[Renal transplantation with living donors. A critical analysis of surgical procedures based on 40 years of experience]. / Transplante renal de donante vivo: un análisis crítico de estrategias quirúrgicas basado en 40 años de experiencia.

INTRODUCTION: Absolute priority in an LDKT programme are donnor safety and kidney optimal anatomical and functional preservation. Reduced donnor morbidities, both at short and long term, are important objectives. Excellent technical grafting is a must as are the strategies employed for facilitatig it. We revised the incidences of our whole LDKT programme (40 years 243 donors) to confirm if these exigences have been acomplished or a change to new surgical procedures is recommended. MATERIAL AND METHODS: Between 1968-2008 243 nephrectomies and grafting has been performed, a reduced number per year (A cadaver programme has been running simultaneously since 1964). For the nephrectomies a Turner-Warrick apprach was inititialy used and since 1973 a miniincisional, anterior, extraperitoneal approach of approximately 10 cm in length. The right kidney was removed in 75% of the cases and the right iliac area for the implant in 85% In adjacent opperating rooms, one team performs the nephrectomy while the other prepares and dissects free the grafting vessels. Most of the time the same senior surgeon performed both operatios: the nephrectomy and the implant. Peroperative and postoperative complications were evaluated by urologists and nephrologists in charge. RESULTS: No donors dead, organs lost or major complications in the donors have been documented. Minor complications such as intestinal paresia, wound infection, persistent incisional pain were common. Miniincisional abdominal approach reduced postoperative pain and hospital stay (4 days). At long term no incisional hernia or abdominal paresia have been documented. Simultaneous work reduces ischemia time (30-45 s warm: 30-45 min cold) and opperatig room occupation(patient preparation plus anesthesia plus operation) estimated in 90-120 min for the nephrectomy and 120-160 for the grafting. The responsibility of the senior surgeon in both procedures facilitates vessel selection for the grafting. CONCLUSIONS: No reasons have been found to reconvert our current nephrectomy procedure to laparoscopic or modify current surgical strategy. Superior safety of open surgery for donors and organs is confirmed. Pain and recovery time are reduced in laparoscopic surgery but not as much when compared with miniincisional approach. Open surgery permits optimal anatomical and functional organ extration facilitatig the quality of the implant. As numbers matter in laparoscopic surgery open nephrectomy is recommended for reduced LDKT programmes.

[Unusual elements in renal calculi]. / Elementos no frecuentes en cálculos renales.

A group of 54 renal calculi were spontaneously passed renal stone after a nephritic colic. Two groups of calculi were found: papillary and non-papillary calculi. All calculi were analyzed by infrared spectroscopy and electronic microscopy scan (EMS) and EDAX. When the stones were analyzed with EDAX, elements such as C, N, O, Na, S, Mg, Al, Si, Cl, K, Ca, Mn, Fe, Ni, Zn were detected. The possible origin of these elements is discussed in this work.

Elementos no frecuentes en cálculos renales / Unusual elements in renal calculi

Se analizó un grupo de 54 cálculos expulsados espontáneamente después de padecer un cólico nefrítico. Dos grupos de cálculos fueron encontrados: papilares y no papilares. Todos los cálculos fueron analizados por espectroscopia infrarroja y por microscopia electrónica de barrido y EDAX. Al ser analizados los cálculos por EDAX se detectaron los siguientes elementos químicos; C, N, O, Na, S, Mg, Al, Si, Cl, K, Ca, Mn, Fe, Ni, Zn. El posible origen de estos elementos es analizado en este trabajo

A group of 54 renal calculi were spontaneously passed renal stone after a nephritic colic. Two groups of calculi were found: papillary and non-papillary calculi. All calculi were analyzed by infrared spectroscopy and electronic microscopy scan (EMS) and EDAX. When the stones were analyzed with EDAX, elements such as C, N, O, Na, S, Mg, Al, Si, Cl, K, Ca, Mn, Fe, Ni, Zn were detected. The possible origin of these elements is discussed in this work

Cirugía de la litiasis renoureteral. Indicaciones actuales / Open surgery for kidney and ureteral stone. Current indications

