Informed consent in urology.

Appropriate professional practice includes the diagnostic and treatment process of urologic pathology, as well as patient information and respect for patient autonomy in decision making. Informed consent is the gradual process of providing information to the patient and their subsequent decision making. The informed consent document (ICD), when required, demonstrates that information has been provided sufficiently in advance to allow for the patient's deliberation. The dual need for simple yet complete documents make the preparation of adequate ICDs extremely difficult. If the information process is not carried out properly, the professional may incur a medical malpractice liability that is treated as a loss of opportunity. To avoid such situations, the work of scientific societies in the preparation, accessibility, and dissemination of ICD models is fundamental.

Management of testicular torsion in the ER: lessons learned from medical professional liability claims.

OBJECTIVE: To evaluate emergency care for testicular torsion (TT) in medical professional liability (MPL) claims. METHODS: Claims related to TT from 2000 to 2018 were located. The assistance provided and the association with MPL were analyzed. RESULTS: Eighty complaints were identified, testicular pain was reported in 83.75% of first consultations, with a mean evolution time of 15.5 h. The mean time to diagnosis was 7.98 days. The first consultation was at the hospital in 75.1% of cases, but an ultrasound was performed only in 7.5%. When TT diagnosis was performed, 97.3% had undergone ancillary tests. The MPL was significantly associated with non-criminal proceedings and with less than 6 h of symptoms' evolution, and, within this subgroup, without undergoing an ultrasound scan. CONCLUSIONS: Late consultations, wrong diagnosis and late diagnosis are claimed. When MPL are claimed by means of non-criminal law, the existence of responsibility is frequently considered, even more in those cases when the consultation took place before 6 h of evolution with no ancillary tests having been performed.

Medical malpractice liability and its consequences. / Encuesta a los urólogos sobre responsabilidad profesional médica y sus consecuencias.

INTRODUCTION: Urology is a specialty of medium risk of claim. Receiving a claim for medical professional liability is a stressful experience with significant repercussions. The objective of this study was to assess the impact of these claims on Spanish urologists. METHODOLOGY: A survey on medical professional liability in urology was designed. The Spanish Association of Urology and the Urological Research Foundation approved the questionnaire, generated by the PIEM online tool. RESULTS: The total number of responses obtained was 202 (11.6% rate), of which 25.24% reported having been claimed, 88% reported mood changes after being claimed, 100% in criminal proceedings. The level of emotional involvement reported was the highest at the beginning of the process and progressively decreasing until its resolution. An affected doctor-patient relationship was considered in 67.9% of cases and 71.4% acknowledged increased defensive medicine in their professional practice. A percentage of 6.7% considered leaving the profession. DISCUSSION: The response rate obtained and the medical acts motivating the claims were comparable to those obtained in a similar survey conducted in the United States. The fact that claims are perceived as very stressful situations and may give rise to the phenomenon of the second victim or to the clinical judicial syndrome is clear, so efforts should be devoted to develop training in this matter and programs that address the consequences derived from these situations.

Medical professional responsibility for postvasectomy pregnancy. / Responsabilidad profesional médica en embarazo posvasectomía.

BACKGROUND: The follow-up of patients postvasectomy is frequently limited to a seminogram at 3months if azoospermia is observed. This study evaluates a series of cases of complaints for postvasectomy pregnancy to establish follow-up recommendations that increase the clinical safety and reduce the risk of complaints. MATERIAL AND METHODS: We reviewed the database of the Department of Professional Responsibility of the Council of the College of Physicians of Catalonia, finding 28 complaints for postvasectomy pregnancy between 1992 and 2011. We analysed the clinical and legal variables of the cases. RESULTS: A total of 13 extrajudicial complaints (46.43%), 13 civil lawsuits (46.43%) and 2 criminal lawsuits (7.14%) were recorded. Only 10 cases had a signed document of informed consent specific to vasectomy. In 26 cases, the data from the spermogram was available. A single spermogram was conducted in 20 cases (76.92%), 2 spermograms were conducted in 4 cases (15.38%) and none were performed in 2 cases (7.69%). For 9 of the cases (45%) where only a single spermogram was performed, the test was performed before 3months postvasectomy. In 17 cases (65.38%), the result of the last spermogram was azoospermia, and 3 cases had oligospermia (11.54%). There were 2 failures of interpretation of the spermogram (7.69%) and 2 of normospermia (7.69%). In 2 cases, a spermogram was not performed (7.69%). Pregnancy occurred between 4 and 50 months after the intervention. In 12 cases (42.86%), it was considered that the practitioner was responsible. DISCUSSION: It is recommended that physicians emphasise (during the patient information stage) the possibility of spontaneous recanalisation and to request 2 spermograms, whose result should be azoospermia. Performing the test in the 3months after vasectomy is risky, as is basing the waiting time on the number of ejaculations.

