Comparative study of hybrid laparoendoscopic single-site (LESS) partial nephrectomy and conventional multiport laparoscopy. / Análisis comparativo entre nefrectomía parcial LESS híbrida y laparoscópica convencional multipuerto.

OBJECTIVE: To investigate the surgical and oncological outcomes of hybrid laparoendoscopic single-site (LESS) in partial nephrectomy with reusable components compared with multiport laparoscopy. MATERIAL AND METHOD: Hybrid LESS technique with auxiliary 3.5mm trocar (n=20) was compared with conventional multiport laparoscopy (n=26) by a prospective, paired, nonrandomized, and comparative study in partially nephrectomized patients. RESULTS: Follow-up average was 31±18.6 months. In one case, LESS was converted to laparoscopy. No differences were found regarding age, sex, body mass index, laterality, localization, tumor size or use of double J stent. Dominance of Loop-I (P=0.09) and benign histology (P=0.05) were observed in the LESS group. Neither there were differences regarding operating time, ischemia time, use of hemostatic materials, estimated blood loss, postoperative hemoglobin levels, transfusion or other complications. In any case, to extend the skin incision for specimen extraction was not necessary. Drainage time (P=0.006) and hospital stay (P=0.003) were better in LESS patients. Concerning complications, no significant differences were observed according Clavien-Dindo scale. In laparoscopic group one patient died of pulmonary embolism after hospital discharge. No positive margins were observed in any case. During follow-up neither tumor recurrence nor disease progression were observed. CONCLUSIONS: Regarding surgical outcomes, partial nephrectomy by LESS technique does not imply improvements, excepting shorter hospital stay, probably due to accurate surgical hemostasis and/or selection of cases. No surgical and oncological risks are involved, as well as no improvement in ischemia time, blood loss or transfusion rate. We find no significant difference in cosmetic outcomes.

Umbilical laparoendoscopic partial cystectomy.

OBJECTIVE: To present our center's experience in single-port umbilical laparoendoscopic partial cystectomies, in both benign and malignant pathologies. Patient characteristics, perioperative aspects and the surgical techniques used are reviewed. MATERIAL AND METHOD: Since May 2012, five patients have undergone a transumbilical single-port laparoendoscopic partial cystectomy with curved equipment through a reusable multichannel system and a 3.5mm accessory trocar. Patients were three males and two females aged between 28 and 78 (median: 44±42.5) years. The etiologies were endometriosis (in 2 cases), a tumor in the diverticulum, a congenital bladder diverticulum and ureterocele (1 case of each). RESULTS: Median surgery time was 273±163.4minutes, and intraoperative bleeding 250±175ml. None of the patients required transfusion. The postoperative period was uneventful, with good results and no complications. The hospital stay was 3±1 days. With monitoring of 20±17.5 months, morphological and functional recovery in the bladder and ureter was confirmed in all cases and the patient with neoplastic disease was disease-free more than 2 years after the surgery. CONCLUSIONS: An umbilical laparoendoscopic partial cystectomy represents a viable surgical option and ensures that excellent surgical and cosmetic results are achieved.

Retrograde intrarenal surgery with holmium-YAG laser lithotripsy in the primary treatment of renal lithiasis.

INTRODUCTION: retrograde intrarenal surgery (RIRS) appears as a safe and effective technique as well as a good therapeutic alternative to extracorporeal shock wave lithotripsy (ESWL) and percutaneous nephrolithotomy (PNL). MATERIAL AND METHODS: descriptive study in 50 patients surgically treated between November 2012 and April 2013. Demographic, operative and postoperative data as well as early and late complications data were collected. The minimum follow-up of patients was one year. Surgery was performed under general anesthesia. Flexible ureteroscopy with ureteral access sheath and laser fragmentation were employed. Surgery success was defined as stone free rate in postoperative control test and at three months after surgery (simple radiography, abdominal ultrasound or CT without contrast). RESULTS: mean age was 51.1±15.5 years old. The highest-frequency location was the lower calyceal group (26%), single stones were described in 58% of patients whilst multiple lithiasis were found in the 42%. Regarding the stone burden in 44% of the patients was low (<2 cm), and high (>3 cm) in 22% of the patients. The stone clearance rate was 89.7±17.5. Average surgery time was 96.6±35.2min. Complications were reported in 4 patients (8%), all of them early ones and minor in nature. CONCLUSIONS: RIRS is an effective and safe option whose results are comparable to ESWL and PCNL. RIRS can be considered as first-line treatment. These results are corroborated by numerous studies. To strengthen these findings, prospective studies focusing on quality of life, length of stay, complications and cost-effectiveness of different treatments are needed.

