Beyond lectures and practical courses: Teaching pharmacology using imaginative pedagogical tools.

Pharmacology has broadened its scope considerably in recent decades. Initially, it was of interest to chemists, doctors and pharmacists. In recent years, however, it has been incorporated into the teaching of biologists, molecular biologists, biotechnologists, chemical engineers and many health professionals, among others. Traditional teaching methods, such as lectures or laboratory work, have been superseded by the use of new pedagogical approaches to enable a better conceptualization and understanding of the discipline. In this article, we present several new methods that have been used in Spanish universities. Firstly, we describe a teaching network that has allowed the sharing of pedagogical innovations in Spanish universities. A European experience to improve prescribing safety is described in detail. The use of popular films and medical TV series in biomedical students shows how these audiovisual resources can be helpful in teaching pharmacology. The use of virtual worlds is detailed to introduce this new approach to teaching. The increasingly important area of the social aspects of pharmacology is also considered in two sections, one devoted to social pharmacology and the other to the use of learning based on social services to improve understanding of this important area. Finally, the use of Objective Structured Clinical Evaluation in pharmacology allows to know how this approach can help to better evaluate clinical pharmacology students. In conclusion, this article allows to know new pedagogical methods resources used in some Spanish universities that may help to improve the teaching of pharmacology.

Estenosis de la anastomosis ureteroileal en derivaciones urinarias realizadas mediante abordaje abierto, laparoscópico y robótico. Incidencia y manejo en un centro de tercer nivel / Ureteroileal anastomosis stricture after urinary diversions performed by open, laparoscopic and robotic approaches. Incidence and management in a tertiary care center

Introducción Las estenosis de anastomosis ureteroileal son complicaciones frecuentes en conductos ileales y neovejigas ortotópicas. Analizamos su incidencia en función del tipo de derivación urinaria y del abordaje quirúrgico (abierto, laparoscópico o robótico). Describimos su manejo y los resultados obtenidos.Material y métodos Estudio retrospectivo descriptivo durante 6 años en pacientes con derivación urinaria empleando íleon (conducto ileal o neovejiga ileal). Se recogen datos demográficos, comorbilidades, datos quirúrgicos (abordaje, complicaciones) y resultados. Seguimiento mínimo de un año. Comparación entre grupos, mediante test de la chi al cuadrado en variables dicotómicas. Variables cuantitativas comparadas empleando la prueba de la t Student para grupos independientes o la prueba de Mann-Whitney. Consideramos significación estadística p<0,05.Resultados Incluimos a 182 pacientes (84% varones y 16% mujeres). Edad media 68 años. Abordaje de cistectomía: laparoscópica (67/37%), robótica (63/35%), abierta (43/24%). Tipo de derivación: conducto ileal (138/76%) y neovejiga ileal ortotópica (44/24%). Tipo de reimplante: Bricker (108/59%) y Wallace (47/26%). Estenosis de anastomosis ureteroileal (50/27%): bilateral (26), izquierda (16) y derecha (8). Estenosis según abordaje de cistectomía: laparoscópica (23/46%), robótica (16/32%), abierta (9/18%). Tratamiento de estenosis (33/18%): reimplante ureteroileal (13), nefrostomía permanente (13), dilatación endoscópica (4), nefroureterectomía (2), endoureterotomía (1). Abordaje del reimplante: laparoscópico (5/38%), robótico (6/46%) y abierto (2/15%). Resultados tras reimplantes: reestenosis (0/0%), reintervención (3/23%), estenosis ureteroileal contralateral posterior (1/8%).ConclusiónEl tipo de abordaje empleado en la cistectomía no parece influir en la aparición de estenosis ureteroileales. Abordajes laparoscópicos y robóticos permiten su reparación con resultados

