[Modified technique for transurethral resection of the prostate with suprapubic drainage and local anesthesia]. / Técnica modificada para la resección transuretral de próstata con drenaje suprapúbico y anestesia local.

PURPOSE: To establish a technique for transurethral resection of the prostate (TURP), combining the use of local anaesthesia with an Amplatz suprapubic tube, in patients at high surgical risk. MATERIALS AND METHOD: A study was carried out in 32 patients who underwent TURP with a 30 F Amplatz suprapubic tube following local anaesthesia. This technique was indicated where surgery presented a general risk, in elderly patients, and for patients refusing to undergo spinal intradural or general anaesthesia. The mean age of the patients was 70 years (61-82 years). The risk of surgery was assessed according to the ASA classification. RESULTS: According to the ASA classification, 7 patients were ASA III (21.9%), and 25 patients were ASA IV (78.1%). In 31 of the 32 patients the operation was completed in one session. When questioned about the pain they felt, 11 patients reported no pain, 12 slight discomfort and 3 occasional pain. In the latter three patients, intravenous sedation was enhanced with 0.1 mg etomidate per kg body weight. The volume of the resected fragments ranged from 18 to 120 ml, with a mean of 47 ml, except in one patient with 205 ml who required two treatment sessions. CONCLUSIONS: Large prostate resection in patients at high surgical risk was performed comfortably using a combination of local anaesthesia and an Amplatz suprapubic tube. This procedure is one possible option to be considered as an alternative to other treatments.

Técnica modificada para la resección trnsuretral de próstata con drenaje suprapúbico y anestesia local / Modified technique for transurethral prostatic resection using a suprapubic tube and local anaesthesia

INTRODUCCIÓN: Describimos una técnica para la resección transuretral (RTU) de próstata combinando el uso de anestesia local con un tubo de Amplatz suprapúbico en pacientes con alto riesgo quirúrgico. MATERIAL Y MÉTODOS: Nuestro estudio comprende 32 pacientes sometidos a RTU de próstata con un tubo de Amplatz suprapúbico de 30 Fr bajo anestesia local. Esta técnica se indicó en aquellos casos con alto riesgo quirúrgico. La edad media fue de 70 años (61-82 años). Evaluamos el riesgo quirúrgico de acuerdo a la clasificación ASA.RESULTADOS: De acuerdo con la clasificación ASA del riesgo quirúrgico, se agrupó a los pacientes en los siguientes grupos: 7 pacientes (21,9 por ciento) presentaban ASA III y 25 pacientes (78,1 por ciento) ASA IV. En 31 de 32 pacientes la cirugía se completó en una sesión. Interrogados acerca del dolor percibido, 11 pacientes refirieron no haber sentido dolor, 12 pacientes refirieron una molestia leve, y 3 pacientes un dolor esporádico. En los últimos tres pacientes se incrementó la dosis de sedación intravenosa con 0,1 mg/kg de peso corporal de Etomidato. El volumen medio de los fragmentos resecados fue de 47 ml, con un rango ente 18 y 120 ml, excepto en un paciente con un volumen de 205 ml que precisó dos sesiones quirúrgicas. CONCLUSIONES: La resección de próstatas de gran volumen en pacientes con riesgo quirúrgico se puede realizar con un mínimo de confort para el paciente utilizando una combinación de anestesia local y tubo de Amplatz suprapúbico. Este procedimiento es una opción a tener en cuenta como tratamiento alternativo a otros métodos (AU)

PURPOSE: To establish a technique for transurethral resection of the prostate (TURP), combining the use of local anaesthesia with an Amplatz suprapubic tube, in patients at high surgical risk. MATERIALS AND METHOD: A study was carried out in 32 patients who underwent TURP with a 30 F Amplatz suprapubic tube following local anaesthesia. This technique was indicated where surgery presented a general risk, in ederly patients, and for patients refusing to undergo spinal intradural or general anaesthesia. The mean age of the patients was 70 years (61-82 years). The risk of surgery was assessed according to the ASA classification. RESULTS: According to the ASA classification, 7 patients were ASA III (21,9%), and 25 patients were ASA IV (78,1%). In 31 of the 32 patients the operation was completed in one session. When questioned about the pain they felt, 11 patients reported no pain, 12 slight discomfort and 3 ocassional pain. In the latter three patients, intravenous sedation was enhanced with 0,1 mg etomidate per kg body weight. The volume of the resected fragments ranged from 18 to 120 ml, with a mean of 47 ml, except in one patient with 205 ml who required two treatment sessions. CONCLUSIONS: Large prostate resection in patients at high surgical risk was performed comfortably using a combination of local anaesthesia and an Amplatz suprapubic tube. This procedure is one possible option to be considered as an alternative to other treatments (AU)

