Carcinoma de los ductos de Bellini. Aportación de dos nuevos casos / Bellini duct carcinoma: report of two cases

Objetivo: Presentamos dos casos de carcinoma de ductos de Bellini diagnosticados en nuestro servicio en un plazo de seis meses. Método/resultado: El caso nº1 es una mujer de 75 años de edad en la que un TAC, realizado por estudio de patología digestiva, mostró una masa en el riñón izquierdo que infiltraba grasa perirrenal. El caso nº2 es un varón de 72 años que al realizar estudio por TVP bilateral de miembros inferiores, se evidenció en el TAC una lesión renal derecha dependiente de la pelvis, mal definida, con afectación de la vena cava y renal derecha. Tras la realización de nefrectomía radical en ambos casos, se confirmó el diagnóstico anatomopatológico de carcinoma de ductos de Bellini. Conclusión: El carcinoma de los ductos de Bellini es una rara variedad de tumor renal que deriva de los ductos colectores de la médula renal. Caracterizado tanto por su agresividad, como por su peculiar diagnóstico, histológico e inmunohistoquímico, que lo diferencia del resto (AU)

Objective: We report two cases of collecting duct carcinoma that were diagnosed in our hospital in a six-month period. Methods/results: The first case was a 75-years-old woman showing in CT scan a mass in the left kidney which infiltrated perinephric fat. The second case was a 72-years-old that showed in a CT scan a right renal pelvis lesion, involving inferior vena cava and renal vein. After surgical resection by radical nephrectomy in both cases, we confirmed the histological diagnosis of collecting duct carcinoma. Conclusions: Collecting duct carcinoma is a rare variant of renal cell carcinoma which originates from the epithelium of the collecting tubule. It is characterized by both its aggressiveness and peculiar histological and inmunohistochemical diagnosis, that separates it from the rest of renal tumors (AU)

[Growing incidence in renal cell carcinoma]. / Incidencia creciente en el carcinoma de células renales.

OBJECTIVES: To analyze the change in the behavior of renal cell carcinoma for its presentation, treatment, histology and mortality during a 17 year period. MATERIAL AND METHOD: Retrospective study on 212 patients diagnosed with renal cell carcinoma in our Department from the year 1988 up to 2004, analyzing the clinical and demographic data and comparing them to each other according to two periods: 1988-1996 and 1997-2004. RESULTS: An increase has been appreciated in the incidence of renal tumors in the second period and in a same way an increase in the incidental diagnosis and in the practice of nephron sparing surgery. Clear cell type was the most frequent in both periods and tumoral size was higher in the first period than in second. TNM stage I was the most frequent, although in first period it was higher percentage of stage IV. Cause-specific mortality has increased in the last years. CONCLUSION: An increase is appreciated in the incidence of renal cell tumors. Although the diagnosis is in earlier stages, a descent in the mortality has not been found.

Incidencia creciente en el carcinoma de células renales / Growing incidence in renal cell carcinoma

Objetivos: Analizar el cambio en el comportamiento del carcinoma de células renales en cuanto a su modo de presentación, tratamiento, anatomía patológica y mortalidad durante un periodo de 17 años. Material y método: Estudio retrospectivo sobre 212 pacientes intervenidos en nuestro Servicio por carcinoma de células renales desde el año 1988 hasta 2004, analizando los datos clínico-demográficos y comparándolos entre sí según dos periodos: 1988-1996 y 1997-2004. Resultados: Se ha apreciado un aumento en la incidencia de tumores renales en el segundo periodo y de igual manera un aumento en el diagnóstico incidental y en la práctica de cirugía conservadora de parénquima. El tipo histológico más frecuente fue el de células claras en ambos periodos y el tamaño tumoral era mayor en el primer periodo que en el segundo. El estadio tumoral más frecuente fue el I, aunque en el primer periodo se encontró mayor porcentaje de estadios IV. La mortalidad causa-específica ha aumentado en los últimos años. Conclusión: Se aprecia un aumento en la incidencia de tumores renales y, aunque estos se diagnostican en estadios más precoces, no se ha producido un descenso en la mortalidad

