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.

Angiomiolipoma renal con invasión de vena renal y vena cava inferior. Presentación de un caso y revisión de la literatura / Renal Angiomyolipoma with Extension to Renal and Cava Veins. A Case Report and Revision of the Literature

Introducción El angiomiolipoma es un tumor benigno cuya presentación con invasión del seno renal y formación de trombo venoso tumoral es muy infrecuente, habiéndose descrito aproximadamente 50 casos desde que en 1982 Kutcher describiera el primero. Reporte de caso Presentamos un caso angiomiolipoma renal con afectación venosa diagnosticado mediante TAC a partir del hallazgo de trombo venoso en ecografía y resonancia en una paciente de 43 años embarazada y asintomática que presentó elevación de transminasas en una analítica. Ante la posibilidad de que se tratara de una variante epitelioide y/o clásica con potencial de malignización, se decidió tratamiento mediante nefrectomía y trombectomía abierta, sin incidencias intra ni postoperatorias. La paciente se encuentra asintomática tras 6 meses de seguimiento. La histología fue compatible con angiomiolipoma clásico con trombo venoso. Conclusión La invasión de vena renal por un angiomiolipoma es extremadamente rara. Aunque infrecuente, habría que considerar la posibilidad de malignización para no demorar su tratamiento

Introduction Angiomyolipoma is a benign kidney tumour that rarely affects the renal sinus or the renal or caval vein. Kutcher made the first case report in 1982, and since then there have been described approximately 50 cases. Case Report We present a case of angiomyolipoma with venous thrombus in a 43 years-old asymptomatic pregnant woman who presented elevation of transaminases in a blood test, with an ultrasonography that showed a venous thrombus without any renal mass, being diagnosed after giving birth by scanner. Having in account the possibility of malignancy of the mass, we performed surgical treatment by open radical nephrectomy and thrombectomy, without intraoperative nor postoperative incidences. The patient remains asymptomatic 6 months after surgery. The histology was compatible with classic angiomyolipoma with venous thrombus. Conclussion Angiomyolipoma causing venous invasion is extremely rare, but we should take into consideration its possibility of malignancy in order to treat it as soon as possible

[Nephroblastoma or Wilms tumor. Adult presentation. Report of two cases]. / Nefroblastoma o tumor de Wilms. Presentación en adultos. Estudio de dos casos.

OBJECTIVES: To present to new cases of nephroblastoma or Wilms tumor diagnosed in adult age. METHODS: The first case we report is a 16-year-old female with the diagnosis of stage I nephroblastoma after radical nephrectomy for a right renal mass. She underwent systemic polychemotherapy. The second case is a 33-year-old female with the diagnosis of nephroblastoma after percutaneous biopsy of a right renal mass. Due to the presence of lymph node, hepatic and lung dissemination systemic polychemotherapy (ACTD-VCR-DOX) was given. Right nephrectomy with regional lymph node dissection and hepatic metastasis excision were performed after confirmation of mass reduction. After that, the patient continued receiving systemic polychemotherapy with the same drugs. After resection of a lung nodule which did not disappear, and after confirmation of tumoral presence CB and VP 16 were added. RESULTS: Both patients are disease-free after 58 and 46 months respectively. CONCLUSIONS: This type of tumor typical of childhood is extremely rare in adult age, and despite worse survivals and more aggressiveness are described, they may be treated with the same protocols used in children, following any of the two big co-operative groups: American NWTS or European SIOP.

[Non germinal cell testicular tumors]. / Tumores no germinales de testículo.

OBJECTIVES: We report a review of all patients with testicular tumors undergoing surgery in our Hospital over a 13 year period. There were 151 cases, 50 of them were reported as non germ cell tumors (33%). METHODS/RESULTS: 42% of them were haematopoietic tumors, lymphomas and leukemias. 30% of them were non neoplastic tumors, including vascular tumors and granulomatous orchitis. 12% were identified as Leydig or Sertoli cell tumors. 10% were metastases. CONCLUSIONS: Non germ cell tumors were more frequent in adults (78%) than in children (22%). Among children, 82% of the neoplasias were leukemic infiltration of the testicle.

[Urinary endometrioma]. / Endometrioma urinario.

OBJECTIVES: To analyze the series of cases of endometriosis with urologic involvement reported in our country. METHODS/RESULTS: We found a total of 26 cases of endometriosis including our case, 15 affected bladder and 11 ureter. Independently of ureteral or bladder location, the treatment performed varied, from transurethral resection and laser to cystectomy in cases involving bladder, from segmental ureterectomy with ureteral reimplantation to nephrectomy in ureteral cases. CONCLUSIONS: Surgery is the definitive solution for urinary tract endometriomas. The definitive treatment of endometriosis must be done by gynecologists, by means of hormonal and surgical treatment depending on age, severity and location of the lesions, patient's wishes for future pregnancies, and tolerance to hormone therapy.

