Anastomic urethroplasty in bulbar urethral stricture. 13 years experience in a department of urology. / Uretroplastia anastomótica en el manejo de estenosis de uretra bulbar. Experiencia de 13 años en un Servicio de Urología.

UNLABELLED: Urethral stenosis is a common disease in the clinical practice of urology, with a major impact on the quality of life of patients. The anastomotic urethroplasty is a technique with very precise indications usually membranous or bulbar urethra stenosis with a length of 3 cm or up to 7 cm when it is secondary to urethral disruptions (no stenosis) after pelvic trauma. OBJECTIVE: We review anastomotic urethroplasty performed in our department between 2002 and 2015. METHODS: A retrospective, descriptive and inferential analysis on 107 patients out of 482 treated with Anastomotic urethroplasty by urethral strictures at the Urology Department of the Hospital "Virgen de la Victoria" (Malaga) from January 2002 to September 2015, establishing effectiveness and safety of the technique, as well as factors that might influence the results. The main diagnostic method was retrograde urethrography and voiding cystourethrography in 100% of patients undergoing surgery, using voiding uroflowmetry for subsequent monitoring. The definition of success was a postoperative flowmetry with Qmax>15 ml/s, and in case of lower flow, we perform a cystoscopy to verify recurrence of stenosis or exclude other pathology. RESULTS: The median age was 42 years, with a mean follow up of 59 months. The length of stenosis valued by retrograde urethrography and voiding cystourethrography was in 91.6% of cases of >1 cm and <2 cm. The most common etiology was idiopathic in 72.9%, followed by iatrogenic with 15.9%. Regarding the location, it was observed that the area most often affected was the bulbar urethra with 82.2%, with the membranous urethra in second place. In 77.6% of patients anastomotic urethroplasty was the initial treatment, followed in frequency by direct vision internal urethrotomy 9.3%. In the case of comorbidities associated with treatment with anastomotic urethroplasty it was observed that only Diabetes Mellitus had a tendency to statistical significance, with p=0.092, not demonstrating such significance in the case of hypertension or when the subject presented Diabetes Mellitus together with hypertension. Finally, the intervention was successful in 102 cases (95.3%), with only 5 cases (4.7%) where it failed, 4 of them treated with a new Anastomotic urethroplasty, with resolution of the stricture. CONCLUSIONS: Anastomotic urethroplasty is the treatment of choice for short bulbar urethral stricture, with high success rate and low complication rate, as well as low recurrence of these.

Uretroplastia anastomótica en el manejo de estenosis de uretra bulbar. Experiencia de 13 años en un Servicio de Urología / Anastomic urethroplasty in bulbar urethral stricture. 13 years experience in a department of urology

La estenosis de uretra es una patología frecuente en la práctica clínica diaria de las consultas de Urología, con un impacto importante en la calidad de vida de los pacientes. La Uretroplastia anastomótica es una técnica con indicaciones muy precisas en estenosis generalmente de uretra bulbar o membranosa con una longitud de hasta 3 cm o de hasta 7 cm cuando se trata de disrupciones uretrales (no estenosis) tras traumatismos pelvianos. OBJETIVO: Realizamos una revisión de las Uretroplastias anastomóticas llevadas a cabo en nuestro servicio entre 2002 y 2015. MÉTODO: Análisis retrospectivo, descriptivo e inferencial sobre 107 pacientes de un total de 482 estenosis uretrales tratadas mediante Uretroplastia anastomótica en el Servicio de Urología del Hospital 'Virgen de la Victoria' de Málaga desde enero de 2002 a septiembre de 2015, estableciendo eficacia y seguridad de dicha técnica, así como factores que pudiesen influir en los resultados. El método diagnóstico principal fue la uretrografía retrograda y miccional en el 100% de los pacientes sometidos a tratamiento quirúrgico, recurriendo a la flujometría miccional para el seguimiento posterior. La definición de éxito fue una flujometría postoperatoria con un Qmax >15 ml/s, y en caso de flujos inferiores se realizaron uretrografías o uretroscopias para verificar la recidiva de la estenosis o descartar otra patología. RESULTADOS: La mediana de edad fue de 42 años, con un seguimiento medio de 59 meses. La longitud de la estenosis valorada mediante uretrografía miccional y retrógrada fue en un 91.6% de los casos de >1 cm y <2cm. La etiología más frecuente fue la Idiopática con un 72.9%, seguida por la Iatrógena con un 15.9%. Respecto a la localización se objetivó como la zona más frecuentemente afecta fue la uretra bulbar con un 82.2%, continuándole la uretra membranosa. En un 77.6% de los pacientes la Uretroplastia anastomótica fue el tratamiento inicial, continuando en frecuencia la Uretrotomía Interna con un 9.3%. En el caso de las comorbilidades asociadas al tratamiento con la Uretroplastia anastomótica se objetivó como únicamente la Diabetes Mellitus presenta una tendencia a la significación estadística, con una p = 0.092, no demostrándose dicha significación ni en el caso de la Hipertensión arterial ni cuando el sujeto presentaba Diabetes Mellitus conjuntamente con Hipertensión. Por último, la intervención resultó un éxito en 102 casos (95.3%), con sólo 5 casos (4.7%) en los que fracasó, siendo tratados 4 de ellos con una nueva Uretroplastia anastomótica con resolución de la estenosis. CONCLUSIONS: La Uretroplastia anastomótica es el tratamiento de elección en las estenosis cortas de uretra bulbar por su alto porcentaje de éxitos y baja tasa de complicaciones, así como en las recidivas de éstas