Introduction Ureteroileal anastomosis stricture is a frequent complication after radical cystectomy and ileal conduit or orthotopic neobladder formation. We analyze their incidence based on the technique for urinary diversion and on the surgical approach (open, laparoscopic or robot-assisted). Stricture management is described, along with surgical outcomes.Material and methodsDescriptive retrospective study over 6 years in patients who underwent urinary diversion using ileum (ileal conduit or orthotopic neobladder). Demographic data, comorbidities, surgical approach, complications, and outcomes were collected. Minimum follow-up of 1 year. Comparison between groups using Chi-square test for dichotomous variables. Quantitative variables were compared using the Student's t test for independent groups or Mann-Whitney test. Statistical significance if P<.05.Results The study included 182 patients (84% males and 16% females). Mean age 68 years. Cystectomy approach: laparoscopic (67/37%), robot-assisted (63/35%), open (43/24%). Urinary diversion: ileal conduit (138/76%) and orthotopic ileal neobladder (44/24%). Ureteric reimplantation technique: Bricker (108/59%) and Wallace (47/26%). Ureteroileal anastomosis strictures (50/27%): bilateral (26), left (16) and right (8). Strictures according to cystectomy approach: laparoscopic (23/46%), robot-assisted (16/32%), open (9/18%). Treatment of strictures (33/18%): ureteric reimplantation (13), indwelling nephrostomy (13), endoscopic dilatation (4), nephroureterectomy (2), endoureterotomy (1). Ureteroileal reimplantation approach: laparoscopic (5/38%), robot-assisted (6/46%), open (2/15%). Outcomes after reimplantation: restenosis (0/0%), reintervention (3/23%), contralateral ureteroileal stricture (1/8%).Conclusion Surgical approach in cystectomy does not influence future development of ureteroileal strictures. Laparoscopic and robot-assisted ureteroileal reimplantation achieves high success rates (AU)

Ureteroileal anastomosis stricture after urinary diversions performed by open, laparoscopic and robotic approaches. Incidence and management in a tertiary care center.

INTRODUCTION: Ureteroileal anastomosis stricture is a frequent complication after radical cystectomy and ileal conduit or orthotopic neobladder formation. We analyze their incidence based on the technique for urinary diversion and on the surgical approach (open, laparoscopic or robot-assisted). Stricture management is described, along with surgical outcomes. MATERIAL AND METHODS: Descriptive retrospective study over 6 years in patients who underwent urinary diversion using ileum (ileal conduit or orthotopic neobladder). Demographic data, comorbidities, surgical approach, complications, and outcomes were collected. Minimum follow-up of 1 year. Comparison between groups using Chi-square test for dichotomous variables. Quantitative variables were compared using the Student's t-test for independent groups or Mann-Whitney test. Statistical significance if P < .05. RESULTS: The study included 182 patients (84% males and 16% females). Mean age 68 years. Cystectomy approach: laparoscopic (67/37%), robot-assisted (63/35%), open (43/24%). Urinary diversion: ileal conduit (138/76%) and orthotopic ileal neobladder (44/24%). Uretericre implantation technique: Bricker (108/59%) and Wallace (47/26%). Ureteroileal anastomosis strictures (50/27%): bilateral (26), left (16) and right (8). Strictures according to cystectomy approach: laparoscopic (23/46%), robot-assisted (16/32%), open (9/18%). Treatment of strictures (33/18%): ureteric reimplantation (13), indwelling nephrostomy (13), endoscopic dilatation (4), nephroureterectomy (2), endoureterotomy (1). Ureteroileal reimplantation approach: laparoscopic (5/38%), robot-assisted (6/46%), open (2/15%). Outcomes after reimplantation: restenosis (0/0%), reintervention (3/23%), contralateral ureteroileal stricture (1/8%). CONCLUSION: Surgical approach in cystectomy does not influence future development of ureteroileal strictures. Laparoscopic and robot-assisted ureteroileal reimplantation achieves high success rates.

Ureteroileal anastomosis stricture after urinary diversions performed by open, laparoscopic and robotic approaches. Incidence and management in a tertiary care center. / Estenosis de la anastomosis ureteroileal en derivaciones urinarias realizadas mediante abordaje abierto, laparoscópico y robótico. Incidencia y manejo en un centro de tercer nivel.

