[Urethral stricture in women]. / Estenosis uretral en la mujer.

UNLABELLED: To perform a bibliographic review on female urethra stenosis, following the criteria for evidence based medicine. METHODS: We performed a PubMed Search with the following keywords; "female urethral stricture ","women urethral stricture","female urethral reconstruction "and " female urethral stricture treatment ",without time limits, both in English and Spanish languages. RESULTS: Female urethra stenosis is a rare pathology, in which the working diagnosis is essential, as much as detailed physical examination, urodynamic study and radiological tests. We found in the literature a total of 73 cases treated with dilation with or without maintenance self catheterization, 120 cases treated with meatotomy, 65 cases treated by flap urethroplasty (46 with vaginal flap, 17 with vestibular flap and 12 with labia minora graft and 28 with oral mucosa grafts). There are not comparative studies between the various techniques, making it difficult to set up a therapeutic algorithm. CONCLUSIONS: The surgical treatment with flaps/grafts has the highest success rate; whereas less invasive procedures such as urethrotomy/meatotomy/dilations/self-catheterization should be reserved for short female urethra stenosis or women with high comorbidity.

Laparoscopic pyelolithotomy in pelvic ectopic kidney: Case report and literature review.

INTRODUCTION: Pelvic kidney is a rare congenital anomaly. The ectopic kidney is more susceptible to developing lithiasis. The management of this type of lithiasis is a challenge. The objective of this paper was to conduct a review of available literature on the treatment of stone in ectopic kidney. MATERIAL AND METHODS: Description of a case of transperitoneal laparoscopic pyelolithotomy for the treatment of inferior calyceal lithiasis in a right pelvic kidney. A literature review was performed by using Pubmed. The following terms and combination terms were searched: "pelvic ectopic kidney", "ureterorenoscopy", "extracorporeal lithotripsy", "PCNL", "pyelolithotomy". We incluyed original articles, meta-analysis, review and case reports. RESULTS: 130 articles were excluded by title or duplication. 62 abstracts articles and them 50 full text articles were evaluated. Stone free rate were 75% (SLW), 85% (URSf), 85%-90% (PCNL) and 100% (laparoscopic pyelolithotomy). The literature on treatment on pelvic kidney is poor. CONCLUSION: Factors such stone size, density and location, and upper urinary tract abnormalities, influence the choice of therapeutic approach (retrograde, percutaneous and/or laparoscopic/robotic). Laparoscopic pyelolithotomy is a safe and minimally invasive treatment option for large kidney stones with unfavorable anatomy for the endoscopic approach.

[Effect of surgical approach on radical nephrectomy outcomes: Comparative study between open and laparoscopic nephrectomy.] / Influencia de la vía de acceso para la nefrectomía radical en el tratamiento del cáncer renal: estudio comparativo entre cirugía abierta y cirugía laparoscópica.

OBJECTIVE: The aim of this study is to evaluate the influence of laparoscopy in patients with renal cancer treated with radical nephrectomy in terms of surgical time, hospital stay, postoperative complications and survival.MATERIAL AND METHODS: Retrospective study of 570 patients with renal cancer treated with radical nephrectomyin stage ≤pT3a. Differences between groups were analysed using ANOVA test for quantitative variables and Chi squared test for qualitative. In order to evaluate possible risk factors for longer hospital stay and surgical time, multivariate analysis was performed (lineal regression). For complications we performed binary logistic regression. Overall survival (OS), recurrence free survival (RFS) and cancer specific survival (CSS) were estimated using Kaplan Meier and compared using Log Rank test. Univariate and multivariate analysis was performed using Cox regression in order to identify independent risk factors for overall, cancer specific and recurrence mortality. RESULTS: Two cohorts: 361 (63.3%) open radical nephrectomies (ORN) and 209 (36.7%) laparoscopic (LRN). Surgical time was longer in LRN (p=0.001) globally. After the period when the learning curve was over these differences were no longer significant. Hospital stay was shorter in LRN (p=0.0001). cT stage (p=0.005) and surgical access (p=0.001) acted as independent risk factors for longer surgical time. 33,5% (121 patients) of the ORN had some sort of postoperative complication vs. 11% (23 patients) in the LRN group (p=0.0001). These differences were observed in the Clavien-Dindo's grade II group. Independent risk factors for postoperative complications observed were: ASA≥III (OR=1.82, p=0.004) and stage pT3a (OR=2.29,p=0.0001). Laparoscopy acted as a protective factor for complications (OR=0,26, p=0.0001). Surgical access did not influence RFS (HR=0.87, p=0.50), CSS(HR=0.69, p=0.12). CONCLUSIONS: Laparoscopic access to RN in patients with renal cancer in ≤pT3a stage increased surgical time only in the first years, reduced hospital stayand postoperative complications and did not influence RFS, OS or CSS.

