Cirugía retroperitoneal asistida por robot por puerto único: un abordaje factible / Single-port robot-assisted retroperitoneal surgery: A feasible approach

Introducción: La cirugía mediante una única incisión ha sido un concepto perseguido en el campo de la mínima invasión para el tratamiento de diferentes afecciones. Este concepto, sumado a un abordaje retroperitoneal, puede suponer una disminución de la agresión al paciente a diferentes niveles. Describimos los primeros casos de cirugía retroperitoneal asistida por robot mediante puerto único de nuestro entorno. Material y métodos Presentamos 2 casos de pacientes con masas suprarrenales derechas con un tamaño superior a 4cm. El primer caso se trataba de una mujer de 55 años con diagnóstico incidental de angiomiolipoma, y el segundo, de un varón de 62 años con adenoma suprarrenal no funcionante. Ambos casos se operaron a través de una única incisión subcostal de 4cm mediante el sistema Da Vinci Xi®, anulando el brazo 4 sin realizar reasignaciones de lateralidad en consola. Resultados Los tiempos de consola para las cirugías fueron de 75 y 150min, con tiempos de acceso y acoplamiento robótico inferiores a 30min. El sangrado fue inferior a 100cc en ambas cirugías, sin necesidad de realizar incisiones accesorias o dejar tubo de drenaje. Las piezas quirúrgicas fueron extraídas por la misma incisión sin necesidad de ampliación. En ningún caso fue necesaria analgesia intravenosa postoperatoria (EVA 0) y la estancia fue inferior a 24h en ambos pacientes, sin reportarse ninguna complicación. Conclusiones La cirugía retroperitoneal asistida por robot mediante puerto único es un abordaje factible a través del sistema Da Vinci Xi® (AU)

Introduction: The concept of surgery through a single incision has been pursued in the field of minimal invasion for the treatment of different pathologies. This, added to a retroperitoneal approach, implies less aggression for the patient at different levels. We describe the first cases of single-port robot-assisted retroperitoneal surgery (SP-RARS) in our country using the Da Vinci Xi® system. Material and methods We present 2 cases of patients with right adrenal masses larger than 4cm. The first case was a 55-year-old woman with an incidental diagnosis of angiomyolipoma, and the second case was a 62-year-old man with a non-functioning adrenal adenoma. Both cases were operated through a single 4cm subcostal incision using the Da Vinci Xi® system, annulling arm 4 without reallocating laterality on the surgeon's console. Results Console times for surgeries were 75 and 150min, with access and docking times below 30min. Bleeding was less than 100cc in both surgeries with no need of accesory trocars, make new incisions or leave a drainage tube. The surgical specimens were removed through the same initial incision without the need for enlargement. Postoperative intravenous analgesia was not necessary in any case (VAS 0) and hospital stay was less than 24h in both patients, without reporting any complications. Conclusions SP-RARS is a feasible approach using the Da Vinci Xi® system (AU)

Single-port robot-assisted retroperitoneal surgery: A feasible approach.

INTRODUCTION: The concept of surgery through a single incision has been pursued in the field of minimal invasion for the treatment of different pathologies. This, added to a retroperitoneal approach, implies less aggression for the patient at different levels. We describe the first cases of single-port robot-assisted retroperitoneal surgery (SP-RARS) in our country using the da Vinci Xi® system. MATERIAL AND METHODS: We present two cases of patients with right adrenal masses larger than 4 cm. The first case was a 55-year-old woman with an incidental diagnosis of angiomyolipoma, and the second case was a 62-year-old man with a non-functioning adrenal adenoma. Both cases were operated through a single 4-cm subcostal incision using the da Vinci Xi® system, annulling arm 4 without reallocating laterality on the surgeon's console. RESULTS: Both surgeries were performed with console times of 75 and 150 min, respectively, with access and docking times below 30 min. Bleeding was less than 100 cc in both surgeries without the need to make accessory incisions or leave a drainage tube. The surgical specimens were removed through the same initial incision without the need for enlargement. Postoperative intravenous analgesia was not necessary in any case (VAS 0) and hospital stay was less than 24 h in both patients without reporting any complications. CONCLUSIONS: SP-RARS is a feasible approach using the da Vinci Xi® system.

