Profilaxis farmacológica de la tromboembolia venosa en la prostatectomía radical / Pharmacological venous thromboembolism prophylaxis in radical prostatectomy

ANTECEDENTES Y OBJETIVO: El tromboembolismo pulmonar es una de las causas más comunes de muerte no quirúrgica en pacientes sometidos a cirugía urológica abdominopélvica. Desde el inicio de la profilaxis para la enfermedad tromboembólica venosa los episodios de trombosis venosa profunda y tromboembolia pulmonar han descendido considerablemente. Nuestro objetivo es analizar los predictores de la enfermedad tromboembólica, la variabilidad clínica en la utilización de la profilaxis farmacológica para esta enfermedad y los resultados de su aplicación. MATERIAL Y MÉTODOS: Estudio retrospectivo multicéntrico de 610 pacientes intervenidos mediante prostatectomía radical entre diciembre de 2013 y noviembre de 2014 en 7hospitales generales de España, Italia y Portugal. Se clasificó a los pacientes según sus características basales en grupos de riesgo trombótico y grupos de riesgo hemorrágico. Se evaluaron los eventos tromboembólicos venosos que se presentaron en los diferentes grupos. RESULTADOS: La edad media fue de 65,22años (48-78). El índice de masa corporal medio fue de 26,7 y la mediana del riesgo de ASA fue 2. En todos los pacientes se inició la deambulación en las primeras 24h. En el 4,1% se utilizó compresión neumática intermitente y en el 84,6%, profilaxis farmacológica con heparinas de bajo peso molecular. Solo en el 3,4% se utilizó la combinación de profilaxis mecánica con la farmacológica. Se observó disminución de la incidencia de eventos tromboembólicos en los pacientes que recibieron profilaxis farmacológica, con una reducción absoluta del riesgo del 6,8%. No se objetivó aumento del riesgo hemorrágico en los pacientes que recibieron profilaxis tromboembólica. CONCLUSIONES: En este estudio sobre pacientes sometidos a prostatectomía radical no hubo diferencia en las complicaciones hemorrágicas derivadas del uso de profilaxis farmacológica para la enfermedad tromboembólica venosa. La profilaxis farmacológica reduce el riesgo de presentar un evento tromboembólico en pacientes sometidos a prostatectomía radical, si bien este riesgo no se asocia con la técnica de abordaje

BACKGROUND AND AIM: Pulmonary thromboembolism is one of the most common causes of non-surgical death in patients following urological abdominopelvic surgery. Since the beginning of prophylaxis for venous thromboembolic disease, episodes of deep vein thrombosis and pulmonary thromboembolism have decreased. Our objective is to analyse the prognosis factors of thromboembolic disease, the clinical variability in the use of pharmacological prophylaxis and the results of its application. MATERIAL AND METHODS: Retrospective multicentric study of 610 patients undergoing radical prostatectomy between December 2013 and November 2014, in 7general hospitals in Spain, Italy and Portugal. Patients were classified according to their baseline characteristics into thrombotic risk groups and haemorrhagic risk groups. The venous thromboembolic events that occurred in the different groups were analysed. RESULTS: The average age was 65.22years (48-78). The average body mass index was 26.7 and the average ASA risk 2.1. In all patients, early mobilization began in the first 24hours. In 4.1% intermittent pneumatic compression was used and 84.6% received pharmacological prophylaxis with low molecular weight heparins. Only 3.4% used the combination of mechanical prophylaxis with pharmacological prophylaxis. We observed a decrease in the incidence of thromboembolic events in the patients who received pharmacological prophylaxis, with an absolute risk reduction of 6.8%. There was no increase in the risk of haemorrhage in the patients who received pharmacological prophylaxis. CONCLUSIONS: In this study on patients undergoing radical prostatectomy, there was no difference in haemorrhagic complications derived from the use of pharmacological prophylaxis for venous thromboembolic disease. Pharmacological prophylaxis reduces the risk of presenting a thromboembolic event in patients undergoing radical prostatectomy, although this risk is not associated with the approach technique

Pharmacological venous thromboembolism prophylaxis in radical prostatectomy. / Profilaxis farmacológica de la tromboembolia venosa en la prostatectomía radical.

