The need for re-TUR of the bladder in non-muscle invasive bladder cancer: risk factors of tumor persistence in re-TUR specimens.

AIM: This study evaluated the need for re-TUR of the bladder in non-muscle invasive bladder cancer (NMIBC) with complete transurethral resection (TUR) and examined the risk factors for disease occurrence in re-TUR of the bladder. METHODS: A cohort of 211 patients diagnosed consecutively of NMIBC (July 2009 to October 2011) underwent re-TURB 4-6 weeks after the initial TURB. Association with tumor presence in re-TURB of the following parameters was analyzed: sex, primary/recurrent, number, size, stage, grade, association of carcinoma in situ, early instillation of Mitomycin C, and its classification according to the EORTC risk groups. RESULTS: Fifty-seven (27%) cases exhibited residual tumors in the re-TURB and understaging was observed in 3 (1.4%) patients. The EORTC classified 151 (71.6%) patients as high risk; 124 (58.7%) patients received postoperative instillations of Mitomycin C. 31.8% of high risk patients exhibited tumors in the re-TUR compared to 14% of the low/intermediate risk (P<0.05). A total of 19.4% of patients with early instillation of Mitomycin C had tumor in re-TURB compared to 38.4% of patients without it (P<0.05). Multivariate analysis showed that high-risk tumors behaved as an independent risk factor for the tumor presence in re-TURB (HR=12.65, P=0.008), but early postoperative instillation of Mitomycin C was a protective factor (HR=2.16, P=0.02). The limitations of the study are the absence of randomization and its unicentric character. CONCLUSION: Patients who were at a high risk of tumor recurrence and/or progression according to the EORTC classification exhibited a higher percentage of tumors in re-TURB. Therefore, these patients are optimal candidates for re-TURB.

Traumatic rupture of horseshoe kidney.

We present the case of a 25-year-old male who came to the emergency room for pain and abdominal distension following trauma to the mesogastrium. A CT scan was performed, revealing a voluminous retroperitoneal hematoma with laceration of both inferior renal poles with regard to rupture of the isthmus of a horseshoe kidney. The patient presented anemization and increased pain, requiring selective embolization by means of arteriography of a branch of the right renal artery and placement of a double J stent due to urinary extravasation in the lower left kidney pole. Following 1 year of monitoring, the patient has maintained normal renal function. Renal affection in blunt abdominal trauma is frequent, occurring in 7% of previously pathological kidneys. The traumatic rupture of horseshoe kidney is facilitated by its particular anatomical characteristics, constituting an infrequent entity, knowledge of which is necessary to achieve conservative management that renders it possible to preserve renal function.

Impossible bladder catheter removal. What can we do?

OBJECTIVE: The inability to remove a bladder catheter due to impossible balloon removal is a situation with controversial management; there are no action guidelines and it is limited to individual experience in most cases. In this article, we review the techniques described for removing a urethral catheter and we share our experience with one case. METHODS: A 70-year-old male with permanent bladder catheter was referred to the emergency department due to an inability to deflate the self-retaining balloon during routine change in his health centre. RESULTS: After unsuccessfully trying to puncture the balloon through the inflation channel previously cut above the valve, we punctured it via the suprapubic route under ultrasound guidance with a biopsy needle. Using this technique, we managed to rupture the balloon without free fragments, enabling the catheter to be changed without incident. CONCLUSIONS: There are various techniques for approaching this situation, the knowledge of which enables the urologist to resolve the problem by adapting to patient's characteristics and available resources. Suprapubic puncture of the self-retaining balloon is an easily reproducible technique with minimal complications and a lower rate of free fragments.

Predictive factors for recurrence in clinically localized squamous cell carcinoma of the penis. Analisys of our case series.

