[Urinary diversions and bladder enlargements]. / Derivaciones urinarias y ampliaciones vesicales.

Overall review that offers an integrated insight of the importance and repercussions of urinary by-pass and bladder replacement. Over the last decades there has been a growing interest in the possibility of reconstructing the urinary system and there are now an almost infinite number of surgical solutions. The history of the development of using the intestine for by-passes and the reconstruction of the urinary system is described. The secondary metabolic alterations, the possibility of secondary intestinal tumours and the rudiments of ureterointestinal anastomosis are dealt with. Bladder substitution techniques are highlighted, and the vast experience of the Urology Department of Hospital Miguel Servet explained, including criteria and conclusions that help to choose from the many urological surgery alternatives headed by urinary by-pass and bladder complications.

[Analysis of our series of kidney transplants: urologic complications and survival]. / Análisis de nuestra serie de trasplantes renales: complicaciones urológicas y supervivencia.

PURPOSE: To review our series of 416 renal transplants, with special reference to the surgical complications and their management. METHODS: From June, 1986 to October 1997, we are performed 416 heterotopic renal transplants, harvested from cadavers. Reconstruction of the urinary tract reconstruction was by ureteroneocystostomy in practically all the cases. RESULTS: There were some urological complications in 80 patients (19.2%). The most common urological complication was obstruction of the urinary tract arising from stenosis (3.3%), lymphocele (4.3%) and clotting (1.2%). 78.1% of these urological complications were resolved by endourological techniques. Urinary fistula was observed in 12 cases (2.8%). Vascular complications in 22 (6.9%), lithiasis in 5 (1.2%), and eventrations in 11 (2.6%). The treatment of these complications is described. The actuarial survival rates were 87.8% and 77.3% at one and five years respectively for the graft, and 92.4% and 83.5% for the patients. CONCLUSIONS: Our surgical complication rate in patients undergoing renal transplantation was 19.2%. The most common complication was urinary tract obstruction from stenosis (3.3%), lymphocele (4.3%) and clotting (1.6%); 78.1% of these obstructive complications were resolved by endourologic techniques. Percutaneous drainage and esclerotherapy of the lymphoceles resolved 66.6% of them. Renal biopsy performed with a 14G needle caused 5 severe hemorrhagic complications. There were no complications when an 18G needle was utilized.

[Unusual association of transitional cell carcinoma in the upper urinary tract, with contralateral renal metastasis and renal lithiasis of long clinical course]. / Infrecuente asociación de: carcinoma de células transicionales en T.U.S., con metástasis renales contralaterales y litiasis renal de larga evolución.

Presentation of a case reporting an infrequent association of transitional cell carcinoma of the upper urinary tract (UUT) with a long-standing renal polylithiasis and multifocal metastasis in contralateral kidney. A description is made of the incidence, etiology, prognostic factors as well as diagnosis and therapeutical approach.

[Analysis of a series of radical prostatectomies]. / Análisis de una serie de prostatectomías radicales.

OBJECTIVE: Radical prostatectomy (RP) is an elective therapeutical procedure for localized prostate cancer. The paper describes the critical analysis of our 10-year series. MATERIAL AND METHODS: A total of 216 RP have been performed between June 1986 and December 1996 (60 of them in the last year); with the purpose of securing a minimum follow-up of 4 months, the 204 procedures performed up to October 1996 were studied. Mean age was 64.9 years and PSA median 10.8 ng/ml. Intraglandular clinical stage was found in 192 cases versus 12 cases extraglandular. Up to the end of 1993 Walsh's technique with erectors' preservation was being used although the poor results obtained with regard to potency as well as the existence of positive borders have compelled us to perform the standard extracapsular technique since beginning of 1994. RESULTS: Mean follow-up in our series has been 29.62 months. Post-operative complications reached 29.9%, anastomosis fistula (21 cases) among the early ones and anastomosis stenosis (16 cases) among the late ones. 82.04% patients have total continence or minimal incontinence, the percentage of obstruction being 3.58%. Total impotence is estimated at 92.77%. One patient (0.49%) died in the immediate post-operative. Understaging was observed in 36.7%. 84 patients had extracapsular disease. Our percentage of positive surgical borders is of around 43.13%. Progression has been seen in 47 of 204 patients (23.03%): 8 local relapses, 12 metastasis, 3 with both conditions and 24 biological progression. Progression has been related to pathological stage, pre-operative PSA and Gleason's sum of the specimen. Difference was statistically significant. Overall survival at 1 and 5 years is 99.2% and 95.5% respectively while tumour specific survival is 97.8% and 75.8% at 1 and 5 years. CONCLUSIONS: RP is a surgery with minimal mortality but noticeable morbidity (incontinence 14.35%; impotence 92.77%; other complications from surgical technique 29.9%). Our clinical understaging is of around 36.7%. Progression is related to the specimen's pathological stage, and pre-operative PSA and Gleason. Our overall survival at 1 and 5 years is 99.2% and 95.5% respectively while tumour specific survival is 97.8% and 75.8%.

