Complicaciones intraoperatorias y Postoperatorias de la cirugía de Prótesis de Pene. Diagnóstico y Tratamiento / Intraoperative and postoperative complications of penile implant surgery. Diagnosis and treatment

Describimos las complicaciones más frecuentes de la cirugía de implante de prótesis de pene haciendo hincapié en su manejo práctico. Hemos dividido las complicaciones en intraoperatorias y postoperatorias. Entre las complicaciones intraoperatorias destacan: la perforación de los cuerpos a cavernosos durante la dilñatación, el cross-ver de los cilindros o colocación cruzada y la lesión uretral durante el implante. Las complicaciones más frecuentes postoperatorias son el fallo mecánico de la prótesis, la erosión de cilindros y la infección las prótesis haciendo énfasis en la cirugía de rescate y en las técnicas de reimplante en fibrosis de tejido cavernoso

We describe the most frequent complications associated with penile implant surgery, paying special attention to their practical management. We have analyzed preoperative complications and postoperative complications separately. The intraoperative include perforation of the corpora cavernosa during dilation, cylinder cross-over or cross-placement and urethral injury during implantation. The most frequent postoperative complications are mechanical failure, cylinder erosion and prosthesis infection. We emphasize on rescue surgery and reimplantation techniques in cavernous tissue fibrosis

Intraoperative and postoperative complications of penile implant surgery. Diagnosis and treatment. / Complicaciones intraoperatorias y postoperatorias de la cirugía de prótesis de pene. Diagnóstico y tratamiento.

We describe the most frequent complications associated with penile implant surgery, paying special attention to their practical management. We have analyzed preoperative complications and postoperative complications separately. The intraoperative include perforation of the corpora cavernosa during dilation, cylinder cross-over or cross-placement and urethral injury during implantation. The most frequent postoperative complications are mechanical failure, cylinder erosion and prosthesis infection. We emphasize on rescue surgery and reimplantation techniques in cavernous tissue fibrosis.

Outcomes of an enhanced recovery after radical cystectomy program in a prospective multicenter study: compliance and key components for success.

OBJECTIVE: To investigate the effect of an Enhanced Recovery After Surgery (ERAS) program on complications and length of stay (LOS) after radical cystectomy (RC) and to assess if the number and type of components of ERAS play a key role on the decrease of surgical morbidity. MATERIALS AND METHODS: We analyzed the data of 277 patients prospectively recruited in 11 hospitals undergoing RC initially managed according to local practice (Group I) and later within an ERAS program (Group II). Two main outcomes were defined: 90-day complications rate and LOS. As secondary variables we studied 90-day mortality, 30-day readmission and transfusion rate. RESULTS: Patients in Group II had a higher use of ERAS measures (98.6%) than those in Group I (78.2%) (p < 0.05). Patients in Groups I and II experienced similar complications (70.5% vs. 66%, p = 0.42). LOS was not different between Groups I and II (12.5 and 14 days, respectively, p = 0.59). The risk of having any complication decreases for patients having more than 15 ERAS measures adopted [RR = 0.815; 95% confidence interval (CI) 0.667-0.996; p = 0.045]. Avoidance of transfusion and nasogastric tube, prevention of ileus, early ambulation and a fast uptake of a regular diet are independently associated with the absence of complications. CONCLUSIONS: Complications and LOS after RC were not modified by the introduction of an ERAS program. We hypothesize that at least 15 measures should be applied to maximize the benefit of ERAS.

Diagnostic and prognostic significance of flow cytometry immunophenotyping in patients with leptomeningeal carcinomatosis.

