La formación del residente de urología en cirugía laparoscópica. Elaboración de un modelo de realidad virtual / Urology residents training in laparoscopic surgery. Develoment of a virtual reality model

Introducción: El entrenamiento y aprendizaje de los residentes en la cirugía laparoscópica tiene limitaciones legales, económicas y tecnológicas. La simulación es una herramienta imprescindible en la formación de los mismos como complemento a su formación en la cirugía laparoscópica. Dicha formación debe estar estructurada en un ambiente adecuado, con objetivos claros determinados previamente, tutelada por profesionales con experiencia en clínica y docencia en simulación y con modelos realísticos, usando tanto animales como tejidos ex-vivo de los mismos. Es imprescindible incorporar mecanismos de evaluación objetivos en el progreso formativo del residente. Objetivo: Presentamos el modelo de entrenamiento en cirugía laparoscópica para los resientes de urología en el Hospital Universitario Valdecilla, que se realiza en el Hospital Virtual Valdecilla, centro asociado al Center for Medical Simulation de Boston y acreditado por el Colegio Americano de Cirujanos. Material y método: El modelo está diseñado en 3 bloques, básico para R1, intermedio para R2-3 y avanzado para R4-5, con 9 módulos a entrenar. El entrenamiento se realiza en programas de 4 h en 4 tardes, a razón de 3 semanas por año de residencia, lo que conlleva que al final de la misma hayan realizado 240 h de formación laparoscópica en simulación. Para cada módulo utilizamos como medida de progresión formativa del residente evaluaciones objetivas estructuradas. Resultados: Desde 2003 se han formado 9 residentes de urología más los 5 que están actualmente en formación. El modelo se ha ido modificando y adecuando según las necesidades que el feedback con los alumnos nos trasmitía. La adquisición de las habilidades en un modelo de realidad virtual ha permitido la transferencia a la práctica real con seguridad. Conclusiones: El diseño de un programa formativo en cirugía laparoscópica, en bloques estructurados y de progresiva complejidad, permite alcanzar una formación adecuada para transferir las habilidades adquiridas mediante este modelo a un escenario real con seguridad para el paciente

Introduction: The training and learning of residents in laparoscopic surgery has legal, financial and technological limitations. Simulation is an essential tool in the training of residents as a supplement to their training in laparoscopic surgery. The training should be structured in an appropriate environment, with previously established and clear objectives, taught by professionals with clinical and teaching experience in simulation. The training should be conducted with realistic models using animals and ex-vivo tissue from animals. It is essential to incorporate mechanisms to assess the objectives during the residents’ training progress. Objective: We present the training model for laparoscopic surgery for urology residents at the University Hospital Valdecilla. The training is conducted at the Virtual Hospital Valdecilla, which is associated with the Center for Medical Simulation in Boston and is accredited by the American College of Surgeons. Material and method: The model is designed in 3 blocks, basic for R1, intermediate for R2-3 and advanced for R4-5, with 9 training modules. The training is conducted in 4-hour sessions for 4 afternoons, for 3 weeks per year of residence. Residents therefore perform 240 hours of simulated laparoscopic training by the end of the course. For each module, we use structured objective assessments to measure each resident's training progress. Results: Since 2003, 9 urology residents have been trained, in addition to the 5 who are currently in training. The model has undergone changes according to the needs expressed in the student feedback. The acquisition of skills in a virtual reality model has enabled the safe transfer of those skills to actual practice. Conclusions: A laparoscopic surgery training program designed in structured blocks and with progressive complexity provides appropriate training for transferring the skills acquired using this model to an actual scenario while maintaining patient safety

Urology residents training in laparoscopic surgery. Development of a virtual reality model.