Suprarrenalectomía retroperitoneoscópica por puerto único: experiencia inicial y estandarización de la técnica / Single-port retroperitoneoscopic adrenalectomy: Initial experience and standardization of the technique

Introducción y objetivo: El abordaje mediante cirugía mínimamente invasiva de la patología de la glándula suprarrenal es el más extendido hoy en día, en donde la retroperitoneoscopia ocupa un lugar a tener muy en cuenta; sin embargo, la evolución de estas técnicas hacia abordajes todavía menos invasivos a través de puerto único es anecdótica.La finalidad de este trabajo es describir nuestra experiencia inicial en cirugía retroperitoneoscópica por puerto único (SPORS) de la glándula suprarrenal centrándonos en los datos perioperatorios y dolor postoperatorio.Material y métodosRecogimos y analizamos los datos demográficos y operatorios de una serie de pacientes tratados mediante suprarrenalectomía mediante SPORS. Todos los procedimientos se realizaron mediante una única incisión subcostal de 3-4cm a través de un puerto multicanal. Se recogen diferentes datos quirúrgicos como tiempo operatorio, sangrado, estancia o presencia de complicaciones. Empleamos la escala visual analógica (EVA) para la valoración del dolor postoperatorio.ResultadosEntre diciembre del 2018 y agosto del 2020, 6 pacientes con diferentes patologías suprarrenales fueron intervenidos en nuestro Departamento de forma consecutiva por el mismo cirujano mediante SPORS. Todas las cirugías se realizaron sin requerir colocación de trocares accesorios o reconversión a cirugía abierta. El tiempo medio de las intervenciones fue de 91,6±16,3 min, con un sangrado <150ml, una estancia media de 35,8±13,3 h y un dolor postoperatorio analizado EVA ≤ 3 (mediana de 0,5). El tamaño medio de las piezas fue de 57,8±18mm. No se reportó ninguna complicación según la escala Clavien-Dindo.

Introduction and objective: The minimally invasive surgical approach to adrenal gland pathology is the most widely used nowadays, and retroperitoneoscopy occupies a relevant place. However, the evolution of these techniques towards even less invasive surgery through single-port access is anecdotal. The aim of this work is to describe our initial experience in single-port retroperitoneoscopic surgery (SPORS) of the adrenal gland focusing on perioperative data and postoperative pain.Material and methodsWe collected and analyzed the demographic and operative data of a series of patients undergoing adrenalectomy through SPORS. All procedures were performed through a single 3-4cm subcostal incision with a multichannel port. Surgical data such as operative time, bleeding, length of stay and presence of complications were collected. We used the visual analog scale (VAS) for postoperative pain assessment.ResultsFrom December 2018 to August 2020, 6 patients with different types of adrenal pathology underwent consecutive surgeries in our Department by the same surgeon using SPORS. All surgeries were performed without requiring accessory trocar placement or reconversion to open surgery. The mean operative time was 91.6±16.3minutes, with <150mL bleeding, mean length of stay of 35.8±13.3hours and postoperative pain of VAS ≤3 (median 0.5). The mean size of specimens was 57.8±18mm. No complications were reported according to the Clavien-Dindo scale. (AU)

Single-port retroperitoneoscopic adrenalectomy: Initial experience and standardization of the technique.

INTRODUCTION AND OBJECTIVE: The minimally invasive surgical approach to adrenal gland pathology is the most widely used nowadays, and retroperitoneoscopy occupies a relevant place. However, the evolution of these techniques towards even less invasive surgery through single-port access is anecdotal. The aim of this work is to describe our initial experience in single-port retroperitoneoscopic surgery (SPORS) of the adrenal gland focusing on perioperative data and postoperative pain. MATERIAL AND METHODS: We collected and analyzed the demographic and operative data of a series of patients undergoing adrenalectomy through SPORS. All procedures were performed through a single 3-4 cm subcostal incision with a multichannel port. Surgical data such as operative time, bleeding, length of stay and presence of complications were collected. We used the visual analog scale (VAS) for postoperative pain assessment. RESULTS: From December 2018 to August 2020, 6 patients with different types of adrenal pathology underwent consecutive surgeries in our Department by the same surgeon using SPORS. All surgeries were performed without requiring accessory trocar placement or reconversion to open surgery. The mean operative time was 91.6 ±â€¯16.3 min, with <150 mL bleeding, mean length of stay of 35.8 ±â€¯13.3 h and postoperative pain of VAS ≤3 (median 0.5). The mean size of specimens was 57.8 ±â€¯18 mm. No complications were reported according to the Clavien-Dindo scale. CONCLUSIONS: Even in initially adverse cases, SPORS adrenalectomy is a feasible and safe technique with good cosmetic and perioperative results.

Single-port retroperitoneoscopic adrenalectomy: Initial experience and standardization of the technique. / Suprarrenalectomía retroperitoneoscópica por puerto único: experiencia inicial y estandarización de la técnica.

