Giant adrenal carcinoma associated with renal vein and inferior vena cava thrombus. Case report and literature review.

OBJECTIVE: To present a case of giant adrenal carcinoma associated with renal vein and inferior vena cava (IVC) thrombus. Up to now, there is no similar case reported in the national literature. METHODS: 75 year old woman with signs of virilization. CT-scan showed an 18 cm adrenal mass with venous thrombus and possible pulmonary metastases. The working diagnosis was primary suprarenal carcinoma. RESULT: Due to elderly age and advanced stage, including metastasis, we decided to not perform surgery, and initiate chemotherapy. CONCLUSIONS: Adrenal Cancer is an infrequent and very aggressive tumor. Surgery is the only curative treatment. In advanced stages chemotherapy is recommended, but with poor results.

Evaluation of teleconsultation system in the urological patient during the COVID-19 pandemic. / Evaluación de la teleconsulta en el paciente urológico durante la pandemia COVID-19.

INTRODUCTION: The global pandemic of COVID-19 has led to rapid implementation of telemedicine, but there is little information on patient satisfaction of this system as an alternative to face-to-face care. OBJECTIVE: To evaluate urological patient satisfaction with teleconsultation during the COVID-19 pandemic. MATERIAL AND METHODS: Observational, prospective, cross-sectional, non-interventional study carried out by telephone survey during the period considered as the peak of the pandemic (March-April 2020). A quality survey composed of 11 questions on urological care provided by physicians during the COVID-19 pandemic was conducted, selecting a representative sample of patients attended by teleconsultation. RESULTS: Two hundred patients were contacted by telephone to answer a survey on the quality of teleconsultation. The distribution of patients surveyed among the specialized consultations was homogeneous with the number of consultations cited in the period; 18% of them required assistance from family members. Sixty percent of patients avoided going to a medical center during the pandemic. Of the surveyed patients, 42% had cancelled diagnostic tests, 59% had cancelled medical consultations, 3.5% had cancelled treatments and 1% had cancelled interventions. Ten percent reported a worsening of urological symptoms during confinement. According to physicians, consultations were effectively delivered in 72% of cases, with teleconsultation being carried out by their usual urologist in 81%. Teleconsultation overall satisfaction level was 9 (IQI8-10), and 61.5% of respondents consider teleconsultation as a «health care option¼ after the healthcare crisis. CONCLUSION: Teleconsultation has been evaluated with a high level of satisfaction during the COVID-19 pandemic, offering continuous care to urological patients during the healthcare crisis. The perceived quality offers a field of optional telematic assistance in selected patients, which should be re-evaluated in a period without confinement measures.

Comparative genomics of Listeria species.

Listeria monocytogenes is a food-borne pathogen with a high mortality rate that has also emerged as a paradigm for intracellular parasitism. We present and compare the genome sequences of L. monocytogenes (2,944,528 base pairs) and a nonpathogenic species, L. innocua (3,011,209 base pairs). We found a large number of predicted genes encoding surface and secreted proteins, transporters, and transcriptional regulators, consistent with the ability of both species to adapt to diverse environments. The presence of 270 L. monocytogenes and 149 L. innocua strain-specific genes (clustered in 100 and 63 islets, respectively) suggests that virulence in Listeria results from multiple gene acquisition and deletion events.

A new approach to laparoscopic implantation of the artificial urinary sphincter: Vesicovaginal approach to the bladder neck. / Nueva aproximación al implante laparoscópico del esfínter urinario artificial: abordaje vesicovaginal al cuello vesical.

INTRODUCTION: The artificial urinary sphincter (AUS) is not used extensively in the treatment of female urinary stress incontinence (USI) due to the poor reproducibility of the techniques used. We describe a new approach to laparascopic implantation, of which dissection of the vesicovaginal space is an essential step. This enables an approach under direct vision to the posterior surface of the bladder neck. MATERIAL AND METHODS: We present two cases where this approach was used. A transperitoneal approach was made in the Trendelenburg position. The main steps were: creating the vesicovaginal space until identifying the bladder neck, creating two laterovesical spaces, communicating these with the vesicovaginal space, and dissecting the anterior surface of the bladder neck, attempting to preserve the pubovesical ligament. The cuff and reservoir were inserted through the 12mm infraumbilical trocar. The connections were externalised through a left suprapubic incision and a subcutaneous tunnel created up to the labia majora where the activation pump was placed. The procedure was completed with closure of the peritoneum. It is essential to use a vaginal valve to facilitate dissection. RESULTS: Surgery time: 140 and 135minutes, with no intraoperative complications. After removing the urinary catheter, one patient had elevated postvoid residual urine volume, which was managed conservatively. Hospital stay: 72h. At 3 and 9 months the patients were fully continent. CONCLUSIONS: We present the preliminary results of laparoscopic implantation of an AUS through a vesicovaginal approach to the posterior surface of the bladder neck, which might reduce potential complications that have been observed after the routine techniques.

