Obstructive uropathy: Overview of the pathogenesis, etiology and management of a prevalent cause of acute kidney injury.

Obstructive uropathy is defined as the structural or functional interruption of urinary outflow at any level in the urinary tract. It is regarded as one of the most prevalent causes of acute kidney injury (AKI), accounting for 5%-10% of cases. Acute severe obstruction of the urinary tract is a potentially threatening situation for the kidneys and therefore requires prompt identification and management to relieve obstruction. The aim of the present article is to review and synthesize available evidence on obstructive uropathy, providing a clinical guideline for clinicians. A literature review on obstructive uropathy in the context of AKI was performed, focusing on the least clarified aspects regarding diagnosis and management. Recent literature searching was conducted in English and top-level evidence articles including systematic reviews, metanalyses and large series were prioritized. Acute obstruction of the urinary tract is a diagnostic and therapeutical challenge that may lead to important clinical complications together with direct structural and hemodynamic damage to the kidney. Early recognition of the leading cause and its exact location is essential to ensure prompt urinary drainage together with the most suitable drainage technique selection. A multidisciplinary approach, including urologists, nephrologists, and other medical specialties, is best suited to correctly manage concomitant hemodynamic changes, fluid and electrolyte imbalances, and other related issues. Obstructive uropathy is one of the leading causes of AKI. Recognition of patients suitable for early diversion and feasibility or adequate selection of the indicated technique is sometimes challenging. A thorough understanding of the physiopathology behind the development of urinary obstruction is vital for correct diagnosis and management.

Cell Therapy in the Treatment of Female Stress Urinary Incontinence: Current Status and Future Proposals.

BACKGROUND: Stress urinary incontinence (SUI) is a common condition with a significant impact on the quality of life of female patients. The limitations of current treatment strategies have prompted the exploration of new effective and minimally invasive alternative approaches, including cell therapy. METHODS: A literature search was conducted to update the current clinical status of stem cell therapy in the management of female stress urinary incontinence. RESULTS: Over thirty clinical studies have been designed to assess the feasibility, safety and efficacy of cell therapy for female SUI. Despite differences in cell types and protocols, the overall treatment procedures were similar. Standard subjective and objective assessment tools, and follow-up periods ranged from 6 weeks to 6 years have been used. Cell injection has shown to be a safe therapy in the treatment of female SUI. However, the results from more recent randomized trials have shown less promising results than expected in restoring continence. Heterogeneous research methodologies using different cell types and doses make it difficult to draw conclusions about effectiveness. Several key points remain that need to be further explored in future clinical trials. CONCLUSION: To advance in the development of cell therapy, it is essential to know the mechanisms involved to be able to direct it properly, its efficacy and the durability of the injected cells. Rigorous and homogenized preclinical and clinical studies that demonstrate its scope and improve its application are necessary for validation in the treatment of female SUI.

"Self-Designed Simulation-Based Laparoscopic Training Program for Urology Residents: Results After 6 Years of Experience".

Introduction: Learning laparoscopy (LAP) is challenging and requires different skills to conventional open surgery. There is a recognized need for a standardized laparoscopic training framework within urology to overcome these difficulties and to shift learning curve from patient to skills laboratory. Simulation-based training has been widely commented, but implementation in real day practice is lacking. We present our "LAP training program for residents". Material: Between 2017 and 2022, 11 residents participated in our self-designed program: Theoretical: (Moodle platform) basic knowledge and multimedia content for initiation into LAP. Evaluated through online exam. Practical: exercises for LAP skills acquisition were proposed and encouraged residents' practice in a box trainer available and experimental surgery sessions on a porcine model. On-site E-BLUS (European Basic Laparoscopic Urologic Skills) examination was performed annually. Feedback was obtained through an anonymous online survey. Results: All residents positively evaluated the program. Theoretical: 82% passed the online exam. The most valued topics: LAP in special clinical situations, complications, instruments, and configuration of the operating room (OR). Practical: all residents increased dry-lab box practices. A total of 23 experimental surgical sessions were carried out. For 64%, simulation in the experimental OR was a necessary complement to achieve laparoscopic skills and allowed them to feel more confident. Forty-five percent considered it essential to improve their surgical technique. E-BLUS evaluation was valued as a means to achieve dexterity and safer surgery by 90%. Reduction in time and errors were observed through time, although only 2 passed the E-BLUS. Conclusion: Our program for learning LAP includes the acquisition of knowledge, training of basic skills and surgical technique in a safe environment, as well as an objective evaluation. Encouraged practice of basic skills and surgical technique simulation and improved objective evaluation. It is structured, reproducible, systematic and has been positively valued, although it requires commitment for success.

The effectiveness of adjustable trans-obturator male system (ATOMS) in radiated patients is reduced: A propensity score-matched analysis.

Objectives: This study aimed to compare the effectiveness and safety of the adjustable trans-obturator male system (ATOMS®) to treat post-prostatectomy incontinence (PPI) in radiated patients compared with non-radiated patients, using propensity score-matching analysis to enhance the validity of the comparison. Patients and methods: Consecutive men with PPI treated with silicone-covered scrotal port ATOMS (A.M.I., Feldkirch, Austria) in nine different institutions between 2016 and 2022 were included. Preoperative assessment evaluated 24-h pad usage, urethroscopy and urodynamics, if indicated. Propensity score-matching analysis was based on age, length of follow-up, previous PPI treatment, previous bladder neck stricture, androgen deprivation and pad usage. The primary endpoint was dry rate, defined as no pads post-operatively with a security pad allowed. The secondary endpoints were complications, device removal and self-perceived satisfaction with the Patient Global Impression of Improvement (PGI-I) scale. Results: Of the 710 included patients, 342 were matched, and the study groups were balanced for the baseline matched variables. The mean baseline 24-h pad was 4.8 in both groups (p = 0.48). The mean follow-up was 27.5 ± 18.6 months, which was also equivalent between groups (p = 0.36). The primary outcome was achieved in 73 (42.7%) radiated patients and in 115 (67.3%) non-radiated patients (p < 0.0001). The mean pad count at the last follow-up was 1.5 and 0.8, respectively (p < 0.0001). There was no significant difference in complications (p = 0.94), but surgical revision and device explant rates were higher (p = 0.03 and p = 0.01, respectively), and the proportion of patients highly satisfied (PGI-I = 1) was lower in the radiated group (p = 0.01). At sensitivity analysis, the study was found to be reasonably robust to hidden bias. Conclusion: ATOMS implantation significantly outperformed in patients without adjuvant radiation over radiated patients.

