Positive margins after partial nephrectomy in renal cell carcinoma: Oncological outcomes of conservative management after long-term follow-up. / Márgenes positivos tras nefrectomía parcial en carcinoma de células renales: seguimiento a largo plazo y resultados oncológicos con manejo conservador.

INTRODUCTION: Partial nephrectomy (PN) is the standard treatment for small and localized kidney tumours (cT1). One of the controversial aspects regarding this technique is the management of affected/positive resection margins. We present the long-term oncological results in patients with PSM after PN managed conservatively. MATERIAL AND METHODS: There were 207 PN performed in our centre between 1990 and 2011. 17 patients presented PSM. 2 patients were excluded from the study due to completion nephrectomy afterwards. Follow-up was was done with abdominal contrast-enhanced computed tomography every 6 months for the first 2 years and subsequently, once a year. Cancer-specific survival and disease-free survival were calculated with the Kaplan-Meier method. RESULTS: The median age was 62 years (RIQ: 55-71) and the mean tumour size was 34.8 (10-77) mm. Histopathological results were: 6 (40%) clear cell RCC, 4 (26.7%) papillary, 3 (20%) chromophobe and 2 (13.3%) oncocytic. The pathologic stages were: 11 (73.3%) pT1a, 1 (6.7%) pT1b and 3 (20%) pT3a. The median follow-up was 84 months (IQR 72-120). 2 patients had metastatic recurrence and this was the cause of death. The first one had recurrence at 112 months and the second one at 59. 5-year CSS and RFS were 87.5% and 93.3% respectively. CONCLUSIONS: In our experience, patients with PSM after PN can be managed conservatively with satisfactory long-term oncological outcomes.

[Renal pseudotumor secondary to acute pancreatitis. Report of one case]. / Pseudotumor renal secundario a pancreatitis aguda. A propósito de un caso.

We present the case of a renal pseudotumor corresponding to a esteatonecrotic granuloma, secondary to an enolic acute pancreatitis a few months ago. The main caractheristics, diagnosis and terapeuthics of the renal pseudotumors are discussed with the case report of a 60 year old man who presents a renal mass founded incidentally at a control computed tomography.

Pseudotumor renal secundario a pancreatitis aguda. A propósito de un caso / Renal pseudotumor secondary to acute pancreatiti. A case report

Se presenta el caso de un pseudotumor renal correspondiente a un granuloma este atonecrótico, secundario a una pancreatitis aguda enólica en los meses previos. Las características de los pseudotumores renales, su diagnóstico y la actitud terapéutica son discutidos con el caso de un varón de 60 años que presenta una masa renal hallada incidentalmente en una tomografia computerizada abdominal (AU)

We present the case of a renal pseudotumor corresponding to a esteatonecrotic granuloma, secondary to an enolic acute pancreatitis a few months ago. The main caractheristics, diagnosis and terapeuthics of the renal pseudotumors are discussed with the case report of a 60 year old man who presents a renal mass founded incidentally at a control computed tomography (AU)

Patologia vásculo-renal / Renovascular diseases

Como órgano apo-exocrino, el riñón cumple con dos importantes funciones: el control de la homeostasis y de la presión arterial. Cualquier patología que altere el flujo sanguíneo del riñón tendrá dos efectos inmediatos: la hipertensión arterial (HA) y la insuficiencia renal (IR). Su corrección debe buscar prioritariamente la mejoría de la función renal ya que la respuesta de la HA vendrá por añadidura. El Objetivo de este trabajo es el de actualizar la sofisticada metodología diagnóstica (Angiografía, EcoDoppler, Angio-Tac, Angio-Resonancia y Angioscopia; el uso de contrastes de potenciación), de funcionalidad (Radionefrograma o RMN con Captopril) y terapéutica (Angioplastia transluminal percutánea, Stents simples o cubiertos, Embolizaciones, uso de Balones oclusivos, Fibrinolisis y Tromboaspiración, Cirugía arterial directa y Autotrasplantación renal), en y de las distintas patologías vasculares renales (Lesiones traumáticas vasculares, Estenosis, Aneurismas, Fístulas arteriovenosas, Oclusiones agudas o Trombosis arterial y venosa, Síndrome de Cascanueces). Se apunta y se discute la posibilidad de existir un Síndrome de Fraley venoso inverso a raíz de un caso clínico. Conclusiones. Se establece una controversia de las tecnologías punta más actuales estableciéndose unas líneas guía de actuación para cada situación patológica. (AU)

[Vasculo-renal disease]. / Patologia vásculo-renal.