[Surgical complications in kidney transplantation. Analysis of our series (300 transplantations, 1986-1995)]. / Complicaciones quirúrgicas en el trasplante renal. Análisis de nuestra serie (300 trasplantes, 1986-1995).

OBJECTIVES: To review our series of 300 renal transplants, with special reference to the surgical complications and their management. METHODS: From June, 1986 to August, 1995, we performed 300 heterotopic renal transplants harvested from cadavers. Reconstruction of the urinary tract was by ureteroneocystostomy in practically all of the cases. RESULTS: The overall surgical complication rate was 20.3%. The graft was lost in 2 cases (0.66%). The most common urological complication was obstruction of the urinary tract arising from stenosis (3.6%), lymphocele (5.3%) and clotting (1.6%); 78.1% of these obstructive complications were resolved by endourological techniques. Urinary fistula was observed in 9 cases (3%) and lymphocele in 16 (5.3%), which were resolved by percutaneous drainage and sclerotherapy in 81.2% of the cases. Vascular complications were observed in 14 cases (4.6%), lithiasis in 5 (1.66%) and eventration in 6 (2%). The treatment of these complications are described. The actuarial graft and patient survival rates were 90.9% and 84.7% at one and five years, respectively, for the graft and 93.5% and 89% for the patients. CONCLUSIONS: Our surgical complication rate in patients undergoing renal transplantation was 20.3%. The most common complication was urinary tract obstruction from stenosis (3.6%), lymphocele (5.3%) and clotting (1.6%); 78.1% of these obstructive complications were resolved by endourological techniques. Percutaneous drainage of the lymphocele combined with sclerotherapy achieved resolution in 81.2%. Renal biopsy performed with a 14 G needle caused 5 severe hemorrhagic complications. There were no complications when an 18 G needle was utilized.

[Surgical staplers. Urologic surgery with intestines]. / Suturas mecánicas. Cirugía urológica con empleo de intestino.

Since the late 1980s, different reservoirs and bladder substitution techniques have been added to the urological surgical armamentarium. The necessary use of an intestinal segment--generally detubularized--make these surgical procedures complicated and time-consuming. Furthermore, problems are encountered postoperatively due to the important morbidity arising from these procedures. The present article describes our experience with mechanical sutures and resorbable material. Although the results have not been analyzed, our initial experience at the Miguel Servet Hospital has shown that these devices significantly facilitate the operative procedure, thereby reducing the incidence of urinary and intestinal fistulas. Although there is an evident risk of calculi formation, complicated solutions are not required and the biological tolerance to the metal sutures is excellent.

[Current validity of urethroplasty in two stages]. / Vigencia actual de la uretroplastia en dos tiempos.

Review of 18 patients with complex urethral stenosis, who underwent a two-stage urethroplasty in our Unit over the last three years. Clinical results have been favourable in all patients and, from the radiological point of view, there has been only one re-stenosis. Complications rate has been low and can be superimposed to that of any urethroplasty procedure. The paper emphasizes the enormous relevance of the care taken between both surgical stages on the procedure's final result.

[Secondary ureterectomy in an ectopic ureteral opening into the seminal vesicle]. / Ureterectomía secundaria en la desembocadura ureteral ectópica en vesícula seminal.