INTRODUCTION: Ureteroileal anastomosis stricture is a frequent complication after radical cystectomy and ileal conduit or orthotopic neobladder formation. We analyze their incidence based on the technique for urinary diversion and on the surgical approach (open, laparoscopic or robot-assisted). Stricture management is described, along with surgical outcomes. MATERIAL AND METHODS: Descriptive retrospective study over 6 years in patients who underwent urinary diversion using ileum (ileal conduit or orthotopic neobladder). Demographic data, comorbidities, surgical approach, complications, and outcomes were collected. Minimum follow-up of 1 year. Comparison between groups using Chi-square test for dichotomous variables. Quantitative variables were compared using the Student's t test for independent groups or Mann-Whitney test. Statistical significance if P<.05. RESULTS: The study included 182 patients (84% males and 16% females). Mean age 68 years. Cystectomy approach: laparoscopic (67/37%), robot-assisted (63/35%), open (43/24%). Urinary diversion: ileal conduit (138/76%) and orthotopic ileal neobladder (44/24%). Ureteric reimplantation technique: Bricker (108/59%) and Wallace (47/26%). Ureteroileal anastomosis strictures (50/27%): bilateral (26), left (16) and right (8). Strictures according to cystectomy approach: laparoscopic (23/46%), robot-assisted (16/32%), open (9/18%). Treatment of strictures (33/18%): ureteric reimplantation (13), indwelling nephrostomy (13), endoscopic dilatation (4), nephroureterectomy (2), endoureterotomy (1). Ureteroileal reimplantation approach: laparoscopic (5/38%), robot-assisted (6/46%), open (2/15%). Outcomes after reimplantation: restenosis (0/0%), reintervention (3/23%), contralateral ureteroileal stricture (1/8%). CONCLUSION: Surgical approach in cystectomy does not influence future development of ureteroileal strictures. Laparoscopic and robot-assisted ureteroileal reimplantation achieves high success rates.

Percutaneous radiofrequency for the treatment of small renal masses: Analysis of outcomes and complications after 10 years of experience. / Radiofrecuencia percutánea en el tratamiento de masas renales pequeñas: análisis de resultados y complicaciones tras diez años de experiencia.

INTRODUCTION AND OBJECTIVE: The management of renal tumors ≤ 4 cm in elderly population or patients with comorbidities is a challenge, for which ablative therapies are an interesting alternative. The objective is to evaluate in our center the role of percutaneous radiofrequency in the treatment of small renal masses, the associated complications and the results obtained. MATERIAL AND METHODS: Retrospective evaluation of the radiofrequency treatments carried out between April 2010 and April 2020 in our center. Demographic data, associated comorbidities, tumor characteristics, complications and oncological and functional outcomes were reviewed. RESULTS: Fifty-seven tumors were treated in 53 patients. Mean follow-up of 48.2 months. The percentage of complete ablations obtained was of 89.5%. There were 19.3% of complications. According to Clavien-Dindo and SIR classification systems, 3.5% and 5.3% were major complications. A statistically significant association was found between the initial result of ablation and age (p = 0.047), RENAL-m (p = 0.044), the presence of cystic component (p = 0.049) and tumor size (p = 0.01). The cut-off point for size was established at 25 mm (p = 0.012). In multivariate analysis, only size remained as a predictor of initial ablation result (p = 0.01; OR 1.183; CI 95% 1.041-1.345). Cancer-specific survival and 5-year recurrence-free survival were 98.1% and 89.5%, respectively. A mean decrease of MDRD-4 of 6.59 mL/min (p = 0.005) was observed in the first six months after RFA. CONCLUSIONS: Given the excellent oncological and functional results demonstrated, ultrasound-guided percutaneous radiofrequency ablation is an effective and safe treatment for small renal masses in selected patients.

Activity and short-term outcomes of kidney transplantation during the COVID-19 pandemic. / Actividad y resultados a corto plazo del trasplante renal durante la pandemia COVID-19.

