Manejo de la masa suprarrenal: lo que el urólogo debe saber / Management of adrenal mass: What urologist should know

El incidentaloma suprarrenal es una entidad en aumento en la práctica clínica habitual debido al gran número de exploraciones radiológicas que se realizan. No existen guías clínicas publicadas sobre el manejo del incidentaloma suprarrenal apoyadas por ninguna sociedad científica. Toda masa suprarrenal debe ser estudiada para descartar malignidad o hipersecreción hormonal. Creemos que la patología suprarrenal quirúrgica debe ser manejada por el urólogo, por ser la especialidad que mayor relación tiene con en el retroperitoneo alto. El objetivo de esta revisión es desarrollar los aspectos fundamentales que el urólogo debe saber en el manejo de las masas suprarrenales. Conjuntamente con el servicio de endocrinología de nuestro hospital describimos los principales estudios a realizar ante el diagnóstico de una masa suprarrenal y el esquema terapéutico vigente en nuestro centro (AU)

Adrenal incidentaloma's prevalence is rising because of the big volume of radiologic explorations that we daily do. No comprehensive guidelines have been published by professional societies to guide the evaluation of patients with adrenal incidentalomas. All adrenal masses should be inspected for malignancy or hypersecreting disorders. In our point of view, adrenal surgery should be performed by the urologist, because it's the medical speciality which knows the best this anatomical region. The objective of this review is to present the main points that the urologist may know in the management of adrenal masses. Together with the department of Endocrinology of our hospital, we describe the main studies to perform in front of adrenal mass diagnosis and the current therapeutical diagram utilized in our center (AU)

[Management of adrenal mass: What urologists should know]. / Manejo de la masa suprarrenal: lo que el urólogo debe saber.

Adrenal incidentaloma's prevalence is rising because of the big volume of radiologic explorations that we daily do. No comprehensive guidelines have been published by professional societies to guide the evaluation of patients with adrenal incidentalomas. All adrenal masses should be inspected for malignancy or hypersecreting disorders. In our point of view, adrenal surgery should be performed by the urologist, because it's the medical speciality which knows the best this anatomical region. The objective of this review is to present the main points that the urologist may know in the management of adrenal masses. Together with the department of Endocrinology of our hospital, we describe the main studies to perform in front of adrenal mass diagnosis and the current therapeutical diagram utilized in our center.

[Surgical experience and results in transperitoneal laparoscopic adrenalectomy]. / Experiencia y resultados en la suprarrenalectomía laparoscópica transperitoneal.

INTRODUCTION: Laparoscopic adrenalectomy is currently the gold standard in surgical management of adrenal pathology. OBJECTIVES: To analyze our results after 12 years of experience in this surgery and to compare with the main published series. MATERIAL AND METHODS: we describe retrospectively 100 adrenalectomies performed between 1997-2009. Analyzed variables: age, size, side, preoperative diagnosis, operative time, blood loss, reconversion, hospital stay and histopathologic report. We utilized Fisher test and chi square test to compare categoric data. We utilized t-Student test to compare means from independent groups with normal distribution. We considered statistical significance when p<0.05. RESULTS: Mean age was 53.1 years (+/-14.4). Mean size was 3,7 cm (+/-2.2). In 51% of cases it was the left side. Mean follow-up was 15 months (+/-11.9). Preoperative diagnosis was: functional mass (44%), pheocromocytome (17%), incedentaloma>4 cm (20%), metastasis (10%) and adrenal carcinoma (5%). Mean operative time was 145.1 min (+/-55.6). Mean hematocrite loss was 6.26 points (+/-3.3). Reconversion rate was 9.6%. 2 cases of prolonged postoperative ileus. 2 patients required transfusion. 1 patient death because of an descompensation of liver cirrhosis. 80% of complications were on right side. Mean hospital stay was 6 days (+/-5.6). In last 30 procedures we realized statistical differences with first group, in terms of operative time (119.1 min vs 171.2 min) and hospital stay (4.1 days vs 6.1) (p<0.05). CONCLUSIONS: Transperitoneal laparoscopic adrenalectomy is a surgical feasible and safe procedure in urological groups with previous laparoscopic experience. Our results are similar with the published series and confirm the efficacy, security and reproducibility of this technique.