INTRODUCTION AND OBJECTIVE: The minimally invasive surgical approach to adrenal gland pathology is the most widely used nowadays, and retroperitoneoscopy occupies a relevant place. However, the evolution of these techniques towards even less invasive surgery through single-port access is anecdotal. The aim of this work is to describe our initial experience in single-port retroperitoneoscopic surgery (SPORS) of the adrenal gland focusing on perioperative data and postoperative pain. MATERIAL AND METHODS: We collected and analyzed the demographic and operative data of a series of patients undergoing adrenalectomy through SPORS. All procedures were performed through a single 3-4cm subcostal incision with a multichannel port. Surgical data such as operative time, bleeding, length of stay and presence of complications were collected. We used the visual analog scale (VAS) for postoperative pain assessment. RESULTS: From December 2018 to August 2020, 6 patients with different types of adrenal pathology underwent consecutive surgeries in our Department by the same surgeon using SPORS. All surgeries were performed without requiring accessory trocar placement or reconversion to open surgery. The mean operative time was 91.6±16.3minutes, with <150mL bleeding, mean length of stay of 35.8±13.3hours and postoperative pain of VAS ≤3 (median 0.5). The mean size of specimens was 57.8±18mm. No complications were reported according to the Clavien-Dindo scale. CONCLUSIONS: Even in initially adverse cases, SPORS adrenalectomy is a feasible and safe technique with good cosmetic and perioperative results.

[Neprhon sparing surgery for renal tumours on kidney transplantation]. / Cirugía conservadora en el tratamiento de los tumores renales de novo en injertos de trasplante renal.

INTRODUCTION: Nowadays, nephron sparing surgery for renal carcinoma achieves good oncological results, similar to radical surgery, with the advantage of preserving renal function. Renal cell carcinomas appear de novo in 4.6% of post-transplant patients compared with 3% of tumors in the general population, affecting less than 10% to renal allograft. OBJECTIVE: The purpose is to analyze our experience and make a literature review about the role of nephron sparing surgery to treat de novo renal tumours in renal grafts. MATERIAL AND METHODS: A retrospective and descriptive analysis has been realized, finding four patients who presented with de novo renal tumours over renal graft after kidney transplantation and treated by nephron sparing surgery. A Medline review is done to search similar series published. Oncological and functional results were reviewed and analyzed. We worked with SPSS 12.0 software. RESULTS: Medium age at diagnosis was 46.5 y (42-62). Medium size was 2.4cm. (1.5-3.5) and final histology showed medium tumours size of 3.0cm. (1.7-3.5). Medium hospital stay was 6.0d. Medium time from transplantation to diagnosis was 92 months (42-192). NSS was done in all cases, in 3 cases tumorectomy and one partial nephrectomy. Transfusion was only needed in one case. All cases had pT1aN0M0 RCC histology exam. Renal function did not change from preoperative. All patients are free of progression with a medium follow-up of 46.5 months (15-58). CONCLUSIONS: NSS could be an option to treat graft tumours in selected cases, preserving renal function. In our experience, is a safe and efficient treatment in patients with small de novo renal tumours over renal graft.

[Insignificant prostate cancer. Analysis our series]. / Cancer de próstata insignificante. Análisis de nuestra serie.

The objective of this study is to analyse the specimen of radical prostatectomy of patients who had, prior to the surgery insignificant prostate cancer biopsies. The end point is demonstrate the possibility of an active surveillance as a therapeutic option for prostate cancer in selected is the possibility of an active surveillance as therapeutic for the prostate cancer, in selected individuals if we are able to find diagnostic algorisms to predict the real insignificant tumours. The selected group of patients for the study has a PSA less or equal 10, one positive core of prostatic transrectal ultrasound biopsy with a Gleason score less than 7. This group of patients is considerate as having a potential insignificant tumour. We will consider prostatectomy's specimens and the Gleason sore is less than 7 and the tumoral volume is les or equal to 5%. Of 394 patients with prostate cancer and homogeneous criterias for our study, we have selected 53 patients according to the criteria of insignificant tumour in the biopsy. Our results showed that only 22 of 53 (41.5%) patients were identified as having an insignificant prostate cancer in the RP specimens. Moreover 92.2% of this tumours were organ-confined. In conclusion we are able to say that tumours of low-risk and low tumoral volume in the biopsy, do not correlate always to insignificant tumours in PR specimens, but we have observed that the majority are organ-confined tumours. Finally, the diagnostic's algorisms dies not to predict tumours that may safely treated with active monitoring.

[Inferior caval agenesis and renal trauma]. / Agenesia de vena cava inferior y traumatismo abdominal cerrado.

We are publishing a case of sixteen years old male, with inferior caval agenesis suffering a fall, and having a serious trauma over the left renal unit. We review the recommendations of intervention in front of high grade renal trauma and we too study the existing knowledge on the literature in order to get a posible higher incidence of this kind of trauma in patients with these anomaly.