INTRODUCCIÓN: Toda reflexión sobre litiasis renoureteral y su terapéutica se centra actualmente en la LEOC (Litotricia Extracorpórea por Ondas de Choque), como tratamiento único o asociado a otras técnicas. En ciertos casos la endourología y la litotricia de contacto, se consideran como primera alternativa. La retroperitoneoscopia es otra opción en aquellos centros donde se desarrolla. El abandono de la cirugía abierta es muy manifiesto a favor de las nuevas alternativas, sobre todo en aquellos centros con litotritor extracorpóreo. Los buenos resultados que se obtienen con las técnicas alternativas y la comodidad que el paciente vive, han hecho que el número de casos que se someten anualmente a cirugía abierta sea mínimo. MATERIAL Y MÉTODOS: La Unidad de Litiasis-Litotricia de la Fundación "Jiménez Díaz" (FJD), que realiza LEOC (Modulith SL 20, Storz (r) ), analiza 54 pacientes operados en los últimos años (1990-200), con el fin de concluir en los motivos de la indicación quirúrgica. No se incluye la nefrectomía por lesión renal terminal post-litiásica (pionefrosis, pielonefritis xantogranulomatosa,...).RESULTADOS: La cirugía abierta realizada ha sido la tradicional según el caso: pielotomía (simple o ampliada, ñ infundibulotomía), nefrotomía anatrófica, ureterolitectomía,..., y corrección de aquellas anomalías u obstrucciones asociadas a la patología litiásica (hidro-nefrosis congénita, ureterocele,...). DISCUSIÓN: Actualmente existen casos de litiasis difíciles de solucionar incluso con cirugía abierta. Es la litiasis renal compleja. Sin duda la cirugía es la alternativa más eficaz y resolutiva. Si la LEOC, la URS (Ureterorenoscopia) o la NPL (Nefrolitotomía percutánea) fracasan, y la litiasis es sintomática, debe ser operada. Ante situaciones críticas (complicaciones de estos métodos, se requiere una solución eficaz y urgente, siendo la cirugía tradicional la única alternativa. CONCLUSIONES: La cirugía abierta se indica hoy ante casos de litiasis renal compleja y litiasis renoureteral complicada. El aprendizaje quirúrgico debe ir paralelo al endoscópico, laparoscópico o extracorpóreo. La cirugía abierta será la primera alternativa terapéutica en algún caso. En situación de urgencia clínica, se deben tomar decisiones quirúrgicas, que deberán ser realizadas con la destreza y precisión que se merecen (AU)

[Surgery of renoureteral lithiasis. Current indications]. / Cirugía de la litiasis renoureteral. Indicaciones actuales.

INTRODUCTION: Today, the issue about kidney and ureteral stone and their management is based on ESWL (Extracorporeal Shock Wave Lithotripsy) like singly or as a part of combination therapy. In some cases, endoscopic procedures (URS, PNL) with contact lithotripsy, is the first-line treatment. Retroperitoneoscopic is a therapeutical option in some hospitals. Open stone surgery is now drastically reducing and the endoscopic and extracorporeal methods are increasing, overcoat ESWL in those hospitals who has an own lithotripter. The optimal results of non-invasive procedures, and the ESWL advantages for the patients (outpatient and anesthesia-free treatment, decreased morbidity,...), has caused limited annual indications of open surgery for stone disease even a complete disappearance in many center. MATERIALS AND METHODS: The Stone and Lithotripsy Unit of "Jiménez Díaz" Foundation (FJD) (Madrid), who has an own lithotipter (Modulith SL 20, STORZ) make an evaluation of 54 patients treated with open surgery (1990-2000) in order to reflect on the indications. Nephrectomy for serious paremquimal lithiasic lesions (complicated pyelonefhritis, xantogranulomatosis....) is not included. RESULTS: The open surgery techniques for stone diseases were the classic according to every case: pielolithotomy (simple or extended +/- infundibulolithotomy), anatrophic nephrotomy, ureterolithotomy,.... At the same time it should be resolved those anomalous structures or obstruction associated to the stone disease (congenital hydroneprosis, ureterocele,...). DISCUSSION: Now days are difficult cases of stone diseases to be managed for any methods included open surgery. It's the renal complex stone. Of course, surgery is the best option, the more effectively choice. When endoscopic procedures (URS, NPL) fall and the stone is synthomatic must be operated. When they are serious situation (septic shock, complications derived from the others methods,...). It's necessary an urgent and effectively treatment and it's the open surgery. CONCLUSION: Open surgery is actually indicated for the complex renal stone and the complicated ureteral stone. So, the training on open surgery should be at the same time on the endoscopic, laparoscopic or extracorporeal. Open surgery will be the first-line treatment in some case. Open surgery should be considered in those urgent situation and will be done with skill and precision.