INTRODUCTION: The training and learning of residents in laparoscopic surgery has legal, financial and technological limitations. Simulation is an essential tool in the training of residents as a supplement to their training in laparoscopic surgery. The training should be structured in an appropriate environment, with previously established and clear objectives, taught by professionals with clinical and teaching experience in simulation. The training should be conducted with realistic models using animals and ex-vivo tissue from animals. It is essential to incorporate mechanisms to assess the objectives during the residents' training progress. OBJECTIVE: We present the training model for laparoscopic surgery for urology residents at the University Hospital Valdecilla. The training is conducted at the Virtual Hospital Valdecilla, which is associated with the Center for Medical Simulation in Boston and is accredited by the American College of Surgeons. MATERIAL AND METHOD: The model is designed in 3 blocks, basic for R1, intermediate for R2-3 and advanced for R4-5, with 9 training modules. The training is conducted in 4-hour sessions for 4 afternoons, for 3 weeks per year of residence. Residents therefore perform 240 hours of simulated laparoscopic training by the end of the course. For each module, we use structured objective assessments to measure each resident's training progress. RESULTS: Since 2003, 9 urology residents have been trained, in addition to the 5 who are currently in training. The model has undergone changes according to the needs expressed in the student feedback. The acquisition of skills in a virtual reality model has enabled the safe transfer of those skills to actual practice. CONCLUSIONS: A laparoscopic surgery training program designed in structured blocks and with progressive complexity provides appropriate training for transferring the skills acquired using this model to an actual scenario while maintaining patient safety.

[Buccal mucosa urethroplasty in anterior urethral strictures]. / Uretroplastia con mucosa oral en estenosis de uretra anterior.

UNLABELLED: Buccal mucosal graft can be used for succesfull repair in both pendulous and bulbar strictures. MATERIAL AND METHODS: We present our experience with buccal mucosal graft repair in 8 patients with onlay patch that varies from 4 to 16 cm. in length. Three pendulous, two bulbar and three panurethral strictures were repaired. These patients were observed for 36 to 60 months. RESULTS: No stricture recurrences were observed. Only one patient had lower lip paresthesia for six months.

Uretroplastia con mucosa oral en estenosis de uretra anterior / Buccal mucosa urethroplasty in anterior urethral structures

Los injertos de mucosa oral pueden ser utilizados para la reparación satisfactoria de estenosis de uretrapéndula y bulbar. Material y métodos: Presentamos nuestra experiencia con injertos de mucosa oral en 8 pacientes. La longitud del injerto fue entre 4 y 16 cm. Se han realizado tres uretroplastias en uretra péndula, dos en uretrabulbar y tres panuretrales. El seguimiento ha sido entre 36 y 60 meses. Resultados: No se han observado recurrencias. Un paciente refirió parestesias en el labio inferior durante seis meses (AU)

Buccal mucosal graft can be used for succesfull repair in both pendulous and bulbar strictures. Material and methods: We present our experience with buccal mucosal graft repair in 8 patients with onlay patch that varies from 4 to 16 cm. in length. Three pendulous, two bulbar and three panurethral strictures were repaired. These patients were observed for 36 to 60 months. Results: No stricture recurrences were observed. Only one patient had lower lip paresthesia for six months (AU)

Seminoma en paciente con Síndrome de Kartagener / Testicular seminoma in a patient with Kartagener's syndrome

Objetivo: Presentar la asociación de seminoma en paciente afecto de SK y su relación con la fertilidad. Métodos: Se describe la presencia de un seminoma en paciente afecto de SK, haciendo hincapié en la posible correlación de ambas patologías con la fertilidad, así como se comentan citas bibliográficas de interés. Resultado: Paciente con tumor testicular y SK al que se realizó orquiectomía, resultando ser un seminoma en el estudio anatomopatológico. Se realizaron dos espermiogramas en los que se corroboró la azoospermia, siendo difícil de diferenciar la posible implicación de ambas patologías en relación con la ausencia de espermatozoides en el eyaculado. Conclusiones: Presentamos un caso de seminoma en paciente afecto de SK y azoopermia. Tras la orquiectomía la evolución es favorable, haciéndose breve referencia bibliográfica al SK y sus potenciales implicaciones en la fertilidad. La asociación de este síndrome con tumor testicular es excepcional en la bibliografía consultada (AU)

