[Are we underutilizing suprapubic catheter as a valid option for patients requiring a permanent catheter unsuitable for clean intermittent self-catheterization?] / ¿Estamos infrautilizando el catéter suprapúbico como una opción válida en pacientes que requieren cateterismo permanente y que no son candidatos a cateterismo intermitente limpio?

Sr Director: Es sobradamente conocido que los pacientes que requieren cateterismos crónicos sufren, como complicaciones a largo plazo, infecciones del tracto urinario de repetición, formación de litiasis, restricción de su independencia y empeoramiento de la calidad de vida, e incluso aumento de incidencia de cáncer urotelial (1). El cateterismo intermitente limpio (SIL) es considerado por las principales guías clínicas (AEU, EAU) como el gold estándar para estos pacientes, aunque con fuerza débil de recomendación. Esta práctica está basada en la hipótesis de reducir el tiempo de exposición del urotelio a cuerpos extraños, además de aproximarse de una manera más fisiológica al ciclo de llenado-vaciado vesical normal. Sin embargo, desde su propuesta de introducción en 1966 (2), la evidencia disponible se apoya principalmente en estudios retrospectivos, asociando el cateterismo crónico con mayor incidencia de proteinuria y reflujo vesicoureteral (3).

Sr Director:Es sobradamente conocido que los pacientes que requieren cateterismos crónicos sufren, como complicaciones a largo plazo, infecciones del tracto urinario de repetición, formación de litiasis, restricción de su independencia y empeoramiento de la calidad de vida, e incluso aumento de incidencia de cáncer urotelial (1). El cateterismo intermitente limpio (SIL) es considerado por las principales guías clínicas (AEU, EAU) como el gold estándar para estos pacientes, aunque con fuerza débil de recomendación. Esta práctica está basada en la hipótesis de reducir el tiempo de exposición del urotelio a cuerpos extraños, además de aproximarse de una manera más fisiológica al ciclo de llenado-vaciado vesical normal. Sin embargo, desde su propuesta de introducción en 1966 (2), la evidencia disponible se apoya principalmente en estudios retrospectivos, asociando el cateterismo crónico con mayor incidencia de proteinuria y reflujo vesicoureteral (3).

Insights into the Management of Overactive Bladder with Transdermal Oxybutynin: A Practical Review.

Overactive bladder (OAB), clinically defined as urinary urgency, with or without incontinence, generally accompanied by an increase in urinary frequency and nocturia, after any local disease or metabolic disorder that would explain these symptoms have been ruled out, is a highly prevalent condition that affects millions of men and women worldwide. Not only can the symptoms of OAB be very bothersome, but OAB can have significant detrimental effects on many aspects of individuals' lives, representing a particularly impactful health burden to quality of life and productivity. Besides a wide range of conservative treatments, the clinical efficacy of which remains an open issue, antimuscarinics are the mainstay of pharmacotherapy for this condition but anticholinergic troublesome side effects like dry mouth, and the patient's perception of lack of efficacy and poor adherence, are common reasons of abandonment of treatment. An alternative to oral administration treatment, with a lower incidence of dry mouth and other anticholinergic adverse effects, might be attractive to patients and a real treatment option for physicians. Delivery of oxybutynin directly through the skin with oxybutynin transdermal (OXY-TDS) avoids the first-pass hepatic metabolism that occurs with orally administered oxybutynin and prevents the appearance of anticholinergic adverse events. OXY-TDS being equally effective than oral treatment improves adherence, persistence, and patient satisfaction. The aim of this review is to focus on evidence available of the use of OXY-TDS in the management of patients with OAB, and to help clinicians in the challenges involved in the treatment options for patients with this condition.

Efficacy of Transdermal Oxybutynin in the Treatment of Overactive Bladder Syndrome: Does It Make Sense Using It in 2017?

