[Analysis of the clinical decision in the initial management of BPH]. / Análisis de la decisión clínica en el manejo inicial de la HBP.

RATIONALE: Diagnostic management of prostate benign hyperplasia remains a controversial issue subject to variations as made evident in surveys conducted in our country showing that 47.9% urologists regularly perform intravenous urography. The aim of this paper was to determine the preferred strategy from the standpoint of a more accurate diagnosis for evaluation of patients with prostate benign hyperplasia and no absolute indication for surgery. MATERIAL AND METHODS: The methodology used was an analysis of the decision taken by elucidation of the problem using a decision tree with three major choices: (a) to perform IPSS, flowmetry and ultrasound: (b) to perform IPSS and flowmetry, or (c) to perform IPSS alone. Basic analysis by estimation of the expected value and three sensitivity analysis, one-tailed and two-tailed, were used to see whether the dominant choice changed. RESULTS: The choice of performing IPSS alone, resulted in accurate diagnosis adjustment in 80.5% cases. When flowmetry was added from the beginning, this percentage declined to 66.2%; if ultrasound was also done, the decline reached down to 11.2%. The Odds Ratio (OR) for diagnosis imbalance was 15.52 and 33, in choice (a) versus choices (b) and (c), respectively. The OR for the IPSS and flowmetry choice to cause imbalance versus IPSS alone was 2, 12. Also, the choice with greater expected value was IPSS, and this result did not change with the sensitivity analysis. CONCLUSIONS: The choice that considers the possibility of symptom quantification in the IPSS scale and, based on the results, continuation of the diagnostic sequence is the one that should be followed, since it provides higher effectiveness from the standpoint of diagnosis adjustment.

Prevalence of benign prostatic hyperplasia in Spanish men 40 years old or older.

PURPOSE: We estimate the prevalence of benign prostatic hyperplasia (BPH) according to symptoms as well as prostate obstruction determined by uroflowmetry and prostate size. MATERIALS AND METHODS: A cross-sectional study was performed at the autonomous community of Andalusia in 1,106 men 40 years old or older. The International Prostate Symptom Score (I-PSS) questionnaire was used to establish symptoms, abdominal and transrectal ultrasonography was done to measure prostate size and uroflowmetry was performed to measure urinary flow obstruction. RESULTS: The prevalence of moderate or severe symptoms was 24.94% and it increased with age. Of the 1,106 subjects 4.19% had severe prostatism, while 12.45% had poor quality of life (I-PSS greater than 3). Average prostate size was greater than 30 gm. in men 60 years old or older. Maximum urine flow was less than 10 and 15 ml. per second in 25.97 and 55.67% of the men, respectively. The prevalence of BPH, defined as I-PSS greater than 7, maximum flow less than 15 ml. per second and prostate size greater than 30 gm., was 11.77% (range 0.75 to 30 at ages 40 to 49 and greater than 70 years, respectively). CONCLUSIONS: The prevalence of BPH increases with age. Moderate prostatism is perceived as resulting in poor quality of life by young subjects and good quality of life by some older subjects. In some men there were symptoms and obstruction but no prostate enlargement. This percentage persists with age after 50 years, when the prevalence of BPH starts to increase.

[Prostatic electrovaporization, a new treatment for prostatic hyperplasia]. / Electrovaporización prostática, un nuevo método de tratamiento de la HBP.

TUR remains the choice technique for the surgical management of bph BUT, though effective, is not entirely free of morbidity. Over the last few years, new techniques have been developed trying to decrease morbidity, of which laser procedures are the most successful ones. We report here the prostate electrovaporization technique and our preliminary results in 75 patients seen over a 5-month period. The efficacy of the system is evaluated using the IPSS score and peak flow values; safety was assessed through the complications arisen, vesical catheter time and operating time. Mean hospital stay was 2 days, length of operation 32 minutes and post-operative vesical catheter time 48 hs; at 3 months, mean peak flow was 19.2 ml/seg and mean IPSS 7. Based en our preliminary results, quick convalescence, decreased cost and casiness of the technique, we consider prostate electrovaporization a likely alternative to conventional TUR, although further longer-term studies are warranted in order to evaluate the histological changes caused by this procedure on the prostate tissue.