UNLABELLED: The kidney as an apo-exocrine organ has two important functions: the control of homeostasis and arterial blood pressure. Any pathological disorders witch alters the renal blood flow results in two consequences: renovascular hypertension and renal insufficiency. Renal revascularization looks for with priority the improvement of renal function; the good response and control of hypertension shall come after. The goals of this paper is to actualize the sophisticated diagnostic methods (Angiography, Eco-Doppler, AngioCT, AngioMR, Angioscopy; and the use of contrast potential-mediums), functionality tests (RN and MR with Captopril) and management (Percutaneous transluminal angioplasty, simple or covered Stents, Embolizations, Occlusive balloons, Fibrinolysis and Trombus Aspiration; direct Arterial Surgery and renal Autotransplantation) of different renovascular diseases. (Blunt renal injuries, Stenosis, Aneurysms. A-V fistuls, Acute Occlusions or arterial and venous, Thrombosis. Nutcraker Syndrome). The possibility of the presence of an inverse venous Fraley's Syndrome is presented and discussed. CONCLUSIONS: A controversy of the last technical methods are established and discussed and a Guideline is recommended for each renal vascular disease.

[Partial nephrectomy in renal cell carcinoma]. / Nefrectomía parcial en el carcinoma de células renales.

INTRODUCTION AND OBJECTIVES: Renal Cell Carcinoma (RCC) represents 3% of all neoplasm. The growing incidental diagnosis of small renal tumor has allowed the application of nephron sparing surgery (NSS), even in those cases with a normal contralateral kidney. We present the results of NSS at our center in the last decade. MATERIAL AND METHODS: A retrospective analysis of all NSS that were made at our center in cases of renal masses. Difference is made between elective surgery (tumors less than 4 cm with a normal contralateral kidney) and obligatory surgery (all other cases). RESULTS: From 1990 since 2000 a total of 65 NSS were made from a total of 436 surgeries for renal tumors (14.9%). In 22 patients NSS was obligatory, while in 43 was elective. Mean (SD) age was 59.1 years (+/- 11.7), mean tumor size 3.4 cm (+/- 1.4), mean hospital staying was 9.2 days (+/- 7). Renal normothermic ischaemia was use during surgery in all cases, with a mean ischaemic time of 25.7 min. Nine tumors (13.8%) were benign. Morbidity: 10.8%. Mortality: 1.5%. The cancer specific survival at 36 months of follow-up (mean 37.4) is 98.4% and global survival is 90.3%. CONCLUSIONS: Nephron Sparing Surgery is a valid alternative in the treatment of RCC, specially for tumors less than 4 cm in diameter and having a normal contralateral kidney; NSS is also an effective technique for patients bearing renal tumors in a solitary kidney.

[Primary bladder actinomycosis]. / Actinomycosis vesical primaria.

Primary actinomycosis of the bladder is an infrequent presentation of this condition. The main concern is obtaining a differential diagnosis from tumours of the bladder and the subsequent impact this has on the therapeutic choices. Contribution of one case report of a male patient with actinomycosis of the bladder, with remarks on relevant diagnostic (including differential diagnosis) and therapeutic data.

Actinomycosis vesical primaria / Actinomycosis vesical primaria

La actinomicosis vesical primaria constituye una rara forma de presentación de esta enfermedad. Su principal problema radica en la realización del diagnóstico diferencial con procesos tumorales vesicales, con la consiguiente repercusión terapéutica. Presentamos el caso clínico de un paciente afecto de actinomicosis vesical, comentando los datos más relevantes en su diagnóstico (incluyendo el mencionado diagnóstico diferencial) y tratamiento (AU)

[Ambulatory treatment of ureteral lithiasis using shock wave extracorporeal lithotripsy]. / Tratamiento ambulatorio de la litiasis ureteral mediante litotricia extracorpórea por ondas de choque.

Presentation of the results obtained with extracorporeal shock wave lithotripsy (ESWL) applied to 3173 ureteral lithiasis with a Dornier HM-4 equipment. Location of lithiasis was pyeloureteral junction (329), lumbar ureter (1068), sacral ureter (238), iliopelvic ureter (1474) and "lithiasic path" (64). All lithiasis were treated in situ. Treatments were carried out ambulatory with no anaesthesia. Treatment/lithiasis rate was 1.3. Percentage of stone-free patients with ESWL alone was 79.2% after the first session, and reached 86.14% with retreatment. Percentage of success for lithiasis in pyeloureteral junction was 81.8%, 79.7% for lumbar ureter lithiasis, 80.09% sacral lithiasis, 90.10% iliopelvic ureter lithiasis and 79.9% for those in the "lithiasic path". 12.6% lithiasis required post-ESWL auxiliary manoeuvres. Post-ESWL minor complications (pain, vegetations) occurred in 5.6% cases and major complications (obstruction, fever, sepsis) in 2.9%. The factors influencing lithiasis fragmentation were the number of shock waves and the lithiasis duration. Size of lithiasis and presence or absence of ureteral catheter had no influence. These results suggest that ESWL is an effective method for managing ureteral lithiasis.

