Micro-ureteroscopy: Initial experience in the endoscopic treatment of pelvic ureteral lithiasis.

OBJECTIVES: To present to report the first case of ureteral lithiasis resolved using a new endoscopic approach, which we call microureteroscopy (m-URS) and attempts to reduce the ureteral damage caused by conventional instrumentation. MATERIAL AND METHODS: We selected a 53-year-old patient with a 16-mm calculus in the right distal ureter. For endoscopic access, we used a 4.8 Fr sheath from the microperc set and fragmented the stone with a 230-micron laser fiber. RESULTS: Complete fragmentation of the stone was achieved. We placed a JJ catheter due to significant ureteral edema. The surgical time and postsurgical stay were 156minutes and 24hours, respectively. There were no complications, the requirements for analgesia were minimal, and the patient was free of residual stones. CONCLUSIONS: The m-URS technique is feasible, simple and effective for the treatment of pelvic ureteral lithiasis in women and optimizes minimal invasion, with results that can be comparable to conventional endoscopic techniques in terms of ease of access and quality of endoscopic vision without affecting the resolution capacity. Larger studies and greater technological development is needed to define the definitive role of this procedure. Currently, its major limitations lie in the treatment of proximal ureter lithiasis and in the treatment of men. This technique could also be a viable alternative for pediatric patients.

Análisis de los factores que influyen en la pérdida hemática en la nefrolitotomía percutánea: registro de la Asociación Española de Urología sobre la posición supina / Analysis of the Factors Affecting Blood Loss in Percutaneous Nephrolithotomy: A Registry of the Spanish Association of Urology in the Supine Position

Objetivo: La nefrolitotomía percutánea (NLP) es la técnica mínimamente invasiva de elección para el tratamiento de la litiasis renal mayor de 2 cm. El objetivo de este estudio es analizar los diferentes factores que influyen en el descenso de hemoglobina durante el procedimiento, realizado en posición supina. Material y métodos: Realizamos un estudio prospectivo multicéntrico observacional de la nefrolitotomía percutánea en posición supina, basado en el registro de la AEU. Se estudian los diferentes factores que influyen en el descenso de hemoglobina: datos demográficos y antropométricos, comorbilidad asociada, localización y tamaño de la litiasis, variantes anatómicas y aspectos técnicos del procedimiento. Resultados: Desde septiembre de 2008 hasta diciembre de 2012 se han registrado 397 NLP en posición supina, realizadas en 15 centros españoles. El descenso medio de hemoglobina fue 2,3 ± 1,5 g/dl y la tasa de transfusión de 5,5%. No hubo diferencias significativas en el descenso de hemoglobina entre varones y mujeres, IMC ni por grupos de edad. Tampoco existen diferencias entre los pacientes con antecedentes cardiovasculares, diabetes, HTA o tratamiento anticoagulante. El tamaño y la localización de la litiasis no influyen de forma significativa en la pérdida hemática. La duración del procedimiento (> o < 120 min), técnica de punción (ecografía, fluoroscopia), el tipo de dilatación del trayecto percutáneo (Alken, balón o Amplatz) y la ausencia de catéter de nefrostomía final (tubeless) no afectaron al descenso de hemoglobina. Únicamente el número de trayectos percutáneos (≥ 2) y el acceso a través de un cáliz medio tuvieron repercusión estadísticamente significativa en la pérdida hemática (p = 0,03 y p = 0,01 respectivamente) (AU)

Conclusiones: La NLP en posición supina es un procedimiento mínimamente invasivo para el tratamiento de litiasis renales múltiples y de gran tamaño (> 2 cm), que implica escasa pérdida hemática, con mínima tasa de transfusión de hemoderivados. Los únicos factores relacionados con mayor descenso de hemoglobina fueron el número de accesos percutáneos y la localización del trayecto en el cáliz medio (AU)

