[Categorization of adrenergic alpha 1 receptors in detrusor of patients with obstructive BPH. Initial study on experimental animal model]. / Categorización de receptores alpha 1-adrenérgicos en el detrusor de pacientes con HBP obstructiva. Estudio inicial en modelo animal de experimentación.

INTRODUCTION: The action of alpha 1-adrenergic receptor antagonists in ameliorating irritation and obstruction in patients with bladder outlet obstruction (due to Benign Prostatic Hyperplasia-BPH) has been demonstrated. Although it is well known that alpha 1-a receptors are responsible for prostate smooth muscle relaxation, the mechanism by which irritative bladder symptoms are improved is unknown. Different alpha 1 receptor subtypes may be involved. The objective of this study is to investigate the changes in the alpha-adrenergic receptor populations in the obstructed detrusor, and to determine which subtype is proportionally increased in this situation (bladder outlet obstruction). MATERIAL AND METHODS: This was an in vivo study in an experimental model: male NZ (New Zealand) rabbits. The bladder neck of one group of rabbits was obstructed surgically using the technique proposed by Levin et al. Subsequent to bladder catherization with a 8Fr catheter, the bladder neck was exposed by means of a low medial abdominal incision. The bladder neck was tied with a 2/0 silk thread below the ureteral orifices. The catheter was taken out at the end of the intervention. The rabbits were sacrificed after 4 weeks using intracardiac pentothal and cystectomy was performed. A control group that did not undergo bladder obstruction were also sacrificed at this time, for the comparative study. Part of the detrusor was used for a pathological study and the rest for a physio-pharmacological study in which the organ was placed in a bath of adrenoceptor agonists (phenylephrine and noradrenaline) and antagonists WB101, AH11101A and BMY7378 (antagonists of the alpha 1a, b, d, respectively). RESULTS: The findings of the pathological study show that the bladder wall was thicker in the rabbits that underwent bladder obstruction. The physio-pharmacological studies demonstrate that the detrusor response to the selective alpha-1 adrenergic agonist was greater in the rabbits that underwent bladder obstruction, however detrusor contractility was decreased (KPSS). With bladder obstruction the alpha 1d receptors were increased. DISCUSSION AND CONCLUSIONS: Receptor-binding studies (Malloy et al) aim to differentiate the alpha-adrenoreceptor populations. These studies identify and quantitate the different receptor subtypes in tissue without taking into account their activity. The isometric and physio-pharmacological tests evaluate active receptors, i.e. those that respond to agonist and antagonist stimuli. This enables detrusor activity to be evaluated accurately. The results obtained in this investigational study support the hypothesis that there is a high statistically significant increase in the alpha 1 adrenergic receptors in the obstructed detrusor. Furthermore, in agreement with previous molecular studies, during prostate obstruction alpha 1d is the predominate sub-population in the bladder. These findings may have patho-physiological, clinical and pharmacological implications. If this hypothesis which has been demonstrated in an experimental model, is also demonstrated in studies in humans, pharmacological development should not only be focussed on selective alpha 1a receptor antagonists (prostate) but also on those of alpha 1d, for relieving symptoms in patients with bladder outlet obstruction (BPH and prostatism).

Duloxetina y otros antidepresivos tricíclicos: efectos farmacodinámicos en el tracto urinario inferior / Duloxetine and others tricyclic antidepressants: pharmacodynamic effects on lower urinary tract

