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.

Modelo predictivo de mortalidad en pacientes con tumor urotelial de vejiga tras cistectomía radical / Mortality prediction model for patients with bladder urothelial tumor after radical cystectomy

OBJETIVO: Elaborar un modelo predictivo de mortalidad cáncer específica (MCE) a 1, 3, y 5 años basándonos en variables clínicas precirugía y patológicas poscirugía en pacientes con tumor urotelial vesical tratados con cistectomía radical. MATERIAL Y MÉTODOS: Análisis retrospectivo de 517 pacientes diagnosticados de tumor urotelial vesical y tratados con cistectomía radical (1986 y 2009). Se recogieron variables demográficas, clínicas, quirúrgicas y patológicas, así como complicaciones acontecidas y evolución tras cistectomía radical. Análisis comparativo con test de Chi cuadrado y ANOVA. Cálculo de supervivencia con método de Kaplan-Meier y test de log-rank. Análisis univariante y multivariante mediante regresión logística para identificar las variables predictoras independientes de MCE. Se calculó la probabilidad individual de MCE a 1, 3 y 5 años según la ecuación general (función logística). La calibración se obtuvo mediante método de. Hosmer-Lemeshow y la discriminación con elaboración de una curva ROC (área bajo la misma). RESULTADOS: El tumor urotelial vesical fue la causa de muerte en 225 pacientes (45%). Se obtuvo una MCE el 1.°, 3.° y 5.° años del 17%, 39,2% y 46,3% respectivamente. El estadio pT y pN se identificaron como variables pronósticas independientes de MCE al 1.°, 3.° y 5.° años. Se construyeron 3 modelos predictivos. La capacidad predictiva fue del 70,8% (IC95% 65-77%, p = 0,000) para el 1.° año, del 73,9% (IC95% 69,2-78,6%, p = 0,000) para el 3.° año y del 73,2% (IC95% 68,5-77,9%, p = 0,000) para el 5.° año. CONCLUSIONES: El modelo predictivo permite estimar el riesgo de MCE a los 1, 3 y 5 años con fiabilidad del 70,8, 73,9 y 73,2% respectivamente

OBJECTIVE: Based on preoperative clinical and postoperative pathological variables, we aim to build a prediction model of cancer specific mortality (CSM) at 1, 3, and 5 years for patients with bladder transitional cell carcinoma treated with RC. MATERIAL AND METHODS: Retrospective analysis of 517 patients with diagnosis of cell carcinoma treated by RC (1986-2009). Demographic, clinical, surgical and pathological variables were collected, as well as complications and evolution after RC. Comparative analysis included Chi square test and ANOVA technique. Survival analysis was performed using Kaplan-Meier method and log-rank test. Univariate and multivariate analyses were performed using logistic regression to identify the independent predictors of CSM. The individual probability of CSM was calculated at 1, 3 and 5 years according to the general equation (logistic function). Calibration was obtained by the Hosmer-Lemeshow method and discrimination with the elaboration of a ROC curve (area under the curve). RESULTS: BC was the cause of death in 225 patients (45%); 1, 3 and 5-year CSM were 17%, 39.2% and 46.3%, respectively. The pT and pN stages were identified as independent prognostic variables of CSM at 1, 3 and 5 years. Three prediction models were built. The predictive capacity was 70.8% (CI 95% 65-77%, p = .000) for the 1st year, 73.9% (CI95% 69.2-78.6%, p = .000) for the third and 73.2% (CI% 68.5-77.9%, p = .000) for the 5th year. CONCLUSIONS: The prediction model allows the estimation of CSM risk at 1, 3 and 5 years, with a reliability of 70.8%, 73.9% and 73.2%, respectively

Mortality prediction model for patients with bladder urothelial tumor after radical cystectomy. / Modelo predictivo de mortalidad en pacientes con tumor urotelial de vejiga tras cistectomía radical.

