Surgical thromboprophylaxis in daily urologic surgery: Beyond bridge therapy. / La tromboprofilaxis quirúrgica en el día a día de la cirugía urológica: más allá de la terapia puente.

INTRODUCTION: With the advanced laparoscopic and robotic surgery, thromboembolic prophylaxis in urologic procedures has traditionally been based on the experience of other surgical specialties. This paper aims to analyze the current recommendations, through a detailed study of the European clinical guidelines and bibliography, applying the recommendations of thromboprophylaxis to the daily urological practice. OBJECTIVES: To elaborate general recommendations to surgical patients in Urology, avoiding the risk of perioperative thromboembolic events. Optimize medication in chronic patients and accurately classify who are eligible for bridge therapy. MATERIAL AND METHODS: A review of the available literature and the European clinical guidelines was carried out. We analyzed the most recent consensus articles by studying the available bibliography, trials and reviews on which the European guidelines for thromboprophylaxis in urology are based. RESULTS: Thromboembolic prophylaxis should be targeted towards surgeries that require abdominal approaches, prolonged bed rest or oncological pathologies. Bridge therapies with low molecular weight heparins should be limited. Patients undergoing treatment for chronic conditions can benefit from bridge therapies in specific cases. CONCLUSIONS: According to the current guidelines, there might be an overuse of heparins in the daily clinical practice. The development of -direct oral- anticoagulants have shown to reduce the time to reintroduction of medication for chronic conditions as well as a more effective bleeding management.

[Complex renal cyst. Laparoscopic treatment]. / Quiste renal complejo. Tratamiento laparoscópico.

The difference between the simple renal cysts, that doesn't require surgical treatment, and those that need it, sometimes is difficult. The laparoscopic surgical treatment (laparoscopic cyst decortication -laparoscopic partial nefrectomy or radical laparoscopic nefrectomy) its becoming the gold standard technique, recommending this procedure in Bosniak cyst type III or IV, and in the symptomatic renal cyst type I/II and in any patients with Bosniak cyst renal II. We present a case report in which a renal cell carcinoma was found after laparoscopic cyst decortication of Bosniak cyst type II with laparoscopic radical nefrectomy posteriorly.

[N1 prostatic adenocarcinoma treated with radical surgery and immediate hormonal management]. / Adenocarcinoma de próstata N1, tratado con cirugía radical y manipulación hormonal inmediata.

OBJECTIVES: To study the survival in patients with prostate adenocarcinoma, lymph nodes involvement in the intraoperative pathological examination, evaluating both radical surgery and early ablation as treatment. Identification of clinical factors that can predict node involvement. METHOD: 20 patients who underwent radical prostatectomy between 1988-1998 were included in the study. All patients clinically diagnosed with T1-2N0Mx prostate adenocarcinoma (T.N.M. 1992), single metastatic node involvement in the pathological study and early sub-albuginea orchidectomy. This group was compared to a 200-patient control group also with T1-2N0Mx prostate adenocarcinoma but with no pathologic nodular involvement. Statistical study: contingency 2Xb tables (Pearson's chi 2 or Fisher's exact test) to compare qualitative variables; Student's t test for means comparison; Kaplan-Meier for actuarial survival calculations and comparison of Log-rank survival curves. For the study of clinical variants with influence in node involvement a logistic regression model was used. RESULTS: Mean age was 63 +/- 0.8 years. Median follow up 56 months. Mean PSA 33 +/- 4.4 ng/mL and 55% had Gleason 5-7. 16 patients were stage pT3. Specific 5-year survival was 90 +/- 8% and biochemical progression free survival 63 +/- 12%. Clinical variables with statistical significance for node involvement are: pre-surgical PSA greater than 20 ng/mL (RR = 4.6), and Gleason higher than 4 (RR = 3). The remaining variables showed no statistical significance. CONCLUSIONS: Gleason and PSA are the only clinical values that predict node involvement. The procedure performed obtains good results and a survival comparable to that of the control group.