INTRODUCCIÓN: Durante años la farmacología de la dinámica miccional ha estado presidida por el protagonismo del sistema nervioso autónomo y sus componentes simpático y parasimpático. Recientes investigaciones advierten de una mayor complejidad de la dinámica miccional, atribuyendo un papel más relevante al sistema nervioso central (SNC), al esfínter estriado y al arco aferente, ofreciendo nuevas opciones farmacológicas entre las que hay que destacar a los Antidepresivos Tricíclicos (A.T.), motivo de esta revisión de conjunto. MATERIAL Y MÉTODOS: A partir del trabajo de la Primera Consulta sobre Incontinencia (Montecarlo, 1999), se han revisado las publicaciones anteriores y posteriores sobre los A.T. tanto experimentales (estudios isométricos e "in vivo") como clínicas, indagando sobre evidencias farmacológicas, mecanismo de acción, tolerancia y otros efectos. RESULTADOS: Sólo un grupo reducido de A.T. ha sido sometido a estudios urodinámicos y empleados en clínica. Los recientes trabajos sobre Duloxetina han despertado un interés especial por su potencial farmacológico. Simultáneamente se ha producido un cambio notable en la interpretación fisiológica de la dinámica miccional de singular trascendencia. CONCLUSIONES: Nuevos conocimientos sobre el control periférico y central de la dinámica continencia-micción ofrecen respaldo a innovadoras estrategias farmacológicas entre las que destacan los A.T., cuya eficacia y tolerancia es revisada (AU)

Categorización de receptores alfa1-adrenérgicos en el detrusor de pacientes con hbp obstructiva.Estudio inicial en modelo animal de experimentación / Alfa1-Adrenergic receptors categorisation in the detrusor of patients with obstructive bph. Early study in experimental models

INTRODUCCIÓN: Los antagonistas de los receptores adrenérgicos alfa1 han demostrado su acción en pacientes con obstrucción al flujo vesical (Hiperplasia Benigna de Próstata-HBP) al mejorar los síntomas obstructivos e irritativos. Si bien es conocido que los receptores alfa1a son los responsables de la relajación del músculo liso de la próstata, es desconocido el mecanismo por el cual se mejoran los síntomas irritativos de responsabilidad vesical. Diferentes subtipos de receptores alfa1 podrían estar implicados. El objetivo de esta investigación es indagar en los cambios poblacionales de receptores -adrenérgicos en el detrusor obstruido, y determinar que subtipo es el que proporcionalmente aumenta en esta situación (obstrucción vesical al flujo miccional). MATERIAL Y MÉTODOS: El estudio se realiza in vivo en un modelo animal de experimentación: conejos machos NZ (Nueva Zelanda). Un grupo de ellos es obstruido quirúrgicamente, a nivel del cuello vesical, mediante la técnica propuesta por Levin et al.1,2. Previa cateterización vesical con sonda 8Fr, y a través de una incisión media abdominal baja se expone el cuello vesical, que será ligado con una seda de 2/0, por debajo de los orificios ureterales, retirando la sonda al final de esta intervención. Después de 4 semanas se sacrifica el conejo con pentotal intracardiaco y se realiza cistectomía. El grupo control son otros conejos no sometidos a obstrucción vesical que se sacrifican también en este momento para estudio comparativo. Parte del detrusor es sometido a estudio anatomo-patológico y el resto a un estudio fisio-farmacológico en baños de órgano mediante agonistas (phenilefrina y noradrenalina) y antagonistas de adrenoceptores: WB4101, AH11101A y BMY7378, antagonistas respectivos de los receptores alfa1a,b,d. RESULTADOS: Los hallazgos anatomo-patológicos demuestran mayor grosor de la pared de la vejiga en los casos de obstrucción vesical. Los estudios fisio-farmacológicos ponen de manifiesto que la respuesta del detrusor al agonista selectivo alfa1-adrenérgico es mayor en los conejos sometidos a obstrucción vesical, sin embargo la contractilidad del detrusor está disminuida (KPSS). En condiciones de obstrucción son los receptores alfa1d los que se ven aumentados. DISCUSIÓN Y CONCLUSIONES: Los estudios que pretenden diferenciar las distintas poblaciones de alfa-adrenoceptores son estudios de binding (Malloy et al.)3 que localizan y cuantifican los distintos subtipos de receptores presentes en el tejido sin tener en cuenta su actividad. Los ensayos isométricos y fisiofarmacológicos evalúan receptores activos, es decir, que responden a estímulos agonistas y antagonistas, lo que permite valorar con exactitud la actividad del detrusor. Los resultados obtenidos en este estudio de investigación, apoyan la hipótesis del incremento de receptores adrenérgicos alfa1 en el detrusor obstruido con una p altamente significativa, y coincidiendo con trabajos moleculares previos4, durante la obstrucción prostática la subpoblación predominante en la vejiga es la alfa1d. Estos hallazgos pueden tener implicaciones fisiopatológicas, clínicas y farmacológicas. Si esta hipótesis, demostrada en experimentación animal, se consigue demostrar en la fase humana de la investigación, el desarrollo farmacológico deberá localizarse no sólo en fármacos antagonistas selectivos de receptores alfa1a (próstata), sino también de los 1d, con responsabilidad clínica vesical en situación de obstrucción vesical al flujo miccional (HBP y prostatismo) (AU)