OBJETIVO: El objetivo del estudio es evaluarla influencia de la laparoscopia en pacientes concáncer renal tratados con nefrectomía radical (NR) en términos de tiempo quirúrgico, estancia media, complicaciones postoperatorias y supervivencia.MATERIAL Y MÉTODO: Análisis retrospectivo de 570 pacientes con cáncer renal tratados con NR en estadio ≤pT3a comparando cohorte de acceso abierto (NRA) y laparoscópico (NRL). Contraste de variables cualitativas con el test de Chi cuadrado y cuantitativas con ANOVA. Para identificar factores de riesgo (FR) de tiempo quirúrgico y estancia media se utilizó regresión lineal multivariante y para complicaciones la regresión logística binaria. Estimación de la supervivencia libre de recidiva (SLR), global (SG) y cáncer específica (SCE) mediante Kaplan-Meier y test de log-rank para analizar las diferencias. Análisis multivariante mediante regresión de Cox para identificar variables predictoras independientes (VPI) de SLR y SCE. Todos los cálculos se han realizado con el paquete estadístico IBM® SPSS® statisticsv-21. RESULTADOS: Dos cohortes: 361 (63,3%) NRA y 209(36,7%) NRL. El tiempo de cirugía fue mayor en NRL (p=0,001) de forma global siendo las diferencias entre ambas en el periodo tras la curva de aprendizaje no significativas. La estancia media fue menor en NRL(p=0,0001). El estadio cT (p=0,005) y la vía de acceso (p=0,001) se comportaron como VPI de prolongación del tiempo quirúrgico. El 33,5% (121 casos) de las NRA presentaron algún tipo de complicación en el postoperatorio, frente al 11% (23 casos) de las NRL (p=0,0001). Esta diferencia se observó en complicaciones tipo II de Clavien. VPI de complicaciones postoperatorias: ASA≥III (OR=1,82, p=0,004) y el estadio pT3a (OR=2,29, p=0,0001). La laparoscopia se comportó como factor protector de complicaciones (OR=0,26, p=0,0001). La vía de acceso no influyó en la SLR (HR=0,87, p=0,50) ni en la SCE (HR=0,69,p=0,12). CONCLUSIONES: El acceso laparoscópico a la nefrectomía radical en pacientes con cáncer renal en estadio ≤pT3a aumentó el tiempo quirúrgico pero solo en los primeros años, presentó menor estancia y complicacionespostoperatorias y no influyó en la SG,SLR y SCE.

[Laparoscopic treatment of retroperitoneal fibrosis.] / Tratamiento laparoscopico de la fibrosis retroperitoneal.

OBJECTIVES: Retroperitoneal fibrosis is a disease that may condition a severe involvement of various organs, mainly upper urinary tract, even causing renal insufficiency. It was first described by Albarran in 1905 and it is also known as Ormonds disease. The correct diagnosis includes, in many cases, the performance of one or more tests: CT scan, MRI, renal scan, etc. It is often necessary the insertion of double J catheters on percutaneous nephrostomy tubes with the aim to preserve renal function. Initial treatment is medical, based on corticoids, and , less frequent, immunosuppressive or chemotherapy drugs. Surgery is the treatment of choice when ureteral entrapment by the fibrous plaque is not solved with medical treatment. Such operation may be performed with a conventional open approach (laparotomy) or by pure, hand assisted laparoscopic surgery, or robotic surgery. In all cases, the technique involves freeing the ureters from the fibrous plaque that entraps them, leaving them intraperitoneal, and it is recommendable to wrap them with an omental flap. The implantation of minimally invasive techniques has made that, in groups with experience in laparoscopy, open surgery is being abandoned and the laparoscopic approach indication is increasing. Our group has performed 10 laparoscopic ureterolysis from 2005. In two patients, it was bilateral. Despite surgical repair, two renal units were lost, keeping the rest with different levels of renal function depending on the preoperative level of disease. We did not have major complications and the mean hospital stay was 5.5 days. Although, there is not important published scientific evidence about this technique and it is unlikely we will have it in an immediate future, due to the rarity of this disease, and the different degree of involvement that conditions. It is not unreasonable to propose that, based on the literature reviewed and our own experience, laparoscopic approaches, despite being complex, may solve the ureteral entrapment with similar results to open surgery but less morbidity and shorter hospital stay.

