[Proceedings in the implantation of a laparoscopic radical prostatectomy program]. / Implantación de un programa de prostatectomia radical laparoscópica.

OBJECTIVE: To describe our proceedings in the implatation of our laparoscopic radical prostatectomy program (LRP). METHODS: Our working agenda and step-oriented implementation of our LRP program are shown. RESULTS: Four main steps were scheduled to acomplish this goal. These were: Preparatory phase, programed open conversion, development and analysis. Overlapping of each of these phase occured although their major content run on a time-basis. After basic skills acquisition and updating of our equipment we moved into the fixed-time open conversion we allowed us to progresively improve our performance without putting our patients into risks. Operative time of this phase exceeds that of our open cases in 63 minutes and no major complications took place. A rapid decrease in the operative time was noted after the first 15 cases (197' vs 264'). CONCLUSION: Implantation of a program of LRP can be done safely with a pre-planned program tailored to the needs and characteristics of each group and institution.

[Hematuria and sharp renal failure as debut of secondary bladder amiloidosis. Presentation of a new case and revision of the literature]. / Hematuria y fracaso renal agudo como debut de amiloidosis vesical secundaria. Presentación de un nuevo caso y revisión de la literatura.

The primary bladder amiloidosis is an uncommon pathology, not existing in the world more than 150 published cases, being even more exceptional the secondary bladder amiloidosis being described around 25 cases. The secondary bladder amiloidosis associates in most from the patients to arthritis reumatoide of long evolution. The diagnoses clinical it is difficult, being necessary the differential diagnosis with the bladder tumour. The pathological study and inmunohistochemics, confirm the diagnosis. We present the case of a patient that I debut with frank hematuria, hemodynamic uncertainty and renal inadequacy that it required combined treatment, doctor and surgical for the resolution of their square.

[Myofibroblastic tumor of bladder]. / Tumor miofibroblástico de vejiga.

The myofibroblastic tumor, is a mesenchymal benign tumor of exceptional character, being its localization but habitual it is the lung; while its appearance in the bladder, is exceptional, not existing but of 100 published cases, of this tumor type in the bladder. This tumor type that clinic and radiologics, behave as a wicked tumor. The pathological diagnosis is complex, due to its similarity with the sarcomas, being necessary to appeal to the inmunohistochemics for a I diagnose of certainty. The treatment by means of wide resection is usually enough not existing any case of metastasis at the present time at distance, neither of malignization. We present a new case of this neoplasm, carrying out a wide bibliographical revision.

[Treatment with sildenafil of cold glands syndrome after inflatable penile prosthesis]. / Tratamiento con sildenafilo del síndrome de glande frío tras implante de prótesis hidráulica de pene.

OBJECTIVE: To evaluate the effect of sildenafil on the response of glans penis during sexual intercourse in patients with penile prosthesis who show cold glans syndrome symptoms. MATERIAL AND METHODS: Fourteen patients who had undergone three-piece inflatable penile prosthesis implantation were evaluated. In spite of the normal functioning of the device all of them complained of a degree of dissatisfaction during SI due to a lack of engorgement in the glans penis. The patients were advised to have a dose of 100 mg VO sildenafil about 45 minutes before activating the PP and starting SI. All of them followed this scheme at least three times. They ticked questions 7, 8, 13 and 14 of the International Index of Erectile Function (IIEF) questionnaire with/without having had sildenafil. RESULTS: Twelve out of thirteen patients (85.7%) indicated a more pleasant SI on sildenafil. It was related to an increase in penile glans engorgement and sensitivity. The scores obtained in the IIEF questions showed a significant increase on taking sildenafil. The partners also talked of a more comfortable SI that they related to a less painful penetration. Sildenafil-related morbidity was not found. CONCLUSIONS: Sildenafil could be used to improve functional results of the penile prosthesis in those patients with CGS and seems to increase satisfaction during SI.

[Complications of inguinal lymphadenectomy for penile carcinoma. Origin, management, and prevention]. / Complicaciones en las linfadenectomías inguinales por carcinoma del pene. Origen, manejo y prevención.

