La importancia de la evidencia y de la adherencia a los protocolos clínicos en bienestar de los pacientes. Caso clínico de morbimortalidad / The importance of timely and safe care. Report of one case

We report a 32-year-old woman with chronic kidney disease on hemodialysis undergoing a nephrectomy for left xanthogranulomatous pyelonephritis with a coralliform calculus and septic shock. Her clinical evolution was torpid, subfebrile, with persistent elevation of inflammatory parameters and with the finding of intra-abdominal collections interpreted as post-surgical. Finally faced with microbiological evidence of infection of the collections, the patient was operated and tended to improve. Subsequently, she underwent a difficult mechanical ventilation weaning, identifying the abrupt discontinuation of benzodiazepines as a contributing factor to agitation. We report this patient for educational purposes and to reinforce some quality-of-care concepts such as safety and opportunity of healthcare.

Bladder squamous cell carcinoma in a pregnant woman: case report and review of the literature.

BACKGROUND: Bladder tumors in pregnancy are extremely rare. No more than 50 cases have been published to date, including all histologic variants, and only three cases of bladder squamous cell carcinoma have been described. CASE PRESENTATION: We present a clinical case of a 31-year-old woman with bladder squamous cell carcinoma in the second trimester of pregnancy. After a C-section at 30 weeks, we performed radical cystectomy with extended bilateral lymphadenectomy, hysterectomy and right oophorectomy. The Studer neobladder technique was performed for urinary tract reconstruction. Definitive pathology showed invasive bladder squamous cell carcinoma, Grade 2, with microscopic infiltration of the perivesical fat, negative margins, and 3/28 lymph nodes with carcinoma (pT3aN2M0). The patient underwent 18 months of surveillance after radical cystectomy, without recurrence by PET-CT. CONCLUSIONS: Bladder cancer in pregnant women is extremely rare but must be considered in those with recurrent gross hematuria and/or recurrent urinary tract infection. To our knowledge, this case involves the longest recurrence-free survival of a pregnant woman with squamous cell bladder cancer published thus far.

[The importance of timely and safe care. Report of one case]. / La importancia de la evidencia y de la adherencia a los protocolos clínicos en bienestar de los pacientes. Caso clínico de morbimortalidad.

We report a 32-year-old woman with chronic kidney disease on hemodialysis undergoing a nephrectomy for left xanthogranulomatous pyelonephritis with a coralliform calculus and septic shock. Her clinical evolution was torpid, subfebrile, with persistent elevation of inflammatory parameters and with the finding of intra-abdominal collections interpreted as post-surgical. Finally faced with microbiological evidence of infection of the collections, the patient was operated and tended to improve. Subsequently, she underwent a difficult mechanical ventilation weaning, identifying the abrupt discontinuation of benzodiazepines as a contributing factor to agitation. We report this patient for educational purposes and to reinforce some quality-of-care concepts such as safety and opportunity of healthcare.

Early ureteroscopic treatment in patients with urosepsis associated with ureteral calculi is a safe approach. A pilot study.

INTRODUCTION: Emergency drainage of the urinary tract is the first necessary approach in patients with urosepsis secondary to obstructive ureteral calculi. The appropriate waiting time before definitive treatment has not been determined. We hypothesized that early ureteroscopic treatment after the patient has been stabilized is as safe as deferred treatment. MATERIAL AND METHODS: A pilot study was developed between November 2013 and September 2017. Patients with urosepsis associated with ureteral calculi were included. All the patients were initially decompressed with a ureteral stent. Patients were randomized to early ureteroscopic treatment (EUT), who received definitive treatment during the initial hospitalization, or deferred ureteroscopic treatment (DUT), that received definitive treatment in a second hospitalization. The stone location and size, sex distribution, age, APACHE II score, length of hospital stay, days with ureteral catheter and complications were registered. Statistical analysis was performed using Stata 12.0. RESULTS: A total of 13 patients were included in the EUT group and 13 in the DUT group. No differences in sex distribution, stone location, APACHE II score, age, stone size and time between admission and urinary drainage were found. Total length of hospital stay and complications were also similar between both groups. A statistically significant difference was found in terms of duration of antibiotic treatment (p = 0.04) and total days with double J catheter (p = 0.0009). CONCLUSIONS: EUT for ureteral stone is as safe as DUT in patients admitted with urosepsis secondary to ureterolithiasis. EUT is associated with a shorter period of ureteral stent and it is not associated with an increase in complications.

Hypothermic machine perfusion versus static cold preservation in kidney transplantation. / Perfusión hipotérmica de máquina versus preservación en frío estático en el trasplante de riñón.

