Estimulación transcutánea del nervio tibial posterior en el tratamiento de la incontinencia urinaria de urgencia refractaria, de origen idiopático y neurógenico / Transcutaneous stimulation of the posterior tibial nerve for treating refractory urge incontinence of idiopathic and neurogenic origin

Objetivo: Evaluar la eficacia del tratamiento con la estimulación transcutánea del nervio tibial posterior (T-PTNS) en pacientes con incontinencia urinaria de urgencia, de origen neurógenico o no neurógenico, refractaria a las opciones terapéuticas de primera línea. Material y métodos: Se incluyeron 65 pacientes con incontinencia urinaria de urgencia refractaria a tratamiento médico. Antes de T-PTNS se realizó anamnesis, estudio urodinámico y potenciales evocados somatosensoriales (PESS), estudiando el estado funcional urólogico mediante un diario miccional. El tratamiento consistió en 10 sesiones semanales de T-PTNS de 30 minutos de duración. Resultados: Un 57,7% de los pacientes presentaban PESS tibiales anormales y en un 42% PESS pudendos anormales. Se objetivó una mejoría sintomática estadísticamente significativa en todos los parámetros clínicos tras el tratamiento con T-PTNS, y en el 66% se evidenció una mejora global, independientemente del género, presencia de alteraciones neurológicas de base, hiperactividad detrusoriana en el estudio urodinámico o trastornos en los PESS. No se produjeron efectos adversos durante el tratamiento. Conclusiones: T-PTNS es un tratamiento efectivo y bien tolerado en pacientes con incontinencia de urgencia refractaria a terapias de primera línea, y debería ser ofrecida precozmente en la estrategia de tratamiento. Son necesarios nuevos estudios para identificar los parámetros óptimos de estimulación, los protocolos de tratamiento más efectivos y la eficacia a largo plazo, así como su aplicabilidad a pacientes con un sustrato neurogénico

Objective: To assess the efficacy of treatment with transcutaneous posterior tibial nerve stimulation (TPTNS) in patients with urge urinary incontinence, of neurogenic or nonneurogenic origin, refractory to first-line therapeutic options. Material and methods We included 65 patients with urge urinary incontinence refractory to medical treatment. A case history review, a urodynamic study and a somatosensory evoked potentials (SEP) study were conducted before the TPTNS, studying the functional urological condition by means of a voiding diary. The treatment consisted of 10 weekly sessions of TPTNS lasting 30 minutes. Results: Some 57.7% of the patients showed abnormal tibial SEPs, and 42% showed abnormal pudendal SEPs. A statistically significant symptomatic improvement was observed in all clinical parameters after treatment with TPTNS, and 66% of the patients showed an overall improvement, regardless of sex, the presence of underlying neurological disorders, detrusor hyperactivity in the urodynamic study or SEP disorders. There were no adverse effects during the treatment. Conclusions: TPTNS is an effective and well tolerated treatment in patients with urge incontinence refractory to first-line therapies and should be offered early in the treatment strategy. New studies are needed to identify the optimal parameters of stimulation, the most effective treatment protocols and long-term efficacy, as well as its applicability to patients with a neurogenic substrated

Changes over the last 15 years in the psychopharmacological management of persons with borderline personality disorder.

OBJECTIVE: To describe the pharmacological management of borderline personality disorder (BPD) in Spain from 2001 through 2016, the factors associated with prescriptions, and changes in pharmacotherapy over this time period. METHODS: Retrospective, cross-sectional, observational study conducted in a sample of 457 patients with BPD consecutively admitted to a specialist BPD Program between January 2001 and November 2016. Data on sociodemographic and clinical variables, as well as pharmacological treatment upon the admission to the programme, were used to describe pharmacological prescriptions, the factors associated with these medications, and changes in prescription over the last 15 years. RESULTS: Most (88.4%) patients were on pharmacological treatment, with 53.8% of persons taking ≥3 medications. No significant changes in these percentages were observed over the study period. The use of tricyclic antidepressants and benzodiazepines decreased, while the use of atypical antipsychotics increased. Axis I comorbidity was the main factor associated with pharmacological treatment and polypharmacy. CONCLUSIONS: This study provides further evidence confirming the worldwide overuse of prescription medications for BPD and shows that there has been a shift in the prescription pattern in the last 15 years. These results suggest that real clinical practice only partially adheres to clinical treatment guidelines.

