[Ureterocutaneous fistula after nephrectomy: two cases]. / Fístula ureterocutánea tras nefrectomía: aportación de dos casos y revisión de la literatura.

The ureteral fistulas are related to the gynecological surgery, digestive surgery and reconstructive urologic surgery of the upper urinary tract. Fistulas are described ureterovaginal, ureteroduodenal, ureterocolonic, ureteropleural, ureterovascular, etc. However, the ureterocutaneous fistulas of the ureteral stump after nephrectomy are a very unusual entity. We report two cases as well as their resolution by means of surgery.

Fístula ureterocutánea tras nefrectomía: aportación de dos casos y revisión de la literatura / Ureterocutaneous fistula after nephrectomy: two cases

Las fístulas ureterales se relacionan con la cirugía ginecológica, cirugía digestiva y cirugía urológica reconstructiva del aparato urinario superior. Están descritas fístulas ureterovaginales, ureteroduodenales, ureterocolónicas, ureteropleurales, ureterovasculares, etc. Sin embargo, las fístulas ureterocutáneas del muñón ureteral tras nefrectomía son una entidad muy inusual. Presentamos dos casos así como su resolución mediante cirugía (AU)

The ureteral fistulas are related to the gynecological surgery, digestive surgery and reconstructive urologic surgery of the upper urinary tract. Fistulas are described ureterovaginal, ureteroduodenal, ureterocolonic, ureteropleural, ureterovascular, etc. However, the ureterocutaneous fistulas of the ureteral stump after nephrectomy are a very unusual entity. We report two cases as well as their resolution by means of surgery (AU)

[Long-term results of end-to-end urethroplasty]. / Resultado a largo plazo de la uretroplastia término-terminal.

OBJECTIVE: We evaluated long term results of end-to-end urethroplasty. MATERIAL AND METHODS: We reviewed 40 patients with bulbar urethral stricture of diverse origin: iatrogenic 40%, traumatic 15%, infectious 2% and unknown 40%. In 17 cases internal urethrotomy was made previously. The radiological study with retrograde and voiding cystogram revealed a bulbar location in all cases and a length inferior to 1 cm in 13 cases, between 1-2 cm in 26 cases and 2-3 cm in 1 case. The maximum flow rate varied between 3-13 ml/s. The absence of bacteriuria was valued by means of preoperating culture. The average time of pursuit was 45 months (12-142 months). The stricture was considered resolute when not appear compatible radiological or functional finds of failure. RESULTS: In 37 cases (92%) the results were satisfactory, without secondary surgical procedure. After surgery maximum flow-rate varied between 18-45 ml/s. In two patients with failure, internal urethrotomy was decisive. In this case the stricture origin was traumatic. The third patient with failure was finally chosen to make new end-to-end urethroplasty, with good later result. CONCLUSIONS: End-to-end urethroplasty is a highly decisive technique for bulbar urethral stricture. The preoperating diagnosis is based on the radiological study (retrograde and voiding cystogram). The postoperating control must be based on clinic and uroflow study. Traumatic stricture repair showed worse results. In cases of failure, internal urethrotomy allows to complement successful results of end-to-end urethroplasty.

[Survival prognostic factors valuation on a series of 202 patients with surgical treatment of renal cell carcinoma]. / Valoración de factores pronósticos de la supervivencia en una serie de 202 pacientes intervenidos por carcinoma de células renales.