A good alternative to reduce the kidney shortage: kidneys from nonheartbeating donors.

BACKGROUND: Because of the shortage of kidneys available for transplantation, we began in 1985 to harvest kidneys from non-heartbeating (NHB) donors. METHODS: We compared the results of a group of 66 kidney recipients from NHB donors (NHB group) with 122 kidney recipients from heartbeating donors (HB group). We analyzed, in the NHB group, the influence of ischemia times in graft survival and we tested the best cut-offs by receiver operating characteristic curves. We also studied, using a univariate and multivariate Cox hazard model, the capacity of different variables to predict graft loss. RESULTS: Patient and graft survival were similar in both groups during the follow-up. The percentage of delayed graft function was the only significant difference between both groups (NHB group 62% vs. HB group 32%; P=0.0001). Delayed graft function, in the NHB group, is influenced by the warm ischemia time, which is directly related to the number of days to achieve a serum creatinine<300 mmol/L (P=0.0001). The best cut-off times in this group were 45 min for warm ischemia time and 22 hr for cold ischemia time. Recipients have a greater likelihood of losing the graft beyond those limits (P=0.017, relative risk: 7.3). The incidence of acute rejection was similar in both groups, and it was the only predictor factor of graft loss in the complete series of patients (P=0.0001), in the NHB group (P=0.007), and in the HB group (P=0.02). CONCLUSIONS: Reducing the incidence of acute rejection and shortening ischemia time are conditions needed to guarantee a long graft survival of kidneys from NHB donors.

Double-barreled wet colostomy: a safe and simple method after pelvic exenteration.

UNLABELLED: The clinical and functional outcome of ureteric division to the distal segment of a loop colostomy: the double-barrelled wet colostomy have been analysed. METHODS: 13 patients (8 female and 5 male, age 37 to 72 years) underwent pelvic exenteration with double-barrelled wet colostomy. The primary tumour included endometrial (n = 6), rectal (n = 1), anal (n = 1), cervical (n = 2), prostatic (n = 1) and bladder (n = 2). Indications for pelvic exenteration were locally advanced disease, recurrence and severe radiation or surgical damage. Six patients had pre-existing colostomy, and three had a Bricker ureteroileal diversion. The double-barrelled-wet colostomy technique consisted in anastomosing both ureters to a colon segment 25 cm distal to the loop colostomy. There was no operative mortality. Complications included one urinary leak which closed with conservative management and one case of recurrent episodes of pyelonephritis which finally required nephrectomy. Intravenous urography in the remaining patients showed good flow through the ureters to the conduit with no reflux. Postoperative plasma electrolytes, urea and creatinine were normal from day seven onwards. Urodynamic studies in four patients showed efficient contraction of the colon conduit with pressure levels similar to those in the colon proximal to the colostomy. In five cases biopsies of the conduit were taken at 3 and 16 months; no dysplasias were found. Four patients died due to disease progression. The overall mean survival was 41.2 months. The remainder are currently disease-free, maximum followup period being 19 months. Double-barrelled wet colostomy is a safe and simple technique with low morbidity. The patient needs to carry only one stoma and functional results are good.

[Kidney transplantation with donors in heart block. Long-term results]. / Transplante renal con donantes en parada cardíaca. Resultados a largo plazo.

OBJECTIVES: The shortage of renal grafts has led to the search for other alternatives. The use of grafts from non-heart-beating donors (NHBD) can increase the number of transplants 8% to 20%. Clinical studies conducted by different groups, have found that the long-term graft and patient survival are not different from those of recipients of kidneys from heart-beating donors (HBCD). METHODS/RESULTS: The long-term results of a group of 52 recipients of NHBD kidneys were compared with those of 98 recipients of HBCD grafts. There were no differences in donor and recipient ages, HLA compatibility, reperfusion and cold ischemia times. There were no differences in the incidence of rejection episodes or non-functioning kidneys. Warm ischemia between 30 to 60 min or < 30 min did not influence the incidence of non-functioning kidneys. However, NHBD graft recipients had a higher incidence of acute tubular necrosis (67% versus 46%), recovers of renal function was slower, the duration of oliguria was longer and dialysis was required. The 8-year actuarial survival data were similar for both groups; 65% for the NHBD and 70% for the HBCD graft recipients. CONCLUSIONS: We can conclude that NHBDs are an important source of donor kidneys. The 12 points established by The First International Workshop on Non-Heart-Beating Donors which appear at the end of the present article are embodied in the Treaty of Maastricht regulations of organ transplantation from non-heart-beating donors.

