Estado actual y evolución del manejo de la patología funcional y del suelo pélvico en los hospitales de la Comunidad de Madrid / Evolution and current status of the management of functional and pelvic floor pathology in the hospitals of the Community of Madrid

Introducción y objetivo Las disfunciones del suelo pélvico (DSP) incluyen un amplio número de patologías sujetas a una alta variabilidad en su manejo según los medios y capacitación de los centros y sus profesionales. El objetivo del estudio es constatar y describir la variabilidad clínica en el manejo de las DSP en los servicios de Urología de los centros sanitarios públicos de la Comunidad de Madrid, así como la dotación de medios disponibles en la actualidad en dichos centros. Material y métodos Encuesta realizada en septiembre de 2021 dirigida a facultativos especialistas en Urología Funcional de los hospitales públicos de la Comunidad de Madrid. Esta se basa en una encuesta realizada en 2011 por Díez et al. con la misma finalidad. Se analizaron las características asistenciales de los distintos centros y el manejo de las principales patologías funcionales del suelo pélvico. Se compararon los resultados con los de la encuesta de 2011 para las preguntas equiparables. Resultados El número de Unidades de Suelo Pélvico (USP) ha aumentado notablemente en los últimos 10 años. El uso de dispositivos ajustables en el tratamiento de la IUE masculina se ha extendido en los centros encuestados. La colposacropexia laparoscópica/robótica se ha convertido en el tratamiento de referencia del prolapso de órganos pélvicos (POP). Conclusiones Las USP multidisciplinares son el modelo a seguir para el manejo de las DSP. Se constata la variabilidad en el manejo de la incontinencia urinaria, POP, el síndrome de dolor vesical y la neuropatía del nervio pudendo (AU)

Introduction and objective Pelvic floor dysfunction (PFD) includes a large number of pathologies subjected to a significantly varied management, depending on the hospitals’ resources and educational levels of their professionals. The aim of this study is to determine and describe the clinical variability in the management of PFD in the urology departments of the public health centers of the Community of Madrid, as well as the resources currently available in these centers. Material and methods The survey was carried out in September 2021 and was addressed to physicians specialized in functional urology in the public hospitals of the Community of Madrid. This survey is based on the one performed in 2011 by Díez et al. for the same purpose. The characteristics of the healthcare services provided in the different centers and the management of the main functional pathologies of the pelvic floor were analyzed. The results were compared with those of the 2011 survey for equivalent questions. Results The number of Pelvic Floor Units (PFUs) has remarkably increased in the last 10 years. The use of adjustable devices in the treatment of male SUI has become widespread in the centers included in the survey. Laparoscopic/robotic sacrocolpopexy has become the gold standard treatment for pelvic organ prolapse (POP). Conclusions Multidisciplinary PFUs represent the reference framework for the management of PFD. Variability in the management of urinary incontinence, POP, bladder pain syndrome and pudendal nerve neuropathy is recognized (AU)

Evolution and current status of the management of functional and pelvic floor pathology in the hospitals of the Community of Madrid.

INTRODUCTION AND OBJECTIVE: Pelvic floor dysfunction (PFD) includes a large number of pathologies subjected to a significantly varied management, depending on the hospitals' resources and educational levels of their professionals. The aim of this study is to determine and describe the clinical variability in the management of PFD in the urology departments of the public health centers of the Community of Madrid, as well as the resources currently available in these centers. MATERIAL AND METHODS: The survey was carried out in September 2021 and was addressed to physicians specialized in functional urology in the public hospitals of the Community of Madrid. This survey is based on the one performed in 2011 by Díez et al. for the same purpose. The characteristics of the healthcare services provided in the different centers and the management of the main functional pathologies of the pelvic floor were analyzed. The results were compared with those of the 2011 survey for equivalent questions. RESULTS: The number of Pelvic Floor Units (PFUs) has remarkably increased in the last 10 years. The use of adjustable devices in the treatment of male SUI has become widespread in the centers included in the survey. Laparoscopic/robotic sacrocolpopexy has become the gold standard treatment for pelvic organ prolapse (POP). CONCLUSIONS: Multidisciplinary PFUs represent the reference framework for the management of PFD. Variability in the management of urinary incontinence, POP, bladder pain syndrome and pudendal nerve neuropathy is recognized.

