[Prostatic high resolution micro-ultrasound (MUS) imaging.] / Ecografía de alta resolución prostática (microultrasonografía-ExactVuTM).

OBJECTIVE: Prostate cancer (PCa) diagnosis has improved with multiparametric magnetic resonance (mpMRI) and new more specific biomarkers. However, mpMRI has some limitations such as variability, long learning curve and high cost. More progress is needed in the PCa diagnosis scenario, and it is here where high resolution micro-ultrasound (MUS) imaging system emerge. MATERIAL AND METHODS: Retrospective study between February (2017-2018); including 96 patients with PCa suspicion, undergoing transrectal prostate biopsy guided by MUS. Procedure was performed by 2 urologists blinded to mpMRI results at first (92% available). PRI-MUS protocol was used to identify suspicious features. 2 core targeted biopsy of suspicious areas (PRIMUS >3) was completed first and then it was followed by a 12-core systematic biopsy and finally sampling of mpMRI targets if available. Data were collected reporting sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) to detect clinically significant PCa (csPCa) (Gleason score >7). RESULTS: Overall, MUS csPCa detection rate was 59.37%. 171 cores were registered, of them csPCa were distributed as follow: 1.2% PRI-MUS 1, 16.3% PRIMUS 2, 28% PRI-MUS 3, 39% PRI-MUS 4 and 15% PRI-MUS 5. Sensitivity in csPCa detection for PRI-MUS >3 was 82% with 93% NPV, but with low 39% specificity and 19% PPV. Comparing 79 patients with mpMRI available; sensitivity by area of MUS was 82% versus 30% of mpMRI, with 93% NPV versus 88%. Specificity and PPV were higher in mpMRI in comparison to MUS. CONCLUSIONS: Although this is a preliminary series, MUS is presented as an attractive imaging technique, cost-effective, easy to learn and with high efficacy in image- guided prostate biopsy. Overall PCa detection rate increases over conventional ultrasound; and offers high sensitivity and NPV in csPCa detection over mpMRI but with lower specificity.

OBJETIVO: El diagnóstico del cáncer de próstata (CaP) ha mejorado con la resonancia magnética multiparamétrica (RMmp) y nuevos biomarcadores más específicos. No obstante, la RMmp tiene unas limitaciones: variabilidad, larga curva de aprendizaje y coste elevado. Por ello se hacen necesarios más avances en el escenario diagnóstico, y es aquí donde irrumpen los microultrasonidos de alta resolución (MUS) 29 MHz.MATERIAL Y MÉTODOS: Entre Feb 2017-2018; 96 pacientes con sospecha de CaP; recibieron biopsia prostática transrectal guiada por MUS. Procedimiento realizado por 2 urólogos a los que se ocultó los resultados de la RMmp (disponible en 92%). Se empleó protocolo PRI-MUS; obteniendo 2 muestras de área sospechosa (PRIMUS >3) más biopsia sistemática. Se añadieron muestras adicionales de áreas PI-RADS >3. Se recogen datos de sensibilidad, especificidad y valor predictivo positivo (VPP) y negativo (VPN) para detectar CaP clínicamente significativo (CaPcs) (Gleason Score >7). RESULTADOS: La tasa de detección global de los MUS para CaPcs fue del 59,37%. Se registraron 171 cilindros positivos, de los cuales CaPcs fueron: 1,2% PRI-MUS 1, 16,3% PRI-MUS 2, 28% PRI-MUS 3, 39% PRI-MUS 4 y 15% PRI-MUS 5. La sensibilidad en la detección de CaPcs en PRI-MUS >3 fue del 82% con VPN 93%, pero con baja especificidad 39% y VPP del 19%. Comparando los 79 pacientes con RMmp; la sensibilidad por zona de los MUS fue del 82% frente al 30% de la RMmp, con un VPN del 93% frente al 88%. La especificidad y el VPP fueron superiores en la RMmp frente a MUS. CONCLUSIONES: Aunque la serie es preliminar, los MUS se presentan como una técnica de imagen coste- efectiva, sencilla de aprender y con alta eficacia en la biopsia prostática. La tasa de detección global de CaP duplica a la de los ultrasonidos convencionales; y ofrece alta sensibilidad y valor predictivo negativo en la detección de CaPcs frente a la RMmp.

Ecografía de alta resolución prostática (microultrasonografía-ExactVuTM) / Prostatic high resolution micro-ultrasound (MUS) imaging