OBJECTIVES: Evaluation of changes in symptoms among patients with overactive bladder syndrome treated with transdermal oxybutynin and tolerability after 12 months of follow-up. METHODS: This was a multicenter, retrospective, single-cohort, observational study. Changes in symptoms were evaluated primarily with a 3-day voiding diary. Results were compared to baseline. Subgroup analyses were performed in patients previously treated for OAB or not and aged < 65 years versus ≥65 years. RESULTS: Clinical records of 105 patients were examined; 92.4% were women. At 12 months, 58 patients continued to receive transdermal oxybutynin. Changes in symptoms according to the voiding diary were evaluated in 47 patients. Significant improvements from baseline were observed in urinary frequency (-2.6 voids/24 hours (95% CI: -3.5; -1.8), p < 0.001); daily number of urgent episodes (-4.7 episodes/day (95% CI: -6.1; -3.6), p < 0.001); and urge incontinence (-1.9 episodes/day (95% CI: -2.9; -1.3), p < 0.001). No statistically significant differences were found in subgroup analyses. In total, 38.1% of patients had adverse events, primarily in the application site (27.6%). No severe systemic adverse events occurred. Only 6 patients (5.7%) reported dry mouth. CONCLUSIONS: Improved symptoms and good tolerability observed after 1 year of treatment with transdermal oxybutynin shows that it currently has a place in the treatment of OAB patients.

Tolerabilidad, persistencia y satisfacción. Estudio de cohortes retrospectivas realizado en condiciones de práctica clínica habitual en pacientes con síndrome de vejiga hiperactiva tratados con oxibutinina transdérmica. Estudio OSCAR / Tolerability, persistence and satisfaction. Retrospective cohort study in patients with overactive bladder syndrome treated with transdermal Oxybutynin under Standard ClinicAl pRactice. OSCAR Study

OBJETIVOS: Determinar la tolerabilidad, persistencia y satisfacción de los pacientes con síndrome de vejiga hiperactiva (SVH) tratados con oxibutinina transdérmica (OXI-TDS). MÉTODOS: Estudio observacional retrospectivo, multicéntrico, en pacientes con SVH que hubieran iniciado tratamiento con OXI-TDS, al menos 12 meses antes de su inclusión. La tolerabilidad se evaluó a través del número criterios de gravedad y tipo de resolución de las reacciones adversas y mediante el cálculo de la función cognitiva con el Mini-Mental State Examination al año de tratamiento. Para la evaluación de la persistencia se utilizó el porcentaje de pacientes que permanecieron en tratamiento durante el periodo de observación y para la evaluación de la satisfacción del paciente con el tratamiento se elaboró un cuestionario ad hoc. RESULTADOS: El estudio evaluó la historia clínica de 105 pacientes, con una media de edad de 59,4 ± 11,8 años, de los cuales el 92,4% fueron mujeres. A los 12 meses de tratamiento, el 5,7% y el 27,6% de los pacientes presentaron sequedad de boca y reacciones adversas en la zona de aplicación del parche de intensidad leve o moderada, respectivamente. Ningún paciente presentó alteraciones de la función cognitiva. La persistencia fue del 55,2% y el 92,9% consideraron muy cómodo/cómodo el uso del parche de OXI-TDS. CONCLUSIONES: En el estudio realizado en pacientes con SVH, se observa una baja incidencia de reacciones adversas de expresión sistémica, incluyendo la sequedad de boca, tras un año de tratamiento con OXI-TDS, mejorando las tasas de adherencia al mismo. Los pacientes presentan una elevada persistencia al tratamiento y refieren una alta satisfacción con el mismo

OBJECTIVES: To determine the tolerability, persistenceand satisfaction of patients with overactive bladder syndrome (OAB) treated with transdermal oxybutynin (OXY-TDS). METHODS: Observational, retrospective, multicenter study, in patients with OAB who had started treatment with OXY-TDS at least 12 months before their inclusion. Tolerability was evaluated by number, severity criteria, resolution type of adverse reactions, and cognitive function with Mini-Mental State Examination (MMSE), at 1 year of treatment. The patients who remained under treatment during the observation period were considered persistent. Patient satisfaction was evaluated using an ad hoc questionnaire.RESULTS: The clinical history of 105 patients was evaluated. 92.4% were women. The mean age of all the patients was 59.4 ± 11.8 years. After 12 months of treatment, dry mouth was present in 5.7% of patients and 27.6% had mild or moderate adverse reactions in the area of application. The persistence in treatment was 55.2%. The use of the OXY-TDS was considered comfortable or very comfortable by 92.9% of patients. CONCLUSIONS: The study performed in patients with OAB shows that OXY-TDS provides low incidence of systemic adverse effects, including dry mouth, high persistence, improved adherence rates and high satisfaction of patients after one year of treatment

[Tolerability, persistence and satisfaction. Retrospective cohort study in patients with overactive bladder syndrome treated with transdermal Oxybutynin under Standard ClinicAl pRactice. OSCAR Study.] / Tolerabilidad, persistencia y satisfacción. Estudio de cohortes retrospectivas realizado en condiciones de práctica clínica habitual en pacientes con síndrome de vejiga hiperactiva tratados con oxibutinina transdérmica. Estudio OSCAR.