Some patients with epithelial-cell cancers develop leptomeningeal carcinomatosis (LC), a severe complication difficult to diagnose and with an adverse prognosis. This study explores the contribution of flow cytometry immunophenotyping (FCI) to the diagnosis and prognosis of LC. Cerebrospinal fluid (CSF) samples from patients diagnosed with LC were studied using FCI. Expression of the epithelial-cell adhesion molecule (EpCAM) was the criterion used to identify the epithelial cells. To test the diagnostic precision, 144 patients (94 diagnosed with LC) were included. The prognostic value of FCI was evaluated in 72 patients diagnosed with LC and eligible for therapy. Compared with cytology, FCI showed greater sensitivity and negative predictive value (79.79 vs. 50%; 68.85 vs. 51.55%, respectively), but lower specificity and positive predictive value (84 vs. 100%; 90.36 vs. 100%, respectively). The multivariate analysis revealed that the percentage of CSF EpCAM+ cells predicted an increased risk of death (HR: 1.012, 95% CI 1.000-1.023; p=0.041). A cut-off value of 8% EpCAM+ cells in the CSF distinguished two groups of patients with statistically significant differences in overall survival (OS) (p=0.018). This cut-off value kept its statistical significance regardless of the absolute CSF cell-count. The FCI study of the CSF improved the sensitivity for diagnosing LC, but refinement of the technique is needed to improve specificity. Furthermore, quantification of CSF EpCAM+ cells was revealed to be an independent prognostic factor for OS in patients with LC eligible for therapy. An 8% cut-off value contributed to predicting clinical evolution before initiation of therapy.

Revisiting guidelines for integration of flow cytometry results in the WHO classification of myelodysplastic syndromes-proposal from the International/European LeukemiaNet Working Group for Flow Cytometry in MDS.

Definite progress has been made in the exploration of myelodysplastic syndromes (MDS) by flow cytometry (FCM) since the publication of the World Health Organization 2008 classification of myeloid neoplasms. An international working party initiated within the European LeukemiaNet and extended to include members from Australia, Canada, Japan, Taiwan and the United States has, through several workshops, developed and subsequently published consensus recommendations. The latter deal with preanalytical precautions, and propose small and large panels, which allow evaluating immunophenotypic anomalies and calculating myelodysplasia scores. The current paper provides guidelines that strongly recommend the integration of FCM data with other diagnostic tools in the diagnostic work-up of MDS.

Standardization of flow cytometry in myelodysplastic syndromes: a report from an international consortium and the European LeukemiaNet Working Group.

Flow cytometry (FC) is increasingly recognized as an important tool in the diagnosis and prognosis of myelodysplastic syndromes (MDS). However, validation of current assays and agreement upon the techniques are prerequisites for its widespread acceptance and application in clinical practice. Therefore, a working group was initiated (Amsterdam, 2008) to discuss and propose standards for FC in MDS. In 2009 and 2010, representatives from 23, mainly European, institutes participated in the second and third European LeukemiaNet (ELN) MDS workshops. In the present report, minimal requirements to analyze dysplasia are refined. The proposed core markers should enable a categorization of FC results in cytopenic patients as 'normal', 'suggestive of', or 'diagnostic of' MDS. An FC report should include a description of validated FC abnormalities such as aberrant marker expression on myeloid progenitors and, furthermore, dysgranulopoiesis and/or dysmonocytopoiesis, if at least two abnormalities are evidenced. The working group is dedicated to initiate further studies to establish robust diagnostic and prognostic FC panels in MDS. An ultimate goal is to refine and improve diagnosis and prognostic scoring systems. Finally, the working group stresses that FC should be part of an integrated diagnosis rather than a separate technique.

Carcinoma de células renales del túbulo colector / Collecting duct renal cell carcinoma