Objetivo: El diagnóstico del cáncer de próstata (CaP) ha mejorado con la resonancia magnética multiparamétrica (RMmp) y nuevos biomarcadores más específicos. No obstante, la RMmp tiene unas limitaciones: variabilidad, larga curva de aprendizaje y coste elevado. Por ello se hacen necesarios más avances en el escenario diagnóstico, y es aquí donde irrumpen los microultrasonidos de alta resolución (MUS) 29 MHz. Material y métodos: Entre Feb 2017-2018; 96 pacientes con sospecha de CaP; recibieron biopsia prostática transrectal guiada por MUS. Procedimiento realizado por 2 urólogos a los que se ocultó los resultados de la RMmp (disponible en 92%). Se empleó protocolo PRI-MUS; obteniendo 2 muestras de área sospechosa (PRIMUS > 3) más biopsia sistemática. Se añadieron muestras adicionales de áreas PI-RADS > 3. Se recogen datos de sensibilidad, especificidad y valor predictivo positivo (VPP) y negativo (VPN) para detectar CaP clínicamente significativo (CaPcs) (Gleason Score > 7). Resultados: La tasa de detección global de los MUS para CaPcs fue del 59,37%. Se registraron 171 cilindros positivos, de los cuales CaPcs fueron: 1,2% PRI-MUS 1, 16,3% PRI-MUS 2, 28% PRI-MUS 3, 39% PRI-MUS 4 y 15% PRI-MUS 5. La sensibilidad en la detección de CaPcs en PRI-MUS > 3 fue del 82% con VPN 93%, pero con baja especificidad 39% y VPP del 19%. Comparando los 79 pacientes con RMmp; la sensibilidad por zona de los MUS fue del 82% frente al 30% de la RMmp, con un VPN del 93% frente al 88%. La especificidad y el VPP fueron superiores en la RMmp frente a MUS. Conclusiones: Aunque la serie es preliminar, los MUS se presentan como una técnica de imagen coste- efectiva, sencilla de aprender y con alta eficacia en la biopsia prostática. La tasa de detección global de CaP duplica a la de los ultrasonidos convencionales; y ofrece alta sensibilidad y valor predictivo negativo en la detección de CaPcs frente a la RMmp

Objective: Prostate cancer (PCa) diagnosis has improved with multiparametric magnetic resonance (mpMRI) and new more specific biomarkers. However, mpMRI has some limitations such as variability, long learning curve and high cost. More progress is needed in the PCa diagnosis scenario, and it is here where high resolution micro-ultrasound (MUS) imaging system emerge. Material and methods: Retrospective study between February (2017-2018); including 96 patients with PCa suspicion, undergoing transrectal prostate biopsy guided by MUS. Procedure was performed by 2 urologists blinded to mpMRI results at first (92% available). PRI-MUS protocol was used to identify suspicious features. 2 core targeted biopsy of suspicious areas (PRIMUS > 3) was completed first and then it was followed by a 12-core systematic biopsy and finally sampling of mpMRI targets if available. Data were collected reporting sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) to detect clinically significant PCa (csPCa) (Gleason score > 7). Results: Overall, MUS csPCa detection rate was 59.37%. 171 cores were registered, of them csPCa were distributed as follow: 1.2% PRI-MUS 1, 16.3% PRIMUS 2, 28% PRI-MUS 3, 39% PRI-MUS 4 and 15% PRI-MUS 5. Sensitivity in csPCa detection for PRI-MUS > 3 was 82% with 93% NPV, but with low 39% specificity and 19% PPV. Comparing 79 patients with mpMRI available; sensitivity by area of MUS was 82% versus 30% of mpMRI, with 93% NPV versus 88%. Specificity and PPV were higher in mpMRI in comparison to MUS. Conclusions: Although this is a preliminary series, MUS is presented as an attractive imaging technique, cost-effective, easy to learn and with high efficacy in image-guided prostate biopsy. Overall PCa detection rate increases over conventional ultrasound; and offers high sensitivity and NPV in csPCa detection over mpMRI but with lower specificity

How to build a robotic program.

OBJECTIVE: Advancements in the robotic surgical technology have revolutionized the standard of care for many surgical procedures. The purpose of this review is to focus on the different issues involved in developmental phase of starting a robotic program and to evaluate the important considerations in developing this program at a given healthcare institution. METHODS & RESULTS: Although every hospital might desire a robotic program, there are many requirements needed to uphold a successful and self-sustainable program in the current healthcare market. Patients' interest in robotic-assisted surgery has and continues to grow because of improved outcomes and decreased periods of hospitalization. Resulting market forces have created a solid foundation for the implementation of robotic surgery into surgical practice. A thorough market analysis, including that of competing entities and estimated surgical volume, is necessary prior to purchasing a robot. Another issue to be addressed is determining whether one has trained surgeons or the capability to recruit the appropriately trained surgeons to keep a robotics program afloat. Formally trained robotic surgeons have better patient outcomes and shorter operative times. An assessment of facilities and staff is also imperative prior to making such a substantial investment. Ultimately, after a well thought-out analysis, a decision must be made as to whether the institution can support and maintain a robotics program. CONCLUSIONS: Individual economic factors of local healthcare settings must be evaluated when planning for a new robotics program. The high cost of the robotic surgical platform is best offset with a large surgical volumen,interdisciplinary utilization of the technology may be the solution. A mature, experienced surgeon is integral to the success of a new robotics program. Define procedures to be performed, necessary training, staff involved,equipment, facilities, setting-up, economical resources and marketing are important issues to be teaken into account before acquiring a surgical robotic system.

