Consenso de la Asociación Española de Urología sobre el uso de mallas en la cirugía del prolapso de órganos pélvicos / Consensus statement of the Spanish Association Of Urology on the use of meshes in pelvic organ prolapse

INTRODUCCIÓN: Recientemente la Food and Drug Administration ha prohibido el uso de mallas transvaginales para el tratamiento quirúrgico de los prolapsos de órganos pélvicos (POP) en Estados Unidos. Esto ha suscitado una repercusión a escala mundial en el manejo de la patología del suelo pélvico por parte de los diferentes especialistas. OBJETIVO: Lograr un consenso sobre el uso de mallas en el tratamiento quirúrgico de los POP. ADQUISICIÓN DE DATOS/EVIDENCIA: Se organizó un Comité de expertos de la Asociación Española de Urología (AEU) para una revisión de la literatura y analizar la seguridad y eficacia del uso de mallas de polipropileno en la cirugía de los POP. RESULTADOS/EVIDENCIA DE LA LITERATURA: La evidencia refleja que el uso de mallas, comparado con el uso de tejidos nativos, ofrece una mejor eficacia a expensas de nuevas complicaciones y una mayor tasa de revisiones quirúrgicas, siendo estas menores en manos de cirujanos expertos. CONCLUSIONES: La cirugía del POP debe ser realizada por cirujanos con experiencia, adecuadamente formados y en centros de referencia. El paciente debe recibir una información correcta acerca de las diferentes opciones de tratamiento. Las mallas transvaginales solo deben indicarse en casos complejos y en recidivas tras cirugía del POP. PROPUESTA AEU: Creación de una guía clínica y de un registro nacional para la evaluación a largo plazo. Elaboración de un Consentimiento Informado a disposición de todos los profesionales y pacientes, así como un plan de formación específico para conseguir una mejor capacitación en la cirugía compleja del suelo pélvico

INTRODUCTION: Recently the Food and Drug Administration has banned the use of transvaginal meshes for the surgical treatment of pelvic organ prolapse (POP) in the United States. This has caused a worldwide impact on the management of pelvic floor pathology by different specialists. OBJECTIVE: To achieve a consensus on the use of meshes in the surgical treatment of POPs. ACQUISITION OF DATA/EVIDENCE: A Committee of experts of the Spanish Association of Urology (AEU) was organized to review the literature and analyze the safety and efficacy of the use of polypropylene meshes in POP surgery. RESULTS/EVIDENCE FROM THE LITERATURE: The evidence reflects that the use of meshes, compared to the use of native tissues, offers better efficacy at the expense of new complications and a higher rate of surgical reviews, these being minor in the hands of expert surgeons. CONCLUSIONS: POP surgery must be performed by experienced surgeons, properly trained and in referral centers. The patient should receive correct information about the different treatment options. Transvaginal meshes should only be indicated in complex cases and in recurrences after POP surgery. AEU PROPOSAL: Creation of a clinical guideline and a national registry for long-term evaluation. Preparation of an Informed Consent available to all professionals and patients, as well as a specific training plan to achieve better training in complex pelvic floor surgery

Consensus statement of the Spanish Association Of Urology on the use of meshes in pelvic organ prolapse. / Consenso de la Asociación Española de Urología sobre el uso de mallas en la cirugía del prolapso de órganos pélvicos.

INTRODUCTION: Recently the Food and Drug Administration has banned the use of transvaginal meshes for the surgical treatment of pelvic organ prolapse (POP) in the United States. This has caused a worldwide impact on the management of pelvic floor pathology by different specialists. OBJECTIVE: To achieve a consensus on the use of meshes in the surgical treatment of POPs. ACQUISITION OF DATA/EVIDENCE: A Committee of experts of the Spanish Association of Urology (AEU) was organized to review the literature and analyze the safety and efficacy of the use of polypropylene meshes in POP surgery. RESULTS/EVIDENCE FROM THE LITERATURE: The evidence reflects that the use of meshes, compared to the use of native tissues, offers better efficacy at the expense of new complications and a higher rate of surgical reviews, these being minor in the hands of expert surgeons. CONCLUSIONS: POP surgery must be performed by experienced surgeons, properly trained and in referral centers. The patient should receive correct information about the different treatment options. Transvaginal meshes should only be indicated in complex cases and in recurrences after POP surgery. AEU PROPOSAL: Creation of a clinical guideline and a national registry for long-term evaluation. Preparation of an Informed Consent available to all professionals and patients, as well as a specific training plan to achieve better training in complex pelvic floor surgery.

