The challenging management of malignant ureteral obstruction: Analysis of a series of 188 cases.

Background: Malignant ureteral obstruction (MUO) is a common condition that complicates the course of advanced malignancies. The aims of this study are to analyze the causes, management, and survival of patients with obstructive nephropathy due to malignant ureteric obstruction and to determine prognostic factors. Furthermore, we studied the complications and outcomes in patients who underwent urinary diversion. Materials and methods: A retrospective study was conducted on patients with computed tomography-confirmed MUO between January 2016 and November 2020. Demographic, clinical, radiological, laboratory, and management data were collected. Survival curves were estimated using the Kaplan-Meier method, and univariate and multivariate Cox proportional hazards models were used to test the association between parameters and survival. Results: A total of 188 patients were included. The mean age was 69.01 years (SD, 14.95 years), and the majority (54.8%) were male. The most common mechanism leading to MUO was compression by a pelvic mass (36.9%), and the 3 most frequent tumors causing MUO were prostate (17.6%), bladder (16.5%), and rectal cancer (11.7%).Forty-seven patients (25%) underwent urinary diversion: 23 (48.9%) underwent double-J stenting and 21 (44.7%) underwent percutaneous nephrostomy. The most common reason for urinary diversion was acute kidney injury (53.3%). Recovery of renal function was observed in 55.8% of the patients after urinary diversion. The most frequently identified complications after urinary diversion were urinary tract infection (24.4%), hematuria (17.0%), and urinary sepsis (14.9%). The median survival after hydronephrosis diagnosis was 6.43 months (interquartile range, 1.91-14.81 months). In patients who underwent urinary decompression, the median survival after urinary diversion was 8.67 months (interquartile range, 2.99-17.28 months). In the multivariate analysis, a lower grade of hydronephrosis and cancer cachexia negatively impacted survival. Conclusions: Cancer patients with MUO have a poor prognosis; therefore, the risk-benefit ratio of urinary diversion should be carefully considered. Cachexia and hydronephrosis grade can be useful in selecting suitable candidates for urinary diversion.

Primary testicular lymphoma: Clinical characteristics and oncological outcomes.

Background: Primary testicular lymphoma (PTL) is a rare testicular malignancy, despite being considered the most common testicular tumor in patients older than 60 years. Primary testicular lymphoma represents only 1%-9% of testicular neoplasms. Few studies have been published regarding its clinical features and management. This study aimed to analyze the clinical characteristics and outcomes of PTL. Materials and methods: Orchiectomy specimens of 15 patients with PTL diagnosed during 2000-2020 at our institution were retrospectively studied. We collected information on demographic data, clinical features, management aspects, and outcomes of PTL treatment. Kaplan-Meier survival curves and Cox regression analyses were used to study survival. Results: The median patient age was 69 years (interquartile range, 61-72 years). The most prevalent clinical presentation was testicular swelling (80%), and only 13.33% of the patients presented with systemic symptoms. Central nervous system involvement was detected in 6 patients (40%). Of the 15 patients, 5 (33.33%) had stage IE and 10 (66.67%) had stage IVE lymphoma. Diffuse large B-cell lymphoma was the most common histological subtype. Twelve patients (80%) received chemotherapy. During follow-up, 4 patients (26.67%) relapsed. The recurrence rate in the contralateral testicle was 13.33%. The median cancer-specific survival was 21.58 months (95% confidence interval, 0-43.95 months). Univariate Cox regression analysis showed that central nervous system involvement and International Prognostic Index score were significantly associated with shorter cancer-specific survival. Conclusions: Primary testicular lymphoma has a high relapse rate and poor prognosis. Management strategies typically include radical orchiectomy and systemic chemotherapy. Central nervous system involvement and International Prognostic Index scores were associated with lymphoma-specific survival.

Prospective long-term experience in the treatment of renal tumors with cryotherapy: follow-up with computed tomography scan and contrast-enhanced ultrasound.