[Laparoscopic-extraperitoneal colposuspension]. / Colposuspensión laparoscopica-extraperitoneal.

Female stress urinary incontinence is a highly prevalent disease with a broad range of surgical approaches with different percentages of success depending on the severity of the condition and the appropriateness of the technique in the indication. A few years ago, laparoscopy was introduced as another therapeutical possibility. The paper presents the Burch-like colposuspension through an extraperitoneal laparoscopic approach for the first time in our country, describing the technique and the preliminary results with a mean follow-up of over 6 months. Our preliminary results, as well as the more numerous from other authors seem to indicate that when a Burch-like colposuspension is indicated, extraperitoneal laparoscopic approach may be the ideal one once the learning curve for laparoscopic surgery is overcome.

[Renal metastasis from breast carcinoma: a new case and review of the literature]. / Metástasis renal de un carcinoma de mama: un nuevo caso y revisión de la literatura.

OBJECTIVES: Breast carcinoma is the most common malignant tumor in the female. A vast majority of the cases present metastasis at the time of diagnosis. A case of breast carcinoma metastatic to the kidney is described to emphasize that in the presence of a renal mass, a secondary or metastatic tumor should be suspected. The literature is briefly reviewed. METHODS: We report on the diagnosis and treatment of an expanding left renal mass in a female patient with a previous history of multiorgan tumors (ovarian, breast and small bowel) or different histological types that had been diagnosed and treated at different periods. RESULTS: Following radical nephrectomy, analysis of the surgical specimen disclosed a metastatic tumor from breast carcinoma. No subsequent treatment was required and the patient is well 6 months postoperatively. CONCLUSIONS: Metastasis from a primary tumor must be suspected in patients with a previous history of tumor presenting with a renal mass. Renal metastasis presents in the advanced stages of tumor dissemination. Treatment depends on patient general condition and the stage of the primary and metastatic tumors.

[Penile prosthesis. Implantation under local anesthesia]. / Prótesis de pene. Implantes bajo anestesia local.

UNLABELLED: We report our motivation, technique, results and the current status of penile prosthesis implantation under local anesthesia at our institution. The lack of anesthetists to cope with the surgical demands and the conflicting views on the priority assigned to the different pathologies prompted us to seek an alternative approach. TECHNIQUE: Anesthetic blockade with mepivacaine (2%) for the pudendal nerve branches (dorsal and perineal, in some cases; cavernous, in the first one) responsible for penile innervation, and anesthetic blockade of the genitofemoral and ilioinguinal nerves that innervate the scrotum and its contents. Of the five patients, 80% had excellent and 20% had good tolerance of the procedure. The definition of the foregoing categories are discussed herein. Currently, we have no waiting list or conflicts relative to treatment priorities. We reserve the technique for patients with anesthetic contraindications, as case number five.

[Acute focal bacterial nephritis. Pathology mimicking renal masses]. / Nefritis aguda bacteriana focal. Patología mimetizante de masas renales.

Focal acute bacterial nephritis is an uncommon form of renal acute infection with a clinical presentation that, although similar to other acute infections of the renal parenchyma, must be taken into account in order to reach a correct differential diagnosis with other processes which have very similar radiological images but highly different management approaches, such as the renal carcinoma. This paper present one case in which the sings and symptoms were crucial to establish the diagnosis.

[Unilateral ureteral hernia. Report of a case]. / Hernia ureteral unilateral. A propósito de un caso.

Hernia of the ureter is an uncommon condition and may classified into two types in relation to the peritoneum: extraperitoneal (without hernial sac) and paraperitoneal (with permeable peritoneum and redundant sac). This condition is generally asymptomatic and may be detected incidentally during urography or herniorrhaphy. We report on a case that had been detected during radiologic control evaluation of a left percutaneous nephrostomy prior to treatment with ESWL of a calculus in the ipsilateral lumbar ureter.

