[Radical prostatectomy. A review of our series between 1997-2003]. / Prostatectomía radical. Revisión de nuestra serie en el periodo 1997-2003.

OBJECTIVE: To evaluate the complications and results of our series of 398 radical retropubic prostatectomies as an elective treatment for clinically localized prostate cancer. PATIENTS AND METHODS: Between January 1997 and June 2003, a total of 398 radical retropubic prostatectomies have been performed. Mean age was 63.8 years (45.8-78.2), mean PSA at diagnosis 9.32 ng/ml (0.9-129.7). Mean surgical time was 141.6 minutes (70-280), and mean hospitalization was 6.75 days (2-37). RESULTS: Mean follow-up was 65.18 months. We report as peroperatory complications: rectal injury 1.8%, lymphatic leakage 0.3%, urinary fistula 5%. As delay complications: uretrovesical junction stenosis 6%. We observed 49.1% of patients with positive surgical margins. We don't report any peroperatory death. The overall survival rate is 98.5%, the cancer specific survival rate is 99.75%, and the recurrence-free survival rate is 84.97%. CONCLUSIONS: Radical retropubic prostatectomy is an excellent treatment form for patients with clinically localized prostate cancer. A strict selection of patients candidates is important to obtain good results.

Prostatectomía radical. Revisión de nuestra serie en el periodo 1997-2003 / Radical prostactectomy. A review of our serie between 1997-2003

Objetivos: Analizar los resultados y complicaciones de nuestra serie de 398 casos de prostatectomía radical retropúbica como tratamiento electivo del cáncer de próstata órgano confinado. Material y metodos: Entre enero de 1997 y junio de 2003 hemos realizado un total de 398 prostatectomías radicales. La edad media fue de 63,8 años (45,8-78,2), con una media de PSA al diagnóstico de 9,32 ng/ml (0,9-129,7). La media del tiempo quirúrgico es de 141,6 minutos (70-280), y la media de días de ingreso hospitalario de 6,75 días (2-37).Resultados: El seguimiento medio de nuestra serie ha sido de 65,18 meses. Como complicaciones peroperatorias destacamos: lesión rectal 1,8%, linforrea 0,3%, fístula urinaria 5%. Como complicaciones tardías: estenosis anastomosis uretrovesical 6%.Hemos objetivado un porcentaje de márgenes positivos del 49,1%. No hemos tenido ningún exitusperoperatorio. La supervivencia global de la serie es del 98,5%, la supervivencia cáncer específica del 99,75%, y la supervivencia libre de enfermedad del 84,97%.Conclusiones: La prostatectomía radical es una excelente opción de tratamiento en pacientes con cáncer de próstata órgano confinado. Es indispensable para obtener buenos resultados una correcta selección de los pacientes candidatos a tratamiento quirúrgico (AU)

Objetive: To evaluate the complications and results of our series of 398 radical retropubic prostatectomies as an elective treatment for clinically localized prostate cancer. Patients and methods: Between january 1997 and june 2003, a total of 398 radical retropubic prostatectomies have been performed. Mean age was 63.8 years (45.8-78.2), mean PSA at diagnosis 9.32 ng/ml (0.9-129.7). Mean surgical time was 141.6 minutes (70-280), and mean hospitalization was 6.75 days (2-37). Results: Mean follow-up was 65.18 months. We report as peroperatory complications: rectal injury 1.8%, lymphatic leakage 0.3%, urinary fistula 5%. As delay complications: uretrovesical junction stenosis 6%. We observed 49.1% of patients with positive surgical margins. We don´t report any peroperatory death. The overall survival rate is 98.5%, the cancer specific survival rate is 99.75%, and the recurrence-free survival rate is 84.97%. Conclusions: Radical retropubic prostatectomy is an excellent treatment form for patients with clinically localized prostate cancer. A strict selection of patients candidates is important to obtain good results (AU)

[Retrospective study of 130 patients with organconfined prostate cancer treated with brachytherapy]. / Estudio retrospectivo de 130 pacientes con cáncer prostático organoconfinado tratados con braquiterapia prostática.