Melanoma en glande. A propósito de un caso / Melanoma of the glans penis. Case report

Objetivo: Presentar un nuevo caso de melanoma localizado en el glande. Métodos/Resultados: Presentamos en este artículo el caso de un paciente diagnosticado y tratado en nuestro servicio, describiendo su forma de presentación así como su manejo terapéutico. Conclusiones: El melanoma de localización peneana es una forma infrecuente de presentación de este tipo de tumores cutáneos. Hacemos especial hincapié en su diagnóstico, presentación clínica y manejo terapéutico, ya que se trata de una neoplasia que requiere un diagnóstico y tratamiento precoces debido a su pronta diseminación metastásica (AU)

Objective: To report one case of melanoma of the glans penis. Methods/Results: We present the case of a patient diagnosed and treated in our department describing diagnosis and therapeutic management. Conclusions: Melanoma of the penis is an uncommon presentation form of this kind of cutaneous tumor. We especially emphasize its diagnosis, clinical presentation and therapeutic management due to its prompt metastatic dissemination requiring early diagnosis and treatment (AU)

Tratamiento quirúrgico de la incontinencia urinaria de esfuerzo mediante cabestrillo suburetral SPARC. Análisis de nuestra experiencia / Stress urinary incontinence surgical treatment with suburethral suprapubic sparc sling

Introducción: La incontinencia urinaria de esfuerzo (IUE) presenta una gran morbilidad y una elevada incidencia. Existen múltiples técnicas quirúrgicas descritas para el tratamiento de la misma, con diversos resultados. Los cabestrillos suburetrales se han establecido en los últimos años como un método simple y poco invasivo para el tratamiento de la incontinencia urinaria de esfuerzo. Material y Método: Analizamos retrospectivamente nuestra serie de 86 pacientes diagnosticadas de IUE, intervenidas, entre Octubre de 2001 y Diciembre de 2005, mediante un cabestrillo suburetral suprapúbico (SPARC(C)). Resultados: La media de edad es de 58,7 años (39-80). La estancia media hospitalaria es de 2,43 días (1-8) y la duración media de sonda de 1,52 días (1-10). En el 14,5% de los casos, se realizó cirugía asociada, siendo la más frecuente, la colpoperineoplastia anterior (10,7 %). Las complicaciones son poco frecuentes; perforación vesical (5,8%), RAO antes del alta (7%), ITU (15,3%), RAO crónica (3,5%). En el 3,5% de las mujeres, se realizó lisis del cabestrillo, por retención crónica. El seguimiento medio es de 10,14 meses, encontrándose un 71,4% de continencia total. Un 26,2% de las pacientes presentaron síntomas de hiperactividad de novo, con problemas de incontinencia en el 54,5% de estas. (p<0,002; OR 5.0 (IC 95% 1,75-14,28). Conclusiones: El SPARC© es un método sencillo, con un tiempo hospitalario corto y una rápida reincorporación a la vida social. Los resultados pueden ser valorados rápidamente y con una tasa elevada de éxito. La aparición de urgencia de novo es elevada y empeora los resultados funcionales. Es necesario un mayor seguimiento para valorar resultados funcionales a largo plazo

Introduction: Stress urinary incontinence (SUI) has a high incidence and important morbidity. Multiple surgical techniques have been described to treat it, with despair results. Suburethral slings have become, in recent years, a simpler and less invasive method to treat SUI surgically. Material and method: The purpose of this paper is to review, retrospectively, 86 patients treated at our institution, from 10/01 to 12/05 of SUI, with a suprapubic suburethral sling (SPARC). Results: Medium (range) age is 58.7 (39-80), hospital stay was 2.43 d (1-8) and catheter was removed 1.52 d (1-10). 14.5% of patients underwent other vaginal surgeries at same time, most frequently anterior colpoperineoplasty (10.7%). Complications are not very frequent; bladder perforation (5.8%), acute urinary retention (7%), chronic urinary retention (3.5%) and UTI (15.3%). Sling release was performed in 3.5% of women with chronic urinary retention. Total continence was found in 71.4% of patients with 10.1 months medium follow up (1-32). De novo urge symptoms were found in 26.2% of women, with urge incontinence in 54.5% of them. (p < 0,002; OR 5.0 (IC 95% 1.75-14.28). Conclusions: Suprapubic suburethral SPARC sling is a simple method, with few complications and fast social recovery. Outcome can be measured soon, with a high continence rate. De novo urge symptoms are high and they worsen functional results. It is necessary longer follow-up to evaluate long term outcomes

[Radical prostatectomy with minilaparotomy "minilap" for patients with prostate cancer]. / Técnica de minilaparotomía "minilap" en pacientes sometidos a prostatectomía radical por cáncer de próstata.

