Importancia de la formación médico-quirúrgica andrológica para los residentes de Urología / The value of andrology medical-surgical training programs for Urology residents

Actualmente es necesaria una formación específica en Andrología dentro de la formación en Urología. Dicha formación, tanto en el programa MIR como una vez terminada la especialidad, debe ser dirigida y multidisciplinar. De hecho, el programa de formación andrológica del urólogo no termina con su periodo de residencia. Los avances en conocimientos relacionados con la infertilidad, la reproducción, la medicina sexual y la cirugía reconstructiva requieren un alto grado de dedicación y un esfuerzo permanente de formación continuada. El campo de la Andrología ha evolucionado significativamente tanto en Europa como en los Estados Unidos en los últimos 30 años. Aunque los programas de formación andrológica en estas 2regiones comparten algunos aspectos comunes, también existen diferencias sustanciales. Se revisan en este capítulo los modelos formativos en nuestro entorno internacional, así como el desarrollo habitual en España, para así entender la importancia de la formación médico-quirúrgica andrológica para los residentes de Urología

Nowadays, sub-specialty expertise in andrology is required within the Urology training program. These practices -during the MIR (Medical Intern Residency) program and once the specialty studies are over- should be performed under supervision and have a multidisciplinary nature. In fact, the urologist's andrology training program does not finish with his residency period. The unceasingly increasing knowledge related to infertility, reproduction, sexual medicine and reconstructive surgery require a high level of dedication and engagement with continuing education. The field of Andrology has evolved significantly in Europe and in the United States in the past 30 years. Although the andrology training programs in these 2 regions share some common aspects, there are also substantial differences between them. This chapter includes a review of the Spanish training programs and those in our international environment, with the objective to comprehend the importance of andrology medical-surgical training for Urology residents

The value of andrology medical-surgical training programs for Urology residents. / Importancia de la formación médico-quirúrgica andrológica para los residentes de Urología.

Nowadays, sub-specialty expertise in andrology is required within the Urology training program. These practices -during the MIR (Medical Intern Residency) program and once the specialty studies are over- should be performed under supervision and have a multidisciplinary nature. In fact, the urologist's andrology training program does not finish with his residency period. The unceasingly increasing knowledge related to infertility, reproduction, sexual medicine and reconstructive surgery require a high level of dedication and engagement with continuing education. The field of Andrology has evolved significantly in Europe and in the United States in the past 30 years. Although the andrology training programs in these 2regions share some common aspects, there are also substantial differences between them. This chapter includes a review of the Spanish training programs and those in our international environment, with the objective to comprehend the importance of andrology medical-surgical training for Urology residents.

De la definición al impacto social de la eyaculación precoz. Consenso de experto / From the definition to the social impact of premature ejaculation. Expert consensus

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[Efficacy and safety of two dosing regimens with Tadalafil in Spanish men with erectile dysfunction: results from the SURE study in 14 European countries]. / Eficacia y seguridad de Tadalafilo en dos regímenes de dosificación diferentes en pacientes españoles con disfunción eréctil: resultados procedentes del estudio SURE realizado en 14 países europeos.

OBJECTIVE: [corrected] To compare the efficacy and safety of tadalafil 20 mg administered 3 times/week (SCH) vs. on demand (OD) in a cohort of Spanish men with erectile dysfunction (ED), since Tadalafil period of responsiveness lasts up to 36 hours post-dosing. MATERIAL AND METHODS: The 418 Spanish patients participating in the European multicenter, crossover, open-label SURE clinical trial (comprising 4262 men) were randomly assigned to one of the treatment sequences: tadalafil 20 mg SCH for 5-6 weeks followed by tadalafil 20 mg OD for 5-6 weeks, or the inverse sequence. At completion, patients were asked to select the regimen they preferred to receive in an extension phase. RESULTS: In both regimens, tadalafil led to a similar improvement in erectile function compared to baseline. However, the SCH regimen showed statistically significant higher scores for several IIEF questions (i.e. sexual desire domain). Normal erectile function (IIEF EF domain score > or = 26) was achieved by 69.3% of patients on SCH and 64.3 % on OD, with a sexual intercourse success rate (SEP3) of 75.6% and 72.2% respectively (p<0.05). Nevertheless, more patients preferred to receive tadalafil OD for the extension phase (55.9% vs 44.1%, p<0.05). Tadalafil was well tolerated in both regimens. The most common TEAEs (> or = 5%) were headache, dyspepsia and back pain. There were no clinically significant differences in the incidence of TEAEs between regimens. CONCLUSIONS: Tadalafil 20 mg is efficacious and well tolerated for the treatment of ED, regardless the regimen of administration (OD or SCH). Patients can choose the pattern of administration that fits better with their expectations.

