Surgical wound infection in urology. Analysis of risk factors and associated microorganisms. / Infección de herida quirúrgica en urología. Análisis de factores de riesgo y microorganismos asociados.

OBJECTIVES: Open surgery continues to have a fundamental role in urology, and one of its main complications is surgical wound infection. Our objective was to analyse surgical wound infection in patients who underwent surgery in our Department of Urology and to assess the risk factors, microorganisms and resistances by type of surgery. MATERIAL AND METHODS: This was a prospective observational study that included 940 patients: 370 abdominal/open lumbar surgeries and 570 genitoperineal surgeries. We analysed age, sex, comorbidities, stay and type of surgery, as well as the causal microorganisms and antibiotic resistances. RESULTS: For genitoperineal surgery, we found 15 cases (2.6%) of surgical wound infection associated with previous urinary catheterisation. Most of the isolated microorganisms corresponded to enterobacteriaceae, highlighting the resistance to beta-lactam. In abdominal/lumbar surgery, we found 41 cases (11.1%) of surgical wound infection. The incidence rate was 3.3% in prostate surgery; 9.8% in renal surgery; and 45.0% in cystectomy. Heart disease was associated with a higher incidence rate of surgical wound infection. The most common microorganisms were Enterococcus spp. (27.1%), E.coli (22.9%) and Staphylococcus aureus (14.6%). Enterococcus and beta-lactamase-producing E.coli are resistant to ampicillin in 37.5% and 41.7% of cases, respectively. CONCLUSIONS: We found a low incidence rate of surgical wound infection in genitoperineal surgery, compared with renal surgery and cystectomy. The presence of heart disease and carrying a previous urinary catheter are factors associated with surgical wound infection. Enterococcus and E.coli are the most common pathogens, with high rates of resistance.

Evolution of primary care referrals to urology. Impact of a protocol on prostate disease and continuing education.

OBJECTIVE: To analyze the evolution of primary care referrals to the Urology Department after the implementation of a joint protocol on prostate disease and a continuing education program in our healthcare area. MATERIAL AND METHODS: In January 2011, we launched an action protocol on prostate disease, which was complemented by training sessions and an e-mail-based consultation system. We analyzed primary care referrals to the Urology Department between 2011 and 2013 and determined the reasons for the consultations and the compliance with the established criteria on prostate disease. We obtained data from the "Request for Appointment in Specialized Care" program of the Community of Madrid. We calculated the sample size with a 95% confidence level and a 50% heterogeneity. RESULTS: A total of 19,048 referrals were conducted. The most common reason for the referrals was lower urinary tract symptoms associated with benign prostate hyperplasia, with a 27% reduction and a compliance that went from 46% at 67%. Although prostate-specific antigen consultations increased by 40%, they improved their appropriateness (from 55% to 72%). This was the main type of consultation for suspicion of malignancy (30%). Also worth mentioning were female incontinence, which doubled in number, and a 41% reduction in erectile dysfunction, which could be due to the primary care training. CONCLUSIONS: The collaboration between the Department of Urology and primary care succeeded in improving the appropriateness of prostate disease referrals and modified the tendency to refer the rest of the diseases included in the project.

Uncontrolled non-heartbeating donors (types i-ii) with normothermic recirculation vs. heartbeating donors: evaluation of functional results and survival.

OBJECTIVE: Non-heartbeating donors (NHBD) are an alternative to heartbeating donors (HBD). Our objective was to compare functional results and kidney survival from NHBDs and HBDs. MATERIAL AND METHODS: A retrospective study comparing the results of 236 normothermically preserved kidneys from type i and ii type NHBDs with the results of 250 from HBDs that were transplanted in our center between 2005 and 2012. Homogeneity between groups was tested and we evaluated the presence of delayed graft function (DGF) associated with pretransplant variables of the donor and recipient. RESULTS: Both groups show homogeneity in pretransplant characteristics in terms of: age, HLA incompatibilities, and recipient hemodialysis time. Average follow-up time was 33 months (range 0-87) for NHBDs and 38 months (range 0-90) for HBDs. 5.5% of NHBDs showed primary non-function (PNF) vs. 4% of HBDs (P=.42) and 80.9% of DGF vs. 46.8% of HBDs (P<.001). At the end of the follow-up, there were no statistically significant differences in the survival of grafts (92.8% for NHBD vs. 93.6% for HBD, P=.71) and recipients (99.1% NHBD vs. 98.6% HBD, P=.28). CONCLUSIONS: Although the DGF percentage was greater for NHBDs, final creatinine as well as graft and recipient survival were similar for both groups. Therefore, in our experience, kidneys from NHBDs have similar results to those from HBDs and are an excellent source of organs for transplantation.