INTRODUCTION: prostate cancer is the most frequent tumor in males. The use of PSA contributes to diagnose tumors with low stage. Radical Prostatectomy (R.P.) is the gold standard to treat this tumor; however such is not exempt of risks. Different technical modifications like minimal incisions minilaparotomy "minilap" had contributed to improve results. We review our experience with Minilap on patients underwent a RP. MATERIAL AND METHODS: Between April 1997 and September 2005 carry out 110 RP with Minilap technique. All cases were performed with minimal incision 7-8 cm of length. We use and specific retractor developed in our hospital. Median age at time of surgery was 65 (47-79). Clinical stage in 39 (35.4%) were T1c, 64 (58.3%) T2 and 7 (6.3%) T3. Sixty eight percent were Gleason score < or =6, 34(30.9%) 7 and 1 (0.9%) Gleason 8. RESULTS: In 86 cases (38.5%) pathological stage were pT2, 21 (19%) pT3, 1 (0.9%) pT4 and 2 (1.8%) pT0. Nine patients (8%) had postoperative complications. No re-interventions were necessary and 101 (90%) were discharge without per operatives complications. Mean length of stay was 4 days and 97 (88.8%) of patients were discharge with only five days length of stay. Urinary continence rate with a year like minimal follow up is 92.3% and 40% preserve sexual activity. CONCLUSIONS: Minimal invasive techniques like minilap can be done in regular form with good results and without long learning curve.

[Vesicoureteral reflux in spinal cord injured patients. Treatment results and statistical analysis]. / Reflujo vesicoureteral en pacientes lesionados medulares. Analisis estadistico de resultados en el tratamiento.

INTRODUCTION: VUR in spinal cord injured patients is cause of important morbidity and mortality. The aim of this paper is to make a statistical, retrospective and descriptive study to analyze VUR treatment results, in neurogenic bladder SCI patients. MATERIAL AND METHOD: We study 40 patients (80 renal units) with VUR in neurogenic bladders and SCI, between March, 1990 and November, 2004. Median age is 43.05 y (9-76). 77.5% of patients are males (3.4:1). Time from injury to VUR is 24.7m (0.2-87). Median follow up is 8.23a (0.5-29). Traumatic lesions are most frequent (70%). Median bladder capacity is 244.9 ml (43-555) and median bladder compliance is 16.12 ml/cm H2O (0.3-61.6). Detrusor overactivity is found in 72.2% and detrusor-sphincter dyssynergia in 71.8%. Initial conservative treatment is done with indwelling catheter and anticholinergics RESULTS: Complete remission was found in 57.5% of RU, descending VUR a 23.7% (66.2% previously to 42.5% after; p<0.02), and predominant in unilateral reflux. Partial response was found in 3.8%, progression in 12.5% and recidiva post CR in 10.9%. Younger patients have better remission rates (39.4 to 47.6 y; p=0.04). Urodinamycs variables don't found any significant differences in treatment results. Endoscopic treatment with bulking agents gets a good response rate (56.3%) (p=0.18). CONCLUSIONS: Initial conservative treatment gets a 23.7% reduction of VUR, especially in men, young and unilateral reflux patients. Anyhow, we observe some progression and recidiva. Detrusor overactivity and detrusor-sphincter dyssynergia didn't influence in treatment results, but they are found in all patients with recidiva. With longer reflux evolution, we observe better responses, but also a higher recidiva rate (p=0.007). Endoscopic bulky injection techniques found out a good response rate (56.3%), also in patients with recidiva after conservative treatment.

Técnica de minilaparotomía “Minilap” en pacientes sometidos a prostatectomía radical por cáncer de próstata / Radical prostatectomy with minilaparotomy “Minilap” for patients with prostate cancer

Introducción: El cáncer de próstata es en la actualidad el tumor mas frecuente en el varón. Muchos de estos tumores con la utilización del PSA y diagnóstico precoz se detectan en fases localizadas. La prostatectomía radical (PR.) sigue siendo el método de tratamiento más usado, si bien dicha cirugía no está exenta de riesgos Los refinamientos técnicos y en la técnica como las incisiones mínimas minilaparotomía (Minilap), han contribuido a mejorar los resultados. Presentamos nuestra experiencia con la técnica de Minilap en pacientes sometidos a PR.. Material y métodos: En el período comprendido entre abril de 1997 y septiembre de 2005 realizamos 110 PR. según técnica de Minilap. En todos los casos se utilizaron incisiones de 7-8 cms. Para la realización de esta técnica utilizamos un separador multivalvas desarrollado en el propio Hospital. La edad media era de 65 años (47- 79) por estadios, 39 (35,4%) eran T1c, 64 (58,3%) cT2 y 7 (6,3%), cT3. En 68,2% el Gleason era ≤6, 34 (30,9%), 7 y 1 (0,9%), 8. Resultados: El estadio patológico fue pT2 86(38,1%), pT3 en 21 (19%), pT4 1(0,9%) y 2(1,8%) pT0. En 9 (8%) casos se presentaron complicaciones postoperatorias. Ninguno precisó reintervenciones y 101(90%) no presentaron complicaciones perioperatorias. La mediana de estancia postoperatoria fue de 4 días y 97 pacientes (88,8%) fueron dados de alta en los 5 primeros días. Al año un 92.3% presentan continencia urinaria completa o fugas mínimas y un 40% vida sexual activa. Conclusiones: Técnicas mínimamente invasivas para la cirugía de cáncer de próstata como la Minilap pueden realizarse de forma habitual con buenos resultados y sin necesidad de una curva de aprendizaje prolongada