OBJECTIVE: Based on preoperative clinical and postoperative pathological variables, we aim to build a prediction model of cancer specific mortality (CSM) at 1, 3, and 5 years for patients with bladder transitional cell carcinoma treated with RC. MATERIAL AND METHODS: Retrospective analysis of 517 patients with diagnosis of cell carcinoma treated by RC (1986-2009). Demographic, clinical, surgical and pathological variables were collected, as well as complications and evolution after RC. Comparative analysis included Chi square test and ANOVA technique. Survival analysis was performed using Kaplan-Meier method and log-rank test. Univariate and multivariate analyses were performed using logistic regression to identify the independent predictors of CSM. The individual probability of CSM was calculated at 1, 3 and 5 years according to the general equation (logistic function). Calibration was obtained by the Hosmer-Lemeshow method and discrimination with the elaboration of a ROC curve (area under the curve). RESULTS: BC was the cause of death in 225 patients (45%). One, three and five-year CSM were 17%, 39.2% and 46.3%, respectively. The pT and pN stages were identified as independent prognostic variables of CSM at 1, 3 and 5 years. Three prediction models were built. The predictive capacity was 70.8% (CI 95% 65-77%, p=.000) for the 1st year, 73.9% (CI95% 69.2-78.6%, p=.000) for the third and 73.2% (CI% 68.5-77.9%, p=.000) for the 5th. CONCLUSIONS: The prediction model allows the estimation of CSM risk at 1, 3 and 5 years, with a reliability of 70.8, 73.9 and 73.2%, respectively.

Ampliación vesical con uso de aparato digestivo. Indicaciones, seguimiento y complicaciones / Bladder augmentation using the gastrointestinal tract. Indication, follow up and complications

La ampliación vesical utilizando el tracto gastrointestinal tiene por objetivo crear un reservorio de baja presión y alta capacidad, permitiendo una continencia y vaciado adecuados, preservando el tracto urinario superior.OBJETIVO: Analizar las indicaciones, complicaciones y resultados de nuestra serie de enterocistoplastias de aumento.MÉTODO: Revisamos retrospectivamente los pacientes sometidos a enterocistoplastia de aumento en nuestro servicio entre los años 1997 y 2010 ambos inclusive. Las indicaciones fueron: Cistitis intersticial, vejiga neurógena y retracción vesical inflamatoria. En todos los casos se realizó cistografía, uretrocistoscopia, estudio urodinámico y diario miccional, así como los estudios propios de cada patología. Mediante laparotomía media y abordaje extraperitoneal se realiza la liberación vesical con apertura bivalva hasta los orificios ureterales. La ampliación vesical se realiza con un segmento de 15-20 cm de íleon detubulizado a 20 cm de la válvula ileocecal; en los casos de insuficiencia renal se añadió una cuña de 7 cm de cuerpo gástrico. La sonda vesical se retiró tras cistografía a los 15 días. El seguimiento se realizó mediante ecografía con residuo postmiccional, analítica sanguínea, urocultivo y diario miccional.Realizamos un estudio descriptivo de las características demográficas, complicaciones postoperatorias según la clasificación de Clavien y a largo plazo(AU)

RESULTADOS: Incluimos 24 pacientes, 19 mujeres y 5 varones con una edad media de 48,5 años y una mediana de 47 (21-77). El seguimiento medio fue de 7,5 años con una mediana de 8. Las indicaciones fueron: 7 cistitis intersticiales, 9 retracciones vesicales y 8 vejigas neurógenas. No hubo complicaciones intraoperatorias. Las complicaciones postoperatorias fueron 3 Clavien I, 2 tipo II, 2 IIIa y 1 IIIb. A largo plazo 3 pacientes presentan incontinencia urinaria, 2 acidosis metabólica leve, 5 precisan autocateterismos, 6 litiasis vesicales, 2 infecciones urinarias febriles y 1 estenosis de la boca anastomótica. En tres casos se realizó ileogastrocistoplastia sin deterioro hidroelectrolitico ni de la función renal.CONCLUSIONES En pacientes seleccionados la enterocistoplastia de aumento constituye una opción terapéutica eficaz con escasa morbilidad y complicaciones en el tratamiento de la disfunción del tracto urinario inferior(AU)

