Priapismo de bajo flujo transformado en priapismo de alto flujo por fístula arterio-lacunar secundaria a la técnica de Winter / Low-flow priapism turned into high-flow priapism due to arterial-lacunar fistula secondary to Winter's procedure

El priapismo es una afección patológica que consiste en una erección peneana persistente más allá de la estimulación sexual. Presentamos el caso de un paciente de 80 años, diagnosticado inicialmente, por la historia clínica, valores gasométricos de los cuerpos cavernosos y ultrasonografía Doppler color peneana, de priapismo de bajo flujo. Durante la realización de la técnica de Winter se produce iatrogénicamente la laceración bilateral de las arterias dorsales, originando una fístula arterio-lacunar y, en consecuencia, un priapismo de alto flujo. Se realizó una arteriografía selectiva de la pudenda al no ser concluyente la eco-Doppler color, que puso de manifiesto dicha fístula y permitió la embolización supraselectiva bilateral con microcoils (AU)

Priapism is a pathological condition which is a persistent penile erection beyond sexual stimulation. We report a patient of 80 years, initially diagnosed by medical history, blood gas values of the corpora cavernosa and penile color Doppler ultrasound of low-flow priapism. During the performance of the technique of Winter occurs iatrogenically bilateral laceration of the dorsal arteries, causing arterial-lacunar fistula and therefore a high-flow priapism. We performed selective arteriography of the pudendal, not being eco-color Doppler conclusively that showed that fistula and allowed superselective bilateral embolization microcoils (AU)

Complicación derivada del uso de Hem-O-Lok en la prostatectomía radical laparoscópica / Complications arising from the use of Hem-O-Lok in laparoscopic radical prostatectomy

Se presenta una rara complicación pos operatoria, la formación de pseu dodivertículo uretral, que se produce después de una prostatectomía radical laparoscópica con preservación de nervios, procedimiento llevado a cabo con la colocación de Hem-o-lok sobre los pedículos látero-prostáticos, en un paciente con cáncer de próstata clínicamente localizado. Por tanto, estos dispositivos deben utilizarse con precaución en la región de la anastomosis vesicouretral...

We present a rare postoperative complication, pseudodiverticulum urethral formation, occurring after a laparoscopic radical prostatectomy with nerve-sparing procedure carried out with the placement of Hem-o-lok c in the latero-prostatic pedicles, in a patient with clinically localized prostate cancer. As such, these devices should be used with caution in the region of the vesicourethral anastomosis...

[Determination of free prostatic specific antigen cut point for the selection of patients in first prostate biopsy]. / Determinación del punto de corte del porcentaje de PSA libre para la selección de pacientes sometidos a primera biopsia de próstata.

OBJECTIVES: Determine the cut point of free PSA rate for optimize the first prostate biopsy indication. MATERIAL AND METHODS: Prospective trial between june 2002-september 2004, We included patients in first prostate biopsy with normal rectal digital examen, total PSA between 3-10 ng/ml and normal transrectal prostate ultrasound. We realize descriptive stadistic analisis of variables age, total PSA, prostate volume and % free PSA and analitic stadistic analisis with ROC curves of variables total PSA and % free PSA for determine as of her predicts the best one rate of prostate cancer. RESULTS: We reclute 727 men with a mean age 62.91 years, total PSA mean 6.12 ng/ml, prostate volume mean 42.78 cc and % free PSA mean 15.22%. We had 106 prostate cancer, the prostate cancer rate in first biopsy was 14.6%; 77 cases had 1 lobe prostate cancer and 29 in 2 lobes. The most frecuent gleason was 6 (46 cases 43.4%) and the second gleason 7 (43 cases 40.6%). In the ROC curves analysis, total PSA had area under the curve 0.476 (p=0.3) and 0.611 (p=0.023) for % free PSA. The optime cut point for % free PSA in our trial was 19% (Sensibility 91.4% and Specificity 20%). The use of this cut point had allowed the saving us 138 biopsies (19.11%) with the lost one of diagnose of 10 cases of cancer of prostate. CONCLUSIONS: The use of the % free PSA is useful and allows in our region the best indication of the patients who are going to first biopsy of prostate, avoiding the accomplishment of unnecessary biopsies.