The ectopic ureter opening to the seminal vesicle is uncommon in the male and even less in a duplex kidney. It commonly presents as recurrent urinary infection with pelviperineal pain. Treatment is by heminephrectomy with total ureterectomy and removal of the seminal vesicle if it is cystic. Herein we describe a 70-year-old patient who had previously undergone a heminephrectomy and partial ureterectomy due to an ectopic ureter opening to the seminal vesicle of the ureter of the upper pelvis of the left kidney. The patient was submitted to a second ureterectomy procedure due to pyoureter in the ureteral stump. The main features of this pathological condition are described and the surgical approach is discussed.

[Value of CAT staging in renal adenocarcinoma. Correlation with anatomo-pathologic findings]. / Valor del estadiaje del TAC en el adenocarcinoma renal. Correlación con los hallazgos anatomo-patológicos.

On a total of 128 renal adenocarcinomas diagnosed in our Unit between January 1975 and August 1990, the data provided by CATs carried out in 85 of them was compared with that from surgical and anatomo-pathological findings. The precision in both the diagnosis and the tumour staging was determined, evaluating the involvement of perirenal, nodular, venous and neighbouring structures fat. The diagnosis of renal adenocarcinoma was made correctly in 96% cases. With regard to staging, maximal precision was achieved in the involvement of adjacent structures and vena cava, followed by the renal vein, perirenal fat and lymphatic nodes, in this order. We conclude that CAT provides a high diagnostic reliability, permitting with a single study the determination of the most defining parameters of renal cancer staging.

[Multilocular renal cyst]. / Quiste multilocular renal.

A case of multilocular renal cyst in a 37-year-old patient is presented, which met all of the diagnostic criteria described by Powell (1951) and Boggs and Kimmelstiel (1956). The frequency of renal hydatid cyst observed in our setting warrants differential diagnosis from this disease entity. Conservative surgery is advocated as treatment.

[PSA in the staging and monitoring of cancer of the prostate]. / PSA en el estadiaje y monitorización del cáncer de próstata.

The prostatic surface antigen (PSA), exclusively secreted by the prostatic epithelial cells, can be raised in the sera of patients with various prostatic pathologies. Serum levels of this marker depend on many factors (prostatic manipulation, associated inflammation, volume of benign node hyperplasia, volume and grading of tumour differentiation), all of which will have to be taken into account when interpreting any specific level. The usefulness of this antigen has a distinctive role in the suspected diagnosis, staging and monitoring following treatment of prostate cancer. PSA has shown to be more effective than other markers in the diagnosis of prostate cancer. Following the review of 106 patients with prostate cancer in various clinical stages, PSA was higher in 76.5% and PAP only in 49%. There is also a correlation between PSA and the extension of the disease. Of 43 patients surgically (stages B, C, D1) or radiologically (stages D2) staged, increases PSA has been found in 25% B stages, 77.7% C stages and 88.4% D stages. With regard to post-treatment monitoring, PSA is highly useful to determine its effectiveness, detect any residual illness and predict a recurrence or progression.

[Diagnostic and therapeutic considerations in bilateral renal carcinoma. Report of a case and review of the literature]. / Consideraciones diagnóstico-terapéuticas en el carcinoma renal bilateral. Aportación de un caso y revisión de la literatura.

Conservative surgery is considered to be the treatment of choice in patients with bilateral renal tumors or tumor in the solitary kidney owing to the need to preserve renal function. A case of a 63-year-old patient with bilateral renal carcinoma is described. The presenting symptoms were pain and paraneoplastic signs. The patient did not present hematuria throughout the course of the disease. The urographic, ultrasound and tomodensitometric work up correctly determined tumor size, characteristics and anatomic relationship. Arteriography permitted mapping of the vascular structures of both kidneys. Fine needle aspiration biopsy permitted histologic classification preoperatively. The approach was via a Chevron incision. An extended nephrectomy was performed on the left kidney and surgical enucleation of the tumor in the right kidney in a one stage procedure. The diagnostic aspects are discussed and the therapeutic options are reviewed with special reference to the conservative procedures.

[Bladder adenocarcinoma of urachal origin. A rare tumor]. / Adenocarcinoma vesical de orígen uracal. Un raro tumor.

