Obesity in percutaneous nephrolithotomy. Is body mass index really important?

OBJECTIVE: To evaluate the influence of obesity in the results of percutaneous nephrolithotomy (PCNL) in terms of efficacy and safety and to evaluate other aspects such as fluoroscopy time, radiation exposure, total operative time, hemoglobin loss, hospital stay, and the need of auxiliary procedures. MATERIALS AND METHODS: We evaluated prospectively all the PCNLs performed at our institution between 2011 and 2012. A series of perioperative and postoperative details were recorded in our database. The patients were distributed in 4 groups using World Health Organization's classification of body mass index (BMI): normal weight, ≤ 25 kg/m(2); overweight, 25-29.9 kg/m(2); obese, 30-39.9 kg/m(2); and morbidly obese, ≥ 40 kg/m(2). Modified Clavien classification was used for reporting the complications. Results were compared between the groups using the chi square and multivariate logistic regression tests. RESULTS: A total of 255 procedures were performed between January 2011 and December 2012. Overall stone clearance was 76.3% and complication rate using the modified Clavien grading system was 31.4%. No statistical differences in terms of complication rate and stone free rate were noted between the 4 groups. Total operative time and radiation doses increase along with BMI. No difference was found in fluoroscopy time, failure to gain access, hospital stay, or need for auxiliary procedures. CONCLUSION: Obesity does not increase complications in PCNL, and the efficacy of the technique is similar to normal weight patients with appropriate expertise. Total operative time and radiation exposure increase along with BMI, putting patients at risk.

Effects of testosterone treatment on body composition in males with testosterone deficiency syndrome.

OBJECTIVE: We evaluated the safety of testosterone treatment and its efficacy on body composition in males with testosterone deficiency syndrome (TDS) over 24 months. METHODS: 50 males aged 50-65 years with TDS (Aging Males Symptoms Scale [AMS] > 26 and calculated free testosterone [cFT] 250 pmol/l) were administered 50 mg testosterone gel daily for one year. During the second year, patients received 1000 mg of testosterone undecanoate every 2-3 months. Outcome measures were clinical chemistry values and total testosterone; sex hormone-binding globulin and cFT, changes in AMS and International Prostate Symptom Score; and changes in body composition measured by dual-energy-x-ray absorptiometry. RESULTS: There were no clinically significant changes in clinical chemistry safety parameters. There were significant improvements in both total and cFT and in AMS scores after three months (p < 0.001). Lean mass increased 2.35% at 12 months and 4.5% at 24 months, but proportionally more muscle mass was gained in arms and legs than in the trunk. Fat mass decreased 4.2% at 12 months and 9.1% at 24 months. CONCLUSIONS: Testosterone treatment in males with TDS leads to body changes affecting lean and fat mass with significant improvement in AMS scores, and has an excellent safety profile.

Estudio de la eficacia y preferencia de los pacientes con disfunción eréctil grave después de tomar los 3 inhibidores de la fosfodiesterasa 5 / Study of the efficacy and preferences among severe erectile dysfunction patients after taking 3 phosphodiesterase 5 inhibitors

Objetivo: Evaluar la eficacia de sildenafilo (100 mg), vardenafilo (20 mg) y tadalafilo (20 mg) en el tratamiento de la disfunción eréctil grave. Evaluar la preferencia de los pacientes después de tomar los 3 fármacos. Material y metodos: Los pacientes tomaron de forma secuencial sildenafilo (100 mg), vardenafilo (20 mg) y tadalafilo (20 mg) al menos 4 veces cada uno durante 30-45 días con un período de lavado entre un fármaco y otro de 7 días. En total, se incluyó a 151 pacientes para obtener una muestra válida de 108 casos (18 por cada grupo de aleatorización, 6 grupos en total). Los pacientes incluidos tenían disfunción eréctil grave. Resultados: Las puntuaciones del índice internacional de función eréctil mejoraron con respecto a las basales, y estas fueron estadísticamente significativas en todos los casos (P < 0,0001). Cuando se compararon las puntuaciones del índice internacional de función eréctil, el Erectile Dysfunction Inventory of Treatment Satisfaction, versión paciente, Erectile Dysfunction Inventory of Treatment Satisfaction, versión pareja y Sexual Encounter Profile (SEP) mediante el test no paramétrico para medidas relacionadas de Friedman, se observaron diferencias estadísticamente significativas en todos ellos menos en SEP-2 y SEP-3. Cuando se compararon entre ellos mediante el test de Wilcoxon, encontramos diferencias estadísticamente significativas en el índice internacional de función eréctil entre tadalafilo y sildenafilo (P < 0,003) y entre tadalafilo y vardenafilo (P < 0,001). También las encontramos en el Erectile Dysfunction Inventory of Treatment Satisfaction, versión pareja entre sildenafilo y vardenafilo (P < 0,013). En todos los otros casos, excepto en el SEP-2 y SEP-3, las diferencias entre tadalafilo y los otros 2 fármacos fue muy cercana a la significancia. No hubo ninguna diferencia entre sildenafilo y vardenafilo. Cuando se evaluó la preferencia por un fármaco u otro, 20 eligieron sildenafilo (18,5%), 19 vardenafilo (17,8%), 43 tadalafilo (39,8%) y 22 no eligieron ninguno por falta de eficacia (24,05%). Conclusiones: Las diferencias estadísticamente significativas observadas cuando se compararon los diferentes cuestionarios utilizados llevan a creer que aparte de la preferencia subjetiva de los pacientes per se, su preferencia se basa también en la respuesta superior a un fármaco en comparación con los otros (AU)