INTRODUCTION: During the COVID-19 pandemic, the national transplant activity has been reduced due to the overload of the health system and concern for patient safety in this situation. The aim of our work is to expose the activity of kidney transplantation in Cantabria during the state of alarm, as well as to assess the safety of the transplantation program. MATERIAL AND METHODS: Retrospective study of kidney transplants performed in our Center from the beginning of the state of alarm until the beginning of the lockdown easing in Cantabria. Descriptive analysis of the demographic data of recipients and their donors, intraoperative data and postoperative outcomes. Comparative analysis with the data of the same period in 2017-2019, by means of the χ2 for categorical variables, Student's T and Mann-Whitney U tests in case of quantitative variables of normal and non-normal distribution, respectively. RESULTS: Fifteen kidney transplants were performed in the period described. Delayed renal function (DRF) was seen in 7.5% of patients, and 26.6% showed data of acute rejection; no patient presented COVID-19 disease. Comparative analysis showed a remarkable increase in the number of transplants in comparison with previous periods (15 vs 5.6), at the expense of donors from outside Cantabria (93.3%). We found no statistically significant differences in terms of cold ischemia time (p=0.77), DRF (p=0.73), need for dialysis (p=0.54), or appearance of post-surgical complications (p=0.61). CONCLUSIONS: The evolution of the pandemic in our region, and the adoption of strict protective measures has allowed the early and safe resumption of the renal transplantation program, increasing the number of transplants performed compared to previous years and maintaining comparable early post-operative results.

[Visual hallucinations in the works of Oliver Sacks]. / Las alucinaciones visuales en la obra de Oliver Sacks.

INTRODUCTION: Hallucinations are one of the most bizarre experiences in several diseases. They appear in mental diseases as well as in physical illnesses and may be the consequence of the usage of drugs of abuse. However, a detailed analysis of how patients feel under hallucinations caused by different diseases is uncommon. AIM: This article analyses how visual hallucinations are considered in the works of the neurologist and writer Oliver Sacks, with special attention to his book Hallucinations. DEVELOPMENT: Hallucinations have been under consideration by culture, religion and arts, which has led to multiple interpretations. Sacks's interest in perception of sensations led him to work on the analysis of hallucinations, given the limited knowledge on the topic. References to hallucinations appeared in several of his books like Migraine, Awakenings and A leg to stand on. In Musicophilia Sacks approached the auditory hallucinations and in Hallucinations he considered them in depth. In the latter work, Sacks analyses especially those present in Charles Bonnet syndrome, in situations of sensory deprivation, in patients with epilesy, those present during treatment with levodopa and those caused by drug of abuse. CONCLUSIONS: Hallucinations is one of Sacks's books with greater neuroophthalmological content. The descriptions of the hallucinations of his patients or those experienced by himself, as well as the reflective analysis on the world of perception make this book one of the most fascinating works of Oliver Sacks.

TITLE: Las alucinaciones visuales en la obra de Oliver Sacks.Introducción. Las alucinaciones visuales constituyen una de las manifestaciones más singulares de diversas situaciones clínicas, ya sea en el ámbito de las enfermedades mentales, de las alteraciones físicas o del consumo de drogas. Sin embargo, el análisis detallado de su vivencia en relación con las causas que pueden producirlas es poco frecuente. Objetivo. Considerar la representación de las alucinaciones visuales en las publicaciones del neurólogo y escritor Oliver Sacks, con especial atención a su obra Hallucinations. Desarrollo. Las alucinaciones han llamado la atención de la cultura, la religión y el arte, lo que ha conllevado múltiples interpretaciones. El interés de Sacks por la percepción de las sensaciones le llevó a investigar los mecanismos por los que se producen las alucinaciones, debido al escaso conocimiento que se tenía sobre el tema. Las alucinaciones aparecieron ya en obras como Migraine, Awakenings o A leg to stand on. En Musicophilia abordó las alucinaciones auditivas, y en Hallucinations las consideró de forma monográfica. En esta última obra, Sacks analizó especialmente las presentes en el síndrome de Charles Bonnet, en situaciones de privación sensorial y en pacientes con epilepsia, las precipitadas por la levodopa y las causadas por drogas de abuso. Conclusiones. Hallucinations es una de las obras de Oliver Sacks con mayor contenido neurooftalmológico. La descripción de las alucinaciones de sus pacientes o las experimentadas en su propia piel y la reflexión sobre el mundo de la percepción hacen de Hallucinations una de las obras más fascinantes de Sacks.

Influence of behavioral traits in the inter-individual variability of nociceptive, emotional and cognitive manifestations of neuropathic pain.