Influencia de la vía de acceso para la nefrectomía radical en el tratamiento del cáncer renal: estudio comparativo entre cirugía abierta y cirugía laparoscópica / Effect of surgical approach on radical nephrectomy outcomes: Comparative study between open and laparoscopic nephrectomy

OBJETIVO: El objetivo del estudio es evaluarla influencia de la laparoscopia en pacientes concáncer renal tratados con nefrectomía radical (NR) en términos de tiempo quirúrgico, estancia media, complicaciones postoperatorias y supervivencia. MATERIAL Y MÉTODO: Análisis retrospectivo de 570 pacientes con cáncer renal tratados con NR en estadio ≤ pT3a comparando cohorte de acceso abierto (NRA) y laparoscópico (NRL). Contraste de variables cualitativas con el test de Chi cuadrado y cuantitativas con ANOVA. Para identificar factores de riesgo (FR) de tiempo quirúrgico y estancia media se utilizó regresión lineal multivariante y para complicaciones la regresión logística binaria. Estimación de la supervivencia libre de recidiva (SLR), global (SG) y cáncer específica (SCE) mediante Kaplan-Meier y test de log-rank para analizar las diferencias. Análisis multivariante mediante regresión de Cox para identificar variables predictoras independientes (VPI) de SLR y SCE. Todos los cálculos se han realizado con el paquete estadístico IBM® SPSS® statisticsv-21. RESULTADOS: Dos cohortes: 361 (63,3%) NRA y 209(36,7%) NRL. El tiempo de cirugía fue mayor en NRL (p = 0,001) de forma global siendo las diferencias entre ambas en el periodo tras la curva de aprendizaje no significativas. La estancia media fue menor en NRL(p = 0,0001). El estadio cT (p = 0,005) y la vía de acceso (p = 0,001) se comportaron como VPI de prolongación del tiempo quirúrgico. El 33,5% (121 casos) de las NRA presentaron algún tipo de complicación en el postoperatorio, frente al 11% (23 casos) de las NRL (p = 0,0001). Esta diferencia se observó en complicaciones tipo II de Clavien. VPI de complicaciones postoperatorias: ASA ≥ III (OR=1,82, p = 0,004) y el estadio pT3a (OR=2,29, p = 0,0001). La laparoscopia se comportó como factor protector de complicaciones (OR=0,26, p = 0,0001). La vía de acceso no influyó en la SLR (HR=0,87, p = 0,50) ni en la SCE (HR = 0,69, p = 0,12). CONCLUSIONES: El acceso laparoscópico a la nefrectomía radical en pacientes con cáncer renal en estadio ≤ pT3a aumentó el tiempo quirúrgico pero solo en los primeros años, presentó menor estancia y complicaciones postoperatorias y no influyó en la SG,SLR y SCE

OBJECTIVE: The aim of this study is to evaluate the influence of laparoscopy in patients with renal cancer treated with radical nephrectomy in terms of surgical time, hospital stay, postoperative complications and survival. MATERIAL AND METHODS: Retrospective study of 570 patients with renal cancer treated with radical nephrectomy in stage ≤pT3a. Differences between groups were analysed using ANOVA test for quantitative variables and Chi squared test for qualitative. In order to evaluate possible risk factors for longer hospital stay and surgical time, multivariate analysis was performed (lineal regression). For complications we performed binary logistic regression. Overall survival (OS), recurrence free survival (RFS) and cancer specific survival (CSS) were estimated using Kaplan Meier and compared using Log Rank test. Univariate and multivariate analysis was performed using Cox regression in order to identify independent risk factors for overall, cancer specific and recurrence mortality. RESULTS: Two cohorts: 361 (63.3%) open radical nephrectomies (ORN) and 209 (36.7%) laparoscopic (LRN). Surgical time was longer in LRN (p=0.001) globally. After the period when the learning curve was over these differences were no longer significant. Hospital stay was shorter in LRN (p=0.0001). cT stage (p=0.005) and surgical access (p=0.001) acted as independent risk factors for longer surgical time. 33,5% (121 patients) of the ORN had some sort of postoperative complication vs. 11% (23 patients) in the LRN group (p=0.0001). These differences were observed in the Clavien-Dindo’s grade II group. Independent risk factors for postoperative complications observed were: ASA≥III (OR=1.82, p=0.004) and stage pT3a (OR=2.29, p=0.0001). Laparoscopy acted as a protective factor for complications (OR=0,26, p=0.0001). Surgical Access did not influence RFS (HR=0.87, p=0.50), CSS (HR=0.69, p=0.12). CONCLUSIONS: Laparoscopic access to RN in patients with renal cancer in ≤pT3a stage increased surgical time only in the first years, reduced hospital stay and postoperative complications and did not influence RFS, OS or CSS

Tratamiento laparoscopico de la fibrosis retroperitoneal / Laparoscopic treatment of retroperitoneal fibrosis