INTRODUCTION: The prostate brachytherapy with I 125 seeds has an indication in patients with organconfined prostate cancer. Our objective is to describe the population treated in our institution with permanent I125 seeds implants, the dosimetric characteristics of the technique and the preliminary results of our group-study in terms of evolution and toxicity. MATERIAL AND METHODS: Between May 2000 and March 2003, 130 patients with permanent implants of I125 seeds were treated. Beforehand we did prostate volumetric with transrectum prostate echography in order to assess the configuration of the implant, number of seeds and their place in the prostate with the objective to get a fine coverage of PTV (planet target volume). Stage distribution: 75.72% T1c; 24.28% T2a; Gleason<6, 94%. The PSA pretreatment average was 6.38 ng/ml. The average prostate volume was 30 cc. The 16.67% of the patients included had hormonal treatment previously to get the implants. The average age was 64 years. The characteristic techniques of the implants were: the average width of the needle as 24 (14-35) and the average of the seeds 76 (46-111). Finally the average activity was 0.39 mCi/seed, which means average total implant activity of 80 mCi. RESULTS: We analyzed 130 patients with average follow up 6 months. A 1 to 2 year surveillance was carried out on 98.9% and the global free disease surveillance (biochemic relapse) of 98.9% at the year and of the 87.8% at the end of the 2 years. The relapse in the low risk patients was 98.8% after the first year and 88.7% at the end of 2 year. On the contrary in the middle risk was of 100% and 83% respectively, although the amount of patients in significantly less. As a relevant acute secondary effects we found slight rectitys or GI (RTOG scale) in 1.4 and that needs synthomatic medication or GII (RTOG scale) in 0.8%. We found slide hematuria or GI (RTOG scale) in the 53% and other measures or GII (RTOG scale) in the 2.64% was needed. Finally we had to set a urinary prove for acute retention in 4.3%. CONCLUSION: The prostate brachyterapy is a complex procedure that needs a multidisciplinary team participation in order to be able to carry out. It avoids a long term hospitalization and allows for the patient to have daily activity within a short period of time. Despite the fact of the brief follow-up, the results over biochemical relapse and toxicity were similar to the ones in the literature. Tolerance to the implant was good. It would necessary a longer follow-up in order to be able to come to long term conclusions.

[Intraprostatic embolization of cholesterol crystals]. / Embolización intraprostática de cristales de colesterol.

The cholesterol embolism syndrome (CES) is an unusual disease that carries a high mortality rate. Finding intraprostatic cholesterol crystal embolization as the result of transrectal prostate biopsy in a patient with several risk factors for atherosclerosis, should alert the urologist to the possibility of CES existence.

Estudio retrospectivo de 130 pacientes con cáncer prostático organoconfinado tratados con braquiterapia prostática / Retrospective study of 130 patients with organconfined prostate cancer trated with brachitherapy

Introducción: La braquiterapia prostática con semillas de I125 está indicada en pacientes con cáncer de próstata organoconfinado. Nuestro objetivo es describir la población tratada en nuestra institución mediante implante permanente con semillas de I125, las características dosimétricas de la técnica y los resultados preliminares de nuestra serie en cuanto a evolución y toxicidad. Material y métodos: Entre mayo 2000 y marzo de 2003 fueron tratados 130 pacientes con implante permanente transperineal de semillas de I125. Previamente a todos se les realizó volumetría mediante una ecografía prostática transrectal para determinar la configuración del implante, número de semillas y su localización en la próstata con el fin de obtener una adecuada cobertura del PTV (planed target volume o volumen planificado para tratar). Distribución por estadios: 75,72% T1c; 24,28% T2a. Gleason < 6, 94,24%. La mediana del PSA pretratamiento 6,38 ng/ml. El volumen prostático mediano fue de 30 cc. El 16,67% de los pacientes cuando los recibimos llevaban tratamiento hormonal previo al implante. La edad mediana fue de 64 años. En cuanto a las características técnicas de los implantes: la mediana de agujas utilizadas fue de 24 (14-35), y la mediana de semillas: 76 (46-111). Finalmente la mediana de la actividad fue de 0,39mCi/semilla, lo que supuso una actividad total implantada media de 80 mCi. Resultados: Analizamos los 130 pacientes con un seguimiento mínimo de 6 meses. La supervivencia a 1 y 2 años fue del 99,1% y la supervivencia libre de enfermedad global del 98,9% al año y del 87,8% a los dos años La supervivencia libre de enfermedad bioquímica en los pacientes de bajo riesgo eran, al año de 98,8% y a los dos años del 88,7%. Por el contrario en los de riesgo intermedio eran del 100% y del 83,3% respectivamente, aunque el número de pacientes es significativamente menor. Como efectos secundarios agudos relevantes encontramos rectitis leve o GI (escala de la RTOG) en 1,4% y que necesitó medicación sintomática o GII (escala de la RTOG) en 0,8%. Se presentó hematuria leve o GI (escala de la RTOG) el 53%, y que precisaran otras medidas o GII (escala de la RTOG) en el 2,64%. Finalmente hubo que colocar sonda urinaria por retención aguda el 4,3%. Conclusión: La braquiterapia prostática es un procedimiento complejo que exige la participación de un equipo multidisciplinar en su realización. Evita una hospitalización prolongada y permite al paciente recuperar sus actividades cotidianas en un periodo corto de tiempo. Aunque la media de seguimiento es corta, los resultados en cuanto a supervivencia libre de recidiva bioquímica y toxicidad son comparables a los descritos en la literatura. La tolerancia al implante ha sido buena. Es necesario un mayor seguimiento para poder establecer conclusiones a largo plazo

