Key areas in the learning curve for robotic urological surgery: a Spanish multicentre survey.

BACKGROUND: The number of robotic-assisted procedures offered in Spain is rapidly increasing despite a lack of consensus criteria for training and credentialling. OBJECTIVE: This national multicentre study was designed to analyze the different areas of the robotic urological surgery learning curve. MATERIAL AND METHODS: A questionnaire was sent to all 13 urology units in Spain with an active robotics programme requesting information on training and problems encountered. RESULTS: In most centres (n = 11, 84.6%), training programmes were animal-based; cadavers were used at only 2 (15.4%). Proctoring in initial procedures was practiced by 12 groups (92.3%). When initiating the robotics programme, the console was shared at 8 units (61.5%). Prior experience in open and/or laparoscopic surgery was reported by 10 of the groups (76.9%), and experience in open surgery only by 2 (15.4%) or robotic surgery alone by 1 (7.7%). The procedure with which the robotics programme was started in all 13 participating units was radical prostatectomy. The number of cases needed to complete the learning curve for this procedure was 20-25 cases according to 8 (61.5%) surgery teams. CONCLUSIONS: Up until March 26, 2010, 1,692 operations, mostly radical prostatectomies, were conducted using the da Vinci robot in our country.

[Renal angiomyolipoma causing inferior vena cava thrombus and secondary Budd-Chiari's syndrome]. / Angiomiolipoma renal causante de trombo en cava y síndrome de Budd-Chiari secundario.

OBJECTIVE: We report one case of renal angiomyolipoma with three characteristics: renal sinus origin, inferior vena cava tumor thrombus reaching the right atrium and Budd-Chiari syndrome. METHODS: The characteristics of the case are presented and discussed. RESULTS/CONCLUSIONS: Renal angiomyolipoma is a benign mesenchymal tumor. It is an uncommon tumor (2-6.4% of all kidney tumors), with a female predominance. Angiomyolipoma most often originate from the renal parenchyma but they can rarely originate from the renal sinus. They can involve the renal vein, the inferior vena cava and even the right atrium as a tumor thrombus. Angiomyolipoma commonly present as an incidental finding on radiographic studies, but the clinical presentation varies from flank pain to fatal pulmonary tumor embolism. The Budd-Chiari syndrome is an extremely rare presentation. Because of the risk of potentially fatal cardiopulmonary embolism and death, surgical treatment (radical nephrectomy plus tumor thrombectomy) of these lesions is indicated even when they are asymptomatic.

[Establishment of a robotic program]. / Establecimiento de un programa de cirugía robótica en un hospital.

Robotic surgery is expanding little by little in urology. At present only few centers have incorporated this new technology in Spain but it is predictable that this number will exponentially increase in a near future. We described the experience of our center establishing and developing a program of robotic surgery that it is operating since July 2006. It is important to know some basic premises that it is compulsory to fulfill to reach optimal results.

[Involvement of bladder neck and periurethral sphincter in dyssynergia in patients with spinal cord injury]. / Participación del cuello vesical y el esfínter periuretral en la disinergia de pacientes con lesión medular traumática.

OBJECTIVE: To determine the degree of association of detrusor-periurethral dyssynergia and detrusor-bladder neck dyssynergia and if the voiding periurethral electromyographic (EMG) activity is also a valid method for diagnosing detrusor-bladder neck dyssynergia. METHODS: A clinical, videourodynamic and selective periurethral EMG study was performed in 24 patients (mean age 33 years) with spinal cord injury and hyperreflexia of the bladder. RESULTS: The prevalence of bladder neck dyssynergia was 12.5% (3 cases) in this series. All patients with dyssynergic bladder neck also showed intermittent or sustained periurethral sphincter EMG activity. However, 15 patients showed increased intermittent or sustained voiding periurethral EMG activity that was not associated with detrusor-bladder neck dyssynergia. Utilizing the videourodynamic demonstration of detrusor-bladder neck dyssynergia as reference, selective periurethral EMG showed a sensitivity of 100% and a specificity of 29% for the diagnosis of detrusor-bladder neck dyssynergia. CONCLUSIONS: The finding of bladder neck dyssynergia indicates the existence of detrusor-periurethral dyssynergia. However, not all cases of detrusor-periurethral sphincter dyssynergia is associated with bladder neck dyssynergia; therefore a videourodynamic study should be performed to rule out bladder neck dyssynergia in those patients with detrusor-periurethral sphincter dyssynergia. This is important in making the differential diagnosis and also has significant therapeutic repercussions.

[Metachronous recurrence of idiopathic high flow priapism]. / Recurrencia metacrónica de priapismo idiopático de alto flujo.