With the description of this new case of urachal adenocarcinoma in the vesical cupula we provide a review on the clinical, pathological and immunohistochemical aspects of this rare tumour, as well as a diagnostic and therapeutical approach. Its subepithelial infiltrant nature delays discovery and denotes both an insidious evolution and poor prognosis. Mucinoid production, nodes pattern and certain immunohistochemical substances as well as abnormalities in the cell's DNA content are attributes of this entity. Only surgery, either partial or exeresis, is effective since this is a radioresistant and dubiously chemosensitive tumour.

[Radical cystectomy for the treatment of infiltrating bladder carcinoma. Analysis of 15 years]. / La cistectomía radical en el tratamiento del carcinoma vesical infiltrante. Análisis de quince años.

Radical cystectomy continues to be the procedure of choice in the treatment of invasive bladder cancer and it is currently an exceptional procedure as monotherapy. The development of surgical techniques for urinary diversion, with less complications, has led to a significant improvement of the overall results achieved with this procedure. We performed a retrospective study of 143 cystectomy procedures that had been performed over a period of 15 years in patients with this tumor type. We evaluated the operative mortality, the morbidity resulting from the procedure, and patient nutritional status and its relation to the appearance of complications. Similarly, we analyzed the different therapeutic strategies we utilized throughout the course of our urological evolution, clearly differentiated into three periods during which we associated radical cystectomy with radiotherapy pre- and post-surgery, neoadjuvant or adjuvant chemotherapy (monotherapy with CDDP or multiple therapy with M-VAC). The operative mortality rate was 0.94% and the incidence of early complications varied according to the different periods, 62% and 32%. Late complications were observed to be 24%. The overall 5-year survival rate was 39% for cystectomy + radiotherapy, 59% when we utilized cisplatin as adjuvant therapy, and 70% (2 years) when we utilized M-VAC neoadjuvant chemotherapy. We believe that distant metastasis was the most common cause of late failures of total cystectomy for infiltrating bladder tumor. Similarly, we believe that the reduced incidence of early complications reported in recent years can be ascribed to the enhanced surgical techniques, better nutritional status of the patient undergoing this procedure, antibiotic therapy, perioperative care, and overall better management and understanding of this disease entity; i. e., the use of a combined therapeutic approach.

[Diagnostic and therapeutic management of testicular tumors. Review of 15 years]. / Manejo diagnóstico y terapéutico de los tumores testiculares. Revisión de quince años.

We reviewed our data on the diagnosis and treatment of testicular tumors during the period spanning January, 1975 to December, 1989 and compared them with the data reported in the literature. The records of 26 cases of germ cell tumors were analyzed. These had a follow-up ranging from 6 to 162 months (mean 36 months). We highlight the usefulness of CT and tumor markers in the diagnosis, staging and follow-up. We consider radical inguinal orchiectomy to be the initial treatment. The therapeutic approach thereafter depends on the histological findings and tumor stage. Currently, patients are followed very carefully after orchiectomy of stage I tumors. Multiple chemotherapy of tumors in the advanced stages has increased the incidence of survival and complete remission. Furthermore, this chemotherapeutic approach has occasionally converted surgery into and adjuvant treatment modality.

[Parotid metastasis of renal adenocarcinoma: report of a case]. / Metástasis parotidea de adenocarcinoma renal: a propósito de un caso.

Renal adenocarcinomas are tumours which sometimes tend to remain clinically silent, and initially become evident through distant metastasis. This paper presents the case of a 54 year-old patient whose initial clinical evidence was parotid metastasis from kidney clear cells adenocarcinoma. The patient had a metastasis and renal tumour exeresis with application of supplementary chemotherapy and immunotherapy, presenting early pulmonary metastasis which remains currently unchangeable. Some comments apropos of distant metastasis, its prognosis and regression in renal tumours are made.

[Malignant fibrous histiocytoma of the scrotal wall. Presentation of a case and review of the literature]. / Histiocitoma fibroso maligno de la pared escrotal. Aportación de un caso y revisión de la literatura.

A case of Malignant Fibrous Histiocytoma in a 64 years old man, its rarity consisting in the location, the scrotal wall, is presented. An exposition on this pathological form of presentation, symptomatology, A.P., diagnostic, natural history, prognosis and treatment is made. Also, we review the literature on Malignant Fibrous Histiocytomas on the scrotal wall.