Objectives: To analyze the change in the behavior of renal cell carcinoma for its presentation, treatment, histology and mortality during a 17 year period. Material and method: Retrospective study on 212 patients diagnosed with renal cell carcinoma in our Department from the year 1988 up to 2004, analyzing the clinical and demographic data and comparing them to each other according to two periods: 1988-1996 and 1997-2004. Results: An increase has been appreciated in the incidence of renal tumors in the second period and in a same way an increase in the incidental diagnosis and in the practice of nephron sparing surgery. Clear cell type was the most frequent in both periods and tumoral size was higher in the first period than in second. TNM stage I was the most frequent, although in first period it was higher percentage of stage IV. Cause-specific mortality has increased in the last years. Conclusion: An increase is appreciated in the incidence of renal cell tumors. Although the diagnosis is in earlier stages, a descent in the mortality has not been found

[Problem-based learning in urology training. The Faculty of Medicine of the Universidad de Castilla-La Mancha model]. / El aprendizaje basado en problemas en la enseñanza de la urologia. Modelo de la Facultad de Medicina de la Universidad de Castilla-La Mancha.

Ongoing changes in the social, economic, technological and scientific realms have generated new needs and led various organizations to suggest that educational institutions should reorient their educational strategies toward developing effective professionals with the skills to meet these needs. These "modern" strategies include problem-based learning, in which the student seeks and selects information, analyzes the data obtained, integrates both prior and newly acquired knowledge, and, finally, offers diagnostic and therapeutic options to resolve the problem posed, as would occur in professional practice. With this approach, prior skills and practical experience form the foundation of learning. Problem-based learning incorporates some aspects of cognitive psychology, a model that mainly centers on the nature of the knowledge structures found in active memory, the processes involved in information storage and retrieval and the various factors that activate these processes. At the Faculty of Medicine of the Universidad de Castilla-La Mancha, urology is part of a core subject (Medical and Surgical Pathology II) taught in the fifth year of coursework together with nephrology. Each course includes approximately 75 students, divided into five groups. The rotation lasts six weeks, with students spending a mean of two hours a day on theory (nephrology and/or urology) and the remaining time on rotations in the various activities: three weeks in nephrology and three weeks in urology. Upon completion of the rotation, the students write a combined theoretical examination with 100 multiple-choice questions (50 on urology) and take a practical skills examination. At the end of the course, another practical test consisting of an objective, structured clinical examination is taken, in which standard patients are used and the professor directly assesses the level of skills acquired with a "real" case.

El aprendizaje basado en problemas en la enseñanza de la urología. Modelo de la Facultad de Medicina de la Universidad de Castilla-La Mancha / Problem-based learning in urology training. The faculty of medicine of the Universidad de Castilla-La Mancha model

Las nuevas necesidades derivadas de los actuales cambios sociales, económicos, tecnológicos, científicos, etc..., han hecho que distintos organismos hayan sugerido a los estamentos educativos la necesidad de desarrollar cambios en las estrategias educativas orientados al desarrollo de un profesional eficaz con competencias adaptadas a estas necesidades. Dentro de las estrategias “modernas” se encuentra la enseñanza basada en problemas o aprendizaje por problemas (PBL), mediante la cual el estudiante busca y selecciona la información, razona e integra los conocimientos previos y adquiridos, dando finalmente unas posibilidades diagnósticas y terapéuticas al problema planteado, tal y como se va a enfrentar en su actividad profesional. Los conocimientos previos y la actividad constituyen los pilares fundamentales del aprendizaje. El PBL incorpora algunos de los aspectos de la psicología cognitiva, modelo cuya parte principal determina la naturaleza de las estructuras del conocimiento que se encuentran en la memoria activa, en los procesos de almacenamiento y recuperación de la información y los diversos factores que lo activan. La urología en la Facultad de Medicina de la Universidad de Castilla-La Mancha forma parte de una asignatura troncal (Patología Médica y Quirúrgica II) que se imparte durante el quinto curso. La urología se desarrolla integrada con nefrología. El número de alumnos por curso es aproximadamente 75 divididos en 5 grupos. La “rotación” dura seis semanas durante las cuales los estudiantes tienen una media de 2 horas diarias de teoría (ya sean de nefrología y/o urología) y el resto son rotatorias por distintas actividades: tres semanas en nefrología y tres semanas en urología. Al finalizar la rotación los udiantes realizan un examen teórico conjunto con 100 preguntas de respuestas múltiple (50 de urología) y un examen práctico de las habilidades. A final de curso existe otra prueba práctica (OSCE: examen clínico objetivo y estructurado) con la utilización de pacientes estandarizados, debiendo el profesor evaluar de forma directa el nivel de competencias adquiridas ante un “caso real”