OBJECTIVE: To evaluate the predictive factors for relapse in clinically localized squamous cell carcinoma of the penis undergoing surgical treatment. METHODS: Forty-nine patients were diagnosed with cancer of the penis in our Service between 1999 and 2009. In the present study we excluded 18 subjects: 9 due to the presence of palpable adenopathies, 6 due to histological characteristics other than squamous cell carcinoma, two lost to follow-up, and one due to death at the time of diagnosis. Diagnosis was based on physical examination and biopsy findings. The primary lesion was treated by circumcision, partial surgery or total penectomy. Disease relapse was defined by lymph node or metastatic involvement after three months from surgery. Univariate and multivariate analysis were carried out using the chi-squared test and logistic regression to identify the factors involved in tumor relapse. RESULTS: Thirty-one patients were included in the study. Mean follow-up was 36 months (median 29). The histopathological study yielded the following profile: 55% pT1 cases, 32% pT2 cases and 13% pT3 tumors. Regarding histological grade, the distribution was G1: 29%, G2: 32%, G3: 39%. Recurrence and mortality rates were 38.7% and 35.5%, respectively. In the univariate analysis, location of the lesion (p=0.004), type of surgery (p=0.008), tumor stage (p=0.003) and cellular grade (p<0.001)were significantly correlated to disease relapse. In the multivariate analysis, only cellular grade proved statistically significant (p=0.01). CONCLUSION: In our series, only histological grade could be regarded as an independent predictor of tumor relapse.

Stuttering priapism: case report and bibliographic review.

OBJECTIVE: To review the presentation, physiopathology, diagnosis and therapeutic alternatives of stuttering priapism with the contribution of a new clinical case. METHODS: A 25 year old man, studied in another center for recurrent episodes of priapism for about 18 months. These episodes occur daily, significantly interfering with patient's quality of life. RESULTS: Initially he was treated with Bicalutamide 50mg/24h with no improvement. Blood test, penile Doppler ultrasound and selective arteriography of pudendal arteries showed no abnormalities. Tadalafil 5mg/24h was given for two months without response. Subsequently were treated with Diazepam 10 mg/24h and Terbutaline 5 mg/24h allowing control of the disease, remaining asymptomatic at present. CONCLUSIONS: Stuttering priapism is a rare form of presentation of this disease, caused by an alteration in the regulatory mechanisms of erection mediated by 5PDE and cGMP. Several drugs have been proposed in treatment with variable effectiveness, though there is no series long enough to recommend either as first choice. The use of inhibitors 5PDE so long, has been used successfully by some groups. Knowledge of these alternatives is important for the treatment of this complex and unusual pathology.

Laparoscopic partial nephrectomy with prior superselective embolisation as treatment for giant renal angiomyolipoma. / Nefrectomía parcial laparoscópica previa embolización supraselectiva como tratamiento de angiomiolipomas renales gigantes.

OBJECTIVE: Cases of giant renal angiomyolipoma (>9cm) are a therapeutic challenge due to their low frequency and large size. The treatment objective for patients with renal angiomyolipoma should be complete tumour extirpation, with a nephron-sparing surgical technique, without complications and using a minimally invasive approach. MATERIAL AND METHODS: We present 3 cases of giant angiomyolipoma (10 12 and 14cm) treated with a combined approach: superselective embolisation and subsequent laparoscopic partial nephrectomy, in 3 separate hospitals. RESULTS: None of the cases required conversion to open surgery. One of the 3 patients underwent arterial clamping, and none of the patients had complications. CONCLUSIONS: The combined approach provides a procedure with the criteria of minimal invasiveness, nephron sparing, little bleeding and reduced warm ischaemia time.