[Pyeloureteral junction stenosis: our experience and review of the literature]. / Estenosis de la unión pieloureteral: exposición de nuestra experiencia y revisión de la literatura.

OBJECTIVES: To study patients with ureteropelvic junction obstruction treated in our department and a retrospective study of this pathology, focus our attention in the diagnosis and treatment. MATERIAL AND METHODS: 62 patients from 7 weeks to 68 years old (mean 29 +/- 1.9). Half of the patients were men and the other half women. In 30 patients the UPJ obstruction was on the right side and 32 patients was on the left side. RESULTS: The most frequent symptom was the flank pain (46.8%). To confirm the diagnosis, we had IVU in the 61.3% of the patients and ultrasound in the 38.7%. The treatment was the Anderson-Hynes pyeloplasty in the 96.8% of the patients. In 33 patients we used a ureteral catheter. The overall success rate was 90.3%. The 29% of the patients presented postoperative complications. CONCLUSIONS: Open pyeloplasty is the gold standard treatment of the UPJ obstruction in selected cases, mainly in children.

[Determining factors in the presence of carcinoma in prostate biopsies]. / Factores influyentes en la presencia de carcinoma en las biopsias de próstata.

PURPOSE: Prostate biopsy is the diagnostic method to detect prostate carcinoma. We try to identify the optimal PSA cut-off, biopsy indication and the clinico-pathological characteristics in order to differentiate those patients with negative biopsy in which we should repeat the proceeding. METHOD: We study 344 biopsies in 292 patients for 16 months. An univariate and multivariate study to identify the influent factors in the existence of prostate cancer in the first biopsy and in the patients with a second one was taken place. RESULTS: Patients in the first biopsy Univariate study: Out of these variables (PSA, PSA ratio, digital rectal examination and prostate volume) just the PSA has statistical significance. Multivariate study: Only the the PSA is an indepent influence factor. Receiving Operated Curve: The optimal cut-off is 10.5 ng/ml. Patients with a second biopsy Univariate study: None of the variables is related with the existence of prostate cancer. Groups comparison: A comparison between the patients in the first biopsy and the patients with a second biopsy is performance with no statistical differences in the variables already mentioned. CONCLUSION: The patient with a PSA greater than 4 ng/ml should be perform a prostate biopsy, mostly if his PSA is over 10 ng/ml. In our experience we do not related the need of a second biopsy with any factor in particular, therefore in our opinion and because of the high rate of negative false, all of the patients should be controlled and undergo a second biopsy if any change in PSA or clinics modification takes place.

[Pheochromocytoma]. / Feocromocitoma.

Presentation of 7 case reports of pheochromocytome, diagnosed and treated in our Centre between 1981 and 1995. Clinically all patients had hypertension. Three presented the triple condition of hypertension, pulsatile headache and palpitations. The most useful analytical studies were urine vainillylmandelic acid (VMA) and catecholamines. The main radiologic method was the scanner (CT). Pre-surgical preparation was with alpha-blockers in 5 patients, adding beta-blockers in 3. Treatment was surgical in all cases, and the approach was selected based on the tumour's size and location. One patient with severe rheumatic heart disease died on day 3 post-surgery. Mean follow-up is 19 months, and only one patient requires anti-hypertensive medication following surgery.

[Retroperitoneal sarcomas]. / Sarcomas retroperitoneales.

Presentation of 11 cases of retroperitoneal sarcoma. Mean time from the beginning of symptoms to diagnosis is 6 months. The primary complementary study is CT. Surgery was performed in all cases, using complete resection in 6 cases, and partial resection in 5. Ten patients relapsed. 9 of which were treated with surgical rescue, in one or more occasions; chemotherapy was added in 6 cases and radiotherapy in 7. Survival at five years is 68%, with a mean follow-up of 66 months.

[The complications of retropubic radical prostatectomy]. / Complicaciones de la prostatectomía radical retropúbica.