Recomendaciones sobre el uso de las instilaciones endovesicales de ácido hialurónico en el síndrome de dolor vesical / Recommendations on the use of intravesical hyaluronic acid instillations in bladder pain syndrome

Introducción El síndrome del dolor vesical (SDV) es un síndrome complejo, sin etiología claramente establecida, que engloba diferentes entidades como la cistitis intersticial. Esto conlleva dificultades para establecer una definición precisa, obtener datos de prevalencia exactos y definir criterios diagnósticos y métodos estandarizados de estudio. Tampoco existe homogeneidad sobre el tratamiento del SDV. Las instilaciones endovesicales con ácido hialurónico (AH) son una opción, sin aún recomendaciones específicas.Objetivo Sintetizar la evidencia científica sobre las opciones terapéuticas disponibles para el SDV y consensuar un plan de trabajo y unas recomendaciones para el uso de las instilaciones endovesicales con AH.La Asociación Española de Urología, a través del Grupo de Urología Funcional, Femenina y Urodinámica, generó una comisión de expertos. Esta comisión fue la encarga de revisar la literatura (evidencia), consensuar el plan de trabajo y proponer recomendaciones.ResultadosExiste una gran variabilidad en la literatura sobre el tratamiento del SDV, sin un régimen estándar de instilación endovesical con AH (frecuencia y duración del tratamiento de inicio y mantenimiento).Conclusiones Las instilaciones endovesicales de AH (dosis habitual de 40mg) son efectivas y seguras. Pueden combinarse con otras opciones, siendo aún necesario comprobar la eficacia en algunos casos. El tratamiento se divide en varias sesiones iniciales semanales, seguidas de tratamiento de mantenimiento, generalmente mensual (duración de los ciclos no establecida).Se consensuaron recomendaciones sobre el manejo del SVD, con criterios diagnóstico y pautas para el tratamiento con AH endovesical (inicio, reevaluación y seguimiento) (AU)

Introduction Bladder pain syndrome (BPS) is a complex syndrome, without a clearly defined etiology that encompasses different entities, such as interstitial cystitis. This leads to difficulties in establishing a precise definition, obtaining accurate prevalence data, and defining diagnostic criteria and standardized assessment methods. Moreover, there is no consensus regarding the treatment of BPS. Intravesical instillations with hyaluronic acid (HA) are an option, although no specific recommendations have been made yet.Objective To synthesize the scientific evidence on the therapeutic options available for BPS and to establish a work plan and recommendations for the use of intravesical instillations with HA.The Spanish Association of Urology, through the Functional, Female, and Urodynamic Urology Group, created a commission of experts. This commission was in charge of reviewing literature (evidence), agreeing on the work plan, and proposing recommendations.ResultsThere is great variability in literature on the treatment of BPS, without a standard regimen of intravesical instillation with HA (frequency and duration of initial and maintenance treatment).Conclusions Intravesical HA instillations (usual dose of 40 mg) are effective and safe. They can be combined with other options, with efficacy still to be determined in some cases. Treatment is divided into several initial weekly sessions, followed by maintenance treatment, usually monthly (unestablished duration of cycles).Recommendations on the management of BPS were agreed, with diagnostic criteria and guidelines for treatment with intravesical HA (initiation, reassessment, and follow-up) (AU)

Recommendations on the use of intravesical hyaluronic acid instillations in bladder pain syndrome.

INTRODUCTION: Bladder pain syndrome (BPS) is a complex syndrome, without a clearly defined etiology that encompasses different entities, such as interstitial cystitis. This leads to difficulties in establishing a precise definition, obtaining accurate prevalence data, and defining diagnostic criteria and standardized assessment methods. Moreover, there is no consensus regarding the treatment of BPS. Intravesical instillations with hyaluronic acid (HA) are an option, although no specific recommendations have been made yet. OBJECTIVE: To synthesize the scientific evidence on the therapeutic options available for BPS and to establish a work plan and recommendations for the use of intravesical instillations with HA. The Spanish Association of Urology, through the Functional, Female, and Urodynamic Urology Group, created a commission of experts. This commission was in charge of reviewing literature (evidence), agreeing on the work plan, and proposing recommendations. RESULTS: There is great variability in literature on the treatment of BPS, without a standard regimen of intravesical instillation with HA (frequency and duration of initial and maintenance treatment). CONCLUSIONS: Intravesical HA instillations (usual dose of 40 mg) are effective and safe. They can be combined with other options, with efficacy still to be determined in some cases. Treatment is divided into several initial weekly sessions, followed by maintenance treatment, usually monthly (unestablished duration of cycles). Recommendations on the management of BPS were agreed, with diagnostic criteria and guidelines for treatment with intravesical HA (initiation, reassessment, and follow-up).

