Consensus statement of the Spanish Association Of Urology on the use of meshes in pelvic organ prolapse. / Consenso de la Asociación Española de Urología sobre el uso de mallas en la cirugía del prolapso de órganos pélvicos.

INTRODUCTION: Recently the Food and Drug Administration has banned the use of transvaginal meshes for the surgical treatment of pelvic organ prolapse (POP) in the United States. This has caused a worldwide impact on the management of pelvic floor pathology by different specialists. OBJECTIVE: To achieve a consensus on the use of meshes in the surgical treatment of POPs. ACQUISITION OF DATA/EVIDENCE: A Committee of experts of the Spanish Association of Urology (AEU) was organized to review the literature and analyze the safety and efficacy of the use of polypropylene meshes in POP surgery. RESULTS/EVIDENCE FROM THE LITERATURE: The evidence reflects that the use of meshes, compared to the use of native tissues, offers better efficacy at the expense of new complications and a higher rate of surgical reviews, these being minor in the hands of expert surgeons. CONCLUSIONS: POP surgery must be performed by experienced surgeons, properly trained and in referral centers. The patient should receive correct information about the different treatment options. Transvaginal meshes should only be indicated in complex cases and in recurrences after POP surgery. AEU PROPOSAL: Creation of a clinical guideline and a national registry for long-term evaluation. Preparation of an Informed Consent available to all professionals and patients, as well as a specific training plan to achieve better training in complex pelvic floor surgery.

Mortality prediction model for patients with bladder urothelial tumor after radical cystectomy. / Modelo predictivo de mortalidad en pacientes con tumor urotelial de vejiga tras cistectomía radical.

OBJECTIVE: Based on preoperative clinical and postoperative pathological variables, we aim to build a prediction model of cancer specific mortality (CSM) at 1, 3, and 5 years for patients with bladder transitional cell carcinoma treated with RC. MATERIAL AND METHODS: Retrospective analysis of 517 patients with diagnosis of cell carcinoma treated by RC (1986-2009). Demographic, clinical, surgical and pathological variables were collected, as well as complications and evolution after RC. Comparative analysis included Chi square test and ANOVA technique. Survival analysis was performed using Kaplan-Meier method and log-rank test. Univariate and multivariate analyses were performed using logistic regression to identify the independent predictors of CSM. The individual probability of CSM was calculated at 1, 3 and 5 years according to the general equation (logistic function). Calibration was obtained by the Hosmer-Lemeshow method and discrimination with the elaboration of a ROC curve (area under the curve). RESULTS: BC was the cause of death in 225 patients (45%). One, three and five-year CSM were 17%, 39.2% and 46.3%, respectively. The pT and pN stages were identified as independent prognostic variables of CSM at 1, 3 and 5 years. Three prediction models were built. The predictive capacity was 70.8% (CI 95% 65-77%, p=.000) for the 1st year, 73.9% (CI95% 69.2-78.6%, p=.000) for the third and 73.2% (CI% 68.5-77.9%, p=.000) for the 5th. CONCLUSIONS: The prediction model allows the estimation of CSM risk at 1, 3 and 5 years, with a reliability of 70.8, 73.9 and 73.2%, respectively.

[Management of pancreatic lesions in urologic surgery]. / Manejo de la lesión pancreática en cirugía urológica.

Surgical trauma of the pancreas cauda can occur when the renal hilum is dissected during left radical nephrectomy, mainly when normal anatomy is altered by the tumoral or inflammatory pathology. This lesion can be appreciated during the surgical procedure or else a pseudocyst or pancreatic fistula can become evident post-operatively. The urologist's knowledge of what the correct management both intra-operatively and postoperatively of this pathology should include will lessen the significant morbidity it implies. Presentation of a series of 6 patients presenting pancreatic trauma during left radical nephrectomy. Comments on the pathophysiology of this disorder, intra-operative management and post-operative treatment, specifically emphasizing the use of Total Parenteral Nutrition and Momatostatin IV.

[Hemangioma of the adrenal gland]. / Hemangioma de la glándula suprarrenal.

Adrenal gland haemangioma is an uncommon tumour which finding usually occurs by chance. This paper presents one case of cavernous haemangioma in this location on which surgery was performed successfully. The basic aspects of the case are revised from a pathohistological and diagnostic point of view intended to attempt to suspect its presence preoperatively.