Treatment for long bulbar urethral strictures with membranous involvement using urethroplasty with oral mucosa graft.

INTRODUCTION: Urethroplasty with oral mucosa grafting is the most popular technique for treating nontraumatic bulbar urethral strictures; however, cases involving the membranous portion are usually treated using progressive perineal anastomotic urethroplasty. We assessed the feasibility of performing dorsal (or ventral) graft urethroplasty on bulbar urethral strictures with mainly membranous involvement using a modified Barbagli technique. MATERIAL AND METHODS: This was a prospective study of 14 patients with bulbomembranous urethral strictures who underwent dilation urethroplasty with oral mucosa graft between 2005 and 2013, performed using a modified technique Barbagli, with proximal anchoring of the graft and securing of the graft to the tunica cavernosa in 12 cases (85.7%) and ventrally in 2 (14.3%). The minimum follow-up time was 1 year. We evaluated the subjective (patient satisfaction) and objective (maximum flow [Qmax] and postvoid residual volume [PVRV], preoperative and postoperative) results and complications. Failure was defined as the need for any postoperative instrumentation. RESULTS: A total of 14 patients (median age, 64+13 years) underwent surgery. The main antecedent of note was transurethral resection of the prostate in 9 cases (64.3%). The median length of the stenosis was 45+26.5mm. Prior to surgery, 50% of the patients had been subjected to dilatations and 4% to endoscopic urethrotomy. The mean surgical time and hospital stay were was 177+76min and 1.5+1 day, respectively. The preoperative Qmax and PVRV values were 4.5+4.45mL/sec and 212.5+130 cc, respectively. The postoperative values were 15.15+7.2mL/sec and 6+21.5cc, respectively (P<.01 for both comparisons). Surgery was successful in 13 cases (92.9%). None of the patients had major complications. There were minor complications in 1 (7.1%) patient, but reintervention was no required. CONCLUSION: The repair of long bulbar urethral strictures with membranous involvement using urethroplasty with free oral mucosa grafts represents a viable alternative for patients with nontraumatic etiology and little fibrosis. The dilation of the urethral lumen achieves good results with minimum failure rates and little probability of complications. For many of these patients, the length of the stricture is too long to perform the tension-free anastomosis technique.

Comparative study of retrograde intrarenal surgery and micropercutaneous nephrolithotomy in the treatment of intermediate-sized kidney stones.