ARTICULO SOLO EN INGLES. OBJETIVO: Los avances de la tecnología robótica quirúrgica han revolucionado el estándar de tratamiento en muchos procedimientos quirúrgicos. El objetivo de esta revisión está focalizado en los diferentes aspectos involucrados en la fase de desarrollo de inicio de un programa de robótica y en evaluar lasconsideraciones importantes para desarrollar este programa en un hospital determinado.MÉTODOS/RESULTADOS: Aunque todos los hospitales desearían tener un programa de cirugía robótica, son necesarios muchos requerimientos para mantener un programa de éxito y auto sostenible en el mercado de la salud actual. El interés de los pacientes por la cirugía asistida por robot ha aumentado y sigue creciendo debido a la mejora de los resultados y la disminución de los periodos de hospitalización. Las fuerzas de mercado resultantes han creado una base sólida para la implementación de la cirugía robótica en la práctica quirúrgica. Antes de la compra de un robot es necesario un análisis profundo del mercado, incluyendo las entidades que compiten y el volumen quirúrgico estimado. Otro aspecto a tratar es determinar si uno tiene cirujanos formados o la capacidad de reclutar los cirujanos apropiados ya formados para  mantener el programa de robótica a flote. Los cirujanos robóticos formados formalmente tienen mejores resultados en sus pacientes y tiempos de operación más cortos. También es imperativo un análisis de las instalaciones y el personal antes de hacer semejante inversión. Finalmente, después de un análisis bien pensado, se debe tomar la decisión de si la institución puede apoyar y mantener un programa robótico.CONCLUSIONES: Cuando se planea un nuevo programa de cirugía robótica se deben evaluar los factores económicos individuales del marco sanitario local. El alto coste de la plataforma de cirugía robótica está mejor compensada con un gran volumen quirúrgico y uso interdisciplinario de la tecnología. Un cirujano maduro, experimentado es parte integral del éxito de un nuevoprograma de cirugía robótica. Definir los procedimientos que se van a realizar, el entrenamiento necesario, el personal involucrado, el equipo, las nstalaciones, la puesta en marcha, los recursos económicos y el marketingson aspectos importantes a tener en cuenta antes de adquirir un sistema robótico quirúrgico.

How to build a robotic program / Como construir un programa de cirugía robótica

Objective: Advancements in the robotic surgical technology have revolutionized the standard of care for many surgical procedures. The purpose of this review is to focus on the different issues involved in developmental phase of starting a robotic program and to evaluate the important considerations in developing this program at a given healthcare institution. Methods & results: Although every hospital might desire a robotic program, there are many requirements needed to uphold a successful and self-sustainable program in the current healthcare market. Patients’ interest in robotic-assisted surgery has and continues to grow because of improved outcomes and decreased periods of hospitalization. Resulting market forces have created a solid foundation for the implementation of robotic surgery into surgical practice. A thorough market analysis, including that of competing entities and estimated surgical volume, is necessary prior to purchasing a robot. Another issue to be addressed is determining whether one has trained surgeons or the capability to recruit the appropriately trained surgeons to keep a robotics program afloat. Formally trained robotic surgeons have better patient outcomes and shorter operative times. An assessment of facilities and staff is also imperative prior to making such a substantial investment. Ultimately, after a well thought-out analysis, a decision must be made as to whether the institution can support and maintain a robotics program. Conclusions: Individual economic factors of local healthcare settings must be evaluated when planning for a new robotics program. The high cost of the robotic surgical platform is best offset with a large surgical volumen, interdisciplinary utilization of the technology may be the solution. A mature, experienced surgeon is integral to the success of a new robotics program. Define procedures to be performed, necessary training, staff involved, equipment, facilities, setting-up, economical resources and marketing are important issues to be teaken into account before acquiring a surgical robotic system

Objetivo: Los avances de la tecnología robótica quirúrgica han revolucionado el estándar de tratamiento en muchos procedimientos quirúrgicos. El objetivo de esta revisión está focalizado en los diferentes aspectos involucrados en la fase de desarrollo de inicio de un programa de robótica y en evaluar las consideraciones importantes para desarrollar este programa en un hospital determinado. Métodos/resultados: Aunque todos los hospitales desearían tener un programa de cirugía robótica, son necesarios muchos requerimientos para mantener un programa de éxito y auto sostenible en el mercado de la salud actual. El interés de los pacientes por la cirugía asistida por robot ha aumentado y sigue creciendo debido a la mejora de los resultados y la disminución de los periodos de hospitalización. Las fuerzas de mercado resultantes han creado una base sólida para la implementación de la cirugía robótica en la práctica quirúrgica. Antes de la compra de un robot es necesario un análisis profundo del mercado, incluyendo las entidades que compiten y el volumen quirúrgico estimado. Otro aspecto a tratar es determinar si uno tiene cirujanos formados o la capacidad de reclutar los cirujanos apropiados ya formados para mantener el programa de robótica a flote. Los cirujanos robóticos formados formalmente tienen mejores resultados en sus pacientes y tiempos de operación más cortos. También es imperativo un análisis de las instalaciones y el personal antes de hacer semejante inversión. Finalmente, después de un análisis bien pensado, se debe tomar la decisión de si la institución puede apoyar y mantener un programa robótico. Conclusiones: Cuando se planea un nuevo programa de cirugía robótica se deben evaluar los factores económicos individuales del marco sanitario local. El alto coste de la plataforma de cirugía robótica está mejor compensada con un gran volumen quirúrgico y uso interdisciplinario de la tecnología. Un cirujano maduro, experimentado es parte integral del éxito de un nuevo programa de cirugía robótica. Definir los procedimientos que se van a realizar, el entrenamiento necesario, el personal involucrado, el equipo, las instalaciones, la puesta en marcha, los recursos económicos y el marketing son aspectos importantes a tener en cuenta antes de adquirir un sistema robótico quirúrgico