[Shattered kidney in a patient with asymptomatic chronic hydronephrosis. Case report and literature review]. / Estallido renal en paciente con hidronefrosis crónica asintomática. A propósito de un caso y revisión de la literatura.

The incidence of renal anomalies in patients who suffer a renal trauma is around 4.4 and 19%. We introduce a case of a patient whose first sign of a chronic hydronefrosis was a renal burst secondary to an abdominal trauma.

[Low-dose 0.25% spinal levobupivacaine with epidural extension for cesarean section: comparison with 0.5% hyperbaric bupivacaine]. / Dosis bajas de 1-bupivacaína 0,25% espinal con extensión con salino epidural para cesárea: comparación con bupivacaína 0,5% hiperbárica.

INTRODUCTION: When low doses of local anesthetic are used in combined spinal-epidural anesthesia for cesarean section, an epidural catheter can be used to enhance a possibly incomplete block or insufficient dose. OBJECTIVE: To compare the efficacy of spinal 0.5% hyperbaric bupivacaine with fentanyl (20 microg) at a conventional high dose of 0.07 mg cm(-1) (group 1) vs 0.25% levobupivacaine at a low dose of 7.6 mg with fentanyl (20 microg) and epidural volume extension with 6 mL of saline through an epidural catheter (group 2). MATERIAL AND METHODS: A randomized clinical trial enrolling patients scheduled for elective cesarean section. RESULTS: Sixty-two patients were studied (31 in each group). Characteristics in the groups were comparable at baseline and the maximum level of sensory block achieved was sufficient for all but 1 patient in group 2 who required general anesthesia. The bupivacaine dose in group 1 ranged from 10.5 to 12 mg. The motor block and duration was less intense in group 2 (P<0.0001) and patients in that group could be transferred out of the postanesthetic care unit earlier. CONCLUSIONS: The use of low doses of levobupivacaine with an opiate in combination with volume extension through an epidural catheter in the context of combined spinal-epidural anesthesia is a safe, effective technique that may allow the doses and motor block to be reduced when hyperbaric levobupivacaine is administered, without adverse events for patients.

Genetic parameters for growth characteristics of free-range chickens under univariate random regression models.

Repeated measures from the same individual have been analyzed by using repeatability and finite dimension models under univariate or multivariate analyses. However, in the last decade, the use of random regression models for genetic studies with longitudinal data have become more common. Thus, the aim of this research was to estimate genetic parameters for body weight of four experimental chicken lines by using univariate random regression models. Body weight data from hatching to 84 days of age (n = 34,730) from four experimental free-range chicken lines (7P, Caipirão da ESALQ, Caipirinha da ESALQ and Carijó Barbado) were used. The analysis model included the fixed effects of contemporary group (gender and rearing system), fixed regression coefficients for age at measurement, and random regression coefficients for permanent environmental effects and additive genetic effects. Heterogeneous variances for residual effects were considered, and one residual variance was assigned for each of six subclasses of age at measurement. Random regression curves were modeled by using Legendre polynomials of the second and third orders, with the best model chosen based on the Akaike Information Criterion, Bayesian Information Criterion, and restricted maximum likelihood. Multivariate analyses under the same animal mixed model were also performed for the validation of the random regression models. The Legendre polynomials of second order were better for describing the growth curves of the lines studied. Moderate to high heritabilities (h(2) = 0.15 to 0.98) were estimated for body weight between one and 84 days of age, suggesting that selection for body weight at all ages can be used as a selection criteria. Genetic correlations among body weight records obtained through multivariate analyses ranged from 0.18 to 0.96, 0.12 to 0.89, 0.06 to 0.96, and 0.28 to 0.96 in 7P, Caipirão da ESALQ, Caipirinha da ESALQ, and Carijó Barbado chicken lines, respectively. Results indicate that genetic gain for body weight can be achieved by selection. Also, selection for body weight at 42 days of age can be maintained as a selection criterion.

