[Fournier gangrene: evaluation of prognostic factors in 90 patients]. / Gangrena de Fournier: estudio de los factores pronósticos en 90 pacientes.

INTRODUCTION: This study evaluates the risk factors and prognostic variables that affect survival of patients with gangrene of Fournier. MATERIAL AND METHODS: The study retrospectively analyzed 90 consecutive patients with gangrene of Fournier treated in our institution between 1975 and 2008. We evaluated the average age, associated systemic diseases, and the source, time of evolution and extent of necrotizing fasciitis. The outcomes were assessed according to whether the patient survived or died. All patients had aggressive surgical debridement, and received parenteral antibiotic therapy. RESULTS: The mortality rate was 34.4%. The mean age was 63.0 years (range 33-95), a statistically significant difference was found between the age of the survivors (median age, 59.84 years) and those who died (median age, 70.20 years) (p = 0.001). Medical comorbidities were identified in 51 patients; the death rate was higher in patients who had any medical disease, especially those who suffered from cancer. Although diabetes mellitus was the most common associated pathology, it was not related to a statistically significant worst prognosis. The source of the infection was identified in 62 patients, who showed a higher mortality (p = 0.015), the mortality rate when a urological source is identified was 50%. Moreover, patients suffering from a more extensive necrotizing infection showed a worst prognosis. CONCLUSIONS: The gangrene of Fournier has a high mortality rate. Large series are required to study prognostic variables of this disease. The patient age, the presence of systemic risk factors, especially cancer, a urological source of infection and the extent of the disease have impact on the prognosis of Fournier's gangrene.

[Staphylococcus aureus prostatic abscess and subdural empyema: a case report]. / Absceso prostático por Staphilococo aureus y empiema subdural: presentación de un caso.

INTRODUCTION AND OBJECTIVES: To report one case of prostatic abscess and subdural empyema by Staphylococcus aureus. METHODS: We describe the case of a 51 year old male patient who was diagnosed of prostatic abscess and subdural empyema by Staphilococcus aureus. We use clinical presentation and physical exploration based on rectal digital examination, as diagnostic approach method. And computerized axial tomography and transrectal ultrasonography, which allows the guided needle drainage of the abscess, as diagnostic confirmation methods. RESULTS: The clinical picture resolved with the transrectal ultrasonography guided needle aspiration of the abscess and conservative treatment with antibiotics and urinary diversion. CONCLUSIONS: Prostatic abscess is an uncommon entity nowadays. Provided the great variety of symptoms, a great degree of clinical suspicion is needed for the diagnosis, and once it is got it, immediate aggressive treatment must be initiated. Transrectal ultrasonography allows not only the diagnosis, but also the drainage of the abscess. The culture of the obtained material identifies the etiological agent and the most specific antibiotic therapy.

[Endoscopic modified technique of ureteral resection during nephroureterectomy]. / Modificación técnica de la desinserción ureteral endoscópica en la nefroureterectomía.

We show a technical modification of the ureteral endoscopic resection with which we try to avoid comunication between urine and surgical bed in order to prevent tumor local spread of upper urotelial tumor.

[Clinical usefulness of the ImmunoCyt urinary test in the follow-up protocol of patients with urothelial neoplasms]. / Utilidad clínica del test urinario ImmunoCyt en el protocolo de revisiones de pacientes con antecedentes de neoplasia uroteliales.