Ongoing changes in the social, economic, technological and scientific realms have generated new needs and led various organizations to suggest that educational institutions should reorient their educational strategies toward developing effective professionals with the skills to meet these needs. These “modern” strategies include problem-based learning, in which the student seeks and selects information, analyzes the data obtained, integrates both prior and newly acquired knowledge, and, finally, offers diagnostic and therapeutic options to resolve the problem posed, as would occur in professional practice. With this approach, prior skills and practical experience form the foundation of learning. Problem-based learning incorporates some aspects of cognitive psychology, a model that mainly centers on the nature of the knowledge structures found in active memory, the processes involved in information storage and retrieval and the various factors that activate these processes.At the Faculty of Medicine of the Universidad de Castilla-La Mancha, urology is part of a core subject (Medical and Surgical Pathology II) taught in the fifth year of coursework together with nephrology. Each course includes approximately 75 students, divided into five groups. The rotation lasts six weeks, with students spending a mean of two hours a day on theory (nephrology and/or urology) and the remaining time on rotations in the various activities: three weeks in nephrology and three weeks in urology. Upon completion of the rotation, the students write a combined theoretical examination with 100 multiple-choice questions (50 on urology) and take a practical skills examination. At the end of the course, another practical test consisting of an objective, structured clinical examination is taken, in which standard patients are used and the professor directly assesses the level of skills acquired with a “real” case

[Surgery of large residual mass after chemotherapy in advanced testicular germ cell tumor]. / Cirugía de gran masa residual tras quimioterapia en tumor germinal testicular avanzado.

Treatment for testicular tumours has progress in such a manner in the last years that high cure percentages can at present be achieved. After chemotherapy, in most cases, residual mass can appear. In this cases surgery is considered a viable therapeutic option although it implies an advanced surgical training since it is a complex technique and implies serious implications. We submit the case of a patient who presented a large residual mass from a testicular germ cell tumour after being treated with orquiectomía and chemotherapy. Surgery was performed resulting in total and radical extirpation of residual mass.

Cirugía de gran masa residual tras quimioterapia en tumor germinal testicular avanzado / Surgery of a large retroperitoneal residual mass after chemotherapy in advanced testicular germ cell tumour

El tratamiento de los tumores testiculares ha avanzado de tal manera en los últimos años que se consiguen altos porcentajes de curación. Tras la quimioterapia, en muchos casos aparecen masas residuales que son susceptibles de cirugía como opción terapéutica que obtiene buenos resultados, pero que precisa un grado de entrenamiento quirúrgico avanzado ya que es una técnica dificultosa y con importantes complicaciones. Presentamos el caso de un paciente que tras orquiectomía y quimioterapia por tumor germinal testicular avanzado, presentó masa residual de gran tamaño que precisó cirugía de la misma, consiguiéndose la extirpación radical (AU)

Treatment for testicular tumours has progress in such a manner in the last years that high cure percentages can at present be achieved. After chemotherapy, in most cases, residual mass can appear. In this cases surgery is considered a viable therapeutic option although it implies an advanced surgical training since it is a complex technique and implies serious implications. We submit the case of a patient who presented a large residual mass from a testicular germ cell tumour after being treated with orquiectomía and chemotherapy. Surgery was performed resulting in total and radical extirpation of residual mass (AU)

Bilateral adrenal myelolipoma.

Myelolipomas are rare benign tumors often found incidentally due, in the majority of cases, to the fact that they are asymptomatic. The incidence of adrenal myelolipomas at autopsy is low (0.2%). These tumors are made up of fat and hematopoietic cells. Their origin is unclear and different theories have been put forward, including development from rests of mesenchymal stem cells, embolism of bone marrow, extramedullary hematopoiesis and, according to the most widely accepted theory, metaplasia of the reticuloendothelial cells of blood capillaries. Due to their uncertain etiology and low frequency, management of adrenal myelolipomas is usually individualized and carried out depending on the protocols of each center. The development of improved imaging techniques has increased their diagnosis in routine clinical practice. Thus, they have been included in the heterogeneous group of 'incidentalomas' of the adrenal gland.