Urethral stenosis is a common disease in the clinical practice of urology, with a major impact on the quality of life of patients. The anastomotic urethroplasty is a technique with very precise indications usually membranous or bulbar urethra stenosis with a length of 3 cm or up to 7 cm when it is secondary to urethral disruptions (no stenosis) after pelvic trauma. OBJECTIVE: We review anastomotic urethroplasty performed in our department between 2002 and 2015. METHODS: A retrospective, descriptive and inferential analysis on 107 patients out of 482 treated with Anastomotic urethroplasty by urethral strictures at the Urology Department of the Hospital 'Virgen de la Victoria' (Malaga) from January 2002 to September 2015, establishing effectiveness and safety of the technique, as well as factors that might influence the results. The main diagnostic method was retrograde urethrography and voiding cystourethrography in 100% of patients undergoing surgery, using voiding uroflowmetry for subsequent monitoring. The definition of success was a postoperative flowmetry with Qmax>15 ml/s, and in case of lower flow, we perform a cystoscopy to verify recurrence of stenosis or exclude other pathology. RESULTS: The median age was 42 years, with a mean follow up of 59 months. The length of stenosis valued by retrograde urethrography and voiding cystourethrography was in 91.6% of cases of >1 cm and <2cm. The most common etiology was idiopathic in 72.9%, followed by iatrogenic with 15.9%. Regarding the location, it was observed that the area most often affected was the bulbar urethra with 82.2%, with the membranous urethra in second place. In 77.6% of patients anastomotic urethroplasty was the initial treatment, followed in frequency by direct vision internal urethrotomy 9.3%. In the case of comorbidities associated with treatment with anastomotic urethroplasty it was observed that only Diabetes Mellitus had a tendency to statistical significance, with p = 0.092, not demonstrating such significance in the case of hypertension or when the subject presented Diabetes Mellitus together with hypertension. Finally, the intervention was successful in 102 cases (95.3%), with only 5 cases (4.7%) where it failed, 4 of them treated with a new Anastomotic urethroplasty, with resolution of the stricture. CONCLUSIONS: Anastomotic urethroplasty is the treatment of choice for short bulbar urethral stricture, with high success rate and low complication rate, as well as low recurrence of these

Urachal adenocarcinoma with late brain metastases.

OBJECTIVE: To describe a case of urachal adenocarcinoma with late brain metastases in a sixty one year old man who presented abdominal discomfort and hematuria during six months. METHODS: The clinical suspicion was bladder tumor and diagnostic studies were performed (urinary cytology, cystoscopy, abdominal ultrasound and abdominopelvic CT scan). Surgical treatment was performed. RESULTS: Negative urinary cytology. Cystoscopy showed a lesion with infiltration of the bladder dome. Ultrasound and CT scan showed a five centimeter rounded lesion, with intermediate density, internal echoes and calcifications on the anterior supravesical middle line, that infiltrated the bladder. The extension study had not findings. Partial cystectomy and lymphadenectomy were performed. The histopathologic diagnosis was mucin-secreting urachal adenocarcinoma. After five years without disease the patient suffered lung and brain metastases. CONCLUSIONS: Urachal adenocarcinoma is a tumor which must be distinguished of primary bladder adeno-carcinoma. The mucing-secreting adenocarcinoma can be associated with calcifications that can be demostrated on imaging studies. Late metastases without signs of local recurrence (after five years without disease) are an infrequent clinical-pathologic finding.

[Obstructive uropathy secondary to vesico-ureteral endometriosis: clinical, radiologic and pathologic features]. / Uropatía obstructiva secundaria a endometriosis vésico-ureteral: características clinico-radiológicas y anatomopatológicas.