Transcutaneous stimulation of the posterior tibial nerve for treating refractory urge incontinence of idiopathic and neurogenic origin. / Estimulación transcutánea del nervio tibial posterior en el tratamiento de la incontinencia urinaria de urgencia refractaria, de origen idiopático y neurógenico.

OBJECTIVE: To assess the efficacy of treatment with transcutaneous posterior tibial nerve stimulation (TPTNS) in patients with urge urinary incontinence, of neurogenic or nonneurogenic origin, refractory to first-line therapeutic options. MATERIAL AND METHODS: We included 65 patients with urge urinary incontinence refractory to medical treatment. A case history review, a urodynamic study and a somatosensory evoked potentials (SEP) study were conducted before the TPTNS, studying the functional urological condition by means of a voiding diary. The treatment consisted of 10 weekly sessions of TPTNS lasting 30minutes. RESULTS: Some 57.7% of the patients showed abnormal tibial SEPs, and 42% showed abnormal pudendal SEPs. A statistically significant symptomatic improvement was observed in all clinical parameters after treatment with TPTNS, and 66% of the patients showed an overall improvement, regardless of sex, the presence of underlying neurological disorders, detrusor hyperactivity in the urodynamic study or SEP disorders. There were no adverse effects during the treatment. CONCLUSIONS: TPTNS is an effective and well tolerated treatment in patients with urge incontinence refractory to first-line therapies and should be offered early in the treatment strategy. New studies are needed to identify the optimal parameters of stimulation, the most effective treatment protocols and long-term efficacy, as well as its applicability to patients with a neurogenic substrate.

Volumetric MRI study of the habenula in first episode, recurrent and chronic major depression.

The habenula (Hb) can play an important role in major depressive disorder (MDD) as it is a key node between fronto-limbic areas and midbrain monoaminergic structures. In vivo neuroimaging studies have shown reductions in Hb volume in a post-mortem sample of patients with affective disorders but findings in unipolar MDD are not consistent. The current study aimed to investigate whether the Hb volume differed between patients with different stages of unipolar MDD and healthy subjects. We also explored differences in grey (GM) and white matter (WM) volumes and potential age and gender effects. High-resolution images were acquired using a 3T-scanner from 95 participants (21 with first-episode MDD; 20 with remitted-recurrent MDD; 20 with treatment-resistant/chronic MDD; and 34 healthy controls).Two researchers blinded to clinical data manually delineated habenular nuclei, with excellent inter-rater agreement. Multivariate analysis of covariance revealed a significant group-by-gender interaction (F9,258=2.22; p=0.02). Univariate effects emerged for Hb-WM volumes (F3,86=3.12; p=0.03) but not for total Hb volumes (F3,86=0.59; p=0.62) or Hb-GM volumes (F3,86=2.01; p=0.12). Women with a first-episode MDD had greater Hb-WM volumes than healthy controls and patients with treatment-resistant/chronic MDD (p<0.01). These findings remained unaltered when controlled for total intracranial volume or medication load. Our results do not support decreased total Hb volumes in unipolar MDD, in patients with first-episode or in patients with long-lasting recurrent or chronic depression. However, the increased Hb-WM volume we observed in women with a first-episode suggests involvement of Hb and its projections in early stages of the recovery process and in the course of MDD.

Microstructural white-matter abnormalities associated with treatment resistance, severity and duration of illness in major depression.