Between January 1989 and October 1995, 104 prostatectomies were performed in patients with prostate carcinoma in our centre. Mean follow-up 22 months, range 3-84 months. Overall frequency of complications was 33%. No fatal complications were reported. Complications in the early post-operative occurred in 17 patients (16%); late complications in 18 patients (17%), the most frequent one was stenosis of urethrovesical by-pass. No case of total incontinence has been recorded. The rate of stress incontinence at 3 months was 36% and 15% at 9 months.

[Bladder metastasis of lung adenocarcinoma]. / Metástasis vesical de adenocarcinoma de pulmón.

Secondary or metastatic vesical tumours are a very uncommon condition (less than 1% of vesical tumours). Dissemination routes are usually through blood and lymph, and diagnosis occurs typically in advanced stages. This paper presents one case of metastatic vesical neoplasia that developed 5 years after diagnosis of the primary lung tumour.

[Paratesticular rhabdomyosarcoma]. / Rabdomiosarcoma paratesticular.

Contribution of one case of right paratesticular rhabdomyosarcoma in a 3-year and 4-month old male patient. Following radical orchiectomy and clinical staging, grading is IRS Group I (fully resected localized disease). Subsequently, the patient received 7 polychemotherapy courses and was found to be asymptomatic 4 years after treatment.

[Radical prostatectomy in prostate adenocarcinoma. Clinical factors influencing the pathological stage. Diagnostic model]. / Prostatectomía radical en adenocarcinoma de próstata. Factores clínicos influyentes en el estadio patológico. Modelo diagnóstico.

MATERIAL AND METHODS: Study on the efficacy of stage diagnosis, how to support it based on clinical objective data and description of a prognostic model. Analysis of 160 patients diagnosed with localized prostate adenocarcinoma undergoing radical prostatectomy in the Clínica Universitaria de Navarra between 1988-1997. The statistical study used Fisher's or Pearson's tests for the comparison of qualitative variables. A logistic regression multivariate analysis was run to avoid confounding factors in the pathological stage. RESULTS: 85/160 (53%) were correctly staged. Incorrect staging occurred in patients with higher clinical stage (T1-T2a: 25%; T2bc: 65%). The univariate study shows that the pathological stage is significantly correlated to: a) serum PSA levels (15 ng/mL in P2 vr. 25 ng/mL in P3-4), the most suitable cutoff value being 15 ng/mL. b) digital rectal examination and Gleason. Negatively influencing factors in the multivariate study were: PSA greater than 15 ng/mL, Gleason greater than 5 and a T2bc clinical stage. Risk groups: 4 risk groups are established based on the above factors (inclusion in group 1 involves an 8% risk of having P3, 30% in group 2, 56% in group 3 and 84% in group 4). CONCLUSIONS: The clinical factors with influence in the pathological stage are PSA, Gleason and clinical stage. The reliability of the risk groups established based on these factors is remarkable.

[Upper tract urothelial tumor. Factors that influence survival]. / Tumor de urotelio de vías altas. Factores influyentes en la supervivencia.

MATERIAL AND METHODS: Study of the pathoanatomical features and influential factors on survival of 59 patients diagnosed with a tumour of the upper tract urothelium managed with radical surgery. RESULTS: Mean age 65 years, 83% male, and tumour located in the renal pelvis in 64% cases. 54% was pT1-2, 73% G1-2. 10% had node involvement and 15% metastasis. 44% presented concomitant vesical tumour. No surgery-related deaths were reported. 60% was still alive at study completion. Five-year overall actuarial survival was 60 +/- 7%. Mean survival was 134 months, and median survival 156(101-168 months. 95% CI). Gender, site, morphology, type, concomitant vesical tumour, nodes number and involvement do not significantly influence survival. Only tumour differentiation (p = 0.006) and pathological stage (p = 0.005) are significant in the univariate analysis. The multivariate study showed that pathological stage is the only factor that influences survival. CONCLUSIONS: The most influential independent factor on survival of patients with upper tract endothelium tumour is the pathological stage. Grade is influential in the univariate analysis, and is likely to be a subsidiary factor. Due to the small number of cases, it can not be ruled out that node involvement and type of tumour have an influence on survival.