[Necrotizing pancreatitis following radical cystectomy for infiltrating bladder carcinoma]. / Pancreatitis necrotizante tras cistectomía radical por carcinoma vesical infiltrante.

Mortality from radical cystectomy is still high, in some series accounting for 1-10% deaths. Morbidity is even higher and can reach 50%. This paper contributes the case of a 66-year old male patient diagnosed with an infiltrant tumour of the bladder following TUR. The patient's background included prior surgery for gastroduodenal ulcus, alcohol consumption, and obesity. Following routine pre-operatory investigations, the patient underwent radical cystectomy using routine techniques and urinary by-pass via transcolonic ureterosigmoidostomy. Increased transaminases, leucocytosis, vomiting, jaundice and extended intestinal ileum were noted during the patient's post-operative period, while blood and urine amylase concentrations were moderately high. Following CAT study, laparotomy was performed and the diagnosed confirmed. The patient died on day 14 of surgery due to secondary pulmonary complications. Post-operative pancreatitis is a low-frequency, high-mortality acknowledged complication. Even though most cases are secondary to biliarypancreatic and surrounding pancreas area surgery, it has also been described in some instances of distant surgery such as the present case. Alcohol consumption, biliary lithiasis, prior cholecystectomy and diabetes are predisposing factors. High amylase values do not always accompany this condition. Early diagnosis and treatment are crucial for the patient's prognosis. Respiratory complications are the usual cause of death in these patients.

[Eosinophilic cystitis and glandular-cystic cystitis as pseudotumor lesions]. / Cistitis eosinofílica y cistitis glánduloquística como lesiones seudotumorales.

OBJECTIVES: To report on two different types of cystitis presenting as pseudotumor. The differential diagnosis between the foregoing lesions and true tumors can only be established by biopsy. METHODS: We report two cases of cystitis (eosinophilic cystitis and glandular-cystic cystitis) with clinical, radiological and endoscopic features of a bladder tumor. The diagnosis, etiopathological aspects, clinical course and treatment of both types of cystitis are reviewed. RESULTS/CONCLUSIONS: Hematuria is the most frequent and most important symptom of these uncommon lesions. They present as space occupying lesions in more than 50% of the cases and have no specific diagnostic features. The diagnosis can only be made by pathological examination following TUR-biopsy.

[Keratinizing squamous metaplasia (cholesteatoma) of the upper urinary tract]. / Metaplasia escamosa queratinizante (colesteatoma) del tracto urinario superior.

Presentation of four cases of keratinizing squamous metaplasia (KSM), two of the renal pelvis, one pyelocaliceal and one ureteral. Nephrouretetectomy was performed in all cases. All our patients showed good evolution. A review of the literature is made discussing all the etiological, diagnostic and therapeutical aspects of the condition. Its benign evolution is highlighted as well as the current need, once a better knowledge of the condition's natural history is available, of using a conservative approach.

[Wunderlich syndrome. Report of 3 cases]. / Síndrome de Wunderlich. Aportación de tres casos.

Contribution of three cases of Wunderlich Syndrome, two of which caused by an angiomyolipoma, and the third one encountered in an anticoagulated patient. We reflect on the obscure pathoetiogenesis of this uncommon disease and on the need to establish the appropriate diagnosis through different radiological examinations (ultrasound, CAT, arteriography) in order to apply the correct therapeutic approach, which in most cases will have an emergency nature, trying to adopt the most conservative attitude possible.

[Adrenocortical carcinoma with inferior vena cava thrombosis]. / Carcinoma cortico suprarrenal con trombosis de vena cava inferior.

Presentation of one case of a large non-functional left corticosuprarenal carcinoma with associated thrombosis of the left renal vein and abdominal cava vein, a location rarely reported in the literature. Correct pre-operative magnitude diagnosis was possible, thus allowing the use of the appropriate surgical technique leaving no need for improvisation. In spite of the overall poor prognosis of this malignant tumoration, even more when there is a venous extension, the patient is now free of relapse or tumoral metastasis three years after surgery.