OBJECTIVES: To describe renal cell carcinoma prognostic factors and set up the relationship with survival rates in this neoplasm. Likewise we show epidemiologic, clinical, diagnosis and therapeutic facts. MATERIAL AND METHOD: We review 202 patients underwent surgical treatment for renal cell carcinoma and the following features were recorded: gender, age and presenting symptoms, especially incidentally discovered tumors; tumor-related factors like TNM tumor stage, tumor grade and venous involvement: therapy-related recorded were surgical techniques and cytokine-based therapy. RESULTS: 60% of the patients showed organ-confined disease, 10% of patients with renal cell carcinoma presented with nodal positive disease and 7% with systemic metastases. 42% of patients presenting incidental tumor, with survival rates substantially better than that for symptomatic patients. 42% of patients with nodal positive disease presented systemic metastases at diagnosis, and 30% at surveillance. Systemic metastases presented a particularly poor prognosis for patients with renal cell carcinoma, with 12-months survival rates that 0%. Patients with cytokine-related therapy for metastatic disease presented 24-months survival rates that 20%. CONCLUSIONS: Renal cell carcinoma remains a major source of mortality, basically at advanced disease (nodal positive disease or systemic disease), without a clear improvement of survival rates despite the newer therapy modalities.

Resultado a largo plazo de la uretroplastia término-terminal / Long-term results of end-to-end urethroplasty

Objetivo: Evaluamos los resultados a largo plazo de la uretroplastia término-terminal. Material y Métodos: Revisamos 40 pacientes afectos de estenosis de uretra bulbar de etiología diversa: yatrógena40%, traumática 15%, infecciosa 2% y desconocida 40%. En 17 casos se realizó previamente uretrotomíainterna. El estudio mediante CUMS reveló una localización bulbar en todos los casos y una longitud inferior a 1cm en 13 casos, entre 1-2 cm en 26 casos y entre 2-3 cm en 1 caso. El flujo máximo varió de 3-13 ml/s. Se valoró mediante cultivo preoperatorio la ausencia de bacteriuria. El tiempo medio de seguimiento fue de 45 meses (12-142 meses). Se consideró resuelta la estenosis cuando no aparecieron datos radiológicos ni flujométricos compatibles con reestenosis. Resultados: En 37 casos (92%) los resultados fueron satisfactorios, no precisando los pacientes ningún otro procedimiento quirúrgico secundario. Tras la cirugía el flujo máximo varió entre 18-45 ml/s. En dos de los tres pacientes con reestenosis la uretrotomía interna endoscópica fue resolutiva. Se trató de dos pacientes con estenosisde origen traumático y longitud mayor a 1,5 cm. En el tercer paciente con recidiva se optó finalmente por realizar una nueva uretroplastia termino-terminal, con buen resultado posterior. Conclusiones: La uretroplastia término-terminal es una técnica altamente resolutiva en la estenosis de uretrabulbar. El diagnóstico preoperatorio se basa en el estudio radiológico (CUMS). El control postoperatorio debe fundamentarse en la clínica y estudio flujométrico. El origen traumático de la estenosis empeora los resultados de la cirugía. En casos de reestenosis la uretrotomía interna endoscópica permite complementar de forma exitosa los resultados de la uretroplastia (AU)

Objective: We evaluated long term results of end-to-end urethroplasty. Material and methods: We reviewed 40 patients with bulbar urethral stricture of diverse origin: iatrogenic 40%, traumatic 15%, infectious 2% and unknown 40%. In 17 cases internal urethrotomy was made previously. The radiological study with retrograde and voiding cystogram revealed a bulbar location in all cases and a length inferior to 1 cm in 13 cases, between 1-2 cm in 26 cases and 2-3 cm in 1 case. The maximum flow rate varied between 3-13 ml/s. The absence of bacteriuria was valued by means of preoperating culture. The average time of pursuit was 45 months (12-142 months). The stricture was considered resolute when not appear compatible radiological or functional finds of failure. Results: In 37 cases (92%) the results were satisfactory, without secondary surgical procedure. After surgery maximum flow-rate varied between 18-45 ml/s. In two patients with failure, internal urethrotomy was decisive. In this case the stricture origin was traumatic. The third patient with failure was finally chosen to make new endto- end urethroplasty, with good later result. Conclusions: End-to-end urethroplasty is a highly decisive technique for bulbar urethral stricture. The preoperating diagnosis is based on the radiological study (retrograde and voiding cystogram). The postoperating control must be based on clinic and uroflow study. Traumatic stricture repair showed worse results. In cases of failure, internal urethrotomy allows to complement successful results of end-to-end urethroplasty (AU)

[Urologic findings in pseudoxanthoma elasticum: report one case]. / Manifestaciones urológicas del pseudoxantoma elástico: a propósito de un caso.