Cirugía urológica funcional y SARS-CoV-2: cómo y por qué hay que retomar ya la actividad quirúrgica adaptados a la nueva realidad / Functional urology surgery and SARS-CoV-2: how and why surgical activity should be resumed now, adapting to the new reality

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Consenso de la Asociación Española de Urología sobre el uso de mallas en la cirugía del prolapso de órganos pélvicos / Consensus statement of the Spanish Association Of Urology on the use of meshes in pelvic organ prolapse

INTRODUCCIÓN: Recientemente la Food and Drug Administration ha prohibido el uso de mallas transvaginales para el tratamiento quirúrgico de los prolapsos de órganos pélvicos (POP) en Estados Unidos. Esto ha suscitado una repercusión a escala mundial en el manejo de la patología del suelo pélvico por parte de los diferentes especialistas. OBJETIVO: Lograr un consenso sobre el uso de mallas en el tratamiento quirúrgico de los POP. ADQUISICIÓN DE DATOS/EVIDENCIA: Se organizó un Comité de expertos de la Asociación Española de Urología (AEU) para una revisión de la literatura y analizar la seguridad y eficacia del uso de mallas de polipropileno en la cirugía de los POP. RESULTADOS/EVIDENCIA DE LA LITERATURA: La evidencia refleja que el uso de mallas, comparado con el uso de tejidos nativos, ofrece una mejor eficacia a expensas de nuevas complicaciones y una mayor tasa de revisiones quirúrgicas, siendo estas menores en manos de cirujanos expertos. CONCLUSIONES: La cirugía del POP debe ser realizada por cirujanos con experiencia, adecuadamente formados y en centros de referencia. El paciente debe recibir una información correcta acerca de las diferentes opciones de tratamiento. Las mallas transvaginales solo deben indicarse en casos complejos y en recidivas tras cirugía del POP. PROPUESTA AEU: Creación de una guía clínica y de un registro nacional para la evaluación a largo plazo. Elaboración de un Consentimiento Informado a disposición de todos los profesionales y pacientes, así como un plan de formación específico para conseguir una mejor capacitación en la cirugía compleja del suelo pélvico

INTRODUCTION: Recently the Food and Drug Administration has banned the use of transvaginal meshes for the surgical treatment of pelvic organ prolapse (POP) in the United States. This has caused a worldwide impact on the management of pelvic floor pathology by different specialists. OBJECTIVE: To achieve a consensus on the use of meshes in the surgical treatment of POPs. ACQUISITION OF DATA/EVIDENCE: A Committee of experts of the Spanish Association of Urology (AEU) was organized to review the literature and analyze the safety and efficacy of the use of polypropylene meshes in POP surgery. RESULTS/EVIDENCE FROM THE LITERATURE: The evidence reflects that the use of meshes, compared to the use of native tissues, offers better efficacy at the expense of new complications and a higher rate of surgical reviews, these being minor in the hands of expert surgeons. CONCLUSIONS: POP surgery must be performed by experienced surgeons, properly trained and in referral centers. The patient should receive correct information about the different treatment options. Transvaginal meshes should only be indicated in complex cases and in recurrences after POP surgery. AEU PROPOSAL: Creation of a clinical guideline and a national registry for long-term evaluation. Preparation of an Informed Consent available to all professionals and patients, as well as a specific training plan to achieve better training in complex pelvic floor surgery

Consensus statement of the Spanish Association Of Urology on the use of meshes in pelvic organ prolapse. / Consenso de la Asociación Española de Urología sobre el uso de mallas en la cirugía del prolapso de órganos pélvicos.

INTRODUCTION: Recently the Food and Drug Administration has banned the use of transvaginal meshes for the surgical treatment of pelvic organ prolapse (POP) in the United States. This has caused a worldwide impact on the management of pelvic floor pathology by different specialists. OBJECTIVE: To achieve a consensus on the use of meshes in the surgical treatment of POPs. ACQUISITION OF DATA/EVIDENCE: A Committee of experts of the Spanish Association of Urology (AEU) was organized to review the literature and analyze the safety and efficacy of the use of polypropylene meshes in POP surgery. RESULTS/EVIDENCE FROM THE LITERATURE: The evidence reflects that the use of meshes, compared to the use of native tissues, offers better efficacy at the expense of new complications and a higher rate of surgical reviews, these being minor in the hands of expert surgeons. CONCLUSIONS: POP surgery must be performed by experienced surgeons, properly trained and in referral centers. The patient should receive correct information about the different treatment options. Transvaginal meshes should only be indicated in complex cases and in recurrences after POP surgery. AEU PROPOSAL: Creation of a clinical guideline and a national registry for long-term evaluation. Preparation of an Informed Consent available to all professionals and patients, as well as a specific training plan to achieve better training in complex pelvic floor surgery.