[BCG therapy in NMIBC: How much and for how long?.] / Opciones terapeúticas tras fracaso de BCG.

Bladder cancer is the 9th most prevalent cancer in the world. It is divided into muscle invasive bladder cancer (MIBC) and non muscle invasive bladder cancer (NMIBC). Over 75% belong to the second group and it will be classified according to the risk of progression and recurrence. In high and intermediate risk tumors. There is indication for the use of bladder instillations with BCG as it reduces the number of recurrences and disease progression to MIBC. In spite of this, disease control is not possible in all cases and there could be recurrence or progression of the disease to MIBC. This article is a review of the therapeutic options of tumor recurrence after failure of BCG treatment.

[Current status of extracorporeal shock wave lithotripsy in urinary lithiasis.] / Estado actual de la litotricia extracorpórea por ondas de choque en la litiásis urinaria.

Over the last decade, urinary lithiasis' prevalence has dramatically increased due to diet and lifestyle changes, growing 10.6% and 7.1% in men and women respectively. Extracorporeal shock wave lithotripsy has lost relevance in current practice due to endoscopic device development and unpredictability of results. Instrument miniaturization is leading to an increase of the percutaneous approach of increasingly smaller stones, while most flexible ureteroscopes durability and digitalization has allowed urologists to address larger stones. So that, decision algorithm is now impossible to define, but what is clear is that ESWL has declined worldwide. Can it disappear as a urinary lithiasis treatment modality? If we don't improve appropriate candidate selection and optimize disintegration efficiency, guidelines are going to replace the more "boring" ESWL by popular and more attractive endoscopes. Shock wave technology has evolved in the last two decades, however lithotripsy fundamental principle has not changed. ESWL has passed the test of time and centers dedicated to stone treatment should have a lithotripter in order to offer an appropriate balance in different options for different clinical situations. New developments will be focused on improvements in location (in-line navigation systems; Vision track system) and automatic ultrasound location on a robotic arm; monitoring and stone fixation, implementation of different focal sizes with new acoustic lenses, multitask working stations that allow endourological approach, coupling control (avoiding microbubbles) and low cost devices for different applications. On the other hand, optimizing outcomes by: slower pulse rates, ramping strategies and patient selection with soft stones, short stone-skin distance, low BMI and favorable collecting system anatomy, allow us to achieve better outcomes in shock wave treatments. SWL still represents a unique non invasive method of stone disease treatment with no anesthesia and low complication rates; and a high proportion of stones could still be treated with shock waves and remains among patient's first options. This update objective has been to review the evolution, identify shock wave new developments and clarify their impact on our daily practice in urinary stones treatment.

Estado actual de la litotricia extracorpórea por ondas de choque en la litiásis urinaria / Current status of extracorporeal shock wave lithotripsy in urinary lithiasis