[Endoscopic treatment of vesicoureteral reflux]. / Tratamiento endoscópico del reflujo vesicoureteral.

AIM: We report our experience of the endoscopic treatment of vesicoureteric reflux in children by submucosal injection of polytetrafluoroethylene (Teflon). PATIENTS AND METHODS: From April 1995 to September 1999 we treated 30 cases of vesicoureteric reflux in 22 children aged 19 months to 8 years. All the children underwent general anesthesia and subureteric injection of polytetrafluoroethylene paste with a pediatric cystoscope. Patients were discharged the day of the operation and were followed-up 15 days, six months and one year postoperatively with ultrasound and radionuclide cystography. When reflux persisted, the treatment was repeated. RESULTS: Open surgery was performed in one patient with reflux after two repeat injections. Another patient underwent a second, successful, injection. The overall success rate with endoscopic treatment was 96.5% and only one injection was required in 93.1%. None of the patients required hospitalization because of complications due to the operation or the endoscopic technique. CONCLUSIONS: We consider submucosal injection of Teflon to be a first-line technique in the treatment of vesicoureteric reflux in children. The success rate is similar to that of open surgery but with endoscopic treatment morbidity and costs are lower and hospital stay is shorter.

Tratamiento endoscópico del reflujo vesicoureteral / Endoscopic treatment of vesicoureteral reflux

OBJETIVO: Se presenta nuestra experiencia en el tratamiento endoscópico del reflujo vesicoureteral en la infancia mediante la inyección submeatal de Teflon. PACIENTES Y MÉTODOS: Entre abril de 1995 y septiembre de 1999 se han tratado con este método 30 reflujos vesicoureterales en 22 niños con edades comprendidas entre 19 meses y 8 años. En todos ellos se realizó inyección submeatal de Teflon previa administración de anestesia general, bajo control endoscópico a través de un cistoscopio infantil. Los pacientes fueron dados de alta el mismo día y revisados en nuestras consultas a los 15 días, 6 meses y al año de la intervención mediante ecografías y cistografías isotópicas. En caso de recidiva puede repetirse de nuevo la inyección endoscópica. RESULTADOS: Uno de los pacientes requirió cirugía abierta tras el fracaso de dos tratamientos endoscópicos. Otro paciente requirió una segunda inyección de Teflon que resultó exitosa. El porcentaje global de curaciones con el tratamiento endoscópico fue del 96,5% con un 93,1% de éxitos con una sola inyección. Ningún paciente presentó complicaciones secundarias a la intervención o a la técnica quirúrgica que precisaran ingreso hospitalario. CONCLUSIÓN: Se considera la inyección submeatal de Teflon una de las técnicas de elección en el tratamiento del reflujo vesicoureteral, ya que presenta un porcentaje de éxitos similar al de la cirugía abierta, y aventaja a esta última en su baja morbilidad, coste y estancia hospitalaria (AU)

Abordaje renal percutáneo en decúbito supino. Quince años de experiencia / Percutaneous renal approach in supine decubitus position. Fifteen years experience