OBJECTIVES: To report the case of a 37 year-old woman suffering from endometriosis of the urinary tract, that presented with lumbar and pelvic pain associated to cyclic recurrent haematuria. METHODS: Following history, physical examination, abdomino-pelvic ultrasound (USS), CT scan and cystoscopy with biopsies, surgical treatment was indicated RESULTS: Imaging (USS-CT ) revealed a protrusion of the left bladder hemi-trigone with a nodular, irregular thickening and ipsilateral grade II-III/IV uretero-hydronefrosis. Cistoscopy confirmed a swollen and oedematous lesion in left hemi-trigone that seemed extrinsic in origin. With the clinical diagnosis of a possible neoplasia of gynaecological origin, the patient underwent surgical treatment consisting in radical hysterectomy with bilateral oophorectomy, partial cystectomy and left ureteroneocystostomy. CONCLUSIONS: The frequency of endometriosis in the urinary tract is relatively low and therefore, endometriosis presenting with ureteral obstruction (uretero-hydronephrosis) has been rarely reported in the literature and should be part of the differential diagnosis in young women, especially if symptoms are cyclic. The treatment is surgery and the final diagnosis by pathology report.

Uropatia obstructiva secundaria a endometriosis vésico-ureteral: características clínico radiológicas y anatomopatológicas / Obstructive uropathy secondary to vesico-ureteral endometriosis: clinical, radiologic and pathologic features

OBJETIVOS: Describir un nuevo caso de afectación del tracto urinario por endometriosis en una mujer de 37 años que consultó por dolor pélvico, lumbar y hematuria de carácter cíclicos.MÉTODO: Tras la realización de historia clínica y exploraciones complementarias como ecografía abdominal, TAC abdominopélvico y cistoscopia con toma de biopsias se indicó tratamiento quirúrgico.RESULTADOS: En las pruebas de imagen realizadas (ECO-TAC) se apreció una impronta y engrosamiento nodular e irregular de la hemibase vesical izquierda, con afectación ureteral y dilatación pielocalicial grado II-III/IV. En la cistoscopia se observó lesión congestiva y edematosa a nivel de hemitrígono izquierdo. Con el diagnóstico clínico de neoformación ginecológica localmente avanzada con afectación uréterovesical se realizó tratamiento quirúrgico consistente en histerectomía, anexectomía bilateral, cistectomía parcial y ureterocistoneostomía izquierda.CONCLUSIONES: La frecuencia de la afectación del tracto urinario por endometriosis es relativamente baja, sin embargo, la afectación ureteral obstructiva (hidronefrosis) es un hecho escasamente referido en la literatura consultada y que debe tenerse en cuenta ante cuadros de este tipo en mujeres jóvenes, principalmente si se acompaña de síntomas cíclicos. El diagnóstico definitivo es histológico y el tratamiento quirúrgico(AU)

OBJECTIVES: To report the case of a 37 year-old woman suffering from endometriosis of the urinary tract, that presented with lumbar and pelvic pain associated to cyclic recurrent haematuria.METHODS: Following history, physical examination, abdomino-pelvic ultrasound (USS), CT scan and cystoscopy with biopsies, surgical treatment was indicatedRESULTS: Imaging (USS-CT) revealed a protrusion of the left bladder hemi-trigone with a nodular, irregular thickening and ipsilateral grade II-III/IV uretero-hydronefrosis. Cistoscopy confirmed a swollen and oedematous lesion in left hemi-trigone that seemed extrinsic in origin. With the clinical diagnosis of a possible neoplasia of gynaecological origin, the patient underwent surgical treatment consisting in radical hysterectomy with bilateral oophorectomy, partial cystectomy and left ureteroneocystostomy.CONCLUSIONS: The frequency of endometriosis in the urinary tract is relatively low and therefore, endometriosis presenting with ureteral obstruction (uretero-hydronephrosis) has been rarely reported in the literature and should be part of the differential diagnosis in young women, especially if symptoms are cyclic. The treatment is surgery and the final diagnosis by pathology report(AU)

[Multiple bladder inverted papillomas]. / Papilomas invertidos vesicales múltiples.

OBJECTIVE: To describe the clinical and histological findings of the unusual involvement of the urinary bladder by multiple inverted papillomas of transitional cells. METHODS/RESULTS: A 53-year-old male presented with obstructive symptoms and gross hematuria lasting for one year. Ultrasound examination of the urinary bladder demonstrated two polypoid masses. Transurethral resection was performed and histopathological examination of specimens showed a subepithelial, non-atypical cell proliferation arranged in a trabecular pattern. DNA-ploidy showed diploid population and ki-67 determination revealed a low proliferation index. CONCLUSIONS: Multiple inverted papillomas of the urinary bladder are very rare. Histological examination is essential for the definitive diagnosis. Determination of DNA-ploidy and proliferative index may be useful for appropriate management of this disease.

[Spontaneous retroperitoneal hematoma secondary to the rupture of suprarenal myelolipoma]. / Hematoma retroperitoneal espontáneo secundario a rotura de un mielipoma suprarrenal.