[Skin metastasis in prostatic adenocarcinoma]. / Metástasis cutáneas en un adenocarcinoma prostático.

Skin metastasis of prostatic carcinoma are extremely rare. Presentation of one significant case of these spread.

[Urologic surgery without hospitalization]. / Cirugía urológica sin ingreso.

The improvement of surgical utensils, the development of endoscopic techniques, the simplification of many surgical procedures and the increasing substitution of classic surgery with treatments using the physical effects originated from innovative devices, together with the evolution of anaesthetic techniques, make possible for urological operations to be now simpler and less aggressive. All of what, whenever both the hospital and the social environment so allow it, can let us in many cases dispense with hospitalizations which, up to now, were considered essential or, at any rate, significantly reduce the patient's stay in hospital.

[Cystic multilocular nephroma. Report of a case]. / Nefroma multilocular quístico. Presentación de un caso.

We present a new case of multilocular cystic nephroma, and a review of literature. If C.T. diagnoses a cystic disease we apply the Bosniak classification. Multilocular cystic nephroma appears as a cystic disease, separately fibrous thin walls, with or without calcifications. We have to make a distinctive diagnosis between RCC and multilocular. Definitive diagnosis is always histological.

[Extracorporeal piezogenerated shockwave lithotripsy. Our experience in 500 cases]. / Litotricia extracorpórea por ondas de choque piezogeneradas. Nuestra experiencia en 500 casos.

Between April 1987 and August 1988, 498 patients suffering renal or ureteral lithiasis, all of them with a 6 months or more follow-up period, have been treated in our Unit. Patients were treated in an ambulatory regime without need for anesthesia or analgesia. Up to 27% of the cases has surgical background for lithiasis. One hundred and twenty-six patients had a double J ureteral catheter placed prior to lithotripsy treatment. Fourty-four percent cases needed only one session, 25% two, 12% three and 18% more than three sessions. At the time of discharge 86% patients had no lithiasis or fragments less than 3 mm. Only 9% had fragments larger that 3 mm. It is our opinion than piezoelectric extracorporeal lithotripsy has been proven as a safe, effective and painless procedure in most renal lithiasis.

El manejo de la torsión testicular en Urgencias: lecciones aprendidas de las reclamaciones por responsabilidad profesional médica / Management of testicular torsion in the ER: Lessons learned from medical professional liability claims

Objetivo: Evaluar la atención en Urgencias por torsión testicular en reclamaciones por responsabilidad profesional médica.MétodoSe extrajeron las reclamaciones relacionadas con torsión testicular del 2000 al 2018, analizando la asistencia dispensada y la asociación con responsabilidad profesional médica.ResultadosSe identificaron 80 reclamaciones, registrándose como síntoma principal el dolor testicular en el 83,75% de las primeras asistencias, con 15,5h de evolución media. El tiempo hasta el diagnóstico fue de 7,98 días de media. La primera consulta fue hospitalaria en el 75,1% de los casos, pero solo en el 7,5% se realizó ecografía. Cuando se diagnosticó la torsión testicular, se hizo uso de pruebas complementarias en el 97,3% de los casos. La responsabilidad profesional médica se asoció significativamente con la vía de reclamación no penal y con cuadros de menos de 6h de evolución, y dentro de este subgrupo, con la no realización de ecografía.ConclusionesSe reclaman consultas tardías, el error y el retraso en el diagnóstico. Cuando la reclamación es por vía no penal, es frecuente que se considere la existencia de responsabilidad, y más en los casos en que la consulta fue antes de las 6h y sin haber realizado prueba complementaria alguna. (AU)

Objective: To evaluate emergency care for testicular torsion in medical professional liability claims.MethodClaims related to testicular torsion from 2000 to 2018 were located. The assistance provided and the association with medical professional liability were analyzed.ResultsEighty complaints were identified, testicular pain was reported in 83.75% of first consultations, with a mean evolution time of 15.5h. The mean time to diagnosis was 7.98 days. The first consultation was at the hospital in 75.1% of cases, but an ultrasound was performed only in 7.5%. When testicular torsion diagnosis was performed, 97.3% had undergone ancillary tests. The medical professional liability was significantly associated with non-criminal proceedings and with less than 6h of symptoms’ evolution, and, within this subgroup, without undergoing an ultrasound scan.ConclusionsLate consultations, wrong diagnosis and late diagnosis are claimed. When medical professional liability are claimed by means of non-criminal law, the existence of responsibility is frequently considered, even more in those cases when the consultation took place before 6h of evolution with no ancillary tests having been performed. (AU)