[Radiotransparent lithiasis. Diagnosis and treatment]. / Litiasis radiotransparente. Estudio y tratamiento.

OBJECTIVE: To analyze current clinical, diagnostic and therapeutic aspects of uric acid lithiasis. The role of helical CT in its diagnosis, ESWL and alkalinization in its treatment, and metabolic and crystalographic analyses are discussed. METHODS: The incidence of uric acid calculi is estimated to be from 5% to 7% in the Lithiasis-Lithotripsy Unit of the Jiménez Díaz Foundation. The diagnostic and therapeutic possibilities of helical CT and ESWL are illustrated in a case of complex bilateral renal uric acid staghorn stone. RESULTS: Ultrasound and endoscopic uroradiology are fundamental in the diagnosis of radiotransparent obstructive bilateral renal stone. Ureteral catheterization was warranted due to the anuresis that resulted from bilateral obstructive renal failure. Stone dissolution combined with ESWL achieved rapid resolution of the large calculi. CONCLUSIONS: Helical CT without contrast enhancement should be performed along with the conventional urological diagnostic tests for ureteral lithiasis, especially in patients with renal colic. Although urinary alkalinization is the conventional treatment for uric acid stones, ESWL permits faster resolution in large, obstructive or ureteral stones in patients with renal colic. Complete assessment of patients with uric acid calculi includes metabolic and crystalographic analyses.

[ESWL-resistant lithiasis]. / La litiasis resistente a LEOC.

INTRODUCTION: To the extent in which the "lithotripter" improves technically. SWEL experts provide different explanations to the failures of this technique. It will depend on the type of "lithotripter" as well as the calculus and its features (size, number, location, composition, obstruction, impact, absence of expansion chamber, presence of ureteral catheter, ...). Not all facts in SWEL have a clear explanation today. Physically, the "cavitation" phenomena (shock, rebound, negative pressure, explosion, heat, ...) explain almost anything that takes place during SWEL. Certainly, the type of lithotripter has some influence, but the calculus fragility, determined by the chemical composition and the crystalline architecture, could be more determinant. MATERIAL AND METHOD: From a total series of 6,500 SWEL procedures performed in the Lithiasis-Lithotrity Unit at the "Jiménez Díaz" Foundation (JD) (January 1991-July 1998), 20 cases considered as failures after multiple SWELs were analyzed. Also the actual diagnostic tests (X-rays, helicoid CAT, densitometry, ...) were studied to establish a pre-SWEL chemical recognition of the calculi that may determine the behaviour of each case prior to treatment. RESULTS: After multiple SWELs (average 5 sessions) negative results were obtained in 65% cases. These cases were resolved with surgery (38%), ureterorenoscopy and ultrasound lithotrity (23%) or watchful wait in absence of signs and symptoms (39%). 57% were calcium phosphate calculi, 29% calcium oxalate monohydrate (COM) and 14% hypercalciuria calculi. CONCLUSIONS: SWEL resistant cases, either unresolved or undergoing multiple SWELs, demonstrate the existence of calculi that cannot be broken by SWEL, although no coincident or similar reasons can be established in all cases. Calcium phosphate dihydrate (brushite) and calcium oxalate monohydrate (COM) together with cystine are the most difficult to destroy with current shockwaves. Helicoid CAT could recognise chemically each case prior to SWEL, since it basically differentiates the most frequent ones, uric acid, struvite and calcium oxalate.

[Lithiasis of the distal ureter: ESWL or URS]. / La litiasis del uréter distal: LEOC o URS.