Introducción: El carcinoma renal de los conductos colectores de Bellini es un tumor renal escasamente prevalente, con baja supervivencia cáncer-específica, aunque realmente se desconoce su tasa de respuesta a terapias antiangiogénicas. Objetivos: Se revisa de manera retrospectiva una serie de tumores de túbulo colector con especial énfasis en la indicación de terapias diana y en los resultados de la misma. Material y métodos: Análisis retrospectivo del carcinoma renal de túbulo colector tratados en nuestra institución desde enero 2000 a junio 2010, teniendo en cuenta la edad del paciente, el sexo, el motivo de consulta, los antecedentes oncológicos, el lado de afectación, el tratamiento quirúrgico, otras características anatomopatológicas, el tamaño tumoral, la estadificación TNM (2009), el tratamiento adyuvante y el tiempo de supervivencia. Resultados: Se describen 6 pacientes, 5 varones y una mujer; con una media de edad de 75 (±7,7) años. Cuatro de ellos (66,6%) presentaban enfermedad diseminada al diagnóstico. Cinco(83,3%) fueron tratados mediante nefrectomía radical y tres (50%) recibieron tratamiento sistémico adyuvante, sin respuesta. La mediana de supervivencia fue 5,5 meses (4,75-14,75). Sólo dos pacientes (33,3%), ambos con enfermedad localizada al diagnóstico, se encuentran en remisión completa. Conclusión: El carcinoma renal de túbulo colector es una enfermedad con mal pronóstico, escasa supervivencia y mala respuesta a terapias diana (AU)

Introduction: Bellini’s renal cell collecting duct carcinoma is a rarely prevalent renal tumour, with low cancer-specific survival, although its rate of response to antiangiogenic therapies is unknown. Objectives: We retrospectively revise a series of collecting duct tumours, with special emphasis on the indication of target therapies and on their results. Materials and methods: Retrospective analysis of renal cell collecting duct carcinoma treated at our institution from January 2000 to June 2010, taking into account the patient’s age, sex, reason for the consultation, oncological background, side of the affection, surgical treatment, other anatomopathological characteristics, tumour size, TNM clinical staging (2009), adjuvant treatment and survival time. Results: Six patients are described, five men and one woman, with a mean age of 75 (± 7.7) years. Four of them (66.6%) presented disseminated disease upon diagnosis. Five (83%) were treated with radical nephrectomy and three (50%) received systemic adjuvant treatment, without response. The means survival was 5.5 months (4.75-14.75). Only 2 patients (33.3%), both with localized disease upon diagnosis, are in complete remission. Conclusion: Renal cell collecting duct carcinoma is a disease with a bad prognosis, little surviva land bad response to target therapies (AU)

[Collecting duct renal cell carcinoma]. / Carcinoma de células renales del túbulo colector.

INTRODUCTION: Bellini's renal cell collecting duct carcinoma is a rarely prevalent renal tumour, with low cancer-specific survival, although its rate of response to antiangiogenic therapies is unknown. OBJECTIVES: We retrospectively revise a series of collecting duct tumours, with special emphasis on the indication of target therapies and on their results. MATERIALS AND METHODS: Retrospective analysis of renal cell collecting duct carcinoma treated at our institution from January 2000 to June 2010, taking into account the patient's age, sex, reason for the consultation, oncological background, side of the affection, surgical treatment, other anatomopathological characteristics, tumour size, TNM clinical staging (2009), adjuvant treatment and survival time. RESULTS: Six patients are described, five men and one woman, with a mean age of 75 (± 7.7) years. Four of them (66.6%) presented disseminated disease upon diagnosis. Five (83%) were treated with radical nephrectomy and three (50%) received systemic adjuvant treatment, without response. The means survival was 5.5 months (4.75-14.75). Only 2 patients (33.3%), both with localized disease upon diagnosis, are in complete remission. CONCLUSION: Renal cell collecting duct carcinoma is a disease with a bad prognosis, little survival and bad response to target therapies.

Significance of the volume of fetomaternal hemorrhage after performing prenatal invasive tests.