BACKGROUND AND AIM: Pulmonary thromboembolism is one of the most common causes of non-surgical death in patients following urological abdominopelvic surgery. Since the beginning of prophylaxis for venous thromboembolic disease, episodes of deep vein thrombosis and pulmonary thromboembolism have decreased. Our objective is to analyse the prognosis factors of thromboembolic disease, the clinical variability in the use of pharmacological prophylaxis and the results of its application. MATERIAL AND METHODS: Retrospective multicentric study of 610 patients undergoing radical prostatectomy between December 2013 and November 2014, in 7general hospitals in Spain, Italy and Portugal. Patients were classified according to their baseline characteristics into thrombotic risk groups and haemorrhagic risk groups. The venous thromboembolic events that occurred in the different groups were analysed. RESULTS: The average age was 65.22years (48-78). The average body mass index was 26.7 and the average ASA risk 2.1. In all patients, early mobilization began in the first 24hours. In 4.1% intermittent pneumatic compression was used and 84.6% received pharmacological prophylaxis with low molecular weight heparins. Only 3.4% used the combination of mechanical prophylaxis with pharmacological prophylaxis. We observed a decrease in the incidence of thromboembolic events in the patients who received pharmacological prophylaxis, with an absolute risk reduction of 6.8%. There was no increase in the risk of haemorrhage in the patients who received pharmacological prophylaxis. CONCLUSIONS: In this study on patients undergoing radical prostatectomy, there was no difference in haemorrhagic complications derived from the use of pharmacological prophylaxis for venous thromboembolic disease. Pharmacological prophylaxis reduces the risk of presenting a thromboembolic event in patients undergoing radical prostatectomy, although this risk is not associated with the approach technique.

Influence of secondary diagnoses in the development of urinary incontinence after radical prostatectomy.

OBJECTIVE: To study whether there are factors related to secondary diagnoses (SDg) present in patients with prostate cancer that influence the development of urinary incontinence after radical prostatectomy (RP). MATERIALS AND METHODS: A retrospective multicenter observational study was performed reviewing the medical records of 430 men who underwent RP due to organ-confined prostate cancer in 9 different hospitals. Two study groups were distinguished: Group A (GA): Patients without urinary incontinence after RP; Group B (GB): patients with any degree of post-surgical urinary incontinence. RESULTS: Average age at surgery was 63.42 years (range 45-73). 258 patients were continent after surgery and 172 patients complaint of any degree of incontinence after RP. A higher percentage of healthy patients was found in group A (continent after surgery) than in group B (p = 0.001). The most common SDg prior to surgery were hypertension, lower urinary tract symptoms, dyslipidemia, diabetes mellitus and erectile dysfunction, but none did show a greater trend towards post-surgical incontinence. CONCLUSIONS: A better health status prior to surgery is associated to a lower incidence of new-onset urinary incontinence after radical prostatectomy. However, no correlation was found between the most common medical disorders and the development of post-surgical urinary incontinence.

A type primary amyloidosis of the urinary bladder: Clinical case and bibliographic review.

OBJECTIVE: Amyloidosis is a disease characterised by deposition of eosinophilic hyaline material in different tissues. Urinary bladder involvement is uncommon with less than 200 cases of the primary form published in the literature. We present a new case of primary AA type amyloidosis of the urinary bladder (typical of secondary forms). METHODS: A 66-year-old male was seen in the outpatient urology consultation with several-weeks history intermittent haematuria with decreased voiding urinary calibre. In addition, he had intense nocturia, 10-12 times per night, and occasional urgency. Physical examination of the abdomen and genitals was unremarkable. Urine sediment and blood tests were normal. Urine cytology studies were requested and revealed urothelial cells with no atypical cells and a moderate quantity of neutrophils and erythrocytes. Cystoscopy was performed and revealed yellowish erythematous lesions at the level of the vesicoureteric junction and the fundus. The lesions were biopsied. Pathology studies revealed urothelial mucosa with marked chronic inflammation and accumulations of amyloid-appearing hyaline material in the area of the vessels with green birefringence on polarised light. TUR of the bladder was later performed with the goal of completely resecting the lesion. The result of the pathology studies confirmed the biopsy findings and immunohistochemistry studies revealed AA type amyloid (typical of secondary forms). RESULTS: Two years after the intervention, the patient remains asymptomatic with normal endoscopic follow-up studies. CONCLUSIONS: Primary AA type amyloidosis of the bladder is a very uncommon pathology with few cases reported in the international urology literature. Nevertheless, we must keep it in mind in the differential diagnosis when faced with a patient with haematuria and/or persistent urinary symptoms.