UNLABELLED: A nephritic colic is the clinical picture that evidences the presence of ureteral stones, the natural evolution being their spontaneous passing. Stones in the distal ureter are self-eliminated in about 71-80% cases. The adoption of a "watchful wait" involves an uncertain occupational and medical evolution since, although in some cases the stones will pass with no problems, in other instances they can result in severe, life threatening situations for the patient's health (intractable pain, anuria or sepsis). When a decision is made to treat the condition, there are two choices available: "in situ" SWEL (extracorporeal lithotrity), or URS (ureterorenoscopy), long-standing conflicting techniques each with its own advantages and disadvantages, which should now be considered complementary. SWEL's major disadvantage is the number of repetitions required and the long wait, sometimes even months, until the last fragment is passed. The greater strength of URS is that it can be resolutive in just one episode (95% cases), thus avoiding the obstruction problems that can arise after SWEL. In the Lithiasis-Lithotrity Unit of FJD, SWEL is the first therapeutical option for the treatment of stones in the distal ureter. SWEL and URS are equally likely to be performed although SWEL is the initial choice for efficiency reasons that are explained. We achieve 93.6% positive results with a 1.82% re-SWEL rate (retreatment), 0.60 coefficient of efficiency (EQ) and 0.69 modified coefficient of efficiency (EQM) (Chart). No serious complications were recorded. Morbidity is variable with little clinical significance. CONCLUSION: Distal ureter lithiasis can be treated with either URS and SWEL, both considered "different and complementary". The choice in each particular case and within each hospital will depend on availability of means to perform one or the other, equipment's efficiency, skill of the urologist, patient's preference and cost of each treatment.

[Resolution with vascular endoprosthesis after first angioplasty failure in the treatment of post-transplant stenosis of the renal artery]. / Resolución con endoprótesis vascular tras primera angioplastia fallida en el tratamiento de la estenosis de la arteria renal post-trasplante.

We report a case of renal artery stenosis after a living transplant kidney, treated successfully with percutaneous transluminal angioplasty (PTA) and vascular endoprosthesis. PTA is the initial treatment of choice for most patients with high grade transplant renal artery stenosis. Surgical revascularization is indicated if PTA cannot be done or is unsuccessful.

[Kidney transplant from living donor. Experience at the Jiménez Díaz Foundation]. / Transplante renal con donante vivo. Experiencia de la Fundación Jiménez Díaz.

OBJECTIVES: To discuss the organizational and surgical aspects, results, remarkable events and some ethical considerations of the renal transplantation program with grafts from living donors at our institution over a 25-year period. METHODS: The renal transplant program of the Jiménez Diaz Foundation began in 1964 and the first kidney graft from a living donor was transplanted in 1968. Since then and until December 1993, 157 renal grafts from living donors have been transplanted. The donors were parents in 94, siblings in 55 and the spouse in 4 occasions. Moreover, two free kidneys and two grafts from nonrelated donors were transplanted. The surgical procedure was also similar; i.e., right nephrectomy through a supracostal lumbotomy to remove the kidney and transplantation in the right iliac fosa with anatomosis to cava and common iliac or hypogastric artery. Changes in the surgical technique warranted by the intraoperative findings were infrequent. The ureter was anastomosed to the bladder using an extra- or transvesical technique depending on the surgeon's experience. Harvesting and transplantation of the kidney graft were performed simultaneously by two surgical teams. RESULTS: There were no major complications in the donors or technical difficulties or errors during harvesting that might have compromised graft viability, although complications such as hemorrhage, urinary fistula, thrombosis and prolonged anuria were observed early postoperatively. The incidence of grafts lost specifically related with the technique was less than 3%. Nineteen recipients had died early postoperatively from acute rejection and sepsis. Recipient and graft survival were basically related with the degree of histocompatibility and the changing therapeutic strategy over the 25-year period. The best results were found in 33 transplants involving HLA identical siblings, with a five-year actuarial survival rate of 89%, a 10- and 15-year survival of 70% and a 22-year survival of 22%, followed by those who were haploidentical who had donor-specific transfusions and the haploidentical cases treated with cyclosporine. The poorest results were seen in the historical group of 52 transplant procedures performed between 1968 and 1981 who were treated with the classical medication. CONCLUSIONS: The good results achieved and the minimal risk to donors demonstrated by our experience over a period of 25 years support continuation of the renal transplantation program with grafts from living donors, as well as our approach of having two surgical teams working simultaneously.

[Strategy changes in the treatment of ureteral lithiasis and nephritic colic]. / Cambios de estrategia en el tratamiento de la litiasis ureteral y del cólico nefritico.

