports registered in our centre over the last 25 years. For outcome analysis, 93 cadaver donor nephrectomies were excluded. The analysis focuses on three well differentiated areas: kidney transplant surgery, nephrectomies for malignant diseases, and nephrectomies for benign pathologies including a very specific subgroup that includes the infectious-inflammatory diseases. In parallel, we performed a bibliographic review in which more than 87,000 cases of open surgeries where referenced, adding the articles about laparoscopic nephrectomies published over the last decade. RESULTS: Global mortality of the series (the first 30 postoperative days) was 0.8%, mostly cases of transplant nephrectomies (4), and one upper urinary tract transitional cell carcinoma. Significant morbidity appeared in 47 cases (8%), 15 of which (2.5%) required reoperation, being intensive bleeding with hypovolemia of variable severity the most frequent cause. The series includes non selected cases of a wide spectrum of pathologies. Any comparison with minimally invasive approaches should take into consideration, among other parameters, selection of the cases.

[Report of two cases of bladder and prostate oat cell tumors]. / "Presentación de dos casos: vesical y prostático de oat-cell".

OBJECTIVES: To report two cases of bladder and prostate oat cell tumors with bad outcome, in accordance to the bibliographic review. METHODS: The case in the bladder was associated with squamous differentiation and adenocarcinoma. Radical treatment followed by adjuvant chemotherapy did not stop the fatal outcome which ended 13 months later in acute septicemia having developed multiple metastases. The case in the prostate presented as oliguria-anuria and bilateral hydronephrosis which required the placement of a nephrostomy tube in an emergency basis. Once diagnosis was achieved the extemal urinary diversion was converted to intemal to improve patient's comfort. There was no response to systemic chemotherapy and the patient died 4 months after diagnosis. CONCLUSIONS: These cases add to the rare presence of this pathology in the bibliography. In our country, 15 cases have been confirmed in the bladder and 5 in the prostate; around the world, 150 and 59 respectively. Although there is a certain tendency to think that radical treatment and chemotherapy is the least bad of the options, some consequences of conservative attitudes offer similar results, mainly when preserving the bladder.

[Evidence on the improvement of quality standards for retropubic surgery for BPH]. / Evidencias de la mejoría de los standares de calidad en la cirugía retropúbica por H.B.P.

OBJECTIVES: To report the first consolidated results of the technical variation of the bladder-capsule plasty, a complement of the well-known trans-cervical hemostatic adenomectomy. METHODS: We analyze 65 recent consecutive patients with BPH undergoing surgery by such technique with follow-up between 6-48 months, analyzing the parameters which in this type of operation are significant to evaluate quality. RESULTS: We evaluated bleeding, transfusions, surgical wound complications, postoperative discomfort, number of days with catheter, and hospital stay; also reoperations and morbidity-mortality, which show a notable improvement in comparison with what appears to be typical of this operation, considered the most aggressive approach for the surgical treatment of BPH. CONCLUSIONS: We report a personal modification of the transcervical hemostatic adenomectomy, published in 1974, after an experience of more than 1000 operations: the bladder-capsule plasty. The changes introduced in this 65 cases make us consider, even in present times, open surgery for BPH as the best solution for the obstructive problem in selected cases, with the lowest reoperation rates, and improving on factors such as "invasiveness" and "higher cost" which have been historically attributed to it.

[Vesicocapsuloplasty: technical variation of retropubic surgery for benign prostatic hypertrophy. Preliminary report]. / La vesicocapsuloplastia: variante técnica en la cirugía retropúbica por H.B.P. Informe preliminar.

OBJECTIVES: To report a technical variation in the retropubic adenomectomy operation which improves the standards for this type of open surgery significantly. METHODS: We review the charts of the last 35 patients undergoing surgery with this technical variation, with a minimum follow-up of one year, following a pooled experience of 1033 cases of retropubic open surgery for BPH by the hemostatic transcervical adenomectomy technique. RESULTS/CONCLUSIONS: During surgery this variation allows a better access to the prostatic bed facilitating direct haemostasis and search for adenoma remnants. In the same way it allows to perform prostate biopsies in those cases of BPH with PSA values over normal range and previous negative biopsies. Finally, "vesicalization" of the prostatic bed contributes to avoid post operative spasms and it would be the anatomical basis for avoidance of bladder neck retraction in the middle term. With all reservations implied in the application of a recent technical variation, the limited number of cases, and short follow-up, we may say that significant improvements have been seen in immediate standards such as intraoperative and postoperative blood loss, bladder spasms, post surgical analgesics requirements, and hospital stay reduction.