[Immunoprophylaxis of recurrence of T1 G2 bladder tumors with interferon alpha-2b]. / Inmunoprofilaxis de recidivas de tumores vesicales T1 G2 con interferón alpha-2b.

Assessment of results with -2b Interferon used as prophylaxis in 20 patients who underwent surgery for T1,G2 urothelial vesical tumours. Dosage was weekly intravesical instillation of 50 x 10(6) IU for three months and then monthly up to one year treatment. Mean follow-up was 17.20 months (4-41 months). Relapse rate over this time was 50%, all before 15 months, a relapsing ratio of 2.82% patients/month and a disease-free interval of 27.5 months. Chances of being disease-free at 30 months is 48.21%. Progression of disease, whether in grade or stage, was observed in 25% cases. No patient showed relevant changes or side effects during treatment, except for 5 patients who reported mictional symptoms mainly during the first 3 months, none of which required discontinuation of treatment. From the data obtained, it can be deduced that for the time being no reason justifies the use of -2b Interferon versus other conventional chemotherapeutical or immunotherapeutical (BCG) agents in the prophylaxis of this type of tumours.

[Vesico-intestinal fistulae]. / Fístulas vesicointestinales.

Review of vesicointestinal fistulae cases treated in the Urology Unit at our hospital over the last few years. Most frequently seen cause was colorectal cancer (66%) and most frequent location was vesicosigmoideal (50%). Clinical signs and symptoms were varied, mainly urinary infection in 100% cases, pneumaturia in 66% and fecaluria in 50%. Opaque enema and cystography were great diagnostic aids as complementary methods. Also U.I.V., cystoscopy, rectoscopy and C.A.T. were used. Treatment was surgical in all cases where the patient's general health status allowed it.

[Transitional cell tumor of the bladder in childhood]. / Tumor transicional de vejiga en la infancia.

Presentation of one case of transitional cells tumour of the urinary bladder in a 10-year old patient. We emphasize the rarity of such tumours during the first decade of life as well as their good prognosis, the only management required being just an endoscopic resection.

[Primary abscess of the psoas. Report of 3 cases and review of the literature]. / Abcesos primarios del psoas. Aportación de tres casos y revisión de la literatura.

Three cases of abscesses rated as primary of the psoas, after dismissing any likely cause that can be involved in the genesis of secondary abscesses of the psoas, are presented. A review of the literature is made, emphasizing the etiological change in the psoas' abscesses as well as the possible causes involved in the etiopathology of this picture which appears to be caused by distant dissemination from a septic nucleus. This theory is also supported by over 80% cases where Staphylococcus aureus is the causative organism. Reference is made to which clinical data is most relevant and to the value of the traditional diagnostic procedures: simplex x-ray, u.i.v., ultrasound techniques, radionuclides and CAT, the latter being the ideal diagnostic procedure in these processes. Finally, different therapy approaches are presented. Percutaneous draining (supported by ultrasound scanning and CAT) appears to have greater acceptance by most authors, relegating the surgical drainage for selected cases.

[Adenocarcinomas of the urachus]. / Adenocarcinomas del uraco.

Tumors of the urachus account for 1% of all malignant bladder tumors and 20-39% of primary adenocarcinoma of the bladder. We report 4 cases (3 males, 1 female) of urachal adenocarcinoma. One of the patients had a signet ring cell tumor. The most common clinical sign was a suprapubic mass followed by hematuria. In three cases, cystoscopy revealed a mass at the level of the bladder dome. The IVP was normal in all but one patient in whom a filling defect at the level of the dome was evidenced by the cystogram. In one patient, CT revealed a fistulous track between the bladder and the tumor mass. Treatment was by surgery in all of the cases. Supratrigonal cystectomy and en bloc resection of the anterior infraumbilical abdominal wall was performed in 3 cases, followed by wide cystoplasty using intestine in 2 cases. One patient underwent radical cystectomy and Bricker urinary diversion. Two patients are alive and disease-free at 2 and 10 years, respectively. The other two patients have died; one following operation for high gastrointestinal hemorrhage, and the other at two years from generalized metastasis. The clinical findings reported in the literature, the diagnostic protocols and treatment of these tumor types are discussed.