Long-Term Outcomes of the Altis® Single-Incision Sling: Up to 10 Years' Follow-up.

INTRODUCTION AND HYPOTHESIS: Single-incision slings (SIS) have emerged as a less invasive alternative to conventional slings for stress urinary incontinence (SUI) treatment. However, long-term efficacy and safety results remain uncertain owing to a lack of studies. MATERIAL AND METHODS: A retrospective review of 155 patients treated with Altis® for SUI between February 2012 and June 2017, held in 2022, as a continuation of a prospective study in which all patients (197) were reviewed for 2 years after surgery (1, 6, 12, and 24 months). Preoperative demographic data, comorbidities, and pressure-flow studies were also recorded. Continence status and satisfaction rates were assessed using the International Consultation on Incontinence Questionnaire-short form (ICIQ-SF) and the Patient Global Impression of Improvement (PGI-I) respectively. The assessment in the 2022 retrospective review was performed via a telephone survey. RESULTS: Mean follow-up time after surgery was 85.3 months (82.5-88.1). In 2022, complete continence was present in 75.4% of the patients. The presence of urinary urgency conditioned the ICIQ-SF score (10.9 vs 1.7 points, p < 0.01), with the ICIQ-SF = 0 in 84.5% of the patients with no associated urgency. Satisfaction assessed by the PGI-I was high, with 84.6% of the patients showing improvement. De novo urgency was present in 37,9% of the patients by 2022. Urinary tract infections were the most frequent complication (9.7%), with only 5 documented cases of mesh erosion. CONCLUSIONS: Altis® SIS is a safe and effective device for SUI treatment, with satisfaction rates comparable with those of the conventional slings. Persistence or development of urinary urgency influences the results.

Is Extracorporeal Shock Wave Lithotripsy a Treatment Option for Renal Colic?

Background: Renal colic is characterized by sharp, intense flank pain. Nonsteroidal anti-inflammatory drugs are the treatment of choice, although extracorporeal shock wave lithotripsy (SWL) is a noninvasive alternative for pain management. The objective of our study is to present results obtained using rapid SWL to treat renal colic in our center. Methods: We analyzed 214 patients undergoing rapid shockwave extracorporeal lithotripsy between October 2014 and June 2018: 69.63% were male, and 30.37% female, with a mean age of 47.35 years (range, 16–84). The average stone size was 6.71 mm (3–16). Stone locations were as follows: The pelviureteric junction (PUJ) (10.75%), proximal ureter (45.79%), midureter (24.77%), and distal ureter (18.69%). Results: Pain relief was achieved in 81.31% of the patients. The rates of successful pain control according to stone location were 65.22% when the stone was located in the PUJ, 79.59% in the proximal ureter, 88.68% in the midureter, and 85.00% in the distal ureter. Complete or partial stone resolution was achieved 4 weeks postoperatively in 78.50% of cases (64.95% and 13.55%, respectively). According to the stone location, the overall rate of resolution (complete + partial) was 90.00% for distal ureteral stones, 86.80% in the midureter, 73.47% in the proximal ureter, and 60.86% in the PUJ. 44 patients (20.56%) demonstrated complications. The most common complications were persistent pain, acute renal failure and fever. Conclusions: Immediate SWL was found to be a safe and effective treatment option for pain related to renal colic in 81% of the patients studied (AU)

Value of Music and Nitrous Oxide for Pain Control during Extracorporeal Shock Wave Lithotripsy (ESWL)

Objectives: To compare the efficacy of 4 different analgesic regimens that include music and nitrous oxide during the treatment of renal lithiasis with ambulatory extracorporeal shock wave lithotripsy (ESWL). Materials and Methods: A single-centre, longitudinal, prospective, randomized, open and parallel group study was conducted. Patients with renal lithiasis were included and were randomized to Group A (basal analgesia: midazolam (1 mg), fentanyl (0.05 mg) and dexketoprofen (50 mg)), Group B (basal analgesia and nitrous oxide), Group C (basal analgesia and music) and Group D (basal analgesia, nitrous oxide and music). For the measurement of pain, a visual analogue scale ranging from 0 (no pain) to 100 (maximum pain imaginable) was used. Patient satisfaction was assessed using a Likert questionnaire. The epidemiological data of the patients in terms of lithiasis, previous clinical and ESWL sessions, and pain measured with the VAS before, during (maximum) at the end of the session and at discharge were recorded. Data on complications were also collected, as was the patients’ subjective evaluation of the treatment and their satisfaction. The ESWL procedure was performed with a Storz Modulith SLX-F2® lithotripter. A maximum of 4000 waves were applied at a frequency of 1.5 Hz. Results: Eighty patients were included (20 per group). None of the analgesia guidelines proved to be superior to the others for pain control during the ESWL session. Patients younger than 50 years had significantly higher values for the maximum VAS. Only 13.75% of patients required rescue analgesia. A total of 77.5% described their experience as good, very good or excellent, regardless of the assigned group. Conclusions: The addition of nitrous oxide and/or music did not result in a statistically significant improvement over the basal analgesia regimen of midazolam, fentanyl and dexketoprofen; however, the degree of patient satisfaction was very high (AU)