OBJETIVOS: La fibrosis retroperitoneal es una enfermedad que puede condicionar una afectación severa de distintos órganos, fundamentalmente del aparato urinario superior, pudiendo llegar incluso a ser la causa de una insuficiencia renal. Fue descrita por Albarrán en 1905 y se le conoce también como enfermedad de Ormond. El diagnóstico correcto que incluye, en muchos de los casos, la realización de una o varias pruebas: TAC (tomografía axial computarizada), RNM (resonancia nuclear magnética), gammagrafía renal, etc, obliga con relativa frecuencia, a la colocación de catéteres doble J o nefrostomías percutáneas con el fin de preservar la función de los riñones. El tratamiento inicial es médico, basado en la utilización de corticoides y, con menos frecuencia inmunosupresores o quimioterápicos. La cirugía es el tratamiento de elección cuando el atrapamiento ureteral por la placa fibrosa no queda resuelto con el tratamiento médico indicado en cada paciente. Dicha cirugía puede hacerse mediante un abordaje convencional (laparotomía) o mediante cirugía laparoscópica pura, manoasistida o robótica. En todos los casos la técnica consiste en liberar el o los uréteres de la placa fibrosa que los atrapa, dejarlos situados a nivel intraperitoneal y es recomendable utilizar un manguito de epiplon para envolverlos. La implantación cada vez mayor de las técnicas menos invasivas ha hecho que, en los grupos con experiencia laparoscópica, se vaya abandonando la cirugía abierta y sea cada vez más frecuente la indicación del abordaje laparoscópico. Nuestro grupo ha realizado 10 ureterolisis laparoscópicas desde el año 2005 en el que la indicamos por primera vez. En dos pacientes la técnica se realizó en los dos uréteres a la vez. Se perdieron, a pesar de la cirugía, dos unidades renales, manteniéndose el resto con distintos niveles de función renal dependiendo del grado de afectación que presentaban previamente. No tuvimos complicaciones mayores siendo la estancia media hospitalaria de 5,5 días. Aunque la literatura actual no tiene publicaciones sobre estas técnicas con importante evidencia científica y, por la rareza de la enfermedad y el distinto nivel de afectación que condiciona, es poco probable que las tengamos en un futuro inmediato, no es descabellado plantear, en base a la literatura revisada y a nuestra propia experiencia que, aunque complejos, los abordajes laparoscópicos pueden solucionar el atrapamiento ureteral con resultados similares a la cirugía abierta pero con menor morbilidad y menor estancia hospitalaria

OBJECTIVES: Retroperitoneal fibrosis is a disease that may condition a severe involvement of various organs, mainly upper urinary tract, even causing renal insufficiency. It was first described by Albarran in 1905 and it is also known as Ormonds disease. The correct diagnosis includes, in many cases, the performance of one or more tests: CT scan, MRI, renal scan, etc. It is often necessary the insertion of double J catheters on percutaneous nephrostomy tubes with the aim to preserve renal function. Initial treatment is medical, based on corticoids, and, less frequent, immunosuppressive or chemotherapy drugs. Surgery is the treatment of choice when ureteral entrapment by the fibrous plaque is not solved with medical treatment. Such operation may be performed with a conventional open approach (laparotomy) or by pure, hand assisted laparoscopic surgery, or robotic surgery. In all cases, the technique involves freeing the ureters from the fibrous plaque that entraps them, leaving them intraperitoneal, and it is recommendable to wrap them with an omental flap. The implantation of minimally invasive techniques has made that, in groups with experience in laparoscopy, open surgery is being abandoned and the laparoscopic approach indication is increasing. Our group has performed 10 laparoscopic ureterolysis from 2005. In two patients, it was bilateral. Despite surgical repair, two renal units were lost, keeping the rest with different levels of renal function depending on the preoperative level of disease. We did not have major complications and the mean hospital stay was 5.5 days. Although, there is not important published scientific evidence about this technique and it is unlikely we will have it in an immediate future, due to the rarity of this disease, and the different degree of involvement that conditions,. It is not unreasonable to propose that, based on the literature reviewed and our own experience, laparoscopic approaches, despite being complex, may solve the ureteral entrapment with similar results to open surgery but less morbidity and shorter hospital stay

[Surgical treatment of female urethral diverticula. Our experience. Bibliographic review]. / Tratamiento quirúrgico del divertículo uretral femenino. Nuestra experiencia. Revisión de la literatura.

OBJECTIVES: Female urethral divertilum is a rare disease; its diagnosis has increased with the use of new diagnostic technologies. It must be suspected in women consulting for chronic irritative symptoms without response to conventional treatments. Transvaginal surgical excision is the most accepted therapeutic option. We reviewed their clinical presentations, diagnostic findings, and therapeutic options and report our experience. METHODS/RESULTS: We retrospectively reviewed our case series, finding 4 patients with the diagnosis of female urethral diverticulum; we performed a bibliographic review. CONCLUSIONS: Urethral diverticulum is a rare clinical entity which has to be included in the differential diagnosis of women with chronic lower urinary tract symptoms. Clinical presentation may vary from asymptomatic to rich voiding symptoms. The most frequently used diagnostic method is voiding cystourethrogram; other techniques such as transvaginal ultrasound or MRI are very useful for complicated cases. Surgical treatment by transvaginal diverticulectomy with closure in several layers is the most frequent approach. Postoperative complications are rare.