The purpose of bladder augmentation using the gastrointestinal tract is to create a low-pressure and high-capacity reservoir, permitting suitable continence and voiding, preserving the upper urinary tract.OBJECTIVE: To analyze the indications, complications and results of our series of augmentation enterocystoplasties.METHOD: We retrospectively reviewed patients undergoing augmentation enterocystoplasty in our department between 1997 and 2010, both included. The indications were: Interstitial cystitis, neurogenic bladder and inflammatory bladder retraction. In all cases a cystography, urethrocystoscopy, urodynamic study and voiding diary were performed, as well as the specific studies of each condition. Bladder release is performed by means of medial laparotomy and an extraperitoneal approach with bivalve opening to the urethral orifices. The bladder augmentation is performed with a 15-20 cm segment of detubularized ileum obtained at 20 cm from the ileocecal valve; in cases of kidney failure, a 7-cm gastric body wedge is added. The bladder catheter was removed following cystogram after 15 days.Monitoring was performed by means of ultrasound with postvoid residual, blood analyses, urine culture and voiding diary. We performed a descriptive study of the demographic characteristics, postoperative complications according to the Clavien classification and in the long term(AU)

RESULTS: We included 24 patients, 19 women and 5 men with a mean age of 48.5 years and a median of 47 (21-77). Mean follow up was 7.5 years with a median of 8 (1-11). The indications were: 7 interstitial cystitis, 8 bladder retraction and 7 neurogenic bladder. There were no intraoperative complications. The postoperative complications were 3 Clavien I, 2 type II, 2 IIIA and 1 IIIB.In the long term, 3 patients presented urinary incontinence, 2 mild metabolic acidosis, 5 required self-catheterization, 6 bladder stones, 2 febrile urinary tract infections and 1 stricture of the anastomotic mouth. In three cases, an ileogastrocystoplasty was performed without hydroelectrolytic impairment or impairment of kidney function.CONCLUSIONS: In selected patients, augmentation enterocystoplasty constitutes an efficacious therapeutic option in the treatment of lower urinary tract dysfunction with scant morbidity and few complications(AU)

Angiomixoma agresivo paratesticular. Diagnóstico diferencial de lesiones mixoides paratesticulares / Aggressive paratesticular angiomyxoma: differential diagnosis of myxoide paratesticular lesions

El angiomixoma agresivo es un tumor mesenquimal poco frecuente, descrito sobre todo en área pélvica y genital. Es de crecimiento infiltrativo, con frecuentes recurrencias locales y afecta generalmente a mujeres. Hemos estudiado un caso en un varón adulto con un tumor localizado en escroto (paratesticular). El tumor está compuesto de células fusiformes o estrelladas, en el seno de un estroma mixoide y numerosos vasos grandes y pequeños, algunos con hialinización de la pared. Las células tumorales muestran expresión positiva para receptores hormonales de estrógenos y progesterona. No ha habido recurrencias después de 36 meses del diagnóstico. Es importante el reconocimiento de esta neoplasia por su conducta clínica incierta con riesgo de recurrencias locales. Cuando se sospechosa angiomixoma agresivo se debe realizar resección quirúrgica amplia para prevenir recurrencias. En este trabajo comparamos esta neoplasia mixoide con otros tumores, especialmente angiomiofibroblastoma y liposarcoma mixoide (AU)

[Laparoscopic lymphadenectomy in the treatment of stage I non-seminomatous germ cell tumors]. / Linfadenectomía laparoscópica en el tratamiento de los tumores germinales no seminomatosos estadio I.

OBJECTIVE: To review the role of laparoscopic lymphadenectomy for stage I nonseminomatous germ cell tumor of the testis. METHODS: The current literature on this subject is reviewed and the advantages and disadvantages of this technique are discussed. RESULTS/CONCLUSIONS: Although there is no agreement on the management of nonseminomatous germ cell tumors of the testis, some groups advocate performing retroperitoneal lymphadenectomy after orchidectomy, particularly for tumors with a high risk of dissemination. The laparoscopic approaches that were introduced basically in the 90's, have permitted performing surgical techniques with a low morbidity and a shorter recovery time. Laparoscopic retroperitoneal lymphadenopathy is one such technique. According to the experience of several groups, this technique has an acceptable operating time (approximately 5 hours), low complication rate and short hospital stay (2-5 days according to the different series). For those with experience in performing the laparoscopic approach, it is a therapeutic alternative that should be considered for this type of testicular tumor.

[Testicular microlithiasis: diagnosis associated with orchialgia]. / Microlitiasis testicular: diagnóstico asociado a orquialgia.