[Carcinoma of the penis: long-term follow-up]. / Carcinoma de pene: seguimiento a largo plazo.

Penis epidermoid carcinoma is responsible for about 1% of deaths by neoplastic diseases in developed countries. During a 5-10 years follow-up review, we found 14 patients, 9 of which started as localized stages in glans and/or prepuce. Lymph node affection was found in 9 cases, either at beginning of diagnosis or during follow-up. Lymphadenectomy, which demonstrated metastatic affection in 4 cases, was considered indicated in 6 patients. Two cases received inguinal chain radiotherapy and the remaining one underwent chemotherapy as first therapy. Percentage of actual survival rate, found after 5 years, among the 14 patients studied was 42.8% (6 cases), still unchanged after a 10-year follow-up. Five patients died due to their basic illness progression and 3 died of other tumour-unrelated processes. The paper analyzes the results obtained based on the literature reviewed, and discusses current therapy approaches for inguinal metastatic conditions.

[Retroperitoneal laparoscopic nephrectomy: a case report]. / Nefrectomía laparoscópica por vía retroperitoneal: caso report.

Presentation of the first exclusively retroperitoneal laparoscopic nephrectomy performed on a female patient diagnosed with chronic pyelonephritis in the right kidney who referred frequent discomfort in the ipsilateral lumbar fossa as well as sporadic urinary infections. The entire procedure was performed without entering the peritoneal cavity, creating a space in the retroperitoneum, using for that hydrostatic dilation following Gaur's recommendations and introducing in that space a total of 4 trocars. Surgery lasted 3 hours an 35 minutes, with a post-operative stay of 3 days; the anaesthetics used after surgery was minimum and patient's return to her usual daily activities was almost immediate after discharge. Considering our group's previous experience in laparoscopic nephrectomies, both in humans (another 3 cases) and experimental surgery (18 pigs), we believe retroperitoneal approach is a huge step ahead in urological laparoscopic surgery, since this is the typical approach in our specialty and allows a closer contact with the condition being treated. On the other hand, the combined retro- and transperitoneal accesses will involve-are already involving-a greater variety of laparoscopic techniques in urology.

[Laparoscopic bilateral nephrectomy of native kidney in kidney transplantation carriers]. / Nefrectomía bilateral laparoscópica de riñones nativos en trasplantado renal.

Severe vesicouretheral reflux sometimes causes terminal renal failure which then requires renal transplantation. In these patients it may be necessary to perform bilateral nephrectomy when associated to serious hypertension or urinary infections with a significant clinical impact. This paper presents the clinical picture of a patient with a corpse renal transplantation, due to terminal renal failure secondary to reflex nephropathy, in whom it was necessary to perform bilateral nephrectomy due to the uncommon urinary infections requiring hospitalization for treatment. The bilateral nephrectomy was done through transperitoneal laparoscopic approach, using seven points for trocars introduction. The procedure lasted 4 hours and the patients was discharged within 48 hours with no complications. Accumulate experience in the use of laparoscopy in urology has allowed this technique to be feasible. After designing the experimental model, our group has had the chance to accomplish laparoscopic nephrectomies in humans. We believe that this is the first case of bilateral nephrectomy conducted in our country using the laparoscopic approach.

[Urethral sonography in the diagnosis and preoperative evaluation of urethral stenosis]. / Sonouretrografía en el diagnóstico y evaluación preoperatoria de la estenosis de uretra.

An area of spongiofibrosis can be found proximal and distal to all stenosis of the urethra. The severity of such spongiofibrosis as well as its length are in many instances decisive when choosing an adequate surgical approach. Conventional radiological diagnosis of stenosis of the urethra only shows the area of urethral stricture but is unable to inform on the fibrosis of the spongy body. Sonourethrography or urethral echography affords a dynamic tridimensional examination of the anterior urethra which provides accurate data on the length of the stenosis, as well as the extend and severity of the spongiofribosis. Sixteen patients diagnosed with stenosis of the urethra through sonourethrography were evaluated. This easy-to-perform investigation, allowed the identification of 4 patients with peristenotic intense spongiofibrosis, hypercongenital urethra, who underwent open urethroplastia. The urethra of another 3 patients showed normal echogenicity, but diminished elasticity, and were diagnosed as of moderate spongiofibrosis requiring extensive internal urethrotomy. We believe sonourethrography should become a procedure to be included as part of the routine pre-surgical investigation of the stenosis of the urethra due to its non-invasive nature, easiness to perform, and because it provides highly useful information which would allow a decreased number of re-stenosis following surgery of the urethral stenosis.