OBJECTIVES: To determine the tolerability, persistenceand satisfaction of patients with overactive bladder syndrome (OAB) treated with transdermal oxybutynin (OXY-TDS). METHODS: Observational, retrospective, multicenter study, in patients with OAB who had started treatment with OXY-TDS at least 12 months before their inclusion. Tolerability was evaluated by number, severity criteria, resolution type of adverse reactions, and cognitive function with Mini-Mental State Examination (MMSE), at 1 year of treatment. The patients who remained under treatment during the observation period were considered persistent. Patient satisfaction was evaluated using an ad hoc questionnaire. RESULTS: The clinical history of 105 patients was evaluated. 92.4% were women. The mean age of all the patients was 59.4 ± 11.8 years. After 12 months of treatment, dry mouth was present in 5.7% of patients and 27.6% had mild or moderate adverse reactions in the area of application. The persistence in treatment was 55.2%. The use of the OXY-TDS was considered comfortable or very comfortable by 92.9% of patients. CONCLUSIONS: The study performed in patients with OAB shows that OXY-TDS provides low incidence of systemic adverse effects, including dry mouth, high persistence, improved adherence rates and high satisfaction of patients after one year of treatment.

Prospective urodynamic model for prediction of urinary incontinence after robot-assisted radical prostatectomy.

OBJECTIVES: To assess the preoperative urodynamic predictors of urinary incontinence (UI) 1 year after robot-assisted radical prostatectomy (RARP) and to design a nomogram capable of predicting its occurrence. MATERIALS AND METHODS: Our prospective study included 58 previously continent patients who underwent RARP, in most cases, bilateral nerve-sparing and bladder neck preservation. A urodynamic examination including a urethral pressure profile was performed preoperatively. Multivariate analysis was used to assess the predictors for the need to use 1 or more pads/day and a nomogram was constructed. RESULTS: There was a 20.6% incidence of UI at 1 year after RARP. Bladder compliance, maximum urethral closure pressure and the development of bladder outlet obstruction, correlated well with the incidence of UI on the multivariate analysis (p = 0.043, 0.001, and 0.05, respectively). CONCLUSION: Bladder compliance <27.8 ml/cm H2O, maximum urethral closure pressure <50.3 cm H2O and the bladder outlet obstruction are independent urodynamic factors correlating with UI after RARP. The new nomogram can objectively predict a patient likelihood of requiring 1 or more pads/day 1 year after RARP with a good accuracy.

Comprehensive prediction model of urinary incontinence one year following robot-assisted radical prostatectomy.

OBJECTIVES: Urinary incontinence (UI) still remains one of the major functional complications after robot-assisted radical prostatectomy (RARP). As the cause for UI is multifactorial, it is quite difficult to make a prediction preoperatively. Considering intraoperative and postoperative risk factors, besides the preoperative ones, we designed an incontinence prediction model, administered 1 month after the surgery, in order to identify incontinent patients at 1 year. PATIENTS AND METHODS: We retrospectively reviewed 244 patients who underwent RARP at our institution. Only 209 patients had sufficient data, a 1-year follow-up and were continent preoperatively. The association of UI with the risk factors was assessed by univariable and multivariable regression models. RESULTS: There was a 17.2% global UI rate at 1 year after RARP. Only age-adjusted Charlson comorbidity index, erectile function assessed by International Index of Erectile Function-5, prostate volume, nerve-sparing status and 24-hour urine loss at 1 month correlated with UI (p = 0.032, 0.009, 0.031, 0.018 and <0.001, respectively). The accuracy of the prediction model of UI was 92.8% (c-index), with an area under the curve of 91.9%. CONCLUSION: Age-adjusted Charlson comorbidity index, International Index of Erectile Function-5, prostate volume, nerve-sparing status and 24-hour urine loss at 1 month after RARP can predict an individual's risk of UI at 1 year after RARP with good accuracy. Further external validation is required in order to generalize the use of this model.