Objective: Percutaneous nephrolithotomy (PCNL) is the minimally invasive procedure of choice for removing renal stones larger than 2 cm. This study has aimed to identify the different variables that might influence decrease of hemoglobin during the surgery performed in supine position. Material and methods: A prospective, multicenter, observational study of supine PCNL, based on the Spanish Association of Urology database, was analyzed. The different preoperative and postoperative factors that might affect the decrease of hemoglobin were assessed: demographics and anthropometric data, comorbidities, size and location of the stones, anatomical variants and technical aspects of the procedure. Results: From September 2008 to December 2012, 397 supine PCNL procedures performed in 15 Spanish centers were registered. Mean hemoglobin decrease was 2.3 ± 1.5 g/dl and overall blood transfusion rate was 5.5%. No statistically significant differences were found between genders, body mass index (BMI) and age in terms of blood loss. There were also no differences between patients with cardiovascular, hypertensive, diabetic and anticoagulant treatment background. Blood loss was not significantly influenced by stone size and location. Technical aspects of the procedure as operative time (> 120 min ≤), access to the pelvi-caliceal system (ultrasound, fluoroscopy), percutaneous tract dilation technique (Alken, balloon or Amplatz) or placement of nephrostomy (tube versus tubeless) were not associated with differences in pre-op/post-op hemoglobin. Only multiple percutaneous tracts (≥ 2) and middle calix access were statistically significantly (P = 0.03 and P = 0.01) related with less blood loss (AU)

Conclusions: PCNL in supine position is a minimally invasive procedure for removal of large (≥ 2 cm) and multiple renal stones, with a low incidence of blood loss and minimal transfusion rate. Multiple percutaneous tracts and middle calix puncture were the only statistically significant variables associated with decrease in hemoglobin levels (AU)

Analysis of the factors affecting blood loss in percutaneous nephrolithotomy: a registry of the Spanish Association of Urology in the supine position.

OBJECTIVE: Percutaneous nephrolithotomy (PCNL) is the minimally invasive procedure of choice for removing renal stones larger than 2 cm. This study has aimed to identify the different variables that might influence decrease of hemoglobin during the surgery performed in supine position. MATERIAL AND METHODS: A prospective, multicenter, observational study of supine PCNL, based on the Spanish Association of Urology database, was analyzed. The different preoperative and postoperative factors that might affect the decrease of hemoglobin were assessed: demographics and anthropometric data, comorbidities, size and location of the stones, anatomical variants and technical aspects of the procedure. RESULTS: From September 2008 to December 2012, 397 supine PCNL procedures performed in 15 Spanish centers were registered. Mean hemoglobin decrease was 2.3±1.5 g/dl and overall blood transfusion rate was 5.5%. No statistically significant differences were found between genders, body mass index (BMI) and age in terms of blood loss. There were also no differences between patients with cardiovascular, hypertensive, diabetic and anticoagulant treatment background. Blood loss was not significantly influenced by stone size and location. Technical aspects of the procedure as operative time (> 120 min ≤), access to the pelvi-caliceal system (ultrasound, fluoroscopy), percutaneous tract dilation technique (Alken, balloon or Amplatz) or placement of nephrostomy (tube versus tubeless) were not associated with differences in pre-op/post-op hemoglobin. Only multiple percutaneous tracts (≥2) and middle calix access were statistically significantly (P=.03 and P=.01) related with less blood loss. CONCLUSIONS: PCNL in supine position is a minimally invasive procedure for removal of large (≥2 cm) and multiple renal stones, with a low incidence of blood loss and minimal transfusion rate. Multiple percutaneous tracts and middle calix puncture were the only statistically significant variables associated with decrease in hemoglobin levels.

El aprendizaje de la nefrolitectomía percutánea en posición supina. Estudio observacional multicéntrico / Learning of percutaneous nephrolithotomy in supine position. An observational multicenter study