Since inguinal lymphadenectomy (LFD) technique in the treatment of epidermoid carcinoma of the penis was first described, control of its high mobility has been one of the concerns for oncological urologists. Our group has reviewed the complications of 21 inguinal LFDs performed since 1982 in our centre and found that two thirds of these procedures had at least one complication, the most frequent being lower limb lymphedema (28.5%) among those appearing late, and healing alterations (38%) together with fluid collections or persistent lymphorrhea (33.3%) among the early ones. Other complications were infection, local recurrence and haemorrhage of the femoral vessels. Most authors agree on the high morbidity of this technique. We highlight the origin, management and prevention of each of these complications so as to reduce their frequency while placing inguinal LFD in its real position within the therapeutic approach of epidermoid carcinoma of the penis.

[Effectiveness of transrectal ultrasonography in local staging of prostatic cancer]. / Eficacia de la ecografía transrectal en el estadiaje local del cáncer de próstata.

OBJECT: To evaluate the value of rectal examination, transrectal ultrasound and their association in patients with prostate cancer undergoing radical prostatectomy. MATERIAL AND METHODS: Retrospective study on 56 patients who underwent radical prostatectomy between 1995-1995, mean age 63.2 +/- 10 years, to compare local clinical staging of extracapsular dissemination and seminal vesicle invasion performed by rectal examination and transrectal ultrasound with pathological findings in the prostatectomy specimens. The sensitivity, specificity, VPP, VPN, accuracy and percentage of under- and over-staged patients were assessed. RESULTS: Prevalence of locally advanced disease was 48%. Sensitivity to detect extracapsular dissemination was significantly higher with ultrasound (38%) than rectal examination (6%). Association of both techniques increased the sensitivity (50%) though not significantly; sensitivity to detect vesicle invasion was very low (14%). Accuracy of ultrasound to establish an overall definition of the local stage was 66%, but 59% patients with locally advanced disease were understaged and only 10% patients with localized disease were overstaged. CONCLUSIONS: Transrectal ultrasound showed low sensitivity to define the locally advanced disease mainly at the seminal vesicle level, with acceptable specificity. Overall evaluation of findings with RE and TRU increase discreetly the efficacy of prostate capsule staging.

[Conservative surgery in renal adenocarcinoma]. / Cirugía conservadora en el adenocarcinoma renal.

Conservative surgery in renal adenocarcinoma has originated a growing interest over the last few years for several reasons: 1. Refinement in renal imaging techniques. 2. Improvement in surgical techniques. 3. Greater number of tumours discovered incidentally usually at low stage, and 4. Good long-term results in patients treated this way. We conducted a retrospective analysis of 8 patients diagnosed with renal adenocarcinoma and treated with conservative surgery over a 5-year period, between January 85 and December 90. Complete tumour removal by enucleation was achieved in all patients, with low morbidity rates since only 1 patient had to be re-operated due to late haemorrhage. Since follow-up is short in most patients, no long-term results are provided. We conclude that enucleation is a simple technique which allows complete removal of small size renal adenocarcinoma with low morbidity and no mortality.

[Morbidity of and tolerance to ultrasonography-guided transrectal biopsy of the prostate]. / Morbilidad y tolerancia de la biopsia transrectal ecodirigida de la próstata.

OBJECTIVE: The objective of the study is to evaluate the infectious complications of the ultrasound-guided prostate transrectal biopsy using two different antibiotic prophylactic regimes. Also, patient tolerance to ultrasound-guided transrectal biopsy is assessed. METHODS: Prospective study in 100 patients randomized to antibiotic prophylaxis with Pefloxacin (800 mg as single dose) versus Ciprofloxacin (250 mg/8 h/72 h). Tolerance data collection was done through completion of a questionnaire immediately after biopsy. RESULTS: Out of the 92 patients eligible for the study, 44 (48%) were assigned to Pefloxacin and 28 (52%) to Ciprofloxacin. In-house validation indicated both groups were matched. 90% patients showed good tolerance to the ultrasound technique and 81.5% patients to the transrectal biopsy. 31.5% patients presented no post-biopsy events; among the remaining only one patient (1%) required medical care and hospitalization. No patient had infectious complications. CONCLUSIONS: Prostate transrectal ultrasound and transrectal prostate biopsy was an approach well tolerated by most (81.5%) patients studied. Percentage of major complications was very small (1%), while post-biopsy events (haematuria, rectorrhage, etc) which do not require medical care should be considered not as complications but as effects intrinsic to the approach itself. Antibiotic prophylaxis whether with Pefloxacin or Ciprofloxacine was highly effective, although Pefloxacin is preferred due to its single dose administration and lower cost.