BACKGROUND: Fetal erythrocytes cross the placenta during gestation, but invasive prenatal procedures might develop into fetomaternal hemorrhage (FMH). We examine whether flow cytometry immunophenotyping might be useful for measuring the volume of FMH after such procedures. METHODS: Fetal erythrocytes (%) were determined in 153 pregnant women after amniocentesis (129) and chorionic villous sampling (24) using a monoclonal antibody against fetal hemoglobin. Fetal erythrocytes were identified for their high expression of fetal hemoglobin (HbF(++) ). Blood samples from two control groups, 53 healthy males and 21 pregnant women not submitted to invasive tests, were used to establish normal values of circulating HbF(++) erythrocytes in adults. RESULTS: The highest percentage of HbF(++) erythrocytes in the control groups was 0.015%. The rate of HbF(++) erythrocytes in samples after invasive tests ranged between <0.01% and 0.15%. Seventy-three women (47%) had ≤0.015% HbF(++) erythrocytes, and this rate was higher in 80. Nine women presented >1 ml of FMH (volume of packed cells corresponding to 0.054-0.15% HbF(++) erythrocytes), but only two had sonographic evidence of bleeding. CONCLUSIONS: Most women in our series had a very low volume of FMH after the invasive tests. Acute bleeding should be thoroughly investigated in women with either more than 1 ml of packed cells or more than 0.05% of HbF(++) erythrocytes. Intermediate values between >0.015% and <0.05%, should be carefully considered depending on the week of gestation. Data obtained before 15 weeks might reflect previous cell trafficking between fetus and mother instead of acute hemorrhage.

Identification of feto-maternal haemorrhage around labour using flow cytometry immunophenotyping.

OBJECTIVE: To determine the normal range of feto-maternal haemorrhage (FMH) due to labour, and to investigate if the type of delivery might influence the volume of FMH. STUDY DESIGN: In a prospective cohort trial setting we studied 346 women in their 3rd trimester of gestation. Women were classified according to the type of delivery: vaginal, instrumental and caesarean section. Fetal erythrocytes in maternal blood were measured by flow cytometry immunophenotyping using a fluorochrome-conjugated monoclonal antibody against fetal haemoglobin. For each woman, two blood samples were studied; one pre-labour and one post-labour. The difference between FMH values obtained post- and pre-delivery was established as FMH due to delivery. RESULTS: FMH due to labour ranged between <0.01 and 25.19 ml, being <1.15 ml in 96.13% of cases. This value was established as the upper limit of normal FMH due to delivery. No statistical significance was found between the volume of FMH and type of delivery. Analyzing distributions of groups, most data followed a normal distribution, apart from some patients who had higher volume of FMH. Among these patients caesarean sections showed a higher FMH volume, with statistically significant differences between vaginal deliveries and caesarean sections (p=0.001), and between instrumental deliveries and caesarean sections (p=0.008). CONCLUSIONS: FMH due to labour is small. The route of delivery could not be established as a risk factor for FMH but caesarean section increases the risk of suffering a higher amount of transplacental bleeding.

JAK2 as a molecular marker in myeloproliferative diseases.

The molecular pathogenesis of the myeloproliferative disorders (MPD) is poorly understood, except for chronic myeloid leukemia (CML). Recently, several groups have discovered a novel recurrent unique acquired clonal mutation in a tyrosine-kinase JAK2 in patients with Philadelphia-negative MPD and other myeloid disorders. It consists in a guanine-to-thymine change encoding a valine to phenylalanine at codon 617 (JAK2 V617F). JAK2 and the other members of the Janus kinase family are tyrosine kinases that function as intermediates between membrane receptors and intracellular signalling molecules. The mutation occurs within the enzymatically inactive JH2 pseudo-kinase domain that regulates the active JH1 kinase domain. The JAK2 activation leads to constitutive JAK and STAT (activators of transcription) hyperactivation with induction of growth factor hypersensitivity and cell transformation. Some authors have found a higher risk of vascular thrombosis and higher platelet activation when the mutation is present. Therefore, the JAK2 mutation offers a molecular target for new drugs investigation in a similar way to bcr/abl rearrangement in CML. For all these reasons, several studies related to JAK2 have arisen in the last year. In this report, we will review the literature and discuss its possible clinical and prognostic significance.