Objetivo: Estudiar prospectivamente los resultados operatorios y las complicaciones de la nefrolitectomía percutánea (NLP) en posición supina para valorar la dificultad de su aprendizaje y cómo afecta la experiencia a los resultados. Establecer una comparación relativa con los datos publicados en la literatura acerca de la posición en prono. Material y métodos: Estudio prospectivo observacional multicéntrico sobre NLP en posición de Valdivia o en su variante de Galdácano. Se recogen variables demográficas y variables específicas dependientes de la litiasis. Se valoran aspectos técnicos, tiempo quirúrgico, tasa de éxito y complicaciones según la clasificación de Clavien-Dindo. Resultados: Desde septiembre de 2008 a junio de 2011 se han registrado 335 NLP en posición supina realizadas en 13 centros españoles. La proporción hombre/mujer fue 1:1,28 y la edad media 51,3 + 14,5 años; 211 (63%) casos fueron realizados por urólogos con experiencia de > 50 casos y 124 (37%) por urólogos con menos experiencia. El tiempo operatorio medio fue 113,3±46,4min, 106,6±38,2 en experimentados vs. 124,9±56,2 en noveles (p<0,002). No se detectó diferencia en el tamaño medio de la litiasis, pero en el grupo con experiencia se trató una mayor proporción de casos coraliformes y de litiasis múltiples que en el grupo novel (p<0,001). La tasa de éxito evaluada como ausencia total de restos litiásicos fue 69,6%, sin diferencias entre grupos (68,2 vs. 71,8%). En 102 (30,6%) pacientes hubo litiasis residual, precisando tratamiento complementario 60 (17,9%). La tasa relativa de éxito global fue 82,1% y la tasa de complicaciones 25,4%, sin detectarse diferencias entre grupos. No obstante, el grupo novel presentó mayor número de complicaciones mayores (p>0,001). Conclusión: La NLP en supino está teniendo una rápida y consolidada difusión en nuestro entorno, y su efectividad y seguridad parece equivalente a la descrita en la literatura para la NLP en prono. Resulta posible conseguir buenos resultados con una modesta curva de aprendizaje. La tasa de complicaciones mayores asociadas al procedimiento disminuye con la experiencia (AU)

Objective: To prospectively study the post-operative results and complications of percutaneous nephrolithotomy (PNL) in supine position to assess difficulty of learning it and how experience affects the results. To establish a relative comparison with the data published in the literature on the prone position. Material and methods: A prospective observational multicenter study on PNL in Valdivia position or in its Galdakao variant was performed. Demographic variables and specific variables related to the lithiasis were collected. Technical aspects, surgery time, success rate and complications according to the Clavien-Dindo classifications were assessed. Results: A total of 335 PNL in supine position conducted in 13 Spanish centers were registered from September 2008 to June 2011. The man: woman ratio was 1:1.28 and mean age 51.3 + 14.5 years. 211 (63%) cases were performed by urologists with experience in > 50 cases and 124 (37%) by urologists with less experience. Mean operation time was 113.3±46.4min, 106.6±38.2 for the experienced ones vs. 124.9±56.2 in the novice ones (P<0.002). No difference was detected in the mean size of the lithiasis. However, in the experienced group, there was a greater proportion of coraliform cases and multiple lithiasis than in the novice group (P<0.001). Success rate evaluated as total absence of lithiasic residuals was 69.6%, without differences between groups (68.2 vs. 71.8%). In 102 (30.6%) patient had residual lithiasis and 60 (17,9%) required complementary treatment. Relative global success rate was 82.1% and complications rate 25.4%, without detecting differences between groups. However, the novel group had more major complications (P>0.001). Conclusion: The PNL in supine position is obtaining rapid and consolidated diffusion in our setting and its effectiveness and safety seems to be equivalent to that described in the literature for PNL in prone position. It is possible to obtain good results with a modest learning curve. The rate of greater complications associated to the procedure decreases with experience (AU)

[Learning of percutaneous nephrolithotomy in supine position. An observational multicenter study]. / El aprendizaje de la nefrolitectomía percutánea en posición supina. Estudio observacional multicéntrico.

OBJECTIVE: To prospectively study the post-operative results and complications of percutaneous nephrolithotomy (PNL) in supine position to assess difficulty of learning it and how experience affects the results. To establish a relative comparison with the data published in the literature on the prone position. MATERIAL AND METHODS: A prospective observational multicenter study on PNL in Valdivia position or in its Galdakao variant was performed. Demographic variables and specific variables related to the lithiasis were collected. Technical aspects, surgery time, success rate and complications according to the Clavien-Dindo classifications were assessed. RESULTS: A total of 335 PNL in supine position conducted in 13 Spanish centers were registered from September 2008 to June 2011. The man:woman ratio was 1:1.28 and mean age 51.3+14.5 years. 211 (63%) cases were performed by urologists with experience in >50 cases and 124 (37%) by urologists with less experience. Mean operation time was 113.3 ± 46.4 min, 106.6 ± 38.2 for the experienced ones vs. 124.9 ± 56.2 in the novice ones (P<.002). No difference was detected in the mean size of the lithiasis. However, in the experienced group, there was a greater proportion of coraliform cases and multiple lithiasis than in the novice group (P<.001). Success rate evaluated as total absence of lithiasic residuals was 69.6%, without differences between groups (68.2 vs. 71.8%). In 102 (30.6%) patient had residual lithiasis and 60 (17,9%) required complementary treatment. Relative global success rate was 82.1% and complications rate 25.4%, without detecting differences between groups. However, the novel group had more major complications (P>.001). CONCLUSION: The PNL in supine position is obtaining rapid and consolidated diffusion in our setting and its effectiveness and safety seems to be equivalent to that described in the literature for PNL in prone position. It is possible to obtain good results with a modest learning curve. The rate of greater complications associated to the procedure decreases with experience.