Objective: To present the association between Seminoma and Kartagener's Syndrome (KS), and its relation with infertility. Methods: We report one case of Seminoma in a patient with Kartagener's Syndrome, focussing on the possible relation between both pathologies and fertility. Bibliographic references are discussed. Results: Orchyectomy was performed on a patient with Kartagener's Syndrome and testicular tumour. The pathology result was Seminoma. Azoospermia was obtained twice in the postoperative espermiogram, not being easy to establish the implication of each pathology (KS or Seminoma) in infertility. Conclusions: A patient with KS and Seminoma plus azoospermia is reported, with a great outcome from the oncological point of view. Bibliographic references are described. The association between KS and Seminoma is exceptional in the literature (AU)

Trasplante renal sobre prótesis aortobifemoral / renal transplantation in patients with a vascular aortobifemoral prosthesis

Introducción: Cada vez es más frecuente en la práctica clínica, la existencia de pacientes en insuficiencia renal terminal subsidiarios de trasplante renal que han recibido con anterioridad una cirugía protésica de revascularización. Hasta hace poco tiempo, estos pacientes eran desestimados como candidatos a trasplante renal. Contamos aquí nuestra experiencia en cinco casos. Material y métodos: De un total de 1483 trasplantes renales, 5 eran pacientes portadores de prótesis aorto-bifemoral (2 por aneurisma y 3 por enfermedad oclusiva). Revisamos las características, evolución y complicaciones de estos pacientes. Resultados: El injerto vascular se había colocado entre 6 meses y 16 años antes del trasplante. La técnica quirúrgica del trasplante fue la clásica, anastomosando la arteria renal al injerto vascular. Complicaciones quirúrgicas fueron; 1 trombosis de la arteria renal que precisó trombectomía y 1 estenosis ureterovesical. 2 pacientes fallecieron con injerto funcionante por neumonía a los 6 meses y 7 años, 3viven con injerto funcionante a los 7 meses, 3 y 7 años. Durante la evolución aparecieron otras complicaciones vasculares no relacionadas con el trasplante. Conclusión: El trasplante renal sobre prótesis aorto-bifemoral es una opción válida en pacientes seleccionados (AU)

Introduction: Nowadays, it is much more common in end stage renal disease patients with vascular grafts, to be kidney transplant candidates. We expose our experience in five cases. Material and methods: Of all 1,483 kidneys transplanted in our center, 5 recipients had a previous aortobifemoral bypass (2 due to abdominal aortic aneurysm, and 3 due to vascular occlusive disease). We review the clinical features, outcome and complications in these patients. Results: The vascular surgery was done 6 months to 16 years prior to transplantation. The renal transplant was done in iliac foss a with arterial anastomosis to the vascular graft. Surgical complications were: 1 renal artery thrombosis that was treated with thrombectomy, and 1 stricture at the ureterovesical junction. 2 patients dead at 6 months and 7 years with a functioning allograft and 3 patients live with functional allograft at 7 months, 3 years and 7 years. Conclusion: Kidney transplantation may be successful in selected patients with aortobifemoral bypass (AU)

Masa escrotal como resultado de la extensión de un pseudoquiste pancreático / Scrotal mass as result of the extension of a psseudocyst pancreatic

Las causas de orquitis son diversas y entre ellas se encuentran los procesos inflamatorios. Nosotros queremos comunicar el caso de un varón joven con clínica y exploración de orquitis, originada esta por la extensión de un pseudoquiste pancreático, no sospechado en un principio y descubierto por técnicas de imagen (AU)

There are several causes for orchitis and among them there are inflammatory process. We want to communicate the case of a young man with a clinical history and physical examination compatible with orchitis produced by the extension of a pancreatic pseudocyst that was not suspected in the beginning and discovered by imaging procedures (AU)

[Mediastinal lymph nodes during the course of a metastatic prostate cancer]. / Adenopatías mediastínicas en la evolución de un cancer de próstata metastásico.

Prostate carcinoma is one of the most frecuent cancers in men. Significant numbers of patients have regional lymph node and bone metastases during the course of the disease. Mediastinal lymphadenopathy and cutaneous metastases are uncommon and signify well-advanced disease. We report the case of a patient with prostate cancer who develops mediastinal lymphadenopathy, pulmonary nodules and cutaneous metastases 8 years after the diagnosis.