Amiloidosis vesical primaria de tipo AA: caso clínico y revisión de la literatura / AA Type primary amyloidosis of the urinary bladder: Clinical case and bibliographic review

OBJETIVO: La amiloidosis es una enfermedad caracterizada por el depósito de material hialino eosinofílico en distintos tejidos, siendo muy infrecuente la afectación vesical. Nuestro objetivo es dar a conocer un nuevo caso de amiloidosis vesical primaria de tipo AA y una revisión de la literatura al respecto. MÉTODO: Varón de 66 años de edad que acude a consulta por referir hematuria intermitente de dos semanas de evolución, junto con urgencia y nicturia de 10-12 veces. La exploración física abdominal y genital resultó anodina así como el sedimento, urocultivo y citologías (microhematuria e inflamación). En cistoscopia se apreció, a nivel de trígono y fondo vesical, una mucosa con lesiones eritematosas-amarillentas, ligeramente sobreelevadas que se biopsian. El resultado anatomopatológico fue de mucosa urotelial con marcada inflamación crónica y acúmulos perivasculares de material hialino de aspecto amiloide. Se completó el tratamiento con resección transuretral de la lesión vesical confirmando el diagnóstico de amiloidosis vesical tipo AA (propio de formas secundarias). El estudio de probable afectación sistémica fue normal. RESULTADOS: Tras dos años de seguimiento el paciente se encuentra asintomático, sin evidencia de recidiva en las cistoscopias. CONCLUSIONES: Las formas de amiloidosis vesical primaria de tipo AA son una patología muy infrecuente, con pocos casos descritos en la literatura urológica internacional. No obstante debemos tenerla en cuenta en el diagnóstico diferencial ante un paciente con hematuria y/o sintomatología urinaria persistente (AU)

OBJECTIVE: Amyloidosis is a disease characterised by deposition of eosinophilic hyaline material in different tissues. Urinary bladder involvement is uncommon with less than 200 cases of the primary form published in the literature. We present a new case of primary AA type amyloidosis of the urinary bladder (typical of secondary forms). METHODS: A 66-year-old male was seen in the outpatient urology consultation with several-weeks history intermittent haematuria with decreased voiding urinary calibre. In addition, he had intense nocturia, 10-12 times per night, and occasional urgency. Physical examination of the abdomen and genitals was unremarkable. Urine sediment and blood tests were normal. Urine cytology studies were requested and revealed urothelial cells with no atypical cells and a moderate quantity of neutrophils and erythrocytes. Cystoscopy was performed and revealed yellowish erythematous lesions at the level of the vesicoureteric junction and the fundus. The lesions were biopsied. Pathology studies revealed urothelial mucosa with marked chronic inflammation and accumulations of amyloid-appearing hyaline material in the area of the vessels with green birefringence on polarised light. TUR of the bladder was later performed with the goal of completely resecting the lesion. The result of the pathology studies confirmed the biopsy findings and immunohistochemistry studies revealed AA type amyloid (typical of secondary forms). RESULTS: Two years after the intervention, the patient remains asymptomatic with normal endoscopic follow-up studies. CONCLUSIONS: Primary AA type amyloidosis of the bladder is a very uncommon pathology with few cases reported in the international urology literature. Nevertheless, we must keep it in mind in the differential diagnosis when faced with a patient with haematuria and/or persistent urinary symptoms (AU)

Cost-effectiveness analysis of the surgical treatment of female urinary incontinence using slings and meshes.

