Expulsión espontánea de litiasis de gran tamaño / Spontaneous expulsion of large ureteral lithiasis

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Abordaje renal percutáneo en decúbito supino. Quince años de experiencia / Percutaneous renal approach in supine decubitus position. Fifteen years experience

Han transcurrido ya 15 años desde que desarrolláramos en nuestro Servicio el abordaje percutáneo al riñón con el paciente en posición de decúbito supino. En el momento presente nos acercamos ya a los 1 .000 accesos renales percutáneos en decúbito supino (359 nefrostomías y 613 nefroscopias) y aunque son ya varias las escuelas urológicas de nuestro país y del extranjero que siguen nuestro procedimiento, creemos que éste no ha alcanzado aún la difusión que merece, teniendo en cuenta las ventajas que reporta su empleo: gran simplicidad y mínima morbilidad.Con este tipo de abordaje, además de nefrostomías percutáneas, hemos realizado intervenciones tales corno nefrolitotomías, ureterolitotripsias anterógradas, endopielotomías, resección percutánea de tumores pielocaliciales, repermeabilizaciones ureterales anterógradas, etc., sin tropezar con los inconvenientes inherentes al decúbito prono, y sin observar incremento alguno en la morbilidad que pudiera ser atribuido al empleo de esta peculiar forma de acceder percutáneamente al riñón. El acceso percutáneo al riñón lo solemos realizar bajo simple anestesia local, que complementamos con sedación general intravenosa en el caso de las nefroscopias. Sólo en 187 pacientes, la nefroscopia fue realizada con anestesia raquídea y en 32, con anestesia general, obedeciendo casi siempre estas otras alternativas a las preferencias de cada anestesista. Situamos al paciente en decúbito supino, colocando debajo de la fosa lumbar correspondiente una bolsa de plástico de 3 litros, rellena con aire.El punto de acceso cutáneo lo situamos, entre la 12.ª costilla y la cresta ilíaca, a un dedo por encima del lugar de apoyo del flanco (coincide con la línea axilar posterior). Las nefrostomías percutáneas resultaron exitosas en el 93,2 por ciento, y las nefroscopias, en el 95,2 por ciento de los casos, ocurriendo la mayor parte de los fracasos durante el llamado período de aprendizaje. Un paciente falleció tras una nefrostomía (sepsis y hemorragia). Contamos con cuatro reconversiones por complicaciones: tres por hemorragia y una por perforación accidental de la pelvis y peritoneo en un riñón en herradura. Sólo en 2 casos (de nefroscopias) pudimos confirmar que casualmente habíamos atravesado el colon o el repliegue peritoneal (sin trascendencia alguna). Consideramos que esta forma de abordaje percutáneo al riñón confiere a esta cirugía una gran simplicidad, facilitando al máximo su ejecución en la práctica diaria. Por otra parte, evita la irradiación de las manos del urólogo y reporta para el paciente una considerable reducción del riesgo quirúrgico. (AU)

Technique and complications of percutaneous nephroscopy: experience with 557 patients in the supine position.

PURPOSE: Percutaneous nephroscopy is usually performed with the patient prone, which is uncomfortable for the patient and does not prevent damage to the colon. We assess the possibility of performing percutaneous nephroscopy using local anesthesia with the patient supine, and evaluate the advantages and complications. MATERIALS AND METHODS: A total of 557 consecutive percutaneous nephroscopies were attempted in 221 men and 242 women in the supine position. Patient age ranged from 8 to 87 years (mean 55.1). Patients are supine with a 3 l. serum bag below the ipsilateral flank. We catheterize the affected uretheral meatus with a 5F catheter through a flexible cystoscope. The tract is infiltrated with local anesthesia. The skin is punctured in the posterior axillary line which corresponds to approximately 1 cm. above the bag. We use an Alken set to dilate the tract to 30F, which is the size of the Amplatz sheath we commonly use. RESULTS: Nephroscopy was performed in 519 cases (93.1%). Mean operation time was 85 minutes (range 15 to 240). Serious bleeding occurred in 3 cases. The colon was never damaged in patients treated in the supine position. CONCLUSIONS: Percutaneous nephroscopy using local anesthesia with the patient supine is safe and easy. According to our experience the advantages in comfort to the patient and feasibility to the surgeon justify its use.

[Prognostic value of cytology in terms of survival in prostatic cancer]. / Valor pronóstico de la citología en el cáncer de próstata en relación a la supervivencia.

The cytologic grade of malignancy and its relationship with survival was evaluated en 154 consecutive patients with prostatic cancer. The cytological aspirates were stained by the Papanicolay method and evaluated by two cytopathologists. Specimens were characterized as well, moderately or poorly differentiated, based on standard criteria. Patients without tumoral extension were initially untreated, and in the case of tumoral extension or posterior progression in the case of initially localized tumors, they were hormonally treated. The follow-up had a range between 33 and 120 months. The disease-specific survival was estimated by the Kaplan-Meier's curves. Our results indicate that there is a worse survival expectancy to the moderately differentiated tumors compared with the well differentiated. No difference was showed with the poorly differentiated, due to the low number of patients with it. The overall survival was compared to the control population survival, showing no difference except for the patients younger than 65 years old. The cytological aspirate of the prostate is not only a good method to diagnose prostatic cancer, our results confirm the prognostic value of the cytologic malignancy grading.

[Significance of ploidy in prostatic cancer, quantified by a prospectively applicable procedure]. / Valor de la ploidía en el cáncer de próstata, cuantificada mediante un procedimiento de aplicabilidad prospectiva.

OBJECTIVES: To determine the ploidy of prostatic adenocarcinoma cells obtained by fine-needle punction-aspiration biopsy using computer-assisted image analysis and its prognostic value. METHODS: The clinical applications of the two most commonly utilized methods, flow cytometry and cytophotometry, is difficult. The ploidy of prostatic adenocarcinoma cells obtained by fine-needle punction-aspiration biopsy in 54 patients was determined by image analysis. Previous cytological preparations from our files were utilized in the present study. Before processing the preparations, the Papanicolau stain used originally was removed. To make the technique simpler, we did not use the Feulgen stain but the progressive hematoxylin stain, which is faster and easier to use. The representative ploidy histograms were classified into four types first and then into two grades of DNA malignancy. The survival curves were plotted using the Kaplan-Meier method and according to the ploidy. RESULTS: Patients with high grade DNA malignancy had a worse survival rate than those with low grade malignancy. Statistical analysis using the log-rank test showed a significant difference, with p < 0.001. CONCLUSIONS: Tumor ploidy in prostate cancer can be determined prospectively using cytological smears with progressive hematoxylin staining and has a prognostic value.

[Calyceal ectopic diverticulum]. / Ectopia-diverticulo calicial.

The authors present 15 cases of calicial ectopias. They then review some of the names frequently given to this illness and discuss certain theories which link this anomaly with other kidney cystoses, taking special care to point out the difficulties involved in the correct performing of a differential diagnosis with calculous hollows, particularly those situated in lower calices.