Determinación del punto de corte del porcentaje de PSA libre para la selección de pacientes sometidos a primera biopsia de próstata / Determination of free prostatic specific antigen cut point for the selection of patients in first prostate biopsy

Objetivo: Determinar el punto de corte de %PSA libre que nos permita optimizar la indicación de primera biopsia de próstata. Material y métodos: Estudio prospectivo entre junio 2002 y septiembre 2004 en el que incluimos pacientes sometidos a primera biopsia de próstata con tacto rectal normal, niveles de PSA total entre 3-10 ng/ml y ecografía transrectal de próstata normal. Realizamos estudio estadístico descriptivo de las variables edad, PSA, volumen prostático y porcentaje de PSA libre. Realizamos análisis estadístico analítico mediante curvas ROC de las variables PSA y % PSAL determinando cual de ellas predice mejor la existencia de cáncer de próstata en la primera biopsia transrectal de próstata. Resultados: Se reclutan un total de 727 hombres con una edad media de 62,91 años, el PSA medio de 6,12 ng/ml, el volumen prostático medio 42,78 cc, el % PSA libre medio de 15,22%. Se diagnosticaron un total de 106 tumores de próstata, obteniendo una tasa de biopsia prostática del 14,6%; 77 con afectación de 1 lóbulo y 29 con afectación de los 2 lóbulos. El gleason más frecuente fue el 6 (46 casos 43,4%) seguido del gleason 7 (43 casos 40,6%). En el análisis mediante curvas ROC el área bajo la curva para el PSA total fue de 0,476 (p=0,3) y para el % PSA libre de 0,611 (p=0,023). El punto de corte óptimo para el % PSA libre en nuestra serie se situó en el 19% con una sensibilidad del 91,5% y una especificidad del 20%. El uso de este parámetro nos hubiese permitido la realización de 138 biopsias menos (19,11%) con la pérdida de diagnóstico de 10 casos de cáncer de próstata. Conclusiones: El uso del %PSA libre es útil y permite en nuestro medio la mejor indicación de los pacientes que van a ser sometidos a primera biopsia de próstata, evitando la realización de biopsias innecesarias

Objetives: Determine the cut point of free PSA rate for optimize the first prostate biopsy indication. Material and methods: Prospective trial between june 2002-september 2004, We included patients in first prostate biopsy with normal rectal digital examen, total PSA between 3-10 ng/ml and normal transrectal prostate ultrasound. We realize descriptive stadistic analisis of variables age, total PSA, prostate volume and % free PSA and analitic stadistic analisis with ROC curves of variables total PSA and % free PSA for determine as of her predicts the best one rate of prostate cancer. Results: We reclute 727 men with a mean age 62.91 years, total PSA mean 6.12 ng/ml, prostate volume mean 42.78 cc and % free PSA mean 15.22%. We had 106 prostate cancer, the prostate cancer rate in first biopsy was 14.6%; 77 cases had 1 lobe prostate cancer and 29 in 2 lobes. The most frecuent gleason was 6 (46 cases 43.4%) and the second gleason 7 (43 cases 40.6%). In the ROC curves analysis, total PSA had area under the curve 0.476 (p=0.3) and 0.611 (p=0.023) for % free PSA. The optime cut point for % free PSA in our trial was 19% (Sensibility 91.4% and Specificity 20%).The use of this cut point had allowed the saving us 138 biopsies (19.11%) with the lost one of diagnose of 10 cases of cancer of prostate. Conclusions: The use of the % free PSA is useful and allows in our region the best indication of the patients who are going to first biopsy of prostate, avoiding the accomplishment of unnecessary biopsies

[Review of cut-off points between stages T1 and T2 in the 1997 TNM classification of renal carcinoma]. / Revisión del punto de corte entre los estadios T1 y T2 en la clasificación TNM del carcinoma renal de 1997.

OBJECTIVE: We retrospectively review the patients treated at our institution for renal cell carcinoma (RCC). We compare the patients classified in TNM state T1N0M0 in the 1997 revision with the 1992 one in order to determine survival differences. We divide patients in three size related groups and compare its survival rates. MATERIAL AND METHODS: We review 168 surgically treated patients. 72 of them were classified into T1N0M0 stage. We compare cancer-free survival in patients included in 1997 and 1992 T1 stage. We divide patients in three groups: 1-3 cm, 3-5 cm, 5-7 cm and compare respective cancer-free survival. RESULTS: There is a survival difference between T1(1997)-T2(1992) (p = 0.478). There is an inferior survival in size group 5-7 cm compared with 1-3 cm and 3-5 cm ones (p = 0.02/0.0465). CONCLUSIONS: In our patients, 1997 revision of T1 size supposes a descent of cancer-free survival compared with 1992 one. We consider a better stage limit under 5 cm, instead of actual 7 cm.