Extracción renal. Situación actual / Kidney extraction. Current situation

El trasplante renal (TR) es el mejor tratamiento para la enfermedad renal crónica terminal. EnEspaña no se dispone de suficientes órganos para suplirla demanda de pacientes en lista de espera a pesar deser uno de los países líderes en donación. La supervivencia del injerto depende de la calidad delórgano, el daño que sufre durante el proceso de donación y trasplante, así como de la posibilidad de que seproduzca rechazo. Entre los factores que debemos minimizar y optimizar se encuentran las lesiones inducidaspor los mecanismos de isquemia-reperfusión, en los momentos que rodean la muerte del donante, la extraccióny la preservación del órgano hasta su trasplante.Tradicionalmente la preservación del órgano hasta elmomento del implante se ha llevado a cabo mediante laconservación en frío, ya que es una técnica con amplia disponibilidad y bajo coste. El uso de máquinas de perfusión en donaciones en asistolia y criterio expandido,ha demostrado mejores resultados a corto plazo (falloprimario, inicio retrasado de función) sin afectar a lasupervivencia del receptor o del injerto. El objetivo de este trabajo es revisar la situación actual,así como los recursos disponibles para aumentar el poolde órganos trasplantables y la calidad de estos. Hemosrealizado una revisión sobre la extracción renal, manejodel donante, métodos y técnicas de preservación paraoptimizar la donación renal de donante cadáver.(AU)

Kidney transplantation (KT) is the besttreatment for end-stage renal disease. Despite Spain isone of the leading countries in donation, the need fortransplantable organs exceeds the available supply. Graft survival depends on the quality of the organ, thedamage it suffers during the donation and transplantation process, as well as the risk of rejection. Among the factors that must be controlled and minimized are the ischemia-reperfusion injuries that occursin the moments surrounding the death of the donor, theprocurement and the preservation of the organ until kidney transplantation.Static cold storage is the traditional method of preservation of the organ until the moment of implantation, sinceit is a technique with wide availability and low cost. Theuse of perfusion machines in DCD and expanded criteria has shown better short-term results (primary failure, delayed onset of function) without affecting recipient orgraft survival.The objective of our article is to review the current situation and the resources available to increase the pool oftransplantable organs and their quality. We conducted a systematic review on kidney extraction,donor management, preservation methods and techniques to optimize cadaveric donor kidney donation:(AU)

Estudio comparativo entre pacientes sometidos a colposacropexia laparoscópica con y sin cirugía previa para el tratamiento del prolapso apical / Comparative study between patients undergoing colposacropexy laparoscopic surgery with and without prior surgery for the treatment of apical prolapse

Introducción: La colposacropexia esel tratamiento de elección para el prolapso apical. Losestudios que comparan esta técnica como cirugía primaria para el prolapso de órganos pélvicos (POP), consu éxito en los POP recidivados tras cirugía son escasos.Material y método: Análisis retrospectivo de unaserie de pacientes con diagnóstico de POP sometidas acolposacropexia laparoscópica, comparando un gruposin cirugía previa para el prolapso, con otro que harecidivado tras cirugía previa (con o sin malla). Nuestroobjetivo fue analizar las diferencias respecto al tiempoquirúrgico (de piel a piel), complicaciones intraoperatorias, estancia media, resolución de los síntomas y recidiva. Como datos preoperatorios se compararon: edad,índice de masa corporal (IMC), paridad, histerectomíaprevia, exploración física, sintomatología y flujometría; y como datos peri/postoperatorios: seguimiento, duración intervención, complicaciones intra y postoperatorias, estancia media, exploración física (clasificaciónBaden-Walker), resolución síntomas y flujometría.Resultados: Han sido intervenidas 23 pacientes en12 meses. Nueve (39,1%) eran POP recidivados trascirugía previa, 6 (66,7%) de ellas con algún tipo demalla. Seguimiento (media meses): 6,44 ± 4,19 (cxprevia) vs 4,79 ± 4,00. Ambos grupos fueron comparables respecto a las variables preoperatorias. Laspacientes intervenidas previamente presentaban mayordispareunia (p<0,05). No encontramos diferencias enel resto de síntomas entre ambos grupos. No hubo diferencias en duración de la intervención, estancia media, ni respecto a las complicaciones intraoperatorias(p>0,05) entre ambos grupos. La sensación de bultovaginal, la urge-incontinencia y la dispareunia se resolvieron en todas las pacientes. La flujometría mejoró enambos grupos (p>0,05).Conclusiones: La colposacropexia laparoscópicaes una técnica eficaz y segura para la corrección delPOP tras cirugía previa, con o sin malla.(AU)

Introduction: Colposacropexy is thetreatment of choice for apical prolapse. Studies comparing this technique as primary surgery for pelvic organprolapse (POP), with its success in recurrent POPs aftersurgery, are scarce.Material and methods: Retrospective analysisof a series of patients diagnosed with POP who under went laparoscopic colposacropexy, comparing a groupwithout previous prolapse surgery with another groupthat has recurred after previous surgery (with or without mesh). Our objective was to analyze the differences regarding surgical time (skin to skin), intraoperativecomplications, mean stay, resolution of symptoms andrecurrence. As preoperative data, we compared: age,body mass index (BMI), parity, previous hysterectomy,physical examination, symptoms, and flowmetry; andas peri/postoperative data: follow-up, intervention duration, intra and postoperative complications, mean stay,physical examination (Baden-Walker classification),symptom resolution and flowmetry.Results: Twenty-three patients have been operated onin 12 months. Nine (39.1%) were recurrent POPs afterprevious surgery, 6 (66.7%) of them with some type ofmesh. Follow-up (mean months): 6.44 ± 4.19 (previouscx) vs. 4.79 ± 4.00. Both groups were comparablewith respect to preoperative variables. Previously operated patients had greater dyspareunia (p<0.05). Wedid not find differences in the rest of symptoms betweenboth groups. There were no differences in the durationof the intervention, mean stay, or regarding intraoperative complications (p>0.05) between both groups. Sensation of vaginal lump, urge incontinence and dyspareunia resolved in all patients. Flowmetry improved in bothgroups (p>0.05).Conclusions: Laparoscopic colposacropexy is aneffective and safe technique to correct POP after previous surgery, with or without mesh.