CASE REPORT: A 21-year-old woman presented with retinal angioid streaks and yellowish streak skin abnormalities in neck and axillary folds. Skin biopsy showed bluish-gray tangled masses of calcified elastic fibers in the mid- to lower dermis suggestive of Pseudoxanthoma elasticum (PXE). She consulted in Urology Department for lower urinary tract infection. Renal ultrasonography revealed multiple highly reflective foci in the corticomedullary junction. COMMENT: Pseudoxanthoma elasticum is a rare genetic disorder characterised by fragmentation and calcification of elastic fibers in the skin and media of arteries. Frequent manifestations include hypertension, angina pectoris, transient cerebral ischemic attacks, intermittent claudication, upper gastrointestinal bleeding, retinal angioid streaks and thickened skin. A characteristic appearance of highly reflective foci in the renal parenchyma have been reported in patients with PXE, but it's not specific for this syndrome. However, the presence of this structural pattern in a young patient with dermatological abnormalities should lead to the consideration of PXE in the differential diagnosis list. Besides ultrasonography findings, only a ureteral disruption case in a patient underwent ureteroscopic manipulation has been described to our knowledge. In our case, the true significance of these disease in recurrent urinary tract infection is uncertain.

Valoración de factores pronósticos de la supervivencia en una serie de 202 pacientes intervenidos por carcinoma de células renales / Survival prognostic factors valuation on a series of 202 patients with surgical treatment of renal cell carcinoma

Objetivos: Describir los principales factores pronósticos del carcinoma renal y estudiar su relación con la supervivencia especifica. Recoger datos demográficos, clínicos, diagnósticos y terapéuticos de los pacientes. Material y métodos: Se revisaron 202 casos de carcinomas renales operados entre 1988-2003. Las variables valoradas respecto al paciente fueron: edad, sexo y presentación clínica. Se investigó la importancia del incidentaloma. Con respecto al tumor se valoró: estadio TNM, grado histológico, tamaño y afectación venosa. Con respecto al tratamiento: principales vías de abordaje y técnicas quirúrgicas y terapia adyuvante inmunoterápica. Resultados: Un 60% de los pacientes presentó enfermedad órgano confinada, un 10% afectación nodal y un 7% enfermedad metastásica. Un 42% se presentaron incidentalmente, con una significativa mejor supervivencia respecto a tumores sintomáticos. Un 42% de los pacientes pN+ presentaron metástasis a distancia al diagnóstico y un tercio las desarrollaron durante el seguimiento. La supervivencia de los pacientes metastásicos sin tratamiento adyuvante fue inferior al año, mientras que un 20% de los tratados con inmunoterapia permanecían vivos a los 2 años. Conclusiones: El carcinoma renal es un tumor con alta mortalidad, fundamentalmente en sus estadios más avanzados (pN+ o pM+). Pese a las nuevas modalidades de tratamiento, no se ha logrado mejorar sustancialmente la supervivencia (AU)

Objectives: To describe renal cell carcinoma prognostic factors and set up the relationship with survival rates in this neoplasm. Likewise we show epidemiologic, clinical, diagnosis and therapeutic facts. Material and method: We review 202 patients underwent surgical treatment for renal cell carcinoma and the following features were recorded: gender, age and presenting symptoms, especially incidentally discovered tumors; tumor-related factors like TNM tumor stage, tumor grade and venous involvement; therapy-related recorded were surgical techniques and cytokine-based therapy. Results: 60% of the patients showed organ-confined disease, 10% of patients with renal cell carcinoma presented with nodal positive disease and 7% with systemic metastases. 42% of patients presenting incidental tumor, with survival rates substantially better than that for symptomatic patients. 42% of patients with nodal positive disease presented systemic metastases at diagnosis, and 30% at surveillance. Systemic metastases portend a particularly poor prognosis for patients with renal cell carcinoma, with 12-months survival rates that0%. Patients with cytokine-related therapy for metastatic disease presented 24-months survival rates that 20%.Conclusions: Renal cell carcinoma remains a major source of mortality, basically at advanced disease (nodal positive disease or systemic disease), without a clear improvement of survival rates despite the newer therapy modalities (AU)