[Secondary bladder amyloidosis with severe recurrent hematuria: transurethral Mickuliz procedure as hemostatic option]. / Hematuria grave recidivante por amiloidosis vesical secundaria. Mikulicz transuretral como opción hemostática.

OBJECTIVES: Primary localized amyloidosis of the urinary bladder generally has a benign course. On the contrary, secondary amyloidosis, a consequence of systemic amyloidosis, may have massive bleeding and produce complications such as bladder rupture or life-threatening hemodynamic problems requiring desperate hemostatic procedures such as hypogastric artery embolization or ligature, or cystectomy. We report one case in which hemostasis was achieved by a Mickulicz transurethral bladder tamponage. METHODS: 58 year old female with very aggressive rheumatoid arthritis and secondary renal amyloidosis under chronic hemodialysis presenting with severe hematuria after hip replacement. An inflamed bladder was found, the biopsy of which showed edema in all layers with blood vessel walls enlarged by amiloyd deposits. After several unsuccessful transurethral hemostatic procedures, intravesical formalin irrigation was carried out together with a Mikulicz type gauze packaging after urethral dilation. The gauze was withdrawn three days later without bleeding recurrence; however she presented subsequent neurological impairment and finally died 14 days after the last urological procedure. CONCLUSIONS: Transurethral packaging of the urinary bladder in a woman with massive hematuria is a hemostatic option that we recommend to be used before other more dramatic or invasive options are chosen.

Priapismo recurrente "stuttering priapism": presentación de un caso y revisión de la literatura / Stuttering priapism: case report and bibliographic review

OBJETIVO: Revisar la forma de presentación, fisiopatología, diagnostico y alternativas terapéuticas del priapismo recurrente mediante la presentación de un nuevo caso.MÉTODOS: Varón de 25 años, estudiado en otro centro por presentar episodios recurrentes de priapismo desde hace aproximadamente 18 meses. Estos episodios se producen a diario, interfiriendo de forma importante con la calidad de vida del paciente.RESULTADOS: Se inicio tratamiento con Bicalutamida 50mg/24h sin mejoría. En la analítica, ecografía dopplerpeneana y arteriografía selectiva de arterias pudendas no se evidenciaron alteraciones. Se pautó Tadalafilo 5mg/24h durante dos meses sin respuesta. Posteriormente se instauró tratamiento con Diazepam 10 mg/24h y Terbutalina 5 mg/24h permitiendo el control de la enfermedad, quedando asintomático en la actualidad.CONCLUSIONES: El priapismo recurrente es una forma poco común de presentación de esta enfermedad, producida por una alteración en los mecanismos de regulación de la erección mediados por la 5PDE y el GMPc.Se han propuesto varios fármacos en su tratamiento con eficacia variable, aunque no existen series suficientemente largas para poder recomendar ninguno como primera opción. El uso de inhibidores de la 5PDE de forma prolongada, ha sido utilizado con éxito por algunos grupos.El conocimiento de estas alternativas, es importante para el tratamiento de esta compleja e infrecuente patología(AU)

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 priaprism 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(AU)

[Obstruction following surgical repair of female stress urinary incontinence. Diagnosis and treatment]. / Obstrucción tras cirugía correctora de la incontinencia femenina de esfuerzo. Diagnóstico y tratamiento.

OBJECTIVES: To report our experience in the diagnosis and treatment of the lower urinary tract obstruction after urinary incontinence corrective surgery, analysing the different techniques performed, retropubic or vaginal urethrolysis. METHODS: We report a series of 14 patients with the diagnosis of obstruction after incontinence corrective surgery. They were classified in 2 groups, those who underwent retropubic procedures (5 cases) and those who underwent prolene mesh sling procedures (9 cases). We detail preoperative clinical-urodynamic parameters, and postoperative bladder outlet obstruction confirmation. Retropubic urethrolysis was performed in all patients after retropubic surgery, with the association of hysterectomy if indicated. The performance of a new sling- urethropexy was individualized. In three cases of retropubic surgery repeated urethropexy was not done. Unilateral section was performed in the sling series for all except one case of double section. A new mesh sling was performed in two cases; two cases did not undergo reoperation. Urethrolysis results were evaluated both subjectively by satisfaction degree scales and objectively by clinical-urodynamic evaluation, comparing clinical data and urodynamic parameters using the proper statistical test. RESULTS: In the retropubic surgery group all patients are continent. Satisfaction degree is: very satisfied 3 patients and 2 quite satisfied. Two presented with voiding urgency not needing anticholinergic drugs, and their urodynamic data returned to normal values without post void residual. The obstructed patients in the sling group reported minimal urgency after urethrolysis in 2 cases. Two patients have stress urinary incontinence: one of them is better than before and refused to undergo a new operation; the other one, who repeated sling, developed a clinical picture of urgency-incontinence again, underwent second section and continues having stress urinary incontinence. Among 7 patients undergoing sling, 4 are very satisfied, 1 quite satisfied, 1 somewhat satisfied and 1 not at all satisfied. Voiding difficulties have disappeared in all cases; comparisons between pre and postoperative urodynamics maximum flow, detrusor pressure at maximum flow and postvoid residual show statistically significant differences. Post-urethrolysis parameters return to preoperative values. CONCLUSIONS: The immediate development of symptoms after surgical correction of urinary stress incontinence is the best diagnostic criteria for obstruction. Detrusor muscle responds to obstruction, but sometimes its response is so minimal that it is difficult to diagnose urodynamically. The knowledge of preoperative values helps to confirm the diagnosis. In any case, urodynamic parameters did not influence the success of urethrolysis. Urethrolysis is an effective operation to cure symptoms secondary to obstruction after incontinence corrective surgery. When a sling has been the procedure performed, probably it is not worth to perform a standard urethrolysis; a simple section of one of the branches seems to be enough to improve symptoms. Currently, there is not scientific evidence about the convenience or not of bladder neck-urethral re-suspension after urethrolysis. The only case-scenario in which it is clearly indicated is that when there is stress incontinence in addition to obstructive symptoms.