Encuesta a los urólogos sobre responsabilidad profesional médica y sus consecuencias / Medical malpractice liability and its consequences: A survey among AEU urologists

INTRODUCCIÓN: La urología es una especialidad de riesgo medio de reclamación. Recibir una reclamación por responsabilidad profesional médica es una experiencia estresante con importantes repercusiones. El objetivo de este estudio fue valorar el impacto de dichas reclamaciones sobre los urólogos españoles. METODOLOGÍA: Se diseñó una encuesta sobre responsabilidad profesional médica en urología. La Asociación Española de Urología y la Fundación para la Investigación en Urología aprobaron la encuesta, facilitando su realización mediante la herramienta PIEM por vía electrónica. RESULTADOS: Se obtuvieron 202 respuestas (tasa de 11,6%). El 25,24% reportaron haber sido reclamados en alguna ocasión. El 88% refirieron una afectación del estado de ánimo tras ser reclamados, siendo del 100% en la vía penal. El grado de afectación emocional reportado fue máximo en el inicio del proceso y fue decreciendo hasta su resolución. El 67,9% consideró una afectación en la relación médico-paciente y un 71,4% reconocieron un cambio en el ejercicio de la profesión, aumentando la medicina defensiva. Un 6,7% consideró abandonar el ejercicio de la profesión. DISCUSIÓN: La tasa de respuesta obtenida y las actuaciones médicas que motivan las reclamaciones fueron similares a las obtenidas en una encuesta similar realizada en Estados Unidos. Se confirma que las reclamaciones son percibidas como situaciones muy estresantes, pudiendo dar lugar al fenómeno de la segunda víctima o al síndrome clínico judicial, por lo que deben destinarse esfuerzos a la formación en dicha materia y a programas que traten las consecuencias derivadas de dicha situación

INTRODUCTION: Urology is a specialty of medium risk of claim. Receiving a claim for medical professional liability is a stressful experience with significant repercussions. The objective of this study was to assess the impact of these claims on Spanish urologists. METHODOLOGY: A survey on medical professional liability in urology was designed. The Spanish Association of Urology and the Urological Research Foundation approved the questionnaire, generated by the PIEM online tool. RESULTS: The total number of responses obtained was 202 (11.6% rate), of which 25.24% reported having been claimed, 88% reported mood changes after being claimed, 100% in criminal proceedings. The level of emotional involvement reported was the highest at the beginning of the process and progressively decreasing until its resolution. An affected doctor-patient relationship was considered in 67.9% of cases and 71.4% acknowledged increased defensive medicine in their professional practice. A percentage of 6.7% considered leaving the profession. DISCUSSION: The response rate obtained and the medical acts motivating the claims were comparable to those obtained in a similar survey conducted in the United States. The fact that claims are perceived as very stressful situations and may give rise to the phenomenon of the second victim or to the clinical judicial syndrome is clear, so efforts should be devoted to develop training in this matter and programs that address the consequences derived from these situations

Responsabilidad profesional médica en embarazo posvasectomía / Medical professional responsibility for postvasectomy pregnancy

Introducción: El seguimiento de los pacientes posvasectomía queda frecuentemente limitado a un seminograma a los 3 meses si se objetiva azoospermia. Este trabajo evalúa una serie de casos de reclamaciones por embarazo posvasectomía, con el objetivo de establecer recomendaciones de seguimiento que aumenten la seguridad clínica y disminuyan el riesgo de reclamaciones. Material y métodos: Se revisó la base de datos del Servicio de Responsabilidad Profesional del Consejo del Colegio de Médicos de Cataluña, localizándose 28 reclamaciones por embarazo posvasectomía entre 1992 y 2011. Se analizaron las variables clínicas y jurídicas de los casos. Resultados: Se registraron 13 reclamaciones extrajudiciales (46,43%), 13 demandas civiles (46,43%) y 2 penales (7,14%). Únicamente en 10 casos constaba la firma de un documento de consentimiento informado específico para vasectomías. En 26 casos se dispuso de los datos correspondientes al espermiograma. En 20 casos (76,92%) se realizó un único espermiograma, en 4 se realizaron 2 (15,38%) y en 2 casos no se realizó ninguno (7,69%). Cuando solo se llevó a cabo un único espermiograma, en 9 casos (45%) este se realizó antes de los 3 meses. En 17 casos (65,38%) el resultado del último espermiograma fue de azoospermia, 3 casos de oligospermia (11,54%), hubo 2 fallos de interpretación del espermiograma (7,69%), 2 de normospermia (7,69%) y en 2 casos no se realizó espermiograma (7,69%). El embarazo se produjo entre los 4 y los 50 meses de la intervención. En 12 casos (42,86%) se consideró que existía responsabilidad profesional. Discusión: Se recomienda enfatizar en la información al paciente la posibilidad de la recanalización espontánea y solicitar 2 espermiogramas con resultado de azoospermia, resultando de riesgo su realización antes de los 3 meses o basar el tiempo de espera en un número de eyaculaciones