[Duloxetine and other tricyclic antidepressants: pharmacodynamic effects in the lower urinary tract]. / Duloxetina y otros antidepresivos tricíclicos: efectos farmacodinámicos en el tracto urinario inferior.

INTRODUCTION: During years the pharmacology of the lower urinary tract function has been presided by the protagonism of the autonomic nervous system and its components, sympathetic and parasympathetic. Recent investigations proved a greater complexity of micturional dynamics, attributing a more important role to the central nervous system (SNC), to the striated sphincter and to the afferent arc, offering a new opportunity to the Tricyclic Antidepressants (T.A.), reason for this general review. MATERIAL AND METHODS: Using as reference the work of the First Consultation on Incontinence (Montecarlo, 1999), the previous and later publications about T.A. have been reviewed, including experimental (isometric and "in vivo" studies) and clinical studies, investigating on pharmacological evidences, mechanism of action, tolerance and other effects of T.A. RESULTS: Only a reduced group of T.A. have been submitted to experimental evaluations and employed in clinical trials. The recent works on Duloxetine have waked up a special interest by their pharmacological potential. CONCLUSIONS: New knowledge on the peripheral and central control of the continence-miction dynamic offer new pathways for the treatment with T.A., whose effectiveness and tolerance are reviewed.

Cirugía de la litiasis renoureteral. Indicaciones actuales / Open surgery for kidney and ureteral stone. Current indications

INTRODUCCIÓN: Toda reflexión sobre litiasis renoureteral y su terapéutica se centra actualmente en la LEOC (Litotricia Extracorpórea por Ondas de Choque), como tratamiento único o asociado a otras técnicas. En ciertos casos la endourología y la litotricia de contacto, se consideran como primera alternativa. La retroperitoneoscopia es otra opción en aquellos centros donde se desarrolla. El abandono de la cirugía abierta es muy manifiesto a favor de las nuevas alternativas, sobre todo en aquellos centros con litotritor extracorpóreo. Los buenos resultados que se obtienen con las técnicas alternativas y la comodidad que el paciente vive, han hecho que el número de casos que se someten anualmente a cirugía abierta sea mínimo. MATERIAL Y MÉTODOS: La Unidad de Litiasis-Litotricia de la Fundación "Jiménez Díaz" (FJD), que realiza LEOC (Modulith SL 20, Storz (r) ), analiza 54 pacientes operados en los últimos años (1990-200), con el fin de concluir en los motivos de la indicación quirúrgica. No se incluye la nefrectomía por lesión renal terminal post-litiásica (pionefrosis, pielonefritis xantogranulomatosa,...).RESULTADOS: La cirugía abierta realizada ha sido la tradicional según el caso: pielotomía (simple o ampliada, ñ infundibulotomía), nefrotomía anatrófica, ureterolitectomía,..., y corrección de aquellas anomalías u obstrucciones asociadas a la patología litiásica (hidro-nefrosis congénita, ureterocele,...). DISCUSIÓN: Actualmente existen casos de litiasis difíciles de solucionar incluso con cirugía abierta. Es la litiasis renal compleja. Sin duda la cirugía es la alternativa más eficaz y resolutiva. Si la LEOC, la URS (Ureterorenoscopia) o la NPL (Nefrolitotomía percutánea) fracasan, y la litiasis es sintomática, debe ser operada. Ante situaciones críticas (complicaciones de estos métodos, se requiere una solución eficaz y urgente, siendo la cirugía tradicional la única alternativa. CONCLUSIONES: La cirugía abierta se indica hoy ante casos de litiasis renal compleja y litiasis renoureteral complicada. El aprendizaje quirúrgico debe ir paralelo al endoscópico, laparoscópico o extracorpóreo. La cirugía abierta será la primera alternativa terapéutica en algún caso. En situación de urgencia clínica, se deben tomar decisiones quirúrgicas, que deberán ser realizadas con la destreza y precisión que se merecen (AU)