Experiencia y resultados en la suprarrenalectomía laparoscópica transperitoneal / Surgical experience and results in transperitoneal laparoscopic adrenalectomy

Introducción: La suprarrenalectomía laparoscópica es actualmente el gold estándar en el manejo quirúrgico de la patología suprarrenal. Objetivos: Analizar nuestros resultados tras 12 años de experiencia en esta cirugía y compararlos con las principales series publicadas. Material y métodos: Estudio descriptivo y retrospectivo. Análisis de 100 suprarrenalectomías realizadas entre junio de 1997 y junio de 2009. Se describen las siguientes variables: edad, tamaño, lateralidad, diagnóstico preoperatorio, tiempo quirúrgico, pérdida sanguínea, reconversión, complicaciones, estancia media y resultado anatomopatológico. Se utilizaron el test de Fisher y el test de chi cuadrado para comparar datos categóricos. Se utilizó el test t de Student para comparar medias de grupos independientes con distribución normal. Se consideró la significación estadística cuando p<0,05. Resultados: La edad media fue de 53,1 años (±14,4). El tamaño medio fue de 3,7cm (±2,2). En el 51% de los casos fue izquierda. La media de seguimiento fue de 15 meses (±11,9). El diagnóstico preoperatorio fue masa funcionante (44%), feocromocitoma (17%), incidentaloma mayor de 4cm (20%), metástasis (10%) y carcinoma suprarrenal (5%). El tiempo quirúrgico medio fue de 145,1 min (±55,6). El descenso medio de hematocrito fue de 6,26 puntos (±3,3). La tasa de reconversión fue del 9,6%. Hubo 2 casos de íleo postoperatorio prolongado. Dos pacientes requirieron transfusión. Uno murió en el postoperatorio por descompensación de cirrosis hepática asociada. El 80% de las complicaciones fueron en el lado derecho. La estancia media hospitalaria fue de 6 días (±5,6). En el grupo de los 30 últimos procedimientos se obtuvieron diferencias significativas en cuanto al tiempo quirúrgico (119,1 vs. 171,2min) y a la estancia media hospitalaria (4,1 vs. 6,1 días, p<0,05). Conclusiones: La suprarrenalectomía laparoscópica transperitoneal es una cirugía factible y segura en grupos con experiencia laparoscópica previa. Nuestros resultados se asemejan a las series publicadas en cuanto a la eficacia y a la morbilidad de la técnica (AU)

Introduction: Laparoscopic adrenalectomy is currently the gold standard in surgical management of adrenal pathology. Objectives: To analyze our results after 12 years of experience in this surgery and to compare with the main published series. Material & methods: we describe retrospectively 100 adrenalectomies performed between 1997–2009. Analized variables: age, size, side, preoperative diagnosis, operative time, blood loss, reconversion, hospital stay and histopathologic report. We utilized Fisher test and chi square test to compare categoric data. We utilized t-Student test to compare means from independents groups with normal distribution. We considered statistical significance when p<0.05. Results: mean age was 53,1 years (±14,4). Mean size was 3,7cm (±2,2). In 51% of cases it was the left side. Mean follow-up was 15 months (±11,9). Preoperative diagnosis was: functional mass (44%), pheocromocytome (17%), incedentaloma >4cm (20%), metastasis (10%) and adrenal carcinoma (5%). Mean operative time was 145,1min (±55,6). Mean hematocrite loss was 6,26 points (±3,3). Reconversion rate was 9,6%. 2 cases of prolonged postoperative ileus. 2 patients required transfusion. 1 patient death because of an descompensation of liver cirrhosis. 80% of complications were on right side. Mean hospital stay was 6 days (±5,6). In last 30 procedures we realized statistical differences with first group, in terms of operative time (119,1min vs 171,2min) and hospital stay (4,1 days vs 6,1) (p<0,05). Conclusions: Transperitoneal laparoscopic adrenalectomy is a surgical feasible and safe procedure in urological groups with previous laparoscopic experience. Our results are similar with the published series and confirm the efficacy, security and reproducibility of this technique (AU)

[Effectiveness and tolerability of zoledronic acid in the treatment of metastatic prostate cancer]. / Efectividad y tolerabilidad del acido zoledrónico en el tratamiento del cancer de próstata metastásico.