Introduction: The prostate brachitherapy with I 125 seeds has an indication in patients with organconfined prostate cancer. Our objective is to describe the population trated in our institution with permanent I125 seeds implants, the dosimetric characteristics of the technique and the preliminary results of our group-study in terms of evolution and toxicity. Material and methods: Between May 2000 and March 2003, a 130 patients with permanent implants of I125 seeds were trated. Beforehand we did prostate volumetric with transrectum prostate ecography in order to asses the configuration of the implant, number of seeds and their place in the prostate with the objective to get a fine coverage of PTV (planet target volume). Stage distribution: 75.72% T1c; 24.28% T2a. Gleason<6, 94%. The PSA pretreatment average was 6.38 ng/ml. The average prostate volume was 30 cc. The 16.67% of the patients included had hormonal treatment previously to get the implants. The average age was 64 years. The characteristic techniques of the implants were: the average width of the needle as 24 (14-35) and the average of the seeds 76 (46-111). Finally the average activity was 0.39 mCi/seed, wic means average total implant activity of 80 mCi. Results: We analized 130 patients with average follow up 6 months. A 1 to 2 year surveillance was carried out on 98.9% and the global free disease surveillance (biochemic relapse) of 98.9% at the year and of the 87.8% at the end of the 2 years. The relapse in the low risk patients was, 98.8% after the first year and 88.7% at the end of 2 year. On the contrary in the middle risk was of 100% and 83% respectively, although the amount of patients in significantly less. As a relevant acute secondary effects we found slight rectitys or GI (RTOG scale) in 1.4 and that needs synthomatic medication or GII (RTOG scale) in 0.8%. We found slide hematuria or GI (RTOG scale) in the 53% and other measures or GII (RTOG scale) in the 2.64% was needed. Finally we had to set a urinary prove for acute retention in 4.3%. Conclusion: The prostate brachiterapy is a complex procedure that needs a multidisciplinary team participation in order to be able to carry out. It aboids a long term hospitalitzation and allows for the patient to have daily activity within a short period of time. Despite the fact of the brief follow-up, the results over biochemical relaps and toxicity were similars to the ones in the literature. Tolerance to the implant was good. It would necessary a longer follow-up in order to be able to come to long term conclusions

Embolización intraprostática de cristales de colesterol / Intraprostatic embolization of cholesterol crystals

La Enfermedad por émbolos de colesterol (EEC) es una patología poco conocida pero con una alta mortalidad asociada. La presencia de embolias de cristales de colesterol a nivel intraprostático como hallazgo poco común en las biopsias prostáticas transrectales en un enfermo con factores de riesgo tromboembólico, debe alertarnos sobre la posible existencia de la EEC

The cholesterol embolism syndrome (CES) is an unusual disease that carries a high mortality rate. Finding intraprostatic cholesterol crystal embolization as the result of transrectal prostate biopsy in a patient with several risk factors for atherosclerosis, should alert the urologist to the possibility of CES existence

[Prostatic brachytherapy indications and technique]. / Indicaciones y técnica de la braquiterapia prostática.