INTRODUCTION: The adequate preservation of the allograft prior to kidney transplant is key for a good outcome after transplantation. Currently, there are two main methods: hypothermic machine perfusion and static cold preservation. The main objective of this summary is to compare both preservation systems. METHODS: We searched in Epistemonikos, the largest database of systematic reviews in health, which is maintained by screening multiple information sources, including MEDLINE, EMBASE, Cochrane, among others. We extracted data from the systematic reviews, reanalyzed data of primary studies, conducted a meta-analysis and generated a summary of findings table using the GRADE approach. RESULTS AND CONCLUSIONS: We identified 10 systematic reviews including 34 primary studies, of which 13 were randomized trials. We concluded preservation by hypothermic machine perfusion probably decreases the risk of delayed graft function and could lead to a slight increase in graft survival. However, there are no differences in patient survival between the two methods.

INTRODUCCIÓN: La adecuada preservación del aloinjerto previo al trasplante renal es crucial para mantener buenos resultados luego del trasplante. En la actualidad existen dos métodos principales, la perfusión hipotérmica asistida por una máquina y la preservación en frío estático. El objetivo principal de este resumen es comparar ambos sistemas de preservación. MÉTODOS: Realizamos una búsqueda en Epistemonikos, la mayor base de datos de revisiones sistemáticas en salud, la cual es mantenida mediante el cribado de múltiples fuentes de información, incluyendo MEDLINE, EMBASE, Cochrane, entre otras. Extrajimos los datos desde las revisiones identificadas, analizamos los datos de los estudios primarios, realizamos un metanálisis y preparamos una tabla de resumen de los resultados utilizando el método GRADE. RESULTADOS Y CONCLUSIONES: Identificamos 10 revisiones sistemáticas que en conjunto incluyeron 34 estudios primarios, de los cuales 13 corresponden a ensayos aleatorizados. Concluimos que la preservación mediante perfusión hipotérmica de máquina probablemente disminuye el riesgo de retraso en el funcionamiento del injerto y podría llevar a un leve aumento en la sobrevida del injerto. Sin embargo, no existen diferencias en la sobrevida del paciente entre ambos métodos.

Bipolar or monopolar transurethral resection for benign prostatic hyperplasia? / ¿Resección transuretral bipolar o monopolar para hiperplasia prostática benigna?

INTRODUCTION: Transurethral resection is currently considered as standard endoscopic treatment for lower urinary tract obstruction due to benign hyperplasia under 80 cc. Monopolar resection loops has been traditionally used but bipolar energy has recently displaced precedent technology. The purpose of this summary is to evaluate the efficacy and safety of both technologies. METHODS: To answer this question we used Epistemonikos, the largest database of systematic reviews in health, which is maintained by screening multiple information sources, including MEDLINE, EMBASE, Cochrane, among others. We extracted data from the systematic reviews, reanalyzed data of primary studies, conducted a meta-analysis and generated a summary of findings table using the GRADE approach. RESULTS AND CONCLUSIONS: We identified 13 systematic reviews including 32 primary studies, among them 31 randomized trials. We concluded although there may be no difference in terms of efficacy among both techniques, the use of bipolar energy reduces the incidence of transurethral resection syndrome and probably reduces the risk of bleeding that requires red blood cell transfusion.

INTRODUCCIÓN: La resección transuretral es el método de elección para la resolución endoscópica de la uropatía obstructiva baja por hiperplasia benigna de la próstata menor a 80cc. Tradicionalmente esta ha sido realizada con asas de resección que utilizan energía monopolar. El uso de energía bipolar ha desplazado la tecnología precedente en el último tiempo. Se dispone a evaluar la eficacia y seguridad de ambas tecnologías para la técnica. MÉTODOS: Para responder esta pregunta utilizamos Epistemonikos, la mayor base de datos de revisiones sistemáticas en salud, la cual es mantenida mediante búsquedas en múltiples fuentes de información, incluyendo MEDLINE, EMBASE, Cochrane, entre otras. Extrajimos los datos desde las revisiones identificadas, reanalizamos los datos de los estudios primarios, realizamos un metanálisis y preparamos tablas de resumen de los resultados utilizando el método GRADE. RESULTADOS Y CONCLUSIONES: Identificamos 13 revisiones sistemáticas que en conjunto incluyen 32 estudios primarios, de los cuales 31 corresponden a ensayos aleatorizados. Concluimos que, si bien podrían no existir diferencias de eficacia entre ambas técnicas, la utilización de energía bipolar disminuye la incidencia de síndrome post resección transuretral y probablemente disminuye el riesgo de sangrado que requiere transfusión.

Labhardt's colpoperineocleisis: subjective results of an alternative treatment for genital prolapse in patients who are not sexually active--2-year follow-up.