Variantes agresivas de cáncer de próstata resistente a la castración (cprc): cáncer de próstata neuroendocrino / Recommendations for follow up in castration resistant prostate cancer

El cáncer de próstata resistente a la castración (CPRC) se caracteriza por una importante heterogeneidad molecular, patológica y clínica. Aunque la mayoría presentan dependencia a la señal del receptor androgénico (RA), existen fenotipos independientes a ésta. El cáncer de próstata neuroendocrino (CPNE) es un subtipo histológico poco frecuente y de pronóstico adverso debido al diagnóstico tardío, características clínicas heterogéneas y a la falta de tratamientos sistémicos efectivos. El tratamiento estándar es la quimioterapia (QT) basada en platino, presentando respuestas de escasa duración. Existen formas puras o mixtas con un componente de adenocarcinoma. Es raro su diagnóstico de novo, siendo más frecuente su aparición en estados avanzados del cáncer de próstata (CP), como consecuencia de la inhibición del receptor androgénico (RA) realizada por diversos tratamientos. Así, podría representar una evolución agresiva desde un adenocarcinoma (CPAD) a través de un mecanismo de transdiferenciación epitelio-NE. El desarrollo de estudios preclínicos han permitido la determinación de alteraciones moleculares y genómicas asociadas a esta evolución y que pueden ayudar al desarrollo de nuevas dianas terapéuticas. En los últimos años se han producido importantes avances en la identificación y caracterización de variantes clínicas y patológicas del CPRC. El CPNE es uno de los subtipos más agresivos. Un mayor conocimiento de la biología de la enfermedad es necesario para desarrollar nuevos tratamientos y biomarcadores que ayuden al manejo de esta variante agresiva del CP

Castration resistant prostate cancer (CRPC) is characterized by an important molecular, pathological and clinical heterogeneity. Although most of them present androgen receptor (AR) signal dependence, there are independent phenotypes. Neuroendocrine prostate cancer (NEPC) is a rare histologic subtype with adverse prognosis due to late diagnosis, heterogeneous clinical features and lack of effective systemic treatments. Platinum based chemotherapy is the standard treatment, presenting short limited responses. There are pure forms or mixed with adenocarcinoma component. De novo diagnosis is unusual, being more frequent in advanced stages of prostate cancer, as a consequence of the inhibition of androgen receptor performed by various treatments. Thus, it could represent an aggressive evolution from carcinoma through a NEEpithelial transdifferentiation. Development of preclinical studies has permitted characterization of molecular and genomic alterations associated with this evolution and they may help to develop new therapeutic targets. Over the last years, there have been important advances in identification and characterization of clinical and pathological CRPC variants. NEPC is one of the most aggressive subtypes. A better knowledge of the disease biology is necessary to develop new treatments and biomarkers that help to manage this aggressive variant of PC

Factores Pronósticos de Recurrencia y Mortalidad en los Pacientes con Tumor de Urotelio Superior Tratados con Cirugía / Prognostic Factors for Recurrence and Mortality in Upper Urinary Tract Tumor

Objetivo Identificar factores pronósticos de recurrencia y mortalidad cáncer-específica en pacientes con tumor de urotelio superior tratados con cirugía. Material y Métodos Análisis retrospectivo de pacientes con tumor de urotelio superior operados entre 1999 y 2011 (139 pacientes). Se recogieron variables demográficas, clínicas, diagnósticas y patológicas así como el tratamiento, las complicaciones y la evolución. Análisis descriptivo mediante la prueba de la Chi cuadrado para variables categóricas y el test ANOVA para variables continuas. Análisis univariante y multivariante mediante modelo de riesgos proporcionales de Cox. Significación estadística si p < 0,05. Cálculos realizados con SPSS statistics v-21. Resultados En el análisis multivariante se identificaron como factores predictores independientes de recurrencia: crecimiento sólido tumoral (HR = 4,02; p < 0,001) y alto grado citológico (G3) (HR = 3,42; p = 0,01). La presencia de tumor vesical previo o concomitante (HR = 1,84; p = 0,07) presentó una tendencia a la significación. Se identificaron como factores predictores independientes de mortalidad cáncer-específica: presencia de tumor vesical previo o concomitante (HR = 2,23; p = 0,02), crecimiento sólido tumoral (HR = 2,73; p = 0,008), presencia de hidronefrosis (HR = 2,46; p = 0,02) y estadio patológico avanzado pT3-pT4 (HR = 2,74; p = 0,01). Conclusión En nuestra serie, la existencia de tumor vesical previo o sincrónico, el crecimiento tumoral sólido y el alto grado citológico se comportaron como factores pronósticos de recurrencia. La hidronefrosis, el tumor vesical previo o sincrónico, el estadio pT3­4 y el crecimiento tumoral sólido, se comportaron como factores pronósticos de mortalidad cáncer-específica.

Objective To identify predictors of recurrence and cancer-specific mortality in patients with upper urinary tract carcinoma treated with surgery. Material and Methods Retrospective analysis of patients with upper urinary tract urothelial carcinoma getting surgery between 1999 and 2011 in our institution (139 patients). We collected demographic, clinical, pathological and diagnostic variables as well as the treatment performed, the occurred complications and the evolution. A descriptive analysis was performed using the Chi square test for categorical variables and the ANOVA test for continuous variables. We performed an univariate and multivariate analysis using a proportional Cox risks model. Statistical significance was considered when p < 0.05. All calculcations were performed with SPSS statistics v-21. Results In the multivariate analysis, the solid tumor growth (HR = 4.02; p < 0.001) and a high cytological grade (G3) (HR = 3.42; p = 0.01) were identified as independent predictors; the presence of previous or concomitant bladder tumor (HR = 1.84; p = 0.07) showed a trend to statistical significance. In the multivariate analysis, the presence of previous or concomitant bladder tumor (HR = 2.23; p = 0.02), the solid tumor growth (HR = 2.73; p = 0.008), the presence of hydronephrosis (HR = 2.46; p = 0.02) and the advanced pathological stage pT3-pT4 (HR = 2.74; p = 0.01) were identified as independent predictors of cancer-specific mortality. Conclusion The existence of previous or concomitant bladder cancer at the diagnosis of upper urinary tract carcinoma, solid growth pattern and high cytological grade (G3) were identified as independent predictors of recurrence in our series. The existence of hydronephrosis at diagnosis, prior or concomitant bladder tumor, pathologic stage pT3­4 and the solid growth pattern were identified as independent predictors of cancerspecific mortality.