Introduction: The aim of this article was to evaluate the oncological results and safety of cryotherapy for the treatment of renal tumors. Material and methods: This study was a prospective review and follow-up of patients who underwent cryotherapy from January 2008 to May 2021. Cryotherapy was offered to patients with bilateral tumors, tumors in solitary kidneys, or comorbid patients. Follow-up consisted of a computed tomography (CT) scan and contrast-enhanced ultrasound (CEUS), with analysis of concordance (kappa index). Overall survival and kidney survival were analyzed (Kaplan-Meier). Results: Cryotherapy was performed 71 times in 67 patients. A total of 74.6% of patients were men. The mean age of patients was 69.7 years (standard deviation (SD) 11.3]. Mean follow-up was 52.7 months (SD 36.2). Mean tumor size was 26.2 mm (SD 7.6). 90% were cT1a, 10% cT1b stage. Type of access was open in 1 patient, laparoscopic in 8, percutaneous US-guided in 8 and percutaneous CT-guided in 54 patients. Biopsy was taken in 60 patients (84.5%) and consisted of renal cell carcinoma (22), oncocytoma (9), papillary carcinoma (4), angiomyolipoma (1), sarcoma (1), and non-conclusive (23).There were 22 complications such as pain in 2 patients, hematoma in 8 and 2 cases of bleeding, all resolved conservatively except for one case of bleeding which required embolization.Recurrences occurred in 16 cases (22.5%). Management was cryotherapy in 25%, radical nephrectomy in 31.3% and surveillance in 43.8%. Concordance between contrast-enhanced ultrasound and CT was 0.8 (excellent).Mean glomerular filtration did not change. One patient developed metastasis.No cancer-specific mortality was found. Overall survival at 12, 24 and 48 months was 98.5%, 96.8% and 76.9% respectively. Kidney survival at 12, 24 and 48 months was 97%, 93.5% and 93.5% respectively. Conclusions: Cryotherapy for renal tumors is a safe treatment for comorbid or solitary kidney patients, with rare major complications and good oncological outcome.

Kidney Autotransplantation and Orthotopic Kidney Transplantation: Two Different Approaches for Complex Cases.

Introduction: Transplantation surgery teams often have to face complex cases. In certain circumstances, such as occlusion of the iliac vessels or prior pelvic surgery, heterotopic kidney transplantation may not be feasible and orthotopic kidney transplantation (OKT) could be a good alternative. Kidney autotransplantation (KAT) has been described as a potential treatment for complex renovascular, ureteral, or neoplastic conditions. There are scarce data regarding the complications and outcomes of these procedures; therefore, we present our experience. Materials and Methods: We retrospectively analysed the medical records of both 21 patients who had received OKT and 19 patients who underwent KAT between 1993 and 2020. We collected demographic features and data regarding surgical technique, complications, and graft outcomes. Kidney graft survival was calculated using Kaplan-Meier survival analysis. Results: Regarding OKT, in 15 (71.43%) cases, it was the first kidney transplantation. The most common indication was the unsuitable iliac region due to vascular abnormalities (57.14%). The early postoperative complication rate was high (66.67%), with 23.81% of Clavien grade 3b complications. During the follow-up period (mean 5.76 -SD 6.15- years), we detected 9 (42.85%) graft losses. At 1 year, the survival rate was 84.9%. Concerning KAT, the most frequent indication was ureteral pathology (52.63%), followed by vascular lesions (42.11%). The overall early complication rate was 42.11%. During the follow-up period (mean of 4.47 years), 4 (15.79%) graft losses were reported. Conclusions: Although OKT and KAT have high complication rates, these techniques can be considered as two valuable approaches for complex cases, in the absence of other therapeutic options.

Kidney Autotransplantation in the Management of Residual Retroperitoneal Mass in a Germ Cell Tumor.

The main indication for kidney autotransplantation is ureteric disease, although it is also performed to treat renovascular diseases or neoplasms, such as complex intrasinusal kidney tumors or in patients with a solitary kidney. Only a few cases of kidney autotransplantation in the context of resection of complex retroperitoneal masses have been reported in the literature. CASE PRESENTATION: We report the case of a 26-year-old man with history of nonseminomatous germ cell tumor who had undergone a left radical orchiectomy 3 months earlier. Follow-up computed tomography revealed a residual retroperitoneal postchemotherapy mass involving the renal hilum. It was surgically removed via en bloc resection and bench ex vivo nephron-sparing surgery, and subsequently autotransplantation, thereby avoiding the necessity of nephrectomy and the resulting risk of chronic kidney disease. The pathology of the excised specimen demonstrated mixed germ cell tumor, composed of immature teratoma and yolk sac tumor, and confirmed tumor-free margins. CONCLUSIONS: This technique should be taken into account in selected patients as an alternative to radical nephrectomy when a retroperitoneal tumor is unresectable using standard surgical techniques or when a radical nephrectomy is considered, especially in patients with chronic kidney disease or solitary kidney, or in young patients who will potentially need nephrotoxic chemotherapy.

Spontaneous urinoma debuting as retroperitoneal abscess: report of 2 cases and literature review.