En las últimas décadas la prevalencia de la enfermedad litiásica urinaria se ha incrementado dramáticamente debido al cambio de dieta y estilo de vida, creciendo un 10,6% y 7,1% en hombres y mujeres respectivamente. La litotricia extracorpórea ha perdido protagonismo en la actualidad debido al desarrollo tecnológico de los instrumentos endoscópicos y a la impredecibilidad de sus resultados. La miniaturización de los instrumentos esta derivando en un incremento del abordaje percutáneo en cálculos cada vez más pequeños; mientras que la mayor durabilidad y la digitalización de los ureteroscopios flexibles ha permitido a los urólogos abordar cálculos cada vez más grandes. De manera que el algoritmo de decisión terapéutica es ahora casi imposible de definir; pero lo que está claro es el descenso de la litotricia extracorpórea en todo el mundo. ¿Puede desaparecer como modalidad terapéutica de la litiásis?. Si no mejoramos la selección de los candidatos más adecuados y no optimizamos la eficacia desintegradora, las guías clínicas progresivamente van a sustituir a la más 'aburrida' litotricia extracorpórea, por los populares y más atractivos nuevos endoscopios. En las dos últimas décadas la tecnología de las ondas de choque ha evolucionado, sin embargo el principio fundamental de la litotricia no ha cambiado. La Litotricia extracorpórea ha superado la prueba del tiempo y los centros que se vayan a dedicar al tratamiento de la litiasis deberán contar con un litotriptor en aras a un adecuado equilibrio en las diferentes opciones a ofrecer en las diferentes situaciones clínicas. Las novedades se centrarán en mejoras en la localización (sistemas de navegación in-line y lateral (visión Track System ) y localización automática ultrasónica con brazo robótico; seguimiento y fijación del cálculo, implementación de diferentes tamaños focales con nuevas lentes acústicas que incrementan el área focal, estaciones de trabajo multifuncional para permitir abordaje endourológico, control del acoplamiento (evitando microburbujas) y dispositivos de bajo coste con diferentes aplicaciones. Por otro lado, la optimización del tratamiento mediante: el escalonado de dosis, la reducción de la frecuencia de ondas de choque, la selección de pacientes con litiasis no duras, con distancias piel-cálculo cortas, bajo índice de masa corporal y anatomía favorable del sistema colector, permitirá conseguir mejores resultados de las ondas de choque. La litotricia extracorpórea todavía representa el único método no invasivo de tratamiento litiásico, con baja tasa de complicaciones y que puede realizarse sin anestesia; y una proporción elevada de cálculos todavía pueden ser subsidiarios a tratamiento con ondas de choque y sigue vigente entre las primeras opciones de los pacientes. El objetivo de esta actualización ha sido revisar la evolución, identificar los nuevos desarrollos en el tratamiento con ondas de choque y clarificar su impacto en nuestra práctica clínica cotidiana en el tratamiento de la litiásis urinaria

Over the last decade, urinary lithiasis' prevalence has dramatically increased due to diet and lifestyle changes, growing 10,6% and 7,1% in men and women respectively. Extracorporeal shock wave lithotripsy has lost relevance in current practice due to endoscopic device development and unpredictability of results. Instrument miniaturization is leading to an increase of the percutaneous approach of increasingly smaller stones, while most flexible ureteroscopes durability and digitalization has allowed urologists to address larger stones. So that, decision algorithm is now impossible to define, but what is clear is that ESWL has declined worldwide. Can it disappear as a urinary lithiasis treatment modality? If we don´t improve appropriate candidate selection and optimize disintegration efficiency, guidelines are going to replace the more 'boring' ESWL by popular and more attractive endoscopes. Shock wave technology has evolved in the last two decades, however lithotripsy fundamental principle has not changed. ESWL has passed the test of time and centers dedicated to stone treatment should have a lithotripter in order to offer an appropriate balance in different options for different clinical situations. New developments will be focused on improvements in location (in-line navigation systems; Vision track system) and automatic ultrasound location on a robotic arm; monitoring and stone fixation, implementation of different focal sizes with new acoustic lenses, multitask working stations that allow endourological approach, coupling control (avoiding microbubbles) and low cost devices for different applications. On the other hand, optimizing outcomes by: slower pulse rates, ramping strategies and patient selection with soft stones, short stone-skin distance, low BMI and favorable collecting system anatomy, allow us to achieve better outcomes in shock wave treatments. SWL still represents a unique non invasive method of stone disease treatment with no anesthesia and low complication rates; and a high proportion of stones could still be treated with shock waves and remains among patient`s first options. This update objective has been to review the evolution, identify shock wave new developments and clarify their impact on our daily practice in urinary stones treatment

[Testosterone and coronary artery disease]. / Testosterona y enfermedad coronaria.

UNLABELLED: Elderly patients present testosterone deficit syndrome (TDS) in a prevalent manner. TDS is defined as a clinical and biochemical syndrome with total fasting testosterone below normal levels in two consecutive measurements. A significant relationship with comorbidities such as diabetes mellitus, obesity or metabolic syndrome has been observed in these patients. These latter are recognized risk factors of coronary artery disease (CAD) and arteriosclerosis. It seems logical to think that CAD is more frequent in patients with TDS, and it is supported on multiple works demonstrating the correlation of theses two pathologies. We intend to illustrate the management of patients with TDS and CAD presenting a clinical case and the recommended diagnostic and therapeutic approach. A Sixty-four year old male with hypertension, non-insulin dependent diabetes mellitus and obesity consulted for erectile dysfunction and diminished sexual desire. Fasting total testosterone and glycosylate hemoglobin were determined. IIEF-5 was 12, Erection hardness Score was 2 and IIEF item 12 1 point over 5. His total testosterone was 150 ng/dl, which was confirmed in a second test; HDL cholesterol level was 30 mg/dl. Interrogated again, the patient referred oppressive chest pain appearing after running 50 meters for the last three months that never happened in rest or with minor efforts. APPROACH: It is a patient with high cardiovascular risk and atypical chest pain so recommendation was given to consult a cardiologist. Stress test was performed. It was a submaximal, evaluable test (reached 80% of his maximum theoretical heart rate) stopped due to angina. Clinically and electrically it was positive at medium charge. Coronary angiogram was indicated showing a severe (85%percnt;%) lesion at the medial third of anterior descendant artery. Balloon angioplasty was performed and a 3.0 x 24 mm drug-coated stent was placed. Cardiologic treatment was prescribed as well as combination therapy for his erectile dysfunction and diminished libido with testosterone and a PDE 5 inhibitor.