Han transcurrido ya 15 años desde que desarrolláramos en nuestro Servicio el abordaje percutáneo al riñón con el paciente en posición de decúbito supino. En el momento presente nos acercamos ya a los 1 .000 accesos renales percutáneos en decúbito supino (359 nefrostomías y 613 nefroscopias) y aunque son ya varias las escuelas urológicas de nuestro país y del extranjero que siguen nuestro procedimiento, creemos que éste no ha alcanzado aún la difusión que merece, teniendo en cuenta las ventajas que reporta su empleo: gran simplicidad y mínima morbilidad.Con este tipo de abordaje, además de nefrostomías percutáneas, hemos realizado intervenciones tales corno nefrolitotomías, ureterolitotripsias anterógradas, endopielotomías, resección percutánea de tumores pielocaliciales, repermeabilizaciones ureterales anterógradas, etc., sin tropezar con los inconvenientes inherentes al decúbito prono, y sin observar incremento alguno en la morbilidad que pudiera ser atribuido al empleo de esta peculiar forma de acceder percutáneamente al riñón. El acceso percutáneo al riñón lo solemos realizar bajo simple anestesia local, que complementamos con sedación general intravenosa en el caso de las nefroscopias. Sólo en 187 pacientes, la nefroscopia fue realizada con anestesia raquídea y en 32, con anestesia general, obedeciendo casi siempre estas otras alternativas a las preferencias de cada anestesista. Situamos al paciente en decúbito supino, colocando debajo de la fosa lumbar correspondiente una bolsa de plástico de 3 litros, rellena con aire.El punto de acceso cutáneo lo situamos, entre la 12.ª costilla y la cresta ilíaca, a un dedo por encima del lugar de apoyo del flanco (coincide con la línea axilar posterior). Las nefrostomías percutáneas resultaron exitosas en el 93,2 por ciento, y las nefroscopias, en el 95,2 por ciento de los casos, ocurriendo la mayor parte de los fracasos durante el llamado período de aprendizaje. Un paciente falleció tras una nefrostomía (sepsis y hemorragia). Contamos con cuatro reconversiones por complicaciones: tres por hemorragia y una por perforación accidental de la pelvis y peritoneo en un riñón en herradura. Sólo en 2 casos (de nefroscopias) pudimos confirmar que casualmente habíamos atravesado el colon o el repliegue peritoneal (sin trascendencia alguna). Consideramos que esta forma de abordaje percutáneo al riñón confiere a esta cirugía una gran simplicidad, facilitando al máximo su ejecución en la práctica diaria. Por otra parte, evita la irradiación de las manos del urólogo y reporta para el paciente una considerable reducción del riesgo quirúrgico. (AU)

Technique and complications of percutaneous nephroscopy: experience with 557 patients in the supine position.

PURPOSE: Percutaneous nephroscopy is usually performed with the patient prone, which is uncomfortable for the patient and does not prevent damage to the colon. We assess the possibility of performing percutaneous nephroscopy using local anesthesia with the patient supine, and evaluate the advantages and complications. MATERIALS AND METHODS: A total of 557 consecutive percutaneous nephroscopies were attempted in 221 men and 242 women in the supine position. Patient age ranged from 8 to 87 years (mean 55.1). Patients are supine with a 3 l. serum bag below the ipsilateral flank. We catheterize the affected uretheral meatus with a 5F catheter through a flexible cystoscope. The tract is infiltrated with local anesthesia. The skin is punctured in the posterior axillary line which corresponds to approximately 1 cm. above the bag. We use an Alken set to dilate the tract to 30F, which is the size of the Amplatz sheath we commonly use. RESULTS: Nephroscopy was performed in 519 cases (93.1%). Mean operation time was 85 minutes (range 15 to 240). Serious bleeding occurred in 3 cases. The colon was never damaged in patients treated in the supine position. CONCLUSIONS: Percutaneous nephroscopy using local anesthesia with the patient supine is safe and easy. According to our experience the advantages in comfort to the patient and feasibility to the surgeon justify its use.

[Prognostic value of cytology in terms of survival in prostatic cancer]. / Valor pronóstico de la citología en el cáncer de próstata en relación a la supervivencia.

The cytologic grade of malignancy and its relationship with survival was evaluated en 154 consecutive patients with prostatic cancer. The cytological aspirates were stained by the Papanicolay method and evaluated by two cytopathologists. Specimens were characterized as well, moderately or poorly differentiated, based on standard criteria. Patients without tumoral extension were initially untreated, and in the case of tumoral extension or posterior progression in the case of initially localized tumors, they were hormonally treated. The follow-up had a range between 33 and 120 months. The disease-specific survival was estimated by the Kaplan-Meier's curves. Our results indicate that there is a worse survival expectancy to the moderately differentiated tumors compared with the well differentiated. No difference was showed with the poorly differentiated, due to the low number of patients with it. The overall survival was compared to the control population survival, showing no difference except for the patients younger than 65 years old. The cytological aspirate of the prostate is not only a good method to diagnose prostatic cancer, our results confirm the prognostic value of the cytologic malignancy grading.