[Conservative treatment in major kidney trauma]. / Tratamiento conservador en traumatismo renal mayor.

The kidney is frequently involved in penetrating abdominal injuries, and less so in closed abdominal traumatism. This paper presents one case of major renal trauma with total renal fracture and development of urinoma that separated both segments that, after a minimally invasive manoeuvre (percutaneous drainage), evolved favourably thus avoiding a surgical procedure which, quite reasonably, would have led to nephrectomy.

[Malignant neoplasms and kidney transplantation]. / Neoplasias malignas y transplante renal.

In 661 renal transplantations, 2 potentially migrated tumours (0.38%), 5 preexisting neoplasias (0.76%), and 31 "de novo" tumours were seen in 29 patients (4.4&). Although of very low incidence, the likelihood of tumour migration from elderly donors, given the circumstances surrounding removal, offers a high risk. None of the preexisting neoplasias relapsed following transplant. The highest prevalence was seen in skin (40%), lung (13%), kidney (13%) and bladder (6.6%) "de novo" tumours. Incidence of lymphoma was low. Dominant etiological factors of the recipient were older age, effective and tolerated immunosuppression, viral infections, environmental agents and antigenic stimulation of the graft. Skin lesions have responded well to local treatment, without need to discontinue immunosuppression, a measure that is mandatory in other malignant tumours. Also, the conclusions of a round table during the 25th National Meeting of Urotransplantation of the Spanish Association of Urology held in 1994 on "Oncology and Renal Transplantation" are presented.

[The nutcracker phenomenon: an infrequent cause of hematuria]. / Fenómeno nutcracker o cascanueces: una infrecuente causa de hematuria.

The nutcracker phenomenon consists in the compression of the left renal vein by the aortomesenteric clamp. This is an infrequent cause of haematuria. The present paper presents one case of nutcracker phenomenon showing haematuria after mild accidental lumbar bruising, with arteriographic diagnosis. CAT assessment showed a mark in the lumbar ureter as well as peripyelic and periureteral varices.

Embolization of non-tolerated non-functioning kidney graft: alternative to surgical removal.

The results of treatment by percutaneous transcatheter embolization in eight cases of non-tolerated non-functioning kidney graft are presented. The symptoms resulting from non-tolerance of the renal graft were fever, pain and haematuria. Embolization was well tolerated in all eight cases and the only adverse effect was post-embolization self-limited fever in five cases. The symptoms of non-tolerance of the graft disappeared immediately in all cases, with minimal morbidity and no mortality. In only one patient was it necessary to perform second embolization procedure to achieve permanent control of symptoms. We conclude that percutaneous embolization of non-tolerated non-functioning kidney graft is an effective procedure with significantly less morbidity than with surgical graft nephrectomy.

[Transplantectomy today: indications and complications]. / La transplantectomía hoy: indicaciones y complicaciones.

Analysis of the indications for transplantectomy and its complications over a 12-year period. Over a total of 159 failure grafts, we performed 53 transplantectomies (33.3%). The percentage of complications was 16.9%. Three patients died (5.6%) during the more or less immediate post-operative period. In our experience, consistent and prolonged maintenance of immunosuppression should avoid the need for transplantectomy in a high percentage of grafts. Only 15 transplantectomies were made on 104 failure grafts after 6 months (14.4%). Our short but successful experience with embolization of 2 rejected grafts confirms the validity of this conservative alternative versus conventional surgical transplantectomy in selected cases.

[Renal angiomyolipoma. Our case histories]. / Angiomiolipoma renal. Nuestra casuística.

We reviewed the cases of angiomyolipoma that had been diagnosed and treated in our urology services from 1978 to 1991. The study showed a higher incidence in the females; it frequently presented as a solitary tumor; a high specificity was found for the US (hyperechoic mass) and CT (areas of low attenuation ratio) findings. Owing to these diagnostic techniques, conventional surgery is no longer the only treatment. Embolization is considered to be the first therapeutic approach.