Hepatotoxicidad por tamsulosina / dutasterida: reporte de un caso probable

La tamsulosina y dutasterida son medicamentos ampliamente usados como tratamiento de la hipertrofia benigna de próstata. teniendo un buen perfil de seguridad. Existen escasos reportes de injuria hepática asociado al uso de tamsulosina; sin embargo, no hay reportes de toxicidad hepática por el uso de dutasterida y del uso combinado de tamsulosina/dutasterida. Se presenta el caso de un varón de 64 años quien desarrolla injuria hepática tras el uso combinado de tamsulosina/dutasterida, desarrollando un patrón de daño hepatocelular y clínica de hepatitis aguda. Se realizo descarte de patología hepática viral, autoinmune y enfermedades metabólicas de depósito, así como de patología biliar mediante ecografía abdominal y colangioresonancia. En la evaluación de causalidad, presentó CIOMS-RUCAM: 6 puntos (probable) y Naranjo: 4 puntos (posible). El paciente presentó respuesta clínica y laboratorial luego de suspender el medicamento.

Tamsulosin and dutasteride are drugs widely used to treat benign prostatic hypertrophy. having a good safety profile. There are few reports of liver injury associated with the use of tamsulosin; however, there are no reports of hepatic toxicity from the use of dutasteride and the combined use of tamsulosin/dutasteride. We present the case of a 64-year-old man who developed liver injury after the combined use of tamsulosin/dutasteride, developing a pattern of hepatocellular damage and acute hepatitis symptoms. Viral, autoimmune, and metabolic storage diseases of the liver were ruled out, as well as biliary pathology by means of abdominal ultrasound and resonance cholangiography. In the causality evaluation, CIOMS-RUCAM presented: 6 points (probable) and Naranjo: 4 points (possible). The patient presented a clinical and laboratory response after discontinuing the drug.

[Urology clinics referral Patterns after initiation of a Primary Care BPH-LUTS protocol.] / Evolución de las derivaciones desde atención primaria a la consulta de urología tras la aplicación de un protocolo de pacientes con síntomas del tracto urinario inferior por hiperplasia benigna de próstata.

OBJECTIVE: In the Spanish health system, General Practitioners (GPs) play a key role in regulating the flow of patients to hospital care. Most of patients with BPH can be managed through out the evolution of the disease exclusively by the GPs.  METHODS: A pre-experimental study was carried outin two periods, before (pre-test) and after (post-test) of the dissemination of a management protocol for patients with BPH. The protocol was trialled in the health area of Villarrobledo and included all referrals to the urology clinic for BPH from Primary Care. We analyzed the appropriate referrals according with the criteria set for thin the protocol and compared the complementary tests through statistical study (descriptive, a bivariate, multivariate analysis and rate calculation) using version 21of the SPSS. RESULTS: Referral rate decreased after the application of the protocol but did not increase the rate of appropriated referrals. Patients referred after setting forth protocol by GPs that assisted to the education program were younger. There were referred less patients with elevated PSA and more patients with clinical progression. These GPs used less test to achieve diagnosis. The GPs whodid not attend were significantly younger, mainly women, with no previous specific training in BPH and without a full time GP position. CONCLUSIONS: The implementation of a protocol has reduced the referral rate, but it has not improved the appropriate referrals. More research is required to understand the determinants of inequalities in referral from primary care.

OBJETIVO: Los médicos de Atención Primaria (MAP) son fundamentales en la regulación del flujo de pacientes desde Atención Primaria (AP), por tanto,es esencial buscar métodos de adecuada gestión de la demanda asistencial y así optimizar recursos. En la hipertrofia benigna de próstata (HBP) se estima que 2/3 de los pacientes pueden ser manejados íntegramentedesd e AP a lo largo de todo el proceso de la HBP.MATERIAL Y MÉTODOS: Hemos realizado un estudio pre experimental en dos períodos, antes (pre-test) y después (post-test) de la creación de un protocolo de manejo y derivación de pacientes con HBP. Analizamos la adecuación a los criterios de derivación y el uso de los estudios complementarios para llevar a cabo el diagnóstico, realizando un análisis estadístico (descriptivo, bivariante, multivariante y cálculo de tasas) utilizando SPSS (versión 21). RESULTADOS: La tasa de derivación disminuyó tras la aplicación del protocolo, pero no logró mejorar la adecuación. Los pacientes derivados por los MAP que asistieron al programa educativo fueron más jóvenes. Se remitieron menos pacientes con PSA elevado y más pacientes con progresión clínica. Se utilizaron menos estudios complementarios. Los MAP que no acudieron a la formación eran más jóvenes, principalmente mujeres, sin formación especifica en HBP y con contrato temporal. CONCLUSIONES: A pesar de reducir la tasa de derivación no se consiguió mejorar la adecuación de la derivación de los pacientes. Consideramos necesario analizar la problemática de los MAP y valorar otras intervenciones que podrían mejorar la calidad en la transferencia de responsabilidades.

Erectile dysfunction in patients with arterial hypertension. Cardiovascular risk and impact on their quality of life. / Disfunción eréctil en pacientes con hipertensión arterial. Riesgo cardiovascular e impacto en su calidad de vida.