[Multifocal renal cell carcinoma on renal allograft]. / Carcinoma de células renales multicéntrico en injerto renal.

Development of neoplasms after a renal transplantation is well known, but allograft neoplasms are uncommon. Diagnostics studies include routine ultrasonography, and CT. In some selective cases, if the graft is functionally salvageable and it is technically feasible, a nephron-sparing surgery should be performed. In any case, standard intervention is nephrectomy. We report a case of multifocal renal cell carcinoma diagnosed in a kidney grafted 17 years before.

[Emergency conservative surgery on a unique kidney with broken multiple angiomyolipoma]. / Cirugía conservadora de urgencia en monorrena por rotura de angiomiolipoma múltiple.

A case of retroperitoneal hemorrhage due to the rupture of a multiple angiomyolipoma in a female with a unique kidney is described. Hipovolemic shock was the first symptom, being possible to perform on her a successful conservative surgery. Etiology, diagnostic methods and treatment of the spontaneous retroperitoneal hemorrhage are discussed.

Adenopatías mediastínicas en la evolución de un cáncer de próstata metastásico / Mediastinal lymph nodes during the course of a metastatic prostate cancer

El cáncer de próstata es uno de los tumores más frecuentes. Un número importante de pacientes presentarán adenopatías regionales y metástasis óseas en el curso de la enfermedad. Sin embargo, las adenopatías mediastínicas y las metástasis cutáneas son infrecuentes y significan enfermedad avanzada. Presentamos el caso de un paciente diagnosticado de cáncer de próstata que desarrolla adenopatías mediastínicas, nódulos pulmonares y metástasis cutáneas, 8 años después del diagnóstico

Prostate carcinoma is one of the most frecuent cancers in men. Significant numbers of patients have regional lymph node and bone metastases during the course of the disease. Mediastinal lymphadenopathy and cutaneous metastases are uncommon and signify well-advanced disease. We report the case of a patient with prostate cancer who develops mediastinal lymphadenopathy, pulmonary nodules and cutaneous metastases 8 years after the diagnosis

Carcinoma de células renales multicéntrico en injerto renal / Multifocal renal cell carcinoma on renal allograft

El desarrollo de neoplasias después de la realización de un trasplante es un hecho conocido; pero el desarrollo de una neoplasia sobre el órgano trasplantado es raro. Las pruebas diagnósticas incluyen la ecografía rutinaria y la TC. En algunos casos seleccionados, si el injerto es funcionante y es técnicamente factible, se puede realizar cirugía conservadora de nefronas. El patrón estándar de tratamiento es la trasplantectomía. Presentamos un caso de carcinoma renal multicéntrico en un riñón trasplantado 17 años antes

Development of neoplasms after a renal transplantation is well known, but allograft neoplasms are uncommon. Diagnostics studies include routine ultrasonography, and CT. In some selective cases, if the graft is functionally salvageable and it is technically feasible, a nephron-sparing surgery should be performed. In any case, standard intervention is nephrectomy. We report a case of multifocal renal cell carcinoma diagnosed in a kidney grafted 17 years before

Cirugía conservadora de urgencia en monorrena por rotura de angiomiolipoma múltiple / Emergency conservative surgery on a unique kidney with broken multiple angiolypoma

Se presenta el caso una hemorragia retroperitoneal debida a la rotura de un angiomiolipoma (AML) en una paciente monorrena. La paciente debuta con un shock hipovolémico por lo que es necesario realizar una cirugía de urgencia, pudiendo ser en este caso conservadora. Se revisan así mismo las distintas etiologías, diagnóstico y tratamiento de la hemorragia retroperitoneal espontánea

A case of retroperitoneal hemorrhage due to the rupture of a multiple angiomyolipoma in a female with a unique kidney is described. Hipovolemic shock was the first symptom, being possible to perform on her a successful conservative surgery. Etiology, diagnostic methods and treatment of the spontaneous retroperitoneal hemorrhage are discussed

[Nosocomial infection and infection of the surgical site in a third level hospital (2002-2005)]. / Infección nosocomial y del sitio quirúrgico en un hospital de tercer nivel (2002-2005).