[Treatment of ureteral lithiasis with shock waves]. / Tratamiento de la litiasis ureteral con ondas de choque.

OBJECTIVE: To present our results with ESWL in situ in the treatment of ureteral lithiasis. Distal ureter calculi can be managed by ESWL or URS. For complex ureteral calculi associated with ureteral malformations, failed ESWL or complications other procedures are utilized (URS) and open surgery has its indications. METHODS: From October 1990 to December 2000 the Lithiasis-Lithotripsy Unit of the FJD has performed 2,500 ESWL in situ for ureteral calculi without endoscopic or percutaneous procedures (double-J or PN). The calculus was located in the lumbar ureter in 45%, sacro-iliac in 11% and renal pelvis in 44%. 67% were males and 33% females (mean age 48 and 42 years, respectively). Stone size was 5-20 mm in 88% of the cases; 1.5% had bilateral involvement, 1.7% multiple and 1.5% had a solitary kidney. 15% had renal colic when the procedure was performed. IVP was performed during ESWL for ureteral uric acid stones. RESULTS: The overall success rate was 95%; 97% for stones in the lumbar ureter and 89% for stones in the distal ureter. Repeat-ESWL rate was 1.10. Renal colic resolved during ESWL, although stone fragmentation was partial. Hematuria is common post-ESWL and irritative voiding symptoms on passage of stone fragments. Post-ESWL colic was observed in 20% of the cases but were managed without difficulty with medication. There were 3 cases of severe complications (0.12%), colon perforation, severe renal hematoma and peritonitis. Septic obstruction was found in 1.5% that required catheterization or nephrostomy. Radiologic and asymptomatic Steinstrasse was observed in 10% of the cases. CONCLUSIONS: ESWL in situ is the treatment of choice in ureteral lithiasis and has been demonstrated by many groups. The size and degree of stone impaction have a negative influence on the results. Resistance to fragmentation, which is basically determined by stone chemical composition, influence the results. Monohydrate calcium oxalate stones have been found to be the most resistant. Previous insertion of a catheter (double-J or nephrostomy) does not enhance the results. It appears to be useful during an episode of renal colic. Distal ureteral calculi can be treated by ESWL and URS. If a lithotriptor is available, ESWL without endoscopic procedures is the first choice.

[Surgery of renoureteral lithiasis. Current indications]. / Cirugía de la litiasis renoureteral. Indicaciones actuales.