Prostate cancer is an important health problem, mainly in elderly men. It is the second cause of death among men in USA ant the third at the "Registro del Cáncer de Tarragona", behind both the lung and colorectal cancer. About the 58% of the newly diagnosed cancers are localized, therefore, they have to be treated with curative intention. Radical prostatectomy is considered the gold standard treatment for organ confined prostate cancer in our country. On basis to the experience of American groups and the improvement of both, image techniques and dosimetric calculation, brachytherapy has been brought in as a new option in the treatment of localized prostate cancer. We started our program of brachytherapy for prostate cancer on May 2000. We have performed 51 procedures by now. Our protocol and the technique to perform a prostatic brachytherapy are described following.

Indicaciones y técnica de la braquiterapia prostática / Indications and procedure of prostatic brachitherapia

El cáncer de próstata es un problema de salud importante que afecta principalmente á los varones de edad avanzada. Es la segunda causa de muerte entre los varones en EE.UU. y la tercera en frecuencia entre los varones en el Registro del Cáncer de Tarragona, después del cáncer de pulmón y del cáncer colorectal. Se estima que un 58 por ciento de los cánceres de próstata diagnosticados serán órganoconfinados y, por tanto, tributarios de un tratamiento con intención curativa. En nuestro medio la prostatectomía radical es considerado el tratamiento de elección para el cáncer de próstata órganoconfinado. En base a la amplia experiencia en el tratamiento del cáncer de próstata órganoconfinado mediante braquiterapia de algunos grupos en EE.UU., junto con la mejora a nivel de técnicas de imagen y cálculo dosimétrico, está terapéutica ha empezado a introducirse en nuestro medio como una nueva opción para el tratamiento del cáncer de próstata. Nuestro grupo inició su experiencia con la braquiterapia prostática en mayo de 2000, habiéndose realizado hasta la actualidad 51 procedimientos. A continuación exponemos nuestro protocolo de inclusión y técnica para la realización de braquiterapia en el cáncer de próstata órgano confinado (AU)

Hematuria por fístula arterioureteral. Tratamiento endovascular / Hematuria for arterioureteral fistula. Endovascular treatment

Se presenta el caso clínico de una paciente con hematuria macroscópica anemizante, causada por la presencia de una fístula entre la arteria iliaca externa y el uréter. Tras su diagnóstico, se realizó un tratamiento mediante abordaje endovascular. Las fístulas arterioureterales son una rara entidad, que supone una urgencia vital. Su diagnóstico debe basarse en la sospecha clínica (falta de datos en las exploraciones complementarias). Su tratamiento clásico ha sido la cirugía abierta, pero el abordaje endovascular debe ser valorado dada su menor agresividad (AU)

[Incidence and treatment of urinary lithiasis in renal transplantation]. / Incidencia y tratamiento de la litiasis urinaria en el injerto renal.

INTRODUCTION: Urinary calculi is an uncommon complication in kidney transplantation; several stone risk factors are found in transplanted patients, but in most cases there is not a relationship between these risk factors and stone formation. The treatment of these patients is complex due to their both immunosuppressive status and border-line renal function. MATERIAL AND METHOD: From 1980 to February 2000, 1198 kidney transplant have been performed in our institution. We describe our series consisting in 22 urinary calculi (15 in the graft, 3 in the urether and 4 in the bladder) in 18 patients, including 7 stones detected in cadaveric donor patients. RESULTS: We performed external shock wave lithotripsy in 7 patients, bench surgery in 4, endoscopic mechanic lithotripsy in 5, open surgery in 1 and observation in 6. Calcium oxalate (mono and dihidrate) was found in 9 of 13 calculi. Metabolic changes were found in 15 of the 18 patients, the most common was hiperuricemia. There were not complications of every treatment applied and 9% of them needed a savage treatment. We found recurrence in 4 cases (22.2%). Now 12 of the patients are stone-free (66.7%) and three have non-significative stones (83.3% without symptoms). CONCLUSIONS: Detection of renal calculi in cadaveric renal donors is not a reason to refuse the graft for further transplantation. In both renal calculi up to 2 cm and uretheric calculi surgical treatment is assessed as first option. In caliceal stones smaller than 5 mm observations is the best treatment.