OBJECTIVE: Retrograde intrarenal surgery (RIRS) has proven efficacy with minimal morbidity in the treatment of intermediate-sized kidney stones. The aim of this study was to examine the feasibility of micropercutaneous nephrolithotomy (microperc) for this indication and evaluate its results compared with those of RIRS. MATERIAL AND METHODS: From September to December 2013, we performed a comparative prospective study between RIRS and microperc, with 20 consecutive patients with intermediate-sized (1-3cm) kidney stones. We employed a flexible dual-channel ureteroscope (Cobra, Richard Wolf GmbH) and a Microperc 4.85/8 Fr (with the patient supine) with flexible fiberoptics (0.9mm, 120° and 10,000 pixels) (PolyDiagnost GmbH). The study variables were demographic data, stone characteristics, percentage of stone elimination, complications (Clavien-Dindo), surgical time, hospital stay and need for auxiliary procedures. RESULTS: The patients underwent RIRS (n=12) or microperc (n=8). There were no differences in the demographics or stone characteristics between the 2 groups. The percentage of stone elimination with RIRS and microperc was 91.7% and 87.5% (P=1), respectively. One of the patients who underwent RIRS (8.3%) experienced postoperative fever; one of the patients who underwent microperc (12.5%) experienced postoperative colic pain (both cases were classified as Clavien I). The operative times were similar: 120min (111.2-148.7) and 120 (88.7-167.5) min for RIRS and microperc (P=.8), respectively. None of the patients required a blood transfusion. The hospital stays were also equivalent: 1 day (1-2) and 1.5 days (1-3.5) for RIRS and microperc (P=.33), respectively. Two patients treated with microperc (25%) required auxiliary procedures (simultaneous RIRS and flexible nephroscopy after percutaneous trajectory dilation to treat, in both cases, a significant fragment that had migrated to an inaccessible calyx), and 1 patient in the RIRS group (8.3%) required percutaneous nephrolithotomy due to unfavorable infundibular-calyceal anatomy (P=.54). CONCLUSIONS: Microperc is a minimally invasive method that is emerging as an effective and safe treatment for intermediate-sized kidney stones. Studies are needed to better evaluate its cost-effectiveness, the need for complementary treatments and its possible complementarity with RIRS when working with patients in the supine position.

Efficacy and safety of fosfomycin-trometamol in the prophylaxis for transrectal prostate biopsy. Prospective randomized comparison with ciprofloxacin.

OBJECTIVE: Prostate biopsy is the standardized diagnostic method for prostate cancer. However, although there is not a standardized protocol, there are recommendations in order to reduce the incidence of complications. The objective of the present work is to assess the efficacy and safety of antibiotic prophylaxis in the prostate biopsy by comparing two antibiotic regimes: two doses of fosfomycin-trometamol 3g (FMT) every 48 hours with 10 doses of oral ciprofloxacin 500 mg every 12 hours during 5 days. MATERIAL AND METHODS: Randomized prospective study was performed with 671 patients who had undergone to walking transrectal ultrasound guided prostate biopsy. Patients of group A (n=312) were treated with ciprofloxacin, and patients of group B (n=359) with FMT. Efficacy and tolerability of two prophylactic regimes were compared. Urine culture was carried out at 2 weeks after biopsy. Initially, patients with asymptomatic bacteriuria were not treated with antibiotics; urine culture was repeated after 1 month, persistent bacteriuria was treated according to antibiogram. RESULTS: No differences between groups were found in age (P=.78), cancer presence (P=.9) or number of biopsy cylinders (P=.93). The mean number of cores obtained was 11.3 ± 3.25 (range 6-20). Digestive intolerance was observed for 9 patients (2.9%) of group A and 10 patients (2.8%) in group B. One patient (.3%) of group A showed severe allergic reaction. In total, 167 patients (24.6%) had complications: 16 (2.4%) fever, 47 (6.9%) hemospermia, 81 (11.9%) hematuria, 7 (1%) rectal bleeding and 16 (2.4%) urinary retention. No statistically differences between groups were observed (27.6% vs. 22.6%; P=.17). However, hemospermia was more frequent in group A (9.9% vs. 4.5%; P=.006). Bacteriuria after biopsy was detected in 44 patients (6.6%), being more frequent in group B patients (4.2% vs. 8.6%; P=.02) although a higher number of second treatment cycles were not needed (53.9% vs. 29%; P=.17). The likelihood of resistance to ciprofloxacin in patients with bacteriuria in A was greater than that of FMT in B (69.2% vs. 41.9%; P=.0004). CONCLUSIONS: Antibiotic prophylaxis with FMT (2 doses of 3g) in prostate biopsy is an alternative as effective and safe as ciprofloxacin (10 doses of 500 mg), which carries lower rate of resistance. According to our experience, this drug is a safe, well-tolerated, and easily manageable prophylactic option, facilitating patient compliance. More prospective multicenter studies are necessary to confirm these findings.

Analysis of the factors involved in the failure of urethroplasty in men.