[Unusual clinical forms of presentation and infrequent pathologic associations of xanthogranulomatous pyelonephritis]. / Inusuales formas clínicas de presentación y asociaciones patológicas raras de la pielonefritis xantogranulomatosa.

OBJECTIVE: To describe the unusual clinical forms and rare associations of xanthogranulomatous pyelonephritis seen in a variable proportion of cases. METHODS: Analysis of our series of 83 cases and 2573 cases reported in the literature showed 8 different and less frequent clinical forms and up to 7 rare associations, which are discussed in this study. RESULTS: There are different clinical forms under "renal infection", ranging widely from asymptomatic to severe septic forms that affect patients of all ages--from the newborn to the elderly-, preferentially in association with conditions of immunosuppression, and other more uncommon or rare forms in which xanthogranulomatous pyelonephritis is often incidentally discovered. CONCLUSIONS: These forms are not extremely rare since more than 2500 cases have been reported in the literature. Knowledge about the different forms permits stratification of this condition into different clinical forms of presentation and provides further insight into the associated conditions, some of which are rare. Overall, such forms or associations have been reported to account for 20 to 40% of all cases, according to the studies reported elsewhere. This overall incidence is rather significant and should be taken into account.

[Excision of large masses in urologic surgery]. / Exéresis de grandes masas en cirugía urológica.

OBJECTIVES: To analyze a series of big masses excised in urologic surgery detailing the reasons after which the indications for surgery were set up, evaluating technical difficulties appeared during the procedures and balancing them with the aimed benefits. METHODS/RESULTS: 10.581 Operative reports from 1980 were retrospectively reviewed and 8 cases were selected as fit with the concept of giant mass, being of more or less weight depending on the organ they arose from. They vary in weight from a 350 gr. prostate with benign prostatic hyperplasia to a 5.150 gr. renal carcinoma. All masses diagnosed but not excised are excluded from the analysis. CONCLUSIONS: Various difficulties appearing during excision were recorded depending on size, location, and etiology of each mass which resulted in operative time, transfusions, complications and outcomes. Only specific clinical cases seem to justify an, almost always, very aggressive approach.

[Single kidney derived to sigmoid for urinary tuberculosis: remarkable morpho-functional status 51 years after surgery]. / Riñón único derivado a sigma por tuberculosis urinaria: notable situación morfofuncional a los 51 años de la cirugía.

OBJECTIVES: To report a solitary kidney ureterosigmoidostomy (US) secondary to urinary tuberculosis which we believe has the longest follow-up in the world literature. With this purpose we performed an analysis of the experience with such a urinary diversion published in our country, which maybe has been exaggeratedly excluded during the last decades. METHODS: Male patient who was diagnosed of urinary tuberculosis at the age of 17 in 1950 and underwent left nephrectomy. Due to bladder retraction he underwent cystectomy and urinary diversion to the sigmoid colon following the technique by Coffeyone year later. Follow-up for half a century has demonstrated an excellent outcome with almost no effect on renal function and urinary tract morphology, and very low incidence of infectious complications. DISCUSSION: We review cases of US with longest follow-up in the literature, finding a remarkable number of cases followed for more than 30 years. It is true they were performed almost exclusively for benign diseases. There is only one published citation in which US was indicated for bladder carcinoma and after 31 years of follow-up patient died from a nonrelated disease at the age of 85. We also review the scarce number of papers published in our country, focusing on the "Ponencia al Congreso Nacional de Urología 1983" which presented a thorough review of "urinary diversions" with the cooperation of 27 Spanish centers.

[3 rare cases of textiloma after renal surgery. Review of the literature]. / Tres raros casos de textilomas tras cirugía renal. Revisión de la literatura.

OBJECTIVE: To review the literature on textiloma or surgical sponges left during renal surgery because of the important medical-legal implications of this complication. METHOD: Three cases of textiloma in patients undergoing renal surgery are presented. Two of them had undergone surgery at other hospitals 26 and 4 years earlier. The third patient had undergone transplantation at our hospital and was reoperated 4 months later for a purulent cutaneous fistula caused by the textiloma. RESULTS/CONCLUSIONS: A review of the literature since 1950 showed few reports of textiloma. The risk factors according to the type of surgery performed and current controls in the operating room to avoid this complication that can occasionally be severe, are presented in detail. The forms of presentation, diagnostic methods and difficulties encountered due to the long period of time the foreign body has been left indwelling, are analyzed. To our knowledge, 8 cases of textilomas have been reported in patients undergoing renal surgery.