Incidencia y tratamiento de la litiasis urinaria en el injerto renal / Incidence and treatment of urinary calculi in the renal graft

INTRODUCCIÓN: La litiasis urinaria es una complicación infrecuente del trasplante renal; diversos factores de riesgo se han encontrado en pacientes trasplantados renales, pero en muchos casos no hay una relación entre estos factores de riesgo y la formación del cálculo. El tratamiento de estos pacientes es complejo debido a su estado de inmunosupresión y su función renal límite. MATERIAL Y MÉTODO: Desde 1980 hasta febrero de 2000 se han llevado a cabo 1.198 trasplantes renales en nuestro centro. Describimos nuestra serie, que consiste en 22 cálculos (15 en el injerto, 3 en el uréter y 4 en la vejiga) en 18 pacientes, incluyendo 7 litiasis diagnosticadas en el donante cadáver. RESULTADOS: Se practicó litotricia extracorpórea por ondas de choque (LEOC) en 7 ocasiones, cirugía en banco en 4, litotricia mecánica endoscópica en 5, cirugía abierta en 1 y actitud expectante en 6. Los cálculos contenían oxalato cálcico (mono o dihidrato) en 9 de los 13 analizados. Aparecieron alteraciones metabólicas en 15 de los 18 pacientes, la más común fue la hiperuricemia. No han aparecido complicaciones del tratamiento y en dos litiasis (9 por ciento) fue necesario un tratamiento de rescate. Cuatro cálculos recidivaron (22,2 por ciento). Están libres de litiasis 12 pacientes (66,7 por ciento) y 3 con litiasis clínicamente no significativas (83,3 por ciento asintomáticos). CONCLUSIONES: La presencia de litiasis en el donante renal cadáver no es una razón para rechazar el injerto para el trasplante. En el tratamiento de los cálculos renales mayores de 2 cm y ureterales, debe valorarse el tratamiento quirúrgico como primera opción. En los cálculos calicilares menores de 5 mm la abstinencia terapéutica es la actitud recomendable (AU)

[Hematuria secondary to arterioureteral fistula. Endovascular treatment]. / Hematuria por fístula arterioureteral. Tratamiento endovascular.

Presentation of case of patient with macroscopic anemic hematuria caused for the presence of a fistula between the external iliac artery and the ureter. After the diagnosis, a treatment with endovascular mangement was made. The arterioureteral fistulae are a very rare entie, which supposes a vital emergency. The diagnosis depend upon the clinical evidences (complementary explorations rarely provide specific findings). Classic treatment is bases on open surgery, while endovascular treatment may be an alternative with less aggressiveness.

[Renal hematoma after shockwave extracorporeal lithotripsy]. / Hematomas renales tras litotricia extracorpórea por ondas de choque.

OBJECTIVE: Renal haematomas after shock wave extracorporeal lithotripsy (SWEL) represent a potentially serious complication. This paper examines those cases of post-SWEL renal haematoma seen in our Centre, analyzing the likely risk factors. PATIENTS AND METHODS: Between May 1988 and June 1996, 12,800 patients were treated with 15100 lithiasis at some level of the urinary tract requiring 16,000 SWEL sessions. All treatments were done with a Dornier HM-4 lithotripter. Voltage applied ranged from 18 to 26 Kv, averaging 2500 waves/session. Complementary testing (ultrasound/computerised tomography) was requested immediately after treatment if clinical complications were suspected. RESULTS: A total of 10 renal haematomas (0.078%) were diagnosed. Six cases were mild, but 4 presented extensive haematoma with significant haemodynamic consequence. Although in one case nephrectomy was undertaken to control haemorrhage, death finally occurred by disseminated intravascular coagulation. Four patients who developed haematoma were hypertensive and 3 had a previously corrected haemostasis alteration. CONCLUSIONS: The possibility of renal haematoma should be taken into account in the face of persistent and unjustified pain after SWEL treatment. Normalization of blood pressure values, correction of urinary infection as well as adequate correction of haemostatic disorders is advisable.

[Kidney transplantation with donors in heart block. Long-term results]. / Transplante renal con donantes en parada cardíaca. Resultados a largo plazo.