Objective: To evaluate the efficacy of sildenafil (100 mg), vardenafil (20 mg) and tadalafil (20mg) in the treatment of severe erectile dysfunction and to evaluate their preferences after having taken all three drugs. Material and methods: The patients took sildenafil (100 mg), vardenafil (20 mg) and tadalafil (20 mg) sequentially at least four times each over 30-45 days with a wash-out period of 7 days between one drug and the next. In total, 151 patients were included to obtain a valid sample of 108 cases (18 for each randomization group, six groups in total). The included patients had severe erectile dysfunction. Results: The IIEF scores improved compared to baseline values, these improvements being statistically significant in all cases (P<0.0001). When the scores on the IIEF, EDITS patient version, EDITS partner version and SEP using Friedman's non-parametric test for related measures were compared, statistically significant differences were observed in all of them except SEP-2 and SEP-3. When compared with each other using Wilcoxon's test, we found statistically significant differences in the IIEF between tadalafil and sildenafil (P<0.003) and between tadalafil and vardenafil (P<0.001). We also found these in the EDITS partner version between sildenafil and vardenafil (P<0.013). In the other cases except SEP-2 and SEP-3, the differences between tadalafil and the other two drugs were very close to significance. There was no difference between sildenafil and vardenafil. As for their preference for one drug over the others, 20 chose sildenafil (18.5%), 19 vardenafil (17.8%), 43 tadalafil (39.8%) and 22 did not choose any due to lack of efficacy (24.05%). Conclusions: The statistically significant differences observed when comparing the different questionnaires used lead to the belief that, apart from the subjective preference of patients per se, their preference is also based on a greater response to one drug in comparison with the others (AU)

Key areas in the learning curve for robotic urological surgery: a Spanish multicentre survey.

BACKGROUND: The number of robotic-assisted procedures offered in Spain is rapidly increasing despite a lack of consensus criteria for training and credentialling. OBJECTIVE: This national multicentre study was designed to analyze the different areas of the robotic urological surgery learning curve. MATERIAL AND METHODS: A questionnaire was sent to all 13 urology units in Spain with an active robotics programme requesting information on training and problems encountered. RESULTS: In most centres (n = 11, 84.6%), training programmes were animal-based; cadavers were used at only 2 (15.4%). Proctoring in initial procedures was practiced by 12 groups (92.3%). When initiating the robotics programme, the console was shared at 8 units (61.5%). Prior experience in open and/or laparoscopic surgery was reported by 10 of the groups (76.9%), and experience in open surgery only by 2 (15.4%) or robotic surgery alone by 1 (7.7%). The procedure with which the robotics programme was started in all 13 participating units was radical prostatectomy. The number of cases needed to complete the learning curve for this procedure was 20-25 cases according to 8 (61.5%) surgery teams. CONCLUSIONS: Up until March 26, 2010, 1,692 operations, mostly radical prostatectomies, were conducted using the da Vinci robot in our country.