Recuerdo y actualización de las bases anatómicas del pene / Review and update of the anatomy of the penis

El conocimiento de la anatomía del pene es fundamental para realizar un correcto diagnóstico y enfoque del tratamiento más adecuado, de las distintas enfermedades que puede presentar: estenosis de uretra, disfunción eréctil, incurvación, congénita o adquirida, etc.; siendo imprescindible su conocimiento anatómico para un buen manejo quirúrgico.El pene es el órgano masculino involucrado en la función miccional y sexual. El cuerpo del pene esta compuesto por tres cuerpos eréctiles, léase las estructuras profundas: los cuerpos cavernosos y el cuerpo esponjoso, este último rodea y cubre la uretra. La fascia de Buck se relaciona con las estructuras profundas del pene. La fascia superficial formada por tejido más areolar, el dartos, se relaciona con la piel y la vascularización.La irrigación de las estructuras profundas depende de la arteria peneana común, rama de la arteria pudenda interna. La sangre del pene drena a través de 3 sistemas venosos: el superficial, el intermedio y el profundo.Los nervios peneanos son ramas de los pudendos y los cavernosos. Los nervios pudendos son los encargados de la inervación somática motora y sensitiva. Los nervios cavernosos son una combinación de fibras aferentes parasimpáticas y simpáticas, y corresponden a los nervios del sistema autónomo del pene(AU)

OBJECTIVES: The knowledge of penile anatomy is basic to perform a proper diagnosis and direct the most adequate treatment of the various diseases that may appear: urethral stenosis, erectile dysfunction, congenital or acquired penile curvature, etc.; being its anatomical knowledge essential for a proper surgical management.The penis is the male organ involved in both voiding and sexual functions: the body of the penis is composed by three erectile bodies, (i.e the deep structures): the corpora cavernosa and the corpus spongiosum, this last surrounding and covering the urethra. Buck’s fascia is in relation to the deep structures of the penis. The superficial fascia, dartos, is made up from a more areolar tissue and is in relation to skin and vessels. The vascularization of the deep structures comes from the common penile artery, a branch of the internal pudendal artery. Penile blood drains through three venous systems: superficial, intermediate and deep systems. Pudendal nerves are in charge of the sensitive and motor somatic innervations. Cavernosal nerves are a combination of parasympathetic and sympathetic afferent fibers, corresponding to the nerves of the autonomic system of the penis(AU)

Historia clínica dirigida y exploración física en pacientes con disfunción eréctil: Aspectos clínicos que no podemos olvidar / Directed Clinical History and physical examination in patients with erectile dysfunction. Clinical features we cannot forget

OBJETIVO: Con este trabajo pretendemos establecer unas pautas de recogida de datos en la historia clínica en el paciente con disfunción eréctil, con el fin de caracterizar el problema que se presenta, revelar posibles factores de riesgo asociados, evaluar la necesidad de pruebas complementarias adicionales y decidir si es necesario un abordaje con participación multidisciplinaria.MÉTODOS: Revisión de la literatura sobre las directrices y recomendaciones en el manejo inicial y clínico de la DE.CONCLUSIONES: La historia sexual es la parte más importante de la rutina básica del paciente con disfunción eréctil y la finalidad del andrólogo será identificar el tipo de disfunción sexual, su comienzo, gravedad, duración y las expectativas de tratamiento(AU)

OBJECTIVES: We aim in this work to establish directions for data collection in the chart of the patient with erectile dysfunction (ED), to characterize the presenting problem, reveal possible associated risk factors, evaluate the need of additional complementary tests, and decide if a multidisciplinary approach is necessary.METHODS: Bibliographic review about directions and recommendations on initial and clinical management of ED.CONCLUSIONS: Sexual history is the most important part of the basic routine with a patient with ED, and the purpose of the andrologist is to identify the type of sexual dysfunction, time of start, severity, duration, and treatment expectations(AU)

[Intraureteral foreign body]. / Cuerpo extraño intraureteral.

OBJECTIVE: We present a rare localization for a foreing body in the urinary system, and review the bibliography to know about it existence, frequency and localization. METHODS: We present the case of a 49 year old woman who referreds she had introduced a metallic objet in her genital area. RESULTS: After the necessary tests, we could see a metallic cylinder. It was 8 cm long and was localized inside the right pelvic ureter. CONCLUSIONS: The presence of strange bodies in the urinary system is a rare urological emergency. Treatment is the key element of the extraction of the least bloody way possible.

[Bilateral obstructive uropathy as clinical presentation of primary bladder lymphoma]. / Uropatía obstructiva bilateral como forma de presentación de linfoma vesical primario.