BACKGROUND: Although white-matter abnormalities have been reported in middle-aged patients with major depressive disorder (MDD), few data are available on treatment-resistant MDD and the influence of relevant variables related to clinical burden of illness is far from being well established. METHOD: The present study examined white-matter microstructure in a sample of 52 patients with MDD in different stages (treatment-resistant/chronic MDD, n = 18; remitted-recurrent MDD, n = 15; first-episode MDD, n = 19) and 17 healthy controls, using diffusion tensor imaging with a tract-based spatial statistics approach. Groups were comparable in age and gender distribution, and results were corrected for familywise error (FWE) rate. RESULTS: Widespread significant reductions of fractional anisotropy (FA) - including the cingulum, corpus callosum, superior and inferior longitudinal fascicule - were evident in treatment-resistant/chronic MDD compared with first-episode MDD and controls (p < 0.05, FWE-corrected). Decreased FA was observed within the ventromedial prefrontal region in treatment-resistant/chronic MDD even when compared with the remitted-recurrent MDD group (p < 0.05, FWE-corrected). Longer duration of illness (ß = -0.49, p = 0.04) and higher depression severity (at a trend level: ß = -0.26, p = 0.06) predicted lower FA in linear multiple regression analysis at the whole-brain level. The number of previous episodes and severity of symptoms were significant predictors when focused on the ventromedial prefrontal area (ß = -0.28, p = 0.04; and ß = -0.29, p = 0.03, respectively). Medication effects were controlled for in the analyses and results remained unaltered. CONCLUSIONS: Our findings support the notion that disruptions of white-matter microstructure, particularly in fronto-limbic networks, are associated with resistance to treatment and higher current and past burden of depression.

[Post-traumatic high flow priapism in a child]. / Priapismo de alto flujo postraumático infantil.

We report on the case of a post-traumatic high-flow priapism in a 14 year-old boy, which was confirmed by cavernous blood gas measurement color flow Doppler sonography, and arteriography. It was successfully treated with superselective embolization of the right internal pudendal artery, resulting a clear disappearance of cavernus rigidity.

Priapismo de alto flujo postraumático infantil / Post-traumatic high-flow priapism in childhood

Presentamos el caso de un priapismo de alto flujo tras traumatismo perineal directo en un varón de 14 años, que se confirmó mediante gasometría de cuerpos cavernosos, estudio Eco-doppler peneano, y arteriografía pudenda. Se trató satisfactoriamente mediante embolización supraselectiva de una rama de arteria pudenda interna derecha, obteniendo disminución manifiesta de la rigidez cavernosa (AU)

[Multiple urethral lithiasis. Report of a case]. / Litiasis uretral múltiple. A propósito de un caso.

OBJECTIVE: To report a case of multiple urethral calculi, an uncommon urological condition in our setting. The clinical, radiological and therapeutic aspects are discussed and the literature is briefly reviewed. METHODS/RESULTS: A 77-year-old male consulted at the emergency services of our hospital for dysuria, pollakiuria and difficulty in voiding. The patient also referred and indurated area in the penile ventral aspect. Radiological examination disclosed three calculi in the penile urethra with were successfully removed by meatotomty and urethrolithotomy. The patient is currently asymptomatic. CONCLUSIONS: Urethral calculus is uncommon in developed countries. "Milking" is not advocated due to the high incidence of urethral injury. Treatment is by simple urethrolithotomy in combination with other techniques (urethroplasty, diverticulectomy, etc.), if required.

[Castleman's disease in the retroperitoneal region]. / Enfermedad de Castleman de localización retroperitoneal.

OBJECTIVE: To describe a case of Castleman's disease presenting as a retroperitoneal mass, with special reference to the differential diagnosis from other retroperitoneal lesions. The histological features, variants, clinical manifestations, etiopathogenesis and treatment of Castleman's disease are reviewed. METHODS: A 64-year-old male presented with voiding symptoms and hypogastric pain. An ultrasound scan showed a 5 x 6 cm mass located behind the bladder and above the prostate, which was confirmed by an abdomino-pelvic CT scan. RESULTS: Retroperitoneal sarcoma was suspected and the mass was resected. The histopathological analysis showed giant lymphoid hyperplasia (vascular hyaline variant of Castleman's disease). CONCLUSIONS: Retroperitoneal Castleman's disease is a lymphoproliferative disorder with two well-defined histological types and a mixed variant. Although this lesion is frequently localized to the mediastinum (71%), extrathoracic lesions have been described. Definitive diagnosis is based on the postoperative pathological findings.