OBJECTIVES: To assess the effectiveness and tolerability of zoledronic acid in prostate cancer patients with bone metastases at the hormone-sensitive (HS) and hormone-independent (HI) stages. MATERIALS AND METHODS: A nationwide, observational, prospective, open and multi-centre trial was devised, with a total of 218 male patients diagnosed with prostate cancer at the HS stage (36%) or HI stage (64%) who were administered zoledronic acid (4 mg/IV/month for 6 months) in addition to their specific oncological treatment. Effectiveness was assessed by the following means: 1) Assessment of the improvement in pain and mobility; 2) Incidence and time to onset of skeletal-related events (SREs) and 3) Analysis of bone markers. Tolerability was assessed by means of registering the number and type of adverse effects. A satisfaction survey was carried out amongst the patients after the end of the trial. RESULTS: Out of the 218 patients, 170 (78%) were evaluable for effectiveness. A decrease in pain ratings at rest and during movement was observed in all patients, whether in the HS or HI groups (p < 0.0001). Improved mobility was observed likewise (p = 0.005), as was quality of life. The global incidence of skeletal events was 11.2%, with a time to onset of SREs of 10.7 months. There were no significant differences observed between HS vs. HI patients. Osteolysis markers (N-telopeptide) decreased significantly with the treatment across both the HS and HI groups. For safety reasons. 212 patients were evaluable (97.2%). The incidence of adverse drug reactions was 16% (34/212) and was found to be significantly higher in HS patients (22.4%) compared with HI patients (11.9%). Overall, the tolerability of zoledronic acid was good, with no significant morbidity in either group (HS and HI). 66% of the patients reported feeling satisfied or very satisfied. CONCLUSIONS: Zoledronic acid proved effective in the relief of pain, improving mobility and quality of life as well as reducing or delaying the occurrence of skeletal-related events in prostate cancer patients presenting metastatic bone disease, regardless of the phase, whether HS or HI, they found themselves in. Tolerability and patient satisfaction were rates as good.

Efectividad y tolerabilidad del ácido zoledrónico en el tratamiento del cancer de próstata metastásico / Effectiveness and tolerability oz zoledronic acid in the treatment of metastatic prostate cancer

Objetivos: Evaluar la efectividad y tolerabilidad del ácido zoledrónico en pacientes con cáncer de próstata y metástasis óseas en fase hormono sensible (HS) y hormono independiente (HI). Material y Métodos: Se diseñó un estudio de ámbito nacional, observacional, prospectivo, abierto, y multicéntrico, Se incluyeron un total de 218 varones diagnosticados de cáncer de próstata en fase HS (36%) o HI (64%) que recibieron, además del tratamiento oncológico específico, ácido zoledrónico (4 mg/IV/mes durante 6 meses). Se evaluó la efectividad mediante: 1) Evaluación de la mejoría del dolor y movilidad; 2) Incidencia y tiempo de aparición de eventos esqueléticos (TEE); y 3) Análisis de marcadores óseos. La tolerabilidad se estudió registrando el número y tipo de efectos adversos. Se realizó una encuesta de satisfacción al paciente tras finalizar el tratamiento. Resultados: De los 218 pacientes, 170 (78%) fueron evaluables para efectividad. En todos ellos, ya fueran del grupo HS o HI, se observó una disminución de la puntuación del dolor en reposo y en movimiento (p<0,0001), una mejora en la movilidad (p=0,005), y en la calidad de vida. La incidencia global de eventos esqueléticos fue del 11,2%, con un TEE de 10,7 meses. No hubo diferencias significativas entre los pacientes HS respecto a los HI. Los marcadores de osteolisis (N-telopéptido) descendieron significativamente con el tratamiento, tanto en los HS como HI. Para seguridad fueron evaluables 212 pacientes (97,2%). La incidencia de las reacciones adversas fue del 16% (34/212), siendo significativamente mayor en los pacientes HS (22,4%) con respecto a los HI (11,9%). Globalmente la tolerabilidad al ácido zoledrónico fue buena, sin morbilidad significativa entre ambos grupos (HS y HI).Un 66% de los pacientes contestaron sentirse satisfechos o muy satisfechos. Conclusiones: El ácido zoledrónico se mostró eficaz para aliviar el dolor, mejorar la movilidad y aumentar la calidad de vida y reducir o retrasarlos eventos esqueléticos en los pacientes con cáncer de próstata con enfermedad ósea metastásica sintomática, independientemente de la fase, HSo HI en que se encuentren. La tolerabilidad y la satisfacción de los pacientes fue buena (AU)