[Significance of ploidy in prostatic cancer, quantified by a prospectively applicable procedure]. / Valor de la ploidía en el cáncer de próstata, cuantificada mediante un procedimiento de aplicabilidad prospectiva.

OBJECTIVES: To determine the ploidy of prostatic adenocarcinoma cells obtained by fine-needle punction-aspiration biopsy using computer-assisted image analysis and its prognostic value. METHODS: The clinical applications of the two most commonly utilized methods, flow cytometry and cytophotometry, is difficult. The ploidy of prostatic adenocarcinoma cells obtained by fine-needle punction-aspiration biopsy in 54 patients was determined by image analysis. Previous cytological preparations from our files were utilized in the present study. Before processing the preparations, the Papanicolau stain used originally was removed. To make the technique simpler, we did not use the Feulgen stain but the progressive hematoxylin stain, which is faster and easier to use. The representative ploidy histograms were classified into four types first and then into two grades of DNA malignancy. The survival curves were plotted using the Kaplan-Meier method and according to the ploidy. RESULTS: Patients with high grade DNA malignancy had a worse survival rate than those with low grade malignancy. Statistical analysis using the log-rank test showed a significant difference, with p < 0.001. CONCLUSIONS: Tumor ploidy in prostate cancer can be determined prospectively using cytological smears with progressive hematoxylin staining and has a prognostic value.

[Nephrectomy through lumbar endoscopy. Report of 3 cases]. / Nefrectomía a través de lumboscopia. A propósito de tres casos.

After a long experience with transperitoneal laparoscopic surgery of the kidney, we have incorporated the Gaur balloon technique for dissection. We report our experience of 3 nephrectomy procedures performed via lumboscopy, with the patients lying in the lumbotomy position. A 12 mm skin incision is made in the axillary midline. Blunt dissection of the muscle planes is carried out and the retroperitoneal space is explored digitally. A 16 F balloon-tipped catheter is introduced and the balloon is distended with 720 ml saline solution. The catheter is removed and a Hasson trocar with optics and 3 accessory trocars are inserted. The kidney is dissected and the elements of the vascular pedicle are clipped or stapled independently. The kidney is fragmented inside a Lapsac and removed. In our view, this procedure is easier to perform and carries less morbidity than transperitoneal laparoscopic nephrectomy.

[Retroperitoneal angiomyolipoma stemming from the psoas. Comments on a case]. / Angiomiolipoma retroperitoneal originado en el psoas. Comentarios sobre un caso.

We report a case of subclinical retroperitoneal tumor in a young patient. Although different diagnostic techniques were utilized (US, urography, CT, etc.), the tumor type could not be determined preoperatively. A malignant tumor was suspected, therefore surgical excision was warranted. The pathological analysis disclosed an angiomyolipoma in the psoas muscle, a benign tumor in an uncommon site. The foregoing finding prompted us to report the present case.

[Experience with endoscopic urethrocervicopexy: long-term results]. / Experiencia con la uretrocervicopexia endoscópica: resultados a largo plazo.

With the purpose of evaluating the long-term results of percutaneous endoscopic urethrocervicopexy performed in our unit since 1987, using a modified Stamey's technique, in the treatment of stress urinary incontinence in women, 51 patients who had undergone surgery up to June 92 were retrospectively studied. Mean time since surgery was 35 months, and satisfactory results during this time were accomplished in 60.5%, bearing in mind that the patients are totally "dry" and do not require sanitary towels. Comparison of our results and those contributed by other authors in the literature, indicating the decrease over time in the number of good results, and that between three to four years after intervention, the stress urinary incontinence reappears in one third of the women. Finally, we try to provide an statistical correlation of the cases in which continence was not achieved, including the patient's personal features or their medical-surgical background.