RSK promotes G2 DNA damage checkpoint silencing and participates in melanoma chemoresistance.

The incidence of malignant melanoma is growing rapidly worldwide and there is still no effective therapy for metastatic disease. This type of cancer is highly resistant to conventional DNA-damaging chemotherapeutics, and intense research has been dedicated for understanding the molecular pathways underlying chemoresistance. The Ras/mitogen-activated protein kinase (MAPK) signalling pathway is often deregulated in melanoma, which frequently harbours activating mutations in NRAS or BRAF. Herein, we demonstrate that the MAPK-activated protein kinase RSK (p90 ribosomal S6 kinase) contributes to melanoma chemoresistance by altering their response to chemotherapeutic agents. We find that RSK phosphorylates checkpoint kinase 1 (Chk1) at an inhibitory site, Ser280, both in vitro and in vivo. Our results indicate that RSK is the predominant protein kinase operating downstream of mitogens and oncogenes of the Ras/MAPK pathway, and consistent with this, we find that RSK constitutively phosphorylates Chk1 in melanoma. We show that RSK inhibition increases Chk1 activity in response to DNA-damaging agents, suggesting that the Ras/MAPK pathway modulates Chk1 function and the response to DNA damage. Accordingly, we demonstrate that RSK promotes G2 DNA damage checkpoint silencing in a Chk1-dependent manner, and find that RSK inhibitors sensitize melanoma cells to DNA-damaging agents. Together, our results identify a novel link between the Ras/MAPK pathway and the DNA damage response, and suggest that RSK inhibitors may be used to modulate chemosensitivity, which is one of the major obstacles to melanoma treatment.

[Influence of the delay in urinary NMP22 preanalytical processing]. / Influencia del retraso en el procesamiento preanalítico de la orina en la determinacin del NMP22.

OBJECTIVES: To evaluate the influence of the delay in urinary NMP22 preanalytical processing. MATERIAL AND METHODS: Twenty-eight voided urine samples were taken: bladder cancer (14), urine tract infections (4), lithiasis (4), healthy volunteers (1), and with other no malignant bladder diseases (5). All samples, were maintained at environment temperature, and were processed according to the stabilization of parts of urine collected at 0, 30, 90 and 150 minutes. Samples were stored at 4 degrees C until its determination. NMP22 was determined with the IMMULITE One analyzer. RESULTS: There were no significant differences for NMP22 levels between each different point of time studied. CONCLUSIONS: Delay up to 2 hours and a half when we add stabilization solution to urine samples no affects NMP22 results. That thing, might provide more confidence and flexibility on quantitative immunoassays that required urine stabilization.

Influencia del retraso en el procesamiento preanalítico de la orina en la determinación del NMP22 / Influence of the delay in urinary NMP22 preanalytical processing

Objetivo: Evaluar la influencia del retraso en el procesamiento preanalítico de orinas en las que se realiza la determinación del marcador tumoral NMP22. Material y métodos: Se recogieron 28 muestras de orina: tumores vesicales (14), infecciones urinarias (4), litiasis (4), voluntarios sanos (1), y otras patologías vesicales benignas (5). De cada muestra, mantenida a temperatura ambiente, se fueron estabilizando alícuotas con el conservante suministrado por el fabricante a los 0, 30, 90 y 150 minutos, guardándose a 4ºC hasta su procesamiento. El análisis del NMP22 se realizó en autoanalizador IMMULITE One. Resultados: No se apreciaron diferencias significativas en los niveles del NMP22 entre los diferentes puntos de demora estudiados. Conclusiones: La demora de hasta dos horas y media en la adición de la solución conservante a la orina para determinación de NMP22 no afecta significativamente a los resultados obtenidos. Este hecho permite una mayor confianza y flexibilidad en los inmunoensayos cuantitativos que requieren estabilización de la muestra