Introduction: prostate cancer is the most frequent tumor in males. The use of PSA contributes to diagnose tumors with low stage. Radical Prostatectomy (R.P.) is the gold standard to treat this tumor; however such is not exempt of risks. Different technical modifications like minimal incisions minilaparotomy 'minilap' had contributed to improve results. We review our experience with Minilap on patients underwent a RP. Material and Methods: Between April 1997 and September 2005 carry out 110 RP with Minilap technique. All cases were performed with minimal incision 7-8 cm of length. We use and specific retractor developed in our hospital. Median age at time of surgery was 65 (47-79). Clinical stage in 39 (35.4%) were T1c, 64(58.3%) T2 and 7(6.3%) T3. Sixty eight percent were Gleason score ≤6, 34(30.9%) 7 and 1(0.9%) Gleason 8. Results: In 86 cases (38.5%) pathological stage were pT2 , 21(19%) pT3, 1(0.9%) pT4 and 2 (1.8%) pT0. Nine patients (8 % ) had postoperative complications. No re-interventions were necessary and 101(90%) were discharge without per operatives complications. Mean length of stay was 4 days and 97(88.8%) of patients were discharge with only five days length of stay. Urinary continence rate with a year like minimal follow up is 92.3% and 40% preserve sexual activity. Conclusions: Minimal invasive techniques like minilap can be done in regular form with good results and without long learning curve

Reflujo vesicoureteral en pacientes lesionados medulares. Analisis estadístico de resultados en el tratamiento / Vesicoureteral reflux in spinal cord injured patients. Treatment results and statistical analysis

Introducción: El RVU en pacientes con lesión medular es una causa importante de morbilidad y mortalidad. El objetivo de este trabajo, es realizar un estudio retrospectivo, descriptivo y estadístico que analiza los resultados en el tratamiento del reflujo vesicoureteral, en los pacientes con vejiga neurógena establecida. Material y método: Se estudian 40 pacientes con RVU, secundario a vejiga neurógena por lesión medular, entre marzo/90 y noviembre/04. Se observa RVU en el 66,2% de las UR. La edad media es 43,05a (9-76). El 77,5% son hombres (3,4:1). La evolución desde la lesión medular hasta el diagnóstico del RVU de 24,7 meses (0,2-87m). El tiempo de seguimiento es de 8,23a (0,5- 29). Etiología traumática en el 70%. La capacidad vesical media es de 244,9 ml (43-555ml), la compliance vesical media es de 16,12 ml/cm. H20 (0,3-61,6). La hiperactividad del detrusor se aprecia en 72,2% y la disinergia vesico-esfinteriana externa en 71,8%. El tratamiento inicial es conservador con sondaje vesical y terapia anticolinérgica. Resultados: Curación completa del RVU en el 57,5%, se reduce un 23,7% (66,2% frente 42,5%, p<0,02); predominantes en reflujos unilaterales. Mejoría parcial, con reducción del grado previo en 3,8%. Progresión a grados superiores en 12,5%. Recidivas post-curación completa en 10,9% Los pacientes más jóvenes curan mejor (39,4 frente a 47,6 años, p=0,04). Al analizar las variables urodinámicas, no encontramos diferencias estadísticas. El tratamiento endoscópico consigue una curación del 56.3% (p=0,18). Conclusiones: Con el manejo conservador inicial, se consigue una reducción del reflujo vesicoureteral en el 23,7%, preferentemente en aquellos pacientes con reflujo unilateral, jóvenes (p=0,04) y varones. La presencia o ausencia de hiperactividad o disinergia, no empeora o mejora los resultados, sin embargo se asocia con recidivas. A mayor tiempo de evolución, mejores tasas de curación, pero también mayores recidivas (p=0,007). El tratamiento endoscópico con sustancias abultantes, obtiene una buena tasa de curación (56,3%), incluso en pacientes recidivados después del tratamiento conservador