Paciente con SDT y enfermedad coronaria / Testosterone and coronary artery disease

Los pacientes de edad avanzada presentan, de manera prevalente, deficiencia sintomática de testosterona. El síndrome de déficit de testosterona (SDT) se define como un síndrome clínico y bioquímico con niveles de testosterona total en ayunas por debajo de niveles normales, en dos mediciones consecutivas. En estos pacientes se ha observado una relación significativa con comorbilidades como la diabetes mellitus, la obesidad o el síndrome metabólico. Estos últimos son reconocidos factores de riesgo de enfermedad coronaria y ateroesclerosis. Parece lógico pensar que la enfermedad coronaria es más frecuente en pacientes con SDT, y esto se sostiene con múltiples trabajos que demuestran la correlación entre estas dos patologías. Se propone ilustrar el manejo de pacientes con SDT y enfermedad coronaria mediante la presentación de un caso clínico y la actitud diagnóstico terapéutica recomendada. Varón de 64 años hipertenso y diabético no insulin-dependiente, obeso, que consulta por disfunción eréctil y disminución del deseo sexual. Se solicita una testosterona total en ayunas y hemoglobina glicosilada. Presenta un IIEF-5 de 12, un Erection Hardness Score de 2 y un ítem 12 del IIEF de 1 punto sobre 5. Presenta una testosterona total de 150 ng/dl que se confirma disminuida en una segunda medición, un colesterol HDL de 30 mg/dl. Reinterrogando al paciente refiere un dolor torácico opresivo que surge cuando corre 50 metros, desde hace 3 meses, y que no se produce nunca en reposo ni con esfuerzos menores. ACTITUD: Se trata de un paciente con alto riesgo cardiovascular y dolor torácico atípico por lo que se recomienda remitir a la consulta de cardiología (AU)

Se realiza una prueba de esfuerzo siendo una prueba submáxima valorable (alcanzó el 80% de su frecuencia cardiaca máxima teórica) suspendida por angina. Clínica y eléctricamente positiva a carga intermedia. Se indica un cateterismo coronario dando una lesión severa (85%) en el tercio medio de la arteria descendente anterior,s e realiza angioplastia de la lesión de la arteria descendente anterior con balón y stent farmacoactivo de 3.0x24 mm. Se indica tratamiento por parte de cardiología y tratamiento combinado para su disfunción eréctil y disminución de libido mediante testosterona y un inhibidor de la fosfodiesterasa 5 (AU)

Elderly patients present testosterone deficit syndrome (TDS) in a prevalent manner. TDS is defined as a clinical and biochemical syndrome with total fasting testosterone below normal levels in two consecutive measurements. A significant relationship with comorbidities such as diabetes mellitus, obesity or metabolic syndrome has been observed in these patients. These latter are recognized risk factors of coronary artery disease (CAD) and arteriosclerosis. It seems logical to think that CAD is more frequent in patients with TDS, and it is supported on multiple works demonstrating the correlation of theses two pathologies. We intend to illustrate the management of patients with TDS and CAD presenting a clinical case and the recommended diagnostic and therapeutic approach. A Sixty-four year old male with hypertension, non-insulin dependent diabetes mellitus and obesity consulted for erectile dysfunction and diminished sexual desire. Fasting total testosterone and glycosylate hemoglobin were determined.IIEF-5 was 12, Erection Hardness Score was 2 and IIEF item 12 1 point over 5. His total testosterone was 150 ng/dl, which was confirmed in a second test; HDL cholesterol level was 30 mg/dl. Interrogated again, the patient referred oppressive chest pain appearing after running 50 meters for the last three months that never happened in rest or with minor efforts (AU)

APPROACH: It is a patient with high cardiovascular risk and atypical chest pain so recommendation was given to consult a cardiologist. Stress test was performed. It was a submaximal, evaluable test (reached 80% of his maximum theoretical heart rate) stopped due to angina. Clinically and electrically it was positive at medium charge. Coronary angiogram was indicated showing a severe (85%) lesion at the medial third of anterior descendant artery. Balloon angioplasty was performed and a 3.0 x 24 mm drug-coated stent was placed. Cardiologic treatment was prescribed as well as combination therapy for his erectile dysfunction and diminished libido with testosterone and a PDE 5 inhibitor (AU)

Linguistic and psychometric validation of the Erection Hardness Score to Spanish.