Background: The follow-up of patients postvasectomy is frequently limited to a seminogram at 3 months if azoospermia is observed. This study evaluates a series of cases of complaints for postvasectomy pregnancy to establish follow-up recommendations that increase the clinical safety and reduce the risk of complaints. Material and methods: We reviewed the database of the Department of Professional Responsibility of the Council of the College of Physicians of Catalonia, finding 28 complaints for postvasectomy pregnancy between 1992 and 2011. We analysed the clinical and legal variables of the cases. Results: A total of 13 extrajudicial complaints (46.43%), 13 civil lawsuits (46.43%) and 2 criminal lawsuits (7.14%) were recorded. Only 10 cases had a signed document of informed consent specific to vasectomy. In 26 cases, the data from the spermogram was available. A single spermogram was conducted in 20 cases (76.92%), 2 spermograms were conducted in 4 cases (15.38%) and none were performed in 2 cases (7.69%). For 9 of the cases (45%) where only a single spermogram was performed, the test was performed before 3 months postvasectomy. In 17 cases (65.38%), the result of the last spermogram was azoospermia, and 3 cases had oligospermia (11.54%). There were 2 failures of interpretation of the spermogram (7.69%) and 2 of normospermia (7.69%). In 2 cases, a spermogram was not performed (7.69%). Pregnancy occurred between 4 and 50 months after the intervention. In 12 cases (42.86%), it was considered that the practitioner was responsible. Discussion: It is recommended that physicians emphasise (during the patient information stage) the possibility of spontaneous recanalisation and to request 2 spermograms, whose result should be azoospermia. Performing the test in the 3 months after vasectomy is risky, as is basing the waiting time on the number of ejaculations

[The diagnostic situation with prostatic cancer in primary care]. / Situación diagnóstica del cáncer de próstata en atención primaria.

OBJECTIVES: To evaluate the quality of diagnosis in primary care (PC) of prostate cancer (CP) and to analyse the factors linked to late diagnosis. DESIGN: Retrospective, cross-sectional study. SETTING: Five PC centres and a hospital (covering about 130,000 inhabitants). PATIENTS: All CP diagnosed in PC between April 1989 and October 1996. MEASUREMENTS AND MAIN RESULTS: PC clinical history, hospital records and request for specialist consultation in 41 cases were reviewed. In cases coming from PC (71%), the most frequent clinical picture was mixed prostate syndrome (44.8%). PSA (20.7%) and urine sediment (17.2%) were the most commonly requested investigations. Rectal touch (RT) occurred in one case (3.4%) and four cases were diagnosed as CP. In the urology service, RT occurred in 68% of cases, with PSA determined in 59% of those who had not had it. After the first visit, 44% were diagnosed as CP. Two time intervals in common between PC and hospital were studied: referral-specialist visit and specialist visit-diagnosis. In PC there were mean delays of 50 days (SD, 53; percentile [P] 25 = 14; P50 = 35; P75 = 75) and 420 days (SD, 595; P25 = 72; P50 = 194; P75 = 490), respectively. In the hospital the times were 6 days for the first (SD, 6; P25 = 2; P50 = 5; P75 = 8.5), and 168 for the second (SD, 176; P25 = 34; P50 = 130; P75 = 271). The differences were statistically significant: p = 0.0006 and p = 0.05. CONCLUSIONS: Doing RT and PSA determination in primary care would favour diagnosis in the cases of CP. The creation of training programmes and rapid referral routes to hospital could reduce the delays looked at.