OBJECTIVE: We report the event of an atypical presentation of primary bladder lymphoma, treated in our hospital, and review the literature of such tumors, representing 0.2% of bladder tumors, being macroscopic hematuria with clots the most frequent reason for patient consultation. METHODS: We report the case of an 83 years old man who went to the emergency room because of oligoanuria of 48 hours of evolution. He was diagnosed of bladder tumor. RESULTS: The pathology turned out to be a primary bladder lymphoma cell B. CONCLUSIONS: Primary bladder lymphoma is a rare entity that presents a similar behaviour to other bladder tumors, having a good response to treatment with chemotherapy.

Uropatia obstructiva bilateral como forma de presentación de linfoma vesical primario / Bilateral obstructive uropathy as clinical presentation of primary bladder lymphoma

OBJETIVO: Dar a conocer un caso de presentación atípica de linfoma vesical primario tratado en nuestro hospital, así como revisar la bibliografía de este tipo de tumores, que representan el 0.2% de los tumores vesicales, siendo su forma de presentación más frecuente la hematuria macroscópica con coágulos.MÉTODOS: Presentamos el caso de un varón de 83 años, que acudió a Urgencias por oligoanuria de 48h de evolución, en el que se diagnosticó un tumor vesical.RESULTADO: La anatomía patológica resulto ser un linfoma vesical primario de células B.CONCLUSIONES: El linfoma vesical primario es una entidad poco frecuente, que cursa de forma indistinguible a otros tumores vesicales, presentando una buena respuesta al tratamiento con quimioterapia(AU)

OBJECTIVE: We report the event of an atypical presentation of primary bladder lymphoma, treated in our hospital, and review the literature of such tumors, representing 0,2% of bladder tumors, being macroscopic hematuria with clots the most frequent reason for patient consultation.METHODS: We report the case of an 83 years old man who went to the emergency room because of oligoanuria of 48 hours of evolution. He was diagnosed of bladder tumor.RESULTS: The pathology turned out to be a primary bladder lymphoma cell B.CONCLUSIONS: Primary bladder lymphoma is a rare entity that presents a similar behaviour to other bladder tumors, having a good response to treatment with chemotherapy(AU)

Cuerpo extraño intraureteral / Intraureteral foreign body

OBJETIVO: Presentar una localización atípica de cuerpos extraños en el interior del aparato urinario, así como revisar en la bibliografía su existencia, frecuencia y localización.MÉTODOS: Presentamos el caso de una mujer de 49 años, que refiere la introducción de un objeto metálico en el área genital.RESULTADO: Tras la realización de las pruebas complementarias pertinentes, se objetiva un cilindro metálico de 8 cm de longitud, localizado en el interior del uréter pelviano derecho.CONCLUSIÓN: La presencia de cuerpos extraños en el interior del aparato urinario es una rara urgencia urológica, su tratamiento fundamental consiste en la extracción del elemento de la manera menos cruenta posible(AU)

OBJECTIVE: We present a rare localization for a foreing body in the urinary system, and review the bibliography to know about it existence, frequency and lo-calization.METHODS: We present the case of a 49 year old woman who referreds she had introduced a metallic objet in her genital area.RESULTS: After the necessary tests, we could see a metallic cylinder. It was 8 cm long and was localized inside the right pelvic ureter.CONCLUSIONS: The presence of strange bodies in the urinary system is a rare urological emergency. Treatment is the key element of the extraction of the least bloody way possible(AU)

Holmium laser treatment for low grade, low stage, noninvasive bladder cancer with local anesthesia and early instillation of mitomycin C.

PURPOSE: We evaluated the results of laser photocoagulation of recurrent low stage noninvasive bladder cancer. MATERIALS AND METHODS: The study included 36 patients with a recurrent superficial papillary tumor within 1 year of endoscopic resection. Patients underwent laser photocoagulation of the recurrence under local anesthesia and sedation. They received early instillation of 40 mg mitomycin C and were discharged home without a catheter a few hours after the operation. Patients completed a visual analog scale to quantify the perceived level of pain, including 1--no pain to 10--maximum pain. Patients were reviewed after 3, 6 and 12 months to evaluate tumor recurrence. RESULTS: The mean and median visual analog scale score was 3 points (range 1 to 10). No patient had urinary infection or a catheter at hospital discharge. The incidence of recurrence at 12 months was 25%, mainly in the first 15 cases. CONCLUSIONS: Laser photocoagulation with local anesthesia and sedation is easy to perform and well tolerated. There were no complications and the recurrence rate was similar to that of transurethral resection, as calculated using the recurrence calculator of the 2006 guidelines on TaT1 (nonmuscle invasive) bladder cancer from the European Association of Urology.