[Camey II type substitution ileocystoplasty. Our experience]. / Ileocistoplastia de sustitución tipo Camey II. Nuestra experiencia.

We present our experience in the performance of Camey II type substitution ileocystoplasty. The operation was performed between January 1988 and February 1989 on 11 patients who had been diagnosed as having vesical tumour by means of transurethral resection. All of them had received preoperative systemic chemotherapy. Technically, we single out the performance of ileo-obturating lymphadenectomy prior to the cystoprostatovesiculectomy in the same operation, creation of the neobladder with detubulized terminal ileum, uretero-ileal reimplantation according to Le Duc-Camey technique and use of mechanical sutures to reestablish intestinal continuity. Operative and postoperative mortality has been null. As complications, we may mention a urthro-ileal fistula as a result of the suture tension at this level, due to shortness of the mesointestine, and which yielded with conservative measures. Amongst tardive complications we may single out a urethro-ileal stenosis, which required performance of an internal urethrotomy. Daytime continence in all patients, except one. Night continence in six cases. Absence of ureteral reflux and upper urinary tract with correct function and morphology in all cases. The follow-up time ranges from 3 to 16 months. We conclude that this type of vesical substitution offers all patients a good quality of living and adequate mictional comfort.

[Urinary undiversion]. / Desderivacíon urinaria.

As a novel item we present a case of the reconversion of a Bricker-Wallace type external urinary bypass into vesical replacement according to Camey technique type II. 5 years after radical cystectomy and external urinary bypassing due to a malignant infiltrating vesical carcinoma and considering the patient's malignant pathology controlled, we have converted this bypass into a bladder replacement with detubulized ileum. Renal function is preserved by means of a ileo-ileal intussusception mechanism, achieving mictional physiology and maintaining both daytime and nocturnal continence, thanks to the integrity of the external sphincter. The major advances in reconstructive urological surgery in recent years have enabled us to make a fresh study of these patients with bypasses, as in fact many of them are going to be able to be reconstructed.

[Obstruction of the pyelo-ureteral junction in adults. Diagnostic and therapeutic management]. / Obstrucción de la unión pielo-ureteral en adultos. Manejo diagnóstico y terapéutico.

The ureteropelvic junction (UPJ) is the most common site of upper urinary tract obstruction. We report on 46 adult patients (50 renal units) that had been treated for a UPJ anomaly at our department over a 10-year period. The most common clinical manifestations observed were lumbar pain and/or colic (82.6%) and infection (34.8%). Genitourinary malformations were observed in 21.8% of the patients. The following treatment modalities were performed: 8 nephrectomies, 39 repair surgery procedures, 3 renal units with mild dilatation and no obstruction did not undergo surgery and were closely followed. The Anderson-Hynes pyeloplasty procedure was performed in 37 (95%) renal units and the Foley Y-V plasty in 2 (5%). The most important complications were anastomotic stricture (4) and urinary fistula (2). Overall, the results of repair surgery were good in 69.2%, fair in 20.5% and poor in 10.3% of the cases. Better results were achieved in those cases with moderate (86% good results) than in those with severe (47% good results) dilatation. Following pyeloplasty, 95% of the patients were pain-free, 1 (2.3%) patient had episodes of symptomatic infection and deterioration of renal function was observed in only 1 patient with a single kidney and severe chronic renal failure prior to surgery. At 2 years, dilatation had improved in 64%, remained unchanged in 31%, and became worse in 5%. In the management of pyelocaliceal dilatation, we believe it is fundamental to clearly establish the presence of obstruction and predict the functional recovery of the obstructed kidney. Our diagnostic and therapeutic approach is described. For upper urinary tract dilatation, the following is performed: simple or diuresis IVP, diuresis renography, ultrasonography and CUMS (if reflux is suspected). When doubts exist or when the results are unclear, pressure flow urodynamic studies are performed. Thus, we perform repair surgery in dilatations with functional obstruction to avoid progressive renal deterioration. The literature on the diagnostic techniques for the assessment of obstruction and functional recovery is reviewed.