Eficacia y seguridad de Tadalafilo en dos regímenes de dosificación diferentes en pacientes españoles con disfunción eréctil: Resultados procedentes del estudio SURE realizado en 14 países europeos / Efficacy and safety of two dosing regimens with tadalafil in spanish men with erectile dysfunction: results from the sure study in 14 european countries

Fundamento y objetivo: Comparar eficacia y seguridad de tadalafilo 20 mg administrado 3 veces/semana ('pautado') vs. 'a demanda' en una cohorte de españoles con disfunción eréctil (DE) aprovechando que su efecto permanece hasta 36 horas postdosis. Material y método: Los 418 españoles participantes en el estudio europeo SURE (multicéntrico, cruzado y abierto en 4.262 pacientes), se distribuyeron aleatoriamente a una de las siguientes secuencias: tadalafilo 20 mg 'a demanda' (D) durante 5-6 semanas seguido de tadalafilo 20 mg pautado, 3 veces por semana (P) otras 5-6 semanas; o la inversa. Al finalizar los pacientes eligieron el régimen que preferían en una extensión del estudio. Resultados: Tadalafilo en ambos regímenes mejoró la función eréctil (FE) respecto a la basal. El régimen P obtuvo significativamente mejores puntuaciones que el D en ciertos dominios del cuestionario IIEF (p.ej. deseo sexual), y más pacientes (69,3% vs 64,3%, P5%) relacionados con el tratamiento fueron cefalea, dispepsia y dolor de espalda. No hubo diferencias significativas en la incidencia de los mismos. Conclusiones: Tadalafilo 20 mg es eficaz en el tratamiento de la DE en cualquiera de los regímenes de administración ('a demanda' ó 3 veces/semana) empleado, siendo bien tolerado. Los pacientes pueden escoger la pauta de administración mas adecuada

Objetive: To compare the efficacy and safety of tadalafil 20 mg administered 3 times/week (SCH) vs. on demand (OD) in a cohort of Spanish men with erectile dysfunction (ED), since Tadalafil period of responsiveness lasts up to 36 hours post-dosing. Material and methods: The 418 Spanish patients participating in the European multicenter, crossover, open-label SURE clinical trial (comprising 4262 men) were randomly assigned to one of the treatment sequences: tadalafil 20 mg SCH for 5-6 weeks followed by tadalafil 20 mg OD for 5-6 weeks, or the inverse sequence. At completion, patients were asked to select the regimen they preferred to receive in an extension phase. Results: In both regimens, tadalafil led to a similar improvement in erectile function compared to baseline. However, the SCH regimen showed statistically significant higher scores for several IIEF questions (i.e. sexual desire domain). Normal erectile function (IIEF EF domain score ≥26) was achieved by 69.3% of patients on SCH and 64.3 % on OD, with a sexual intercourse success rate (SEP3) of 75.6% and 72.2% respectively (p<0.05). Nevertheless, more patients preferred to receive tadalafil OD for the extension phase (55.9% vs 44.1%, p<0.05). Tadalafil was well tolerated in both regimens. The most common TEAEs (≥5%) were headache, dyspepsia and back pain. There were no clinically significant differences in the incidence of TEAEs between regimens. Conclusions: Tadalafil 20 mg is efficacious and well tolerated for the treatment of ED, regardless the regimen of administration (OD or SCH). Patients can choose the pattern of administration that fits better with their expectations

[Analysis of the reasons for non graft initial function in our series of the last eleven years]. / Análisis de las causas de no función inicial del injerto en nuestra serie de los últimos once años.