[Laparoscopic renal surgery]. / Cirugía renal laparoscópica.

Spurred by the development of laparoscopic lymphadenectomy and nephrectomy, laparoscopic surgery has gained acceptance in Urology, although not as rapidly as endourology. Laparoscopic access to the kidney is easier by the transperitoneal than by the retroperitoneal approach. Insertion of a trocar through the umbilicus for the optic and utilizing three to five accessory trocars is the standard practice. In some simple procedures two accessory trocars will suffice, four trocars and periumbilical trocar are required for nephrectomy, and an additional trocar is inserted in the hypogastrium for distal ureter release in nephroureterectomy. The procedure is performed using intravenous general anesthesia with endotracheal intubation and the patient is placed in the supine decubitus position with a 45 degrees lateral tilt or in the total lateral decubitus position (nephrectomy) with a slight anti-Trendelenburg. Exposure of the kidney is achieved by opening the posterior peritoneum along the line of Toldt and, in some cases, releasing the hepatic angle or the splenic colon. The kidney can be released partially or completely depending on the type of surgery. It is easier to perform an extended nephrectomy since dissection is performed better between the capsule of Gerota and the pararenal tissue. The renal vessels can be controlled with clips or an automatic stapling/cutting device. Laparoscopic access to the mid and upper ureter is very simple and the only difficulty encountered is in its correct identification. The current and future applications of laparoscopic renal surgery are discussed, including some original procedures that have been performed by the authors, such as in situ excision of a renal tumor and two pyelolithotomy procedures in solitary kidney.

[Laparoscopic cystoprostatovesiculectomy and ureterosigmoidostomy. Experimental surgical model]. / Cistoprostatovesiculectomia y ureterosigmoidostomía laparoscópicas. Modelo quirúrgico experimental.

The authors have performed 26 experimental laparoscopic cystoprostatovesiculectomies in pigs, 17 of which were followed by ureterosigmoidostomies, also laparoscopically. Using a 10 mm trocar at the umbilical level (optics), another 10 mm at the hypogastric level (pliers and titanium staple applicator), a third 5 mm in left iliac fossa (pliers) and another 5 mm in right iliac fossa (electric shears), cystectomy is performed with a routine technique: stapling and section of deferents, umbilical arteries, vesical lateral pedicles and prostate-seminal pedicles. A double ligature precedes the section of the urethra in the pelvian fundus. A plier passed within an Amplatz jacket (previously introduced through the anus) assists the laparoscopic ureterosigmoidostomy "in elephant trunk" which is performed by sero-muscle suture using 3-zero reabsorbable single-strand material. Overcoming the anatomical differences existing with humans, the illustrated experimental model confirms the possibility of performing this type of procedures in human beings, which would considerably curtail the morbidity associated with this type of surgery.

[Percutaneous treatment of a mycotic renal abscess, caused by Aspergillus fumigatus, in an AIDS patient]. / Tratamiento percutáneo de absceso renal micótico por Aspergillus fumigatus en un paciente con SIDA.

Presentation of one case of renal mycosis by Aspergillus as a primary complication in one patient diagnosed with acquired immunodeficiency syndrome. The importance of conservative treatment at all costs through percutaneous drainage is underlined, specially if we considered the short life expectancy of patients who have developed AIDS.

[Laparoscopic nephrectomy: experimental surgical model]. / Nefrectomía laparoscópica: modelo quirúrgico experimental.

Presentation of 39 experimental laparoscopic nephrectomies carried out in pig. With the animals under general anaesthesia and using 4 laparoscopic trocars the authors dissected the kidney and clipped separately the ureter, renal arteria and vein. Once these elements were sectioned, they placed the kidney inside a small plastic pouch (introduced within the peritoneal cavity through one of the trocars) and after extracting its neck through the hole in the abdominal wall created by the 11 mm trócar, they performed different intra-abdominal fragmentation procedures on the extirpated kidney. Following fragmentation testing with a 7 and 10 mm punch, resectoscopic electric loop, arthroscopic cutter and ultrasonic tissue aspiration procedures, they concluded stating that an increase in the power of these last equipment would convert them into an ideal procedure for laparoscopic exeresis of any intra-abdominal organ.