OBJECTIVES: To analyze the possible association between orchidalgia and testicular microlithiasis and to determine if this condition has a negative effect on fertility. METHODS: Two male patients with similar findings of microlithiasis on the testicular ultrasound were studied. One patient had a history of thalassemia and the other patient had intermittent episodes of testicular torsion. A histological study was performed in both patients. RESULTS: The testicular pain remitted spontaneously in the first case and after orchidopexy in the other patient. Biopsy disclosed a diminished spermatogenesis and no anomaly, respectively. CONCLUSION: Our findings and the reports published in the literature indicate that testicular microlithiasis cannot be considered to be an etiological factor in orchidalgia or infertility.

[Simplified Ramírez urethropexy in the treatment of genuine stress urinary incontinence in women. Multicenter study of clinical and urodynamic results]. / Uretropexia simplificada de Ramírez en el tratamiento de la incontinencia urinaria de esfuerzo genuina en la mujer. Estudio multicéntrico sobre los resultados clínicos y urodinámicos.

OBJECTIVES: To evaluate the clinical and urodynamic data of a multicenter study on female urinary stress incontinence undergoing surgical repair with the Ramírez simplified urethropexy. METHODS: Clinical, urodynamic and videocystographic data were analyzed in a multicenter series of 340 female patients with urinary stress incontinence (mean age 51.7 +/- 9.7 years) before and after the Ramírez urethropexy technique (mean follow-up 21.7 months). RESULTS: Post surgical urinary continence was 78.4%. Cystocele repair was demonstrated in 57.7%. Urge incontinence decreased in 17.1%. Daytime frequency statistically significantly decreased in 19%. Urinary obstructive symptoms increased in 19.3%. Bladder instability significantly decreased posturethropexy. Peak urinary flow rate and mean urinary flow rate diminished in 65% and 59%, respectively. Postvoiding residual urine increased significantly. No statistical correlation between posturethropexy continence and videocystographic bladder neck morphology was observed. CONCLUSIONS: The clinical and urodynamic data obtained in our series indicate that the Ramírez urethropexy technique, a simple and fast procedure, may be considered an alternative treatment in female urinary stress incontinence.

[New perspectives in the preservation of kidney grafts]. / Nuevas perspectivas en la preservación de injertos renales.

OBJECTIVES: Graft preservation, together with overcoming the immunological barrier responsible for graft rejection, are the most important problems of organ transplantation. The different solutions to the foregoing problems are briefly analyzed. METHODS/RESULTS: The literature on graft rejection and preservation is briefly reviewed, highlighting the most outstanding developments. The availability of cyclosporine in the early eighties significantly enhanced the results of immunosuppression and made it less aggressive for graft recipients. The use of liquids for hypothermic preservation of the donor organ, with the advantages and disadvantages it entailed, was a major advancement in cold ischemia. Different solutions (Eurocollins, Wisconsin, HTK) were developed to reduce metabolic derangements from the time the organ was harvested until it was transplanted, with the aim of permitting immediate graft function in order to reduce the incidence of acute tubular necrosis. Further insight into the histological lesions caused by ischemia, the endothelial lesion and its role in tubular dysfunction have led different groups to use pulsatile perfusion once again, particularly since non-heartbeating donor programs were developed. CONCLUSIONS: Although the advancements in the preservation of renal grafts have permitted extending the cold ischemia time beyond 24 hours, the incidence of tubular necrosis continues to be significant. The foregoing, together with the development of renal transplant programs for non-hearbeating donor kidneys, have emphasized the need for further knowledge and understanding of graft viability and early function.

[Lymphocele after renal transplantation: therapeutic controversies in the age of laparoscopy]. / Linfocele postrasplante renal: controversias terapéuticas en la era de la laparoscopia.

We present 11 lymphoceles in 180 consecutive kidney transplants (6%). We study the potential etiologic factors, symptoms, diagnostic evaluation and treatment, stressing the role of laparoscopy in management of bulky and loculated symptomatic lymphoceles. This technique allows to reduce morbidity, increasing efficacy and shortening hospitalization.

[Laparoscopic bilateral nephrectomy of native kidney in kidney transplantation carriers]. / Nefrectomía bilateral laparoscópica de riñones nativos en trasplantado renal.