Community-associated urinary infections requiring hospitalization: risk factors, microbiological characteristics and patterns of antibiotic resistance.

OBJECTIVE: Although patients with urinary tract infections (UTIs) are usually managed as outpatients, a percentage of them requires hospitalization. To review risk factors and microbiological characteristics of community-associated UTIs (CAUTIs) requiring hospitalization has been our objective. MATERIAL AND METHODS: A prospective observational study was carried out from November 2011 to December 2013. Incidence, microbiological characteristics and antibiotic resistance patterns in patients with CAUTIs that required hospitalization were analyzed. Risk factors (including diabetes mellitus, urolithiasis, urinary catheterization) and resistance rates of each pathogen were also analyzed. RESULTS: Four hundred and fifty seven patients were hospitalized in our department with CAUTI. The mean age was 56.2±19.85 years. Of them, 52.1% patients were women, 19.7% had urinary indwelling catheter and 11.4% have had a previous UTI. The most frequently isolated pathogens were Escherichia coli (60.6%), followed by Klebsiella (9.2%), Enterococcus (8.4%) and Pseudomonas (7.2%). Enterobacteriaceae other than E.coli were more prevalent in male and older patients. On the other side the most frequently isolated pathogen in patients with a previous UTI and a urinary catheter was Entercoccus. The resistance rates E. coli against ampicillin/amoxicillin + ß lactamase inhibitor was 23.5%, against third-generation cephalosporins 16.6%, against fluoroquinolones 31.3% and 16.7% against aminoglycosides. 11.4% E. coli strains were producers of extended-spectrum Beta-lactamases (ESBL). Finally, the resistance rates of Enterococcus and Pseudomonas against quinolones were of 50.0% and 61.5%, respectively. CONCLUSIONS: CAUTIs that require hospitalization are most frequent in older age, male gender, and presence of urinary catheter, with urolithiasis and with previous episodes of UTI. These factors are also related to isolation of pathogens other than E. coli and higher resistance rates.

[Ultrasonography in urology]. / Ecografía en urología.

After its introduction more than twenty years ago, ultrasound has continually increased in importance in urology diagnostics and is currently one of the most frequent exploratory techniques used. It corresponds to one out of every four imaging techniques carried out in medicine. The possibility of intervention under echographic control, for either diagnostic or therapeutic purposes, has been studied ever since ultrasound first appeared. Nowadays, interventionist echography is a commonly used technique in urology and is applied in a wide range of procedures carried out on the prostate gland, bladder and kidney that require echography-guided puncture techniques. Timely modifications of ultrasound for control and monitoring of treatments such as shock wave extracorporeal lithotripsy or transperineal brachitherapy has increased even more its day-to-day use by urologists. New technologies currently under development such as high-energy ultrasound in the management of kidney and prostate cancer, 3-dimensional ultrasound, Doppler-energy and contrast ultrasound have also increased the importance of this procedure in urology.

[Expression of p21ras in locally confined renal adenocarcinoma and its prognostic implications]. / Expresión de la proteína p21ras en el adenocarcinoma renal localmente confinado y sus implicaciones pronósticas.

OBJECTIVE: The p21ras protein is encoded by the three ras genes (H-, K- and N-ras) and participate in the regulation of normal cell growth and cell differentiation. The objective of this study is to determine the expression of this protein in locally confined renal cell carcinoma, as well as its relations with different histopathological variables and their prognostic implications. METHOD: 58 renal cell carcinomas, in pT1-T3a N0 M0 (TNM 1997) stages, treated by radical or partial nephrectomy with curative intention. We analysed different clinical and anatomopathological variables, as well as expression of p21ras in paraffinated tissue, using immunohistochemical techniques. RESULTS: The mean percentage of stained nuclei was 6.1%, with a range lying between 0 and 45%. We did not obtain statistically significant association between expression of p21ras and the tumour size (p = 0.698), the nuclear grade (p = 0.676) or the histopathological stage (p = 0.095). The survival analysis also did not show significant differences when we stratified the patients using the mean value of the sample as reference point (p = 0.134). CONCLUSIONS: Expression of p21ras was not demonstrated to be related to any of the histopathological variables analysed: size, grade and stage, or with survival. Therefore, this protein does not appear to be related to the evolution of renal cell carcinoma.

[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.

[Non-palpable prostatic cancer. Cure with adenomectomy?]. / Cáncer de próstata no palpable. Curación con adenomectomía?

The currently growing importance of prostate cancer (PC) is given by the large increase in the number of cases diagnosed with this condition, to a great extent due to the diffusion of the most recent diagnostic techniques. Together with the traditional rectal examination, we have available today the PSA (prostate specific antigen) and the transrectal ultrasound, which allow to diagnose tumours undetectable with palpation. This paper presents the case of a male patient with high levels of PSA (in metastatic values), normal rectal examination and three series of negative prostate biopsies in spite of a high suspicion of PC, the diagnosis being confirmed after adenomectomy, with a subsequent PSA levels normalization, these levels remaining below 3 ng/ml after 22 months follow-up, which allows to think of a "recovery" (?) with just the removal of the prostate adenoma.