Estado actual de la Colposacropexia Laparoscópica (CSPL) en la corrección del Prolapso de Órganos Pélvicos (POP) / Current status of laparoscopic sacrocolpopexy in the treatment of pelvic organ prolapse

OBJETIVO: La restauración quirúrgica de la anatomía del suelo pélvico en el POP (Prolapso Órganos Pélvicos) debe evitar la disección de extensas áreas, que lesionan tejidos sanos y la fibrosis cicatricial que produce rigidez no funcionante. La colposacropexia laparoscópica (CSPL) corrige el POP al suspender los elementos pélvicos descendidos con mínima invasión (CMI). Distintas estrategias y abordajes actuales hacen que sea un procedimiento diverso. MÉTODOS: Se realiza revisión bibliográfica de la experiencia publicada sobre colposacropexia abdominal (CSPA) en los últimos 20 años. Se analiza la filosofía de cada técnica, ventajas, inconvenientes, y resultados. RESULTADOS: Dentro de las teorías actuales que explican cómo es la anatomía y la funcionalidad del suelo pélvico la Teoría Integral del Piso Pélvico (TSI) anuncia que la desviación anatómica produce disfunción pélvica (algoritmo diagnóstico) (1). La intrusión quirúrgica con fines reparadores puede enmascarar los resultados si no se conoce la verdadera fisiopatología de los defectos encontrados. Si bien las herramientas actuales de diagnóstico no logran resolver la problemática en su totalidad, los resultados de las diferentes técnicas hoy son mucho mejores que abordajes de épocas anteriores. CONCLUSIONES: La CSPL es una adecuada estrategia que consigue restaurar la anatomía del POP, principalmente apical, restaurando la función con invasión mínima. El desarrollo técnico y el mejor conocimiento de la anatomía funcional de la pelvis femenina esta hoy permitiendo comprender con mayor precisión su fisiopatología lo que facilita diseñar el tipo de cirugía sitio-específica. Se ofertan vías de abordajes y técnicas diferentes según el defecto, donde los procedimientos combinados ofrecen buenas soluciones. Es preciso un entrenamiento quirúrgico apropiado para obtener la mejor competencia, y una correcta y segura reparación

OBJECTIVES: Surgical restoration of pelvic floor anatomy in pelvic organ prolapse (POP) should avoid extensive areas that may injure healthy tissues and lead to scar fibrosis producing dysfunctional rigidity. Laparoscopic sacrocolpopexy corrects POP by lifting pelvic elements with a minimally invasive procedure Various current strategies and approaches make it a diverse procedure. METHODS: We performed a bibliographic review on the published experience about abdominal sacrocolpopexy over the last 20 years. We analyze the philosophy of each technique, advantages, disadvantages, and results. RESULTS: Among current theories that explain how is the anatomy and function of the pelvic floor, the comprehensive theory of the pelvic floor announces that anatomical deviation produces pelvic dysfunction (diagnostic algorithm)(1). Surgical invasion with reconstructive purposes may hide results if the true physiopathology of the defects found is not known. Although current diagnostic tools cannot solve the problem as a whole, results of different techniques are much better than those of previous times. CONCLUSIONS: Laparoscopic sacrocolpopexy is an adequate strategy that restores anatomy in POP, mainly apical, and function with minimal invasion. Technical development and better knowledge of the female pelvis functional anatomy is enabling today a more precise understanding of its physiopathology, so it facilitates the design of site-specific operations. Various surgical approaches and techniques are offered depending on the defect, where combined procedures give good solutions. It is necessary to have an appropriate surgical training to obtain the better competence, and a safe and correct repair

La fotovaporización prostática con láser (PVPL) podría constituir una alternativa eficaz y segura a la resección transuretral (RTUP) en pacientes / Greenlight-XPS laser vaporization, the new standard of treatment in men with myasthenia gravis and benign prostatic obstruction?

OBJETIVOS: Los pacientes con miastenia gravis (MG) diagnosticados de sintomatología del tracto urinario inferior (STUI) secundaria a hiperplasia benigna de próstata (HBP), presentan una elevada incidencia de incontinencia urinaria al ser sometidos a resección transuretral de próstata (RTUp), secundaria a la lesión inadvertida de las fibras musculares del esfínter externo. La fotovaporización prostática con Láser podría ser una alternativa de tratamiento, ya que podría evitar el daño inadvertido del esfínter debido a que la energía no se transmite más allá de la punta de la fibra. MÉTODOS: Presentamos el caso de un varón con antecedente de MG y HBP sintomática tratado de forma satisfactoria mediante fotovaporiazación selectiva con Láser verde (GreenLight-XPS). RESULTADOS: El paciente no presentó incontinencia urinaria tras la cirugía. CONCLUSIONES: La fotovaporización prostática con Láser verde (GreenLight-XPS) podría ser el tratamiento estándar de aquellos varones con MG y HBP candidatos a tratamiento quirúrgico, con volumen prostático menor de 60 cc. A pesar de la baja incidencia de estos pacientes, futuros casos son necesarios para corroborar esta afirmación

Patients with Benign Prostatic Obstruction (BPO) and Myasthenia Gravis (MG) treated with Transurethral Resection of the prostate (TURP) show a high incidence of urinary incontinence due to unnoticed damage to muscle fibres of the external sphincter. Photoselective laser vaporization could be an alternative treatment based on the hypothesis that using Laser as energy source in the treatment of BPH prevents sphincter damage because the energy is not transmitted outside the fiber tip. METHODS: We report the case of a man diagnosed of MG and symptomatic BPO treated satisfactorily with photoselective laser vaporization (GreenLight-XPS). Results Patient did not experienced postoperative secondary incontinence. CONCLUSION: Laser photoselective vaporization (GreenLight-XPS) could be the standard treatment for men with MG and BPO, whose prostate volume is less than 60 cc who are candidates for surgical treatment. Despite the extremely low incidence of these cases, further investigations are needed to confirm this affirmation