Severe vesicouretheral reflux sometimes causes terminal renal failure which then requires renal transplantation. In these patients it may be necessary to perform bilateral nephrectomy when associated to serious hypertension or urinary infections with a significant clinical impact. This paper presents the clinical picture of a patient with a corpse renal transplantation, due to terminal renal failure secondary to reflex nephropathy, in whom it was necessary to perform bilateral nephrectomy due to the uncommon urinary infections requiring hospitalization for treatment. The bilateral nephrectomy was done through transperitoneal laparoscopic approach, using seven points for trocars introduction. The procedure lasted 4 hours and the patients was discharged within 48 hours with no complications. Accumulate experience in the use of laparoscopy in urology has allowed this technique to be feasible. After designing the experimental model, our group has had the chance to accomplish laparoscopic nephrectomies in humans. We believe that this is the first case of bilateral nephrectomy conducted in our country using the laparoscopic approach.

[Malignant neoplasms in kidney transplant recipients]. / Neoplasias malignas en receptores de un trasplante renal.

OBJECTIVES: This study is a retrospective analysis of malignant tumors in renal transplant recipients. A review of the pertinent literature allowed us to develop a protocol for early diagnosis and treatment of tumors arising in this group of patients. METHOD: 171 renal transplants have been performed over a period of 4 years. The renal grafts had been harvested from cadavers (mean age 32.01 years). All recipients (mean age 44.3 years) were immunosuppressed with prednisone, azathioprine and cyclosporine A. RESULTS: Five "de novo" malignant tumors were detected in 4 patients (2.3%). The tumors were basal cell epithelioma of scalp and gastric adenocarcinoma in the same patient, lymphoma of the CNS, carcinoma of the breast and adenocarcinoma of the colon. The patient with a gastric adenocarcinoma died after a disease-free interval of 28 months, following treatment of the cutaneous lesion. The patient with lymphoma of the CNS had died before receiving treatment and the remaining 2 patients are disease-free at 12 and 6 months' follow-up. CONCLUSIONS: The possible role of viruses is underscored. Transplant recipients should be followed very closely since they are likely to develop a tumor, especially of skin and lips. The importance of gynecological and neurological assessment and control of native kidneys cannot be overemphasized. Performing an autopsy on donors can reduce the risk of transplanting tumors. Kidney transplantation should be delayed if the graft recipient has a tumor. Correct diagnosis and treatment will enhance the results in these patients.

[Spontaneous bladder rupture with no apparent reason, a peculiar clinical occurrence]. / Rotura vesical espontánea sin causa aparente, una presentación clínica particular.

OBJECTIVES: Herein we describe a case of spontaneous rupture of the bladder presenting with uncommon clinical features that led to difficulty in making the diagnosis. The literature on similar cases in briefly reviewed. METHODS/RESULTS: A case of rupture of the bladder arising from no apparent cause is described. Oliguria and abdominal pain were the presenting features and analysis disclosed renal failure. CONCLUSIONS: Rupture of the bladder may cause acute renal failure and acute abdomen and should therefore be included in the diagnostic algorithms of both disease entities.

[Hemangioma of the adrenal gland]. / Hemangioma de la glándula suprarrenal.

Adrenal gland haemangioma is an uncommon tumour which finding usually occurs by chance. This paper presents one case of cavernous haemangioma in this location on which surgery was performed successfully. The basic aspects of the case are revised from a pathohistological and diagnostic point of view intended to attempt to suspect its presence preoperatively.

[Subcapsular renal hematoma following shock wave lithotripsy]. / Hematomas renales subcapsulares tras litofragmentación por ondas de choque.

OBJECTIVES: The present study analyzed the incidence of subcapsular hematoma of the kidney (SH) following extracorporeal shock wave lithotripsy (ESWL), its management and the possible risk factors that influence the development of this condition. METHODS: We received the records of 1600 patients submitted to 2250 ESWL sessions. SH was evaluated according to the following parameters: clinical features, diagnostic methods, management, follow up and the patient -and ESWL- related factors that influence the development of this condition. RESULTS: Five cases of SH were found (0.22% incidence), which had been diagnosed by ultrasound (US). Eighty per cent had sustained lumbar pain and a fall in hemoglobin values. The patients were managed conservatively and US follow up evaluation was done. At six months, resolution was almost complete with no sequelae. No patient had any of the risk factors described in the literature (hypertension, concomitant urinary tract infection or coagulation disorders) or changes in the ESWL unit standards. CONCLUSIONS: Although SH following ESWL is uncommon, sustained lumbar pain and a fall in hemoglobin values are risk factors that should be taken into account and corroboration and follow up by US should be done. Unless complications present, the patients should be managed conservatively.