OBJECTIVES: Estimate the frequency of erectile dysfunction in patients with essential hypertension and associated variables, degree of control, cardiovascular risk and the impact on quality of life. MATERIAL AND METHODS: Type of study: Observational study of prevalence in men with essential hypertension. MEASUREMENTS: Sociodemographic and comorbidity variables were collected from each patient (age, Charlson index, dyslipidaemia and prostatic hyperplasia), degree of control of essential hypertension and treatment, cardiovascular risk and metabolic syndrome. The erectile dysfunction was diagnosed by the International Index of Erectile Function (IIEF-15). Quality of life questionnaires were carried out in essential hypertension (MINICHAL), and the international scale of prostatic symptoms (IPSS). RESULTS: The study included 262 hypertensive men with an average age of 65.84years. Erectile dysfunction was presented in 46.1%, being severe in 54.9%. The bivariate analysis shows an independent association between erectile dysfunction and the variables: age, Charlon index, dyslipidaemia, benign prostatic hypertrophy, diastolic blood pressure, years of diagnosis of hypertension, number of treatments, Regicor and Framingham-Wilson, glycaemia, creatinine and GPT, glomerular filtration through the MDRD formula, irritative symptomatology (IPSS) and somatic manifestations (MINICHAL). The final multivariate model found association with age, presentation of dyslipidaemia, prostatic hyperplasia and metabolic syndrome. CONCLUSIONS: Erectile dysfunction is significantly associated with age, dyslipidaemia, benign prostatic hypertrophy and metabolic syndrome.

Prospective study comparing laparoscopic and open adenomectomy: Surgical and functional results. / Estudio prospectivo comparativo entre adenomectomía laparoscópica y abierta: resultados operatorios y funcionales.

INTRODUCTION: Open adenomectomy (OA) is the surgery of choice for large volume benign prostatic hyperplasia, and laparoscopic adenomectomy (LA) represents a minimally invasive alternative. We present a long-term, prospective study comparing both techniques. PATIENTS AND METHODS: The study consecutively included 199 patients with benign prostatic hyperplasia and prostate volumes>80g who were followed for more than 12 months. The patients underwent OA (n=97) or LA (n=102). We recorded and compared demographic and perioperative data, functional results and complications using a descriptive statistical analysis. RESULTS: The mean age was 69.2±7.7 years (range 42-87), and the mean prostate volume (measured by TRUS) was 112.1±32.7mL (range 78-260). There were no baseline differences among the groups in terms of age, ASA scale, prostate volume, PSA levels, Qmax, IPSS, QoL or treatments prior to the surgery. The surgical time (P<.0001) and catheter time (P<.0002) were longer in the LA group. Operative bleeding (P<.0001), transfusion rate (P=.0015) and mean stay (P<.0001) were significantly lower in the LA group. The LA group had a lower rate of complications (P=.04), but there were no significant differences between the groups in terms of major complications (Clavien score≥3) (P=.13) or in the rate of late complications (at one year) (P=.66). There were also no differences between the groups in the functional postoperative results: IPSS (P=.17), QoL (P=.3) and Qmax (P=.17). CONCLUSIONS: LA is a reasonable, safe and effective alternative that results in less bleeding, fewer transfusions, shorter hospital stays and lower morbidity than OA. LA has similar functional results to OA, at the expense of longer surgical times and longer catheter times.

Prevalencia de hiperplasia benigna de próstata en mayores de 40 años como causa de insuficiencia renal crónica / Prevalencia of benign prostatic hyperplasia at age 40 as a cause of chronic renal failure

Con el objetivo de determinar la prevalencia de uropatía obstructiva crónica en pacientes mayores de 40 años con insuficiencia renal crónica como consecuencia de hiperplasia benigna de próstata (HBP), se desarrolló un estudio observacional, descriptivo y retrospectivo en una población conformada por todos los pacientes varones mayores de 40 años con insuficiencia renal crónica (IRC) como consecuencia de hipertrofia benigna de próstata, atendidos en el consultorio de Nefrología del Hospital EsSalud “Augusto Hernández Mendoza” de la ciudad de Ica, entre Mayo del 2011 y Abril del 2012; encontrándose que la edad promedio fue 74,3 ±0,9 años, el tiempo promedio de insuficiencia renal crónica fuede 28,8±1,2 meses, 62 (53,4 %) pacientes presentaron comorbilidades, siendo la diabetes mellitus la más frecuente (37; 31,9%), 62 (53,4%) pacientes recibían tratamiento farmacológico, 35 (30,17%) presentaron uropatía obstructiva crónica, con un tiempo de enfermedad promedio de 24,8±2,2 meses, ademas la presencia de diabetes mellitus (6; 16,2%) y la administración de antagonistas de calcio (7; 58,3%) se asociaron a uropatía obstructiva crónica; concluyendo que la uropatía obstructiva crónica es frecuente en el paciente con IRC a consecuencia de HBP y se asocia a diabetes mellitus y tratamiento con antagonistas de calcio. (AU)

In order to determine the prevalence of chronic obstructive uropathy in patients older than 40 years with chronic renal failure as a result of benign prostatic hyperplasia (BPH ) , an observational, descriptive and retrospective study was conducted in a population consisting of all male patients over 40 years with chronic (CRF) renal failure as a result of benign prostatic hypertrophy, served in the office of Nephrology Essalud " Augusto Hernandez Mendoza" Hospital of the city of Ica, between May 2011 and April 2012 , finding that the average age was 74.3 +/- 0.9 years, the average time of chronic renal failure was 28.8 +/- 1.2 months, 62 ( 53-4%) patients had comorbidities , diabetes mellitus being the most frequent ( 37, 31.9%) , 62 ( 53-4%) patients received pharmacological treatment, 35 ( 30.17 %) had chronic obstructive uropathy with a mean disease duration of 24.8 +/- 2.2 months, plus the presence of diabetes mellitus (6 , 16.2% ) and administration of calcium antagonists (7 , 58.3 % ) were associated with chronic obstructive uropathy, concluding that chronic obstructive uropathy is common in patients with CRF as a result of BPH associated with diabetes mellitus and calcium antagonist therapy. (AU)