INTRODUCTION: Today, the issue about kidney and ureteral stone and their management is based on ESWL (Extracorporeal Shock Wave Lithotripsy) like singly or as a part of combination therapy. In some cases, endoscopic procedures (URS, PNL) with contact lithotripsy, is the first-line treatment. Retroperitoneoscopic is a therapeutical option in some hospitals. Open stone surgery is now drastically reducing and the endoscopic and extracorporeal methods are increasing, overcoat ESWL in those hospitals who has an own lithotripter. The optimal results of non-invasive procedures, and the ESWL advantages for the patients (outpatient and anesthesia-free treatment, decreased morbidity,...), has caused limited annual indications of open surgery for stone disease even a complete disappearance in many center. MATERIALS AND METHODS: The Stone and Lithotripsy Unit of "Jiménez Díaz" Foundation (FJD) (Madrid), who has an own lithotipter (Modulith SL 20, STORZ) make an evaluation of 54 patients treated with open surgery (1990-2000) in order to reflect on the indications. Nephrectomy for serious paremquimal lithiasic lesions (complicated pyelonefhritis, xantogranulomatosis....) is not included. RESULTS: The open surgery techniques for stone diseases were the classic according to every case: pielolithotomy (simple or extended +/- infundibulolithotomy), anatrophic nephrotomy, ureterolithotomy,.... At the same time it should be resolved those anomalous structures or obstruction associated to the stone disease (congenital hydroneprosis, ureterocele,...). DISCUSSION: Now days are difficult cases of stone diseases to be managed for any methods included open surgery. It's the renal complex stone. Of course, surgery is the best option, the more effectively choice. When endoscopic procedures (URS, NPL) fall and the stone is synthomatic must be operated. When they are serious situation (septic shock, complications derived from the others methods,...). It's necessary an urgent and effectively treatment and it's the open surgery. CONCLUSION: Open surgery is actually indicated for the complex renal stone and the complicated ureteral stone. So, the training on open surgery should be at the same time on the endoscopic, laparoscopic or extracorporeal. Open surgery will be the first-line treatment in some case. Open surgery should be considered in those urgent situation and will be done with skill and precision.

Leoc eficaz, inmediata o de urgencia: ¡una atractiva alternativa estratégica a considerar en el tratamiento del cólico renal! / Effective inmediate or emergency swel: an attractive strategic alternative for the management of renal colic

INTRODUCCIÓN: El cólico renal originado por la obstrucción ureteral aguda, motivada por impacto litiásico, provoca una inten-sa elevación de la presión intracavitaria. El tratamiento farmacológico clásico (analgésicos, antiinflamatorios y espasmolíticos) es sintomático y temporal pudiendo aparecer de nuevo el dolor al mantenerse la obstrucción. La opción terapéutica etiopatogénica vs la sintomática sería el tratamiento definitivo. MATERIAL Y MÉTODOS: En la Unidad de Litiasis-Litotricia de la FJD desde sus comienzos, se indica LEOC "in situ" inmediata o de urgencia, durante el cólico renal junto al tratamiento farmacológico habitual, una vez identificado el cálculo ureteral con precisión. De un total de 2.100 casos de Litiasis Ureteral tratados (1991-1999) se han atendido en situación de cólico renal el 15 por ciento. RESULTADOS: El cólico renal se soluciona en todos los casos (100 por ciento) aunque la fragmentación resulte parcial y/o precise una segunda LEOC diferida sobre restos litiásicos. El dolor no vuelve a aparecer como sucede cuando cede el efecto de la analgesia ya que la obstrucción ha sido resuelta. DISCUSIÓN: La colocación de un catéter ureteral o una nefrostomía con fines analgésicos para realizar una LEOC diferida del cálculo ureteral, que ha originado la obstrucción ureteral aguda y el cólico renal, no mejoran los resultados de la LEOC. Existen razones físicas que apoyan la práctica de LEOC "in situ" inmediata o de urgencia durante el cólico renal. El cálculo obstructivo al ser fragmentado, junto al edema ureteral que se origina, permite el paso de la orina. Al desaparecer la obstrucción desaparece la hiperpresión intracavitaria y así el dolor de manera definitiva. CONCLUSIONES: La LEOC inmediata, "in situ" o de urgencia en el caso del cálculo ureteral obstructivo, durante el cólico renal es una atractiva alternativa estratégica de tratamiento a considerar sobre todo en aquellos centros donde exista la posibilidad de realizarla, con la misma disponibilidad que cualquier otra actuación urológica (AU)

[Bladder hyporeflexia caused by vinca alkaloids]. / Hiporreflexia vesical producida por los alcaloides de la vinca.