Estenosis uretral en la mujer / Urethral stricture in women

OBJETIVOS: Realización de una revisión bibliográfica sobre la estenosis de uretra femenina (EUF), según los criterios de la Medicina Basada en la Evidencia. MÉTODOS: Búsqueda en Pubmed de los estudios publicados con las siguientes palabras clave: «female urethral stricture», «women urethral stricture», «female urethral reconstruction» y «female urethral stricture treatment», sin límites de tiempo; en inglés y castellano. RESULTADOS: La EUF es una patología poco frecuente, en la que el diagnóstico de sospecha es fundamental; al igual que la exploración física detallada, el estudio urodinámico y las pruebas radiológicas. En total, hemos encontrado en la literatura 73 casos tratados con dilatación con o sin autocateterismos de mantenimiento, 120 casos tratados con meatotomía, 65 casos tratados con uretroplastia con colgajo (46 con colgajo vaginal, 17 con colgajo vestibular y 2 de labio menor) y 53 pacientes tratadas con uretroplastia con injerto (13 con injerto vaginal, 12 con injerto de labio menor y 28 de mucosa oral). No existen estudios comparativos entre las diferentes técnicas, lo que hace difícil establecer un algoritmo terapéutico. CONCLUSIONES: El tratamiento quirúrgico con colgajos/injertos tiene el porcentaje más elevado de éxito; mientras que los procedimientos menos invasivos como la uretrotomía / meatotomía / dilataciones / autocateterismos deberían reservarse para casos con EUF cortas y mujeres con alta comorbilidad

OBJECTIVES: To perform a bibliographic review on female urethra stenosis, following the criteria for evidence based medicine. METHODS: We performed a PubMed Search with the following keywords: «female urethral stricture», «women urethral stricture», «female urethral reconstruction» and «female urethral stricture treatment», without time limits, both in English and Spanish languages. RESULTS: Female urethra stenosis is a rare pathology, in which the working diagnosis is essential, as much as detailed physical examination, urodynamic study and radiological tests. We found in the literature a total of 73 cases treated with dilation with or without maintenance self catheterization, 120 cases treated with meatotomy, 65 cases treated by flap urethroplasty (46 with vaginal flap, 17 with vestibular flap and 12 with labia minora graft and 28 with oral mucosa grafts). There are not comparative studies between the various techniques, making it difficult to set up a therapeutic algorithm. CONCLUSIONS: The surgical treatment with flaps/grafts has the highest success rate; whereas less invasive procedures such as urethrotomy / meatotomy / dilations / self-catheterization should be reserved for short female urethra stenosis or women with high comorbidity

Tratamiento quirúrgico del divertículo uretral femenino. Nuestra experiencia. Revisión de la literatura / Surgical treatment of female urethral diverticula. Our experience. Bibliographic review

OBJETIVO: El divertículo uretral femeninoes una patología de baja frecuencia y cuyo diagnósticose ha visto incrementado por el uso de nuevas técnicasdiagnósticas. Debe sospecharse ante mujeresque acuden a la consulta con sintomatología crónicairritativa sin respuesta a tratamientos convencionales. Laopción terapéutica más aceptada es la escisión transvaginaldel mismo. Revisamos su presentación clínica,aspectos diagnósticos y opciones terapéuticas presentandonuestra experiencia.MÉTODOS/RESULTADOS: Hemos realizado un estudioretrospectivo de nuestra casuística, localizando 4enfermas diagnosticadas de divertículo uretral femeninoy revisada la literatura científica al respecto.CONCLUSIONES: El divertículo uretral es una entidadclínica infrecuente que hay que tener en cuenta en todamujer con sintomatología crónica del tracto urinarioinferior. Su forma de presentación puede ser desdeasintomática hasta sintomatología miccional florida. Elmétodo diagnóstico más usado es la cistouretrografíamiccional, aceptando la gran utilidad de técnicascomo la ecografía transvaginal o la resonancia magnéticanuclear en casos complejos. El tratamiento quirúrgicomediante diverticulectomía transvaginal con cierreen varios planos es el abordaje más empleado. Lascomplicaciones postoperatorias son escasas