Fractura urotelial en la hidrodistension vesical por cistopatía interscial (IC) y síndrome de vejiga dolorosa (PBS) / Bladder urothelial fracture in interstitial cystitis hydrodistention (IC) and painful bladder syndrome (PBS)

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Biochemical markers of bone turnover and clinical outcome in patients with renal cell and bladder carcinoma with bone metastases following treatment with zoledronic acid: The TUGAMO study.

BACKGROUND: Levels of bone turnover markers (BTM) might be correlated with outcome in terms of skeletal-related events (SRE), disease progression, and death in patients with bladder cancer (BC) and renal cell carcinoma (RCC) with bone metastases (BM). We try to evaluate this possible correlation in patients who receive treatment with zoledronic acid (ZOL). METHODS: This observational, prospective, and multicenter study analysed BTM and clinical outcome in these patients. Serum levels of bone alkaline phosphatase (BALP), procollagen type I amino-terminal propeptide (PINP), and beta-isomer of carboxy-terminal telopeptide of type I collagen (ß-CTX) were analysed. RESULTS: Patients with RCC who died or progressed had higher baseline ß-CTX levels and those who experienced SRE during follow-up showed high baseline BALP levels. In BC, a poor rate of survival was related with high baseline ß-CTX and BALP levels, and new SRE with increased PINP levels. Cox univariate analysis showed that ß-CTX levels were associated with higher mortality and disease progression in RCC and higher mortality in BC. Bone alkaline phosphatase was associated with increased risk of premature SRE appearance in RCC and death in BC. CONCLUSION: Beta-isomer of carboxy-terminal telopeptide of type I collagen and BALP can be considered a complementary tool for prediction of clinical outcomes in patients with BC and RCC with BM treated with ZOL.

Tratamiento conservador del carcinoma de células renales en el injerto renal / Conservative Treatment of Renal Cell Carcinoma in Kidney Transplantation

Contexto: Se pretende evaluar el conocimiento actual acerca del tratamiento del carcinoma de células renales (CCR) que afecta al injerto en los pacientes trasplantados de riñón. Adquisición de evidencia: Revisión de la literatura actual basada en el análisis de los casos publicados de cirugía conservadora de nefronas en el carcinoma de células renales que afecta al injerto renal. Síntesis de evidencia: Se han descrito 51 casos de nefrectomía parcial en injerto renal, con una supervivencia del injerto del 88% y un índice de recurrencia del 6%. La mayoría de los pacientes estaban asintomáticos al diagnóstico (75%) y el tamaño medio de las lesiones fue de 2,8cm. La técnica más utilizada fue la enucleación. El 77% de las pautas inmunosupresoras incluían ciclosporina A. Seis pacientes fueron tratados mediante radiofrecuencia y 2 recibieron crioablación percutánea, con una supervivencia del 100% de los injertos y un único caso de recidiva, que requirió segundo tratamiento. Conclusiones: La cirugía conservadora del parénquima renal es una opción terapéutica empleada ante CCR sobre injerto renal que consigue buen control oncológico y buena supervivencia del injerto. La modificación de la inmunosupresión con la supresión de ciclosporina A y la introducción de inhibidores de mTOR podría ser una medida adecuada en estos pacientes y merece futuras investigaciones (AU)

Purpose: To evaluate the new treatment strategies in renal cell carcinoma (RCC) that affects the graft in renal recipients. Acquisition of evidence: A literature review is made, analyzing all the published cases of conservative surgery in renal graft RCC. Synthesis of evidence: A total of 51 partial nephrectomies in renal graft patients have been described, with a graft survival rate of 88% and a recurrence rate of 6%. Most of the patients (75%) were asymptomatic at the time of diagnosis, and the mean lesion size was 2.8cm. Enucleation was the most frequent technique employed. 77% of all immunosuppressor regimens included cyclosporine A. Six patients with graft RCC were subjected to radiofrequency ablation and two patients underwent percutaneous cryoablation, with a single case of relapse and a graft survival rate of 100%. Conclusions: Nephron-sparing surgery is a good management option in renal graft RCC, affording good oncological control and graft survival. Modification of immunosuppression with the withdrawal of cyclosporine A and the introduction of mTOR inhibitors is an adequate measure in such patients (AU)

[Conservative treatment of renal cell carcinoma in kidney transplantation]. / Tratamiento conservador del carcinoma de células renales en el injerto renal.