INTRODUCTION: The Erection Hardness Score (EHS) is a one-item questionnaire that assesses rigidity on a 4-point scale. AIM: To perform a validation of a Spanish version of the EHS by comparison with the International Index of Erectile Function (IIEF) questionnaire. METHODS: Validation of the EHS included: (i) professional translation of the scale; (ii) scientific evaluation of the translation from four independent urologists; (iii) assessment on five individuals to test correct comprehension and idiomatic adequacy (iv) validation of the EHS by a cross-sectional, multicenter comparison with the IIEF. MAIN OUTCOME METHODS: Patients were required to respond to a Spanish version of the EHS and IIEF. Statistic correlation was carried out between the EHS score and IIEF-erectile function domain (EF) score. RESULTS: A total of 125 patients were recruited. Overall prevalence of erectile dysfunction (ED) by the EHS questionnaire was of 80.2% patients (n=97). Mean EHS was 2.74±0.97. Mean IIEF-EF score was 17.4±9.5. The EHS showed good reliability. The rate of missing responses to the EHS questionnaire was 0%. A one-factor analysis of variance was performed between the EHS and EF subdomain of IIEF (P=0.000). Pearson's correlation coefficient between EHS and EF subdomain of IIEF was 0.834, P<0.01. CONCLUSIONS: The EHS is a reliable tool to test ED and its Spanish version was satisfactorily understood by patients and correlated with IIEF-EF.

Disfunción eréctil de origen vascular / Vascular erectile dysfunction

La etiología vascular de la disfunción eréctil está presente en el 60% de los pacientes con DE. La enfermedad de pequeños vasos, como en la diabetes, y la arteriosclerosis de arterias de mayor tamaño, como en la hipertensión, causa insuficiencia arterial y disfunción eréctil.El tabaco altera la hemodinámica arterial del pene, causando disfunción eréctil en un alto porcentaje de fumadores de edad avanzada: la fibrosis y estenosis de las arterias pélvicas acelera la arteriosclerosis existente. La disfunción venoclusiva puede deberse a la disminución de la distensibilidad de cuerpos cavernosos o anormalidades inherentes en la albugínea.El factor de crecimiento vascular endotelial puede desempeñar un papel en la modulación de la vascularización de la arquitectura normal del pene.Distintos acontecimientos, todos ellos importantes, pueden causar disfunción eréctil. Además, ninguna causa puede participar de forma independiente. Una cascada de situaciones (incluidos los factores psicológicos, así como los orgánicos) pueden llevar a la disfunción eréctil. Una comprensión continuada de las causas orgánicas de la disfunción eréctil permitirá al médico descubrir tratamientos para su corrección, así como proporcionar seguridad al paciente(AU)

Vascular etiology is present in up to 60% of the patients with erectile dysfunction (ED). Both small vessel disease, such as that in diabetes mellitus, and arteriosclerosis of bigger size arteries, as in hypertension, cause arterial insufficiency and erectile dysfunction.Tobacco smoking alters the arterial hemodynamics in the penis, causing erectile dysfunction in a high percentage of advanced age smokers: pelvic arteries fibrosis and stenosis accelerates the existing arteriosclerosis. Venous occlusive dysfunction may be due to the decrease of corpora cavernosa compliance or tunica albuginea inherent anomalies.Vascular endothelial growth factor may play a role in the modulation of vascularization of the normal penile architecture. Various events, all of them important, may cause erectile dysfunction. Moreover, no cause can participate independently. A cascade of situations (including psychological factors as well as organic) may lead to erectile dysfunction. A continuous understanding of organic causes of erectile dysfunction will allow physicians to discover treatments for their correction, as well as to give confidence to the patient(AU)

[New position for laparoscopic pyeloplasty. Our experience]. / Nuevo posicionamiento para realizar la pieloplastia laparoscópica. Nuestra experiencia.

OBJECTIVES: To share our experience performing laparoscopic pyeloplasty and our contributions to this surgery. METHODS: Between March 2004 and January 2006 we have performed 12 laparoscopic pyeloplasties in 12 patients. We modified our technique as we found difficulties during operations. By the only modification of patient position we have achieved a significant improve in our technique. RESULTS: We describe how we performed the operation in the first cases and how we do it today, with the new position. We also describe the advantages observed. CONCLUSIONS: With our technique we achieve an important surgical time reduction, improvements in safety and reduction of surgical complications.

[Robotic renal surgery: pyeloplasty]. / Cirugía renal robótica: pieloplastia.

The treatment of ureteropyelic junction (UPJ) obstruction offers a perfect sketch of the parallel evolution of the availability of technology and changes in surgical proceedings. From the open Anderson-Hynes pyeloplasty, passing through percutaneous or retrograde endopyelothomy with various instruments, to the laparoscopic approach, technology and human talent have found a field for development in this reconstructive procedure. Robotic surgery is young and starts to define its role in urology surgery. There are established procedures such as radical prostatectomy; it remains to be established what operations will benefit from the robotic technology, so results are under continuous evaluation. The non stopping advance of computer technology guarantees future achievements of robotic technology. The objective is to achieve that surgeons could perform difficult surgical procedures with a level of accuracy and clinical results that would be difficult to achieve with conventional methods. We analyze the technical features, results and comparative studies of the robotic pyeloplasty from the medical literature. Robotic surgery has demonstrated its usefulness in the performance of pyeloplasties, with good results in primary and secondary UPJ stenosis in children and adults, in various aetiologies. Robotics enables to diminish the difficulties of intracorporeal suture and the learning curve for surgeons without laparoscopic experience. Nevertheless, although initial clinical experience with robotic pyeloplasty is favourable, continuous evaluation of results is necessary to determine if the surgical procedure is as effective in the long-term as laparoscopic and open pyeloplasty.