El proceso de la derivación urológica desde atención primaria (AP), Reflexión sobre los criterios / No disponible

OBJETIVO: La derivación de pacientes entre la Atención Primaria (AP) y la Especializada (AE) es un proceso común. Conlleva múltiples implicaciones para el paciente, médico y sistema sanitario. En Urología, sólo la Hiperplasia Benigna de Próstata (HBP) posee criterios de derivación. La incontinencia urinaria, el cáncer de próstata (CaP), y la ecografía urológica, están en proceso. El objetivo de este trabajo es comunicar con análisis crítico, las características de la información que se registra de la consulta de derivación CD (motivos clínicos/justificación) y la eficacia que provoca para la consulta del urólogo. MÉTODO: Se realiza estudio observacional, descriptivo y cuantitativo de las CD realizados entre AP/AEUrol (Urología), en el área sanitaria de nuestro hospital (Dic2010-Sep2012). Se estudia: Base de Datos CD (BD), documento interconsulta, sistema HORUS, y CSDerUrol (cuestionario-encuesta específico). RESULTADOS: La CD supone el 67,89% (total primeras consultas), el 14,79% de total de consultas. El 78% son varones (edad media 53a). El 11,84% registra motivo de consulta (98% en documento interconsulta), con prioridad normal (94,67%). El 34% es HBP. HORUS no se explota para la CD. El 40% inicia proceso de diagnóstico, con exploraciones insuficientes. El 18,1% consta como proceso cerrado/concluido. La satisfacción del paciente se recoge (20%). Puntos clave para la mejora son: mejorar los motivos CD, conocer las expectativas del paciente, y la creación de protocolos (guías de actuación y/o criterios de derivación). CONCLUSIONES: El proceso de derivación es complejo. El sistema informático no incluyen el motivo clínico de la CD. Se deben alcanzar acuerdos institucionales AP/ AEUrol que garanticen la implementación y uniformidad a la asistencia

OBJECTIVES: The flow of patients between Primary Care (PC) and Specialized care (SC) is a common process. It carries many implications for the patient, physician and health system. In Urology, only benign prostatic hyperplasia (BPH) has referral. and urological ultrasound, are in the process. The aim of this paper is to communicate, with critical analysis, the characteristics of the information recorded in the referral visit (clinical reasons / rationale) and the effectiveness for urology consultation. METHODS: Observational, descriptive and quantitative study of the referral visits made between PC/SC (Urology) in the health care area of our hospital (December 2010-September 2012). We studied: Referral Visit Database (RVD), consultation document, HORUS system, and specific referral visit survey questionnaire. RESULTS: Referral visits account for 67.89% (all first consultations), 14.79% of the total number of visits. 78% were male (mean age 53 y.o). 11.84% recorded reason for consultation (98% in referral document) with normal priority (94.67%). 34% of them were for BPH. HORUS is not exploited for the referral visit. 40% start the diagnostic process with insufficient exams. 18.1% are listed as closed process / completed. Patient satisfaction was evaluated (20%). Key points in the improvement are: improve referral visit reason for consultations, to know patient's expectations, and to develop protocols (guidelines, and/or referral criteria). CONCLUSIONS: The referral process is complex. The computer system does not include the referral reason for consultation. Institutional agreement between PC/SC Urology must be reached to ensure uniformity in the implementation and support

Adenoma nefrogénico de localización prostática. Aportación de un caso / Prostatic nephrogenic adenoma. Case report

OBJETIVO: Presentamos el caso de un adenoma nefrogénico de uretra prostática como hallazgo incidental tras una resección trasuretral de próstata.MÉTODO/RESULTADO: Se trata del diagnóstico incidental de adenoma nefrogénico de uretra prostática en varón de 50 años intervenido de hiperplasia benigna prostática mediante resección trasuretral.CONCLUSIONES: El adenoma nefrogénico es una lesión benigna del tracto urinario, infrecuente, asociado con una historia previa de traumatismo o irritación sobre el urotelio. Los factores predisponentes incluyen las infecciones, cálculos, cirugía, traumatismos y el trasplante renal(AU)

OBJECTIVE: We present a case of prostatic urethra nephrogenic adenoma as an incidental finding following transurethral resection of the prostate.METHOD/RESULT: It is an incidental diagnosis of nephrogenic adenoma of prostatic urethra in a 50-year-old male operated for benign prostatic hyperplasia by means of transurethral resection.CONCLUSIONS: Nephrogenic adenoma is an infrequent and benign lesion of the urinary tract, associated with a previous history of trauma or irritation on the urothelium. Predisposing factors include infections, calculi, surgery, trauma and kidney transplantation(AU)

Absceso prostático. Diagnóstico y tratamiento de un proceso urológico poco frecuente en la actualidad / Prostatic abscess: diagnosis and treatmente of an infrequent urological entity

OBJETIVO: Presentar dos casos clínicos de absceso prostático de difícil manejo y revisar el diagnóstico y tratamiento de esta entidad.MÉTODOS/RESULTADOS: Descripción de dos pacientes con absceso prostático. El primer caso es un varón diabético de 73 años a quien se le instaura un manejo conservador con drenaje percutáneo transrectal y quien tras una evolución tórpida fallece de una sepsis urológica. El segundo caso es un varón de 59 años con mala evolución clínica tras tratamiento antibiótico ambulatorio realizándose una resección transuretral de próstata con resultado satisfactorio.CONCLUSIÓN: El absceso prostático es una entidad rara. Afecta principalmente a personas debilitadas lo que le confiere un carácter grave. Las medidas encaminadas a su resolución deben ser rápidas y oportunas(AU)