Nefrectomía parcial laparoscópica previa embolización supraselectiva como tratamiento de angiomiolipomas renales gigantes / Laparoscopic partial nephrectomy with prior superselective embolisation as treatment for giant renal angiomyolipoma

Objetivo: Los casos de angiomiolipoma renal gigante (> 9 cm) son un reto terapéutico por su baja frecuencia y su tamaño. El objetivo del tratamiento de los pacientes con angiomiolipoma renal debe ser la extirpación completa del tumor, con una técnica quirúrgica conservadora de nefronas, sin complicaciones y mediante un abordaje mínimamente invasivo. Material y métodos: Presentamos 3 casos de angiomiolipoma gigante (14, 12 y 10 cm) tratados mediante abordaje combinado: embolización supraselectiva y posterior nefrectomía parcial laparoscópica, en 3 hospitales diferentes. Resultados: Ningún caso precisó reconversión a cirugía abierta, en uno de los 3 pacientes se realizó clampaje arterial y ninguno experimentó complicaciones. Conclusiones: El abordaje combinado permite una cirugía con criterios de mínima invasión, conservadora de nefronas, con escaso sangrado y disminución del tiempo de isquemia caliente

Objective: Cases of giant renal angiomyolipoma (> 9 cm) are a therapeutic challenge due to their low frequency and large size. The treatment objective for patients with renal angiomyolipoma should be complete tumour extirpation, with a nephron-sparing surgical technique, without complications and using a minimally invasive approach. Material and methods: We present 3 cases of giant angiomyolipoma (10 12 and 14 cm) treated with a combined approach: superselective embolisation and subsequent laparoscopic partial nephrectomy, in 3 separate hospitals. Results: None of the cases required conversion to open surgery. One of the 3 patients underwent arterial clamping, and none of the patients had complications. Conclusions: The combined approach provides a procedure with the criteria of minimal invasiveness, nephron sparing, little bleeding and reduced warm ischaemia time

Síndrome de supresión de acetato de abiraterona / Abiraterone acetate suppression syndrome

No disponible

Hidronefrosis terminal gigante / Giant terminal hydronephrosis

No disponible

Isquemia renal secundaria a hematoma retroperitoneal / Renal ischemia secondary to retroperitoneal hematoma

No disponible

Imposibilidad para la retirada de sonda vesical ¿Qué hacer? / Impossible bladder catheter removal. What can we do?

OBJETIVO: La imposibilidad de retirada de una sonda vesical por imposibilidad para retirar el balón es una situación de manejo controvertido, sin unas pautas de actuación limitándose a la experiencia individual en la mayoría de los casos. En este artículo revisamos las técnicas descritas para retirar un catéter uretral y aportamos nuestra experiencia con una de ellas. MÉTODOS: Varón de 70 años, portador de sonda vesical permanente remitido al servicio de urgencias por imposibilidad para desinflar el balón de autoretención durante un cambio rutinario en su centro de salud. RESULTADOS: Tras intentar sin éxito puncionar el globo a través del canal de inflado previamente cortado por encima de la válvula, puncionamos este por vía suprapubica bajo control ecográfico con una aguja de biopsia. Con esta técnica conseguimos el estallido del balón sin fragmentos residuales permitiendo el cambio de la sonda sin incidencias. CONCLUSIONES: Existen varias técnicas para el abordaje de esta situación cuyo conocimiento permite al urólogo la resolución del problema adecuándose a las características del paciente y los recursos disponibles. La punción suprapubica del balón de autoretención es una técnica fácilmente reproducible con un mínimo índice de complicaciones y menor tasa de fragmentos residuales(AU)

OBJECTIVE: The inability to remove a bladder catheter due to impossible balloon removal is a situation with controversial management; there are no action guidelines and it is limited to individual experience in most cases. In this article, we review the techniques described for removing a urethral catheter and we share our experience with one case. METHODS: A 70-year-old male with permanent bladder catheter was referred to the emergency department due to an inability to deflate the self-retaining balloon during routine change in his health centre. RESULTS: After unsuccessfully trying to puncture the balloon through the inflation channel previously cut above the valve, we punctured it via the suprapubic route under ultrasound guidance with a biopsy needle. Using this technique, we managed to rupture the balloon without free fragments, enabling the catheter to be changed without incident. CONCLUSIONS: There are various techniques for approaching this situation, the knowledge of which enables the urologist to resolve the problem by adapting to patient’s characteristics and available resources. Suprapubic puncture of the self-retaining balloon is an easily reproducible technique with minimal complications and a lower rate of free fragments(AU)