Objectives: To evaluate the influence of the delay in urinary NMP22 preanalytical processing. Material and methods: Twenty-eight voided urine samples were taken: bladder cancer (14), urine tract infections (4), lithiasis (4), healthy volunteers (1), and with other no malignant bladder diseases (5). All samples, were maintained at environment temperature, and were processed according to the stabilization of parts of urine collected at 0, 30, 90 and 150 minutes. Samples were stored at 4 ºC until its determination. NMP22 was determined with the IMMULITE One analyzer. Results: There were no significant differences for NMP22 levels between each different point of time studied. Conclusions: Delay up to 2 hours and a half when we add stabilization solution to urine samples no affects NMP22 results. That thing, might provide more confidence and flexibility on quantitative immunoassays that required urine stabilization

The G-cells in the dog: a light and electron microscope immunocytochemical study.

An immunohistochemical study has been performed to analyse the distribution of gastrin cells in the gastrointestinal tract of the dog. This study revealed that G-cells immunoreactive for gastrin were almost exclusively present in the pyloric antral mucosa, mainly in the middle third of the pyloric mucosa. The calculated number of G-cells per surface unit area was 8.5 x 10(3)-1.2 x 10(4) cells cm-2. Some gastrin-immunopositive cells were found in the first 10 mm of the proximal duodenum, mainly in the villous region. The fundic area of the dog stomach, the oesophagus, small intestine, caecum, colon, rectum, salivary glands, liver and pancreas were all immunonegative for gastrin. At the ultrastructural level, three different types of granules (150-400 nm) were evident in G-cells: electron-dense, electron-lucent and intermediate forms. Most of them were located in the subnuclear region of the cell. The effect of fixation of the antral mucosa at different pH levels was studied. In samples fixed with acid solutions, most of the G-cell granules were of the electron-dense type and were strongly immunopositive for gastrin. Fixation of samples at a basic pH resulted in most of the gastrin granules losing their contents into the cytoplasm, and the positive reaction to gastrin was then located in the cytoplasm and at the periphery of the electron-lucent granules.

A comparative study between etiological factors of calcium oxalate monohydrate and calcium oxalate dihydrate urolithiasis.

A comparative study between different etiological factors of calcium oxalate monohydrate (COM) and calcium oxalate dihydrate (COD) is presented. The most frequent alteration in COD urolithiasis was associated with hypercalciuria, whereas in COM urolithiasis was associated with urinary pH. A comparison between COM and COD groups of stone formers that exhibited 1, 2 or 3 alterations was performed. Thus, in individuals with two simultaneous alterations, the association between altered urinary pH and hypomagnesiuria was the most frequent in the COM group, whereas the association between hypercalciuria and altered urinary pH was most frequent in the COD group. In individuals with three simultaneous alterations, the association between hypercalciuria, hyperphosphaturia and hyperuricuria was most frequent in both COM and COD stone formers.

[Color-coded cardiac Doppler]. / Doppler cardíaco codificado en color.

Color flow mapping with Doppler technique was reviewed. We describe the advantages and technical was reviewed. We describe the advantages and technical limitations of the technique. The usefulness of color flow mapping in acquired and congenital disease was studied. We conclude that new information was added, concerning complex intracardiac flow, in order to the traditional study with classic continuous and pulsed Doppler examination.

[Anomalous bands of the left ventricle. Study with echocardiography and Doppler ultrasound]. / Bandas anómalas del ventrículo izquierdo. Estudio con ecocardiografía y Doppler.

Of a total of 3654 echocardiographic and Doppler studies, found 95 left ventricular bands. We described the different Echo-patterns. Color-flow Doppler mapping demonstrated normal left ventricular inflow and outflow, and also lack of turbulence around the band. We conclude left ventricular bands are an abnormal but not Pathological finding.