OBJECTIVE: To report two cases of prostatic abscess of difficult management and review the literature on diagnosis and management of this entity.METHODS /RESULTS: We describe two patients with prostatic abscess. The first one, a 73-year-old diabetic male, was treated using a more passive approach with percutaneous transrectal drainage; after a slow response, the patient passed away due to sepsis. The second case was a 59-year-old male who experienced a negative clinical response to antibiotic treatment. While under antibiotic ambulatory care the patient was treated with a transurethral resection of the prostate, which yielded a successful outcome.CONCLUSION: Prostatic abscess is a rare entity that affects individuals experiencing weakness and can be a serious condition. Measures taken to arrive at a resolution must be rapid and appropriate(AU)

Mielolipoma suprarrenal. Aportación de un caso y revisión de la literatura / Adrenal myelolipoma. Contribution of a case and bibliographic review

OBJETIVO: Presentamos el caso de un mielolipoma de localización adrenal.MÉTODO/RESULTADO: Presentamos una paciente de 29 años que es diagnosticada de un adenoma suprarrenal de 6 cm durante una revisión endocrinológica. Se le practica una suprarrenalectomía laparoscópica. El estudio patológico confirma el diagnóstico de mielolipoma suprarrenal.CONCLUSIONES: El mielolipoma es un tumor infrecuente constituido por elementos hematopoyéticos en diferentes estadios madurativos y sin alteraciones histológicas, combinados con tejido adiposo maduro en proporciones variables. La mayoría son hallazgos incidentales durante exploraciones radiológicas complementarias.La cirugía de la masa está indicada cuando la lesión sea mayor de 6 cm, funcionante y/o sintomática (AU)

OBJECTIVE: We report the case of a myelolipoma of the adrenal glands.METHOD/RESULTS: The patient is a 29 year old who is diagnosed with an adrenal adenoma during a review in endocrinology. He underwent laparoscopic adrenalectomy. The pathological study confirmed the diagnosis of adrenal myelolipoma.CONCLUSIONS: The myelolipoma is a rare tumor composed of hematopoietic elements in different maturation stages and without histological changes, combined with mature adipose tissue in varying proportions. Most are incidental findings during radiologic complementary. Treatment should be tailored to each particular case. Surgery is indicated when the mass exceeds the size 4-6 cm or when it is functioning (AU)

Síndrome metabólico y disfunción eréctil / Metabolic síndrome and erectile dysfunction

OBJETIVO: Puesta al día de un síndrome que en los pasados años ha ido incrementando las patologías coincidentes en el mismo, tales como obesidad, hipertensión, hipercolesterolemia, diabetes tipo II, con la reciente adición de la disfunción erectil y la androgenodeficienciaMÉTODO: Revisión global de la literatura tomando como referencia las últimas aportaciones y muy especialmente las debidas al profesor M. Serrano Ríos, de Madrid, y su grupoRESULTADOS: El síndrome metabólico parece actualmente consolidado como terminó universalmente aceptado, a pesar de su complejo itinerario semántico y nosologico. La inclusión de la disfunción erectil y la androgenodeficiencia le da más solidez patogénica y aproxima más al terreno profesional de la endocrinología a dos procesos prioritariamente urológicos. El urólogo recibe a su vez una nueva perspectiva de procesos que son inexcusablemente propios y a los que ha de atender con mayor amplitud exploratoria, analítica y terapéuticaCONCLUSIÓNES: El síndrome metabólico puede ser reconocido en la consulta urológica con más frecuencia de lo sospechado. El urólogo queda obligado, en este proceso típicamente médico, a ejercer con más dedicación y amplitud el compromiso médico de su especialidad médico quirúrgica(AU)

OBJECTIVES: To update a syndrome that has increased the number of pathologies included such as obesity, hypertension, hypercholesterolemia, type II diabetes mellitus, and the recent addition of erectile dysfunction and androgen deficiencyMETHODS: Global review of bibliography taking the last articles as a reference and mainly those from Prof. M. Serrano Rios and his group in Madrid.RESULTS: Metabolic syndrome seems to be consolidated as a universally accepted term, despite its complex semantic and gnoseologic itinerary. The inclusion of erectile dysfunction and androgen deficiency gives more pathogenic solidity and makes the professional field of endocrinology closer to two mainly urological processes.The urologist has a new perspective of processes that are of his own, that he has to take care of in a comprehensive manner, with physical examination, blood tests and therapy. CONCLUSIONS: Metabolic syndrome may be more frequently than suspected recognized in the urologist office. Urologists are compelled, in this typically medical process, to exercise with more dedication and fullness the medical compromise of our medical-surgical specialty(AU)

Controversias en la anatomía quirúrgica prostática. Revisión de la literarura / Controversies in the Prostate Surgical Anatomy. A literature review

Introducción: La técnica para la prostatectomía radical ha evolucionado dinámicamente durante los últimos años en base a una mayor experiencia quirúrgica acumulada y descubrimientos anatómicos. Nos parece oportuno revisar y actualizar algunos conceptos anatómicos básicos que nos permita conseguir una uniformidad de criterios y términos al referirnos a esta técnica quirúrgica. Material y Método: Hemos realizado una búsqueda bibliográfica en Medline/PubMed. Palabras clave: cavernosal nerves,prostatectomy, anatomy, neurovascular bundle. Realizamos una lectura detallada de los resúmenes de los artículos obtenidos, seleccionando aquellos que se ajustaban a los diferentes temas fijados para la revisión. Conclusiones: La glándula prostática no posee una cápsula verdadera sino que esta representada por una banda fibromuscular incompleta que es intrínseca a la glándula. La fascia periprostática parece ser una estructura distinta de esta banda fibromuscular. La Fascia de Denonvilliers en una fascia histológicamente compuesta por dos láminas pero quirúrgicamente indistinguibles. Las fibras ubicadas longitudinalmente por debajo del labio posterior del cuello vesical parecen corresponder a la fascia longitudinal posterior que pertenece al músculo detrusor. Los nervios cavernosos se sitúan entre dos hojas de la fascia endopélvica que podríamos denominar fascia periprostática (más interna) y fascia del elevador (más externa). Los nervios cavernosos son referencias del plexo pélvico y se ubican dentro de un fascículo neurovascular con distribución variable alrededor de la próstata según cada individuo (fascículo único o dispersos por la superficie antero lateral de la próstata). Consideramos conveniente que la comunidad de Urólogos unifique los términos para denominar las fascias pélvicas y evitar superposición de términos (AU)