[Foamy carcinoma of the prostate]. / Carcinoma espumoso de la próstata.

OBJECTIVES: We report the first case of prostatic foamy gland carcinoma in the Spanish literature. METHODS: Case of a 69-year-old male who consulted for PSA elevation up to 101 ng/ml. Transrectal ultrasound showed a heterogeneous gland with a hipoechogenic area in the right lobe and possible capsular disruption. Six ultrasound guided needle biopsies were performed. The samples from the right lobe were reported as Gleason 6 foamy cell prostatic adenocarcinoma. RESULTS: Prostatic foamy cell carcinoma is a rare tumor, and so are its bibliographic references. Its cells lack of prominent nucleus and nucleoli. They show a plentiful and xanthomatous cytoplasm, with abundant intracytoplasmic pink secretions characteristically. It may be mistaken with low grade adenocarcinomas, and it is essential to differentiate it from the clear cell prostatic adenocarcinoma, prostatic adenosis, and even from benign prostatic hyperplasia. It usually has an intermediate grade, with a Gleason score greater than 4.

[Bilateral renal solitary fibrous tumor]. / Tumor fibroso solitario renal bilateral.

OBJECTIVES: We report the first case of bilateral renal solitary fibrous tumor diagnosed in a patient suffering from tuberous sclerosis. METHODS: From the bibliographic review, only 15 cases of solitary fibrous tumor have been described in the kidney. We did not find any case of simultaneous bilateral involvement. We did not find any case described in a patient with tuberous sclerosis either, as the present case, being a 51-year-old female with presenting with a big abdominal mass arising from the left kidney (25 cm) and another 2 cm mass in the right kidney. CONCLUSIONS: We emphasize the extreme rarity of this tumor in the kidney. It has benign characteristics and behavior, and good prognosis, but requires surgical treatment to obtain a proper histopathologic diagnosis, based on immuno-histochemical studies.

[Hyperdense renal cyst]. / Quiste hiperdenso renal.

OBJECTIVE: We update the diagnostic criteria for renal cystic masses, emphasising in the clinical entity known as hyperdense renal cyst. METHODS: We report the case of a male patient who presented with an atypical left renal cyst. Radiological examinations (US and CT) were performed. A description of renal cyst classification is made. We review the diagnostic criteria for hyperdense renal cyst using the iconography from this case and also its therapeutic approach. RESULTS: An image compatible with left simple renal cyst was found on ultrasound. A CT scan study showed an homogeneous mass with a high attenuation value, non vascular in nature, which complies with all diagnostic criteria for hyperdense renal cyst. CONCLUSIONS: Hyperdense renal cyst is a simple cyst which has suffered bleeding or infection. Diagnosis is made by CT scan and it does not require treatment.

[Prostatic ductal carcinoma]. / Carcinoma ductal prostático.

OBJECTIVES: We presented one case of prostatic adenocarcinoma of ductal origin, known as endometrial adenocarcinoma before. The first case was published in 1967 by Mellicow. Since then we could only recover 8 cases by spanish authors. METHODS/RESULTS: 61-year-old patient presenting with urethral bleeding, PSA 12 ng/cc, and an exophytic urethral mass. Histology was compatible with ductal adenocarcinoma of the cribiform type. Radical prostatectomy was carried out with good outcome at six months follow up. CONCLUSIONS: Prostatic ductal adenocarcinoma is a rare tumor, accounting for 0.2-5% of prostatic tumours. Its behaviour is variable, similar to the acinar cell type. Strikingly, there are scarce references to this tumor type; accordingly to the statistics of incidence it should have been referred more often, which would help to its study in terms of outcomes, treatment, and prognosis.

[Testicular leukemic infiltration]. / Infiltración leucémica testicular.

OBJECTIVES: To remind that despite its low incidence, leukemic relapse in the testicles worsens the prognosis of this haematopoietic neoplasia. METHODS/RESULTS: We report the case of a 20-year-old male suffering from acute lymphoblastic leukemia in complete remission after induction and maintenance treatment, who suffered a leukemic relapse in both testicles. Diagnosis was made by ultrasound and confirmed after bilateral testicular biopsies. The patient died due to fungal infection after new treatment with systemic chemotherapy and bone marrow transplantation. CONCLUSIONS: It is necessary to suspect the existence of leukemic cells within the testicles in patients with this disease, mainly acute lymphoblastic leukemia, who present with acute testicular symptoms. Testicular biopsy confirms the diagnosis. Treatment is systemic, with testicular radiation to eradicate the leukemic reservoir. Despite the achievement of local disease control, this situation worsens the prognosis.