Gangrena de Fournier: Estudio retrospectivo de 41 casos / Fournier gangrene. A retrospective study of 41 cases

Introducción La gangrena de Fournier es una fascitis necrotizante con diseminación rápidamente progresiva que afecta la región perineal y genital. A pesar de los avances terapéuticos, puede relacionarse a un alto índice de mortalidad. El objetivo este estudio es analizar la epidemiología y la morbimortalidad de la gangrena de Fournier en nuestro centro en los últimos años. Material y Métodos Estudio retrospectivo de 41 pacientes con diagnóstico de gangrena de Fournier tratados entre los años 1998–2007. Se analizaron datos correspondientes a edad, sexo, comorbilidad, origen, extensión, evolución, estudio microbiológico, aspectos quirúrgicos, tratamiento antibiótico y mortalidad. Resultados De los 41 pacientes tratados en este periodo, el 93% fueron hombres, con edad media de 60 años. La diabetes fue el antecedente patológico más común (49%) seguido del alcoholismo (46%) y la inmunosupresión o neoplasia (34%). El origen fue perianal en el 66% de los casos, seguido del urológico (32%). El tiempo de evolución antes del diagnóstico fue 3 días (mediana). El 49% precisaron varias revisiones quirúrgicas, y la mortalidad fue del 29%. La mayoría (93%) de los cultivos fueron positivos, y en el 76% de los casos se aisló más de un microorganismo (los más frecuentemente aislados fueron enterobacterias y anaerobios). En el análisis univariado, el tratamiento antibiótico con carbapenémicos y la ausencia de complicaciones sistémicas se asociaron a menor mortalidad. Conclusiones La gangrena de Fournier sigue siendo una patología grave con una mortalidad elevada. El diagnóstico precoz y tratamiento quirúrgico y antibioterápico agresivos son necesarios para su adecuado tratamiento (AU)

Methods Retrospective study of 41 patients treated for Fournier′s gangrene between 1998 and 2007. Variables studied included, demographic variables, aetiology, microbiology, surgical and antibiotic treatment, morbidity, and mortality. Results The mean age of the patients was 60, and 93% were male. The most common co-morbidity was diabetes (49%), followed by alcoholism (46%) and immunosuppression or neoplasia (34%). The origin was perianal in 66% of cases, followed by a urological origin (32%). The median time from the onset of symptoms to diagnosis was 3 days. Several surgical debridements were required in 49% of the patients, and the mortality rate was 29%. Most cases had positive cultures (93%), and in 76% more than one microorganism was isolated (enterobacteriaceae and anaerobic flora). In the bivariate analysis, antimicrobial treatment with carbapenems and the absence of systemic complications were associated with lower mortality (AU)

[Fournier gangrene. A retrospective study of 41 cases]. / Gangrena de Fournier: Estudio retrospectivo de 41 casos.

INTRODUCTION: Fournier's gangrene is a rapidly progressing necrotizing fascitis that affects the perineal and genital area. Mortality still remains high. The aim of this study was to evaluate the epidemiological progression and morbidity-mortality of Fournier's gangrene at our centre over the past 10 years. METHODS: Retrospective study of 41 patients treated for Fournier's gangrene between 1998 and 2007. Variables studied included, demographic variables, aetiology, microbiology, surgical and antibiotic treatment, morbidity, and mortality. RESULTS: The mean age of the patients was 60, and 93% were male. The most common co-morbidity was diabetes (49%), followed by alcoholism (46%) and immunosuppression or neoplasia (34%). The origin was perianal in 66% of cases, followed by a urological origin (32%). The median time from the onset of symptoms to diagnosis was 3 days. Several surgical debridements were required in 49% of the patients, and the mortality rate was 29%. Most cases had positive cultures (93%), and in 76% more than one microorganism was isolated (enterobacteriaceae and anaerobic flora). In the bivariate analysis, antimicrobial treatment with carbapenems and the absence of systemic complications were associated with lower mortality. CONCLUSIONS: Fournier's gangrene continues to be a severe surgical emergency, with a high mortality rate. Early diagnosis and aggressive surgical and antibiotic therapy are necessary for adequate management.

Metodología diagnóstica ante la recidiva bioquímica después de braquiterapia / Diagnostic methodology for the biochemical recurrence of prostate cancer after brachytherapy

En la actualidad el cáncer de próstata es la neoplasia no cutánea más frecuente entre los hombres en USA, ocupando en nuestro país la segunda posición tras el cáncer de pulmón. En los últimos años se ha modificado el perfil del cáncer de próstata diagnosticado debido a la amplia difusión de la determinación del PSA. En la actualidad aproximadamente el 47% de los cánceres de próstata que se diagnostican son de bajo riesgo. En esta situación terapias mínimamente invasivas como la braquiterapia cada vez tienen una mayor aceptación en nuestro medio. Se analiza la especial cinética del PSA tras la braquiterapia y la dificultad que entraña el diagnóstico de la recidiva bioquímica tras braquiterapia realizando una revisión de la evidencia científica disponible en la literatura