Revisión del punto de corte entre los estadios T1 y T2 en la clasificación TNM del carcinoma renal de 1997 / Cut-off point revision between 1997 TNM classification stages T1 and T2 o renal carcinoma

OBJETIVO: Realizamos un estudio retrospectivo de los pacientes tratados en nuestra institución por carcinoma de células renales (CCR). Comparamos los pacientes clasificados en el estadio T1N0M0 según la revisión TNM de 1997 con la clasificación según la revisión de 1992 para establecer diferencias de supervivencia. Comparamos diferentes cortes por tamaño tumoral y valoramos su implicación en la supervivencia. MATERIAL Y MÉTODOS: Análisis retrospectivo de una serie de 168 pacientes intervenidos por CCR, de ellos 72 clasificados en estadio T1N0M0. Comparamos supervivencia según las dos últimas revisiones TNM y en tres grupos de tamaño: 1-3 cm, 3-5 cm y 5-7 cm. RESULTADOS: Hallamos menor supervivencia en los pacientes T11997 (p=0,0478) y en grupo de tamaño 5-7 cm, con respecto al 1-3 cm (p=0,02) y al de 3-5 cm (p=0,0465).CONCLUSIONES: En nuestra serie, la revisión de 1997 en el estadio T1 supone un descenso de supervivencia. El límite en 7 cm es excesivo, lo consideramos más apropiado por debajo de 5 cm (AU)

Difficulties in assessing community-acquired infection as a risk factor for nosocomial infection at an intensive care unit.

OBJECTIVE: To analyze the relationship between presentation with a community-acquired infection (CAI) and the risk of subsequent nosocomial infection, and the assessment of a likely diagnostic bias in this association. DESIGN: A prospective cohort study. APACHE-II and TISS were used to assess severity and therapeutic intensity, respectively. Nosocomial infection (NI) was diagnosed according to SENIC and CDC diagnostic criteria. The relative risk and its 95% confidence interval were estimated. SETTING: The intensive care unit (ICU) of the University of Granada Hospital (Spain). It is a ten-bed multidisciplinary unit. PATIENTS: 448 patients admitted to the intensive care unit (ICU) between December-1986 and April-1988 who stayed at the ICU for at least 24 hours were included in the study. RESULTS: The crude analysis suggests that CAI may prevent NI. When data were stratified by other variables a previous infection acted as a preventive factor in patients admitted to the ICU from emergency room, in patients with lower severity level and in those with shorter stay lengths at ICU. Patients with a CAI showed higher severity; they were treated more aggressively, they had a longer stay at ICU before a NI was diagnosed and they remained at ICU longer. In multivariate analysis the NI risk in patients with a CAI compared with those not infected previously and controlling for other variables was of 0.36. CONCLUSION: The presence of a CAI may introduce a differential information bias in the study of NI.

Influence of nosocomial infection on mortality rate in an intensive care unit.

OBJECTIVE: To assess the impact of nosocomial infection on the mortality rate in an intensive care unit (ICU). DESIGN: Prospective cohort study. SETTING: The ICU of the University of Granada Hospital in Spain. PATIENTS: All patients (n = 279) admitted for > or = 48 hrs at the ICU between December 1986 and April 1988. MEASUREMENTS: Nosocomial infections were diagnosed according to Study on the Efficacy of Nosocomial Infection Control (SENIC) and Centers for Disease Control criteria. Patient severity on admission (using Acute Physiology and Chronic Health Evaluation (APACHE II) and Therapeutic Intensity Scoring Systems were also used. RESULTS: Mortality risk was 2.48 times higher in patients with a nosocomial infection than in noninfected patients. Relative risk of mortality in nosocomially infected patients was higher in young and less severely ill patients, in those patients with respiratory diseases, and in those patients with longer ICU stays. Logistic stepwise regression analysis, adjusting for several confounding factors (affected organ system, APACHE II score, and therapeutic intensity), showed that the risk of death in nosocomially infected patients was 2.1 times greater (95% confidence interval = 1.0 to 4.41) than in patients without such infection. CONCLUSIONS: Nosocomial infection increases the risk of death. The effect is stronger in younger and less severely ill patients.