Neuropathic pain is a complex disorder associated with emotional and cognitive deficits that may impair nociceptive manifestations. There is high inter-individual variability in the manifestations of human neuropathic pain, which largely depends on personality traits. We aim to identify the influence of different behavioral traits in the inter-individual vulnerability to neuropathic pain manifestations using behavioral, electrophysiological and genetic approaches. We first selected mice with extreme social and emotional traits and look for correlation with the spontaneous neuronal activity in the central amygdala. Neuropathic pain was induced to these mice to evaluate the influence of behavioral traits on nociceptive manifestations and gene expression profiles in the amygdala. Our results show an association of the spontaneous central amygdala neuronal activity with the sociability behavior. We demonstrate that low sociable, high anxious and low depressive phenotypes develop enhanced nociceptive hypersensitivity after nerve injury. However, greater emotional alterations and cognitive impairment are observed in high sociable, anxious-like and depressive-like mice, indicating that nociceptive, emotional and cognitive manifestations of neuropathic pain do not correlate with each other. Gene analyses identify high Pdyn and Il6 levels in the amygdala as indicative of enhanced nociceptive hypersensitivity and reveal an association between high Gadd45 expression and attenuated emotional and cognitive manifestations of neuropathic pain.

[The scotomas as a metaphor in the work of Oliver Sacks]. / Los escotomas como metafora en la obra de Oliver Sacks.

INTRODUCTION: The use of medical metaphors is common in the social discourse and in the media. However, the use by physicians themselves to define different concepts to the original meaning of the medical word is rare. AIM: To analyze the term «scotoma¼ in its metaphorical sense in the works of the neurologist and writer Oliver Sacks. DEVELOPMENT: Sacks used scotoma metaphorically in two works, in the autobiographical book A leg to stand on and in an essay Scotoma: forgetting and neglect in science. In the first case, he used it to define the sensorial loss of his leg after an accident, which could be interpreted as a «mental scotoma¼. In the second case, Sacks analyzed the process and the reasons of forgetting the works of some early scientific discoverers and discussed why this happened. In this case, Sacks made an analogy with the process suffered by scientific discoveries and the reasons why some of them are largely ignored, in a situation that he called «historical¼ or «social scotoma¼. CONCLUSIONS: Sacks does not use the term «scotoma¼ uniformly. When used to describe the sensorial loss of his leg, it might be considered that scotoma is there a second, although minor but accepted, meaning of the word. However, its use in the definition of historical neglect of early discoveries can be clearly defined as a medical metaphor in full sense.

TITLE: Los escotomas como metafora en la obra de Oliver Sacks.Introduccion. La utilizacion de metaforas medicas es frecuente en el discurso social y en los medios de comunicacion. Sin embargo, su empleo por los propios medicos para definir conceptos distintos al significado original del termino resulta poco habitual. Objetivo. Analizar el empleo del termino «escotoma¼, en su sentido metaforico, en las obras del neurologo y escritor Oliver Sacks. Desarrollo. Sacks uso escotoma metaforicamente en dos obras, en el libro autobiografico A leg to stand on y en un ensayo, Scotoma: forgetting and neglect in science. En el primer caso, lo utilizo para describir la situacion de perdida sensorial de su extremidad inferior, que experimento despues de un accidente, lo que podria interpretarse como un «escotoma mental¼. En el segundo caso, Sacks analizo el proceso y las razones del olvido de las obras de algunos descubridores cientificos precoces y comento por que habia sucedido, una situacion que denomino «escotoma historico¼ o «social¼. Conclusiones. Sacks no utiliza el termino «escotoma¼ de forma uniforme y, si bien en el caso de su accidente podria considerarse como una acepcion menor, pero aceptada, es indudable su uso como metafora medica para describir el olvido y la ignorancia de algunos descubrimientos cientificos en determinadas situaciones historicas.

Comparación de ceftazidima-amikacina contra imipenem en el tratamiento de fiebre neutropénica / Comparison of ceftazidime/amikacin vs imipenem in the treatment of neutropenic fever

