Diferencias entre el Urocultivo Previo y el cultivo del Catéter doble J. Implicancias clínicas / DIFFERENCES BETWEEN PREVIOUS URINE CULTURE AND DOUBLE J CATHETER CULTURE. CLINICAL IMPLICATIONS

Las infecciones urinarias complicadas, dentro de las cuales se encuentran las asociadas a catéteres, son un hallazgo frecuente de la práctica clínica. Las complicaciones infecciosas después de los procedimientos urológicos son una fuente importante de morbimortalidad y consumen múltiples recursos sanitarios. La colonización bacteriana en el catéter ureteral juega un papel esencial en la patogénesis de la infección, y el uso de profilaxis antimicrobiana en urología es controvertido. El objetivo de nuestro trabajo fue evaluar la utilidad de la profilaxis antibiótica en la extracción del catéter doble J

Complicated urinary infections, among which are those associated with catheters, are a frequent finding in clinical practice. Infectious complications after urological procedures are an important source of morbidity and mortality and consume multiple healthcare resources. Bacterial colonization in the ureteral catheter plays an essential role in the pathogenesis of infection, and the use of antimicrobial prophylaxis in urology is controversial. Te objective of our work was to evaluate the usefulness of antibiotic prophylaxis in the extraction of the double J catheter

Surgical Technique of Supine Percutaneous Nephrolithotomy in Children / Técnica quirúrgica de la nefrolitotomía percutánea en supino en niños

Percutaneous nephrolithotomy (PCNL) in children has becomemore widely used due to its high efficacy and safety and to the development of miniaturized instruments. A supine approach is promising due to advantages such as better ventilation, reproducibility, and ergonomics. The purpose of the present study is to describe our surgical technique with special considerations in the pediatric population. We used an oblique supine position supported by one silicone gel positioning pad under the hip and another under the ipsilateral flank. The anatomical landmarks used to guide the puncture were the 11th and 12th ribs, the posterior axillary line, and the iliac crest. Initially, a ureteral catheter was introduced endoscopically. A retrograde pyelography was performed to guide the puncture, which was performed using a biplanar technique. A hydrophilic guide wire was then advanced through the needle. Dilation was performed with Alken telescopic dilators until 14 Ch. Fragmentation was performed either with a 13 Ch semirigid cystoscope or a flexible ureteroscope using a holmium: yttrium aluminum garnet (Ho:Yag) laser.We left a double J catheter. Supine PCNL in the pediatric population has comparable efficacy in terms of stone free rate to that of the prone approach as well as less complications. Certain considerations in children are careful padding and placement of the patient close to the edge of the table. Puncture should be guided by ultrasound to reduce radiation exposure. Miniaturized equipment is not widely available, so adaptation of adult equipment for the pediatric population is sometimes necessary.

La nefrolitotomía percutánea en niños se ha vuelto ampliamente utilizada por su alta efectividad, seguridad, y por la miniaturización de los instrumentos endoscópicos. El abordaje en supino es prometedor por sus ventajas, como mejor ventilación, reproducibilidad, y ergonomía. El propósito es describir nuestra técnica quirúrgica con las consideraciones especiales a tener en cuenta en la población pediátrica. Todos nuestros pacientes han sido intervenidos bajo la siguiente técnica quirúrgica: en una posición oblicua en supino, utilizando soportes de silicona ubicados debajo de la cadera y del flanco ipsilateral, se marcan los reparos anatómicos: las costillas once y doce, la línea axilar posterior y la cresta ilíaca. Inicialmente se introduce un cateter ureteral por vía endoscópica, con el cual se realiza una pielografía retrógrada para guiar la punción con una técnica biplanar. Se avanza una guía hidrofílica y, sobre esta, los dilatadores telescopados de Alken hasta un tracto de 14 Ch. Se realiza la fragmentación con un cistoscopio semirígido de 13 Ch o con un ureteroscopio flexible utilizando el láser Ho:Yag. Se deja un cateter JJ. La nefrolitotomía percutánea en la población pediátrica es comparable en términos de tasa libre de cálculos al abordaje en prono, con menos complicaciones. Una consideración importante en niños es una adecuada posición, cerca al eje de la mesa. La punción debe ser guiada por ultrasonido para disminuir la exposición a radiación. La disponibilidad de equipos miniaturizados es limitada, por lo cual usualmente es necesario adaptar los equipos de adultos.