Manifestaciones urológicas del pseudoxantoma elástico: a propósito de un caso / Urologic findings in pseudoxanthoma elasticum: report one case

Caso clínico: Mujer de 21 años con estrías angioides retinianas y estrías cutáneas en axilas y cuello. Tras biopsia cutánea con calcificaciones en las fibras elásticas de dermis, fue diagnosticada de Pseudoxantoma elástico. Remitida al Servicio de Urología por infección del tracto urinario inferior, en estudio ecográfico renal presentó múltiples focos hiperecogénicos de pequeño tamaño en la unión córtico-medular. Comentarios: El Pseudoxantoma elástico es una rara enfermedad genética que se caracteriza por la fragmentación y calcificación de las fibras elásticas de la piel y arterias. Las manifestaciones clínicas incluyen hipertensión, angor pectoris, ictus, claudicación intermitente, hemorragia digestiva alta, estrías angioides retinianas y estrías cutáneas. La ecografía se caracteriza por la presencia de múltiples focos hiperecogénicos a nivel del parénquima renal, pero este hallazgo no es específico del Pseudoxantoma elástico. Sin embargo, la presencia de este patrón ultrasonográfico en pacientes jóvenes con anomalías dermatológicas debe hacernos pensar en este síndrome dentro de las diferentes posibilidades diagnósticas. Aparte de los hallazgos ecográficos descritos, sólo una lesión ureteral en una paciente sometida a ureteroscopia ha sido descrita en relación al ámbito urológico de este síndrome. En nuestro caso, la relación entre esta enfermedad y la presencia de infección urinaria recurrente no esta clara

Case report: A 21-year-old woman presented with retinal angioid streaks and yellowish streak skin abnormalities in neck and axillary folds. Skin biopsy showed bluish-gray tangled masses of calcified elastic fibers in the mid-to lower dermis suggestive of Pseudoxanthoma elasticum (PXE). She consulted in Urology Department for lower urinary tract infection. Renal ultrasonography revealed multiple highly reflective foci in the corticomedullary junction. Comment: Pseudoxanthoma elasticum is a rare genetic disorder characterised by fragmentation and calcification of elastic fibers in the skin and media of arteries. Frequent manifestations include hypertension, angina pectoris, transient cerebral ischemic attacks, intermittent claudication, upper gastrointestinal bledding, retinal angioid streaks and thickened skin. A characteristic appearance of highly reflective foci in the renal parenchyma have been reported in patients with PXE, but it’s not specific for this syndrome. However, the presence of this structural pattern in a young patient with dermatological abnormalities should lead to the consideration of PXE in the differential diagnosis list. Besides ultrasonography findings, only a ureteral disruption case in a patient underwent ureteroscopic manipulation has been described to our knowledge. In our case, the true significance of these disease in recurrent urinary tract infection is uncertain

Técnica de Burch en el tratamiento quirúrgico de la incontinencia urinaria de esfuerzo femenina. Valoración de los resultados y análisis de las causas de los fracasos / Burch procedure in the surgical treatment of urinary stress incontinence