Objetives: To assess the effectiveness and tolerability of zoledronic acid in prostate cancer patients with bone metastases at the hormone-sensitive (HS) and hormone-independent (HI) stages. Materials and Methods: A nationwide, observational, prospective, open and multi-centre trial was devised, with a total of 218 male patients diagnosed with prostate cancer at the HS stage (36%) or HI stage (64%) who were administered zoledronic acid (4 mg/IV/month for 6 months) in addition to their specific oncological treatment. Effectiveness was assessed by the following means: 1) Assessment of the improvement in pain and mobility; 2) Incidence and time to onset of skeletal-related events (SREs) and 3) Analysis of bone markers. Tolerability was assessed by means of registering the number and type of adverse effects. A satisfaction survey was carried out amongst the patients after the end of the trial. Results: Out of the 218 patients, 170 (78%) were evaluable for effectiveness. A decrease in pain ratings at rest and during movement was observed in all patients, whether in the HS or HI groups (p<0,0001). Improved mobility was observed likewise (p=0,005), as was quality of life. The global incidence of skeletal events was 11.2%, with a time to onset of SREs of 10.7 months. There were no significant differences observed between HS vs. HI patients. Osteolysis markers (N-telopeptide) decreased significantly with the treatment across both the HS and HI groups. For safety reasons, 212 patients were evaluable (97.2%). The incidence of adverse drug reactions was 16% (34/212) and was found to be significantly higher in HS patients (22.4%) compared with HI patients (11.9%). Overall, the tolerability of zoledronic acid was good, with no significant morbidity in either group (HS and HI). 66% of the patients reported feeling satisfied or very satisfied. Conclusions: Zoledronic acid proved effective in the relief of pain, improving mobility and quality of life as well as reducing or delaying the occurrence of skeletal-related events in prostate cancer patients presenting metastatic bone disease, regardless of the phase, whether HS or HI, they found themselves in. Tolerability and patient satisfaction were rates as good (AU)

Experiencia inicial en el diagnóstico y tratamiento del tumor vesical superficial con Hexvix® / Initial experience in the diagnosis and treatment of superficial bladder tumors with Hexvix®

Objetivo: El actual standar en el diagnóstico y seguimiento del tumor vesical es la cistoscopia con luz blanca. Recientes estudios sugieren que la cistoscopia con fluorescencia a través de derivados de las porfirinas puede mejorar la detección de lesiones vesicales. Hemos analizado los resultados en el diagnóstico y tratamiento de lesiones vesicales utilizando la cistoscopia de fluorescencia con hexaminolevulinato (Hexvix®) en nuestro centro. Métodos: Entre septiembre 2006 y septiembre 2007, a 39 pacientes consecutivos con sospecha ó confirmación de tumor vesical se les administró una instilación endovesical de Hexvix® una hora antes de la cirugía. Se realizó en primer lugar una cistoscopia con luz blanca (CLB) y posteriormente con luz azul (CLA). Se resecaron todas las lesiones papilares y las sospechosas para análisis histológico. La edad media fue de 70.1 años (50-86). 30 hombres (76.9%) y 9 mujeres (23.1%). Las características de los tumores fueron: 18% tumores primarios, 51% recurrencias y 30% controles cistoscópicos. 24 pacientes habían recibido con anterioridad algún tratamiento (9 mitomicina C y 15 BCG). 7 pacientes demostraron citologías urinarias positivas previas. Resultados: Todas las lesiones papilares visualizadas con luz blanca se confirmaron con luz azul (18 pacientes). De éstos, 17 tuvieron biopsias positivas (6 pTaG1, 9 pT1G1-3, 1 pT2, 1 CIS). En 15 pacientes (38.4%) se objetivó al menos 1 lesión más solo visualizada con la luz azul. En este grupo, 8 pacientes (20.5%) tuvieron un diagnóstico histológico positivo (3 pTaG1, 2 pT1G3, 3 CIS). En 5 de estos casos (13%) el manejo terapéutico posterior cambió al introducir la luz azul (BCG vs MMC). Todos los casos de CIS (4) fueron diagnosticados mediante luz azul. En el postoperatorio no se demostraron efectos secundarios (locales ó sistémicos) debidos a la administración de Hexvix® Conclusiones: Nuestros resultados sugieren un incremento en el diagnóstico de lesiones tumorales vesicales, papilares y planas, con el uso de la cistoscopia bajo fluorescencia. Esto ha determinado un cambio de actitud terapéutica relevante en un 13% de los pacientes. Obviamente, se necesita mayor experiencia para consolidar estos resultados y un seguimiento a largo plazo para valorar el impacto a nivel de recurrencia y progresión tumoral (AU)