Pediatric Urology: Past, Present and Future / Urología pediátrica: pasado, presente, futuro

At Johns Hopkins, around the turn of the 20th century, Halsted revolutionized the training of future surgeons by having them serving as apprentices, learning mainly by spending long, celibate hours in the hospital observing surgery with the mantra of "See one, do one, teach one." Urology was an infant specialty at that time, growing under Halsted's pupil, Hugh Hampton Young. Young himself pioneered operations for exstrophy that have withstood the test of time. It was only because of the invention of the cystoscope that Urology separated from its parent, General Surgery, clearly an early example of disruptive innovation. Although described separately at that time, Pediatric Urology was not practiced as a distinct full-time entity until the century was nearly complete. Pediatric surgeons cared for the bulk of pediatric urological disorders. Hypospadias and many penile disorders fell under the auspices of plastic surgeons. During the 1950s, the Section of Pediatric Urology became the first surgical section of the American Academy of Pediatrics. The Society of Pediatric Urology (SPU) was soon born. It was roughly two decades later the Canadian Bob Jeffs sought specialty training from D.I. Williams at the Great Ormand Street in London. He later returned to Toronto as the first North American full-time committed pediatric urologist. Other Americans soon followed, and by 1980 the establishment of Pediatric Urology programs in North American children's centers became the norm, with trainees going abroad for fellowship training in London or at Alder Hey in Liverpool.

En Johns Hopkins, a principios del siglo XX, Halsted revolucionó la formación de los futuros cirujanos haciéndoles servir como aprendices, aprendiendo principalmente pasando largas horas célibes en el hospital observando cirugía con el mantra de "Ver a uno, hacer a uno, enseñar a uno." La urología era una especialidad incipiente en aquella época, que crecía bajo la tutela del alumno de Halsted, Hugh Hampton Young. El propio Young fue pionero en operaciones de extrofia que han resistido el paso del tiempo. Sólo gracias a la invención del cistoscopio se separó la Urología de su progenitora, la Cirugía General, un claro ejemplo de innovación disruptiva. Aunque en aquel momento se describió por separado, la Urología Pediátrica no se practicó como una entidad diferenciada a tiempo completo hasta casi finalizado el siglo. Los cirujanos pediátricos atendían la mayor parte de los trastornos urológicos pediátricos. La hipospadias y muchos trastornos del pene eran competencia de los cirujanos plásticos. En la década de 1950, la Sección de Urología Pediátrica se convirtió en la primera sección quirúrgica de la Academia Americana de Pediatría. Pronto nació la Sociedad de Urología Pediátrica (SPU). Aproximadamente dos décadas más tarde, el canadiense Bob Jeffs recibió formación especializada de D.I. Williams en el Great Ormand Street de Londres. Más tarde regresó a Toronto como el primer urólogo pediátrico norteamericano comprometido a tiempo completo. Pronto le siguieron otros estadounidenses, y en 1980 la creación de programas de urología pediátrica en centros infantiles norteamericanos se convirtió en la norma, con alumnos que se desplazaban al extranjero para realizar una beca de formación en Londres o en Alder Hey (Liverpool).

Variables que influyen en el pronóstico de la cirugía fotovaporización prostática mediante láser verde en el tratamiento de hiperplasia prostática benigna (HBP), en el servicio de urología del Hospital Carlos Andrade Marín / Influential variables in the prognosis of prostate photovaporization surgery through green laser in the treatment of benign prostatic hyperplasia in the Urology Department of HCAM

Introducción: Determinar los factores de riesgo preoperatorios e intraoperatorios que influyen en el resultado final de la intervención con láser verde KTP en pacientes con Hiperplasia prostática benigna. Materiales y Métodos: Se realizó un estudio retrospectivo en una cohorte de 153 pacientes con diagnóstico de Hiperplasia Benigna de Próstata (HBP), sometidos a cirugía mediante láser verde KTP y realizada desde mayo 2010 a septiembre 2013 en el Hospital Carlos Andrade Marín. Analizamos variables preoperatorias como edad, volumen prostático medido por ecografía, peso prostático por tacto rectal, PSA, antecedentes urológicos, antecedentes patológicos personales y clasificación ASA; así como variables intraoperatorias: tiempo quirúrgico y complicaciones. Resultados: Éxito quirúrgico ocurrió en el 59% de la muestra. En el análisis bivariado y multivariado, tanto el volumen prostático medido por ecografía (≥ 40 cm3) y las complicaciones intraoperatorias fueron significativas. Discusión: La fotovaporización con láser verde es una técnica implementada en nuestro medio para el tratamiento de HBP. Es preciso estudiar múltiples variables para predecir el éxito o fracaso de la intervención quirúrgica. Palabras clave: laser verde, hiperplasia prostática benigna, fotovaporización.