[Necrotizing vasculitis located exclusively in the bladder: report of a case]. / Vasculitis necrotizante de exclusiva localización vesical: presentación de un caso.

Necrosing vasculitis and, within it, nodosa polyarteritis, is an infrequent entity characterized by the absence of pathognomonic signs and symptoms, but which can potentially affect the entire body. The initial description was made by Kussmaul and Maier in 1866. Sings and symptoms of this clinical picture are not frequently circumscribed to the urinary tract. We describe here one case of a particularly infrequent presentation, as a vesical mass with gross haematuria. The paper discusses the clinical picture, diagnosis and treatment of this process.

[The use of kidney grafts++ from donors of the same age or below 3 years (weight equal or below 15 Kg)]. / Utilización de injertos renales de donantes de edad igual o inferior a 3 años (peso inferior o igual a 15 kgrs).

Over the last few years an impasse has been seen in the number of donors for organ transplantation. This has prompted a re-statement on the use of a group of grafts which, historically, were considered suboptimal: those from donors aged 3 years or under (weight less than or equal to 15 kg). 124 transplantations from corpse donors performed in adults over a 36 months period (Jun 90/July 93) were revised. 24 grafts (19.3%) from donors aged 3 years or under were used. Thirteen (54%) of these grafts were from donors aged 24 months or under, and six (27%) from donors aged 12 months or under. A comparative analysis is made on the clinical and functional evolution of these grafts, as well as their current survival status versus those from donors aged between 3 and 60 years (n = 86, 69.3%). Transplants made with grafts from donors older than 60 years (n = 14, 11.2%) were excluded from the analysis. Our results suggest that use of kidneys from donors aged 3 years or under--weight less than or equal to 15 kg--, implanted as units is acceptable when compared to grafts from older donors. Considering the current impasse in donations for organ transplantation we believe use of this type of donors, as a useful source of grafts, should be advocated.

[Functional and economic impact of the use of Wisconsin University conservation solution versus Eurocollins in relation to the period of cold ischemia in renal transplantation of cadaveric donor]. / Impacto funcional y económico de la utilización de la solución de conservación de la Universidad de Wisconsis frente Eurocollins en relación al tiempo de isquemia fría en trasplante renal de donante cadáver.

Comparison of the effect of the Wisconsin University (WU) conservation solution in the graft's functional evolution and survival, and its cost-benefit relationship versus the Eurocollins (EC) solution with regard to cold ischaemia duration in a series of 142 consecutive adults renal transplantations from corpse donor, removed with beating heart. Of 142 kidneys, 92 (64.7%) were kept in WU and 50 (35.2%) in EC. Of the WU group, 62 (67.3%) kidneys were transplanted after a cold ischaemia of under 24 hours and 30 (32.6%) after cold ischaemia of more than 24 hours. In the EC group, 23 (46%) were kept in cold ischaemia for an interval shorter than or equal to 24 hours and 27 (54%) for more than 24 hours. Incidence of initial graft dysfunction (IGD) was greater in the EC groups (65% and 78%) versus the WU groups (39% and 50%), the difference being statistically significant (p). The graft function, as indicated by the creatinine levels was always better in the WU groups. There was a decreased need for complementary dialysis sessions, less days of oliguria and shorter hospitalization in the WU groups (p). There were no significant differences in the four series with regard to rejection episodes, cyclosporin-related nephrotoxicity, and vascular and urinary tract complications. All of which turn cost-effective the higher cost per litre of the WU versus the EC solution. Graft survival at 12 and 24 months was also significantly (p) higher for grafts kept in WU. This paper presents the results obtained in the analysis of our transplanted patients. In our experience, the WU solution allows better conservation of renal grafts, with less IGD and better graft survival at 12 and 24 months. These results turn cost-effective the higher cost per litre of the WU versus the EC solution.