[Left inferior vena cava with renal cell carcinoma]. / Vena cava renal izquierda en un paciente con carcinoma de células renales.

We presented a case of inferior vena cava on the left side diagnosed by abdominal CT scan during the study of a renal cell carcinoma in the right side. This anomaly is very rare but it may suppose a more difficult approach to the nephrectomy.

Cost-effectiveness analysis of main diagnosis tools in women with overactive bladder. Clinical history, micturition diary and urodynamic study.

OBJECTIVES: The aim of the present clinical research is to analyze, in the light of the best scientific evidence, the performance and the cost of the main diagnostic tools for overactive bladder (OAB). METHODS: It is an exploratory transversal study in which 199 women diagnosed of OAB between 2006 and 2008 were selected and underwent to following prospective analyses: physical examination, urine analysis, micturition diary (MD) and urodynamic study (UDS). A percentage of 80% was assumed as highly sensitive and a diagnostic difference among tests of 10% would be considered clinically relevant. Tests' sensitivity for diagnosis of OAB was statistically established by two ways: isolated and combined. Besides, the direct and indirect costs of these tests performance were conducted. Cost-effectiveness study of clinical history (CH), MD and US for the diagnosis of OAB was performed. RESULTS: Overall sensitivity for OAB diagnosis is low for the 3 tests used in isolated way, whilst the combination of any two tests shows good overall sensitivity. The combination of CH and MD has appeared as the most cost-effective alternative to OAB diagnosis. CONCLUSIONS: For OAB diagnosis, CH-DM combination shows the same sensitivity than the association of either of them with the UDS, but unlike to these, it shows the lowest cost.

On the prediction of Hodgkin lymphoma treatment response.

PURPOSE: The cure rate in Hodgkin lymphoma is high, but the response along with treatment is still unpredictable and highly variable among patients. Detecting those patients who do not respond to treatment at early stages could bring improvements in their treatment. This research tries to identify the main biological prognostic variables currently gathered at diagnosis and design a simple machine learning methodology to help physicians improve the treatment response assessment. METHODS: We carried out a retrospective analysis of the response to treatment of a cohort of 263 Caucasians who were diagnosed with Hodgkin lymphoma in Asturias (Spain). For that purpose, we used a list of 35 clinical and biological variables that are currently measured at diagnosis before any treatment begins. To establish the list of most discriminatory prognostic variables for treatment response, we designed a machine learning approach based on two different feature selection methods (Fisher's ratio and maximum percentile distance) and backwards recursive feature elimination using a nearest-neighbor classifier (k-NN). The weights of the k-NN classifier were optimized using different terms of the confusion matrix (true- and false-positive rates) to minimize risk in the decisions. RESULTS AND CONCLUSIONS: We found that the optimum strategy to predict treatment response in Hodgkin lymphoma consists in solving two different binary classification problems, discriminating first if the patient is in progressive disease; if not, then discerning among complete and partial remission. Serum ferritin turned to be the most discriminatory variable in predicting treatment response, followed by alanine aminotransferase and alkaline phosphatase. The importance of these prognostic variables suggests a close relationship between inflammation, iron overload, liver damage and the extension of the disease.

Squamous cell carcinoma of the oesophagus in a patient with Klippel-Trenaunay syndrome.

The Klippel-Trenaunay syndrome (KTS) is a rare disorder characterized by a triad of port-wine stains, varicose veins, and bony or soft tissue hypertrophy of one extremity. Digestive bleeding is the most commonly observed gastrointestinal manifestation. In rare cases, the syndrome is associated with malignancies. We report the case of a 38-year-old woman with KTS and dysphagia caused by an oesophageal squamous cell carcinoma.

[Acute pancreatitis of biliary etiology]. / Pancreatitis aguda de etiología biliar.