Spontaneous urinoma is a urological entity that can be complicated by a retroperitoneal abscess. Urinoma can be iatrogenic, traumatic, or can be caused by obstructive uropathy. We report two cases of spontaneous urinomas, describing a not previously published cause of urinoma: pyeloureteritis. (I) A 55-year-old Caucasian female started with intense left-sided flank pain for 3 days. CT scan revealed a voluminous retroperitoneal abscess, which extended through the posterior pararenal space and the left lumbar paravertebral musculature. (II) A 48-year-old Caucasian male presented with constitutional symptoms over the previous 2 months and investigations showed a voluminous urinoma and marked pyeloureteritis findings on CT scan. Both patients were managed by endoscopic placement of a double-J stent and drainage of the collection (open and percutaneous approach, respectively). Urinoma was confirmed by fluid biochemical analysis, which demonstrated that fluid creatinine was markedly raised as compared to the serum creatinine. Urinoma in the absence of obstruction or trauma is rare. These two case reports highlight one of the conditions leading to urinoma and the management of retroperitoneal abscess. Pyeloureteritis is a cause of spontaneous urinoma and it should be considered in the lack of another obstructive cause.

Long-term results of the treatment of complex ureteral stenosis with extra-anatomic ureteral bypasses.

INTRODUCTION: Complex ureteral obstruction is a pathology that has always been a challenge for the urologist, especially in patients with high surgical risk or with a short life expectancy. MATERIAL AND METHODS: Between 2002 and 2017, 13 extra-anatomical bypasses were placed. A descriptive retrospective study was carried out. An analysis of the permeability time of the prosthesis was performed using Kaplan-Meyer curves. Demographic and etiological characteristics as well as early and late complications were analysed. RESULTS: Etiologies were benign in 39% (including 3 transplant recipients) and malignant in 69%. Permeability rates were 90.9% at each of 12, 24 and 48 months, respectively, and 75.8% at 60 months. There were no deaths in the early postoperative period, nor intraoperative complications. The most frequent complications were infections. Three of them were associated with bypass extrusion, which needed to be removed. A total of 5 prosthesis had to be removed. 40% of the patients did not present complications. CONCLUSIONS: The extra-anatomical ureteral bypass is an alternative to permanent nephrostomy in the treatment of complex ureteral strictures. Their patency rates after long-term follow-up vary from 90% to 75% at 48 and 60 months, respectively. Their complication rates can be considered acceptable in the patients' clinical contexts.

Well-Leg Compartment Syndrome After Percutaneous Nephrolithotomy in the Galdakao-Modified Supine Valdivia Position.

PURPOSE: The objective is to present a case of well-leg compartment syndrome in the Galdakao-modified supine Valdivia position. RESULTS: The case of a 32-year-old male, obese (105 Kg) and a former smoker is presented. The patient was positioned in the Galdakao-modified supine Valdivia position, with lower limbs bandaged, to perform a right percutaneous nephrolithotomy. In the immediate postoperative period, significant pain was reported in the left lower limb. The limb appeared oedematous and cyanotic, although pedis pulses were preserved. Doppler ultrasound ruled out venous thrombosis. Suspecting compartment syndrome, the patient underwent a complete decompression fasciotomy of the four left leg compartments. After the surgery, values of creatine phosphokinase reached 80.000 UI/L and serum creatinine levels were 1.53 mg/dL. The patient was taken to the intensive care unit. Six months after the episode, the patient still needs rehabilitation care. The compartment syndrome is a rare complication in lithotomy position, but never described in the Galdakao-modified supine Valdivia position before, with the lower limbs in moderate flexion, and with the ipsilateral lower limb in a slightly inferior position with respect to the other. It may lead to skin necrosis, permanent neuromuscular dysfunction, myoglobinuric renal failure, amputation and even death. Therefore, this complication must be suspected and early decompression of the compartment must be performed. Risk factors include obesity, peripheral vascular disease (advanced age, hypertension, hyperlipidemia and diabetes mellitus), height, hypothermia, acidemia, BMI, male sex, combined general-spinal anesthesia, prolonged surgery time, systemic hypotension, ASA (American Society of Anesthesiologists) class, lack of operative experience, vasoconstricting drugs, important bleeding during the surgery and increased muscle bulk. CONCLUSION: Compartment syndrome is a potentially life-threatening complication that may occur in the Galdakao-modified supine Valdivia position. It should be suspected in cases with risk factors and compatible clinical symptoms and signs, and treated rapidly to avoid further complications.

Prospective long-term results, complications and risk factors in pelvic organ prolapse treatment with vaginal mesh.