OBJECTIVES: The overall objective of this study was to carry out a prospective investigation of the usefulness of the IMMUNOCYT commercial kit in the follow-up of patients treated for bladder cancer and to evaluate its utility as a complement to urinary cytology and a possible tool for reducing the number of follow-up cystoscopies required. SUBJECTS AND METHODS: From September 2001 to December 2002, the ImmunoCyt test and urinary cytology were performed in urine simples from a total of 136 patients (115 with a history or suspicion of bladder cancer and 21 patients with other urological pathologies). Urine simples were fixed with an equal volume of 50% alcohol. Urinary cytology and the ImmunoCyt test were interpreted by a cytopathologist unacquainted with the result of the corresponding cytology and bladder biopsy report. Samples were staged and graded using the 1997 TNM classification of the UICC and the 1998 WHO/ISUP classification. Histopathological confirmation of lesions was available for 111 patients (81.6%). RESULTS: The gender distribution was 89% men and 11% women. Mean age was 71.68 years (range 27 to 98 years). Overall sensitivity and specificity were 77.9% and 92.3% for the ImmunoCyt test and 47.9% and 100% for urinary cytology, respectively. The positive (PPV) and negative predictive values (NPV) were 96.4% and 61.7%, respectively, for the ImmunoCyt test and 100% and 36.7% for cytology. In Ta and low-grade carcinomas, the sensitivity of the ImmunoCyt test was 70% (n=20) and 76.4% (n=34) respectively, whereas it was 25% (n=28) and 29.7% (n=37), respectively, for urinary cytology. The differences observed between the sensitivities of the ImmunoCyt test and cytology were statistically significant (X2 p<0.05) overall and for Ta and low-grade carcinomas. The sensitivity and specificity of the combination of both tests were 86.8% and 96.2%, respectively. The sensitivity of the combination of both tests for Ta and low-grade carcinomas was 80% (n=20) and 82.3% (n=34), respectively. The ImmunoCyt test was diagnostic in 36.2% of tumors overall. CONCLUSIONS: In view of the results obtained, we decided to change our follow-up protocol to reduce the number of follow-up cystoscopies by 32.2% in the first 5 years of postoperative follow-up (in a cohort of 140 patients who undergo surgery annually). This benefits patients by reducing the number of urinary infections and iatrogenesis originated by follow-up cystoscopy. In addition, this 32.2% reduction in the number of cystoscopies in 5 years will yield a savings of approximately 35,560 EUR to the health care system in 5 years.

[Ileal neobladder with double chimney. Ureterointestinal anastomosis]. / Neovejiga ileal con doble chimenea. Anastomosis ureterointestinal.

Radical cystoprostatectomy is accepted as the standard treatment for muscle-invasive bladder cancer. During last years the indications for orthotopic neobladders have increased due to their advantages over other kind of diversions. Hautmann neobladder is one of the most commonly used. Several modifications have been later described. For example, after perform the W-shape pouch ureters can be anastomosed to a not-detubularized bowel segment (chimney modification). Here is described a modification of the Hautmann neobladder with two chimneys. Each ureter is spatulated in a golf club manner and anastomosed to the open end of each bowel loop. This kind of anastomosis provides several advantages. It is possible to use shorter ureteral segments by increasing the length of bowel used. It allows an anastomosis without tension, and less ischemia so the risk of stenosis and fistula is decreased. It is not necessary to perform additional enterothomies and in case of reintervention it is easier to access each anastomosis without damaging the other one.

[Primary adenocarcinoma of the urinary bladder: our experience]. / Adenocarcinoma vesical primario: nuestra experiencia.

Adenocarcinoma of the bladder is an uncommon neoplasm. Depending on its origin it is classified in: primary, secondary and urachal. Generally it grows to the density of the wall, so its clinical appearence is delayed, with the subsequent delayed diagnosis and although an agressive treatment is performed, it frequently has a very bad prognosis. Since there are very few publications of this kind of neoplasm in the literature the lines of actuation in this pathology are not well established. We report the eleven cases of adenocarcinoma neoplasm of the bladder treated in our centre and review the literature.

[Bilateral brucellosic psoas abscess: one case is related and literature review]. / Absceso de psoas brucelósico bilateral: presentación de un caso y revisión de la literatura.

The Brucellosis is a zoonotic and unfrequent infection but it is endemic in Spain. It is a well documented cause of fever of unknown origin with varied and nonspecific symptoms. The onset of symptoms of brucellosis may be abrupt or insidious, developing over several days to weeks. Virtually any organ system can be involved with brucellosis and localization of the process may cause focal symptoms. The most frequent focal presentation is the osteoarthicular. Some times it can complicates with para-perivertebral abscess. The unilateral psoas abscess(PA) is uncommon and the bilateral afection is exceptional. The manifestations of PA usually are insidious, the classic tiad of: feber, lumbar pain and functional impotence is rare. For the diagnosis the serology c tests and cultures are necesary. The imaging techniques like: Ultrasonography and Tomography have improved the diagnosis and treatment of this pathologies' complications. The recommended therapy is the use of doxycicline and streptomicine. Some times the use of percutaneous drainage or open surgery is necessary.

[Renal injuries: diagnosis and current management]. / Traumatismos renales: diagnóstico y manejo actual.

Abdominal trauma is relatively frequent and around 5% of the cases correspond to renal trauma. At present, a large percentage of cases can be managed conservatively. Generalised use of CT and cumulative experience have defined the cases that can be treated with good prospects. The currently accepted indications for imaging techniques and the most frequent ratings used are described. Similarly, the indications for surgical renal examination are listed and the principles for renal reconstruction described in the most recent publications of the most experienced medical centres.