OBJECTIVES: To report one case of metachronous recurrence of idiopathic high flow priapism. METHODS. We describe the case of a 28-year-old male patient who presents with penile partial tumescence which started 10 hours before and history of a similar episode seven years before. Physical examination confirmed the clinical picture, with mild local discomfort on palpation. Blood tests were normal. Cavernous blood gases were compatible with arterial blood O2 saturation levels. The patient had a satisfactory progressive response to oral administration of diazepam. No pathologic findings were seen at the time of arteriography. RESULTS: Complete resolution of the episode. Erectile function was satisfactorily preserved. There was no relapse after one year of follow-up. CONCLUSIONS: We remark the validity of a deferred therapeutic attitude in front of pictures of high flow priapism, as well as the possibility of resolution with conservative measures. We emphasize the peculiarities of this case, mainly its idiopathic character and the metachronous recurrence.

[New contributions of the usefulness of electromyography of cavernous bodies in the diagnosis of erectile dysfunction]. / Nuevas aportaciones de la utilidad de la electromiografía de los cuerpos cavernosos en el diagnóstico de la disfunción eréctil.

OBJECTIVES: To test the concordance between clinical and neurophysiologic data of the various types of erectile dysfunction, and to describe a diagnostic algorithm based on corpus cavernosum electromyography (cc-EMG). METHODS: 32 patients with a mean age of 50.6 years (typical deviation 13.2 years) referred with the diagnosis of erectile dysfunction underwent medical history, neuroandrologic physical exam, neurophysiologic studies (bulbocavernous muscle electromyography, S2-S4 latency period, threshold and latency of pudendal nerve somatosensory potentials, as well as genital sympathetic evoked potentials-SSR-), and corpus cavernosum electromyography(cc-EMG) both in basal conditions and after administration of 20 micrograms of E-1 prostaglandin (PGE-1). RESULTS: 1--A significative relationship was shown between clinical data of arterial or corpus cavernosum intrinsic origin erectile dysfunction and patients with vascular or structural lesion on cc-EMG data. 2--A significative relationship was shown between patients without previous pathologic history and patients with normal or anxiety cc-EMG. 3--No significative relationship was shown between patients with neurologic lesion and patients with autonomic lesion on cc-EMG. 4--No significative relationship was found between patients with peripheric neurologic lesion and patients with inferior autonomic lesion on cc-EMG. 5--A significative relationship was shown between patients with suprasacral neurologic lesion and patients with superior autonomical lesion on cc-EMG. CONCLUSIONS: Isolated application of pudendal nerve neurophysiologic techniques for the diagnosis of erectile dysfunction is not enough. Autonomic innervation studies should be included, with a cc-EMG dichotomic qualitative interpretation.

[Paratesticular leiomyosarcoma: report of a new case]. / Leiomiosarcoma paratesticular: descripción de un nuevo caso.

OBJECTIVE: To report an additional case of paratesticular leiomyosarcoma. METHODS: Herein we describe a 68-year-old male patient that presented with a growing, indolent, right inguinoscrotal lesion that he had noted several weeks earlier. Physical examination showed a mass involving the distal right spermatic cord and was confirmed by ultrasound and CT. Analyses were normal. Radical orchidectomy with high ligation of the right spermatic cord was performed. RESULTS: Histopathological and immunohistochemical studies demonstrated a well-differentiated paratesticular leiomyosarcoma. Local recurrence was observed at 3 1/2 years' follow-up. Complete excision of the tumorous tissue was performed with no other adjuvant therapy. Six months thereafter, there is no evidence of local recurrence or distant metastasis. CONCLUSIONS: This tumor type is uncommon. Like other authors, we believe that orchifuniculectomy is the treatment of choice. Furthermore, adjuvant radio or chemotherapy does not significantly influence survival in these patients.

[Priapism secondary to chronic myeloid leukemia: value of initial treatment with cavernous lavage plus adjuvant methoxamine]. / Priapismo secundario a leucemia mieloide crónica: valor del tratamiento inicial con lavado cavernoso más metoxamina adyuvante.

OBJECTIVE: To report a case of priapism secondary to leukemia, with special reference to the initial treatment in the emergency services. METHODS: A 53-year-old male with chronic myeloid leukemia presented with prolonged involuntary painful erection of 12 hours' duration. The physical examination and particularly the cavernosal blood gas study, indicated low flow priapism. Punction-lavage of the corpora cavernosa was performed. Because complete response was not achieved with this procedure, adjuvant intracavernous methoxamine was administered. RESULTS: Complete detumescence was achieved after the third dose of methoxamine. There was no recurrence and erectile function was preserved. CONCLUSIONS: We underscore the utility of combined cavernous lavage + adjuvant alpha-1 adrenergic agonist as initial therapy in priapism with this special etiology.

[Extrarenal retroperitoneal angiomyolipoma: bibliography review and report of a new case]. / Angiomiolipoma pararrenal: "revisión de la bibliografía" y presentación de un nuevo caso.

OBJECTIVES: To report the 7th case of pararenal angiomyolipoma published in the world literature and to review the international bibliography. METHODS: We report the case of a 46-year-old female with history of renal colic and a complex mass on radiological tests. RESULTS/CONCLUSIONS: Extrarenal retroperitoneal angiomyolipoma is a rare pathology with no more than 7 published cases. The diagnostic difficulty and radiological similarities with liposarcoma make surgery the treatment of choice.