Introduction: To determine preoperative and operative risk factors that may influence the final outcome of prostatic surgery using KTP green laser in patients with Benign Prostatic Hyperplasia. Methods: Retrospective study performed within cohort of patients with Benign Prostatic Hyperplasia who underwent surgery using KTP greenlight laser, conducted between May 2010 to September 2013, at Carlos Andrade Marín Hospital. Several pre-operative variables were analyzed, among them: age, ultrasound, prostatic volume, prostatic weight assessed by rectal examination, PSA, urological history, medical history and ASA classification; and also intraoperative variables like surgical time and surgical complications. Results: Successful outcome was seen in 59% of treated patients. In the bivariate and multivariate analysis prostatic volume measured with ultrasound and intraoperative complications achieved significance. Discusion: Green laser photovaporization is a technique already implemented in our country for the BPH treatment. Multiple variables should be analyzed in order to predict surgical outcome.

Is diagnostic cystoscopy painful? Analysis of 1,320 consecutive procedures.

OBJECTIVE: To prospectively evaluate self-reported pain levels associated with diagnostic cystoscopy. MATERIALS AND METHODS: Patients who underwent diagnostic cystoscopy and subsequently graded their pain level during the procedure were enrolled. Pain was graded on a Likert visual analog scale (VAS) of 1-10 where 0 = no pain and 10 = excruciating unbearable pain. Local lidocaine gel 2% was used as intraurethral lubricant. RESULTS: Data from 1320 consecutive cystoscopies (929 males, 391 females, age range 15-93 years) between 6/2009-1/2010 were analyzed. This was the first cystoscopy for 814 patients. The overall mean VAS was 2.74 ± 1.51 (range 0-9) for rigid cystoscopy and 2.48 ± 1.53 (range 0-10) for flexible cystoscopy (P = 0.004). The reported mean pain level for first-time cystoscopy was significantly higher than that for repeat cystoscopy (2.8 ± 1.6 vs. 2.2 ± 1.4, P < 0.001), regardless of gender or type of cystoscope. Men reported significantly higher pain levels than women 2.6 ± 1.5 vs. 2.4 ± 1.4 (P < 0.04). The highest mean pain level was reported by men (3.4 ± 1.6) and women (2.5 ± 1.6) for rigid cystoscopy compared to flexible cystoscopy (2.5 ± 1.4 and 1.1 ± 1.9, respectively, P < 0.001). Pain levels > 5 were reported in 75 (5.7%) cystoscopies. CONCLUSIONS: Cystoscopy was not associated with distressing levels of pain. Pain levels during first cystoscopies were higher than those for repeated ones. Using a flexible cystoscope is associated with a lower pain level in both men and women and it should be used for both genders.

Is Diagnostic Cystoscopy Painful? Analysis of 1,320 Consecutive Procedures

Objective To prospectively evaluate self-reported pain levels associated with diagnostic cystoscopy. Materials and Methods Patients who underwent diagnostic cystoscopy and subsequently graded their pain level during the procedure were enrolled. Pain was graded on a Likert visual analog scale (VAS) of 1-10 where 0 = no pain and 10 = excruciating unbearable pain. Local lidocaine gel 2% was used as intraurethral lubricant. Results Data from 1320 consecutive cystoscopies (929 males, 391 females, age range 15-93 years) between 6/2009-1/2010 were analyzed. This was the first cystoscopy for 814 patients. The overall mean VAS was 2.74 ± 1.51 (range 0-9) for rigid cystoscopy and 2.48 ± 1.53 (range 0-10) for flexible cystoscopy (P = 0.004). The reported mean pain level for first-time cystoscopy was significantly higher than that for repeat cystoscopy (2.8 ± 1.6 vs. 2.2 ± 1.4, P < 0.001), regardless of gender or type of cystoscope. Men reported significantly higher pain levels than women 2.6 ± 1.5 vs. 2.4 ± 1.4 (P < 0.04). The highest mean pain level was reported by men (3.4 ± 1.6) and women (2.5 ± 1.6) for rigid cystoscopy compared to flexible cystoscopy (2.5 ± 1.4 and 1.1 ± 1.9, respectively, P < 0.001). Pain levels > 5 were reported in 75 (5.7%) cystoscopies. Conclusions Cystoscopy was not associated with distressing levels of pain. Pain levels during first cystoscopies were higher than those for repeated ones. Using a flexible cystoscope is associated with a lower pain level in both men and women and it should be used for both genders. .

[Transumbilical laparoscopic simple nephrectomy using a flexible cystoscope and standard laparoscopic instruments]. / Nefrectomía simple laparocópica transumbilical con el uso de cistoscopio flexible e instrumentos laparsocópicos estándar.