[Radical prostatectomy. The surgical complications]. / Prostatectomía radical. Complicaciones quirúrgicas.

Study of 165 patients with prostate adenocarcinoma who underwent radical prostatectomy using a retropubic approach. Mean PSA is 19 ng/ml, mean age 63 years and median follow-up 26 months. 22 patients (13.2%) reported complications during the first month post-surgery, primarily urinary fistula of more than 5 days long in 5 patients and rectal injury in 3.49 patients (29%) reported complications after the first month, mainly urinary incontinence in 26 cases and stenosis of the urethrovesical juncture in 15. The group with early complications showed no significant differences compared to those who had none, neither in PSA (p = 0.3) or a worse pathological stage (p = 0.1), and no evidence is shown in terms of biochemical progression or in disease free progression (p = 1). Patients with urethrovesical juncture stenosis have higher mean PSA (p = 0.01), greater biochemical progression (p = 0.006), worse Gleason (p = 0.03 = and worse progression free survival (p = 0.01). Patients with stress incontinence showed no differences compared to the other groups relative to the studied factors.

[Photovaporization of the prostate with Greenlight HPS laser as outpatient major surgery]. / Fotovaporización prostática láser Greenlight HPS en régimen de cirugía mayor ambulatoria.

OBJECTIVE: To assess the efficacy and safety of photovaporization of the prostate with Greenlight HPS laser as major outpatient surgery. MATERIALS AND METHODS: A prospective study was conducted of a cohort of 50 patients with lower urinary tract symptoms secondary to benign prostatic hyperplasia who underwent photovaporization with Greenlight HPS laser (120 W) as major outpatient surgery from May 2008 to February 2009. Inclusion criteria were moderate to severe obstructive lower urinary tract symptoms (IPSS of 10 or more and flowmetry with Qmax of 10 ml/sec or less due to benign prostatic hyperplasia with prostate volume less than 80 ml. Preoperative assessment included IPSS; flowmetry; physical examination; ultrasound examination of the kidney, bladder, and prostate (retropubic and transrectal); and measurement of postvoid residue and PSA levels. Surgical data were assessed (vaporization time, operating time, joules, complications during and after surgery). Patients were followed up 1 and 3 months after surgery (PSA, flow rate, IPSS questionnaire). RESULTS: No patient admission or readmission was required, and bladder catheter was successfully removed from all patients within 24 hours of surgery. Mean patient age was 66.75 years. Mean prostate volume was 44.5 ml (SD + or - 21). Twenty patients (40%) had prior catheterization. Qmax and postvoid values significantly improved. Major complications at follow-up included voiding syndrome-urgency in 6 patients (12%) and mild transient hematuria in 3 patients (6%). CONCLUSIONS: Photovaporization of the prostate with Greenlight HPS laser may be safely and successfully performed as a major outpatient surgical procedure, which undoubtedly represents a change in care, for surgical treatment of patients with lower urinary tract symptoms secondary to benign prostatic hyperplasia.

La tromboprofilaxis quirúrgica en el día a día de la cirugía urológica: más allá de la terapia puente / Surgical thromboprophylaxis in daily urologic surgery: Beyond bridge therapy