[Hand-assisted laparoscopic nephrectomy]. / Nefrectomia laparoscópica mano-asistida.

INTRODUCTION AND OBJECTIVES: To present the number of cases of hand-assisted laparoscopic nephrectomy. This study evaluates our results and difficulties of starting a progresive programme of laparoscopy. MATERIAL AND METHOD: Between november 2003 and november 2005, 35 hand-assisted laparoscopic nephrectomies were carried out, of a total of 45 laparoscopic nephrectomies. 22 radical nephrectomies, 3 simple nephrectomies and 10 nephroureterectomies. The average age of patients was 66 years (47-89). On average, they were overweight (IMC 28,3), with approximately 38% being obese. ASA 2.3 (1-4). The tumors measured 4.8cm on average, and 80% of these were T1. In 28.6% of the cases, they had previously undergone abdominal surgery. RESULTS: One was undertaken in 2003, 17 in 2004, and 17 in 2005. The surgery time was 140 minutes, 130 minutes (80-210) in radical nephrectomies, 135 minutes (120-150) in simple nephrectomies and 163 minutes (80-240) in the nephroureterectomy. Patients began an oral diet 1.7 days later, and were able to get up 1.7 days later. In the case of obese patients, they began an oral diet 2.3 days later and were able to get up (2.4 days) later than those non obese cases. (1.5 and 1.4 days respectively). The average stay has been 5.8 days (3-15). The average stay of the cases without complications was 4.2 days and those that encountered complications 9.7 days. In no cases was there a need for a blood transfusion. In 11.4% we had major complications with an average stay of 11.7 days. In 5.7% of cases there were reconversions, and 5.7% of cases were reoperated. 17.1% had minor complications, with an average stay of 8.8 days CONCLUSIONS: The advantage of hand-assisted nephrectomy is that it allows one to begin a laparoscopy, with a reduced learning time, and with satisfactory results, allowing the incorporation of laparoscopy surgery in hospitals with a reduced annual volume.

Nefrectomía laparoscópica mano-asistida / Hand-assisted laparoscopic nephrectomy

Introducción y Objetivos: Presentamos nuestra casuística de nefrectomías laparoscópicas mano-asistidas. Se valoran nuestros resultados y las dificultades del inicio de un programa progresivo de laparoscopia. Material: Desde noviembre 2003 hasta noviembre 2005 se han realizado 35 nefrectomías laparoscópicas Mano-asistidas, de un total de 45 nefrectomías laparoscópicas. 22 nefrectomías radicales, 3 nefrectomías simples y 10 nefroureterectomías. Media de edad 66 años (47-89). Tenían una media de sobrepeso (IMC 28,3); 38% eran obesos. ASA 2,3 (1-4). Los tumores tenían 4,8 cm de tamaño medio; 80% eran T1. El 28,6% habían sido operados previamente de cirugía abdominal. Resultados: Se realizaron 1 en 2003, 17 en 2004, y 17 en 2005. El tiempo quirúrgico ha sido 140 minutos, 130 minutos (80-210) en nefrectomías radicales, 135 minutos (120-150) en nefrectomías simples y 163 minutos (80-240) en nefroureterectomías. Los pacientes iniciaron dieta oral en 1,7 días y se levantaron en 1,7 días. Los obesos iniciaron la dieta (2,3 días) y se levantaron (2,4 días) más tarde que los no obesos (1,5 y 1,4 días respectivamente). La estancia media ha sido 5,8 días (3-15); en los no complicados 4,2 días y en los que han tenido complicaciones 9,7 días. En ningún caso se trasfundió. Hemos tenido 11,4% de complicaciones mayores con EM de 11,7 días. Un 5,7% de reconversiones y 5,7% de reoperaciones. Y 17,1% de complicaciones menores, con EM de 8,8 días. Conclusiones: La nefrectomía mano-asistida es una técnica que por sus ventajas permite un inicio en la laparoscopia, con menor curva de aprendizaje, y resultados satisfactorios, permitiendo incorporar la cirugía laparoscópica a hospitales con un menor volumen anual