[The use of kidney grafts++ from donors of the same age or below 3 years (weight equal or below 15 Kg)]. / Utilización de injertos renales de donantes de edad igual o inferior a 3 años (peso inferior o igual a 15 kgrs).

Over the last few years an impasse has been seen in the number of donors for organ transplantation. This has prompted a re-statement on the use of a group of grafts which, historically, were considered suboptimal: those from donors aged 3 years or under (weight less than or equal to 15 kg). 124 transplantations from corpse donors performed in adults over a 36 months period (Jun 90/July 93) were revised. 24 grafts (19.3%) from donors aged 3 years or under were used. Thirteen (54%) of these grafts were from donors aged 24 months or under, and six (27%) from donors aged 12 months or under. A comparative analysis is made on the clinical and functional evolution of these grafts, as well as their current survival status versus those from donors aged between 3 and 60 years (n = 86, 69.3%). Transplants made with grafts from donors older than 60 years (n = 14, 11.2%) were excluded from the analysis. Our results suggest that use of kidneys from donors aged 3 years or under--weight less than or equal to 15 kg--, implanted as units is acceptable when compared to grafts from older donors. Considering the current impasse in donations for organ transplantation we believe use of this type of donors, as a useful source of grafts, should be advocated.

[Functional and economic impact of the use of Wisconsin University conservation solution versus Eurocollins in relation to the period of cold ischemia in renal transplantation of cadaveric donor]. / Impacto funcional y económico de la utilización de la solución de conservación de la Universidad de Wisconsis frente Eurocollins en relación al tiempo de isquemia fría en trasplante renal de donante cadáver.

Comparison of the effect of the Wisconsin University (WU) conservation solution in the graft's functional evolution and survival, and its cost-benefit relationship versus the Eurocollins (EC) solution with regard to cold ischaemia duration in a series of 142 consecutive adults renal transplantations from corpse donor, removed with beating heart. Of 142 kidneys, 92 (64.7%) were kept in WU and 50 (35.2%) in EC. Of the WU group, 62 (67.3%) kidneys were transplanted after a cold ischaemia of under 24 hours and 30 (32.6%) after cold ischaemia of more than 24 hours. In the EC group, 23 (46%) were kept in cold ischaemia for an interval shorter than or equal to 24 hours and 27 (54%) for more than 24 hours. Incidence of initial graft dysfunction (IGD) was greater in the EC groups (65% and 78%) versus the WU groups (39% and 50%), the difference being statistically significant (p). The graft function, as indicated by the creatinine levels was always better in the WU groups. There was a decreased need for complementary dialysis sessions, less days of oliguria and shorter hospitalization in the WU groups (p). There were no significant differences in the four series with regard to rejection episodes, cyclosporin-related nephrotoxicity, and vascular and urinary tract complications. All of which turn cost-effective the higher cost per litre of the WU versus the EC solution. Graft survival at 12 and 24 months was also significantly (p) higher for grafts kept in WU. This paper presents the results obtained in the analysis of our transplanted patients. In our experience, the WU solution allows better conservation of renal grafts, with less IGD and better graft survival at 12 and 24 months. These results turn cost-effective the higher cost per litre of the WU versus the EC solution.

[Retroperitoneal laparoscopic nephrectomy: a case report]. / Nefrectomía laparoscópica por vía retroperitoneal: caso report.

Presentation of the first exclusively retroperitoneal laparoscopic nephrectomy performed on a female patient diagnosed with chronic pyelonephritis in the right kidney who referred frequent discomfort in the ipsilateral lumbar fossa as well as sporadic urinary infections. The entire procedure was performed without entering the peritoneal cavity, creating a space in the retroperitoneum, using for that hydrostatic dilation following Gaur's recommendations and introducing in that space a total of 4 trocars. Surgery lasted 3 hours an 35 minutes, with a post-operative stay of 3 days; the anaesthetics used after surgery was minimum and patient's return to her usual daily activities was almost immediate after discharge. Considering our group's previous experience in laparoscopic nephrectomies, both in humans (another 3 cases) and experimental surgery (18 pigs), we believe retroperitoneal approach is a huge step ahead in urological laparoscopic surgery, since this is the typical approach in our specialty and allows a closer contact with the condition being treated. On the other hand, the combined retro- and transperitoneal accesses will involve-are already involving-a greater variety of laparoscopic techniques in urology.