INTRODUCTION: Nosocomial infection rates constitute an indicator of welfare quality, permitting to adopt measures of prevention and control. It has been developed a surveillance plan of the nosocomial infection in hospitals, showing to be an efficient method to diminish its incident. OBJECTIVE: To know the indicators and characteristics of the nosocomial infection and of the infection of the site surgical particularly, in a urology service in a global form and by procedures. MATERIAL AND METHODS: Prospective study by means of the epidemiological surveillance system from 2002 to 2005 in 4.618 patients hospitalised at least 24 hours, with a total of 3.096 surgical. RESULTS: The overall incidence of nosocomial infection was 6,10%, 3.42% for urinary infection and 2,81% for the infection of the chirurgical site. For procedures, the incidence of the infection of the surgical site for cistectomy was 22,8%, 6,6% for surgery of kidney and ureter and 4,36% for open surgery of prostate. Eschericia Coli (43,6%) was the most frequently isolated organism, accounting for 43,6% of the causative organisms in the infection of the surgical site and 43,6% in the urinary infection. Pseudomonas aeruginosa is the next organism in frequency with a 15% in both infections. CONCLUSION: Our nosocomial infection rates are lower than the published standard values. The main infection rate of the surgical sites present in the most complex surgical techniques, whereas Escherichia Coli is the most frecuently isolated ethiological agent. The surveillance of the infection of the surgical site and related factors permit to incorporate improvements in the clinical-surgical practice which will be an indicator of reference in subsequent analysis.

Infección nosocomial y del sitio quirúrgico en un hospital de tercer nivel (2002-2005) / Nosocomial infection and infection of the surgical site in a third level hospital (2002-2005)

Introducción: La medida de las tasas de infección nosocomial constituye un indicador de calidad asistencial, permitiendo adoptar medidas de prevención y control. Se ha desarrollado un plan de vigilancia de infección nosocomial en los hospitales, demostrando ser un método eficaz para disminuir su incidencia. Objectivo: Conocer los indicadores y características de la infección nosocomial en general y de la infección del sitio quirúrgico en particular en un servicio de Urología de forma global y por procedimientos. Material y métodos: Estudio prospectivo mediante el sistema de vigilancia epidemiológica entre 2002-2005 en 4.618 pacientes ingresados al menos 24 horas, practicándose un total de 3.096 intervenciones. Resultados: Se observó una tasa global de infección nosocomial del 6.10%, de infección urinaria del 3,42% y de infección del sitio quirúrgico del 2,81%. De esta última por procedimientos, la cistectomía se sitúa en el 22,8%, seguido de la cirugía del riñón y uréter (6,6%) y de la cirugía abierta de próstata (4,36%). Los gérmenes más frecuentemente aislados en la infección del sitio quirúrgico son EScherichia Coli (43,6%) y Pseudomonas aeruginosa (15%). En la infección urinaria los gérmenes más frecuentes son Escherichia Coli (43,6%) y Pseudomonas aeruginosa (15%). Conclusión: Las tasas de infección nosocomial son inferiores a los valores estandares publicados. La mayor tasa de infección del sitio quirúrgico se presenta en las cirugías más complejas técnicamente, siendo Escherichia Coli, el agente etiológico más frecuente. La vigilancia de la infección del sitio quirúrgico y factores relacionados permiten incorporar elementos de mejora en la práctica clínico-quirúrgica, aportando un indicador de referencia en análisis posteriores