Introduction: VUR in spinal cord injured patients is cause of important morbidity and mortality. The aim of this paper is to make a statistical, retrospective and descriptive study to analyze VUR treatment results, in neurogenic bladder SCI patients. Material and method: We study 40 patients (80 renal units) with VUR in neurogenic bladders and SCI, between March, 1990 and November, 2004. Median age is 43.05 y (9-76). 77.5% of patients are males (3.4:1). Time from injury to VUR is 24.7m (0.2-87). Median follow up is 8.23a (0.5-29). Traumatic lesions are most frequent (70%). Median bladder capacity is 244.9 ml (43-555) and median bladder compliance is 16.12 ml/cm H20 (0.3-61.6). Detrusor overactivity is found in 72.2% and detrusor-sphincter dyssynergia in 71.8%. Initial conservative treatment is done with indwelling catheter and anticholinergics Results: Complete remission was found in 57.5% of RU, descending VUR a 23.7% (66.2% previously to 42.5% after; p<0.02), and predominant in unilateral reflux. Partial response was found in 3.8%, progression in 12.5% and recidiva post CR in 10.9%. Younger patients have better remission rates (39.4 to 47.6 y; p=0.04). Urodinamycs variables don’t found any significant differences in treatment results. Endoscopic treatment with bulking agents gets a good response rate (56.3%) (p=0.18). Conclusions: Initial conservative treatment gets a 23.7% reduction of VUR, especially in men, young and unilateral reflux patients. Anyhow, we observe some progression and recidiva. Detrusor overactivity and detrusor-sphincter dyssynergia didn’t influence in treatment results, but they are found in all patients with recidiva. With longer reflux evolution, we observe better responses, but also a higher recidiva rate (p=0.007). Endoscopic bulky injection techniques found out a good response rate (56.3%), also in patients with recidiva after conservative treatment

[Stress urinary incontinence surgical treatment with suburethral suprapubic SPARC sling]. / Tratamiento quirúrgico de la incontinencia urinaria de esfuerzo mediante cabestrillo suburetral SPARC. Análisis de nuestra experiencia.

INTRODUCTION: Stress urinary incontinence (SUI) has a high incidence and important morbidity. Multiple surgical techniques have been described to treat it, with despair results. Suburethral slings have become, in recent years, a simpler and less invasive method to treat SUI surgically. MATERIAL AND METHOD: The purpose of this paper is to review, retrospectively, 86 patients treated at our institution, from 10/01 to 12/05 of SUI, with a suprapubic suburethral sling (SPARC). RESULTS: Medium (range) age is 58.7 (39-80), hospital stay was 2.43 d (1-8) and catheter was removed 1.52 d (1-10). 14.5% of patients underwent other vaginal surgeries at same time, most frequently anterior colpoperineoplasty (10.7%). Complications are not very frequent; bladder perforation (5.8%), acute urinary retention (7%), chronic urinary retention (3.5%) and UTI (15.3%). Sling release was performed in 3.5% of women with chronic urinary retention. Total continence was found in 71.4% of patients with 10.1 months medium follow up (1-32). De novo urge symptoms were found in 26.2% of women, with urge incontinence in 54.5% of them. (p < 0.002; OR 5.0 (IC 95% 1.75-14.28). CONCLUSIONS: Suprapubic suburethral SPARC sling is a simple method, with few complications and fast social recovery. Outcome can be measured soon, with a high continence rate. De novo urge symptoms are high and they worsen functional results. It is necessary longer follow-up to evaluate long term outcomes.

[External beam radiotherapy on locally advanced prostate carcinoma following iliac staging lymphadenectomy]. / La radioterapia en el cáncer de próstata localmente avanzado tras estadiaje ganglionar con linfadenectomía.

INTRODUCTION AND OBJECTIVES: Locally advanced prostate cancer supposes a high risk condition of post-treatment progression due to the limit situation that represents. Our purpose was to analyze prognoses factors in function of progression probability after using a treatment with external source radiotherapy on patients with this kind of tumors. MATERIAL AND METHODS: We retrospectively reviewed a set of 128 patients submitted to pelvic staging limphadenectomy prior to accomplish an external radiotherapeutic treatment. We employed the Kaplan-Meier curves to study the probability of progression, logarithmic ranks test were used for detection of possible statistically significant differences and proportional risks Cox model was employed to study possible risk factors of progression (employing astro criteria). RESULTS: 5 years freedom probability from progression was of 49,93%; in spite of appreciating important differences in the groups stratified by the predictive variables used (total PSA, gleason of pathological biopsy, clinical stage and % of cores affection on biopsy), none of them reached statistical meaning, being the level of total PSA the closest to it. CONCLUSIONS: The external radiotherapeuthic treatment represents a valid alternative in the treatment of locally advanced prostate cancer, with a tolerable index of secondaries. It must be used combined with hormonotherapy. It seems that the use of higher radiation doses, in a safer way thanks to 3D conformed radiotherapy, allows to improve the results. The most powerful clinical predictor of evolution must be the total PSA.