OBJECTIVE: To determine the cost-utility and cost-effectiveness of the surgical treatment of female urinary incontinence using suburethral slings and prolapse meshes compared with therapeutic abstention. STUDY DESIGN: An economic analysis was performed on 69 women receiving surgical treatment for urinary incontinence using suburethral slings and prolapse meshes. To calculate the procedure's cost-effectiveness, an incremental analysis up to one year was performed using the incremental cost-effectiveness ratio (ICER). The costs were calculated using a cost-by-process model. Answers to the health-related quality of life questionnaires EQ-5D (generic) and International Consultation Incontinence Questionnaire Short-form (specific) were collected before the operation and as well as one month and one year post-operation to calculate the utility, using quality-adjusted life years (QALY), and the effectiveness, respectively. To complete the economic evaluation, we derived confidence ellipses and acceptability curves. The analysis was conducted for the entire sample and also for each type of urinary incontinence. RESULTS: In total, 45 women presented with stress incontinence, 15 with mixed incontinence and 9 with incontinence associated with prolapse. The average cost per patient at one year post-operation was 1220 €. The QALY achieved at one year was 0.046. The results reveal an ICER at one year of 26,288 €/QALY, which is below the cost-effectiveness threshold considered acceptable, and this value was lower for stress incontinence (21,191 €/QALY). The cost-effectiveness was 106.5 €/International Consultation Incontinence Questionnaire Short-form unit. CONCLUSION: Surgery for female urinary incontinence using slings is cost-effective compared with abstention in our public health environment.

[Correlation between Gleason score on prostate biopsies diagnostic of adenocarcinoma and radical prostatectomy specimens]. / Estudio de correlación entre las sumas de Gleason de las biopsias de próstatas con adenocarcinoma y de las piezas de prostatectomía radical.

OBJECTIVES: We analyse the concordance between Gleason scores on prostate biopsies diagnostic of adenocarcinoma and radical prostatectomy specimens. METHODS: We reviewed the charts of 214 patients who underwent radical prostatectomy between January 1992 and November 2002. We calculated the percentage of correct diagnosis, understaging and overstaging for individual Gleason and for groups with scores between 2-4, 5-6, 7 and 8-10. We performed the statistical analyses of concordance for the groups using the kappa weighted index (< 0.4 low reliability, 0.4-0.75 good reliability; > 0.75 excellent reliability). RESULTS: 41 patients were excluded. The percentages of right diagnosis, understaging and overstaging for the remainder 173 were 32.3%, 44% and 23.7% respectively for individual Gleason scores, and 52.6%, 32.4% and 15% respectively for grouped Gleason scores. Statistical analysis resulted in a kappa weighted index of 0.52, a result which did not vary after excluding patients treated with neoadjuvant hormonal therapy CONCLUSIONS: In our series, the statistical correlation obtained for grouped Gleason scores is good. However, understaging is the biggest problem for prostate biopsies diagnostic of adenocarcinoma when compared with definitive pathologic results on the specimen. Besides, and in opposition, more than 50% of our patients deemed as less differentiated (Gleason score 7 and 8-10) presented lower grades in the specimen. Both limitations should be taken into consideration when therapeutic options are exposed to our patients.

Embolia de la arteria renal / Renal artery embolism

OBJETIVOS: Presentación de un caso de embolia de la arteria renal. Revisión de aspectos clínicos, diagnósticos y terapéuticos de esta afección vascular con interés urológico. MÉTODOS/RESULTADOS: Varón de 47 años, con antecedentes cardiovasculares, que consulta de manera urgente por dolor lumbar izquierdo. El estudio iconográfico (ecografía y UIV) descarta patología obstructiva y orienta hacia proceso vascular renal. Se realiza arteriografía, objetivándose embolia de la arteria renal izquierda. El tratamiento fibrinolítico intraarterial resulta exitoso. CONCLUSIONES: La embolia de la arteria renal constituye una urgencia urológica vascular no traumática poco frecuente. Suele presentarse en personas con cardiopatías embolígenas, fundamentalmente fibrilación auricular asociada a estenosis mitral. Más de la mitad de los casos son asintomáticos; cuando existen síntomas, el cuadro clínico más habitual es un dolor lumbar repentino, intenso y rebelde a la analgesia. Analíticamente aparece hematuria, piuria, proteinuria, leucocitosis, elevaciones de la LDH, GOT y fosfatasa alcalina y deterioro variable de la función renal. El diagnóstico se sospecha por una ecografía sin signos de uropatía obstructiva y una anulación funcional renal en la UIV. La confirmación diagnóstica se hará mediante arteriografía. El tratamiento de elección ante el diagnóstico precoz es la fibrinolisis intraarterial, reservando la cirugía para salvar la función renal. Las principales complicaciones son la hipertensión vasculorrenal y la insuficiencia renal (AU)

[Renal artery embolism]. / Embolia de la arteria renal.