INTRODUCTION AND HYPOTHESIS: Genital prolapse affects up to 50 % of multiparous women and has an impact on quality of life (QoL) for many. Vaginal obliterative techniques are relevant in older patients who are not sexually active. We performed Labhardt's colpoperineocleisis in such patients. The objective was the evaluation of subjective outcomes of this technique using PGI-I. METHODS: Retrospective cohort analysis of patients. We performed a bivariate, multivariate analysis, and survival curves for subjective improvement. RESULTS: Seventy-four cases were analyzed. Average age of the patients was 72 years, median parity 4, 95.9 % POP-Q stage III or IV, anterior leading edge defect in 61.1 %. Operating time: 54 min, estimated blood loss 70 ml, no intraoperative complications, 12 patients had protocol deviations with changes in the recommended type of suture. Median hospital stay was 2 days and average follow-up 24.9 months. There was 13.5 % anatomical recurrence, 3 of which (30 %) were in patients with protocol deviations. 1.9 % developed clinically significant de novo stress urinary incontinence (SUI). PGI-I: 64 (86 %) reported subjective improvement and 10 did not. In the subjective improvement group, 98.4 % reported being very much or much better. In the non-subjective improvement group 80 % reported that they were the same as before surgery and 20 % were worse. In bivariate analysis anatomical recurrence showed significance and persisted after multivariate analysis with an OR of 8322 for subjective failure. CONCLUSION: Labhardt's colpoperineocleisis is a safe technique with good subjective results. It has few complications, an acceptable recurrence rate, and a low rate of de novo SUI. It may be important to use the #0 or #1 polydioxanone sutures, as these are associated with better outcomes in this series. Comparative studies with other obliterative techniques are needed.

[Nephron-sparing surgery for the treatment of small renal tumors. The role of radiofrequency]. / Cirugía conservadora de riñón para tumores renales pequeños, papel de la radiofrecuencia.

OBJECTIVES: Laparoscopically assisted radiofrequency is a minimally invasive nephron-sparing treatment option for renal tumors, mainly in patients with high comorbidity. We present the short-term results of our series patients treated with this novel technique. METHODS: Renal lesions smaller than 4 cm, suspicious of malignancy or metastasis on CT scan or MRI are candidates for radiofrequency. Under laparoscopic vision the tumor is identified, and percutaneous biopsy is performed. Depending on the size of the tumor, a number of punctures with the radiofrequency needle are performed with the aim to achieve tumor necrosis during at least one cycle of radiofrequency. Follow-up is performed with MRI in the first postoperative day and then after CT scan or MRI at 1, 3, 6 and 12 months. The persistent absence of contrast or vascular necrosis of the lesion is considered a satisfactory ablation without recurrence. RESULTS: 12 patients, two with metastasis and ten with primary lesions (mean age 60.8 years), with one or more lesions suspicious of malignancy underwent radiofrequency. Mean ASA was 2.4. 15 tumors were treated, with a mean diameter of 2.8 cm. An average of 2.5 punctures was performed with the radiofrequency needle. Biopsy results showed: one case of thyroid cancer metastasis, one case of melanoma metastasis, and 10 cases of renal cell carcinoma. Mean hospital stay was 25.8 hours. There were not short-term complications. Follow-up time was 8.8 months. Today there is no evidence of recurrence in imaging tests. CONCLUSIONS: Radiofrequency is effective eradicating small renal lesions, both primary and metastatic; it is especially useful in patients with high comorbidity. Despite the number of patients with adequate follow-up is not enough, the technology is promising. The approach under laparoscopic vision contributes to an effective biopsy, avoiding dissemination and enabling a more precise radiofrequency by direct vision control of tumor necrosis.

Cirugía conservadora de riñón para tumores renales pequeños, rol de la radiofrecuencia / Neprhon-sparing surgery for the treatment of small renal tumors. The role of radiofrequency