Factores predictores de recidiva en el carcinoma epidermoide de pene clínicamente localizado. Análisis de nuestra serie / Predictive factors for recurrence in clinically localized squamous cell carcinoma of the penis. Analisys of our case series

OBJETIVO: Evaluar los factores predictores de recidiva del carcinoma epidermoide de pene clínicamente localizado tratado con cirugía.MÉTODOS: 49 pacientes fueron diagnosticados de cáncer de pene en nuestro servicio entre 1999 y 2009. Excluimos 18 pacientes: 9 por adenopatías palpables, 6 por histologías diferentes al epidermoide, 2 por pérdida del seguimiento y 1 por fallecimiento al diagnóstico.El diagnóstico se estableció mediante exploración y biopsia de la lesión. La lesión primaria fue tratada mediante circuncisión, cirugía parcial o penectomía total.Se definió como recidiva la afectación ganglionar o metastásica a partir del tercer mes tras la cirugía.Realizamos un análisis uni y multivariante mediante chi cuadrado y regresión logística para identificar los factores implicados en la recidiva.RESULTADOS: 31 pacientes fueron incluidos en el estudio. El seguimiento medio fue de 36 meses con una mediana de 29.El análisis histopatológico evidenció 55% pT1, 32% pT2 y 13% pT3. El grado histológico fue G1: 29%, G2: 32%, G3: 39%.Las tasas de recidiva y mortalidad fueron 38,7%, y 35,5% respectivamente.En el análisis univariante la localización de la lesión (p=0,004), el tipo de cirugía (p=0,008), el estadio (p=0,003) y el grado celular (p<0,001) se relacionaron de forma estadísticamente significativa con la recidiva.En el análisis multivariante solo el grado celular resultó estadísticamente significativo (p=0,01).CONCLUSIÓN: En nuestra serie, solo el grado histológico puede considerarse factor predictivo independiente de recidiva(AU)

OBJECTIVE: To evaluate the predictive factors for relapse in clinically localized squamous cell car-cinoma of the penis undergoing surgical treatment.METHODS: Forty-nine patients were diagnosed with cancer of the penis in our Service between 1999 and 2009. In the present study we excluded 18 subjects: 9 due to the presence of palpable adenopathies, 6 due to histological characteristics other than squamous cell carcinoma, two lost to follow-up, and one due to death at the time of diagnosis. Diagnosis was based on physical examination and biopsy findings. The primary lesion was treated by circumcision, partial surgery or total penectomy. Disease relapse was defined by lymph node or metastatic involvement after three months from surgery.Univariate and multivariate analysis were carried out using the chi-squared test and logistic regression to identify the factors involved in tumor relapse.RESULTS: Thirty-one patients were included in the study. Mean follow-up was 36 months (median 29). The histopathological study yielded the following profile: 55% pT1 cases, 32% pT2 cases and 13% pT3 tumors. Regarding histological grade, the distribution was G1: 29%, G2: 32%, G3: 39%. Recurrence and mortality rates were 38.7% and 35.5%, respectively.In the univariate analysis, location of the lesion (p=0.004), type of surgery (p=0.008), tumor stage (p=0.003) and cellular grade (p<0.001) were significantly correlated to disease relapse.In the multivariate analysis, only cellular grade proved statistically significant (p=0.01)(AU)

Metástasis de cáncer de próstata en cartílago tiroides: manifestación inusual del adenocarcinoma prostático. Presentación de un caso / Metastatic prostate cancer on the thyroid cartilage: unusual symptoms of prostatic