OBJECTIVES: We present our initial experience with transumbilical surgery in a simple nephrectomy performed with a flexible cystoscope and standard laparoscopic instruments. METHODS: A 15 year-old child, with severe left renal parenchyma atrophy, secondary to recurrent urinary tract infection (UTI) complicated with left pyelonephritis. Decision for simple nephrectomy was taken and we planned to perform a single port laparoscopic nephrectomy. In the lumbotomy position, two 5mm ports were insertend through a 3 cm umbilical incision. One trocar permitted the progression of the flexible cystoscope (Olympus) and the other the entrance of the PKS Plasma Trissector. The latter was then changed for a 10mm port to allow the entrance of the Weck clips. A Maryland grasper for countertraction was placed without port in the lef-upper quadrant and progressed directly into de peritoneal cavity under direct vision. RESULTS: The standard laparoscopic steps were duplicated uneventfully. Mean operative time was 90 minutes and mean blood loss was 200 mL. Hospital stay was 18 hours. No transfusion was needed. CONCLUSION: Single port urologic surgery will expand in the future. There is lack of commercial availability of the ideal hardware needed for the procedures. Versatility of urologic instruments allow for its use in different settings.

Laparoscopic pyelolithotomy: optimizing surgical technique.

The classic approach to renal stone disease includes shockwave lithotripsy, ureteroscopy or percutaneous nephrolithotripsy, and, in some cases, a combination of both. The usefulness of laparoscopy in this regard remains debated. In this report and video, we present our technique of laparoscopic pyelolithotomy assisted by flexible instrumentation to achieve maximal stone clearance in a selected group of patients.

Outbreak of cystoscopy related infections with Pseudomonas aeruginosa: New Mexico, 2007.

PURPOSE: Personnel at the New Mexico Department of Health investigated a Pseudomonas aeruginosa outbreak potentially associated with outpatient cystoscopy performed by a urologist during January 1 to April 22, 2007. MATERIALS AND METHODS: We compared infection rates with baseline rates, reviewed infection control procedures and performed environmental sampling at the urologist office. We also performed a case-control study. Cases had blood or urine cultures positive for P. aeruginosa during January 1 to April 22, 2007. Controls had blood or urine cultures ordered through the same laboratory. Clinical and environmental isolates were typed by pulsed field gel electrophoresis. RESULTS: A total of 23 case-patients were identified, including 17 with urinary tract infections alone, 2 with bacteremia alone and 4 with urinary tract infections plus bacteremia. Seven case-patients experienced P. aeruginosa infection after cystoscopy was performed by this urologist. On multivariate analysis cystoscopy done by this urologist was the strongest risk factor for positive P. aeruginosa culture (OR 46.5, 95% confidence limits 3.1, 705). Recent hospitalization, having a urinary catheter and age 75 years or older were also independently associated with case status. Multiple breaches in cystoscope reprocessing procedures were identified. The urologist cystoscope was culture positive for P. aeruginosa. All 4 available clinical isolates from patients in whom cystoscopy was done by this urologist had pulsed field gel electrophoresis patterns identical to those of specimens from the cystoscope. The implementation of proper reprocessing methods terminated the outbreak. CONCLUSIONS: Our investigation implicated a contaminated cystoscope as the likely source of these infections. Health care personnel who disinfect cystoscopes should follow manufacturer recommendations and guidelines on reprocessing flexible endoscopes. The development of cystoscope specific guidelines might promote increased compliance with correct reprocessing procedures.

Flexible cystoscopy during urodynamic evaluation of spinal cord-injured patients.

Eighty-one consecutive flexible cystoscopic examinations were performed on 69 patients with spinal cord injury (SCI) at the time of their urodynamic study. The indications for cystoscopy included hematuria, recurrent urinary tract infections, symptoms of bladder outlet obstruction, the presence of an intraurethral sphincter stent requiring evaluation, neurogenic vesical dysfunction requiring endourodynamic study (cystometrogram through the working port of the flexible cystoscope), or bladder calculi. Flexible cystoscopy was accomplished in all patients, whether lying supine or seated in a wheelchair (N = 16). Only 6 of 39 patients with previous episodes of autonomic dysreflexia became hypertensive during cystoscopy. When a urodynamic catheter could not be inserted, the flexible cystoscope was particularly useful in defining the urethral anatomy or obstruction and in performing endourodynamic evaluation. The only complication was the development of febrile urinary tract infection in four patients. The flexible cystoscope is a valuable tool in the urodynamic laboratory caring for patients with SCI and is effective for use in endourodynamics, especially when patient positioning or catheter placement is difficult. The procedure is well tolerated, causes minimal stimulation leading to the development of autonomic dysreflexia, and provides accurate cystometric data.