Resumen: ANTECEDENTES: la fiebre neutropénica es una de las principales complicaciones del tratamiento oncológico y es causa importante de morbilidad y mortalidad; afecta a más de 80% de los pacientes con neoplasias hematológicas durante el primer ciclo de quimioterapia. El tratamiento consiste en antibióticos de amplio espectro con respuestas terapéuticas heterogéneas. OBJETIVO: determinar el tiempo promedio de la desaparición de la fiebre después de la administración de la primera dosis del antibiótico. MATERIAL Y MÉTODO: estudio prospectivo, aleatorizado, doble ciego, efectuado del 1 de mayo al 24 de septiembre de 2014, en el que los pacientes se distribuyeron al azar para recibir tratamiento con ceftazidima-amikacina o imipenem durante 10 días. Se registraron la temperatura y fiebre. Se tomaron hemocultivos previo al tratamiento y a las 48 horas en caso de persistencia de fiebre. Se registraron todos los hemocultivos con crecimiento bacteriano. RESULTADOS: se evaluaron 31 pacientes, de 17 a 61 años de edad (promedio de 33.6 ± 13.9); 15 pacientes recibieron ceftazidima-amikacina (48.4%) y 16 pacientes imipenem (51.6%). El tiempo promedio de remisión de la fiebre fue de 11.2 ± 16.3 vs 9.6 ± 14.8 horas (p = 0.6) en el grupo de ceftazidima-amikacina e imipenem, respectivamente. CONCLUSIONES: no hubo diferencia en el tiempo de mejoría clínica entre los pacientes tratados con imipenem o ceftazidima-amikacina. Ambos esquemas antimicrobianos fueron igual de eficaces para el tratamiento de la fiebre neutropénica secundaria a quimioterapia.

Abstract: BACKGROUND: Neutropenic fever is one of the major complications of cancer treatment and it is an important cause of morbidity and mortality. It occurs in more than 80% of patients with hematologic malignancies during the first cycle of chemotherapy. Treatment consists on broad-spectrum antibiotics with heterogeneous therapeutic responses. OBJECTIVE: To determine the average time for disappearance of fever after the administration of the first dose of antibiotics. MATERIAL AND METHOD: A prospective, randomized, double blind study was conducted. Patients were randomized to receive treatment with ceftazidime/amikacin or imipenem for 10 days. A record of temperature and fever was kept. Blood cultures prior to treatment and at 48 hours were taken in case of persistent fever. All blood cultures were recorded for bacterial growth. RESULTS: Were evaluated 31 patients with ages between 17 and 61 years (mean 33.6 ± 13.9). Fifteen patients received ceftazidime/amikacin (48.4%) and 16 patients imipenem (51.6%). The average time of remission of fever was 11.2±16.3 vs 14.8 ± 9.6 hours (p = 0.6) for the ceftazidime/amikacin and imipenem group, respectively. CONCLUSIONS: There was no difference about the time of clinical improvement among patients treated with imipenem or ceftazidime/amikacin. Both antimicrobials schemes were equally effective for the treatment of secondary neutropenic fever chemotherapy.

Initial experience with the new da Vinci single-port robot-assisted platform. / Experiencia inicial con la nueva plataforma de puerto único da Vinci robótico.

OBJECTIVE: To describe our experience in the first cases of urological surgeries performed with the da Vinci single-port robot-assisted platform. MATERIAL AND METHODS: We performed 5 single-port robot-assisted surgeries (R-LESS) between May and October 2014. We performed 3 ureteral reimplant surgeries, one ureteropyeloplasty in an inverted kidney and 1 partial nephrectomy. The perioperative and postoperative results were collected, as well as a report of the complications according to the Clavien classification system. RESULTS: Of the 5 procedures, 4 were performed completely by LESS, while 1 procedure was reconverted to multiport robot-assisted surgery. There were no intraoperative complications. We observed perioperative complications in 4 patients, all of which were grade 1 or 2. The mean surgical time was 262minutes (range, 230-300). DISCUSSION: In our initial experience with the da Vinci device, R-LESS surgery was feasible and safe. There are still a number of limitations in its use, which require new and improved R-LESS platforms.

[Evaluation of pain during mobilization and endotracheal aspiration in critical patients]. / Evaluación del dolor durante la movilización y la aspiración endotraqueal en pacientes críticos.