[Comparative study of duplex Doppler ultrasonography and dynamic cavernosometry by infusion in the diagnosis of arteriogenic impotence]. / Estudio comparativo entre eco-doppler duplex y cavernosometría dinámica por infusion en el diagnóstico de impotencia arteriogénica.

The findings of duplex doppler ultrasonography (DDU) of cavernous arteries (CA) and of dynamic infusion cavernosometry in 61 patients who underwent both diagnostic procedures were examined. Our work consisted in comparing the blood flow velocity in the CAs during the systolic peak, as measured with DDU, with the gradient CA occlusion pressure/mean brachial blood pressure and in attempting to determine whether there was a correlation between both measurements and whether patients were similarly classified by both methods. The results of each examination separately were also compared with the response to isolated injection of intracavernous drugs (ICI). Of the 61 patients, 56 were eligible for the study as 5 patients were excluded owing to a massive venous leak. A 78.6% of the patients were categorized similarly by both diagnostic methods. The correlation coefficient between both methods for the 56 evaluable patients was R = -0.756, implying a statistically significant correlation between the two measurements (p < 0.0001). The sensitivity, specificity and predictive value of a positive test as regards the response to the ICI of vasoactive drugs in both diagnostic methods showed very similar values in our sample. We conclude that both methods--the Doppler Ultrasonography and the measurement of the occlusion pressure of the cavernous arteries--are equally valid for assessing the arterial function of the cavernous bodies in erection. If we consider that the erectile function of the penis consists in storing energy in the form of pressure and that this pressure is supplied by the cavernous arteries, from a physiological point of view, it is more consistent to measure the pressure in these arteries.

[Obstructive uropathy in Gardner syndrome: a new case and an alternative therapeutic option]. / Uropatía obstructiva en el síndrome de Gardner: un nuevo caso y otra opción terapéutica.

Gardner's Syndrome comprises numerous pathological entities, one of which is the intraabdominal desmoid tumour which can provoke obstructive uropathy through ureteral trapping. Contribution of one case treated with resection of the trapped ureter, reanastomosis and plasty with peritoneal flap. Discussion of the diagnosis, evolution, and the different therapeutical choices found in the literature.

[Complications of radical nephrectomy in the treatment of kidney adenocarcinoma]. / Complicaciones de la nefrectomía radical en el tratamiento del adenocarcinoma de riñón.

PURPOSE: To evaluate the peri- and post-surgical complications in Renal Adenocarcinoma (RAC) treated with Radical Nephrectomy (RN). MATERIAL AND METHOD: Revision of 109 patients with RAC who underwent transperitoneal anterior abdominal RN. Patients were locally staged post-surgically as: T1 + T2 61.5%, T3a 22.9%, T3ab 11% and T3b 4.6%. Approach and conservation of homolateral suprarenal gland were decided based on the preferences of the performing urologist. Hilar lymphadenectomy was performed in all cases. RN was done by a staff member in 77% cases and by a training resident assisted by a staff member in the remaining 23%. RESULTS: Peri-operative complications occurred in 10% patients, most commonly with left RN (13% vs. 7%) (p = 0.1), and further within this group the most frequent ones occurred in those using midpoint laparotomy (17.8% vs. 4%) (p = 0.1). Blood transfusion during surgery was required in 23% patients, this being more frequent when tumours had extended into the venous system (47%) and in left RN by midpoint laparotomy (39% vs. 12.5%) (p = 0.02). There were 32 post-surgical complications in 27 (24.8%) patients, the most common being sepsis of the surgical wound (6.4%); complications were more usual in patients undergoing right RN (31% vs. 20%) (p = 0.08) and in patients with blood transfusions (40% vs. 20%) (p = 0.4). There were no deaths. CONCLUSIONS: In our series, RN showed low intraoperative morbidity (10%), non-insignificant post-operative morbidity (24.8%) and no mortality. We consider subcostal laparotomy to be the best surgical approach in left RAC, with low morbidity and low peri-operative blood requirements.