Since lithotripters were first introduced to the clinical practice in 1980, extracorporeal shock wave lithotrite (ESWL) has been universally recognized as the first choice to resolve urinary tract lithiasis, ureteral calculi being the most susceptible lithiasic site for controversy. The urologist approach to the lithiasic patient has changed mainly as compared to that of ureteral calculi. These profound changes translate an undeniable advance of the extracorporeal procedures versus those of endourology, basically based on ESWL low morbidity. In those cases when lithiasis is found in a situation of nephritic colic, there is a real therapeutical chance with ESWL, thus leading to drug therapy losing its major role. We present 768 patients with ureteral lithiasis (1991-1994), 20-25% of which were examined for a nephritic colic. Once the colic situation is overcome in all instances, 35% will require a new lithotrite for complete lithiasic resolution. Overall, our rate of successful ureteral lithiasis resolution is 97% (30% need repeated session).

[Silica, aluminum, iron, sulfur, and barium in a urinary calculus]. / Silice, aluminio, hierro, azufre y bario en un cálculo urinario.

Presentation of the analytical results by Sweep Microscopy of a small papillary calculus spontaneously eliminated after a nephritic colic. The main component is monohydrate calcium oxalate. When the stone core was analyzed with EDAX, silica, aluminium, iron, sulphur and barium were detected. The origin of these elements is discussed and the presence of barium emphasized as exceptional.

[Ambulatory ureteral lithotripsy with "Modulith SL-20"]. / Litotricia ureteral ambulatoria con el "Modulith SL-20".

Analysis of our experience in 'in situ' ambulatory shockwave extracorporeal lithofragmentation of ureteral stones in 104 patients seen in the Lithotrity Unit, Urology Service, Fundación "Jiménez Díaz". Using Modulith SL 20, a third generation lithotripter, 'in situ' disintegration was achieved in 82.69% of cases, 51.92% of which were fragmented in a single lithotrity session. As a first choice, no ureteral handling was used in any of the patients prior to lithotrity. In 9.62% of patients it was necessary to place a 'double J' by-pass catheter, due to the disease presenting with a septic picture. The patient's position was either dorsal or ventral decubitus depending on the lithiatic site, while location and focusing of the stones was done radiologically. All patients were treated ambulatory without hospitalization. Only 18% was given oral or i.v. anaesthesia. Fursemide 40 mg was administered to all patients shortly before starting the session. Each patient received an average of 3,200 shockwaves per session (14-18 Kv, average 16 Kv). Haematuria was the single and modest side effect that happened during the 24 hours following lithofragmentation in 30% of patients, while 20% reported slight discomfort at the time of eliminating the gritted stones. We conclude stating that 'in situ' shockwave extracorporeal lithotrity of ureteral stones with Modulith SL 20 allows for elective disintegration of ureteral stones in whatever location they are found, due to the patient's easy positioning. The simple location and focusing of ureteral stones has allowed us to treat and solve some cases of ureteral lithiasis at the precise moment of the nephritic colic painful emergency, thus speeding up and facilitating the resolution of the condition. Our results and our strategy imply a new change of direction in the management of these lithiasis, as opposed to the well established and historical doctrines in existence regarding stones with ureteral location.

[Bladder leiomyoma. Report of a new case]. / Leiomioma vesical. Aportación de un nuevo caso.

Benign mesenchymal tumors arising from muscle fiber are rarely encountered in the urogenital tract and account for 1-5% of all bladder tumors. This tumor type can present as multiple lesions and at different sites. Intramural, extramural and endovesical lesions, which are the most frequent, can be found in the bladder. An intramural tumor that had been incidentally detected is described and the literature reviewed, highlighting the benign nature of this tumor type, which does not recur if resection is complete.

[Bladder paraganglioma. Apropos of a case]. / Paraganglioma vesical. A propósito de un caso.

A case of non-secreting bladder paraganglioma whose clinical manifestation was that of painless hematuria is described herein. Treatment was by partial cystectomy.

[Penile metastasis of prostatic carcinoma. Apropos of a case]. / Metástasis peneana por carcinoma prostático. A propósito de un caso.

This paper present the case of a man 72 year old with secondary penis cancer, as a late manifestation of a earlier well differentiated prostate focus, identified by P.A.A.F., which determined the rarity of the presentation and the choice of diagnostic method by puncture-aspiration with a thin needle. Treatment is very complex and neither radiotherapy nor estrogens therapy produced satisfactory results, leaving de choice of total penectomy only for those cases with intractable pain and if there is no pelvic extension.