OBJECTIVE: To describe a case of adrenal myelolipoma in a patient that presented with retroperitoneal hemorrhage. METHODS/RESULTS: A 53-year-old patient that presented with retroperitoneal hemorrhage is described. A CT scan showed a 14 cm fat-containing mass in the right adrenal area surrounded by another hyperdense mass suggestive of hemorrhage. A right adrenalectomy was performed. Histopathologic analysis of the mass confirmed the clinical diagnosis of ruptured adrenal myelolipoma. The clinical and therapeutic aspects are discussed and the literature is briefly reviewed. CONCLUSIONS: Adrenal myelolipomas are rare benign lesions and are usually asymptomatic. Spontaneous rupture is very uncommon and is related with the size of the tumor. To our knowledge, only six cases have been previously reported in the literature.

[Treatment of erectile dysfunction with vacuum devices]. / Tratamiento de la disfunción eréctil con dispositivos de vacío.

OBJECTIVE: To analyze the results achieved with vacuum devices in the treatment of erectile dysfunction. METHODS: A telephone survey was conducted on 150 patients undergoing treatment with a vacuum device. Of these, 89 responded; 79 of which were considered valid for the study. The duration and frequency of use, side effects and degree of patient and partner satisfaction were analyzed. Mean follow-up was 59.5 months. RESULTS: There were 14 dropouts early in the course of treatment. The remaining 65 patients used the device for a mean duration of 34.6 months, 3.7 times monthly. 63.3% of the patients achieved erection in more than half of the attempts. The most frequent side effects were pain (27 patients) and ecchymosis (7 patients). Forty-eight patients discontinued treatment at 10.8 months' mean follow-up. The most common causes for discontinuing treatment were lack of efficacy, refusal of the partner and pain. CONCLUSIONS: Treatment of erectile dysfunction with the vacuum constriction device should be utilized as an alternative to intracavernosal drug-induced erection therapy when oral therapy fails or is contraindicated. A male with a stable partner and impotence arising from venous leakage or mild cavernous artery insufficiency is the ideal candidate.

[Bladder leiomyoma during pregnancy]. / Leiomioma vesical durante el embarazo.

OBJECTIVE: To describe an additional case of rapidly growing leiomyoma of the bladder in a pregnant woman. METHODS: A case of leiomyoma of the bladder in a woman at 8 months of pregnancy is presented. Transurethral resection was performed, but the tumor recurred a few weeks later. The tumor was resected by partial cystectomy after delivery. CONCLUSIONS: Leiomyoma of the bladder is an uncommon benign lesion that is successfully managed by surgical resection. The rapid recurrence of the tumor in our patient can be ascribed to the hormonal changes during pregnancy.

[Spontaneous retroperitoneal hematoma: our experience]. / Hematoma retroperitoneal espontáneo: nuestra experiencia.

We report 15 cases of spontaneous retroperitoneal haematoma. The etiology and the diagnostic and therapeutic procedures were evaluated. The haematoma source was the adrenal gland in 4 patients and the causes were pheochromocytoma (1), adenoma (1), myelolipoma (1) and idiopathic (1). In 10 patients the source was the kidney and the causes were angiomyolipoma rupture (6), renal cell carcinoma (3) and ureteral calculi (1). In the remaining case, the haematoma was produced by fibrinolytic and anticoagulant therapy in a patient with acute myocardial infarction. The imaging diagnostic techniques employed were abdominal ultrasonography and CT scan, which allowed the diagnosis of haematoma and showed his size and extension in all the cases. With these two techniques, and with the retrograde pyelography in one patient, we obtained the etiologic diagnosis in 12 of the 15 cases. Surgical treatment was performed in 12 patients (adrenalectomy in 2, simple nephrectomy in 3, radical nephrectomy in 5 and partial nephrectomy in 2).

[Bladder sarcomatoid carcinoma. Bladder carcinoma simulating lymphoma]. / Carcinoma sarcomatoide vesical. Carcinoma vesical simulando un linfoma.

OBJECTIVE: To describe an unusual type of vesical carcinoma (sarcomatoid carcinoma) associated with the spread of inflammation. The article discusses the diagnostic difficulties and prognosis. METHOD/RESULTS: We describe a patient with vesical sarcomatoid carcinoma associated with the spread of inflammation that practically obscured the undifferentiated area, mimicking a lymphoma. This is interpreted as a favourable immunological reaction, despite the highly aggressive behaviour of the sarcomatoid component. CONCLUSIONS: Only on rare occasions do vesical carcinomas present such a prominent degree of spindle-shaped cells. This finding could create some diagnostic confusion, hence an immunohistochemical study is essential. The identification of sarcomatoid carcinoma has important implications both for treatment and for prognosis. The literature refers to the marked aggressiveness of this type of tumour. The peculiarity of the case resides in the associated spread of inflammation which improved the prognosis.