[Reutilization of a transplanted kidney by a 2nd receptor]. / Reutilización de un riñón trasplantado por un 2o receptor.

Contribution of what we believe to be the first case of successful reutilization of the same renal graft by a second receptor after functioning for some time in other patient. Transplantectomy was performed 8 days after initial RT, subsequent to the recipient suffering a fatal AVC. The purpose of this paper is to underline the sequence and technical methodology of this procedure which may become a resource to be taken into account in similar cases.

[Ureterointestinal anastomosis in ileal conduit in single kidney. New surgical technique]. / Anastomosis ureterointestinal en conducto ileal en monorreno. Nueva técnica quirúrgica.

Introduction of a new approach for uretero-ileal implantation when only one kidney is available. The technique follows the same approach as the Wallace-type re-implantation but in this case the uretero-ileal anastomosis plate is formed with the far en 2-3 cm of ureter. All cases performed with this technique have been highly successfull as reported in this clinical account.

[Cadaver kidney grafts from donors over 60 years of age should be considered as suboptimal]. / Los injertos renales de donantes cadáver mayores de 60 años deben ser considerados subóptimos.

Considering the scarcity of organs for transplantation, one possible solution is the use of grafts from aged donors (over 50 years). We have reviewed our experience in the case of kidney transplantation considering the period from 1989-1994 in order to attain a minimum follow-up of 36 months. We compare three groups: donors aged between 50-60 years (n = 32), donors aged over 60 years (n = 25) and a control group formed by donors of "ideal" ages. The results show that kidneys from donors over 60 years evidence, as compared to the control group, a higher incidence of acute tubular necrosis (p = 0.032), significantly higher blood creatinine levels in all the intervals considered, and a graft survival which is 14% less at 12 months and 40% less at 36 months (p = 0.0009). These differences are most probably to be attributed to the changes caused in these organs by advancing age and by previous pathological situations, as we have not detected a higher incidence of immunologic or surgical complications.

[Hydatid cyst and renal adenocarcinoma: an exceptional association]. / Quiste hidatídico y adenocarcinoma renal: una asociación excepcional.

Presentation of one case of an exceptional association in the same renal unit of a hydatid cyst and an adenocarcinoma, in a female patient who arrived to the emergency service with a picture of haematuria and lower back pain. The paper discusses the diagnostic complications posed by the large central necrotic component of the tumour, the adjacent position of both lesions and, basically, the initial intention of performing conservative surgery after it was demonstrated that the patient had mild renal insufficiency and simple cysts in the other kidney. In the end, faced with the perioperative finding of a neoplastic-like mass, radical surgery was performed. Analysis of the diagnostic and therapeutical difficulties with complex cystic masses in general.

[Clinico-pathologic study of renal cell carcinoma]. / Estudio clínico-patológico del carcinoma de células renales.

Renal cell carcinoma (RCC) is an uncommon tumour with high mortality mainly due to late diagnosis. The various morphological variables and the clinico-pathological stage, however, induce highly different evolutions. Awareness of these characteristics would be a significant part of deciding the most appropriate therapy for each case. The pathological anatomy of 130 renal cell carcinomas obtained through nephrectomy was reviewed. A follow-up of at least 5 years was done in 121 patients. Also, a survival study related to the various clinical and pathological parameters was carried out. A significantly lower survival rate was observed for solid tumours with spindle or giant cells and nuclear degrees superior to 2, over 10 mitosis in 10 fields and staging higher than II. A significant correlation was also found between number of mitosis and staging, presence of metastatic disease, survival interval, degree of tumoral necrosis, histological type, cell type and nuclear grade. Our results indicate that staging, histological type, cell type, microscopic vascular infiltration, nuclear grade and number of mitosis can be highly predictive of the evolution and prognosis of RCC patients.

[Intradiverticular bladder tumors]. / Tumores vesicales intradiverticulares.

Retrospective study conducted on 58 patients with vesical diverticulum seen in our unit between 1975 and 1992, of which a total of 11 (18.9%) patients had vesical tumours. Of these, 6 (10.3%) were intradiverticular and 5 (8.6%) extradiverticular. Sixty-six percent of patients with intradiverticular tumours also had prior or concurrent history of extradiverticular vesical tumours. The most frequent clinical presentation was gross haematuria. The abdomino-pelvic CT is the most sensitive morphological examination although in 33% cases it resulted in overstaging. Curative treatment was only possible in the 4 patients with urothelial tumours, in whom 3 partial cystectomies with pelvian lymphadenectomy (2 pT1 G2 and 1 pT3 G3) and 1 TUR (T1 G2) were performed. The 2 (33%) remaining patients had advanced locoregional epidermoid carcinoma (T4 N+). All patients with urothelial carcinoma are alive with follow-up ranging between 6 months for the one infiltrant case and 136 months for a surface tumour undergoing partial cystectomy. Prognosis for both epidermoid carcinoma was ominous with mean survival time of 9 months. Review of the literature and discussion of epidemiological, clinical, diagnostic, therapeutic and prognostic issues.

