[Intrasinus renal hilium approach, EUREKA time for spanish urological surgical anatomy.] / Vía intrasinusal de abordaje al hilio renal, un momento E U R E K A de la investigación anatómica quirúrgica urológica española.

Historical research has allowed us to reviewand document the author of the first description of the intrasinusal route for access to the renal hilum as astrategy for accessing kidney stones through the bibliography. This new route described and published by M. Serés represented a paradigm shift in open surgery for kidney stones. We want to highlight that the Spanish urological anatomical-surgical investigation with the investigations of Manuel Serés, meant a singular contribution and of enormous importance for the History of International Urology, whose value we must claim with its indisputable and reliable references.

La investigación histórica nos ha permitido revisar y mostrar documentalmente por la bibliografía el autor de la primera descripción de la via intrasinusal para el acceso al hilio renal como estrategia de accesoa la litiasis renal. Esta nueva via descrita y publicada por M. Serés supuso un cambio de paradigma en la cirugía abierta de la litiasis renal. Queremos resaltar que la investigación anatomo-quirúrgica urológica española con las investigaciones de Manuel Serés, significó una aportación singular y de enorme trascendencia para la Historia de la Urología Internacional, cuyo valor debemos reivindicar con sus referencias indiscutibles y fehacientes.

[The volume of urological knowledge in the last 25 years.] / El "volumen" del saber urológico en el último cuarto de siglo.

Few specialties have gone through as many transitions in the last decades as Urology. Progressive physiology advances in several disease have become part of the urological knowledge. Laparoscopic surgery and ESWL (Extracorporeal Shock Wave Lithotripsy) wave have completely turn upside down the whole management of disease. The current text provides a back to the future sigh into Urology.

Pocas especialidades médicas y quirúrgicas han experimentado en las últimas décadas tantos y tan significativos avances terapéuticos como la Urología. Además de progresos en los conocimientos fisiopatológicos de las distintas enfermedades que conforman el corpus del saber Urológico. La cirugía laparoscópica y las ondas de choque extracorpóreas han revolucionado la especialidad en su totalidad, provocando cambios de paradigma tanto en las indicaciones terapéuticas como en la interpretación de algunos procesos patológicos. Aportamos unas reflexiones desde una mirada retrospectiva.

A multicolor fluorescence in situ hybridization assay: A monitoring tool in the surveillance of patients with a history of non-muscle-invasive urothelial cell carcinoma: A prospective study.

BACKGROUND: Non-muscle-invasive urothelial cell carcinoma (NMIUCC) has a high tendency to recur and affected patients must be monitored regularly using invasive cystoscopies. The aim of the current study was to compare a multicolor fluorescence in situ hybridization (FISH) assay (UroVysion) with routine follow-up (cystoscopy and cytology) in the monitoring of patients with a previous history of NMIUCC. METHODS: An unselected cohort of patients under surveillance for a previous history of NMIUCC was prospectively studied. A total of 248 examinations in 223 patients were analyzed. Each exploration was comprised of cytological and FISH microscopic examination of voided urine samples and cystoscopy. The sensitivity, specificity, and positive (PPV) and negative (NPV) predictive values for tumor recurrence of all 3 techniques were determined. RESULTS: The sensitivities of FISH and cystoscopy were not found to be significantly different (92.9% and 82.1%, respectively). The specificities of FISH and cystoscopy were 92.7% and 89.7%, respectively. The PPV and NPV of FISH were 53.5% and 97.2%, respectively, whereas those of cystoscopy were 63.4% and 98.9%, respectively. No significant differences were found between these 2 tests. In contrast, the sensitivity and specificity of cytology were 14.3% and 99.5%, respectively. CONCLUSIONS: Given the lack of statistically significant differences with regard to FISH and cystoscopy results, the authors propose that FISH could be a useful monitoring tool in the surveillance of patients with a previous history of NMIUCC.

Phase II study of vinorelbine and estramustine in combination with conformational radiotherapy for patients with high-risk prostate cancer.