[The estimation of the cost of nosocomial infection in an intensive care unit]. / Estimación del coste de la infección nosocomial en una unidad de medicina intensiva.

BACKGROUND: Nosocomial infection (NI) represents an increase of hospital morbidity and mortality. The data available concerning the hospital expenses due to the prolongation of hospital stay associated to NI are fundamentally derived from American studies. The aim of this study was to evaluate the direct cost of nosocomial infection in an intensive medicine unit (IMU). METHODS: A study of cases and paired controls was carried out with a cohort study made up of 88 cases and 88 controls paired by age and severity (APACHE II grading). Previously identified confusion factors were controlled in the analysis. RESULTS: The mean stay in the IMU for infected patients was 17.2 days and for non infected patients 6.8 days. When these stays were adjusted by the variables associated with both NI and in the IMU this became 14.2 days for infected patients and 9.9 days for uninfected patients. The prolongation of stay in the IMU due to NI was 4.3 days. The extra cost for the hospital due to infection acquired by a patient's during stay in the IMU was estimated as 239,441 pesetas. CONCLUSIONS: The methodology used was considered as valid for estimating the prolongation of stay in intensive medicine units attributed to nosocomial infection. The high economic expense which nosocomial infection represents emphasizes the justification for measures of control of this entity.

[Dehydroepiandrosterone sulfate and lipids in acute myocardial infarct]. / Dehidroepiandrosterona-sulfato y lípidos en el infarto agudo de miocardio.

To establish the possible relationship between acute myocardial infarction (AMI) and dehydroepiandrosterone-sulfate (DHEA-S) in a group of 15 patients with AMI, blood levels of DHEA-S and certain lipids (total cholesterol, LDL-cholesterol, HDL-cholesterol and triglycerides) were determined at admission in the hospital and after 10 days. As controls a group of healthy individuals or with minor diseases, and a group of 24 severely ill non-cardioischaemic patients have been studied. DHEA-S and HDL-cholesterol levels have been found significantly lowered both in patients with AMI (at 10th day) as well as in the severely ill non-cardioischaemic patients, in comparison with the healthy volunteers group. We conclude, then, than the lowering in DHEA-S and HDL-cholesterol seems not to be specifically relates with AMI but has a certain relationship with severe disorders in general.

Usefulness of severity indices in intensive care medicine as a predictor of nosocomial infection risk.

To evaluate the relationship between severity and nosocomial infection in critical patients, we have conducted a prospective study at the Intensive Care Unit of the University of Granada Hospital (Spain). Patients' severity was evaluated by APACHE II and TISS. We found a positive association with nosocomial infection risk for an APACHE II score greater than 12 points (RR = 2.45) and for first-day TISS greater than 20 points (RR = 2.51). With a multivariate analysis we did not find an association between APACHE II and nosocomial infection risk, but each TISS point suggests an infection risk increment of 6%. We concluded TISS may be considered a good infection risk predictor. TISS could also be taken into account when nosocomial infection rates from several ICUs are compared.

[Dehydroepiandrosterone sulfate, cortisol and their precursors in severely ill (acute and chronic) patients]. / Dehidroepiandrosterona-sulfato, cortisol y sus precursores en enfermos graves (agudos y crónicos).

This study tries to evaluate the interrelationship amongst certain corticoadrenal hormones (Dehydroepiandrosterones-Sulphate (DHEA-S), progesterone, 17-OH progesterone and cortisol) in male patients with severe organic processes (24 chronic and 22 acutely ill) and comparing them with a control group of 15 healthy male subjects or suffering mild processes. Corticoadrenal hormone behaviour in the presence of a severe disease show marked differences between the androgenic and the glucocorticoid pathways. While DHE-S shows a significant decrease in severe disease, independently of the underlying disease (acute or chronic), the contrary occurs with the glucocorticoid pathway, in which cortisol and specially its precursors, progesterone and 17-OH-progesterone, predominantly present in the acute situation, normal or significantly increased levels. These differences between the two adrenal pathways suggest that apart from ACTH there must be another regulatory mechanism of the androgenic pathway which may facilitate the androgenic adaptation to the situation of severe disease.