Introduction and objectives: To present the number of cases of hand-assisted laparoscopic nephrectomy. This study evaluates our results and difficulties of starting a progresive programme of laparoscopy. Material and Method: Between november 2003 and november 2005, 35 hand-assisted laparoscopic nephrectomies were carried out, of a total of 45 laparoscopic nephrectomies. 22 radical nephrectomies, 3 simple nephrectomies and 10 nephroureterectomies. The average age of patients was 66 years (47-89). On average, they were overweight (IMC 28,3), with approximately 38% being obese. ASA 2.3 (1-4). The tumors measured 4.8cm on average, and 80% of these were T1. In 28.6% of the cases, they had previously undergone abdominal surgery. Results: One was undertaken in 2003, 17 in 2004, and 17 in 2005. The surgery time was 140 minutes, 130 minutes (80-210) in radical nephrectomies, 135 minutes (120-150) in simple nephrectomies and 163 minutes (80-240) in the nephroureterectomy. Patients began an oral diet 1.7 days later, and were able to get up 1.7 days later. In the case of obese patients, they began an oral diet 2.3 days later and were able to get up (2.4 days) later than those non obese cases. (1.5 and 1.4 days respectively). The average stay has been 5.8 days (3-15). The average stay of the cases without complications was 4.2 days and those that encountered complications 9.7 days. In no cases was there a need for a blood transfusion. In 11.4% we had major complications with an average stay of 11.7 days. In 5.7% of cases there were reconversions, and 5.7% of cases were reoperated. 17.1% had minor complications, with an average stay of 8.8 days Conclusions: The advantage of hand-assisted nephrectomy is that it allows one to begín a laparoscopy, with a reduced learning time, and with satisfactory results, allowing the incorporation of laparoscopy surgery in hospitals with a reduced annual volume

[Diagnostic and therapeutic approach to bilateral germinal tumor. Presentation of a case and review of the literature]. / Actitud diagnóstica y terapéutica en el tumor germinal bilateral. Presentación de un caso y revisión de la literatura.

The germinal bilateral tumor represents from 1 to 4% of the testicle tumors, and it usually turns to be one of the most difficult ones when talking about diagnosis and treatment. We are attaching a 30 years old patient case, with a diagnosis consisting in a seminoma with yolk sac tumor area from the left testicle, that was treated with orquiectomy. Eleven months later, the patient presented a second neoplasm in the contralateral testicle, whose histology was a classical seminoma with carcinoma "in situ" peritumoral, being also treated with orquiectomy. Medical literature is revised with emphasis in the involved risk factors and the techniques used to treat these testis tumor groups: carcinoma "in situ" detection appears to be the strongest predicting factor. Testicular contralateral biopsy is proposed in some select cases. Even though radical orquiectomy is still the treatment to choose, local radiotherapy and conservative surgery are also an option in patients with bilateral tumor.

Actitud diagnóstica y terapéutica en el tumor germinal bilateral.Presentación de un caso y revisión de la literatura / Diagnosis and terapeutic management in germinal bilateral tumors. A report of one case and literature revision

El tumor germinal bilateral representa entre el 1 y el 4 por ciento de los tumores de testículo y suele plantear al urólogo importantes dificultades en su diagnóstico y tratamiento. Aportamos el caso de un paciente de 30 años, diagnosticado de seminoma con áreas de tumor del saco vitelino en teste izquierdo, que fue tratado con orquiectomía. Once meses después, presentó una segunda neoplasia en el teste contralateral, cuya histología fue de seminoma clásico con carcinoma "in situ" peritumoral, siendo tratado también con orquiectomía. Se revisa la literatura médica, con especial referencia a los factores de riesgo implicados y al manejo de estos tumores: la detección de carcinoma "in situ" aparece como factor predictivo más potente. Se plantea la realización de biopsia testicular contralateral en casos seleccionados. Aunque la orquiectomía radical sigue siendo el tratamiento de elección, la radioterapia local y la cirugía conservadora representan una alternativa en casos de tumor bilateral (AU)

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[Half-stay and morbidity in a cohort of patients treated with urologic surgery iin the treatment with acenocumarol (Sintrom)]. / Estancia media y morbilidad en una cohorte de pacientes sometidos a cirugía urológica en tratamiento con acenocumarol (Sintrom).