[An arteriovenous fistula as a complication of percutaneous nephrostomy]. / Fístula arteriovenosa como complicación de la nefrostomía percutánea.

Percutaneous nephrostomy has emerged as a substitute for surgical nephrostomy. The complication rate is low, hematuria being one of the most common. Treatment should be conservative while possible since the clot plays an important role in the tamponade of hemorrhage. Arteriovenous fistulas following percutaneous nephrostomy are rare. Diagnosis is by arteriography and treatment is by selective embolization.

[Metastatic disease of the penis. Report of 3 cases]. / Enfermedad metastásica del pene. A propósito de tres casos.

Metastatic lesions of the penis are uncommon, only some 200 cases having been reported in the literature. Priapism is the most frequent symptom, although increased penis size, ulceration and nodes formation have also been described; metastasis happens simultaneously in 20% cases while in 50% of cases they appear 2 years after initial diagnosis. Survival of untreated patients has not exceed 24 weeks, whereas treated patients have survived 47 weeks.

[Lymphatic staging by laparoscopic surgery]. / Estadiaje ganglionar mediante cirugía laparoscópica.

Lymphadenectomy is mandatory in vesical and prostatic tumours for a precise staging of candidates to radical surgery. Presentation of our series of 18 ilioobturative lymphadenectomies between May 1992 and February 1993, performed in 14 prostate carcinoma and 4 vesical tumours. As most interesting results, the average number of nodes removed, which was 8, and the discovery of nodular affectation in 5 cases, understaged by the non-invasive procedures, are highlighted; likewise, the reduction in surgery duration up to the current frame of 80 to 120 minutes must be emphasized. Mortality due to the procedure was null. We believe that laparoscopic lymphadenectomy should be the choice technique in the staging of tumoral dissemination in the ilioobturative domain.

[Laparoscopic exeresis of a completely duplicated kidney]. / Exéresis laparoscópica de riñón con duplicidad completa.

During the '80s, laparoscopy in general has undergone an enormous boom as representative of minimally invasive surgery, urology standing out in that progression as the specialty leading the endoscopic approach both for the tradition and profusion of techniques developed. In Spain, major scope laparoscopic surgery started with lymphadenectomy in which we are the second Spanish and first Andalusian group to perform it. The experience accumulated by our group has allowed us to perform and present one case of laparoscopic nephrectomy, this being the first time in Andalusia and second in Spain that an Urology Unit develops this technique, the distinct feature being the presence of complete duplicity of the kidney. The procedure had no peri or post-operative complications and the patient was discharged four days later. We conclude that although presently the indications of renal exeresis for this procedure are limited, these will soon be expanded thanks to the urologists' concern, the accumulation of experience and the improvement of the instrumentarium.

[Local anesthesia in the surgical management of hydrocele and cysts of the spermatic cord]. / La anestesia local en el tratamiento quirúrgico del hidrocele y quiste de cordón espermático.

Traditional management of vaginal fluid collections has always been surgery. The benignancy of this disease does not correspond with the morbidity caused by the anaesthetic techniques used. Over the last few years, sclerotherapy has become increasingly attractive as an alternative to hydrocelectomy. Indications are, nonetheless, restricted, presenting a relapse rate which varies according to the substance used and the operating team. The study proposes the use of local anaesthetics for the surgery of vaginal fluid collections so as to minimize the immediate postoperative period and thus the hospital stay. Between May and October 1991, 55 patients, 49 with hydrocele (4 bilateral) and 6 with sperm cord cyst, were treated in our Unit. Patients were monitored in the theatre (EKG, blood pressure and oximeter) to supervise their life constants, and 2% Mepivacaine (10-20 cc) was infiltrated into the sperm cord and the area of scrotal wall to be cut. Surgical techniques range from dissection to scission of the bag until partial eversion, requiring the use of reabsorbable suture and a careful haemostasis to avoid drainage. Anaesthetics tolerance has been highly satisfactory in 52 patients (94%), good in one patient (2%) and unsatisfactory in two cases (4%). Recorded complications include: severe bradycardia and hypotension in one case (2%), persistent right renoureteral pain in one case (2%), scrotal haematoma in 5 cases (9%) and suture dehiscence in another patient (2%). It is concluded that surgical management of vaginal collection with local anaesthetics is feasible, and reduces the immediate postoperative period also avoiding morbidity derived from a more aggressive anaesthetic technique.