Currently prostate cancer is the most frequent extracutaneous neoplasia in males in the USA, and second after lung cancer in our country. Over the last years the profile of prostate cancers diagnosed has changed due to the wide diffusion of PSA determination. Currently, almost 47% of prostate cancers are low risk at diagnosis. In this situation, the minimally invasive therapies such as brachytherapy have a growing acceptance in our environment. We analyze the special PSA kinetics after brachytherapy, and the difficulty entailed by the diagnosis of biochemical recurrence after brachytherapy, performing a bibliographic review of the available scientific evidence

Hernia vesical masiva / Massive bladder hernia

OBJETIVO: Presentamos el caso de una herniavesical masiva en bolsa escrotal que había condicionadola migración de prácticamente la globalidad de la vejiga.MÉTODOS Y RESULTADOS: Varón de 65 años en estudio por HBP que presenta una tumoración en bolsa escrotal, que resultó ser una hernia vesical masiva en bolsa escrotal derecha, del tipo paraperitoneal y acompañada de hernia inguinal, que fue tratada con resección de la porción herniadade la vejiga y corrección de la hernia inguinal con malla de Marlex. En un segundo tiempo se realizó RTU de próstata. Controlado a los seis meses el paciente está asintomático.CONCLUSIONES: La hernia vesical es una patología poco frecuente, que en la mayoría de los casos supone un mero hallazgo preoperatorio en el contexto de la reparaciónde una hernia inguinal. Puede ser del tipo intraperitoneal,extraperitoneal o paraperitoneal. Su diagnóstico es clínico y su confirmación puede ser por cistografía retrógrada,ecografía o TAC. El tratamiento es quirúrgico, ya sea mediante la reducción simple o con resección de la porción herniada

OBJECTIVES: We report a case of a huge bladder hernia conditioning the migration of almost all the bladder into the scrotum. ;;METHODS AND RESULTS: 65-year-old male being studied for BPH who presents a scrotal tumor, which turned out to be a huge inguinal bladder hernia in scrotum, paraperitoneal, accompanied by an inguinal hernia. The treatment consisted in bladder resection and repair of the inguinal hernia with a marlex mesh. Later on, a TURP was done. At a six month control, the patient was non-asymptomatic. ;;CONSLUSIONS: Bladder hernia is an uncommon pathology, and in most of the cases it is an incidental finding during the repair of an inguinal hernia. It can be intraperitoneal, extraperitoneal or paraperitoneal. The diagnosis is clinical, but comfirmation can be done by retrograde cystoghraphy, ultrasonography or CT. The treatment is surgical, repairing the herniation or adding the resection of the bladder herniation

[Massive bladder hernia]. / Hernia vesical masiva.

OBJECTIVES: We report a case of a huge bladder hernia conditioning the migration of almost all the bladder into the scrotum. METHODS AND RESULTS: 65-year-old male being studied for BPH who presents a scrotal tumor, which turned out to be a huge inguinal bladder hernia in scrotum, paraperitoneal, accompanied by an inguinal hernia. The treatment consisted in bladder resection and repair of the inguinal hernia with a marlex mesh. Later on, a TURP was done. At a six month control, the patient was non-asymptomatic. CONCLUSIONS: Bladder hernia is an uncommon pathology, and in most of the cases it is an incidental finding during the repair of an inguinal hernia. It can be intraperitoneal, extraperitoneal or paraperitoneal. The diagnosis is clinical, but comfirmation can be done by retrograde cystoghraphy, ultrasonography or CT The treatment is surgical, repairing the herniation or adding the resection of the bladder herniation.

[Surgical treatment of the congenital curvature of the penis by the Nesbit technique]. / Tratamiento quirúrgico de la incurvación congénita de pene mediante la técnica de Nesbit.

OBJECTIVES: To evaluate the results of the Nesbit technique in patients with congenital penile curvature. METHODS: From January 1990 to July 2002, 19 patients with congenital penile curvature were treated following the Nesbit technique. Mean age was 25.89 (range 19-37), and the most common curvature was ventral (73.68%). RESULTS: Complete correction was achieved in 18 patients (94.73%), and 17 patients reported a high degree of satisfaction (89.47%). CONCLUSIONS: The Nesbit technique is an easy and safe procedure for the correction of congenital penile incurvation.