[Tumor bladder antigen (TBA). A new method for the diagnosis and detection of recurrence of bladder cancer]. / Antígeno vesical tumoral (BTA). Nuevo método para el diagnóstico y detección de recidiva del cáncer vesical.

OBJECTIVE: To compare the usefulness and accuracy of the BTA test versus urinary cytology. METHODS: The BTA test was performed in 45 patients distributed into three groups: group I comprised patients with hematuria of unknown origin; group II had a diagnosis of bladder cancer; and group III comprised patients who had undergone TUR for a bladder tumor and were undergoing endoscopic control evaluation. The sensitivity and specificity of each diagnostic method were determined for each group of patients. RESULTS: The BTA test showed a higher sensitivity than urinary cytology in all groups, the difference being significant for groups II and III. Its specificity, however, was lower than that of cytology in groups I and III, and similar in group II. CONCLUSION: The BTA test is a simple and useful method for the diagnosis and follow-up of bladder cancer. It has a higher sensitivity than urinary cytology, although its specificity is lower due to the higher number of false positives observed in patients with inflammatory bladder conditions. Randomized studies are warranted to determine if the accuracy of urinary cytology can be enhanced with the combined use of the BTA test which has been demonstrated to have a higher specificity.

[Posttraumatic hematuria associated with pelvic arteriovenous fistula]. / Hematuria postraumática asociada a fístula arteriovenosa pélvica.

OBJECTIVE: To describe a patient with severe hematuria of late onset and pelvic arteriovenous fistula secondary to pelvic trauma. METHODS/RESULTS: A patient with multiple fracture of the pelvis and sacrum from a road traffic accident presented severe posttraumatic hematuria associated with pelvic arteriovenous fistula. The fistula was resolved by selective embolization and the hematuria immediately ceased. CONCLUSION: Patients with severe or long-lasting hematuria after pelvic trauma and no injuries to the urinary system, warrant arteriographic evaluation to discard vascular lesions. If present, these lesions are generally easily resolved by selective embolization.

[Mucinous adenocarcinoma of the prostate. Report of 3 cases and review of the literature]. / Adenocarcinoma mucinoso de próstata. Presentación de tres casos y revisión de la literatura.

OBJECTIVES: To describe 3 cases of mucinous adenocarcinoma, an uncommon variant of prostatic adenocarcinoma, and review the literature. METHODS: 3 cases of mucinous adenocarcinoma of the prostate are described. The histological and immunohistochemical features, diagnostic and therapeutic aspects of this variant of prostatic adenocarcinoma are presented and the literature briefly reviewed. RESULTS/CONCLUSIONS: This variant of prostatic adenocarcinoma is characterized by the presence of extra and intracellular mucus formation. It is generally seen in the advanced stages and responds poorly to any form of therapy.

[Disk kidney. Report of a case]. / Riñón en disco. Presentación de un caso.

Crossed fused renal ectopia (CFRE) is a rare anomaly, the incidence of which is estimated in one case per 700-1,000 births. We present here one case of Disk Kidney, an uncommon variant of CFRE, diagnosed in a female adult patient. Fused renal congenital anomalies are reviewed and the etiologies and presentation forms commented.

[Retrospective study of the treatment of 329 patients with prostatism syndrome and review of the literature]. / Análisis retrospectivo del tratamiento de 329 pacientes con síndrome de prostatismo y revisión de la bibliografía.