OBJECTIVES: Female urethral divertilumis a rare disease; its diagnosis has increased with theuse of new diagnostic technologies. It must be suspectedin women consulting for chronic irritative symptomswithout response to conventional treatments.Transvaginal surgical excision is the most acceptedtherapeutic option. We reviewed their clinical presentations,diagnostic findings, and therapeutic options and reportour experience.METHODS/RESULTS: We retrospectively reviewed ourcase series, finding 4 patients with the diagnosis offemale urethral diverticulum; we performed a bibliographicreview.CONCLUSIONS: Urethral diverticulum is a rare clinicalentity which has to be included in the differential diagnosisof women with chronic lower urinary tract symptoms.Clinical presentation may vary from asymptomatic torich voiding symptoms. The most frequently useddiagnostic method is voiding cystourethrogram; othertechniques such as transvaginal ultrasound or MRI arevery useful for complicated cases. Surgical treatment bytransvaginal diverticulectomy with closure in severallayers is the most frequent approach. Postoperativecomplications are rare

Hematuria grave recidivante por amiloidosis vesical secundaria. Mikulicz transuretral como opción hemostática / Secondary bladder amyloidosis with severe recurrent hematuria: transurethral Mickuliz procedure as hemostatic option

OBJETIVO: Al contrario que la amiloidosisvesical primaria o localizada, cuyo curso es generalmentebenigno, en la forma secundaria, consecuenciade amiloidosis sistémica, el sangrado puede sermasivo, con necesidad de procedimientos hemostáticosdesesperados como la ligadura de las arterias hipogástricaso la cistectomía. Describimos un caso en elque la hemostasia se logró mediante un taponamientovesical transuretral de tipo Mikulicz.MÉTODO Y RESULTADO: Una mujer de 58 años conartritis reumatoide muy agresiva, amiloidosis renalsecundaria y en hemodiálisis crónica, presentabahematuria grave después de haber sido operada de lacadera . Se le encontró una vejiga inflamatoria en cuyabiopsia, todas las capas estaban edematizadas y lasparedes de los vasos engrosadas por depósitos deamiloide. Después de varios procedimientos hemostáticostransuretrales infructuosos, se realizó una formolización vesical, y un taponamiento endovesical de tipoMikulicz con vendas de gasa introducidas a través dela uretra previamente dilatada. La gasa exteriorizadapor uretra pudo retirarse al tercer dia, sin que reaparecierala hematuria, aunque tuvo un posterior deterioroneurológico, falleciendo finalmente a los catorcedías de la última intervención.CONCLUSIÓN: El taponamiento vesical transuretral enuna mujer con hematuria intensa es una opción hemostáticaque recomendamos probar antes de elegir otrasmás dramáticas o invasivas

OBJECTIVES: Primary localized amyloidosis ;;of the urinary bladder generally has a benign course. ;;On the contrary, secondary amyloidosis, a consequence ;;of systemic amyloidosis, may have massive bleeding ;;and produce complications such as bladder rupture or ;;life-threatening hemodynamic problems requiring desperate ;;hemostatic procedures such as hypogastric artery ;;embolization or ligature, or cystectomy. We report one ;;case in which hemostasis was achieved by a Mickulicz ;;transurethral bladder tamponage. ;;METHODS: 58 year old female with very aggressive ;;rheumatoid arthritis and secondary renal amyloidosis ;;under chronic hemodialysis presenting with severe ;;hematuria after hip replacement. An inflamed bladder ;;was found, the biopsy of which showed edema in all ;;layers with blood vessel walls enlarged by amiloyd ;;deposits. After several unsuccessful transurethral hemostatic ;;procedures, intravesical formalin irrigation was carried ;;out together with a Mikulicz type gauze packaging after ;;urethral dilation. The gauze was withdrawn three days ;;later without bleeding recurrence; however she presented ;;subsequent neurological impairment and finally died 14 ;;days after the last urological procedure. ;;CONCLUSIONS: Transurethral packaging of the urinary ;;bladder in a woman with massive hematuria is a ;;hemostatic option that we recommend to be used before ;;other more dramatic or invasive options are chosenOBJECTIVES: Primary localized amyloidosis ;;of the urinary bladder generally has a benign course. ;;On the contrary, secondary amyloidosis, a consequence ;;of systemic amyloidosis, may have massive bleeding ;;and produce complications such as bladder rupture or ;;life-threatening hemodynamic problems requiring desperate ;;hemostatic procedures such as hypogastric artery ;;embolization or ligature, or cystectomy. We report one ;;case in which hemostasis was achieved by a Mickulicz ;;transurethral bladder tamponage. ;;METHODS: 58 year old female with very aggressive ;;rheumatoid arthritis and secondary renal amyloidosis ;;under chronic hemodialysis presenting with severe ;;hematuria after hip replacement. An inflamed bladder ;;was found, the biopsy of which showed edema in all ;;layers with blood vessel walls enlarged by amiloyd ;;deposits. After several unsuccessful transurethral hemostatic ;;procedures, intravesical formalin irrigation was carried ;;out together with a Mikulicz type gauze packaging after ;;urethral dilation. The gauze was withdrawn three days ;;later without bleeding recurrence; however she presented ;;subsequent neurological impairment and finally died 14 ;;days after the last urological procedure. ;;CONCLUSIONS: Transurethral packaging of the urinary ;;bladder in a woman with massive hematuria is a ;;hemostatic option that we recommend to be used before ;;other more dramatic or invasive options are chosen