OBJECTIVES: To report a case of renal artery embolism. To review the clinical, diagnostic and therapeutic features of this disease interesting for the urologist. METHODS/RESULTS: Case of a 47 year old male with history of cardiovascular disease who presents in the emergency room with left flank pain. Radiological studies (Intravenous pyelogram (IVP) and ultrasound) ruled out urinary tract obstruction and oriented to renal vascular disease. Arteriography was performed showing left renal artery embolism. Fibrinolytic therapy was successful. CONCLUSIONS: Renal artery embolism is an unusual non traumatic vascular urologic emergency. Generally, it appears in patients with emboligenous heart diseases, mainly auricular fibrillation associated with mitral stenosis. More than half the cases are asymptomatic; if they have symptoms, the most common presentation is sudden onset of intense flank pain, resistive to analgesia. Laboratory tests show hematuria, pyuria, proteinuria, leucocytosis, increased LDH, GOT and alkaline phosphatase, and variable renal function impairment. An ultrasound showing no signs of obstructive uropathy and absent function in the IVP lead to diagnosis. In the case of early diagnosis, intra-arterial fibinolysis is the treatment of choice, leaving surgery for cases where renal function is in danger. Main complications are vasculorenal hypertension and renal failure.

Siringocele de la glándula de Cowper / Syringocele of Cowper's glands

OBJETIVOS: Aportar un nuevo caso de siringocele de la glándula de Cowper, recordando aspectos etiopatogénicos, diagnósticos y terapéuticos. MÉTODOS Y RESULTADOS: Un paciente de 26 años acude por presentar síndrome irritativo miccional de reciente aparición, e incontinencia por goteo postmiccional de larga evolución. El diagnóstico de siringocele se lleva a cabo mediante cistouretrografía miccional seriada (CUMS), y se confirma de forma endoscópica, a la vez que se realiza el tratamiento definitivo. CONCLUSIONES: El siringocele o dilatación quística del conducto de la glándula de Cowper tiene una etiología habitualmente congénita. Existen 4 tipos morfológicos: simple, perforado, imperforado y roto. El diagnóstico se realiza mediante CUMS y se confirma endoscópicamente. Aportamos la ecografía transperineal al bagage diagnóstico. El tratamiento consiste en la incisión endoscópica (AU)

Quiste broncogénico retroperitoneal simulando un tumor suprarrenal / Retroperitoneal bronchogenic cyst mimicking an adrenal tumor

OBJETIVO: Presentar un caso de quiste broncogénico retroperitoneal, anomalía del desarrollo del intestino anterior primitivo origen de bronquios y pulmones. MÉTODO/RESULTADO: Describimos el caso de un varón de 38 años, diagnosticado de masa poliquística suprarrenal izquierda tras un cuadro de dolor lumbar, de la que fue intervenido quirúrgicamente. El estudio anatomopatológico demostró que se trataba de un quiste broncogénico. Comparamos éste con alguno de los pocos casos recogidos en la literatura. CONCLUSIONES: El quiste broncogénico retroperitoneal es causa de tumores retroperitoneales en el espacio espleno- o hepatorenal, y aunque infrecuente, debe ser considerada en los diagnósticos diferenciales (AU)

T.V.T. (cinta libre de tensión) nueva técnica quirúrgica para el tratamiento de la incontinencia urinaria de esfuerzo / Tension-free vaginal tape (TVT) for surgical treatment of female stress urinary incontinence

OBJETIVOS: Descripción de la técnica quirúrgica y análisis de los resultados a corto plazo de la uretrosuspensión con cinta de prolene en la incontinencia urinaria de esfuerzo. MÉTODOS: Realizamos la novedosa técnica quirúrgica a 20 pacientes con incontinencia urinaria de esfuerzo pura entre noviembre de 1998 y mayo de 1999. RESULTADOS: Las pacientes fueron portadoras de sonda vesical 24 horas y sólo 1 de ellas requirió sondajes intermitentes durante 1 mes por residuos post-miccionales altos. No hubo complicaciones intraoperatorias y una paciente, en el postoperatorio inmediato, presentó hematoma en cara posterior de recto que se solucionó con tratamiento conservador. Con un seguimiento de 4,5 meses,... el 95 por ciento de las pacientes están continentes y una es incontinente por una incorrecta colocación de la cinta. CONCLUSIONES: Si bien los primeros resultados son alentadores debemos ser cautos en su valoración y esperar un seguimiento objetivo y continuo para precisar la eficacia a largo plazo (AU)