PURPOSE: To evaluate the efficacy and safety profile of vinorelbine and estramustine in combination with three-dimensional conformational radiotherapy (3D-CRT) in patients with localized high-risk prostate cancer. METHODS AND MATERIALS: Fifty patients received estramustine, 600 mg/m(2) daily, and vinorelbine, 25 mg/m(2), on days 1 and 8 of a 21-day cycle for three cycles in combination with 8 weeks of 3D-CRT (total dose of 70.2 gray [Gy] at 1.8-Gy fractions or 70 Gy at 2.0-Gy fractions). Additionally, patients received luteinizing hormone-releasing hormone analogs for 3 years. RESULTS: All patients were evaluated for response and toxicity. Progression-free survival at 5 years was 72% (95% confidence interval [CI]: 52-86). All patients who relapsed had only biochemical relapse. The most frequent severe toxicities were cystitis (16% of patients), leucopenia (10% of patients), diarrhea (10% of patients), neutropenia (8% of patients), and proctitis (8% of patients). Six patients (12%) did not complete study treatment due to the patient's decision (n = 1) and to adverse events such as hepatotoxicity, proctitis, paralytic ileus, and acute myocardial infarction. CONCLUSIONS: Vinorelbine and estramustine in combination with 3D-CRT is a safe and effective regimen for patients with localized high-risk prostate cancer. A randomized trial is needed to determine whether the results of this regimen are an improvement over the results obtained with radiotherapy and androgen ablation.

Holmium laser enucleation of prostate: outcome and complications of self-taught learning curve.

OBJECTIVES: To analyze the self-learning curve of a single surgeon with holmium laser enucleation of the prostate and to evaluate the safety, effectiveness, and outcome of the procedure after 2 years of experience. METHODS: The data from the first 125 patients who underwent holmium laser enucleation of the prostate were retrospectively analyzed. The patients were assessed preoperatively and at 1, 3, 12, and 24 months postoperatively. The patient evaluations included serum prostate-specific antigen measurement, peak urinary flow rate determination, postvoid residual volume measurement, and symptom scores. To assess the effect of the learning curve on the perioperative data and complications, the patients were divided into subgroups of 25 consecutive patients. RESULTS: The mean patient age was 71.4 years. The average prostate volume was 75.8 mL, and the mean weight of the enucleated tissue was 46.7 g. The average operative time was 109.8 minutes. The operative times and enucleation and morcellation efficiency rates improved significantly during the learning process. The mean hemoglobin loss was 1.7 g/dL. The median catheter time and hospital stay was 44 and 30 hours, respectively. Compared with baseline, at 1 year postoperatively, the median postvoid residual urine volume had declined by 99 mL, the mean peak urinary flow rate had increased by 19 mL/s, and the mean American Urological Association symptom score had decreased by 16.5 points. All changes observed were significant and regardless of the prostate size. Persistent stress urinary incontinence (4.8%) occurred with the first enucleations of large-size prostates. Other complications included bladder neck contracture (4%) in small-size prostates and bulbar urethra stricture (1.6%). CONCLUSIONS: Holmium laser enucleation of the prostate is a safe, reproducible and effective surgical modality. Case selection is necessary to avoid the morbidity associated with the first stages of the self-taught learning curve, mainly urinary incontinence.

[Oncologically safe simplified nephroureterectomy: combination with percutaneous ureteral the ligation-section]. / Nefroureterectomía simplificada y oncológicamente segura: combinación con sección-ligadura ureteral percutánea.

OBJECTIVES: We propose a modification to open nephroureterectomy. METHODS: By a single incision (lumbar incision) a percutaneous ligation-section of the finely dissected terminal ureter is performed. RESULTS/CONCLUSIONS: This technique offers a better quality of life in the immediate postoperative period, shortens the surgical time, and it has the advantage of being oncologically safe, avoiding a double surgery.

Detrusor quantitative morphometry in obstructed males and controls.