OBJECTIVES: 1) To assess the prevalence of pain during nursing care procedures, and 2) to evaluate the usefulness of certain vital signs and the bispectral index (BIS) in detecting pain. METHODS: A prospective, observational analytical study was made of procedures (endotracheal aspiration and mobilization with turning) in critically ill sedated patients on mechanical ventilation. The Behavioral Pain Scale was used to assess pain, with scores of ≥3 indicating pain. Various physiological signs and BIS values were recorded, with changes of >10% being considered clinically relevant. RESULTS: A total of 146 procedures in 70 patients were analyzed. Pain prevalence during the procedures was 94%. Vital signs and BIS values increased significantly during the procedures compared to resting conditions, but only the changes in BIS were considered clinically relevant. In the subgroup of patients receiving preemptive analgesia prior to the procedure, pain decreased significantly compared to the group of patients who received no such analgesia (-2 [IQR: {-5}-0] vs. 3 [IQR: 1-4]; P<.001, respectively). CONCLUSIONS: The procedures evaluated in this study are painful. Changes in vital signs are not good indicators of pain. Changes in BIS may provide useful information about pain, but more research is needed. The administration of preemptive analgesia decreases pain during the procedures.

How should we address the diagnosis of overactive bladder in women?

OBJECTIVE: Determine the degree of completion, agreement and diagnostic performance of various instruments for assessing the presence and intensity of urgency and other symptoms of idiopathic overactive bladder (OAB) and determine which is the best diagnostic combination. MATERIAL AND METHODS: Observational, noninterventional, cross-sectional multicentre study on 247 women aged 18 years or older, with a clinical diagnosis of OAB, evaluated in 55 functional urology and urodynamic units. The women completed the Patient Perception of Intensity of Urgency Scale questionnaire, an independent bladder control self-assessment questionnaire (B-SAQ), the Overactive Bladder Questionnaire Short-Form and a 3-day voiding diary (VD3d), and they underwent a urodynamic study (UDS). The degree of completion and agreement among the instruments was assessed using the Kappa index (95% CI) and Cramér's V. The diagnostic performance of each tool and their combination was studied using absolute frequencies of positive cases for each OAB symptom. RESULTS: The patients mean age was 57.66 years (SD, 13.43). There was a high degree of completion (>85%). The agreement among the instruments was poor or moderate, and there was no agreement with the UDS. The best combination of tools for the diagnosis of OAB in women was the B-SAQ and VD3d. CONCLUSIONS: The degree of completion of all instruments was high, the agreement between them was poor-moderate and not significant for the UDS. The instruments that had the best diagnostic performance for assessing urgency and other OAB symptoms, providing data on their severity and discomfort, were the B-SAQ and the VD3d.

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.

Reparación de fístula urinaria en injerto renal mediante nefrectomía parcial y omentoplastia / Urinary Fistula Repair in a Renal Graft Throught a Partial Nephrectomy and Omentoplasty

Objetivos: Presentar el manejo mediante nefrectomía parcial e interposición del epiplón en casos de fístula urinaria en pacientes receptores de trasplante renal. Material y método: Presentamos un paciente con necrosis del polo inferior del injerto renal que afecta al sistema calicial, pero con la vascularización pieloureteral conservada, manejado de manera satisfactoria mediante nefrectomía parcial del segmento renal necrótico y sutura primaria del sistema colector con interposición del epiplón mayor. Realizamos una revisión de los casos de nefrectomía parcial en injerto renal descritos, analizando sus características y destacando la forma de presentación, los métodos diagnósticos, así como las técnicas quirúrgicas empleadas y sus resultados posteriores. Resultados: Existen pocos casos en la literatura contemporánea que describan un manejo quirúrgico conservador de las fístulas urinarias por necrosis segmentaria tras un injerto renal. El abordaje mediante nefrectomía parcial en estos casos presenta buen resultado en nuestra experiencia y en los casos descritos. Conclusiones: El manejo conservador de nefronas es factible y debería aplicarse en casos en los que la función renal previa y la cantidad de parénquima sano indiquen una correcta evolución posterior del injerto renal, a pesar de la evidente complejidad quirúrgica (AU)

Objectives: We present the management with partial nephrectomy and interposition of the greater omentum in case of urinary fistulas in renal allograft. Material and method: We present a patient with necrosis at the inferior pole of the renal graft that affected calyceal system but with pyeloureteral vascularization preserved. The patient’s condition was satisfactorily managed with a partial nephrectomy of the necrotic renal segment and primary suturing of the collecting system with interposition of the greater omentum. Were viewed the cases published to date of partial nephrectomy in renal allograft, and examined their outcomes by analyzing the patient presentation, diagnostic tools, and surgical techniques used. Results: There are few cases in the current literature that describe conservative surgical management of urinary fistulas caused by segmental necrosis after renal transplantation. Surgical approach using partial nephrectomy in these cases produces favorable outcomes in our experience and reported cases. Conclusions: Despite its obvious surgical complexity, this nephron-sparing management is feasible and should be implemented in cases where the prior renal function and the quantity of healthy parenchyma indicate a favorable subsequent evolution for the renal graft (AU)

Comparative study of morbidity and mortality between ileal conduit and ureterosigmoidostomy after radical cystectomy for bladder neoplasm.