OBJETIVO: Revisar las formas atípicas de presentación del cáncer de próstata metastasico mediante la presentación de un caso de afectación del cartílago tiroides.MÉTODOS:Paciente de 49 años ingresado por hematuria monosintomática de 48 horas de evolución, asociada a dolor lumbar irradiado a miembros inferiores y masa cervical izquierda desde hace 3 meses. RESULTADOS: Se realizó TC Toraco-Abdomino-Pélvico con hallazgo de lesión insuflante en la lámina izquierda del cartílago tiroides sugestiva de condrosarcoma, tumoración vesical de 4 cm en cara posterior y metástasis óseas en los cuerpos vertebrales L4-S1 y en la pala iliaca izquierda. En la cistoscopia se evidencia infiltración prostática de la cara posterior vesical sin lesiones sugestivas de tumor urotelial. El PSA resultó de 617 ng/ml. Tacto rectal con próstata aumentada de tamaño y consistencia Ante estos hallazgos se realizo ecografía transrectal con biopsia prostática con el resultado anatomopatológico de adenocarcinoma prostático Gleason 8 bilateral.Se inició tratamiento con bloqueo hormonal completo con Bicalutamida y Goserelina, alcanzando el PSA niveles de 29 ng/ml.En relación a la masa cervical se realizó laringectomía parcial vertical izquierda con reposición con cartílago septal. El estudio anatomopatológico reveló la presencia de un adenocarcinoma prostático.CONCLUSIONES: La metástasis del cáncer de próstata en el cartílago tiroides es excepcional con solo cinco casos descritos en la literatura. Este hecho, unido a la escasa frecuencia de los tumores que asientan en dicho cartílago y su diagnostico mediante sospecha radiológica, hace muy difícil incluir la metástasis del cáncer de próstata en el diagnostico diferencial rutinario de las masas cervicales(AU)

OBJECTIVE: To review the unusual localizations of metastasic prostate cancer with the contribution of a clinical case of prostatic adenocarcinoma metastasis in the thyroid cartilage.METHODS: 49-year-old-male admitted with history of 48 hour hematuria associated with lumbar pain radiating to the lower extremities and cervical tumour for 3 months.RESULTS: CT scan of the thorax, abdomen and pelvis was performed showing an insufflating lesion on the left thyroid cartilage lamina suggesting chondrosarcoma, a 4 cm tumour on the posterior side of the bladder, and metastases on L4-S1 vertebral bodies and left iliac bone. Cystoscopy revealed an image on the posterior vesical wall suggesting prostatic infiltration by a tumoral process without evidence of urothelial tumors. PSA was 617 ng/ml. Digital rectal examination: Prostate with augmented consistency. Due to these results an ultrasound-guided transrectal prostatic biopsy was performed with the pathological result of Gleason 8 prostatic adenocarcinoma involving boths lobes.Complete androgen blockade with Bicalutamide and Goserelin was started with good response lowering the PSA level down to 29 ng/ml. Regarding the cervical mass suggestive of thyroid chondrosarcoma a left vertical partial laryngectomy was performed with replacement of the thyroid cartilage by septal cartilage. Pathological study of the piece revealed the presence of prostatic adenocarcinoma.CONCLUSION: Metastatic prostate cancer in the thyroid cartilage is exceptional, there being only five cases described in the literature. This fact, linked to the scant frequency of tumours lying in this cartilage and diagnosis by means of radiological suspicion, makes it very difficult to include metastatic prostate cancer in the routine differential diagnosis of cervical masses(AU)

Ampliación vesical con uso de aparato digestivo. Indicaciones, seguimiento y complicaciones / Bladder augmentation using the gastrointestinal tract. Indication, follow up and complications