[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.

Dual kidney transplantation involving organs from expanded criteria donors: a review of our series and an update on current indications.

BACKGROUND: Our purpose was to review our kidney transplantation program based on the use of expanded criteria donors, and to determine current indications for dual kidney transplantation (DKT). In 1996, a program was initiated to transplant kidneys from donors of over 60 years performing single or dual transplantation. METHODS: In 1996, a program was initiated to transplant kidneys from donors of over 60 years performing single or dual transplantation. DKT were performed with donors >75 and donors between 60 and 74 years of age and glomerulosclerosis of >15%. The kidneys of donors between 60 and 74 years of age and with glomerulosclerosis of <15% were used for single kidney transplantation (SKT). In 2005, we started to perform SKT despite glomerulosclerosis being >15%, taking into account donor and recipient characteristics. RESULTS: From 1996 to 2004, 222 SKTs and 88 DKTs were performed. Graft survival after 1 and 4 years was, respectively, 91% and 78% for SKT and 95% and 79% for DKT. In 2005, we started to perform SKT despite glomerulosclerosis being >15%, taking into account donor and recipient characteristics. From 2005 to 2011, 328 SKT and 32 DKT were performed. During this period most kidneys used for DKT were from female donors >75 years old, weighing <65 kg, with a creatinine of >1 mg/dL and glomerulosclerosis of >15%. The recipients for DKT were mostly male, <70 years old and whose weight was >75 kg. CONCLUSION: DKT from expanded criteria donors shows good outcomes. However, in many cases SKT may fulfill the need of the recipient. The archetype for DKT is an older female weighing <65 kg and the most common recipient is an overweight male who is <70 years old.

Renal biopsy with 16G needle: a safety study.

INTRODUCTION AND OBJECTIVE: The development of percutaneous renal biopsy as a routinary diagnostic procedure for renal masses is topic of discussion for the last few years. However, this technique has been associated with some complications, although infrequent, and morbidity. Our objective is to carry out a descriptive study about complications and outcomes of orthotopic kidney biopsies with 16 G needle. MATERIAL AND METHODS: A retrospective review of 180 orthotopic ultrasound-guided renal biopsies performed in our service among January 2008 to May 2010 was carried out. The procedure was developed using an automated biopsy gun (16G needle). Multiple clinical variables, early post-procedure complications and its management were collected. Complication rates as well as the relationship between risk factors and occurrence of complications were studied. RESULTS: Mean age was 55.8 years. The average number of biopsy cylinders per intervention was 2.49. The overall complication rate was 5.6%. An interventionist attitude derived from complication of the procedure was necessary in only 3 patients (1.67%). No surgical interventions were required and no death as consequence of procedure was registered. No relationship between hypertension (P=.09) previous anticoagulation (P=.099) or previous antiaggregation (P=.603) and complications were demonstrated. In 2.8% of biopsies the material obtained was insufficient for diagnosing. CONCLUSIONS: Percutaneous ultrasound-guided renal biopsy with 16G needle is a safe technique with high diagnostic performance.

[An analysis of the value of bowel preparation for preventing postoperative complications in endoscopic surgery]. / Análisis de la utilidad de la preparación intestinal en la prevención de complicaciones postoperatorias en cirugía endoscópica.

OBJECTIVES: To assess the relationship between mechanical preparation of the bowel before endourological surgery and the occurrence of postoperative complications. MATERIALS AND METHODS: A prospective, randomized study was conducted in 162 patients undergoing TUR of the bladder, TURP, and lase adenomectomy from October 2008 to February 2009. No patient was excluded. An enema was administered before surgery to 66 patients, but not to the remaining patients. Variables analyzed included occurrence of urinary tract infection (UTI), fever, acute urinary retention (AUR), postoperative need for enemas or laxatives, surgical field contamination, and mean hospital stay. A descriptive analysis, a means comparison (t test), and a Chi-square test were performed. RESULTS: Mean patient age was 70.5 years (SD+/-10.62), and mean hospital stay 4.8 days (SD+/-3.9). UTI occurred in 6.2% of patients, fever in 3.1%, and AUR in 1.2%, and 15.4% of patients required enemas or laxatives. Fecal contamination of the surgical field was found in one patient (0.6%). There were no statistically significant differences between the study groups in the variables analyzed. CONCLUSIONS: In our series, bowel preparation using enema has shown no value for decreasing postoperative complications of endourological surgery.