Introduction: Radical prostatectomy technique has improved in the last years based on accumulated surgical experience and new anatomical findings. We think it is time to update anatomical concepts to standardized the criteria for mentioning structures related with radical prostatectomy. Material and Method: With the followings key words: “cavernosal nerves, prostatectomy, anatomy, neurovascular bundle” we search in Medline/PubMed database selecting papers fulfilling the search criteria. Conclusions: The prostate does not have a true capsule but rather an incomplete fibromuscular band as an intrinsic part of the gland. Periprostatic fascia seems to be a different structure from this fibromuscular band. Histologically Denonvilliers´s fascia is formed by two thin layers that cannot be separated during surgery. The longitudinal smooth muscle fibres located beneath the posterior bladder neck corresponds to the posterior longitudinal fascia of the detrusor muscle. Cavernosal nerves are located between the two layers of the endopelvic fascia, the inner layer could be named periprostatic fascia and the outer, levator ani fascia. Cavernosal nerves merged from the pelvic plexus running within a neurovascular bundle around the prostate that could be found as a singular bundle or spread all around the anterolateral surface of this gland. There are overlapping terms to designate the pelvic fascia, therefore it could be useful for Urologists to standardized them (AU)

Hematuria de origen papilar o medular: entidad de díficil diagnóstico / Hematuria of papillary or medullar origin: a difficult diagnosis entity

Objetivo: Los hemangiomas renales de origen papilar o medular renal, es una entidad de difícil diagnóstico, siendo una de las causas más frecuentes de episodios crónicos de hematuria, por patología benigna, fundamentalmente en pacientes jóvenes (1). El objetivo de esta presentación es mostrar la dificultad de este diagnóstico y la necesidad de sospecharlo en cuadros con historia similar a la que expresan estos casos. Métodos: Se presentan 4 casos de hematuria espontánea de origen renal, con expresión clínica de dolor cólico, de la serie histórica del Servicio de Urología de la Fundación Jiménez Díaz-Capio, los dos últimos del año 2005-6. Se presenta la metodología diagnóstica y terapéutica realizada, incluidos los estudios de angioTAC y la URS (ureterorenoscopia flexible), asi como diversas opciones de tratamiento. Resultado: La hematuria se identificó como “esencial” al descartar la relación responsable con patología tumoral o litiásica, y de origen renal al señalar claramente su origen. Se interpretó relacionada con angiomas o microangiomas de origen papilar o medular. En un caso la malformación vascular fue interpretada como FAV (fístula arteriovenosa) a ese nivel. Tras la URS exploradora, la hematuria cedió espontáneamente en dos casos. El caso histórico más antiguo requirió la exploración quirúrgica de las estructuras calicilares. Conclusión: Hace años y siguiendo el desarrollo profesional de la Especialidad de Urología, todos estos casos, de gran dificultad diagnóstica, eran sometidos a cirugía convencional, en muy pocas ocasiones con actitud conservadora, basada ésta en la exploración de las cavidades renales, intentando observar y encontrar el lugar del sangrado activo. La mayoría de los casos eran sometidos finalmente a Nefrectomía total o parcial. La posibilidad actual, de poder explorar las cavidades renales en su totalidad con el ureterorenoscopio flexible, permite un mejor diagnóstico de las lesiones y un tratamiento más conservador. El diagnóstico último de angioma renal papilar es anatomo-patológico, sin existir datos patogneumónicos de diagnóstico por la imagen Se piensa en esta patología, al final del proceso diagnóstico, y al identificar la zona papilar como origen del sangrado. La serie histórica de casos clinicos, con los hallazgos anatomo-patológicos de las nefrectomías realizadas, permite señalar la entidad, como angioma papilar, en pacientes con clínica similar (AU)

Objectives: Renal haemangiomas of renal papillary or medullar origin are a difficult diagnosis entity, being one of the most frequent processes of chronic episodes of hematuria, secondary to benign disease, mainly in young patients (1). The objective of this paper is to show the difficulty of this diagnosis and the need to suspect it in cases with clinical history similar to the ones described in these cases. Methods: We report 4 cases of spontaneous hematuria of renal origin, with clinical presentation as renal colic, from the historical case series of the Fundacion Jimenez Díaz - Capio, the last two from the years 2005-6. We present the diagnostic and therapeutic methodology employed, including angio-CT and flexible ureterorenoscopy (URS) as well as various treatment options. Results: Hematuria was identified as “essential” when any relation with tumor or lithiasic pathologies was ruled out, and of renal origin when the source was clearly pointed. We interpreted it was related to angiomas or microangiomas of papillary or medullar origin. In one case, the vascular malformation was interpreted as an arterial venous fistula (AVF) at that level. Hematuria stopped spontaneously in two cases after exploratory URS. The eldest historical case required surgical expiration of the caliceal structures. Conclusion: Years ago, following the professional development of Urology as speciality, conventional surgery was carried out in all these cases, of very difficult diagnosis, with a very small number of cases undergoing a conservative approach based on the examination of renal cavities trying to observe and find the bleeding point. Most cases underwent complete or partial nephrectomy. Currently, the possibility of exploration of all renal cavities with the flexible ureterorenoscope enables a better diagnosis of the lesions and a more conservative treatment. The ultimate diagnosis of renal papillary angioma is the pathologic diagnosis, without pathognomonic data in the imaging tests. This pathology is thought of at the end of the diagnostic workup, and when the papillary area is identified as the source of bleeding. The historical case series, with the pathologic findings from nephrectomy specimens, permits us to point out this entity as papillary angioma, in patients with similar clinical presentation (AU)