[Renal angiomyolipomatosis and pulmonary lymphangiomyomatosis. Its relationship with Bourneville syndrome]. / Angiolipomatosis renal y linfangioleiomiomatosis, su relación con la enfermedad de Bourneville.

INTRODUCTION: Renal angiomyolipomas are not very frequent in urologic activities. Pulmonary lymphangioleiomyomatosis is a rare disease that occurs mainly in women of reproductive age. Tuberous sclerosis shows lesions to different organs, including these both entities. MATERIAL AND METHOD: We retrospectively analyze patients treated in our center. Three most representatives cases are reported. An indexed literature review is done, in order to establish a clinical protocol to manage these kinds of patients. RESULTS: [corrected] Between 1990 and 2004, eight patients have been attended with an angiomyolipoma renal diagnostic. Five women (62%) and three men (38%). Medium age is 52,3y (29-69). In 3 of them (all women), it was also done a diagnostic of pulmonary lymphangioleiomyomatosis. CONCLUSIONS: Bourneville syndrome is not very frequent. Associated angiomyolipomas usually are multiple, bilateral, with tender to grow and require more interventions. Previous diagnostic let us prevent future complications with vigilance, selective arterial embolization and nephron-spare surgery. Tumour size and the presence of symptoms are more decisive to decide best therapy alternative. Young patients with pulmonary lymphangioleiomyomatosis should be advise against pregnancy and the use of preparations containing estrogens.

Angiolipomatosis renal y linfangioleiomiomatosis, su relación con la enfermedad de Bourneville / Renal angiomyolipomatosis and pulmonary lymphangiomyomatosis. It´s relationship with bourneville syndrome

Introducción: Los angiomiolipomas renales son poco frecuentes en la actividad urológica. La linfangioleiomiomatosis es una rara enfermedad pulmonar que afecta mayoritariamente a mujeres en edad reproductiva. La Esclerosis Tuberosa afecta a diversos órganos, incluyéndose entre sus presentaciones, estas dos entidades. Material y método: Se revisan de forma retrospectiva los pacientes atendidos en nuestro centro, haciendo referencia a tres casos representativos de la enfermedad. Se expone su manejo clínico y Resultados: Asimismo se realiza una revisión de la literatura indexada, que nos permita establecer un protocolo de actuación. Resultados: Entre 1990 y 2004, han sido atendidos 8 pacientes con angiomiolipoma renal. 5 mujeres (62%) y 3 hombres (38%). La media de edad es de 52,3 años (29-69). En 3 pacientes (todas mujeres) se diagnosticó también linfangioleiomiomatosis. Conclusiones: La enfermedad de Bourneville es poco frecuente. Los angiomiolipomas que se asocian, suelen ser múltiples, bilaterales, tendentes al crecimiento y requieren más intervenciones. El diagnóstico precoz permite prevenir futuras complicaciones mediante vigilancia, embolización arterial selectiva o cirugía conservadora. Es importante el tamaño y la presencia de síntomas para decidir la mejor terapia. Las pacientes jóvenes con linfangioleiomiomatosis pulmonar deben ser advertidas del uso de preparados estrogénicos y evitar embarazos

Introduction: Renal angiomyolipomas are not very frequent in urologic activities. Pulmonary lymphangioleiomyomatosis is a rare disease that occurs mainly in women of reproductive age. Tuberous sclerosis shows lesions to different organs, including these both entities. Material and method: We retrospectively analyze patients treated in our center. Three most representatives cases are reported. An indexed literature review is done, in order to establish a clinical protocol to manage these kinds of patients. Resultados: Between 1990 and 2004, eight patients have been attended with an angiomyolipoma renal diagnostic. Five women (62%) and three men (38%). Medium age is 52,3 y (29-69). In 3 of them (all women), it was also done a diagnostic of pulmonary lymphangioleiomyomatosis. Conclusions: Bourneville syndrome is not very frequent. Associated angiomyolipomas usually are multiple, bilateral, with tender to grow and require more interventions. Previous diagnostic let us prevent future complications with vigilance, selective arterial embolization and nephron-spare surgery. Tumour size and the presence of symptoms are more decisive to decide best therapy alternative. Young patients with pulmonary lymphangioleiomyomatosis should be advise against pregnancy and the use of preparations containing estrogens