INTRODUCTION: Outcome of urethroplasty techniques in our environment and risk factors for recurrence of stenosis in these patients are studied in this paper. MATERIAL AND METHODS: Retrospective study on men with urethral strictures treated with urethroplasty in the period 2000-2012. Maximum flow (Qmax), post-void residual (PVR) urine and patient perception of voiding were obtained pre- and postoperatively. Complications were recorded according to the Clavien-Dindo scale. Recurrent stricture was defined according to clinical criteria and endoscopic or imaging confirmation (failure of urethroplasty). Univariate analysis (log-rank) and multivariate (Cox regression) were performed to define the variables implied in the recurrence. RESULTS: 82 patients with mean age 55.6 ± 17.4 (19-84 years) underwent surgery for urethroplasty. 28% of patients showed multiple stricture, 73.2% bulbar stricture, 41.54% penile stricture and 14.6% membranous stricture. End-to-end anastomosis was performed in 26 cases (31.7%), flap urethroplasty in 21 (25.6%), urethroplasty with free graft in 31 (37.8%) and two-time urethroplasty in 4 (4.9%). Graft urethroplasty showed a longer operative time (p = 0.02) and shorter hospital stay (P = 0.0035). The results were: mean ΔQmax (mean on baseline) 9.1 ± 7.5 and mean ΔPVR -65.8 ± 136 (both P < 0.0001). Minor early complications occurred in 8 (9.8%) and major in 3 (3.6%). Recurrence occurred at a mean time of 39.8 ± 39.2 months in 18 patients (21.9%). The percentage of recurrence-free patients was: 91.4% (1-year), 82.1% (5-year) and 78.1% (10-year). Univariate analysis assessed technique used (log-rank, P = 0.13), age (P = 0.2), length stricture (P = 0.003), previous Sachse (P = 0.18), associated lichen (P = 0.18), multiplicity (P = 0.36), year of surgery (P = 0.2), Qmax (P = 0.3) and RPM (P = 0.07) preoperative. End to end anastomosis (HR 4.98, P = 0.04) and length > 3 cm (HR 4.6, P = 0.01) were identified by regression analysis as independent variables associated with poor prognosis. CONCLUSION: Length stricture is both prognostic factor and criterion on choosing the type of urethroplasty, and it makes more complicated to compare the success rates of each surgical procedure. Whatever the stricture size is, the results of anastomotic urethroplasty are worse than those of urethroplasty with buccal mucosal-free grafts.

SU-E-T-264: New Concrete Designed and Evaluation for Megavoltage X Radiotherapy Facilities (CONTEK-RFH2).

PURPOSE: The most common material for shielding is concrete, which can be made using various materials of different densities as aggregates. New techniques in radiotherapy, as IMRT and VMAT, require more monitor units and it is important to develop specifically designed shielding materials. METHODS: Arraela S.L. has developed new concrete (CONTEK®-RFH2), which is made from an arid with a high percentage in iron (> 60%), and using the suitable sieve size, enables optimum compaction of the material and a high mass density, about 4.1-4.2 g/cm3 . Moreover, aluminate cement, used as base, gives high resistance to high temperatures what makes this product be structurally resistant to temperatures up to 1200 ° C. The measurements were made in a LINAC Elekta SL18 to energies 6MV and 15 MV with a field size of 10×10 cm2 for concrete samples in the form of tile 25cm×25cm with variable thickness. RESULTS: The linear attenuation coefficient, µm, was determined for each energy by fitting the data to Eq. 1, where Xxm is the exposure in air behind a thickness xm of the material, and X0 is the exposure in the absence of shielding. These results are compared with the ordinary concrete (2.35 g cm-3) for 6MV and 15MV energies (Ref. NCRP Report No.151). Results are tabulated in Table1. Results of attenuation are compared with ordinary concrete in Fig. 1. CONCLUSIONS: The new concrete CONTEK®-RFH2 increases photon attenuation and reduces the size of a shielded wall. A very high percentage in iron and a suitablesieve size approximately double the density of ordinary concrete. High mass attenuation coefficient makes this concrete an extremely desirable material for use in radiation facilities as shielding material for photon beam, and for upgrading facilities designed for less energy or less workload.