[Endourologic treatment of ureteral ruptures in closed abdominal trauma]. / Tratamiento endourológico de las roturas ureterales en traumatismos abdominales cerrados.

The traumatic fracture of the ureter is a very uncommon entity, which accounts for 1-5% of all urological traumatism. In most cases it is secondary to penetrating lesions, endoscopic or open surgery iatrogeny, its occurrence as secondary to closed traumatism being very rare. The paper presents four patients with partial ureteral fractures caused by closed traumatism. Management was in all cases conservative with endourological methods, using backward ureteral intubation, and no case required the use of other types of complementary surgical approaches; functional recovery of urinary tract was complete in all four patients.

[Multicentricity in renal adenocarcinoma: its incidence and the therapeutic implications]. / Multicentricidad en el adenocarcinoma renal: incidencia e implicaciones terapéuticas.

Unsuspected multicentricity in single Renal Adenocarcinoma (RAC) together with the prospects of incomplete neoplasia removal are the 2 major disadvantages for the acceptance of traditional renal surgery in birenal carriers of medium size, low grade single RAC. This paper is a retrospective review of our series of RAC patients who underwent radical nephrectomy between January 1986 and October 1994 with the following purpose: 1) To evaluate our incidence of unsuspected multicentricity. 2) To evaluate the characteristics of such multicentricity. 3) To evaluate, in the assumption that traditional surgery had been indicated for patients with small size RAC, in how many patients tumoral resection would have been incomplete due to existence of satellite tumoral nodes in the preserved renal parenchyma. Of 110 patients undergoing radical nephrectomy, 11.8% (13/110) had unsuspected multicentricity. In 10 patients there was multiple satellite nodes with size ranging from 0.3 to 3 cm. We conclude that there is not relationship between multicentricity and size or stage of primary tumour and that, by applying strict criteria (size, location, well defined tumoral wall and form of presentation) to select the patients who can be candidates to traditional renal surgery, the probability to perform it in patients with multicentric RAC would be considerably reduced.

[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.

[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.

[Neurostimulation and neuromodulation in urinary incontinence]. / Neuroestimulación y neuromodulación en la incontinencia urinaria.

Electric stimulation in Urology has undergone considerable development since the 1970s. The implantation methods for urinary system stimulation are used for bladder emptying in neurogenic bladders (Neurostimulation) or the modulation of the electrical transmission of the voiding cycle caused by chronic detrusor-sphincter dysfunction (Neuromodulation). Both techniques have in common the direct stimulation of the sacral roots, responsible for the urinary reflex arc. The first of them works via external stimulation over an implanted antenna, and the second via permanent stimulation through an implanted pacemaker. We review in this article the indications, technique and results of both therapies, specially focused on the Spanish experience.

[Urinary tract infections and their prevention]. / La infección urinaria y su prevención.

CONTEXT: This article reviews diverse aspects of the prevention of urinary tract infections, including confirmation of the diagnosis, application of hygiene and dietary measures, antibacterial prophylaxis (preferably consisting of a single nocturnal oral dose per day of an antibiotic or drug with high urinary excretion and good tolerance), and administration of vaccines made with Escherichia coli and other Gram-negative bacilli, consisting of immunostimulating fractions of E. coli strains or E. coli type-1 fimbriae administered through the parenteral or oral route. OBJECTIVE: We aimed to review the new preventive measures against urinary tract infections. ACQUISITION AND SYNTHESIS OF EVIDENCE: We reviewed various microbiological aspects, as well as the physiopathology and virulence factors of uropathogenic E. coli strains expressing type-1 and P fimbriae. The association between blood groups and urinary tract infections in blood group antigen-secretors and nonsecretors was analyzed. CONCLUSIONS: New preventive measures against urinary tract infection consist of the use of phenol-inactivated vaccines administered via the mucosal route, inhibitors of bacterial adherence and biofilm formation and cyclic adenosine monophosphate stimulators, especially in women aged between puberty and menopause, who show the highest incidence of these infections.