OBJECTIVES: Despite the growing trend in the development of orthotopic neobladders, the procedure cannot be performed in many cases, thereby retaining the validity of other techniques. We propose a comparative analysis between patients with radical cystectomy for bladder neoplasm and reconstruction using the ileal conduit (IC) or ureterosigmoidostomy (USG). PATIENTS AND METHOD: Observational retrospective study on 255 patients with radical cystectomy between 1985 and 2009, selecting group assignments by the use of IC and USG. Analysis of the demographic and preoperative characteristics, perioperative complications, pathology and medium to long-term complications. Comparison of groups using T-Student, U-Mann-Whitney and chi square tests, with P<.05 indicating statistical significance. Preparation of survival tables according to Kaplan-Meier, establishing comparisons using the log-rank test. RESULTS: There were 41 cases of IC and 55 cases of USG, with a mean patient age of approximately 61 years. USGs were performed on a greater number of females than ICs. There were no differences in the need for transfusion, with similar results as other series. There was a greater trend towards the appearance of intestinal fistulae and greater morbidity and mortality in the postoperative period in USG, although it was not significant. There was a greater long-term presence of eventrations in IC, and of pyelonephritis and the need for taking alkalinizing agents in USG. The appearance of peristomal hernias in IC was less than in previous series. With a mean follow-up greater than 50 months, the overall survival was 40% at 5 years, with no differences according to urinary diversion. CONCLUSIONS: IC and USG are two applicable urinary diversions in the event that orthotopic neobladder surgery cannot be performed. They have a similar long-term complication and survival profile in our series, although with a higher morbidity in postoperative complications for USG.

Urinary fistula repair in a renal graft through a partial nephrectomy and omentoplasty.

OBJECTIVES: We present the management with partial nephrectomy and interposition of the greater omentum in case of urinary fistulas in renal allograft. MATERIAL AND METHOD: We present a patient with necrosis at the inferior pole of the renal graft that affected calyceal system but with pyeloureteral vascularization preserved. The patient's condition was satisfactorily managed with a partial nephrectomy of the necrotic renal segment and primary suturing of the collecting system with interposition of the greater omentum. We reviewed the cases published to date of partial nephrectomy in renal allograft, and examined their outcomes by analyzing the patient presentation, diagnostic tools, and surgical techniques used. RESULTS: There are few cases in the current literature that describe conservative surgical management of urinary fistulas caused by segmental necrosis after renal transplantation. Surgical approach using partial nephrectomy in these cases produces favorable outcomes in our experience and reported cases. CONCLUSIONS: Despite its obvious surgical complexity, this nephron-sparing management is feasible and should be implemented in cases where the prior renal function and the quantity of healthy parenchyma indicate a favorable subsequent evolution for the renal graft.

Giant cavernous hemangioma in renal graft: a case report.

BACKGROUND: We present a case of giant cavernous hemangioma in renal graft tumor; we have not found any cases described in literature. CLINICAL CASE: Patient transplanted from a deceased donor, 8 years previous to her admission due to deterioration in renal function, observing a 12-cm renal mass in the front face of the renal graft, which displaces it, provoking obstructive uropathy. On ultrasonography and computed tomography, it is seen as a complicated, cystic lesion. Tumorectomy with a good functional recovery of the graft was carried out. A histopathologic study showed a mass with extensive adherences to the perirenal adipose tissue and a cross section showed a spongy appearance with blood clots in the centre, microscopically formed by vascular channels, lined by a layer of endothelial cells, and filled with blood. CONCLUSIONS: Giant cavernous hemangioma in renal graft tumor has not been previously described. Given its benign condition, nephron-sparing surgery should be carried out if possible.