Introducción: Con el avance de la cirugía laparoscópica y robótica, la profilaxis tromboembólica en los procedimientos urológicos se han basado clásicamente en la experiencia de otras especialidades quirúrgicas. En este trabajo se realiza un análisis de la actualidad de las recomendaciones, basado en un estudio pormenorizado de las guías clínicas europeas y en la bibliografía, aplicando las recomendaciones de tromboprofilaxis a la práctica urológica diaria. Objetivos: Elaborar unas recomendaciones generales aplicables a los pacientes quirúrgicos en urología, evitando la aparición de eventos tromboembólicos en el periodo perioperatorio. Optimizar la medicación y el ajuste en pacientes crónicos y conocer qué pacientes son candidatos a terapias puente. Material y métodos: Se ha realizado una revisión de la literatura disponible y de las guías clínicas europeas. Se analizan los artículos de consenso más recientes realizando una revisión de la bibliografía disponible y los estudios y revisiones en los que se basan las guías europeas de tromboprofilaxis en urología. Resultados: La profilaxis tromboembólica se debe emplear en aquellas cirugías que requieran abordajes abdominales, encamamiento prolongado o enfermedades oncológicas. Las terapias puente con heparinas de bajo peso molecular deben ser reducidas. Los pacientes en tratamiento crónico se pueden beneficiar de terapias puente en casos concretos. Conclusiones: El empleo de heparinas, tan habitual en la práctica clínica, puede ser excesivo según las guías actuales. La aparición de nuevos fármacos anticoagulantes, los cuales poseen antagonistas directos, permiten la reducción de los tiempos de reintroducción de la medicación crónica y un control más eficaz del sangrado

Introduction: With the advanced laparoscopic and robotic surgery, thromboembolic prophylaxis in urologic procedures has traditionally been based on the experience of other surgical specialties. This paper aims to analyze the current recommendations, through a detailed study of the European clinical guidelines and bibliography, applying the recommendations of thromboprophylaxis to the daily urological practice. Objectives: To elaborate general recommendations to surgical patients in Urology, avoiding the risk of perioperative thromboembolic events. Optimize medication in chronic patients and accurately classify who are eligible for bridge therapy. Material and methods: A review of the available literature and the European clinical guidelines was carried out. We analyzed the most recent consensus articles by studying the available bibliography, trials and reviews on which the European guidelines for thromboprophylaxis in urology are based. Results: Thromboembolic prophylaxis should be targeted towards surgeries that require abdominal approaches, prolonged bed rest or oncological pathologies. Bridge therapies with low molecular weight heparins should be limited. Patients undergoing treatment for chronic conditions can benefit from bridge therapies in specific cases

Fotovaporización prostática láser Greenlight HPS en régimen de cirugía mayor ambulatoria / Photovaporization of the prostate with Greenlight HPS laser as outpatient major surgery

Objetivo: valorar la eficacia y seguridad de realización del procedimiento fotovaporización láser Greenlight HPS en régimen de cirugía mayor ambulatoria. Material y métodos: estudio prospectivo de una cohorte de 50 pacientes con sintomatología de tracto urinario inferior secundaria a hiperplasia benigna de próstata, a los que se realizó fotovaporización láser Greenlight HPS (120 W) en régimen de cirugía mayor ambulatoria entre mayo de 2008 y febrero de 2009. Los criterios de inclusión eran moderada o severa sintomatología obstructiva de tracto urinario inferior (IPSS ≥ 10 y flujometría con Qmáx ≤ 10 ml/seg) por hiperplasia benigna de próstata con volumen de próstata menor de 80 cc. Evaluación preoperatoria con IPSS, flujometría, exploración física, ecografía renal vesicoprostática (retropúbica y transrectal) con medición de residuo postmiccional y antígenoprostático específico (PSA). Se valoraron los datos operatorios (tiempo de vaporización, tiempo de cirugía, julios, complicaciones intra- y postquirúrgicas). Se efectuó revisión postquirúrgica al mes y a los tres meses (PSA, flujo, cuestionario IPSS).Resultados: no se requirió ingreso ni reingreso en ningún paciente, retirándose con éxito la sonda vesical en todos los sujetos antes de las 24 horas postquirúrgica. La edad media de nuestros pacientes fue de 66,75 años con un volumen prostático medio de 44,5 cc (desviación estándar: ±21). Veinte pacientes (40%) presentaban sondaje previo. Se apreció una mejoría significativa de valores Qmáx y RPM. Las principales complicaciones en el seguimiento fueron: síndrome miccional-urgencia en el 12% (6 pacientes) y hematuria leve transitoria en el 6% (tres pacientes). Conclusiones: el procedimiento de fotovaporización láser Greenlight HPS puede realizarse de manera segura y satisfactoria en régimen de cirugía mayor ambulatoria, lo que sin duda representa un cambio asistencial en el tratamiento quirúrgico de los pacientes con sintomatología de tracto urinario inferior secundaria a hiperplasia benigna de próstata (AU)