A retrospective study has been carried out, comparing 87 patients with acute pancreatitis of biliary etiology and 53 patients with pancreatitis secondary to other causes. The clinical presentation, laboratory data, radiological findings (chest X-rays, radiography of the abdomen and gastrointestinal, echography), morbidity and mortality have been analyzed. In acute pancreatitis related to biliary disease, pain is most frequently located in the right hypochondrium and the levels of amylase, GOT, GPT an alkaline phosphatase were higher, although only the last two parameters showed significant differences. Morbidity (local and general complications) did not show differences in both groups, but mortality was higher in pancreatitis secondary to biliary disease (5.6% compared to 3.7%).

[Differential traits of prostatic cancer detected through an early screening program versus the one detected during urologic consultation]. / Rasgos diferenciales del cáncer de próstata procedente de un programa de detección precoz frente al detectado en una consulta de urología.

OBJECTIVE: To compare some features of prostate cancers (PCa) detected in a screening program, versus cancers diagnosed in an outpatient clinic. MATERIAL AND METHODS: Retrospective study of 393 patients with biopsy evidence of PCa: 93 (23.7%) from a screening campaign, and 300 (76.3%) detected in an outpatient Urology clinic. Features studied at the moment of diagnosis were age, PSA, digital rectal examination (DRE), transrectal ultrasound (TRUS) characteristics and volume stimation, PSA density (PSAD), clinical stage and Gleason score. A comparison was established between the two groups of patients taking into account the mentioned parameters. RESULTS: A higher age, PSA and DPSA values were found among cancers detected out of the screening program. A greater probability of abnormal DRE and a more advanced clinical stage was also noted. In the screening group, 78.5% of the cancers were localized and 8.6% metastatic. In the outpatient clinic group, the proportions were 50.7% and 26%, respectively. No differences were found with respect to TRUS findings, prostate volume, or Gleason score. CONCLUSIONS: Cancers detected in screening programs are found in earlier stages. Nevertheless, results from long term randomized studies are necessary to verify if these data really mean that a disease-specific mortality reduction can be achieved.

[Surgical treatment of stress urinary incontinence in our setting: analysis of results]. / Tratamiento quirúrgico de la incontinencia urinaria de esfuerzo en nuestro medio: análisis de resultados.

INTRODUCTION AND OBJECTIVE: Surgical repair is the most effective option for the treatment of stress urinary incontinence (SUI) between the different therapeutical options available at present. The main objective of our study is to compare the outcome of the different techniques employed in the treatment of SUI in our setting. METHOD: We have performed a retrospective analysis of the patients who underwent surgical intervention for SUI between 1991 to 1999 (213 surgical interventions in 194 patients) clustering the surgical procedures into three groups: abdominal, abdomino-vaginal, and sling procedures. The results of the treatment were defined as follows: total continence, significant improvement and insufficient improvement. Comparison of continence rates was performed with chi 2 test and Fisher's exact test. Association between qualitative variables was also evaluated by means of chi 2 test. Multivariate analysis of predictive factors was performed with a Cox model. The outcome was also evaluated by Kaplan-Meier's curves, and comparisons made with log-rank test. Statistical significance level was established for p < 0.05. RESULTS: Global cure rate at 24 months was 54.5% (116 patients). Significant improvement was observed in 33 patients (15.5%), and insufficient improvement was seen in 64 patients (30%). The most frequent postoperative complications were suprapubic pain (33%), acute urinary retention (26%), significant postvoiding residual urine (24%) and wound seroma or infection (20%). None of the analyzed factors (age, weight, number of births, preoperative pads, postoperative acute urinary retention, and need for postoperative bladder clean intermittent catheterization were independent predictive factors for postoperative continence. The actuarial analysis with Kaplan-Meier curves shows no statistical differences between the studied techniques (log rank p = 0.41). Sling techniques presented with a superior rate of most postoperative complications. CONCLUSIONS: The cure rate of our serie was 54.5% at 24 months, with a 70% of clinically satisfactory responses. With regard to continence status, it seems that there is not a better surgical technique in our hands, presenting sling techniques with a higher rate of postoperative complications. We could not find no pre o postoperative independent factors as predictors of postoperative continence.

[Epidemiologic analysis of clear cell and chromophilic carcinoma of the kidney]. / Análisis epidemiológico del carcinoma renal de células claras y cromofílico.