Presentation of one case of hyporreflexic bladder like a first step of neurotoxicity due to Vinca alkaloids. These drugs produces peripheral neuropathies as usual, but in some rare occasions they may affect to the autonomic nervous system with its effects in the bladder producing hyporreflexic. This disease reverts spontaneously after suppressing drugs.

Hiporreflexia vesical producida por los alcaloides de la vinca / Hyporreflexic bladder due to vinca alkaloids

Se presenta un caso de hiporreflexia vesical como primera manifestación de neurotoxicidad, debida a la administración de los alcaloides de la Vinca; estas sustancias comúnmente producen neuro-patía periférica, pero en raras ocasiones afectan al sistemas nervioso autónomo con su correspondiente efecto sobre la vejiga produciendo hiporreflexia, dicha alteración se corrige espontáneamente tras la supresión del fármaco (AU)

[Efficient, immediate or emergency ESWL: an attractive strategic alternative to be considered in the treatment of renal colic!]. / LEOC eficaz, inmediata o de urgencia: una atractiva alternativa estratégica a considerar en el tratamiento del cólico renal!

INTRODUCTION: Renal colic due to acute ureteral obstruction caused by lithiasic impact results in severe rise of intracavitary pressure. Traditional drug therapy (painkillers, anti-inflammatories, spasmolytics) is symptomatic and provisional, and pain can reappear when obstruction is maintained. A pathoetiological approach would be the ultimate therapy vs the symptomatic one. MATERIAL AND METHODS: From the beginning, the approach used at the Lithiasis-Lithotrity Unit at the FJD, once the ureteral stone is accurately identified during a renal colic, is that of immediate or emergency "in situ" SWEL together with the usual drug therapy. 15% of 2100 cases of ureteral lithiasis treated (1991-1999) were renal colic. RESULTS: Renal colic can be resolved in all cases (100%) even when fragmentation may be partial and/or require a second deferred SWEL on remnants of the first lithiasis. When obstruction has been resolved, pain does not reappear as it happens with the effects of analgesics. DISCUSSION: Placement of a ureteral catheter or nephrostomy for analgesia in order to perform deferred SWEL of the ureteral stone origin of the acute ureteral obstruction and the renal colic, do not improve SWEL results. There are physical reasons to support the practice of immediate or emergency "in situ" SWEL during a renal colic. Fragmentation of the obstructive stone together with the resulting ureteral oedema allow urine passage. Intracavitary pressure and pain disappear when the obstruction is withdrawn. CONCLUSIONS: Immediate, "in situ" or emergency SWEL in cases of obstructive ureteral stones during a renal colic, is an attractive strategic alternative for drug therapy that should be considered mainly in institutions with means to perform the procedure.

[ESWL-resistant lithiasis]. / La litiasis resistente a LEOC.

INTRODUCTION: To the extent in which the "lithotripter" improves technically. SWEL experts provide different explanations to the failures of this technique. It will depend on the type of "lithotripter" as well as the calculus and its features (size, number, location, composition, obstruction, impact, absence of expansion chamber, presence of ureteral catheter, ...). Not all facts in SWEL have a clear explanation today. Physically, the "cavitation" phenomena (shock, rebound, negative pressure, explosion, heat, ...) explain almost anything that takes place during SWEL. Certainly, the type of lithotripter has some influence, but the calculus fragility, determined by the chemical composition and the crystalline architecture, could be more determinant. MATERIAL AND METHOD: From a total series of 6,500 SWEL procedures performed in the Lithiasis-Lithotrity Unit at the "Jiménez Díaz" Foundation (JD) (January 1991-July 1998), 20 cases considered as failures after multiple SWELs were analyzed. Also the actual diagnostic tests (X-rays, helicoid CAT, densitometry, ...) were studied to establish a pre-SWEL chemical recognition of the calculi that may determine the behaviour of each case prior to treatment. RESULTS: After multiple SWELs (average 5 sessions) negative results were obtained in 65% cases. These cases were resolved with surgery (38%), ureterorenoscopy and ultrasound lithotrity (23%) or watchful wait in absence of signs and symptoms (39%). 57% were calcium phosphate calculi, 29% calcium oxalate monohydrate (COM) and 14% hypercalciuria calculi. CONCLUSIONS: SWEL resistant cases, either unresolved or undergoing multiple SWELs, demonstrate the existence of calculi that cannot be broken by SWEL, although no coincident or similar reasons can be established in all cases. Calcium phosphate dihydrate (brushite) and calcium oxalate monohydrate (COM) together with cystine are the most difficult to destroy with current shockwaves. Helicoid CAT could recognise chemically each case prior to SWEL, since it basically differentiates the most frequent ones, uric acid, struvite and calcium oxalate.