Objective: To assess the efficacy and safety of photovaporization of the prostate with Greenlight HPS laser as major outpatient surgery. Materials and methods: A prospective study was conducted of a cohort of 50 patients with lower urinary tract symptoms secondary to benign prostatic hyperplasia who underwent photovaporization with Greenlight HPS laser (120 W) as major outpatient surgery from May 2008 to February 2009. Inclusion criteria were moderate to severe obstructive lower urinary tract symptoms (IPSS of 10 or more and flowmetry with Qmax of 10 ml/sec or less due to benign prostatichyperplasia with prostate volume less than 80 ml. Preoperative assessment included IPSS; flowmetry; physical examination; ultrasound examination of the kidney, bladder, and prostate (retropubic and transrectal); and measurement of post void residue and PSA levels. Surgical data were assessed (vaporization time, operating time, joules, complications during and after surgery). Patients were followed up 1 and 3 months after surgery (PSA, flow rate, IPSS questionnaire). Results: No patient admission or readmission was required, and bladder catheter was successfully removed from all patients within 24 hours of surgery. Mean patient age was66.75 years. Mean prostate volume was 44.5 ml (SD +/-21). Twenty patients (40%) had prior catheterization. Qmax and postvoid values significantly improved. Major complications at follow-up included voiding syndrome-urgency in 6 patients (12%) and mild transient hematuria in 3 patients (6%).Conclusions: Photovaporization of the prostate with Greenlight HPS laser may be safely and successfully performed as a major outpatient surgical procedure, which undoubtedly represents a change in care, for surgical treatment of patients with lower urinary tract symptoms secondary to benign prostatic hyperplasia (AU)

[Verrucous carcinoma of the penis: report of 2 cases]. / Carcinoma verrucoso de pene: a propósito de dos casos.

OBJECTIVE: To report two cases of verrucous carcinoma of the penis, a rare tumor with a characteristic course and specific treatment that accounts for approximately 1% of tumors in the male. METHODS: Two patients, aged 86 and 51 years, with verrucous carcinoma of the penis are described. Treatment was by partial penectomy and resection of the glans penis, respectively. The anatomopathological characteristics and prognostic aspects are reviewed. RESULTS/CONCLUSIONS: Verrucous carcinoma of the penis usually presents as an exophytic lesion in the glans penis or prepuce and should be distinguished from epidermoid carcinoma which carries a worse prognosis and requires a different therapeutic approach. The differential diagnosis is based on the biopsy findings. Verrucous carcinoma of the penis carries a good prognosis and can be managed by conservative surgery (partial penectomy).

[Epididymal carcinoma. Bibliographic review in reference to a case]. / Carcinoma de epidídimo. Revisión bibliográfica con motivo de un caso.

OBJECTIVE: To describe a case of epithelial cell paratesticular carcinoma of the epididymis and briefly review the literature on this tumor type. METHODS/RESULTS: A 69-year-old male consulted for a testicular mass and intrascrotal pain, together with irritative bladder symptoms. The patient underwent orchidectomy, but consulted again shortly thereafter for persistent irritative bladder symptoms. A TUR biopsy of the bladder wall demonstrated undifferentiated carcinoma arising from the epididymis. The patient did not respond to chemotherapy. He developed systemic metastasis and died 4 months after the diagnosis. CONCLUSIONS: Carcinoma of the epididymis is a rare malignant paratesticular tumor arising from the epithelial cells with a very poor prognosis. Its clinical features are unspecific and this tumor type should be taken into account when making differential diagnosis from intrascrotal masses arsing from other causes. Due to the rarity of this disease, it has not been possible to identify treatments that might achieve better results.