La ampliación vesical utilizando el tracto gastrointestinal tiene por objetivo crear un reservorio de baja presión y alta capacidad, permitiendo una continencia y vaciado adecuados, preservando el tracto urinario superior.OBJETIVO: Analizar las indicaciones, complicaciones y resultados de nuestra serie de enterocistoplastias de aumento.MÉTODO: Revisamos retrospectivamente los pacientes sometidos a enterocistoplastia de aumento en nuestro servicio entre los años 1997 y 2010 ambos inclusive. Las indicaciones fueron: Cistitis intersticial, vejiga neurógena y retracción vesical inflamatoria. En todos los casos se realizó cistografía, uretrocistoscopia, estudio urodinámico y diario miccional, así como los estudios propios de cada patología. Mediante laparotomía media y abordaje extraperitoneal se realiza la liberación vesical con apertura bivalva hasta los orificios ureterales. La ampliación vesical se realiza con un segmento de 15-20 cm de íleon detubulizado a 20 cm de la válvula ileocecal; en los casos de insuficiencia renal se añadió una cuña de 7 cm de cuerpo gástrico. La sonda vesical se retiró tras cistografía a los 15 días. El seguimiento se realizó mediante ecografía con residuo postmiccional, analítica sanguínea, urocultivo y diario miccional.Realizamos un estudio descriptivo de las características demográficas, complicaciones postoperatorias según la clasificación de Clavien y a largo plazo(AU)

RESULTADOS: Incluimos 24 pacientes, 19 mujeres y 5 varones con una edad media de 48,5 años y una mediana de 47 (21-77). El seguimiento medio fue de 7,5 años con una mediana de 8. Las indicaciones fueron: 7 cistitis intersticiales, 9 retracciones vesicales y 8 vejigas neurógenas. No hubo complicaciones intraoperatorias. Las complicaciones postoperatorias fueron 3 Clavien I, 2 tipo II, 2 IIIa y 1 IIIb. A largo plazo 3 pacientes presentan incontinencia urinaria, 2 acidosis metabólica leve, 5 precisan autocateterismos, 6 litiasis vesicales, 2 infecciones urinarias febriles y 1 estenosis de la boca anastomótica. En tres casos se realizó ileogastrocistoplastia sin deterioro hidroelectrolitico ni de la función renal.CONCLUSIONES En pacientes seleccionados la enterocistoplastia de aumento constituye una opción terapéutica eficaz con escasa morbilidad y complicaciones en el tratamiento de la disfunción del tracto urinario inferior(AU)

The purpose of bladder augmentation using the gastrointestinal tract is to create a low-pressure and high-capacity reservoir, permitting suitable continence and voiding, preserving the upper urinary tract.OBJECTIVE: To analyze the indications, complications and results of our series of augmentation enterocystoplasties.METHOD: We retrospectively reviewed patients undergoing augmentation enterocystoplasty in our department between 1997 and 2010, both included. The indications were: Interstitial cystitis, neurogenic bladder and inflammatory bladder retraction. In all cases a cystography, urethrocystoscopy, urodynamic study and voiding diary were performed, as well as the specific studies of each condition. Bladder release is performed by means of medial laparotomy and an extraperitoneal approach with bivalve opening to the urethral orifices. The bladder augmentation is performed with a 15-20 cm segment of detubularized ileum obtained at 20 cm from the ileocecal valve; in cases of kidney failure, a 7-cm gastric body wedge is added. The bladder catheter was removed following cystogram after 15 days.Monitoring was performed by means of ultrasound with postvoid residual, blood analyses, urine culture and voiding diary. We performed a descriptive study of the demographic characteristics, postoperative complications according to the Clavien classification and in the long term(AU)

RESULTS: We included 24 patients, 19 women and 5 men with a mean age of 48.5 years and a median of 47 (21-77). Mean follow up was 7.5 years with a median of 8 (1-11). The indications were: 7 interstitial cystitis, 8 bladder retraction and 7 neurogenic bladder. There were no intraoperative complications. The postoperative complications were 3 Clavien I, 2 type II, 2 IIIA and 1 IIIB.In the long term, 3 patients presented urinary incontinence, 2 mild metabolic acidosis, 5 required self-catheterization, 6 bladder stones, 2 febrile urinary tract infections and 1 stricture of the anastomotic mouth. In three cases, an ileogastrocystoplasty was performed without hydroelectrolytic impairment or impairment of kidney function.CONCLUSIONS: In selected patients, augmentation enterocystoplasty constitutes an efficacious therapeutic option in the treatment of lower urinary tract dysfunction with scant morbidity and few complications(AU)