[Current status of neurostimulation and neuromodulation for vesicourethral dysfunction]. / Estado actual de la neuroestimulación y neuromodulación para la disfunción vésicouretral.

OBJECTIVE: To describe the current indications, techniques and results of sacral root stimulation in patients with spinal cord lesions as a treatment for patients with high pressure bladders and/or urinary incontinence despite conservative management, as well as sacral root neuromodulation with permanent stimulators for complex bladder dysfunction: vesical instability, sensory urgency, chronic pelvic pain and chronic voiding dysfunction. METHODS/RESULTS: The literature is reviewed, both techniques are described and the results of the most significant series are discussed, with special reference to the first groups that utilized these techniques. CONCLUSIONS: There is ample experience in the application of sacral root electrical stimulation. The reported results are comparable with those achieved by other treatments, such as augmentation cystoplasty. Neurostimulation and neuromodulation techniques are simple, the complications are minimal and they do not prelude the use of other therapies.

[Electric stimulation of sacral roots for the treatment of urinary incontinence due to detrusor instability: application of a technique and results in a clinical case]. / Estimulación eléctrica de raíces sacras para el tratamiento de la incontinencia urinaria por inestabilidad del detrusor: inicio de una técnica y resultado en un caso clínico.

OBJECTIVE: To describe a case treated with a new technique in our therapeutic algorithm for non-neurogenic vesicourethral dysfunction. METHODS/RESULTS: A 47-year-old female underwent retropubic urethropexy for stress urinary incontinence. She remained incontinent due to detrusor instability to a degree that was socially unacceptable. After conservative treatment had failed, a percutaneous electrode was applied to the sacral nerve root and she received electrical stimulation of 4-6 milliamperes, 15 Hz and 200 microseconds duration for 7 days. Incontinence remitted for as long as 3 months after the electrode had been removed. CONCLUSION: The results achieved with sacral nerve electrical stimulation reported in the literature and our results support the use of this technique in urological clinical practice.

[Clinical and neuro-urodynamic assessment of radical prostatectomy]. / Evaluación clínica y neuro-urodinámica de la prostatectomía radical.

OBJECTIVES: To study the clinical and urodynamic parameters after radical prostatectomy in order to standardize the management of these patients in the medium-term. METHODS: 35 cases submitted to radical prostatectomy from February, 1989 to March, 1994 were retrospectively evaluated clinically and urodynamically using a clinical questionnaire, free flowmetry, cystometry, pressure/flow voiding test with simultaneous videocystography and sacral-evoked potentials. The mean age was 65 years and mean follow-up was 14 months. RESULTS: 80% (28) were continent or minimally incontinent on exertion, 9% (3) required the use of some absorbent system and 11% (4) were completely incontinent and required the use of a collecting system. No statistical differences were observed between continence status and tumor stage, patient age or neurovascular preservation. Overall the urodynamic parameters fell within the normal ranges, except for a reduced maximum cystometric capacity. A significant difference (p = 0.05) was found in those patients with significant incontinence vs those who did not for maximum free flow, which disappeared on flowmetry with transducer catheter. Seventy per cent of the incontinent cases were evident on evaluation; 60% had stress incontinence and 40% had instability waves with differential pressure over 80 cm H2O. Six per cent met the criteria for obstruction, whose localization was done during videocystography. Eleven per cent showed non inhibited contractions and 6% showed diminished bladder compliance. The sacral reflex arch was normal in all patients. CONCLUSIONS: The urodynamic study was found to be normal in the majority of patients submitted to radical prostatectomy; therefore performing the study routinely is not justified. However, incontinent patients and those with disturbances on free flowmetry may show incontinence due to instability or obstruction of the urethrovesical junction. We therefore advocate performing a complete study on all patients with significant incontinence and free flowmetry for the rest at least three months after surgery and a complete study should be done if disturbances are found.