OBJECTIVE: Our objective was to evaluate the effect about half stay at hospital, in patients treated with Sintrom, which required different urological surgery. PATIENTS AND METHOD: We evaluated 55 patients in treatment with Sintrom which required different urological surgery. We analysed a cohort control group with similar characteristic without anticoagulation therapy. The patients was at hospital 3 days before surgery to realize the change Sintrom/Heparina. We used the haematology service's protocol at the Hospital del Mar. We analysed in each patient the half stay at hospital and the morbidity referred to bleeding complications. The decrease of haemoglobin higher than 2 g/dl was considered significant. RESULTS: About half stay, all patients required more days of hospitalization. The additional morbidity was obvious in the transurethral resection of the prostate and in great not endoscopical surgery. In the rest of surgery the complications referred to bleeding have repercussion about stay at hospital. CONCLUSIONS: We found a significant increased half stay at hospital and the morbidity referred to bleeding complications and its consequence (transfusion, second surgery,...).

Estancia media y morbilidad en una cohorte de pacientes sometidos a cirugía urológica en tratamiento con acenocumarol (Sintrom®) / Half stay at hospital and morbidity about a patients cohort in treatment with acenocumarol (Sintrom®) who need urological surgery

OBJETIVO: Nuestro objetivo fue evaluar el efecto sobre la estancia media y la morbilidad, en pacientes que estaban recibiendo tratamiento con Sintrom® y precisaron una intervención urológica. PACIENTES Y MÉTODO: Incluimos una serie de 55 pacientes en tratamiento anticoagulante que requirieron distintas intervenciones urológicas. Se analizó un grupo control de similares características pero sin terapia anticoagulante. Los pacientes ingresaron 3 días antes para realizar el cambio Sintrom®/Heparina siguiendo el protocolo del Servicio de Hematología del Hospital del Mar. Se analizó en cada paciente la estancia media hospitalaria y la morbilidad referida a complicaciones por sangrado. Se tomó como referencia la disminución de la hemoglobina en más de 2 g/dl. RESULTADOS: Con relación a la estancia media, todos los pacientes requirieron más días de ingreso hospitalario. La morbilidad añadida fue evidente en las resecciones transuretrales (RTU) de próstata y en la cirugía mayor no endoscópica. En el resto de intervenciones quirúrgicas las complicaciones, referentes al sangrado, tuvieron su repercusión en el aumento de los días de estancia hospitalaria. CONCLUSIÓN: Encontramos un incremento significativo en la estancia media comparada con la media hospitalaria y en la morbilidad asociada a un aumento del sangrado y sus consecuencias (transfusiones, reintervenciones...) (AU)

[Vesico-sphincter dysfunction in 108 cases of multiple sclerosis]. / Disfunción vésico-esfinteriana en 108 casos de esclerosis múltiple.

OBJECTIVE: To study vesicosphincteric dysfunction in 108 patients with multiple sclerosis. METHODS: We reviewed the clinical records of 108 patients with multiple sclerosis and analyzed those with voiding symptoms ascribable to multiple sclerosis. These patients underwent complete urodynamic assessment and complementary tests according to their symptoms. The Blaivas classification was used for the clinical classification of multiple sclerosis. RESULTS: 64 of the 108 patients presented voiding symptoms ascribable to multiple sclerosis (59.2%). The clinical features presented as episodes in 75% and were progressive in 25% of the cases. In 6% of the patients, the voiding symptoms were the first symptoms of multiple sclerosis. Urodynamic assessment showed detrusor hyperreflexia in 73% of the patients, hyporeflexia in 14%, and 13% showed normal urodynamics. All complications were infective; no patient showed upper urinary tract complications. CONCLUSIONS: Vesicosphincteric dysfunction in multiple sclerosis is frequent. Most of the patients present bladder hyperreflexia. The urological complications are usually infective. Involvement of the upper urinary tract is rare.

[Uretero-colonic fistula in non-functioning ureter]. / Fístula uretero-colónica en uréter desfuncionalizado.

OBJECTIVE: To present a case of ureterocolonic fistula secondary to acute sigmoid diverticulitis in a nonfunctioning ureter due to a previous nephrectomy. METHODS/RESULTS: A 68-year-old patient that had undergone nephrectomy due to xanthogranulomatous pyelonephritis two years earlier, consulted for long-standing non-specific abdominal pain. Radiological evaluation showed a pneumogram pattern in the ureteral stump associated to a pelvic mass. The patient underwent surgery for a suspected uretero-intestinal fistula. The intraoperative findings and anatomopathological study demonstrated a uretero-sigmoid fistula due to diverticular disease of colon. CONCLUSIONS: Uretero-intestinal fistulas present unimportant clinical features. Radiological assessment and a clinical suspicion are important to diagnosis.