PURPOSE: We studied the usefulness of computer assisted morphometry for measuring detrusor muscle cell diameter and the connective tissue-to-smooth muscle ratio in patients with bladder outlet obstruction, acute urinary retention and a nonobstructed control group. MATERIALS AND METHODS: A prospective study was done in patients with bladder outlet obstruction undergoing transurethral prostate resection. Patients were divided into 33 with obstruction and 14 in acute urinary retention. A total of 15 males without obstruction undergoing transurethral prostate resection for bladder tumor formed the control group. Detrusor specimens were obtained during transurethral prostate resection. Detrusor muscle cell diameter was measured using light microscopy and a semiautomatic image analysis system. The connective tissue-to-smooth muscle ratio was automatically determined with computer assisted image analysis. Symptoms and urodynamic assessment were performed preoperatively and 6 months postoperatively. RESULTS: A total of 62 patients were included. The obstruction and acute urinary retention groups had a statistically higher detrusor muscle cell diameter and more fibrosis than the control group. Patients in acute urinary retention had more intrafascicular fibrosis (higher connective tissue-to-smooth muscle ratio at 40x magnification) than patients with obstruction. There were no differences in detrusor muscle cell diameter or interfascicular fibrosis (connective tissue-to-smooth muscle ratio at 10x magnification) between the obstruction and acute urinary retention groups. Detrusor muscle cell diameter correlated with symptom duration and functional recovery after transurethral prostate resection. Detrusor fibrosis correlated with preoperative detrusor pressure at maximum flow and postoperative compliance. Patients in acute urinary retention had fewer symptoms and higher residual volume. Other urodynamic parameters and their improvement after surgery were similar in the acute urinary retention and obstruction groups. CONCLUSIONS: Morphometric differences in detrusor muscle cell diameter and the connective tissue-to-smooth muscle ratio were observed between controls and patients with obstruction. There is an increase in detrusor muscle cell diameter and fibrosis in bladder outlet obstruction and more intense intrafascicular collagen deposition in patients in acute urinary retention.

Tuberous sclerosis complex. Forty-years of follow-up of a patient affected.

OBJECTIVES: To report the case of a patient diagnosed with tuberous sclerosis complex (TSC), describe its clinical features, diagnosis, and to attract attention on the fact that after 40 years of follow-up, the patient has presented practically all the manifestations described in the literature. METHODS: A 42-year-old man diagnosed with.TSC presented the emergency department due to left lumbar pain and self-limited gross hematuria. On clinical examination patient was haemodynamically stable, but with decrease in haemoglobin (6.8 g/dL). Abdominal CT scan showed a 20 cm diameter heterogeneous mass in the left kidney suggesting hemorrhage of an angiomyolipoma. RESULTS: Left radical nephrectomy was performed and the pathological study of the surgical specimen confirmed the diagnosis of angiomyolipoma. Inmunohistochemical staining was positive with HMB-45. CONCLUSIONS: To recommend that patients with TSC be evaluated by a multidisciplinary group of clinicians, including urologists, neurologists and dermatologists. As patients with TSC survive into adulthood they will require more intervention by the urologist. CT scan is usually enough for the diagnosis of angiomyolipomas. Complete nephrectomy is appropriate when the whole kidney has been replaced by angiomyolipoma. The identification of molecular markers (HMB-45) facilitates histopathological diagnosis.

Insertion (8;11) in a renal oncocytoma with multifocal transformation to chromophobe renal cell carcinoma.