OBJETIVO: La radiofrecuencia con asistencia laparoscópica es una opción de tratamiento minimamente invasivo para la conservación de parénquima renal, especialmente en pacientes con comorbilidad aumentada. Se presentan los resultados a corto plazo de los pacientes tratados por esta novedosa técnica.MÉTODOS: Las lesiones renales menores de 4 cm., sospechosas de malignidad o de metástasis a la TC o RNM son candidatas para radiofrecuencia. Bajo visión laparoscópica el tumor es identificado, realizándose una biopsia por punción percutánea. Según tamaño del tumor, se realiza un determinado número de punciones con aguja de radiofrecuencia, con el fin de lograr la necrosis del tumor durante al menos 1 ciclo de radiofrecuencia. El seguimiento es realizado con RNM en el día post operatorio 1 y luego con TC o RNM al mes, 3, 6 y 12 meses. La ausencia persistente de contraste o la necrosis vascular de la lesión es considerada una ablación satisfactoria sin recurrencia.RESULTADOS: Doce pacientes, 2 por enfermedad metastásica y 10 por lesiones primarias (edad promedio 60.8 años), con una o más lesiones sospechosas de malignidad fueron tratadas con radiofrecuencia. El ASA promedio fue de 2,4. El número de tumores tratados fue de 15 con un diámetro de 2,8 cm. Se utilizaron un promedio de 2,5 punciones con aguja de radiofrecuencia. Los resultados de la biopsia fueron metástasis de 1° tiroídeo: 1 paciente, metástasis de melanoma: 1 paciente y cáncer de células renales en 10 pacientes. La estadía hospitalaria promedio fue de 25.8 horas. No existieron complicaciones a corto plazo. Tiempo de seguimiento 8.8 meses. Hasta hoy no hay evidencias de recidiva en los controles imagenológicos(AU)

CONCLUSIONES: La radiofrecuencia es efectiva en erradicar lesiones renales pequeñas, tanto primarias como metastásicas, siendo especialmente útil en pacientes con comorbilidad aumentada. A pesar de que no hay una cantidad suficiente de pacientes con seguimiento adecuado, esta tecnología es prometedora. El abordaje bajo visión laparoscópica contribuye a una biopsia efectiva, evitando diseminación y permite una radiofrecuencia más certera al constatar bajo visión directa la necrosis del tumor(AU)

OBJECTIVES: Laparoscopically assisted radiofrequency is a minimally invasive nephron-sparing treatment option for renal tumors, mainly in patients with high comorbidity. We present the short-term results of our series patients treated with this novel technique.METHODS: Renal lesions smaller than 4 cm, suspicious of malignancy or metastasis on CT scan or MRI are candidates for radiofrequency. Under laparoscopic vision the tumor is identified, and percutaneous biopsy is performed. Depending on the size of the tumor, a number of punctures with the radiofrequency needle are performed with the aim to achieve tumor necrosis during at least one cycle of radiofrequency. Follow-up is performed with MRI in the first postoperative day and then after CT scan or MRI at 1, 3, 6 and 12 months. The persistent absence of contrast or vascular necrosis of the lesion is considered a satisfactory ablation without recurrence.RESULTS: 12 patients, two with metastasis and ten with primary lesions (mean age 60.8 years), with one or more lesions suspicious of malignancy underwent radiofrequency. Mean ASA was 2.4. 15 tumors were treated, with a mean diameter of 2.8 cm. An average of 2.5 punctures was performed with the radiofrequency needle. Biopsy results showed: one case of thyroid cancer metastasis, one case of melanoma metastasis, and 10 cases of renal cell carcinoma. Mean hospital stay was 25.8 hours. There were not short-term complications. Follow-up time was 8.8 months. Today there is no evidence of recurrence in imaging tests.çCONCLUSIONS: Radiofrequency is effective eradicating small renal lesions, both primary and metastatic; it is especially useful in patients with high comorbidity. Despite the number of patients with adequate follow-up is not enough, the technology is promising. The approach under laparoscopic vision contributes to an effective biopsy, avoiding dissemination and enabling a more precise radiofrequency by direct vision control of tumor necrosis(AU)

Mismatch repair expression in testicular cancer predicts recurrence and survival.

We investigated mismatch repair (MMR) gene expression in testicular cancer as a molecular marker for clinical outcome (recurrence, response to chemotherapy and death) using protein expression and specific genetic alterations associated with the presence or absence of MMR activity. One hundred sixty-two cases of paraffin-embedded testis cancer specimens were subjected to immunohistochemical analysis using monoclonal antibody for MLH1 and MSH2 MMR proteins and genetic analysis using specific polymorphic markers. The degree of MMR immunoreactivity and genetic instability in the form of loss of heterozygosity (LOH) and/or microsatellite instability (MSI) were determined by comparing matched normal and tumor tissue. The degree of immunohistochemical staining for MMR expression was associated with a shorter time to tumor recurrence, resistance to chemotherapy and death. Furthermore, clinical relapse and cancer specific death was also associated with tumors exhibiting a high degree of MSI, p = 0.01 and 0.04, respectively. In contrast, LOH was not associated with recurrence, resistance to chemotherapy or death. Therefore, MMR expression defines testis cancers with distinct molecular properties and clinical behavior, such that tumors with decreased MMR immunostaining and/or increased frequency of MSI have a shorter time to recurrence and death despite chemotherapy.