OBJECTIVES: The shortage of renal grafts has led to the search for other alternatives. The use of grafts from non-heart-beating donors (NHBD) can increase the number of transplants 8% to 20%. Clinical studies conducted by different groups, have found that the long-term graft and patient survival are not different from those of recipients of kidneys from heart-beating donors (HBCD). METHODS/RESULTS: The long-term results of a group of 52 recipients of NHBD kidneys were compared with those of 98 recipients of HBCD grafts. There were no differences in donor and recipient ages, HLA compatibility, reperfusion and cold ischemia times. There were no differences in the incidence of rejection episodes or non-functioning kidneys. Warm ischemia between 30 to 60 min or < 30 min did not influence the incidence of non-functioning kidneys. However, NHBD graft recipients had a higher incidence of acute tubular necrosis (67% versus 46%), recovers of renal function was slower, the duration of oliguria was longer and dialysis was required. The 8-year actuarial survival data were similar for both groups; 65% for the NHBD and 70% for the HBCD graft recipients. CONCLUSIONS: We can conclude that NHBDs are an important source of donor kidneys. The 12 points established by The First International Workshop on Non-Heart-Beating Donors which appear at the end of the present article are embodied in the Treaty of Maastricht regulations of organ transplantation from non-heart-beating donors.

[Postgraduate training in urology]. / La formación postgrado en urología.

Presentation of an updated protocol for training of In-house Urologists. Preparation of this protocol was the result of a pilot program undertaken in our Hospital by the Teaching Committee. The protocol contemplates in an comprehensive way all the activity developed by In-house physicians during their training, at the end of which the Teaching Committee prepares a curriculum approved by the Urology Tutor and the Consultant. With this a better assessment of the knowledge, capacities and attitudes of trained urologists can be obtained.

[Transplantectomy today: indications and complications]. / La transplantectomía hoy: indicaciones y complicaciones.

Analysis of the indications for transplantectomy and its complications over a 12-year period. Over a total of 159 failure grafts, we performed 53 transplantectomies (33.3%). The percentage of complications was 16.9%. Three patients died (5.6%) during the more or less immediate post-operative period. In our experience, consistent and prolonged maintenance of immunosuppression should avoid the need for transplantectomy in a high percentage of grafts. Only 15 transplantectomies were made on 104 failure grafts after 6 months (14.4%). Our short but successful experience with embolization of 2 rejected grafts confirms the validity of this conservative alternative versus conventional surgical transplantectomy in selected cases.

[Renal angiomyolipoma. Our case histories]. / Angiomiolipoma renal. Nuestra casuística.

We reviewed the cases of angiomyolipoma that had been diagnosed and treated in our urology services from 1978 to 1991. The study showed a higher incidence in the females; it frequently presented as a solitary tumor; a high specificity was found for the US (hyperechoic mass) and CT (areas of low attenuation ratio) findings. Owing to these diagnostic techniques, conventional surgery is no longer the only treatment. Embolization is considered to be the first therapeutic approach.

[Leukoplakia of the upper urinary tract]. / Leucoplaquia del tracto urinario superior.

Leukoplakia is a morphological term that attempts to define keratinizing desquamative squamous metaplasia of the transitional epithelium. It is uncommon in the upper urinary tract (less than 100 cases have been reported) and has been attributed to infection or mechanical injury to the epithelium and/or genetic factors. We present a case of leukoplakia in a male patient with renal tuberculosis that had been in remission for the past 15 years. Eight years earlier he had intermittently passed keratin laminas (pathognomonic of leukoplakia) during the course of various episodes of nephritic colic. After discarding a reactivation of tuberculosis and malignancy of the metaplastic lesion, we continued conservative treatment with radiologic and cytologic control evaluations.

[Treatment of ureterocele in the adult]. / Tratamiento del ureterocele en el adulto.

Review of 18 cases of ureterocele in the adult. The first clinical symptoms are unspecific, with a long-term evolution, and were found while carrying out routine urological examinations. The association to secondary lithiasis in over 60% cases and the presence of complete duplicity in 44% cases is highlighted. The choice treatment is by endoscopy in the simple cases without hydronephrosis or associated reflux. The technique of transversal incision in 'smiling mouth' at the base of the ureterocele produces good results.