OBJECTIVE: To assess the long-term results and complications of pelvic organ prolapse treatment with transvaginal mesh. STUDY DESIGN: Prospective observational study of 75 women who underwent surgery between 2005 and 2008 by the same surgeon. 44 patients (58,7%) underwent concomitant treatment of stress urinary incontinence. Anatomical criterion for failure was prolapse grade >I in any compartment. Analysis of functional features consisted of an assessment of urinary, sexual, and defecation symptoms, and pelvic pain. Subjective global evaluation of the treatment was carried out through the Visual Analogue Scale (VAS). Analysis of the early and late complications and their medical or surgical management was performed. Evaluation of risk factors for failure of treatment and extrusion was carried out through logistic regression. RESULTS: The median follow-up was 5,3 years. The anatomical results showed correction in 91,3% of the patients. Median subjective VAS evaluation: 9/10. Urinary symptoms improved after the surgery. Constipation and dyspareunia rates worsened. Pelvic pain improved. There were two early complications: one rectal perforation, repaired intraoperatively and one pulmonary embolism, managed medically. Late complications: 9 extrusions (3 managed with topical oestrogen, 3 with expectant management, and 3 reoperated, one twice), one cervix elongation and one forgotten gauze (both reoperated), 4 de novo pain managed successfully conservatively. 58,8% of the complications occurred after one year. Risk factors analyzed showed no statistical significance. CONCLUSIONS: Vaginal mesh provides favorable anatomical, functional and subjective outcomes in long-term follow-up. The number of complications is relatively low, but many complications occurred a long-time after surgery.

Empleo de catéteres y stents ureterales en el transplante renal / The use of ureteral stents and catheters in renal transplantation

OBJETIVO: Las complicaciones urológicos mayores, fístulas y estenosis, afectan principalmente a la anastomosis vesico-ureteral y se presentan en el periodo temprano post-trasplante (TR). El empleo sistemático de catéteres ureterales continúa siendo controvertido con muchos grupos utilizándolos sólo de forma selectiva en función de la existencia de factores de riesgo pretrasplante o intraoperatorios. MÉTODOS: Se llevó a cabo una revisión de la literatura mediante la búsqueda automatizada en las bases de datos bibliográficas Medline como fuente bibliográfica principal y en Clinical Key. La estrategia de búsqueda incluyó los siguientes términos: 'stent' AND 'kidney transplantation'. RESULTADOS: La revisión de la literatura puso de manifiesto el efecto protector del empleo de catéteres ureterales en la ureteroneocistostomía del TR tanto para el desarrollo de fístulas (RR 0,29, 0,12 a 0,74, p=0,009) como de estenosis (RR 0,27, 0,09 a 0,81, p=0,02). El empleo de catéteres en pacientes inmunodeprimidos se asoció a un incremento significativo en la incidencia de ITUs post-TR (RR 1,49 IC 95% 1,04 a 2,15, p=0,03) que fue prevenida por la profilaxis antibiótica dirigida a la neumonía por pneumocistis carinii con cotrimoxazol. Las tasas de permeabilidad de los stent metálicos autoexpandibles y los by-pass extra-anatómicos en el tratamiento de la estenosis ureteral post-TR en pacientes de alto riesgo quirúrgico o tras el fracaso previo de la cirugía, con un número limitado de pacientes incluidos, ha variado entre el 50% y el 100%. CONCLUSIONES: El empleo de un catéter ureteral en la ureteroneocistostomía extravesical disminuye la incidencia de complicaciones anastomóticas. El tratamiento de elección de la estenosis ureteral post-TR es el tratamiento quirúrgico. El uso de stents metálicos y by-pass extraanatómicos debe limitarse al tratamiento de estenosis ureterales complejas en las que ha fallado el tratamiento primario, pacientes con elevado riesgo quirúrgico o disfunción crónica del injerto

OBJECTIVE: Mayor urological complications, fistulae and stenosis, mainly affect the vesicoureteral anastomosis and present in the early post-transplant period. The systematic use of ureteral catheters keeps selecbeing controversial with many groups using them only selectively depending on the existence of pretransplant or intraoperative risk factors. METHODS: We performed a bibliographic review through automatized search in the Medline bibliographic database, as the main bibliographic source, and also in Clinical Key. The search strategy included the following terms: 'stent' AND 'kidney transplantation'. RESULTS: The bibliographic search revealed the protective effect of the use of ureteral catheters in the transplant ureteroneocystostomy for both development of fistulae (RR 0.29, 0.12 to 0.74, p = 0.009) and stenosis (RR 0.27, 0.09 to 0.81, p = 0.02). The use of catheters in immunosuppressed patients was associated with significant increase of the incidence of post-transplant urinary tract infections (RR 1.49 IC 95% 1.04 to 2.15, p = 0.03) that was prevented by antibiotic prophylaxis with cotrimoxazole directed against pneumocistis carinii. The rates of permeability of self-expandable metallic stents and extra-anatomic bypasses in the treatment of ureteral stenosis after renal transplantation in high surgical risk patients or after the failure of previous surgery, has varied from 50% to 100%, with a limited number of patients included. CONCLUSIONS: The use of ureteral catheters in the extravesical ureteroneocystostomy reduces the incidence of anastomotic complications. Surgery is the treatment of choice of post-transplant ureteral stenosis. The use of metallic stents and extra-anatomic bypasses should be limited to complex ureteral stenosis when primary therapy has failed, in high surgical risk patients or chronic graft dysfunction