Nefroma multilocular quístico. Presentación de un caso / Multilocular cystic nephroma. A new case presentation

Presentamos un nuevo caso de nefroma multilocular quístico y se realiza revisión de la literatura. Ante una lesión quística compleja diagnosticada por T.C. aplicamos la clasificación de Bosniak. El nefroma multilocular se presenta en forma de lesión quística múltiple separada por tabiques fibrosos, con o sin calcificaciones, por lo que plantea el diagnóstico diferencial entre CCR y nefroma multiquístico. El diagnóstico definitivo es histológico (AU)

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Situación diagnóstica del cáncer de próstata en atención primaria / Diagnostic situation of prostate cancer in primary care

Objetivo. Valorar la calidad diagnóstica en atención primaria (AP) del cáncer de próstata (CP) y analizar factores asociados al posible retraso diagnóstico. Diseño. Estudio transversal retrospectivo. Emplazamiento. Cinco centros de AP y centro hospitalario (CH) (población aproximada, 130.000 habitantes). Pacientes. Todos los CP diagnosticados en el CH entre abril de 1989 y octubre de 1996. Mediciones y resultados principales. Se revisaron: historia clínica de AP, hospitalaria y petición de consulta especializada de los 41 casos. En los casos procedentes de AP (71 por ciento) la clínica más frecuente fue el síndrome prostático mixto (44,8 por ciento). El PSA (20,7 por ciento) y sedimento de orina (17,2 por ciento) fueron las exploraciones más solicitadas. Se realizó tacto rectal (TR) en un caso (3,4 por ciento) y 4 casos fueron orientados como CP. En el servicio de urología, el TR se realizó en un 68 por ciento de los casos, determinándose el PSA en el 59 por ciento de los que no lo tenían. Tras la primera visita, un 44 por ciento fue orientado como CP. Se estudiaron 2 intervalos de tiempos comunes: derivación-visita especializada y visita especializada-diagnóstico. En AP se obtuvo una media de 50 días (DE, 53; percentil [P] 25 = 14; P50 = 35; P75 = 75) y 420 (DE, 595; P25 = 72; P50 = 194; P75 = 490), respectivamente. Los resultados en el CH fueron de 6 días (DE, 6; P25 = 2; P50 = 5; P75 = 8,5) para el primero y 168 (DE, 176; P25 = 34; P50 = 130; P75 = 271) en el segundo. Las diferencias resultaron estadísticamente significativas: p = 0,0006 y p = 0,05. Conclusiones. La realización del TR y determinación del PSA desde AP favorecería la orientación diagnóstica en los casos de CP. La creación de programas formativos y vías de derivación rápida al CH permitiría reducir los intervalos estudiados Objetivo. Valorar la calidad diagnóstica en atención primaria (AP) del cáncer de próstata (CP) y analizar factores asociados al posible retraso diagnóstico. Diseño. Estudio transversal retrospectivo. Emplazamiento. Cinco centros de AP y centro hospitalario (CH) (población aproximada, 130.000 habitantes). Pacientes. Todos los CP diagnosticados en el CH entre abril de 1989 y octubre de 1996. Mediciones y resultados principales. Se revisaron: historia clínica de AP, hospitalaria y petición de consulta especializada de los 41 casos. En los casos procedentes de AP (71 por ciento) la clínica más frecuente fue el síndrome prostático mixto (44,8 por ciento). El PSA (20,7 por ciento) y sedimento de orina (17,2 por ciento) fueron las exploraciones más solicitadas. Se realizó tacto rectal (TR) en un caso (3,4 por ciento) y 4 casos fueron orientados como CP. En el servicio de urología, el TR se realizó en un 68 por ciento de los casos, determinándose el PSA en el 59 por ciento de los que no lo tenían. Tras la primera visita, un 44 por ciento fue orientado como CP. Se estudiaron 2 intervalos de tiempos comunes: derivación-visita especializada y visita especializada-diagnóstico. En AP se obtuvo una media de 50 días (DE, 53; percentil [P] 25 = 14; P50 = 35; P75 = 75) y 420 (DE, 595; P25 = 72; P50 = 194; P75 = 490), respectivamente. Los resultados en el CH fueron de 6 días (DE, 6; P25 = 2; P50 = 5; P75 = 8,5) para el primero y 168 (DE, 176; P25 = 34; P50 = 130; P75 = 271) en el segundo. Las diferencias resultaron estadísticamente significativas: p = 0,0006 y p = 0,05. Conclusiones. La realización del TR y determinación del PSA desde AP favorecería la orientación diagnóstica en los casos de CP. La creación de programas formativos y vías de derivación rápida al CH permitiría reducir los intervalos estudiados (AU)