OBJECTIVE: Finding differences in the characteristics of the two most frequent variants of renal cancers: the clear-cell renal carcinoma, and the chromophilic one. MATERIAL AND METHODS: Retrospective analysis of epidemiological characteristics of patients diagnosed of renal carcinoma in our hospital between 1991 and 2001. Statistical differences were searched between patients' characteristics (age, sex, smoking habitus) and tumors' characteristics (size, focality, stage, side and grade). RESULTS: Sixty six renal tumors were diagnosed, of which 41 (62.1%) were clear-cell tumors and 9 (13%) were chromophilic. We only found statistical differences between both subpopulations' tumor size (p < 0.05), being greater for clear-cell tumors (7 +/- 3.92 cm) than for chromophilic ones (4.89 +/- 1.96 cm). We could also appreciate a bias towards a less advanced stage of the chromophilic type, although not statistically significant. CONCLUSIONS: Clear-cell renal carcinoma and chromophilic renal carcinoma are the two more frequent variants of renal tumors. The chromophilic type is smaller and is usually found in a less advanced stage, although this bias could not be demonstrated in our series.

[The natural history of sperm cleareance after vasectomy]. / La historia natural del aclaramiento de espermatozoides en el semen tras la vasectomía.

OBJECTIVE: To study the time required to obtain a negative sperm analysis after vasectomy. MATERIAL AND METHODS: We reviewed 239 consecutive vasectomies performed between september 1998 and september 1999. All of them were done in an ambulatory basis. Follow up interval was 41-853 days (mean 144, median 104). The first semen analysis was requested between 1 and 6 months after the surgical procedure. If the sample still showed spermatozoa, then a new one was requested every two months. Probability of becoming azoospermic was studied with Kaplan-Meier curves. RESULTS: Persistent spermatozoa could be found in 31 patients (13%) at the end of follow-up. Despite having a positive semen analysis, 10 patients (4.2%) discontinued medical visits. Time required to obtain a negative sperm count ranged from 58 to 362 days (mean 133, median 99). The probability of being azoospermic 200 and 260 days after vasectomy was 80-90% respectively. A total of 328 semen analysis were requested (range 1-4, mean 1.37, median 1) CONCLUSIONS: A minimum of 200 days (6.6 months) are needed to clear all the spermatozoa in semen after vasectomy in 80% of our patients. Requesting the first semen sample 7 months after vasectomy is cost-effective, reducing unnecesary medical visits and increasing the rentability of this test.

[Adverse effects of transrectal prostatic biopsy. Analysis of 303 procedures]. / Efectos adversos de la biopsia prostática transrectal. Un análisis de 303 procedimientos.

INTRODUCTION AND OBJECTIVE: Prostate biopsy is a basic step towards prostate cancer (Pca) diagnosis, but usually not free from complications. In this article we have reviewed the adverse effects of this procedure in our setting. MATERIAL AND METHODS: We studied in a prospective fashion the complications arising from transrectal prostate biopsy with the aid of a questionnaire fulfilled by 303 patients who underwent this procedure, within the context of a Pca screening program. All biopsies were transrectal ultrasound guided and randomly taken (sextant). A cleaning enema was applied the night before, and 100 mg of intramuscular tobramycin were administered prior of the procedure. RESULTS: Ninety patients (29.7%) had no adverse effects at all, and 136 (44.9%) reported at least one minor complication (hematuria, hemospermia, or autolimited dysuria). Lastly 77 (25.4%) presented with major complications--urinary retention, fever, need for medical assistance (primary or hospital care) or treatment. Thirty-five patients (11.5%) reported to present with fever after biopsy, 145 (47.8%) hematuria, 95 (31.3%) hemospermia, 77 (25.4%) rectal bleeding, 67 (22.1%) urinary difficulty, and 9 (2.9%) urinary retention. Up to 39 (12.8%) needed to visit their G.P., and 19 of them were referred to Hospital, where only 6 (1.9%) were admitted longer than 24 hours. No intensive care unit admittances or deaths were reported. CONCLUSIONS: The rate of post-transrectal biopsy adverse effects is high in our experience. This phenomenon could be explained, in part, due to data collecting by means of a self-administered questionnaire. Probably the high fever rate presented here could be diminished with other type of antibiotic prophylaxis.