OBJECTIVES: New drugs for the treatment of prostatism have been developed in recent years; only surgery, however, has been demonstrated to achieve cure. Each modality of drug therapy may afford symptomatic relief in those patients in whom surgery is not indicated and a symptom-based stepwise indication could be established. METHODS: 329 patients with prostatism were treated by surgery, administration of finasteride, alphablockers or plant extracts, according to the recommendations of the WHO. Patient evaluation included abdominal US. PSA determination and uroflowmetry. Patients with urodynamic or other derangements were excluded from the study. RESULTS: Patients with a worse quality of life and important obstructive symptoms underwent surgery. Patients with important obstructive symptoms and no complications requiring surgery (infection, urinary retention, etc.) received finasteride, which proved to be effective in these patients, although 16.6% required another type of treatment and two presented impotence. Patients treated with plant extracts had moderate prostatism; 17% of these patients required another type of treatment. Patients treated with alphablockers presented symptoms that were similar to those treated with plant extracts, but they had a more important irritative component; 24% of these patients withdrew from the study due to the side effects or inefficacy of their treatment regimen. CONCLUSIONS: Further studies and a longer follow-up are warranted to determine whether these new drugs can replace or effectively delay (avoiding the appearance of complications) surgery. We believe that the indications for each treatment should be established according to the different stages of prostatism. Moreover, further insight into the pathogenesis of BPH, appropriate diagnostic methods and patient selection are essential to the development of new therapeutical modalities and to achieving enhanced results.

[Pyeloureterostomy in stenosis of the pyeloureteral junction of an incomplete collecting system]. / Pieloreterostomía en estenosis de la unión pieloureteral de un doble sistema colector incompleto.

OBJECTIVES: The possible solutions to a case of ureteral duplication complicated by obstruction of one of the collecting systems are reviewed. METHODS/RESULTS: We report an uncommon case of ureteropelvic junction obstruction in the lower system of an incomplete duplication of the collecting systems that was resolved by pyeloureterostomy. CONCLUSIONS: Anastomosis of the lower renal pelvis to the upper ureter may provide a simple solution for the functional recovery of an important renal segment.

[Our experience with renal adenocarcinoma (II): clinical course, diagnosis, and prognostic factors before surgical treatment]. / Nuestra experiencia en adenocarcinomas renales (II): Clínica, diagnóstico y factores pronósticos antes del tratamiento quirúrgico.

OBJECTIVES: We evaluated the form of presentation, clinical features and analytical values and their relationship with survival in renal cell carcinoma patients and analyzed the efficiency of different diagnostic and staging procedures. METHODS: We reviewed the form of presentation, clinical features, staging procedures and analytical values of 229 consecutive renal cell carcinomas diagnosed at our hospital between 1975 and 1991. RESULTS: Malaise and weight loss or symptoms different from those of the classical triad (hematuria, pain and a flank mass) are factors of poor prognosis and lower survival. The time of presentation of symptoms does not influence prognosis. Computerized tomography was found to be the best imaging technique, with a low sensitivity and a high specificity in our experience. We have found a correlation between hypercalcemia and lower survival, but not for the more advanced tumoral stage. There was a correlation between the levels of hemoglobin and alkaline phosphatase and survival: patients with hemoglobin levels less than 14 g/dl or alkaline phosphatase levels greater than 85 U/l had a lower survival rate and a more advanced tumoral stage. CONCLUSIONS: Computerized tomography was found to be the best imaging technique. Symptoms different from those of the classical triad, malaise and weight loss, hypercalcemia, low levels of hemoglobin or high levels of alkaline phosphatase are factors of poor prognosis.

[Renal autotransplantation in a case of idiopathic retroperitoneal fibrosis refractory to other treatments]. / Autotrasplante renal en un caso de fibrosis retroperitoneal idiopática refractaria a otros tratamientos.

We report a case of renal autotransplantation in a patient with right retroperitoneal fibrosis that had been previously treated by ureterolysis with intraperitonization and corticoid therapy without success. The literature is briefly reviewed and the therapeutic possibilities in refractory retroperitoneal fibrosis are discussed, with special reference to renal autotransplantation.