UNLABELLED: FUNDAMENTAL: [corrected] To know which risk factor of delayed graft function in our patients. MATERIAL AND METHODS: We analyzed 469 transplants, 270 had good initial function and 199 had delayed function graft. Variables studies in booth groups were: age, sex and dead cause of donant, type of extraction and place were it was done, implantation side, vases multiple, isquemia times, age and receptor sex, HLA compatibility, retransplant, Ac Anti-VHC, PTH pretransplant, years in waiting list, hiperinmunization, number of transfusion, and type of inmunosupretion. RESULTS: Univariant study: significant differences were found in age and dead cause of donant, isquemia times, years in waiting list, hiperinmunization, number of transfusions, and HLA-B incompatibility. Multivariate study: we have significant differences in age of donant, could isquemia time, years in waiting list, cuadruple? Inmunosupretion. CONCLUSIONS: Results suggest to short could and revascularization isquemia time as possible, and use less nefrotoxic inmunosupretion pautes in high-risk patients.

Análisis de las causas de no función inicial del injerto en nuestra serie de los últimos once años / Analysis of the reasons for non graft initial function in our serie of the last eleven years

FUNDAMENTO: Conocer los factores de riesgo de disfunción inicial del injerto en nuestra serie. MATERIAL Y MÉTODO: Analizamos 469 trasplantes. 270 con buena función inicial y 199 sin función inicial. Las variables estudiadas en ambos grupos mediante estudio uni y multivariante fueron: edad, sexo y causa de muerte del donante, tipo de extracción y donde se realizó, lateralidad de la implantación, vasos múltiples, tiempos de isquemia fría, edad y sexo del receptor, compatibilidad HLA, retrasplante, Ac AntiVHC, PTH pretrasplante, años en lista de espera, hiperinmunización, número de transfusiones y tipo de inmunosupresión. RESULTADOS: Estudio univariante: hubo diferencias significativas en la edad y causa de muerte del donante, tiempos de isquemia, años en lista de espera, hiperinmunización, número de transfusiones e incompatibilidad HLA-B. Estudio multivariante: hubo diferencias significativas en la edad del donante, tiempo de isquemia fría y de revascularización, e inmunosupresión cuádruple. CONCLUSIONES: Los resultados aconsejan acortar en lo posible los tiempos de isquemia fría y de revascularización, y utilizar pautas inmunosupresoras menos nefrotóxica en casos de alto riesgo (AU)

FUNDAMENT: To know which risk factor of delayed graft function in our patients. MATERIAL AND METHODS: We analyzed 469 transplants, 270 had good initial function and 199 had delayed function graft. Variables studies in booth groups were: age, sex and dead cause of donant, type of extraction and place were it was done, implantation side, vases multiple, isquemia times, age and receptor sex, HLA compatibility, retransplant, Ac Anti-VHC, PTH pretransplant, years in waiting list, hiperinmunization, number of transfusion, and type of inmunosupretion. RESULTS: Univariant study: significant differences were found in age and dead cause of donant, isquemia times, years in waiting list, hiperinmunization, number of transfusions, and HLA-B incompatibility. Multivariate study: we have significant differences in age of donant, could isquemia time, years in waiting list, ¿cuadruple? Inmunosupretion. CONCLUSIONS: Results suggest to short could and revascularization isquemia time as possible, and use less nefrotoxic inmunosupretion pautes in high-risk patients (AU)

[Urinary lithiasis secondary to indinavir in an HIV-positive patient]. / Litiasis urinaria secundaria a Indinavir en enfermo HIV positivo.

OBJECTIVE: Indinavir is a protease inhibitor used in the treatment of HIV with a lithogenic capacity as a urological side effect. The pathogenesis, diagnosis and treatment of indinavir urolithiasis are briefly reviewed. METHODS: A 37-year-old male, seropositive for HIV on treatment with indinavir, lamiduvine and zidovudine, consulted for colicky left lumbar pain, nausea, vomiting and dark urine for the past three days. RESULTS: Patient evaluation showed a nonfunctioning left kidney and ureterohydronephrosis of unknown origin. URS showed a yellowish, friable material with a mucinous appearance that occupied the entire lumen of the ureter. Fragmentation was achieved with the lithotriptor probe. Six months later the patient had fully recovered and was asymptomatic. CONCLUSIONS: The incidence of protease inhibitor-induced urolithiasis is increasing. This condition should be distinguished from uric acid calculi whose treatment will aggravate the indinavir urolithiasis.