[Dermatomyositis as paraneoplastic syndrome of bladder tumor]. / Dermatomiositis como síndrome paraneoplásico de tumor vesical.

The dermatomyositis is a connective tissue disease characterized by changes affecting both the skin and the muscle, appearing most frequently around the fifth and sixth decades and which association to a vesical tumour is very rare. This paper contributes one case of paraneoplastic dermatomyositis associated to infiltrant vesical tumour, presenting erythematous damage in face, nape of the neck and upper thorax, as well as periorbital heliotrope erythema and fingernails base and sides telangiectasia, all of which are typical signs of dermatomyositis.

[The use of the double-J catheter as urinary obstruction prophylaxis in lithiasis]. / Uso del catéter doble J como profilaxis de la obstrucción urinaria en patología litiásica.

Our experience in the use of the double-J catheter in the prevention and treatment of urinary obstruction in stone disease is presented. This retrospective study spans the period January, 1985 to June 1989. Fifty-five double-J catheters were placed in 51 patients (catheter replacement was required in 4). Catheter placement was done antegradely in 17, retrogradely in 34 and intraoperatively in 4 cases. The indications were for treatment post-ESWL in 45 patients, stone remnants following percutaneous nephrolithotomy in 1, post-ureteroscopy in 2, and after open surgery in 2 patients. Complications were observed in 24% of the cases, hematuria being the most common complication. The foregoing agrees with the 20-40% complication rate reported in the literature. Thus, we can conclude that the double-J catheter is well-tolerated and is a simple yet useful endourologic tool in the prevention and treatment of urinary obstruction in stone disease.

[Diagnostic evaluation of closed renal trauma]. / Evaluación diagnóstica de los traumatismos renales cerrados.

Renal traumatism is a relevant entity, its early and precise diagnosis having great weight in the initiation of appropriate treatment and its success. All 189 contained renal traumatisms seen in our service between 1981 and 1989, are studied. The purpose of the present work is to determine the diagnostic reliability of the different tests available, chiefly comparing echography versus urography, as well as CT. The method used is measurement of Sensitivity, Specificity and Predictive values, arranged by grades and compared using the squared-chi method (Fisher's exact test). Regarding the primary results we must emphasise the rejection of a void hypothesis in grades II and III with an error level lower than 0.01 for positive predictive values in echography vs. urography; as well as the high values of sensitivity and specificity of CT in high degree traumatisms. To conclude, those traumas where a complementary study is necessary urography may provide more information than echography; although in traumatisms where high degree lesions are suspected, CT will provided the most valuable information.

[Primary hyperthyroidism. Our experience]. / Hipertiroidismo primario. Nuestra experiencia.

The present study was performed in ten cases of hyperparathyroidism with a history of recurrent renal colic with or without passing calculi. Most of these patients had undergone stone surgery. Diagnosis was based on patient history, and metabolic and radiologic work up, and confirmed histologically following surgical exploration of the neck and removal of the pathologic parathyroid gland.

[Nephrogenic adenoma: presentation of a case and review of the literature]. / Adenoma nefrogénico: presentación de un caso y revisión de la literatura.

We report a case of nephrogenic adenoma in a patient who had previously undergone a nephrectomy procedure for renal TB, and with a history of recurrent infection of the urinary tract. The present case shows the role of chronic inflammatory disease in the pathogenesis of nephrogenic adenoma.