Objectives: White light cystoscopy is the current standard for the diagnosis of bladder cancer and monitorization for recurrence. Recent studies suggest that porphyrin based fluorescence cystoscopy may improve endoscopic detection of bladder tumors. We aimed to evaluate the improvement that hexaminolevulinate fluorescence cystoscopy could lead in bladder cancer detection and treatment at one single centre. Methods: Between September 2006 and September 2007 a total of 39 patients with known or suspected bladder cancer underwent bladder instillation with 50 ml 8 mM hexaminolevulinate (HAL) for 1 hour. The bladder was inspected using white light cystoscopy (WLC), followed by blue light (fluorescence) cystoscopy (BLC). Papillary and suspicious lesions were resected for histological examination. Mean age was 70.1 years (50-86). Thirty patients were male (76.9%) and 9 female (23.1%). The tumor characteristics were: 18% primary tumors, 51% recurrences and 30% control cystoscopies. 24 patients had previously received some treatment (9 MMC and 15 BCG). Only 7 patients had previous positive urine cytology. Results: All papillary lesions visualized with WLC were confirmed by BLC (18 patients). From these, 17 have positive biopsies (6 pTaG1, 9 pT1G1-3, 1 pT2, 1 CIS). In 15 patients (38.4%) we found at least 1 lesion more with BLC. In this group 8 cases (20.5%) had positive histological diagnosis (3 pTaG1, 2 pT1G3, 3 CIS). In five patients (13%) post-TUR therapeutic management has changed by using BLC (BCG vs MMC). All four patients with CIS were diagnosed by BLC. There was no evidence of local or systemic side effects due to HAL in the postoperative time. Conclusions: Our results suggest there is an improvement in the diagnosis of papillary and flat lesions in bladder cancer by using HAL fluorescence cystoscopy. This has changed the management in the postoperative period (MMC vs BCG) in 13% of the patients. Obviously, we need more patients to assess our data and long term follow-up to analyze the impact in terms of tumor recurrence and progression (AU)

[Brachyterapy in localized prostate cancer]. / Braquiterapia en el cáncer de próstata localizado.

INTRODUCTION AND OBJECTIVES: Considering the high frequency of localized prostate cancer in stages, at the moment there are minimally invasive techniques that compete with the classic surgery. One of them is the Low Dose Rate (LDR) Brachytherapy with permanent implants of 1125 seeds. The objective of the present study is to expose our experience from the year 1998, when we made the first treatment, until today. The results and the morbidity of the patients over a 7 and a half years period are analyzed. MATERIAL AND METHODS: A total of 800 patients were treated with LDR brachytherapy, with average age of 68 years and range between 48 and 83 years. In all patients the 1125 seeds were used with Rapid-Strand and peripheral load by means of intraoperative planning. RESULTS: The urinary rate of complications was of 3% of AUR, and 0.2% of urinary incontinence. The morbidity on the digestive apparatus was of a 12% intermittent bleeding, 2% of proctitis, and a 0.3% of rectal fistulas.

[Ultrasonographic diagnosis of Fournier's gangrene]. / Diagnóstico ecográfico de gangrena de Fournier.

OBJECTIVES: The usefulness of ultrasound in the detection of Fournier's gangrene in the early stages is described herein. METHODS/RESULTS: We discuss the clinical course of the patient with scrotal inflammation of a torpid course suspected as Fournier's gangrene on the ultrasound findings. CONCLUSIONS: The use of ultrasound in cases with acute scrotal inflammation of a torpid course as in this case, permits early detection of Fournier's gangrene, a fulminant condition. A review of the literature has shown that the findings described herein have been infrequently reported.

[Urethral protrusion caused by blunt trauma of the anterior urethra]. / Protrusión uretral por traumatismo cerrado de uretra anterior.

We report an uncommon case of complete rupture of the anterior urethra secondary to blunt trauma, with protrusion of the urethral mucosa through the urinary meatus. The singular images of this case are presented and the mechanisms involved in this unusual type of lesion are analyzed.