OBJETIVO: Presentar nuestra experiencia con la técnica de Burch en el tratamiento de la incontinencia urinaria de esfuerzo femenina (IUE), así como analizar las posibles causas de los fracasos. MATERIAL Y MÉTODOS: En un periodo de 10 años (1987-1997), se han intervenido 157 pacientes afectas de IUE mediante esta técnica. Su edad media era de 54,2 años (30-76) y el seguimiento medio fue de 50,24 meses. La técnica se indicó sin tener en cuenta los hallazgos de la exploración física, la severidad, ni los resultados del perfil uretral en el estudio urodinámico. RESULTADOS: A los tres meses de la cirugía, el porcentaje de curación/mejoría fue del 80,7 por ciento. Al año desciende al 76 por ciento. A partir del 2º año se estabilizaron en torno al 70 por ciento y se mantiene a los 5 años. Si tenemos en cuenta la severidad de la incontinencia, si ésta es leve-moderada, el porcentaje de buenos resultados a los 5 años es del 87 por ciento. Si existen alteraciones asociadas del detrusor, baja al 51,8 por ciento, y si el perfil uretral es malo desciende al 42,4 por ciento. CONCLUSIONES: La técnica de Burch es útil en el tratamiento de la IUE, pero con buena selección de los pacientes (AU)

[The Burch technique in the surgical treatment of stress urinary incontinence in women. Assessment of results and analysis of failure causes]. / Técnica de Burch en el tratamiento quirúrgico de la incontinencia urinaria de esfuerzo femenina. Valoración de los resultados y análisis de las causas de los fracasos.

OBJECTIVE: To present our experience with the Burch procedure in the treatment of female urinary stress incontinence (USI) and the assessment of the causes of failure with this technique. MATERIAL AND METHODS: From January 1987 to june 1997 this technique was applied to 157 patients with USI. The mean age of these women was 54.2 years (30-76) and the mean follow-up was 50.24 months. Physical examination, urethral profile and the severity of the USI were not considered in the indication of the procedure. RESULTS: After three months, we had total continence or improvement in 80.7%. This rate decreased to 76% after one year. From the second year it was 70%, maintained to fifth year. Considering the severity of incontinence, in patients with mild-moderate grade, we obtained good outcomes after 5 years in 87%. If there was associated detrusor alterations, the rate decreased to 51.8%, and with a bad urethral profile, decreased to 42.4%. CONCLUSIONS: The Burch procedure is useful in the treatment of USI but requires a good selection of the patients.

[Renal adenocarcinoma with vena cava invasion: current status of its diagnosis and treatment using total segmentary cavectomy]. / Adenocarcinoma renal con invasión de vena cava: estado actual de su diagnóstico y tratamiento mediante cavectomía total segmentaria.

OBJECTIVES: Renal adenocarcinoma is characterized by marked venotropism; 20-49% show extension into the main renal vein and 4-19% into the vena cava. The present study analyzes the different diagnostic methods to evaluate the vascular involvement by renal carcinoma and presents the results achieved by total segmental cavectomy with ligation of the left renal vein and without vena caval reanastomosis. METHODS: Three patients (two males, one female) underwent total segmental cavectomy with ligation of the left renal vein in our Service over the last 10 years. A bilateral subcostal approach with access to the large vessels was utilized in all three cases. The superior and inferior renal vena cava were exposed and the hepatic veins were ligated at the level of the intrahepatic segment. Incision of the vena cava was performed, the thrombus was removed and the renal vessels were ligated. The proximal and distal segments of the vena cava were ligated after cavectomy. In the third patient, intrahepatic extension of the thrombus required the use of a temporary filter for the proximal segment of the vena cava. RESULTS: The early postoperative course was satisfactory; adequate renal function was maintained and no problems with venous return were observed. Of the diagnostic methods analyzed, MRI was found to be the most useful. A relationship was found between survival and the pathological stage and the presence or absence of lymph node metastasis. CONCLUSIONS: Total segmental cavectomy without reanastomosis and with ligation of the left renal vein appears to be a feasible technique which achieves good results. MRI is the diagnostic method of choice in the evaluation of vascular tumor extension.

[Ureterohydronephrosis secondary to a cyst of retroperitoneal mesentery]. / Ureterohidronefrosis secundaria a quiste de mesenterio retroperitoneal.

Retroperitoneal primary cysts are rare clinical entities. A contribution is made of one case presenting this condition with repercussion on the excretory route. Ultrasound and computerized axial tomography studies suggest the diagnosis but this is confirmed through laparotomy. Choice treatment is enucleation, typically easy because of the minimal adherence to surrounding structures. Recurrence is rare and malignancy practically non-existent.