Birth of healthy twins after fertilization with in vitro cultured spermatids from a patient with massive in vivo apoptosis of postmeiotic germ cells.

OBJECTIVE: To examine whether the results of assisted reproduction with the use of elongated spermatids from a man with incomplete arrest of spermiogenesis and a high frequency of apoptosis among postmeiotic germ cells can be improved by germ cell in vitro culture. DESIGN: Case report. SETTING: Private assisted reproduction centers and a university department. PATIENT(S): Man with incomplete spermiogenesis failure. INTERVENTION(S): Testicular spermatid extraction, in vitro culture of testicular biopsy samples, intraoocyte injection of elongated spermatids, embryo culture, and transfer. MAIN OUTCOME MEASURE(S): Fertilization rate, embryo morphology, and pregnancy. RESULT(S): An assisted reproduction attempt with viability-selected elongated spermatids from a fresh testicular biopsy sample resulted in a poor fertilization result and embryo quality. Further analysis of the sample used in this attempt showed a high incidence of apoptosis among postmeiotic germ cells. A second attempt was then performed with in vitro culture of testicular cells for 24 hours before spermatid injection. This procedure led to a significant decrease in the frequency of apoptosis among viability-selected spermatids, to improvement of the fertilization rate and embryo quality, and to the birth of healthy twins. CONCLUSION(S): In vitro culture of testicular biopsy samples before assisted reproduction with elongated spermatids may improve the efficacy of treatment in cases of massive in vivo apoptosis of postmeiotic germ cells.

[Vascular assessment before kidney transplantation. Role of computerized helical tomography]. / Evaluación vascular pretrasplante renal. Papel de la tomografía helicoidal computerizada.

OBJECTIVE: To present our experience with helical CT for vascular assessment prior to renal transplantation. METHODS: In our hospital, all candidates to renal transplantation are referred to the Urology Transplant Unit for previous assessment. For the past 3 years, patients with multiple arterial calcifications (non linear) have been evaluated by helical CT with three-dimensional reconstruction of the calcification densities, which provides an accurate representation of the lesion. RESULTS/CONCLUSIONS: Pretransplant evaluation has been fundamental for individualized planning of the renal transplant surgery. The use of helical CT is extending in our field and it has also been utilized in graft donor assessment. In our experience, the extent and thickness of arterial wall calcifications are accurately depicted by helical CT. These findings could have an important significance when making pre and perioperative decisions in renal transplantation.

[Renal artery stenosis in the transplant patient]. / Estenosis de la arteria renal en el trasplantado.

OBJECTIVE: To present our experience in the diagnosis and treatment of renal artery stenosis in kidney transplants. METHODS: A review of 601 renal transplants performed in adults showed 32 cases of renal artery stenosis. The diagnostic techniques utilized were arteriography in 18 patients, DIVAS in 15, echo-Doppler in 11 patients and MAG with captopril test on two occasions. RESULTS: Arterial hypertension was the most common symptom (92.8%), alone (53.1%) or in association with impaired renal function (43.7%). 46.8% of the cases could be managed by drug therapy. Percutaneous transluminal angioplasty was performed in 14 patients. Surgery was required on two occasions. CONCLUSIONS: The incidence of renal artery stenosis in our series of renal transplants in adults up to 1997 was 5.3%. Arterial hypertension with or without impairment of renal function was the most common symptom. Currently, echo-doppler and MAG with captopril test are the most widely utilized diagnostic techniques. Percutaneous transluminal angioplasty is the treatment of choice in renal artery stenosis when arterial hypertension is refractory to drug therapy. Good results are achieved in 57%, although it is not free from complications. In case of failure, revascularization surgery is the alternative approach.

[Surgical treatment of obstructive disease of the transplanted kidney]. / Tratamiento quirúrgico de la patología obstructiva del riñón trasplantado.