[Leukemoid reaction as a paraneoplastic manifestation of bladder carcinoma]. / Reacción leucemoide como manifestación paraneoplásica del carcinoma vesical.

Sometimes vesical malignant tumours present themselves with highly characteristic paraneoplastic signs like hypercalcemia, or more rarely like a leukaemoid reaction within the symptomatic setting typical of vesical neoplasia. We present a case of vesical urothelioma where the leukaemoid reaction was present in the diagnosis and later in the tumour relapse after the appropriate treatment.

[Wilms tumor of the adult. Description of a case and review of the literature]. / Tumor de Wilms del adulto. Descripción de un case y revisión de la literatura.

Wilms tumour is an infantile neoplasia with low incidence in adults. Worldwide literature describes 260 cases but only 50 meet the diagnostic criteria described by Kilton. This paper presents one case diagnosed in our service and includes a review of the literature.

[Melanoma in urology: our experience and review of the literature]. / El melanoma en urología: nuestra experiencia y revisión de la literatura.

Melanomas make up 2% of all body tumours, but the figure is increasing mainly in countries with longer sun hours daily. Genitourinary location is even more infrequent. That explains our clinical report when we discovered the three cases seen in our unit, one in a female urethra, one suprarenal and the third one in the bladder.

[An analysis of the prognostic factors in renal-cell carcinoma]. / Analisis de factores pronósticos en el carcinoma de células renales.

OBJECTIVES: The study proposes the analysis of the influence of gross, microscopical and clinical pathoanatomical prognostic factors in the survival of patients with RCC through univariance and multivariance statistical analysis, and its global evaluation as a predictive model. PATIENTS AND METHOD: The study involved 218 RCC cases operated on over 20 years, with a mean follow-up of 60 months. RESULTS AND CONCLUSIONS: All prognostic factors studied have a significant influence on the survival. When studied jointly, they include separately and in order of significance the metastatic involvement, mitotic index, cava vein involvement, nuclear grade and sarcomatoid histologic pattern. Also, we confirm that considered jointly they conform a valid predictive model.

[Apoptosis in renal adenocarcinoma. Expression of bcl-2 in locally confined tumors]. / Apoptosis en el adenocarcinoma renal. Expresión de bcl-2 en tumores localmente confinados.

INTRODUCTION AND OBJECTIVE: Bcl-2 is a proto-oncogene known to be a negative regulator of apoptosis, whose expression conferring prolonged cell survival and contributing to tumorigenesis. Inconsistent results concerning bcl-2 expression and the frequency of apoptosis were noted in renal cell carcinoma. To investigate a possible role of bcl-2 protein in renal cell carcinomas, we analyzed its expression and relationship with clinical and pathological parameters, including prognostic impact. METHODS: 58 patients diagnosed of renal cell carcinoma stage pT1, pT2 and pT3a N0 M0 (TNM 1997) were treated by radical or partial nephrectomy. We analyzed clinical and pathological parameters including bcl-2 expression in paraffin-embedded tumor samples using immunohistochemical technique. RESULTS: Bcl-2 immunopositivity was detected in 44/58 of the samples in different grades of intensity. There was no correlation of nuclear grade, tumoral size, stage or recurrency with bcl-2 immunopositivity. Bcl-2 expression was not related to prognosis if we divided all cases into subgroups according of stain intensity. CONCLUSIONS: Bcl-2 expression was not related with any pathological parameters; size, nuclear grade and stage or prognostic.

[Tumor pathology in horseshoe kidney]. / Patología tumoral en el riñón en herradura.

Within renal aberrations, the most frequent one is the horseshoe kidney. Adenocarcinoma is the most common primary renal neoplasia. The association of tumour and horseshoe kidney is uncommon, with only 135 cases described in the literature. Presentation of 4 patients with tumours in horseshoe kidney: 3 adenocarcinoma and one urothelial tumour of renal pelvis. As a result of our experience we consider that arteriography is a key imaging technique for pre-operative study of these patients, medial laparotomy being the choice access for approach, and prognosis depending on tumour staging, with no influence from the malformation.