[Lithiasis of the distal ureter: ESWL or URS]. / La litiasis del uréter distal: LEOC o URS.

UNLABELLED: A nephritic colic is the clinical picture that evidences the presence of ureteral stones, the natural evolution being their spontaneous passing. Stones in the distal ureter are self-eliminated in about 71-80% cases. The adoption of a "watchful wait" involves an uncertain occupational and medical evolution since, although in some cases the stones will pass with no problems, in other instances they can result in severe, life threatening situations for the patient's health (intractable pain, anuria or sepsis). When a decision is made to treat the condition, there are two choices available: "in situ" SWEL (extracorporeal lithotrity), or URS (ureterorenoscopy), long-standing conflicting techniques each with its own advantages and disadvantages, which should now be considered complementary. SWEL's major disadvantage is the number of repetitions required and the long wait, sometimes even months, until the last fragment is passed. The greater strength of URS is that it can be resolutive in just one episode (95% cases), thus avoiding the obstruction problems that can arise after SWEL. In the Lithiasis-Lithotrity Unit of FJD, SWEL is the first therapeutical option for the treatment of stones in the distal ureter. SWEL and URS are equally likely to be performed although SWEL is the initial choice for efficiency reasons that are explained. We achieve 93.6% positive results with a 1.82% re-SWEL rate (retreatment), 0.60 coefficient of efficiency (EQ) and 0.69 modified coefficient of efficiency (EQM) (Chart). No serious complications were recorded. Morbidity is variable with little clinical significance. CONCLUSION: Distal ureter lithiasis can be treated with either URS and SWEL, both considered "different and complementary". The choice in each particular case and within each hospital will depend on availability of means to perform one or the other, equipment's efficiency, skill of the urologist, patient's preference and cost of each treatment.

Asthma mortality in Cuba during 1972-1993.

UNLABELLED: Morbi-mortality due to asthma has increased in recent years both throughout the world in Cuba. A study of mortality caused by this disease has conducted in order to describe its current trend in the country. METHOD: A time series study was conducted which included all deaths attributed to asthma in Cuba recorded in the vital statistics records of the Ministry of Public Health from 1972 to 1993. Rates, secular trends of general mortality and according to gender were estimated. The proportional mortality for the 1972-1993 period was calculated and the potential years of life lost during the 90-92 trienium were quantified. RESULTS AND DISCUSSION: A drop in these global rates occurred between 1972 and 1975, with values of 3.6; 4.1; 3.0; 2.2; respectively; possibly due to the introduction of disodic chromoglycate among other drugs and the beginning of the Asthmatic Patient Program. An later increase in mortality was observed until 1993 (5.9 x 100,000 inhabitants) which may attributed to a drop of the intensity and regularity of said program and to other internationally knowledge factors which are present in our country. The trend of general mortality rose during this period and was greater in females than in males; which means that the risk to die of this cause has increased. Proportional Mortality since 1980 (0.50%) also increased until 1993 (0.80%). Potential years of life lost due to premature death ranged from 5,646 in 1990 to 7,386 in 1992. The increase in proportional mortality and the potential years of life lost suggest that this disease should been given priority by the National Health Program as a preventable cause of death, especially in women. CONCLUSIONS: There is a rising trend of mortality among asthmatic patients during the period under consideration. Asthma is a cause of premature death in Cuba.