Evaluation of CD7 and terminal deoxynucleotidyl transferase (TdT) expression in CD34+ myeloblasts from patients with myelodysplastic syndrome.

There is an emerging use of flow cytometry to evaluate patients with myelodysplastic syndrome (MDS). We have studied CD7 and TdT expression in the CD34+ myeloid blast cell population in 55 bone marrow samples of patients with MDS. CD7 and/or TdT were detected in 38 out of 55 patients (69%). CD7 expression was not related to other bad prognosis data but conversely, we found an association between TdT+ CD34 myeloblasts and high-risk MDS patients according to the International Prognostic Scoring System. Therefore, CD7 and TdT may help to establish the diagnosis of MDS and, TdT expression also seems to be a useful marker in distinguishing risk groups.

[Normothermic ischemia effects in renal microcirculation]. / Caracterización de los efectos de la isquemia normotérmica en la microcirculación renal.

We report the results obtained in a experimental work designed to evaluate the consequences of warm ischemia in hypothermic isolated renal perfusion. We perfused a number of kidneys after a period of 45 min of vascular occlusion. An alternative group of kidneys were perfused without previous warm ischemia. Ureter was canulated in all the procedures and output collected during the HP. Creatinine was added to the perfusion solution initially in order to determine creatinine clearance. HP hydrodynamics was recorded on real time through a computerised system. According to the results, renal vascular resistance as well as CrCl were higher in ischemic kidneys. Both facts along with minimal differences in pathologic study suggest an increase in vascular tone of efferent-postglomerular arteriole during HP. HP was an adequate technique to minimize histologic consequences of ischemia. Mycrovascular an biochemical changes produced during HP may be produced, essentially, by dynamic causes.

Advantages of flow cytometry immunophenotyping for the diagnosis of central nervous system non-Hodgkin's lymphoma in AIDS patients.

BACKGROUND: Neurological disorders are common in HIV-infected patients. Central nervous system (CNS) lymphoma should always be considered because it is an important cause of morbidity and mortality. OBJECTIVES: To investigate the clinical utility of flow cytometry immunophenotyping (FCI) in diagnosing or discarding leptomeningeal involvement in HIV-infected patients and to compare its sensitivity with that of conventional cytological methods. METHODS: Fifty-six cerebrospinal fluid (CSF) samples from 29 HIV-infected patients were independently evaluated by flow cytometry and cytology. The description of an aberrant immunophenotype was the criterion used to define the malignant nature of any CSF cell population. RESULTS: FCI and cytology gave concordant results for 48 of the 56 CSF samples studied: 37 were negative for malignancy and 11 had evidence of CNS lymphoma. Discordant results were obtained for eight CSF samples, and the accuracy of the FCI findings could be demonstrated for four CSF samples described as positive for malignancy according to the FCI criteria. CONCLUSIONS: A high level of agreement was found between the results obtained using the two methods, but FCI gave at least 25% higher sensitivity than conventional cytomorphological methods for the detection of malignant cells. This advantage suggests that, in case of negative flow cytometry results, disorders other than non-Hodgkin's lymphoma should be strongly considered.

Evaluation of an extraction method in the determination of the 2,4,6-trichloroanisole content of tainted cork.

A method based on solvent extraction and GC-electron-capture detection analysis for the determination of 2,4,6-trichloroanisole (TCA) from cork has been evaluated and optimised. Our sample treatment consists of an extraction stage with pentane while the sample and solvent are kept in contact in a mechanical shaker (shake-flask extraction). Different extraction conditions have been tested in order to find the best compromise between efficiency and time of analysis. Different columns were evaluated for use in the concentration and purification step. A silica column was found to give the best performance in terms of recovery of TCA and repeatability. Pentane and mixtures of pentane-diethyl ether at different ratios were tested as eluting agents. It was found that 10 ml pentane allowed the recovery of retained TCA. Finally, the eluate was concentrated and injected into the chromatograph for TCA determination. The optimised chromatographic conditions enabled the quantification of TCA and 2,6-dichloroanisole, which was assayed as the internal standard. The shake-flask extraction method was compared with Soxhlet and ultrasound assisted extraction procedures using pentane as a solvent. Similar results were obtained for the shake-flask and Soxhlet extraction methods, while sonication gave significantly lower recoveries. The optimised shake-flask method was applied to determine the distribution of TCA in naturally contaminated cork bark.