[Epidermoid carcinoma of the male urethra. Our experience in 5 cases]. / Carcinoma epidermoide de uretra masculina. Nuestra experiencia en cinco casos.

OBJECTIVES: Epidermoid carcinoma of the male urethra is a rare tumor that accounts for 70% of primary neoplasms of the urethra. The present study reviews our experience of 5 years in the diagnosis and treatment of this tumor type. METHODS: From 1991 to 1994, we diagnosed and treated 5 male patients with epidermoid carcinoma of the urethra; mean age 58 years (range 43 to 76 years). The tumor was localized in the bulbomembranous urethra in 3 cases (60%) and in the penile urethra in the remaining 2 cases (40%). All patients presented with urethral stricture and complications following treatment (internal urethrotomy and dilatation). The tumors of the posterior urethra were Levine stage C and D at the time of diagnosis, while those of the anterior urethra were Levine stage B and C. RESULTS: Two patients with tumor in the posterior urethra underwent radical cystoprostatourethrectomy and bilateral inguinal lymphadenectomy, whereas the remaining patients underwent emasculation or urethrectomy. Patient survival has ranged from 1 to 2.5 years at the present time. One patient with tumor in the bulbous urethra has died despite postoperative radio and chemotherapy, the outcome has been poor in another patient with tumor in the posterior urethra and no progression has been observed in the remaining patients at present. CONCLUSIONS: a) Urethral stricture with a torpid course and localized complications (fistula, periurethral abscess, etc.) following standard therapy have been the only widely accepted etiologic factors that we have observed in our patients; b) This tumor type must be suspected since treatment by radical surgery will have some likelihood of success if the carcinoma is diagnosed early, while it is still localized; c) To date, radio and chemotherapy have achieved poor results, the former being effective in tumors of the penile urethra only when given at a high dose; d) Patients generally die from localized complications, tumor recurrence, or lymph node metastasis (sepsis, hemorrhage, etc.).

[Genital rhabdomyosarcoma. Diagnostic and therapeutic considerations. Apropos of a case of cavernous origin]. / Rabdomiosarcoma genital. Consideraciones diagnósticas y terapéuticas. A propósito de un caso de origen cavernoso.

A case of perineal rhabdomyosarcoma possibly originating in the corpus cavernosum penis is reported. Treatment was by surgery first followed by chemotherapy. The poor outcome prompted us to review the literature on the diagnosis and treatment of this condition. We can conclude from data published elsewhere that rhabdomyosarcoma localized to the GU tract is a tumor that is amenable to treatment by chemotherapy combined with radiotherapy in most of the cases. When planning treatment, diagnosis must be well-established histologically and staging must be precise in order to avoid unwarranted radical surgery.

[Cyst of the prostatic utricle or remnant of the Mullerian duct?]. / Quiste del utrículo prostático o de restos de conducto de Muller?

The presence of a deep pelvic cyst posed the problem of diagnosing cysts originating from a prostatic utricle and those from mullerian vestiges. A case is presented of a male who came for consultation complaining of infertility. After complementary tests, the diagnosis of deep pelvic cyst was arrived at. It was considered that the cyst originated from vestiges of the mullerian duct based on the following clinical and pathological findings: - Appearance in the third decade of life. - No association with external genital anomalies. - Difficulty of surgical removal due to adherence to the prostate gland, seminal vesicles and posterior vesical wall.

[Determination of prealbumin and retinol transport protein as a control method in the nutritional status of surgically treated patients]. / Determinación de prealbúmina y proteína transportadora de retinol como método de control del estado nutricional de los pacientes quirúrgicos.

We present the results gleaned from a study using retinol-transporting prealbumin and protein determination as a technic for assessing the nutritional status of 14 patients on parenteral feeding following an aggressive surgical procedure. We can conclude from the findings of the present study that these parameters are statistically significant.