[Detection of prostatic cancer in the PSA range between 3 and 3.9 ng/ml]. / Deteccion del cáncer de próstata en el rango de PSA entre 3 y 3,9 ng/ml.

OBJECTIVE: In our study, we analyze the benefit of lowering the PSA cutoff point for which a prostate biopsy is indicated from 4 to 3 ng/ml. MATERIALS AND METHODS: We have considered 4.278 individuals coming from a prostate cancer screening program. We studied 1.217 interventions in which PSA was determined, indicating the prostate biopsy with PSA > or = 3 ng/ml. Digital rectal examination was never the indication for the biopsy. All biopsies were sextant and assisted by transrectal ultrasound. We compared the performance of the biopsy using 4 and 3 ng/ml as cut points. RESULTS: Of the 1.217 interventions performed, 947 had PSA values lower than 3 ng/ml, 80 between 3 and 3.9 ng/ml and 190 over 4 ng/ml. A total of 189 patients (70% of these two last groups) underwent a prostate biopsy. With 4 ng/ml as the cut point, 134 biopsies were indicated, detecting 28 cancers (positive predictive value 20.9%). However 189 biopsies were indicated and 34 cancers detected by lowering the cut point to 3 ng/ml (positive predictive value 17.9%). The reduction in the biopsy performance was not statistically significant (OR = 0.89). None of the 6 additional cancers detected was palpable or ecographically visible (T1c), all of them had a Gleason score under 7 and half of them could be considered clinically relevant. CONCLUSIONS: Lowering PSA cutoff point from 4 to 3 ng/ml improved the detection rate in 21.4% not jeopardizing the biopsy performance. Therefore we think that the group of patients with PSA between 3 and 3.9 ng/ml as candidates for prostate biopsy, should be included in screening programs.

[Selective bladder sparing with transrectal resection of muscle-infiltrating tumors]. / Preservación vesical selectiva mediante resección transuretral de los tumores músculo-infiltrantes.

OBJECTIVE: To disclose te ability of TUR as monotherapy in muscle invasive bladder cancer. MATERIAL AND METHODS: 27 patients with muscle-invasive bladder cancer recruited throughout 1991-1999 were allocated into a protocol based on TUR. 30-45 days after the first TUR a second procedure was performed. The number of recurrences and progressions was registered. Progression-free survival and survival were analyzed using Kaplan-Meier estimates. RESULTS: Two patients were excluded due to persistence of muscle-invasive disease after the second resection. 8 subjects (32%) were lost in follow-up. 17 were eventually evaluable. 12 patients (70.5%) had recurrences. Eventually, 4 more cystectomies were undertaken for invasive recurrences (4/17, 23.5%). During the study period, 3 deaths were recorder (3/17, 17.6%). The actuarial probability of progression at 93 months was estimated on 60%. CONCLUSIONS: 75% of patients retained their bladders. The proportion of patients lost in follow-up was very high. Patients must commit to a close surveillance.

[Preliminary results of the treatment of high grade (T1G3) superficial tumors of the bladder with transurethral resection]. / Resultados preliminares del tratamiento de los tumores vesicales superficiales de alto grado (T1G3) mediante resección transuretral.

OBJECTIVE: To examine the results of monotherapy with TUR in the treatment of primary T1G3 transitional cell carcinoma (TCC). METHODOLOGY: Thirty-two patients with primary TCC of the bladder were allocated into a surveillance program. Risk factors for progression to muscle-invasive disease were determined. Immediately, projections of disease-free and progression-free survival were calculated. RESULTS: Five patients (15.6%) were lost in follow-up. Twenty-three (85%) had superficial recurrences. Four patients (14.8%) progressed to muscle-invasive or metastatic disease. No independent risk-factors for progression were disclosed. Median disease-free survival was 8 months. Projection of the risk of recurrence at 79 months was 84.9%. Median time to progression has not been reached yet. Projection of progression at 79 months was 46.3%. CONCLUSIONS: The above mentioned treatment schedule is associated with very high recurrence rates. In addition, recurrences are very frequent. Nevertheless, in the medium run, projections of progression suggest that surveillance can be an alternative to other treatments in the management of T1G3 TCC of the bladder.