Introduction: Nosocomial infection rates constitute an indicator of welfare quality, permitting to adopt measures of prevention and control. It has been developed a surveillance plan of the nosocomial infection in hospitals, showing to be an efficient method to diminish its incident. Objective: To know the indicators and characteristics of the nosocomial infection and of the infection of the site surgical particularly, in a urology service in a global form and by procedures. Material and Methods: prospective study by means of the epidemiological surveillance system from 2002 to 2005 in 4.618 patients hospitalised at least 24 hours, with a total of 3.096 surgical. Results: The overall incidence of nosocomial infection was 6,10%, 3,42% for urinary infection and 2,81% for the infection of the chirurgicalsite. For procedures, the incidence of the infection of the surgical site for cistectomy was 22,8% 6,6% for surgery of kidney and ureter and 4,36% for open surgery of prostate. Escherichia Coli (43,6%) was the most frequently isolated organism, accounting for 43,6&% of the causative organisms in the infection of the surgical site and 43,6% in the urinary infection. Pseudomonas aeruginosa is the next organism in frecuency with a 15% in both infections. Conclusion: Our nosocomial infection rates are lower than the published standard values. The main infection rate of the surgical sites present in the most complex surgical techniques, whereas Escherichia Coli is the most frecuently isolated ethiological agent. The surveillance of the infection of the surgical site and related factors permit to incorporate improvements int he clinical-surgical practice which will be an indicator of reference in subsequent analysis

[Testicular epidermoid cyst: uncommon lesion of difficult preoperative diagnosis]. / Quiste epidermoide testicular: una rara entidad de dificil diagnostico preoperatorio.

Intratesticular epidermoid cysts are rare tumours that constitute one percent of all testicular masses. They are bening lesions that make differential diagnosis from malignant testicular tumours difficult. The absence of serum markers elevation and ultrasound imaging could support these lesions being bening epidermoid cysts, and in that case, conservative surgery is adequate. We present the case of a 22 years old patient who complains of a left testicular mass. In this case ultrasound diagnosis was non-specific and a left radical inguinal orchiectomy was performed.

Tumor renal en ectopia renal cruzada con fusión / Renal cell carcinoma in crossed fused renal ectopia

La ectopia renal cruzada es una anomalía renal congénita poco frecuente y en la mayoría de los casos se presenta con fusión de ambos riñones. Estos pacientes suelen permanecer asintomáticos hasta la 4ª-5ª década y desarrollar entonces problemas de infecciones urinarias, litiasis, masa abdominal o dolor que simula un problema gastrointestinal. Presentamos el caso de un tumor de células renales aparecido en un paciente con ectopia renal cruzada con fusión, descubierto en un TAC realizado por sospecha de patología gastrointestinal (AU)

Crossed renal ectopia its a rare congenital malformation and in most cases it presents with fusion of both kidneys. Patients should be asynptomatic until 4ª-5ª decade and at that time they unfold urinary infection, urolithiasis, abdominal mass or pain that simulates a gastric disease. We report a case of renal cell carcinoma in a patient with crossed fused renal ectopia, showed in a Scan that was performed for gastric disease suspicion (AU)

Quiste epidermoide testicular: una rara entidad de difícil diagnostico preoperatorio / Testicular epidermoid cyst: uncommon lesion of difficult preoperative diagnosis

Los quistes epidermoides intratesticulares son tumores raros, constituyendo el 1% de todos los tumores testiculares. Se trata de tumoraciones benignas que plantean un difícil diagnóstico diferencial preoperatorio frente a los tumores malignos testiculares. La ausencia de elevación de los marcadores tumorales y la apariencia ecográfica, pueden orientar hacia su diagnóstico preoperatorio y en este caso la cirugía conservadora del testículo. Se presenta el caso de un paciente de 22 años que consulta por una masa en el testículo izquierdo. En este caso, el diagnóstico ecográfico preoperatorio no descartaba otras patologías por lo que se procedió a la realización de orquiectomía inguinal izquierda (AU)

Intratesticular epidermoid cysts are rare tumours that constitute one percent of all testicular masses. They are bening lesions that make differential diagnosis from malignant testicular tumours difficult. The absence of serum markers elevation and ultrasound imaging could support these lesions being bening epidermoid cysts, and in that case, conservative surgery is adequate. We present the case of a 22 years old patient who complains of a left testicular mass. In this case ultrasound diagnosis was non-specific and a left radical inguinal orchiectomy was performed (AU)