Flow cytometry and the study of central nervous disease in patients with acute leukaemia.

Central nervous system (CNS) leukaemia is still a matter of debate and new technologies are required to improve the classic morphological definition. One hundred and sixty-eight cerebrospinal fluid (CSF) samples from 31 patients with acute leukaemia were analysed by flow cytometry and conventional cytology. Concordant positive and negative findings were found in 158 samples but 10 produced discrepant results. Cytology seemed to offer more precise information in one CSF sample and flow cytometric accuracy could be demonstrated in five samples. We conclude that flow cytometry is of great help in confirming CNS leukaemia and eliminating other conditions. Therefore, leukaemic patients can benefit from double cytological and flow cytometric CSF studies.

Hepatitis B virus-specific T-cell proliferation and cytokine secretion in chronic hepatitis B e antibody-positive patients treated with ribavirin and interferon alpha.

Immune elimination of hepatitis B virus (HBV) during antiviral therapy depends on the activation of T-cell responses, which are generally impaired in chronic hepatitis B. HBV-specific T helper (Th)-cell reactivity has been assessed post-treatment in liver and peripheral blood of 18 anti-HBe-positive patients with chronic hepatitis B administered combined ribavirin/interferon alfa (IFN-alpha) therapy. The results showed that patients with undetectable HBV DNA by quantitative polymerase chain reaction under combination therapy were able to mount an HBV-specific CD4(+) Th-cell proliferative response and such T-cell reactivity is detectable 1 year after HBV DNA clearance. Hepatitis B virus core (HBcAg) and e (HBeAg) antigen-specific Th-cell proliferation was found more frequently in the liver and peripheral blood in those patients who sustained the alanine aminotransferase (ALT) normalization together with HBV DNA loss. However, HBV-specific IFN-gamma production in vitro in peripheral blood mononuclear cells augmented in 4 of 5 sustained responders and all 13 nonresponders, interleukin 10 (IL-10) production decreased in all 5 sustained responders but increased in 7 of 13 nonresponders. Furthermore, intrahepatic HBcAg plus HBeAg-specific Th-cell proliferation only occurred in sustained responders (2 of 3, 67%, vs. 0 of 9; P =.045) whose cells showed in vitro significantly increased productions in HBcAg/HBeAg-specific IFN-gamma and IL-12 compared with nonresponders in whom IFN-gamma and IL-12 productions decreased together with increased IL-10 secretion. In conclusion this study indicates that combined therapy with ribavirin and IFN-alpha for chronic hepatitis B not only significantly reduces viremia levels but also induces lasting CD4(+) T-cell proliferation and Th1 cytokine release at the site of infection, which may lead to sustained eradication of the HBV.

Circulating immune complexes from HIV-1+ patients induces apoptosis on normal lymphocytes.

Isolated immune complexes from sera of 49 out of 67 human immunodeficiency virus-1-positive (HIV-1+) patients (CIC-HIV+), composed of anti-HIV-HIV-Ag, could induce apoptosis on normal phytohaemagglutinin (PHA)-activated lymphocytes. DNA degradation was detected by propidium iodide staining. This activity is directed against CD4+ lymphocytes as demonstrated by double binding of CIC-HIV+ and anti-CD4 on apoptosis cells. Expression of Fas antigen is prior to apoptotic phenomena. CIC-HIV+ apoptosis inducers belong mainly to asymptomatic HIV-infected patients, indicating that immune complexes from these patients can destroy CD4+ lymphocytes.