OBJECTIVES: To review renal graft obstruction post-transplantation and its surgical management. METHODS/RESULTS: Our experience and those of other Spanish centers are analyzed and the literature reviewed. The different causes of obstruction following transplantation are briefly analyzed and the advantages and disadvantages of the different therapeutic options are discussed. CONCLUSIONS: Graft obstruction post-transplantation continues to be an important challenge to the urologist. However, in most of the cases the therapeutic alternatives are relatively standardized and achieve satisfactory results.

[Retroperitoneal fibrosis without dilatation of the upper urinary tract and non-obstructive anuria]. / Fibrosis retroperitoneal sin dilatación de vías altas y anuria no obstructiva.

OBJECTIVE: An unusual case of retroperitoneal fibrosis with non-obstructive anuria is described and the therapeutic alternatives are discussed. METHODS/ RESULTS: Repeated obstruction of the double-J ureteral catheter and intense lumbar pain did not permit endourological management and surgery was required. Excellent results were achieved and the patient is asymptomatic 12 months postoperatively. CONCLUSIONS: Conservative endourological management and corticosteroids may not always be feasible. The anuria without dilation in the case described is not unlike other reported cases considered as reflex anuria whose mechanism remains unknown.

[Complications of immunotherapy with BCG. Report of a case with retractile bladder]. / Complicaciones de la immunoterapia con BCG. A propósito de un caso de vejiga retráctil.

OBJECTIVES: We report a case of contracted bladder following BCG immunotherapy to prevent recurrence of a superficial bladder carcinoma. Other possible complications and their prevention are also discussed. METHODS: The patient had extreme contracted bladder and marked bilateral ureterohydronephrosis that required cystectomy and bladder substitution. The histopathological examination revealed detrusor muscle fibrosis without inflammation. RESULTS: Surgery achieved good results and the patient is disease-free 5 months postoperatively. CONCLUSIONS: The major complication that must be avoided is absorption following traumatic catheterization. Recognizing the early symptoms, particularly cystitis, together with adequate and early treatment of the localized effects can significantly reduce the incidence of severe toxicity.

[Sterilization of catheters used for intermittent bladder emptying using a domestic microwave oven]. / Esterilización de catéteres empleados para vaciado vesical intermitente con microondas casero.

In contemporary urology it is increasingly frequent the indication of intermittent catheterization. Patients undergoing this type of therapy use several non-standardized methods to make catheterization as clean as possible. Microwave sterilization has been successfully used for certain materials and biological residues. For this reason and because it is a rather inexpensive system, we tried to demonstrate that sterilization of catheters used by our patients for intermittent catheterization using domestic microwave ovens at home is a convenient, inexpensive and clean alternative that should be taken into account. The catheters used were those employed in our hospitalized patients for a minimum of 4 days, which involves a high percentage of contamination. In 15 cases, the catheter was treated in a 800 W domestic microwave oven after having washed it with water so as to eliminate macroscopic organic residues, and in another 15 cases they were thoroughly washed before microwave treatment. In either case, the treatment was done for over 6 minutes at maximum power with the precautions described in the text. In all instances, the catheter's sterility was confirmed except for one case where contamination occurred during post-treatment handling.

[Cancer and kidney transplantation]. / Cáncer y trasplante renal.

The higher risk of developing malignant tumours in transplanted patients is a fact widely acknowledged over the last decade. This paper includes an analysis of our series and a review of the literature. Cancers developed by the transplanted patient or "de novo" cancers and, within this group skin and lip cancer (58%), are by far the most frequent ones. Their biological behaviour is, in general, more aggressive than similar ones in non-transplanted population. Also, different incidence rates and behaviour have been established depending on the immunosuppressive regime given to the patient. Most common pre-existing carcinoma was renal cancer (one third of cases). When these patients had been adequately treated before the transplant, the minimum disease-free interval that has to elapse to be included in a waiting list will depend on the type of tumour. Transferred tumours are the least frequent but more worrying ones due to both their clinical and legal implications. In view of the existing evidence, it is of particular relevance to insure the primitive nature of any CNS tumour as well as the absence of tumoral disease in young females who die of brain haemorrhage.