We report the case of a 43-year-old male with multiple tumor foci showing microscopic features of chromophobe renal carcinoma (ChRCC) arising in an oncocytoma. Conventional cytogenetics of fresh tumor cells and fluorescence in situ hybridization (FISH) revealed the following abnormal karyotype: 46,XY,der(8)ins(8;11)(p?;q13),der(11)ins(8;11)inv(11)(q12?p15) with CCND1 (11q13) rearrangement. To our knowledge, chromosome 8 has not been reported as a partner involved in structural rearrangements of 11q13 in oncocytomas. FISH in paraffin tissue sections revealed a rearrangement of CCND1 (11q13) in the oncocytoma cells. The multiple foci of chromophobe carcinoma presented multiple copies of CCND1, suggesting that they represented a transformation from oncocytoma into ChRCC. There was immunohistochemical overexpression of CCND1 in both oncocytoma and chromophobe carcinoma cells. In this case, the correlation of the microscopic findings with changes in CCND1 gene associated to CCND1 overexpression in both components suggest that the ChRCC would have originated from the preexisting oncocytoma. It is not possible to detect, by cytogenetic techniques alone, if the ChRCC component have also the CCND1 rearrangement in addition to the detected polysomy. FISH techniques on paraffin tissue sections may help to identify genetic aberrations such as CCND1 rearrangement in order to establish a diagnosis of oncocytoma.

Correlation between histologic findings and cytogenetic abnormalities in bladder carcinoma: a FISH study.

OBJECTIVES: To investigate the chromosomal abnormalities present in bladder carcinoma using a fluorescence in situ hybridization assay and to correlate the genetic findings with the pathologic grade and stage. METHODS: Samples from 37 bladder carcinomas were obtained at cystectomy or transurethral resection. In all cases, a histologic evaluation and fluorescence in situ hybridization analysis were performed. Pericentromeric DNA probes for chromosomes 7, 8, 9, and 17, and locus-specific DNA-probes for the 9p21 and 9q34 bands, were used in the fluorescence in situ hybridization assay. RESULTS: Grade 1-2 tumors were characterized by the loss of genetic material on chromosome 9 in 35.3% of cases and either no detectable alterations or multiple aneusomy events in 47.1% and 17.6% of the tumors, respectively. Polysomy was the most frequent occurrence in grade 3 and pT1-T4 carcinomas. No significant difference was found between the loss of 9p21, 9q34, or chromosome 9 and the different tumor classifications. A statistically significant difference was found in the frequency of polysomy between grade 1-2 and grade 3 tumors and between pTa and pT1-T4 tumors for chromosomes 7, 8, 9, and 17, as well as chromosome bands 9p21 and 9q34 (P <0.005). CONCLUSIONS: These findings show that chromosome 9 losses do not correlate with the tumor grade or stage, but are the only aberrations found at a significant frequency in low-grade lesions. The results suggest that pT1 tumors are closely related to muscle-invasive tumors at the genetic level and show that polysomy of the chromosomes assessed correlates with high-grade and high-stage bladder carcinoma.

[Adrenal surgical pathology. Report of our cases and bibliographic review]. / Patología quirúrgica adrenal. Reporte de nuestra casuística y revisión bibliográfica.

OBJECTIVES: Adrenal masses have different presentations, from an incidentally diagnosed mass to a blooming Cushing's syndrome, this stimulated our interest to evaluate and describe our case series over the last 10 years, besides to perform a bibliographic update. METHODS: Retrospective and descriptive study of 22 patients suffering from adrenal masses, evaluating their clinical and radiological characteristics, functional disturbances, and histological diagnosis, emphasizing the first suspicion or finding suggesting adrenal disease. RESULTS: Men were more often affected than women in this series, 12 men vs. 10 women. Mean age was 51.2 years (33-71). Regarding side, 10 cases were right, 8 left and 2 presented bilateral disease, one of them bilateral adenoma and the other asynchronous renal carcinoma metastasis. The inverted "Y" morphology usually observed on CT scan was lost in 14 patients. Size varied between the following ranges: 2-4 cm--9 cases, 4-6 cm--12 cases, and one case of a gigantic cyst within the left hemi-abdomen. CONCLUSIONS: Results in our series are similar to those in the literature, adrenal masses are uncommon and despite their low incidence they have different clinical and a histological forms of presentation. 27% of them were incidental, which represents a significant percentage in comparison with other series. Adequate clinical and functional studies as well as their radiological characteristics will set the indication for adrenalectomy or follow-up. Most cases < 4 cm (7/9) were renal carcinoma metastasis or pheochromocytoma. Incidentally diagnosed cases have increased with the development of new imaging technologies as well as with more frequent use of them. The functional study of adrenal masses has suffered little change. Surgical treatment of these pathologies is suffering important changes with the advent of laparoscopic urologic surgery.