Nuevo posicionamiento para realizar la pieloplastia laparoscópica. Nuestra experiencia / New position for laparoscopic pyeloplasty. Our experience

Objetivo: Nuestra intención con el presente artículo pretende compartir nuestra experiencia en relación con la realización de la pieloplastia laparoscópica y nuestras aportaciones en este sentido. Métodos: Hemos realizado 12 pielopastias laparoscópicas a otros tantos pacientes entre marzo del 2004 y enero 2006. A lo largo de nuestra serie hemos ido codificando la técnica quirúrgica a medida que nos hemos ido encontrando con dificultades durante la realización de la misma. Mediante la única modificación del posicionamiento del paciente hemos logrado una importante mejora en nuestra técnica. Resultados: Describimos en este artículo como realizábamos la intervención en nuestros primeros casos y de que forma estamos realizándola en este momento, gracias al nuevo posicionamiento. Asímismo damos cuenta de cuales son las ventajas que apreciamos. Conclusiones: Con nuestra técnica logramos una importante reducción en el tiempo quirúrgico, mejoras en cuanto a seguridad de la técnica y reducción de las complicaciones quirúrgicas (AU)

Objectives: To share our experience performing laparoscopic pyeloplasty and our contributions to this surgery. Methods: Between March 2004 and January 2006 we have performed 12 laparoscopic pyeloplasties in 12 patients. We modified our technique as we found difficulties during operations. By the only modification of patient position we have achieved a significant improve in our technique. Results: We describe how we performed the operation in the first cases and how we do it today, with the new position. We also describe the advantages observed. Conclusions: With our technique we achieve an important surgical time reduction, improvements in safety and reduction of surgical complications (AU)

Cirugía renal robótica: pieloplastia / Robotic renal surgery: pyeloplasty

El tratamiento de la estenosis de la unión pieloureteral nos ofrece un boceto exquisito de la evolución paralela entre la disponibilidad tecnológica y los cambios acontecidos en el proceder quirúrgico. Desde la pieloplastia abierta de Anderson-Hynes, pasando por la endopielotomía percutánea o retrógrada con distintos dispositivos; hasta llegar al abordaje laparoscópico, la tecnología y el ingenio humano han encontrado en este proceder reconstructivo un interesante escenario de desarrollo. La cirugía robótica se encuentra en su adolescencia y comienza a definir su papel en la cirugía urológica. Existen procedimientos asentados como la prostatectomía radical, resta por definir que tipo de intervenciones se van a beneficiar de la tecnología robótica, por ello los resultados están en continua evaluación. El avance imparable de la tecnología informática garantiza los futuros logros de la tecnología robótica. El objetivo es conseguir que el cirujano pueda realizar procedimientos quirúrgicos difíciles con un nivel de precisión y unos resultados clínicos difícilmente alcanzables con los métodos convencionales. Se analizan aspectos técnicos, resultados y estudios comparativos de la pieloplastia robótica en la literatura. La cirugía robótica ha demostrado su utilidad para realizar con buenos resultados la técnica de la pieloplastia en estenosis primarias y secundarias, en niños y adultos y en diferentes etiologías. La robótica permite disminuir las dificultades de la sutura intracorpórea y la curva de aprendizaje para cirujanos no habituados a la laparoscopia. No obstante, aunque la experiencia clínica inicial con la pieloplastia robótica es favorable, se hace necesaria una evaluación continua de los resultados para determinar si este proceder es tan eficaz a largo plazo como lo son la pieloplastia abierta y laparoscópica

The treatment of ureteropyelic junction (UPJ) obstruction offers a perfect sketch of the parallel evolution of the availability of technology and changes in surgical proceedings. From the open Anderson-Hynes pyeloplasty, passing through percutaneous or retrograde endopyelothomy with various instruments, to the laparoscopic approach, technology and human talent have found a field for development in this reconstructive procedure. Robotic surgery is young and starts to define its role in urology surgery. There are established procedures such as radical prostatectomy; it remains to be established what operations will benefit from the robotic technology, so results are under continuous evaluation. The non stopping advance of computer technology guarantees future achievements of robotic technology. The objective is to achieve that surgeons could perform difficult surgical procedures with a level of accuracy and clinical results that would be difficult to achieve with conventional methods. We analyze the technical features, results and comparative studies of the robotic pyeloplasty from the medical literature. Robotic surgery has demonstrated its usefulness in the performance of pyeloplasties, with good results in primary and secondary UPJ stenosis in children and adults, in various aetiologies. Robotics enables to diminish the difficulties of intracorporeal suture and the learning curve for surgeons without laparoscopic experience. Nevertheless, although initial clinical experience with robotic pyeloplasty is favourable, continuous evaluation of results is necessary to determine if the surgical procedure is as effective in the long-term as laparoscopic and open pyeloplasty