[Lymphocele after renal transplantation: therapeutic controversies in the age of laparoscopy]. / Linfocele postrasplante renal: controversias terapéuticas en la era de la laparoscopia.

We present 11 lymphoceles in 180 consecutive kidney transplants (6%). We study the potential etiologic factors, symptoms, diagnostic evaluation and treatment, stressing the role of laparoscopy in management of bulky and loculated symptomatic lymphoceles. This technique allows to reduce morbidity, increasing efficacy and shortening hospitalization.

[New perspectives in the preservation of kidney grafts]. / Nuevas perspectivas en la preservación de injertos renales.

OBJECTIVES: Graft preservation, together with overcoming the immunological barrier responsible for graft rejection, are the most important problems of organ transplantation. The different solutions to the foregoing problems are briefly analyzed. METHODS/RESULTS: The literature on graft rejection and preservation is briefly reviewed, highlighting the most outstanding developments. The availability of cyclosporine in the early eighties significantly enhanced the results of immunosuppression and made it less aggressive for graft recipients. The use of liquids for hypothermic preservation of the donor organ, with the advantages and disadvantages it entailed, was a major advancement in cold ischemia. Different solutions (Eurocollins, Wisconsin, HTK) were developed to reduce metabolic derangements from the time the organ was harvested until it was transplanted, with the aim of permitting immediate graft function in order to reduce the incidence of acute tubular necrosis. Further insight into the histological lesions caused by ischemia, the endothelial lesion and its role in tubular dysfunction have led different groups to use pulsatile perfusion once again, particularly since non-heartbeating donor programs were developed. CONCLUSIONS: Although the advancements in the preservation of renal grafts have permitted extending the cold ischemia time beyond 24 hours, the incidence of tubular necrosis continues to be significant. The foregoing, together with the development of renal transplant programs for non-hearbeating donor kidneys, have emphasized the need for further knowledge and understanding of graft viability and early function.

[Laparoscopic lymphadenectomy in the treatment of stage I non-seminomatous germ cell tumors]. / Linfadenectomía laparoscópica en el tratamiento de los tumores germinales no seminomatosos estadio I.

OBJECTIVE: To review the role of laparoscopic lymphadenectomy for stage I nonseminomatous germ cell tumor of the testis. METHODS: The current literature on this subject is reviewed and the advantages and disadvantages of this technique are discussed. RESULTS/CONCLUSIONS: Although there is no agreement on the management of nonseminomatous germ cell tumors of the testis, some groups advocate performing retroperitoneal lymphadenectomy after orchidectomy, particularly for tumors with a high risk of dissemination. The laparoscopic approaches that were introduced basically in the 90's, have permitted performing surgical techniques with a low morbidity and a shorter recovery time. Laparoscopic retroperitoneal lymphadenopathy is one such technique. According to the experience of several groups, this technique has an acceptable operating time (approximately 5 hours), low complication rate and short hospital stay (2-5 days according to the different series). For those with experience in performing the laparoscopic approach, it is a therapeutic alternative that should be considered for this type of testicular tumor.

[Incrusted alkaline cystitis. Physiopathological basis for treatment with acetohydroxamic acid]. / Cistitis incrustada alcalina. Bases fisiopatológicas del tratamiento con ácido acetohidroxámico.

Alkaline incrusting cystitis is an uncommon clinical condition that usually presents in the course of bladder disease. It has characteristic presenting features and is difficult to treat despite currently available therapeutic measures. Three such cases that had been diagnosed and treated at our department is described herein. The literature is reviewed and the pathologic mechanisms of this condition are analyzed.

[A right kidney autotransplant after inferior cavectomy]. / Autotrasplante renal derecho después de cavectomía inferior.

We investigated the feasibility of diverting blood supply from the right kidney after resection of the vena cava by autotransplantation to the right iliac fossa. The experiment was conducted in 10 mini-pigs that had previously undergone partial ligation of the vena cava to produce collateral circulation. Although a good collateral circulation had developed, it was not sufficient to drain the complementary venous supply (right kidney). All the animals developed venous thrombosis and, consequently, irreversible renal failure.