Obstrucción tras cirugía correctora de la incontinencia femenina de esfuerzo. Diagnóstico y tratamiento / Obstruction after female stress urinary incontinence corrective surgery. Diagnosis and treatment

OBJETIVO: El objetivo de este estudio es presentar nuestra experiencia en el diagnóstico y tratamiento de la obstrucción del tracto urinario inferior secundaria a cirugía anti-incontinencia, analizando las diferentes técnicas quirúrgicas realizadas, uretrolisis retropubiana o vaginal. MÉTODO: Presentamos una serie de 14 enfermas diagnosticadas de obstrucción tras cirugía antincontinencia. Se clasifican en dos grupos, las intervenidas con técnicas retropúbicas (5 casos) y a las que se practicó sling con malla de prolene (9 casos). Se detallan parámetros clínico-urodinámicos previos a dicha cirugía, y la confirmación de obstrucción del tracto urinario inferior post-cirugía antincontinencia. Se practicó uretrolisis retropúbica en todas las enfermas con antecedentes de cirugía retropubiana, asociando histerectomía si indicada. Se individualizó la realización de nueva resuspensión-sling. No se realizó resuspensión en tres casos . En los casos con sling se practicó sección del sling en una rama y en uno de los casos en ambas ramas. En dos casos se construyó un nuevo sling con malla, y dos casos no fueron intervenidos. Se valoró el resultado de la uretrolisis subjetivamente mediante escala de grado de satisfacción y objetivamente mediante evaluación clínico-urodinámica, comparando los datos clínicos y los parámetros del estudio urodinámico completo, con el correspondiente estudio estadístico. RESULTADOS: En el grupo de cirugía retropúbica todas las pacientes son continentes. El grado de satisfacción es: muy satisfechas 3 pacientes y 2 bastante satisfechas. Dos presentan urgencia miccional sin precisar anticolinérgicos, y los datos urodinámicos retornan a los valores normales sin residuo postmiccional. Las enfermas obstruidas por sling, tras la uretrolisis refieren en dos casos mínima urgencia miccional. Dos casos presentan incontinencia de esfuerzo, una de ellas, se encuentra mejor que previamente y no quiere una tercera cirugía; la otra, intervenida con nuevo sling, desarrolló un nuevo cuadro de urgencia-incontinencia, segunda sección y persiste incontinencia de esfuerzo. De las siete pacientes intervenidas, 4 están muy satisfechas, 1 bastante satisfecha, 1 ligeramente satisfecha y otra nada satisfecha. La dificultad miccional ha desaparecido en todos los casos y la comparación de los parámetros urodinámicos pre y post-uretrolisis demostraron que el flujo miccional máximo, presión del detrusora flujo máximo y residuo postmiccional tienen diferencias estadísticamente significativas. Los valores post-uretrolisis retornan a los valores pre-cirugía de incontinencia. CONCLUSIONES: La relación temporal inmediata clara entre la intervención antiincontinencia y la parición de la sintomatología es el mejor criterio diagnóstico de la obstrucción tras dicha cirugía. El detrusor responde a la obstrucción, pero la respuesta es, a veces, tan mínima, que hace difícil el diagnóstico urodinámico. El conocimiento de los valores previos a la cirugía ayuda a confirmar el diagnóstico. En cualquier caso, los parametros urodinámicos no han influido en el éxito de la uretrolisis. La uretrolisis es una técnica efectiva en conseguir la desaparición de la sintomatología producida tras la obstrucción por cirugía antiincontinencia. Cuando la técnica realizada ha sido un sling, posiblemente no merezca la pena realizar una uretrolisis reglada, la simple sección de una de las ramas del sling parece ser suficiente para mejorar la clínica. No existe en estos momentos seguridad científica sobre la conveniencia o no de resuspensión cervicouretral tras la uretrolisis. En el único caso que está claramente indicada es en aquel donde, además de sintomatología obstructiva, existe incontinencia de esfuerzo (AU)