PURPOSE: To evaluate the new treatment strategies in renal cell carcinoma (RCC) that affects the graft in renal recipients. ACQUISITION OF EVIDENCE: A literature review is made, analyzing all the published cases of conservative surgery in renal graft RCC. SYNTHESIS OF EVIDENCE: A total of 51 partial nephrectomies in renal graft patients have been described, with a graft survival rate of 88% and a recurrence rate of 6%. Most of the patients (75%) were asymptomatic at the time of diagnosis, and the mean lesion size was 2.8 cm. Enucleation was the most frequent technique employed. 77% of all immunosuppressor regimens included cyclosporine A. Six patients with graft RCC were subjected to radiofrequency ablation and two patients underwent percutaneous cryoablation, with a single case of relapse and a graft survival rate of 100%. CONCLUSIONS: Nephron-sparing surgery is a good management option in renal graft RCC, affording good oncological control and graft survival. Modification of immunosuppression with the withdrawal of cyclosporine A and the introduction of mTOR inhibitors is an adequate measure in such patients.

Ajuste rápido de dosis de tapentadol en el tratamiento del dolor mal controlado / No disponible

Introducción: el tapentadol es un nuevo fármaco de acción dual MOR/NRI, que actúa a nivel central, efectivo en el tratamiento del dolor moderado e intenso, que presenta un perfil de tolerabilidad mas favorable que otros opiáceos. Esto podría permitir una titulación rápida que permita un control precoz del dolor. Material y métodos: presentamos dos casos clínicos en los que se realiza una titulación rápida de la dosis de tapentadol en pacientes hospitalizados con dolor mal controlado. Este ajuste rápido, permitió controlar el dolor, en ausencia de efectos secundarios, acortando el tiempo de estancia hospitalaria de estos pacientes. Conclusiones: el perfil favorable de efectos secundarios mostrado por el tapentadol, permite un ajuste rápido de la dosis, que consigue un control eficaz del dolor en un menor lapso de tiempo (AU)

Background: tapentadol is a new drug with a centrally acting, dual action mechanism on MOR/NRI. It is effective on moderate to severe pain and shows a favourable side effects profile in comparison to other major opiates. This could allow a fast dose titration to achieve an earlier pain control. Material and methods: we present two cases on which we have performed a fast dose titration in hospitalised patients with bad pain control. This fast titration allowed an early control of the pain, in absence of side effects, achieving a shortening in their hospital stay. Conclusions: the favourable side effects profile of tapentadol, allows a fast dose titration, achieving an efficacious pain control in a shorter time lapse (AU)

Sorprendente migración torácica de un proyectil abdominal de arma de aire comprimido / Surprising thoracic migration of an abdominal projectile of a compressed air weapon

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Perforación de aurícula derecha secundaria a radionecrosis post-mastectomía / No disponible

El empleo de grandes radiaciones ionizantes en el tratamiento del cáncer de mama después de una mastectomía radical ha sufrido un descenso significativo en los últimos años, debido a la introducción de la quimioterapia adyuvante, al auge del tratamiento conservador y a los sustanciales cambios en las técnicas radioterapéuticas, lo que justifica un descenso importante de la toxicidad cardiovascular, secundaria a la radioterapia. Presentamos, un caso excepcionalmente raro, de una mujer anciana que presentó una lesión sangrante paraesternal izquierda crónica con aumento del débito en la última semana, compatible con perforación de la aurícula derecha secundaria a radionecrosis, inducida por el tratamiento que recibió con radioterapia post-mastectomía radical izquierda por un cáncer de mama hace 30 años, en un hospital de otra Comunidad Autónoma(AU)

The use of large ionizing radiations in the treatment of breast cancer after a radical mastectomy has significantly declined in the last years due to the introduction of adjuvant chemotherapy, the increase of the conservative treatment and the substantial changes in radiotherapeutic techniques, which justify a steady decline in the cardiovascular toxicity as a complication of radiotherapy. We present an exceptionally rare case of an elderly woman who presents a chronic left parasternal bleeding injury with increase of the flow during the last week, consistent with perforation of the right auricle as a result of radionecrosis, caused by the treatment with radical left post-mastectomy radiotherapy for breast cancer, received 30 years ago at a hospital of another Autonomous Community in Spain(AU)