[Extrinsic ureteral obstruction secondary to inflammatory gynecologic pathology]. / Obstruccion ureteral extrínseca secundaria a patología inflamatoria ginecológica.

OBJECTIVE: To present two cases of extrinsic ureteral obstruction secondary to gynaecological inflammatory diseases, and to perform a bibliographic review. METHODS: We present two cases of obstructive uropathy with uretero-hydronephrosis secondary to tubo-ovarian abscesses diagnosed at our department. Clinical features at presentation, diagnostic tests, and preoperative management are reported. RESULTS: We report the clinical resolution of each case and perform a review about this pathology. CONCLUSIONS: Extrinsic ureteral obstruction is a frequent problem in urology. Inflammatory gynaecologic disease should be included among possible causes at the time of differential diagnosis. A methodical diagnosis process allows defining the exact location of the obstruction, diagnostic possibilities, and most adequate treatment plan for each case. Although association of gynaecological pathology and urinary tract obstruction is well known, there are not many bibliographic references in the national and international literature.

Clinical utility of a multiprobe FISH assay in voided urine specimens for the detection of bladder cancer and its recurrences, compared with urinary cytology.

OBJECTIVES: To evaluate the clinical utility of a Multi-color FISH (fluorescence in situ hybridization) assay in voided urine specimens for the detection of bladder cancer and its recurrences, comparing the results with those afforded by urinary cytology. METHODS: Voided urine samples from 86 patients were obtained for urine cytology and FISH analysis. The latter was performed using a mixture of fluorescent labeled DNA probes for the centromeric regions of chromosomes 3, 7 and 17, and the 9p21 region. Cystoscopy with biopsy or tumor resection was performed in all patients, comparing the pathological results with the cytological and FISH findings. RESULTS: Urinary cytology affords an overall sensitivity of 63.8%, the figure being 25% for grade 1, 66.6% for grade 2 and 94.7% for grade 3 tumors. The sensitivities for FISH were 53.3% for grade 1, 83.3% for grade 2 and 100% for grade 3 tumors, with an overall sensitivity of 80.4%. The specificities of urinary cytology and FISH were 86.1 and 85.3%, respectively. CONCLUSIONS: FISH improves the sensitivity rates obtained with urine cytology for bladder cancer detection in all tumor grades and stages, and offers similar specificity. FISH doubles the accuracy of urinary cytology in application to low grade-stage tumors, and detects all high grade infiltrating tumors.

[Saving surgical time with great hemostatic safety and efficiency using the LIGA-SURE system in complete pelvic urologic surgery]. / Ahorro de tiempo quirúrgico con gran seguridad y eficacia hemostática mediante el sistema LIGA-SURE en cirugía urológica pelviana compleja.

OBJECTIVE: To achieve an effective, safe and fast hemostasis. To translate it into a great diminution of operating time, avoiding multiple ligatures that are time consuming and being merely a mechanical, repetitive act do not add any element of quality to surgery in general and to urologic pelvic procedures in particular. METHODS: A new hemostatic system has been experimented in pelvic urologic open surgery, specifically in radical cystectomy (RC) (with orthotopic substitution or urinary diversion) and radical prostatectomy (RP). It achieves vascular sealing by means of tissue collagen precipitation when applied in previously dissected vascular pedicles during radical cystectomy and neuro-vascular bundles during radical prostatectomy. RESULTS: It has been noted a complete efficacy in the coagulation of all vascular pedicles as well as a significant decrease in operating time (around 25%) because the use of ligatures is completely avoided. It has also been noted a great decrease in blood loss, with reductions in transfusion needs down to 50% of the cases. CONCLUSIONS: The new hemostatic system by tissue collagen coagulation allows a fast, effective and safe hemostasis in complex urological pelvic surgery, which translates into operative time savings and minimal blood loss.